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How to spot an eating disorder | Psyche

Illustration by Natsumi Chikayasu

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Guide

How to spot an eating disorder

Worried about someone’s behaviour around food? Eating disorders are serious and secretive: knowing the red flags will help

Illustration by Natsumi Chikayasu

Need to know

When you are close to someone – a family member, a romantic partner, a longtime friend – you are likely to be fairly attuned to subtle changes in behaviour that could signal a shift in that person’s wellbeing. For many people, these changes are connected to eating. You might notice that a friend tends to disappear to the bathroom shortly after meals, or that a family member has been making more frequent comments about their own weight or shape. Perhaps your spouse’s eating patterns have changed, resulting in a sudden increase or decrease in weight. If you are a parent, you may have observed that your child is playing with the food on their plate more than they used to.

Subtle and often-secretive tendencies such as these may be signs of an eating disorder. But it can be challenging to know just what to make of them and what to do if you notice them in someone you care about.

Eating disorders are complex conditions that bring about changes in behaviour, thoughts and attitudes related to food, eating and body image. They can have severe and potentially life-threatening consequences, especially if left untreated. Eating disorders often take root during adolescence or early adulthood, though they can affect people of any age, sex, gender, ethnicity, culture or religion. They can also be stealthy, inducing someone to go to great lengths to avoid being questioned about their illness. Someone who has an eating disorder may become defensive, angry or dismissive if they are directly confronted about the issue.

If you have noticed changes in someone close to you related to their weight, shape or eating behaviour – or if you are unsure, and simply interested to learn more – this Guide will help you better understand how eating disorders manifest and affect individuals and their loved ones. It will help you tell the difference between typical and atypical thoughts and behaviours related to eating, body shape and weight, recognise the signs of an eating disorder, and take the first steps toward supporting a person who might be struggling with one.

Eating disorders are diverse, and so are their consequences

First, let’s look at some common types of eating disorders and typical features of each. Most people are likely to have heard of bulimia nervosa (also known as ‘bulimia’) or anorexia nervosa (also known as ‘anorexia’). However, there are a number of other eating disorders that many people are not familiar with, and they can have equally devastating effects.

  • Anorexia nervosa: intense fear of weight gain or being fat; severe food restriction, often resulting in significantly low body weight; focus on and/or distorted perception of body shape/weight; difficulty recognising the seriousness of the illness.
  • Bulimia nervosa: recurrent episodes of eating larger-than-average quantities of food in a relatively short period of time (bingeing) followed by what is called purging (eg, self-induced vomiting; laxative misuse) or other compensatory behaviours (eg, fasting); the bingeing is characterised by feelings of loss of control over eating; evaluation of self is heavily influenced by body shape/weight.
  • Binge eating disorder: recurrent episodes of eating larger-than-average quantities of food past the point of feeling full (bingeing), which are accompanied by feelings of a loss of control, guilt and discomfort, and followed by marked distress.
  • Other specified feeding or eating disorder: an eating disorder that causes significant distress or impairment but whose symptoms are not characterised by another diagnosis – often referred to as an ‘atypical’ presentation. This can include, for example, atypical bulimia nervosa (a person may binge and purge less often), purging disorder (a person may only purge without binging), or night eating syndrome (when a person wakes up at night to binge eat).
  • Avoidant/restrictive food intake disorder: avoidance of certain foods due to apparent lack of interest in eating or food, the sensory characteristics of food, or concern about aversive consequences of eating (but not driven by fear of gaining weight).
  • Rumination disorder: persistent regurgitation of food after swallowing, followed by rechewing, swallowing or spitting out the regurgitated contents.

Disordered eating is a term used to refer to a collection of behaviours or symptoms that may lead to a diagnosed eating disorder. If we think of a continuum with eating disorders on one end and ‘normal eating’ on the other, we could say ‘disordered eating’ falls somewhere in the middle. Both disordered eating and eating disorders should be taken seriously, and both warrant attention and intervention. Throughout this Guide, when we refer to ‘eating disorders’, we actually mean both eating disorders and disordered eating.

While eating disorders are often thought to start as preoccupations with food and weight, they are very unlikely to be only about food, eating or weight. They are most definitely not a ‘choice’ that someone makes. It is important to understand that there is a multifaceted interplay between biological, social and psychological factors that may compound over time and result in an eating disorder. Biological factors that may increase risk include, for example, genetic predisposition and health conditions that influence what one can eat (eg, diabetes or Crohn’s disease). Social factors may include cultural norms and ideals; marginalisation and stigma; and past or current traumatic or highly distressing situations. Lastly, psychological factors can include, for example, low self-esteem and co-occurring mental health conditions such as depression or anxiety. When a person develops an eating disorder such as anorexia or bulimia, they have often been struggling to cope with challenges in their life for some time.

