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News Articles About Eating Disorders
Height and weight added to codes on nondiscrimination
If you've been jeered at because you appear too fat, too thin, too short or too tall, the law is on your side in San Francisco. The Board of Supervisors passed a law Monday banning discrimination based on weight or height and authorizing investigations into such complaints.
Jim Herron Zamora, OF THE EXAMINER STAFF
Tuesday, May 9, 2000
Height and weight added to codes on nondiscrimination
If you've been jeered at because you appear too fat, too thin, too short or too tall, the law is on your side in San Francisco.
The Board of Supervisors passed a law Monday banning discrimination based on weight or height and authorizing investigations into such complaints.
"Clearly discrimination in any form is wrong," said Tom Ammiano, president of the Board of Supervisors and the law's sponsor. "Many San Franciscans are being denied employment, housing, bank loans merely because they are perceived as being overweight."
Without debate or discussion, the board added height and weight to the same anti-discrimination codes that provide protections based on race, religion, color, ancestry, age, sex, sexual orientation, gender identity, disability and place of birth.
San Francisco joins Santa Cruz, Washington, D.C., and Michigan, which have similar laws on the books. The City's law bans bias in housing, employment and accommodations, which include hotels, bars, restaurants and movie theaters.
Praise for the law came from representatives of several groups that support "fat acceptance" and oppose all forms of societal disapproval for those considered overweight.
"This gives people the legal basis to fight discrimination they face every day," said Sondra Solovay, an Oakland attorney and author of "Tipping the Scales of Justice: Fighting Weight-Based Discrimination."
Several "anti-sizism" activists who attended the meeting said they had personally experienced discrimination.
Carole Cullum, a self-employed attorney, said major law firms seemed enthusiastic about her job prospects in phone interviews but chilled upon meeting her. Jo Kuney said that when she was a temp worker, no company would place her in a downtown office because "I was too heavy. I did not have the corporate look," she said.
"Fat people can no longer be told they can't have a job just because they don't have 'front office appeal,' " said Nancy Gold, one of many activists who supported the law. "The law can do that. And that's how racism was changed, that's how sexism was changed, and that's how sizism is going to change."
Under the new law, the city Human Rights Commission has the power to investigate and mediate complaints of bias, and to make findings that could be used in a lawsuit.
Larry Brinkin, a Human Rights Commission employee, said his agency has long received reports of such discrimination but has never been able to act on them.
"It clearly exists but there were no laws against it," he said.
Although the measure has drawn a lot of publicity for provisions protecting the overweight, Brinkin is quick to note that the law will also help people viewed as too thin, too short or too tall.
Anorexia phobia
Brinkin said that it's not uncommon for skinny people to be denied jobs because prospective employers see them as possibly suffering from AIDS or anorexia. He said that a prospective employer might not ask if a job candidate was HIV-positive, but would assume that a gay man who appears underweight has AIDS-related wasting syndrome.
Brinkin also pointed out that skinny women are often demonized by assumptions that they suffer from eating disorders.
"Look at everything that (TV actor) Calista Flockhart has endured because she lost some weight," Brinkin said.
Professions that tie job performance to a certain level of physical activity, such as cops and firefighters, are exempt from the law. So are professional athletes such as the Giants or 49ers.
The law would protect anyone doing contract work for The City, even if the work is performed outside San Francisco, Brinkin said.
No one - including business groups - has publicly opposed the measure. San Francisco Chamber of Commerce spokeswoman Carol Piasente said earlier her organization would "support any legislation that would eliminate discrimination."
Law hard to apply
Enforcing the measure could prove difficult. Brinkin said that the new law would probably not provide much solace to slightly overweight folks who are waiting in line outside a trendy South of Market hot-spot only to see long-legged, ultra-thin super-model types breeze past the line into the front door. To prove a case, a complainant would likely have to be told in person or in writing that they were being denied an opportunity because of their weight or height.
A prospective employer could turn down a candidate who appears too fat and not get caught if no reason for the denial is ever given, supporters said.
But Brinkin, Cullum and other supporters of the law said that the very existence of such legislation will prod some employers and businesses into better practices.
"Proving discrimination has always been hard, it will remain hard," said Cullum, who serves on the city Board of Permit Appeals. "But at least now we have the law on our side."
