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

What are eating disorders?

Eating disorders are complicated psychological conditions that affect a person’s physical and mental 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-ee-ah) involves food restriction (limiting or not having certain foods or food groups). People with anorexia drastically limit their food intake (both in quantity and variety) and have an intense fear of weight gain. Their weight is often affected by their lack of caloric intake.
2. Bulimia Nervosa (pronounced: bull-ee-me-ah) involves cycles of binge eating followed by purging behavior(s). People with bulimia will eat an unusually large amount of food in a short period of time and then purge by self-induced vomiting, using laxatives, diuretics, or excessively exercising 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 other eating disorders such as an intense fear of weight gain and a preoccupation with food but does not meet the exact clinical criteria for another eating disorder. Atypical anorexia (where a person’s weight is not significantly low), purging disorder (similar to bulimia but without the binge eating element) and night eating syndrome are all examples of OSFED..
5. Avoidant restrictive food intake disorder (ARFID). ARFID exists in three different subtypes; fear of consequence (such as choking on food or vomiting after eating), sensory sensitivities (such as being bothered by strong smells or certain textures of foods), or lack of interest in food/low appetite. A person with ARFID does not eat enough which is marked by lower than expected weight, nutritional deficiencies, 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.

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 diets often restrict the amount and types of food eaten, which often leads to cravings and excessive hunger, thus causing 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, but overall, studies suggest that 1.2% of adolescent boys and 5.7% of adolescent girls have diagnosed eating disorders (López-Gil et al. 2023). The prevalence is likely higher because many eating disorders go undiagnosed.

Body Image and Self-Esteem: Teens are constantly exposed to unrealistic body ideals in the media such as airbrushed images, very skinny models, and constant celebrity images on social media which may cause 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 how it really is. 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. This is sometimes diagnosed as the mental health condition body dysmorphic disorder (BDD) if it gets in the way of normal life. These negative thoughts can be difficult to navigate, and it is helpful to work on 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 that don’t involve your physical body (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, social media “influencers” and other media outlets. You could send emails or messages to a company if you 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 is very hard. People who have eating disorders might be in denial, and possibly 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 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 eating)
• 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 or how much
• Being the “food police” (watching or commenting on everything they eat), which could cause them to feel uncomfortable and not trust you

Additional Resources

Anorexia Nervosa: Symptoms of anorexia can be hard to notice because people with this condition can be very good at hiding their eating disorder behaviors. They may take small bites, organize their food, or “pick” at food when they eat. They often avoid eating around others to hide their behavior or because it causes anxiety. They may also dress in clothes that hide the amount of weight that they have lost and avoid being seen in revealing clothes such as bathing suits.

Some of the signs of anorexia nervosa are:

Physical:

• Brittle nails
• Low energy
• Constipation (trouble having regular and soft bowel movements)
• Dehydration (not enough fluids in the body)
• Dizziness
• Dramatic weight loss
• Dry skin
• Extreme thinness
• Growth of lanugo (soft furry hair) on face, back, and arms
• Hair loss
• Loss of periods (amenorrhea)
• Low blood pressure and irregular heartbeat
• Orangey color to the skin
• Paleness
• Poor concentration
• Sensitivity to cold
• Slow heart rate
• Slow or stunted growth
• Swelling of legs, feet, or ankles
• Weak bones (that can lead to fracture and osteoporosis)

Emotional:

• Anxiety or nervousness
• Denial of a problem
• Depression
• Distorted body image (believes their body looks different than it actual does)
• Body checking (frequent checking of weight, measuring of body parts, examining in the mirror)
• Fear of weight gain
• Irritability
• Lack of emotion
• Low self-esteem
• Obsession with food
• Perfectionism
• Withdrawal from friends and activities

Bulimia Nervosa: You often can’t tell if someone has bulimia by their appearance because many of the symptoms aren’t as obvious as with anorexia nervosa. People with bulimia are usually not underweight and often hide their eating habits and behaviors so friends and family won’t always notice that there’s a problem.

