Letters to the Editor

The Role of Weight Stigma in the Development of Eating Disorders


Am Fam Physician. 2021 Jul ;104(1):7-9.

Original Article: Eating Disorders in Primary Care: Diagnosis and Management

Issue Date: January 1, 2021

Available at: https://www.aafp.org/afp/2021/0101/p22.html

To the Editor: We want to thank Dr. Klein and colleagues for their article highlighting the crucial role that family physicians play in the early identification of eating disorders.

The authors did not discuss the effect of weight stigma on the development of eating disorders.1 One of the strongest risk factors for the development of an eating disorder is previous weight loss attempts.2,3 For patients who are not already struggling with an eating disorder, encouragement from a physician to pursue weight loss without careful consideration could contribute to the development of disordered behaviors, including bingeing, restriction, and purging. Therefore, when patients present to a primary care clinic with the goal of weight loss, screening for disordered eating thoughts or behaviors should be a top priority. Increasing physician awareness of the risks associated with recommending weight loss or dieting to patients is crucial.

The authors emphasized the importance of objective data (i.e., body mass index [BMI]) over validated screening tools (i.e., SCOFF questionnaire), citing concerns about self-report bias on survey instruments. Unfortunately, an overreliance on BMI is likely to result in physicians failing to detect the occurrence of eating disorders in patients with larger bodies. Evidence suggests that the higher a person's BMI, the greater the likelihood that they meet the criteria for an eating disorder.4,5 For this reason, a screening process that relies heavily on BMI is likely to miss the bulk of individuals in a primary care setting who would benefit the most from early identification and intervention. Further, clinicians often praise patients with larger bodies for behaviors (e.g., calorie counting) and mindsets (e.g., a goal weight) that would be considered problematic for other people. Diagnostic criteria for eating disorders that use BMI in the definition can be explicitly harmful to people with larger bodies, delaying diagnosis and treatment and inadvertently supporting symptomatic behaviors.

Family physicians have an essential role in the prevention and treatment of eating disorders and sub-diagnostic disordered eating behaviors. Physicians must also be aware of the role they could play in the development of eating disorders and consider incorporating evidence-based practices such as weight-neutral health promotion counseling.6

Author disclosure: No relevant financial affiliations.


show all references

1. Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring). 2006;14(10):1802–1815....

2. Stice E. Risk and maintenance factors for eating pathology: a meta-analytic review. Psychol Bull. 2002;128(5):825–848.

3. Stice E, Rohde P, Shaw H, et al. Weight suppression increases odds for future onset of anorexia nervosa, bulimia nervosa, and purging disorder, but not binge eating disorder. Am J Clin Nutr. 2020;112(4):941–947.

4. Duncan AE, Ziobrowski HN, Nicol G. The prevalence of past 12-month and lifetime DSM-IV eating disorders by BMI category in US men and women. Eur Eat Disord Rev. 2017;25(3):165–171.

5. Udo T, Grilo CM. Prevalence and correlates of DSM-5–defined eating disorders in a nationally representative sample of U.S. adults. Biol Psychiatry. 2018;84(5):345–354.

6. Mensinger JL, Calogero RM, Stranges S, et al. A weight-neutral versus weight-loss approach for health promotion in women with high BMI: a randomized-controlled trial. Appetite. 2016;105:364–374.

In Reply: We appreciate the comments from Dr. Westby and colleagues regarding two critically important concepts in the care of persons at risk of or diagnosed with eating disorders.

We agree that weight stigma is a critical risk factor for the onset and maintenance of eating pathology,1 and that dieting attempts increase the risk of eating disorders.2 Notably, weight stigma has been associated with increased vulnerability to mal-adaptive eating during the COVID-19 pandemic.3 Although a comprehensive exploration of the etiologic role of weight stigma in eating disorders was beyond the scope of our article, we advised clinicians to assess and confront weight stigma and discussed how praise for weight loss might result in or reinforce eating pathology. We also dedicated the final section to prevention (e.g., avoiding stigmatizing language, promoting acceptance of larger body sizes, emphasizing health instead of weight or appearance-related goals).

Dr. Westby and colleagues raise essential points about the prevalence of eating pathology in individuals with larger bodies, which clinicians may fail to assess or detect. We also highlighted the importance of analyzing anthropometric trends and percentile changes, ideally in graphic form, instead of absolute measurements.

Objective data alone without psychosocial history taking (e.g., through clinical interview, screening tools) can miss important diagnoses. However, the sensitivity of screening tools such as the SCOFF questionnaire varies across populations,4 and assessments of disordered eating may not be universally feasible or prioritized across clinical settings and visit types. Therefore, following the American Academy of Pediatrics' recent clinical report on eating disorders, we advocate for multifaceted assessment approaches that can be effectively implemented.5

The U.S. Preventive Services Task Force is currently assessing techniques and outcomes of screening for eating disorders in primary care settings.6 Until further data are available, we conclude that during clinical encounters, history should be corroborated when possible, objective findings systematically reviewed, and screening tools interpreted in context.

Primary care clinicians are on the front lines in promoting health, positive body image, and quality of life. Therefore, clinicians must be mindful of weight bias and associated distress, and harmful weight control behaviors.1,2 Clinical recommendations, particularly for individuals with disordered eating, body image concerns, high body weight, or weight loss attempts, must be articulated with sensitivity and precision. Additional resources about addressing weight bias can be found at https://www.obesityaction.org/action-through-advocacy/weight-bias/. We are grateful that the importance of nonstigmatizing, size-inclusive approaches is being highlighted in American Family Physician.

Author disclosure: No relevant financial affiliations.

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Uniformed Services University of the Health Sciences; the Departments of the Air Force, Army, Navy, or the U.S. military at large; the Department of Defense; or the U.S. government.


show all references

1. Puhl RM, Himmelstein MS, Pearl RL. Weight stigma as a psychosocial contributor to obesity. Am Psychol. 2020;75(2):274–289....

2. Stice E, Rohde P, Shaw H, et al. Weight suppression increases odds for future onset of anorexia nervosa, bulimia nervosa, and purging disorder, but not binge eating disorder. Am J Clin Nutr. 2020;112(4):941–947.

3. Puhl RM, Lessard LM, Larson N, et al. Weight stigma as a predictor of distress and maladaptive eating behaviors during COVID-19: longitudinal findings from the EAT study. Ann Behav Med. 2020;54(10):738–746.

4. Solmi F, Hatch SL, Hotopf M, et al. Validation of the SCOFF questionnaire for eating disorders in a multiethnic general population sample. Int J Eat Disord. 2015;48(3):312–316.

5. Hornberger LL, Lane MA; Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279.

6. U.S. Preventive Services Task Force. Screening for eating disorders in adolescents and adults. June 25, 2020. Accessed February 22, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/document/draft-research-plan/screening-eating-disorders-adolescents-adults

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


May 2022

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article