David Herzog, M.D.

I agree with Naomi, I think this is an historic moment, I think it's important we're having this meeting today. I don't know if anyone saw the Boston Globe this morning, but the front page has an article about a dancer's death which raises questions about the Boston Ballet telling the woman to lose weight. This is story about a 22 year old woman who in the last week of her life was riding with her parents on a trip to California and died suddenly. She had been losing weight over the past 2 years. I think it's key and I think the press will grab this one because... sometimes eating disorders are seen as a fad.. come on, just eat, stop purging, and its actually more serious than that.

Now, I'm going to be showing some slides. There are different figures, but eating disorders affect somewhere around at least 5 million if not more American women, most of them young, and often some of our most gifted. If you look at this first slide, most of the individuals with eating disorders, as Dr. Ruth Striegel Moore was saying before, have bulimia nervosa or binge eating disorder. A smaller percentage have anorexia nervosa. An additional number, and that number may be anywhere between 3 to 5 million, have what's called Eating Disorder Not Otherwise Specified. You have symptoms of eating disorders, but do not fit all the criteria. And in our study this group appears for treatment just as much as these individuals. So if we look at the clinic at Massachusetts General Hospital, those people coming for help, we've seen even a greater number of people with this Eating Disorder Not Otherwise specified. So the number of people with eating disorders may be more in the 8 to 10 million range.

This affects women at a critical stage of career and family development and has a potential devastating impact on their reproductive and general health as well as their other psychological well being. Anorexia clearly has an impact on the heart, here we see a pulse of between 25 and 30. For those who don't know, normal pulse would be in the 80's. But this is an area that doesn't get a lot of attention for obstetrics, for those who then become pregnant, their babies are quite small, their time of birth, high death rate, very low birth weight infants, and as I say, this perinatal mortality, their death, even if not at the time of birth, shortly thereafter. So that's obviously a great risk for those who are able to have children and obviously infertility is a great issue for those who cannot.

One of the other really more severe complications of anorexia nervosa for those who survive is osteoporosis. Osteoporosis we tend to think of as for older women, closer to death, menopausal. And this is a study we did in the early 80's because we started seeing these young women with fractures. One young woman 23 years old had her... collapse, lost 2 inches in height. But the individuals who had anorexia nervosa had substantially lower bone density than normal controls. And if you take consecutive women with anorexia nervosa, and if you can think of normal bone density as 180, nearly all of the women had bone density one standard deviation below the norm and most of it had their bone density two standard deviations. So it's significantly lower than the norm. And it didn't matter whether they were 40 or they were 18 or 19. In fact, some of the lowest bone densities were for 19 and 20 year old women who had the bones of 75 and 80 year old women and the risk of fracture that result from that. And if you look at the reversibility of that, this is a follow-up study of that population several years later, that this low bone density persisted even if they gained weight and regained their menses, so this is a serious problem and we have to intervene early. Now, all of these disorders are chronic and at times fatal. There are effective treatment for these disorders and treatment is most effective if begun early.

If you look at the outcome of treatment for anorexia nervosa, about 50% totally recover, 30% get better, and 20 or 30% remain chronically ill. What's particularly troubling is the mortality rate, the death rate is 5.6% per decade. We've been involved in a longitudinal study funded by the National Institute of Mental health, where we've been following women with anorexia and bulimia now up to their tenth year. These are 250 young women, and 5 of these young women have died. So people do die, and again, the message has to become clear, this is a very serious problem. In bulimia nervosa, although 70% seem to have substantial reduction in their symptoms, 30% go on to have a chronic disorder.

These are the range of treatments...psychotherapy, pharmacotherapy, use of medication... There is typically a lag time between the onset of symptoms and medical care. And the reasons for this vary. The young women may not reveal or actively conceal her symptoms because she is unaware of the significance to her health, unaware of effective treatment, reluctant or ashamed to discuss these symptoms with someone who may not understand them. Or unwilling to consider relinquishing the symptoms. In other cases, physician, teachers or mental health professionals might not recognize the symptoms and consequently may not recommend or initiate appropriate care. The difficulty women have in discussing their eating disorder symptoms with their physicians is highlighted in two different studies, the first of which showed that physicians were not aware of eating disorders in 50% of their patients who were found to have eating disorders. Routine screening questions, inquiring about disordered eating, purging and weight loss would allow for increased reporting. In a second prospective study in an infertility clinic identifying eating disorders in 58% of women who had irregular menstrual periods or no periods at all. Yet none of these women reported their eating symptoms to the gynecologists. Once again, routine screening would increase identification of these patients.

