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                              EATING DISORDERS
                     WHEN THINNESS BECOMES AN OBSESSION

By Dixie Farley

Hula hoops, the bunny hop, punk hair styles. Fads come and go, and most are harmless. But when it's a fad to self-induce symptoms of a severe illness, the current craze isn't harmless anymore.

That hazardous fad involves bulimia, a severe eating disorder of compulsive bingeing and purging. People with bulimia rapidly eat tremendous amounts of food and then get rid of the food by vomiting or other means. Bulimia symptoms are found in 40 percent to 50 percent of patients with another potentially life-threatening disorder called anorexia nervosa, or compulsive self-starvation.

"Bulimia almost has celebrity status, the 'in' thing to have," says Dr. Sue Bailey, director of the Eating Disorders Clinic at the Washington (D.C) Hospital Center. According to Bailey, victims think at first that they've found a great solution to weight control, that "they can eat whatever they want and get rid of it. Then, after a couple of years, it hits: 'I thought I could stop any time. But I can't'".

Bailey was medical consultant to a recent Gallup Poll which projected that about 2 million American women 19 to 39 and 1 million teenagers are affected by some symptoms of bulimia or anorexia. In her own survey of several Washington, D.C., area private schools, Bailey found that 28 percent of one school's eighth graders said they would consider vomiting to lose weight.Many reported dieting since age 13, being dissatisfied with their body since age 10, and always trying to be perfect. "In other words," she says, "many girls were showing a real vulnerability to an eating disorder."

U.S. studies of female high school and college students suggest a bulimia prevalence ranging from 4.5 percent to 18 percent. But in the American Journal of Psychiatry (July 1985), Kathleen Hart and Dr. Thomas Ollendick of Virginia Polytechnic Institute and State University reviewed many studies and found that when more stringent criteria are used with college samples, the prevalence of the syndrome of bulimia is markedly less than that suggested by the prevalence of the symptom of binge eating. Their own study put the occurrence of bulimia syndrome in female college students at 5 percent. Anorexia is estimated to occur in one of every 200 females aged 12 to 18. Males are said to account for about 5 percent to10 percent of bulimia and anorexia cases. (Because male victims are so few, we'll refer to all patients as females.) More research is needed to determine the exact incidence of bulimia and anorexia.

People of all races can develop bulimia and anorexia, but the vast majority of patients are white, which may reflect socioeconomic, rather than racial, factors. Yet the illnesses are not restricted to females with certain occupational or educational backgrounds. What causes the illnesses and why they occur primarily in females are unknown.

The disorders are obsessive--that is, most victims can't stop their self-destructive behavior without professional medical help. Left untreated either disorder can become chronic and can result in severe health damage, even death. While the number of deaths from bulimia are unknown, 101 deaths from anorexia were reported in 1983, the latest year for which statistics are available. Fortunately, early diagnosis with prompt treatment greatly improves the chances of recovery from these disorders.

The American Psychiatric Association's criteria for diagnosing bulimia and anorexia are currently being revised. All criteria must be met for a case to be recognized as an occurance of bulimia or anorexia. The working draft of the revisions reads as follows.

For the syndrome of bulimia:

• Recurrent episodes of binge-eating (rapid consumption of a large amount of food in a discrete period of time, usually less than two hours).
• During the eating binges there is a feeling of lack of control over the eating behavior.
• The individual regularly engages in either self-induced vomiting, use of laxatives, or rigorous dieting or fasting in order to counteract the effects of the binge-eating.
• A minimum average of two binge-eating episodes per week for a least three months.

For the syndrome of anorexia nervosa:

• Intense fear of becoming obese, even when underweight.
• Disturbance in the way in which one's body weight, size or shape is experienced--e.g., claiming to "feel fat" even when emaciated, belief that one area of the body is "too fat" even when obviously underweight.
• Refusal to maintain body weight over a minimal normal weight for age and height--e.g., weight loss leading to maintenance of body weight 15 percent below expected; failure to make expected weight gain during period of growth, leading to body weight 15 percent below expected.
• In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea). (Primary amenorrhea means menstruation fails to occur at puberty; secondary amenorrhea means menstruation ceases after having been established.)

Ordinarily, bulimia begins between ages 17 and 25. However, because many bulimics are deeply ashamed of their bingeing and purging and therefore keep these activities a guarded secret, an actual diagnosis may not be made until a patient is well into her 30's or 40's. In Cosmopolitan (January 1985), for example, actress Jane Fonda revealed that she had been a secret bulimic from age 12 until her recovery at age 35--bingeing and purging as much as 20 times a day.

