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Feature: March 5, 1997
Starving for Perfection
How Three Students Struggled with Bulimia and Anorexia
By Kathryn F. Greenwood
The middle child in a family of three girls, Deborah came to Princeton with everything going for her. She had been a varsity athlete and a team captain at her boarding school. This attractive, intelligent woman says she should have had the time of her life in college, but it didn't turn out that way. During freshman year, she lost a sense of who she was and came to feel that she didn't fit in. She didn't make an athletic team, and the academics overwhelmed her-she failed one course and struggled in her others.
She reacted to the stress by binging, purging, and overexercising. "By the end of freshman year, I wasn't keeping anything down. I was getting sick after all my meals," she says. During her sophomore year, the bulimia got worse. She would eat alone at restaurants in town and would binge and purge up to five times a day. While studying in Firestone Library she would snack, purge, then snack some more. "I can't tell you the kind of panic you live with on a daily basis when you're getting sick in the public bathrooms and are so worried that someone's going to hear you." As her life careened out of control, she recalls, even "little things like doing laundry seemed like incredible tasks." Lacking energy to study, she watched her grades sink further. She denied having a problem, even after her boyfriend and her best friend confronted her about it.
(The names of "Deborah" and the two other women profiled in this article, "Alicia" and "Sarah," have been changed, along with some of the details of their personal lives.)
Deborah is one of the 10 to 20 percent of the nation's female undergraduates who suffer from eating disorders, including anorexia (self-starvation), bulimia (binging and purging), and compulsive overeating, according to Susan B. Packer, the associate director of the university's Counseling Center. Some surveys have indicated that one-fourth of college-age women have suffered from an eating disorder at one time or another, says Thomas Pini of the Center for the Treatment of Eating Disorders, in Livingston, New Jersey.
Because no survey has been done, administrators can't accurately state the number of Princeton students with eating disorders. Beth A. Turetsky, a clinical psychologist at the Counseling Center, says that about a hundred with either eating disorders or eating "concerns" visit the center each year, and occasionally a problem is severe enough for a student to withdraw from school. (An eating concern isn't classified as a clinical disorder; symptoms include a negative body image and a preoccupation with food and caloric intake.) The Counseling Center sees more cases of anorexia and bulimia than compulsive overeating, perhaps because binge eaters are less likely to seek help. Nationally and at Princeton, the numbers of students seeking help for eating disorders or concerns have increased over the last five years.
No one would claim that eating disorders are unique to Princeton, but the school's competitive environment provides for them a fertile breeding ground. Universities of Princeton's caliber attract perfectionists and overachievers-characteristics of those with eating disorders. Kids who were high-school superstars may just be run-of-the-mill students at high-octane schools, and adjusting to their deflated status can be painful. "Princeton can be a very humbling experience for someone who doesn't have a huge and healthy self-esteem," says Tara Christie '97, an eating-concerns peer educator. An eating disorder becomes a way to regain a sense of control over one's life. Students and counselors have also observed that eating and exercise can become arenas in which women compete-a student who can't be the best in the classroom or on the playing field can at least excel at being the thinnest. If the woman next to her in the dining hall limits herself to a salad and a bagel without butter, a student may also forgo meat, potatoes, and dessert.
Another factor is the perception that at Princeton all women are thin, attractive, and athletic. "If you walk around campus, it looks like a J. Crew catalogue," says Christie. "There are no fat people here." Dating and other social pressures contribute to the problem, too. Peer educator Candy Messinger '98 suggests that bicker, the system by which the five selective eating clubs choose members, places a premium on looks. Then there are the September "face parties," in which upperclass men go through the Freshman Herald noting the best-looking women. Such rites, says Messinger, send a message that to be accepted, a woman has to be pretty and thin. Parents can also be part of the problem-the mother of one first-year woman dropped her at Princeton with a scale in hand and instructed her daughter's resident adviser to make sure she didn't gain weight. But peer educator Stephanie Borbe '97, who came to Princeton with an eating concern, believes that the pressure to be thin more often comes from other women. "Among ourselves, women sometimes make the problem worse," she says.
Such problems are pervasive in our youth-oriented culture, of course; nationwide, an estimated 5 million people suffer from eating disorders, and many more have eating concerns. "Most women," says Turetsky, "at some point in their lives are preoccupied with their bodies and food." Women aren't the only ones who fall prey to society's view of the perfect body: an estimated 10 percent of those with eating disorders are male, and Pini notes that the problem is on the increase among college men. (For more on the nature of eating disorders and their medical complications, see box, above.)
