What We Want You To Know About Eating Disorders

It is problematic that when we think of the words “eating disorders” we are still more likely to conjure an image of an emaciated, white, cisgender female body than a trans body or a brown body or a fat body. We, as advocates, have a long way to go to change the conversation. The Marginalized Voices Project from NEDA highlights the true diversity of eating disorder expression. Marcella Raimondo, Ph.D., MPH has written about some of the data about marginalization and eating disorders:

“The National Eating Disorders Association’s Marginalized Voices campaign is confronting the prevailing myths about who struggles with eating disorders, underscoring that everyone’s experience is equally as valid and deserving of care and recovery. 

  • Black teenagers are 50% more likely than white teenagers to exhibit bulimic behaviors, such as bingeing and purging. 
  • A 2014 study found that rates of disordered eating have increased across all demographic sectors, but at a faster rate in male, lower socioeconomic and older folks.
  • Transgender college students were significantly more likely than members of any other group of college students to report an eating disorder diagnosis in the past year – 2015 study.
  • Teenage girls from low income families are 153% more likely to struggle with bulimia than girls from wealthy families.
  • Only 20% of those with eating disorders fit the “emaciated body” stereotype.”

When conversations about inclusion show up in any setting, there is often a retraction into the potential for fear and loss in the community that has been dominant. In the eating disorder treatment world, there is a concern that folks who do fit the false, but traditional, diagnostic categories of anorexia will be forgotten – or their treatment will suffer – if more inclusive perspectives and modalities become available. This is such a false dichotomy. 

Is it be possible that the push for body inclusion in the eating disorder treatment community could improve care for everyone? What if it would help with primary prevention? What if modalities became bigger and better? What if inclusion is not a loss, but the only path to body liberation for every body?

We have assembled a list of 10 things about eating disorders that we are not always exposed to in dominant culture. We hope this is a simple and handy educational tool to share wherever you may find it useful.

Here are 10 things we want you to know about eating disorders:

  1. You cannot tell by looking at someone if they have an eating disorder. Eating disorders affect people of every size, shape, gender, age, race, and socio-economic status. They are not limited to thin white women. You can learn more here.
  2. Weight is never the best indicator of eating disorder status, although these things are commonly conflated. We know, through clinical practice, that people with higher body weights can have extremely restrictive eating patterns and would meet criteria for anorexia nervosa despite the diagnostic criteria mentioning “underweight” as a feature of anorexia. This article (which links to a valuable podcast interview with Body Trust® Provider Dr. Rachel Millner) discusses “Atypical Anorexia” (terrible label) or “Higher Body Weight” Anorexia which needs more understanding and attention.
  3. Binge eating disorder (BED) is the most common of all eating disorders and has only been recognized formally as an eating disorder since 2013. BED is the eating disorder most commonly seen in cisgender men. Behavioral weight loss was, and still is, a common treatment for BED. A focus on weight loss is contraindicated for anyone with an eating disorder, present or past and this does not exclude BED. The National Eating Disorder Association is the best resource for helping professionals and patients to learn more about BED.
  4. Dieting is a risk factor for an eating disorder. The younger a person starts dieting, the more likely they are to develop an eating disorder (Neumark-Sztainer, 2006).
  5. For people assigned female at birth, the onset of menses and menopause may be the highest risk times for the development of an eating disorder. In preparation of the onset of menses, a young person gains about 15 pounds. The individual, their parents and the medical community often pathologize this normal, natural change in body shape and weight. Dieting behaviors often begin around this time, setting the person up for a lifetime of weight cycling and disordered eating. People going through menopause also receive negative messages about the protective weight gain that happens during this period of life. Margo Maine says “Instead of thinking of this as our spare tire, we need to think of it as a life preserver.”
  6. Every organ in the body is impacted by an eating disorder and many physicians do not have adequate training to provide the kind of care someone with an eating disorder needs. Look for providers that specialize in treating eating disorders, and be prepared to educate the person’s physician if you cannot find a specialist. Here is a PDF with information for conducting a basic physical exam for patients with eating disorders.
  7. Orthorexia, an obsession with food quality and purity, is recognized by most providers in the eating disorder treatment community but currently does not have diagnostic criteria in the DSM-5. Research is currently being conducted on this preoccupation with healthy eating. Some with a recognized eating disorder pass through orthorexia on the way to full recovery.
  8. The standard of care for eating disorder treatment is to take a “team approach” and we see this most commonly in the treatment of anorexia and bulimia. The treatment team typically includes a physician, psychiatrist, dietitian, and therapist, all of whom specialize in eating disorders. The physician monitors the patient’s weight and vitals to make sure they are medically stable. The psychiatrist manages and monitors medications. The dietitian works to normalize eating behaviors while improving relationship with food/body and challenging eating disorder thoughts. And the therapist addresses the underlying issues at the root of the eating disorder: body shame, trauma, emotional regulation, while supporting the changing relationship with food and body. Sometimes several therapists may be working with one patient—one for individual therapy, one for family therapy, one specializing in trauma and so on. The team communicates regularly to keep each other in the loop and make sure the patient is receiving consistent messages across team members.
  9. Many patients need a higher level of care to help with eating disorder recovery. This treatment could be inpatient (hospital), residential, or an intensive outpatient program. You can read more about the different levels of care here.
  10. It takes many people seven to ten years to fully recover from an eating disorder. Living in a world steeped in diet culture and weight bias is likely one reason for the amount of time needed to truly heal.

The National Eating Disorder Association is an excellent resource for more information on eating disorders. Familiarize yourself with the diagnostic criteria for anorexia, bulimia, binge eating disorder and OSFED (a category for eating disorders that don’t quite fit the other categories). Knowing the criteria, limits and exceptions to meeting diagnostic criteria for an eating disorder can be helpful, particularly when communicating with other healthcare professionals.

You might also take a look at the efforts of the Eating Disorder Coalition, an organization working to advance the “recognition of eating disorders as a public health priority” in the United States.

In Body Trust,