There is no one sign of an eating disorder; however, there are red flags. For anorexia nervosa, bulimia nervosa, and binge eating disorder, these can include excessive “fat, weight, or calorie talk,” a pattern of eating a limited choice of low-calorie foods, and/or a pattern of intermittent binge eating on calorie-dense foods. People with anorexia nervosa may excessively exercise or excessively stand, pace or fidget. Some individuals with eating disorders may avoid weight gain following meals by inducing vomiting or abusing laxatives, diuretics and diet pills. Feeling self-conscious about one’s eating behavior is common. People with eating disorders often avoid social eating settings and eat alone.
People with avoidant restrictive food intake disorder don’t have excessive concerns with weight and shape. They may avoid eating many foods due to a variety of reasons, including low appetite, disgust or sensitivity to many foods. They may fear negative consequences from eating certain foods, such as nausea, vomiting, or abdominal pain. See more on warning signs
There is no single cause of an eating disorder. Like other mental health conditions, eating disorders are complex diseases that result from the interplay between biological, psychological, and socioenvironmental factors. We now understand that genetics play a role in the risk of developing an eating disorder. Environment also plays a role, especially in triggering the onset of an eating disorder, often in adolescence or young adulthood. Pressure to diet, or weight loss related to a medical condition or life stressor, can be the gateway to anorexia nervosa or bulimia nervosa. Losing those first five to 10 pounds in someone who is genetically vulnerable seems to make further dieting increasingly compelling and rewarding.
The onset of puberty, particularly in girls, can often precipitate an eating disorder. Social media usage, particularly image-based platforms such as TikTok and Instagram, is associated with eating disorder development. Once an eating disorder is established, the consequences of restricting, bingeing, or purging play an increasing role in sustaining the disorder. This occurs through changes in the body’s controls of hunger and fullness sensations, changes in the gastrointestinal tract, and altered learning, habit, and decision-making about what and when to eat.
Treatment for an eating disorder is challenging. It involves interrupting thoughts and behaviors that have become automatic. Recovery takes a team, including family, friends, and other social supports, and medical and mental health professionals. Be empathic, but clear and firm. List specific signs or changes in behavior you have noticed and are concerned about, without overly focusing on physical appearance, for example, “I have noticed that you have been skipping family meals.” Help locate a treatment provider and offer to go with your friend or relative to an evaluation.
Be prepared that the individual may be uncertain or ambivalent about seeking treatment. Reassurance that this ambivalence is normal and that treatments are effective is important for instilling hope. Treatment assists those affected with an eating disorder to change what they do. It helps them establish healthy eating and weight control behaviors and challenge the irrational thoughts that sustain them. Full eating disorder recovery is possible and liberating, allowing individuals to be free from the psychological confines of an eating disorder, heal from the physical complications of starvation, and overall live a more joyous life.
Yes. It is true that young girls and women are more often affected. However, eating disorders can affect individuals of any gender, age, socio-economic status, racial/ethnic identity, and body size. An estimated 10 percent of people with anorexia nervosa and bulimia, and a third or more of people with binge eating disorder, are male. Avoidant restrictive eating disorder appears to be slightly more common in males than in females. Further, for men, eating disorder symptoms can present differently, with more focus on muscularity.
Other at-risk groups include sexual and gender minorities, racial/ethnic minorities, and athletes in sports that value leanness and aesthetics, such as dance, gymnastics, and distance running. Age of onset varies. Some people are only mildly affected until some life event triggers clinical worsening – a stressor, physical illness, or co-occurring psychiatric illness, such as depression or anxiety. Evidence strongly suggests that anxiety disorders, especially social anxiety disorder, and obsessive-compulsive personality traits increase an individual’s vulnerability to an eating disorder.
Occasional overeating, such as at Thanksgiving or other holidays and celebrations, is normal. By contrast, binge eating is the frequent consumption of a large amount of food associated with a sense of loss of control over eating. Binging is usually private and associated with feelings of embarrassment, shame, depression, and guilt over the behavior. It often includes eating rapidly, until uncomfortably full, or when not hungry.
Food addiction is a controversial term used by some researchers to describe parallels between the difficulties some people experience in limiting eating and substance addiction. Unlike in addiction, however, where an individual is addicted to one particular class of drug, it is difficult to identify one food that underlies “food addiction.” Similarly, the withdrawal syndrome caused by drug dependence is difficult to show in those who overeat. Despite the similarities between eating disorders and addiction, the neurobiology of binge eating and of drug addiction are not the same.
Research on eating disorders is progressing rapidly. It is now clear that eating disorders are biologically based illnesses, not simple lifestyle choices. Recent genetic work has focused on identifying genes that increase risk for an eating disorder and on gene-environment interactions that may contribute to the onset of an eating disorder. Emerging research suggests that there are significant genetic correlations between several eating disorders and psychiatric and metabolic traits. Brain imaging research is examining altered decision-making around food choice and reward learning in individuals with eating disorders. Other research focuses on understanding how starvation, exercise and binge-purge behaviors change brain reward circuits and gut-brain signaling. This work holds promise for developing novel treatments in the coming years.
