Going the Distance: Bringing Awareness to Rural Eating Disorders

By Brian Belko posted 29 Mar, 2022 17:04

Going the Distance: Bringing Awareness to Rural Eating Disorders
by Jenny Copeland, PsyD
Reconnect Eating Disorders Program at Ozark Center

Across society, among both professionals and general community members, a pervasive stereotype exists: the perception only thin, white, affluent, girls suffer from eating disorders (ED). Although much work has been done amongst clinicians and advocates to combat this misperception, particular groups in the United States continue to be disproportionately harmed by it. For some communities, this stereotype remains so ubiquitous their experience has rarely been examined by researchers to better understand the prevalence of EDs or their unique experiences.

Individuals residing in rural, impoverished communities are a key example of this. Although more research has examined EDs among low-income individuals (e.g., Sonneville & Lipson, 2018), much less data is available on rural EDs. A wider body of research is available internationally including rural Australia (McCormack et al., 2013), Brazil (Petroski, Pelegrini, & Glaner, 2012), Burkino Faso (Terhoeven et al., 2020), China (Feng & Abebe, 2017), India (Das & Ashok, 2018), Iran (Mohammadi et al., 2020), Italy (Rathner & Messner, 1993), and South Africa (Wassenaar et al., 2000).

Nowhere to be Found

To date only three ED studies in the rural United States are easily accessible. Two of these (Bagley, Character, & Shelton, 2003; Pepper, 2009) found no significant differences in ED symptoms, individual barriers to care, or systemic barriers between metropolitan and rural populations. This suggests rural residents are at least equally at risk for an ED. In contrast, Batchelder and colleagues (2021) found meaningful differences. When comparing ED behaviors among rural adolescents to national norms from the Youth Risk Behavioral Surveillance Survey, the authors concluded they are “common among rural adolescents.” The authors pointed out the discrepancy between the availability of ED services and the evident need for them, calling it “particularly problematic” (Batchelder at al., 2021).

To move outside metropolitan areas and into the rural communities of the United States is to step outside of what many know and often accept about EDs. Rural communities have a particular culture, with distinct health concerns and barriers to care (Smalley et al., 2010). There is a pronounced shortage of mental health providers in rural America (Ezekial et al., 2021). Substantial self- and public stigma specific to mental health concerns not only impact openness to seeking treatment, but are also suggestive of pervasive negative perceptions of mental healthcare (Stewart, Jameson, & Curtin, 2015). In the end, rural residents delay seeking treatment, presenting with more severe symptoms in the face of limited treatment availability (Cheesmond, Davis, & Inder, 2019; Crumb, Mingo, & Crowe, 2019). These disparities only become more pronounced for specialty behavioral health services (Smalley et al., 2010).

It is time to consider how this might impact individuals with EDs in these communities. The truth is rural residents may be at an increased risk for EDs with a noteworthy combination of vulnerabilities present here. Two factors in particular may contribute to rural residents’ risk for disordered eating and EDs: food insecurity and trauma.

Food insecurity is more prevalent in rural communities than metropolitan areas. The Food Research and Action Coalition (2018) reported 15% of rural communities experience household food insecurity as compared to 11.8% of metropolitan areas. A growing body of research has established a connection between food insecurity and disordered eating behaviors. Becker and colleagues (2017; 2019) identified a significant relationship between household food insecurity and specific ED behaviors such as binge eating, compensatory mechanisms, and dietary restraint. More severe ED symptoms and diagnoses are similarly connected with food insecurity (Christensen et al., 2021; Hazzard et al., 2020; Lydecker & Grilo, 2019; Rasmusson et al., 2019).

A history of trauma has also been shown to play a role in the development and maintenance of EDs (Brewerton, 2007; Smyth et al., 2008). Increased rates of traumatic experiences present in rural communities, with 78.2 percent of rural residents reporting a history of at least one potentially traumatic event (Handley et al., 2015). This risk factor may be exacerbated by the interaction between traumatic experiences and food insecurity. Becker and colleagues (2018) indicated individuals with the greatest food insecurity report greater exposure to trauma, as well as more severe ED pathology.

