Eating Disorders Overlooked in Men, Minorities

Batya Swift Yasgur, MA, LSW

March 27, 2018

Eating disorders (EDs) are underdiagnosed and undertreated in men, minorities, normal and higher-weight individuals, and those who are not affluent, new research shows.

Investigators studied college students across the country and found that women were almost five times more likely than men to be diagnosed with EDs and that white students were nearly twice as likely to be diagnosed as students of color.

Affluent students were also more likely than nonaffluent students to be treated, and students who were underweight were more likely than overweight students or students of normal weight to be diagnosed or treated.

"There is a stereotype that eating disorders affect only skinny, white, affluent girls — sometimes abbreviated 'SWAG' — leaving out numerous people who do not fit that stereotype and contributing to disparities in treatment and diagnosis," lead author Kendrin Sonneville, ScD, RD, told Medscape Medical News.

"Clinicians should recognize that EDs are universal and implement universal screening of all patients, regardless of background, race, ethnicity, gender, and weight status, in routine clinical practice," she said.

The study was published online March 2 in the International Journal of Eating Disorders.

Antiquated Ideas

EDs are underdiagnosed and undertreated. Only one third of individuals who have EDs ever receive treatment, the authors note.

"Antiquated ideas about who develops EDs, held by the general public and clinicians alike...may perpetuate inequities in treatment," they write.

Research conducted in clinical samples may "further perpetuate myths and stereotypes because of systematic differences between people who do, and do not, seek treatment."

"The reason I conducted the study is that I worked as a clinician prior to obtaining my doctorate in public health," said Sonneville.

"I realized that the population trends I was studying looked very different from the people I used to see in my clinic, many of whom fit the SWAG stereotype, and I wanted to understand disparities in care and barriers to getting treatment," she added.

To investigate the question, the researchers analyzed data from the Healthy Bodies Study (HBS), a population-level survey that explored disordered eating in a randomly selected sample of undergraduate and graduate students at 12 participating institutions across the country.

The survey included extensive demographic information (age, sex, sexual orientation, race/ethnicity, and socioeconomic background), as well as self-reported height and weight.

ED symptoms were assessed using the Eating Disorder Examination Questionnaire (EDE-Q). Participants answered questions concerning their perceived need for ED treatment, lifetime ED diagnosis, and past-year ED treatment.

Students who had not received ED treatment during the past year but whose global EDE-Q score was ≥2 were asked about barriers to ED treatment.

The researchers utilized a diagnostic hierarchy of criteria, based on the DSM-5: threshold anorexia nervosa (AN), threshold bulimia nervosa (BN), threshold binge eating disorder (BED), subthreshold BN, subthreshold BED, and purging disorder (PD).

Anorexia Most Common Diagnosis

Of the students who participated in the HBS (n = 7704), 1747 met criteria for an eating disorder. Of these, 2.0% were underweight, 79.9% were white, 19.1% were affluent, and 84.9% were women.

The most common EDs were threshold BED and threshold BN (26.8% and 26.5%, respectively).

Although BED and BN were the most common conditions, respondents with AN were found to have the highest rates of perceived need for treatment, diagnosis, and past-year treatment (73.5%, 73.2%, and 57.2%, respectively).

Only 30.7% of respondents in the overall sample perceived a need for treatment, only 10.5% had received a diagnosis, and only 13.6% had received treatment in the past year.

When the researchers controlled for age and sexual orientation and compared individuals who were underweight to individuals of healthy weight, those who were underweight were far more likely to perceive a need for treatment (odds ratio [OR] = 3.73; 95% confidence interval [CI], 1.63 - 8.54), to have been diagnosed (OR = 6.48; 95% CI, 3.14 - 13.37), and to have received treatment (OR = 5.63, 95% CI, 2.74 - 11.55).

Individuals who were overweight or obese were significantly less likely to have been diagnosed than individuals of healthy weight (OR = 0.61; 95% CI, 0.40 - 0.95; and OR = 0.45, 95% CI, 0.26 - 0.78, respectively).

"Although only 2% were underweight, they were the ones most likely to have been diagnosed and treated and to perceive that they needed treatment," Sonneville observed.

White students were more likely than students of color to have been diagnosed (OR = 1.81; 95% CI, 1.03 - 3.21).

Students who were not affluent were more likely to have perceived a need for treatment than nonaffluent students (OR = 1.52; 95% CI, 1.13 - 2.04) and were more likely to have received treatment (OR = 1.89, 95% CI, 1.31 - 2.72).

Women were much more likely than men to have perceive a need for treatment (OR = 1.97; 95% CI, 1.35 - 2.86), to have been diagnosed (OR = 4.66; 95% CI, 1.80 - 12.11), and to have been treated (OR = 1.64; 95% CI, 1.00 - 2.67).

The three most common survey responses regarding reasons for not seeking treatment were as follows: "I prefer to deal with issues on my own" (28.1%), "I have not had a need for counseling or therapy" (23.0%), and "I'm not sure how serious my needs are" (19.7%).

"Our findings confirmed what I had seen in clinical practice, which is that people who meet the SWAG stereotypes are more likely to be diagnosed and treated with an eating disorder than those who do not," Sonneville commented.

One reason for this is that many people with EDs, including men and members of minorities, do not recognize themselves as having an ED because they do not conform to the stereotypes they see in the media, she said.

Novel Research

Commenting on the study for Medscape Medical News, S. Bryn Austin, ScD, professor of pediatrics, Harvard Medical School, Boston Children's Hospital, and Harvard T. H. Chan School of Public Health, who was not involved with the study, called it "novel."

The study "has a fairly large sample of college students from a range of US colleges, which is already a cut above many studies that may have been done in a single college, in clinical samples, or in selected groups on college campuses, such as sororities or sports teams," Austin said.

The results "point to a need for universal screening for eating disorders in routine primary care visits and college and adolescent health services," she emphasized.

Sonneville added that "there are effective treatments for eating disorders, and it's a shame that these treatments are not getting to the people who actually need them."

She noted that the five-question SCOFF questionnaire is a helpful, brief screening tool that can easily be incorporated into clinical practice. In addition, it's "a good way to allow the clinician to start a conversation and identify people at risk," Austin said.

The authors and Dr Austin have disclosed no relevant financial relationships.

Int J Eating Disord. March 2, 2018. Abstract

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