Eating is a daily practice that helps nourish our bodies by keeping them strong and healthy. It is the “fuel” that provides energy for the day. Eating habits may become unhealthy patterns ladened with guilt and shame
Eating disorders are some of the most challenging mental illnesses and are serous, life-threatening conditions. Affecting one in 20 people during their lifetime, eating disorders frequently occur in people with other mental illnesses, including depression, anxiety disorders and substance abuse issues and as with other mental illnesses, early identification and early intervention are keys to recovery.
NAMI joins NEDA this week in support of the aim to ultimately prevent eating disorders while reducing the stigma surrounding these conditions and improving access to treatment.
NAMI recently spoke with Andrea Vazzana, Ph.D., a clinical psychologist and eating disorders specialist, to learn more about eating disorders and how to help a friend or loved one living with one of these conditions.
NAMI: What is the current prevalence of eating disorders in America?
Vazzana: Overall, over 10 percent of young women currently meet criteria of one of the eating disorders, anorexia nervosa, bulimia nervosa or eating disorder NOS (not otherwise specified). The new Diagnostic and Statistical Manual (DSM5), set to publish in May this year, includes binge eating disorder as a mental illness. Men can also live with eating disorders. While the prevalence of men to women was previously thought to be a ratio of 1-to-10, it is now believed that the ratio is closer to 1-to-6, meaning that six times more women than men have the condition. Although not as common in men, it is important to recognize that more men are now being treated for these mental illnesses.
Some believe that eating disorders are more prevalent in women because of what is called the “thin-ideal”. Biology and environment are both contributors to this condition, and researchers have found that the cultural pressure to equate thinness with beauty, as well as some sports that encourage low body fat and thinness, are factors. It is not always the ideal cultural “think” to equate thinness in men and therefore that social factor is often removed. Still, there are some sports and cultures where being thin is idealized and therefore a contributor.
What are the types of eating disorders and are there any recent changes in prevalence and conditions?
Vazzana: Eating disorders NOS, will be changing with the new DSM, to be published in May. The criteria and diagnosis will change. Binge eating will be a full-blown disorder all on its own. Binge eating disorder is similar to bulimia in that it includes the binging, but not the purging, aspect of the condition.
What are the most common co-occurring disorders (mental health conditions)?
The most common is depression and dysthymia, what some consider a less-severe but often longer lasting condition than depression. Half to three-fourths of those with eating disorders meet the criteria for depression in their lifetime, and there is a direct relationship to malnourishment and depression.
In addition to depression, the other most common co-occurring conditions are anxiety disorders, specifically social phobias and, with people living with anorexia, OCD, which impacts about 25 percent of individuals with this condition.
Substance abuse, particularly alcohol abuse, is co-occurring in about 5 percent of people living with anorexia and from 25-40 percent of people living with bulimia.
Personality disorders are also common co-occurring conditions, particularly for people living with bulimia.
What are current treatment options available and what are likely outcomes?
Recovery from eating disorders is possible. The right treatment choice depends on the type of eating disorder, but treatment approaches are often similar for the various conditions, and coordination of care between mental health care providers, nutritionists and medical professionals is important, depending on the individual’s treatment plan. Nutritional guidance, as well as individual and family counseling, is an important treatment options to consider.
The best rates of recovery for people living with bulimia involve cognitive behavioral therapy (CBT) where the focus is often on normalizing weight and eating behaviors and challenging distorted thinking patterns that are usually associated with this condition. One of the goals is to interrupt the thought pattern that leads to individuals evaluating themselves in terms of shape and weight. Individual therapy is often another key to recovery.
The best rates of recovery for people living with anorexia include treatment plans that incorporate family-based therapy, often the Maudsley Method, which is often used for adolescents and children with Anorexia still living at home. This intervention involves parent coaching to encourage feeding their children to help restore their weight—eating meals with them and encouraging eating. With anorexia, it is important that the individual restore their weight as soon as possible; the longer they are in a danger zone of thinness and malnutrition, the worse the outcome. Early intervention is key; people living with anorexia (about 5 percent) have the highest probability for mortality, including death by suicide.
In addition to psychotherapies, medications, specifically, selective serotonin reuptake inhibitors, SSRIs, a type of antidepressant medication, are sometimes used in patients that are responding to CBT as an adjunct therapy.
What myths are the most common and what stereotypes exist that create barriers to understanding and treatment?
The myths surrounding eating disorders are vast and include myths primarily around race, age and social economics.
When people think of anorexia, they often mistakenly think of young, white, high social status females. This is not the case. There are 5-10 million people in America who have eating disorders, and one out of 6 are men, who more deeply experience the negative aspects of stereotypes and have unique barriers to treatment and acceptance.