Exercise and addiction
There is little evidence of exercise addiction in women who don't already have some type of eating disorder such as bulimia or anorexia, according to a recent study in the British Journal of Sports Medicine. For years, mental health officials have wondered whether the compulsive need to exercise was a disease in women who are preoccupied with body image.
From the Journal Sentinel
Last Updated: April 30, 2000
Researchers from the University of Birmingham analyzed exercise patterns of women who were members of fitness clubs, professional athletes and those with eating disorders.
The women underwent testing for psychological symptoms, personality traits, self image and self esteem, exercise beliefs and levels of physical activity.
The researchers concluded that women who don't have an eating disorder but who exercise excessively had none of the personality traits or psychological problems that would merit defining their behavior as addictive or psychologically unhealthy. In fact, those women had healthy self-esteem, the authors said.
"Taken together . . . these results argue against the notion that primary exercise dependence is a pathology and certainly undermine the claim that it is a prevalent pathology," the researchers wrote.
New therapiesGene therapy and tissue engineering may be standard treatments for many sports injuries in the coming decade, according to a panel of surgeons at a recent meeting of the American Academy of Orthopaedic Surgeons.
Scientific research using therapies such as genes, stem cells and tissue engineering may speed up healing from orthopedic injuries, the panelists said.
For instance, in a typical muscle injury it might take two weeks before muscle regeneration begins.
Often the healed muscle has a lot of scar tissue that can cause complications.
"Our research shows that by adding gene therapy to the treatment program, muscles heal with less scar tissue, creating a near complete recovery of the muscle," said Johnny Huard, one of the panelists.
The panelists said that while gene and cell therapies still are in the research phase, the new therapies should be standard treatment in the next 10 years.
Advantage, tennisTennis scored an ace in 1999.
The number of tennis players ages 12 and older increased from 19.5 million in 1996 to 20.8 million in 1999, according to information supplied by the Sporting Goods Manufacturers Association.
The number of frequent tennis players, those who played at least 21 times a year, increased from 4.9 million to 5.4 million.
Sales of tennis equipment through the third quarter of the year also were up.
Racket sales were up 7% and ball sales were up 3.5%.
Compiled and written by Journal Sentinel reporter John Fauber.
Anorexia nervosa: cardiac complications
Anorexia nervosa is associated with a number of cardiac complications, some of which do not manifest until the refeeding stage of therapy. The mortality rate for anorexia nervosa has been estimated by meta-analysis to be 5.9%, the majority of deaths being the result of serious cardiac complications.
Postural hypotension is common in anorexia nervosa. Most patients with anorexia exhibit relative exercise intolerance. Their relative bradycardia has been mistaken for good ventricular function; in fact during exercise most patients demonstrate a blunted heart rate response, relatively low blood pressure, a significant incidence of ventricular ectopy, and decreased oxygen consumption. Diminished exercise capacity in anorexia has been attributed to a loss of muscle mass, dysfunction of remaining muscle, and impaired cardiovascular responses.
Bradycardia is a very common sequela of anorexia, with the resting heartrate often less than 45 / minute. Excessive vagal tone is thought to be the cause. Cardiac vagal tone is expressed as the change in R-R interval in response to complete cholinergic blockade. Cardiac vagal tone in anorexic subjects was 465 +/- 52 (SE) ms, about 30% higher than values reported for healthy subjects. Vagal tone values were directly related to percent weight loss. Prolonged QT interval is common in patients with anorexia nervosa; it will often revert to normal after refeeding. However, prolonged QT interval can predispose to torsades de pointes, an often fatal dysrhythmia. This mechanism has been described in sudden death in anorexia nervosa (as well as in liquid-protein dieting).
Athletes plagued by eating disorders
Research carried out at the University of Leeds by former international marathon runner Dr Angie Hulley shows that almost one in 10 of Britain's top female distance runners have some kind of eating disorder
A campaign is to be launched to tackle the growing problem of eating disorders in sport.
BBC NEWS
The Eating Disorders Association has joined forces with the British Olympic Association and UK Athletics to highlight the dangers faced by athletes.
Research carried out at the University of Leeds by former international marathon runner Dr Angie Hulley shows that almost one in 10 of Britain's top female distance runners have some kind of eating disorder.
The widespread nature of the problem was illustrated by the fact that five out of seven of the under 20 UK World Championship cross-country team in 1996 admitted to suffering from an eating disorder.
Similar trends have been reported in sports such as gymnastics, ice-skating and tennis.
