8:55 p.m. Get home and puke before even putting backpack down. Go to my bedroom to eat more.

9:35 p.m. Again.

…

Breakdown of Age of Anorexia Onset by Percentage

In the Feb. 26 issue of Red Letter Daze, the anonymous Cornell Diary, “Binge, Purge and Repeat,” exposed some of Cornell’s own quiet, private anguish: a student suffering from an eating disorder. However, this student is not alone.

In the United States, eating disorders are more common than Alzheimer’s disease. 5 to 10 million people have eating disorders, compared to 4 million with Alzheimer’s disease, according to the National Eating Disorders Association’s website.

“Our numbers continue to rise. We see 400-500 people a year [concerning body image, eating disorders and disordered eating],” said Dr. Greg Eells, director of Counseling & Psychological Services (CAPS) at Gannett.]

DEFINING EATING DISORDERS

“What defines an eating disorder is usually the pathology, an abnormal state of the body, before and after the eating,” said Prof. David Levitsky, psychology, who studies the effects of nutrition on behavior, control of food intake and body weight, obesity, nutrition and health.

A.J. Rubineau, lead medical clinician of the Cornell Healthy Eating Program at Gannett, explained that an eating disorder is a diagnosis outlined by the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV. The most common eating disorders include anorexia nervosa, bulimia nervosa and binge eating disorders.

According to the National Eating Disorders Association website, anorexia nervosa is “a serious, potentially life-threatening eating disorder characterized by self-starvation and excessive weight loss.”

“Anorexics don’t eat. [Each one] completely avoids eating food. They will talk about food, prepare it, but will not eat it,” Levitsky said. “With the bulimics, overeating and purging are abnormal acts and are very dangerous. They can lead to cardiac problems, burning and scarring of the esophagus, rotting teeth via stomach acids, and calcium decays. The dentist may be the first one to recognize an eating disorder.”

The National Eating Disorders Association defines a Binge Eating Disorder (BED) as “a type of eating disorder not otherwise specified and is characterized by recurrent binge eating without the regular use of compensatory measures to counter the binge eating.”

Levitsky said that the diagnostic term for over-eating is a certain number of overeating episodes per month or week, but that “everyone overeats at one time or another — like at celebrations.”

In addition to the most common eating disorders, there exists the category of ‘disordered eating,’ which describes behaviors that do not meet the criteria of a classic eating disorder according to the DSM-IV.

Claudette Peck is a nutritionist on staff at Dartmouth and is a member of the Eating Disorders Program consultation team there. “Disordered eating is on the continuum of an eating disorder,” Peck said.

However, Rubineau cautioned: “Just because you don’t meet criteria for an eating disorder does not mean you do not get treatment.”

Peck believes that the new eating disorder related term “orthorexia,” coined by Steven Bratman, a Colorado MD, falls into the category of disordered eating.

Orthorexia, or literally “correct eating” in Latin, is “just as dangerous as anorexia” according to Bratman’s website, orthorexia.com.

“However, the underlying motivation is quite different — while an anorexic wants to lose weight, an orthorexic wants to feel pure, healthy and natural,” Bratman stated on his website.

This drive for purity, according to orthorexia.com, leads to curbing food intake, emaciation and even death.

“Whenever you categorize foods as ‘good’ or ‘bad,’ then you become much more rigid and inflexible in your eating,” Peck said. “And when that happens, there becomes a fixation. As a result, you begin to alter the food in your diet, and judge your character based on your eating.”

Peck went on to say, “Eating disorders have overtones of anxiety disorders — it becomes all about control, a shift in attitude, and ‘if I don’t eat a certain way, then I have to compensate to fix it.’”

WARNING SIGNS

In response to the Cornell Diary “ Binge, Purge and Repeat,” Eells said, “It is accurate, we see a lot of that here [at CAPS]. They don’t really want to talk about their eating disorder, but we try to engage them. I was not surprised at all [by the Cornell Diary]. It is fairly descriptive. If you don’t eat a lot, you don’t need a lot of vodka to get ‘shit-faced.’”

