Most of us have heard of anorexia, and may imagine a stereotypical image of a young woman, but this tells a small part of the story. Adults, boys and men — and people of all ethnicities and races — are very much a part of the statistics.

Fortunately, there is hope for increased awareness and prevention. To learn more, BeWell spoke with Jennifer Waldrop, MPH, RD, nutritionist at I Thrive @ Stanford (Health Promotion Services).

How prevalent are eating disorders?

According to the National Eating Disorders Association, an estimated 20 million women and 10 million men have clinically significant eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, or OSFED (other specified feeding or eating disorder). Even though these numbers are staggering, in reality they underestimate the true scope of the problem because the figures only include individuals who seek help or meet Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.

Don’t eating disorders primarily affect teens and adolescent white girls?

When eating disorders or body image conflicts are mentioned, some assume that those who suffer from such conditions are only preteen, adolescent, or young adult women. However, more and more older women, approaching or beyond “midlife,” are admitting that they also struggle with their bodies and their eating. Furthermore, eating disorders do not discriminate on the basis of race, ethnicity or culture. While more research is needed in this area, we do know that the prevalence of eating disorders is similar among Non-Hispanic Whites, Hispanics, African-Americans, and Asians in the United States, with the exception that anorexia nervosa is more common among Non-Hispanic Whites. And while women are more commonly affected by eating disorders, millions of men and boys battle all forms of the illness.

What is the difference between an eating disorder and “disordered eating”?

As described by NEDA, eating disorders — such as anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder — include extreme emotions, attitudes, and behaviors surrounding weight and food issues. These disorders are diagnosed according to narrow criteria. Another eating disorder, known as OSFED (other specified feeding or eating disorder), still has specific criteria that must be met in order for the patient to receive this diagnosis, and that criteria is narrowing.

Disordered eating is defined as “a wide range of irregular eating behaviors that do not warrant a diagnosis of a specific eating disorder” (DSM-5). Disordered eating is a descriptive phrase, not a diagnosis. Thus, while many people who have disordered eating patterns may fit the criteria for OSFED, it is also possible to have disordered eating patterns that do not fit within the current confines of an eating disorder diagnosis.

In an increasingly image and weight-focused world where dieting, “clean eating,” food elimination, and calorie counting are perceived as normal, it is hard to know when healthy eating crosses the line into disordered eating. One major distinction is in the mindset. To assess this, we often ask people: “how much head space is taken up thinking about food, fat, weight, exercise, calories, size, and shape?” Gauging the amount of mental energy and the level at which these factors interfere with life and social functioning can provide insight into whether an individual is exploring eating habits, developing disordered eating habits, or has an eating disorder.

With eating disorders, there are often underlying mood and anxiety symptoms caused by brain chemistry changes and a disconnection between the gut brain (stomach) and brain-disrupting appetite cues. Ultimately, happiness and ability to thrive are undermined as rigid thoughts begin to take up more and more headspace — leaving little room for healthy relationships, creativity, and joy.

By contrast, what exactly is “normal eating?”

I have to defer to Ellyn Satter, an internationally recognized expert on eating and feeding; her beautiful definition of normal eating is one I share with people frequently:

“Normal eating is going to the table hungry and eating until you are satisfied. It is being able to choose food you like and eat it and truly get enough of it — not just stop eating because you think you should. Normal eating is being able to give some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food. Normal eating is giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good. Normal eating is mostly three meals a day, or four or five, or it can be choosing to munch along the way. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful. Normal eating is overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more. Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.”

Who is most at risk for developing an eating disorder or disordered eating?

The #1 risk factor associated with developing an eating disorder is dieting in younger years. We are also at risk if we receive disparaging comments about our bodies from the media culture, family, friends, and romantic partners — especially during younger years. Negative messages may be internalized as, “If I don’t weigh less and look a certain way, I won’t be loved, accepted or desirable.” A family or personal history of anxiety, depression and eating disorders also places one a risk.

Risks for DE/ED increase when food thoughts get entangled with negative emotions. The person at risk begins to develop eating symptoms not to sate appetite, but to quell or “stuff” negative emotions such as anger, anxiety, loneliness, tiredness, boredom, or guilt. Eventually, a person turns to food to “numb out” and food becomes the way to stop emotional pain.

