Eating Disorders

February 10, 2006 – Volume 16, Issue 6
Is societal pressure to be thin to blame? By Pamela M. Prah

Introduction

Actress Lindsay Lohan was quoted recently as saying she had an eating disorder, but she later claimed Vanity Fair magazine misquoted her. Lohan and other super-thin celebrities are often pictured as “thin-spirations” on eating-disorder Web sites.  (AP Photo/Chris Polk)
Actress Lindsay Lohan was quoted recently as saying she had an eating disorder, but she later claimed Vanity Fair magazine misquoted her. Lohan and other super-thin celebrities are often pictured as “thin-spirations” on eating-disorder Web sites. (AP Photo/Chris Polk)

Tabloids and TV entertainment shows are full of gossipy reports about young, pencil-thin Hollywood actresses who might be anorexic or bulimic. Eating disorders, however, are far from glamorous. Anorexia has the highest mortality rate of any mental illness. Up to 35 million Americans have an eating disorder. Moreover, contrary to the old stereotype, overachieving white girls from affluent families are not the only victims. Also afflicted are men, middle-aged women, African-Americans and children as young as 8. Many Americans blame the nation's obsession with appearances for causing eating disorders, but genetics and brain chemistry also play roles. Public-health experts say Web sites that give tips on hiding eating disorders should be closed down, while patients' advocates are pushing Congress to require insurers to cover more of the costs of treatment and to make eating disorders a national priority — just like obesity.

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Overview

Anna Westin, of Chaska, Minn., and Shelby Starner, of Stroudsburg, Pa., both had eating disorders they tried to hide.

Anna wore baggy clothes to conceal her shrinking, starving body. Shelby, who had a multi-album recording contract by age 14, perfected vomiting into Snapple bottles — up to 14 times a day — to avoid clogging the sinks and alerting her parents. 1

The disorders eventually killed them both. Anna committed suicide at age 21 after battling anorexia for five years. Shelby died of bulimia at 19.

“Anna knew she had an eating disorder,” says her mother. “She hated it and wanted to be free of it. That drove her to suicide.”

Anorexia, bulimia and compulsive eating affect an estimated 35 million Americans, according to the National Eating Disorders Association (NEDA).

Victims of eating disorders are obsessed with food and the fear of getting fat. Anorexics either refuse to eat enough to maintain a normal weight or eat only enough to survive, typically seeing themselves as fat even though they often are dangerously thin.

Bulimics generally follow a so-called binge-and-purge cycle — compulsively eating large amounts of food and then offsetting weight gain by vomiting, fasting, exercising excessively or misusing laxatives, diuretics or enemas.

Jennifer Shortis has suffered from an eating disorder since age 15, when she began dieting with friends in Baldwinville, Mass. Within months, she had developed anorexia. Now 24, she weighs 76 pounds and is still struggling to regain a normal weight. Anorexia has the highest mortality rate of any mental illness, with death often caused by suicide. As many as 35 million Americans may have an eating disorder. (Corbis Images/Ed Quinn (1999)
Jennifer Shortis has suffered from an eating disorder since age 15, when she began dieting with friends in Baldwinville, Mass. Within months, she had developed anorexia. Now 24, she weighs 76 pounds and is still struggling to regain a normal weight. Anorexia has the highest mortality rate of any mental illness, with death often caused by suicide. As many as 35 million Americans may have an eating disorder. (Corbis Images/Ed Quinn (1999)

Eating disorders are considered serious mental illnesses; anorexia has the highest mortality rate of any mental illness, with death often caused by suicide. 2

While anorexia and bulimia are distinct diagnostic categories of eating disorders, binge, or compulsive, eating is not an official category of mental illness, nor is obesity. 3 Binge eaters differ from bulimics in that they don't try to purge their food.

Anorexia and bulimia are commonly — and mistakenly — thought to primarily afflict overachieving white girls from affluent families. “Eating disorders are truly an equal-opportunity disease,” says Ellen Rome, a pediatrician in Cleveland and spokeswoman for the Academy for Eating Disorders in Chicago. “We are seeing it in all walks of life,” including among men, middle-aged women, blacks, Hispanics, rich and poor.

“One of the myths is that it's 'other' people who have these disorders,” says psychologist Douglas Bunnell, past president of the Seattle-based NEDA. “They are everybody's sister, daughter, wife, friend. You know someone with an eating disorder. You may not be able to spot it necessarily, but people with these disorders are living among us.”

And physicians say eating disorders are appearing in younger and younger patients. “It's not uncommon to find 8- and 12-year-olds with these disorders,” says Rome.

But there are no reliable statistics on whether eating disorders are on the rise or just being diagnosed more often, because they aren't tracked by the federal government. “It's a national disgrace that we still don't have published data on how many people have an eating disorder,” says Ruth Striegel-Moore, who heads the psychology department at Wesleyan University in Middletown, Conn., and specializes in eating disorders.

However, NEDA estimates that up to 10 million females and 1 million males struggle with anorexia or bulimia, or both. Among U.S. women, about 1 percent are anorexic and up to 5 percent are bulimic, says Bunnell, director of the Renfrew Center of Southern Connecticut, a respected eating-disorder clinic in Wilton. Another 25 million are estimated to suffer from binge eating.

The death of 32-year-old pop singer Karen Carpenter in 1983 from an eating disorder helped raise awareness of the problem, but today the diseases are everyday fodder for the tabloids and entertainment shows. “We do sort of make anorexia glamorous,” says Bunnell, who fears the celebrity focus and attention “almost marginalize the illness.”

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But experts say eating disorders are caused by a complex mix of biological, psychological and social factors, such as brain chemistry, metabolism, coping skills and personality — along with a culture that promotes thinness. Activities that require a lean appearance — such as acting, dancing, modeling, gymnastics or distance running — also increase the risk of developing an eating disorder.

Sarah Putnam, 21, a senior at North Carolina's Elon University, changed her major from musical theater to corporate communications because the pressure to be thin in theater “was obviously killing me.” Putnam had initially enrolled at Wagner College, in Staten Island, N.Y., where she says theater students shared ideas for staying thin, such as taking laxatives and exercising excessively. Her 25-pound weight loss — to just 100 pounds — won her praise from faculty and friends. At one point, she says, she was throwing up six times a day. She says she got help when her eating disorder “had completely taken over my life.”

Recent research now suggests that genetics may play a bigger role than previously thought. While an “anorexia gene” has yet to be discovered, research indicates that people may be born with a predisposition to developing an eating disorder.

“Genes load the gun, environment pulls the trigger,” the Illinois-based National Association of Anorexia Nervosa and Associated Disorders (ANAD) explains on its Web site. 4

Victims of eating disorders typically try to hide their problem and balk at getting help. Some, like Shelby, instead turn to Web sites that promote anorexia and bulimia as choices and lifestyles rather than as diseases — sites that many experts say should be shut down. The sites offer tips on how to avoid detection, such as throwing up while showering to conceal the sounds of vomiting and wearing hidden ankle weights to fool doctors during weigh-ins. Particularly startling are the sites' “thinspirations” — galleries of photos of unusually thin people, typically actresses, such as Lindsay Lohan, Nicole Ritchie, Mary-Kate Olsen and Calista Flockhart.

Sufferers who do seek help are in for a long haul. Anorexia treatment typically takes five to seven years. Inpatient care for an eating disorder can cost up to $30,000 a month and more than $100,000 for outpatient therapy and medical monitoring, according to ANAD.

Treatment is costly because both mental and physical problems are involved. Irregular heartbeats and electrolyte imbalances are common in both anorexic and bulimic patients, as are psychiatric disorders like anxiety, depression and obsessive-compulsive disorder. Many victims also have alcohol and drug problems.

Insurance rarely covers more than a small portion of the costs. Kitty Westin says her insurance company's refusal to cover Anna's treatment and the financial burden her daughter knew she was putting on the family contributed to her suicide. For years, mental health advocates have lobbied Congress, with little success, to require more insurance coverage for eating disorders and other mental illnesses.

Mary Ellen Clausen, an eating-disorders activist in Syracuse, N.Y., says treatments for her two daughters have cost more than $1 million over eight years. Insurance has paid for some, but the family has largely footed the bill. “Our 401(k)s are a thing of the past,” she says. “We have re-mortgaged our house, taken out loans and maxed out all our credit cards.”

Since treatment is successful only about half of the time for anorexia and bulimia, researchers are seeking new approaches. For bulimics, cognitive therapy, medication and nutritional counseling appear promising. Medication — typically an anti-depressant — appears less effective for anorexics until after they gain weight.

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Ironically, while 11 million Americans with eating disorders are virtually starving themselves, the United States is facing an obesity epidemic affecting some 60 million people. Obesity and binge eating aren't recognized as eating disorders, but some experts think they should be. Meanwhile, they warn, many people with obesity may have real eating disorders but are not getting help.

As eating-disorder experts and family members lobby Congress for more research funds and insurance coverage, here are some of the questions people are asking:

Should binge eating and obesity be categorized as eating disorders?

Experts disagree about whether binge eating and obesity — which affect some 85 million adult Americans — should be considered distinct eating disorders like anorexia and bulimia.

The authoritative Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), recognized anorexia and bulimia as mental disorders in 1980. Currently the DSM lists binge eating in a catch-all “eating-disorders category otherwise not specified.” Obesity is not included at all.

The distinction is important because mental health professionals use the manual to diagnose and treat patients with eating problems, and insurance companies use it to figure out whether to pay for treatment, explains Pauline Powers, president of the National Eating Disorders Association, professor of psychiatry at the University of South Florida, and member of an APA working group on eating disorders. The catch-all category offers less guidance to mental health professionals, and some insurance companies are more restrictive in their coverage for this category, treating the condition as less serious than anorexia and bulimia. 5

“The more definitive a disease is, the more likely insurance will cover it,” says Annie Hayashi, a spokeswoman for the National Association of Anorexia Nervosa and Associated Disorders. “It's much more difficult to get coverage” for patients diagnosed with binge eating, since it's included in the broader category, she says.

Hayashi notes that the association's history reflects the evolving study of eating disorders — it was founded in 1976, three years before the term bulimia nervosa was even coined.

Many experts, including Powers, predict binge eating will be listed as a third, distinct type of eating disorder the next time the association updates its manual — probably in 2011. Meanwhile, the APA is planning in the next few months to update its treatment guidelines for all eating disorders, greatly expanding the section on binge eating.

Binge eaters rapidly consume excessive amounts of food and feel as though they can't stop. But unlike bulimics, they usually don't try to get rid of the food by vomiting, fasting, using laxatives or other unsafe ways.

Binge eating can lead to serious health complications, such as diabetes, hypertension, cardiovascular disease and obesity, but little is known about it or its prevalence. “Presumably, more people are affected by binge eating, but we just don't know,” says Bunnell. NEDA estimates that 25 million Americans struggle with binge eating. “Some binge eaters may be on their way to a formal eating disorder or on the way out of it. We don't know.”

