Eating disorders are on the rise among American teens. Since the COVID pandemic, health care providers have documented an increase in children and adolescents seeking help for a variety of mental health concerns, including a notable spike in symptoms of eating disorders such as calorie restriction, binging, purging, and compulsive exercise. Since the family meal is a setting where parents are uniquely positioned to both look for, and potentially intervene in, disordered eating patterns, we asked experts in the field to help us understand what parents need to know about eating disorders and family dinner.
We spoke with Dr. Jennifer Goetz, Child and Adolescent Psychiatrist at McLean Hospital and instructor at Harvard Medical School specializing in the treatment of eating disorders across the lifespan, and Oona Hanson, a Parent Coach in private practice and Family Mentor at Equip, a virtual, evidence-based eating disorder treatment program. Here are some of the key takeaways they shared for parents to keep in mind:
What are eating disorders, and how are they different from “disordered eating”? What red flags should parents be looking for?
Dr. Goetz says that while there are clinical definitions of the major eating disorders – including anorexia, bulimia, binge eating disorder, and avoidant/restrictive food intake disorder (ARFID) – those criteria don’t always capture how much the behavior is impacting a person’s life. She prefers to look at how a child’s relationship with food, eating, exercise, and body image may be interfering with their ability to engage in life in a meaningful way. “There’s no official definition, but disordered eating is, in general, eating in a way that doesn’t honor the depth and breadth of foods that the body needs in order to thrive,” she says.
But both Hanson and Dr. Goetz note that it may be challenging or confusing for parents to pick up on disordered eating patterns, partly because of cultural influences. “Dieting and disordered eating are normalized and glorified in our culture,” Dr. Goetz shares. “This comes in many forms, including advertisements around weight loss medications and programs that really are glorified restrictive eating programs to more overt content like celebrities talking about diets, cleanses and other harmful behaviors. Many of these now come under ‘wellness’ culture and can also be found on social media.” Hanson adds that many of these diet ideals are ingrained in the way parents and even teachers, especially in health and nutrition classes, may talk about food and exercise – often without realizing it. “I’ll need to run an extra mile tomorrow after eating this,” “I’m being so bad/naughty by eating this ice cream,” or “I’ve earned this big breakfast after that hike!” are all examples of promoting what Hanson calls the “burn and earn” mentality – and kids, she says, pick up on that kind of language.
That kind of cultural programming can make it easy for kids and teens to develop disordered eating habits under the guise of “health,” and for parents to miss the signs. But Hanson stresses that it’s crucial for parents to listen to their gut instincts and be wary of any change in a child’s eating habits. “If children are cutting out whole food groups they really enjoyed, that’s a huge red flag,” she says, cautioning that social media can be a major influence on teens’ ideas about “wellness” and “health promoting behaviors.” While a child suddenly going vegetarian or vegan may be a temporary response to a TikTok about industrial farming, it also may be the first sign of a preoccupation with food that may lead to a child not getting enough nutrition, or becoming increasingly rigid and rule-bound in their approach to eating.
The bottom line, Dr. Goetz says, is that any change in a child’s eating habits or emotional state should be a signal to parents to stay alert. “Food coming back uneaten in a lunchbox, changes in the amount or content of what a child eats at dinner – like maybe they used to eat bread, but they’ve stopped, or they’re filling their plate with salad and not much else. Frequent use of the bathroom directly after meals can be a warning sign, if purging is a concern,” she says. “But beyond those behaviors directly related to food, look for things like isolation, increased fatigue, irritability—these can all be signs that your child or teen isn’t getting proper nutrition.”
If parents do have concerns about a child’s eating and relationship with food, what should they do? How can they address the concern?
First, Hanson suggests, approach the subject with curiosity. Both she and Dr. Goetz agree that it’s important for parents to realize that talking about their concerns won’t either cause or worsen an eating disorder, and can help pinpoint problems early on. “Come with compassion, not with panic, like ‘Oh my God, are you developing an eating disorder?” says Hanson. “Ask questions. ‘I’ve noticed you don’t seem to want to eat ice cream anymore. Can we talk about that?’”
