I came across this completely by accident but found it incredibly interesting, particularly the part regarding eating disorders and genetics. Sure I knew there was a link, but not many articles go in depth.
The Hunger Artists
Are genes and brain chemistry at the root of eating disorders?
By Emily Sohn
Dinnertime was always stressful at the Corbett house. Every evening at 6 o'clock precisely, the five kids would take their assigned places at the table between Mom and Dad. Food was served family style, and whatever you took, you had to eat. You couldn't have dessert until after you had finished everything on your plate. "It was not a relaxing time to sit at the table and eat," recalls Cathie Reinard, 35, about her childhood in Rochester, N.Y. But the rigid rules just added to an underlying tension. As the kids got older, it became clear that most meals would end with Mom's excusing herself, going into the bathroom, and making herself throw up.
Messages about food were inconsistent and confusing to the Corbett kids, especially the three girls. On the one hand, dessert was served every night, and food was always part of family gatherings. On the other hand, the girls, all petite and athletic, were constantly being told they were fat--both by Mom at home and by their gymnastics coach, who wanted his athletes lean. Food was forbidden fruit. Between-meal snacks were prohibited, and the padlock on the kitchen pantry kept little hands away from the candy, Pop-Tarts, and soda stashed inside.
With so many rules and restrictions, it's no wonder that all three girls developed eating disorders, say the Corbetts, now grown and with families of their own. Cathie started sticking her fingers down her throat in high school, after a gymnastics injury prevented her from working out. Her identical twin, Bonnie, developed anorexia in college, dropping 50 pounds off her 5-foot, 120-pound frame in six months. It began, she says, when a boyfriend pointed out her growing beer belly. Their older sister, Liz, 38, was an "exercise bulimic": To make up for eating sprees, she repeatedly pushed her body to the point of injury from daily workouts that could last for three hours or more. Even their brother Daryl, 41, lost his appetite for a few months when he broke up with his first girlfriend in college.
Their mother, Margery Bailey, still feels very guilty about her children's problems. And no wonder. When Bonnie was hospitalized with anorexia at age 19 in 1985, Bailey says the doctors severely restricted her visits. "I was told it was my fault."
Dysfunctional families are still a common target of blame, as is a dysfunctional culture obsessed with thinness. But as doctors learn more about eating disorders, it is becoming clear that genetics and biology may be equally important causal factors for the estimated 5 million to 10 million Americans who struggle with anorexia, bulimia, and binge-eating disorders. Although family and culture may provide the ultimate trigger, it seems increasingly likely that hormones and brain chemicals prime a certain group of people to push themselves to starvation.
The hidden killer. Eating disorders are the deadliest of all psychiatric disorders, killing or contributing to the deaths of thousands every year. An estimated 50,000 people currently suffering from an eating disorder will eventually die as a result of it. Anorexics, who pursue thinness so relentlessly through diet and exercise that they drop to below 85 percent of ideal body weight, often suffer heart attacks, arthritis, osteoporosis, and other health problems. Bulimics eat uncontrollably, then compensate by throwing up, taking laxatives, or exercising obsessively--behaviors that can upset the body's chemical balance enough that it stops working.
As with depression and other serious psychiatric illnesses, eating disorders now appear to be a familial curse. Relatives of eating disorder patients are 7 to 12 times as likely to develop an eating disorder as is the general population, studies show. Depression, anxiety disorders, and other related illnesses also appear more frequently in the same families. That doesn't rule out a shared environment as a contributing factor, says psychologist Michael Strober of the University of California-Los Angeles. But, he adds, "anytime you see a disorder that runs in families, you begin to suspect some hereditary influence."
The women in Bailey's family have been fighting a losing battle with food for generations. When Bailey was 18, her 55-pound mother starved herself to death, sneaking laxatives in the hospital until the very end. Other relatives have also suffered from anorexia. "I was always told I was fat and ugly and dumb," recalls Bailey, a 63-year-old retired nurse. She vividly remembers how she and her brothers secreted cans of food because they weren't getting enough to eat at meals. But, she concedes now, the sheer number of eating disorders in her family suggests something deeper going on.
Deadly eating disorders exist in cultures far removed from Hollywood and Madison Avenue and have been around far longer than glossy women's magazines. But if that weren't evidence enough for an underlying biology, the patients themselves are the first to say their eating disorders have a power far greater than peer pressure. Indeed, Stephanie Rose's illness had such a strong "personality" that she named it "Ed." It started with a diet to lose 8 pounds of weight gain after her freshman year of college. But her success became an obsession that landed her in the hospital nine times over the next four years. She crashed a car and a bicycle, both times after passing out from nutrient deprivation. She chugged bottles of poison-control syrup to make herself throw up, even if she had eaten only a bite of a tuna fish sandwich or a few grains of cereal. Even in the hospital, she shoved batteries in her underwear to fool the nurses when they weighed her. Talking and reading took too much energy, so she stared at the TV instead, gray-skinned, too weak to think.
