Eating disorder awareness: Myths, facts, truths, and anecdotes

[Trigger warning for eating disorders]

This week has been designated National Eating Disorders Awareness Week, and the tagline for 2014 is I Had No Idea. It recognizes the fact that eating disorders are more prevalent and more dangerous than many people recognize and that they touch every aspect of life. NEDA’s awareness articles cover everything from sexuality to race and culture to the drive for perfection to gender identity, because eating disorders don’t discriminate.

Talking about eating disorders is always a question mark for me — for some women, simply discussing it can be immensely triggering, and in areas of education, one girl’s cautionary tale can be another’s instructional video. (I’ve mentioned in the past that my introduction to bulimia came through educational efforts.) But for a week like this one, raising awareness — and, as part of that, dispelling myths — makes it worth the risk. Because a lot of people really do have no idea. At Skepchick, Olivia examines five common myths about eating disorders, and a couple of them really hit home for me.

1. Eating disorders are just a phase or a fad diet. They’re not really serious. If we can just convince people they look fine and they should eat, they can get over it.

Olivia points out that, in fact, eating disorders have a high rate of relapse and the highest mortality rate of any mental illness. Mine started in high school and lasted nearly a decade, in the sense that every time I was out, it pulled me back in. Body image was an issue for me — particularly when I was working in fashion and had to, on occasion, fit into borrowed clothes — but my real concern was overall perfection, with body shape as a part of that. Convince me that my body was swell as it was? Sure, I might have bought it, but realistically I recognized that society didn’t care how I felt about my body when the time came for them to judge it.

I started bingeing and purging when I was a student applying for college, a daughter trying to make her parents proud, a girlfriend trying to earn the attention of an absentee boyfriend, and a young woman trying to get her life in order in preparation for impending adulthood. (A flight of mental health issues was yet to be uncovered.) That my body should be perfect was just one aspect of the larger fact that everything else had to be perfect, too. My tendency to soothe the stress in my life — whether it was interpersonal, academic, social, professional, or extracurricular, and I had plenty of each — with ice cream definitely stood in the way of that, and ultimately something had to give. Like digestion.

I’ve had my molars resealed twice from the stomach acid, and six years after I last purged I still get acid reflux. I spent unreasonable amounts of time with food in my sinuses. I abused laxatives when vomiting wasn’t convenient, which, for the uninformed, leads to considerable amounts of poop. As diet plans go, this one was far from glamorous. I’d imagine that few people would list my daily activities and still feel like following up with, “But she looks great!”

5. You can tell if someone has an eating disorder by looking.

This is one of the ones that gets me the most, and one of the reasons that people throwing around the word “anorexic” to mean “extremely thin” make me rage. Sometimes it’s dismissive — “Oh, my gawd, look at that woman, she’s anorexic” — and sometimes it’s said with real or faux concern — “Look at them! We have to do something to help those anorexic women!” But it’s never helpful.

For one, it pathologizes a certain body type. And while a given person who is extremely thin may, in fact, be anorexic, they could have another illness, be extremely athletic, or simply be naturally that thin. And declaring a woman anorrexic generally accompanies other judgments about her attractiveness and/or viability as a sexual partner, which… no.

More important, though, it makes it easy to miss eating disorders in women who don’t fit the stereotypical body shape. The most common eating disorder isn’t anorexia but is, in fact, binge eating disorder, and the wide variety of different disordered approaches to eating — and reasons behind those approaches — means that bodies come in every shape along the spectrum. And the idea that all you have to do is look for who has water for lunch, who disappears into the bathroom after meals, who cuts her food into tiny bites and wastes away to ribs and cheekbones is a Lifetime Original fantasy.

How about this for a poster: “Help Save This Woman’s Life,” above the image of a round-cheeked young woman smiling and eating a chicken panini. Shortly thereafter, she’ll fall just short — by the grace of God — of having a heart attack on the bathroom floor, but it’s hard to fit everything onto one poster. At lunch meetings, eating a sandwich is expected, so you eat a sandwich; if you’re bulimic, you go home and undo it afterward. I never got thin beyond the point where people told me how great I looked — not because I was able to stop when I felt I was thin enough, but because bingeing and purging often means that bulimics don’t get alarmingly thin. When people with bulimia die — and a lot of them do — it’s usually for reasons other than malnutrition. No one knew to offer me help, because no one knew, because I hid it, because that was the point.

