Is the Incidence of Eating Pathology and Intense Body Dissatisfaction in poorer communities of color comparable to national incidence?

doi:10.21203/rs.3.rs-2833958/v1

Download PDF

Research Article

Is the Incidence of Eating Pathology and Intense Body Dissatisfaction in poorer communities of color comparable to national incidence?

https://doi.org/10.21203/rs.3.rs-2833958/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: Communities of color have been under-assessed and under-diagnosed with eating disorders. Most of the previous research on BIPOC communities has focused mainly on eating pathology as it relates to food insecurity. The purpose of this study was to explore whether the incidence of eating pathology and intense body dissatisfaction in poorer communities of color was comparable to the incidence reported by the National Institute of Mental Health and National Eating Disorder Association. The data outcomes may be relevant to community based mental health clinics and their partners as it will potentially highlight gaps in research, diagnostic assessment, and treatment interventions specific to eating disorders in marginalized communities.

Methods: The data was collected from 309 individuals seeking mental health treatment in a community based mental health clinic in East Harlem NYC. Two separate assessments were utilized. The first assessment was conducted at intake within the comprehensive psychosocial assessment. It was a self-reported measure that assessed frequencies of 5 types of eating pathology: 1.) restricting, 2.) restricting/binging 3.) restricting/purging, 4.) binge/purging, and 5.) binging. Body and Weight Attitude Likert assessment scale, a 14-item measure was created based on 5 sub-scales: 1.) income 2.) restricting eating and obsessive thought behavior 3.) body dissatisfaction 4.) binge-eating and compensatory behavior 5.) emotional distress.

Results: This is the first study to investigate rates of eating pathology and attitudes around body image and weight in a poorer community with the majority of the community identifying as people of color. What we found was high rates of body dissatisfaction and high incidence of eating pathology which is not only comparable to the NIMH and NEDA’s data for a white population but is higher than what the current data supports for any racialized group. Our data also shows higher rates of eating disorder diagnosis, particularly for AN, AAN, and EDNOS than what is supported in either NIMH and NEDA for any racialized group We discovered the incidence of frequency of restricting food was highest in the Black and mixed-Race participants. Black participants had the highest rate of diagnosis of an eating disorder of restricting type, which is much higher than the national incidence. Body dissatisfaction is the most notable risk factor in the development of eating disorders. The mixed-race group (n=97) rated highest on intensity of body dissatisfaction. This study highlights the need for further investigation, so we don’t perpetuate the neglect of these communities in both mental and medical health care.

Eating disorders

body dissatisfaction

atypical anorexia

communities of color

food insecurity

eating pathology

race and weight bias

restricting disorders

Eating disorders impact around 9% of the global population and around 30 million people living in the United States. Eating disorders have the highest rate of mortality of any other mental health disorder. It has been long assumed that the incidence of eating disorders impact white individuals at a much higher rate. The exception to this would be the national incidence of binge-eating disorder, which has the highest incidence in Black individuals. Previous research on eating disorders in communities of color focuses almost solely on pathological eating patterns as it relates to food insecurity, rates of binge-eating and obesity. What we found was high rates of body dissatisfaction and high incidence of eating pathology, especially high frequencies of restricting behavior which is not only comparable to the NIMH and NEDA’s data for a white population but is higher than what the current data supports for any racialized group. This suggests that there may be under-assessment of eating disorders across all racial groups. Weight and racialized biases have led to the under-assessment and under-treatment of eating disorders in all racial groups.

Eating Disorders

Eating disorders impact around 9% of the global population and around 30 million people living in the United States (National Institute of Mental Health, 2022). Eating disorders have the highest rate of mortality of any other mental health disorder, with 10,200 deaths annually or one death every 5 minutes (NIMH, 2022). That, by percentages, is a higher number than people who die of opioid overdoses (National Eating Disorders Association, 2022).

There are substantial psychiatric comorbidities associated with eating disorders such as depression and increased suicidality (Chamay-Weber et al., 2005), with 26% of individuals with eating disorders attempting suicide each year (NIMH, 2022). Medical complications can be very serious, causing long-lasting damage to one’s organ system, and even life threatening (Rosen, 2010).

Adults are at a much higher risk than previously thought with 0.8% of 20–39-year-olds diagnosed with Anorexia Nervosa, 1.5% with Bulimia Nervosa and 3.5% with Binge Eating Disorder, while percentages are comparable for adults 40 to 60+ and for adolescents 10-19 years old. (NEDA, 2022). Further, 13% of women over the age of 50 experience eating issues that require interventions by healthcare providers (NIMH, 2022), although it’s important to note that these numbers do not account for atypical anorexia or other eating and feeding disorders that have severe clinical implications as well (APA, 2013). Even faced with the seriousness of eating disorders, it remains both underdiagnosed and undertreated, with only one-third of individuals struggling with eating disorders ever receiving treatment (Hart et al., 2011) and only 6% ever receiving a diagnosis from a medical professional (NIMH, 2022). Unfortunately, this leaves many people inappropriately treated or not treated at all for an eating disorder, leaving individuals at risk for lifelong struggles with medical complications and emotional torment (Woodland, 2023).

Food Insufficiency and Insecurity

Research has suggested that food insufficiency and food insecurity increase disordered eating behaviors (Becker et al., 2019; Becker et al., 2017; Goode et al., 2021; Hazzard et al., 2022). It is believed that fluctuations in food availability can lead to disordered eating patterns such as restriction when food is scarce and binge eating when food is available (Becker et al., 2017).

