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Perfect Illusions: Eating Disorders and the Family
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What causes an eating disorder?

Anorexia Nervosa and Bulimia Nervosa are very complicated disorders, and the reasons for developing them can be different from one person to the next. Although many view these behaviors as self-destructive acts, most individuals who develop eating disorders do not perceive their behaviors as self-harmful. To the contrary, most patients feel that they begin the behaviors to try to fix problems that they are experiencing in their lives.

The most common reason that we hear from people about why they develop anorexia or bulimia is that at one point in time they felt terribly out of control. This loss of control could be something they were feeling inside themselves, or something that was happening to them from their outside environment. The experience of being out of control directly affects their feelings about themselves, and usually results in low self-esteem.

The following are some of the most common causes of eating disorders:

Major Life Transitions
Most eating-disorder patients have difficulty with change. Anorexics, in particular, prefer that things be predictable, orderly and familiar. Consequently, transitions such as the onset of puberty, entering high school or college, major illness, or the death of a loved one can overwhelm these individuals and result in their feeling out of control.

The onset of puberty is arrested in many females with eating disorders because their body weight and/or body fat is lowered to the point where they lose their menstrual cycle. Women whose body weights fall below a menstrual threshold essentially return to a more childlike state, both physically and psychologically. They neither feel nor look like adolescent nor young adult women, and therefore postpone the transition to adolescence or young adulthood.

Family Problems
Some individuals with eating disorders come from disordered families. The families of anorexic patients are often characterized by extremely controlling parents and poor boundaries between the parents and their children. For many of these individuals, anorexia is a misguided, but understandable, attempt at differentiating themselves from their parents. Put another way, some anorexics are very protective of their illness because they feel it is the first thing in their lives that they have done that was truly "their own idea."

In contrast, individuals who struggle with bulimia often come from families where there is disconnection among the family members. For these individuals, the bulimia can be a desperate attempt to draw attention to themselves, or an effort to fill up, numb or distract themselves from the feelings of emptiness related to the disconnection.

Social and Romantic Problems
Most people who develop eating disorders report painfully low self-esteem prior to the onset of their eating problems. Many patients report going through a painful experience, such as being teased about their appearance, being shunned or experiencing the difficult break-up of a romantic relationship. They begin to believe that these things happened because they were fat and that if they become thin, the experiences won't happen again..

Failure at School, Work or Competitive Events
Eating-disorder patients can be perfectionists with very high achievement expectations. If their self-esteem is disproportionately tied to being successful, then any failure can produce devastating feelings of shame, guilt or self-worthlessness. For these individuals, losing weight can be seen as the first step to improving themselves. Binge eating and purging can serve the purpose of proving their worthlessness, or it can provide an escape from these feelings.

A Traumatic Event
According to current statistics, between one-third and two-thirds of patients who visit treatment centers for eating disorders have histories of sexual or physical abuse. It appears, however, that the prevalence of sexual abuse in eating disorders is about the same as that for other psychiatric disorders.

However, there are patients whose eating disorders are a direct consequence of, or an attempt to cope with, their sexual or physical abuse. Such individuals may try to consciously or unconsciously avoid further sexual attention by losing enough weight to lose their secondary sexual characteristics, such as their breasts. Similarly, the consistency or type of some foods can directly trigger flashbacks of abuse, resulting in an individual avoiding certain foods altogether.

Major illness or injury can also cause a person to feel extremely vulnerable or out of control. Anorexia and bulimia can be attempts to control or distract themselves from the trauma.

Biological Vulnerability
We have also learned that some people develop eating disorders in response to other psychiatric symptoms that occur before their eating-related problems. These other psychiatric symptoms appear to be triggered biologically, and may or may not be related to events in their environments. Between one-third and one-half of eating-disorders patients report struggling with significant depression or anxiety before their eating disorders developed. These episodes of depression and/or anxiety appear to be severe enough that they felt extremely out of control and fearful that they were falling apart. Once again, restrictive eating, excessive exercise and/or bulimia can be attempts to control the depression and anxiety.

