Israel tackles eating disorders head on

Throughout history, the ideal female figure has been full and rounded, but more recent decades have seen the birth of a new phenomenon: eating disorders like anorexia and bulimia. The main culprit has been the media – print and digital – that spread the word: “Painfully Thin is Beautiful.” In anorexia, people may even starve themselves to death, while bulimics stuff and purge themselves by vomiting, causing serious damage to their digestive system, teeth and throat, in addition to malnourishment.

Who would have thought that young women who look like they have been on a hunger strike for a few weeks – dressed up in the latest fashions and coated with makeup – could be regarded by young people as worth imitating? About 90 percent of those suffering from eating disorders are girls and women (although in other countries like England, males constitute as many as 30% of the victims).

In the 19th century, only a handful of cases were reported, but thanks to the influence of the world media, by the 1960s the estimated figure in the Western world ballooned to 0.25 percent.

According to recent research, nearly 14% of Israeli girls and 7.1% of boys in the nine to 14 age group have the potential to develop eating disorders. But while physicians and various therapists in the field believe that the phenomenon is growing every year, the Health Ministry has failed to compile a patient registry to assess the numbers.

Thus the ministry bases itself on mere estimates of 1,500 new cases a year, and states that 330,000 Israelis will suffer from eating disorders at some time in their lives. Without documentation regarding the extent of the disorders, the medical establishment also lacks enough inpatient and outpatient facilities and professionals to treat them. It is believed that 2% of Israeli youths suffer from bulimia, 1.2% from anorexia and 3% to 5% more from non-specific eating disorders.

One in 20 anorectics actually die of the disorder.

Ironically, about a quarter of Israeli children are overweight.

The vast majority of professionals in the field are women, or at least so it seemed at the recent International Conference on Treatment Modalities for Eating Disorders at the Ramada Hotel in Jerusalem. Perhaps this is because it is considered a “helping profession” and the vast majority of patients are of women, or maybe it’s because only women have the extreme patience needed to coax the victims back to a healthy life.

The two-day conference, organized by the Israeli Association of Eating Disorders (IAED), was attended by some 300 people, a third of them from abroad, including countries like Brazil, Australia, Holland, Belgium, Sweden, Canada. the US and the UK. One of the guest speakers was Dr. Rachel Adatto, who on her last day as a member of the 18th Knesset explained what difficulties she went though for the law she initiated to minimize the negative influence of advertising on impressionable young people.

The law, which she conceded is imperfect, prevents the use of presenters or models in advertisements who are anorectic and requires photos that have been doctored with computer programs such as Adobe Photoshop to disclose that fact. She worked on the law for two-and-a-half years, with the Justice Ministry itself throwing up one of the many roadblocks, as it initially opposed the legislation on the grounds that it violated “freedom of occupation.”

Adatto credited Prof. Yael Latzer, the conference chairman, a psychotherapist, clinical social worker and director of Rambam Medical Center’s eating disorders treatment institute, for providing her with scientific proof that media exposure is involved in eating disorders.

At one of the panel discussions, a lecturer spoke about the role of sexual abuse in triggering some cases of anorexia or bulimia among children or teenagers. One lecture presented the highly unusual case of a teenage girl who went blind at the age of three and who started restricting her diet and exercising vigorously, eventually losing 17% of her body weight. She became weak, sank into depression and developed an irregular heartbeat and obsessive thoughts.

‘I THINK the Knesset should play a role and go into fields where the health minister and others don’t take responsibility,” said Adatto, who throughout her term was a strong opponent of Deputy Health Minister Ya’acov Litzman and who made it no secret she wanted to succeed him.

“My role started with an unimportant meeting of the Knesset Public Complaints Committee on the lack of hospital beds in the periphery. The lack of facilities for treating eating disorders was touched upon, and it was opened like a Pandora’s box. I learned that there was a lack of facilities around the country.”

Adatto, a gynecologist and lawyer by training and former chairman of the Knesset’s health lobby, set a body mass index (BMI) of 18.5 as the cutoff for presenters and models.

(BMI is calculated by dividing body weight by the square of one’s height.) Thus, according to the law, an adult with a BMI below 18.5 is underweight; between 18.5 and 24.9 of normal weight; between 25 and 29.9 overweight; and 30 and over obese.

The law also covers presenters and models representing products with no connection to fashion, and also stipulates that photographs of people under the legal minimum BMI may not be published in advertisements anywhere, whether in print (including billboards) or electronically.

Advertising companies must now ensure that models and presenters are equipped with recent authorization from a physician stating the person has a BMI no lower than 18.5. Unfortunately, the law does not include fines as deterrents, but families whose loved ones were influenced by anorexic images can easily sue the companies, possibly no less an effective punitive measure than a direct fine.

