It is important to have awareness of disordered eating behaviors (including dieting) because they can be precursors to eating disorders. Disordered eating may include (and is not limited to) a rigid food and exercise regime; feelings of guilt or shame when unable to maintain said regime; a preoccupation with food, body, and exercise that has an impact on quality of life; compulsive eating; compensatory measures to ‘make up for’ food consumed (i.e.: excessive exercise, food restriction, fasting, purging, and laxative or diuretic use); and weight loss supplement use. Checking-in with intentions behind and behaviors around food and exercise may be helpful in determining if it is an unhealthy relationship. Eating disorders may include the behaviors mentioned but they are complex psychiatric illnesses with biological components, and they can be life-threatening. Eating disorders are 50-80% genetically based — they are not a choice.

When an individual is struggling with an eating disorder, they generally engage in multiple behaviors with more frequency and intensity. The level of obsession with food, exercise, and body thoughts and behaviors can distinguish disordered eating from an eating disorder. These thoughts are generally all-consuming and may include (but are not limited to) fixation on calories; good and bad foods; ingredients; measurement; taste; body size and shape; type and frequency of exercise; feelings of failure when unable to sustain these behaviors; and avoidance of social activities.

Many of us are familiar with Anorexia, Bulimia, and Binge Eating Disorder (BED), however there are additional conditions not included below which require intervention as well. While awareness of “typical” signs/symptoms of the more “familiar” eating disorders is critical, it is also important to note that there is a spectrum of maladaptive behaviors (some close to becoming official diagnoses and some not close enough), and that disordered eating and eating disorder symptoms can manifest at different times and overlap. It is also vital to have an understanding that eating disorders come in all shapes and sizes, they do not discriminate between age; gender; race; class; sexual orientation and ethnic groups, and you cannot tell if someone is struggling on the basis of appearance.

This list is intended as a general overview of signs that may indicate a serious problem:

• Behaviors and attitudes that indicate weight loss, dieting, and control of food and food rituals are becoming primary concerns
• Limited range of preferred foods that become narrower over time (i.e.: picky eating that progressively worsens)
• Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, all animal products)
• An increase in concern about the health of ingredients; an inability to eat anything but a narrow group of foods that are deemed ‘clean,’ ‘healthy,’ or ‘pure’
• Self-esteem overly related to body image
• Extreme concern with body size and shape
• Expresses a need to “burn off” calories taken in
• Maintains an excessive, rigid exercise regime – despite weather, fatigue, illness, or injury
• Intense anxiety, depression and/or distress if unable to exercise
• Dry skin and hair, and brittle nails
• Fine hair on body (lanugo)
• Muscle weakness
• Poor wound healing
• Difficulties concentrating
• Feeling cold all the time
• Noticeable fluctuations in weight, both down and up
• Feelings of disgust, depression, or guilt after eating, and/or feelings of low self-esteem
• Evidence of binge eating, including the disappearance of large amounts of food in short periods of time; feeling lack of control over the ability to stop eating. Sometimes including behaviors to prevent weight gain, such as self-induced vomiting, use of laxatives/diuretics, or excessive exercise
• Cuts and calluses across the top of finger joints and dental problems such as enamel erosion (a result of inducing vomiting)
• Swelling around the area of salivary glands
• Withdrawal from usual friends and activities

If this list causes any level of concern, or thoughts about food, weight, exercise routine, body shape or size are taking a predominant role, seeking professional help for early detection is strongly encouraged. A study by the National Association of Anorexia Nervosa and Associated Disorders reported that Anorexia Nervosa has the highest death rate of any psychiatric illness (including major depression). Without treatment, up to 20% of people with serious eating disorders die. With treatment though, the mortality rate falls to 2-3%.

It is challenging to trust our bodies will tell us what is needed for nourishment and movement… we just need encouragement and courage to disengage with the external messages and to reconnect with ourselves. Eating and moving without the influence of culture and others, while making reasonable health choices and embracing body diversity, will help us with body acceptance, overall wellness, and the prevention of maladaptive behaviors. Increasing awareness, addressing the stigma and bias, and working to eliminate shame will help bring us even closer to the prevention of eating disorders.

The risks associated with disordered eating are severe. People with disordered eating may experience:

• A clinical eating disorder (anorexia nervosa, bulimia nervosa, binge eating or other specified feeding and eating disorders (OSFED))
• Weight gain
• Osteoporosis – a condition that leads to bones becoming fragile and easily fractured
• Fatigue and poor sleep quality
• Constipation and/or diarrhea
• Headaches
• Muscle cramps

*The above information was cited in full from: Seitz, Simone. “Disordered Eating as a Precursor to Eating Disorders.” NationalEatingDisorders.org, 2019, www.nationaleatingdisorders.org/blog/disordered-eating-precursor-eating-disorders.

