Dying to be Thin by Maia J. Lagerstedt, Fairfield County Weekly, Jan 17-23, 2001
The time for making New Year's resolutions has come and gone. And for the second year in a row, I have not set myself up on a strict diet to lose 20 pounds. Last year, in an act I can only label as rebellious, I blew it off entirely. This year, I resolved to be healthy. Whether or not those 20 pounds get whittled away remains to be seen.
I also stopped buying women's magazines some years ago. I got tired of being inundated with images of women with "ideal" bodies, with new dieting strategies, with tips on how to dress "10 pounds slimmer." But everywhere I look, it seems, I'm confronted by the slender, beautiful ideal I'm supposed to aspire to. And it's not just me. Most of us fall into it at some point or another, that struggle to be thin. Virtually every woman I know is concerned with her weight. My friends talk about it. My friends' 10-year-old daughters talk about it. Already they're being herded into the same trap: thin=beautiful=happy.
Occasionally, the media take a look at the negative effect our obsession with thinness has on young girls, even girls in their teens and into their 20s. We've read enough of those women's magazines to be familiar with terms like "anorexia" and "bulimia," and we kind of know what they mean. We've heard horror stories about people with bulimia nervosa who go on eating binges and later force themselves to throw up what they've eaten. A good majority of people with bulimia are able to hide it from their friends and families because they maintain a normal body weight. In fact, many sufferers tend to be slightly overweight as the process of purging themselves is an ineffective way to "undo" the effects of the binge. If a person's idea of a binge is what most of us would consider a normal meal -- or less than a normal meal -- then the binge-and-purge cycle may cause them to drop dangerously below their normal body weight into a state of emaciation. Still others -- people with anorexia nervosa -- literally starve themselves by drastically reducing their food intake. In a society where weight and body image gets so much attention, we all know someone who is now or has been on a diet. But we may not know someone who is afflicted with an eating disorder. And if we do, we certainly don't expect it to be anyone who falls outside the common demographic. We don't expect it to be someone who is older or someone who is male.
My mother was 56 when she was diagnosed with anorexia nervosa. Until I saw her dramatic weight-loss it never occurred to me that a woman in her mid-50s could develop an eating disorder. Certainly not my mom, who when I was growing up made some of the tastiest, most decadent food this side of the Mason-Dixon line -- homemade deep-fried doughnuts, fried chicken and the best potato salad you ever tasted in your life. And yet, after months of barely eating she had become dangerously underweight. As bad as I wanted to understand what was happening, I couldn't. When did this happen?
According to Dr. Doug Bunnell of the
Frank Sammet, who works at the University of Iowa Hospitals and Clinics with renowned eating disorder specialist Dr. Arnold Anderson, made a similar case. "More often than not," he said, "people start out thinking they're doing something good for themselves. It just gets misdirected."
That's exactly what happened with my mother. After my dad suffered a heart attack in October of 1998, and was subsequently diagnosed with diabetes, my parents were forced to take a look at their diets and make some changes. Those changes were supposed to be healthy and positive ones: eating right, exercising and losing weight. My father seemed to approach the idea with a healthy, if somewhat begrudging, attitude. For my mother, the pressure of planning and preparing foods that fell within the confines of a healthy and somewhat restrictive diet let loose an emotional floodgate.
"I just remember opening the refrigerator door one day," she told me recently, "and I couldn't figure out what I could make that [your dad] could eat, between his heart and the diabetes." Meal preparation had become a nightmare. Food was no longer something that could be enjoyed; it had become the enemy. After all, look what it had done to my father. Overwhelmed with frustration, she burst into tears, grabbed the garbage can and started indiscriminantly throwing away food: bread, milk, meat, ketchup, relish, mayonnaise -- everything.
"I don't know what I was thinking...It was perfectly good food," she said in the way she always says things that are difficult, adding a slight touch of humor. She paused for a second. After nearly two years in therapy, she knows that she covers up her feelings with a joke, and I saw the recognition of that fact cloud her expression. "No," she said slowly, "I do know what I was thinking. I was thinking that food can kill you." After that incident, she stopped eating.
Eileen Binkley is 55. She is a retired teacher and school librarian. I could almost hear that in her voice over the telephone, even before she told me. She is warm and well-spoken. She is also a recovering anorexia nervosa patient with a story that is strikingly similar to that of my mother. They both took unresolved issues from childhood into their adult lives, and at a certain point those issues came bubbling to the surface and manifested themselves in eating disorders.