I know my parents feel some degree of guilt about the fact that I went so long without getting any help, and they’re probably always going to at least a little bit, because they’re my parents. But I was really, really good at hiding my disorder, and I had a disorder that was particularly easy to hide. When I finally did get help that really stuck (following a crisis I’m not really prepared to share about quite yet) it was half-sideways via issues I had no idea were even related to an eating disorder. And that’s why observances like National Eating Disorders Awareness Week are, I think, important. Because when the common myths of it’s only rich girls, it’s only white girls, it’s only girls, it’s all about vanity and wanting to be thin, she just needs to eat something, it’s because of magazines, it’s only a phase, it’s only the really skinny ones continue to stand unchallenged, thousands of women and girls — and men and boys — fail to get the help they need, because they or the people around them don’t recognize that something is very, very wrong.


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30 Responses to Eating disorder awareness: Myths, facts, truths, and anecdotes

  1. Amanda says:

    Just thought I’d add, but not all anorexics are thin. I’ve been anorexic for 7 years, but before then I was obese so now I’m underweight but not “oh my god she’s OBVIOUSLY anorexic” underweight. Anyone can have an eating disorder, and I think we all need to get our heads out of this stereotypical mold and get everyone the treatment they need.

    • Amanda says:

      Sorry I forgot to add where I was going with that- I went into cardiac arrest when I was in the “healthy” BMI range but anorexic for 3 years. You don’t have to be thin to be super unhealthy and on your way to death.

  2. emily says:

    A girl in my Girl Scout troop in high school was bulimic. She told us a few years later, when we were all in college and having a GS reunion. Our troop leader said something like “well, you never did it on camping trips.” We went camping every month. She said no, she was just really good at hiding it. I was pretty surprised. (actually, now that I’m thinking more about it, she was also in Explorers with me. Though we weren’t actually good friends, we basically spent two weekends a month together and I never noticed. Pretty scary stuff.)

  3. Kid_A says:

    Caperton – if you’re going to discuss eating disorders and what makes you so mad about how we generally address them then you could at least think to include overating in the conversation. This article is a same old same old from a bulimic/anorexic.

    • EG says:

      Yeah, Caperton, how dare you address what you want to address instead of what Kid_A wants you to address? Jeez, what’s wrong with you?

    • trees says:

      Caperton – if you’re going to discuss eating disorders and what makes you so mad about how we generally address them then you could at least think to include overating in the conversation. This article is a same old same old from a bulimic/anorexic.

      If you mean binge eating disorder, she addresses that here:

      More important, though, it makes it easy to miss eating disorders in women who don’t fit the stereotypical body shape. The most common eating disorder isn’t anorexia but is, in fact, binge eating disorder, and the wide variety of different disordered approaches to eating — and reasons behind those approaches — means that bodies come in every shape along the spectrum. And the idea that all you have to do is look for who has water for lunch, who disappears into the bathroom after meals, who cuts her food into tiny bites and wastes away to ribs and cheekbones is a Lifetime Original fantasy.

      How about this for a poster: “Help Save This Woman’s Life,” above the image of a round-cheeked young woman smiling and eating a chicken panini.

  4. I saw firsthand one of my sisters struggle with bulimia. She had always been an overweight child, but by the time high school arrived, she wanted to be thin like the popular girls. My sister hid her behavior for a long time. One of my other sisters figured it out before my parents did. For a time, she lost a significant amount of weight.

    Several years ago, she made the decision to stop. Since then, she’s gone in the opposite direction. She keeps a very poor diet and has gained 100 pounds since then. Every Christmas I notice how much more she has put on. It worries me.

    This is no critique of her body size, but at this point, I worry for her overall health. Bulimia was certainly unhealthy, but so is her current state of affairs. Before long, she will be a candidate for obesity surgery and at a very young age. It’s her life and her body, I concede. I just wish there was something I could do.