Some of the signs of bulimia nervosa are:

Physical:

• Constipation (trouble having regular and soft bowel movements)
• Dehydration (not enough fluids in the body)
• Dry, flaky skin
• Electrolyte problems (not the right balance of the fluids in the body)
• Irregular heartbeat (caused by low potassium levels)
• Irregular periods
• Sore throat
• Swollen face (from extra fluid in the body or enlarged salivary glands)
• Tooth decay/loss (cavities, loose teeth)
• Weight fluctuations (weight loss and gain)

Emotional:

• Anger that is hard to control
• Denial of a problem
• Depression or anxiety
• Distorted body image (believes that their body looks different than it actually does)
• Body checking (frequent checking of weight, measuring of body parts, examining in the mirror)
• Fear of weight gain
• Impulsivity
• Intense focus on “flaws” and physical appearance
• Shame or guilt
• Withdrawal from friends

Binge Eating Disorder: Most of the outwardly physical signs of binge eating disorder are related to weight fluctuations that can occur with eating large quantities of food.. People with binge eating disorder are often, but not always, in larger bodies. The loss of control that happens in binge eating disorder can lead to significant emotional distress such as guilt and shame.

Some of the signs of binge eating disorder are:

Physical:

• Gallbladder disease
• High blood pressure and cholesterol levels
• Insulin resistance
• Joint pain
• Type II Diabetes
• Weight gain

Emotional:

• Anxiety
• Depression
• Shame, loneliness, and self-hatred
• Withdrawal from friends

What happens when a person doesn’t eat?

Our bodies use food as fuel to keep all the important organs and cells running well. When a person doesn’t eat, their body doesn’t get the fuel it needs, causing organs and body parts to suffer. This is often called low energy availability, simply meaning that the body has low energy stores and not enough energy for normal body functions. Low energy availability affects the body in the following ways:

Heart & Circulation: The heart is a muscle that can shrink and weaken when a person doesn’t eat enough. This can create circulation problems and an irregular or very slow heartbeat. Blood pressure can drop very low during starvation and a person may feel dizzy when they stand up (which can lead to fainting if severe).

Stomach: The stomach becomes smaller when a person doesn’t eat or eats less for a prolonged period of time so when they start eating again, the stomach will likely feel uncomfortable (stomach aches and/or gas). Also, the stomach will not empty as fast, making a person feel full longer.

Intestines: The intestines will move food slowly through the gastrointestinal system often resulting in constipation (trouble having a bowel movement) and/or stomach aches or cramps when eating meals.

Brain: The brain, which controls the body’s functions, does not work properly without food. For example, a person may have trouble thinking clearly or paying attention. They could also feel anxious and sad.

Body Cells: The balance of electrolytes in the blood can be changed with malnutrition or with purging. Without food, the amount of potassium and phosphorous can get dangerously low which can cause problems with muscles and brain functioning.  Low potassium or phosphorus can also cause life-threatening heart rhythm problems.

Bones: When a person doesn’t eat, their bones often become weak due to low calcium and low hormone levels, which increases the risk of breaking a bone (like a stress fracture) and prematurely developing weak bones (increasing risk for osteoporosis).

Body Temperature: The body naturally lowers its temperature in times of starvation to conserve energy and protect vital organs. When this happens, there is a decrease in circulation (blood flow) to fingers and toes which will often cause hands and feet to feel cold and look bluish.

Skin: Skin becomes dry when the body is not well hydrated and when it does not get enough vitamins and minerals from food. The skin will naturally protect the body during periods of starvation by developing fine, soft hair called “lanugo” that covers the skin to keep the body warm.

Hair: When hair doesn’t get enough nourishment from the vitamins and minerals that are naturally found in food, it becomes dry, thin, and it can even fall out.

Nails: Nails require nutrients in the form of vitamins and minerals from the diet. When a person doesn’t eat, nails become dry, brittle, and break easily.

Teeth: Teeth need vitamin D and calcium from food sources. Without vitamin D and calcium, a person can end up with dental problems such as tooth decay and gum disease. Purging can also destroy tooth enamel.

There are many theories about what causes eating disorders and for each person the reason can be different. However, most eating disorders are caused by a combination of biological, psychological, and environmental factors and sometimes the cause may not be completely clear.

