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The Weight of it: the burden of eating disorders.

Recently, plus size model Robin Lawley was the victim of degrading taunts when, unbeknownst to her, an untouched photo of her in lingerie, which showed a gap between her thighs, was posted on a pro "thigh gap" Facebook page.

Insulting comments, like "pig." followed, indicating that her "thigh gap" was not large enough and she herself not thin enough. Lawley shared her response: "You sit behind a computer screen objectifying my body, judging it and insulting it, without even knowing it." The thigh gap, she said, was "just another tool of manipulation that other people are trying to use to keep me from loving my body" (Lawley, 2013).

The thigh gap is the new ideal for many who have eating disorders. On the Internet, you can find numerous Pinterest, Tumblr, and Instagram pages dedicated to showing thigh gaps. Some are titled "Iamhideous," or "bonesland." They're another example of our obsession with being thin, which can be found in every magazine, on television commercials, and on Facebook and other social networking vehicles. Those obsessed with being thin call it "Thinspiration." Millions of young girls and boys are reminded every day that their body types and images are not perfect. It is a vicious cycle--one that catches almost 24 million men and women. It's deadly, too, since eating disorders have the highest mortality rate of any mental illness (Disorders, 2014).

TOOLS OF MANIPULATION

Lawley may have said that the "thigh gap" was simply another tool of manipulation, but in the eating disorder world, a multitude of these tools exist. Pro-anorexia and pro-bulimia websites and blogs, often called "ProAna" or "ProMia" sites, prey on their victims. They extol rules for not eating, contain multiple photos of skeletal girls, and objectify the ultra thin body with statements like, "Being thin is more important than being healthy." If you want to see a photo-book's worth of thigh gaps, go on Facebook, Tumblr, and Instagram, search "Thigh gap," and up will pop hundreds of thigh gap pictures.

SOCIAL NETWORKING AND EATING DISORDERS

Now picture your daughter, niece, or friend, as she "likes," "shares," or "tags" a photo that personifies thinspiration--it becomes, in essence, says Dr. Emily Sandoz, assistant professor of psychology at the University of Louisiana at Lafayette, her endorsement and that of everyone in her social circle. This stamp of approval yields a far greater impact than any advertisement can ever have. "Imagine [if] a commercial came with a personal endorsement from fifty of your closest friends," said Sandoz. "That's impact. The thin beauty ideal is just part of the crucible that leads to harmful eating, exercise, and substance abuse to change one's body."

Since social media gives teens unprecedented access to a world of images and messages that glorify thinness, says Claire Mysko of the National Eating Disorders Association, this increases the pressure that young people feel to present themselves in a "perfect" light via social media. "I think that social media fuels the comparison and perfectionism that comes into play with so many eating disorders," said Mysko. "In a Proud2Bmel poll, 86 percent of members polled said that social media has a negative impact on their body confidence."

The research bears this out. Florida State University researcher Dr. Pamela K. Keel studied 960 female college students on their time with social media sites like Facebook. Keel found that "women who spent more time on Facebook reported a higher incidence of appearance-focused behaviors and greater eating pathology" (Keel, 2014). The same was true in a 2011 University of Haifa study. This study found that the more time girls spent on Facebook, the more they suffered from eating disorder conditions, physical dissatisfaction, negative physical self-images, and an urge to diet to lose weight (Haifa, 2011). Finally, at Harvard University, researchers found an increase in eating disorders among adolescent Fiji girls when exposed to media (Chellel, 2011). The study's author, Dr. Anne Becker, has been quoted as saying that "body images impressions can be transmitted, like a virus, through a social network to affect, second-hand, even those without direct exposure to western media" (Park, 2011).

