Eating Disorders

Overview

What Is It?

Eating disorders are mental illnesses, and although they revolve around eating and body weight, they aren't entirely about food but also about feelings and self-expression.

Eating disorders are devastating mental illnesses that affect an estimated 20 million American women and 10 million American men sometime during their life. Approximately 85 percent to 95 percent of the people who suffer from the eating disorders anorexia nervosa and bulimia nervosa are women.

Although eating disorders revolve around eating and body weight, they are often more about control, feelings and self-expression than they are about food. Women with eating disorders often use food and dieting as ways of coping with life's stresses. For some, food becomes a source of comfort and nurturing, or a way to control or release stress. For others, losing weight may start as a way to gain the approval of friends and family. Eating disorders are not diets, signs of personal weakness or problems that simply will go away without proper treatment.

Eating disorders occur in all socioeconomic and ethnic groups. They usually develop in girls between ages 12 and 25. Because of the shame associated with this complex illness, many women don't seek treatment or get help until years later. Eating disorders also occur in young children, older women and men, but much less frequently.

There are four official eating disorders diagnoses: anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified (EDNOS).

Anorexia is a disorder in which preoccupation with dieting and thinness leads to excessive weight loss. If you suffer from this disease, you may not acknowledge that weight loss or restricted eating is a problem, and you may "feel fat" even when you're emaciated. Women with anorexia intentionally starve themselves or exercise excessively in a relentless pursuit to be thin, losing more than 15 percent of their normal body weight. Roughly half of all women suffering from anorexia never return to their pre-anorexic health, and about 20 percent remain chronically ill. The death rate for anorexia is among the highest of any psychiatric illness. The deaths are about evenly divided between suicide and medical complications related to starvation.

Women with bulimia regularly and sometimes secretly binge on large quantities of food—often between 2,000 and 5,000 calories at a time and, on rare occasions, even up to 20,000 calories at a time—then experience intense feelings of guilt or shame and try to compensate by getting rid of the excess calories. Some people purge by inducing vomiting, abusing laxatives and diuretics, or taking enemas. Others fast or exercise to extremes. If you suffer from this disease, you feel out of control and recognize that your behavior is not normal but often deny to others that you have a problem. Women struggling with bulimia can be normal weight or overweight and may experience weight fluctuations.

Women with binge eating disorder (BED) also binge on large quantities of food in short periods, but unlike women with bulimia, they do not use weight control behaviors such as fasting or purging in an attempt to lose weight or compensate for a binging session. When the binge is over, an individual with BED will often feel disgusted, guilty and depressed about overeating.

A fourth type of eating disorder, eating disorder not otherwise specified, refers to symptoms that don't fit into the other three eating disorders diagnoses. Individuals struggling with EDNOS, may have elements of BED, or be close to a diagnosis of anorexia or bulimia, but don't quite meet full diagnostic criteria. EDNOS is simply a catchall term for anyone with significant eating problems who doesn't meet the criteria for the other diagnoses. The majority of those who seek treatment for eating disorders fall into this category.

Although it has become synonymous with eating disorders, anorexia is relatively rare, affecting between 0.5 percent and 1 percent of women in their lifetimes, according to the National Alliance on Mental Illness. Another 2 percent to 3 percent develop bulimia and 3.5 percent develop binge eating disorder.

Yet, statistics don't tell the whole story. Many more women who don't necessarily meet all the criteria for an eating disorder are preoccupied with their bodies and are caught in destructive patterns of dieting and overeating that can seriously affect their health and well being.

There is no single cause of eating disorders. Biological, social and psychological factors all play a role. Evidence suggesting a genetic predisposition reveals that anorexia may be more common between sisters and in identical twins. Therefore, a woman with a mother or sister who has anorexia is 12 times more likely than the general public to develop that disorder and four times more likely to develop bulimia. Furthermore, among identical twins, whose genetic makeup is 100 percent the same, there is a 59 percent chance that if one twin has anorexia, then the other twin will also develop an eating disorder. For fraternal twins sharing only 50 percent of their siblings' genes, there is an 11 percent chance that the other twin will have an eating disorder.

Other research points to hormonal disturbances and to an imbalance of neurotransmitters, chemicals in the brain that, among other things, regulate mood and appetite.

