In this sobering but ultimately hopeful documentary, NOVA examines a disturbing increase in the prevalence of eating disorders, particularly anorexia and bulimia. Meet students, ballet dancers, fashion models, and other young women who are seeking recovery or have conquered their disease. Discover how leading eating disorder specialists are making dramatic advances in the diagnosis and treatment of these devastating conditions that affect millions of people.
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Dying to Be Thin
PBS Airdate: December 12, 2000
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NARRATOR: A ballerina must have more than grace and flawless technique to be successful. She must also be abnormally thin. It is a dangerous obsession for many dancers.
KATEY TRACEY: If they want thin, I will give them thin. And I did. I dropped more weight in two weeks than I had ever done in my life.
DR. LINDA HAMILTON: Dancer thin is not like thin on the street. We're talking about 15 percent below your ideal weight for height, which is basically an anorexic weight. If your career is on the line, if the roles are on the line, whether or not you reach that ideal, you will do practically anything.
NARRATOR: Starving herself for nearly a year, Katey Tracey weighed twenty pounds less than she does today. The bones in her chest began to protrude. She had developed anorexia nervosa, the deadliest of all psychiatric disorders.
KATEY TRACEY: It was going from one extreme to the next and people in the dance world they were praising it. They were saying, "Gosh you look so good. It looks nice. You have a new body!"
NARRATOR: The dance world was stunned when a member of the Boston Ballet, Heidi Guenther, died at age 22 when her heart gave out. The cause appeared to be an eating disorder.
ELEENA MELAMED: I remember always watching gymnastics and figure skating and all of these sports, and having them talk about eating disorders and how thin these gymnasts have to be. And I would just think to myself, "look at what dancers have to go through." It's kind of a dirty little secret. Nobody talks about it.
NARRATOR: Eating disorders are common in the dance world but they are spreading as the pressure to be thin intensifies.
KATEY TRACEY: Everybody wants to know the secret to being thin, because that's success. That's love. That's glory. That's power. That's a crock.
RUTH STRIEGEL-MOORE: Today, we're told to believe that we too can look this way if only we work hard enough at it. So there's this whole myth that everybody can achieve the impossible. And that's very damaging. Because if then you don't achieve this look, something is wrong with you.
NARRATOR: Erin is fourteen years old. Tormented by an irrational fear of fat, she has been starving herself for three months.
RENEE: Erin, what is your reaction?
ERIN: Just that it's true.
RENEE: Can you kind of look in the mirror, with your image kind of reflecting back, and kind of tell me what you see about yourself, your physical self, also, when you look in the mirror?
ERIN: I see somebody that is fat and ugly and a disappointment.
RENEE: I know that this is hard for you.
NARRATOR: Erin is beginning treatment at DePaul-Tulane's eating disorders unit in New Orleans. Her mother brought her to this specialized center after she almost died of malnutrition at a hospital near their home in Texas.
KARRI MEADOR: She's so into being skinny, to being slim. She thinks she's fat. She's not. I just think she's going to die, and she doesn't believe me. I had to tell her in the hospital. I go, "Erin, you're going to die."
KATHRYN: Go ahead and step up.
NARRATOR: At 20 percent below her normal weight, Erin has already suffered medical complications which will only get worse without treatment.
DR. WALTER KAYE: This is a very deadly illness. It has the highest death rate of any psychiatric illness. Approximately half a percent of people with anorexia nervosa die every year from malnutrition or other kinds of complications. So over the course of 20 years, 10 percent of people with anorexia are going to die from this.
NARRATOR: Prolonged starvation can cause a number of medical conditions, including dangerously low blood pressure, severe osteoporosis, damage to the kidneys and liver, and ultimately, heart failure.
Erin stopped eating when her mother, who works for the military, took a job in Korea for a year. Feeling alone and abandoned, she became obsessed with her appearance.
ERIN: I know I would be thin, and everybody would like me and you know, I wouldn't be having to worry about my weight and all that stuff. I felt like I'd be loved more.
I saw a Karen Carpenter movie. And that taught me a lot about how, you know, how not to eat, to lose weight and stuff—the water diet and everything. So that actually was pretty much what I got from it, you know? I can live without eating, you know.
NARRATOR: After struggling for years with an eating disorder, Karen Carpenter died of heart failure at the age of 32. At the time of her death in 1983, most people had never heard of anorexia nervosa. But today it's a different story.
