Clinical Context

Skinny, white, affluent, girls, or SWAG for short, summarizes the stereotype of individuals with eating disorders (EDs) in the United States. However, a study by Swanson and colleagues, published in the July 2011 issue of the Archives of Psychiatry, punches some significant holes in the concept of SWAG and EDs.^[1]

Researchers evaluated data from National Comorbidity Survey Replication Adolescent Supplement, which features a face-to-face interview with more than 10,000 US adolescents between the ages of 13 and 18 years. They found that the lifetime prevalence rates among these young people for anorexia nervosa (AN), bulimia nervosa (BN), and binge ED (BED) were 0.3%, 0.9%, and 1.6%, respectively. Subthreshold BN and BED accounted for another 3.3% of the cohort.

Rates of AN were similar among females and males, whereas BN and BED were more common among girls. Hispanics had the highest rates of BN compared with other racial and ethnic groups, and adolescents of color had a trend toward higher rates of BED compared with whites. Non-Hispanic white adolescents had the highest rates of AN. In contrast to the SWAG framework, no measures of socioeconomic status had a significant effect on the prevalence of EDs.

What happens when these individuals get older and go to college? The current study evaluates trends in student perception of EDs, as well as rates of diagnosis and treatment.

Study Synopsis and Perspective

EDs are underdiagnosed and undertreated in men, minorities, normal and higher-weight individuals, and those who are not affluent, new research shows.

Investigators studied college students across the country and found that women were almost 5 times more likely than men to be diagnosed with EDs and that white students were nearly twice as likely to be diagnosed as students of color.

Affluent students were also more likely than the nonaffluent to be treated, and students who were underweight were more likely than overweight students or students of normal weight to be diagnosed or treated.

"There is a stereotype that [EDs] affect only skinny, white, affluent girls, sometimes abbreviated 'SWAG,' leaving out numerous people who do not fit that stereotype and contributing to disparities in treatment and diagnosis," lead author Kendrin Sonneville, ScD, RD, told Medscape Medical News.

"Clinicians should recognize that EDs are universal and implement universal screening of all patients, regardless of background, race, ethnicity, gender, and weight status, in routine clinical practice," she added.

The study was published online March 2 in the International Journal of Eating Disorders.^[2]

Antiquated Ideas

EDs are underdiagnosed and undertreated, with only one third of individuals ever receiving treatment, the authors note.

"Antiquated ideas about who develops [EDs], held by the general public and clinicians alike, may also perpetuate inequities in treatment," they write.

Research conducted in clinical samples may "further perpetuate myths and stereotypes because of systematic differences between people who do and do not seek treatment."

"The reason I conducted the study is that I worked as a clinician prior to obtaining my doctorate in public health," said Dr Sonneville.

"I realized that the population trends I was studying looked very different from the people I used to see in my clinic, many of whom fit the SWAG stereotype, and I wanted to understand disparities in care and barriers to getting treatment," she added.

To investigate the question, the researchers analyzed data from the Healthy Bodies Study, a population-level survey that explored disordered eating in a randomly selected sample of undergraduate and graduate students at 12 participating institutions across the country.

The survey included extensive demographic information (age, sex, sexual orientation, race/ethnicity, and socioeconomic background), as well as self-reported height and weight.

ED symptoms were assessed using the Eating Disorder Examination Questionnaire. Participants answered questions concerning their perceived need for ED treatment, lifetime ED diagnosis, and past-year ED treatment.

Students who had not received ED treatment during the last year but whose global Eating Disorder Examination Questionnaire score was ≥2 were asked about barriers to ED treatment.

The researchers utilized a diagnostic hierarchy of criteria, based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: threshold AN, threshold BN, threshold BED, subthreshold BN, subthreshold BED, and purging disorder.

Anorexia Most Common Diagnosis

Of the students who participated in the Healthy Bodies Study (n=7704), 1747 met criteria for an ED. Of these, 2.0% were underweight, 79.9% were white, 19.1% were affluent, and 84.9% were women.

The most common EDs were threshold BED and threshold BN (26.8% and 26.5%, respectively).