In some women, an event or series of events triggers the eating disorder and allows it to take root and thrive. Triggers can be as subtle as a degrading comment or as traumatic as rape or incest. Times of transition, such as puberty, divorce, marriage or starting college, can also provoke disordered eating behaviors. Parents who are preoccupied with eating and overly concerned about or critical of a daughter's weight, and coaches who relentlessly insist on weigh-ins or a certain body image from their athletes, especially in weight-conscious sports such as ballet, cheerleading, diving, wrestling and gymnastics, may also unintentionally encourage an eating disorder. Additionally, the pressure of living in a culture where self-worth is equated with unattainable standards of slimness and beauty can also perpetuate body image and/or eating issues.

Furthermore, the discrepancy between our society's concept of the "ideal" body size for women and the size of the average American woman has never been greater—leading many women to unrealistic goals where weight is concerned.

Diagnosis

Because the consequences of eating disorders can be so severe, early diagnosis is crucial for lasting recovery. Eating disorders in general can disrupt physical and emotional growth in teenagers and can lead to premature osteoporosis, a condition where bones become weak and more susceptible to fracture. Additionally, the triad of osteoporosis, amenorrhea and disordered eating behaviors has the risk of leading to hormonal imbalances, which could also contribute to increased infertility and a higher risk of miscarriages.

Anorexia nervosa

Anorexia nervosa, a serious, potentially life-threatening disease characterized by self-starvation and excessive weight loss, has the highest mortality rate of any mental illness. Its onset is typically in early to mid-adolescence, and it is one of the most common psychiatric diagnoses in young women seeking treatment. Among the physical effects of anorexia are:

• anemia, often caused by iron deficiency, which reduces the blood's ability to carry oxygen and causes fatigue, difficulty breathing, dizziness, headache, insomnia, pale skin, loss of hunger and irregular heartbeat
• elevated cholesterol, which occurs because eating disorders affect liver function, reducing bile acid secretions that contain cholesterol and enabling more cholesterol to remain in the body rather than being secreted
• low body temperature and cold hands and feet
• constipation and bloating
• shrunken organs
• low blood pressure
• slowed metabolism and reflexes
• slowed heart rate, which can be mistaken as a sign of physical fitness
• irregular heartbeat, which can lead to cardiac arrest
• slowed thinking and cognitive and mood changes secondary to long-term starvation

Women with anorexia have an intense fear of becoming fat and, therefore, are obsessed with food, body shape and size. It is common for women with anorexia, for example, to collect recipes and prepare gourmet meals for family and friends, but not eat any of the food themselves. Instead, they allow their bodies to wither away and "disappear," gauging their hunger as a measure of their self-control. Women struggling with anorexia diet because they want to improve their feelings of self-esteem and love, not to lose a few pounds. Depression and insomnia often occur with eating disorders.

Women struggling with anorexia may tend to keep their feelings to themselves, seldom disobey authority and are often described as perfectionists. These individuals are often good students and excellent athletes. Anorexia is common in dancers and competitive athletes in sports such as gymnastics and figure skating, where success is measured not only on athletic performance, but also on having the "ideal" body.

Symptoms of anorexia nervosa can include:

• distorted body image and intense persistent fear of gaining weight
• excessive weight loss
• menstrual irregularities
• excessive body/facial hair
• compulsive exercise

Bulimia nervosa

Bulimia nervosa involves using food and eating for emotional calming or soothing. Bingeing becomes a way to relieve stress, anxiety or depression. Purging the calories, through self-induced vomiting, laxative or diuretic abuse or over-exercising, relieves the guilt of overeating and may also be a way of releasing emotional tension or stress until the binge-purge cycle becomes a habit. Women struggling with bulimia are usually more impulsive, more socially outgoing and exhibit less self-control than those struggling with anorexia. They are also more likely to abuse alcohol and other substances.

Only 6 percent of those struggling with bulimia receive mental health care. Eating disorders are incredibly secretive illnesses, and the symptoms can be hidden or appear subtle, even to friends and loved ones. For example, women struggling with bulimia are not necessarily thin; they can be at an average weight and even a little bit overweight. Even so, they may be starving nutritionally because they are not getting the vitamins, minerals and other nutrients they need.

