Response to Letter to Editor Regarding 'early Course of Symptom Development in Anorexia Nervosa' by Ranzenhofer Et Al. (2022).

My coauthors and I thank Dr. Akgul et al. for their comments regarding our recent study reporting on the timing of specific eating behaviors and eating disorder symptoms preceding diagnosis of anorexia nervosa. One of the key findings of our study was that “dieting” (defined as “deliberately changing eating patterns in any way to influence shape or weight”) was often the first behavior to emerge (relative to other behaviors such as purging and excessive exercise) and adolescents reported that this behavior began around a year and a half before diagnosis. On average, this was six months earlier than when parents reported the emergence of dieting. In their letter to the editor, “The protective role of family mealtime in anorexia nervosa,” Dr. Akgul et al. noted that, in their clinic in Ankara, Turkey, duration between onset of dieting and eating disorder diagnosis was much shorter, around 5–6 months. They hypothesize that this difference may result from different family mealtime patterns across cultures (New York vs. Ankara, Turkey). This is an intriguing hypothesis. It is possible that family meals increase opportunities for parents to observe teens’ eating behavior and notice and respond to emerging eating disorder symptoms. Family meals may both protect against the development of disordered eating (per existing literature) and provide an opportunity to identify problems and intervene more quickly. It is also possible that myths about dieting and weight loss efforts (i.e., the idea that “all teens [girls] are on a diet”) could contribute to delay between onset of behavior change and eating disorder presentation. There may be cultural differences in this normalization of dieting and weight loss efforts. Regardless of the “why,” monitoring teens who diet and addressing misconceptions about weight gain during adolescence may help reduce eating disorder risk factors and/or engender earlier intervention. The original work was supported by the National Institute of Mental Health (R01 MH110445 to J.E.S. and J.P.; K24 MH113737 to J.E.S.; K23 MH121780 to L.M.R.) and the Hilda and Preston Davis Foundation.