Archive for Anorexia

Back Pain and Anorexia

Back pain. Responsible for billions of dollars in lost worker productivity, it’s one of the most common and disabling illnesses in America today.
And one of the most puzzling. Orthopedists, osteopaths, chiropractors, acupuncturists, and other health-care professionals all have different ideas about its causes and treatment. One controversial approach posits that most back pain is due entirely to emotional factors which cause benign physical changes in the body.

John E. Sarno, M.D. is Professor of Clinical Rehabilitation Medicine at the New York University School of Medicine and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at New York University Medical Center. Over the past 25 years, he has treated many thousands of patients with disabling back pain through educational lectures and claims a 90-plus percent success rate. He has written extensively on the subject, including his two most recent books, Healing Back Pain (Warner 1991) and The Mindbody Prescription (Warner 1998).

According to Sarno, most back pain is caused by tension myositis syndrome (TMS), a condition in which repressed rage causes the brain to select certain parts of the body for mild oxygen deprivation. The most frequently targeted areas are the neck, shoulders, and middle and lower back. Although “myo” means muscle, Sarno notes that nerves and tendons can also be involved.

Sarno’s theory, which draws heavily on psychoanalytic concepts, posits that the driving force behind back pain is unconscious or repressed rage. The pain serves as a distraction to prevent the sufferer from dealing with terrifying thoughts. According to Sarno, the rage is comparable to dangerous criminals in a maximum security prison. Unacceptably frightening thoughts exist below the level of consciousness but are constantly struggling to reach awareness.

Sarno says that there are three sources for the rage: past anger; a sense of inferiority; and daily life pressures. Past anger may involve childhood traumas such as sexual or extreme emotional abuse. Daily life pressures include work deadlines, taking care of children, and even positive life events such as getting pregnant or married.

One of the most interesting parts of the theory involves the sense of inferiority. It is more fully described in The Mindbody Prescription. According to Sarno, the “child,” what Freud called the “id,” is an illogical, narcissistic part of the unconscious that is easily angered. A desire to be perfect, to do “good,” and other self-imposed pressures enrages the “child,” adding to the reservoir of anger.

So what does all this have to do with anorexia nervosa?

Sarno posits the existence of “TMS equivalents,” other psychosomatic conditions besides back pain, which proceed according to the same model. These include such common ailments such as tension headache, migraine, constipation, diarrhea, and certain allergies. In addition, Dr. Sarno identifies a category of more serious illnesses in which TMS may play a role, including high blood pressure, arteriosclerosis, and even cancer.

On page 184 of the appendix to The Mindbody Prescription, Sarno suggests that eating disorders are psychosomatic in nature and follow the TMS model: “I have had many patients who have moved from more severe psychosomatic manifestations to milder ones: bulimia or anorexia nervosa to back pain, for example. My interpretation is that they have improved psychologically and no longer require the powerful distraction.”

Similarly, on page 130, he notes: “The more deeply repressed the rage, the greater the potential for serious illness. That idea is, of course, highly theoretical.”

It is not surprising that emotions play a powerful role in the development of anorexia nervosa. Previous articles on this topic page have stressed the psychological factors involved in eating disorders (see “The Psychological Basis of Anorexia Nervosa,Part I and Part II”). What makes Dr. Sarno’s theory unique is that it attempts to explain a whole host of illnesses, from mild to severe, with a single, unifying “mindbody” model.

As stated previously, the theory is highly controversial. Most members of the medical community reject it, preferring a “structural diagnosis” for back pain (e.g., disc herniation or degeneration). It should also be noted that Dr. Sarno has no psychoanalytic training, although he professionally associates with psychotherapists whom he recommends for patients with more intractable emotional difficulties. And although he believes that most back pain is due to TMS, Dr. Sarno stresses the importance of having a thorough medical examination to rule out serious disease.

Among Dr. Sarno’s supporters are Benjamin J. Sadock, M.D., professor and vice chairman of the Department of Psychiatry at NYU Medical Center, and Dr. Andrew Weil, a graduate of Harvard Medical School well-known for his writings on complementary medicine and mindbody phenomena. On page 4 of the May 2000 edition of his newsletter, Self Healing, Dr Weil writes: “According to John Sarno, MD, a physician who has greatly influenced my thinking on the subject, back pain can be a defensive mechanism. The unconscious mind may distract you from uncomfortable emotions by keeping back muscles in spasm.” On page 4 of the October 2000 edition of Self Healing, Dr. Weil adds: “Many patients have told me that just reading one of Dr. Sarno’s books has given them a new perspective on their situation, helped them focus on relaxing the affected muscles, and resolved their pain within a short time, often forever.”

Insurance Update

There’s progress on insurance coverage for anorexics, but there’s still a long way to go.
A previous article on this topic page reported that insurers frequently refuse to cover long hospital stays anorexics often require. But because of recent state and federal legislative action, that situation is changing.

