Early Signs of Eating Disorders in Tween and Teen Girls
Eating disorders are an umbrella term referring to one of several conditions characterized by disturbances in body image, an overvaluation of weight, shape, and size, and an intense fear of weight gain.
The three most prevalent eating disorders in the United States, and the ones we will learn more about in this article, are binge eating disorder, bulimia nervosa, and anorexia nervosa.
If you are concerned about your daughter’s eating habits or you simply want to be more informed, I encourage you to continue reading. My hope is that this article will teach parents what to look out for so that they can intervene quickly if disordered eating patterns are noticed. Treatment is much more successful when initiated early in the course of an eating disorder. This blog will also provide information on treatment options and resources if you think your daughter may be showing some of these early signs.
Why are young girls at risk for the development of an eating disorder?
Young girls are bombarded with messages from the media and diet culture promoting the thin ideal and encouraging dieting to achieve weight loss. For young girls in the tween and teenage years, many of whose bodies are undergoing dramatic changes as a result of puberty, these messages can be damaging to self-esteem, body image, and mental health.
Diet-promoting content is pervasive on social media platforms such as Instagram and TikTok. 2023 Pew Research Center survey data indicates that 73% of teenage girls use TikTok and 69% use Instagram. Teenage girls also use these apps at higher rates than teenage boys.
According to data from the National Institutes of Health (NIH), most eating disorders are diagnosed between 18-21 years of age. Behaviors may start much earlier than an official diagnosis. The same data also shows that eating disorders disproportionately affect young girls. According to the National Alliance for Eating Disorders, between 5.5%-17.9% of young women and 0.6-2.4% of young men will be diagnosed with an eating disorder by the time they reach early adulthood.
Eating disorders are serious conditions and a diagnosis can be scary for both the family and child. One of the best ways to prevent warning signs from escalating into a full-blown eating disorder is early intervention. As parents, we play an important role in helping our children develop a healthy relationship with food. I encourage all parents to emphasize the importance of health over weight and discuss food in neutral terms, rather than creating a value system in which certain foods are “good” or “bad.”
To that end, let’s dive in on what the early signs of binge eating disorder, bulimia nervosa, and anorexia nervosa look like.
Types of Eating Disorders
There are 8 classes of eating disorders identified in the DSM-5, or Diagnostic and Statistical Manual of Mental Health Disorders, which is the resource used by mental health professionals to diagnose mental health conditions. The DSM is published by the American Psychiatric Association. The fifth edition, which is the most recent version, came out in 2013. The 8 classes of eating disorders are the following:
Anorexia Nervosa (AN)
Bulimia Nervosa (BN)
Binge Eating Disorder (BED)
Other Specified Feeding and Eating Disorders (OSFED)
Pica
Rumination Disorder
Avoidant/Restrictive Food Intake Disorder (ARFID)
Other Unspecified Feeding or Eating Disorders (UFED)
The eating disorder space is highly complex and rapidly changing. For the purposes of this article, we will focus on the three most common eating disorders in the United States - binge eating disorder, bulimia nervosa, and anorexia nervosa. These eating disorders have been heavily researched. There are well-established treatment guidelines and ample resources for those seeking treatment. They are also the most likely to affect young girls.
Signs of Eating Disorders
If you’ve noticed that your child’s eating patterns have changed, you may be wondering if she is exhibiting behaviors consistent with an eating disorder. So, what are some signs to watch out for?
The National Eating Disorders Association, or NEDA, has an excellent resource on warning signs. According to NEDA, common emotional signs of an eating disorder include eliminating food groups (such as carbs or fats), making excuses to avoid mealtimes, developing rituals around food (such as eating foods in a certain order), and an extreme focus on calories, weight loss, and body shape.
Of course, one of the major physical signs of an eating disorder is a change in body weight. Eating disorders are typically associated with weight loss, however, with binge eating disorder and bulimia nervosa, weight may actually increase. Additional physical signs include GI complaints (acid reflux, constipation), the loss of a period or less frequent periods, insomnia, and feeling cold constantly.
In addition to the above, binge eating disorder, bulimia nervosa, and anorexia nervosa each have more specific signs which we will discuss.
Causes of Eating Disorders
As you may have gathered, eating disorders are very complex. Researchers believe that genetics, mental health, environment, low self-esteem, and certain personality traits, such as perfectionism, all play a role.
