Gender, Ethnic Differences May Hamper Eating Disorder Diagnosis

The problem is compounded when the sufferers don't display the typical symptoms of disordered eating. "We need to think more broadly about who struggles with eating disorders," said adolescent medicine and eating disorder specialist Rebecka Peebles, MD, instructor in pediatrics (adolescent medicine). Peebles pointed out that diagnostic and even treatment criteria were developed with Caucasian women or girls in mind. "We may not be asking the right questions for these other groups at all."

In the gender study, Peebles compared 104 boys aged 8 to 19 who had eating disorders with about 1,004 similarly aged girls who had the condition. She found that boys were less likely than girls to have used purging behaviors, such as vomiting or using laxatives, to control their weight in the month prior to the study (23.5 percent vs. 32.4 percent). They were also more likely to be diagnosed with an "Eating Disorder Not Otherwise Specified," or EDNOS, rather than with anorexia or bulimia, than girls (62.2 percent vs. 49.1 percent), perhaps because they express themselves differently.

"We're taught to be alert for patients who express a desire to be thin," said Peebles. "But clinically, boys often talk about wanting to be more fit and eat healthily, which doesn't set off the same kind of alarm bells."

Fitness is fine, but rigorous exercise coupled with severely restricted food intake can spell trouble just as surely as the more familiar binging and purging cycles seen in girls. Even though the National Eating Disorders Association estimates that approximately 10 percent of people diagnosed with eating disorders are male, alert parents of boys can still sometimes struggle with convincing their health care provider that their son has an eating disorder.

"There is a perception that boys rarely get eating disorders," said Peebles, "and many boys undergo pretty extensive medical workups for other conditions, like gastric problems or brain tumors, before their physicians hit on the right diagnosis."

Ethnic differences may also play into the range of symptoms experienced by people with eating disorders. In the second study, Peebles used a Web-based questionnaire to survey a variety of people who visit Web sites that promote eating disorders about their experiences with the condition. Then she examined differences between ethnic groups, which included Caucasians, African Americans, Hispanics, Asians and Native Americans.

She found that American Indians and Alaskan Natives, although a very small proportion of the overall sample, were significantly more likely than Caucasians to use laxatives to control their weight. Nearly half (46.7 percent) had been hospitalized at least once as a result of their disordered eating, a criteria shared by fewer than one in five Caucasians (13.2 percent), and they reported a longer duration of disease than the other groups.

"We were surprised and intrigued by these preliminary results," said Peebles, who cautioned that more research is needed. "We know that this group is at high risk for other psychiatric issues, such as alcoholism and PTSD. Our findings suggest that it may be important to screen them for disordered eating."

The Native Americans who participated in the survey also reported higher maximum lifetime weights and lower minimum lifetime weights than other groups, suggesting more dramatic swings in body size.

Peebles plans to continue her studies to determine how best to diagnose and treat eating disorders in different genders and ethnic groups. "It's so important to identify these 'walking wounded' among us," she said. "Many people think that only Caucasians or women have weight and body issues, and that other groups just don't mind. There is a lot of stuff we just don't know yet."

Peebles is presenting the research as two separate abstracts at the annual meeting of the International Eating Disorders Conference on May 4 and May 5 in Baltimore.

Other Stanford and Packard Children's researchers involved in the work include undergraduate student Aileen Kurobe; medical student Jenny Wilson; James Lock, MD, PhD, professor of psychiatry and behavioral sciences; and Iris Litt, MD, the Marron and Mary Elizabeth Kendrick Professor in Pediatrics, emerita.