I think I've blogged on this before, but the recent uptick in "-orexia" terms in the news have me more than a little annoyed.

"Brideorexia" is defined by the Urban Dictionary as "When a bride goes overboard trying to get skinny for her wedding day." The dictionary uses the term in a sentence as: Damn, How did she get so f*cking skinny?!?! She came down with a case of brideorexia!

I get that the Urban Dictionary isn't the Oxford English Dictionary, but would it be too much to ask for a hint of accuracy and classiness? A woman isn't absolved of an eating disorder when a ring is slipped on her finger and she does shopping for the Pretty White Dress. Nor does the Pretty White Dress provide immunity from developing an eating disorder. It might be more expensive than almost any item of clothing she has bought before, but it's still just a dress.

"Drunkorexia" means that a person restricts their food all day to "save up" for the calories consumed during a night of alcohol consumption. Now, the comorbidity of eating disorders and alcoholism is well known and sadly rather common. But drunkorexia isn't the lone purview of sorority girls and frat boys at a kegger. Alcoholism and eating disorders can and do exist side by side. But this isn't particularly novel, and certainly not a "new" disorder. The struggle of those who deal with both EDs and substance abuse shouldn't be minimized by some cutsey name.

"Stressorexia" typically occurs when working moms get too stressed or busy to eat, and begin the cycle of weight loss and disordered eating. Stress is a big trigger for eating disorders, and I certainly see how stress and loss of appetite can lead to the beginnings of an eating disorder. But unlike several publications have observed, stressorexia isn't a "new" eating disorder. It might be a new cadre of excuses why you can't eat or don't have time to eat or why you've lost weight. It might be a new background against which eating disorders are expressed. But seriously? The stress/eating disorders link is hardly a new disorder, nor is it separate from any other eating disorder.

I'm not against publicizing a surge in eating disorders amongst working mothers, and certainly those women who will strive the hardest to be the "perfect" mom and employee will be the most likely to fall victim to an eating disorder. And there's a big difference between using stress as a reason to skip lunch and lose a few, and an eating disorder that may result.

We also have pregorexia, where a pregnant woman is afraid to gain the necessary weight for her and her unborn baby. It's described as "the pregnant woman's eating disorder," as if it's something to covet. A pregnant woman with an eating disorder is precisely that: a pregnant woman with an eating disorder. And women with eating disorders are not refusing to gain pregnancy weight out of desire to be like some thin celebrity; they're afraid to gain weight because of a life-threatening eating disorder. Someone who wants to stay thin during pregnancy might have issues, but it's different than an eating disorder.

There's manorexia, which is a man who is anorexic. Other than the presence of a Y chromosome, it's still anorexia. A male's experience of an eating disorder would be different than a female's, but that doesn't mean it's a different disorder. A 12-year-old girl's experience of anorexia is different than mine, someone who is nearly 30, but no one would diagnose her with "girlorexia."

Would they?

The first time I ever remember fasting (outside of medical necessity) was to raise money to end hunger in my high school church youth group. It was a 30-hour fast and pledge-a-thon, and I remember feeling all special when I skipped dinner the first night--a Friday--because of a) how conspicuous I was by not sitting at the table and b) I got a lot of homework done. That first night, I don't remember being particularly hungry or disturbed. I just did what I normally did and went to bed. End of story.

The next morning, I also did what I normally did and went to work at the public library (I was marked as a nerd from the start, apparently), came home, and went to get in the shower before heading to the end-of-fast celebratory pizza dinner. I don't remember being especially hungry, but I do remember nearly passing out in the shower. Apparently, I was swaying on my feet, and my mom just gave me a glass of orange juice and said "Here. Drink it." I told her no, that would be cheating, I'm okay, and she said, basically, drink it anyway. I did and felt tremendously guilty as I headed to the church.

I found out, of course, that some of the kids had been painting the rec room all afternoon and had been guzzling Sunny D. This left me incredibly pissed because I thought it was supposed to be fasting, and starving kids in Calcutta didn't get any fluorescent orange-flavored juice drink, did they? Nope. They also didn't get to bust out pizzas after only 30 hours, either, but that didn't stop me.

It was neither a negative or positive experience. I mainly participated because I thought I would be a loser if I didn't. I think the fact that I had no emotional attachment to the experience probably saved me a little bit from having the AN triggered then. It wasn't like when I started restricting in college and felt better. In high school, I just felt kinda peeved that no one told me juice was fair game during a fast and I nearly got a concussion in the shower.

Well, 'tis the season of Yom Kippur- it was yesterday, actually, and seeing that I'm not observant in general or of religious things in particular, it probably shouldn't be all that surprising that I'm not blogging about it until now.

Harriet had a great post yesterday about eating disorder recovery and religious fasting, and there was a fascinating post from The Frontal Cortex today about the author's experience fasting yesterday for Yom Kippur.

I have to confess: I'm a terrible faster. When I don't eat, my thoughts don't become more ethereal and holy - they become fixated on calories, so that the only thing I can listen to is the impatient gurgling of my stomach. (My belly drowns out the sermon.) I get cranky and tired and squander hours daydreaming about ice cream - my wife tells me that I regress into a five year old...

For me, the lesson was rather obvious: my brain needs glucose like my laptop needs alternating current. Even a few hours without food means that I'm running on reserve power; I could feel my executive function (and my frontal lobes) begin to sputter and quit. And then I passed out.

Besides his own personal experiences, blogger Jonah Lehrer shares the results from an interesting study, in which a group of students were first asked to complete a mentally challenging task, to "exercise" the brain and strip it of glucose. The students were then split into two groups; both were given lemonade, but one group was given lemonade sweetened with sugar, and the other was given Splenda-laced lemonade. After fifteen minutes, the students were asked to choose different apartments, and the group that received Splenda lemonade made much more impulsive choices. Writes Lehrer:

The reason, according to Baumeister, is that the parts of the brain responsible for careful, rational deliberation were simply too exhausted to think. They'd needed a restorative sugar fix, and all they'd gotten was Splenda. This research can also help explain why we get cranky when we're hungry and tired: the brain is less able to suppress the negative emotions sparked by small annoyances.

Which is, perhaps, why depression so often accompanies dieting and disordered eating. It could also explain why I was so peeved about the Sunny D scenario. Another study found that adequate glucose was necessary for the brain to exert "willpower." And it could be why dieters spend more on impulse purchases.

Whether or not you choose to fast--for religious reasons or not--is ultimately up to you. But if you do, you might want to lock up the credit cards along with the ice cream.

I think most people have some sort of functional addiction- that is, a mild addiction that really doesn't interfere with life and health. You could probably put my obligatory morning 2-3 cups of coffee in that category. Sure, I've been a nasty coffee fiend, usually in concert with the eating disorder, but mostly, I just love coffee. And caffeine. I hate mornings, and so I gravitate towards anything that might make it just a little bit easier. Am I addicted to caffeine? Probably, a little bit. Does it really harm me? At this level, I doubt it.

My aunt probably has a functional addiction to exercise. The amount she exercises isn't excessive, but if she doesn't get her morning workout, she says she feels cranky and out-of-sorts. Is her exercise harming her life and health? Probably not. Is it still an addiction? I would say so.

I've had both functional and non-functional exercise addictions, and my problem was not only the addiction itself but how it was billed by those around me. When people heard I exercised every single day, rain or shine, snow or sleet, they didn't ask why I didn't want to take a day off or even if I would let myself take a day off. No, they lauded my devotion and willpower, which has led to a hate/hate relationship with that last word. They patted me on the back and told me I was "hard core" and how they wished they could do what I did.

