Eating disorders, the treatment thereof, and the diet culture that fuels them are social justice issues. This page is intended as a resource to share basic information around this hugely important (yet all too often overlooked) topic.
Here are a couple important things to keep in mind as you read:
Uncertainty is necessary for growth. Many of us are trained to try and tie up loose ends, but this work does not lend itself to finding certainty. We must work together to create space for the uncertainty, because it is valuable and valid.
Intersectionality is foundational to this work. In the words of Kimberlé Williams Crenshaw, who is credited with coining the term, intersectionality refers to “the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage. Intersectionality cannot be discussed outside of the context of systems of power and inequality.”
Overview on Eating Disorders
Eating disorders occur across all socioeconomic statuses, racial and ethnic groups, ages, gender identities, sexual orientations, abilities, sizes, etc. They are associated with anxiety, depression, OCD, substance abuse, and trauma.
DSM-V Eating Disorders:
- Rumination Disorder
- Avoidant/Restrictive Food Intake Disorder
- Anorexia Nervosa – Restricting and Binge & Purge Subtypes
+ Atypical Anorexia Nervosa
- Bulimia Nervosa
- Binge Eating Disorder
- Other Specified Feeding or Eating Disorder – Purging Disorder, Low Frequency Binge Eating Disorder, Night Eating
- Unspecified Feeding or Eating Disorder
- Approximately 80% of patients don’t “look the part”
- Carries the highest mortality rate of any psychiatric condition: about 15%, half of which occurs as a result of suicide
- Carries a risk of suicide that is 30x higher than the general population
- A disorder that is easily hidden
- Diagnosis often requires direct questions
Binge Eating Disorder
- Often diagnosed with overeating – food restriction treatment approach in many medical settings which is not helpful
Who gets an eating disorder?
Societal, research, and medical/clinical institutions perpetuate the myth of the Cisgender, Neurotypical, Able-Bodied, White, Thin, Straight, Affluent Teenage Girl.
This reflects a limited imagination – socially, clinically, and in research settings – for people with eating disorders who are:
- Living with disabilities
- …or any configuration thereof, as well as additional areas of marginalization
Assumptions circulate around who is at risk for and who is immune to eating disorders. Prevention strategies, treatment, and research are geared accordingly which actively harm marginalized communities struggling with eating disorders.
- Black teenagers are 50% more likely than white teenagers to exhibit bulimic behaviors, such as bingeing and purging.
- A 2014 study found that rates of disordered eating have increased across all demographic sectors, but at a faster rate in male, lower socioeconomic and older folks
- Transgender college students were significantly more likely than members of any other group of college students to report an eating disorder diagnosis in the past year- 2015 study.
- Teenage girls from low income families are 153% more likely to struggle with bulimia than girls from wealthy families.
- Only 20% of those with eating disorders fit the “emaciated body” stereotype. https://www.nationaleatingdisorders.org/marginalized-voices
- AN & BED prevalence similar across racial groups, BN higher among Latinos and African Americans than Whites
- Lifetime prevalence of any binge eating (ABE) was greater among each ethnic group in comparison to Whites (Marques ,Alegria ,Becker,Chen ,Fang ,Chosak ,Diniz, 2011; Becker, 2003)
- Eating disorders prevalence data suggests more similarities than differences in race/ethnic groups (Marques, Alegria, Becker, Chen, Fang et al., 2011)
- Some studies show lower prevalence for African Americans – research argue this is due to diagnostic biases (Ham, Iorio, & Sovinsky, 2012).
Dx and Race
- Study of 91 clinicians reviewing case profiles
- All cases were exactly the same eating disorder profile, the only differing characteristic was race
- Case of White woman- 44% diagnosed her with an ed
- Case of Latinx woman- 40% diagnosed her with an ed
- Case of Black woman- 16% diagnosed her with an ed
(Impact of Client Race on Clinician Detection of Eating Disorders (2006) Gordon, Brattole, Wingate, Joiner)
- Lifetime prevalence of mental health service utilization was lower among ethnic groups than for Whites with a lifetime history of any eating disorder.(Sala, et.al., 2013; Marques ,Alegria, Becker, Chen, Fang, Chosak, Diniz, 2011; Becker, 2003)
- Differences in clinical presentation not captured by traditional instruments that were developed primarily for white populations (Sala, et.al., 2013; Alegria et al., 2007)
- Different help seeking patterns (Sala, et.al., 2013; Becker et al., 2003)
- Individual and the clinician might not recognize the eating disorder (Sala, et.al., 2013; Cachelin et al., 2001)
Transgender folks and eating disorders
- College Study – Trans students reported significantly higher past year eating disorder diagnosis rates, past month use of diet pills, vomiting, and laxative use when compared to all other groups (Diemer, 2015).
