Recognizing Eating Disorders in All Shapes and Sizes

During National Eating Disorder Awareness Week, Molly Perlman, MD, MPH, CEDS-C, discussed evolving epidemiology, diagnostic challenges, and the importance of universal screening for eating disorders. Perlman, chief medical officer at Monte Nido, emphasized that weight bias continues to obscure timely diagnosis of eating disorders and related behaviors. She noted that only 6% of individuals with eating disorders were underweight, and that 2 in 3 patients entering higher levels of care in her organization’s dataset were in average or larger bodies (according to body mass index categories defined by the US Centers for Disease Control and Prevention).¹

Perlman stated that the longstanding stereotype of eating disorders exclusively affecting a “skinny, white, affluent girl” had been debunked. She reported that more than a third of affected individuals identified as male, and highlighted elevated risk for binge eating disorder in Black communities.² She also underscored high comorbidity with eating disorders and posttraumatic stress disorder (PTSD), noting that approximately half of patients in treatment screened positive for active PTSD and necessitated concurrent management.

Perlman observed that patients in larger bodies often experienced longer delays before diagnosis, contributing to greater psychiatric burden at presentation, including higher eating disorder symptom severity and higher Patient Health Questionnaire-9 scores. She cautioned that anorexia nervosa can occur at any body size and that restrictive behaviors, excessive exercise, and misuse of medications, including stimulants and glucagon-like peptide-1 receptor agonists, warranted careful assessment.

Perlman highlighted that screening is essential to early intervention. She advised clinicians to ask open-ended questions about patients’ relationships with food and to assess meal patterns, restriction, and binge behaviors regardless of weight, gender, or ethnicity. She emphasized that, “if we don't ask our clients about eating disorder behavior, they're definitely not gonna tell us,” noting that eating disorders are egosyntonic, often requiring clinicians to help patients name symptoms and challenge entrenched beliefs to facilitate recovery.

Dr Perlman is chief medical officer at Monte Nido, an eating disorder care organization.

References

1. Monte Nido 2025 outcomes report. Monte Nido. October 2025. Accessed February 26, 2026. https://www.montenido.com/outcomes-report

2. Franko DL, Thompson-Brenner H, Thompson DR, et al. Racial/ethnic differences in adults in randomized clinical trials of binge eating disorder. J Consult Clin Psychol. 2012;80(2):186-195.