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Dying to be Thin
Ask the Experts
Answers from Dr. Craig Johnson, Set #1
Posted December 13, 2000
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Q: I have been using laxatives several times a week for three years straight. I am 31 years old and have teetered between fasting and purging since I was 18. I often worry what could happen to me. Sometimes I bleed when I go to the bathroom. I get panic attacks and take Prozac and Xanax. What are the danger signs, and what will be the long-term affects of my disorder? I am scared sometimes, but nothing scares me enough to stop! I must be thin!


Johnson: The use of laxatives for weight regulation is one of the most medically dangerous and psychologically unsettling behaviors practiced by eating disordered patients. Laxatives work by artificially stimulating the bowel. Over time the bowel becomes dependent or addicted to the stimulant. In fact, the bowel develops a tolerance for the stimulant, which then requires the individual to use progressively larger doses or quantities to accomplish bowel movement. The long-term medical consequence of having a laxative-dependent bowel can be having to have a colostomy. Most patients can be detoxed or weaned from the laxatives, but this can be a very painful process requiring hospitalization. It is a very psychologically demanding task, because the principal side effect is rebound edema or bloating. This bloating or fluid retention is, of course, very frightening to individuals who already have an irrational fear of being fat. The good news is that most patients can be cured with informed treatment. It is however, a very painful process.

If you are considering using laxatives for weight control, there are several important facts you should know:
  • Studies have shown that by the time food gets to the bowel, 70% to 80% of the calories in the food have been absorbed. Laxatives are actually a very poor tool for weight control.

  • What fools people into thinking that they are losing weight is that laxatives cause dehydration, so when the person steps on the scale the numbers are lower. But they are lower due to fluid loss, not a reduction in body mass. The cruel next step is that within 24 hours the body will attempt to replace the fluids, usually at a level that is above normal for the individual. So when they get on the scale the next day, their weight is actually higher than before they took the laxatives due to the rebound edema. The individual usually panics and takes more laxatives, which will temporarily lower her or his weight again, but will eventually provoke even more rebound edema. This sets in motion a very vicious cycle of yoyo fluid balance, which provokes more and more laxative use.

Q: I have a 10-year-old daughter (adopted at six months of age from Korea) who eats very poorly. She is 56" tall and weighs 60 pounds. She is not at all conscious about weight or size, because we have never made food an issue in our home. It is almost painful to watch her eat as she will chew a bite endlessly to delay swallowing it sometimes. She has innocently asked me once if I knew what it felt like to just have the food almost stick in your throat and not want to go down. (There is no physical obstruction.) Her food choices are extremely limited: no fruits, no vegetables, very little protein, no milk. She is a carbohydrate eater (plain pasta or rice). She is an extremely anxious, perfectionist child who is just so hard on herself. I would much rather have a report card of C's with a more relaxed child. Once I spoke with a child psychologist about her anxiety, and it was suggested that she might be experiencing seasonal affective disorder, because things seem to escalate during the late fall and winter.

My question to you is: Can a child have an eating disorder that is due to an imbalance in brain chemistry? If so, how does one begin to get this evaluated?


Johnson: Most people who struggle with an eating disorder are also struggling with some form of depression or anxiety. In fact, approximately 50% of eating disordered patients have had a depressive episode or anxiety attack prior to the onset of their eating problems. We know that these disorders have a strong biological basis and that they can be treated with medications. We have also learned that semi-starvation, binge eating (particularly complex carbohydrates), excessive exercise, and even self-induced vomiting alters neurochemistry in ways that may actually help individuals feel less depressed and calmer.

My specific recommendation regarding your daughter is that you request an evaluation with a child psychiatrist who is familiar with eating disorders. I would be particularly interested in ruling out whether she is showing early signs of obsessive compulsive disorder or anxiety disorder. EDAP, which you can access through the Help/Resources section of this Web site, maintains a national listing of professionals who are familiar with eating disorders.

Q: How does one know if he or she has anorexia or is just plain skinny? I am a male and have been skinny all my life. I do not have much of an appetite and cannot eat large amounts of food at a time. I cannot gain weight.I do not think I'm fat. In fact, it's the opposite. I know I'm skinny and am very self-conscience of this fact. I have had a physical, have had my thyroid checked for overactive metabolism, and have been checked for diabetes. The doctors say they can find no medical reason for me being this thin and that since I've always been this thin there is probably nothing I can do about it. I've also been told by the doctors that it's better to be thin. But I get from your program that it is not that way at all. Is it possible I have had anorexia since childhood and have just never known it?


Johnson: The cardinal features of anorexia nervosa are psychological in nature and include an irrational fear of fat coupled with a relentless pursuit of thinness and a misperception of oneself as being very overweight. As you can see, it is unlikely that you have the psychological features of anorexia nervosa. It is very important for us to remember that there are many men and women who are genetically lean. They will start and end life thin. In fact, it is as difficult for them to gain weight as it is for some people to lose weight.

There are also many things that affect appetite that are not related to anorexia nervosa, bulimia, and binge-eating disorder. For example, one of the side effects of depression is loss of appetite. If you remain concerned that you may have an eating disorder or some related difficulty, then I would suggest that you consult a professional. I would much prefer that you error in the direction of being safe rather than sorry.

Q: What can I do to help my daughter when she is in denial of her eating disorder?

Teresa from Arkansas

Johnson: The strategy depends upon whether your daughter is an adult or a child/adolescent. If she is a child or adolescent, I feel very strongly that you gather her up and take her to an informed professional. Begin with an outpatient assessment and intervention. If this proves ineffective, then I feel she should be admitted to an Eating Disorder Program, where her weight can be restored and her other symptoms (binge eating, purging) can be stopped. It is very difficult for an individual to think clearly when these symptoms are active. These interventions may not work in the early stages of the illness, but one must see if promptly stopping the behaviors and restoring normal weight helps.

The issue with adults is more difficult. One should collect as much concrete data as possible that demonstrates your concern. I like gathering a number of significant others and confronting the individual with the data that has resulted in your fears and concerns. This can be a very frustrating and humbling process. It is important to remember that adults in our country have the right to exercise very bad judgment around issues such as these. In fact, if they are not ready enough to pursue treatment themselves, the treatment probably will not work. Nonetheless, while you may not be able to be insistent, you can certainly be persistent. For more specific information, see Frequently Asked Questions in the Help/Resources section on this Web site.

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