The crisis we ignore: confronting structural barriers and eating disorder taboos in racialised communities

Eating disorders (EDs) have profound physical and psychological impacts, worsening quality of life. EDs have high comorbidity with other psychiatric conditions and are associated with suicidal thoughts and attempts. The medical complications that often accompany EDs involve almost all organ systems and can be life-threatening.

What the data tells us about prevalence

In the past decade, we’ve seen a rise in eating disorders worsened by the pandemic. Lifetime prevalence of eating disorders in the UK is estimated at 6%, affecting 2-3 million people. NHS admissions for eating disorders exceeded 30,000 admissions for the first time in 2023/2024. While demand is growing, eating disorder services are struggling to keep up having faced years of neglect, underfunding, fragmented care pathways, and an overstretched workforce. There remains a postcode lottery in the availability and quality of ED services, meaning some individuals have been discharged with body-mass indexes as dangerously low as 13. Access to treatment is a significant issue with a 2019 survey showing 23% of people with eating disorders received psychological treatment and under 6% of children and young people accessing NHS specialist services in 2022-2023.

The status quo is leaving seriously ill people unable to get the help they need. Inequities facing racially minoritised individuals with eating disorders only deepen this crisis, yet this intersection is seldom discussed, fuelling silence and shame. This year’s theme for Eating Disorder Awareness Week is about community and how networks can help those in crisis. But what happens when mental health stigma is strong, and eating disorders are an almost unspeakable taboo within your community? For many racialised individuals, this can mean further isolation. Cultural stigma is a barrier, but the onus cannot be put on communities alone. The health system must respond with empathy and address the structural barriers that inhibit people from accessing care.

There remains a stubborn, prevailing stereotype that eating disorders only affect ‘skinny, White, affluent girls’ yet there are similar and, in some cases, increased rates of eating disorders among racialised groups. While there is minimal research in the UK on eating disorders and racialised communities, existing evidence gives a damning portrait of bias and unfair treatment:

• Minority ethnic individuals in the UK were less likely to seek and receive ED treatment and are less frequently diagnosed.
• Ethnic minorities feel less confident to seek help for an eating disorder and are less likely to be referred to eating disorder services.
• Between 2018/2019 and 2020/21 eating disorder hospital admissions rose among Asian and British Asian groups rose by 62%, the highest increase compared to any other ethnicities. This rise suggests patients were not receiving timely treatment and were consequently ending up in hospital.
• Southeast London community health concluded that South Asian people were more likely to exhibit bulimic pathology than their white counterparts.
• Stereotypes about who gets an eating disorder might prevent ethnic minorities from seeking treatment.
• For White ethnicities, hospital admissions for eating disorders rose by 31% across three years, whereas admissions among ethnic minorities rose by 53% – the biggest rise was for those of Black African descent people, admissions increased by 216%.
• Evidence from our rapid review found Asian groups were less likely than White people to be diagnosed with anorexia nervosa and less likely to be referred for treatment.

Interconnecting causes of inequity

There are several factors that may result in racial inequities. Evidence shows precipitating factors and presentations of eating disorders can be shaped by culture, yet diagnostic criteria remains culturally insensitive. For example South Asian individuals are more likely to present with somatic concerns and report a loss of appetite over a fear of fatness. Clinicians unaware of these cultural differences may fail to recognise an eating disorder diagnosis.

Sociocultural barriers may play a role in perpetuating inequities such as body image pressures related to western beauty standards, community-level stigma around eating disorders and religious observances. Furthermore appearance-related pressures from elders, lack of knowledge of eating disorders, confidentiality concerns when approaching primary care services and cultural family dynamics and expectations (for example, in Caribbean communities, the view that personal issues should remain in the home) can all pose as barriers that hinder help-seeking behaviour in racialised individuals. Long waiting times, language barriers, poor communication, cultural insensitivity and discrimination can exacerbate inequities. A greater awareness and action to address of these barriers within the health system is needed to improve diagnosis and outcomes.

The complex mix of factors which shape the experiences of racialised individuals with eating disorders, and the clear evidence of inequities, highlights the need for decisive action. Neglect is costing lives and causing devastating harm for vulnerable people across England. The Department of Health and Social Care and NHS England must address inequities in diagnosis and treatment for minoritised ethnic communities. These bodies should consider meaningfully engaging and co-designing services with communities, employing a race equity lens and accelerating research exploring ethnicity and eating disorders to generate innovative solutions for change.

For too long progress in eating disorders has been slow and uneven and those on the ground have not seen conditions materially improve at an acceptable pace. Eating disorders have a devastating toll on people’s lives, and the longer we take to fix the system, the longer people needlessly suffer. Together, we can pave a bold, compassionate path forward that uproots these unacceptable inequities and community-level stigma around eating disorders.