Dieting doesn't have to lead to a disorder, but hyper-vigilance about calories, fat, weight, and exercise can fuel a deadly cycle of body dissatisfaction and dieting obsession. It can start very innocently. Culturally, we give praise for "watching your calories" or "showing willpower." Take "Jill" as an example. She is a straight-A student and a perfectionist with schoolwork. People know her as an "overachiever." Though not overweight, Jill and her friends went on a diet. Jill got lots of compliments on her weight loss and that felt good. Amy Blumberg, a psychotherapist in Poughkeepsie working with eating-disorder patients comments, "An eating disorder can start with a decision to eat more healthfully and lose weight. Praise for weight loss can accentuate the desire to be thinner. Very often it is someone with self esteem issues who believes 'if only I were thin...then everything would be better.' Once they start losing weight, it doesn't satisfy them."

Jill lost five pounds on her diet. Friends and adults in her life tell her she looks great. She now separates foods into categories of good or bad. Jill continues to lose weight. She weighs herself daily, even a few times a day, calculating which foods cause the scale to go up. At any time in the day, Jill can tell you how many calories she's eaten, and if that means it's a good or bad day. There's a party this weekend, and Jill doesn't want to go because she knows that means pizza and chips. She hasn't lost "enough" weight and really wants to be "good." Sometimes she feels like she doesn't deserve to eat. She decides not to go to the party. Soon Jill is isolated from her peers, exercises compulsively, severely restricts her intake, and has frequent emotional outbursts.

Jill has anorexia. She loses 16 pounds before her parents notice the drastic change beneath her layers of sweatshirts. Jill's mom seeks out a nutritionist knowing that Jill needs to gain weight. It is apparent to the nutritionist that due to the excessive fear of weight gain, elimination of all fat from her diet, compulsive exercise, rapid weight loss, and recent loss of her period, Jill has an eating disorder. Jill is referred to a therapist, her family physician is alerted, and Jill begins the hard work of confronting her eating disorder. It may take years for Jill to break the calorie-counting habit and reconnect with a positive self worth that is anchored in something other than her physical appearance.

Dr. Theresa Yonker, a holistic psychiatrist in Red Hook, says, "An eating disorder is distorted thinking. An anorexic perceives herself larger than she is, and that's a distorted perception of reality. It's a complex disorder that develops over time in a stressful environment, whether it is real or perceived stress. It develops as a coping mechanism. It looks like it's about food, but it involves much more, including genetics, family dynamics, depression, and control issues."

There are three main categories of eating disorders: restriction, termed anorexia nervosa, binge/purge cycles, or bulimia; and overeating or binge eating disorder. Eating disorders go beyond the desire for weight loss and self-control. They masquerade as a disease about food. Food, calories, and weight obsession act as distractions from emotional struggles, trauma, and control issues buried underneath. They also act as a vehicle to play out psychiatric issues including depression, anxiety, bipolarity, and obsessive compulsive disorder. Blumberg, says, "An eating disorder is an unconscious way of coping with emotional conflict. It's a psychological illness that acts as a way to avoid intense feelings and to focus on something that they feel they can control."

Is an eating disorder a mental illness? Yonker says, "The DSMIV [Diagnostic and Statistical Manual of Mental Disorders] lists and defines each type of eating disorder, but nobody ever fits neatly into those categories. Each person is very different. They have symptoms, and the question is, 'What's the root cause?' Fundamentally, it goes back to basic nutrition and what's happening intracellularly in regard to oxygen, neurotransmitters, and amino acids. When you look at building blocks of nutrition it is clear. You need fat for essential fatty acids, protein to make amino acids, and carbohydrate as an energy source. Neurotransmitters are made of amino acids, from protein, so if you don't have the basics, you don't have serotonin [a neurotransmitter involved in regulating mood, depression, anxiety, and appetite]."

Anorexia and bulimia affect ten million adult women and one million men in the United States. Compulsive overeating affects millions more. Anorexia nervosa is self-starvation with an intense fear of weight gain, and a distorted body image. Feeling "fat" can be constant despite dramatic weight loss. Anorexia has the highest mortality rate of any mental disorder.

