Category: Types of Eating Disorders

Cyrus is worried about his son Miles, who was recently diagnosed with binge eating disorder. “I honestly don’t understand what is going on, or what we are supposed to be doing at home to help,” says Cyrus. “We’ve got Miles in therapy, but other than that, we’ve received no guidance about what we should be doing. Are we supposed to keep binge foods out of the house? Should we remind him that binge eating is not healthy? Is there a cure for binge eating disorder?” 

These questions make sense, and it’s frustrating that Cyrus isn’t getting more guidance as he faces this challenge. Binge eating disorder is a very common type of eating disorder, but it’s extra tricky to handle it in our society, where binge eating and weight gain are criticized and deeply feared. The good news is that there is a lot that Cyrus can do to help Miles recover. 

What causes binge eating disorder?

All eating disorders are biopsychosocial disorders, which means they are caused by a combination of biological, psychological, and social factors. 

For example, a child may have a genetic predisposition and traits that make it more likely they will develop an eating disorder. Specifically, there are neurobiological traits that make some people more sensitive and responsive to hunger cues, the physical sensations, and emotional experience of eating. Additionally, people who have ADHD or autism are more likely to develop eating disorders than the general population.

Psychologically, a child may have traits including perfectionism, impulsivity, anxiety, and depression, which increase the likelihood of developing an eating disorder. People who have OCD, GAD, PTSD, and other common mental health issues are more likely to develop eating disorders.

Finally, our social environment encourages eating disorders. We live in a culture in which parents, teachers, doctors, and coaches all worry about children getting fat. Meanwhile, peers tease and bully fat kids. This is not only about individuals being fatphobic; it’s the result of weight stigma, which is baked into our culture.

The outcome of weight stigma is not a thinner population, but a population that is so afraid of fat that we encourage food restriction and body shame. Counter-intuitively, both these things predict weight gain and, of course, eating disorders. 

Society doesn’t cause eating disorders by itself, but if biology and psychology load the gun, our society is standing by at the trigger, just waiting to pull it.

What is the cure for binge eating disorder?

Many people assume that the problem with binge eating disorder is binge eating. However, binge eating is the very top of binge eating disorder symptomology. 

Shame triggers binge eating, and binge eating triggers shame. It’s a self-perpetuating loop, which is why it’s usually best to address the other symptoms and causes rather than the binge eating itself. Trying to stop binge eating without addressing its causes is ineffective and even harmful.

Eating disorders have both physical and emotional components. Therefore, your child needs both psychotherapy and nutritional therapy. 

A therapist can support your child in understanding their unique psychology and develop coping skills. They should also address any underlying mental health conditions, especially ADHD, autism, anxiety, OCD, and PTSD. Unless these conditions are treated, it will be very hard to recover from binge eating disorder. 

In addition to a therapist, a certified eating disorder dietitian (CEDRD) can support your child in learning how to eat in a way that will minimize binge eating episodes. The biggest physical risk factor for a binge eating episode is skipping meals and restricting food. 

Many people who have binge eating disorder eat too little and/or go too long between meals. This exacerbates the problem and increases the likelihood of binge eating. The most important physical treatment for binge eating disorder is feeding the body regular meals and snacks and eating enough food throughout the day. 

How can parents help with binge eating disorder? 

Parents alone can’t cure binge eating disorder; you’ll need professionals on board to help. But parents play an essential role in recovery. Parents can help kids recover from binge eating disorder by following these five steps:

1. Feeding structure

The biggest risk factor for a binge eating episode is not eating enough food. Skipping meals and restricting food are common, particularly for kids in larger bodies who are afraid of weight gain. However, restriction sets them up for larger and more frequent binge eating episodes. Parents should take an active role in recovery by feeding kids three meals and 2-3 snacks per day. Your child should not go more than 2-4 waking hours without eating. 

Additionally, eating should be an important aspect of family life, and family meals should happen as often as possible. Binge eating is often done in secret, so it’s important to model the social nature of eating together and sharing meals. Eating is an important social and emotional activity, so pleasant family meals should be a priority.

2. All foods fit

Many parents are worried about kids’ health and weight and restrict kids’ sugar and “junk food” intake. This is popular advice, however, the evidence shows that restricting food to only “healthy” options at home increases kids’ likelihood of binge eating. Work with a non-diet registered dietitian to build your comfort with a wide variety of food. Yes, you should serve veggies and fruit, but you should also serve snack foods and desserts. A healthy diet incorporates all sorts of food. Restriction is a major trigger for binge eating episodes, so avoiding it is key. 

3. Weight is not the same as health

It’s natural in our culture to be afraid of weight gain. Many parents believe they must keep an eye on their kids’ weight and worry about weight gain. But weight is not the same as health, and worrying about weight is associated with weight gain and eating disorders. Instead of worrying about your child’s weight, learn about a non-diet approach to health, which is shown to improve health behaviors and health outcomes. This approach focuses on healthy behaviors like eating, moving, sleeping, stress management, belonging, and human connection. Unlike weight control, these behaviors improve health with zero side effects.

4. Emotional regulation

Once you have your child in therapy to address underlying mental health conditions, you need to build their emotional regulation skills at home. Whether we mean to or not, parents teach kids how to regulate their emotions from the time they are born. It’s embedded in our DNA to learn emotional regulation from parents. Most people with eating disorders lack emotion regulation skills. Luckily, due to your role as their parent, you are by far the best person to build your child’s emotional regulation. Literally nobody else can do it as quickly and effectively as you. Get intentional about teaching and modeling emotional regulation skills and you’ll make a big difference, fast. 

5. Avoid shame

Above all, you want to avoid bringing shame to the process of eating and weight. Things like telling your child to eat less, pointing out that binge eating is leading to weight gain, and locking up food can be harmful. While doing these things might make intuitive sense to you, they are not an effective cure for binge eating disorder and can make things worse. 

Food and body shame lie at the heart of eating disorders and drive disordered behavior, so you don’t want to add to it. Work on your own issues with food and weight, and talk about your fears and worries with another adult, not your child. You should never criticize your child’s eating and weight.

If you are tempted to criticize your child’s eating or weight, shift your energy to the other four steps I’ve described. They are much more likely to help your child recover.

For privacy, names and identifying details have been changed in this article.

See Our Parent’s Guide To The Different Types Of Eating Disorders

Avoidant restrictive food intake disorder (ARFID) is an eating disorder that features highly selective eating patterns. The major risk for kids with ARFID is not getting enough nutrients and becoming weight suppressed, which can interfere with growth and overall health. Getting expert advice when a child has ARFID can help parents understand what their child is going through and support recovery from this eating disorder.

ARFID is strongly associated with kids who are highly sensitive. This sensitivity often includes being sensitive to food flavor (taste and smell) or texture. But eating is a 5-senses experience, so a child may also be sensitive to the way food looks and even the way it sounds and the sounds of others eating. Beyond the 5 senses, kids who are highly sensitive may also be very tuned into the emotional experience of eating and how their parents and others around them feel when eating. 

ARFID is typically seen beginning at a young age. It is strongly associated with people who have ADHD and autism. Over time, ARFID can cascade into another eating disorder such as anorexia, bulimia, or binge eating disorder. It is typically characterized by high levels of anxiety about food and eating. Behaviorally, someone with ARFID will refuse to eat foods that make them feel anxious. Without intervention, the list of “safe foods” can dwindle to just a handful of options. 

Many parents feel overwhelmed when their child has ARFID, but there are very good treatments available, and there is a lot that parents can do to help. 

I interviewed two dietitians who specialize in treating ARFID, Rebecca H. Thomas RD, LDN, and Stefanie Ginsburg, RD, CEDS-S. They are members of the ARFID Collaborative, a group of clinicians dedicated to increasing ARFID awareness, education opportunities, training options, and treatment access. 

Here is their expert advice for parents who want to support their child’s recovery from ARFID: 

How do you explain ARFID to parents?

When we paint the picture for parents of what it is like to have ARFID, we ask them to think of some of their fears or things they dread doing. This may be flying, waiting at the DMV, a fear of heights, or maybe it’s creepy crawly things, like snakes or spiders. 

Then we ask them to imagine having to engage with that fear or disliked thing, at least 3 times a day! All the while, enduring pressure and shame from an authority figure (maybe a boss or professor) for not being able to manage this easily. 

Think about how doing this on a regular basis might affect your motivation to participate in daily activities that involve these fears. This can be what it is like for children who have ARFID.

What is the hardest part of treating ARFID from your perspective? 

There are so many obstacles within the treatment for ARFID. We would have to say the hardest part is helping parents and clients stay motivated to continue care. Progress with food acceptance and increasing dietary variety can take a long time and requires consistency and endurance. 

Oftentimes parents are overwhelmed with their child’s struggle and with the amount of work it takes them to carry over the treatments from sessions into daily life. It can feel disheartening when you’ve spent months working on one food, and they are still only taking one bite. We try our best to let them know that things DO get better and easier and part of our role is to cheerlead even the smallest of wins and successes.

What treatment do you recommend for ARFID? 

We recommend a hybrid-individualized approach that incorporates CBT-AR, Satter’s Division of Responsibility of Feeding, FBT-AR, food chaining, and food exposure therapy. 

We have seen the most success with children when families are re-feeding from home and are being consistent providing the food we are working on at home between sessions. Parental commitment is an essential part of treatment.

How can parents be helpful in treating ARFID? 

Presence and consistency. As we mentioned before, treatment is a 50/50 effort. Providers can give you guidance, coaching and resources, but ultimately, it is the caregivers showing up everyday to say: “I know this is hard for you, but we can do hard things. Let’s figure out how to get through this meal/food together” that is going to be the most helpful.  

It can also be helpful to remind them that we do not have to “like” a food in order to eat it. We think there is a fair amount of unnecessary pressure to like all the food you eat. A lot of our normalized eating consists of eating and drinking items that can be tolerated.

How do you measure recovery/What does recovery look like?

Recovery from ARFID involves the following key elements:

1. Ability to maintain nutrition status
2. Preventing unwarranted weight fluctuations
3. Being free of nutritional deficiencies
4. Having enough energy to do daily activities
5. Staying on a regular growth trajectory
6. Managing daily eating with minimal distress
7. Dietary variety

The term recovery when it comes to ARFID is typically a life journey. It involves both acclimating to and building resilience for food-related anxieties or indifferences. One degree of change helps pave the way for ongoing progress in recovery.

What resources/books do you recommend to parents who have kids with ARFID? 

• How to Nourish Your Child Through an Eating Disorder by Casey Crosbie RD, CSSD  Wendy Sterling MS, RD, CSSD.  
• Helping Your Child with Extremely Picky Eating by Katja Rowell, MD  Jenny McGlothlin MS, SLP  
• Avoidant Restrictive Food Intake Disorder: A Guide for Parents and Carers by Rachel Bryant-Waugh  
• Raising Adventurous Eaters: Practical Ways to Overcome Picky Eating and Food Sensory Sensitivities by Lara Dato MS OTR/L, SC-FES  
• Food Refusal and Avoidant Eating in Children, Including Those with Autism Spectrum Conditions. A Practical Guide for Parents and Professionals Book by Elizabeth Shea and Gillian Harris.  
• The Picky Eater’s Recovery Book by Dr. Jennifer Thomas (For those that have teens or young adults with ARFID)

Regardless of the type of eating disorder your child has, including ARFID, expert advice can help you support your child’s recovery.

See Our Parent’s Guide To The Different Types Of Eating Disorders

There are four red flags that a child has binge eating disorder, and some of them may surprise you. Binge eating disorder is the newest eating disorder in the DSM-5, the diagnostic manual used in the United States. Most people think of binge eating disorder as the opposite end of the spectrum from anorexia. They assume that people who have binge eating disorder love eating “too much,” lack self-control and have high body weight. 

However, these assumptions are both incorrect and dangerous. They can interfere with our ability to recognize and treat binge eating disorder. Here are the red flags parents should know about and how to respond to them when they show up in a child.

💡Remember: Binge eating disorder is a mental disorder, and therefore we want to pay attention to the state of mind that drives the behavior and the mental impact of their behavior. 

