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Preamble

Unhealthy Body Image

Body image describes how an individual conceptualises his or her physical appearance. The body image a person has results from the interaction between the person's thoughts, beliefs, feelings and behaviours regarding their own body, and their perception of what counts as the ideal body within their own social and cultural setting. Unhealthy body image can affect men and women, children and the elderly from all backgrounds.

While there is no single or standard definition, "unhealthy" body image can be taken to involve a dissatisfaction with one's physical appearance leading to unhealthy responses which can include poor eating behaviours, changing levels of physical activity, substance abuse or reduced social interactions. This description emphasises that, from a health and medical point of view, the important difference between healthy and unhealthy body image is the nature of the behavioural and health-related consequences of the body image a person has.

There is potential for body image issues to arise at an early age. Evidence suggests that self-awareness starts to emerge around the age of eighteen months, though this remains an area of research and debate. The age or stage of development when a child begins to evaluate their body for acceptability is still being investigated.

The onset of puberty is a period of both substantial physical change and altered peer-relationships. It can be a period of major transition in a person's body image. Body image satisfaction has been identified as the greatest single predictor of self-esteem for adolescents. Mission Australia's National Survey of Young Australians has identified body image as one of the leading issues of concern to young Australians of both genders. Children and young people with physical and developmental disabilities can also experience body image concerns.

Unhealthy body image affects lifestyle choices and negatively affects mental and physical health, and social functioning. It can lead to unhealthy dieting, eating disorders, excessive exercise or under-exercise, substance use, and the desire for unnecessary surgical intervention. Once established, an unhealthy body image can continue through adult life.

Eating Disorders

Eating disorders can result from unhealthy body image. Such disorders include anorexia nervosa and bulimia nervosa. The former is characterised by self imposed starvation coupled with an intense fear of weight gain (despite continued weight loss). The latter involves episodes of binge eating followed by purging (such as self-induced vomiting, laxative or diuretic misuse and excessive exercise). The health consequences of the food restriction and starvation associated with anorexia and bulimia include impairment of bone mineral acquisition leading to osteoporosis, fertility problems, kidney dysfunction, reduced metabolic rate, cardiac irregularities, muscle wasting, oedema, anaemia, stunting of height / growth and hypoglycaemia and reduced mental functioning.

Eating disorders are serious psychiatric illnesses. The prevalence of eating disorders among children and adolescents is rising. While it is difficult to assess exactly how common eating disorders are (as many cases may go undiagnosed) it is estimated that one in 100 adolescent girls develop anorexia nervosa, and that it is the third most common chronic illness in girls, after obesity and asthma. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) state that eating disorders have the highest mortality rate of any psychiatric illness, with a death rate higher than that of major depression.

Cognitive Behavioural Therapy - a form of psychotherapy designed to change problematic thinking habits, feelings and behaviours - has been shown to be an effective treatment for bulimia nervosa in the Australian primary care setting. Long term follow up studies indicate that many patients with bulimia nervosa have good outcomes, with up to 50% being free of symptoms at five years or more after treatment. Unfortunately there is no evidence for a similarly effective treatment for anorexia nervosa. A major contributor to the poor prognosis for this illness is the high rate of relapse following initial treatment. This has promoted interest in interventions aimed at preventing deterioration and relapse, which may in turn lead to more effective treatments in the future.

The Influence of the Popular Media

Research is continuing into the range of individual and social factors that might contribute to the development of unhealthy body image and eating disorders. It is generally recognised that the popular media is a significant social and cultural factor that influences the development of people's self-perception and body image. Young people especially, are susceptible to social pressures to conform to ideal stereotypes. The public is constantly presented in the popular print and electronic media with images of attractive, thin women and athletic, handsome men. These idealised images do not truly reflect the bodies of most people in the community, and can contribute to unrealistic perceptions about appropriate physical appearance which may lead to body dissatisfaction and eating disorders. Repeated exposure to these images could have a cumulative impact on vulnerable individuals.

There is no national system of regulation relating to the portrayal of body image in the print and electronic media, nor the use of digital manipulation techniques such as airbrushing. This is despite growing community concern and debate around issues such as the use in advertising of very young and / or extremely underweight fashion models. The development of national industry standards may be an effective step along the way to responsible body image portrayal in the media.

The Role of Medical Practitioners

According to the World Health Organisation Collaborating Centre for Mental Health and Substance Abuse, medical practitioners have an important role in fostering healthy beliefs about body weight and shape by challenging unrealistic thoughts, beliefs and values, providing education and providing referral for therapy. Medical practitioners play an important role in the early detection and management of individuals at risk of developing unhealthy body image or eating disorders. Doctors can identify symptoms of eating disorders or body image problems which would otherwise appear unrelated. Early intervention may lead to a more complete recovery, and reduce the risk of an eating disorder becoming chronic. Doctors have opportunities to educate patients on the benefits of healthy eating and appropriate physical activity, and to advise parents about healthy eating and healthy weight for children and adolescents. Doctors are aware of the complex processes of behaviour change needed to establish and maintain a healthy weight, and can advise those with body image concerns about the risks and likely successes of various weight control 'diets'.

For those individuals who have an established eating disorder, general practitioners are often responsible for coordinating referral to, and care by, consulting tertiary services and local dietetic and psychological services. In the management of eating disorders, doctors recognise the potentially long-term nature of the illness and the need for continuity of care and coordinated multi-disciplinary management. Because there are often long-term care relationships between doctors and patients, doctors will be aware of the adverse impacts of eating disorders on families, friends and colleagues, and will often be a source of important support for patients and their families during a very disruptive and psychologically disturbing time.

In some cases, people turn to medical procedures or cosmetic surgery to achieve their ideal body. Advertising and other promotions which appeal to youth can encourage cosmetic surgery as an easy solution to personal issues, including body image dissatisfaction. Doctors can provide impartial advice to people on cosmetic procedures, including whether they are medically indicated, and the potential health risks that may be involved. This also applies to drugs and other substances that individuals may use to enhance or change physical appearance. Evidence-based medical counselling can help individuals develop realistic views about their need for cosmetic procedures, and what can be achieved by them.

The AMA Position

The AMA believes that the following measures and proposals will contribute to reducing the impacts of unhealthy body image and eating disorders.

A National Approach

The AMA believes that a nationally coordinated approach is necessary in order to develop effective and consistent practices in preventing and addressing the incidence of unhealthy body image and eating disorders. To achieve this, a peak national network of researchers, educators, policy-makers and industry stakeholders should be established to coordinate this national approach to body image and eating disorders.

Media Portrayals of Body Image

While acknowledging the impact of other social pressures to conform to idealised body types, the AMA recommends that the 'media industry' (ie., publishers, programmers and advertisers) depicts a more realistic range of body images and role models. This should happen at a national and industry-wide level, through conformity with appropriate standards that are developed by industry in conjunction with experts and stakeholders in the area of body image issues. If the Australian media industry can neither develop nor abide by such standards, then the AMA believes that government regulation should be considered.

The advertising and media industry should not portray normal bodily changes, such as those associated with ageing, as abnormal or problematic.

Direct to consumer advertising of pharmaceutical products designed to play on body image and weight concerns is an unacceptable practice.

Schooling and Public Education

The school system can play a very important role in helping children and young adults build and maintain a healthy body image. There is a need for increased understanding of how school curricula and other aspects of school life can impact positively and negatively on the development of body image and eating disorders. In particular, schools should:

incorporate issues around development of healthy body image into its health curriculum programs (including recognition of the impacts that bullying may have on body image);

develop programs in media literacy, and integrate media literacy skills into other curriculum areas so that young people can critically evaluate media content and messages pertaining to ideals about body type, and develop realistic views of self and society;

develop and monitor their physical activity programs to be aware of the risk of unhealthy body image developing, and associated excessive exercise. An emphasis on team based sports can be an effective vehicle to promote healthy lifestyles and to deter disordered eating and athletic enhancing behaviours;

There is a need for increased government commitment to appropriately targeted public education on the association between diet, physical activity and health, and the health risks associated with eating disorders.

Cosmetic and Restorative Surgery

Medical procedures to modify or enhance physical appearance should not be provided to young people under 18 years of age, unless those procedures are in a person's medical and/or psychological interests.

The AMA discourages the marketing and advertising of cosmetic surgery as an easy solution to individuals' personal or social problems.

The AMA supports the need for measures to ensure safety and quality of practice in cosmetic surgery, and that the interests of the patient are always paramount. It is essential for people considering cosmetic surgery to discuss the risks and potential benefits with their doctor.

The AMA recognises the importance of restorative surgery in cases where accident, injury or surgery has a significant impact on body image satisfaction.

Treatment Services

Services for eating disorder patients vary widely in their accessibility, availability and the type of care provided to patients and their carers. This variability is most pronounced for those living in rural and regional areas. A greater focus is needed on ensuring appropriate access to early intervention and treatment services for young people in rural and remote locations.

A 'one size fits all' approach to the treatment of eating disorders does not adequately cater for the needs of all those who have eating disorders or body image problems. Mechanisms need to be in place to allow health and medical professionals to readily access recent information about best-practice for the identification, diagnosis and treatment of body image and eating disorder problems.

