Eating Disorders and Beyond
Learning Objectives
 Learn how to prevent eating disorders by providing a
healthy feeding environment
 and a healthy emotional environment
 Learn how to Identify symptoms of eating disorders
including anorexia, bulimia, EDNOS, prader-willi, pica
and hoarding
 Learn when to seek professional help
 Learn the importance of encouraging a positive body
image
 Learn how a positive attitude toward eating, and your
body, IS THE BEST GIFT you can give your children
Contact info for presentation outline/copy
Meaghan:
Meaghan@soundnutritioncounseling.com
Anne:
meyer@whidbey.com
Who is the child that has
brought you here today?
The Division of Responsibility
Parent/Caretaker provide:
Children choose:
Structure, support,
opportunities
How much, whether
to eat from what
the parent provides
The Division of Responsibility
Infants
Parent/Caretaker
is responsible for:
The Child is
responsible for:
WHAT
HOW MUCH
The parent helps the infant to be calm
and organized and feeds smoothly,
paying attention to information coming
from the baby about timing, tempo,
frequency and amounts.
The Division of Responsibility
Toddlers through Adolescents
Parent/Caretaker
is responsible for:
The Child is
responsible for:
WHAT, WHEN,
WHERE
HOW MUCH &
WHETHER
The parent’s job is to trust the child to
decide how much and whether to eat. If
parents do their job with feeding,
children will do their job with eating.
The Division of Responsibility
Toddlers through Adolescents
Parent/Caretaker feeding jobs:
Choose and prepare the food
Provide regular meals and snacks
Make eating times pleasant
Show children what they have to learn about food
and meal time behavior
Not let children graze for food/beverages between
meal/snack times
Let children grow into the bodies that are right for
them
The Division of Responsibility
Toddlers through Adolescents
The Child’s eating jobs:
Children will eat well
They will eat the amount they need
They will learn to eat the food their parents eat
They will grow predictably
They will learn to behave well at the table
Eating Disorders
DSM (Diagnostic & Statistical Manual of
Mental Disorders) definitions
The full spectrum of eating disorders
Disordered eating & sub-clinical eating
issues
Getting help
What are eating disorders?
 Anorexia Nervosa
 Bulimia Nervosa
 Eating Disorder Not Otherwise Specified
(EDNOS)
Anorexia Nervosa
 Characterized by self-starvation and excessive weight
loss.
 DSM definition
 Refusal to maintain body weight
 Intense fear of weight gain
 Disturbance in the way in which one’s body weight or
shape is experienced.
 Females: cessation of menstrual cycle
Anorexia Nervosa
Sub-types
 Restricting Type
 Bingeing and/or Purging T
Bulimia Nervosa
 Characterized by a secretive cycle of binge eating followed by
purging
 DSM definition:
 Repeated episodes of binge eating in a discrete period of time
 Feeling out of control during a binge
 Recurrent inappropriate compensatory behaviors
 Self-evaluation is unduly influenced by body shape and weight
Bulimia Nervosa
Sub-types:
 Purging (vomit, laxative,
diuretic, enema)
Non-purging (fasting or
exercising)
Eating Disorder Not Otherwise Specified
(EDNOS)
 Do not meet diagnostic
criteria for AN or BN
Meet AN criteria but menstruate
BN but don’t binge
AN but normal weight
Chews/spits out food
(“shamming”)
 Very serious
 Binge Eating Disorder
Eating Disorder Not Otherwise Specified
(EDNOS)
Most EDs are EDNOS
 n = 2028 females age
12-23
 3.06% met criteria for
ED
 0.39% anorexia
(12.7%)
 0.30% bulimia (9.8%)
 2.37% EDNOS
(77.5%)
Binge Eating Disorder
 Periods of uncontrolled, impulsive, or
continuous eating
 No purging, may include sporadic fasts or
repetitive diets
 Compulsive eating may be triggered by
negative feeling states
 Body weight range from normal to severely
passed normal weight
Eating Disorders:
General Characteristics
 Severe disturbances in eating behavior
 Low self-esteem
 Self and other alienation
 Disturbance in perception of body shape and
size
 Maturity fears
 Emotion regulation problems
 Primary manner of coping with “life”
The Most Common Factor
Eating Disorders are a way to
cope with a painful life.
Rule-outs for
Child-specific Eating Concerns
Eating disorders may:
 symptomatic of other disorders
 sensory hypersensitivities
 oral motor difficulties
 reflect co-morbid conditions of anxiety and/or
depression
 biological problems
All primary bio-medical diagnostic possibilities
should be ruled out by a physician
Eating Disorders: The Function
Eating disorders are the solution to the
dilemmas of one’s life.