- Algars (2012) found that after surgical transition, both trans men and women reported that the disordered eating symptoms subsided.
- 2016 study examined the treatment experiences of 84 transgender individuals with eating disorders- not one person reported a positive experience with treatment (Duffy, Henkel, & Earnshaw, 2016)
Disabilities and eating disorders
- Physical disabilities mistakenly seen as protective factor against eating disorders
- Young women with specific physical disabilities (Spina bifada and arthritis) higher rates of AN and BN (Gross, Ireys, Kinsman, 2000)
- Study of women with scoliosis – restrictive eating related to effects of disability not weight (Smith, Latchford, Hall, Dickson, 2008)
- Limited studies on disabilities and eating disorders
Limitations of screening tools
- Focus on looks and appearance
- Heteronormative standards around body image
- Bodies are viewed as one dimensional
Eating Disorder Treatment Balance & Expansion
- Psycho education – Medical risks, Psychological risks, therapy interfering aspects
- Willingness to hold space for process and readiness AND ambivalence
- Reframe “resistance” to protection
- Treatment agreements – harm reduction
What would treatment through a social justice lens look like?
- Addressing and understanding power differentials between staff and clients, both in their professional roles and in their identities
- Operating with the knowledge that marginalized people often have many previous negative experiences with healthcare systems
- Understanding that motivation to change can be a barrier, as readiness for recovery can work against marginalized folks with eating disorders
- Providing space for patients to show up safely and authentically, in all their identities
Violence & Body Attacks
- Body terrorism is hating your body and having others hate your body
- It is real, widespread, and on the rise
- It is usually disguised as “healthism for your own good.”
Shame: “intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance or belonging.” – Brené Brown
Body shaming: harmful statements, attitudes and actions toward another person’s body
Diet Culture, White Supremacy, and Barriers to Recovery
As an eating disorder clinician, my biggest struggle in working with people suffering is not the disorder but society’s diet culture. Clients often express the following:
- I’m getting compliments now that I’ve lost weight
- If my body changes, my dating pool decreases
- If I gain weight, I don’t get love from my family
- I’m assigned the boring or less visible jobs at work
- People make negative comments to me about my body and express concern about my weight
- I can’t eat in public, as I get negative looks and/or comments
- People laugh at me when I exercise, even though I’m told I should exercise
The Toxicity of Diet Culture
- Diet culture attaches our worth and value to thinness.
- Diet culture actively encourages eating disorders by prescribing and praising restriction, excessive exercise, calorie tracking, food labeling, weight monitoring and just being hyper vigilant about everything we eat and how much we weigh.
- Diet culture blames, criticizes and shames bodies that are different in any way.
- Diet culture abusively demands that we work towards a privileged body by any means. If we do not work towards a privileged body and/or do not achieve it, diet culture says we deserve any negative outcome, including any harm that comes to our bodies.
- Diet culture is so thoroughly manipulative that it has become interwoven into mainstream living and is embedded in our vocabulary and ultimately our way of living.
Flaws in Weight Loss Research
“Most obese persons wil not stay in treatment of obesity. Of those who stay in treatment, most will not lose weight, and of those who do lose weight, most will regain it.” – Albert Stunkard, 1958
History of BMI
- BMI = weight(kg)/height squared: a math project in the 1850s, designed by a Belgian statistician
- Arbitrary line of defining weight categories
- No science behind it; however, it has evolved into a firmly believed standard of health
- Embedded in racism and oppression (Sabrina Strings, PhD)
“Obesity Paradox” Literature
- Diseases exist across the weight spectrum – there is no disease that only impacts heavier people – and in fact, thin people die from diseases more frequently
- Research shows people who are classified as “obese” by the BMI can be fit and healthy without weight loss
- Over the past 40 years, more than 2 billion weight loss attempts were made, billions were spent on the promise of weight loss…and “obesity” rates tripled
- This shows that intentional weight loss is unsustainable and hardly ever works in the long term
Poor research design and outcomes
- Less than one year of follow-up
- No focus on mediating/moderating factors such as chronic dieting, weight cycling, weight stigma, lack of medical access, etc
Body Justice: What Does it Mean to You?