Biological

• A family history of anorexia, bulimia and/or binge eating disorder may increase certain people’s risk of developing an eating disorder because of their genes or family upbringing
• Chemicals in the brain that control hunger, digestion, and appetite
• Hormones (such as leptin and ghrelin) that control satiety and hunger

Psychological

• Obsessive compulsive disorder (OCD)
• Past or current trauma such as physical, emotional, or sexual abuse
• Anxiety
• Depression
• Desire to have control over some aspect of life
• Inability to control behaviors
• Personality traits such as perfectionism (wanting to be perfect), extreme desire to succeed, and impulsivity (doing things without planning or considering the consequences)
• Family values about body size, appearance, and food
• Low self-esteem or self-worth
• Sense of loss

Environmental

• Society’s intense focus on thinness and dieting
• Participation in sports that focus on body shape and size such as dancing, rowing, gymnastics, track, wrestling, etc.
• Abusive or troubled relationships that cause emotional stress and feelings of loss of control
• Stress at school, sports, with peer groups, etc.
• Specific cultural attitudes about how a person should look and behave

You can’t tell whether a person is struggling with an eating disordered just by looking at them, but there are often warning signs. Warning signs or “red flags” might suggest that a young person may develop or already has an eating disorder. Below are lists of signs that are linked to certain types of eating disorders. A person who has an eating disorder may have one or more of these signs. These signs may also mean that a person has another kind of health condition, so it’s best to talk with a trusted adult about your concerns before jumping to any conclusions.

Red flags for Anorexia Nervosa:

• Skips meals
• Makes excuses not to eat
• Over-exercises (makes exercise a top priority)
• Eats only “safe” foods (low calorie, low-fat)
• Doesn’t eat certain food groups (ex. carbs, fats)
• Has unusual behaviors around food (organizing food, cutting food into small pieces, always finding something wrong with food, pushing food around the plate, adding excessive amounts of condiments)
• Cooks or bakes food for others but doesn’t eat it
• Watches food shows or visits food websites or social media feeds constantly
• Obsessively reads nutrition information or counts calories
• Constantly weigh themselves, or “body checks” (looks at their body in the mirror or feels their body with their hands)
• Chews a lot of gum or drinks large amounts of water, coffee, diet soda, or calorie-free beverages
• Denies that there is a problem despite weight loss
• Recent switch to vegan/vegetarianism
• Withdraws from social gatherings involving food

Red flags for Bulimia Nervosa:

• Uses the bathroom after eating or in the middle of meals
• Consumes unusually large amounts of food at one time
• Loses control around food
• Has scars or calluses on hands and knuckles from using their finger to vomit
• Hides food or empty wrappers
• Diets often
• Food may be missing from cabinets at home or disappear rapidly

Red flags for Binge Eating Disorder:

• Frequently eats large amounts of food in one sitting
• Loses control around food
• Eats when not hungry
• Eats alone, often eats in secret
• Eats as a way to control emotions
• Hides food or empty wrappers
• Others notice food disappearing rapidly
• May hoard food

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 check for dehydration), 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 medical team
• 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 (DXA) 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. Your 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 anxiety, depression, obsessive-compulsive disorder, or substance abuse.
• Create a place where someone can (privately) discuss their 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 balanced eating, how to achieve weight goals, vitamin and mineral supplements, and exercise.
• Discuss the harmful myths and societal 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 and vital sign checks for patients who are recovering from an eating disorder anywhere from once a week to once a month. They will 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, 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 often 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.

Inpatient: 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.

What is healthy balanced eating?

Healthy eating is important for both your mind and body. During the recovery process, work with your dietitian to help you learn balanced eating habits. The goal of eating is to keep your body nourished, energized, and strong. Eating in a balanced way helps you concentrate and learn in school, reach and maintain a healthy weight for you, grow to your maximum height, and keep your muscles and bones strong. An eating plan is not supposed to be strict; it is flexible and may differ from person to person and depending on your situation or environment. It involves incorporating regular meals and snacks during the day, eating when you are hungry and stopping when you are full, and enjoying treats. To eat in the most beneficial way for your body, you must eat foods from all of the food groups (carbohydrates, protein, fruits, vegetables, dairy, and fats) because each food group has different benefits.

Carbohydrates: The carbohydrates in foods like grains and starchy vegetables supply your brain and your muscles with energy. They help keep your mind sharp and focused, and are needed for sports performance. Carbohydrates provide energy to all of the cells in your body and whole grains especially provide the fiber you need for normal digestion.

