Disparities in Eating Disorder Diagnoses and Treatment

Eating disorders are notoriously difficult to diagnose and treat. Sadly, it is estimated that up to 45% of people with eating disorders never receive treatment.1 Some people live nearly their entire lives with an eating disorder that slips detection by a doctor, friend, or family member. Or, loved ones do approach them about their eating habits, and the person decides not to pursue care for a wide variety of reasons. Disparities in eating disorder diagnoses and treatment can be one reason why they don’t get the care they need.

Despite the complications with diagnosing and treating eating disorders, the importance of getting professional help and medical care cannot be overstated. Eating disorders are serious- anorexia nervosa has the highest mortality rate of any psychiatric illness. Anorexia and other eating disorders can manifest a lifetime of physical and mental problems, like chronic malnutrition, osteoporosis, muscle wasting, weakened immune system, and more. Everyone struggling with an eating disorder deserves to get the care they need to recover.

Unfortunately, like healthcare as a whole, significant disparities exist when it comes to getting treatment for eating disorders. The signs of eating disorders often fly under the radar, and many who struggle with disordered eating resist receiving help. Additionally, eating disorders are typically thought of as an issue only young white women deal with, which can lead to missed diagnoses when eating disorders are present in other groups.

The lack of access to physical and mental health care also ensures that certain groups are less likely to receive treatment for eating disorders and other serious illnesses. Today’s post discusses the disparities that occur in eating disorder treatment, which is not a super fun, lighthearted topic. But it affects people of all kinds every single day, so listen up!

What Causes Eating Disorders?

In short, finding the origin of eating disorders proves complex. Eating disorders can arise because of the culmination of many factors, and it’s difficult to pinpoint casual relationships.

We do know, however, that people who begin dieting young have a much higher risk of developing an eating disorder. According to the National Eating Disorders Association, 14- to 15-year-olds who diet “moderately”, are 5 times more likely to develop an eating disorder.2 Those who practice more extreme dieting and restriction are 18 times more likely to develop an eating disorder.

Yeah, don’t diet.

So yes, dieting is a risk factor for disordered eating. And dieting at a young age is not uncommon. A study from 2015 found that 1 out of 4 kids under the age of 7 have been on a diet. Additionally, 1/3 of boys and most girls between ages 6-8 wanted their bodies to be thinner.3 This huge number of little ones that are dieting, or wishing their bodies were different, puts a significant chunk of people at risk for developing full-blown eating disorders later in life.

Other risk factors for developing disordered eating, besides dieting at a young age, include:

  • Having a close relative with an eating disorder or other mental illness
  • Feeling body image dissatisfaction
  • Having a personal history with anxiety and anxiety disorders
  • Struggling with perfectionist tendencies
  • Displaying behavioral inflexibility
  • Having a history of trauma or a high ACEs score
  • Being teased or bullied about weight or looks
  • Many, many more.

For a fuller list of eating disorder factors, check out NEDA’s list and video on the subject. Quite a bit of this information feels pretty intuitive. It makes logical sense that a person who feels body dissatisfaction or was/is teased about their weight might resort to disordered eating patterns.

So many people struggle with body dissatisfaction, but it doesn’t have to be this way!

Anyone can have these risk factors, and anyone can develop an eating disorder. Eating disorders are not reserved for a certain type of person who looks a particular way or had a specific type of childhood. Most of us know this consciously, yet we can’t help but picture a stereotype about who gets eating disorders. Let’s explore that in more detail.

The Typical Depiction of Eating Disorders

When most people reflect on who might have problems with disordered eating, they tend to think of young white women. I reflected on characters from TV shows, movies, or books that discussed disordered eating, and I could only think of young white women. DJ Tanner, for example, from Full House went to great lengths to lose weight, sucking on ice cubes instead of eating a meal. Or of Ellen from the movie To The Bone, a film about anorexia nervosa. Most of the disordered eating memoirs I have read were also written by white women.

While it’s true that many young white women do have disordered eating tendencies, thinking they are the only ones who do develop eating disorders is a mistake.

Disordered eating and eating disorders are not reserved for a certain type of person. Anyone, regardless of race, sex, size, weight, religion, socioeconomic states, etc. can get an eating disorder. Doctors, registered dietitians, and other healthcare professionals must understand this fact, and they should know about the signs and symptoms that point toward disordered eating. Too many people with eating disorders fall through the cracks and never get the help they need.

