The Thin Ideal and Anorexia Nervosa: Case in Point

I’ve blogged previously about the role of the “thin ideal” in Anorexia Nervosa (AN). Conventional wisdom holds that young girls develop AN as a result of excessive dieting in pursuit of thinness, which is considered beautiful in western culture. I don’t believe that the thin ideal causes, or even contributes much, to the development of AN. However, I do believe that the thin ideal delays diagnosis, makes recovery more challenging, and normalizes and trivializes life-threatening symptoms.

I had a recent experience with a patient’s family which illustrates the way in which the thin ideal can interfere with recovery from AN. The patient, whom I will call Norah, presented in my office for eating disorder treatment at the age of 17. I diagnosed Norah with AN and began treating her with Family-Based Treatment (FBT). Norah turned out to have a relatively mild, short-lived case of AN (yes, such cases do occur, though they are not the norm), which responded quickly to a brief course of FBT.

Within a few months, Norah was virtually symptom-free and doing quite well overall. Her vital signs were good, she was getting regular periods, she no longer body-checked or weighed herself compulsively, her mood had improved, and she ate three solid meals each day with her parents or friends, consuming a wide variety of foods with no resistance. Sounds great, right?

There was just one problem: Norah’s weight had plateaued about 5 pounds below the target weight I had set for her based on her historic growth curves. This happened despite the fact that she was eating quite well, not purging, and engaging in minimal physical activity. Many teens in recovery from AN have huge nutritional requirements during re-feeding, so this was not entirely surprising. Besides, Norah had always been petite and naturally thin with a fast metabolism. Most likely, she just needed a lot more food.

Norah is a senior in high school who is planning to go away to college next year. I strongly recommended to Norah’s parents that they require her to reach full weight restoration prior to leaving for college, and that they increase her daily caloric intake to help her reach that goal. I explained that full weight restoration and return to normal growth and development are essential to recovery, and I provided them with literature on this subject. Given how tiny Norah is, a loss of even a few pounds would be enough to push her over the edge. In fact, it only took a loss of a few pounds to send her spiraling down into AN in the first place. In order to be well enough to live independently, I explained, Norah needs to gain these last five pounds and learn to maintain her optimal body weight.

Upon hearing this recommendation, Norah had a fit. She screamed and cried and lamented the injustice of it all. Why should she have to weigh “more than I’ve ever weighed before in my whole life?” (yes, one whole pound more than her historic high). I was not entirely surprised by Norah’s reaction. Although Norah had been unusually compliant in treatment thus far (and yes, such cases do exist, though they are not the norm), even a compliant anorexic has her limits.

Norah’s tantrum was foreseeable. After all, she has Anorexia Nervosa. Of course she would not want to eat more or gain more weight. Plus, Norah is a teenager with big dreams – a high school senior desperate to leave town, escape from her parents’ watchful eyes, and explore greener pastures. The mere possibility that she might not be allowed to go away devastated her.

What was not foreseeable was her mother’s reaction. Norah’s mother did not agree with my recommendation: she did not wish to require Norah to eat more food or gain more weight. Sure, she would like for Norah to gain more weight, but she was not willing to make that happen. She did not think it was fair to Norah, who had worked so hard in school and in recovery, to have to gain more weight in order to be allowed to go away for college. “After all,” said Norah’s mother, “Norah was not happy with her body at that weight, and that’s something we all need to take into consideration.”

No. Actually, we don’t need to take that into consideration.

Imbedded in Norah’s mother’s comment are several assumptions:

1.) That it is perfectly normal and rational for a teenage girl who has always been small and thin to dislike her body and aspire to be thinner

2.) That the rational solution to this teenager’s drive for thinness is to allow her to remain even thinner than before, thus interrupting normal adolescent growth and development

3.) That requiring the teenager to reach her optimal body weight – even when her optimal body weight conforms to the societal ideal – will somehow harm her psyche

None of these assumptions are true, of course. But the thin ideal makes these assumptions seem reasonable to parents and pediatricians and therapists and dieticians alike.

In an ideal world, these assumptions would always seem ludicrous to sensible adults, regardless of the patient’s size or weight. It should not be considered normal or rational for a teenager of any size or shape to dislike her body and aspire to be thinner. Losing weight should never be seen as a solution to body dissatisfaction, especially when weight loss disrupts normal adolescent growth and development. And requiring a teenager to reach and maintain her optimal body weight should not harm her psyche, regardless of whether her optimal weight lies within the realm of what society considers beautiful.