Fitness and Health

The AMA advises against the use of fad or crash "diets" which make claims of dramatic weight loss, weight gain, or performance enhancement.

The AMA recommends that individuals engage in healthy eating habits and an active lifestyle in accordance with evidence-based dietary guidelines and physical activity recommendations.

Safe and supportive environments should be available to facilitate access, increase participation, and a willingness to engage in a range of healthy physical activities by people with body image concerns. Having an unhealthy body image can also limit physical activity, as those who feel self-conscious about their body may be less likely to participate for fear of exposing their body.

The AMA encourages the fitness industry to actively promote participation in physical activity as a preventative health strategy rather than to achieve the 'ideal' body.

Research

Adequate funding should be provided for further research into:

the impact of media on body image, particularly among children and adolescents;

the risk factors for developing eating disorders;

the protective factors that may reduce the incidence of eating disorders;

the health impacts of unhealthy body image and eating disorders across all population groups, and the effective interventions and treatments for them, particularly regarding anorexia nervosa.

References:

1. Thompson JK. Body Image Disturbance: Assessment and Treatment. 1990. New York: Pergamon Press.

2. Cash, TF. Body Image: Past, Present and Future. Body Image 2004. vol1: 1-5

3. Brownell, CA., Zerwass, S. & Ramani GB. "So Big": The Development of Body-Self-Awareness in Toddlers. Child Development. 2007. vol 78:142-1440

4. Wood, KC., Becker JA., Thompson JK. Body Image Dissatisfaction in Preadolescent Children. Journal of Applied Development Psychology. 17: 85-100.

5. Wood KC, Becker JA and Thompson JK. Body Image Dissatisfaction in Preadolescent Children. Journal of Applied Developmental Psychology. 1996 17: 85-100

6. Mission Australia. National survey of young Australians 2007: Key and emerging issues. Located at: http://www.missionaustralia.com.au/document-downloads/doc_details/48-nat...

7. Eating Disorders Foundation of Victoria Inc. Physical and Psychological effects. Located at: http://www.eatingdisorders.org.au/content/view/18/37/

8. Gonzalez, A., Kohn, MR., Clarke, SD. Eating disorder in adolescents. Australian Family Physician vol. 36. No. 8. 2007

9. Hay, PJ. Understanding bulimia. Australian Family Physician. Vol 36. No. 9. 2007

10. Walsh T, Kaplan AS, Attia E et al. Fluoxetine after Weight Restoration in Anorexia Nervosa: A Randomised Control Tiral. JAMA. 2006;2605- 2612

11. The Bronte Centre. Located at: www.brontecentre.com

12. Government Response to the Parliamentary Inquiry into Issues Relating to the Development of Body Image Among Young People and Associated Effects on Their Health and Wellbeing. (Victorian Government: Family and Community Development Committee) - January 2006

13. For example, the 2008 Senate Standing Committee Inquiry into the Sexualisation of Children in the Contemporary Media Environment.

14. Treatment Protocol Project. Management of Mental Disorders. 2000. World Health Organisation Collaborating Centre for Mental Health and Substance Abuse.

15. Gonzalez, A., Kohn, MR., Clarke, SD. Eating disorder in adolescents. Australian Family Physician vol. 36. No. 8. 2007

16. Abraham, SF. Dieting, body weight, body image and self esteem in young women: doctors dilemmas. MJA 2003; 178: 607-611

17. Dieting is so prevalent in our society that Australians spend about $1 million a day on weight loss attempts. Unfortunately, nine out of ten weight-loss diets are unsuccessful or may actually be harmful or eventually increase weight gain. Vic Health. Parliamentary Inquiry into issues relating to the development of body image among young people and associated effects on their health and wellbeing. 2004 Vic Health Response.

18. Gonzalez, A., Kohn, MR., Clarke, SD. Eating disorder in adolescents. Australian Family Physician vol. 36. No. 8. 2007

19. Elliot DL et al. Preventing Substance Use and Disordered Eating: Initial Outcomes of the ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternatives) Program. Arch Pediatr Adolesc Med. 2004;158:1043-1049

20. Government Response to the Parliamentary Inquiry into Issues Relating to the Development of Body Image Among Young People and Associated Effects on Their Health and Wellbeing. (Victorian Government: Family and Community Development Committee) - January 2006

Related document (Public):

Published: 26 Apr 2009

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Body Image and Health - 2002. Revised 2009

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Body image describes how an individual conceptualises his or her physical appearance. The body image a person has results from the interaction between the person's thoughts, beliefs, feelings and behaviours regarding their own body, and their perception of what counts as the ideal body within their own social and cultural setting.

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In the United States, as many as 10 in 100 young women suffer from an eating disorder. Overeating related to tension, poor nutritional habits and food fads are relatively common eating problems for youngsters. In addition, two psychiatric eating diso

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Photo by Goodshoot/Thinkstock

I was 12 when I saw my first made-for-TV movie about eating disorders. The year was 1997, and Amy Jo Johnson, the actress famous for playing the pink Power Ranger, starred as a gymnast-turned-bulimic in Perfect Body.* The '90s was a big decade for eating disorder melodramas. Tracey Gold battled her own disorder and starred in For the Love of Nancy in 1994. A few years earlier there was Kate's Secret, then A Secret Between Friends, and later Sharing the Secret. Lots of secrets. But the women keeping them were mostly young, thin, popular, and white.

For all the information and raised awareness, the stereotype won't die-eating disorders are a white-woman problem. And it's not just a false image set forth by Lifetime movies and the author pics of eating disorder memoirists. Communities of color buy into it, too. "There's this mentality that this is a white chick illness," says nutritionist Michele Vivas, who specializes in eating disorder treatment and works with teenagers in Oakland, Calif. "An African-American girl came in and her mom suggested to the school principal that they start a program to increase eating disorder awareness. The principal looked at her and said, 'Why would we have that? Black folks don't get eating disorders.' "

Doctors have this misconception, too. A 2006 study found that clinicians were less likely to assign an eating disorder diagnosis to a fictional character based on her case history if her race was represented as African-American rather than Caucasian or Hispanic. And although statistics do show that eating disorders predominantly occur in white women, many eating disorder professionals believe those numbers are skewed, as women of color have been alienated from a support network that for too long has bought into the myth.

"When eating disorders were first being recognized, people seeking treatment were young, white girls, so the belief developed early that nobody else suffers from them," says Gayle Brooks, vice president and chief clinical officer of the Renfrew Center, the country's first residential treatment facility for eating disorders. "When that became the core of our understanding, we stopped looking at diversity being an issue. We missed a lot."

According to the National Eating Disorders Association (NEDA), "exact statistics on the prevalence of eating disorders among women of color are unavailable" because, "due to our historically biased view that eating disorders only affect white women, relatively little research has been conducted utilizing participants from racial and ethnic minority groups." And as Carrie Arnold detailed in a piece for Slate, eating disorder research is "dramatically underfunded." Still, we know these women exist. Here are a few.

I met Anahi Ortega at the NEDA conference in 2012, where the topic was "What About Us? Diversity and Complexity in Eating Disorders," and Ortega was a featured speaker.

Born in Mexico, Ortega moved to California with her family as a baby and spent much of her childhood performing Mexican folkloric dance. She quit dancing at age 12, around the time that her father, who had been sober for many years, resumed drinking and began commenting on her developing curves. Ortega started dieting. Then cutting meals. Soon, she fell into anorexia. "It was so easy to hide at first," she remembers. "I was very good at it."

One reason it was so simple to get away with not eating has to do with the traditional Mexican meal structure. "A lot of [Latino] families have a two-meal-per-day pattern," Vivas says. "It's easier to get out of eating when you have to get out of two meals a day." Ioana Boie, assistant professor in the department of counseling at Marymount University in Arlington, Va., agrees. "In California, you see people still adhering to traditional meal times you see in Mexico," she says. "Eating dinner at 3 or 4 p.m." This is "exactly how I stayed under the radar," Ortega told me, explaining how easy it was to tell her parents she was eating all her meals at school when she wasn't eating a thing. It wasn't until Ortega's anorexia escalated into cutting and bulimia at 15 that anyone really took notice-she was hospitalized after accidentally overdosing on diet pills and nearly suffered a stroke.

Doctors diagnosed Ortega with bulimia, and she began group therapy. But cultural differences overshadowed any benefits she may have gotten from shared struggles. "The only thing we had in common was the eating disorder," she says. "I felt so different in a room full of white girls. When we talked about eating disorders, I could relate. When we talked about home, I couldn't."

Ortega eventually enrolled at California State University-Monterey Bay. Her disordered eating ceased, but she continued cutting and began abusing drugs and alcohol. She eventually withdrew from school and attended a codependency program. Her drug use stopped, but the eating disorder kicked back up. "If it wasn't one, it was the other," she says.

"I thought I was the only black person who didn't know how to eat."

Ortega's new doctors in Monterey gave her a different diagnosis: EDNOS-eating disorder not otherwise specified, a catchall definition for anyone who doesn't fit the strict standards for anorexia, bulimia, or binge eating disorder. "That made it hard to find treatment," she says. "I didn't fit the criteria for anorexia or bulimia."

