There’s no shortage of myths and misconceptions about eating disorders, and it’s time to put them to rest. In reality, all these myths do is isolate those who are combatting the illness, but don’t fit the conventional mold of being a thin, young woman. Although there seem to be endless misconceptions about eating disorders, it’s crucial to strike down some of the most prominent myths, including those that affect me, my relationship with eating disorders and their continued impact on my recovery.
First, there is the myth that a person has one of the three main eating disorders. I’m referring, of course, to anorexia nervosa, bulimia nervosa and binge eating disorder. However, eating disorders often exist on a continuum, where individuals may have symptoms and behaviors associated with more than one disorder, and they may transition from one to another, revolving through and becoming trapped in an eating disorder cycle. So, if a person opens up to you and shares that they suffered from both anorexia and bulimia, it shouldn’t come as a surprise. Nonetheless, these three aren’t the only eating disorders people struggle with. Avoidant/restrictive food intake disorder, other specified feeding and eating disorders (OSFED) and orthorexia are all serious illnesses worth mentioning.
Second, there’s the myth that if you have anorexia, you’re rail thin. I cannot stress this enough — eating disorders don’t have a look. While it is true that one of the main diagnostic criteria for anorexia is weighing below 85% of one’s ideal body weight, or being below a certain BMI (a measurement which should be taken with a grain of salt), this criteria is not a universal truth. A study of adolescent patients with anorexia found that 31% had all the features and complications of the disease without being underweight. Atypical anorexia, which falls under OSFED in the eating disorder world, is the term used to describe those who meet all the criteria for anorexia nervosa, except the significant weight loss, and is in fact not atypical at all.
Those struggling with this form of anorexia are just as prone to the medical complications of mainstream anorexia as those who lose a great deal of weight. In fact, these anorexics are in fact at a heightened risk for serious complications, since the extent of their illness is often overlooked because they aren’t underweight. These misdiagnoses lead the individual to believe they aren’t really sick, or sick enough, because their weight is fine. In turn, they often engage even further with severely restricted eating, doing more drastic harm to their physical and mental health. This mentality of “not being sick enough” is the very topic of Dr. Jennifer Gaudiani’s book “Sick Enough,” which every medical professional should read.
More generally, less than 6% of people with eating disorders are underweight. Fortunately, the eating disorder community is making strides away from using this as a defining criterion. The “atypical” in front of this type of anorexia needs to be dropped because it is very typical to have anorexia with a normal or even larger-sized body. What’s more important is that these individuals are likely underweight for their body, meaning they are below their set point. They shouldn’t have to be society’s definition of underweight to warrant treatment. On the whole, you can be a normal weight and still have anorexia if you’re undereating for your body type and deal with the mental battle of restricting food.
Third, the myth that if you have anorexia, you don’t eat. Ever. If that were the case, your anorexia would be short-lived since you would die in a matter of weeks. However, people struggle with anorexia for years. While no one’s individual case is the same as another, it’s more so about eating a bare minimum and being extremely restrictive with your food. It’s a mental illness characterized by an intense fear of weight gain, obsessive-compulsive movement, over-exercising, distorted body image and an obsessive occupation with food — these components can all exist at the same time.
Still, let it be clear that not everyone with anorexia suffers from every single one of these. Any combination of them is a valid struggle that warrants treatment. Needless to say, this disorder is extremely complex, evident by the fact that many want to recover, and want to be at a healthier weight for their body, but at the same time they are not able to eat the foods, and the amount of foods, that will get them there due to crippling anxiety.
Fourth, the myth that recovery from a restrictive eating disorder simply means eating a “normal” 2,000 calorie diet. This is rarely the case. Recovering from a restrictive ED will require a lot of food, and while the amount will vary for each recovering individual, they will often need much more than a mere 2,000 calories a day. In the case of anorexia, specifically, those suffering from it have gone through a prolonged period of energy deficit that they now have to make up for. Once refeeding syndrome is no longer a concern, recovering individuals may often need upward of 3,000 calories a day, and once they’ve become more comfortable with the idea of eating more for recovery, they can often eat this amount, plus some, with ease due to bouts of extreme hunger.