Symptoms of bulimia include:

• preoccupation with food, weight and appearance
• binge eating, usually in secret
• vomiting and extreme use of laxatives or diuretics after binges
• menstrual irregularities
• compulsive exercise

Among the physical effects of bulimia are:

• dehydration
• chronic diarrhea
• extreme weakness
• damage to bowels, liver and kidneys
• electrolyte imbalance and low potassium levels, which lead to irregular heartbeat, and in some cases, cardiac arrest
• tooth erosion from repeated exposure to stomach acid
• broken blood vessels in the eyes and a puffy face due to swollen glands, which can be indications of self-induced vomiting
• cuts and calluses across the fingers from self-induced vomiting
• tears of the esophagus due to forced vomiting

Binge eating disorder

Binge eating disorder (BED) affects approximately 1 percent to 5 percent of people in the United States. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), released in 2013, recognizes BED as an official eating disorder.

Similarly to bulimia, people with BED engage in binge eating, or a rapid consumption of large quantities of food, but they do not use compensatory behaviors such as fasting or purging to "undo" the effects of binge eating and control their weight. People with BED eat large amounts of food even when they aren't hungry. They struggle to differentiate between physical and emotional hunger, feel uncomfortably full after eating and often feel distressed about their binge sessions.

Like the other two official eating disorders diagnoses, BED can occur together with other psychiatric disorders, such as depression, substance abuse or anxiety disorders. Over time, women with BED tend to gain weight due to overeating, so the disorder is often (but not always) associated with obesity.

Symptoms of binge eating disorder include:

• episodes of binge eating when not physically hungry
• cycles of frequent dieting
• feeling unable to stop eating voluntarily
• awareness that eating patterns are abnormal
• weight fluctuations
• depressed mood
• feelings of shame
• antisocial behaviors
• obesity
• feeling "numb" or "spaced out" during a binge episode
• feeling out of control while eating
• losing track of time while eating

If BED is left untreated, it can lead to obesity, which has its own medical consequences such as:

• high blood pressure
• high cholesterol
• gall bladder disease
• diabetes
• heart disease
• certain types of cancer

Tests for Eating Disorders

Eating disorders are complex mental illnesses and there is no medical test that can diagnose an eating disorder. However, when seeking eating disorders treatment, your health care professional may draw some of your blood to determine if you are suffering from any medical consequences related to an eating disorder. Here are some things that may be tested:

• Electrolyte balance. This primarily checks for dehydration but may also be indicative of malnutrition brought about by self-induced vomiting or laxative and/or diuretic abuse. Electrolytes are a specific combination of minerals your body needs to maintain balance to function properly, such as sodium and potassium. Common symptoms of imbalance are leg cramps, heart palpitations, high or low blood pressure and swelling in the legs and feet. An electrolyte imbalance can lead to kidney failure, heart attack and even death.
• B₁₂ and folic acid intake assessment. Lack of B12 and folic acid can lead to, or be caused by, problems with the metabolism of protein, carbohydrates and fat, and with the body's ability to absorb nutrients. Low levels of B12 or folic acid can contribute to depression and anxiety.
• Blood glucose (blood sugar) level. Low levels of blood glucose can be the result of dehydration and malnutrition.
• Liver function test. The malnourishment associated with eating disorders can lead to liver damage.
• Cholesterol measurements. Anorexia or binge eating disorder can increase blood cholesterol levels.
• Thyroid function test. This test rules out any problems with the thyroid, which can affect weight. It is an important test for someone in recovery who may be having a hard time gaining or losing weight. If necessary, medications would be prescribed to regulate the thyroid.

Your health care professional will probably also perform a complete analysis of your urine. This helps evaluate kidney function, urine sugar levels and ketone levels, as well as helps diagnose systemic diseases and urinary tract disorders. Ketones, which can accumulate in the blood rather quickly when the body is starved of food and nutrients, indicate the body is "eating its own fat" for energy. Accumulation of ketones in the blood can lead to ketoacidosis, which can cause coma and death.

Your health care professional may also take a blood pressure reading, provide a referral for a bone density test to evaluate for osteopenia or osteoporosis and perform an electrocardiogram to look for heartbeat irregularities.

Treatment

Many women don't realize how damaging eating disorders are to their health. Women struggling with eating disorders may believe that their state of emaciation is normal and sometimes even attractive. Or they think that purging is the only way to avoid gaining weight. Therefore, it is critical that all health care professionals remain educated on the signs and symptoms of eating disorders and intervene if they become concerned.