    • trees says:

      Maybe your sister has had a relapse in her bulimia, irrespective of her size, or she may be practicing a different eating disorder like binge eating.

    • Andie says:

      You can support her, no matter what. Don’t comment on her size. She knows how big she is. Let her know you love her and are there for her.

    • piny says:

      I’m breaking a promise to myself because this sends chills up my spine. I can imagine my dad saying exactly this. I understand that you love and are worried about your sister, but they are not the same. Being unfit is nothing like an eating disorder. They’re not two extremes on the same line. Like Caperton said, eating disorders are just plain not about fitness.

      Here’s what you can do:

      Never ever say anything like this to your sister. Never say anything like this in a context where it might get back to your sister. Don’t even let your family say things like this – if you hear them, shut them down. I think that her experience of her adolescence may shadow your sister’s ability to trust family in recovery – an eating disorder can be profoundly isolating, especially since family often “have no idea” for years. Set yourself apart for her; make it clear that you will not cooperate with her disorder or minimize it.

      Your sister’s bulimia is a terrible compulsion. It’s not a bad habit or weakness – it’s a spiral. Most survivors don’t recover all at once.

      (And a lot of survivors go through long a recovery period where they let go their eating habits and exercise routines. It doesn’t necessarily mean that she has another eating disorder, or that she’s depressed or anything similar. She could very well be making the rational decision to table physical fitness for now.)

      If you want to support your sister, let her know that you are supportive and that you worry about her as a survivor who might need help going forward. Tell her that you are really proud of her and that you know how difficult it is to get over an eating disorder. Don’t give the impression that you assume everything is fine now. Ask if she is happy, if there is anything she needs.

      Let her know that you are there for her and you will always listen to her. Let her know that if she feels like she is scared or in crisis she can come to you to vent. If she tells you that she is worried, support her in her concern and encourage her to take her mental health seriously.

      She will probably be dealing with a lot of shame, and you can help. Tell her how glad you are that she has confided in you, and never let her tell herself that she does not deserve help and comfort. If she beats herself up for some weird compulsion, tell her that she is neither of those things and that you are glad that she is sharing her fear of ice cream or whatever.

      If she starts on some sort of weight loss or exercise program while the compulsion to eat in self-hatred is still in her head, her new routine may well become a new set of disordered habits that will in turn need to be dismantled. Her ability to live with a human body without sliding into self-torture is the priority here. It has the power to warp everything else.

      I know how scary it is to watch a family member go through this, and how helpless you can feel in the face of it. But you can help her most by acknowledging the severity and likely tenacity of her disorder. And please don’t underestimate her shame and paranoia around her body, or your ability to exacerbate it, even with the best of intentions.

  5. wagtail says:

    I read on my sister’s blog reflections of her time with an eating disorder. She wrote that everyone praised her weight loss and that she’s angry about it now.

    I felt strangely betrayed reading this. When she had an eating disorder, we were terrified for her and of her. Her shocking weight loss and damaged health made us cry but she cut people out of her life that she thought were encouraging her to be “fat.” Meanwhile she criticized our own eating habits. It was impossible to change the subject from food, on which she was an expert and we were deluded fat-enablers. Her disease was a tyrant over all of us. It made her cruel and monotonous and robbed me of a great friend and beloved sister for many years. I am sure we never praised her weight loss, but guess that she was so voracious for any sign at all of her praiseworthiness that she interpreted our silence that way.

    Oh it makes me so damn sad to think of those days. I wish I had known of resources for people who love others with disordered eating.

    • Andie says:

      It’s possible that she’s referring to other people praising her, not necessarily you.

      I’ve lost a lot of weight a few times, once through a real attempt to lose weight, but mostly through periods of ill-health and people can be jerks about it. They’ll tell you how great you look while you’re suffering and even when you point out that you are suffering, they’ll still act like the weight loss is a good thing because hey, at least you look good.

      I have no doubt that while maybe immediate family may have been horrified, she probably did have other people praising her weight loss.

      Sometimes ‘Everyone’ just means ‘a whole lot of people’. However, I say with the caveat that I haven’t read this blog and it’s possible that she may have specifically referenced family members, in which case, I would be in the wrong.

