Are Cleansing and Detox Diets Just Fancy Anorexia?

(Originally published on July 25 2016)  I’ve seen a quote about cleanse diets and detoxing being shared on Facebook quite a lot lately. Each time it shows up, it gets hundreds to thousands of likes and hundreds of shares. Amazing the power of a superficially logical statement that is actually based on a fallacy. This is one I would call a false analogy and its stunning in it’s shear reductionism: “Cleansing and detox diets are just fancy anorexia.” I decided I’d like to write a few things about it.

First, the quote. It is by someone named Jessica Goldstein. I didn’t know who she was or where the quote originated, but I tracked it down to a website called ThinkProgress, for which Jessica Goldstein is the culture editor and, obviously, a writer. Let’s start with the quote, and then I’ll get to the context of the quote:

I have this theory that the reason cleansing and detoxing have taken off is because it’s this socially acceptable way to have an eating disorder, basically, for a finite period of time. No one would ever say, “Oh, you should definitely just not eat for the entire month before your wedding.” But you can say, “You should do this lemon and cayenne pepper cleanse, you’ll feel amazing,” and somehow that’s okay. But it’s just fancy anorexia.

This quote is actually from an interview that ThinkProgress did with Timothy Caulfied, author of Is Gwyneth Paltrow Wrong About Everything?: How the Famous Sell Us Elixirs of Health, Beauty & Happiness and Canada Research Chair in Health Law and Policy, and professor at the University of Alberta School of Public Health, where he is the long-time research director of the Health Law Institute.

There are many other quotes that could have been mined from this article/interview, but it is not surprising that this one quote comparing cleanse diets and detoxing to anorexia got singled out. It seems to make such a powerful point. People are engaging in unscientific and extremely unhealthful dietary practices. They are on their way to dire straits! People are killing themselves. Oh, my. Why this cleansing stuff is one step away from a full-on eating disorder!

The quote is actually a statement posed to Caufield. Does he agree? Well, he says he does, but then his actual response says nothing of cleanse diets being a fancy and acceptable cover-up of anorexia or anorexia-like behaviors. But again, it’s not odd that people chose to take the question/statement and leave the interviewee’s actual response behind. His response was less succinct and provocative:

You’re right. It has this sort of veil of healthiness to it, this idea that, as you know from the book, people really encouraged me. They said, “Good for you! Keep it up! Don’t give in!” It was seen as a very noble thing, and how it’s portrayed in celebrity culture helps that. I did a Google Trends search recently, comparing the word “dieting” to “detox” and “cleanse,” and it’s incredible, confirming just what you said, the idea of detoxing and cleansing has overwhelmed the idea of dieting. Dieting is vain and superficial, but detoxes and cleanses are all about health. When in fact, even an executive of Clean Cleanse, the one that I did, he admitted that most people go on it for dieting reasons. And you do lose weight, because you’re basically extreme dieting for a short period of time.

So, does he agree that it’s fancy anorexia, or does he not? His response has little to do with the actual content of the quote, except for the idea that it is socially acceptable and encouraged behavior. He compares detoxing and cleansing to dieting, not to anorexia.

Now I’ll repeat my opinion of the statement. It’s ridiculous. It is quite popular right now, among health advocates, to invoke a slippery slope regarding eating disorders. All the trendy and sometimes extreme dietary practices currently being promoted by various charlatans and celebrities are seen as a road to orthorexia or anorexia.

If you want to learn how to shield yourself from the type of BS I’m discussing in this article, read my free book The BS Vaccine For Fitness and Nutrition.

The answer mentioned Google trends. Well, anorexia is trending even more heavily than cleanse diets or detoxing. Do you think this is a coincidence? People in all walks of life who have probably never given a thought to anorexia are now suddenly concerned with it. Many of them probably have never heard of it and know absolutely nothing about it. The same thing goes for the many, many people who absolutely agree with this statement when it is shared on social media. Most of them have probably never given it a second thought but suddenly, as such trends go, everybody is an expert on cleanse diets, detoxing, and eating disorders!

