Starving in the midst of plenty

MK Adatto, who has introduced a number of bills aimed at combating eating disorders, says it’s an issue of life and death.

By JUDY SIEGEL-ITZKOVICH
MK Rachel Adatto 311 (photo credit: Judy Siegel-Itzkovich)
MK Rachel Adatto 311
(photo credit: Judy Siegel-Itzkovich)
Once upon a time in the early 17th century, Flemish Baroque painter Peter Paul Rubens painted voluptuous, nearly obese figures as the ideal female image. While that is certainly not considered healthy, today the ideal woman – as shown in fashion photos – is likely to be so skinny that her ribs stick out.
Anorexia, in which people may even starve themselves to death, or bulimia, when they stuff themselves and them vomit it out, are increasingly common, especially in women and girls. In the 19th century, only a handful of cases were reported, but thanks to the influence of the world media, by the 1960s the figure 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 for developing eating disorders.
Two percent 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, a fifth of Israeli children are overweight.
Israeli girls have the poorest body image of any other national group surveyed in a comparison study, and large numbers of them are on permanent weight-reducing diets. Every year, some 1,500 children and adolescents are diagnosed with eating disorders, but more than 300 adults and teens get no treatment because of the lack of specialized facilities and funding.
Although one would expect Haredi youth to be less at risk because of their supposed lack of exposure to the mass media, the phenomenon is spreading in this sector as well. Haredi teenage girls – first in the US and now in Israel – who worry about finding a marriage partner are pushed to lose weight to compete in the “good looks category.”
The situation is so serious that Kadima MK Rachel Adatto, a gynecologist by training and chairman of the Knesset health lobby, this month initiated a conference in the Knesset auditorium to discuss the problem and report on progress in getting her private member’s bills passed into law.
One would prohibit the appearance on the catwalk of models with less than an 18.5 body mass index (BMI), which is calculated by dividing body weight by the square one’s height. Thus, 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. Their photos also could not be published anywhere, whether in print (including billboards) or electronically.
In addition, according to the bill, images that are doctored (as by Photoshop) to make them look thinner than they are would have to bear warnings stating that they are not authentic.
In the second bill, people under the age of 24 would not be dispensed laxatives without a doctor’s prescription. Adatto, who visited facilities that treat eating disorders before writing the bills, said she met a young woman who admitted to taking up to 120 laxative pills per day to lose weight. A third bill she wrote would monitor websites that give advice on drastically losing weight, vomiting out food and tips to promote anorexia and bulimia.
Dr. Yitzhak Vorgaft, head of the eating disorders department at Ziv Medical Center in Safed and head of the Israel Association for Prevention, Treatment and Research of Eating Disorders, was co-organizer of the conference.
He runs the country’s only inpatient department for eating disorders that treats adults.
“There are many factors involved in getting such bills passed,” said Adatto, who is also a lawyer. “There are various ministries, the media, lobbyists. As we went deeper into the issue, we learned more and more about problems in the health sector, such as the lack of places for outpatient and inpatient care.”
There is some good news, however.
Soroka University Medical Center in Beersheba will soon open its own unit for eating disorders in-hospital, joining that at Ziv, plus Schneider Children’s Medical Center in Petah Tikva and Sheba Medical at Tel Hashomer for teens. Rambam Medical Center in Haifa also has a eating disorders clinic.
Only about half of anorectics and bulimics recover, said Vorgaft in his lecture, “and it takes two to five years of treatment to achieve a cure. Thirty percent have a partial recovery, while 15% develop a chronic case and 5% die of the disorder.”
Vorgaft presented a psychological profile of people with eating disorders; they are perfectionists with rigid thinking, feel overwhelmed, have difficulty seeing the big picture and can’t easily sort the wheat from the chaff.
Add this to living in a world in which money and looks are very important, and the result is a person at risk.
“Youngsters are sometimes victims of the society in which they live,” he said.
He recommended early monitoring by a family physician or pediatrician and close observation of pupils by the school nurse, “that is, if schools had them.” Once diagnosed, children with eating disorders should ideally be seen at a multidisciplinary clinic staffed by a psychiatrist, clinical dietitian, social worker, psychologist and various therapists.
“But this costs a lot of money, and inpatient departments for anorectics need to offer enticing food to induce patients to want to eat, and that costs money,” said Vorgaft, adding that his department is the only one to function five times a week. It costs about NIS 600 a day per patient to treat these disorders.
“The Health Ministry has set a diagnostic- related group (DRG) payment by the health funds for only NIS 340 a day. Thus any hospital director with such units knows it will be a money-losing facility.
So who will volunteer to open such units?” So there are too few specialized departments.
Of 250 youths hospitalized for eating disorders in 2007-8, less than 10% were sent to specialized departments with expertise in treating and rehabilitating them so they can reintegrate into society.
The rest went to general hospital departments, he said.
Asked later to comment, the Health Ministry told The Jerusalem Post that ministry director-general Dr. Ronni Gamzu had instructed the budgeting division to look into changing the pricing for such services. In addition, the ministry will offer an incentive payment of NIS 50,000 to each hospital that agrees to open (or expand) an eating disorders clinic. He also asked four hospitals to open such clinics in the periphery.
Dr. Eitan Gur, director of the eating disorders department for adults at Sheba, called for an amendment to the Psychiatry Law enabling doctors and nurses to force feed anorectic patients in danger of death. After hearing this plea, Adatto said she would positively consider initiating such a bill as well.
The average patient in his 24-bed department stays for three months; every year, some 160 adolescents and adults (almost all girls and women) are admitted.
“There is a long queue for admission, and the criteria are strict; they must have a BMI of 10 or lower to get in,” Gur said.
Numerous patients are recidivists, returning every few weeks.
“I remember a woman who refused to remain for treatment; she was hospitalized with us 14 times. It cost NIS 1.2 million only for occupying a bed, without including the treatment. If she had agreed to medication and other treatment, it would have saved the expenses of a rehabilitation home for 15 girls for a year,” he said.
Another extreme case was an 18-yearold who weighed only 39 kilos but said she wanted to diet until she reached 22 kilos.
“She had no menstruation for more than four years, suffered from hypoglycemia and hypothermia and developed kidney insufficiency. Her BMI reached an incredibly low figure of 9.”
As she was considered an adult, she insisted on leaving Sheba but is now being treated in Jerusalem, Gur said.
“I hear she keeps trying to get out of bed and escape.”
Einat Tzuberi, head of the eating disorders clinic at the Shalvata Mental Health Center in Ra’anana, reported on her study of seven intermediate and high schools where dance is studied by adolescents.
These included two high schools for the arts, which she found were much more likely than regular schools to cultivate the rigid thinking, perfectionism, feeling of being overwhelmed and the belief that looks are everything.
Adatto, who presented shocking images of starving women models, congratulated Adi Barkan, who for years at his model agency ordered young women to lose weight. Now he preaches the opposite advice and uses the Internet to combat eating disorders.
Girls who return to normal eating, said Miri Givon, a social worker and clinical director of Rambam’s eating disorders clinic, need support not to relapse.
“It’s hard for them to remain in school and to regular jobs. If they leave home, they have a difficult time finding other housing. To prevent them from developing ‘revolving-door syndrome,” she insisted, they need a hostel with 24-hour supervision.
But these are few and far between, especially in the periphery.
The Kadima MK concluded that despite strong pressure against her Knesset bill on models with low BMI, she hopes it passes on its second and third readings.
“Opponents describe my bills as violating freedom of expression. But these and other young women deserve to live,” she concluded.