Unfortunately, many healthcare professionals and people in the general public may look at a person who doesn’t encompass the “eating disorder aesthetic” (aka, isn’t a young, white women), and dismiss any signs or symptoms that might be more obvious in a young female. Let’s talk about some of the myths and disparities that exist when it comes to eating disorder treatment in a bit more detail.

Types of Disparities in Eating Disorder Diagnosis and Treatment

There are several characteristics and attributes that can affect how a person views the world, and how the world views a person. As a result, people who look a certain way, or have a certain identity, may be less likely to receive medical attention for all different kinds of conditions, including eating disorders. There are a nearly limitless amount of factors that can affect a person’s chances of receiving help, and today we will cover body size, race, sex, gender or sexual identity, and socioeconomic status.

Body Size

One common misnomer is that only small or thin people have eating disorders. That is definitely not true. People of all sizes can have disordered eating tendencies, whether it’s skipping meals, binging and purging, or trying to eat a “perfect diet”. In fact, one majorly messed up thing about diet culture is that people in larger bodies that display disordered eating are often praised for their efforts to “get fit”.

“I see you’re eating tiny meals and exercising A LOT. Good job, way to take care of your health”, “Have you lost weight? Whatever you’re doing, keep it up. You look great”, or “You’re willpower is really admirable. I have noticed you aren’t eating any of the desserts at this potluck, and I think it’s great that you’re working so hard at this,” are all common phrases thrown at people in larger bodies when they might display disordered eating practices.

These “compliments” can come from friends, family members, coworkers, and even healthcare professionals. Some doctors will praise their patients in larger bodies when they admit to eating less than 1200 calories in an attempt to lose weight, because they often believe that stringent calorie counting and losing weight are the only means for improving one’s overall health.

While we are discussing size, please refrain from verbally observing someone’s body size at all times. Avoid complimenting someone on their weight loss, because you don’t know if they are using unhealthy or disordered practices to achieve it. Receiving compliments about one’s body reinforces the idea that smaller bodies are “better”, and that we should do everything we can to shrink ourselves.

On the other end of the spectrum, don’t gossip about how so-and-so looks “anorexic”. That person could be struggling with an eating disorder, sure. But maybe they are dealing with food insecurity issues, or have other health problems that are none of your business.

Eating disorders don’t care what size a person’s body is; they want to take over your life no matter what your body looks like or how much you weigh. Doctors and other healthcare professionals must look for signs and symptoms of eating disorders in people with larger bodies as diligently as they would for those in smaller ones.

Racial Identities

As discussed earlier, discrimination is a huge deal in the medical system, and racial discrimination is incredibly prominent within it and every other facet of life. Some evidence-based examples of racial discrimination within healthcare can be found in the administration of pain medication and the mortality rates of mothers giving birth.

Doing research for racial discrimination in the medical field made me feel like I was trapped in the 1800’s. It’s the 21st century, but black women in America are over 30 are 4-5 times more likely to die during child birth than white women of the same age.4 Black women with a bachelor’s degree or higher are 5.2 times more likely to die while giving birth than college-educated white women. Pregnancy-related deaths among Alaska Native/American Indian women are approximately 2.3 times higher than white women, too. On top of that, these disparities didn’t change much, if at all, between 2007-2008 and 2015-2016.4

Generally, ethnic minority groups are less likely to have access to health insurance, and as a result, are less likely to receive medical attention. Even if a person of color has access to health care, that still doesn’t mean everything is simply hunky dory. Many groups of people who don’t identify as white are not monitored as carefully as their white counterparts. This applies to pregnant women who need regular and close monitoring, but whose medical complaints and concerns are often dismissed.5

Those dismissals can have very real and serious consequences. For example, one study monitored the rate at which patients of different ethnicities are given pain medications when they complain of pain. An impressive meta-analysis that compiled data from over 20 years showed that black patients were about 22% less likely than white patients to receive pain medication.6 Why?

