Evidence shows a number of biases that can be inbuilt, even in clinical settings, and demonstrates some considerations around under-represented groups that healthcare practitioners should be aware of.
Dr Gary Cooney, Consultant Psychiatrist in Eating Disorders here in St Patrick’s Mental Health Services (SPMHS), explores some of the difficulties in detecting eating disorders and looks at some groups which can be under-represented in eating disorder treatment because of these difficulties.
Challenges in detecting eating disorders
Some common eating disorders tend to go under the radar as the emphasis can be put on more well-known eating disorders, such as anorexia and bulimia. For example, in our wider culture – such as in education, media, literature, social media, film and so on – there is a lot of emphasis put on anorexia nervosa and bulimia nervosa, which may come at the cost of some other eating disorders which may be even more common, such as binge eating disorder. There can be a sense of some of those other eating disorders being overlooked sometimes.
Often, there is a belief that someone with an eating disorder would have certain, obvious signifiers in relation to their weight, size, shape and so on, which isn’t always the case. Physical health supports can very often become the clinical focus, particularly for people in larger bodies, without looking into the psychiatric or psychological factors which might be driving the person’s presentation to a clinical setting in the first place.
Similarly, there can be misconceptions around the typical profile of a person with an eating disorder being that of young, white, cisgender, women and girls of middle class backgrounds. The difficulty with this is that people who don’t fit that bill can then become more difficult to detect and take longer to identify. It’s important not to take a person’s appearance or profile as a sign of reassurance and not to neglect the possibility that they may have an eating disorder.
Under-represented groups
Because of these challenges, there are a number of groups who aren’t stereotypically thought of as being at risk of eating disorders and where, as a result, eating disorders can be harder to detect. In turn, this means a significant proportion of people with eating disorders are underserved.
While this does create obstacles for people in these groups experiencing eating disorders, it’s important to be aware that there is increasing recognition of the need to consider these under-represented groups, with more research being undertaken and evidence found in this area. This growing body of work and increasing awareness should help to overcome of these obstacles in detection for these groups, some of which are explored below.
Eating disorders in men
Eating disorders in men are important to consider. In certain eating disorders, such as binge eating disorder, the lifetime prevalence is fairly equal between men and women, with 2% to 3% of both experiencing this in their lifetimes. Some other eating disorders see a higher lifetime prevalence among women than men: with bulimia nervosa, for example, 1.3% of women experience this in their lifetimes compared to 0.5% of men, which is roughly a three to one ratio. However, in clinical practice, these proportions aren’t always reflected in the profile of patients, with often a much higher majority of women in treatment.
This leads to questions about where the gap is coming from. Evidence suggests that men perceive their eating disorders to be less severe or less distressing than women. It indicates that they may also be slower to accept that they’re experiencing an eating disorder, because of the bias or stigma around eating disorders in men. It also shows that there may be higher genetic loading and worse adverse experiences in early life for men who present with eating disorders, which suggests they may be further along in their illness or that their illness may be more severe before it comes to attention.
In addition, even though there’s more movement away from using Body Mass Index (BMI) to measure the severity of eating disorders, it is still used when we think about individuals and where they sit in relation to eating disorder risk profile. Men and women are of different builds, however, so the BMI scale doesn’t work equally for both groups. Men are at a higher risk for every point on the BMI scale compared to women. This is something that perhaps isn’t thought about as often as it should be.
Eating disorders in the transgender community
There are high levels of eating disorders in the transgender community. A large study suggests that 7.4% of people in the transgender community experience eating disorders, while other studies show that between 2% and 20% if people who have gender dysphoria or who are transgender may be experiencing symptoms of an eating disorder.
The model of the origins of eating disorders for people in the transgender community may be to do with discrimination they face, peer rejection or alienation they experience, or the difficulty of living with gender dysphoria and the barriers to healthcare associated with that. A study from the University of British Columbia showed consistent themes of food restriction and other eating disorder behaviours to delay the onset or progression of puberty. This indicates that, for some people experiencing adolescence and gender dysphoria who is alarmed at the onset of puberty, they may use a restrictive mechanism to try to prevent or delay their body changing. This might create an established framework of coping strategies or mechanisms they find helpful to address the emotional or psychological difficulties they are facing.
Eating disorders in ethnic minority groups
Evidence from the United Kingdom (UK) and United States (US) shows that people in Western societies from a non-Caucasian (non-white) background are less likely to receive support for mental health in general, including eating disorders. A large study from 2013 also showed that, in Western society, people from ethnic minorities are also less likely to seek treatment to begin with, less likely to receive treatment when they do seek help, and less likely to receive a diagnosis or referral to a specialist service.
Eating disorders and food insecurity
Stereotypes about eating disorders affecting people of middle class or people of wealth are common. However, there is increasing evidence of a link between eating disorders and food insecurity.
Food insecurity is defined as the experience of not having enough access or resources to provide sufficient and nutritious food. Evidence shows that food insecurity is linked with all forms of eating disorders, but that, very often, people with eating disorders of this origin can go under the radar.
Many screening tools used around eating disorders focus on areas like body image, shape, fear around gaining weight, and so on, without looking at some of the other aspects of why food restriction may be established.
For example, there is evidence that, where people don’t have access to funds and therefore cannot afford to feed themselves or their families, they may go through periods of restriction, which are not unlike someone with restrictive eating disorders such as anorexia. If that’s followed up with a period of time where there’s a little more money available, the person can be exposed to what’s called “swamp effect,” where they’re surrounded by cheap and highly palatable, or enjoyable, foods. This can trigger a process around binge eating, and some of the compensatory behaviours, like purging, or getting sick on purpose.
While the origins of eating disorders may be different for people in the context of food insecurity, there is a very similar range of thought processes, emotions and behaviours to those found in eating disorders of other origins.
Eating disorders and older adults
A significant proportion of people in older age can experience eating disorders. In people aged over 40, 3.5% of women and up to 2% of men experience eating disorders. However, it can be very difficult to detect eating disorders in an older population. This can be related to misunderstandings that eating disorders affect younger people only, and difficulties for people in middle or older age to overcome stigma or a sense that, at this stage of life, they should have matured enough not to have a difficulty or to have been able to get help sooner.
Eating disorders can also be mistakenly linked in older age groups to sporting interests, athleticism or similar. Weight loss can also be put down to physical health problems too. All of this means eating disorders can be missed or harder to identify.
Eating disorders and autism spectrum disorder (ASD)
There is increasing awareness around ASD in society and some people with ASD do experience eating disorders also. For example, avoidant-restriction food intake disorder (ARFID) can have a lot of overlap with ASD and how disordered eating can occur, in the context of people being very specific about what they will and won’t eat, or having strong reactions to certain textures, certain colours, certain smells and flavours. This can lead to nutritional difficulties or cause physical problems. There is growing development around our understanding of ARFID, including its overlap with ASD, with increasing focus on its overlap with ASD coming down the tracks, which is to be welcomed. Being mindful in this way of the specific needs of people with dual diagnosis or diagnoses beyond eating disorders only, such as ASD, is something to be particularly aware of in clinical practice.
