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A personal Battle With Anorexia


Kari Hanson's life seemed perfect when she was a senior at Mandan High School.

In the fall of 2000, Hanson won one of the most coveted sports awards in North Dakota when she was named Miss Basketball. She also led Mandan to its second straight Class A high school basketball state title.

In addition to being named Miss Basketball, Hanson made plenty of other headlines on the basketball court as a junior and a senior. Head coach Greg Amundson said he received 20 letters from NCAA Division I schools inquiring about Hanson. The University of Connecticut - the top women's basketball program in the nation - at one time showed some interest in Hanson. She might not have been on the school's "A" list, but UConn was aware of her.

Hanson chose Kansas State University in Manhattan, Kan., to continue her career. KSU was a heralded program in Division I and Hanson fit into the school's plans. She almost immediately worked her way into the team's starting lineup. She was living her dream ­ on the court

But Hanson was living a much different life off the court. Off the court, she was barely living at all.

Toward the end of Hanson's freshman year of college, she was diagnosed with anorexia nervosa, a state of starvation accomplished by severe dieting or purging and in some cases extreme exercise

Because of her battle with the disorder, Hanson is no longer playing basketball for the KSU women's team.

Hanson's life on the college basketball court may be over, but her life off the court is geting better. Hanson is ready to talk about her disorder. She's ready to let basketball fans in North Dakota know where she's been the past few years. Maybe if she talks about her ordeal, she says, her story could help save somebody's life.

Kari's story

Hanson says she slipped into her problem after graduating from high school. The coaching staff at KSU asked her to lose about 10 pounds. Hanson, who then weighed about 160 pounds, lost the weight, but lost it rapidly and not in a healthy manner.

A normal day for Hanson went something like this: Eat half of a granola bar, run on the track and work out in the gym, eat a sandwich, lift weights and do a cardio workout, eat a small salad and go to bed.

"They asked me to lose weight and I was trying to make people happy," said Hanson, a 5-foot-8 point guard. "It wasn't so much because of my looks. I can understand the coach's point of view ­ they don't want a guard with a lot of extra weight.

"I learned how to count calories. I just ate as least as I could to get through the day. I trained myself and thought it was good to be hungry. It made me feel like I was accomplishing something. I was a slave as far as the things I did. It is like an addiction"

Some of Hanson's personality traits that contributed to her eating disorder were evident earlier.

Amundson recalled Hanson's first game in a Braves' uniform. She was disgusted with the decisions she made on the floor and she was angry with the way her team played.

She grabbed her backpack and told her parents to meet her at her car. On the way to the game she ran out of gas and left her car stranded on the highway. Instead of accepting a ride with her parents, she jogged about a mile to reach her car. Things didn't go her way that night and she needed time alone.

Her sense of perfection would also explain why she graduated high school with a 4.0 grade point average.

"I'm a very, very strong perfectionist," Hanson said. "If somebody tells me to do something, I do it 100 percent, there's no ifs ands or buts about it."

Hanson's mom, Phyllis, said that characteristic has always been evident.

"If the coaches told her to practice 10 hours a day, she would push herself to do that and push herself to do one more," Phyllis said. "She's always had the urge to excel. Grade-wise, she tried to get straight A's. She always kept her room organized. She likes things in order."

As expected, Hanson made her coaches at KSU happy by losing the weight. She drifted back into her normal routine. Hanson also impressed her KSU coaches with her talent on the floor. She found herself in KSU's starting lineup and her team was ranked in the top 20 in the nation KSU upset Iowa State University around Christmas time and gained even more national recognition.

Hanson's obsession with basketball paid off. She was in the main five on a nationally-ranked team - something she strived for.

But after the ISU upset, Hanson hit a roadblock.

She tore 80 percent of the cartilege in her knee and it floated around in her knee joint. Every two weeks Hanson needed her knee drained. The pain was excruciating. She hoped to return to her team in mid-season, but the surgery wasn't a success. She went through another surgery around Easter time.

Hanson slipped into a depression. Basketball was her life, and she couldn't play.

"I lost my idenity," Hanson said. "I was very obsessive. I was willing to do anything to play or to be the best. My life was off balance."

Rock bottom

From being immobilized after her surgery, Hanson gained a little weight. That's when trouble set in.The KSU coaching staff told her the weight would need to come off when she returned to the court. She also didn't want her knee to support extra weight.

So Hanson basically quit eating.

She consumed only 600 calories a day and burned off about 2,500. Before college, her body fat tested at 22 percent. At one point it got down to seven percent. She eventually shed several pounds from her frame and once weighed in at 113 pounds. She also began to take laxatives.

Hanson began distancing herself from her boyfriend, friends, teammates and family. At meal time, she brought her food back to her room and ate alone, despite being invited to sit with her teammates.

For Hanson, it was the worst case scenario. Her career on the court was suffering, and her life off the court began to change, too.

"My relationship with my best friend suffered," Hanson said. "The friendship drifted. She didn't know what to do or say. I cut everybody out of my life. I told my boyfriend the only way he could see me was if he came to the gym. He got the brunt of everything and he stayed by my side. I tried so hard to push him out. He blames himself that he didn't get help for me earlier. I don't blame him. I lied a lot to make it sound like I was eating more."

Like most people who suffer from anorexia nervosa, insomnia set in. Hanson eventually was prescribed medicine to help her sleep. She still sometimes struggles sleeping. Her skin turned yellow from taking laxatives.

"I had big bags under my eyes," she said. "I was sick, tired all of the time. I would just lay and snooze on and off all day long. My sleep was just off the wall. I would read before I went to bed, wake up and clean house. I tossed and turned and laid there."

Hanson, a kinesology major, saw her grades began to slip, although not as much as they could have. Hanson maintains a 3.6 grade point average as she works to complete a doctorate degree in physical therapy.

"I couldn't concentrate," Hanson said. "I didn't have enough fat around my brain to process anything. My memory went away and I was going through mood swings. My hormones were imbalanced. It was like I was bipolar. A lot of things were comfort issues. If I felt like I was losing control of the situation, I would flip out."

Hanson recalled spending several hours preparing for an important exam. Because of starvation, she couldn't concentrate during the exam and she couldn't remember what she had studied.

"I had an anxiety attack during it and I failed," Hanson said. "I couldn't process what I was reading. It was really scary."

Hanson also battled a slow heart rate, which slowed the flow of blood to her brain. Exercise was out of the question for fear of the stress it could put on her heart, which could've resulted in a heart attack.

"I was sleeping and I was dreaming," Hanson said. "The side effect is not being able to wake up. I jumped head first on the floor and cut my chin open The doctor said it had to do with my heart rate being slow.

"I did lose bone mass, but I had very dense bones to start off with. I have been plugging with the calcium. I did lose some bone mass, but it's not below average."

Getting help

Hanson was confronted by several friends at KSU and the coaching staff, but she continued to deny she needed help. She flew home to Mandan in August. Her parents knew immediately she had a problem. Once of Hanson's close friends saw her and cried.

"Her coloring wasn't good," Phyllis Hanson said. "I recognized some of her eating habits. She was real careful not to eat too much and not to eat certain foods. She did all of the good things most of us should be doing, like dabbing fat off pizza. She read everything about how to lose weight and she combined that with intense exercise. She was in excellent shape, but she took that to an extreme, too."

Hanson was taken to a hospital in Kansas City, where she received treatment. She saw a doctor twice a week, a therapist twice a week and a nutritionist once a week. She was not allowed to exercise because she was too weak, something that lasted for about a year.

"I could hear my mom and dad whispering some things," Hanson said. " I was oblivious to the whole thing. I was really mad and I felt nobody was listening to me."

Hanson was presented with three choices in her treatment - she could go back to her parents' home and rehab, she could be admitted into a hospital or her parents could live with her in Manhattan until she was stable. For five months, Hanson's parents rotated living with her in Manhattan. Hanson's dad is a scientist for the United States Department of Agriculture and her mom is the school nurse at the elementary schools in Mandan. Her dad worked out of an office in Manhattan and her mom was granted time off from work when she needed it.

"I had more arguments with my mom than my dad," Hanson said. "It was hard for me because I hadn't eaten with people I always ate alone.

"My parents have been incredible," she said. "I realized how much they loved me. They were willing to drive 13 hours one way and that isn't easy. Our relationship has improved. I would leave in the summers and play on national teams. We traveled all around the nation. I never got to see my parents."

When Hanson began her sophomore year at KSU, she was transferred out of the dorms where athletes lived. She won't be cleared to play basketball again until her weight reaches 135 pounds. As far as competing at the college level, Hanson said her career is finished.

"I pulled away from the team," Hanson said. "It was hard for them to see me going through this. I was always really hyper and had energy. I was always a jokester, laughing and happy. They saw me when I was sad and depressed and I had no energy."

Putting pieces back together

Hanson has played intramural and pickup games. She once smoothly used a wide selection of moves on the court, but her body now is physically unable to perform those moves. She used to be automatic from the 3-point and free-throw line, but she has lost the strength to be a sharp shooter.

While Hanson struggles with losing her basketball identity, she deals with it on a day-by-day basis. She still focuses on her school work and she plans to travel to China this winter for a missions trip through a church.

"What I had gone through made me realize I was living my life for the wrong thing," Hanson said. "I was sacrificing my life for basketball and my happiness for basketball. I let my coaches have a say in what my life was like. I was obsessed with basketball and I put it first."

Now Hanson puts her own life and her own happiness first. If she were still involved with basketball, she wouldn't be able to complete her missions trip in China.

"I know for a fact I wouldn't be where I'm at without God," Hanson said. "The counselor said I'm in the process of recovering really fast. It's hard because I'm addicted to exercise. I don't like to fail. I want to be the best, no regrets."

Phyllis Hanson and her husband do miss watching their daughter play competitively on the court, but they are thankful that she became interested in playing intramural ball. They are also pleased that she has developed other interests, such as playing recreation volleyball and softball and focusing on school and a relationship with God.

"There's a time for every athlete to say it's the end," Phyllis said. "Her's came a little sooner. She's starting to play again and the love of the game is coming back again. That's what scared me, seeing her having no feeling toward playing initially. She's realizing the importance of having other activities and school and faith. If she was playing ball she wouldn't have those opportunities."
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Self Injury

Whether cutting, burning, head banging, scratching, and even scab picking, growing numbers of adolescents are hurting themselves. In fact, the latest statistics show that as many as 3 million people -- mainly adolescents -- practice self-harm.

And "the rates certainly seem to be increasing," says David S. Rosen, MD, MPH, chief of the section of teenage and young adult health in the department of pediatrics at the University of Michigan Health Systems in Ann Arbor .

"We live in a more stressful world; people's behaviors are more infectious because of the Internet and instantaneous communication, and we recognize [self-harm] much more than we have in the past."

While doctors are getting better at recognizing it, treatment is still evolving, experts tell WebMD.

Why Do Young People Harm Themselves?

Actress Angelina Jolie has talked openly about how she once cut herself to express pain. The movie Thirteen , which was written by a 13-year-old girl, highlighted cutting. In it a 13-year-old girl is transformed from a well-behaved honor student into a rebellious member of her school's popular crowd.

According to many experts, self-harm is not necessarily attention-seeking behavior. Most agree that self-harm is a way of coping with feelings that the individual has difficulty controlling or expressing.

"If you think about youth suicide, which 15 years ago was heavily portrayed in the media, it did seem as though media representations increased rates of that behavior, so if that is a model, then a lot of media attention to [self-harm] could, in fact, increase the likelihood that someone might try this if she is feeling bad," he says.

What Is Self-Harm?

Cutting is overwhelmingly the most common type of self-harm, but some people bang their head, some people stick themselves with pins and needles, and some people scratch or rub until they abrade their skin, he says.

"Picking scabs can also be a [type of] self-harm," says Karen Conterio, author of Bodily Harm and founder of SAFE (Self Abuse Finally Ends) Alternatives at Linden Oak Hospital in Naperville , Ill.

"Everyone has picked off a scab, and that doesn't mean they should be running to the nearest psychologist," she says. But "if you pick a scab because you are anxious and can't get the words out or think 'I am fat' or 'I am ugly' and then pick a scab, or if you created a wound on your face and then picked the scab, it could be self-harm," she says.

Cutting Is Not a Suicide Attempt

"Many people are viewed as suicidal, but [self-harm] is much more of a self-preservation act," she says.

Steven Levenkron wrote the book(s) on cutting -- literally. Levenkron took a fictional look at the behavior in The Luckiest Girl in the World and examined it further in Cutting: Understanding and Overcoming Self-Mutilation. The USA network made a movie on his fiction called Secret Cutting .

"The first cut is a result of a large insult or catastrophe, and the second cut takes less provocation. The third cut takes even less, and the next thing you know you are cutting because you anticipate having a bad day, and after that they cut because they are at a low point in [their] mood cycle, and then finally they cut because its been too long since the last cut," Levenkron tells WebMD.

Who Cuts?

Self-harm can occur with other disorders such as depression, obsessive-compulsive disorder, addictions, and eating disorders. It usually starts around puberty and can get worse if not treated.

And "anybody could be doing it," Rosen says. "It's more girls than boys, and more people start when they are 13 or 14, and self-harm is associated with depression, low self-esteem, anxiety, and a history of trauma or abuse," Rosen says.

Women who are abused physically or verbally by their partner are 75 times more likely to harm themselves, according to a study in the Emergency Medical Journal . And men who harm themselves were more than twice as likely to report partner abuse than their non-self-harming counterparts, report researchers from Addenbrooke's Hospital in Cambridge , England .

However, they are not sure if it's the chicken or the egg. Either domestic abuse could lead to self-harm, or self-harm could be associated with personality traits that make a person more likely to choose to be or stay in an abusive relationship.

"There seems to be a high percentage of people who report physical, sexual, or emotional abuse, but that doesn't have to always be the red flag," SAFE's Conterio says. "Divorce can be a trigger, or sometimes there is an ill child in the family where the healthy child is neglected and may feel guilty, as in 'why I am I healthy? Why is my sibling sick?' So they self-harm," she says.

You can tell by "unexplained injuries or injuries such as 'my cat scratched me' or hiding of arms or legs in warmer weather. I think if a parent does suspect their child is self-harming, they should ask, 'Are you hurting yourself?" she says. If they say yes, then get some evaluation to see how serious it is, she recommends.

"Noticing a cutter in summer is easy as pie if they are wearing short sleeves -- its 'gotcha,'" says Levenkron.

Parents and peers need to recognize the signs of distress linked to cutting such as being increasingly anxious, depressed, unable to handle feelings or emotions, and panicky.

"We try to help people understand why they do this and develop strategies to manage the anxiety, [and] there is some sense that medication can be helpful," Rosen says.

Cutting is often associated with other psychiatric illness, so addressing other disorders can help stop the self-harm, he says.

SAFE offers a 30-day inpatient program for adolescents, and for adults there is an inpatient/outpatient program.

With a combination of medications and therapy, Levenkron says that 90% of self-mutilators in his practice give up the self-harming behaviors within one year of treatment. This is followed by much longer period of time in therapy to heal the underlying causes of these behaviors.

For more information, call SAFE at (800) DONT CUT or visit www.selfinjury.com.
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Pro Anorexia

Aug. 2, 2001 -- The visitors, almost all of them young women in their teens and 20s, visit the Web sites by the thousands each day. All are struggling with body image issues and many have full-blown eating disorders. They come, incredibly enough, not to find help, but to find allies in their battle against their perceived fatness.

Pro-anorexia Web sites have proliferated on the Internet within the last two years, and there are now hundreds of them with names like Dying to be Thin and Pro Ana (for anorexic) Sanctuary. Most warn people who are trying to recover from eating disorders to stay away, but experts say the message is lost on those who are desperate to have their weight-loss obsessions validated, such as this visitor:

"My parents have been making me talk to this counselor once a week, but I continue to lose weight. I tried to hide that but my family and friends notice. Now they say if I don't gain two pounds in the next week, the doctor is putting me in an eating disorder clinic. What do I do?? I can't gain the weight. I am so close to where I want to be. And I don't want to be in some clinic. Do any of you have any advice that could help me?"

At 5'6" tall and 101 pounds, the young girl posting this message in mid July at the Yahoo! chat room My Friend Ana is between 20 and 40 pounds underweight, according to standard weight tables. But the "advice" she received included drinking huge amounts of water prior to her weigh-in and hiding rolls of pennies in her underwear.

"I am appalled when I see these sites, which present eating disorders as normal," Vivian Hanson Meehan, RN, president of the National Association of Anorexia Nervosa and Associated Disorders, or ANAD, tells WebMD. "Young people struggling with this issue want to believe family and friends are wrong when they tell them they are too thin or they should eat. Anorexia is a deadly disease, but these sites treat it as a choice."

According to ANAD figures, 7 million women and 1 million men in the U.S. suffer from eating disorders. More than 80% have developed the illness by age 20, and 6% of serious sufferers -- those who are repeatedly hospitalized -- die from it.

While many of the sites claim to promote healthy weight loss, most of the sites visited for this story contained tips to help anorexics and bulimics hone their skills. For example, one site found through Yahoo!, called The Perfect Body, proclaims anorexia to be "a lifestyle, not a disease" and offers readers "tricks" to help other food-averse visitors hide their disease. Here are some examples:

When you are watched while eating, or in my case w/ your parents, put the food in your mouth and spit it out in your cup while u pretend u r drinking, so they won't know, they'll just think u r drinking. -- Steph

When you go to restaurants or a party or something and you are served, play with your food a lot, if you have to eat. Eat only when someone is looking, and put some food in a napkin. That is exactly what I did on my birthday with the cake. ... But you really have to be careful, cause there really aren't any good explanations on why you put your food in a napkin.

WebMD contacted Yahoo! for the company's view about these sites. A company spokeswoman read this prepared statement:

"The Internet is a rapidly growing medium and, as is true elsewhere in our society, we and our users are struggling with society's most challenging issues," she read. "When content with the sole purpose of promoting harm is brought to our attention, we will evaluate it and in extreme cases remove it. Although this issue affects an extremely small portion of our overall user base, it is something we take very seriously."

Judy Sargent, 33, tells WebMD that these pro-anorexia Web sites "give people ideas about how to best starve themselves or purge, and they make it seem like a game. ... People don't realize how dangerous anorexia is and how much it will take from their life."