Dairy: Vitamin D and calcium-rich dairy foods help keep your bones strong. The protein in dairy foods also helps keep you full between meals. Soy milk is a diary alternative that provides similar amounts of these important nutrients for those who avoid cow’s milk for any reason.

Fruits/Veggies: These foods contain many important vitamins and minerals, and the fiber you need for normal digestion.

Protein: Protein has lots of important functions in your body such as nourishing your hair, repairing and building muscles, and making hormones and enzymes.  Protein helps you feel full after a meal or snack.  It also is important for fighting infections and healing wounds and cuts.

Fats: Fats found in oils (such as canola oil or olive oil), nuts, nut butters, and fish are great for your heart and your skin. Eating these and other fats such as cheese and butter with meals and snacks can boost your hormone levels, which may help regulate periods for people who menstruate or testosterone levels for males. Fats are also important for the absorption of fat soluble vitamins (vitamin A, D, E and K) which we get from other important sources like fruits and vegetables. They can also aid with bowel movements. Fat is also important for satiety (feeling full) between meals, and adds flavor to your meals.

Meal plans: Meal plans are designed to help you transition back to healthy eating. During treatment, you may get a meal plan from your dietitian that breaks down each meal into servings of food (called “exchanges”) from the different food groups. Each meal should include exchanges from all or most of the food groups, and the number of exchanges you need from each food group will be based on your specific nutritional needs. Your dietitian will help you design meals and snacks based on the exchanges on your meal plan that fit your individual needs. Long term recovery means moving away from meal plans and learning to follow your hunger cues.

Snacks: Snacks give you energy between meals and prevent you from getting overly hungry. Balanced snacks should be made of two or more food groups. Check out the sample list of snacks below. You can see how the snack ideas are made from different food groups such as carbohydrate, fat, dairy, fruit, vegetable, and protein groups.

Sample Snack List:

• Banana with peanut butter (fruit/protein/fat)
• Grapes and a cheese stick (fruit/dairy/fat)
• Vanilla yogurt with strawberries (dairy/fruit)
• Cheese and crackers (fat/dairy/grain)
• Hummus and baby carrots (fat/protein/vegetable)
• Nuts and dried fruit (fat/protein/fruit)

Grocery shopping: Try grocery shopping with someone you feel comfortable around. You can work with your dietitian to help set goals for trying new foods or reintroducing foods you used to enjoy. If going to the grocery store seems stressful, your dietitian can help you create a list of foods you plan to buy before you go. Once you are more comfortable with grocery shopping, take time to explore the whole grocery store and look for different brands or new foods to try.

Food journal: A food journal can help you keep track your hunger/fullness and your feelings at meal or snack time. Recording this information can also help you tune into your body’s hunger/fullness cues and help you identify areas where you need more support. Talk to your dietitian about whether keeping a food journal is right for you.

Cooking: Helping to plan your meals and snacks ahead of time helps minimize the stress that can be experienced during meal preparation. Your dietitian can assist you with meal planning and how to get the best support around meals and snacks.

Hunger and fullness: Eating when you’re hungry and stopping when you’re full will help your body balance its energy needs and keep you feeling comfortable. Part of normalizing your eating habits will first include the re-feeding process and then re-learning how to listen to your body. Throughout the recovery process, your dietitian can help you tune into your body’s hunger and fullness cues. Learning to both listen and understand your body’s cues takes time. Using a hunger and fullness scale can help you better understand your body. Rate your hunger level before you eat and after you finish. As you keep track of your hunger/fullness cues, you can start to see a pattern in your eating habits. Picture a range of hunger and fullness from 0-10 where “0” means absolutely starving and “10” means uncomfortably full. Ideally you will learn to eat when you are a “3” or “4” and stop eating when you reach a “7” or “8”. If you already keep a food journal, talk to your dietitian about including your hunger and fullness rating in your food journal.

Myth: Everyone with an eating disorder is underweight.

Truth: Eating disorders affect 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 occur in all genders. Evidence shows that transgender and gender non-binary populations are at 2-4 times great risk of experiencing an eating disorder compared to cisgender 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 females, 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 factors can cause an eating disorder, and recovery involves a lot of time and support from family, friends, and eating disorder specialists such as a therapist, dietitian, 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 about and act around 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. Eating disorders can be a deadly condition; the prevalence of those with anorexia nervosa who have died by suicide is as high as 20% (Quian et al, 2022)

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”. 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. Additionally, healthy eating to this extreme can impact social life as many individuals who very carefully watch their intake may feel anxious about eating in public, going to events or simply eating outside the home.