It has been found that restricting food consumption, whether involuntary or voluntary, leads to a preoccupation with food (Hazzard et al., 2022). The more severe the food insecurity, the higher the risk for intentional food restriction (Becker et al., 2017). According to restraint theory, when one intentionally restricts their intake of food, there is an increased risk of binge eating behavior (Herman & Polivy, 1975). Further, it has been suggested that unintentional weight loss may be as powerful of a trigger to initiating anorexia as intentional dieting (Brandenburg & Anderson, 2007).

Although food restriction is still correlated with eating disorder pathology, it has been argued that individuals struggling with food insecurity rarely reported the reason for restriction was due to poor body image or specific weight concerns but rather restricted food intake to make food last (Middlemass et al., 2018). Other research has found that individuals with severe food insecurity, specifically those who also have children in the home, reported higher rates of weight and body shape dissatisfaction along with high rates of compensatory behaviors such as purging, laxative abuse and obsessive exercising behavior (Becker et al.,2019). Body dissatisfaction is the most notable risk factor for the development of an eating disorder (Chen et al., 2022; Franko et al, 2012). It has been argued that as many as 17%-20% of those with food insecurity reported engaging in self-induced purging behavior as a means of controlling weight especially after a self-reported binge-eating episode (Becker et al., 2019; Becker et al., 2017).

Racial Bias in the Under-Assessment of Eating Disorders

Are minority clients being assessed thoroughly and accurately, especially for restricting eating pathology? It has been argued that people of color are less likely to have an eating disorder or experience symptomology that is synonymous with eating disorders (NIMH, 2022). However, Black people are 50 % less likely to get a diagnosis of an eating disorder and have a much less chance of getting diagnosed with anorexia than their white counterparts, even if they experience identical symptoms (NEDA, 2022). Further supporting this claim, research has found that of those who had a diagnosis of and received treatment for restrictive eating disorders were more likely female than male (Sonneville & Lipson, 2018). It has also been argued that the perceived need for treatment was more associated with individuals from more affluent backgrounds and of higher socioeconomic status (Sonneville & Lipson, 2018)

Earlier studies support this bias (Gordon et al., 2006; Gordon et al, 2002), finding that clinicians were able to recognize disordered eating behaviors when a case scenario was presented across racial groups but were less likely to give a diagnosis of an eating disorder or recommend treatment for a Black client. A recent study found that Black women use compensatory behaviors such as fasting, laxative use, eating very little, or making themselves purge to control weight more than any other racial group, especially in adulthood (Simone et al., 2022).

Individuals can feel demoralized and frustrated by racially based stereotypes that mental health clinicians and medical providers have around eating disorders (Becker et al., 2010). Research also suggests that barriers to treatment are directly related with the racial stereotypes of the clinician with Gordon et al. (2006), finding that patients of color are less likely than their white counterparts to be asked by a physician about disordered eating behavior and to be less likely to be referred for further mental health treatment for eating pathology (Becker et al., 2003).

Eating disorders are not a mental health issue specific to white affluent young women. Trauma and poverty increase the risk of disordered eating (Becker et al., 2017). It is more common than not that a majority of clients coming into a community mental health clinic, especially in marginalized communities, suffer from some form of trauma, whether it be inter-personal or childhood trauma, community violence and crime, systematic racism, or all of the above (Woodland, 2023). A significant portion of a community of lower socioeconomic status is supported by food stamps and suffer from food insecurity (Woodland, 2023). However, Woodland (2023) argued that community clinics are assessing for tobacco and substance use but neglecting to assess for eating disorders or pathological eating patterns (Woodland, 2023).

Individuals who struggle with their weight are more likely to be referred to weight loss programs than for treatment of eating disorders (Mond et al., 2009), or to have weight loss as a primary treatment goal. For someone struggling with an eating disorder, this could have deadly consequences (Spotts-De Lazzor & Mulheim, 2019). Further, individuals with BED express the desire to lose weight as well as the desire to stop the disordered eating behavior, however, most have used only dieting as a form of intervention, and most individuals have never been in mental health treatment for their eating disorder (Coffino et al., 2022).

In the initial assessment of clients’ medical records in the community based mental health clinic in East Harlem, there is a significant indication that community members are struggling with eating disorders across the spectrum. Of the 366 individuals admitted to the clinic in the past year, 137 of them reported some form of disordered eating behavior. Most significantly, 45% of those reporting disordered eating patterns, reported restricting food intake 1-2 times daily or 1-2 weekly without binging behavior while another 7% reported purging behavior 1-2 times daily or 1-2 weekly (Data from MEDI-EHR, September 29^th, 2022).

This highlights a bigger unseen issue around, at minimum, disordered eating patterns that can lead to poor body image, self-loathing, and with a population that isn’t thought of to struggle with eating disorders, isolation, and shame. If the research can highlight issues such as disordered eating behavior and eating disorders in these communities, we can start treating individuals with different mental health interventions on a micro level and support social change in health care and how we are assessing and treating individuals and communities on a macro level.

NYC has placed a great deal of focus on obesity in marginalized communities. Further, the identified interventions support diet and exercise as the only means of treatment with no regard to the clinical implications around disordered eating. This has done very little to address the underlying issues that are impacting the community and ultimately are keeping marginalized communities sick. If we can highlight that people in communities of color do in fact struggle with eating disorders across the spectrum, we can help shift the idea that eating disorders only impact affluent white women but also impact both men and women in communities of color. On an individual level, we can start to utilize more appropriate mental health treatment interventions to help individuals live fuller and healthier lives.