Binkley was always concerned with her weight. It was part of her need to be good, to be perfect. From the time she was in her early teens, dieting was a normal way of life. She was never overweight, really. "There were times when I was heavier, and then times when I was thinner," she said. But if you passed her in the school cafeteria or in the hallway, you wouldn't have walked by with the impression that she should lose some weight.
Then about 10 years ago, her life took a turn toward the tumultous. "It was a lot of things," she confided. Her voice trailed off a little as she tried to find the right words to put a lifetime of issues into a few short sentences. She had been raised to place higher importance on what other people wanted from her than on what she wanted for herself, to believe that being "good" meant sacrificing her wants and needs for the wants and needs of others, she explained. Also during that time, Binkley began experiencing excessive indigestion after eating certain foods. At the suggestion of a friend, she went to see an allergist who found that she was allergic to several foods and prescribed a strict diet.
"I really think that became sort of the cap to the whole thing," she said, "because fairly rapidly, I [lost] some weight...I was eating some good foods, but I found I was actually able, will-power wise, to cut out all these foods I was used to eating. I thought, 'I don't need all this food...look what I can do.' It was very empowering. It was something that I felt I was missing most of my life, the empowering bit, so I really think that that was the beginning of the end for me." After nearly four years of therapy, Binkley said that this was a connection she made only recently.
My mother, who still struggles with anorexia, also indicated that not eating gave her a feeling of empowerment. "This was something that I could control," she told me this past October.
After two years of struggling -- my struggling -- with her illness, I decided it was time we talk about it. Really talk about it. We met for lunch in Brattleboro, Vt. Lunch, I realized, had been my idea, and on the drive up, I was struck by the irony of talking about her problems with food over a meal. It had been one thing to wrestle with my mother's illness, it was quite another to begin to realize what it all meant, and I started to cry. All I wanted to do was turn the car around and go home. I wanted everything to be the way it used to be. I didn't want her to be sick. But there we were, sitting in a quaint little restaurant, having our lunch, making small talk and occasional jokes about food. Eventually, we got around to really talking. I'll never forget the pit that formed in my stomach, though, when she said those words: "This was something that I could control." There was such conviction and determination in her voice. My shock must have shown on my face, because she quickly tried to take the edge off the chilling earnestness of her statement by again trying to add a little humor. "Well, at least I'm not bulimic." We both laughed nervously. The restaurant, which had been nearly empty when we were seated, had begun to fill up. "Maybe we shouldn't talk about this here," she said. "I don't want to spoil anybody's appetite."
We resumed the small talk, the mother-daughter catching-up that we always do when we haven't seen each other in a while. She was happy to be having lunch with me. "Oh," she said, "do you remember that day...?" It must be that bond between mother and daughter, because I knew exactly what she was talking about and I knew she remembered it as vividly as I did. Our first official mother-daughter outing took place when I was 10. My mom took me out to lunch at this luncheonette in the center of town where I grew up. It was a tiny place, just a counter and a few booths. It's still there, I think, 25 years later. But I remember sitting at the counter with my mom, feeling very grown up. We each ordered a hot dog and a coke. To this day, I hold every hot dog I eat (which are few and far between) to that standard. The bun was buttered and grilled. I can still taste it. That was the first time I ever had relish. I remember thinking, since I was feeling so grown up, that it was about time I tried it. "Yeah," I told her. "That was a great day."
After my father's heart attack, I went home, as I always do, for Christmas. My mother, who had never been particularly heavy, had lost a lot of weight. More than 20 pounds. And on her 5'2" frame the difference was severe. She seemed almost boastful that she now weighed only 110 pounds. "Some people think I'm getting too skinny," she said, shooting a look at my dad who just raised his eyebrows and went back to reading the paper. If I sensed a little tension, I chalked it up to holiday stress. It wasn't until two days after Christmas that I realized there was something dreadfully wrong. In fact, I didn't realize it. She had to tell me. "I haven't been able to eat anything since Christmas dinner," she said. I was stunned.