Furthermore, approximately one-third of eating-disorder patients report struggling with obsessive-compulsive symptoms before they developed their eating disorder. For these individuals, the obsessive fear of fat and compulsive behaviors to control this fear are the outward symptoms of the more central problem of obsessive-compulsive disorder.

These are just some of the reasons that people develop eating disorders. It is important to remember that while many individuals with eating disorders think and act in very similar ways, the reasons why they have developed these thoughts and actions can be quite different.

Who is most at risk for developing and eating disorder?

The following are the most common risk factors that have been identified:

  • Adolescent or young-adult females in middle- to upper-class groups in Westernized cultures.
  • Working or aspiring to work in a field that places high emphasis on thinness, such as acting, modeling, ballet or gymnastics.
  • Previous history of being overweight or teased about weight that results in dieting behavior.
  • Family history of eating disorders, weight consciousness, alcoholism, depression or obsessive-compulsive disorder.
  • Low self-esteem, high achievement expectations, perfectionism, social insecurity and difficulty identifying and expressing feelings.
  • A tendency to be overly cautious, fearful of change, hypersensitive and orderly.
  • Families that lean too much in the direction of being either over-protective and controlling, or too disengaged and uninvolved.
  • A history of physical, sexual or significant relational trauma.
  • A large discrepancy between how individuals present themselves to others and how they actually feel about themselves.
  • Difficulty identifying and/or verbalizing feelings, particularly anger.

What are the long-term medical and emotional consequences of these disorders?

The longer these illnesses persist, the greater the impairment to the individual's ability to work, love and play. The course of these illnesses is very similar to other psychiatric difficulties, such as drug and alcohol abuse, depression, anxiety, phobia and obsessive-compulsive disorder. The illnesses dramatically interfere with the ability to work consistently or to go to school. They ruin relationships, and make it very difficult to experience pleasure in life.

In addition to being emotionally devastating, the illnesses can create serious medical problems. Adolescence is a time of rapid growth and development. The average weight gain for girls between the ages of 11 and 14 is 40 pounds. Approximately 90 percent of adult bone mass is gained during adolescence. Osteoporosis ("porous bones" that break easily) can begin early in both girls and boys who are dieting or suffering from anorexia. An extended period of semi-starvation stunts growth, can delay the onset of menstruation and can damage vital organs such as the heart and brain. Listed below are some of the most common medical problems.

Medical Consequences of Anorexia Nervosa:

  • Starvation deprives the body of protein and prevents the body from processing fat. In an effort to protect itself, the body slows down.
  • The heart muscle changes and its beat becomes irregular. The ultimate result can be heart failure that results in death.
  • Dehydration, kidney stones and kidney failure may result.
  • Menstruation often stops, even before extensive weight loss. This is called amenorrhea, which is defined as 3 months of absent menses. The risk for osteoporosis and osteopenia rises when menses are absent for 6 months or longer.
  • A fine body hair, called lanugo, develops on the arms and can even cover the face.
  • Muscles atrophy or waste away, resulting in weakness and lost muscle function.
  • Delayed gastric emptying caused by a lack of energy and slowed body function results in bowel irritation and constipation.
  • Loss of bone calcium leads to osteoporosis.

Medical Consequences of Bulimia Nervosa

  • Vomiting, laxatives and diuretics flush sodium and potassium from the body, resulting in an electrolyte imbalance. Arrhythmia (an irregular heartbeat) can result, which can ultimately lead to heart failure and death.
  • The stomach acids in vomit can erode tooth enamel, resulting in damage such as cavities and discoloration.
  • Self-induced vomiting can result in irritation and tears in the lining of the throat, esophagus and stomach.
  • Laxative abuse can create dependency and result in an inability to have normal bowel movements.
  • Abuse of emetics to induce vomiting can result in toxicity, heart failure and death.
  • Medical Consequences of Binge Eating Disorder
  • High blood pressure, elevated cholesterol levels and elevated triglyceride levels can cause hardening of the arteries, heart disease and heart attacks.
  • Over-eating simple carbohydrates, such as sweets and junk food, places stress on the pancreas. At first, there is an abnormally low amount of glucose in the blood. Later in life, secondary diabetes can result.

