I was initially hesitant to do this interview because I don't think that publicizing these websites is necessarily a good thing (I know many people who first started visiting pro-anorexia sites after hearing about them on TV). That being said, ignoring an issue never works, so there you have it.

I think the interview went really well, all things considered. You can see my dorky Santa teddy bear coffee mug at some point, I believe.

{{Note, there is some talk of rather low calorie diets. If that sort of thing bothers you, then I would advise not watching it.}}

Lest you think I'm normal, let me provide you with yet another example proving otherwise. When my print version of the International Journal of Eating Disorders arrives in the mail, I totally geek out. Last month was no different. I've generally seen most of the articles before, as they are published online before they appear in the print journal, but I like sitting down on my couch with the journal and reading what's new.

What struck me about one particular study in last month's journal was not the study itself, but rather a reaction to it on Facebook.

What the study found

The researchers, which included recovering ER physician Suzanne Dooley-Hash, evaluated a series of 942 adolescents (ages 14-20) who showed up in the emergency room for any reason. They were given a computerized questionnaire, which evaluated (among other things) them for the presence of an eating disorder. The SCOFF questionnaire is below. Marking yes to 2 or more questions was considered positive for an eating disorder.

The researchers also assessed the patients' BMIs, and the presence of tobacco, alcohol, and substance abuse. Interestingly, BMI was associated with the presence of an eating disorder, but maybe not in the way you would expect. The teens with a BMI over 30 were actually most likely to test positive for an eating disorder- they were 3.2 times more likely to show signs of an ED than so-called "normal weight" adolescents.

Overall, the researchers found that 16% of the teens shows signs of an ED, and that nearly 30% of those with ED symptoms were male. Frankly, I think those numbers are a little high, as the SCOFF seems to evaluate a lot for disordered eating as much as a clinical eating disorder but that's outside the scope of this blog post.

But what's the denominator?

This, of course, brings me to the Facebook comment. In full, it read:

In the "International Journal of Eating Disorders" that came in the mail today I read a fascinating study on the prevelance and correlates of eating disorders among emergency department patients ages 14-20.  

They found that in a screening of nearly 1,400 patients that 16% screened positive for an eating disorder. That is much higher than the average of .5-1% for AN, 1-3% for BN, and 3-5% for EDNOS typically reported. In addition they found nearly 27% of those screened were male, much higher than the less than 10% typically reported. 

This supports much of the research we see that ED is on the rise, and that boys and men are just as much at risk.

Sad. We have much work to do.

 Here's the thing: the researchers were screening adolescents who were in the emergency room. This does not mean that that 16% of teens have eating disorders. It means that 16% of patients who were in this particular emergency room answered yes to at least two out of five questions on a survey.

Let me repeat: this study does NOT mean that 16% of teens have an eating disorder. Although the author of this comment didn't directly say this, it was sort of implied in the part where they said that "EDs are on the rise." One would likely expect that teens in the ER would be more likely to have an ED given the high levels of physical and psychiatric co-morbidity that they have. My guess is that people with EDs are much more likely to wind up in the ER than people without EDs. As well, teens are at higher risk for EDs and disordered eating, which further explains the high numbers.

Nor is this evidence that EDs are on the rise. I don't think there have been previous studies looking at the percentage of adolescents presenting to an ER who have ED signs and symptoms, so it's impossible to say whether these numbers are more or less than before. As well, the current research on the number of EDs in the US or elsewhere isn't all that great, so I'm rather cautious about saying whether EDs are on the rise. My bet is that we are certainly more aware of them, and so people might be more inclined to seek care (or be pushed into care, as the matter might be), but again, that doesn't mean that EDs are more common.

When evaluating these statistics, it's important to remember the denominator; that is, the portion of the population that the researchers are surveying. Here, it was adolescents in the ER. I bet you could find 100% prevalence on an inpatient eating disorders unit. We rightly should not be alarmed that so many people have eating disorders if these statistics were surveyed. Well, obviously people being treated for eating disorders almost certainly have an eating disorder.

The study is important in that it shows that ER docs can play an important role in identifying EDs. Most of them have their heads too far up their asses to actually do anything about it, but it is good and useful information. I don't like the SCOFF survey (like, at all), but it is quick and dirty, so I understand why they might have used it. Other than that, I think the study is very useful, but we all need to be careful how we interpret and talk about these results.

As I mentioned in the Lipstick post, I received an email about a study conducted about women and makeup use by the Renfrew Center Foundation.

I emailed the PR rep, Jennifer, with the following:

I have a question for you, Renfrew, and Dr. Ressler: I'm curious why an eating disorder organization is studying makeup use in women. I don't see the connection, nor do I see what going without makeup has to do with eating disorders awareness week.


I have a blog post here: http://ed-bites.blogspot.com/2012/01/lipstick-connection.html


I really am interested in hearing a response from you guys. Thanks so much.

Jennifer's response:

Thank you for your response, Carrie.  Attached please find a copy of the full press release which further explains the survey that we conducted as well as our campaign, Barefaced & Beautiful, Without & Within. 


Barefaced & Beautiful, Without & Within is a call to action - an opportunity for women to join together and go without makeup in order to celebrate their natural beauty and start a healthy dialogue about body image, self-confidence and self-esteem.  


It is our goal that through this campaign, we will get people talking in broader terms. For many, negative feelings about one's self-image can set the stage for destructive behaviors, such as addictions or disordered eating.  It is our hope that Barefaced & Beautiful - a community of supporters sharing natural photos of themselves - will promote a greater understanding of how beauty and confidence come from within.


Upon your review, please do not hesitate to contact me if you have any further questions or if you would like to schedule a time to speak with our expert.

