Anorxia, culture, and a Golden Fork award

JG's thoughtful responses to my previous post included a link to an interesting article on eating disorders and culture. It's a good overview of the conventional wisdom on the role of culture in eating disorders, and I'm putting the link up here in case anyone wants to read it.

JG writes, "I'd give anything to spare a young woman today from going through what I did." That's how I feel--I'd give anything to spare a young woman from going through what my daughter did.

I think if we keep talking about this, keep questioning, raising the issues, that's a good thing. I wrote here months ago about the posters at my younger daughter's middle school--there were bulletin boards in the hallways promoting "healthy eating," exercise, and, yes, unbelievably, weight loss. I went in and talked with the assistant principal about it. The posters went away for a while, and have no, my daughter says, been replaced with posters saying something like "Losing weight is not healthy for children and adolescents."

Yay! Hamilton Middle School got it! I hereby award them a Golden Fork award for being responsive to the issue. One small step at the table, one giant step (I hope) for our understanding and treatment of eating disorders.

Fear of food

I was in the food co-op this afternoon, picking up a bunch of spinach, when another shopper spoke to me. She was a young mother, shopping with her preschooler, and she watched me put the spinach in my cart with frank shock. Then she shook her head. "Boy, you're brave," she said.

It took me a minute to understand what she was referring to. Once I got it, I couldn't stop thinking about it. Here was fear of food in a different context from the one I'm used to seeing--the kind of fear of food anorexics feel--and it made me think. Our relationship to food is so primal, so necessary for survival, that to be afraid of it seems not just counterintuitive but, also, awful.

If I'm honest, I must admit that I have fears around food, too. I'm guessing many of us do. I spent years being afraid of fat because of the cultural hysteria around overweight. I grew up in the 1960s, eating a lot of packaged, chemically preserved food--Snowballs and Tastykakes, anyone?--and now try to eat organic when I can, partly from fear of what's in our food supply, partly because organic food tastes better, and partly because organic practices are better for the earth and animals.

And I got to wondering just how pathological my food fears are. I'm not afraid of spinach--in fact I cooked it up and ate it for dinner, and it was delicious--but I wouldn't willingly eat a hot dog (red meat, nitrates).

How sad to have fear enter into the essentially joyful relationship we should have with food. I don't make New Year's resolutions, but I think I'll make that a priority on my list this year: to vanquish my own food fears and reestablish a healthier and happier relationship with food in 2007.

Mr. Wrong goes to New York!

The publication date for MR. WRONG: REAL-LIFE STORIES ABOUT THE MEN WE USED TO LOVE is getting close, and I'm thrilled to be traveling to New York City for a reading. Even better, I won't be standing up there alone, but will be in the company of some of the highly entertaining writers with essays in the collection--Roxana Robinson, Catherine Texier, Caroline Leavitt, Raphael Kadushin, and Dana Kinstler. The reading is at the Barnes & Noble at 82nd & Broadway, Feb. 7 at 7 p.m. It's going to be a lot of fun.

For those of you closer to (my) home, I'll be reading on Feb. 14 at Borders West in Madison, along with Jackie Mitchard and Raphael Kadushin.

Watch this space for news of the MR. WRONG contest--and to find out how you can win a chance to tell your story to the world, plus a signed copy of the book and a MR. WRONG T-shirt. Yes, I'm having T-shirts made up, and they're a hoot.

Anorexia treatment and mixed messages

Recently I talked to a mom whose daughter is struggling with anorexia, and she told me about an appointment they'd had with their pediatrician, who'd been quick to notice the issue and to push for early intervention. The doctor said to the girl, "You need to drink a milkshake every day." Then she added, "But of course, it's your choice."

I've heard this kind of story over and over again, and it makes me crazy. As this mom astutely commented, "Would a doctor ever prescribe an antibiotic for an infection, but then say it was your choice whether to take it or not?"

When it comes to anorexia, way too often the medical profession is willing to settle for inadequate treatment and mixed messages. Would a doctor tell a diabetic it was his choice to take insulin?