An alarming study from the Mayo Clinic shows that anorexia has been increasing by 36 percent every five years since the 1950s. Today, some eight million people, mainly women but some men, suffer from anorexia and bulimia, a related disorder. Young women, ages 15 to 24, are the most vulnerable.
ALISHA: I had been very overweight and I had exercised and eaten right and, you know, then my mom was so proud of me. And it was the compliment thing. And I thought, "I'm so close to being able to model." And I thought well, maybe I ought to try it. It's OK be a little skinny. The camera puts on 10 pounds anyway. It won't matter. You know. And the compliments people gave me, and just even the idea, "hey, I wear a number one, I am the top."
CINDY: I saw a TV movie on bulimics. And I was watching, and I was like, "hey, wow. Look what she's doing. She's eating all that food, throwing up and she's losing weight." And that night I went into the bathroom and I started. I didn't think there was anything wrong with it, 'cause it's on TV, and sometimes they make it look so glamorous to have an eating disorder.
NARRATOR: It has become a self-fulfilling prophecy. The popular television series Friends played on anorexic chic in an ad which was soon pulled.
RUTH STEIGEL-MOORE: In some ways we all have distorted views of what is beautiful. And the repeated exposure to a particular image teaches you to like that particular image. And we have become so used to seeing extremely thin women that we have learned to think that this is what is beautiful.
NARRATOR: The mystique of thin began with the arrival of the British model Twiggy, in the late 1960s. Standing five feet, six inches tall, she weighed only 91 pounds and was dubbed Britain's top mini-model.
Since then, fashion models have become increasingly thinner, with body weights nearly 25 percent less than the average American woman, who weighs 140 pounds.
DR. JOAN BRUMBERG: I think there are two primary things going on right now with the cultural availability of eating disorders. First the whole society is involved in the perfection game, alright? That we all can fix our bodies, make our bodies over. And then I think, among young women...they're increasingly tuned in to a celebrity culture where the models and actresses bodies are considerably thinner than they have ever been in the past.
This is very seductive and hard for young girls to resist. This is not about illness. This is about idealized beauty and perfection of a certain type.
NARRATOR: These plus-size models are boldly challenging contemporary ideals of beauty. Ranging from size 12 to 18, they are much more in tune with the average American woman. Now a plus-size icon, Kate Dillon started out as a skinny model.
KATE DILLON: I think that it happens to everybody at some point where you feel one way about yourself. And that your initial...your intuition about who you are is that you're a good person, that you're beautiful, that you're strong, that you're capable. And at some point it's met with an outside force that's telling you, "no, you're none of those things."
I remember getting ready for my first day of Junior High. And I was sitting at my mirror, putting on my electric blue mascara and my frosted pink lipstick. And I was thinking I was like, "yeah, I'm fine. I'm looking good." You know?. And when I got to school it was just...they were just horrible to me, telling me I was fat. And whether it was in PE or coming home on the bus every day, they'd stand up, and they would jump up and down and chant, "Overweight Kate. Overweight Kate." And I remember just like, you know, I'm like, sitting in the front seat ...I would always wear these massive sweaters...and I was sitting in the front seat and just like, trying so hard not to cry, because I was so embarrassed and horrified.
NARRATOR: Desperate to fit in, Kate took extreme measures.
KATE DILLON: The end of my seventh grade year I'd lost 30 pounds and I grew like four inches. And I was cool. Suddenly everyone liked me. My plan worked, sadly and unfortunately. But it seems to be that that's the way the culture is, you know? You sort of, you do what they want and they'll say, "Cool. Good. You're good now."
NARRATOR: Kate became not just thin, but anorexic. And she caught the eye of the fashion world. Weighing 50 pounds less than what she does today, Kate's image before the camera concealed a painful inner struggle.
KATE DILLON: I looked beautiful. I mean it's not like...you would not look at that picture and see someone who is feeling bad about themselves, or see somebody who hadn't eaten in two weeks. I mean, I look at my face, my face looks so hollow. I look so...my eyes look like they're bulging out. And I just look so weak.
That was the day that they told me to lose like ten or twenty pounds, and I kind of knew that that was crazy. Like I remember thinking, "From where? Like twenty pounds? How am I going to lose twenty pounds?" And I remember thinking, "I don't have to do this. Like what have I been doing the last couple years? What have I been doing my whole life?"
NARRATOR: A year later, Kate walked away from modeling. She was in search of a life where starvation was not the price of success.