“Other signs of an eating disorder is a student checking him or herself in the mirror several times a day, more of a compulsion than ‘Is my hair in the right place,’” Rubineau said. “It is an irresistible urge, often a critical assessment we [at CHEP] call ‘body checking.’”

For someone who is trying to diet, when they walk by food, they may feel as though food is “mocking her,” Rubineau continued. “A student feels withdrawn because they are dissatisfied with their appearance; it interferes with social life, isolation is indicative of that.”

Americans in general, according to Rubineau, do not exercise enough and eat too much. However, on campus she says, we sometimes see the opposite — exercise too much for eating too little. This stems in part from the fact that young people are just learning to feed themselves and make sense of this new body and campus.

One Cornell student, *Katie, arrived at Cornell having already experienced an eating disorder. She described her daily routine prior to her diagnosis of anorexia nervosa: “It varied, because it depended on how much I weighed. If I woke up and the scale read 85 lbs, I would try to skip meals that day. If it read 83 lbs, I would measure out 1/2 cup of dry oats and eat that for breakfast. For lunch, I had to eat five baby carrots and a peanut butter sandwich on whole wheat bread that I baked myself. Usually I would eat half of the sandwich at lunch and half when I was starved again two hours later. After practice, track and cross country, I made myself wait until 7:30 to eat dinner. I was always starving when I got home, and I often couldn’t stop eating at night. I figured the longer I waited to start eating, the less food I could physically consume before going to bed.”

Red flags and warning signs of an eating disorder manifest in some unusual ways: “Janitors have found bags of vomit in dormitory buildings,” Rubineau said. “Teammates and parents will come in with concerns.”

PRIME VICTIMS

For many students, like Katie, an eating disorder starts before they get to campus. According to Peck, many students — especially those at institutions of higher education such as the Ivy League — grew up with a competitive nature, which was cultivated by peer competition, parents and the culture in general.

“They have to be the best at everything — look the best, exercise the most,” Peck said. “It puts people completely out of balance. It does not give them permission to be human, flexible and make mistakes.”

Katie said that her eating disorder, specifically anorexia nervosa, began during the summer between her sophomore and junior year of high school, before she turned 16. The Cornell campus, however, did not contribute to her eating disorder in any way. In fact, according to Katie, “Cornell is the reason I’m healthy and happy and looking forward to the rest of my life. I don’t know if I’d have recovered and moved on with my life if not for my experiences here.”

Eells believes that our culture is about individual achievement and a considerable amount of discipline goes into an eating disorder. At Cornell, “the same skills and abilities, effort, focus and control that got you here academically also fuel an eating disorder. The [Cornell] Diary conveys the kind of suffering that accompanies an eating disorder.”

For Princeton alumnus Olivia Albrecht, being a member of the organization Eating Concerns Peer Educators while she was in school provided her personal insight about Princeton’s campus during her time there: “The observation was that on Princeton’s campus the average student is not overly thin, but trim … virtually no student’s overweight. All the statistics suggest that Americans are overweight in every age category, yet the opposite seemed true on campus.”

“[We] generated the hypothesis that an Ivy League institution with very driven students might have higher levels of eating disorders than the average population,” Albrecht said, “so we asked this research question [for a campus survey] ‘Is the national prevalence of men and women 18-25 with eating disorders higher or lower than the average found at Princeton?’”

Up to a quarter of college age women in this country have some type of eating disorder or disordered eating. Poor body image and poor self-esteem are significantly more prevalent than that. 91 percent of women recently surveyed on a college campus had attempted to control their weight through dieting, 22 percent dieted “often” or “always,” according to the National Eating Disorders Association.

