April Dunlap was 17 and weighed 165 pounds when she began a diet and exercise regimen. After three months, the 5-foot-5 teen had lost the 20 pounds she had hoped to shed. But she kept going. "It was like a drug," she said. "I always wanted to lose a little more."
When she hit 120 pounds, Dunlap's mother worried that April was losing too much weight. The family's doctor agreed. Four months after Dunlap's diet began, she found herself in a treatment program for anorexia nervosa. After only 10 days, she had gained enough weight to be discharged from the hospital.
"If it wasn't for my mother, it would have taken a lot longer for me to realize I had a problem," said Dunlap, now 28 and living in Charleston, W.Va.
Dunlap's whirlwind experience with her eating disorder is becoming increasingly common today: A new breed of patient is getting treatment well before the disease drags the person into a downward spiral toward starvation, sustained heart damage, weak bones, kidney damage, long hospitalizations and numerous relapses.
Health experts are seeing a glimmer of hope that the devastation wrought by eating disorders may be easing nearly 30 years after the illnesses first sprang into the public consciousness with the death of singer Karen Carpenter from anorexia-induced heart failure. Among the encouraging signs: More patients are getting medical treatment based on sound science; they're getting it earlier in the course of the disease; and they're recovering faster, often without the need for hospitalization or residential care.
One eye-opening statistic appears to speak to the trend: A recent government analysis found that hospitalizations for people with the primary diagnosis of an eating disorder plunged 23 percent between 2007-08 and 2008-09. It was the first such decline since the federal Agency for Healthcare Research and Quality began tracking such hospitalizations in 1999.
"Any little movement is significant, and this is a pretty big one," said William Encinosa, a senior economist at the agency who worked on the report, which was published last year.
Eating disorders, which primarily affect teenage girls, are loosely categorized as mental illnesses centered on obsessive thoughts, emotions and behaviors regarding food. Anorexia involves self-starvation leading to excessive weight loss that damages the heart, bones, nervous system and organs. An estimated 1 in 200 Americans has the disease, and the death rate is 4 percent.
Bulimia is characterized by bingeing followed by self-induced vomiting, use of laxatives or excessive exercise to purge food and prevent weight gain. It affects 2 percent to 3 percent of Americans and is not thought to be as deadly as anorexia, though a 2009 study in the American Journal of Psychiatry found it was lethal in nearly 4 percent of cases, mostly due to suicide or electrolyte imbalance caused by dehydration.
Another type of eating disorder, binge eating, rarely leads to hospitalization or death.
The stigma surrounding anorexia and bulimia have kept many patients isolated. But for a variety of reasons, eating disorders are coming out of the shadows.
Surveys conducted by the National Eating Disorders Association show that Americans are more familiar with anorexia and bulimia now than they were 10 years ago. That awareness has been accompanied by a weakening of the stigma associated with eating disorders that might, in the past, have prevented some people from seeking help quickly, said William Walters, who manages the telephone hot line for the New York-based organization.
"Parents are being more proactive. Coaches are being more proactive about their athletes," he said. "People feel they can ask for help."
Encinosa credits the heightened awareness to a combination of education in schools, TV shows on the topic and public statements by such celebrity patients as Princess Diana and Paula Abdul.
In April Dunlap's case, a made-for-TV movie about two high school students with eating disorders put her mother, Gloria, on alert. When April began her rapid weight loss, Gloria took action.
"I could see it wasn't normal," Gloria Dunlap said.
Some experts are skeptical that the big drop in hospitalizations reflects actual improvement in treatment. More insurance companies are steering patients to outpatient programs or partial hospitalization, in which patients attend day programs but go home at night, said Dr. Ovidio Bermudez, medical director of the Eating Recovery Center in Denver. Perhaps the drop in hospitalizations simply means insurers are being stingy.
Nor does the federal data indicate whether deaths from eating disorders have declined, since mortality rates are not tracked.
There is no evidence that the incidence of eating disorders has dropped, Bermudez said. To the contrary, anorexia and bulimia have been spreading among populations other than white teenage girls.
But many experts say the tide is turning. In their view, much of the decline in hospitalizations is probably due to improvements in treating the disorders and preventing relapses.
In the early 1980s, when eating disorders were first recognized as a medical problem, treatments were typically psychological therapies that focused on the patient's low self-esteem and communication problems within the family. Success was unpredictable.
Today, doctors and therapists focus on a handful of treatments that have been validated by clinical studies. For teens with anorexia, the first-line treatment is something called family-based therapy, in which parents and siblings work with the patient at home to help restore normal eating habits, said Dr. James Lock, an adolescent psychiatrist at Stanford University who specializes in treating eating disorders. Treating patients at home instead of in a hospital setting is less disruptive to their lives and is thought to promote recovery.
The therapy cures about 40 percent of patients in three to six months, and another 40 percent to 50 percent improve but remain ill, studies have found. The remaining 10 percent stay the same or get worse.
Researchers are still investigating the best way to treat teens with bulimia. Evidence is mounting in favor of cognitive behavioral therapy, which involves helping individuals change their attitudes and thoughts about food and body image. Studies show that about 40 percent of people with bulimia will recover after three to six months and another 40 percent will improve but still struggle with the disease; 20 percent remain the same or get worse, according to a 2010 review in the journal Minerva Psychiatry.
Treatment experts are also taking account of other psychiatric conditions, such as anxiety, that tend to accompany eating disorders. Treating those conditions as well leads to a more complete recovery, Bermudez said.
Although there are no drugs designed to treat eating disorders, many doctors are testing medications approved for other uses. Studies of the antipsychotic Zyprexa show it appears to help soften the mental rigidity that keeps patients with anorexia stuck on the idea that they are fat, Bermudez said. Prozac has been approved for treating bulimia.
Treatment center directors say they are seeing younger patients than before - in some cases as young as 8. According to the latest federal data, hospitalizations for children under age 12 increased by 72 percent over the last decade. While that may be a sign that kids are developing eating disorders at younger ages, some experts believe it may also reflect swifter diagnosis.
"If you intervene early, you can spare these kids from the worst of the weight loss," said Doug Bunnell, director of outpatient services at the Renfrew Center's eating disorder clinic in Old Greenwich, Conn.
Further progress may well depend on the vigilance of primary-care doctors, who will need to look beyond skinny teenage girls for signs of anorexia and bulimia, Bermudez said.
"We aren't there yet," he said.
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