A Closer Look at What's Behind Eating Disorders

Eating disorders are a classification of psychiatric illnesses within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). They are characterized by highly distressing attitudes, beliefs and behaviors related to a person's food intake, body shape and weight, according to Elizabeth Wassenaar, M.D., the regional medical director of the Eating Recovery Center in Denver.

Consequently, eating disorders have a negative impact on both physical and psychological health and are life-threatening if left untreated.

It is important to recognize that eating disorders are not a choice. They don't develop suddenly or disappear overnight. Food is not the root of the problem; it's the coping mechanism. As with drug use, food is a substance used to deal with underlying issues. This is why, in order to recover, nutritional rehabilitation is not enough.

"There's a lot more driving this. People aren't engaging the eating disorder necessarily because of the food on the plate," explained Molly Perlman, M.D., MPH, CEDS, chief medical officer of Monte Nido & Affiliates in Miami and a member of the board of directors of the Eating Disorders Coalition.

"It's all these pieces: the trauma history, depression, sense of self-worth, relationships and more," Perlman said.

Risks, causes and triggers of eating disorders

Unfortunately, there is not one definitive cause for eating disorders.

"They stem from a complex interplay between multiple factors, including genetic, environmental, sociocultural and psychological," Wassenaar said. "No one is immune to eating disorders. They do not discriminate, and they affect people of all ages, races, ethnicities, genders, shapes and sizes."

A trigger is not a singular event, but a conglomeration of factors that appear to provide people in need a way to cope with life's hardships.

Experts have identified other commonalities. Negative psychological and emotional effects, particularly depression, anxiety, perfectionism and low self-esteem, have been linked to eating disorders.

The risk increases for people with a close family history of eating disorders, according to Henry Cheng, M.D., the regional medical director of The Renfrew Center of New York. Many patients have experienced varying forms of trauma, especially sexual trauma. Furthermore, people with jobs and extracurriculars related to physique, such as dancing and modeling, are at higher risk.

Types and stages of eating disorders

Several kinds of eating disorders have been identified, but the most common are anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). People with eating disorders can range in weight from emaciation to obesity, depending on severity and type.

The cardinal features of anorexia are severe weight loss and the inability to maintain body weight. Those are combined with a fear of gaining weight and issues with body image, said Johnny Williamson, M.D., a Chicago-area psychiatrist who practices virtually with the eating disorder treatment program Alsana.

Anorexia nervosa has two subtypes: restricting and binge eating/purging. Restricting anorexia sufferers achieve weight loss through dieting, fasting and exercising. Binge eating/purging patients typically engage in episodes of overeating followed by compensatory behaviors, such as vomiting or overexercising and the use of diet pills, laxatives and/or diuretics.

People with bulimia experience bingeing episodes with out-of-control consumption within a short period, during which the person feels unable to stop, even well past the point of satiation, Williamson explained. This episode is followed by one or more of the compensatory behaviors.

People with binge eating disorder experience the overeating aspect without the purging and compensatory symptoms.

Mental health professionals have established stages of change and recovery for all eating disorders that determine the patient's mental progression toward recovery. The first stage is precontemplation, during which they are unaware of or denying the problem but beginning to show warning signs.

Second is contemplation, when they acknowledge the problem and consider seeking help, though some may still be resistant to change.

Third is the preparation stage, in which they've decided to enter recovery but don't know how to approach it. Next is the action stage, when changes have been implemented and patients are actively working toward recovery.

From there, they enter the maintenance and/or relapse stages, during which they either maintain recovery behaviors or slip back into old patterns.

It's not uncommon for people to go back and forth between stages. Every recovery journey is different, and eating disorders are notoriously resistant to rehabilitation.

Socioeconomic and cultural factors

Previously, experts believed there was a positive correlation between eating disorders and high socioeconomic status (SES), but recent studies have indicated otherwise. The variance in SES has the biggest impact on identification and treatment because it skews the results in favor of people with higher SES. Low SES is related to poor access to care, which is likely inadequate anyway, so data skews toward people with high SES and doesn't necessarily reflect actual incidence.

Culture has a direct impact on eating disorder development. Perlman said Westernized countries that emphasize a particular image show higher rates of eating disorders. Social media is frequently discussed as a primary risk—for good reason, according to the experts interviewed for this report—because it exposes so many people to triggering content.

"The impact of our social patterns of trying or needing to present ourselves as something that's altered from who we are to be accepted cannot be overstated," Williamson said. "I think it creates these messages that we're not good enough, desirable or what we're supposed to be, and maybe even that we're not healthy."

The fashion and entertainment industries have elevated incidences of eating disorders because of close scrutiny and criticism about appearances. Perlman said these industries often utilize editing programs to depict unattainable standards that are particularly perilous for impressionable minors.

Athletic sectors act similarly, especially those that require specific body types and sizes. Many young men involved in wrestling engage in disordered eating behaviors to meet weight class requirements.

Familial values have relevant effects across generations. Children of parents who place great emphasis on high achievement are significantly more likely to develop eating disorders. Over-involved parents—sometimes called "helicopter parents"—increase risk.

People in families undergoing sudden Westernization may transfer instability-related insecurity to the culturally accepted medium of diets, and new access to stereotypically unhealthy Western food increases the chance of binge eating.

Facts, stats and studies

Eating disorders have been around for a long time and, thus, have accumulated a considerable amount of information and research:

• Approximately 30 million Americans—including 10 million men—have eating disorders. Globally, this number jumps to 70 million.
• The typical age of onset is late teens to early 20s. The incidence in younger ages has climbed in recent years. More than half of girls and one-third of boys have experienced symptoms.
• Eating disorders have the highest mortality rate of any psychiatric illness. About 1 in 5 anorexia nervosa sufferers commit suicide. According to Wassenaar, one person in the United States dies every 52 minutes from eating disorder-related complications.
• Since COVID-19 emerged, eating disorder-related hospitalizations have drastically increased. Of those, 97 percent had one or more comorbidities.
• Current research aims to discover underlying neurobiological factors of eating disorders through the use of brain imaging and scans.
• Perlman is collaborating on data publications for patients who have been in treatment, and results show more than half of them met the full criteria for post-traumatic stress disorder (PTSD). Further findings conclude that treating trauma concurrently with eating disorders promotes full recovery.
• Perlman is working to get more frontline providers—coaches, nurses, teachers and so on—trained in eating disorder screenings to recognize warning signs.

If you're concerned you may be developing an eating disorder, speak with a healthcare professional right away. Taking that first step isn't always easy, especially if you don't have a therapist you see regularly. Fortunately, video visits have become a viable option for most people, and more physicians and therapists have added them as a service. Giddy telehealth makes it easy to get connected to a qualified healthcare professional who can help with a variety of physical and mental health conditions.