According to an article published on, the Mental Health Parity Act of 1996 was intended to put coverage for mental illnesses, including eating disorders, on an equal footing with that of physical ailments. However, the Act, which went into effect in January 1998, contained loopholes. The most important of these, according to the article, is the provision prohibiting insurers from setting spending caps for mental health costs. Employers are able to circumvent this restriction by limiting the number of covered visits patients can have with therapists, or the number of covered days for inpatient or outpatient treatment.

U.S. Senators Pete Domenici (R-New Mexico) and Paul Wellstone (D-Minnesota) have sought to remedy this situation by introducing a Congressional bill that would provide full insurance “parity” between treatment for mental and physical illnesses. According to a February 25, 1999 press release by the National Alliance for the Mentally Ill (NAMI), the bill would guarantee equitable coverage for disorders such as severe anorexia by eliminating “unequal restrictions on annual and lifetime mental health benefits, inpatient hospital days, outpatient visits, and out-of-pocket expenses.”

NAMI notes that the legislation would only apply to employers with group plans that already cover emotional disorders. In addition, small businesses with 25 or fewer employees would be exempt.

A 1999 Clinical Psychiatry News article reprinted on Medscape observed that the House version of the bill, introduced by Representative Marge Roukema (R-New Jersey), would provide broader coverage–including provisions that would equalize inpatient and outpatient visit limits, copays, and deductibles for mental health and purely physical conditions. However, the more modest Senate version, according to the article, is designed to minimize opposition from business and insurance interests.

Opponents of the legislation say that it will greatly increase premiums. According to CPN, the 1996 Act exempts plans in which compliance would increase costs by more than one percent, but neither version of the proposed legislation contains this exception. Mental health advocates, according to CPN, argue that any added costs would be offset by increased worker productivity. This position appears to be bolstered by a caringonline article which notes that the portion of medical premiums attributable to mental health benefits actually decreased by 0.2 percent in Maryland after that state’s implementation of a parity statute.

The CPN article observes that the Senate bill does not require plans to provide parity for substance abuse coverage. This issue is of considerable importance to anorexic patients because many of them have a history of drug and alcohol problems.

According to , as of May 2000, 31 states had parity statutes with widely varying provisions.

State legislation covers substance abuse in Kentucky and Vermont, but not in Arizona, Indiana, Maine, New Jersey, New Mexico, or Tennessee. Massachusetts and Missouri parity statutes include substance abuse only if it stems from a mental illness.

State employees are covered in Indiana and Louisiana, but not in Arkansas. North Carolina covers only state employees.

In Arkansas, there is a small business exemption for companies with less than 50 employees, while in Maine the exemption is limited to employers with a staff of less than 20. California’s statute, on the other hand, has no small business exemption at all, and New Hampshire covers group plans and HMO’s regardless of size.

There are also a number of special provisions peculiar to individual states. For example, Hawaii’s parity statute only covers schizophrenia, schizoaffective disorder, and bipolar disorder. By contrast, Vermont covers any condition involving mental illness and provides comprehensive coverage of deductibles and out-of-pocket expenses.

While the Domenici-Wellstone bill would cover severe conditions, at least one state is considering legislation which would apply to milder cases. According to a February 9, 1999 article in The Daily, the Washington State Legislature has conducted committee hearings on a bill that would require insurance companies to cover treatment for eating disorders in their early stages. According to the article, Dr. James Farrow, director of the University of Washington’s adolescent medical program, said that there would be far fewer instances of severe anorexia and bulimia nervosa if insurers paid for early-stage care.

For suggestions on what to do when insurance companies refuse to pay for treatment, and a sample letter regarding same, visit the website of the Academy for Eating Disorders. Although unrelated to insurance, readers may be interested in an article in the Academy’s Fall 2000 Newsletter, also available online, about the eating disorders documentary “Dying to Be Thin.” The program will air December 12, 2000 at 9:00 p.m (EST) on NOVA/PBS. Directed by Larkin McPhee (who authored the article), it contains case studies of eating disorder sufferers ranging in age from 12 to 56.

Don’t Play The Numbers Game

Three cheers for the AHA! Dietary guidelines recently announced by the American Heart Association emphasize good eating habits over numerical criteria as a means of promoting health. While the recommendations are designed to alleviate and prevent cardiovascular disease, anorexics would do well to study them.
The Dietary Guidelines were approved by the AHA’s Science Advisory and Coordinating Committee in June 2000. They state: “The present formulation of the AHA Dietary Guidelines acknowledges the difficulty in most cases of supporting specific target intakes with unequivocal scientific evidence. Moreover, many individuals find it difficult to make dietary choices based on such numerical criteria. Therefore, the approach taken here is to focus the major population guidelines on the general principles…”

AHA’s advice includes the following:

eat fatty fish, such as salmon, at least twice weekly;
consume fruits, vegetables (especially those that are dark green, deep orange, and yellow), and whole grains; and
limit salt and alcohol intake. No more than one drink a day for women.
A previous article on this topic page has discussed the obsession anorexics have with numbers. Behaviors such as calorie counting, pound counting, and dress-size comparisons help maintain the illness. That a respected scientific body has chosen to promote general principles of good nutrition over figures bodes well for anorexics and sufferers of other eating disorders trying to overcome their illnesses.

