Tell if Someone Is Anorexic

Eating disorders are a serious thing that affect more people than you may assume. Anorexia nervosa, also referred to simply as “anorexia,” most often affects adolescent girls and young women, but it can also affect males or older women. One recent study suggests that 25% of people suffering from anorexia are male.[1] It is characterized by severe restriction of what one eats, low body weight, intense fears about gaining weight, and a disturbed view of their own bodies.[2] It is often a response to complicated social and personal issues. Anorexia is a serious disorder and can cause severe damage to the body. It has one of the highest death rates of any mental health issue.[3] If you think a friend or loved one has anorexia, read on to learn how to help.

Steps

Observing the Person’s Habits

  1. Observe the person's eating habits. People with anorexia have an antagonistic relationship with food. One of the driving forces behind anorexia is an intense fear of gaining weight, and anorexics severely restrict their food intake -- i.e., starve themselves -- in order to avoid gaining weight. However, simply not eating is not the only sign of anorexia. Other potential warning signs include:[1][4]
    • Refusal to eat certain foods or whole categories of foods (e.g., “no carbs,” “no sugars”)
    • Food-related rituals, such as excessive chewing, pushing food around on the plate, cutting it into smaller and smaller pieces
    • Obsession with measuring food, such as constantly counting calories, weighing food, double- or triple-checking nutrition labels
    • Refusal to eat out because it’s hard to measure calories
  2. Consider whether the person seems obsessed with food. Even though they eat little, people with anorexia are often obsessed with food. They may obsessively read many magazines about cooking, collect recipes, or watch cooking programs. They may talk frequently about food, although these conversations are often negative (e.g., “I can’t believe anyone eats pizza when it’s so bad for you).[5]
    • Obsession with food is a common side-effect of starvation. A landmark starvation study performed during WWII demonstrated that people who are starving fantasize about food. They will spend inordinate amounts of time thinking about it. They will often talk about it with others and to themselves.[6]
  3. Ask yourself if the person routinely makes excuses to avoid eating. For example, if invited to a party where there will be food, they may say they ate before they arrived. Other reasons commonly given to avoid food include:
    • "I’m just not hungry"
    • "I’m on a diet/need to lose weight"
    • "I don’t like any of the food available"
    • "I’m sick "
    • "I have 'food sensitivities'" (A person who truly has food sensitivities will eat enough as long as they are given food that works with their sensitivities.)
  4. Observe if the person you are concerned about seems underweight, yet still talks about dieting. If the person seems very thin but still talks about needing to lose weight, they may have a disturbed view of their own body. One hallmark of anorexia is “distorted body image,” where the person continues to believe they are much heavier than they actually are. People with anorexia will often deny suggestions that they are underweight, even if they have many visible bones.[4]
    • People with anorexia may also wear large or baggy clothes to hide their true size. They may dress in layers, or wear pants and jackets even in the hottest weather. Part of this is to hide body size, and part of it is because people with anorexia often cannot regulate their body temperature effectively and are thus frequently cold.
    • Don't rule out overweight or obese people automatically. It is possible to be anorexic at a large size. Anorexia, restricted eating, and fast weight loss are very dangerous regardless of the person's BMI, and you shouldn't wait until they become underweight before getting them help.[7][8]
  5. Watch the person’s exercise habits. People with anorexia may compensate for food they eat by exercising. Exercise is excessive and usually very rigid.[1] A person with anorexia may dangerously over-exercise, going for too long or pushing their body too hard.
    • For example, the person may exercise for many hours each week, even if they are not training for a particular sport or event. People with anorexia may also exercise even when they are fatigued, ill, or injured, because they feel compelled to “burn off” the food they have eaten.
    • Exercise is a particularly common compensating behavior for males with anorexia. The person may believe he is overweight, or may be unhappy with his body composition. He may be preoccupied with body-building or “toning.” Distorted body image is common with males, too, who will often be unable to recognize how their body actually appears and will see themselves as “flabby” even if they are fit or underweight.[9][10]
    • People with anorexia who cannot exercise, or who have not exercised as much as they want to, will often appear fidgety, restless, or irritated.
  6. Look at the person’s appearance, keeping in mind that it may or may not be affected by anorexia. As it progresses, anorexia causes a host of physical symptoms. However, you cannot tell if a person has anorexia just from their appearance.[11] A combination of these symptoms with disordered behaviors is the best sign that the person is suffering from an eating disorder. Not every person has all of these symptoms, but people with anorexia will usually display several of the following:[12][1][13]
    • Dramatic, rapid weight loss
    • Unusual facial or body hair in females
    • Increased sensitivity to cold
    • Hair thinning or loss
    • Dry, pale, yellowish skin
    • Fatigue, dizziness, or fainting
    • Brittle nails and hair
    • Bluish fingers

