Eating disorders have increasingly become the focus of research studies due to their prevalence, especially in Western cultures. Of the adolescent and young adult populations in the United States, for example, between .3 and .9 % are diagnosed with anorexia nervosa (AN), between .5 and 5 % with bulimia nervosa (BN), between 1.6 and 3.5 % with binge eating disorder (BED), and about 4.8 % with eating disorder otherwise not specified (EDNOS) [1–4]. According to the fifth edition of the DSM, individuals that do not fit the criteria for AN, BN or BED are diagnosed with sub-threshold or atypical conditions that fit under other specified feeding or eating disorder (OSFED) [5]. Due in part to decreased thresholds for the diagnoses of AN, BN or BED in the DSM-V, rates of OSFED have been found to be lower than previous rates of EDNOS, while the rates of AN, BN or BED have stayed the same or slightly increased [6]. Furthermore, the age at onset is concerning, as most eating disorders originate during adolescence [4]. Despite the potentially serious health consequences that result from disordered eating [7], many in the general public believe that issues with eating are due to personal shortcomings [8, 9]. This creates a foundation of stigma regarding why individuals develop an eating disorder (e.g., to be “skinny”) and the purpose the disorder serves (e.g., to gain control). Such stigma may dishonor the actual experience of those who have lived with an eating disorder, as people could assume eating disorders are self-inflicted. In turn, those developing unhealthy habits may be discouraged from seeking help [10].
Previous research has identified biological, psychological, and sociocultural factors related to the development of eating disorders. However, it is important to explore individual narratives to identify similarities and differences among individuals with and without eating disorders. Obtaining such knowledge can help scholars determine the public’s educational needs and better target missing gaps in their knowledge. More accurate information may reduce stigma regarding eating disorders, which may in turn encourage those experiencing symptoms to seek help sooner, as they may no longer fear the negative feedback from peers and family that such stigma causes.
Factors that contribute to eating disorders identified by research
Research has identified many risk factors, ranging from individual to sociocultural, that contribute to the development of eating disorders. Based on empirical literature, we present some of the most salient factors below.
Individual factors
Genetics and biology are individual factors that play a role in the development of eating disorders. Genetic contributions to the development of eating disorders have been suggested by twin studies, with heritability estimates ranging from 0.39 to 0.74, depending on the disorder [11]. Abnormalities in the regulation of certain neurochemicals, such as 5-Hydroxytryptamine (HT) and the serotonin-transporter-linked polymorphic region (5-HTTLPR), have been closely linked with eating disorders [11–13]. Further, recent research has identified mutations on two specific genes that have been associated with increased risk of developing eating disorders in families: estrogen-related receptor α (ESRRA) and histone deacetylase 4 (HDAC4) [14]. In addition, early puberty has also been associated with disordered eating behaviors, potentially due to increases or irregularities in circulating sex hormones, especially estrogen [15, 16].
Body dissatisfaction has been commonly identified as an influential risk factor for eating disorders. Individuals dissatisfied with their bodies are at an increased risk of engaging in disordered eating behaviors such as bingeing and purging in order to gain satisfaction and move closer to the thin ideal [14, 17]. Engaging in dieting behaviors also increases the risk for the occurrence of eating pathology such as binge eating and purging [15, 18].
Researchers have recognized perfectionism as a specific risk factor in the development of eating disorders, as this personality trait may lead to a persistent pursuit of the thin ideal [15, 19, 20]. Perfectionism can also be a maintenance factor for disordered eating since it promotes dieting, bingeing, and purging, and enhances eating disorder symptoms, particularly when combined with low self-esteem [12, 15]. Similarly, research has shown that negative affect in general, such as high levels of stress, guilt, hostility, anger, anxiety, and depressed mood, is associated with increases in eating disorder symptoms [12, 13, 17–21].