“Salvation through deprivation”
A safe place to hide
A relationship that makes sense
Some Characteristics of Families with Eating Disorders
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Sponsoring of the false self
Psychological Fusion
Lack of healthy emotional expression
High levels of conflict
Performance based value system
Absence of nurturing and comfort
Inability to teach self-soothing
Food insufficiency (not enough food)
Fear of starvation - hoarding
Family Dynamics and Early Childhood Development
 Caregivers measure her/his adequacy by weight of the
baby – this drives the feeding not the child’s needs
 Caregiver/child interactions: vacillations between
negativism, anxiety, feelings of failure as a caregiver
 Simple feeding challenges may undermine the
confidence of infant and caregiver
 Absence of routine, chaos in the family, and lack of
timely feeding patterns - derail competent eating
Most Important
Unresolved eating disorders or negative
attitudes about food and weight in the
caregiver can result in an eating
disorder in a child.
The Internal Experience of
Eating Disorders
Individual Differences
Although there are commonalities among
eating disorders – every eating disorder is
as unique as the individual who suffers
from the disorder.
Affective States
 Depressive Symptoms
Depressed mood
Social withdrawal
Low self-esteem
Hopelessness
Overwhelmed or empty
 Anxiety Symptoms
Social Anxiety
Risk avoidant
Fearful
Shy/timid
Emotional Concerns
Starved for care and affection
Longing to be protected, cherished
View self as Failure, weak,
Shame-based (I’m irreducibly bad)
Unworthy, ineffective, imperfect, lazy
Fears of abandonment/withdrawal of love
Anger and aggression outside of awareness
Experience emotion as out of control
Empty – no internal guide
Feelings are overwhelming
Cognitive Patterns
 Preoccupation - inadequate, incompetent, and
being unlovable
 All or nothing thinking (views the world in all or
nothing terms)
 Focus – maturity fears: growing up is
unrewarding, frightening, and “I do not have
what it takes to be a grown up.”
 Perfectionism: I must be perfect to be
respected, valued and loved
Somatic States
 Sense of “numbness” or
a need to be numb
 Difficulty sensing
internal cues
 Difficulty sensing a
“self” on the inside – no
internal guide
 Emptiness in the
stomach may mean: I’m
in control or I am a
depleted person
Relationship Patterns
 Control and perfectionism
 Emotional fusion
 Emotional exploitation
 Role as designated patient
 Role as “good child”
 Difficulty with intimacy
 Superficial relating style
 People pleasing style
 Avoidant and dependent relating styles
Why do some children develop eating
disorders and others do not?
The Goodness of Fit Model -Thomas and
Chess (1977), Lewin, K. (1935)
Temperament/Personality interacts with the
child’s environment (family, school,
community, and culture).
The better the fit the less likely an eating
disorder will occur
The Turtles and The Hares
(Johnson, 2005)
Turtles: Shy,
harm avoidant,
restrained,
compliant,
obsessive,
anxious,
concrete,
orderly,
inflexible, and
perfectionistic
Hares
 Dramatic, erratic, novelty seeking, impulsive,
easily bored, argumentative, drawn to and then
overwhelmed by complexity.
 It is not believed that there is a single gene
which causes eating disorders.
 Some personalities are more vulnerable then
others to eating disorders
Subclinical Disordered Eating
Dysfunctional Eating
Eating in chaotic and irregular ways – dieting, fasting,
bingeing, skipping meals
Dysfunctional eating is separated from the normal
function of satisfying hunger and providing energy
for health, growth and well-being.
Dysfunctional eating functions to reshape the body or
relieve stress, and is not regulated by hunger and
satiety.
Dysfunctional eating inappropriately relies upon
internal and external controls, such as emotions
or will power.
Francis Berg, Children and Teens Afraid to Eat
“Disordered Eating”
 Not formally defined
 Central features:
Strong body
dissatisfaction
Does not rely upon
internal cues
Control-based vs. trustbased
Chronic as full-blown EDs
 Increased risk for
depression
 Culturally reinforced
 Disordered Eater who
Restricts
Dieting
Restricting through PseudoVegetarianism or “health nut”
 Disordered Eater who
compensates for eating
with exercise
 Disordered Eater who
Binges or Overeats
 Diet mentality - Good/bad
food
#1
DISORDERED
EATING
Dieting & eating disorders
 Perhaps the most common trigger of
disordered eating is dieting.