EDNOS is the most common diagnosis in Latina women. Boie says that's due in part to anorexia's diagnostic requirement of a "preoccupation with thinness." Like Ortega, many Latina women aren't focused on being stick skinny; the "guitar shape" is considered superior. According to Ortega, "It's the perfect thing-curvy, but not too much."

Ortega got back to a stable weight but relapsed immediately. Finally fed up with her interchanging issues, she checked herself into intensive inpatient treatment at the Center for Anorexia and Bulimia at Herrick in Berkeley, Calif. Her three-weekstay at Herrick marked the first time Ortega felt entirely comfortable in a treatment setting. She'd been in plenty of support groups and outpatient programs over the years, but she'd always felt like an outsider because of her heritage. "Most of the girls were there because their parents were forcing them to go," the 25-year-old says of the other patients she encountered before Herrick. "Their parents were involved with the medical treatment, while mine complained about having to drive me to appointments-treatment talk was nonexistent." Just as eating disorder outreach needs to better target young women of color, "you have to target the [minority] parents and have them involved" as well, Ortega says.

Ortega didn't think recovery was possible until she attended her first NEDA conference in 2011 and met Stephanie Covington Armstrong, the author of Not All Black Girls Know How to Eat. There she was: another woman of color who'd grappled with the disease.

Armstrong's early memories around eating aren't particularly out of the ordinary, but her life changed dramatically at age 12, when she says she was molested by a relative and had "the need to squash down feelings that are never resolved." She did this through food, kicking off years to come of disordered eating. "I thought I was the only black person who didn't know how to eat," she told me.

The abuse kicked off a string of troubled relationships and a teenage suicide attempt. She left her Brooklyn, N.Y., home and relocated to Los Angeles to pursue acting. "Each day, I trekked 5 to 10 miles searching for work, and before long, I had whittled myself down to a magical size 2," she writes in her memoir. "For the first time in my life, I didn't care if I ate or not; in fact I had no desire for food at all (read: depression). I felt phenomenal." When she came across an article titled, "Bulimia, the New Diet," a switch flipped. Armstrong didn't read it as a warning, but as an "educational how-to."

Armstrong didn't know black women could be bulimic. No one around her suspected it either. "When I was in the midst of my eating disorder, it let me hide in plain sight," she says of her race. "When I was throwing up 20 times a day, no one would have looked at my brown skin and been like, 'That poor thing has a problem.' It protected me in a way."

Do many black women suffer from eating disorders? According to research, it depends on the type of disorder. In a 2000 study, researcher Ruth Striegel found that anorexia and bulimia were in fact more common in white women in a community sample, but that young black women were as likely as their white counterparts to report binge eating or vomiting and even more likely to report fasting and laxative and diuretic abuse. "I think there may be certain cultural factors that make individuals more vulnerable to a particular type of eating disorder," the Renfrew Center's Brooks says. "Within the African-American culture, they may be more vulnerable to bulimia and binge eating because there may still be some protective measures around the beauty ideal not being so pencil thin. However, conflicts around body image and using food to manage emotions-you're going to see that in women of color. It just may manifest itself in a different way."

For Armstrong, it manifested in bulimia. "There's so much shame in eating disorders, and in the black community, you're not supposed to talk about things like sexual abuse or too much drinking," Armstrong says. She also says that her pride-an adherence to what she calls "the strong black woman archetype"-stood in the way of seeking help. "It is so difficult for black women in this country. We're not going to let you see one more thing you can judge about us," she says. "We don't want you to know how we feel about ourselves-it's not the same way you feel about yourself."

Armstrong's pride finally crumbled when she moved back to New York and noticed an ad in the Village Voice for a bulimia research study. She thought it might be her only hope for recovery. But when she showed up at the researcher's office, the doctors looked confused. When one researcher told her that she was the first African-American applicant in the program, she lost her cool. "It really just pissed me off," she says. "I felt like the purple giraffe in the room-people aren't used to women of color coming forward with problems or issues."

Brooks says practitioners need to catch up to the reality that eating disorders do not discriminate. "A lot of times there can be discomfort talking about race-it's such a charged issue in our culture and the feeling that if we talk about it, I may offend you or give you the message that your race is the only thing that is really important to me," she says. "Clinicians need to be trained on how to deal with cross-cultural issues and feel comfortable with that themselves so they can bring that into the therapy room. I also think we need to get more people of color in the field of eating disorders, treating them." There are even smaller things eating disorder professionals can do, like diversify the public face of eating disorders. Scan the websites and brochures of many treatment facilities and you'll see mostly white women staring back at you.

Armstrong's race may have kept her bulimia under wraps, but Sophie Lee says that being Asian put the spotlight on her body consciousness. "We don't have a sense of privacy," the 25-year-old Korean-born college student says of her culture. "We feel it's OK to comment on people's appearance because our parents and relatives make a lot of comments. We're [raised] to think that's OK."

Lee's family relocated from Korea to Singapore when she was 4, and growing up there impacted her body image early on. "Southeast Asians are freakin' skinny, like emaciated skinny, but that's their natural weight," she says. "The bone structure is very different than in East Asians." Lee was always the tallest in her class, and she felt bigger than the other girls. But at 14, she moved again with her family, this time to Virginia, and suddenly felt a different kind of body consciousness. "I remember feeling like I was surrounded by fat people," she says. "People who'd also immigrated kept telling me they'd gained like 30 pounds when they moved to America because of the food. That terrified me."

Fellow immigrants warned her that American food would lead to unwanted pounds, and the continuing open dialogue around weight got to her. "It's not thought of as being rude," says New Jersey psychologist and NEDA conference presenter Hue-Sun Ahn, who specializes in eating disorders, racial identity, and acculturation. "People think they're being caring and doing it for the benefit of whoever's hearing it. Unfortunately, it can be very triggering to somebody that has an eating disorder."

Just as Ortega was influenced by the guitar-shaped women of the telenovelas she saw on TV at home, Lee says she strove for Korean pop culture perfection. "My parents watched a lot of Korean shows, and the actresses looked so skinny," she says. "That was my ideal body image. The Caucasian body is impossible for me to achieve. Our model is the K-pop people," idolized as much for their bodies, Lee says, as for their talent.

Ahn says it's almost impossible to know how cultural factors influence the development of eating disorders. "It's hard to tease out because the world is becoming so globalized," she says. "I know other immigrants who have visited their country of origin and [eating disorders are] very prevalent there or maybe even more so. A lot of Asian students I work with have had a healthy body image in the U.S. but then gone back to their country of origin and they're thought of as being overweight. I think there's even a thinner ideal in many Asian cultures." Lee says Asian cultures value a completely different feminine ideal. "American women want to be toned, they want to look fit," she says. "Asian girls don't want muscles. They want to be as skinny and pale as possible."

And so did Lee. She got her hands on her cousin's diet books, which served as calorie restriction guidebooks, and restricted food through high school until she was hospitalized for five days, where she says her parents' poor English left them vulnerable to prejudiced assumptions. "It wasn't overt racism, but I think the doctors thought they were ignorant," she says. "Like they were 'typical Korean immigrants.' "

Having just turned 18, Lee checked herself out of the hospital and soon suffered a hairline fracture on her ankle due to excessive walking. Forced to restrict her exercise, she limited her food intake again. She graduated high school and was accepted to her first-choice college, but school officials forced her to withdraw and seek treatment when a student reported her for looking too frail. "I think if I'd stayed in college, I would've died in my sleep," she says. "That saved my life."

The school recommended a six-week inpatient treatment program, but instead Lee moved into an apartment with a friend and transitioned from anorexia to bulimia. "Every single day, I was planning from 7 a.m. to 4 p.m. how to eat, puke, eat, puke, eat, puke," she says. The roommate eventually moved out, and Lee returned home. She credits her family's connection to Christianity with her recovery. The turning point came in 2008, when she returned to Singapore at 21. "I remembered myself as a cheerful girl," she says. "In Virginia, I didn't know who I was. I thought my identity there was the anorexic girl. I could envision a happier version of myself in Singapore." She stayed for five months and started gaining weight-which she's kept on.

In 2011, the New York Times published an article on the alarming increase of eating disorders in the Orthodox Jewish community, and a landmark study that same year called attention to the prevalence of binging and purging in Native American populations. An earlier study found greater body dissatisfaction among Hispanic and Asian girls than white girls.

The overall picture is clear: Eating disorders don't care about the color of your skin or the socioeconomic status of your family. It's not just media images that are to blame, or various cultures' expectations of women, or genetics. It's not just about stress, or trauma, or power and control. It's all of it, and everyone is at risk. It's time for treatment, research, and funding to catch up accordingly.

Correction, March 20, 2014: This article originally misstated the title of the movie Perfect Body.

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The Dangerous Myth That Only White Women Get Eating Disorders

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I was 12 when I saw my first made-for-TV movie about eating disorders. The year was 1997, and Amy Jo Johnson, the actress famous for playing the pink Power Ranger, starred as a gymnast-turned-bulimic in Perfect Body .* The '90s was a big decade for eating disorder melodramas.

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Abstract

Health Issue

Eating disorders are an increasing public health problem among young women. Anorexia and bulimia may give rise to serious physical conditions such as hypothermia, hypotension, electrolyte imbalance, endocrine disorders, and kidney failure.