"But that was two days ago..." I said. Thinking she was coming down with something, I made her a toasted English muffin and got her some orange juice; she nibbled a little and when she thought I wasn't looking, she threw the rest away. I didn't say anything, but I started to get an idea about what was wrong. Two months later, she called to tell me that her doctor had diagnosed her with anorexia nervosa and had made her see a therapist.
"How much weight have you lost?" I asked. I wasn't prepared for the answer.
"I'm down to about 92," she said. I felt sick. I don't remember much else about that conversation, except that I was trying hard not to sound upset. She sounded cheerful, but there was an eerie ring to it. And now, when we talk about it, she tells me her weight never got that low, that she was weighing herself on two different scales, hers and her doctor's, and that I must be confused. I want to believe her, but sometimes I don't know how. Nearly two years later, she's doing much better and is maintaining a weight of about 106 pounds. I find myself caring less about her actual weight and just being thankful that she's getting help.
In the case of Eileen Binkley, it was the intervention of a couple of close friends that brought her disorder to light. "You know how with people who have substance abuse problems or addictions, they have interventions where friends invite you to a...," she paused, "a 'confrontation party,' for lack of a better term." Her amusement at that terminology reminded me of my mother, making a joke...finding the humor. I could almost imagine the two of them chatting away and laughing. "Two of my very good friends did exactly that. They said, 'We've been watching you go downhill for a while now and we're very concerned and we'd like to help you do something about it.'" Fortunately, one of Binkley's intervening friends was also a guidance counselor. "She had some experience with this and I think she suspected what was wrong...and she knew exactly where to suggest that I go for some help." Her friend recommended the Renfrew Center in Philadelphia.
She went and enrolled in the center's intensive outpatient program. "I was very resistant to doing an in-patient thing. I guess it was the part of me that felt a little bit ashamed. Here I was, a middle-aged adult, so why should I be having this problem?"
Binkley's sense of responsibility to her job and her family wouldn't allow her to spend time away in an in-patient facility. And then there was the stigma of being middle-aged battling a disorder more commonly associated with teenagers. "The media does give attention to teenagers," said Binkley, "which is fine. That's good. That's usually where it starts, but it helps to get the word out there because I think there's an added stigma for those of us who are older. The idea seems to be that it's not something that an older adult gets."
While eating disorders sometimes don't manifest themselves until a person is older, the roots go back to adolescence or even further. Sammet explained using one of Dr. Anderson's metaphors. "Dr. Anderson often talks about...kindling on a fire. You may have little sticks that get piled up, comments by your auntie, comments from your girlfriend. [Sometimes] it's a gymnastics coach. 'Your performance would improve incredibly if you dropped five pounds' or 'Be careful, there's too much fat in that. You shouldn't be eating that.' Over time, all these little sticks kind of get thrown on the pile and then something comes along to spark the illness. Like many other illnesses, there may be some predisposing factor that may or may not...manifest depending on whether or not the right environmental situations or circumstances are present."
In my mother's case, her childhood and adolescence played a significant role in shaping her attitude toward her body image and her own self-worth. Born out of wedlock to a 16-year-old mother, there was a stigma on her that to this day still stings.
"I hate the word 'illegitimate.' It's not true," she said after we had left the restaurant and found a stone wall by a little gurgling stream. The air was crisp and smelled like autumn. The sun was in my eyes as I tried to look at her while she was talking. I would have shielded them, but I think I liked not really being able to see.
"My therapist doesn't think this is funny, but I do," she continued. We were sitting cross-legged, facing each other, and she started to giggle. "I used to think that [being illegitimate] meant I wasn't created by God. I thought I was made by some angel who was practicing on left-over body parts."
I didn't know whether to laugh or cry, so I ended up doing both. The sun had moved behind a tree, and now I could see her. We both wiped away our tears, and I distracted myself by swinging my legs over the side of the wall and dangling them over the stream. My mom did the same.
Despite the apparent levity of the moment, we both knew it wasn't funny. She had been a beautiful baby; I couldn't imagine that she didn't know that. Her feelings of unattractiveness and lack of self-worth, it turned out, were perpetuated by years of sexual abuse. If I know anything, I know those are words you never want to hear your mother say. From the time she could remember until she was 9 years old, I found out, my mother suffered sexual abuse at the hands of an older relative. "It only stopped because he died," she told me. My stomach churned and I was no longer concerned with hiding my tears.