The medical and research communities generally recognize binge eating as an eating disorder but disagree over whether it should be considered a distinct disorder — separate from bulimia — or simply a non-purging form of bulimia, says Wesleyan University's Striegel-Moore.

She says the popularity of today's “super-size” meals — some of which would qualify as a binge — is helping to drive the disorder. “We live in a society where overeating has become normative . . . and is promoted.”

Meanwhile, combating obesity is a top public health priority. In 2001, then-U.S. Surgeon General David Satcher issued a “call to action” to prevent and reduce obesity, a problem he feared “could reverse many of the health gains achieved in the U.S. in recent decades.” 6

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But there's disagreement over whether obesity is linked to eating disorders.

ANAD's Hayashi says her association considers obesity an eating disorder, but “not everyone agrees.”

Advocates of making obesity an eating disorder say that including it in the DSM will help medical professionals find the proper treatment for obese people. Opponents, however, argue that not all obese people have eating disorders and that including them all would neither be accurate nor helpful to everyone.

“I think obesity is an eating disorder, but I'm in the minority,” says Powers.

However, NEDA's Bunnell cautions that “being obese doesn't necessarily mean that a person has an eating disorder,” noting that an eating disorder is a psychiatric diagnosis associated with a variety of emotional and physical factors. “Obesity doesn't tell you that about a person.”

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Striegel-Moore agrees that some binge eaters are obese, but says adamantly: “Obesity is not an eating disorder.” By definition, she says, a psychiatric disorder must be associated with “clinically significant impairment,” and not all individuals who are obese experience such impairment. “To be an eating disorder, there has to be disturbance in body image and eating behavior. Not all individuals evidence such symptoms. So, unless there are behavioral or body-image symptoms, obesity does not represent an eating disorder.”

Many observers doubt the APA will include obesity as a distinct disorder when it updates its manual. Powers predicts certain syndromes related to obesity, such as “night-eating syndrome,” will be listed as eating disorders, but not obesity. Night-eating syndrome is characterized by eating 25 percent of a person's daily calorie count after dinner.

Does insurance adequately cover eating disorders?

Kitty Westin doesn't exactly say that Blue Cross-Blue Shield of Minnesota killed her daughter in 2000 — only that the insurer's refusal to pay for Anna's treatment for anorexia helped push her to suicide.

Like many families, the Westins were shocked to discover the family's “Cadillac” health-insurance plan covered only a small portion of the cost of treatment, which extended several years and cost tens of thousands of dollars. Westin says the insurer refused to pay even after the hospital said Anna could die without it.

“It blew us away,” she says, adding that Anna felt she was a burden on her family and that the insurer's refusal to pay “contributed to her despair.”

The Westins and the state of Minnesota sued the insurer and won an out-of-court settlement in June 2001 that required Blue Cross-Blue Shield to set up an independent, three-member panel to review all denials of insurance coverage. (The state, county and insurer each select a member.) Two other Minnesota health-insurance carriers voluntarily agreed to the provisions of the settlement. “It made a huge difference in Minnesota,” Westin says.

Larry Akey, a spokesman for America's Health Insurance Plans (AHIP), says 47 states require mental health coverage, and 95 percent of his group's 1,300 members provide some sort of mental-health benefit, which may include eating disorders. 7 But eating-disorder experts say many states allow insurers to charge higher co-pays for mental health services or to limit services, and only 22 states require insurers to cover treatment for eating disorders that is equal to coverage for physical disorders.

By severely limiting coverage or not covering treatment at all, victims' families and health professionals contend that insurers threaten the recovery of eating-disorder sufferers. Many insurers limit the number of days they will pay for hospitalization for eating disorders, and it's usually not enough to properly treat the patient, says ANAD's Hayashi, especially for anorexics, where the first priority is getting them to gain weight.

However, anorexics are expensive to the health-care system, costing about as much as treating patients with schizophrenia — a chronic, debilitating mental disorder, says Wesleyan's Striegel-Moore. Anorexics can develop abnormal blood clotting, osteoporosis, dehydration and kidney problems, while bulimics may suffer from bowel problems, abdominal pain and erosions in the teeth, stomach and esophagus.

However, while insurers may cover treatment for these physical complications, they often balk at covering psychological counseling for what caused the complications in the first place, creating what Striegel-Moore calls “perverse situations.” If an anorexic is so depressed she jumps out the window and breaks her leg, an insurer will pay for treating the leg but not the eating disorder that prompted her to jump, she says. “It's a real problem.”

In the end, Striegel-Moore says, the policy is penny-wise and pound-foolish, because victims often end up in the emergency room — one of the most expensive places to receive care — for treatment of related ailments. “People with eating disorders are high consumers of health services [for their physical ailments], because they are not getting the [mental health] services that would treat their eating disorders,” she says.

Activist Clausen of upstate New York discovered the peculiarities of the health-insurance system when both her daughters developed eating disorders. After her oldest daughter tried to commit suicide, the insurance company paid for her intensive care but refused to fully cover the treatment for the eating disorder that made her suicidal, says Clausen. She says the insurance battles left her emotionally and financially drained and threatened her daughter's recovery. The insurer would cover only 14 days of treatment, so she was discharged just as she was getting better, and the cycle started all over again.

Insurers argue that they are simply offering the benefits employers request and can afford. “Many purchasers opt for some limits to medical care to keep premiums affordable and to keep the array of benefits they offer as broad as possible,” says AHIP's Akey.

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Claire Sheahan, a spokeswoman for the Blue Cross-Blue Shield Association, says people often blame the insurance company for not offering certain benefits, “but it's not the insurer's choice. Every benefit is negotiated with the employer.”

According to a 2005 poll of 1,500 adults commissioned by NEDA, 76 percent of respondents said eating disorders should be covered by insurance companies “just like any other illness.” The results show that “the public agrees not only that eating disorders are serious illnesses but also that they deserve — and demand — treatment and adequate insurance coverage,” said NEDA. 8

Howerver, say medical experts, insurers often use the APA's formal criteria for diagnosing eating disorders as excuses “to exclude coverage.” For example, says Powers, one of the four criteria for determining if a female is anorexic is the loss of menstrual periods. Some insurers will refuse to cover female anorexic patients who don't lose their periods but are otherwise clearly anorexic.

Another criterion for anorexia is that the person weighs at least 15 percent less than the normal weight for their height. “Let's say someone has lost 13 percent,” says Bunnell of NEDA. “That doesn't mean they aren't anorexic.” Similarly, one of the criteria for bulimia is bingeing or purging twice a week. “Suppose you binge or purge 1.5 times a week?”

Should Web sites promoting anorexia and bulimia be shut down?

Shelby Starner's mother, Kathy Benn, says her talented daughter got tips for hiding her bulimia from Internet sites that promote anorexia and bulimia as lifestyles rather than diseases. “These Web sites make it seem like eating disorders are a trend and a cool thing to do,” she told the Pittsburgh Tribune-Review not long after Shelby's death at age 19. 9 “These girls don't realize that people die from this. It's terrifying.”

Shelby's bulimia caused an imbalance of her body's electrolytes, which caused her brain to swell and led to a fatal seizure.

Experts say there are probably thousands of Web sites and blogs that promote anorexia (dubbed pro-“ana” sites) or bulimia (pro-”mia” sites). Although many have been around since the late 1990s, the pro-ana sites became more widely known in 2001 after exposés by Time and other publications as well as TV shows like “Oprah” and “Dr. Phil.”

Many experts say the sites are dangerous and should be shut down. But others say they provide support to sufferers and give researchers new insights.

Kitty Westin, left, and Sharon Haugen became eating-disorder activists after their daughters died from the illness. Rep. Jim Ramstad, R-Minn., supports equal insurance coverage for eating disorders, or mental-health parity. (EDC Photo/Mark Lerro)
Kitty Westin, left, and Sharon Haugen became eating-disorder activists after their daughters died from the illness. Rep. Jim Ramstad, R-Minn., supports equal insurance coverage for eating disorders, or mental-health parity. (EDC Photo/Mark Lerro)

“These sites are just awful,” says Rome of the Academy for Eating Disorders. In addition to the photos of ultra-thin people, some contain “reverse triggers,” or photos of extremely overweight people. Many are interactive with blogs and discussion boards.

Benn isn't alone in blaming the sites for giving young people ideas. According to a 2005 study, 66 percent of teens who had visited a pro-ana or pro-mia site said they had tried some of the weight-loss techniques suggested. 10

“Ana's Underground Grotto” is one of many sites clearly promoting an eating disorder. “This is a pro-ana Web site,” it declares. “That means this is a place where anorexia is regarded as a lifestyle and a choice, not an illness or disorder. There are no victims here.”

Most of the pro-ana sites also provide warnings. For example, “Thin Files” advises, “If you are currently in recovery from an eating disorder or if you are offended or otherwise disturbed by the existence of pro-ana, I suggest you go no further.” And “Blue Dragon” says its tips “are to give you fresh ideas on how to stay on track so that you don't fall into a depression and kill yourself — not to teach you how to 'not eat.' ”

Blogs like www.miafriends.org are full of suggestions, such as always carry a plastic Ziploc bag or a large cup with a lid to vomit into. Visitors to the sites, mostly teenage and college-age women, post before-and-after photos of themselves; images of waiflike models, actresses and even tiny Tinkerbell from “Peter Pan” adorn the sites. In an essay on “40 reasons not to eat,” one threatens, “If you eat, you'll look like those disgusting, fat, ghetto and trailer-trash hookers on 'Jerry Springer.' ”

The National Eating Disorders Association says the sites could “encourage a 'cult'-type destructive support system.” The Academy for Eating Disorders says there is always a “creative tension” between respecting free speech and protecting vulnerable individuals, particularly children. “It's important to note that the peak age of onset of eating disorders is during adolescence, and thus these sites target largely an audience of children,” says the academy's Web site. 11

Several years ago, eating-disorder researchers and support groups began prodding major Internet servers to take down the sites or delete them from search engines. Yahoo! encourages groups like ANAD to alert the company of online content that may be illegal or harm children, says spokeswoman Mary Osako. ANAD's Hayashi estimates that hundreds of such sites have been taken down, but more pop up to replace them.

Some pro-ana sites are clearly frustrated by efforts to silence them. “Ana's Underground Grotto” notes that several sites that had linked to its site had been changed to “anti-pro-ana sites” or have gone dead or offline. The notice adds that it will no longer list sites hosted by Geocities, Tripod, Angelfire, Homestead or myweb.ecomplanet because those links “continually get deleted.”

Lori Rosenthal, a professor of psychology at Boston's Emerson College, says the sites provide support for sufferers and useful information for researchers. “These sites offer social support and friendship,” she says, and often in a more effective and reader-friendly manner than more formal eating-disorder treatment sites.

