EATING DISORDERS: MHFA GUIDELINES

WHAT ARE EATING DISORDERS?

A person has an eating disorder when their attitudes to food, weight, body size or shape lead
to marked changes in their eating or exercise behaviours, which interfere with their life and
relationships. Eating and exercise behaviours that people with eating disorders may engage in
include: dieting, fasting, over-exercising, using slimming pills, diuretics, laxatives, vomiting, or
binge eating (consumption of an unusually large amount of food accompanied by a sense of
loss of control).

Eating disorders are not just about food and weight. They are also not about vanity or will-
power. Eating disorders are serious and potentially life threatening mental illnesses, in which a
person experiences severe disturbances in eating and exercise behaviours because of
distortions in thoughts and emotions, especially those relating to body image or feelings of
self-worth. People in all age groups, genders and socio-economic and cultural backgrounds can
be affected by eating disorders. A person with an eating disorder can be underweight, within a
healthy weight range, or overweight.

There are three different types of eating disorders: anorexia nervosa, bulimia nervosa, binge
eating disorder. If the person you are helping is underweight and using extreme weight-loss
strategies, they may have anorexia. If the person is engaging in binge eating followed by
extreme weight-loss strategies, they may have bulimia. Although by definition, a person with
anorexia is underweight, a person with bulimia can be slightly underweight, within a healthy
weight range, or overweight.

If the person regularly eats an unusually large amount of food in a short period of time,
accompanied by a sense of loss of control over their eating, but does not use extreme weight-
loss strategies to compensate, they may have binge eating disorder. People with binge eating
disorder may be within a healthy weight range or overweight.

How can I tell if someone has an eating disorder?

You may not be able to tell if the person has an eating disorder based simply on their
appearance. So it is important to know the warning signs, which include behavioural, physical
and psychological signs.

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WARNING SIGNS OF A DEVELOPING EATING DISORDER

Behavioural warning signs

• Dieting behaviours (e.g. fasting, counting calories/kilojoules, avoidance of food groups

or types)
• Evidence of binge eating (e.g. disappearance or hoarding of food)
• Evidence of vomiting or laxative use (e.g. taking trips to the bathroom during or
immediately after meals)
• Excessive, obsessive or ritualistic exercise patterns (e.g. exercising when injured or in
bad weather, feeling compelled to perform a certain number of repetitions of exercises
or experiencing distress if unable to exercise)
• Changes in food preferences (e.g. refusing to eat certain ‘fatty’ or ‘bad’ foods, cutting
out whole food groups such as meat or dairy, claiming to dislike foods previously
enjoyed, a sudden concern with ‘healthy eating’, or replacing meals with fluids)
• Development of rigid patterns around food selection, preparation and eating (e.g.
cutting food into small pieces or eating very slowly)
• Avoidance of eating meals, especially when in a social setting (e.g. skipping meals by
claiming they have already eaten or have an intolerance/allergy to particular foods)
• Lying about amount or type of food consumed or evading questions about eating and
weight
• Behaviours focused on food (e.g. planning, buying, preparing and cooking meals for
others but not actually consuming; interest in cookbooks, recipes and nutrition)
• Behaviours focused on body shape and weight (e.g. interest in weight-loss websites,
books and magazines, or images of thin people)
• Development of repetitive or obsessive behaviours relating to body shape and weight
(e.g. body-checking such as pinching waist or wrists, repeated weighing of self,
excessive time spent looking in mirrors)
• Social withdrawal or avoidance of previously enjoyed activities

Physical warning signs

• Weight loss or weight fluctuations

• Sensitivity to the cold or feeling cold most of the time, even in warm temperatures
• Changes in or loss of menstrual patterns
• Swelling around the cheeks or jaw, calluses on knuckles, or damage to teeth from
vomiting
• Fainting

Psychological warning signs

§ Pre-occupation with food, body shape and weight

§ Extreme body dissatisfaction
§ Distorted body image (e.g. complaining of being/feeling/looking fat when a healthy
weight or underweight)
§ Sensitivity to comments or criticism about exercise, food, body shape or weight
§ Heightened anxiety around meal times
§ Depression, anxiety or irritability
§ Low self-esteem (e.g. negative opinions of self, feelings of shame, guilt or self-
loathing)
§ Rigid ‘black and white’ thinking (e.g. labelling of food as either ‘good’ or ‘bad’)

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Some warning signs may be difficult to detect. This is because the person:

• may feel shame, guilt and distress about their eating or exercise behaviours and
therefore these will often occur in secret
• may actively conceal their eating and exercise behaviours
• may deny having a problem
• can find it difficult to ask for help from family and friends.

What are the risks associated with eating disorders?

A person with an eating disorder can experience a wide range of physical and mental health
problems. Although rapid weight loss or being very underweight are known to bring about
these problems, a person does not need to be underweight for these to occur.

