Eating Disorders

Weight control out of control

John decided to try out for crew. The coach told him that he would have to lose 2 pounds by the next morning to "make weight" for the novice lightweight shell. A sophomore on the team who had met a similar weight requirement the preceding year recommended a water pill, sweating off a couple of pounds in the sauna, and no food before weigh-in. John took the advice and lost the 2 pounds, but he felt tired and lightheaded the next day.

Laura created her own weight requirement. Although her family did not agree, she became convinced that she was overweight. The girls in her sorority were always talking about diets-who looked good and whQ didn't because she had gained weight. Laura became obsessed with her weight and the sorority scale. She started a very restricted diet and used coffee, diet drinks, and diet pills to allay hunger. By these extreme measures she lost 4 pounds but not her unhappiness. Exercising an hour a day, she hoped, would remove more weight. "If only I could lose 5 pounds I would be happy," she told friends.

Brenda had experimented with a lot of diets in the past and was sometimes able to lose a few pounds, but she always seemed to get hungry and would gain back the weight. A friend told her to try vomiting if she blew her diet. Although at first the idea of sticking her hand down her throat and making herself vomit seemed disgusting to her, Brenda tried it a few times after she had overeaten. She didn't feel any aftereffects, and soon she found that she could eat whatever she wanted and then throw up and not gain weight. Her thoughts revolved around food. She organized her day according to where and when she would eat and then vomit. She stopped seeing friends, afraid that they might find out, and began eating meals off campus. Brenda saw blood a couple of times in what she vomited but didn't want to tell anyone for fear that someone would discover her secret.

All three students, for compelling personal reasons, were using ineffective and harmful methods of weight control. Given the pressure to acquire the ideal body portrayed in the media, many students try these techniques that, when their use becomes compulsive, repetitious, and an end in themselves, culminate in a true disorder.

It is puzzling in this land of plenty, with our emphasis on nutrition, exercise, and health, that some of the brightest, most attractive young men and women are unhappy with their bodies and themselves and are resorting to futile and dangerous methods to control their weight. This is often done because they have the mistaken notion that they are overweight and that happiness will result if they lose a few pounds.

What causes people to diet excessively, use diet pills, or even develop an eating disorder?

The exact cause is unknown. Current theories suggest that a combination of psychological, physiological, and environmental factors may predispose a vulnerable person to develop an eating disorder.

In our society women, more than men, are subjected to pressures to be unnaturally thin. They are encouraged to attain a body weight that is lower than the body's natural set point. The female body is programmed to have 20 to 26 percent body fat. To get below the weight that provides that percentage, a woman must battle her body's regulatory mechanisms, which are designed to keep her weight stable and ensure survival during times of deprivation.

In misguided efforts to trick the body, people may try any of a number of ineffective, harmful, or nonsensical techniques to achieve weight loss. Phony diet clinics, false advertising, popularized fad diets, and schemes by charlatans out to make money from America's obsession with weight control give many people access to harmful dieting techniques. These techniques, if used repetitively by a vulnerable person, can lead to a full-blown eating disorder.

Why are eating disorders so prevalent?

The societal pressures on women to be attractive, successful, and thin are strong. The desirable woman portrayed in the media is much thinner than the average woman. Popular slogans such as "thin is in" and "you can never be too rich or too thin" have equated thinness with happiness. The result is that for the first time in history, being attractive means being thin.

Compare our fashion models and Miss America with the voluptuous, substantial female figure of Rubens's time or the hourglass ideal of the Victorian Age. The women chosen for the Miss America pageant have shown a decrease in weight of 7 percent over the last 15 years, while the average American woman has shown an increase of 3 to 5 percent. Many men and women in our society are strongly influenced by these symbols and social forces. When surveyed, women consistently report that their ideal body weight is 2 to 15 percent less than the norms established for the actual weights of average women. Thus, women are striving for an unhealthy and unattainable weight, which they mistakenly think will result in overall self-satisfaction.

Consider the demand to be thin in the context of the abundance and significance of food in our culture. Social events revolve around eating. Advertisements for food and quick ways to prepare it bombard us. Flip through a "woman's" magazine. You will find articles on dieting, photographs of unrealistically thin models, low-calorie recipes, and ads from reducing camps and eating disorder clinics. No wonder we are confused.

Are eating disorders more common in women?

About 90 percent of all patients with diagnosed eating disorders are women. Men have the problems as well, but patterns of eating disturbance are predominantly found in women.

During puberty, males gain height and muscle while females gain fat. In evolutionary terms, the male's muscle and strength are necessary for his roles as food provider and fighter, and the female's extra fat and broad hips are aids in childbearing. The result is that the male develops a body close to his idealized image, whereas the female develops a body that is further from the "ideal" female body.

The adolescent is frequently influenced by peer groups and societal pressures. The teenager going through puberty is often trying to attain an idealized thin body by dieting at a time when her developing body is demanding to be fed.