Rosenthal acknowledges the sites are potentially dangerous, but she doesn't think they should be shut down. Aside from free-speech concerns, she says, the sites have much to teach. For example, by reading the sites and their discussion boards, she says, researchers can glean new insights into how anorexics and bulimics feel and why some refuse to get treatment. Preliminary results of her current study show that two-thirds of those who join the pro-ana discussion boards are looking for someone to talk to, and one-third are looking for tips on how to starve themselves.

Walter H. Kaye, professor of psychology at the University of Pittsburgh School of Medicine's Western Psychiatric Institute and Clinic, agrees. “If you weigh 60 pounds and you think you're fat, even though that's a very real feeling to you, other people might look at you and be mystified,” Kaye said. “But these Web sites probably make these girls feel like there is someone that understands them and won't judge them.” 12

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Background

Saints and Witches

In the Middle Ages, women who starved themselves were first considered saints — then they were denounced as witches and finally they were seen as just plain unhealthy.

In the 14th century, St. Catherine of Siena, for example, died of starvation at the age of 33 after eating only bread, raw herbs and water since age 25. In his 1985 book Holy Anorexia, Rudolph M. Bell, a professor of Italian history at Rutgers State University, documents 261 cases of women starving for religious reasons between 1206 and 1934. 13 Many were elevated to sainthood and praised for helping the sick at their own health's expense.

But toward the end of the Middle Ages, women who fasted were thought to possess evil spirits and were accused of being witches bent upon destroying the Catholic Church.

By the 17th and 18th centuries, however, women who wasted away were considered neither witches nor saints but simply victims of poor health. In fact, many women who supposedly died from consumption, known today as tuberculosis, are now thought to have suffered from anorexia.

Richard Morton, the physician to the king of England, is credited with the first reference to anorexia in medical literature in 1689 when he described cases of “nervous consumption” in Phthisiologia: or, A Treatise of Consumptions. Morton defined the disorder as separate from “consumption.” 14

Ironically, one of Morton's first cases involved a man. Today anorexia is widely seen as a “woman's disease,” and men often refrain from getting help because of the stigma.

In the 1870s, medical accounts of anorexia came from E. C. Lasegue, a French professor of medicine, and W. W. Gull, a London surgeon. In 1873 Gull coined the term “anorexia nervosa” (from the Greek word for "lack of appetite"). Gull defined anorexia as an independent disease while Lasegue thought it was a “peripheral,” or a disorder of the nervous system. Both agreed, however, that anorexia was a psychological disease.

In 1888, the British medical journal Lancet published 11 articles over a two-month period regarding anorexia, greatly boosting awareness of the disorder. 15 By the 1940s, the medical community generally accepted anorexia as a psychological disorder. 16

Early researchers gave various reasons for eating disorders. French neurologist Pierre M. F. Janet, a pioneer in psychiatry, linked anorexia and the loss of appetite in young girls to emerging adolescent sexuality. So did Sigmund Freud, the founder of psychoanalysis. Both concluded that anorexic girls feared adult womanhood and sex and wanted to stay thin and childlike.

In the 1960s and '70s, Hilde Bruch, a professor of psychiatry at Baylor College of Medicine in Houston, suggested that anorexics had an “inadequate sense of self” and restricted their eating to act out their frustration and feelings of inadequacy. Her treatments focused on helping anorexics “find a voice.” 17 Bruch's 1979 book about anorexia nervosa, The Golden Cage, is widely considered a classic.

 “Anorexia and bulimia were certainly foreign to me until I woke up three years ago and realized they were eating me alive,” actor Tommy Schrider of New York told a congressional briefing in December 2003. “Never in my wildest dreams could I ever have conceived of the debilitating despair, the soul-crushing hopelessness that my eating disorder wreaked upon me.” (EDC Photo/Mark Lerro)
“Anorexia and bulimia were certainly foreign to me until I woke up three years ago and realized they were eating me alive,” actor Tommy Schrider of New York told a congressional briefing in December 2003. “Never in my wildest dreams could I ever have conceived of the debilitating despair, the soul-crushing hopelessness that my eating disorder wreaked upon me.” (EDC Photo/Mark Lerro)

Arthur Crisp, chairman of psychiatry at St. George's Hospital Medical School in London, also was influential, arguing that anorexia was a way to cope and avoid adolescence; Gerald Russell of the University of London researched anorexics' intense fear of fatness.

Russell coined the term “bulimia nervosa” in 1979 and helped develop the disorder's diagnostic criteria. Bulimia, Greek for “bull's appetite,” has a sparser record in the medical books, but not in history. The first modern bulimia case was described in 1903 by Janet in Les Obsessions et la Psychasthenie.

But reports of people bingeing and purging have been around for centuries. Ancient Romans, for example, visited so-called vomitoriums during feasts so they could regurgitate and eat some more. Emperors Claudius and Vitellius may be the first documented cases of individuals who binged and purged. 18

Social Pressure

Cultural shifts and fashion fads have profoundly affected how women want to look and how much they think they should weigh. In the United States, plumpness once signaled that a woman was well fed and affluent. By the early 1900s, however, women wanted to look like the “Gibson Girl” created by illustrator Charles Dana Gibson and popularized by magazines such as Scribner's and Harpers. With her incredibly tiny waist, the Gibson girl gave women a nearly impossible ideal to achieve.

The 1920s ushered in the “flappers,” pencil-thin women who wore loose-fitting dresses that exposed arms and legs. In the 1940s and '50s, the full figure again was the ideal, popularized by movie stars like Ava Gardner, Jane Russell and Marilyn Monroe. But that changed in the 1960s when a 97-pound British model known as Twiggy (Leslie Hornby Armstrong) hit the fashion runway, and many women tried to look like her. Before Twiggy, the average fashion model weighed just 8 percent less than the average American woman, but today fashion models are thinner than 98 percent of American women. 19

Many experts say the first Barbie doll, launched in 1959 by Mattel, epitomizes the unrealistic expectations that American pop culture puts on girls and women. The average American girl has at least one Barbie by the time she is 3 years old. But if Barbie were a real person, she would stand 5'9” and weigh a mere 110 pounds, with the unrealistic body measurements of 39-18-33.

“Barbie, Tinkerbell, and countless others . . . reinforce the societal message about the value of thinness,” writes psychologist Cynthia R. Kalodner in her 2003 book Too Fat or Too Thin? 20

In the 1970s, few people talked about eating disorders, and little was known about them. When Vivian Meehan, a nurse at a hospital in Highland Park, Ill., discovered that her daughter had anorexia nervosa, she found little information about it and no support systems. After she put an ad in the local newspaper asking if anyone was interested in discussing the ailment, she was bombarded with calls. In 1976, she formed the National Association of Anorexia Nervosa and Associated Disorders, one of the country's first organizations devoted to eating disorders.

Four years later, the American Psychiatric Association recognized anorexia and bulimia as separate mental disorders.

In the late 1970s, Argentinian psychiatrist Salvador Minuchin, who practiced in Philadelphia, theorized that family behavior shapes the anorexic's eating habits and recommended that treatment involve the entire family. In the early 1980s, New York psychotherapist Steven Levenkron described anorexics as seeing themselves as either being in charge of everything — including food intake and weight — or being completely powerless. His novel The Best Little Girl in the World was made into a TV movie in 1981, giving many Americans their first glimpse of eating disorders.

People with eating disorders also tend to have certain personality traits that may play a role in their illness. For example, anorexia sufferers often have low self-esteem, are perfectionistic and need to be liked or in control. Researchers speculate that focusing on weight loss and food allows anorexics to ignore — possibly unconsciously — problems that are too painful or seem too difficult to solve.

Eating disorders often occur in early adolescence, either just as a person enters puberty, or just before or in early adulthood. Researchers speculate that as a girl's body begins to develop, she starts worrying about getting “fat” in places where she wasn't before. Girls also may feel powerless as their bodies change, so they react by taking total control of what they eat.

Eating disorders are often triggered by seemingly trivial incidents like a brother teasing his sister about her weight or a coach's off-hand remark. Significant life events also can act as a trigger, such as being sexually or physically abused as a child, starting high school or college, beginning a new job or getting married or divorced.

Complex Treatment

The complexity of eating disorders calls for treatment focusing on both the body and mind. Anorexics first must gain weight and receive medical treatment to correct the likely damage to their hearts and other organs caused by starving themselves. For bulimics, the goal is to stop the purging, so the focus is on learning new patterns of regular, non-binge meals and healthy, but not excessive, exercise.

Experts say that all eating-disorder patients benefit from some form of psychotherapy to deal with their underlying emotional issues. This can include cognitive-behavior therapy in which the therapist and patient work together to identify illogical thinking patterns about food, body image, weight and perfection, or interpersonal therapy, in which patients look at their interactions with others that may exacerbate, but not actually cause, the eating disorder. In many cases, treatment also must tackle serious accompanying psychiatric disorders, such as depression, anxiety, panic, obsessive-compulsive disorder and alcohol and drug problems.

Just as the 1990s were ending, researchers in the United States and Britain were finding that brain chemistry and genetics play a bigger role in the onset of eating disorders than originally thought. Doctors at London's Maudsley Hospital found in late 1998 that increased levels of the brain chemical serotonin, which affects mood and appetite, may be linked to anorexic behavior, while University of Pittsburgh researchers found that decreased serotonin activity may cause bulimic behavior. 21

These studies suggest that people with eating disorders have variations in their genes for serotonin receptors. Low levels of serotonin are found in people who are depressed, while high levels are found in anxious or overwhelmed people who are perfectionists. According to one theory, bingeing helps people with low serotonin levels increase those levels, making them feel better. Conversely, withholding food can make people with high serotonin levels feel calmer.

In essence, goes the thinking, eating too much or too little actually makes the person feel better.

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Current Situation

New Research

Eating disorders are more widespread than originally thought and probably run in families, but researchers are still trying to figure out why.

Recent studies by Striegel-Moore of Wesleyan University dispel the notion that eating disorders are maladies of young, white girls. Her research indicates that young, black women also suffer from eating disorders. But few studies have included or targeted minorities, so there are little reliable data.

Most experts think rates for men are much higher than studies suggest. “You probably hear the ratio that 1-in-10 patients will be male, but it's probably more like 1-in-6,” says Bunnell, of the National Eating Disorders Association. Males are even more reluctant to seek treatment because eating disorders are seen as a “women's disease.”

Indeed, they feel the same cultural pressure to be svelte that women feel, says Bunnell, citing billboards “with perfect male bodies that none of us could ever have.” Men now “get to feel what women have felt for 40 years,” he adds.

Treatment centers also are seeing older women — in their 30s, 40s, 50s and even 60s — seeking help. The big question is whether they have newly developed the disease or have had the disorder since they were younger but were never properly diagnosed.

Medical experts have always suspected that people with eating disorders “cycle” from being anorexic then to bulimic and then back again, and now they are more clearly seeing that. “About one-third, if not more, of patients who have anorexia nervosa will transition into bulimia within two years of their illness. That is the general trend,” says Bunnell.