Frankly, I wanted to smack them.

Our culture has a totally screwed-up attitude towards both food and exercise. They're related, to be true, and I have historically been much more painfully aware of the "food" aspect. However, as I've begun to address my exercise issues in therapy, I've started to realize just how blind our culture is to exercise addiction. It's seen as a good thing, not a problem.

Which is why this article from my local paper has me a little bit tweaked: Ultra runner brings sport to Ann Arbor

From the text of the story:

Meet the ultra marathoner. You, too, can be one if you have steadfast willpower, oodles of devotion to training and a true love of adventure.

It sounds so positive, and maybe for many people, it is. But the words "ultra marathoner" immediately raise red flags in my head, and for the man featured in this article, it was no exception.

Asked if running is his first priority, he said, "Absolutely."

"It's like an addiction," said Purdy, a married father and retired Ford employee. "You need to get your fix, otherwise you feel crabby. You don't go to the bathroom the same, don't sleep the same."

And people are celebrating this? Certainly, the man is dedicated and talented. I don't doubt that for a second. But that's not the issue. The issue is that someone admits they have an addiction, and we tell them how much willpower they have. It's like patting a heroin addict on the back for the lengths they go to in order to score some dope. Sounds kind of silly when you think about it. It's not willpower- it's desperation!

I have no idea if this man's health or quality of life is being impacted by this. Maybe it isn't. But I also think we should stop blithely celebrating such addictions, even if they leave someone functional.

I've heard talk of the greater good plenty before. People donate money for the greater good. They "take one for the team." And so on. The idea is that a small, personal sacrifice right now will yield greater benefits in the future.

I'm pretty talented at delayed gratification--in fact, I'm pretty sure it's the only real way I know how to gratify myself. Outside of the fact that I've managed to equate denial with happiness, I really get the idea of the greater good. I get how it works, and I like the idea. Because it isn't all about me.

To some extent, I thought the eating disorder was operating on the plane of the greater good. I was denying myself something now (food, rest, free time), for a tremendous payout later (feeling like I was good enough). The eating disorder really didn't work like that, as my self-denial was really an attempt to nullify the anxiety I felt about needing anything. The end goal was subsumed in the here and now minutiae of anorexia, the calorie counting, the tallying of sit-ups and push-ups, the Holy Grail Quest for calorie-free food.

The writer of an OCD blog, titled "Beyond the Doubt," used the idea of the greater good in his own recovery from OCD, and has a developed website called Your Greater Good. The idea is that the OCD rituals feel good right now. They make the anxiety better, and are classified as a "good" choice. However, in the long run, the obsessions and compulsions only make you feel worse. They don't free you from what you fear; instead, they tether you to it even more strongly than before. This makes engaging in OCD behaviors not such a "good" choice. The idea, then, is to find something of greater good than your rituals, something that can provide perspective and motivation to allow you to make the more difficult decision to resist the anxiety.

I've found this idea to be tremendously helpful to me in my own recovery. I enjoy the advocacy work that I do, and it's not about making the eating disorder "worth it." It's about making the pain of recovery worth it. Much of the time, my greater good has nothing to do with eating disorders. It might be the opportunity to travel. It might encompass being there for a friend. A huge motivator for me is that I promised Aria I would never, ever leave her again. That keeps me going when few other things can.

So what's your greater good? How can you use it to keep moving forward in recovery?

"People ask me: "Why do you write about food, and eating, and drinking? Why don't you write about the struggle for power and security, and about love, the way the others do?" . . . The easiest answer is to say that, like most other humans, I am hungry."
--M.F.K. Fisher

Or maybe, writing about food and eating and drinking (and our relationships to all three) means that you simultaneously write about power and security and love.

What do you think?

At FEAST's table at this year's NEDA conference, one of our professional advisors brought a basket full of crocheted food. It wasn't just that it was, you know, crocheted food that made it amusing; it was the sheer level of detail on these things. The pizza I'm "eating" not only as a crust and cheese and toppings, it has a layer of tomato sauce as well. There was almost every different type of food on the FEAST table, and it was a huge hit.

A new photo manipulation program called Be Funky provided me with way too much fun this afternoon. I don't usually share pictures of myself for privacy reasons, but I do like this photo and it's not too personal. Here's the original:


So where does Be Funky come in? I was screwing around with some photos of myself I had- not many since I'm notoriously camera-shy, but I thought this image would make a funny one to play with. And, in no particular order, here are my results (the last is my favorite):

Gas and flatulence are one of the unpleasant (and fragrant!) aspects of refeeding and re-introducing your body to the digestion process. I always referred to it as the Basset Hound Stage, because I always wanted a dog to blame the smell on. Thankfully, this past summer wasn't nearly as bad as the other times- at least in that respect. As for the reasons why I turned into a veritable gas-passing machine, I just assumed that my digestive tract was a wee bit confused and things weren't being processed as efficiently.

But now I know exactly why.

This probably marks me as a total geek--though what about me doesn't, besides my love of trashy true crime shows--but I was so thrilled to see this research article titled "Monitoring Bacterial Community of Human Gut Microbiota Reveals an Increase in Lactobacillus in Obese Patients and Methanogens in Anorexic Patients."

I know, I know--huh? Well, stand back, kids. I'm a professional!
::insert trumpets here::

What are "methanogens"? They're bacteria that live in your gut and, as they break down your undigested food, they release methane. What is methane? You guessed it- methane is fart gas. Well, okay, it's more than that, 'cuz my organic chemistry professor told me so, but it's also the major gaseous component of farts. (Why am I getting the feeling that this post is going to greatly increase the popularity of "ED Bites" amongst pre-pubescent boys?)

In the study, anorexics had higher numbers of methanogens than normal weight controls. The particular bacterial species that the authors found to be increased in the guts of anorexia patients was Methanobrevibacter smithii, of which Wikipedia says this:

"[M. smithii] is important for the efficient digestion of polysaccharides (complex sugars) because it consumes end products of bacterial fermentation."

Anorexia results in a negative energy balance (by definition), through decreased intake, increased exercise, or both. As such, there will likely be fewer complex carbohydrates available in the gut. The authors of the study concluded the "increase might represent an adaptive use of nutrients in this population." Translation: methanogens help extract more calories from an already limited intake, thus getting more bang for your calorie buck.

The authors didn't subtype the AN patients, which may have made a difference in the composition of bacteria. I would imagine this would be especially so in those who abuse laxatives. It would also be interesting to see how gut bacteria changes during recovery. I think this is an under-explored area, and I would love to see more of this research.

This fantastic little tidbit titled "Scare yourself skinny" is almost inconceivably wrong. The blog is about pretty much what it sounds like: how anti-obesity campaigners can use fear to scare people thin. The idea comes from the use of warning labels on cigarette packets. Before the labels, cigarettes were cool and hip. Now, they're cancer sticks. The labels and warnings may very well have prevented me from starting smoking, but I'm not sure they would have been enough to get me to quit. It didn't work that way with my eating disorder, and I don't think it would work that way for smoking or weight.

Still, it's a popular tactic, as evidenced by the recent New York City Health Department campaign in favor of calorie counts on menus and subway posters titled "Pouring on the Pounds." (h/t VoiceinRecovery for pointing out the posters to me several weeks ago). You can even adopt a five pound piece of pet fat to help remind you of that icky icky fat you just don't want to have (all for only $149.95 plus shipping!). I personal prefer the little fuzzy adipose cell at Giant Microbes, and have adopted one myself to remind myself that fat isn't all bad.

