“Feel the fear and do it anyway.” ¹ 

If you were asked, how many people do you think you could recall by name? 50? 150? 500? British anthropologist Robin Dunbar theorized that the human brain can maintain around 150 stable social relationships,² but less conservative estimates hover in the 500s.³ Based on these estimates, I’d venture to say that each of us knows at least fourteen, but maybe as many as fifty-five, of the 28.8 million people with a history of an eating disorder in the United States.⁴ 

I am one of them. 

I was officially diagnosed with anorexia in college, but if anyone were to ask, I wouldn’t be able to pinpoint the exact moment my eating disorder started. My eating disorder has been an unfortunate companion throughout most of my conscious life, serving as a crutch for me to lean on whenever things got to be too much to handle: a tangible way for me to exercise control amidst the uncontrollable chaos of life. In some ways, the diagnosis itself didn’t truly matter when I had been struggling with the illness for so long, but in other ways it allowed me to finally admit to myself the reality of my situation and open up to receiving help. With my therapist, dietician, and weekly group therapy, I was able to begin the long road to recovery with a team of people, both professionals and friends, alongside me. The fact that I had access to care in order to help treat this disorder was an immense privilege that I don’t take lightly, and it’s a privilege that not nearly enough people have access to. 

February is National Eating Disorder Awareness month. Eating disorders, or EDs, are mental health conditions typically associated with preoccupations with food, weight or shape, or with anxiety surrounding eating or the possible consequences of consuming certain foods. Regardless of the type, most behaviors associated with eating disorders include some sort of restrictive eating or avoidance of foods, binge eating, purging via vomiting or laxative misuse, or compulsive exercise.⁵ An estimated 9%, or 28.8 million, of Americans will have an eating disorder at some point in their lifetime, with the prevalence of all eating disorders generally estimated to be higher in women compared to men.⁶ The three most common EDs are anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED); brief descriptions of each are provided below. 

• Anorexia nervosa is, “characterized by self-starvation and weight loss resulting in low weight for height and age.”⁷ Anorexia can manifest differently on the individual level; the restricting subtype is characterized by losing weight primarily through dieting, fasting, or excessively exercising, whereas the binge-eating/purging type is characterized by individuals also engaging in intermittent binge-eating and/or purging behaviors.
• Bulimia nervosa is, “characterized by alternating dieting, or eating only low calorie ‘safe foods’ with binge eating on ‘forbidden’ high calorie foods.”⁸ Binge eating itself, defined as eating a large amount of food in a short period of time, is usually associated with a sense of loss of control over what, or how much one is eating. For those with bulimia, a binge is followed by an episode of purging, which can take the form of either vomiting, fasting, exercising, or misusing laxatives. Sometimes bulimia also includes severely limiting eating for periods of time. This often leads to stronger urges to binge eat and then purge.⁹
• Binge-eating disorder (BED) shares similarities with bulimia nervosa in which there are episodes where an individual will, “consume large quantities of food in a brief period, experience a sense of loss of control over their eating and are distressed by the binge behavior.”¹⁰ However, those with BED do not regularly use compensatory behaviors to rid themselves of the food they consume. Oftentimes, a binge will be followed by a period of restriction of intake, generating a cycle of bingeing and restricting. 
• Additionally, the DSM-5 recognizes avoidant/restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED), unspecified feeding or eating disorder (UFED), pica, and rumination as separate eating disorders.¹¹ 

Portrayals of people with eating disorders in the media are often of emaciated white teenage girls. Despite these narratives, in reality there is no way to tell if someone has an eating disorder based on their appearance. Yes, EDs can have drastic physical side effects, but first and foremost they are mental illnesses: there is no specific way to “look” like you have an eating disorder. In reality less than 6% of individuals with eating disorders are medically underweight.¹² As an aside, the criteria for what classifies as underweight, and what has historically been used to help diagnose EDs, relies on the Body Mass Index, or BMI. The BMI was developed by Adolphe Quetelet, a Belgian statistician, using very limited data from European white men, with the intention of capturing the “average” male physique by dividing their weight by their height squared.¹³ The formula, and its less than statistically sound logic, has been used to make generalizations about the health of entire populations, a practice that has seeped into how we conceptualize what “healthy” is, despite the data not being applicable to any population other than young, white, European men.

While I cannot speak on behalf of every individual with an ED, it’s not outlandish to suggest that, for some, the desire to lose weight or alter their appearance can originate from ideas pushed forward by diet culture, societal ideals of beauty, and the morality of existing in a smaller body. The widespread use of BMI as an indicator for an individual’s overall health, as if weight is the only metric useful in determining whether someone is “healthy” or not, is an outdated and problematic measure. The continued use of it only provides further opportunity for the multi-billion dollar wellness industry to profit off of insecurities, not to mention how it creates a serious barrier to accessing treatment for eating disorders.

