Numbers Game

Posted on 12. Dec, 2010 by in Features

Alex knows how many calories are in an egg. She knows how many calories are in a yolk, and how many are in the white. “That’s something I will know for the rest of my life,” she said. “That’s a raw fact. That’s like three times three for me.”

Every bite adds up. Heeseung Kim

The number of calories is only one side of the equation, though. The number of pounds is the other, and for a while, Alex wasn’t the only one closely tracking Alex’s body weight. Yale requires some students with abnormally low body weights to present themselves at Student Medicine once a week to be weighed. Students whose weights do not increase are asked to leave the school for medical reasons. Alex was weighed once a week when she was a freshman. At the clinic, she would list what she had eaten that week on a form, though not always truthfully, urinate in a cup so she couldn’t water-load to hide weight loss, and change into a paper gown so she couldn’t hide weights in the pockets of her clothes. Then she would step onto the scale.

For me, a young adult male of average height and weight, it was hard to see why the school would consider treating Alex’s case with such draconian severity. In a society obsessed with food, what makes these particular students’ obsession with food so dangerous? And I was taken aback when Alex, who on the whole seems healthy and perfectly sane, revealed she could still recite caloric contents for so many foods. Anorexia left a kind of scar on Alex’s mind; for just about every food she has eaten, the disease carved a number into her memory.

She had mentioned earlier that when most people hear about someone with an eating disorder, they want to ask, “Why can’t she just go eat a hamburger?” not realizing how little these mental illnesses have to do with the food itself. It’s the same question parents and friends want to ask when they first confront one of these illnesses—the  simple, naïve, and desperate question: Why can’t you just eat?

For God’s sake, just eat.

Splitting pears. Heeseung Kim

Alex is unusual in that she may be exactly what many people think of when they think of a girl with anorexia. (She has also been through periods of bulimia, exercise bulimia, and binge eating.) In high school, she was a valedictorian and a cheerleader. “In Texas, we do cheerleading the way people do piano lessons,” she says. She started in fourth grade. Cheer was a class in high school, in addition to practice after school. She was also on a competitive cheerleading team unaffiliated with the school. “I was expected to be a certain way,” she says. The uniforms for her competitive cheer squad had low necklines and were cut just above the girls’ thighs.

As I have done with the names of the other students in this piece, I’ve changed Alex’s name to write about her eating disorder, which began to develop when she was in tenth grade. In eleventh grade, her cheer coach told her she couldn’t continue at her low weight, but Alex didn’t make any effort to change her eating patterns. So when she came to Yale, the weekly weigh-ins made her eating unpredictable. “Numbers just make you more paranoid. If you gain a pound, you don’t see it as a good thing,” she said. “Unless you’ve made the decision to get better, you’re really pissed at yourself.”

If Alex’s weight increased during a week, she would be more restrictive in the following week. Yet Alex wanted to stay at Yale, so when she lost weight, she would binge. “It’s the scariest situation,” she told me. “You just can’t stop.”

Alex’s case shows what mandatory weigh-ins can and can’t accomplish. Yale can effectively force students to accept treatment by offering them a choice between going to the clinic and going home. But since nobody can begin to recover from an eating disorder until he or she has decided that she wants to be healthy, the school can’t force anyone to be healthy. All the system can really do is prevent hospitalizations.

When I wrote Yale Psychiatrist Dr. Carole Goldberg to ask about the weigh-ins, she responded simply, “Weigh-ins are necessary when someone’s weight is at a dangerous/life threatening BMI,” and added that students have the choice whether they want to see their body weights, in other words whether they step on the scale forward or backward. Alex noted that the choice is never made clear to students who are coming in to be weighed. She adds that if a person with an eating disorder hasn’t decided they want to improve, they won’t ask for their weight to remain hidden, and even if they are given the choice, they might still want to know, Alex explained. A better policy might be to require Student Medicine staff to explicitly offer every student being weighed the choice of seeing her weight or even to disallow her from seeing her weight.

Alex is still alarmingly thin, and food can still be difficult for her. She is barely above the school’s minimum BMI right now, she confides. “I’ve been above and below the line so many times, I can’t count.”

