You’re worried. You see or hear something that makes you wonder if your daughter, or your brother, or your friend could have an eating disorder.
You’re not sure. You don’t want to make something out of nothing. But you know that eating disorders can hurt a person’s body and mind. So what should you do? And when?
Doctors say the earlier a person struggling with an eating disorder can get treatment, the more effective that treatment will be.
Here, Sanford Health clinical psychologist Tricia Myers, Ph.D., and family medicine physician Neelima Nyayapati, M.D., offer help for people trying to recognize signs and symptoms of an eating disorder in a loved one. They also have advice for approaching the topic, and they explain how treatment works.
Dr. Myers and Dr. Nyayapati work in the Sanford Eating Disorders & Weight Management Center in Fargo, North Dakota, which provides specialized care to a diverse group of patients with eating disorders. They serve patients from neighboring states as well, with telemedicine available as an option in some cases for continued care.
What is an eating disorder?
“Eating disorders involve a disturbance of body image, where people may not see their body accurately, and they have some very serious medical complications that go along with the restriction or the purging behaviors,” said Dr. Myers, who typically works with children and adolescents.
Dr. Myers describes four types of eating disorders. The two major eating disorders are anorexia nervosa and bulimia nervosa.
- Anorexia nervosa: A person doesn’t eat enough, and their weight drops dangerously low. They have a disturbance of body image, feeling fat, and may deny the seriousness of low weight.
- Bulimia nervosa: A person has binge-eating episodes where they feel unable to control or stop eating and then try to compensate for eating that much by vomiting or using diuretics or laxatives, or by exercising excessively or compulsively, or by fasting afterward.
- Binge-eating disorder: A person has large episodes of eating and may feel shame, guilt or disgust, but they don’t try to compensate for the excessive eating.
- Avoidance and restrictive food intake disorder: A person eats too little, but it’s not because of body image concerns. The reasons may range from anxiety to intolerance of food textures, which can occur at a very young age.
Who might have an eating disorder?
In adolescents, Dr. Myers said anorexia tends to start in the early teen years, while bulimia tends to begin in the late teen years. Those who treat adults tend to see a mixture of eating disorders.
Anxiety, obsessive-compulsive disorder and perfectionism can play a role in the development of anorexia, especially in younger ages. Being involved in activities that focus on body shape or weight or thinness could play a role, too. And societal pressure to look a certain way helps foster eating disorders in later adolescence.
Dr. Myers’ patients can be as young as 10, tending to struggle with restrictive eating. Dr. Nyayapati sees many adolescent and adult patients, with some as young as 10 as well.
Onset of an eating disorder can occur at any age. In some cases, patients may have struggled with an unidentified eating disorder for a few years before receiving help.
What are signs and symptoms of an eating disorder?
Some physical symptoms of eating disorders are specific to starvation and would typically be found in people with anorexia. They also could be found in people with bulimia who have experienced weight loss because of fasting, purging or exercise. Other physical symptoms can occur because of repetitious purging actions, which may differ depending on the method.
General warning signs of eating disorders:
- A preoccupation with weight or food, counting calories or dieting
- Eating habits that become more ritualized, or appear compulsive
- Exercise patterns that appear compulsive or excessive
- Secretive eating
- Larger episodes of eating
- Missing food from the household
- Frequent trips to the bathroom after eating episodes
- Feelings of depression, anxiety or significant isolation or withdrawal
- Increased irritability in teens (in combination with other behaviors)
- Decreased concentration
Common symptoms of starvation:
- Significant weight loss
- Feeling cold all the time, or hypothermia
- Dry skin
- Skin sores
- Hair falling out, or brittle hair
- Brittle nails
- Feeling tired/low energy level
- Frequent headaches
- Neck discomfort
- Sleep disturbances
- Feeling lightheaded
- Low heart rate
- Low blood pressure
- Delayed onset, halted or scant menstruation
- Frequent urination (if the person is filling up on liquids to avoid eating)
- Back pain because of muscle fatigue
- Dental issues (sensitivity to hot or cold, erosion, cavities)
- Swollen cheeks because of enlarged salivary glands
- Palpitations and rhythm problems of the heart because of the loss of electrolytes
- Abdominal bloating
- Feeling nauseated
- Reflux-like symptoms
- Swelling in hands and feet
- Sore throat
- Red dots in the white part of the eye (pressure from vomiting)
- Mouth ulcers
- Skin changes or calluses on the back of the fingers
Think your child may have an eating disorder?
If you start to notice signs or symptoms in your child that concern you, Dr. Myers said openly talking about them right away is key.