Many women resort to techniques that confuse their under-lying metabolism. They may experiment with diet pills, diuretics (water pills), fad diets, excessive exercise, or vomiting in an effort to stop the normal weight gain. Women also tend to have a lower metabolic rate and therefore burn calories more slowly than men do.

A woman's self-image is often closely tied to her physical appearance and thinness. Women are encouraged to be pleasers and to identify their self-worth with attractiveness. These factors combine to make a woman deny her body's normal physiological demands in order to reach an unrealistic body weight. She is made to believe she is overweight and worthless unless she can somehow achieve thinness. Her life is then "run" by the scale.

Who is at risk for eating disorders?

Studies have shown that eating disorders are most common in white, middle-class or upper-class females. They are more common in families that emphasize weight control and in families whose members have a history of eating disorders or alcohol and other drug abuse.

Women who are vulnerable are often described as high achievers; they are the perfectionists who set unrealistically high standards for themselves. These women may feel depressed and unsatisfied if they do not achieve their goals. The end results are low self-esteem and a sense of failure. Paradoxically, to others they seem to be very successful and to have all the ingredients for happiness. If these women are concerned with weight, they may turn to rigid and possibly harmful dieting and exercising in an effort to achieve unrealistic thinness or perceived perfection.

Some men as well as women with compulsive personalities are also more likely to develop an eating disorder, as are people who have poor social skills, difficulty with their sexual identity, and underlying depression.

What are the warning signs that someone may be susceptible to eating disorders?

Here is a short list of behaviors and beliefs that may mean an individual is susceptible to developing an eating disorder, with its serious physical and emotional consequences.

  1. Preoccupation with food, eating habits, weight.
  2. Belief that thinness equals happiness.
  3. Perception of being overweight despite others' appraisal of low or normal weight and even in the face of verifiable weight loss. This indicates a distorted body image.
  4. Experience that eating or weighing on a scale can determine one's emotional state, leading to the use of food to control emotions.
  5. Ê Frequent use of a harmful or ineffective method of weight control - diet pills, fad diets, laxatives, diuretics, starvation, or vomiting.

Why is using the methods in item 5 in the previous question harmful and ineffective?

Strict dieting can actually precipitate an eating disorder. Dieting is read by the body as starvation. The body resists weight change because weight is regulated by a set point, the biologically determined normal, healthy weight. An alteration in weight above or below this set point results in the body's using its regulatory mechanisms to return the body weight as close as possible to the set point.

The body responds to dieting, or caloric restriction, by lowering the basal metabolic rate (the rate at which energy is expended, expressed as the calories the resting body uses each day to support essential functions). When the body detects starvation (dieting), it preserves fat in an effort to remain near the set point for total weight. Instead of burning fat, it uses lean body mass, principally muscle, for fuel and the building blocks for synthesis of new cells and new proteins.

Remember, your body doesn't know you are living in the twentieth century and that you may be trying to be unnaturally thin. Your body has the physiology of the caveman who had to survive times of famine. When you starve (diet), fat is preserved in case of further starvation. When you resume eating after dieting, your body is induced to store fat. Chronic dieters thus lose more lean body mass with each dieting episode and gain fat with each re-feeding, the exact opposite of what the dieter wants to accomplish. Continual dieting, with its yo-yo effect, results in a higher percentage of body fat with a return to the original body weight.

Dieting also causes your body to generate hormones that, in addition to preserving fat, make you want food even if you are not conscious of hunger. This hormonally driven hunger can override your willpower and lead to overeating, a so-called binge. (See the section on bulimia later in this chapter.) New research has shown that chronic dieting also lowers the metabolic rate.

How does dieting lead to vomiting?

The chronic dieter is in a dilemma. The body is trying to get more calories, but the willpower says no. Occasionally the body's mechanisms, using hormones, break through the willpower, and the dieter loses control and overeats. The overeating may occur at the end of the day, at a time of stress or boredom, during a late-night study session, or during the temptations of a party. Having blown the diet, the dieter suffers all the uncomfortable physical and emotional effects of overeating.

After overeating, some chronic dieters try to get rid of the food. They may have heard from a friend that vomiting would prevent weight gain, or they may have read about self-induced vomiting in a magazine and decide to try it. Some people buy ipecac, an over-the-counter preparation that is used to induce vomiting in certain cases of poisoning. What they do not know is that vomiting is harmful and ineffective and that ipecac itself is a poison, toxic to the heart.

The loss of control felt during overeating leads to a determination not to wreck the diet the next day, and an even more rigorous diet with totally unrealistic goals may be started. Most dieters don't realize they are not fighting a lack of willpower when they overeat. They are following the demands of the body to be fed. These demands are in the form of signals from hormones such as glucagon, growth hormone, and others. Instead of starting a more rigorous diet, a wise dieter would do better to block the hunger hormones by eating small, frequent meals (see the section below on effective weight loss).

Why doesn't vomiting work to get the weight off?

