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Eating Disorders Myths Busted - Myth #5: Eating Disorders are the province of white upper-middle class teenage girls

Myth # 5: Eating Disorders are the province of white upper-middle class teenage girls

In this fifth of a series of videos debunking nine myths about eating disorders, Cynthia Bulik, Ph.D., of the University of North Carolina, explains that eating disorders affect women and men across the lifespan.  The video was excerpted from a talk, "Eating Disorders Essentials: Replacing Myths with Realities," presented at the NIMH Alliance for Research Progress Winter Meeting, February 7, 2014 in Rockville, MD.

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So another myth – that eating disorders are somehow the province of white upper middle class teenage girls. Another one that's got to go. The number of middle age women that come into our clinic and say that they went to their physician and were told by their physician that they can't have an eating disorder because that's only for teenagers. Or the number of guys that show up and have the courage to say, “I think I'm suffering from this women's illness,” and then their physician puts them through a huge battery of tests because you can't have a teenage girl's illness. That's the kind of things we're still running into out there. Running into out there that we need to get into medical education to change people's perceptions about who is affected by these disorders. Eating disorders absolutely do not care about your race, your ethnicity, your sex, your socioeconomic status. They cut across all of those lines. And so, we need to be vigilant and aware for everyone who comes through the door who might be at risk for these disorders. So these are the official U.S. epidemiological statistics. So anorexia nervosa, about one percent in females, about three percent in males. Bulimia, about 1.5 percent in females, .5 percent in males. Binge eating disorder as you can see is the most common eating disorder, afflicting about 3.5 percent of females and two percent of males. And this is just binge eating behavior. So binge eating just as a behavior occurs in about five percent of females and four percent of males. That all translates to about 14 million Americans – and that number is probably an under-estimate. And it goes up when you include sub threshold conditions. The PIMDs down there will take you directly to the article that I was referring to, or that I pulled the stats from. 

Okay. So this is just a little bit about men. One of the reasons that we really had no idea how often men are afflicted by eating disorders is we just failed to ask them the questions. When we do ask them, they tell us. So this is a study in 1800 men in the northwestern United States. About 26 percent reported overeating, 20 percent talked about losing control, which, as you remember, is the hallmark feature of binge eating. Eight percent binge ate every week, 1.5 percent purged, and three percent used laxatives. So we need to ask men these questions in order to elicit this information. The only complicated thing in assessing bulimia and binge eating disorders in men is we found that men don't particularly like to say that they feel ou-of-control. It's just not something that flows naturally off their tongues. So we have to go around that question backwards sometimes and say things simply like, “do you ever feel like once you start eating you just can't just stop?” It's a lot easier for them to say yes to than actually asking the out-of-control question. 

So here are some realities. So this is a really interesting work about African-Americans and eating disorders. So there's some suggestion that African-Americans women might be slightly protected against the development of anorexia, but there are higher rates of binge eating disorder in the African- American population. Here's a quote from Stephanie Armstrong, "I needed to suffer in silence, that somehow my legacy of strong, independent ancestors did not allow me to lean on anyone outside my community. These beliefs swallowed me up and separated me from the very people who would've been able to help me." So there's a second layer of shame about talking about eating disorders in various racial and ethnic groups, especially if it doesn't jibe with what the belief is about how you "should" feel about your body. 

So eating disorders in Latinos. This is from Rosie Molinari. There is also a higher prevalence of binge eating disorder and bulimia nervosa in Latina women than in Caucasian women, but underutilization is a huge problem. So we're seeing much less use of healthcare than the prevalence would suggest. So Rosie says, "Many Latinas report feeling caught between two standards of beauty, leaving them either not feeling beautiful in either culture or feeling beautiful in one, but not the other. They feel as if they are on the precipice of judgment, caught between American pop culture and the values and cultural traditions of their families." I think nicely capturing that feeling – like you have a foot in two cultures and how that can be pulling you apart. 

