Episode 149 Transcript

You're listening to the Fierce Fatty podcast episode 149. Atypical anorexia, let's do it.

Hello, welcome to this episode first fatties. Nice to see ya, Hey, I just got some details back on the first fatty vacation, and I want to tell them to you and tell them to you. So for those who don't know, our first fatty vacation is to the Dominican Republic. And it is also a fats, Joy themed vacation. So it's for fat folks. What does fat mean? Who is fat? To answer that question is kind of difficult, because a lot of times it's measured against women's clothing. And not everyone wears women's clothing. And also women's clothing sizes are different in every country, and also different brands, they're different. So a very, very rough guide of what is fat, or what is plus size is someone who is size 1618 as a minimum, and so that might be someone who is like a two XL in of a gendered clothing. But more importantly, a definition of who is fat is if you've experienced systemic marginalization due to the size of your body, so that is, you know, not fitting in chairs, not having blood pressure cuffs that, that fit, being denied opportunities, whatever types of opportunities because of your body size. And it's not your perceived body size, it's the kind of systemic things that have happened versus someone saying, You're too big when you're actually a straight size person. So I'll leave it up to the people who are coming on the trip to work out if they feel like they are a fat person. And in the past, whenever I've said something is a space for fat folks, people have been good in selecting if that hits, if that fits them. And the reason why we're making a fat, fat joy and fat only trip is because to make it a safe space, right? So that everyone is kind of in the same boat in a kind of roundabout right way, right? Because everyone's going to be different sizes, but as long as everyone is a small vat or higher then beautiful. All right, so dates for the trip June 14 to June 18. When the podcast comes out, the trip would have been live for a few days. So go to the show notes and look at the link and it will give you all of the details and you'll have the chance to get early bird tickets, the first eight spots out of thing it's twin, D It's just I'm just looking at my my doobly doo here 18 Okay, so the first eight out of 18 Get earlybird pricing. So go check that out if that interests you the types of things that we are doing. Okay, so, here's here's a snapshot of the things that we're doing when you're low Beach, relax on a palm lined white sand beach and enjoy the clear turquoise waters. I've seen pictures of this place fucking gorgeous. It's so it's like out of a I don't know when you imagine exotic places or you know, a hot places. You know, it's this is this is what it's like it's beautiful. Next Pearl Beach Club. Have a delicious lunch at a private pool, and beautiful with beautiful beachfront views. Cap Karna harbor visit, visit shops and take pictures and afterwards take a dip in a marina port and sip a complimentary cocktail. Oh whoa indigenous ecological park and reserve visit. The reserve consists of a network of trails including 12 freshwater lagoon swim in one of the lagoons with its clear water glittery water and enjoy the sights and sounds of the surrounding tropical forest. Off Road adventure driving your own ATV across a diverse landscape of the Dominican countryside, stock photos and sample locations. receives delicacies like chocolate and organic coffee, cooking class difference delivered by a professional chef who will explain the cooking styles of the region and teach you about traditional Dominican cuisine. And group dining, spend time with your new travel buddies and your host me Vinny at local restaurants. And at the hotel, something delicious local cuisine. And we're gonna be talking about fat joy and kind of setting intentions and laughing having fun splashing in the water, eating food, all that type of stuff. I really would love it to happen. And the only way to happen is if you come along, if we don't have enough interest, then it won't happen. So it's all down to you. Who knows? I have no, I have no idea. What is going to happen with this? I you know, I did a survey to see if you were interested. And you are a lot of people said that they were in theory, I guess. And so it's down now to if in reality that extends to actually making it happen. Pricing wise, you're able to break up the payments, they've have a financing option type of thing. I don't know if it's financing. I don't think there's any interest on it. It's you know, like, you know, have you seen like, now when you buy clothes as the option to spread the payments over X amount or something? I want to find out more about that. And, yeah, so I, I know for sure. But anyway, there's that option, I think you have to put 25% of the price down. early bird pricing is 2695 2695. Yeah, so that's that if you'd love to come then come if you would love to come but can't afford it, I totally get it. The price is a little bit higher for us because we have included things that are accessible. So for example, the transport from the airport, instead of being in, you know, small, a small bus we have, we have a bus with bigger seats. So that we are in a hotel that has bigger showers, we had to pick a hotel that was a little bit more expensive. So just kind of just some transparency there. Again, this is absolutely accessible in regards to if you need to rent a scooter or a wheelchair, we have that option. We have options for buses that have ramps, the activities that we're doing, they are all well, it's it's activity level one. So the activities we're doing, as you can see from the things that I was telling you, like quani low beach, so that's accessible Pearl Beach Club, and so again, that's accessible in regards to wheelchairs, and also folks who have limited mobility. And then there's other things like you know, like the ecological park and and that's, you know, as much as you want to explore, you can do that. And if others want to explore more than they can do that too. No one is going to be left behind. I absolutely promise you. And you know, rather than the ATV, if that's not something that you want to do, you don't have to write. But again, we're going to be driven right to the adventurer place so the ATV So yeah, if you've got questions, if you're unsure about anything, then please do send me an email fattie at fierce fatty.com or go on to the link in the show notes to get all of the details because I'm just kind of giving you a little overview right of the things that we're doing. But then you've got more details on what that looks like every single day and all that jazz. So who knows that is going to happen. You tell me if you want to come? I would love to see you there. Okay, so let's talk about what we're talking about today, which is atypical anorexia, and I've never done an episode that is dedicated to atypical anorexia. And actually researching for this episode, I was like, Yeah, I know. I know, you know, atypical anorexia, I know about that. But I've learnt some, you know, more facts around it. And I thought that it was really interesting, and I thought that you would find it interesting to her. And a big trigger warning here we're going to be talking about the effects of atypical anorexia.