Although it is not well publicized, vomiting does not cause you to lose any weight. There is nothing about vomiting that will make you lose fat, which is what most dieters are trying so desperately to accomplish. In fact, vomiting may actually cause you to gain fat and lose muscle. The reason vomiting doesn't work is that when you eat, you immediately retain and digest most of the calories. The stomach empties rapidly. The food is then in the small intestine, where it is quickly absorbed.

Eating a heavy meal during a high-caloric binge usually takes place over 40 to 120 minutes. By that time much of the food has left the stomach and been absorbed. Also, only about 30 to 60 percent of the ingested food is removed by vomiting. In a binge of, say, 5,000 to 10,000 calories, from 1,500 to 6,000 calories will be retained and stored.

In addition, vomiting causes you to lose water and electrolytes, resulting in electrolyte imbalances and dehydration. Vomiting can also harm your upper digestive system (see section below on the dangers of bulimia).

In a binge your body produces high amounts of insulin to process the ingested food. The retained calories are stored as glycogen or as fat. If you vomit, the excess insulin remains in your system, lowering your blood sugar and making you hypoglycemic and hungry.

What about diet pills?

Some people use diet pills or large amounts of caffeine to suppress appetite. However, it has been known for years that diet pills work for only a short time and cause problems far greater than the supposed benefits. They should never be used except under a doctor's strict supervision.

Excess caffeine or over-the-counter diet pills do not usually work on the appetite center. They can make you feel very jittery and strung out, disrupt your sleep, increase your heart rate, give you skipped heartbeats, and cause dehydration. They do nothing to help you lose fat. Instead, they cause all the problems associated with starvation and the side effects of the pills themselves. Avoid diet pills.

Does the use of laxatives cause weight loss?

Many people think that by using laxatives, they are losing weight. This is not true. Laxatives affect the large intestine, where the body absorbs water from the fecal matter. The absorption of calories occurs in the small intestine; by the time the digested food reaches the large intestine, all the calories have already been absorbed.

Because laxatives induce the loss of water, along with the rapid passage of stool, a person may feel that a weight loss has occurred. Serious side effects of laxatives are a disruption of the normal functioning of the bowel, electrolyte imbalances, and dehydration. Don't use laxatives for weight control.

Since diet pills and laxatives don't work, what about water pills?

Diuretics, or water pills, induce water loss by increasing the passage of water in the urine. Unless prescribed for a specific medical condition, they should not be taken by healthy young persons. You lose only water, not fat, and have all the problems of dehydration and electrolyte imbalance. Some of the minerals and electrolytes necessary for normal circulation and muscle and heart function are depleted. Diuretics have been reported to cause fainting attacks, muscle cramps, heart irregularities, and long-term kidney problems. Avoid these harmful pills.

What is left to help me lose weight?

First, you must be sure that you do indeed need to lose weight. If you are just trying to lose the last 4 or 5 pounds so that you can fit into a high-cut swimsuit, you may be unrealistic and fighting your body's set point in vain. If you are overweight, choose a weight goal that is achievable and healthful and give yourself adequate time to reach it. Review the section on nutrition and weight control in chapter 1. You may also want to see a nutritionist at your student health service for guidance in implementing a safe and effective weight loss plan.

The plan should involve the areas of nutrition, behavioral change, attitude change, and exercise. Here are guidelines to safe and effective weight loss.

  1. Set a realistic weight goal and allow time to reach it.
  2. Plan to lose no more than 1 to 2 pounds per week.
  3. Eat frequent small meals to avoid the hunger response.
  4. Do not weigh yourself more than one or two times every 2 weeks.
  5. Design meals that have less fat (20 to 30 percent total calories as fat), fewer simple sugars, more complex carbohydrates (60 percent), and less protein (15 to 20 percent).
  6. Incorporate calorie-burning aerobic exercise into your daily life for 20 to 30 minutes a day. This can include brisk walking.
  7. Cut out empty calories. Avoid situations that encourage snacking, or snack on low-calorie, filling foods.
  8. Identify emotional factors that trigger eating, and substitute activities to distract you or to meet the symbolic needs of food.
  9. Decrease alcohol consumption. Alcohol contains empty calories and decreases your resolve to stay away from high-calorie snacks.
  10. Eat slowly, put down your fork between bites, and place your free hand in your lap. Chew your food well and enjoy its flavor.
  11. If you crave a certain food that is nutritionally unsound, get rid of its power over you by eating it infrequently and in a controlled situation.
  12. Enlist friends to help you with your weight loss efforts.
  13. Work with a weight management group on campus or with an effective nationally recognized weight loss group such as Weight Watchers or Overeaters Anonymous.

What is meant by an eating disorder?

An eating disorder is a disturbance marked by abnormal body image, abnormal concern about weight gain, and abnormal patterns of eating. There are two principal eating disorders, anorexia nervosa and bulimia. Not only are they harmful techniques to control weight, they are symptoms of underlying emotional problems that cause dysfunction in a person's life. These disorders are more fully defined below.

