Drawn picture of person walking up a staircase outside, symbolizing a person'a journey on eating disorder and substance use disorder recovery.

By: Molly Edwards, MPH, RD, LDN

As someone in long-term recovery from a substance use disorder, I’ve had a unique window into how addiction and eating disorders can intersect and reinforce each other. Through my own experience with substance use, I’ve seen similar drivers of perfectionism, control, and emotion regulation. It’s also clear that both conditions can thrive in secrecy, isolation, and shame, and carry high risks if left unaddressed.

This article is for providers who want to better understand the intersection of eating disorders (EDs) and substance use disorders (SUDs), and for individuals who may be struggling with both. Whether you’re a therapist, dietitian, physician, or someone navigating dual diagnosis, understanding this connection is essential for effective, compassionate care, and moving toward long-term recovery.

 

Eating Disorders and Substance Use Disorders: The Statistical Reality

 

The co-occurrence of eating disorders and substance use disorders, known as “dual diagnosis” or “co-occurring disorders,” is quite common yet remains significantly understudied. 

  • Up to 50% of individuals with eating disorders use alcohol or other substances (five times higher than the general population).1 
  • Up to 35% of individuals with alcohol or drug use disorders have eating disorders (11 times greater than the general population).2
  • Roughly one in five individuals with an ED will develop a SUD at some point in their lifetime.

Eating disorders have the second highest mortality risk of all mental health conditions, surpassed only by opioid use disorder.4,5 This risk is further elevated when an eating disorder co-occurs with a substance use disorder.4 Despite this high risk, there is a lack of research that leaves healthcare providers feeling unprepared to address dual diagnosis, leading to fragmented care where clients may receive treatment for one condition while the other goes unaddressed. 

Colorful image with Purple words at the bottom reads "National Recovery Month"

Understanding the Connection: Why ED’s and SUD’s Co-Occur

 

Eating disorders (EDs) and substance use disorders (SUDs) often overlap because they share common risk factors. Trauma and adverse childhood experiences (ACEs), personality traits like impulsivity or perfectionism, co-occurring mental health conditions, and even genetic predispositions can increase vulnerability to both.6,7 Both disorders affect the brain’s reward system and serve similar coping functions, whether that’s emotion regulation, stress relief, social anxiety, self-punishment or self-soothing, or a tool to change mental and physical state.

 

The relationship between eating disorders and substance use varies significantly depending on how the ED presents and the substances involved. Substance use can play a big part in someone’s disordered eating patterns by altering appetite, dulling physical and emotional sensations, or increasing impulsive behavior.6

 

Food vs. Substances

 

While eating disorders and substance use disorders share many similarities, there’s one fundamental difference that shapes treatment approaches: we don’t need substances to survive, but we need food to live. 

In substance use recovery, abstinence from the substance can be a viable and often necessary goal. But with eating disorders, abstinence from food isn’t an option. Instead, recovery involves developing a healthy, balanced relationship with something we must interact with multiple times every day. This unique challenge means treatment goals, relapse prevention strategies, and daily coping tools will be tailored differently, but their connection remains important.

 

Mutual Influence and Impact

 

Although recovery paths differ, EDs and SUDs profoundly influence each other’s symptoms and outcomes. Substance use can disrupt hunger cues, alter appetite, interfere with nutrient absorption, and complicate psychiatric treatment, all of which make ED recovery harder.6,8 On the other side, malnutrition from disordered eating affects brain function, mood regulation, and decision-making, making it harder to maintain sobriety.9

This back-and-forth influence can create a see-saw effect, when one behavior decreases, the other may intensify as a substitute coping mechanism. Without integrated care, individuals may trade one harmful behavior for another rather than achieving lasting recovery.

 

The Importance of Integrated Care

 

As eating disorder dietitians, one of our most important roles is to create a space where clients feel safe to share openly, this includes how substance use may be shaping their recovery journey. When conversations about substances are avoided or met with judgment, individuals may feel they need to choose which struggle to prioritize, leaving crucial pieces of their experience unsupported.

Integrated care does not mean that every provider becomes an expert in both EDs and SUDs. Instead, it means building a team where expertise is shared: therapists and dietitians who understand dual diagnosis, medical providers who can monitor health and medications, psychiatrists who recognize the complex interactions at play, and, when needed, higher levels of care that can provide wraparound services. 