According to the National Eating Disorders Association, “Anorexia nervosa is an eating disorder characterized by weight loss (or lack of appropriate weight gain in growing children); difficulties maintaining an appropriate body weight for height, age, and stature; and, in many individuals, distorted body image. People with anorexia generally restrict the number of calories and the types of food they eat. Some people with the disorder also exercise compulsively, purge via vomiting and laxatives, and/or binge eat.

Anorexia can affect people of all ages, genders, sexual orientations, races, and ethnicities. Historians and psychologists have found evidence of people displaying symptoms of anorexia for hundreds or thousands of years.

Although the disorder most frequently begins during adolescence, an increasing number of children and older adults are also being diagnosed with anorexia. You cannot tell if a person is struggling with anorexia by looking at them. A person does not need to be emaciated or underweight to be struggling. Studies have found that larger-bodied individuals can also have anorexia, although they may be less likely to be diagnosed due to cultural prejudice against fat and obesity.

In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients it needs to function normally. Thus, the body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences.

The body is generally resilient at coping with the stress of eating disordered behaviors, and laboratory tests can generally appear perfect even as someone is at high risk of death. Electrolyte imbalances can kill without warning; so can cardiac arrest. Therefore, it’s incredibly important to understand the many ways that eating disorders affect the body.”

Emotional and Behavioral Symptoms:

• Dramatic weight loss
• Dresses in layers to hide weight loss or stay warm
• Is preoccupied with weight, food, calories, fat grams, and dieting
• Refuses to eat certain foods, progressing to restrictions against whole categories of food (e.g., no carbohydrates, etc.)
• Makes frequent comments about feeling “fat” or overweight despite weight loss
• Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
• Denies feeling hungry
• Develops food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate)
• Cooks meals for others without eating
• Consistently makes excuses to avoid mealtimes or situations involving food
• Expresses a need to “burn off” calories taken in
• Maintains an excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury
• Withdraws from usual friends and activities and becomes more isolated, withdrawn, and secretive
• Seems concerned about eating in public
• Has limited social spontaneity
• Resists or is unable to maintain a body weight appropriate for their age, height, and build
• Has intense fear of weight gain or being “fat,” even though underweight
• Has disturbed experience of body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of low body weight
• Post-puberty female loses menstrual period
• Feels ineffective
• Has strong need for control
• Shows inflexible thinking
• Has overly restrained initiative and emotional expression

Physical Symptoms:

• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
• Dizziness/Fainting/syncope
• Feeling cold all the time
• Sleep problems
• Menstrual irregularities—amenorrhea, irregular periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
• Cuts and calluses across the top of finger joints (a result of inducing vomiting)
• Dental problems, such as enamel erosion, cavities, and tooth sensitivity
• Dry skin
• Dry and brittle nails
• Swelling around area of salivary glands
• Fine hair on body (lanugo)
• Thinning of hair on head, dry and brittle hair
• Cavities, or discoloration of teeth, from vomiting
• Muscle weakness
• Yellow skin (in context of eating large amounts of carrots)
• Cold, mottled hands and feet or swelling of feet
• Poor wound healing
• Impaired immune functioning

*Information cited from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia. on 1/29/2020

According to the National Eating Disorders Association, “Binge eating disorder (BED) is a severe, life-threatening, and treatable eating disorder characterized by recurrent episodes of eating large quantities of food (often very quickly and to the point of discomfort); a feeling of a loss of control during the binge; experiencing shame, distress or guilt afterwards; and not regularly using unhealthy compensatory measures (e.g., purging) to counter the binge eating. It is the most common eating disorder in the United States.

The health risks of BED are most commonly those associated with clinical obesity, weight stigma, and weight cycling (aka, yo-yo dieting). Most people who are labeled clinically obese do not have binge eating disorder. However, of individuals with BED, up to two-thirds are labelled clinically obese; people who struggle with binge eating disorder tend to be of normal or higher-than-average weight, though BED can be diagnosed at any weight.

The diagnostic criteria include eating a significantly more amount of food in a discreet period of time than what most people would eat in a similar time under the same circumstances. It involves eating more rapidly than normal, eating until feeling ill, eating large amounts of food even when not hungry, feeling disgusted or guilty about what or how much was eaten, and often eating alone. The binge eating occurs, on average, at least once a week for 3 months.”