The Counseling Center, located at the McCosh Health Center, has a team of professionals to treat students with eating disorders and concerns. Students can make an appointment with a psychologist, a physician, a nurse practitioner, a nutritionist, or an athletic trainer. They are limited to 10 individual counseling sessions each year. If they need additional counseling, the center can refer them to outside therapists. The center also offers a recovery group for students with eating disorders and a support group for those with eating concerns.
The center's program for eating disorders was created 10 years ago in response to complaints by students about the services then available. At that time, the Counseling Center offered only therapy that focused on psychoanalysis. But exploring the underlying causes for an eating disorder, including a patient's family history, can take years, says Packer. Students today can still get psychoanalytic help, as well as more immediate relief from the symptoms of their disorders. Therapy also involves helping patients identify what triggers their binging, and teaching them how to curb it.
Eating disorders may erupt in the hothouse environment of college, but the seeds are usually planted earlier. A desire to be thin often shows up in prepubescence: 50 percent of fourth-grade girls diet because they think they're too fat, according to the American Anorexia/Bulimia Association. Anorexia typically sets in during early adolescence and bulimia during the late teenage years and young adulthood, says John Blake, a consulting psychiatrist.
Once established, eating disorders take over a person's life. Sufferers from anorexia and bulimia are preoccupied with counting calories, planning their next snack, making sure they will be near a toilet after eating, and exercising enough to burn off what they eat.
Alicia, who developed a combination of anorexia and bulimia in high school and has struggled with it at Princeton, used to exercise six hours a day. Every morning before high school, she ran or worked out on a treadmill, and after school she practiced for several hours with her athletic team. Often she didn't get home until 10 at night, and in her exhausted state it would take her until three in the morning to finish her homework.
A self-described perfectionist, she kept meticulous records of what she ate. "All your thoughts are occupied with how many calories you've consumed today and what you'll eat tonight for dinner. You wonder whether you'll have time to go to the bathroom after that and whether anyone will be around to notice," says Alicia. "It becomes your life. You don't want to go out anymore because you don't like eating around other people. You want to snack but not let anyone know that you're snacking. It's this game you play. It absorbs you."
Her disorder developed in reaction to various adolescent pressures. She had also gotten involved in modeling, "and the little comment from Mom about my hips didn't help." She started by dieting, but eventually she became anorexic, and then she began to binge and purge. At five-foot-ten and weighing just 115 pounds, Alicia took to wearing baggy clothes to hide her body shape. She also found herself baking a lot, but never eating what she made: "You want to feed other people," she explains. "You feel good knowing they're eating more than you."
Despite all the obvious signs, Alicia was in denial about her condition. Her parents didn't pick up on it, and only after several encounters with friends did she admit to having a problem. Over several years, she began to come to grips with it, helped by two close friends who were also struggling with eating disorders.
Alicia talked about her problems one day last fall while sitting outside the Chapel lingering over a cup of frozen yogurt. Coming to Princeton, she said, had been a relief. She escaped the glare of people who knew of her disorder and were constantly commenting on how much or little she ate. By then she had stopped counting calories and had her anorexia under control, and her binging and purging was less frequent. She made new friends who offered support: her roommate, who was food preoccupied, and her boyfriend, who had suffered from an eating disorder in high school. By the end of freshman year she had stopped purging, but not until the second semester of her sophomore year was she at last comfortable with herself and what she ate. The feeling was liberating.
Nevertheless, Alicia still finds it difficult to eat in front of other people in a dining hall. "You're conscious of what you're eating and how much you're eating and how much or how little other people are eating," she said. "If you have a piece of cake, what are people going to say about you?"
People with eating disorders come from all socioeconomic backgrounds and often seem to have healthy self-esteem, says Turetsky, but they aren't as confident as they appear. Beneath the symptoms are underlying issues and feelings, she explains, and eating disorders become a dysfunctional way to manage them.
In Deborah's case, it took several years for her to come to terms with her bulimia. It wasn't until late fall of her sophomore year that she could admit to having a problem. She visited the Counseling Center but didn't click with the therapist she met there, and the two psychoanalysts she was referred to didn't work out, either: one was too far away from campus, and the other suggested she take Prozac, but Deborah wanted nothing to do with drugs. So she found a psychotherapist near her home and commuted there on weekends for several months for counseling sessions. Before long she had stopped purging but still felt uneasy in the presence of food.
