Writing about Eating Disorders

As a longtime newspaper editor and reporter, I loved conflict and irony. And when the story pitted a parent against a child - especially an apple falling far from the tree - it was even better. Everybody can either relate or feel superior.

In my own home, conflict and irony weren't nearly as fun. I was the restaurant critic of the San Jose Mercury News, a coveted job packing a luscious expense account that enabled me to run around the San Francisco Bay Area (and much of California) to eat. Meanwhile, my 18-year-old daughter was home, struggling with every bite. Lisa had gotten drawn into America's lamentable epidemic of eating disorders.

Ten million women and one million men have eating disorders, and 25 million people have serious issues with binge eating. Age, ethnicity and relative wealth are no barriers in a culture obsessed with food on the one hand and beauty (currently defined by jutting collarbones) on the other. Americans spend $46 billion a year on diets to lose weight.

Naturally, my editors saw a story here. At first I was horrified, but as I had my regular food stories and reviews to do, there was no time pressure. I would have to fit a painfully personal project in without skipping anything else, which made it even less appealing. But Lisa reached a period of stability, and was willing to share material from journals she'd been keeping. The idea of offering information that might help others, finding some good in a bad situation, appealed to both of us. We could give some meaning to the statistics.

The Mercury News ran "A Daughter's Inner Battle" as the front-page centerpiece on Dec. 7, 2003. We were overwhelmed by the response. I expected outrage on the order of: "How could you exploit your daughter in this way?" and instead got hundreds of heartbreaking calls, emails and letters that continued until I left the paper two years later.  Among the comments people made:

"It was not until I read your daughter's words that I finally had a mirror held up to me."

"I cried most of the way through it."

"So many of us have had our secret pain over food."

"As the single father of two teenage daughters, I need and welcome all the information and guidance I can get about the subjects you so candidly discussed."

Desperate parents, spouses and friends asked which modes of therapy were best, where to find help that didn't cost a fortune, and how to get their loved ones to accept treatment in the first place, as if I were the doctor.

Lisa is now 24, and our book, Hungry: A Mother and Daughter Battle Anorexia, will be published in August 2009. As in the original story, the book includes interviews, research, and Lisa's voice and my voice, so that readers can see eating disorders from both the child's and parent's point of view.

Weaving all that into a coherent narrative was daunting. But even without having transitions back-and-forth with a personal story, reporting about eating disorders gets complicated. If you're called upon to write about eating disorders, there are some important things you should know.

A relatively recent phenomenon

Eating disorders didn't register on the national radar until 1983, when superstar singer Karen Carpenter died of a heart attack after a long struggle with anorexia nervosa. The issue has come to the fore more recently with celebrities like Oprah Winfrey and the late Princess Diana disclosing their personal battles and the deaths of some supermodels. (Anorexia has the highest death rate -- 10 percent -- of any mental disorder.)

Bulimia has become an everyday feature of college dorms. The National Women's Health Information Center reports that up to 80 percent of female college students have binged and purged. While most patients are young women in Westernized countries (now including South Korea, Japan, India and the Philippines), physicians report alarming increases in under-12 children, boys, and women in their 70s.

If you tackle this subject, you will hear a lot about the "root causes" of anorexia, bulimia and binge eating. Not much is known with certainty. The causes may be biological, psychological, experiential or cultural. A patient may have a familial predisposition to depression or anxiety, but the eating disorder doesn't appear until there's a "trigger," which could be as serious as the death of a parent or as seemingly silly as one classmate's offhand comment about weight.

While experts disagree about the causes, when it comes to treatment you really get the clash of the titans. Psychiatrists prescribe antidepressants, nutritionists dispense food diaries, and psychologists splinter into groups recommending, among other therapies, psychoanalysis and cognitive behavioral or its offshoot, dialectical behavioral therapy (also called mindfulness.)

Here are issues to watch out for:

Be skeptical of patients' self-reporting. Patients with eating disorders are notoriously deceptive, besides being sometimes delusional and always self-absorbed. They can get caught up in their drama, and exaggerate for effect. Conversely, they hide symptoms and report that nothing is wrong. Check out whatever the patient says with another source.