“Express those concerns as a parent in a way that is supportive, not focusing on weight or shape but instead on specific behaviors,” she said.
Share two or three examples of what you’re noticing and say you’ve been wondering if it might indicate an eating disorder. Express your concern for your child.
It’s better, Dr. Myers said, “just being upfront, not blaming, not trying to do a simple fix like, ‘You just need to stop doing this,’ but instead coming from a more understanding viewpoint. ‘This must be difficult, and I’m here to talk, and I am so concerned I would like to set up an appointment with a professional to discuss this further.’”
Then, bring up your concerns openly during a visit with your child to the pediatrician.
“Patients may feel more comfortable discussing these concerns with the primary care physician since it is easier for the patient to be able to trust their physician and explain the concerns,” Dr. Nyayapati said.
Then, the health care provider can refer the patient to specialized care, such as the Sanford Eating Disorders and Weight Management Center.
“The main thing I see from families is their concern and their worry and their love for their child,” Dr. Myers said. “Sometimes there are parents who want to have that quick fix, and other times there are parents who feel kind of paralyzed by their fear, and so they have a difficult time setting those limits with their child or having those discussions, following through with bringing their child in for an appointment.”
What is treatment like?
“Earlier intervention and specialized treatment with a team experienced in treating individuals with eating disorders is really important,” Dr. Myers said. The first step is a consultation and evaluation by a specialist to determine whether there is an eating disorder and a discussion about treatment options.
At Dr. Myers’ and Dr. Nyayapati’s clinic, treatment typically includes an initial evaluation with all providers, a weekly therapy appointment with a psychologist, at least four appointments with a dietitian who specializes in treating eating disorders, and rechecks with the medical doctor every two to four weeks, with weekly rechecks possible depending on the condition of the patient starting treatment. Pertinent medical concerns could warrant a recheck sooner as well.
“Initially in treatment, we’re going to focus on the eating behaviors or the exercise behaviors or the purging behaviors, and we’re working to normalize those,” or return to a healthier pattern, Dr. Myers said.
“Then we would address body image concerns or talk about what they’ve learned from their experience and how they can prevent a relapse in the future.”
Family-based intervention works
Families get involved, too, when adolescents are being treated.
“The family-based intervention for anorexia nervosa, in particular, is a highly effective treatment with a lot of evidence to support it through the research: 80 to 85%,” Dr. Myers said.
She describes the three phases of family-based intervention:
- Parents temporarily take control of their child’s eating and behaviors, making sure they eat adequately and don’t exercise excessively.
- The control gradually shifts back to the adolescent, appropriate to his or her age.
- The focus shifts to why the eating disorder occurred, addressing body image concerns or anxiety or depression, for example.
The length of treatment can vary. Treatment for anorexia can last a year. Treatment for bulimia can vary widely in adults, but it lasts a minimum of four months.
“We definitely take an individualized approach to treatment and meet patients where they’re at,” Dr. Myers said.
Hospitalization for eating disorders
Medical complications related to malnutrition, such as acute kidney injury and dehydration, can result in hospitalization. There, the focus is primarily to stabilize the patient, correct the patient’s fluid status and electrolytes, and observe for other potentially serious medical complications.
Another common scenario for hospitalization would be if a patient is not making progress at an outpatient level and continues to have symptoms.Then the goal is to help the patient restore nutrition in a medical setting, where providers can also monitor and treat any medical complications. This is usually a longer-term hospital stay.
“A lot of what I tell my patients is, food is their medicine,” Dr. Nyayapati said. It might not help every long-term medical complication, but generally, “if they eat, then their symptoms of starvation do restore” — they do get better.
After treatment ends
Everyone with an eating disorder is different. “There are some individuals that, after a course of treatment, will never struggle with an eating disorder again,” Dr. Myers said. Others may struggle intermittently, such as during stressful periods.
“And then there’s a certain proportion that will have chronic struggles.” It’s impossible to predict how each patient will turn out, but she said early intervention can help prevent chronic struggles. It also helps limit medical impact.
Dr. Myers encourages families to keep communicating. “I think it’s just important to continue to be supportive and be open to talking if they choose to bring it up and to talk about it,” she said. “If friends or parents notice concerning behaviors in the future, again have those conversations at an early point when they notice them so that they don’t progress more and make it more difficult to get back on track.”
“There’s a lot of self-blame and guilt associated with it,” Dr. Nyayapati said. “It’s important for parents and families to reassure patients that it’s not the kid or adolescent’s fault at all. It’s a medical disorder, and it is treatable.”
“There is a lot of hope,” Dr. Myers added. With specialized treatment, “we can see a lot of change occur.”
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