What is Anorexia?

So what is anorexia? Well, anorexia, technically, is just the medical term for loss of appetite. This loss of appetite can be from any cause so the term taken alone does not necessarily refer to an eating disorder. However, anorexia is almost always used as a shorthand for anorexia nervosa. This is a very serious mental health condition.

Just because someone skips some meals, fasts, or does a cleansing detox diet, we can not pronounce them anorexic! In order for anorexia nervosa to be diagnosed, many clinical criteria must be met. At the end of this article, I’ve provided a detailed overview of anorexia nervosa, with signs and symptoms. Take some time to go over it, and you should see that superficially comparing a cleanse diet to this disorder is more than just simplistic and silly. I’ve also gone on to compare the effects of anorexia nervosa and bulimia.

Most of the comments by Caulfield are pointing out that cleanse diets are mostly undertaken for weight-loss reasons. They are not about cleansing but are simply a very extreme and now socially acceptable diet. If so, these diets are not the only trendy diets in history that feature extreme deprivation. However, as these trends have come and gone, the health industry has never declared a full-scale anorexia epidemic.

Diets of any type can be socially isolating. One of the reasons for the success of diet programs like Weight Watchers is that friends often do them together. Some of the power of the cleanse and detox fad, driven by celebrity endorsement, is that it is popular and socially acceptable, something that friends can undertake together. Now, is taking a negative and socially unacceptable behavior like anorexia and disguising it with a fancy “cleanse diet” label to make it socially acceptable the same thing as taking something that people do anyway but sometimes find isolating, and choosing a mode that is less isolating? Dieting is somewhat stigmatized in our society, and many people compare yo-yo dieting to anorexia or an eating disorder. But dieting itself is nowhere near as stigmatizing as an eating disorder.

Others invoke a slippery slope, saying yoyo dieting inevitably leads to an eating disorder. Dieting behaviors can morph into eating disorders but to generally declare that anyone who engages in a particular diet trend is on their way to an eating disorder, or has one, is just as alarmist as food-fear mongers preaching about toxins in our food.

Fasting and Anorexia

Many cultures make it a regular practice to fast. For example, Ramadan is a month of fasting for Muslims, a time to remember the suffering of the poor and to appreciate what God has given you. This is but one example of cultural or religious fasting. Buddhist monks fast daily, from noon to dawn. And there is a long history of Christian fasting, which today varies from church to church. Examples are Advent and Lent in the Catholic church, which today means eating less food in general and abstaining from meat and meat products.

When such fasting is a part of the culture, is it disordered eating behavior? Is it behavior in which no mentally healthy person would engage? Will it morph into full-on anorexia nervosa? I’ll bet you’re not ready to accept that. So, why should so many accept that a cleanse diet is nothing more than fancy anorexia? A cleanse diet is really just a fast. Regardless of the pseudo-scientific reasons, as opposed to religious reasons, it’s still a fast. And the idea that a fast cleanses us, both physically and spiritually, is nothing new.

I actually think that what upsets opponents of cleansing and detox diets more than the actual diets is that so many people become steadfast promoters of them and encourage others to do it. The idea that you are more health-savvy and even more righteous and superior, while you are actually engaging in a ridiculous pseudoscientific fad, upsets some folks of a more scientific bent. But this is not about science itself, but a type of ‘moral outrage’ aimed at the proponents of such behavior. If a religious person fasts, the same folks may find it hard to understand, but since the faster isn’t trying to convince the masses to join him, they don’t give it much thought.

Sure, some folks are using these diets in an extreme fashion and too often. Some with the right disposition may actually develop an eating disorder and there are those who are so obsessed with healthy eating that they eat in a way that is obsessive. Others may actually be using this behavior as an acceptable way to cover up disordered eating behaviors, just as Goldstein said at the beginning of her statement. While all of this is possible, it is not probable that it applies to everyone using cleanse diets or detoxing. The last part of her statement is the real target here because it compares cleansing and detoxing themselves to anorexia. In other words, it equates them.

