Eating Disorders: The Well Known Signs Plus Unfamiliar Red Flags

In light of eating disorder awareness week 2024 (February 26 - March 3), I figured the topic of common, and sometimes easily missed, eating disorder signs was fitting. The amount of times I’ve been asked as an eating disorder professional by loved ones “Is this my fault?”, or “Did I cause this eating disorder for my child?”, and “How did I miss the signs?”, goes to show we as a community are undereducated on the disordered eating behaviors that can quickly spiral towards a diagnosable disease. In this blog I will break down common behavior changes and medical presentations of EDs, some being well known while others may surprise you.

What are the different eating disorders?

First I’ll start with a quick ED-101 on some, but not all, types of eating disorders and what they are. Screening tests like the SCOFF Questionnaire and EAT-26 can help screen for most to all of these EDs as certain signs and symptoms coincide across diagnoses. 

  • Anorexia Nervosa (AN) is characterized by a fear of gaining weight that leads to severe food restrictions, both in quantity and variety, resulting in a low BMI (less than optimal BMI, or <18.5kg/m2) and very low body weight. Different subtypes include AN-binge and purge type and AN-restricting type to help classify ED behaviors in conjunction with the low BMI to still meet criteria for AN.

  • Atypical Anorexia Nervosa (AAN) is a new diagnosis in the Diagnostic Statistical Manual, 5th edition (DSM-V). This branch of AN meets all behavioral presentations, without the low BMI. Still someone in this category is at a body weight that is not appropriate for them and weight gain is part of recovery.

  • Bulimia Nervosa (BN) includes body image disturbances with behaviors of binging food followed by purging multiple times per week for months at a time. Purging can include laxative use/abuse, self induced vomiting, and/or diuretic use. 

  • Avoidant Restrictive Food Intake Disorder (ARFID) has transitioned in its location within the DSM editions, but today is clearly defined. Signs and symptoms of ARFID are very similar to AN, ie food restrictions and low body weight, but are not (usually) associated with the body image disturbances. Individuals with ARFID struggle with texture, taste, and smell sensitivities in food that can stem from negative experiences with food, fear of being allergic to trying new foods, and/or rigidity with trying foods all characterized by fear and anxiety, rather than someone just being picky with food because they have that choice.

  • Binge Eating Disorder (BED) is also a newer DSM diagnosis. This disorder includes the binging behavior without purging or compensatory actions immediately after eating, but feelings of guilt and shame may follow. There may or may not be weight changes in someone with BED. This disorder is still rooted in restrictive eating behaviors.

  • Other Specified Feeding or Eating Disorders (OSFED) is a diagnosis for someone that clearly presents with an ED, but falls outside the criteria for any DSM-V specific disorders. OSFED was previously Eating Disorder Not Otherwise Specified (EDNOS) in past DSM editions.

Common Signs of an Eating Disorder

The below are some common signs among all the eating disorders:

  • Abnormal lab findings

  • Restrictive food behaviors– quality and quantity

  • Wearing baggier clothing to hide one’s body, or changes in clothing style in general

  • Mood swings, lack of flexibility, and increased depressive/anxiety symptoms

  • Weight changes 

  • Changes to nails– deep ridges, brittle nails

  • Skin changes- drier skin, possible lanugo hair growth with severe weight loss

  • Orthostatic vital signs and/or bradycardia– presents as lightheadedness, dizziness, vision changes, and/or fainting spells

  • Hair thinning/hair loss

  • Muscle aches and/or joint pain

  • Lack of interest in usual hobbies

  • Poor concentration and brain fog

  • Increased isolation– could also include eating alone and avoiding family mealtimes or food related situations in general

  • Gastrointestinal disturbances– constipation, diarrhea, gastroparesis

  • RIgidity with exercise– ruins one’s day if they cannot participate in their planned routine, compensating for what’s eaten by exercising more, exercising when sick or injured, secretly exercising

  • Thinking about food most of the day– I usually quantify this as greater than 5 hours per day, or I also ask my clients if they can be present without food being on their mind

  • Body checking- viewing reflections in mirrors and large windows, pinching, wrapping one’s hand around their wrist, measuring body parts with a measuring tape, etc.

Signs Specific to Each Eating Disorder

Some signs that are specific to AN and AAN include:

  • Weight loss from usual body weight, or in a child drop in one’s normal growth trajectory

  • Fear of gaining weight, obsession with the scale

  • Counting calories

  • Hyperfixation with nutrition labels

  • Lack of hunger cues, or ignoring of hunger cues– may be seen as having great will power

  • Cook and bake for others, but don’t eat what they themselves make

  • Eat “healthy” to avoid certain foods or food ingredients and lack flexibility in these rules

  • Skipping meals and/or snacks

  • Hiding food

  • The AN-binge and purge subtype includes binging/purging behaviors common to BN 

Medical and behavioral signs of ARFID are similar to the above, except it does not (usually) include the fear of gaining weight. Food aversions come from texture, taste and smell sensitivities– actual fears that present similarly to the signs and symptoms of AN.

Bulimia nervosa also includes similar signs of AN and AAN, plus some of the following:

  • Laxative use/abuse– daily dose that’s within normal range or multiple doses multiple days per week

  • Self induced vomiting (SIV)

  • Regular bathroom use after meals

  • Poor dentition, especially damage to the front teeth due to erosion from vomiting 

  • Russels sign, or bulimia knuckles– calluses on the tops of one’s fingers from SIV

  • Eating binges that leave someone sickly full while may also continue to eat– the amount being larger than considered normal for one sitting or multiple sittings, this is different than someone who restricts and eats a normal amount of food but feels very full

BED presents differently than the above eating disorders in some ways, but not completely immune to the above signs/symptoms. The disorder can still include body image disturbances, thinking about food multiple hours per day and struggling to stay present in food related situations plus may include avoiding social situations that involve food, lab abnormalities, changes in clothing style, changes in hair, skin, and/or nails, food rigidity, exercise rigidity, mood changes, and more. Weight changes may occur, but not always– someone may maintain their set point range and when seeking recovery their body reaches a homeostasis with improved eating behaviors. Some individuals will seek different treatment approaches for BED, like weight loss or OA, but as an eating disorder professional I strongly recommend against seeking weight loss as a goal for recovery. Also per the latest research on EDs and BED, having weight loss be one of the interventions for recovery is not indicated.

Eating disorders are not easily detected, in that you cannot look at someone across the room and say whether or not they have an eating issue. The screening questionnaires available are valuable in diagnosing an ED. The disease can be sneaky and quickly disordered eating patterns can transition into a diagnosable ED, so seeking treatment early is recommended and shows greater success in recovery. Achieving full recovery is possible with an eating disorder, yet everyone’s treatment plan and trajectory varies. If you’re worried you or a loved one is struggling with disordered eating/an ED, start by reaching out to one of us today at Enhance Nutrition to guide you in the right direction for treatment. Also check out the “Nutrition Links” on our website for easy-access ED resources.