Furthermore, anorexia may affect one’s metabolism for life. Some evidence suggests those in recovery from anorexia need increasingly more calories to maintain the same rate of weight gain toward weight restoration, and they may also need more calories than others who haven’t had an eating disorder to maintain their weight once it is restored.
Fifth, the myth that if you purge, you’re bulimic. This isn’t necessarily true and is where the thin line between different eating disorders becomes evident, specifically the line which differentiates anorexia from bulimia. Where does one start and the other begin? It’s hard to tell, and that’s why many eating disorder survivors have had periods where their particular disorder has manifested as different ones. While many associate bulimia with purging, and purging is one of the defining features of that eating disorder, many people are unaware that purging can also be present in anorexia. Anorexia has two subtypes, one being the binge-purging type that describes those who restrict for long periods of time (e.g. a whole day), then eat a large amount of food and purge to make up for it. It also includes those who purge what little food they can bring themselves to eat.
Sixth, the myth that purging equals puking. While purging via self-induced vomiting is the most commonly recognized form, there are various others we must be aware of to be inclusive of all people who struggle with bulimia. Other avenues of purging include the misuse of laxatives, diuretics or other medications, as well as fasting and excessive exercise.
Seventh, the myth that restriction is the solution to binge eating disorder: It is never OK to prescribe eating disorder behaviors to an individual, no matter their body size. Too often, people with binge eating disorder are prescribed a restrictive eating disorder to stop their patterns of binge-eating, and this only worsens the binge-restrict cycle, as bingeing is the body’s biological response to restriction. Going back to myth number four above, this is why so many people in recovery from restrictive eating disorders encounter extreme hunger and eat large amounts of food. These “binges” — which I put in quotes for the term’s ambiguous definition of a “large amount of food” — are essentially saving the life of someone who is malnourished.
Eighth, the myth that eating disorders only inflict teenage girls and young adult women. Eating disorders can develop at any age, and regardless of gender. Dieting can often be a precursor to eating disorders. Stressful periods of life can also trigger eating disorders. Finally, research is starting to examine genetic predispositions to restrictive eating disorders, like anorexia, and this may mean that people who simply fall into energy deficit, even unintentionally, can end up with full-blown eating disorders. More research is needed on this topic.
Ninth, the myth that eating disorders are phases: If you’ve had times in your life where you restricted food for a few days or you were overwhelmingly concerned with food and body for that one week last year, and then it just phased out, that simply wasn’t an eating disorder. Your feelings and concerns were of course valid, but they seem like a moment of self-consciousness projected on food and body at that time. That happens to almost everyone, but it’s not an eating disorder.
Eating disorders are different in that they are a mental illness, and to better understand this, it’s worth examining the distinction between an eating disorder and disordered eating behaviors. You can, and many people do, engage in the latter without having an eating disorder. When those behaviors become fixed and you’re unable to shake them due to crippling fear, and/or they become such strong compulsions that you simply can’t not do them, you may have crossed into eating disorder territory.
Last but not least, the myth that once you gain weight, you’ve recovered from anorexia. Again, eating disorders are a mental illness and anorexia is not solely an obsession with weight loss. So the idea that weight gain cures anorexia doesn’t make sense. Yes, weight gain for someone whose anorexia has led them to be underweight (this doesn’t always happen) is a crucial first step towards recovery as it is the difference between life and death. But it is only the tip of the iceberg.
Oftentimes, nutritional rehabilitation and getting to a healthy weight for each individual — their natural, unsuppressed bodyweight otherwise known as their set point — must happen before the individual can do the necessary psychological work to reach full recovery.
Nyla Booras can be reached at nbooras@umich.edu.
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