Eating disorders are not new. They have been known since ancient Roman times, when some of the behaviors associated with the disorders were considered socially acceptable at the feasts celebrating the Saturnalia and other festivals. What is new in the 1980s is the extent of the incidence and the global dysfunction a serious eating disorder can cause in someone's life.

Does eating a lot at salad bars and brunches, and even dreaming of food, mean I have an eating disorder?

Not really. Many people dream of food, and they pig out at salad bars and smorgasbords. Food is pleasurable, and eating is usually a gratifying event. If food is running your life and you are consistently overeating to the point of discomfort, you may have the beginning of a problem. A true eating disorder takes control of your life.

Are obesity and overeating considered eating disorders?

Everyone occasionally overeats, or eats well beyond the point of satiety. Holidays and celebrations are frequent inspirations for mass overeating and weight gain. This is called situational overeating. The body's natural set point will return the body weight to normal in a few weeks or months.

The person who consistently overeats regardless of hunger or uses food as a drug to take the place of relationships, to fill a void, or to self-treat depression, has a form of eating disorder. Overeating in this context needs to be treated as an addiction. Psychological help is usually required to address the person's underlying problems.

Obesity is more complicated and involves more than overeating. About one in five Americans is obese. Obesity is defined as weighing 20 percent above the desirable body weight in the Metropolitan Life Insurance Table (see Chart 1.2 in chapter 1).

The more overweight you are, the shorter your life span will be and the greater is your risk for diabetes, hypertension, heart disease, gallbladder disease, and complications if you undergo surgery. Contrary to popular belief, obese people are usually not happy or jolly. They are often ridiculed, rejected, depressed, and lonely, especially in the teenage years.

Some people are genetically prone to obesity. Their body's set point is at a higher body fat percentage. Researchers have found that identical twins raised separately have nearly identical body weights despite different upbringing and diet. Other researchers believe that early childhood weight gain and eating patterns predispose to obesity. Late obesity may result from overeating initiated by underlying emotional problems such as loneliness, depression, and inadequate response to stress.

Treatment for obesity and chronic overeating is crucial to prevent the serious medical and psychological problems that can result. Seek help from your student health service dietitian or a community resource such as Overeaters Anonymous, TOPS (Take Off Pounds Sensibly), or Weight Watchers. Set a reasonable, long-term goal and keep at it. Losing weight healthfully and dealing with your underlying emotional concerns can add years to your life.

A friend has lost 20 pounds and looks too thin. Does this mean my friend has anorexia?

The classic definition of anorexia nervosa involves four criteria:

  1. Loss of 5 to 15 percent of normal body weight (for a 120-pound woman, 6 to 18 pounds) coupled with a refusal to maintain normal body weight
  2. Extreme fear of gaining weight
  3. Distorted body image (feeling fat even when thin)
  4. Absence of three or more consecutive menses (amenorrhea)

These are the symptoms in the current definition established by the American Psychiatric Association and published in their Diagnostic and Statistical Manual of Mental Disorders, referred to as the DSM-III-R (R for revised, 1987). For a diagnosis of anorexia nervosa, all four symptoms must be present.

Anorectics are often young women aged 13 to 17 at the time of onset of the illness. Anorexia may persist many years as a chronic illness and may require hospitalization. With professional help, the chances for recovery are good. If your friend has anorexia, you may be able to recognize several warning signs. She will usually be following an extremely rigid diet and have strange, restrictive eating patterns. She may be exercising excessively, often compulsively and at unusual times of the day. During meals she may play with her food more than eat it, or she may avoid social situations that involve eating. She may weigh herself many times a day and talk about how fat she is. Because of self-starvation, she may feel cold, dizzy, weak, tired, and have an irregular heartbeat. She weighs about 5 to 15 percent less than her ideal weight.

She may be more socially backward than your other friends and may not want to date or socialize with boys. Because of starvation, her basal metabolic rate will decrease and she may find it more difficult to lose weight. Because of her distorted body image, she may still feel fat even if she is skeletal. Her academic work and physical performance usually decline, and she is likely to stop having menstrual periods. Her hands may have a yellow tint.

If the condition is recognized early, most young women can be helped before they develop serious physical or mental illness. If your friend has these symptoms, encourage her to get professional evaluation and counseling.

What are the dangers of anorexia?