The press release was a Word document, which I've copied here:

So, to some extent, Renfrew isn't trying to deliberately link lipstick and eating disorders. They mentioned disordered eating, not eating disorders, which is very good. But it still rubs me the wrong way for some reason. I guess what I really want to know is why the Renfrew Center is studying makeup use. It just doesn't compute.

Jennifer's email ended with an invitation to speak with Dr. Ressler. I would like to ask her directly the question in the above paragraph. And since I'm going to be sending her the question via email, there's plenty of room to add other questions.


What other questions would you like to ask Dr. Ressler? Feel free to suggest away! I may edit your question slightly for clarity, brevity, or to combine several questions into one. I can't promise that I will submit every question asked, either, but I will do my best to make something comprehensive but not overwhelming.

As I've mentioned before, I get lots of email from PR people. Mostly, they neither bother me nor really attract much of my attention. One from this morning, however, did.

First, the pitch:

Dear Carrie,


It’s no surprise that most women wear makeup, but what drives the desire to wear bright red lips on a trip to the grocery store or a face full of foundation to the gym, beach or pool? And how does wearing makeup influence a woman’s self image? I thought you might be interested in covering this on your blog.


The Renfrew Center Foundation, a non-profit charitable organization dedicated to advancing the education, prevention, research and treatment of eating disorders, recently conducted a survey which revealed that nearly half of all women have negative feelings about their image when not wearing makeup and equate a “bare face” with feeling unattractive and insecure. Additionally, more than a quarter of the women surveyed began wearing makeup before age 13.


We’d love to work with you on a story revealing the results of this survey and are happy to provide nationally renowned body image expert, Adrienne Ressler of The Renfrew Center Foundation, to discuss the findings.


If interested, I’d be happy to send a full press release on The Renfrew Center Foundation’s survey on women’s attitudes towards makeup. The release also provides information regarding The Renfrew Center Foundation’s Barefaced & Beautiful, Without & Within campaign, a national call to action for women to go without makeup on February 27th in conjunction with National Eating Disorders Awareness Week (February 26- March 3).


Let me know if this is of interest.

The only thing I can think is: what the HELL does makeup have to do with eating disorders?!?


I know that body image obsessions are common in EDs, and I know that makeup can be part of that. But I almost never wear makeup, and I still got an eating disorder. So I'm just wondering how going without makeup is related to Eating Disorders Awareness Week. It's kinda maybe tangentially related, maybe, if you lump body image distress in with eating disorders.

But really? Makeup doesn't cause eating disorders.

Last week, the American Medical Association released a policy statement about Photoshopping models and eating disorder prevention.

The statement:

Advertisers commonly alter photographs to enhance the appearance of models' bodies, and such alterations can contribute to unrealistic expectations of appropriate body image – especially among impressionable children and adolescents. A large body of literature links exposure to media-propagated images of unrealistic body image to eating disorders and other child and adolescent health problems.


The AMA adopted new policy to encourage advertising associations to work with public and private sector organizations concerned with child and adolescent health to develop guidelines for advertisements, especially those appearing in teen-oriented publications, that would discourage the altering of photographs in a manner that could promote unrealistic expectations of appropriate body image.


"The appearance of advertisements with extremely altered models can create unrealistic expectations of appropriate body image. In one image, a model's waist was slimmed so severely, her head appeared to be wider than her waist," said Dr. McAneny. "We must stop exposing impressionable children and teenagers to advertisements portraying models with body types only attainable with the help of photo editing software."

And if the AMA had left out the mention of "eating disorders" at the end of the first paragraph, I wouldn't have had anything to say except to nod my head in agreement.  Because the alteration of images is appalling and imappropriate and, indeed, harmful.  The problem is the link to eating disorders.  The AMA said there was a "large body of research" linking media exposure to eating disorders.

So I went looking to see if I could find this large body of research.  I went to PubMed and searched for "eating disorders media" and indeed, I pulled up 264 studies on the subject.  But if you read the studies more closely, you'll see that there's lots of links between "disordered eating" and "eating pathology" and "body image dissatisfaction" and media exposure, but there's very little mention of linkage to outright, diagnosable eating disorders as spelled out by the DSM-IV.  One study did actually say that "media contributes to the development of eating disorders," but when I looked at the studies cited, all I saw were examples that linked media exposure to disordered eating.

A lot of the media coverage of the story has said that Photoshopped images "promote anorexia."  I'm not entirely sure I understand what that means.  I think I know what they're getting at--that looking at these images make you more likely to develop anorexia--but there's no actual evidence that this is true (at least, none that I could find).  We don't think ads for disinfectant somehow promote OCD.  We also don't think that those Bluetooth headsets promote schizophrenia because it looks like you're talking to yourself.

I think the big difference is that people don't think they know what it's like to have schizophrenia because they've been paranoid at one time or another, or that they've had a rather animated conversation with themselves.  But people do think they know what it's like to have an eating disorder because they've dieted and asked their husbands if these jeans make their butts look big. 

It's a common mistake, confusing disordered eating and eating disorders.  Many men and women are unhappy with their bodies and are on a diet.  People with eating disorders also often express extreme body dysmorphia and restrict their food intake.  They do look alike on the outside, but the internal experience is very different.  Dr. Sarah Ravin summarizes the difference between disordered eating and eating disorders as follows:

Disordered eating is very widespread in our country, especially among women. I define disordered eating as a persistent pattern of unhealthy or overly rigid eating behavior – chronic dieting, yo-yo dieting, binge-restrict cycles, eliminating essential nutrients such as fat or carbohydrates, obsession with organic or “healthy” eating – coupled with a preoccupation with food, weight, or body shape.


By this definition, I think well over half of the women in America (and many men as well) are disordered eaters.