What is the treatment for eating disorders?

Tragically, eating disorders are quite lethal. The death rate is about 12 times higher than for other women of similar ages. One in ten will die from the illness. Anorexia nervosa ranks as the third most common chronic illness among adolescent females in the United States. There is hope and help for eating disorders. Early intervention is the key. A team of professionals, specifically trained in eating disorders, can evaluate and set up an individualized treatment plan. This should include a comprehensive assessment and a coordinated care plan.

Comprehensive Assessment
A comprehensive assessment will include a full physical exam and laboratory studies to determine the patient's physical status and risk of death. The assessment should also include a meeting with a nutritionist to help re-establish a safe diet plan and provide ongoing nutritional counseling. In addition, the assessment should include a complete mental health evaluation. This psychiatric evaluation should include a review of the patient's symptoms, current life situation, treatment history, personal history and family history, as well as a thorough examination of the patient's thoughts, feelings and behaviors. The mental health evaluation is extremely important because a proper diagnosis is essential. Research shows that nearly 50% of individuals with eating disorders suffer from at least one other psychiatric disorder. It is important that these co-occurring disorders be identified and treated.

Coordinated Care Plan
After the assessment, a coordinated Care Plan will be established. A team of experienced eating-disorder professionals will work together to assist the patient in recovery. Treatment is tailored to the individual, and may include an internist, nutritionist, individual or group therapist, psycho-pharmacologist and family therapist. Treatment interventions are first aimed at nutritional rehabilitation and the restoration of normal eating patterns to correct the biological and psychological effects of malnutrition. The long-term goals are to diagnose and help resolve the associated psychological, family, social and behavioral problems so that a relapse does not occur.

There are many types of psychotherapy or "talking therapy" used in the treatment of eating disorders. We can only touch on a few here. Two types of psychotherapy, cognitive behavioral therapy and interpersonal therapy, are now proving to be very effective in the treatment of eating disorders.

Cognitive behavioral therapy is designed to help the patient gain control of unhealthy eating behaviors and to alter the distorted and rigid thinking that perpetuates the syndrome. The treatment uses a combination of procedures to change the patient's behavior, their attitudes about shape and weight and, where relevant, elements such as low self-esteem and extreme perfectionism.

In interpersonal therapy, the focus is on the patient's current circumstances and relationships. The initial sessions are typically devoted to a detailed analysis of the interpersonal context in which the eating disorder has developed and been maintained.

These types of therapy can take place in individual, family or group sessions, and it is likely that a combination of the three will be recommended. The goals of individual psychotherapy are to help the patient regain physical health, reduce symptoms, increase self-esteem and proceed with personal and social development. Family therapy attempts to establish more appropriate eating patterns, encourage communication and allow family members to feel more connected to one another. Group therapy allows the patient to feel less alone with his or her symptoms, receive feedback from his or her peers and enhance social skills.

Typically, therapy takes place on an outpatient basis. However, hospitalization may be necessary when an eating disorder has led to physical problems that may be life-threatening, or when the patient is also experiencing severe emotional distress.

In addition to therapy, medication may be helpful in the treatment of eating disorders. Patients with severe eating disorders appear to have abnormalities in their brain's neurotransmitter systems, as do patients with depressive disorders, obsessive-compulsive disorders and anxiety disorders. Because these illnesses are thought to have biological roots, they respond well to medications that work by affecting brain chemistry.

Although the use of medication is more common for patients with bulimia than with anorexia, there is evidence that some medications do assist with recovery in both illnesses. Anti-depressants are helpful for patients with significant symptoms of depression, anxiety or obsessions. They may also have a specific role in reducing bulimia's binge-purge cycle. For anorexia, medication is best used after the patient has gained weight and the psychological effects of starvation have lessened, although some anti-depressants appear to help stabilize weight recovery.