"Force-feeding" and anorexia

Recently I've been asked to speak about the Maudsley approach to healing anorexia on several radio shows. In every interview there is a question or comment about "force-feeding" anorexics, and it's always offered in a tone of mingled horror and contempt, as if there could be nothing worse than coercing someone into eating.

To which I usually respond something like, "Actually, there's nothing worse than watching someone compulsively starve herself to death."

Now an interesting paper published in the American Journal of Psychiatry takes on both the moral and legal issues around the idea of what the authors call coerced care for eating disorders. I love the analogy its author, Dr. Arnold Andersen, uses for how dieting can lead into anorexia: "The situation resembles that of a person boarding a canoe headed for Niagara Falls on a journey that begins voluntarily but ineluctably transforms into a nonvoluntary propulsion toward the Falls, with the person at times not recognizing that the upcoming Falls even exist."

That describes it so very well. Someone who is deep in anorexia cannot see the falls or even know they exist. They need the strong hand extended from the shore to pull them out of the current.

Far worse to watch the boat go merrily over the falls.

More on culture and eating disorders

A new study released by the University of Minnesota shows that teenagers who read lots of magazine articles about dieting are five times as likely to practice "extreme dieting measures"--including fasting and intentional vomiting--than teens who don't.

According to an article in the Chicago Tribune, Harvard Med School researcher Alison Field commented, "The articles may be offering advice such as cutting out trans fats and soda, and those are good ideas for everybody. But the underlying messages these articles send are, `You should be concerned about your weight and you should be doing something.'"

This study will come as no surprise to any parent of an eating-disordered child. It describes perfectly the nexus between culture and eating disorders, which is not black and white, either/or. Do magazine articles cause anorexia and bulimia? No, but they clearly, clearly play a role in triggering adolescents who are vulnerable.

And it's not just teen magazines, either. Not long ago on an online forum for parents who are re-feeding their anorexic children, someone started a thread on what triggered each child's descent into anorexia. I was shocked by how many parents mentioned a school health class. And in fact, a 6th-grade "health" class that focused on the dangers of obesity and the virtue of cutting out fats, carbs, and other "bad" foods was the catalyst that led to my own daughter's full-blown anorexia a year and a half later.

As parents, we're used to thinking about all sorts of potentially risky behaviors: drugs, early sexual behavior, alcohol, etc. Now we can add another one to the list.

And yet another Leaden Fork award goes to . . .

Reader's Digest, for its well-meaning but shamefully one-sided advice on how to avoid compulsive overeating. In fact, this could be a primer for how to induce an eating disorder.

Blog reader Deborah Lee brought this to my attention, and points out a couple of items on this top 10 list that really bugged her:

"3. Never, ever buy a snack at gas stations, drugstores, or discount chains.

4. Never, ever stop at a food store just to buy a snack."

Writes Lee, "While I understand the sentiment in these statements, and it may be sound advice in principle, this sort of black-and-white, all-or-nothing thinking is what eating disorders thrive on, and is completely unnecessary."

I'm with you on this, Deborah. Of course Reader's Digest is just one of many media outlets that get this way wrong. Especially in this season, when the default assumption is that we're all trying to lose weight and need "tips" like these. Open just about any women's magazine right now and you'll see headlines like "How to Stick to Your Diet,""Want to lose weight? Be sure not to skip breakfast," and a host of other ridiculous headlines.

I'm looking forward to a year that started without a lot of advice on how to lose weight--and focused instead on creating a healthy and joyful relationship with food, exercise, love, work, and all the other pleasures of being a human being.

How about it?

Listen to the MPR show with Katharine Loeb

The host of the show did a fantastic job--one of the best interviews I've heard or participated in on the subject.

Here's a link to the show.

Talk to me live tomorrow!

I'll be doing a live call-in show tomorrow, Friday, December 29th, 2006, on "Midmorning," hosted by Kerri Miller and produced by Minnesota Public Radio. The other guest on the program will be Dr. Katharine Loeb, assistant professor of psychiatry at Mt. Sinai School of Medicine in New York, and an avid supporter of the Maudsley approach. We'll be discussing anorexia research and treatments, and I'm looking forward to our conversation.