Body Image (BI) Process
- How do we conceptually hold the process of shifting BI with our folks? It is a radical shift and may be too much for people to hold.
- How do we hold and honor the stories that come up with exploring BI? These often center around trauma, violence, pain, and injustice.
- How do we honor the internalized fatphobia/isms that serve as coping mechanisms?
- How do we acknowledge the world we live in with various forms of oppression and body targeting?
- How do we hold space for bodies in transition, bodies that are changing, and bodies with differing levels of ability?
Ask what folks hope for in weight loss
- This is generally love, respect, value, inclusion, etc
- Acknowledge how our systems of oppression attacks these essential human needs
- Acknowledge how capitalism manipulates us by knowing these essential human needs
- Belonging vs. fitting in
Resistance in shifting BI
- If your resistance could talk…what would it say?
Consultation with Body Trust – Hilary Kinavey, MS, LPC, and Dana Sturtevant, MS, RD (2019)
Nutter, S., Russell-Mayhew, S., Ellard, J. H., & Arthur, N. (2020). Reducing unintended harm: Addressing weight bias as a social justice issue in counseling through justice motive theory. Professional Psychology: Research and Practice, 51(2), 106–114. https://doi.org/10.1037/pro0000279
Douglas V, Balas B, Gordon K. Facial femininity and perceptions of eating disorders: A reverse-correlation study. PLoS One. 2021 Aug 6;16(8):e0255766. doi: 10.1371/journal.pone.0255766. PMID: 34358270; PMCID: PMC8345843.
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Javier SJ, Belgrave FZ. “I’m not White, I have to be pretty and skinny”: A qualitative exploration of body image and eating disorders among Asian American women. Asian Am J Psychol. 2019 Jun;10(2):141-153. doi: 10.1037/aap0000133. Epub 2018 Dec 27. PMID: 31156760; PMCID: PMC6538263.
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O’Connor SM, Hazzard VM, Zickgraf HF. Exploring differential item functioning on eating disorder measures by food security status. Eat Weight Disord. 2021 Aug 23. doi: 10.1007/s40519-021-01289-z. Epub ahead of print. PMID: 34426950.
Burke, N. L., Schaefer, L. M., Hazzard, V. M., & Rodgers, R. F. (2020). Where identities converge: The importance of intersectionality in eating disorders research. International Journal of Eating Disorders, 53(10), 1605–1609. https://doi.org/ 10.1002/eat.23371.
Coffino, J. A., Udo, T., & Grilo, C. M. (2019). Rates of help-seeking in US adults with lifetime DSM-5 eating disorders: Prevalence across diagnoses and differences by sex and ethnicity/race. Mayo Clinic Proceedings, 94(8), 1415–1426. https://doi.org/ 10.1016/j.mayocp.2019.02.030.
KM Huryk, CR Drury, KL Loeb (2021) Diseases of affluence? A systematic review of the literature on socioeconomic diversity in eating disorders- Eating behaviors
JL Mensinger (2021) Traumatic stress, body shame, and internalized weight stigma as mediators of change in disordered eating: a single-arm pilot study of the Body Trust® framework- Eating Disorders https://doi.org/10.1080/10640266.2021.1985807
Harrop, E. N., Mensinger, J. L., Moore, M., & Lindhorst, T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. The International journal of eating disorders, 54(8), 1328–1357. https://doi.org/10.1002/eat.23519
Kim, Y.-R., An, Z., & Treasure, J. (2023). Atypical anorexia nervosa: Implications of clinical features and BMI cutoffs. International Journal of Eating Disorders, 1– 3. https://doi.org/10.1002/eat.23911