With Eating Disorders, Looks Can Be Deceiving

The New York Times

By Jane E. Brody

July 27, 2020

Distorted eating behaviors occur in young people irrespective of their weight, gender, race, ethnicity or sexual orientation.

Appearances, as I’m sure you know, can be deceiving. In one all-too-common example, adolescents and young adults with disordered eating habits or outright eating disorders often go unrecognized by both parents and physicians because their appearance defies common beliefs: they don’t look like they have an eating problem.

One such belief is that people with anorexia always look scrawny and malnourished when in fact they may be of normal weight or even overweight, according to recent research at the University of California, San Francisco.

The researchers, led by Dr. Jason M. Nagata, a specialist in adolescent medicine at the university’s Benioff Children’s Hospital, found in a national survey that distorted eating behaviors occur in young people irrespective of their weight, gender, race, ethnicity or sexual orientation. And it’s not just about losing weight.

The survey revealed that among young adults aged 18 to 24, 22 percent of males and 5 percent of females were striving to gain weight or build muscle by relying on eating habits that may appear to be healthy but that the researchers categorized as risky. These practices include overconsuming protein and avoiding fats and carbohydrates. The use of poorly tested dietary supplements and anabolic steroids was also common among those surveyed.

The Covid-19 pandemic has likely exacerbated the problem for many teenagers whose daily routines have been disrupted and who now find themselves at home all day with lots of food being hoarded in kitchens and pantries, Dr. Nagata said in an interview. “We’re seeing more patients and referrals for eating disorders and their complications,” he said.

Without a proper diagnosis and intervention, young people with distorted eating behaviors can jeopardize their growth and long-term health and may even create a substance abuse problem. The findings suggest that abnormal behavior with regard to food and exercise is often overlooked, misunderstood, ignored or perhaps viewed as a passing phase of adolescence.

This is especially true among teenage boys. One-third of the high school boys surveyed said they were trying to gain weight and bulk up, and many were using risky methods to achieve their goals, Dr. Nagata told me. Sixty percent of the girls surveyed said they were trying to lose weight. Some consumed unbalanced diets that can jeopardize their growth and long-term health; others resorted to induced vomiting or abused laxatives, diuretics, diet pills or engaged in other hazardous behaviors like fasting or excessive exercise.

Over all, distorted eating was more than twice as common among females than males. It was also reported more often among those who described themselves as Asian/Pacific Islanders, gay, lesbian or bisexual.

The survey was conducted among a national sample of 14,891 young adults who were followed for seven years, starting at an average age of 15. The goal was to see if the youngsters’ perceptions and habits surrounding food and exercise could serve as warning signs of behaviors that could injure them physically and emotionally.

Among the boys in the study, those most at risk worried that their bodies were puny — too small, too skinny or insufficiently muscular, prompting them to consume unbalanced diets, exercise obsessively and take supplements or steroids that are a hazard to their health. When overly fixated on building their bodies, they can become socially withdrawn and depressed and develop a disorder called muscle dysmorphia that can lead to heart failure, resulting from insufficient calories and overexertion.

A missed diagnosis is likely when a young person’s relatives or doctors have preconceived notions about how someone with an eating disorder looks or behaves. For example, Dr. Nagata said, a teenage girl or young woman who is anorexic can fall under the medical radar because her weight is normal or even overweight.

Although diagnosis of an eating disorder like anorexia or bulimia was twice as common among the young adults whose weight was normal or underweight, the fact that these disorders also exist in heavier young adults is often overlooked, Dr. Nagata said.

“Almost half of those with anorexia nervosa are at or above normal weight,” he said. “Young people with atypical anorexia have the same body image distortions and severe psychological distress as those with regular anorexia. They’re at high medical risk and just as likely to be hospitalized for complications caused by their distorted eating behaviors.”

Dr. Nagata’s colleague and co-author of the study, Dr. Kirsten Bibbins-Domingo, an internist at the university, said in an interview, “Physicians who care for young adults should think about patterns of eating that are harmful, and not just among very thin women. Young adults with abnormal eating habits too often fall between the cracks because physicians think of them as healthy. However, abnormal eating patterns are not uncommon in adolescence and young adulthood, and that’s when patterns of behavior related to later health and disease are established and solidified.”

The problem of disordered eating behaviors among teens and young adults is often encouraged or compounded by participation in certain competitive sports and other activities that overemphasize a particular body weight and physique. Among these are gymnastics, wrestling, dance, figure skating, weight lifting and bodybuilding.

Social media, with its heavy focus on appearance, has fostered the problem as well, Dr. Nagata said. Even toys, like Barbie dolls and action figures, have made a contribution. “A study of male action figures found that they have become bigger, more muscular and more extreme in their appearance over a 30-year period,” he said.

“If youngsters are obsessed with an idealized body image, their thinking and behavior become disordered and can take over their lives,” he said. “The detrimental effects can be subtle. Prior to the pandemic, they may have rejected going out with friends so they could spend more time in the gym. It’s a warning sign when they withdraw from normal activities and become preoccupied with their appearance.”

Unhealthy weight control methods can predispose people to eating disorders and actually lead to weight gain, not loss. I struggled with weight gain in my early 20s and, having failed to control my weight any other way, I eventually resorted to fasting all day until supper. But once I started eating, I couldn’t stop and ended up gaining even more weight. I had developed a binge-eating disorder that resolved only when I stopped trying to diet and returned to eating three wholesome meals a day, including one small snack so I didn’t feel deprived.

Dr. Bibbins-Domingo wants doctors to be proactive in asking about eating and exercise habits when treating adolescents and young adults. “They should have a conversation about what these young people are eating, when they’re eating and how they’re eating, and be able to give advice about healthy eating patterns.

“Without making a value judgment about body size, they can open the door to a discussion about eating and exercise habits,” Dr. Bibbins-Domingo suggested. “The physician might ask, ‘What did you eat yesterday, and where, and what do you think about the choices you made?’ or ‘Do you want to address weight issues?’”

The pandemic may offer one silver lining, Dr. Nagata said. “With more families eating meals together, it’s easier for parents to monitor what their kids are eating.” Having family meals together is one of the basic tenets of therapy for eating disorders, he said.