On this episode of 51%, we discuss eating disorders: what they look like, why they develop, and how they’re treated. We also speak with advocates with the Strategic Training Initiative for the Prevention of Eating Disorders, or STRIPED, who are working to restrict the sale of over-the-counter diet pills to minors.
While 51% typically focuses on women’s stories, the subject of today’s episode is not necessarily unique to the female experience. We’re talking about eating disorders, which can affect people of all genders, ages, and races. In fact, they’re a lot more common than you might think, and as with other mental illnesses, cases have surged during the coronavirus pandemic.
S. Bryn Austin is an award-winning researcher and professor at the Harvard T.H. Chan School of Public Health, Harvard Medical School, and Boston Children’s Hospital.
“Eating disorders are common, they are deadly, and they are expensive,” says Austin. “Eating disorders will affect nearly 30 million Americans in their lifetime, or close to 9 percent of the U.S. population. And eating disorders are among the deadliest of any mental condition, with over 10,000 Americans needlessly dying each year — that equates to one death every 52 minutes. Think about that: every 52 minutes, somebody’s sister or brother, parent, or child dies from this preventable and treatable condition.”
So what are these preventable and treatable conditions? Well, when we talk about eating disorders, we usually talk about the big three: anorexia nervosa, bulimia nervosa, and binge eating disorder. A person with anorexia nervosa will restrict their food intake, purge, over-exercise, and otherwise do what they can to achieve or maintain a dangerously low body weight. A person with bulimia nervosa gets there by eating large amounts of food, followed by bouts of self-induced vomiting. Binge eating, meanwhile, sometimes results in weight gain, as a person seemingly “loses control” and eats an exorbitant amount of food in short bursts of time.
The National Eating Disorder Association says binge eating is the most common eating disorder in the U.S. — but overall, it details 11 different conditions on its website, with the vague “unspecified feeding or eating disorder” among them. Austin says the range of ways in which we fall out with our bodies is wide.
“Eating disorders can be related to many kinds of factors. There’s widespread pressure to lose weight, to maintain a lower weight. And it’s not just what’s considered beautiful — there is frank discrimination that’s happening all across the country related to weight,” she adds. “It’s legal, in most parts of the U.S., to not hire somebody, to fire someone — they can even be fired and told it’s happening because of their weight, and in most places people don’t have any recourse. We know it happens in schools: there’s evidence that teachers are rating students at higher weights with lower subjective scores. They’ll rate them lower on academic performance, completely unrelated to their academic performance, and instead related to these biases around weight.
These biases set people up, especially young people, to feel like they need to do anything they can to keep weight off. And that sets up a really dangerous cycle, for many people, of weight loss and weight regain.”
Austin says there are many ways that American society is not equipped to prevent or tackle eating disorders — and it’s a costly situation, as eating disorders cost the U.S. more than 10,000 lives and roughly $65 billion a year. So in 2009, she started the Strategic Training Initiative for the Prevention of Eating Disorders, or STRIPED, to build a network of trained professionals around the issue. Their latest focus has been a trio of bills in the California, Massachusetts, and New York state legislatures aimed at restricting the sale of over-the-counter diet pills and muscle-building supplements to minors.
Austin says over-the-counter diet pills are a $2.6 billion industry, but besides encouraging eating disorders, they can be extremely harmful to consumers.
“These products are not medically recommended, the American Academy of Pediatrics has come out explicitly and said children should not be using over-the-counter diet pills,” Austin warns. “But you can see these in every store, brick and mortar store, pharmacy, grocery, we see them in gyms — and during the pandemic, we’ve been especially worried about what children are seeing online through social media, with influencers who are hocking these kinds of products, promising magical weight loss, “make you look like a model” if you use these products. All of it is a lie.
These products have been laced with pharmaceuticals that were pulled from the market decades ago. Phen-fen is one that shows up in these products. Other types of pharmaceuticals that may be legal to sell when overseen by a doctor, but are not legal in a dietary supplement — and they’re not even disclosed. 23,000 Americans are sent to emergency rooms every year because of dietary supplements, and fully a quarter of those are the weight loss supplements.”
Joanne Chung is a 17-year-old advocate with the STRIPED Youth Corps in New York City, which has been taking to Tik Tok to advocate for the bill among America’s youth.