All eating disorders have negative impacts on a person. They can affect the function of every organ in the body and can cause irreparable damage and life-threatening situations. This is true for any type of eating disorder. Malnourishment and starvation syndrome – or semi-starvation, involving symptoms such as dizziness and passing out, feeling cold frequently, and difficulties with concentration and problem-solving – can affect not only those with a low body weight, but also those who restrict eating for long periods and then overeat or binge. Other complications associated with eating disorders include cardiovascular and pulmonary effects such as blood pressure changes or electrical signalling problems (potentially leading to cardiac arrest); problems with brain function; metabolic problems such as low blood sugar or high cholesterol; and digestive dysfunction.

Some of the adverse psychological and social outcomes associated with eating disorders include social isolation and withdrawal, difficulty regulating emotions, greater substance use, and an elevated risk of suicide.

All of these risks underscore the need to identify an eating disorder when it arises and to provide support for treatment and recovery at the earliest possible opportunity. Eating disorders can be difficult to treat, but when intervention happens early, the chances of recovery are significantly improved.

We are both clinical psychologists at the InsideOut Institute for Eating Disorders, based at the University of Sydney, where our team conducts research, develops new treatments and works on pathways to health for people with eating disorders. In this Guide, we hope to equip you with knowledge that will help you to spot the signs of an eating disorder if someone in your life has one. We also hope to highlight the vital role that loved ones can play in supporting someone with an eating disorder, and offer practical strategies to help facilitate recovery.

What to do

Learn the truth about eating disorder myths

There are a lot of misconceptions about eating disorders. Understanding these myths, and why they can cause more harm than good, can be helpful for preserving a relationship with someone who might have an eating disorder and for knowing what kind of support to provide. Here are some common ones:

Myth: ‘All eating disorders lead to being extremely underweight.’ Eating disorders are not determined by weight, nor can weight alone reveal the severity or impact of an eating disorder. Some eating disorders, such as anorexia nervosa, are characterised by severe weight loss, while others are not; and some people with restrictive eating have had extreme weight loss but still sit within the normal weight range or higher. Other eating disorders, including bulimia nervosa and binge eating disorder, do not involve being underweight as part of their presentation. You can’t tell someone has an eating disorder merely by looking at them.
Myth: ‘People with an eating disorder should “just eat more”.’ While achieving a normal weight is an important part of the recovery process, particularly when an eating disorder has caused severe weight loss, it does not mean that someone has fully recovered. To assume that it does would minimise the complex medical and psychological impacts of an eating disorder. Further, eating disorders are not a matter of someone being a ‘picky eater’, though the complex relationship between food, eating and self can sometimes result in someone with an eating disorder being willing to try only a limited variety of foods.
Myth: ‘Eating disorders affect only young women.’ While the peak onset of eating disorders is often between the ages of 12 and 25, with women being at a higher risk than men, these trends have led to a widespread misconception that eating disorders are a ‘girl’s illness’. Recent studies indicate that eating disorders are more prevalent in males than was previously thought. Truth is, eating disorders can affect anyone, at any stage of life.

Look for changes in someone’s mealtime behaviour and relationship to eating

As the signs of an eating disorder go, behavioural changes related to mealtimes and eating may be relatively easy to notice – particularly if you eat with your loved one as part of a regular routine (eg, family meals). These behaviours may gradually increase in intensity and severity over time. They include:

  • making excuses not to eat;
  • cutting out whole food groups from one’s diet;
  • limiting the diet to purely healthy foods in a restrictive or extreme way;
  • eating in secret or showing evidence of bingeing (eg, empty containers left out; hiding food; disappearance of large amounts of food from a shared storage space);
  • repeatedly visiting the bathroom close to completion of meals;
  • drinking instead of eating;
  • rigid behaviours or rituals around food; and/or
  • much greater interest in and focus on food preparation.

These behaviours often go beyond ‘regular’ dieting and may present differently (or in different combinations) depending on the type of eating disorder the person is experiencing. Independently, some of the behaviours highlighted above (such as increased interest in food preparation) might not warrant any concern. However, repeated patterns of behaviours such as these can indicate that someone may be struggling. Specific examples could include going to the bathroom within half an hour of finishing dinner most nights of the week; routinely playing with food on the plate instead of eating; cutting food into smaller pieces in the absence of a valid reason; or not wanting different food types mixing or touching. These behaviours can be particularly telling if they are accompanied by distress.