People fail to realize that a potentially serious eating disorder may underlie their weight loss. Also, it is easy to confuse eating disorders with other emotional problems. Although women with depression may lose or gain weight, for example, that doesn't necessarily make them anorexic or mean they are binge eating. Unlike those with anorexia, bulimia or binge eating disorder, women struggling with depression do not have a distorted body image, a drive to be thin or a compulsion to binge and/or purge.

Eating disorders can be fatal; in fact, they are the deadliest mental illness. If you think you may have an eating disorder, you should seek treatment immediately. The sooner you recognize there is an issue and choose to seek treatment, the greater your chances are for lasting recovery.

Depending on the severity of your disordered eating behaviors, there are various treatment options:

• Inpatient treatment programs offer 24/7 support and medical monitoring and are designed for those whose eating disordered behaviors have led to extremely low body weight and/or serious medical complications.
• Residential treatment programs also offer 24-hour observation and support, but individuals in residential eating disorders treatment do not require the same level of medical and psychiatric supervision as is available at the inpatient level of care.
• Partial hospitalization programs are daytime treatment programs that allow people in treatment to practice recovery skills with guidance during the day and on their own in the evenings and at night.
• Outpatient programs offer individuals struggling with eating disorders the opportunity to "step down" from a higher level of care while maintaining their daily activities. These types of programs provide additional support for anyone struggling with self-esteem or body image issues.

Insurance coverage for eating disorders treatment varies depending on the individual and their insurance policy. Eating disorders treatment centers work with patients and their families to secure the best possible option to foster lasting recovery.

And treatment is no easy task. When a woman with anorexia starves herself, she feels better. When a woman with bulimia or binge eating disorder binges, she feels less depressed. The eating disorder serves a purpose in the mind of the woman who has it. It becomes a kind of companion that is hard to let go of.

Not surprisingly, relapses are common and lasting eating disorders recovery often comes only after engaging in multiple treatment approaches. You may find it most effective to work with a multidisciplinary treatment team. This team of dietitians, psychotherapists and physicians may use a variety of treatment methods, including:

• psychological counseling or cognitive-behavioral therapy to help you replace negative attitudes about your body with healthier, more realistic ones
• medical evaluations to stabilize you physically
• nutritional counseling to teach you good nutritional habits
• medications, such as antidepressants, to address coexisting conditions
• family therapy to establish the support system you need for lasting recovery

Treatment of anorexia is often approached as a three-step process:

• restoring weight loss due to severe dieting and purging
• treating psychological conditions such as distorted body image, low self-esteem and interpersonal conflicts
• long-term remission and rehabilitation or full recovery

A one-year study published in the Journal of the American Medical Association determined that there was no significant difference between those with anorexia who took antidepressants and those who received a placebo—evidence that there is no "magic pill" to make your disorder go away and keep it away.

The only antidepressant approved by the Food and Drug Administration for treatment of bulimia is the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac), but doctors may also prescribe other antidepressants for the condition, including the SSRIs sertraline (Zoloft) and paroxetine (Paxil), and the tricyclic antidepressants amitriptyline (Elavil) and desipramine (Norpramin). The antidepressant bupropion (Zyban) may also be used, although it is not typically recommended as individuals struggling with bulimia because they may experience seizures as a side effect.

While health care professionals may find it beneficial to prescribe various medications to their eating disorders patients, medications are primarily reserved for coexisting conditions.

Some physicians may also prescribe antipsychotic medications to help reduce the rigid and distorted thinking and agitation that can accompany anorexia, but these drugs can frighten patients by dramatically increasing appetite, so they should be used with caution. For people struggling with anorexia who experience extreme anxiety surrounding eating, antianxiety drugs, such as benzodiazepines, may be used.

Cognitive behavioral therapy (CBT) is currently the primary evidence-based treatment approach for bulimia and binge eating disorder. By addressing both structured eating patterns and thoughts that interfere with self-worth and mood management, CBT teaches skills to help you manage triggering situations. Another often utilized treatment philosophy is dialectical behavioral therapy (DBT), which teaches self-regulatory skills and focuses on emotional management.

Another approach to treating eating disorders is family-based treatment. In a family-centered treatment program, the family assumes responsibility for making the patient eat. No one is "blamed" for triggering the illness; rather, the eating disorder is treated as a medical condition, and the family is taught to care for the sick person. The power shifts back to the individual after he or she reaches an acceptable weight. This method works best on people with anorexia, but it also works on some with bulimia. It is typically utilized in adolescents and is being researched for use in young adults.

