Judging from the other reviews, it goes to show how easy it is to miss an eating disorder... That's the true horror story of the film.

The clues were everywhere:
- her gazing at the cake shop,
- her half-eaten salad at her lunch break,
- her childhood photo from the "Pork Queen Fair" when she was overweight,
- Ganush's granddaughter remarking that she used to be fat,
- the multiple times that Ganush rips out her hair and vomits into her mouth,
- the sounds of buzzing flies/creaking doors/etc. everytime she felt her stomach growling,
- her disgust with the cake she made,
- her binging on the ice cream and the obvious lie she told her boyfriend about her being lactose intolerant,
- her drinking only coffee at the diner, before succumbing to binging on an ice cream again,
- her resisting the temptation of the "free cookie" and rewarding herself by buying a new coat.

The fact that her boyfriend wasn't the one who died but (in reality) her getting run over by the train, shows that it was all in her head as she was becoming more and more psychotic, either because of undernutrition or because of an underlying form of schizophrenia.