Eating disorders affect millions of people around the world. They’re most common in cultures that focus on weight and body image and can affect people of all genders, races, ages, and ethnic backgrounds. People who have a negative body image and those who diet are at risk of developing an eating disorder such as anorexia nervosa, bulimia, binge eating disorder, or a category called other specified feeding or eating disorder (OSFED). Eating disorders have serious health consequences and require treatment. Recovery is likely with early intervention, the help of specially trained health care providers, and a support network.

What are eating disorders?

Eating disorders are complicated psychological conditions that affect a person’s physical and emotional health. They involve intense emotions and behaviors about food. Eating disorders are very dangerous illnesses and can lead to permanent physical and psychological consequences if left untreated.

The five classifications of feeding and eating disorders are anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder (OSFED) and avoidant restrictive food intake disorder (ARFID).

1. Anorexia Nervosa (pronounced: an-or -rex-e-ah) involves food restriction (limiting or not having certain foods or food groups). People with anorexia drastically limit their food intake and have an intense fear of gaining weight, even though their weight might be too low.
2. Bulimia Nervosa (pronounced: bull-e-me-ah) involves cycles of binge eating followed by a purging behavior. People with bulimia will eat an unusually large amount of food in a short period of time and then exercise excessively or purge by self-inducing vomiting, using laxatives, enemas, or diuretics in an attempt to avoid gaining weight.
3. Binge eating disorder involves eating an unusually large amount of food in a short period of time and feeling a loss of control during this episode. People with binge eating disorder do not purge afterwards, but often feel shame or guilt about their binge eating.
4. Other specified feeding or eating disorder (OSFED) involves some combination of symptoms of the other eating disorders such as an intense fear of weight gain and a preoccupation with food (thinking about food or having food related thoughts most of the day). Many people with OSFED have symptoms of the other eating disorders, but may not meet the exact clinical criteria, and therefore are diagnosed with OSFED.
5. Avoidant restrictive food intake disorder (ARFID). A person who has ARFID does not eat enough which is marked by unhealthy weight, nutritional deficiency, and/or interference with social functioning. The main difference between anorexia and ARFID is that someone with ARFID does not have a fear of gaining weight or body image concerns. ARFID may be characterized by a limited list of foods someone will eat, extreme pickiness, or fear or adverse reaction to food such as choking or vomiting.

Disordered eating is a term used to describe when someone doesn’t have a diagnosed eating disorder, but their eating patterns and behaviors put them at risk for developing an eating disorder. For example, anorexia nervosa can start when dieting becomes too extreme; binge eating disorder or bulimia nervosa can start because dieting often restricts the amount and types of food, so when a diet is broken, it can lead to uncontrollable eating and loss of control around food. Sometimes extreme healthy eating is referred to as “orthorexia” which is not a diagnosable eating disorder but may still be a problem if interfering with health or day-to-day functioning.

Prevalence rates or how often eating disorders occur varies with each disorder. While anorexia nervosa and bulimia nervosa are fairly rare, binge eating disorder and OSFED are slightly more common. A study done in 2011 estimated that 0.3% of Americans between the ages of 13-18 suffer from anorexia, 0.9% from bulimia, and 1.6% from binge eating disorder (Swanson et al. 2011). Estimates of OSFED differ from study to study, but may be as high as 15%.

Body Image and Self-Esteem: Teens are constantly exposed to unrealistic standards in the media such as airbrushed images, very skinny models, and constant celebrity images on social media and may feel pressure to lose weight or look a certain way. Because of these pressures, many teens develop negative body image and self-esteem. It’s important for teens to find ways to feel comfortable with the natural shape and size of their bodies.

Body distortion: Body distortion is when someone sees their body shape, size and appearance differently from what everyone else sees. Body distortion causes a person to over-focus on flaws or imperfections that they are insecure about. Most people who struggle with an eating disorder have body distortion issues and often worry about how they look or what people will think of them. These negative thoughts can be difficult to get rid of, and it is helpful to learn positive self-talk strategies with a therapist.

How do I improve my body image?