Eating disorders are seen in men and women from childhood to the elderly, with the peak of onset in late adolescents. In the college population, athletes and women who live in Greek Life houses have a higher risk for developing eating problems. The seeds of eating disorders start early, as shown in these findings from Project EAT:

• 38% of adolescent boys and 50% of adolescent girls are taking diet pills, smoking more cigarettes and skipping meals to lose weight.

• In a 10-year follow up survey, women using extreme weight control behaviors — such as vomiting, laxative use or fasting — doubled from 8% to 20%.

• 46% girls and 26% of boys reported body dissatisfaction and were more likely to report binge eating and lower levels of physical activity.

What are the signs that we, or someone else, might have a problem with food?

A complete list of symptoms can be found here, but problems with food can be a concern when you see another person skipping meals, drinking excessive fluids (not to quell thirst but to fill up the stomach), leaving the table immediately after eating (to purge the food), or having so many rigid rules about what to eat, how much, and what foods to avoid. Elimination of entire food groups is also cause for concern (e.g., no carb or no fat diets in order to lose weight). Some people suffering from eating disorders cannot eat with others because they fear “the food police.” Many eat alone or in secrecy from others.

What should we do if we think that we, or a loved one, has an eating disorder/disordered eating?

Expressing care and concerns about another person’s eating behavior is a delicate balance. The emphasis needs to be on their health and well-being, not “how awful they look.” Sudden weight gain/loss in a short amount of time also suggests that the person is highly stressed and may be using food to cope with negative feelings. Eating disorder risk does not increase because a person is confronted by a friend or a friend group. Checking in with a person of concern can become a catalyst for them to get help. Find a quiet space, address specific concerns, and encourage your loved one to seek professional help. For step by step guide to having a conversation, see these helpful tips.

How are eating disorders or disordered eating best treated?

Eating disorders are often treated by a team that includes a registered dietician, medical provider and therapist. A core component of treatment is psychotherapy, which can help a person disentangle the food-emotion connection and learn to cope more actively and directly with negative emotions.

Mindful eating and intuitive eating are methods that help students tune into their internal eating cues, rather than being so affected by external cues (such as emotional upset) and by living in unsupportive eating environments.

What eating behaviors should we practice in order to healthfully lose weight and/or maintain a healthy weight?

• The best way to maintain a healthy weight and create a culture of positive body image is to avoid dieting. We see in study after study that dieting is the best predictor of weight gain.

• Take on a health-focused approach in which you nourish your emotional and physical needs with choices that feel right to your body.

• Focus on food quality: less processed, mostly plant-based food choices with a balance of lean protein, slow-digesting carbohydrates, fats and plenty of fruit and vegetables.

• Cook and eat real food. Simple homemade meals made can build a nutrient-rich foundation. Learning to cook is the best investment in your health. Blue Apron, Homemade, and Dream Dinners are a few businesses that can improve your cooking skills.

• Focus on frequency. The foods we eat most often have the biggest impact on our health. Focusing on one cookie is much less effective than focusing on the quality of your meal.

• Chew, chew, chew. Opt for whole fruit instead of juice, and otherwise drink unsweetened beverages.

• Savor your food. Mindfully eating and enjoying foods adds to the pleasure of eating and helps us to eat an amount that is just right for our bodies.

• When you think about wanting to eat, ask yourself first: “Am I really hungry?” If the answer is “no,” ask yourself what you are really hungry for. Check in with yourself to see if emotional distress is driving you to eat. Name that emotion(s), if possible. Learn how to cope directly with the negative emotion, rather than “taking it out” on food/eating/restricting. Counseling can help to teach you how to process your actual emotions, and to learn about appetite awareness training — another method to help you tune into internal body cues to eat/stop eating.

… any final thoughts?

Eating Disorders are serious illnesses that often require professional treatment by an Eating Disorder Care Team (team of physicians, nutritionists, therapists, and psychiatrists) that cares for the recovery of the whole person. Fat phobia is the mental state that causes people to develop and maintain eating disorder symptoms. Some helpful websites to understand eating issues are:

Andrea’s Voice (for all ED resources)
Academy of Nutrition and Dietetics
Center for Change 
Gurze Books (good videos on EDs as well)
Eating Disorders Resource Center
Eating Disorder Hope
Eating Disorder Referral and Information Center
Eating Disorder Awareness and Prevention
Healthy Girl
International Association of ED Professionals
Jessica Weiner (nationally recognized speaker on BI/ED issues)
National Eating Disorders Association
National Institute of Mental Health 
About Face (body image issues)
Body Positive (boosting body image at any weight)