Home > Archive > December 2009/January 2010 Vol. 91 No. 3

December 2009/January 2010 Vol. 91 No. 3

Family Matters: Anorexia: It's Not About Food

Rahel Musleah
Sophie Casson
While there are no exact statistics, it is clear that Jewish girls are among those suffering from eating disorders. The question is: How can we identify and help them?

Ann Levine had already lost a child in a horrific car accident when her 17-year-old daughter, Rebecca, became anorexic. What began as a diet before a school dance escalated to a full-scale disorder within months. Levine, a mental health professional, says she missed the early warning signs—changes in her daughter’s eating habits, skipping meals, insisting she was full, not eating foods she had previously enjoyed.

When Levine finally insisted Rebecca have a medical checkup, “there was no hiding anymore. She had lost over 25 pounds.

“Managing my own anxiety and wishing I could do something that would make...her healthy was the most difficult,” says Levine (many names in the article, including the Levines, have been changed to protect privacy). “My fear that she was going to die was so strong.”

Rebecca began seeing a nutritionist and therapist and continued to be medically supervised in college. “She was angry for a long time and said people were making a big deal over nothing,” says Levine. “The only thing she could control, as she struggled with academic pressures, growing up, transitions and loss was the food she put into her body.” Rebecca is now healthy.

Superficially, eating disorders seem to be about food. In fact, they are a chronic form of emotional distress and a serious illness, most often seen in girls.

They are “a coping mechanism when life feels out of control, overwhelming, disappointing or painful,” says Catherine Steiner-Adair, director of Eating Disorders Education and Prevention at McLean Hospital, a clinical instructor in the department of psychiatry at the Harvard Medical School in Boston, a clinical and consulting psychologist in private practice in Chestnut Hill, Massachusett and co-author of “Full of Ourselves: Advancing Girl Power, Health and Leadership,” a curriculum for middle-school girls that increases self-esteem and body acceptance. “What remains sadly consistent,” she says, “is how many girls refer to their bodies as the ultimate measure of their worth.”

Psychotherapist Abigail Horvitz Natenshon distinguishes between disordered eating—unbalanced or unhealthy eating most of us do occasionally or even regularly—and clinical eating disorders, which have a genetic basis and are among the most lethal of mental health illnesses. Otherwise “benign” disordered eating behaviors such as dieting, skipping meals or excessive exercise could trigger a clinical disorder in a susceptible person.

In 2006, the National Institute of Mental Health confirmed that anorexia and bulimia are biological, brain-based disorders; in response, group health insurers will be required to cover treatments for these disorders in the same manner as medical and surgical procedures are covered; a federal law should take effect in January 2010.

Since the 1960s, eating disorders in the form of anorexia, bulimia, binge eating, overexercising and obesity have doubled, according to the American Academy of Child and Adolescent Psychiatry. Anorexia is characterized by the refusal to maintain about 85 percent of normal body weight, intense fear of gaining weight and an undue influence of body shape or weight on self-image; bulimia is a repetitive cycle of out-of-control binging accompanied by purging, fasting, food restriction or laxative abuse to compensate for intake of calories.

Precise numbers are hard to come by, partly because of secrecy, denial and misunderstanding, but experts estimate that there are 70 million cases of eating disorders worldwide, 11 million in the United States; 10 to 15 percent of these are males. Eighty-six percent of victims are young people under the age of 20, and 11 percent of high school students are afflicted. Eating disorders are also common in adults, taking the forms of dieting and compulsive overexercising that masquerade as healthy activities. The majority of people with severe eating disorders do not receive adequate care.

No comprehensive statistics pinpoint the extent of eating disorders among Jews, but it crosses denominational lines. The Renfrew Center in Philadelphia (www.renfrewcenter.com), a facility that specializes in treating eating disorders, has a Jewish inpatient population of about 11 percent. Renfrew, which has locations throughout the country, has opened a track geared to observant Jewish women at its New York site.

Psychologists point out that Jews tend to be a high-achieving group with perfectionist tendencies, traits that make people vulnerable to eating disorders. “Be an A student, be an incredible society. We also want to be the best weight losers,” says Faye Wilbur, director of the Boro Park Counseling Center of the Jewish Board of Family and Children’s Services in New York, which treats eating disorders—mostly among adolescents and young adults, but also children as young as 9 and boys and women with overeating issues. But, she says, “it’s not a Jewish problem. It’s a cultural problem. America thrives on and admires thinness.”

