Flying Under the Radar: Subthreshold Eating Disorders

At some point or another, most of us will develop an uneasy relationship with food. As your body goes through its normal changes, you might find yourself skipping meals, obsessing over calorie counts, or running to the gym after dessert. These behaviors might not raise alarms; they might even seem healthy.

But beneath the veneer of self-discipline and ritual, something deeper may be going on—something that clinicians call a subthreshold eating disorder.

Subthreshold, or subclinical, eating disorders are just what they sound like: patterns of disordered eating that don’t quite meet the criteria for a full diagnosis like anorexia nervosa, bulimia, or binge-eating. They exist in a gray zone—disguised as healthy, but not yet catastrophic. And for that reason, they’re easy to miss. Easy to normalize, especially in our diet culture that praises/demands the pursuit of thinness at all costs.

Yet these conditions can cause real suffering. A person might not purge (or binge) every day, but they might still live with intense guilt after eating. They might not starve themselves to dangerous weights, but they may restrict just enough to feel constantly hungry, anxious, or tired. Their lives are often shaped by an invisible, exhausting negotiation with food and body image.

Many people live in these in-between places. Adolescents, especially, seem to inhabit this psychological limbo. In one study, nearly 27% of teenage girls reported disordered eating behaviors that didn’t meet diagnostic criteria—but that were strongly linked to depression, low self-esteem, and even suicidal ideation. Boys, too, are affected, though they’re less likely to talk about it or seek help.

Why do subthreshold eating disorders fly under the radar? In part, it’s because they can masquerade as virtue. A teen who won’t eat carbs might be seen as health-conscious. An adult who “makes up” for meals with extra workouts might be praised for their discipline. The language of wellness often obscures the warning signs of a disorder. Yet subthreshold eating disorders can also cause medical complications. 

Subthreshold starvation, compensatory exercise, purging every once in a while creates wear and tear on a body. In time, it puts the body in a below optimal medical place.

And there’s another reason: many people struggling with subthreshold symptoms don’t believe they’re “sick enough” to ask for help. They compare themselves to the most extreme stories—hospitalizations, feeding tubes, emaciated bodies—and decide their pain doesn’t count. That belief can delay treatment and, in some cases, lead to more entrenched disorders down the line, particularly during periods of stress or transition, such as adolescence, job transitions, divorce, pregnancy, or menopause. As an eating disorders specialist, I have had numerous conversations with clients who tell they are fine or not sick enough, thin enough, etc to have an eating disorder. I have been in social situations where people, who know I am an eating disorders specialist, tell me they know somebody with a mild eating disorder. I have to tell them that mild eating disorders are concerning. 

But here’s the thing: you don’t need to be at death’s door to deserve care.

Early intervention matters. Therapy, support groups, and nutritional counseling can all help people change their relationship with food and their bodies. Even a single conversation—with a parent, a teacher, a doctor, a friend—can make a difference. It can break the silence and offer a way forward.

If we want to support people in our communities—and ourselves—we need to stop drawing such rigid lines between “disorder” and “not-a-disorder.” Mental health exists on a spectrum, and healing starts with recognition. We need to name the gray zones, sit with their complexity, and create space for compassion, not just diagnosis.

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References

The hidden burden of eating disorders: an extension of estimates from the Global Burden of Disease Study 2019; Damian F Santomauro , Sarah Melen , Deborah Mitchison , Theo Vos, Harvey Whiteford, Alize J Ferrari ; Lancet Psychiatry; 2021

Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: a multicenter study ;  Scott J Crow, W Stewart Agras, Katherine Halmi, James E Mitchell, Helena C Kraemer;  International Journal of Eating Disorders; 2002

DSM-5 eating disorders and other specified eating and feeding disorders: is there a meaningful differentiation?; A Kate Fairweather-Schmidt , Tracey D Wade; International Journal of Eating Disorders; 2014

Defining "significant weight loss" in atypical anorexia nervosa; K Jean Forney, Tiffany A Brown, Lauren A Holland-Carter, Grace A Kennedy, Pamela K Keel; International Journal of Eating Disorders; 2017

Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa; Andrea K Garber, Jing Cheng, Erin C Accurso , Sally H Adams, Sara M Buckelew, Cynthia J Kapphahn  , Anna Kreiter , Daniel Le Grange, Vanessa I Machen, Anna-Barbara Moscicki , Kristina Saffran , Allyson F Sy, Leslie Wilson, Neville H Golden ; Pediatrics ; 2019

Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature; Erin N Harrop, Janell L Mensinger , Megan Moore, Taryn Lindhorst; International Journal of Eating Disorders; 2021

Are diagnostic criteria for eating disorders markers of medical severity?; Rebecka Peebles, Kristina K Hardy, Jenny L Wilson, James D Lock; Pediatrics ; 2010

Subthreshold Eating Disorders: Diagnostic Issues, Natural Evolution and Treatment Implications;  P. Monteleone, P. Cotrufo, M. Maj; European Psychiatry; 2020

The Business of Body Hatred: How Meta Profits (Again) from Eating Disorders

Blame it on the algorithm.

It’s a sentiment most are familiar with in this age of clickbait, doom-scrolling, and digital footprints. The machinations of content dissemination to target audiences for profit have largely been regarded with a healthy dose of suspicion but ultimately accepted as a necessary evil: an inevitable byproduct of the conveniences and tech frills that accompany the age of information.

In 2021, the Facebook Papers painted a devastating picture of the lengths the social media giant had gone to for profit – and the harm that occurred as a result. This group of internal documents, leaked by whistleblower Frances Haugen, offered proof of the company’s willingness to not only allow pro-eating disorder content, but to intentionally encourage vulnerable populations to view it. Facebook, Haugen said, had gone to great lengths to hide “disturbing” research about how its use of the algorithm to promote such content led to teenagers’ heightened feelings of negativity about their bodies and increased their risk of developing deadly eating disorders.¹ Investigations revealed that the company had been struggling to engage young people–and that attracting them with dangerous pro-eating disorder content was part of a larger strategy to retain them as members of a core audience. Documents surfaced that proved Haugen’s claims that the company was well aware of the harm being caused, while continuing to perpetuate it.

Despite these damning revelations and a slew of lawsuits in 2021 and 2022, not much has changed. Targeted weight-loss ads are quite literally everywhere–even for those who have used ad preferences to indicate they do not wish to see such content. I currently work with someone who has shared that they’ve seen a huge uptick in weight loss and food restriction advertisements on their feed in the last month alone, despite having spent years reporting and blocking such content, as well as tailoring their ad settings against it.

With recent advancements in AI technology, the algorithm is only getting sneakier. Women who have announced their engagements on social media, for example, have suddenly found themselves inundated with targeted weight-loss ads that are specific to brides, using phrases such as “shredding for the wedding” and “intermittent fasting for your big day.”² The nonprofit organization Fairplay for Kids, which fights child-targeted marketing, released a report in 2022 that accused Meta of marketing weight loss to children as young as nine, through accounts tagged with “thinspiration” or “bonespiration” and obviously promoting disordered eating. The report found that out of the 1.6 million unique users following these accounts, many followed each other, too, which creates a “pro-eating disorder bubble”, or feedback loop, “that is worth at least $1.8 million per year for Meta, and the revenue generated from all users following this bubble is $227.9 million per year.”³

All this points to a clear need for regulation over algorithmic technology, which experts are currently calling for.⁴ In the meantime, Fairplay for Kids is helping people like you get involved. Click here for an easy way to contact your representatives about supporting legislation to help protect people under 18 from developing eating disorders as a result of social media marketing!

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¹ “The Facebook Papers and their Fallout.” The New York Times, 25 Oct 2021. 

² Khan, Aamina Inayat. “How Targeted Weight Loss Ads Can Haunt Future Brides.” The New York Times, 19 Nov 23.

³ “To help prevent eating disorders, regulate social media algorithms, expert says.” Harvard T.H. Chan School of Public Health, 27 Apr 2023.

⁴ Monahan, David. “New Report Shows Meta Profits from Pushing Pro-Eating Disorder Content to Children on Instagram.” Fairplay for Kids, 14 Apr 2021.