Unknown Speaker 9:50

What it's like and the differences that people in bigger bodies experience and so if that's not feeling good for you today, then maybe skip this episode because we We'll be talking about that I'm not gonna be talking about anything like calories or, or weights, specific weights. So you don't need to worry about that. Alright, so a typical anorexia let me just read out a little bit here. Atypical anorexia, basically, I'm not reading by the way, I'm just talking Exia is anorexia in someone who is in a body that is not very small or underweight. Okay. So if you think about anorexia, a lot of the times what we think about is someone in a very small body. That actually should be called atypical anorexia. Because the most typical form of anorexia is anorexia in people with bigger bodies. And just to look a heads up oh, look at Quick what Mayo Clinic say about anorexia nervosa. Anorexia is an eating disorder characterized by an N Abloh, abnormally low body weight, intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape using extreme efforts that tend to significantly interfere with their lives. So notice that with this just standard definition, characterized by having a small body and that's the first thing that they lead with at Mayo Clinic. But really, that's it's kind of like where, where you're starting out if you already have a smaller body, then it's more likely that if you if you have anorexia, that you'll get a smaller body. If you have a bigger body, chances are that you'll still have a bigger body even if you have anorexia because there's only a certain amount of weight that your body can lose before it just says no, that's enough. And a lot of times for people who are in bigger bodies, it's not low enough to be classed as having anorexia but they will be classed as having a typical anorexia which is problematic and we'll talk about that now. Okay, so here's a quote. Atypical anorexia is dangerous because it did it's often not recognized family and family it's an even doctors might be praising a young woman. I don't know why they say women here because everyone can have an IDI but it is more common in women praising a human for impressive weight loss when she is actually critically unwell. A typical anorexia patients have all the same symptoms and behaviors as typical patients typical anorexia patients except the most visible one low weight. A 2016 study found that there were they were just as physically compromised and distressed emotionally as their typical typical counterparts. Both are driven by an obsessive fear of weight gain and being fat but atypical anorexia patients had what they what they study called significantly higher levels of distress related to eating and body image and a fear of fatness, but their weight history might exacerbate. Let me read that again. So people who are in bigger bodies who have anorexia have significantly higher levels of distress related to eating and body image and a fear of fatness that their weight history might exacerbate. So, you know, people in bigger bodies have got that evidence that lived experience of what it's like to be in a bigger body and what would happen if they got back to that bigger body that maybe they had before? Or if they have lost weight, and what that experience is like and what if then they get a even bigger body than what they had previously. So there's a New York Times Magazine article, which is the which came out in a month a month, like six weeks ago, and I had pinned it to read is really good. And I have linked it in the show notes, but it's behind a paywall, depending on how many times you've looked at New York, New York Times, as I've also linked a link so that you can read it from behind the paywall. So if you if you there's it's an archive.ph link and so if you're like what the fuck is this, this dodgy link that Vinnie has given me, that's just what that is. And so you can go and read it. It's about a I'm 45 minute read. So it's quite in depth. And so I'm going to pick out some of the things in here that I thought were was really, really interesting and I'm going to read a few paragraphs from the very beginning. And the title of it is you don't look anorexic. Okay, so are you sitting comfortably, then I shall begin for centuries, the eating disorder that would become known as anorexia nervosa, mystified the medical community, which struggled to understand or even define an illness that causes people to deliberately deprive themselves of food. As cases rose, over the course of a 19th and 20th centuries, anorexia was considered a purely psychological disorder akin to hysteria. So William with the girl, an English physician who coined the term anorexia, Nova Llosa, in the late 1800s, called it a perversion of the ego. There's a link there to the perversion of the ego. And there's a there's a kind of article in this 1800s I don't know what it was a magazine for doctors, and him describing a patient and he has a I think it was woodblock illustration of the patient, and her symptoms and all that type of stuff. And it's quite interesting. There's mention of weight in there. So if you don't want to see that, yeah, so and yeah, and saying it's a perversion of the ego kind of sounds like he was quite perplexed about what was happening. Okay, continuing in 19, after an autopsy revealed an atrophied pituitary gland. Anorexia was thought to be an endocrinologic injure and DRO Coronado logical disease and chronological disease oh my god, I've worked so hard. That theory was later debunked, and in the mid 20th century, psychoanalytic explanations arose pointing to sexual and developmental dysfunction and later, unhealthy family dynamics. More recently, the medical field has come to believe that anorexia can be the product of a constellation of psychological, social, genetic, neurological and biological factors. Since anorexia nervosa became the first eating related disorders listed in the Diagnostic and Statistical Manual of Mental Disorders. That's called the DSM in 1952. So anorexia was put in the DSM in 1952, its criteria have shifted as well. Initially, anorexia had no weight criteria, and was classified as a psycho sociological, psycho physiological disorder. In 19, in a 1972 paper, a team led by the prominent psychiatrist John finer, suggested using a weight loss of at least 25% as a standard for research purposes. And in 1980, the DSM introduced that figure in its definition, along with a criterion that patients weigh well below, quote, unquote, normal for their age and height, although normal was not defined. Doctors who relied on that number soon found that that patients who had lost at least 25% of their body weight were already severely sick. So in 1987, the diagnosis were revised to include those who weighed less than 85% of their, quote, normal body weight, well qualified as normal was left for physicians to decide. In the 2013 DSM, the criteria shifted, again, characterizing those who suffer from anorexia as having a significantly low weight, a description that would also appear in the 2022 edition. So this is interesting. So the first time that anorexia was mentioned, it was in 1952. In the DSM, as in, you know, in that in that context, in the DSM, and there was no way attached to it. And I wonder, I wonder, the discussions around that at that time, if you listened to the episode last week of the biggest scammers in the weight loss industry.