“Girls in middle- to upper-class Jewish communities have lots of pressure to perform and do well,” Levine says. Holiday meals magnified the problem in her Conservative home. “Instead of food and drink being joyous, they became the source of conflict.”

Eating plays such a central role in spiritual practice, notes Steiner-Adair, “it makes issues around food loaded.”

Natenshon contends that food in the context of Jewish observance can be a source of emotional strength and identity, ultimately offering protection against the onset of an eating disorder. “Through Shabbat dinners, parents model a healthy foundation for living and eating and human connection. This is the stuff of cherished memories, continuity, tradition and mental health. It is only when behaviors become excessive or compulsive that they become pathological.”

Kimberly Israel, who struggled with anorexia between 1991 and 1999, attributes her recovery in part to finding herself and connecting to others at the Hillel at her university. Israel, who was raised Reform, says she would have laughed if, in her last year of high school, someone had said she was on her way to an eating disorder. She began by exercising and eating low-fat foods. Soon, she felt good being smaller than everyone else. Her weight dropped to 93 pounds in her first three months at the University of Michigan.

She had lived in a small town, and suddenly, at college, she felt anonymous. “I was losing an identity I’d built up in high school,” says Israel. “Anything I did, I did to perfection.... The only time I didn’t feel fine was when I was forced to eat or stop exercising.” The hardest part of the illness, she recalls, is that she did not have any perspective on reality. Israel had to leave school, was hospitalized and battled the disease in inpatient and outpatient settings. “My college experience was hospitals and therapists three times a week.”

Now a social worker in San Diego, Israel, 36, is a mother of two, which is almost miraculous because her period stopped the summer before college and did not resume for nine years. She is still reluctant to call herself recovered: “If my jeans don’t fit one day, I still think about it. If there’s any change or trauma, I have to be careful I don’t start skipping meals, restricting foods and overexercising. But I look at women in the throes of the disorder and I don’t find anything remotely attractive about it.”

Transitions—between childhood and adolescence, between high school and college—are a particularly delicate time. Orthodox girls often spend the year after high school in Israel. Many gain 20 to 25 pounds; to lose the weight, they simply stop eating before they go home and continue in that pattern.

David Klein says his daughter’s symptoms “spun out of control” in Israel, and she had to come home. The yeshivas in Israel “have no clue how to deal with eating disorders.” Klein notes his daughter’s illness forced him and his wife to recognize family issues: “We were part of the solution but also part of the problem.”

Their daughter, now 29, is married with three children. In the Orthodox community, when girls are “on the [matrimonial] market,” he says, thinness can be a Catch-22, a fine line between beauty and pathology. “Matchmakers say girls must be thin, though if a girl has an eating disorder, it’s a negative factor in a shiddukh [match].”

In homes where grandparents or great-grandparents went through the Holocaust, an illness in which a child looks like a survivor creates an added source of agony, says Steiner-Adair. Often, parents blame themselves for not catching the symptoms early enough; they may believe they have no right to participate in treatment, particularly after a child turns 18.

Parents need to learn the warning signs. Says Natenshon: “Because disordered eating is so common, people tend not to recognize when benign problems morph into pathology. Healthy eating is not fat-free eating. Children need fat in their daily diets to grow their neurological and reproductive systems.”

Natenshon is the author of Doing What Works: An Integrative System for the Treatment of Eating Disorders from Diagnosis to Recovery (NASW Press) and When Your Child Has an Eating Disorder: A Workbook for Parents and Other Caregivers (www.empoweredparents.com). She urges parents to play a role within the treatment process, alongside a professional team that usually consists of a physician, psychotherapist, nutritionist and pharmacologist. That support network is essential as patients recover, says Israel, eventually reaching their own moment of readiness to change their destructive behavior.

“The myth that people with eating disorders don’t get better—that it’s like alcoholism—is disempowering,” says Natenshon. “There are plenty of success stories with early and effective treatment.” Statistics indicate that 80 percent recover: 50 percent recover so fully as to never have to deal with eating issues again; the other 30 percent may need to be treated on an as-needed basis to prevent recurrence.

Tamra Golden represents one such success story. Fifteen years ago, she struggled with anorexia athletica, a disorder involving restricted food intake and excessive exercise.

