First, do no harm

I'm not convinced that you can "prevent" eating disorders, and this caution puts me at odds with many of my allies in the eating disorder world. I believe eating disorders are an underlying condition in the brain of certain people and that some combination of stress and malnourishment turn it on, like a secret password.

It could be that if this password is not activated during critical periods of development that it loses its power to activate - so if we can get an adolescent with this predisposition through young adulthood without a diet, serious flu, or traumatic experience they may never turn it on. Or, alternately, we may be able to protect these potential patients with extra supports and skills so that the activation lacks the power to rise to a real problem. I don't know, and I don't think anyone does. There's a lot of well-meaning certainty out there, and it is worrying.

I also think it is possible that people with this predisposition are driven toward the triggers, like the girl in the fairy tale whose parents protected her from every sharp object but one, and that was enough. The attraction to certain sports, certain friends, certain media - these could be driven from within rather than imposed from the outside.

We do know that with all the well-meaning prevention efforts out there there still are no validated effective eating disorder prevention methods. We know that educational programs about eating disorders are likely to backfire. We know that educational programs focusing instead of self-esteem and body acceptance have at least short-term effects on whether young people take up dieting and unhealthy eating and exercise - but not whether this delays, or even worsens, future eating disorders. We just don't know.

In the vocabulary of eating disorder prevention there are two categories: primary, and secondary. The first are society or community-wide efforts. The latter are targeted to people identified at high risk. Secondary prevention is what I would call "early intervention." These programs attempt to turn around early disordered thoughts and behaviors. Again, we don't know whether these efforts are effective.

So, where are we? How can those of us worried about the risk of eating disorders in young people do a better job of heading them off?

I am a huge fan of the school of thought in a growing number of people in the field and explained well here by Katja Rowell: First, Do No Harm.


  1. I agree with a lot of what you write in this post Laura.

    First, what is AN? I don't think that anyone truly or precisely understands what happens in AN. (The mechanisms of BN are better understood). My own experience of AN really was like a switch being turned in my head.

    I had struggled with OCD for many yrs so was familiar with intrusive thoughts and the compulsive urge to conduct behaviours which temporarily relieved those thoughts. Although AN was in some ways similar to OCD, it was also different.

    I also had 'special interests' pre-AN (the autistic, obsessive type) which served as a means of reducing anxiety as well as being a 'pleasure' that made life feel more predictable. In some ways the calorie counting and obsessive planning of what I would eat, what exercise I would do, and the making of charts of my behaviours was like a pleasurable autistic 'special interest'. However, it was also borne out of fear: not that I was too fat, but that I was 'not good enough' as a whole person. At the time I started to restrict and over-exercise my life felt very chaotic.

    The time I recognised that something was wrong was quite early on in the illness. I had lost weight inadvertently and didn't want to lose more. But I was terrified of eating more and exercising less. When food was placed in front of me I panicked and cried. This horrible 'voice' (thoughts...) in my head instructed me that I MUST NOT eat. I felt very confused and conflicted, as if my mind was playing tricks on me.

    In terms of prevention of AN: I think the only way it can be prevented is for parents/carers to be absolutely vigilant in knowing and recognising the early warning signs. This enables quicker intervention. There is no evidence that 'love your body' campaigns do any good whatsoever (and may even do harm...) - and I, for one (at least...), didn't restrict food and over-exercise because of body dissatisfaction. My behaviours were more closely linked to mood regulation.

    I (very) strongly feel that there is FAR TOO MUCH emphasis placed upon body image in both the aetiology and treatment of AN. The majority of girls who develop AN are rather obsessive, rule-bound high achievers and perfectionists who are probably drawn into the pursuits that are associated with a risk of developing AN - like athletics, ballet, modelling (etc.) - because these pursuits appeal to the vulnerable individual's temperament and character.

  2. Thanks Laura for the mention and the link. Cathy, your story is very illustrative as well. I have learned so much from Laura and this blog and the other parent forums. Thank you Laura! I hear many stories and experiences similar to Kathy's with AN, but what about BED?
    I would love to hear from folks (experts/those with BED) if body image/feeding/history of dieting might be more of a contributing factor? I talk with lots of adult women (almost exclusively) who are moms I am working with, but also on their own who struggle with bingeing, checked-out eating, and many share their stories of life-long dieting, usually foisted on them in early childhood or around puberty. Many talk of their parents' well-meaning intentions of "health" and size concerns. But still, the restriction and focus on weight was absolutely instrumental in their journey, as they tell it, to what some call "dieting casualties." I hope to help parents at least not cause harm inadvertently through well-meaning, often "expert"-advised attempts to control their child's weight. Many parents are genuinely confused about what to do and say. Many "health" messages are distinctly unhealthy. Might a healthy feeding relationship limit disordered eating, promote eating competence and down the road "prevent" ED, perhaps more BED? What are your thoughts on the studies on Family Meals that suggest less disordered eating? What do your readers think? Is this your experience?

  3. This is wonderful...this is more to the point for me as a someone who has had anorexia since i was 12. I agree with these points completely. Blaming the parents is foolish, but educating the parents so they know how to help their children is priceless. Parents cannot be expected to automatically know how to handle a situation like eating disorders when so little information was previously available. I admire what you are doing Laura and I think you are helping the eating disorder community in many ways. You have changed my perspective in a few ways as well, and always tend to discuss topics sensitive to me. Though you may discuss these difficult topics, I love your compassionate ways of communicating, your honesty, and your unwavering commitment to help others. I know you have helped many parents find healing, and have offered guidance to parents who may not have had a clue how to handle their situations before reading your book and blog. Keep it up you do make a difference.

  4. It may just be the security settings on my computer, but I can't get onto the first link.

  5. Marcella, thank you - I think I fixed it!

    FamilyFeeding, I don't know. I have to confess I think we'd only shave off a percentage of EDs but I don't think that's the point. The point is we should be doing these things for the good of ALL. Even if it didn't prevent EDs we need a better eating culture. We're a mess right now.

    As you know, Cathy, I think the underlying brain disorder is just seizing on the body image trope.

    Jaded, you are so kind. We're all in this together - this sharing. And I'm so glad to be a part of it.


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