Considering the Person’s Emotional State

  1. Consider the person’s mood. Mood swings can be very common among people with anorexia, because hormones are often imbalanced by the body’s starvation.[14] Anxiety and depression commonly co-occur with eating disorders.[15]
    • People with anorexia may also experience irritability, listlessness, and trouble focusing or concentrating.[16]
  2. Analyze the person’s self-esteem. People with anorexia are often perfectionists. They may be over-achievers, and they often perform very well at school or work.[5] However, they often suffer from very low self-esteem. A person suffering from anorexia may frequently complain that they are not “good enough,” or that they can’t “do anything right.”[1]
    • Physical self-confidence is also usually very low in people with anorexia. Although they may speak about getting to their “ideal weight,” it is impossible for them to attain that because of their distorted view of their body image. There will always be more weight to lose.
  3. Be alert to the person exhibiting guilt or shame. People with anorexia will often feel very ashamed after eating. They may interpret eating as a sign of weakness or a lapse in self-control. If the person you're concerned about frequently expresses guilt over eating, or guilt and shame over their body size, this could be a warning sign of anorexia.[4]
  4. Think about whether the person has become withdrawn. People with anorexia may withdraw from their friends and usual activities.[1] They may also begin to spend increasing amounts of time online.[15]
    • People with anorexia may spend time on “pro-Ana” websites, which are groups that promote and support anorexia as a “lifestyle choice.” It is important to remember that anorexia is a life-threatening condition that can be successfully treated, not a healthy choice made by healthy people.
    • People with anorexia may also post “thinspiration” messages on social media. These types of posts may include pictures of extremely underweight people or messages making fun of people who are a normal weight or overweight.
  5. Note whether the person spends significant time in the bathroom after eating. There are two types of anorexia nervosa: Binge-Eating/Purging Type and Restricting Type. The restricting type is the one most people are familiar with, but the binge-eating/purging type is also common.[1] Purging can be in the form of induced vomiting after eating, or the person may use laxatives, enemas, or diuretics.
    • There is a difference between binge-eating/purging type anorexia and bulimia nervosa, another eating disorder. People suffering from bulimia nervosa do not always restrict calories when they aren’t binge-eating. People suffering from binge-eating/purging type anorexia will severely restrict calories when they are not binge-eating and purging.
    • People suffering from bulimia nervosa will often binge-eat huge quantities of food before purging.[17] People with binge-eating/purging type anorexia may consider much smaller quantities of food a “binge” that requires purging, such as a single cookie or small bag of chips.[12]
  6. Consider whether the person is secretive about their habits. People with anorexia may be ashamed of their disorder. Or they may believe that you just don’t “understand” their eating behaviors and would try to keep them from performing them. People with anorexia will often try to conceal their behaviors from others to avoid judgment or interference.[18] For example, they may:
    • Eat in secret
    • Hide or throw away food
    • Take diet pills or supplements
    • Hide laxatives
    • Lie about how much they exercise