Bulimia usually begins in conjunction with a diet. But once the binge-purge cycle becomes established, it can get out of control. Some bulimics may be somewhat underweight and a few may be obese, but most tend to keep a nearly normal weight. In many, the menstrual cycle becomes irregular. Sexual interest may diminish. Bulimics may exhibit impulsive behaviors such as shoplifting and alcohol and drug abuse. Many appear to be healthy and successful, perfectionists at whatever they do. Actually, most bulimics have very low self-esteem and are often depressed.

Binges may last eight hours and result in an intake of 20,000 calories (that's roughly 210 brownies, or 5 1/2 layer cakes, or 18 dozen macaroons). One study, however, showed the average binge to be slightly less than 1 1/4 hours and slightly more than 3,400 calories (an entire pecan pie, for instance). Most binges are carried out in secret. Bulimics often spend $50 or more a day on food and may even steal (food or money) to support the obsession.

To lose the gained weight, the bulimic begins purging, which may include using laxatives--from 50 to 100 or more tablets at one time--or diuretics (drugs to increase urination) or self-induced vomiting caused by gagging, using an emetic (a chemical substance that causes vomiting), or simply mentally willing the action. Between binges, the person may fast or exercise excessively.

Bulimia's binge-purge cycle can be devastating to health in a number of ways. It can upset the body's balance of electrolytes--such as sodium, magnesium, potassium and calcium--which can cause fatigue, seizures, muscle cramps, irregular heartbeat, and decreased bone density, which can lead to osteoporosis. Repeated vomiting can damage the esophagus and stomach, cause the salivary glands to swell, make the gums recede, and erode tooth enamel. In some cases, all of the teeth must be pulled prematurely because of the constant wash by gastric acid. Other effects may be rashes, broken blood vessels in the cheeks, and swelling around the eyes, ankles and feet. For diabetics, bingeing on high-carbohydrate foods and sweets is particularly hazardous, since their bodies cannot properly metabolize the starches and sugars.

Bulimia's severe health risks and potential for becoming obsessive do not bode well for a decision to "try it out." Dr. Bailey points out, "Very rarely do I hear someone say, 'Oh yes, I had bulimia for three years and I just atopped one day and now I'm fine.' It's very hard to give up the behavior. Once somebody tells me they've done this several times--in my mind, they're probably hooked."

While anorexia nervosa most commonly begins in adolescence or the early 20's, onset also is reported (albeit far less frequently) in people ranging in age from about 8 to 60. The incidence in 8- to 11-year-olds is said to be increasing.

Anorexia may be a sudden, limited episode--that is, the person may lose a drastic amount of weight within a few months and then recover. Or the illness may gradually work itself into the victim's life and go on for years. A person may diet normally for several weeks, for instance, and then increasingly restrict her food intake until the diet gets out of control. Anorexia may fluctuate between spells of improvement and worsening, or it may become steadily more severe.

Anorectics are described as having low self-esteem and feeling that othersare controlling their lives. Some may be very over-active--exercising excessively despite fatigue. The preoccupation with food usually prompts strange food-related patterns, or rituals: crumbling food, moving it about on the plate, cutting it into very tiny pieces to prolong meals, and not eating with the rest of the family. The anorectic sometimes becomes a gourmet cook, preparing elaborate meals for others while eating low-calorie food herself.

The anorectic becomes obsessed with a fear of fat and with losing weight. In her mind's eye, she sees normal folds of flesh as fat that must be eliminated. She may have trouble sleeping. Because there's no longer a fat tissue padding, sitting or lying down brings discomfort, not rest. As her obsession increasingly controls her life, she may withdraw from friends.

Many of the anorectic's peculiar behaviors and bodily changes are typical of any starvation victim. Thus, some functions are often restored to normal when sufficient weight is regained. Meanwhile, the starving body tries to protect itself--especially its two main organs, the brain and the heart--by slowing down or stopping less vital body processes. Thus menstruation ceases, often before weight loss becomes noticeable, blood pressure and respiratory rate slow down, and thyroid function diminishes--resulting in brittle hair and nails, dry skin, slowed pulse rate, cold intolerance, and constipation. With depletion of fat, the body temperature is lowered. Soft hair called lanugo forms over the skin. Electrolyte imbalance can become so severe that irregular heart rhythm, heart failure, and decreased bone density occur. Other physical signs and symptoms can include mild anemia, swelling of joints, reduced muscle mass, and lightheadedness.