The health consequences of eating disorders can be dire. Overall, 10,200 deaths from 2018-19 in the US were associated with EDs, with estimates ranging from as low as 5,500 to as high as 22,000.¹⁴ There is an often circulated statistic that every 52 minutes one person dies as a direct consequence of an eating disorder, making EDs the second highest mortality rate of any psychiatric illness behind opioid use disorder.¹⁵ But it cannot go unmentioned that the rates of EDs for racial and ethnic minoritized communities are even more alarming. Adolescents who experience racial discrimination are three times more likely to develop BED than those who haven’t experienced racial discrimination.¹⁶ People of color with eating disorders are half as likely to be diagnosed or receive treatment in comparison to white people.

Additionally, access to resources may play a role in prevalence as well, as experiencing food insecurity is associated with 1.67 higher odds of developing BED and 1.31 higher odds of binge eating symptoms in early adolescence.¹⁷ Knowing this, it’s imperative that when we talk about EDs we acknowledge that there are socioeconomic factors at play that have the potential to influence types, rates, and severity of these illnesses. Eating disorder prevention and treatment is an intersectional issue deeply related to issues of equity in public health. 

All that being said, there are no concrete ways to determine whether or not someone will develop an ED in their lifetime. They are complex disorders with biological, psychological, social, economic, and even political drivers that can affect anyone at any time. These statistics about eating disorders are alarming, but I say them with compassion and intention as someone who was fortunate enough to recover and can speak on behalf of those who can’t. For my recovery, it was extremely important to have these difficult conversations confronting the reality of these illnesses in order for me to be willing to take actionable steps to get better. Knowing how prevalent and serious eating disorders are, it’s important that we look deeper into the societal reasons that perpetuate them in order to understand how to mitigate them, a much larger issue that will be discussed further in part two of this blog series.

Footnotes

¹Jeffers, Susan J. Feel the Fear and Do It Anyway : How to Turn Your Fear and Indecision into Confidence and Action. 1987. London, Vermilion, 2007.
²Ro, Christine. “Dunbar’s Number: Why We Can Only Maintain 150 Relationships.” Bbc.com, BBC Future, 9 Oct. 2019, www.bbc.com/future/article/20191001-dunbars-number-why-we-can-only-maintain-150-relationships
³McCormick, Tyler H., et al. “How Many People Do You Know?: Efficiently Estimating Personal Network Size.” Journal of the American Statistical Association, vol. 105, no. 489, 1 Mar. 2010, pp. 59–70, https://doi.org/10.1198/jasa.2009.ap08518. Accessed 10 Dec. 2020. In 2012, researchers asked how many people individuals could recall by name in an attempt to efficiently estimate personal network size. From their survey and analysis, they estimated Americans have a mean network size of 611, with a median of 472.
⁴“Eating Disorder Statistics | ANAD – National Association of Anorexia Nervosa and Associated Disorders.” ANAD – National Association of Anorexia Nervosa and Associated Disorders, 29 Nov. 2023, anad.org/learning-library/eating-disorder-statistic/.
⁵Guarda, Angela. “What Are Eating Disorders?” American Psychiatric Association, 2023, www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders.
⁶Deloitte Access Economics. Social and Economic Cost of Eating Disorders in the United States of America Report for the Strategic Training Initiative for the Prevention of Eating Disorders and the Academy for Eating Disorders. 2020.
⁷Guarda, Angela. 2023
⁸Guarda, Angela. 2023
⁹Mayo Clinic. “Eating Disorders.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 28 Mar. 2023, www.mayoclinic.org/diseases-conditions/eating-disorders/symptoms-causes/syc-20353603.
¹⁰Guarda, Angela. 2023.
¹¹Kelvas, Danielle. “12 Different Types of Eating Disorders | DSM-5 & Related.” Withinhealth.com, 6 Nov. 2023, withinhealth.com/learn/articles/types-of-eating-disorders.
¹²(“Eating Disorder Statistics | ANAD – National Association of Anorexia Nervosa and Associated Disorders”)
¹³Egan, Natalie, et al. Advancing De-Implementation of Universal BMI Surveillance Prepared by Advancing De-Implementation of Universal BMI Surveillance Background. 2023.
¹⁴Deloitte Access Economics.
¹⁵Bunnell, Douglas. “Eating Disorder Statistics.” National Eating Disorders Association, 2024, www.nationaleatingdisorders.org/statistics/
¹⁶Raney, Julia H., et al. “Racial Discrimination Is Associated with Binge-Eating Disorder in Early Adolescents: A Cross-Sectional Analysis.” Journal of Eating Disorders, vol. 11, no. 1, 17 Aug. 2023, p. 139, pubmed.ncbi.nlm.nih.gov/37592364/, https://doi.org/10.1186/s40337-023-00866-0.
¹⁷Bunnell, Douglas.