In NYLON’s monthly column Plus Us, writer Gianluca Russo explores the many ways in which fat people are discriminated against — both systematically and on an interpersonal level — in society today, and looks to open up difficult dialogue in order to provide support, advice, and resources to the community.
Hanna Caldwell’s body image battle began at eight years old. Four years later, while receiving hospital treatment for an unrelated infection, a medical professional told her, “Life isn’t all cheeseburgers and jelly beans, kid.” Aside from the fact that Caldwell was a vegetarian, the comment struck her deeply, serving as the catalyst for a decade-long eating disorder. Now 22, Caldwell is fighting once again, trapped in a disordered eating cycle amidst the COVID-19 pandemic.
“I've always overanalyzed my body and haven’t had any sort of relationship with it other than the fact that I don't like it,” Caldwell tells NYLON. “It’s much easier not to obsess about my body and food when [there’s someone else around], but I was living alone from March until the end of July, and I don't think I could form a [positive] image of what I look like in my head for the past four or five months.”
Caldwell isn’t alone. Many have opened up in recent months about pandemic-induced and -intensified eating disorder battles. According to The New York Times, the National Eating Disorders Association saw a 78 percent increase in use of its help line through April and May. Plus, a new study published in the International Journal of Eating Disorders found that nearly two-thirds of participants reported an increased fear of falling into disordered eating patterns. One fact is clear: Having body positive mental health practitioners and eating disorder specialists has never been so important.
“Every single person deserves to have safe and respectful care without attaching it to a number on the scale,” says Shira Rose, an eating disorder psychotherapist in New York City.
Unfortunately, as body positivity has become increasingly commercialized, finding truly fat positive resources is harder than ever before. Many providers who claim to support size inclusivity also promote weight loss, contradicting the movement they’re claiming to align with. The Health At Every Size initiative has fought against this, but with diet culture rampant, even the medical industry cannot escape its influence.
“I hear patients say they keep failing at diets and need to have better willpower, need to try harder,” explains Jessica Moreno, a psychiatric clinical pharmacist at Beaumont Medical Group who points eating disorder patients in the direction of treatment professionals best suited for their needs. “I'm sitting across the room from them saying that these diets are failing you, you're not failing them. [We need to provide] more compassion that I think they're just not used to hearing.”
"We recognize size and health as two different things that are not intricately connected, and we shouldn’t make assumptions based on size."
Moreno has found it useful to derail the conversation from weight loss to nutrition, two separate entities that are often equated as one. If a patient approaches her set on dieting with the goal of weight loss, she takes the time to examine their lab data including blood pressure, heart rate, cholesterol, etc. “Very often it's these young women who are actually otherwise completely healthy, who have normal blood pressures, who have normal heart rates, whose cholesterol levels are normal, their blood sugar levels are normal,” she says.
Rose adds, “The most common outcome of dieting is cycling, which causes all of the health issues we associate with people in larger bodies like diabetes, high cholesterol, and all those other things.”
That is precisely why weight can never be the sole indicator of health as it’s often mistaken to be. Lab tests and results are the key to determining whether an individual has a health component to address, and that cannot be seen from solely a number on a scale.
“We recognize size and health as two different things that are not intricately connected, and we shouldn’t make assumptions based on size,” says Dr. Rachel Millner, a psychologist and certified eating disorder specialist. “We can help people use behaviors that could support their health and their wellbeing that have nothing to do with body size or weight loss.”
Dr. Millner adds, “Every health problem impacts people across the weight spectrum, and doctors and health care providers find ways to intervene with people in thin bodies without weight loss being a part of it, so they need to do the same for people in fat bodies.”
That message is especially applicable to those in fat bodies who are fighting eating disorders. Many interviewed for this piece stated that their eating disorders were ignored, belittled, or pushed aside, simply due to the fact that they “didn’t look like someone with anorexia.” Eating disorders and body image issues take no singular form or size, and health practitioners must realize that in order to provide adequate treatment.
Unfortunately, that often does not happen, and thus points to a larger issue between the fat community and medical industry. Trust between the two parties is becoming increasingly fragile as more and more fat people face discrimination from within the doctor’s office. In fact, fatphobia within the medical industry is so rampant, that it even can result in death due to untreated medical conditions.
Aside from feelings of shame or embarrassment that one might be grappling with, the insurance industry actively works against the fat community, often preventing them from receiving care and, in turn, life saving guidance from providers who are not accessible without coverage.
