Eating Disorders: Anorexia, Bulimia, and Evidence-Based Care

More than 28 million Americans will experience an eating disorder in their lifetime. That’s not a distant statistic-it’s someone you know. Maybe it’s the classmate who always skips lunch, the coworker who disappears after meals, or the teenager who won’t look in the mirror. These aren’t just about food. They’re about control, pain, and survival. And left untreated, they kill.

What Anorexia and Bulimia Really Look Like

Anorexia nervosa isn’t just being thin. It’s a brain disorder where fear of weight gain overrides hunger, logic, and even the will to live. People with anorexia often have a body weight far below what’s healthy for their height and age. But here’s the truth most people miss: less than 6% of those with eating disorders are classified as "underweight" by medical standards. You can’t tell someone has anorexia just by looking at them.

Bulimia nervosa is different in appearance but just as dangerous. It’s a cycle of binge eating-consuming large amounts of food in a short time-followed by purging. Vomiting, laxatives, fasting, or excessive exercise are used to undo the binge. One in ten people with bulimia develops swollen cheeks from repeated vomiting, a sign many don’t recognize as part of the disorder. Unlike anorexia, people with bulimia often maintain a normal weight, making it easier to hide.

Both disorders come with physical damage. Anorexia can cause heart failure, bone loss so severe it mimics old age, and organ shutdown. Bulimia erodes tooth enamel, ruptures the esophagus, and throws electrolytes out of balance-leading to sudden cardiac arrest. The body doesn’t care if the behavior is "mental" or "emotional." It responds with damage.

The Hidden Death Toll

Anorexia has the highest death rate of any mental illness. One person dies every 52 minutes from an eating disorder. That’s over 10,200 deaths each year in the U.S. alone. For every death, dozens more struggle silently. Suicide accounts for nearly a third of these deaths. People with anorexia are 18 times more likely to attempt suicide than those without an eating disorder. Bulimia isn’t far behind, with a mortality rate nearly double that of the general population.

The statistics are grim, but they don’t tell the whole story. Behind each number is someone who felt trapped. Someone who believed they were worthless unless they controlled their body. Someone who thought no one could help.

Why Most People Never Get Help

Only 27% of women with eating disorders by age 40 or 50 ever receive treatment. For bulimia and binge eating disorder, fewer than half ever seek help. Why?

One reason: stigma. Many believe eating disorders are a choice, a phase, or a cry for attention. They’re not. They’re complex brain disorders with genetic, biological, and environmental roots. Half the risk for binge eating disorder is inherited.

Another reason: access. There are only about 35 specialized residential treatment centers in the entire U.S. with a total of 1,200 beds. That’s less than 0.004% of the 30 million people affected. Wait times are brutal. One person on Reddit waited 27 months for care after being diagnosed with severe anorexia and a BMI of 14.5.

Insurance denials are rampant. In a 2022 survey, 68% of people with eating disorders reported at least one insurance denial. Some needed 3 or more denials before getting approval. One person raised $78,000 on GoFundMe to pay for 90 days of treatment. The system is broken.

What Actually Works: Evidence-Based Care

Not all treatment is equal. Many therapists still use outdated methods. But science has moved forward. There are now proven, evidence-based approaches that work.

For adolescents with anorexia, Family-Based Treatment (FBT) is the gold standard. Parents take charge of meals and recovery-not therapists, not the patient. In 12 months, 40-50% of teens recover with FBT, compared to just 20-30% with traditional individual therapy. It’s simple, powerful, and backed by decades of research.

For adults with bulimia or binge eating disorder, Enhanced Cognitive Behavioral Therapy (CBT-E) is the most effective. It doesn’t just target eating behaviors. It addresses the underlying thoughts: "I’m not good enough," "My worth is tied to my weight," "If I eat this, I’ll lose control." After 20 sessions, 60-70% of patients stop bingeing and purging. That’s not improvement-it’s remission.

And now, for the first time ever, there’s a medication approved specifically for binge eating disorder: lisdexamfetamine (Vyvanse). In clinical trials, it led to a 50.9% remission rate-more than double the placebo group. It’s not a cure, but it’s a tool. A real, FDA-approved tool.

What Treatment Actually Involves

Treatment isn’t just therapy. It’s medical, nutritional, and psychological.

First, doctors check vital signs, heart rhythm, and electrolytes. Many patients arrive with dangerously low potassium or heart rates below 40. Refeeding syndrome-a dangerous shift in fluids and minerals-can happen when calories are increased too fast. It’s why medical supervision is non-negotiable.

Nutritionists don’t just hand out meal plans. They help rebuild trust with food. For someone who hasn’t eaten in days, starting with 1,200 calories a day feels overwhelming. Progress is slow. Gaining a pound a week is a win.

Therapy focuses on breaking the cycle. For bulimia, that means interrupting the binge-purge loop. For anorexia, it’s challenging the belief that being thin equals safety. Dialectical Behavior Therapy (DBT) helps with emotional regulation. Motivational interviewing helps people find their own reason to recover-because no one can be forced into healing.

The System Is Failing, But Change Is Possible

The data shows we know how to treat these disorders. We just don’t do it.

Only 12% of treatment centers use standardized tools like the Eating Disorder Examination Questionnaire (EDE-Q) to track progress. Only 43% follow evidence-based protocols. Rural areas are nearly invisible-22% of rural counties have zero specialists. Children under 12 are being hospitalized at rates up 119% since 2012. The system is collapsing under demand.

But there are glimmers of hope. Telehealth is expanding access. Apps like Recovery Record have shown 32% greater symptom reduction than standard care. The 2023 Mental Health Parity Act led to $3.2 million in fines for insurers who denied care. The NIH is funding a $25 million study to find early biological markers in children.

Recovery isn’t linear. Relapse is common. But it’s not failure-it’s part of the process. The key is early intervention. People who start treatment within three years of symptoms have a 65% chance of full remission. Wait longer, and the odds drop.

What You Can Do

If you’re struggling: reach out. Even if you’re scared. Even if you think no one will understand. Call the National Eating Disorders Association helpline. Text "Help" to 741741. You are not alone.

If you know someone who might be struggling: don’t wait for them to ask for help. Say something. "I’ve noticed you’ve been skipping meals. I care about you. Can we talk?" Don’t comment on weight. Don’t give advice. Just be present.

If you’re a clinician: get trained. FBT and CBT-E require 120-180 hours of specialized instruction. Don’t wing it. Lives depend on it.

If you’re an insurer or policymaker: enforce parity laws. Fund treatment centers. Cover what science says works. The cost of inaction is $64.7 billion a year-and thousands of lives.

Recovery Is Possible

One woman, after seven years of bulimia, finally got CBT-E through a university clinic. Her binge-purge episodes dropped from 14 times a week to two. Another, after a 30-day residential program, gained 15 pounds and learned how to sit with discomfort without turning to food or restriction.

Recovery doesn’t mean being perfect. It means being alive. It means having meals with friends without shame. It means looking in the mirror and not hating what you see. It means knowing your worth isn’t measured in pounds or calories.

The path is hard. But it’s not impossible. And it’s worth it.