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