“I am an invisible man… I am a man of substance, of flesh and bone, fiber and liquids… I am invisible, understand, simply because people refuse to see me. A matter of the construction of their inner eyes, those eyes with which they look through their physical eyes upon reality.” ~ Ralph Ellison, Invisible Man
When Ralph Ellison wrote the novel Invisible Man in the late 1940s, the invisibility to which he referred was a societal blindness to the humanity and experience of African Americans. Ellison used invisibility as a mechanism for pointed critical analysis––to articulate his frustration with a social system that deprived him of personhood. The novel grapples with this notion of the ‘invisible man’ through the black nationalist and communist movements of the early 20th century, but the metaphor could have easily applied to the racial health disparities of the 1940s. Despite general recognition of inequitable health outcomes, it wasn’t until 1976 that the Centers for Disease Control and Prevention (CDC) began to consider race in national health surveys.
Ellison could not have anticipated how his book would apply to other ‘invisible’ populations in public health today, yet the metaphor of the ‘invisible (wo)man’ aptly frames a new discourse around who is included––or rather, excluded––in health studies. Patterns of omission reflect larger social narratives––particularly those in which stigma is a debilitating obstacle to the discussion of prominent public health matters.
Despite its growing prevalence in American society, disordered eating is one such matter that is glaringly absent from public health conversations. In 2015, the CDC quietly removed questions tracking eating disorders from its Youth Risk Behavior Surveillance System Survey (YRBSS)––the last national health survey to screen for unhealthy weight control behaviors in the United States. This measure, which met little resistance, effectively denies the legitimacy of disordered eating as a serious public health issue. In addition to creating a dangerous gap in the data, Alfredo Morabia, a prominent epidemiologist, writes that the removal of questions from national health surveys is “tantamount to saying these people literally do not count.” While the true causes for the removal of these questions are unstated, it is reasonable to investigate how the stigma associated with eating disorders could have played at least some role in what appears to be an attempt to effectively conceal persistent trends in dangerous eating behaviors. This hesitancy to discuss eating disorders is perplexing given that obesity has fallen squarely within the purview of the public health community.
Affecting nearly 39.8% of adults in the United States, obesity is at the forefront of American health concerns. It leads to increased rates of Type 2 diabetes, hypertension, heart disease, and stroke, ranking it among the top contributors to the chronic disease burden. Due to the alarming prevalence of obesity and its related consequences, today’s public health interventions are increasingly channeled toward (often drastic) measures of dieting and weight-loss. But while public attention centers on obesity (almost morbidly and obsessively so), there exists a distinct gap in the discourse on, let alone the recognition of, its silent twin: disordered eating.
In the United States alone, at least 30 million people suffer from clinical eating disorders––a number that is likely to grossly underestimate the issue due to the stigma associated with eating disorders and the frequent difficulty of even diagnosing those who suffer from them in the first place. Alarmingly, these numbers are only increasing among youth, and come at the very moment that the CDC has resolved to discontinue screening. Prior to 2015, the YRBSS discovered that over 20 percent of Maryland’s high school girls and nearly 10 percent of high school boys regularly went 24 hours without eating to achieve weight loss. More horrifically, 44 percent of middle school students in Baltimore County were concerned with losing weight. Given that eating disorders have the highest mortality rate of any mental illness and that only 6 percent of those clinically diagnosed will receive treatment, eating disorders are clearly a serious public health issue. Yet the amount of federal support for eating disorder research comes to a mere $0.73 per affected individual, while funding and attention for obesity is significantly greater. The noticeable lack of attention paid to this equally prominent issue is reflective of the social reality that eating disorders are an ugly and preferably ignored issue in public health.
Though infrequently connected, eating disorders and obesity share many similarities: They are both rooted in American cultural norms and seriously impact health outcomes. Indeed, when it comes to food and body image, American society is a hodgepodge of contradictions: Impossible standards of thinness are cast alongside advertisements of high-calorie fast foods, extreme dieting fads are promoted on television (itself one of the chief contributors to our sedentary lifestyle), and the primary sponsors of athletic events are companies with unhealthy food and beverages.
At the intersection of these conflicting social influences, eating disorders form a spectrum in which obesity manifests itself on one side and anorexia on the other. Within this spectrum, there are many misconceptions about who, precisely, is affected by eating disorders. Increasingly, the stereotype of the young, emaciated white female is an inaccurate reflection of the vast number of people that struggle with food, as these issues are being observed among growing numbers of people of all weights, ages, races, genders, and sexual orientations. It is perhaps least acknowledged that many people classified as ‘obese’ battle alternately with anorexia and binge eating disorder. By continuing to avoid discussions on eating disorders, the ‘invisibility’ of many marginalized groups is compounded by society’s rejection of both their identity and their eating condition.
Devoting attention to eating disorders as part and parcel of the obesity epidemic––or rather, treating obesity as the most visible manifestation of a much broader, systemic eating issue––can allow public health officials to reaffirm the experience and existence of people at all points on the spectrum of eating disorders. Moreover, it is imperative that the CDC reinstate questions that track unhealthy eating behaviors in national health surveys. The data that they would generate is vital to understanding the nature of eating disorders and the ways in which they can be addressed. On a symbolic level, it is a key gesture in affirming that the people who suffer from eating disorders are not invisible––that their struggles are not to be ignored.
Photo: “Long Shadow”