Sadly, we do not live in an ideal world. I am a member of society, just like everyone else, and I’m not immune to the impact of the thin ideal. Norah’s case seems particularly striking to me precisely because her body has always conformed to the thin ideal, and would still conform to the thin ideal after complete weight restoration. Therefore, it seemed particularly dangerous – and ridiculous – not to require her to achieve full weight restoration, because – hey – even at her optimal body weight she’d still be thin.

Here’s where the thin ideal colors my thinking. If Norah had been a large girl whose healthy body naturally gravitated towards a higher weight, her mother’s reaction might have made sense to me. If the poor girl had a stocky body type that placed her on the higher end of the growth charts, it may have seemed rational to allow her to stop five pounds short of full weight restoration. Her body dissatisfaction and drive for thinness would have seemed legitimate rather than disordered. I may have “taken into consideration” the fact that Norah “wasn’t happy with her body before.” Mother’s remark would not have changed my recommendation, but it would have given me pause. I’m not proud of this, but there you have it.

In response to Norah’s mother’s comment, I reminded Norah’s parents, as I had done at the start of treatment, that they are the leaders of Norah’s treatment team and I am a consultant to them. My job is to use my expertise in adolescent AN to guide them, inform them, and empower them to make the right decisions for their daughter. Along with these explanations, I also acknowledged that any recommendation I make is only as good as the parents’ willingness and ability to carry it out.

Ultimately, Norah’s parents chose to reject my recommendation. I suspect that the thin ideal played an important role in their decision. As for me, this situation highlighted the role of the thin ideal in my own belief system and shed light on an important point: an anorexic patient’s body dissatisfaction, drive for thinness, and resistance to weight restoration are symptoms of a serious illness, regardless of her size or weight. And that is something we all need to take into consideration.

16 Replies to “The Thin Ideal and Anorexia Nervosa: Case in Point”

  1. Great post! It’s so true, and so hard to explain how I think the thin ideal very much does affect eating disorders, but not always in the way we think.

  2. I think so often recovery is delayed when those with eating disorders appear to be a “normal” weight according to societal standards. It can be nearly impossible to help someone who is struggling with disordered eating to see the reality of their situation, when everywhere they look there are others who are also underweight. Not to mention the fact that they are very likely being praised by friends and even random strangers for their thinness…it’s sad that disordered eating seems to becoming more of a norm in our society, rather than the exception.

  3. My wife forwarded this read to me and it is very timely as our daughter nudges ever closer to full weight restoration, albeit not easily.

    We have had so many conversations about the value of completing weight restoration. Our daughter looks perfectly healthy and her vitals are good, though there is no question the ED is ever-present mentally. We have been at it the better part of a year. Now that she is 95% restored, is it worth the strife to find the last few pounds? Our family dynamic is drastically and negatively impacted when we aggressively push high-calorie meals and snacks. What’s worse, our persistence seems to promote her attention to the ED itself. She can’t just “forget about it” because we are constantly on her.

    Obviously we are monitoring her weight carefully. I’m just not convinced that her target-weight is an empirical truth (she is young and still growing). That last five pounds too often seems like punishment and only our psychologist is satisfied.

  4. This is so important. I find myself trying to say this to parents all the time: we get caught up in this thinking and become part of the problem. There’s a strong social pull. And yet if WE can’t see it for the delusion it is, we let our kids down.

    We need to look at weight as benign and unmeaningful as shoe size, oxygen level, skin color. That’s hard to do in a society that does not, but it is still our loving caregiving JOB.

  5. Sarah,

    You wrote that “I explained that full weight restoration and return to normal growth and development are essential to recovery, and I provided them [the parents] with literature on this subject.”
    Could you identify the specific literature that you gave to these parents on this subject?

    Also, if, as one commenter wrote, above, weight is “benign and unmeaningful” then why do five more pounds matter? As long as this teenager is medically healthy, as determined by medical professionals, and eating normally, as judged by her parents, why should we get hung up with the number on the scale? Isn’t that giving undue significance to one factor — weight — that it probably doesn’t deserve? Isn’t that mindset similar to weight prejudice? In other words, if this teenager weighs less than you think she should (by 5 pounds), then why would we conclude that she necessarily has a mental illness? Maybe her current weight is her natural set-point.