Historical images and accounts of anorexia date back hundreds of years.
DR. JOAN BRUMBERG: In the fourteenth century, the mystic Saint Catherine of Sienna, starved to death at the age of 33. An extreme ascetic, her self-denial was quite different from that of most young women today.
Certainly during her lifetime she engaged in food refusal and a number of other penitential acts. But her pathway into that behavior is so markedly different. It's motivated by her faith. She also often gave away the food that she didn't eat. So in many respects she's not at all like a contemporary anorectic.
In the 19th Century, it is also possible to envision middle and upper class girls who want to be very thin for a totally different set of reasons than today. They didn't want to be thin because it was sexy. They wanted to be thin because it meant that they were spiritual. They wanted to be thin because it meant they had kind of conquered their carnal appetites, such as food and eating.
I see the common theme in all this is that women are using the appetite as a voice. And they are using the appetite to express different things depending upon their historical situation.
NARRATOR: Today, at least three out of every hundred girls will develop anorexia or bulimia, often in the wake of puberty.
SUSAN WILLARD: I believe there are these separation, individuation, identity formation problems that are occurring. And I think that has to do with fears of maturity. I think that development of someone from a child into an adult, the adolescent process, has a glitch somewhere. And that the eating disorder is born out of the struggle to grow up.
NARRATOR: But, why do some girls develop eating disorders and others don't?
RUTH STREIGEL-MOORE: There are a lot of precipitants. You know, it could be the parents got divorced. It could be a break-up with a boyfriend. It could be any number of what may seem to be very small stresses to most people, and yet for a particular girl...the straw that broke the camel's back. But you won't have those onsets unless the girl already is vulnerable in some way. So simply because, you know, parents divorce doesn't mean now their daughter is going to develop an eating disorder. Those events have to sort of occur in the context of an already existing vulnerability.
NARRATOR: Erin's personality made it especially difficult for her to deal with upheavals in her life.
DR. WALTER KAYE: From a biological standpoint we're actually finding that people with these disorders actually share some common personality traits. And that is, both bulimics and anorexics tend to be people who are obsessional, perfectionistic. And they are concerned about doing things right. Things have to be done kind of with symmetry and exactness. And that they tend to be people who are what we call "harm-avoidant." That is, that they worry about the consequences of their behavior. They don't want to do things wrong.
ERIN: I just like everything to be controlled, just in control, you know, kind of like, I don't know, just like traffic. I hate when people try and cut on you. And they are sitting right here...and traffic right here...and people right here...cause they are trying to get in another lane. I'm just like, "Keep the lane straight." That's just me. That's just how I am.
DR. WALTER KAYE: Now when we go back and we start looking at families of people who have eating disorders, we actually see a very high rate of a spectrum of eating disorders in their families. We see that roughly about seven percent of the family members have anorexia or bulimia nervosa, and we see roughly maybe another five to seven percent of family members have a spectrum of eating disorders. They don't have anorexia or bulimia, but they have some variant of eating disorders.
NARRATOR: In search of a biological explanation, Dr. Kaye peered inside the brains of recovered anorexic and bulimic patients. He discovered unusually high levels of a brain chemical called serotonin, which is well known for the role it plays in mood and appetite.
DR. WALTER KAYE: Over-activity of the serotonin system reduces appetite.
The other thing about having increased serotonergic activity is it seems to be...at least in animals and human studies...goes along with having kind of obsessive, anxious, harm-avoiding kinds of behavior.
NARRATOR: Dieting, even starvation, may be a way for people with eating disorders to lower their serotonin levels in an attempt to reduce their intense anxiety.
DR. WALTER KAYE: This may explain the vicious cycle that people with anorexia get in. They have too much serotonin. They starve themselves. That drives down the serotonin.
NARRATOR: But the brain quickly adapts by adding more serotonin receptors.
DR. WALTER KAYE: So even a little bit of serotonin sets off these receptors. So people have to keep starving themselves more and more to reduce the serotonin, but the receptors keep up regulating. So they can never really escape from it.
NARRATOR: For patients with anorexia, weight gain is a crucial first step toward recovery.
KATHLEEN: So we have about 10 minutes, okay?
NARRATOR: Anorexia is one of the most difficult psychiatric illnesses to treat. Nearly 50 percent of patients will relapse within the first year. But new research shows that these rates can be dramatically reduced if patients like Erin reach their normal weight before leaving the hospital.