Medication is generally used together with psychotherapy and a coordinated treatment plan. Before medication is prescribed, a psychiatrist or family physician will discuss any co-existing medical problems, review current medications being taken and assess the patient's physical health in order to ensure proper dosage and guard against potential negative interactions or side effects. Several medication trials are sometimes necessary to establish the proper dosage. It is important for the patient to continue seeing a psychiatrist or family physician to monitor these medications.

Whether with therapy, medication or a combination of both, eating disorders can be successfully treated. Seventy to eighty percent of people with eating disorders respond to treatment. Relapses can occur, but the sooner treatment begins, the better the chances for recovery and a return to a healthy life.

How do you help someone you suspect might have an eating disorder?

If you are concerned about your friend, don't keep your suspicions to yourself. Being healthy means accepting and nourishing your body. Someone who is not eating, or is eating too much, may need help. In a caring way, tell your friend what you see or hear. You can let your friend know that you are concerned by using "I" statements, such as the following:

  • "I'm worried about you because you haven't eaten lunch this week."
  • "I heard you talking about taking laxatives [or diet pills], and that scares me."
  • "Are you OK? Were you vomiting after lunch? I'm concerned about you."

Listen carefully to what your friend says. Think about how your friend may feel. Your friend may feel ashamed or scared. Your friend may feel unimportant or out of control, or think that life doesn't matter. Not eating, or eating too much, may be your friend's way of coping with problems at home or at school.

What if they get mad or deny it?
It is very common for people with problems to say that there is nothing wrong. They may beg you not to tell, or promise you that they won't do it anymore. Your friend may get angry because of fear, shame or other strong emotions.

What your friend is doing is scary and unhealthy. Tell your friend that you care and that you want her or him to get help. Encourage your friend to talk to an adult. Say you would be willing to go along to provide support. Tell your friend that you want to help and don't want to keep your concern a secret. Your friend's health might be in danger. You may decide to tell your friend that you want to talk to an adult about the situation.

Being worried about your friend and wanting to help is a good thing. Consider telling what you know to your parents or your friend's parents, a teacher, or the school nurse or counselor. Tell someone who will understand and can get help for your friend. It is not "tattling" or "ratting" on your friend if you are worried about her or his health.

Here are some suggestions of what to say:

  • "I'm worried about ______ because I saw her (him) throw up on purpose/take a laxative/talk about taking diet pills/throw away her (his) lunch."
  • "I'm concerned about ______ because she (he) always complains about being too fat/seems so sad/says she (he) never can do anything right."

Many people have saved the lives of their friends with eating disorders by alerting those close to them about their observations and their friends' behaviors. Don't hold back.

Do boys or men suffer from eating disorders?

Yes. Eating disorders affect both men and women. While eating disorders are less common in men, approximately 10% of those suffering from eating disorders are male (Wolf, 1991, Fairburn & Beglin, 1990).

Female anorexics outnumber their male counterparts by about 15 to one. If they receive good, timely treatment, male anorexics tend to have just one major bout with the illness (Ira M. Sacker, M.D. & Marc A. Zimmer, Ph.D. 1987).

Increasingly, studies are showing that men suffer from eating disorders that often go undiagnosed because these disorders are associated with women more than with men. However, there is a broad consensus that eating disorders in males are clinically similar to, if not indistinguishable from, eating disorders in females (Margo 1987; Schneider & Agras, 1987; Crisp et al., 1986; Vandereycken & Van der Broucke, 1984).

Most research into these serious disorders has been conducted on females. However, as many as one million men may also struggle with these diseases. Eating disorders include extreme attitudes, emotions and behaviors surrounding both food and weight issues. They include anorexia nervosa, bulimia nervosa, and binge eating disorder: emotional and physical problems that can have devastating effects and life-threatening consequences.

