- The Washington Times - Sunday, May 13, 2001

There was rapid weight loss and a diet that temporarily consisted only of oranges. There was a large amount of time spent in the bathroom and avoiding food or bingeing on it.

These were the first clues Stephanie Watt had that her then-12-year-old daughter, Kristen, had an eating disorder.

Mrs. Watt and her husband, Mike, got Kristen the help she needed to deal with anorexia and bulimia. Kristen, a normally outgoing soccer player and top student, lost 50 pounds in less than five months and over the next two years went through two inpatient counseling programs.

Even after returning to a normal weight, however, Kristen´s body had been through too much. Her electrolytes were dangerously out of balance. She died suddenly in July 1999.

"Every day I blame myself," Mrs. Watt says. The Stockton, Calif., woman has started a foundation in her daughter´s name to raise awareness of eating disorders and help parents and health professionals understand the signs, symptoms, causes and treatment.

"There were signs I continually missed," she says. "Even in the hospital, we never thought she was in a high-risk situation. You never think you can die."

Kristen Watt´s situation was extreme, but she was among an estimated one in 100 adolescent girls suffering from anorexia (intense fear of getting fat and refusal to eat) or bulimia (binge eating followed by vomiting or laxative abuse), says Dr. Angela Guarda, a psychiatrist and director of the Eating Disorders Clinic at Johns Hopkins University Hospital.

"It is very common for parents, in retrospect, to say they didn´t notice at first," Dr. Guarda says. "They didn´t put the puzzle together. One reason is because about 60 percent of teen-age girls are dieting."

The difference between dieting and having an eating disorder can be tough to gauge, Dr. Guarda says. When dieting becomes an obsession, it is time for parents to step in, she says.

"The difference between a normal dieter and one with an eating disorder is that dieting has become a ruling passion in the latter," Dr. Guarda says. "Individuals often describe being preoccupied with food and weight 90 percent of the time."

Other early clues are restrictive eating behaviors. A person with an eating disorder will start eliminating entire groups of food, such as those that contain fat, and narrowing food choices, Dr. Guarda says. Most of the teens she counsels say they are vegetarians. That proclamation should be a red flag for parents, she says.

"This can be a key sign to notice," she says. "Ask them what kind of a vegetarian they are. Are they eating Indian curry that is loaded with ghee (butter)? Or just salad? A lot of the world is vegetarian, but they also eat fat. In a person with an eating disorder, fat is the component of food they typically limit."

An exaggerated increase in exercise should pique a parent´s interest, too. While some daily physical activity is healthful, an anorexic or bulimic person often will become obsessive about working out, the psychiatrist says.

"She may become agitated if she can´t work out," Dr. Guarda says. "If the family is going on an outing, the daughter panics because she can´t go on her morning run."

A patient with an eating disorder will show signs of depression and social isolation, Dr. Guarda says. Because many social situations have to do with food, an anorexic will avoid those situations.

Another situation an anorexic will avoid is family mealtime, she says.

"She may develop food rituals such as eating slowly, refusing to eat with the family or refusing to eat food prepared by others," Dr. Guarda says. "It is not uncommon for me to see patients who have not eaten with their parents for a year. Sometimes this goes unnoticed since family meals are not the norm anymore. It makes it hard for parents to pick it up. Sometimes the first time they notice is at Thanksgiving."

Eventually, people with an eating disorder also become obsessed with food. Extreme hunger gives way to reading labels and cookbooks and eventually in about 50 percent of cases, binge eating.

"Within six months to a year of severely limiting their food intake, many anorexics will begin to binge-eat the foods they have not allowed themselves to eat," Dr. Guarda says. "Signs of this include bags of cookies disappearing, candy wrappers in the room and weight gain."

Bulimia is a much harder eating disorder to catch because many bulimics are a normal weight, says Dr. Tomas Silber, a specialist in adolescent medicine at Children´s National Medical Center.

"Many times when parents find out, it is just a matter of luck," Dr. Silber says. "They catch their child throwing up in the bathroom."

A less apparent sign of repeated vomiting is swollen salivary glands, says Dr. Silber. Swollen salivary glands will give a bulimic a "chipmunk cheek" appearance, he says. Some bulimics have scabs on their knuckles from putting their hands in their mouths to induce vomiting, he adds. Others have teeth that are severely damaged by stomach acid.

Kristen Watt followed a typical pattern from anorexia to bulimia. Mrs. Watt, like many parents, found out about Kristen´s vomiting by looking in the bathroom and at her daughter´s clothes.

"She wasn´t real good about covering her tracks," Mrs. Watt says. "She spent large amounts of time in the bathroom. I would find clothing with vomit on it."

