Eating Disorders

In any conversation about weight and health, it is important to understand the risk and prevalence of eating disorders. The National Institute of Mental Health (NIMH) defines eating disorders as “serious and sometimes fatal illnesses that cause severe disturbances to a person’s eating behaviors.”¹ People with eating disorders often experience a preoccupation with food choices and body weight, and they frequently have a distorted body image, believing that self-worth is tied to body size and shape.² Eating disorders are serious and complex health conditions, and their prevention, proper diagnosis, and treatment must involve a multi-faceted approach, including physical, emotional, and social issues related to each individual’s needs.³

The short video below summarizes the main types of eating disorders, and you’ll find sections with more details on each type further down this page.

Researchers have estimated that about 9 percent of people living in the United States, or 28.8 million Americans, will have an eating disorder in their lifetime.⁴ The prevalence of eating disorders also seems to be increasing.⁵ Eating disorders can be accompanied by many health complications, and among all mental illnesses, eating disorders have one of the highest fatality rates. Anorexia nervosa in particular can be deadly; it has the second highest mortality rate of mental illnesses, outranked only by substance use disorder.⁶ Eating disorders cause approximately 10,200 deaths each year, or one death every 52 minutes in the United States.⁴ In a large study of U.S. college students published in 2020, those with the greatest level of eating disorder symptoms were 11 times more likely to have attempted suicide compared with those who did not have an eating disorder.⁷

Historically, there has been a stereotype of eating disorders typically affecting young, white, straight women and resulting in a visibly underweight body. But this is a false stereotype. Eating disorders can affect anyone, regardless of their background, body size, gender, sexuality, race, ethnicity, or age. This is an important point because misconceptions about who is affected by eating disorders have resulted in these illnesses being underrecognized, undiagnosed, and untreated in people who don’t fit the stereotype.⁸

Risk factors for eating disorders are multifactorial. The National Eating Disorders Foundation lists the following risk factors for eating disorders⁹:

• Biological Factors
  • Having a close relative with an eating disorder or other mental health condition
  • History of dieting or negative energy balance
  • Having type 1 diabetes

• Psychological Factors
  • Perfectionism
  • Body image dissatisfaction
  • Personal history of an anxiety disorder
  • Behavioral inflexibility (always following the rules or feeling there is one “right way” to do things)

• Social Factors
  • Experiencing weight stigma
  • Experiencing teasing or bullying
  • Believing there is an “ideal body”
  • Having a limited social network
  • Acculturation, such as when people of different ethnicities are introduced to Western media that emphasizes diet culture and an ideal body shape
  • Having experienced historical or intergenerational trauma, such as Holocaust survivors and Indigenous groups that experienced colonization

It is especially important to note how dieting and weight stigma are associated with the risk of developing an eating disorder. For example, in one U.S. survey, adults who reported experiencing weight stigma were more likely to have disordered eating, regardless of BMI.¹⁰ In another study, 14-year-old girls who were told by a family member or another person in their life that they were “too fat” were, at age 19, more likely to be dissatisfied with their body and to be using unhealthy weight control behaviors, such as vomiting, taking diet pills, and using laxatives. These effects were seen regardless of BMI, meaning that these unhealthy outcomes also occurred in girls with a normal weight BMI who were labeled by others as “too fat.”¹¹ In one cohort of teens followed for three years, those who dieted were five times more likely to develop eating disorders, and those who were on severely restrictive diets were 18 times more likely to develop eating disorders.¹² It’s also worth noting that dieting in young people is actually linked to greater weight gain over time, not less. For these reasons, the American Academy of Pediatrics discourages dieting in young people and recommends that families concerned about a child’s body weight focus on adopting healthy and sustainable eating and physical activity patterns rather than trying to change weight.¹³ When we talk about weight management interventions or public health policies, it’s important to be mindful of the risks of overly restrictive diets or practices that stigmatize people based on weight.

With proper diagnosis and treatment, people can recover completely from eating disorders. Treatment can involve individual, group, and/or family psychotherapy; medical care and monitoring; nutrition counseling; and medications such as antidepressants and mood stabilizers. A registered dietitian is often a vital part of the treatment team.¹

Anorexia Nervosa

Anorexia nervosa, often referred to as simply “anorexia,” is an eating disorder characterized by severe restriction of the amount and often types of foods eaten due to an obsession about body weight, fear of gaining weight, and/or a distorted body image. Anorexia results in extreme nutrient inadequacy, weight loss and/or failure to grow normally, and eventually organ malfunction. A 2019 review of studies estimated that 1.4 percent of women and 0.2 percent of men will have anorexia at some point in their lifetime.¹⁴ Anorexia often begins during adolescence, but it can emerge much later in adulthood. In addition to severe food restriction, some people with anorexia also may exercise compulsively and have binge-eating and purging episodes, during which they eat large amounts of food and then purge it by vomiting or using laxatives or diuretics.¹ Though some people with anorexia are noticeably underweight, the disorder can also affect people in larger bodies, who may be less likely to be diagnosed because of their size.¹⁵

