Last week I explored the issue of body image and the role anxiety plays in driving poor body image and eating disorders. This week I wanted to give an overview of what to look for when it comes to signs of an eating disorder. 

Sometimes it’s very hard to diagnose or identify disordered eating. Especially for family members. People often reach out asking how they can tell if their loved one has an eating disorder or not. One would think it would be a fairly straightforward and easy thing to identify. But you have to remember that someone with an eating disorder can be very gifted when it comes to covering up the disorder. Pure genius in fact! There is no end to the creative ways that individuals suffering from an eating disorder hide it from the people who love them.

So some of the subtle signs of anorexia that you won’t see in the diagnostic and statistical manual of psychological disorders are as follows:

Changes in routine. Suddenly they stop doing things they have always done or start doing things they have never done. For example, an individual may begin to eat meals alone. Sometimes that means eating meals in private away from other members of the family. It is not uncommon for an individual with an eating disorder to pretend to be eating food, when in reality they are packaging it up and pitching it. Obviously, it’s easier to do this if you are not sitting down for a meal with other family members.

Refusing to join in celebrations where food is the focus. Making excuses about not going to holiday events, (even the big ones) begging off on attending weddings or parties, suddenly not hanging out with friends especially when food is involved. In adults that means no cocktail hour, in teens that means no overnights….too much pressure to eat and drink on moral principle. 

Changes in the way they dress. Some individuals go from wearing normal fitting clothes to wearing only baggy clothes to hide their thinness. Whereas other individuals suffering from anorexia want to display the thinness and do so too excess. In other words, they wear clothing that is very tight, very short, very sheer, or a combination of such characteristics, with the goal of flaunting their newfound thinness.

Abrupt dietary changes. Another common scenario is that the individual suddenly becomes vegetarian, and/or then vegan. In fairness, some people become vegan because they feel morally compelled to do so. But there’s such a high percentage of individuals suffering from anorexia who end up being vegan that the correlation has to be viewed from the perspective of the anorexic thought process. It goes something like this: “No one is going to argue with me if I tell them I don’t eat meat on moral principles, whereas if I tell them I’m afraid to eat meat because of all the fat  I am much more likely to get pushback.” 

What is interesting about this one is that for those who use animal rights as an explanation for restricting, they often discover over the course of treatment that being vegan makes it much more difficult to maintain a healthy/slender weight than if they allow themselves to eat 100% grass-fed, wild-caught animal or fish protein. Being vegan means that you are often stuck eating more carbs because you have limited options for protein and carbs are generally more “fattening” than good protein.

Social isolation. Withdrawing from friendships and/or important relationships is another common early sign of an eating disorder.

Giving up sports. Even sports in which the individual has excelled can also be another early symptom of anorexia.

Developing obsessive-compulsive rituals. As the anorexia worsens, so too do the rituals around food preparation, eating rituals, and patterns of restricting. The individual may develop a full-blown obsessive-compulsive disorder that is tied directly to the eating disorder. If you think of the eating disorder as an anxiety disorder, the OCD and ritualized behavior is an attempt at managing the anxiety.

Did you know that when it comes to bulimia or Bulimarexia, there are actually four different ways that one can purge? Most people don’t realize this. Indeed, many therapists aren’t aware of it. The obvious way is by vomiting, but you can also purge by abusing laxatives, restricting insulin if you are diabetic and over-exercising. That’s right exercising is a way of purging for many individuals suffering from Bulimarexia. Let’s talk about each one of these.

Purging. If you have a child whose weight is very low and who eats when pressured, but still is  not gaining weight you might consider the possibility that they are purging the food that they are eating. Most anorexics simply refuse to eat but if pressured enough, they will eat and then figure out a way of ridding themself of the calories. The most obvious way is to purge. You would think that this would be pretty easy to spot. The problem is that they are so good at covering up the fact that they are purging that is isn’t all that easy. 

For example, some know that they can wait several hours to vomit because the food may take hours or days to digest. They will eat something red and then check their vomit to make sure that the meal came back up in its entirety. Some people have such slow gastric emptying as a side effect of Bulimarexia that they can wait 24 hours and still get rid of all the food they ate. So even if they don’t go to the bathroom right after they eat they could still be purging.

One of the ways to determine if they are purging is to check the toilet and look for evidence of vomit. Be sure to check on the underside of the toilet seat for specks of vomit. Also be aware that they may purge in the shower, believing that the noise of the shower covers up the vomiting. I can tell you horror stories about pipes getting clogged up as a result. Finally, I have had patients that would just purge into bottles and recap them and leave them in their bedroom hidden for months at a time. Their rooms are often no-go zones so it was fairly easy to pull this off.

Besides being dehydrating, purging is also a serious potential threat to one’s teeth as it destroys the enamel, sometimes permanently. I have had patients suffering from Bulimarexia who lost all of their teeth, or had all of their teeth turn black. I had one patient who not only lost all of her teeth, but she lost most of her jaw bone and was never able to have teeth or even implants again. This is a very heavy price to pay.

Laxative Abuse. Another way of purging is by abusing laxatives. This is also very dangerous as it causes severe dehydration and damage to the gastrointestinal system, especially the lower bowel. If they ask for laxatives due to constipation, be on the lookout. Magnesium is the best way to prevent constipation safely, but it can also be abused so it may be necessary to dispense it rather than giving them free access. 

Restricting Insulin. Although this is unusual, it isn’t as unusual as you might think. I’ve had several diabetics use their insulin protocols as a way of managing calories. Again very dangerous, and potentially life-threatening

When an eating disorder accompanies type 1 diabetes, the mortality rate climbs to nearly 35 percent. In addition to the increased risk of death, there is also an increase in the escalation of medical complications from diabetes in those who restrict insulin such as vision loss and kidney failure. The health issues that a diabetic might typically expect to experience in 30 years can begin to occur within five or seven years if they are abusing insulin as well as exhibiting obvious symptoms of an eating disorder.

For example, if a type I diabetic begins insulin manipulation at the age of 17, they could become totally blind, begin suffering from extreme nerve pain, or need to be on a kidney transplant list by their mid-20s. Their ability to have children may be permanently compromised as well.

Here are some of the signs of insulin abuse that you should look for:

• The person seems dehydrated, tired, and irritable.

• The person’s insulin supply seems to be lasting longer than expected. They purchase fewer bottles than usual.

• The blood sugar log on their glucometer shows that they have not been maintaining healthy levels.

Taking action is absolutely critical. If you suspect that your loved one is manipulating their insulin, you must insist that they get a Hemoglobin A1C test. 

Over-Exercising. This is one of the more obvious ways that an individual with Anorexia and/or Bulimarexia purges. Over-exercising is much easier to spot although you would be surprised how good the individual can get at keeping it under the radar. They often get up in the middle of the night to exercise, I’m talking about 1000 push-ups or sit-ups. Or they say they are going for a walk and come back three or four hours later. There’s no guarantee that they walked. They may have run the entire time. They often break bones when they do this because even tripping can cause a shin or leg bone to fracture given the osteopenia or osteoporosis that many such individuals suffer from.

While  I don’t believe that absolutely no exercise is always the antidote to this problem, and mind, that is the approach most residential treatment programs use. Instead, I believe that exercise can be a reward for refeeding and weight restoration. It just needs to be used very carefully and monitored continuously.

If you have any suspicions at all that your loved one may be suffering from anorexia, bulimia or bulimarexia, you are probably right. I am the Eating Disorder Pro and I can help.