Now the Harvard Eating Disorders Center was the scientific arm for the 1st eating disorders screening program, which was held at 600 colleges across the country. The question is frequently asked why screen for eating disorders? Because these are prevalent disorders, they are often secretive disorders, there are substantial risk for medical complications, and there's a high mortality rate. Why should we screen in the college population? Because in colleges we see high rates of eating disorders, there's considerable interest in this in college population. There are college resources available, there are college counselors. Now in addition to screening, there was also an educational goal to the screening program, raise public awareness. Train college counselors to identify eating disorders. Help college students recognize patterns of disordered eating, not just in themselves, but for their roommates but for others. And demystify the treatment process of eating disorders. So that people who have these problems might actually seek help.

I thought we might spend a few minutes looking at an edited video that was shown at all these college sites. (These are quotes from women in a video.)

'I remember the first time that I binged and purged, I knew that it wasn't normal behavior... and it was really shameful to me.'

'My value was completely dependent on my weight and what I'd eaten.'

'There was a time I was throwing up blood and I knew there was something wrong, that wasn't normal.'

'I was wishing I could go and hide in a hole somewhere and start to disappear.'

'It looked like I should have been on top of the world, I was doing great in school, I had a boyfriend, I mean if you looked at me you would have thought everything was great and inside I was just miserable.'

'Images I saw on television and magazines, anywhere, anywhere that you looked. That was the role model that you were supposed to, that was the lead you were supposed to follow.'

'It is a very competitive society. We're pushed in a lot of directions. And women are supposed to be thin. Yeah, you're really supposed to be thin. Definitely.'

'The purging was never quick or easy or silent so it also involved making sure roommates or family or other people weren't around and obviously all of this was done in secret.'

'Part of the problem with eating disorders is your children become absolutely expert, even more than the CIA, at hiding any piece of information that would allow you to know that they had this problem.'

'I was doing up to about 500 sit-ups a night. I was doing sit-ups in hospitals, you're avoiding everything, everything's superficial. And that's it, that's your life. Your eating disorder, you can't have anything else. It's very hard to live a normal life and have an eating disorder.'

'I had no clue I was over the line. Like when you get dressed in the dressing room, and you have the 3-way mirrors. Every once in awhile I'll get a glance from angles I never see me. And like, Oh my god, maybe I look thin. And then soon as I look in regular orientation like I always do, I'm like, no it's still there.'

'Wasn't until I had a pretty mild heart attack and was told I wasn't going to make it through the night did I realize that I needed to get better.'

'Just the sense of shame and sort of self-revulsion that I felt I know I didn't want to live with that, and when I felt I couldn't make it stop, I knew I needed help. But I didn't know how to get the help.'

'And when you realize that you can't do it by yourself and you want some sort of support system whether it's a family whether it's a friend, it's just a piece where you really decide you don't want to be alone with it.'

'I decided that do I want to die, do I want to live, do I want to have children, do I want to get married, do I want to go back to school. I mean, do I want to be Stephanie or do I want to be an eating disorder my whole life.'

Okay, as I said it's a 60 minute video. Now... we did screen students, and when we analyzed the data, we found that a very high percentage, 75% of those participating in this program were found to have clinically significant symptoms. That means frequent purging or binging, being obsessed with their food or weight and that these were associated with social and academic impairment. And that 90% of the 9,000 participants had never accessed care for an eating disorder prior to the screening program. Of particular concern was the trend that the more seriously affected ethnic minority groups, in this sample, the Native American and the Latinos, were the least likely groups to receive a referral for further evaluation and care.

These studies along with our clinical experience lead us to our position that, in absence of access to care, for those women with eating disorder symptoms, is an urgent research and training priority. We take the position that the most effective means of early identification of disordered eating and timely health care delivery.... We feel the best approach is to develop a curriculum for professional training for primary care physicians and mental health professionals. Develop and disseminate effective clinical assessment tools which would increase reporting. Finally, develop a national public awareness campaign to increase public awareness about eating disorders. And I'll stop there. Thank you very much.

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