Note differences in appearance or an increased focus on body image

More often than not, eating disorders are associated with body image concerns and may be coupled with an increased focus on – and attempts to control – weight, body shape or appearance. Some potentially noticeable signs include:

  • weight changes in a relatively short period of time, or multiple changes over time;
  • wearing looser clothing than usual;
  • feeling colder in the absence of temperature changes or in warm environments;
  • repeated negative comments about one’s own body, weight or shape;
  • checking one’s own body frequently; and/or
  • increased frequency or intensity of exercise in the absence of a clear reason (such as joining a new sports team).

Many of the above signs might not be immediately obvious, particularly if they are encountered in isolation, and they may have alternative explanations. However, repeated and combined behaviours like these could be an indication of an eating disorder and should be monitored.

Consider negative shifts in mood or social behaviours

A person’s mood and how it is displayed or expressed (affect) can provide some further insight into the likelihood that they are experiencing an eating disorder. Signs to look out for include:

  • social withdrawal or isolation;
  • rapid changes in mood;
  • increased anxiety; and/or
  • high levels of control or obsessionality (which may or may not be related to food or the body).

When considering changes in mood, it can be helpful to keep in mind that, sometimes with eating disorders, mood and affect are not always congruent. For example, someone can be angry even if their outward behaviour does not match what they feel. While this may be the case for all of us from time to time, this incongruence may be more pronounced in individuals with eating disorders.

Changes in social behaviour – such as someone who was previously social starting to avoid going out with other people – may be especially telling if the pattern extends to most or all of the person’s social supports, and if there is little else that would better explain the change.

Not all people with an eating disorder will exhibit all the signs mentioned in the lists above. Similarly, these lists are not exhaustive, but are intended to provide you with domains for consideration. Noticing a few of the signs may not be a cause for concern. It’s when these changes start to become distressing or disruptive to the individual or to the people around them that closer attention should be paid.

Have a compassionate conversation about your concerns

If you have noticed some of the behaviours described above and they concern you, you will want to initiate a conversation with your loved one. These conversations are not always easy. You might be unsure about when and where to start or what to say. Those are completely normal and valid concerns, and they might be accompanied by worry, frustration, confusion or feeling helpless or powerless. These feelings are important and could form part of the conversation you have.

However, it is important to try to not let these emotions get in the way of a clear message or goal for the conversation. Your primary goal, for example, may be to simply ‘check in’ with your loved one to see if there is anything you can do to support them generally. Depending on the direction of conversation, you may then be able to express concern about recent changes in behaviours or attitudes, including those related to food.

Choose a time when you feel that you and your loved one are likely to be relatively calm, in a private space, and where neither of you feels unable to walk away if needed (eg, avoid doing this in the car if you can). Remember that these conversations take time, may need to be had several times, and may not always have a clear outcome. This is perfectly OK; it is important to keep your own expectations realistic. Keep in mind the following points to help you facilitate the conversation:

  • Use non-judgmental and non-blaming language. Try to use ‘I’ statements when discussing your concerns. For example: ‘I miss sharing meals together like we used to’ instead of ‘You don’t eat with the family any more.’ Similarly, saying ‘I feel concerned that you’re not spending time with friends/the family as much as you used to; are you OK?’ is better than ‘You’re always locked in your room.’
  • Don’t be critical or focus on their weight or appearance. Instead, try a broader approach to asking about how they are doing, such as: ‘I’ve noticed lately that you haven’t been as talkative as usual… how are things going?’ Keep questions open-ended if possible (rather than asking questions that demand yes-or-no answers) and be prepared for a guarded response. Give the person the opportunity to talk about their feelings if they wish to.
  • Let them know you are there for them. The fact that you are ready to offer support if they want it can be helpful for them to know, now or in the future.
  • Try to avoid thinking as if the person is the eating disorder. If someone has an eating disorder, it is better to work from the viewpoint that the disorder is separate from who they are. Just as an illness such as cancer does not define who someone is, an eating disorder should not be seen that way either.
  • Gently encourage care. Try to get the person to their general practitioner or another qualified health professional (such as a clinical psychologist) for an assessment. If you sense resistance, and if the person is not critically unwell, be patient and persistent. If it is ultimately your responsibility to get the person to receive care (eg, you are their parent) then you may need to tolerate some negative feedback and resistance as part of the process.
  • Don’t try to offer a simplistic solution. Examples of what not to say include ‘Just eat, you’ll feel better’ and ‘Just don’t worry about your body.’ People with an eating disorder do struggle with eating and do feel badly about their body, but the point is to get them the help they need to recover, which isn’t as simple as suggesting that their thinking or behaviour is wrong.

