Doctors urged to look for signs, ask tough questions

In the late 1960s, Debbie first opened up and told a psychologist, “I think something’s wrong. I eat and I feel guilty, so I throw it up.”
He answered, “It’s not such a bad idea.”
He was wrong.
Debbie’s never gotten proper treatment for bulimia and has struggled with it for about 40 years, using it to help her cope with critical parents, an abusive husband and several frustrating jobs. The illness began as binging and purging a few times a year, but now the 61-year-old, 5-foot 6-inch, 107-pound grandmother binges and purges up to twice a day.
“If you purge, you get rid of nervous feelings and go back to your normal self. You don’t face the negative feeling,” she said.
Debbie is just one of a growing number of adult women with eating disorders. No one tracks the ages of eating disorder patients, but the prevalence of the illness has increased at least tenfold in the past 50 years and the disorder is difficult to cure.
While public opinion has largely held that girls in adolescence and early adulthood are the most likely to be affected by eating disorders, this is no longer the case, Anzai said.
“We’re clearly seeing more people in their 30s, 40s and 50s who’ve been sick and were either never treated or partially treated,” said Neal Anzai, M.D., medical director of the Center for Anorexia and Bulimia at Alta Bates Summit Medical Center in Berkeley.
There are three general categories of eating disorders, including anorexia, which is essentially self starvation, bulimia, basically binging and purging, and those not otherwise specified, which include behaviors that don’t meet all the criteria of a specific eating disorder.
Before the 1960s, anorexia affected about .1 percent of the population in America and some European countries, and bulimia was virtually unknown, Anzai said. Today, about 1 percent of the American population has anorexia and some experts say bulimia rates are as high as 5 percent. If one broadens the definition of bulimia to include occasional binging and purging, around 40 percent to 50 percent of students in college dorms admit to having tried it. “It’s almost normal behavior in colleges,” Anzai said.
Many sufferers are in denial and may visit a general physician complaining of vague symptoms including weight loss, gastrointestinal issues or amenorrhea.
“The signs are there, but physicians don’t always ask,” Anzai said. “If someone comes in with low weight, low heart rate, hasn’t had a menstrual period or (she’s) very thin, the physician needs to ask, ‘You’re really thin. What’s going on?’ They need to push beyond the patient’s, ‘I’ve always been thin.’ They need to ask more directly, ‘Have you had an eating disorder?’”
“You never know if you’re coming across an adult woman who’s been struggling with it for years and never told anyone,” added Janice Bremis, executive director of the Eating Disorders Resource Center in Silicon Valley.
Signs of eating disorders don’t change much when women get older and include dramatic weight loss in a very short period of time, fractures, weighing less than 85 percent of one’s ideal body weight, dental enamel erosion, swollen parotid glands, electrolyte abnormalities, and low blood pressure, among other symptoms.
While there aren’t health risks specific to older women, as the illness lengthens, risks include osteoporosis, amenorrhea, collapsing vertebra, anemia, nerve disorders, esophageal tears and gynecological problems. If patients have been starving themselves, the brain shrinks and can cause cognitive problems including extreme obsessive compulsiveness, body image disturbance, impaired memory, difficulty with abstract thinking and attention deficit.
The sooner one starts treatment for the disorder, the greater chance of recovery, said Carol Dietrich, director of the Intensive Eating Disorders Treatment Program at El Camino Hospital in Mountain View, so it’s crucial to get the patient into therapy immediately.
Eating disorders are notoriously hard to treat and anorexia has the highest mortality rate of any mental illness. A 22-year-long study of Scandinavian women found anorexia’s fatality rate to be nearly 20 percent and the cure rate only about 17 percent.
Anzai added, “A lot of times the doctor is too afraid to confront the patient. Many patients are in denial and too ashamed to get a referral, so if you miss an opportunity, the patient may not be confronted for another year or decade.”
 It’s also important to refer patients to a specialist who focuses specifically on eating disorders, because if not, the patient may get some treatment, but stay chronically ill for a long time.
“We’ve had patients who’ve been in multiple therapies, never with anyone who knows what they’re doing. The chance of getting it completely better is much less,” Anzai said.
Above all, show compassion not judgment, urged Debbie. “I went to a gastroenterologist who was reprimanding and very negative,” she said. “Understand that having this problem means you’ve probably had a difficult life. To actually be around people who know I have a problem and still like me and forgive me is something where I feel like maybe I am worthwhile after all.”

Alice Chen is a freelance writer in the Bay Area.