Activitities and Occupational Hazards:

Certain athletic activities appear to put males at risk for developing eating disorders. Gymnasts, runners, body builders, rowers, wrestlers, jockeys, dancers, and swimmers are particularly vulnerable to eating disorders because their sports necessitate weight restriction (Andersen, Bartlett, Morgan, & Brownell, 1995). It is important to note, however, that weight loss in an attempt to improve athletic success differs from an eating disorder when the central psychopathology is absent.

Body Image:

Body image concerns appear to be one the strongest variables in predicting eating disorders in males. Studies have demonstrated (Wertheim et al, 1992) that the drive for thinness was a more important predictor of weight loss behaviors than psychological and/or family variables. This desire was true of both adolescent males and females.

Kearney-Cooke and Steichen-Asch (1990) concluded that the preferred body shape for contemporary men without eating disorders was the V-shaped body, whereas the eating-disordered group strove for the lean, toned, thin shape.

The authors also found that most of the men with eating disorders reported negative reactions from their peers. They reported being the last ones chosen for athletic teams and often cited being teased about their bodies at the times when they felt most ashamed of their bodies.

Media Influence:

Studies also demonstrate that cultural and media pressures on men for the "ideal body" are the rise. This increased focus on body shape, size and physical appearance will likely contribute to increased numbers of eating disorders in males. (Schneider & Argas, 1987).

Nemeroff, Stein, Diehl, and Smolak (1994) suggest that males may be receiving increasing media messages regarding dieting, and ideal of muscularity, and plastic surgery options (such a pectoral and calf implants).

DiDomenico and Andersen (1988) found that magazines targeted primarily to women included a greater number of articles and advertisements aimed at weight reduction (e.g., diet, calories) and those targeted at men contained more articles and advertisements concerning fitness, weight lifting, body building, or muscle toning. The magazines most read by females ages 18-24 had 10 times more diet content than those most popular among men in the same age group.

Personality Variables, Cultural and Family Influences:

Males with anorexia do not tend conform to the cultural expectations for masculinity such as: competitiveness, muscularity/strength, physical aggressiveness, independence and competence in athletics (Kearney-Cooke & Steichen-Asch, 1990).

Kearney-Cooke and Steichen-Asch (1990) found that men with eating disorders tend to have dependent, non-confrontational and passive-aggressive personality styles, and to have experienced negative reactions to their bodies from their peers while growing up. They tend to be closer to their mothers than their fathers. The authors concluded that "in our culture, muscular build, overt physical aggression, competence at athletics, competitiveness, and independence generally are regarded as desirable for males, whereas dependency, passivity, inhibition of physical aggression, smallness, and neatness are seen as more appropriate for females. Boys who later develop eating disorders do not conform to the cultural expectations for masculinity; they tend to be more dependent, passive, and non-athletic: traits which may lead to feelings of isolation and disparagement of body."

Sexual Attitudes, Behaviors and Endocrine Dysfunction:

Males with anorexia display a considerable degree of anxiety with regard to sexual activities and relationships. Fichter and Daser (1987) compared males and females with anorexia and found that males displayed significantly more sexual anxieties than did females. The authors noted that 80% of the males in their study grew up in families that regarded sex as a taboo subject. Corresponding with the reported sexual anxiety, low levels of sexual activity among the males with anorexia were also noted.

Burns and Crisp (1984) found that males with anorexia in their study admitted "obvious relief" at the diminution of their sexual drive during the acute phase of their disease.

Eating-disordered males differed significantly from eating-disordered females in terms of sexual experience in a study conducted by Herzog et al. (1984). Males with eating disorders were significantly less likely to have had sexual relations before the onset of their eating disorder, or to be involved in a sexual relationship at the time of evaluation than were females with eating disorders. Males with bulimia, however, appear to be more sexually active than males with anorexia, both premorbidly and at the time of their illness (Pope et al., 1986).

A study by Andersen and Mickalide (1983) suggest that a disproportionate number of males with anorexia may have a persisting or preexisting problems in testosterone production.

