KidsMD Health Topics

Anorexia Nervosa

  • Overview

    "It's important to note that eating disorders are illnesses of denial and secrecy; they're often very difficult to track down."

    Sara Forman, MD, Director of Children?s Hospital Boston's Outpatient Eating Disorders Program

    From TV shows like “The Biggest Loser” to celebrity diets and infomercials touting “two-minute abs,” America is obsessed with how we look.

    So it’s sad but not surprising that a negative body image is not uncommon among today’s youth and teens, especially among girls. Sometimes, though, feelings of negative body image and associated unhealthy behaviors spiral out of control. Anorexia nervosa (AN, or simply “anorexia”) is a form of self-starvation, a complicated eating disorder with medical, behavioral and psychological components:

    • It’s characterized by low body weight (less than 85 percent of the normal weight for the child’s height and age), a distorted body image and an intense fear of gaining weight.
    • Many teens and their families struggle with anorexia nervosa. Eating disorders are the third most common chronic disease in the United States.
    • An estimated 0.5 percent of 15- to 19-year-olds have anorexia nervosa.

    Anorexia, and the malnutrition that results, can damage nearly every organ system in the body, and may be fatal. Early diagnosis and treatment are extremely important.

    How Children’s Hospital Boston approaches anorexia nervosa

    The Eating Disorders Program at Children’s Hospital Boston provides comprehensive evaluation and treatment services every year to more than 200 adolescents with anorexia nervosa, bulimia nervosa and related eating disorders. Staffed by expert specialists, the program addresses your child’s medical, nutritional and psychological needs in order to effectively treat her disorder.

    Our healthcare team also gives guidance to many providers in the northeastern United States and beyond.

    Providers from the outpatient Eating Disorders Program and other members of Children’s Division of Adolescent Medicine have helped develop inpatient clinical guidelines for children who are admitted to the hospital for eating disorder-related medical needs.
    Our providers also consulted on the National Eating Disorders Screening Project. They have advocated for insurance coverage for eating disorders at the Massachusetts State House, and give frequent presentations on eating disorders throughout New England.

    Get real, Barbie!

    In recognition of the National Eating Disorders Awareness Week, Children's Center for Young Women's Health created a replica of what the Barbie doll's proportions would be if translated to an actual woman.

    Barbie stands 5 feet 9 inches with a 39-inch bust, 18-inch waist and size 3 shoe — an imbalance that would probably require her to walk on all fours!
    Boys and their bodies: recognizing eating disorders in males

    When you read the terms “anorexia” and “bulimia,” what comes to mind? If you’re like most people, your brain probably conjures up images of smoky-eyed, waif-thin European models, or maybe the teenage girls who emulate them here in America. But according to a recent report from Pediatrics, eating disorders affect a far more diverse group of people than many realize.

    Anorexia nervosa: Reviewed by Sara Forman, MD
    © Children’s Hospital Boston; posted in 2011

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  • In-Depth

    Our culture's obsession with achieving lower weight conveys an unavoidable message to maturing adolescents. According to the 2009 Youth Risk Behavior Survey, 33 percent of adolescent girls believed that they were overweight and 56 percent were attempting to lose weight.

    Adolescents with unrealistic expectations about weight may end up suffering from anorexia nervosa. Read on to learn more about the causes and signs of anorexia nervosa, as well as how Children’s Hospital Boston can help young adults struggling with an eating disorder.


    What causes anorexia nervosa?

    It’s hard to pinpoint the cause of anorexia nervosa. The condition usually begins with dieting, but gradually progresses to extreme and unhealthy weight loss. There are several factors thought to be associated with anorexia:

    • Social attitudes toward body appearance — often unrealistic — are believed to play a large role.
    • Adolescents who develop anorexia are more likely to come from families with a history of weight problems, physical illness and mental health problems, such as depression or substance abuse. Genetics may also play a role.
    • Often teens with anorexia come from families with high levels of stress, poor patterns of communication, unrealistically high expectations and underdeveloped problem-solving skills.
    • Sports or activities in which leanness is emphasized (e.g., ballet, running or wrestling) and sports in which scoring is partly subjective (e.g., skating or gymnastics) are associated with a higher incidence of eating disorders.
    • Teens with anorexia often have other mental health problems, such as anxiety disorders, obsessive-compulsive disorder (OCD), affective (or mood) disorders and problems with substance abuse. They may also be dependent, immature in their emotional development and likely to isolate themselves from others.

