When I was coming of age in the sixties and early seventies, eating disorders were not the commonly diagnosed disease they are today. There was only one diet soda on the market, Tab. Packaged foods listing calories and fat grams on their wrappings did not exist yet. But there was the impossibly thin model, Twiggy. She was the first supermodel, the original waif, five-foot-six and only 91 pounds. Twiggy was the face of the mod sixties, ushering in an era of fake eyelashes, miniskirts, and androgynous, childlike bodies. To young girls like me who were both eager to grow up but anxious about leaving behind the safety of childhood, Twiggy represented our ideal of feminine beauty. The physical attribute that I coveted most was her amazing "no thigh? legs.
It is hard to imagine now what an impact Twiggy had on a generation of teens like me. She was what we aspired to be, and no one questioned the wisdom of that aspiration. No one wondered publicly if there was something unhealthy or dangerous about the glamourous model's thinness. Twiggy did not confess to the world any secret eating problems she may have had, as many of today's starlets have. In the sixties there was none of that, just wonder and envy over how Twiggy managed to stay so thin.
At fifteen, I was the oldest of five teenage girls, just beginning to develop hips. I began starving myself in an attempt to feel special and stand out in a family of competitive Montana horseback riders. I developed ritualistic methods of eating, carefully counting out portions of lettuce leaves and raisins, two of my favorite no-fat foods. When I look back at family pictures today, I see that I looked a lot like Twiggy. And yet my success at losing weight was never enough. Still, I thrived on the compliments and the obvious envy of my sisters, and took more pride in my weight loss than anything else. I know now that I became a classic anorexic, dropping down to 100 pounds on a five-foot-six- inch frame. On paper, I possessed the same measurements as my role model. But now, when I look at pictures of me from that period of my life, they look awful to me. I have dark circles under my eyes, and my hair is stringy. I look pretty spaced out. Yet I vividly remember how thrilled I was with the way I looked, absolutely thrilled. My boyfriend at the time, who himself was very thin, also liked my thinness, even though my anorexia made me so withdrawn socially that at its peak, I really had no friends other than him.
At the same time that my dramatic weight loss was taking place, a class- mate of mine was exhibiting the same signs of rapid weight loss. Later, I found out that she had been pregnant and was starving herself to end the pregnancy. Eventually, depleted of sustenance, she miscarried. I remember being shocked that her dieting could kill. Still, I never linked her experience to mine. After all, her self-starvation killed her baby; she herself survived.
As often happens in families of anorexics, no one voiced their concerns directly to me, which might have helped turn my disorder around earlier. While my mother thought I would grow out of this stage of not eating, I only recently found out that it was my grandmother who took me to the doctor. She was too worried about my starving to let it go without further examina- tion. I know that my mother was overwhelmed at the time with the family problems that I will describe shortly. But it warms my heart to learn that my grandmother was watching over me during that turbulent time.
Ma (as we all called my grandmother) took me to our aging family physi- cian, who happened to be close to retirement. Though my family had noticed my changed eating habits, we really did not know that my restrictive eating and the resulting weight loss were dangerous. Assuming that if there were a problem, the doctor would diagnose it, neither Ma nor I mentioned the fact that I had virtually stopped eating meals, only that I was losing my hair, had stopped getting my period, and looked tired and unhealthy. Even these symptoms, disturbing as they might seem, did not trouble me. I was just too pleased with how thin I had become. I never once thought about future health problems that could result from my starvation.
I was reassured when our doctor found no cause for alarm and recom- mended that I put olive oil in my hair. When I tell this story now, I always say, "He should have told me to add the olive oil to my food.? He really didn't understand what was going on. But we weren't giving him all the information. In fact, very few health professionals in the mid-sixties would have recognized my symptoms as an eating disorder.
Times have changed since then, certainly. But it still surprises me how often eating disorders are overlooked, or misdiagnosed. How my large, sup- portive family could have spawned an eating disorder is another source of wonder for me. Looking back now as an eating disorders expert, I realize that my family, ideal as it was in many ways, had despite itself primed me for an eating disorder.
When the youngest of my five siblings, Keith, was born, the whole family was delighted to finally have a boy in the family. We doted on him, and we were devastated when we discovered that he had developed a disease known as retinal blastoma when he was only nine months old. Although it is now quite treatable, at the time, it was quite often fatal. By the time Keith was six years old, he had lost both eyes to the disease. My mother and grandmother learned Braille and translated all of his schoolbooks so he could continue at our country school. My mother also learned and then taught him mobility training so he could negotiate the barnyard and school grounds. He was a great kid. I don't remember him ever complaining. Instead, as he got sicker, he drew us all closer together. He loved to listen to my sisters' and my girl talk about boyfriends and other topics that normally would bore a young boy silly. During the last six months of his illness, Keith moved into the bedroom off the living room. I would spend hours just lying with him, and I think my sisters did the same.
