• How long have eating disorders been around? What is their history?

There are descriptions of disorders very like what we now call anorexia nervosa and bulimia nervosa in ancient Egyptian hieroglyphics and Persian manuscripts. Scrolls originating in early Chinese dynasties also mention behaviors similar to the starving and stuffing of today’s eating disorders. Ancient Romans overindulged at lavish banquets and then relieved themselves in a vomitorium (lavatory chamber that accommodated vomiting) so they could return to the feast and continue eating.

African tribal lore contains stories of individuals who refused to eat during times of famine so their children might have the little bit of food that was available. They were much admired by peers who could not exercise the same rigid self-denial. When the famine passed, a few of the voluntary restrictors continued to refuse to eat and were in danger of dying. Some were healed by shamans who induced trance states similar to what we now know as hypnotherapy.

In Europe, the first formal description of anorexia nervosa in medical literature was made by Richard Morton in London in 1689. He is credited with first describing an anorexic patient as “a skeleton clad only with skin.”

Two other physicians, Lasegue in 1873 in France and Gull in 1874 in England, wrote the first two articles about anorexia nervosa in modern medical literature.

At first anorexia nervosa was thought to be a form of tuberculosis or a manifestation of some other physical disease or disorder, perhaps related to hormone imbalance or endocrine deficiency. It was not until the 1930s that researchers began to believe that the causes of self-starvation were psychological and emotional. Today clinicians believe that eating disorders represent the final outcome when emotional distress interacts with physiological imbalance (including the imbalances caused by dieting) in a vulnerable individual. Effective treatment, of course, will address both physical and psychological factors.

• What’s the most effective treatment for someone with an eating disorder who is also abusing alcohol and other drugs?

In most cases, effective treatment means tackling the substance abuse first. When people are clean and sober, they don’t use substances. Period. That same kind of abstinence is not possible with food, so in some ways recovery from substance abuse is easier than recovery from an eating disorder where the person must face the trigger substance (food) three or four times a day.

After nine to twelve months of sobriety, most people have become stable enough to move on to treatment of the eating disorder. If they are truly committed to sobriety, they won’t switch coping behaviors back to alcohol and other drugs when the going gets rough. If, however, they begin by working on the eating disorder, without a commitment to sobriety, they almost always escalate substance abuse as they decrease disordered eating behaviors.

Of course if the person is in medical danger because of the eating disorder, some intervention should be made early on to preserve life. A physician and treatment team must make this judgment call. Many substance abuse treatment centers have an eating disorders track for their dual-diagnosis patients.

• Why don’t you have more on this site about support groups?

We are ambivalent about eating disorders support groups. For someone who has recently begun to starve or stuff, especially someone young in years, we recommend formal treatment to quickly break disordered eating patterns and restore physical and psychological health. If people find friends and acceptance in a support group, they may begin to define their identity as “eating disordered” so they can continue to belong and participate. That makes recovery much harder.

On the other hand, we know that not everyone will get into treatment, and of those who do, not everyone will make progress and recover in a timely manner. For these more chronic sufferers, a support group can provide valuable encouragement and a safe place to problem solve and talk about challenges.

We are especially concerned about informal groups led by parents or people who themselves are still recovering from an eating disorder. In our experience, the most effective groups are led or supervised by a professional mental health therapist as part of an integrated treatment program. Without the involvement of an experienced professional, groups tend to deteriorate into subtle competitions to see who can be the thinnest and who can produce the most alarming story. Without supervision, the group’s focus tends to shift from developing more effective behaviors to caretaking and noncritical acceptance of even the most irresponsible choices and decisions.

Also, if a lay leader is not confirmed in his or her own recovery, there will be temptation to relapse when group dynamics become intense and the focus remains on food and weight behaviors instead of on problem solving.

For these reasons we are cautious advocates of support groups. While many people have found much help in well-run groups, in too many cases unsupervised support groups have led to problems and even crises when no experienced professional was present to defuse problems before they escalated.

• I’m anorexic, not bulimic. Why are my teeth decaying at the gum line?

People who have anorexia often have saliva deficient in the buffers that protect teeth from the effects of acid manufactured by bacteria in the mouth. There is also significant acid in many of the low-cal foods and soft drinks that anorexics favor.

Normal saliva contains buffers that protect teeth from acid. The body makes those buffers in part from materials found in fatty foods. If you don’t eat enough dietary fat, your body can’t protect your teeth adequately. Tell your dentist what’s going on. There are steps you can take to prevent or minimize further damage.

• How do I calculate my ideal weight? How much body fat is healthy?

We don’t like the term “ideal” weight; it’s too dependent on unrealistic images foisted on us by the media. Your healthy body weight is that weight at which you are strong, energetic, and healthy. Everybody’s body is different. Don’t rely on charts, tables, or complex formulas involving body measurements to determine what’s healthy for you. Instead, eat a balanced, moderate, and varied diet that includes lots of fruits, vegetables, and whole grains. Low-fat or non-fat dairy products contribute to healthy bones. Go easy on high-fat and high-sugar foods, but allow yourself to enjoy moderate amounts to satisfy your body’s need for the nutrients they provide and so you don’t feel deprived and vulnerable to bingeing.