1. Binge eating episodes

Binge eating disorder is defined by binge eating episodes. These are specific episodes during which the person consumes more than is typical, faster than usual, and gets uncomfortably full. In contrast, a person can consistently and mindfully consume large quantities of food and feel satisfied and pleasantly full afterwards. This person is not binge eating. 

A binge eating episode is typically defined as consuming an unusually large amount of food in a short period of time. This will vary from person to person. One person’s “normal portion” can be very different from another person’s. But in general we’re looking for a quantity of food that exceeds that individual person’s “normal” serving size. 

Additionally, a binge eating episode involves consuming food more rapidly than normal. You will see your child eating more quickly, and maybe more messily than is typical. A binge eating episode may involve eating food when not hungry, when the food isn’t particularly palatable, and/or to the point of being uncomfortably full. This is due to the mindless or numb state which often accompanies binge eating episodes. 

💡How to respond to binge eating episodes: Never shame or embarrass your child for binge eating episodes. They result in significant physical and mental pain and suffering. Be kind, gentle, and accepting of your child during and after a binge eating episode. Soothe their body and mind with compassion and empathy. If your child has at least one binge eating episode per week for three months in a row, they qualify for a binge eating diagnosis and should be evaluated and treated as soon as possible.

2. Sneaking, hiding, and lying about food

Binge eating disorder involves tremendous shame and embarrassment. Therefore, a key symptom of binge eating disorder is signs of shame like sneaking, hiding, and lying about food and eating. It’s very important to keep in mind that shaming or embarrassing your child for doing these things will make binge eating disorder worse, not better. Treating shame with shame only makes shame worse and, therefore, the symptoms of shame more severe. 

💡How to respond to sneaking, hiding, and lying about food: If your child is frequently eating food alone to avoid embarrassment, that may be a symptom of binge eating disorder. Many parents believe the treatment for sneaking and lying behavior is to expose the behavior and talk about it as something that needs to stop. But you want to be very careful about how you approach this to avoid triggering more shame and pain. Get your child treatment and learn how to talk about food and eat together as a family without triggering the urge to sneak and hide while eating. 

3. Shame and despair

Remember that eating disorders are mental disorders. So while there are behavioral patterns you can observe, shame and despair are most likely driving the behaviors. In binge eating episodes, your child may be coping with unconscious emotions by eating. People with binge eating disorder experience a loss of control over their eating. They feel compelled and driven to eat in ways that do not make them feel good. 

Criticizing binge eating behaviors is deeply damaging and will make your child’s disorder worse. A child who has a binge eating episode will likely feel disgusted, depressed, and guilty after eating. They are experiencing extreme distress around the most natural and necessary human behavior: eating. 

💡How to respond to binge eating shame and despair: Never forget that your child’s binge eating episodes are physically and mentally painful. Do not prohibit your child from eating, limit their access to food, or restrict their eating. Instead, support them in emotional literacy and emotional regulation. Validate their feelings to build their self-worth and make them more resilient against shame. You doing this is possibly the most important ingredient for your child’s recovery from binge eating disorder.

4. Restricting food

Something that surprises many people is that a key sign of binge eating disorder is food restriction. Most people are so focused on the binge eating episodes that they don’t realize there is often a period of restriction preceding binge eating episodes. Most types of eating disorders have some form of restriction.

This often means skipping breakfast, or not eating all day. Physiologically, such restriction will result in a significant drive for food at the end of the day. The body will be literally starving. This drives the mind to become obsessed with food and feel compelled to eat a large quantity of food. Such cycles are very often present in people who have binge eating disorder but are rarely discussed. 

💡How to respond to restricting food: Make sure that you are doing the work to feed your child regularly throughout the day. Parents must prioritize feeding their kids’ bodies at regular intervals. During eating disorder recovery, your child should eat three full meals and 2-3 snacks every day on a regular schedule. This means eating every 2-4 hours. Just like with anorexia, parents must take responsibility to ensure their child with binge eating disorder eats regularly and adequately. When this happens, while the psychological urge to binge may continue, it will not be amplified by physiological urges. 

See Our Parent’s Guide To The Different Types Of Eating Disorders

Dana reached out because her 11-year old child Riley recently gained weight and she’s worried that it’s due to binge eating disorder. “The last thing I want to do is shame her for her weight,” says Dana. “But how do I address the fact that I think she might be binge eating without bringing up the fact that she has actually gotten bigger?”

This is a common challenge facing sensitive, worried parents. They don’t want to make the problem worse by approaching it the wrong way. And parents are wise to be careful when a child has gained weight, particularly around puberty. 

A female child in the 50th percentile for weight will gain almost 50 lbs from age 10 to 16. This weight gain may come on gradually or suddenly. A male in the 50th percentile for weight will gain 63 lbs in the same period.

All this means that significant weight gain is to be expected. But our culture is deeply fatphobic and believes that weight gain predicts poor health rather than indicates healthy  growth. In this body-toxic culture, something that is natural and normal like pubertal weight gain is pathologized and questioned.

However, binge eating disorder is the most common eating disorder and can have a lasting impact on your child’s lifetime health. Weight gain alone is not an indication of an eating disorder, but if your child has gained weight combined with other symptoms, it may indicate binge eating disorder. So how can parents discern when weight gain is normal and when it indicates disordered eating?

What is binge eating disorder?

Binge eating disorder is a serious type of eating disorder that was only recently formally recognized by the DSM-5, which is how mental disorders are diagnosed in the United States. There are a lot of misconceptions about binge eating disorder, including: 

Myth: binge eating disorder always causes weight gain

Truth: not everyone who has binge eating disorder will gain weight, and some will lose weight

---

Myth: people who are in larger bodies always have binge eating disorder

Truth: a small percentage of people who are in larger bodies have binge eating disorder

---

Myth: binge eating disorder can be overcome with willpower. Just stop eating so much!

Truth: like all eating disorders, BED is a complex mental disorder. Willpower is not the path to recovery; treatment is.

---

Myth: people who binge eat love food too much

Truth: many people with BED barely notice what or how much they are eating. They also feel tremendous physical discomfort and shame. This is not about “loving food.”

---

Myth: Binge eating disorder isn’t as serious as anorexia or bulimia

Truth: Binge eating disorder is just as dangerous as other eating disorders and can cause lifelong mental and physical health consequences.

Does Riley have binge eating disorder?

Dana reached out to me because she’s noticed that Riley has gained weight and she’s worried about binge eating disorder. But weight gain alone does not indicate that your child has an eating disorder. So the question is whether there are other symptoms of an eating disorder.

When I talked to Dana, that’s what I focused on. 

“I guess the weight is my biggest concern because I’m worried about her health,” says Dana. “But it’s also how much Riley eats. She consumes way more food than her older sister. She kind of goes into a zone when she’s eating, and it’s as if she’s barely there. Then afterwards she has to lie on the floor because her stomach hurts so much. I’ve also noticed that she sneaks food into her bedroom. Then she takes the empty packages all the way out to the big trash can in our driveway rather than putting them in her bedroom trash can or our kitchen trash can.”

Now we’re starting to see the behavioral patterns of binge eating disorder. Looking through the lens of a mental disorder vs. a weight-based disorder, we start to see that Riley may be numbing out while eating, feeling compelled to eat, and feeling shame about eating, as evidenced by her habit of sneaking food and trying to hide the evidence.  

What are the behaviors of binge eating disorder?

Every person who has an eating disorder has slightly different behavioral and emotional patterns, but generally we’ll see at least some of the following behaviors:

• Eating large quantities of food without appearing to enjoy the food or slow down as physical fullness increases. This often results in stomach pain and discomfort after eating.
• Sneaking and hiding food. This is often a symptom of feeling compelled to eat and ashamed of the compulsion. 
• Restricting food for most of the day. Many times a person with BED will try to avoid binge eating by restricting food. This sets them up for a combination of physiological and emotional binge eating at the end of the day. 
• Decreased/changed levels of social interaction and signs of anxiety and/or depression. This may be partly based on their shame about eating, their desire to avoid food, and fear of being judged when eating.

While weight gain is often a parents’ biggest concern, binge eating disorder is a mental disorder. Therefore, we want to look at behavioral symptoms and emotional distress rather than weight or other physical symptoms. That said, weight gain or loss can be a physical symptom of binge eating disorder. 

What to do if you suspect your child has binge eating disorder

Here are six things to do if your child has gained weight and you suspect binge eating disorder:

1. Check your weight bias

We live in a body-toxic culture filled with weight stigma. Weight stigma is the norm in our culture, but it is also unhealthy and dangerous. So evaluate whether your concerns are primarily about weight and the potential weight consequences of your child’s food behaviors. This can take some time. Don’t assume your child has an eating disorder until you are fairly sure you have detangled your fears about weight from your child’s mental health. Get some help if you need it. 

2. Educate yourself

Learn about binge eating disorder and become familiar with the psychological profile and emotional symptoms. For example, your child may be highly sensitive and have a history of worry, nervousness, and anxiety. They may have a history of picky eating or food aversions. Look for persistent feelings of shame and unworthiness. You also want to think carefully about any restrictive eating patterns you’ve seen like dieting and/or cutting out foods like meat, dairy, carbs, and sugar.

3. Take notes

Write down the behavioral symptoms you see. Take note of your child’s food and eating behaviors as well as other signs of mental health or disordered thinking and behavior. Take at least one week to document the daily behavioral symptoms you’re observing. This will help you when you reach out to a provider to help your child.

4. Learn about body image

Negative body image is involved in most eating disorders. Evaluate how your child feels about their body. Most children in our body-toxic culture feel bad about their bodies at least some of the time, but if your child is naturally in a larger body or if your family is particularly body-conscious, those are risk factors. Has anyone in your family shamed your child for their weight in the past? Are there people in your family who have been the food police and monitored or restricted your child’s eating due to weight or health concerns? Do you or your partner diet or control your weight in any way? All of these contribute to negative body image in children.

5. Get help for your child

If you believe your child has binge eating disorder, then find a non-diet eating disorder therapist or dietitian. A general provider is unlikely to have the tact and training necessary to provide a diagnosis of binge eating disorder. And a general therapist or RD could cause more harm than good. Doctors are also generally under-qualified and under-prepared to handle this well. Now that binge eating disorder is in the DSM-5, treatment is typically covered by insurance. Parents often need to fight for adequate care since this is a new diagnosis, but a good provider can help you navigate the system.

6. Get help for yourself

Weight and eating are tricky issues in our culture, and how you feel about your child’s eating and weight will make a huge impact on their ability to recover. If you only treat your child and don’t make changes in your own beliefs and behaviors, recovery will be partial at best. Find a coach, therapist, or dietitian who can help you navigate your child’s eating disorder recovery.

All eating disorders are tough to treat. This is because of the combination of biological, psychological and social factors that cause them. But when parents get educated and involved in treatment, a child is more likely to recover. 

Dana is on board. “I know that sending Riley off to get treated without addressing our own issues and making changes at home won’t be as effective,” she says. “I want her to be happy and healthy, and that’s going to be a team effort.”

I’m so glad to hear her say that, and I know she’s on her way to making a positive impact on Riley’s recovery.

See Our Parent’s Guide To The Different Types Of Eating Disorders

Arianna had an eating disorder for a few years before getting a diagnosis. “It’s all so obvious in hindsight,” says her mom, Renee. “She had all the classic symptoms of an eating disorder except she didn’t look like she had an eating disorder. I just didn’t know what to look for.”

Renee’s not the first parent to miss an eating disorder due to the biases and assumptions that drive our cultural understanding of eating disorders. Most people assume that an eating disorder has a “look.” But in fact, the majority of eating disorder diagnoses are not for anorexia. They’re for Other Specified Feeding and Eating Disorders (OSFED). This guide will help you understand OSFED, a serious and often-missed eating disorder.

OSFED is the most common eating disorder. The symptoms cause significant distress but do not fit into the strict criteria for anorexia, bulimia, Avoidant and Restrictive Food Intake Disorder (ARFID), or binge eating disorder.

The advantage of a catchall OSFED category is that people can get a diagnosis for an eating disorder even if they don’t meet the narrow criteria for other disorders. The drawback is that even though it’s very common, few people outside of the eating disorder community know what it is. It also means that people who have very different symptoms get grouped together in a category despite needing very different care.