In a recent article reviewing the Guidelines, Time Magazine’s Christine Gorman, writes: “If you follow the advice, your dietary percentages will fall into line naturally…Now you won’t need a calculator to figure out what’s best for you.”1. This is an effective counterweight to media images of reedy models gushing about their measurements.

Another is a program that was sponsored by the
Baltimore Museum of Art and profiled in a July 18, 2000 New York Times article2. According to the article, several Girl Scout Troops and over 50 other girls and women attended a program at the museum entitled “Feast, Famine, and the Female Form: Exploring Body Image Through Art.” The program, according to The Times, is part of a national campaign to prevent eating disorders. Psychologists gave participants a walking tour of the museum’s art exhibits, warning them about the dangers of excessive dieting, and stressing the fact that women need a certain amount of fat in order to bear children. The campaign attempts to foster body image acceptance among participants, and the idea that beauty knows no particular shape or size.

The article points out that “although obesity is the greater concern numerically, anorexia is the psychiatric illness with the highest mortality rate.” The Times piece notes similar efforts elsewhere in the United States, including “Go Girls,” a media literacy program developed in Seattle by Eating Disorders Awareness and Prevention, Inc., and “Free to Be Me,” a course developed in the St. Paul area by epidemiologist Dr. Diane Neumark-Sztainer.

Americans, in particular, have become a nation obsessed with figures, and food is only one of many casualties. Consider our recent presidential politics. During the debates, the candidates wrangled endlessly over statistics on Medicare, Social Security, and projected budget surpluses. Now we have a dead-heat election with interminable recounts and related media analysis. If you’re as sick of it as I am, apply that attitude toward your eating habits. Stop the numbers game and start living.

Anorexia and Sexual Orientation

A California psychotherapist recently emailed me about an anorexic client who was a lesbian. “Once she accepted that she was gay, her anorexia was no longer an issue,” he wrote. The clinician then asked me whether there was any research on anorexia nervosa and sexual orientation.

The answer is yes, but the association is complex. Recent studies indicate that while male homosexuals have a greater risk of developing anorexia than their “straight” counterparts, lesbian populations show less incidence of the illness than heterosexual women.

Eating disorders specialist Barton J. Blinder cites research by Herzog indicating that male anorexic patients experience sexual isolation, sexual inactivity, and conflicted homosexuality1. Herzog hypothesized that cultural pressure exerted by the gay community on homosexual men to be thin and attractive increases their risk for eating disorders2. While gay men represent three to five percent of the total male population3, they account for 20 percent of eating disorders among men4.

According to an article appearing on Medscape, a study of 135 eating disordered men conducted by psychiatrist Daniel J. Carlat, M.D. at Anna Jacques Hospital in Newburyport, Massachusetts found that 46 percent had bulimia, and 42 percent of the bulimic men were either homosexual or bisexual5. Thirty men (22 percent) had anorexia, and of these, 58 percent were asexual, which was defined by the researchers as lacking all sexual interest for one year prior to the study6. The researchers are quoted in the article as follows: “Homosexuality can be seen as a risk factor which puts males in a subcultural system that places the same premium on appearance in men as the larger culture places on women.”7.

However, the article also reports the observation of New York psychologist and eating disorders specialist Janet David, Ph.D. that the amount of research on this subject is small and should, therefore, be cautiously interpreted.

In contrast to male homosexuality, there is evidence that lesbianism may be a “protective factor” against developing an eating disorder8. Research by Siever indicates that pressure for thinness exerted by members of one’s community, from greatest to least, is as follows: heterosexual females, gay males, lesbian females, and heterosexual males9. This theory, however, remains controversial10.

Nothing in this article is meant to suggest that anyone should consider changing his or her sexual orientation. Gregory M. Herek, Ph.D., of the University of California at Davis, provides an excellent overview of this subject. Herek notes that the American Psychological Association has condemned the practice of “reparative therapy” touted by religious groups and others as a method of promoting heterosexuality in homosexuals. He describes the methodological and ethical problems with studies purporting to demonstrate the success of this technique.

Current research indicates that approximately 90 percent of anorexics are female and ten percent are male 11, but there is evidence that diagnostic criteria for anorexia nervosa are gender-biased. For example, one standard requirement for making a diagnosis of anorexia in women is three months of amenorrhea (absence of a menstrual period), but there is no equivalent criterion for men12. Research indicates that amenorrhea is not an important factor in determining the severity, or even existence, of anorexia in women13.