Anorexia nervosa can be a very serious illness, with a fatality rate of 2 to 15 percent in chronic cases. The sooner someone gets help, the less likely she is to have a serious or chronic condition. The medical problems seen in anorectics are primarily caused by starvation. The body is forced to use lean body mass (muscle, bone, and organs) for nutrients and fuel. Without adequate intake of food, the body becomes malnourished and enters a state of starvation. The medical problems of anorexia include the following:

  1. Dry skin, dry hair, brittle nails, fine baby hair on body and face
  2. Anemia (low red blood cell count), malnourishment
  3. Low basal metabolic rate and fatigue
  4. Intolerance to cold
  5. Decreased kidney function, increased risk of kidney stones
  6. Amenorrhea (menstrual periods may not return even with resumption of normal body weight), possibly leading to future fertility problems
  7. Loss of bone mass (osteoporosis), leading to risk of stress fractures and true fractures
  8. Constipation
  9. Delayed emptying of food from stomach, leading to an exaggerated sense of stomach fullness when eating
  10. Yellow skin tint from buildup of carotene
  11. Impaired performance - difficulty in concentrating, difficulty in academic work, decline in exercise ability
  12. Abnormal liver function
  13. Multiple heart problems, including low blood pressure, slow heart rate, thinning of heart muscle wall, irregular heartbeat, fainting, possibly irreversible decline in heart function
  14. Serious emotional problems and social isolation; high risk of suicide

Most deaths of anorectics have been due to cardiac arrest (stoppage of the heart). If not successfully treated, anorexia can become a chronic illness that permanently impairs health and happiness.

What is bulimia?

Bulimia comes from the Greek bous (ox) and limos (hunger), which refer to the voracious eating that is typical of this disorder. It is also known as the binge-purge syndrome because it is characterized by frequent binge eating, resulting in physical and emotional discomfort that is relieved by purging.

Binges are often precipitated by dieting or fasting and are followed by self-induced vomiting or the use of purgatives (laxatives or diuretics). They are usually terminated by sleep and exhaustion, and the whole cycle is accompanied by intense feelings of shame and guilt. Bulimia is very often a secret behavior because of this painful humiliation. Most sufferers are of normal weight and are difficult to identify because unlike anorectics, they do not advertise the problem by weight loss.

Ninety percent of bulimics are women. Incidence figures are difficult to obtain because it is a hidden illness, but researchers estimate that between 1 and 20 percent of college women have had full-blown symptoms of bulimia as defined by the Diagnostic and Statistical Manual (DSM-III-R).

The bulimia criteria are the following:

  1. Recurrent episodes of binge eating
  2. Feeling of lack of control during binges
  3. Regular episodes of self-induced vomiting, use of diuretics or laxatives, strict dieting or fasting, and vigorous exercise
  4. Minimum of two binges per week for at least 3 months
  5. Persistent overconcern with body shape and weight

The part that is new in the revised criteria is that a purging behavior of some sort is required for the diagnosis, and this purging is quantitated. The occasional binger and situational purger do not necessarily meet DSM-III-R criteria.

Bulimia usually begins in adolescence after a teenager has experimented with various reducing diets. She may have failed to lose weight, or she may have been successful at losing a great deal of weight. Bulimia may be mixed with periods of anorexia and may persist for 10 to 20 years. With professional help, bulimia can be controlled and cured.

A friend induced vomiting a couple of times. Is that a sign of bulimia?

Not necessarily. Many people may experiment with self-induced vomiting for a variety of reasons. It is a disorder only when it becomes a habitual or compulsive behavior or is associated with other problems. Your friend may decide that vomiting is too unpleasant or dangerous and will stop on her own. There are also people who start to use vomiting for weight control and then realize that it is a problem. If they can stop voluntarily before the binging-purging becomes habitual, they may be able to escape the cycle.

Are there any outward signs that can identify bulimia?

Certain behaviors and physical symptoms, if persistent, should arouse the concern of friends and relatives.

  1. Ingestion of large meals followed by disappearance into the bathroom
  2. Eating for extended periods or eating very large meals without weight gain
  3. Secret eating, stealing food, or lying about eating
  4. Parotid, or salivary, glands (located below and in front of the ear) swollen from prolonged vomiting, giving chipmunk or mumpslike appearance
  5. Irregular weight loss or gain, rapid fluctuations in weight
  6. Red, puffy eyes or bloodshot eyes, especially after being in the bathroom
  7. Foul breath, poor dental hygiene
  8. Frequent sore throats
  9. Frequent talk of food and weight
  10. Physical problems-lightheadedness or fainting, rapid heartbeat, diarrhea/constipation, and irregular menses or loss of periods-not attributed to other medical conditions
  11. Use of diet pills, diuretics, laxatives
  12. Scabs on knuckles from self-induced vomiting; dry mouth, cracked lips
  13. Alcohol or other drug abuse
  14. Low self-esteem, depression, apparent thoughts of suicide
  15. Outside pressure to lose weight, which triggers dieting and struggle with body image
  16. Erratic performance

I've read some articles about bulimia and all the terrible things that can happen. But I've been binging and purging for three years and nothing has happened to me. I don't want any scare tactics, but I do want to know what can happen to my body.

No scare tactics, just the facts. The medical problems of bulimia are attributable both to the frequency of the purging and to the amount of food restriction. There are long-term and short-term effects, and there are reversible and irreversible side effects.