DR. WALSH: There is ample evidence that the lower the weight, the greater the risk of death and the greater the risk of medical complications. So I think what we ought to pay attention to in the treatment of anorexia nervosa, as sort of an index of how someone is doing, is the weight. And if their weight isn't back to normal, treatment isn't ended.
NARRATOR: But weight gain alone is not enough. Anorexia is a complex mental and physical illness that requires a multi-disciplinary team to treat it.
SUSAN WILLARD: Okay, why don't we go ahead and staff Erin?.
NARRATOR: Psychotherapists, a physician, nurses, art therapists, body image specialists and nutritionists will work together to tackle Erin's eating disorder.
SUSAN WILLARD: In order to treat eating disorders effectively, we need to address both parts of the problem. We need to address the underlying causes and issues, and we need to address the symptoms, the eating behaviors that are so dangerous. And I believe as an inpatient, people (sic) need to address these things simultaneously—and address them both with a vengeance.
NARRATOR: Five weeks into her stay at the hospital, Erin is gaining weight and has begun to face some traumatic issues in her past. She admitted to having been sexually abused, not uncommon among these patients.
ERIN: Trauma is what really hit if off. Bringing up my trauma issues really made me want to...I just I wanted to get rid of it somehow...the feelings, too many feelings, way too many feelings. Flush them down the toilet.
RUTH STREIGEL-MOORE: Having been sexually abused teaches a girl a number of things. One is that she is powerless. It's just a horrendous experience to go through. And one way to cope with that sense of powerlessness is to try and find some way of having power and control. And by managing one's weight, that can be one way to have power and control. Some women will overeat quite explicitly as a way of making themselves less attractive. Others will diet as a way of staving themselves into an unappealing small size. So there's sort of any number of explanations that women then come up with, but they all have to do with trying to cope with what has been an extremely traumatic experience.
NARRATOR: Talking about the abuse marks a significant turning point in Erin's treatment.
ERIN: Secrets. You don't keep secrets, you know. Secrets are bad. And I was keeping it a secret. And if I would have kept that, and went home with it, I would have just gotten sick again.
NARRATOR: Group and individual therapy are critical components of the treatment process.
MEGAN: I just thought that I could live the rest of my life not eating and it was like a power thing. I was like, "Look, Mom. I don't have to eat. I can piss you off. I don't have to eat, you know." And it works. It works. I mean, that's the last thing your parents want is for you to die. And so when you sit there, and you're like, "I'm not going to eat. I'm just going to slowly kill myself," it works. You can get back at anybody. And I guess...I don't know. I guess I need to find a way to forgive her, you know, because I'm just punishing myself. I'm killing myself. And it's so stupid because you don't win.
SUNNY: Losing your life isn't winning is it? It hurts her, but it hurts you more. How does it feel to be looking at all those feelings from back when they got divorced?
MEGAN: It just makes me mad.
SUNNY: Mad because?
MEGAN: Because I didn't tell them.
SUSAN WILLARD: These are not generally kids who can scream and yell and say, "I hate you, why did you do this to me?" They're very sweet and they're very kind. And they're parent pleasers. And so they are aggressive in the sense that they are driving the knife deeper into the family and the family watches them die. But they are very sweet and very kind and very quiet about the process.
NARRATOR: At age 21, Eleena Melamed has also paid a heavy emotional price. A gifted dancer, she was told to lose weight at age 12.
ELEENA MELAMED: I remember having a teacher come up to me and pinch my back, pinch the skin on my back and say, "What is this? Are you drinking milk? You know you need to lose weight."
NARRATOR: Eleena eliminated fat from her diet. In time, she became anorexic.
ELEENA MELAMED: "My Anorexic Year," I call it. I was the happiest I had ever been in my life. I was getting all the good parts in our performances at the school. I was getting all the attention. I was not being ignored anymore. When I was heavy I was ignored instead of nurtured. And when I was really thin I was all of a sudden...was nurtured and taken care of. And the teachers loved me and they cared about me and it was like I was a whole new person.
NARRATOR: After starving herself for over a year, Eleena lost control and began to eat.
ELEENA MELAMED: Gaining weight was for me the worst thing. I was just so ashamed of my body. I felt like I was the biggest failure and the weakest person. Just the worst person. I remember picking up a knife from the kitchen and starting to cut myself on my arms, on my legs. I had so much pain inside of me, and so much hatred and animosity towards myself, that feeling the pain and making it real pain—as far as being able to see the blood and see the cut—it was calming. I did that for a long time.