A single pomegranate seed. Heeseung Kim

It is almost impossible for a person who has not experienced an eating disorder to understand what it is like to suffer from one. Try imagining, I’m told, that someone follows you around everywhere you go, berating you for what she sees as your shortcomings. This person also talks incessantly about food, telling you how many calories are in the food around you, calculating how many you’ve eaten, multiplying calories by servings, adding up meals and subtracting how long you’ve exercised and how many steps you’ve taken. She’s exact. She will certainly remind you about things like mayonnaise on a sandwich or the milk and sugar in your coffee (although people with eating disorders tend to drink their coffee black).

Or imagine that not eating for you is like cigarettes for a chain-smoker; that vomiting puts you in a good mood. Imagine that you have suppressed your body’s ability to feel hunger and satiety, that food is no longer food for you. A longtime family friend offers you a plate of homemade cookies, and when you take one you pick it up as you would pick up a spider. When you eat it you pledge, “This is the last cookie I will ever eat in my life.” When you wake up in the morning on a day when you know you won’t have time to work out, you start figuring out how you will eat less to make up for it. You never weigh yourself, because the last time you weighed yourself the amount of weight you had gained was so terrifying you didn’t leave your room for four days, nauseated with despair. It’s easier not to go to social gatherings than to go and refuse food that’s offered to you, and it’s easier not to talk to anyone than to have to answer questions about what you’re doing to yourself, so you spend a lot of time on your own. You hide from your roommates so they don’t notice you coming back from your second trip to the gym in a day. You start measuring bananas to make sure they aren’t longer than the standard size for bananas used in calculating caloric intake.

Unpeeling an orange. Heeseung Kim

Measuring bananas is important, because there are always numbers in your head. Calories, grams, cups, servings, steps, miles, bites, pounds. Smaller numbers are good and exciting; larger numbers are frightening. If it seems as though everything you know is falling apart, numbers are something you can control. They reduce all your problems into one problem, like a math problem with one right answer, and losing weight is like solving the problem and getting the right answer.

That was the mindset of Aimee Liu, a junior at Yale in 1974, when eating lunch with Jen, a Political Science-African Studies double major, and Lia, an Economics major. That day, Liu remembers in her 2007 bestseller Gaining: The Truth About Life After Eating Disorders, Jen and Lia, both seniors, were planning out their lives after graduation.

“As Lia chewed her tuna fish sandwich,” Liu writes, “I was calculating that one bite contained fifty calories, five grams of carbohydrates, and four grams of fat. The mayonnaise made the waxed paper glint in the bright sun. I tried to imagine not noticing the oil, not thinking about the water weight the salt from the Fritos would cause. I tried to understand how Lia could ignore what she was putting into her mouth and focus on her future.”

This was in 1974, although it might as well have been written in 2010. Liu was in the third class of women to graduate from Yale. “There were a lot of us walking around campus with anorexia, and a lot of us, less obviously, with bulimia,” she told me. “It appalls me now to look back on what I squandered when I was at Yale. The eating disorder had really stunted my brain. I couldn’t read properly, I couldn’t think properly, because my brain was starved.”

Liu has spent much of the intervening decades learning and writing about eating disorders. She asked me to make sure I mentioned the book in this article, since she feels that it offers useful advice on how to recover or help someone recover from an eating disorder. Her own recovery took several years, and began, as she recalls in Gaining, with a love affair. In her junior year, she met a graduate student studying sculpture. People with eating disorders, she told me, need “friends, lovers, who are not judgmental, who have the patience to look past the eating disorder and really separate the person from the condition, who treat food as an expression of love and affection and acceptance,” who can help someone learn not to see food as being right or wrong.

An estimated 11 percent of college students suffer from an eating disorder (most of whom are women—there are about seven women with anorexia or bulimia nervosa for every man). Yet there are at least two reasons why students at a school such as Yale might be more likely to develop eating disorders, especially anorexia. There’s a correlation between anorexia and personality traits that could make an anorexic high school senior more likely to attend a selective college. “Obsessional perfectionists are at increased risk for anorexia nervosa, so vulnerable individuals are often high achievers academically,” Dr. Angela Guarda, director of the Eating Disorders Program at the Johns Hopkins Hospital, explained in an email. Other researchers noted that the stress of leaving home for the first time, which brings on eating disorders in many predisposed freshmen, might be compounded by the intensely competitive environment at a school such as Yale.