Exploring weight bias in eating disorder treatment

Among other things, OSFED is used to categorize people who meet all the criteria for anorexia except low body weight. Anorexia is the only mental disorder that carries BMI criteria. To get diagnosed with anorexia you must have a “significantly low BMI.” But BMI is a population tool that was never meant to be used to determine individual health. 

BMI (body mass index), which is based on the height and weight of a person, is an inaccurate measure of body fat content and does not take into account muscle mass, bone density, overall body composition, and racial and sex differences.

Medical News Today

The problem with BMI as a diagnostic for an eating disorder is that if someone was born and has lived their life in the 100th percentile for weight and drops to the 50th percentile, they are very ill, but they don’t technically have a “significantly low BMI.” 

Assumptions about weight and eating disorders can slow down diagnosis. That’s what happened to Renee. “I saw all the signs of an eating disorder,” she says. “She was restricting her food, and definitely over-exercising. I could tell she had a negative body image, though she didn’t talk about it with me very often. But when I tried to talk to her pediatrician about it, the doctor was so pleased about Arianna’s weight loss and fitness routine that he brushed me off.”

Renee is not alone. Many parents who talk to doctors find themselves frustrated and feeling dismissed because their child doesn’t fit the criteria for anorexia or bulimia. Nonetheless, they know that something is wrong. They suspect an eating disorder, but the fact that few people know about OSFED gets in the way of diagnosis.

OSFED: a misunderstood eating disorder

OSFED is poorly understood and recognized in our culture, yet it constitutes the majority of eating disorder diagnoses. When it was called by its previous name, EDNOS, more than half of all patients seen at eating disorder treatment centers were in this catchall category. 

Since OSFED is a broad category, it is often misinterpreted as being less serious. But studies have shown that people with OSFED experience eating pathology and medical consequences that are just as severe, often even more severe than those who are diagnosed with anorexia or bulimia. 

In fact, one study found that 75% of people who were diagnosed with EDNOS (now called OSFED) had comorbid psychiatric disorders and 25% had suicidal thoughts. Professionals say that people who are diagnosed with OSFED need the same level of treatment and support as those with anorexia or bulimia. And untreated OSFED often leads to a future diagnosis of anorexia, bulimia nervosa, or binge eating disorder. 

A lack of understanding

Renee kept pushing for answers, and Arianna was diagnosed with OSFED about a year ago. Aside from the delay in treatment, Renee is frustrated by friends and family who don’t understand. “It’s really invalidating when my friends assume that because she doesn’t have anorexia or bulimia it’s somehow not serious,” she says. “And if I feel invalidated, I can only imagine how she feels!” 

Most people assume that when someone has an eating disorder it must be anorexia. But less than 6% of people with eating disorders are medically diagnosed as “underweight.” If parents and loved ones only think of eating disorders as having the look of emaciation, we risk under-diagnosing and under-treating the majority of eating disorders.

Weight is a very tricky element of eating disorder diagnosis and treatment. Parents can’t assume that a child’s weight alone is a sign of health or illness without careful evaluation of emotional and behavioral symptoms that will more reliably indicate an eating disorder. That’s why I created this guide to OSFED, a poorly-understood eating disorder.

One key is to recognize the behavioral and emotional signs that typify most eating disorders.

Behavioral symptoms of eating disorders

Here are the behavioral symptoms that commonly cross across all eating disorders: 

• Different eating behavior, particularly skipping meals, eating less in public, sneaking food, lying about food, etc.
• More emotional outbursts like yelling or crying, or emotional withdrawal
• Marked changes in social behavior like being more or less socially active, getting a dramatically different friend group, etc.
• Body checking and monitoring with a scale, mirror, reflective surfaces, etc.
• Wearing tighter or looser clothing and/or changing outfits frequently because nothing seems right
• Talking about their body and other people’s bodies, what they’re eating, what they weigh, etc.
• Sudden interest in “health” foods, nutrients, carbs, sugar, and fat
• Increased exercise and a lack of flexibility about exercising (e.g. I have to exercise to feel OK)
• More interpersonal conflicts and social isolation

Emotional symptoms of eating disorders

Here are the emotional symptoms of most eating disorders:

• A tendency towards perfectionism and/or binary (black and white) thinking patterns
• History of trauma
• Anxiety and/or depression
• Lack of emotional regulation skills to manage feelings of stress and anxiety
• A sense of being different or “other” 
• People-pleasing
• Low self-worth
• Strong desire to be “good” as defined by society
• Defensiveness, particularly when confronted about unusual eating behaviors
• Irritability and moodiness

Even if your child never meets the diagnostic criteria for an eating disorder, these behavioral and emotional signs are enough to warrant therapy. This can help prevent a future eating disorder.

What to do if you suspect OSFED

This guide will help you spot whether your child has an eating disorder and understand OSFED in particular. If you suspect your child has an eating disorder, please follow these steps: 

1. Take a deep breath, and remind yourself that this is hard, but you can handle it. Your emotional reaction is understandable, but you’re going to need a lot of self-compassion to get through this.
2. Contact your child’s physician and have them physically evaluated to check for any physical symptoms of an eating disorder.
3. Schedule an appointment with a therapist and/or dietitian who specializes in eating disorders. These are people who are trained specifically to diagnose and treat eating disorders. Particularly with OSFED, you want an eating disorder specialist, not a general therapist or dietitian.
4. Educate yourself by learning as much as you can about eating disorders in general and your child’s specific symptoms.
5. Find out how you can change your own home environment to support your child’s recovery. Eating disorders are highly responsive to social environments, so you will need to make changes to foster change.

Catching up with Renee

Renee says that Arianna is doing well with treatment. “I wish we had started earlier, but I’m also glad I pushed so hard for the diagnosis,” she says. “She’s actually been doing really great, and our whole family has adjusted to support her mental health. It’s made a difference for all of us. We’re all feeling better these days!”

I know that having a child with any type of eating disorder is hard, and I hope this guide to OSFED is helpful.

For privacy, names and identifying details have been changed in this article.

See Our Parent’s Guide To The Different Types Of Eating Disorders

Eating disorders are so challenging, and one of the reasons is that what causes eating disorders is complicated. Eating disorders are complex and multi-layered. The people who develop eating disorders are worthy of so much compassion and love. I hope this article brings some color to the conversation and helps you understand eating disorders more clearly.

I’m sharing all my knowledge of decades living with an eating disorder and several years in full recovery. I’ve built on my own experience with many years spent researching and studying eating disorders. And I’ve also interviewed hundreds of professionals who treat eating disorders, people who have eating disorders, and parents who have kids with eating disorders.

From my perspective, the information currently available about eating disorders is clinical, dispassionate, and biased. These rigid clinical diagnoses and behavioral descriptions of eating disorders keep us locked in place. We miss the larger truth of why eating disorders occur and what comprehensive treatment looks like.

What follows is a wholehearted description of how I see eating disorders right now. This is personal but also factual. I’m not going to give you a boring, dispassionate account of the technicalities of eating disorders. Rather, this is an attempt to share the human reasons we suffer. And, hopefully, how we can find our way to recovery.

Remember that each eating disorder is unique. Therefore, this article is just one lens through which to view eating disorders.

What causes eating disorders?

A combination of biological, psychological, and social factors contribute to eating disorder development. 

Biological:

• Genes appear to play a role in eating disorder development. There is not a single gene recognized as the cause of eating disorders. But there are numerous genes that researchers have identified as common among people who develop mental disorders. This may explain why eating disorders typically show up alongside other disorders like anxiety, depression, substance abuse, etc.

• Epigenetics is a sort of code that triggers genetic activity. A person may have the genes that underlie mental disorders. But researchers agree that genes alone don’t cause mental disorders. Epigenetic triggers come from environmental conditions beginning in utero. They can even pass through generations in a family. It appears that epigenetics can be shaped by trauma, abuse, and neglect (physical and emotional).

• Neuroception is a body-based sensation of being either safe or unsafe. Developed by Dr. Stephen Porges, neuroception means that neural circuits in the body distinguish safety or threat and cue the body to respond physiologically, emotionally, and cognitively. When neuroception senses emotional and physical threats, the body responds with a state of fight, flight, freeze, or shutdown. This impacts every aspect of the physical and emotional experience of being alive. A person who has an eating disorder is often living in a heightened state of threat, sensing danger in their body and mind and seeking comfort and safety in their eating disorder behaviors.

Psychological:

• Anxiety is a common partner to eating disorders. Since it can be hard to spot, it may be helpful to know what anxiety looks like. In its more active form it looks like perfectionism, people-pleasing, and codependency. In its less active form it may look like procrastination, avoidance, and withdrawal. Other signs include chronic shame, stress, and worry.

• Emotional regulation skills are likely protective against eating disorders. Emotional regulation is something children learn from parents beginning in infancy and extending through early adulthood. When adequately developed over time, a person becomes able to self-regulate. Sometimes we miss emotional developmental milestones. When this happens, a person will have trouble self-soothing and responding appropriately to everyday stress and disruption.

• A person who has an eating disorder may believe that their identity – who they are – is based primarily on what they look like and what they do. This belief can lead a person to try and “perform goodness.” When this happens, a false self takes over and the true self is hidden in shame and unworthiness. This can happen when a family and/or society teaches a person that they need to change who they are and how they behave to be loved. Healing takes place when the true self is allowed to emerge and be loved as-is.

• Mental disorders often appear in clusters, and eating disorders are part of a larger psychological ecosystem. Disorders that commonly show up with eating disorders are autism, attention deficit hyperactivity disorder, anxiety, depression, suicidality, self-harm, substance abuse, and obsessive compulsive disorder. These disorders should be addressed holistically. Otherwise, an eating disorder may fail to recede, morph into something else, or return after treatment.

Social: 

• Families are a child’s first social group. And family norms and structure shape how a child feels about themselves and the world. Families don’t cause eating disorders. However, family beliefs and behaviors about emotions and bodies can contribute to an eating disorder. For example, many parents are not aware of the role of emotional co-regulation. Therefore their kids may miss emotional developmental milestones. Additionally, many families accidentally enforce and encourage disordered eating. Therefore they may pass along harmful messages about food and bodies based on their own cultural training.

• There is a strong connection between diet culture and weight stigma and eating disorders. These two conditions lay the groundwork for the thoughts and behaviors that comprise an eating disorder. Diet culture is founded in the belief that bodies can and should be weight-controlled using food restriction and exercise. Weight stigma is discriminatory acts and beliefs against people who live in larger bodies. Diet culture and weight stigma are pervasive in our culture. And they are likely the driver behind increasing rates of eating issues in the United States. Since the BMI levels were arbitrarily lowered in 1998, the weight loss industry has grown dramatically. In 1985 the U.S. weight loss industry was valued at $10 billion in annual revenue, but today it is worth at least $72 billion.

As a culture we assume weight loss is a personal goal, but it is in fact a money-making industry.

• Cultural group oppression:
  • There is evidence that people who are not heterosexual and/or cis-gender are at higher risk of eating disorders. LGBTQ+ people are chronically oppressed in our culture. And self-repression is often required to maintain physical and emotional safety in a hostile culture.
  • While they can impact anyone, females are at higher risk than males. The most likely reason for this is the cultural oppression of females in a patriarchal, male-dominated culture. The chronic objectification of the female body leads women to self-objectify. Then they naturally fall into unhealthy pursuit of the “thin ideal” or “wellness culture.”
  • People of color are much less likely to receive a diagnosis for an eating disorder. But they are at least as likely (if not more likely) to have symptoms. The trauma of living as a person of color in a white-dominant culture likely contributes to eating disorders.

Why do people get them?

There are so many factors that contribute to eating disorders. One way to view them is as coping mechanisms. I believe they develop in response to unmanaged stress and emotional dysregulation. In our culture, stress is chronic, and many people are raised without adequate emotional regulation development. Thus, coping behaviors become essential to function within our high-pressure society. Eating disorders join shopping, gambling, gaming, sex, using drugs and alcohol, and other addictions, compulsions, and obsessions as a way to cope with life. 

An eating disorder is just another way to numb a person from the pain of being human in our society. Dieting* is constantly prescribed and weight loss is celebrated. Thus, an eating disorder often begins with a well-intentioned plan to feel better and meet societal goals. There are many false and misleading health claims associated with diet plans and weight loss. And these actively promote eating disorder beliefs and behaviors. 

