Breaking Eating Disorder Stereotypes, Plus a 5-Step Practitioner Training to Improve Diagnosis
Co-authored by Gabrielle Simons, MS, RD, LDN, and Eliza Whitaker, MS, RDN, on July 1, 2024 — Medically Reviewed by Kathy Shattler, MS, RDN
Stereotypical beliefs about who is affected by eating disorders can lead to misdiagnosis or a lack of diagnosis for those who need treatment.
Photo by Clay Banks @claybanks/Unsplash
Eating disorders can affect people of all sizes, racial identity, socioeconomic status, sexual orientation, and gender identities.
Stereotypical beliefs about who is affected by eating disorders (EDs) can lead to misdiagnosis or lack of diagnosis for those who need treatment.
When individuals internalize stereotypes, they may not recognize signs of eating disorders or believe they deserve help.
Primary care doctors, psychiatrists, social workers, and dietitians working with diverse populations must be equipped with awareness and tools to screen and treat their patients for EDs.
Breaking the stereotypes is important to help people of color, people in larger bodies, people of gender identities other than female, and people with food insecurity to self-identify and seek treatment.
What are the different types of eating disorders?
The feeding and eating disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5TR) are:
Eating disorder risk factors
Eating disorders affect individuals of all genders, body sizes, socioeconomic statuses, and racial identities. Yet, many studies fail to be inclusive.
According to the National Eating Disorders Association (NEDA), it’s estimated that 9% of Americans, over 28 million people, will have an eating disorder during their lifetime. Those in larger bodies have the greatest risk of developing an eating disorder. This risk increases as BMI increases.
There are 10,200 deaths per year as a direct result of eating disorders, or one death every 52 minutes. Eating disorders are the second highest cause of death due to a psychiatric illness, just one spot behind the leading cause — opiate addiction.
There is no one cause of an eating disorder, but there are a number of risk factors, including biological, psychological and social risk factors.
Risk factors include, but are not limited to:
Family member with a history of an eating disorder
History of a mental health condition
History of dieting
Inadequate food intake due to food insecurity, dieting, fear of eating certain foods or food groups, and high energy expenditure compared to intake (i.e. in athletes)
Type 1 diabetes
Perfectionism
Cognitive inflexibility
History of substance use disorder
Weight stigma
Acculturation
Trauma history
Do I have an eating disorder? Self-assessment tests and quizzes.
If you find yourself asking if you have an eating disorder, speak to a trusted healthcare professional. Eating disorders are complex health conditions that require proper diagnosis and treatment.
Self-screening tools for individuals provide results and recommendations after completion. These tools can be helpful in identifying patterns and behaviors that may indicate an eating disorder, but they should not be used as a substitute for professional diagnosis.
Only qualified healthcare providers can diagnose an eating disorder.
The following tools are not meant to diagnose an eating disorder, but they can provide valuable information and help individuals make decisions about seeking professional help:
The Eating Disorders Screening Tool by the National Eating Disorders Association is appropriate for ages 13 and up. This tool can help determine if more support is needed. The results include recommendations for where to seek further support.
The Renfrew Center — a pioneer in eating disorder treatment since 1985 for adolescent girls, women, transgender, and nonbinary individuals — has several “quizzes” for self-assessment:
The Food Quiz by The Renfrew Center can help individuals determine if they have a healthy attitude toward food and eating.
The Body Quiz can help individuals determine if they have a positive view of their body.
The Emotion Quiz helps individuals determine if they are connected to their true and authentic selves.
What are the side effects of eating disorders?
According to the authors of a 2020 systematic review published in Current Psychiatry Reports, eating disorders “represent a significant public health concern, as they are associated with substantial psychosocial impairment, psychiatric comorbidity, medical complications, and suicidality.”
While eating disorders have a large impact on mental and emotional health, they also take a toll on the physical body.
For example:
Anorexia nervosa can contribute to osteoporosis, muscle loss, constipation, low blood pressure, infertility, and organ failure, amongst other complications.
Bulimia nervosa may result in electrolyte imbalances, severe dehydration, and gastrointestinal problems
Binge eating disorder can lead to high cholesterol, high blood pressure, and adult-onset diabetes.
These are just a few of the many complications associated with eating disorders.