Vomiting may cause you to have swollen eyes and broken blood vessels in the white part that can last for several days. It may also rupture blood vessels in the nose, causing nosebleeds, and there may be broken blood vessels across the cheeks. The salivary glands may be swollen and tender. Tooth enamel can be eroded or stained by the action of the acidic vomitus and the sugary foods eaten during a binge. The enamel change is irreversible and requires expensive work to fill cavities, eradicate stains, or replace enamel with caps. There may be chronic sore throats and bleeding from the throat. You may be prone to throat infections, and if you do not explain that the cause is bulimia, your physician may treat you with antibiotics or even suggest you have your tonsils removed.

The repeated vomiting can stretch the connection between the esophagus (swallowing tube) and the stomach, causing a hiatal hernia, or slippage of the esophagogastric junction. This type of hernia cannot be repaired and leads to lifelong heartburn and other digestive problems caused by the reflux of acid from the stomach into the esophagus. Violent vomiting can rupture the esophagus-a medical emergency requiring surgery and a long period of recuperation. Another danger is the accidental inhalation of vomitus, which may cause what is called aspiration pneumonia.

Frequent purging can cause inflammation and bleeding of the stomach by disrupting its delicate lining. Stomach ulcers and acid burns in the esophagus can also result. The binging can cause overdistension of the stomach and even stomach rupture and death.

When vomiting, you are unable to empty everything from the stomach. The remaining food is digested and stored as fat. With frequent large binges, you will actually gain weight. Vomiting removes electrolytes and acid from the stomach and seriously upsets the electrolyte and acid-base balance in the body. Sodium, potassium, bicarbonate, and chloride are necessary for nerve and muscle function. Low levels of these electrolytes cause neuromuscular problems like muscle cramps, spasms, and heart irregularities and even heart block and death. An electrocardiogram (EKG) or a blood test can sometimes detect these problems but may miss them if you are a frequent purger or mix purging with the use of diuretics and laxatives. Rapid, irregular heartbeats and heart stoppage are the suspected cause when bulimia is fatal.

When you binge on sugary foods, your body triggers an insulin response appropriate for that amount of food. If you purge, this will be too much insulin for the remaining food. Insulin is the body's hormone that lowers the blood sugar after a meal and stores it as fat or as glycogen for later use. The wide variation between the amount you eat and the amount of food available for digestion after you vomit causes erratic surges in insulin and other hormones, resulting in extreme fluctuations of blood sugar levels. Your blood sugar can be reduced to such a low level that you feel the effects of hypoglycemia, or low blood sugar-nervousness, sweating, rapid pulse, lightheadedness, fatigue, hunger, and, if low enough, unconsciousness and seizures.

You will experience all the effects of dehydration and electrolyte imbalances for as long as a week after an episode of binge-purge. Immediately after purging you feel exhausted, depleted, puffy, and perhaps lightheaded. The longer-lasting effects are fatigue, irritability, dizziness or even fainting, generalized bloating and swelling of feet or hands, and depression.

Your confused metabolism will not know if you are starving or feasting. In consequence, you may have a decrease in metabolic rate, preservation of fat and loss of lean body mass, and wide fluctuations in weight due to shifts in body fluids.

Your digestive system may not be able to adjust when you resume regular eating, and you may experience bloating, constipation, and abdominal cramping. As you begin to eat normally, your body's fluid balance system (the renin-aldosterone system) will no longer be disrupted by the constant need to adjust to the dehydration caused by vomiting or use of laxatives. You now retain fluid. This is called refeeding edema and is one of the most difficult and frustrating events during recovery.

If you use laxatives, your intestines become dependent on them for daily function. You will have recurring episodes of constipation and bloating, and the laxatives cause damage to the bowel lining. If you use diuretics, the long-term kidney problems referred to earlier are likely to be far worse, and there is more danger of the serious electrolyte imbalance mentioned above. If you use syrup of ipecac to induce vomiting, the chemicals in this drug can accumulate in your body and cause direct toxicity to the muscles, resulting in muscle aches and cramps. Ipecac is also directly toxic to the heart muscle and leads to untreatable, irreversible heart failure.

If you are a man, you may have a decrease in the level of the hormone testosterone. This can lead to loss of sex drive and infertility.

More than medical problems, victims of bulimia have serious emotional and psychological problems. Their lives are controlled by this habit, and they withdraw from friends and social events. They may become secretive, isolated, and guilt-ridden. They may be lonely, frightened, and ashamed and may not be able to turn to other people for comfort and strength because of the embarrassment of being caught. They spend extra money for food, even stealing and lying and hiding food, and in desperation may search through trash bins and discarded food trays in the cafeteria.

People who suffer from bulimia may be using food and purging as a way of reducing stress, which paradoxically causes more stress. Their behavior does not resolve underlying conflicts and problems, nor do they learn how to handle relationships. They may become seriously depressed and even suicidal at times. Their self-image remains tied to being thin (and perfect) instead of their accepting the natural body and the normal imperfections of a human being.

Although the toll that bulimia takes is not always evident physically, it may be even more damaging emotionally. It is important to know that help is available and that there are controls and a cure.

How can I prevent an eating disorder from happening to me?