Deborah learned that her illness was due to several factors, among them trying to be the perfect child in her parents' eyes; academic pressures; her inability to find a niche at Princeton after failing to make a varsity team; and above all, her own demanding personality. "I'm very critical and drive myself very hard," she says.
There isn't any one category of student who appears to have a higher incidence of eating disorders, according to Turetsky, but certain athletes are typically more susceptible to problems with eating and exercise. Those vulnerable include women and men who participate in endurance sports (track, swimming), in sports with weight limits (wrestling, lightweight football, lightweight crew), or in sports in which one's appearance can be a factor (gymnastics, diving).
Greg Gastaldo, a physician on the Counseling Center's eating-disorders team and the director of athletic medicine, says that some experts believe that eating disorders may be more prevalent in athletes. According to the American Anorexia/Bulimia Association, 10 percent of female athletes suffer from eating disorders, and 20 to 30 percent of female athletes have abnormal eating habits, also called "disordered eating." A female athlete with disordered eating, explains Gastaldo, may severely restrict her diet not because she believes she is fat, but to stay slim to enhance her performance. Among men, a wrestler with disordered eating may restrict his intake of water and nutrients to make weight for a match. Most athletes who take such measures usually stop once they quit playing competitively, says Gastaldo.
Some athletes, in particular runners, may perform better if they are thinner, says Turetsky. Peter Farrell, the coach of women's track and cross country, says that dealing with athletes with eating disorders and eating concerns goes with any coach's job. Endurance sports such as running attract compulsive, highly driven, type-A personalities, and "I'm suspicious of everyone, particularly recruits," who may try to hide a disorder.
In a 1994 Sports Illustrated article, Farrell said that about 70 percent of his athletes had eating problems, though not necessarily full-blown eating disorders. But today his team is healthy, he says. In 20 years of coaching, he's seen coaches at other schools ignore anorexia in their athletes so their teams will win championships. "You can do extremely well as a coach with a handful of anorexics. You can ride their backs to a national title," says Farrell. "What I'm amazed at is how long [the women anorexic runners] last." He's seen them run well for two or three years, although generally speaking, once an athlete admits to having a problem and seeks help, "running is over, because they will never have the same passion, that same drive."
The women's swimming coach, Susan Teeter-Eggert, who in years past has had several team members with eating disorders or concerns, keeps her eyes open for potential problems. But only once, about 10 years ago, did she have to ask an athlete to stop swimming because she wouldn't admit to her problem. Teeter-Eggert attributes eating disorders and food preoccupation more to the emotional makeup of students than to the pressure to be thin for swimming.
Princeton coaches are becoming more aware of eating problems among athletes. Recently Farrell, softball coach Cindy Cohen, Associate Director of Athletics Amy Campbell, and members of the eating concerns/disorders team formed a committee to develop guidelines for coaches to identify and counsel athletes with eating problems.
Instead of contributing to her eating disorder, running on the track and cross-country teams helped Sarah, a recent graduate, get over her illness. A distance runner, she became anorexic during her freshman year in high school. She would consume only fruit, vegetables, and milk, totaling about 500 calories a day. She's not entirely sure why she developed anorexia, but attributes it in part to her father, who was strict, demanding, and critical. A brother and sister also struggled with eating disorders, which appear to run in families. All three children had a tense relationship with their father.
Despite her being a star athlete and valedictorian of her high school, Sarah says, she was "really unhappy and lonely, and I didn't feel like I could do anything right." Unlike many anorexics, she never thought she was fat. Limiting her food intake was a way to punish herself-"I felt like I didn't deserve to eat," she says-and a way to control some part of her which her parents couldn't touch.
When Sarah arrived at Princeton, she was five-foot-seven and weighed 102 pounds. In her new environment and away from her parents' hypercritical gaze, she began to admit to her illness. She told Farrell she was anorexic and thought that perhaps she shouldn't run. The coach made a deal with her: if she gained weight, she could race. "That was a huge incentive for me because I love to run," says Sarah. In the first three weeks of college she gained 15 pounds, then gradually put on more weight; today she weighs 138.
Sarah relied for support on her coach and teammates and friends from the Princeton Evangelical Fellowship. She also looked to her brother and sister for help. A big part of dealing with her illness was learning to like herself and discovering that people liked her. The process, she says, wasn't easy, and there were times in both high school and college when she doubted that life was worth living.