Dr. Bunnell acknowledges that a history of sexual abuse is all too common among people with eating disorders. "There have been estimates," he explained. "But the best answer is about 30 percent of people with eating disorders have experienced that sort of trauma. It's not an easy thing to research. Not so long ago -- within the decade -- there was a time in which one was almost encouraged to make the assumption that someone had a sexual abuse history if [a patient] had an eating disorder... I'm not sure there's even great evidence that you're at specific risk for an eating disorder with that history...but that's a strong risk factor for all sorts of psychiatric problems including eating disorders."
Eileen Binkley talks about a different kind of abuse, the kind that's not physical, not sexual. It's the kind of emotional and mental abuse that parents, often unwittingly, perpetrate on their children in the name of trying to raise them right. "I know my parents loved me very deeply," she said, acknowledging that they would be extremely hurt if they ever thought that their actions could be construed as abusive. "But growing up in a strict household..." Again she trailed off a little, trying to find the right words, the diplomatic ones that wouldn't hurt. "My main purpose in life was to be a good girl -- to please my parents."
Issues that are never dealt with have a way of coming back around. Like water in a barrel, if it keeps flowing into the barrel, no matter how tightly it's sealed or how hard you to try to cover it up, at some point the barrel is going to spring a leak or overflow. "I never really dealt with any issues at the root of it," said Binkley. "I never really changed in that sense." Through her adult life and into her marriage, Binkley was still putting others ahead of herself, still trying to be the good girl her parents had taught her to be and that now her husband had come to expect her to be.
Most of us understand the drive for thinness, but for those who don't suffer from an eating disorder, understanding that a person could starve herself or himself is difficult. The solution seems so cut and dried: If you need to gain weight, eat. Those of us on diets who would love to be told we "had to" gain weight simply don't understand. I know people haven't meant to be unkind in the last two years when I've talked about my mother's condition. But their ignorance of its severity has been apparent in comments like, "I wish that could happen to me so I could lose about 10 pounds." I remember saying that myself in what was certainly a feeble attempt to trivialize the whole matter. My mother sees that lack of understanding, too. She's very open about her anorexia, but she knows that no one really understands that for her gaining weight is not so simple. "They listen and they try to be polite," she wrote in a recent e-mail, "but you can see it behind their eyes: 'Yeah, so go eat a cheeseburger.' "
What they don't understand is that my mother doesn't see herself the way they do. Even when her weight dipped into the 90s, she would obsessively go to the mirror to check herself because she was feeling fat. She told me the only way she could tell was by looking. And then looking again, sometimes only five or 10 minutes later. Other sufferers don't even have the comfort of a thin reflection in the mirror. An anorexic's perception is so distorted that they can't even tell by looking in the mirror that their reflection is that of an emaciated person.
"One of the most interesting phenomena with anorexia or eating disorders," Dr. Bunnell explained, "ís perceptual distortion." Instead of being able to see their overall appearance, a person may focus on a particular area of the body, convinced that it should be thinner, smaller. Thinner thighs, smaller buttocks, a flatter stomach. "In some ways it looks psychotic, it's so at odds with reality," Bunnell continued. "But [these patients] aren't psychotic in any other way." That perceptual distortion only operates with regard to themselves; in a group of other people with anorexia nervosa, a person can be very sympathetic and can see the emaciation of his or her peers. "Until the attention comes to them; they genuinely don't see themselves the way that other people see them."
People with eating disorders, when they get below a certain body weight -- somewhere around 85 percent of their targeted healthy weight -- are both psychologically and physiologically impaired. When the brain is starved, a person loses his or her ability to think rationally. In those cases, the first order of business is to get the patient medically stable, so that higher order cognitive therapy can be employed to change a person's perception of themselves. "It's a really systematic way in which you go in and challenge people's thoughts or self-thoughts," explained Dr. Bunnell. "So if a [person's] thought is 'I'm worthless,' you deliberately and consciously with practice go in and refute that." It sounds straightforward and simple, but as with most things, it is easier said than done.
After nearly two years of therapy, my mother is still struggling with the concept of her self-worth. Meanwhile, I'm admiring a woman who, through sheer force of will, broke a cycle of abuse, packed my lunch every day and read me bedtime stories every night, and who in my adult life has been there for me every time I've needed her.