Purpose

The purpose of this study was to explore whether the incidence of eating pathology and intense body dissatisfaction in poorer communities of color was comparable to the incidence reported by the National Institute of Mental Health and National Eating Disorder Association. The data outcomes may be relevant to community based mental health clinics and its partners as it will potentially highlight gaps in research, diagnostic assessment, and treatment interventions specific to eating disorders in marginalized communities.

Demographics

Data utilized for this study was collected from a community mental health clinic in East Harlem, New York. East Harlem is predominately a community of color, with 43.8% of the community identifying as Hispanic and 36.6% Black. East Harlem ranks as the 3^rd poorest neighborhoods in NYC. The clients at the clinic all have either Medicaid or Managed Medicaid, representing a lower socioeconomic class of individuals which is relevant to the variable of food insecurity, as Medicaid and Managed Medicaid is only available to individuals living below a certain percentage of the Federal Poverty Level, as identified by the Department of Health and Human Services. For 2023, individuals living at up to 138% of the Federal Poverty Level were eligible for Medicaid in the state of New York. For individuals 18-60 years old, this reflects an annual income of $18,755 or below (New York State, 2022) The sample did not include individuals with private insurance or with no insurance.

Participants

Subject Population:

The clinical sample was recruited from individuals that were seeking or were already accessing mental health treatment at a community-based outpatient mental health clinic. The subjects were identified for participation through the intake process or through chart review. Patients under the age of 18 were not eligible for participation, as were vulnerable populations such as prisoners, cognitively impaired, individuals actively psychotic. If a subject with an eating disorder needed a higher level of care, such as hospitalization or partial hospitalization, they were referred out and excluded from the study. Subjects struggling with severe medical ailments were also be excluded. Otherwise, males and females between the ages of 18-70 were included in the sample with no other exclusions.

Data Collection

Data was collected from 367 clients. Data could not be used from 58 clients due to either clients being discharged before full assessment was completed (n=48) or clients still being in preadmission stage (n=11). The final number of participants used for the study was 308.

Participants

Participants were 71% female being 71.0% (n=220), 27.1% male (n=84), and 1.3% (n=4) identified as a gender other than male or female. The age range was 17-70. Please see Table 1 for racial demographics.

Table 1 Dempgraphics by Race

Procedures

The procedures were approved by Tulane’s Institutional Review Board (IRB). Medical charts were reviewed to obtain the information. Data pulled from the medical record system ©Medi-EHR, a behavioral health medical record system was analyzed. The level of frequencies with each variable and grouping each variable by race was conducted in ©Jamovi (Version 2.2, 2021).

Ethical Considerations

The eating pathology assessment was conducted by a licensed therapist and the assessment is a section of the broader comprehensive assessment required to be completed during the initial sessions. The eating pathology assessments were completed prior to full admission to the clinic. After admission to the clinic, the Body and Weight Attitude assessment scale were conducted by the participant’s assigned licensed therapist. This was designed this way so that any participants who had potentially upsetting interactions with the information had mental health support available. The information collected involves asking about pathological eating behavior and eating and body attitudes so there was a risk of psychological or emotional distress. The therapists that administered the assessments were all well trained and equipped to manage and support a client through emotional and psychological distress. The information gathered was kept in the participants electronic medical record, which is a HIPPA compliant and a confidential system. There is a minimal risk of identifying information being breached.

Benefits

There were no direct benefits to the subjects participating in this research, but the knowledge gained may enhance clinical knowledge of the issues and better inform clinical interventions, which could indirectly benefit participants in the future.

Measures

The first measure was an intake assessment that measured self-reported eating patterns. This data was gathered from the initial implementation of the assessment August 1, 2021through January 19, 2023, and was collected from all eligible clients. The clients were asked about the following disordered eating categories, 1.) restricting 2.) restricting/binging, 3.) restricting/purging, 4.) binging/purging, and 5.) binging. The levels were broken down into 1.) 1-2 times daily, 2.) 1-2 times weekly, 3.) 1-2 times monthly, and 4.) Never.

Body and Weight Attitude assessment scale, a 14-item measure was created based on the Eating Disorder Examination Questionnaire (EDE-Q-6) (Fairburn & Beglin, 1994) the DSM-V criteria for eating disorders (DSM-V, 2013), and the Eating Disorder Diagnostic Scale (EDDS; Stice, Telch, & Rizvi, 2000), a 22-item self-report questionnaire designed to measure symptomology for Anorexia, Bulimia, and Binge-eating disorder. Both scales have gone through rigorous development and validation process (Fairburn & Beglin, 1994; Stice, Telch, & Rizvi, 2000). The internal consistency scale for the EDE-Q coefficients of the subscales ranged 0.68 to 0.85 for the Shape Concern subscale, and 0.51 to 0.76 for the Weight Concern subscale (NIMH, 2022). Although the EDDS has not been extensively studied, it shows reliability and validity to be sufficient in detecting full and subthreshold diagnosis for anorexia, bulimia, and binge eating disorder. The measure used for this study has five sub-scales:

Subscale 1-Income

The purpose of this scale was to explore eating patterns around income and food insufficiency as defined by the use of food stamps. This subscale included the following statements: “My food depends on my available income”, “I restrict food only when I do not have money to purchase food”, and “I use food stamps to buy food”.