D-I-E-T
(a four letter word!)
 Dieting = external cues guide eating (versus internal
hunger/fullness/satiety)
 Dieters are 8 times more likely to develop an ED
than non-dieters.
 Not all dieters  ED, but almost all EDs start with
dieting
 Yo-Yo dieting  risk for heart disease and other
biomedical problems
 Forces body into starvation mode
 Mind-body disconnect
Body believes there is a famine and responds accordingly….
Mind-Body Disconnect
(with Disordered
Eating/Dieting)
 Slowed metabolism
 Food preoccupation
 Under Eating = not enough nutrients
for normal functions
Miss important nutrients (calcium!)
Loss of muscular strength & endurance
Loss of coordination
Dehydration & electrolyte imbalances
Fainting, weakness, slowed heart rates
Slower reaction times
Decreased concentration
Dieting = semi-starvation
Dieting and Eating
Disorders
We Vote For Health At Every Size
 Weight-Centered: You must lose weight to be
healthy
 Lifestyle-Centered: Live a healthy lifestyle
and you will always lose weight and be
healthy.
 Health At Every Size: When you attend to
your biopsychosocial wellness your body
will reflect your natural weight.
Emotional Eating
 Using food for the purpose of affect regulation
(mood altering)
 Food and Mood
Brain chemistry – reward pathway, neurotransmitter
precursors, immediate effect of food, stress
 Non-hunger eating – when food is more than fuel
 Often “treated” with a diet
Diet/binge cycle
Tribole, NCES
(Seemingly healthy)
Signs & Symptoms
of Disordered Eating
 Thoughts about "feeling fat“
 Food preoccupation disguised as
“interest” (or cooking, cooking shows,
recipe collecting)
 Interest in vegetarianism
 Interest in food labels
 Fasting
 Compulsive exercise
 Laxative use
 Scale use
More Signs & Symptoms
of Disordered Eating
 Pro-ana sites & pro-mia
“Ed-ucation”
“thin-spiration”
 Menstrual irregularities
 Gastrointestinal
complaints
 Excessive condiment use
 Sneaking food
Getting Help
If you have any concerns:
Assessment by a Registered Dietitian
specialized in EDs is recommended
Help your children by helping yourself:
Embrace your own food issues and get help
Getting Help
Early detection is ideal
Outpatient care
Levels of care:
Outpatient
Residential treatment
Hospitalization
Getting Help
 The Treatment Team (look for ED experience)
Medical professional (MD, ARNP)
Nutrition professional (RD)
Psychotherapist (LCSW, PhD, LMHC)
Medication manager (MD, ARNP)
 Be the parent!
Getting Help
Other resources:
(Do not diagnosis your own child)
 Support groups for ED sufferer
 Support groups for family & friends of ED sufferer
 Therapeutic groups
 Online support
 Books and newsletters
Learning stage
Changing stage
Anticipating
Some Statistics
 In the U.S
5-10 million girls and women
1 million boys and men
are struggling with eating disorders including
anorexia, bulimia, binge eating disorder
 Most fashion models are thinner than
98% of American women
 Without treatment, up to twenty percent of people
with serious eating disorders die
 With treatment - two to three percent
Other Eating Concerns
 Food Insecurity & Hoarding
 Prader-Willi
 Pica
What is Prader-Willi?
1 in 12,000 – 15,000
Genetic disorder that typically causes low
muscle tone, short stature, incomplete
sexual development, cognitive disabilities,
problem behaviors, and a chronic feeling of
hunger
Prader-Willi
Multidisciplinary Team
 Physician experienced in PWS
 Mental Health practitioner
Family therapy upon diagnosis
 Registered Dietitian familiar with principles of
feeding dynamics
 Prader-Willi Syndrome Association (USA) at 1-800926-4797
What is Pica?
The persistent eating of nonnutritive substances, such as:
 dirt
 clay
 paint chips
 plaster
 chalk
 cornstarch
 laundry starch
 baking soda
 coffee grounds
 cigarette ashes
 burnt match heads
 cigarette butts
 feces
 ice
 glue
 hair
 buttons
 paper
 sand
 toothpaste
 soap
How Common is Pica?
Difficult to estimate prevalence in
non-institutionalized populations
4-26% in institutionalized
populations
Usually begins in childhood and
lasts just a few months
What Causes Pica?