We also know that eating disorders do not just affect white women. The rates are as common in young Hispanic and Native American women as they are in Caucasian women. With African American and Asian American women, however, there does seem to be a lower prevalence, with the exception of pre-adolescent African American girls. With Caucasian girls, the prevalence is lower and rates increase with puberty and continue to increase as into early adulthood.
Age is another myth; eating disorders do not just affect teens and young adults. More and more are being diagnosed for the first time in middle age. And unless effectively treated, eating disorders will last into adulthood for many.
How can someone help a friend or loved one who may have or one who is living with an eating disorder? How should they/could they intervene if needed and how can the provide support?
Regarding intervention, the key to remember is that the earlier the better. In terms of identifying a problem, it is important to know that it is common to have body dissatisfaction. Most women are more critical. However, when they go beyond dissatisfaction and they are harshly critical and disparaging of their bodies, and when there is noticeable evidence of over-thinness and over concern about food and weight, there may be a problem.
Some people mistakenly wait to intervene, thinking that the individual may grow out of their condition. The best thing to do is to let them know about your concern. You have observed behavior—talking poorly about their body, other signs—and you just want to be honest. Saying something like, “I have noticed these things and I am concerned about your health,” without being judgmental, can be the most natural first step. Because individuals living with eating disorders are generally already self-critical, it is important to so separate the illness from the individual. Try not to focus comments on appearance but rather focus comments on health by expressing concerns and the need for further medical evaluation. Recognizing that people with eating disorders often consider being thin with success, being persistent and consistent while avoiding criticism and comments on thinness, is important.
After an individual is in treatment for an eating disorder, one of the best things a family member or parent can do is to get family-based treatment or therapy. During meals, families and friends should try not to be angry even if they see their friend or loved one struggling with eating. Working to avoid impatience can be challenging, but neutral and supportive reassurance offer the best outcomes.
It is important that friends and family strive to avoid commenting on appearance. Avoid comments like, “You’re gaining some weight, that looks great!” Compliment other things, perhaps superficial aspects of clothing, conversations, other activities and contributions, but avoid mentions of size or appearance if possible.
What do you think is the most important thing for people to know about eating disorders?
The importance of intervening early! Treatment works best the earlier you can begin it. The longer the condition persists, the more deadly it becomes with more physical complications to manage.
Andrea Vazzana, Ph.D.,is a clinical assistant professor of child and adolescent psychiatry at the NYU School ofMedicine and a licensed psychologist at the Child Study Center.
People often think “Eating disorders are a woman’s disease.” This myth is constantly reinforced by character portrayals on television, targeted advertisements, and even studies and articles that draw from exclusively female samples. The sad reality is that eating disorders affect any and all genders, and those who do not identify as female may even suffer more with the very diagnosis of their disease due to the stereotype that eating disorders are feminine. Therefore, although eating disorders affect each individual differently, it is important to consider one’s gender identification in order to increase efficacy for prevention, detection, and treatment of the disease.
Why do men get eating disorders?
While beauty standards for women emphasize thinness, men are taught to prioritize muscle gain. Similar to women’s beauty standards, this fixation on strength derives from cultural gender norms and is perpetuated at a very young age. Throughout the past five decades, the muscles on action figures have been getting significantly larger. Comparable to the physically impossible size measurements of Barbie, the 1998 Wolverine doll had a waist the size of its bicep and half the size of its chest.1 One study confirmed that male college students who were assigned to play with the most unrealistic action figure dolls then reported the lowest levels of self-esteem.2 Another study found that men’s confidence surrounding their physique plummeted after watching music videos that featured hyper-muscular stars. Even more fascinating—researchers still observed this drop in self-esteem after the male participants watched music videos in which the main star did not have outrageous bulging muscles, but rather, was a more realistic depiction of an average (white) American male.3 These unanimous declines in body image indicate that men are deeply susceptible to ingesting harmful media standards, and these standards can take a lifelong toll on their body image.
What do eating disorders look like for men?
These dips in body image can oftentimes lead men to develop an unhealthy fixation on their build or, in some cases, an eating disorder. The estimated rates of men with eating disorders vary. Some studies cite that for every 10 women with an eating disorder there is 1 man with the disorder1, 4, while other studies indicate that 25% of eating disorders occur in men5. The discrepancy in these statistics is due to the fact that many men with eating disorders do not report their disease, due to shame and fear of suffering from a “female” issue. Another stereotype is that the men who are diagnosed with eating disorders are predominantly homosexual. This assumption has been widely disproved, and in fact 80% of men with eating disorders are heterosexual.4 That being said, confusion surrounding sexual orientation can be a contributing cause for eating disorder in some men, so it is important to acknowledge sexuality during the treatment process.