    Finally, do you think there are any differences between your directive approach (setting an exact target weight, instructing the parents what they “need” to do, etc.) and the FBT approach as manualized by Lock and LeGrange?


  6. We saw this when taking my young adult daughter to an eating disorder internist. She set a target weight that was too low for my daughter, explaining “I will settle for this weight even though it would be better if she were five pounds more”

    We stopped seeing this internist and worked with a family based treatment provider who had us feed my daughter fully and see where her weight stabilized. She didn’t set a number or range, we just fed her fully.

    As we fed my daughter, her father kept saying how upset he was that we were “making her fat”. He kept expressing fear that she would get too upset with the size of her body. He is one who has a thin ideal mentality.

    She wound up at a weight range ten pounds more than what the ED internist set for her. And she stabilized at that weight range long term. We saw that she had many less eating disordered thoughts and behaviors and her body dysmorphia lessened.

    I shudder to think what would have happened had we stuck with the ED internist who set her weight ten pounds less. She would not have had the opportunity to gain full remission.

  7. I wholeheartedly agree with this article. I literally had to face my fears about the potential of making my daughter “fat”. When we refed her and at about 95% of her IBW, she looked breathtakingly beautiful, like a willowy child model. I was a fat child and I carried a lot of baggage from my childhood regarding body size and image. I struggled so much with this than one day I had to ask myself “Would I rather have my daughter dead of fat?”. Jus the fact that I asked that question took the wind out of me. The answer was obvious. I wanted my daughter alive even if it meant that she would be “fat”. So, we ignored her Peds advice to stop at the 50% (where she was still desperately mentally ill) and re-fed until she reached the 76% (where she had tracked most of her life pre-illness). She didn’t get “fat” but she is not thin by society’s standards. She is the size that she was genetically predisposed to be. But, who cares what size she is! She has been healthy and in recovery for almost 6 years now. P.S. I also agree with the concept of a buffer weight. We don’t focus on one number but rather on a range of about 3-4 lbs. She hasn’t gone over her normal range but she has at times dip closer to the lower end of her range and we immediately see changes of state. So, why would we keep our children at 1-2 lbs away from falling into the ED hole again? My d’s buffer allows her to have a short illness without fear of relapse or have increases in sports training that give us room to readjust meals, before it is too late.

  8. Chris,

    Some of your questions suggest a misunderstanding of what I’ve written.

    This teenager doesn’t weigh “five pounds less than I think she should.” She weighs five pounds less than what she would have weighed, based on her individual historic growth curve, if she had never gotten AN. Healthy children and adolescents tend to track around the same percentile from age 2 until age 20. Check out the CDC growth curves.

    It is unlikely that the “natural set point” for a 17-year-old girl would be less than what she had weighed at age 16. This is particularly true for a teenager who has always been thin, and who is recovering from AN. This girl had tracked in the same percentiles for height and weight from age 2-16, at which point she developed AN and dropped off her growth curve. Most likely, her natural set point was the same weight she had been pre-AN, or perhaps a couple pounds more to factor in normal growth and development. The target weight I set for her was one pound higher than her pre-AN weight.

    Your comment “If this teenager weighs less than you think she should (by 5 pounds), then why would we conclude that she necessarily has a mental illness?” makes no sense. I diagnosed this teenager with AN based on her initial presentation in my office, at which point she was significantly underweight and met the diagnostic criteria for AN. At the time of this anecdote, her AN was mostly in remission.

    Again, the target weight was not based on what I think she should weigh; rather, it was based on her individual growth history. That is the whole point of this blog post. I don’t think this is akin to weight prejudice at all. Rather, it’s the opposite. I didn’t determine her optimal body weight; her body did. My recommendation was that this patient should get to the weight that would give her the best chance at sustained remission when she left for college. Five pounds matter a lot, especially in a short, small-framed girl, for whom five pounds accounts for a substantial fraction of her total body weight.

