Eating Disorders 101

Watching what you eat, like most things, is good for you in moderation. To eat nutritious foods and feel comfortable in your body is certainly a good goal. But when you focus excessively on what you eat, when you eat, and how much you eat to the point where it impinges on your life and impairs your ability to function, you may have an eating disorder.

What’s Normal Eating Behavior and What Isn’t?

How can you know if your concern about your diet and your body’s shape is veering toward — or may already be — an eating disorder? You can’t just look in a mirror. Despite what many people think, you don’t have to be female or skinny — or fat — to have an eating disorder. You don’t even have to look as though anything is wrong. “Weight can be an indicator of an eating disorder, but it certainly isn’t the only one,” says Ilene Fishman, a licensed clinical social worker in New York City and Montclair, New Jersey, who spent a decade during her adolescence battling — and eventually recovering from — her own severe anorexia.

The stereotype pinning eating disorders to young, white, well-to-do females doesn’t always match up with reality. “Eating disorders are found across all age groups, social classes, gender, sizes, education levels, races, and ethnicities,” says Tomoko Udo, PhD, the coauthor of a large-scale study on the prevalence of eating disorders published in the April 16, 2018, issue of the journal Biological Psychiatry: A Journal of Psychiatric Neuroscience and Therapeutics. (1) Indeed, stereotypes about who is affected by eating disorders can be a real barrier in getting help for the people who don’t fit those stereotypes, says Dr. Udo.

Because eating disorders aren’t always obvious, they’re far more common than many of us realize. At some point in their lives, at least 30 million Americans (even some 10 million boys and men) will experience an eating disorder. (2)

The most common eating disorders that affect both genders are: 

• Anorexia This disorder is marked by extreme control over calorie intake, an intense fear of gaining weight, and often an unrealistic view of body size and shape.
• Bulimia Also known as binge-purge syndrome, this disorder is marked by frequent, rapid overeating followed by purging to avoid gaining weight. Purging may include forced vomiting, obsessive exercising and misuse of laxatives and diuretics.
• Binge-eating disorder This disorder is marked by frequent out-of-control eating in a short amount of time, often until the person feels uncomfortably full. It often occurs in secret because of self-disgust and embarrassment. People with this condition don’t purge. (3)
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What Causes Eating Disorders?

Eating disorders are complex illnesses caused by an interaction of genetic, biological, behavioral, psychological, and social factors, according to the National Institute of Mental Health. (4) 

Having a parent or sibling with an eating disorder, for example, may predispose a person to develop one. So, too, might having an anxiety or depressive disorder, or experiencing a trauma, such as sexual abuse. (5) Even being bullied in childhood can dramatically increase one’s risk. (6)

We also live in a culture that has, historically, valued waist size over accomplishments. Movies, television shows, and fashion magazines have perpetuated this value system by featuring unhealthy and unrealistic bodies, thus contributing to eating disorders.

But that has started to change in recent years. More and more celebrities are stepping forward to reveal the toll that the culture of thinness has taken on them, helping to increase awareness about eating disorders and reduce the stigma.

Among them are:

• Gabourey Sidibe The Oscar-nominated star of Precious and American Horror Story: Apocalypse vividly describes how she used bulimia to cope with depression in her memoir This Is Just My Face: Try Not to Stare. “My emotions were out of control, and all I could do was cry about it for hours,” she wrote. “One day, I cried so long and hard that I started vomiting. When I was done, I wasn’t crying anymore. I wasn’t even thinking about what had made me cry to begin with. I felt empty, which was a great thing — before this, I’d felt too full of emotions. … I wasn’t even trying to lose weight — that’s not the way it works. I was trying to stop myself from crying.” (7)
• Kesha In an interview in the May 13, 2015, issue of Vogue, the pop star recalled what led her to seek in-patient treatment for bulimia at Timberline Knolls Residential Treatment Center in Lemont, Illinois, in 2014. “There was a lot of not eating — and I started thinking [that] being hungry to the point of feeling almost faint was a positive thing. The worse it got, the more positive feedback I was getting. Inside I was really unhappy, but outside, people were like, ‘Wow, you look great.’” (8)
• Lily Collins Collins suffered with anorexia and bulimia as a teenager, then risked a relapse years later by losing a significant amount of weight to play a character with anorexia in the movie To the Bone. In 2017, she told the British newspaper The Independent that she chose to play the role to bring awareness to eating disorders. “This is something I needed to talk about and bring to the attention of more people. It is still considered quite taboo to talk about, and yet it’s becoming more and more prevalent within today’s society, and not just with women.” (9)

The Disorder Healthcare Providers Often Miss

Healthcare providers often overlook the signs of an eating disorder, and many even say things that could make the disorder worse. Not asking a patient who has lost a significant amount weight about his or her eating habits, and instead praising them for finally getting their weight under control, is one common scenario, says Nanci Pradas, PhD, a psychotherapist in private practice in Bedford, Massachusetts. Many doctors also prescribe medication for depression without considering how a patient’s mental state might be affecting their eating behavior.

The reason eating disorders fall through the cracks in doctor’s offices so easily is simple: Few doctors receive in-depth training in identifying and treating eating disorders, even in family medicine and psychiatric residency programs, according to a national survey published in the May 2015 issue of the International Journal of Eating Disorders (10)

Telltale Eating Disorder Signs to Look For

You might want to consider consulting an expert if you notice any of these red flags in yourself or a friend or family member:

• Being consumed by thoughts of food, weight, fat, or calories
• Avoiding once favorite foods
• Preferring to eat alone instead of with others so that no one can judge how little or how much is being eaten
• Exercising excessively; for example, planning the day around working out, setting unrealistic goals or ignoring signs of injury or fatigue
• Finding more and more fault with one’s body, or seeing it as looking very different from how other people say it does
• Paying increased attention to other people’s bodies
• Regularly using appetite suppressants, laxatives, diuretics, or enemas (4,11)
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How Dangerous Are Eating Disorders?

In a word, very. Although many people in the grip of an eating disorder appear very high functioning on the outside, excelling at work and at home, inside, their bodies are in crisis. Some eventually fully recover. Others cycle through periods of recovery and relapse. And some become chronically ill or die. Anorexia is especially deadly. Research published in the July 2011 issue of the journal Archives of General Psychiatry shows it is the deadliest of all psychiatric illnesses, far surpassing schizophrenia and bipolar disorder. (11) An estimated 20 percent of those who develop it eventually die from medical complications such as irregular or very low heartbeat (arrhythmia), sudden cardiac arrest, severe liver disease, or suicide.

Even those who survive may face serious health issues, including but not limited to:

• Irreversible bone loss
• Muscle loss and weakness, including in the heart muscle.
• Anemia
• Severe dehydration, which can lead to kidney failure
• Dry skin and hair loss
• Slowed digestion (gastroparesis)
• Fainting, fatigue, and overall weakness
• Menstrual irregularities or loss of libido
• Depression (12)