Eating disorders of the magnitude that we have just been discussing do not happen suddenly. Many factors put someone at risk for an eating disorder and then remain as constants after it has developed. These factors include family, social environment, and pressures from others that you may not be able to control or resist.

More than a classic eating disorder, what you may have a problem with is overemphasizing appearance and equating self-esteem with ideal weight. This emphasis in our culture has led to a destructive and harmful body image in many people. The factors that cause you to judge your self-worth on the basis of your weight are factors to deemphasize.

Here are ways to avoid the thought patterns and chronic food restrictions that lead to eating disorders.

  1. Avoid fad diets. They lead to restriction and starvation. Avoid dieting in general. Remember, your body has a natural physiological set point, or a healthy, desirable weight, and it will resist most efforts to change that set point. If you have gained weight, learn how to take it off slowly and gradually without overrestricting food intake. See your student health service for their weight management guidelines or join a weight management group. You can also follow a sensible weight reduction program like that recommended by Weight Watchers.
  2. Avoid frequent weigh-ins. Focus on how you feel, not on a number on a scale.
  3. Emphasize health, not weight.
  4. Avoid excessive hunger. This can lead to overeating. Try to eat three to six small meals a day.
  5. Record your moods, exercise, and food intake. This short-term diary can make you aware of using food to reduce stress, to cure boredom, or to feel better after an unpleasant situation. You may also be punishing yourself for eating. To reduce stress, substitute a relaxation technique and eliminate the guilt of overeating.
  6. Avoid comparisons. Your body is unique and will not fit the mold of idealized magazine models. Be realistic about what is a healthy body weight for you.
  7. Don't set a weight goal. Curb the thought that "if only I weighed 125, I would be happy." Body weight has little to do with happiness.
  8. Use self-analysis to build a positive body image. Emphasize your strong points-your hair, nice legs, straight nose, and good posture-whenever you start thinking about what you perceive as a "bad" body part. Use feedback from your friends to reinforce your good points. Don't put yourself down.
  9. Eat normal meals during the day. You will avoid becoming overly hungry or feeling deprived at night and won't blow your diet by overeating late in the day.
  10. Allow forbidden foods occasionally. Giving yourself permission to eat these foods takes away their power over you and the sense of deprivation that can lead to binging.
  11. Plan meals. Save the psychic energy devoted to what-to-eat. Especially plan meals for busy days so that you are not limited to high-calorie fast foods.
  12. Seek professional help. If your thinking or behavioral pattern worries you or your friends, see a counselor at the student health service. Try reality testing with a disinterested professional who can guide you toward a realistic body image and eating pattern. Early intervention and help in changing harmful weight control patterns or destructive body image can facilitate recovery and prevent future problems.

What can I do if a friend has an eating disorder?

Be honest. In a private setting and in a nonjudgmental, caring manner, discuss what observations you have made that concern you. "I've noticed you have been losing a lot of weight and I'm worried that it may be affecting your health. Can we talk about it?" or "I'm concerned because I heard you vomiting last night. Do you want to talk about it?" or "You seem to be having a lot of worries about your weight and what you should weigh. Sometimes it seems that is all you think about. Do you think you can talk to me about it?"

Expect denial, particularly if your friend is anorectic or is embarrassed about vomiting. But the message will get through that you care and will continue to do so even if the "awful secret" is known. Your friend may open up and admit there is a problem but that he or she doesn't know what to do. If there is denial, have another confrontation in a week or more, again in a private setting, and give specific reasons for your concern.

If your friend does admit to a problem, see if she (it's usually a female) can voluntarily stop on her own within a week or two. Or see if you two can set up a buddy system so that if she is having a problem or feels that it is imminent, she can call on you for help.

Encourage her to stop weighing herself all the time, and do some reality testing with her. Point out that her weight is normal or that she has actually lost a lot of weight-whichever is accurate. Your friend may have become unrealistic about her true body image. Help your friend list her positive attributes. Post it where she can refer to it daily. Find out where to get professional help on campus and go with your friend to confer with a counselor.

My roommate is showing signs of an eating disorder. Because she is not a close friend, should I tell her family or the resident adviser in the dorm?

It is probably not a good idea to tell other people. Your best tactic is to be honest about your observations and see if she will discuss the problem with you. If not, she has at least gotten the message that her behavior is of concern. She may open up to you later. You can leave a list of professionals or referrals.

You should not threaten to unmask someone with an eating problem because that will only reinforce the person's sense of embarrassment and shame. Also, don't question someone's friends; instead, talk directly to the person you are concerned about.

Among other actions to avoid: don't allow your friend to talk you out of your suspicions if they are well founded or let her swear you to secrecy and not go for outside help. Professional guidance is usually needed to reach someone with well-established anorexia or bulimia.

If your roommate or friend has just been experimenting with vomiting or using laxatives, talking about it frankly may help her stop. If she wants her behavior to remain a secret, chances are the problem is more serious. She may already have tried to stop on her own and has found that she can not. Your role in that case is to be honest about your concerns, to be caring, and to offer to go with her to get help.

