Understanding the 'Chew and Spit' Eating Disorder

A Lesser-Known Behavior

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Among the lesser-known and less-studied eating disorder behaviors is that known as chewing and spitting. This activity consists of chewing food, usually one 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 in the DSM-5

In the prior version of the Diagnostic and Statistical Manual (DSM-IV), the chew and spit method 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).

While the DSM-5 does not list chewing and spitting under any single disorder, the behavior has been found to 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 amongst individuals who have undergone bariatric surgery, a growing population.

Research on the Chew and Spit Method

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 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.

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 permitted 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. Chewing and spitting out food has been estimated to be present in about 30.5 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.”

Chewing and Spitting: A Patient's View

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.

Assessing and Treating Chewing and Spitting

Chewing and spitting is not commonly assessed by professionals, and clients may be reluctant to report it. While it may seem like a benign symptom, the consequences may be quite serious, including swollen salivary glands, ulcers, and dental problems such as cavities and tooth decay.

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 normalizing 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 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. 


Aouad, P., Hay, P., Soh, N., & Touyz, S. (2016). Chew and Spit (CHSP): a systematic review. Journal of Eating Disorders4, 23. https://doi.org/10.1186/s40337-016-0115-1

Conceição, E. M., Utzinger, L. M., & Pisetsky, E. M. (2015). Eating Disorders and Problematic Eating Behaviours Before and After Bariatric Surgery: Characterization, Assessment and Association with Treatment OutcomesEuropean Eating Disorders Review: The Journal of the Eating Disorders Association23(6), 417–425.

De Zwaan, M. (1997). Chewing and spitting out food in eating disorder. International Journal of Psychiatry in Clinical Practice,1(1), 37–38.

Guarda, A. S., Coughlin, J. W., Cummings, M., Marinilli, A., Haug, N., Boucher, M., & Heinberg, L. J. (2004). Chewing and spitting in eating disorders and its relationship to binge eatingEating Behaviors5(3), 231–239.

Song, Y. J., Lee, J.-H., & Jung, Y.-C. (2015). Chewing and spitting out food as a compensatory behavior in patients with eating disordersComprehensive Psychiatry62, 147–151.

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