“Part of what you see happening around the college campus is that there is high concentration of people that are at a high risk age,” said Dr. Beth Frenkel, supervising psychologist of the Eating Disorders Program at University Medical Center at Princeton. “Historically, young women from the upper and middle socio-econmic classes had higher rates of eating disorders. However, eating disorders have become more prevalent.”

According to Frenkel, anorexia and bulimia are a set of disorders that originally were seen predominantly among Caucasians, “but that doesn’t mean that it does not occur among all ethnicities.”

For anorexia, ages of onset are the middle teenage years, 14-18 years old, and 90 percent of those with anorexia are female. Age of onset for bulimia is young adulthood, with a similar picture for the male to female ratio. For those who suffer from binge eating, age of onset is in the 40s, 35 percent are male, and the population is significantly more ethnically diverse.

Frenkel pointed out that it is difficult for males to acknowledge when they have an eating disorder, because “in this country, eating disorders are a ‘girl’ thing.”

She went on to say that society negatively views males with female characteristics; males are therefore less likely to “come out” or admit to an eating disorder or disordered eating.

“Thinness is a female ideal,” Frenkel said.

Patterns of male eating disorders are currently being examined. While some males with eating disorders show the typical symptoms of anorexia or bulimia, other males try to get more muscle, and eat and exercise inappropriately in order to look like a stereotypical body builder.

Rubineau said, “Our experience with men and eating disorders on campus supports the general literature at around 10 percent. For the most part, men with eating disorders are looking for some way to get the body more cut. It may be the overlap with disordered eating around athletics. More men show signs of an eating disorder with over-exercise.”

Eating disorders are more prevalent among athletes in sports that have body requirements and require an athlete to ‘make weight,’ such as ballet, gymnastics, running, crew and wrestling.

Of all the factors present and leading to an eating disorder, however, socioeconomic status is the most strongly correlated. And this has added significance for an Ivy League student population that draws many of its members from the higher tax brackets. According to Levitsky, there may be a higher incidence [of eating disorders] in the Ivy League because of the phenomena of socioeconomics.

“We like to think of ourselves as egalitarian, but we [in the Ivy League] draw from upper to middle class, so there is more tendency for eating disorders,” Levitsky said.

Obesity is inversely related to socioeconomics: The higher the income, the less obesity abounds. The higher the socioeconomic group, the greater the tendency may be for an eating disorder.

“These are not unrelated,” Levitsky said. “As you go up the socioeconomic scale, there is an abhorrence to being large, a pressure to be thin, and the increased probability of an eating disorder.”

THE EFFECT OF CULTURE AND THE MEDIA

In addition to specific factors that play a role in eating disorders like genetics, gender, sports and socioeconomic status, American culture and the media add more pressure to be thinner than is realistically possible.

“There are good data showing that thinner people get the better jobs, apartments, man or woman, and unfortunately, there is some reality to that,” Levitsky said. “So if you are a large person or tend to be large, we can understand the drive to be thinner.”

Eells says peoples’ views of what is attractive is shaped largely by their culture: “Eating disorders primarily occur in cultures where the media portray a [thin] ideal that is not representative of the variability of body types found in reality and that this small sample of thin people on television and the media conveys a message that this is how your are supposed to look.”

“We live in a culture that glamorizes thin and demonizes fat,” Rubineau summarized.

Frenkel, however, cautioned, “The media creating unrealistic images of masculine and feminine beauty do contribute significantly to people feeling poorly about themselves and their bodies, but by itself, I do not think it causes eating disorders, because then all of us would have eating disorders. I have never come across a patient that said pictures in a magazine caused their eating disorder. Media images were one more thing that made them feel badly about themself.”

Not only do cultural and media perceptions of a thin ideal affect people mentally, they also affect us economically.

“In the current economic climate, a lot of people cannot pay for hospitalization for an eating disorder. 70 to 80 percent of those who get hospitalized for eating disorders have anorexia, because insurance companies are more likely to pay for them to get inpatient treatment, as anorexics are seen as more critical,” Frenkel said. “Bulimia is seen as mostly treatable on an outpatient basis. However,these illnesses kill people at an astonishing rate. Eating disorders have the highest mortality rate of any psychiatric illnesses, and approximately 30 percent of people with both disorders persist with some type of eating disorder or disorded eating.”