Orthorexia Nervosa

Many people think that cleanse diets are healthy and will not only cleanse them but improve their overall physical and spiritual wellbeing. The desire to cleanse the body of toxins may be part of an obsession with healthy food which has been named orthorexia nervosa. Instead of a focus on an ideal body appearance, there is a focus on a healthy lifestyle, food quality, etc. to the point that their diet becomes so limited they risk malnutrition. Many different dietary practices are used, such as macrobiotic diets, raw food, vegan, and fruitarian. However, many have begun to assume that with orthorexia comes extreme physical danger. This is not necessarily the case. It is the obsessive-compulsive manifestation that is the real problem. The danger is psychological and emotional.

The question is, then, whether fasting is all that physically dangerous. Well, one thing to realize is that fasting does not always mean going completely without. For example, during Ramadan, the fasting only lasts through a specific period of the day, and it goes from 11 to 18 hours, depending on the season. Periodic fasting, in general, can mean a continuous absolute fast for days, or just to skipping meals regularly (which means I fast all the time).

Periodic fasting, intermittent fasting, or whatever you’d like to call it is to today one of the most popular weight-loss strategies. And while many have expressed opinions about its efficacy and its danger, it seems worth noting that fasting, in general, has never caused such outrage as cleanse and detox diets do now. Why? At its heart, it’s just a type of fast. Yet, intermittent fasting even at its height was never as popular and widespread as cleansing and detox diets. Is the outrage as much due to the popularity as the content? Is it due to people’s negative opinions of its chief endorser(s)? Is it due to the shoddy pseudo-scientific underpinnings, based on a complete misunderstanding of how the body works? I think it is all of these things.

How does it affect health? How does any fasting affect health? Although fasting has actually been used clinically for various reasons, and with favorable results, such as fasting prior to chemotherapy to reduce side effects, there is not a lot of literature on its health effects. By far, the most literature exists on Ramadan fasting, because it is the most standardized type of fasting in the world. But it’s not standardized enough! Just like all fasting, it is not just one practice. The practices and variables are quite wide and because of this, it is hard to generalize its effects.

No one can really tell you that a periodic cleanse diet is dangerous to your health. Likely, no matter how silly it is, and no matter people’s opinions of its practitioners, an occasional cleanse is most likely not going to harm you. As a weight-loss strategy, it is doomed to failure, but to say that it’s a poor way to lose weight is nowhere near the same as saying it’s a one-way ticket to an eating disorder and various ill health effects.

Before we start shouting about dietary practices causing eating disorders or being eating disorders, we need to consider the impact on a person’s life. A person could go on periodic cleanse diets and it could develop into something more. But such a person may well have developed an eating disorder regardless. Be careful with the difference between a manifestation and a cause. Obsessive use of cleanses or detox diets may be a manifestation of an underlying problem, but not the cause of it. On the other hand, a person could go on periodic cleanse diets, and…that’s all. No big negative effect on their life. I’d like to point out something to the more vocal folks on Facebook: Just because you find a person’s attitude, moralizing, and advancing of ridiculous dietary fads to be annoying on FB doesn’t mean that person’s life is in a shambles and they are a couple of days away from a check-in at the eating disorder clinic.

I mentioned that two fallacies are associated with this thinking: Slippery slope and false analogy. Slippery Slope may well be the fallacy you come across most often. It is used by everyone from lay-folks to health professionals and more, with few understanding it or even recognizing it. The basic fallacy is as follows:

A person argues that a certain act or event will inevitably lead to a bad final result. What most people do not understand is by invoking this slippery slope they are actually stating that a chain of events will occur. One event will lead to the next, which will lead to the next, etc., and so on until the imagined disaster occurs at the end of the chain. You may have noticed the humorous television commercials by DirectTV, which use a slippery slope to describe the quite unlikely seeming results of using cable TV, like ‘ending up in a roadside ditch.’ Most slippery slope arguments, in contrast, seem superficially plausible and while some may actually list a chain of events, most simply describe the final result. What you must recognize, though, is that regardless if they are explicitly stated, the chain of events exists!