The most effective current treatments are behavioral interventions that focus on helping individuals with eating disorders normalize their eating and weight control behaviors. For adolescents with anorexia nervosa, family-based treatment has the best evidence. The focus of effective family-based therapies is on helping parents to support and monitor their child’s meals. For severely ill patients at very low weight, and for many adult patients who are unable to gain weight in outpatient treatment, admission to a specialized residential or hospital-based treatment program can be lifesaving.
The most consistent indicator of relapse after intensive treatment is incomplete weight restoration, so reaching a healthy weight is necessary for recovery from anorexia nervosa. Evidence now suggests that weight gain of three to four pounds a week is safe even for very malnourished patients under close medical monitoring and 24-hour nursing care. Some programs utilize feeding tubes. However, many behavioral specialty programs can achieve four pounds a week weight gain with meal-based feeding alone in most cases. Close outpatient follow-up care following hospitalization is important, as relapse risk is elevated for six months following inpatient treatment.
Emerging treatments with promise, although still in their infancy, include the use of psychedelics, which may assist with reducing the cognitive rigidity associated with anorexia nervosa. Brain stimulation methods, such as repetitive transcranial magnetic stimulation (rTMS), targeting the dorsolateral prefrontal cortex are also of growing interest. Neuroimaging research has suggested abnormal connections in this area of the brain. To date, there are no pharmacological treatments approved for anorexia.
For bulimia nervosa, cognitive behavioral therapy is the most successful outpatient treatment approach. Fluoxetine is currently the only FDA-approved medication; however, other medications, including other antidepressants, show promise in clinical trials.
People with binge eating disorder also respond to cognitive behavioral interventions. Interpersonal therapy is also effective in both bulimia and binge eating disorder. The only FDA-approved pharmacological treatment for BED is lisdexamfetamine. However, research on other medications (such as serotonin reuptake inhibitors and topiramate) shows benefit. There is interest in the use of GLP-1 agonists in reducing binge eating, but more research is needed. Research for the treatment of avoidant restrictive food intake disorder (ARFID) is still relatively limited. However, existing research supports the use of cognitive behavioral therapy with family-based therapy also shows promise in younger children. There are no approved medications for the treatment of ARFID.
In general, one of the most important emerging predictors of treatment success for eating disorders across diagnoses is early behavior change. Even in individuals who are initially highly ambivalent about entering treatment and demoralized by their illness, motivation often increases as they start experiencing progress in controlling their disorder and recognize recovery is within reach.
With the advent of two federal laws (the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA)) more individuals are now eligible for coverage of treatment for eating disorders. The ACA prohibits insurance from denying coverage for a pre-existing condition and provides for coverage for young adults up to age 26 under their parents’ insurance. This is important as many individuals develop an eating disorder in their teens or early adulthood.
The problem, however, is that inpatient or residential treatment for severe anorexia nervosa, which typically achieves rates of weight gain on the order of 2-4 pounds/week, may require weeks or sometimes months of treatment for severely undernourished individuals to reach a healthy weight. Treatment must also focus on helping patients normalize food choice, eating and weight control behaviors and should address the treatment of co-occurring conditions. The criteria set by insurance companies to assess medical necessity for ongoing hospitalization or residential care are often stringent. As a result, even when patients qualify for admission, adequate treatment remains difficult to obtain for many, as insurance will often only cover partial weight restoration at a higher level of care. The evidence suggests that only full weight restoration in anorexia nervosa is associated with improved prognosis. Continued outpatient care following the achievement of a normal weight for a minimum of 6-12 months is also important to minimize relapse. For more information on insurance-related questions see the National Eating Disorders Association (NEDA) and the Eating Disorders Coalition.
Here are some questions that may be relevant to an inpatient or residential admission for treatment of anorexia nervosa.
- What percentage of your patients reach full weight restoration (a normal weight range) before leaving the program? Ideally, most patients should achieve a BMI greater than 19 (or 90% of ideal body weight in the case of adolescents) by discharge.
- What are your average rates of weekly weight gain? Are these published? Weekly weight gain for underweight patients should be 2-4 pounds/week for inpatient or residential treatment settings.
- Do you employ oral (meal-based) refeeding only? If not, what percentage of patients have a feeding tube placed? Specialized behavioral treatment programs for eating disorders, in most cases, do not regularly employ feeding tubes. Meal-based behavioral interventions should focus on helping patients manage their anxiety about eating, broaden the variety and amounts of foods consumed, and eat meals with others across a variety of social settings.
- What types of therapy do you offer? Behavioral approaches that focus on normalizing eating and weight control behaviors and on managing associated thoughts and feelings are most effective. Talk therapies focused more on understanding the “meaning” or “root cause” of the eating disorder are less likely to be beneficial.
- How are families involved in treatment? Increasingly, most experts believe that involvement of significant others and caregivers in treatment is an important component of the treatment of eating disorders.
- What are the credentials and training of your staff? A multidisciplinary team should include a range of providers with experience and training in the treatment of eating disorders and associated conditions. Examples of disciplines typically represented on a team include psychiatrists, psychologists, social workers, occupational therapists, dietitians and counselors.
- What medical services do you provide, and how do you manage medical complications or co-occurring psychiatric conditions? Inpatient and residential programs should have either on-site or readily available access to treatment for co-occurring conditions, including medical management of potential complications.
Lists of outpatient and inpatient providers are available from the Academy of Eating Disorders and the National Eating Disorders Association.