There is the minor detail that fat molecules line all of our cells, and help conduct nerve impulses. It makes our hair and nails shiny and healthy. It provides padding against injury and daily wear and tear. It helps keep us warm. It's not all that bad.*

The author of the blog post cited several studies that showed how fear tactics can work to change behavior. And if you were just considering the short-term, I would tend to agree. But even I, Anxiety Freak Extraordinaire, become inured to risk and fear. Serious ED symptoms rapidly stopped frightening me. It was just the way things were. Fear tends not to change things long-term.

There's the small fact that people aren't fat just because they're not scared enough of it. Our culture is awash in this fear. I can't believe that people aren't aware of it. Then there's the fact that some people aren't fat because they drink too much Coke and too little "water, seltzer, or low-fat milk." Some people are just fat, and no amount of fear is going to make them lose weight.

Weight has an environmental element, true. So does height. Where, then, are the articles titled "Scare yourself tall"? Shouldn't you be scared of your decreased salary? Shouldn't you?

(EDITED TO ADD: I just found a great piece in Slate tackling the politics of the "soda tax" called The Growing Ambitions of the Food Police.)

*Yes, I'm trying to convince myself of this, too.

At this year's NEDA conference, I attended a session titled "Dangers and Phobias," which was a three-fer session: the first part was on the dangers of eating disorders, the second part was a whirlwind tour of neurobiology that even I could barely follow, and the third part was about phobias and eating disorders. Now, an eating disorder isn't just a simple phobia of food, but a food phobia is a major part of an eating disorder. This phobia takes on different forms in different eating disorders (it might be a phobia of eating carbs*, or a phobia of not throwing up, etc), but this phobic response is almost always present.

Maybe it's because I also have a hella lotta anxiety issues outside of the anorexia, but this presentation on the relationship between eating disorders and phobias really hit home for me. I became anxious around food, so I started avoiding it. This decreased my anxiety to a point, but then the anxiety came back. So I avoided it more. And so the cycle continued. Each time I avoided food, it cemented that fear. If I eat, I thought, something really bad is going to happen. That "something bad" could be a magical mysterious weight gain of 100 pounds, it could be I would feel like crap, it could be that I "ruined" the day. When nothing bad happened (as it usually did), I linked that to not eating. That tiny shred of self-esteem from watching the scale go down? That was because of my not-eating. The stylish new jeans I let myself wear? Not-eating. The (seeming) decrease in fear around food? Not-eating.

Eating would somehow erase all of that. Eating and gaining weight would remove the whole foundation on which I had built my life. That's a pretty big fear.

I discussed this fear in therapy a lot, which was much more enjoyable than facing the fear. I learned where it might have come from and what purpose it might be serving. All of this discussion did precious little to alleviate these fears. In fact, the longer I went on not-eating, or purging, or over-exercising, the more these fears cemented themselves in my brain. Many aspects of these phobias turned into habits.

I've been facing these fears head-on in the past few months. Not dissecting them, not just introducing myself by with stickers saying "Hello My Name Is" and then moving on, but having the kind of staring contest with them that even my cat would envy. Did I gain weight when I started eating again after this relapse? Yes. I also needed to rather badly, but still, weight gain was an element. Did my world fall apart? Yes, but it fell apart because of the fears, not from facing them.

Do I have my moments? Um, yeah. I'm not happy-go-lucky about food, nor do I think that would be a reasonable goal for me. For that matter, I don't want to be totally nonchalant about food. When I get sloppy, I start skipping meals and then minimizing the negative effects of said skipped meals. Paying attention isn't a bad thing.

I don't know sometimes if I'll ever be totally "over" this fear. I hope and believe in a time when it won't rule my life, but my years with anorexia have profoundly changed me. There's no going back, but there is the moving forward.

*Blogger spell check doesn't recognize the word "carbs." Can I tell you how excited that makes me?

A new proposal by French lawmakers would require that airbrushed photos are labeled as such. Similar laws have been proposed in the UK (two news stories on the subject can be found here and here), on the grounds that these ads can be "very damaging." Eating disorders are usually cited as one of these damages, along with more general body image woes.

Rachel at The F Word blogged about the subject here, and compared the issue of labeling airbrushed ads with the warnings on cigarettes. And to some extent, I agree with this line of thinking. These ads are damaging. Younger and younger girls are dieting. People think that they can actually look like the models in the ads. Body dissatisfaction is eerily normal.

All of these things are very bad. Even without mentioning eating disorders, I think we need to take a long, hard look at what our ads are teaching. A label, even just to identify that these images have been digitally altered, is a place to start. More and more people find smoking distasteful, less associated with the virile Marlboro Man and more associated with stink and lung cancer.

What I object to is having this legislation linked directly to eating disorders. The French proposal is headed by an eating disorders expert and is part of an ongoing campaign against eating disorders. An Australian article on the subject said that

"[French Parliamentarian Valerie] Boyer said being confronted with unrealistic standards of female beauty could lead to various kinds of psychological problems, in particular eating disorders...

"These images can make people believe in a reality that often does not exist," Ms Boyer said, adding that the law should apply to press photographs, political campaigns, art photography and images on packaging as well as advertisements."

I agree that this false reality (that all so-called "beautiful" people are thin, etc.) is troublesome and plays right into eating disordered thinking. I mean, two days before I was admitted to the hospital, I had people asking me for diet tips! Plenty of people without eating disorders have similar delusions that I do.

However, these delusions are the result of an eating disorder, not a cause.

I'm not naive enough to think that Size Zero and airbrushed models have nothing to do with eating disorders. They're part of the cultural backdrop against which eating disorders are expressed. In the Middle Ages, the obsession was with fasting and holiness. This didn't cause eating disorders, either, though it did alter the meanings people ascribed to their symptoms. Learning how to live in this fundamentally effed-up environment is one of my major tasks in recovery. I try to participate as little as possible, but short of turning hermetic, there's going to be Cosmo on the newsstands and I'm going to see pictures of "scary skinny celebrities" and celebrity weight gain. I intend to fight it, but in the meantime, I have to live among it.

Our culture has a damaging obsession with food and weight and appearance. This needs to stop, even if it doesn't prevent a single eating disorder.

A recent study found that higher parental and grandparental education and higher grades increases a person's risk for an eating disorder. This makes a whole lot of sense to me. And I'm not talking about how parents with higher levels of education might push their kids harder, etc. Or even how more educated parents have more money and therefore their kids experience more pressure to be thin. This could be true- I don't know. But I think the relationship is much more subtle than that.

One of the characteristics of an eating disorder is a drive for thinness. Considering that, through the ED, I defined "thinness" as "success" and/or "perfection," the drive for thinness in me (and in others I've spoken with) seems to be an offshoot of perfectionism. Indeed, even in non-ED university students, researchers found a relationship between stress, perfectionism, and drive for thinness.

Besides the eating disorder, my other main perfectionistic focus has been school. I skipped half of my brother's high school graduation party to study for an 8th grade history test. I worked until all hours of the night in high school, and usually through dawn in college. Driven by fear and anxiety, and fueled by pots of coffee, I stayed at the top of my class.