    What are the different types of anorexia nervosa?

    There are two subgroups of anorexic behavior. Both have the goal of reducing calories:

    • restricting type— An adolescent severely limits the intake of food, especially food that contains fat.
    • binge/purge type— An adolescent restricts intake, and may then have a binge followed by a purging of calories.

    Signs and symptoms

    While each child may experience symptoms differently, some of the most common signs of anorexia include the following:

    • low body weight (under  85 percent of the normal weight for the child’s height and age)
    • intense fear of weight gain, even as he or she is losing weight
    • distorted view of body weight, size, or shape; sees himself or herself as too fat or normal sized, even when very underweight.
    • refusal to maintain normal body weight
    • in females, absence of three consecutive menstrual cycles without another cause
    • excessive physical activity
    • denies feelings of hunger
    • preoccupation with food preparation
    • bizarre eating behaviors (e.g., using a fork to eat raisins or cutting food into very small pieces)

    Other symptoms may include:

    • dry skin
    • dehydration
    • abdominal pain or bloating
    • constipation
    • fatigue
    • hypothermia(problems maintaining normal body temperature) and feeling cold when others are hot
    • emaciation
    • development of lanugo (fine, downy body hair)
    • yellowing of the skin
    • stress fractures

    If your child is struggling with anorexia, she may also be socially withdrawn, irritable, moody or depressed.

    What are the warning signs to look out for?

    Eating disorders are illnesses of denial and secrecy; they're often very difficult to track down. So family members and friends shouldn't feel badly about not figuring out right away if their loved one has a problem.

    That being said, there are some signs you can look for:

    • unexplained weight loss
    • dizziness
    • fainting
    • fatigue
    • irritability or moodiness
    • going to the bathroom often, especially after meals
    • cutting food into tiny pieces and pushing it around the plate

    Also be on the lookout for major change in eating or exercise behavior.

    What are the potential complications of anorexia nervosa?

    Anorexia is a serious disease. It can affect many systems of your child’s body, including:

    • cardiovascular (heart) — Complications may include mitral valve prolapse (a floppy valve in the heart), arrhythmias (a fast, slow or irregular heartbeat), bradycardia (slow heartbeat), hypotension (low blood pressure) and heart failure.
    • hematological (blood)— About one-third of anorexic adolescents have mild anemia (low red blood cell count). Leukopenia (low white blood cell count) occurs in up to 50 percent of anorexic adolescents.
    • gastrointestinal (stomach and intestines) —Normal movement in the intestinal tract often slows down with very restricted eating and severe weight loss. Gaining weight, and taking certain medications, can help to restore your child’s normal intestinal function.
    • renal (kidney) — Anorexia may cause dehydration, which can result in highly concentrated urine. Polyuria (increased production of urine) may also develop in anorexic patients when the kidneys start to lose their ability to concentrate urine. These changes usually return to normal when your child gets back to a normal weight.
    • endocrine (hormones)— One of the most telling symptoms of anorexia is amenorrhea, or when the menstrual cycle is missed for three or more consecutive cycles without any other underlying cause. Amenorrhea may appear before your child loses any amount of weight, and continue after her normal weight is restored. Adolescents with anorexia may also have lower levels of growth hormone, which may explain their failure to grow normally. Luckily, normal nutrition usually restores normal growth.

    skeletal (bones) — If your child has anorexia, she is at an increased risk for low bone density. If the anorexic behavior has started before the bones have been fully formed (usually mid to late teens), she may have a greater risk of osteopenia (decreased bone tissue) or osteoporosis (bone loss) or fractures.


    Researchers are actively exploring the question of whether anorexia can be prevented.

    Awareness increases the chance of early detection and intervention — which in turn can reduce the severity of symptoms, enhance your child's normal growth and development and improve her quality of life.

    Encouraging healthy eating habits and realistic attitudes toward weight and diet may also be helpful.

    To some extent, parents can help prevent eating disorders in their children:
    Here at Children’s Hospital Boston, our doctors encourage parents to avoid using food as a behavioral reward and to provide variety in appropriate portion sizes.

    Parents should carefully monitor growth and development, helping their children avoid obesity through sensible eating and physical activity.