“The response has definitely been very positive,” she notes. “I think that as a youth myself, I’m able to connect and reach out to people my age and sort of speak for my own experiences as to how we can help people, and also just inform people of what’s wrong with the current weight loss industry.”
Chung spoke with me from her home in Queens, and says she struggled a lot with her own body image in middle school. She grappled with undiagnosed anorexia between the ages of 12 and 14 — two years of standing in front of the mirror, over-exercising, and counting calories. She never made the jump to diet pills (although she was certainly tempted), but at her lowest point, she was just 88 pounds.
“I didn’t go to the doctor often, but for the doctor’s appointment, I specifically remember right before I dropped a lot of weight — 20 pounds in just a couple of months — I was told that I was getting really skinny, and that my mom had to keep an eye out as to how much I ate,” says Chung. “[But] even [then], I found that as encouragement to keep going — at that point, I realized ‘Wow. I had a lot of progress.’”
Chung says it’s hard to pinpoint what exactly prompted her anorexia. She didn’t really participate in sports, so she wasn’t watching her weight for athletic reasons. She had plenty of friends and a supportive family, but that picture of a “skinny ideal” was presented to her at a young age. She looks back on her favorite children’s TV shows, like Nickelodeon’s iCarly, where the main characters were fit and beautiful in a conventional way, while heavier side characters, like Gibby, went shirtless to the tune of a laugh track. Chung says fatter characters were always demoted to comic relief — or worse, the butt of the joke. And who wants to be that? But regardless of the factors that may have established her mindset, Chung says isolation is what fueled it.
“I definitely saw isolation as something that enabled that result of a negative self image and self perception, because you see the minor flaws in everything,” says Chung. “And so I definitely got attacked by my own thoughts, and I amplified these because, as a child, I was a bit obese, I was a bit overweight — but that was simply because it was baby fat, right? But even then people would joke around about how I looked, and I was bullied for that in middle school. And so I definitely took that into account, and I decided to completely alienate myself and stop eating. That isolation was the main thing that pushed me, because I let no other thoughts really come into play — nothing healthy, no healthy habits.”
Chung says her worst months were in the summer, when it was easier to isolate herself, because she was less likely to see her school friends. Left to her own devices, she’d spiral and spend time in front of the mirror, avoiding food, and over-exercising to the point of exhaustion. Then, when her friends did call, she wouldn’t have the energy to meet up with them for lunch — and part of her didn’t want to. All the while, Chung says she was scrolling through “thinspo” social media accounts on her phone, which became its own form of isolation.
“[Thinspo] was definitely a trend where a lot of accounts dedicated themselves to posting pictures of extremely skinny legs and skinny bodies, saying ‘this is what [I’m] striving for,'” she explains. “Basically, just a part of the eating disorder community pushing this agenda, promoting, glamorizing, and romanticizing this terrible image that isn’t what should be deemed as perfect, and is not.”
We’ll get back to Chung in a minute — Chung says she never received formal treatment for her eating disorder, but for many people, this might be where treatment would come in. But how does that work?
To learn more, I stopped by HPA/Livewell, an Albany practice that specializes in mental health and eating disorders. Owner and Director Dr. Julie Morrison leads me through some practically empty hallways on the way back to her office – but she says HPA/Livewell, like most practices, is particularly busy right now on its telehealth lines. She says treatment for eating disorders can go several ways.
What does eating disorder treatment look like?
So eating disorder treatment looks different for everybody. Depending on how symptomatic somebody is, and what level of support they have at home, it can change that. There’s interventions that you can do in outpatient therapy that can be, you know, an hour with a therapist, once a week, a dietitian gives maybe a meal plan, they work with their primary care doctor – that’s sort of the lower end, outpatient work, and then it goes all the way up to hospitalization.
Really what we’re doing with this work, generally speaking, a lot of research supports exposure-based work as well as cognitive behavioral therapy, where you’re really looking to help people with the way they think, the way that they behave. You’re trying to have somebody do the thing they’re the most afraid of. So if you take somebody, for example, who has anorexia, and maybe they’re afraid of eating certain foods because they’re afraid of gaining weight, what we would do is sort of expose them to that and see that either a.) they didn’t gain the weight that they thought they were going to, or b.) maybe they gained, but the outcome was not as threatening or terrifying as they want to believe. So that kind of work at all different levels is being done.