The show airs at 9 a.m. central time. You should be able to catch it online at http://news.mpr.org/programs/midmorning/. Call in with your questions at 651-290-1592.

Talk to you tomorrow!

Is Anorexia Cultural?

That's the $64,000 question. Folks in Brazil are wondering why so many women are dying of anorexia there. Is there something about the culture that is suddenly contributing to a surge of cases? Is the media reporting on anorexia more? What's going on?

More and more, researchers see a genetic component to anorexia and other eating disorders, including chromosomal abnormalities. A 2006 study that looked at anorexia and twins found that genetics accounted for more than half the cases of anorexia, suggesting that people are born with a susceptibility to anorexia and then get triggered during the vulnerable time of adolescence and young adulthood.

Makes sense to me. If culture were the sole culprit, anorexia would be far more prevalent than it is.

Brazil is a country where many people don't have enough to eat; anorexia is typically a disease of "starvation in the midst of abundance." Maybe the rise in prevalence--if there is one--is a symptom of widening gap between the very rich and the rest of the country in Brazil. Maybe it's a sign that the Brazilian economy is improving.

Whatever the statistical explanation, I know one thing for sure: Young women (and men) in Brazil and elsewhere don't have to die. Anorexia can be cured, especially if it's treated early, in adolescence. It's not a cultural metaphor; it's a disease with a tragic trajectory that inflicts a great deal of suffering on anorexics and their families.

Changing the culture, one heart and mind at a time

Last night a friend told me that since my daughter Kitty's illness, her daughter had become very outspoken on the subject of anorexia. She said that whenever other teenage girls joked about it, she "set them straight"--a commendable act of friendship.

But what really made me want to stand up and cheer was when she told me about the day her daughter--Kitty's friend--came home and headed straight for the refrigerator. Apparently someone had told Kitty's friend she looked like she'd lost some weight. "I can fix that," she said, reaching for the whipped cream.

Here's what blows my mind about that: In a culture where all of us are so conditioned to think that thin is always good (and thinner is always better), it's hard to go against the stream. We parents of anorexics are shoved right up against this cognitive dissonance when we re-feed our ill children. It took the gut-wrenching experience of watching my child nearly starve herself to death to open my eyes and change my reflexive thin=good, fat=bad mentality. But Kitty's friend, who is still in high school, is a much quicker study than I am. She's learned from Kitty's nightmare and is already applying the lesson in her own life.

Her insight and perspective give me hope that although change seems to come slowly, it does come, one heart and mind at a time.

Hand-On Parenting Gets a Rave

This morning's story in the New York Times titled "Parenting as Therapy for Child's Mental Disorders" is yet another acknowledgment by both the media and the medical community that sometimes parents can make all the difference for their children.

The article references how kids with ADD and other types of mental health issues often respond well to parents' efforts to modify their interactions with the world through changing their behavior. Writer Benedict Carey quotes one parent as saying, “If you are willing to take on the responsibility of extra parenting, you can make a big difference.”

This will sound familiar to anyone who's used the Maudsley approach to refeeding an anorexic. Kids with ADD often are prescribed Ritalin or other stimulants to "fix" their behavior; there's no such magic pill for anorexia. Maybe it's a good thing.

Just one more reason for parents to follow their instincts when it comes to what their children need.

Our Bodies, Our Ideas of Our Bodies

I was fascinated to read in Women's Wear Daily that fashionistas are now having some models' photos retouched to make them look heavier. In the wake of the Madrid revolt, where models with BMIs under 18 were not allowed to walk the runway, this seems like more of a good thing. And I definitely applaud the demystification of anorexia chic.

There's certainly nothing chic about anorexia, as I have reason to know all too well.

Still, I can't help feeling like this misses the point on a number of levels. If these models are so thin that readers of Allure don't want to look at them, then they need food and professional help, not an airbrushed photo. The problem isn't in our perception--it's in their realities.

The current politically correct (and highly ironic) focus on too-thin models is just one more manifestation of our compulsion to make our bodies conform to a culturally defined weight, look, shape, or style. That, right there, is the problem--and it isn't going to be fixed with an airbrush, any more than it's going to be fixed with the next great diet or exercise regime.