• Write down things that your body can do when it’s healthy (running, dancing, hiking, biking, etc.).
• Write down 10 qualities you like about yourself (caring, responsible, funny, smart, creative etc.).
• Make a list of accomplishments you are proud of.
• Buy clothes that you feel comfortable in and give away any that make you feel self-conscious or uncomfortable.
• Relax using all your senses. Take a bath, listen to music, play a game, sing, or meditate.
• Spend time with positive people who make you feel comfortable and you can be yourself around.
• Remind yourself that everyone’s body is unique and not everyone is meant to be the same shape or size.
• Be critical of advertisements, magazines and the media. Many people will send emails or messagesto a company if they find their ads or articles upsetting or hurtful.
• Make yourself smile when you look in the mirror. It might feel weird at first, but after a while, you could start to notice a difference in the way you see yourself.

What do I do if I think my friend has an eating disorder?

Approaching a friend who you think has an eating disorder can be very hard. People who have eating disorders might be in denial, and therefore very defensive about their behaviors. They also tend to be very secretive about their behaviors, and often refuse to talk about their problems. Despite the strong reactions, it’s very important to continue to try and help someone you care about. In most cases, they need a lot of support and encouragement from friends and family to help them take the first step to seek treatment.

What are some suggestions for supporting someone you care about?

• Talk about the issue in a supportive and caring way
• Remind them how much you care about them and how important they are to you
• Read as much as you can about eating disorders to better understand what they’re going through
• Be direct
• Talk to them in private, not around other people or in public
• Instead of using the word “you” say “I” (ex. I’ve noticed that you have been eating less, or I’ve noticed that you always go to the bathroom after meals)
• Be patient and go slowly, it may take them a while to come to terms with their issue, and admit that they are struggling
• Always be there as a support and encourage them to seek treatment, if necessary
• If you feel uncomfortable talking to them directly or feel as if they won’t listen, write them a letter
• Talk to your parent(s) or a professional such as a teacher, school counselor, health care provider, nurse, or another trusted adult that will respect your friend’s privacy
• Be encouraging

Things to avoid:

• Sounding threatening or judgmental
• Talking about food or weight
• Offering them advice regarding food, exercise, etc.
• Controlling what they eat and how much
• Being the “food police” (watching or commenting on everything they eat), which could cause them to feel uncomfortable and not trust you

Teens with eating disorder behaviors or symptoms may be referred to an eating disorder program by their pediatrician, family doctor, or nurse practitioner. While no two programs are exactly the same, outpatient programs usually perform a complete assessment to provide appropriate treatment for teens with eating disorders and support for family members. The approach is usually multidisciplinary, which means that more than one specially trained health care provider will be involved in the evaluation and treatment plan. All of these team members will likely involve the family as well, to plan the guidance and support needed at home. College students and young adults often see the team alone, but may still work with parents or other family members.

The first visit typically includes:

Medical Evaluation by a health care provider (HCP) who is specialized in caring for teens.

Your HCP will:

• Check your blood pressure, pulse, temperature, and weight
• Ask you and your family about your medical history
• Ask you questions about your eating habits and menstrual periods
• Order tests such as labs (blood tests), urinalysis (to see if you are drinking the right amount of fluids), EKG (a test which looks at the activity of your heart if your heart rate is low), and/or bone density test (DXA scan), if needed

Mental Health Evaluation by a psychologist or social worker experienced in eating disorder treatment.

You and the mental health provider may talk about:

• How you feel about the way your body looks
• Your food related behaviors
• Your family’s concerns about your health
• Your thoughts and feelings about being evaluated for an eating disorder
• Your treatment goals
• Anything else you feel is important for the counselor to know

Nutrition Evaluation by a registered dietitian experienced in eating disorder treatment.

You and your dietitian will:

• Talk about your food likes and dislikes
• Talk about any behaviors you have related to food
• Discuss common myths about food and eating disorders
• Talk about your health goals and concerns about changing your behaviors
• Work with you and your family on creating a healthy eating plan for you

After the evaluation:

Your HCP will talk to you about a personal treatment plan that will likely include:

• Individual and family therapy
• Medical monitoring by your primary care provider
• Nutritional counseling and support from your dietitian

The Treatment Team: Eating disorders are both medical and psychological conditions. Therefore, treatment usually includes working with a team of specialists including: a doctor or nurse practitioner, therapist or counselor, a dietitian, and sometimes a psychiatrist or family therapist.

