September is National Recovery Month—a time to raise awareness about recovery and the many paths people take toward healing. But when we talk about recovery, substance use often gets the spotlight on its own, while another critical piece of the conversation can be overlooked: eating disorders.
The two can be deeply interconnected. Up to 50 percent of people with eating disorders also misuse alcohol or illicit drugs—a rate five times higher than the general population, according to the National Eating Disorders Association (NEDA). For some, substances may become a way to cope with the distress, anxiety or difficult emotions associated with disordered eating.
Yet despite this significant overlap, eating disorders and substance use are often treated separately, creating gaps in care for people navigating both.
To better understand this connection, the warning signs to watch for and how loved ones and healthcare professionals can offer support, BlackDoctor spoke with Jessica Scheer, CEO of the National Eating Disorders Association (NEDA), about what patients and families need to know.
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According to Scheer, the connection between eating disorders and substance use is not unusual. In fact, the two can intersect with other mental health conditions as well.
“They’re incredibly common. Eating disorders walk alongside substance use,” Scheer says.
Researchers are learning more about the genetic profile of eating disorders and how they overlap with other mental health conditions, including ADHD and obsessive-compulsive disorder, which can also overlap with substance use.
One possible connection is the role substances can play in managing distress.
“When people are having distressing thoughts, either about behaviors or about foods specifically, they will look to substances to help manage that distress,” Scheer says.
For some people, substance use may become a way of coping with the emotional distress associated with disordered eating.
“That’s often why people with disordered eating and eating disorders will use substances as a way of managing their overall mental distress, specifically the distress that might come from their disordered eating,” she says.
Recognizing an eating disorder or substance use problem isn’t always straightforward, particularly because the signs can vary from person to person. But Scheer says social isolation can be an important signal that something may be wrong.
“Social isolation is usually the first sign we notice that something’s amiss,” she says.
That withdrawal can show up in a person’s relationship with food, exercise or other parts of their daily life. Someone may begin avoiding shared meals, spending more time alone or pulling away from activities they once enjoyed.
“When people move away from shared meals, and it is harder to engage them in anything that approaches what their feelings are asking them to process in real time with someone they care about, that’s a real red flag,” Scheer says.
Of course, everyone has days when they don’t have the energy or desire to talk. The concern comes when the behavior becomes consistent.
“When that happens consistently, we know that that’s something you need to take note of and find ways to have a sensitive and direct conversation about your concerns for that person,” she says.
Another important point: There isn’t one specific behavior or appearance that defines an eating disorder.
“Eating disorders are actually a set of disorders. And so there’s not just one particular behavior that can be concerning,” Scheer says.
Some people may restrict food or water or develop rigid food-related rituals. Others may engage in binge eating or begin planning when and where they can eat alone.
“They’re doing these things privately,” Scheer says.
That range of behaviors can make eating disorders difficult to recognize, particularly in communities where people may not have the language or clinical terminology to describe what they’re experiencing.
Scheer encourages people to pay attention to changes in their relationship with food, including statements such as “emotional eating” or “eating with their feelings.”
Those behaviors can be worth noticing just as much as someone refusing to discuss food altogether.
One of the first steps toward getting help, she says, is becoming familiar with what concerning behaviors can look like.
NEDA also offers a free screening tool that can help people better understand where they may fall on the spectrum for developing an eating disorder, along with educational information and potential next steps.
For family members and friends, knowing how to approach someone they’re concerned about can be difficult. Scheer says the goal should be to create an open, nonjudgmental space rather than immediately confronting someone about their eating or weight.
“A huge part of the journey is coming into these conversations with a calm, open presence,” she says.
Scheer recommends having these conversations privately and avoiding blame or focusing directly on someone’s eating habits or weight.
Instead, loved ones can point out changes they’ve noticed in the person’s overall well-being.
For example, you might say:
“I noticed that we haven’t talked on the phone for a while.”
Or:
“Hey, we haven’t gone to the movies. It used to be our thing.”
Another option might be:
“I noticed you were really quiet at the barbecue last week.”
These observations can create an opening for a larger conversation.
“These things where you’re noticing that people are having a hard time dealing with being in everyday life are usually the best way to help you have a bigger conversation about, ‘Hey, is something wrong? Is something going on?’” Scheer says.
Loved ones can also pay attention to physical changes or other symptoms. Once they become more familiar with the potential effects of an eating disorder, those observations may provide another way to begin a conversation.
“If you’re not ready to talk about disordered eating, they might be willing to problem-solve about some of the other aspects and effects of having an eating disorder,” Scheer says.
“And that’s a great way to get closer to help.”
If someone is struggling with an eating disorder, a single conversation is unlikely to resolve the issue.
“When something like this takes over someone’s life, it’s not something you can just displace or address with one conversation,” Scheer says.
Clinicians have described how an eating disorder can serve a protective purpose for someone, she explains, which can make changing those behaviors complicated.
“It feels protective in some way,” she says.
That’s why loved ones shouldn’t necessarily interpret resistance or a lack of immediate change as a reason to stop offering support.
“One sensitive conversation isn’t going to be enough to get them on the right path,” Scheer says.
She notes that it can take between two and a half and six years for people to get the help and treatment they need.
“So it’ll take more than one sensitive conversation to really help them,” she says.
Seeking treatment can bring its own challenges. People may feel embarrassed, worry about being judged or fear that a healthcare professional won’t recognize what they’re experiencing as an eating disorder.
Scheer says NEDA’s screening tool can help patients advocate for themselves.
“When someone takes our screening tool, sharing the result that they get on screen can be a wonderful self-advocacy tool for them to share with their doctor or maybe even their therapist,” she says.
Patients also don’t necessarily have to start their care journey with a particular type of specialist.
“There’s more than one route to getting help for this,” Scheer says.
When looking for a healthcare professional, Scheer recommends considering providers trained in Health at Every Size (HAES) approaches who understand the distinction between body size and health.
That can be particularly important because eating disorders don’t only affect people in smaller bodies.
“Even in the medical community, our medical providers aren’t given a lot of training on eating disorders, and 94 percent of the people struggling with an eating disorder are not actually underweight,” Scheer says.
As a result, someone in a “normal weight” or higher-weight body who raises concerns about an eating disorder may have those concerns dismissed or go unrecognized.
“When we’re working with someone who is HAES-accredited, they’ve been trained to understand the complexity of this and can hopefully connect that person with the right professional,” Scheer says.
The conversation also has implications for communities of color, where barriers to accessing eating disorder care can make an already complicated health issue even more difficult to address.
“It’s important to recognize the complexity of these intersections, not just with eating disorders and substance use, but also with communities of color,” Scheer says.
Scheer says communities of color experience eating disorders but do not have the same access to care as white communities.
“Because that access to care is not as equitable, it is harder for this community to access the care that they need,” she says.
While the eating disorder field has evolved, Scheer says there is still more work to do to improve awareness, access and care.
For people who may recognize themselves or someone they love in these warning signs, taking the first step doesn’t necessarily mean having all the answers. It can start with learning more, having a compassionate conversation, using a screening tool or finding a qualified professional who understands eating disorders and can help guide the next steps.
If you or someone you love is struggling with an eating disorder, these resources can help you better understand the signs, take an initial step toward support and find professional care.
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