The human body comes with a marvelous ability to regulate its own appetites. Then we muck it all up with our ideas of what it should look like.

In the ideal world, all kids would be raised to eat when they're hungry and stop eating when they're not hungry, just as wise woman and nutritionist Ellyn Satter writes in her books. We would learn from an early age to value our connection with our hunger and feelings of fullness.

Though we don't, alas, live in the ideal world, we can still nurture our own interior connection with our bodies, our hunger, and ourselves. We can begin to accept the fact that bodies come in all shapes and sizes, that while one person might be healthy at size 4, another might be just fine at size 16. We can learn to value health over faddish or slavish notions of appearance.

I'll lift a fork to that.

And another Leaden Fork award goes to . . .

economist Susan Lee, whose December 4 commentary on public radio's Marketplace show began like this: "How much you weighed used to be a private matter. If you wanted to look like a tub of lard, that was pretty much your business. But now fat is a public issue."

And included this line later on: "Why else would people be willing to pay extra to make sure that no kid looks like a tub of lard?"

Tub of lard? Is this how we really want to describe a child or adult who's overweight? Since when does this level of judgment belong in an economist's commentary on public radio?

I haven't heard anyone use that kind of language since 7th grade. Maybe 6th. Susan, in case you aren't aware of this, words are powerful. There's no call for that kind of demeaning, demoralizing, judgmental language from anyone in the media.

Read Lee's whole commentary here. Then tell the folks at Marketplace what you think of her choice of words here.

The Leaden Fork Award

When our family started dealing with anorexia, one of the first things that happened was that we became highly sensitized to questions of weight and body image. And folks, once you tune in to what people are saying--about their own weight and bodies, about yours, about other people's--you'll be astonished and appalled.

The media, of course, is a huge offender. Several exposures recently have inspired me to highlight some of the most egregious offenders with a special Leaden Fork Award (kinda the opposite of Laura Collins' Golden Fork--for more on Laura Collins see her fabulous site).

My first Leaden Fork Award goes to the well-intentioned but way-off-base folks at braincake, a site meant to be all about empowering girls. (Thanks to Gale Petersen for bringing this to my attention.) The flash intro to their site shows the words "If I could change the world," and follows it with various wishes, apparently in the words of girls themselves. One of those wishes is: "If I could change the world, I'd . . . reengineer chocolate to have negative calorie. The more I ate, the skinnier I'd get!"

Congratulations, braincake! Your Leaden Fork award is well-deserved for the way you've bought in to the myth that when it comes to girls, thinner is always better. You've trivialized girls' dreams and wishes. And you've blithely ignored the very real and very destructive problem of eating disorders.

Want to be part of changing the world? Send the misguided folks at braincake an e-mail and tell them you want them to change their intro, pronto. The address is braincake@carnegiesciencecenter.org. Tell 'em I sent you.

Got any candidates for the Leaden Fork award? Send them my way at hnbrown@tds.net.

In Memoriam: Vivian Langan, 1927-2006

My mother-in-law died last week. Aside from being a wonderful person in so many of the ways that count, she taught me to eat. I wanted to take a moment to remember and celebrate her for this.

I grew up in a household of dieting women. I think I understood that certain foods were good and certain foods were bad from the time I was one; in fact, one of my mother's favorite photos of me as a child shows me at about 16 months sneaking cookies from a tin in a kitchen cabinet. Hilarious, huh? In my family, the nicest thing you could possibly say to anyone is "You've lost weight!" Our family meals veered between the good stuff and Weight Watchers diet food, including possibly the worst "food" ever manufactured, diet chocolate mint soda.

My mother-in-law was thin. Not stick thin, not too thin, but thin in a healthy way. She was an athlete from before the days of Title IX, member of a curling team that won the national championships in the 1960s, tennis player, runner, and overall physically active person. And she loved both to cook and to eat.

At first her cooking appalled me. Real butter? We might all drop dead from eating that. Or at least gain 50 pounds. In my family quantity trumped quality any day.

But gradually I came to understand, from watching her cook and eat, that when you eat good food, real food, it's satisfying in a way that carrot sticks and artificial sweetener can never manage. That you don't need 20 cookies when they're made with real butter and chocolate; one or two suffices.

