To judge by many public service announcements, eating disorders are diseases that affect young, white females, and mainly involve starvation or binging-and-purging. In reality, these equal-opportunity destroyers vary as much as the people they hurt.
“Eating disorders can affect people of all genders, sexual orientations, races, ethnicities, sizes, ages and socioeconomic backgrounds,” said Dr. Jason Nagata, assistant professor of pediatrics at UC San Francisco’s School of Medicine. “And you can't tell that somebody has an eating disorder just based on appearance alone.”
Nagata says we need to expand our ideas regarding what an eating disorder looks like.
“The traditional questions that we ask in terms of screening or assessment — like fasting or skipping meals, severe restriction of food intake, vomiting, laxatives and diuretics — are all mostly based on the premise that people want to become thin and lose weight,” he said.
But that is not always the case. Consider the growing trend of young men chasing a chiseled torso through high-protein, low-carb diets, muscle-building drugs, supplements and excessive exercise.
“While engaging in muscle building behaviors alone may not necessarily constitute an eating disorder, they may put young people at risk for one,” said Nagata.
One example is muscle dysmorphia, sometimes called “bigorexia” or “reverse anorexia.” A preoccupation with lean muscularity, it’s often linked to obsessive-compulsive disorders.
“Muscle dysmorphia’s official classification as a subtype of body dysmorphic disorder may contribute to the under-recognition of muscularity concerns in people with eating disorders,” said Nagata.
Competition and concealment
Sports in general can easily conceal eating disorders. The same fixation on flawlessness that fuels great athletes can include obsessing about physical dimensions, especially in dance and gymnastics — or in sports like wrestling, where required weigh-ins drive some to crash-diets and dehydration.
“That sort of calorie-tracking, fitness-tracking is really problematic and can really maintain eating disorders; it can spur eating disorders,” said Cheri Levinson, director of the University of Louisville Eating Anxiety Treatment Laboratory.
Levinson and colleagues published research suggesting the app My Fitness Pal may contribute to eating disorders.
She recommends focusing on joyful movement and on giving the body proper fuel to avoid a host of possible ailments. She listed a few.
“Heart health; bone and hormone impacts; gastrointestinal problems; metabolic changes; and, of course, impacts on the brain that come along with starvation,” she said.
But eating disorders extend far beyond starvation, or the familiar anorexia and bulimia. There’s atypical anorexia, which lacks a low weight requirement; binge eating disorder, which lacks bulimia’s purging episodes; and OSFED (other specified feeding or eating disorders), a catch-all for related behaviors that don’t check all the diagnostic boxes for clinical disorders.
“OSFED is actually the most common type of eating disorder,” said Levinson. “Prevalence rates are around 10%. And it is as impairing and harmful as the other major subtypes.”
Around 40% of people in the U.S. engage in disordered eating — unhealthy patterns like stuffing down emotions or snacking out of boredom.
Standards and sickness
In short, eating disorders encompass a wide spectrum of behaviors and demographics. But conventional wisdom and diagnostic tests don’t always keep pace.
“Prior medical guidelines and guidelines required that loss of periods be a requirement in anorexia nervosa,” said Nagata.
Such standards can contribute to the stigma felt by men who need help.
Nagata says too little attention is also paid to how eating disorders affect another underdiagnosed group: the LGBTQ community, members of which already face discrimination and barriers to healthcare .
“When one's sex assigned at birth is mismatched with one's gender identity, that can exacerbate some of the struggles with these gendered norms in society,” he said.
Transgender men who are assigned female sex at birth might engage in disordered eating to suppress menses, and cultural body ideals might push transgender women who are assigned male sex at birth to lose weight at any cost.
Though more research is needed, Nagata says it’s clear that disorder diagnoses are “quite elevated” in transgender populations.
They are even more elevated in a population that might surprise people who associate eating disorders with the waifish.
“Ninety percent of people with an eating disorder are either normal weight, overweight or obese category,” said Levinson. “So people of all body sizes get eating disorders.”
So, too, do people of all ages.
“Many of these individuals are 50-plus, 65-plus; some have never been diagnosed — their entire life, they’ve struggled with an eating disorder,” said Jean Doak, clinical director of the UNC Center of Excellence for Eating Disorders.
Sometimes, menopausal drops in estrogen levels cause weight gain; social changes that attend growing older can affect behavior, too.
Either way, change is challenging.
“Seeking treatment at that age is incredibly commendable. I can't imagine what it would be like for an older individual to navigate these unchartered waters,” said Doak.
Hurdles and health
But the alternatives to navigating those waters are dire: In the U.S., eating disorders kill someone every 52 minutes and drive higher suicide rates.
Unfortunately, treatment centers in rural states are as rare as hen’s teeth. Most are private, and many don’t accept federal and state programs like Medicaid.
“If you have state insurance, or you don't have commercial insurance, and you have an eating disorder, it is very, very, very difficult to get residential or inpatient treatment,” said Levinson.
For those who successfully run the insurance gantlet, treatments can range from 24/7 inpatient care to outpatient cognitive behavioral therapy.
And treatment can work, especially if patients start early, stay in treatment and arrive motivated to make changes in their lives.
“Now, motivation for change isn't necessarily the same as a willingness to immediately let go of all eating disorder behaviors, that's a process and a journey unto itself,” said Doak. “But just having that motivation for change — for something to be different in an individual's life — is a great factor that can lead to an improved prognosis.”
Ultimately, addressing eating disorders means confronting their social, cultural and psychological origins and removing the stigma and systemic hurdles that stand between people and the help they need.
Unfortunately, a distorted, Photoshopped reality still awaits patients at the checkout line or on Instagram.
“I just think about the messages that’s sending our kids and adolescents: that people are supposed to be thin, and that we're all supposed to have these thin bodies,” said Levinson. “That’s just not reality; bodies are supposed to have the same type of variation and the same type of diversity that we see in really all human characteristics.”