Gender Dysphoria and Homosexuality:

Fichter and Daser (1987) found that males with anorexia saw themselves and were seen by others as more feminine than other men, both in attitudes and behavior. In general the males with anorexia appeared to identify more closely with their mothers than with their fathers.

Homosexuals are over-represented in many samples of eating disordered men. While the proportion of male homosexuals in the general population cross-culturally is estimated to be 3%-5% (Whitman, 1983), samples of eating-disordered men are commonly twice as high or greater (Fichter & Daser, 1987).

Several authors have noted that homosexual conflict preceded the onset of an eating disorder in up to 50% of male patients (Scott, 1986; Dally, 1969; Crisp, 1967).

Conflict over gender identity or over sexual orientation may precipitate the development of an eating disorder in many males (Crisp, 1983). It may be that by reducing their sexual drive through starvation, patients can temporarily resolve their sexual conflicts (Crisp, 1970).

Homosexual men may be at an increased risk for developing an eating disorder because of cultural pressures within the homosexual community to be thin (Schneider & Agras, 1987). Herzog et al., (1990) found that homosexual men weighed significantly less than heterosexual men, were more likely to be underweight and to desire an underweight ideal weight. Compared to the heterosexuals, homosexual men were less satisfied with their body build, and scored significantly higher on the "Drive for Thinness" scale of the Eating Disorders Inventory (EDI).

Gender Differences Regarding Dieting and Body Shape:

A national survey of 11,467 high school students and 60,861 adults revealed the following gender differences (Serdula et al., 1993):

Among the adults, 38% of the women and 24% of the men were trying to lose weight.

Among high school students, 44% of the females and 15% of the males were attempting to lose weight.

Based on a questionnaire administered to 226 college students (98 males and 128 females) concerning weight, body shape, dieting, and exercise history, the authors found that 26% of the men and 48% of the women described themselves as overweight. Women dieted to lose weight whereas men usually exercised (Drewnowski & Yee, 1987).

A sample of 1,373 high school students revealed that girls (63%) were four times more likely than boys (16%) to be attempting to reduce weight through exercise and caloric intake reduction. Boys were three times more likely than girls to be trying to gain weight (28% versus 9%). The cultural ideal for body shape for men versus women continues to favor slender women and athletic, V-shaped muscular men (Rosen & Gross, 1987).

In general, men appear to be more comfortable with their weight and perceive less pressure to be thin than women do. A national survey indicated that only 41% of men are dissatisfied with their weight as compared with 55% of women; moreover, 77% of underweight men liked their appearance as opposed to 83% of underweight women. Males were more likely than females to claim that if they were fit and exercised regularly, they felt good about their bodies. Women were more concerned with aspects of their appearance, particularly weight (Cash, Winstead, & Janda, 1986).

DiDomenico and Andersen (1988) found that magazines targeted primarily to women included a greater number of articles and advertisements aimed at weight reduction (e.g., diet, calories) and those targeted at men contained more articles and advertisements concerning fitness, weight lifting, body building, or muscle toning. The magazines most read by females ages 18-24 had 10 times more diet content than those most popular among men in the same age group.


Andersen, R.E., et al. (1995). Weight loss, psychological and nutritional patterns in competitive male body builders. International Journal of Eating Disorders, 18, 49-57.

Andersen, ROE. (1995). Eating Disorders in Males. In K. Brownell, K. & Fairburn, C.G., (Eds.), Eating Disorders and Obesity: A comprehensive Handbook. New York: Guilford Publications, Inc.

Dept. of Health and Human Services (1987, 1995). Anorexia Nervosa and Bulimia.

Eating Disorder Awareness and Prevention, EDAP (1998). Males and Eating Disorders.

Kearney-Cooke, A., & Steichen-Asch, P. (1990). Men, Body Image, and Eating Disorders. In A. Andersen (Ed.), Males with eating disorders (p. 47 New York: Brunner/Mazel.

