Statement of Ruth Streigel-Moore, PhD at the APA CoSponsored Congressional Briefing

Ruth Striegel-Moore, PhD

Eating disorders has become a household word. There's not a day where we don't see something like this (shows tabloid paper) in the supermarket... There's a lot of media attention paid to eating disorders. Despite all the attention.. eating disorders are trivialized and not taken seriously. Also, in light of all the attention that eating disorders get, there are a lot of myths about eating disorders. One myth is that eating disorders are synonymous with anorexia nervosa. Another is that eating disorders are just a transient adjustment problem. Another is that only Caucasian women develop eating problems. Another myth is that eating disorders are problems of the rich and famous and this gets reinforced by the images we are presented (shows slides) here are three very famous models and of course... Princess Diana. Another myth is that eating disorders are caused by a single causal factor. There are theories floating around that it's the sugar in your food that causes your eating disorder. Another myth is that eating disorders cannot be treated effectively, and as Rep. Lowey was saying earlier, correctly, in fact there are effective treatments available yet many women do not avail themselves to treatment. Finally, there's the myth relevant to today that eating disorders cannot be prevented. If I don't address all the myths to your satisfaction, I have a handout with rebuttals for each various myth.

My job is to introduce the topic and give some definitions. So here's an overview of what the eating disorders are that are being recognized. There's Anorexia Nervosa, Bulimia Nervosa, and a third category called Eating Disorders Not Otherwise Specified, which I'll come back to in a minute. To give you an idea of what the key features are... basically in an eating disorder, at least two of these three features are present. There's body image disturbance... such as feeling fat, being emaciated or extreme emphasis on one's shape or weight. There are excessive weight control efforts such as fasting for long periods of time or purging by means of vomiting or using drugs that have an anorectic effect. Lastly, in eating disorders there's a loss of control over eating. If you hear about anorexia nervosa, the key features are relentless pursuit of thinness, body image disturbance, severe emaciation and amenorrhea. In bulimia nervosa... a recurrent pattern of overeating large amounts of food and feeling out of control, and again undue emphasis on shape and weight and recurring compensatory behaviors. More recently, there's a third eating disorder recognized as binge eating disorder. Essentially, it's a similar form of eating disorder to bulimia but does not involve compensatory behaviors such as restricted dieting, excessive exercise, binging and so forth.

It's important to recognize that the eating disorders I've described occur on a continuum from having no concerns of these issues to severe forms recognized as eating disorders. And that's important, in part, because it's difficult to draw the line between the clinical symptom and these more normative problems.

Why are eating disorders so important, why are they such an important health issue for women? First of all, the prevalence of the serious forms of eating disorders on the extreme end of the continuum, there are approximately 5% of adolescent and young women suffering from them. So in terms of the sheer numbers, they're very important. Depending on how we define the problem and looking further along the continuum to look at serious dieting... there are many more individuals affected. Secondly, eating disorders are important because of the serious health and mental health problems associated with them. Eating disorders serve as risk factors for serious mental health problems such as depression and substance abuse. So they often lead into other serious mental health problems that often times don't get recognized. A second point is that even the more subclinical forms...let's take laxative abuse, binge eating... have serious health consequences.

To further address another myth, when we talk about eating disorders, we think about white women and that is a myth. Eating disorders are also common among minority populations. When we look at African American women, we see that for binge eating the rates are 5% in this sample (slide). In fact, this number exceeds the rate for Caucasian women. Coming back to the issue of serious health risk, often times the symptoms start early, and children are already dieting. In this slide I brought shows that for ten year old girls trying to lose weight, they already show differences in micronutrient intake for Vitamin A and calcium. You can already at that age show that the diets of these girls are not as good as the diets of the girls not trying to lose weight.

When we think about what causes eating disorders, and this is very important to the discussion of prevention, here are some points I want to make. One is that there are multiple risk factors from multiple domains, meaning it's not just a single thing that's causing eating disorders. It comes from a variety of levels from the cultural level down to personal vulnerability. The second is that there are specific and general risk factors. Specific meaning there's something uniquely contributing to the development of eating disorders and then there are general risk factors meaning they contribute not only to eating disorders but to other mental health problems. And if you have certain preventive interventions that will address these factors, then they will benefit not only the women who are at risk for developing eating disorders, but other populations as well, such as depression or anxiety disorders and so forth. Third is that exposure to risk occurs in multiple settings... the influences come from a variety of settings, family, school, the media and so forth. Also, factors that contribute to developing an eating disorder are developmentally specific. So what may be exposing you to risk at a certain age may no longer be a problem at a later age. Therefore we need to consider developmental research, for example, to really target appropriately the various interventions that we consider. Lastly, these causal factors are cumulative, meaning that the more risk factors a person is exposed to, the more likely that they will be to develop a disorder.

Now the culture is very important, as Dr. Jeanine Cogan was saying in her opening remarks. There are number of cultural factors: cultural attitudes about the body, the thin ideal for women, and not to mention the cultural definition of femininity. In our culture, women define themselves, in part, through their appearance. At a very existential level.. it is important to how feminine we feel whether or not you think you are physically attractive. So in that cultural context, women and girls are at high risk to internalize certain assumptions and ideals such as the thinness beauty ideal... the what's beautiful is what's good stereotype and consequently develop body image dissatisfaction. To visually show you the change over time here, a painting by Reuben, the Three Graces, figures which today you might think need liposuction. But more recently if you just look at 20 years from 1965 to 1985 you can see a dramatic change in that time period in the thinness ideal. Now you may not be able to read the text, but that's important. Women are told to think positively and to think for themselves, but of course the images that are presented are not very healthy or positive. In fact, do not think for yourself, you're supposed to look all exactly the same...

The other important point I would like to make is the tight link between the thinness attitude and the cigarette industry which has been relentlessly exploited. Even the names of the cigarettes carry the name slim, it's really very thinly veiled what's going on here. Cigarettes are being marketed to young girls as a way of staying thin. All in the name of women's liberation, 'we've come a long way baby', you see in the background the stout heavy women. And for the campaigns for the African American women, they don't show the backgrounds because they don't want to show images of slavery. Another one, 'you cannot be too rich or too thin', this is the cultural context we live in... That's the cultural context in which these problems occur.

The last point I want to leave you with, the cultural context is very important but in the other domains, you need to consider the woman's constitutional vulnerability, heavier girls will be higher at risk. Parents can accentuate those cultural messages or accentuate them and there's a whole host of family aspects that can contribute that have nothing to do with appearance, but have to do with inadequate parenting, violence against women.... The point is that there are a variety of factors to think about in terms of where to go with prevention. Thank you.

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