Emotional and Behavioral Symptoms:

• Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food.
• Appears uncomfortable eating around others
• Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
• Fear of eating in public or with others
• Steals or hoards food in strange places
• Creates lifestyle schedules or rituals to make time for binge sessions
• Withdraws from usual friends and activities
• Frequently diets
• Shows extreme concern with body weight and shape
• Frequent checking in the mirror for perceived flaws in appearance
• Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); feels lack of control over ability to stop eating
• Disruption in normal eating behaviors, including eating throughout the day with no planned mealtimes; skipping meals or taking small portions of food at regular meals; engaging in sporadic fasting or repetitive dieting
• Developing food rituals (e.g., eating only a particular food or food group [e.g., condiments], excessive chewing, and not allowing foods to touch).
• Eating alone out of embarrassment at the quantity of food being eaten
• Feelings of disgust, depression, or guilt after overeating
• Fluctuations in weight
• Feelings of low self-esteem

Physical Symptoms:

• Noticeable fluctuations in weight, both up and down
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Difficulties concentrating

*Information cited from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bed on 1/29/2020.

According to the Anxiety and Depression Association of America, “Body Dysmorphic Disorder (BDD) is a body-image disorder characterized by persistent and intrusive preoccupations with an imagined or slight defect in one’s appearance. People with BDD can dislike any part of their body, although they often find fault with their hair, skin, nose, chest, or stomach. In reality, a perceived defect may be only a slight imperfection or nonexistent. But for someone with BDD, the flaw is significant and prominent, often causing severe emotional distress and difficulties in daily functioning.

People with BDD suffer from obsessions about their appearance that can last for hours or up to an entire day. BDD obsessions may be focused on musculature (i.e. fixation on muscle mass or definition). Hard to resist or control, these obsessions make it difficult for people with BDD to focus on anything but their imperfections. This can lead to low self-esteem, avoidance of social situations, and problems at work or school.

BDD sufferers may perform some type of compulsive or repetitive behavior to try to hide or improve their flaws although these behaviors usually give only temporary relief.”

Symptoms of BDD:

• Camouflaging (with body position, clothing, makeup, hair, hats, etc.)
• Comparing body part to others’ appearance
• Seeking surgery
• Checking in a mirror
• Avoiding mirrors
• Skin picking
• Excessive grooming
• Excessive exercise
• Changing clothes excessively

*Information cited from https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/body-dysmorphic-disorder-bdd on 1/29/2020.

According to the National Eating Disorders Association, “Bulimia Nervosa (BN) is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating. The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.

The body is generally resilient at coping with the stress of eating disordered behaviors, and laboratory tests can generally appear perfect even as someone is at high risk of death. Electrolyte imbalances can kill without warning; so can cardiac arrest. Therefore, it’s incredibly important to understand the many ways that eating disorders affect the body.”

Emotional and Behavioral Symptoms:

• In general, behaviors and attitudes indicate that weight loss, dieting, and control of food are becoming primary concerns
• Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
• Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics
• Appears uncomfortable eating around others
• Develops food rituals (e.g. eats only a particular food or food group [e.g. condiments], excessive chewing, doesn’t allow foods to touch)
• Skips meals or takes small portions of food at regular meals
• Disappears after eating, often to the bathroom
• Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
• Fear of eating in public or with others
• Steals or hoards food in strange places
• Drinks excessive amounts of water or non-caloric beverages
• Uses excessive amounts of mouthwash, mints, and gum
• Hides body with baggy clothes
• Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury—due to the need to “burn off ” calories
• Shows unusual swelling of the cheeks or jaw area
• Has calluses on the back of the hands and knuckles from self- induced vomiting
• Teeth are discolored, stained
• Creates lifestyle schedules or rituals to make time for binge-and-purge sessions
• Withdraws from usual friends and activities
• Looks bloated from fluid retention
• Frequently diets
• Shows extreme concern with body weight and shape
• Frequent checking in the mirror for perceived flaws in appearance
• Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); feels lack of control over ability to stop eating
• Purges after a binge (e.g. self-induced vomiting, abuse of laxatives, diet pills and/or diuretics, excessive exercise, fasting)
• Extreme mood swings

Physical Symptoms

• Noticeable fluctuations in weight, both up and down
• Body weight is typically within the normal weight range; may be overweight
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
• Dizziness
• Fainting/syncope
• Feeling cold all the time
• Sleep problems
• Cuts and calluses across the top of finger joints (a result of inducing vomiting)
• Dental problems, such as enamel erosion, cavities, and tooth sensitivity
• Dry skin
• Dry and brittle nails
• Swelling around area of salivary glands
• Fine hair on body
• Thinning of hair on head, dry and brittle hair (lanugo)
• Cavities, or discoloration of teeth, from vomiting
• Muscle weakness
• Yellow skin (in context of eating large amounts of carrots)
• Cold, mottled hands and feet or swelling of feet
• Menstrual irregularities — missing periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
• Poor wound healing
• Impaired immune functioning