Golden began running competitively at age 14. Worrying that too much food in her stomach would make her sick during runs, she ate a small breakfast and lunch. Despite rapid weight loss, she continued winning, becoming one of the best runners in Illinois. Though she is 5 feet 6 inches tall, her weight had dropped to 88 pounds.

Golden’s father, Jim, remembers “walking on eggshells. I wanted to let her know I was there and not make more of it than it was, but also not pretend it wasn’t there. I wanted her to win but I also harbored fears that she would snap and break.”

The summer before college, Golden developed pneumonia and her doctor issued an ultimatum: Stop running until she reached 100 pounds. “For me that was like an undoing,” she says. “I lost control and overate,” reaching 165 pounds. With therapy and time, she put her illness behind her.

Today, Golden rarely thinks of that chapter of her life. Currently a nurse, she is married, has had her first child and is still running. “It feels like just a blip on my radar,” says Golden. “With therapy, hard work and time, you can leave an eating disorder behind and take with you only the life lessons. You can grow stronger and live your life.” H


One Girl’s Story

At 8:15 A.M., 16-year-old Zara is standing during Shaharit, numbers running through her head. She adds 250 plus 120, 16 for the gum, 300 for lunch and 100 from breakfast.

As the total presents itself, she sighs in relief: 786 calories, a successful day. Around her, peers at the Ramaz school in New York are lost in prayer. If Zara had not been consumed with calculating calories, she would have noticed the praise being offered to God for creating a body wondrous in design.

After yesterday’s tally is done, she maps out the day’s eating. She schedules time for exercise and had had no breakfast—perhaps she can keep her intake to around 500.

But by 11, Zara is feeling light-headed and cannot concentrate in class. She excuses herself and races to a candy machine to buy a Kit Kat bar. Breaking it into four sticks, she gobbles two and saves the others to nibble on during the day.

A Kit Kat has 54 calories per stick. Leaning on the candy machine, she feels defeated, a loser. She decides to skip lunch. Morale renewed, she returns to class.

Since the age of 11, Zara’s life has revolved around food. There were the memorization of a calorie-counter book and tears if more than 400 calories were consumed; binging, followed by Ex-Lax and dashes to the bathroom. There were rage at her body, leggy but with wide hips, and the triumph of achieving her lowest weight—92 pounds—at age 12. While others prepared for bat mitzvas, she marked the passage to womanhood by starving herself.

As I write, I weep for the girls and boys engaged in a battle with their bodies. Yet in reviewing Zara’s story, I also cry for the girl I was: Zara is my younger self, and her story is my own. —Shira Dicker

Shira Dicker is a New York-based writer and publicist.

Hungry for a Response

The Jewish community is beginning to wake up to the prevalence of eating disorders and disordered eating and is developing ways to combat it, says psychologist Catherine Steiner-Adair. With funding from the Hadassah Foundation, she has created a Jewish component to her prevention curriculum, “Full of Ourselves.” Called “Bishvili: For Me” (www.bishviliforme.com), it draws on Jewish ethics and spirituality and targets day schools, afternoon school, youth groups and camps. A version for the Orthodox community is currently being developed.

The title “Full of Ourselves” reflects the difficulty girls have in claiming their strengths, explains Steiner-Adair. “Being full of yourself doesn’t mean being stuck up. It means you believe you matter.” To sustain “psychologically healthy and pleasurable relationships with food,” she adds, girls must learn how to identify feelings that upset them, deal with conflict, bullying and disconnections in relationships and how to nourish other appetites—including spiritual ones.

“Rosh Hodesh: It’s a Girl Thing!,” another program for middle and high school girls funded by the Hadassah Foundation, teaches girls to recognize cultural biases that affect their self-worth. “Coming into adolescence has become treacherous.... At the time your body is filling out, you’re being told, ‘skinny, skinny,’” says Deborah Meyer, executive director of Moving Traditions (www.movingtraditions.org), which sponsors the program in 190 Jewish institutions. The five-year curriculum doesn’t mention eating disorders directly; participants with the illness are referred to professional help.