The way I see it, disordered eating “comes from the outside” whereas eating disorders “come from the inside.” What I mean is this: environment plays a huge role in the onset of disordered eating, such that the majority of people who live in our disordered culture (where thinness is overvalued, dieting is the norm, portion sizes are huge, etc) will develop some degree of disordered eating, regardless of their underlying biology or psychopathology.


In contrast, the development of an eating disorder is influenced very heavily by genetics, neurobiology, individual personality traits, and co-morbid disorders. Environment clearly plays a role in the development of eating disorders, but environment alone is not sufficient to cause them. The majority of American women will develop disordered eating at some point, but less than 1% will fall into anorexia nervosa and 3% into bulimia nervosa.

I think it's great that the AMA is trying to protect children and adolescents from companies that would turn actual women into bobblehead models (the woman in the Ralph Lauren ad looks a bit like a bobblehead since her head is so disproportionately large compared to her body).  Our ideas of what "normal" and "healthy" look like are disorted and it is harmful.  On that subject, the research is clear.

So this whole life-size Barbie doll created a spark of discussion not just on my blog, but also on the Today show.  Take a look at a clip from this morning's show via Hulu:



Did you notice that one word was absent from this discussion of eating disorders? One aspect of the discussion that is so frequently ignored, here and elsewhere?

Biology.

I'm not trying to ignore culture and the ins and outs of people's lives that can have a significant effect on the development of an eating disorder. I'm not trying to say that an eating disorder is "just" biology, because the idea that anything is either biological or cultural is pretty ludicrous.

But biology is pretty much absent from our discussions about eating disorders in the mass media. Sure, people will mention that genetics influence eating disorders, but the discussion stops there. Of course, biology is being mentioned, which it wasn't just a few short years ago. Still, the notion that eating disorders are rooted in biology and have an actual neurological basis is rarely mentioned in most stories about eating disorders.

So often, media stories file eating disorders under one or two major causes: unrealistic beauty images and control issues. There might be lip service to ideas about neuroscience and genetics and biology, but it doesn't get much discussion. And that bugs me. I don't want a slew of cookie cutter stories on eating disorders, blathering on and on about DNA and nothing else. Eating disorders are very complicated and biology is one aspect of the story.

But it's a big aspect. It explains so much about why people get sick and why they have such a hard time getting better. And we (as a community, as a culture) basically ignore it.

It's something that continues to baffle me.  We talk about biology in lots of other contexts--why are eating disorders so different?  Why are we so resistant to bringing up the biology factor?

Other members of the Academy for Eating Disorders alerted me to this upsetting/appalling/annoying article in Bicycling Magazine.  It's so awful that I'm not going to link to it for any number of reasons: lots of height/weight stats, weight loss stats, and I also don't want to give the article any more traffic than it's already getting.

Earlier this week, Pepsico announced a makeover for its Diet Pepsi.  The problem wasn't the taste of the soda, or the colors of the can.  No, the problem was the shape of the can.  Now, instead of being short and squat just like all of the other soda cans, Diet Pepsi is going to be tall and sleek and skinny.  And, so the ad campaign would like us to think, we can be too if only we chug cans of Diet Pepsi.

I find the whole thing offensive and annoying.  Yes, yes, I know the big wigs on Madison Avenue would like us all to think that thin is better, but um, can you guys be a little more creative with your message?

Not surprisingly, eating disorder groups have been up in arms about the can and the message that it sends.  In one article, a NEDA spokesperson said that the ad campaign was "thoughtless and irresponsible."  In a more in-depth interview with the Wall Street Journal, NEDA CEO Lynn Grefe said:

“I could care less about the shape of the can,” Lynn Grefe, head of NEDA, tells the Health Blog. “They could make it doughnut-shaped for all I care.”


It’s the Diet Pepsi media campaign that’s the problem, she says. The campaign celebrates being skinny and suggests that strong, confident women must be so. That the Skinny Can campaign is being paired with Fashion Week, an event put on by an industry that has had to address eating disorders among its model ranks, is particularly problematic, says Grefe.


This campaign won’t cause anyone to develop an eating disorder, but could trigger someone who is already vulnerable to negative body-image issues to start dieting or become more extreme in their dieting, which could eventually lead to disordered eating, says Grefe.


...And recent evidence shows that hospitalizations for eating disorders are on the rise, calling attention to the messages that are being perpetuated about thinness and dieting. “It is exactly that kind of thinking that has truly caused the increase in people feeling bad about themselves,” says Grefe.

But there's quite a leap in logic there.  No one's quite sure what is causing the increase in eating disorder hospitalizations.  It's likely that EDs are on the rise in younger adolescents, yes.  At the same time, most young people feel bad about themselves in some respect or another.  Yet very few develop eating disorders.

All of Grefe's statements were technically correct.  Yet I'm not convinced of the direct link between skinny can --> body image issues --> eating disorder.  I had body image issues my whole life, yet I only developed anorexia after I was depressed and thought that eating better and exercising more would make me feel better. Okay, yes, I wanted to lose 5 pounds, but that wasn't the real motivator.  Nor do I know that my body image issues wouldn't have been there in a non-diet-oriented culture.  More and more studies are linking body image disorders with deficits in neurological functioning.

These efforts sound good on paper, and I don't think protesting the skinny can is bad in and of itself.  Like I said, it's rather obnoxious.  Frankly, if I'm going to buy one of your products, I'd like to be respected a bit lot more.  I'm just not sure about the fact that so many people take for granted that there must be a connection between skinny things (jeans, cans, models) and eating disorders.  I do think that these messages are definitely a part of the cultural milieu in which eating disorders exist.  But eating disorders have existed long before the advent of Size Zero supermodels and (apparently) Size Zero diet soda cans.  I'm guessing that if all of this skinny model nonsense went away, another cultural issue would fill the void and be used as a scapegoat for eating disorders.