Some serious health consequences associated with eating disorders include severe
malnutrition, brain dysfunction and heart or kidney failure, which may lead to loss of
consciousness or death. Heart failure and death can occur in both anorexia or bulimia.

It is common for a person with an eating disorder to experience another mental illness, such
as depression, and to be at risk of becoming suicidal. For more information on assisting
someone who is suicidal, please see the other guidelines in this series: Suicidal thoughts and
behaviours: MHFA Guidelines.

The need for early intervention

Because eating disorders are complex mental illnesses, people with eating disorders will
benefit from professional help. For most people, the earlier help is sought for their unhealthy
eating and exercise behaviours, the easier it will be to overcome the problem. A delay in
seeking treatment can lead to serious long-term consequences for the person’s physical and
mental health. So, the earlier the person gets help, the more likely they are to make a full
recovery. Therefore, the sooner you discuss your concerns with the person the better.

APPROACHING SOMEONE WHO MAY HAVE AN EATING DISORDER

Your aim should be to provide support for the person so that they feel safe and secure enough
to seek treatment or to find someone else they can trust to talk to openly, such as a family
member, friend, teacher or co-worker.

Before you approach the person, learn as much as you can about eating disorders. Do this by
reading books, articles and brochures, or gathering information from a reliable source, such as
an eating disorder support organisation or a health professional experienced in treating them.

How should I approach the person?

Make a plan before approaching the person; choose a place to meet that is private, quiet and
comfortable. Avoid approaching the person in situations that may lead them to become
sensitive or defensive, such as when either you or they are feeling angry, emotional, tired, or
frustrated, are drinking, having a meal, or in a place surrounded by food.

It is better to approach the person alone, because having the whole family or a number of
people confront the person at the same time could be overwhelming. Be aware that the person
may respond negatively no matter how sensitively you approach them.

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What if I don’t feel comfortable talking to the person?

It is common to feel nervous when approaching a person about their unhealthy eating and
exercise behaviours. Do not avoid talking to the person because you fear it might make them
angry or upset, or make their problem worse. When you speak to the person, they might feel
relief at having someone acknowledge their problems, or they may find it helpful to know that
someone cares about them and has noticed that they are not coping.

What should I say?

The way you discuss the person’s problem will depend on the age of the person and the degree
to which their problem has developed.

Initially, focus on conveying empathy and not on changing the person or their perspective.
When talking with them, you need to be non-judgemental, respectful and kind. This means
you should not blame the person or their loved ones for the person’s problems and avoid
speculating about the cause. Be aware that you may find it tough to listen to what they have
to say, especially if you do not agree with what they are saying about themselves, food or
exercise. It is important that you try to stay calm.

Discuss your concerns with the person in an open and honest way. Try to use ‘I’ statements
that are not accusing, such as “I am worried about you”, rather than ‘you’ statements such as
“You are making me worried”. Try not to just focus on weight or food. Instead, allow the
person to discuss other concerns that are not about food, weight or exercise. Make sure you
give the person plenty of time to discuss their feelings and reassure them that it is safe to be
open and honest.

Explain to the person that you think their behaviours may indicate there is a problem that
needs professional attention. Offer to assist them in getting the help they need, but be careful
not to overwhelm the person with information and suggestions.

Remember that you don’t have to know all the answers. There will be times when you don’t
know what to say. In this instance, just be there for the person by letting them know you care
and are committed to supporting them. Reassure the person that they are deserving of your
love and concern, and let them know you want them to be healthy and happy.

THINGS TO AVOID:

In order to be supportive, it is important to avoid doing or saying things that might make the
person feel ashamed or guilty. For instance, you should avoid:
• Being critical of the person
• Giving simple solutions to overcoming the person’s problems, such as saying things
like “all you have to do is eat”
• Making generalisations such as ‘never’ and ‘always’ (e.g. “you're always moody” or
“you never do anything but exercise”)
• Saying or implying that what the person is doing is ‘disgusting’, ‘stupid’ or ‘self-
destructive’
• Making promises to the person that you cannot keep
• Trying to solve the person’s problems for them

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How will the person react?

The person may react in a variety of different ways. They might react positively, for instance
by being receptive to your concerns, admitting that they have a problem, or being relieved
that someone has noticed their problem. The person might react negatively, for instance by
being defensive, tearful, angry or aggressive, by denying they have a problem or seeking to
re-assure you that they are fine. It is also possible that the person may want time to absorb
your comments and concerns. However the person might react, be aware that you are unlikely
to resolve the problem in the first conversation and do not expect that the person will
immediately follow your advice, even if they asked for it.

What if the person reacts negatively?