The Orthodox Union has funded a documentary, Hungry to be Heard, to “galvanize the community to take action,” says Rabbi Tzvi Hersh Weinreb, OU’s executive vice president (for more information, contact Frank Buchweitz, OU’s director of community services at 212-613-8188). Thin, an HBO documentary by photographer Lauren Greenfield (www.laurengreenfield.com), is also available in book form (above) from Chronicle and as a traveling exhibit, January 22 to March 21 at the University of Missouri in St. Louis, and April to June at the University of Utah in Salt Lake City. Though it does not have a specifically Jewish orientation, it follows four young women struggling with anorexia over the course of six months at the Renfrew Center in Florida.

With the help of the Jewish Women’s Foundation of New York, the Foundation for Jewish Camp (www.jewishcamp.org) created “Beyond Miriam,” a resource guide and seminar for directors and staff on girls’ body image, eating disorders and cutting. JWF also funded a program for grades 3 through 5 called “NoBody’s Perfect,” administered by FEGS (www.fegs.org).

Until a comprehensive strategy evolves, however, eating disorders still “take a back seat to alcoholism, drugs and AIDS,” says Ann Levine, whose daughter struggled with anorexia. “I don’t know of any structured way that brings it to kids’ attention the way other problems are addressed. There’s less shame in drug abuse.” —R.M.


For More Information

■ ATID’s list of Jewish eating disorders resources: www.atid.org/resources/eating.asp
■ “Litapayach Tikvah—To Nourish Hope: Eating Disorders: Perceptions and Perspectives in Jewish Life Today,” a manual from the Union of Reform Judaism.

■ We Need to Talk (Devora) by Rachel Sofer.
■ Life on the Fringes: A Feminist Journey toward Traditional Rabbinic Ordination (JFL Books) by Haviva Ner-David. In her book, Ner-David, the first woman to receive Orthodox ordination, recounts her bout with anorexia.
■ Going Hungry: Writers on Desire, Self-Denial, and Overcoming Anorexia (Anchor) edited by Kate Taylor. Includes a chapter by Jewish writer Ilana Kurshan.
■ Body and Soul: A Guide for Addressing Eating Disorders in a Jewish Education Setting (ATID) by Caroline Peyser.


Treating Eating Disorders in Israel
Over 1,000 children ages 18 and under are treated each year in Hadassah Hospital’s Child and Adolescent Psychiatry Unit for a variety of emotional and psychiatric disturbances. About half of those in its outpatient care and half of those hospitalized in its 10 beds are battling eating disorders. One of only three inpatient centers for eating disorders in Israel, Hadassah’s young patients come from all over the country. And they are getting younger.

“While [the] core of eating disorders has probably always existed as a biological problem, added psychosocial stresses mean that more and more people are affected, at younger and younger ages,” says Dr. Esti Galili-Weisstub, head of the unit. “Our youngest anorexic patient was 8 years old. Her treatment, as for all our eating disorder patients, was multidisciplinary—behavioral modification, family intervention, psychotherapy and medication—with the aim of total cure.”

Opened 10 years ago at Hadassah–Mount Scopus, the unit today operates from custom-designed premises in Hadassah’s Children’s Hospital at Ein Kerem, comprising the inpatient beds, an after-school day treatment center for adolescents and an outpatient clinic.

Most anorexic and bulimic youngsters are cared for as outpatients, attending the after-school center, where their eating is supervised and they do their homework. The more severely ill are hospitalized until they reach a minimum target weight. Their day in the hospital opens with a group session, followed by a communal breakfast—the first of six meals eaten daily under supervision. The remainder of the morning is given to school subjects taught by teachers from the education ministry. The afternoons are for art, music, drama and movement therapies. Social workers and psychologists work with young patients individually, with their families and in groups.

“Our daughter seemed like a regular kid to us,” says the mother of a 14-year-old girl hospitalized in the unit. “We didn’t realize her self-esteem was rock-bottom until she tried to draw attention by being the thinnest girl in her class. It was only then that we realized how much help she—and we—needed.”

When the unit’s team of child psychiatrists, nurses, social workers, clinical psychologists and dieticians is satisfied that eating habits are changing, youngsters are gradually discharged—initially, returning daily to the unit.

“Our patients are adolescents, and we give them space, self-respect and independence, under supervision, while they conquer their eating disorders,” says Dr. Galili-Weisstub. —Wendy Elliman

For additional resources on eating disorders, and a look at how they are treated at Hadassah Hospital in Jerusalem, look at Hadassah Magazine’s Web site, www.hadassahmagazine.org.

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