Growing up in a larger body: youth- and parent-reported triggers for illness and barriers to recovery from anorexia nervosa

Abstract

Background

A significant portion of youth with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) have history of ‘overweight/obesity’ (i.e., body mass index ≥ 85th percentile for age-and-sex) prior to the onset of the eating disorder (ED) diagnosis, but research on this population remains limited. The present study used semi-structured interviews to explore themes related to triggers of weight loss, treatment, and recovery among youth with AN/AAN and history of ‘overweight/obesity,’ and their parents.

Method

The sample included eleven youth and parent dyads (Median [IQR] age of youth = 16.0 (1.5) years, 90.9% female, 90.9% White, 27.3% Hispanic) who were evaluated for an ED in a multidisciplinary ED program at a pediatric hospital between November 2020 and April 2021. Nine youth and separately, nine parents of these 11 dyads completed semi-structured interviews with the research team. Seven matched pairs of patients and parents completed demographic surveys and study interviews. Interviews were recorded, transcribed, and coded by four research team members using a reflexive thematic approach.

Results

Weight stigma was the most frequently reported theme for a trigger for weight loss that led to the onset for developing AN/AAN by both youth and parents. Regarding barriers to recovery, themes from more than a half of youth included uncertainty of weight goals in treatment and feeling they are “not sick enough.” Notable themes for attitudes towards treatment from most parents included general agreement with clinician recommendations, but also an uncertainty of weight restoration goals and a belief that their child need to have a “normal” weight.

Conclusion

These results highlighted how the majority of interviewed youth with history of ‘overweight/obesity’ reported weight stigma as both a trigger for the development of AN/AAN as well as a barrier to recovering. Internalized weight stigma among parents may influence their attitudes towards weight restoration as a treatment goal where these youth and parents may experience uncertainty of weight goals in treatment. This study demonstrated triggers and barriers to treatment that may be unique to youth with ED and history of ‘overweight/obesity’ and more research is needed to address weight stigma in multidisciplinary ED treatment for this understudied population.

Introduction

Individuals with anorexia nervosa (AN) and atypical anorexia nervosa (AAN) experience significant weight loss as a result of key behaviors and characteristics associated with AN/AAN, including restrictive eating, intense fear of gaining weight, and body image disturbance (APA, 2013). A recent review has shown that psychological and physiological symptoms of individuals with AAN and AN are generally similar with some variability in the frequency of physical complications (Walsh, Hagan, and Lockwood) [41]. Research suggests that up to 36.7% of adolescents with AN/AAN grew up in larger bodies, and had premorbid body mass indexes (BMI) ≥ 85th percentile for age-and-sex prior to developing an eating disorder (ED), meeting the cutoff for ‘overweight or obesity’ (Lebow, Sim, and Kransdorf, [22]; Matthews, Kramer, and Mitan, [27], Meierer et al., [28], Lin et al., [24]; CDC, [11]). These adolescents (hereafter referred to as adolescents with AN/AAN and premorbid ‘overweight/obesity’) often present with more rapid rate of weight loss, greater percentage of weight loss, longer duration of illness, more complications of malnutrition, greater severity of ED symptoms, and greater psychological symptoms (e.g., anxiety and depression) compared to those without premorbid overweight/obesity (Lin et al., [25]; Matthews, Kramer, & Mitan, [27], Garber et al.,[15], Lebow, Sim, & Krandorf, [22], Meierer et al., [28],Whitelaw et al., [42], Moskowitz & Weiselberg,[30]).