Sexual, physical, and emotional abuse have all received empirical support as risk factors for psychiatric difficulties, which can include eating disorders [22]. Specifically, research has shown that sexual abuse can occur in 29 % of individuals with eating disorders, and physical abuse may occur in 57 % of individuals [23, 24]. Additionally, emotional abuse is a significant predictor of eating disorder symptoms among women when other types of abuse are controlled for, suggesting that emotional abuse may be particularly salient [12, 25].
Sociocultural factors
Many sociocultural factors affect the development of eating disorders. In families, for example, mothers’ and fathers’ own body dissatisfaction and dieting behaviors have been associated with their children’s eating-related attitudes and behaviors [26, 27]. Parental weight-related teasing, negative comments about body shape, pressure to lose weight, and encouragement to diet have also been associated with body dissatisfaction, dieting, disordered eating behaviors, and eating disorders among both females and males [12, 15, 26, 28–31]. Furthermore, parents who engage in high levels of parental control, expressed emotionality, critical comments, hostility, or emotional overinvolvement and negate their child’s emotional needs are more likely to have children who develop eating disorders [12, 32].
Peer influences on the development of eating disorders can also be broken down into a variety of factors. Peer pressure to conform to cultural ideals has been consistently identified as an important factor associated with the development of disordered eating behaviors, especially among adolescents [29, 33]. In particular, girls may learn attitudes and behaviors from their peers, such as the importance of being thin and dieting behaviors, through modeling, teasing, and conversations about body image and eating [12, 33]. Similarly, romantic partners play a significant role in the development of eating disorders through negative comments about appearance and encouragement to lose weight, which can lead to weight concerns, body dissatisfaction, and disordered eating behaviors among both men and women [34, 35].
It is also worth mentioning that eating disorders among athletes are common, as there is a large focus not only on being in shape, but on being the fittest and therefore the “best” [36, 37]. There is an even greater risk of developing an eating disorder with participation in certain competitive sports that focus on leanness, such as gymnastics [38]. Athletes who believe that being leaner will increase their performance are more likely to engage in disordered eating [39]. This belief may be encouraged or reinforced by coaches and instructors, further increasing athletes’ risk for developing disordered habits [40].
Lastly, the media has an influential, if often controversial, role in the development of eating behaviors due its representation of the thin ideal. There is support that, regardless of the level of internalized thin ideal, women who were warned that a thin media image was altered experienced lower body dissatisfaction in comparison to those who were not warned the image was altered [41]. A preference for a thin and virtually unattainable body has been associated with the development of eating disorders, particularly AN [42].
A relatively small number of studies have examined individuals’ perceptions regarding the causes of eating disorders [10, 36, 43–55]. Some studies have solely focused on the perceptions of either the general public [10, 43–47] or those with eating disorders [36, 37, 50–55]. Both types of studies have identified a common set of risk factors, with public perceptions and the perceptions of individuals with eating disorders varying slightly [e.g. 48,49]. Overall, both populations have a basic understanding of what eating disorders are and characteristics of each eating disorder [10, 36, 43–55]. However, despite this knowledge, many adults without eating disorders may be unsympathetic to those suffering from eating disorders, believe that having an eating disorder would not be distressing, and report that eating disorders are not difficult to treat [9].
Public perceptions of factors that contribute to eating disorders
The studies to date that have focused on identifying public perceptions of the factors associated with the development of eating disorders have surveyed individuals drawn from communities or schools. Typically, these samples have been quite large, numbering over 100 [43, 44] or even several hundred [10, 45, 46], and have included both females and males [10, 43, 44, 46–48]. Despite the importance of large samples, all of these studies have been limited in that the researchers did not ask open-ended questions; rather, participants responded to forced-answer questions where they either had to identify which item was a cause of eating disorders or identify to what degree a particular item was a cause.
The public commonly places blame on individuals with eating disorders, suggesting that they have control over their “self-inflicted” illnesses [48]. Of the individual factors associated with the development of eating disorders, the majority of people who do not have eating disorders identify psychological explanations such as emotional state, personality, and low self-esteem [10, 43, 46–48]. The general public also believes that individuals’ own behaviors and attitudes related to body image such as dieting, a desire to be thin, and body image distortion are important factors in the development of eating disorders [43, 47, 48]. Traumatic events, genetics, and sexual abuse were rarely discussed or, if they were mentioned, rated low on the level of significance in causing eating disorders [10, 47].