This "prevention" work sounds good. It's hard to oppose it and not sound like some sort of misogynistic skeleton-lover. It's not that I like these images, approve of them, or even think they're healthy. They're not. I'm just wishing more people would question the connection between these messed-up ads and their impact on eating disorders.

In the end, Laura said it best:

Somewhere in here, in the headlong and well-intentioned efforts, is also a confusion of ideas: disordered eating and eating disorder; and body image distress and Body Dysmorphic Disorder. There is an assumption that preventing body image distress will prevent BDD, and that preventing disordered eating will prevent eating disorders. That assumption needs to be questioned as well: do we really know that these are true? If so, how strong is the effect? One kid in 20? One in 1,000? One in 100,000? Not that one in a million isn't a good thing, but is that where our efforts should go? Or is preventing eating disorders the only reason for these efforts?

Model and actress Isabelle Caro, most famous for posing her emaciated body in a 2008 anti-anorexia billboard, died at age 28.

Her goal, says the Los Angeles Times obituary, was to show others the dangers and horrors of anorexia in order to prevent the illness.  A noble and honorable goal, to be sure--but Caro knew and lived these dangers and horrors of anorexia, day in and day out.  Still she could not shake her illness and instead died at age 28.

The billboard that flung Caro into the limelight was produced by fashion company Nolita, in an effort to raise awareness about anorexia in the fashion industry.  Aside from the fact that I'm not convinced of the relationship between anorexia and fashion, Nolita was happy to use Caro's wasted body in their ads.  They were happy to use the shock value and run with it.  Yes, the company likely meant well by it, but what was that phrase about the road to hell being paved with good intentions?

After the April 2008 billboard, Caro went on to be a guest judge on "Top Model France," to write a book and song lyrics, to appear in television and film.  All while deathly ill with anorexia.

When I heard of Caro's untimely death, all I could think was: these people were using this poor girl.  They knew she was sick.  It was obvious just by looking at her.  They knew she was dying from a lethal illness and yet the chose to look the other way.  Maybe they figured that as long as Caro thought she was fine, then she had to be fine.  She was "trying" to get better, but your heart, your liver, your immune system don't much give a damn about trying.

It was like what I used to tell people: I'm working on it.  Which is all well and good, but Caro's and my lack of progress should have made it damn clear to anyone not blind that no progress was actually being made.

Yeah, I'm angry.  Media outlets and corporations were all too happy to let Caro continue on her merry way and not actually address her illness.  I'm guessing some of them told her she should gain weight and eat some more.  Gee, you don't say.  Caro had probably never heard that advice before, right?  If they cared, they should have refused to cast her until she was healthy.  It's hard enough to give up an eating disorder even when it's robbing you of everything in your life.  But when you can have the life you want and the eating disorder? 

The immediate cause of her death wasn't disclosed.  But the media industry--the very ones Caro turned to in her efforts to warn others of the dangers of anorexia--did quite a bit to contribute to her death.  She very well might have died if she didn't become famous.  Yet the people who knew and worked with her had an opportunity to close down any path but wellness and recovery.  And they didn't.

That's what makes me the most angry and the most sad.  That so many people are willing to ignore such a blatant disorder and look the other way.

As much as I love keeping up to date on ED news and research, I sometimes cringe when I click on a link.  Is the author of this news story going to screw it up?  Will they have done their homework?  Much of the time, the stories are a mixed bag--some bits are okay, some could use a bit of tweaking.

Every once in a while, though, someone knocks it out of the park.  With these two stories, though, the authors didn't do so in a good way.  It was awful.  I don't know whether I blame the journalist more, or I blame the people they interviewed.  Or both.

So for the first one:

Is Victoria's Secret Peddling Eating Disorder Porn?

No, Victoria's Secret is peddling overpriced unmentionables.  They're also peddling sex and clothes that make your partner want to do you.  They're peddling an image.  They're peddling an image of a sexualized, idealized women with huge boobs and a tiny waist.

It's very common for people with eating disorders to compare themselves to these idealized images and find themselves wanting.  It's also very common to try and lose a few pounds or get breast implants.  All of which are a waste of time and money and form a tremendous drain on society.  But really?

Eating disorders existed long before women with gigantic breasts and push-up bras paraded around on national television. In the Middle Ages, women with eating disorders compared themselves to holy women and other saints.  Those were the idealized images of what a woman could be, if she tried hard enough.  Part of that trying involved fasting for religious purposes. 

Today, some people with eating disorders fast for cosmetic purposes, or to be better at a sport or it just sort of happens.  It could very well be that women in the Middle Ages had a variety of reasons that motivated their behaviors.  They probably did.  The world may very well be a better place if Victoria's Secret disappeared. It would definitely be a better place if we stopped promoting only one body type as beautiful or sexy.  But whether there would be fewer eating disorders?  I'm not entirely convinced. 

These images, and our society's obsession with food and fat, are the cultural backdrop against which eating disorders occur.  We use and co-opt this language to help explain what we're going through.  Although exactly what motivates an eating disorder is far from irrelevant, motivation doesn't always explain causation.

Which brings me to the second article.

Butler Hospital Physician Too Familiar With Eating Disorders

Based on this doctor's quotes, however, I might advise a little more familiarity before saying such things as this:

Qualls said the disease usually arises from a person’s unhappiness with their appearance.

The media play a role in the equation, he said, providing a model of the body that may not be realistic or healthful for people to strive to imitate.

...Diseases such as compulsive purging or not eating tend to occur during transitions in life, he said. Among them: girls going from eighth grade to high school, “which is a triggering event because all of the sudden boys become more important,” he said. “The next change is when they go into college. Once they experience [a disorder], they are at risk of this recurring at any point for the rest of their lives.”

