By Anna Bardone-Cone, PhD, Bowman & Gordon Gray Distinguished Term Professor; Professor of Psychology & Neuroscience at the University of North Carolina at Chapel Hill; Director of Clinical Psychology; Fellow of the Academy for Eating Disorders; Content Expert, National Center of Excellence for Eating Disorders
As many readers may be aware, one of the real challenges people with eating disorders face is finding a healthcare provider who is knowledgeable and trained in treating these conditions. There are countless stories of people unable to find a trained provider in their area and/or having negative experiences in their doctor’s offices. Fortunately, there have been some recent developments to help overcome this challenge within the field! Led by Dr. Christine Peat, the National Center of Excellence for Eating Disorders (NCEED) is designed to serve as thecentralized hub dedicated to education and training on eating disorders for both healthcare providers AND the general public, offering a full suite of resources including: webinars, online self-paced trainings, a comprehensive resource library, and toolkits.Below we provide some information on common myths related to eating disorders regarding identification, their seriousness, whom they affect, and recovery.
You can always tell if someone has an eating disorder because they will look extremely thin.
*No* - There are several different types of eating disorders with only anorexia nervosa characterized by an extremely low weight (American Psychiatric Association, 2013). And even for anorexia nervosa, it may not be obvious how thin someone is since they may wear clothing that is baggy and can hide their weight loss. Additionally, DSM-5 includes an Other Specified Feeding or Eating Disorder diagnosis of atypical anorexia nervosa which includes all symptoms of anorexia nervosa except that significant weight loss has not yet led to the individual being very underweight. For other eating disorders, individuals are typically in a normative weight range (bulimia nervosa) or overweight (binge-eating disorder). Thus, being extremely thin is not the only indicator of a possible eating disorder.
Males do not develop eating disorders.
*No* - Individuals of any gender identity can develop an eating disorder. Historically, it was considered a rarity for a male to have an eating disorder, however, recent research suggests that the gender discrepancy for eating disorders may not be as large as initially thought. Indeed, more recent estimates suggest a 1:2 to 1:5 male-to-female ratio (Hudson, Hiripi, Pope, & Kessler, 2007: Udo & Grilo, 2018) instead of the 1:9 ratio reported in the DSM-IV (American Psychiatric Association, 1994). The gender discrepancy is least evident for binge-eating disorder. Of note, certain groups of males may be at elevated risk for eating disorders including gay men (Feldman & Meyer, 2007) and boys/men who participate in sports where weight is highly monitored and where there is pressure to maintain a low weight (e.g., wrestling; Chapman & Woodman, 2016), but any male can develop an eating disorder. Patterns of eating disorder symptoms for males may have some differences from females including a greater focus on pursuing muscularity, such as rigid dietary practices, excessive exercise, and (sometimes illicit) supplement use to bulk up, as well as features common to anorexia nervosa, such as obsessionality and fear (but of losing muscle instead of gaining weight) (Murray, Accurso, Griffiths, & Nagata, 2018). It is important to be aware that males do develop eating disorders in order to minimize misdiagnosis which can result in delayed treatment.
Girls/women of color are not at risk for eating disorders.
*No* - Data from the NIMH Collaborative Psychiatric Epidemiological Studies, which pooled findings from across multiple studies of diverse samples, found that the rates of binge-eating disorder, bulimia nervosa, and anorexia nervosa were similar for women across racial/ethnic groups: Blacks, Latinas, Asian Americans, and non-Latina Whites (Marques et al., 2011). Male data from this report found that Latino males had higher rates of bulimia nervosa than Caucasian males. Although little research on eating disorders exists for Native Americans, this group exhibits high rates of eating disorder attitudes/behaviors (e.g., Lynch, Eppers, & Sherrodd, 2004). Racial/ethnic groups are also more similar than dissimilar when considering body dissatisfaction, which is a robust predictor of eating disorders. Looking across Blacks, Latinas, Asian Americans, and non-Latina Whites, the only differences (which were small) were for both Latinas and non-Latina White women reporting higher body dissatisfaction then Black women (Grabe& Hyde, 2006). Thus, eating disorders do not selectively apply to White individuals. This misconception can lead to eating disorders being underdiagnosed among racial/ethnic minoritiesand, relatedly, women of color being less likely to receive a referral for eating disorder concerns than White women with similar levels of symptoms (Becker, Franko, Speck, & Herzog, 2003; Gordon, Brattole, Wingate, & Joiner, 2006; Gordon, Perez, & Joiner, 2002).
Eating disorders can simply be a normal part of adolescence.
*No* - Some aspects of eating disorders are sadly somewhat normative in adolescence, at least for some cultures (e.g., U.S.) – for example, body dissatisfaction and dieting are prevalent among teenagers. Although body image concerns and restrictive eating in adolescence does not mean someone will develop an eating disorder, it does increase risk (Stice, 2002). Eating disorders themselves are not normative, and require intervention. One study of almost 500 adolescent girls followed across about eight years found that 5.2% of them at some point met criteria for anorexia nervosa, bulimia nervosa, or binge-eating disorder (Stice, Marti, Shaw, & Jaconis, 2009). Given the potential for chronicity for eating disorders, the high mortality rate for anorexia nervosa, and the greater challenge in treating anorexia nervosa among adults, possible symptoms of eating disorders in adolescence should not be ignored and dismissed as part of that developmental stage.