While not everyone who diets will develop an eating disorder, almost all eating disorders** begin with a diet. 

*defined as any effort to lose/control weight using food and/or exercise 

**with the exception of ARFID 

What are the most common types of eating disorders?

According to research published by Hay et. al. in 2017, the rates of eating disorders are as follows:

47% OSFED. The most common eating disorder is a catch-all category called other specified feeding or eating disorder (OSFED). This category includes a mix of eating disorder behaviors.

22% BED. The second most common eating disorder is binge eating disorder. This often involves a restrict-binge cycle in which a person restricts food and then binge eats. 

19% Bulimia. This often involves a restrict-binge-purge cycle. A person restricts consuming calories for an extended period of time. Next, they eat and then seek to purge the calories consumed with vomiting, laxative use, and/or over-exercise.

8% Anorexia. This is characterized primarily by restriction and being medically underweight. It is the only mental disorder that has a BMI requirement for diagnosis.

5% ARFID. The only eating disorder that is not technically associated with a desire to lose weight. ARFID typically involves restricting food and appears to be due to sensory and emotional drivers.

While these categories may be helpful, it’s important to remember that all eating disorders are mental disorders. This means that regardless of the specific behaviors, effective treatment must get beneath the behaviors to address the underlying thoughts, beliefs, and emotional dysregulation that drives them.

A path forward

This description of eating disorders hopefully adds some flavor and nuance to what you’ve seen elsewhere. But of course each eating disorder is unique. And I can’t possibly capture the vast nature of these complex mental disorders in a single article. I hope that if you have an eating disorder, you get help and find your path to healing.

And if you love someone who has an eating disorder, please remember that there is a lot you can do to help recovery. Eating disorders are so much more than a personal problem, which means loved ones can make a significant impact.

See Our Parent’s Guide To The Different Types Of Eating Disorders

When you have a child with anorexia, it may be necessary to teach family members about the eating disorder and explain what to say and what not to say, and a letter can work well for this. This is especially true if your child’s eating disorder is visible. While there are many eating disorders that are invisible, low-weight anorexia can be surprising and even distressing for loved ones to see. This can lead to unhelpful and even harmful comments.

One problem with eating disorders is that people think they understand them. After all, eating disorders appear simple: a person doesn’t want to eat because they want to be thin. But this definition misses the vast experience of having anorexia, its physical consequences, and the depth of its mental distortions. 

Anorexia, like all eating disorders, is a health condition, not a choice. It’s not something that even the most well-meaning and loving family member can talk your child out of. This is not a situation in which a TV-style intervention will likely be helpful.

In fact, often well-meaning family members accidentally make things worse, not better. Of course, all they want is for your child to feel better, but they are operating out of instinct, not knowledge. And unfortunately, instinct doesn’t typically serve us well when we’re dealing with an eating disorder.

What to tell family members about anorexia

If your child is visibly ill with anorexia, then it may be helpful to provide family members with some guidance about the illness, what to say, and what not to say. However, this should be done carefully and thoughtfully. Anorexia is a personal health condition, and you should respect your child’s right to privacy as much as possible.

I recommend you talk to your child about whether and how to talk about their condition with family members. You may want to bring in their therapist to help you address this. When an eating disorder is visible, it can be very helpful to educate family members so they don’t say the wrong thing. But we must be very aware of privacy when doing it.

There are no hard and fast rules about whether and how to do this, but it’s important to think carefully and consciously about how to proceed.

Following is an email/letter you could provide to family members if your child has agreed to this language. Of course, there are hundreds of ways to write this letter – this is just one option.

Family letter: about anorexia

Dear Family,

It’s been another crazy year, and we’re looking forward to seeing you at Marcy’s wedding this summer! Before we get together I wanted to share some information with you about Ellen’s health. I’m sharing this information with Ellen’s permission because we know you will have questions and want to do our best to address them before the wedding.

Ellen has anorexia nervosa. This is an eating disorder that we’re working hard to address with the appropriate professionals. When you see her, you may be surprised by Ellen’s appearance, and we’d like you to consider the best response when you see her since I know how much you love her and want her to be safe and healthy. 

Here’s what we’d like you to know:

Eating disorders are an illness, not a choice

It looks like there’s a simple choice to eat or not eat. But eating disorders are complex medical and psychological conditions that do not respond to simple encouragement or willpower. Treatment relies on highly-trained specialists.

When loved ones assume that eating disorders are a choice, their well-meaning comments can actually make things worse (not better). Please believe us when we say that we have explored the necessary options for Ellen’s care and that it’s more complex than most people realize. That’s why I’m sharing this letter with the family about anorexia. I know most people don’t know much about it, and I hope this guidance is helpful.

What to say when you greet a person who has an eating disorder

When you see Ellen, you may be tempted to say something about her appearance. But focusing on her appearance, positive or negative, can be harmful. So instead, say things like:

• I’m so happy to see you!
• It’s wonderful to catch up with you!
• I’ve missed you! 
• How are you?

What not to say: “You’re so small/thin/tiny/like a skeleton.” While you may think the person needs to “wake up” and see that they have a problem, comments about their appearance do nothing to reverse the trajectory of the eating disorder. In fact, they actually give the eating disorder a dopamine hit. This sort of comment will not “wake her up,” but it will “wake up” the eating disorder and give it more power (not less).

What else not to say: After getting this letter, you may find that Ellen’s appearance is healthier than you assumed it would be. You may be tempted to praise her for that. But it’s actually just as harmful to comment on her appearance positively as it is to comment on it negatively. Just stay away from appearance-based comments including: 

• You look so healthy! 
• You look radiant!
• You’re glowing!
• That dress fits you like a glove!

The bottom line is to please focus on Ellen as a person, not her body.

What to say when a person with an eating disorder doesn’t eat

Now that you know about her eating disorder, you may feel as if you need to encourage her to eat. Please don’t do this! If you find yourself distressed by her eating habits, you can say things like:

• So what’s been going on with you lately?
• How are you?
• Can I share something that happened to me recently? (this should not be about food, eating, weight, or health)

What not to say: “Just eat” (or any variation). This assumes that eating is a simple choice for Ellen. It’s not. This is like telling a cancer patient that they just need to stop growing tumor cells. An eating disorder is a health problem that needs to be treated by trained health professionals. Your care and love are so helpful, but please don’t try to treat the eating disorder by convincing her to eat. 

Avoid comments like:

• Try the cake, it’s delicious!
• Come on, you’ve got to try this amazing hamburger!
• Wouldn’t you like just one bite of my salad? You always liked it when you were younger!
• You look hungry! Have a bite!
• Let’s put some meat on those bones!

As with appearance, it’s best to focus on Ellen the person, not what she’s eating.

What to say when a person with an eating disorder is upset

At times Ellen may look sad or distressed to you. Please consider whether this is something that demands a response. While I’m sure you want to cheer her up and make her feel better, just like convincing her to eat, it’s rarely helpful. But if she is clearly upset and you believe the time is right, you could say things like:

• Would you like to talk?
• Weddings can be pretty stressful, huh?
• Is there anything I can do to support you right now?

What not to say: “Come on, why are you so upset? Cheer up!” Any version of “snap out of it” is like telling her to “just eat.” It’s not going to be helpful and may be harmful. Ellen, like all people, has feelings and emotional experiences. And sometimes she may be resting her face or relaxing – just because she’s not smiling doesn’t mean she’s sad. And if she is sad, we’re working on validating and supporting her rather than asking her to suppress her feelings and move on.

What to say to me

Yes, this has been a real challenge for our family, and I appreciate the concern that I anticipate you have. Sometimes I may want to talk about it, and sometimes I won’t want to. I would really appreciate it if you would treat me fairly normally by asking the usual questions like “how are you,” without asking for details about Ellen’s health. Many times I won’t be able to answer your questions. I hope you can understand this. The greatest support you can give me is compassion without questions. 

What not to say: “Have you tried acupuncture/natural medicine/hypnosis” (or any other treatment you have in mind). Please trust that we have her professional treatment team lined up and are addressing this. I’ll ask for advice if I want it, but unsolicited advice, no matter how well-meaning it is, can be really hurtful to me right now. Some other things I’d rather you not say include:

• Why is she doing this?
• How long will she have this?
• Where did this come from?
• What’s wrong with her?
• She looks so thin! 
• She looks terrible!
• Don’t all girls today have some type of eating disorder?
• My friend’s daughter had anorexia and she …

The bottom line is that I’m a lot more sensitive than usual right now.

We want to talk about other things

We are working hard to address this, and sometimes it’s nice to have a break. So what we would like most of all is to enjoy the wedding. For Marcy’s sake and for ours, we’d appreciate it if Ellen’s health isn’t a topic of conversation. I know you love Ellen and are concerned, but unless one of us seeks you out to talk about it, let’s just enjoy each other and the wedding itself.

Thank you so much for making it through this letter. I’m sure you can imagine it was hard for me to write. I hope it’s been helpful, and we look forward to seeing you in June!

Love, Jordan

How to send a letter to family about anorexia

If you decide that a letter is the best way to educate your family about anorexia, then you should first consider what should and should not be included. Every family is different, and every case of anorexia is unique. So you should create a letter that fits your family and unique circumstances.

Once you’ve settled on the letter’s content, you can either email it or mail it. Of course, email is much easier, and you have the added benefit of being able to send it to everyone at the same time. You may want to use the BCC field of emails, which will avoid having a long email chain of responses. While some families might want to include everyone and begin a big “Reply-all” email exchange, if you want to avoid that, you can use BCC.

Once you have sent the email, you should expect to hear back from people in some way. Depending on your family, these responses may be supportive and thoughtful. Some responses may not respect the boundaries you set out in the letter. This is fairly normal and to be expected. Remember that you are not obligated to answer questions about your child’s health or treatment.

A good response for overly-nosey emails is “Thank you so much for checking in. I know you are concerned and appreciate that. To respect Ellen’s privacy, I can’t share any details beyond what I included in the letter. Thanks for understanding!” Boundaries don’t have to be rude to be effective.

Another thing that might happen is that people might feel hurt that you didn’t tell them earlier or reach out for help from them. While understandable, this response also requires you to hold a boundary. You can say something like “I really appreciate your concern and know that you would have helped if you could. For now, we’re handling it the best we can. Thank you for your support!”

How your family responds to your letter about anorexia may be wonderful or make you feel bad. But either way, you should know that holding your and your child’s boundaries is valid and important. While of course people like to be informed, we don’t owe our family our children’s private health information. And remember: you are doing the best you can when you can. Thank you for caring for your child’s health and privacy.eating disorde

See Our Parent’s Guide To The Different Types Of Eating Disorders

On social media and in places of worship and yoga studios, a diet may be prescribed for spiritual growth, but it’s often orthorexia in disguise.

Spiritual leaders, teachers, bloggers, and influencers may say things like “a pure diet is a sign of spiritual goodness and enlightenment.” This sort of positioning of spirituality can be harmful since it links how and what a person eats to whether they are spiritual or not.

This sort of connection between spirituality and eating has been around for a long time. And there are many religious traditions that have promoted fasting and not eating certain foods for hundreds, even thousands of years.

Religious diets

Many religious traditions restrict some foods, at least some of the time. For example:

• Buddhism: many Buddhists follow a vegetarian or vegan diet.
• Catholicism: the religion has several holy days and periods of fasting. Restrictions include no meat on Fridays during lent and fasting on Good Friday and Ash Wednesday.
• Hinduism: the religion follows a lacto-vegetarian diet and features several fasting periods.
• Islam: Halal includes strict dietary restrictions and fasting periods.
• Judaism: kosher dietary rules require that foods are prepared under strict guidelines. Pork and shellfish are not allowed, and there are fasting periods.
• Mormonism: followers are advised to eat respectfully, use portion control, not waste, and avoid overindulgence.

If you follow a religion or spiritual practice that restricts food, be aware of the risks for eating disorders. This is particularly true for orthorexia.