Schneider, J.A., & Agras, W.S. (1987). Bulimia in males: A matched comparison with females. International Journal of Eating Disorders, 6, 235-242.

Shiltz, T. (1997). Eating Concerns Support Group Curriculum. Greenfield, WI: Community Recovery Press.

Wertheim, E.H. et al. (1992). Psychosocial predictors of weight loss behaviors and binge eating in adolescent girls and boys. International Journal of Eating Disorders, 12, 151-160.

Wolf, N. (1991). The beauty myth. New York: William Morrow.

Is an eating disorder hereditary?

(This information is provided by Cynthia M. Bulik, Ph.D., Professor of Psychiatry at the Virginia Institute for Psychiatric & Behavioral Genetics, Virginia Commonwealth University.)

Although there does appear to be a genetic component, just because an individual may be genetically predisposed does not mean that she or he will necessarily express the genes. Both anorexia and bulimia nervosa do run in families, and twin studies suggest that genetics do contribute to the familial tendencies. We now have significant genetic linkage signals on chromosome 1 for anorexia nervosa and on chromosome 10 for bulimia nervosa.

Environment plays a role both in promoting the expression of the genes as well as protecting from the expression of the genes. Offspring of individuals with eating disorders are at increased risk, but it is not inevitable that they will develop them.

Ten universities and medical centers will collaborate on research of the genetics of anorexia nervosa and bulimia. They will study four hundred people over a ten-year period. The National Institute of Health/National Institute of Mental Health is providing support for this study about the genetics of anorexia nervosa. Dr. Cynthia M. Bulik, Ph.D., is one of the researchers.

Do minority women suffer from eating disorders?

The study of eating disorders in minority populations in the U.S. remains in its infancy. However, those studies indicate that minority females may be just as likely as white females to develop eating disorders, despite the misguided common wisdom that minority women have a kind of cultural immunity to developing them.

Minority women with eating disorders experience the same feelings of shame, isolation, pain and struggle as their white counterparts.

Since this disordered eating behavior has not been as visible among minority women, it often goes unnoticed until it reaches dangerous levels. Only stepped-up research and efforts to increase awareness of the dangers can begin to stem this disturbing trend. African-American, Hispana/Latina, Asian-American and Native American women are all affected. More info at NOVA: Dying to be Thin

Why can such a serious illness go unnoticed by parents, teachers and friends?

Eating disorders become the deepest, darkest secret that somebody can have. People with an eating disorder rarely want to let someone know about it unless they happen to be friends who also have eating disorders, with whom they can trust and share that information.

The illness can be so deeply cloaked in shame and self-loathing that sufferers of eating disorders become very good at hiding their illnesses, and go to great lengths to camouflage their bodies, misdirect others' attention and hide their behavior; they become exceptionally proficient at lying.

Bulimia can be easier to hide, because it often doesn't visibly alter one's body, but takes its toll internally. An adult with an eating disorder can isolate himself or herself; a young adult living at home can develop many concealment behaviors that can be hard to spot if you aren't looking for them, and sometimes even if you are.

Even when suspected, a person with an eating disorder will deny the problem, working to convince parents, family, and friends that the problem does not exist, and can continue to effectively hide it from doctors and therapists as well. The illness itself, and his or her dependence on it, can become so powerful that the individual doesn't question his or her own lies and distorted behavior.

The eating disorder becomes the only way a person can exert control over his or her life. By giving up the secret and giving up the ritual, the person gives up that control, that coping mechanism, which helps him or her deal with a chaotic world.

Often it is hard to see something that is going on right before your eyes. A parent sees a child every day and doesn't have the benefit of perspective from a distance. Behaviors can change so gradually over time that they just become normal, and are incorporated into the household fabric.

Then there's the phenomenon that parents often just don't want to see what's going on. Some parents want to believe it's just a phase, or that these behaviors don't exist at all. They carry the weight of responsibility for the wellbeing of their children. Parents don't want to believe that something could be so terribly wrong.

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