Campaign targets coaches and athletes
Among the general population, it is estimated that less than one per cent of people suffer from anorexia nervosa, and up to five per cent from the bingeing and purging disorder bulimia nervosa.
The new campaign will feature a series of leaflets giving advice on the early warning signs and risk of eating disorders.
The leaflets will be targeted at coaches, friends and family and the athletes themselves.
They will be widely distributed by the three organisations taking part in the campaign, who also hope to establish a network of experts who can be readily accessible to provide help and support.
The leaflets have been written by Peta Bee, a member of the UK Athletics working party on eating disorders.
Vulnerable personality
She said that athletics and other high performance sports might attract people whose personality made them vulnerable to eating disorders.
"They tend to like to train alone, to be driven to push themselves hard and to be perfectionists," she said.
Ms Bee said that in the short term reducing body fat could improve athletic performance as oxygen could be transported to the muscles more quickly.
But she warned that in the longer term loss of muscle bulk would reduce speed and power and badly affect athletic performance.
"In the very long term eating disorders can cause all sorts of problems," she said.
19-year-old 'suffered heart attack'
"Osteoporosis is common in people who suffer from eating disorders, young women of 17 can have the same bone density as a 75-year-old. The impact on the body's salt levels can cause kidney damage, and bulimia can lead to internal bleeding."
Ms Bee said in one case an eating disorder had led to a 19-year-old athlete suffering a heart attack.
"Intensive training will speed up weight loss and accelerate the process," she warned.
Nicky Bryant, chief executive of the Eating Disorders Association, said athletes were under intense pressure to perform well.
She said: "It may be that athletes find that through excessive exercise they can limit their weight and that, in the short term, can help run faster and perform better.
"But in the longer term restricting nutritional intake will reduce their ability to perform."
Ms Bryant said that taking excessive exercise as a means to control weight was commonly associated with anorexia.
"The earlier an eating disorder is diagnosed and help and treatment is started, the better the prognosis for recovery.
"We want to help people to spot the signs and symptoms of an eating disorder, and to know how to seek help."
Clinicians are under increasing pressure to transfer inpatients with anorexia nervosa to less intensive treatment early in their hospital course. This study identifies prognostic factors clinicians can use in determining the earliest time to transfer an inpatient with anorexia to a day hospital program.
William T. Howard, M.D., M.S., Karen K. Evans, R.N., M.A., Charito V. Quintero-Howard, M.D., Wayne A. Bowers, Ph.D. and Arnold E. Andersen, M.D.
OBJECTIVE: Clinicians are under increasing pressure to transfer inpatients with anorexia nervosa to less intensive treatment early in their hospital course. This study identifies prognostic factors clinicians can use in determining the earliest time to transfer an inpatient with anorexia to a day hospital program. METHOD: The authors reviewed the charts of 59 female patients with anorexia nervosa who were transferred from 24-hour inpatient care to an eating disorder day hospital program. They evaluated the prognostic significance of a variety of anthropometric, demographic, illness history, and psychometric measures in this retrospective chart review. RESULTS: Greater risk of day hospital program treatment failure and inpatient readmission was associated with longer duration of illness (for patients who had been ill for more than 6 years, risk ratio=2.7), amenorrhea (for patients who had this symptom for more than 2.5 years, risk ratio=5.7), or lower body mass index at the time of inpatient admission (for patients with a body mass index of 16.5 or less, risk ratio=9.6; for those with a body mass index 75% or less than normal, risk ratio=7.2) or at the time of transition to the day hospital program (for patients with a body mass index of 19 or less, risk ratio=3.9; for those with a body mass index 90% or less than normal, risk ratio=11.7). CONCLUSIONS: Inpatients with anorexia nervosa who have the poor prognostic indicators found in this study are in need of continued inpatient care to avoid immediate relapse and higher cost and longer duration of treatment.
Shame and guilt in women with eating-disorder symptomatology
Shame associated with eating behavior was the strongest predictor of the severity of eating-disorder symptomatology. Other effective predictors were guilt associated with eating behavior and body shame.
Burney J, Irwin HJ.
School of Psychology, University of New England, Armidale NSW, Australia.