Spiritual diets

The rise of social media has powered a dangerous era in which non-experts and people with questionable motives actively and religiously promote disordered eating behaviors as a path to enlightenment. Some dangerous trends include:

• “Spiritual signaling” with food, especially veganism
• Detox juices and teas
• Fasting diets
• Religous adherence to working out
• Strong visual correlation of a “spiritual body” being lean
• “Clean” and “pure” diets being promoted as the path to enlightenment and health
• Suggestion that weight will “melt off” when you follow the right path

Influencers and diet companies alike use the power of social media to spread their brands of pseudo-spirituality. They co-opt the language of spirituality and self-love to peddle programs, supplements, and clothing. It feels like spirituality and self-care, but when you break it down, it’s really just marketing and sales.

What is orthorexia?

Orthorexia is a type of eating disorder that falls under the category of Other Specified Feeding or Eating Disorders (OSFED). And it’s strongly correlated with Obsessive-Compulsive Disorder (OCD). It was first recognized in 1998 and translates to an obsession with “healthy” or “clean” eating. According to professionals who specialize in treating eating disorders, it is the fastest-growing type of eating disorder right now.

Someone who has orthorexia restricts certain foods that they believe are not healthy or clean. They may also incorporate cleanses and fasts to pursue purity.

Symptoms of orthorexia include:

• Cutting out or eliminating foods (e.g. meat, dairy, carbs, sugar, etc.)
• Fasting and detox practices
• Deep fear of accidentally consuming the food that’s been cut out
• Obsesively checking nutrition labels and calling restaurants for detailed ingredient lists
• Firm definition of foods that are “healthy,” “clean,” “good,” or “pure”
• Noticeable interest in and discussion of what other people eat
• Following influencers on social media in categories like clean eating, vegan, paleo, etc.

Like all eating disorders, orthorexia has significant underlying causes. These may include anxiety, depression, and poor emotional regulation skills. Orthorexia can begin small and then quickly snowball. Many parents are proud of their children in the early stages of orthorexia. It can seem both spiritually pure and healthy.

But like all eating disorders, orthorexia can become a major impediment and risk to life. As a mental illness, it requires intensive treatment.

The link between orthorexia and spirituality

Many people who are pursuing a spiritual path can find themselves accidentally falling into orthorexia. Part of this is because of the ease with which religious texts can become deeply rooted in a person’s brain. Spirituality is easily matched with diet culture. Diets promote clear rules and rigid expectations with a clear payoff. This approach fits well with many spiritual practices. And the influence of social media means a religious approach to food and eating can become obsessions.

We are in an unfortunate time of diet history right now. Many for-profit diets are wrapped in a cloak of “consciousness” and “spirituality.” This cloak makes it easy for a person to fall into disordered behaviors.

Here’s a perfect example of a diet dressed in spiritual clothing. This is a sponsored post from @DailyOm on Facebook. We added some notes to help identify the positive messages from the questionable and purely diet-oriented ones.

This example shows the model most modern diet marketers use. They promise spirituality and health, then add the goal of weight loss. Almost everyone in our culture wants to lose weight. So this message is actually critical to the success and sales of this company. But it’s cloaked well enough that a person can imagine they are pursuing spiritual growth, not a diet. When diet is linked to spiritual growth, it can easily trigger orthorexia.

A note about weight loss

It’s important to remember that all diets have a 95% rate of weight regain. They also have a 65% rate of gaining additional weight. They also dramatically increase the risk of eating disorders, up to 18x. Every diet promises to reduce weight painlessly and permanently. But there is simply no evidence that they can meet those claims for all but 5% of the population. And diets are not harmless. They permanently decrease metabolic rate, increase cortisol (stress) hormones, and increase the risk of eating disorders.

The risk of diets for spiritual growth

Following religious dietary restrictions is everyone’s individual choice. But parents need to be aware that spiritual messages about eating and food can be very dangerous. Following a diet for spiritual growth can lead to orthorexia.

Rates of eating disorders are drastically increasing. There are multiple factors, including diet industry marketing, weight stigma, social media, and COVID-19 restrictions, that appear to be creating a perfect storm for eating disorder development.

The best thing parents can do is counteract restrictive messages about food and eating with positive messages like:

• All food is good food
• We don’t typically eat that as part of our religious practice, but we also honor every person’s individual choice
• Our religion includes limited periods of fasting, but in general we eat regularly to fuel our bodies every day
• We respect every person’s right to choose what they do and do not eat
• This is a diet-free home, and we don’t support dietary restriction unless clearly specified for religious reasons (and even then it’s still optional)
• You can be spiritual without following the dietary restrictions outlined in ancient texts and modern sermons
• We don’t follow clean eating “prophets” who promote disordered eating behavior
• Social media should be consumed with caution, especially when it comes to spiritual messages strongly aligned with eating and exercise behaviors

If you have a child who has an eating disorder, please carefully consider religious food restrictions and fasting traditions. For your child, a diet for spiritual growth may be orthorexia, and therefore needs special consideration. Most religious leaders recognize the need to adjust dietary restrictions in special circumstances.

by Mimi Cole

In this article, Mimi Cole tells us about eating disorders, orthorexia, and recovery. Mimi has lived experience with all three and is pursuing her Masters in Clinical Rehabilitation and Mental Health Counseling so she can help others recover from eating disorders.

Mostly when we talk about eating disorders, we’re talking about underweight anorexia. This misses the vast majority of eating disorders, and I think it’s time that everyone understands the other signs and symptoms. For example, here are some common signs and symptoms of an eating disorder that have nothing to do with weight: 

• A new interest in clean eating or diets
• Changes in eating patterns that result in cutting out a food group or switching to “healthier” ingredients. 
• Trying to get everyone around them on the same eating bandwagon, such as “eating clean” or gluten-free
• Focusing on a lot of niche or specialty items that narrow and specify dietary behavior
• Asking permission to eat certain foods, i.e. “Are you sure it’s OK if I eat this?”
• Reading labels, worrying about grams of fat, carbohydrates
• Emotional distress after eating food that they believe is bad. 
• Sharing exercise plans after eating
• Fear of eating certain foods
• Becoming hyper-focused on unattainable sports goals
• They suddenly start doing something intensely every day like a new sport or exercise
• Noticing a change in relationship with exercise (i.e. hates exercise and suddenly really into it)

It’s important to recognize orthorexia when we think about eating disorders and recovery.

When to seek support

If your child is showing any of these symptoms, it’s a good idea to see a dietitian who understands all types of eating disorders. It may feel extreme to you, but it’s really better to be safe than sorry. Orthorexia is a serious eating disorder that is focused on eating a certain way and exercising. It may or may not result in drastic weight loss, but the condition is still very serious.

A lot of parents think it’s a good sign when a child suddenly becomes interested in “healthy” eating and exercise, but a sudden and intense change in a person’s relationship with food and their body is often a warning sign. It’s important for parents to seek support so they can understand how to parent through food and body issues. 

If you’re seeing these signs in your child, then they may need some nutritional counseling. A lot of parents forget that they can begin with a dietitian. Many kids may be more willing to speak with a dietitian than they are a therapist, and as long as the dietitian is trained in eating disorders, they will know whether to recommend psychotherapy who can play a vital role in recovery from eating disorders. 

Just be sure you work with a dietitian who is qualified to identify eating disorders – most dietitians do not have this training. While these professionals mean well, they can miss symptoms and accidentally cause more harm.

Eating disorders, including orthorexia, often require varied treatment to bring about recovery.

Understanding diet culture

I wish that more parents understood diet culture and its dangers. There are so many misconceptions about the efficacy and importance of weight loss. Our culture perpetuates these through powerful authority figures, including doctors, teachers, and celebrities. Doctors’ recommendations to lose weight are based on racist and fatphobic roots, and it has a very negative impact on our health. I get really sad thinking about how many people think weight loss is a good recommendation, but it’s actually very harmful. 

A common phenomenon throughout my lifetime is that parents become afraid when their kids gain weight. What they don’t know is that it is very normal for kids’ bodies to change, and we need to normalize adolescents gaining weight. It shouldn’t be something that is shamed. Intentional weight loss during adolescence has long-term consequences such as the development of disordered eating and eating disorders, a compensatory and restrictive minded relationship with food, and a fixation on the body. 

Parents should do their own body work and recognize the effects of diet culture on their own beliefs and behaviors. Negative comments about parents’ own bodies are easily and often picked up by kids. It’s important to be very conscious of how parents’ own beliefs affect their kids’ thoughts about food and their own bodies. 

Healthy doesn’t mean weight loss

Unfortunately, diet culture has co-opted the word “healthy,” and it no longer means what you think or want it to mean. Healthy has become an idea that you need to exercise and eat a restricted food diet: more fruits and vegetables, and less sugar. But health is not achieved by restricting your food groups. You can have a healthy diet that includes carbs, sugar, and fats. In fact, the more that you restrict those foods, the more you crave them. 

A classic example is telling your kids they can’t have sugar because it’s “not healthy.” This only reinforces the idea that sugar is “off limits” and kids tend to want it even more. The foods we restrict gain power that they don’t deserve. They become much more attractive because we restrict them. 

An “all foods fit” mentality works really well. Focus on building: an add, not subtract mentality. Add more fruits and vegetables, add more fiber, but don’t take things away. We have this image in our minds that if we allow our kids access to sugary foods, they will only eat that food forever, but that’s just not true. 

I eat dessert almost every day. It’s okay to have dessert every day. I also eat vegetables every day. I incorporate a lot of different foods in my diet, and that’s actually healthy.

Forget the BMI

The BMI is an outdated, narrow tool that doesn’t adequately measure for health. I really think it does a lot of harm for kids to be told they are “overweight” for a number of reasons, including that the standards changed in 1998, so people who were “normal” went to “overweight” overnight. The BMI is not backed up by research. We know that health indicators and biomarkers like blood sugar levels are not determined by weight, but by health promoting behaviors. 

People in larger bodies can be healthier than people in smaller bodies. What changes the relationship between weight and health is usually weight stigma and discrimination, and this weight based treatment can lead to suboptimal health behaviors independent of weight. 

Also, we know that intentional weight loss stimulates your body’s stress response leading to chronic inflammation: that’s definitely not healthy. And since almost nobody maintains intentional weight loss, it’s an unnecessary stressor. 

Recommendations for parents

1. It is never appropriate to comment on the amount of calories in food (on or off the table). When you say something like “I wonder how many calories are in this” it immediately causes others to think about their own food. A healthy relationship with food should never include calorie counting but joy, relationship, and satiation.

2. Eating disorders are frequently missed in marginalized bodies. Fat people, Black and Hispanic people, and transgender people get eating disorders, too. 

3. Recovery from eating disorders, including orthorexia, is possible. Yes, it really happens.

4. Recovery takes time, sometimes a long time of doing the right recovery things (e.g. sticking to a meal plan, eating fear foods, etc), to unlearn sometimes years of a chaotic relationship with food. It takes time to put space between anxiety and compulsions. Celebrate progress and the smaller moments throughout the recovery process.

5. Recovery typically includes gentle nutrition, intuitive movement, and body trust and intuition. Gentle nutrition means meeting nutrient needs for vegetables and fruit and fiber, while not getting stuck in a dieting / restrictive mentality. Intuitive movement means engaging in movement that makes you feel good and isn’t forceful. Body trust and intuition mean knowing that our bodies are wise, and can be listened to and trusted. 

About Mimi Cole

Mimi Cole is a graduate student studying Clinical Rehabilitation and Mental Health Counseling at UNC Chapel Hill. She plans to specialize in the treatment of eating disorders and disordered eating. You can follow her on Instagram @the.lovelybecoming

See Our Parent’s Guide To The Different Types Of Eating Disorders

Most people assume that low body weight is the greatest risk factor for anorexia. Almost everyone assumes that someone who has anorexia appears emaciated. It has always been believed that being underweight is the reason anorexia is so dangerous.

However, research shows that low weight is not the greatest risk factor of anorexia. In fact, “atypical anorexia nervosa” is both common and equally dangerous. Atypical anorexia has all the same diagnostic criteria except low body weight.

This is important information. Many people who meet the criteria for anorexia are not “underweight.” They rarely get treatment and are often dismissed as less serious. This experience can leave a person struggling with atypical anorexia for decades without support.

Study finds that weight status is not greatest risk factor of anorexia

A study found that the greatest health risk of anorexia was not weight status, but the total weight loss and recent weight loss based on the disorder. (Journal of Adolescent Health). In other words, anorexia occurs in “average,” “overweight,” and “obese” weight categories. And these people can have the same health complications as someone who is in the “underweight” weight category.

