Eating Disorders Come in All Colors, Shapes and Sizes

adolescents; teenagers; NEDA

Chances are you or someone you know has been personally affected by an eating disorder. Eating disorders encompass a group of psychiatric illnesses—including anorexia, bulimia, binge eating disorder, and avoidant restrictive food intake disorder—that lead to serious, often life-threatening consequences. It’s estimated that about 1-2 percent of people in the U.S. have an eating disorder at some point over their lifespan. The majority of those affected are children and adolescents. Despite the widespread misconception, eating disorders do not solely affect affluent, white, young girls. An eating disorder can impact any individual irrespective of race, gender, socioeconomic class and weight.

This week is National Eating Disorder Awareness (NEDA) Week, a nationwide call to acknowledge, understand and support individuals and their families experiencing an eating disorder. With the theme “Come As You Are,” NEDA Week is calling for inclusivity: “a message to individuals at all stages of body acceptance and eating disorders recovery that their stories are valid.” Implicit in this message is that up until now, we have not accepted all individuals who have experienced a difficult relationship with food and their body. Historically, the narrative of what someone with an eating disorder looks like has been one of emaciated white girls. Those who do not fit this standard body and racial image have been neglected and their conditions have persisted untreated. In order to allow all individuals with eating disorders to come as they are, we need a broader, more nuanced, understanding of those susceptible to and suffering from eating disorders.

One chronically under- and un-diagnosed group of youth with eating disorders is boys. Until the advent of the DSM-5, a manual that classifies mental disorders used by mental health professionals in the U.S., our diagnostic criteria were female-centric (e.g., the historical inclusion of amenorrhea, the absence of menstrual periods, as a diagnostic criterion) and assessment tools tend to be based in a female centric conceptualization of the illness. The unique ways in which an eating disorder can manifest in boys is often not considered. Sex differences in eating disorders are being actively explored here at Children’s Hospital of Philadelphia.

What’s more, individuals who are living in a larger body are told to lose weight in order to be “healthy.” The reality is that eating disorders occur across the spectrum of body mass index (BMI). BMI is traditionally used to categorize someone’s weight as underweight, normal, overweight and obese.  Research shows that eating disorders occur at similar rates in each category, suggesting that one’s BMI, and by extension weight, is not indicative of having an eating disorder. One cannot diagnose an eating disorder based on an individual’s weight. Assuming that only someone who appears emaciated has an eating disorder means than many, many individuals suffering from an eating disorder will not be assessed for restrictive eating, compulsive exercise, bingeing, purging, etc.

 The narrative has not just been restricted to body size or gender. There is also the misconception that these illnesses are exclusively “Western diseases” designed by Western advertisements and the obsessive health culture. While “healthism” and its accompanying fat bias are a result of our current culture, eating disorders have been around for centuries and found across cultures. Despite the fact that eating disorders do occur indiscriminately across all ethnicities, African American and Latinx individuals with an eating disorder are significantly less likely to receive the proper help and treatment they need. Just like with body size, an individual’s demographic characteristics such as age, ethnicity or sex do not dictate whether or not they can have an eating disorder.

The realization that eating disorders come in all colors, shapes and sizes sets the stage for important conversations between parents and teens. The median age of onset for eating disorders is 12 years old. Parents should be aware that their child does not have to look like they have an eating disorder in order to have one—as we’ve written, one’s weight is not a proxy for health. Observe if your child skips meals or avoids certain foods in fear of “getting fat,” consuming “too many calories” or “being unhealthy.” The latter is very important because in our fat-phobic society, eating disorder behaviors can hide under the guise of “being healthy” and people can initially interpret that as a good thing. Providers also have an important role to play—they should be aware of the signs of an eating disorder and immediately refer specialists who will best help their patients. It is important to remember that weight loss in a teen of any size can be a warning sign of the beginning of a problem.

Systematically excluding any food group is not healthy. Feeling driven to exercise is not healthy. Food and exercise should be fun, flexible and enjoyed. It’s time that our response and efforts to treating eating disorders reflect the fact that they come in all colors, shapes, and sizes.