*headdesk*

In case this isn't obvious by now: my eating disorder had nothing--nothing--to do with wanting to look good or attract men.  Nothing.  I thought that eating better, exercising more, and yes, maybe losing 5 pounds would help me feel less depressed.  After a while, I knew I looked atrocious.  I thought nothing about sex and dating.  I knew that the ED was destroying my health and appearance, and yet I couldn't stop.

The concept of "re-education" sounds very Soviet, and maybe it is, but I kind of want to have an intensive training program for these journalists and especially these doctors before they are allowed to even see another ED patient.

I have to confess: I have a soft spot in my heart for the Discovery Channel show MythBusters. It's a great show to teach the otherwise uninterested about how to conduct a solid experiment, and there's lots of pyrotechnics--what's not to love? Besides that, the ever-nerdy biologist in me loves to poke holes in commonly held theories and ideas, whether historical, sociological, or scientific.

Which is why I loved this article from (of all places) Discovery News: New TV Show Perpetuates Anorexia Myths. The new TV show, hosted by Jessica Simpson, is called "The Price of Beauty" and will air on VH1. Simpson says this about the show:

“I have always believed that beauty comes from within and confidence will always make a woman beautiful, but I know how much pressure some women put on themselves to look perfect. I am really looking forward to discovering how beauty is perceived in different cultures and participating in some of the crazy things people do to feel beautiful. I know we will all learn a lot on this journey and I am so excited that VH1 is coming along on what I’m sure will be a wild ride.”

Which is all well and good- I have no problem with a show looking at different cultural ideals of beauty, and how it varies from place to place. I think it could be both entertaining and eye-opening.

So what does this have to do with anorexia?

In one of the first episodes, Simpson interviews anorexia sufferer Isabelle Caro, whose appearance in an anti-anorexia billboard caused quite an uproar several years ago. And since Discovery News writer Benjamin Radford did such a good smack-down of the issues, I'll let him speak:

What Isabelle Caro, Jessica Simpson, and the VH1 show don’t realize is that anorexia has little or nothing to do with fashion modeling. Eating disorders such as anorexia nervosa and bulimia are biological diseases, not voluntary behaviors. The idea that a model, photo of a model, or Web site can "encourage" anorexia is not supported by science or research. Images of thin people cannot "encourage" anorexia, any more than photographs of bipolar patients "encourage" bipolar disorder, or photos of diabetics "encourage" diabetes.

Though many people are convinced that anorexia is a threat to most young women because of the media images they see, that’s not what the scientific evidence says. Anorexia is a very rare and complex psychological disorder with many indications of a strong genetic component; as anorexia expert Cynthia Bulik noted in her 2007 study “The Genetics of Anorexia,” published in the Annual Review of Nutrition, “Family studies have consistently demonstrated that anorexia nervosa runs in families.” Most research studies have failed to find a cause-and-effect link between media images of thin people and eating disorders.

...Nearly every woman in America regularly sees thin women in everyday life and the media, yet according to the National Institute of Mental Health, only about one percent of them develop the disease. If there a strong link existed between media exposure and anorexia, we would expect to see an incidence many orders of magnitude higher than is found.

Anorexia is a tragic disease; some young women (and men) do diet to excess and have body image issues. But the scientific research shows that they are the exception, not the rule. The first step in solving a problem is correctly understanding it, and TV shows like “The Price of Beauty” may actually end up doing more harm than good.

Since research suggests that the causes of anorexia have more to do with genetics than thin fashion models, efforts to educate young girls about the artificiality of airbrushed media images won’t do anything to treat or cure anorexia. Girls and young women deserve facts and truth instead of myths and misinformation.

(emphasis mine)

Can I hear a "Hallelujah, amen!"?

If anorexia is seen as a cultural illness by a bunch of diet-crazed beauty freaks, no wonder the allocation for research dollars is minimal, that insurance companies can put up such resistance to covering eating disorder treatment*, that I have been told by so many people to snap out of it and get over it. Yes, I have been exposed to the thin body ideals. Yes, I have probably internalized some of that. No, that has nothing to do with my anorexia.

I wasn't trying to be thin to look like some sort of magazine model; I was terrified of eating and gaining weight. I was aware that anorexia made me look pretty atrocious--I couldn't sense that I had lost weight as my illness progressed, but I could see the gray-yellow skin, the blue nails and lips, the brittle, thinning hair. The culture of thin provides a vocabulary for many sufferers, and it helped me explain to myself and others why I didn't want to eat or tried to avoid eating. I did believe my own bullshit, to some degree. One of the key aspects of anorexia is the inability to understand just how sick you are. So, yeah, telling yourself and your parents and your friends and anyone who cares to listen that your starvation is just an attempt to lose a few pounds and/or just another diet is an easily available defense. It makes sense to you and it helps get those around you to stop breathing down your bony neck.

Anorexia existed before the advent of supermodels, and I have a feeling it will exist after. In the meantime, I'm sending a huge thank you to Benjamin Radford for speaking out on this issue. You can post your own comments at the bottom of the article, so send him some ED Bites lovin'.

*There are other reasons insurance companies can do this, too, not the least of which is the lobbying power fueled by astronomical profits and the fact that it's cheaper to let sufferers die than pay for treatment. But I digress...

Several weeks ago, there was a massive to-do over a horrifically Photoshopped image of a Ralph Lauren model. Boing Boing said it best: "Dude, her head is bigger than her pelvis!" And in the image, indeed it was. Ralph Lauren later fired the model, Filippa Hamilton, for being too fat, even though she's a size 4. Last week, documentary filmmaker Darryl Roberts (he directed the movie "America the Beautiful") was supposed to have appeared on Larry King Live until the people at Ralph Lauren allegedly had the segment pulled. Now, the America the Beautiful Action Group has created a Facebook page encouraging people to boycott Ralph Lauren.