The relationship of shame and guilt to eating-disorder symptomatology was investigated in a sample of 97 Australian women. In terms of the objective of predicting the severity of eating disturbance, the study explored the predictive utility of proneness to shame and guilt in a global sense, shame and guilt associated specifically with eating contexts, and shame associated with the body. The study also sought to determine if shame is a more prominent emotion than guilt among women who have eating difficulties. Shame associated with eating behavior was the strongest predictor of the severity of eating-disorder symptomatology. Other effective predictors were guilt associated with eating behavior and body shame. Eating disturbance was unrelated to proneness to shame and guilt in a global sense. Discussion of these findings focuses on the issue of determining whether self-conscious affects are best regarded as causes or as consequences of eating disturbance.
PMID: 10661368 [PubMed - indexed for MEDLINE]
Anorexics suffer bladder problems: possible anorexia-estrogen link?
Anorexic women are more likely to develop problems with their urinary system, scientists have warned. Researchers from two London hospitals have found that anorexia is often linked to bladder problems, such as needing to go to the toilet very regularly and urgently. "Anorexics also tend to have low levels of the hormone estrogen and it might be that this predisposes them to urinary symptoms," Prof. Linda Cardozo said.
Anorexic women are more likely to develop problems with their urinary system, scientists have warned.
BBC News 1999.
Researchers from two London hospitals have found that anorexia is often linked to bladder problems, such as needing to go to the toilet very regularly and urgently.
According to the British Journal of Obstetrics and Gynaecology, the researchers found that nearly two-thirds of women with anorexia nervosa are likely to suffer from bladder problems.
This is three times the rate of women without the eating disorder.
The women, assessed at King's College and Maudsley Hospitals, said the condition could dominate day to day life.
Alienation
Professor Linda Cardozo, professor of Urogynaecology at King's College Hospital, said the symptoms could increase the alienation commonly felt by anorexics.
She said: "Teenage girls and young women with anorexia nervosa, many of whom have gone to extraordinary lengths to hide their condition from their family and friends, often find it particularly difficult to admit having bladder problems.
"The effect of silently suffering from two socially isolating conditions can have a devastating effect on sufferers' lives."
Both anorexia and bladder problems have been linked to feelings of anxiety.
Professor Cardozo said the bladder problems might be associated with the mental state that led the sufferer to develop anorexia in the first place.
Alternatively, it could be that anorexia caused mental changes that brought on the urinary problems.
"Anorexics also tend to have low levels of the hormone oestrogen and it might be that this predisposes them to urinary symptoms," she said.
Meatless Diets in Female Athletes: A Red Flag
Physically active adolescent girls and young women may eliminate meat from their diets to achieve or maintain low body weight. By doing so, they risk developing protein, iron, and zinc deficiencies. Further, meatless diets in this population may signal the possibility of amenorrhea and/or disordered eating, with the attendant risk of osteoporosis.
Alvin R. Loosli, MD; Jaime S. Ruud, MS, RD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 11 - NOVEMBER 98
In Brief: Physically active adolescent girls and young women may eliminate meat from their diets to achieve or maintain low body weight. By doing so, they risk developing protein, iron, and zinc deficiencies. Further, meatless diets in this population may signal the possibility of amenorrhea and/or disordered eating, with the attendant risk of osteoporosis. Educating young women and their parents and coaches regarding the risks of a meatless diet and using the preparticipation exam to screen for these problems can promote preventive measures.
In a survey of 854 adolescent girls and young women, Moore (1) reported that 67% were dissatisfied with their weight, and 54% were dissatisfied with their body shape.
These figures reflect the enormous pressure on today's young women to be attractive and achieve a certain body weight. The resulting preoccupation with weight has been attributed to American cultural values and the media's depiction of women (2).
Whatever the cause, female athletes can also be preoccupied with body weight and shape, and this is especially true of those who must maintain a low body weight for their sport (3). For example, Wiita and Stombaugh (4) reported that 25% of 22 female adolescent runners were unhappy with their weight and felt pressure from coaches and parents to be thin.
In an effort to reach or maintain an ideal weight, female athletes may avoid eating meat because they think it is fattening (5). This is not a step toward true vegetarianism for religious, moral, or environmental purposes but rather one taken under the sway of distorted beliefs about food, body weight, and nutrition (6). For this reason, a meatless diet in a female athlete should be a red flag to physicians, trainers, and other healthcare professionals, because it may indicate potential problems for the athlete that include inadequate intake of protein, iron, and zinc as well as amenorrhea and serious eating disorders.
