Racism and eating disorders

Racism is a problem in the eating disorder community, and it can be a contributor, maybe even a cause of eating disorders. Racism causes tremendous stress for the people who experience it. Additionally, the media, doctors, and therapists rarely recognize that eating disorders are at least as common in non-white communities. Treatment centers, researchers, books, and articles about eating disorders are predominantly white-oriented.

Black people get eating disorders at least as often as white people. But parents, doctors, therapists, and even eating disorder professionals often miss the signs of eating disorders in marginalized communities. This is primarily due to implicit racial biases.

Many people like to say that mental health does not discriminate, but it does. Take a look around and see who is featured in mental health and eating disorder articles, books, and movies. The vast majority are white. This leads to unseen discrimination and racism that must be recognized and addressed.

Discrimination against Black people runs deep in healthcare and society. As a result, many people of color will never gain a mental health diagnosis or receive treatment. And racism means it’s unlikely they will get an eating disorder diagnosis.

There are several ways that racism affects eating disorder identification and treatment in Black people:

• There is very little research on eating disorders in any community.
• Most eating disorder research participants, professionals, and researchers are white.
• Clinicians are significantly less likely to screen Black people for eating disorders.
• Clinicians rarely recognize symptoms of sub-clinical anorexia, bulimia, and binge eating disorder – the most common eating disorders.
• Food insecurity, which disproportionately affects Black people, is strongly correlated with eating disorder development.
• Chronic stress, trauma, and Adverse Childhood Events (ACEs), which are associated with eating disorders, disproportionately affect Black people.

Statistics about eating disorders in African Americans

There is very little research on eating disorders. But it is especially scarce when it comes to African Americans. [1] Two important studies have given us important insights. And the research shows that eating disorders are likely equally prevalent among Black and white females*.

• Black girls were 50% more likely than white girls to exhibit bulimic behavior. [17]
• About 2.6% of Black girls were clinically bulimic, compared to 1.7% of white girls. [17]
• Black girls scored an average of 17 percentage points higher than their white counterparts on the severity of bulimia. [17]
• Black women were as likely as white women to report binge eating or vomiting. [2]
• Recurrent binge eating was more common among Black women than among white women. [2]
• African Americans have a younger age of onset for anorexia than the general US population. [3]
• Anorexia is less common in Blacks than Whites, but it is approximately twice as persistent. [3]

*Eating disorders occur in males as well as females. I am currently seeking data regarding male eating disorders in Black people and will add it as soon as possible.

Eating disorders are more than anorexia

For too long, the eating disorder field has failed to present a diverse picture of who gets eating disorders. Most people think of eating disorders as anorexia and assume they only affect white teenage girls. The media almost always begins articles about eating disorders with the image and first-person story of a thin white woman battling anorexia.

But eating disorders affect all ages, genders and races. And anorexia is the least common eating disorder. [4]

The most common eating disorder – more than double the proportion of anorexia and bulimia combined – is binge eating disorder. [4]

This bias means that parents and healthcare providers are typically ignorant of eating disorder symptoms. When you’re only looking at weight, you miss the majority of eating disorders.

Under-diagnosed and under-treated

Because of the low level of research into the field, physicians rarely catch eating disorders unless they are specifically prompted. Even then, they often miss eating disorder symptoms. The only diagnostic tool that most physicians use is weight. So unless a patient is significantly underweight, they are unlikely to recognize an eating disorder. Physicians infrequently assess patients for binge eating, and often fail to recognize bulimia and binge eating disorder. [5, 6]

Although eating disorders can have a significant impact on life and health, they are rarely diagnosed and treated. Non weight-based eating disorder remain invisible. It’s likely that even the scarce research available for eating disorders is a woeful under-count of the true prevalence.

• Only a minority of people who know that they may have an eating disorder seek treatment. [4]
• The incidence of bulimia nervosa and binge eating disorder have exploded in the second half of the twentieth century. [4]
• Fewer than half of individuals with bulimia nervosa or binge eating disorder ever sought treatment for their eating disorder. [4]

But it’s not just that people with eating disorders don’t seek help. A study found that most people with an eating disorder have received treatment for another emotional problem. [4] This means they have received mental healthcare and their eating disorder remains undiagnosed. Their mental healthcare providers failed to recognize and diagnose their eating disorder.

Racism may mean doctors don’t look for an eating disorder

Doctors are unlikely to catch eating disorders in white populations. They are even less likely to find them in Black patients. Because they do not expect eating disorders among Black people, doctors miss them. [3]

This is of special concern since anorexia arises at younger ages in Black people. It’s also diagnosed less frequently. So it’s untreated for a longer time compared to whites. [3]

Doctors and therapists should be trained to look for eating disorders. And they should be trained to overcome their racial biases, which impact healthcare at every level.

We know that racism impacts healthcare. For example, Black American women are two to three times more likely to die from pregnancy-related causes than white women. [7] Additionally, Black Americans are dying of Covid-19 at three times the rate of white people.

Healthcare outcomes for Black Americans are far worse in every aspect. So it’s no surprise that racism impacts eating disorder diagnosis and treatment.

Racism is stressful

There is evidence to suggest that people who have eating disorders are more likely to be sensitive to chronic stress. [8] When you’re chronically stressed, food and eating disorder behaviors can be powerful soothing agents. Eating disorder behaviors are considered coping mechanisms.