One survey found that half of young medical residents and trainees had at least one false belief about black people feeling less pain. Some claimed that black skin was thicker and had fewer nerve endings. Others stated that black people’s blood coagulated more quickly.7 To be clear, this makes no biological sense. These beliefs, however, can lead to some patients getting pain medication, while others are left to suffer for absolutely no reason other than their appearance. Some healthcare providers also inadvertently view non-white patients as non-compliant or fussy when they complain about their pain. That’s messed up.

Ever since working in a hospital during my dietetic internship, it was clear to me that racial disparities exist. Evidence from the studies and meta-analyses above show that these disparities aren’t simply anecdotes or stories people tell themselves or one another. They’re real.

How do these disparities translate to specifically disordered eating? There aren’t a ton of studies that focus on disordered eating treatment and racial identities. Fortunately, one 2006 study did investigate the differences in eating disorder diagnoses among those of different ethnicities.

91 healthcare professionals received a case study that depicted a patient displaying problematic and disordered eating behavior. Mary, the hypothetical patient, was described as white to some clinicians, and as hispanic or black to others. After reviewing the case study, the professionals were asked if they thought Mary had any problems, and what they were if they agreed. Of the clinicians who were told Mary was white, 44% of them saw her behavior as problematic. 41% of clinicians who read that Mary was hispanic also said yes to this question.8

Oddly, or not so oddly, only 17% of professionals decided that the behaviors listed were problematic when Mary was a black patient. When Mary was black, clinicians were also significantly less likely to recommend that she should get professional help.8 This study does a good job of illustrating how clinicians can miss signs and symptoms of eating disorders simply because a patient, hypothetical or real, might not fit their mental image of what an eating disorder patient may look like.

Now, the vast majority of doctors wouldn’t purposely misdiagnose or ignore signs and symptoms in patients just because of their race. But, primarily associating disordered eating with a very specific type of person skews a person’s perceptions about who needs help.

I would never claim to be an expert on the topic of health disparities among racial lines, but I believe that being aware of these issues is important for people of all races to understand and recognize. This stuff runs deep and has a tremendous effect on the quality of life of people everywhere. These are just a couple of the thousands of examples where racial disparities exist in healthcare, and it is a huge, overwhelming, horrible issue.

If you would like more information from actual experts on these topics, please check out the following:

Sex

Few people associate eating disorders with males, but men are not immune to eating disorders. In fact, males make up about 1/3 of the people who struggle with eating disorders. Approximately 10 million men in America will have an eating disorder at some point in their lives.9

Eating disorders in all populations are incredibly serious, and early intervention is important for anyone struggling. Males with eating disorders, however, have a higher mortality rate than females with eating disorders, a group with already high mortality rates.9

Some men and boys have eating disorders because they desire to lose weight and become thinner. They may employ fasting, excessive cardio, binging and purging, abusing laxatives, or other means to shrink their bodies. Other boys go to great lengths to gain weight, specifically in the form of muscle.

According to NEDA, 90% of boys who exercise do so because they want to “bulk up”.9 I don’t have personal experience about being a young boy in America, but I did hear some of the boys in my class undergo body scrutiny because of their “chicken legs” or “skinny arms” by other kids and some adults. Other boys are scrutinized for being short, having a larger body, or anything else.

Clearly boys and men deal with unnecessary and harmful body observations like girls and women do, and I can see why some males aspire to gain muscle. That can eventually become slippery slope, descending into disordered eating. This is also true for young male athletes who might be berated by a coach or parent to work out and gain muscle for sports-related reasons.

Eating disorder treatment disparities exists among males largely because their symptoms are much less likely to be detected by a healthcare professional, friends, or family members than a female’s eating disorder symptoms. Additionally, males are significantly less likely to seek out eating disorder treatment.10 This isn’t just true for eating disorders, it’s true among males with other mental health issues as well.

It seems to be less culturally “acceptable” for a man or boy to admit to friends, family members, or healthcare professionals that they struggle with an eating disorder or mental illness. Plus, a significant lack of public awareness that eating disorders are a male issue too has led many people naively believing they shouldn’t be concerned about boys who display unhealthy eating behaviors or spend way too many hours in the gym.

Females are about 5 times more likely to receive a diagnoses and 1.5 times more likely to get treatment than males are for disordered eating.10 There is a silver lining for men and boys who do receive treatment for eating disorders, though. In general, males respond to eating disorder treatment about as well as their female counterparts. That number is sadly still not super high, but at least males do not fare worse than females in treatment.