Sarah's case demonstrates that recovering from an eating disorder can take years. Turetsky and others stress that the individual must admit there is more to the problem than the desire to control one's weight and that a full recovery demands a willingness to explore underlying causes. In wrestling with their diseases, the three women profiled here have learned that eating disorders, even when conquered, can have longer-term psychological and physical consequences.
Alicia no longer tries to please everyone, and she is comfortable about being herself and expressing her opinions. She eats healthily, and the desire to look a particular way is "not overpowering anymore." She's content with two hours of exercise a day (down from six). But she admits that a certain preoccupation with body and weight "never really leaves you." Medically, she suffers from her long bout with anorexia and bulimia: she doesn't get her period, her bones are sore, and she has unexplained chest pains. "Why did I do that to myself?" she asks.
Ten years after her illness first surfaced, Sarah is pretty much over it. "I used to think it was a disgrace, that it was shameful," she says, but now "I don't regret going through it." Dealing with anorexia made her stronger, and "When you turn something into a strength, then you're over the bad parts." A second-year medical student, she is less preoccupied with herself and no longer feels a need to be the best, but is content to be a decent human being.
Today, Deborah feels more confident and independent. She has plenty of friends and earns A's and B's. She eats healthily and exercises regularly but not obsessively. "This is the least stressed year I've had at Princeton," she says. Still, she admits, "I'd be lying if I said I wasn't concerned with my body image," and she remains angry about the toll bulimia has taken. "This disease destroyed my experience at Princeton. I missed out on so many activities that I just never had the energy or mindset to do. I will leave here with half of the experience I could have had. I won't leave college saying these were the best days of my life."
Kathryn F. Greenwood is PAW's staff writer.
FACTS ABOUT EATING DISORDERS
- More than five million Americans suffer from eating disorders.
- 5 percent of adolescent and adult women and 1 percent of men have anorexia, bulimia, or binge-eating disorders.
- 15 percent of young women have substantially disordered eating attitudes and behaviors.
- 1,000 women die each year of anorexia.
- 5 percent of college women are bulimic.
- 10 percent of female athletes suffer from eating disorders.
- 20-30 percent of female athletes have abnormal eating habits.
- 50 percent of fourth-grade girls diet because they think they're too fat.
- 1 percent of teenage girls become anorexic.
(Source: the American Anorexia/Bulimia Association, in New York City)
Binge eating is the most common clinical eating disorder. It is found in 2 percent of the general population. Binge eaters are usually overweight. Unlike bulimics, they don't purge. They are prone to medical problems associated with obesity, such as high cholesterol, high blood pressure, and diabetes. They may also suffer from guilt, shame, and depression.
bulimia sufferers typically are near normal in weight, but may have a distorted body image. They are perfectionists and high achievers who want to be accepted by others. Bulimics consume large amounts of food and then rid their bodies of the calories by vomiting, taking laxatives or diuretics, or by exercising obsessively. They are often ashamed of their eating habits. Overeating is often a reaction to anxiety, depression, anger, frustration, or loneliness. Purging sometimes acts as punishment for a binge. Episodes of binging and purging can range from once or twice a week to several times a day.
Through repeated purging, bulimics may irritate their esophagus, throat, and salivary glands, and damage the outer layer of their teeth. They may also have an electrolyte imbalance or suffer from an irregular heart rhythm, digestive problems, muscle weakness, or amenorrhea (loss of menstrual discharge). Bulimia can damage vital organs, including the liver and kidneys. In rare instances, binging may rupture the stomach.
Those suffering from anorexia tend to be model individuals. They are obedient, keep their feelings to themselves, and are often perfectionists, good students, and excellent athletes. But inside, anorexics may feel insecure and not worthy of praise. Being in control is important to them, and restricting caloric intake is one way to gain control. They intentionally starve themselves, sometimes consuming as few as 200 calories a day, and are 15 percent or more under their normal body weight. They may look emaciated but are convinced they are overweight and terrified of putting on pounds.
The medical complications associated with anorexia include amenorrhea, fatigue, skin problems, bloating, constipation, hair loss, stomach pains, kidney and liver damage, electrolyte imbalances, infertility, and depression. Starvation can damage vital organs such as the heart and brain, and it can affect an individual's ability to think rationally. Ten percent of anorexics die from the illness.
More information on eating disorders is available from the following sources:
- National Eating Disorders Organization, 6655 S. Yale Ave., Tulsa, OK 74136 (918-481-4044; www.laureate.com).
- The American Anorexia/Bulimia Association, 293 Central Park West, Suite 1R, New York, NY 10024 (212-501-8351).
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