Subscale 2-Restricting eating and obsessive thought behavior

The purpose of this scale was to explore restrictive eating and thought patterns typically found in restrictive eating disorders such as anorexia. The two statements included in this scale were: “I think about restricting food”, and “When I restrict food, I feel better about my body”

Subscale 3- Body Dissatisfaction

The purpose of this subscale was to examine Body Dissatisfaction unduly influenced by the disturbance in self-perceived weight and shape, which is the most notable risk factor for eating disorders. This scale included the most statements: “I am unhappy with how my body looks”, “My weight effects my self-esteem”, “I am unsatisfied with my weight”, “I feel depressed when I think about my body”, and “I feel shame around how my body looks”.

Subscale 4- Binge-eating and compensatory behavior

The purpose of this scale was to explore behaviors that are connected to binge-eating disorder and bulimia. This scale includes two statements: “I binge eat food”, and “After eating I use purging, over-exercise, or laxatives to control my weight”.

Subscale 5- Emotional distress

This subscale explored emotional distress around food and eating and included two statements: “I obsess with thoughts about food”, and “I get anxious or irritable around food and eating”.

The minimum score is 14 and the maximum score is 70. The Likert scale rated the participants answers as never, rarely, sometimes often and always. The higher the score the more the behavior and attitudes are clinically indicated for an eating disorder.

Research Question

Is the incidence of eating pathology and intense body dissatisfaction in poorer communities of color comparable to incidence reported by the Nation Institute of Mental Health and National Eating Disorder Association for a white population?

Eating Pathology

A descriptives frequency test was conducted split by race with each of the five pathological eating categories. The restricting food eating pathology was most significant with 30.1% of Black and 32% mixed-Race of participants reporting restricting food 1-2 times daily or 1-2 times weekly, whereas only 14.8% of Hispanic participants and only 11.6% of white participants reported significant restricting behavior (See Table 2). Binge-eating behavior, either 1-2 time daily or weekly, was also significant, with 20.6% of the participants of mixed-Race reporting the highest frequency and Hispanic participants reporting 16.4%, Black participants reporting 13.6% and white participants reporting 11.6% daily or weekly binge-eating behavior. This was consistent in the Body and Weight Attitude assessment scale with the statement “I binge eat food often or always” for the Hispanic group 19.7%, interestingly, only 11.3% of mixed-Race reported always or often to that statement, even though 20.6% of the mixed-Race group reported the highest rates of frequent binge eating behavior. Important to note that only 1.9% of Black participants, 2.3% of white participants, 4.1% of mixed-race participants and no Hispanic participants reported restricting/binging monthly.

Not of huge clinical significance, but worth noting, of the 43 white participants, 11.6% reported binge/purging 1-2 times daily or 1-2 weekly, with less than 2% of Black and Hispanic participants reporting any significant binge purge behavior and no participants of mixed race reporting frequent binge purging behavior. Also, worth noting that only 1.9% of Black participants, 2.3% of white participants and no Hispanic or mixed-race participants reported restricting and binging monthly, rather 93.2% of Black, 93.4% of Hispanic, 95.3% of white, and 91.8% of mixed race reported never participating in restricting/binge behavior. There were no significant findings in the category of restricting/purging.

Table 2 Frequencies of Disordered Eating

Subscale Body Dissatisfaction

When conducting Body and Weight Attitude assessment by Race we found significant findings, especially in the subscale of Body Dissatisfaction. With the statement “I am unhappy with how my body looks”, 24.3% of Black, 36.1% Hispanic, 30.2% of white, and 46.4% of mixed race reported a frequency of either often or always (See Table 3). With the statement “My weight effects my self-esteem”, 22.3% of Black, 36.1% of Hispanic, 32.6% of white, and 39.2% of mixed-race reported feeling that often or always. With the statement “I am unsatisfied with my weight”, the mixed-race group reported the with 49.5%, reporting that often or always Hispanic with 44.3%., Black and white participants reported similar finding with 37.6% of Blacks and 37.2% whites reporting feeling this way often or always. With the statement “I feel depressed when I think about my body”, 29.5% of Hispanics, 26.8% of the mixed-race group, and 25.6% of white participants reported feeling this way often or always. Black participants only scored 8.7% feeling depressed when they think about their body often or always. In the final question in the Body Dissatisfaction subcategory “I feel shame with how my body looks, 29.5% of Hispanics, 28.7% of mixed-Race, 23.3% of whites score a frequency of often or always, while a lesser percent, but still significant, 14.6% of Blacks reported this frequency of often or always.

Subscale Emotional Distress

In the subscale of Emotional Distress, the most significant findings were with the 16.3% of white participants stating they often or always “obsess with thoughts around food” with 11.5% of Hispanics reporting that frequency. Black and the mixed-Race participants less with 6.8 % of Blacks and 9.3% of the mixed-Race reporting that frequency. With the statement “I get anxious or irritable around food and eating” there were similar comparisons within the different Races with 11.6% experiencing that feeling often or always, 8.2% of Hispanics, 9.3% of the mixed-Race, and 8.7% of Blacks reported a frequency of often or always.

Subscale Restricting

In the subscale of Restricting, there were significant findings with 23% of Hispanics, 18.6% of mixed-Race, 14.6% of Blacks and 14% of whites reporting often or always to the statement “I think about restricting food”. With the statement “When I restrict food, I feel better about my body”, 14.8% of Hispanics, 14% of white participants, 8.7% of Black, and 8.2% of mixed-Race reported feeling that often or always.