THE TRIGGER EFFECT

Body impressions being transmitted like a virus may seem like a bold comparison, but in eating disorder communities, these images can produce a "trigger effect." While no one cause sparks an eating disorder, a trigger is defined as "a person, place, thing, event, or emotion that sets an eating disorder in place" (Disorders F. E.). In some research, eating disorders are believed to be caused by abnormal neurological circuitry and/or biochemical reactions within the control regions of the brain (Rosen, 2013). Genetics have been thought to contribute (University of California, 2010). An eating disorder can be brought on by low self-esteem or troubled personal relationships or school pressure. Even cultural norms and pressure can possibly bring on an eating disorder (NEDA). A wide range of issues can prompt an eating disorder or a relapse given the triggers that may exist on websites and social media where extreme thinness is glamorized.

CONTENT AS A TRIGGER

Eating disorders as a lifestyle choice is becoming a trend. When thinspirational content can be viewed on multiple platforms, parents and educators should be concerned. Even books can serve as possible triggers, leaving some authors cautious about how they portray the story that they want to tell.

As a recovering bulimic, Sarah Darer Littman, author of Purge, hoped that writing a novel about someone fighting to overcome bulimia would help others believe that recovery is possible. When a few book reviews listed her book as "triggering" despite the fact that it was the opposite of her intent, she was devastated. "I was extremely worried about the trigger effect [in writing the book], and had a professional at the Wilkins Center for Eating Disorders read a manuscript for the book prior to sending it to my editors for precisely that reason," said Littman. "I spoke to my therapist and she said if someone isn't ready for recovery, they will find a way to be triggered."

Laurie Halse Anderson and her book, Wintergirls, a well-known book about anorexia, has been the subject of the trigger debate. In a 2009 New York Times article, Anderson addressed the issue, stating that she, too, had shared her manuscript with experts and asked if there were things in the book that triggered unsuspecting people. In the article, she said, "What their response was was that we have a culture that glamorizes this. The docs say, Yes, the book is going to trigger people. Turning on the television triggers people; looking at billboards, going to the computer, walking past a magazine rack. But the challenge in the book, they felt I had met, was to show the entire story. There is nothing glamorous or lovely about an eating disorder. It's horror" (Parker-Pope, 2009).

Clearly, what speaks to someone often does so for different reasons. Author of Thin, Grace Bowman is a former anorexic whose eating disorder was brought on by the stress of school and the elevated expectations of her teachers and parents. Thin chronicles her journey from anorexia to wellness, covering a time, she says, when she felt that she had lost her way.

The book served, says Bowman, as a way to show "what I could do and who I was." In the end, however, it turned out to be much more, according to the author; Thin became about "speaking up" amidst all the noise, internal and external, that comes with eating disorders. "I felt that I could perhaps express some feelings which were hard to attach to words, and that if other people read those words, their feelings would feel validated and more understandable. I think it's important to understand that not everything will be helpful--the rise of pro-Ana websites aptly demonstrates that."

NEDA's Mysko agrees, saying that stories that provide specific details or tips about disordered eating behaviors, low weights, or calorie counts can be triggering so it is important that in sharing personal stories, we do so responsibly so as not to trigger others. That is why sites like Proud2Bme offer book and entertainment reviews which help to evaluate the content's trigger effect. Proud2Bme (http://proud2bme.org/) is an online community created by NEDA for teens with the goal of promoting a positive body image and healthy attitudes about food and weight.

But books overall, says Dr. Emily Sandoz "pale in comparison" to social networking content, though whether or not teens can relate to these stories really "depends on the person." "Some find it quite comforting to know they're not alone," said Sandoz. "Others find it difficult to read about something that sounds so much like their struggle. It's important that the teen connects with the work, as every spin on finding the way out of this struggle is a little different."

BEYOND THE STEREOTYPE

Traditionally, so much has been written in the research and mass media about girls and eating disorders, that we may assume that this is the only population affected by eating disorders. But as more research becomes available, we discover that they also dramatically affect boys and athletes.

Nearly one-third of young adult males use unhealthy weight control behaviors, like skipping meals, fasting, smoking, extreme exercise, vomiting, and taking laxatives (Disorders N. A., 2014). Large-scale research efforts have shown that, in the past thirty years, male body-image concerns have rapidly increased and are now at a rate that is comparable with female concerns (NEDA).