Since my family's main activity was raising and riding horses, it never occurred to us that Keith would not continue to be involved and compete, even as he lost first one eye, and then the other. He adored his horse, Cutie, the half-Shetland, half-quarter horse that we all learned to ride on. Cutie was a pretty, round little bay with the most amazing arched neck. Keith inherited Cutie from my sister Laura when she moved up to a faster horse. Like all of us, Keith started riding early, first sitting behind an older sibling, then alone. By the time he lost his second eye at age six, he was an accomplished rider, so it did not seem like a big stretch to continue riding. In barrel racing and pole-bending competitions, I would sit behind him on his horse, coaching him through the patterned races and making sure he was safe. I would hold my arms outstretched to show the judges that I was not guiding the horse.
Keith died when he was only twelve. Six months before that, my parents had divorced. Against this backdrop of loss and sorrow, my anorexia was a project for me. It gave me focus when my world was coming apart. Away at college, my anorexia gave way to periods of bingeing followed by even more stringent fasting. For a while I maintained my stick figure, but eventually the bingeing won out, and I gained 60 pounds. I hated myself and everything about the eating disorder: the eating in secret, the crumbs in my bathrobe pocket, the lack of control. I began taking food from my roommate, stealing food from the dining halls, even shoplifting food from local stores. All of this is common behavior for a bulimic. Stolen food does not "count? for the eating-disordered person. I would stay up late bingeing on my stash of pilfered food, which made me groggy in classes the next day. As I gained weight, I felt less and less attractive, assuming that people wouldn't like me because of my size. My thoughts were so centered on food- and size-related issues that I had little time to develop any other thoughts. My self-confidence slowly eroded as I became more and more one-dimensional.
I eventually, gradually, shook free of my eating disorder without any professional help, but I regret the seven years I lost doing so. I realize now how damn lucky I was. It might not have gone that way. Most people do not gradually recover on their own. I would love to do those early years in high school and college over, years I squandered amid the chaos of an eating disorder. I missed out on relationships, on learning how to make good friends. I was just a skinny body, a hollow shell; I didn't have much of a personality, I didn't have the energy to develop one.
Partially to pull my life back together while recovering from my eating disorder, I dropped out of college and helped start a natural foods cooperative. After five years of talking to customers about food, I became interested in what science had to say about food and nutrition issues, and decided to return to school and work toward an undergraduate degree in nutrition.
Ironically, I did not connect the interest in studying nutrition to my own past and my eating disorder; to me, those bygone problems with food were ancient history, a dim memory. But when in my first nutrition course, I was assigned a term paper on anorexia nervosa, something clicked. This was an unfamiliar topic to all of us in the mid-seventies, and neither I nor my fellow students knew that anorexia was about to become a major public concern.
As I combed the medical literature, researching my assigned topic, it hit me: I had been an anorexic. Still, although I found this revelation an interesting insight into my own past, I did not know that eating disorders would become my professional focus.
I completed my undergraduate degree at the University of Montana and was accepted into the graduate program of my dreams, at the University of California at Berkeley. In the intellectually charged atmosphere of Berkeley in the seventies, I began to learn more about the political, cultural, and social issues that contribute to the development of eating disorders. In a society where body size is overvalued, dieting and fear of food, we were beginning to realize, were in fact "women's issues.? All of this was critical in the development of my thinking about eating disorders.
After earning my master's degree in public health and completing a dietetic internship at Berkeley, I returned to the University of Montana and taught nutrition part-time. Eating disorders were still considered a curious offshoot of the field, hardly a subject worthy of adopting as a specialty. Yet I found myself teaching a whole unit on them in my introductory nutrition class, often bringing in as guest speakers students who had sought me out to discuss their personal struggles with an eating disorder. The response of my students was overwhelming. Many shared openly, in large classes, their own experiences with eating disorders. Each semester, several students would seek my advice on whether it was possible to recover from their disorder, and what steps they needed to take to do so.
Just as my own teaching experiences were showing me how serious a problem eating disorders were among college students, research and interest in the field accelerated in the 1980s. I took all of this in, avidly staying on top of the latest scientific findings. The top nutrition textbooks by this time included chapters on eating disorders and weight control. Students, and even faculty members, came to me for individual help with these issues. The topic of eating disorders seemed almost to choose me.
Several years later, my university department generously gave me leave to enter Columbia University's doctoral program in nutrition education. I jumped at the chance to earn a degree that I knew would open doors for me professionally. At Columbia, I was exposed to the latest thinking about food, society, women's issues, food production and the environment, and yes, eating disorders. It was an amazing education that taught me how to think critically and to develop my own ideas about eating disorders and how to treat them. A number of the doctoral students were from other countries, including Africa, China, and South America. I learned a lot from them about how parenting and culture affects how we feel about food and our bodies. Columbia's gradu- ate program specialized in nutrition education for children and was also one of the few programs at the time that focused on the connection between nutrition and exercise physiology. I was lucky enough to work with the best thinkers and researchers in those fields. Looking back, I see now how all of these factors steered me toward, and prepared me for, working with eating- disordered children.