Parents can also feel confident about about getting professional help quickly if they feel something is amiss. “Engage your child’s pediatrician as soon as you become concerned,” Dr. Goetz says. “They will help assess your child and determine what additional treatments may be needed.” Hanson points out that it’s uncommon for a family to seek early help for eating disorders. “I’ve never had a family enter eating disorder treatment and say, ‘We got this immediately, at the first warning sign.’ Almost every family comes in and says, ‘I wish I had acted sooner. This wouldn’t have been so painful if we had caught it earlier.’”
One caution, Hanson says: “Many pediatricians haven’t had sufficient training in eating disorders.” She says that health professionals may have been trained to take a “wait and see” approach, even if a child is losing weight, but this isn’t always recommended in current treatment guidelines. Especially complicated, Hanson adds, is the case of a child in a larger body who exhibits signs of an eating disorder. Well-meaning doctors may congratulate that child for weight loss, missing the red flags that signal something is seriously wrong. “Sometimes parents have to advocate and get a second opinion from an eating disorder professional,” Hanson says. “Weight loss or lack of expected gain in a growing child should always be cause for further investigation.”
Research shows that family dinners can help reduce the risk of eating disorders, but of course, it’s not as simple as just sitting down and eating food together. What might a positive, risk-reducing family meal environment look like?
“Is it a place kids want to be?” Hanson asks. “Is the food delicious? What will be enjoyed by everyone, or will everyone find something they can enjoy? Whether that’s frozen pizza or a Julia Child roast chicken, the nutritional quality on the plate matters so much less than the deeper nourishment of the table. We can’t reduce the nourishing impact of a family dinner to a food label. You could be serving whatever wellness culture would say is healthy, but if there’s food policing or body shame or stressful conversation and diet talk at the table, that’s not a healthy meal for that child.”
Dr. Goetz agrees. “Kids in particular, but teens also, are like sponges—they are soaking in everything around them. And that includes their parents’ relationship with food. Bringing the family around the dinner table to eat a balanced meal with protein, carbohydrate, vegetables and sweets teaches kids that a balanced approach to eating with lots of variety is normal—because parents do it, it becomes their normal. Family dinners also allow an opportunity to engage each member of the family in discussion around their day; it shows interest in the child and that their views are important and cherished in the family. This way of relating to kids and teens both teaches them the importance of a balanced and varied, non-restrictive approach to eating AND that they matter and are a valued member of the family system. It’s really a win-win.”
We’ve talked about diet culture and about creating family meal environments where all foods are encouraged, but there’s no denying that parents are also getting a lot of messaging from a variety of sources – including health care providers – about things like weight and body size. How can parents reconcile those messages with reducing eating disorder risk? It seems like a tricky balance.
Dr. Goetz urges parents to be mindful of the way their own relationships with food and body image impact kids. “It starts from a young age; girls as young as 6 believe themselves to be fat and have already started thinking about dieting,” she says. “If parents are trying to get their kids to eat balanced meals but themselves are dieting and constantly talking about wanting to lose weight/trying to lose weight/on diets, kids pick up on that. They internalize that and in someone with a vulnerability to an eating disorder, it can really set the stage for its development. I have worked with a lot of families of kids with eating disorders. Parents often tell me they are dieting while we’re trying to nourish their child back to health, and I have to work hard with the parents to move away from their own diets because kids won’t heal their relationship with food if parents continue to engage in disordered behaviors.”
Hanson points out that “a lot of parents have realized those things aren’t helpful, but they don’t realize any kind of binary is the same thing – healthy vs. unhealthy is the same as good vs. bad, or ‘real food’ vs. ‘junk food.’ Kids are concrete thinkers.” She also wants parents to recognize that body weight, shape, and size are tied up in the messaging kids get everywhere. “If your child doesn’t fit the very narrow thin ideal, they’re probably getting messages about that all day long at school, doctor’s office, social media, that something is wrong with them,” she says. “What I’ve seen happen is, parents say the child is being teased and is unhappy with their weight, and the parents say let’s exercise together or diet together. But we’re actually siding with the bully.” Hanson stresses that the role of a parent should not be to try to help change the child’s body shape or size, but to communicate unconditional love and acceptance.