The Health Care Provider’s (HCP) role is to:

• Keep track of a person’s medical health by checking height, weight, blood pressure, pulse, and temperature.
• Draw blood or take urine samples, if necessary, to make sure the chemicals in the body called electrolytes are balanced.
• Order special tests such as an EKG to monitor heart rhythm, or a bone density test (DEXA) to see if osteoporosis (thinning of the bones) is present or developing.
• Offer suggestions on achieving weight goals, calcium and vitamin supplements, exercise, hormone replacement, and possibly medication for anxiety or depression.
• Determine the best treatment option for you. The HCP may suggest meeting with a therapist and nutritionist, going into residential treatment, having a family-based therapist, or being hospitalized until medically stable.

The Therapist/Counselor’s role is to:

• Help improve self-esteem, body image, and confidence.
• Involve parents and other family members in providing support, guidance, and supervision of meals.
• Teach healthy ways to manage emotions and stressful situations.
• Address other emotional problems that may be related to the eating disorder, such as depression, obsessive-compulsive disorder, or substance abuse.
• Create a place where someone can (privately) discuss her/his needs and goals.
• Provide a safe place to experience feelings of sadness, anxiety, anger, etc.
• Discuss disordered eating thinking and behaviors, and teach strategies to become mentally healthy.

The Family-based Therapist’s role is to:

• Provide parents guidance and support around refeeding their child.
• Teach parents how to manage mealtime conflict.

The Registered Dietitian’s role is to:

• Help create a safe and healthy eating plan that is balanced in all the food groups.
• Answer questions about food.
• Teach why our bodies need specific nutrients and which foods provide them.
• Offer suggestions on healthy eating, how to achieve weight goals, vitamin and mineral supplements, and exercise.
• Discuss the harmful myths and confusing messages about food and diets.

Treatment for an eating disorder is a very individualized process. Therefore, there are different types of treatments depending on how medically stable a person is and how much emotional support they need.

What to expect at each level of treatment:

Outpatient: for someone who is beginning to struggle with an eating disorder, or who is stepping down from residential or intensive outpatient (sometimes called IOP). There are two approaches to outpatient treatment: multi-disciplinary and family-based.

Multi-disciplinary: This type of treatment often involves regular meetings with ALL members of the treatment team. Medical providers usually schedule weight-checks for patients who are recovering from an eating disorder anywhere from 3 times a week to once a month. They may also want to check blood pressure, heart rate, and urine to make sure the patient is drinking enough fluids. Meetings with the therapist and dietitian may be scheduled weekly or bi-weekly.

Family-based treatment (FBT): This type of treatment puts parents and/or family members in charge of the recovery process. Family members control their child’s food and offer support at every meal and snack with guidance from a licensed therapist who specializes in family-based treatment. Family-based treatment is usually done at home, and may involve only the family-based therapist and a medical doctor, but other health professionals may also be involved. The focus of the treatment is on weight restoration and behavioral change. Once weight is restored the therapy will focus on normal adolescent developmental issues.  This type of therapy is sometimes referred to as the “Maudsley” approach.

Intensive outpatient program (IOP): This type of treatment is for people either transitioning back into school, work, etc. from residential or partial hospital level of treatment, or for people who are not ready for or do not require a higher level of treatment. Intensive outpatient treatment usually involves evening group meetings 3-5 days per week. The amount of time spent at the program each day varies between programs. Usually one meal is supervised which may be provided by the program or brought by the patient.

Partial hospitalization program (PHP): This type of treatment occurs during the day and 2-3 meals are provided and supervised along with group and individual therapy, and nutrition education. Patients in partial programs often attend 5 days per week and go home at night.

Residential: This type of treatment is for medically stable patients who need a very structured level of treatment. Patients live and sleep in a center with other young people. Patients in residential programs have frequent meetings with their team (therapist, dietitian, nurse and/or health care provider, and psychiatrist) and have a lot of group meetings. After residential treatment, patients often meet with an outpatient team, or transfer to an intensive outpatient program.

In-patient: This type of treatment is for people with severe eating disorders who are medically unstable or people who were unsuccessful with treatment at a lower level. Patients receive 24-hour hospital supervision and care and have a very structured schedule. Once medically stable, patients may go home or go to residential treatment.

Treatment of eating disorders varies from person to person. Some people only do outpatient treatment, while others may need to transition through multiple levels of care as part of their eating disorder treatment. Transitioning into outpatient from inpatient or residential treatment may be very challenging in the beginning.