Eating disorders often occur alongside mental health conditions. In fact, eating disorders are classified as mental health disorders in the DSM-5. Anxiety, depression, and OCD are among the mental health conditions associated with eating disorders. Anxiety in particular is highly comorbid with eating disorders, meaning that the two often occur together. According to one estimate, 81% of adults with bulimia nervosa also have an anxiety disorder.
One of the biggest risk factors for the development of an eating disorder is dieting.
Many people link the start of their eating disorder with an intentional effort to restrict food intake.
As a side note, emerging research indicates that nutrition has a significant impact on mental health. If you’re interested in the link between nutrition and mental health, explore more information on the growing field of nutritional psychiatry, as discussed at the 2024 FNCE conference.
Binge Eating Disorder
Binge Eating Disorder is the most common eating disorder in the United States. The National Alliance for Eating Disorders reports that 3.5% of women and 2% of men in the U.S. struggle with binge eating disorder.
Let’s first discuss what characterizes a binge, and how it’s different from overeating. Overeating is normal - everybody does it from time to time. Have you ever started eating a piece of cake and maybe had more than you intended, just because it tastes so good?
Binge eating is distinctly different from this type of behavior. According to the DSM-5, binge eating is characterized by rapid eating, eating past the point of fullness, and eating large amounts of food when not physically hungry. A binge involves the consumption of an amount of food that is larger than what most people would consume in a similar period of time, for instance, 2 hours.
Binge eaters also feel a lack of control during the binge - a feeling that they cannot stop eating. This is key, and a big reason why binge eating is different from overeating. When we overeat, we typically do not enter the dissociative state characteristic of a binge.
Finally, binges are often associated with feelings of shame, disgust, and guilt. They are often conducted alone and in secret. In contrast to bulimia nervosa, binge eating is not associated with compensatory behaviors - behaviors intended to purge the food or prevent weight gain.
To receive a clinical diagnosis of binge eating disorder, binge eating must occur at least once a week for 3 months.
Signs of Binge Eating Disorder
Common signs and symptoms of binge eating disorder (BED) include stealing or hiding food, restricting food following a binge (skipping meals, having small portions, fasting), and recurrent attempts at dieting. Individuals with BED may also plan their schedule around binges. For instance, they may choose to stay home or not attend a social event in order to have the privacy to binge. Changes in weight can also be a sign of BED. Specifically, as a result of frequent binges, weight may increase.
If you think your child may be engaging in some of these behaviors, such as sneaking food, but is not exhibiting binge eating disorder, explore more about why kids sneak food.
You may also have concerns over your child’s weight, related to or separate from binge eating. How do we speak to our kids about weight? This is a difficult topic to discuss, but the overarching goal is to emphasize healthful lifestyle choices rather than weight.
Bulimia Nervosa
Bulimia nervosa also involves binge eating episodes. However, the difference between bulimia nervosa and binge eating disorder is that individuals with bulimia engage in compensatory behaviors after a binge. Compensatory behaviors include self-induced vomiting, excessive exercise, fasting, and the overuse of laxatives and/or diuretics.
In order to receive a clinical diagnosis of bulimia nervosa, an individual must engage in a binge-purge episode at least once a week for 3 months.
Bulimia nervosa is a bit less prevalent than binge eating disorder. It is estimated that about 3% of women and 1% of men in the United States are affected.
Signs of Bulimia
In addition to the signs of binge eating, there are some unique indicators of bulimia to be aware of. These include the use of laxatives and/or diuretics (such as coffee), fasting, extreme exercise (exercising for hours - far beyond what seems normal), consistently going to the bathroom after meals, excessive use of gum or mouthwash, cuts or calluses on the knuckles (as a result of self-induced vomiting), and dental issues, such as cavities and bleeding gums.
Individuals with bulimia may lose weight, however, weight is not part of the diagnostic criteria. Individuals with bulimia may be underweight, normal weight, or overweight.
Anorexia Nervosa
Lastly, we’ll discuss anorexia nervosa. The diagnostic criteria for anorexia nervosa require that the individual display three things - a significant restriction in food intake and extremely low body weight, an intense fear of weight gain, and distortions in body image and overvaluation of body weight and shape. Individuals are often unable to recognize the seriousness of how little they weigh. About 4% of women and 0.3% of men in the U.S. have anorexia nervosa.