Nevertheless, I have hope that eating disorder treatments will continue to become more and more effective. Awareness of these issues will hopefully lead to increases in eating disorder prevention efforts down the road. We have to make sure we do not continue leaving young men behind when it comes to getting the help they need for eating disorder treatment.

LGBTQ+ Identities

Unfortunately, LGBTQ+ folks see lots of disparities in healthcare. Eating disorders are no exception, which is highly problematic given the fact that some in the LGBTQ+ community have a higher likelihood of developing eating disorders.

Increased stress and trauma from prejudice and discrimination can heighten one’s risk of developing an eating disorder. According to NEDA, about 33% of LGBTQ+ youth that are homeless or in the care of social services have experienced violent assaults after coming out. Sadly, up to 42% of homeless youth are in the LGBTQ+ community as well.10

Up to 42% of males with eating disorders identify as gay, despite gay males only comprising about 5% of the male population. Additionally, gay males are about 12 times more likely to purge than heterosexual males.5

Adult lesbians also struggle with disordered eating at alarming rates. About 66.7% of lesbian adults had major risk factors for developing an eating disorder, and 34.7% have been diagnosed with an eating disorder at some point in their lives.6 Transgender and nonconforming individuals also express higher rates of eating disorders than the general population, though research in this area is still very limited.

Disparities in treatment for eating disorders, and mental health in general, are common among the LGBTQ+ population. For starters, many individuals in this community lack health insurance and are unable to receive routine medical care. Mental health care can be even harder to come by, as even those who have health insurance may still not have access to counselors, therapists, or psychiatrists. Those in the LGBTQ+ community often deal with widespread stigma that can have lasting physical and mental health effects.

Many LGBTQ+ individuals are hesitant to visit doctors and other clinicians too, especially if they have endured disrespect when receiving medical care in the past. This highlights the importance of education on communicating with those in the LGBTQ+ communities for medical professionals. This could include information about using proper pronouns and correcting common myths people may believe about these groups. Building a sense of trust between a doctor and patient is critical to helping patients get what they need.

To end this section on a high note, some studies have found that people who feel well connected to a community report lower levels of eating disorder behavior, anxiety, and depression.10 Logically, it makes sense that feeling like you have support, and that other people have your back, would reduce risky behavior and mental health issues. But the fact that data confirms it is promising, and it shows just how important it is for everyone to be supported, especially those in the LGBTQ+ community.

To read more about disparities in healthcare among LGBTQ+ folks, check out this post from Cigna.

Socioeconomic Status

Only rich people get eating disorders, right? Wrong. It may be tempting to believe that those with lower incomes don’t succumb to eating disorders, but once again, eating disorders don’t discriminate.

One risk factor for developing an eating disorder is negative calorie balance. When a person doesn’t get enough calories throughout the day, it can trigger physiological and psychological changes that may make a person more likely to fast or avoid eating. This might go back to our hunter-gatherer days, where a negative calorie balance told our biological systems that food supplies were low. As a result, our body tries to “help” by whispering to us that we should eat less to conserve food resources. This isn’t true for everyone in negative calorie balance, of course, but it may provide an explanation for some people’s experiences.

Negative calorie balance can occur because a person purposely diets, or because of food insecurity. Food insecurity often leads to people skipping meals or eating less than they should because there isn’t enough food for the entire family. One common theme I hear when working with parents of low incomes is that they often skip meals themselves, so that they make sure their kids have enough to eat. It’s heart-breaking.

Psychologically, being food insecure can lead to anxiety and a poor relationship with food and their body. Individuals who are food insecure struggle with binge eating disorder, purging, and overexercising at higher rates than those who are not food insecure.11 Body image issues also arise, as people in larger bodies are often victims of weight stigma. Those of low incomes carry awareness that others often perceive them as “poor, fat, and lazy”. This is a sentiment I also hear regularly from some of my participants, and it always knocks the wind out of me.

When it comes to eating disorders, those with lower incomes have a very small chance of being diagnosed with an eating disorder or receiving any kind of treatment. For starters, many people in lower income brackets don’t have health insurance, so they don’t have access to regular doctor’s visits or mental health screening and care. As a result, many people never see a doctor unless they have to go to the emergency room and pay out of pocket. Those kinds of medical bills can wipe out savings and create a mountain of debt.