If you are transitioning from inpatient or residential to outpatient treatment, here are some important things to remember:

• Before you leave inpatient or residential treatment, set up an outpatient team that you can meet with regularly. Ask your treatment team to help you find providers that are the right fit for you and who accept your health insurance. Usually an outpatient team consists of a therapist, dietitian, HCP or nurse practitioner, and often psychiatrist and/or a family therapist.
• Some days will be easier than others. It’s OK and normal for you to have some challenging days.
• It will be your responsibility to follow your meal plan when you are in an outpatient setting, not engage in unhealthy behaviors, and maintain a healthy weight.
• Don’t be afraid to seek support from family and friends when necessary, especially around meals. In some cases, your parents might be asked to be in charge of your meal plan.
• Think about one meal at a time, and try not to become discouraged if you have a hard time once in a while.
• Be completely honest with your treatment team and tell them if and when you have any thoughts about disordered eating or if you begin using unhealthy behaviors again.
• Realize that treatment and recovery are a process and that might mean stepping back up to a higher level of care at some point if your behaviors and/or weight are not improving at the outpatient level of care.

Group Support Meetings can also be helpful before treatment or during recovery. People with eating disorders often find it helpful to meet other people who are experiencing similar challenges. Group meetings are both encouraging and valuable because young people can share stories, feelings, accomplishments, and coping methods. Group meetings can usually be found at local health centers, agencies, or schools.

Therapy: Because an eating disorder is both a medical and psychological condition, most people with eating disorders meet with a therapist or counselor as part of treatment. Although some people may feel embarrassed about going to therapy, it’s important to keep an open mind. Many teens, including those with and without eating disorders, find therapy very helpful.

Why should I see a therapist?

There are a lot of benefits to seeing a therapist and the specific benefits can differ from person to person. Although there are many different types of therapy, therapy tends to be individualized, meaning that you and your therapist will work on what’s most helpful to you.

Here’s what an individual therapist can do for you:

• Provide a safe place to (privately) share feelings without judgment and without fear of causing problems or hurting someone else’s feelings
• Give you a place to address other emotional problems that may be related to the eating disorder such as depression, obsessive-compulsive behaviors, and/or substance abuse
• Help you process parts of your life that may affect your mood
• Help you figure out reasons why you may have developed an eating disorder, what function/role it has played in your life, and what triggers you to use certain behaviors
• Help you examine thoughts that might be unhealthy, distorted, or obsessive
• Teach you healthy ways to cope with stress and manage strong feelings
• Help you build self-confidence, self-esteem, and a positive body image

One teen wrote: “It has always been hard for me to open up even to my closest family members and friends. When I finally started opening up in therapy and sharing thoughts and feelings that I had never talked about before, I noticed a huge difference in my mood and how happy I was. Since then, my friends have told me what a huge difference they see in me and how much more open I am. I know this sounds cheesy, but there is no way this would have been possible had I not gone to therapy.”

What are the different types of therapy I might find?

CBT (cognitive behavioral therapy): A type of therapy that teaches you how to be alert to the thoughts you have as you do certain behaviors. CBT targets thoughts and behaviors that are unhealthy or unhelpful. The focus of CBT is to decrease negative thoughts or unhealthy behaviors.

DBT (dialectical behavioral therapy): A type of therapy that encourages you to embrace the thoughts and feelings you have but to think in ways that prevent harmful behaviors. It is primarily a group-based therapy with individual therapy back-up. You keep logs of your thoughts and feelings, and you will learn and discuss coping strategies with your therapist.

Family therapy: A type of therapy that involves you and your family members and or friends meeting with a therapist. Many treatment programs will include family therapy because it can be a very helpful place to discuss family issues and tensions while there is a therapist or counselor there to find a solution. It can also be a good place to talk to your family members and friends about your eating disorder and how they can best support you throughout the process of recovery. Note: this is different from family-based treatment (FBT) which is described above.

Group therapy: Is when you and other peers meet with a counselor as a group and can share experiences, stories, goals, etc. It can be very helpful to talk to other people who are going through the same thing as you and get advice on what has helped them.

Tips:

• It’s ok to feel uncomfortable at first. It takes everyone different amounts of time before people begin to feel comfortable opening up to their therapist. If this is your first time seeing a therapist, it is totally normal for you to be shy.
• Be honest. Therapy gives you a chance to share how you genuinely feel without being judged or offending anyone. Everything you say to your therapist is confidential, unless you say something that makes them concerned for your, or someone else’s safety. The more honest you are with your therapist, the more helpful therapy will be.
• If you don’t think your therapist is a good match for you, find another therapist. It’s very important for you to feel like you can trust your therapist. If you don’t connect with them, don’t be afraid to ask your parents to find you another one. The more comfortable you feel, the easier it will be for you to open up and be honest.