Regular, moderate exercise helps stabilize weight, and it also gives you a whole host of long- and short-term health benefits.

You are at a healthy weight when you have enough strength and energy to lead a healthy, normal life. You know you are on the right track when your blood pressure, cholesterol, and blood sugar levels are normal, and when you have no back or joint pain because of undernutrition (loss of minerals from bones) or extra weight. If you are a woman, the presence of normal menstrual periods is an indicator of health.

If you are female, and if you want additional reassurance, ask your doctor to arrange a pelvic ultrasound. This procedure reflects nutritional status during the previous two months and indicates the reproductive status of your uterus and ovaries. This kind of ultrasound gives a picture of reproductive maturity, which can be halted and even reversed by dieting and weight loss.

And that pesky body fat issue: The most commonly accepted figures for healthy levels are 18 to 23 percent for adult men and 18 to 28 percent for adult women. Anything less than that may produce significant physiological problems such as loss of bone minerals leading to osteoporosis and hormone deficiencies that contribute to loss of libido, sexual difficulties, and impaired fertility.

• I read in a book that bingeing can permanently distend one’s stomach. Is this true?

For some people, bingeing does indeed stretch and distend the abdomen, making it look poochy. Eating a large meal and then falling asleep, when all the muscles have relaxed, can have the same effect. Some folks tighten up when they stop bingeing, others do not in spite of crunches and other exercises.

• I am trying to eat, but when I do, I feel bloated for hours. It’s not body image distortion, but a real, physical feeling of being too full. Help!

One of the common consequences of an eating disorder is slowed gastric motility. That means that food stays in your stomach and intestines longer than it did before you began to diet. Your GI tract does not pass digesting food along as rapidly as it did before. Of course you then feel stuffed.

If you persist in eating normal amounts of normal foods, your body should gradually return to normal. In the beginning it may help to limit really greasy foods and other items that are harder to digest. As you progress in recovery, you can add back reasonable portions of these foods so your body can learn to handle them once again. In addition, small frequent meals may be easier for your body to handle than three large ones.

In cases like this, it’s always a good idea to check with a physician to rule out the possibility of a medical problem. Serious problems are rare, but they do happen. If loss of gastric motility is causing undue distress, your doctor can prescribe medications for temporary use that will speed up the digestive process. These meds, however, should not be used indefinitely. The goal is to achieve normal digestion without artificial aids. Best wishes, and congratulations on all you have accomplished so far.

• Do I need to fast periodically to detoxify my body?

No. This is a subject that has grown an extensive mythology, but none of it is based on scientific fact. Your body is very efficient in cleansing itself, including the digestive tract. There is no evidence to suggest that you get “toxic” by eating normally. Nor do your stomach and intestines need to rest every once in a while. In fact, fasting can be dangerous for people with eating disorders. It can cause headaches, fatigue, nausea, crankiness, drops in blood pressure, and irregular heart beat. It is especially dangerous for people with diabetes, liver disease, or impaired kidneys. Pregnant women should never fast. We do not recommend this hazardous and ineffective practice.

• Are there different degrees of eating disorders?

Yes. Because of unrealistic cultural demands for thinness, probably most of us are more concerned about body shape and size than a totally healthy person would be. It’s a long way, however, from an occasional, brief diet and fleeting dissatisfaction about body shape and size to the rigid preoccupations and ever-present obsessions about food and weight manifested by people who have clinical eating disorders.

There are also differences in mental, physical, and emotional impairment between someone who has just begun an eating disorder and someone else who has starved or stuffed for many years. Likewise, there are differences between people whose symptoms are less severe and those who are in crisis.

The problem with all of this is that, without treatment, eating disorders tend to get worse, not better. It is not unusual for someone to begin an eating disorder with seemingly minor behaviors that quickly progress to threaten life and happiness. If you are concerned about yourself or your minor child, arrange for medical and psychological evaluations right away. If you are concerned about a friend, urge her/him to seek professional advice before the problem becomes intractable.

• I used to have an eating disorder, and now I want to help other people. What can I do?

First you must decide if you want to make helping people a career or a volunteer activity. If you want a career, prepare yourself by getting at least a masters degree in psychology, counseling, psychiatric nursing, or clinical social work. If you want more training, you could become a psychiatrist or a clinical psychologist. The people in your campus academic counseling center can help you arrange the classes you need for these options. Be aware that you will need to meet licensing requirements in most states in the U.S.

If you want to do volunteer work, we recommend you get involved with NEDA – National Eating Disorders Association. They have several programs across the United States. Visit their Website for details on how you can combat eating disorders in your own community.

Wanting to help others is admirable, but make sure your recovery is solid before you begin. Focusing on disordered eating behaviors and the painful underlying issues may undermine your own progress unless your are comfortable with your body, enjoying a wide variety of normal foods, and aware of and on top of the issues that brought you to starving or stuffing in the first place. You must decide if it would be wisest for you to move on or if you are indeed strong enough to help others. See the letter from a licensed professional counselor on our Forum page for more thoughts on this issue.