Offering Support

  1. Learn about eating disorders. It can be easy to judge people suffering from an eating disorder. It can be difficult to understand why someone is doing such unhealthy things to his or her body. Learning about what causes eating disorders and what the people suffering from them experience will help you approach a possible sufferer with empathy and care.
    • Talking to Eating Disorders: Simple Ways to Support Someone with Anorexia, Bulimia, Binge Eating, or Body Image Issues, by Jeanne Albronda Heaton and Claudia J. Strauss, is a highly recommended resource.
    • The National Eating Disorders Association is a non-profit organization that provides extensive resources for friends and families of those affected by eating disorders.[19] The Alliance for Eating Disorders Awareness is a non-profit organization aimed at providing education and resources to heighten awareness of eating disorders and their impacts.[20] The National Institute of Mental Health has a variety of excellent information and resources for individuals with eating disorders and their loved ones.[21]
  2. Understand the real risks of anorexia. Anorexia starves the body, and can result in serious health conditions. In females between 15-24, anorexia nervosa causes 12 times more deaths than any other cause.[22] In up to 20% of cases, anorexia will cause early death. It can cause a variety of medical issues, including:[22][23][24]
    • Lack of menstruation in females
    • Lethargy and exhaustion
    • Inability to regulate body temperature
    • Abnormally slow or irregular heartbeat (due to weakened heart muscles)
    • Anemia
    • Infertility
    • Memory loss or disorientation
    • Organ failure
    • Brain damage
  3. Find an appropriate time to talk with the person in private. Eating disorders are often a reaction to more complicated personal and social issues. They may also have genetic factors at work. Talking about your eating disorder with others can be an intensely embarrassing or uncomfortable topic. Make sure you approach your loved one in a safe, private environment.[5]
    • Avoid approaching the person if either of you is feeling angry, tired, stressed, or unusually emotional. This will make communicating your care for the person much more difficult.[25]
  4. Use “I” statements to convey your feelings. Using “I”-statements can help the other person feel less like you are attacking him/her. Frame the discussion as safe and in the other person’s control. For example, you could say something like “I’ve noticed some things lately that worry me. I care about you. Could we talk?”
    • The person may become defensive. S/he may deny having a problem. S/he may accuse you of meddling in his/her life, or harshly judging them. You can reassure them that you care about him or her and would never judge, but don’t get defensive.
    • For example, avoid saying things like “I’m just trying to help you” or “You need to listen to me.” These statements will make the other person feel attacked and encourage them to stop listening to you.
    • Instead, keep the focus on positive statements: “I'm concerned about you and I want you to know that I’m here for you” or “I am ready to talk whenever you feel ready.” Give the other person room to make his/her own choices.
  5. Avoid blaming language. Using “I” statements will help you with this. However, it’s very important that you do not use other blaming or judgmental language. Exaggerations, “guilt trips,” threats, or accusations will not help the other person understand your true concern.[7]
    • For example, avoid “you” statements, such as “You’re making me worried” or “You’ve got to stop this.”
    • Statements that play on the other person’s sense of shame or guilt are also unproductive. For example, avoid saying things like “Think about what you’re doing to your family” or “If you really cared about me you’d take care of yourself.” People with anorexia may already feel an intense sense of shame about their behavior, and saying things like this could only make the disorder worse.
    • Don’t threaten the person. For example, avoid statements such as “You will be grounded if you don’t eat better” or “I’ll tell everyone about your problem if you don’t agree to get help.” These will cause significant distress and can make the eating disorder worse.
  6. Encourage the person to share his/her feelings with you. It’s important to give the other person time to share how s/he is feeling too. Conversations that are one-sided and all about you are unlikely to be productive.[7]
    • Don’t rush anyone through this type of conversation. It can take time to process feelings and thoughts.
    • Reiterate that you do not judge or criticize your their feelings.
  7. Suggest the person take an online screening test. The National Eating Disorders Association (ensure the any advice supplied applies in the nation you live in) has an online screening tool that is free and anonymous. Asking someone to take this test may be a “low-pressure” way to encourage them to acknowledge their problem.[26]
    • There are two screenings available through NEDA: one specifically for college students, and one for adults.
  8. Emphasize the need for professional help. Try to communicate your concern in productive ways. Emphasize that anorexia is a serious condition but is highly treatable under professional supervision.[1] Destigmatize the idea of seeing a therapist or counselor by letting them know that seeking help is not a sign of failure or weakness, nor a sign that they are “crazy.”
    • People with anorexia are often struggling to find control in their lives, so emphasizing that seeking therapy is an act of courage and control over one’s life may help them accept it.
    • You can frame this as a medical issue, which may help. For example, if your loved one or someone you know had diabetes or cancer, you would encourage her/him to seek medical help. This is no different; you are simply asking them to seek professional help for an illness.
    • NEDA has a “Find Treatment” feature available on their website. This feature can help you find a counselor or therapist who specializes in anorexia.[27]
    • Particularly if the person is a young person or teenager, family therapy may be helpful. Some studies suggest that family-based therapy is more effective for teens than individual therapy, because it can help address ineffective communication patterns within the family as well as offer ways for everyone to support the sufferer.[28]
    • In some severe cases, inpatient treatment may be required. This is common when the person is so underweight that they are at a high risk of things such as organ failure. People who are psychiatrically unstable or suicidal may also require inpatient treatment.[29]
  9. Seek support for yourself. It is hard to cope with seeing a loved one struggle with an eating disorder. It can be particularly difficult if the person you're concerned about refuses to acknowledge that a problem exists, which is all too common with sufferers of eating disorders. Seeking help from your own therapist or a support group can help you stay strong.
    • NEDA has a list of support groups on their website.[30] They also have a Parent, Family & Friends Network.[19]
    • The National Association of Anorexia Nervosa and Associated Disorders (ANAD) has a list of support groups by state.[31]
    • Your physician may also be able to refer you to local support groups or other support resources.
    • Seeking counseling is particularly important for parents of children with anorexia. It is important not to control a child’s eating behaviours or use bribes, but it’s hard to accept that when you see any child at risk. Therapy or a support group can help you learn ways to support and help a child without making his/her disorder worse.

