Table 2 Youth-identified Themes for Triggers for Eating Disorder and Recovery Barriers (n = 9)
Theme | Definition | n (%) | Example excerpt(s) |
|---|---|---|---|
Triggers for weight loss | |||
Weight stigma | Internalized weight stigma, pressures of the thin/fit ideal, feeling fat or overweight, feeling a weight number was too high, low body image, peers dieting or involved in other fitness/health culture, unhelpful social media influences, comparison of weight/shape with others | 7 (77.8) | I’ve always had a bad body image and like weight was always a really big part of my life so it was, I think I've always had kind of like a bad view on it, no matter what. |
When I was younger I was a little bit like overweight and like before I used to have a nutritionist too because I was like a little bit overweight and they were trying to help me with that, so I think that was part of the reason because I kind of knew—like I kind of saw it like my friends. | |||
Comments from others | Family members or peers commenting on the patient’s body, what they were eating, or how much (or little) activity they were doing, or a doctor, nurse, coach, teacher, etc. commenting on their weight, lifestyle, or activity | 6 (66.7) | I think it was mostly just like offhanded comments, just like “oh, you’re eating a lot today” or like “you look you’ve changed a little bit.” That kind of thing. |
…if I ever asked my mom if I could have like a snack or something, that’s when she would talk to me about it, like “yes I could have a snack” or “no I couldn't have a snack now,” but I think that was like maybe the only time. And sometimes…when I was younger like I overheard because sometimes I would like sleep over to my cousins’ house and my mom would tell my aunts what I could and couldn't eat. | |||
I mean I used to be overweight. So I guess doctors did mention that…pediatrician mostly, but also sophomore year, I was put on a new type of medication and my psychiatrist mentioned my weight going up a lot. | |||
Unintentional weight changes | Preceding illness, activity change, or other cause for weight change that led to wanting to lose any weight gained or liking and wanting to keep/continue any weight lost | 3 (33.3) | I had Mono last January and I lost my appetite from that. So part of it was just losing appetite kind of spiraled into restricting… I was kind of like, I saw a change in my body for losing weight and I kind of wanted to keep it up. |
A while ago like during the winter I got some stomach virus and it just made me lose a lot of weight cause I kinda just lost my appetite and I never really recovered for a little while. And I've lost a lot of weight from that but it wasn't intentional… And like when I saw I was gaining weight back I kind of freaked out about it and I wanted to lose the weight that I just made like gain back. | |||
Belief in “healthism” | Believing that losing weight, diet change, and/or exercise/fitness is the “right” or “healthy” thing to do for themselves | 3 (33.3) | I had been overweight most of my life and I kinda just wanted to change that, it started off healthily like just working out and cutting out snacks and then it progressively got worse with the eating… I just thought it was like Good—the healthy option for me. |
Positive reinforcement | Receiving compliments or other reinforcement from friends/family/others on their weight loss, leading to continued drive to lose weight | 3 (33.3) | I really started losing weight because um, I noticed myself losing weight a little bit and I really liked the validation that I saw—that I got—when looking at my weight go down so I decided to do it more drastically. It made me feel better… when my weight loss was starting to get noticeable, people would be like ‘oh you’ve lost weight!’ or like ‘oh you're so skinny now!’ And it just felt good. |
I just think in general people make it harder, because like everybody has a comment saying about like everything. Like I know like, when I lost weight, everyone congratulated me on how good I looked and that was like—it turned into something worrisome. | |||
Teasing/bullying | Teased or bullied about their appearance/weight | 1 (11.1) | And like my cousins…like I saw that they were like really like skinny … and I feel like sometimes they would like kind of made fun of me because of that. So like that’s when I started like noticing it I feel like. And that’s kind of what led me to change a little bit, the way I was exercising. |
When “healthy” becomes “unhealthy” | |||
Concerns from others | Parent, family, or professional (such as a doctor) raising concerns about the extent of weight loss, dietary changes, and/or exercise | 8 (88.9) | I wasn't really worried until I actually like went to the hospital and found out that, whatever my, I was really not eating enough and that there would be like problems if I kept not eating enough and that like my heart rate was kind of slow or something like that. |
But now I am concerned b/c my parents are starting to get involved. My doctors are telling me that it has a lot of long-term effects. And that scares me because I don’t want it to affect the rest of my life. | |||
Loss of control | Patient feels like they lost control of their weight loss and/or exercise or became consumed by thoughts of food, body, weight and/or exercise | 6 (66.7) | Then I kind of realized that I can’t just be eating whatever I want and I felt I needed to start restricting myself b/c I was starting to gain weight. And I’ve never had it happen before and it was happening really fast and that really scared me. |
I feel like probably like four or five months ago is when like I feel like when people saw me, it like turned from like ‘Oh my God you look so good, you lost so much weight!’ to like ‘you lost too much weight, like don't be too thin.’ | |||
Health consequences | Realizing there were physical and/or mental health consequences to their behaviors | 5 (55.6) | I definitely like started feeling the symptoms of it. Like I would get really lightheaded when I was exercising and just being |
constantly like tired, cold all the time. That kind of thing kind of had a pretty big impact in my life. | |||
