Unusual Anorexia

My sister and her beau were up this weekend, visiting and doing some tax-free shopping. With them both being medical types, conversation often veered to interesting maladies they'd seen or heard of lately.

Something her hospital is starting to see is people (women thus far) who've either had their stomachs stapled or bypass surgeries, who now are anorectic. These are emaciated people with lots of skin hanging from their bones, who are absolutely thrilled with how great they look since the surgery. The denial, or at least the distorted self-image, is profound. One individual they both know goes out of her way to brag to others about the surgery and recommends it to the obese people she meets. She doesn't detect the shocked looks that people quickly stifle, and is (thus far) absolutely immune to helpful advice.

Some notes about anorexia.

The word anorexia means “loss of appetite,” but this name is misleading. Anorectics—95 percent of whom are women—often have a normal appetite but because of an abnormal fear of being fat and a distorted body image, they're convinced that they're obese and refuse to eat. In most cases their weight is within—or below—acceptable limits. Anorexia is considered a psychological disorder because there is no known physical cause for the extreme weight loss associated with the condition.

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Anorexia is most likely to begin sometime between adolescence and the early 20s, but it can appear in children under the age of 10 or in women as old as 70. Although the disorder receives a great deal of publicity, it's relatively rare. For example, among teenage girls—the group at highest risk—the rate of anorexia is under 1 percent. While the disorder is most common among the middle and upper classes, it occurs in all social classes and ethnic groups.

Certain personality traits increase the risk of developing anorexia. Anorectic girls are often described as “model children” or perfectionists. Many have overcontrolling parents who are themselves fascinated by fitness and appearance. Faced with the impossible task of always being perfect, these girls discover that they can take charge of at least one aspect of their lives by exerting control over their eating and their weight.

Family background may also predispose a woman to anorexia. If you have a mother or sister with anorexia, you are more likely to have the problem than if there were no history of the disorder in your family. However, in a number of cases, there is no familial link.

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Anorexia and eating disorders are unhealthy responses to stress, painful feelings, and other problems. While the specific cause is unknown, the condition seems to stem from a combination of psychological, biological, familial, and cultural factors.

One would figure that few obese people have suffered anorexia before becoming obese (though there has been a great internet joke/photo going around showing a morbidly obese man wearing a T-shirt that says "Overcame Obesity"). Nonetheless, there may be personalities lurking within a few obese people that would over-control their eating if they could just control it in the first place. There may be others whose self-image becomes distorted as they lose weight after surgery.

A few folks truly can't control their weight because of a physiological condition (like a flawed metabolism) or medications (like some steroids). Most obese people are either addicted to food, lack sufficient self-discipline, don't have (or exercise) the necessary coping mechanisms, etc. Nobody catches obesity. However, some folks who are overweight can become depressed, gorge on comfort food and become fatter, etc. In the most morbidly obese, somebody is facilitating their obesity by providing them care and feeding. These feeders could limit the food available, but choose not to for various reasons.

Medical conditions and personal choice drive some people to get various of the surgeries that can help people lose weight without necessarily addressing what caused them to gain the weight in the first place.

Severe obesity is a chronic condition that is very difficult to treat. Surgery to promote weight loss by restricting food intake or interrupting digestive processes is an option for severely obese people. A body mass index (BMI) above 40 - which means about 100 pounds of overweight for men and about 80 pounds for women - indicates that a person is severely obese and therefore a candidate for surgery. Surgery also may be an option for people with a BMI between 35 and 40 who suffer from life-threatening cardiopulmonary problems (for example, severe sleep apnea or obesity-related heart disease) or diabetes. However, as in other treatments for obesity, successful results depend mainly on motivation and behavior.

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Two ways that surgical procedures promote weight loss are:

1. By decreasing food intake (restriction). Gastric banding, vertical-banded gastroplasty, and gastric bypass are surgeries that limit the amount of food the stomach can hold by closing off or removing parts of the stomach. These operations also delayed emptying of the stomach (gastric pouch).

2. By causing food to be poorly digested and absorbed (malabsorption). In the gastric bypass procedures, the surgeon makes a direct connection from the stomach to a lower segment of the small intestine, bypassing the duodenum, and some of the jejunum.