It’s also really important that we work to help people get back the quality of their life. You know, if you’re a parent, recognizing how the disordered eating affects your parenting [and] encouraging change so that you have an increased quality of life.
What would you say is usually the biggest obstacle in treatment?
I think that when you look at disordered eating, you want to recognize that eating disorders are a coping skill that get developed over time, usually to cope with a bigger issue other than that clichéd “weight / shape / size concerns” – and certainly there are those, and they can be incredibly difficult. But eating disorders, a lot of times they’re coping skills for other things, too. And I think that one of the hardest things as clinicians, the hardest thing for us is that we’re basically trying to sell to someone that their coping skill isn’t good for them. So we’re saying to them, “Listen, I know that this is the one thing that you think has solved your problems. But guess what, it made another one. And so I want you to trust me that you should change that.” And that’s really hard.
What would be an example of something that this would be a coping skill for?
Yeah, absolutely, really good question. So just giving a concrete example: they’re in college, and they go to the dining hall, and they’re socially anxious or nervous about meeting people. And they’re like, “Oh, my gosh, I can’t go into the dining hall. I don’t know anybody. So I’m just gonna not go to lunch.” Well, then, all of a sudden, I’ve started to lose weight. Now I feel a little bit, I don’t know why, but I kind of feel a little more confident. OK, well, I’m still really uncomfortable with going to the dining hall. So I’m just not going to go to breakfast either. All of a sudden, they ended up with anorexia – but it never started there. You know, you get somebody who’s been bullied, we get this a lot, especially with kids, right. They’ll get a nickname, and the nickname has something to do with them being heavier than their friends. And they hate how that feels, so they’re like, “You know what, I’m not going to eat anymore. I’m going to restrict the food that I eat, and I’m just going to lose weight so they stop bullying me.” [That person] didn’t get up one morning and say, “I want to have anorexia.” They didn’t say, “Let’s try that. That sounds fun.” They just said, “It really feels bad to get bullied, I’m going to take away that thing that people bullied me about.” But that thing that keeps them from getting bullied – they think, right, the thing that keeps them safe from being humiliated – actually now is risking their life medically.
When we talk about preventing eating disorders, what are some things we should be keeping in mind?
Well, I think when you’re talking about preventing eating disorders, the first thing you have to recognize is that you never know who’s listening. And you never know what someone’s going to think about what they’re going to remember. And so I think you want to be cautious around comments about weight, shape and size, even if you’re joking. Most people have no negative intent. They don’t mean any malice by the things that they say, yet they can get people pretty stuck pretty fast. People also can comment on somebody else’s body who might be struggling with an eating disorder, and they say, “Oh, you look so good.” That person who’s got bulimia, they say, “Oh, thanks,” in their brain, they’re sitting there saying, “You’ve no idea what I do to myself to look like this. But because you commented on the way that I look, I now feel like I have to maintain that.” So I think one of the first things that we can do is just be reasonable about what we comment on just as people, as friends, as parents, recognizing that, you know, bodies do come in all different shapes and sizes, and that it’s really not anybody’s business to be commenting on that.
It’s not just commenting, but what’s being posted. Gone are the days where we communicate just with what we say. But now it’s what we do via posting different things on social media platforms. And so I think you have to be responsible, you know, looking through the eyes of somebody with an eating disorder. Could this make them worse? Or somebody who already is a little body conscious, could this make them now feel like they’re not good enough?
Especially when we talk about social media and stuff like that, how has that changed the way that we have to deal with these kinds of things? Because it’s not just magazines and TV and movies anymore, where people are getting their idea of what a body should look like.
Social media is tough because it’s constant. People drive and they’re looking at their phones, right? If people walk in fall into potholes, because they’re looking at their phones, right? It’s constant, and it’s constantly refreshed, and it’s constantly new. And so what happens also is, as you click on something, your phone says, “Wow, you’re interested in this, right?” Well, guess what’s next, guess what goes on your “For You” page. So it might be something you had a little bit of interest in, maybe somebody saying, “Oh, I feel like I want to eat healthier.” So they start eating a little bit differently, and they look at something on social media. Well, your phone just told you that, “You know what, I think you’re interested in this.” So now you’re starting to get these on your “For You” pages, different things about this diet, and that diet, and body-related comments. It’s difficult because we’re constantly chasing it.
