Fight Anorexia–Eat Together

{I’m away this week, but will continue to do some (re)posts–this article originally appeared in the ‘Weight’ issue of catapult magazine}

Years ago, I was idly leafing through one of the many church-supply catalogs that came to our house (a parsonage) and was amused to find featured a new product: a pre-filled disposable communion cup. Shaped like a single-serve coffee creamer, it had a double foil lid — peel back the first layer and there’s your communion wafer; the second uncovers your little sip of grape juice. The advertising copy proclaimed the product’s convenience and cleanliness. I grew up Baptist, where we were served grape juice in our pews in individual cups, and later drifted into the Anglican tradition, where I kneel at the rail and drink wine from a common cup.  Then, as now, that ready-filled communion cup strikes me as a terribly lonely and sad invention. When I eat the Lord’s Supper, I want to feel that I’m doing so along with the body of Christ. That hermetically sealed cup just doesn’t say “community” to me.

But, really, what can you expect from a culture in which we do so much eating in our cars, in which family meals eaten around a table are special occasions instead of sacramentally commonplace? Individual food idiosyncrasies are normal and accepted and “have it your way” is the ethic not just of a fast-food place, but of many families’ habitual food practices. The right of each person to decide for herself what she will and will not eat is highly respected; parents are discouraged (probably with good reason) from becoming authoritarian about their children’s eating. If all of these habits worked well, I’m not sure there’d be much reason for wringing my hands over the sad individualism communicated in that single-serve communion cup. But they don’t work well: diet-related disease is rampant, as is obesity. On the equation’s other side, anorexia and related disorders become more and more common. When these problems appear, words and phrases like “individual responsibility,” “willpower,” and “determination” are thrown around, suggesting that, again, the affected individual shoulders the responsibility for recovery. Is it really so?

Harriet Brown’s memoir Brave Girl Eating: A Family’s Struggle with Anorexia challenges popular conceptions of eating disorders. Traditionally understood as stemming from family problems, anorexia is often pronounced to be “not about the food.”  Thus, it’s often said that focusing on eating won’t work until “underlying psychological issues” are dealt with. Unfortunately, anorexics might die before that happens: it’s the deadliest of all psychological disorders, and it has an abysmal recovery rate.  Only 30-40% of anorexics will recover completely; 20% die; the rest cycle in and out of hospitals and treatment programs, never really getting to live a full life. When Brown’s fourteen-year-old daughter, Kitty, became ill with anorexia, Brown, a writer, read everything she could about the disorder. Unsatisfied with traditional explanations and treatment options, and terrified by the poor recovery rates, she came across a lesser-known but promising treatment known as Family Based Treatment (FBT), also called the Maudsley approach. It sounds simple enough. Phase 1: restore the patient’s weight. Phase 2: return control over eating to the patient. Phase 3: resume normal development.  It’s done at home, with mom or dad sitting with their anorexic child at every meal, packing them with the thousands of calories needed for their recovery.

Absurdly simple, or just plain absurd? Amazingly, patients treated with FBT have close to a 90% recovery rate — more than twice the recovery rate of patients treated with traditional methods, which usually involve expensive inpatient care. FBT seems so revolutionary because for so long it has been assumed that no one — and least of all, parents — should make anorexics eat. They’ll eat when their underlying issues are resolved, or so it is said.  Brown persuasively draws on studies demonstrating that “cognitive and emotional symptoms associated with anorexia are actually physical by-products of starvation.” In a study conducted in the mid 1940s at the University of Minnesota, Ancel Keys underfed 36 healthy young men for six months; most lost 25% of their body weight. In addition to showing the physical signs associated with malnutrition, some exercised compulsively and all developed obsessive thoughts and behaviors around eating: hallmarks of anorexia. Additionally, levels of aggression, depression, phobias and compulsions went up — not returning to normal until eight months of “re-feeding.” This study and others suggest that FBT’s proponents are correct in prioritizing the restoration of lost weight above dealing with “underlying issues.” The brain can’t function properly without an adequate supply of fat and glucose, let alone when it is undergoing starvation. A Creole proverb says, “An empty sack cannot stand up; a starving belly cannot listen to explanations.” Focusing on restoring the physical body first only makes sense.

It also seems wonderfully sensible that in FBT, parents (guided by professional therapists and doctors) are the ones taking charge of their children’s care. Brown is careful to say that she and her family have their share of faults, but she comes across as a dedicated mother, one who admits that sending Kitty off to a residential treatment facility would be easier in some ways but who nonetheless faces down the “demon” of anorexia (as she characterizes it) together with her husband. The reasons she gives for choosing this path are many; perhaps the most touching and persuasive is:

We have something no one else in the world has: we love Kitty best. No one else in the world can possibly want her to get better as much as we do. No one else loves her as fiercely, as nonjudgmentally, as unconditionally as we do.