While current diagnostic tools favor making a diagnosis of anorexia in females, research suggests that the incidence of eating disorders is increasing in both genders14. The reason for the reported rise is probably due to both a genuine increase and better detection methods.

Untreated Anorexics

Between July 11 and August 11, 2000, I ran a poll on this topic page regarding treatment preferences among eating disorder sufferers. My thanks to all who participated. However, the results were, to say the least, disturbing.

The question was as follows: “Eating Disorder Sufferers Only. In your opinion, which of the following treatments has benefitted you most? (A) individual/group therapy; (B) alternative/complementary therapies; (C) traditional medicine; (D) any combination of the above; and (E) have not been treated.”

Out of 33 respondents, seven (21 percent) preferred individual/group therapy; two (six percent) preferred alternative/complementary therapies; two (six percent) chose “any combination of the above”; and a whopping 22 (67 percent) said they had not been treated. None of those responding said they preferred traditional medicine.

Granted, the polling is not scientific. Several professionals knowledgeable about eating issues informed me that an internet-based sample of this sort may be skewed in favor of people looking for information before making a decision about treatment. Despite this caveat, most of the professionals I queried agreed that the poll results were still disconcerting. They noted that because people suffering from eating disorders are often in denial, they frequently resist suggestions to seek professional help.

“One of the fundamental aspects of anorexia is the value which is attached to it by those with the illness,” writes Lucy Serpell, Ph.D., of Lucy Serpell’s Eating Disorders Resources, in an email. “For various reasons, most people with anorexia do not voluntarily seek treatment because they do not see their disorder as a problem, rather, they see it as a solution to their problems.”

Ms. Serpell, whose doctoral thesis examined eating disorders issues, recommends the following publications for further reading:

Hall, A. “Deciding to stay an anorectic”, Postgraduate Medical Journal, 58, 641-647 (1982).
Vitousek, K., Watson, S., & Wilson, G. T. “Enhancing Motivation for Change in Treatment-Resistant Eating Disorders”, Clinical Psychology Review, 18(4), 391-420 (1998).
Vitousek, K. B., & Ewald, L. S. “Self-Representation in Eating Disorders: A Cognitive Perspective” in Z. V. Segal & S. J. Blatt (Eds.). The Self in Emotional Distress (New York: Guilford Press 1993), pp. 221-257.
Anorexia nervosa and other eating disorders are complex psychological illnesses which can be triggered by a variety of factors. A December 13, 1999 Associated Press article reprinted in C- Health’s Canoe, a Canadian online service, noted U.S. Surgeon General David Satcher’s report stating that two-thirds of all persons with mental disorders never seek treatment. Clearly, treatment can make the difference between life and death. According to the National Women’s Health Information Center, approximately 2 to 3 percent of those treated for eating disorders die from their condition, but the death rate among untreated anorexics is in the 5 to 20 percent range. The Center cites a study finding a 42 percent weight loss relapse among anorexics after hospital discharge, indicating the importance of continuing intervention and follow-up.

Not only is the quantity of life affected by eating disorders, the quality of life is affected as well. Anorexia nervosa can bring on a whole host of illnesses, including osteoporosis, electrolyte imbalance, and heart problems. See “Signs, Symptoms, and Consequences of Anorexia.”

If you have been diagnosed with an eating disorder, now is the time to get treatment. If you suspect you have one, now is the time to get evaluated by a qualified health care professional. Delay will only diminish your chances for recovery.

The Trouble With Tables

Lately I have been receiving an increasing number of messages from women asking for advice about their weight/height, both on the boards and via email. Careless comments on this subject can be harmful to people susceptible to, or struggling with, eating disorders.

I have usually responded to such inquiries by simply noting that healthy weight is a highly individualized concept dependent upon many factors, and encouraging people with such concerns to seek competent medical advice. Unfortunately, I have occasionally voiced opinions on this subject based upon my recollection of standard weight-height charts and anecdotes about various actresses. That was very wrong, and for this error in judgment I humbly apologize. For the reasons stated below, I am now convinced that the mere mention of such numbers to persons with eating issues is, in the absence of face-to-face consultation with a qualified medical professional, fraught with danger.

“We do not allow our members to exchange anything number-related (weights, sizes, BMI [body mass index], calories, etc.) because it only feeds into the “competitive” nature of the illness, or the feelings of worthlessness based on a number,” writes Amy Medina of the Something Fishy Website in an email. “It takes away from the true purpose of the discussion – to explore the feelings underneath the symptoms. We have some strict policies in place, one of which is the “no numbers” rule. Another is related to medical questions: we don’t allow them at all. We have always stressed that even if we could answer the questions accurately, or diagnose them, it would be dangerous and unethical to do so, if for no other reason than their problem cannot be treated online.”

