How Can You Spot Anorexia or Bulimia Before It Becomes Dangerous?

You can spot anorexia or bulimia early by watching for changes in eating, weight, and behavior: strict food rules, skipping meals, intense fear of weight gain, eating in secret, or going to the bathroom right after meals. Fainting, chest pain, confusion, or a very slow or irregular heartbeat need emergency care. This article covers early behavioral and physical signs, danger signals, how clinicians evaluate eating disorders, and how to start a conversation.

Early Signs of Anorexia and Bulimia: What You May Notice First

Eating disorders are mental health conditions that involve serious disturbances in eating behavior and in thoughts about food, weight, and body shape. MedlinePlus, from the National Institutes of Health, describes anorexia nervosa and bulimia nervosa among the main eating disorders (MedlinePlus: Eating Disorders). They can affect people of any gender, age, body size, or background, so a person does not have to look underweight to be seriously ill.

Early signs are often easy to explain away. A teenager who says they are "just eating healthier" or an adult who is "just being disciplined" may be hiding something that is growing. Several factors contribute to eating disorders, including genetics, temperament, stress, and social pressure, and the mechanism is not fully understood.

Warning Signs of Anorexia Nervosa

Anorexia nervosa often involves restricting food intake, an intense fear of gaining weight, and a distorted view of one's own body. Signs that may be noticed by family and friends include:

• Skipping meals, making excuses not to eat, or eating only a very narrow list of "safe" foods
• Cutting food into tiny pieces, moving food around the plate, or eating very slowly
• Weighing or measuring food, counting calories, or checking the body in the mirror repeatedly
• Noticeable weight loss, or, in a growing child or teen, failure to gain expected weight and height
• Wearing baggy layers to hide the body or because of feeling cold
• Withdrawing from meals with family or friends
• Rigid or excessive exercise, even when ill, injured, or exhausted

Physical changes can include feeling cold often, dizziness, fatigue, thinning hair, dry skin, and, in people who menstruate, missed or irregular periods. These can have other causes, so one sign alone does not establish an eating disorder.

Warning Signs of Bulimia Nervosa

Bulimia nervosa involves repeated episodes of eating a large amount of food with a sense of loss of control, followed by behaviors meant to undo the eating. These may include self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise. Because many people with bulimia have a weight in the typical range, it can stay hidden for years.

• Disappearing to the bathroom right after meals, or running water to cover sounds
• Large amounts of food vanishing, or finding wrappers and hidden food
• Swollen cheeks or jaw, sore throat, or scrapes or calluses on the knuckles
• Dental problems such as enamel wear, cavities, or sensitive teeth
• Frequent use of laxatives, diet pills, or diuretics
• Weight that goes up and down, along with shame and secrecy about eating

If a person is binge eating without purging or other compensating behaviors, that may point to a different condition. See our article on binge eating disorder versus overeating for that distinction.

Changes in Mood and Thinking That Often Accompany Eating Disorders

Behavior around food is only part of the picture. People may become irritable, anxious, withdrawn, or perfectionistic. Preoccupation with food, weight, and body shape can crowd out schoolwork, hobbies, and friendships. Eating disorders commonly occur along with depression, anxiety, and obsessive-compulsive symptoms (MedlinePlus: Obsessive-Compulsive Disorder). Some people also harm themselves (MedlinePlus: Self-Harm), and thoughts of suicide can occur. If you or someone you know is thinking about suicide, call or text 988, the Suicide and Crisis Lifeline, or call 911 if there is immediate danger.

Social media and online communities can play a role for some young people. A systematic review of pro-anorexia and pro-eating disorder websites reported psychological harms for adolescent females who used them (Psychological Impact of Pro-Anorexia and Pro-Eating Disorder Websites on Adolescent Females). Notice if someone is secretive about what they look at online, but keep in mind that internet use is one possible contributor among many.

When Anorexia or Bulimia Becomes Physically Dangerous

Eating disorders can affect nearly every organ system. The danger often comes from the body's response to starvation, vomiting, or laxative misuse, and it can be present even when a person looks outwardly well.

Heart and electrolytes

Repeated vomiting, laxatives, and diuretics can lower blood levels of potassium and other electrolytes, which can disturb the heart's rhythm. Severe undernutrition can also slow the heart and lower blood pressure. Fainting, chest pain, palpitations, or a very slow or irregular pulse can be signs of a heart problem and need emergency evaluation.

Bones

Prolonged undernutrition and missed periods can weaken bones, and bone loss during adolescence may not be fully regained later. You can read about bone density measurement at MedlinePlus: Bone Density. Stress fractures or repeated injuries in an athlete can be one clue.

Digestive tract and teeth

Vomiting can irritate the throat and esophagus, wear down tooth enamel, and enlarge the salivary glands. Laxative misuse can cause dehydration and bowel problems. Vomiting blood or severe, persistent chest or abdominal pain needs emergency care.

Brain and mood

Undernutrition can affect concentration, mood, and thinking. Research has examined brain chemistry in people with anorexia and bulimia (Characterizing cerebral metabolite profiles in anorexia and bulimia nervosa), but this work is still developing and does not yet translate into a simple test.

Special concern with type 1 diabetes

People with type 1 diabetes face added risk if they restrict food or deliberately skip or reduce insulin to lose weight. This can lead to dangerously high blood sugar and diabetic ketoacidosis, an emergency (MedlinePlus: Diabetes Type 1). Anyone who suspects this should speak with the diabetes care team about it, and should not change insulin doses on their own.

How Clinicians Evaluate a Suspected Eating Disorder

There is no single test that confirms an eating disorder. Clinicians combine history, examination, and testing. A review on the role of the primary care physician describes how routine visits can detect eating disorders through questions about eating, weight concerns, and menstrual history, together with a physical exam (Detection, evaluation, and treatment of eating disorders: the role of the primary care physician). Depending on the situation, a clinician may check weight and height trends, heart rate and blood pressure, blood tests including electrolytes, and an electrocardiogram (ECG). They may also ask about mood, anxiety, and safety.

Treatment is individualized and often involves a team: a medical clinician, a mental health professional, and a dietitian. Family-based approaches are commonly used for younger patients, and a trial of treatment for anorexia and bulimia nervosa is described in the medical literature (Randomized controlled trial of a treatment for anorexia and bulimia nervosa). Outcomes vary, and many people recover with appropriate support. Some people need a higher level of care, such as hospital or residential treatment, when medical stability is at risk.

How to Talk With Someone You Are Worried About

• Choose a private, calm time, not during a meal.
• Describe what you have seen without blame: "I've noticed you've been skipping dinners, and I'm worried about you."
• Avoid comments about weight, appearance, or food choices, including compliments about weight loss.
• Expect denial or anger. That reaction is common and does not mean you were wrong to speak up.
• Offer to help find a clinician, and offer to go along to the first appointment.

Living with a family member who has an eating disorder can be hard on everyone. A qualitative review of family experiences found significant effects on family dynamics (Family member's perceived impact of anorexia nervosa and bulimia nervosa on family dynamics), and caregivers may benefit from support of their own. For other mental health warning signs, see our article on warning signs of a mental health crisis. If you are worried about appearance concerns more broadly, our article on body dysmorphic disorder may also help.

What to Do Next

If you notice several of these signs, or one sign that is getting worse, make an appointment with a primary care clinician, pediatrician, or mental health professional. Write down what you have noticed, when it started, and any physical symptoms. If the person is a minor, a parent or guardian can usually make the appointment. If there are any emergency signs, go to the nearest emergency room or call 911 rather than waiting for a scheduled visit.

When to Seek Medical Care