Eating disorders were not yet recognized as mental illnesses when Liu was at Yale. “There wasn’t any treatment,” she said. “I went to DUH (Department of University Health) and actually tried to get some help, and instead, people just said, you need to gain a little weight. Period. End of story.”

I briefly described Alex’s weigh-ins for Liu. “The weighing thing is really tricky—it’s really really tricky, because it’s not the only barometer of health, and it’s such a humiliating exercise for people to go through, especially if they’re singling out certain people for this treatment,” she said.“It doesn’t sound like a great policy to me, but on the other hand I don’t have an easy solution or an alternative.”

Symptoms of anorexia are commonly described in medical literature of the 17th, 18th, and 19th centuries, but physicians then did not distinguish eating disorders from other psychological conditions. They termed these behaviors melancholy, hysteria, or something equally nonspecific and chalked them up to the mysterious and unpredictable anatomies of women.

But as historian Rudoph M. Bell argues in his book Holy Anorexia, an epidemic which can now be identified as anorexia nervosa struck European convents in the late medieval period. The sisters aspired to an ideal of holiness as some anorexic women of today aspire to an ideal of beauty. According to Bell’s research, more than half of the 170 female saints who lived in Europe since the year 1200 and for whom a reliable historical record exists “displayed clear signs of anorexia.”

St. Catherine of Siena, born in that city in 1347, was “the classic anorexic,” in Liu’s words. She was also an active and influential figure during her life, tirelessly caring for the sick in convent hospitals and helping to persuade Pope Gregory XI to return the papacy to Rome from Avignon, France, where the papal court had lain since 1309. Her restrained eating habits were also well known, however, and many, including her family, thought she was possessed or a witch.

No one really understands the combination of social, psychological, and genetic or chemical factors that cause eating disorders. But fasting in Catherine’s day suggests those mechanisms predate our time.

“I think this campus has a terrible problem, and I think people need to talk about it,” Tonya had said at the end of our first meeting. We had been talking outside a coffee shop, smartly dressed graduate students and older, professorial couples with foreign accents going by on the sidewalk. The noise of construction equipment came from across the street, where a university building was undergoing renovations. It was a warm fall day, the leaves just beginning to turn. At one point, someone Tonya knew to have an eating disorder walked past us. “This is not the best place to be in recovery,” Tonya remarked.

Eating disorders, particularly anorexia, can make people viciously competitive, driven to look thinner than the thinnest of their peers, to push unhealthy habits to further extremes. At Yale, this aspect of the illness has created a kind of invisible sisterhood whose members are often engaged in unspoken and potentially dangerous contests with one another. Alex called it “a gym cult.” “You’re running on the elliptical next to a girl,” she said, “and you’re like, ‘Her thighs are smaller, but oh, my calves are smaller, so it’s O.K.’ It’s a sick, sadistic competition, because really, you’re hurting yourself.”

Today, Tonya is waiting for me just inside the cavernous maw of Payne Whitney, Yale’s castle of a gymnasium, at the base of its nine-storey tower. “So how do you envision this working?” she asks after we’ve gone inside. I didn’t really have a plan. I just wanted to follow Tonya to the gym and work out with someone who works out obsessively.

“I just have to say,” she goes on, “cardio is the most solitary thing I do.”

Tonya’s symptoms, overexercise and daily alternation between binges and periods of restriction when she was in high school, fall into the category psychologists call “eating disorder not otherwise specified,” or EDNOS. She is healthier now than she was then, but she still counts calories obsessively, and she had recently gone to the gym at 10:30 at night because she was feeling anxious. After working out, she felt better.

“I can never look in the mirror and know how I really look, because I can’t trust anything about my mind,” she had told me. When she looks at her abdomen in the mirror, “probably 85 percent of the time it’s this gross cellulity mass of disgustingness. I know that can’t be true—physically it just can’t be true.”

She has spent too much time in the gym for it to be true, and after we’ve taken the elevator to the fitness center on the fourth floor, I also wonder how she could ever think that it could be true. She walks past me toward the treadmills—her body is muscular and lean. “For people I know who have eating disorders, it’s not about being thin or fit,” Tonya told me. She swam for ten years and played field hockey in high school, so she was always in good shape. She’s never looked thin, she told me (“I have a lot of muscle mass—thank God, frankly, because I would have been dead”) but I can’t imagine her ever looking fat either.