  6. For Eating Disorder Awareness Week, my school brought Ryan Sallans to our school and his story was so amazing. I not only learned about a story about someone who has gone through an eating disorder, but also someone who has gone through transition. I think it is important to listen to these stories so that the myths can be further eradicated. Thanks for bringing this myths to the forefront so people can know the social stigmas and ignorance behind eating disorders.

  7. Drahill says:

    One thing I’d add is that, thanks in no small part to the diet industry, most people have no clue what disordered eating looks like. A while ago, people at least had some idea as to what disordered eating MIGHT look like – severe caloric restriction, excluding entire food groups or types (save for ethical diets, of course), unusual eating patterns or other signifiers that perhaps a person might have a problem. But now, there are so many “diet plans” out there than advocate everything from the most extreme caloric restrictions to bizarre patterns to eating only a few kinds of foods to everything else.

    My experience with this is personal. I had a friend who, we later discovered, had been anorexic for a long time (but never became incredibly thin). None of us could ever recall seeing her refuse food, but we could all remember her constantly being on some new “diet” that required her to eat only small amounts, eat only cabbabe or something else along those lines. We realized too late that she had forever been using these things as a guise for an eating disorder, but because it was packaged as a “diet” we never second guessed.

    • EG says:

      excluding entire food groups or types (save for ethical diets, of course)

      I’m not sure this is a blanket exception, either. I’ve known at least one person who became a vegetarian, became bulimic, recovered from the bulimia, and became vegan. I strongly suspect that for some people–not all or most–ethical diets are also forms of or covers for or used as eating disorders.

      • EG says:

        My mother has dieted her entire life, feeling bad about her weight. I don’t remember a time when she wasn’t watching her weight. But she’s never been as thin as she is now, when she’s excluding gluten for (tested and confirmed) health reasons and has become a vegetarian along with it. And the vegetarianism she says is motivated by ethical concerns–and I have no doubt that it is–but I can’t help but notice how easily and seamlessly it fits into a lifetime of restricted eating.

      • Drahill says:

        Well, I think that’s a given. However, I’ve seen actual veg*n debates about whether people who use the diet as cover for disordered eating truly meet the definition. Technically, vegan is a lifestyle, which is why you now here the whole “plant-based diet” stuff. A person who eschews animals as food but wears leather technically should not be called a vegetarian or vegan – at least by the standards that are currently out there. I also think the qualifier “ethical” is useful because it will largely separate out those who adhere to the diet for ethical reasons as opposed to those who use it for other purposes.

      • EG says:

        That sounds like a “no true Scotsman” to me. Vegans are just like any other group of humans, so there are going to be a bunch of people who are inconsistent.

        What I mean is, I don’t think that it’s easy to separate out ethical motivations from other motivations. There are many young women who committed to animal rights, and there are many young women who suffer from eating disorders. Those two groups are surely going to overlap at some point, and I’m not sure that it’s going to be a conscious use of veganism for eating-disordered purposes rather than a group of people finding something that meets multiple needs, some of which might not even be conscious.

      • EG says:

        Like, I don’t think my mother is lying when she says her decision to become a vegetarian after many decades of happy meat-eating is based on ethical concerns. But am I really supposed to think it’s a coincidence that, after a lifetime of feeling deep insecurity and unhappiness about her weight, when she voluntarily decided to give up a what had previously been a large and filling part of her diet, at the same time that she gave up for medical reasons what had been another huge part of her diet, she became thinner than ever before?

        I don’t think she’s lying or using vegetarianism as a cover. I do think there are social and emotional forces at work in her decision other than the ones she’s aware of or admitting to.

      • Drahill says:

        EG, I think what you are discussing is an issue of motive, which is largely impossible for anyone to give you an answer on.

        I am always careful to use the term “disordered eating” as opposed to “restricted eating.” Almost everyone practices some form of restricted eating, even if the sole restriction is based upon what they like. I have a fairly severe reaction to the Nightshade family of foods, which means I have to restrict (sometimes quite a lot at certain places) what I can eat. My father has celiac disease. My sister has severe lactose intolerance. I am a vegetarian and alcohol-free by religious choice. All of us are restricted our food choices, but I doubt any of us would fall into the “disordered eating” category, precisely because the restriction is based upon either 1.) true medical need or 2.) true ethical or religious belief.