Protein
Diets that do not include animal food such as meat, chicken, and fish tend to be low in protein. In a study (4) in which adolescent female runners underwent dietary analyses twice in 3 years, the runners limited their consumption of beef, milk, and cheese, and their daily protein intake decreased significantly from 1.6 g per kilogram of body weight to 1.1 g/kg. While these values are higher than the US Department of Agriculture's Recommended Dietary Allowance (RDA), the runners' daily protein intakes were lower than those recommended for endurance athletes (1.2 to 1.7 g/kg) (7).
Furthermore, the runners' mean daily energy intake decreased from 2,150 kcal to 1,647 kcal over the 3 years. Given their average height, weight, and activity level, these female adolescent runners should have consumed closer to 2,500 kcal. Insufficient energy intake increases protein requirement, because more protein is needed to maintain nitrogen balance when energy intake is low. In addition, female athletes who avoid meat may also limit their intake of chicken, fish, and eggs—important dietary sources of high-quality protein.
Iron and Zinc
Female athletes who eliminate meat from their diets may not take in enough of two key minerals, iron and zinc (8).
Getting enough iron is a particular concern for those who do not eat meat because the body's absorption of iron depends on the form of iron in foods. Meat contains heme iron, which is absorbed at a much greater rate than the nonheme iron found in plant foods (15% to 35% vs 2% to 20%) (9). The rate of absorption depends on dietary substances that enhance absorption (ascorbic acid) or inhibit it (tannins, wheat, bran) and on the amount of iron stores. Meat promotes the absorption of both nonheme and heme iron and is currently the only dietary factor known to influence heme iron absorption. Ascorbic acid found in citrus fruits enhances the absorption of iron from nonheme food sources.
Snyder et al (10) reported that the bioavailability of iron was significantly lower in female runners who ate a modified vegetarian diet (less than 100 g of red meat per week) than in those who regularly ate red meat (0.66 mg vs 0.91 mg per day). Both groups had similar total calorie intakes and consumed similar amounts of dietary iron (about 14 mg/day). However, the athletes who ate red meat consumed more heme iron than the others (1.2 vs 0.2 mg/d) and also had significantly higher serum ferritin levels.
Decreased consumption of red meat and low calorie intake explain why female athletes have difficulty meeting the RDA of 15 mg of iron. Surveys (11) of female athletes show mean daily energy intakes ranging from 1,706 to 3,572 kcal, with an average of 13 mg/d of iron.
Low dietary iron intakes can contribute to iron deficiency, one of the most common nutritional deficiencies in the United States. Data from the Third National Health and Nutrition Examination Survey (12) indicated that 9% to 11% of adolescent girls and young women have iron deficiency, and 2% to 5% have iron-deficiency anemia.
Iron deficiency is associated with many adverse health effects, including changes in immune function, cognitive development, temperature regulation, energy metabolism, and work performance (13). Subtle negative effects of iron deficiency, such as fatigue and lack of concentration, can be magnified with intense training (14). Female athletes who have low iron stores also risk illness and injury and thus may reduce their ability to train and compete (8).
Similarly, zinc intake and absorption are influenced by the amount of animal products in the diet. Meat, liver, eggs, and oysters are among the best sources of dietary zinc and provide about 70% of the zinc consumed by most people in the United States (15). Furthermore, meat contains a more easily absorbed form of zinc than plant foods, and high amounts of dietary fiber, phytic acid, and oxalic acid—substances found in plant foods—may interfere with zinc absorption. Thus, the athlete who avoids animal foods may have trouble meeting daily requirements for zinc, especially if caloric intake is low.
The RDA for zinc is 12 mg for women. The average daily intake for sedentary and athletic women in the United States is about 10 mg. One study (16) reported that vegetarian women had significantly lower mean daily zinc intakes than nonvegetarian women (8 mg vs 11 mg).
Amenorrhea
Meatless diets have also been linked to menstrual abnormalities (17-21). Pedersen et al (21) reported that the prevalence of menstrual irregularities among 41 nonvegetarian women was 4.9%, vs 26.5% among 34 vegetarian women.
Kaiserauer et al (18) compared nine regularly menstruating runners with eight amenorrheic runners and seven regularly menstruating controls with regard to nutrient intakes, estrogen levels, and physical characteristics. The amenorrheic subjects consumed significantly less total fat and calories than eumenorrheic runners, and they ate no red meat, while 44% of the eumenorrheic runners ate meat.