Anorexia can affect mental and physical health in many ways. It can cause excessive weight loss, osteoporosis, anemia, muscle wasting and weakness, brittle hair and nails, skin abnormalities, growth of fine hair all over the body, severe constipation, low blood pressure, slowed pulse and breathing rate, low body temperature, fatigue, infertility, menstrual irregularities or loss of periods, heart and brain damage, and organ failure.¹ The goals of treatment for anorexia are to restore a healthy body weight and significantly reduce the weight obsession and behaviors associated with the eating disorder.

Bulimia

Bulimia nervosa is characterized by episodes of eating large amounts of food followed by purging, which is accomplished by vomiting or the use of laxatives and diuretics. People with bulimia often feel a lack of control over these episodes. The prevalence of bulimia is estimated to be 1.9 percent in women and 0.6 percent in men.¹⁴ People with bulimia typically have a BMI in the normal weight or overweight range; underweight is less common.¹⁶

Signs and symptoms of bulimia include a chronically inflamed and sore throat, swollen salivary glands, gastric reflux, severe erosion of tooth enamel due to exposure to stomach acid, intestinal distress, dehydration, and electrolyte imbalances, which can lead to stroke or heart attack.¹

Fig. 7.16. This photo shows the erosion on the lower teeth caused by bulimia. For comparison, the upper teeth were restored with porcelain veneers.

Binge-Eating Disorder (BED)

Like those with anorexia or bulimia, people with binge-eating disorder (BED) have lost control over their eating. They will periodically overeat to the extreme, often quickly and to the point of discomfort, but their loss of control over eating is not followed by fasting, purging, or compulsive exercise. BED may be diagnosed at any weight, but compared with other eating disorders, is more often seen in people living in larger bodies.¹ BED is the most common eating disorder in the U.S.; it has been estimated to affect 2.6 percent of people in their lifetime. Unlike bulimia and anorexia, which often begin in adolescence, the average age of onset of BED is 23 years of age.¹⁷ There may be a link between dieting and BED, as many people with BED also have a history of dieting, and restricting food intake may increase the urge to binge.¹⁸

The health consequences of BED are those linked to weight stigma and having a higher body weight, such as hypertension, cardiovascular disease, type 2 diabetes, and chronic pain. Additionally, people with BED often experience guilt, shame, and depression, and BED is also associated with phobias, social anxiety, posttraumatic stress disorder, and alcohol use disorder.¹⁸ Treatment often involves psychiatric and nutritional counseling as well as medications to treat depression or other mental health conditions.¹

Orthorexia

Orthorexia is a newer disordered eating behavior defined as an obsession with healthy eating. The term “orthorexia” was first defined in 1998, but it has yet to be formally classified as an eating disorder, making it difficult to determine how prevalent it is. Research suggests it may be identified as a form of obsessive-compulsive disorder. While focusing on a healthy diet isn’t inherently a bad thing, a person with orthorexia takes the emphasis on healthy or “clean” eating to the extreme, so much so that it becomes a fixation, putting their health at risk. Signs of orthorexia include compulsively reading food labels, cutting several food groups out of the diet, spending an unusual amount of time focusing on what foods may be available at upcoming events, and experiencing a high level of stress when healthy foods are not available. The obsession with healthfulness comes with a high social cost as it is often difficult to enjoy eating out or sharing meals with friends and family. There is no formal treatment plan for orthorexia, but many eating disorder experts treat it similarly to anorexia and obsessive-compulsive disorder.¹⁹

If you think you or someone close to you may have an eating disorder and you want to learn more or find help, we’ve provided links to more resources below. Note that there are several other types of eating disorders not covered here, so if you’re struggling with your relationship with food but your experience doesn’t match one of the disorders described above, it may still be worth learning more and speaking with a professional to seek help.

• The National Eating Disorder Association offers many resources, including a short online screening tool that “can help determine if it’s time to seek professional help.” 
• ANAD is a nonprofit providing free support services, including a helpline, recovery mentorship, and support groups, to anyone struggling with an eating disorder, disordered eating, and body image.
• Project HEAL is a nonprofit that offers free, 1-hour phone assessments for eating disorders, as well as free and sliding scale treatment, with a focus on increasing access for people identifying as BIPOC, LGBTQ+, and from other marginalized communities.