At her sickest, the 5-foot, 5-inch Needham, Mass., resident weighed 75 pounds. She had a mild heart attack at age 21 as a result of her starved state. Doctors told her bluntly that she was going to die, and nurses sat with her 24 hours a day to make sure she didn't pull out her feeding tube. Now 29, fully recovered and happily married with a 15-month-old baby of her own, Rose can't believe she would flirt with death for arms that looked like toothpicks. "It was like someone took over my body," she says, "this guy, Ed."
The most convincing evidence for genetics comes from twins. If one twin has an eating disorder, the other is far more likely to have a similar illness if the twins are identical rather than fraternal. Since identical twins are genetic clones of each other, that is powerful evidence that genes play an important role, says psychiatrist Cynthia Bulik of Virginia Commonwealth University: "Until now, people would have said there wasn't a genetic effect in anorexia. And what we're saying is that there really is, and it's not minimal."
Gene hunt. Several groups of researchers are now hunting for the specific genes involved in eating disorders, with some promising leads. The first two comprehensive scans of the human genome have recently turned up hot spots for anorexia-linked genes on several chromosomes, including Chromosome 1, which seems to harbor genes for the most severe form of anorexia. "We now know the location of several genes in the human genome which increase risk for anorexia nervosa," says University of Pennsylvania psychiatrist Wade Berrettini, a senior author of a study in the March issue of the American Journal of Human Genetics. "Prior to this, we did not." Other preliminary work is pointing to different areas of the genome that may be involved in bulimia, says psychiatrist Walter Kaye of the University of Pittsburgh.
None of the scientists exploring the genome expects to find easy answers or simple genetic switches. Indeed, hundreds of genes are already known to influence appetite and eating regulation in some way, a testament to how complex the eating impulse really is in the grand scheme of human biology.
But some patterns are emerging. The most obvious is that 90 percent of eating disorders occur in girls and women, most often beginning in adolescence. This clue has some experts exploring the genes that control hormone production. During the teen years in most girls, estrogen-producing genes kick in, triggering puberty. And there is evidence, says Michigan State psychologist Kelly Klump, suggesting that those genes may also contribute to eating disorders in some girls: Genes appear to be involved in 17-year-old twins with eating disorders but not in 11-year-old twins, who are mostly prepubescent. But even more striking, Klump says, a recent study of 11-year-old twins who had gone through puberty and exhibited warning signs of the illness showed the same genetic pattern as the 17-year-olds. Klump notes, by analogy, that depression hits girls twice as hard after puberty as before.
Other researchers are linking eating disorders to personality traits that are hard-wired into the brain. Anorexics tend to be Type A--anxious, perfectionist, rigid. Those traits can translate into an unhealthy body image: When a driven perfectionist sets her mind on being slender, self-control can become a measure of success. Anorexics also tend to be ritualistic about the food they eat, cutting it into tiny pieces or eating only a specific type of food at only a specific time of day.
Obsessed. Such an obsessive temperament often appears to be inborn. In Kathryn Carvette DeVito's case, the first signs appeared at age 7. She started having panic attacks on the school playground and became preoccupied with getting her homework perfect, starting over and over again if necessary. Then she developed some classic symptoms of obsessive-compulsive disorder: "If I touched a doorknob 15 times, everything would be OK," she says. Kathryn hit puberty earlier than her classmates, and when a doctor told her she was heavier than the average sixth grader, her obsessions turned to food. She dropped to a low of 85 pounds before seeking help when she was 19. Even now, though the 5-foot, 2-inch Boston University senior sees a psychologist weekly and has stabilized her weight at about 100 pounds, she says that she sometimes eats as little as 100 calories a day. She works out every day and does sit-ups in her bed at night.
Brain chemicals may contribute to illnesses such as Kathryn's, says the University of Pittsburgh's Kaye. It may be that people who go on to develop the anxiety and obsessiveness associated with eating disorders have abnormally high levels of serotonin, one of the brain's major chemical messengers for mood, sexual desire, and food intake. Losing weight lowers serotonin, so anorexics may stop eating in a subconscious attempt to lower their uncomfortably high serotonin levels, says psychiatrist Evelyn Attia of the New York State Psychiatric Institute. But when a person stops eating, her brain churns out even more serotonin, Attia says. So, the anorexic gets caught "in a vicious cycle where the behavior tries to compensate for the uncomfortable feeling of biochemical imbalance but can never catch up."
Kaye also has evidence that the brains of recovered bulimics process serotonin in a way that is different from the brains of healthy people. It's not entirely clear yet if their brains were different before they developed the disease or if dieting caused the changes. Still, such chemical differences suggest that drugs like Prozac, used to treat depression and compulsive behaviors, might be helpful for treating eating disorders as well. In a small study, Kaye found that Prozac, which helps the brain's pathways work better, helped prevent relapses in recovered anorexics.
