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Makailah Dowell grew up facing food scarcity and homelessness in small-town Idaho. Her biological parents were never in the picture, so she was raised by her grandmother, who struggled to make ends meet on a housekeeper’s salary. For the most part, they survived on food stamps and discounted, lower-quality groceries—except for the rare days when her grandmother would get a haul of free food from the hotel where she worked.
“That’s when the binge eating came out,” Dowell remembers. After a long day at school, where she was bullied for being a heavier-bodied biracial African American, Dowell would respond to an uncommon bounty of food by spiraling into an uncontrollable binge. Afterward, the guilt was unbearable. She began purging to try to undo the damage.
By the time Dowell realized she had a problem, she was deep in the throes of bulimia. But when she asked her doctor for help, he dismissed the issue. For her, the bias of the health system was clear. “He just looked at my weight and my race and said that there were no concerns,” she says. It took five years for her to get a diagnosis for her disorder, at age 16—and only because a dentist noticed the alarming decay of her tooth enamel, which is a common side effect of purging.
Eating disorders are conventionally associated with skinny, white, affluent girls, aka the SWAG stereotype. The common image of an eating disorder patient is a gaunt, young white woman. Perhaps she’s cutting into a meager slice of fruit or a thin round of cucumber, and hoping to fit into an even-smaller pair of designer jeans. But new research is illuminating the extent of cases like Dowell’s. For example, heavier-bodied folks can and do get eating disorders, as a New York Times feature recently explored.
Some of the most striking recent data concerns the intersection of eating disorders and food insecurity. Defined by the U.S. Department of Agriculture as “the limited or uncertain availability of nutritionally adequate and safe foods,” food insecurity affects 34 million Americans, including 5 million children. A disproportionate number of food-insecure people live in single-mother households, identify as Black or Hispanic, and reside in rural areas—that is, they fit a profile very much like Dowell’s.
Across every core measure, eating disorder pathology worsened as food insecurity increased.
The breakthrough study on food insecurity and eating disorders came out of Trinity University in 2017. In partnership with the San Antonio Food Bank, researchers investigated the prevalence of eating disorder behaviors among food pantry clients. Their sample considered people who do not fit the SWAG stereotype in two major ways: The majority of participants identified as ethnic and racial minorities, and nearly 60 percent earned under $10,000 a year. The researchers interviewed participants while they waited in line for food distribution, collecting data on levels of food insecurity and eating disorder symptoms including restriction, binging, and weight self-stigma. When they plotted the results, they found a clear linear relationship: Across every core measure, eating disorder pathology worsened as food insecurity increased.
To the researchers’ surprise, food insecurity was also associated with high rates of what are called “compensatory behaviors,” like vomiting and laxative use. In short, they found evidence of a wide range of eating disorder symptoms, with heightened severity among the most food-insecure.
In hindsight, the link between food insecurity and eating disorders makes a lot of sense, says Carolyn Becker, a psychology professor who researches body image and eating disorders and co-authored the San Antonio study. She cites the famous World War II study by Ancel Keys, known as the Minnesota Starvation Experiment, in which 36 healthy young adult men voluntarily lost 25 percent of their body weight. Over the yearlong experiment, Keys watched the participants develop a number of hallmark eating disorder symptoms, including binging, purging, abnormal mealtime rituals, and a general obsessing over food. Even after the experiment, they struggled to reclaim a healthy relationship with food: In a follow-up study 57 years later, many reported binge eating and abnormal weight gain. The findings suggest that prolonged food restriction—even when unrelated to weight concerns—puts people at risk for eating disorders.
For decades, eating disorder experts have relied on the Keys study to illustrate the myriad adverse effects of hunger and restriction, both to their patients and in the media. That it didn’t also pique their interest into the communities most vulnerable to hunger—that is, food-insecure populations—speaks to the field’s immense blinders to people outside the wealthy, white paradigm. Becker herself admits to being clouded by the eating disorder stereotype; for much of her career, she conducted research on more stereotypical patient profiles, like sorority members.
Her pivot came after a couple of students pitched her the idea of researching eating disorders in marginalized populations. Later, while contemplating such a project on a walk with her dogs, Becker remembered the Minnesota Starvation Experiment. She saw an opportunity to test if Keys’ findings could apply to food-insecure communities, and went back to her students to design the study. When the results came in, Becker says, “it was so sad, because the rates of pathology were so significant, the poverty was so significant, and this population has been so ignored in the literature.”