Unknown Speaker 19:38

And we know by the 1950s, weight loss and diets and all that bullshit was in in full full force, right full swing, people were absolutely trying to become smaller and absolutely presumed to know that fat bodies were bad. My wonder One how much that influenced folks with anorexia because we've had cases since the 1800s have been identified and even before you know, we started last last episode on talking about stuff hate happening in the early 19th century, but anti fatness has been around for hundreds of years. So yes, one, how much anti fatness influenced folks with anorexia, and also how much anti fatness influenced the idea that there should be a weight categorization. Because if you lose 24.9% of your body weight, that's just a diet. But if you lose 20, lose 25% of your body weight, then that is our Axia. You know, according to the DSM in 1980. And, and so, I wonder previously to that when they didn't have that weight limit or weight criteria, which is absolutely bizarre, it's the only mental illness and has a weight criteria. Can you imagine if you were like, Oh, you don't have depression, because you're too fat to have depression, only thin people have depression. You're just imagining it. Yeah, and I wonder if diet companies or those invested in anti fatness, push, push back to get a definition. And even if it is people in the mental health world, pushing back and they they are living in a world that is anti fat. The idea that whatever fat person loses weight, well, then that's good no matter how much you know. And people who are, who are the higher weight people are regularly encouraged to lose 25% plus of their weight, right? And so at least in the 1980s, if you had a 400 pound person, and they lost weight and they became a 250 pound person, then folks might start to say, Okay, well, what's going on here? Are they engaging in disordered eating? Do they have an eating disorder? Whereas more recently in the 22,020 13 DSM, we've got that has to have significantly low weight and I wonder what was going on there? of why is it that we have positioned fat folks who have an eating disorder if they are still currently fat as that's okay. Or that is not a typical anorexia. And a lot of people haven't even heard of a typical anorexia. Right. I mean, a lot of a lot of doctors GPS don't know don't know that term. And if they do, they probably think it's, it's, you know, not that common when actually it's the most common, you know, straight up anorexia is way less common than atypical anorexia. Yeah, so I find that interesting to think about of why is it then we got to the 23rd. Why is it we've got to 2013 and then we've got the significantly low weight isn't a mental illness, the same mental illness depending on your size? Is it the fact that a fat person could quote, still stand to lose weight? And then so then, okay, well, it's not a bad thing in that circumstance, but you know, we do have the atypical diagnosis in the DSM. So let me continue. In that 2013 addition, then a new diagnosis appeared a typical anorexia nervosa nervosa after healthcare providers noticed more patients showing up for treatment with all the symptoms of anorexia nervosa except one, a significantly low weight. So isn't that interesting, right. So physicians saw fat people coming in with anorexia, and instead of expanding the definition of what anorexia is they reduced it further to be so it's only for people who have a significantly low weight. Okay, continuing. Those with atypical anorexia, doctors observed suffer the same mental and physical symptoms as people with anorexia nervosa, even life threatening heart issues and electrolyte balances. They restrict calories intensively obsess about food eating and body image and view their weight as inextricably linked to their value. They often skip meals eaten secret adhere to intricate rules about what foods they allow themselves to consume and create unusual habits like chewing and spitting out food. Other exercise to the point of exhaustion abused laxatives and purge their meals. But unlike those diagnosed with anorexia, people with atypical anorexia can lose significant amounts of weight, but still have a medium or large body size. others because of their body's metabolism, hardly lose any weight at all. To the outside world. They appear quote unquote, oh word. Yeah, so that's the introduction of the history of a typical anorexia. And so starting in the mid 2000s, a number of people seeking treatment for the disorder rose sharply whether more people are developing atypical anorexia or or seeking treatment, or more doctors are recognizing it is unknown, but this group now comprises up to half of all patients hospitalized in eating disorder programs. So half of all patients hospitalized in eating disorder programs, have those with atypical anorexia. And so just a reminder here, atypical anorexia wasn't in the DSM, until 2013. Okay, so if you were kind of similar age to me, I'm, I'm 38. You might be thinking, holy shit, I never knew about this, I think that I have lived with a typical anorexia myself. And we, you know, we didn't, we didn't know these things, we didn't know that. As a fat person, you could be not eating enough. I always thought, when I was not in, in fat positivity, I always thought, if you were fat, you had eaten enough, full stop. And until you became very thin, then that was evidence that you had not eaten enough. But that's not how the body works, right? How fat on your, on your body, having adipose tissue is not this unlimited fuel source, right? Someone could die of starvation and be a very fat person. Because the body needs so much to run just to just run basic organs right? need so much just to keep you alive, nevermind. Other things like going out in the world and walking around and, and using your brain and keeping you warm, and all that type of stuff. So every day, we need so much energy to be able to do that. And, you know, when we stop eating enough food, a lot of people think well, you know, your body just kind of keep burning and burning and burning fat to make energy until you become thin. And that's not what happens, right? That's not what happens. Our fat cells don't contain all of the things that we need to live and thrive. And also, our body stops that process from happening because our body goes into a starvation state. A lot of hormones are whizzing around telling us to to conserve our energy, making us extra hungry. And our metabolism can go out of whack. Right? And, and so you can have a fat person who, whose body is desperately desperately unwell from being under nourished, you know, the same reasons that someone with a smaller body would die from anorexia are the same reasons that someone with a bigger body would die from anorexia, right? The body is eating away at muscles and your heart being

Unknown Speaker 29:26