Create a supportive environment

As mentioned earlier, the initial conversation might not lead to any immediate or obvious changes, which should, realistically, be expected. An eating disorder can be elusive and will likely ‘protect itself’ – you may face denial, frustration and anger or avoidance. This doesn’t mean that your message has not been heard. Further, it does not mean that you have run out of options. There are a number of other ways to support someone who might be living with an eating disorder:

  • Model healthy behaviours and attitudes – even if you think they are not being noticed. For example, avoid referring to particular foods, such as chocolate, as ‘bad’.
  • Do not body-shame. Refrain from commenting on your own or other people’s appearance, bodies or eating in a judging way, even if your intentions or the comments themselves seem positive to you. For example, avoid comments such as ‘What that person is wearing doesn’t suit their body’ or ‘They really pack the food away; they must have hollow legs.’ Often someone with an eating disorder is highly sensitive to such comments, which may increase their fear of being judged.
  • Do not assign blame. Blaming yourself for someone’s eating disorder – or blaming that person – is unhelpful to everyone.
  • Be consistent. Stick to routines and rules for all members of a household, rather than singling out the individual who might have an eating disorder. For example, if family dinners are common, do not change the routine to accommodate the individual with the eating disorder, regardless of whether they participate or not. Special treatment of this sort in the early stages of an eating disorder can actually reinforce unhelpful behaviours.
  • Seek professional help. The best time to seek professional support is as soon as you know or suspect something is wrong. You can start by talking with a general practitioner, paediatrician or other health professional you trust to learn more about eating disorders, get their perspective, or develop a plan for how to help get your loved one to see a professional.

Take care of yourself while supporting your loved one

Seeing someone you love struggling with an often-invisible illness is scary and worrying. It is crucial that you keep your own wellbeing and needs in mind while supporting someone who might, or does, have an eating disorder.

Set aside time for yourself every day to take care of needs that are not related to caring for others or external demands of any kind. Aim for at least an hour, uninterrupted if possible, of ‘me’ time. If this is difficult, start small (say 15-20 minutes) and work your way up if you can. You may want to go for a coffee with friends or alone, read a book, paint, watch TV, play a game, do a puzzle, take a bath, or something else – as long as it is your time.

Also be alert to warning signs of burnout. For example: do you find yourself getting more agitated? Do you grow resentful? Do you start becoming emotional? Do you start to feel fatigued more easily? Being aware of these things can help you monitor and manage your own needs.

An upskilling programme for people who care for those with eating disorders could help you develop more coping strategies and skills. These programmes – such as those provided in Australia by InsideOut and Butterfly, or in the UK by Beat’s POD (peer-support and online development), and in the US by FEAST 30 Days – provide information, psychological strategies and resources to help with managing caring duties in a safer, more adaptive and sustainable way. Relatedly, you may be carrying a heavy burden with a significant amount of responsibility, and if you feel your own stress or anxiety increasing, it may be time to seek support for yourself, which can include the support of a professional such as a clinical psychologist. If your loved one does receive a diagnosis, consider seeking your own support soon afterwards to help work through early challenges that may arise.

The steps we have covered in this What to Do section are not intended to ‘resolve’ the eating disorder or even to reduce the symptoms – instead, they provide starting points, points of consideration, and points of discussion. Remember that, while the path ahead of you can at times feel isolating, you are not alone in navigating this challenge. Like your loved one, you too are learning about dealing with the possibility of an eating disorder. Take a moment when you can to breathe, process and focus on setting one foot in front of the other.

