Beyond #SkinnyTok: What you need to know about eating disorders
#SkinnyTok was all over the news this summer, and even though the hashtag has been banned, it’s just the latest in a long line of controversies around body image, diet culture and eating disorders.
It’s estimated that 28.8 million Americans – or roughly 9% of the U.S. population – will develop an eating disorder in their lifetime. Eating disorders are serious illnesses with a high mortality rate – and yet, most of us don’t know much about them beyond the depictions we encounter on TV, in movies, or on our social media feeds.
We asked two faculty members from the School of Nutritional Sciences and Wellness (SNSW) to help us understand what they are, who’s at risk, and what to do if you’re struggling.
What is an eating disorder?
Put simply, an eating disorder is a mental, behavioral and/or physical condition marked by significant disturbances in a person’s eating behaviors. The “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” (DSM-5) currently recognizes seven eating or feeding disorders: anorexia nervosa, bulimia nervosa, binge-eating disorder, avoidant/restrictive food intake disorder (ARFID), pica, rumination disorder and other specified feeding or eating disorder (OSFED).
Many – but not all – eating disorders involve preoccupation with or anxiety about weight, body size or shape. Other common features include food restriction and feeling a loss of control or other distressing emotions around food and eating.
| Anorexia Nervosa | Characterized by food restriction leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health; intense fear of gaining weight or becoming fat; disturbance in the way one's body weight or shape is experienced |
| Avoidant / Restrictive Food Intake Disorder (ARFID) | Characterized by an apparent lack of interest in eating of food, avoidance based on sensory characteristics of food, or fear of aversive consequences of eating. Associated with significant weight loss, failure to thrive or growth challenges in children, and significant nutritional deficiency. |
| Binge-Eating Disorder | Characterized by recurrent episodes of binge eating, which includes eating much more rapidly than normal, eating until uncomfortably full, eating large amounts of food when not feeling physically hungry, and/or experiencing feelings of shame and guilt after eating; feeling a loss of control over eating during an episode. Episodes occur, on average, at least once a week for three months. |
| Bulimia Nervosa | Characterized by recurrent episodes of binge eating, followed by compensatory behaviors in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise. Cycles occur on average, at least once a week for three months. |
| Pica | Persistent eating of nonnutritive, nonfood substances over the period of at least one month in people over the age of 2 years old. |
| Rumination Disorder | Characterized by repeated regurgitation of food - which may be re-chewed, re-swallowed, or spit out - when not attributed to an associated gastrointestinal or other medical condition. |
| Other Specified Feeding or Eating Disorder (OSFED) | Applies when symptoms characteristic of a feeding or eating disorder that cause clinically significant distress or impairment occur but do not meet the full criteria for any of the other feeding and eating disorders. Includes atypical anorexia nervosa, low-frequency or limited-duration bulimia nervosa or binge-eating disorder, purging disorder, and night eating syndrome. |
Eating disorders exist on a spectrum of severity, said Ashley Carrillo, an assistant professor of practice in SNSW and registered dietitian.
“Two people can have the same diagnosis, but it presents differently depending on how severe it is,” she said. “That can make it confusing for folks, because they may feel like, ‘I don’t have this symptom or that symptom, so I don’t need to get help,’ even when they do.”
She also noted that someone can experience disordered eating behaviors even without meeting all the criteria for a formal eating disorder diagnosis.
“Disordered eating behavior still includes some of the symptomology of eating disorders, like food restriction, compulsiveness, eating associated with guilt or shame, and so on,” she said. “A lack of diagnosis doesn’t necessarily mean there isn’t an issue.”
Who do eating disorders affect?
There's no "type" when it comes to eating disorders.
“Anyone, of any age, gender, race, ethnicity, body size, sexual orientation or socioeconomic status can be affected by eating disorders,” Carrillo said. “They really don’t discriminate. The discrimination piece shows up on the back-end – who can access healthcare, who can get a diagnosis, who can access treatment.”
The persistent cultural understanding of eating disorders as primarily affecting young, white, cis women can prove a barrier to diagnosis and treatment.
An example of this is atypical anorexia nervosa, a sub-type of OSFED in which an individual meets the criteria for anorexia nervosa but doesn’t fall into an underweight category according to the body mass index (BMI). It’s also the most common form of anorexia, according to Carrillo. In fact, fewer than 6% of people with eating disorders are medically diagnosed as “underweight."
“A person with atypical anorexia doesn’t fit the emaciated appearance we tend to associate with eating disorders,” she said. “This might mean it takes them longer to be diagnosed, or they may have trouble getting approved for treatment.”
Athletes are another group who doesn’t fit the cultural stereotypes around eating disorders – and that’s a problem, according to Carmen Fleming, an associate professor of practice in SNSW who specializes in sports nutrition.
“It’s a common misconception that athletes don’t develop eating disorders because physically, they’re very high functioning,” she said. “They’re really fit, they’re not eating junk food, they’re exercising. But the reality is that athletes – or people who just consider themselves athletic – are about 2 to 3 times more likely to develop an eating disorder than the general population.”
Fleming thinks it shouldn’t be surprising that athletes are at higher risk of disordered eating.