One of the people that I spoke to, she shared her experience with both dealing with social media and also her own problems with anorexia – she was building this community only of people who were in the same situation as her.
If you think of the old adage, “misery loves company” that’s actually proven in research. We seek out people who feel the same way as us. If go home and I say, “Hey, you know, I believe in these kind of thinspo ideas,” right? If I say that to my mom, my mom’s gonna go bananas about it. But if I go to the other people that I know believe in that, they’re gonna actually encourage me. And if I don’t want to make change, I want to find other people who are going to encourage me to double down, to stay invested in this disordered eating, because that’s what I feel like I’m supposed to do. So you sort of build your community around that.
If you’re someone’s loved one friend, parent, and you’re starting to notice that they are building that community, or they’re otherwise showing signs of an eating disorder, how do you break through that? Is there a way that you should approach them about it?
So it’s always a really tricky thing to kind of figure out. How should you address somebody in your life that you think might have disordered eating? Because no one wants to be offensive, and everyone’s worried. One of the biggest things is to not focus on weight, shape and size. Right? Yes, of course, that’s something that we notice, or we’re concerned about. But really, what you want to focus on is, “Things seem different for you. You’re not having dinner with us anymore, you’re not with us anymore, you seem to be isolating yourself. We’re not going out like we used to, or we’re not spending time the way we did before, or you seem distracted.” This person’s in your life, they engage with you in a certain way, and disordered eating will keep them from engaging with you – it has to because it’s part of the diagnosis. It’s an illness of disconnection, you have to disconnect from others who would otherwise say to you, “Don’t have that behavior.” What you want to point out is that you miss that person, you know, that you’re concerned. Because you’ve noticed this change, not necessarily in how they look, but how they are.
We don’t do the intervention thing, that’s TV. It’s really about consistent, sustained checking in, because sometimes the first time you talk to somebody, nothing’s gonna happen other than maybe planting the seed. And so don’t give up, I think, is the other thing. You want to keep recognizing that,” You said you’re OK, but you still haven’t been out with us in a while,” or “You know, you always want to hang out, but after we’ve eaten, is something going on, are you OK?” Pointing out both things consistently. And then the other thing is that, if you can get someone to have a conversation with you, encourage them just to talk to somebody – it can be their primary care doctor, you can pick a practice like ours, for example, and say, “Hey, let’s just do an evaluation. If there’s nothing going on, you can’t treat nothing, you know? Just go talk to someone check in.” Your caring, despite the way the person presents, will have its effect.
In speaking to Bryn Austin, she also mentioned what parents should do if they notice signs of an eating disorder in their child. She also mentioned that there’s a shortage of pediatricians who are trained in dealing with eating disorders. Would you agree with that? What should we do about that?
Yeah, well, we’re not quite sure yet. It’s not that pediatricians or physicians in general don’t want to know, it’s just that, usually, things were always compartmentalized. You know, you look at behavioral health almost separately from medicine, and I think in fairness to them, despite some psychiatry rotations, there’s not a whole lot on behavioral health when you’re in medical school and you become a doctor. A lot of primary cares end up farming out those referrals, but don’t actually know how to talk about this stuff. So you know, if somebody who is heavier loses weight? A physician is sort of programmed to say, “Good for you. Great, you made a great healthy lifestyle change.” They forget to ask how they did it. What we want to do is sort of encourage our physicians to ask a few more questions. How did we get from point A to point B? Has this person’s quality of life changed? How are they physically feeling, given the fact that their weight has changed?
And it doesn’t just mean that they’ve lost weight – we cannot forget that people with bulimia, they’re usually of average weight. People with binge eating disorder can be overweight. Those are still significant struggles, we don’t identify eating disorders just based on weight. And so physicians usually are just given that information, right? They’re given those numbers that say, “Your height is this, your weight is this,” and they decide if you’re healthy or not. We want to recognize that those are just markers. They are not specifics about someone’s health.
When we think about healthy eating and healthy exercise, what exactly does that look like?
I heard someone describe healthy eating to me once as eating like a two-year-old. How does a two year old eat? They eat when they’re hungry, they stop when they’re full. They have what they want. They listen to their bodies. When they want to drink, they have a drink. If they’re looking for something they seek it out, right?