Dismantling the SWAG stereotype
Historically, eating disorders were thought to mostly affect skinny white affluent girls, a pervasive mischaracterization known as the SWAG stereotype.
According to the authors of a 2020 review of emerging evidence on food insecurity and eating disorders, the stereotype “has shaped approaches to ED assessment, prevention, and treatment, as well as etiologic models.”
“For instance, ED assessment tools used extensively today were typically developed and validated in samples that largely fit the SWAG stereotype,” the study authors said.
Individuals who fall into this identity group also deserve care as much as anyone else. However, it is equally important to recognize that people who do not fit this identity group are at a higher risk of being undiagnosed or misdiagnosed and may face challenges in affording treatment.
Regardless of their identities or type of insurance, all people deserve access to adequate care and support.
The following section presents evidence that challenges the misconception that eating disorders only affect skinny, white, affluent girls (SWAG).
Skinny (Thinness)
Medical professionals diagnose less than 6% of individuals with eating disorders as underweight.
Providers may overlook patients with eating disorders if they assume the patients are underweight. This can lead to patients who need help not receiving the necessary screening and assessment. Additionally, many patients do not speak up about their eating struggles because they believe they are not sick enough, often because they are not underweight.
Someone in a larger body who is considered "overweight" or "obese" by medical institutions may receive advice on weight loss to manage conditions such as high blood pressure and diabetes. However, if this person has an underlying eating disorder, focusing on weight management could be inappropriate and may unintentionally cause harm or exacerbate symptoms of the eating disorder.
White
Black, Indigenous, and people of color (BIPOC) are affected by eating disorders at similar rates to white individuals.
The tragic and potentially fatal reality is that they are about half as likely to be diagnosed as white individuals.
In addition, they are less likely to be asked about ED symptoms by their medical providers than non-minority patients. Why this occurs is complex.
If people understand an eating disorder as only characterized by food restriction and being underweight, they may not recognize overeating and subsequent feelings of shame and guilt as issues worthy of medical attention.
Affluent
It is a myth that affluent people — individuals with a higher economic status — are more frequently affected by EDs.
In fact, binge eating disorder has a higher prevalence among people with food insecurity than those who are food secure. The affluent are more likely to access treatment, however.
The cost of eating disorder treatment can be enormous and is often not covered or minimally covered by insurance plans. It is estimated that for some individuals, full healing (what some call ‘recovery’) may take 2 years and cost around $250,000:
Outpatient counseling generally costs $150/session
Intensive outpatient treatment costs $1,500/week
Residential and inpatient treatment costs $2,000/day
For affordable or free support and treatment, please refer to the resources listed at the end of this article.
Girls (Women)
Women and girls are most often diagnosed with eating disorders, but these disorders also affect boys, men, gender non-binary, and transgender individuals.
In fact, 25% of people diagnosed with an eating disorder are men, a statistic that is likely underreported due to the stigma surrounding eating disorders. Men with eating disorders may not recognize their symptoms as signs of an eating disorder because it is often viewed as a problem affecting only women.
Additionally, transgender college students are diagnosed with eating disorders at four times the rate of their cisgender classmates. This could be related to accentuating specific gendered features, conforming to gender ideals of attractiveness, suppressing secondary sex characteristics, or even social stress.
A review of eating disorders in the transgender population suggests that some causal factors for eating disorder development in the trans population include gender dysphoria and various forms of trauma, including stigma, abuse, social discrimination, and exclusion.
Gender-affirming care often has weight requirements. These recommendations for weight loss could exacerbate an eating disorder. It is a tricky issue to navigate, and another reason why those working in gender-affirming care benefit from eating disorder awareness and training.
5-Step Health Care Professional Training to Improve Eating Disorder Diagnosis
As a healthcare professional, you can work to solve systemic issues leading to the underdiagnosis of eating disorders. This starts with recognizing that anyone can have an eating disorder.
The following five steps can be used to aid in the detection, diagnosis, and treatment of eating disorders so everyone struggling receives the care they need to heal.
1. Familiarize yourself.
Familiarize yourself with the range of feeding and eating disorders, and diagnostic criteria. A PDF document of diagnostic criteria for each disorder can be found here.
2. Screen your patients/clients.
There are multiple screening tools available for eating disorders. They are far from perfect for capturing all instances of EDs, but they are a good start.