Notably, youth with AN/AAN and premorbid ‘overweight/obesity’ (i.e., history of ‘overweight/obesity’ prior to the onset of AN/AAN) experience greater weight stigma (i.e., negative attitudes, stereotypes, and/or discriminatory behaviors towards an individual based on their body weight or size; Pearl, [32]) compared to those with premorbid ‘normal’ weight status (Matthews, Kramer, & Mitan, [27]; Mensinger, [29]; Harrop et al. [18]). These adolescents report more weight-based teasing by peers and weight-talk by parents compared to those with premorbid ‘normal’ weight status, and this weight stigma was associated with increased symptoms of ED, anxiety, and depression (Matthews, Kramer, & Mitan, [27]). In addition, adolescents with AN/AAN and premorbid ‘overweight/obesity’ may experience greater external pressure from people such as their peers, family, and healthcare providers to achieve weight loss to mitigate real or perceived risks of childhood ‘overweight/obesity’ (Lin et al., [24]). For some, weight loss may be medically necessary to reduce cardiometabolic disease sometimes associated with elevated weight (Rajjo et al., [37]). However, a high emphasis on weight loss and anti-obesity public health efforts can inadvertently reinforce weight stigma in this population, who are frequently exposed to sociocultural messages about ideal body image, dieting, fitness, and health [34],Tan, Corciova, & Nicholls, [38]; Matthews et al., [27], Ata & Thompson [3],World Health Organization, [43]). These messages may promote weight stigma and drive for thinness, which are well-known risk factors for ED (Bristow et al., [9, 10]). Moreover, weight stigma among healthcare providers may inadvertently reinforce youth’s ED behaviors and impact their treatment (Harrop et al., [18]). For example, youth with AAN presenting at higher weights reported the negative impact of weight stigma on their ED behaviors, willingness to seek help, use of healthcare services, quality of treatment, as well as clinical outcomes (Harrop et al., [18]; Eiring et al., [14]). Thus, youth with AN/AAN and premorbid ‘overweight/obesity’ may represent a medically, psychologically, and socially vulnerable group that warrants more attention for both ED prevention and treatment efforts.

Given the unique experiences of adolescents with AN/AAN with premorbid ‘overweight/obesity,’ it is critical to understand what factors may increase their risk of developing an ED (Lin et al., [24]) and what factors may impact effective ED treatment. Many previous studies on triggers for the onset of AN focused solely on ‘underweight’ female patients and found that a desire to achieve the thin ideal is one of the most common triggers in this population (Barakat et al., [4]; [12]. Growing, but still limited, research has suggested that youth with AN/AAN and premorbid ‘overweight/obesity’ who are hospitalized for medical stabilization commonly report weight-based teasing and positive reinforcement for weight loss as triggers for the development of EDs (Lin et al., [24]). However, there remains a paucity of research on triggers for ED and treatment factors (e.g., acceptance of treatment approaches, agreement with weight restoration, treatment outcomes) that may impact the illness course of this population [20]. This information is warranted to inform ED prevention efforts as well as treatment seeking and engagement to optimize the recovery process.

To address these gaps in the literature on the unique experiences of youth with AN/AAN and premorbid ‘overweight/obesity,’ this study aimed to explore triggers of EDs, motivation for recovery, and barriers to recovery for this population. Specifically, using semi-structured interviews, we sought to describe and understand youth- and parent-reported preceding events or triggers of the development of AN/AAN as well as their attitudes towards treatment and weight restoration.

Methods

Study overview

We performed a qualitative, reflexive thematic analysis study with an inductive approach to better understand the unique experiences of youth with AN/AAN and premorbid ‘overweight/obesity.’ We conducted semi-structured interviews of youth and parents, to assess triggers for weight loss, treatment motivation and acceptance, and barriers to recovery. Interviews were conducted with the youth and parents separately.

Participants

We sought youth aged 11–19 years who received a multidisciplinary ED evaluation at a specialized pediatric ED program and met criteria for AN or AAN. All participants were newly diagnosed within 3 months of recruitment and had a history of ‘overweight/obesity’ (BMI ≥ 85th percentile for age and sex) prior to weight loss. This history was determined by having a developmental BMI growth trajectory above ≥ 85th percentile for the majority of the time between age 2 until just prior to the start of weight loss. Participants had to be English-speaking as the semi-structured interviews were only conducted in English. Participants were excluded if they had a significant cognitive impairment or active psychosis at the time of recruitment. We also asked a parent or guardian of each youth participant to be involved in the study.

Procedure

This study took place from November 2020 through April 2021. Potential participants were first identified through review of the ED clinic’s pre-visit phone intake. All participants were recruited via phone or video conference. As part of the phone intake, the ED program coordinator obtained verbal permission for our research assistant to make outreach for recruitment via phone or e-mail. Once youth and/or parents consented to the study, a member of the study team completed a virtual interview.

Study method

Research team

Our study team consisted of multidisciplinary clinicians and researchers invested in and/or trained to provide care of youth with EDs. The team included a medical physician, a psychologist, a registered dietitian, and a research assistant. The team members discussed potential sources of personal bias prior to and while coding the interviews, to help limit how this may have impacted the coding process.