Men can suffer from any and all types of eating disorders, but some of the most prevalent eating disorders among men are binge eating disorders or exercise addictions. As for the former, American culture is actually more accepting of men with binge eating disorder than their female counterparts. This acceptance is positive for men who may avoid emotional scarring from fat shaming, but it is negative for men who are enabled to continue binge eating because their symptoms are not validated as being disordered eating, and therefore they are significantly less likely to seek treatment. However, the severity of binge eating disorder among men should not be minimized. A recent article, which profiled men with binge eating disorders, included testimony from a man whose early life traumas caused him to weigh 724 pounds by the time he was 34 and from another man who gained and lost 100 pounds 4 times throughout his life.4
Exercise addiction, sometimes called Anorexia Athleticism, is also prevalent among men with eating disorders.1 These addictions usually stem from a cultural aversion to softness, particularly in men.6 Many of the behaviors characteristic of this addiction are similar to those of anorexia, including restlessness, physical over-activity, and self-starvation.1 This addiction can also lead men to develop substance abuse problems, particularly with steroids. Over two million men in the United States have reported using anabolic steroids at some point in their lives, and while these drugs do not have any immediate effects, they can have disastrous physical and emotional long-term effects, such as high cholesterol, depression, and prostate enlargement.1
How do we treat men with eating disorders?
Because there are so few studies on men with eating disorders, there is not enough substantive literature that indicates how (or if) eating disorder treatment should vary between men and women. However, there are some known factors to bear in mind when treating male eating disorder clients. While women are more susceptible to developing eating pathology if they have a history of feeling fat, men have a much greater risk of developing an eating disorder if they were actually obese during childhood.1 Additionally, men who have a history of sexual trauma are more prone to develop an eating disorder due to the body image disturbance that can occur as a result of their abuse.1 Men who experience a sexual assault can also develop a drive to build their muscle mass because they believe that becoming stronger and more masculine will make them more prepared in the event of a future threat.1 Additionally, depression can be a major cause of eating disorders, but since depression is also stigmatized as a “feminine” disease, it can go severely underreported.1
Men who have confusion surrounding their sexuality may find comfort in starvation, especially because anorexia can lower their testosterone levels and lead to asexuality, so by wiping out their sexuality altogether they no longer have to cope with the internal worry.1 However, this can make treatment much more difficult because regaining weight will unleash any sexual feelings they may have been repressing, which restarts the sexual discovery many men dread. Eating disorders are also common among men who identify with an “undifferentiated” or “feminine” gender role. Therefore, understanding the sexuality and gender of a male patient is imperative in order to grasp the underlying influences for one’s eating disorder.
Finally, many male eating disorder clients who engage in excessive exercise have Muscle Dysmorphia, which is categorized as an obsession with one’s body or muscle size.1 However, since there are no official diagnostic criteria relating to food or diet, it is not technically considered an eating disorder, even though the symptoms and treatment suggestions are almost identical to those for eating disorders.1 Therefore, treatment practitioners must be able to identify the ways in which Muscle Dysmorphia manifests and may contribute or cause an eating disorder.1
Although there is still major progress to be made in the depiction of eating disorders as diseases that affect all genders, there is promising evidence to suggest that men can successfully recover from eating disorders. However, because men are taught a completely unique set of beauty standards, their eating disorders manifest in many different ways and they require specialized treatment that reflects these cultural gender differences. The sooner we abandon the stereotypical notion that eating disorders exclusively affect one group of people, the quicker we can pave the way for reduced stigma, access to recovery, and a bright future for all eating disorder clients.
Trigger Warning: Eating Disorders
The holidays can be stressful for someone who is struggling with an eating disorder. We get it. A lot happens this time of year—extra family time, busy schedules, social gatherings—and most of it centers on food.
To help you prepare for the upcoming holidays, our staff has come up with some tips and words of encouragement. Add any or all of them to your recovery tool box for Thanksgiving and other upcoming holiday events.
- Continue doing what works for you despite the fact that your schedule may change, stress may increase, and time may be short.
- Remember: it’s progress, not perfection.
- Have a plan for food and skills to use during the day.
- Keep practicing self-care by feeding yourself, getting enough water, moving when/if/how it makes sense for your body, resting when you need to, and connecting with others.
- All foods fit, and your body knows how to use them.
- Allow yourself to ask for more support from others you trust, whether that be family, friends, or treatment team members.
- Remember that although it may seem like everyone is sharing happy memories with their loved ones, not everyone is and it’s okay since that is often real life. Stay away from social media if it allows you to have a more realistic picture of the world.
- Consider what would make you enjoy the holiday season more, whether that be doing something traditional, such as baking or going to church, or something less traditional, such as getting a pedicure or volunteering. Make the holiday season your season, not something that you think it should be.
Wishing you all a happy holiday season!