Sarah Cox was admitted to hospital and placed on a feeding tube because she was malnourished, yet hospital staff discharged her with a weight loss plan. “I was told: ‘You’re still overweight, you still need to lose weight.’”
Cox says her eating disorder began after she was told by her GP to lose weight and that her body mass index (BMI) was too high at every appointment she attended throughout 2018-19, despite displaying no indicators of poor health such as blood test abnormalities or high or low blood pressure.
Cox remembers raising concerns with her GP about the diet after she passed out multiple times and being told: “You are still overweight. You need to ramp it up, not ramp it down.”
In 2020 Cox developed atypical anorexia, an eating disorder with all the same symptoms as anorexia except the person never becomes clinically underweight. Between 2020 and 2021, Cox was admitted to hospital more than 10 times.
Experts in diet and nutrition say cases such as Cox’s reveal why health, not weight loss, needs to be the focus of public health messaging, but that dietary guidelines from government bodies are doing the opposite – contributing to eating disorder risk.
Cox says when she was treated by one of the chief psychiatrists in eating disorders for Queensland, he told her she would never have developed a disorder if medical professionals had not put so much pressure on her to lose weight.
Dr Fiona Willer, a dietitian and lecturer at the Queensland University of Technology, says the primary risk of developing an eating disorder comes from trying to change one’s weight, yet it is a message reinforced by some doctors and health departments. “Everyone’s saying, ‘if you’re larger-bodied, you should try to be smaller-bodied’.”
The National Eating Disorders Strategy, released last week to guide policies, programs and services over the next decade, identifies challenging weight stigma as one of the key social and environmental factors that can help prevent eating disorders. “This includes ensuring that policies related to nutrition, physical activity and weight management do not contribute to eating disorder risk,” the strategy states.
But the federal government’s website for dietary health guidelines, eatforhealth.gov.au, include “tips for losing weight” while the CSIRO’s website tells Australians they can “lose 3x more weight” through its total wellbeing diet, giving examples with before and after pictures captioned “Terry lost 100kg” and “Adele lost 18kg”.
Willer says the government’s weight-centric position echoes stigmatising beliefs in the wider community and health professionals can also be affected by weight stigma.
The federal and New South Wales governments’ health department websites, as well as the Victorian government’s Better Health Channel, include BMI calculator tools, despite experts saying it is not necessarily useful as an indicator of an individual’s health.
Cox says BMI calculators were a “huge driving force” for her eating disorder. She says she used “every one of them” – including those on the Australian Heart Foundation’s website and on the government’s website for its 2011 “swap it, don’t stop it” campaign. The campaign featured a cartoon balloon person with a tape measure they pulled tighter around their waist, which Cox says added to the weight stigma.
Fusing the concepts of weight and health is incorrect, Willer says. “People can be completely well nourished in a smaller body, a medium-sized body, a large body, a much larger body.
“We have a huge disconnect between what weight science says and what policy currently says and we have a whole heap of weight discrimination hanging from that misinformation,” she says.
The nutritionist Rosemary Stanton says the promotion of weight loss “doesn’t come from health, it comes from this whole idea of an ideal body image”.
Stanton says the focus on healthy eating needs to replace the idea of weight loss, otherwise it creates a culture where people are encouraged to diet and think that medications can help them to lose weight. She says she is particularly “horrified” by people thinking that injecting themselves with Ozempic is a good way to lose weight.
“People have lost the pleasure of eating,” she says. Public health messaging, Stanton says, has largely focused on addressing people with a weight that is hazardous to their health. “It’s a balancing game … and we’ve probably balanced it the wrong way and ignored eating disorders.”
Willer says for weight stigma to decline, body size should be added to weight discrimination laws and public health messaging should overtly state weight is no longer a relevant factor. Instead, health and wellbeing need to be the central values, Willer says, especially because “we know with level-A certainty” weight lost through dieting tends to come back within two to five years.
Asked whether there were plans to change the language on government websites to adhere to the new eating disorder strategy, a federal health department spokesperson told Guardian Australia the government would “consider how messaging, communication methods and platforms are tailored to different groups and use positive, contextual and culturally safe language to avoid weight related stigma and disordered eating”.
Cox says she recovered from anorexia only after being admitted to a health facility last year where staff told her they were not looking at the scales to work at her ideal weight but at her health indicators.
“And then this year has been the first year I’ve had my life back.”