Bulimia is the secretive cycle of binging and purging (making oneself vomit) and a feeling of total loss of control. Binge eating disorder, also called compulsive overeating, is the disregard of hunger and satiety cues marked by recurrent episodes of eating large amounts of food without purging. Sil Reynolds, nurse practitioner in Stone Ridge, distinguishes between two types of overeaters. Reynolds sees "dieters who deprive themselves constantly and then binge on restricted foods, versus compulsive overeaters who are addictive in nature." The difference can be seen in treatment. Reynolds says, "Deprivation-sensitive overeaters can learn to stop dieting through intuitive eating [a process of learning to eat when hungry and stopping when full]. Compulsive overeaters that are addictive in nature usually involve trauma, and that can be addressed with psychotherapy."

Is there public sanctioning of this mental illness? "There is a cultural push for being slim, efficient, competent, and sexy, and a terrible prejudice against people who are fat," remarks Blumberg. The average American woman is 5'4" and weighs 140 pounds. The average American model is 5'11" and weighs 117 pounds. Is it surprising that half of all 9-to-11-year-olds say they diet, along with 82 percent of their families? What children see in the media, hear in school, and see modeled at home lays the groundwork for eating behaviors and body image problems. Over half of teenage girls and nearly one third of teenage boys skip meals, fast, smoke, vomit, and take laxatives to control their weight.

What happens when kids go off to school? Does anyone notice when the peanut butter and jelly is repeatedly thrown out? Connie Marcus, RN, school nurse for Saugerties High School, says her awareness of eating issues starts with other students. Marcus comments, "Other kids are worried about their friends and seek someone to talk to. I may have a student that says a friend has strange eating habits or is throwing up in the bathroom. I will call the child in, discuss calling the parent, and then refer her to a social worker. I won't identify which student initially came to me with concerns."

The causes of an eating disorder range from cultural pressures for thinness, life stress, mental illness, a history of trauma, and genetics. A recent study found that over half of the responsibility for developing anorexia is genetic. What this means is that for a teen with genetic predisposition, trying a new diet with her friends may catapult her into an eating disorder.

There is much unknown about how eating disorders develop. What is known is that risk rises with childhood anxiety, depression, trauma, physical neglect, and sexual abuse. Research also shows that ill-adapted paternal parenting behaviors, including limited affection, communication, and time spent with the child, also increase risk. This means that a child with an absentee father figure, either due to death, divorce, or workload, or emotionally absent due to alcoholism, or lack of communication, is at an elevated risk for an eating disorder.

Recovery rates for people with eating disorders vary considerably. The sooner treatment is initiated, the better the prognosis. Literature shows the most effective treatment engages the team approach, drawing on different professional's expertise. Blumberg adds, "The goal is of the team is to manage the physical symptoms while addressing underlying issues."

The team is comprised of experienced professionals, including therapists, dietitians, family therapists, psychiatrists, physicians, and parents. Each professional adds specific support for the client or family. A therapist will address the underlying psychological issues such as self-esteem, control, trauma, anxiety, or depression. Reynolds says, "I see myself as a translator. What is the eating disorder trying to say? It's usually: 'See me, listen to me.' I try to teach my patients to be kind and compassionate with themselves." A psychiatrist can support with pharmacological treatment. As Yonker says, "My goal is balancing neurotransmitters and serotonin levels with amino acid therapy and addressing basic nutrition. I want to teach clients healthy coping mechanisms including adequate sleep, exercise, and 'playtime' to reduce stress loads on the body and its physiology."

The physician monitors organ functions and bloodwork, and plays an integral part in deciding when hospitalization is needed. The dietitian closely monitors weight, and helps the client unlearn dieting behaviors, reintegrate normalized eating patterns according to hunger and fullness cues, and reduce specific food fears. Family therapy is important, as an eating disorder does not develop in a vacuum, but in a sea of family dynamics. Reynolds says, "I work with a team because it gets the best results. For adolescents, parents play an active role, and are considered part of the team. It's a family disease."

We, as a community, have the opportunity to model positive body image and counter mass media's propaganda. In Madrid, waiflike models are now banned from the catwalk in hopes that the fashion industry will support an image of beauty and health over-glamorized emaciation. On HBO in November, filmmaker Laura Greenfield's documentary Thin will explore four women's struggle with eating disorders and the cultural demand to be skinny.

What can you do? Talk with children about models in magazines, and allow space for dialogue. Liberalize food choices even for overweight youth, and remind children that no food is inherently "good" or "bad." Use movies, books, and special outings for rewards, not food. Compliment personality traits, qualities, and actions, not body size or weight loss. Above all, express unconditional love to your children. Tell them that no matter their size, shape, or grade point average, you will always love them.