The LGBT community. So again, and this is another thing that has kept many from seeking treatment. This myth that if you have an eating disorder and you're a guy, of course you're gay because only gay men get eating disorders. Not the case at all. So the prevalence of eating disorders is somewhat higher in gay than in straight men, but we don't know if that's just because they're more comfortable disclosing that they have an eating disorder or seeking healthcare for it. There's no difference in prevalence between lesbian and straight women, and the myth that only gay men get eating disorders keep men from seeking treatment. And Frank Bruni, one of my favorite New York Times writers, tells a wonderful story about his development of anorexia and bulimia when he as at the University of North Carolina. And his one quote is, "It was Haagen-Dazs or love. I couldn't have both." But he tells a wonderful story about how it is to be coming out and dealing with an eating disorder as a man at the same time. 

And then there's the age myth. Back to those teenage girls. So we have become increasingly interested, because when I opened my program in 2003, we were wedged between a child and adolescent psychiatric unit, because we thought most of our patients were going to be adolescents. But within three years, over 50 percent of our patients were over the age of 30. And now, at any given time, up to 70 percent of our patients are women and men in middle age and beyond. So we did an online survey of over 1800 women, ages 50 and over, just trying to find out what they're thinking about their body image and what kind of disordered eating behaviors they're exhibiting. Eight percent purging in the last five years. So remember, this is women 50 and older –3.5 percent binge eating. 

Remember that's exactly the number that we saw in the national co-morbidity study – 7.5 percent diet pills, seven percent excessive exercise, 2.5 percent diuretics, two percent laxatives, one percent vomiting, and 41 percent of women over 50 checked their body daily. And this is an eating disorder behavior whereby people might pinch fat or measure their thighs or their waists just to see if the size is changing at all. So this is really common behavior in mid-life women. In 62 percent, their weight or shape negatively impacted their life. Thirty-six percent said that they spent at least half of their time in the last five years dieting. Seventy-nine percent said that weight or shape affected their self-perception, and 64 said that they thought about their weight or shape daily. This is robbing energy from a very important productive and growing portion of the United States population. 

Why mid-life and why now? You'll find out in a minute that genetic factors underlie risk for eating disorders. But one of the things that's always interesting is what environmental factors might trigger the onset of that underlying genetic predisposition. And what we're starting to see is a lot of pressure on middle-aged women and men not to age, and to stay fit, and to not do what their bodies might naturally do as they get older. Expectations of aging have shifted, and you've probably heard this over and over again that 70 is the new 50. So the expectations are definitely there not to age. 

Three patterns. So one pattern is people might've had an eating disorder when they were adolescents, and then it sort of went underground. It might've smoldered for a while. They never completely recovered. They might've gotten careers, gotten their education, had children, and then something happens again in mid-life, and it resurfaces. That’s probably the biggest group. The second group in terms of size are people who have had chronic illness all along, and are still alive, and are still suffering from one of the other disorders. There's a lot of crossover across eating disorders, so someone might've had anorexia as a teen, and then bulimia or binge eating disorder later in their life. And then the intriguing group are those people who really do have onset in mid-life. This is a smaller group, but nonetheless really intriguing. And we dig and dig, but don't necessarily find a history in adolescence. 

So some of the triggers that we're seeing when we look at the mid-life triggers -- infidelity, empty nest, lots of transition and loss – really captures it. Bounce back children. You launch them, they go off to college, they can't get a job. All of a sudden they end up back home. Lots of issues related to unemployment, illness, or surgery. A very understudied biological factor is peri-menopause. We're having so many women talk to us about the impact that menopause and peri- menopause has on their eating disorder symptoms. And then death, retirement, and trauma – either new trauma or reactivation of an old trauma. 

And this is just a fun picture. Every once in a while these things just jump out at me. This is sort of a nice classic pizza making grandma. This is my great grandmother on my dad's side. She had so many talents. She had an ample lap. She read me lots of books. And then I see these pictures of the weight lifting grandma and the sort of hipster grandma. And the title of this was "Want to Look Like This at 72?" And I think that sort of shows how the expectations of grandma have changed over time.