Get Real About Eating Disorders

If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

By Kelly Brownell, PhD
WebMD Weight Loss Clinic - Live Events Transcript
Event Date: Tuesday, March 1, 2005

MODERATOR: Welcome to WebMD Live, Dr. Brownell. Anorexia, bulimia, binge eating -- all are serious health problems, yet there are those who still look at these behaviors as phases or lifestyle choices. Could you please comment?

BROWNELL: These are serious disorders indeed, and while it is true that some people get over them on their own, often it is the case that people need help from the outside. The eating disorders are not only important medically, but can seriously disrupt a person's day-to-day life and affect their happiness as well as their health.

MEMBER QUESTION: I have been struggling with bulimia for over 10 months now. I am an active member of the boards on WebMD and I read story after story of others like me. But I don't really know how my condition compares to others (I generally binge/purge between 2 and 6 times daily). I know any eating disorder behaviors should be cause for concern, I just don't know how deep I am in. So my question is: how do you classify eating disorders, specifically bulimia, as far as severity is concerned?

BROWNELL: By any diagnostic criteria, you have an eating disorder. Severity can be defined by a number of different factors, but when all is said and done, if you are engaging in behaviors that can be harmful medically and psychologically, and have been unable to stop them on your own, help from a therapist is in order. It is important to seek out someone expert on the treatment of eating disorders, so you do not just get general therapy help. The good news is that treatments for bulimia can be quite successful. I suggest you go to the web site of the National Eating Disorders Association (NEDA) for helpful information on how to find a therapist.

MEMBER QUESTION: My daughter has bulimia. She is in therapy but does not seem to be improving. She says she knows this is life threatening, but does she really? How can I help her? I am very afraid.

BROWNELL: If a person sees a therapist and does not improve it could be that the problems are very difficult, the person with the problems is resisting change, or the right therapy is not being applied. In the case of eating disorders, there are scientifically proven treatments, but a small number of therapists use them. It is important, therefore, to seek out someone who knows the proven therapies and will use them. I suggest contacting the NEDA web site as mentioned above. I cannot comment on the therapy your daughter is receiving, of course, but it is perfectly within your right to get different help if your daughter is not improving. Good luck!

MODERATOR: That web site is

MEMBER QUESTION: What are some of the scientifically proven treatments for eating disorders?

BROWNELL: There are two proven treatments. One is called cognitive behavior therapy, and the other is called interpersonal therapy. In controlled studies, these two have about equivalent effects.

Medication can be helpful for some people, but is usually a second line of intervention unless there are other reasons (like serious depression) for using a drug.

It is perfectly reasonable when one seeks therapy to ask the therapist whether they are truly knowledgeable in using one of these therapies. If the therapist is not expert in these therapies, calling around to the local university psychology departments or the psychiatrist departments in the local hospital may turn up some names.

I'm very happy you asked this question. It is one of the most important questions that could be asked.

MODERATOR: Would you recommend any therapy for family members dealing with someone with eating disorders? Would it be of benefit to the one being treated for eating disorders?

BROWNELL: Especially for younger people with eating disorders, the family is nearly always involved, at least to some extent. Families can be extremely helpful in the process, but it depends in part on the family relationships and the approach the therapist is using.

If you have a family member in treatment, I would discuss with the person being treated and the therapist how you and other family members can be most helpful. Then make yourself available in any way possible. Just the fact that you're eager to help is a good sign and suggests a solid relationship that a person can draw upon for strength. The therapist can help channel that goodwill to specific behaviors and attitudes that might be struggling with the eating disorder.

MEMBER QUESTION: Would you please talk a little bit about the underlying causes for eating disorders?

BROWNELL: There are a number of causes. As scientists we cannot be entirely certain what the cause is for any person. There are certainly biological vulnerabilities. Studies have shown that an individual who has family members with an eating disorder is more likely to have one, but of course environment is involved as well. Scientists have investigated different family environments and psychological variables such as perfectionism in an attempt to see what makes certain individuals vulnerable to the eating disorders. The most likely scenario for any individual is that a variety of factors interact to create an eating disorder. It is also the case that treatments seem to be helpful to people no matter what the cause of the disorder. Hence, it is impossible to find a specific cause for most eating disorders but we do know that individuals benefit from proven treatments.