Key points – How to spot an eating disorder

  1. Subtle changes in behaviour can be signs of disordered eating. These may include shifts in someone’s eating habits and in how they talk about food or their body.
  2. Eating disorders are diverse, and so are their consequences. They involve a variety of different symptoms, but they can all take a serious physical and psychological toll.
  3. Learn the truth about eating disorder myths. You can’t identify eating disorders based on appearance alone. They aren’t addressed by ‘just eating more’. And they can affect anyone, not only girls and young women.
  4. Look for changes in someone’s mealtime behaviour and relationship to eating. These can include declining to eat meals, severe restrictions on food, repeated bathroom visits just after meals, or eating in secret.
  5. Note differences in appearance or an increased focus on body image. For example: unexplained weight changes, repeated negative comments about one’s body, and increased concealment with looser clothing.
  6. Consider negative shifts in mood or social behaviours. Increased anxiety, changes in mood, or pulling away from social interaction could be additional signs that there is something wrong.
  7. Have a compassionate conversation about your concerns. If you have noticed signs of a possible eating disorder, check in and express what concerns you in a non-critical way. Offer your support, and gently encourage talking with a professional.
  8. Create a supportive environment. Avoiding critical comments about food or bodies, maintaining routines and not casting blame for disordered eating are all ways to do this.
  9. Take care of yourself while supporting your loved one. Make sure to set aside time each day just for you, and be mindful of signs that you yourself might need more support.

Learn more

What to expect when a loved one seeks treatment for an eating disorder

Eating disorders can be diagnosed by trained specialist doctors (such as GPs, paediatricians and psychiatrists), psychologists, dieticians, mental health social workers, or nurses. A good first step once someone is ready to engage in recovery is an appointment with an eating disorder-informed GP, who can provide a referral to a psychologist and dietician who are specialised in eating disorders. You may wish to use an online resource to help locate a health provider who works with eating disorders. These include: in Australia, InsideOut’s treatment services database or the National Eating Disorders Collaboration’s service locator; in the US, Eating Disorder Hope’s treatment finder; in Canada, the National Eating Disorder Information Centre’s provider finder; and in the UK, the National Health Service’s service finder. Alternatively, a GP may also feel it more fitting to refer a patient to a specialist eating disorder service or to a psychiatrist, depending on the individual circumstances.

If/when the person you care about enters recovery, you’ll want to encourage them to continue working with their treatment team, particularly as the eating disorder will likely make them want to disengage when they experience a setback in treatment. Be supportive by gently reinforcing the importance of pushing on with recovery and encouraging them to be honest with the treatment team if they are experiencing difficulties.

Recovery is ‘non-linear’ – that is, it does not always follow a straightforward path. Setbacks are completely normal and to be expected. Know that it can take multiple attempts to recover from an eating disorder and that there is no ‘perfect’ way to recover from an eating disorder. More importantly, recovery is different for everyone. There is no universal definition of recovery, and it is not simply a matter of a change in weight. Instead, recovery may be seen as gaining the coping skills needed to work through times when the eating disorder urges are stronger.

Finally, know that lapses do occur, and these are different from relapses (starting back at square one). Recognise and celebrate the victories and try to minimise lamenting what at times feel like ‘losses’. This is particularly important given that recovery often takes place over a long period of time. Reaching treatment milestones is incredibly valuable for maintaining motivation. Remember that, while the hardest work is up to your loved one, you can play a vital role in supporting them during their recovery journey.

Links & books

Written from both a clinical and lived-experience perspective, the book 8 Keys to Recovery from an Eating Disorder (2011) by Carolyn Costin and Gwen Schubert Grabb offers a self-directed approach to recovery. It provides valuable insight both for individuals looking to recover from an eating disorder and for their loved ones.

The book Boys Get Anorexia Too: Coping with Male Eating Disorders in the Family (2006) by Jenny Langley is useful for loved ones who may be concerned about a male with an eating disorder. It breaks through the stereotype of eating disorders being female-only conditions. Bev Mattocks’s Please Eat… (2013) is another thought-provoking book on this topic, a mother’s perspective on supporting her son through recovery from anorexia.

The book Off the C.U.F.F.: A Parent Skills Book for the Management of Disordered Eating (2016) by Nancy L Zucker, professor in psychiatry at Duke University in North Carolina, is written for parents looking to equip themselves with the skills to identify and support a young person with disordered eating.

Rachel Bryant-Waugh’s guide ARFID Avoidant Restrictive Food Intake Disorder (2020) is written specifically for parents and carers looking to support a child with this condition. It will help loved ones learn the signs and symptoms of ARFID and how to respond in a helpful way.

Letting Go of ED – Embracing Me (2019) by Maria Ganci and Linsey Atkins is a reflective journal for any individual on a journey through eating disorder recovery. The book is equally useful for supporters of individuals with an eating disorder as it provides a nuanced look at some of the challenges experienced during the healing process.

The podcast Butterfly: Let’s Talk delves into topics related to eating disorders, body image and advocacy. It includes episodes focused on perfectionism, identifying eating disorders, and how parents can support body acceptance.

The Understanding Body Matters podcast aims to help those who may be experiencing disordered eating or body image concerns learn more about these issues.

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11 January 2023