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Backing into an eating disorder: An illness that often starts with good intentions of being healthier

© Mayo Clinic

Thanks to made-for-TV movies, most of us have a stereotype of how eating disorders start. Someone, usually a privileged young girl wanting to be skinny and hating how she looks, begins dieting in earnest, and gets carried away. Despite increasing health risks, she persists, hyper-focused on her body and terrified of getting fat.

This type of eating disorder exists, but it’s not what I see most often in my psychology practice.

The danger of this sort of narrative is that it implies that eating disorders are a choice — one that is driven by vanity, or shallow concern about appearance. People assume eating disorders persist due to selfishness, lack of perspective or stubbornness.

This is flat-out wrong. Eating disorders are illnesses, not choices. And, importantly, wanting to be unrealistically thin is only one of many things that drives an eating disorder.

In my practice, I have worked with both adults and children who:

  • Started training for a sport, increasing their exercise, and cutting out junk food to improve their performance or times
  • Decided to shift to “clean eating,” eliminating certain food types or macronutrients because of concerns about health or animal rights
  • Began counting calories after learning about healthy diet and being given a food log assignment in science or health class
  • Cut out snacks and sweets at their annual checkup when their doctors told them that their BMI was elevated
  • Lost their appetite or interest in food due to anxiety, depression or a medical issue, and began losing weight as a result

Most often, I see people who were trying to get healthy when they made changes to their diet and exercise habits. They wanted to be fit and strong, not skinny. None of these people stopped eating altogether. Weight loss started because they were trying to follow the rules and do things the right way — doing what most people think of as the right thing to do.

In fact, many of them received well-intended advice or encouragement from their coaches, their health care providers, even their families, to pursue these changes. However, in doing so, they inadvertently backed into an eating disorder and placed themselves at serious risk of related medical problems.

From healthy choice to unhealthy rigidity

How does healthy turn into unhealthy for people who develop eating disorders? After all, many people try to change their eating and exercise habits and never go on to develop disordered eating. As you might expect, there’s not a simple answer.

It’s often hard to draw an exact line between where the healthy habits ended and the eating disorder started. People rarely wake up one day and decide they’re going to purposely starve themselves to lose a dangerous amount of weight. Rather, they start to shift their eating to be more in line with what they see as “right,” and over time, these small changes begin to add up.

Eventually, eating and exercise habits become increasingly rigid and relentless. Once an eating disorder starts to manifest, the goal posts keep moving. A person with an eating disorder never feels satisfied. What started as a small goal, such as “I’ll try to drink less pop” or “I want to run 3 miles,” slowly becomes unrealistic and unreachable, for example, “I will NEVER eat any refined sugars” or “I MUST run 7 miles every day, regardless of how I feel.” Because this shift usually happens slowly, it often takes both the child and the family by surprise. This is part of why eating disorders often take a very long time to be detected.

Preventing eating disorders

As a parent or caregiver, how can you prevent your child from backing into an eating disorder? Here are some things you can do, and some things to look out for.

What you can do

*            Model healthy behavior — Approach your own eating and exercise with flexibility and grace. Changes to your diet should never come at the cost of spontaneity or being able to enjoy a wide range of foods without guilt or shame. When it comes to exercise, show your child how to be active for the fun of it, and how rest days and unplanned breaks are important pieces of being healthy. Avoid comments such as “I’m going to have to run for an hour tonight to work off all this extra food.”

*            Evaluate how you talk about food and bodiesIt’s alarmingly common in our society to talk about food, eating and bodies in a way that’s really unhealthy. Take inventory of how you talk about these topics, and attempt to eliminate anything that perpetuates the “thin ideal,” that labels food as “good” or “bad,” or reinforces the eating disorder mindset. That is something we all should be doing. Do your best to stop making comments about your body or the bodies of other people. In addition, avoid certain comments about food, such as “Ugh, I was so bad and ate so much today. Tomorrow I’ll be better.” Your child is listening, and even comments meant to be positive — such as “You’re so lucky. You can eat anything you want!” — can be problematic.

*            Take a break — When in doubt about whether your child’s habits have become unhealthy or rigid, implement a day off from working out to go see a movie or propose an impromptu trip to get ice cream. Make sure this is something your child can do without distress — and make sure you’re able to do so too! If your child sees you doubling up on workouts after a trip to the bakery, that’s going to undermine your message.

*            Eat a meal together when you can — Family meals have been linked to just about every positive outcome you can think of. You don’t need to cook gourmet dinners for your family, or even have everyone sit down for a formal meal every night. With kids and adults running in five different directions with activities every night, this can feel almost impossible to implement. The main thing is to take time for connection, at least occasionally throughout the week. Make sure you have some idea what your kids are eating throughout the day, even if you’re not preparing it yourself. Often, eating disorders sneak up when kids and families are running around so much, and having to grab food so quickly that no one knows what they’re actually eating in a day.

What to watch out for

It’s very important to be aware of red flags that might indicate that your child is drifting in a dangerous direction. Key among them is a child who is becoming rigid, single-minded or obsessive about diet or exercise. This is never healthy. While it’s great if your child is passionate about a sport or activity, rest days — or time off after a season — and eating a variety of all kinds of foods is a must. If your child refuses or is stressed or anxious while taking a break or eating a range of food, this is cause for concern.

Other things to watch for include:

*            Prioritizing an eating or exercise plan over socializing, sleeping or time with the family

*            Exercising despite being injured, exhausted, sick — or to the extent that menstruation does not begin, stops occurring or occurs only intermittently

*            Linking exercise to eating or weight, such as only eating dessert on run days

*            Preoccupation with weight or shape, including frequent weight checks

*            Constantly looking in the mirror or taking body measurements or talking about weight or body shape

*            Losing weight or failing to make expected gains in weight or height

*            Social isolation or withdrawal

*            Fatigue, dizziness, lightheadedness or fainting

Catch it early

It is easy to write off the risks of an eating disorder because you feel your child “knows better” or has never expressed a desire to be thin. It can be incredibly rewarding to see your child become passionate about an activity — to set goals, stick to them and see a positive outcome. It is hard to know when to intervene when this results in dietary restriction or weight loss.

If you become concerned about your child’s eating or exercise habits, it’s much better to overreact than underreact. Catching eating disorders early is linked to the best recovery outcomes. Never hesitate to bring your child to see a primary care provider or a mental health professional to discuss your observations.

Jocelyn R. Lebow, Ph.D., L.P.

Dr. Lebow is a clinical psychologist at Mayo Clinic in Rochester, Minnesota who specializes in the treatment of children and adolescents. Her research focuses on improving prevention, assessment and treatment of adolescent eating disorders.

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