Key Issues

Eating disorders are primarily a problem among women. In Ontario in 1995, over 90% of reported hospitalized cases of anorexia and bulimia were women. In addition to eating disorders, preoccupation with weight, body image and self-concept disturbances, are more prevalent among women than men.

Women with eating disorders are also at risk for long-term psychological and social problems, including depression, anxiety, substance abuse and suicide. For instance, in 2000, the prevalence of depression among women who were hospitalized with a diagnosis of anorexia (11.5%) or bulimia (15.4 %) was more than twice the rate of depression (5.7 %) among the general population of Canadian women. The highest incidence of depression was found in women aged 25 to 39 years for both anorexia and bulimia.

Data Gaps and Recommendations

Hospitalization data are the most recent and accessible information available. However, this data captures only the more severe cases. It does not include the individuals with eating disorders who may visit clinics or family doctors, or use hospital outpatient services or no services at all. Currently, there is no process for collecting this information systematically across Canada; consequently, the number of cases obtained from hospitalization data is underestimated. Other limitations noted during the literature review include the overuse of clinical samples, lack of longitudinal data, appropriate comparison groups, large samples, and ethnic group analysis.

Background

Eating disorders are an increasing public health problem among young women[]: they may give rise to serious physical problems such as hypothermia, hypotension, electrolyte imbalance, endocrine disorders and kidney failure. Women with eating disorders are also at risk of long-term psychological and social problems, including depression, anxiety, substance abuse and suicide. The costs in terms of quality of life, loss of productivity, serious medical problems and mortality are high. []

Clinical eating disorders include anorexia nervosa and bulimia nervosa. [] Anorexia is characterized by a severely calorie-restricted diet, resulting in a body weight that is at least 85% below that expected for age and height. [] Bulimia is identified by frequent fluctuations in weight and recurrent episodes of compulsive bingeing followed by self-induced vomiting, purging, fasting, laxative use and/or excessive exercise in attempts to avoid weight gain.[] Eating disorders not otherwise specified include behaviours such as chronic dieting, purging and binge-eating, which do not meet the full criteria for a specific eating disorder,[] they are two to five times as common as the clinical eating disorders.

Eating disorders are, by and large, a problem among women. From the data collected in the Ontario Health Survey, Mental Health Supplement, the lifetime prevalence of bulimia (according to the criteria of the Diagnostic and Statistical Manual, 3rd revision [DSM-III-R]) among women aged 15 to 65 was estimated as 1.1% in 1990.[] In 1995, 95% of reported hospitalized cases of anorexia and more than 90% of hospitalized cases of bulimia in Ontario were women.[]

In addition to eating disorders, preoccupation with weight and body image, and self-concept disturbances, are more prevalent among women than men.[, -] Personal, behavioural and socio-environmental factors, such as negative body image, low self-esteem, fear of becoming fat, chronic dieting and social pressures to be thin, are identified risk factors.[, , -]

Body Image

Body image concerns and preoccupation with body weight and shape increase as girls become older and more aware of the idealized societal preference for a thin body shape.[] The images of women in the media and popular culture place pressure on vulnerable young girls and women to live up to these expectations, regardless of their natural body shape.[, ] In British Columbia, it was found that by age 18, 80% of girls at all weights reported that they would like to weigh less.[, ] A school-based population study involving 1,739 adolescent women aged 12 to 18 years in Toronto, Hamilton and Ottawa found that current dieting to lose weight was reported by 23% of participants, binge-eating by 15%, self-induced vomiting by 8.2% and the use of diet pills by 2.4%.[]

Body shape dissatisfaction and preoccupation with weight are not limited to adolescents but also occur in children. A recent Canadian school-based study concluded that 34% of prepubescent girls, 36% of early pubescent girls and 76% of post-pubescent girls were dissatisfied with their body shape.[] In a survey of eating and smoking behaviours among boys and girls in grades 4 to 8 in southwestern Ontario and Charlottetown, more than 25% from each grade reported not eating breakfast every day, and there was a sharp increase among girls beginning in grade 7.[] Unhealthy eating patterns in childhood can adversely affect health, contribute to chronic disease in later life, and often persist into adolescence and adulthood, since change is difficult once eating patterns are established.[]

Morbidity

The starvation associated with anorexia and the chronic vomiting frequently associated with bulimia can cause serious medical problems, such as hypothermia, hypotension, anemia, osteoporosis, endocrine abnormalities, dehydration, kidney stones, metabolic alkalosis and dental caries.[] Girls and women with eating disorders are also at increased risk of menstrual irregularities such as amenorrhea, infertility, [, ] miscarriages and fetal complications such as prematurity, low birth weight, malformations and low Apgar scores.[, -]

Mothers who have or have had an eating disorder may also create abnormal behavioural patterns when feeding their children, such as irregular feeding schedules, detached non-interactive mealtimes, and use of food for non-nutritive purposes, which may lead to second-generation eating problems. [-]

Psychological Morbidity

In addition to depression, anxiety and obsessive-compulsive disorders, eating disorders are also associated with diminished libido, altered sleeping patterns, irritability and suicide attempts.[, , ] Ontario women with bulimia have higher levels of anxiety, depression and alcohol abuse than those without bulimia.[, , , ] Smoking and substance abuse are much more prominent among teenaged girls with eating disorders than among those with healthy eating habits. [, , ] In a recent analysis of the 1997 Ontario Student Drug Use Survey, adolescent females who perceived themselves as overweight were almost 50% more likely to smoke than those who considered themselves of average weight or too thin, whereas weight perceptions were not associated with smoking among males.[] Several studies have suggested an association between a traumatic experience (sexual or physical abuse) and later self-injury. A recent study found that among patients with eating disorders there is a more than 30% lifetime risk of self-injurious behaviour.[]

Mortality

The rate of death from anorexia is higher than from bulimia because of the complications of starvation and electrolyte imbalances, or suicide.[, ] A recent review reported a mortality rate of 0.6% for anorexia as compared with 0.3% for bulimia.[] A longitudinal U.S. study (21-year follow-up) of 84 women with anorexia reported that 14 women (16.7%) had died, and 12 of the 14 had died of causes directly related to anorexia; the observed death rate was 9.8 times greater than expected.[]

Socio-Economic Status

Although previous studies in Canada and the United States have demonstrated differences in education and socio-economic status (SES) in the prevalence of obesity, [-] the relation between eating disorders and SES is still unclear.[, ] Jones et al[] observed that SES was not significantly associated with disturbed eating behaviours in a school-based Ontario population (n = 530), findings that are consistent with those of previous studies and may reflect the pervasive influence of the media on all SES groups.[]

Ethnic Subgroups

Cultural beliefs and attitudes are identified as significant contributing factors in the development of eating disorders.[] Canadian research on eating disorders and ethnic background, however, is extremely limited.

A few studies propose that cultural beliefs may actually protect ethnic groups against eating disorders, but their effect may be eroded as adolescents face pressures of acculturation.[] A recent study of Mexican-American women across generations reported that second-generation women displayed the most disordered eating patterns and the highest degree of acculturation to mainstream U.S. culture.[] Experiences of cultural change (such as those of immigrants, for example) may also increase vulnerability to eating disorders.[, ]

This Study

This study presents data from the NPHS and national databases to investigate the burden of eating disorders in Canada and to explore the differences in attitude to weight between men and women.

Methods

NPHS

Within the NPHS, 1996-1997 (see Appendix A for details about the methods of data collection for the NPHS), the population selected for this analysis consisted of women and men aged 20 to 64, excluding pregnant women and people less than 3 feet (0.9 metres) or greater than 6 feet 11 inches (2.1 metres) in height. All data were weighted to represent the total population at the date of each survey.

Respondents who perceived themselves to be either underweight or overweight were asked to state their desired weight. The responses were analyzed according to four categories of body mass index (BMI) - underweight (BMI < 20), acceptable weight (BMI 20-25), some excess weight (BMI 25-27) and overweight (BMI > 27).

CIHI

From the CIHI database, any separations from hospital with an ICD-9 code of 307.1 for anorexia and 307.5 for bulimia and other unspecified disorders of eating from 1994 to 1999 were extracted. Crude hospitalization rates, age-specific rates, and age-standardized hospitalization rates per 100,000 separations across provinces and territories were examined. Furthermore, age-specific rates for the comorbidity of depressive disorder (ICD-9 code of 311) among those with a hospital separation for an eating disorder were also examined for the year 2000.

Results

Prevalence

The prevalence of eating disorders is difficult to ascertain, since many people may not even be aware that they have an eating disorder, are reluctant to seek medical care or have not been hospitalized. Although epidemiologic research can approximate the prevalence of eating disorders within a population, the lack of standard methodologies and community samples results in conflicting estimates.

Hospitalization data are the most recent and accessible information available, but only the more severe cases are captured and not the individuals with eating disorders who may visit clinics or family doctors, use hospital outpatient services or use no services at all. Currently, there is no process for collecting this information systematically across Canada; consequently, the number of cases obtained from hospitalization data is an underestimate.

Inpatient crude hospital separations in Canada for any diagnosis of anorexia, bulimia and other unspecified eating disorders appear to have increased somewhat (by 4.7%), from 10.2 to 10.7 per 100,000 women between 1994 and 1999 (Figure ). Although the rates among men were notably lower, they also increased slightly (4.8%) during the same period, from 0.6 to 0.7 per 100,000 men (Figure ). These increases may be due to better awareness and detection of eating disorders and improved specialized inpatient treatment programs.