She talks rapidly, and I usually have to interrupt her if I want to ask her a question. “This is what it’s like when my eating disorder is in the driver’s seat,” she once apologized.“Talking so fast and from so many angles I want to scream. Instead I just work out or deprive myself of food.” When Tonya says something darkly self-deprecating like that, it’s hard to know how to respond. On the one hand, her jokes can be very funny, and you have the feeling she’d like you to laugh at them. But you also know that she’s joking because it’s a way of dealing with what’s happened to her, with what she’s done to herself.

I step onto a treadmill beside her, and glancing at the numbers on her display, set the speed to one or two tenths of a mile below hers. I’m reasonably fit, but I have no desire to race Tonya, since I’m sure she would win. Besides, in the back of my mind there’s a story she told me about a trip to the gym in her residential college one day last spring.

The gym was busy, and there was only one treadmill free. Tonya left her wallet and keys on the treadmill to reserve it and went to the bathroom, but when she returned another girl had moved her things off the treadmill and was running on it. The other girl was also struggling with an eating disorder, Tonya knew, by that frightening instinct many people with eating disorders seem to have for picking out others with similar problems. Tonya and the girl on the treadmill began to argue and scream at each other. Later, Tonya wrote an enraged email to her therapist and nutritionist. “I hope she falls down five flights of stairs, breaks both legs, and gains 50 pounds,” she remembers telling them. “That’s how I felt,” she tells me.

I look over at a girl stretching on the mats next to us. She is very flexible and bony, and I find myself wondering about her, though I wouldn’t have given her a second thought before I began reporting this article. I steal glances at her elbows, her hair, the tendons in her neck, and the knock of her knees, looking for anything abnormal. That’s not how Tonya would see her, I realize, even if Tonya were still as sick as she once was. Would Tonya instead have admired the bones in her calves, the self-denial in her drawn cheeks? I can only imagine.

The gym is strangely quiet. It’s a big room, and any human noise is lost in the whirr of the ventilation and the machines. The girl on the mat leaves, and a while later, after Tonya has gone for a spin on one of the stationary bikes, she and I are on the treadmills again, cooling down.

“You caught me on an abnormally good workout day,” she says. “I’m not, like, dying.”

“I am, a little bit,” I admit.

The two of us run through some sit-ups and push-ups and get ready to go. “I have mountains of work,” Tonya says. The life of a Yale student: reading and studying until late tonight, at work until 1 tomorrow afternoon, and class at 2:30 until evening. We walk down rows of people on treadmills, ellipticals, stair-steppers, stationary bikes, recumbent bikes, and rowing machines. Is this an especially healthy subset of the Yale population, or one that is peculiarly diseased?

One more thing, Tonya offers, as we descend the stairs down to the main floor. She takes the stairs down from the fourth floor fitness center, but she always takes the elevator up. “That’s my concession to myself, that I don’t have to do everything. Basically, I’m weird.”

I tell Tonya she seems quite healthy to me. She does, especially given some of the stories I’ve heard about people who are very ill.

“I’m working on it. I’m working on it, and that’s what counts.”

It can be difficult not to feel in awe of someone like Tonya and her inhuman routine of workouts and restricted eating. As Kelly put it to me, “Anorexia makes you superhuman in ways that eventually make you die.”

A year ago last summer, Kelly decided to go for a run. She came home tired out after about five minutes. The next day, she ran for fifteen minutes. The day after that, she ran for three miles. She ran every day after that, adding other exercises to her routine and beginning to restrict her eating. She was anorexic before leaving for Europe for a term abroad at the end of the summer.

Much of the time she was sick she does not remember. “It feels like a different person,” she told me. “In a lot of ways I think it was. It is.”

Kelly remembers announcing to her friends one day in high school that she could never become anorexic because she would be too hungry. “I was a dorky kid who watched the Food Network,” she told me. As a teenager, she would throw fancy dinner parties at her house for her friends on her birthday, cooking and baking all day. Her mother was the sous-chef and her father, with a towel over his arm, was a waiter. I asked Kelly about her favorite dishes to prepare: squash soup, handmade gnocchi with homemade pesto and tomatoes and red peppers, crème caramels, trifles, berry compotes and coulis. “I loved macerating berries in alcohol. That was one of my favorite things to do.” In fact, many people who suffer from eating disorders loved to cook as children or become fascinated by cooking, cookbooks, and cooking shows, perhaps as a way of vicariously enjoying food.