Far but Not Forgotten

With this increased risk for ED in rural communities, it is vital effective treatments be made available. Certified Community Behavioral Health Centers (CCBHC) often serve as the safety net for rural or impoverished communities. These agencies excel in the integration of multidisciplinary services not just within the team or agency but also throughout the community. Each center is equipped with the precise providers, resources, and wisdom with which to best serve their community.

The Reconnect Eating Disorders program at Ozark Center in Joplin, Missouri, is the first documented program to develop in a CCBHC. This program provides evidence-based, multidisciplinary care – particularly for those who are uninsured or underinsured. It is designed to meet the needs of the community by utilizing the unique strengths and resources of a CCBHC. Each team member completes advanced training to facilitate their specialization in the trauma-informed treatment of EDs. This in addition to the natural support and mentoring from fellow team members. The treatment team includes therapists and registered dietitians, as well as providers who are often not included outside of a CCBHC.

In these settings, two program areas can provide essential assets for the ED team. Community Support Specialists, called Reconnect Coaches on this team, are individuals with bachelor’s level education, a passion and heart for the clients we serve, and extensive, ongoing professional education in EDs. Their role limits or even removes the power differential associated with other team members such as therapists or dietitians. In this way they walk alongside our clients in their everyday lives, promoting new application of skills and providing support in natural environments such as the grocery store or the home. Medical Support (more commonly referred to as Healthcare Home) is a team of registered nurses and a physician consultant who regularly monitor clients’ medical safety as well as facilitate collaboration with primary care providers, psychiatry, and other relevant specialists.

The inclusion of Reconnect Coaches and Medical Support brings crucial benefits to ED treatment. Importantly, these team members provide help in a manner which circumvents barriers to mental health care. Reconnect Coaches especially meet clients where they are at, both literally and figuratively. Additionally, these team members allow us to increase the intensity of treatment for our most precarious clients without admitting them to a more restrictive environment. This not only improves safety, but also supports clients’ efforts to recover in their community. Given that a substantial portion of our clients would benefit from a higher level of care yet cannot financially access it, this advantage cannot be overstated.

It is not just critical team members which make CCBHCs uniquely well-suited to provide ED treatment to rural communities. These agencies have a foundation in trauma-informed care to ensure a safe and compassionate treatment environment. Trauma-informed care has been described as the centerpiece of a CCBHC’s work, such that when “our services are not build on emerging science around what trauma survivors need to heal and recover, we risk re-traumatizing the people we serve” (Johnson & Henderson-Smith, 2016). In the treatment of EDs, we must especially consider the influence of weight stigma and body shaming.

Weight bias and internalized weight stigma negatively impact well-being, psychological and physical health, and self-care behaviors (e.g., Major, Tomiyama, & Hunger, 2018; Tomiyama et al., 2018). A safe environment includes an accessible setting and comfortable furniture for all bodies. It should be free of diet talk, staff discussions of their own eating, and body commentary. It is also how bodies and weight are talked about, responded to, and treated among team members. The inclusion of weight loss goals can be inherently harmful and contraindicated for those with EDs. Trauma-informed care should be weight inclusive, with no body size or shape being preferable to another (Tylka et al., 2014).

Wide Open Spaces – for Change

Rural residents are an overlooked ED population, and may be at a greater risk for developing an ED. These distinctive cultures include multiple marginalized communities who are also disproportionately impacted by EDs such as people of color and gender diverse individuals (Diemer et al., 2015). Members of these communities face far more than disparity of access to ED treatment. Often the treatment they receive lacks evidence supporting its use with specific marginalized groups, potentially limiting the treatment’s effectiveness.

The work is only just beginning to bring a voice to rural residents, an overlooked group of humans struggling with EDs. More research is needed, certainly, to better understand the lived experiences of rural residents with their EDs. Not only this, but also how to better serve them in the context of the exceptional strengths, needs, and barriers in these communities. CCBHCs are in an ideal position to expand their service options to include EDs, though concerns surrounding sustainability must be addressed. Ozark Center’s Reconnect Eating Disorders program is the first effort in this area – and hopefully not the last.