Myth: Everyone with an eating disorder is underweight.

Truth: Eating disorders effect individuals across the weight spectrum. Eating disorders do not discriminate based on body-size.

Myth: Eating disorders are just an extreme form of dieting.

Truth: Unlike dieting, eating disorders aren’t just about losing weight. Eating disorders are psychological problems with serious physical consequences.

Myth: Only girls and women have eating disorders.

Truth: Eating disorders happen in all genders. Evidence shows that trans gender and gender non-binary populations are at 2-4 times great risk of experiencing an eating disorder compared to cis-gender individuals.   According to the National Eating Disorder Association, up to 1 in 3 eating disorder diagnoses in teens are male, and disordered eating behaviors in general are as common among males as they are among females. Similar to with women, risk factors for all genders include being an athlete in a sport with weight requirements, like wrestling, rowing, and gymnastics, or endurance sports like track and field, cross country, and swimming. Studies have shown that about the same amount of men suffer from binge eating disorder as women. Men with eating disorders might be focused on gaining muscle mass, so it might appear that they are simply “getting in shape.”

Myth: People choose to have an eating disorder.

Truth: No one chooses to have an eating disorder. A combination of things can start an eating disorder, and recovery involves a lot of time and support from family, friends, and eating disorder specialists such as a therapist, nutritionist, and medical provider.

Myth: People with anorexia don’t eat anything.

Truth: Although some people with anorexia eat very small quantities, some just restrict the types of foods or amounts that they allow themselves to eat. For example, they may only eat foods that are low in fat or calories, or foods that don’t have carbs in them. They might also try to hide their eating disorder and attempt to eat what would appear to be a normal amount when in front of other people.

Myth: The media is the cause for all eating disorders.

Truth: The media’s constant focus on dieting, losing weight, and being thin can definitely contribute to an unhealthy obsession with food and weight, but whether or not someone develops an eating disorder has a lot to do with other factors, too.

Myth: Someone can only have one type of eating disorder.

Truth: People with one type of eating disorder can develop symptoms of another eating disorder over time. For example, some people who restrict their food intake may go on to develop binging and/or purging behaviors.

Myth: It’s almost impossible to recover from an eating disorder.

Truth: Complete recovery is possible, but it can take a long time. Recovery can take anywhere from months to years because it requires someone to change the way they think and act about food, as well as deal with stress, trauma, abuse, and/or other psychological problems. It also takes a team of specialists to address all the issues that led to the eating disorder. Recovery can rarely be done without professional help.

Myth: Only white, upper-class girls suffer from eating disorders.

Truth: Eating disorders affect all genders, races, ages, and socioeconomic groups.

Myth: Eating disorders aren’t very serious.

Truth: Eating disorders are serious psychological conditions and can lead to very serious medical problems. Most of these medical problems are a result of malnutrition (not getting enough nutrients) or weight-loss techniques such as vomiting. There can also be medical consequences as a result of self-harm. Eating disorders must be taken seriously and require treatment before they become too severe.

Myth: Eating disorders are rare.

Truth: Lifetime prevalence of full-diagnosed eating disorders among the United States population is around 5%, with projected lifetime mean prevalence estimates increasing to 14.3% for male individuals and 19.7% for females.

Myth: You can never exercise too much.

Truth: It is possible to over-exercise, and it can actually be very dangerous. Over-exercising or “compulsive exercising” is actually a form of purging. Compulsive exercisers will make exercise their top priority, feel guilty when they don’t exercise, and use exercise as a way to either “earn” or “burn off” food and exercise an obsessive amount. They might exercise despite being injured or sick, or exercise regardless of weather conditions.

Myth: You can never eat too healthy.

Truth: When someone becomes obsessed with only eating foods they think are “pure” or “natural,” and limits their food intake to a very narrow selection of “healthy” or “clean” foods, it can lead to what is called “orthorexia” and may be considered a form of OSFED. People with orthorexia often will avoid eating “unhealthy” foods such as those with fats, preservatives, artificial ingredients, and/or processed sugar. By severely limiting the types of foods they eat, they may not be getting essential nutrients such as calcium and fats, which can lead to malnutrition.