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Dying to be Thin
Ask the Experts
Answers from Dr. Craig Johnson, Set #4
Posted December 20, 2000
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Q: I have been battling both depression and overeating for 12 years. Although they are intricately linked, I have come to realize that both battles must be fought concurrently and with equal importance. I cannot seem to find a therapist who believes it is important enough to focus on my overeating problems. They all say the same thing: "Once we get to the roots of your depression, the eating problem will naturally begin to work itself out because it's a symptom of your depression." Although this is probably true, it may take me years or forever to deal with my depression, and in the meantime I am fat and miserable and my confidence level is zero. My obsession with my weight prevents me from finding the energy and confidence I need to begin making strides on my depression—it is a double-edged sword. Can you please recommend how I should go about tackling this? There are too many options, and I think one needs the right combination to tackle both depression and eating. After 12 years of therapies, drugs, diets, and exercise, with nothing working, I feel hopeless.


Johnson: There has been a constant theme among the questions we have received, and it is a theme we deal with on a daily basis in our treatment program. The theme is: " I will not be able to accomplish self-esteem, feel empowered, be less depressed, less self-conscious etc., until I am thin." The problem is that very few people have the genetic potential to be the size and shape idealized in our culture. That is the stone-cold, harsh reality of genetically mediated weight and shape regulation.

I make the point with our patients that I am 5'10" tall. If I developed a belief system that I would only have self-esteem if I could become 6'2" tall, I would be doomed to low self-esteem. This is because height is largely genetically mediated, meaning there is not much I can do about it. Many men, athletes etc. have as much difficulty trying to increase their body mass above what is genetically prescribed for them as people who are trying to decrease their body mass. These indivduals will often have to resort to health-threatening products such as steroids to get bigger than what their genetic code wants them to be.

So, does this mean that one has no control over her size and shape? Absolutely not. Many people have weight difficulties as a result of disordered eating and lack of exercise. The only way we can establish a genetically appropriate size and shape for someone is by normalizing food intake and exercise over a prolonged period of time.

The road to recovery for an eating disorder is actually quite simple. One needs to eat reasonably, exercise reasonably, and make peace with your size and shape given reasonable eating and reasonable exercise. Reasonable eating is not hard to define. Any competent dietician can recommend a meal plan that meets normal nutritional needs, guards against the person entering into a semi-starved state, and is a meal plan that the individual can follow the rest of her life. Meal plans that are too low in calories or exclude food groups (fats, carbohydrates, proteins) are likely to fail or trigger physiological/metabolic adaptations that make people crazy.

Similarily, any competent trainer can recommend a reasonble exercise schedule that one could sustain over a long period of time. Walking four times a week for 45 minutes would be quite reasonable. The difficult part of the equation is making peace with your size and shape given reasonable eating and reasonable exercise. It can indeed be quite difficult for a woman in this culture if she is genetically destined to be 5'2", weigh 140 lbs. and be pear-shaped. It is tragic if she is predisposed to be morbidly obese. For better or worse, we simply have not found safe and effective ways for most people to alter their genetic predisposition for height, weight, eye color, and shape. While we wait for these gene therapies, we need to eat reasonably, exercise reasonably, and make peace with our size and shape given reasonbable eating and reasonble exercise.

Q: I was reading Minority Women: The Untold Story on the Web site, and I can see how one may believe that traditionally, African-American and Hispanic women are less prone to eating disorders, but nonetheless, not immune to them. I understand there are insufficient data for Asian women, but I believe that Asian women are actually just as prone to eating disorders as white women. (This isn't based on any actual data.) Particularly in the Indian-American (subcontinent of India) culture, women and girls are pressured to look good and compete with one another. Perfectionism is a character trait of anorexics, and it is also a stereotype that Asians are hard-working overachievers/perfectionists (emphasis on stereotype). Although in China it is traditionally better to be "healthy looking" (more on the chub side than the slim side), this ideal of beauty is no longer embraced as the younger generations embrace Western culture (a trend that is echoed throughout the Web site).