But the disease and its causes are widely misunderstood by the general public, according to a 2005 poll. Most American women blamed dieting and media coverage as the primary reasons people developed eating disorders, while men said it was caused by lack of willpower.

Research debunks another widely held myth about eating disorders: that they are the result of bad parenting. “It's clear that 'bad parenting' is not, per se, a risk factor” for developing an eating disorder, says Striegel-Moore.

However, many families are still faulted and shut out from treatment, says Clausen, who founded Ophelia's Place, a resource center in upstate New York for those with eating disorders. Clausen says she felt blamed for her two daughters having eating disorders, and that she “had to fight to get into therapy” with her daughters. “We need to involve the families,” she says.

A nationwide public-art campaign to raise awareness of eating disorders was launched in the late 1990s by artists Robin Lasser, of San Jose State University, and Kathryn Sylva of the University of California, Davis. Above, one of their billboards in Fairfield, Calif. (Eating Disorders in a Disordered Culture, www.eating.ucdavis.edu)
A nationwide public-art campaign to raise awareness of eating disorders was launched in the late 1990s by artists Robin Lasser, of San Jose State University, and Kathryn Sylva of the University of California, Davis. Above, one of their billboards in Fairfield, Calif. (Eating Disorders in a Disordered Culture, www.eating.ucdavis.edu)

In fact, one of the most promising new treatments for young anorexics involves the entire family. The so-called Maudsley Method, developed at London's Maudsley Hospital, neither blames the family for “causing” the disease nor the anorexic for “getting” it. Instead, everyone helps the anorexic manage and treat the disorder. Parents are told that food functions as medicine for the anorexic, just as insulin is medicine for a diabetic. So the parents must ensure the anorexic gets his or her medicine. The treatment appears less effective for older adolescents, adults or those who binge and purge.

Families may also play another, even larger role: Research increasingly shows that eating disorders tend to run in families. The National Alliance on Mental Illness estimates, for example, that a girl has a 10 to 20 times higher risk of developing anorexia nervosa if she has a sibling with the disease.

Differences in brain wiring also play a role. Researchers at the University of Pittsburgh found in 2005 that a chemical deep inside the brain, called dopamine, could make an anorexic unable to accept that they are too thin or the seriousness of their condition. 22

Researchers also are finding that psychotropic medications — which affect emotions — can help treat eating disorders. Antidepressants have helped bulimics but seem to work for anorexics only after they reach a normal weight.

Professionals increasingly agree that the first step in treating anorexia is to help the person gain weight, then dive into therapy or medication. “It's very hard to do psychotherapy with a starving brain,” says Bunnell.

Striegel-Moore acknowledges “the picture is totally bleak” for anorexics because no treatment has proven to be clearly superior to others — at least not until they've begun to gain weight. “It's really an emergency.”

Cognitive therapy appears to work in about 50 percent of bulimia cases, says Striegel-Moore.

Stalled in Congress

Eating-disorder experts haven't had much luck convincing Congress to make it easier for victims of eating disorders — and other mental disorders — to get insurers to pay for treatment. However, they hope the federal government's campaign to combat obesity will translate into more attention, research and federal dollars devoted to eating disorders.

The only federal law related to eating disorders was a 1989 congressional resolution establishing a National Eating Disorders Awareness Week. “That just goes to show how little has happened legislatively” regarding eating disorders, says Jeanine C. Cogan, policy director of the Eating Disorders Coalition for Research, Policy & Action, which is lobbying Congress to make eating disorders “a public-health priority.”

High on the coalition's wish list is “mental health parity,” which would require insurers to cover mental illness at the same level as physical illnesses. Although Congress passed a federal mental health parity law in 1996, it didn't prohibit insurers that offer mental health benefits from charging higher co-pays for those benefits than they charge for physical illnesses or from imposing stricter limits on treatment for mental illness. Mental health advocates have been lobbying for a broader version even before the 1996 bill passed.

People with eating disorders have a mental illness that distorts their body image, as dramatized in a poster from the National Eating Disorders Association. Men and women who starve themselves to stay thin can die from the resulting organ damage. (National Eating Disorders Association)
People with eating disorders have a mental illness that distorts their body image, as dramatized in a poster from the National Eating Disorders Association. Men and women who starve themselves to stay thin can die from the resulting organ damage. (National Eating Disorders Association)

Cogan says anorexics who are forced to be discharged from hospitals before they've gained enough weight usually end up being readmitted later, thus costing the health-care system more over the long term. In the 1980s, for example, before the widespread use of managed-care contracts, anorexic patients used to stay 50 days in a hospital getting treatment, and only 10 percent returned for further treatment. Now, she says, the average stay is only 15 days, but 33 percent of the patients return.

Cogan admits that mental health parity “seems stalled” and unlikely to pass as long as the House Republican leadership, particularly House Speaker J. Dennis Hastert R-Ill., opposes the measure. Many House Republicans, employers and insurance companies oppose parity, arguing that it would increase costs for employers at a time when many businesses are already struggling to pay for health care.

Meanwhile, most states require some level of coverage for mental illnesses, including eating disorders, but the requirements vary widely. While 47 states have a law or regulation affecting mental health coverage, many allow insurers to charge higher co-pays for mental health services or to limit service, says Lee Dixon, director of the Health Policy Tracking Service, in Falls Church, Va.

Only 26 states have what Dixon calls true “parity.” But four of those (Hawaii, Montana, Oklahoma and South Dakota) specifically exclude eating disorders from coverage. The remaining 22 states treat eating disorders as mental disorders and are covered.

When the movement to get mental health parity began at the state level nearly a decade ago, attention focused on biologically based mental illnesses like schizophrenia and bipolar disorder, Dixon says. Since then, research has shown that there is a biological basis for most, if not all, mental illnesses — including eating disorders.

In the meantime, eating-disorder experts are optimistic the nation's preoccupation with obesity will focus more attention on eating disorders. “A lot of funding is being directed to obesity now,” says Rome, of the Academy for Eating Disorders. “We would love to have some funding for eating-disorder work as well.”

NEDA estimates that the National Institutes of Health in 2005 spent $647 million on Alzheimer's research — a disease that affects 4.5 million people — but only $12 million on anorexia, which affects an estimated 11 million.

Some experts worry, however, that encouraging obese Americans to lose weight may trigger eating disorders. “The more we intensify our efforts to eliminate obesity, if we don't do it in a meaningful way it could lead to eating disorders,” Cogan says. She notes that research has shown that for some people, their eating disorder developed after going on a diet. “We have to be careful.”

The coalition also hopes Congress will direct the Centers for Disease Control and Prevention to do a better job tracking the number of people who die of eating disorders. As it stands, anorexia and bulimia are rarely put on a death certificate. Instead, the death is usually attributed to the physical ailment that killed the person, such as heart failure or low electrolytes.

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Outlook

New Medications

Many eating-disorder experts believe researchers eventually will find better ways to help sufferers and prevent others from developing the disorder in the first place.

“We've come quite a way in understanding how to treat a substantial number of people with bulimia and anorexia nervosa — that's the good news,” says NEDA's Bunnell. “The bad news is that we are talking about only about 50 percent of the patients responding to those therapies. We are left with what do we do with the other 50 percent.”

Several new medications hold promise. A schizophrenia medication called olanzapine has shown some benefit for anorexics, says the APA's Powers. And topiramate, a drug used to control seizures, may reduce frequency of bulimics' bingeing and purging. Another treatment, called “vagus nerve stimulation” — currently used to treat epilepsy and depression — also may help bulimics. The vagus nerve starts in the brain, goes down the neck where it affects the vocal cords, the acid content of the stomach and other organs. Some researchers think the treatment might help bulimics stop vomiting.

“There is a lot of exciting work being done,” Powers says.

Experts also hope research on the genetic link will eventually help professionals predict who is most likely to develop anorexia, possibly intervening earlier to prevent the onset of the disorder.

Meanwhile, efforts continue to help the general public better understand that eating disorders are serious illnesses and not just diets gone bad. “Clearly, these aren't choices, they are illnesses,” says Powers.

“We are near a tipping point with public awareness about eating disorders,” says Bunnell. “My hope would be that in five years it would be common for mothers to talk to their daughters about their risks,” particularly if the family has a history of eating disorders.

“We have to talk about it,” agrees New York activist Clausen, whose two daughters continue to battle eating disorders. “There's still a stigma, a denial” associated with eating disorders.

Westin agrees. She says her family in Minnesota was swamped with calls and letters from families “thanking us for being honest” by stating in Anna's death notice that she died of anorexia, something that was “unheard of” before then, she says.

Both mothers launched eating-disorder centers in their areas because no facilities were available nearby. While more information is available now, advocates worry that the media “glorifies and trivializes” the illnesses, says Cogan of the eating-disorders coalition. She hopes that in the next five to 10 years people will acknowledge eating disorders as serious illnesses that are an important public-health issue.

The more people know about eating disorders, the more they may seek help. “Eating disorders are very serious illnesses,” Westin says, “but they should never be fatal.”

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Pro/Con

Does insurance adequately cover eating disorders?

Pro

Karen Ignagni
President and CEO, America's Health Insurance Plans. Written for The CQ Researcher, February 2006

Eating disorders such as bulimia and anorexia are serious conditions that can have devastating consequences for individuals and their loved ones. Accordingly, more than 95 percent of all employer-sponsored health insurance plans provide some benefits for treatment of these and other mental health disorders. More than nine-out-of-10 people buying insurance on their own choose policies that have mental health coverage.

The issue with which policymakers and health-care stakeholders must grapple is how to ensure that coverage for services related to eating disorders is accessible to all those who need it.

In the past, many legislators gravitated to coverage mandates. Today, however, lawmakers are increasingly recognizing that coverage mandates often have unintended consequences. Many states have put the brakes on new mandates because they have been found to raise costs and thus inhibit access to coverage, as well as usurp employer and consumer purchasers' decision-making authority.

The discussion about coverage for eating disorders underscores the need for more data about which courses of treatment best help patients. Indeed, our entire health-care system suffers from a dearth of information about which therapies, technologies and providers are the safest and most effective.

Rather than taking a disease-by-disease approach to making health care more affordable and accessible, policymakers should focus on three priorities:

  • Evaluating how health costs can be brought under control to ensure that consumers and purchasers can get the coverage they want.

  • Determining the consequences of having legislators construct benefit packages that employers and individuals must purchase.

  • Finding the tipping point for employers and individuals to determine when mandates, however well intentioned, prevent the purchase of insurance.

Those afflicted with eating disorders deserve access to health-care services based on the best available medical evidence. Legislators need to encourage more research to determine what works rather than imposing coverage on purchasers. Collaboration among all stakeholders will do far more to improve treatment options and quality of care for eating disorders than mandating coverage requirements.