When anorectics adopt the bulimic bingeing and purging, they risk their health even further. Some use the emetic syrup of ipecac to induce vomiting after a binge. The recording artist Karen Carpenter was an anorectic who died of syrup of ipecac abuse. Building up over time, the alkaloid emetine in the ipecac irreversibly damaged her heart muscle, which eventually led to her death by cardiac arrest.

What causes anorexia nervosa and bulimia is puzzle upon puzzle for researchers. They are just beginning to uncover clues, and not all experts agree with all theories. Writing in the March 1982 issue of Psychosomatic Medicine, Dr. Joel Yager, director of the Adult Outpatient Eating Disorders Program at the University of California, Los Angeles, School of Medicine, advises: "Given the present lack of knowledge, we need to remain skeptical about facile formulas that purport to explain anorexia nervosa. We are better off retaining a certain amount of confusion and ambiguity, waiting for additional information to support, modify, or refute the myriad of current hypotheses."

One theory about anorexia and bulimia is that many females feel excessive pressure to be as thin as some "ideal" perceived in magazines and on television. Evidence suggests that the pressure is increasing. For example, a study of Playboy centerfolds and Miss America contest winners form 1959 to 1978 showed a progressive decrease in the women's weight and bust and hip measurements.

Dr. David Jimerson, chief of the Section on Biomedical Psychiatry of the Intramural Research Programs, National Institute of Mental Health, suggests that a certain biological factor that is linked to clinical depression may contribute to the development of anorexia and bulimia. Jimerson explains that a biological change in some people can predispose them to depression. "We're looking at whether that same biological predisposition, or some related alteration, might also predispose to the onset of an eating disorder." In fact, says Jimerson, 7 of 10 anorectics and bulimics are depression-prone, as are many of their relatives.

Jimerson points out that the neurotransmitter (a chemical involved in sending nerve "messages" to and from the brain) serotonin is linked to both mood and eating functions and that decreased serotonin activity has been linked to impulsive behavior. Bulimic are often impulsive. Further, says Jimerson, antidepressant drugs "affect the brain's serotonin transmitter system--many bulimics appear to improve with antidepressant therapy." While the institute's research is preliminary, Jimerson feels that "by looking at drugs that affect the serotonin and the other major neurotransmitter systems, we may be better able to help patients with eating disorders."

Several other theories suggest biological factors. For instances, malfunctioning of the hypothalamus occurs in anorexia and may precede onset of the illness. The hypothalamus is a part of the brain that controls such bodily functions as hormonal secretions, temperature and water balance regulation, and sugar and fat metabolism. Also, endorphin hormones, which are released during purging and excessive exercise (causing the famous jogger's "high"), are believed to be addictive.

Anorexia and bulimia may be triggered by an inability to cope with a situation in life: puberty, the first sexual contact, ridicule over weight, death of a loved one, or separation from family because of college. It's been suggested that choices afforded by the women's movement may be misinterpreted as obligations, thus creating another stress with which anorectics-to-be cannot cope.

In her book Eating Disorders, the late Dr. Hilde Bruch offered this explanation: "The urgent need to lose weight is a cover-up symptom, expressing an underlying fear of being despised or disregarded, or of not getting or even deserving respect. Desperate about their inability to solve their problems, the patients begin to worry about their weight and get a sense of accomplishment from manipulating their body."

Bruch also maintained that patients with anorexia learned to eat, not to satisfy hunger, but to satisfy the expectations of others; thus, their eating or not eating involved their self-esteem. She described anorectics as struggling against overcontrolling parents to gain a sense of "leading a life of their own."

Some studies have found these characteristics of families of anorectics: poor communicating skills, conflict avoidance, over concern with appearances, overemphasis on high achievement, and overinvolvement with one another. But UCLA's Yager found that the significance of many of the researchers' observations could not be properly evaluated. "If common personality patterns are to be found in these families," he wrote, "they will have to be at more subtle levels."

While there are differences of opinion about treatment for anorexia and bulimia, the one point on which all agree is that early treatment is important to recovery. In fact, it is essential because, as either disorder becomes more and more entrenched, damage to the body becomes less reversible.

How then to treat these disorders?

According to Bruch, "A realistic body-image concept is a precondition for recovery in anorexia nervosa." Considering the anorectic's tenacious denial of being too thin or eating too little, convincing her that she needs to gain weight is no small task. A prime example of resistance is this defense by one of Burch's patients, "Of course I had breakfast; I ate my Cheerio." In contrast, bulimics usually cooperate with the medical staff; they may even seek treatment voluntarily.

