A Dietician Answers Questions
about Eating Disorder

by Cheryl Simons as told to Valerie Nanninga Engeltjes

What can concerned family members or friends do if they suspect someone of having an eating disorder?

First, educate themselves. People with eating disorders are adept at hiding their behavior, so it's important to know the symptoms to look for.

People with anorexia are easier to identify because of the weight they lose. Sometimes it's hard for family members of a person with bulimia to know it's going on unless they see some bizarre behaviors around meal time.

What are signs of anorexia?

One sign is preoccupation with food. People with anorexia are concerned with what they're eating, reading labels carefully to determine calories and grams of fat.

A change in eating patterns is another key. Are they eating less? Perhaps you hear them get on the scale often, so you know they're weighing themselves frequently.

They may become irritable. Poor nutrition also leads to problems with sleeping and concentrating. They may be more susceptible to colds because of a depressed immune system from a lack of protein intake.

Watch the supplies of sanitary napkins or tampons. If supplies aren't being depleted, this could be a sign that menstruation has stopped.

What about signs of bulimia?

People with bulimia are more secretive than those with anorexia.

They may binge on the way home from school or work so families don't find out. Are there a lot of fast food bags in the car? Is food disappearing from the pantry and refrigerator faster than usual?

The person may go to the bathroom immediately after eating. Do they turn on the shower or faucet to cover up the sound of vomiting?

Watch for laxatives, diuretics, Ipecac syrup, or diet pills in purses, drawers, or other hiding places.

What kinds of information do you look for when you talk to people with an eating disorder?

When I conduct an eating disorder assessment with patients, I ask how they feel about their body, what their menstrual cycle is, and what they consider an appropriate weight for them.

Their answers tell me a lot. Let's assume someone's normal weight should be 120. If she's anorectic, she may say 100 is the right weight.

Patients often display restrictive eating patterns. They may tell me what calorie amount they try to stay within. They may eat only one meal a day. Or, if they eat three meals, it may be specific foods. Cereal for breakfast, lettuce for lunch, and peas for dinner. They'll eat the same foods every day because they're afraid if they eat other foods outside the safe categories, theyll gain weight. They've compartmentalized foods into good and bad categories.

How can a teenage girl get away with eating just peas for supper? Don't her parents pay attention to what she's eating?

Sometimes we wonder what goes on at home. If the parents see a change in eating patterns, do they just let it go or do they confront the person?

Sometimes the family doesn't know what to do about it. Sometimes it's part of family dynamics. I knew one mother who was trying to get her daughter to stop binge eating and purging. The more she focused on it, the more her daughter wanted to engage in it.

Perhaps some parents try to keep the focus off it, thinking the victim will eventually see what she's doing to her body.

What are some of the effects on the body?

Binge-purge behavior can harm many different areas of the body.

Repeated vomiting can inflame, scar, and even tear the esophagus. The passageway can become so narrow that it's difficult for food to pass through or it can rupture, requiring surgery.

Vomiting can cause the stomach lining to become inflamed. Sometimes a person breathes in the vomit, which can damage the lungs. People can break blood vessels in their eyes from forceful vomiting. The stomach acid can erode the teeth's enamel.

Laxative abuse can damage the lining of the colon. The result may be bloody stools or ulcers. Ultimately, the bowels may become lazy from disuse and the person develops constipation.

The loss of nutrients and fluids from purging can lead to kidney stones, kidney failure, dehydration, and an uneven heart rate.

Ipecac syrup is toxic and can cause muscle and heart weakness. Its use has led to death in some patients.

With the increased awareness and education about eating disorders and their harmful effect, is the number of cases decreasing?

No. This continues to be a significant problem, especially with adolescent girls. I work with all ages, and teenagers are the most difficult patients. They don't see the long-term implications of engaging in these behaviors.

We can educate adults about the physiological and physical problems of starvation and binge eating/purging. That can motivate them to change.

But adolescents ignore these serious implications.

Do eating disorders have their roots in the teen years?

Most of the patients I've worked with have had some history of eating disorder behaviors in high school. I had a patient who was 32 and just recently became anorectic. But we can trace the problem back to high school when she was always concerned about her eating and her body.

It usually starts innocently. People have told me they started vomiting with a friend. One patient said her mother was a nurse and told her about a person at a hospital who was vomiting and lost a lot of weight. And then after one meal, she had eaten too much and remembered the story her mom told her. She started self-induced vomiting. It became a habit off and on over the past ten years. She came to us because it has become consistent. She vomits every day now.

I worked with one patient who took six laxatives every day for 20 years.

What is a dietitian's role with patients?

Dietitians are a part of the treatment team. It can be difficult to work with eating disorder patients at first. They're going to have problems with digestion because their gastrointestinal system isn't used to processing food normally. They often experience bloating, intestinal gas, and constipation.

There are some steps they can take to reduce the discomfort such as limiting fat and raw, high fiber vegetables, eating cold or room-temperature foods, reducing milk and lactose intake, and increasing the amount of insoluble fiber.

We begin by helping them normalize eating. It can even be difficult for them to tolerate seeing the meal in front of them. It seems overwhelming.

I take their lists of good and bad foods and work to increase the foods on the good side. We try to gradually introduce the foods into their diet so they can see they can eat the food and not gain 20 pounds.

What kind of expectations do you have about their weight gain or loss?

We try to get people with anorexia up to gain to 3 pounds a week. We start with 1500 calories per day and increase it 500 calories each week. The maximum is 3500. Their goal is to gain enough weight to be on the low end of their ideal body weight range. Then we try to stabilize them.

We try to teach people with bulimia healthy eating so their weight can stabilize. Most are a little overweight - 10 to 30 pounds - but we don't allow them to be on a weight reduction diet. We encourage weight maintenance.

It's important for them to normalize their eating patterns before they can even address weight reduction. Putting them on too restrictive a diet might actually increase their urge to binge and purge.

What advice would you give to parents or others who know someone with an eating disorder?

Get help fast. It's important that the therapist and dietitian work together. Sometimes the patient isn't willing or ready to address food issues. However, it's important the dietitian control the food issues so the therapist can work on other issues in the patient's therapy.

It's also important that the therapist and dietitian have a good relationship. Eating disorder patients can be secretive and say one thing to the therapist and something else to the dietitian. Professionals have to be willing to confront patients if they revert to old coping mechanisms.