In order for this argument to succeed, a person must know the precise causal events that will lead to the described, and dramatic, outcome. Not only is it impossible to name a series of linked causal events that will take place solely as a result of a single action or event, but then each and every one of these events must occur, one after another, in a precise sequence. Any break in the chain and the result cannot occur. Once you understand just how unlikely this all is, you will start to see that these statements are not even superficially plausible.

The statement that diets, yo-yo dieting, or cleanse diets will end up in an eating disorder is just such a slippery slope argument. Many people reacting to the above quote seem to be invoking this same argument. They say, well, cleansing diets may not be the same thing as anorexia, but that’s where they’ll end up!

The original statement itself, however, is a false analogy. The problem with analogies in general is that people often see them as more powerful than they are. They seem to almost scream at us. Here’s proof! This thing is just like this other thing! But an analogy is nothing more than a helpful explanatory tool. It is a way of illustrating a concept or thought process. It cannot prove anything. When we use comparisons to explain things, we are saying that two things are analogous. In order for our analogy to be valid, the items we compare must be alike in enough respects, and in proper context. If you’ve read through the articles I linked above, you already know why the statement in question is just such an invalid analogy: Cleanse dieting and anorexia nervosa are not sufficiently similar, and the comparison itself is misleading.

Unfortunately, given the culture of the internet, human tendencies in general, and the way all these subjects are trending, it is difficult to make people see that these expressions of anger about cleanse diets are not an expression of critical thought, but more of moral outrage. It is hard to make people see the errors in their thought process when they imagine themselves experts! Yet, as I said before, most of those expressing this outrage and this concern about potential eating disorders have probably never before given such problems a second thought, have no experience with such matters, and certainly would not be able to ‘diagnose’ such a disorder. Trust me, just as Gwyneth Paltrow got the whole cleanse craze started, someone else, or a group of people, got the current anorexia trend started as well! It may have well been the very quote in question here. How is one really different from another when they are based on the same lack of understanding, rush to understanding, or plain ignorance?

It may seem as if I am severely criticizing Jessica Goldstein and her statement. In fact, I am not. I am criticizing the spread of her quote, the subsequent misunderstanding, and the thought process this represents. When scientists say they have a theory, it means something completely different! When laypeople say “I have a theory,” what they usually mean is “I am blue-skying it here to make a point.” Although I do understand the point she was trying to make, I do not think her theory holds water, nor do I think it should have spread like wildfire over social media. Cleanse diets are not just fancy anorexia. People do not choose to have eating disorders, and they certainly do not turn them on and off and have an eating disorder for a ‘finite period of time’ based on choice.

Anorexia Nervosa: Explanation, Signs, and Symptoms

The term anorexia nervosa comes from the Greek word for “lack of appetite” and a Latin word implying a nervous origin. It is a major emotional eating disorder and is characterized by three main criteria:

• Significant self-induced starvation, or near-starvation
• An extreme desire for thinness or being extremely afraid of becoming fat
• The presence of medical signs and symptoms resulting from starvation

The short-hand anorexia is often used for this condition but this term only denotes loss of appetite as a symptom and can occur as a result of many medical conditions. It is important, then, to recognize that anorexia nervosa describes an emotional disturbance resulting in anorexia, and not just any extreme lack of appetite. The term anorexia may also be misleading in the early stages of the disorder since lack of appetite rarely occurs early on.

Those with anorexia nervosa sometimes eat only minimal amounts of food, causing bodyweight to drop dangerously. They may perceive themselves to be fat, or be extremely afraid of becoming fat, even though they may look perfectly normal to everyone else or even be very thin or emaciated. This perception and fear is accompanied by depression. Signs of anorexia include obsessive exercise and calorie or fat-gram counting. Like bulimia nervosa, self-induced vomiting may occur. In fact, only half of those with the disorder will lose weight by drastically reducing calories alone. The other half will use extreme dieting along with binge eating and purging behaviors. Some will purge even after eating only small amounts of food. It is also possible for bulimia nervosa to occur as a separate, but concurrent, disorder. Signs of depression, anxiety, and irritability usually occur.

