WHAT'S EATING HER?
Too thin, too fat, or in between, someone who has an eating disorder struggles with more than just her weight
By Sunly Coo, Contributing Writer
Like most college girls, Jenny (not her real name) enjoyed wearing the latest in fashion, even going on a diet to fit into more revealing outfits. But unlike her friends, or most women for that matter, she went to extreme lengths to keep off the unwanted fat. It was a secret she hid from family and friends, the almost compulsive need to lose weight by skipping meals and throwing up whatever she ate by sticking a finger down her throat. Ironically, what triggered the need was her friends' teasing comments about her heavy frame. As she shed off the pounds, she received praise that only reinforced her desire to stay on her unhealthy diet plan, until she eventually could slip into skimpy clothes. But it didn't end there. Every time she looked in the mirror, she still saw a flab here or a bulge there. She grew obsessed with her "not thin enough" appearance. Skinnier and skinnier she became until she was reduced to nothing more than skin and bones.
Anorexia nervosa
Jenny's experience is a textbook case of anorexia nervosa. She fulfills all of the disorder's four criteria as listed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV): a weight below 85 percent of the ideal, an intense fear of becoming fat despite being underweight, a distorted perception of one's body image, and an absence of at least three consecutive menstrual cycles.
Like most eating disorders, anorexia tends to afflict teenagers but, according to the Mayo Clinic, it can strike well before puberty or even in midlife. St. Luke's Medical Center chief psychiatrist Monina Garduño-Cruz explained: "There is a bimodal peak in terms of the incidence of eating disorder. The first is during 14 or 15 years of age, the second peak about 18 years of age, when all of these conflicts come out, like identity issues. But we've also seen cases of adults who continue to have eating disorders."
One such patient was Carla. She was in her early twenties when she first brought herself to Cruz's clinic. "She was aware she was having problems with her weight. There were a lot of comments from her officemates and relatives that she was too thin, and she started reading about anorexia," Cruz said. "She would purge and take laxatives and diuretics to force herself to urinate and move her bowels. She was also vomiting."
Carla and Jenny represent only one category of people with anorexia. They have what is technically called "binge-eating/purging" anorexia, where weight-control is done by purging-vomiting after eating or using laxatives, enemas, and other medications. They may purge after bingeing-eating a lot of food in a short amount of time-or after taking in something as insubstantial as a piece of candy.
Restrictive anorexia, on the other hand, entails forcing oneself to limit food intake. One also loses calories by exercising excessively, which Jenny did by pounding away on the treadmill for four to six hours a day. People with anorexia can swing back and forth between restrictive and binge-eating/purging.
Bulimia
"Bulimia is more common than anorexia," Cruz added. "People with bulimia usually label foods as fatty foods. Because of the guilt that ensues after the bingeing, they purge." Unlike anorexia, though, it is harder to spot because persons who have bulimia are generally overweight or of normal weight.
According to DSM, an individual has bulimia when she binges periodically and compensates for it by forcing herself to vomit, using laxatives and other medications, fasting, or exercising excessively. The behaviors should occur at least twice a week for at least three months, and not during periods of anorexia. Lastly, her self-image is also overly influenced by body shape and weight.
"Bulimia usually happens earlier than anorexia, during the transitional period from adolescence to adulthood," said Dr. Norieta Calma-Balderrama, head of child and adolescent psychiatry at the University of the Philippines-Philippine General Hospital.
Beneath the obsession
To the casual observer, the endless preoccupation with weight can be misinterpreted as a sign of vanity. But to experts, it can't be further from the truth. And the truth is, the disorders may not even be rooted to a single cause but rather a combination of different factors-psychological, biological, and sociocultural.
People with eating disorders may have psychological traits that contribute to their condition-heightened emotional sensitivity and low self-esteem. "Most of the time in our clinic, it has something to do with their identity, self-esteem, the way they look…. It's a call for attention, for love," Balderrama said.
An obsessive-compulsive streak and a strong drive for perfectionism may help explain why people with anorexia can sustain their efforts to lose weight longer than most people could, and why they never think they are thin enough. Among individuals with bulimia, experts discovered that many have difficulties controlling impulsive behaviors, hence the tendency to binge regularly. They also appear to have problems expressing their emotions such as anger, and they usually come from a family where conflicts run high. These factors may contribute to their need for control, which is channeled to their body weight.