Slavin et al (19) found similar results in 128 recreational athletes and 36 elite female cyclists. Nine (7%) of the recreational athletes and 12 (33%) of the elite cyclists were amenorrheic, and none of the 12 cyclists ate red meat. Amenorrhea was present in 3 of the 84 recreational athletes (about 4%) who ate diets balanced from four food groups and in 6 of the 44 (about 14%) who ate high-carbohydrate, low-fat diets.
The primary health risk posed by amenorrhea is premature osteoporosis. Amenorrhea is associated with decreased bone mineral content of the lumbar spine (22-25) and increased risk of scoliosis (26) and stress fractures (27-28). More recent data have shown that amenorrheic athletes may have reduced bone mineral density at multiple skeletal sites (29). Noted sports nutritionist Nancy Clark has stated that eating small portions of red meat—4 to 6 oz two to three times per week—can be part of the solution for athletic amenorrhea (30).
Eating Disorders
Restrictive eating behaviors can lead to a multitude of nutrition-related health problems, the most serious of which are anorexia nervosa and bulimia nervosa. Though many factors account for an athlete's predisposition to eating disorders, including sports-related pressures, perfectionism, high expectations, low self-esteem, and emotional instability (31), a meatless diet may be a warning sign to healthcare professionals about a potential eating disorder.
In fact, a meatless diet has been associated with anorexia. Gadpaille et al (32) suggested a link between athletic amenorrhea and meatless diets in runners with eating disorders. Of 13 amenorrheic runners, 12 (87%) were vegetarians, and 8 (62%) had eating disorders diagnosed through a psychiatric interview according to criteria of the Diagnostic and Statistical Manual of Mental Disorders. Only 3 (about 16%) of the 19 menstruating runners were vegetarians, and none had diagnosed eating disorders.
In a recent cross-sectional study (33) of 107 female adolescents who did not eat meat and 214 who did, those who did not eat meat dieted twice as often, vomited four times as often, and used laxatives eight times as often as those in the meat-eating group.
Anorexia nervosa and bulimia can cause serious health consequences for patients, including intermittent hospitalization and death. Early identification of a disordered eating pattern may allow intervention and prevention of these conditions.
Preparticipation Screening
Female athletes who change their eating habits to reduce calories and fat may eliminate meat from their diets. These athletes, their coaches, and physicians should be aware that those who do not eat meat risk adverse effects on health, training, and performance. They are also at risk for eating disorders, amenorrhea, and osteoporosis, which are components of the female athlete triad, a syndrome seen in some physically active girls and young women. Any component of the triad can impair health and performance, and the presence of all three compounds the risk.
The American College of Sports Medicine recently published a position stand (34) on this syndrome. This is an important document that emphasizes prevention through the education of athletes, peers, parents, coaches, and healthcare professionals regarding the contributory psychological factors, warning signs, and outcomes of the triad.
The preparticipation exam is an ideal time for physicians to ask about weight, nutrition, menstrual function, and performance goals. At-risk athletes should be referred to a sports nutritionist who can assess dietary habits and provide sound nutrition information.
Female athletes who consume no meat may seek to legitimize their restrictive eating behaviors by calling themselves vegetarians. Although it is theoretically possible to compete athletically on a meatless diet, it requires much education and commitment. Those who wish to do so should be informed about the risks and educated about eating a balanced diet that includes alternative sources of protein, iron, and zinc, since these may not be adequately available from certain plant foods. They should also be screened for disordered eating and amenorrhea, and if either is found, for osteoporosis; screening for iron-deficiency anemia is also important.
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Dr Loosli practices at the Center for Sports Medicine at St Francis Memorial Hospital in San Francisco. He is an instructor in family practice at the University of California at Davis School of Medicine and is an editorial board member of The Physician and Sportsmedicine. Ms Ruud is a nutrition consultant with Nutrition Link in Lincoln, Nebraska. Address correspondence to Alvin R. Loosli, MD, Center for Sports Medicine, St Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109.
Family, Medical Professionals Help Recovery From Anorexia
So that's what a heart attack feels like, Caroline Winkler thought. She knew anorexics' hearts gave out eventually, but could that really be happening to her? She had been starving herself for less than two years. She still weighed more than 90 pounds at 5 feet 6 inches. She didn't actually consider herself anorexic. Anorexics were supposed to be real thin.