In a culture where we outsource so much — cooking, cleaning, childcare — Brown’s words are a reassuring hug from an ever-loving mother. Love, I suspect, is the active ingredient in FBT. The first act of love from parent to child involves feeding and nourishment. Nursing a newborn and holding them close communicates love. Many of the things Kitty does when ill, and when working through FBT, mimic babyhood: she eats with baby utensils, sleeps on her parents’ bedroom floor, goes with them to work, is accompanied by them at every meal and snack (a good five hours a day spent at the table) and cries herself to sleep in their arms. She gains weight. Slowly, she returns from near-death. She’s able to start high school and spend time with friends again.

Of course, there are bumps in Kitty’s road. Without her parents’ supervision, she tends to restrict her eating. Criticism of FBT in general (and of this book in particular) may take issue with this fact, citing it as proof that parental supervision of an anorexic’s eating isn’t viable in the long term. However, the best-odds alternative — residential treatment — isn’t either. For one thing, it’s not terribly effective once patients leave the facility. And it is very expensive.  As Brown demonstrates, most states allow health insurance companies to put a separate cap on mental health coverage.  Hers allows just $1,800 annually, straining her family’s finances (and ruining the finances of families who are less well-off).  FBT is an approach that can (and does) work well much more cheaply, and without the stress of taking young girls — sometimes very young girls — away from their families and into institutions. And so what if Kitty isn’t ever able to manage her eating all on her own? What if that’s not what she’s supposed to have to do anyway?

Eating is (or should be) an intensely communal act. Brown nods in this direction, but I was surprised that she did not hit more directly on the fact that FBT — and Kitty’s journey, particularly — takes this fact richly into account in a way that traditional anorexia treatments haven’t. While traditional therapists tiptoe around the issue of food, citing issues of control and obsession as primary, FBT creates an environment where it is “impossible not to eat.” This sounds less like the setting of One Flew Over the Cuckoo’s Nest (see Lauren Greenfield’s documentary Thin on the Renfrew Eating Disorder Clinic) and more like dinnertime at Grandma’s. Sit down and eat with your anorexic loved one until she finishes each meal or snack? Do we need to be told this?  Yes, maybe we do, when many of us

have fallen for the notion that food is a regrettable necessity. As if the ideal, the holy grail we are all working toward, is to do without food altogether — and as if we not only should but could attain this state, were we are good enough, determined enough, strong enough. As if that’s what we should want.

As Brown notes, our culture is deeply conflicted about food. But maybe what we need most — not just people with eating disorders, but all of us — is to eat together more. Almost in passing, Brown mentions that, pre-illness, Kitty was out of the house three hours each evening at gymnastics practice, eating dinner alone most nights. Somehow, I wasn’t surprised to read this, having recently come across data indicating that children from families who eat together regularly have a much lower incidence of eating disorders than children from families who don’t. If the best hope for anorexics right now is having a loved one sit and eat with them, and help them to eat, might eating together in general have more curative and preventative powers than we can currently understand? Brown doesn’t go that far, but I find her suggestions and story tantalizing as an invitation to think more seriously about the value of eating communally.

Of course, this community has to be of a certain kind. Residential eating disorder clinics form “communities,” but, as Brown demonstrates through Kitty’s limited experience with an eating disorder lunch group, grouping disordered eaters together might do more harm than good: in residential facilities anorexics tend to share tips on being “better anorexics.” (Again, see the Greenfield documentary Thin, or Google “pro-ana.”) Healthy eaters would be the best helpers; Brown herself admits to feeling unequal to the task because of her own issues with body image and food. Perhaps it would have been outside the scope of a family memoir, but I would have liked her to call for a healing of what Michael Pollan calls “our national eating disorder” for the sake of those who, on either end of the spectrum, fall victim to its most extreme forms.

Maybe, though, that could be a job for the church. After all, food and food-related metaphors are integral in much of what the church confesses. The primal sin took the form of forbidden fruit. Jesus is the true manna, the bread of life.  He gave his body and blood to his disciples (and, by extension, to us) in the last supper. Acts 2 tells us that the early church ate their meals together “with glad and generous hearts, praising God.” Paul’s first letter to the Corinthians urges them to practice the Lord’s Supper rightly; done wrongly, the body and blood of Christ is profaned, for when you eat the Lord’s Supper, you proclaim his death and the expectation of his return. Do it right, then — wait for each other, share with one another, make sure everyone has enough. Eating together this way — a self-controlled, loving-toward-others way — proclaims Christ.

It’s time for our church communities to eat in a way that proclaims Christ, but what would that look like? Minimally, it might look like eating together with thankfulness and joy.  God made our bodies, and made us to eat food and give thanks for it. Pass the communal cup with gratitude; pass the bread broken from a single loaf. And be sure that all — especially the most vulnerable — are served.

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