Once you develop an eating disorder, you will never fully recover.
*No* - Recovering from an eating disorder is hard but it is possible and individuals with eating disorders and their families should have hope that things can get better. Several treatments have been shown to be effective for eating disorders, including cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for bulimia nervosa and binge-eating disorder and family-based therapy for children and adolescents with anorexia nervosa (Kass, Kolko, & Wilfley, 2013). In terms of what recovery can look like, research suggests that individuals can recover in a comprehensive way (physically, behaviorally, and cognitively) so that they are indistinguishable from those who never had an eating disorder on a range of disordered eating attitudes and beliefs (Bardone-Cone et al., 2010; Bardone-Cone, Johnson, Raney, Zucker, Watson, & Bulik, 2019). This is encouraging! From qualitative research, individuals who identify as recovered highlight that in addition to the absence of eating disorder behaviors, they experience: acceptance and appreciation of their bodies, increased self-worth not contingent on appearance, relaxation in relation to food, and freedom from obsessive disordered eating thinking (Björk, Wallin, & Pettersen, 2012; Noordenbos, 2011). As research on recovery continues, the hope is to identify predictors of comprehensive recovery so that health care professionals can help more individuals with eating disorders attain meaningful and freeing recovery.
Interested in learning more? Cynthia Bulik, PhD (NCEED Senior Faculty) and the Academy for Eating Disordersdeveloped the 9 Truths document which helps dispel common misconceptions about eating disorders. The document has been translated into several different languages and is also accompanied by a peer-reviewed journal article summarizing the research evidence that supports the 9 Truths (Schaumberg et al., 2017).
References
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American Psychiatric Association (2013): Diagnostic and Statistical Manual of
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Bardone-Cone, A. M., Harney, M. B., Maldonado, C. R., Lawson, M. A., Robinson, D. P., Smith, R., & Tosh, A. (2010). Defining recovery from an eating disorder: Conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behaviour Research and Therapy, 48, 194-202.
Bardone-Cone, A. M., Johnson, S., Raney, T. J., Zucker, N., Watson, H. J., & Bulik, C. M. (2019). Eating disorder recovery in men: A pilot study. International Journal of Eating Disorders.
Becker, A. E., Franko, D. L., Speck, A., & Herzog, D. B. (2003). Ethnicity and differential access to care for eating disorder symptoms. International Journal of Eating Disorders, 33,205-212.
Björk, T., Wallin, K., & Pettersen, G. (2012). Male experiences of life after recovery from an eating disorder. Eating Disorders: The Journal of Treatment & Prevention, 20,460–468.
Chapman, J., & Woodman, T. (2016). Disordered eating in male athletes: A meta-analysis. Journal of Sports Sciences, 34,101–109.
Feldman, M. B., & Meyer, I. H. (2007). Eating disorders in diverse lesbian, gay, and bisexual populations. International Journal of Eating Disorders, 40, 218–226.
Gordon, K. H., Brattole, M. M., Wingate, L. R., & Joiner, T. E. (2006). The impact of client race on clinician detection of eating disorders. Behavior Therapy, 37, 319-325.
Gordon, K. H., Perez, M., & Joiner, T. E. (2002). The impact of racial stereotypes on eating disorder recognition.International Journal of Eating Disorders, 32, 219-224.
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Lynch, W., Eppers, K., & Sherrodd, J. (2004). Eating attitudes of Native American and White female adolescents: Acomparison of bmi‐and age‐matched groups. Ethnicity and Health, 9, 253-266.
Marques, L., Alegria, M., Becker, A. E., Chen, C. N., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across U.S. ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44, 412-420.
Murray, S. B., Accurso, E. C., Griffiths, S., & Nagata, J. M. (2018). Boys, biceps, and bradycardia: The hidden dangers of muscularity-oriented disordered eating. Journal of Adolescent Health, 62, 352–355.
Noordenbos, G. (2011). Which criteria for recovery are relevant according to eating disorder patients and therapists? Eating Disorders: The Journal of Treatment & Prevention, 19, 441-451.
Schaumberg, K., Welch, E., Breithaupt, L., Hübel, C., Baker, J. H., Munn, C. M. A., … Bulik, C. M. (2017). The science behind the Academy for Eating Disorders’ nine truths about eating disorders. European Eating Disorders Review, 25,432–450.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128, 825–848.
Stice, E., Marti, C. N., Shaw, H., & Jaconis, M. (2009). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118, 587–597.
Udo, T., & Grilo, C. M. (2018). Prevalence and correlates of DSM-5–defined eating disorders in a nationally representative sample of US adults. Biological Psychiatry, 84, 345-354.