        I do think the situation with your mother reveals an interesting dynamic that plagues a lot of people who have dabbled in disordered eating (up to and including eating disorders). At what point can a person who previously had issues with disordered eating embrace a voluntary food-restriction program for health or ethical reasons and NOT be questioned as to their motives? If I am reading you correctly, the answer is never. I have to think about the implications of that for myself. But I can easily see how it could become tiresome quite fast for somebody.

      • EG says:

        I doubt any of us would fall into the “disordered eating” category, precisely because the restriction is based upon either 1.) true medical need or 2.) true ethical or religious belief.

        But in making these exceptions, you are doing exactly what you say is impossible for anybody to give an answer on, which is talking about and making judgments about motive. Whose ethical and religious beliefs are “true”? What does that even mean? How pure or devoted does someone have to be for them to qualify?

        And why privilege religious belief over beliefs about body and control? What makes the food restrictions resulting from one belief more justifiable than the other? Certainly religious beliefs have caused people to do significant harm to themselves as well.

        If you’d prefer me to use “disordered eating” instead, I will. I do think we need an intermediary term for food restricting that falls short of diagnosable disorder but is significantly more rigid than just restricting based on likes and dislikes, particularly when the restricting requires ongoing hunger not necessitated by a dearth of food.

      • If you’d prefer me to use “disordered eating” instead, I will. I do think we need an intermediary term for food restricting that falls short of diagnosable disorder but is significantly more rigid than just restricting based on likes and dislikes, particularly when the restricting requires ongoing hunger not necessitated by a dearth of food.

        I use “disordered eating” rather than “eating disorder” when speaking about my (at this point significantly mitigated) emotional food issues for exactly this reason. I’m a lifelong vegetarian but it has exactly 0% to do with my disordered eating stuff – I have eaten, at various points, healthily, badly, too much and too little – and I honestly don’t think any of those would have been different if I’d had meat in my diet.

      • Drahill says:

        But in making these exceptions, you are doing exactly what you say is impossible for anybody to give an answer on, which is talking about and making judgments about motive. Whose ethical and religious beliefs are “true”? What does that even mean? How pure or devoted does someone have to be for them to qualify?

        And why privilege religious belief over beliefs about body and control? What makes the food restrictions resulting from one belief more justifiable than the other? Certainly religious beliefs have caused people to do significant harm to themselves as well.

        EG, I am not making a determination about motive. If somebody tells me they restrict food on the basis of a sincere legitimate belief, I do not question it further. I take them at their word. What I was pointing out is that you seem the refuse to take your mother at her’s. If she professes that she is vegetarian for ethical reasons, why not believe her? You say it is because she has a history of restricting food for unhealthy reasons, thus you are inclined to believe this is more of the same. But the question I posed above – which you haven’t answered – is at what point does your mother (or any other person with a disordered eating history) get to have their food choices be their own again?

        Also, having worked with individuals with eating disorders (tangentially), I can attest that those who work directly with them do not question motives either. If a person is receiving ED treatment and states they have an ethical (note: not religious – that is a subset of ethical) food restriction, common practice dictates that that restriction is honored and worked with. You seem surprised that can be done.

      • EG says:

        common practice dictates that that restriction is honored and worked with. You seem surprised that can be done.

        That just seems like unnecessary snark to me.

        Of course common practice in treatment would dictate honoring and working with the restriction. Not only is that the respectful thing to do, not doing it would discourage people from coming to treatment. So it is not only respectful, but expedient.

        But that doesn’t mean it’s always a correct assessment of what’s motivating the restriction.

        You seem to think that I’m holding the motives of people with disordered eating to higher scrutiny than anybody else’s. I’m not–it’s just that we’re discussing eating disorders here and not, say, relationships. I think most people’s motivations are complex amalgams of personality, consciously known and understood feelings/ideas, and unconscious responses to social and emotional forces. And I don’t think there’s a point at which significant elements of any of those stop influencing us, though of course their influence can wax and wane. So no, after decades of dieting, I don’t think there’s a point at which my mother’s decisions about how to restrict her eating are unaffected by them, just as I don’t think there will ever be a point at which my decisions about interpersonal relationships will ever not be affected by various parts of my own life.