Sargent should know. She struggled with anorexia for a decade and was hospitalized 26 times. Three of those times, she wound up in intensive care, and she watched three close friends die from eating disorders. Now a registered nurse, she has written a book about her illness titled The Long Road Back: A Survivor's Guide to Anorexia.

"I ended up with no friends and no life, locked behind closed doors in a psychiatric ward," she says. "All my friends had gone on to college or had married, and I had none of those things. Eventually eating disorders consume your whole life. They don't lead to happiness. They take everything away."
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Older Women and EDs

Dec. 11, 2002 -- Some women who struggle with eating disorders like bulimia and anorexia nervosa may have immune systems that have been thrown out of whack and are now interfering with their bodies' own ability to control food intake and body weight.

A new study suggests that eating disorders may stem from some of type of immune system abnormality that causes other difficult-to-treat diseases like rheumatoid arthritis, multiple sclerosis, and lupus.

Anorexia and bulimia affect up to 3% of women at some point during their lifetime. Both conditions tend to develop at a young age and can cause serious mental and physical problems.

Anorexics tend to develop a distorted body image that causes them to limit food intake severely and become dangerously underweight, while bulimics go through cycles of "binging and purging" -- eating excessive amounts of food followed by induced vomiting.

Although the exact causes of the eating disorders are unknown, recent research has suggested that an abnormality in the nerves of the area of the brain that controls hunger may be to blame. And the researchers of the current study thought the problem might be that antibodies in the body cause damage to these nerves.

In the current study, Swedish investigators found that 74% of women with anorexia or bulimia had developed these antibodies that may make it harder for them to regulate food intake and body weight.

Their findings appear in the early edition of the December issue of the Proceedings of the National Academy of Sciences.

This may mean that the cause behind eating disorders may lie within the immune system. In conditions where the immune system goes awry, the body -- for an unknown reason -- forms antibodies that attack other areas of the body, as if they are foreign objects. This group of conditions is called autoimmune disorders and includes rheumatoid arthritis, lupus, and multiple sclerosis.

Researcher Serguei Fetissov of the Karolinska Institutet in Uppsala , Sweden , and colleagues say it's unclear whether the antibodies directly affect the brains of women with eating disorders. But laboratory tests in rats showed the antibodies could indirectly interfere with brain signals involved in metabolism and weight control.

However, a small number of healthy women also carried similar antibodies, and researchers say merely having these antibodies in the blood may not guarantee development of an eating disorder.
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Body's Food Cycle Amiss in Night Eaters

Night eating syndrome is commonly seen in overweight people. And new research shows that the cause may be an abnormal food cycle in the body.

Researchers say that people with night eating syndrome appear to have disturbed circadian rhythms of food intake. Circadian rhythms are the cycle that your body operates on -- your body's 24-hour clock.

Night eating syndrome is seen in about 6% of people who seek treatment for obesity, according to Albert Stunkard, MD, emeritus director of the Weight and Eating Disorders Program at the University of Pennsylvania School of Medicine. Night eating syndrome may also run in families.

First described by Stunkard in 1955, night eating syndrome may be stress related and is often accompanied by depression. Individuals with the disorder eat one - third or more of their daily calories after their evening meal, sometimes rising from their beds once or twice a night to snack.

Speaking at the North American Association for the Study of Obesity (NAASO) annual meeting this week, Stunkard presented some of his latest findings.

In his new study, Stunkard and colleagues monitored sleep/wake activity over one week in 55 obese adults with night eating syndrome. Participants were compared with 60 people of similar weight who did not have night eating syndrome.

The researchers found that night eating syndrome involves a disturbed circadian rhythm of food intake while circadian sleep rhythm remains normal.

"The circadian rhythm of food intake is extremely disturbed and the timing is delayed by 4 or 5 hours compared to that in normal people," Stunkard tells WebMD.

According to the researchers, night eating syndrome "is the first clinical disorder to manifest different circadian rhythms of two biological systems."

Stunkard also found that 36% of those with night eating syndrome had at least one first-degree relative with the disorder, compared with 22% of those who were not night eaters.

The researchers also report that night eating syndrome may respond to treatment with the antidepressant Zoloft.

In a separate study of 17 night eaters, 29% of patients taking Zoloft experienced total remission of the disorder, and 18% improved significantly. This study was funded by the National Institutes of Health and Pfizer Pharmaceuticals, the manufacturers of Zoloft.

On average, nighttime awakenings fell by 60%, nighttime eating by 70%, and number of calories eaten after supper by 40%, they report.

A paper describing these research findings will be published in the January issue of the International Journal of Eating Disorders .

Stunkard says that their ongoing research is looking at the effect of certain hormones, such as insulin and leptin, on circadian rhythms.
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Chromium May Cut Carb Craving in Depression

A popular nutritional supplement may reduce serious carb cravings in people with depression.

The supplement is chromium picolinate. The new finding comes from a small clinical trial sponsored by Nutrition 21, which years ago purchased the patent rights to chromium picolinate from the U.S. Department of Agriculture.

John P. Docherty, MD, president of Comprehensive Neuroscience Inc., White Plains , N.Y. , and adjunct professor of psychiatry at Cornell University , penned the report. Docherty presented the findings at the National Institute of Mental Health's annual New Clinical Drug Evaluation Unit Conference, held this week in Phoenix .

"It is an exciting finding," Docherty tells WebMD. "The real benefit of this is the high rate of response in this subgroup of depressed patients. If this finding holds up, it is a very important finding for depression. And there was a very, very favorable side effect profile."

Chromium Picolinate's Effects on Metabolism

Chromium picolinate is a nutritional supplement. The "picolinate" part of the compound is thought to enhance the body's ability to absorb chromium. Chromium is a necessary mineral. The typical Western diet barely contains an adequate amount of chromium -- so chromium supplements are quite popular. It's the second most popular mineral supplement in the U.S.

All kinds of claims have been made about chromium picolinate. Few of them are proven. One known effect is the supplement's ability to increase the body's sensitivity to insulin, helping it work better to control blood sugars. It's not clear whether the supplement provides significant help to people with diabetes. A recent analysis of well-designed studies showed that it does not significantly affect blood sugar or insulin levels in people who do not have diabetes.

Depression, Diabetes, and Carb Craving

Docherty notes that there is a connection between diabetes and depression. People with depression, he says, are twice as likely to get diabetes. What's the link?

The most common form of depression, ironically, is called atypical depression. Instead of losing their appetite, people with atypical depression often overeat. Many of these people report an almost irresistible craving for carbs.

Docherty's study enrolled 113 people with atypical depression. Two-thirds took chromium picolinate supplements for eight weeks, and one-third got a placebo.

When the researchers looked at all the patients -- those with and without carb cravings -- they found no overall depression benefit from the chromium supplement compared to placebo. It did, however, cut carb craving.

But chromium did improve depression in certain patients. Researchers found that atypical depression patients who also had carb cravings improved with chromium compared to placebo.

"In that group with high carb craving -- a third of the patients -- we had a very significant benefit from chromium picolinate," Docherty says. "Compared with placebo, it had a 2-to-1 advantage in reducing depression overall."

Maybe, Docherty speculates, this small study has found the missing link between depression and diabetes.

"This could turn out to be a very big benefit if the relationship between depression and diabetes is mediated by carb craving," he says. "It might be that if you eat more carbs, you tax your insulin system more and are at greater risk for diabetes. This treatment chromium picolinate may lower high risk of diabetes in people with depression. That would be terrific."

Chromium Picolinate for Carb Craving?

It is not clear that chromium picolinate -- or anything else -- can help normal people eat fewer carbs, says Leslie Bonci, MPH, RD, director of sports nutrition at the University of Pittsburgh Medical Center. She is also a nutritional consultant for several sports teams and the Pittsburgh Ballet Theatre.

"What is carb craving? It would be really difficult to define that," Bonci tells WebMD. "Yes, there are some people who are going to gear more toward the pasta and potatoes than steak and tofu, but that doesn't have a clinical definition. ... It would be a stretch to say that across the board, carb cravers should go with chromium. Bodies aren't that smart. Psychological and environmental factors do a lot more to determine the cravings we have."

On the other hand, Bonci says, the findings regarding insulin sensitivity and chromium picolinate are "exciting." Moreover, she explains, many people do get too little chromium in their diets.

Huge exposures to chromium can be dangerous. But Bonci notes that people who take chromium supplements don't get harmful side effects.
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The Color of hunger

Is the face of eating disorders only white and middle class?

Not even close, according to Becky Thompson, a professor of African-American studies and sociology who studies eating problems from a multiracial perspective. Thompson is the author of "A Hunger So Wide and So Deep: A Multiracial View of Women's Eating Problems" (University of Minnesota Press, 1997). The book culminates her unique research, based on eighteen multiracial women's struggles with anorexia, bulimia, dieting and compulsive eating.

Thompson's subjects are African American, White, biracial, Latina and Jewish; their classes and sexual orientations vary. The link? They've grown up with a variety of stresses--racism, homophobia, sexism and abuse--which Thompson pinpoints as the true catalysts of many body problems.

So why the shroud of silence? Shame makes it especially difficult for women who don't fit the "profile" to speak up and seek help. For many ethnic women, healing from body problems goes hand-in-hand with finding a solid racial, sexual, or personal identity.

Why do you use the term "eating problems" instead of "eating disorders?"

BT: Racism, poverty, homophobia or the stress of acculturation from immigration-those are the disorders. Anorexia, bulimia and compulsive eating are very orderly, sane responses to those disorders. So that's why I don't even use the word "disorder." I'm shifting the focus away from the notion of eating problems as pathology, and instead labeling forms of discrimination as pathological. I even thought for a while that I should say "eating issues." But I ended up using the term because eating problems do become problems for women.

What about perceptions that eating problems are linked to vanity and appearance, rather than to trauma?

BT: It's perfectly acceptable for a woman at a lunch table to say something like, "God, I really want to lose five pounds," or "My dress doesn't fit right," or "I want to go to the gym so I can look better." It's not nearly as acceptable for that same woman to sit at a table and say, "I got beat up last night," or "I'm really worried about my son on the street." We need to figure out a way to have the real conversations with each other, and to make those as acceptable as ones about bodies and dieting.

One thing I found really interesting was that you used the term "body consciousness" rather than "body image."

BT: I would never have known to be critical of the concept of body image until I was talking to an African-American woman named Jocelyn, and she described her body image as "just ashes up in the air...." It hit me that I had to start way back and not assume that women are "in their bodies" to begin with. For women who've been traumatized, issues of embodiment aren't anything to take for granted. I had to look at whether they felt comfortable residing in their bodies, or just in part of their bodies; whether they considered their bodies a friend or an enemy; whether their bodies felt like safe places to be. These are things people who haven't been traumatized don't consider: If you're used to your home being in one place, it won't dawn on you what it's like to be homeless.

You would picture body issues as kind of a "homelessness" that goes on until a woman becomes comfortable, or has a sense of her body as a safe place?

BT: I was talking to some people once who couldn't get their hands on what it meant to not live in your body. It's very hard to understand unless you've been through it. One of the images I use is, you're driving down the street to go to your house, and you turn into what you thought was your driveway, and the house has just completely disappeared. You're gonna spend time going from one neighborhood to the next going, "Did you see? Do you know what happened?" You're gonna try to get a story of how it happened. Your life will never be the same without that home, with all your things in it. Women who have had to leave their bodies because of trauma try to recreate a sense of home in their bodies.

How strong is the link between trauma and eating problems?

BT: In my study, I sought a community sample—everyday women who were working three jobs, holding half the world up. It's not like I interviewed women who'd been hospitalized. The women I talked to were community leaders, professionals, mothers, artists. They were knock-down-drag-out, amazing women—and the level of trauma in their lives was shocking. That left me to wonder what level of trauma so many marginalized women are living through in a day-to-day way that's just become like the air they breathe. I find that really troubling. I had no idea I'd find that depth of violence in the lives of the women I interviewed. And at the same time, they were very inspiring in their ingenious and methodical ways of healing. Really creative! The negative thing is that none of them got professional help from people who had background in eating problems.

Right. They went to Overeaters Anonymous, and that sort of thing, but they weren't hospitalized.

BT: They weren't treated, but they also avoided some of the stigmatizing aspects of a medical solution to eating problems. They didn't get caught up with being restrained in an eating disorders clinic, or an inpatient clinic. They didn't get pushed with drugs.

I like that you expand the definition of body consciousness beyond weight.

BT: The whole body image category came out of the fashion industry. I tried to think of body consciousness as something that had to do with weight, height, skin color, hair texture, facial structure. All of these things go into how we perceive ourselves, how others perceive us, and the kind of power we're granted in the world. A lot of body literature is problematic because it ranks gender oppression as more severe than other kinds of oppression. That's totally missing the mark. There's a simultaneity of oppression-we don't need to rank them, but we can recognize them all. Jocelyn felt like she couldn't change her skin color or her hair texture, but she could change her body size. That was part of her thinking process, and the way she chose to protect herself while growing up. So it's not possible to talk about body consciousness outside of colorism, or plain old racism.

Why did you pick a multiracial focus on body image?

BT: In the 1980s, I did workshops called Women's Hunger and Feeding Ourselves, in university and community settings. I also worked at The Multicultural Project, which is a community-based, anti-racist, anti-oppression training center. Many of the people who came to these workshops fit the standard portrait-White, middle-class, heterosexual women. But a lot of the people who came didn't fit that portrait-women of color, lesbians, and working-class women. A lot of people lump White women into one homogeneous group. You can't do that. The White Christian women I talked to never would have addressed the issues of anti-Semitism and feeling like they didn't fit in to mainstream American culture. Many Jewish women felt like they were getting hit with one thing after the next-if it wasn't the shape of their bodies it was their noses. If it wasn't their noses, it was their curly hair.

Why do you think there's such a silence for women of color, lesbians and working-class women around this issue?

BT: In my situation, as a lesbian, when I first started to seek treatment for my own eating problems after ten years, I snuck to the support meetings. I thought that it would kind of sully my lesbian credentials. The notion of it being a heterosexual phenomenon made it harder in the '80s for some lesbians to come forward, for fear that they would be seen as having internalized all those patriarchal standards, or weren't "real lesbians." I'm part of that same invisibility.

So it's more of a taboo--as though you crumbled to the patriarchy?

BT: There's a long history of scrutiny that Black women have needed to have because of racism within the health profession. Black women are regularly mistreated by the medical system and misunderstood by psychologists. There are also problems for African-American women who come from families where being big was considered positive in previous generations, and eating was a sign of celebration. To dare develop anorexia or bulimia is in a way to feel like you're betraying your ancestors.

There's a belief that Black women don't develop anorexia and bulimia in the same proportions as White women. Is that a myth?

BT: There's no reliable statistical analysis. We need a quantitative study that's race- and class-sensitive. I don't think it's possible at this point to even say with any clarity whether anorexia and bulimia is more common among White women than among Black women. The level of secrecy would make that hard to measure.

Does that play into people's feelings, that they have to protect the public image of their communities?

BT: In 1994, Essence surveyed its readers about overuse of laxatives, chronic use of diet pills, dieting and starvation. Then they compared the results with statistics from a 1984 Glamour survey of White readers. In every single category, Black women scored higher in terms of difficulties than White women did. Those statistics are very revealing. Eating problems often reflect trauma, and Black women face so many different kinds of trauma.

What were some of the biggest myths these women shattered?

BT: There's a continued tendency in American culture to view healing as an individual process. The women in this book talk about healing as part of the body politic: If eating problems are a consequence of racism, sexism and homophobia, nothing less than revolution will do. The women in the book talk about healing through activism-through working at a battered women's shelter, or a rape crisis hotline. Some of the Jewish women in the group put together a body image awareness group that met every three weeks for two years. They didn't feel comfortable going to Overeaters Anonymous, because it's so Christian-based. They wanted a self-help group that was "leaderful"-meaning everyone in the group led, instead of following one facilitator. That kind of creativity speaks to the collective process of justice work.

How can we begin making change?

BT: We're living in an incredibly regressive, conservative time, so talking about issues of revolution can feel fraudulent. We need very specific and concrete coping strategies. One of the most valuable models is the National Black Women's Health Project. They do self-help groups that are both about self-transformation and community-based politics. They've done these for over ten years, and go all over the country educating women on nutrition and issues of embodiment.

Would you say the answer is a combination of education and activism?

BT: It's consciousness-raising that takes into account race and class. People also need to get uppity. We need to demand that treatment centers have multiracial sessions. One conference after the next has sessions on eating problems where everyone on the panel is White, and there's a real taboo against being a professional who's also had eating problems. It's like if you've had eating problems, you somehow can't speak to the issues as a professional. We need to get rid of those dichotomies. Healing is a profoundly communal affair.

Thin Not 'In' for Everyone (I have major issues with this article because it doesnt add up to me after reading the article above "The color of hunger" - Choose whether or not you want to place this article on your site. I am giving it to you because I found it but I do not agree with the idea that minorities have less eating disorders. In fact, maybe in the past that was the case but now that our entire world has become fashion and body conscious, there is no way we can say that minorities have less eating disorders. I mean, I heard that a woman from an african nation won a miss universe or miss something or another pageant. It was the first time they had won b.c it was the first time that the person chosen was as thin as the western women. Well a lot of the women in the country started to go on diets and started fasts b.c they too wanted to look like the person from their country who won. I also know for a fact that eating disorders are on the rise in countries like china. And as far as minorities in the US. I think maybe they are afraid to speak up or people dismiss the possibility of them having EDs because of their race. Either way, I dont agree with this article at all.
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Minorities and EDs

Not all American women are obsessed with thinness. In fact, unless they feel extreme pressure to conform to mainstream society, blacks and Hispanics are much less likely than their white counterparts to develop bulimia, a new study shows.

"For some minority women, while they may be unhappy with their bodies, being thin is just not that high on their list of values; in the dominant mainstream culture, the ideal body is high on the value list," says study leader Thomas Joiner Jr., PhD, the Bright-Burton Professor of Psychology at Florida State University in Tallahassee, in a news release. "It just shows how powerful the protective quality associated with many minority groups -- strong families and connections to a community -- can be."