NARRATOR: Despite her fragile state, Eleena's talent did not go unnoticed. At age 17, she was invited to join the prestigious American Ballet Theatre in New York, by artistic director, Kevin McKenzie. But her struggles with weight would continue.
ELEENA MELAMED: All of a sudden there's that added pressure of being on stage every day next to these amazing, beautiful dancers. And I just...I buckled under the pressure. I could not lose weight. It made me eat more, because I got very depressed. I felt horrible about myself.
NARRATOR: Eleena now faced one of the most difficult decisions of her life: whether to pursue her dream to be a professional dancer no matter the personal cost.
Erika Goodman made that decision many years ago and now, at age 54, she lives with the consequences—a lifelong struggle with anorexia and severe osteoporosis. A former Joffrey Ballet dancer, she is no stranger to extreme dieting practices.
ERIKA GOODMAN: The scale becomes your altar. It becomes the site where you pray every morning. You pray that it will be down another pound or another ounce or anything to show that the work that you're doing—and the work is starving—is working. Because other things in your life aren't working, and it's the one thing you have control over. And that's a major thing. I think that's what keeps a lot of these people in this anorexic mode. It's control. Nobody else can control that for you.
NARRATOR: Described by a critic as a treasure of her generation, Erika danced in an era when anorexia was a silent threat and all too easy to overlook.
ERIKA GOODMAN: The really perverse irony of this is that what has been taken away from me are my legs. And for somebody who had always been very flexible, I'm very stiff. And, it's only now that I know. It's only when you're paying for it. You're paying for it then, you see, but you don't know. The cash register hasn't rung. It's ringing now. And it's not until it rings. It's like sleeping. You can have your alarm clock set, but it's not until it goes off that you're going to awaken.
NARRATOR: Eating disorders are too prevalent to ignore today. Dancers at the New York City Ballet attend a seminar on health issues.
Anorexia and bulimia are rare among men, but increasing.
DR. HAMILTON: I think women get more eating disorders than men because we have such a focus on our appearance. Although it's changing a little bit. Men have to have the abs now and a little bit more muscle tone. If you look at professions like jockeys, for example, or weight lifters, you'll often see a higher incidence of eating disorders, because their careers are on the line based on their weight.
NARRATOR: For women, a loss of body fat from dieting or even strenuous exercise can shut down the production of the hormone estrogen, which is crucial to bone growth and menstruation.
This is a total bone density scan of a healthy twenty-five year old woman, compared to a woman of the same age who has gone five years without menstruating. Nearly a third of her bone mass is irretrievably lost.
This woman in her 30s has gone 15 years without a period, transforming her bones into that of a seventy year old women.
As a preventive measure, the Ballet offers its dancers bone density scans.
Katey Tracey lost her period for nearly a year when she had anorexia.
KATEY TRACEY: Being a woman, being an athlete, I realized that I was susceptible to bone loss. The potential for injury, the potential for loss of reproductive abilities scared me. It scared me to point that I thought, "If I don't get some kind of physical help, I might be in jeopardy."
DR. MICHELLE WARREN: Dancers are at particular risk for developing osteoporosis because they do everything to exaggeration. They diet to keep their weight down. They avoid foods with fat in them, and, unfortunately, a lot of foods with fat have calcium. And you get bones that are thin and fragile, essentially osteoporotic bone.
Kathleen, it looks pretty good. Your value is...
NARRATOR: Getting help right away probably made all the difference for Katey. Her bone scan is normal.
Strenuous exercise can lead to another form of anorexia. In a 26-mile marathon, the finish line comes too soon for Jennifer Schmid.
JENNIFER SCHMID: At about three miles to the end of the race I knew I was in danger with this disorder because all my thoughts were consumed with, "How soon am I going to get to the gym after this?"
NARRATOR: Unlike most patients with anorexia, Jennifer has no issues with food. She has always eaten voraciously but got into trouble when her workouts burned more calories than she could consume.
JENNIFER SCHMID: I think my personality has a lot to do with this. I've always kind of had a perfectionist personality. It kind of runs in the family, being a little bit obsessive compulsive and kind of self-critical. "Self-disciplined" is what...is how a lot of people describe me.
WALTER KAYE: Our lab and other laboratories have found, retrospectively, that if you ask people—and their parents—who have developed anorexia what they were like when they were children, a majority of them developed an anxiety disorder before they ever developed anorexia. As a child (sic) from around the age of eight years old.