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Surgery to produce weight loss is a serious undertaking. Each individual should clearly understand what the proposed operation involves. Patients and physicians should carefully consider the following benefits and risks:

Benefits: Immediately following surgery, most patients lose weight rapidly and continue to do so until 18 to 24 months after the procedure. Although most patients then start to regain some of their lost weight, few regain it all. Surgery improves most obesity-related conditions. For example, in one study blood sugar levels of most obese patients with diabetes returned to normal after surgery. Nearly all patients whose blood sugar levels did not return to normal were older or had diabetes for a long time.

Risks: 10% to 20% of patients who have weight-loss operations require follow-up operations to correct complications. Abdominal hernias are the most common complications requiring follow-up surgery. Less common complications include breakdown of the staple line and stretched stomach outlets. More than one-third of obese patients who have gastric surgery develop gallstones. This can be prevented with supplemental bile salts taken for the first 6 months after surgery. Nearly 30% of patients who have weight-loss surgery develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies can be avoided if vitamin and mineral intakes are maintained. Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus.

For patients who remain severely obese after nonsurgical approaches to weight loss have failed, or for patients who have an obesity-related disease, surgery may be the best next step. But for other patients, greater efforts toward weight control, such as changes in eating habits, behavior modification, and increasing physical activity, may be more appropriate.

Why would a person who couldn't manage to control their weight through diet, exercise, pills, and/or various behavioral modifications, suddenly find the willpower to over-control their eating to the point of becoming anorectic? A couple speculations come to mind.

- Some obese folks are perfectionists who are mortified by their excess weight and inability to control it. Given surgery to augment their self-control, a few may go off the deep end and over-control themselves for fear of regaining the weight. Some may lack the ability to see themselves as anything but fat.

- Obese people (the genuinely obese, not folks weighing 20 pounds more than a supermodel with today's ever-decreasing optimum weights) can also have distorted self-images. They either don't see, or have considerable difficulty perceiving the fact that they weigh far more than the average person. Somewhere in the process of losing considerable weight after surgery, their self-image must go through a major shock. A few people may drastically overcompensate and continue to see themselves as normal when they're wasting away.

It's sometimes rather difficult for a doctor to determine what causes a person's obesity when the patient is being honest and forthrigth with them. Add some dishonesty and/or denial, and it can be well-nigh impossible to get to the root of the problem. Some forms of denial come with considerable deception...like anorectics and bulemics who will eat normally to impress or fool someone, then use various forms of purging to prevent weight gain. Some obese people put on the same show, then binge elsewhere.

A doctor (with HMO, insurer, etc.) may eventually agree to do weight loss surgery to help alleviate health problems, not realizing they are enabling a person with psychological issues to potentially do something just as or even more unhealthful after surgery. As weight loss surgeries continue to become more common, we're going to see more and more unusual "side-effects" to the surgery.

So what it the prognosis for a person with anorexia to overcome the condition and resume a normal life? First, remember that anorectics don't view themselves as sick. Some form of intervention is generally necessary, whether it be family, friends, a doctor, etc. With treatment, the following is possible (from the first link).

An estimated 50 to 70 percent of anorectics in treatment return to their normal or near­normal weight. Reaching this goal takes at least 6 months. About 15 to 20 percent will have an occasional relapse. Women who force themselves to vomit, and purge with laxatives are at highest risk for failure. They may binge intermittently during or after treatment. If you fit this description, you need to continue seeing your doctor or therapist for help and encouragement. Fifteen to 20 percent of anorectics need treatment for many years.

For those who don't try to beat the disease, the prognosis is guarded. An estimated 10 to 20 percent of anorectics die from related problems. The cause of death ranges from starvation and suicide to heart problems brought on by imbalances in the body due to excessive vomiting. Some women succumb to infections and diseases that overcome their weakened immune systems.

Treatment substantially improves the odds of survival. Among those who seek therapy, the mortality rate is only 5 percent. Recovery rates may grow even higher in coming years as researchers find better ways of fighting this very dangerous disorder.

It's sad that many obese people never stop living unhealthy lifestyles. Weight-loss surgery doesn't correct an unhealthy lifestyle, it just attempts to minimize the impacts. For the newly anorectic, they've just replaced one unhealthy lifestyle with another, and they now need a different kind of help.