Con

Jeanine C. Cogan, Ph.D.
Policy Director, Eating Disorders Coalition for Research, Policy & Action. Written for the CQ Researcher, February 2006

Treatment for mental disorders in general and eating disorders in particular is not adequately covered by most health-insurance plans. For this reason, Congress passed legislation in 1996 requiring insurance companies to end their practice of capping the dollars spent on treatment for mental illness and reimburse for these conditions on par with the treatment of physical illness.

The intent of the law was to stop discrimination based on mental illness and provide parity for mental health treatment. Unfortunately, the insurance industry evaded the spirit of the law by replacing the caps on dollars spent for mental health treatment with caps on the number of visits to be reimbursed.

This practice has notable consequences for people suffering from eating disorders. The death rate for women with anorexia is 12 times greater than the general death rate for women in the same age group. Moreover, research indicates that as the length of treatment decreases for people with eating disorders, the risk for relapse and death increases.

According to a congressional briefing at the Renfrew Center, a residential treatment facility, prior to the proliferation of reimbursement caps eating-disorder patients stayed an average of 50 days. In 2001 the average stay had dropped to only 15 days, and the rate of returning patients rose to 33 percent compared to 10 percent when more days were reimbursed.

Other research corroborates this trend. Examining the changing patterns of hospitalization in eating-disorder patients, Wiseman and her colleagues found that readmissions of eating-disorder patients increased 27 percent between 1985 and 1998 as lengths of stays were briefer, and weight at discharge was lower.

And Baran and his colleagues found that the majority of patients discharged while still at a low weight are eventually readmitted. This suggests that the economic rationale for shortening eating-disorder treatment is canceled out by the higher costs associated with relapse and readmissions.

This documented trend of the revolving door results in sicker patients and higher death rates. As the duration of eating-disorder symptoms is prolonged, the prognosis for recovery decreases and the mortality rate increases.

Clearly, for people with severe eating disorders, adequate health-insurance reimbursement is not simply good public policy, it is a lifesaver. As such, the Eating Disorders Coalition is working with Congress toward the passage of mental health parity legislation that would continue to eliminate obstacles for life-saving treatment.

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Chronology

 
Early History The first medical account of ailments now known as eating disorders appears in the 17th century.
First CenturyThe ancient Romans abhorred being fat and set aside so-called vomitoriums where people who stuffed themselves with enormous amounts of food could throw up.
Middle AgesDevout Christians refuse food as a way to get closer to God, but by the late Middle Ages women who fast excessively are thought to possess evil spirits.
1689Richard Morton, the king of England's physician, describes cases of “nervous consumption” in his medical textbook, Phthisiologia: or, A Treatise of Consumptions.
1873Sir William Gull, an English physician, coins the term “anorexia nervosa” and describes it as “a perversion of the ego.”
1903French neurologist Pierre M.F. Janet describes a woman's compulsive eating in his book Les Obsessions et la Psychasthenie.
1960s-1980s Researchers suggest that anorexics act out their frustrations and feelings of inadequacy by restricting their eating. . . . Eating disorders are generally attributed to dysfunctional families.
1967The media's ideal for beauty shifts from full-figured women to waif-like Twiggy, the 92-pound British teen fashion model.
1976Vivian Meehan, a nurse in Highland Park, Ill., creates National Association of Anorexia Nervosa and Associated Disorders.
1979University of London researcher Gerald Russell coins the term bulimia nervosa.
1980American Psychiatric Association (APA) recognizes anorexia and bulimia as separate mental disorders.
1983Pop singer Karen Carpenter, 32, dies of a heart attack after a two-year battle with anorexia.
1989Congress creates National Eating Disorders Awareness Week.
1990s Researchers determine that genetics and brain chemistry may play a bigger role than societal pressures in determining whether someone develops an eating disorder.
1991-92National Collegiate Athletic Association finds that eating disorders exist in most men's and women's college sports.
1996Mental Health Parity Act requires lifetime and annual dollar limits on mental health care to equal the benefits for treatment of physical ailments.
1998-99Doctors in London find that increased levels of the brain chemical serotonin, which affects mood and appetite, may be linked to anorexic behavior; University of Pittsburgh researchers find that decreased serotonin activity may cause bulimic behavior.
2000s Experts debate whether binge eating should be a distinct and separate type of eating disorder.
January 2000“Healthy People 2010,” the federal government's health priorities for the next decade, seeks to reduce the number of people who relapse after getting help for eating disorders.
2001Web sites promoting eating disorders as a lifestyle, not a disorder, become popular.
2005State lawmakers in Iowa, Oregon and Washington require insurers to provide coverage for mental disorders equal to that for physical illnesses; the measures bring to 22 the number of states that cover treatment for eating disorders.
2006APA plans to update its treatment guidelines for eating disorders, including a larger section on binge eating. By 2011, the APA is expected to list binge eating as a separate eating disorder, alongside anorexia and bulimia.
  

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Short Features

The 1983 death of anorexic pop singer Karen Carpenter first alerted the American public to the deadly danger of eating disorders. But today celebrities and their eating disorders are frequent topics for Hollywood gossip sheets, TV shows and online blogs.

“The media reflect and exacerbate the problems,” argues Ellen Rome, a pediatrician in Cleveland and spokeswoman for the Chicago-based Academy for Eating Disorders. “These teen girls watch and read and observe and emulate.”

Psychologist Douglas Bunnell, a past president of the National Eating Disorders Association (NEDA), agrees. However, he cautions, by portraying the most extreme cases, the media can end up “marginalizing the illness.” He says his patients will look at scrawny celebrity photos and conclude, “ 'See, I'm not anorexic. I am not like that.' ”

On the other hand, Bunnell adds, “When they put Mary-Kate Olsen, Lindsay Lohan or whoever the star of the moment is who has an eating disorder out there, they are showing how shocking it is, and how people shouldn't develop these disorders.”

New York psychotherapist Steven Levenkron, who treated Carpenter before her death, wrote in a 2001 book that in some cases the media attention balloons “into circus sideshows,” becoming “a spectator sport for the non-afflicted public.” 1

Kate Dillon became a plus-size model after battling anorexia as a super-thin model. (Getty Images/Nick Elgar)
Kate Dillon became a plus-size model after battling anorexia as a super-thin model. (Getty Images/Nick Elgar)

The tribulations of Rachel and Clare Wallmeyer, 34-year-old Australian twins who have been fighting anorexia for 20 years, have been chronicled on TV in their homeland for years and became a story for U.S. entertainment shows in 2005. 2 At one point, the twins lived on watermelon, Diet Coke and at least 20 laxatives a day, and their combined weight was 105 pounds. Since 2003, the U.S. show “Entertainment Tonight” has been following the treatment of former TV reporter Melissa Dehart, who at one point dropped to 56 pounds.

But media coverage of eating disorders is not new. Talk-show host Oprah Winfrey covered the story of Rudine, a woman who died in 1995 weighing only 38 pounds, while Maury Povich hosted the anorexic twins Michaela and Samantha Kendall. Michaela died in 1994 and Samantha died three years later. 3

Model Kate Dillon said she got the idea to purge from a TV movie. At five feet 11 inches tall and a size 4, she was anorexic when she appeared in Vogue and Elle. She quit modeling in the mid-1990s when she was ordered to lose 20 pounds from her 125-pound frame. “I wanted freedom from this ideal, from these cultural ideals. I wanted freedom to be who I was,” she said during PBS's “Dying To Be Thin” broadcast in 2000. 4 Now she is a plus-size supermodel. “Plus size is no different than skinny, it's just another way of being beautiful,” she said.

Dillon is not alone in speaking publicly about her problem. The roster of celebrities sharing their stories include actress and 1980s fitness guru Jane Fonda; Jamie-Lynn DiScala, from HBO's “Sopranos,” who contemplated suicide while suffering for years with anorexia and bulimia; and singer-dancer Paula Abdul, the “American Idol” judge who in 2005 won an award from NEDA for discussing her own struggles with eating disorders.

Eating-disorder support and research organizations often take issue with advertisements they think promote or trivialize eating disorders. The National Association of Anorexia Nervosas and Associated Disorders successfully lobbied several companies, including Chanel, Hershey Foods and Revlon, to get them to change or pull ads touting slogans like, “You can never be too rich or too thin.” And NEDA is currently targeting Spencer Gifts for its T-shirts that flippantly read, “I beat Anorexia.”

The group “About Face” takes a more sarcastic approach when criticizing the culture of thinness. In 1995, it plastered hundreds of copies of a poster around San Francisco that spoofs a Kate Moss ad for perfume with “Emaciation Stinks: Stop Starvation Imagery.” The group also has a poster with a circus theme showing caged models that says, “Please Don't Feed the Models.”

But experts are clear that the media and Hollywood, by themselves, can't prompt someone to become anorexic or bulimic. “It's almost normative now for 16-year-old girls to loathe their bodies. That's certainly a byproduct of the culture,” says Bunnell, adding, “I don't think the culture causes eating disorders, but it absolutely contributes to it.”

[1] Steven Levenkron, Anatomy of Anorexia (2001).

[2] “Can These Anorexic Twins Be Saved?” The Insider, Nov. 3, 2005, http://insider.tv.yahoo.com/celeb/3278/.

[3] Cynthia R. Kalodner, Too Fat or Too Thin? (2003), p. 4.

[4] Transcript, “Dying to Be Thin,” PBS, Dec. 12, 2000. www.pbs.org/wgbh/nova/transcripts/2715thin.html.

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After failing to make the all-around competition at the 1992 Olympics, gymnast Kerri Strug began training with a new coach and eating less. If she were a little leaner or lighter, the 14-year-old thought, maybe she would perform better. Besides, her new coach frequently weighed his gymnasts, adding to the pressure. 5

Eventually, the 4-foot-9-inch gymnast weighed 78 pounds when her team won the first U.S. Olympic gold medal for gymnastics in 1996.

“I did lose a lot of weight in 1993, and my parents were very concerned,” Strug says today. But she says it wasn't an eating disorder. “I did not stop eating but was eating very little for someone exercising eight hours a day. All was taken care of within a matter of weeks. My parents ordered me my favorite cake, and I was back to eating what I wanted in moderation versus just fruit, veggies and protein.”

Most athletes with eating disorders can be found in sports where athletes are judged partly on physical appearance or where a really thin body is necessary for good competition, says Virgina Overdorf, a professor of movement science at William Patterson College in Wayne, N.J. For instance, while only about 3 percent of the general population develops eating disorders, up to 60 percent of athletes who compete in “aesthetic sports” — like gymnastics, diving and figure skating — develop disorders, says Teri McCambridge, an assistant professor of pediatrics at the Johns Hopkins University School of Medicine.

Similarly, long-distance runners, jockeys and cross-country skiers have a higher incidence of eating disorders than athletes in other sports. The belief “that the thinner athlete is the better athlete” pervades some sports cultures and encourages athletes to lose weight, says Ron Thompson, a psychologist in Indiana and a fellow at the Academy for Eating Disorders in Chicago.