Data collection

Semi-structured interviews. Interviews with a researcher were recorded as audio files with participants’ permission, lasted up to 30 min, and followed a semi-structured interview guide developed for this study. The audio files were transcribed afterwards by two research team members. All participants were paid $25 for their time. This study was approved by the hospital Institutional Review Board.

The interviews were designed to assess the following topics from both youth and parents:

• 1. Triggers for weight loss (i.e., experiences/feelings that made them change the way they ate, exercise, or thought about their body that led to weight loss; e.g., “What made you first change the way you ate, exercised, or thought about your weight/body?”)

• 2. When “healthy” becomes “unhealthy” (i.e., recognition and acceptance of ED behaviors; e.g., “When did people start worrying about your weight loss and everything going on?,” “At some point, did you start worrying about your weight loss or health?,” “When did someone start worrying about your child’s weight loss or behaviors?”)

• 3. Treatment goals (i.e., what being “healthy” and “in recovery” mean; e.g., “What would it mean to you to be healthy? How would you know that you are healthy?”). For youth, the interview also asked specifically about their motivation for recovery (e.g., “What could motivate you to gain the weight that your treatment recommends?”)

• 4. Barriers to recovery (e.g., “What would make it challenging for you to achieve your health goals?,” “Is there anything that you worry could make it harder for your child to get better?”). For parents, the interview also asked specifically about their attitudes towards treatment (e.g., “How do you feel about your child’s treatment including weight gain?,” “How would you feel about them returning to their previous highest weight?”).

Chart review. Chart review of electronic medical records was performed to identify the patient’s weight and growth history, amount of weight loss, and presenting weights.

Demographic survey. Youth and parents completed a demographic survey which included variables such as gender, race, and ethnicity.

Data analysis

Applying the Braun and Clarke reflexive thematic analysis with an inductive approach (Braun & Clarke, [6,7,8]) within the Interpretive Description methodological framework (Thomson Burdine, Thorne, & Sandhu, [40]; Ghorbani & Matourypour, [16]), the research team sought to describe and understand themes related to triggers of weight loss, treatment, and recovery among youth with AN/AAN and history of ‘overweight/obesity,’ and their parents. The research team reviewed and explored the semi-structured interviews by first becoming familiar with all of the qualitative data, generating initial codes, coding the interview scripts among the researchers consistently, identifying and defining recurring themes and patterns, and organizing these into broader themes. Subsequent revisions refined themes to be more concise. All theme names and definitions emerged throughout the process of inductive analysis. To limit any bias impacting thematic analyses and to ensure reliability and consistency, each interview was coded by two randomly assigned team members, and any inconsistencies were resolved with a review by all four team members.

Results

Sample characteristics

A total of 11 youth and parent/guardian dyads (ages 13–19) consented to the study. Table 1 shows demographic and weight information. Patients had a median (interquartile range [IQR]; range) age of 16.00 (IQR = 1.50; range 13–19) years. Most youth identified as cisgender female (N = 10, 90.9%) and White (N = 10, 90.9%). Three (27.3%) were of Hispanic/Latinx ethnicity. Of these 11 dyads, nine youth and separately, nine parents completed interviews. Two youth did not complete interviews but their parent did complete an interview after consenting. In total, seven matched pairs of patients/parents had completed surveys and interviews.

Table 1 Sample characteristics

All participants had BMI percentiles ≥ 85th percentile (considered ‘overweight’ or ‘obesity’ by U.S. Centers for Disease Control and Prevention [CDC] criteria) during their premorbid growth and development prior to their diagnosis of AN/AAN. Seven (63.6%) had BMI percentiles ≥ 95th percentile (considered ‘obesity’ by CDC criteria) during their premorbid growth and development. At the time of their ED diagnosis, participants presented at a median BMI percentile of 53.00 (IQR = 48.67; range = 4.7–96.6), which is considered within the ‘normal’ BMI range for age and sex by CDC criteria. However, they had lost a median of 14.19% (IQR, 7.01; range = 7.4–40.0) of their total body weight in 9.00 (IQR = 2.50; range = 1.5–24) months, which is considered moderately to severely malnourished by both the American Society for Parenteral and Enteral Nutrition (Becker et al., [5]) and the Society of Adolescent Health and Medicine [17].

Interview results

Tables 2 and 3 show the themes, definitions, frequency, and example quotes for patients and parents, respectively.

