http://www.nytimes.com/2004/04/04/n...ml?pagewanted=1

'Am I Too Fat?'
BY TINA KELLEY

Published: April 4, 2004


HITE PLAINS

THE two friends shopping at The Westchester mall figured the serious talk about dieting started about a year ago.

The two, Catherine Gray, 14, of Eastchester, and Maria Fufidio, 15, of Larchmont, say that they have tried dieting, and that they have a friend who, before she got her navel pierced, lost 10 pounds on the South Beach diet, which limits bread, potatoes and other carbohydrates.



"We go to an all-girls school," Catherine said, reciting what she said was a typical dialogue at the Ursuline School in New Rochelle:

"I think I'm going to get a bag of chips."

"I'm so fat."

"You're fat? Look at me!"

And so on.

"You see somebody say they're fat that you're bigger than, and you think you must be fat," said Catherine, who is not. "I get scared a lot with my friends." One of them is pressured by her parents and throws up after meals, she said, and eating disorders have sent "a lot of friends" of Catherine's older sister to the hospital, where she visited them.

Even as the number of obese children reaches record levels, bringing adult diseases like Type 2 diabetes to the teenager set, the national obsession with dieting has spread to younger and younger people. With dieting comes the risk of eating disorders like anorexia and bulimia.

According to studies cited by the National Eating Disorders Association, 42 percent of girls in first through third grade want to be thinner, 81 percent of 10-year-olds are afraid of being fat, and 51 percent of 9- and 10-year-old girls feel better about themselves if they are on a diet.

In many ways, this fixation on weight at ever earlier ages comes at an inopportune time physiologically. At a recent Hadassah meeting at the Woodlands Community Temple in White Plains, Dr. Marcie Schneider, the director of adolescent medicine at Greenwich Hospital, and Erica Leon, a registered dietitian, spoke about early adolescence as a time when a little bit of pudginess is necessary for proper growth, and youngsters wrestle constantly with their body image.

"I can't tell you how many kids I've seen who've been on the Atkins diet, or on the South Beach diet," Ms. Leon said, adding that overweight children who try diets can be at risk of developing eating disorders.

After the presentation, three mothers from Hartsdale who wanted to help their children avoid such issues spoke about how their young daughters are already beginning to become weight-conscious.

"My older daughter, who is 10, is starting," Elka Klarsfeld said. "She's looking in the mirror and asking, 'Is this normal?' "

Andrea Katz said, "My 7-year-old is using the word fat, but she's not crazy yet."

Ms. Klarsfeld added, "Mine comes out of the shower and says, 'Do I have a belly?' "

Ms. Katz added that it was "very comforting" to learn that children need extra body weight to grow.

Julie Stein's daughters are 5 and 9. "I think all of the kids really are aware at this point what their weight is," she said, "and you try to make them not aware."

Their concerns were confirmed by Samantha Annichiarico, 11, who was eating with her mother and brother at the Galleria mall in White Plains recently. She said she had a classmate who went to Weight Watchers.

"She said her mom goes, and her mom wanted her to go," Samantha said. She recalled first talking about dieting with her friends when they were in the fourth grade.

Dr. Schneider said that young people gain half of their adult weight in their teenage years, up to 10 to 15 pounds a year.

"They need tons of extra calories," she said, adding that fourth graders who are talking about dieting could jeopardize their ability to grow normally. "You need to gain before you grow, and that slight weight gain at the beginning of puberty is money in the bank."

"I see a lot of kids who get brought to me to lose weight who don't need to lose weight," Dr. Schneider said. "It's a focus for a lot of the parents, and becomes a focus for the kids. People talk about this stuff in elementary school, which is younger than I think it used to be.

"It's very important to make the judgment call - can this kid lose weight or afford to lose weight? It's constructive to say to the child, 'It's a stage, it'll change,' " she said. As for middle school students, she said, "They're at the peak of body image thing, and at the same time their goal in life is to be the same."

Anorexia is a mental illness in which the victim eats barely enough to survive, because her distorted thinking makes her think she is fat. Bulimia, a mental illness in which someone binges on large amounts of food, then purges it through vomiting or the abuse of laxatives, is on the rise, and is surfacing in younger and younger patients, mostly girls, said Judy Scheel, the director of the Center for Eating Disorder Recovery in Mount Kisco.


About 90 percent of victims of eating disorders are female, and often the male victims are on teams like wrestling and crew, where they must keep their weight low for competitive reasons. Dr. Scheel believes that where girls claim the eating disorder enables them to be thin, boys typically state their goal is to achieve or maintain a muscular but thin physique. The average onset for bulimia used to be 17, but to see teenagers age 14 and 15 with bulimia is common these days, Dr. Scheel said.

"Personally, I think it has to do with parenting," said Dr. Scheel, a psychotherapist who treats eating disorders using the relational model, looking at the dynamics of the patient's family. "Life is fast paced, and we have not taken a lot of time to really listen to our children, to have relationships with them. It's so much easier to deal with just the behavior, instead of the emotions." Parents may need different strategies to address such issues, she said. "What I have seen every time is a miss in the relationship, in the attachment, with parents who are consumed with how a child does, not who she is, to, at the other extreme, gross infringement and abuse,'' she said. "Or you're in a loving family, but you don't have an emotional language, you can't put a label to your feelings. No one asks how you are feeling, but, 'How's it going? What are you doing?' ''

Patients may have a hard time relating to people, she said. "By the time an eating disorder sets in, the relationship is entirely with food, and you're often starting from ground zero in regards to how to relate to someone else," she said.