A young woman is at a greater risk of developing an eating disorder when her mother or sister also suffers from one, suggesting a possible genetic link. Although experts have yet to isolate the culprit gene and uncover the biochemical process involved, they are speculating that serotonin, one of the hormones responsible for depression, may play a key role. The brain chemical also helps regulate food intake. Often, the blame for young girls becoming obsessed with their weight is laid at the door of Hollywood and the fashion industry. The media's fascination with models and celebrities like Nicole Richie and Keira Knightley, who flaunt their stick-like figures, has altered the perception of millions of girls on what is considered attractive. To impressionable minds, the emaciated look is equated with beauty, popularity, and success.
At high risk
Certain factors predispose an individual to anorexia or bulimia. "If you look at the histories of those with eating disorders, a lot of them were overweight or obese at some time in their life, usually in childhood," Cruz said. At no other time in a person's life is being fat more uncomfortable and painful than during puberty or adolescence, when peers can be cruel as one struggles to discover one's identity.
Going through major transitions (attending a new school, parents separating) or feeling helpless in situations (having a dysfunctional family, being sexually abused) can also trigger the onset of an eating disorder. "The issue is about losing control. So the preoccupation with their weight is their attempt to gain some control on their life. It becomes displaced to eating and weight," Cruz said.
Researchers also found that the incidence of the disorders tends to rise in certain fields of interest, such as ballet, dance, gymnastics, track and field, wrestling, modeling, and on-camera film or television work.
"We don't have studies in the Philippines on how rampant the disorders are," Balderrama said. "But here (at St Luke's Center for Weight Management and Clinical Nutrition), it's not very common that we see them. In clinical practice, we've had very few, like in Medical City we have about two. Here we've had about two from like 100 patients who would consult. But out there it would be more."
Complications and treatment
While experts do not know the prevalence of anorexia and bulimia in the country, they do know that if the condition is left unchecked, a host of serious medical complications, including malnutrition, will occur. Anorexia and bulimia can lead to low potassium level, which causes irregular heart rhythm and other cardiovascular problems; tooth and gum diseases due to frequent exposure to stomach acids during bouts of vomiting; and gastrointestinal problems such as an irritated rectum caused by an overuse of laxatives, an inflamed esophagus that can lead to rupture and bleeding in severe cases, and constipation due to repeated purging.
Electrolyte imbalance, dehydration, anemia, kidney and lung problems, bone loss, fatigue, and depression are also possible complications. Females with anorexia also experience amenorrhea; males, decreased testosterone.
But for both disorders, "the worst complication," Cruz said, "is death." Among all mental illnesses in America, anorexia has the highest mortality rate at about five percent, according to the Mayo Clinic; while the US National Library of Medicine reports that other estimates are pegged twice as high. Sudden deaths due to arrhythmia or severe electrolyte imbalance can happen even when the person is not dangerously underweight.
Since people with anorexia or bulimia generally do not recognize they have a serious disorder, many of those who receive treatment are already in advanced stages. In such cases, immediate medical care for conditions such as dehydration or cardiovascular diseases becomes the first line of defense. Intervention should be geared toward two ultimate goals-regaining normal weight and realizing that their eating behavior is not a solution to other problems-and thus should be holistic.
The patient also undergoes nutritional therapy and psychological treatment, which commonly includes psychotherapy and cognitive behavior therapy, found to be the most effective for bulimia. Psychiatrists advise family involvement during therapy, not only to rally for support but to help resolve the patient's emotional issues, which usually trace back to conflicts within the family. Antidepressants may be prescribed, such as fluoxetine, the only drug specifically approved for bulimia by the US Food and Drug Administration.
"There have been studies," Cruz said, "that show antidepressants or selective serotonin-reuptake inhibitors help control the impulse problem of eating disorder." Balderrama confirmed: "The first thing that changes when you take antidepressant is your appetite becomes better."
Despite all these, the odds in the battle against bulimia and anorexia are grim. "For all eating disorders, prognosis is only about 50-percent actual recovery. Twenty-five percent improve but still continue to exhibit symptoms of the disorder. Twenty-five percent do not improve at all and are lost to follow-up," Cruz revealed. Such was the case with Carla, who refused to involve her parents in the treatment.