The study found that in adolescents with restrictive eating disorders:

• Total weight loss and recent weight loss were better predictors of physical risk than weight at admission.
• No complication of anorexia was independently associated with being underweight.
• Adolescents with atypical anorexia nervosa can experience the same severe physical complications despite not being underweight, including low:
  • Pulse rate
  • Systolic blood pressure
  • Phosphate levels

Lead author Melissa Whitelaw, A.P.D, is calling for a change to anorexia nervosa’s diagnostic criteria based on her findings. She believes that the current DSM criteria of being underweight is inappropriate. She says that patients with atypcial anorexia experience serious health complications. These occur even if they are within or above what is considered a “healthy” weight range.

“We need to redefine anorexia … the definition should refer to weight loss, not just underweight,” said Whitelaw in an interview.

Higher weight anorexia is equally dangerous to health

Whitelaw’s research shows that we should worry about weight loss in any body.

This is a major issue since so many people pursue weight loss as a health-promoting activity. Weight loss can cause the human body to go into “starvation mode.” Starvation mode can be triggered when a person loses as little as 10% of their body weight in a short amount of time.

Sudden weight loss is a major risk to the human body. The body responds by slowing down the heart rate to conserve energy. The body’s response to sudden intense weight loss is not based on the starting weight.

People in larger bodies are at high risk of developing all the symptoms of anorexia. This occurs even if they remain above what is considered a “healthy” weight.

Significant weight loss is a negative health condition

Praise and encouragement is the most common reaction to weight loss. In fact, we should be treating weight loss with concern and worry.

“If adolescents lose weight, it doesn’t matter what weight they are, a health professional should monitor them to check that weight loss is appropriate and if so, that it is done gradually,” said Whitelaw in an interview. “They should also monitor the adolescent’s dietary intake and relationship with food and exercise for signs the patient was spiraling into an eating disorder. Following large amounts of weight loss, careful medical assessment is also recommended.”

Whitelaw’s research is important. People who have atypical anorexia are often considered to be less medically critical. Professionals have assumed that low total body weight is the most dangerous feature of anorexia.

As a result, a large number of people who live with anorexia in larger bodies suffer. Diagnosis and treatment are much harder for people in larger bodies.

Weight bias impacts treatment and outcomes

Weight bias is common among medical and even eating disorder treatment providers. These well-meaning professionals frequently encourage weight loss efforts for everyone but the smallest bodies. These professionals often encourage larger-bodied patients to continue and even refine their anorexia symptoms.

Weight loss encouragement is common for people who live in larger bodies. This means that well-meaning people can accidentally exacerbate anorexia. People like:

• Parents
• Doctors
• Coaches
• Teachers
• Family members
• Friends

Because of weight stigma and diet culture, most people who have atypical anorexia never receive treatment. In addition, they often get worse because of a lack of care.

Diet culture is major risk factor for health

Diet culture promotes weight loss with the stated goal of improving health. The diet industry has driven weight loss efforts and as a result is a $72 billion industry. However, there is no evidence that intentional weight loss lasts or improves health outcomes.

About 95% of people who intentionally lose weight – through any method – will regain the weight in 2-5 years. Additionally, most people who intentionally lose weight will gain more, and begin weight cycling, a major health risk factor.

Weight loss efforts are not benign. Dieting is a major risk factor for eating disorders. One study found that dieting is the most important risk predictor of new eating disorders. Female subjects who dieted at a severe level were 18 times more likely to develop an eating disorder. Subjects who dieted at a moderate level were five times more likely to develop an eating disorder. (BMJ, 1999)

What parents can do to help their kids be healthy

Parents can help their kids be healthy by doing the following things at home:

• Don’t talk about dieting or weight loss
• Never encourage intentional weight loss
• Don’t allow your child to adopt a diet or weight loss program
• Monitor your child for significant weight loss and treat it as a risk factor, not a cause for celebration

Most importantly, if you see any symptoms of an eating disorder, including weight loss, have them evaluated.

If your child is in a larger body even after weight loss, then have them checked by a non-diet professional. Few doctors or traditional nutritionists and therapists receive training for atypical anorexia. Sadly, they can easily cause more harm than good. All types of eating disorders are serious and require care and treatment.

Parents who have kids with avoidant/restrictive food intake disorder (ARFID) face challenges not just in feeding their kids and keeping them healthy, but also in accessing treatment.

ARFID is an eating disorder. Its symptoms include strong food aversions and food avoidance. These symptoms exist without the desire to lose weight or change the body size or shape.

ARFID is characterized by food fear and anxiety and can lead to malnutrition. Thus, it is a physically dangerous condition that is often misdiagnosed due to lack of awareness and understanding. ARFID frequently coexists with anxiety disorders and has been associated with autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). Many times it is first observed when the child is very young.

In younger children, ARFID is often dismissed as “picky eating,” leading to under-treatment. In adolescents, ARFID is often misdiagnosed as anorexia, which can lead to inappropriate treatment.

We have gathered stories from parents who have a child who has ARFID. This is so that we can better understand this eating disorder from their perspective.

What is ARFID?

ARFID is characterized by an aversion to eating. People who have ARFID may avoid eating because they fear vomiting or choking. They may also be disgusted by certain food textures, colors, appearances, and smells. As a result, they tend to have a very limited diet. Here’s how parents who have kids who have ARFID describe their child’s symptoms:

“She began making proclamations about food that she used to eat but just said she didn’t eat anymore. I don’t eat chicken, I don’t eat peas, broccoli, casserole. Her lunch box started to come home full every day. She stopped eating every other filling on her sandwich except tomato sauce or jam.” – Anonymous mom of a daughter

“He had an extremely limited diet that progressively got worse year after year. It developed an inability to eat in social situations, with friends, school camps, etc. There are also high levels of anxiety around food and rigid food rules around color, shape, texture, and brands.” – Kelly

“He refuses foods based on sensory characteristics. There’s also a fear of food, a hatred of food and food smells, and social anxiety around food. Sometimes he throws up if he experiences an unsafe taste or texture. He has a severely limited diet and is basically surviving on milk and baby biscuits/snacks.” Issac’s Mum

“[My child experienced] significant weight loss, malnutrition, fatigue, withdrawing from friends, extremely selective and rigidity in foods. It is not just a child being picky. Nor is it related to an obsession with body image, weight, etc.” – Kristin

“A lot of it doesn’t make sense. You worry about them a lot. I despaired a lot in the beginning.” – Anonymous

“My son has never opened his mouth to try new foods. We offer him whatever we are eating every meal but he refuses to even try it. The look in his eyes is fear. Before he could talk, he used to scream and cry the moment you put food near his mouth. Now he just politely says “no.” But if you keep encouraging he will scream and cry and turn his head away.” – Megan

“When we heard about ARFID, we dismissed it. We thought it was people who have a fear of choking or some other fear surrounding the act of eating. Then we found out that it can include kids who only eat certain colors, textures, brands, etc. We realized that she fit into this mould. She was not simply a “picky eater that will grow out of it.” – Brenda

What it looks like

People who have ARFID typically resist trying new foods. They worry extensively about getting sick as a result of eating particular foods. Here’s what parents who have kids who have ARFID have to say about what it looks like:

“She looks healthy and is growing “normally.” But I worry about her future because her diet consists mainly of processed carbs. Also, food jagging is frustrating. Just when we think we have her eating something new, she eliminates the food she’s been eating forever. So when we think we’re up to eight safe foods, we go back down to seven.” – Krista

“She managed to stay normal on the growth chart through age 14, as she was eating limited yet high-calorie foods. Once she was in “malnutrition”, the only help we could find was for anorexia, which was FBT protocol. The eating disorder experts told us that the goal is to get the weight back on. And FBT is the only proven way to do that. FBT is not easy to adopt with ARFID kids. Its its goal is to take complete food control away from the kid (horribly impossible with ARFID) and to get them to “normal eating” again (ARFID kids were never normal eaters). We used some of FBT to get her out of the danger zone, then we stopped treatment as we were unable to implement what FBT requires long term.” – Brenda

“Since a child with ARFID cannot be bribed to eat food, you need to give them whatever they are willing to eat. You cannot starve them until they are hungry enough to eat. You do whatever it takes to get them to eat something.” – Megan

“Not all kids are underweight and can in fact be overweight due to high levels of carbs and sugar as preferred foods.” – Kelly

Why it’s hard to treat

ARFID was only added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. It is poorly understood and there is little in terms of evidence-based treatment. Here’s what parents who have kids who have ARFID have to say about why it’s so hard to treat:

“We have enlisted a food therapist for three years, yet no new foods have been added. We have seen professionals who have made the situation worse as they have no knowledge of this disorder.” Anonymous mom of a son

“I still have not managed to find a health professional in Brisbane who knows about ARFID to diagnose my son. Every time I speak to a doctor, they have never heard of ARFID and would tell me that I am self diagnosing and that my son is just a typical fussy toddler.” – Megan

“Trying to find a therapist who knows ARFID is impossible. And we live in the Bay Area where Stanford and other medical facilities have many resources, but all we are finding is typical anorexia therapy.” – Brenda

What it feels like to parent a child who has ARFID

All eating disorders are disruptive for the families. They are challenging and complex. ARFID can be particularly difficult due to the lack of awareness and understanding. Many parents report feelings of shame and despair. Here’s what parents who have kids who have ARFID have to say about what it feels like to have a child with this condition:

“When they lose safe foods and you start to think they will literally starve to death, it’s absolute panic mode. Which only makes things worse.” Anonymous mom of a son

“There is a lot of judgment from other parents and people in general who do not understand or are not aware of ARFID. A lot of people think that the child is not eating because the parents are not strict enough or that you spoil them too much by giving into what they want. Others may even think that they don’t eat because you’re not a good cook. It’s really taken an emotional toll on me. The anxiety of having a child with ARFID is hard enough let alone the judgments from family and friends that come with it.” – Megan

“I have learned to focus on her strengths. I have learned to accept that we are having spinach pie, her No. 1 safe food, for the 3rd time this week.” – Anonymous mom of daughter

It’s a family affair

ARFID, like all eating disorders, doesn’t only impact the person with the disorder. It impacts the whole family and peer relationships. It can be challenging to eat a family meal when one person resists food. It’s also very difficult to eat socially. Here’s what parents who have a child who has ARFID have to say about how it has impacted their family:

“It not only affects the child and the immediate family. It affects everyone in that child’s life. We have to plan when going to visit relatives to make sure we have something on hand she can eat (I refuse to put that stress on others). I have to pull friends’ parents aside, when she’s having a playdate at their house or over for a party, to explain that her refusing to eat the pizza they ordered for everyone is normal and that they should not worry about it. (I either feed her beforehand or send a snack with her).” – Krista

“It is destroying my family. I feel like nobody understands, as if everybody blames me for causing it. As if they are dismissing me as a manic parent. I have to find money to pay for private treatment as I need to do something. It’s hard seeing my little boy so sad and him telling me he hates life and doesn’t want to be here anymore – all because of food.” – Issac’s Mum

“[This is causing tremendous] stress on the family. Screaming and crying at every meal is just insane to cope with. We need some rest but nobody will look after him at mealtimes. It sucks your soul. My son is super severe and I get that sometimes it is untreatable but it’s heartbreaking to force-feed my son three times a day.” – Claire

“You know that they won’t eat their aunt’s roast chicken or bread rolls with seeds on them and they have a meltdown in front of the whole family at the BBQ. There is nothing for them to eat and they are hungry and you didn’t bring anything because your brother said he will make sure there are plain rolls. But he doesn’t really understand what a few sesame seeds on the top of a bread roll mean to a kid with ARFID. My dear Dad drove back to the shops and bought a pack of plain rolls and a jar of peanut butter and a tub of cherry tomatoes so that she could eat something.” – Anonymous mom to daughter

What parents wish people knew about ARFID

One of the most important steps we can take to help parents who have kids who have ARFID is to understand their situation and have compassion. ARFID is tricky and there is rarely a quick fix. Here’s what parents who have a kid who has ARFID would like other people to know about it:

“I wish people knew that it’s not just picky eating and it’s difficult seeing your child have such significant anxiety. Also that it’s not a result of poor parenting or entitled children.” – Kelly

“I wish there was more awareness around ARFID. The fact that it is a genuine eating disorder and that you really need to break all of the typical rules around feeding and eating when you’re dealing with a child with ARFID.” – Megan

“I wish people would get it out of their heads that you can force a child to eat, or they’ll eat when they’re hungry. When you’ve seen a child with ARFID interact with food, you see how difficult it is for them. Yes, everyone has certain foods they don’t like. Some people even have foods they physically can’t eat without gagging. But ARFID is extreme. ” – Krista

“I wish people knew that it’s not a junk food diet. That I have tried everything 10 times over. That it is hard and their judgment hurts – that yes I have tried this and that and a load of other stuff besides. That no you don’t understand if you are not living it, and commenting on how hard being out socially for food with us is not helpful.” – Isaac’s Mum

“I wish people understood that no, she won’t eat when she’s hungry. She’ll feel hunger but still won’t eat even in a house full of a variety of great food. Even as a baby, the doctors told me she would eventually take the bottle from her dad when she got hungry. It didn’t happen. She waited until I was accessible to nurse.” – Brenda

Treatment considerations

When you have a child with a less-common type of eating disorder it can be harder to get care. While there is little research on ARFID, we do know quite a lot about treating anxiety disorders, autism, and ADHD. And something we know about all of those is that they respond well to structure. A child who has anxiety, autism, and/or ADHD benefits when their parents are consistent and structured whenever possible. This is also true of eating disorders.