The team looked at the effects of body dissatisfaction and acculturative stress -- the pressure to adapt to a society's dominant cultural norms while rejecting the standards of one's own ethnic or racial group. They surveyed 118 white, black, and Hispanic female college students.

Overall, white and Hispanic students were more likely to report having bulimia and body dissatisfaction than were the black students, although blacks also reported being unhappy with their bodies. Bulimia was notably more prevalent in those black students who also reported particularly strong acculturative pressure.

Obsession with body image and the cyclic bingeing and purging of bulimia affects people of all races and ethnicities, and our society's strong emphasis on physical perfection leads to eating disorders in both men and women. But in this study, the researchers identified "a subgroup of women whose body dissatisfaction is not associated with bulimia," says Joiner. "Minority women may be protected as long as they are not actively acculturating."
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Male Athletes Have Poor Body Image, Too

Having poor body image is often associated with women but a new study shows that male athletes have their share of problems with it, too.
A survey of elite college athletes showed that 20% of male athletes believed they weren't muscular enough. Jennifer Cater, a psychologist at Ohio State University Sports Medicine Center, recently presented the research at the meeting of the American Psychological Association.
It appears, however, that male and female athletes view body image problems differently. Women in the study wanted to lose weight (an average 6.8 pounds), while men wanted to gain (an average 3.2 pounds).
Men Struggle With Magazine Images
"Some male athletes see pictures in men's fitness magazines of big, extremely muscular men and feel that they don't measure up," Carter says in a news release. Researchers also found the following about male athletes:
22% believed that parts of their body were too fat.
20% believe they are not sufficiently lean and muscular.
9% use and/or spend a lot of money on performance-enhancing drugs or substances.
5% avoid situations exposing their bodies.
Carter's study specifically looked at athletes in "lean" sports -- gymnastics, swimming, diving, cross country running, and track. There is an added pressure in these sports to be lean for aesthetic or performance reasons she says.
The findings for athletes in lean sports showed that 17.5% of them showed symptoms of eating disorders compared with only 9% of athletes in non-lean sports -- basketball, football, and hockey.
Overall the study shows that men make up an estimated 10% of the American eating disorder population.
Carter says the problem needs more attention, especially because there is little research on it and poor body image can be disguised in men. "I don't have male athletes approaching me to say they have an eating disorder, but I do see athletes who say they are concerned about their body and want to be bigger and more muscular. Sometimes their desire to be more muscular has little to do with improving their athletic performance," she says.
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Chris Godsey gets real about mens growing body obsession

Brad Pitt is a beautiful man. I'm a male, I'm straight, and I don't mind admitting that Brad's body, especially in "Fight Club , " is an impressive sight. Same with D'Angelo, in that powerful, sexual "Untitled" video; he's a put-together dude, and there's no reason to deny it.

But while I'm cool with thinking those guys are fine, I'm bothered by my occasional inability to see them, Men's Health magazine, or any Soloflex commercial, without honestly believing that unless I have three percent body fat, a hairless torso and washboard abs, I'm a sorry human being.

I spent the week after watching "Fight Club" counting calories like Sarah Ferguson; if I catch "Untitled" on MTV Jams before heading to work in the morning, I usually skip breakfast and double that day's workout.

After a long time believing I run, lift, bike, hike and try to "eat right" in the interest of being fit, I've realized my motivations are more superficial than healthy. Instead of seeking true mental and physical fitness, I worry about appearances—about what I'm convinced I should look like, based on magazines, movies and MTV.

I go through streaks of avoiding certain foods not because they taste bad or otherwise disagree with me, but because I'll feel guilty after eating them...like getting freaky with Little Debbie or Sara Lee is something I should be ashamed of.

The thing is, I'm actually in pretty decent shape—about 6' 2", 200 pounds, and relatively solid. I don't lift much, but I do a lot of pushups, pullups and crunches, and I run and bike about 80 miles a week. Most of the time, I usually eat whatever I want, and while I'm working some back fat and a little extra around the middle, I'm not doing too bad. I'm not ripped, but I'm not flabby, and I'm healthy enough to feel lucky.

Still, since high school, I haven't been content. On an intellectual level, I understand that every human body is different, and that there are no "right" and "wrong" ways to look, and that I don't have to live up to anyone's standards by my own.

But what are my standards? A few years ago, I lived with a bodybuilder who was my height, plus 40 pounds, and about four percent body fat. I felt skinny and soft and sub-par that whole year. Now, I live with a competitive runner who weighs about 140, and if I'm not careful, I start feeling like an oaf, all big and clumsy and excessive.

My head just about explodes trying to find a balance between what women want to see, what constitutes fitness, and how much (and why) I actually care. It's tough to observe my own standards when they never stay the same, and when they're manipulated by forces I don't always comprehend.

So what the hell is going on? Why do I spend so much time in the mirror, flexing and twisting and prodding and scrutinizing every part of my body that I deem less-than perfect? Why can a Polo Sport ad inspire me to denounce all fat and commit every waking moment to some sort of muscle-building or cardiovascular activity? Why, after my girlfriend tells and shows me in 50 different ways that she considers my physical presence a religious experience, do I ask her if she's attracted to me? It's like I'm a...

I don't want to say it, but it's true. It's like I'm a woman. My sense self-esteem too often depends on how I see my body, and my body image is increasingly affected (infected?) by a continuous, arbitrary onslaught of images and messages that dictate the rights and wrongs of physical appearance. And I'm not the only guy going through it...

I've got buddies who are manly men—who would punch me for saying what I did about Brad Pitt—but who get real touchy about what their asses look like in a pair of jeans. I know dudes who won't eat anything that's not low-fat, non-fat or otherwise tasteless because they "need to lose a couple pounds." Just the existence of magazines like FLEX and Men's Fitness proves that men provide a viable market for folks looking to make money by exploiting bullshit ideas of perfection.

I used to wonder why every woman in Glamour and Shape is impossibly gorgeous and half-dressed—I couldn't figure out why women (straight women, at least) wanted to gawk at sexy pictures of other women. Then I realized something: they don't want to see those models, they want to be them .

Somebody way smarter than me figured that out a long time ago and started making serious cash selling women images and ideas that breed dissatisfaction and self-doubt.

Men are also consumers, and we're just as receptive to the suggestive sell. Now, somebody's making money off our insecurity, too. Karma's for real, baby, and it's coming to get us.

This is complicated stuff, man. Why do so many people obsess about body image? Do we want to look good for other people, or for ourselves? Are we trying to attract a mate, or prove our dominance over the competition?

Do conflicting messages breed insecurity and self-abuse? Or are magazines and movies just mirroring a culture that values style over substance, looking good over feeling good, and what sells over what's right?

One thing I do know: Body image is no longer an exclusively female problem. In fact, men now have 10% of all eating disorders. Body image isn't limited by race, culture, religion, social or financial status, education or geography either. It's a human problem, and it runs remarkably deep. And since we caused it, I'd like to believe we have the ability to fix it.

Where do we start?
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Not For Females Only

It is generally assumed that the problem of eating disorders is a female issue because, after all, appearance, weight, and dieting are predominately female preoccupations. Magazine articles, television shows, movies, books, and even treatment literature dealing with eating disorders focus almost exclusively on females.

Binge eating is seen somewhat differently than the classic eating disorders anorexia and bulimia. Males have always been included in the literature and in treatment programs for compulsive overeating. Compulsive overeating, however, has only recently been recognized as its own eating disorder—binge eating disorder—and it still is not accepted as an official diagnosis. Because anorexia and bulimia are official diagnoses, the term eating disorder usually refers to one of these two disorders.

Males do develop anorexia and bulimia, and, rather than being a new phenomenon, this was observed over three hundred years ago. Among the first well-documented accounts of anorexia nervosa, reported in the 1600s by Dr. Richard Morton and in the 1800s by the British physician William Gull, are cases of males suffering from the disorder. Since these early times, eating disorders in males have been overlooked, understudied, and underreported. Worse still, eating disordered males seeking treatment are turned down when requesting admission to most of the programs in the country because these programs treat females only.

The number of females suffering from eating disorders far exceeds that of males, but in the last few years reported cases of males with anorexia nervosa and bulimia nervosa have been steadily increasing. Media and professional attention have followed suit. A 1995 article in the Los Angeles Times on this subject entitled "Silence and Guilt" stated that roughly one million males in the United States suffer from eating disorders.

A 1996 article in the San Jose Mercury News shocked readers by reporting that Dennis Brown, a twenty-seven-year-old Super Bowl defensive end, revealed that he used laxatives, diuretics, and self-induced vomiting to control his weight and even underwent surgery to repair bleeding ulcers made worse by his years of bingeing and purging. "It's always been the weight thing," said Brown. "They used to get on me for being too big." In the article, Brown reported that after making such statements in an NFL-sponsored interview session, he was pulled aside and reprimanded by coaches and team officials for ". . . embarrassing the organization."

The following research summaries, provided by Tom Shiltz, M.S., C.A.D.C., from Rogers Memorial Hospital's Eating Disorder Center in Oconomowoc, Wisconsin, are included here to provide insight into the various biological, psychological, and social factors influencing male eating disorders.

Approximately 10 percent of eating disordered individuals coming to the attention of mental health professionals are male. There is a broad consensus, however, that eating disorders in males are clinically similar to, if not indistinguishable from, eating disorders in females.
Kearney-Cooke and Steichen-Asch found that men with eating disorders tend to have dependent, avoidant, and passive-aggressive personality styles and to have experienced negative reactions to their bodies from their peers while growing up. They tend to be closer to their mothers than to their fathers. The authors concluded that "in our culture, muscular build, overt physical aggression, competence at athletics, competitiveness, and independence generally are regarded as desirable for boys, whereas dependency, passivity, inhibition of physical aggression, smallness, and neatness are seen as more appropriate for females. Boys who later develop eating disorders do not conform to the cultural expectations for masculinity; they tend to be more dependent, passive, and non-athletic, traits which may lead to feelings of isolation and disparagement of body."
A national survey of 11,467 high school students and 60,861 adults revealed the following gender differences:
Among the adults, 38 percent of the women and 24 percent of the men were trying to lose weight.
Among high-school students, 44 percent of the females and 15 percent of the males were attempting to lose weight.
Based on a questionnaire administered to 226 college students (98 males and 128 females) concerning weight, body shape, dieting, and exercise history, the authors found that 26 percent of the men and 48 percent of the women described themselves as overweight. Women dieted to lose weight whereas men usually exercised.
A sample of 1,373 high-school students revealed that girls (63 percent) were four times more likely than boys (16 per-cent) to be attempting to reduce weight through exercise and caloric intake reduction. Boys were three times more likely than girls to be trying to gain weight (28 percent versus 9 per-cent). The cultural ideal for body shape for women versus men continues to favor slender women and athletic, V-shaped, muscular men.
In general, men appear to be more comfortable with their weight and perceive less pressure to be thin than women. A national survey indicated that only 41 percent of men are dissatisfied with their weight as compared with 55 percent of women; moreover, 77 percent of underweight men liked their appearance as opposed to 83 percent of underweight women. Males were more likely than females to claim that if they were fit and exercised regularly, they felt good about their bodies. Women were more concerned with aspects of their appearance, particularly weight.
DiDomenico and Andersen found that magazines targeted primarily to women included a greater number of articles and advertisements aimed at weight reduction (e.g., diet, calories) and those targeted at men contained more shape articles and advertisements (e.g., fitness, weight lifting, body building, or muscle toning). The magazines most read by females ages eighteen to twenty-four had ten times more diet content than those most popular among men in the same age group.
Gymnasts, runners, body builders, rowers, wrestlers, jockeys, dancers, and swimmers are vulnerable to eating disorders because their professions necessitate weight restriction. It is important to note, however, that functional weight loss for athletic success differs from an eating disorder when the central psychopathology is absent.
Nemeroff, Stein, Diehl, and Smilack suggest that males may be receiving increasing media messages regarding dieting, ideal of muscularity, and plastic surgery options (such as pectoral and calf implants).
The increase in articles and media reports on males with eating disorders is reminiscent of the early years when eating disorders in females first began to get public attention. One wonders if this is our early warning of how frequently the problem with males really occurs.

The studies indicating that somewhere between 5 and 15 percent of eating disorder cases are males are problematic and unreliable. Identifying males with eating disorders has been difficult for several reasons, including how these disorders are defined. Consider that until DSM-IV, the diagnostic criteria for anorexia nervosa included amenorrhea, and since originally bulimia nervosa was not a separate illness but rather absorbed into the diagnosis of anorexia nervosa, a gender bias existed for both of these disorders such that patients and clinicians held the belief that males do not develop eating disorders.

Walter Vandereycken reported that in a 1979 study, 40 percent of internists and 25 percent of psychiatrists surveyed believed that anorexia nervosa only occurs in females, and that in a 1983 survey 25 percent of psychiatrists and psychologists considered femaleness fundamental to anorexia nervosa. Being overweight and overeating are culturally more acceptable and less noticed in males; therefore, binge eating disorder also tends to go underrecognized.

As it now stands, the three essential requirements for the diagnosis of anorexia nervosa—substantial self-induced weight loss, a morbid fear of becoming fat, and an abnormality of reproductive hormone functioning—can be applied to males as well as females. (Testosterone levels in males decrease as a result of this disorder, and in 10 to 20 percent of cases, males remain with features of testicular abnormality.) The essential diagnostic features for bulimia nervosa—compulsive binge eating, a fear of fatness, and compensatory behaviors used to avoid weight gain—can also be equally applied to males and females.

For binge eating disorder, both males and females binge eat and feel distress and out of control over their eating. However, the problem of identification continues. Males with eating disorders have been so rarely acknowledged or encountered that the diagnostic possibility of anorexia nervosa, bulimia nervosa, or binge eating disorder is overlooked when males present with symptoms that would lead to a correct diagnosis if presented by a female.

Diagnostic criteria aside, the problem of identifying males with eating disorders is heightened by the fact that admitting to an eating disorder is difficult for anyone, but even more difficult for males due to the perceived notion that only females suffer from these illnesses. In fact, males with eating disorders commonly report fears of being suspected of homosexuality for having what is considered a "female problem."

GENDER IDENTITY AND SEXUALITY
As far as the sexuality issue goes, males with all variations of sexual orientations develop eating disorders, but studies have indicated a possible increase in gender identity conflict and sexual orientation issues among many males who do develop eating disorders. Dieting, thinness, and obsession about appearance tend to be predominantly feminine preoccupations, so it is not surprising that male eating disorder patients often present with gender identity and orientation issues including homosexuality and bisexuality. Tom Shiltz has also compiled the following statistics on sexuality, gender identity, and eating disorders, reprinted here with his permission.

GENDER DYSPHORIA AND HOMOSEXUALITY
Fichter and Daser found that male anorexics saw themselves and were seen by others as more feminine than other men, both in attitudes and behavior. In general, the patients appeared to identify more closely with their mothers than their fathers.
Homosexuals are overrepresented in many samples of eating disordered men. While the proportion of male homosexuals in the general population cross-culturally is estimated to be 3 to 5 percent, samples of eating disordered men are commonly twice as high or higher.
Several authors have noted that homosexual content preceded the onset of the eating disorder in up to 50 percent of male patients.
Conflict over gender identity or over sexual orientation may precipitate the development of an eating disorder in many males. It may be that by reducing their sexual drive through starvation, patients can temporarily resolve their sexual conflicts.
Homosexual men may be at an increased risk for devel-oping an eating disorder because of cultural pressures within the homosexual community to be thin. Herzog and colleagues found that homosexual men weighed significantly less than heterosexual men and were more likely to be underweight and to desire an underweight ideal weight. Compared to the heterosexuals, homosexual men were less satisfied with their body build and scored significantly higher on the "Drive for Thinness" scale of the Eating Disorder Inventory (EDI).
Body image concerns may be important predictors of eating disorders in males. Wertheim and colleagues found that a desire to be thinner was a more important predictor of weight loss behaviors than psychological or family variables for both male and female adolescents.
Kearney-Cooke and Steichen-Asch found that the preferred body shape for contemporary men without eating disorders was the V-shaped body, whereas the eating disordered group strove for the "lean, toned, thin" shape. The authors found that most of the men with eating disorders reported negative reactions from their peers. They reported being the last ones chosen for athletic teams and often cited being teased about their bodies as the times when they felt most ashamed of their bodies.
SEXUAL ATTITUDES, BEHAVIORS, AND ENDOCRINE DYSFUNCTION
Anorexic males display a considerable degree of anxiety with regard to sexual activities and relationships. Fichter and Draser compared male and female anorexics and found that males displayed significantly more sexual anxieties than did females. The authors noted that 80 percent of the males in their study grew up in families that regarded sex as a taboo subject. Corresponding with the reported sexual anxiety, low levels of sexual activity among the anorexic males were also noted.
Burns and Crisp found that male anorexics in their study admitted "obvious relief" at the diminution of their sexual drive during the acute phase of their disease.
Eating disordered males differed significantly from eating disordered females in terms of sexual experience in a study conducted by Herzog and colleagues. Males with eating disorders were significantly less likely to have had premorbid sexual relations or to be involved in a sexual relationship at the time of evaluation than were females with eating disorders. Bulimic males, however, appeared to be more sexually active than anorexic males, both premorbidly and at the time of their illness.
A study by Andersen and Mickalide suggests that a disproportionate number of male anorexics may have persisting or preexisting problems in testosterone production.
One problem with eating disorder and gender studies is that what are often considered feminine traits, such as a drive for thinness, body image disturbance, and self-sacrifice, are the hallmarks of eating disorders in both males and females. Therefore, using these traits to determine the degree of femininity in anyone with an eating disorder, male or female, is misleading. Furthermore, many studies involve self-reporting and/or populations in treatment settings, both of which may provide unreliable results. Since many individuals find it difficult to admit they have an eating disorder, and since the admission of homosexuality is also a difficult matter, the actual incidence of homosexuality among males with eating disorders in the general population is an unclear and undetermined issue.