About the Author

Jenny Copeland, PsyD,
is a clinical psychologist with Ozark Center where she leads the Reconnect Eating Disorders treatment team. She is an active member of the Missouri Eating Disorders Council. Dr. Copeland has conducted studies on weight stigma among healthcare providers, and developed programming rooted in weight inclusive frameworks to help people pursue balance within and outside themselves to find freedom in their bodies. Her work has earned awards including the Research and Evaluation Fellowship at The School of Professional Psychology at Forest Institute and the inaugural NAAFA Health At Every Size Scholar Award. For more information about the innovative Reconnect Eating Disorders Program, please visit: https://www.freemanhealth.com/ozarkcenter/service/eating-disorders


Bagley, C. A., Character, C. D., & Shelton, L. (2003). Eating disorders among urban and rural African American and European American women. Women & Therapy26(1-2), 57-79.

Batchelder, H. R., Martz, D. M., Curtin, L., & Jameson, J. P. (2021). Interpersonal violence victimization and eating disorder behaviors in rural adolescents. Journal of Rural Mental Health.

Becker, C.B., Middlemass, K.M., Gomez, F., & Martinez-Abrego, A. (2019). Eating disorder pathology among individuals living with food insecurity: A replication study. Clinical Psychological Science, 7(5), 1144-1158.

Becker, C.B., Middlemass, K.M., Johnson, C., Taylor, B., Gomez, F., & Sutherland, A. (2018). Traumatic event exposure associated with increased food insecurity and eating disorder pathology. Public Health Nutrition, 21(16), 3058-3066.

Becker, C.B., Middlemass, K., Taylor, B., Johnson, C., & Gomez, F. (2017). Food insecurity and eating disorder pathology. International Journal of Eating Disorders, 50(9), 1031-1040.

Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders, 15(4), 285-304.

Cheesmond, N.E., Davies, K., & Inder, K.J., (2019). Exploring the rôle of rurality and rural identity in mental health help-seeking behavior: A systematic qualitative review. Journal of Rural Mental Health, 43(1), 45-59.

Christensen, K.A., Forbush, K.T., Richson, B.N., Thomeczek, M.L., Perko, V.L., Bjorlie, K., Christian, K., Ayres, J., Wildes, J.E., & Chana, S.M. (2021). Food insecurity associated with elevated eating disorder symptoms, impairment, and eating disorder diagnoses in an American University student sample before and during the beginning of the COVID-19 pandemic. International Journal of Eating Disorders, 54(7), 1213-1233.

Crumb, L., Mingo, T.M., & Crowe, Al. (2019). “Get over it and move on”: The impact of mental illness stigma in rural, low-income United States populations. Mental Health & Prevention, 13, 143-148.

Das, K., & Ashok, K. S. (2018). Anorexia nervosa in rural South India. Archives of Mental Health19(1), 47.

Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health57(2), 144-149.

Ezekial, N., Malik, C., Neylon, K., Gordon, S., Lutterman, T., & Sims, B. (2021). Improving Behavioral Health Services for Individuals with SMI in Rural and Remove Communities. Washington, DC, American Psychiatric Associate for the Substance Abuse and Mental Health Services Administration.

Feng, T., & Abebe, D. S. (2017). Eating behaviour disorders among adolescents in a middle school in Dongfanghong, China. Journal of Eating Disorders5(1), 1-9.

Food Research & Action Center (2018). Rural hunger in America: Get the facts. https://frac.org/wp-content/uploads/rural-hunger-in-america-get-the-facts.pdf. Accessed February 24, 2022.