Amenorrhea: When someone stops getting their a menstrual period (or never gets their period even though they should). Amenorrhea is a sign that someone’s weight may be too low or that the hormones in the body are not working right.

Anorexia nervosa: An eating disorder in which people drastically limit their food intake, have an intense fear of gaining weight, and have weight loss that is not appropriate for their development and physical health..

Avoidant Restrictive Food Intake Disorder (ARFID): An eating disorder which is marked by low weight status for prior growth, nutritional deficiency, and/or interference with social functioning without fear of weight gain or body image concerns.

Binge eating disorder (BED): An eating disorder characterized by eating an unusually large amount of food in a short period of time and feeling a loss of control during these episodes. They do not purge afterwards, but often feel a lot of shame or guilt about their binge eating.

BMI (Body Mass Index) :  A number that is calculated based on someone’s weight and height. This number is to help determine whether or not someone is below, in, or above a healthy weight range for their age based on their growth chart.

Bone density: A measure of how strong your bones are.

Bulimia nervosa: Cycles of binge eating followed by a purging episode. People with bulimia will eat an unusually large amount of food in a short period of time and then compensate after in an attempt to avoid gaining weight.  They may compensate by exercising excessively and/or purging by self-induced vomiting or use of laxatives, enemas, or diuretics.

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.

Challenge foods: Foods that people with eating disorders try to avoid because they may be considered unhealthy or because eating them may lead to binging or purging/vomiting. They may also be called “trigger” or “risk” foods.

DBT (dialectical behavioral therapy): A type of therapy that encourages patients to embrace the thoughts and feelings they have but to think in ways that prevent harmful behaviors. It’s primarily a group-based therapy with individual therapy back-up. Patients keep logs of their thoughts and feelings, and during treatment, they learn and discuss coping strategies.

DXA (Dual-energy X-ray Absorptiometry) scan: A test that measures bone density and strength of bone.

ED behaviors: Habits that people develop when they have an eating disorder. Behaviors may include vomiting after meals, cutting food into very small pieces, counting calories, exercising obsessively, overeating, skipping meals or eating very small meals, etc.

EKG (electrocardiogram): A test that looks at the activity and rhythm of the heart.

Electrolytes: nutrients that keep the heart and body working properly. These include sodium, potassium, and chloride.

Exchanges: Servings of foods from different food groups. Some meal plans are based on the exchange system, meaning they are divided into main groups (protein, fat, starch/grain, beverage, dairy, fruit, and vegetable).

Family-based treatment (FBT): A type of therapy that empowers parents to learn ways to get their child to eat. The therapist meets with the whole family to support the parents in feeding their child and the child in their efforts to recover. The goal of family-based treatment is weight restoration. This type of therapy is sometimes referred to as the “Maudsley” approach.

Family therapy: A type of therapy that involves the patient and their family members meeting with a therapist together. It can be a helpful place to discuss family issues and tensions while a therapist or counselor is there to find a solution.

Group therapy: A type of therapy where peers share experiences and stories with each other, and is usually led by a therapist or counselor.

Meal plan: An eating plan that is designed by a registered dietitian. A meal plan gives recommendations about the amount and types of food a person should eat to achieve or maintain a healthy weight.

OSFED (Other specified feeding or eating disorder): A combination of symptoms of 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) that does not meet the clinical diagnosis for anorexia nervosa, bulimia nervosa, or binge eating disorder.

Purging: Any behavior that someone with an eating disorder uses to “get rid of” calories. Purging behaviors include vomiting, taking laxatives, diet pills, or excessive/compulsive exercise.

Safe foods: Foods that people with eating disorders can eat comfortably. Safe foods are often unprocessed, low-fat, or low-calorie foods, but can be different for every person.

Trigger: Anything that makes someone want to engage in certain behaviors or have eating disordered thoughts.

Vital signs: Measurements which include body temperature, blood pressure, and pulse.

Weight goal range: A range of weight that a treatment team decides is a healthy weight for a person’s recovery. It takes into account what a person weighed before the eating disorder, their gender, age, and physical activity level  A person’s weight range will increase as they grow and get older.