However, although BED and BN were the most common conditions, respondents with AN were found to have the highest rates of perceived need for treatment, diagnosis, and past-year treatment (73.5%, 73.2%, and 57.2%, respectively).

Only 30.7% of respondents in the overall sample perceived a need for treatment, only 10.5% had received a diagnosis, and only 13.6% had received treatment in the past year.

When the researchers controlled for age and sexual orientation and compared individuals who were underweight with individuals with a healthy weight status, those who were underweight were far more likely to perceive a need for treatment (odds ratio [OR], 3.73; 95% confidence interval [CI], 1.63-8.54), to have been diagnosed (OR, 6.48; 95% CI, 3.14 - 13.37), and to have received treatment (OR, 5.63; 95% CI, 2.74-11.55).

Individuals who were overweight or obese were significantly less likely to have been diagnosed than individuals of healthy weight (OR, 0.61 [95% CI, 0.40-0.95]; and OR, 0.45 [95% CI, 0.26-0.78], respectively).

"Although only 2% were underweight, they were the ones most likely to have been diagnosed and treated and to perceive that they needed treatment," Dr Sonneville observed.

White students were more likely than students of color to have been diagnosed (OR, 1.81; 95% CI, 1.03-3.21).

Students who were not affluent were more likely to have perceived a need for treatment than nonaffluent students (OR, 1.52; 95% CI, 1.13-2.04) and were more likely to have received treatment (OR, 1.89; 95% CI, 1.31-2.72).

Women were much more likely than men to have perceive a need for treatment (OR, 1.97; 95% CI, 1.35-2.86), to have been diagnosed (OR, 4.66; 95% CI, 1.80-12.11), and to have been treated (OR, 1.64; 95% CI, 1.00-2.67).

The 3 most common survey responses regarding reasons for not seeking treatment were as follows: "I prefer to deal with issues on my own" (28.1%), "I have not had a need for counseling or therapy" (23.0%), and "I'm not sure how serious my needs are" (19.7%).

"Our findings confirmed what I had seen in clinical practice, which is that people who meet the SWAG stereotypes are more likely to be diagnosed and treated with an [ED] than those who do not," Dr Sonneville commented.

One reason for this is that many people with EDs, including men and members of minorities, do not recognize themselves as having an ED because they do not conform to the stereotypes they see in the media, she said.

Novel Research

Commenting on the study for Medscape Medical News, S. Bryn Austin, ScD, professor of pediatrics, Harvard Medical School, Boston Children's Hospital, and Harvard T. H. Chan School of Public Health, Boston, Massachusetts, who was not involved with the study, called it "novel."

The study "has a fairly large sample of college students from a range of US colleges, which is already a cut above many studies that may have been done in a single college, in clinical samples, or in selected groups on college campuses, such as sororities or sports teams," Dr Austin said.

The results "point to a need for universal screening for [EDs] in routine primary care visits and college and adolescent health services," she emphasized.

Dr Sonneville added that "there are effective treatments for [EDs], and it's a shame that these treatments are not getting to the people who actually need them."

She noted that the 5-question SCOFF questionnaire is a helpful, brief screening tool that can easily be incorporated into clinical practice. In addition, it's "a good way to allow the clinician to start a conversation and identify people at risk," Dr Austin said.

The authors and Dr Austin have disclosed no relevant financial relationships.

Int J Eating Disord. Published online March 2, 2018.

Clinical Implications

• In a previous study of adolescents, rates of AN were similar among females and males. Hispanics had the highest rates of BN compared with other racial and ethnic groups, and adolescents of color had a trend toward higher rates of BED compared with whites. No measures of socioeconomic status had a significant effect on the prevalence of EDs.
• The current study demonstrates that most college students with significant symptoms of EDs do not believe that they need counseling or therapy, and even fewer actually receive treatment. Male sex and lower socioeconomic status were associated with lower rates of treatment for EDs, and students of color were less likely to be diagnosed with an ED.
• Implications for the Healthcare Team: The healthcare team should be aware of disparities in the perception, diagnosis, and management of EDs and should direct attention to improving these disparities.

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