Approximately 3-5% of teens have a diagnosable eating disorder. Even higher numbers of teens and young adults, including many males, struggle with disordered eating behaviors and thoughts. (The term “disordered eating” is used to include situations when the symptoms don’t meet full criteria for a clinical diagnosis but are concerning.) Eating disorders are most likely to develop before the age of 26. Since eating disorders are serious and often hidden, here is some information about them, including how to recognize them in your children.
Eating disorders involve dysfunctional behaviors, thoughts and emotions around eating, food and body weight. These usually include body dissatisfaction, preoccupation with eating/body weight, and low self-esteem. There are significant, even life-threatening, medical and psychological risks, including an elevated risk of suicide. (See “risks” list below). In fact, Anorexia Nervosa carries the highest risk of death of any mental disorder. It’s best to catch them early when treatment is most effective and health risks can be mitigated or avoided.
While it seems that an eating disorder such as Anorexia Nervosa (AN) would be easy to detect, the onset can be insidious. The weight loss may be gradual enough to escape notice, and the behaviors can be in line with what our culture deems to be healthy (avoiding sweets, exercising, and losing weight). Other eating disorders, such as Bulimia Nervosa (BN) and Binge Eating Disorder (BED), are less obvious from outward appearance, as people can be of any weight and body type. In addition, people with disordered eating often feel intensely ashamed and hide their eating, weight-related behaviors and appearance. For example, people with AN may wear baggy clothing to conceal just how thin they are. Binge eating and purging by vomiting are generally hidden from family and friends. And adolescents often keep their insecurities and emotional distress from parents and others.
Even with this knowledge, we will continue to miss signs of disordered eating in our children. Prevention includes careful consideration of the culture and messaging surrounding weight, food and body image we set in our homes. For example, avoid the following: labeling food as “good” or “bad,” making judgments about body shapes and sizes (including your own), and talk about diets and calories. Instead, model pleasure in eating well-balanced full meals, and allow children to eat when hungry and stop when full.
Here is a brief description of the three main eating disorders.
Anorexia Nervosa (AN):
Symptoms include: weight loss/substantially underweight (or falling off the growth curve), restricting of food intake, intense fear of gaining weight, distorted body image (see themselves as overweight even when severely underweight), self-esteem inordinately tied to perceived body shape/size.
Physical signs include: disruption in menstrual cycles, extreme thinness, feeling cold, dizzy spells, fatigue, lanugo (fine body hair), dry skin, brittle nails, constipation, stomach upset, insomnia, hair loss, frequent colds.
Behavioral/psychological signs include: dressing in layers/baggy clothes, preoccupation with dieting or “healthy” eating, food restrictions (such as no carbs), food/eating rituals such as cutting food up into little pieces, cooking/baking for others but not eating the food, avoiding mealtimes, compulsive exercise routine (even when injured/ill/bad weather), frequent comments about being “fat”.
Bulimia Nervosa (BN):
Symptoms include: binge eating/purge cycles, associated feelings of shame and guilt, fear of weight gain. Binge eating: eating a large amount of food in a short period of time, eating until uncomfortably full and beyond, feeling out of control of the eating. Compensatory (purge) behaviors: induced vomiting, excessive exercise, use of laxatives or diuretics, restricting caloric intake.
Physical signs include: swollen salivary glands, frequent sore throat, tooth decay/tooth enamel worn down, sores/calluses on knuckles, acid reflux, rapid weight gain. Of note: someone with BN can be any weight/size.
Behavioral/psychological signs include: frequent dieting, secretive eating (and not wanting to eat in front of people), going to the bathroom immediately after eating, hiding food, excessive exercising, taking long showers (to hide purging by vomiting in the shower).
Binge Eating Disorder (BED):
Symptoms include: recurrent episodes of binge eating (see above), without associated compensatory behaviors. Feelings of guilt, shame, depression, and low self-esteem. This is the most common eating disorder.
Physical signs include: rapid weight gain (or weight changes), stomach upset/cramps.
Behavioral/psychological signs include: frequent dieting, social withdrawal, irregular meal schedules/habits, eating in secret, hoarding food, hiding food wrappers, frequent mirror checking.
Relative Energy Deficiency in Sport (RED-S):
Eating disorders such as AN are often missed in athletes, as many aspects of the athletic culture encourage and normalize the behaviors and symptoms. These include the normalization of low heart rate and menstrual irregularities (especially with endurance sports such as long-distance running), a “tough it out” culture (playing through the pain, “don’t give up,” “no pain, no gain”), the overvaluing of lean bodies (especially with “lean body sports” such as gymnastics, dance, and figure skating), “cutting” and monitoring weight in sports with weight categories (e.g. wrestling and crew), and attention to body shape in sports with skimpy clothing (e.g. swimming).
The “female athlete triad” is now more accurately referred to as RED-S, to include men. The criteria are insufficient energy availability in relation to the body’s needs, absence of regular menstrual periods/ low estrogen, and low bone mineral density (osteopenia or osteoporosis, which can be irreversible). In males, there can be decreases in male hormonal systems. The energy deficit can result from inadequate caloric intake, high expenditure through exercise, or a combination of the two. RED-S can be unintentional, perpetuated by the training regimen and culture, or it can be a sign of an eating disorder. Either way, the health risks are significant. Once a problem is recognized, if an athlete cannot follow medical and nutritional recommendations, it may be a sign of an eating disorder, and a psychological consultation may be indicated. It can be helpful to emphasize the fact that athletic performance improves when one’s body is getting the nutrients and energy that it needs (see: The New York Times, “I Was the Fastest Girl in America, Until I Joined Nike,” 11/7/19).
Warning Signs for Eating Disorders In General:
- Athletes: decrease in performance, fractures, recurrent injuries
- Recurrent illnesses
- Weight changes/ falling off of growth curve
- Late menarche; skipped menstrual periods
- Depression/low energy
- Talk about weight, counting calories, “energy balance,” “eating healthy”
- Body checking/mirror checking
- Counting calories/dieting
- Rigid exercise habits with guilt if missed workout
- Comments about body image
- Regularly declining dessert
- Change in diet to vegetarian/vegan (not a problem in and of itself)
- Eating in secret/guilt or shame around eating (“I shouldn’t have…”)
Risks / Negative Consequences:
- Mental health (such as depression, irritability, poor concentration, suicidal thoughts)
- Immune system dysfunction
- Changes in metabolism (e.g., cold intolerance in AN)
- Endocrine dysfunction (of note, oral contraceptives can mask estrogen deficits/menstrual dysfunction)
- Gastrointestinal problems
- Cardiovascular risks (abnormal heart rhythm, changes in heart rate, sudden death)
- Electrolyte imbalances (can cause sudden death)
- Hematologic (such as anemia, low white count)
- Low energy, fatigue, muscle weakness
- Bone loss: can be irreversible
The most effective treatment for eating disorders involves a comprehensive, coordinated, multi-pronged approach consisting of medical care, nutritional counseling, psychological assessment and treatment if indicated, psychiatric care if needed, and for athletes, involvement of coaches/trainers. Family therapy is often recommended. For anorexia nervosa, weight restoration is the cornerstone of treatment.
If you are concerned, consulting with your child’s pediatrician or primary care physician is a good place to start.
Depending on the severity of the illness, different levels of care may be recommended: outpatient, intensive outpatient, residential, hospitalization.
There are some medications specifically approved for treatment of BN and BED. And it is also important to actively assess for and treat commonly co-occurring mental health issues such as depression and/or anxiety.
For more comprehensive information about eating disorders and treatment resources, The National Eating Disorders Association (NEDA) is a great resource: www.nationaleating disorders.org/learn.