When an eating disorder and addiction show up together
Published about 1 month ago • 5 min read • eating disorder
Eating Disorders and Other Addictions: When They Co-Occur
Hi Reader,
Over the past year, more of what I read has come from the world of addiction recovery and family systems. The more I read, the more I recognize. The secrecy. The insistence that everything is under control. The family walking on eggshells. The setback that arrives right after everyone finally exhales.
Eating disorders and addiction share far more than most people realize, and they frequently co-occur. Many people who have an eating disorder also struggle with substance use or another addictive behavior, and many people who struggle with addiction also have an eating disorder. Too often, only one of them gets noticed.
After more than 25 years as a registered dietitian specializing in eating disorders, I have seen this overlap again and again. Understanding it is one of the most protective things you can do, whether you are in recovery yourself or supporting someone who is.
Eating Disorders Behave Like Addiction, and Like Fear
I have long described anorexia as an addiction and a phobia operating at the same time. The drive to restrict reinforces itself the way a substance does, while the fear of food and of losing control can be as powerful as any phobia. Bulimia and binge eating disorder follow a similar cycle: urge, behavior, brief relief, shame, and then the urge again.
Because eating disorders and addictions run on the same cycle and the same need for relief, it is not surprising that they so often appear together. Both also thrive in secrecy. A person can look well, hold a demanding job, and still be in real medical danger.
How Often They Co-Occur
The overlap is well documented. A 2019 meta-analysis by Bahji and colleagues found that about 1 in 5 people with an eating disorder also have a substance use disorder at some point in their lives, with the highest rates in eating disorders that involve binge eating or purging.
Looking from the other side, a 2003 report from the National Center on Addiction and Substance Abuse at Columbia University estimated that up to 35 percent of people who use alcohol or drugs also have an eating disorder. That figure is more than twenty years old, and newer research on how many people in addiction treatment have an unidentified eating disorder is still lacking.
The combination carries real risk. A Danish nationwide study published in the American Journal of Psychiatry found that when the two occur together, the risk of death from one adds to the risk from the other. Eating disorders already carry one of the highest mortality rates of any psychiatric illness. This is why recognizing both matters so much.
What Co-Occurring Illness Can Look Like
In my practice, I see the overlap play out in quiet ways. Someone uses stimulants or diet pills to quiet hunger. Someone restricts during the day to "make room" for alcohol at night. Someone drinks or uses to numb the shame after a binge or purge.
The overlap also shows up as behaviors shift over time. As restriction, bingeing, or purging ease, drinking, vaping, shopping, or gambling may take on a new pull. As substance use changes, new food rules, skipped meals, bingeing, or exercise that feels driven may become more noticeable. Distress about body changes often surfaces during substance use or recovery. From the outside, progress with one behavior can look like recovery. Underneath, the other illness may still be active. This can happen at any point: during active illness, in the middle of treatment, or years into recovery.
Similar, But Not the Same
Research has not established that one illness causes the other. What it shows clearly is that they co-occur often. Shared factors like temperament, genetics, trauma, and difficulty tolerating strong emotions likely all play a role.
The differences matter just as much. You cannot abstain from food. Recovery means returning to eating several times a day, often in front of others, facing exactly what the illness fears most. The eating disorder can also feel like the solution rather than the problem, offering a sense of safety, control, or identity. That is not a character flaw. It is how the disease works.
Treatment programs usually focus primarily on one illness. An eating disorder program may screen for substance use but not be set up to treat it, and a substance use program may ask about eating without treating the eating disorder. Many centers advertise care for both, but in practice the focus usually stays on one. When only one illness is being treated, the other can continue unaddressed.
What You Can Do
If you are in recovery
If you are in eating disorder recovery and notice yourself reaching for alcohol, pills, vaping, or another behavior, tell your treatment team. If you are in recovery from a substance and notice new food rules, skipped meals, bingeing, purging, or exercise that feels driven, tell your team as well. That is not failure. It is information, and it is exactly what your team needs to help you.
Be honest with your dietitian, therapist, and doctor about all of it, even the parts that feel embarrassing or seem unrelated. Ask your team to help you build new ways to meet the need underneath the behavior. Naming feelings, sitting with discomfort, and reaching out for support are skills, and like any skill, they grow stronger with practice.
If you work with more than one provider, make sure they are talking to each other. And if your treatment focuses on only one illness, ask how the other will be treated, not just screened. You deserve care that treats all of you.
If you are a parent or caregiver
Pay attention to both conditions, not just the one that brought your loved one into treatment. Skipped meals before drinking, trips to the bathroom after eating, diet pills or stimulants, exercise that continues through illness or injury, or new food rules as substance use changes can all be signs that the other condition is active. Food rules can also loosen with the use of another substance. For example, marijuana can make it easier for someone to eat when eating feels frightening. From the outside, that can look like progress. Underneath, the eating disorder may still be active and simply being managed by the substance. You do not need to be certain before you speak up.
Share what you notice with the treatment team, and ask directly whether both conditions are being treated. If the program focuses on one, ask who is treating the other. A person in substance use treatment needs a specialist who understands the full range of eating disorders, including restriction, binge eating, purging, compulsive exercise, and laxative misuse. Likewise, a person in an eating disorder program needs a specialist who understands substance use and non-substance addictions such as gambling, shopping, or gaming.
Take care of yourself, too. Supporting someone through co-occurring illnesses is exhausting, and you are allowed to ask for help. If you feel out of options, find a comprehensive family care specialistfor eating disorders who can guide your whole family. Recovery is not a straight line, for the person you love or for you, and every honest step forward counts.
If you or someone you love is navigating this journey, the Nutrition Improvement Center is here. Reach out today to schedule an appointment and take the next step toward recovery.
Taking care of you, Iris
Iris Epstein, RDN, CEDS, CAI Founder, Nutrition Improvement Center for Restrictive Disorders nicrd.com | iris@nicrd.com | 845-362-1300
P.S. Have you or someone you love experienced an eating disorder alongside another addiction? Hit reply and tell me what that was like. I read every message, and colleagues are welcome to reach out too.
Sources: Bahji A, et al. Psychiatry Research, 2019. National Center on Addiction and Substance Abuse (CASA) at Columbia University, 2003. Mellentin AI, et al. American Journal of Psychiatry, 2022. Arcelus J, et al. Archives of General Psychiatry, 2011.
With care,
Iris
Nutrition Improvement Center
Caregiver Meal Support Download Here:
Three handouts for caregivers supporting a loved one with an eating disorder. Through these brief guides delivered over several days, you’ll gain clarity, reassurance, and a better understanding of your role during meals.
Visit the NIC YouTube Channel:
Get free educational videos on eating disorders, nutrition therapy, and family recovery support. Learn how to heal your relationship with food or help a loved one.
Read or Print Previous NIC Articles
Read or print free in-depth articles on eating disorder recovery, nutrition therapy, and family healing. Practical guidance to support every step of your journey.
REFER A FRIEND TO SUBSCRIBE TO THE NIC NEWSLETTER BY FORWARDING THIS EMAIL AND CLICKING HERE: WWW.NICRD.COM