a muscle and it becoming weaker and weaker and all of the other processes that are happening right. Which to me, when I understood this about atypical anorexia, I was like, what you know, isn't what I just really it I found it very hard to wrap my head around the idea that you could starve and be fat, because, you know, I just saw fatness as this just unending fuel source. but it's it's not right Okay, continuing with some some quotes. So studies suggest that the same number of people even as many as three times as many will develop a typical anorexia as traditional anorexia in their lifetime. So let me read it again, study suggests that the same number of people, even as many as three times as many will develop a typical anorexia as opposed to traditional anorexia in their lifetimes. One estimate suggests that as much as 4.9% of the female population will have the disorder for boys the number is lower when estimate was 1.2. For men, it's likely even lower, though little research exists for non binary people, the number jumps to as high as 7.5% That's a big difference, isn't it? For non binary people? 7.5% for for women 4.9%. And when we think like, oh, that's not that many people. It's, it's a lot of people to have a life threatening mental health condition. Yeah. So despite its prevalence, atypical anorexia is still considered widely under diagnosed and under researched. And many primary care doctors have never even heard of it. Patients too are unaware of it and see themselves having a weight issue. Yeah, that's the thing. It's like, it doesn't matter what you do to get thin, just get thin, is the is the message that we hear, right? It doesn't matter if you have to cut cut off healthy organ, putting yourself into into your digestive system into a disease state. It doesn't matter if you use that device, a spire assist which pumps your stomach after you eat. It doesn't matter. If you never eat food or you eat so so much food, you're in a forced starvation state which is the same, which is the same amount of calories that many diets Noom prescribe, that doesn't matter, because you're getting thinner. And of course, thinner is healthier. Oh, yeah, it's caused you to have an eating disorder. Oh, who cares? You're fat? Is what society says. So, and it's hard. Yeah, it's hard. I mean, how many of us fat people have had that experience of losing weight and going to the doctor, for example, and the doctor saying you've lost weight? Amazing. Right? That's so good, good for you. How did you lose? It doesn't matter. It doesn't matter. You're thinner. That's all that matters. And even if you did say to the doctor, well, you know, I'm, I'm eating this and that and it's clearly not enough for a human to live on what the doctor say. That sounds like you're not eating enough. Very unlikely. Very unlikely. Okay, continuing in 2020. Aaron Harrop, an Assistant Professor of Social Work at the University of Denver completed a survey of 39 people with atypical anorexia, most of whom were fat. They used to work and found that participants endured the disorder for an average of 11.6 years before seeking help. They lost an average of 64 pounds, and a quarter of the group had yet to receive treatment. By comparison, the treatment delays for anorexia are on average 2.5 years for bulimia 4.4 for binge eating disorder on average are 2.5 for bulimia 4.4 for binge eating disorder 5.6 According to a 2021 review, okay, so people with atypical anorexia have to wait 11.6 years. And that's even if they get help. Where as on average, a straight size person will have to wait 2.5 years. That is a huge difference. Imagine what living with anorexia does if you were doing that for 11.6 years, with no support with people encouraging you with you being convinced that your body is wrong. And so presumably from that, then Um, fat folks must have poor outcomes. I don't know this is I'm speculating, but I you know, in regards to even if they are able to go to treatment, and are they are they then more likely to have longer term effects? Are they likely more more likely to die versus straight size people don't know. Continuing to make it easier for people with atypical anorexia to be screened, treated and insured, there's a growing movement in the field to collapse the categories of anorexia and atypical anorexia into one to no longer see them as separate illnesses due to decouple anorexia from his virtually synonymous Association within us. Many, however, are fiercely resistant to letting go of the metric of weight, it would require altering the organizing principle by which the public and the greater medical field conceive of the condition. It would also require recognizing that anyone in any body can starve themselves into poor health. And you'd never know it by looking at them. That is, that's a really powerful sentence, I think. And that's it. And that, and then fat people have to deal with the stigma of there's no way that you are anorexic because you're fat. We all know, anorexic people have discipline and are thin because of that discipline. But look at you fat person, you're so undisciplined that you could never have anorexia. And these are the types of thoughts that I would have. When I was severely restricting what I ate, of, there's no way that I'm hurting. There's no way that I'm not getting enough food, because we all know that fat people. That's not their story, right? That if we're if I really was starving myself, I'd be thin. But I really was starving myself. Continuing the line between the two diagnosis is not particularly scientific, and has harmful effects on patient's ability to secure care. So this is what happens. When a human body is stabbed for long enough. It undergoes a complex series of biological, metabolic and hormonal changes to ensure its own survival. Every system moves to conserve energy, and the body begins to mind muscle and fat for glucose to keep the heart running and the brain functioning. The metabolism slows, which is why some people can eat very little and hardly lose any weight. If malnutrition worsens, their hair becomes fragile and falls out and muscle mass dwindles, including within the heart. People with severe anorexia of any kind can have orthostatic hypotension, heart rates lower than 60 beats per minute and electrolyte imbalances that may cause arrhythmias or even lead to cardiac arrest. From what little research on atypical anorexia exists, the medical complications appear to be the same as anorexia, and occur in similar rates across body sizes. So you don't have to be someone who is living in a very small body to experiences those things, is just when the body is forced into

Unknown Speaker 38:43