Stress impacts our bodies in many ways. And racism is inherently stressful, which can trigger an eating disorder and other problems. Living your life in a body that is discriminated against can create chronic, toxic stress. Researchers have observed a strong link between discrimination and the following health conditions:

• Hypertension & diabetes [9]
• Adverse birth outcomes [10]
• Cigarette smoking, alcohol/substance use, improper nutrition and refusal to seek medical services [11]
• Mental health disorders [12]

We can make a connection between the stress of racism and an eating disorder diagnosis. For example, bulimia is strongly associated with stress and is higher for Black people. This may be due to the stress of racism. [13]

Additionally, the most common eating disorder among Black people is binge eating disorder, with an onset age of 22.75 years. This older age of onset may reflect that the cause is stress from racism, not body image. [3] Racism impacts Black people on many levels of mental health. And of course it impacts eating disorder diagnosis and treatment.

Food insecurity and eating disorders

Food insecurity disproportionately affects Black people and other people of color. At least 72% of African-American and Latino children are at high risk. In addition, 25% of these children face a constant struggle with hunger. [14]

Here are some connections between food insecurity and eating disorders:

• 7% of individuals with food insecurity exhibited a clinically significant eating disorder. This compared with less than 3% of participants in the non-food insecure group.
• Adults who experience significant food deprivation regularly are more likely to engage in several disordered eating behaviors.
• Food insecure individuals engaged in more objective binge eating and overeating. Also night-time eating, purging and other compensatory behaviors. These include exercising harder than usual and using laxatives/water pills. And food restriction, such as skipping two or more meals in a row, and dietary restraint.
• High food insecurity corresponded with an increase in weight/body shape concerns. This is because of weight stigma: societally held judgement, biases, and prejudice predetermined by weight and body shape.

Source: Food Insecurity and Disordered Eating

Here are two critical thoughts:

1. People facing food insecurity are twice as likely to develop an eating disorder than people who are not.
2. Black Americans are more likely to experience food insecurity than white Americans.

It’s likely that the prevalence of eating disorders in Black people is much higher than reported.

How to help

If you are Black and suspect your child may have an eating disorder, please pursue treatment. Don’t stop even if a doctor or other professional doubts you. Unfortunately, discrimination is an enormous problem in treating eating disorders in Black children. All parents who have kids with eating disorders must become advocates for adequate care. But Black parents have an even larger burden.

If you would like to read about eating disorders from Black writers, here are some articles and books:

• It’s Time to Correct the Narrative Surrounding Black Girls and Eating Disorders, by Anissa Gray for Shondaland
• When Black Girls Hear That ‘Our Bodies Are All Wrong,’ by Mikki Kendall for The New York Times
• Yes, Black Women Struggle With Eating Disorders Too, by Karla Mosley for Glamour
• What You Need to Know About Eating Disorders, by Aysha Ives, MS for Ebony
• The Care and Feeding of Ravenously Hungry Girls, by Anissa Gray (book)
• Not All Black Girls Know How to Eat, by Stephanie Covington Armstrong (book)

The National Eating Disorders Association has a comprehensive list of resources that may help. The list includes a free online eating disorder support group for BIPOC. 

If you would like to support therapy resources for Black girls and women, this is a wonderful organization: Therapy Fund for Black Women and Girls

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NOTE: I am white. I have done my best to become educated on anti-racism. But I may have made some mistakes in this article. Please contact me if you believe I need to make changes.

See Our Parent’s Guide To The Causes Of Eating Disorders

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References

[1] Media and Cultural Influences in African-American Girls’ Eating Disorder Risk, Jones, Cook-Cottone, International Scholarly Research Notices, 2013

[2] Recurrent Binge Eating in Black American Women, Striegel-Moore, Wilfley, Pike, Dohm, Fairburn, Arch Fam Med, Jan 2000

[3] Prevalence of Eating Disorders among Blacks in the National Survey of American Life. Taylor, Caldwell, Baser, Faison, Jackson, Int J Eat Disord, Nov 2007

[4] The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Hudson, Hiripi, Pope, Jr., Kessler, Biol Psychiatry, Feb 2007

[5] A survey of binge eating and obesity treatment practices among primary care providers. Crow SJ, Peterson CB, Levine AS, Thuras P, Mitchell JE, Int J Eat Disord. Apr 2004

[6] Health problems, impairment and illnesses associated with bulimia nervosa and binge eating disorder among primary care and obstetric gynaecology patients. Johnson JG, Spitzer RL, Williams JB, Psychol Med, Nov 2001

[7] Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. Centers for Disease Control and Prevention Weekly, Petersen, Davis, Goodman, Cox, Syverson, Seed, Shapiro-Mendoza, Callaghan, Barfield, September 6, 2019

[8] de Castro, Gee, & Takeuchi, 2008; Williams & Mohammed, 2009; Meyer et al, 2008; Guyll et al, 2001

[9] Williams & Neighbors, 2001; Kaholokula et al, 2010; McClure et al, 2010

[10] Nuru-Jeter et al, 2009; Dominguez et al, 2008; Canady et al, 2008

[11] Lee, Ayers, & Kronenfeld, 2009; Peek et al, 2011

[12] Jang et al, 2010; Mezuk et al, 2010

[13] The role of acculturative stress and body dissatisfaction in predicting bulimic symptomatology across ethnic groups. Perez M, Voelz ZR, Pettit JW, Joiner TE Jr, Int J Eat Disord, 2002 May

[14] North Carolina State University Extension (2017)

[15] Physical and mental health outcomes associated with prior food insecurity among young adults. Darling, Fahrenkamp, Wilson, D’Auria, Sato, Journal of Health Psychology, 2017

[16] Disordered eating behaviors and food insecurity: a qualitative study about children with obesity in low-income households. Tester, Lang, Laraia, Obesity Research and Clinical Practice, 2016

[17] Black Girls Are 50 Percent More Likely To Be Bulimic Than White Girls. Georee, Sovinsky, Iorio, ScienceDaily, ScienceDaily, March 2009