Terrifying NHS figures released this week reveal that over 20 percent of older teenage girls in England were identified as having an eating disorder. Tom Quinn from the eating disorders charity BEAT observes that while “eating disorders are often thought to be rare mental illnesses … they are far more common than most people realise.”
With one in five of all 17-19-year-old girls and one in 20 boys having an eating disorder, parents can no longer think it would never happen to their family. It’s a child in every class or friend group.
This tallies with the experience of Dr Monica Cain, a psychologist specialising in eating disorders. “I’m always inundated with cases, but I’m noticing that access to NHS treatment is getting harder and more restricted so more people are forced to go private.”
I know this all too well, having lived with an anorexic daughter for two years, one who narrowly avoided hospitalisation despite many trips to A&E, missed two terms of school, was prescribed antidepressants and whose illness dominated not only her life, but that of our whole family.
I remember the mother of an anorexic son telling me she’d scroll obsessively through the photos on her phone, trying to pinpoint the exact moment when they went from a happy, normal family to the one engulfed in misery and madness. I too look back on the crucial six months when we were harbouring the illness without realising it, searching for the clues that were there all along.
Every sufferer of an eating disorder is an individual, but in my many discussions with other parents I’ve discovered common factors; what we’d wish we’d known and the red flags that we could have picked up on sooner.
1. Eliminating food groups
Dr Cain says that the first sign to look out for is if a child starts behaving differently around food. This can be cutting up food into small pieces, pushing it around their plate or, in my daughter’s case, an obsession with only eating perfectly round bagels.
More usually, children will start finding ways to avoid food. “They’ll make excuses, saying they’ve eaten before or they’re not hungry,” says Dr Cain. “They’ll try to deflect from having to eat with the family if that’s always been the norm.”
Another classic tell-tale sign is if they become a vegetarian or find some newfound intolerance. Of course, not all vegetarians are anorexics, but I don’t know a single anorexic who isn’t vegetarian or vegan. Those with an eating disorder are smart and know that vegetarianism is the most acceptable, even admirable, way of cutting out a whole food group from a diet.
This extends to other forms of restriction such as a supposed dairy or wheat intolerance, a trait so common among the eating disordered that NHS dieticians apparently refer to almond milk as “anorexia milk”.
My daughter announced at age 12 that she was a vegetarian without referring to animal welfare or the environmental cost of meat production. Eight months later, she was dangerously underweight and attending a clinic.
2. A newfound interest in healthy living
It’s hard to see a child declaring an interest in “getting healthy” – eating well and exercising – as a negative, but if this comes out of nowhere and coincides with adolescence, then be careful. Signe Darpinian, author of Raising Body Positive Teens: A Parents’ Guide to Diet-free Living, Exercise, and Body Image, says on the podcast Burnt Toast that expressing a desire to eat better and exercise more is so prevalent among eating disordered teens that “If my daughter came to me and said she wanted to eat healthier, I would respond to it in the same way as if she told me she wanted to start smoking cigarettes.”
Teenagers need huge amounts of calories to fuel their growth and for many of them, these calories come in the form of junk and a craving for sweet things. Alarming as this can be parents, especially those who diligently fed them carrot sticks and hummus, they usually grow out of it gradually and in their own time.
3. Beware the phone
Our daughter was given a smartphone on going to secondary school, with the proviso that we had full access to it to check it was being used appropriately. Despite these good intentions, her use of it was soon unregulated, especially during lockdown. Before long we didn’t even have an up-to-date passcode.
If I’d looked earlier, I’d have found that she’d been logging her daily food intake and weight onto a calorie-counting app called MyFitnessPal. I’d have learned that the mildly concerning weight loss we’d noticed was almost 20 percent of her body weight. In addition, her TikTok and Instagram algorithms latched onto her searches for healthy breakfasts and abs exercises and were soon bombarding her with “what-I-eat-in-a-day” clips, fitness challenges and before-and-after photos of increasingly thin women.
4. Don’t be afraid to talk to your child
Like many of us, I’m squeamish about talking about children’s weight. To even notice whether a child is thin or fat is taboo. Her father and I would confer about her shape or wonder what prompted that tearful outburst about how “nobody eats breakfast”, but avoided talking to her directly. I think we worried that if we talked to her about food or weight, we’d somehow make it worse or that by giving it words, we’d make it true or “turn” her into an anorexic.
In our phone conversations with the GP or in our covert observations of her food intake, we fell into the trap of optimism bias. Look, we told ourselves, she ate dessert, she’s always been on the skinny side. We sought false reassurance.
If you suspect that something is wrong, almost invariably there is something wrong. Our mistake was thinking we had to make it about food and weight, when we could have gone in much earlier with a more general conversation to allow her to open up.
“Ask them about how they’re feeling about life, school, home and what’s happening in general,” advises Dr Cain. “If you manage to get them talking about what’s going on in their life, you can then gently say ‘I’ve noticed that you’re not eating as you used to,’ so it’s not the first thing you mention.”
When we were first given the diagnosis of anorexia in the eating disorders clinic, I was wracked with guilt and shock. “We should have done something before. I knew something was wrong,” I sobbed. “Every parent who’s ever been here says the same,” the therapist reassured me, “but you’re here now and that’s what matters.”
5. You’re not to blame
You’re responsible for your child, but you’re not responsible for your child’s anorexia. In response to these new statistics, I heard a radio pundit attribute his pre-teen children’s healthy attitude to food to his wife’s wonderful parenting, but we have far less control over the outcomes of their lives than we think. An eating disorder has nothing to do with the time you announced that you’d eaten too much chocolate or expressed dissatisfaction with the size of your stomach. The causes are complex but thought to combine social, genetic, physical and social factors.
6. Not everyone with an eating disorder is thin
In some ways, we were ‘lucky’ that our daughter embodied every stereotype of an anorexic (extremely thin, white, affluent). Her low weight led to a swift NHS response, but others, especially from different ethnic groups, can present as having a healthy weight when they are in the grips of a disorder.
Those with bulimia or binge-eating disorder will usually look a “normal” size. Even with anorexia, in our experience, it was the rate of weight loss rather than her actual weight that seemed to be most crucial. When she began to lose weight, she had a normal body mass index for some months, but her hair was falling out, she struggled with academic work, her periods stopped and her hands were purple with cold. When she began to put on weight or even just maintained, she functioned far better and her periods returned, despite being technically underweight at this point.
Atypical anorexia is when a person shows all the symptoms of anorexia without being underweight. This sounds like an oxymoron, but if someone with a larger body restricts their food to dangerously low levels then they will suffer all the dangerous effects of anorexia (such as disordered thinking, slow heart rate and electrolyte imbalances) long before they look thin. In fact, they’ll often find themselves congratulated on their weight loss.
7. Full recovery is possible
Part of my reluctance to acknowledge the eating disorder stemmed from a sense that anorexia is a frightening lifelong condition without respite, or worse, fatal. Even now, I hear people liken it to alcoholism, something that will always be lurking under the surface.
While it is a serious illness with the highest mortality rate of any psychiatric disorder, many will not only recover but will thrive. According to BEAT, around 46 percent of anorexia patients and 45 percent of those with bulimia fully recover. These are just from those who were diagnosed and had treatment, there will be many more who will have recovered without ever having had a formal diagnosis.
The younger a patient and the more support they get, the more they’ll recover. I clung onto stories of hope when we were at our lowest and now ours is one of them. About 18 months into her anorexia, something clicked for our daughter and she slowly began to eat without being forced. I thought she’d have to go to a local university and that we’d be supervising her meals and snacks for ever, but she eats freely, never weighs either herself or her food and barely remembers that frightening time.