The person may react negatively because they:

• are not ready to make a change

• do not know how to change without losing their coping strategies
• have difficulty trusting others
• think you are being pushy, nosey, coercive or bullying
• do not see their eating and exercise behaviours as a problem

If the person reacts negatively, it is important not to take their reaction personally. Avoid
arguing or being confrontational and do not express disappointment or shock. Resist the
temptation to respond angrily, as this may escalate the situation. Do not to speak harshly to
the person. Instead, be willing to repeat your concerns. Assure the person that even if they
don’t agree with you, your support is still offered and they can talk with you again in the future
if they want to.

Getting professional help

Eating disorders are long-term problems that are not easily overcome. Effective treatments are
available. The most effective treatment involves receiving help from a number of different
types of professionals.

You should suggest to the person that they may benefit from seeking professional help. It is
best to encourage the person to seek help from a professional with specific training in eating
disorders. Some general practitioners (GPs) or family doctors may not be able to recognise an
eating disorder because they are not formally trained in detecting and treating them. In some
countries, however, a referral from a GP/family doctor is needed to see another trained
professional such as a psychiatrist, psychologist, dietician or family therapist.

If the person is very underweight, they may not be able to take responsibility for seeking
professional help and may therefore need your assistance to do so. This is because the
symptoms of an eating disorder can affect the person’s ability to think clearly.

What if the person doesn’t want help?

Some people with an eating disorder may refuse professional help. The person may do this for
a number of reasons. For instance, they may:

• feel ashamed of their eating and exercise behaviours

• fear gaining weight or losing control over their weight
• be afraid of acknowledging that they are unwell
• do not think that they are unwell

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• believe that there are benefits to their eating or exercise behaviours (e.g. controlling
their weight may make the person feel better about themselves, or give them a sense
of accomplishment).

It is important to know that an adult has a right to refuse treatment, except under specific
circumstances described in relevant local legislation (e.g. if the person’s life is in danger).
Although you may feel frustrated by the person’s behaviours, it is important that you do not
try to force them to change, or threaten to end your relationship with them. Instead,
encourage the person’s interests that are unrelated to food or physical appearance.

Acknowledge their positive attributes, successes and accomplishments, and try to view them
as an individual rather than just someone who has an eating disorder. You cannot force the
person to change their attitudes or behaviours, or to seek help, but you can support them until
they feel safe and secure enough to seek treatment.

Rather than giving up, continue to be supportive, positive and encouraging, while you are
waiting for them to accept their need to change. Continue to suggest the person seek
professional help, while being sensitive towards their fears about the process of seeking help.
If you would like further support, seek advice from an organisation that specialises in eating
disorders.

IN AN EMERGENCY

A person does not have to be underweight to require emergency medical assistance for an
eating disorder. Symptoms that indicate a crisis or advanced disorder, for which you should
always seek emergency medical help, include when the person:

§ has accidentally or deliberately caused themselves a physical injury

§ has become suicidal
§ has confused thinking and is not making any sense
§ has delusions (false beliefs) or hallucinations (experiencing things that aren’t there)
§ is disoriented; doesn’t know what day it is, where they are or who they are
§ is vomiting several times a day
§ is experiencing fainting spells
§ is too weak to walk or collapses
§ has painful muscle spasms
§ is complaining of chest pain or having trouble breathing
§ has blood in their bowel movements, urine or vomit
§ has a body mass index (BMI) of less than 16
§ has an irregular heart beat or very low heart beat (less than 50 beats per minute)
§ has cold or clammy skin indicating a low body temperature or has a body temperature
of less than 35 degrees Celsius/95 degrees Fahrenheit.

If the person is admitted to hospital for any reason, you should tell the medical staff that you
suspect they have an eating disorder.

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HOW CAN I CONTINUE TO BE SUPPORTIVE?

Offer ongoing support to the person

To help the person feel secure, reassure them that you are not going to take control over their
life, but rather will assist them to get help. Explain that even if there are limits to what you can
do for them, you are still going to try and help, and you will be there to listen if they want to
talk. Suggest that the person surround themselves with people who are supportive.

Give the person hope for recovery

Reassure the person that people with eating disorders can get better and that past
unsuccessful attempts do not mean that they cannot get better in the future. Encourage the
person to be proud of any positive steps they have taken, such as acknowledging that their
eating or exercise behaviours are a problem or agreeing to professional help.

What isn’t helpful?

It is especially important that you do not let issues of food dominate your relationship with the
person. Try to avoid conflict or argument over food. Do not give advice about weight loss or
exercise and avoid reinforcing the idea that physical appearance is critically important to
happiness or success. Also, do not comment positively or negatively on the person's weight or
appearance, e.g. by saying “you're too thin”, “you look well” or “good, you have gained
weight.”