When it comes to food, this looks like serving regular meals and snacks, and keeping the eating environment consistent and as pleasant and stress-free as possible. You can serve food that your child will eat while also serving other foods so your child gets exposure, even if it’s just visual exposure, to other foods. To be clear, this isn’t “treating” the ARFID, but it is going to make it more likely that your child gets the nutrition they need, which can be a challenge.

Next, we know that emotional regulation is important for all kids, especially those who have anxiety, autism, ADHD and/or an eating disorder. So building emotional regulation skills for yourself, your family, and particularly your child who is struggling is very important. Again, this may not be a “cure,” but it can create a calmer environment for your child and therefore reduce symptoms and make it easier to eat.

Finally, there is a new treatment called SPACE (Supportive Parenting for Anxious Childhood Emotions) that has been found effective in treating kids with ARFID.

---

See Our Parent’s Guide To The Different Types Of Eating Disorders

When parents learn how to help their bulimic daughter, everyone benefits. Bulimia can be a scary diagnosis. And like all eating disorders, it needs specialized and intensive care. But the good news is that parents can make a significant impact on recovery. Your daughter needs you. You can help.

How to help your bulimic daughter

Managing an eating disorder diagnosis isn’t easy. But parents can help by accepting and supporting their child. Your love and acceptance can make a huge impact on her ability to recover. Here are the five things you can do to help your bulimic daughter:

1. Accept your child’s diagnosis

It’s very common for parents to resist an eating disorder diagnosis. That’s because it’s scary to hear that your daughter has a problem. Hardly anyone talks about eating disorders, especially bulimia. Bulimia often carries the most shame among eating disorders.

At the same time, it’s very likely that your daughter will assure you she is fine and doesn’t need treatment. It’s very likely that she will tell you she doesn’t need help. This is actually part of the disorder and is to be expected.

But if she has been binge eating and purging, she does need help, and a few weeks of therapy is not enough. Therefore, accepting your daughter’s bulimia is key to helping her recover.

2. Understand that this is a serious problem that needs to be addressed thoroughly

Bulimia is extremely complex and persistent. Your daughter’s bulimia is likely more serious than you think it is because bulimia tends to live in the shadows. It is a powerful coping mechanism that provides your daughter with soothing endorphins. She is reliant on her bulimia to feel OK in her life. As a result, treatment is deep and intense.

Letting go of her bulimia in exchange for healthy coping skills will take time and persistence. But the consequences of a lifetime of bulimia are far more serious. There are serious physical, mental, and emotional health impacts of the disorder. Rest assured that living with bulimia doesn’t have to be your daughter’s fate. It will take time and energy to recover. But it is very possible.

3. Recognize that bulimia requires specialized treatment and recovery

Eating disorders are poorly understood and under-treated. Of all the eating disorders, anorexia has received the most attention and funding for treatment. As I already said, bulimia is often avoided because it can seem distasteful and many people do not appear sick even when they are.

Therefore, finding help for your bulimic daughter can be a challenge. But you need specialized care from someone who is qualified to treat bulimia. This is not a condition that should be treated by a general therapist or dietitian. Please be sure to seek a specialist who was trained in and gets supervision for eating disorder treatment specifically.

4. Respect your child’s process and body throughout recovery

Recovery is hard for everyone. Bulimia provides a protective numbing layer that your child relies on. As a result, recovery requires her to remove her numbing layer and show her parents, loved ones, and friends her true self. Recovery empowers her to recognize her unique wants and desires. It also empowers her to say “no” to things she doesn’t want.

This can be incredibly hard for parents to tolerate. Therefore, it helps if you prepare yourself for conflict and challenging conversations as she recovers.

At the same time, your daughter may gain weight during recovery. It’s best if you avoid any mention of weight gain. However, if she mentions it to you, consider your response very carefully. Parents who respect their daughter’s full recovery process make a huge impact on the strength of her recovery.

5. Get help for yourself so that you can manage the stress of having a bulimic daughter

Your daughter’s bulimia is going to be hard on you. This is not parenting 101. You’ll be asked to learn new things and stretch yourself. Remember that your child must change to recover. Therefore, you’ll need to accommodate her as she changes, grows, and expands.

The most successful parents find support for themselves. When parents learn and grow, their kids feel better. Ideally, it would be great if you could get some therapy and/or coaching to understand your complex feelings about your daughter. Professionals can provide you with education, ideas, and an outlet for your frustration during the process.

Understanding bulimia

Bulimia nervosa is an eating disorder that involves restriction, binge eating, and purging. In this way, it combines the behavioral aspects of anorexia and binge eating disorder, while adding a third behavior: purging.

Many people misunderstand bulimia and focus only on purge behaviors. But it’s important to recognize that purging takes place most often after a period of food restriction. Binge eating is the most common response to restriction. Purge behavior typically comes after restriction and binge eating.

A person who has bulimia often begins with food restriction or anorexic behaviors. While a small population of people will continue with anorexia and become medically underweight, the majority of people do not. The most common response to restriction is binge eating. Most people find themselves driven to eat large quantities of food to make up for the deficit created by dieting and restriction. Therefore, binge eating is often driven by the biological response to hunger.

An obsession with maintaining a low weight makes binge eating feel both scary and unacceptable. Therefore, a sense of being broken and “addicted to food” is common. Binge eating episodes are followed by tremendous shame. Some people will deal with this shame by purging. These are the people who, with repetition, develop bulimia nervosa.

Why your daughter has bulimia

There is no single reason why a person develops an eating disorder. Because there is a complex interaction between inborn temperament, life experience, and the society in which we live. Here are some of the factors that appear to contribute to the development of bulimia nervosa:

• Highly sensitive temperament
• Highly conscientious, with a tendency towards perfectionism
• Conditions including anxiety, depression, obsessive compulsive disorder, attention deficit disorder, and autism
• Sexual abuse/harassment/assault
• PTSD/C-PTSD
• Adverse Childhood Experiences (ACEs)
• Family fatphobia and focus on body weight
• Family history of food restriction and dieting
• History of dieting and weight cycling
• History of food insecurity
• Racism
• Poor body image
• History of self-harm, antisocial behavior, and suicidality
• Living in a society that believes thinness equals health, beauty, morality, and wellness
• Being female in a patriarchal society

These conditions combine to create an environment that supports eating disorder development. Not every person who develops an eating disorder has all of these conditions, but most have several.

Treatment for bulimia

Treatment for bulimia typically begins with nutritional counseling to try and get the body in a medically secure place. But it’s also important to work on the underlying conditions that fostered the disorder. As a result, treatment almost always includes psychotherapy and possibly group therapy.

The eating disorder has become a powerful coping mechanism for your daughter. It is how she survives in her life right now. Therefore, in treatment, she needs to gradually learn to replace her eating disorder behaviors with adaptive coping tools.

Remember that bulimia is not just purging. It is also restricting and binge eating. And all of these behaviors are driven by emotional dysregulation. Stopping the purging behavior may seem like the most important first step. But treatment is much more complex and nuanced.

While your daughter is in treatment for bulimia, she may still engage in purge behaviors. Most parents find this very frustrating. However, your child’s provider may be trying to create the conditions for recovery rather than attacking the eating disorder head-on. Head-on attacks can create resistance and rebellion. They can be counterproductive in bulimia recovery.

Can she recover from bulimia?

Yes. It is possible to recover from bulimia. Many people recover from bulimia and go on to live healthy, fulfilling lives. The recovery process for bulimia, like all types of eating disorders, involves learning self-care and emotional management.

Many people who recover from bulimia are often better off than they were before. The process of recovery gives them an advantage over people who never went through an eating disorder and its recovery. Self-awareness can help them better handle life’s ups and downs.

Full recovery requires time to establish amazing tools. The result can be a fabulous life.

See Our Parent’s Guide To The Different Types Of Eating Disorders

Most people have heard about eating disorders, but what about their close cousin, disordered eating? It’s important to learn about disordered eating, because it often precedes an eating disorder. And since early treatment for an eating disorder results in much better outcomes, catching disordered eating before it turns into an eating disorder is important. Here are some key facts about disordered eating:

• Many eating disorders begin as disordered eating
• Disordered eating is so common that it’s considered normal
• 75% of women report they have disordered eating
• Stopping disordered eating can prevent many eating disorders
• Disordered eating is often unintentionally passed from parents to children

The number of eating disorders recorded annually worldwide has doubled in the past 18 years. The global rate of eating disorder prevalence doubled from 3.5% of the population to 7.8% between 2000 and 2018.[1] These alarming statistics tell us that something is seriously off with the way we approach food and eating.

Our kids are at risk. Even though disordered eating is common, it’s not benign. One study found that teens who diet or restrict food are at least five times more likely to develop an eating disorder.[2]

Parents can help their kids avoid body hate, disordered eating, and all types of eating disorders by addressing these topics early and often. Talk to your child about disordered eating. Don’t worry about making mistakes – worry about leaving the gigantic elephant in the room!

What is disordered eating?

Disordered eating is a combination of behaviors that are so common they are often believed to be “normal.” They include:

• Dieting, or any form of food restriction with the goal of weight loss
• Anxiety about food and meals
• Fear of specific foods
• Skipping meals
• Ignoring/distracting from hunger
• Rigidity surrounding food and exercise behaviors
• Feeling guilt and shame about eating and food choices
• Preoccupation with food and body weight
• Using food restriction, fasting, purging, and exercise as a way to compensate for eating behavior
• The belief that some foods are “good” and others are “bad”

According to a recent survey, 75% of women report disordered eating behaviors or symptoms. That means that three out of four women have an unhealthy relationship with food or their bodies.[3]

Since women spend the most time parenting children (Pew Research), our disordered relationship with food is a challenge. Our beliefs about food and our bodies, and our disordered eating, can negatively impact our kids’ body image and food behaviors. But it’s never too late for parents to heal themselves and help their kids feel better.

What are the symptoms of disordered eating?

Sadly, disordered eating symptoms can be hard to catch. This is because they are incredibly normal in our diet-culture society. It seems like everyone is restricting food. Some cut out sugar. Other cut out meat. Most people say they are restricting for “health.” But there is no evidence that cutting out food or losing weight increases our health. That’s right: losing weight does not improve health.

If you worry that your child may have developed disordered eating, consider these common symptoms:

• Frequent weighing
• Following social media accounts that provide food and diet advice, diet products (e.g. “skinny” teas, meal replacement shakes, supplements, “detox” products, etc.)
• Maintaining precise food and exercise logs
• Attempting to distract from hunger by “filling up” on low calorie foods or exercising
• Cutting out entire macronutrient groups (i.e. carbs, fats, proteins)
• Becoming a vegetarian or vegan
• Eating only “clean” foods or “superfoods” and cutting out foods like sugar, carbs, and fats
• Not eating food even when they want/crave the food because the food is considered “bad” or “unhealthy”
• Having strong opinions about food, eating, and weight, to the point of getting into arguments about them
• Refusing to eat a favorite dish because it’s “not allowed” in their eating program

Common excuses for disordered eating

Your child likely has a very good reason for their disordered eating behavior. Some common excuses include:

Everyone’s doing it: every parent knows this excuse all too well. But when it comes to disordered eating, it’s often very true. But just because all of their friends skip breakfast and avoid sugar doesn’t mean your child should follow suit. In fact, given that we live in a society of near-constant diet trends, if “everyone’s doing it” your child should probably not do it!