Subscale Binging and Compensatory Behavior

Regarding the statement “After eating, I use purging, over-exercise or laxatives to control my weight”, the findings of frequencies were not as significant, but important to note with the overall incidence of bulimia, 4.1% of mixed-Race, 3.3%, of Hispanics and 2.3% of white participants reported a frequency of often or always. The Black participants score less than 1%. It is important to note that although only 2.3% of white participants reported a higher frequency in the Body and Weight Attitude assessment scale and 11.6% of white participants reported binging and purging daily or weekly in the eating pathology assessment. With the statement “I binge eat food” 8.7% of Blacks, 19.7% of Hispanic, and 11.3 of mixed-race and 7% of white individuals reported that they binge-eat often or always.

Eating Disorder Diagnosis

Of the 103 Black participants, 2.9% were diagnosed with Unspecified Eating Disorder, compared to 2.0% in the mixed-race group according to their medical records. Neither of the other racial groups had a diagnosis of EDNOS. The Black participants were the only group to have a diagnosis of atypical anorexia at 2.9%. Of the 43 white participants, 4.7% had a diagnosis of binge-eating disorder compared to 1.0% in the mixed-Race group. There was no diagnosis of BED in either the Black or Hispanic groups. There was only one diagnosis of anorexia, which was in the white participant’s group (See Table 4).

Income

More than half of each racial group reported using food stamps to buy food with 58.3% of Black participants, 57.4% of Hispanic, 65.1% of white, and 65% of mixed-Race participants reporting using food stamps to buy food often or always. The frequencies are far less when responding to the statement “My food intake depends on my available income” with 26.8% of mixed-Race, 17.5% Black, 16.4% Hispanic, and only 2.1% of white participants responding with often or always.

Table 3 Attitudes around Body and Weight

Table 4 Diagnosis

The purpose of this study was to explore the incidence of eating pathology and intensity of body dissatisfaction in poorer communities of color comparable to incidence reported by the Nation Institute of Mental Health and National Eating Disorder Association for a white population. What we found was high rates of body dissatisfaction and high incidence of eating pathology which is not only comparable to the NIMH and NEDA’s data for a white population but is higher than what the current data supports for any racialized group. Our data also shows higher rates of eating disorder diagnosis, particularly for AN, AAN, and EDNOS than what is supported in either NIMH or NEDA for any racialized group (NIMH, 2022; NEDA, 2022). As we will discuss below, national incidence of eating disorders and eating pathology may actually be higher than national data supports. It can be argued that weight and race bias prevent proper assessment of body attitudes and eating pathology. Each of the study participants (n=309), were directly asked questions regarding weight and body attitudes and patterns around eating pathology, resulting in higher reported incidence compared to incidence reported by either NEDA or NIMH.

The NIMH (2022) argues that communities of color are less likely to experience symptomology of an eating disorder and less likely to have an eating disorder (independent of whether an individual received a diagnosis). Ironically, the following statistic on their website to the above claim is that Black individuals are 50% less likely to be diagnosed with an eating disorder or receive any type of appropriate treatment at all (NIMH, 2022). Further, they assert that Blacks have a lesser chance of an anorexia diagnosis than white individuals even though they struggle with the identical symptoms for a longer duration (NIMH, 2022). However, our data clearly shows that BIPOC communities have high incidence of eating pathology, especially the rates of restricting behavior and high rates of body dissatisfaction, which challenges NIMH claim that the BIPOC community are less likely to experience symptomology of an eating disorder and less likely to have an eating disorder. As discussed above, our data in a BIPOC community are not only comparable to the incidence in a white population but actually surpasses the incidence of restricting behavior and eating pathology.

We must consider eating disorder assessments and diagnosis through the perspective of weight and racial biases. In looking at three ED disorder categories, AN, BN, and BED, the NIMH (2022) reported Blacks at the highest statistical percentage of any racial group and of any ED category, for BED at 2%-5% struggling with the disorder, which is a much higher rate than the white or Hispanic population. However, our data suggests otherwise with Black participants reported similarly to their white counterparts with the statement “I binge eat food” 8.7% of Blacks and 7% of white individuals reported that they binge-eat often or always. With the highest at 19.7% Hispanics reporting, they binge-eat often or always, which is much higher than what NIMH reported for BED at 1%-3.2% (2022) if we were to equivalate the frequency of reported binge-eating behavior to a BED diagnosis.

It is important to consider the rates of eating disorder diagnosis within racial groups. As already discussed, people of color are much more likely to be underassessed and under-diagnosed with an eating disorder, especially an ED of restricting type (Woodland, 2023). Of the participants (n=309), 3.9% had a diagnosis of an eating disorder. Black participants had the highest rate of a restricting disorder, AAN, at 2.9%. and 2.9% for a diagnosis of EDNOS. This is much higher than research suggests at 0.2%-0.5% for Black individuals (NIMH, 2022). As discussed above, Black participant are considered to have the highest rates of BED at 2.0%-5.0% (NIMH, 2022), however, none of the Black (n=103) participants in our sample had an official diagnosis of BED, whereas 4.7% of white individuals were diagnosed with BED, which is significantly higher than the expected range of 1.6%-3.5% (NIMH, 2022). It is important to note that the Hispanic group (n=63) did not have any diagnosis of an ED. Also, interesting to note that not one participant had a diagnosis of bulimia, which does not fit with known incidence of bulimia, whereas the NIMH reports the incidence of bulimia comparable for white and black individuals with a range of 0.5%-1.5% (2022). This is concerning as our data shows that 11.6% of white participants and 2% of Black and Hispanic participants reported binging/purging 1-2 times daily or 1-2 times weekly.