From the outside, I was a success. I sure looked the part. My parents were proud- why wouldn't they be? Over-achievement wasn't going to worry my parents, especially not after my brother! And this drive, this ineffable need to do more, do it better, was hauntingly familiar to both my parents, but especially my mother. It wasn't abnormal or pathological, right? It was familiar.

This post is not intended as any sort of mother-bashing (though several of my therapists have had a field day with what I am about to share), but my mom was pretty darn obsessive and perfectionistic about school and, instead of food/weight, her other obsession was cleaning. She skipped out on dates with my dad because she had to study. My dad, who had tickets to a concert/play/whatever, didn't want to waste the tickets, so he took my mom's mom instead.* And, also just like me, my mom excelled at school. She placed top in the state in her subject exams upon college graduation.

Both my parents graduated from college- my dad did so somewhat grudgingly, as school was never his "thing," but graduate he did. I know my mom's dad graduated from college, but I'm not sure about my dad's dad. I know neither of my grandmothers went to college, but everyone finished high school.

What I see in my family is not so much a legacy of high parental expectations, but a legacy of perfectionism and drive to succeed. Did my parents have high expectations? Maybe, but my freakishly higher expectations of myself were what drove me. So I fundamentally disagree with the authors' conclusions that:

"Thus, higher parental and grandparental education and higher school grades may increase risk of hospitalization for eating disorders in female offspring, possibly because of high internal and external demands."

Internal demands, yes. This is how the perfectionism manifests itself in myself, my mother, and many of my maternal relatives (of whom I know the most about). My dad is also a perfectionist, though in a very different way than my mother and I. So the link between higher grades and higher parental/grandparental education does make sense, but not in the way the authors might have assumed.

Anxiety can drive success. People have told me they wish their kids could have my GPA and "work ethic" and I have to tell them no, you really don't wish that. I love learning and enjoyed many of the aspects of school, but my high school and undergrad years were pretty hellish. I was lucky, in a sense, that the symptoms of my mental illness helped me succeed, but it also makes it harder for lots of people (myself included) to understand that these personality traits--the drivenness, the perfectionism--have downsides, too.

Note: I realized as I was blogging that the study seemed awfully familiar, and I remembered that Laura also posted about the study and its conclusions here.

*My grandmother, at that time, looked rather young and not unlike Doris Day, so they probably pulled off the whole "couple" routine. It's the epitome of putting the "fun" in "dysfunctional." She also appeared in the newspaper around this time to share the recipe for her "legendary" ham loaf. I have the picture somewhere- I should post it. It's a hoot.

I found this interesting video via Twitter (thanks, Jane!), from an American RadioWorks documentary on belief systems during World War II. One of the belief systems that were examined were the conscientious objectors, and the subsequent Minnesota Starvation Study. In the video, one of the study participants views old silent film from the time of the study and narrates his memories and feelings.



My Mad Google Skillz dug up the actual documentary website, which you can find here: A Duty to Starve. I find the quotes from the study participants to be especially intriguing and revealing about the personal experiences of starvation. It's a profound experience, and it tends to mark you for life. You don't just forget about it after it's over.

What I think one of the most eye-opening aspects of the Minnesota study was how much starvation affects the mind. People knew starvation affected the body- it was fairly obvious. But no one before had tried to study how starvation affected the brain. And your brain is a veritable Hoover for calories; though only 2.5% of your body by weight, it uses 20% of the calories you eat. Without these calories, the brain starts shutting down. All that interests a starving person is food. Not friends, not sex, not that snazzy new pair of peek-toe pumps, just food.

I am incredibly grateful to these men for helping science get such insight on starvation.

There were a couple interesting papers this week that looked at hormones and bone formation in the context of eating disorders.

The first one, Relationships of hormones of adipose tissue and ghrelin to bone metabolism, looks at how one of my favorite compounds--leptin--affects bone mass. Besides regulating hunger and fullness, and, as a consequence, eating behaviors, leptin also helps lay down bone mass during puberty. Adequate fat stores is required for leptin production, which helps explain why people with AN during puberty can have both low bone mass and stunted growth. Lowered body fat means lower leptin levels, and lower leptin leads to less-than-optimal bone formation.*

The study concluded that adipose tissue, far from being inert globules of stored Crisco, has a profound impact on bone formation.

A different study, Hormone Predictors of Abnormal Bone Microarchitecture In Women with Anorexia Nervosa, tried to tease out the importance of either hormonal and nutritional deficiencies in the development of osteopenia/osteoporosis in people with AN. The researchers found that women with AN had more tiny, microscopic spaces within bone itself and a reduced bone volume compared to control women. The researchers also measured the hormone levels in the two groups of women and found three major hormones that could predict reduced bone microarchitecture: leptin, androgens, and insulin-like growth factor 1. What's interesting is that these hormone levels were predictive regardless of the person's BMI. Part of this could be due to the fact that the hormone levels are related to BMI, ergo the effect will still be there even if you don't know BMI. The other aspect could be due to the fact that weight is a pretty individual thing, and so what is an abnormally low BMI in one person could be perfectly healthy in another.

Still, both studies agree on this: EDs can have dramatic, negative effects on bone structure that can last for a lifetime.

*I'm also wondering if this is why "small body frame" is a risk factor for osteoporosis- could a smaller frame mean lower circulating leptin levels? Interesting...

I read a thought-provoking piece in the NY Times Magazine called "Are your friends making you fat?" I've been finding the idea of networks and social networks both interesting and compelling, and I wrote about it quite a bit at my job this spring. Information and infectious diseases do flow through networks of people. The math to determine exactly how they spread, and at what rate, is rather atrocious but also really fun. (I have an MPH in epidemiology- it's sort of a career hazard.)

Where I first learned this idea was in a seminar course on STDs, and a study of a syphilis outbreak in Baltimore in the 1980s. Basically, researchers used known patterns of drug use since syphilis was typically transmitted during a sex for drugs exchange. People might not always remember their partners, but they typically remembered where they got high. With this information, healthcare workers could narrow down the number of people who needed testing. The problem with translating these types of studies into non-infectious diseases is this: networks don't tell us whether the disease is a virus or bacteria, or even how the disease is transmitted. There can definitely be clues about transmission in these networks, but rarely are there specific answers. Rather, we find associations.

Which is why I find the idea of "social contagion" rather troubling. Certainly we affect each other's habits and lifestyles. I don't doubt that. But I'm not convinced from these studies that simply being friends with a fat person is going to make me fat.

An anorexic friend can't make you anorexic. An anorexic parent can't make you anorexic (though the whammy hits from both the genetic and environmental side, for double the trouble). A black friend isn't going to make me tan better- though I wouldn't mind if they helped me burn just a bit less. A tall friend isn't going to make me taller.

I've made friends with many people who also struggle with eating disorders and other mental health issues. If you just looked at my Facebook page, you might start to think that hanging around these people may have caused my eating disorder. Or maybe that I even caused theirs. We have an association (ie, interest in eating disorder advocacy), but that says nothing about cause.

Do we see trends of behaviors passing between friends and family? Absolutely. Can these have both positive and negative effects? Absolutely. But talk of causation, especially for something as complexly regulated as body weight, seems rather premature.

The Twitter-sphere has been discussing the difference between disordered eating and eating disorders (specifically EDNOS) today. I haven't responded, in part because I like to formulate a complete answer than spewing something half-baked, and also because I can't explain myself in 140 characters or less! But the more I think about it, the more I realize that I don't necessarily have all the answers, but that these are answers that are worth having.

