Understanding the 'Chew and Spit' Eating Disorder

Among the lesser-known and less-studied eating disorder behaviors is that known as chewing and spitting. This activity consists of chewing food, usually food that is highly enjoyable and energy-dense, and spitting it out before swallowing. The intent of the behavior is to enjoy food’s taste while preventing the ingestion of calories. Chewing and spitting has some similarities to bingeing in that it involves consuming larger amounts of high calorie foods than intended, but is also similar to restrictive eating in that the food is not actually ingested.

Initially, spitting was thought to be just an alternative to vomiting, so was studied primarily in women with bulimia nervosa. In the prior version of the Diagnostic and Statistical Manual (DSM-IV), chewing and spitting was listed as a potential symptom of eating disorder not otherwise specified (EDNOS), which in the DSM-5 has been replaced with the category of other specified feeding and eating disorder (OSFED).

However, the DSM-5 does not list chewing and spitting under any single disorder because it is now recognized that the behavior can occur across all eating disorder diagnoses. This means that it may be exhibited by patients diagnosed with anorexia nervosa, bulimia nervosa, or other specified eating disorder. It has further been noted to occur in elevated rates amongst individuals who have undergone bariatric surgery, a growing population.

One of the first published case reports (De Zwaan, 1997) of the behavior described a 19-year-old woman with anorexia accompanied by chewing and spitting:

She either spent hours in the bathroom or spit the food into carrier bags, both at home and while walking on the streets. The chewing and spitting out took up to 6 hours every day, preventing her from studying and from social contacts. Her mother insisted on family meals every day. As in her anorectic days, she was successful in hiding the food from her plate in her pockets and under the table without her parents noticing it. She was very much ashamed of her behavior and at first refused even to talk about it, either in individual or in group therapy.

Research on chewing and spitting is sparse. Chewing and spitting is more commonly associated with other restrictive eating disorder behaviors (such as diet pill abuse, dietary restriction, and excessive exercise) than with binge/purge behaviors. The behavior may be frequent and it may be associated with greater psychopathology.

Chewing and spitting is also associated with more severe eating disorder symptoms and suicidal ideation. Individuals who chew and spit, relative to other patients with eating disorders who do not chew and spit, have higher scores on measures of body image concerns, preoccupation with shape and weight, depression, anxiety, and obsessive compulsive behavior.

Among eating disorder patients admitted to a behavioral, inpatient, and partial hospitalization program for eating disorders that consented to participate in a study by Guarda and colleagues, 34 percent admitted to at least one episode of chewing and spitting in the month prior to admission, and 19 percent reported being regular chewers/spitters who engaged in the behavior several times a week. In a study of Korean patients with eating disorders, 25 percent engaged in chewing and spitting. The prevalence of chewing and spitting out food has been estimated to be about 31 percent of patients post-bariatric surgery.

In their paper, Guarda and colleagues report that “Although diverse in presentation, the behavior is described as driven and compelling and is sometimes associated with feelings of loss of control. As with most eating disorder behaviors, its escalation can lead to social exclusion, severe food obsession, self-loathing, guilt, and remorse. For individuals who chew and spit large amounts of food daily, financial difficulties can be a further consequence.”

A review of studies of chewing and spitting indicate that the behavior is used as a weight-control method and “was often associated with negative emotions such as self-disgust, remorse, and shame, but may have been be less distressing than binging and purging.”

In online communities, patients who chew and spit report a great deal of shame about the behavior. It is also described as a behavior that becomes driven and compulsive and very hard to stop. There is often great secrecy around the behavior and those who engage in chewing and spitting may become isolative as they try to conceal it.

While it may seem like a relatively benign symptom, especially as compared to vomiting, the consequences of chewing and spitting may be quite serious. Symptoms are similar to those found with vomiting in bulimia nervosa and can include:

• visibly swollen salivary glands
• stomach ulcers
• dental problems such as cavities and tooth decay
• hormonal imbalances

Addressing these medical symptoms requires stopping the behavior. Warm compresses and tart candies can help provide relief for swollen salivary glands. Patients should see a medical doctor and a dentist to discuss potential treatment options for gastrointestinal, hormonal, and dental issues.

Chewing and spitting is not commonly assessed by professionals, and clients may be reluctant to report it due to shame about the behavior.

Little in the treatment literature specifically addresses chewing and spitting.  Psychotherapy and nutrition therapy for patients with eating disorders who chew and spit should address the normalization of eating behaviors through the adoption of regular meals. Cognitive-behavioral strategies helpful in addressing chewing and spitting include acknowledgement of feelings of shame, challenging of dietary rules, management of emotional distress, and practice of increased flexibility.

If your family member is displaying signs of an eating disorder, you may want to watch for signs of chewing and spitting. Specific signs of chewing and spitting may include:

• traces of chewed but undigested food in their room, in the bathroom, or in the trash
• eating in private or out of the house
• secretive behavior at meals
• shame around eating

If you (or someone you know) is chewing and spitting, it is important to seek help from a professional who is well-versed in eating disorders.