Despite all these biomedical advances in understanding eating disorders, victims still face a long and uncertain road to recovery. Only about half of anorexics and bulimics ever recover enough to maintain a healthy weight and positive self-image. Thirty percent of anorexics have residual symptoms that persist long into adulthood, and 1 in 10 cases remains chronic and unremitting. Without treatment, up to 20 percent of cases end in premature death.
Denial and resistance to treatment are fierce psychological obstacles once an eating disorder has taken hold, so scientists are looking more and more to prevention. And ironically, given the move away from cultural explanations for the disorders, the best interventions for now may still be psychosocial. Surveys show that 42 percent of children in first through third grade want to be thinner and that 81 percent of 10-year-olds are afraid of being fat. Those attitudes are clearly not genetic, and they are so pervasive that they could be pushing the genetically vulnerable over the edge. "If people never diet," Bulik says, "they might never enter into the higher-risk category for developing eating disorders."
One of the most striking examples of culture's influence comes from Fiji, where a bulky body has always been a beautiful body. Women on the South Pacific island have traditionally complimented one another for gaining weight. Food is starchy, calorie-dense, and plentiful. But when TV came to the island in 1995--with shows like Melrose Place and commercials celebrating thinness--the depictions of beauty radically altered Fijians' self-image--especially the girls'. According to a study published this month by Harvard psychiatrist and anthropologist Anne Becker, by 1998 the proportion of girls at risk for developing eating disorders more than doubled to 29 percent of the population. The percentage of girls who vomited to lose weight jumped from zero to 11 percent. "We actually talked to girls who explicitly said, `I want to be thin because I watch TV, and everyone on TV has all those things, and they're thin,' " Becker says. Likewise, non-Western immigrants to the United States are more likely to develop eating disorders than are their relatives in the homeland.
Cost of starvation. While scientists debate and explore the causes of eating disorders, victims and their families are being hard hit financially. Hospitalization and around-the-clock care to revive a starving patient can cost more than $1,000 a day. Full recovery can take years of therapy, often involving the whole family. But because eating disorders are classified as a mental illness, insurance plans rarely cover the full costs of treatment. Kitty Westin slammed into just that painful wall. Her daughter Anna had struggled with anorexia as a teenager but seemed healthy when she came home to Chaska, Minn., after her sophomore year at the University of Oregon in Eugene. Within months, depression and anxiety again consumed Anna. She couldn't sleep. She withdrew from her family and friends. She stopped eating and spent hours at the gym every day. By summer's end, Anna, who had always been petite, could barely stand without feeling dizzy. At 5 feet, 4 inches, she weighed 82 pounds, and her vital signs were dangerously low. No matter how hard she fought the anorexia, she felt powerless. "It won't leave me alone," she told her mother.
For the next six months, Anna checked in and out of the hospital. She would improve as an inpatient. But as soon as she went home, she'd get sick again, says Kitty Westin, who quit her job as a psychologist to take care of her daughter. The family's health insurance company, Blue Cross and Blue Shield of Minnesota, refused to fully cover the costs of residential treatment, leaving the family to pay for whatever they could. On Feb. 17, 2000, worn out from her struggle, Anna killed herself. She was 21. Her mother, now a full-time advocate for better insurance coverage, says the family's battles with the insurance company exacerbated Anna's illness. "See, I'm not sick," Anna would say. "The insurance company says I'm not sick."
Such attitudes are slowly changing. In June 2001, the state of Minnesota settled a lawsuit against Blue Cross for repeatedly denying coverage to children with mental health problems. The settlement required the company to pay the state $8.2 million for treating families that had been refused coverage. The company is also becoming more accountable to eating disorder patients via an appointed, independent three-member panel that must review mental health appeals soon after receiving them. Westin is convinced that such a process would have saved Anna's life. "There is no doubt in my mind," she says, "that a panel would have reversed the [insurance company's] decision."
A legal acknowledgment that eating disorders are real medical illnesses brings hope to families who already know that their problems won't just go away. The grown Corbett women, for example, all still struggle with body image and health problems related to their eating disorders. Their mother, Margery, was hospitalized recently for dehydration from drinking too much alcohol and not eating enough. Liz sometimes freezes at the thought of going out to parties because she can't figure out what to wear. Cathie, who has a 3-year-old daughter and a 9-month-old son, purged during her second pregnancy and has damaged the enamel surface of her teeth from years of bulimia. Meanwhile, Bonnie continues to struggle with anorexia, 17 years after it began. She takes vitamins and mineral supplements to avoid anemia. She takes birth control pills to keep her hormone levels up. And she has recently started taking medicine to treat end-stage osteoporosis. At 35, she has the bones of an 86-year-old woman and says her hips would probably shatter if she fell. The whole family takes things one day at a time. "You get the cards you're dealt," says younger brother Rick, 31, the only sibling spared by the illness. Instead of cancer or heart disease, he says, his family got eating disorders. "Everyone has their own battles to fight," Bonnie adds. "This is ours."