Even a sport like wrestling, which may not require leanness per se, breeds athletes “who think they can improve performance by losing weight,” says Leigh Cohn, publisher of Gurze Books, which specializes in eating disorders and education, and co-author of the 2000 book, Making Weight: Healing Men's Conflicts with Food, Weight, and Shape.

Thompson and his associate Roberta Sherman identified a phenomenon they called “sport body stereotypes,” which dictate how athletes in different sports are expected to look. Distance runners are supposed to be thin, for instance, while football players are supposed to be larger. Athletes trying to maintain the body stereotypes associated with aesthetic and lean sports are more at risk of developing an eating disorder, says Thompson.

Aesthetic and lean sports tend to be individual sports rather than team sports, and their athletes often share a personality type — the “perfectionist personality,” says McCambridge. Characterized by a competitive drive for excellence, the perfectionistic personality is often found in both athletes and eating-disorder patients and can cause athletes to have more difficulty than the general population in maintaining a healthy diet.

Thompson explains that athletes, like those suffering from anorexia nervosa, exhibit a mental toughness, are never satisfied with their performance and make decisions based on what they think will please those around them. These traits allow athletes “to keep going when they are out of juice,” says Cohn, “in the same way anorexics can stop themselves from eating even though they're hungry.”

Some experts say coaches can unwittingly encourage eating disorders by suggesting an athlete lose weight without encouraging healthy weight-loss practices, according to McCambridge. Moreover, she says, a coach might attach punishment to weight gain, telling athletes they can't play unless they make a certain weight.

But Overdorf doesn't believe coaches cause eating disorders. While they may make careless comments about weight, those comments only affect athletes already predisposed to an eating disorder, she says.

Thompson blames the athletic culture that views some eating-disorder symptoms as normal — even desirable. For example, up to 67 percent of female athletes experience amenorrhea, the loss of menstruation, which is a common symptom of an eating disorder, explains Thompson. Even though amenorrhea can be harmful to women, many coaches don't see it as a problem. For instance, Thompson found that less than half of 3,000 National Collegiate Athletic Association coaches that he surveyed thought amenorrhea was abnormal and needed intervention. Many even thought it was advantageous, as it prevented menstruation from impairing performance.

Olympic gold medalist Kerri Strug and other athletes in “aesthetic” events are at risk for developing eating disorders. (Getty Images/Tony Duffy (1996)
Olympic gold medalist Kerri Strug and other athletes in “aesthetic” events are at risk for developing eating disorders. (Getty Images/Tony Duffy (1996)

Other research suggests that athletic participation can protect against eating disorders by building self-esteem, Thompson says, but mainly at non-elite levels in non-lean sports. And Mark F. Reinking, an assistant professor of physical therapy at St. Louis University, co-authored a study comparing disordered-eating symptoms of female collegiate athletes and non-athletes. The female athletes did not show more disordered-eating symptoms than the non-athletes. In fact, “athletes had a more normalized body satisfaction than the non-athletes,” says Reinking. 6

However, female athletes participating in lean sports were more at risk for developing disordered-eating behavior, suggesting that sports that don't emphasize leanness, like basketball and field hockey, might protect athletes from developing eating disorders.

Antonia Baum, a psychiatrist at George Washington University Medical Center, speculates that some athletes might join a sport because it provides an environment that could facilitate an eating disorder. Nancy Clark, director of nutrition services at Sports Medicine Associates, in Brookline, Mass., and author of Sports Nutrition Guidebook, agrees. “Many women get into sports, and they're disguised as athletes,” she writes, such as “the teenage girl who gets into running, where really the goal is to burn off calories.” 7

— Melissa J. Hipolit

[5] Eli Saslow, “Strug's Golden Years Come After Olympics,” The Washington Post, Aug. 10, 2004, p. D3.

[6] Mark F. Reinking and Laura E. Alexander, “Prevalence of Disordered-Eating Behaviors in Undergraduate Female Collegiate Athletes and Nonathletes,” Journal of Athletic Training, March 2005, pp. 47-51.

[7] Barbara Maston, “Sports Women; Anorexia: It's Not Going Away,” The Boston Globe, April 9, 2003, p. E12.

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Bibliography

Books

Kalodner, Cynthia R. , Too Fat Or Too Thin? Greenwood Press, 2003. The director of the counseling psychology program at Maryland's Towson State University provides a practical guide to eating disorders, including lists of books, movies and Web sites for students and parents interested in learning more.

Levenkron, Steven , Anatomy of Anorexia , W.W. Norton & Co., 2001. A New York psychotherapist stresses the importance of detecting early symptoms of anorexia and outlines various treatment options.

Lock, James, and Daniel le Grange , Help Your Teenager Beat An Eating Disorder , The Guilford Press, 2005. Two professors of psychiatry provide a roadmap for parents whose children have eating disorders, explaining the latest research in easy-to-understand language. Lock is director of the Eating Disorders Program for Children and Adolescents at Stanford University; le Grange is director of the eating-disorders program at the University of Chicago Hospitals.

Articles

“Body Image in Hollywood: Sending Wrong Messages?” CNN, Nov. 25, 2005. A report on Hollywood's obsession with being super-thin includes interviews with Jane Fonda, Paula Abdul and Jamie-Lynn DiScala about their eating disorders.

“Dying To Be Thin,” PBS, Dec. 12, 2000; www.pbs.org/wgbh/nova/thin/. NOVA talks to medical experts about eating disorders and provides tips for teachers interested in discussing the topic in class.

Matson, Barbara , “Sports Women; Anorexia: It's Not Going Away,” The Boston Globe, April 9, 2003, p. E12. Female athletes in sports that value a lean appearance — like gymnastics, figure skating and distance running — are at high risk for developing an eating disorder.

Reaves, Jessica , “Anorexia Goes High Tech,” Time, July 31, 2001. Reaves' report was one of the first national articles to examine the wave of pro-anorexia Web sites that started to flood the Internet in the late 1990s.

Silverman, Lauryn , “Hunger's Diary,” Youth Radio, also aired on National Public Radio's “Morning Edition,” May 16, 2005; www.youthradio.org/health/npr050516_anorexia.shtml. This first-person account of her struggle with anorexia by a high-school junior from Berkeley, Calif., won the 2005 Gracie Allen Award from the American Women in Radio and Television.

Tyre, Peg , “No One To Blame,” Newsweek, Dec. 5, 2005, pp. 51-60. A review of the latest advances and treatment for anorexia, including new findings related to genetics.

Reports and Studies

“American Public Opinion on Eating Disorders: A Poll Conducted on Behalf of the National Eating Disorders Association,” GMI Inc., March 2005. Most American women blame dieting and media coverage as the primary causes of eating disorders, while men blame a lack of willpower. Neither is accurate.

American Psychiatric Association Work Group on Eating Disorders , “Practice Guidelines for the Treatment of Patients with Eating Disorders,” American Journal of Psychiatry, January 2000, pp. 1-39. The latest guidance from the APA on eating disorders, slated to be updated in 2011.

Centers for Disease Control and Prevention, Department of Health and Human Services , National Youth Risk Behavior Surveillance, 2003, May 2004; www.cdc.gov/mmwr/PDF/SS/SS5302.pdf. Eighteen percent of high-school girls admit fasting for 24 hours or longer to trim down, while 11 percent tried diet pills or powders and 8 percent took laxatives or threw up, according to the latest government report.

National Association of Anorexia Nervosa and Associated Disorders , “A Brief Review of Therapies Used in the Treatment of Eating Disorders,” 2005; www.anad.org/site/anadweb/content.php?type=1&id=6901. Patricia Santucci, a physician, explains the major methods used to treat eating disorders, including one of the newest therapies, the Maudsley approach.

National Institute of Mental Health , “Eating Disorders: Facts About Eating Disorders and the Search for Solutions,” 2001; www.nimh.nih.gov/Publicat/eatingdisorders.cfm. A government booklet describes the symptoms, causes and treatments for eating disorders, with information on getting help.

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The Next Step

Adult Women

Morris, Bonnie Rothman , “Older Women, Too, Struggle With a Dangerous Secret,” The New York Times, July 6, 2004, p. F5. Doctors who are seeing a growing number of adult women with eating disorders suspect they have struggled with weight and body image throughout their lives.

White, Tanika , “A New Midlife Crisis: Fear of Food,” Los Angeles Times, Dec. 4, 2005, p. A22. As adult women develop eating disorders in higher numbers, experts blame media images that suggest older women should look like 20-year-olds as well as older women's feelings of loss of control over their lives.

African-Americans

Brodey, Denise , “Blacks Join Whites in Threatening-Disorder Mainstream,” Intelligencer Journal (Lancaster, Pa.), Sept. 20, 2005, p. B5. More African-American girls are seeking help for severe eating disorders than ever before, and experts are wondering if they receive proper treatment.

Tharp-Taylor, Shannah , “Anorexia in Blacks Gets New Scrutiny,” Chicago Tribune, Aug. 25, 2003, p. 1. Eating-disorder experts are researching whether African-American anorexics are more common than previously thought.

Athletes

Case, Christa , “First Steps to Curb Eating Disorders Among Top Athletes,” The Christian Science Monitor, Aug. 26, 2004, p. 11. Many experts believe the attributes that produce athletic success, like perfectionism and strict discipline, can lead to eating disorders.

Hersh, Philip , “Are Ski Jumpers Too Thin?” Chicago Tribune, Jan. 16, 2002, p. 7. Ski-jumping techniques favor lighter athletes, pushing jumpers to develop eating disorders.

Josephs, Ira , “Ounce of Prevention,” The Philadelphia Inquirer, March 6, 2005, p. D1. Wrestling has gone through a steady period of reform, helping to eliminate fasting and purging, after three NCAA wrestlers died in 1997.

Liddane, Lisa , “Athletic Females at Risk for Disorder,” Chicago Tribune, Aug. 21, 2002, p. 7. Female athletes are at risk for developing a health-threatening disorder termed the 'female athlete triad,' which is the lost of menstruation due to disordered eating that causes bones to become porous and brittle.

Norwood, Robyn , “Fed Up With the Hunger,” Los Angeles Times, July 21, 2004, p. A1. Jockeys are beginning to push for an increase in the minimum weights horses carry after years of pressure from owners and trainers to be as light as rules permit triggered numerous eating disorders.

Binge Eating

The Associated Press, “Some Can Blame Genes for Binge Eating, Researchers Suggest,” The Houston Chronicle, March 20, 2003, p. A12. A study focused on a gene that helps the brain regulate appetite suggests mutations in the gene can make the body feel too much hunger and can lead to binge eating.

Squires, Sally , “Secret Lives of Bingers and Nighttime Noshers,” Los Angeles Times, Jan. 23, 2006, p. F4. Clinical experience and a few studies suggest binge-eating disorder and night-eating syndrome are two distinct disorders that affect about 2 percent of the general population.