JENNIFER SCHMID: I've always had anxiety since I was a little child. It's just been in different ways and different situations. But exercise was the one thing for me that could take that anxiety away. The more I worked out the better I felt. And then, little bits wouldn't be enough. I'd have to go more, and I'd have to go more, and pretty much it just spun out of control.
NARRATOR: When Jennifer's heart rate plummeted after working out, she was admitted to the eating disorders unit at Methodist Hospital in Minnesota. Her mother was grateful to have Jennifer's marathon workouts brought to a halt.
NANCY SCHMID: Up in until now...up until she's been in the hospital...there hasn't really been anything I can do. I have tried being real supportive. I've tried backing away and not having anything to do with her. I've tried to do a lot of different things to see what would work. And really nothing did work until she got into the hospital.
NARRATOR: Now that Jennifer has been hospitalized for a week, her vital signs have improved. She is taking a drug called Paxil which helps to regulate levels of serotonin in her brain and lessen her anxiety.
JENNIFER SCHMID: I haven't worked out in two weeks, and that's the longest span I've gone since I can remember. And I haven't had any anxiety at all or experienced anxiety or obsessive thoughts since I've been on this medication.
NARRATOR: Drugs like Prozac or Paxil act on the serotonin system, but they are not always effective, especially in patients who are severely underweight.
DR. TIMOTHY WALSH: The studies that people have done—including our own group—have done to date have not found that medications like Prozac or Prozac itself is very helpful in the treatment of anorexia nervosa. Perhaps one reason is that most of the trials of medications for people with anorexia nervosa have been done while they're underweight. And it may be that the effects of starvation on the brain prevent Prozac from working.
NARRATOR: But as patients gain weight, medications like Prozac appear to help them avoid a relapse.
JENNIFER SCHMID: I want to live. I'm going to live. I'm going to live though this. This program has taught me that and given me the nutrients and things to start thinking clearer. And there are so many things I want to do. I'm young. I've got a whole life out in front of me, and I plan to live it to its fullest.
NARRATOR: In today's image conscious world, surveys show that 80 percent of women are dissatisfied with their bodies. Girls as young as nine and ten years old are dieting, even though they are at normal weight.
RUTH STREIGEL-MOORE: The diet industry is a very, very big industry. It sells the myth of transformation. If you do our product, you, too, can be Princess Diana. You, too, can marry your Prince. You, too, can be wealthy. And it's amazing how people can suspend this belief and buy in to anything. You know, "Lose 30 pounds in five days!" And again, I think it gets nurtured in a culture that values extreme thinness. And of course underneath that is...what's the basic message? The message is, "You're not okay the way you are. You need to be transformed."
NARRATOR: At Cornell university, Dr. Joan Brumberg is conducting a seminar on the history of female adolescence in America. The pressure to be thin is keenly felt by these college women and is spreading across all racial and social classes.
MICHELLE: When I grew up in a predominantly black neighborhood, it just wasn't an issue. And it never affected me before I came here. And all of a sudden now everyone is so little, you know?
DR. JOAN BRUMBERG: We know now that there are eating disorders in the African American community. So these observations about cultural differences are really interesting. And yet everybody seems to say around this table that the pressure is pretty intense right now.
GABRIEL: I believe that very few women escape a battle with their bodies. I think that it's to varying degrees, but I think that many women at different points in their lives are unhappy with their bodies. I don't think there are a lot of women who can say, honestly, they love their bodies.
NARRATOR: For more than a decade, Anne Chavarro has faced a particularly difficult battle to overcome bulimia nervosa which is characterized by binge eating and purging.
Most people who develop this secretive illness are around the age of 18 and of normal weight. But the obsession with food and dieting begins earlier.
ANNE CHAVARRO: In high school, it was how little you could eat in order to make it through the day, you know? And what size pants could you fit into, you know? 'Cause we were always trying to lose weight. Then I moved to Manhattan and all my friends were actors and actresses and models. Almost all of them had eating disorders. So you kind of get the hang of it, and then you start reading some books on trying to get help for your eating disorder and in reading those books you find techniques that work
NARRATOR: Bulimia nervosa is a relatively new disorder, medically recognized only in 1979.