MEMBER QUESTION: Is too much exercise considered a problem? My friend said overexercising is a type of bulimia.

BROWNELL: Exercising to excess can be one form of purging. But exercise, of course, is also a healthy behavior. One needs to know when the line is crossed and normal healthy exercise becomes obsessive, preoccupying, and potentially harmful to one's health because of injuries.

Just as it is important to eat in a reasonable way, it is important to exercise in a reasonable way. Most people realize whether they are driven to exercise because they are being pulled toward something positive, namely good health and vitality, versus being pushed away from something negative like weight gain. If a person believes they are exercising in excessive amounts or are driven to it in a compulsive way, they should get help so that eating and exercise fall into a reasonable pattern and neither one is done to extreme.

I am pleased you asked this question, because many people wish to know whether exercise is harmful or helpful.

MEMBER QUESTION: I have a tendency to binge eat, but I do not purge. Instead, I will try to exercise, but don't always have the time. My question is, do you ever truly overcome eating disorders or do you have to work at controlling it every day of your life?

BROWNELL: People have different levels of recovery from eating disorders. Some people manage the disorder but never completely get rid of the underlying psychological drive to control food intake in a way that helps minimize weight gain. Other people, particularly after a round of successful therapy, really do seem to be over the disorder and can move on in their lives.

Some people with eating disorders are very fearful at the thought of giving up the disorder. This is especially true for people with anorexia nervosa. It is important for such people to realize that they will be much happier, not to mention healthier, if they are free of the disorder and can go about living their lives. It takes courage, however, to seek out help when one is fearful of losing the disorder, but the bravest people are the ones who put themselves forward and do the hard work to get better.

MEMBER QUESTION: Would you please comment on whether bulimia is more of a physical disease or a mental disorder? And, if it's a mental disorder, how do you know if a patient is lying about changes in his/her behavior?

BROWNELL: Experts generally consider bulimia to be more of a psychological than a biological problem. With that said, the distorted eating and purging that goes on with bulimia can certainly have medical consequences. In addition, there may be biological vulnerabilities that make some people susceptible to eating disorders.

For the most part, eating disorders occur in private. People who are not ready to get help very often hide their behavior and will not be truthful when confronted. Sometimes a straightforward and candid talk with such a person can accomplish two things. It can open the door for them to be truthful but can also show your support. In the case of somebody who is engaging in dangerous behavior and the person's basic health is being threatened, a more direct approach can sometimes be helpful. In these cases parents might be told, or in the case of a student a school official may be alerted as well. In the case of adults with an eating disorder, they generally have to come to the conclusion on their own that they need help. But a caring environment can often make this easier.

MEMBER QUESTION: I seem to have fallen back into the eating-disorder rut. I was seriously anorexic but had recovered. Now I'm into binge eating/purging. I'm so frustrated. I can't figure out what is causing this. When I eat I can't stop and feel guilty. So I try to puke it all up and it makes me feel even worse.

BROWNELL: It is not uncommon for people to move back and forth between different eating disorders. So the fact that you were anorexic at one time and now struggle with the binge eating and purging problems is certainly something we see a lot in our own clinic.

Relapse into another eating disorder generally seems to occur when people are stressed in some way. People who are under stressful circumstances and feel their control is threatened, will sometimes revert to an eating disorder in order to re-establish control over at least part of their life. The fact that you recovered previously from anorexia is a very good sign, and suggests that with the right help you may be able to recover from what you suffer from now. I would be optimistic, but also I would seek help to try to speed your progress to recovery.

MEMBER QUESTION: I'm addicted to food the same way an alcoholic is addicted to alcohol. I know I need help but I don't know where to begin. I've asked for help from my doctor but his only advice was to cut back on calories and make healthy choices. If only it were that easy. It seems as though nobody takes me seriously and thinks it's something that I can just stop if I tried a little harder, but it's so much more than that. How and where can I get the help I need?

"Sometimes what lies between unhealthy and healthy eating is simply knowledge."