To start forming these answers, we first need to define "disordered eating" and EDNOS. A Newsweek article on EDNOS, which prompted this discussion in the first place, had this quote from Susan Ice*, Medical Director at the Renfrew Center, about EDNOS:

"EDNOS is a hodgepodge of things that don’t necessarily belong together, except that they don’t belong anywhere else."

The Newsweek article pointed out that there are plenty of insurance issues regarding EDNOS; whereas insurance companies may grudgingly cover anorexia and bulimia treatment (if you're lucky), they frequently will not cover treatment for EDNOS. I don't necessarily know their logic--nor even if they have any--but this strikes me as more of an insurance issue than an EDNOS issue.

Problems with EDNOS remain, however. It's the most common ED diagnosis, yet differentiating EDNOS from full-syndrome anorexia, bulimia, and binge eating disorder doesn't always yield significant results. People with EDNOS are typically just as ill and just as impaired as those with other eating disorders. That so many people are diagnosed with something titled "not otherwise specified" is troubling, and indicates that we really don't know a whole lot about eating disorders. Leading ED researchers have noted that the DSM criteria for eating disorders are in much need of revision. I don't advocate getting rid of the category entirely, because it is a way to account for the continuing evolution of both eating disorders and our understanding of them. That being said, we need to get a heck of a lot more clear on what's going on with eating disorders.

Then we have the issue of disordered eating. I was surprised at how difficult it was to actually find a definition of disordered eating. The most amusing was "eating that is irregular or disordered." Just file under "circular reasoning" and then hit me with the Duh Truck, why don't you. Wikipedia equated "disordered eating" with EDNOS, though I wouldn't call the two issues the same. The best definition I found, and one which involves way too much hand waving for my nit-picky scientific mind, was from Eating Disorder Expert:

"“Disordered eating” is a term used to describe eating habits or patterns that are irregular. Many different types of disordered eating habits exist, but for the most part these habits do not add up to a diagnosis of an eating disorder...Excluding whole food groups (for example, all fats or all carbohydrates), eating only at particular times of the day, eating only specific foods, eating only foods of a specific colour, eating only foods of a specific texture, not eating certain foods together in a sitting and not eating specific foods from the same plate can all be types of disordered eating."

I would also place dieting and body image obsession into this category, which basically includes 95% of the American public. Research from UNC-Chapel Hill found that three out of four women in the US have disordered eating attitudes. It's significant. It's severe. It sucks.

It's not an eating disorder.

Disordered eating can look like an eating disorder, especially when the eating disorder is just forming. Similarly, a full-blown alcoholic may start as a binge drinker at parties on the weekend. Neither disordered eating or binge drinking is healthy or something I would advocate. But most of those with disordered eating or binge drinking do not go on to develop eating disorders or alcoholism. This isn't to say that they aren't deserving of help and wouldn't benefit from therapy or taking a long, hard look at their behaviors. Far from it. But I have many behaviors that could stand improvement that are still far from pathological.

Right now, we don't have the diagnostic accuracy to be able to separate people into two groups: those with eating disorders and those with disordered eating. Nor do we know how to separate those with disordered eating and those without any eating issues. Disordered eating hasn't been clinically defined; for that matter, neither really has EDNOS. As much as I hate the "less than 85% ideal body weight" and bingeing and purging twice a week for three months criteria of the DSM and think they're crap, it's a start. Although I can personally define disordered eating as well as Justice Homer Stewart can define obscenity (i.e., "I'll know it when I see it."), this isn't very useful to anyone but, you know, me.

I can't get more specific than this; we don't have the definitions or the research. What I can say is this:

I see eating disorders as primarily biological issues. I see disordered eating as primarily a cultural issue.

"But Carrie," you say, "what about Anne Becker's research on the island of Fiji?" Becker, an anthropologist, found that the arrival of American TV on Fiji in the mid-90s resulted in an increase in disordered eating attitudes, dieting and self-induced vomiting. After three years of TV viewing, approximately 12% of Fijian adolescent girls admitted to self-induced vomiting, compared to 0% before the arrival of American TV. This is clearly problematic, and I regret the introduction of TV and the loss of innocence on Fiji.

Yet the study did not indicate the frequency of self-induced vomiting (not that any is good, but again, I think of the relationship between binge drinking and alcoholism. It can look the same, but it's not), nor do people comment on the rate of disordered eating attitudes before the arrival of American TV. Just over 12% of Fijian girls had a high score on the Eating Attitudes Test before TV came to the island; after three years, that number was 30%- a significant increase. The number of girls with high levels of disordered eating more than doubled in three years- it's sad and it's serious and it's a big, big problem. But that means that even without American TV and models and ads, about one in eight Fijian adolescent girls had high levels of disordered eating. Could these be the beginnings of eating disorders? Perhaps. The test doesn't distinguish between disordered eating and eating disorder. But neither were any full-syndrome eating disorders diagnosed in the first three years following the arrival of American TV.

Of course, I would never claim that anyone could split nature and nurture. Both are important. But I see dieting as a cultural phenomenon, one that is rapidly sweeping around the world. Eating disorders exist in all cultures, races, genders, socioeconomic classes, and time periods. Certainly many eating disorders start as disordered eating, but then they progress into something much more sinister and something the sufferer has much less choice over.

Both issues are important, but they are rather different. Promoting better body image and self-esteem will hopefully decrease the amount of disordered eating, and maybe result in fewer eating disorders being triggered by malnutrition in the form of dieting or "healthy eating." I'm not sure it will have much effect on eating disorders. I wasn't thinking about supermodels when I first thought about eating "better" and exercising more. I didn't obsess about freakishly skinny women until after I had started losing weight.

There is a fundamental difference between disordered eating and an eating disorder. I might not always be able to tell you exactly what it is, but I'll know it when I see it.

*Full disclosure: she was my MD when I was at Renfrew in 2001, and her last name kind of fits her. She was quite competent, but she also terrified me. Then again, she was also the one increasing my meal plan practically twice daily.

...keep on going.

I first heard this song on the lovely Sarah's recovery CD, and I totally fell in love with it. It's one of those roll down the windows, crank the volume, and sing along sorts of songs. It's also one of my mottoes, and a song I use to help me pick up my spirits when ED gets mean and exhausting.

So turn up that volume and enjoy!



The original quote, "If you're going through hell, keep going," is by Winston Churchill.

I had a fantastic time in Minneapolis at the NEDA Conference this year. I got to meet a huge array of people who I knew electronically but whom I had never seen in person (Twitter friends and FEAST-y moms, this means you!). I got to have lengthy discussions with Walt Kaye, Cindy Bulik, and Jenni Schaefer. I finally got my copy of Eating With Your Anorexic signed. I learned a bunch of new stuff about eating disorders and in general it was a great weekend.

Great, but not perfect.

I waited to write this partly because the internet connection was crap and cost $14/day, which was something I wasn't willing to spring for after I realized just how crappy it was. I also waited to write this because I wanted at least a little perspective and not to jump in, all emotion mind, and really put my foot in my mouth so far that I could tickle my ileum with my big toe. How much perspective I've gained in the last 24 hours is hard to say, but I haven't changed my mind.

So. Let's start with the good stuff, shall we? There was a lot more discussion of science and research and evidence-based treatment than I heard the past two times I attended the NEDA conference. This is a Very Good Thing. The more knowledge we have of what works--in part so that we can jettison what doesn't--the better off the treatment world will be. Cindy Bulik's talk on Friday afternoon about the current state of ED science was fascinating and will warrant its own post.

