When Carolyn Black Becker, a psychologist who studies eating disorders, used to explain her research to colleagues, she would get blank stares. The field, after all, was disproportionately focused on young girls and women who were underweight, white, and from middle-class families. Becker herself had spent most of her career focused on the prevention of eating disorders among sorority members.
In that light, her decision to study eating disorders in people who were facing food insecurity — that is, people without reliable access to sufficient food — seemed unusual, even bizarre to some. “Everybody looked at me like I had two heads,” Becker recalled.
But she also thought she was onto something. And when she finalized the results of her first major study on the issue, conducted among clients of a food bank in San Antonio, the data were striking: In addition to seeing high levels of food restriction — the deliberate effort to reduce amount of food one eats — she and her colleagues reported high rates of binge eating and purging, such as self-induced vomiting or laxative misuse. Those rates increased depending on people’s level of food insecurity, from 2.9% among people who were only mildly food insecure to 37.6% among people who had so little food even the children went hungry.
It wasn’t just that some people experiencing food insecurity were eating more at times, which would make sense. It’s also that they felt guilty and ashamed for doing so. They reported vomiting after eating to keep from gaining weight, and 22.8% used laxatives or diuretics for the same reason.
Other experts say those kinds of findings makes sense.
“The thought that people are going to receive this food and robotically be able to eat perfectly and stop at fullness each time — it seems really laughable to me,” said Kimmie Singh, a dietitian in private practice in New York.
There remains precious little study of eating disorders in people facing food insecurity. But Becker, who teaches at Trinity University in San Antonio, and her colleagues are at the forefront of a field that they believe is critical, especially now.
Even before the economic fallout from the coronavirus pandemic, the U.S. Department of Agriculture estimated that 11.1% of American households experienced food insecurity. With the unemployment rate skyrocketing, the number of people being served by food banks is, anecdotally, surging. And hidden within that population, Becker and some others researchers believe, is a large and growing group of people who challenge every cliché about eating disorders.
A hole in the literature
In 2015, Becker and political scientist Keesha Middlemass were co-teaching an undergraduate seminar at Trinity about the politics of the food system when two students approached them about starting a research project working with underserved populations.
Several days later, while walking her dogs, Becker found herself thinking about the Minnesota Starvation Study, a well-known experiment conducted during World War II. At the time, University of Minnesota physiologist Ancel Keys was asked by the government to figure out how to renourish the millions of people who were facing starvation after the war.
So Keys recruited 36 conscientious objectors and slashed their food intake by half until they had lost a quarter of their body weight. Then, he set about renourishing them. The results of the study were written up and published as two, 6-inch-thick hardcover tomes.
The study was largely forgotten until the 1980s, when anorexia researchers noticed haunting parallels between the previously healthy young men (who showed no abnormal fixation on food before the study) and the eating disorders of patients who showed up in clinics. As the men were starved, they became obsessed with food. They also became more anxious and depressed. And when Keys began to provide free access to food after the study’s starvation phase, the men began binge eating, reporting that they continued to feel ravenous even after consuming 10,000 calories.
To some of the first eating disorder scientists, the Keys study meant that characteristics that seemed to be the hallmarks of anorexia, such as being unable to stop thinking about food, weren’t so much a disorder as they were part of the normal human response to starvation.
Becker had a different realization. The dietary restraint imposed by food insecurity wasn’t unlike the forced food restrictions imposed by the Minnesota Starvation Study. And if the young men binged when they had access to food, it seemed likely that those with food insecurity would, too.
Researchers had found similar patterns in rats. When physiologist Mary Boggiano at the University of Alabama at Birmingham studied rats living their normal rat lives and eating standard rat chow, they all consumed normal amounts of rat food. From a research perspective, it was pretty boring. But make the rodents’ access to rat chow intermittent and add in some super-tasty Oreos along with a dose of stress (in the form of mild foot shocks), and all of a sudden researchers had a group of binge-eating rats. The rodents showed many of the same physiological markers observed in low-income minority populations with food insecurity.
Given the obvious parallels between food insecurity and eating disorders, Becker expected to find studies on the subject. “We put our students on a massive literature search, and basically found a hole in literature big enough to drive a truck through,” she said.