Handley, T. E., Kelly, B. J., Lewin, T. J., Coleman, C., Stain, H. J., Weaver, N., & Inder, K. J. (2015). Long-term effects of lifetime trauma exposure in a rural community sample. BMC public health15, 1176. https://doi.org/10.1186/s12889-015-2490-y

Hazzard, V.M., Loth, K.A., Hooper, L., & Becker, C.B. (2020). Food insecurity and eating disorders: A Review of emerging evidence. Current Psychiatry Reports, 22(74). doi:10.1007/s11920-020-01200-0

Johnson, K., & Henderson-Smith, L. (2016). CCHBCs: Are you embracing the urgency to become trauma-informed?. National Council for Well-Being. https://www.thenationalcouncil.org/BH365/2016/08/29/ccbhcs-embracing-urgency-become-trauma-informed/

Lydecker, J.A., & Grilo, C.M. (2019). Food insecurity and bulimia nervosa in the United States. International Journal of Eating Disorders, 52(6), 735-739.

Major, B., Tomiyama, J.A., & Hunger, J.M. (2018). The negative and bidirectional effects of weight stigma on health. In B. Major, J. F. Dovidio, & B. G. Link (Eds.), The Oxford handbook of stigma, discrimination, and health (pp. 499–519). Oxford University Press.

McCormack, J., Watson, H.J., Harris, C., Potts, J., & Forbes, D. (2013). A hub and spokes approach to building community capacity for eating disorders in rural Western Australia. The Australian Journal of Rural Health, 21(1), 8-12.

Mohammadi, M. R., Mostafavi, S.-A., Hooshyari, Z., Khaleghi, Al, Ahmadi, N., Molavi, P., Khan, A. A., Safavi, P., Delpisheh, A., Talepasand, S., Hojjat, S. K., Pourdehghan, Ostovar, R., Hosseini, S.H.,

Mohammadzadeh, S., Salmaian, M., Alavi, S. S., Ahmadi, A., & Zarafshan, H. (2020). Prevalence, correlates and comorbidities of feeding and eating disorders in a nationally representative sample of Iranian children and adolescents. International Journal of Eating Disorders, 53, 349-361.

Petroski, E. L., Pelegrini, A., & Glaner, M. F. (2012). Reasons and prevalence of body image dissatisfaction in adolescents. Ciencia & Saude Coletiva17(4), 1071-1077.

Pepper, A. C. (2009). Disordered eating, antifat attitudes, and barriers to treatment in college women from urban and rural areas. University of Montana.


Rasmusson, G., Lydecker, J.A., Coffino, J.A., White, M.A., & Grilo, C.M. (2019). Household food insecurity is associated with binge eating disorder and obesity. International Journal of Eating Disorders, 52(1), 28-35.


Rathner, G., & Messner, K. (1993). Detection of eating disorders in a small rural town: an epidemiological study. Psychological Medicine23(1), 175-184.


Smalley, K.B., Yancey, C.T., Warren, J.C., Naufel, K., Ryan, R., & Pugh, J.L. (2010). Rural mental health and psychological treatment: A review for practitioners. Journal of Clinical Psychology, 66(5), 479-489.


Smyth, J. M., Heron, K. E., Wonderlich, S. A., Crosby, R. D., & Thompson, K. M. (2008). The influence of reported trauma and adverse events on eating disturbance in young adults. International Journal of Eating Disorders, 41(3), 195-202.


Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. International Journal of Eating Disorders, 51(6), 518-526. doi:10.1002/eat.22846


Stewart, H., Jameson, J.P., & Curtin, L. (2015). The relationship between stigma and self-reported willingness to use mental health services among rural and urban older adults. Psychological Science, 12(2), 141-148.


Terhoeven, V., Nikendei, C., Barinighausen, T., Bountogo, M., Friederich, H.C., Ouermi, L., Sie, A., & Harling, G. (2020). Eating disorders, body image and media exposure among adolescent girls in rural Burkina Faso. Tropical Medicine & International Health, 25(1), 132-141.


Tomiyama, J.A., Carr, D., Granberg, E.M., Major, B., Robinson, E., Sutin, A.R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16, 123. https://doi.org/10.1186/s12916-018-1116-5


Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The weight-inclusive versus weight-normative approach to health: Evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity, 2014.


Wassenaar, D., Le Grange, D., Winship, J., & Lachenicht, L. (2000). The prevalence of eating disorder pathology in a cross‐ethnic population of female students in South Africa. European Eating Disorders Review: The Professional Journal of the Eating Disorders Association8(3), 225-236.