When you think "eating disorder" you likely picture an emaciated girl whose ribs stick out and whose cheeks are sunken in. And I'm guessing that when you see an obese teenage boy, the last thing you're thinking is "I wonder if he has an anorexia?" What many people don't realize though, is that eating disorders come in all shapes and sizes.

Recently, there was study out of the Mayo Clinic published in The Journal of The American Academy of Pediatrics that brought to light the reality that eating disorders can affect overweight and obese individuals as well, particularly teenagers. Unfortunately, the symptoms often go unnoticed and untreated—even with obvious signs of malnutrition—and are even sometimes celebrated as side effects of positive lifestyle changes. According to Dr. Leslie A. Sim, the director of the eating disorder program at the Mayo Clinic and co-author of the study, adolescents with a history of obesity are at a significant risk of developing an eating disorder. Sim explains that early intervention is key to making sure that the eating disorder does not progress. I completely agree with this, but what about taking it one step further and focusing on prevention? I believe that preventing the disordered eating behaviors in the first place is the most important lesson to learn from this study. But now with fat-shaming childhood anti-obesity campaigns (especially in the United States), kids and teens are feeling even more pressure to be thin. The truth is, overweight doesn't necessarily equal unhealthy or inactive. There are many overweight kids out there who are just as healthy and active as normal weight kids, perhaps even more. Shouldn't we, instead, be encouraging positive self-esteem and body image, healthy and mindful eating and being active in an enjoyable way? And if a child or teen is obese, inactive and showing risk factors for chronic disease, their parents should be the first ones to take a very careful look at their own lifestyle and what kind of food and eating environment they are providing for their child. It's almost never the child's fault. 

As a counselling Registered Dietitian, I have picked up on eating disorder bahaviours in the most unsuspecting clients in the past. The overweight Lawyer who has been pressured by his wife to lose weight. A quarterback of a football team who has been pressured by his coach to "lean out." An obese teenage girl who decides she wants to become a vegetarian. Because of their physical appearance and the fact that they don't fit the eating disorder stereotype, their family and friends never suspect that they are binging and purging, using laxatives or restricting their food intake so severely that they cannot function at school. Girls often stop menstruating altogether because their bodies can no longer support normal reproductive function, but this may be passed off as possible Polycystic Ovarian Syndrome or irregular periods. I have literally had to convince parents that their child is exhibiting eating disorder behaviours and symptoms of malnutrition and that it is imperative that they be screened. These loving parents are often encouraging their children to diet or to keep up with their lifestyle changes because outwardly, they are overweight and "unhealthy." It is not until these kids show severe signs of malnutrition that action is taken. 

Anyone, regardless of his or her shape or size, can develop a life-threatening eating disorder. 

As someone who "dieted" quite a bit as a teenager, I know that diet practices can easily spiral out of control and enter the realm of disordered eating behaviours. The pressure to be thin (for teenage girls) and lean/buff (for teenage boys) is incredibly high and because most teens aren't highly educated in nutritional science or the art of mindful eating, they often go online or ask their friends how to lose weight. Whichever diet practices they end up following (low carb, low fat, low calorie, etc.), their initial weight loss is often met with positive feedback from their peers, their family and their doctor. This can often spur further weight loss, more drastic weight loss practices, disordered eating behaviours and—as this study reports—full-blown eating disorders. 

So, what should parents watch out for? 

Whether your child or teenager falls within the overweight, obese or normal weight category, there are certain "red flags" that would warrant a discussion or intervention right away:

"I want to become a vegetarian (or vegan)": I cannot tell you how many times parents have brought their teenage girl into my office because she wanta to become a vegetarian. Although vegan or vegetarian lifestyles can be quite healthy if followed correctly, 9 times out of 10, this girl already exhibits signs of an eating disorder and is looking for an excuse to further cut out calories from her diet. Although there are exceptions, sudden drastic changes in diet often mean that an eating disorder is potentially on the horizon. 

"I'm on a diet": "Diet" means restricting food intake in some way, shape or form. Whether it's cutting out whole food groups, severely cutting back on calories, or going on a detox, "dieting" rarely translates into healthy, sustainable lifestyle change.

"I'm going to eat in my room instead of eating at the table with the family": Eating in isolation often means that he or she is a) not eating at all, b) eating very little or c) can even mean that they are overeating and then purging to get rid of it. If skipping family meals becomes a habit for your teen or child, it may be a sign that something is up. 

"I just need to weigh myself one more time": When your child becomes pre-occupied with their weight, such as weighing herself daily or several times a day, take this as a sign that she is practicing unsafe weight loss practices.

"How many calories does that have in it?" Obsessions with calories, fat grams, carbohydrate grams, or sugar often means that your child is obsessing about food and keeping an unhealthy tally of his daily calories. Regardless of how many calories per day he is aiming for, take this as a sign that he is restricting his intake and that it could easily cascade into something more serious.  

"I'm going to start two-a-day workouts": Excessive exercise most certainly means that your child is trying to burn as many calories as possible. And where there is excessive exercise, there is likely disordered eating behaviours. 

"I just need to go to the bathroom...again": Going to the bathroom an unusual amount of times during or after a meal could mean that they are purging their food, especially if it happens often. Make sure that your child or teen feels that it is safe to talk to you about this, otherwise, he or she will continue to hide this behaviour and deny that there is a problem. 

How to help your child or teen:

If you have a teenager who is overweight or obese, he or she is likely faced with extreme pressure to lose weight daily. Don't add to that pressure. Don't encourage or suggest that your teen to go on a diet. Restrictive diets don't work long-term, and for teenagers, can often lead to unhealthy weight loss practices that can spiral out of control. Don't count calories, buy fake "diet" foods, or insist that your child should stop eating as much as she does. Instead, encourage and practice intuitive eating, model healthy eating and living, bring healthy foods into your home and involve your kids in meal preparation and cooking. Insist on having family meals. Be active with your kids. Talk to them about the pressure that they feel and about their self-esteem and body image. Focus not on physical appearance, but on how they feel physically, mentally and emotionally. If you suspect that your teenager or child is dieting or has an Eating Disorder, do not attempt to "fix" them yourself, because you just can't. Trust your instinct and seek help from a Psychologist or Psychotherapist who specializes in eating disorders as well as a Dietitian who specializes in eating disorders.

For tips on how to help your child develop a healthy relationship with food from day one, check out The Ellyn Satter Institute, and come on over to my Facebook page where I post daily nutrition tips for moms.