From my mother in law I began learning how to listen to my body's appetite and hunger, and satisfy it. I began the long process of learning to care for myself through eating, while stepping around the traps of obsession and guilt.

So as I mourn her passing, as I begin the long missing of her, I also want to celebrate her in this as well as so many other ways. Vivian, wherever you are, I'm raising a forkful of shrimp salad to you. Made with Hellman's mayonnaise, not the fake-o stuff, and served on good crackers. This one's for you.

Are We All Calorie Phobic?

What is it about calories that freaks everyone out?

In one of the recent radio interviews I've given about anorexia and refeeding, I was struck by what a big deal the interviewer made about the number of calories required for a recovering anorexic to gain and then maintain weight. She just couldn't get over the number I mentioned in the NYT Magazine article--between 3,000 and 5,000 calories per day--and made a point of interjecting with what she considered the "normal" number of calories required by a teenage girl.

It reminded me of that old Lenny Bruce routine about the word c***sucker, where first the prosecutor and then the judge kept saying the word over and over: "Your Honor, he said c***sucker!" "He really said c***sucker?" "Yes, your honor, he said c***sucker!" And so on.

I had the same feeling about this: as if talking about so many calories (let alone eating them) was somehow disgraceful or shocking or obscene. I think this is part of what makes it challenging for anorexics in this country to recover--that in this culture we are so phobic about calories that we can't bear to feed someone that much, even when they so clearly require it for recovery.

Myself, I'd much rather see a recovering anorexic eat a few too many calories (and what is "too many" in this context?) than not enough. Anyone who's lived with the firsthand experience of anorexia should be far more phobic about "not enough" than about "too much."

Update on Kitty

For everyone who has so lovingly asked about Kitty and how she's doing:

She's doing really well. She was apprehensive about the New York Times article coming out, nervous that people would say things to her in school. And they did say things, but they were pretty much all supportive. And I think that's helped her feel empowered.

She's busy with real life now, not trapped by what I think of as the red shoes of anorexia--which make you dance and dance even when you're so exhausted you just want to fall over.

The goal of Maudsley treatment is to get an anorexic back to normal adolescent development. She's there. At least for now. Which is all we can really know or ask for at the moment.

Thanks, all, for your messages of caring and support for her. I know they touched her.

Why talk About Anorexia?

Last Sunday I published a first-person account of our family’s year-long efforts to refeed our 14-year-old anorexic daughter. Since then I’ve been taken to task in the blogosphere for publishing the personal and often harrowing essay.

I was accused of violating my daughter's privacy, of writing something that would haunt her for the rest of her life; every boyfriend and potential boss, goes the accusation, will now know intimate details of her life. How could I, or any parent, reveal such details? Maybe, she suggested, I was getting back at my daughter in a passive-aggressive way for the hell she'd put us through last year.

I considered the criticism honestly and thoughtfully. And I want to explain why I did what I did. Not just for me, because I'm just one mother telling one story. I want to explain this for all the mothers and fathers out there whose children struggle with mental illness, whether it's anorexia or schizophrenia or dyslexia or ADD or bipolar disorder or an as-yet unnamed malady that affects their child's brain, mind, thinking, and behavior.

What all of these have in common is that they come with a deep and abiding sense of shame and stigma. Every parent knows the feeling; it’s a question of degree. When you see or the world tells you that there's something wrong with your child, and that it's possibly, even probably, your fault, your instinct is to cover it up, hide it, put a lid on it and a hood over its face. Don't talk about it. Don't ask about it. Just accept the verdict and do the best you can.

But I believe with all my heart that if we are quiet about our children's illnesses, if we act as though there is something shameful about them, if we slink around and hang our heads and speak in hushed whispers about the agonies our children are going through, then we are not doing our job as parents. If we put Privacy with a capital P above the real true needs of not just our children but everyone's children, then we are failing them and we are failing the greater community that we inhabit.

As one eating disorders expert told me, "The reason there's not more research on anorexia is that there's no strong advocacy group pushing for it. Look at the autism parents—look what they've accomplished by putting it out there."