“It really is about luck and privilege whether or not people are able to access appropriate treatment,” Moreno says. In some states, she explains, dietitian services are not even covered by insurance, let alone the fact that the fat community in those spots of the country may struggle to gain proper coverage to begin with.
“Insurance approval for eating disorder treatment has historically been partially based on body size,” Dr. Millner says. “Even in treatment centers, the chairs, exam tables, and gowns have not been designed to fit fat bodies. There has been this bias or assumption that people in fat bodies have binge eating disorders, not considering that people in fat bodies also have anorexia and bulimia.”
She adds, “The research around health and bodies is biased. The research doesn't take into account the impact of size oppression, fatphobia, or social determinants of health...I think the eating disorder field [in particular] has failed and harmed a lot of people with marginalized identities, especially fat people.”
As daunting as it may seem, there are ways to find body positive mental health and eating disorder practitioners. A free tool to use: Google. Use search terms like “Health at Every Size,” “fat positive,” and “intuitive eating,” followed by your city and state, to narrow down the healthcare options available to you. Among the different types of practitioners to search for are licensed clinical social workers, mental health counselors, psychologists, and eating disorder specialists. The vetting process doesn’t stop there, however: Rose suggests digging into the websites and social media pages of the providers you find before reaching out.
“If you're seeing any inconsistency, like ‘We provide Health at Every Size framework, but we also provide weight loss plans,’ that's a really big red flag to be wary of,” she advises. Then, upon narrowing down your options to providers who seem like the best fit, schedule phone calls and introductory meetings with them to further understand their methods and recovery techniques. “Ask questions like, ‘How do you treat a client in a larger body? What do you say to a client who says they want to lose weight?' If you're working with somebody battling an eating disorder, are you gonna [encourage weight loss] or say, ‘You deserve better than the life of dieting?’”
“About 90 percent of my clients find me through my Instagram account, so making myself visible and putting my work in the social media sphere allows me to both show that I am very much a human as well as a therapist. And it's actually important to be both [to best help patients],” says therapist Rachel Otis, who holds a Master’s Degree in Counseling Psychology with a concentration in Somatic Psychotherapy from the California Institute of Integral Studies.
That personal journey of living in a fat body is what guides Otis’ methods and approach, as it does with Rose and many other fat positive practitioners. Few can understand the systematic fatphobia this community faces on a regular basis without having that lived experience. “My passion comes from seeing firsthand that there's still a huge gap in mental health and physical health resources in our country,” Otis says. “[We need to] bridge the mind body connection.”
Dr. Millner adds, “As therapists and dietitians within the fat positive community, we really want clients to be able to access safe and positive care. So even if a client can't find a practitioner in their direct community, they could always reach out to us — a positive therapist or dietician — that they follow on social media, and we can try to find a referral for them.”
While social media can be problematic and harmful in many ways, doing your utmost to curate a fat positive, uplifting feed can help you on a day-to-day basis as well. Whether it’s following inclusive specialists like those interviewed for this piece, or size-inclusive fashion bloggers who promote positive messages, the images you scroll by daily will impact how you feel.
And in terms of finding accessible treatment, online resources are often key. The Association for Size Diversity and Health, for instance, publishes a thorough resource guide that not only outlines body positive providers, but also books, articles, websites, and other outlets to seek care. Dr. Millner also suggests looking to Facebook as most big cities have groups dedicated to sharing resources on the topic.
“There’s nothing more special [than telling] clients in a larger body that nothing was ever wrong with their body," says Rose. "There's nothing wrong with them. A lot of times, that’s the first time they’re ever heard that before, and it feels so incredibly rewarding to be able to provide a safe place for my clients in a world that's not been safe for them.”
If you or someone you know has an eating disorder and needs help, call the National Eating Disorders Association helpline at 1-800-931-2237, text 741741, or chat online with a Helpline volunteer here.
If you or someone you know is seeking help for mental health concerns, visit the National Alliance on Mental Illness (NAMI) website, or call 1-800-950-NAMI(6264). For confidential treatment referrals, visit the Substance Abuse and Mental Health Services Administration (SAMHSA) website, or call the National Helpline at 1-800-662-HELP(4357). In an emergency, contact the National Suicide Prevention Lifeline at 1-800-273-TALK(8255) or call 911.