        Basically, I am saying people make decisions about their dietary exclusions for combinations of reasons that blur together–just as they do all significant and probably most insignificant decisions, and that I am therefore unhappy with simple, blanket exclusions like “ethical reasons.”

      • EG says:

        I have eaten, at various points, healthily, badly, too much and too little – and I honestly don’t think any of those would have been different if I’d had meat in my diet.

        I don’t doubt it. I would never argue that all or most or even a plurality of people who restrict their diets ethically do so for reasons related to disordered eating. I known far too many vegetarians to entertain that notion! It’s just that I’ve also known too many who do overlap those categories to think that they can’t have anything to do with each other, either.

      • trees says:

        I’m a lifelong vegetarian but it has exactly 0% to do with my disordered eating stuff – I have eaten, at various points, healthily, badly, too much and too little – and I honestly don’t think any of those would have been different if I’d had meat in my diet.

        You were raised this way, yes?, and in a place where this is a cultural norm. You didn’t make some radical dietary change that may be read as oppositional. It makes sense that your vegetarianism is completely unrelated to disordered eating.

      • trees says:

        I strongly suspect that for some people–not all or most–ethical diets are also forms of or covers for or used as eating disorders.

        This is probably pretty common, and it’s definitely true for me in my 25+ years of living with eating disorders.

  8. Donna L says:

    [Warning: graphic discussion of effects of bulimia]

    I find it profoundly sad that there’s still so much misinformation, and so little understanding, of what eating disorders can be like after all these years.

    It’s very difficult for me to write about (so I almost never do), but one of the very dearest friends I’ve ever had in my entire life, my brilliant, wonderful, sweet friend Jo, died in early 1991 of the effects of her eating disorder, at the age of 45 — she was always 10 years older than I was, but now I’m considerably older than she’ll ever be — after suffering with it since she was in high school. She used to say she was “bulimorexic,” and I don’t know if there really is such a thing, but although there were periods when she was very thin, most of the time she wasn’t. But she never really stopped binging and purging for long, for the entire time I knew her. She was under medical care and in therapy with a specialist that whole time, but I’m not sure how much it helped. All I could do was give her support, when she felt like talking about it. I never pretended to be able to help her in any other way. How presumptuous would that have been?

    And then one night, after she had been very reclusive for quite some time — my son was then about 9 months old, and she hadn’t met him yet — her stomach burst. She called 911, and said to the EMT’s as they carried her off, “I’ve really done it to myself this time, haven’t I?” I’ll never forget getting the call about what had happened. By the time I got to St. Vincent’s Hospital, she was already in a coma, close to brain death, and her face was so swollen it was almost unrecognizable. I stood there and held her hand, and told her I loved her. (Of course it brought back memories of doing exactly the same thing 15 years earlier, the night my mother died.) She died later that night without ever regaining consciousness.

    For a long time after that, I kept thinking I saw her in the street, something that happens a lot, I believe, when someone you love dies. I still think about her often.

    Back then, very few people seemed to know or understand anything about bulimia. Even fewer knew about my friend’s illness — she kept it well hidden from everyone except her closest friends. Her therapist was kind enough after her death to talk to me for a while, and suggested the name of an organization to which I could make a donation in her name.

    I’m so sorry that the state of knowledge, and the efficacy of treatment, doesn’t seem to have progressed much in the last 23 years.

  9. irishup says:

    Thank you for this post, Caperton. Jedi hugs are offered to everyone who has lived with ED and/or love(s/d) someone who has.

    Disclosure: A huge part of my activism (online and elsewhere) is with an organization called F.E.A.S.T. : Families Empowered And Supporting Treatment of Eating Disorders. I am also a moderator at the parent and caregiver support forum “Around the Dinner Table”. My lived experience with ED is from the perspective of a parent.