    Parents should stress health and fitness—not “thinness.”

    Long-term outlook

    Treatment for anorexia nervosa is a slow process that may last years.

    The vast majority of adolescents suffering from anorexia will enter a recovery phase, but there may be a lifelong struggle with food and consequent weight loss or gain.

    The mortality rate for adolescents with anorexia is between three to five percent, and is usually caused by a cardiovascular problem such as heart failure. Suicide is also a significant risk in older adolescents.

    Questions to ask your doctor

    You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider, and that you understand your provider’s recommendations.

    If you’ve made an appointment to talk to a doctor about your child’s eating and/or exercise habits, you probably already have some ideas and questions on your mind. But at the appointment, it can be easy to forget the questions you wanted to ask. It’s often helpful to jot them down ahead of time so that you can leave the appointment feeling that you have the information you need.

    You may want to suggest that your child write down what she wants to ask her health care provider, too.

    Some of the questions you may want to ask include:

    • How much experience do you have treating anorexia?
    • What are the treatment options?
    • How will we know whether the treatment is working?
    • Will my child need to be hospitalized?
    • What’s therapy and how does it work?
    • How will the treatment for anorexia affect my child’s day-to-day life?
    • What is the long-term outlook for my child?
    • What can I do to help support my child’s health and help her cope with her condition?

    When to seek medical advice

    If you notice changing eating or exercising habits in your child, it might mean that she has an eating disorder such as anorexia. You should make an appointment with your child’s pediatrician right away.

    If your child has already been diagnosed with anorexia, you should call her doctor if you see any further change in your child’s behavior relating to food or exercise.

    Useful medical terms

    Anorexia Nervosa (Anorexia) is an eating disorder characterized by self-starvation with or without over-exercise or purging. Anorexia is a complex disease involving psychological, sociological and physiological elements.

    Anxiety disorder is a generalized term used to describe mental health disorders relating to excess worrying, phobias and nervousness. A person suffering from an anxiety disorder may have panic attacks and may be unable to pursue normal daily routines.

    Behavioral problem or disorder is a generalized term used when a child or teenager behaves—over a long period of time—in ways that are not socially acceptable for her age and situation or in ways that are destructive or self-destructive.

    Bipolar disorder is a mood disorder characterized by severe mood swings. A person with this disorder may go from being manic, extremely elated and energetic to being depressed, sad, and sluggish. People with this disorder are sometimes known as “manic depressives.”

    Bulimia Nervosa (commonly known as Bulimia)is an eating disorder characterized by extreme overeating or “binge” eating followed by self-induced vomiting, excessive exercising, inappropriate use of laxatives or enemas or fasting.

    Clinician is an individual who is trained to practice medicine or psychological counseling and who works directly with people instead of in a laboratory.

    Depression (clinical) is a mental health disorder characterized by a sad mood that is both prolonged and severe. Clinical depression can be treated with medication, therapy, and hospitalization if necessary.

    Diagnostic evaluation refers to a clinician assessing the symptoms presented by your child in order to come to an informed opinion about what condition is causing those symptoms.

    Dietician/Nutritionist refers to professionals with specialized training in nutrition. They, along with nurses and doctors, help families design healthy eating plans and provide long-term follow-up.

    Mood disorder is a generalized term referring to mental health disorders where a person’s general mood is distorted or inappropriate given the circumstances. Clinical depressionand bipolar disorder are both mood disorders.

    Nurse Practitioner refers to a person with an Advanced Practice Nurse (APN) degree who manages patient care and provides primary care services as well as specialty services. Unlike most nurses, nurse practitioners can diagnose patients and prescribe medications.

    Psychiatrist refers to a medical doctor who has specialized training in behavioral and mental health disorders. Psychiatrists can prescribe medication to their patients.

    Psychologist refers to a mental health professional who is not a medical doctor and who does not prescribe medication. Clinical psychologists have extensive training in therapy and psychological testing.

    Social Worker refers to a professional who patients and their families deal with the broad range of psychosocial issues and stresses related to coping with illness and maintaining health.

    Center for Young Women's Health

    Explore the Center's website for in-depth information on issues affecting teen girls today, including healthy eating, nutrition and eating disorders.


    Talking about eating disorders

    Read our Q & A with Sara Forman, MD, Director of Children's Outpatient Eating Disorders Program.