 Cause unknown
 Usually begins in
childhood and lasts
just a few months
 Increased risk with:
Nutritional deficiencies
Dieting
Malnutrition
Cultural factors
Parental neglect
Food deprivation
Developmental problems
Mental health conditions,
such as OCD &
schizophrenia
Pregnancy
Does My Child Have Pica?
 Repetitive consumption of a nonfood item, despite
efforts to restrict it, for a period of at least 1 month
or longer
 The behavior is considered inappropriate for your
child's age or developmental stage (older than 18
to 24 months)
 The behavior is not part of a cultural, ethnic, or
religious practice
Complications
 Potential for poisoning
 Displacement of nutrient-dense food 
nutritional deficiencies
 Digestive tract blockages or tearing
 Infections from bacteria
Treating Pica
 Call doctor if child is at
risk or already consuming
nonfood substances
 Positive reinforcement for
edible foods
 Collaboration with mental
health practitioner
 Poison control
800-222-1222
What is “Normal Eating”?
Normal Eating
HOW TO GET YOUR KIDS TO EAT BUT NOT TO
MUCH
SATTER, 1987, PP. 69-70.
What is “Normal Eating”?
 Positive attitudes and behaviors toward food
 Food acceptance skills
 Internal regulation
 Contextual skills
 -Ellyn Satter, RD, MSW
What is “Internal regulation”?
 Appetite
 Hunger
 Satiety
We’re born with the ability to…
Over time…
Eating Attitudes & Behaviors:
General Conflicts
 Diet vs nondiet mentality (Intuitive Eating, Tribole)
 Weight-centered vs Health-centered
 Non-hunger vs Hunger eating
 External versus Internal cues
Eating Attitudes & Behaviors:
General Conflicts
 Targeting/blaming specific foods/food
groups:
Food is food
Food “power”
Food “power” over enjoyment
The benefits of neutrality
 Glamorized foods/nutrients
 “You are what you eat”…
Eating Attitudes & Behaviors:
General Conflicts
 Children With Healthier Diets Do Better In School,
Study Suggests
 Learn to shake the salt habit
 While the FDA considers limiting sodium, it's up to
you to curb your craving
 New proposal for global, legal junk food ad ban
 White bread may bring greater disease risk
 Key to way stomach expands found
 Blueberry and green tea containing supplement
protects against stroke damage
The Food Need Pyramid
 Current national
recommendations:
 asks Americans to focus on
external control
 disregards appetite, hunger, and
satiety
 disregards psychosocial needs
 Food-avoidant environment 
food preoccupation 
incompetent, disordered eaters
The Food Need Pyramid
 At least 2 generations of
confused parents
 Confused, conflicted
regarding food
 Who will teach our children
to be competent, normal
eaters?
 Feeding relationship data
not reflected in national
policy
Food Need Pyramid
Nutrition
Sustaining
Good
Tasting
Reliable
Access
Enough
Current Recommendations
 Upside down food need pyramid
 Emphasis is on nutrition
 Disregards psychosocial needs
 Focus on external control
 Does not reflect the science on eating attitudes
and behavior
Current Recommendations
 Contributed to a fear-based, food-avoidant
environment
 Food preoccupation  nation of incompetent,
disordered eaters
 Confused, conflicted parents and grandparents 
no one to teach our kids to be competent, normal
eaters
 Do not reflect data on the feeding relationship
Our Food Culture
 Harmful messages 
eating pathology
“Super Nutrients”
Good/bad food
Fatness  death
 Deprivation
Deprivation backlash
“I shouldn’t
be eating
this”
Our Food Culture
Percentage of Children Ages 6 to 17 who
Ate Meals with Their Family, by Number
of Days Meals Eaten Together, 2003
Age
6-11
12-14
15-17
0-3 days
19.9
26.3
35.8
4-5 days
24.5
26.1
28.0
6-7 days
55.5
47.6
36.3
Why do people hoard food?
Food insecurity  hoarding
Because of Food Insecurity
 Food security = assured access to enough food for
an active healthy life
 Food insecurity = limited or uncertain availability of
nutritionally adequate and enjoyable food
Hoarding and Food Insecurity
It is normal to fear
starvation!
Food Insecurity
 What type of child manifests food insecurity:
 Any child who has learned to fear not having enough
food
 Any child with tendencies to be anxious or obsessive
 Children of all ages dependent upon others to ensure
they will be fed
 Any child at any percentile, body weight, or size
A fat child’s fear of not having enough is as
legitimate as a thin child’s fear
Hoarding: Prevention and Intervention
 Prevention: Honor the Division of
Responsibility
 Intervention: Provide structure,
reliable access, and enough food
 Establishing food security takes
time – Be Patient and Consistent
Remember Sleeping with Bread
Hoarding and Food Insecurity
 Bottom line: access & enough food
 Any time access restricts our ability
to take care of a physiological
need, there will be insecurity and
feelings of deprivation
 Any time there is deprivation, there
is a deprivation backlash – often in
the form of hoarding
Hoarding and Food Insecurity
It is normal to fear
starvation!