Table 2 Youth-identified Themes for Triggers for Eating Disorder and Recovery Barriers (n = 9) 

Table 3 Parent-identified Themes for Triggers for Eating Disorder and Recovery Barriers (n = 9)

Triggers for weight loss

Interviews with both youth and parents resulted in six themes under the topic “triggers for weight loss.” Weight stigma was the most frequently reported trigger by both youth (77.8%) and parents (88.9%). For example, “weight was always a really big part of my life… I think I've always had kind of like a bad view on it, no matter what.” Other youth- and parent-reported themes were generally consistent with each other, including comments from others (66.7% for youth, 55.6% for parents; e.g., “I think it was mostly just like offhanded comments, just like ‘oh, you’re eating a lot today’ or like ‘you look you’ve changed a little bit’), unintentional weight changes (33.3% for youth, 22.2% for parents; e.g., “I had Mono last January and I lost my appetite from that”), and a belief in “healthism” (33.3% for youth, 33.3% for parents; “I just thought it was like good—the healthy option for me”). Otherwise, some youth also reported positive reinforcement (33.3%; e.g., “I lost weight, everyone congratulated me on how good I looked…”) and teasing/bullying (11.1%; e.g., “I feel like sometimes they would like kind of made fun of me because of that”) as triggers while parents reported mental health concerns (33.3%; e.g., “She’s had ongoing anxiety and social anxiety, in particular now, so I think all of the these things kind of just, you know snow balled…”) and sports participation (22.2%; e.g., “It started where she was thinking of joining the track team and she wanted to get in shape”) as triggers.

When “healthy” becomes “unhealthy”

Similar themes were identified when the youth’s behaviors became “unhealthy.” The most common theme was concerns raised by others, such as parents and clinicians (88.9% for youth, 66.7% for parents), followed by loss of control in behaviors or thoughts (66.7% for youth, 100% for parents) and presence of health consequences (55.6% for youth, 33.3% for parents).

Treatment goals

Youth and parents reported four treatment goals that were similar, including having a good relationship with food/exercise (100% for youth, 88.9% for parents), resolution of health consequences (44.4% for youth, 33.3% for parents), and being at a “healthy weight” (33.3% for youth, 22.2% for parents). Having a good body image also emerged as a goal for youth (22.2%) while going back to “normal” was identified as a theme for parents (44.4%; “It will be that [Patient] is eating regularly without having to be told, reminded or forced.”). Youth identified four motivations for recovery: getting better for others (44.4%), physical recovery (33.3%), learning more about the health consequences of the ED (11.1%), and wanting to have a good body image (11.1%).

Barriers to recovery

For youth, the ED itself (100%) was the most common barrier. Other barriers to recovery included receiving comments about food or body from others (77.8%; “when people comment on how much weight I've lost it feels good…”), uncertainty of weight goals (66.7%; “And my mom want me to like gain all that weight back. But from like doctors and stuff I've been told that I don't really need to…”), feeling they are “not sick enough” (55.6%; “Even now I still don’t think, I still have a hard time calling it an eating disorder b/c I know that some people have it and they have it so much worse…”), and beliefs in “normal” weights (44.4%; “I don’t want to gain weight. Like right now I'm not seriously underweight. I'm at like a normal weight. So gaining weight would bring me back overweight and I don't want that to happen…”). Parents identified four barriers to recovery. Most common were mental health concerns (e.g., ED, anxiety, depression; 77.8%). Other barriers were social influences (33.3%), environmental stressors (33.3%), and limited access to treatment (11.1%). Parent attitudes toward treatment was notable for their trust/agreement with their clinician recommendations (55.6%; “…But a range that the medical community at this moment considers normal and that gives her the energy that she needs to do her stuff…”), belief that their child need to have a “normal” weight (44.4%; “I mean to look at him you would never think that he had an eating disorder. He's healthy…”), and uncertainty about weight restoration goals (33.3%; “I think what worries me about the weight gain at this stage is that it could go horribly wrong…”). Both youth and parents reported uncertainty of weight restoration goals and beliefs about youth being in “normal” weights were commonly identified as concerns related to treatment and recovery.