  • Tests

    How is anorexia nervosa diagnosed?

    It can be hard to diagnose anorexia nervosa, since many adolescents with the disorder try to keep their illness very private and hidden. Parents, teachers, coaches or instructors may be able to identify a child or adolescent with anorexia, but the diagnosis is usually made by a qualified mental health professional or medical provider.

    Since early treatment can often prevent future problems, if you note symptoms of anorexia in your child, it’s a good idea to seek evaluation and treatment sooner rather than later.

    If an eating disorder is suspected, some components of the evaluation may include:

    • a careful patient and family history
    • physical examination
    • laboratory tests, including a complete blood count and a urinalysis
    • mental health and nutritional assessments

    To help diagnose anorexia, your child’s doctor will:

    • assess weight changes
    • inquire about self-perceptions of weight and desired weight
    • ask your child about binging and out of control eating and purging
    • ask your child about use of laxatives and diet pills
    • ask your child about:
      •  abdominal pain
      •  bloating
      • constipation
      • hair loss or change in hair texture
      • cold intolerance
      • fatigue
      • weakness
      • fainting
      • substance use
      • sexuality
      • depression
      • amount of physical exercise
      •  stress fractures

    Your child’s doctor will likely also conduct the following studies:

    • a social history — a review of risk factors focusing on the home, education and activities
    • a family history — information about conditions and disorders within the family, including eating disorders, obesity, alcoholism, depression or other mental illness
    • a physical exam —a clinician will assess and examine your child’s blood pressure, pulse, temperature, weight and height, skin and hair changes, heart function and abdomen.

    After we complete all necessary tests, Children’s experts will meet to review and discuss what they have learned. Then we will meet with you and your family to discuss the results and outline the best treatment options for your child.

    Get more information about eating disorders

    Boston Children’s Eating Disorders Program has put together a list of  links with additional information about eating disorders, including their causes, prevention and treatment.

  • Anorexia is usually treated with a combination of:

    • individual therapy (usually including both cognitive and behavioral techniques)
    • family therapy
    • nutritional rehabilitation
    • behavior modification

    Medication (usually antidepressants) may be helpful if your child is also feeling depressed. It's important to remember that family members play a vital supportive role in any treatment process.

    The Eating Disorders Program at Boston Children's Hospital

    Children's Eating Disorders Program is committed to helping you, your child and your family at every step of the treatment process. The program uses a multidisciplinary approach for evaluation and treatment to help formulate an individualized treatment plan and make preliminary recommendations that will work best for your child's individual needs and circumstances.

    Providers in our Eating Disorders Program see both inpatients and outpatients —about 200 new cases annually. As outpatients, adolescents are seen by a physician from Children's Division of Adolescent Medicine, as well as a dietician. Your child will also see a psychologist or social worker with whom you can meet separately. Your doctor will recommend follow-up visits if necessary.

    If your child becomes really sick—her condition gets worse, causing unstable vital signs, for example—he or she will be admitted to the hospital. Inpatients are placed on the hospital's "Restrictive Eating" clinical practice guideline. This means they meet with the same types of caregivers as an outpatient would, while participating in a special meal plan with customized weight gain goals.

    What to expect at your appointment

    While no patient's experience is exactly like another's, below is a general idea of what you will experience when your child has an appointment in the Children's Eating Disorders Program.

    What to bring

    Please bring contact information for any providers your child is seeing (therapist, nutritionist, pediatricians).

    Your first appointment

    Your initial consultation will include:

    • A medical evaluation by a doctor skilled in adolescent medicine and eating disorder treatment. The doctor will assess your child's health by checking her height, weight, blood pressure, pulse and temperature, and will determine the severity of any existing medical complications she may have. Our doctor will contact your child's primary care provider to help coordinate care.
    • A mental health consultation with a counselor experienced in treating adolescent eating disorders. Fighting back against these disorders requires improving your child's body image and self-esteem and addressing other emotional issues.
      • During treatment, some adolescents discover they have other problems such as depression, obsessive-compulsive disorder or substance abuse. The therapist can assist in diagnosing these difficulties. Therapy can also be an important part of getting well if family tensions, relationships with friends or poor communication skills are disrupting your child's life.
    • A nutrition evaluation with a dietician. This can help you and your child create a safe eating plan and answer questions about food. Teens receive many mixed messages in a culture obsessed with fast food, dieting and body image. The dietician can discuss some of these harmful myths, and help your child design an individualized guide to achieving healthy eating and healthy living.