Many sufferers may use alcohol and other drugs to help cope with the psychological distress, anxiety, guilt, depression, and shame. Also, appetite suppressant drugs such as diet pills, methamphetamines, cocaine, nicotine may be used. Diuretics may be abused to control “water weight” and laxative abuse is common as well.

Usually beginning in adolescence, anorexia nervosa is much more prevalent in females than males, by 10 to 20 times. It has been reported to occur in up to 4 percent of adolescent and young adult students and has been reported more frequently in recent years, with prepubertal onset becoming more common, although the most common age of onset is midteens (14 to 18 years) with about 5 percent occurring in the early ’20s. It is estimated to occur in 0.5 to 1% of adolescent girls.

Other Signs and Symptoms

• Rapid weight loss occurring over several weeks or months
• Continual dieting even though the person is very thin or when weight is very low
• Intense fear of or preoccupation with gaining weight
• Often eating in secret or having other strange eating habits or rituals
• A seeming obsession with food, calories, or nutrition
• Very interested in cooking and the desire to cook large gourmet meals for other which they rarely consume themselves
• May often express that they “feel fat”, regardless of actual weight
• Unable to objectively assess their own weight
• Overly self-critical, self-loathing, or perfectionist attitude
• self-esteem tied into body shape or weight
• Frequent illness due to malnourishment
• Loose baggy clothing to hide the weight loss
• Social withdrawal
• In females, infrequent or irregular menstrual periods (it is important to note that endurance training in female athletes can also cause this “amenorrhea ” and therefore this symptom alone should not be taken as a sign of anorexia nervosa)
• Sleep disturbances including insomnia, early morning waking, or oversleeping

Physical signs other than low body weight

• Raynaud’s syndrome: tips of fingers and toes cold and red, or white and blue in color, due to poor circulation
• Irregular heartbeat
• Low blood pressure
• Low body temperature
• Lanugo hair: a fine layer of hair covering the body, grown to help create body heat in the absence of body fat and muscle
• Dry skin
• Brittle nails
• Thinning hair on scalp
• Calluses forming on hands
• Constipation or diarrhea
• Yellowing skin

Associated Disorders

• Bulimia nervosa
• Body dysmorphic syndrome
• Depression
• Social phobia
• Obsessive-compulsive disorder

Mortality

Anorexia nervosa has the highest death rate of any eating disorder. Among those followed for a sufficient length of time, up to 20% die as a result of the disorder, with around 5-10% dying within 10 years of onset. Up to 30% of these deaths are suicides, and anorexics are 50 times more likely to commit suicide than the general population.

Treatment

Many people with anorexia nervosa will actively refuse treatment. As an ethical dilemma is inherent in treating a disorder that is an irrational drive to lose weight or remain thin when that person does not wish to be treated, initial assessment and treatment are often delayed for months or years. when treatment is undertaken, it is often due to the demands of loved ones and the patients often drop out of treatment. When treatment is accepted, any components that involve increasing food intake, gaining weight or reducing physical activity may be resisted, even though psychotherapy and family therapy may be accepted. It is also not uncommon for treatment to be accepted, even in an inpatient setting, but the treatment protocols to be subverted in secret. Patients might throw out food, secretly use laxatives, or refuse certain treatments. When treatment is forced, an anorexic might use legal means to protect themselves from being treated.

