What does a person with an eating disorder look like? The picture may not be as clear-cut as many people think. Researchers at Washington University in St. Louis led a groundbreaking study with an important lesson: Eating disorders don't discriminate.
"There's been a perception that eating disorders mostly affect thin, white women," said Ellen Fitzsimmons-Craft, an associate professor of psychological and brain sciences. "Our study of college students dispels that myth."
The study, funded by a National Institute of Mental Health grant, surveyed 29,951 students from 26 colleges and universities, including WashU. Two-thirds of respondents were female. The students were asked to answer a series of questions about their health, including their mental health and their attitudes toward food and body image.
Thirteen percent of respondents showed signs of eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder — an unprecedented insight into the magnitude of the crisis on campus.
Importantly, the risk of eating disorders was relatively similar for white, Black, Asian, and Latino students.
"No matter their racial or ethnic background, these students all live in a culture that encourages or expects individuals to conform to certain body ideals," said Fitzsimmons-Craft, also an associate professor of psychiatry at the Medical School. "These findings show that eating disorders can happen to anyone."
The study was published in The International Journal of Eating Disorders. Co-authors include Carli Howe, a research coordinator with the Center for Healthy Weight and Wellness; Mia Kouveliotes, an undergraduate studying global health and environment; Zhaoyi Pan, Lawrence Monocello, and Marie-Laure Firebaugh from the Department of Psychiatry in the School of Medicine; and Denise Wilfley, a professor of psychological and brain sciences and of medicine, pediatrics, and psychiatry in the School of Medicine.
The most common eating disorders found in the study were bulimia nervosa, a condition marked by regular bouts of binge eating followed by self-induced vomiting or purging, and binge eating disorder, in which a person engages in regular binge eating (but without the accompanying behaviors seen in bulimia nervosa), often in response to negative emotions, like feeling upset or stressed. Combined, those disorders were seen in 13% to 18% of women (depending on race) and 10% to 12% of men. Anorexia nervosa, a condition that causes people to severely limit food intake out of an intense fear of gaining weight, was much less common, affecting 2% to 4% of women and less than 1% of men.
There were some minor differences between racial groups. Asian women, for example, were more likely than other women to show signs of anorexia nervosa, while Hispanic women were most likely to show signs of bulimia nervosa or binge eating disorder. Importantly, while the big picture looked similar for everyone, where differences did emerge, students from historically underrepresented racial and ethnic groups often had a higher prevalence, dismantling the stereotype that eating disorders mostly affect white women.
Anorexia nervosa can have noticeable symptoms, but other, more common types of eating disorders can be completely hidden from others, even close friends and family, Fitzsimmons-Craft said. "You would never know if someone had bulimia nervosa or a binge eating disorder based just on how they looked," she said. "Even doctors can miss these problems, especially if the person doesn't fit the stereotype."
The study found that eating disorders often go hand in hand with other psychological problems. For example, up to 78% of women and 68% of men with eating disorders also showed signs of major depressive disorder. "In the past, health professionals would often put eating disorders and other psychological problems in completely different silos," Fitzsimmons-Craft said. "That approach caused a lot of damage."
The new findings underscore the need for counselors, doctors, and others to ask about eating habits when treating someone for depression, anxiety, alcohol use disorder, or another mental health concern, Fitzsimmons-Craft said. "These are treatable problems, but early identification is really the key."
Fitzsimmons-Craft and Wilfley are working to provide resources for people with eating disorders through Body U, an online program funded by the Missouri Eating Disorders Council, part of the Missouri Department of Mental Health. The program, available to all adults in Missouri, provides individuals with access to online screening for disordered eating and then offers individuals access to free, tailored online programs to meet their needs. When appropriate, users will receive referrals to health providers.
Body U is now available in every public university in Missouri through close partnerships with all 13 public universities in the state, a level of outreach and programming to address eating disorders unmatched by any other state in the country. With a grant from the U.S. Department of Health and Human Services, Fitzsimmons-Craft and Wilfley have also brought Body U to six public school districts and two private schools serving middle and high school students in Missouri, providing an important resource for young people at a time when eating disorders often first take hold.
"We're going to stay committed to these efforts," Fitsimmons-Craft said. "We want awareness about eating disorders to become part of the culture, and we want widespread access to screening, prevention, and treatment to become the norm, not the exception."