 Fears of not having
enough drives hoarding
behavior.
The Division of Responsibility
Parent/Caretaker provide:
Children choose:
Structure, support,
opportunities
How much, whether
to eat from what
the parent provides
Children know how to Eat & Grow
32
30
28
26
eating
24
22
20
Day 1 Day 2
Day 3 Day 4 Day 5
Children
know how to
eat and grow
Children
know how to
eat and grow
Missed
cues
Disruptions in the DOR
Examples
Rewarding with food (e.g. potty)
Clean plate club
Restricting access to palatable food (forbidden foods)
Assumption that parent knows internal needs of child
better than the child
Disruptions in the DOR
 “He won’t eat anything but graham crackers, yogurt,
milk, & pears, so that’s what I end up giving him each
day” (mother of 13 mo)
 “If we were to let him eat as much as he wants, he
would eat so much he would explode!” (mother of 10
mo)
 “You can’t have dessert until you’ve eaten your
veggies” (caregivers everywhere, with children of all
ages)
Disruptions in the DOR
What Division of Responsibility (DOR)
dilemmas do you have?
Practice using the DOR to solve problems
Share with group
The Division of Responsibility
Parent/Caretaker provide:
Children choose:
Structure, support,
opportunities
How much, whether
to eat from what
the parent provides
The Eating Environment:
Making Eating Times Pleasant
The Eating Environment:
Making Eating Times Pleasant
 The table needs to be a pleasant place to be
Eat with your children (show up)
Light, positive conversation
Avoid pressure, food focus
Wandering attention = full
Avoid clean plate club
Avoid hunger extremes (with snacks)
The Importance of Family Meals
 Family connectedness
 Families who eat together, eat better
 Teens less at risk for substance abuse
 Better grades
 Some research related to decreased likelihood
of eating disorders
Eating Competence
 Attitudes and Behaviors
no good/bad food
food police
clean plate club
 Internal regulation
hunger scale
 Food Acceptance skills
 Contextual skills
Defining Body Image
In our mind’s eye, how we see ourselves
The perception of how we believe others
see our bodies
The experience of living in our body
Giving the Gift of Positive Body
Image
 Love the body you
were born with
 Model positive
attitudes and
behaviors
 Teach your children to
love and accept their
bodies
More on Body Image…
 Help your children by:
 Promoting Size and
Shape Diversity
 Educating your children
about models and the
media
 Limiting exposure to
advertisement that
demoralizes your children
 Encouraging pleasurebased movement without
associating it with weight
loss
Primary Prevention:
Honor the Division of Responsibility
between parent and child
Secondary Prevention:
Seek professional help if you suspect
a feeding problem
Eating disorders are always biopsychosocial . . .
The Healing Begins with YOU!
Resources
 The Prader-Willi Syndrome Association
(www.pwausa.org) 1-800-926-4797
 Books
 -Raising Emotionally Intelligent Children by
John Gottman
 -Child of Mine by Ellyn Satter
 -Secrets of Feeding a Healthy Family by
Ellyn Satter
 -Your child’s Weight: How to help without
harming, by Ellyn Satter
 -The Body Project by Joan Brumberg
 -Big Fat Lies by Glen Gaesser
 Clinicians who treat eating disorders
 Websites
 www.ellynsatter.com
References






National Eating Disorder Association
www.edreferral.com
Rader Programs
Eating Disorder Recovery Online
Anred
Eating Disorders: Nutrition Therapy in the Recovery
Process. (Dan and Kathleen Kim Lampson Reiff)
 Children Afraid to Eat. (Francis Berg)
 The Parent’s Guide to Childhood Eating Disorders
(Marcia Herrin and Nancy Matsumoto)
References
 The Prader-Willi Syndrome Association
(www.pwausa.org)
 Medline Plus
(http://www.nlm.nih.gov/medlineplus/praderwilli
syndrome.html)
 Barth, 1988
 Fischer, 1989
 Gila, Castro, Cesena, & Toro, 2005
 Goodsitt, 1977
 Keck & Fiebert, 1986
References
 Ritvo, 1984
 Seiffge-Krenke, 1997
 The prevalence of eating disorders not otherwise
specified. Machado PP, Machado BC, Gonçalves S,
Hoek HW.Int J Eat Disord. 2007 Apr;40(3):212-7
 http://www.kidshealth.org/parent/emotions/behavior/pic
a.html
 http://www.webmd.com/mental-health/mental-healthpica
 Frac.org
 Growth chart example:
http://www.supermagnus.com/mac/Growth_Charts/
References
 Family meals:
http://www.childtrendsdatabank.org/indicators/96FamilyMeals.cfm
 Appetite. 2007 Apr 7; Do not eat the red food!: Prohibition of
snacks leads to their relatively higher consumption in children.