DR. TIMOTHY WALSH: Certainly the behavior was well recognized for centuries or even millennia. I mean we know the Romans were doing some strange things with food and vomiting at the time of Christ. But from a clinician's perspective it was very rarely talked about. Binge eating and purging just weren't on the radar screen until about 20 years ago."
NARRATOR: For Anne, bulimia seemed to offer a perfect solution to her conflicts over food.
ANNE CHAVARRO: You realize that you can eat whatever you want and get rid of it, it's sort of like a high. Emotionally, it makes you strung out. It's almost like being on drugs, you're totally strung out, you know? And because you're constantly depleting your body of food in between the binges, you're lethargic. You're so tired, you're so drawn out, that you can't do the things that you even want to do. So it becomes like a cycle. It's a cycle, you know? And you can't break out of it.
NARRATOR: Anne's life became consumed with hiding her bulimia and fighting depression, which frequently accompanies this illness. She ate enormous amounts of food and purged up to 20 times in a single day.
ANNE CHAVARRO: It doesn't only hurt you. It hurts whoever is in your family that you're very close to. So your friends, it hurts all them, even though you do not mean to hurt them, you know? The self-loathing comes in. You start hating yourself. And then...like the types who hide...like I used to hide it. And then it's like...it's even worse.
NARRATOR: For the past three months, Anne has been receiving treatment from Columbia Presbyterian Medical Center's psychiatric institute. Dr. Walsh has put Anne on Prozac, which helps with her mood and appetite by acting on the serotonin system.
DR. TIMOTHY WALSH: For many patients with bulimia, taking Prozac helps them both feel better emotionally and gives them better control of their binge eating and vomiting. And that's a fact. I mean, it's one of the things we can now take advantage of in our treatment of patients.
NARRATOR: Anne has changed her behavior dramatically, but breaking the cycle of bingeing and purging is like giving up an addiction.
DR. TIMOTHY WALSH: During a binge, people typically will report, something changes. At least they feel numb. They're not thinking about whatever it is they were worrying about, so there is a reward there. They don't feel good, but they feel different and they feel some relief, I think, from the distress they were experiencing. And one wonders if that isn't a critical component that keeps this behavior occurring.
NARRATOR: In addition to medication, most people with bulimia benefit from psychotherapy. One of the best-studied techniques, cognitive behavior therapy, is designed to break bad eating habits and establish a healthier body image and a new approach to food.
ANNE CHAVARRO: I actually had like, a banana nut muffin, and that was like taboo for at least two years. Unless I was going to throw it up I couldn't eat it.
NARRATOR: To understand more about bingeing, Dr. Walsh and his colleagues designed an experiment. They provided a large amount of food and allowed patients to eat whatever they wanted. The result was an average of 3600 calories or nearly two days worth of food in a single sitting.
JANET GUSS: There's something disturbed about their satiety or satisfaction as it relates to food. It seems to be a general disturbance in feeling satisfied with a meal the way that you and I would feel just stuffed and maybe stop eating. We felt maybe they are not experiencing that sensation.
NARRATOR: Anne is participating in a study to see if her treatment has had any impact on her stomach's ability to handle food more normally. Anne is given a liquid meal that is tagged with tiny amounts of radioactivity. This machine, a "gamma counter," detects emissions from the meal and will monitor the rate at which food leaves her stomach.
After food enters the normal person's stomach, small amounts begin to empty into the small intestine. This triggers the release of cholecytokinin or cck, a hormone that helps transmit sensations of fullness to the brain. As more cck is released, the person starts to feel full and eventually stops eating.
In the case of bulimia, it appears that over time, bingeing on large amounts of food causes the stomach to empty more slowly into the small intestine so less cck is released. The message to the brain to stop eating is weaker so the person does not feel full and keeps eating.
After three months of treatment, Anne's stomach is emptying at a more normal rate compared to three months ago.
JANET GUSS: I can see that there has been an increase in her gastric emptying rate, which is what we would want to see. It is more typical of a normal control subject...a normal individual...so at least from that perspective, the gastric emptying data looked to be improved in the three-month period that she received treatment.
NARRATOR: About fifty percent of patients who receive treatment for bulimia are cured, while the remaining half, like Anne, are substantially better. But it still may take several years before Anne fully recovers.
At the American Ballet Theatre, life is looking up for Eleena. She admitted she had an eating disorder and director Kevin McKenzie offered her a medical leave of absence.