• How can I be certified as an eating disorders specialist?

There is no course of study that leads to a degree in eating disorders. Because anorexia nervosa, bulimia, and binge eating disorder are multidimensional problems (multiple causes, complex dynamics, paradoxical motivations, interlinked triggers, self-reinforcing maintainers, and the like), a clinician is well advised to obtain a general degree and subsequent license in medicine (psychiatry, pediatrics, gastroenterology, etc.), psychology, counseling, or clinical social work. After that basic preparation, additional work, both theoretical and clinical, can lead to specialization in the field of eating disorders.

At present there is only one organization that offers certification in this field, and that certificate may or may not be recognized by state licensing bodies and insurance companies. For information,contact the International Association of Eating Disorders Professionals.

• I’m too skinny. How can I gain weight?

You have to eat more calories each day than you burn up in basic metabolic functions and activity. Here are a few suggestions: eat larger portions than usual; eat five or six times a day rather than the usual three. Don’t ever skip meals. Choose high calorie snacks in addition to healthy whole grains, fruits, and vegetables. Keep snacks small in size but calorically dense so they don’t fill you up and spoil your appetite for the next meal.

Example: peanut butter and nuts on half a whole wheat bagel. Spread olive oil on bread or use it as a dipping sauce. Use real mayonnaise made with vegetable oil on salads and sandwiches instead of the reduced-fat varieties.

Snack between meals, but don’t spoil your appetite. A couple of extra sandwiches on whole-grain bread each day in addition to your regular meals should lead to weight gain.

The trick is to eat healthy foods. Ice cream, sauces, gravies, and fatty meats will give you calories, but their fats are saturated and therefore not very healthy. Focus on foods that contain olive or canola oil or other monosaturated or polyunsaturated vegetable oils. All are beneficial to health when used as part of a balanced meal plan.

Drink a couple of cans of liquid supplement in between meals. Avoid the weight-loss stuff (like Slim-Fast) and stick with true supplements like Susta-Cal and Ensure. Ask your pharmacist for a recommendation, including a recommendation for taste. Some of these food substitutes taste like cardboard, but they are nutritionally complete and balanced.

Reduce your aerobic exercise for a while and switch to weight lifting which promotes muscle development. Muscle weighs more than fat. Remember that you will tend to gain weight as you grow older and, if you are female, after childbirth and menopause. You may always be slender, but you will be rounder and curvier.

If you feel anxious when you think about weight gain, wear loose clothing as your body changes. Tight jeans, waistbands, or belts may trigger panic, and you don’t need that. Also, if you find that the new weight seems to be concentrated in the middle part of your body, be patient. Once your weight stabilizes at its new level, you can design an exercise program to redistribute it and develop new muscle all over your body.

Note: Be aware that every human body, in the words of one visitor to the ANRED Website, “has its own metabolic destiny, regardless of what fashion dictates.” If Mother Nature designed you to be slim, gaining weight for you may be as difficult or impossible as losing it is for someone who is naturally round and plump. If a physical exam shows that you are healthy, you will be smart to check with a counselor who can help you resist society’s insistence that you be someone you are not.

• My child wants to be a vegetarian, and I’m concerned. Something is not right. Could she be developing an eating disorder?

In most cases, vegetarianism is a healthy way to eat. In fact, adult vegetarians tend to live longer, are generally leaner, and are less likely to be diagnosed with heart disease and some cancers than adults who consume animal products. (source: authors of study summarized below)

There may be a problem, however, when adolscents decide to give up meat and other animal-based foods. A study at the University of Minnesota found that teen vegetarians were more weight- and body-conscious, more likely to have been told by a doctor that they had an eating disorder, and more likely to have tried a variety of healthy and unhealthy weight control practices including diet pills, laxatives and vomiting. They were also more likely than their peers to have contemplated or attempted suicide.

The study also found that male vegetarians were even more likely to engage in unhealthy weight control practices, such as vomiting after eating and weighing themselves frequently, than were non-vegetarian males.

The findings suggest that vegetarianism may serve as a red flag for eating and other problems related to self-image in teens, concludes Dr. Cheryl L. Perry and colleagues who ran the study.

Semi-vegetarians, those who ate some animal products, were more likely to engage in weight-control practices. Semi-vegetarians, the authors suggest, may be using vegetarianism as another form of weight control.

The study appeared in J Adolesc Health 2001;29:406-416 and was reported by Reuters Health, December 10, 2001.

• I just can’t seem to lose weight unless I stop eating. Is this bad for me?

Yes. In fact, you could die. Or you could develop gout, gallstones, kidney stones, kidney failure, and dangerously irregular heart rhythms that might lead to cardiac arrest. If you eat less than1200 calories per day, it’s almost certain that you are not getting the protein, fat, carbohydrates, vitamins, minerals, and micronutrients necessary for health.

To lose weight you must burn more calories than you consume. Please work with a dietitian who can help you design a healthy meal plan. Also consult a personal trainer who can help you stick to a realistic exercise program. If your health is threatened by overweight or obesity, ask your physician about surgery. For some people it is the only effective method of weight loss.