Binge-eating
Recently recognized as a disorder in itself, binge-eating occurs in typically two-hour episodes at least twice a week for a minimum of six months. Individuals suffering from it feel a loss of control during these episodes and experience guilt afterwards. But unlike anorexia or bulimia, they do not purge after eating, which explains why most of them are overweight or obese. "So it is possible that many obese people could be binge eaters," Balderrama speculated. "In the last convention we had, even APA (American Psychological Association) has associated obesity with depression. Binge eating is actually a manifestation of the depression. They eat because they are depressed, and they get depressed because they eat too much. You have to break the cycle."
Balderrama added that before binge-eating could be considered a disorder, it should also be "associated with three or more the following: eating rapidly, eating until feeling uncomfortably full, eating large amounts of food even when they're not even hungry, and eating alone because they're embarrassed." Other signs include hoarding food and hiding empty food containers.
As in anorexia and bulimia, the same multitude of psychological, biological, and sociocultural factors can contribute to the disorder. Binge eaters are also overly conscious of their appearance, equating it with their sense of self-worth.
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Are you friends of Ana or Mia?
Dozens of web sites, perhaps more, promote anorexia and bulimia as a lifestyle. Girls belonging to this network fondly call their conditions Ana and Mia, respectively, and openly trade tips on how to lose weight and avoid food. Some of them include "spraying something disgusting in your mouth, like perfume" to discourage eating, spitting food out after chewing ("it feels like you ate"), and eating naked in front of a mirror. Forms of punishment include exercising until one faints from exhaustion, slapping oneself, and cutting oneself. The one common advice they all agree on is to keep everything to themselves. "Never tell anyone about Ana, they will never understand," one entry said.
Many of these girls are aware that they have eating disorders, as one web site called Friends of Ana and Mia indicated on their search description: this site is "meant for people who are already suffering from an eating disorder and who do not wish to yet recover." For these people, Ana and Mia are more than just disorders. They are considered as friends.
A female with anorexia posted on another site a letter from Ana, which she presumably wrote herself. The following passage, extracted from the long letter, offers an insightful look into how the individual perceives the disorder: "In the past you have heard all of your teachers and parents talk about you. You are 'so mature,' 'intelligent,' '14 going on 45,' and you possess 'so much potential.' Where has that gotten you, may I ask? Absolutely nowhere! You are not perfect, you do not try hard enough, furthermore you waste your time on thinking and talking with friends and drawing! Such acts of indulgence shall not be allowed in the future. Your friends do not understand you. They are not truthful. In the past, when the insecurity has quietly gnawed away at your mind, and you asked them, 'Do I look ... fat?' and they answered 'Oh no, of course not,' you knew they were lying! Only I tell the truth. Your parents, let's not even go there! You know that they love you, and care for you, but part of that is just that they are your parents and are obligated to do so. I shall tell you a secret now: deep down inside themselves, they are disappointed with you. Their daughter, the one with so much potential, has turned into a fat, lazy, and undeserving girl. But I am about to change all that."
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At war with their lunch
Hollywood and the fashion industry are often blamed for holding up nearly
stick-thin women as a standard of beauty, against which girls and women
should measure themselves. Many observers have noted that this has led to
females having serious insecurities about their bodies. This makes them
believe that if they're not as thin as this model or that actress, they're
not beautiful enough-or they're not beautiful at all.
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This pressure is said to be an important reason behind the number of women having serious eating disorders like anorexia and bulimia. They eat as little as they can, or even throw up what they've eaten just so they could maintain their figure; they swear off food altogether and still see themselves as fat and ugly; or they spend hours and hours exercising to burn off excess fat that, in truth, isn't really there. The number of girls with eating disorders may be small-for example, the prevalence of anorexia in females can go as high as 5.7 percent in Western countries, and 3.2 percent in non-Western countries-but the fact that they're there at all has became a source of alarm.
Not surprisingly, celebrities themselves admit to having eating disorders, blaming the problem on the pressure to look their "best." Even someone as greatly admired and envied as Princess Diana admitted to suffering from bulimia. In a BBC interview some years before she died, she'd said: "You inflict it upon yourself because your self-esteem is at a low ebb, and you don't think you're worthy or valuable."
Other celebrities have admitted to suffering from anorexia or bulimia at certain points in their lives. Some of them are men. These include former child star Mary-Kate Olsen; model Carrie Otis; award-winning actresses Sally Field and Jane Fonda; and singers Karen Carpenter, Elton John, and Daniel Johns, singer of the Aussie band Silverchair.
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