In the 1980s, the authors of the Diagnostic and Statistical Manual of Mental Disorders gave eating disorders their own section, kick-starting a wave of research into conditions like anorexia and bulimia. But the majority of clinical studies focused on underweight white females—and as a result, the primary evidence base is skewed toward that narrow subset of the population. The historical samples used in research have shaped everything from how eating disorders are screened, diagnosed, and treated. Simple wording choices can have a huge impact: “The assessments that [doctors] use are very culturally slanted,” says Leslie Garcia, an eating disorder recovery coach who works from a decolonized perspective. She explains that the standard questions “don’t necessarily resonate with people of color.” For example, one of the five questions on the Eating Disorder Screen for Primary Care, a common diagnosis tool, is “Have any members of your family suffered with an eating disorder?” Considering the persistent exclusion of people of color from diagnosis and treatment—and divergent cultural norms around mental health disclosure—a nonwhite respondent might not be able to answer that question accurately. And although the majority of people with eating disorders are not underweight, most insurance companies calculate coverage based on “medical necessity,” a murkily defined term that all too often hinges on low-weight status, full stop.
In the wake of the San Antonio study, a small but growing number of others have begun to amass further evidence in defiance of the SWAG stereotype. Food insecurity has recently been linked to heightened rates of binge eating disorder, bulimia, and anorexia, and unhealthy weight control behaviors like laxative use and fasting—all of which, at their core, point to a disordered relationship with food. In late 2022, researchers at the University of Minnesota ventured toward explaining why this is the case. In a survey of 75 food-insecure young adults, the majority of whom were female and people of color, they found support for the “feast-famine” effect, a natural tendency to binge after periods of food scarcity. This biological response is exacerbated by the schedule of the Supplemental Nutrition Assistance Program (formerly known as food stamps), which distributes lump-sum benefits once a month. The average household on SNAP uses over three-quarters of the benefits by the middle of the month, leaving participants in the lurch between distributions. More frequent—and more robust—benefits would offer recipients consistent access to food, and decrease the likelihood of the feast-famine effect taking hold.
These early findings raise more questions about who else has been excluded from the eating disorder conversation.
These early findings raise more questions about who else has been excluded from the eating disorder conversation. When researchers turn the spotlight on food-insecure populations, they encounter folks at the intersection of myriad marginalized identities. “Food insecurity is often housing insecurity, which is also linked to trauma, which is also linked to racism, which is linked to a whole host of other things,” says Fatima Cody Stanford, a Harvard Medical School–affiliated physician and scientist who specializes in obesity. Each of these issues should be a lens through which to consider relationships with food. To accommodate people outside the eating disorder stereotype, we need much more research to understand the breadth and depth of their lived experiences.
“There are a lot of misunderstandings of who has eating disorders and what that actually means,” says Rebecca Eyre, a licensed therapist and the CEO of Project Heal, a nonprofit aimed at dismantling barriers to eating disorder care. The organization provides free clinical assessments, free or heavily discounted treatment placements, help with insurance navigation, and cash assistance for tertiary recovery costs, like food and gas. Across all programming, providers work from a harm reduction model, weighing how various kinds of help might actually cause more damage, and working to develop alternative solutions to ensure the well-being of patients. For example, if placing a Black woman with a larger-sized body in residential treatment, Project Heal staff would be careful to avoid facilities where the patient is likely to experience microaggressions and high-weight stigmatization. If placing a transgender patient, they’d consider a program’s gender-neutral signage and doctors who respect chosen names and genders. “We understand which treatment centers do those things well and which ones are farther behind,” says Eyre, “and we are careful about where we place people according to that information.” If an identity-affirming inpatient option isn’t available, Project Heal builds hybrid recovery programs from a variety of outpatient resources.
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While nonprofits like Project Heal broaden access to recovery resources, the problems that seed and exacerbate eating disorders persist. For food-insecure communities, eating disorder rates will likely get worse before they get better. Congress recently made cuts to COVID-19 food benefits, which gave all eligible families the maximum monthly SNAP allowance regardless of income. Though the emergency aid was always a temporary measure, it reduced poverty to record lows, proving just how much Americans need more support—not less. For many families, the termination amounts to losing hundreds of dollars a month. Together with inflation (grocery prices spiked by 11.4 percent in 2022), the rollback deals a critical blow to low-income households. “We’re going to see more food insecurity across the board,” says Annette Nielsen, executive director of the Hunter College NYC Food Policy Center.
Makailah Dowell considers herself one of the lucky ones. After her bulimia diagnosis, she and her grandmother fought tooth and nail for her Medicaid to cover psychotherapy. Together, they managed to cobble together an at-home treatment plan. (They couldn’t afford residential care, which can cost over $1,200 per day.) Against all odds, she recovered. Today, she works as a lead peer mentor at Equip, a nationwide telehealth eating disorder program, helping people of all backgrounds achieve recovery. For her, accessible care means going into the communities that need it—not expecting people in those communities to jump through hoops for basic resources. “We’re too busy working 60-hour weeks,” she says. “We’re too busy catching up on bills.”