I have not joined this Facebook group for a variety of reasons, one being the fact that I never bought any of his stuff anyway, so my boycott of the company would have precisely zero effect on their bottom line. The other major reason is that I really, really, truly dislike how negative ads like Ralph Lauren's are conflated with causing eating disorders.

In an open letter to Ralph Lauren, Roberts writes that:

I’ve had the pleasure of meeting tens of thousands of young girls while promoting my documentary “America the Beautiful.” To look in the eyes of over 100,000 college women and hear their pain (body image, self-esteem) has been an experience that I will never forget. I’ve also heard from over 80,000 parents that are in pain because they have to hear from their sons and daughters in pain. It does truly become a generational cycle.

I’m sure that you’re fully aware that a lot of the American population feels that the unhealthy ads in magazines are damaging to women. The damage comes in various forms; body image problems, low self-esteem and for some of the women, they get a full blown eating disorder like your niece Jenny.

{snip}

Believe it or not, [adults and parents] get hurt as much as the young girls that read the magazines and look at the ads. “How? You wonder.” When a young girl reads these ridiculous fashion magazines and gets triggered into a full blown eating disorder, who do you think gets left holding the bag for the $30,000 a month treatment? I’ve met parents that have had their entire savings wiped out and some have taken out second mortgages on their homes to pay for the treatment of their young daughters.

Although Roberts says that he was told by an ED expert that 50-80% of the risk for developing an eating disorder is genetic, the message here is clear.

I'm all in favor of supporting a boycott for Ralph Lauren because he's engaging in false advertising (which is what I think the dramatically altered images really are), for being denigrating towards women, or for just being a douchebag. All of these are quite possibly true.

All of these have NOTHING to do with eating disorders.

Yes, our thin-is-in culture plays a role in triggering eating disorders, but the holy-is-in culture played a role in triggering eating disorders during the Middle Ages. I'm not saying that we should support or participate in this culture (it's damaging even if you exclude any triggered eating disorders), but we can also oppose it for reasons that have nothing to do with EDs.

Writes Sue Sierralupe of the Oregon Natural Health Examiner:

The National Organization for Women (NOW) is one of the many organization demanding a change in advertising policies that encourage eating disorders. NOW has prioritized encouraging women's self esteem with Body awareness education, "Love your Body Day" and a posting of ads offensive to women and ads that are supportive of women. NOW has asked Ralph Lauren to apologize encouraging unrealistic body images that lead to eating disorders.

...Most cases of anorexia and bulimia are symptoms of unhealthy self esteem. According to the Women's Center for Healthy Living (WCHL), "Anorexia and bulimia are characterized in part by a refusal to eat and repeated attempts at dieting. Even if individuals suffering from anorexia or bulimia are a normal weight, their body images are distorted, causing them to continually attempt weight loss. The thought process of those suffering from anorexia or bulimia is that if they only weighed a certain number, life would be "good" and they would feel good about themselves. The truth is that weight cannot and does not determine your self-esteem or self-worth."

Which is pretty much bass-ackwards. I don't oppose NOW for trying to promote women's health by ads that aren't sexist and offensive. I rather think that's a good idea. But EDs aren't just a feminist "up yours" to the patriarchy done in a nice feminine way. They're an illness.

Many people with EDs have a history of low self-esteem because they also suffered from perfectionism, and nothing saps your self-esteem like the feeling that you are never good "enough." Yet the one thing that absolutely wrecked my self-esteem was my eating disorder. The truly pitiful self-esteem happened after; it wasn't great before, but it wasn't literally and metaphorically in the toilet, either. EDs aren't about the vapid pursuit of an ever-decreasing weight. They're about scrambled neurotransmitters, about how ED symptoms can help mediate feelings of anxiety and depression, they're about genetics, and a vicious cycle that doesn't seem to stop. Furthermore, the symptoms of body dysmorophia and "feeling fat" are a relatively recent phenomenon- they weren't consistently present before the 1800s, and didn't comprise a majority of AN cases until into the 1900s.

Ultimately, Sarah Ravin said it best: this focus on EDs as just really extreme body image dissatisfaction "trivializes the anguish that eating disordered people experience."

I got invited to join a Facebook group of this name late last night, and I spent part of the day contemplating my response. I hesitated in writing for several reasons, not the least of which were that I don't have time right now to be responding to a lot of potentially irritated people, and also because I wanted to frame my thoughts properly. After a while, I figured what the hell- I'll bite. I decided to blog my thoughts here and post a link to the group so I didn't have to check two places for comments.

I searched through my blog archives and was astonished to discover that I had never answered this question head-on, in its own post. So, here it is.

To me, the question of "Does media play a role in eating disorders?" is usually asked in a sense of "Does media play a role in causing eating disorders?" And that answer, I would have to say, is pretty minimal. Media provides lots of context, and more than enough triggers, but to say that people with eating disorders are "dying to be thin" minimizes the seriousness of the illness and does everyone a disservice.

I was flipping through a copy of The Handbook of Treatment for Eating Disorders and I stumbled across an article that looked at the Three Ps of eating disorder onset: Predisposing factors (ie, genetics and other neurobiological factors), Precipitating factors (ie, culture, dieting, "healthy eating," etc), and Perpetuating factors (ie, what keeps the illness going). The role of the media certainly fits in the category of "precipitating factors," but although these factors are important, they seem more incidental than causative. Predisposing factors are largely homogeneous; precipitating factors can vary widely.