BROWNELL: For many years scientists believed there was no basis to the claim many people made that they were addicted to food. Recent studies in both laboratory and with humans using modern techniques of neuroscience suggests that there may be a biological basis for the claim that food can be addictive. Unfortunately, the work is so new that no interventions have been proposed based on these discoveries. Therefore, we have to do the best we can with what we know from the past.

I have several suggestions for you. One would be to pay particular attention to the foods that you find difficult to control and to see if you can substitute those foods in your diet with foods that do not trigger overeating. This may be easier said than done as well, in which case getting help from a therapist who really understands about eating and eating disorders may be helpful. It can be difficult to avoid the problem foods, but if one can make a commitment to specifically surrounding oneself with nontrigger foods, and to consider food an important way to nurture the body, sometimes progress is possible.

MEMBER QUESTION: I noticed that there is not as much focus on binge eating disorder. Why is this?

BROWNELL: Binge eating disorder is an important issue. It is defined as recurrent episodes of eating large amounts of food without the purging behavior that occurs in bulimia. In addition, people generally feel out of control during these eating episodes.

Binge eating disorder was relatively late on the scene compared to anorexia and bulimia. A number of studies have now been done, however, suggesting good news. The same two treatments that are most effective for bulimia, namely cognitive behavior therapy and interpersonal therapy, are also the therapies most helpful for binge eating disorder.

An excellent book on binge eating, that can be helpful for people with either binge eating disorder or bulimia, is called Overcoming Binge Eating by Christopher Fairburn.

MODERATOR: You can read a transcript of our discussion with Dr. Fairburn in our archived transcripts.

MEMBER QUESTION: What is interpersonal therapy? And how is it used?

BROWNELL: Interpersonal therapy tends to focus on the key relationships in a person's life. It focuses less on the eating disorder, per se, than on the stress caused by difficult interactions with important people in one's life.

The therapy itself tends to discuss and analyze these relationships, but more important provides people with more constructive ways of interacting with others. The theory is that reducing stress caused by difficulties in relationships will relieve the need to eat in problematic ways as a means for coping with stress.

Cognitive behavior therapy, on the other hand, is more focused on the symptoms of the eating disorder itself. As I mentioned before, both treatments have approximately equivalent effects.

MEMBER QUESTION: To preface, I have been a clinical social worker for more than 30 years. I am writing this on the third anniversary of the death of a friend's daughter who died after a 10-year battle with anorexia. I have noted that many women who appear to be anorexic seem to have red hair. Over the years, I have become increasing aware of this characteristic. Am I just imaging it or could there be a genetic link to people with red hair and anorexia?

BROWNELL: I have not heard even of speculation that hair color is related to a person's likelihood of having an eating disorder. This does not mean that such a relationship does not exist, just that I have not heard anybody propose this before. Sometimes very important scientific discoveries come from an observation that someone makes in real life. So while we cannot say at this time whether hair color is connected in any way with an eating disorder it never hurts for scientists to ask the question.

MODERATOR: Is there any genetic susceptibility to eating disorders?

BROWNELL: More and more scientists are finding that genetics contribute at least in part to eating disorders. There are a number of methods scientists use to test this idea, and a number of them have shown at least some genetic contribution. What we cannot say quite yet is what specifically might be inherited. One could inherit psychological characteristics, specific brain chemistry, or other biological factors that make one vulnerable to an eating disorder. But even as this science gets completed, it is clear that because one has a genetic vulnerability does not mean that one is guaranteed to have an eating disorder. Irrespective of what the genetic studies will show, it will probably be the case that at least some people with no biological vulnerability will develop eating disorders, and that people with vulnerability do not. Understanding genetics will only help us understand a part of the picture.

MODERATOR: Having just watched the Oscars, I wonder about the effect someone like Renee Zellweger might have on a young girl with the potential to become anorexic. Zellweger looked scary thin and her dieting has been in the news. Do these images help legitimize the culture of obsessive dieting and lead to anorexia?