starvation. Recent research has found that body size is a less relevant indicator of the severity of both eating disorders. And other factors, including the percentage of body mass lost the speed of that loss and the duration of the malnourished nourish state. So it having a small body doesn't tell you that your anorexia is more severe than someone in a bigger body. There are other indicators to show you how severe it is. And I'm going back to and I've mentioned it many times before, I mentioned in the last episode, Minnesota, the Minnesota starvation experiment, to see reminding us of what starvation does to us mentally, as well as physically and those those people who went through the experiments were given calories, which are actually more generous than than modern diets, many modern diets and they really, really struggled with their mental health left with eating disorders, left, you know, being hospitalized, left with less fingers than what they started with because one gentleman chopped off three of his fingers and Um, yeah, more recent research suggests that losing just 5% of one's body weight can be associated with a clinically significant eating disorder. Wow, this is huge, right? Losing just 5% body weight can be associated with a clinically significant eating disorder. And what is it that we are told to lose it is going to help us and our health so much five to 10% of your body weight. I had that Weight Watchers key ring, which was in the shape of a 10 for years for the 10%. But But weight loss when I got the 10% weight loss. And I was like 10%, I can do more than that. And I did. But they make it a thing. And it's, it's it's made up right. There's no scientific data to show that losing five to 10% of your body weight, it will improve your health. It's a marketing ploy. And here we've got this information losing just 5% of your body weight can be associated with clinically significant eating disorder. Yes, yeah. Recovery is different. When atypical anorexia patients were given the same high calorie foods in the same portions as anorexia patients, they did not recover as well. It might sound like a no brainer. GABA says Scarborough's, someone in the thing, they have a larger body size, and so we believe they need more nutrition to recover. Hmm, it's like having a, you know, maybe someone in a smaller body there like a fee at 500. And then someone in a bigger body, it's like they're a jeep, right? And then you put the same amount of fuel in both and expect them both to have the same results. And it's probably like, you know, we need we need, you know, what they're saying here is we need more fuel to recover when you're in a bigger body need more nutrition to recover? Some psychologists report that atypical anorexia is hard. It's harder to treat than anorexia because the fear of weight gain is even greater in people who have been bullied and shamed for their size. Yes. And so we have, we have stories that inter woven in this piece, I'm not done with this piece, but inter woven in this piece is stories of different people and their experiences with a typical anorexia. And basically, their experiences are, it's took a long time to be diagnosed, even if when they were diagnosed, either they weren't believed by other people, or they didn't believe it themselves, because they were so kind of entrenched in the idea that their body was bad, and they need to become thin. And then when they went to treatment, so people were sent to what do you call, I remember the name of them, but you know, treatment facilities, treatment facilities, and they were treated really badly. So they even though their their charts would say that they had a typical anorexia. They were treated as if they had binge eating disorder. Because folks associate binge eating disorder with with people with bigger bodies, and were denied foods were given less food because of their body size. And also, care was denied by insurance companies who would pull funding after a couple of weeks or not give any type of funding to go to treatment, because they have higher body weights than what you see with people with typical anorexia, which is not typical, should be called the atypical. Yeah, so anyway, so continuing on in recognition of the inconsistent care that people with atypical anorexia sometimes receive a small vanguard of professionals in the field are experimenting with ways to improve treatment for people with larger bodies. But there's only so much can they can do before butting up against systemic challenges. And the biggest one is discriminatory insurance coverage. The issue stems not only from the lack of knowledge about a relatively new diagnosis, it's also a product of how the diagnosis is named and coded, because it's labeled a typical and filed under the murky, other specified feeding or eating disorder category, it is often seen as less dangerous. It is an absurd diagnosis, says Jennifer L. Qadiani. an internist who specializes in eating disorders in Denver, and the author of sick enough a guide to the medical complications of eating disorders. There's nothing atypical about it. If there's anything atypical it's the people who get underweight. Mm hmm. Yes, Jennifer To make it easier for people to secure care, some therapists, social workers and researchers have been advocating combining atypical anorexia and anorexia by removing the requirement to have a significantly low weight from the standard anorexia diagnosis. So how a typical anorexia is treated is apparently the most effective treatment. Treatments also often involve cognitive behavioral therapy, dialectical behavior therapy and family based treatment. And psychotherapy, medication nutrition counseling. You know, the nutrition counseling, I wonder if, if when they're in a fat body, it's like, Hey, don't eat too much. You don't want to get me I'm gonna put on weight group and our family therapy and hospital hospitalization. Mm hmm. Yeah, so we hear a lot of fat folks going to treatment for needy. And being told don't, don't put on weight, recover, but don't Don't, don't, but don't go away, don't want it to be bigger than you are or, or even if they're straight size, we don't want you to get fat, like if someone is is has a low body weight. Even the staff who are trained in in eating disorders and how to treat them will put the heebie jeebies up them and say, you know, but we don't we don't want you to get above a certain way, you know. And there's not any, there's not any resources on anti fat bias, which is a huge part of fear of fatness, the real experience of living in a fat phobic world and how that is real, and really painful for folks. And so how that is a genuine fear. And also the perceptions of fatness being unhealthy and lovable and attractive, all that type of stuff. And those those being, you know, false for a lot of a lot of folks, right? Yeah. So I asked people to tell me their experiences with atypical anorexia, and I got an incredible message from a health care provider. So this is an experience from the inside. All right, so this person says in the US, I worked in an inpatient unit. And a typical anorexia wasn't a billable Insurance Code for inpatient level of care. Already, you know, that first sentence, you were not you were denied care if you had a bigger body when you had a mental health condition. That is the most fatal mental health condition

Unknown Speaker 48:06