Since females identified with eating disorders outnumber males by a large margin and gender issues such as homosexuality or bisexuality seem prevalent in reported cases involving males, there has been much speculation on why this should be the case. According to Dr. Arnold Andersen, who edited the only book on this subject to date, Males with Eating Disorders (Brunner/Mazel, 1990), definitive answers are not available, but sociocultural influences appear to play a much bigger role than biological ones. (An upcoming book by Andersen, Leigh Cohn, and Tom Holbrook entitled Making Weight: Healing Men's Conflict with Food, Weight, and Shape will be available in December 1999 from Gürze books.)

Andersen and other researchers, such as George Hsu, agree that the most important factor may be that there is less reinforcement for slimness and dieting for males than for females. Dieting and weight preoccupation are precursors for eating disorders and these behaviors are more prevalent in females. Andersen points out that by a ratio of 10.5 to 1, articles and advertisements concerning weight loss are more frequent in the ten most popular women's versus men's magazines.

It is more than interesting that the 10.5 to 1 ratio parallels that of women to men with eating disorders. Furthermore, in subgroups of males where there is a great emphasis on weight loss—for example, wrestlers, jockeys, or football players (such as in the above-mentioned case of Super Bowl defensive end Dennis Brown), there is an increased incidence of eating disorders. In fact, whenever weight loss is required for a particular group of individuals, male or female, such as in ballerinas, models, and gymnasts, there is a greater likelihood that those individuals will develop eating disorders. From this it can be speculated that as our society increasingly places pressure on men to lose weight, we will see an increase in males with eating disorders.

In fact, it is already happening. Men's bodies are more frequently the targets of advertising campaigns, leanness for men is increasingly being emphasized, and the number of male dieters and males reporting eating disorders continues to rise.

One final note is that, according to Andersen, eating disordered men differ from eating disordered women in a few ways that may be important for better understanding and treatment.

They tend to have genuine histories of pre-illness obesity.
They often report losing weight in order to avoid weight-related medical illnesses found in other family members.
They are likely to be intensely athletic and to have begun dieting in order to attain greater sports achievement or from fear of gaining weight because of a sports injury. In this respect, they resemble individuals referred to as "obligatory runners." In fact, many eating disordered men may fit another proposed but not yet accepted diagnostic category, referred to as compulsive exercise, compulsive athleticism, or a term coined by Alayne Yates, activity disorder. This syndrome is similar to but separate from the eating disorders and is discussed in this book in chapter 3.
TREATMENT AND PROGNOSIS FOR MALES
Although more research needs to be done on the specific psychological and personality features of males with eating disorders, the basic principles for treatment currently promoted are similar to those for treating females and include: cessation of starvation, cessation of binge eating, weight normalization, interrupting binge and purge cycles, correcting body image disturbance, reducing dichotomous (black-and-white) thinking, and treating any coexisting mood disorders or personality disorders.

Short-term studies suggest that the prognosis for males in treatment is comparable to that for females, at least in the short term. Long-term studies are not available. However, empathetic, informed professionals are necessary, due to the fact that males with eating disorders feel misunderstood and out of place in a society that still doesn't understand these disorders. Even worse, males with eating disorders are often made to feel uncomfortable and otherwise rejected by females similarly afflicted. Although it may turn out to be true, it is often mistakenly assumed that males with eating disorders, most particularly anorexia nervosa, are more severely disturbed and have a poorer prognosis than females with such disorders.

There are good reasons why this may appear to be the case. First, since males often go undetected, only the most severe cases come into treatment and thus under scrutiny. Second, there seems to be a contingent of males with other serious psychological disorders, most notably obsessive-compulsive disorder, where food rituals, food phobias, food restriction, and food rejection are prominent features. These individuals end up in treatment mostly due to their underlying psychological illnesses, not for their eating behavior, and they tend to be complex, difficult-to-treat cases.

STRATEGIES FOR PREVENTION AND EARLY INTERVENTION OF MALE EATING DISORDERS
Recognize that eating disorders do not discriminate on the basis of gender. Men can and do develop eating disorders.
Learn about eating disorders and know the warning signs. Become aware of your community resources (e.g., treatment centers, self-help groups, etc.). Consider implementing an Eating Concerns Support Group in the school setting to provide interested young men with an opportunity to learn more about eating disorders and to receive support. Encourage young men to seek professional help if necessary.
Athletic activities or professions that necessitate weight restriction (e.g., gymnastics, track, swimming, wrestling, rowing) put males at risk for developing eating disorders. Male wrestlers, for example, present with a higher rate of eating disorders than the general male population. Coaches need to be aware of and disallow any excessive weight control or body building measures employed by their young male athletes.
Talk with young men about the ways in which cultural attitudes regarding ideal male body shape, masculinity, and sexuality are shaped by the media. Assist young men in expanding their idea of "masculinity" to include such characteristics as caring, nurturing, and cooperation. Encourage male involvement in traditional "nonmasculine" activities such as shopping, laundry, and cooking.
Never emphasize body size or shape as an indication of a young man's worth or identity as a man. Value the person on the "inside" and help him to establish a sense of control in his life through self-knowledge and expression rather than trying to obtain control through dieting or other eating disorder behaviors.
Confront others who tease men who do not meet traditional cultural expectations for masculinity. Confront anyone who tries to motivate or "toughen up" young men by verbally attacking their masculinity (e.g., "sissy" or "wimp"). Dem-onstrate respect for gay men and men who display personality traits or who are involved in professions that stretch the limits of traditional masculinity (e.g., men who dress colorfully, dancers, skaters, etc.).
Research has shown that a man who develops an eating disorder presents the following profile: he appears to lack a sense of autonomy, identity, and control over his life; he seems to exist as an extension of others and to do things because he must please others in order to survive emotionally; and he tends to identify with his mother rather than with his father, a pattern that leaves his masculine identity in question and establishes a repulsion of "fat" that he associates with femininity. With this in mind, the following suggestions for prevention can be made:
Listen carefully to a young man's thoughts and feelings, take his pain seriously, allow him to become who he is.
Validate his strivings for independence and encourage him to develop all aspects of his personality, not only those that family and/or culture find acceptable. Respect the person's need for space, privacy, and boundaries. Be careful about being overprotective. Allow him to exercise control and make his own decisions whenever possible, including control over what and how much he eats, how he looks, and how much he weighs.
Understand the crucial role of the father in the prevention of eating disorders and find ways to connect young men with healthy male role models.
Source: Used with permission of Tom Schlitz, M.S., C.A.D.C., of the Rogers Memorial Hospital Eating Disorder Center.

With more time and research devoted to analyzing and understanding the sociocultural, biochemical, and gender-related factors in the roots of the problems of males with eating disorders, optimal prevention and treatment protocols will be revealed.
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Eating Disorders Not Just a Girl Problem

Although fewer men than women suffer from eating disorders, a new study indicates that the number of men with anorexia or bulimia is much higher than previously believed. Despite this, men, whose treatment needs are the same as those of women, do not seek help and, therefore, do not get adequate treatment.

"[Eating disorders] have been seen largely as an issue affecting women, and because of that, I think men have been far less likely to identify themselves as affected by it or to seek out treatment -- much in the same way as men with breast cancer tend to show up in breast cancer clinics much, much later," says the study's author, D. Blake Woodside, MD.

Because there are few large studies of men with anorexia and bulimia, Woodside, who is with the department of psychiatry at the University of Toronto, evaluated and compared 62 men and 212 women with eating disorders with a group of almost 3,800 men with no eating disorders.

Although more than twice as many women as men had eating disorders, there were more men affected than would be expected, suggesting that the occurrence of eating disorders may be higher among men than the current National Association of Anorexia Nervosa and Associated Disorders estimates. According to the group, men are thought to make up about 1 million of the 8 million Americans with eating disorders.

In terms of symptoms and unhappiness with their lives, there was little difference between men and women with eating disorders. Both sexes suffered similar rates of anxiety, depression, phobias, panic disorder, and dependence on alcohol. Both groups also were much more unhappy with how things were going in their lives than men with no eating disorders.

Woodside says his study supports the assumption that anorexia and bulimia are virtually identical diseases in men and women.

A number of reports in the medical literature suggest that gay men account for a significant percentage of male anorexia. Woodside's study did not look at this issue, but he says it should be studied further to rule out whether gay men may simply be more likely to seek treatment for anorexia, though not necessarily more likely to suffer from the disorder than heterosexual men.

"Perhaps it may have a bit of a 'snowball effect,' because men may feel if they come forward they will be thought of as homosexual, even if they are not," Woodside says.

Another expert who treats eating disorders says society has a tendency to glamorize eating disorders while at the same time making fun of the people who have them.

"The media and society believe it's all about these beautiful models trying to lose weight, when that's really not what eating disorders are about," says Mae Sokol, MD. "They're less about food and eating and much more about people's sense of self-esteem and identity and who they are."

Sokol says anorexia may be less noticeable in men than women because men can still have muscle mass even though they are thin.

"In fact, it's more dangerous for men to develop anorexia nervosa than for females ... because when males get down to the lowest weight ranges, they've lost more muscle and tissue, whereas [fat] is something you can lose for a period of time without repercussions," says Sokol, a child and adolescent psychologist at Menninger, a psychiatric hospital in Topeka, Kan.

Despite the media's focus on anorexia, bulimia, and other eating disorders, Sokol says that men are still brought up to believe it's not something that's supposed to happen to them.

"The public thinks of it as a 'girl disease,' and these guys don't want to have to come out and say, 'I have a girl disease.' Plus, to have to come to a [treatment facility] where most of the patients are women -- they don't feel good about that at all," she says.

Woodside agrees that feeling uncomfortable may be a big part of why men are less likely to go for help for an eating disorder.

"I think, for a lot of them, it's definitely a case of 'Do I fit in here?' when men come in [to a treatment center]," he says.

In an editorial accompanying Woodside's study, Arnold Anderson, MD, writes that men seeking treatment "are often excluded from programs by gender alone or are treated indistinguishably from teenage girls."

Anderson , of the department of psychiatry at University of Iowa Hospitals and Clinic in Iowa City , says more research comparing men and women with eating disorders is welcomed because it will help identify factors that may lead to different treatment approaches.
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Body Image Problems Not Just in Women

Men may still hesitate to ask for directions or give up the TV remote, but they're apparently crossing the gender line into another area once firmly dominated by women: Obsessing about their body image and developing eating disorders.

In the past two decades, reports the British Medical Journal, the number of men who openly report dissatisfaction with their physical appearance has tripled -- and today, nearly as many men as women say they are unhappy with how they look. Meanwhile, therapists report seeing 50% more men for evaluation and treatment for eating disorders than they did in the 1990s.

And the root of this trend may be a new type of disorder -- an obsession for six-pack abs and bulging biceps that seems especially common in athletes and other fitness enthusiasts.

Though statistics show that about 10% of men suffer from the two best-known eating disorders -- anorexia and bulimia -- a growing body of evidence suggests that men may be especially vulnerable to muscle dysmorphia, a condition in which one obsesses about lacking muscle definition and mass, even with a muscular body. This condition is not unlike that satirized in Saturday Night Live sketches featuring the Schwarzenegger-like, sweatsuit-wearing Hans and Franz, whose mission was to "pump you up."

Laughs aside, the problem is so real that in the March/April issue of ACSM's Health & Fitness Journal, published by the American College of Sports Medicine, Ball State University nutritionist Katherine A. Beals, PhD, RD, highlights the growing trend among fitness buffs and offers advice to athletic trainers on spotting the problem in weight lifters and other fitness center regulars. "Millions of boys and men today harbor a secret obsession about their looks and are endangering their health by engaging in excessive exercise, bingeing and purging rituals, steroid abuse, and overuse of nutritional and dietary [products]," she writes.

Although a relatively new area of medical research, many experts believe this disorder is grossly underreported. But those at particular risk, says Beals: men who constantly seek instant results from workouts and frequently check their progress in mirrors or on scales. Though her findings are geared to athletes -- or those who want to be -- others say that less-athletic men are not immune to muscle dysmorphia and related body image problems.

"As far as we know, all men are prone to these types of issues," says Katharine Phillips, MD, director of the Body Image Program at Brown University's Butler Hospital and author of several books on men's body image problems, including The Adonis Complex: The Secret Crisis of Male Body Obsession. "The reasons why haven't been well studied, but one factor may be the availability of anabolic steroids, which are potentially dangerous but can make men become much more muscular than Mother Nature ever intended."

Another possible reason being explored: Feelings of threatened masculinity. "Perhaps this is the one domain left where men can feel like men, since women can do everything that men can do, except they can't bench-press hundreds of pounds," she tells WebMD. "What has happened over the years is there's an increasing emphasis on men's appearance, and in particular on looking muscular, and it coincides very nicely with the increasing equality women have attained in society."

Whatever the causes, and likely there are many -- including life experiences or even genetics -- there's no denying that some men are feeling the pressure. Even GI Joe dolls have bulked up in recent years.

"In women with eating disorders, the focus is usually on thinness, but men tend to want to be muscular and gain weight," says Catherine Loomis, PhD, psychologist at the Eating Disorders Center at Rogers Memorial Hospital in Oconomowoc, Wis., one of the nation's few treatment centers that specifically treats men with eating disorder and body image problems. "A lot of it has to do with cultural pressures placed on men to look a certain way. As a result, they may develop a fear of certain foods and anxiety over the way they eat."

Even boys and teens -- especially those who are overweight -- are suffering emotional trauma in their quest for bigger muscles, and setting themselves for possible future medical problems. "They may try to eat lot of protein but limit fat, and they often develop a fear of foods and an anxiety that results from restrictive eating," she tells WebMD. "Often, these are people who are perfectionists and have or could develop obsessive-compulsive disorder."

So when do men cross the line from a healthy workout to an unhealthy and potentially dangerous obsession? One hint: Exercising more than once or twice each day, with no days off from weight lifting.

"I usually note four points that determine whether you've crossed the line or not," says Roberto Olivardia, PhD, another Adonis Complex author and psychologist at McLean Hospital and at Harvard Medical School who specializes in men's body image problems:

Distortion of body image: "If you see yourself as being fat or puny, but others around you say that you're muscular, that's a red flag," he tells WebMD.
Exercise interferes with other areas of life. "If your relationships, job, or school suffer because of your exercise routines, that's a warning sign."
Your harm yourself in pursuit of fitness. "If you're taking steroids, tearing joints or ligaments because of overtraining, or you're fainting because you're not taking in enough liquids, that's a sign of trouble."
Your self-esteem is based solely on your appearance. "If you feel that the perfect body is the only way you can feel good about yourself, that's another warning sign. You need to get self-esteem from many areas in your life -- and not only from your muscles."
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Men Have Body Image Problems, Too

Mirror, mirror on the wall, who's the puniest man of all? For many avid weightlifters, that's the nagging question that just won't go away -- no matter how much time they spend at the gym or how toned and ripped they become.

A new study shows that a growing number of men may be at risk for developing a distorted body image syndrome called muscle dysmorphia. The syndrome affects very muscular men who, regardless of their actual physique, are convinced they look puny and out of shape.

With body image a national obsession, and working out a socially desirable activity, the condition has become increasingly common. But while women tend to suffer from disorders that drive them to be thinner, muscular dysmorphia drives men to be ever bigger and more muscular.

Muscle dysmorphia is a new form of a known syndrome called body dysmorphic disorder. But instead of being exceptionally dissatisfied with one particular body part, men with muscle dysmorphia are unhappy with their entire body.

To find out more about the condition, Precilla Choi, PhD, of the School of Human Movement , Recreation and Performance at Victoria University in Melbourne , Australia , and colleagues interviewed 24 Boston-area male weightlifters who'd been diagnosed with the syndrome and compared their responses with those of 30 comparable weightlifters without the condition.

Their study appears in the October issue of the British Journal of Sports Medicine .

The researchers found that men with muscle dysmorphia saw themselves as not only less physically attractive, but also less healthy, than the other men. They say studies in women show an association between having an attractive body and feelings of overall good health. This may now be the case for men, as well.

The men with muscle dysmorphia were also more likely to be dissatisfied with their overall body appearance, muscle tone, and weight than the other group. They had a strong desire for bigger muscles and were very concerned about not gaining any fat.

The researchers say that as more men hit the gym solely to improve their physical appearance and muscle tone, the incidence of muscle dysmorphia is likely to grow.
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Never Buff Enough

When pumping iron becomes an obsession, some young men develop a little known and often-secret syndrome called muscle dysmorphia. Focusing totally on getting big and buff, they exercise compulsively, shutting out much of the rest of their lives. The problem, though, is no matter how big they may get, they still feel they look small.

The disorder, according to a study in the August issue of the American Journal of Psychiatry, not only causes emotional problems but can also lead to the use of anabolic steroids, putting the men at risk for serious physical and mental side effects.

"Our study showed that men with muscle dysmorphia are very different from normal weightlifters," says author Roberto Olivardia, PhD, a clinical psychologist and research fellow at Harvard Medical School's McLean Hospital in Belmont, Mass. "So weightlifting is only a problem when it interferes with relationships or school and work performance." Still, the incidence is on the rise and media images of an ideal V-shape may be the culprit, the authors suggest.

To study the little-known disorder, Olivardia interviewed over 50 male weightlifters, aged 18 to 30. All the men could bench press their body weight 10 times or more, but about half were still preoccupied with their perception of looking small. Along with comparing their exercise behavior, steroid use, and childhood environment, the researchers probed for eating disorders, depression, and anxiety.

Even though the men were actually big, those with muscle dysmorphia were less satisfied with their bodies, used more anabolic steroids, and had more eating disorders than the comparison group. Often describing shame or embarrassment, they also had a significantly higher incidence of depression and anxiety. But the study didn't find a clear pattern of how the disorder emerged, highlighting the need for further research, the authors suggest.

"Boys and men are now bombarded with the same unrealistic body images that girls and women are," says Katharine Phillips, MD, an expert in body image issues and an associate professor of psychiatry at Brown University School of Medicine in Providence, R.I. Phillips, Olivardia, and a co-author of this study all co-authored a book on the growing trend of muscle dysmorphia and similar conditions called The Adonis Complex. Citing action heroes or fashion models as their ideal, Phillips tells WebMD that some young men become overly preoccupied with the pursuit of bigness. "Kids often give us clues when they're getting into trouble, but we tend to ignore them. So keep an eye out for the following warning signs," she urges.