Previous research has focused mainly on investigating eating pathology in marginalized communities through the perspective of poverty and food insecurity. Further, the research identifies BED as the primary pathological eating pattern (Woodland, 2023). Our research indicates that there are far more clinical implications to disordered eating patterns in this community such as body and weight dissatisfaction, which is the highest indicator for the development of an eating disorder. Further, our data suggests that participants, in the Black and mixed-Race groups, reported significant rates of severe restricting behavior compared to the white or Hispanic participants. This counters the racialized stereotype that young white women are the demographic most impacted by severe restricting disorders, such as anorexia (Woodland, 2023). We did see a higher rate in the mixed-Race group with frequent binge eating, but no racial group indicated high rates of restricting and binge eating patterns that previous research links to poverty and food insecurity paradox (Woodland, 2023). Which challenges earlier research in these communities.

Significant Restricting Food Behavior

Research argues that Supplemental Nutrition Assistance Program (SNAP) may play a role in the binge-eating, food-insufficient paradox (Dinour et al., 2007). Goode et al. (2021) suggest that food insecurity is not significantly related to obesity but may increase the risk of eating pathology, particularly binge-eating behavior. Becker et al. (2017) suggest that fluctuations in the availability food can lead to disordered eating patterns of restriction when food is not available and binge eating when there is food available (e.g., at the end of the month when food is scarce at the beginning of the month when food stamps are replenished).

However, our data does not support this finding with only 1.9% of Black participants, 2.3% of white, 4.1% of mixed-race, and no Hispanic participants reporting a restricting/binging pattern monthly, and more than half of each racial group always utilizing SNAP to buy food. The clinic where the research was conducted is in the 3^rd poorest neighborhood in NYC (nyc.gov, 2022) so the majority of the clients are considered to be in the lower socioeconomic class. The most significant finding in our data analysis around eating pathology was with restricting behavior with 30.1% of Black and 32% mixed-Race of participants reporting restricting food 1-2 times daily or 1-2 times weekly, whereas only 14.8% of Hispanic participants and only 11.6% of white participants reported significant restricting behavior.

Atypical Anorexia

The DSM-V lists the first diagnostic criteria of eating disorder of restricting type as restriction of energy intake relative to requirements, without the requirement of low body weight (America Psychiatric Association, 2013). The American Psychiatric Association added the diagnoses of atypical anorexia to the fifth edition of the DSM (2013). An individual suffering from atypical anorexia meets all of the criteria of anorexia, with the exception of low body weight (APA, 2013).

Some might suggest that atypical anorexia is less serious and less dangerous than anorexia (Spotts-De Lazzer & Muhlheim, 2019), however individuals with atypical anorexia, similar to those with anorexia, have an intense fear of gaining weight and engage in very dangerous behaviors to control weight, such as severe food restriction, fasting, compensatory behaviors, and excessive exercise (Vo & Golden, 2022). Because current weight in individuals with AAN tend to be either of normal weight or overweight, many healthcare professionals neglect to assess thoroughly for an eating disorder, because of a false assumption that if one does not look emaciated, there is no eating disorder presented (Vo & Golden, 2022). Unfortunately, many are left undiagnosed and untreated, leaving many not to receive any intervention until late into their illness (NEDA, 2022). However, medical complications can be just as severe in individuals with AAN compared to individuals with AN, and it has been argued that individuals with AAN have more severe pathological eating patterns (Vo & Golden, 2022).

Research has indicated that there are some differences in the demographic differences with those with ANN, with a higher proportion of those diagnosed as male or nonwhite (Vo & Golden, 2022). Many argue that ANN is not a different condition than AN but rather on the spectrum of the same condition (Spotts-De Lazzer & Muhlheim, 2019). If we look at EDNOS and ANN through the lens of the severity of eating pathology, those diagnoses, as argued above, are comparable to anorexia, just without the criteria of low body weight. NIMH (2022) states that Black individuals have rates of anorexia of 0.2%-0.5%, which is slightly lower than 0.3%-0.4% for their white counterparts. Our data suggests a much more significant rates of AAN, 2.9% and EDNOS, 2.9%for the Black participants and 2.1% of mixed-Race participants with a diagnosis of EDNOS. This indicates that individuals across racial groups nationwide are being under-assessed and under-diagnosed for eating disorders of restricting type, which supports and that our data in a BIPOC community are not only comparable to the incidence in a white population but actually surpasses the incidence of restricting behavior and eating pathology.

Race and Weight Bias

Many individuals who are over-weight or in larger bodies are often confronted with weight bias (Nutter et al., 2020). Weight bias perpetuates negative stereotypes and attitudes towards larger sized people that lead to discrimination (Carel & Latner, 2016). Weight bias is not immune in healthcare settings (Kinavey & Cool, 2019), and research suggests that providers may see patients as lazy or gluttonous leading to encouraging a treatment goal of weight loss and to overlook eating disorder symptomology (Akoury et al., 2019). The idea that weight is controllable, otherwise termed as ‘obesity discourse’ simply by intake and expending calories (Bombak, 2014), oversimplifies the complexities of eating and weight struggles.

Even trained specialists and professionals can have both explicit and implicit biases towards larger bodied individuals that are based on attitudes that are anti-fat or pro-thin (Puhl et al., 2013). Further, if a treatment of weight loss is suggested or encouraged, a provider might introduce iatrogenic disease or symptoms, which can have severe or even deadly consequences (Spotts-De Lazzer & Muhlheim, 2019). If a larger bodied individual identifies a primary treatment goal of weight loss, there needs to be further assessment so we can gather a more accurate clinical picture of current behaviors and appropriate treatment interventions from a well-informed and compassionate place.

