What is it?

Overview

What Is It?
Eating disorders are mental illnesses, and although they revolve around eating and body weight, they aren't entirely about food but also about feelings and self-expression.

Eating disorders are devastating mental illnesses that affect an estimated 10 million American women. Approximately 85 to 95 percent of the people who suffer from the eating disorders anorexia nervosa and bulimia nervosa are women. Although eating disorders revolve around eating and body weight, they aren't entirely about food but also about feelings and self-expression. Women with eating disorders often use food and dieting as ways of coping with life's stresses. For some, food becomes a source of comfort and nurturing, or a way to control or release stress. For others, losing weight is a way to gain the approval of friends and family. Eating disorders are not diets, signs of personal weakness or problems that will go away without treatment.

Eating disorders occur in all socioeconomic and ethnic groups. Eating problems usually develop in girls between age 12 and 25. [Because of the shame associated with this complex illness, many women don't seek treatment or get help until years later. Eating disorders also occur in older women and in men, but much less frequently.

There are several categories of eating disorders, including anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS). All are considered psychiatric disorders.

Anorexia nervosa is a disorder in which preoccupation with dieting and thinness leads to excessive weight loss. If you suffer from this disease, you may not acknowledge that weight loss or restricted eating is a problem, and you may "feel fat" even when you're emaciated. Women with anorexia nervosa intentionally starve themselves or exercise excessively in a relentless pursuit to be thin, losing more than 15 percent of their normal body weight. Roughly half of all women suffering from anorexia nervosa never return to their pre-anorexic health, and about 20 percent remain chronically ill.

Some women with anorexia also purge, but they do not have bulimia. The main difference between someone with anorexia who purges and someone with bulimia is weight: severely underweight individuals receive a diagnosis of anorexia. The death rate for anorexia nervosa is among the highest of any psychiatric illness. The deaths are about evenly divided between suicide and medical complications related to starvation.

Women with bulimia nervosa regularly and sometimes secretly binge on large quantities of food—up to 20,000 calories at a time—then experience intense feelings of guilt or shame and try to compensate by getting rid of the excess calories. Some purge by inducing vomiting, abusing laxatives and diuretics, or taking enemas. Others fast or exercise to extremes. If you suffer from this disease, you feel out of control and recognize that your behavior is not normal but often deny to others that you have a problem. Women with bulimia can be normal weight or overweight, but they often experience weight fluctuations.

A third type of eating disorder, "eating disorders not otherwise specified" (EDNOS), refers to symptoms that don't fit into the other two categories of eating disorders. Individuals with this type of problem, may have binge eating disorder, or be close to a diagnosis of anorexia or bulimia, but don't quite meet full diagnostic criteria. EDNOS is simply a catch-all term for anyone with significant eating problems who doesn't meet the criteria for the other diagnoses. The majority of those who seek treatment for eating disorders fall into this category.

Although it has become synonymous with eating disorders, anorexia is relatively rare, affecting between 0.5 percent and 3.7 percent of women in their lifetimes. Another 1.1 percent to 4.2 percent develop bulimia. Yet statistics don't tell the whole story. Many more women who don't necessarily meet all the criteria for an eating disorder are preoccupied with their bodies and are caught in destructive patterns of dieting and overeating that can seriously affect their health and well-being.

There is no single cause of eating disorders. Biological, social and psychological factors all play a role. Evidence suggesting a genetic predisposition shows that anorexia may be more common between sisters and in identical twins. It is estimated that one has roughly a six to 10 times greater chance of developing an eating disorder if an immediate relative has one. Other research points to hormonal disturbances and to an imbalance of neurotransmitters, chemicals in the brain that, among other things, regulate mood and appetite. Scientists have also learned that appetite and energy expenditure are regulated by a highly complex network of nerve cells and molecular messages called neuropeptides.

In some women, an event or series of events triggers the eating disorder and allows it to take root and thrive. Triggers can be as subtle as a degrading comment or as devastating as rape or incest. Times of transition, such as puberty, divorce, marriage or starting college, can also provoke eating problems. Parents who are preoccupied with eating and overly concerned about or critical of a daughter's weight, and coaches who relentlessly insist on weigh-ins or a certain body image from their athletes, especially in weight-conscious sports including ballet, cheerleading, diving, wrestling and gymnastics, may also encourage an eating disorder. So can the pressure of living in a culture where self-worth is equated with unattainable standards of slimness and beauty.