The Not So Good Thing about all of this is that phrases like "evidence-based" and "family friendly" have become marketing buzzwords that don't necessarily have a basis in reality. Non-rigorous outcome studies (ie, paying people to respond to surveys and not following up on those who don't respond) are not only worthless, they are also misleading. Furthermore, none of these so-called outcome studies have been published in peer-reviewed journals, which makes them as believeable as pharmaceutical research published by drug companies. Viva Viagra, anyone?

Second, assertion of evidence-based treatments may be true, but they likely don't comprise a majority of the treatment used. I mean, I guess an hour of CBT a week is better than nothing, but if you're paying for treatment that's $1000 each day, it seems kinda silly in retrospect. In the literature I read (which, admittedly, was not exactly a random sampling, but I read quite a few), I didn't hear mentions of EDs a biologically based mental illnesses or "food is medicine" or any of the stuff that we now know to be true of eating disorders.

Instead, these centers have glossy brochures in various shades of green or purple with smiling happy people, with the occasional male or token minority thrown in for good measure. For all of the talk I've heard within treatment centers about Photoshopped models, it sure is ironic that the people used in treatment center advertising are overwhelmingly white, have no zits (they don't even have pores!), and they all have straight white teeth. There aren't any pictures of food* outside a glass of water or a rare green apple. Many treatment centers use photos of flowers/trees/leaves and show stunning vistas of mountains and deserts. Those centers that use Magic Ponies in their treatment have pictures of said Magic Ponies. The copy tells prospective patients how warm and caring this place is, how they will get to the bottom of the pesky emotional issues at the root of their eating disorder, and how they will restore a "lean, healthy body weight."**

Like I said, this is advertising. Take your blinders off when you're looking at Cosmo and Vogue, but keep them off when you look at treatment centers.

And saying "family friendly" is nice, but in many treatment centers, that friendliness only goes as far as Mom and Dad's checkbook. One FEAST mom specifically asked different centers how they included parents and got a lot of hand-waving. She followed up by asking how parents contributed to eating disorders, and many responded "Well, we don't blame them, but..." But almost every center I've been at and other people have been at and I've heard of certainly holds parents responsible in some manner for their child's eating disorder.

This is neither family friendly or evidence based. It's nonsense and bullshit.

I remember being excited when I first started hearing people outside the fairly close-knit ED research community using these terms. They really get it, I thought. All of my advocating is really working. Although I've started to see changes (the eating disorder program at UCSD and the University of Chicago, and UNC-Chapel Hill come immediately to mind), most treatment centers throw these terms to those of us advocating for science and evidence like sticks to a dog. Entertaining but hardly significant.

Go get the stick, Fido! Go get it! Good boy! Sit. Stay.

I'm tired of sticks and Milkbone crumbs; I want a nice big can of Alpo. You have the chance to do something meaningful and important- please use it.

Maybe this is just my innate cynicism leaching out and spilling over. It could be. I'd really like to be wrong on this, but I don't think I am. I'm not anti-treatment center, I'm just anti-bad treatment center. I'm anti-false advertising. I'm anti-say one thing and do another. And it's all too common.

*Not that a photo of a bucket of KFC is exactly a great marketing tool, but the main aspect of treatment is, you know, food.
**Um, did you not learn in medical school that fat is an important part of a healthy body? If you're going to be teaching me not to be afraid of fat, this strikes me as vaguely hypocritical. Restoring fat is crucial to patients with AN. It's not pleasant to the sufferer, but don't conspire with ED fears by reassuring me that all I'll gain is muscle.

Hello from Minneapolis! I am at the NEDA Conference in Minneapolis, and I am just dead tired right now. It was a fantastic and exhausting day, so I am going to keep this short and sweet.

I am so thrilled to be able to meet many of the people I routinely correspond with via email or Twitter (yes, you too can follow ED Bites on Twitter. You know what to do- clicky clicky the linky linky), and a special treat was meeting June Alexander who came all the way from Australia. And June came bearing the most wonderful of news.

I have been waiting for ages to announce this, and I have written this post in my mind several times. I was too afraid to type it out because I didn't want to have to hit "delete post" if things didn't work out.

The announcement is this: Elsevier is publishing a textbook on eating disorders titled "Opening the Door on Eating Disorders," and I have been asked to write two chapters! Squee! The publication was finalized just this week, and June told me of it today. I am thrilled. One chapter I'm writing is on the importance of treating EDs as biologically based illnesses, and the importance that makes in treatment outcomes and, more qualitatively, in how the sufferer and his/her family experience treatment. The second chapter is "Oops, I did it again: relapse and recovery," which is going to be about pretty much what it sounds like. These will be written in more formal scholarly prose, so I will have to check the snark at the door. Alas.

I am thrilled more than I can express that I get to be a part of this project. I think it is fantastic, and long overdue. Kudos to June for putting all of this together.

Lots of great people are also participating, but I'm too tired to name them all now. I know I would inadvertently forget someone, which is the last thing I want to do.

More from Minneapolis tomorrow when I'm not coasting on Starbucks fumes (whoever invented Iced Americanos is a freaking genius) and propping my eyelids open with toothpicks.

When I was a junior and senior in high school, the WWJD? (What Would Jesus Do?) bracelets were hugely popular. I got one and wore it proudly to my religiously and ethnically diverse suburban high school. My best friend at the time was Jewish, and she looked at my bracelet in Spanish class one day and asked what radio station it was for.

I told her classic rock. I'm guessing she figured it out, although a sick, evil part of me kind of hopes she hasn't.

The whole point of the bracelet was to serve a reminder to act as Jesus would act if you're not sure what to do. That means being kind, turning the other cheek, charity, forgiveness, whatever. I honestly don't think that such reminders are bad at all, even if they did become rather cliche.

I no longer have my WWJD? bracelet as I dissolved it in acetone in my freshman organic chemistry lab. I've made my peace with All Things Religious, which is really neither here nor there, but I don't ask WWJD much any more.

The concept, though, I still like. A lot. Earlier in my recovery, at my local psych hospital's day program, one of the nurses gave me the advice "Fake it 'till you make it!" This advice left me profoundly irritated because I had just spent the last 6 months pretending everything was fan-freaking-tastic and I ended up back inpatient. Fake what? How can I pretend I'm recovered when a plate of noodles reduced me to a sobbing, quivering ball of goo?

Although I still don't necessarily like that phrase, I have found another one that is more helpful to me: WWRPD? What Would a Recovered Person Do? It's not about pretending that I don't have any issues or about faking my way through a situation. Instead, it's about taking a step back and asking myself how I would act if I were recovered.

I don't always have an answer to this question. Sometimes, I don't know what a recovered person would do, and sometimes, ED recovery has minimal bearing on what my choice is. But it gives me a chance to look forward and imagine what might be and how I might act. It also allows me to "practice" recovery, to try out different options I think might be recovery-oriented but really aren't. It's less about being who I'm not and more about beginning to act the way I want to feel.

Maybe that is what the "fake it 'till you make it" phrase is about, in the end. But asking WWRPD? feels more authentic and real than just "faking it."

I stumbled across an interesting Power Point presentation by Shan Guisinger from the 2004 Human Behavior and Evolution Society in Berlin titled: Is Anorexia Nervosa Addictive?



The information is basic, but provides a good overview of how biology can trap someone predisposed to AN in a viscious cycle of starvation and exercise.

