In this continuing education webinar, Addressing Social Determinants of Health in Eating Disorder Treatment and Prevention, Nicole Christian-Brathwaite, MD, National Medical Director of Child and Adolescent Psychiatry at Monte Nido, and Erikka Taylor, MD, MPH, DFAACAP, Chair of the Board of Directors at Project HEAL and Partner at Catalyst Therapeutic Services, explored how social determinants of health influence eating disorder risk, diagnosis, treatment access, and long-term recovery.

Key Takeaways

• Social determinants of health influence every stage of eating disorder care. Factors such as food insecurity, housing stability, healthcare access, discrimination, and financial barriers affect risk, diagnosis, treatment access, and recovery.
• Many eating disorders remain underdiagnosed because of systemic bias. Traditional assumptions about who develops eating disorders can delay recognition and treatment for people from historically underserved communities.
• Food insecurity and trauma are important risk factors. Chronic stressors and limited access to basic resources can increase vulnerability while making recovery more difficult.
• More equitable care requires broader assessment. Screening for social determinants of health alongside eating disorder symptoms can help clinicians identify barriers and provide more individualized, trauma-informed treatment.

Addressing inequities in eating disorder care

Eating disorders affect people of every race, ethnicity, gender identity, socioeconomic background, and body size. Yet recognition, diagnosis, and treatment remain uneven across populations. While biology and psychology are important contributors to eating disorders, they are only part of the picture. The environments in which people live, learn, work, and access healthcare also play a significant role in determining who develops an eating disorder, who receives timely treatment, and who is left behind. 

What are social determinants of health?

Social determinants of health (SDOH) are the conditions that shape everyday life and influence health outcomes. These include factors such as economic stability, education, healthcare access, housing, neighborhood conditions, and social support. 

Research suggests that social determinants account for approximately 30% to 55% of health outcomes, exceeding the impact of clinical care alone. 

Healthy People 2030 identifies five major domains of social determinants of health:

• Economic stability
• Education access and quality
• Healthcare access and quality
• Neighborhood and built environment
• Social and community context

For eating disorders, these factors influence much more than access to treatment. Food insecurity, discrimination, poverty, unstable housing, and limited healthcare access are all associated with increased eating disorder risk, delayed diagnosis, and disparities in recovery outcomes. 

How social determinants affect eating disorder diagnosis

Despite increasing awareness, many eating disorders still go unrecognized because clinicians, healthcare systems, and even research continue to rely on outdated assumptions about who develops these illnesses.

Historically, eating disorders have been associated with individuals who are:

• White
• Female
• Thin or underweight
• Affluent
• Diagnosed with anorexia nervosa

These stereotypes influence recognition and diagnosis, making it more difficult for people outside this narrow profile to receive appropriate care.

Delayed diagnosis has meaningful consequences, including:

• Increased medical complications
• Greater psychiatric comorbidity
• Longer illness duration
• Increased treatment resistance
• Higher healthcare utilization
• Lower likelihood of full recovery

Early recognition remains one of the strongest predictors of improved outcomes.

Five systemic barriers to eating disorder diagnosis

Many disparities in eating disorder care are rooted in systemic barriers rather than differences in need. Understanding these barriers can help clinicians identify opportunities for more equitable assessment and intervention.

1. Provider bias and stereotypes

Implicit bias continues to influence who is screened for eating disorders and whose symptoms are recognized.

Providers are often less likely to identify eating disorder symptoms in patients who do not match traditional stereotypes. Youth who are boys, Latinx, or members of racially and ethnically marginalized communities experience particularly low rates of service utilization, and these populations are also less likely to complete treatment. 

A striking example illustrates this bias. When clinicians reviewed identical eating disorder case examples, problematic eating behaviors were identified in:

• 44% of White women
• 41% of Hispanic women
• Only 17% of Black women

These findings suggest that diagnostic disparities may begin before treatment is ever initiated.

2. Biased diagnostic criteria and screening tools

Many diagnostic criteria and screening measures were developed using predominantly White, female study populations. 

Current assessments may overlook important presentations because they often:

• Emphasize low BMI
• Focus primarily on the drive for thinness
• Do not account for gender dysphoria-related body image concerns
• Fail to consider cultural influences on eating behaviors
• Do not adequately assess the underlying drivers of eating disorder symptoms

These limitations may contribute to missed diagnoses, particularly among individuals with atypical anorexia nervosa or those whose symptoms do not align with traditional presentations.