Jansen E, Mulkens S, Jansen A.
 Eating Disorders: a Clinical Guide to Counseling and Treatment.
Monika Woolsey, MS, RD
 Food and Mood, Elizabeth Somer, MS, RD
References Images
www.washingtonpost.com
http://newsimg.bbc.co.uk/media/images/41004000/jpg/_41004339_an
orexia203.jpg
http://www.swedauk.org/leaflets/edbox2.gif
http://images.ask.com/fr?q=Warning+Signs+of+Anorexia&desturi=http%3A%2F%2Fwww.freewebs.com%2Fmentalhealthissues%2Fanorexiabulimia.htm&f
m=i&ac=18&ftURI=http%3A%2F%2Fimages.ask.com%2Ffr%3Fq%3DWarning%2BSigns%2Bof%2BAnorexia%26desturi%3Dhttp%253A%252F%25
2Fwww.freewebs.com%252Fmentalhealthissues%252Fanorexiabulimia.htm%26imagesrc%3Dhttp%253A%252F%252Fwww.freewebs.com%252Fm
entalhealthissues%252Fcry.jpg%26thumbsrc%3Dhttp%253A%252F%252F65.214.37.88%252Fts%253Ft%253D13037628548860643162%26thumb
uselocalisedstatic%3Dfalse%26fn%3Dcry.jpg%26imagewidth%3D388%26imageheight%3D299%26fs%3D69%26ft%3Djpg%26f%3D2%26fm%3Di%
26ftbURI%3Dhttp%253A%252F%252Fimages.ask.com%252Fpictures%253Fq%253DWarning%252BSigns%252Bof%252BAnorexia%2526page%2
53D1%2526pstart%253D&qt=0
http://images.ask.com/fr?q=Starvation+Symptoms&desturi=http%3A%2F%2Fwww.smith.edu%2Fourhealthourfutures%2Fanorexia.html&fm=i&ac=18&ftURI
=http%3A%2F%2Fimages.ask.com%2Ffr%3Fq%3DStarvation%2BSymptoms%26desturi%3Dhttp%253A%252F%252Fwww.smith.edu%252Fourhea
lthourfutures%252Fanorexia.html%26imagesrc%3Dhttp%253A%252F%252Fwww.smith.edu%252Fourhealthourfutures%252Fimages%252Fcol22b.j
pg%26thumbsrc%3Dhttp%253A%252F%252F65.214.37.88%252Fts%253Ft%253D7752590126148186640%26thumbuselocalisedstatic%3Dfalse%2
6fn%3Dcol22b.jpg%26imagewidth%3D452%26imageheight%3D247%26fs%3D28%26ft%3Djpg%26f%3D2%26fm%3Di%26ftbURI%3Dhttp%253A%
252F%252Fimages.ask.com%252Fpictures%253Fq%253DStarvation%252BSymptoms%2526page%253D1%2526pstart%253D&qt=0
http://www.helpguide.org/index.htm
http://woxy.lala.com/boards/showthread.php?t=14191&page=137&pp=20
http://plaza.ufl.edu/paty/paperone.html
http://www.telegraph.co.uk/health/main.jhtml?xml=/health/2003/01/14/hdis14.xml&sSheet=/health/2003/01/14/ixhmain.html
http://www.lionking.org/~ryan/sip/characters/fran/binge.html
http://www.thamike.com/fn_images/fat_anorexic.jpg
http://www.funnyguy.com/anorexic.gif
http://www3.sympatico.ca/jim.rowe2/paintings/anorexic3-7.jpg
http://www.fda.gov/fdac/graphics/1996graphics/pyr.gi
http://www.ncfh.org/pateduc/images/!familyo.giff
http://www.wirestaurant.org/images/news/obesity/super_america.jpg
Pbs.org for pic of scale on diet and ED slide