Eating disorders are a group of serious psychological conditions that can have grave impacts on a person’s physical health. And they’re way more common than you probably think. That’s because, most of the time, when people talk about “eating disorders”, they’re only talking about the ones that involve eating next to nothing or purging. And it turns out, those conditions don’t make up most diagnoses. In recent years, research has begun to highlight the wide variation in eating disorder symptoms. And that’s led to a more complete understanding of how these disorders arise, and how to recognize them, so hopefully, more people can get the help they need. Eating disorders are incredibly complex mental health conditions which are influenced by a variety of environmental and genetic factors. But when people talk about eating disorders, usually, only two specific conditions are brought up. The first is Anorexia Nervosa—or just anorexia, for short which is characterized by very restricted food intake, often to the point of becoming too thin and malnourished to survive. The other is Bulimia Nervosa. People with bulimia generally end upon cycles of out of control eating or “binging” followed by purging behaviors. Both involve attempts to limit weight gain in some way, and most often occur alongside a condition known as body dysmorphia, a distressing preoccupation with your own perceived physical flaws. But even though these two disorders are the ones you might hear about most often, they don’t make up most eating disorder diagnoses; in some studies, they account for a quarter or less.
The most diagnosed eating disorder is known as Other Specified Feeding and Eating Disorders (OSFED). If that seems vague, it is meant to be. It’s kind of a catch-all condition. Not everyone with it will have the same symptoms, but they generally meet a mix of the criteria for other eating disorders. And they may have other behavioral symptoms. For example, many people with eating disorders report improperly using laxatives to lose weight or feel empty. The thinking behind this is that these drugs ‘rush’ food through a person’s system, and calories or nutrients won’t be absorbed if everything’s passed out of the body very quickly. But, that’s not how any of this works. Laxatives stimulate the large intestine, not the small intestine where all that food gets absorbed. Just to be 100% clear: laxative abuse is incredibly dangerous, and can have severe, potentially life-threatening consequences. Rather than reducing calories, the body mostly loses water, so people that improperly use laxatives can become dangerously dehydrated. And pharmaceutical misuse is an unfortunately common theme when it comes to eating disorders. For example, people who have diabetes as well as an eating disorder often engage in insulin undertreatment or omission, a potentially deadly behavior that aims to force weight loss by reducing your body’s ability to metabolize food.
Though not identified as its own disorder by the DSM-V, this practice is so common that it’s recently become known as diabulimia—a combination of diabetes and bulimia. It increases the odds of diabetes complications like kidney damage, nerve damage and blindness. These are severe behaviors, so if they remain unnoticed, it’s because they’re done in private. And that’s part of why the prevalence of eating disorders is higher than you might think. There’s more to it than that. A larger, more sinister reason eating disorders can go undiagnosed is cultural. The scientific community has only recently begun to deal with the fact that most eating disorder research has been done mainly or exclusively on women, and specifically, on cisgender women trying to meet unhealthy ideals for feminine bodies. People with eating disorders who aim for traditionally masculine physical ideals can present very differently. They tend to be aiming to bulk up rather than get thin, for example. Studies have found that roughly 90% of American men feel that way, though the US is a bit of an outlier. In other countries, that number is lower. Like, in Uganda and Ukraine, the figure is 49% and 69%, respectively. Of course, wanting to gain muscle doesn’t mean you have a disorder. But it does illustrate how prevalent the pressure is to have a certain physique. And a lot of the ways people might go about getting more muscular—like dieting, exercising, and being conscious of nutrient intake—can be taken to pathological extremes. For example, if a person makes rigid rules for consumption— like “50 pushups before I can have a protein shake” —that’s wandering into unhealthy behavior territory.
Such food rules fall under the broader umbrella of disordered eating behaviors because they tend to stem from — and lead to — people thinking too much about food and eating. And they usually become more restrictive over time. People trying to bulk up may also struggle with a lot of the same psychological issues people with anorexia or bulimia do, like feelings of guilt, inadequacy, and unattractiveness. And they might even have muscle dysmorphia, an unhealthy preoccupation and dissatisfaction with the perceived size of their muscles, or use bodybuilding supplements excessively. The problem is, these kinds of things are often seen as ‘normal’ for guys, or even healthy, so many people don’t even realize what they’re experiencing is a disorder. And even if they do know that they have body or food issues, they may not seek treatment because eating disorders are often stigmatized as like a “girl” or “gay” thing. Of course, it’s not just men who present with eating disorder symptoms like these. Research published recently surveyed 101 women who post so-called ‘fitspiration’ posts on Instagram — that’s fitness inspiration photos, for those of us not familiar with the lingo —and compared them with 102 women who post travel photos. The fitspiration posters scored higher on measures of disordered eating, and nearly 1/5 of them were considered at risk for a clinically relevant eating disorder, because they showed an especially high drive for muscularity and compulsive exercise.
Just how many people unknowingly have this kind of eating disorder is unclear —but it’s almost guaranteed to be higher than previous estimates. And there’s unfortunately more. You see, not all eating disorders have to do with unrealistic body ideals. A good example is Avoidant/Restrictive Food Intake Disorder, or ARFID. The disorder was newly defined when the DSM-5 was published, and it’s characterized by a persistent failure to meet nutritional or energy needs with at least one more extreme consequence stemming from that, like needing a feeding tube. But people with ARFID don’t have body image distortion and aren’t looking to get thin or buff — it’s food or the act of eating itself that’s the issue. A recent study found that those who meet the criteria for ARFID more frequently report issues with things like the texture, flavor, or color of their food, or even a fear of choking. They often also have intense fear of trying or being made to eat new foods. So, in order to avoid all these potential anxiety triggers, they just kind of avoid everything to do with the foods that make them uncomfortable, even if that means eating very little or not getting the nutrients they need.
Generally, ARFID is associated with children, but these aren’t just cases of picky eating. Kids grow out of that. People with ARFID don’t, and symptoms can continue into adulthood. Yet, there’s no consensus on how prevalent ARFID is, which makes sense, as it’s a recently defined disorder. It seems to be more common in boys, and even if it’s not very common, it broadens our understanding of what an eating disorder is and who has them. It is then with increased awareness of just how diverse eating disorders can be, hopefully, we can get much better at identifying them and how they arise —which will make us even better at treating them. Although it’s often a long, hard road, recovery is possible —and it starts with a proper diagnosis.