3. Unequal access to healthcare

Even when symptoms are recognized, access to specialized treatment is not equally available.

Common barriers include:

• Cost of care
• Limited insurance coverage
• Geographic distance from specialty programs
• Transportation challenges

For some communities, stigma surrounding eating disorders and mental health further reduces treatment-seeking, while disparities in insurance coverage contribute to differences in outpatient and inpatient care. 

4. Cultural stigma and internalized stereotypes

Cultural beliefs about mental illness and eating disorders can influence whether individuals recognize symptoms, disclose concerns, or seek professional help.

Several factors may contribute to delayed care:

• Mental health stigma
• Internalized beliefs that eating disorders only affect certain populations
• Limited representation within eating disorder education and resources
• Acculturative stress and experiences of discrimination

When individuals do not see themselves represented in conversations about eating disorders, symptoms may go unrecognized for years.

5. Structural and systemic inequities

Broader social systems also influence eating disorder risk and access to care.

Examples include:

• Restrictive eligibility criteria for specialty treatment
• Structural racism
• Economic inequities
• Limited community resources
• Chronic socioeconomic stress

These structural barriers often intersect, increasing vulnerability while simultaneously reducing access to treatment.

The relationship between trauma and social determinants of health

Many social determinants are also sources of chronic stress or trauma.

Experiences such as food insecurity, housing instability, poverty, discrimination, community violence, immigration-related stress, weight stigma, family instability, and social isolation can contribute to ongoing psychological distress. 

Rather than occurring independently, these stressors often accumulate.

One model presented in the slides illustrates how multiple adversities compound over time. For example, a person experiencing food insecurity, unstable housing, racism, bullying, depression, and limited healthcare access faces substantially greater cumulative risk than someone with stable housing, food security, reliable transportation, and strong family support. 

Importantly, protective factors such as community connection, cultural identity, family support, financial stability, and access to care can help reduce vulnerability. 

Food insecurity is more than a nutrition issue

Food insecurity is often discussed as a public health concern, but it is also an important eating disorder risk factor.

Food insecurity refers to limited or uncertain access to enough food, while food deserts describe communities with limited access to affordable and nutritious food. 

Research summarized in the presentation links food insecurity with:

• Increased perceived stress
• Emotional eating
• Binge eating
• Restriction
• Purging behaviors

The relationship can become cyclical. Unpredictable food access creates chronic stress, periods of scarcity may alternate with periods of availability, compensatory eating behaviors may develop, and shame can discourage individuals from seeking help. 

Recognizing this cycle is essential for providing effective and trauma-informed care.

Incorporating social determinants into clinical assessment

Understanding social determinants requires asking different questions during intake.

In addition to assessing eating disorder symptoms, clinicians can explore factors such as:

• Food security
• Housing stability
• Transportation
• Insurance and financial barriers
• Preferred language
• Recovery supports
• Experiences of bias or discrimination

Several validated screening tools can help identify these needs, including PRAPARE, the Accountable Health Communities Health-Related Social Needs Screening Tool, WE CARE, Health Leads, Hunger Vital Sign®, and THRIVE. 

These conversations help clinicians better understand the context surrounding symptoms and identify barriers that may influence treatment engagement.

Why more inclusive eating disorder research matters

The populations represented in eating disorder research influence how clinicians screen, diagnose, and treat patients.

Historically, research has relied heavily on participants who are White, female, cisgender, insured, treatment-seeking, and living in smaller bodies. 

As a result:

• Screening tools may miss symptoms.
• "Typical" eating disorder presentations become biased.
• Treatment recommendations may not address structural barriers.
• Prevention efforts may overlook those at highest risk.

Clinicians can strengthen evidence-based practice by critically evaluating research before applying findings to individual patients.

Questions to consider include:

• Who was included in the research?
• Who was excluded?
• Was the screening tool validated in this population?
• Were structural barriers considered?
• How might food insecurity, transportation, insurance, or other social determinants affect implementation?

Moving toward more equitable eating disorder care

Improving eating disorder care requires looking beyond symptoms alone and recognizing the broader systems that influence health. Universal screening, culturally responsive assessment, attention to food access and other social determinants, and advocacy for more inclusive research can all help reduce disparities in diagnosis and treatment. 

Eating disorders affect people from every community. By recognizing the role that social determinants of health play in risk, access, and recovery, clinicians can move toward more equitable, individualized care that meets patients where they are and addresses the barriers that too often stand between them and treatment. 

Learn more about Monte Nido’s continuing education sessions.

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