Stereotypes around weight and race can lead to an under-assessment of an eating disorder (Woodland, 2023). Some argue that part of the problem is the very act of labeling or “othering” (Meadows & Danielsdottir, 2016), which creates a distinction between “us” and “them” and to further categorize body sizes as either good or bad, perpetuating the assumption that individuals with larger sized bodies are bad people who deserve bad outcomes. This also supports the idea that thinner bodies are healthier, or in the case of eating disorder assessment, sicker, which disregards the emotional torment of one’s weight and relationship with food and body-esteem (Nutter et al., 2020).

Body Dissatisfaction

Body dissatisfaction is the most notable risk factor in the development of eating disorders (Franko, et al., 2012). Of the questions asked (n=14) on the Body and Weight Attitude assessment scale, five were specific to exploring body dissatisfaction. The mixed-race group (n=97) rated highest, 46.4% on the statement “I am unhappy with how my body looks”, and highest 49.5% on the statement “I am unsatisfied with my weight”. On the other three questions the Hispanic group and the mixed- race group rated comparably. Interesting to note that Black participants rated the lowest on four of the five statements, although they had the highest rates of ED diagnosis. These results are clinically significant and indicate that eating pathology and eating disorders are much more prevalent than previous research suggests.

Future Directions

This is the first study to investigate rates of eating pathology and attitudes around body image and weight in a poorer community with the majority of the community identifying as people of color. It is important to continue challenging racial biases and stereotypes in the BIPOC community, especially around eating disorders. The assumption is that Black and brown individuals struggle with binge-eating, but as we discovered the incidence of restricting food was highest in those communities. It can be argued that weight and race bias prevent proper assessment of body attitudes and eating pathology, leading to underassessment, underdiagnosis, and inappropriate treatment interventions. This study highlights the need for further investigation, so we don’t perpetuate the neglect of these communities in both mental and medical health care.

Limitations

The purpose of this study was to investigate the incidence of eating pathology and intensity of body dissatisfaction in poorer communities of color comparable to incidence reported by the Nation Institute of Mental Health and National Eating Disorder Association for a white population. The community studied is a poorer community. We did not investigate whether income was a factor in restricting behavior. However, we were able to challenge the notion that being poor and food insufficient leads to restricting/binging behavior. Much more research needs to be conducted around both individuals of color and eating disorders. Furthermore, this research was conducted in New York City, which generally rates higher than communities in the South in terms of access to healthcare and social determinants of health, so future research should also be conducted in other areas which may not have as favorable health outcomes, as a rule.

National Institute of Mental Health (NIMH)

National Eating Disorder Association (NEDA)

Eating Disorder (ED)

Binge-eating disorder (BED)

Atypical Anorexia Nervosa (ANN)

Anorexia Nervosa (AN)

Eating Disorder Not Otherwise Specified (EDNOS)

Black, Indigenous, and People of Color (BIPOC)

Ethics approval and consent to participate.

Consent for publication

N/A

Availability of data and materials

Data is currently in Jamovi (version 2.2)

Competing interests

The authors declare that they have no competing interests.