Across Canada, age-standardized hospital separation rates for eating disorders were highest among women in British Columbia (15.9 per 100,000 women) and New Brunswick (15.1), and lowest in Saskatchewan (8.6) and Alberta (8.6) (Figure ).

Differences between Men and Women

The 1996-1997 NPHS data suggest that more women than men wished to weigh much less than their actual weight (see Figure ). Among those who had an acceptable BMI, between 20 and 25, women wanted to lose an average of 5.3 kg, whereas men wanted to gain an average of 2.2 kg. Among those with a BMI between 25 and 27 or greater than 27, women wished to achieve a higher average weight loss than men (8.7 kg versus 5.2 kg and 17.2 kg versus 12.4 kg, respectively). Similarly, among those who were underweight, with a BMI of less than 20, the average desired weight gain was smaller for women than for men (3.6 versus 8.9 kg).

Depression

In 2000, the prevalence of depression among women who were hospitalized with a diagnosis of anorexia (11.54%) or bulimia (15.36%) was more than twice the prevalence of depression (5.7%) in the general population of women, according to the 1998-1999 NPHS.[] (For depression rates of the general population please see the chapter on "Depression".) The highest prevalence of depression was found among women between 25 and 39 years of age for both anorexia and bulimia (see Figure ).

Vulnerable Subgroups

Although distorted body images and eating disorders are experienced by women of all ages, the highest rates of hospitalization for eating disorders occur among young women. Age-specific hospital separation rates are highest among adolescent women aged 15 to 19 years (65.5 per 100,000 women) followed by those aged 10 to 14 years. The rates slowly decrease with age (Figure ). Many young women do not meet the criteria for an eating disorder, but they may still show sub-clinical symptoms (disordered eating behaviours) that can harm their health. [-]

Discussion

Data Limitations

Several limitations were noted during the literature review: lack of longitudinal data, of appropriate comparison groups, of large samples and of ethnic group analysis. Most studies were based on clinical samples, making it difficult to generalize findings to the general population. Furthermore, many of these studies were cross-sectional and limited in their ability to make causal links.

CIHI hospital separation data provide information on the number of times each diagnosis is made and not on the number of people with the diagnosis, which leads to duplicate reporting. Comparable international rates of eating disorders were unobtainable. Nevertheless, two recommendations can be made.

Recommendations

* Data should be collected on eating disorders in Canadian women, including the prevalence and risk factors in subgroups such as disabled, immigrant and visible minority women.

* Cross-cultural and longitudinal evaluations of attitudes and behaviours towards disordered eating should be conducted in large community samples to monitor trends, examine protective and non-protective factors, and assist in the development and planning of preventive and treatment programs.

Authors' Affiliations

University Health Network Women's Health Program, University of Toronto, Toronto, Canada

University Health Network Women's Health Program, University of Toronto, Toronto, Canada

University Health Network Women's Health Program, University of Toronto, Toronto, Canada

University Health Network Women's Health Program, University of Toronto, Toronto, Canada

References

1. Federal, Provincial and Territorial Working Group on Women's Health. Working together for women's mental health. Ottawa: Minister of Public Works and Government Services Canada. 1993

2. The McCreary Centre Society. Adolescent health survey II: province of British Columbia. Vancouver: McCreary Centre Society. 1999

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Eating disorders are an increasing public health problem among young women. Anorexia and bulimia may give rise to serious physical conditions such as hypothermia, hypotension, electrolyte imbalance, endocrine disorders, and kidney failure. Eating disorders are primarily a problem among women. In Ontario in 1995, over 90% of reported hospitalized cases of anorexia and bulimia were women.

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other eating disorders - How far is too far

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Very often people don't meet the exact criteria for anorexia, bulimia or binge eating disorder but they still engage in eating behaviours that cause them major distress. These disorders fall under the term OSFED (Other Specified Feeding or Eating Disorder).

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Despite the stereotype that eating disorders only occur in women, about one in three people struggling with an eating disorder is male, and subclinical eating disordered behaviors (including binge eating, purging, laxative abuse, and fasting for weight loss) are nearly as common among men as they are among women.

In the United States alone, eating disorders will affect 10 million males at some point in their lives. But due in large part to cultural bias, they are much less likely to seek treatment for their eating disorder. The good news is that once a man finds help, they show similar responses to treatment as women. Several factors lead to men and boys being under- and undiagnosed for an eating disorder. Men can face a double stigma, for having a disorder characterized as feminine or gay and for seeking psychological help. Additionally, assessment tests with language geared to women and girls have led to misconceptions about the nature of disordered eating in men.

TREATMENT CONSIDERATIONS

Treatment is not one-size-fits-all. For any person, biological and cultural factors should be taken into consideration in order to provide an effective treatment environment.

Studies suggest that risk of mortality for males with eating disorders is higher than it is for females - early intervention is critical.

A gender-sensitive approach with recognition of different needs and dynamics for males is critical in effective treatment. Men and boys in treatment can feel out of place when predominantly surrounded by women, and an all-male treatment environment is recommended-when possible.

Men and boys with anorexia nervosa usually exhibit low levels of testosterone and vitamin D, and they have a high risk of osteopenia and osteoporosis. Testosterone supplementation is often recommended.
Learn more about treatment > Infographic: Eating Disorders in Men & Boys
Get the facts on eating disorders in men and boys with our infographic!

MEN AND BODY IMAGE

There are numerous studies on male body image, and results vary widely. Many men have misconceived notions about their weight and physique, particularly the importance of muscularity. Findings include:

Most males would like to be lean and muscular, which typically represents the "ideal" male body type. Exposure to unattainable images in the media leads to male body dissatisfaction.

The sexual objectification of men and internalization of media images predicts drive for muscularity.

The desire for increased musculature is not uncommon, and it crosses age groups. 25% of normal weight males perceive themselves to be underweight and 90% of teenage boys exercised with the goal of bulking up.

Muscle dysmorphia, a subtype of body dysmorphic disorder, is an emerging condition that primarily affects male bodybuilders. Such individuals obsess about being adequately muscular. Compulsions include spending many hours in the gym, squandering excessive amounts of money on supplements, abnormal eating patterns, or use of steroids.
Learn more about body image >

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Despite the stereotype that eating disorders only occur in women, about one in three people struggling with an eating disorder is male, and subclinical eating disordered behaviors (including binge eating, purging, laxative abuse, and fasting for weight loss) are nearly as common among men as they are among women.

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Warning: This post deals with issues of abuse, suicide and eating disorders. It contains photographic images that some readers may find distressing.
US Professor of Social Studies Brene Brown famously said "When we deny our stories, they define us. When we write our stories, we get to write a brave new ending."
To that end, I am not writing my story for sympathy, nor for vengeance. I am writing this so that I can heal. To validate my own self love and worth, so that it comes from within and can never be taken away.
My name is Jodi Cahill, I'm a 38 year old PR Executive from Melbourne. I was raised in a loving home, attended an exclusive private girls school, had a great career and fantastic friends.

On paper, my life appeared perfect - yet it was a piece of paper that tore at the very fabric of my existence.

Recently, I stood on the Sydney Harbour Bridge, ready to take my own life. A five-year struggle with a severe eating disorder had left me so drained that I no longer had the strength to go on.

As I stood there, on the precipice of life and death, I looked down at my bare feet, swollen and bloody from running away from the clinic that was caring for me, running away from all my problems.

I took a deep breath, prepared to jump when my phone rang. I paused, and I took the call. It was the Head Nurse, frantic with worry, demanding to know where I was.

That nurse had been there for me in the toughest times. She knew my history. Realising that her panicked pleas were falling on deaf ears, she changed tact, sternly she asked "Where is your integrity ? Where is your loyalty? What would your Grandmother think ?"

Well played. The magic bullet; my Grandma, Juanita, the one person who was always there for me. She took me home and raised me as her own, when her daughter, wanted nothing to do with me.

Just the two of us, she had divorced my Grandfather long ago, we enjoyed an unbreakable bond. She wrapped me in love, made sure I had the best of everything. She would do anything for me, and that love and loyalty, was reciprocated in spades.

Grandma shielded me from my mother, a woman haunted by psychosis, a woman in and out of institutions. On the rare occasions I saw her, she terrified me. She would fix a look on me that was filled with utter hatred and bore through to the marrow of my bones. Left on my own with her, she would lash out at me, meting out bashings and verbal abuse in equal measure.

Still, taking Grandma's lead, I returned my mother's hatred with love and sympathy, praying that I could understand what had made my mother a monster.

So, I made my mother a side note to my life. All I wanted to do was to make my Grandma proud, to ensure I was worthy of her unconditional love. I did well at school, I was a straight-A student, I excelled at swimming, tennis and athletics, drama, gymnastics.

Then my Grandma suffered a stroke. Without a second thought, I put my uni plans on hold and nursed her back to health, honoured that I could return the care she had always given me.

Two years later I went on to university, completing a Bachelor of Business Degree with a Marketing Major.

My Grandma died in January 2004. Her loss broke my heart into a million pieces. The night she died, and the lead up to her death, scarred me forever.