“Parents are influencers,” she says. “We have an influence over our kids. We can do a lot of harm in the process of trying to ‘help.’ Come back to making sure our kids know we love them unconditionally just as they are – and we might need to process that within ourselves.”
We know that while family meals can be protective, there is still a chance that a child will end up diagnosed with an eating disorder. What happens to the family meal then? What can (or should) parents do to set up the mealtime environment for that child’s needs?
“An ED takes so many things away from families,” says Hanson. “Pleasant family meals are one of those, for a while. That being said, getting through those hard meals together as a family and renourishing that child is the foundation of recovery. When you have ED in the home, family meals are not going to be that Norman Rockwell painting, but you can get back to joyful family meals. Recovery is possible.”
Hanson shares that she feels very strongly about the benefits of family-based treatment for kids with eating disorders, which allows therapists to supervise the child’s recovery while working with the whole family on an ongoing treatment plan. “Parents do have a role in helping their child nourish themselves back to health,” Hanson says. “But here’s where it gets tricky for a parent. The whole family has to be able to tolerate a lot of distress. There is an expectation that meals will be unpleasant for a while.”
Dr. Goetz encourages parents who are working with family-based treatment to keep the focus of mealtime on each individual, so the entire dynamic doesn’t have to become about the eating disorder. “Make sure that every member of the family has an opportunity to bring discussion about themselves and their day to the family,” she says. She notes that while family-based treatment may necessarily include things like parents coaching a child with an eating disorder to “take another bite,” as treatment progresses, families can make sure to “include other aspects of each person’s whole being at the table. That’s really important and will prevent the individual with the eating disorder from being seen from just that one angle.”
Hanson adds that this approach is especially valuable for siblings, who also need support. Flexibility and creativity are key, she says, suggesting that siblings may need to have a separate meal with a caregiver from time to time so they can experience a meal without the added dimension of eating disorder treatment. “But a lot of things like games and fun distractions that work to make family meals pleasant can be used during ED treatment as well. Even if you’re a no TV at the table family, if you have a child in recovery, this might be the time to say let’s have kittens on YouTube or Abbott Elementary on TV while we’re eating. If something helps your child to eat, it will get you back to the family meals you want sooner.”
Are there any final thoughts you’d like to share with parents about eating disorders? Any myths you’d like to dispel?
“There is a common belief that eating disorders have ‘a look,’” says Dr. Goetz. “The thin, white, privileged teen or young adult. In reality, eating disorders affect individuals across the lifespan, all ages, all genders, all socioeconomic status and in individuals of all shapes and sizes. You can’t actually look at someone and determine whether they have an eating disorder—someone could be ‘normal size’ and be struggling mightily with restriction and other disordered behaviors.”
Hanson agrees, and adds “People assume people with EDs don’t eat. Most parents don’t know that the vast majority of people with EDs, including anorexia, DO eat. Just because you’re seeing your child eat, don’t rule out ED. Maybe we saw them eat dinner with us, but is that the only meal they may have eaten that day? EDs are very sneaky.”
Hanson also wants parents to know that the idea of an eating disorder being “all about control” is another pervasive myth. “Someone with an ED is under the control of the ED, not the other way around,” she says. “Someone might conceptualize their own eating disorder as a need for control, but the general idea that it’s just about trying to control your environment is incomplete, and it makes it seem like a person is doing that on purpose. They’re not.” She encourages parents to make food abundant, tasty, and available, and provide a predictable structure where kids know when and where dinner will be served each day. “Structure without restriction can be really comforting. Getting kids involved in prepping and cooking and having food skills, even just being involved in ordering the delivery, is powerful. Give them confidence in the long term in their relationship with food.”