“Not Sick Enough”- How Weight-Centric Care Delays Eating Disorder Treatment

When we talk about eating disorders, one of the most persistent and damaging myths is that they only affect people who are visibly underweight. It’s a stereotype reinforced by media, outdated diagnostic criteria, and crucially by parts of the healthcare system itself. For many people seeking help, the first point of contact is often a GP or primary care provider. And too often, they’re met with a response that boils down to: you’re not sick enough.

The assumption that eating disorders have a certain “look” or that BMI can reliably tell us how unwell someone is creates a huge barrier to early intervention. And in a condition where early support can be lifesaving, the consequences can be hugely damaging.

What does “not sick enough” really mean?

For many, it’s hearing things like:

• 🗣️“Your weight is still in the healthy range.”

• ⏳"Let’s monitor things for now and see how it goes.”

• 😬"It doesn’t look like things are that bad at the moment.”

  
  

These comments might be well-meaning, but they ignore the reality of eating disorders: that the impact on someone’s daily life, thoughts, and behaviours is a far more accurate measure of distress than a number on the scale.

How weight-centric care causes harm

Using weight as the primary marker of illness:

• 🚫 Delays diagnosis for people in higher-weight or average-weight bodies, despite severe symptoms.

• 😔 Reinforces shame and the idea that someone has to “get sicker” to be taken seriously and drives people further towards their illness.

• 🌈 Overlooks the wide spectrum of eating disorders, including bulimia nervosa, binge eating disorder and ‘atypical’ diagnoses. 

• 🕰️ Misses early intervention windows, especially in young people, where treatment can be most effective.

  
  

The limitations of BMI thresholds

Many treatment services still rely on BMI cut-offs as part of their referral criteria despite knowing that BMI is a deeply flawed and non-individualised tool. People with restrictive eating disorders can be significantly malnourished and physically compromised while still falling within a “normal” BMI. It doesn’t measure:

• 🧠 Psychological distress

• 🍽️ Nutritional deficiency

• 🧩 Functional impairment

All of which are central to understanding the severity of an eating disorder.

What should we be asking instead?

When someone presents with possible signs of an eating disorder, the more meaningful questions are:

• ⏰ How much time are food, body image, and compensatory thoughts taking up in your day?

• 😟 How distressed do you feel by these behaviours?

• 🙋‍♀️ How much is this interfering with your relationships, work, or ability to function?

• 🌪️ Do you feel things can change without support?

Towards more inclusive, responsive care

We have to move away from the assumption that thinness is a prerequisite for support. Eating disorders exist across all sizes, genders, ages, races, and backgrounds and everyone deserves timely, compassionate care.

As healthcare professionals, we need to validate distress, not weight. And as a community, we need to keep challenging the narrow image of what an eating disorder looks like.

You don’t need to be underweight to be unwell. You don’t need to be “sick enough” to deserve help. 

You shouldn’t need to prove your suffering to earn care. The longer we let weight define who gets help, the more people we leave behind. We need to stop asking, “Are they thin enough?”  and start asking “Are they hurting?”