What do you think about Asian women (including Indian women and Oriental women) and eating disorders? My views are based on observations in my high school, which had a relatively substantial Indian population, and college. I am Chinese. I am really interested in this modern-day problem. Thanks for reading my question.

Happy Holidays!

Sonia from Missouri

Johnson: There is substantial data indicating that anorexia and bulimia actually meet the formal criteria for being a "culture-bound syndrome." We know that the prevalence of eating disorders is highly correlated with the degree of westernization in a culture. Also, as with any epidemic, you start with an index case that has a narrow demographic profile and as the disease spreads, it begins to affect increasingly diverse socioeconomic, ethnic, and demographic groups. The spread of AIDS is a good example. Without a doubt we will begin to see increasing numbers of patients with eating disorders from different subpopulations. Likewise we will see drift to younger and older patients and more males.

Q: My question focuses upon preventative measures, touched upon in a question previously asked. There seems to be a trend among school-aged girls talking about how much each one weighs, what size they are, etc. at an alarmingly early age, evidenced by my two daughters, who began these worrying discussions in the third grade. Since this starts so young, is it advisable to show the NOVA program "Dying to be Thin" to adolescent girls? Or is there too much information given regarding how to be thin? I would like to present this program to their school to be shown to fifth grade and up, to give the girls information about the dangers of dieting as well as warning signs and how to get help if they find they are losing control. I talk with my girls about this. However, the power of peer pressure can overrule parental advice far too easily.

Anonymous from Massachusetts

Johnson: You are wise to be cautious about selecting the right prevention materials. In a previous answer I outlined some of the unusual difficulties of doing prevention work in this field. I would suggest that you contact EDAP (listed in Help/Resources on this Web site) and confer with them about the proper prevention materials and strategy for the age group you are interested in.

Q: I don't know if I am anorexic or not. After I had surgery I lost 15 lbs. and have not been able to gain it back. I want to gain the weight so badly but food turns me off. I hate food because I think it will make me sick. When I eat I feel nauseated, so I eat as little as possible just to get by. I want to fall in love with food again, but don't know how. I've lost my appetite and can't gain the weight. I am very tiny to begin with, and I have never been over 98 lbs. I now weight 84 lbs., and I am 33 years old!! HELP!! Am I sick???

Lee from California

Johnson: It would appear that you would not meet the psychological criteria for an eating disorder. I am concerned that you have unwittingly developed a phobia related to food. Unquestionably I would recommend that you seek a consultation with a psychologist or psychiatrist to clarify what you are struggling with.

Q: I am a bulimic currently in a treatment program, and my E.D. doctor has strongly suggested that I get more intense treatment at St. Paul's hospital, possibly in a residential group home for eating disorders through the hospital. My question is regarding behaviors and their effects on the physical body, such as the use of Ipecac syrup, which I have used on and off for a couple of years, for weeks or months at a time, sometimes several times a day. I had stopped for many months, but now I have started up again. I know it is 'bad' for me, but what exactly is it doing to me physically? And am I really in danger? Thank you so much for your time, thoughts, and expertise on this matter.


Johnson: Syrup of Ipecac is the most lethal form of purging behavior. It is very toxic to the heart. You need to do whatever is necessary to stop using this product. It is extremely harmful.

Q: This is a question about the relationship between osteoporosis and menstruation. I have a friend who has been bulimic for years. She is also a "cutter" and a trauma survivor and has substance-abuse problems. She told me recently that she has not had her period in eight months, that she only gets it regularly when she's on the pill. She claims that it has "always" been irregular like this. She's 27.

Obviously, she has a lot of different issues to address. What I want to know is whether her lack of menstruation puts her directly at risk for bone loss, and what she can do about it, realizing that she's not just going to "get better" any time soon?

Anonymous from Massachusetts

Johnson: Osteoperosis has emerged as one of the most damaging and irreversible side effects of anorexia nervosa. We now know that bone demineralization can begin to occur much sooner than we previously suspected. For some it is within three months of losing one's period. It is also not clear if we can prevent or slow this process by offering medications. It is clear, however, that once the bone density has been lost, it cannot be replaced.