of all of them. Now, if that isn't raging fatphobia, then I don't know what is the only thing that's different body size. Okay, continuing. So providers often had to diagnose them with something else on paper to get them care. Despite that being insurance fraud. I mean, cheat the system. I don't care, but it quickly developed into fat phobia when recurring diagnosis given to fat folks with anorexia was binge eating disorder. So much stigma, and then others providers from then on would see that dx diagnosis and make all kinds of harmful assumptions. The worst is when a fat patient came in intake form said, Edie eating disorder. And the attending psychiatrist, didn't bother to do the questionnaire, and just diagnosed the person with BPD binge eating disorder, despite having blatant anorexia. And I said, Wow, thank you so much for this. I really appreciate your insight. How do you think this affected patients? And this person says one time, I remember one time a patient saw her chart and asked that it be changed. And she had to go through patients support services, which informally brands a person as, quote, non compliant, or even litigious? The attending would say, Why is she wasting so much time on this? She's just avoiding doing the real work of getting care. I'm ashamed to say that I used to think that that was some that think that was some keen psychological insight into a patient when now looking back is just a human being asked that they have some agency and lay evils that will define the quality of care they receive for the rest of their life. It's so nice to hear from someone on the inside, right to see to show that it's not kind of the perceptions of folks in there. It's, this is real, right? And people in eating disorder recovery, how often they are deeply, deeply, deeply entrenched in in anti fat bias. So I'm going to end this episode with the story from the main person in this this article. And that person is called Sharon Maxwell. So I thought I'd leave it till the end, because it's, it's kind of in pieces in that that big article, and I've kind of pieced it together into like, one code, one coherent story without kind of going back with on statistics. And also, I'm just going to be talking for like 10 minutes, I guess, you know, with her story. So if you don't want to hear Sharon story, then I mean, you can go, you're dismissed. Anytime anyway, like, I'm done with you Vinny pause. But I thought we'd end with this. And before I share, Sharon's story, which was written by the New York Times Magazine, just kind of, if you've, if you have kind of recognized, oh, maybe I have atypical anorexia, or maybe I used to, or, or I'm struggling with any type of eating disorder, I just want to say that you are important, your care is important, your mental well being is important, and you deserve to be supported in recovering from an eating disorder. And there are resources out there, there is an increasing drive to have good quality, weight neutral care. However, that is not the standard. And so sending you all the love and fatty hugs, and I encourage you to Google, you know, in your local area, what could be helpful, helpful for you. And, you know, go check out the links in the bio for the New York Times story, because, you know, that might be there's more stuff in there than what we've talked about today. So that that might be helpful for you. And there are other people there, who also have experienced atypical anorexia, and it might be helpful for you to go follow them on social media. And I know at least one of them has a podcast where they talk about this stuff. So that could be helpful too. So I hope you're able to reach out and even if it's just someone you're in your life and tell them that you need help, because I bet they would love to be able to help in any way that's possible. Alright, so let's talk this to Sharon Maxwell story, so I'm just going to be talking and sharing her story. Sharon Maxwell spent much of her life trying to make herself small. A family put her on her first diet when she was 10. Early on Saturday mornings, she and her mother would drive through the empty suburban streets of Hammond ind. In Indianapolis, Indiana. In an effort to attend Weight Watchers meetings. Maxwell did her best at that stage to track her meals and lock her points, but the scale wasn't going down fast enough. So she decided to barely eat anything on Fridays and take laxatives that she found in the medicine cabinet. Food had long been a fraught subject in the Maxwell household. Her parents are also bigger bodied, and dieted frequently. They belonged to a fundamentalist Baptist mega church where gluttony was seen as a sin to eat at home was to navigate a labyrinth of rules and restrictions. Maxwell watched one time as her mother lost 74 pounds in six months by consuming little more than carrot juice. Her skin temporarily turned orange. Sometimes her father sees by a new diet idea abruptly ransacked shelves on in the kitchen sweeping newly forbidden foods into the trash. Maxwell was constantly worried about eating too much. She started to eat alone and in secret, she took two chewing morsels and spitting them out. She hid food behind books in her pockets under mattresses and in between clothes folded neatly in drawers. Through Maxwell's eating it through Mac through Maxwell's teenage years and early 20s Eating became even more stressful. Her thoughts constantly orbited around food, what she was eating or not eating the calories she was burning or not burning the size of her body and especially what people thought of it. her prayer appearance was often a topic of public interest. When she went grocery shopping for her family other customers commented on the items in her cart. Honey, are you sure you want to eat that? One person said other shoppers offered unsolicited advice about diets. Strangers congratulated her when her cart was filled with vegetables. As she grew older, people at the gym clapped and cheered for her while she worked out. People would say go you you can lose her weight. She says. While eating and public other diners offered feedback and they still do to this day on her choices. A few even asking if she wanted to join their gym. Some would call her name's pig fatty. Sometimes people told her she was brave for wearing shorts, while others said she should cover up. She was always aware whether she wanted to be or not of how others viewed her body. Maxwell tried just about every day she could find juice cleanses Atkins Slim Fast South Beach Mediterranean whole 30 zekiel, a regimen regimen based on biblical references. She tried being vegetarian and Vigo at vegan and paleo. She tried consuming less than 500 calories a day and taking HCG fertility hormone rumored to suppress appetite but flagged by the FDA as risky and unproven for weight loss. During periods of religious fasting at her church, she would take the practice to an extreme consuming nothing but water for days. And on one occasion, two weeks. I passed out a few times, but I did it she says sometimes she exercise more than three hours a day in high intensity interval training sessions and kickboxing classes. Eventually she started vomiting up her food. Every day Maxwell stepped on the scale and internalize a number as a reflection of her self worth. Often the number on the scale went down. But if she let up on her rigid food, food rules, even briefly the numbers shot back up like a coiled spring. I just cycled through that she says but it became harder and harder each time to get the weight off.