“Athletes often have perfectionistic tendencies, a drive for a specific kind of success, and that is closely associated with eating disorders," she said.
She said that in her experience, there’s a higher incidence of eating disorders among participants in “aesthetic” sports like gymnastics, diving and synchronized swimming– where bodies are more on display.
“You see them in sports with weight classes, too,” she said. “But it isn’t just those sports. I’ve seen eating disorders in rowers, horse jockeys, cross-country runners, track and field athletes – it can touch any athlete, really.”
What are the risk factors for developing an eating disorder?
While anyone can develop an eating disorder at any time, there are biological, psychological and social factors that can increase a person’s risk.
Biological risk factors include genetics, a family history of eating disorders, other mental health conditions, type-1 diabetes and a history of dieting.
“Dieting, especially at a young age, is one of the number one predictors of disordered eating and eating disorder development,” Carrillo said. “Even seeing adults diet or speak negatively about their own bodies during childhood or adolescence can be predictive of disordered eating.”
Psychological factors like perfectionism, anxiety, depression and body dysmorphia are common in people with eating disorders, as are social factors like experiences of shaming or even bullying associated with body size or shape.
“We’re constantly exposed to idealized bodies through all kinds of media,” Carrillo said. “And because of cultural narratives around weight, size and health, there’s a lot of pressure to achieve or maintain a certain type of body. All of that gets internalized, and for some folks, it can push them into disordered eating behaviors.”
Carrillo said that a history of trauma or food insecurity also increases risk for developing eating disorders.
“If there was a period of time where food wasn’t abundant, you’ll often eat differently because you don’t know where your next meal is coming from,” she explained. “And even when food becomes abundant, that learned behavior - that trauma - stays with people.”
Timing is also a big factor in eating disorder development.
Carrillo said that periods of high stress, like going to college, moving, changing jobs or the death of a loved one can trigger eating disorders.
“This is true for transitional moments too, especially if the body is changing – like during puberty, having children, menopause,” she said. “These times can feel very out of control, and controlling our food intake can give us a sense of safety. But then, the more we try to control our food, the more an eating disorder can start to control us.”
Do eating disorders present differently in different populations?
They do.
“We tend to associate eating disorders with women, but as we’ve said, anyone can develop an eating disorder regardless of gender,” Carrillo said. “They absolutely occur in male-identifying folks, and they present differently in those populations.”
She explained that for men and male-identifying individuals, the physical ideal is less about shrinking the body and more about being lean and muscular.
“The colloquial term is ‘bigorexia,’ she said. “It’s an obsession with muscle and lean body mass. Sometimes you see it in episodes of bulking and cutting to make your body look a certain way, to get that six-pack or big, broad shoulders – that superhero image.”
Masculine-coded disordered eating can also look like an obsession with protein shakes or supplements, weighing food, or stepping on the scale before and after eating.
What should I look for if I think someone in my life may have disordered eating?
Carrillo and Fleming agree that while it can be difficult to spot warning signs for disordered eating, it is possible if you know what to look for.
“Number one in my mind is avoiding eating with others, or avoiding social situations where there’s no control over the food that’s provided – like eating in restaurants or eating in groups,” Fleming said.
Other signs can include lying or secrecy around eating, compulsive exercise – even during illness or injury – and unexplained weight loss or gain.
“Honestly, if you’re close to someone and you start to notice a weird vibe around eating, that could be an indication that something’s going on,” Fleming said.
Carrillo pointed out that for some people, even benign food restrictions like vegetarianism or veganism can pose a risk in the form of orthorexia, or an obsession with correct, virtuous or “clean eating.”
“It comes down to whether there’s an obsessive preoccupation with ‘eating right,’” she said. “If you’re spending a ton of mental energy on eating perfectly, or if there are emotional consequences for eating imperfectly to the point that it affects your quality of life, that’s a sign that you may be sliding towards disordered eating.”
Where can I go for help with disordered eating?
University of Arizona students have access to eating disorder resources through Campus Health.
“Campus Health has several registered dietitians who can see students one-on-one,” Carrillo said. “There’s also a great group called Food and Mood, which meets weekly and is facilitated by a dietitian and a therapist.”
Non-students can find educational resources and screening tools on the National Eating Disorder Association website.
“You can also find information about treatment programs and support groups there,” Fleming said. “I would direct anybody who is struggling – or who knows someone who might be struggling – to that website as a starting point.”
Carrillo pointed to Una Bella Vita as another potential resource for Tucson residents. She also suggested that people who might have difficulty accessing eating disorder treatment visit Project HEAL, a nonprofit organization focused on equitable treatment access for eating disorders.
“They connect folks with the support they need,” she said. “They have a lot of free resources, or they can help pay for treatment if someone can’t afford it.”
Carrillo and Fleming agree that getting educated about eating disorders is essential for increasing awareness, improving prevention and treatment, and reducing stigma.
“Disordered eating is so much more common than people think,” Fleming said. “Nobody is immune. Pressure to look a certain way, or perform a certain way, or have a certain diet is everywhere, and it can lead to some really dark places.”