Who develops bulimia nervosa?

Females and males…children as young as 8 years old…adults as old as 60 years…all races, ethnicities, minorities…all socioeconomic levels…

Research has shown that bulimia nervosa is much more common in females than males—about 90% of diagnoses are made in females. However, a recent literature review suggests that males may be underrepresented in research, and the percentage of affected males is likely higher than thought. An international review of published epidemiologic studies reported lifetime prevalence among women from the various studies ranging from 1.5% to 2.9%. In men, lifetime prevalence reported was between 0.1% and 0.5%. When assessing studies that analyzed data across racial and ethnic groups, bulimia nervosa was more prevalent among Latinos and African Americans than non-Latino whites.

Recent published studies have found a higher incidence than previously thought of eating disorders in males, minority females, and people classified as sexual minorities (people who do not identify as heterosexual, people attracted to the same sex or to both sexes, and people who identify as transgender or gender-nonconforming) than has previously been reported. Murray et al. 2017 reported that males constitute more than one of every four preadolescents with an eating disorder in Australia and as much as one of three in the U.K.

Myths and stereotypes

Many myths exist about who develops bulimia nervosa and why, and what a person with the disorder looks like (see Common myths about eating disorders). While people with the disorder have several common characteristics, bulimia nervosa does not discriminate by race, sexual orientation, gender identity, or socioeconomic or education level. In Western cultures, bulimia nervosa has been diagnosed in Asians, blacks, Latinos, whites, and other ethnic and racial groups, in the LGBTQ community, in Veterans, and in all socioeconomic classes. However, high-quality studies are not available to determine how many cases occur each year in a given group of people or country, or how many people have bulimia nervosa overall. The reason that it’s hard to find out, according to researchers, is that people, especially males, with eating disorders are often unwilling to admit having a problem. Affected individuals are also less likely to respond openly to questions a doctor asks and are less likely to be willing to fill out an eating disorder symptom survey than people without the disorder. However, researchers believe that a two-stage process is the best approach to try to determine how many people have an eating disorder. The process involves screening people by first using a questionnaire and then using those results to follow up and confirm suspected cases through personal interviews.

Stereotypes

For years, the stereotypical person with bulimia nervosa was a thin, white college student from an upper middle or higher socioeconomic class. Older published studies of bulimia nervosa had reported that young white women were more likely than any other group to develop the disorder; however, researchers now think these older data are inaccurate because the people in those studies did not reflect the general population. Many of these studies came from universities and clinics where white women in higher socioeconomic classes were overrepresented. In fact, studies that focused on treatment options often excluded male participants because it was believed that bulimia nervosa did not affect males. One potentially dangerous result of this stereotype was that doctors generally did not believe that bulimia nervosa occurred in other groups of people, and early criteria used to diagnose the disorder were developed under this misconception. Thus, doctors did not consider a diagnosis of bulimia nervosa in some patients even when the signs and symptoms suggested a person might have the disorder.

Affected females and males differ in their focus

In contrast to females, whose eating-disordered behavior and mindset tend to focus on body image, weight loss, and calorie restriction, the male “ideal body” type focuses on a lean, muscular look with low body fat percentage. Another difference in the way bulimia nervosa is generally characterized between males and females is that males may be less likely to use purging behaviors of vomiting or laxatives to compensate for binge eating, but rather tend to use nonpurging behaviors, such as restrictive dieting and/or excessive exercise. This can make diagnosing the disorder in males more challenging.

Middle-age adults with bulimia nervosa

Bulimia nervosa is also more common than previously thought among women in their 40s and 50s in Western cultures. Some reasons suggested for this are pressures that can mount and create high stress levels. These pressures include career, family, children growing up, changes in personal health, body size and shape with aging, and divorce. With age, a woman’s body can also look less like the idealized women seen in much product advertising. Changing metabolism and weight gain are typical changes that women face as they age. Today, women have generally become more conscious about appearance over a longer time span than women from previous generations—in part, because more women are in the work force and live longer than those in previous generations. Thus, the expectation is to maintain a youthful body and appearance for a longer time. Increased exposure to social media sites may also contribute to a negative body image or low self-esteem.

Athletes

Athletes comprise another group affected by bulimia nervosa. As expectations for peak performance rise in top male and female athletes, so does pressure to maintain a peak level of performance and the “ideal body” for their particular sport. This can lead to compulsive exercising, dieting, and in some cases, purging or other compensatory behaviors used by people with bulimia nervosa. A recent research review suggests that participants in certain sports may be at higher risk of developing disordered eating as a coping mechanism to try to maintain their performance level and appearance (Joy et al. 2016). The review authors reported that disordered eating is more prevalent in athletes than nonathletes, particularly at the college level, and that females make up about 90% of athletes with eating disorders.

Some sports, such as gymnastics, wrestling, ice skating, rowing, and diving, promote a certain body image. Maintaining weight limits is important in many of these sports. For example, wrestlers may use drastic means to stay in their wrestling weight class—means that are similar to the compensatory practices used by people with bulimia nervosa. However, study results on whether certain groups of athletes are actually at higher risk of developing bulimia nervosa are mixed. Women’s sports reporting the highest rates of eating disorders were cross-country running, gymnastics, figure skating, rowing and diving, and track and field. Male sports reporting the highest rates of eating disorders were wrestling, cross-country running, and specific track and field events such as pole vaulting and high jumping, which are considered “antigravitational” sports and require a leaner, lighter body type for peak performance.