Because it is well known that purging and losing too much weight by dieting are bad for them, why don't people stop doing those things?

This is a common question from family, friends, and even the victim. Very often the person wants to stop but can not. The old cycle of dieting, binging, and purging recurs habitually and almost automatically. Less serious but analogous is nail biting, a habit most people would like to stop. It is self-destructive and sometimes deforming but can resist all efforts to stop it. An eating disorder can be like that-a very bad habit.

The eating behavior is secretive and shameful, and it can be as addictive as alcohol or other drugs. Recurrences are fueled by anxiety, stress, self-doubt, continued dieting, and omnipresent food. Unless the underlying dynamics and problems are addressed in a therapeutic setting, the symptom of these problems-that is, the eating disorder-is very likely to continue.

Underlying concerns with self-esteem, body image, sexual identity, relationships, stress management, and depression can continue to trigger further anorectic or bulimic behaviors. Just to stop purging, or even to gain weight, does not mean the person has solved the problems that may have caused or complicated the eating disorder.

There is also evidence that shows these eating behaviors can be self-perpetuating. Some researchers believe that anorexia is a disorder that begins in the brain and that gaining weight will not cure the condition. The compulsive and addictive nature of the binge-purge cycle makes it very difficult to stop the behavior voluntarily.

Remember, people with eating disorders are very likely to have tried to stop on their own multiple times but find that they can not. The important message is that with outside help, some people can gain control over their behavior.

How can I find the help I need?

Start with your student health service. Because these disorders have been recognized and researched on college campuses, there usually is a counselor who is expert in the evaluation and management of the problem. If not, it is likely the health service can give you a referral.

Most of the time, treatment is conducted by a team of specialists. The team may consist of a physician, a nutritionist, and a psychologist or a psychiatrist. For the student in serious medical danger from anorexia, hospitalization may be necessary until he or she is no longer in danger.

For additional information, write to ANAD (Anorexia Nervosa and Associated Disorders), P.O. Box 7, Highland Park, IL 60035. Enclose a self-addressed stamped envelope with 3-ounce postage. Or you can call the association at (312) 831-3438.

What happens in therapy?

Therapy may be conducted either individually or in groups. The goal is to help you understand and deal with the factors that are causing the eating disorder. The therapy will focus on eating habits at the beginning, but this is not the principal emphasis. The therapy is not designed to make you fat or even to cause you to gain weight. Regaining your health, physical and emotional, is the objective.

In therapy you will usually be addressing issues such as the meaning of food and thinness to you, your triggers to eating, your relationships to others, and your self-image. Group therapy will allow you to share feelings with others and to reverse the isolation and distortion that characterize an eating disorder.

Depending on the duration of your problem, it can take from three months to a year to feel better about yourself and to begin to eat normally. Eating disorders can definitely be helped and corrected. Be patient and make a commitment to stay with therapy during the rough times. You are not alone. Many other people have had the problem and have conquered it.

Summary of Symptoms and Medical Problems of Anorexia


Medical Problems
Impaired performance Chronic illness, 15% death rate
Weight loss 5% to 15% less than ideal weight Amenorrhea
Continuing to feel "fat."; obsessession
with weight, diet, appearance
Osteoporosis - stress fractures
Avoiding social eating situations; social withdrawal Low blood pressure, irregular heartbeat, cardiac problems
Obsession with exercise; hyperactivity Anemia, malnourishment
Ambivalence about femininity High risk ot suicide
Feeling cold Decreased kidney function
Weakness, dizziness  
Decline in physical and academic performance  
Yellow tint to hands  

Summary of Symptoms and Medical Problems of Bulimia


Medical Problems
Irregular weight loss/gain; rapid fluctuations Impaired performance due to fluid loss (dehydration)
and electolyte imbalance
Erratic performance Loss of dental enamel
Red puffy eyes; swollen parotid (salivary) glands Menstrual irregularities (40%)
Poor dental hygeine, foul breath Irregular heartbeat; low blood pressure
Frequent sore throats Fainting, dizziness due to fluid loss (dehydration)
Low self-esteem Constipation/diarrhea alternating - abnormal bloating
Dizziness Anemia, malnourishment
Drug use, alcohol abuse At risk for suicide, drug use, alcohol abuse
Binges or eats large meals and disappears Low potassium - muscle weakness; heart irregularities
Dry mouth, cracked lips Chronic sore throat
Scabs on knuckles Stomach ulcers, gastritis
Diarrhea alternating with constipation Impaired metabolism; wide fluctuations in weight
  Acute stomach dilation
  Enlarged parotid glands - puffy cheeks,
elevated serum amylase
  Tears of esophagus, esophagitis
  Aspiration pneumonia
  Electolyte imbalances - metabolic alkalosis, low potassium
  Ruptured blood vessel in eye (conjunctiva)
  Edema (fluid retention)