If environmental conditions that ignite that bundle of kindling can lead to the onset of an eating disorder for a woman in her 40s or 50s, why isn't the eating disorder more readily diagnosed? It could be for any number of reasons, supposes Dr. Bunnell. "It would be low on the list of potential diagnoses for a post-menopausal woman." Since amenoria, or missed periods, due to insufficient body weight is one of the diagnostic criteria, a menopausal or post-menopausal woman is harder to diagnose. "If you're talking about the general medical field, probably any girl out of her teenage years would not get an eating disorder consideration unless she's in a high-risk environment," Bunnell added.
For most older women with eating disorders, this has been a chronic illness that has carried over into their later years. Eileen Binkley went on her first diet around the time she turned 13 and lost enough weight that she stopped getting her period. "I don't think it was given any credence," she said ruefully. "The cure-all was [to prescribe] a good dose of iron pills and to send me on my way."
Sitting in the sun on that stone wall with my mom was comforting. She was there and we were talking the way we used to before she got sick. I felt better and I felt brave enough to ask more questions. It seemed unlikely, given what I now knew to be her history, that this would have been her first experience with an eating disorder. Before I could stop myself, I asked the next question: Is this the first time you've done this? I shut my eyes as if doing so would prevent my hearing the answer. "Well, I did the laxative thing...," she said nonchalantly. I knew it before she said it, but it was still something I didn't want to hear: my mother had been bulimic while I was growing up.
Bulimia nervosa comes with its own set of problems. Whether or not a person with bulimia ever achieves a state of emaciation, the condition is still a dangerous one. "There's a lot of overlap here, too," Dr. Bunnell said. "Thirty to 50 percent of women who start off with anorexia nervosa will evolve into [people with bulimia nervosa], and [people with bulimia nervosa] will oftentimes denigrate themselves and talk about themselves as 'failed anorexics.'"
There are different facets to the binge-and-purge cycle that characterizes bulimia. A "binge" can range anywhere from a sky-rocketing 20,000 calories to a mere 100, depending on a person's perception of what constitutes an exorbitant amount of food. And after the binge, the cycle continues as a person with bulimia purges. "They think they want to lose weight, but they are really not in some disciplined way trying to lose weight.
"In fact -- and this is sort of the dirty little secret in therapy that is put out there -- throwing up is not a great way to compensate for overeating," Bunnell continued. "A lot of the nutrition and calories get absorbed before you get rid of them. So people who are binging and purging tend to be a little overweight because they're not really undoing the effects of binging."
In addition to vomiting, the act of purging includes the use of laxatives or diruetics, as well as over-exercise. According to Dr. Bunnell, the line between what is pathological exercise and what isn't is not clear-cut. He uses the example of female athletes who train for stamina and endurance. "[These women] often look [like] or are metabolically aligned with, or are similar to, people with anorexia. Often leading women athletes will lose so much body weight that they'll stop menstruating, which puts them at increased risk for stress fractures and osteoporisis."
In terms of recovery, Dr. Bunnell is encouraging. "People absolutely do get better. The general rule for eating disorders is that a third of the people who get treated will get better," he said, defining "better" as "as close to normal as any woman in our culture can get." Another third, he said, "are in kind of this middle territory where they may be symptomatic sometimes, others may not be symptomatic at all but may be pre-occupied with their weight and shape constantly, where their dietary behavior sort of influences the quality of their life." And then there's the unfortunate third of those suffering from eating disorders who will never get better. "Of that whole group," he stated, "5 to 10 percent of them may die due to complications." Eating disorders have the highest mortality rate of any psychiatric illness.
For Eileen Binkley, recovery means having to keep a watchful eye on remaining healthy, on making sure she maintains a healthy diet and continuing to deal with the issues that have been with her for most of her life. "I've come to the realization," she said, "that I will probably never be cured per se, but I will just have to be vigilant -- probably for the rest of my life. I don't mean that in a fatalistic sense, I think it's just a realization." And she doesn't sound fatalistic. If anything, she sounds positive, even encouraging, as I find myself believing that if Eileen Binkley can be OK, so can my mom.
My mother, in the meantime, has stopped losing weight and has even gained a little of it back. She still watches what she eats, but she makes sure she eats every day. She continues to visit her therapist regularly and even seems to look forward to those visits. She seems happier and more in control of her life than I've seen her in what seems like a very long time. My mind wanders back to that
*published as "Terri Lagerstedt"