    Your additional appointments

    After the initial evaluation, the Eating Disorders Program will help you set up appropriate treatment. The program works with primary care providers to ensure a comprehensive treatment program. Referrals to local health care providers, as well as to providers At Boston Children's Hospital, are available.

    Treatment may involve:

    • Ongoing individual and family therapy
    • Medical monitoring
    • Nutritional support

    Coping and support

    It's essential to remember that, while learning that your child is struggling with anorexia nervosa can feel very isolating, many children and their families have been down this path before. We've helped them, and we can help you, too.

    There are lots of resources available for your family—within Children's, in the outside community and online. These include:

    Patient education:From the very first visit, our staff will be on hand to walk you through your child's treatment and help answer any questions you may have. And they'll also reach out to you by phone, continuing the care and support you received while at Children's.

    Parent to parent: Want to talk with someone else whose child has been treated for anorexia? We can put you in touch with other families who have been through similar experiences and can share their stories.

    Faith-based support:If you are in need of spiritual support, we'll help connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions who will listen to you, pray with you and help you observe your own faith practices during the time you and your child are in the hospital.

    Social work and mental health professionals: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial difficulties.

    On our For Patients and Families site, you can read all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    Children's Behavioral Medicine Clinic helps children who are being treated on an outpatient basis at the hospital—as well as their families—understand and cope with their feelings about:

    • being sick
    • handling pain
    • taking medication
    • changes in friendships and family relationships
    • managing school while dealing with an illness
    • grief and loss

    Children's Psychiatry Consultation Service is comprised of expert and compassionate pediatric psychologists, psychiatrists, social workers and other mental health professionals who understand the unique circumstances of hospitalized children and their families. The team provides several services, including:

    • short-term therapy for children admitted to one of our inpatient units
    • parent and sibling consultations
    • teaching healthy coping skills for the whole family
    • educating members of the medical treatment team about the relationship between physical illness and psychological distress

    Children's Department of Psychiatry offers a free booklet, “Helping Your Child with Medical Experiences: A Practical Parent Guide”. (Please note that Adobe Acrobat is required to view and download the guide.) Topics in the booklet include:

    • talking to your child about her condition
    • preparing for surgery and hospitalization
    • supporting siblings
    • taking care of yourself during your child's illness
    • adjusting to life after treatment
    Multidisciplinary care

    One frequently used treatment for eating disorders involves an interdisciplinary team approach, involving a medical provider, dietician (with experience in treating eating disorders) and a mental health professional.

  • Research & Innovation

    "Part of Children's mission is to take findings generated in its laboratories and translate them to the bedside, and the CTSU [Clinical and Translational Study Unit] provides the space and resources to make that possible."

    Catherine Gordon, MD, MSc, director of the Bone Health Program at Boston Children's Hospital

    In addition to our clinical practice, Children’s researchers are actively involved in finding new ways to understand, treat and prevent anorexia nervosa:


    A study led by Children’s researchers has shown an interesting paradox: People with anorexia have high levels of fat within their bone marrow. If the body isn’t getting enough nutrients, stem cells (the special cells that can change into other types of cells, like fat cells or blood cells) found in the bone marrow develop into fat cells, rather than bone-forming cells. This may help explain one serious consequence of anorexia — early and severe osteoporosis, or bone weakening.


    Another Children’s research initiative aims to find a way to prevent bone loss in teens and in healthy adults. Estrogen helps to maintain bone density in young adults with eating disorders. DHEA is a natural hormone that is also associated with preventing bone loss and strengthening bones. Through a combination of a low-dose estrogen therapy and DHEA, it may be possible to increase bone density.


    We all know that good nutritional habits and adequate exercise are key to staying healthy, but

    less clearly understood is the way social and physical environments play into these goals. Children’s researchers are investigating how school and community settings affect adolescent nutrition, physical activity and risk of eating disorders — and are working to design and evaluate school- and community-based interventions and preventive measures that encourage healthy nutritional habits.

    The Eating Disorders Program at Children's is actively involved in many other research projects aimed at providing a better understanding of adolescent eating disorders and developing new interventions. Our current projects include:

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