Grandma taught me to be brave and fearless, so I compartmentalised my grief and honoured her by continuing to work hard and overachieve. It was the only way I knew to go on.

With the world at my feet, I enjoyed great success as a freelance Marketing/PR gun for hire. I ran exciting projects for record companies, European sports cars and energy drinks. Cognisant of the values instilled in me by my Grandma, I tempered the exhilaration of my projects with charity work, raising money for women's causes and feeding the homeless.

I had a fantastic boyfriend, Simon was successful, caring (he'd make me Tapioca pudding - just like Grandma!) and devastatingly handsome - much to our amusement, friends called us 'Ken and Barbie.'
Throughout her life, Jo Cahill has suffered from depression. It's incredibly important to understand your mental health issues, and seek help if necessary.
But the spectre of my mother and her mental illness continued to live rent-free in my mind. I'd check in with her regularly to ensure she was okay, but we had no real relationship.

In 2010 I received a letter, addressed in my mother's looping handwriting. Inside was a two-page typed letter.

Scanning the first paragraph, it mentioned her need for honesty and how she needed to tell me about our father.

"Our father"? I stopped.

Confused, I read it again.

The next sentence "Neither of us will ever understand our father."

Was she saying what I think she was saying? I couldn't believe what I was reading. I couldn't continue. I suspected what was coming. I began to hyperventilate.

Fifteen minutes later, I forced myself to read on. All my fears, and more, were realised in the next paragraph:

"Jodi, you and I share the same father. From a very young age I suffered abuse of every kind from our father. The night I was brutally raped and fell pregnant, I will remember for the rest of my life ... a gun at my head with our father telling me he would kill me if I went to the police."

I couldn't breathe. I was in complete shock. I felt guilty. I was riddled with disgust. Disgust at what had happened. Disgust at what I was.

All of a sudden, all my mother's demons made sense. What she had suffered. Her hatred of me.

I called my friend Carmel and begged her to meet me. I needed a drink. We met at a bar. There were no tears. I was numb. I passed her the letter, gulping champagne. Carmel's reaction was shock, but she assured me: "God loves all his children."

I snapped: "Are you fucking with me? Look at the letter! Look at what I am!"

Carmel told me to go home, I ignored her and kept drinking, she left.

I sat there, slamming down vodkas, polishing off two bottles of champagne. I blacked out. I don't remember the 20-minute walk that took me to the Bulla Rd bridge. I stood there for a while, then climbed over the railing, trying to work out where to jump, so as not to hurt somebody (thanks Grandma, always thinking of others). I started to fall, the next thing a hand grabbed my ankle and I was being dragged back over the railing. There were police cars everywhere; it looked like a scene from the Blues Brothers.

Eyewitnesses said I was screaming at the police, telling them the sordid tale of my being. I was taken to hospital, were I was sectioned for the next four weeks.

For the first time in my life, I felt a failure. I felt like my disturbed mother and not my valiant Grandmother.

On my release, I threw myself in to my charity work, labouring 24/7 to forget my dark secret and to ensure I never again became like my mother.

I did my research; it seemed the general consensus was that children born like me would suffer physical and psychological deformities. They would never love, never contribute to society. They would never have normal lives. They were more likely to commit violent crime. It seemed children like me were destined to carry the evil genes of their fathers.

I was determined not to let anyone know the horrific truth about what I was, a monster, the product of rape and incest.

As a consequence, I could not share my burden with Simon, and our relationship ended.

Whist I kept the truth to myself, my mother opened the floodgates and shared our secret with extended family. I received a call from my uncle - but rather than offering comfort, he made it about him, carrying on about how he should have been there and how he didn't know. Close cousins now refused to talk to me and treated me as an abomination.

I was disconsolate. I now knew I had to tell all my close friends, it was better coming from me in an environment I could control.

I felt gut-wrenching nausea making those calls. Subconsciously I wanted them to hate me, to validate my own feelings of disgust, but they didn't.

They showed compassion, empathy and love. Vowing to support me and help carry my load.

I was in a quandary, where, because they didn't despise me or pity me, I had to return their support and fight.

I am a control freak. A perfectionist. I needed to regain control of my life. And what easier person to control than yourself ? I began to starve myself. It gave me the power to fill a void, my empty spirit.
I used to be slim, healthy and athletic. Once the anorexia started to take hold, my weight loss spiralled out of control, until I weighed the same as a child.

Friends became concerned. They tried to help. But I was so repulsed by what I was, I pushed them away.

My thoughts now turned to him, my father/grandfather. I looked back at old photos of me as a child, being held by him, his revolting hands around my innocent little body.

I wanted to hurt him. Punch him. Shoot him. But he was long dead. I'd like to dig that mongrel up and shake his malevolent old bones.

So that's what I did. I downloaded a map of Springvale Cemetery, where the evil old bastard was rotting. I found him.

Clutching a bottle of Veuve Clicquot, a packet of smokes and using my lighter to guide the way, I stumbled to the grave site. I stood there crying. Then I got angry, kicking dirt with my feet. I started to dig. And then I fell, in to an open grave next to him (kind of ironic that I once again found myself in a dark hole.)

Lying in the cold, damp dirt, looking up at the sky, I started to scream, letting out my primal rage. Then I found the funny side of it and started to laugh at the absurdity of the situation.

Unable to climb out of the six-foot hole, and with dirt raining down on me from my futile attempts to escape, I finally relented and called the police for help.

The police quickly arrived, their torches pointed down at me, blinding me, as I lay in the empty grave. Laughing hysterically, they thought I was playing some prank. It wasn't until I dissolved in to flood of tears, that the police realised my situation was far more serious.

The kind constables took me home, where I felt in desperate need of a shower. I could scrub all I liked, but never be clean.

Anorexia continued to tighten its cruel grip around me. In 2012, I was hospitalised. My heart rate measured 30 BPM and I was tube-fed for four months.

After a six-month stay, I was sent home. I tried to pick up my work, but I was a mere shell of my former self. I wanted to die. Not because of what I knew, but because of what I had become.

Numerous attempts to get well failed.

Finally my GP, knowing I had less than a week to live, sent me to Sydney for treatment at a world renowned facility for the treatment of severe eating disorders.

My initial three-month stay saw me gain a little weight, and I felt good. My first two weeks home in Melbourne, I finally felt like me again. I reconnected with old friends. Jodi was back! I partied hard, I lost my resolve, my weight quickly dropped to skeletal once again.

My GP and treatment centre begged me to return for treatment. I ignored them. I felt like a failure.

But fortunately, my friends, my GP, and an angel of a nurse at the clinic, finally convinced me to return.

It has now been five months, and my weight is healthier. I look well (although some of the vigour could be attributed to fake tan).

My mother and I are now reconciled. We talk every week. We will never have a mother-daughter relationship - we are both victims of the same terrible crime - but I have begun to understand her.

I have had my setbacks. At times, every mouthful of food makes me feel dirty and violated, I hate myself. It's not about gaining weight, it is about succumbing to the trauma. Sometimes I feel the need to mask my emotions via starving myself.

But my doctor assures me that these feelings are natural and common as anorexics reach their summit on their climb to wellness.

Indeed, climbing is a great analogy for my journey.

As famous climber Ed Viesturs once said, "Getting to the summit is optional; getting down is mandatory.

"When climbing Mount Everest, the summit is merely a halfway point. When you reach it, you've accomplished something amazing, but you've also grown fatigued, cold and are at maximum risk."

I am now on the start of my descent back to base camp, back to wellness, surrounded by my faithful friends and dedicated doctors and nurses, who have become my metaphorical Sherpas, I am going to beat this.

For the last five years, I have found myself in a cold and empty twilight, somewhere that others may also end up, may have been, or are going through and I want to make a difference.

There is absolutely nothing I can do to change my past, but I am in complete control of my future.
Jodi Cahill is a Melbourne based PR Executive and humanitarian, dedicated to charitable causes for the homeless and women battling serious illness.
If you or anyone you know are struggling with an eating disorder or body image issues, contact The Butterfly Foundation on 1800 ED HOPE / 1800 33 4673 or email [email protected]For anyone struggling in any way, call Lifeline's 24hr crisis telephone line on 13 11 14. Alternatively, you can access online one-on-one Crisis Support Chat.

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The sins of the father: The family secret that shattered one woman's world.

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Warning: This post deals with issues of abuse, suicide and eating disorders. It contains photographic images that some readers may find distressing. US Professor of Social Studies Brene Brown famously said "When we deny our stories, they define us. When we write our stories, we get to write a brave new ending."

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Eating disorders can affect people of any age, race, gender or sexual orientation. They are often diagnosed in teenagers and young adults, but many people are first diagnosed with an eating disorder in later adulthood. Sometimes the first signs and symptoms develop at a much younger age.

"I am currently 25 years old and I have had issues with my weight and my self-esteem since junior high. I was your typical, awkward preteen. Chubby, braces, glasses, acne and a sweet, yet painfully shy, personality. I was self-conscious about everything, including my weight." ~Sara

Many changes occur in our bodies during adolescence. These changes can be very difficult for some youth. Sometimes, those who are dissatisfied with their bodies will turn to disordered eating. However, there are many risk factors for eating disorders, and not everyone who is unhappy with their body will develop an eating disorder.