Finding yourself afraid to eat is a rather bizarre phenomenon. Our brains need to explain it somehow--so we turn to the vocabulary we know. I did blog about this almost two years ago now, rather briefly, and I think I shall plagiarize myself a bit:

Could eating disorders be women and men trying to be perfect? To live up to society's expectations? To look like models? I doubt it. That's part of it. It's the cultural context of the illness. In the Middle Ages, women (most of the recorded cases were in females) who starved themselves were considered saints. They fasted to get closer to God. Some, like Catherine of Siena, got hooked. It felt good. Her explanation was of faith. Ask a sufferer today, and a lot of it seems to be 'healthy eating' and images of supermodels and the idea that you can Have It All. It's no more a reason than faith. But it is a context. It does explain the triggers, the psychological environment from which an eating disorder develops.

One of my OCD fears was that I was going to catch AIDS from someone, or that I already had AIDS and was going to give it to someone else. Regardless, it was OCD. But if I was about 15 years older (the OCD AIDS stuff started in about 1993-1994, when I was 13-14), AIDS wouldn't have been on the radar. It might have been another disease. It might have been something else entirely. A person with schizophrenia would not have feared the CIA listening in on phone calls 100 years ago. First off, they probably wouldn't have had a phone, nor would there have been wire taps, and lastly- there was no CIA. Diseases have a context. But that doesn't mean that AIDS fear mongering caused my OCD, nor that the CIA causes schizophrenia.

Or, for that matter, that the media caused my eating disorder.

Much of the debate about media and eating disorders boils down to this: do eating disorders exist along a continuum with more normalized eating (that is, are eating disorders an extreme version of a diet and common body image issues?), or are eating disorders a separate entity. The answers aren't all in, and I won't pretend to understand all the answers that we do have (but I'll pretend enough to do a more in-depth blog tomorrow- stay tuned!), but I believe that eating disorders are a distinct entity separate but similar to our obsession with dieting and thinness.

Let's compare eating disorders to depression. Saying eating disorders are just a really whacked out diet is like saying depression is just a really bad mood. Most people with depression are in a really bad mood--that's kind of the definition of depression, really. And many people with eating disorders appear to be dieting and have body image distortion. But depression isn't a really bad mood that won't go away. When the weather sucks or the store is out of eggs or the car won't start, people will often say, "Ugh- I'm so depressed!" Not really. You're pissed off, sad, annoyed, whatever, but that's not depression. Both eating disorders and depression frequently pass through stages of seeming like just another diet or a really bad mood that lasts for-freaking-ever, but they then take on a life of their own. They stop becoming a choice and become an illness.

I thought for a long time that the thinness ideal had a lot to do with eating disorders, and I've since changed my mind, especially in light of the emerging research that suggests that up to 82% of eating disorder risk is genetic.* Eating disorders existed long before supermodels and they'll probably exist long after. And I think we are missing so many opportunities for prevention and education by focusing on the media aspect and leaving so many other areas out in the cold.

*A, this wasn't the study that I was referring to in a previous post (the study is too new), but it does confirm the numbers in the talk that I scribbled down.

Most news stories on eating disorders fail to make the distinction between what causes an eating disorder and what triggers the disorder. They're two very different things. According to the latest research and thinking, eating disorders are caused by alterations in brain chemistry that register anxiety and mood, hunger and fullness. That, right there, is pretty much the root cause, though I could potentially be burned at the stake as a heretic for saying so.

I'm not a freaky reductionist, though. Environment is important, as environment triggers and maintains the disorder. Environment starts during fetal development and never stops. Your environment could be your season of birth, the magazines you read, the TV shows you watched, the food you ate, the friends you had. Although fully separating genetics and environment is impossible, I am willing to say that the cause of an eating disorder isn't the same as the trigger.

Which is why I read this article with more than a little dismay: 'Crisis In Masculinity' Leads To Eating Disorders In Straight Men

I understand that men have far different experiences of eating disorders than women, and that these stories are worth paying attention to. We can (and should!) learn from them. Although a man's experience of an eating disorder is going to be different, the illness is the same. Same cause, but there could be different triggers.

A eating disorder isn't about a crisis of masculinity or femininity. It's a disorder that started with malnutrition and snowballed out of control. It's not a choice, it's not a way to resolve problems or existential issues. The article says the following:

Images of skeletal models or men with 'six-packs', plus a plethora of choices now open to men, is at the root of body dissatisfaction, Dr [John] Morgan said.

"To be a young man is our society is a difficult thing. What you do and who you are is less straightforward. Women were challenged decades ago to consider which of the many different social roles they adopted. Now men are having to respond to the choices that society gives them.

"Suddenly younger straight men have similar pressures to gay men and women. There is a crisis of masculinity in our society. They are given all these roles and to simply decide to manipulate your body is a nice easy solution to all the complexities of life."

What part of an eating disorder is a "simple decision"? Perhaps the initial weight loss, but the actual disorder is far more complex and this kind of thinking does sufferers a great disservice. Body image woes can certainly trigger an eating disorder, and there is some evidence to suggest that people with eating disorders perceive their own bodies differently than they perceive other people's bodies. And being a young person is almost always a difficult task, and societal pressures don't help, but they don't ultimately cause an eating disorder in women or in men.

Laura pointed out this little, um, gem of an article to everyone.

Business Week Debate Room- Anorexia: A Media-borne Illness?

One person said yes, one person said no. The sheer lack of understanding of each respondant was remarkable. And I don't know that either had a shred of background in psychology, neuroscience, or eating disorders.

Said the person who disagreed that anorexia was a media-borne illness:

Enough of this nonsensical blame game. It’s time to let personal responsibility back into the picture.

And those people with cystic fibrosis just need to take personal responsibility for their lung functioning. And people with diabetes just let their pancreas get out of control. Don't even start for the people with Down's Syndrome. They just haven't taken responsibility for their extra chromosome 21.

Ugh.

There have been many good (and horrific) responses to this post, including one from me, but the best is from Julie O'Toole from the Kartini Clinic.