The first law of its kind in the world, it attracted much attention from other countries struggling with the influences of advertising and the media on body image.

“Over 450 articles about the law appeared in the media around the world, and it promoted awareness of the eating disorders epidemic everywhere,” said Adatto. “It was called the Photoshop Law,” although that was only part of it.

While the media would have been expected to oppose the bill, Adatto said that while they were first cynical, “they eventually raised discussions in a serious way. They understood they have the power to push the bill forward, and they did an excellent job supporting it.”

Another negative influence on eating disorder patients are the websites they set up to communicate with and support each other – and teach others how to fool their parents and doctors. These informal networks may serve as a counterweight to therapists who try to treat them. It is, however, fortunate that a handful of of Israeli “halfway houses” have been set up in recent years to help them regain a normal life after intensive therapy.

DR. ITSHAK Vorgaft, the outgoing president of IAED and director of the eating disorder sub-unit at Safed’s Ziv Hospital, said eating disorders represent “a wide range of psychological, medical and sociological issues, with changes in the cognitive understanding of self, the roles we play, the perception of beauty and success, gender definition the and accelerated role of media in our lives.”

Vorgaft will be replaced in his position at the association by Prof. Eytan Bachar, director of the eating disorders department for adults at Sheba Medical Center at Tel Hashomer.

Latzer noted that eating disorders have become epidemic in proportion, especially among adolescent girls and women, and that the condition now appears in younger children than ever before. She said a new phenomenon was that some of the highly obese who undergo bariatric surgery to lose weight by constricting or shortening the digestive system have been diagnosed with anorexia, as they take weight loss to the extreme.

About 50% to 80% of eating disorders are influenced by genes, but they are predisposing factors, while the environment – the impact of the media and modern life – is also crucial.

“Eating disorders are a complex, poorly understood disturbance that often raises negative emotions not only among lay people but also treatment providers. They are among the psychiatric disorders considered especially difficult to treat. Research on treatment,” she added, “is extremely complex [and] multi-factorial.”

Prof. Daniel Stein, director of the pediatric psychosomatic department at the Safra Children’s Hospital at Sheba Medical Center added that he had witnessed many more cases of children with selective eating, i.e.

children that are very spoiled about what food they eat, and said some of these cases develop into eating disorders.

Dr. Rachel Bachner-Melman, a senior lecturer in behavioral sciences at the Ruppin Academic Center’s psychology department and the Hebrew University said she had noticed more older women showing up with anorexia, even pregnant women.

“I have treated many people with night eating disorder, some of them sleepwalkers who get up in the middle of the night and don’t even realize they’re going to the refrigerator.

Judith Banker, director of the Center for Eating Disorders in Ann Arbor, Michigan, said that both clinical evidence and research must be used to conclude what eating disorder treatments are most effective. She recalled the tragic story of 19th-century Hungarian-Jewish physician Ignaz Semmelweis, who discovered from treating women in labor that their death rate dropped significantly – from as high as 30% to 1% – if those who deliver their babies wash their hands with soap and water. No one understand the mechanism of infection at the time, but he urged cleanliness nonetheless.

Yet the medical establishment ridiculed him; he was confined to a mental asylum and beaten by a guard. He died at the age of 47, two weeks after being committed, from blood poisoning caused by his wounds.

Banker said that Semmelweis, an early pioneer of antiseptic procedures, had much to teach his colleagues, even though he had not conducted research as the basis for changing medical behavior.

“Integrating individual clinical expertise with the best available external clinical evidence from systematic research and patient preference is the way to advance the treatment of eating disorders,” she continued.

But in the US, “everything has been taken over by managed care” to save money, and there is a gap between treatment found to work and what has been found in clinical trials. “Researchers and clinicians often fail to persuade each other. It can take as long as 17 years between between the discovery of an effective treatment and its incorporation into routine care,” she said. This is especially a problem because eating disorders are so complex, with depression, genes, biology, temperament and other factors involved in them, she added.

“Multidisciplinary specialists are needed to treat them. Psychodynamic, family-based therapy and cognitive behavioral therapy [CBT] may be successful in treating anorexia,” Banker continued. “Anti-depressive drugs appear to be of little benefit. In the event of bulimia, certain drugs and CBT can help treat the condition. But only about half of patients are better in five years,” she said.

“Providing clinical care is not rewarded at academic institutions, and the demands of clinical practice make it difficult to stay on top of research. Clinicians in the field feel under attack from the research community.”

In any case, with psychiatric care still the responsibility of the Health Ministry and not the health funds, it takes a minimum of three months to get treatment in public clinics, and the number of beds is much too small. The Adatto law is expected to make a dent in the numbers affected by eating disorders, but the health establishment still needs to launch a comprehensive program to fight the disorder before it spins out of control.