ELEENA: After years of being yelled at and made to feel ashamed and ugly and hideous...to have Kevin McKenzie tell me that it was okay, that he understood, and that it didn't mean that I wasn't a valuable dancer...it just meant that I had a disease that I needed to heal, and he was willing to wait for me...
KEVIN MCKENZIE: I have learned not to tell somebody to just lose weight. But you do need to address this and you do need some professional help with it. It may be something as simple as you not understanding what to eat. And I'm telling you this on the same level that if you were walking in here with chronic tendonitis, I would eventually say, "You have to go to the physical therapist and take care of this," and equate it on that level...give them the name of a doctor and send them off.
DR. HAMILTON: So how did tour go?
ELEENA: It was okay.
NARRATOR: A former dancer herself, Dr. Linda Hamilton understands the extremes to which a dancer will go.
DR. HAMILTON: They are so phobic about fat at this point, by the time I get them, they've maybe not been eating fat for five years. What's always so wonderful is when I get them to eat enough calories and fat, and suddenly their bodies start working again. Their metabolism speeds up, they start to lose weight. And they look at me in amazement like, "Come on...this is working!"
ELEENA: My weight dropped. I mean, I lost I think five pounds within the first two weeks or something just by eating fat...by having 30 grams of fat a day. It was the most amazing thing. You know, I would never believed it if somebody had told me that.
NARRATOR: Eleena is back with the company now rehearsing a soloist part for a 60 th anniversary presentation of Swan Lake.
KEVIN MCKENZIE: I think getting the support has helped on the level that she's happier, she enjoys her dancing. And if she can be guided properly and then really fully realize her talent,the potential is there to be wonderful...is to be absolutely wonderful.
NARRATOR: After leaving her life as a supermodel, Kate Dillon spent the next two years searching for a new career to fit the person she has become.
KATE DILLON: I wanted freedom from this ideal, from these cultural ideals. I wanted freedom to be who I was, whatever that would be. And if I was the biggest dork in the world, well then that was going to have to be okay. And if I was a big mess, then that was going to have to be okay too. And if I was beautiful, that would be fine. And if I was ugly, that would be fine. But that I didn't want to fight myself any more. That I really wanted to just like unzip this suit that I'd been wearing of, "Like me, like me, like me. Think I'm interesting. I want to be perfect." And just take it off and just expose and just be like, "I'm just who I am."
NARRATOR: No longer at war with her body, Kate has settled into a comfortable weight and a new career in modeling.
KATE DILLON: Plus size is no different than skinny, it's just another way of being beautiful. Many of these girls have been struggling with their bodies their whole life. And suddenly they're being told that they're beautiful. And so when you get 25 women up on stage with curvy, beautiful bodies walking around feeling beautiful, it's infectious. And everybody is sort of drunk with that. And when I think about the impact it could have on a young girl, like me maybe, who is 12 years old and isn't going to fit into the right size and isn't going to fit into that mold. And she is going to grow up in a world where things like that exist. Maybe she's not going to feel so bad about herself.
NARRATOR: Back at the DePaul-Tulane eating disorders unit, Erin is preparing to leave. On the right track, she will have to continue treatment at home for at least another year or two to ensure a full recovery.
SUSAN WILLARD: We have Erin being discharged Friday.The best insurance to prevent relapse is continued care in all dimensions of treatment. With her aftercare plan set with a good therapist, a good nutritionist, and an excellent family therapist, with all of that in place and these people pursuing health with Erin and her family, her chances are far better.
ERIN: Dear Treatment Team: I just want to tell you all thank you so much for what you have done for me. You have opened my eyes to a wonderful world of opportunities. I know that I can need and ask for help and assert myself because of you all. I know that there will be rainy days ahead of me and I am ready to fight them. You have helped me so much even though I sometimes got pissed off. If I ever need help again I will come to you all because I trust and believe that you can make miracles.
SUSAN WILLARD: You've really made some great strides forward and you just have to keep up the good work. And you have to keep up with your therapies, all of them, and start to enjoy a real life 'cause I think it's all out there for you, okay? You ready for it? Okay. I'm so proud of you.
ERIN: Everyone has given me an opportunity to have a new life and I thank you for that. Thank you for being my family. I love you all. Now, I am starting on my journey now. Love always, Erin.
Dying to be Thin Narrated by Susan Sarandon Written, Produced, and Directed by Larkin McPhee Photo: Rosalie O'Connor Associate Producer Lisa Fisher Edited by Steve Fischer Camera Robert Hutchings
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