When we say yes to shame and stigma, we consign our children to years of suffering a kind of torture we can only imagine—we don’t want to imagine. We doom them to live terrible half-lives and to die of starvation or exposure or by their own hand. We send them to hell with our pious words and our respect for their Privacy.

I will not do this.

I wrote the article with the permission of my daughter. It is true that she was ambivalent about it. She worried about losing her privacy and feeling exposed. But she overcame those fears because she wanted to help others who were going through what she'd gone through. She wanted to save other lives. She is a generous and good and brave person, my daughter, much braver than anyone else can truly ever know. She was willing to put principle and habit and fear aside for the chance of participating in what we call tikkun olam, repair of the world, the opportunity to heal some small portion of the tear at the heart of the world. Her recovery is in large measure her own doing—with our support and love.

I call that heroism. And I honor it by telling her story and the story of thousands of others like her.

As long as the forces of shame and stigma and conformity press us to shut up, sit down, be embarrassed, we and our children will continue to suffer and, yes, to die, in silence and misery.

I call that stupid.

Love as Part of Recovery from Anorexia

I've been completely overwhelmed by the outpouring of emails I've received since my New York Times Magazine article appeared yesterday ("One Spoonful at a Time," www.nytimes.com). Wow. It's an incredible feeling to be so connected with so many people who have shared the same awful and misunderstood experience.

I want to share one of those emails with you, because it moved me so much. The author has given me permission to excerpt it here. The notion that a parent or other close relation's love and caring are a vital part of recovery from anorexia feels absolutely true to our family's experience.

I'd love to hear what other people think about this.

--Harriet


Hi, Ms. Brown,
I’ve just read “One Spoonful at a Time,” your article in the NY Times about refeeding your daughter, and her long recovery from anorexia nervosa. As a teenager—also 14—I was anorectic, and the memory of the first milkshake my mother asked me to drink is still vivid, a full-body memory. I’m writing as a former sufferer of anorexia nervosa to provide a kind of confirmation of the wisdom of the Maudsley approach, which my parents had never heard of, but which mirrors their approach to helping me escape the grip of the “demon” you describe so well in your article.

Over the years, I’ve tried to figure out just how I escaped anorexia. Two things stand out, and I was amazed to find both addressed very clearly in your article. First, I was simply exhausted by what you’ve called the anorexia demon—the obsessive thoughts about food, about how fat I was, about how undisciplined and grotesque I would be if I gave in and allowed myself to gain weight. I ran three to four miles a day just to keep that demon at bay. I was never as open with my parents as your daughter has apparently been with you, but if I had been, I’d have said precisely the things that you report in your article. I knew what was going through my mind would seem absurd if I revealed it, so I kept it to myself, sometimes completely convinced that I alone knew how true it all was, sometimes not so sure, but always, always fatigued by it.

More importantly, I was deeply affected by my mother’s sense of urgency about my need to eat. Your description of the frustration, fear, and anxiety you’ve experienced as you’ve tried to help your daughter recover is very familiar—I’m sorry to say that my mother went through something very similar with me. The full-body memory I mentioned above is not so much of drinking the milkshake, but of the experience of taking it from my mother’s hands, her presence, her watchfulness, all of which were, in comparison to my masochistic inner voice, so gentle and nonjudgmental. Her concern, and the patient but steel-willed lovingness that went into each milkshake, did the demon in. If you’re ever tempted to believe that your daughter isn’t aware of and grateful for all you and her father have done and continue to do to help her, please think again. I’m not sure how else to put it. And now, over 20 years later, it’s easier for me to admit that on some level what I really needed most was for someone to show that she cared that much, and that her caring was stronger than my self-hatred. I’m not sure why—my parents were always loving people—but maybe it’s just that, once self-imposed starvation really sets in, an opposite and greater-than-equal reaction from a firm, compassionate outside force is required to overcome it. Showing your daughter that you care, that you’re concerned--so much so that you’re not going to back down until she’s regained her health and vitality--is what makes the difference. If that’s the core of the Maudsley approach, I’m sure further tests will continue to reveal its effectiveness.