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During the many years of dieting and deprivation Maxwell experienced mysterious health problems for a decade starting when she was 16. She almost never had her period. She was always cold, and she often had dizzy spells and occasionally passed out in class. When she was in college, she fainted three times in one day and was taken to the emergency room. For an appointment with an endocrinologist one year, Maxwell took a purse full of small plastic bags. Each one contained a day's worth of hair clumps that accumulate accumulated in her brush or had fallen in the shower drain. Her head was popped with board spots. The doctor was pleased with her weight loss and to her memory didn't seem too concerned about her other symptoms. Anything that makes the scale don't go down. Maxwell says I was given a pat on the back. Four years ago at the age of 25, Maxwell walked into her primary care doctor's office near Scottsdale, Arizona, where she lived and worked as a middle school teacher. She was there for an annual physical and she was prepared to be told to lose weight. And she had almost always been instructed. But this time the doctor an osteopath started asking unusual questions. Maxwell's blood work showed abnormally low iron and electrolyte levels. The doctor asked Maxwell what was she eating and what was she doing in relationship to food? Was she starving herself or she vomiting on purpose? Maxwell was surprised by this line of questioning. These are things I had heard in my whole life from my family, my friends, doctors. She says the Osteopath pa told her. She thought Maxwell had an eating disorder and suggested arranging treatment right away. Maxwell would later be diagnosed with atypical anorexia nervosa, and increasingly common yet little known eating disorder that shares all the same symptoms as anorexia nervosa, except for extreme thinness just as many people and possibly many more suffer from atypical anorexia. At the physical Maxwell Maxwell stared at her daughter in disbelief. She always thought that eating disorders were for skinny people. I laughed. She says, I don't use language like this any longer. But I told her she was crazy. I told her. No, I have a self control problem. It took Maxwell a long time to process that she had an eating disorder she had seen so she had been so steeped in the Gospel of dieting, that it was hard to accept that risk stretching her food was not unequivocally healthy. But her doctor instructed. She began making visits to the hospital for intravenous fluids and started taking iron supplements. At night she began attending outpatient sessions at the liberation center, and now shuttered facility in Phoenix where she ate dinner with other clients and attended group therapy. The staff at liberation told her she needed more intensive treatment and recommended attending a residential program. In the summer of 2018, after teaching through the rest of the school year, Maxwell agreed to go to a center in Monterey, Monterey, California, California, that was covered by her insurance. A day after she arrived However, her insurance rescinded approval. Because of her weight, the company didn't believe she was sick enough to meet the criteria for residential care for eating disorders. She was at once ashamed and incensed her art drove her five hours to pick her up, and she spent much of the next 10 days on the phone with the insurance company. Her assure insurance eventually authorized her to go to another facility, the Center for discovery Rancho Palos Palos Verdes, which sits on the Southern California coast. Maxwell's three month stay would consist of group meals, outings to restaurants, to practice dining and public settings, yoga and therapy. I went with the expectation that as soon as I walked in the door, they would be the people who would help me finally become thin once and for all she says. Instead, on her first day, a dietitian at the center explained that she would need to eat three balanced meals and three snacks a day to recover. Her treatment plan also required that she abstained from almost all forms of exercise, so her system could recalibrate. Maxwell panicked, she had never consistently eaten that much in her entire adult life. And she still felt that her body was a problem to be fixed. Maxwell already harbored a deep mistrust of the mental health profession. When she was growing up. She remembers a pastor at her church preaching that psychiatry was the work of the devil. The message seemed to be that anxiety was sinful, a sign of faithlessness Maxwell had left the church two years earlier, but its lessons were still large deeply in her mind. She couldn't abandon her long held belief, one that her doctors reinforced for much of her life. That thinness was the primary measure of health. Maxwell forced herself to go along with each step of the treatment program. She tried to eat three meals and three snacks a day, even though it caused her excruciating fear. For years, her thinking have revolved tightly around food and exercise and during twice weekly individual therapy sessions, and daily group therapy, she tried to learn how to redirect those thoughts. She started to talk about the self judgment, shame and childhood trauma that led to rigid behaviors, and an over reliance on control both central features of restricted eating disorders. After about five or six weeks into treatment, it dawned on her just how much damage she had done to herself. Her esophagus burned from years of purging. She experienced heart palpitations and was often dizzy from or foot orthostatic hypotension, a type of lower blood pressure that leads to dizziness and fainting. And her hair and nails were thin and brittle from malnutrition. I started to realize Holy shit, this is real. She says, I started to see what it had done to my body the magnitude of it. Over the ensuing ensuing weeks, Maxol began eating enough food that the staff allowed her to go on walks and swim, not around calories, but as a part of learning how to live a balanced life. Her physical symptoms started to ease her vital signs and bloodwork improved. She felt less Dizzy a heartbeat more regular. She got her period back for the first time in a decade and perhaps more surprisingly, she was not gaining weight despite eating more food. I think that's a bit of a fat phobic line. To help her overcome her self judgment, a nurse suggested that she look in the mirror and express what she liked about her body. At first, Maxwell couldn't think of what to say. She could hardly make eye contact with her own reflection. But eventually she thought of something. I'm grateful for my curly hair, she said, looking in looking at the nurse in the mirror.