Additionally, the discrepancy between our society's concept of the "ideal" body size for women and the size of the average American woman has never been greater—leading many women to unrealistic goals where weight is concerned.

Diagnosis

Diagnosis

Because the consequences of eating disorders can be so severe, early diagnosis is crucial. Eating disorders in general can disrupt physical and emotional growth in teenagers and can lead to premature osteoporosis, a condition where bones become weak and more susceptible to fracture; increased infertility; and a higher risk of miscarriages or low-birthweight babies.

Anorexia nervosa

Anorexia may be especially deadly for women with insulin-dependent diabetes if they omit or under-use insulin to control their weight.

Among the physical effects of anorexia are:

• anemia, often caused by iron deficiency, which reduces the blood's ability to carry oxygen and causes fatigue, difficulty breathing, dizziness, headache, insomnia, pale skin, loss of hunger and irregular heartbeat

• elevated cholesterol, which occurs because the eating disorder affects liver function, reducing bile acid secretions that contain cholesterol and enabling more cholesterol to remain in the body rather than being secreted

• low body temperature and cold hands and feet

• constipation and bloating

• shrunken organs

• low blood pressure

• slowed metabolism and reflexes

• slowed heart rate, which can be mistaken as a sign of physical fitness

• irregular heartbeat, which can lead to cardiac arrest

• slowed thinking and cognitive and mood changes secondary to long-term starvation

Women with anorexia have an intense dread of becoming fat. Food and body size become obsessions. It is common for women with anorexia, for example, to collect recipes and prepare gourmet meals for family and friends, but not eat any of the food themselves. Instead, they allow their bodies to wither away and "disappear," gauging their hunger as a measure of their self-control. Women with anorexia diet not to lose a few pounds but because they want to improve their feelings of self-esteem and love. Depression and insomnia often occur with eating disorders.

If you have anorexia, you may tend to keep your feelings to yourself, seldom disobey authority and are often described as "too good to be true." You also are likely to be a perfectionist, a good student and an excellent athlete. Anorexia is common in dancers and competitive athletes in sports such as gymnastics and figure skating, where success depends not only on athletic performance, but on having the "perfect" body, as well.

Symptoms of anorexia nervosa can include:

• distorted body image and intense persistent fear of gaining weight

• excessive weight loss

• menstrual irregularities

• excessive body/facial hair

• compulsive exercise

Bulimia nervosa

Bulimia nervosa involves using food and eating for emotional calming/soothing. Binging becomes a way to relieve stress, anxiety or depression. Purging the calories relieves the guilt of overeating until the cycle becomes a habit. Women with bulimia are usually more impulsive, more socially outgoing and less self-controlled than those with anorexia. They are also more likely to abuse alcohol and other substances.

Bulimia is harder to recognize than anorexia. Generally, the symptoms are subtle, and bulimic women aren't usually thin. Even so, if you have bulimia, you may be starving nutritionally because you are not getting the vitamins, minerals and other nutrients you need. Symptoms of bulimia include:

• preoccupation with food

• binge eating, usually in secret

• vomiting and extreme use of laxatives or diuretics after binges

• menstrual irregularities

• compulsive exercise

Among the physical effects of bulimia are:

• dehydration

• chronic diarrhea

• extreme weakness

• damage to bowels, liver and kidneys

• electrolyte imbalance and low potassium levels, which lead to irregular heartbeat, and in some cases, cardiac arrest

• tooth erosion from repeated exposure to stomach acid

• broken blood vessels in the eyes and a puffy face due to swollen glands, which are telltale signs of self-induced vomiting

• cuts and calluses across the fingers from thrusting a hand into the throat

• ruptured esophagus due to forced vomiting

Women with bulimia may also experience binge eating. Symptoms include:

• episodes of binge eating when not physically hungry

• frequent dieting

• feeling unable to stop eating voluntarily

• awareness that eating patterns are abnormal

• weight fluctuations

• depressed mood

• feelings of shame

• antisocial behavior

• obesity

If binge eating leads to obesity, the medical consequences may include:

• high blood pressure

• high cholesterol

• gall bladder disease

• diabetes

• heart disease

• certain types of cancer

The outlook for women with bulimia is generally better than it is for women with anorexia.