An article from Scientific American by Trisha Gura titled "Addicted to Starvation," fills in many of the gaps of the Power Point presentation and is one of the best pieces on AN neurobiology that I've read. One of Gura's more recent blog posts (Brainwashing in Anorexia: Neuroscientists Weigh In) is also quite good.

...you don't bother clicking on the "Casseroles Under 200 Calories!" link in your cooking newsletter because you know they won't cut it for your meal plan.

...instead, you click on the link for energy bar recipes and think "that's more like it."

Dr. Sarah Ravin's latest blog post, titled "Palliative care for anorexia nervosa?" really got me thinking. Dr. Ravin's blog post was based around a 2004 journal article by Michael Strober titled "Managing the chronic, treatment-resistant patient with anorexia nervosa," an article that gave both of us the heebie-jeebies. In the article, Strober articles that people with long-term, chronic anorexia who have failed at previous treatment attempts should be allowed to refuse treatment and essentially receive end-of-life care.

Writes Dr. Ravin:

"I view [palliative care for AN] as a manifestation of both failure and inferiority. Failure on the part of professionals who fear an emaciated patient’s wrath more than they fear her death. Failure on the part of a profession which espouses the dogma that avoiding premature termination of treatment is more important than avoiding premature termination of the patient’s life. Failure on the part of a philosophy that values nurturing the therapeutic relationship more than it values giving a patient a fighting chance at life, health, and happiness. These patients have not failed treatment. Treatment has failed them."

Besides a hearty "hear, hear!" for Dr. Ravin, I realized what my major issues were with this journal article and, more broadly, this point of view. And these major issues are twofold:

First off, this view supposes that a person with anorexia is making a choice not to get better. Of course, anorexia isn't a simple black and white issue of choice/no choice. It's more like making a choice when there's a gun to your head. Yes, you have free will and all of that, but that nice little Glock packs a punch, even without contacting your body. That gun is going to effect what choices you make and how you make them.

Anorexia isn't terminal, yet to a long-term sufferer, sometimes death seems preferable to recovery. When I shrieked to my first therapist that I would rather die than gain ten pounds, I wasn't kidding. And I was forty pounds underweight at the time. That's the level of agony and anxiety that even the prospect of weight gain brought me. Clearly, I wasn't rational. I wanted to refuse all treatment as it didn't seem worth it. And if someone had said, "You know, Carrie, you can avoid all of this pain and torment, we'll just keep you comfortable," that would have sounded mighty nice.

Palliative care in cancer patients is essentially predicated on the assumption that the patient is capable of making rational decisions. My grandfather, when diagnosed with advanced pancreatic cancer, elected hospice over chemo. He was in his mid-80s, had lived a full life, and chemo would extend his life by months at best. He chose quality over quantity, a decision I respect and would likely choose myself, if I were in his position. He was rational- his cancer didn't erode his cognition and ability to make sound decisions. Anorexia is different; anorexia does affect one's ability to make rational choices about food and eating, life and death.

The second issue I have with the article will follow along the lines of the cancer analogy. Chemo is brutal and painful and has some nasty side effects. Your hair falls out. You are constantly nauseous. You feel awful. But we encourage babies and toddlers to have chemo for their cancer. What kind of parent would do that? Easy- one who loves their child and has their eyes on the big picture.

Palliative care in AN strikes me as the worst kind of "killing people with kindness." Strober's gestures are no doubt heartfelt, and he is likely doing what he thinks is best for his patients. He doesn't want to cause them pain and distress. No doubt most oncologists don't want to cause their cancer patients pain and distress, either. But that doesn't stop them from prescribing chemo*. Would it be kinder for an oncologist to say to a patient who is complaining about nausea and vomiting that all they have to do is stop their chemo and their agony will stop? For the short term. But for the long term? That is a life wasted.

If someone offered me palliative care or harm reduction, it would have almost entirely undermined my confidence in my own ability to recover. This confidence is necessary. So if no one else thinks I can get better, then why should I bother trying? As well, one of the most insidious aspects of anorexia is how the illness convinces you that you are worthless. And if treatment professionals are willing to write you off as hopeless or not worth the bother, then it only reinforces those views of yourself.

It's kind of depressing to think about, but I applaud Dr. Ravin for bringing up this difficult subject.

*Or radiation or surgery or whatever- all are unpleasant.

A recent review article titled "Theoretical perspective on anorexia nervosa: The conflict of reward," has to be one of the most fascinating scientific reads I've had for a long time (and my Facebook friends can confirm that I read a lot!). The gist of the paper is that many of the behaviors of AN, such as food restriction and excessive exercise, are initially rewarding, they eventually become punishing. An overlap in the neural circuits that process reward and punishment enables these two factors to become all knotted up, or "contaminated."

The author, Charlotte Keating, begins her argument with the concept of anhedonia, or an inability to experience pleasure, which is central to both major depression and a clinical feature of AN. Moreover, excessive exercisers tend to report greater levels of anhedonia, perhaps because exercise is being misused as a mood elevator. Initially, exercise and food restriction are very rewarding, which may be partly why people with AN become entrenched in these behaviors in the first place. Not eating feels better. Exercising feels better. Continued food restriction and excessive exercise only reinforces the reward, leading to the expectation that not eating and over-exercising will make the person with AN feel better.

The problem, says Keating, is that food restriction and excessive exercise are ultimately rather punishing behaviors. So how can punishing behaviors simultaneously be rewarding? The answer appears to lay in the anterior cingulate cortex, which (among many other things) is involved in the processing of reward, punishment, conflict, empathy, and other rational cognitive behaviors. In people with AN, the ACC doesn't process reward the same way; whether ultimately derived from dopamine circuits, reward is blunted in people with AN.

Writes Keating:

"...it may be that hypoactivity in ACC (which reflects the bulk of literature investigating this region in AN) reflects an impaired ability to adjust maladaptive behaviors which may also lead to illness maintenance."

Thus reward-punishment contamination means that the AN sufferer has a greatly reduced capacity for motivation to change, and to regulate his/her pathological behaviors. Furthermore, a low motivation for change only increases the neural "blurring" between reward and punishment.

The ultimate goal is not only to improve motivation to change by decreasing the blurring between reward and punishment in AN sufferers, but also to target "the mechanisms that may be responsible for bringing about behavior modification."

I've often thought that recovery was a lot like learning to ride a bike. Part of this metaphor stems from the fact that it took me a very long time to learn how to ride a bike without training wheels--I was almost 8. The other part of the metaphor has to do with recovery being a process, just like learning how to ride a bike.

My first bike was a pink Big Wheels that, according to my dad, I rode up and down the driveway for hours on end. When I was 5, I graduated to a purple Huffy with streamers and a little plastic basket in front. Shortly after I got the bike, I thought I would try riding without the training wheels. I pedaled up to the top of our driveway, and started coasting down the (not insignificant) hill. When I got to the bottom, I panicked because I forgot how to stop. So I careened on down the lawn and ultimately crashed into the swing set. The training wheels went back on and stayed on. I was petrified.

But the summer I turned 8, I realized that these training wheels were holding me back, and I was good enough at doing "bike things" that I could probably handle it. Smartly, I took my now training-wheel-free bike over to my friend's house where I could ride on her flat, almost traffic-free street. Not-so-smartly, I looked back to give my mom a thumbs-up when I got pedaling and promptly crashed into a mailbox. My friends were waiting, though, so I wiped off my scraped chin, and kept my eyes on the road.

