If your child responds to your concerns with “No one else notices a problem,” realize that many people are uneasy about approaching someone they suspect has an eating disorder (particularly if she’s in the early stages of the illness), even though they care about her. Some don’t know what to say, some are nervous they’re wrong, some are concerned they’ll be intrusive, and others are worried they’ll cause a problem. When asking for a friend’s opinion about whether she’s too thin, your child will be more likely to approach someone she knows will agree with her than someone who will tell the truth. She is likely to search desperately for any feedback that can be perceived as supportive of her claim that she is healthy. Such attempts can further obscure her ability to believe you when you tell her that she has a disorder and needs help.

In discussing amenorrhea (absent menses), you’ll want to explain that to maintain normal periods the female body needs a healthy intake of food. If a woman does not eat sufficiently, the hormonal signals responsible for stimulating menstruation are interrupted. Thus, her monthly menstrual periods may halt or become increasingly irregular. Amenorrhea can result in bone loss, a problem that affects 90 percent of women with anorexia nervosa and places them at a higher risk of fracture and resulting disability. For more than a decade, we’ve been studying bone loss in anorexia and observed that participating in this research can help motivate some patients to eat more healthfully.

Many people are not aware that some dangerously low-weight women continue to menstruate but experience every other characteristic of anorexia and are severely ill. Thus, someone who retains her menstrual cycles may say and believe she’s healthy when, in fact, that is not the case. To an individual suffering from an eating disorder, even the question of what constitutes low weight can feel like complicated business. One reason she tends to dislike going to a clinician is that it reminds her she’s ill. Perhaps she’ll insist “I don’t have a disorder. I’m naturally this thin.”

In presenting medical consequences as preventable, it is important to avoid statements that your child might perceive as criticism and to focus instead on what she is doing well in taking care of herself, such as getting some rest, setting a limit on an exercise session, or venturing out of isolation to see a friend. It is advisable to approach the topic of heart and bone health from a positive standpoint, underscoring how getting help for her eating disorder will increase her likelihood of enjoying a variety of intellectual, social, and physical activities now and for years to come.

Discussing Body Image
We often use the term body image to refer to how a person thinks and feels about her size and shape. Individuals with eating disorders typically perceive themselves as heavier than they actually are; some see themselves as overweight even when they are strikingly thin. You’ll want to discuss with your child how perplexing it must be for her that friends and family insist she’s too thin when she thinks she’s fine or maybe even a little overweight. Eating disorders are complex, and your mission here is not to correct her misperceptions about her body, but to begin to understand her turmoil and pave the way to revisit the issue in the future. Point out that, with treatment, she can learn to appreciate her body more and to address the mismatch between how she views herself and how others view her.

Encouraging your child to discuss her body image can help her build a bridge to therapy, but it can also put you in closer touch with your feelings about your own body size and shape. When you self-reflect, try to do so in your gentle, nonjudgmental voice, reminding yourself that pressure to be thin is so prominent in our culture that it’s hard not to be affected by it, even if only slightly.