Who gets an eating disorder?

Kristens condition began around the same time as puberty, a typical time for young girls to develop disordered eating, Dr. Silber says.

"Boys and girls are similar until puberty," he says. "Then a remarkable difference takes place. When secondary sex characteristics start to occur, boys acquire muscle mass and girls acquire fat mass. This is normal, but it goes to a girl´s thighs and buttocks as preparation for eventual childbearing. Many young girls are not prepared for this, and they misinterpret this as getting fat rather than getting female."

Ten times more girls than boys have eating disorders, but some boys also develop anorexia or bulimia, Dr. Silber says.

"Traditionally, we see it in boys who have to make weight, such as in wrestling," he says. "Or sometimes a boy might be pudgy and he gets teased, so he becomes fanatical."

Though eating disorders can happen in any family, both Drs. Guarda and Silber say there is a typical patient profile.

"I would say a high-risk patient is one who belongs to the upper middle class or upper class," Dr. Silber says. "She belongs to a family who is concerned about the body and appearances. She may have low self-esteem but be a high achiever in many areas. A genetic history of alcohol, depression or eating disorders adds tons of risk."

Two studies last year showed that scientists are gaining a better understanding of the role of genetics and eating disorders.

Researchers at the University of Pittsburgh compared rates of eating disorders among 1,831 family members of 504 women ages 18 to 28 with anorexia or bulimia.

Dr. Michael Strober, lead author of the study, says nearly 12 percent of women with severe anorexia had female relatives who had some symptoms of the disease. Four percent of the women with bulimia also had relatives with bulimia.

"The rate of bulimia and anorexia nervosa among female relatives of persons with eating disorders was between four and 11 times higher compared with incidents of illness in women without relatives with an eating disorder," Dr. Strober says.

At Virginia Commonwealth University in Richmond, doctors studied rates of anorexia and depression among 2,163 female twins, both fraternal and identical. Overall, 77 women (3.6 percent) had been diagnosed as suffering from anorexia, and six of the women had a twin who shared the diagnosis.

Though researchers admit that is not a huge percentage, it is enough for them to say that genes influence a susceptibility to the disorder.

They also found that 140 sets of twins suffered from major depression, leading researchers to believe there is a genetic component to both disorders. Past research has indicated that 50 percent of women with anorexia have major lifetime depression.

The VCU study authors said living in a shared environment may be somewhat responsible for twins´ propensity toward an eating disorder.

Dr. Guarda says it is not likely one single gene is responsible for eating disorders. The cause more likely is a combination of a genetic propensity combined with environment, she says.

"The media has taken a lot of flak" for promoting a thin, ideal woman, she says, "but not everyone is getting an eating disorder. Only 3 percent of the population develops clinical anorexia or bulimia. The media´s focus on thinness may be lowering the threshold and increasing rates of eating disorders, but it is not the whole answer."

What parents can control

The focus on thinness does not stop at adulthood. In many families, girls begin asking if they look fat or going on diets because they are emulating their mothers, says Abigail H. Natenshon, a Chicago psychotherapist and author of the book "When Your Child Has an Eating Disorder: A Step-by-step Workbook for Parents and Other Caregivers."

"Parents need to be role models in what they say and do," Ms. Natenshon says. "Parents need to be an emotionally healthy role model and a role model for healthy eating. One of the reasons eating disorders are so prevalent is that we have forgotten what healthy eating is."

Dr. Silber agrees.

"I tell mothers to stop talking about dieting," he says. "It is the same as with parents who are smokers. Just because they smoke, it does not give their teens license to smoke.

Another way to instill healthful eating habits is to sit down to meals as a family as much as possible, Ms. Natenshon says.

"Making meals and sitting down together is the best way to observe a child´s behavior," she says. "Too many kids are fending for themselves because we are too busy to eat together. They are eating fast food and Power Bars. Kids tell me they believe dieting is the only way to keep their weight down."

At those family meals, talking will go a long way, Ms. Natenshon says. Start a dialogue about dieting, she advises.

"Ask your child, 'What are your dieting goals? How did you decide this is the best way to lose weight?´" Ms. Natenshon says. "Many parents don´t take eating disorders seriously until it is too late. This is one of the most lethal mental health disorders, but if detected and treated early enough, it is curable in a majority of cases.

"Parents owe it to their children to educate themselves and take eating disorders seriously," she says. "They have to know that eating disorders are not going to show up in the doctor´s office kids will keep it a secret or in lab tests. It is going to show up at home, in the bathroom and at the kitchen table."

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