After querying several knowledgeable professionals and consulting with management, I have decided to adopt for this topic page a modified version of Something Fishy’s message boards rules. Please read it now.

Standardized weight and height charts are, at best, a rough guide to well-being. Over-reliance upon them can be hazardous. “They are not a reflection of what is healthy, but rather a reflection of actuarial data from insurance companies on mortality rates,” writes Bryan Gusdal, M.A., in an email. Mr. Gusdal is Director of the Westwind Eating Disorder Recovery Centre in Brandon, Canada. “They do not take into account lifestyle components such as smoking or exercise. BMI measures are a little better, but not much. Barry Saunders was a leading rusher in the NFL, and his BMI was 30. Was he obese? Was he unhealthy? He certainly was fit. Standards of health might be a better measure than standards of mortality rates. They just are not measuring the same thing. Glenn Gaesser’s Big Fat Lies (Fawcett Columbine 1996) has a good discussion on the origins of height-weight charts, their shortcomings and misuse. Questions of lifestyle would be more appropriate in terms of health, without so much reference to weight. The weight issue is more focused on appearance than it is on health, even though it is often presented as a health concern.”

Mohey Mowafy, Ph.D., Professor and Director of the Didactic Program in Dietetics at Northern Michigan University, concurs. “I have been teaching human nutrition, including a course on “body weight: its meaning and management,” for more than 25 years, and have never lived a semester without living the lively and often controversial discussion of the weight and height tables. The tables are good guidelines, but totally useless if perceived as axiomatic standards. They prove most valuable with individuals having the largest deviations from their ranges. Such cases certainly require a closer look. The tables are used often because they are easy and cheap. I teach my students to use them as a part of a comprehensive assessment that includes body composition and muscle mass, plus the usual family and personal health history, dietary and activity patterns, lab results, if and when needed, and whenever feasible, an assessment of the individual’s motives and motivations to change his or her weight.”

I have, to the best of my knowledge, deleted all messages appearing on these boards which violate the new rules which I have developed for this topic page. I will continue to monitor the messages accordingly. If I have overlooked any, or if you have additional concerns, please inform me. I very much regret having to impose any form of censorship, but under the circumstances, the potential for harm from such missives outweighs any possible benefits.

Anorexia and Vegetarianism

There are pluses and minuses to vegetarian diets. On the positive side, they provide more fiber and less fat than traditional American fare, but they carry an increased risk of deficiencies in vital nutrients such as calcium and protein. And the regimen is very popular among sufferers of anorexia nervosa.

An October 16, 1998 Scripps Howard News Service article appearing online at ABC cited a University of Minnesota study finding that vegetarian teenagers have a greater tendency to develop eating disorders than their meat-eating counterparts. The study, first reported in the 1997 Archives of Pediatrics & Adolescent Medicine, indicated that twice as many teenage vegetarians than non-vegetarians said they dieted frequently, and four times as many said they purged, according to Scripps Howard. However, the study drew no conclusions regarding cause and effect.

Nevertheless, a survey of 116 anorexic patients cited by Scripps Howard indicated that 54 percent avoided red meat; only four percent had done so before their illness. Similarly, research into the food habits of 131 young adult women reported in the International Journal of Eating Disorders found that 34.3 percent were vegetarians whose diets were significantly more restrictive than the rest of those studied1.

Three studies conducted at the University of California, Davis suggest there is a biological basis to vegetarianism among anorexics. One caveat: they all involve rats, and, therefore, the results may not apply to the more complex human animal.

The first study2 investigated the effect of vagotomy, tropisteron, and an amino acid-imbalanced diet on appetite. The vagus nerve is important in several aspects of gastrointestinal function3, including amino acid, glucose, and fatty acid metabolism4.

The investigators surgically severed the vagus nerve below the diaphragm in half the rats (VAGX)5. The others were given a “sham” operation in which the vagus was left intact6. These groups were further subdivided into those given either a saline injection (VEH) and those given tropisteron (TROP), a blocker of serotonin at the brain’s number 3 receptor7. All TROP and VEH groups were either fed a normal diet (BAS) or an amino acid-imbalanced diet (IMB) deficient in the amino acid isoleucine8.

Previous research had shown that IMB diets induce anorexic behavior in rats, and that TROP injections restored normal eating9. There were two trials. In both, it was found that vagotomy lessened the anti-anorexic effect of TROP10. After 3 hours, the greatest decrease in appetite was found in the IMB-fed sham group pre-treated with saline (sham-VEH)11. During this same time period, the IMB-fed sham group pre-treated with TROP increased its intake to 66.4 percent of baseline feeding (BAS)12. But after 6 hours in trial 1, and 9 hours in trial 2, IMB intake was 70.7 percent of BAS in the sham-VEH group, but only 61 percent of BAS in the VAGX-VEH and the VAGX-TROP groups13.