Tests for Eating Disorders

There is no medical test that can diagnose an eating disorder. For that you need a psychological or other diagnostic test. However, your health care professional may draw some of your blood to determine if you are suffering from any medical consequences related to an eating disorder. Here are some things that may be tested:

• Electrolyte balance. This checks for dehydration, malnutrition, self-induced vomiting, and laxative and/or diuretic abuse. Electrolytes are a specific combination of minerals your body needs to maintain balance to function properly, such as sodium and potassium. Common symptoms of imbalance are leg cramps, heart palpitations, high or low blood pressure and swelling in the legs and feet. An electrolyte imbalance can lead to kidney failure, heart attack and death.

• B₁₂ and folic acid intake assessment. Lack of B12 and folic acid can lead to, or be caused by, problems with the metabolism of protein, carbohydrates and fat, and with the body's ability to absorb nutrients. Low levels can contribute to depression and anxiety.

• Blood glucose (blood sugar) level. Low levels can be the result of dehydration and malnutrition.

• Liver function test. The malnourishment associated with eating disorders can lead to liver damage.

• Cholesterol measurements. Anorexia or binge eating can increase blood cholesterol levels.

• Thyroid function test. This rules out any problems with the thyroid, which can affect weight. It is an important test for someone in recovery who may be having a hard time gaining or losing weight.

Your health care professional will probably also perform a complete urinalysis, or analysis of your urine. This helps evaluate kidney function, urine sugar levels and ketone levels, as well as help diagnose systemic diseases and urinary tract disorders. Ketones, which can accumulate in the blood rather quickly when the body is starved of food and nutrients, indicate the body is "eating its own fat" for energy. Accumulation of ketones in the blood can lead to ketoacidosis, which can cause coma and death.

Your health care professional may also take a blood pressure reading and a bone density test, and perform an electrocardiogram to look for heartbeat irregularities.

Treatment

Treatment

Many women don't realize how damaging eating disorders are to their health. Some think emaciation is normal and even attractive. Or they think that purging is the only way to avoid gaining weight. Even health care professionals sometimes fail to recognize the signs and the chance to intervene.

People fail to realize that a potentially serious eating disorder may underlie their weight loss. Also, it is easy to confuse eating disorders with other emotional problems. Although women with depression may lose or gain weight, for example, that doesn't necessarily make them anorexic or mean they are binge eating. Unlike those with anorexia or bulimia, depressed women don't have a distorted body image, a drive to be thin or a compulsion to binge.

Eating disorders can be fatal and are not something you wait to treat. Fortunately, your risk of death or serious damage drops with prompt and aggressive treatment. The sooner you get help, the better your chances for a full recovery.

Treatment for anorexia nervosa, which typically occurs on an inpatient basis, can be quite expensive, and is not always covered by health insurance. Treatment for bulimia is more likely to be done on an outpatient basis and may be more affordable.

And treatment is no easy task. When an anorexic starves herself, she feels better. When a bulimic or binge eater binges, she feels less depressed. The eating disorder serves a purpose in the mind of the woman who has it. It becomes a kind of companion that it's hard to let go of.

Not surprisingly, relapses are common and success often comes only after trying several therapeutic approaches. A treatment team of dietitians, psychotherapists and physicians may use a variety of treatment methods in conjunction, including:

• psychological counseling or cognitive-behavioral therapy to help you replace negative attitudes about your body with healthier, more realistic ones

• medical evaluations to stabilize you physically

• nutritional counseling to teach you good nutritional habits

• medication such as antidepressants to address emotional health problems

• family therapy to establish the support system you need for full recovery

Treatment of anorexia is often approached as a three-step process:

1. Restoring weight loss due to severe dieting and purging
2. Treating psychological conditions such as distorted body image, low self-esteem and interpersonal conflicts
3. Long-term remission and rehabilitation or full recovery.

A one-year study published in the Journal of the American Medical Association determined that there was no significant difference between those with anorexia who took antidepressants and those who received a placebo—evidence that there is no "magic pill" to make your disorder go away and keep it away.

The only antidepressant approved by the Food and Drug Administration for treatment of bulimia is the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac), but doctors may also prescribe other antidepressants for the condition, including the SSRIs sertraline (Zoloft) and paroxetine (Paxil), and the tricyclic antidepressants imipramine (Tofranil), amitriptyline (Elavil), bupropion (Zyban) and desipramine (Norpramin). Prozac is effective at higher doses (60 mg) but has little impact on the binge-purge cycle at low doses (20 mg).