Discussion

This study aimed to identify youth-identified and parent-identified themes related to triggers of weight loss, when “healthy” becomes “unhealthy,” treatment goals, and recovery among youth with AN/AAN and history of ‘overweight/obesity.’ We aimed to use these findings to illustrate the unique experiences of youth with history of growing in larger bodies. The study found that youth with AN/AAN with premorbid ‘overweight/obesity’ may experience a range of internal and external risk factors putting them at an elevated risk for developing an ED. Themes related to weight stigma, youth not feeling “sick enough” for not being low-weighted enough, and desire to be at a “healthy” weight coupled with fear of returning to ‘overweight/obesity’ weight status emerged for youth. Similarly, themes of youth being at a “healthy” weight, belief in “normal weights,” uncertainty of weight goals set by clinicians, as well as agreement with clinicians emerged for parents regarding their attitude towards ED treatment including weight restoration. Understanding both youth’s perspectives and parents’ perspectives on triggers for weight loss, ED treatment goals, and challenges with recovery for those with history of ‘overweight/obesity’ will inform treatment efforts for healthcare providers.

Previous research has demonstrated that weight stigma is highly prevalent among youth with ‘overweight/obesity’ and is one of the key aspects of the lived experiences of this population (Puhl, Himmelstein, & Pearl, [35]). Experiences of weight stigma have been shown to put youth at risk for psychological distress (e.g., low self-esteem, depressive symptoms), maladaptive eating behaviors, body dissatisfaction, and additional adverse physical health consequences (e.g., lower physical activity, substance, weight fluctuations) (Puhl & Lessard, [36]; Puhl, Himmelstein, & Pearl, [35]). These findings from previous research on the general population are echoed in the weight stigma-related themes identified in both the development of an ED and the barriers to recovering from an ED. The themes from the present study showed that adolescents who grow up in larger bodies are likely to identify experiences with weight stigma as a trigger for weight loss and the development of AN/AAN. They reported experiencing internalized weight stigma, pressures of the thin/fit ideal, comments from peers, family members, and/or healthcare providers regarding their body or eating, and weight-based teasing or bullying that led to the onset of developing AN/AAN. Youth also identified positive reinforcement for weight loss as a trigger, emphasizing the potentially harmful impact of praising weight loss in those with larger bodies (Lin et al., [24]). They also identified unintentional weight changes related to illnesses (e.g., viral illness reducing appetite resulting in weight loss) as a trigger for intentional restriction, highlighting the need to closely monitor any unintentional weight loss in this population (Lin et al., [24]). It is important to recognize that youth with history of ‘overweight/obesity’ are at great risk of experiencing exposure to external pressure and internalization of thin/fit ideals, as well as weight stigma, which are common triggers for ED (Hawkins et al., [19]; Thompson & Stice, [39]). Findings from the present study illustrate the significant role of weight stigma in youth with AN/AAN and history of ‘overweight/obesity’ and highlight potential prevention and treatment needs that may be unique to this population. Continued efforts to combat weight stigma are warranted to aid in ED prevention efforts.

Notably, both youth and parents felt that the emergence of health consequences (e.g., dizziness, low energy, and fatigue) helped them recognize that they had crossed the threshold into being unhealthy or disordered. It also helped them recognize the ED when they received concerns from others (e.g., parents and clinicians) and exhibited a loss of control in their dieting or exercise. However, despite being considered moderately to severely malnourished, more than a half of the participants still reported they were “not sick enough,” comparing themselves to a perceived image of someone with AN (e.g., not being low-weighted enough). Feeling that they are not “sick enough” and that individuals with EDs should be sicker or skinnier may lead to continued disbelief or denial of the seriousness of their symptoms, lack of engagement in treatment, and/or a lack of motivation towards recovery (Eiring, Wiig Hage, & Reas, [14]; Harrop et al., [18]). This bias that only those with low weights have EDs may be prevalent also in parents and care providers. Youth with AN/AAN in larger bodies may also experience weight stigma in treatment by healthcare providers (Harrop et al., [18]). In fact, it is a common finding that those with premorbid ‘overweight/obesity,’ who are likely to present with ‘normal’ weights despite significant weight loss, often fail to be diagnosed with an ED (Lebow, Sim, & Kransdorf, [22]). They often have delayed diagnoses and referral to treatment even when there are medical indications for more acute care [1], Jennings & Phillips, 2017). Early recognition and treatment are important for a better chance of ED recovery (Allen et al., [2]), so helping healthcare providers, the general population, and patients understand that EDs can occur at any weight, will be critical for comprehensive care and better recognition of EDs in all body sizes.

