Eating disorders are complex illnesses with as many different causes, symptoms, and presentations as there are people who suffer. When we talk about diagnostic criteria or signs and symptoms, it is important to acknowledge that not everyone has the same experience with an eating disorder and some things can resonate while others feel completely untrue for your or a loved one’s experience. The DSM is flawed and limiting in diagnostic criteria for many reasons but can also be a helpful place to start when we are considering the possibility of an eating disorder. We’ll talk through some of that criteria and where I feel it lacks with each disorder. An important note that I, as a dietitian, don’t actually diagnose eating disorders. I usually have a pretty good hunch, but a diagnosis that goes in your chart can really only come from a therapist, doctor, or psychiatrist.
Disordered eating is present almost anywhere you look. Not everyone who has disordered eating patterns meets criteria for having an eating disorder. That doesn’t mean that the behaviors are supportive or “healthy”, but it might mean that the impact on their life is less significant than for someone else who engages in more behaviors or in that disordered behavior more intensely. The truth is, if eating is stressing you (or anyone!) out, it’s worth talking to a professional. We know that dieting is a risk factor for eating disorder development, so even “small” restrictive or compensatory behaviors can intensify over time. So many of us didn’t grow up with good role models for a healthy relationship with food, so it’s okay to seek support even if you don’t think you have a “real” eating disorder!
Sometimes I hear messaging along the lines of “an eating disorder doesn’t require treatment if labs are normal, body weight is above a certain threshold, or there aren’t other medical complications from malnutrition or compensatory behaviors”. That could not be farther from the truth. We don’t wait to treat any other disease until it is actively life threatening. Can you imagine if a loved one got a stage one cancer diagnosis, and the doctor recommended waiting to get support or treatment until it was stage four? An eating disorder is no different from another deadly illness. Any level of distress with food is worthy of support, care, and treatment. Our mental imagery of eating disorders isn’t even accurate to what the majority of eating disorder diagnoses really look like. The emaciated, young, white girl is only one example, and a very small percentage of who struggles with eating disorders. Medical professionals do everyone a disservice when we only take eating disorders seriously when they look or behave a certain way.
Our bodies are so, so, so resilient. Survival is the cornerstone of our human existence, and our bodies have extensive measures in place to ensure we keep on keeping on even when the circumstances are not ideal. This means that we oftentimes don’t see changes in lab values or the physical symptoms of an eating disorder until behaviors are extreme and chronic. If we start seeing abnormal lab values, it means our bodies have surpassed their checks and balances for surviving “famine” and no longer have the stores or resources to maintain our baseline needs. This usually takes some time. Waiting to get treatment until we reach this point is unnecessary and can make treatment more intensive, more life-altering (higher levels of care, leaving work or school for a period of time, etc), and more complicated. Now, of course, seeking treatment at this point is also necessary and beneficial - there is no wrong time to seek help.
Treating an eating disorder is best with an interdisciplinary team of people who have done their own work dismantling their fatphobia, diet culture beliefs, and body image struggles. Human beings may never be perfectly able to fully resolve the impacts of living in diet culture and they owe it to their clients to not be fully entrenched in those beliefs. We can’t effectively treat an eating disorder that is rooted in the pursuit of thinness if we, as a provider, are still existing in the belief that body size is important for self-acceptance, health, or to have a “good” body. The treatment team should ideally include a doctor, therapist, psychiatrist, and dietitian who each have expertise in eating disorder treatment.
I sometimes describe the dietitian’s role on the treatment team as the intermediary between the medical side and the therapeutic side. We are co-monitoring labs and medical symptoms from a nutritional lens while also supporting with food exposures, challenging disordered beliefs, and sitting with the intense emotions that accompany body image work. While I support dietitians and our education to be experts in our field, many dietitians do not have the training to effectively treat eating disorders. Look for experience in higher level of care, supervision, or specific eating disorder credentials when choosing an eating disorder dietitian. It’s okay to interview your providers! Your RD and therapist are two people who you will share incredibly vulnerable and personal information with - you want to make sure they feel like people you can trust and be fully yourself with.
As we get into the series, I hope that I can answer some of your questions about specific eating disorder presentations and what treatment and recovery can look like. While eating disorders are complex and impact our mental and physical health, they are also treatable! Recovery is possible and everyone deserves a healthy relationship with food, their body, and taking care of themselves. Let me know in the comments if you have any specific questions you’d like me to answer with the first official Navigation post: Navigating ARFID.
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