Self-Check:

References:

• ¹Eating disorders. (2021). The National Institute of Mental Health. Retrieved June 10, 2022, from https://www.nimh.nih.gov/health/statistics/eating-disorders.shtml#part_155061.
• ²Body image. (2019). National Eating Disorder Association. Retrieved June 10, 2022, from https://www.nationaleatingdisorders.org/toolkit/parent-toolkit/body-image.
• ³Treatment. (2017). National Eating Disorders Association. Retrieved June 10, 2022, from https://www.nationaleatingdisorders.org/treatment
• ⁴Report: Economic Costs of Eating Disorders. (2020, June 11). T.H. Chan Harvard School of Public Health. Retrieved June 10, 2022, from https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/
• ⁵Zipfel, S., Schmidt, U., & Giel, K. E. (2022). The hidden burden of eating disorders during the COVID-19 pandemic. The Lancet Psychiatry, 9(1), 9–11. https://doi.org/10.1016/S2215-0366(21)00435-1
• ⁶Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders: A meta-review. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 13(2), 153–160. https://doi.org/10.1002/wps.20128
• ⁷Lipson, S. K., & Sonneville, K. R. (2020). Understanding suicide risk and eating disorders in college student populations: Results from a National Study. The International Journal of Eating Disorders, 53(2), 229–238. https://doi.org/10.1002/eat.23188
• ⁸Identity & Eating Disorders. (2017). National Eating Disorders Association. Retrieved June 10, 2022, from https://www.nationaleatingdisorders.org/identity-eating-disorders
• ⁹Risk Factors. (2017, February 21). National Eating Disorders Association. https://www.nationaleatingdisorders.org/risk-factors
• ¹⁰Lee, K. M., Hunger, J. M., & Tomiyama, A. J. (2021). Weight stigma and health behaviors: Evidence from the Eating in America Study. International Journal of Obesity (2005), 45(7), 1499–1509. https://doi.org/10.1038/s41366-021-00814-5
• ¹¹Hunger, J. M., & Tomiyama, A. J. (2018). Weight Labeling and Disordered Eating Among Adolescent Girls: Longitudinal Evidence From the National Heart, Lung, and Blood Institute Growth and Health Study. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 63(3), 360–362. https://doi.org/10.1016/j.jadohealth.2017.12.016
• ¹²Patton, G. C., Selzer, R., Coffey, C., Carlin, J. B., & Wolfe, R. (1999). Onset of adolescent eating disorders: Population based cohort study over 3 years. BMJ (Clinical Research Ed.), 318(7186), 765–768. https://doi.org/10.1136/bmj.318.7186.765
• ¹³Golden, N. H., Schneider, M., Wood, C., Committee on Nutrition, Committee on Adolescence, & Section on Obesity. (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics, 138(3), e20161649. https://doi.org/10.1542/peds.2016-1649
• ¹⁴Galmiche, M., Déchelotte, P., Lambert, G., & Tavolacci, M. P. (2019). Prevalence of eating disorders over the 2000–2018 period: A systematic literature review. The American Journal of Clinical Nutrition, 109(5), 1402–1413. https://doi.org/10.1093/ajcn/nqy342
• ¹⁵Anorexia Nervosa. (2017, February 25). National Eating Disorders Association. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia
• ¹⁶Bulimia Nervosa. (2017, February 26). National Eating Disorders Association. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia
• ¹⁷Kessler, R. C., Berglund, P. A., Chiu, W. T., Deitz, A. C., Hudson, J. I., Shahly, V., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Benjet, C., Bruffaerts, R., de Girolamo, G., de Graaf, R., Maria Haro, J., Kovess-Masfety, V., O’Neill, S., Posada-Villa, J., Sasu, C., Scott, K., … Xavier, M. (2013). The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry, 73(9), 904–914. https://doi.org/10.1016/j.biopsych.2012.11.020
• ¹⁸Binge-eating disorder—Symptoms and causes. Mayo Clinic. Retrieved July 14, 2022, from https://www.mayoclinic.org/diseases-conditions/binge-eating-disorder/symptoms-causes/syc-20353627
• ¹⁹Yager, J. (2022). Eating disorders: Overview of epidemiology, clinical features, and diagnosis. UpToDate. https://www.uptodate.com/contents/eating-disorders-overview-of-epidemiology-clinical-features-and-diagnosis
• ²⁰Orthorexia. (2018). National Eating Disorder Association. Retrieved JUne 14, 2022, from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia.

Image Credits

• “Facing Herself” by Taylor Smith, is from Unsplash (license information)
• Fig 7.16. “Oral Manifestation of Bulimia” by Jeffrey Dorfman is licensed under CC BY-SA 3.0