SAMHSA’s ‘no wrong door‘ policy reminds us that effective treatment systems work when anyone seeking help can find it, no matter where they first reach out. Sometimes, we as dietitians may be that door. By staying within our scope while acknowledging the ways substance use and eating behaviors intersect, learning more about signs and symptoms, and connecting clients to the right resources, we help create pathways to recovery that are comprehensive and truly supportive.

If you’re struggling with both eating disorder behaviors and substance use, or if you’re a provider working with someone who might have a dual diagnosis, here are important questions to consider:

For Individuals:

  • Does my treatment team understand how my eating behaviors and substance use connect?
  • Do I feel safe talking about both, without fear of judgment or being dismissed?
  • Am I being offered resources that support the whole of my recovery?

For Providers:

  • Am I creating an environment where clients feel comfortable disclosing substance use?
  • Am I equipped to provide appropriate care at this time, or should I refer to someone with more specialized training?
  • Do I have trusted colleagues or programs I can refer to for integrated support?
  • How can I continue learning about the intersections of EDs and SUDs?

Recovery is Possible

 

While dual diagnosis presents unique challenges, recovery from both eating disorders and substance use disorders is possible. The key is understanding that these conditions are often two sides of the same coin, different expressions of underlying patterns that need integrated, compassionate care.

If you’re experiencing both conditions, please know that you’re not alone. You deserve recovery, and you deserve comprehensive care that addresses all aspects of your experience. Healing isn’t about perfection, it’s about progress, and every small step forward matters. 

Are you navigating recovery from both disordered eating and substance use? As a registered dietitian in long-term recovery, I bring a specialized focus to support individuals with these co-occurring challenges. Learn more about me and my approach to care here. 

At Lutz, Alexander & Associates Nutrition Therapy, all of our dietitians are highly trained in eating disorder treatment, and together we’re committed to walking alongside you in your recovery journey. Contact us today.

 

Patient Resources:

 

References:

  1. Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., & Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis. Psychiatry research, 273, 58–66.
  2. Hudson, J. I., Hiripi, E., Pope, H. G., Jr, & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348–358.
  3. Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., & Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis. Psychiatry research, 273, 58–66. https://doi.org/10.1016/j.psychres.2019.01.007
  4. Mellentin, A. I., Mejldal, A., Guala, M. M., Støving, R. K., Eriksen, L. S., Stenager, E., & Skøt, L. (2022). The Impact of Alcohol and Other Substance Use Disorders on Mortality in Patients With Eating Disorders: A Nationwide Register-Based Retrospective Cohort Study. American Journal of Psychiatry, 179(1), 46–57. https://doi.org/10.1176/appi.ajp.2021.21030274
  5. National Alliance for Eating Disorders. (2025, February 28). Not One More 2025 | ACUTE Center for Eating Disorders. Alliance for Eating Disorders. https://www.allianceforeatingdisorders.com/nom25-acute/
  6. Gregorowski, C., Seedat, S., & Jordaan, G. P. (2013). A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders. BMC psychiatry, 13, 289. https://doi.org/10.1186/1471-244X-13-289
  7. Kanbur N, Harrison A. Co-occurrence of Substance Use and Eating Disorders: An Approach to the Adolescent Patient in the Context of Family Centered Care. A Literature Review. Substance Use & Misuse. 2016 Apr 20;51(7):853–60. 
  8. Mahboub, N., Rizk, R., Karavetian, M., & de Vries, N. (2021). Nutritional status and eating habits of people who use drugs and/or are undergoing treatment for recovery: a narrative review. Nutrition reviews, 79(6), 627–635. https://doi.org/10.1093/nutrit/nuaa095 
  9. Savoie-Roskos, M. R., Yaugher, A. C., Condie, A. W., Murza, G., Voss, M. W., & Atismé, K. (n.d.). Diet, nutrition, and substance use disorder. Utah State University Extension. Retrieved September 7, 2025, from https://extension.usu.edu/heart/research/diet-nutriton-and-substance-use-disorder
  10. Substance Abuse and Mental Health Services Administration. (2024, March 29). Co-Occurring disorders and other health conditions. SAMHSA. Retrieved September 7, 2025, from https://www.samhsa.gov/substance-use/treatment/co-occurring-disorders
  11. Merlo, L. J., Stone, A. M., & Gold, M. S. (2009). Co-occurring addiction and eating disorders. In R. K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.), Principles of addiction medicine (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
  12. National Institute of Mental Health. Substance Use and Co-occurring Mental Disorders. NIMH; 2021.