Exercising more than two hours a day, at the expense of friends, hobbies, or homework
Using large quantities of dietary supplements such as creatine and protein powder
A sudden onset of disproportionately large neck or shoulders
Preoccupation with muscularity
Avoiding social situations
If this sounds like your son, you may want to talk it over with him. "Kids often want to discuss what's going on, but we tend to minimize their concerns or hope that they'll go away. There's no need to panic," Phillips says, adding that it's a good idea to take the following initial steps:

Listen thoughtfully to your son, without criticizing, blaming, or teasing
Point out that muscular men in the media may have used anabolic steroids
Encourage other sources of self-esteem like school performance and hobbies
Unfortunately, some kids may need more than parental support. "If your son remains primarily focused on weightlifting, he may need professional help," Phillips tells WebMD. "Treatment of muscle dysmorphia is still under study, but antidepressant drug therapy is very effective," she explains. Drugs such as Prozac, Anafranil, Luvox, Paxil, and Zoloft are especially helpful in controlling these types of obsessive/compulsive symptoms.

Behavioral therapy is often combined with drug therapy. By using simple strategies to help reduce symptoms and modify distorted thinking, this practical approach allows young men to face the situations they've been avoiding. "Developing a weekly plan with less time devoted to exercise and more time with friends is one example," Phillips suggests.
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Eating Disorders Don't Discriminate

When it comes to eating disorders such as anorexia and bulimia, the spotlight has been almost exclusively on women, so much so that men with these disorders often fall through the cracks. But, experts say, the disease is as serious in men as it is in women and can lead to many of the same complications.

"We've been concerned with a number of issues," Arnold Andersen, MD, tells WebMD. "One of them has been the unavailability of services and the relative neglect -- both in recognition and in treatment -- of eating disorders in males." Andersen is the director of the Eating Disorder Services and in the department of Psychiatry at the University of Iowa College of Medicine.

Eating disorders affect about 5% of adolescents, and it's estimated to be six to ten times more common in women than in men. There are three main subtypes: anorexia nervosa with food restriction, anorexia nervosa with binging and purging (through vomiting and/or laxatives) and bulimia nervosa (the binging and purging without major weight loss).

Andersen says that about 15% of his clinic's patients are male. Katherine Halmi, MD, says about 10% of her clinic's patients are men. Halmi is director of the eating disorders program at the New York-Presbyterian Hospital -- Westchester Division.

"There is very little difference between males and females," Halmi tells WebMD. "Psychologically, it is the same factor: they are very preoccupied with their body image. ... They lack self-confidence. And because of that, they place too much emphasis on their appearance. If you have self-confidence then you aren't so overly preoccupied with how you look. It doesn't mean that much to you."

The course of the illness is similar in men and women, says Halmi. "It can be a single episode with treatment and cure, or it can be a chronic prolonged course with multiple weight gains and relapses, or it can be a constant downhill course to death," says Halmi.

"There is no difference in prognosis in males or females: about one quarter of the patients will be cured, and one quarter will remain very seriously and chronically ill and have an early death rate. The other half retains problems but they are not seriously ill: they are constantly preoccupied with weight, they may eat peculiar diets, they may exercise a lot, but they are able to function," she says.

"Treatment involves a cognitive type of psychotherapy in which we teach patients how to monitor their thoughts and emotions," says Halmi. "We teach them logical exercises like cognitive restructuring in which they take a malfunctioning idea, like 'I am too fat,' then examine the evidence to support that thought, the evidence against it, and then force themselves to reach a reasonable conclusion about it. We also teach them problem-solving techniques. ... Actually, it is very easy for us to treat men and women in the same unit."

Andersen, however, isn't so sure that male and female patients are alike in every way. He says he's found that men diet for different reasons than women, who often feel cultural pressure to look thin. "They dieted to avoid ever being teased again for being a 'fatty boy;' they dieted to improve sports performance; they dieted to avoid getting dad's medical diseases related to weight; and they dieted to become slimmer and fitter to improve a gay relationship. So men have very specific personal reasons as opposed to a cultural endorsement."

Another difference, he says, is a male's perception of fatness. "Five to 10% above average is when men start perceiving any fatness. Women feel fat at 13 to 15% below normal. So they have a different threshold for being fat," he says. "And they have a different body image to achieve. ... The kind of image men have now is becoming equally impossible to achieve -- but the specifics are very different."

Because of these differences, Andersen believes treatment should include some gender-specific components. "Sure there are gender-neutral aspects of treatment [such as] nutritional rehabilitation, normalization of eating patterns, and changing core beliefs," he says.

At his clinic, men also attend all-male support groups and are taught how to develop a different body. This sometimes involves testosterone, which can be very low in men with eating disorders, to build lean muscle mass. "If they leave with a technically normal weight on the scale but a belly, they are going to go right back to starving," he says. It also involves a "prescription" for exercise, which can be tricky because some men overexercise to control their weight.

Andersen recently uncovered another problem associated with exercise: many men with eating disorders have evidence of bone thinning; therefore, there is a higher risk of a break. Bone thinning -- medically known as osteoporosis or osteopenia depending on the severity -- is a well-established complication in women with eating disorders, but its prevalence among men is unknown.

When Anderson and colleagues analyzed data from 31 men who were patients at his clinic, he found that a measure of bone health was substantially lacking in more than 35% of the men. He also found that some of the men even had more severe bone thinning than women with eating disorders.

"The average anorexic male has the bones of an 80-year-old man," says Andersen.

"This is really the first [study] that I have seen that has shown that osteopenia and osteoporosis is a problem in men as well as women," Cynthia Bulik, PhD, tells WebMD. "I think most clinicians are alert to this [problem] in women but they perhaps don't order the tests as readily in men." Bulik, an associate professor of psychiatry at Virginia Commonwealth University and the director of the Eating Disorders Program at the Medical College of Virginia, was not involved in the study.

In all, Andersen would like to see more attention paid to males with eating disorders and more resources available to them. "My goal has been to evolve gender-specific treatments that don't treat guys with eating disorders like girls," says Andersen. "They come from different social learning backgrounds, they have different medical needs, different psychological needs, different body image needs, and they are headed back to a different role in society."

Vital Information:

Doctors say that even though eating disorders are much more common in women, men do suffer from them and follow a similar disease course, although motivations and thought patterns are usually different.
Experts note that while the reasons men and women may develop eating disorders may differ, there is no difference between the sexes in their prognosis: A quarter will be cured; a quarter will remain seriously ill over time and die prematurely; and half will still be troubled by the disease long term but will not become seriously ill.
Doctors should realize men with eating disorders often suffer from osteoporosis and related diseases and should be treated for them.
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Family Meals Help Prevent Eating Disorders

In today's on-the-run society, the traditional sit-down family meal has pretty much gone by the wayside. But researchers say restoring regular family meals can help teenage girls avoid dangerous eating disorders.
"It doesn't have to be a home-cooked meal. The idea is to bring people together," University of Minnesota researcher Dianne Neumark-Sztainer, PhD, MPH, RD, says in a news release.
Armed with data from more than 4,700 ethnically diverse adolescent girls and boys, Neumark-Sztainer and colleagues examined family meal patterns and eating behaviors.
They found that those who regularly ate meals in a structured, positive atmosphere were less likely to show signs of eating disorders, such as vomiting, chronic dieting, and using diet pills.
Nearly 18% of girls who ate one to two family meals each week showed signs of eating disorder behaviors. This number fell to 9% of girls who had family meals three to four times a week. Girls who ate five family meals weekly had an even lower risk of eating disorder behaviors. While boys also benefited from the family meals, the association between eating disorder tendencies and family meals was not as strong.
"Making family meals a priority, in spite of scheduling difficulties, emerged as the most consistent protective factor for disordered eating," the authors write in the November issue of the Journal of Adolescent Health.
Researchers suggest that parents keep conversation light and positive at the dinner table, especially if their children have issues surrounding food.
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Moms: Are You Nursing an Eating Disorder?
The style in which an infant nurses -- rapid and vigorous or slow and lackadaisical -- may offer some revealing glimpses into the future of her emotional health. When combined with a mother is who is anxious about her body weight and shape, these very early patterns of feeding can point to the baby's subsequent development of an eating disorder such as anorexia or bulimia, according to research presented here at the annual meeting of the American Psychiatric Association.

As young as two weeks of age, infants of mothers with eating disorders appear to have distinct styles of feeding and sucking that may predispose them to developing eating disorders themselves, says Stewart Agras, MD, a psychiatrist at Stanford University School of Medicine.

For instance, a pattern of rapid and vigorous sucking -- in a child with a family history of eating disorders -- might be a precursor to bulimia or binge eating.

Meanwhile, very slow, apathetic sucking might herald anorexia nervosa.

Previous research has indicated that "picky eating" among toddlers and small children has been associated with later onset of anorexia, Agras explains, and children who were identified as "picky eaters" at age 3 had also displayed very slow, nonvigorous sucking behavior as infants.

In their study, Agras and colleagues looked at the children of 41 women with eating disorders and 153 women without. In particular, the researchers compared the feeding patterns of the babies in the two groups.

"What we are seeing are early patterns of feeding behavior that persist through childhood," Agras tells WebMD. "When we looked at the offspring of eating-disordered mothers, their daughters sucked more quickly than [the offspring of] non-eating-disordered mothers or ... sons of [eating-disordered mothers]. Eating disordered mothers also complained that they had a tremendous problem getting their daughters off the bottle."

The researchers were also able to determine that the moms with eating disorders fed their children on a less regular schedule and demonstrated much more concern about their daughter's weight, as early as age 2.

What's more, by age 5 the daughters of eating-disordered mothers displayed more negative signs, such as depression and whininess, than did the offspring of non-eating-disordered moms, according to Agras.

The combination of a daughter who eats eagerly and quickly with a mother who is concerned about the baby's weight is a recipe for the daughter eventually developing eating problems of her own, Agras tells WebMD.

Agras stresses that these persistent feeding patterns are risk factors and not hard-and-fast blueprints: Many babies who display those patterns will never develop eating disorders.

The most crucial element of the equation, he says, is the mother's anxiety about the body weight and size of her daughter.

Agras also reported new research showing that it is the mother's anxiety about a child's body weight and size -- and not the father's -- that is most associated with development of eating disorders in children. And that maternal anxiety tends to be directed at their daughters, not their sons, he says.

The research is part of an emerging picture of anorexia and bulimia as illnesses that are related to an underlying -- and long-lasting -- pattern of anxious and obsessive behavior, says Walter Kaye, MD, a psychiatrist at the University of Pittsburgh School of Medicine.

Kaye says a chemical in the brain called serotonin is heavily involved in eating disorders and in the anxious and obsessive behavior that accompanies them. People with eating disorders seem to produce and process this chemical in different ways from those without the disorders -- and they continue to do so even after they have been treated for their disorder, Kaye says.

Studies of the antidepressant Prozac, which helps regulate serotonin in the brain, found that people with eating disorders who received the drug did significantly better than people who received a placebo, Kaye says.
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Many Girls With Diabetes, PKU Have Symptoms of Eating Disorders

Girls and young women with metabolic disorders such as diabetes or phenylketonuria (PKU) must often follow restrictive diets that will last throughout their lives. A new study shows that some of these girls and women develop serious eating problems and behave in ways that may worsen their health.

The findings suggest that living with diseases that have strict dietary requirements may affect patients' eating behaviors and attitudes toward food, increasing their risks of developing eating disturbances, researcher Joan C. Chrisler, PhD, writes in the Journal of Developmental and Behavioral Pediatrics.

"There's almost an epidemic of eating disorders in this country among young girls," Chrisler, of Connecticut College in New London , Conn. , tells WebMD. "There's a lot of bulimia, binge eating and chronic dieting. ... We were concerned about girls with chronic illnesses who are on diets that they must maintain for their metabolic health and safety. We wondered how they would react to these diets and whether they are at risk for eating disorders."

Together with colleague Jeanne E. Antisdel, MA, Chrisler studied girls and young women attending specialized summer camps for people with medical problems, along with staffers at the camps.

The first group they looked at was girls with type 1 diabetes mellitus, a condition characterized by the body's failure to make insulin, the hormone that regulates blood sugar. Diabetics must strictly monitor their consumption of sweets and starches to avoid gaining too much weight. Failure to follow a careful diet or take insulin properly can lead to serious complications, such as kidney failure, problems with blood circulation, and eye problems. The diabetes group included 54 girls and young women 11 to 21 years old.

The second group, consisting of 30 girls and women 11 to 36 years old, had PKU, a hereditary disease caused by the lack of the enzyme needed to break down the amino acid phenylalanine in the body. Phenylalanine is found in many foods containing protein, such as red meat, as well as in some fruits and vegetables and the artificial sweetener aspartame. Failure to follow the proper diet may lead to brain damage. These patients are often underweight and are urged to consume nutritional supplements to gain weight. They also may not grow to an average height because of their restricted intake of protein.

All the participants were asked to fill out a questionnaire about their eating attitudes and behaviors, psychological adjustment, and knowledge about their disease.

About a third of the diabetic girls and a quarter of the PKU girls had eating problems, the survey found. The symptoms were not as severe as those in patients who might be seen at an eating disorders clinic, but were worse than those seen in normal populations, the researchers say.

The patterns of the eating disturbances varied according to which disease the participants had. For instance, the diabetic group was more concerned about avoiding fatty foods. Those with PKU, meanwhile, were more preoccupied with self-control and with perceived pressure from others to gain weight.

Psychologically, diabetic girls and women with eating problems tended to have lower self-esteem and a more negative body image than those without these problems. And the PKU patients with eating problems had poorer judgment and lower self-esteem than the others.

Further, diabetic females with eating disorders were less likely to follow other aspects of their treatment regimens. For instance, they were less likely to monitor their blood sugar levels, follow a meal plan, maintain their blood sugar at appropriate levels, and appropriately treat hypoglycemia (low blood sugar) than those without eating disturbances. This lack of adherence to treatment may result in greater health risks, Chrisler tells WebMD.

"My message for both parents and physicians who deal with girls with illnesses like diabetes and PKU is to watch out for any sign that they may be engaging in disordered eating, because that could be devastating to their health condition," Chrisler tells WebMD. "We can't assume they are going to cope well with this. They're going to need support from their family and health care providers."

Gary Rodin, MD, professor of psychiatry at the University of Toronto , tells WebMD that he agrees that the problem of eating disorders in diabetic women often goes unrecognized by physicians.

"In diabetes, we know now that any girl with poorly controlled blood sugars for unexplained reasons should be considered to have an eating disorder until proven otherwise," he says. He says doctors should talk to their patients about their concerns with body image, weight, dieting, binge eating, and, particularly, failing to take enough insulin.

"By the time they get to age 18, about one-third of diabetic girls admit to taking less insulin at some time for the purpose of preventing weight gain," Rodin says. This practice is extremely dangerous, says Rodin, whose own research found that diabetic girls with eating disorders had a threefold increase in the risk of retinopathy (damage to the retina of the eye).

"In diabetes, we know that dietary restriction is a risk factor for [eating disorders]," he says. "This study also suggests that in another disease in which there is dietary restriction, PKU, there may be a similar increase in eating disorders." He suggests more study is needed to confirm the findings.

"Historically, the message for treating diabetes has been one of a restrictive diet and a tighter approach to regulation and management. In diabetic girls, we know that's been counterproductive, leading to binge eating and omitting insulin. Now, there's a tendency to normalize eating and try to tailor insulin to the diet," Rodin says.

Girls and young women are surrounded by pressures to be thin and beautiful, says Chrisler. "My message to girls with these medical conditions is that you can't be beautiful if you're not healthy. Your health must come first. There are many ways to be beautiful -- weight is not the only way."
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Eating Disorders More Likely in Diabetic Girls

Eating disorders are more than twice as likely among teen-age girls with type 1 diabetes as in nondiabetic teens, elevating their blood sugar in the short run and tripling their risk of vision loss in the future, a Canadian study shows.

"Psychological disturbances in eating behavior pose health risks for everyone, but are especially dangerous for people with diabetes," says Gary Rodin, MD, co-author of the study published in the British Medical Journal. "Underdosing of insulin has the same effect on weight loss as purging or vomiting, and is considered to be an eating disorder," adds Rodin, professor and chief of psychiatry at the University of Toronto.

To determine whether eating disorders are more common in diabetics, Rodin and colleagues surveyed almost 1,500 girls ranging from 12 to 19 years of age. Those with type 1 diabetes, who need insulin injections to live, were compared to nondiabetics on the basis of their attitudes toward eating attitudes and their body mass. Blood samples also were obtained from the diabetic participants.

The researchers found that diabetic teens were 2.4 times more likely to have eating disorders, with 11% of them taking less than their prescribed dose of insulin. Overall, 10% of the diabetic teens met the definition for having an eating disorder.

On average, the diabetic teens had a higher body mass and reported more binge eating. Surprisingly, they also reported less dieting to control their weight.

Those with eating disorders also had some abnormal blood results, which indicated these girls are at increased risk for complications of diabetes, such as eye and kidney disease. The findings come on the heels of an American study, published in the Journal of Developmental and Behavioral Pediatrics, which found that a third of the teen-age girls with type I diabetes had symptoms of eating disorders. Also noting low self-esteem and poor body image among these girls, the authors of that study suggest that diet restrictions may increase the risk of eating disorders. And doctors agree.

"Diabetics are regimented in what they eat and when, often causing them to overfocus on food, especially weight-conscious teen-age girls," says diabetes specialist Mark Rappaport, MD, PhD, an Atlanta-based pediatric endocrinologist. "But eating disorders don't develop unless girls are already at high risk," he adds, citing depression as a factor.

Rappaport tells WebMD that insulin underdosing not only causes high blood sugar and capillary changes, but other serious medical problems as well. "Taking less insulin than prescribed affects the way fat is broken down, causing the blood to become too acidic," Rappaport says. "It's called ketoacidosis, and it can lead to coma and even death."

Rappaport urges parents of diabetics to report suspected eating disorders to a doctor. "It's a complicated problem that requires a lot of coordination between diabetes specialists and mental health professionals," he says. "So by all means, discuss suspected eating disorders with your child's physician as soon as possible."