Expanding our Potential for Healing from Eating Disorders through Diversity of Perspectives and Lived Experiences

The first time I read about queer women and women of color with eating disorders was in 1995. I was in grad school, interning at an eating disorder clinic, and a friend of mine who knew I was a biracial queer woman who had battled anorexia recommended the book A Hunger So Wide and So Deep, by Becky W. Thompson. To say that this book resonated with me doesn't even capture what happened. It did more. Reading those stories, I felt seen, validated and soothed... and it was everything to me.

The book is centered around the testimonials of queer women and women of color and their personal experiences with eating disorders. Their stories describe how parents and families who immigrate are responding to racism through anti-fatness. They identify the same confusion and mixed-messaging that I had received as a young person growing up in a biracial household. This book goes beyond the mainstream idea that eating disorders mostly happen to white, hetero, affluent, cisgender, able-bodied, neurotypical girls and integrates the impact of racism and oppression on eating disorders.

Until that point, I truly felt that there was something wrong with me and that my eating disorder made no sense. All of the biographies and textbooks that I had read about eating disorders had not in any way mirrored my own experience. As I read the stories in Thompson's book, it made me see that my story was true and valid. I realized that peoplecould understand, and peopledo understand because they were saying my story! And that was incredibly liberating. I felt seen for the first time.

Growing up, food was a huge part of how my family honored our culture. My parents celebrated food and believed in enjoying all foods. I never saw my mom restrict her diet or only eat salads. At the same time, there was so much mixed messaging. I was encouraged to participate to enjoy the food and family traditions that centered around food and at the same time I was constantly being told not to gain weight. There was this sense of showing loyalty to my culture don't abandon us but, in equal measure don't gain weight.

Thompson's book explained the damaging confusion of these mixed messages and why it was so upsetting to me. It also gave me more understanding of my parents, and particularly my mother who was an immigrant and had experienced oppression and the anxiety of assimilation in this country.  

When my mom came to the US from Peru, she was learning English, looking for a job, and trying to assimilate. What she encountered as a brown woman with an accent, and all of the ways that our western culture regarded her, shaped in her the idea that in order to be successful and included she had to be thin. Even though roundness was celebrated in her culture, she saw that thinness was, and is, valued. Her thinking was: Of all the things that I am, if I'm thin, that can make up for it. It can be one less strike against me.

So, when I started to go through puberty, and gained puberty weight which is a natural, common, physical response to hormonal changes my mom began expressing her concern. I did not know how to make sense of these mixed messages around aspects of myself that were so personal, nuanced and vulnerable. I felt pressure and confusion around food and my changing body. Overwhelmed and angry, I began restricting my food to numb my pain and confusion. So that was how my eating disorder began.

Thompson's book sparked my life's calling my commitment to bring awareness and change to the huge gap that exists in treatment servicesfor underrepresented and underserved folks with eating disorders. Through this work, I have seen the vital role that diversity plays in the treatment of eating disorders. By bringing in different perspectives and expansive thinking to the field, we create greater possibilities for treatment and recovery for everyone. 

Historically, the field of eating disorder recovery and treatment has taken a harmful and exclusive cookie cutter approach to address these issues. The myth that eating disorders only occur in affluent Caucasian girls is damaging to marginalized communities that suffer from eating disorders. This narrow viewpoint continues to reinforce an invisibility that is experienced by marginalized communities. It also limits our ability to understand the underlying problems that cause eating disorders and diminishes the deep complexities and layers that need to be revealed for true healing to occur.

If we think that there is only one perspective, and only one solution, we lock ourselves into one way of thinking for healing and recovery and that is limiting to everyone.

Healing and recovery is personal, individual, and complex. It means different things for different people. And each person's relationship with food is also complex. By bringing in diversity, both in thinking and experience, it allows us to find new, innovative ways to approach treatment. Where in our system and society do we need to change so that recovery is more possible for more people?
Eating problems are very pervasive. They are not confined to specific populations or groups of people. With this greater understanding, we can tap into different people's viewpoints and learn how they use treatment, which grows and strengthens our understanding of what treatment is. We can say, "Let's hear your stories. Let's hear what works for you. " We can hold healing and recovery as an evolving, expansive process. The more expansive we are the more we take on different angles of healing the more we will be able to think of inclusive and inventive ways to approach treatment and recovery. As we open and expand our approach and ideas around treatment, we create a whole new wave and energy that provides more hope and holds healing from eating disorders as absolutely possible.