Illnesses such as depression and schizophrenia have been recognized (and may have existed) for much longer than eating disorders and more commonly have been understood to be a significant problem. There is more research about these disorders, better funding for both research and treatment, and an understanding that they are biologically-based illnesses that are therefore covered differently by insurance than eating disorders, which might hinder sufferers from getting treatment even if they realized they have a problem.

“If people are aware it is going on, it is frightening,” Frenkel said. “If it is scary to me, it is scary to them.”

ROOT CAUSES

While the outward appearance of eating disorders and disordered eating may be subtle, the pathology of the illness more than skin deep. Levitsky says the root cause of the disorder is psychological in nature and must be treated psychologically. There is an impetus to engage in these behaviors, and in almost all cases, the initiation is a distorted mental image of ones self.

“It is obsessive-compulsive behavior directed towards eating. The pathology is excessive thought and behavior. [People with eating disorders] are obsessive and compulsive about a lot of things,” Levitsky said.

According to Rubineau, “The Sun piece … illustrates very dramatically and clearly that these thoughts and impulses are completely enslaving this individual — she is at the mercy of these thoughts and impulses.”

“I was absolutely miserable,” Katie explained. “I don’t think I smiled for the entire four months when it was the worst. I felt guilty and ashamed every single time I ate. … I would chew and spit, which made me feel embarrassed and disgusted and in control at the same time. … I was angry that my friends ate whatever they wanted and were thin. I guess I was a mixed bag of negative emotions.”

Of all the concerns CHEP is presented with, the most frequent, Rubineau said, is “distracting thoughts, that preoccupation with food and body.”

Eells said that part of what is an eating disorder is the illusion of control: “You can throw up, eat and exercise to the extreme, but eventually you will kill yourself.”

With the development of an eating disorder, Eells said, the etiology includes a biological foundation and symptoms brought about by various environmental triggers.

According to Levitsky, there is some biological component.

“If you engage in a behavior obsessively, the brain will reflect,” Levitsky said.

Groups of people with pathological eating habits exhibit more abnormalities in gastrointestinal function, hormone and brain imaging than those who do not.

“Eating disorders are an illness — they are not about food, weight or looks; if they were, people that are overweight would stop losing weight when they reached a healthy range,” Frenkel said.

“All this attention on food and calories,” as Frenkel put it, is about ways to cope: distracting unwanted thoughs, numbing out feelings, and giving people with eating disorders a sense of control.

“Everybody I talked to tried to tell me how many calories I needed as a runner, how important protein and good fats are for athletes,” Katie said. “I knew that. I was an aspiring nutrition major. I knew exactly what I was doing, and I wasn’t going to let anybody stop me.”

However, there are two sides to this coin. People with eating disorders have other issues that are underlying, and they are not going to get better simply by eating.

People decide to cope with negative body image through dieting and exercise, which can get out of control if there are other underlying issues, Frenkel said. These people will not get better just by eating, she explained, but also that they would not get better if they did not eat and maintain a healthy weight.

“We must recognize the underlying issues — people die from these disorders, and it is not that they are physically incapabale of bringing food to their mouth. Something is overriding their drive to survive,” Frenkel said. “ They are not willing to give up their way of coping with things; they do not think they are going to be able to or have to directly face their problem.”

TREATMENT OPTIONS

Rubineau stressed that that eating disorders “are not about fat and thin, it is about disordered thinking, an unhealthy relationship of the body and mind … A fear is to minimize the disorder, and if in your gut, you are worried about a friend, yourself, the relationship with your body, ask us [at CHEP], that is what we are here for.”

For about 10 years, the Cornell Healthy Eating Program team has worked with students to optimize health and performance through good nutrition, knowledge and practice.