Recently, author Lois Metzger wrote a book, A Trick of the Light, highlighting boys with eating disorders. In her research, she was shocked to find that boys got eating disorders. "After that first shock, others kept coming," said Metzger, "...the fact that at least ten percent of all people with eating disorders are male (10 million in this country have eating disorders, which means one million are boys and men)." What she found is that for most boys, extreme exercise is what drives their quest toward the perfect body.

Detailing it in a Huffington Post article, she wrote, "I spoke with young men who said they barely woke up in the morning before launching into 300 sit-ups (and did 500 later in the day and another 300 before bed.) If they ate at all, it was trace amounts. They also ran for miles every afternoon after school. If they couldn't go out and run, because the weather was bad or their parents wouldn't let them leave the house, they ran up and down stairs thousands of times. If they were forbidden to exercise, they did jumping jacks in the shower. They worked out even when beyond exhausted, famished to the point of fainting, or in excruciating pain" (Metzger, 2013).

In Metzger's book, fifteen-year-old Mike has a voice inside his head, an anorexic voice, as Metzger calls it. The voice dictates what Mike tells his parents, turns him against his friends, and pushes him past natural endurance. It tells him to starve himself. During her research, Metzger found that this insidious voice kept coming up over and over again.

"It's the voice in someone's head that can twist logic better than the most skillful lawyer," said Metzger, "... the voice that is controlling, unyielding, always right, never wrong, with the promises of achieving the perfect body if only you will listen, and scolding and demeaning, if you don't." Whereas the voice for girls is focused on thinness, for boys, says Metzger, it is focused on fitness, strength, and building muscle. "Ironically, while girls want to get thin and boys want to get a six-pack or tight abs, they can both end up looking horrifically skeletal, not beautiful, not manly."

Fitness and competition are key components for athletes, so it is easy to see why this group may be at risk for eating disorders. In fact, there are significantly higher rates of eating disorders found in elite athletes--20 percent--than in a female control group. A comparison of psychological profiles of athletes and those who have anorexia found that common factors included perfectionism, competitiveness, repetitive exercise routines, body image distortion, and preoccupation with diet and weight. Studies distinguish between judged sports versus refereed sports, as well as for aesthetic sports like gymnastics, ballet, and figure skating, which have the highest risk factor (NEDA).

During her research, Lois Metzger spoke with Dan Gable, a wrestling coach at University of Iowa. He told her that "wrestlers believe in 'mind over body' and that they are indestructible." With a long history of using extreme measures to "make weight," wrestlers have been known to run in sweatsuits, fast, and do extreme workouts to lose that pound or two to qualify for their wrestling match. In one case, a college student tried to lose seventeen pounds to fit into a 150-pound weight class, says Metzger. "He worked out for two hours in a rubber suit in a 92 degree room, and died of kidney failure and heart malfunction."

As is true of wrestlers, the reason why athletes are so vulnerable is because their bodies are constantly being evaluated, says Sandoz. "Evaluation from themselves, their coaches, their teammates, even random fans," said Sandoz. "In addition, many are encouraged to do whatever is necessary to get their body where it needs to be. This can easily translate into unhealthy eating." Importantly, since athletes are at a higher risk for eating disorders, says Mysko, coaches and educators can play a central role in helping their athletes resist the pressures of competition. "The NEDA offers a downloadable toolkit for coaches," said Mysko.

WHAT TO DO?

As educators, we are shocked that these disorders affect our students and are surprised how well they can keep it hidden. We wonder how it is possible that social networking, media, and the idea of a perfect body has been so ingrained in our psyche, but it has. We see it everyday. The question becomes, What can we do to spread the word to help a teen in trouble or educate our students and colleagues about eating disorders and body images issues?

First, if we think that a student is having eating issues, we can look for possible indications. Signs of an anorexic disorder may include wearing oversized clothing, reading fitness and health magazines, weighing oneself several times a day, repeatedly touching one's stomach or arms, feeling the amount of fat under one's chin, and/or complaints of feeling fat. If you have observed this behavior, consider sharing your concern with the student's counselor, since they are often more knowledgable about these issues (Bardick, 2001).