Many people with bulimia nervosa also struggle with co-occurring conditions, such as:

• Self-injury (cutting and other forms of self-harm without suicidal intention)
• Substance abuse
• Impulsivity (risky sexual behaviors, shoplifting, etc.)
• Diabulimia (intentional misuse of insulin for type 1 diabetes)

*Information cited from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia on 1/29/2020

The majoring of those with disordered eating do not fall within the criteria for Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder and are often classified as Other Specified Feeding or Eating Disorders (OSFED). According to the National Eating Disorders Association, “Despite being considered a ‘catch-all’ classification that was sometimes denied insurance coverage for treatment as it was seen as less serious, OSFED/EDNOS is a serious, life-threatening, and treatable eating disorder. The category was developed to encompass those individuals who did not meet strict diagnostic criteria for anorexia nervosa or bulimia nervosa but still had a significant eating disorder. In community clinics, the majority of individuals were historically diagnosed with EDNOS.

Research into the severity of EDNOS/OSFED shows that the disorder is just as severe as other eating disorders based on the fact children hospitalized for EDNOS had just as many medical complications as children hospitalized for anorexia nervosa. Also, adults with ‘atypical’ or ‘subclinical’ anorexia and/or bulimia scored just as high on measures of eating disorder thoughts and behaviors as those with DSM-diagnosed anorexia nervosa and bulimia nervosa.

People with EDNOS were just as likely to die as a result of their eating disorder as people with anorexia or bulimia. The health consequences of OSFED depend in part on which eating disordered behaviors are being used. It is important to recognize that OSFED is as serious as other eating disorders and should not be trivialized or underestimated. Health consequences of OSFED can be difficult to pinpoint, as it includes a number of conditions. Watch out for all of the signs already listed. The most important thing to look out for is attitudes about food and weight that conflict with a productive, satisfying life.”

Emotional and Behavioral Symptoms:

• In general, behaviors and attitudes indicate that weight loss, dieting, and control of food are becoming primary concerns
• Dramatic weight loss
• Dresses in layers to hide weight loss or stay warm
• Is preoccupied with weight, food, calories, fat grams, and dieting
• Refuses to eat certain foods, progressing to restrictions against whole categories of food (e.g., no carbohydrates, etc.)
• Makes frequent comments about feeling “fat” or overweight despite weight loss
• Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
• Denies feeling hungry
• Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
• Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics
• Appears uncomfortable eating around others
• Develops food rituals (e.g. eats only a particular food or food group [e.g. condiments], excessive chewing, doesn’t allow foods to touch)
• Skips meals or takes small portions of food at regular meals
• Disappears after eating, often to the bathroom
• Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
• Fear of eating in public or with others
• Steals or hoards food in strange places
• Drinks excessive amounts of water or non-caloric beverages
• Uses excessive amounts of mouthwash, mints, and gum
• Hides body with baggy clothes
• Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury—due to the need to “burn off ” calories
• Shows unusual swelling of the cheeks or jaw area
• Has calluses on the back of the hands and knuckles from self- induced vomiting
• Teeth are discolored, stained
• Creates lifestyle schedules or rituals to make time for binge-and-purge sessions
• Withdraws from usual friends and activities
• Looks bloated from fluid retention
• Frequently diets
• Shows extreme concern with body weight and shape
• Frequent checking in the mirror for perceived flaws in appearance
• Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); feels lack of control over ability to stop eating
• Purges after a binge (e.g. self-induced vomiting, abuse of laxatives, diet pills and/or diuretics, excessive exercise, fasting)
• Extreme mood swings

Physical Symptoms:

• Noticeable fluctuations in weight, both up and down
• Body weight is typically within the normal weight range; may be overweight
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Menstrual irregularities — missing periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
• Dizziness
• Fainting/syncope
• Feeling cold all the time
• Sleep problems
• Cuts and calluses across the top of finger joints (a result of inducing vomiting)
• Dental problems, such as enamel erosion, cavities, and tooth sensitivity
• Dry skin
• Dry and brittle nails
• Swelling around area of salivary glands
• Fine hair on body
• Thinning of hair on head, dry and brittle hair (lanugo)
• Cavities, or discoloration of teeth, from vomiting
• Muscle weakness
• Yellow skin (in context of eating large amounts of carrots)
• Cold, mottled hands and feet or swelling of feet
• Poor wound healing
• Impaired immune functioning

*Information cited from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/osfed on 1/29/2020.