What we want to recognize is that no food is necessarily bad. Certainly people have allergies or medical conditions that require watching your sodium or whatever. But what we don’t want to do is identify foods as good or bad, because what it actually ends up doing is creating this sort of mess in your head about, “Should I or shouldn’t I?” And if you constantly say to yourself, “Hey, don’t eat cookies,” well, what do you want to do? Now you want to eat cookies, right? Not because you have an eating disorder. But because you’re a human, you’re a normal human with a working brain. And so by identifying things as good or bad, or “do this and don’t do this,” you actually tee somebody up for a poor outcome. When I say eating regularly, I mean breakfast, lunch, dinner, snacks, listening to your body, being mindful, recognizing when you’re hungry, recognizing when you’re full. It’s interesting, I read something the other day about, “When we’re thirsty, we have a drink. When we’re hungry, we take a walk, have a glass of water, try to distract ourselves, and then finally come home, and overeat. Because what we really should have done is just had lunch.” And it’s really interesting that if you listen to your body, it generally will tell you what it means.
What would you like listeners most to get out of this episode?
One thing that we need people to know, in the face of having been through and not necessarily out yet of a pandemic, is that there’s been a huge rise in disordered eating. People have just had to cope, everyone does the best they can to solve their own problem. And disordered eating really is about somebody just solving their problem in an unhealthy way. It’s not about “Just eat,” it’s not about “Just don’t do that” – there’s not simple answers to this solution of disordered eating. Rather, it’s something that’s developed over time and also deserves the time that it takes to make change. You know, if you think that you’re struggling or there’s somebody in your life who’s struggling, that you’ve been able to talk to – reach out, let’s see if there’s something that maybe they need some help with. Let’s get it before it’s something that’s super hard to treat. What we know is that the earlier we catch something like this, the better the outcome.
Joanne Chung credits her friends and family with pulling her out of her isolation before things got dire. The summer ended, she entered her first year of high school — and she wanted to be a teenager, she wanted to join clubs, get involved in her community, and have more of a social life. Her loved ones wanted the same thing, and they began challenging her whenever she’d skip out on events or bring up her latest diet.
“I had to confront my mother about it actually, and my friends actually, they pointed out that I had an eating disorder,” she notes. “They kept on telling me ‘Oh Joanne, you’re too skinny, too skinny, you keep getting skinnier.’ At that point, I realized that I myself had taken a toll because of this.”
By speaking with her friends, Chung found she wasn’t alone: many of them struggled with body image, and some had even grappled with eating disorders. But first and foremost, Chung realized she was the only person in her life telling her she wasn’t enough — or to put it in her words: “I was the only one humiliating myself.”
In response, Chung says she dove into her community, and particularly her friendships. She kept busy to ward off bad habits — and together, they started some good ones. Chung says she and her friends would set up lunch dates just to make sure they were eating regularly. They made a tradition of going to Chinatown and ordering foods they’d never tried. And she found she’s actually quite fond of cooking — particularly cake, which she can now eat without counting calories or jumping on the scale.
Chung says she still struggles with her body image from time to time, but her community is different now. Instead of “thinspo” aesthetics and photoshopped supermodels, her news feed is filled with friends and messages of body positivity. It’s part of why she joined STRIPED: Chung says the company you keep online plays a huge role in your mindset, and she wanted to promote a healthier message.
“Social media overall, it’s really to connect people, and that can either be taken with a negative or a positive connotation,” she says. “No matter how much Instagram tries to block these messages, they can go through. They promote eating disorders, they promote these unhealthy images, and they glamorize them. They don’t point out the flaws in them. And if people solely focus on that, they’re not realizing that the rest of the people on the Internet don’t think that same way, right? And so it’s really a pick and choose situation when it comes to social media, and I think that as long as you realize that there are two sides of the story, you can definitely see these support groups [online], you can see these people who have recovered from eating disorders who are still so pretty, they’re so perfect, and they’re pushing these healthy agendas to help people.”
STRIPED says efforts to ban the sale of diet pills to minors are still making their way through the California and Massachusetts legislatures. The New York State Senate passed a bill this year, but it stalled in the Assembly. STRIPED plans to resume its push in 2022. You can learn more about the group at the Harvard T.H. Chan School of Public Health website. If you or a loved one is struggling with an eating disorder, the NEDA has a map of different treatment centers across the U.S. on its website — nationaleatingdisorders.org — as well as a hotline that you can text or call Monday through Thursday at 1 (800) 931-2237.