Although sociocultural factors are less commonly identified as causal factors of eating disorders among the general public, a few factors have received support. Of all the sociocultural factors, family issues were the factors most often identified [43, 46, 48, 49]. Pressure from friends as well as social isolation and loneliness were also perceived to be factors contributing to eating disorders [46, 47]. In one study, the portrayal of thin women in the media was a highly significant cause endorsed by adult women [45].
Perceptions of individuals with eating disorders regarding causes
In contrast to studies investigating the perceptions of the general public regarding factors associated with the development of eating disorders, most studies we found that focused on individuals with eating disorders used open-ended measures, either via interview or questionnaires. Despite this, one pitfall of the research to date is that it has often involved relatively small sample sizes, ranging from 15 to 36 [36, 37, 49–51]. Only two studies have included samples over 50 individuals [52, 53]. Additionally, almost all of these studies have focused exclusively on women, with only two including a limited number of men [37, 50]. Furthermore, although research has included assessments of individuals with AN [36, 50, 54] and BN [53, 55] or both [49, 51, 52], studies have failed to examine if differences existed in the perceptions of those with AN versus BN, or include individuals with other eating disorders such as BED, EDNOS, or OSFED.
Similar to public perceptions of causal factors, people with eating disorders also identify individual and sociocultural factors. Individual factors commonly identified among samples of those who were diagnosed with eating disorders include perfectionism, emotional problems or distress, stress, unhappiness with appearance, high expectations of self, and lack of control [36, 48, 50–54]. Behaviors and attitudes related to body image, such as weight loss activities, body image distortion, and a belief that thinness equals happiness, were also frequently identified as factors that related to the development of their disorders [48, 53, 55]. Hereditary factors and sexual abuse were not indicated.
Sociocultural influences identified by individuals with eating disorders included the media, family, peers, and sports. Although rarely mentioned, the media was occasionally identified as playing a role through the importance it places on thinness and self-comparison to the thin ideal [36, 37]. Family factors, in contrast, were often cited and included poor parental care, controlling parents, poor relationship with parents, family tension or high amounts of conflict, critical family environment, emotional abuse, and an emphasis on weight [36, 37, 48–51, 53, 55]. Factors associated with peers and sports were also common and included receiving comments or pressure from friends and coaches about appearance, a need to lose weight for sports performance, and poor relationships with peers [36, 37, 53, 55].
Comparisons of individuals with and without eating disorders
We could only find two studies that examined the perceptions of both individuals with and without eating disorders. First, Haworth-Hoeppner [49] interviewed 21 women with an eating disorder (either AN or BN) and 11 without, asking open-ended questions about the development of eating disorders. In this study, no comparisons were made across the two groups, likely due to the qualitative nature of the project as well as the small sample size. Second, Holliday and colleagues [48] used larger samples of individuals with and without AN and made comparisons across groups regarding the causes of eating disorders and the most important causes. However, this study was limited in that it did not allow participants to describe their own beliefs. Instead, participants responded to a list of eighteen pre-identified causes of eating disorders, which did not allow for individual perspectives and greater depth into the complexity of eating disorders.
The present study
With the prevalence of eating disorders and young age of onset, examining people’s perceptions of the factors contributing to eating disorders is important. Such efforts can enhance public education and potentially decrease the stigma surrounding eating disorders. The present study specifically examined the differences between what people with and without eating disorders perceived to be the causes of eating disorders in order to better understand people’s experiences with eating disorders as well as to better educate the larger population. We also examined differences regarding the causes of eating disorders according to type of eating disorder, including AN, BN, both, and other (e.g., BED, EDNOS, or OSFED). This study strengthens existing research by utilizing qualitative, open-ended responses as opposed to forced-answer questionnaires so that participants could identify causes using their own opinions.