Some types of eating disorders are more common in women and girls than in men and boys. However, eating disorders affect people of all genders. Transgender, non-binary, and gender diverse youth report higher rates of eating disorder symptoms than cisgender youth (those whose gender aligns with the sex assigned to them at birth).

Men, boys and gender diverse individuals may experience more barriers to accessing support for eating disorders, and may be less likely to be diagnosed with an eating disorder. It may be hard for people who are experiencing eating disorder symptoms to talk about their behavior. Sometimes people worry about what others will think about them. Some people may be worried about untrue stereotypes that exist about eating disorders. These fears may make it harder for people to get the help they need. Some people may also be worried about what it would be like to start making changes to their eating.

The information we get about eating disorders from television, magazines or social media is not always true. For example, some people view eating disorders as a choice rather than serious biological illnesses.

Resource List

9 Truths about Eating Disorders

Understanding Eating Disorder Statistics

Eating Disorders in Men & Boys

Eating Disorders: Beyond the Myths

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Who is affected by eating disorders? - Kelty Eating Disorders

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Eating disorders can affect people of any age, race, gender or sexual orientation. They are often diagnosed in teenagers and young adults, but many people are first diagnosed with an eating disorder in later adulthood. Sometimes the first signs and symptoms develop at a much younger age.

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What is Anorexia Nervosa?

Anorexia nervosa is an eating disorder in which a person intentionally limits the intake of food or beverage because of a strong drive for thinness and an intense fear of gaining weight. This can happen even if a person is already thin. The perception of body weight and shape is distorted and has an unduly strong influence on a person's self-concept. The resulting weight loss and nutritional imbalance can lead to serious complications, including death.

Obsessions and anxiety about food and weight may cause monotonous eating rituals, including reluctance to be seen eating by others. It is not uncommon for people with anorexia nervosa to collect recipes and prepare food for family and friends, but not partake in the food that they prepared. They may also adhere to strict, intensive exercise routines to lose or keep off weight.

What Causes Anorexia Nervosa?

Anorexia nervosa does not have a single cause, but is related to many different factors. These factors are sometimes divided into predisposing, precipitating, and perpetuating factors, that make a person vulnerable to develop, trigger the onset, and maintain the eating disorder, respectively. Anorexia nervosa often begins as simple dieting to "get in shape" or to "eat healthier" but progresses to extreme and unhealthy weight loss. Social attitudes toward body appearance, family influences, genetics, and neurochemical and developmental factors may contribute to the development and maintenance of anorexia nervosa. A personal or family history of anxiety, depression or obsessive-compulsive habits is common. Although families in which anorexia nervosa occurs were once labeled as having difficulties with conflict resolution, rigidity, intrusiveness, and over-protectiveness, it is now clear that parents do not cause eating disorders. Research suggests that certain areas of the brain function different with an active eating disorder.

Who is Affected by Anorexia Nervosa?

Anorexia nervosa not only affects individuals who have the diagnosis, but also their family, friends and loved ones. The diagnosis of anorexia nervosa has become more common over the past 20 years. Approximately 90 percent are women between 12 and 25 years of age. Initially found mostly in upper- and middle-class families, anorexia nervosa is now known to affect both sexes and span all ages, socioeconomic, ethnic, and racial groups.

What Kind of Person Tends to Get Anorexia Nervosa?

The typical profile of a person with anorexia nervosa is an adolescent to young adult female who is perfectionistic, hard-working, introverted, resistant to change and highly self-critical. They also tend to have low self-esteem based on body image distortion and avoid risky or potentially harmful behaviors or situations. However, regardless of the age, sex or other characteristics of the individual, weight control habits focused on reducing intake and increasing output of calories (particularly fats and carbohydrates) initially reduces anxiety, stress and negative mood by giving the person a sense of control in at least one are of her/his life. That is, a sense of mastery and accomplishment is achieved as weight is lost. Over time, these habits cause problems of their own that may increase anxiety, stress and negative mood.

What are the Different Types of Anorexia Nervosa?

There are two subgroups of behavior aimed at reducing caloric intake, including the following:

restrictive type - severely limits the intake of food and usually compulsively over-exercises.

binge/purge subtype - eats large amounts of food in a brief period of time (binges) and then compensates by intentionally vomiting (sometimes called purging), taking laxatives, exercising or fasting.

What are the Symptoms of Anorexia Nervosa?

The following are the most common symptoms of anorexia nervosa. However, each individual may experience symptoms differently. Symptoms may include:

Intense dieting or preoccupation with food

Intense fear of gaining weight , even when losing weight or at a very low weight

Distorted view of one's body weight, size, or shape; sees self as too fat, even when very underweight; expresses feeling fat, even when very thin

In females, absence of menstrual cycles without another cause

Hiding/discarding food

Counting calories, grams of fat in the diet

Rapid or excessive weight loss

Feeling tired, cold and weak

Lack of energy

Denial of feelings of hunger

Cold and blue hands and feet

Constipation

Dizziness or fainting

Hair loss

Slow heart rate

Absent or irregular menstruation

Excessive facial/body hair

Binge eating alternating with fasting

Vomiting or taking laxatives after over-eating

Compulsive or excessive exercise

Self-worth determined by weight or shape

Persons with anorexia nervosa may also be socially withdrawn, irritable, moody, and/or depressed. The symptoms of anorexia nervosa may resemble other medical problems or psychiatric conditions. Always consult your physician for a diagnosis.

How is Anorexia Nervosa Diagnosed?

Parents, family members, spouses, teachers, coaches, and instructors may be able to identify an individual with anorexia nervosa, although many persons with the disorder initially keep their illness very private and hidden. A detailed history of the individual's behavior from family, parents, and teachers, clinical observations of the person's behavior, contribute to the diagnosis. Because a number of medical conditions can mimic some features of anorexia nervosa, a complete medical evaluation is needed. Family members who note symptoms of anorexia nervosa in a loved one can help by seeking an evaluation and treatment early. Early treatment can often prevent future problems.

Anorexia nervosa, and the malnutrition that results, can adversely affect nearly every organ system in the body, increasing the importance of early diagnosis and treatment. Anorexia can be fatal. Consult your physician for more information.

Treatment for Anorexia Nervosa

Specific treatment for anorexia nervosa will be determined by a physician based on:

age, overall health, and medical history

extent of the symptoms

tolerance for specific meal plans, therapies, or medications

individual and family preferences

Anorexia nervosa is usually treated with a combination of medical care focused on nutritional rehabilitation and modification of behaviors related to eating and exercise to restore body weight and health, and family and/or individual therapy. Treatment should always be based on a comprehensive evaluation of the individual and family. Family therapy is focused on providing support and limit-setting on problem behaviors. Individual therapy usually includes both cognitive and behavioral techniques. Medication may be helpful if depressed moods or worrisome thoughts interfere with daily life. Re-establishing a normal weight may relieve depression on its own, and anti-depressants are not effective at very low body weight. The frequent occurrence of medical complications and the possibility of death during the course of acute and rehabilitative treatment requires both your physician and a nutritionist to be active members of the management team. Families play a vital supportive role in any treatment process.

Possible Complications of Anorexia Nervosa

Medical complications are common in anorexia nervosa. Almost all complications are reversible with weight restoration related to healthy eating and physical activity. Without treatment, complications persist and can worsen, and can be associated with death. The short-term complications include, but are not limited to, the following:

Heart
As a muscle, the heart is affected by both poor nutrition and exercise. In addition, the control mechanisms for the speed and regularity of the heartbeat are located in the central part of the brain. With prolonged low weight over several years, the heart muscle can eventually give out, causing death.

irregular heartbeat

slow heartbeat

low blood pressure

fainting

with chronic low weight, fatal heart decompensation

Red blood cells that carry oxygen and the white blood cells that fight infection are often low.

Stomach. liver and intestines
Loss of muscles in the gastrointestinal track results in shrinkage of the stomach and slow movement of foods through the track. Paradoxically, starvation can be associated with deposits of fat in the liver.
Full, bloated feeling after eating a small meal
Feeling that the food does not empty from the
Constipation due to loss of muscle in the gastrointestinal track
Inflammation of the liver due to fatty deposits with starvation

Kidney
Dehydration associated with anorexia results in highly concentrated urine. Increased urine production may also develop in patients when the kidneys ability to concentrate urine decreases.

Hormones
Absence of the menstrual cycle is one of the hallmark symptoms of anorexia nervosa, and may precede significant weight loss..

Bones
Persons with anorexia nervosa are at an increased risk for broken bones due to osteoporosis.

Biochemistry and Eating Disorders

To understand eating disorders, researchers have studied the neuroendocrine system, which is made up of a combination of the central nervous and hormonal systems.

The neuroendocrine system regulates multiple functions of the mind and body. It has been found that many of the following regulatory mechanisms may be, to some degree, disturbed in persons with eating disorders:

temperature regulation

sexual function

physical growth and development

appetite and digestion

sleep heart rate

kidney function

emotions

thinking

memory

Eating Disorders, Anxiety and Depression

As already noted, many people with eating disorders may also have anxiety, depression, and obsessive-compulsive traits. There may be a link between anorexia nervosa and these other disorders. For example

In the central nervous system, chemical messengers known as neurotransmitters control hormone production. The neurotransmitters serotonin and norepinephrine, which function abnormally in people who have depression, have been discovered to also have decreased levels in both acutely-ill anorexia and bulimia patients, and long-term recovered anorexia patients.