Although the full legal and ethical considerations of treatment are beyond the scope of this explanation. One of the main ethical issues in the refusal of treatment is the issue of competence and the concept of autonomy. Even though family and friends find it difficult to watch their loved one engaged in behavior seen as foolish, destructive, and even deadly, it is generally agreed that patients who possess the competence to make treatment choices should be allowed to do so. So the question is whether someone suffering from anorexia nervosa has the capacity to understand and make rational treatment decisions. Determination of the right to refuse treatment is associated with four main elements:

• the potential risk of the condition
• the likely benefit of treatment
• likely harm of treatment
• competence of the individual to make a reasonable medical decision

Although many anorexics might accept treatment during an emergency crisis precipitated by their condition, there is a difference between recognizing an emergency and identifying an impending emergency. Therefore, the potential risk component of competence is not as clear-cut and “obvious” as one might think. In fact, some deaths from anorexia nervosa occur after very little clinical warning, such as a sudden cardiac event. The following signs and symptoms could be used to determine the need for immediate medical attention:

• Rapid weight loss of greater than 15lbs in four weeks
• Seizures
• Fainting episodes
• Organic brain syndrome
• Slow heart rate of less than 40 beats per minute (bradycardia)
• Frequent chest pain from exercise
• Heart dysrhythmia
• Kidney dysfunction or low urine output of less than 400cc per day
• Excess loss of body fluid and a rise in blood sodium levels (i.e. volume depletion)
• muscle spasms caused by low blood calcium (tetany)
• rapid diminishing of exercise tolerance

Prognosis

Many anorexia nervosa patients recover, and sometimes recovery occurs spontaneously. Those who receive treatment in specialized anorexia nervosa programs seem more likely to recover than those treated in generalized programs. The results of treatment, however, cannot be reliable predicted at this time. It is clear that the results of short-term intervention such as refeeding and psychiatric treatment does improve quality of life for the short-term, but the long-term prognosis is generally considered to be guarded. The earlier treatment is undertaken, the better the chances for recovery.

Athletes and Anorexia Nervosa

Female athletes, especially, can suffer from anorexia nervosa, especially in those sport that emphasize and require low-body weight, thinness, or a certain body image, such as ballet, gymnastics, figure skating, long-distance running, and other endurance sports. However, disordered eating often occurs in serious athletes which is not necessarily anorexia nervosa or another eating disorder, but a unique but associated manifestation of athletics. This has been given its own term: anorexia athletica.

Comparing the Effects of Anorexia Nervosa and Bulimia Nervosa

While many people understand the basic differences in behavior among those suffering from anorexia nervosa and bulimia nervosa, they might assume that the physiological effects are the same. After all, whether you starve yourself or gorge and then purge, the result is malnutrition, right? Well, in fact, the physiological effects differ among the two in some marked ways. Of course, it is possible for both disorders to manifest in one person, which would complicate the picture. However, the following are the basic differences in effect between the these two major eating disorders.

Basic Characteristics

Anorexia nervosa is characterized by a compulsive pursuit of thinness and a fear of becoming fat. Self-worth becomes centered on body size and shape and there is a preoccupation with food and control of food intake. According to the DSM-IV, the main symptom of anorexia nervosa is a bodyweight that is 85% that of the expected body weight. Sufferers have a distinct fear of weight gain despite being quite underweight, and they tend to have a body dysmorphic disorder, a distorted body image, seeing themselves as overweight when they are actually quite thin and underweight. Perceptions of hunger and satiety become distorted and misidentified.

Although avoidance of eating, especially of high-calorie foods, is one of the main behaviors of anorexia nervosa, self-induced vomiting, laxative, and diuretic abuse, and excessive exercise also can occur. Anorexia nervosa is classified, in fact, into two types, one that restricts food with no active measures to reduce weight, and another that includes purging and active measures to reduce weight.

Bulimia nervosa is characterized by a lack of a sense of control regarding eating and a fear of being overweight. Sufferers go through bouts of binge eating where excessive quantities of food are consumed over a short period of time. Afterward, sufferers try to counteract this behavior by induced vomiting or use of laxatives (less frequent). Binge eating episodes may be preceded by feelings of stress, tension, boredom, loneliness, depression, or fear. There is a sense of being out of control, and although the binging may relieve these negative feelings for a short time, shame, guilt, and self-hatred often follow.