The researchers concluded that the vagus nerve is involved in the anorexic response to IMB diets, and that intact vagus function is required for the full anti-anorexic effect of TROP14.

The second study15 employed the serotonin antagonist ondansetron (OND), which is more specific to the number 3 receptor16. The researchers found that low doses of OND fully restored IMB feeding to control levels, demonstrating that the anorexic pathway employs the number 3 receptor, not the number 4 as previously hypothesized17.

The third study18 investigated taste preferences among rats exposed to IMB diets and another serotonin-3 blocker (let’s call it TROP2). The animals were given either a VEH (saline) injection or a TROP2 injection19. Then each rat was conditioned with one of four diets: IMB; IMB flavored with saccharin (IMB-SAC); a normal diet (COR); or a normal diet flavored with saccharin (COR-SAC)20. For three days thereafter, all animals were allowed to choose between COR and COR-SAC diets21.

There was no significant difference between the groups in food intake over the entire three-day period22. During the first two days, however, the preference for saccharin was lowest for rats pre-treated with VEH and IMB-SAC, but by the third day, their appetite for saccharin had returned23. On the first day, rats pre-treated with COR or COR-SAC ate more than those pre-treated with IMB and IMB-SAC24. However, on the second and third days, rats pre-treated with IMB and IMB-SAC ate more than the others25.

The researchers hypothesize that the VEH/IMB-SAC rats developed a taste aversion to saccharin when fed the imbalanced diet, but their aversion had disappeared by the third day of the experiment26. In addition, say the researchers, the increased appetite, on the second and third days, of the rats pre-treated with IMB and IMB-SAC may have been due to compensation for their decreased intake while being conditioned on amino acid-imbalanced diets 27. They conclude that animals conditioned on amino-acid imbalanced diets will not choose a proper diet over a protein-deficient one until after they have actually experienced its benefits28.

Taken together, these studies demonstrate that anorexia in laboratory animals can be manipulated with drugs, diet, and/or surgery. Although the biological mechanisms underlying these phenomena are not fully understood29, this research may some day benefit humans.

Scripps Howard cites a series of Roper Polls over the last 10 years indicating that approximately one percent of Americans are vegetarians. The data distinguish between those who occasionally eat chicken or fish (5-10 percent), and purists who eschew all animal products (e.g., eggs and milk).

The article strongly suggests that anyone embarking upon a vegetarian diet get competent nutritional counseling. According to research cited by Scripps Howard, most people in the U.S. get 70 percent of their calcium from dairy products. Physicians, according to the article, are particularly concerned that girls who avoid dairy products can develop calcium deficiencies.

Calcium is a mineral essential to developing and maintaining healthy bones. Older women are particularly vulnerable to calcium deficiencies, which are associated with osteoporosis and arthritis.

An additional concern cited in the article is that people who eat no meat run the risk of developing protein and iron deficiencies. Vegetarian sources of iron, according to Scripps Howard, include apricots, bran flakes, and spinach.

Anorexia and Zinc

There is a substantial relationship between zinc deficiency and anorexia, but, as in the case of iron, the relationship is complex, and you should check with your doctor before ingesting any supplements.

According to the British medical organization Foresight , zinc is an essential trace element required for bodily growth, neural function, brain development, and reproduction. Foresight also notes that zinc plays important roles in fighting viruses, bacteria, funguses, and cancer.

United Nations University (U.N.U.) observes that zinc is found in protein-rich foods, including whole grains, meat, fish, and shellfish. U.N.U. notes that vegetarians frequently have trouble getting enough zinc in their diets, a fact with important ramifications for many anorexics.

According to an article in the International Journal of Eating Disorders (1993 Mar; 13(2):229-233), half of all anorexia nervosa patients are vegetarians, which may increase their risk for zinc deficiency. A study reported therein found that 9 outpatient, vegetarian anorexics had significantly lower dietary intakes of zinc, fat, and protein than 11 non-vegetarian anorexics. The researchers conclude that zinc intake should be evaluated in all vegetarians suffering from anorexia nervosa.

The noted medical nutritionist Dr. Andrew Weil recommends 30 mg of zinc per day for people on vegetarian and semi-vegetarian diets. He uses zinc picolinate, which is rapidly absorbed by the body. However, Weil stresses that nobody should ingest more than 100 mg a day because large doses of zinc can weaken the immune system. Regarding dietary sources of zinc for vegetarians, Weil recommends legumes such as dried beans, garbanzos, peas, lentils, and soy. According to Foresight, the U.S. RDA (recommended daily allowance) of zinc for most adults is 15 mg, and for pregnant women it is 20 mg.