March 10, 1999
DAYTON, Ohio (NYT Syndicate) - So that's what a heart attack feels like, Caroline Winkler thought. She knew anorexics' hearts gave out eventually, but could that really be happening to her? She had been starving herself for less than two years.
She still weighed more than 90 pounds at 5 feet 6 inches. She didn't actually consider herself anorexic. Anorexics were supposed to be real thin.
"At first, I thought she was dying," Winkler's mother, Susan, says of those moments last summer. Only at the hospital did the Winklers learn Caroline had suffered not a heart attack but a panic attack.
Panic attacks aren't typical symptoms of anorexia, but psychological symptoms in general are, says Kara Fowler, Winkler's registered dietician at Nutrition Access Inc. in Cincinnati.
She says few people understand that food is not the underlying problem for people with eating disorders, but a way they cope with psychological issues. Like a flu patient's sore throat, food is a symptom rather than a cause, so regular meals don't cure anorexia any more than a cough medicine cures flu.
"Part of the reason Caroline has done so much in moving toward recovery is her recognition that this is not about food and weight and appearance," Fowler says. Winkler hopes her story will help others recognize and treat eating disorders across the spectrum from anorexia nervosa and bulimia nervosa to compulsive and binge eating.
If the first panic attack had an up side, Susan says, it was that Winkler finally started seeing she had a problem. Progress was excruciatingly slow and erratic even from there, but Winkler's four or five panic attacks a day, and the insomnia that limited her sleep to two or three hours, made it more inconvenient to minimize her weight.
So did the edict from executive director Dermot Burke of the Dayton Ballet, where Winkler danced with the second company. She had to gain weight before she could perform, he told her. Dancing in her condition would be too dangerous.
"I was still in denial that there was anything wrong with me," Winkler says. "I said, 'I just have a fast metabolism.' I told people, 'I eat.' I did eat some, so I wasn't anorexic. That would have meant not eating at all."
And those wakeful nights weren't doing much for Winkler's patience and disposition, so anybody who cared to discuss eating habits with her was probably in for a verbal beating. Her parents persisted, though, and finally talked her into seeing what a psychiatrist had to say about whether she had a problem.
Good, she thought. Maybe this will get them off my back. "I don't know what's wrong with my mother, saying all this about me," Winkler told the psychiatrist as Susan sat in the waiting room. After a half-hour session, the doctor shared his diagnosis of "borderline anorexic."
"Borderline!?" Susan responded. "It takes her an hour and a half to eat an English muffin in the morning. She picks the particles apart. She cooks for all of us and doesn't eat."
That evening Susan went online, found a Web site called "Something Fishy" and left a desperate phone message for a nutritionist listed there. Fowler called back and recommended a Cincinnati psychiatrist, Dr. David Seltzer, who has moved to Kokomo, Ind., since Christ Hospital closed its eating disorders program.
"My mom went in with me that time," Winkler says. "This doctor was smart. He made me talk about myself and my feelings. And I went into a panic attack. That's how he diagnosed me. Anorexics cannot talk about themselves or their feelings because it scares them to death."
By this time, loath as she was to admit her disease, Winkler was also terrified of what it was doing to her. The heart-pounding, hyperventilating panic attacks were awful, bringing a sense she was about to die. "It felt like something was coming to get you, like your heart was going to explode," she says.
But no matter how hard she and her parents tried, Susan says Caroline just couldn't eat. "It wasn't that she didn't want to. I remember holding her, just sobbing. She said, 'Am I ever going to be normal again?' You can't imagine how devastating that is to a mother."
The simplest of common knowledge was not obvious to Winkler. "To her," Fowler says, "half a bagel was what you needed for most of the day." Her mother called it a major accomplishment the first time Caroline put butter on anything.
Winkler worked her way up to normal-sized meals, and then on Thanksgiving, she ate a hearty dinner. "At first I thought it was wonderful, but then I was worried she'd go the other way and start purging," Susan says.
She was right. Winkler ate normally through the holiday season, but she often threw up her meals. Her weight was up from her low of 90, but still under 110.
Then two days before Christmas, a discount store greeter falsely accused Winkler of shoplifting. Susan was with her, talking to the greeter and store manager, when another customer pointed her out derisively.
"Caroline seemed to dissolve into a puddle on the ground," Susan says. After that, she could hardly keep any food down. "I must be a bad person," she kept saying. "Everyone keeps getting mad at me."