Middlemass, Becker, and their students surveyed 503 individuals receiving food at the San Antonio Food Bank or one of its affiliate sites around the city. They published their results in 2017 in the International Journal of Eating Disorders.
What they found, beyond the binge eating, was the shame. The vomiting. The laxatives and diuretics.
“There is something with the psychology where the overeating isn’t just the amount of food consumed. It’s really that distress and that feeling that they can’t stop even if they wanted to,” said Janet Lydecker, a psychologist at the Yale School of Medicine. “So that creates feelings of failure and also of feelings that I’m not the person I should be.”
Importantly, the researchers did not actually diagnose anyone with an eating disorder; rather, they found that some participants reported many of the same behaviors as those with eating disorders, making it possible that they, too, had conditions such as anorexia, bulimia, and binge eating disorder. The Trinity team also asked participants about their perception of weight stigma, or prejudice against individuals perceived to be too heavy. Sure enough, even in households in which there was regularly not enough to eat, people reported a desire to diet to lose weight.
When the researchers sat down and started analyzing the results, they found almost linear correlations between eating disorder symptoms and food insecurity. A replication study in 2019, conducted in an even larger population at the same food bank, found almost identical results. “It was some of the saddest and most beautiful data that I had ever seen,” Becker said.
Her work challenged preconceptions about what eating disorders actually were.
Singh, the New York dietician, said those preconceptions stem from the fact that people who have eating disorders and can afford to seek help tend to be wealthier. And most research is done on patients who show up in clinics.
Food insecurity never even entered the picture of how psychology and psychiatry conceptualized an eating disorder, Singh said. As a result, starving yourself to lose weight was considered a disorder, but no one thought about starving yourself to ensure your family had enough to eat.
A pivotal moment in the field
Becker’s work came at a pivotal moment in the eating disorders field. Although the disorder is most often associated with young, thin, white, wealthy young girls and women, others were beginning to recognize that most people struggling with eating disorders don’t fit that stereotype.
Researchers are finding eating disorders in people from 5 to 75, in people of all shapes and sizes, and in all races and ethnicities. African-American, Latina, and Native American teenagers have all been found to be more likely to binge eat and purge than their white counterparts. LGBT groups have been reported to have shockingly high eating disorder rates. Although poverty affects many of these individuals, Middlemass said, researchers still don’t study it systematically.
“Our data is unique in that we are challenging the stereotype” that eating disorders don’t affect low-income people, said Middlemass, now a professor at Howard University.
Last year, after hearing about Becker and Middlemass’ work, the Center for Balanced Living, a treatment center for people with eating disorders in Columbus, Ohio, decided to create a food pantry for clients during the 2019 holiday season. The center collected donations from patients and staff, specifically asking them to avoid bringing in “diet” products that could be unhelpful to those in recovery.
Taylor Lechner, a dietician at the center, said she expected that clients would find the food pantry useful. But she was taken aback by just how many people needed help getting food at all.
“We kept seeing more and more people coming up in our higher level of care that had food insecurity and this was hindering their ability to get food,” Lechner said.
The Columbus facility, now part of the national treatment center known as the Emily Program, is one of the few eating disorder clinics in the U.S. that even asks about food security. There are countless people struggling with both food insecurity and eating disorders who can’t get treatment at all. Patients with Medicaid, the predominant form of health coverage for low-income people, report they have trouble finding specialists and treatment programs who accept their insurance.
“Instead of assuming that eating disorders are driven by internally imposed dietary restriction, wanting to lose weight, and internalized weight bias, there might be some external factors,” Lydecker said. “And if we ignore that, the problem won’t go away even with treatment.”
To Lydecker, the work by Middlemass and Becker has been crucial in forcing the broader eating disorders world to confront those issues. And because they supported it with such strong data, she said, it’s been much easier to get providers and other researchers on board.
With the economic fallout from the coronavirus pandemic, Lechner said even more of her patients will likely struggle to find adequate food. Although she hasn’t had any of her patients disclose new such issues, many have begun to space out appointments to save money — a sign that food insecurity could be just around the corner.
Middlemass said she hopes more researchers will begin to pay attention.
“If anything,” she said. “I wish eating disorders field would be interdisciplinary and think about food outside of just the sort of traditional grocery store or the middle-class perspective.”