The Changing Face of Anorexia

Think anorexia is a teen disease, or a habit taken up by spoiled, white rich girls? Think again.

White women in their teens and 20s still account for most anorexia cases in the U.S. But experts say women in their 40s and 50s, men, black and Hispanic women, and even little girls as young as 8 or 9 years old are showing up in doctors' offices with anorexia, bulimia, and other eating disorders.

These folks are hardly the typical profile dating from the 1980s, when movies like The Best Little Girl in the World portrayed the distorted body image and birdlike eating habits of well-off white teenagers and young women in their 20s. Research, too, focused primarily on this group of patients.

Now, experts wonder, what's going on? Are eating disorders on the rise in these populations

or are we finally seeing what's been there all along?

It's a little of both, suggests Diane Mickley, MD, co-president of the National Eating Disorders Association (NEDA, www.nationaleatingdisorders.org) and the founder and director of the Wilkins Center for Eating Disorders in Greenwich, Conn.

"I've done intakes at our center for 25 years, and there's no question that our patients are getting older, and we have many more middle-aged patients," she says. "Now, this is an illness that starts in adolescence, which burgeoned in the 1970s and 1980s. The majority of patients get better, but some do not, and they get older."

Few of these cases indicate a truly new onset of the disease at age 35 or 45. "Instead, it's the resurgence of a disease that they may have had since adolescence. We do see the occasional patient with middle-aged onset of anorexia, but the increase in older patients coming for care is predominantly among those who've had it for a long time," says Mickley.

Nevertheless, many of these women are seeking care for the first time in their 30s, 40s, and 50s. Why now?

"For women in their 30s, it may be that they want to have children and it forces them to confront something that might be affecting their fertility," says Doug Bunnell, PhD, past president of NEDA and the clinical director of the Renfrew Center of Connecticut. (Headquartered in Philadelphia, the Renfrew Center operates treatment facilities for eating disorders in several states.)

"In the 40s and 50s, what might spur a re-emergence of the disease, and a decision to seek treatment, is often some sort of disruption: divorce, death, cancer or other illness scare, empty nest syndrome — any sort of developmental transition," he adds.

Anorexia Is Getting Younger, Too

As the face of anorexia gets older, it's also getting younger.

"For a long time, kids have talked about weight and being fat or thin at a young age," says Bunnell. "But what we're seeing now is an earlier emergence of actual eating disorder behavior. The research hasn't caught up with what we're seeing clinically, but anecdotally, we're treating girls of 10, 9, and 8 years old with full-blown anorexia nervosa."

One heartbreaking challenge to diagnosing these girls: a key diagnostic criterion for anorexia is the loss of menstrual periods, but more and more of these girls are too young to have even had a first period yet.

Besides age, ethnicity is a telling factor in current cases of anorexia. "For Caucasian and Hispanic girls and women, the rates of anorexia are basically indistinguishable," says Bunnell. "On the other hand, there does seem to be some protective factor from anorexia if you're African-American."

Studies have indeed found very few African-American women with anorexia, compared to white, Asian, and Hispanic women. But that doesn't mean that they are free from eating disorders.

"African-American women have been found in some research to have higher levels of laxative abuse for weight control even than white women, which was surprising," says Gayle Brooks, PhD, vice president and clinical director of the Renfrew Center in Florida. "We see high levels of diuretic use as well." Young black women, in short, are more likely to be "bingeing and purging" than they are to be starving themselves with anorexic behavior.

That, too, may be changing. African-American women do get anorexia. A 2001 study, for example, found that 2 percent of African-American women at a large Midwestern university had the disorder. Kaelyn Carson, a 20-year-old college cheerleader and track star from Michigan, died in the summer of 2001 after a 14-month battle with anorexia.

"Whatever sort of protective function comes from being very culturally connected dissipates over time as pressures rise on women of color, as they do white women, to have their self-esteem determined by body size," says Brooks.

She adds, "the protective qualities of culture become much less influential when a young girl goes into a predominantly white environment, where she's assaulted with images and pressure to look a certain way."

Anorexia: Not Just A Woman's Problem

In the mid-1980s, experts believed that women with anorexia outnumbered men by a factor of 10 to one or more. But in 2001, a Canadian study published in the American Journal of Psychiatry found that female anorexics outnumbered males by only four to one.

"There are a number of treatment centers in the country that specialize in treating men and boys with anorexia, and they seem to be seeing an increase in demand," says Bunnell. Is that because there's been an increase in male anorexia, or simply because doctors are finally recognizing the disease in men? "It's probably a little bit of both."

In 2003, a BBC survey of child and adolescent mental health specialists in Britain found that nearly three-quarters believed that anorexia is underdiagnosed, and not well understood, in males.

What's more, there's no doubt that the pervasive societal pressure about body image has been extended, more and more, to men. For proof, look no further than your nearest magazine stand, where you'll find numerous men's magazines featuring the same kind of unrealistically perfect models that have traditionally been found in Vogue and Cosmo.

"Boys and men are now subjected to increasingly unrealistic expectations about what they should look like, and mixed in with the national antiobesity push, we're seeing more and more tension in boys about their physical appearance," says Bunnell.

Cultural Pressures To Blame?

Experts agree that precious little is still understood about anorexia and other eating disorders in "nontraditional" populations, like men, minority groups, older women, and younger children. But many suggest that it might have to do with the pervasiveness of cultural pressures. "We have a culture that is fat-phobic, that has unrealistic notions of how thin a body type ought to be and at what age," says Mickley.

"One of the things we've been trying to figure out is how much these disorders can be attributed to inherent biological factors, and how much comes from the culture," says Bunnell. (A growing body of studies point to a strong genetic connection for anorexia.)

"The obvious answer is that it's always both. But these days, the cultural pressure about weight is so high, the focus on obesity is so intense, and the culture has broadened so much," he notes. "Maybe as the culture has gotten louder and more intense, it exposes more of that latent vulnerability."

Sources: Diane Mickley, MD, co-president, National Eating Disorders Association and founder/director, the Wilkins Center for Eating Disorders, Greenwich, Conn. Doug Bunnell, PhD, past president, NEDA; clinical director, the Renfrew Center of Connecticut, Wilton, Conn. Gayle Brooks, PhD, vice president and clinical director, the Renfrew Center, Coconut Creek, Fla. "Prevalence of Eating Disorders among African American Women." Journal of Counseling Psychology, January 2001; vol 48: pp 111-116. "Comparisons of Men With Full or Partial Eating Disorders, Men Without Eating Disorders, and Women With Eating Disorders in the Community." American Journal of Psychiatry, 2001; vol 158: pp 570-574.

By Gina Shaw
Reviewed by Charlotte Grayson, MD
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