Her Christmas dinner was some string bean casserole and a sweet potato. That's all she ate the whole day, and it would be fairly typical for the next two weeks. She already knew she was going to a clinic for eating disorders in Philadelphia that Fowler had recommended, the Renfrew Center.
"We made the reservation on Christmas Eve," Susan says. "I was scared of dying," Winkler says. She also thought often about Gabriel, her 18-month-old nephew. "I adore him," she says. If nothing else, she had to get better for Gabriel, and for the child of her own she hoped to have someday if she ever gained enough weight to start menstruating.
Winkler checked in at Renfrew on Jan. 6. The staff started her on a high-calorie diet, but nothing looked good.
"It was food," she says. Some days, all she could handle was the liquid Ensure or Instant Breakfast that Renfrew required as a minimum for patients to stay in the program.
The medical exams turned up bigger problems than the bald spots that had developed. For starters, Winkler had osteopenia, a disease of low bone density on the threshold of osteoporosis. The body can't absorb calcium without estrogen, doctors told her, and her 8 percent body fat was less than half what she needed to produce enough estrogen.
She wouldn't be able to exercise hard for a year. She wouldn't be able to rejoin Dayton Ballet II or any dance company.
Her lower intestines had stopped working, too, because she had abused laxatives for three years.
She was diagnosed with bipolar disorder, which used to be called manic depression. There's a clear connection between clinical depression and eating disorders, Fowler says. Scientists aren't sure which causes which, but they see some of the same brain chemical disruptions in patients who have either disease without the other.
Obsessive-compulsive disorder was another diagnosis. Winkler knows beyond doubt she was obsessed with food, and Fowler says malnutrition alone can trigger those thought processes.
"I'm an obsessive checker," Winkler says. "I check to make sure doors are locked. I check to make sure the stove's off. I check to make sure my heart's beating."
Most of all, she was obsessed with being perfect. Both parents have successful businesses and her only sister is in medical school. "My family is perfect," she says. "I had to be perfect."
As frequently is the case with depression patients, the problems underlying Winkler's eating disorder were misconceptions. The rest of her family isn't perfect, of course, and it certainly wasn't true that she had to be sick for her father to pay attention to her.
"That was just a delusion I had created in my mind, that he wasn't very interested in my life," she says. "It gave me something to worry about and I just kept building and building on it."
The revelation has made them much closer, she says. They still don't have a lot in common, but there's that mutual interest in each other. "He has apologized a thousand times, even though he had nothing to apologize for. I love my parents to death, and I wouldn't trade them for the world."
What shocked Bill Winkler most was to learn that anorexia wasn't about the food. "So if you make food the issue — and virtually everybody does when you see someone wasting away — you're ignoring what are the real problems."
That's the strategy Caroline recommends. "Say, 'Is there something wrong? Is there something that's bothering you?' Don't say, 'Why aren't you eating?"'
Don't tell anorexics they're thin or beautiful, either, she says. "Thin" just reinforces the problem, and "beautiful" is a word they don't even hear. "Their self-esteem is so low."
The hardest change for Winkler has been dismantling the anorexic shield that protected her from the world. It was so much easier just to fantasize about food whenever a bad break or a tough decision came up. "It's very scary because I don't know what I like," she said before returning from Renfrew.
That same morning, she told her Renfrew psychiatrist she was sad, and the doctor said he was glad to hear it. She had always been so bubbly and giggly, and now she was showing a real emotion. Now, the doctor said, she was ready to start healing.
"I was sad about what I had done to myself," Winkler said. "I'm sad I have osteopenia and I can't dance."
She's up to 114 pounds now. Her hair looks great, she's sleeping well and she's had only one panic attack since she returned from Philadelphia on Jan. 23. Medication has her bipolar and obsessive-compulsive disorders under control. She's eating a little more than the normal 2,000 to 2,500 calories a day.
With the ongoing help of her family, friends, therapist, doctors, nutritionist and Burke and his staff, Fowler says she's doing great so far.
She can't imagine going back to a room full of mirrors, though, and that's how dance studios are built. As much as she loves dancing, she has decided in therapy that she used it along with anorexia to escape her feelings, and it also became an excuse for being thin.
"I'm not sure I can ever go back to looking at myself in the mirror every day and being worried about weight," she says. "But I do miss it terribly."
Copyright 1999 The New York Times Syndicate. All rights reserved.
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