Vital Information:

Among adolescent girls, eating disorders are more than twice as common among those with type 1 diabetes, according to a new study.
In this population, eating disorders can increase blood sugar levels, affect vision in the long term, and cause other potentially serious medical problems.
Diabetes doesn't cause girls to develop an eating disorder, but the extra focus on food can trigger the condition for those who already are at high risk.
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Avoiding Eating Disorders in Female Athletes

It's a new twist on the phrase, "Just Say No." Mix health education with sports, and young female athletes will turn away from eating disorders, drug abuse, and risky living, new research shows.

A high school program -- piloted in Portland, Ore., -- has helped female athletes say no to diet pills, laxatives, forced vomiting, body-building steroids, alcohol, smoking, and more. It's also helped boost their self-esteem, and shown them how to beat depression.

"We've helped them learn to make connections between how they feel and what they do… that's big for girls," researcher Diane L. Elliot, MD, a professor of health promotion and sports medicine at Oregon Health & Science University in Portland , tells WebMD.

Her report appears in the latest issue of Archives of Pediatric and Adolescent Medicine.

Some 50% of high school kids participate in school sports. Yet, contrary to popular belief, young female athletes are vulnerable -- like any teen girl is -- to eating disorders and substance abuse, including smoking, diet pills, diuretics, laxatives, amphetamines, and anabolic steroid use, writes Elliot.

A program launched in the 1990s, to turn teen boys against bodybuilding steroids, showed that teens listen to health education when sports performance is the focus, she says. It was called ATLAS (Adolescents Training and Learning to Avoid Steroids).

That highly successful effort provided the model for Elliot's program. "But ours couldn't be ATLAS in skirts. We had to tailor it to girls' specific needs," she tells WebMD.

Preventing Eating Disorders

Elliot's program involved 18 public high schools in northwest Oregon and southwest Washington , with 928 girls participating in 40 different sports teams. All were about 15 years old.

Half participated in health education programs in addition to their regular sports training. The rest continued their regular sports training.

The eight-week program involved 45-minute health education sessions every week. The coach was an integral part, fitting the sessions into the girls' training schedule. But the girls themselves took charge of the health education sessions.

Each week, the teams broke into small groups; one girl took the lead as teacher. "We know that peer teaching works best in teen prevention programs like this," says Elliot. "And the all-girl format helps boost self-esteem. Starting in middle school, boys demand more of a teacher's time, so girls become less assertive."

Better sports performance -- the natural way -- was the message for these female athletes.

"We talked about healthy nutrition, how your body needs protein, calcium, carbohydrates so you can perform better, build muscles, bones, be a better team," says Elliot. "We didn't use calorie goals, because we recognize that girls can get fixated on calories."

Alcohol, diet pills, and self-induced vomiting were also discussed -- but in terms of their effect on muscles, hydration, heart, and stamina during performance.

The topic of depression also came up, since women and girls are more at risk. "Depression is also a big risk factor for drug use," says Elliott. In addition, these female athletes learned about how the media represent women, "that [they are] not healthy, realistic images."

The result: use of diet pills and bodybuilding supplements decreased among the young female athletes on the program. Girls had more knowledge of the immediate effects of drugs. Girls were also better able to control their emotions. And they had better insights into media advertising, so they were less manipulated.

After graduation, Elliott and her colleagues mailed surveys to each of the female athletes. The majority was still using the skills it had learned -- decision making, ability to control emotions, and insight into the media, she tells WebMD.

"There was less alcohol use, less marijuana use among girls in the experimental program, which was what we'd hoped for," she says. "As far as disordered eating, there was a very low percentage in all the girls. Once they get out of school, it becomes less of an issue."

Female Athletes and Their Coaches

Jorge E. Gomez, MD, professor of pediatrics at the University of Texas Health Science Center in San Antonio , wrote an editorial about Elliot's study.

"It's a dilemma that a lot of high school girls, especially female athletes, find themselves in -- there's a lot of pressure to be thin," Gomez tells WebMD.

"Pressure comes not only from peers, from the media, but also from well-meaning coaches," says Gomez. "There's a myth that if you have an athlete performing at a certain level, you can put them at a higher level if you just make them thinner. That myth is wrong. There is no evidence, certainly no concrete evidence, that that's true. But it continues to be something that high school athletes, more so than college athletes, run into."

A young female athlete might even be threatened with losing her spot on a team if she doesn't make a certain weight, he notes. "In a sport like softball, what does it matter how much she weighs? Sometimes it's taken to that extreme.

"Under no circumstances should weight be a performance criterion, except in sports like wrestling where it really does make a difference," Gomez says.

Health education in training programs -- as Elliot shows -- is a great idea. "A lot depends on how this information is portrayed to girls," Gomez tells WebMD. "It's really astonishing that these high school coaches voluntarily gave up 45 minutes of practice time. It shows that most coaches are genuinely interested in the welfare of high school athletes, and are very willing to learn about health issues. Most of these coaches are very well intentioned."
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Controlled Exercise May Help Anorexia

Women hospitalized for anorexia may gain more weight -- and feel less driven to exercise abuse -- when they take part in a safe-exercise program.

The finding comes from patients at The Renfrew Center of Philadelphia, a residential treatment center for women with eating disorders. As part of the Renfrew program, patients making progress toward recovery are given the option of taking part in exercise classes.

The exercise program seems to help, Renfrew Center Foundation researchers Kelly N. Pedrotty and Rachel M. Calogero report. Their study is scheduled to appear in Eating Disorders: The Journal of Treatment and Prevention .

"This news may come as a shock to medical professionals who do not generally include exercise in the treatment for anorexia and bulimia," Calogero says in a news release.

People with eating disorders often abuse exercise. They tend to see it as a way to purge their bodies of calories, rather than as a healthy or enjoyable activity. An extreme and often harmful level of exercise is a common feature of eating disorders.

The Renfrew exercise program is designed to teach healthy exercise. It includes elements of yoga, Pilates, resistance training, sports conditioning, partner work, and group therapy. The program's three levels focus on sensing the self, supporting the self, and strengthening the self.

"The idea behind the program is to change the patient's attitudes about exercise," Pedrotty says in a news release. "For example, if a woman struggles with comparing herself to others during exercise, she is urged to focus on her breathing, pay attention to how her body feels, close her eyes, and experience the exercise for herself."

In the study of 254 Renfrew inpatients, anorexic women who chose to participate in the program gained 40% more weight than those who chose not to participate. Women with bulimia or with an unspecified eating disorder did not gain more weight after participation.

Women who took part in the program also reported feeling significantly less obliged to exercise than those who did not participate.
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Some Sports Spur Eating Disorders

Although participating in sports is usually a self-esteem booster for girls, being involved in some weight-conscious sports might put young women at risk for eating disorders. But new research shows there are some warning signs that parents and coaches can look out for.

The study showed that participating in a sport or activity that puts pressure on athletes to maintain a specified body shape or weight, such as gymnastics and ballet, is a risk factor for developing eating habits that are considered "disordered." Those behaviors include attempting to lose weight or prevent weight gain by forced vomiting, using diet pills, or taking laxatives or diuretics, and could eventually lead to serious eating disorders such as anorexia or bulimia.

Researchers found that girls who participated in such sports were one and a half times more likely to engage in those risky behaviors than were other girls.

But despite this increased risk, researchers say the vast majority of girls involved in weight-related sports (91%) show no signs of disordered eating. That finding prompted the study authors to look for other potential factors that might help identify who's most at risk.

Among those who participated in weight-dependent sports, girls who had these disordered eating habits were more likely to report substance use, symptoms of depression, and poor communication with their parents.

"Coaches and other education and health professionals should be aware that girls with additional risk factors may be more likely to exhibit disordered eating," writes researcher Nancy E. Sherwood, PhD, and colleagues at the University of Minnesota's School of Public Health.

Interestingly, researchers say being underweight or having a low body weight for height was not a reliable predictor of disordered eating among the girls studied.

Because girls who participate in weight-conscious sports face a higher risk of developing disordered eating habits, the study authors recommend that coaches monitor their athletes for these behaviors and receive training in strategies for handling these issues appropriately with girls and their parents.

"Moreover, coaches should monitor their own behavior toward athletes and pay careful attention to messages they send regarding weight-related issues, emphasizing the importance of healthy eating as opposed to the maintenance of arbitrary weight standards for optimal performance," write the authors.

Their study appears in the July/August issue of the American Journal of Health Promotion . The findings were based on data collected from a 1995-96 survey of more than 5,000 seventh, ninth, and 11th graders enrolled in Connecticut public schools.
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Sorry, your Eating disorder does not fit our criteria

Imagine a 20-year-old woman who refuses to eat anything except carrots and toast because she is afraid of gaining weight, even though she is 5-foot-8 and weighs only 99 pounds. She exercises to the point of exhaustion five mornings a week because, though she is bone-thin, she thinks her thighs are too flabby. Her periods are irregular, but she has never gone more than three months without menstruating. Another woman, who is also 20 and also 5-foot-8, has an opposite eating pattern. She goes without eating all day, and starting at 6 p.m. she eats nonstop, whatever she can get her hands on. Her favorite pastime is to sit in front of the television with a gallon of mocha-chip ice cream. She maintains a normal weight of 130 by occasionally forcing herself to vomit. But purging is not always easy in her college dormitory, with four young women sharing a single bathroom, so she ends up vomiting, on average, about once a week. Everyone can agree that these women have some sort of disordered eating. But psychiatrists would say that neither one falls into the strict definition of anorexia nervosa, the most severe eating disorder, or its relative, bulimia nervosa. According to the bible of psychiatric diagnosis, the American Psychiatric Association's Diagnostic and Statistical Manual, anorexia must be accompanied by cessation of menstrual periods for at least three months in a row, and bulimia must involve vomiting or other forms of purging at least two times a week, on average. Instead these women, and thousands like them, would fall into a category that doctors have been relying on for years, a vague nondiagnosis known by the acronym Ednos: eating disorder not otherwise specified. Diagnosing psychiatric conditions is more of an art than a science, and the Not Otherwise Specified label reflects the imprecision of that art. The American Psychiatric Association's manual has a Not Otherwise Specified category for many disorders, whenever symptoms are so vague, so mild or so untreatable that it doesn't seem to warrant the full-fledged diagnosis. With the manual continually under revision, the Not Otherwise Specified grab bag is the place where new diagnoses emerge. For instance, the diagnosis of Asperger's syndrome, a variant of autism, was pulled from a collection of disorders previously labeled Pervasive Personality Disorder Not Otherwise Specified. Much is at stake in whether a condition is elevated to the status of a full-fledged diagnosis. Because no laboratory tests or other objective criteria exist for making psychiatric diagnoses, the American Psychiatric Association's manual is the definitive arbiter of the line between normal and abnormal. Its definitions help determine such practical matters as insurance reimbursement, competence and eligibility for disability. But they also help determine something more elusive, and probably more important: whether someone's behavior should be considered a personality quirk or a symptom of mental illness. Now, in the diagnostic category of eating disorders, the search for greater specificity in the Not Otherwise Specified grab bag is generating much attention. "The Future of Ednos" was a topic at an international meeting on eating disorders in Amsterdam last month, and it is the title of a book expected to be released in Europe next year. To some observers, this new attention comes not a moment too soon. "Ednos right now is a real hodgepodge," said Dr. B. Timothy Walsh, professor of pediatric psychopharmacology at Columbia. "We have people in that category with anorexia nervosa," but they still menstruate so they don't meet all the criteria for a formal diagnosis. Similarly, Dr. Walsh said, "we have people who are obese and binge but don't vomit," so they don't fit into the strict definition of bulimia nervosa, which requires both binging and purging. Or they might binge and vomit once a week, but to qualify as bulimic they would have to vomit at least twice a week. "What we really need to do is collect data," Dr. Walsh said. "All the knowledge base we currently have relates to people who vomit twice a week. But if it turns out that the characteristics of those who binge and vomit once a week are similar to those who do so twice a week, then we can loosen the criteria for bulimia nervosa." The history of eating disorders has been a gradual one as the Diagnostic and Statistical Manual has been revised through the years. Anorexia nervosa first appeared in the version of the manual known published in 1980, and bulimia appeared for the first time in the same edition. Bulimia was renamed bulimia nervosa in the next edition, which came out in 1987. Anorexia nervosa affects 0.5 to 3.7 percent - or about 1.5 million to 11 million American women - at some point in life, according to the National Institute of Mental Health. Rates are lower among men and teenage boys. The lifetime prevalence of bulimia is higher - from 1.1 to 4.2 percent of women - with a similar age and sex distribution. In the current version of the diagnostic manual, published in 1994, one condition - binge eating disorder - was pulled out of Ednos and listed as a "provisional diagnostic category," the first step in the process of achieving its own diagnosis. The disorder is much like bulimia nervosa, but without the purging. The "provisional" designation highlights the need for more research into a condition's prevalence and treatment, and highlighting binge eating disorder in this way was a prelude to its being named as a separate diagnosis in the manual that is to appear in 2012. "That's one of most compelling reasons to get something out of the Not Otherwise Specified category," said Dr. Michael First, associate professor of clinical psychiatry at Columbia. Dr. First is a member of the planning group that is directing the enormous undertaking of revising the manual for its fifth edition. "If you feel that there's a homogeneous group of patients in there for which there's a treatment, the fact that it's called Not Otherwise Specified really obscures it, hindering treatment, hindering research," he said. Another candidate for a new eating disorder in the fifth edition of the manual can be thought of as the flip side of binge eating, a condition that has been labeled "purging disorder" by Dr. Pamela Keel, an associate professor of psychology at the University of Iowa. Just as binge eating disorder has many of the characteristics of bulimia, so does purging disorder. But neither meets the strict criteria for bulimia nervosa. People with purging disorder, Dr. Keel said, are of normal weight, and they purge after eating normal or even small amounts of food. Right now, purging disorder is relatively hidden, buried in the Ednos category. And until the Diagnostic and Statistical Manual panelists ask for more data, as they have for binge eating disorder, not much more will be known, Dr. Keel said. "Within widely used diagnostic interviews, if a person has never had a low weight and denies a history of binge eating, the interviewer skips all questions regarding the use of vomiting, laxatives or diuretics to control weight," Dr. Keel wrote in an e-mail message. "It's very difficult to learn more about a problem if you never ask any questions about it." As Dr. First sees it, several criteria must be met before a diagnosis is pulled out of the Not Otherwise Specified category and into a stand-alone diagnosis. These criteria have to be met before binge eating disorder, purging disorder or any other condition emerges out of the Ednos grab bag. The first requirement is that a significant number of patients must be affected, he said. Second, there has to be evidence of an existing and effective treatment. The criterion of an effective treatment has prevented many conditions from being entered in the Diagnostic and Statistical Manual. In the 1980's, there was an effort to include "sadistic personality disorder." But it failed, said Dr. First, because no treatment existed. "We could have decided to call something sadistic personality disorder," he said, "but if there's no treatment, what would be the point?" The third criterion for removing a condition from the Not Otherwise Specified category is the trickiest to meet. It relates to a kind of diagnosis-creep. Experts working on Diagnostic and Statistical Manual panels must ask how close the condition is to behavior that could be considered normal. For binge eating disorder, for instance, they must ask: When is such behavior a true psychiatric condition, and when is it the kind of thing that almost everyone engages in every Thanksgiving? "This is the matter of what we call false positives," Dr. First said. "It's the danger of defining as a psychiatric syndrome a set of symptoms that normal people have." When a new category is created in the manual, he said, "you're trying to identify a category that will help patients get treatment." "But," he continued, "you're worried that this category is going to be applied to normal people as well." Some psychiatrists want to create a different label for Ednos, calling it instead "mixed eating disorder" or "atypical eating disorder." But Dr. Walsh of Columbia said that would be merely a cosmetic change. "If I'm a clinician and I get a call from a school saying, 'Hey, I've got a person with mixed eating disorder coming over,' I don't know if I'm going to be seeing someone who weighs 80 pounds or 280 pounds," he said. "The whole belief that diagnoses are useful things rests on their ability to put together under one umbrella a relatively homogeneous set of syndromes, which gives the clinician the ability to shortcut a full assessment." Diagnostic labels, said Dr. Walsh, "allow big shortcuts." Dr. Keel, on the other hand, prefers the term "mixed eating disorder" over Ednos. She said the mixed eating disorder label "may have the benefit of eliminating the false impression that Ednos is somehow less severe or less clinically significant than so-called full-threshold eating disorders." But she expressed concern that the term would limit the enthusiasm for teasing out what other identifiable conditions lie within the Ednos category. As experts debate what to do about Ednos - pull out distinct disorders from the grab bag category, change the diagnostic criteria for the existing disorder, give the grab bag a more scientific-sounding name - people with disordered eating are left in a kind of therapeutic limbo. Eventually, the hope is, the uncertainties will be resolved, and the woman with anorexia who still menstruates and the woman with bulimia who only purges once a week, will be able to get the diagnosis and treatment that they need.
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Addicted to Food?

Just seeing and smelling food triggers an increase in a brain chemical that makes you hungry. It's the same signal that makes drug addicts want more drugs, suggesting that this may be the mechanism behind food addiction, a new study shows.

The signal is dopamine, a powerful brain chemical that lies at the heart of addiction. Dopamine is an important part of the brain's pleasure and reward machinery.

Addictive drugs increase brain levels of dopamine. Compared with normal people, addicts have fewer dopamine receptors -- the pleasure switch that high levels of dopamine flips on (to heighten the feelings of pleasure and reward.) Studies at the U.S. Department of Energy's Brookhaven National Laboratory show that obese people also have few dopamine receptors.

Now a research team led by Brookhaven's Nora Volkow, MD, finds that people don't actually have to eat to get a surge of dopamine. It happens when they just see, smell, and have a tiny taste of food. This makes them even hungrier.

The study is published in the June 1 issue of the journal Synapse.

"Eating is a highly reinforcing behavior, just like taking drugs," Volkow says in a news release. "This is the first time anyone has shown that the dopamine system can be triggered by food when there is no pleasure associated with it, since the subjects don't eat the food. This provides us with new clues about the mechanisms that lead people to eat other than just for pleasure. This may help us understand why some people overeat."
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Stifled Emotions Tied to Eating Disorders

Girls growing up amid family problems and abuse are at high risk for eating disorders like anorexia and bulimia -- unless they get help dealing with their emotional reactions to those problems, according to a new study.