A case study reported in Gastroenterology Japan (1992 Aug.; 27(4):554-558) suggests that zinc supplementation may be a therapeutic option for anorexics suffering from gastric disturbances. A 16 year-old anorexic was hospitalized with vomiting and diarrhea. Tests indicated a zinc deficiency. She received intravenous zinc of 40 micromoles/day (a mole is the number of grams equal to the molecular weight of a substance) for a week, and 15 mg of zinc orally for another 60 days. After two days of intravenous treatment, her gastric symptoms disappeared, and her poundage started increasing. After a month of oral supplementation, she regained her normal weight.

According to Foresight, laboratory experiments have shown that zinc-deprived rats consumed 30 percent less food than their zinc-fed counterparts. Research on this subject, reported in a 1998 press release by the University of Illinois At Urbana-Champaign, is intriguing. According to the release, research published by Professor Neil F. Shay in Nutritional Biochemistry (Jan. 1998) and the Journal of Nutrition (Jan., July 1998), shows a rise in neuropeptide Y (NPY) in the brains of zinc-deprived rats. According to the release, NPY is a protein with appetite-stimulating properties. Shay had theorized that NPY levels would decrease; instead they increased, but the higher NPY levels did not stimulate appetite. The release says that “Shay theorizes that zinc deficiency affects the processing capabilities of NPY and negatively impairs its normal appetite-stimulating effect.”

The research, however, is far from conclusive, and rats are not people. U.N.U. notes that while anorexia has been observed in humans with severe zinc deficiency, the condition is relatively rare. According to U.N.U., there have been few human studies, and severe deprivation was not employed in those experiments. In addition, mild to moderate zinc deprivation does not produce anorexia in laboratory animals, according to U.N.U. In fact, increased appetite is often observed under such conditions.

Part of the problem in solving this puzzle, according to U.N.U., involves a “chicken and egg” question. Food-deprived animals do not get enough zinc (and many other essential nutrients). Severely zinc-deprived animals will be food-deprived due to anorexia. According to U.N.U., the research is inconclusive as to which causes the anorexia, the zinc deprivation, lack of some other nutrient due to food deprivation, or perhaps food deprivation itself. Similarly, notes U.N.U., there is an association between anorexia nervosa and zinc deficiency in malnourished children (mean age, 11.6 years), but the causative factor has not yet been determined.

Anorexia and Iron

Iron supplementation has improved the health of some anorexics, but don’t go popping pills without medical supervision. The relationship between anorexia and iron is complex, and unsupervised supplementation can be highly toxic.

According to wholehealthmd, iron is an essential element which helps the blood and muscles supply oxygen to the body. The site notes that iron is abundant in hemoglobin, an oxygen-carrying pigment in red blood cells, and in myoglobin, an oxygen-rich substance found in muscle tissue.

Wholehealthmd lists several other benefits of iron: it plays an important role in maintaining energy levels, clarity of thought, and immune function. The site notes U.S. government figures showing that females, in particular, are often iron-deficient. These statistics indicate that 9 percent of adolescent girls and 11 percent of women under age 50 have low levels of iron. Wholehealthmd notes that iron reserves can be depleted by the following: pregnancy; rapid growth during childhood; dieting, especially of the vegetarian kind; heavy exercise; and menstruation. Compulsive dieting and exercise are two common symptoms of anorexia nervosa.

Eating disorders specialist Barton, J. Blinder, M.D., observes that “chlorosis,” a term used by 18th and 19th century physicians to describe an illness among young women, “may have been in some instances a form of anorexia nervosa accompanied by anemia (iron deficiency), restrictive eating habits, and psychological disturbances.” The relationship between iron deficiency and anorexia nervosa was recently described by Susan M. Ferron, M.D. in a letter to the editor published in the American Journal of Psychiatry (156:801, May 1999).

Dr. Ferron described the case of a 16 year-old girl hospitalized with anorexia nervosa and iron deficiency anemia. According to Dr. Ferron, the cause of the low iron count was unknown.

The girl’s doctors knew that she exercised compulsively, but did not realize that she also ran in place for two hours every night. She had concealed this behavior by performing it in her bathroom or bedroom where nobody could see her.

Once discovered, the girl’s running was stopped. To enforce this restriction, hospital personnel closely monitored her. After “iron supplementation and an improved diet,” her anemia disappeared.

Dr. Ferron’s letter suggests that the key to the patient’s condition was a combination of compulsive exercising and poor diet, and that iron deficiency did not play a direct, if any, role in causing the anemia. She cautioned that “the anemia of anorexia nervosa is usually…without iron deficiency,” and that the physical activities of anorexics with iron deficiency anemia or gastrointestinal bleeding should be closely studied prior to treatment.