Signs of a bulimic eating disorder are much more difficult to identify, since bulimics often maintain a normal weight. Their behavior is frequently practiced in secret, because with it comes feelings of disgust and shame (NIH). Sarah Darer Littman found, in her experience as a recovered bulimic, that bulimia sufferers often try to keep up a strong front under tremendous pressure. "But if you see someone who is having a difficult time and consistently disappears to the bathroom after eating, that's something to look out for."

We can offer the help that we are experienced to provide; a variety of books, websites, blogs, and other materials exist to share with our students. Recommending these materials comes with a cautious caveat, but the most important aspect is, says Emily Sandoz, that the teen connects with the work, since "every spin on finding the way out of this struggle is a little different."

As Sandoz says, connecting with teens means that educators need to be thoughtful when recommending materials. Books like Metzger's A Trick of the Light, or Sherry Shahan's book, Skin and Bones offer strong male protagonists. Bev Mattocks's Boys and Anorexia blog shares her experiences with her son's anorexia. For selections that address obsesity, social networking, and emotional eating, Kelly Barson's 45 Pounds (More or Less) and Erin Jade Lange's Butter, offer unique takes on these subjects.

For nonfiction, Lois Metzger relied upon James Lock and Daniel le Grange's book, Help Your Teenager Beat an Eating Disorder, and Carolyn Costin's The Eating Disorder Sourcebook. Emily Sandoz's book, The Mindfulness and Acceptance Workbook for Bulimia, is a workbook format. Eating disorder blogs from the Eating Disorders Coalition and the Cleveland Center for Eating Disorders (Healthline, 2013) are other good options. For basic information, The National Eating Disorders Association and National Association of Anorexia Nervosa and Associated Disorders share valuable factual information.

Finally, we can add eating disorder programming for teens, parents, and fellow educators to our calendars. Recently, teen librarian Cheryl Capitani of the New Canaan Library, in collaboration with New Canaan's Silver Hill Hospital, gave a program on eating disorders. Although selling it was difficult, Capitani said that discussions were very fruitful and they will definitely do it again, saying that there is "an undeniable value" to offering them to patrons.

As educators, it is essential to remember that these are complicated problems where one size doesn't fit all. Our role may be as diverse as alerting school counselors if we are concerned or just offering a book that we know will help. Whatever it may be, being informed and understanding that it impacts the population right in front of us is a good start, no matter what we do. ?

BOOKS ABOUT EATING DISORDERS

Anderson, Laurie Halse. Wintergirls. Viking, 2009. 304p. $17.99. 978-0-670-0111-0. VOYA April 2009. 4Q 4P M J S

Barson, K.A. 45 Pounds (More or Less). Viking, 2013. 264p. $16.99. 978-0-670-78482-0. VOYA June 2013. 5Q 5P S

Bowman, Grace. Thin. Penguin, 2008. 304p. $15. Trade pb. 9780-1-4-102284-0.

Costin, Carolyn. The Eating Disorders Sourcebook, 3rd Edition. McGraw Hill, 2006. 336p. $17.95 Trade pb. 978-0-07147685-0.

Lange, Erin Jade. Butter. Bloomsbury, 2012. 304p. $16.99. 978-1-59990-780-2. VOYA October 2012. 5Q 5P J S

Littman, Sarah Darer. Purge. Scholastic, 2009. 240p. $16.99. 978-0-545-05235-1. VOYA October 2009. 4Q 4P J S

Lock, James, and Danielle LeGrange. Help Your Teenager Beat an Eating Disorder. Guilford, 2005. 304p. $18.95 Trade pb. 978-1-57230-908-1.

Metzger, Lois. A Trick of the Light. Balzer+Bray/Harper Collins, 2013. 196p. $17.99. 978-0-06-213308-3. VOYA August 2013. 4Q 4P S

Sandoz, PhD, Emily, Kelly Wilson, and Troy DuFrene. The Mindfulness and Acceptance Workbook for Bulimia: A Guide to Breaking Free from Bulimia Using Acceptance and Commitment Therapy. New Harbinger, 2011. 152p. $21.95. 978-1-57224-735-2.