More than 800 undergraduate students took part in the study, conducted by Suzanne E. Mazzeo, PhD, a psychologist with Virginia Commonwealth University in Richmond , and Dorothy L. Espelage, PhD, with the University of Illinois Urbana-Champaign .

Their findings appear in the current issue of the Journal of Counseling Psychology .

Each student in the study completed a questionnaire about her childhood family environment and childhood trauma. They also took tests to determine whether they were depressed, had difficulties identifying and expressing emotions, and if they had an eating disorder.

The researchers found that family conflict and other problems -- as well as physical and emotional abuse and neglect during childhood -- set the stage for potential eating disorders.

And the girl's response to those family problems in childhood, not the family problems themselves, "seems most strongly associated with disordered eating," says Mazzeo in a press release.

Mazzeo speculates on this connection, writing that family problems often lead to physical and emotional abuse and neglect. In that environment, a young girl grows up without the emotional support she needs.

To escape her emotions, the girl may place intense focus outward -- on her appearance. The eating disorder becomes a means of distracting herself from negative emotions. She feels a need to narrow her focus to something "concrete," says Mazzeo.

Psychologists use the term "alexithymia" to describe this difficulty in identifying and expressing emotions.

Depression in reaction to these family problems also leads to eating disorders, Mazzeo says.

Interventions should be targeted toward girls in at-risk family situations, to help them cope with depression and their emotions, and prevent eating disorders, she says.
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When Babies Watch What They Eat

Mindi Rold, a petite 27-year-old, nibbles at a plate of fruit and cheese. This seemingly mundane activity is seen as something of a triumph by those attending a meeting of the Congressional Children's Caucus Tuesday.

The subject of the event was eating disorders, which disproportionately affect young girls. In Mindi's case the disease actually started as early as age six when she remembers becoming concerned about having too much baby fat. That led to a trip to Weight Watchers with her body-conscious father and grandmother and, ultimately, a formal diet at age eight.

"My world changed overnight. My thinking about food changed from just eating when I was hungry to labeling foods good and bad," said Mindi. From that moment until she was successfully treated eight years ago, Mindi struggled to overcome anorexia nervosa -- a mental illness that begins with a diet and can lead to starvation and death.

It's estimated that as many as eight million Americans have eating disorders, and it's not unusual to see the problem in younger children. By age nine, Mindi's emotional state had deteriorated to the point where she wound up in a mental hospital.

"I believed I deserved to be punished; ... from a very early age [I] always had a negative image about myself, ... and the way that I dealt with that was through the food," she tells WebMD. Mindi spent the next 12 years in and out of hospitals. During her teen years, she dropped to 60 pounds.

By age 12, she was taking birth control pills to protect her bones from the ravages of diet-related osteoporosis. In addition, she never started menstruating and suffered heart palpitations. Finally, in desperation, Mindi tried to commit suicide.

Finally, she found her way into a recovery program similar to those treating other kinds of addictions.

Now married and a schoolteacher in Northern California , she brings her message to others.

Some of the symptoms of anorexia include an emaciated look, profound weight loss, and terrible fears of weight gain. The disease can affect almost all organs in the body, including the brain, kidneys, and heart.

Treating anorexia and bulimia nervosa, a related condition involving binge eating and purging behaviors, is complex. It often means dealing with family issues as well as working on related problems like depression or posttraumatic stress disorder.

"Girls are probably targeted because of the pressures of society, because of their upbringing, because of their role in families, because of their genetics," says Susan Ice, MD, medical director of The Renfrow Center in Philadelphia .

An adolescent psychiatrist, Ice suggests seeking out a specialist who knows how to handle the illness, although that can be difficult because there is no formal training.

Advocates, like the Eating Disorders Coalition for Research, Policy, and Action, which hosted the briefing with the Children's Caucus, say more federal research dollars need to be spent on eating disorders. In addition, a national law guaranteeing equal insurance coverage for eating disorders as a mental illness would help those who need long-term care for eating-related conditions.

Virtually all specialists, says the Coalition, agree that anorexia patients tend to suffer relapse or are put in life-threatening situations because their insurance policies require early discharge.

But these reforms, if they come at all, are too late for Melissa Rustemeyer of Rio Rancho, N.M., who died at age 16 after a two-year struggle with bulimia.

"I want to cry knowing I'll never see Melissa again. She wanted to be perfect and loved by everyone without realizing that she was close to perfection from the start," said her sister Jamie.

Pointers for Parents

• Learn all you can about eating disorders, so you can recognize problems early and know how to react.
• Discuss the dangers of dieting fads or starvation diets with your children.
• Children can develop eating disorders as a way of dealing with their emotions. Try to give your kids the space to talk about painful things, and an opportunity to come up with healthy solutions.
• If you're preoccupied with appearance and weight, your children will be, too. Don't mistake baby fat for actual fat and try to impose dieting on your kids.
• Media pressure to be thin and look beautiful doesn't help. Try to emphasize values and educational accomplishments, rather than looks. Let your kids know you are proud of them and you love them for who they are, not what they look like.
• Set a good example for your children, which means eat healthily and exercise. And remember, exercise should be about health, not looks.
• Never force your child to eat if he or she is full, and help your kids find activities they -- and the whole family -- can enjoy.
• Kids need to know that it's what on the inside that counts, not the outside. Children need praise for their accomplishments, and they especially need their parents' love and affection.
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Body Image Still Problem for Teen Girls

In a world where beauty is an obsession, it's no wonder that many teenagers -- particularly girls -- see themselves as being too fat, according to a new study.

Research appearing in the July/August issue of the American Journal of Health Behavior goes on to say that teen girls tend to see themselves 11 pounds over their ideal weight. On the other hand, boys' perception of their current weight versus their ideal body image is about equal.

Body Image Linked to Unhealthy Behavior

The effect of poor body image can be far-reaching.

"The adolescent infatuation with the cultural icon of thinness has contributed to an array of unhealthy behaviors," says Michael Peterson, EdD, from the University of Delaware , in a news release from the Center for the Advancement of Health. These behaviors include:

• Poor eating patterns and extreme dieting
• Preoccupation with food and body image
• Lower self-esteem
• Drug and alcohol abuse
• Overall physical and mental illness

The study looked at more than 200 high school students to find how teens determine their body image. The goal? They hope to use the information with intervention programs in the future.

Perception Versus Reality

Researchers showed the students a range of silhouettes based on body mass index (BMI) -- an indirect measure of body fat based on weight and height. They asked the volunteers to pick the silhouette that most closely matched their perception of their current appearance, select their ideal body image, then list their actual weight and height.

On average, the girls saw themselves as weighing more than their current weight, with a desire to lose weight.

Ironically, boys saw themselves as being heavier than they are but many had a desire to weigh even more. Perception was much closer to reality with the boys however. They actually weighed an average of 172 pounds, but perceived themselves as weighing 185 pounds, with their desired weight being 182 pounds.

Peterson says having this kind of analysis is invaluable in helping health professionals tackle poor teen body image at its source. He says he hopes they can further attack the problem and address questions teens may have, thereby helping them avoid risky behavior and reduce unhealthy side effects.
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Childhood Teasing May Lead to Eating Disorders

Maybe it was just meant in jest, but those negative comments from your best friend or your dad probably still makes you wince. It doesn't matter if it was about your teeth or your weight or your clothes; somewhere in the back of your mind it may still make you psychologically insecure. For some, this can lead to health-damaging eating disorders.

Binge eating, for instance. According to Yale University researchers in an article published recently in the journal Obesity Research , negative comments to a child about his or her general appearance may lead to this eating disorder, which involves eating an unusually large amount of food in a short period of time, or experiencing a loss of control over what and how much food is eaten.

Those who became obese later in life said teasing about their general appearance took its toll on them, too. Women in the study said the general appearance teasing they received focused on how they dressed, or having funny teeth, or being funny looking, or anything about overall appearance, says study co-author Tamara Jackson, MD, a postdoctoral student in the Yale psychiatry department.

Comments more specifically about weight and body size may also cause serious harm. Patients who became obese early in life told the researchers that they were often teased about their weight and size.

The problem doesn't end there. The researchers found that teasing about weight and appearance also impacted other types of eating disorders and on the mental well-being of those subjected to it. And the most harmful teasing often comes from those closest to the person.

"I have many, many patients who were made fun of by coaches at school, or they heard a flippant comment at a dance lesson. Sometimes it's the father commenting that the daughter is gaining weight or the brother teasing the sister that she is overweight," says Demarks Wright, MD, a pediatric cardiologist at Medical City Dallas Hospital . She treats bulimic and anorexic young women.

"If the girl is in love with the person who makes such a comment, it can send her into a tailspin," Wright tells WebMD. "It affects [girls] when they are very young because the desire to be loved is from birth. These comments and the psychological desire to please the person they love is ingrained by the time they are in fifth grade."

"There are precursors to actual development of eating disorders that we can sometimes trace back with treatment," says Welby Pinney, LMFW-ACP, a clinical social worker in Children's Medical Center of Dallas' Center for Pediatric Psychiatry. "People with these diseases have a preoccupation with their appearance. They create a delusional system where they take real stuff and interpret it differently than others would."

Once they start doing this, if anyone says something that fits their delusion, such as telling an anorexic that it looks like he or she has lost a few pounds, then that just reinforces the person's self image thus making him or her continue the behavior, Pinney tells WebMD.

"It's bad enough if it's coming from someone in the back of the room, but if it's coming from some one you're close to, it's devastating," Pinney says.

Wright and Pinney agree that parents need to be educated on how harmful teasing can be and that they need to be the No. 1 supporters of their children, not for being the best but for doing their best. Pinney adds that no one knows which people may be scarred for a lifetime and driven into eating disorders.

"Since eating disorders really start before crystallization of the habit, it's especially hard to avoid contributing to it. So parents need to teach their children that it's not right to tease anyone, because we don't know who the vulnerable kids are," he advises. "We also need to teach kids that if you're being picked on, it's not all right."

Jackson says she and her colleagues hope their study will help clinicians treat people with this disorder by making them investigate the root cause. Although they didn't address exactly how teasing contributes to binging, Wright and other experts say it can contribute to a lifetime of low self-esteem.
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Bulimia Increases Risk of Miscarriage, Premature Delivery

Women with bulimia nervosa are at higher risk for complications if they become pregnant, a study presented last week at the Royal College of Psychiatrists meeting in Edinburgh, Scotland, reveals. But pregnancy actually may be a good time to treat the eating disorder, experts say.

Bulimia typically involves cycles of binge eating and vomiting, laxative use, and/or excessive exercise.

"Women with active bulimia have higher rates of miscarriage and premature delivery than women who have had bulimia in the past, but aren't currently experiencing symptoms," John Morgan, MD, tells WebMD. "Since bulimia is the most common eating disorder, affecting roughly one in 20 women, this is a problem obstetricians and women themselves need to be more aware of." Morgan, the study's lead researcher, is a psychiatrist at St. George's Hospital Medical School in London.

However, there is a silver lining to the cloud of potential complications. "Previous research of ours suggests that by the third trimester of pregnancy, almost all women are virtually binge-free, so pregnancy is a window of opportunity to engage bulimic women in treatment," Morgan says. "Most women with bulimia will talk about their disorder with a health provider if they're asked the right questions, and they respond very well to treatment once they are identified."

Debra Franko, PhD, program director of the Eating Disorders Center at Harvard Medical School, concurs. "My clinical experience is that most women with bulimia shift their focus from themselves to their baby, and start engaging in healthier eating habits as a result," she tells WebMD. "However, afterward they may experience additional problems, so this may be a time to be very vigilant."

The study used a questionnaire to ask nearly 125 women who had active bulimia during their first pregnancy about their experience. The same questionnaire was administered to more than 80 women who had had bulimia in the past, but were not experiencing symptoms during their first pregnancy.

In addition to miscarriage and early delivery, women with active bulimia also appear to be at higher risk for developing diabetes during pregnancy and experiencing postpartum depression. More birth defects also were seen in the group with active symptoms.

"If women know they have bulimia, they should be told that their pregnancy is much more likely to be successful if they are not experiencing symptoms during it," says Mark Blais, PhD, assistant professor of psychiatry at Harvard Medical School. "Their obstetrician should be asking questions about weight loss or fluctuation during pregnancy as well."

Vital Information:

Bulimia nervosa is the most common eating disorder, characterized by cycles of binge eating and vomiting, laxative use, and/or excessive exercise.
In a new study, pregnant women who currently are experiencing symptoms of bulimia are more likely to have complications, including miscarriage, early delivery, diabetes, and postpartum depression, compared to those who had bulimia in the past.
Women with bulimia often begin healthier eating habits when they become pregnant, says one expert, because they shift their focus to their baby, so pregnancy is a good opportunity to treat these women.
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Two Antidepressants Effective for Binge-Eating Disorder

Up to 1 million people in the United States suffer from binge-eating disorders, going through episodes where they feel the compulsive need to eat, to stuff themselves. Afterward, they're often left feeling out of control, ashamed, depressed, and obese. Professional care is usually needed to break the cycle, but to date there are no standard treatment programs for this specific eating disorder. Now, there is more evidence that some common antidepressants may help.
Many doctors believe that eating disorders share a common biological link with other conditions such as depression and anxiety, which if true would mean similar treatments could be effective. For some people, depression and anxiety can be controlled by taking such antidepressants as Luvox (fluvoxamine) or Zoloft (sertraline). They belong to a class of drugs called selective serotonin reuptake inhibitors (SSRIs), which put more serotonin, a mood-regulating chemical, into the body.
A recent presentation at the Eating Disorders Research Society Annual Meeting in San Diego detailed two studies in which people with binge-eating disorder responded favorably to the two medications. Both drugs led to overall improvement when compared with a placebo.
"Over the last decade or two, the eating-disorder community has recognized that there are groups of people who engage in compulsive bingeing behavior ... but don't engage in the purging behavior that is characteristic of bulimia nervosa. ... [Binge-eating disorder] is associated with lots of symptoms of depression and anxiety. ... It is certainly abnormal, very troublesome, and is associated with mental health problems," researcher James I. Hudson, MD, tells WebMD. Hudson was involved in one of the studies; he is the associate chief of biological psychiatry at McLean Hospital in Boston and is also affiliated with Harvard Medical School.
Since SSRIs have been useful for bulimia, Hudson says that it was a natural extension to see if these types of medications could also work for binge-eating disorders.
Sharon Alger-Mayer, MD, with the obesity and eating disorder program at Albany Medical College in New York, believes that the results support a chemical link between eating disorders and anxiety and depression.
"Since the 1970s, people have recognized that the same substances that control mood also control appetite. If there's a low level of serotonin, one may feel depressed but also crave high-carbohydrate, binge-type foods. Consuming high-carbohydrate foods results in increased production of brain serotonin. Thus, the body may be self-medicating by bingeing. ... You might feel better for a short time, but then you feel guilty about bingeing and the whole process repeats. That's why using a drug to increase serotonin levels might suppress the desire to binge."
"I'm not surprised by the findings," Dirk Miller, PhD, tells WebMD. "It's not radically new to suggest that someone with [the disorder] will respond favorably to SSRIs. In practice, clinicians are using them all the time. It's confirming the idea that SSRIs are useful for the treatment of eating disorders -- but they're not the effective treatment for them," says Miller, a psychologist with the Emily Program in St. Paul, Minn., an outpatient eating-disorders program.
"Like all eating disorders, [binge eating] is a pesky problem which is extremely difficult to treat. I think talk therapy would always be the first choice for treating eating disorders," says Miller.
Alger-Mayer agrees that the idea of using SSRIs for binge eating is not new, but says that most of the data to date have focused on Prozac (fluoxetine), which is another SSRI. "This is great data to know. It's new information for these particular drugs," she says. Although she prescribes Prozac if a patient can tolerate it, Alger-Mayer would choose another SSRI if the patient has anxiety or there is another reason not to use it.
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Prozac Prevents Bulimia Relapse

Studies have already shown that the antidepressant fluoxetine, better known by the trade name Prozac, is effective for short-term, emergency treatment of severe bulimia. Now, a new study shows that continued use of the drug can prevent people with bulimia from falling back into the destructive cycle of repeated bingeing and purging.
The researchers first looked at 232 male and female bulimia patients who, on a regular basis, self-induced vomiting to prevent weight gain after episodes of binge eating. They randomly assigned the 150 people who had responded to a preliminary eight-week course of Prozac to either continued Prozac or placebo for 52 more weeks.
If a patient returned to the same frequency of binge/purge episodes they'd experienced before treatment began, and it lasted for two straight weeks, it was considered a relapse.
Interestingly, being depressed -- and about 40% had symptoms of depression -- made no difference to whether a patient responded to treatment with Prozac.
"[Prozac]-treated patients exhibited a longer time to relapse than placebo-treated patients," write study leader Steven J. Romano, MD, and colleagues from 16 U.S. medical centers. Overall, placebo patients relapsed during the first three months, while Prozac patients held out significantly longer. Unfortunately, both groups eventually showed worsening symptoms.
The complete report appears in the January issue of the American Journal of Psychiatry.
According to the researchers, Prozac wasn't merely alleviating any underlying depression in these patients. There's more to it. People with bulimia appear to have an imbalance of, or malfunction in, the brain chemical serotonin. Among its other diverse functions, serotonin helps us recognize when we've had enough to eat. Thus, "a defect in serotonin function may produce impaired recognition of satiety [fullness], thus contributing to binge eating," they write.
"This study demonstrated that continued treatment with fluoxetine in patients who responded to [preliminary] therapy was well tolerated and associated with a significant reduction in the likelihood of relapse during a 52-week monitoring period," the researchers write.
The fact that symptoms gradually worsened for patients in both the Prozac and the placebo groups, however, suggests that a truly effective approach to fighting bulimia will likely include more than just one drug, along with ongoing psychiatric counseling.
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Light Therapy Lessens Bulimics' Binging and Purging

