Eating Disorders: The Rest of the Iceberg

Picture a person with an eating disorder.

Who did you see?

If you’re like many people I ask this question of, you might have imagined an emaciated, young, white woman. Fashionably dressed. Yet this is only the tip of the iceberg. And if I got any part of what you conjured up correct, then this free association exercise tells me that my field is not doing enough to educate about what lies beneath the surface, the full range of eating disorders and the array of people who experience them.

Let’s say your image was of an underweight person. Did you know that anorexia nervosa is the most uncommon of the eating disorders, affecting just 1% of the population? Despite its cultural cache, rates of anorexia nervosa are very low and incredibly stable. Bulimia nervosa is more common and binge eating disorder is more common still. In fact, the majority of people with eating disorders are normal or above average weight. This includes individuals with atypical anorexia nervosa who have lost to a weight that is underweight for their body’s needs and experience the psychological elements of an eating disorder. Conversely, anorexia nervosa is not the only eating disorder associated with being low weight. Avoidant restrictive food intake disorder (ARFID) is also characterized by highly restrictive eating resulting in low weight. People with ARFID are not limiting foods due to fear of fat or concern about appearance, but rather because of texture or color, lack of familiarity, or fear of choking.

If your image was of a young person, then it’s borne out of truth, but a narrow version of it. The peak age of onset for anorexia nervosa and bulimia nervosa is between ages 15 and 25, but ARFID tends to start earlier, in childhood, and most people with binge eating disorder are well into their 30’s or 40’s when they first present for treatment. In the US, eating disorders affect around 2.5% of people over age 40. Research on late-onset eating disorders in women suggests that the transition of menopause may be conceptualized similarly to puberty as a critical risk period associated with biologically-driven changes in appearance.

Did you imagine a white person or a person of color? Each of the six formally defined eating disorders has been described among individuals of all racial and ethnic groups. There is growing evidence of eating disorders among black and Latino populations, despite some differences between these and white, non-Hispanic groups in body satisfaction and drive for thinness. In Asia and Asian communities within the US, anorexia nervosa is well-documented, though there are variations in if and how this group describes a phobia of fat. We need more research, but we know enough to say that eating disorders, on the whole, do not distinguish by race or ethnicity.

If your image was a woman, you’re not alone. As I’ve written previously, many people assume that as an eating disorders clinician, I only treat women. While eating disorders, like many anxiety and mood disorders, affect more women than men, binge eating disorder is about as common in men as women, and men represent between one-tenth to one-fourth of the cases of bulimia nervosa and anorexia nervosa. The ratio of males to females among youth with eating disorders, including ARFID, is a bit higher than in adults. Moreover, research underway on eating disorders in transgender people indicates that body dissatisfaction, core to the distress transgender people experience, puts some of them at risk for disordered eating behaviors. In transgender youth, initial reports suggest that gender-related harassment and discrimination increase the odds of binge eating and fasting or vomiting to lose weight, while peer and family support are protective factors.

Perhaps you imagined someone in designer clothes. Many people believe that eating disorders are only a problem for the wealthy. Within the US, however, these disorders are broadly distributed across socio-economic categories. In 2010, anorexia nervosa and bulimia nervosa were added to the list of problems assessed by the Global Burden of Disease Study and out of over 300 physical and mental disorders, they recently ranked as the 12th leading contributor to health burdens in high-income countries, and 46th in low- and middle-income countries. Eating disorders are having an impact across the wealth spectrum.

Stereotypes about eating disorders persist due to outdated information, and they get reinforced by biased portrayals. Ultimately, this contributes to delays in diagnosis, in treatment-seeking by those affected (or referrals by clinicians), and in establishing new pathways for services in impacted groups with poor access to care.

This National Eating Disorders Awareness Week (aptly themed Come as You Are) it is critical to check old assumptions at the door and try on the latest facts: eating disorders do not discriminate by weight, by age, by race or ethnicity, by gender, or by wealth. Because picture this: there are more people out there who need treatment for their eating disorder than you or I can imagine.

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