Shahan, Sherry. Skin and Bones. Whitman, 2014. $16.99. 978-08075-7397-6. VOYA February 2014. 2Q 2P S

RESOURCES

Bardick, A. D. (2001, December). "Eating Disorder Intervention, Prevention, and Treatment: Recommendations for School Counselors." Professional School Counseling, p. 168.

Chellel, K. (2011, January 5). "Second-hand Television Exposure Linked to Eating Disorders." Retrieved from Harvard University Medical School: http://hms.harvard.edu/news/second-hand-television-exposure-linked-eating-disorders-1-5-11

Disorders, F. E. (n.d.). "Eating Disorders Glossary." Retrieved from FEAST: http://glossary.feast-ed.org/5-psychology-and-therapies/triggers

Disorders, N. A. (2014). "Eating Disorders Statistics." Retrieved from ANAD: http://www.anad.org/get-information/about-eating-disorders/eatingdisorders-statistics/

Haifa, U. o. (2011, February 7). "Facebook Users More Prone to Developing Eating Disorders." Retrieved from Science Daily: http://www.sciencedaily. com/releases/2011/02/110207091754.htm

Healthline. (2013). "Healthline." Retrieved from National Health Institute: http://www.healthline.eom/health-sUdeshow/best-eating-disorders-blogs#l

Keel, P. A. (2014, January 24). "International Journal of Eating Disorders." Retrieved from Wiley Online Library: http://onlinelibrary.wiley.com/ doi/10.1002/eat.22254/abstract

Lawley, R. (2013, October 28). "Why the Dangerous 'Thigh Gap' Trend Makes Me Mad." The Daily Beast.

Metzger, L. (2013, September 6). "What I've Learned about Eating Disorders and Teenage Boys." Retrieved from HuffPost Healthy Living: http:/Zwww. huffmgtonpost.com/lois-metzger/eating-disorders-in-teenage-boys_b_3805176. html

NEDA. (n.d.). "Factors That May Contribute to Eating Disorders." Retrieved from National Eating Disorders Association: http://www. nationaleatingdisorders.org/factors-may-contribute-eating-disorders

NEDA. (n.d.). "Statistics on Males and Eating Disorders." Retrieved from NEDA: http://www.nationaleatingdisorders.org/statistics-males-and-eating-disorders

NIH. (n.d.). "National Institute of Mental Health." Retrieved from Eating Disorders: http://www.nimh.nih.gov/health/publications/eating-disorders/ index.shtml

Park, A. (2011, January 7). "How Social Networks Spread Eating Disorders." Retrieved from Time Health & Family: http://healthland.time. com/2011/01/07/how-social-networks-spread-eating-disorders/

Parker-Pope, T. (2009, May 11). "The Troubling Allure of Eating-Disorder Books." Retrieved from NY Times Blogs: http://well.bhgs.nytimes. com/2009/05/ll/the-troubling-allure-of-eating-disorder-books/?_php=true&_ type=blogs&_r=0

Rosen, M. (2013). "The Anorexic Brain: Neuroimaging Improves Understanding of Eating Disorders." Science News, 20-24.

University of California, S. D. (2010). "Price Foundation Candidate Gene Project." Retrieved from Eating Disorders Center for Treatment and Research: http://eatingdisorders.ucsd.edu/research/genetics/

INTERVIEWS

Claire Mysko. Email interview. March 5, 2014.

Emily Sandoz. Email interview. February 26, 2014.

Lois Metzger. Email interview. March 7, 2014.

Grace Bowman. Email interview. March 10, 2014.

Sarah Darer Littman. Email interview. March 9, 2014.

Rebecca A. Hill is a librarian and freelance writer. She writes on library, literacy, and other education issues and has been published in the American Library Association's Book Links, Middle Ground magazine, School Family Media, and other publications.
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