Helping Your Loved One Through Recovery

  1. Validate your loved one’s feelings, struggles, and accomplishments. With treatment, about 60% of people with eating disorders recover.[32] However, it can take years to see full recovery. Some people may always suffer from feelings of discomfort with their bodies or compulsions to starve or binge, even though they manage to avoid damaging behaviors. Support your loved one through this process.[33]
    • Celebrate even small successes. For someone with anorexia, even eating what seems like a small quantity of food to you may represent a huge struggle for her/him.
    • Don’t judge relapses. Ensure that your loved one gets adequate care, but don’t judge him/her for struggles or stumbles. Acknowledge the relapse, then focus on how to get back on track.
  2. Be flexible and adaptable. In some cases, particularly those involving young people, treatment may incorporate changes to routines by friends and family. Be ready to make changes that are necessary for your loved one’s recovery.
    • For example, the therapist may recommend that certain ways of communication or certain ways of handling conflict change.
    • It can be hard to acknowledge that something you do or say could be affecting your loved one’s disorder. Remember: you didn’t cause the disorder, but you may be able to help your loved one recover from it by changing some things about your behavior. Healthy recovery is the ultimate goal.
  3. Focus on fun and positivity. It can be easy to slip into a “support” mode that can feel smothering to a person struggling with an eating disorder. Remember that a person struggling with anorexia already spends a great deal of his/her time thinking about food, weight, and body image. Don’t let the disorder be the only thing you talk about or focus on.
    • For example, go out to the movies, go shopping, play games or sports. Treat the other person with kindness and care, but let him or her enjoy life in as normal a way as possible.
    • Remember, people with eating disorders are not their disorder. They are people with needs, thoughts, and feelings.
  4. Remind the other person that s/he is not alone. Struggling with eating disorders can feel intensely isolating. While you don’t want to smother your loved one, reminding him/her that you’re there to talk or be supportive can help with recovery.
    • Find support groups or other support activities for your loved one to join. Don’t force her or him to join them, but make the options available.
  5. Help your loved one handle triggers. Your loved one may find certain people, situations, or things “triggering” to his/her disorder. For example, having ice cream around may pose an impossible temptation. Going out to eat may cause anxiety over food. Be as supportive as possible. It can take some time to discover triggers, and they may come as a surprise even to the person with the disorder.[34]
    • Past experiences and emotions may also trigger unhealthy behavior.
    • Stressful or new experiences or situations may also act as triggers. Many people who suffer from anorexia are desperate to feel in control, and situations that make them feel uncertain may trigger the need to perform unhealthy eating behaviors.