    Eating disorders are biologically based developmental brain disorders. That is to say, regardless of whatever precipitating event(s) may have marked the onset of the *behavioral expressions* of the disease, they could not have “caused” the ED, if the predisposing genetic and biological risk factors did not exist as well. EDs are classed as developmental, because peak onset is in adolescence and early adulthood (14 – 24yo) , although both younger onset is being seen more often. The pernicious idea that ED is a disease of rich, vain white girls is not substantiated by epidemiological studies. AN appears across races and ethnicities independently of culture. BN and binge eating disorder are probably nearly as common in men as in women and may even be more prevalent in communities of color.

    We know stereotypes hurt. In medicine, the ED stereotypes results in people not getting the correct diagnosis early, and not getting treatment they need. When it comes to ED, ignorance, indifference and misinformation maim and kill.

    As for the relative risks of having an active ED, vs being whatever size you are when your eating behaviors are ordered (appropriate micro and macro-nutrient content at regular intervals without compensatory behaviors – and including accommodating preferences, mood, and any social roles) as opposed to disordered (mismatch between the body’s nutritional needs and intake, irregular or too-long intervals, compensatory behaviors, rigidity or inability to deviate from rule(s) to accommodate preferences, mood, availability, social roles): There is ABSOLUTELY NO BMI category with anything LIKE the level of morbidity and mortality risks associated with ED. NONE.

    The increased risk in the highest BMI category (BMI 35+) is a ~30% increased risk of mortality in the next year compared to a similar person at a lower BMI. Whereas the increased risk for someone with BED is ~200%, BN/EDNOS ~300%, and AN somewhere between ~550 – 1200% (depending on whose numbers you read). In real life terms: the CDC’s 2009 data give the probability a 23yo US woman would die in the next year @ 0.05%. Adding the risk for “morbid obesity” (BMI 35 or greater) vs EDs, you get

    BMI >35 (*0.3) 0.06%
    BED (*2.0) 0.10%
    BN/EDNOS (*3.0) 0.14%
    AN (*9.0) 0.43%

    So if someone is in recovery from their ED NO MATTER WHAT WEIGHT THEY ARE, THEY ARE HEALTHIER THAN WHEN THEIR EATING DISORDER WAS ACTIVE. Ordered eating is very likely the SINGLE MOST important (and difficult!) thing such people are doing, in terms of BOTH quality and quantity of life. Yet the likelihood is that their BMI is going to be one judged “unhealthy” for a variety of wrongity wrong wrong reasons, and even STILL, whatever benefits *might* accrue to them on the basis of a lower BMI? would be *absolutely* subsumed in what they could lose on so many other levels – health, well being, who knows what else – if they tried to change that BMI by running any kind of caloric deficit.

    There are effective treatments, but access to them, and the necessary sustained support needed to realize effective intervention, are scarce. The most effective interventions are behavioral, not psychodynamic, and require what Dr. Debra Katzman has coined “nutritional rehabilitation” – movement from disordered eating to ordered eating. For minors, the most well validated treatment methods are the Maudsley Method, Family Based Therapies, and behavioral methods such as CBT or DBT modified to address eating behaviors.

    It’s trickier once a person reaches the age of majority. Our society fails young adults with serious mental health diagnoses, full stop. But to the extent that family (whether biological or chosen) can provide the structure to make sure the nutritional rehabilitation gets followed through on, those are the interventions with the most promise.

    Treatment Resources:

    UCAN couples program @ UNC.
    Maudsley Parents has a listing of Family Based Therapy practitioners and great learning resources.
    In the UK The New Maudsley Approach
    In AUS The Butterfly Foundation and the National Eating Disorders Collaboration

    For reading, I recommend

    Lock & Le Grange “Help Your Teenager Beat and Eating Disorder”
    Janet Treasure “Skills-based Learning for Caring for a Loved One with an Eating Disorder”
    “A Collaborative Approach to Eating Disorders” (AUS)
    Cynthia Bulik “Crave: Why you binge eat and how to stop”
    June Alexander “Hope at Every Age” (June blogs @ junealexander)
    Alexander and Le Grange “My Kid is Back”
    Carrie Arnold “Decoding Anorexia” (Carrie blogs @ EDBites)

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