Screening tools for healthcare providers:
SCOFF questionnaire: 5 to 7 questions
Eating disorder screen for primary care (ESP): 5 questions
3. Learn where to refer patients and clients.
If you screen, you need a plan for what to do when the screening results indicate a need for further assessment.
Does your practice or institution include an eating disorder professional, such as a doctor, dietitian, or therapist, who specializes in eating disorders?
This would ideally be someone with the Certified Eating Disorder Specialist (CEDS) certification or at least someone who has undergone training and receives supervision for their work with EDs.
Are there local or virtual providers who accept various insurance plans to whom you can refer your patients?
Can a social worker connect patients and clients to free resources, support, and services such as ANAD and Project HEAL?
4. Promote awareness among patients.
Promoting awareness of eating disorders in waiting rooms, offices, or other public spaces within primary care, nutrition, and therapy offices can help patients recognize eating disorder symptoms within themselves or loved ones.
One simple way is to keep literature in your office or waiting room about eating disorders.
Patients or clients can read about eating disorders while waiting for a visit. This experience could be eye-opening or validating for someone who never realized they may have a diagnosable, treatable condition.
An example of a brochure, which can be printed or adapted, is available in many languages here.
Note that this brochure does not contain any information about avoidant restrictive feeding and eating disorders (ARFID).
5. Pursue further training on eating disorders.
People with eating disorders have the best chances of full healing when receiving individualized care from healthcare professionals who have received specialized training.
There are many options for pursuing training, including webinars, books, and courses. The National Association of Anorexia Nervosa and Associated Disorders (ANAD) has webinars on a variety of topics related to eating disorders and recovery.
There are several books and guides that discuss complications, recovery, and standards of care for those with eating disorders, including:
Sick Enough: A Guide to the Medical Complications of Eating Disorders by Jennifer L. Gaudiani, MD, CEDS, FAED
Intuitive Eating: A Revolutionary Anti-Diet Approach by Evelyn Tribole, MS, RDN, CEDED-S, and Elyse Resch, Ms, RDN, CEDRD-S, FAND
AED Medical Care Standards Guide from the Academy for Eating Disorders (AED) Medical Care Standards Task Force.
If you’re looking for a course, a couple of options include:
Eating Disorders Bootcamp by Jessica Setnick MS, RD, CEDRD-S
$480 for individuals, and $2,100 for group at the time of publishing this article
Nutrition Counseling for Eating Disorders by Marci Evans MS, CEDS-S, LDN
$497 for individual registration at the time of publishing this article; group prices and equity prices available upon request
Disclaimer: Dietitian Insights and its collaborative members are not affiliated with any books, webinars, courses, or other resources mentioned in this piece.
The bottom line
Stigmas associated with eating disorders can make people believe that women and girls who are underweight with restricted eating are the only people who have an eating disorder; however, eating disorders can impact anyone, regardless of gender, body size, racial identity, or socioeconomic status.
The under-diagnosis of eating disorders leaves people to suffer without the care they need to heal. To change this narrative, healthcare providers can work to identify and screen those who exhibit all signs of eating disorders by pursuing training and offering support services to their patients or clients.
Free Eating Disorder Treatment and Support Services
Insurance navigation for ED treatment reimbursement:
IFEDD — The International Federation of Eating Disorder Dietitians
Peer Support:
ANAD provides free peer support through recovery mentors and support groups.
Provider Directories:
Other directories are listed on the National Eating Disorders Association (NEDA) website.
Assessment, treatment placement, cash assistance, and meal support:
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Dietitian Insights articles are authored by registered dietitians who utilize only high-quality sources, including peer-reviewed studies and reputable agencies, to provide the most up-to-date, evidence-based insights. Read our editorial process to learn more about how our content is medically reviewed and kept current and credible.
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Published July 1, 2024
Medically Reviewed By Kathy Shattler, MS, RDN
Edited By Kathy Shattler, MS, RDN, and Kelsey Costa, MS, RDN
Written By Gabrielle Simons, MS, RD, LDN, and Eliza Whitaker, MS, RDN
Note: All information in this article is for educational purposes only and should not be interpreted as medical advice. The reader should consult with a healthcare provider before using any supplements or making any dietary or lifestyle changes. Read the full medical disclaimer.
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