Bring up the topic of disordered eating and it’s likely that people will picture an affluent, thin, White woman. It’s a cultural myth ingrained in our consciousness, it’s a clinical barrier, and most importantly – it’s dead wrong. Eating disorders are just as common in Indigenous communities, but you’d never know it to look at media coverage or clinical approaches.
This misperception has a name: “SWAG” (skinny, white, affluent girl) and according to the National Institute of Health, it has influenced ED treatment: “Unfortunately, it has shaped approaches to ED assessment, prevention, and treatment, as well as etiologic models. For instance, ED assessment tools used extensively today were typically developed and validated in samples that largely fit the SWAG stereotype.”
This means many patients with disordered eating aren’t getting effective treatment – or any treatment at all. But men and women of any race, economic level, or gender can have an eating disorder. Two important facts:
Fact 1: Research shows that Native Americans report binge eating and purging at equal or higher rates than white populations. Compared to their White counterparts, Native Americans are significantly more likely to report body dissatisfaction and pathologic weight control methods, as well as binge eating. Native teenage girls were found to have significantly higher dieting and restricting/purging scores than White girls; Native women were found to have a greater prevalence of disordered eating in general than White women.
Fact 2: Despite this prevalence, Native people remain less likely to be diagnosed or referred for treatment, even when they directly express concerns about their eating behaviors.
Some risk factors for disordered eating are universal. Toxic messages from family and media, unattainable beauty standards, and the promotion of an unhealthy diet culture on social media can all play a role. But Indigenous people face extra risk factors that can amplify their vulnerability – and those risk factors may be unfamiliar to the very providers they depend on for treatment.
Food Trauma and the Legacy of Colonialism
The impact of colonialism lives on in the body. Historical trauma, forced family separation, displacement from ancestral lands, and housing insecurity have created an ongoing cultural disconnection that influences what Indigenous communities eat and how they cope with emotional pain. All of that can feed into higher rates of dieting, food restriction, and purging.
Also damaging: the pressure to conform to Eurocentric standards of fitness and beauty. This isn’t necessarily about vanity. Thinness can be viewed as a way to reduce discrimination and open more economic doors, leading some people to view weight-loss culture as a form of protection and career opportunity.
Food insecurity, rampant in many Native communities, is associated with higher levels of overall disordered eating, binge eating, binge-eating disorder, and bulimia nervosa. Living in a food desert—where high-calorie junk food is easier to obtain than fresh meals – can create a cycle of shame, reactive eating, and binge eating.
Barriers to Eating Disorder Treament
For Indigenous individuals ready to seek help for disordered eating, the path forward is blocked at nearly every turn.
- Behavioral Health Shortages: There’s a critical shortage of mental health providers in many Indigenous communities – and if you’re looking for a provider who’s Indigenous themselves, that pool shrinks even more. It can be hard for patients to feel a therapeutic bond with a provider who’s unfamiliar with the role of historical trauma and the need for cultural connection.
- Limited Resources: More than 1 in 5 Native people under 65 are uninsured; the same amount lack a personal provider. Without professional guidance, people may turn to extreme dieting or other harmful behaviors.
- Shame: People who practice disordered eating often feel intense shame. That can be compounded when their family is navigating financial struggles, housing insecurity, or other challenges; they can feel like they’re burdening their loved ones with yet another problem, one they view as a personal failing rather than a behavioral health issue.
- Clinician Bias and Misdiagnosis: Many diagnostic tools were developed for and tested primarily on white populations. Non-Native clinicians are statistically more likely to miss eating disorders in minority patients, such as the higher rates of Binge Eating Disorder (BED) or Night Eating Syndrome (NES) that are more prevalent in BIPOC communities. Native patients are also less likely to receive a referral for specialized treatment than their white peers.
Reclaiming Sovereignty: The Path to Nourishment
As with so many things in Indigenous health, the solutions must be community-led – from coordination with Tribal leaders to culturally-specific treatment programs that honor Indigenous values.
Here’s what that can look like in practice.
- Emphasize food sovereignty: Recovery plans should include access to traditional, ancestral foods. Reconnecting with Indigenous food systems is about emotional nourishment as much as physical nutrition – and a step toward restoring the patient’s sense of identity and culture.
- Train providers: Eliminating clinical bias and improving diagnostic accuracy isn’t just a matter of good intentions. Training can help providers understand the root factors in disordered eating in Tribal nations, how to recognize BED and NES, and why cultural connection is so vital. It can also help them understand why advice like “intuitive eating” isn’t always realistic when the patient’s food supply is controlled by market forces.
- Offer community education: People ashamed of their behaviors often suffer in solitude and silence. Community-based education – from classes to health fairs – can help patients understand their behaviors as adaptive responses to trauma.
- Expand Telehealth: Virtual care can be a godsend on reservations because it dissolves geographic barriers. No matter how far away the nearest clinic is, a patient can talk to a behavioral health or disordered eating expert from their home. That kind of privacy can be especially appealing for a patient who’s worried about stigma, even if it’s just the fear of a neighbor spotting their truck parked at a local clinic.
Recovery from disordered eating is complex for everyone. Forcing Indigenous patients into treatment models built for different cultures isn’t helpful. Some practices, such as working with patients to reframe their relationships with food, their body, and safety, are constructive. But a number of social and cultural factors have shaped eating behaviors for Indigenous patients – and only a multifactorial approach will open the doors to a more nourishing path.