The first medical text description of anorexia nervosa was in 1689 by Richard Morton, and it--like other human illnesses--existed before it was officially described.

Rather than worry about the effects of the media's absurd and constant portrayal of thin body size on the 1% of women (and perhaps about 0.1% men) who have anorexia nervosa. Let's worry about the effects of it on everyone else, especially children and adolescents who are just now forming their own self-image.

The current obsession with "thin" has done nothing to reduce obesity, but it has made scores of people feel bad about their own inability to attain these unrealistic (and often completely unhealthy) weights.

Why are we so concerned about what everyone looks like and so unconcerned about what everyone acts like?

Raising a toast (of milkshakes!) to some good common sense. Rock on, Dr. O'Toole.

I've seen a few items in the past day or two that made me realize just how foreign the idea of "dieting is dangerous" really is.

Now, I love the Brits. I seriously do. The concept of putting milk in your tea makes a good thing even better. However, the BBC is currently doing a documentary about how hard it is to be a size zero (UK size 4). Which, okay, fine- most young girls (hell, women of every age) probably don't realize exactly how unrealistic it is. There's an intellectual understanding that models are much thinner than we are, to the point that women outwardly scoff at the anorexic-looking models on catwalks and on the covers of magazines.

Yet we still try. Though many people lament their heights -- personally, an extra half an inch would make pants shopping much easier -- they don't lop off a foot or walk on stilts to change it. Why? Because height is determined by genetics. So is weight, but we'll get there in a bit.

What this BBC documentary did is take an ordinary woman and put her on a diet that would make a starvation diet look like a feast. She took substances to "clean out her bowels." Then, she exercised with a personal trainer. And so on.

Here's the kicker, though: after about 2 weeks of this, she ate a little more than she was 'supposed' to. Then, she felt guilty. Then, she purged. A week or two later? She binged and purged again.

Luckily someone stepped in and said, "No more. You're done."

On the other hand, why did we have to do this "experiment" in the first place? Why should I feel grateful that it stopped when it never should have started to begin with?

Lots of people in Hollywood struggle with drug addictions, yet there are no documentaries and realities shows spelling out how to become an addict. No young person was given a bong and a crack pipe along with supplies and told: have fun! We'll see you in a month. But rehab is on your own.

We know that drugs are addictive and dangerous. However unrealistic it might be to give birth and be out partying a week later, we don't take a new mother and send her packing. Drugs change your brain chemistry. That's why they're addicting.

But dieting changes brain chemistry, too. Though I don't consider an eating disorder an addiction per se, there are too many similarities to be ignored. Enough of the neurochemical changes are the same that I think drugs and dieting operate in the same fashion. Recent research has found the brain changes in a person with anorexia to be the same as when a person uses Ecstasy.

This woman's brain changed, too, when she was starved. Binge eating is an essentially universal response to deprivation. And the cycle of binge eating and purging is ruthlessly addictive. When this young woman interviewed other celebrities and TV hosts, she found that she was not alone. Starvation diets were the norm.

You don't need to become a crack addict to better understand cocaine addiction. And you don't need to starve yourself to understand the Size Zero phenomenon OR eating disorders. We're much more highly evolved than that, and besides: dieting is dangerous.

----------------
Please note: I deliberately did not include the names of the newspaper articles or the documentary because I thought they were exploitative, triggering, and vile. So you're on your own for that one.

I was watching the evening news last night as I finished up one of my beading projects, and I heard a little promo for a story after the next commercials. It was something along the lines of "Scientists have found a new way to control our weight and make us look slimmer and younger." All of those phrases were in there, though I can't guarantee in what order.


The first thing that pissed me off: the headless pictures of 'obese' people lumbering around and eating french fries. They're people. They're not button-down shirts straining at the belly. They're not jiggling asses. People. You don't show thin people in this way. Thin people eat fries. Shirts can get too small on thin people (just let me do your wash and you'll see what I mean). Just another stereotype.


The second thing that pissed me off: the hype. As if we should be so excited that we can now conquer obesity like a platoon of armored knights charging the castle of obesity. Let 'em have it, boys! But dude- it's an empty castle. Conquering it will just cost money with no net gain at the end of the day. Is it just me, or does that sound like the war in Iraq? But I digress...


The third thing that pissed me off: since when is weight something that we should control? Wow, let's control our breathing. The amount of urine we pass each day. How many times we blink. Or swallow.


That's the assumption above all assumptions that gets to me: not only is weight something that can be controlled, but that should be controlled.


I hate to break it to you, but your weight is controlled by your DNA.


The gist of the story was this: back in the 1970s, before the advent of antibiotic treatment for ulcers and the development of effective acid-blocking drugs, doctors performed a vagotomy, in which they snipped the vagus nerve connection to the stomach to stop acid production. One of the side effects was weight loss. Now, with gastric bypass surgeries at over 175,000 per year, doctors are on the lookout for 'safer' means to help people lose weight. Enter the vagotomy. Again.


"Obese" volunteers for this surgery were not hard to come by- the fears of fatness and health effects of obesity in the medical community and the media, overblown when not outright false, has people lining up to lose weight and "get healthy." And so went the first round of surgeries. People did lose weight. Not as much as with gastric bypass, but they lost weight. Success!


I'm hearing that ca-ching sound right now.


One of the doctors of the pilot study said:

"But I think this will be a rational alternative for a cadre of patients that are sort of in the middle there. With as much obesity as we have in this country, that's a big middle."

You don't say. Or is it a large group of people who are being told to be afraid- very afraid- for weighing more than a little chart says they should and they're all going to wallow in their own fat and die. Only it's not true. But people believe it is and are willing to let someone snip away a nerve for false security and the hopes to prevent any range of health effects that "overweight" will bring.


I think the word predator comes to mind.