Of note, there is also atypical anorexia nervosa, which is a new diagnosis in the DSM-5. Atypical anorexia nervosa occurs when individuals who were previously overweight experience distortions in body image and lose weight through restriction. Individuals with atypical anorexia nervosa may remain a normal weight or above the normal weight range for their age and sex. Atypical anorexia nervosa can be missed because the individual does not present at a very low body weight; however, atypical anorexia nervosa is just as severe as anorexia nervosa.
Signs of Anorexia Nervosa
One of the major signs of anorexia nervosa is extreme weight loss and very low food intake. People with anorexia may be intensely focused on calories and/or the grams of carbohydrates, fat, or protein in their food. They may restrict the types of foods eaten or cut out entire food groups, such as carbs or dairy. An inflexible exercise regimen is also an indicator. Mealtime avoidance, excessive chewing, denial of hunger, constipation, and self-isolating are additional signs.
Orthorexia
As a pediatric dietitian and child feeding expert, I want to quickly mention an issue I am seeing more of, which is called orthorexia. Orthorexia is not currently recognized in the DSM-5 but has become increasingly more prevalent. People with orthorexia develop an extreme obsession with “healthy” eating and the nutritional content of their food. This obsession is debilitating, and negatively affects the individual’s well-being and quality of life. Research has found that orthorexia is strongly associated with OCD.
Signs of orthorexia include frequent checking of nutritional labels and ingredients, eliminating entire food groups (sugar, carbs, dairy, etc.), anxiety when “healthy” foods are not available, and an obsession with health and lifestyle accounts on social media. People with orthorexia may or not also have body image disturbances.
What are the next steps if you believe your daughter has an eating disorder?
As eating disorders are complex conditions, treatment often requires a multidisciplinary approach. Eating disorder treatment teams typically include a registered dietitian, mental health professional(s), and a physician, although your child’s specific needs may vary.
In eating disorder treatment, there are different levels of care. Outpatient treatment is the lowest level. This involves counseling, either in-person or virtual, from a range of providers, such as a therapist, registered dietitian, psychiatrist, and MD.
Individuals receiving outpatient treatment are deemed medically and psychiatrically stable. If your child needs more support, there are intensive outpatient specialty programs, which involve group and individual therapy. Individuals typically go to a treatment center for 6-10 hours per day, a few times per week.
For those who do not respond to other treatment options, a residential eating disorder program may be the next step. This involves living in a treatment center for a period of time and receiving 24-hour care and support. The individual must be medically stable.
Finally, the highest level of care is an inpatient eating disorder treatment program. In this case, the individual is admitted to a hospital as he or she requires active medical and psychiatric care. This treatment approach is reserved for only the most severe eating disorders.
The first step is finding qualified professionals to assess your child’s needs and craft a treatment plan.
The National Eating Disorders Association website is a great resource to turn to. NEDA maintains a search tool that allows you to find eating disorder providers in your area. They also link directly to practitioner directories compiled by the National Alliance for Eating Disorders, the National Association of Anorexia Nervosa and Associated Disorders (ANAD), and EDReferral. ANAD, which is the oldest nonprofit in the U.S. dedicated to treating eating disorders, provides free peer support services.
Nutritional counseling is an important part of any eating disorder treatment plan. Fay, which is a NEDA partner, matches each client with a registered dietitian for virtual counseling. Fay vigorously vets their dietitians and prides itself on only employing those who are qualified to treat eating disorders. Treatment by Fay is covered by all major insurance providers.
Of course, I also encourage you to speak to your child’s pediatrician for more information on eating disorder treatment options.
Final Thoughts
Hopefully, this blog post has provided useful information on the early signs of eating disorders. This is a scary topic, but know that there are things you can do to support your child if you believe they have an eating disorder. Early intervention has been shown to be effective at both reducing the severity of the eating disorder and increasing the likelihood that treatment will be successful.
Broaching subjects related to weight or eating behaviors with children is complicated. It’s important to make sure that these topics are addressed in a sensitive way, especially given the diet-crazed world we live in.
Ultimately, our children’s health and well-being must always come first. It’s our responsibility as caregivers to recognize the signs of disordered eating and help our children get the treatment they need. Know that you are doing the right thing for your child by speaking to them about your concerns and pursuing treatment.
Thank you to my Dietetic Intern, Olivia O’Bryan for her contributions to this blog post.