I was really not eating enough and that there would be like problems if I kept not eating enough and that like my heart rate was kind of slow or something like that. 'Cause then I started worrying that there would be like health consequences. | |||
Treatment Goals | |||
Good relationship with food/exercise | Lack of guilt, not compensating, eating a variety of food, having a healthy relationship with food, feeling strong, and being able to exercise. | 9 (100) | For me, I think it would mean to be able to do like–like some like daily activities like with my friends– just like eat normally without feeling like uncomfortable or like upset about eating or just eating in general without feeling like guilty or something about it. |
Just to like have a positive view of my body and like food and like getting all my strength back, and just enjoying food again I guess. | |||
Resolution of health consequences | Resolution of the physical consequences of the ED (e.g. feeling tired, weak, cold) | 4 (44.4) | Probably just stop feeling like tired, cold, that kind of thing. |
Sometimes I would get like dizzy doing certain things, so I think like being able to do like running or something without feeling dizzy. | |||
Being at a “healthy” weight | Being at the “right” or “healthy” weight for them | 3 (33.3) | I guess like for everyone else it’s probably like being at a healthy weight and like eating the amount that I should, because it's like on the other end I don't want to—it wasn't healthy being the weight that like I was. And so it's like probably just like being in like a healthy weight range and like stuff like that. |
Having a good body image | Feeling happy with their body and how they look | 2 (22.2) | If I'm like happy with the way I—the way I look—that’s a big factor. |
Motivation for Recovery | |||
Getting better for others | Motivated to eat/get better in order to decrease family stress, worry, and involvement | 4 (44.4) | I think what's motivating me right now is like my parents because when I start eating more and being healthier it makes them happy and I know they get really stressed out and they're worried about my health. So that's the thing for me right now. |
Physical Recovery | Feeling strong and energetic again, feeling better, able to move around, having strength and energy | 3 (33.3) | probably like knowing that like I wouldn’t get like dizzy anymore would like motivate me to gain or eat more because it wasn't really like–I didn't really like getting dizzy so much all the time and not being able to do certain things because of that. |
Education about health consequences of ED | Having a better understanding of the health consequences of the ED helps them want to get better or understand why they need to gain weight. Wanting to be a part of their conversation and treatment. | 1 (11.1) | I think learning the health concerns did want me to get better. B/c I forget sometimes that what I’m doing is actually a really serious thing for my body. |
Body image/Self-esteem | Motivated to get better if they can actually have a good body-image | 1 (11.1) | If I knew I wouldn't have any sort of like body image problems once they gained it back I guess. |
Barriers to recovery | |||
The eating disorder (ED) | Continued ED thoughts about body/food/weight. The eating disorder thoughts still driving their fear of weight gain as treatment. Feeling like gaining weight might get out of control, or that treatment may lead to them to lose control of their weight. Fear of worsening body image | 9 (100) | Just like I feel like that my body image has gotten a little better since losing weight. So I would worry that I would go back, like I would go back to looking at myself badly I guess. |
I’m just worried that I’m going to gain even more than my old weight or people think that I look bigger than I am. Like other people will.. Yea I guess it’s just… yea I’m just scared to feel like that again. | |||
External Commentary | Comments about food or body from others that make eating more challenging | 7 (77.8) | Well, when people comment on how much weight I've lost it feels good and so that doesn't really make me want to eat more, it makes me want to eat less. |
I mean I have a friend who is also kind of worried about her weight and I think that makes it difficult to focus on being healthier when she has some of the same habits that I have. | |||
Uncertainty of weight goals | General uncertainty and lack of clarity in weight restoration goals. | 6 (66.7) | And my mom want me to like gain all that weight back. But from like doctors and stuff I've been told that I don't really need to, like the weight I’m at right now like I should maybe gain a little weight but it doesn't have to be where my parents really want me to be. |
“Not sick enough” | Feeling like they aren’t “sick enough.” People with eating disorders should be sicker or skinnier. Feeling like it “isn’t them.” Continued disbelief or lack of worry there is a problem | 5 (55.6) | Even now I still don’t think, I still have a hard time calling it an eating disorder b/c I know that some people have it and they have it so much worse. And I have a hard time calling it that. |
Just b/c I’m not what they [my parents] think is what someone who has an ED looks like that they don’t take it seriously. And that they make comments sometimes or make jokes, but they do really hurt me, and that can affect my recovery. | |||
Belief in “normal” weights | Goals should be based on BMI/height; weight gain might not be necessary b/c they are at a “healthy” weight; might get “too big” | 4 (44.4) | I think that right now, the weight that I am at is healthy. For the last question, I did think that my weight before was unhealthy b/c when I looked at my BMI, it was close to the overweight range. That really scared me. When I started to kind of really restrict myself, I guess I want to be normal. |
I don’t wanna gain weight. Like right now I'm not seriously underweight. I'm at like a normal weight. So gaining weight would bring me back overweight and I don't want that to happen. | |||
I would never want to be back to the weight that I was. …like I was not [at] a healthy weight before. Like I was overweight, so …I would never want to look like that again, I wouldn't do it. | |||