Now, Kelly is earnest and cheerful and deliberately, exaggeratedly sarcastic (“Oh, that’s interesting!”). When she came home from Europe in the middle of her program there, almost exactly a year before I met her, she was lifeless. Her physician explained to her family that her brain had enough energy for breathing and walking and not much else.

Kelly was able to return to Yale in time for the start of the spring term. Compared to many students here who have suffered from eating disorders for years, Kelly thinks she’s fortunate. Her recovery is indeed impressive. “This was a real disease and I needed to make it better,” she said. “It’s not just a condition, but a malfunction, and I could correct it.” She did.

“I am a smart person. I know that not eating is not a smart idea,” she laughed.

I met Kelly’s parents the day they came to Yale to see her last a cappella concert, where they sat a few rows in front of me, her mother watching the show through her digital camera, even though the group records all its shows with professional equipment. Kelly is an alto. She had a cold that afternoon, but couldn’t bear to miss her final show. She soloed on the closing medley, one hand in the air, wagging her finger at the audience. Sass is the only word for what Kelly has on stage. “Thanks so much for coming,” she told the audience as the singers continued behind her. In a moment the song was over, someone gave Kelly a bouquet for her last performance, and the lights came on.

A scene like that—the hall’s elaborate oaken ceiling disappearing into shadow near its high peak, Kelly in the center of a series of group embraces on stage—belongs in a Yale College admissions video. But the materials Yale sends out to tens of thousands of prospective freshmen each year do not include the stories of those students for whom an eating disorder is another central component of the liberal-arts college experience.

By the time St. Catherine of Siena was seven, she was throwing meat under the table when her mother tried to force her to eat. This may not yet have been symptomatic of an eating disorder, but Catherine was almost certainly anorexic by her adolescence, when mother wanted her to marry her sister’s widower and Catherine rebelled by fasting continually. Her family sent her to their priest, who told Catherine to eat once a day. She did eat, but she would always vomit afterward. This continued throughout her life and even after she joined a convent—others would urge her to eat, and when she ate she would purge, gagging herself with a twig of fennel or a goose feather. (She continued to take communion.)

Catherine starved to death at thirty three. Anorexia nervosa, that very real demon born of the human mind’s imperfections, is the deadliest psychiatric illness. Women with anorexia are twelve times more likely to die young than women without the disease. By the sixteenth century, asceticism was heresy, and the Church was burning anorexics at the stake.

A few weeks after I first met Alex, I had been taught quite a bit about eating disorders, but there was still something I wanted to try for myself. I had written Kelly an email after she had told me about a kind of tofu-based noodle with no carbohydrates called shirataki (“because pasta—pasta has actual sustenance! You can’t have that.”). She replied with a link to a website offering women recipes with very-low-calorie ingredients. According to the site’s author, Lisa Lillien, the noodles are “an AMAZING pasta swap… as long as you prepare them right. It’s really important to rinse them, drain them, and dry them. Sure they’re a little high maintenance, but they’re totally worth it. I mean—HELLO!?—they have only 20 calories per serving!!!”

I find the noodles at a small grocery store around the corner from my dormitory where Kelly directed me, along with a small wheel of low-calorie cheese that she suggested in her email “(which, P.S., if you have only 35 calories YOU ARE NOT CHEESE).” While the clerk swipes the noodles, cheese, and a can of tomato sauce, I ask if the shirataki are popular. He restocks them every week.

I’ve arranged to use my friends’ kitchen this evening. Before the apartment’s tenants leave me with a key, my notebook, and my very-low-calorie food, I have to ask one of them to look up a word for me. Next to the logo of Lillien’s web site indicating her endorsement, the instructions on the back of the packages of the shirataki read, “Parboil for 2-3 minutes to remove authentic aroma. Dry very well.” To parboil just means to boil partially, although, according to Wikipedia, “Parboiling can also be used for removing poisonous or foul-tasting substances from foodstuffs.”

The noodles are packaged in liquid and need to be drained first in a colander in the sink. They are weirdly white and gelatinous, sitting in the colander, but otherwise unremarkable. I lift a forkful to my nose to see if I can pick up the “authentic aroma.”