Funding

N/A

Authors' contributions

N/A

Akoury LM, Schafer KJ, Warren CS. Fat women’s experience in therapy: “You can’t see beyond… Unless I share it with you. Women & Therapy. 2019;42:93–115. http://dx.doi.org/10.1080/02703149.2018.1524063.
American Psychiatric Association. (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th ED. Washington, DC.
Becker CB, Middlemass KM, Gomez F, Martinez-Abrego A. Eating disorder pathology among individuals living with food insecurity: A replication study. Clinical. Psychol Sci. 2019;7(5):1144–11. 10.1177/2167702619851811.
Becker CB, Middlemass k, Taylor B, Johnson C, Gomez F. Food insecurity and eating disorder pathology. Int J Eat Disord. 2017;1032–40. 10.1002/eat.22735.
Becker AE, Franko DL, Speck A, Herzog DB. Ethnicity and differential access to care for eating disorder symptoms. Int J Eat Disord. 2003;33:205–12.
Bombak A. 92014). Obesity, health at every size, and public health policy. American Journal of Public Health, 104, 60–67. http://dx.doi.org/10.2105/AJPH.2013.301486.
Bradenburg BMP, Anderson AE. Unintentional onset of anorexia nervosa. Eat Weight Disorders. 2007;12(2):97–100.
Carels RA, Latner J. Weight stigma and eating behaviors. An introduction to the special issue. Appetite. 2016;102:1–2. http://dx.doi.org/10.1016/j.appet.2016.03.001.
Chamy-Weber C, Narring F, Michaud PA. Partial eating disorders among adolescents: A review. J Adolesc Health. 2005;37(5):416–26. https://doi.org/10.1016/j.jadohealth.2004.09.014.
Chen JY, Piers AD, Lesser EL, Lowe MR. The effect of weight suppression on eating behavior: Does the intentionality of weight loss matter? Appetite. 2022;174:2–8. https://doi.org/10.106/j.appet.2022.106017.
Coffino JA, Ivezaj V, Barnes RD, White MA, Pittman BP, Grilo CM. Ethnic and racial comparisons of weight-loss treatment utilization history and outcomes in patients with obesity and binge-eating disorder. Eat Behav. 2022;44:101594.
Dinour LM, Bergen D, Yeh M-C. The food insecurity-obesity paradox: A review of the literature and the role of food stamps may play. J Am Diet Assoc. 2007;107(11):1952–61.
Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994;16:363–70.
Franco M, Diez Roux A, Glass TA, Caballero B, Brancati FL. Neighborhood characteristics and availability of healthy foods in Baltimore. Am J Preventative Med. 2008;35:561–7.
Goode RW, Kalarchian MA, Craighead L, Conroy MB, Gary-Webb T, Bennett E, Burke LE. (2018). Perceptions and experiences of appetite awareness training among African-American women who binge eat. Eating and Weight Disorders, 30221323. https://doi.org.10.1007./s40519-018-0577-z.
Gordon KH, Brattole MM, Wingate LR, Joiner TE Jr. The impact of client race on clinician detection of eating disorders. Behav Ther. 2006;37:319–25.
Gordon KH, Perez M, Joiner TE Jr. The impact of racial stereotypes on eating disorder recognition. Int J Eat Disord. 2002;32(2):219–24. https://doi.org/10.1002./eat.10070.
Hart LM, Granillo MT, Jorm AF, Paxton SJ. Unmet need for treatment in the eating disorders: A systematic review of eating disorder specific treatment seeking among community cases. Clin Psychol Reviews. 2011;31(5):727–35. https://doi.org/10.1016/j.cpr.2011.03.004.
Hazzard VM, Hooper L, Larson N, Loth KA, Wall MM, Neumark-Sztainer D. Associations between severe food insecurity and disordered eating behaviors from adolescence to young adulthood: Findings from a 10-year longitudinal study. Prev Med. 2022;154. https://doi.org/10.1016/j.ypmed.2021.106895.
Herman CP, Poliivy J. Anxiety, restraint, and eating behavior. J Abnorm Psychol. 1975;84:66–72.
Kinavey H, Cool C. The broken lens: How ant-fat bias in psychotherapy is harming our clients and what to do about it. Women & Therapy. 2019;42:116–30. http://dx.doi.org/10.1080/02703149.2018.1524070.
Meadows A, Danielsdottir S. What’s in a word? On weight stigma and terminology. Front Psychol. 2016;7:1–4.
Medi -EHR. (2022). Medi-EHR [Software] [2022].
Middlemass KM, Cruz J, Gamboa A, Johnson C, Taylor B, Gomez F, Becker CB. Moving beyond weight & shape: Dietary restraint and food insecurity in a marginalized population. Manuscript submitted for publication; 2018.
Mond JM, Hay PJ, Darby A, Paxton SJ, Quirk F, Buttner P, Rodgers B. Women with bulimic eating disorders: When do they receive treatment for an eating problem? J Consult Clin Psychol. 2009;77(5):835–44.
National Eating Disorders Association. (2022). https://www.nationaleatingdisorders.org/.
National Institute of Mental Health. (2022). https://www.nimh.nih.gov/.
(2022). https://www.nyc.gov/assets/ochia/downloads/pdf/all_populations_medicaid.pdfNutter, New York State, Russell-Mayhew S, S., Ellard JH. (2020) Reducing unintended harm: Addressing weight bias as a social justice issue in counseling through justice motive theory. Professional Psychology: Research and Practice, 51, 2, 106–114. http://doi.org/10.1037/pro0000279.
Nutter S, Russell-Mayhew S, Ellard JH. Reducing unintended harm: Addressing weight bias as a social justice issue in counseling through justice motive theory. Prof Psychology: Res Pract. 2020;51(2):106–14. http://doi.org/10.1037/pro0000279.
NYC.gov (2023, February 21).
Puhl RM, Latner JD, O’Brien K, Luedicke J, Danielsdottir S, Forham M. A multinational examination of weight bias: Predictors of anti-fat attitudes across four countries. Int J Obes. 2015;39:1166–73. http://dx.doi.org/10.1038/ijo.2015.32.
Simone M, Telke S, Anderson LM, Eisenberg M, Neumark-Sztainer D. Ethnic/racial and gender differences in dosoredered eating behavior prevalence trajectories among women and men from adolescence into adulthood. Soc Sci Med. 2022;294:114720.
Sonneville KR, Lipson SK. Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. Int J Eat Disord. 2018;518–26. 10.1002/eat.22846.
Spotts-De Lazzer A, Muhlheim L. Could your higher weight patient have atypical anorexia? J Health Service Psychol. 2019;45(1):3–10.
Stice E, Telch CF, Rizvi SL. Development and validation of the eating disorder diagnostic scale: A brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychol Assess. 2000;12(2):123–31. 10.1191/096228098672090967.
The jamovi project. (2021). Jamovi. (Version 2.2) [Computer Software] Retrieved from https://www.jamovi.org.
Vo M, Golden N. Medical complications and management of atypical anorexia nervosa. J Eat Disorders. 2022;10:1–6.
Woodland SL. (2023) Dying to eat: The under-assessment of eating disorders in marginalized communities. Journal of Obesity & Eating Disorders, 9, 1, 1–9. DOI:1036648/2471-8203.9.1.131.

No competing interests reported.

Download PDF

Editorial decision: Major revision
24 Jul, 2023
Reviews received at journal
23 Jun, 2023
Reviewers agreed at journal
08 May, 2023
Reviewers agreed at journal
05 May, 2023
Reviewers invited by journal
23 Apr, 2023
Editor assigned by journal
20 Apr, 2023
Submission checks completed at journal
20 Apr, 2023
First submitted to journal
18 Apr, 2023

You are reading this latest preprint version

Is the Incidence of Eating Pathology and Intense Body Dissatisfaction in poorer communities of color comparable to national incidence?

Status:

Version 1

Abstract

Plain English Summary

Introduction

Methodology

Results

Discussion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1