    You ask: “Finally, do you think there are any differences between your directive approach (setting an exact target weight, instructing the parents what they “need” to do, etc.) and the FBT approach as manualized by Lock and LeGrange?” This question suggests a misunderstanding of what I do. I don’t instruct the parents what they “need” to do. Rather, I give them recommendations based on my knowledge of AN and I provide them with rationales for those recommendations which are supported by the latest science on EDs. Then it is up to the parents whether they wish to accept these recommendations or not. As I mentioned in this post, I let parents know that they are the leaders of their child’s treatment team and all final decisions are theirs to make. I am a consultant to them, and they are in charge. This anecdote is a good example of this – I made my recommendation and explained the reasons for it, the parents rejected it, and I respected that. Also, I do not set an exact target weight; I set a weight range (usually of about 5 pounds) based on the patient’s individual growth history.

    My approach is very similar to FBT as manualized by Lock and Legrange. I use the same basic principles: not blaming the parents or the patient; empowering parents to take charge of the illness; focusing first on re-feeding and weight restoration; handing back control to the adolescent when he/she is ready; postponing work on other issues until weight restoration is complete. The primary difference is that I’m more flexible, and I tailor my approach to the needs of each individual patient and family. For example, I usually do open weights, as manualized by Lock and LeGrange, but on some occasions I will do blind weights based on the parents’ request, or if open weights causes extreme anxiety that is counterproductive to treatment. As another example, rather than beginning to hand back control over food to the patient at 90% or 95% of IBW as manualized by Lock and LeGrange, I usually wait until the patient has stabilized at 100% of IBW for a period of time before beginning Phase II. But the essence of the approach is the same.

    The literature I provide for parents about the importance of full weight restoration includes:

  9. If she’s still dissatisfied with her body, is she then not cured? I don’t think you can fix this. You can’t. I’ve lived with this hatred for my body my entire life.

    1. Dear Whatever,
      The girl described in this anecdote was satisfied with her body presently, but she had not been satisfied with her body before she developed AN (at which point she weighed 5 pounds more than she presently does).

      I don’t use the term “cure” in the context of AN. Rather, I use the term “remission” to signify that the genetic / biological predisposition remains even after symptoms are no longer present.

      In my opinion, a person can be in remission for AN even if they are dissatisfied with their body, so long as the body dissatisfaction is not a preoccupation and does not have a negative impact on her life. Unfortunately, most women in the USA are dissatisfied with their bodies, whether or not they have ever had an ED.

      Body dissatisfaction is treatable. A certain form of CBT (cognitive behavioral therapy) has been show to be effective in improving body image. Some people with EDs experience improvement in body image and increased body dissatisfaction naturally over the course of treatment as their weight stabilizes and their ED behaviors stop, even if body image is not specifically addressed in treatment. Other people may need targeted CBT in order to improve their body image. So yes, in my opinion, body image can be “fixed,” or at least improved.

      1. I actually found ACT helpful for dealing with body image, since CBT really didn’t seem to help me. My problem (and I’ve looked at it from many different angles) is partly that I seem to have a total misperception of my size and have since I was born. It’s a neurological thing.

        For me, what helped was less learning how to like my body and more learning to accept it. As well, I worked on building up other aspects of myself that helped to decrease the relative importance of my body image.

        I still don’t have a great body image. I still have some degree of body dysmorphia. But it doesn’t really bother me that much, it doesn’t get in the way of my life, and it doesn’t interfere with my recovery (body image was definitely a factor in my ED, but it certainly wasn’t the main one).

  10. In our experience with our daughter, body image dissatisfaction pretty much went away once she was weight restored to her projected target weight and weight kept up with her growth at that level for the next 2 years. She didn’t have any therapeutic treatment for it. Just being at the right weight did that for her. Since being in remission, one of the clues that she is falling below her healthy range is… body image dissatisfaction. She will body check, suck her stomach in, pinch her stomach 0r say that she is fat or has fat hips. This is a red flag and when we weigh her, her weight has fallen closer to the edge of her healthy range. A couple of times she has accidentally fallen below it. On the flip side, when she is at her ideal weight range, her mild body dissatisfaction takes on the form of complaining that her chest is too small or that she is not curvy enough.

    Re. Chris’ comments about parents being the experts on what weight to set. I wish our FBT would have set a higher range for us. Our daughter would not have suffered for 18 months while underfed and underweight. Thanks to Dr. Julie O’Toole for writing the article posted above. Reading this article gave us the guidance we needed and our daughter finally was able to recover.