Avoiding Making the Problem Worse

  1. Refrain from trying to control the other person’s behavior. Do not try to force the other person to eat. Don’t bribe your loved one to eat more, or use threats to compel behavior. Sometimes, anorexia is a response to a lack of feeling control over one’s own life. Engaging in a power struggle or taking control away from your loved one may only make the problem worse.[35]
    • Don’t try to “fix” your loved one’s problem. Recovery is as complex as the eating disorder. Trying to “fix” your loved one on your own may do more harm than good. Encourage him/her to see a mental health professional, instead.
  2. Avoid commenting on the other person’s behavior and appearance. Anorexia often involves a great deal of shame and embarrassment for the person suffering from it. Even if well-meaning, commenting on your loved one’s appearance, eating habits, weight, etc., can trigger his/her feelings of shame and disgust.
    • Compliments are also unhelpful. Because the person is dealing with a distorted body image, s/he is unlikely to believe you. S/he may interpret even positive comments as judgment or manipulation.[36]
  3. Avoid “fat-shaming” or “skinny-shaming.” The healthy body weight for each person may differ. If your loved one comments that s/he feels “fat,” it’s important not to respond by saying things like, “You’re not fat.” This only reinforces the unhealthy idea that “fat” is something innately bad that should be feared and avoided.[13]
    • Similarly, do not point out thin people and comment on their appearance, such as “Nobody wants to hug a bony person.” You want your loved one to develop a healthy body image, not focus on fearing or diminishing one particular type of body.
    • Instead, ask your loved one where those feelings are coming from. Ask what s/he thinks s/he would gain by being thin, or what s/he fears about feeling overweight.
  4. Avoid simplifying the matter. Anorexia and other eating disorders are highly complex and often co-occur with other illnesses, such as anxiety and depression. Peer and media pressure may play a role, as may family and social situations. Saying things such as “If you would just eat more, things would be fine” ignore the complexity of the issue your loved one is struggling with.
    • Instead, offer your support with “I”-statements: “I realize this is a tough time for you” or “Eating differently can be hard, and I believe in you.”
  5. Avoid perfectionistic tendencies. The struggle to be “perfect” is a common factor in triggering anorexia. However, perfectionism is an unhealthy way of thinking that hampers your ability to adapt and be flexible, a crucial part of success in life.[37] It holds you and others to an impossible, unrealistic, and ever-shifting standard.[38] Do not expect perfection from your loved one or yourself. Recovering from an eating disorder may take a long time, and both of you will have times when you act in a way that you regret.
    • Acknowledge when one of you slips up, but don’t focus on it or beat yourself up for it. Instead, focus on what you can do going forward to avoid similar mistakes.
  6. Do not promise to “keep it a secret.” It may be tempting to agree to keep your loved one’s disorder a secret in order to gain his/her trust. However, you do not want to help promote your loved one’s behavior. Anorexia may cause early death in up to 20% of its sufferers.[39] It’s important to encourage your loved one to get help.
    • Understand that your loved one may initially be angry with you or even reject you for suggesting s/he needs help. This is common. Just continue to be there for your loved one and let him/her know that you support and care for him/her.

Tips

  • There is a difference between healthy diet and exercise habits and an eating disorder. Someone who pays attention to their diet and exercises regularly may be perfectly healthy. If you notice that the person seems obsessed with food and/or exercise, particularly if they also seem anxious or deceptive about it, you may have cause for concern.
  • Never assume someone is anorexic just because they are thin. Also, never assume someone is not anorexic just because they are not very thin. You cannot tell if someone is anorexic by their body size alone.
  • Don't make fun of someone you think may have anorexia. People who have anorexia are often lonely, unhappy and in pain. They may be anxious, depressed, or even suicidal. They do not need to be criticized; this will just make things worse.
  • Do not force an anorexic to eat outside of a professional setting. The anorexic may become very sick, and, even if they are physically fine from eating, the intake of calories could move the anorexic to intensify their starvation and exercise, worsening their health problems.
  • Keep in mind that if a person has anorexia, it's not anyone's fault. Don't be afraid to admit the problem, and don't be judgmental of someone who has it.
  • If you think you or someone you know may have anorexia, tell someone you trust. Talk to a teacher, counselor, religious figure, or parent. Seek professional advice. Help is available, but you can't get it unless you work up the courage to say something.

Warnings

  • Don't wait until the person becomes underweight to get help. Anorexia is serious and dangerous, no matter what the person's size is. Overweight and obese people with anorexia should get help as soon as possible; it is better that they live at a larger size than risk dying at a smaller one.