It’s certainly there—faint, but entirely nauseating, like rotting fish, but sweeter. The noodles go into a pot of boiling water, and the smell fills the kitchen for a few moments before dissipating. I let them parboil longer than the recommended two to three minutes to be safe. It’s not long enough to cook them, though, and it’s now apparent to me that the noodles must be edible directly out of the package and that boiling is only necessary to eliminate the smell. After straining, rinsing, and drying, I throw some of the noodles on a plate, ladle tomato sauce on top, and sit down.

The sauce is too red, the noodles are too white. And there is still something sickly sweet, papery, and foul about the smell—I feel my gag reflex when I raise my fork to my mouth. Kelly definitely didn’t warn me about this. The noodles have no flavor, though. Apparently shirataki, like some other Asian foods, smells much worse than it tastes. Except that when you bite the noodles with your molars as you would pasta, they squish but don’t quite come apart. You have to slurp them down your throat or chew for a longer time than feels comfortable.

The second course is the “horribly fake alfredo” Kelly mentioned in her email, made with the cheese that is not cheese. The noodles don’t smell as much, presumably since they’ve had a little more time to dry. But the cheese tastes just a little sharper than cheese should. It’s a chemical flavor. And you’d never know how much flavor plain pasta has unless you were to try shirataki.

It’s very filling. Since I’m not anorexic, I made sure to eat a healthy dinner before coming here, but I should have listened more carefully to Kelly—the noodles don’t have many calories, but they take up space in your stomach. It’s like drinking too much water.

A week after her concert, Kelly and I had agreed to meet up outside of Froyo World (110 calories per four-ounce serving, I later learned). But there was a bit of a chill in the autumn air that afternoon, and Kelly was still getting over her cold, so instead we decided to walk a couple of blocks to a bookstore and café where we had met before. Kelly apologized and suggested the two of us have dinner sometime when she was feeling better. Not wanting frozen yogurt because you have a cold shouldn’t be anything to apologize for. “If I were a normal human being, I would just do what I wanted,” she said.

As long as she can’t without second-guessing herself, she hasn’t recovered entirely. “It’s not something that just goes away,” she told me. Her boyfriend had been asking about her eating since she’d come down with the cold. That week she had also asked her Biological Anthropology T.A. to be excused from an assignment on human diet that involved keeping track of everything she ate for several days. “I can remember being so normal, and then this block of crazy, and now I’m here.”

Few people would call students at a school such as Yale or the environment in which we work and live “normal,” but that does not mean we all have eating disorders. When Kelly says she is not normal, she means it differently. Yale students are more susceptible than the general population to the common cold, because we don’t sleep enough and spend much of our time in close proximity to one another. That does not mean a person with a disease is healthy, that there is nothing that can be done to prevent the spread of illness, or that people who are sick can never get well. That much is true of eating disorders as well as colds.

Like Kelly’s, my nose was running earlier this fall, too. But I have never had an eating disorder, and no matter how much I learn about obsession and addiction, about prevention and treatment or about the complicated arithmetic that is Kelly’s illness, I will never really be able to understand what she has experienced. Tomorrow morning I can eat something nutritious and tasty and enjoy it, as I will at lunch and dinner and at breakfast the next day.

For some, every meal is as repulsive as the one I tried.

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2 Responses to “Numbers Game”

  1. Becky Henry says:

    Hi Max,
    Thank you for a very thorough, well thought out and informative article! Great information for all of us to know about to help those with eating disorders. As someone who spends her life assisting the families of those with eating disorders it thrills me to see such an informed, compassionate perspective.
    Becky Henry
    http://www.hopenetwork.info

  2. Tom Brown says:

    The admiration for the physical charms of his interviewees betrayed by the writer ought to be moderated. People with eating disorders don’t have eating disorders because of the “intensity” it brings — though eating disorders brings people to extremes, it doesn’t leave them feeling better about themselves; they have them because of warped self-images, in no small part encouraged (mostly unconsciously) by the opposite sex. In other words, people have eating disorders because they want the opposite sex to talk to them. I wonder if the attention paid to them by this article may slow down the victims’ recovery, since being anorexic is paying them dividends in the attention department. To draw a comparison between eating disorders and any kind of competition (even a “vicious” or “sadistic” one), where the implication is that there is some kind of reward at the end, is irresponsible.


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