If you become aware that the person is visiting pro-ana or pro-mia websites (websites that
promote eating disorder behaviour) you should discourage further visits, as the websites can
encourage destructive behaviour. However, do not mention these sites if the person is not
already aware of them.

EATING DISORDERS IN CHILDREN AND YOUNG PEOPLE

If you suspect that a child or young person is developing an eating disorder, you should follow
the advice above, but also consider the following additional guidelines.

The negative consequences of eating disorders on physical health are much stronger in
children than in adults because the eating and exercise behaviours can disrupt normal physical
development. A child does not need to have all the symptoms of an eating disorder to suffer
from long-term negative effects.

It is important not to accept any symptoms of eating disorders as ‘normal adolescent

behaviour’. Even if you think that the child’s problem is not serious, you should not delay
taking action. If left untreated, these behaviours can quickly develop into serious disorders
that are difficult to overcome.

If you are a parent concerned about your child

If you are worried that your child may be developing an eating disorder, you should observe
their behaviour for any warning signs. If concerned about intruding on your child’s privacy,
remember that it is your right to ensure that they are safe and healthy.

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Seek advice from a professional or organisation specialising in eating disorders. Do not let the
child’s refusal, tears or tantrums stop you from getting help. Be prepared to take responsibility
for getting professional help for your child. If they are underage, you can legally make them
attend an appointment with a GP or family doctor, psychiatrist or other appropriate
professional.

When initiating discussion about professional help with your child, it is important to stress how
much they are loved and that your concerns for them stem from that love. Maintain a caring
and supportive home environment. This means expressing your love and support for your child
no matter how upsetting their behaviour is.

Understand that any resistance to eating, seeking treatment or gaining weight is motivated by
fear and anxiety rather than a desire to be difficult. Always be clear and honest with your child
about what to expect from any professional treatment you seek for them.

Do not let empathy for your child inadvertently lead you to support their disorder. For
instance, you should not let your child always be the one to decide when, what and where the
family will eat, as this may make their problem worse. Also, if your child’s behaviour becomes
harmful to themselves or others, you must be prepared to move them to a safe environment,
such as a hospital.

If you attend an appointment and are worried that the professional is ignoring your child's
condition, or has not correctly diagnosed the eating disorder, then you should seek a second
opinion.

If you are an adult concerned about a child

If you are an adult who suspects that a child is developing or experiencing an eating disorder,
you should first approach the parents, a family member or loved one of the child, before
approaching the child directly.

If you are a young person concerned about a friend

If you are a young person who thinks a friend might be developing an eating disorder, there
are some things you can do to help. If your friend is hiding their behaviours from their family
or loved ones, you should encourage your friend to tell them, or to find a responsible adult
they can trust and talk to about what's going on. The adult could be a parent, teacher, coach,
pastor, school nurse, school counsellor, GP/family doctor, psychologist or nutritionist.

If your friend refuses to tell, you should then tell a responsible and trusted adult yourself, even
if your friend does not want you to. Remember that, because eating disorders are serious
illnesses, they should not be kept secret.

Although telling an adult may make your friend angry, it may also save their life. If you feel
worried about talking to an adult who is close to your friend, ask your own parents or loved
ones for help.

If you or your friend has told an adult about the eating and exercise behaviours, and the adult
has not helped your friend, try talking to another responsible and trusted adult, or a
professional who is trained in assessing and treating eating disorders.

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PURPOSE OF THESE GUIDELINES

These guidelines are designed to help members of the public to provide first aid to someone
who may be developing or experiencing an eating disorder. The role of the first aider is to
assist the person until appropriate professional help is received or the crisis resolves.

DEVELOPMENT OF THESE GUIDELINES

These guidelines are based on the expert opinions of people with lived experience of eating
disorders (consumers and carers) and mental health professionals (clinicians, researchers and
educators) who are from Australia, Canada, Ireland, New Zealand, the United Kingdom and the
United States of America.

Details of the methodology can be found in: Hart LM, Jorm AF, Paxton SJ, Kelly CM, Kitchener
BA. First aid for eating disorders. Eating Disorders 2009; 17(5): 357-384.

HOW TO USE THESE GUIDELINES

It is important to tailor your support to the needs of the person you are helping. These
guidelines are a general set of recommendations only, and most suitable for providing mental
health first aid in high-income countries with developed health systems.

These guidelines have been developed as part of a suite of guidelines about how to best assist
a person with mental health problems. These other guidelines can be downloaded from:

mhfa.com.au/resources/mental-health-first-aid-guidelines

Although these guidelines are copyright, they can be freely reproduced for non-profit purposes
provided the source is acknowledged. Please cite these guidelines as follows:

Mental Health First Aid Australia. Eating disorders: MHFA Guidelines. Melbourne: Mental Health
First Aid Australia; 2008.

Enquiries should be sent to: [email protected]

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