Antidepressants are more effective for treating bulimia than anorexia, but antidepressants are still sometimes prescribed for anorexia. The antidepressant most commonly prescribed for the condition is the SSRI fluoxetine (Prozac). Tricyclic antidepressants may also be prescribed, but they carry a greater risk of cardiac complications and should be used with caution in people with anorexia. Some physicians may also prescribe antipsychotic medications to help control the psychotic thinking and agitation that can accompany anorexia, but these drugs can frighten patients by dramatically increasing appetite, so they should be used with caution. For anorexics who experience extreme anxiety surrounding eating, antianxiety drugs, such as benzodiazepines, may be used.

With respect to bulimia and binge-eating disorder, research on interrupting the binge-eating cycle finds that once a structured pattern of eating is established, the two factors that increase the likelihood of bingeing—hunger and negative feelings—are reduced, which decreases the frequency of binges.

Another approach to treating eating disorders is called the Maudsley model. In this innovative family-centered treatment program, the family assumes responsibility for making the patient eat. No one is "blamed" for triggering the illness; rather, the eating disorder is treated as a medical condition and the family taught to care for the sick child. The power shifts back to the patient after he or she reaches an acceptable weight.

This method works best on patients with anorexia, but it also works on some bulimia patients.

Prevention

Prevention

Helping young women learn to resolve their problems in healthier ways than by manipulating their meals and weight is the goal of eating disorders screening and prevention programs on college campuses across the country. Screening is important because it's so difficult to change body image attitudes and unhealthy eating patterns once they form. Primary prevention needs to take place early, before girls learn to feel bad about their bodies.

How you perceive your body is only one component of a complete self-image, but too often it becomes the sole factor in determining self-esteem. When "how-I-look" becomes more important than "who-I-am," the groundwork is laid for crippling and life-threatening eating disorders.

Parents can help prevent this from occurring by examining their own attitudes about their bodies and by fostering a healthy, positive body image in their children. Take these steps, even with young girls, to discourage unhealthy behaviors:

• Accept that puberty will influence girls' perception of their bodies, but be prepared to step in if certain behaviors become unhealthy.

• Don't reinforce the message that women have to look a certain way.

• Teach girls how their bodies change during adolescence and that it is normal to gain weight during puberty.

• Talk about images of women in the media and how they are unrealistic for most, if not all, women.

• Take women and girls seriously for what they say, feel and do, not for how slim they are or how they look.

• Encourage children to be active as a way to have fun and to enjoy what their bodies can do.

• Exercise with your children to promote a healthy family lifestyle

• Model healthy attitudes about your own body. Girls need to see women who are satisfied with their bodies and appearance or who take positive and healthy steps toward making changes. Girls who see their mothers worrying about their own appearance and weight are more likely to believe that being thin will make them happy.

• Don't nag about eating or focus on eating habits, which could make a child more self-conscious and secretive about her relationship with food.

• Don't compare her to others and don't be judgmental about other people's weight

• Be on the lookout for the use of diet pills, which has been documented in children as young as 10 years old.

Most important, don't ignore an eating disorder. It is a devastating and potentially fatal disease. But people can and do recover from this illness, once it is correctly diagnosed and treated.

Facts to Know

Facts to Know

1. Eating disorders strike an estimated 10 million American women each year. Eighty-five to 95 percent of those suffering from eating disorders are women.

2. Eating disorders begin early, usually between the ages of 12 and 25.

3. Between 0.5 and 3.7 percent of women suffer from anorexia, and between 1.1 and 4.2 percent of women suffer from bulimia.

4. Women with anorexia, though often well-liked and admired for their competence, often strive to seek approval and may have very low self-esteem and feel inadequate. They may use food and dieting as ways of coping with life's stresses.

5. An eating eating disorder usually does not go away without treatment. Eating disorders are mental illnesses that can be deadly if not treated and are difficult to recover from; but many women have recovered successfully and gone on to live full and satisfying lives.

6. Treatment for eating disorders encompasses a mixture of strategies, including psychological counseling, nutritional counseling, family therapy and possibly antidepressant medications.

7. There is a high incidence of depression among women suffering from bulimia, thus the effectiveness of antidepressants. But antidepressants are most effective when combined with cognitive-behavioral therapy.

8. The self-starvation of anorexia can cause anemia; shrunken organs; low blood pressure; slowed metabolism and reflexes; bone mineral loss, which can lead to osteoporosis; and irregular heartbeat, which can lead to cardiac arrest.