Other people believe the disorders have genetic or chemical components, and many people with eating disorders respond well to anti-depressants, for example.

A certain amount of education is necessary to help young people avoid becoming obsessed with their body image.

"Teachers need to stay outside of talking about diets," Dr. Scheel said. "It's like a parent, always talking about their next diet. You have to help a child understand that if you eat healthily and exercise, your body is going to take care of itself.''

And in relatively homogenous populations, like in some Westchester schools, competition runs high. "So the young people don't really see how beautiful diversity is," she said, "and they tend to all be competing for kind of the same goals."

At Horace Greeley High School in Chappaqua one day not long ago, five girls sat huddled around a table in an art class, trying to find the right mix of words, pictures and emotions for a project about body images.

The girls, mostly sophomores around 15 or 16 years old, who had taken other art courses and had chosen to take part in this project, were making posters to be distributed in the community - in health clubs, restaurants, other schools, doctors' offices and hospitals - to explain the dangers of eating disorders.

Ali Recht had drawn a picture of a girl chained in a dungeon, but needed help finding the proper words to complete the poster. The art therapist running the class, Alison Gigl George, tried to help. "The symbol itself is very powerful," she said. "I think that says a lot about the emotional part of eating disorders, feeling chained down, the darkness."

Next to her, Casey Miller suggested, "Why don't you draw some light coming out of the window, to represent hope or something?"

At the end of the table, Madison Levitan had drawn a line of headless torsos, of various shapes and sizes, wearing shirts. She had written, in small letters, in light pencil, "Behavior is the best way to tell if someone you know has an eating disorder," and other facts.

Ms. Levitan said she remembers watching five girls sharing a salad for lunch in middle school. "There were young kids terrified of being fat, and they don't even know what fat is," she said. "People tend to assume that someone who seems happy doesn't have problems."



Ms. George, who works with the Center for Eating Disorder Recovery, said, "The imagery they're coming up with is very powerful, about the secretiveness, the feelings of isolation and the addiction component to eating disorders." She explained that people with eating disorders usually think about food 24 hours a day, seven days a week. "Food is the drug controlling them."

DR. KATHERINE A. HALMI, who runs the eating disorder program at the Westchester Division of New York-Presbyterian Hospital in White Plains, said she had also noticed an increase in younger patients. The program includes one of the country's few inpatient units for people with eating disorders, with 20 beds, serving about 350 people a year.

"In the last decade we've seen a gradual increase in children under 12," she said. "I just admitted an 11-year-old last night to our unit." Dr. Halmi's youngest patient with anorexia was only 9 years old.

"Peer pressure has a lot to do with it," said Dr. Halmi, explaining why the problems are reaching younger girls. "Some come from families who are very health-food oriented, and many have thin mothers who exercise a lot and are very preoccupied with what they're eating, or older sisters who are concerned about their appearance. Magazines aimed at teenagers contribute a lot. The biggest factor with teens and preteens is their own peers. As for how to change the peer culture, I don't have an easy answer."

The program treats its patients using cognitive behavioral therapy, which has been shown to be superior to other therapies in more than 30 randomized, controlled studies, Dr. Halmi said. Between 40 and 60 percent of bulimics are able to stop binging and purging after 20 sessions, in which the therapist teaches a rational way of thinking, and encourages the patient to use that thinking to govern her behavior, Dr. Halmi said.

ANOREXIA is more difficult to treat, and has the highest mortality rate of any psychiatric illness - 7 percent after 10 years, and 20 percent after 20 years.

"If we can get a child and family into treatment before age 18, we have around an 80 percent cure rate," she said. "If we see them when they're over 18, it's a very different outcome. The cure rate is 20 percent or less." Cure is defined as both improved symptoms and coping in a community, she said, and healthy relationships with food and with people.

She estimates that a third of her patients staying in the hospital are ones who have been readmitted, in part because insurance companies are less likely to cover the costs of a complete course of treatment, so patients are released on average after 23 days. In the 1980's, she said, the average stay was three months, and in the entire decade only six patients needed to be readmitted.

Several bills are before Congress that address the issue of eating disorders, including the Mental Health Equitable Treatment Act, in both the House and the Senate, which would provide mental health benefits comparable to medical and surgical benefits, and the Eating Disorders Awareness, Education and Prevention Act in the House, which would raise awareness of eating disorders; these bills have been referred to the appropriate committees. The Improved Nutrition and Physical Activity Act, cosponsored by Senator Hillary Rodham Clinton, includes grants for programs seeking to prevent obesity and eating disorders. It passed in the Senate and has been referred to a House subcommittee on health.

Back at The Westchester mall, Catherine and Maria may be somewhat protected from the eating disorders because they are lifelong competitive swimmers.

"We have athletic builds," Maria said. "We'll never be sticks. We look different in bikinis, compared to naturally skinny girls. We have shoulders and muscles."

Catherine said, laughing, "But it's a really good excuse for why you eat a lot."

Maria said: "I think personally, athletic bodies are better, because I am an athlete. But I think the majority of guys like really bony girls."