    P.S. I apologize for the many typos and mistakes on my previous post. Phone typing is difficult.

  11. This post rings so true for me, based on my experience with my daughter. Her doctor set a target weight that I felt was too low once she reached it. My D was unable to eat independently at that weight. We tried over and over unsuccessfully. Once we decided, over the doctor’s objection, to raise our daughter’s weight a few pounds, she became able to eat lunches on her own very quickly. She ended up gaining several pounds above that weight and then settled. She now has a buffer against getting sick. We really appreciated that buffer when she got the flu recently. She weathered it with no return of ED, even though several meals were missed due to illness.

  12. Sarah, I disagree strongly with the approach you took withNorah and her parents. First of all, the whole idea of the psychotherapist establishing a “target weight” is controversial. Basing the target weight on the CDC growth curves, and directly communicating a specific target weight to the teenager, telling her she “needs” to gain 5 pounds, makes the situation even worse.
    In FBT the therapist does not set a specific target weight. As explained in the FBT manual ( p. 53):”Because many patients with AN, and in some cases their parents, become overly fixated on specific weights or numbers, it is not helpful to focus on specific weight targets in this therapy. Instead, the emphasis should be on the direction of weight gain or loss and return of menses in young women.” Lock, LeGrange, Treatment Manual for Anorexia Nervosa (2013) Furthermore, the paper you cited, above, by Julie O”Toole concurs with this approach. Julie writes: “Once menstruation has returned and vitals are normal, we feel it important to focus more on signs of recovery such as social engagement, happiness, laughter, return of sense of humor, etc. than on the fine details of weight itself.I call this focusing on the “state” rather than the “weight” and parents are often very finely-tuned judges of this. . . . In summary, what is a young person’s ideal body weight, down the line, when they are fully grown? It is that weight in females which allows them to have normal ovulatory periods and which they can maintain when not engaged in eating disorder behaviors.”
    Judged by these criteria, Norah’s parents made a decision that I don’t think you should second-guess. Norah was medically stable, menstruating, eating normally, and socially engaged. By all accounts, she was recovered. Her parents are the best judges of this.
    The only problem, in your opinion, is that Norah was 5 pounds underweight based on your interpretiation of the CDC growth charts. However, the CDC growth charts are not meant to be used to determine a target weight for a person recovering from AN. Those charts are useful for early detection of weight loss in a growing child, and for research studies where the objective is to determine how potent a particular treatment model is in bringing about weight gain. For purposes of determining whether the sufferer’s weight is appropriate for her medical and psychological health, however, the approach described by Lock, LeGrange, and O’Toole makes more sense and has a wider following than any model based on the CDC growth curves.
    Given that the decision by Norah’s parents had a rational basis, I don’t think it is helpful for you to “suspect” that their decision was based on the influence of the so-called Thin Ideal. You don’t have any evidence that the Thin Ideal “played an important role” in their decision. This sounds like bias to me.
    Moreover, it does not surprise me that Norah reacted emotionally to your statement that she “needs” to gain 5 pounds. She probably interpreted this statement as illogical and not evidence based. She is probably correct.
    Finally, I don’t think it is wise for you to declare that “we don’t need to take into consideration” Norah’s position and that the parents should withold college unless she gains 5 pounds. These are strong-arm tactics. They are inconsistent with FBT, a model that is designed to unite parents and their children with one another and to align them together against the illness. It is not designed to align parents against their children or to encourage the use of threats to bring about weight gain.

  13. That was a great post. I guess I could be “Norah” here in that I’m 5 lbs below 90% of my IBW and have absolutely no desire to gain any weight. I have all of the fears that come along with eating more and gaining weight. Reading that clarified a lot for me.

  14. A paper many parents might find helpful is LeGrange, “Calculation of Expected Weight in Adolescents with Eating Disorders,”
    Pediatrics February 2012; 129(2). Full text available online, free, at
    The authors review several methods for calculating expected weight, conclude that there is considerable variation among them, suggest that all the methods are to some extent “arbitrary and should not be seen as absolute indicators of illness or health” and advise clinicians to “refrain from talking about ‘ideal’ weight or expressing the target with unrealistic accuracy.”

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