Parents are often frightened and overwhelmed when a health professional announces their child has a diagnosis of an eating disorder. They wonder how involved they should be in helping their child. Should they stand back and allow their child navigate this difficult time by themselves or should they roll up their sleeves and start preparing and supervising their child’s every bite? Their independent child might proclaim that they “have it under control” and parents might desperately want to allow that, but as they watch their child chop the apple even smaller and push their food around their plate for longer stretches of time, they realize quite quickly that their child does not have this under control at all. How big an issue are eating disorders? Currently, there are seventy million people who suffer from eating disorders worldwide, and 90 percent of them are between the ages of 12 and 25. Eating disorders are not just found in “small and skinny girls,” as previously thought. Eating disorders can be found in people of all shapes and sizes; they are becoming increasingly common among males, transgender adolescents and ethnic and racial minorities as well. Definition of eating disorders Eating disorders often develop during adolescence but can also develop later in life. To the outside world, these complex illnesses appear to be food- and weight-focused, but, on a deeper level, they often serve as a coping mechanism for those suffering from unpleasant, overwhelming or stressful emotions and/or situations. Those who are diagnosed with an eating disorder may have a combination of factors that create a perfect storm for this illness to develop, such as one’s individual traits, genes, psychological make-up (including already existing co-morbidities like depression, anxiety or OCD), and external factors such as cultural cues, dieting/social pressure and environmental factors.
Eating disorders may involve eating too little (restriction), eating too much (binging), vomiting or excessive exercise after eating (purging), or all of the above. For some kids, there is a dramatic and noticeable weight loss, and for others there is no change in weight. Instead, there are profound medical complications associated with their eating disorder symptoms.
Eating disorders typically begin during adolescence. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), used by health professionals to diagnose mental disorders, lists the following most common eating disorders: anorexia nervosa (AN), bulimia nervosa (BN), avoidant/restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED), and binge eating disorder (BED). However, teens with eating disorders don’t always fit into one diagnostic box; instead, they can often exhibit characteristics across several different eating-disorder diagnoses. A summary of the DSM-5 criteria for eating disorders can be found here.
Eating disorder behaviors/symptoms to watch for:
Increased interest in food and exercise (becomes a red flag when it turns into an obsession)
Sorting foods into “good foods and bad foods” and talking about being “scared” or “fearful” of foods
Increased focus on body and shape (some of this is normal during adolescence, but a high degree of distress and preoccupation would be concerning)
Body checking (repeatedly touching, examining, dissecting body in mirror)
Loss of menstrual cycle (though especially “common” among athletes, usually a sign that something physiologically is off)
Increased rigidity and lack of flexibility
Lack of spontaneity around food
Reduction in number of foods willing to eat
Lack of variety in diet—a change from previous patterns
Avoidance of social situations, especially where food is involved
Compensatory behaviors: This is defined as a behavior that is used to eliminate the calories consumed. It is a hallmark feature of bulimia nervosa but is also present in other types of eating disorders such as anorexia nervosa or binge eating disorder. Compensatory behaviors can be vomiting after meals, excessive exercise, the misuse of laxatives, diuretics, diet pills and teas, or it can be a period of food restriction.
Dangerous medical complications Eating disorders can be life-threatening, and anorexia has the highest mortality rate of any psychiatric disorder. If an energy imbalance exists, whether it’s due to intentional reasons (dieting) or unintentional reasons (overtraining), every area of the body will be affected. Insufficient fuel has the power to affect cardiac, gastrointestinal, menstrual, hematological, immunological and psychological functioning. This can be seen in vital sign instability, low resting heart rate, low blood pressure, EKG abnormalities, and large changes in blood pressure/pulse (when the child goes from different positions lying to standing). Medical hospitalization can be required with any of the aforementioned instabilities. Purging, laxatives or diuretics can cause dangerous electrolyte disturbances, including low serum potassium, sodium, phosphorus, and magnesium that could also require hospitalization to correct and should be checked regularly by a physician if any of those behaviors are suspected. Purging can also cause tooth decay and irreversible damage to one’s dental enamel. Additional consequences of malnutrition include hair loss, dry skin, reduced digestive enzymes, reduced hormone levels, reduced brain function (as shown on MRI), abnormalities in liver functions, reduced bone density/stress fractures, increased depression, anxiety and irritability—and this list is not exhaustive.