Related Articles

Sources and Citations

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Wooldridge, T., & Lytle, P. “. (2012). An Overview of Anorexia Nervosa in Males. Eating Disorders, 20(5), 368-378. doi:10.1080/10640266.2012.715515
  2. ↑ http://www.dsm5.org/documents/eating%20disorders%20fact%20sheet.pdf
  3. ↑ https://www.nationaleatingdisorders.org/anorexia-nervosa
  4. ↑ 4.0 4.1 4.2 http://www.allianceforeatingdisorders.com/portal/signs-of-anorexia#.VT-AWiFViko
  5. ↑ 5.0 5.1 5.2 http://www.medicinenet.com/anorexia_nervosa/page5.htm#what_are_anorexia_symptoms_and_signs_psychological_and_behavioral
  6. ↑ http://www.apa.org/monitor/2013/10/hunger.aspx
  7. ↑ 7.0 7.1 7.2 https://broadly.vice.com/en_us/article/when-youre-both-overweight-and-anorexic
  8. ↑ http://www.today.com/health/200-pound-anorexic-obese-teens-risk-disorder-its-often-unrecognized-4B11216388
  9. ↑ http://www.nationaleatingdisorders.org/anorexia-nervosa-males
  10. ↑ Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating Disorders in Men: Underdiagnosed, Undertreated, and Misunderstood. Eating Disorders, 20(5), 346-355. doi:10.1080/10640266.2012.715512
  11. ↑ http://www.nimh.nih.gov/news/science-news/2014/9-eating-disorders-myths-busted.shtml
  12. ↑ 12.0 12.1 http://www.anad.org/get-information/get-informationanorexia-nervosa/
  13. ↑ 13.0 13.1 http://www.mayoclinic.org/diseases-conditions/anorexia/basics/symptoms/con-20033002
  14. ↑ http://www.anad.org/get-information/eating-disorder-signs-and-symptoms/
  15. ↑ 15.0 15.1 http://eatingdisorder.org/eating-disorder-information/anorexia-nervosa/
  16. ↑ http://www.anad.org/get-information/eating-disorder-signs-and-symptoms
  17. ↑ http://www.anad.org/get-information/bulimia-nervosa/
  18. ↑ Becker, A. E., Eddy, K. T., & Perloe, A. (2009). Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V. International Journal Of Eating Disorders, 42(7), 611-619. doi:10.1002/eat.20723
  19. ↑ 19.0 19.1 http://www.nationaleatingdisorders.org/parent-family-friends-network
  20. ↑ http://www.allianceforeatingdisorders.com/portal/who-we-are
  21. ↑ http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml
  22. ↑ 22.0 22.1 https://www.nationaleatingdisorders.org/get-facts-eating-disorders
  23. ↑ http://www.allianceforeatingdisorders.com/portal/did-you-know#.VT-e9CFViko
  24. ↑ http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml#part_145415
  25. ↑ http://www.nedc.com.au/what-to-say-and-do
  26. ↑ http://www.nationaleatingdisorders.org/online-eating-disorder-screening
  27. ↑ http://www.nationaleatingdisorders.org/find-treatment/treatment-and-support-groups
  28. ↑ http://med.stanford.edu/news/all-news/2010/10/family-therapy-for-anorexia-more-effective-than-individual-therapy-researchers-find.html
  29. ↑ https://www.nationaleatingdisorders.org/treatment-settings-and-levels-care
  30. ↑ http://www.nationaleatingdisorders.org/find-treatment/support-groups-research-studies
  31. ↑ http://www.anad.org/eating-disorders-get-help/eating-disorders-support-groups/
  32. ↑ http://www.anred.com/stats.html
  33. ↑ http://www.allianceforeatingdisorders.com/portal/how-to-help-a-loved-one#.VT-XBCFViko
  34. ↑ http://www.anred.com/causes.html
  35. ↑ http://www.allianceforeatingdisorders.com/portal/how-to-help-a-loved-one#.VT-XZCFVikp
  36. ↑ http://www.helpguide.org/articles/eating-disorders/helping-someone-with-an-eating-disorder.htm
  37. ↑ http://nymag.com/scienceofus/2014/09/alarming-new-research-on-perfectionism.html
  38. ↑ http://www.healthychildren.org/English/ages-stages/young-adult/Pages/The-Problem-with-Perfectionism.aspx
  39. ↑ http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/
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