Of course, more accidents were almost inevitable, and I wiped out many times. The worst was on a gravel road when I was left with cuts and scrapes on my left leg from knee to ankle. Ow! But my bike continued to be my ticket to freedom as I rode to friend's houses and even my first job at the local public library. The bike (upgraded to a 26" teal Huffy) went with me to college and I was looking forward to riding it after my first round of hospitalizations for anorexia.

The first time out the spring after my hospital stay was pretty fun. My second time out on my bike, however, didn't go quite as planned. I was about 500 feet beyond the end of our driveway (the same one I ingloriously careened down as an over-confident five-year-old), when I started shaking and felt the world going black. On the edge of the road and with a split second of awareness before I lost consciousness, I threw myself away from the oncoming van and into the ditch at the side of the road. I woke up in the ER about half an hour later, recovering from the first of numerous seizures. Other than wrecking my bike, scraping my knee, and herniating a disk in my back (I crashed into a roadside sign in the ditch), I was lucky. I had a helmet. I wasn't hit by the van.

I didn't really ride after that. Besides having a severely damaged bike, I was terrified and so were my parents. I remembered enjoying riding my bike outside, but I soon became chained to the stationary variety, with its blinking red lights and much more limited opportunities for serious injury. Biking was an endorphin high, but otherwise drudgery.

I'd thought about getting another bike for quite some time, but I never got around to it. Part of it was finances, part of it was fear, and part of it was the fact that riding outside wouldn't be "as good" as riding on a stationary bike. I toyed with the idea this past spring, but I was too compulsive with all of my other exercise to even find the time to go bike shopping.

But I got a bike yesterday--nothing real fancy, but still a nice bike. I didn't get it home in time to go out yesterday, but I did manage to take it for a spin today. It was fun! I was only riding for about 15 minutes as it was getting dark, but I could have kept going for much longer. Not in the it's...not...time...to...stop...yet keep going that drove me during the ED, but in a I'm having fun this sucks I don't want to stop kind of way.

Will I wipe out on this bike? I hope not. But that's why I carry my phone and wear a helmet.

I typically don't hesitate to point out improper or inaccurate media coverage of eating disorders. So I think it's only fair that I point out the good coverage when and where it exists. And CBS News recently produced two segments on anorexia, the first featuring recovered author Leslie Lipton, and another featuring Dr. Tim Walsh, my co-author and advisor on Next to Nothing (each video is approximately 6.5 minutes):






I think both do a good job of explaining the personal effects and the medical issues behind AN.

Good job, CBS!

Optimists are said to see out of "rose-colored glasses," but green is my favorite color. So when my therapist asked me to decorate a pair of kid's sunglasses to show how ED colors my world, I grabbed my lime green Sharpie and started coloring. Each lens became solid green because the ED colors everything.

Except it really doesn't cover everything- at least not equally.

I know that when I look at myself in the mirror, it's the equivalent of wearing green glasses whereas no one else does. What I see isn't what others see. The other problem is that the "greenness" of my vision isn't apparent to me. Why? Most of the time, my thinking matches up to other people's.

The coffee is hot, the shirt is white, we're running late, the scissors are sharp. If I'm seeing green, then everyone is seeing green. So when ED started to distort my thinking and turned my looking-at-myself-vision green, it wasn't immediately obvious. At first, I didn't ask people if they thought I was fat or if I was eating too much, because, clearly, I was fat and I was eating too much. I didn't need reassurance on that. Even if I had, their denial would have simply meant that they were blind to all things green- or they were being nice so as to not hurt my feelings.*

The tint increased slowly on other factors. Lunch would seem too large, so I would cut something out. And then the decreased lunch would start to seem too large, so I would cut something else out. Soon, eating lunch at all seemed rather ludicrous. For me. I could understand that other people would need to eat lunch, though I did feel more than just a twinge of superiority that I didn't need something as banal as lunch. I could still probably judge an adequate lunch for another person, but not for me.

My selective green vision continues, whether it's that I can look in the mirror and declare myself porcine, even though I would say someone who wears Size X (my size) is NOT FAT. I do tend to hold myself to higher standards, but this phenomenon goes beyond even that. I look in the mirror, and I see green. I see fat. It's not that I expect myself to be thinner than everyone else (well, not outside of the AN, that is), it's more that I see what I see and it's green.

Body image-wise, I guess my vision has always been tinted a little bit green. I always thought I was larger than anyone else. Looking back at old photos, I can see that I was probably taller and heavier than "average," but the difference isn't that pronounced. I am not the giant marshmallow man from Ghostbusters in comparison to a group of teeny-tiny people. But when I graduated high school, I would have called myself one of the largest people in my class, hands down. Was I? Probably not. Would I swear to the end of my days that I was? You better believe it.

And maybe that's why I never thought to question these perceptions of myself- they were always real to me, and since my perception of everything else matched up, why wouldn't it for body image, too?

I don't know what to do about having these green glasses on all the time. Having worn them for so long has almost literally colored my vision. I see a larger person in the mirror because I expect to see a larger person in the mirror. And most of the time, I do see what other people see when looking around, just not when looking inward. I don't know how to deal with the fact that objects in the mirror are not what they appear, even if the object in the mirror is very real and seemingly very gross. Previous body image therapy focused on helping me understand that my vision was, in fact, distorted. Which was quasi-helpful then, but not as helpful now.

How do I see what's real if I don't even know what real looks like?

*If my writing professor ever reads this paragraph and sees the mixed metaphors, I will die of shame. This is not indicative of your fantastic teaching, Ann!

In January 1986, a group of fourth-graders were asked a simple question by a reporter for the Wall Street Journal: are you on a diet? And more than three-quarters said yes. Many of them had no medical reason to lose weight, but still thought they weighed too much and were taking steps to lose weight.

I was in kindergarten at the time, and four years later, when I was in fourth grade, I, too, thought I was too big and weighed too much. Was I dieting? No. Was I distressed? Yes.

Almost 25 years later, the original WSJ reporter followed up with some of these women to ask them about how pressures about weight have changed since they were young. Their answer was simple- the pressures have only gotten worse.

In 1986, weight loss efforts for suburban Chicago girls consisted mainly of Diet Coke and Jane Fonda exercise videos. Today, these now-grown women note, girls can look online at pro-anorexia forums, at any number of magazines, and numerous videos on YouTube. There are sites with diet advice, online calorie counters, and online diets. It's all their and all in your face, even in pre-teens.

I'm guessing that girls who look at pro-ana sites and are "attracted" to them are probably more likely to be vulnerable to EDs in the first place. Although, truth be told, many girls visit them for weight loss tips, or with the desire to "become anorexic." I was always enthralled by stories of eating disorders when I was younger, long before I ever started exercising and "eating healthy." But EDs existed long before the advent of supermodels and Photoshop and bulletin boards, and so these pressures serve as triggers, as one more thing that moves the Tipping Point of a full blown eating disorder ever closer to people.

Researcher Kerry Cave noted that

"A preoccupation with body image is now showing up in children as young as age five, and it can be exacerbated by our culture's increased awareness of obesity, which leaves many non-overweight kids stressed about their bodies. This dieting by children can stunt growth and brain development."

And these preoccupations can ultimately lead to eating disorders. None of the women in the study, it should be said, developed an eating disorder, although most suffered from body image woes throughout their lives. And maybe that's the really sad part: how many lives have been blunted by these preoccupation of ours, even if it never reaches the point of formal diagnosis.

Link to the original 1986 article: Fourth Grade Girls These Days Ponder Weighty Matters