Celebrities

Hagen, Mindy B. , “Actress Recounts Exercise-Bulimia Struggle,” The Herald-Sun (Durham, N.C.), Feb. 22, 2005, p. C1. “Sopranos” star Jamie-Lynn DiScala was almost recast after losing 40 pounds due to an eating disorder — exercise bulimia.

Leibrock, Rachel , “The Skinny on the Stars Lindsay Lohan and Nicole Richie: What's Putting Young Hollywood in the Thick of Ultra-Thin?” Sacramento Bee, June 7, 2005, p. E1. Young celebrities like Lindsay Lohan, Mary-Kate Olsen and Nicole Richie undergo extreme weight loss after becoming famous.

Susman, Carolyn , “Lohan Battles Bulimia and Denial,” Palm Beach Post (Florida), Feb. 1, 2006, p. E1. Actress Lindsay Lohan admitted to Vanity Fair that she suffers from bulimia but later claimed she was misquoted, leading psychologists to speculate she is in denial about her problem.

Witlin, Dawn , “Rail-Thin Celebs Motivate Many With Eating Disorders,” The Boston Herald, Nov. 21, 2005, p. 3. Images of emaciated celebrities, like Nicole Richie, reinforce extreme dieting and provide many young Americans with “thin-spiration.”

Genetics

Roan, Shari , “Seeking a Genetic Link to Anorexia Nervosa,” Los Angeles Times, April 7, 2003, p. 3. Scientists suspect a number of genes — not just one — cause personality traits common to people who develop anorexia, prompting the U.S. government to fund research to search for the genes.

Shell, Ellen Ruppel , “The Ancestry of Anorexia Blame Biology, Not Parenting, New Theory Suggests,” The Boston Globe, Dec. 30, 2003, p. D1. Psychologist Shan Guisinger theorizes that anorexics have a biological adaptation in their genes that causes their bodies to shut off hunger signals.

Insurance Coverage

Barnard, Anne , “Wasting Away Women Suffering From Eating Disorders Finally Get the Medical and Psychological Attention They Need,” The Boston Globe, July 1, 2003, p. C4. Doctors and the families of eating-disorder patients are finding private dollars to support new treatment centers for the disorders after insurance companies refuse to pay for treatment after a patient leaves the hospital.

Galloway, Angela , “ 'Great Leap' On Mental Health Law Mandates Equal Insurance Coverage,” The Seattle Post-Intelligencer, March 10, 2005, p. B1. Lawmakers in Washington passed a mental health parity bill requiring insurance companies to cover psychiatric care on the same terms as medical or surgical care.

Waterhous, Therese S. , “Treating Anorexia: The Question of Insurance,” The Seattle Times, Nov. 10, 2004, p. F2. All major insurance companies consider eating disorders to be behavioral-health issues that qualify for mental health benefit provisions — which often offer less coverage — and not medical coverage.

Obesity

The Associated Press, “Teenage Girls' Radical Dieting Can Cause Obesity, Study Says,” The Houston Chronicle, April 21, 2005, p. B2. Researchers found that adolescent girls who use harsh weight-control measures, including skipping meals, vomiting and using laxatives, are more likely to become obese than those who eat high-fat foods or sometimes gorge themselves.

Roan, Shari , “A Reluctance to Broach the Topic of Weight,” Los Angeles Times, May 9, 2005, p. F4. Parents of obese children are reluctant to talk to their children about their weight, fearing it might trigger an eating disorder, but doctors and eating-disorder experts say that with obesity on the rise in the United States, parents must intervene.

Treatment

Gollob, Beth , “When Food Becomes the Enemy,” The Daily Oklahoman, Dec. 27, 2005, p. A13. Tulsa's Laureate Clinic and Psychiatric Hospital helps patients with eating disorders by using art therapy, separate programs for children and adults and teaching healthy eating and exercise habits.

Roan, Shari , “Just One Rule: Eat,” Los Angeles Times, Oct. 3, 2005, p. F1. A controversial new family-centered approach to treating eating disorders engages a patient's entire family in therapy, teaching parents and siblings how to outmaneuver attempts to avoid food.

Uhlman, Marian , “A Way Station to Cure Eating Disorders,” The Philadelphia Inquirer, Aug. 5, 2002, p. E1. Philadelphia's Renfrew Center exclusively treats eating disorders, utilizing many forms of therapy, from individual counseling and group sessions to monitored eating and gentle exercise.

Vuong, Mary , “A Desire to Be Perfect Can Make Treating the Eating Disorder Difficult,” The Houston Chronicle, July 7, 2004, p. 1. A gold standard for treating anorexia nervosa has not been developed because of resistant patients, their development of other disorders — like depression — and the stigma that the problem is self-inflicted.

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Contacts

Academy for Eating Disorders
60 Revere Dr., Suite 500, Northbrook, IL 60062-1577
(847) 498-4274
www.aedweb.org
An international organization for professionals in the field.

Alliance for Eating Disorders Awareness
P.O. Box 13155, North Palm Beach, FL 33408-3155
(866) 662-1235
www.eatingdisorderinfo.org
Disseminates information to parents and caregivers about warning signs, dangers and consequences of eating disorders.

American Psychiatric Association
1000 Wilson Blvd., Suite 1825, Arlington, VA 22209
(703) 907-7300
www.psych.org
Represents physicians who specialize in mental illnesses, including eating disorders.

Anorexia Nervosa and Related Eating Disorders
www.anred.com
Nonprofit organization provides information about eating disorders, including self-help tips and a survey.

Eating Disorder Referral and Information Center
2923 Sandy Pointe, Suite 6, Del Mar, CA 92014-2052
(858) 792-7463
www.edreferral.com
Provides referrals to eating-disorder practitioners, treatment facilities and support groups nationwide.

Eating Disorders Coalition for Research, Policy & Action
, 611 Pennsylvania Ave. S.E., #423, Washington, DC 20003-4303
(202) 543-9570
www.eatingdisorderscoalition.org
Lobbies Congress for more federal attention to eating disorders.

National Alliance on Mental Illness
Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042
(703) 524-7600
www.nami.org
Provides information on eating disorders and advocates on behalf of victims of those and other mental conditions.

National Association of Anorexia Nervosa and Associated Disorders
Box 7, Highland Park, IL 60035
(847) 831-3438
www.anad.org
Provides hotline counseling, a national network of free support groups and referrals.

National Eating Disorders Association
603 Stewart St., Suite 803, Seattle WA 98101
(800) 931-2237
www.nationaleatingdisorders.org
The largest U.S. organization in the field was formed in 2001 with the merger of Eating Disorders Awareness and Prevention and the American Anorexia Bulimia Association.

National Institute of Mental Health
6001 Executive Blvd., Bethesda, MD 20892
(301) 443-4513
www.nimh.gov
Federal agency that studies eating disorders.

“Something Fishy,”
www.somethingfishy.org
This Web site on eating disorders calls itself a “pro-recovery” site, as opposed to sites that promote eating disorders as lifestyles, rather than diseases. Provides information in easy-to-understand terms.

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Footnotes

[1] More information about both young women can be found at www.annawestinfoundation.org/annastory.htm and “Living With Bulimia: Kathy Benn,” Aug. 11, 2005, www.webmd.com/content/article/109/109397.htm.

[2] National Eating Disorders Association, “Statistics: Eating Disorders and Their Precursors,” 2005.

[3] For background, see Alan Greenblatt, "Obesity Epidemic," CQ Researcher, Jan. 31, 2003, pp. 73-104.

[4] National Association of Anorexia Nervosa and Associated Disorders, “Facts About Eating Disorders,” 2005; www.anad.org/site/anadweb/content.php?type=1&id=6982.

[5] Cynthia R. Kalodner, Too Fat or Too Thin? (2003), p. 33.

[6] U.S. Department of Health and Human Services, “The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity,” December 2001; www.surgeongeneral.gov/topics/obesity/.

[7] For background, see Jane Tanner, "Mental Health Insurance," CQ Researcher, March 29, 2002, pp. 265-288.

[8] “American Public Opinion on Eating Disorders,” poll conducted for National Eating Disorders Association by GMI Inc., March 25, 2005.

[9] Jill King Greenwood, “Online Anorexia,” Pittsburgh Tribune-Review, Dec. 4, 2005.

[10] Lucile Packard Children's Hospital at Stanford, press release, “Web Sites Promoting Eating Disorders Are Widely Used by Adolescents with the Condition, Say Researchers at Stanford and Lucile Packard Children's Hospital,” May 16, 2005.

[11] Academy for Eating Disorders, “Position Statement on Pro-Anorexia Web Sites,” www.aedweb.org/policy/pro-anorexia_sites.cfm.

[12] Greenwood, op. cit.

[13] Rudolph M. Bell, Holy Anorexia (1985).

[14] Background drawn from LeeAnn Alexander-Mott and D. Barry Lumsden, Understanding Eating Disorders (1994).

[15] Kalodner, op. cit., p. 52.

[16] For background, see Richard L. Worsnop, “Eating Disorders,” CQ Researcher, Dec. 18, 1992.

[17] James Lock and Daniel le Grange, Help Your Teenager Beat An Eating Disorder (2005).

[18] Kalodner, op. cit.

[19] National Eating Disorders Association, “The Facts & Statistics,” www.nationaleatingdisorders.org.

[20] Kalodner, op. cit.

[21] “Genetic clues to eating disorders,” BBC News, Jan. 21, 1999.

[22] University of Pittsburgh press release, “Specific regions of brain implicated in anorexia nervosa, finds Univ. of Pittsburgh study,” July 7, 2005.

[23] Deborah L. Shelton, “Expert sees growing problem of youngsters with eating disorders,” Los Angeles Times, Jan. 9, 2011, http://articles.latimes.com/2011/jan/09/health/la-he-kids-eating-disorders-20110109.

[24] Margaret Renki, “The Scary Trend of Tweens with Anorexia,” Parenting, www.cnn.com/2011/HEALTH/08/08/tweens.anorexia.parenting/index.html.

[25] Ibid.

[26] Tara Parker Pope, “An Older Generation Falls Prey to Eating Disorders,” The New York Times, March 28, 2011, http://well.blogs.nytimes.com/2011/03/28/an-older-generation-falls-prey-to-eating-disorders/.

[27] Sandra G. Boodman, “Eating Disorders: Not Just for Women,” The Washington Post, March 13, 2007, www.washingtonpost.com/wp-dyn/content/article/2007/03/09/AR2007030901870.html.

[28] Laura Donnelly and Leah Farrar, “Hundreds of Preteen Children Treated for Eating Disorders,” The Telegraph, July 30, 2011, www.telegraph.co.uk/health/children_shealth/8672564/Hundreds-of-preteen-children-treated-for-eating-disorders.html.

[29] Benjamin Radford, “Who's to Blame for Anorexic Children?” Discovery News, Aug. 9, 2011, http://news.discovery.com/human/-thin-models-not-to-blame-for-anorexia.html.