Lastly, when thinking about recovering from AN/AAN, both youth and parents expressed a desire for a healthy relationship with food, exercise, and their bodies. However, they also wanted to be at a ‘healthy’ or ‘normal’ weight. Several youth stated that their weight prior to weight loss was ‘unhealthy’ or ‘overweight’ and expressed fear of returning to that weight, now that they had a ‘normal’ weight since the onset of AN. These youth, and even their parents, experience fear of full weight restoration, as it would put them in the ‘overweight/obesity’ weight status again. Both youth and parents expressed a belief in being at ‘normal’ weights. Notably, weight gain is a key focus of family-based treatment (FBT; [26] which has the strongest evidence for treatment of anorexia nervosa for youth (Le Grange et al., [23]). However, a significant limitation is becoming apparent, as not enough data is available to define ‘full weight restoration’ in the higher spectrum of weights, particularly those with AN or AAN whose natural growth trajectories were in the ‘overweight/obesity’ range. Some weight restoration is needed for physical and psychological recovery from malnutrition, but there is a lack of agreement on the extent of weight restoration (e.g., back to a premorbid ‘overweight/obesity’ status vs. stay within a ‘normal’ weight status), as there are concerns about medical and psychological effects of excess weight gain [21, 31, 33]. Thus, evidence is needed for defining medical and psychological recovery for this growing population of youth with AN and premorbid ‘overweight/obesity,’ as there may need to be additional considerations to monitor during their treatment process. Uncertainty of weight goals can lead to disagreement among patients, caregivers, and providers, which may ultimately lower patient engagement in treatment [13]. Regardless, a crucial factor to be aware of when deciding on weight goals for a patient with history of growing up in a larger body is whether we (as the treatment providers, caretakers, or patients) are responding to unintentional, internalized weight bias that may cause us to keep a patient weight suppressed, hindering them from gaining the needed weight to achieve complete recovery from their ED. Furthermore, more research on empirically supported treatment approaches is needed considering these themes related to the development of AN/AAN and attitudes as well as barriers to treatment unique to this population.

This is the first study to explore themes related to the onset of ED, motivation for treatment, and barriers to recovery from both youth and parents’ perspectives among a group of youth with history of ‘overweight/obesity.’ Applying a reflexive thematic approach, the study obtained an in-depth understanding of what may impact the onset of weight loss and treatment of an ED in a very under-studied population of adolescents with AN/AAN and history of ‘overweight/obesity.’ The themes identified in the study highlighted concerns of weight stigma present in this unique and understudied group of youth and may inform future research to help develop evidence-based treatment guidelines for this population.

However, this study has limitations. Although the present study provides an idea of the experiences of adolescents with AN/AAN who grew up in larger bodies, there is a selection bias where these adolescents were connected to ED care and both adolescents and parents agreed to participate in the study. Therefore, the results may not be generalizable to the many unrecognized or undertreated individuals with AN/AAN and premorbid ‘overweight/obesity,’ or those who may not receive familial support for treatment. Because the sample was limited to youth with a new diagnosis of AN/AAN, it is important to note that these themes may not be generalizable to individuals who are further along their recovery from ED. Future studies would benefit from exploring the topics related to attitudes and barriers to treatment among individuals from different stages of recovery to have deeper understanding of their experiences with treatment and recovery. The role of weight stigma prior to the onset of ED and during as well as after ED treatment needs to be better understood to enhance treatment for this unique group of youth who grew up in larger bodies. In particular, further research on the impact of weight stigma on ED recovery and mood, and the identification of factors that decrease weight stigma is needed to inform evidence-based care.

Conclusion

Interviews with youth who were recently diagnosed with AN/AAN and have history of ‘overweight/obesity,’ and their parents, highlighted the importance of considering the unique experiences that affect the onset of an ED, engagement in treatment, and ED recovery. Themes related to weight stigma, in particular, were identified to have led to the onset of weight loss and be a source of barrier to recovery. Weight stigma in youth and parents may affect their attitudes towards weight gain as a treatment goal. They may also experience uncertainty regarding weight goals set by clinicians in treatment due to their history of ‘overweight/obesity.’ More research is warranted to address the evidence-based guidelines for weight restoration and identify ways to address weight stigma in multidisciplinary treatment for this unique and understudied population.