Although bulimia nervosa patients are preoccupied with weight, body shape, and food, they are usually normal weight or even overweight. Not everyone with a binge-eating disorder is diagnosed as having bulimia nervosa, as not everyone that has episodes of binge eating shows consistent compensating behaviors. Patients with bulimia nervosa, as well as binge eating disorders, often also have depression, obsessive-compulsive disorders, anxiety disorders, substance abuse, and personality disorders.

It is quite possible that one individual could be diagnosed with more than one eating disorder over a lifetime, and there can be a continuum of disordered eating over time. However, while many persons with bulimia nervosa have a previous history of anorexia nervosa, bulimia nervosa in persons with normal weight rarely develops into anorexia nervosa.

Prevalence

Anorexia nervosa (AN) and bulimia nervosa (BN) usually develop during adolescence or young adulthood. Anorexia nervosa is much more common in females, at a ratio of 10:1. The prevalence of AN for young adult women between 14 and 20 years of age is between 0.2 and 0.8%, and diagnoses usually occur before age 25. Although it is difficult to be sure, the rate of AN may be increasing.

Bulimia nervosa is more common in men than is AN. The prevalence is 1 to 2% for young women and about 0.2% for young men. It is more common in competitive athletes, ballet dancers, and people in fashion such as fashion models. An increase in the rate of BN has been suggested, but there is not enough evidence to confirm this. BN is more common in Western industrialized nations.

Basic Behaviors

AN: Semi-starvation, perhaps with compulsive exercise. AN is usually preceded by what would appear to be “normal” dieting behavior.

BN: Gorging or binging by consuming up to 12,000 calories in a short amount of time, followed by purging by self-induced vomiting, laxative abuse, emetics, diuretics, or excessive exercise. A person with BN may seem like their life is centered on fasting or dieting behaviors. Binging, however, may well be planned in advance and can occur several times per day.

Weight

AN: 85% or less of expected weight. This corresponds to a BMI of around 17.5 for adults.

BN: Weight may be normal or slightly higher than normal. Fluctuations in weight occur.

Emotional Characteristics

AN: Those with AN may enjoy food vicariously. They will tend to deny that they’re behavior is abnormal or that they have any problems with food or body image, and go to extreme lengths in this denial. Body image can be severely distorted, and severe mood changes occur with characteristically low self-esteem.

BN: Mood swings as in AN occur, but BN sufferers tend to recognize their behaviors as abnormal more often, and the behaviors themselves lead to further feelings of isolation and self-hating thoughts and behaviors.

Physical Symptoms

AN: A fine, soft downy hair on the face and trunk called lanugo hair, which is similar to the hair one a newborn baby. Brittle hair and nails, dry skin, and cold intolerance.

BN: There may be no outward visible signs. There may be swollen salivary glands in cheeks, and sore knuckles or hands with scars or calluses.

Cardiovascular Effects

AN: Bradycardia (slow heart rate under 60 BPM), hypotension (low blood pressure), orthostatic hypotension (also called postural hypotension, a low blood pressure that occurs when suddenly standing up – resulting in a “head rush” or dizzy spell).

BN: Heart Arrhythmia, palpitations, and heart weakness.

Gastrointestinal Effects

AN: Delayed gastric emptying, decreased motility (decreased movement of the digestive system), and severe constipation.

BN: Bloating, constipation, and flatulence. There is a risk of gastric dilation with rupture due to extreme over-consumption.

Endocrine and Metabolic Effects

AN: Sensitivity to cold, fatigue, hypercholesterolemia, hypoglycemia, amenorrhea or menstrual irregularities.

BN: Menstrual irregularities. Dehydration and/or electrolyte imbalances due to vomiting and laxative abuse. Rebound retention of fluid and edema may occur.

Musculoskeletal Effects

AN: Osteopenia (below normal bone mineral density but not low enough for osteoporosis), muscle wasting and muscle weakness.

BN: Dental erosion and muscular weakness.

Nutritional Deficiencies

AN: Protein-calorie malnutrition and various micronutrient deficiencies

BN: Variable.