[30] “Severity of Binge Eating Disorder Linked to Childhood Sexual or Emotional Abuse, Researchers Find,” Science Daily, May 20, 2010, www.sciencedaily.com/releases/2010/05/100512125230.htm.

[31] Cynné Simpson, “Study Connects Eating Disorders, Depression,” WJLA-TV, June 2, 2011, www.wjla.com/articles/2011/06/study-connects-eating-disorders-depression-61733.html.

[32] Lauren Katims, “Insurer Fears Ruling on Eating Disorders will Raise Costs,” Sacramento Business Journal, Oct. 7, 2011, www.bizjournals.com/sacramento/print-edition/2011/10/07/recent-ruling-on-eating-disorders.html?page=all.

[33] Kathleen Masterson, “Binge Eating Officially Defined as a Mental Disorder,” NPR, Feb. 10, 2010, www.npr.org/templates/story/story.php?storyId=123539741.

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Update

Key events since the CQ Researcher report on Feb. 10, 2006.

Eating-disorder experts have been warning for years that anorexia sufferers were getting younger and younger. So they were not surprised when a coalition of British hospitals announced in 2011 that children as young as 5 were being treated for the disorder, a finding that stunned the public on both sides of the Atlantic.

Miss America 2008 Kirsten Haglund greets the audience at the 2009 Miss America Pageant in Las Vegas (Getty Images/Ethan Miller)
Miss America 2008 Kirsten Haglund, who overcame anorexia and campaigns to raise awareness of eating disorders, greets the audience at the 2009 Miss America Pageant in Las Vegas, Nev., on Jan. 24, 2009. (Getty Images/Ethan Miller)

“I've seen eating disorders in kids as young as 7 or 8, and I have colleagues that have seen even younger patients,” said David S. Rosen, an eating-disorder expert and professor of adolescent medicine, pediatrics and internal medicine at the University of Michigan Health System. “My most common patients now start at ages 11, 12 and 13.”23

The rising number of afflicted young children is one of several worrisome eating-disorder trends over the last few years. Therapists also report seeing more men developing eating disorders and a growing number of older adults with anorexia and other disorders, such as bulimia and binge eating. Experts don't know whether the overall rate of eating disorders is rising or there simply is greater awareness of the problem.Footnote *

“I don't know if there are more people with eating disorders, but there are more people calling for help,” says Lynn Grefe, chief executive officer of the National Eating Disorders Association.

Disease Spreads Among Preteens

More than 60 percent of elementary- and middle-school teachers say eating disorders are a problem in their schools, according to the National Association of Anorexia Nervosa and Associated Disorders. Some 42 percent of children in first through third grades wish they were thinner, and slightly more than half of 9- and 10-year-olds said they feel better about themselves when they're dieting, according to the National Eating Disorders Association.24

The story of a 10-year-old girl in Chattanooga, Tenn., is typical. As recounted last year in Parenting magazine, she began exercising compulsively while eating less and less. “If I put something in front of her that she thought would make her fat, you'd see the fear in her eyes,” her mother said. “She'd force herself to take a bite or two, and then she couldn't eat any more. I tried being nice, and I tried being firm, but there was just no way to make her eat…. If she'd been 13, I would have been worried, but I didn't think it could happen to a 10-year-old.”25

The girl recovered after being hospitalized several times and undergoing intensive therapies.

Disease Hits the Elderly, Men

Meanwhile, more older Americans are asking for help with eating disorders, experts say. Some battled eating disorders early in life and then relapsed decades later; others first develop symptoms in their 40s, 50s or even later.

“We're hearing from women, no matter how old they are, that they still have to achieve this societal ideal of thinness and perfection,” said Cynthia M. Bulik, director of the Eating Disorders Program at the University of North Carolina, Chapel Hill. “Even in their 50s and 60s — and, believe it or not, beyond — women are engaging in extreme weight- and shape-control behaviors.”26

The program initially focused on teenagers, but about half the patients in recent years have been adults.

Until now, eating disorders had been associated more with women, but men are seeking help in growing numbers. Earlier studies had estimated that males accounted for about 10 percent of bulimia and anorexia cases. But a 2007 Harvard University study of 3,000 adults with eating disorders found that 25 percent of those with anorexia or bulimia and 40 percent of binge eaters were male, a rate the researchers called “surprisingly high.”27

Cause Remains a Mystery

Despite ongoing research, experts are unsure of the causes behind the high rates of eating disorders. Many advocates for victims of the disease complain that societal values equate being thin with being beautiful. They want to rein in advertisements that use very thin models.

Several factors combine to trigger eating disorders, said Susan Ringwood, chief executive of Beat, a British eating-disorders organization. “Biology and genetics play a large part, but so do cultural pressures,” she said. “And body image seems to be influencing younger children much more over the past decade. Girls see the pictures in magazines of extremely thin women and think that is how they should be.”28

Photo of an emaciated girl with the slogan “No to anorexia.” (AFP/Getty Images/Damien Meyer)
An Italian billboard sponsored by the Italian clothing firm No-l-ita features a photo of an emaciated girl with the slogan “No to anorexia.” The company also ran the ad in double-page newspaper spreads during fashion week in Milan in September 2007 to protest the promotion of ultra-thin models by major designers. (AFP/Getty Images/Damien Meyer)

In a research study, Beat found that girls as young as 7 who looked at drawings of women believed the thinner ones were happier and more popular.

Some experts, however, suggest that the link between eating disorders and media messages may be overstated. “People have long been blaming families and the media, but eating disorders are biological illnesses, and better treatments will come from more biologically based approaches,” said Walter Kaye, director of the Eating Disorders Treatment and Research Program at the University of California, San Diego, School of Medicine.29

Research increasingly links eating disorders to other psychological problems. For example, a 2009 study concluded that binge eaters often have a history of childhood sexual or emotional abuse.30 Another study found a greater risk of suicide by those with an eating disorder.31

Cultural messages about diet are becoming more complex due to rising concerns, raised by first lady Michelle Obama and others, about childhood obesity. Eating-disorder experts, while agreeing that reducing childhood obesity is a worthy goal, worry that promoting such a campaign could drive thin children to shed more pounds.

“The anti-obesity messages are often ones that can trigger eating-disorder thoughts and behaviors,” says Lisa Lanzano, a dietician who treats patients with eating disorders in Boulder, Colo. “All of a sudden they take carbohydrates out of their diet and they lose weight, and they didn't have much weight to lose to begin with.”

Promising Treatments

Treating eating disorders remains difficult, but the so-called Maudsley Method appears increasingly successful for young people with anorexia. It consists of intense outpatient treatment in which a therapist, working with the family, monitors the patient's physical symptoms while helping to set up an eating routine at home in which the patient gradually restores weight under the guidance of parents or other family members. During the course of about a year of focused therapy, the patient begins to eat independently and eventually establishes a healthy self-image.

Unlike other therapies, it requires focused involvement by parents. Studies have indicated the approach can successfully treat two-thirds or more of anorexic patients. “When I get healthy families who are intact and willing to step in and help, I see really good success in those cases,” says Lanzano.

Many eating-disorder sufferers have trouble getting health insurance. Although Congress in 2008 passed legislation requiring insurers to provide coverage for mental health disorders, the Wellstone-Domenici Mental Health Parity and Addiction Equity Act did not specify which illnesses must be covered. Thus, insurers have considerable leeway over whether or not to cover certain therapies for eating disorders.

In 2009 and again in 2011, lawmakers introduced a comprehensive Federal Response to Eliminate Eating Disorders bill that would require coverage for eating disorders, but it has not advanced.

Going to Court

Patients have had more success in the courts. In August 2011, a three-judge panel of the Ninth U.S. Circuit Court of Appeals in San Francisco ruled that Blue Shield of California must cover an anorexic patient's nine-month stay in an eating-disorder facility. The judges based their decision on California's 1999 Mental Health Parity Act, which required insurers to cover treatment of mental illnesses to the same extent that they cover physical illnesses.

Blue Shield announced it would appeal the decision. “If the court or lawmakers expand benefits to include costly, long-term residential programs that are not medical in nature, premiums will rise for everyone,” said Patrick Johnston, president of the California Association of Health Plans.32

The insurance situation “is still very difficult,” says Grefe of the National Eating Disorders Association. “The [federal] mental health parity act didn't specify which disorders would be covered, so it's up to the insurance company.”

Binge eaters could get coverage based on a potential decision by the American Psychiatric Association (APA). In 2010, an APA working group recommended that binge eating be listed as a disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, scheduled for publication in 2013. That recommendation and other proposed DSM-5 changes must undergo public review, testing in clinical settings and possible revisions before being added to the manual. Anorexia and bulimia are already APA-recognized disorders.

While binge eating is common for most people from time to time, those with the disorder engage in it at least once a week for three months. “This is recurrent, persistent, … accompanied by lots of distress, guilt and unhappiness,” said B. Timothy Walsh, a psychiatry professor at Columbia University Medical Center in New York and chairman of the eating-disorders working group for the upcoming version of the DSM. 33

The inclusion of binge eating as a mental disorder could not only help patients seeking coverage but also lead to better treatments, experts say. “You can't take someone with a binge-eating disorder and just put them on a diet,” says Grefe. “It's a mental disorder.”

— David Hosansky

Chronology

 
2007
February —Harvard University study finds that 25-40 percent of Americans with eating disorders are male, far exceeding earlier estimates.
2008
Oct. 3 —Wellstone-Domenici Mental Health Parity and Addiction Equity Act requires insurance companies to cover mental disorders but does not specifically mandate coverage of treatment for eating disorders.
2009
Feb. 25 —Lawmakers introduce Federal Response to Eliminate Eating Disorders legislation, which would require insurance companies to cover treatment for eating disorders. The bill does not advance; similar legislation is introduced in 2011.
2010
Feb. 10 —American Psychiatric Association recommends listing binge eating as a mental disorder.
2011
Aug. 1 —British hospitals say some 5-year-olds have eating disorders.
Aug. 26 —Court orders Blue Shield of California to cover medical expenses of anorexic patient, a victory for those seeking coverage for eating disorders.
2013
May —New edition of Diagnostic and Statistical Manual of Mental Disorders may include binge eating.
  

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*People with anorexia nervosa fear putting on weight, often because of a distorted self-image, and fail to eat enough to maintain a healthy weight. In extreme cases, anorexia can lead to death by starvation. Bulimia nervosa, in contrast, consists of episodes of overeating and then purging the food through such methods as self-induced vomiting, using laxatives or trying to offset the overeating by excessive exercise. Binge eating involves frequent consumption of large amounts of food without being hungry and then feeling distressed afterward.



Document APA Citation
Prah, P. M. (2006, February 10). Eating disorders. CQ Researcher, 16, 121-144. Retrieved from http://library.cqpress.com/
Document ID: cqresrre2006021000
Document URL: http://library.cqpress.com/cqresearcher/cqresrre2006021000
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