If a person with a lower income is lucky enough to see a doctor that properly diagnoses an eating disorder, they may be referred to an in-patient eating disorder clinic. Several of these facilities exist in the United States. Their goal is to help people recover from eating disorders in a comprehensive way.

Unfortunately, a bed at an eating disorder clinic often costs thousands of dollars, and many don’t accept insurance. Many of these facilities produce a façade of a tranquil, spa-like atmosphere, allowing them to charge high fees, and attract affluent clientele. That’s just not an option for most people, so this kind of care is only reserved for a select few.

An extended stay at an inpatient eating disorder clinic is not the only way to recover from an eating disorder, of course. Even still, genuine mental health care is costly, and patients sometimes receive bills of $100 or more for one session with a counselor or therapist. Again, only the most affluent among us can afford these life-changing, much-needed services.

Thankfully, people are slowly but steadily realizing the importance of mental health care, especially among those struggling to make ends meet. There is no simple solution to these disparities, but increasing access to fresh and healthy food would be a fantastic start. Ensuring that everyone and their families regularly has enough to eat would work wonders on preventing disordered eating that arises out of food insecurity.

If food insecurity speaks to you, see if you can volunteer at your local food pantry or food bank. Volunteering can allow us to feel more connected to our community, and it allows us to see the struggles people all around of face on a regular basis. It is humbling to say the least, and it can provide us with a better understanding of what we can do to make the world a better place.

You can also donate money or groceries to help others put food on the table. If you plan to donate groceries, or other personal care items, please avoid only donating the food that looms in your cupboard that you won’t eat yourself. It’s fine to donate unused canned goods that you won’t put to use, but also include items in your donations that you yourself would be excited to eat. Money donations work well, because they allow food banks and pantries to purchase fresh food, or other much-needed items at their discretion.

It doesn’t appear that food insecurity is going anywhere any time soon, but it could go away much faster if everyone who is able pitched in and lent a hand.

In Conclusion

Eating disorders and disordered eating patterns are much more common than most people realize. A thin, straight, affluent, white women is much more likely to get a proper diagnosis and treatment for eating disorders than people of other identities or groups. There are many reasons for this, but generally, the notion that eating disorders primary affect this group makes healthcare professionals, friends, and family members more likely to detect patterns that might display disordered eating.

Nobody is immune from developing an eating disorder, and being aware that they can affect anyone can help us alter the systems that allow so many to go undetected. If you can, talk to your friends and family members about the dangers of disordered eating, and share this post with anyone who may be interested in its subject matter.

Circumstances around disparities in eating disorders appear bleak now, but I have hopes that things will only continue to improve moving forward.

As Always, a Book Recommendation

Where did the desire for thinness in our culture even originate? Back in our hunter/gatherer days, having a larger body meant that you were well fed, and that was revered. In countries with high rates of starvation, their beauty pageants often consist of women in larger bodies. It seems like our culture tells us to be whatever is hardest to achieve given our environment.

In her incredible book, Fearing the Black Body (affiliate), Sabrina Strings walks the reader through the origins of diet culture. Turns out, it has been around for centuries. Philosophers used to claim that those in larger bodies had reduced mental faculties, so they often went to great lengths to stay small. Doctors created super restrictive diets to help women slim down and achieve the ideal aesthetic. Most importantly, however, is the fact that white people desired another way to separate themselves from their black counterparts.

This is a well-researched, fascinating book, and I hope you’ll give it a shot. It’s important to know how diet culture got started in the first place, because it makes the whole dieting industry seem all the more vile and horrible.

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Sources:

  1. Treatment Seeking for Eating Disorders: Results From a Nationally Representative Study
  2. National Eating Disorders Association – Statistics on Eating Disorders
  3. Common Sense Media – Children, Teens, Media and Body Image
  4. Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths
  5. Why Are Black Women at Such High Risk of Dying from Pregnancy Complications – American Heart Association
  6. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States
  7. How We Fail Black Patients in Pain – AAMC
  8. The impact of client race on clinician detection of eating disorders – Pubmed (behind a paywall)
  9. Eating Disorders in Men & Boys – NEDA
  10. Eating Disorders in LGBTQ+ Populations
  11. Food Insecurity and Disordered Eating – Duke Health

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