"I think about food constantly. I am always trying to control the calories and fat I eat, but so often I end up overeating. Then I feel guilty and vomit or take laxatives so I won't gain weight. Each time this happens I promise myself that the next day I will eat normally and stop the vomiting and laxatives. However, the next day the same thing happens. I know this is bad for my body, but I am so afraid of gaining weight."
The stereotypic image of those suffering from eating disorders is not as valid as once thought.
This vignette describes the daily existence of one person seeking treatment for an eating disorder in our clinic. A second person reported, "I don't eat all day and then I come home from work and binge. I always tell myself I'm going to eat a normal dinner, but it usually turns into a binge. I have to re-buy food so no one notices all the food is gone."
Stop for a moment and try to envision these two individuals. For most people, the image of a young, middle-class, white female comes to mind. In fact, the first quote came from "Patricia," a 26-year-old African-American female, and the second from "Gabriella," a 22-year-old Latina* woman.
Recently, it has become apparent that the stereotypic image of those suffering from eating disorders may not be as valid as once thought. A primary reason why eating disorders appeared to be restricted to white women seems to be that white women were the only people with these problems who underwent study. Specialists conducted most of the early research in this area on college campuses or in hospital clinics. For reasons related to economics, access to care, and cultural attitudes toward psychological treatment, middle-class white females were the ones seeking treatment and thus the ones who became the subjects of research.
Defining Eating Disorders
Experts have identified three major categories of eating disorder:
- Anorexia nervosa is characterized by the incessant pursuit of thinness, an intense fear of gaining weight, a distorted body image, and a refusal to maintain a normal body weight. Two types of anorexia nervosa exist. Those suffering from the so-called restricting type severely restrict their caloric intake by extreme dieting, fasting, and/or excessive exercise. Those of the so-called binge-eating purging type exhibit the same restricting behavior but also fall victim to bouts of gorging, which they follow with vomiting or abusing laxatives or diuretics in an attempt to counteract the overeating.
- Bulimia nervosa consists of episodes of binge eating and purging that occur an average of twice a week for at least three months. Binge eaters devour an excessive amount of food in a brief period of time, during which they feel a general loss of control. A characteristic binge might include a pint of ice cream, a bag of chips, cookies, and large quantities of water or soda, all consumed in a short time. Again, purging behavior such as vomiting, abusing laxatives or diuretics, and/or excessive exercise occurs after the binge in an effort to get rid of the calories taken in.
- Binge-eating disorder (BED) is a more recently described disorder that comprises bingeing similar to bulimia but without the purging behavior used to avoid gaining weight. As among bulimics, those experiencing BED feel a lack of control and undergo bingeing an average of twice a week.
Bulimia and binge-eating disorder are more common than anorexia.
It may come as a surprise to some that both bulimia and BED are more common than anorexia. Interestingly, prior to the 1970's, eating-disorder specialists rarely encountered bulimia, yet today it is the most commonly treated eating disorder. Many experts believe the rise in rates of bulimia has to do in part with western society's obsession with thinness and the shifting role of women in a culture that glorifies youth, physical appearance, and high achievement. Eating-disorder therapists are also treating more individuals with BED. Although doctors identified binge eating without purging as early as the 1950's, BED was not systematically studied until the 1980's. As such, the apparent increase in BED incidence may merely reflect an increase in BED identification. Among females, typical rates for bulimia are 1 to 3 percent and for anorexia 0.5 percent. The prevalence of significant binge eating among obese persons in community populations is higher, ranging from 5 to 8 percent.
Next to white women, African-American women have been studied the most when it comes to eating disorders. Yet apparent contradictions exist in the data.
As the field of eating disorders has evolved, researchers and therapists have begun seeing a number of changes. These include an increase in eating disorders among men. While the vast majority of anorexics and bulimics are female, for example, a higher percentage of men are now struggling with BED. And despite the common wisdom that minority women have a kind of cultural immunity to developing eating disorders, studies indicate that minority females may be just as likely as white females to develop such debilitating problems.
"Patricia" and other African-Americans
Of all minority groups in the U.S., African-Americans have undergone the most study, yet results bear apparent contradictions.
On the one hand, much of the research suggests that even though African-American women are heavier than white women -- 49 percent of black females are overweight as opposed to 33 percent of white females -- they are less likely to have disordered eating than white women are. In addition, African-American women are generally more satisfied with their bodies, basing their definition of attractiveness on more than simply body size. Instead, they tend to include other factors such as how a woman dresses, carries, and grooms herself. Some have considered this broader definition of beauty and greater body satisfaction at heavier weights a potential protection against eating disorders. In fact, some studies conducted in the early 1990's indicate that African-American women exhibit less restrictive eating patterns, and that, at least among those who are college students, are less likely than white women to engage in bulimic behaviors.
Younger, more educated, and perfection-seeking African-American women are most at risk of succumbing to eating disorders.
The overall picture is not so clear, however. Take, for example, Patricia's story. Patricia's struggle with daily bingeing followed by vomiting and laxative abuse is not unique. Nearly 8 percent of the women we see in our clinic are African-American, and our clinical observations parallel research studies reporting that African-American women are just as likely to abuse laxatives as white women are. Data from a recent large, community-based study give more reason for concern. The results indicate that more African-American women than white women report using laxatives, diuretics, and fasting to avoid weight gain.
Much research is now focused on identifying factors that affect the onset of eating disorders among African-American women. It seems that eating disorders may relate to the degree to which African-American women have assimilated into the dominant American social milieu -- that is, how much they have adopted the values and behaviors of the prevailing culture. Not surprisingly, African-American women who are the most assimilated equate thinness with beauty and place great importance on physical attractiveness. It is these typically younger, more educated, and perfection-seeking women who are most at risk of succumbing to eating disorders.
Patricia fits this profile. Recently graduated from law school, she moved to Chicago to take a position with a large law firm. Each day she strives to do her job perfectly, eat three low-calorie, low-fat meals, avoid all sweets, exercise for at least an hour, and lose weight. Some days she is successful, but many days she cannot maintain the rigid standards she has set for herself and ends up bingeing and then purging. She feels quite alone with her eating disorder, believing that her eating troubles are not the kind of problems that her friends or family could possibly understand.