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  • Alternate Character Interpretation: Cassie was the book's real villain. She introduced Lia to the obsession that would destroy her body and ruin her adolescence, then blamed Lia for being the bad influence when Cassie herself slipped up enough to draw her parents' concern. Her very last words for Lia are far more haunting, and far more indicative of how much of a Toxic Friend Influence she was, than any of the things Lia's subconscious had spoken through the "ghost" Cassie's mouth.
  • Angst Aversion: Lia is a very dark and depressing heroine and her struggle gets a lot worse before it gets better.
  • Anvilicious: The book is not at all subtle about just how badly eating disorders can mess people up. Aside from the clear physical degradation that Lia's body goes through, the constant lying and manipulation Lia has to do in order to make it all happen paint a very bleak outlook, and repeatedly hit the reader over the head that anorexia, bulimia, and other such eating disorders can and will destroy one's life. However, that didn't stop some pro-anorexia supporters from taking the wrong message from it anyways.
  • Base-Breaking Character: Lia herself. Some find her a fantastic and complex character whose descent into self-destruction is clearly justified by her mental state, the struggle with anorexia and self-harm that's defined her adolescence, and the bombshell dropped on her at the start of the novel. Others find her a whiny, unsympathetic rich kid who created most of her own problems.
  • Crosses the Line Twice: Elijah bailing on a mentally unstable Lia and leaving her alone in the same hotel Cassie killed herself? Dark, even though his intentions were good. Elijah casually mentioning that he'd stolen the cash she'd withdrawn for their great escape on his way out, save $20 for her cab fare? A little bit amusing. Even Lia doesn't seem to hold it against him.
  • Draco in Leather Pants: Lia is very popular in some pro-anorexia circles. Not the Lia who realises how much she wants to live, gets better at the end, and begins the healing process, but the one who masterfully fools her way through rapid, unhealthy weight loss, meticulously controls her calorie intake to minimalise weight gain, and resourcefully tricks her family into thinking she's in recovery by tampering with the scales and inflating herself before weighing.
  • Fanfic Fuel:
    • If Lia and Elijah ever met up again, what would they say to each other? What could Elijah be doing with his life after he ran off? How would he react to Lia's recovery? Would it be possible for them to have a romantic relationship?
    • Lia drifted away from her other friends before Cassie's death, but some of them are shown to still be friendly to her. Could she reconnect with them?
    • Emma is only in third grade, but Jennifer's Education Mama tendencies are already showing, pushing her into sports, violin lessons, and conversational French while worrying about her weight. Could Emma develop her own issues with her mother as she grows older, as Lia and Cassie did with theirs?
  • Fridge Horror: Before Cassie was 9, something bad involving a boy happened to her in her old neighborhood, implied to be some kind of sexual harassment or even assault. Later when she's in fifth grade, her father blames and yells at her for beating up a boy who snapped the back of her bra. Considering the kind of person this incident shows him to be, it's possible he blamed and punished her for the undescribed previous incident as well, whatever it was. Poor girl.
  • Hard-to-Adapt Work: No adaptations of this book have yet been made or even attempted, likely because Lia's struggle with anorexia would be highly difficult (and Nightmare Fuel-inducing) to realistically portray in a live-action film, or any other media format besides text. However, the existence of the film To the Bone, which deals with similar subject matter, might mean that a Wintergirls adaptation isn't totally impossible.
  • It Was His Sled: Cassie's exact cause of death is a mystery to Lia for much of the book, but is so representative of the book's themes that it's mentioned casually in many synopses of the novel.
  • Jerkass Woobie: Cassie has shades of this. She died alone, messily, and in considerable pain, futilely reaching out in her last hours to a friend she'd abandoned and blamed all her problems on. Lia and Elijah might also qualify.
  • Memetic Mutation: Must. Not. Eat.Explanation 
  • Misaimed Fandom: A major one. Some pro-anorexia circles consider this book their bible, and glamorise Lia's struggle while conveniently leaving out the physical and emotional suffering this condition has brought her. Anderson herself was horrified and infuriated with this interpretation. The book goes into graphic detail about not just what anorexia does to Lia's body (which is scientifically accurate, at that), but also how Lia's webs of lies about how she's supposedly beaten anorexia but continues with it anyways end up destroying her family. There's even a chapter containing only the words "Must. Not. Eat." over and over again, repeated over a hundred times as a Madness Mantra to show that Lia is undergoing Sanity Slippage from being so underweight and stressed out by what she's done to the people she loves. But pro-ana readers take it as a Survival Mantra, using the book to glamorize anorexia, and completely ignore the consequences on Lia's health and family life her anorexia has. Finally, in the ending, Lia ultimately begins to actually recover from her eating disorder, realizing that it came dangerously close destroying Lia's life as it did her best friend Cassie, who died an Undignified Death, alone in a hotel room. In short, the ultimate message of the book is that anorexia will ruin your life and it needs to be cured as soon as possible. So the fact that pro-ana followers use this book as a "how-to" guide goes directly against what the author was saying and completely ignores how terrible one's life will become if they go through with it.
  • Nausea Fuel: Doctor Marrigan's report on Cassie's death is nothing short of revolting. And entirely realistic.
  • Nightmare Fuel: Lia's mental breakdown is not pretty.
  • Too Bleak, Stopped Caring: It can hard to root for Lia. Her struggles with her eating disorder are meant to be sympathetic, but the way she's been lying to her family is not, meaning the book has to walk a very fine line, and sometimes steps over it. It was possibly an Intended Audience Reaction to find Lia hard to root for, but her family isn't much better, given her stepmom came into Lia's life due to a Shotgun Wedding from getting pregnant, and the divorce from Lia's dad hasn't exactly provided a stable space for Lia, Emma, or anyone else. But the fact that Lia continues to lie even after seeing firsthand how bad things are getting, including self-harming herself into unconsciousness and traumatizing her step-sister in the process, as well as how badly everyone around Lia treats her, and the book can be a chore to get through because there's very few breaks from all the trauma.
  • Unintentionally Unsympathetic: Lia for some readers, given that she constantly lies to the people around her and resists their efforts to help her recover. Though this was possibly an Intended Audience Reaction, given that the main conflict of the book is her struggle against her own self-destructive impulses. It is notable that several other characters, most notably her parents and stepmother, openly call Lia out for her lying and self-destructive habits that are taking their toll on not just her, but the entire family.
  • The Woobie: Subtly, but a case could be made for Lia's mother Dr. Chloe Marrigan being this trope. She had a Shotgun Wedding to Lia's father after getting pregnant and spent several years in a loveless marriage with him, during which he cheated on her with at least four or five other women, before they finally got a divorce. In the present, she lives alone and her relationship with her daughter is so troubled that Lia doesn't even want to spend a week of Christmas break at her house. Her job as a cardiologist is implied to be highly stressful and she has no one to support her when things get hard. To drive the point home, her house is covered in halfhearted attempts at redecoration and her garden hasn't been taken care of in a long time and is overrun with dead plants.

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