Though poorly understood, iron does seem to be involved in appetite regulation, which could have implications for sufferers of anorexia nervosa and other eating disorders. Dr. Blinder describes cases of iron deficiency in patients with pica, an illness in which people compulsively eat indigestible objects such as hair or matches. According to Blinder, research has linked low iron levels with decreased dopamine receptors in the brain “and consequent reduction of several CNS [central nervous system] dopamine driven behaviors.” Dopamine is a chemical which helps transmit nerve impulses. Although anorexia nervosa is not pica, the research suggests that iron can influence dietary behavior.

Wholehealthmd stresses that you should only take iron supplements if your doctor says you need them, and after he or she performs the necessary blood tests. The site also stresses the need for regular follow-ups. According to wholehealthmd, excess iron increases the risk of colon cancer and heart disease. The site notes that the recommended daily allowance (RDA) of iron for women over age 50 is 10 mg. The RDA for women under 50 is 15 mg, and, for pregnant women, it’s 30 mg. In addition, wholehealthmd says that, to prevent an overdose, non-anemics should make sure their multivitamins do not contain iron. The site also emphasizes that iron supplements should be kept away from young children. As few as five high-potency iron pills can kill them.

The Canadian Pediatric Society (CPS) notes that iron deficiency is associated with anorexia in infants and very young children. However, as Dr. Blinder points out, anorexia in babies and anorexia nervosa much later in life are very different. According to Blinder, anorexia in the very young tends to be a short-term condition related to anxiety in a particular developmental stage, while an eating disorder such as anorexia nervosa is a long-term condition with deeply ingrained psychological patterns and consquent medical complications.

Anorexia and Women of Color

Conventional wisdom says that anorexia nervosa is largely confined to white, affluent, Western women. Recent evidence suggests otherwise.

On July 5, 2000, BBC Online reported a study of female secondary students in rural Ghana which found that six out of 668 subjects showed signs of anorexia. The study was conducted by doctors from the University of Edinburgh, who screened the girls for height, weight, and other diagnostic criteria.

According to the article, the six who had anorexia-like symptoms said they dieted for religious reasons, especially in stressful situations, and to gain more self-control.

The BBC quotes University of Edinburgh psychiatrist Dr. Alan Carson as saying, “The girls did not present with symptoms of classical anorexia nervosa, but the study does suggest that perhaps it is not confined to the Western world.”

These results should be interpreted with caution. First, the effect is small–less than one percent. Secondly, Dr. Carson, according to the BBC, noted that it is inconclusive. Thirdly, although the subjects came from a variety of backgrounds, the article notes that they were not poor, and food was available to them. The study, therefore, did not address the question of whether anorexia can exist in the lowest socioeconomic strata.

In addition, the report did not discuss the health of the subjects. Ghana, a developing country in Northwest Africa, has a population of approximately 12 million. There are several parasites in that part of the world which, in large enough quantities, can produce anorexia nervosa, including hookworm and hymenolepiasis nana, the smallest common tapeworm capable of living in the human gut. For a further discussion of these and other diseases of the region, click here.

Still, the Ghana study is one of several in recent years that have challenged traditional notions about anorexia and race. In the United States, black women have usually been excluded from studies because of the assumption that the African-American community’s acceptance of larger figures protects its females from eating disorders1. However, a study of 613 white and black pre-adolescent girls at Wesleyan University in Middletown, Connecticut found that the black girls had a significantly greater drive for thinness than the white girls on four standardized measures and a three-day food diary2. The researchers note that the results are “provocative” because, statistically, black girls show more obesity and less anorexia than their white counterparts3.

The evidence seems to indicate, at least in the United States, that both white and non-white women who develop anorexia are influenced by similar factors. A computer-based literature search conducted at the Department of Family and Community Medicine at the University of Arizona came to this conclusion. In this study, the researchers found that eating disorders are equally common among white and Hispanic females, greater among Native American women, and less frequent among black and Asian-American women4. The investigators observed that minorities were at greater risk for developing eating disorders if they were younger, heavier, better educated, and identified more with white, middle-class values5. A brief literature review on the Something Fishy Website comes to similar conclusions.

Studies outside the United States also challenge the traditional notion that eating disorders are a white, Western girl’s problem. Researchers at the University of Capetown administered a questionnaire to 1,435 South African college students, 739 Caucasians and 696 non-Caucasians, from six universities in two large cities. According to the researchers, black students scored significantly higher on standardized measures of eating disturbances than the other ethnic groups tested6. In addition, the investigators found that a similar percentage of black and white females had scores within the clinical range for eating disorders7.

A paper from the University of Hong Kong, Shatin, hypothesizes that anorexics belong to an international social group found in many developing parts of the world8. It cites the “globalization of fat phobia,” increased affluence, and the spread of biomedical technology as factors influencing the proliferation of eating disorders throughout the planet9.

Clearly, more work needs to be done in this area. But the data presented are food for thought.

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