9. The binging and purging of bulimia can lead to liver, kidney and bowel damage; tooth erosion; ruptured esophagus; and electrolyte imbalance, which can lead to irregular heartbeat, which can lead to cardiac arrest.

10. If obesity results from binging, medical consequences include high blood pressure, high cholesterol, gall bladder disease, diabetes, heart disease and certain types of cancer.

11. You should be aware of how you think about all the components that make up your self-image. If your self-image becomes too reliant on looking thin, you should consider how that may be laying the groundwork for an eating disorder. Examine your own attitude about your body, and make sure that it is one of healthy acceptance.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about eating disorders so you're prepared to discuss this important health issue with your health care professional.

1. What are my options for treatment?

2. How would you describe your approach to eating disorders?

3. Is treatment for depression called for?

4. Will you involve my family?

5. What role, if any, will medication play? What percentage of people who see you take medication? Which medications?

6. What can I expect from the medications?

7. What can I expect during a counseling session?

8. When, if ever, do you hospitalize patients?

9. What goals would we set for my treatment?

10. Will I ever be "cured" and completely healthy?

Key Q&A

Key Q&A

1. How can I tell if I have an eating disorder?

   If you've lost a good bit of weight yet still perceive yourself as "fat," despite being within or below normal weight ranges, you have a problem. If you binge by taking in thousands of calories at a time, often in secret, and perhaps followed by purging, you probably suffer from an eating disorder. If you are preoccupied with your body and caught up in destructive patterns of dieting and overeating, you probably have an eating problem, which also can affect your health and well-being, though not as dramatically as an eating disorder. Talk to your health care professional about your feelings and constant need to diet. Have him or her assess the diets you are trying; if they don't offer enough nutrients or calories, they will be almost impossible to stick to.

2. My daughter is neither overweight nor underweight, but I have found evidence of secretive eating, like dozens of candy wrappers under her bed. What's going on?

   Bulimia is often hard to recognize because bulimics don't tend to be at an extreme weight. However, if a person takes in thousands of calories at a time, as in a dozen candy bars at one time, for instance, then purges by making herself vomit, taking laxatives or enemas, fasting, or exercising to the extreme, she has an eating disorder called bulimia. If asked, she will probably deny it. You should talk to your health care professional about how to approach your daughter.

3. Is a compulsion to exercise to the extreme, such as several hours a day, part of an eating disorder?

   If the compulsion is driven by a desire to lose weight, despite being within a normal weight range, or if the compulsion is driven by guilt due to binging, then, yes, this compulsion to exercise is a dimension of an eating disorder.

4. How is anorexia treated? Does it require hospitalization?

   Your health care professional may hospitalize you if your anorexia has resulted in life-threatening complications that are best treated in a hospital, or if continued starvation will soon lead to such complications. In any case, you will likely be treated with a combination of psychological counseling, nutritional education, family therapy and, perhaps, antidepressant medications.

5. How is binge eating treated?

   Frequent binge eating is a symptom of bulimia nervosa and binge eating disorder. Psychological counseling, nutritional education, medications and family therapy may all play a role in recovery from these disorders.

6. Who gets eating disorders?

   Eating disorders are mental illnesses that cut across the socioeconomic and ethnic spectrum. However, 85 to 95 percent of those suffering from eating disorders are women.

7. What causes eating disorders?

   There is no single cause of eating disorders. Biological, social and psychological factors all play a role. A person may even have a genetic predisposition to anorexia. In many women, an event or series of events—a degrading comment, rape or incest, times of transition such as divorce or starting college—triggers the eating disorder and allows it to take root and thrive. Parents or coaches who are preoccupied with eating and overly concerned or critical of a young girl's weight or body image may also encourage an eating disorder, as can societal pressures.

8. I have a young daughter; how do I prevent her from developing an eating disorder?

   Starting young is the best advice. First, instill in her a healthy body image and good eating patterns by modeling these yourself and having open conversations with her. Teach her about how her body will change as she enters puberty so she will expect some weight gain. Show her that women of all body types and sizes can be successful and independent. And talk to her about the unrealistic expectations formed by constant exposure to models and actresses who starve themselves to look emaciated. Don't nag her or focus on her eating habits, but set a healthy example.

Organizations and Support

Organizations and Support

For information and support on coping with Eating Disorders, please see the recommended organizations, books and Spanish-language resources listed below.