Q: Have you ever used Luvox in the treatment of anorexia or bulimia? If so, what success rate has it had?

Ed from Massachusetts

Johnson: Luvox has been very helpful with both anorexia and bulimia. It has been a particularly useful medication when we have a patient who is struggling with obsessive-compulsive symptoms in addition to her eating disorder.

Q: Is there anything that can be done for my 50-year-old sister, who has been anorexic since her 20's? Height 5'3", weight 70 lbs and dropping. She exercises for at least an hour a day, eats the bare minimum, and told me she's eating even less now. She's had many surgeries due to intestinal destruction/obstruction, has been under psychiatric care but will not enter a facility (has consulted with Renfrew). She's always had suicidal tendencies. She takes Miltown and smokes grass for her anxiety. She weighs less then ever now and is "getting her things in order." She never would divulge this info (weight, eating less). This is the first time she's shared her thoughts. Is there any way to do an intervention without pushing her off the edge? Thank you. We're desperate.

Susan from New Jersey

Johnson: One should never give up hope regarding recovery. Our ability to treat these disorders has continuously improved over the years. On the other hand, if a patient has received competent care, and she is 15 to 20 years into the illness, it becomes increasingly unlikely that they will recover. There can come a point when the family and the treatment team need to shift their focus to helping the patient and her significant others "get her things in order." It is important to rememer that 10 to 20 percent of folks that develop these disorders die from them.

Q: Hello, and thanks for providing this service! I have been told by family members and all the medical charts I see that I am way too thin. I am 35 years old, 5'7", and 110 pounds, with body fat of 12 percent. I eat a low-fat but very healthy diet (around 2,000 calories a day) and work out a lot. I consider myself very athletic and not like the waifs typically associated with eating disorders. Although I seem to be on the low end of the charts, I have never missed a period.

My question: As long as I get a regular period, doesn't this mean my weight is fine? I am on the pill, so I don't know if this may be giving me an artificial sense of security, as I know birth control seems to regulate periods. So, can a person who is below the recommended weight/body-fat charts, but gets regular periods, feel assured that she is not getting "too thin"? Shouldn't I only worry if the periods stop? Thanks!!

Anonymous from Ohio

Johnson: At 12 percent body fat you are below the average for menstruation, which is in the 17-22 percent range. As long as you are on birth control you will not know if you would menustrate normally at this weight range/percent body fat. The critical question is if you are beginning to develop osteoperosis. I would recommend that you have a bone-density scan to see if all is well.

I would have other questions for you. How do you feel if you are prevented from exercising due to injury or other life events? In other words, how much do you have to exercise in order to feel emotionally stable? Does the meal plan that you are pursuing result in you being constantly hungry or preoccupied with fats? What would happen if you were in circumstances in which you had to eat several high-fat meals in a row? Would you feel panicky and out of control? How flexible are you in regards to your meal plan and exercise schedule? If none of these things is a problem, then you are doing great.

Q: I am currently 44 years old and the proverbial life-long dieter. I have run the gamut from liquid fasts to hospital-supervised weight loss and have suffered with bulimia. Have I screwed up my metabolism to the point where my body will never lose weight and keep it off? Please donŐt give me the run-around, be straight with me. Thank you for your consideration.


Johnson: I asked Leah Graves R.D., our distinguished dietician here at Laureate, to respond to this question:

Graves: Research would suggest that your metabolism is not permanently lowered by your dieting. However, yo-yo or cyclical dieting can affect body composition. Frequent dieting followed by regaining weight can result in a decrease in muscle mass and an increase in percentage of body fat. Body composition does affect energy use. Those with more muscle mass require more energy than others weighing the same amount but having a higher body-fat level. Focusing on health improvement by eating consistent, reasonable meals/snacks without over- or undereating and regular exercise may allow any decrease in muscle mass to improve. This would help with ongoing weight management.

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