Several approaches are usually used to treat both disorders, including motivating the patient, enlisting family support, and providing nutrition counseling and psychotherapy. Behavior modification therapy and drug therapy may be used as well.

Hospitalization may be required for patients who have life-threatening complications or extreme psychological problems. If the patient's life is not in danger, treatment for either disorder is usually on an outpatient basis. Treatment may take of year or more. However, in their book New Hope for Binge Eaters, Drs. Harison Poper Jr. and James Hudson reported that more than 80 percent of their patients with bulimia responded to antidepressant drug therapy with three to four weeks. For anorectics, however, they write that the benefits of antidepressants "must be regarded as tentative" and that precautions should be taken to determine whether the patient's undernourished body can handle the drugs.

Psychotherapy may be in many forms. In individual sessions, the patient explores attitudes about weight, food and body image. Then, as she becomes aware of her problems in relating to others and dealing with stress, her attention is centered on feelings she may have about self-esteem, guilt, anxiety, depression or helplessness. Constructive, nonjudgmental feedback is given to encourage growth and independence. In behavior modification therapy, the focus is on eliminating self-defeating behaviors. Patients may improve their stress management by learning skills in relaxation, biofeedback and assertiveness. Family therapy is designed to improve overall family functioning. Group psychotherapy may help reduced a sense of isolation and secrecy and is especially effective for bulimics.

Anorexia Nervosa and Associated Disorder, Inc. (ANAD), a support group, says it's important for the patient to have confidence in the type of therapy used as well as a trusting rapport with the therapist. If some improvement isn't apparent after a reasonable time, says ANAD, the patient (or patient advocate, such as a parent) shouldn't hesitate to discuss this with the therapist and, if need be, change therapists. Local places to ask for help in finding a therapist are: the psychiatry department of a nearby medical school; local hospitals; family physician; priest, rabbi or minister; county or state mental health or health and social services departments; and private welfare agencies.

Self-help, or support, groups are an adjunct to primary treatment. Through sharing of experiences, members give mutual emotional support, exchange information, and diminish feelings of isolation. Services may include: information on symptoms and treatment, lists of therapists, newsletters, book reviews, and bibliographies. Requests for information from the following non-profit associations should be accompanied by a stamped, self-addressed, business-size envelope:

American Anorexia/Bulimia Association, Inc. 133 Cedar Lane
Teaneck, NJ 07666

Anorexia Nervosa and Associated Disorders, Inc. P.O. Box 7
Highland Park, ILL 60035

Bulimia, Anorexia Self-Help
6125 Clayton Avenue, Suite 215
St. Louis, MO 63139

National Anorexic Aid Society, Inc.
5796 Karl Road
Columbus, Ohio 43229

One last word on treatment: Beware of health fraud. Fraud promoters are quick to capitalize on a person's desire to lose weight or cure a severe illness. As a guide against fraud, remember: If a product or practice sounds too good to be true, it probably is. To report suspected health fraud, call or write the nearest FDA district office listed in the telephone book.

TIPS FOR PARENTS

Whether their child is 10 or 20, parents of a patient with bulimia or anorexia may find it difficult to deal with such a constant, long-term problem. From the American Anorexia/Bulimia Association, Inc., here are some tips that may help:

• Do not urge your child to eat, or watch her eat, or discuss food intake or weight with her. Your involvement with her eating is her tool for manipulating parents.
• Do not allow yourself to feel guilty. Once your have checked out her physical condition with a physician and made it possible for her to begin counseling, getting well is her responsibility.
• Do not neglect your spouse or other children. Focusing on the sick child can perpetuate her illness and destroy the family.
• Do not be afraid to have the child separated from you, either at school or in separate housing, if it becomes obvious that her continued presence is undermining the emotional health of the family. Don't allow her to intimidate the family with threats of suicide. But don't ignore the threats, either.
• Do not put the child down by comparing her to her more "successful" siblings or friends. Do not ask questions such as, "How are you feeling?" or" How is your social life?"
• Love your child as you should love yourself.
• Trust your child to find her own values, ideals and standards, rather than insisting on yours.
• Do everything to encourage her initiative, independence and autonomy.
• Be aware of the long-term nature of the illness. Families must face months and sometimes years of treatment and anxiety.

Dixie Farley is a member of FDA's public affairs staff.

HHS Publication No. (FDA) 86-2211