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After she left the Center for discovery, and moved to South Carolina Maxwell started a partial hospitalization program at the eating discovery eating recovery descent center in Greenville. She immediately began noticing how her size was affecting the quality of her treatment. When she arrived a staff member member put her in her room and told her to wait. While the people with quote normal eating disorders gathered next door. Her words felt like a gut punch. At lunch she was told to sit by herself at the back of the dining room, while the other clients sat together with their backs to her. I was like, I can't sit with them. She says the center had mistaken her diagnosis for binge eating disorder, and had a policy of separating those clients from the others. Sometimes staff members singled her out and had her eat less than small bodied patients. At a group therapy session in which she was the only large person in the room. Another patient shared that she would rather die than be fat, her literally expressing spirit expressing that while I'm in the room, that to be me to live in this body that I have to recover in would be worse than anything. It's just ostracising Maxwell says the eating Recovery Center does not comment on individual patients experiences but since 2021, it says it has made efforts to counteract weight stigma in its treatment centers in late 2018. Maxwell decided to be more open about her eating disorder with friends and family and started posting about it on Instagram. Over the years she's included photographs of her younger self and shared memories of her decades long journey. Sometimes it felt brazen and edgy, but also good. I am fat and I have anorexia. She wrote in a 2020 post, and I don't have to explain my body to you these days. Maxwell's inner landscape is very different than it once was on a Sunday sun on a sat on a sunny Saturday afternoon in may not far from where she lives in San Diego. She did something that would have brought her waves of anxiety in the past. She went to the beach. Amid the tiny jangle of an ice cream truck she truck she unfurled her towel and sat down. Before she started her recovery. She would have spent her time at the beach worried about what she was wearing or not wearing, what she had eaten or would eat later and what other people were thinking or not thinking about her body, followed by this tangle of thoughts she would miss the experience. Now she doesn't give those things much thought. on that Saturday, she watched her dogs zoom around the sand and laugh with a couple of friends. Her mind was not floating above her body disassociated. Maxwell is choosing to recover as fully as she can, but it's not easy. After 19 years of going undiagnosed. She still suffers from some of the physical, mental and social costs of anorexia. Doctors are monitoring her recovery from Long QT syndrome and electrical issue with the heart that can turn into potential fatal arrhythmia. Long QT syndrome is a rare side effect of anorexia. She also has an annual endoscopy endoscopy to assess the slow healing from her damaged esophagus from years of vomiting. She has incurred mountains of debt from months of treatment. She checks in with a doctor and a therapist regularly and takes photos of her meals to a dietitian. As proof that she's eating three meals a day a standard in recovery. She attends an eating disorder support group even though she has rarely seen another larger bodied person there. She also has started to cook for herself. But to be a larger person in this world is to be constantly reminded her are reminded of how other people view your body. When she posts about recovery and fat positivity on Instagram or Tiktok whether it's theatrically smashing her scale with a baseball bat, or performing slam poetry in her car, a flurry of trolls rise from the backwaters of the Internet to riddle her feed with insults and death threats. You need a sign that says beware of pig one commenter wrote, moo moo goes a cow route another who created a handle at Sharon Maxwell Hayter expressly to bully her. Society pities you because you're eating yourself to into an early grave, and other wrote. But Maxwell has also received direct messages from people who have struggled in similar ways they have never admitted to themselves, let alone to their family or friends how much they are suffering. I just wanted to say that I am a fat person with an eating disorder who isn't yet in recovery but trying one route. Every day I have these crazy disordered thoughts and get into a spiral of how I'm not valid valid enough for recovery. The content has been absolutely pivotal for me, and I'm so happy that you exist. Many people with anorexia describe the illness as a battle between two selves. One is a maniacal super ego hell burned on control at all costs, in a misguided attempt to find safety in imposes preferred prefer perfectionistic rules and restrictions in Sisyphean pursuit of unreachable ideal. Some fear it is intent on self destruction. This self which much Well Matt So of course a conceptualized self enforces all the expectations of one's upbringing in the culture at large and sees the world in lifeless tones of black and white like an OLED TV. The second is what Maxwell calls the authentic self. For her. It's a self that spontaneously breaks into impromptu dance moves and wears T shirts that read, don't be a butthole to yourself and therapy is cool. This self has a passion for gold glitter and animal print and signs up for rec basketball team on a whim, something that she would never have never have allowed herself to do before. She can eat strawberries or a sandwich or an ice cream cone in public. This self is no longer concerned with being quiet and obedient or apologizing for her existence. And perhaps most important, she has no interest in making herself small. He and so you can go follow Sharon Maxwell, on Instagram on Tik Tok. There'll be links in the bio of the show. A reminder of where you can find that is first party.com forward slash 149. If you ever forget what episode you want to find, you can always go first viking.com forward slash podcast and then all of the episodes will be there the most recent at the top. Yeah, so that's atypical anorexia. Thanks for hanging out with me today. And a reminder if you're interested in going on vacation with me, go check out the information on that in the show notes and I will see you for the next episode at face value podcast. Stay fierce, fatty.