A medical provider should check for hypoglycemia, dehydration and cardiac abnormalities if eating disturbances are suspected. Interestingly, food is the medicine. Virtually all of an eating disorder’s medical complications are reversible with nutritional rehabilitation.
Athletes who are not adequately fueling may notice reduced performance (or their coach or parent may spot it first). They might be slower, weaker, more prone to injury, might not make progress despite a lot of training, or be more irritable or depressed and have decreased endurance. This is ironic, given their initial goal of achieving health and excelling at their sport. In 2014, researchers gave a new name to this energy imbalance as it pertained to athletes: RED-S, which stands for Relative Energy Deficiency in Sports.
Family-based treatment Parents are best equipped to help their child fight this terrible disease and to do so in a way that is safe and effective. Nearly all nutritional deficiencies can be corrected at home in the family setting (unless the child is medically unstable and needs medical supervision). In family-based treatment (FBT), parents “take charge.” The approach also opposes the notion that families are to blame for their child’s illness and is the most researched and effective method for eating disorders treatment. With this approach, parents are initially asked to assume total responsibility for their child’s nutrition: meal preparation, grocery shopping and all choices regarding food planning, in the face of their child’s clear inability to do so. This active and positive treatment therapy is the leading outpatient treatment for adolescents with eating disorders and is generally considered to be the first recommended line of treatment. Parental involvement can often prevent the child from requiring a higher level of care such as a partial hospitalization or an inpatient program.
In next week’s post we will learn more about family-based treatment and introduce a tool to help achieve even greater success with FBT.
Crosbie, Casey and Sterling, Wendy. How to Nourish Your Child Through an Eating Disorder. New York, NY: The Experiment Press, 2018. amazon.com/Nourish-Through-Eating-Disorder-Plate/dp/1615194509
Sterling, Wendy et al. "The Use of the Plate-by-Plate Approach for Adolescents Undergoing Family-Based Treatment." Journal of the Academy of Nutrition and Dietetics. In press. https://jandonline.org/article/S2212-2672(18)30433-7/pdf
Lock J, Le Grange D. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. 2nd ed. New York, NY: Guilford Press, 2015.
Lock, James. “Evaluation of Family Treatment Models for Eating Disorders.” Current Opinion in Psychiatry, vol. 24, no. 4, 2011, pp. 274–279. doi:10.1097/yco.0b013e328346f71e.
Lock J, Le Grange D. “Family-based treatment of eating disorders.” Int Journal of Eat Disord. 2005; 37:S64–7).
M. Mountjoy, J. Sundgot-Borgen, L. Burke, et al., “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sports (RED-S).” British Journal of Sports Medicine 48, no. 7 (April 2014): pp. 491–97. doi:10.1136/bjsports-2014-093502.
Wendy Sterling, MS, RD, CSSD & Casey Crosbie, RD, CSSD
Wendy Sterling is a registered dietitian and board-certified specialist in Sports Dietetics. She is the co-author of How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Rebuilding a Healthy Relationship with Food and No Weigh! A Teen’s Guide to Positive Body Image, Food, and Emotional Wisdom. She worked at The Healthy Teen Project as well as the Eating Disorder Center at Cohen Children’s Medical Center of New York. Her research on osteoporosis, menstruation and metabolism has been published in the International Journal of Eating Disorders and the Journal of Adolescent Health. She was most recently published in the Journal of the Academy of Nutrition and Dietetics for her work with the Plate-by-Plate approach in Fall 2018. She is the team nutritionist for the Oakland A’s.
Casey Crosbie is a registered dietitian and a board-certified specialist in Sports Dietetics. She currently serves as program director for the Healthy Teen Project in Los Altos, California, and is co-author of How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Rebuilding a Healthy Relationship with Food. Casey previously served as lead dietitian for the Lucile Packard Children’s Hospital Comprehensive Care Program for Eating Disorders at Stanford. Her research focusing on refeeding syndrome in adolescents with eating disorders was published in Nutrition in Clinical Practice and in the Journal of Adolescent Health. She was most recently published in the Journal of the Academy of Nutrition and Dieteticsfor her work with the Plate-by-Plate approach in Fall 2018.
To subscribe to the SOULFUL Insights health and wellness newsletter click here.