Prevention

Eating disorders screening and prevention programs on college campuses across the country aim to educate young women and men about the signs, symptoms and dangers of eating disorders and teach them how to develop a healthy body image and self-worth and positive coping skills.

Screening is important because it is so difficult to change body image attitudes and unhealthy eating patterns once they form. Primary prevention needs to take place early, before young people learn to feel bad about their bodies. Therefore, eating disorder prevention efforts are beginning to occur in high schools, middle schools and even as early as elementary schools.

How a person perceives his or her body is only one component of a complete self-image, but too often it becomes the sole factor in determining self-esteem. When "how I look" becomes more important than "who I am," the groundwork is laid for crippling and life-threatening eating disorders.

Parents, loved ones and other role models can help prevent poor self-images from occurring by examining their own attitudes about their bodies and by fostering a healthy, positive body image in their children. Take these steps, even with young girls, to discourage unhealthy behaviors:

• Accept that puberty will influence girls' perception of their bodies, but be prepared to step in if certain behaviors become unhealthy.
• Don't reinforce the message that women have to look a certain way.
• Teach girls how their bodies change during adolescence and that it is normal and healthy to gain weight during puberty.
• Talk about images of women portrayed in the media and invite discussion on whether or not the images are realistic or create an unattainable "ideal" body shape and size.
• Take women and girls seriously for what they say, feel and do, not for how slim they are or how they look. It is about what the body does, not what it looks like.
• Encourage children to be active as a way to have fun and to enjoy what their bodies can do.
• Exercise with your children to promote a healthy family lifestyle.
• Model healthy attitudes about your own body. Girls need to see women who are satisfied with their bodies and appearance or who take positive and healthy steps toward making changes. Girls who see their mothers worrying about their own appearance and weight are more likely to believe that being thin will make them happy.
• Don't nag about eating or focus on eating habits, which could make a child more self-conscious and secretive about her or his relationship with food.
• Don't compare young children and teenagers to others and don't be judgmental about other people's weight.
• Be on the lookout for the use of diet pills, which has been documented in children as young as 10 years old.

Most important, do not ignore disordered eating behaviors. Eating disorders are devastating and potentially fatal diseases. But people can and do recover from these illnesses, once they are accurately diagnosed and properly treated.

Facts to Know

1. Eating disorders affect an estimated 20 million American women and 10 million American men sometime during their life. Eighty-five to 95 percent of those suffering from anorexia and bulimia are women.
2. Eating disorders most often begin early, usually between the ages of 12 and 25, but are not limited to people within these ages.
3. Between 0.5 percent and 1 percent of women suffer from anorexia, between 2 percent and 3 percent of women suffer from bulimia and 3.5 percent suffer from binge eating disorder.
4. Women struggling with anorexia, though often well-liked and admired for their competence, often strive to seek approval and may have very low self-esteem and feel inadequate. They may use food and dieting as ways of coping with life's stresses.
5. An eating disorder usually does not go away without treatment. Eating disorders are mental illnesses that can be deadly if not treated and are difficult to recover from; however, recovery is possible. Many women have recovered successfully and gone on to live full and satisfying lives.
6. Treatment for eating disorders encompasses a mixture of strategies, including psychological counseling, nutritional counseling and individual, group and family therapy.
7. Thereis a high incidence of depression among women suffering from bulimia, thus the utilization of antidepressants for some people. But antidepressants are most effective when combined with cognitive-behavioral therapy.
8. The self-starvation of anorexia can cause severe medical complications, such as: anemia; shrunken organs; low blood pressure; slowed metabolism and reflexes; bone mineral loss, which can lead to osteoporosis; and irregular heartbeat, which can lead to cardiac arrest.
9. The bingeing and purging of bulimia can lead to liver, kidney and bowel damage; tooth erosion; tears of the esophagus and stomach lining; and electrolyte imbalance, which can lead to irregular heartbeat and, eventually, cardiac arrest.
10. If obesity results from bingeing, medical consequences include high blood pressure, high cholesterol, gall bladder disease, diabetes, heart disease and risk factors for certain types of cancer.

Questions to Ask

Review the following Questions to Ask about eating disorders so you're prepared to discuss this important health issue with your health care professional.