Within a year of completing my degree at Columbia, my entire academic department at the University of Montana was eliminated, a victim of severe budget cuts. As I searched the country for a position that appealed to me, one job stood out. It involved developing a new program in nutrition education focusing on eating disorders, sports nutrition, and wellness at Dartmouth College in New Hampshire. It seemed the ideal place for me. At Dartmouth, I found myself spending most of my working hours with students who had serious struggles with anorexia, bulimia, and binge eating. I knew I had found my life's work.
Several years later, a child psychiatrist came to me and asked me to treat his anorexic daughter, who was not responding to traditional treatment and was fast becoming seriously ill. After helping her recover, word of my work spread, and soon in addition to my job at Dartmouth I had a private practice treating children, adolescent and adult patients with eating disorders. I learned an immense amount from both the Dartmouth students I treated, and the children and adults in my private practice. I read every scien- tific article I could find on eating disorders, and was pleased to find that the strategies I developed were extraordinarily successful, even on patients other professionals had written off as hopeless cases. In 2003, I left Dartmouth to devote myself full-time to my increasing number of patients from all walks of life, and to writing and lecturing. While I was encountering a wide range of eating-disordered youths in my work, at home, my husband and I were attempting to raise our own two children free of eating disorders. Thankfully, our efforts have been successful, but that success was by no means a foregone conclusion. Raising my daughter, Gretta, especially has taught me a great deal about the challenges of parenting a child with healthy attitudes toward food. I know that the traits that made me susceptible to an eating disorder are part of her genetic inheritance, and I see her confronting the same issues that I stumbled over in my adolescence. Unlike me and my Twiggy-worship of thirty years ago, though, Gretta knows that Paris Hilton is too thin, and that her own natural body size and shape are nothing to be ashamed of. Raising my own children has taught me that parents play a crucial role in shaping the attitudes of their children toward food and eating. In a society where eating disorders are rampant, it often takes special awareness, vigilance, and effort to raise children who will come to the dinner table free of the modern food-related phobias: fear of fat, fear of excess calories, obsession with physi- cal appearance. If you do not know what I mean, take a look at the following statistics from recent surveys:
• Two-thirds of adolescent girls are trying to lose weight.
• 20% are fasting
• 10% are using diet pills
• 10% are using laxatives
Studies show that the numbers of children and adolescents with eating disorders has increased steadily since the 1950s. Progressively younger and younger children are affected by eating disorders. Eating disorders are increas- ing in prevalence in boys, minorities, and across the world, even in third world countries. Here are a few more facts about girls and boys, eating problems, and body image issues:
• More than 70 percent of adolescents are dissatisfied with their bodies and want to lose weight.
• On any given day approximately two-thirds of all teenaged girls and one-fifth of all teenaged boys are dieting.
• Among preadolescents, 60 percent of all girls and 25 percent of all boys report having dieted recently.
• One study found that 13 percent of the girls surveyed and 7 percent of the boys surveyed binged and purged a few times a week or more. • Recent findings indicate that girls who smoke to suppress their appetite are the highest group of new nicotine addicts.
• A 2006 study found that having anorexia increases the risk of death nine-fold.
Because the first line of defense in combating an eating disorder is at home, with the child's family, I involve the parents of my patients in their treatment far more than most other professionals. I give families assignments to work on at home with their child, I suggest new ways of managing food at home, and I take careful note of parents' insight into and feelings about what is happening in the home. Often, simply providing families with information about how eating disorders begin, how they take root, and the practical steps they can take to help put their child on the path to recovery is what turns a desperate situation around. It is not unusual for you as parents to have a hard time mustering the empathy that is crucial to bringing your eating-disordered child back to health. You feel angry, scared, frustrated, hopeless. But once you begin to understand the insidious nature of the disease, you are better able to direct these emotions toward the disorder, not toward the child. You become more sympathetic to your child's plight, which puts you in a better position to help.
My success in treating the patients in my clinical practice, as well as my husband's and my success at home with our children has been gratifying. In recent years, as my work with eating-disordered children has become more widely known, I have been inundated with calls from worried parents from across the country asking for advice and help. Many of them ask for a good book, a practical guide to help them cope with their child's eating disorder. Although there are many books on the topic, none are completely satisfactory to me. So I have decided to write my own, along with Nancy Matsumoto, a journalist and mother of an eleven-year-old boy. Nancy's voice is that of the parent who shares the concerns of parents everywhere that their children grow up with healthy attitudes toward food and eating.