The CHEP team consists of nutritionists, medical clinicians and psychiatrists focused on issues of health and nutrition including eating disorders, illnesses in relation to nutrition and digestion, and anxiety and preoccupation around food and body image.

Although most of the students seen do have some disordered eating, or eating disorder, a proportion of students also come for other concerns related to food and nutrition, including wheat allergies, irritable bowel syndrome, vegetarianism, obesity or unexplained weight loss or weight gain.

According to the numbers from their annual report last year, the CHEP team encountered 450 students in a given school year with a nutritional concern.

90 percent of those were women, including both graduate and undergraduate students. Students suffered from anorexia and bulimia, as well as a broad range of concerns relating to food and body image. These numbers also represented students who sought information about a friend.

As communication specialist for Gannett, Jennifer Austin outlined the rules that the CHEP team follows in treating these students: “Even if you mom calls, we [at CHEP and Gannett] will not talk to her without express, written consent from you [and] cannot communicate outside Gannett with professors, boyfriends, roommates, anyone.”

Austin added, “Most people with eating disorders on campus and community at large get better with treatment.”

All you need to do is ask, according to Rubineau. “Don’t be afraid to ask,” she said. “No concern around food or body is too small. If you think something is wrong, don’t ignore it, there is help, people get better — Cornell is too fun a place, college to short a time to struggle and suffer without help.”

Katie believes, in the end, the quest to overcome an eating disorder is about the pursuit of happiness.

“Looking back, worrying about the shape of my stomach was the biggest mistake and the greatest regret thus far in my 21 years of life,” she said. “For the momentary satisfaction of that additional lost pound, I’ve paid with years of physical, mental, and emotional suffering. I would describe that time in my life as completely wasted with unhappiness. I promise, being happy has nothing to do with losing weight. I am truly happy because I accept the way I am (my mom and sister have the same exact wavy stomach, nothing I can do to change it) and I feel healthy. Though anorexia is a disorder, it’s also a decision. You have to want happiness and make the decision to pursue it.”

The following is an excerpt from a poem, which was written by the student at Cornell featured in this article who suffered from an eating disorder.

[...]

At the end of the tenth grade, I looked in the mirror

And considered for the first time my reflection.

I was fifteen years old, healthy, a runner,

Disgusted by the shape of my midsection.

My friends had flat stomachs, they ate what they wanted

So I gave up dessert in a confused effort to fit.

A couple months with no change and frustration,

I came to the end of my wit.

“This is the day that I do something about it,”

I decided when I woke one morning that summer.

I skipped meals, I lied, I pretended, I exercised,

Looking back, I couldn’t have been any dumber.

I discovered the scale after a couple weeks,

And thrilled in the decline of my weight.

Whether I got to eat or not on each day

Depended on the digit after eight.

The few months surrounding my 16th birthday

Were some of the worst in my 21 years.

I chewed and spit, I cut my wrists, I cried

With barely the energy to make tears.

Despite the help forced upon my miserable soul,

I was only to recover, in time, on my own.

I remained strict with my diet, paranoid to gain

But abandoned the losing for a happier zone.

I came to Cornell and met my new friends

Fast little runners that ate however they chose.

Why did I have to be hungry and so unhappy?

I quit restricting and all my eating woes.

Then I pulled the ultimate freshman move,

And put ten pounds on my weakened frame.

Some of it was muscle, some of it was fat

But for my bones, it was too late in the game.

The ball of my hip cracked vertically,

And I was out of running shoes for 115 days.

Then went my fibula and another three months off

For two years of abuse, how my bone repays.

The injuries revealed my bone density

To be three standard deviations below the mean.

It was a wake-up call to appreciate my body

Having severe osteoporosis at age 18.

Since then, I’ve worked hard every day

To restore my body and salvage my mind

I’ve sacrificed a few years and athletic dreams,

But happiness is worth it to find.

— Katie