1. What are my options for treatment?
2. How would you describe your approach to eating disorders treatment?
3. How do you address depression and/or anxiety? What if I do not feel like I am depressed (or anxious)?
4. Will you involve my family?
5. What role, if any, will medication play? What percentage of people who see you take medication? Which medications?
6. What can I expect from the medications?
7. What can I expect during a counseling session?
8. When, if ever, do you hospitalize patients?
9. What goals would we set for my treatment?
10. What does the recovery process look like?

Key Q&A

Organizations and Support

For information and support on coping with Eating Disorders, please see the recommended organizations, books and Spanish-language resources listed below.

Academy for Eating Disorders
Website: https://www.aedweb.org
Address: 111 Deer Lake Road, Suite 100
Deerfield, IL 60015
Phone: 847-498-4274
Email: info@aedweb.org

American Psychological Association
Website: https://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

Multi-service Eating Disorder Association (MEDA)
Website: https://www.medainc.org
Address: 92 Pearl St.
Newton, MA 02458
Hotline: 1-866-343-MEDA (1-866-343-6332)
Phone: 617-558-1881
Email: info@medainc.org

National Association of Anorexia Nervosa and Associated Disorders (ANAD)
Website: https://www.anad.org
Address: P.O. Box 640
Naperville, IL 60566
Hotline: 630-577-1330
Phone: 630-577-1333
Email: anadhelp@anad.org

National Eating Disorders Association (NEDA)
Website: https://www.nationaleatingdisorders.org
Address: 603 Stewart St., Suite 803
Seattle, WA 98101
Hotline: 1-800-931-2237
Phone: 206-382-3587
Email: info@nationaleatingdisorders.org

Overeaters Anonymous
Website: https://www.oa.org
Address: P.O. Box 44020
Rio Rancho, NM 87174
Phone: 505-891-2664

Renfrew Center
Website: https://renfrewcenter.com/
Address: 475 Spring Lane
Philadelphia, PA 19128
Hotline: 877-736-3739
Email: https://renfrewcenter.com/contact-us

Books

Anorexia Nervosa: A Guide to Recovery
by Lindsey Hall, Monika Ostroff

Anorexia Nervosa: When Food is the Enemy
by Erica Smith

A Starving Madness: Tales of Hunger, Hope and Healing in Psychotherapy
by Ph.D. Judith Ruskay Rabinor, Judith Ruskay Rabinor

Body Wars: Making Peace with Women's Bodies
by Margo Maine

Bulimia: A Guide to Recovery
by Lindsey Hall, Leigh Cohn M.A.T.

Como entender y superar la anorexia nervosa
by Lindsey Hall, Monika Ostroff

Como entender y superar la bulimia
by Lindsey Hall, Leigh Cohn M.A.T., Leigh Cohn

Cure Your Cravings - The Revolutionary Program Used by Thousands to Conquer Compulsions
by Yefim Shubentsov, Barbara Gordon

Eating Disorder Sourcebook: A Comprehensive Guide to the Causes, Treatments and Prevention of Eating Disorders
by Carolyn Costin

Eating in the Light of the Moon: How Women Can Transform Their Relationship with Food Through Myths, Metaphors, and Storytelling
by Anita A. Johnston PhD.

Hunger Within: A Twelve-Week Self-Guided Journey from Compulsive Eating to Recovery
by Marilyn Migliore

If You Think You Have an Eating Disorder
by John Barnhill, Nadine Taylor

Inner Hunger - A Young Woman's Struggle Through Anorexia and Bulimia
by Apostolides Marianne

Making Weight: Healing Men's Conflicts with Food, Weight, Shape and Appearance
by M.D. Arnold Andersen, Leigh Cohn M.A.T., M.D. Tom Holbrook, Leigh Cohn, et al.

Self-Esteem Comes in all Sizes: How to Be Happy and Healthy at Your Natural Weight
by Carol A. Johnson M.A., Gary Foster Ph.D., M.A., Carol A. Johnson, Gary Foster

Women Afraid to Eat: Breaking Free in Today's Weight-Obsessed World
by Frances M. Berg

Spanish-language resources

Medline Plus: Eating Disorders
Website: https://www.nlm.nih.gov/medlineplus/spanish/eatingdisorders.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20984
Email: custserv@nlm.nih.gov

National Easting Disorders Associations
Website: https://www.nationaleatingdisorders.org/neda-espanol
Address: Information and Referral Helpline
603 Stewart Street, Suite 803
Seattle, WA 98101
Hotline: 1-800-931-2237
Phone: 206-382-3587
Email: info@NationalEatingDisorders.org