That light box some people use to beat the "winter blues" may do more good for our minds than we thought: They may be useful in treating other mental disorders, including eating disorders.
Phototherapy -- or the regular use of concentrated bright light -- is a widely recognized treatment for the cyclical bouts of depression experienced by many who have seasonal affective disorder, or SAD. New evidence now shows that light therapy may benefit women who have both SAD and anorexia bulimia, an eating disorder characterized by binging and purging.
The therapeutic effect of light on patients with bulimia underscores the connection between depression and eating disorders, which frequently become worse during winter months, explain Raymond Lam, MD, and colleagues in a report in March's Journal of Clinical Psychiatry.
Lam and colleagues believe the light may relieve binging and purging indirectly by improving mood.
"Light therapy may directly improve mood in these bulimic patients with SAD and thus indirectly improve dysfunctional eating behaviors," write the researchers from the University of British Columbia in Canada.
Twenty-two patients with both SAD and bulimia received a four-week trial of light therapy, with each session lasting 30 minutes to one hour.
Not surprisingly, measures of mood improved considerably following treatment. More important, the number of binges decreased by an average of 46%, and the number of purging events dropped by 36%, they report.
While 10 of the 22 patients had a complete remission of depressive symptoms following the trial, only two of the patients completely stopped their binging and purging behavior.
What that suggests, they say, is that eating disorder behaviors may persist as a habit, despite underlying changes in brain chemistry.
"Theoretically, ... a longer period of light treatment may be required to produce higher abstinence rates in binge and purge episodes," they write.
Despite the preliminary nature of the findings, Norman Rosenthal, MD, an early pioneer in light therapy for SAD, says the beneficial effects of phototherapy in eating disorders should come as no surprise.
"Light is not just an arcane treatment for a specific illness, namely seasonal affective disorder," Rosenthal tells WebMD. "Light is probably doing many things in the brain, and because light is such a fundamental principal in the biology of humans, we can expect that it will have many physical effects on the body. These effects may be used in different ways for therapeutic purposes."
Rosenthal is clinical professor of psychiatry at Georgetown University School of Medicine in Washington, D.C., and author of the book Winter Blues.
He suggests that in bulimic patients, the purging that follows binge eating is not merely a frantic effort to lose the weight one has gained, but may be indulged in because it makes the bulimic feel good. And he believes that light affects the brain in such a way as to both diminish the need for food and to dampen the need for the good feelings that come with purging.
Rosenthal also says that light increases brain levels of serotonin, a chemical involved in mood that also regulates the sense of "satiety" -- the feeling of being full after eating. Thus, it may counteract the feeling that bulimic patients report of never being "full enough," he says.
"If light therapy boosts serotonin, that could easily explain how the brain is letting the person know that the patient is full," Rosenthal says.
As if to bring things full circle, some evidence -- not fully explored by researchers -- suggests that people eat more in the winter months and that patients with eating disorders experience a worsening of symptoms.
"That ties together the effect of light on both seasonal affective disorder and eating disorders," Rosenthal says.
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Treatment Helps Eating Disorders

Few problems are more deadly and more difficult to treat than eating disorders. Now, a Swedish clinic claims its program cures three out of four cases of anorexia and bulimia.
It's not just an ad. The claim appears in the July 1 online issue of one of the world's most respected science journals: Proceedings of the National Academy of Sciences. Most treatments for eating disorders have at best a 50% recovery rate -- and a very high relapse rate. In contrast, nine in 10 patients who recover with the Swedish program remain well at least a year later.
"These results suggest that most patients treated to remission with our method recover from their eating disorders," write Cecilia Bergh, MD, chief of the anorexia center at Huddinge University Hospital, Sweden, and colleagues.
Nearly all patients with eating disorders are women. Patients with anorexia eat very small amounts of food and lose dangerous amounts of body weight. Only half ever recover; as many as one in four die. Patients with bulimia have normal body weight, but they have bizarre eating behavior: they eat large amounts of food and then make themselves vomit to keep from putting on weight. Fewer than half recover fully. Nearly one in three continues this bizarre eating behavior.
What causes eating disorders? Experts disagree. So instead of treating the psychological causes, Bergh's team treated several of the symptoms. These symptoms are:
*Strange eating behavior and no true sense of when enough food has been eaten.
*Cold body temperature.
*A high level of physical activity.
*Disordered social life.
All but the most serious patients were treated outside the hospital. There were five treatment sessions per week, gradually reduced to one per week and finally to one every other week.
Treatment Included:
*Anorexic patients negotiated a weight-gain goal of at least 4.4 pounds.
*All patients were told their psychological symptoms would get better once they had normal eating behavior.
*No patient took any psychiatric drugs.
*Patients ate from a plate on a scale connected to a computer. The computer showed their eating rate on a graph. Patients had to try to make their eating rate match a set rate shown on the computer screen. The eating-rate goal gradually increased over time.
*After eating, patients spent an hour in heated room. They could raise the temperature as high as 104(F.
*Anorexic patients were put in wheelchairs to restrict their physical activity. Bulimic patients were allowed to walk slowly for 30 minutes each day. These restrictions were gradually reduced and finally withdrawn.
*Social schedules were set for each patient. This began with simple tasks such as getting a haircut or meeting friends at a café. Later, patients went to school, work, or to a volunteer program for an hour a day. This gradually increased to full return to work or school.
This treatment worked so well in a pilot study that Bergh's team tried it with 168 new patients. Three out of four got better after an average treatment time of about 15 months. Remarkably, 93% of these patients remained well for at least 12 months.   
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Treating Eating Disorder Patients Against Their Will -- Does it Work?
Few problems are more deadly and more difficult to treat than eating disorders. Now, a Swedish clinic claims its program cures three out of four cases of anorexia and bulimia.
It's not just an ad. The claim appears in the July 1 online issue of one of the world's most respected science journals: Proceedings of the National Academy of Sciences. Most treatments for eating disorders have at best a 50% recovery rate -- and a very high relapse rate. In contrast, nine in 10 patients who recover with the Swedish program remain well at least a year later.
"These results suggest that most patients treated to remission with our method recover from their eating disorders," write Cecilia Bergh, MD, chief of the anorexia center at Huddinge University Hospital, Sweden, and colleagues.
Nearly all patients with eating disorders are women. Patients with anorexia eat very small amounts of food and lose dangerous amounts of body weight. Only half ever recover; as many as one in four die. Patients with bulimia have normal body weight, but they have bizarre eating behavior: they eat large amounts of food and then make themselves vomit to keep from putting on weight. Fewer than half recover fully. Nearly one in three continues this bizarre eating behavior.
What causes eating disorders? Experts disagree. So instead of treating the psychological causes, Bergh's team treated several of the symptoms. These symptoms are:
*Strange eating behavior and no true sense of when enough food has been eaten.
*Cold body temperature.
*A high level of physical activity.
*Disordered social life.
All but the most serious patients were treated outside the hospital. There were five treatment sessions per week, gradually reduced to one per week and finally to one every other week.
Treatment Included:
*Anorexic patients negotiated a weight-gain goal of at least 4.4 pounds.
*All patients were told their psychological symptoms would get better once they had normal eating behavior.
*No patient took any psychiatric drugs.
*Patients ate from a plate on a scale connected to a computer. The computer showed their eating rate on a graph. Patients had to try to make their eating rate match a set rate shown on the computer screen. The eating-rate goal gradually increased over time.
*After eating, patients spent an hour in heated room. They could raise the temperature as high as 104(F.
*Anorexic patients were put in wheelchairs to restrict their physical activity. Bulimic patients were allowed to walk slowly for 30 minutes each day. These restrictions were gradually reduced and finally withdrawn.
*Social schedules were set for each patient. This began with simple tasks such as getting a haircut or meeting friends at a café. Later, patients went to school, work, or to a volunteer program for an hour a day. This gradually increased to full return to work or school.
This treatment worked so well in a pilot study that Bergh's team tried it with 168 new patients. Three out of four got better after an average treatment time of about 15 months. Remarkably, 93% of these patients remained well for at least 12 months.   
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Wolf Down an Antiseizure Medication to Control Binge Eating

Have you ever polished off an entire box of chocolate chip cookies in one sitting? Perhaps you even washed it down with a few candy bars, some cream-filled cakes, and a bag of Cheez Doodles? And then you felt so bad afterwards.

Well, some people do this on a regular basis, and may have a problem called binge eating disorder, which occurs fairly commonly, especially in women. Binge eating disorder is defined as having two or more eating "binges" every week for six months. A binge refers to eating in a two-hour period an amount of food that would seem excessive to most people.

But a new antiseizure drug called Topamax may provide much-needed help for people suffering form this disorder, according to a study published in the May issue of the Journal of Clinical Psychiatry.

If you have a binge eating disorder, you typically feel out of control about your eating and also experience at least three of the following symptoms, according to Nathan Shapira, MD, the study's lead author:

• Eating more rapidly than usual
• Eating until you're uncomfortably full
• Eating large amounts even when you're not hungry
• Eating alone because of embarrassment over how much you're eating
• Feeling disgusted after the binge is over

Toby Goldsmith, MD, one of the study's co-authors, says that many overweight patients who turn to commercial weight-loss programs often fail because of an undiagnosed binge eating disorder.

"If you listen to people at weight-loss meetings talk about their eating patterns, many of them have an eating disorder, but these organizations won't address it, won't even tell them to talk to their health professional. But if people can recognize their symptoms and get their binges under control, their ability to do a weight loss program should improve significantly."

This study is important because there is a clear need for better treatments for the disorder, says David Herzog, MD, professor of psychiatry and pediatrics at Harvard Medical School in Boston . Although other drugs have been tried for this condition, "there has not been a markedly successful drug that allows for a sustained change in behavior," he tells WebMD.

In the study, Shapira, who is assistant professor of psychiatry at the University of Florida in Gainesville , and other researchers studied 13 female patients aged 19 to 54 who were prescribed Topamax to treat their binge eating disorders.

Of the 13 patients studied, nine had at least a 50% reduction in binge eating, which was maintained between three and 30 months. Most patients also lost weight on the drug; the average weight loss was about 26 pounds.

Although outside experts generally praised the trial, Herzog says bigger, more reliable trials with more patients need to be done. Shapira acknowledges that the study was small but says that a larger trial focusing on patients who only have binge eating disorder is now nearing completion.  

Vital Information:

• Binge eating disorder is characterized by having two or more eating binges every for six months and feeling out of control about eating.
• Many overweight people have an undiagnosed binge eating disorder that interferes with their ability to lose weight.
• In a small study, an antiseizure drug known as Topamax was found to be effective in reducing binge eating.
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Women With Anorexia Nervosa Often Relapse

The road to recovery may be a long one for women with anorexia nervosa. A new study shows about one in three women treated for the eating disorder experience a relapse within two years after being discharged from the hospital.

Anorexia nervosa affects less than 1% of the population -- about 90% are teen girls or young women. People with anorexia have such a fear of gaining weight that they severely limit how much they eat, leading to serious health problems from malnourishment or even death.

Although effective treatments have been developed, researchers say many people with anorexia experience relapse. At this point, they say it's not clear whether problems in the initial treatment or inadequate relapse prevention strategies are to blame for the high relapse rates.

Anorexia Nervosa May Be Chronic Disease for Some

In the study, researchers followed 51 women who had regained weight after treatment for anorexia nervosa for the first time at an inpatient hospital program. The results appear in the May issue of Psychological Medicine .

The study showed that within two years of hospital discharge, 35% of the women had relapsed into anorexia, as defined by a drop in body mass index (BMI, a measure of weight in relation to height) below 17.5 for three consecutive months or more. This would be equivalent to a 5-foot-5-inch woman weighing less than 105 pounds.

Researchers found the highest risk period was from six to 17 months after discharge, which contrasts with previous studies that show that those who relapsed would do so within a year after treatment.

"Our most important finding is that in a significant proportion of cases, the illness is chronic and debilitating," says researcher Jacqueline Carter, a psychiatry professor at the University of Toronto , in a news release. "We're pretty good at helping people to become weight-restored in the hospital, but really the challenge now is to figure out how to improve relapse prevention treatments and improve long-term outcomes for people with anorexia nervosa."

The study showed several factors were related to a higher likelihood of relapse, including:

• Excessive exercise immediately after discharge
• A history of suicide attempt
• Previous treatment for an eating disorder
• Obsessive-compulsive symptoms at time of initial treatment
• Excessive concern about body shape and weight at time of discharge

Researchers say knowledge of these risk factors should be used to develop treatments to prevent for anorexia relapse.
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Dairy Foods Help Burn Fat, Speed Weight Loss


Stocking the refrigerator with milk, cheese, and yogurt may make it easier to lose those extra pounds and burn fat without cutting back drastically on calories, according to new research.
Although calories still count, the study showed that obese adults who ate a high-dairy diet lost significantly more weight and fat than those who ate a low-dairy diet containing the same number of calories.
"If you compare a dairy-rich versus a dairy-poor diet you can nearly double the rate of weight and fat loss with the same level of calorie restriction," says researcher Michael Zemel, PhD, professor of nutrition and medicine at the University of Tennessee in Knoxville.
Zemel says the study also showed that eating three to four servings of dairy products a day is more effective at enhancing weight loss efforts than calcium supplementation alone with pills or calcium-fortified foods.
The study appears in the April issue of Obesity Research and was supported by the National Dairy Council.
Previous studies have already shown that dieters who eat a calcium-rich diet are more successful at losing weight, but this study indicates that it's more than just the calcium in dairy products that helps shed pounds.
"Calcium is a critical factor in controlling what your body does with calories, and dairy is an even more critical factor," says Zemel. "Without changing how many calories we take away, we can alter how much weight and fat you lose."
Dairy Products Beat Calcium for Weight Loss

In the study, researchers compared the effects of three different calorie-restricted diets on weight loss in 32 obese adults. Each of the participants reduced their daily calorie intake by about 500 calories per day for 24 weeks and were divided into three groups:
High-dairy. Total calcium intake of 1,200-1,300 milligrams per day from three to four servings of dairy foods, specifically milk, hard cheese, and yogurt.
High-calcium supplemented/low-dairy. Total calcium intake of 1,200-1,300 milligrams per day made up of no more than one serving of dairy per day plus an 800-milligram calcium supplement.
Low-calcium/low-dairy. Total calcium intake of 400-500 milligrams per day with no more than one serving of dairy per day and a placebo supplement.

Researchers say participants were free to choose from fat-free, low-fat, and regular milk, cheese, and yogurt. They typically picked fat-free and low-fat milk and yogurt and regular cheeses, while keeping their overall fat intake the same.
Serving sizes were 8 ounces or a cup for milk and yogurt and 1.5 ounces of hard cheese (about the size of six dice) or 2 ounces of processed cheese, such as two slices of American cheese.

The study showed that all of the groups lost weight, but those who ate the dairy-rich diet lost the most with an average of 24 pounds compared with 19 pounds in the calcium supplement group and 15 pounds in the low-calcium/low-dairy group.
That translates to a loss of an average of 11% of total body weight for those in the high-dairy group versus 6% in the low-calcium/low-dairy group.
"What that means is that if you're including three to four servings of dairy in your diet, you can make a modest degree of calorie restriction as effective as a severe degree of calorie restriction," Zemel tells WebMD.
In addition, researchers found the high-dairy group lost significantly more body fat than those in the other groups, particularly from the midsection. Excess fat in the abdominal area has been linked to a higher risk of heart attack and other health problems.
Dairy's Role in Weight Loss

Previous studies have shown that calcium can boost weight loss by increasing fat breakdown in fat cells. But experts say this study suggests that taking in calcium from dairy products may actually improve on those effects.
"Dairy for some reason, yet unexplained, has a greater effect on fat loss and specifically trunk fat loss than does calcium alone," says Rachel Novotny, PhD, RD, professor and chair of the department of human nutrition, food, and animal sciences at the University of Hawaii in Manoa.
Although the bulk of dairy's weight-loss enhancing effects is caused by its calcium content, researchers say there are a variety of potential mechanisms that may explain those additional benefits and merit further research.
For example, Novotny says that some of the minerals in dairy products, such as phosphorous and magnesium, may enhance calcium's beneficial effects on fat breakdown within the cells. In addition, the proteins in dairy products may help preserve muscle and increase metabolism.
But Novotny and Zemel are careful to point out that the results shouldn't be interpreted as license to indulge in dairy products in hopes of spurring weight loss. They caution that the bottom line of successful weight loss is still burning more calories than you take in.
"The question is whether within those calories are there choices you can make that will enhance the results," says Novotny. "I think the findings suggest that dairy products and calcium can be helpful in preserving muscle, losing fat from the upper body, and actually enhancing the weight loss process."
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Keeping your food portions in check

Vegetables
Raw leafy vegetables 1 cup (2 ounces/56 grams)
Cooked or chopped raw vegetables 1/2 cup (3 ounces/84 grams)
100-percent vegetable juice 3/4 cup (6 fluid ounces/180 milliliters)
Fruits
Chopped, cooked or canned fruit 1/2 cup (3 ounces/84 grams)
100-percent fruit juice 3/4 cup (6 fluid ounces/180 milliliters)
Orange, apple, banana or pear 1 medium
Grains
Cooked cereal, rice or pasta 1/2 cup (3 ounces/84 grams)
Ready-to-eat cereal 1 ounce (28 grams
Whole-wheat sandwich bread 1 slice
Dairy products
Low-fat or fat-free milk or yogurt 1 cup (8 fluid ounces/240 milliliters)
Natural cheese, such as cheddar 1 1/2 ounce (42 grams)
Processed cheese, such as American 2 ounces (56 grams)
Meat and Beans
Cooked skinless poultry, seafood or lean meat 2 to 3 ounces (56 to 84 grams)
Each of the following may be substituted for 1 ounce (28 grams) of meat:
Cooked legumes or dried beans 1/2 cup (3 1/2 ounces/98 grams)
Tofu 1/2 cup (4 ounces/112 grams)
Peanut butter 2 tablespoons
Egg 1 large
Nuts 1/3 cup (1 ounce/28 grams)

Everyday guides for serving sizes
3 ounces chicken or fish Deck of cards or the size of your palm
1 cup of vegetables Size of your fist
Medium apple Size of a baseball
1/2 cup pasta, cooked Ice cream scoop
1 1/2 ounces cheese Pair of dice or pair of dominos
1 teaspoon butter or margarine Tip of your thumb
1 cup dry cereal Large handful

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