Research has shown that some patients with anorexia nervosa may respond well to selective serotonin reuptake inhibitors (SSRIs) after weight is restored.

People with anorexia, or certain forms of depression, seem to have higher than normal levels of cortisol, a brain hormone released in response to stress. It has been shown that the excess levels of cortisol in both persons with anorexia and in persons with depression are caused by a problem that occurs in, or near, the hypothalamus of the brain.

The first line of treatment for Anorexia nervosa is food. Improving nutrition alone often improves depression, although anxiety may increase initially.

Genetic/Environmental Factors Related to Eating Disorders

Because eating disorders tend to run in families, and female relatives are the most often affected, genetic factors are believed to play a role in the disorders.
But, other influences, both behavioral and environmental, may also play a role. Consider these facts from the National Institute of Mental Health:

Genetic factors are known to contribute to the anxiety, depression and obsessive-compulsive traits often occurring in anorexia nervosa. This does NOT mean that parents who are anxious, depressed or have obsessive-compulsive traits CAUSE anorexia nervosa, but that there is an increased vulnerability to develop it.

"Innocent" teasing about body weight or appearance, especially by fathers and/or brother(s), may contribute to the onset of anorexia nervosa (precipitating cause). .

Although most individuals with anorexia nervosa are adolescent and young adult women, these illnesses can also strike men and older women.

Anorexia nervosa is found most often in Caucasians, but these illnesses also affect African Americans and other races.

People pursuing activities or professions that emphasize thinness - such as modeling, dancing, gymnastics, wrestling, and long-distance running - are more susceptible to these disorders.

Prevention of Anorexia Nervosa

Preventive measures to reduce the incidence of anorexia nervosa are not known at this time. However, early detection and intervention can reduce the severity of symptoms, enhance the individual's normal growth and development, and improve the quality of life experienced by persons with anorexia nervosa. Decreasing emphasis on weight and focusing on the balance between energy input and output can be useful. Moreover, having healthy adult role models who do not talk about body shape or size, dieting, fat, or losing weight is helpful. Also, encouraging healthy eating habits and realistic attitudes toward weight and diet may be an effective preventative measure.

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Anorexia nervosa is an eating disorder in which a person intentionally limits the intake of food or beverage because of a strong drive for thinness and an intense fear of gaining weight. This can happen even if a person is already thin.

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Updated May 04, 2017 13:56:45

These women are united in grief in a way few others can understand - each lost a loved one to suicide, brought on by an eating disorder.

The pain is particularly raw for Fiona Ryan, from Victoria.

Her daughter Tess was diagnosed with anorexia at age 11 and last year died aged 16.

"I don't think anybody can understand it unless you've been there with it," she told the ABC.

"It's such an intense experience and something that even when you share it with other people they don't know, they can't get it."

According to researchers, anorexia nervosa has the highest mortality of all mental illnesses.

One in five patients with the condition will die by suicide.

All the families had one thing in common - they all struggled to get doctors to take their concerns seriously.

Annette Baker's daughter Mary battled anorexia from the age of 12, until the illness led to her suicide three years later.

Annette and her husband Stuart fought to get medical help for her daughter.

"The first doctor said to me to 'give her a Coke and a milkshake and she'll be fine with a vitamin pill'," Ms Baker said.

"The second one was a paediatrician who insisted that she had a virus. He suggested she go back to school and start exercising when she was clearly at her sickest."

Doctors never told the family there was a risk of suicide.

"The first we knew about suicide was when Mary took her life, so maybe we were remiss and maybe should have done some more reading or something else, but we weren't certainly on watch or aware and there was no warning at all," she said.

Government pledges to improve services for patients

After the ABC raised concerns over the treatment of eating disorders with Health Minister Greg Hunt, he said he would take action.

"We have to do more for mental health, but specifically for anorexia, which has been such a tragic condition and so it has been, to a degree, overlooked and it's time to put the spotlight firmly on eating disorders," he said.

He has asked the Medicare review committee to look at the opportunities for further assistance to patients.

"It will look at whether new approaches should be made available under Medicare specifically for eating disorders, and particularly for anorexia," he said.

Mr Hunt will also include eating disorders in the fifth mental health plan.

"I think it's very important that we recognise and give due focus to the sheer pain that individuals and families suffer," he said.

"Eating disorders have a tragically high rate of loss of life, and it can affect families for years and years," he said.

According to the National Eating Disorders Coalition, about one in 20 Australians has an eating disorder and the rate in the Australian population is increasing.

Este Darin-Cooper's sister Raia was diagnosed with anorexia when she was 11.

She died by suicide in 2006 when she was 25.

"I thought by now things would have changed. We always put it down to the fact that the illness was quite new in society, people didn't understand it," she said.

"But to look now and think things haven't changed, and haven't moved on at all is just astounding."

Fragmented care, suicidal pleas ignored

All the families said the teens were bounced in and out of hospitals as their weight went up and down.

But none were offered holistic care to treat their physical and mental illness.

Fiona Ryan said at one Melbourne hospital, she was made to feel like she was responsible for her daughter's condition.

"One psychiatrist was giving us advice about what we should do and I said I didn't know if I could do this, hold Tess down and put the food in her mouth without hurting her," she said.

"He said I needed to go into therapy so I could find out why it was that I couldn't save my daughter's life."

"That stayed with me for a long time," she said.

Fiona was told Tess could not get her mental health issues addressed until her weight had increased.

At one point, Fiona was so worried about her daughter's mental health, she waited for 35 hours in an emergency department until Tess was admitted.

"The health system should have been there to help her to get better," she said.

"But the system itself doesn't cater for the fact that these young people have needs that are not just medical, they're not just psychological.

"They need to be looked at as a whole person, and that's not the way that our health system is set up."

The Butterfly Foundation is the peak body for patients with eating disorders.

Its chief executive, Christine Morgan, said too many families were seeking help after losing a loved one to an eating disorder.

"We have families coming to us because they've lost a loved one because of the physical ravages of the illnesses. That's horrific," she said.

"But we're also having families coming to Butterfly who's person has committed suicide and they're saying, 'we didn't even realise suicide was a risk for somebody with an eating disorder'."

Fiona Ryan, whose daughter Tess died by suicide added: "I think there are so many people with eating disorders and the statistics are so bad about it that we have to do something, and we can do something. But we've got to make it a priority."

Solutions exist, say health experts

Patients with eating disorders are not receiving the proper amount of therapy that could help them recover, according to one of Australia's leading eating disorder experts.

Monash University's Dr Richard Newton said for patients with anorexia nervosa, the best, simplest and most cost-effective treatment is cognitive behaviour therapy.

"It requires 20 sessions of treatment to be effective, at the bare minimum, but the maximum number of sessions of treatment somebody can access under Medicare is 10," he said.

"So there is a massive under-dosing of treatment available to people with eating disorders from Medicare in a way that I think is really concerning."

Dr Newton said GPs needed more training to better identify and treat patients with eating disorders.

"The vast majority of people who present to their GP with an eating disorder run the risk of being misdiagnosed, being provided with unhelpful feedback or reassurance that they don't really have a problem when they very manifestly have many problems that are severe and life-threatening," he said.

There are some private hospitals and clinics treating patients with eating disorders, but these services are only available to those families who can afford it.

Of the families the ABC spoke to, those who had been in the private health system had mixed experiences.

Patchy hospital services across Australia

The Butterfly Foundation is calling on the Federal Government to identify eating disorders as a core part of all mental health and suicide-prevention services.

"We must ensure the primary health networks have as a mandate to include eating disorders as core business and we must ensure that we've got a workforce across health and allied health that knows how to identify and treat eating disorders," Ms Morgan said.

"Our dedicated telephone counselling service should be provided 24/7 to make sure that we can reach all Australians that need it."

Despite increased awareness of eating disorders, hospital services across the country are patchy.

"The ones faring most poorly are those that don't have what we call any eating-disorder-specific beds," Ms Morgan said.

"They would be the ACT, Tasmania, the Northern Territory. In Western Australia, whilst they have beds for children and adolescents, they have no eating-disorder-specific beds for adults."

The families hope by speaking out, the lives of other patients with eating disorder will be saved.

"I hope that when it's several years down the track, when I am like Annette Baker, I won't meet another me, and it will be better for families," Fiona Ryan said.

"We know that people with an eating disorder have high risk of suicide and we need to take that seriously. And we need to make sure that they're getting support for their mental health."

Annette and Stuart Baker have created an annual winter solstice event in regional NSW to honour their daughter and to allow people to feel comfortable and talk openly about suicide and other mental health issues.

Topics: health, eating-disorders, doctors-and-medical-professionals, federal-government, suicide, australia

First posted May 04, 2017 06:00:39

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Australia's health system 'failing' patients with eating disorders

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Raia Darin-Cooper fought anorexia for 14 years before she ended her own life at just 25 years old. Her family - and the families of several others whose eating disorders led to their suicides - says it's time for a shake-up of the health system.