Eating disorders in Denmark may be far more common among socially disadvantaged young people than official diagnoses suggest, according to a nationwide study comparing healthcare records with self-reported symptoms. Researchers found that young people with highly educated parents were more likely to receive a diagnosis, while those from families with the lowest educational level reported symptoms more than twice as often as the reference group.
The findings, published in JAACAP Open, raise questions about who is recognised, referred and treated within a healthcare system designed to provide universal access.
Diagnosed eating disorders follow a social gradient
Researchers from the University of Copenhagen and Psychiatric Centre Ballerup examined data from 523,148 people born in Denmark between 1996 and 2003.
Diagnosed eating disorders were identified through Denmark’s national health registers from the age of six to 18. The researchers then compared the results with information about parental education and household income.
Young people whose parents had completed a long-cycle higher education programme, corresponding to roughly 17 to 20 years of education, were 35 percent more likely to receive an eating disorder diagnosis than the reference group.
The reference category consisted of families in which the parents had around 12 years of education, broadly equivalent to upper secondary education.
At the other end of the scale, young people whose parents had completed only basic compulsory education were 30 percent less likely to receive a formal diagnosis.
This pattern might appear to support the longstanding perception that eating disorders, particularly anorexia, are concentrated among affluent or highly educated families. A second part of the study, however, produced almost the opposite result.
Undiagnosed eating disorders show the opposite pattern
For 44,552 participants, the researchers also had access to self-reported information collected through the Danish National Birth Cohort (Bedre Sundhed i Generationer).
The responses were used to identify symptoms associated with anorexia, bulimia and binge eating disorder among young people who had not received a diagnosis through the healthcare system.
In this group, young people whose parents had only basic education were more than twice as likely to report eating-disorder symptoms as those in the reference group. The estimated relative risk was 2.19.
The researchers found no similarly clear pattern for household income. This suggests that parental education may capture differences that income alone cannot explain, including knowledge of symptoms, familiarity with healthcare institutions and the ability to seek specialist assistance.
“Our study suggests that the picture is more complex. It may largely be a question of who is recognised, referred and diagnosed,” Andrea Joensen, a postdoctoral researcher at the University of Copenhagen’s Department of Public Health and one of the study’s lead authors, said when presenting the findings.
Recognition can determine access to treatment
The study does not show that young people from highly educated families are overdiagnosed. Instead, it indicates that other groups may remain unidentified despite experiencing significant symptoms.
Several mechanisms could contribute to this difference. Families with fewer educational resources may find it harder to recognise an eating disorder, communicate their concerns or navigate referrals between general practitioners, psychiatric services and specialised clinics.
The researchers also mention possible differences in trust towards healthcare services and expectations about whether professional treatment will be effective.
An eating disorder that remains undiagnosed can have serious consequences. Else Marie Olsen, consultant psychiatrist (overlæge) at the Psychotherapeutic Outpatient Clinic for Eating Disorders (Psykoterapeutisk Ambulatorium for Spiseforstyrrelser) at Psychiatric Centre Ballerup, said that affected young people often live with shame, guilt and psychological distress while trying to manage the condition without assistance.
Food also plays a central role in many social activities, meaning that symptoms can contribute to isolation from friends, relatives and other communities.
What the Danish study cannot establish
The research is observational and therefore cannot prove that parental education directly causes differences in diagnosis or symptoms.
The self-reported part of the analysis also covers a smaller and more selected group than the national-register study. Participants in long-term cohort research may differ from young people who do not respond to follow-up questionnaires.
Self-reported symptoms are not equivalent to a clinical assessment. At the same time, relying only on hospital and psychiatric records would exclude people who have never entered treatment, which is precisely the gap the study sought to examine.
The distinction between diagnosed and undiagnosed cases therefore matters. Administrative data can show who reaches the healthcare system, but not necessarily everyone who needs help.
Universal healthcare does not eliminate hidden inequality
Denmark’s healthcare system provides broad public access, but formal universality does not guarantee that every social group is equally likely to obtain a diagnosis.
The study suggests that inequalities may emerge before treatment begins: when symptoms are interpreted, when assistance is requested and when a young person is referred for assessment.
“The key message is that eating disorders are not only a problem among affluent families,” Joensen said. “We risk overlooking young people who have just as much need for support but, for various reasons, never find their way into treatment.”
The findings could influence future approaches to early identification and prevention, particularly in schools, primary care and community mental-health services. They also illustrate a broader challenge for Nordic welfare systems: equal formal rights do not always produce equal access when recognising a condition requires information, confidence and the ability to navigate complex institutions.