BROWNELL: I did not watch the Oscars and cannot comment specifically on the appearance of the actor you mentioned. It is the case, however, that people in our society, especially girls and women, are bombarded with images of ultra-thin women, stories of dieting, tales of eating disorders, and pictures of well-known figures who have had plastic surgery. The message that gets transmitted is that you are not good enough. It is up to you, according to the popular culture, to shape and mold yourself into an unrealistic body which is what the actresses and models generally represent.

Most experts believe that these images are toxic to the well-being of the typical individual. However, they cannot be blamed as the sole source of eating disorders. Everybody in the culture is exposed to these images, but only some people, a minority I might mention, develop an eating disorder. It would probably help the well-being of most people in our society if more realistic images of bodies were shown.

MEMBER QUESTION: I had WLS in May of 2003. I went from 333 pounds to 208. In June of 2004 I had a serious back injury and have been out of work since then. In December of 2004 I had a quadruple heart bypass. With all the pain, inactivity and boredom I have turned to my old friend food for comfort. I now weigh 226 pounds. I am terrified I am going to gain back all the weight I lost. I am also afraid that I have stretched my pouch. I am afraid to admit to anyone that I have become a failure.

BROWNELL: If you look at the overall picture, you are still 100 pounds down, which is a tremendous accomplishment. Never forget this, because it can help give you strength. With that said, you might be catching some early warning signs of serious problems. You are doing exactly the right thing to seek out expert help.

My suggestion would be to have a discussion with the surgeon to find out the extent to which the pouch can be stretched, but more importantly, it may be helpful to see a therapist who can work with you to find more constructive ways of coping with the very real stressors you are experiencing. Given all that you've gone through, most people would be seeking out a "friend," that would help them cope with the difficult circumstances -- your friend happens to be food. A therapist may be able to help you find a friend or a better way of coping, which would allow you to alleviate some of the stress and feel comforted, while not jeopardizing the progress you've made with your weight. Good luck!

MEMBER QUESTION: What kinds of liver damage can chronic purging cause?

BROWNELL: Chronic purging can cause a number of biological problems. These differ in different people. If you are concerned about physical effects from purging, it is very important to see a physician and be completely honest with your eating history.

Often people will see physicians when they are experiencing some symptom or have some abnormality in a blood test, but very often are embarrassed about discussing their eating. This puts the physician at a serious disadvantage and doesn't allow him/her to see the full picture. Physicians have heard most everything and certainly won't be surprised by anything you tell them. It is much more important to be healthy than to avoid what embarrassment you may feel.

MEMBER QUESTION: A 12-year-old girl needs help in losing weight. She is 32% on the BMI scale and is having an extremely hard time controlling things she eats as well as how much. No vomiting. She cannot make decisions wisely. What would be a good option for her? She happens to be seeing a nutritionist who is trying to cut back on candy/snack buying at school and snack eating. Most of her eating is done away from home or sneak eating.

BROWNELL: Sometimes what lies between unhealthy and healthy eating is simply knowledge. If a person can be coached by a nutritionist and in so doing develop better eating patterns, then all is well. But sometimes the knowledge itself isn't enough and there are motivational and psychological issues that block a person from doing what they know is right.

MEMBER QUESTION: I was bulimic for many years. Now, taking a laxative, vitamin, or prescribed medicine for more than three days makes me sick. How do I overcome this?

BROWNELL: It is not possible for me to comment in an educated way because this is a question that should be handled by a physician who is working with you. There could be a number of reasons for the symptoms you are experiencing, but only a physician who understands you and your medical history would be in a position to help.

MODERATOR: We are almost out of time, Dr. Brownell. Before we wrap things up for today, do you have any final words for us?

BROWNELL: I have done a number of these live events and today's questions were particularly insightful. When one struggles with a problem it always helps to seek out advice from people who know the field and to be completely honest about what you have experienced. There is help available for the people who go out and get it. What might seem like strength, relying on oneself and not asking for outside help, is really a weakness. Some of the most successful people in life have problems and are wise enough to seek help when they need it. The web site of the national eating disorder association is an excellent place to look for additional information.

MODERATOR: Our thanks to Dr. Kelly Brownell for joining us today. And thanks to you, members, for your great questions. I'm sorry we couldn't get to all of them.

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