It’s healthier: you can’t walk out the door without someone telling you that celery juice is “healthier” or not eating meat changed their life, or eating only meat and no carbs changed their life. Most of the time people say they feel “better than ever” and stronger, more alert, and healthier. But none of the diet trends have been proven by science. And many of them have been soundly debunked as ridiculous marketing designed to sell us products. A healthy diet is not complicated – it includes a variety of food eaten without shame or fear.

I need to lose weight for health reasons: intentional weight loss (i.e. dieting) has been soundly disproved. Between 90-95% of everyone who loses weight intentionally gains it back.[4] A large percentage gains back even more and permanently damages their metabolism.[5] This is true regardless of the purpose of weight loss. In other words, saying that you want to lose weight “for health reasons” doesn’t change the fact that the most common outcome of weight loss is weight gain and poor health.

Parents should listen to their kids when they use these excuses and then share the scientific data about the truth. Don’t think you can do this just once. Your child has likely heard the excuses for disordered eating hundreds, if not thousands of times already in their lifetime. You need to be persistent in order to counter-balance the endless stream of disordered eating excuses.

How can I talk to my child about disordered eating?

Talking to your child about disordered eating is critical to helping them heal their relationship with their body and food. You may feel as if you don’t have the authority to speak to your child about these topics. It’s very possible that you have your own disordered behaviors, and you worry about making things worse.

These fears are normal, but please know that you can’t abdicate food and body issues to professionals. You can’t assign this problem to someone else and hope for the best.

As parents, we are the most important people in our kids’ lives when it comes to food and body. We don’t have to do this perfectly. We just have to do it regularly and with the knowledge that we’re going to make mistakes, but we’re doing our best.

• Take time to reflect on your own relationship with food and your body
• Consider how your beliefs about food and your body may impact your child
• Choose a time when you are both calm and relaxed – not while eating, just after eating, or just before eating
• Tell your child that you want to talk about food and eating
• Let them know that you understand you have sent mixed messages in the past, and you are working on your own relationship with food and eating
• Name the specific behaviors you are observing in a non-judgmental, compassionate way
• Ask them how they feel about their food and eating behavior
• Find out if they are concerned about their body weight and appearance
• Ask them if they would like to talk to a therapist or nutritionist
• If they shut down or close off to you, don’t panic. Just tell them that you’ll keep bringing this up, since it’s important
• Keep the conversation open and talk about food and body image frequently

How to heal your own disordered eating

It’s possible that before you can help your child, you need to get some help for your own disordered eating. Remember – 75% of women report disordered eating behaviors. You are not alone, and this is not a shameful situation. This is merely a side effect of living in our culture that demonizes fat and makes us afraid of food.

It’s very common for parents to realize that they struggle with their own food and body issues while trying to raise healthy kids. Don’t hesitate to reach out for help so that you can be stronger and more aware. We have a Professional Directory with lots of registered dietitians who work with parents to help them heal their own relationship with food and figure out how to feed their kids without fear. Most of them will work with you via phone, so don’t worry if you can’t find someone nearby.

See Our Parent’s Guide To The Different Types Of Eating Disorders

References

[1] Prevalence of eating disorders over the 2000–2018 period: a systematic literature review, American Journal of Clinical Nutrition, Galmiche et al, 2019

[2] Onset of adolescent eating disorders: population based cohort study over 3 years, BMJ, GC Patton et al, 1999

[3] Survey finds disordered eating behaviors among three out of four American women, SELF Magazine in partnership with the University of North Carolina at Chapel Hill, 2008

[4] Does dieting make you fat? A twin study, International Journal of Obesity, Pietlainen et al, 2012

[5] Persistent metabolic adaptation 6 years after “The Biggest Loser” competition, Obesity, Fothergill et al, 2016

When you picture someone who has an eating disorder, you probably think of someone who is dangerously underweight. But, in fact, the majority of eating disorders occur in people who do not appear to be emaciated. The classic portrayal of a drastically underweight white female who has anorexia represents a very small fraction of eating disorders.

Why does this matter? Well, when we assume that eating disorders always result in underweight, we fail to notice the millions of people who never become underweight from a BMI standpoint and yet are suffering greatly from an eating disorder. As parents, we need to know that even if our children are in a healthy BMI range, they still may be suffering from an eating disorder.

Here are some statistics about anorexia nervosa, bulimia nervosa, and binge eating disorder:

U.S. Population: 323 million

National surveys estimate that 6.1% of women (20,000,000) and 3% of men (10,000,000) in America will have an eating disorder at some point in their lives.

30,000,000 Americans have experienced an eating disorder during their lifetime.

Almost 10% of all Americans have experienced an eating disorder.

Anorexia Nervosa: 4.5 million

0.9% (.009) of women (2,907,000) and 0.3% (.003) of men (1,453,500) experiences anorexia during their life.

4,460,000 Americans have experienced anorexia during their lifetime.

Anorexia comprises 14.5% of all eating disorders.

Bulimia Nervosa: 6.5 million

1.5% (.015) of women (4,845,000) and 0.5% (.05) of men (1,615,000) experiences bulimia during their life.

6,460,000 Americans have experienced bulimia during their lifetime.

Bulimia comprises 21.5% of all eating disorders.

Binge Eating Disorder

3.5% (.035) of women (11,305,000) and 2.0% (.02) of men (6,460,000) experiences binge eating disorder during their life.

17,765,000 Americans have experienced binge eating disorder during their lifetime.

Binge eating disorder comprises 59% of all eating disorders.

There is incredible diversity in the eating disorder community, and it’s important for parents, healthcare providers and others to recognize that we come in many shapes, sizes, colors and genders.

---

Source: National Eating Disorders Association (NEDA)

The vast majority of eating disorders are diagnosed in females, but this is increasingly being seen as a gender bias. Eating disorders in boys and men are likely vastly under reported, diagnosed and treated.

Men experience all types of eating disorders. Recent estimates state that 20 million women and 10 million men will suffer from a clinically significant eating disorder at some time in their life (Wade, Keski-Rahkonen, & Hudson, 2011). A study of 2,822 students on a large university campus found that 3.6% of males had positive screens for ED. The female-to-male ratio was 3-to-1 (Eisenburg, 2011).

One of the reasons males are not seen as having eating disorders is because many times their disorders look strikingly different from that of females. Specifically, while females are socially conditioned to seek the physique of an underweight fashion model, males are socially conditioned to seek the physique of a heavily-muscled superhero.

This key difference in the “ideal body type” is partially responsible for the misunderstanding of male eating disorders. Research from Labre in 2005 showed that most males strive to achieve a lean and muscular physique. This desire has markedly increased since the 1970s. The sexual objectification of men in the media is on the rise and is strongly correlated with a male obsession with muscularity.

• 25% of normal weight males perceive themselves to be underweight (Atlantic, 2014)
• 90% of teenaged boys exercised with the goal of bulking up (Eisenberg, 2012)
• 68% of college-aged men say they have too little muscle (AOL body image survey)

Just as women see a body type that can be achieved naturally by less than 5% of the female population, men are exposed to body types that are similarly difficult to achieve.

Bobby Holland Hanton, body double for Chris Hemsworth’s Thor, said he must eat 35 meals per day and undertake two strenuous training sessions to achieve a physique close to the Australian actor’s size (Mel Magazine).

Researchers believe that muscle dysmorphia, a subtype of body dysmorphic disorder, is directly correlated to increased media attention on highly-muscular male bodies, which connect muscularity with masculinity. The disorder was first described in scientific literature fewer than 25 years ago. Sometimes called ‘Bigorexia,’ it was recently included as an official diagnosis in the DSM-5.

• 2.2% of men in the United States have body dysmorphic disorder (Phillips KA, Wilhelm S, Koran LM, et. al)
• 9-25% of men who have body dysmorphic disorder have muscle dysmorphia (Phillips KA, Wilhelm S, Koran LM, et. al)

Body dysmorphia is often characterized by:

• Preoccupation with body size and shape
• Conviction that body is insufficiently muscular
• Compulsive weight lifting
• Abnormal eating patterns
• Use of over-the-counter herbal or dietary supplements
• Use of anabolic-androgenic steroids (AASs), which includes testosterone and synthetic testosterone derivatives
• Use of appearance- and performance-enhancing substances such as human growth hormone, thyroid hormones, insulin, clenbuterol, etc.

Compulsive weight lifting

It is not uncommon for teenage and young adult men to find belonging and success in the weight room. Whether they are lifelong athletes looking to “bulk up” for a particular sport or newbies trying to build out a “weak” or “skinny” adolescent physique, the gym is full of men seeking to change their body size and shape.

Working out in the gym is not always a sign of an eating disorder or muscle dysmorphia. The vast majority of boys and men will work out for a while and then move onto other pursuits. Or they may find that they love working out, and continue working out for a long time in a measured, healthy manner.

As parents, we want to be aware that our sons can definitely be in a healthy relationship with the gym and their bodies, but we also want to be aware of the signs that he is crossing over into obsession. One sign is a continually increasing the amount of time spent at the gym. While one hour per day may be required by his football coach, he may opt to spend 3 or more hours at the gym, which may be a signal of disordered body image.

The main sign that our son is obsessed with achieving particular results at the gym is an inflexibility with his workout schedule. This means that when you go on vacation, your son requires the same access to and time at the gym as he does at home. It also means that he will sacrifice other activities and opportunities in order to go to the gym. This inflexibility is a sign that the gym is taking up a significant part of his identity, and it may be worthwhile speaking with an expert about whether his preoccupation is healthy.

Herbal and dietary supplements and male eating disorders

One of the most common and obvious signs that your son is becoming obsessed with achieving a lean and muscular body is the use of over-the-counter herbal and dietary supplements. These are unregulated, and often contain illegal AASs and other anabolic compounds.

Dietary supplements (typically shakes) are broadly marketed in stores like the Vitamin Shoppe and GNC, as well as on social media, by thousands of “thought leaders” (salespeople) who sell them directly as part of the #fitspo movement.

If your son is using products such as these, you may want to consider whether he is pursuing an unattainable ideal while simultaneously consuming dangerous products. Aside from the fact that these products are not regulated and therefore may contain dangerous ingredients, they promise an unrealistic result. These products are heavily promoted by peers, coaches and social media, making them extremely appealing to young men.

Anabolic-androgenic steroids (AASs) and male eating disorders

Perhaps the most dangerous aspect of muscle dysmorphia is the use of AASs. Since it is impossible for the majority of men to achieve the size and physique of a man like Chris Hemsworth, they must turn to steroids to pursue the “dream body.”

Studies have estimated that 2.9 million to 4.0 million mostly-male individuals have used AASs at some time in their lives, and that about 1 million of those are or have been dependent on AASs. (Pope HG Jr, Wood RO, Rogol A, Nyberg F, Bowers L, Bhasin S).

The majority of AAS users today are not competitive athletes. Most are nonathlete weightlifters who use AASs to achieve a leaner and more muscular physique. Since the use of AASs, over-the-counter supplements and other appearance- and performance-enhancing supplements have only been broadly used since the 1980s, the research is still preliminary, but long-term health risks include damage to the:

• Cardiovascular system
• Psychiatric health
• Reproductive and sexual performance
• Neurobiology

If you believe your son may be facing muscle dysmorphia and/or an eating disorder, please seek advice from an eating disorder specialist who is certified by the International Association of Eating Disorders Professionals Foundation (IAEDP) and can help you determine whether any treatment is necessary.

See Our Parent’s Guide To The Different Types Of Eating Disorders

---

Additional resources:

Body Image Disorders and Abuse of Anabolic-Androgenic Steroids Among Men (JAMA)

The Adonis Complex: How to Identify, Treat and Prevent Body Obsession in Men and Boys

Research on Males and Eating Disorders (NEDA)