"It's a very challenging kind of an illness," said Dr. Ahmed Boachie, program director of the Eating Disorder Program at Southlake Regional Health Centre in Newmarket, Ont.
"There are a lot of myths and misconceptions. So many, many times even some of us physicians don't seem to get the illness — the nature of it and why people refuse to eat."
Boachie and Dr. Karin Jasper, co-authors of "A Parent's Guide to Defeating Eating Disorders" (Jessica Kingsley Publishers), bring years of expertise to the topic. Boachie said the subtitle refers to spotting a stealth bomber because an eating disorder can do damage before you know it's there — it's hard to detect on radar.
Parents should watch for a sudden change in the child's relationship with the family, especially related to food — for example, suddenly making excuses about why she can't be there at meals or saying "I'm not hungry, I'll eat when I get to school," Boachie said.
"Sometimes as they lose weight they become depressed and they isolate themselves from friends and they rationalize that, you know, 'I need to take time to study,' and they become alone, and you see them going on Internet sites and talking more about food."
If a child protests before eating a meal and rushes to the washroom immediately after eating, a parent should be suspicious of intentions to throw up, he said.
Other indicators could be a tendency to wear loose clothes, complaints of feeling cold or tired all the time, or even hair falling out.
"You better go to the family physician as soon as possible," Boachie advised. "Every single day they delay getting the diagnosis and treatment, it's not a good outcome."
Jasper said it's possible the doctor won't recognize an eating disorder because symptoms can mimic some other kinds of illnesses, especially in the early stages.
"So it may be that the family doctor picks up that the child is depressed and sends the child to a psychiatrist to see about that, or it may be that he thinks the child is just having some dieting problems and sends her to the dietitian to get some advice about her food intake," she said.
Bonnie Munslow of Aurora, Ont., struggled to figure out what was wrong when her daughter Sarah complained of stomach problems in Grade 8 or 9.
"She was having a hard time eating breakfast in the morning. We thought she was lactose intolerant so we were buying lactose-free milk and lactose pills and then she was avoiding cheese. That's the way things started up, as far as we recall," Munslow said.
Sarah's concerned mother took her to the family doctor a number of times, thinking there might be intolerance to gluten, or a problem like Crohn's disease related to the digestive system.
"And in that time period, which was probably a couple months, Sarah also started fainting, and of course we were very alarmed."
The physician saw a loss of 15 pounds over several months, and asked Munslow if Sarah was dieting.
"Our family doctor was convinced that it was an eating disorder and Sarah wasn't being forthcoming about it with the doctor, or us at all. It's a very, very secretive disease."
Eventually, Sarah "came clean" and received treatment that included a nine-week stay in hospital, Munslow said.
Jasper noted that a recent study found only eight per cent of family physicians surveyed, and 26 per cent of psychologists surveyed, said they had the tools necessary to diagnose and treat eating disorders.
Boachie said it's often an independent, smart kid who listens to everybody and does homework who can develop an eating disorder, and the child or teen doesn't want to give up their independence or admit to a problem.
Jasper said parents need to trust their own gut feelings.
"Many parents that we've talked to say that they've had to go several times back to the doctor to insist on having the child assessed again."
Anorexia nervosa is characterized by deliberate weight loss, while bulimia nervosa involves repeated bouts of overeating and purging. Boachie says about five per cent of Canadians will develop eating disorders. Among kids and teens, the incidence is zero to one per cent for anorexia, and around three to five per cent for bulimia, he said.
At Southlake, patients are interviewed and fill in questionnaires, and if physical complications are at a minimum, they begin therapy which usually involves family members.
But Boachie acknowledged there aren't enough treatment programs in Canada.
"For every one that we get to a treatment centre, there will be more than 10 of them who will be out there without anybody pulling them up. We don't have enough resources, and they quickly become overwhelmed."
Left untreated, an eating disorder can result in serious medical complications, Jasper said.
"About up to 20 per cent of people with eating disorders will die, half of those as a result of the complications of the eating disorder, and about half from suicide," she warned.
As for Sarah, now age 19, Munslow said she still sees Boachie, a psychiatrist, once every few months for a chat and to be weighed.
"She beat it. It's always going to be in the back of her mind, and she says that. But coming with maturity and going through all the therapy that she did, hopefully there won't be any relapses."