Question experts' qualifications. The field of eating disorders has grown quickly, and there is no special licensing board for practitioners who claim expertise. The expert may be a dietician, nutritionist, social worker, psychologist or psychiatrist, all legitimate professionals. However, a therapist calling herself an eating disorders specialist may just be someone who knows the disease because she had it herself.

Study the studies. As journalists know and the public often doesn't, "studies say" anything. Data may be derived from a very small sample or be reported in a questionable way, perhaps because of a high dropout rate in the study group. Research often is funded by a company that has a considerable financial interest in the result.

Scrutinize Web resources. As with studies and experts, look for who's behind Web resources. Referral information may be supplied solely by health care providers with a profit motive. It is basically advertising, not vetted by the Web site's editors. Find the fine-print disclaimers. That said, Web resources are bountiful, ranging from the NIH's comprehensive links to the patient-oriented, teen-friendly Something Fishy to sites promoting better ways to starve or purge, such as Pro Ana Mia.

Expect problems accessing facilities. Understand HIPAA privacy regulations. For access to an eating disorders unit, you'll have to convince the hospital's public information officer that you're a serious journalist and promise you'll abide by their rules. When I toured a unit, I was allowed to take notes, but not to speak to patients.

Understand the addiction model. Eating disorders have a lot in common with alcohol and drug addiction, and can be understood in that way -- particularly with their highs, lows, self-loathing and recidivism, the whole depressing cycle. But the addiction model is of limited use in treatment, because you can't just say no to food. We must eat to live. Not only that, Americans now eat constantly and everywhere, so that for someone with an eating disorder, the issue is always in his or her face.

Ideas for stories about eating disorders

Reporting about eating disorders requires some patience, both in teasing out a line of inquiry and staying on track. But here's the good news. There's a lot to report. Here are some ideas for stories:

There already is evidence that the national panic about obesity is contributing to eating disorders. When the Centers for Disease Control revised the height-weight tables in 2000, many people became overweight or obese overnight. Instead of helping people make rational choices, this ramped-up fear is increasing our obsession with weight, as well as our tendency to look for a magic bullet. Like addictions, eating disorders are not personal failings that can be solved by will power. Often there is a genetic component or biochemical imbalance.

Eating disorders have become an industry, with treatment centers commonly charging $1,300 a day, patients staying at least six weeks and often returning for another stay ("frequent fliers," staff call them), and families willing to mortgage the house if it'll buy a little hope. The market is so large and diverse that many facilities now specialize in treating certain populations. One takes only teenage Christian boys.

Rates of recovery are low, and there is a lot of disagreement about treatment. Researchers recently found that recovered anorexics showed increased dopamine. Brain chemistry may yet yield more hope for cures.

The Mental Health Parity Act of 2008 requires most group plans to provide coverage for the treatment of mental illness that is comparable to what they provide for physical illnesses. The Obama administration plans to weigh in on health-care reform. It will be interesting to follow how patients with the three eating disorders defined as mental illnesses are affected by both of these developments.

European fashion associations now require models to maintain a certain body mass index, but associations in the United States have not taken similar action. Why not?

The focus on obesity brings up old saws about metabolism, as if there is a body of indisputable facts, commonly accepted. We hear: "It's not my fault I'm fat. I have a slow metabolism." Or: "He gets to eat all he wants and never gain an ounce, with his fast metabolism." Exercise regimes promise to "fire up your metabolism." But the science of metabolism is far from settled.

There has been some reporting on the increase of eating disorders among Hispanics in the United States, but not about other ethnic groups or recent immigrants. You can blaze trails here.

Sheila Himmel is the former restaurant critic for the San Jose Mercury News. "Hungry: A Mother and Daughter Battle Anorexia," a book by Himmel and her daughter, Lisa Himmel, will be published in August 2009 by Berkley Publishing Group.

Photo credit: my life as lizz via Flickr