Academy for Eating Disorders
Website: http://www.aedweb.org
Address: 111 Deer Lake Road, Suite 100
Deerfield, IL 60015
Phone: 847-498-4274
Email: info@aedweb.org

American Psychological Association
Website: http://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

Harris Center for Education and Advocacy in Eating Disorders
Website: http://www.harriscentermgh.org
Address: 2 Longfellow Place, Suite 200
Boston, MA 02114
Phone: 617-726-8470
Email: dherzog@partners.org

Multi-service Eating Disorder Association (MEDA)
Website: http://www.medainc.org
Address: 92 Pearl St.
Newton, MA 02458
Hotline: 1-866-343-MEDA (1-866-343-6332)
Phone: 617-558-1881
Email: info@medainc.org

National Association of Anorexia Nervosa and Associated Disorders (ANAD)
Website: http://www.anad.org
Address: P.O. Box 640
Naperville, IL 60566
Hotline: 630-577-1330
Phone: 630-577-1333
Email: anadhelp@anad.org

National Eating Disorders Association (NEDA)
Website: http://www.nationaleatingdisorders.org
Address: 603 Stewart St., Suite 803
Seattle, WA 98101
Hotline: 1-800-931-2237
Phone: 206-382-3587
Email: info@nationaleatingdisorders.org

Overeaters Anonymous
Website: http://www.oa.org
Address: P.O. Box 44020
Rio Rancho, NM 87174
Phone: 505-891-2664

Renfrew Center
Website: http://www.renfrew.org
Address: 475 Spring Lane
Philadelphia, PA 19128
Hotline: 877-367-3383
Email: foundation@renfrew.org

Shape Up America!
Website: http://www.shapeup.org
Address: 15009 Native Dancer Road
North Potomac, MD 20878

Anorexia Nervosa: A Guide to Recovery
by Lindsey Hall, Monika Ostroff

Anorexia Nervosa: When Food is the Enemy
by Erica Smith

A Starving Madness: Tales of Hunger, Hope and Healing in Psychotherapy
by Ph.D. Judith Ruskay Rabinor, Judith Ruskay Rabinor

Body Wars: Making Peace with Women's Bodies
by Margo Maine

Bulimia: A Guide to Recovery
by Lindsey Hall, Leigh Cohn M.A.T.

Como entender y superar la anorexia nervosa
by Lindsey Hall, Monika Ostroff

Como entender y superar la bulimia
by Lindsey Hall, Leigh Cohn M.A.T., Leigh Cohn

Cure Your Cravings - The Revolutionary Program Used by Thousands to Conquer Compulsions
by Yefim Shubentsov, Barbara Gordon

Eating Disorder Sourcebook: A Comprehensive Guide to the Causes, Treatments and Prevention of Eating Disorders
by Carolyn Costin

Eating in the Light of the Moon: How Women Can Transform Their Relationship with Food Through Myths, Metaphors, and Storytelling
by Anita A. Johnston PhD.

Hunger Within: A Twelve-Week Self-Guided Journey from Compulsive Eating to Recovery
by Marilyn Migliore

If You Think You Have an Eating Disorder
by John Barnhill, Nadine Taylor

Inner Hunger - A Young Woman's Struggle Through Anorexia and Bulimia
by Apostolides Marianne

Making Weight: Healing Men's Conflicts with Food, Weight, Shape and Appearance
by M.D. Arnold Andersen, Leigh Cohn M.A.T., M.D. Tom Holbrook, Leigh Cohn, et al.

Self-Esteem Comes in all Sizes: How to Be Happy and Healthy at Your Natural Weight
by Carol A. Johnson M.A., Gary Foster Ph.D., M.A., Carol A. Johnson, Gary Foster

Women Afraid to Eat: Breaking Free in Today's Weight-Obsessed World
by Frances M. Berg

Medline Plus: Eating Disorders
Website: http://www.nlm.nih.gov/medlineplus/spanish/eatingdisorders.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20984
Email: custserv@nlm.nih.gov

National Easting Disorders Associations
Website: http://www.nationaleatingdisorders.org/information-resources/general-information.php#NEDA_Espa_ol
Address: Information and Referral Helpline
603 Stewart Street, Suite 803
Seattle, WA 98101
Hotline: 1-800-931-2237
Phone: 206-382-3587
Email: info@NationalEatingDisorders.org