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It’s not about the scale: Understanding the mental side of eating disorders

Written By: Vicki Powers, UT Physicians | Updated: February 28, 2024
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People with eating disorders often hide their mental illness. Learn the crucial warning signs to catch it early.

Eating disorders are an insidious mental illness, and cases skyrocketed during the COVID-19 pandemic. It’s not based on a number on the scale. What we can’t see is what’s going on in someone’s head and what they’re feeling. While some people may not be satisfied with their bodies, people who have an eating disorder view it differently.

 Zachary S. Appenzeller, PsyD
Zachary S. Appenzeller, PsyD

“Those with eating disorders place more importance on their self-worth and value toward their body, shape, and weight. Their dissatisfaction with their body is not necessarily higher,” said Zachary S. Appenzeller, PsyD, an eating disorder specialist at UT Physicians Psychiatry Outpatient Clinic – BBSB.

Thoughts and feelings of inadequacy and low self-esteem can be the beginning phases that trigger an eating disorder. Pair that with traits such as perfectionism and obsessiveness to create a perfect storm. Early perfectionism can be the highest marker for eating disorders, said Appenzeller, assistant professor in the Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School at UTHealth Houston.

The challenge is it’s not as simple as recognizing if someone is losing weight. Research indicates just 6% of those with this illness are medically underweight. Those who have bulimia nervosa, for example, are actually in average-sized bodies and sometimes even overweight.

When diet and exercise become triggers

Dieting is not always a benign behavior, especially for those who have a high genetic vulnerability for developing eating disorders. It can be the final straw that sparks someone into developing a full-blown eating disorder that can take over their lives.

Dieting and working out at the gym are two normalized activities that can both become extreme for those with a genetic disposition for eating disorders. And unfortunately, genetic vulnerabilities account for about 50% of those who develop eating disorders, he said.

Appenzeller describes it as behaviors that are hugely overlooked and normalized, because people consider those who do them as “gym rats” or “dieting.” But they’re actually doing them in unhealthy ways.

Idolizing perfection

A fake reality of perfect bodies is a large contributor to an earlier age of onset (10- and 11-year-olds) as well as the severity of eating disorders these days, says Appenzeller. The prevalence of these images on social media plays into it, as well. It’s the preteen girl following celebrities on social media. It’s the adolescent male who wants to bulk up after seeing muscles on male models.

Some of the common traits of those with eating disorders (obsessiveness, perfectionism, and drive) play right into this notion of trying to achieve something that doesn’t exist. Appenzeller said they’re so dissatisfied and believe these unrealistic ideals need to be met.

The reality of this male disease

Eating disorders affect different ages, race, and gender, despite the myth that it’s mostly adolescent white females. Latina females have higher rates of bulimia nervosa during adolescence while anorexia nervosa is overrepresented among white females. 

In the last few years, the number of males presenting with eating disorders has increased, especially for those aged 12-14. Appenzeller questions whether it’s a genuine increase in numbers of males or just better recognition of eating disorders.

Anorexia nervosa, for example, is no longer a 1:10 ratio of males to females. It’s closer to a 1:3 ratio of males to females struggling with an eating disorder, according to stats from the National Institute of Mental Health. The male angle is rarely discussed.

“There is a large number of males obsessed with their physical appearance. They’re spending hours in the gym with an ideal to be muscular and big,” Appenzeller said. “This is just as psychologically tormenting as those who are significantly restrictive of food.”

Potential eating disorder signs

Parents and other adults working with children need to be aware of potential behaviors that might indicate an eating disorder:

  • Creation of significant rules around good foods and bad foods.
  • Eat less than they used to eat.
  • Eat in private and not comfortable eating around others, due to anxiousness.
  • Not growing in height or increasing their weight.

“Pediatricians and parents should be noting if there is a plateau in weight,” Appenzeller said. “That’s not normal, and that would be a big red flag that something might be going on behind the scenes.”

Catching signs of this disease early can prevent the realm of emotional, psychological, physical, and mental issues that can result. Over time, the condition can lead to heart damage, kidney failure, growth retardation, seizures, stomach ulcers, tooth decay, and more.

Sadly, eating disorders are the second highest mortality rate of any mental illness. This is attributed to both the suicidal tendencies as well as malnourishment and organ failure that can lead to death.

It’s not a choice but recovery is

One of the most important aspects to remember, according to Appenzeller, is that developing an eating disorder is not a choice, just like no one chooses to develop cancer or heart disease. This could be someone who dieted at some point, like most people in the world, and had enough vulnerability factors that got them stuck in pushing down their weight.

“There’s so much empathy that can be tapped into, that it’s no longer just this person who’s vain or overly superficial,” Appenzeller said. “Even if developing an eating disorder is not a choice, recovery can be.”

Acceptance, love, and safety are some positive ways family and friends can support those with eating disorders. It might take a team of experts to focus on all angles — psychological, behavioral, nutritional, and medical – but it all begins with taking the first step to recognize the issue.

As the clinical practice of McGovern Medical School at UTHealth Houston, UT Physicians has locations across the Greater Houston area to serve the community. To schedule an appointment, call 888-4UT-DOCS.