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Hello, I'm Norman Swan. Welcome to this program on eating disorders -
taking a holistic approach.
The number of Australians with an eating disorder
has probably doubled in the last ten years to about 1 in 20.
Eating disorders are commonest in young women,
but the incidence in young men has been increasing,
and the problems don't necessarily disappear with age.
It's likely you have several patients with an eating disorder in your practice
but you may not know it.
Typically, people hide their symptoms,
making early detection and intervention difficult.
In rural Australia, the absence of local specialist services
for people with eating disorders means the burden of care falls to GPs.
This program is intended to assist you in early and effective intervention.
We're coming to you across Australia
through the Rural Health Education Foundation's satellite network.
There are a number of useful resources available
on the Rural Health Education Foundation's website at:
Now let me introduce our expert panel to you.
Jenny O'Dea is Associate Professor in Nutrition
at the University of Sydney.
- Welcome, Jenny. - Hello.
Natalie Wild is a recovery officer
with the Eating Disorders Foundation of Victoria,
and has personal experience of an eating disorder.
- Welcome, Natalie. - Thank you.
Gaye Clews is a psychologist
with a Masters degree in Sports Science and Eating Disorders.
She's a former world number-one triathlete,
and currently runs the Psychology/ Counselling Department
at Radford College in Canberra.
- Welcome, Gaye. - Great to be here.
Jane Reffell is a general practitioner with 28 years' experience,
from Bangalow in New South Wales,
where she runs a women's health and wellbeing practice.
- Welcome. - Hi, Norman.
Natalie, when did you first wake up to the fact
you might have had a problem with your eating?
Now, looking back,
it probably started when I was 12, when I started Year 7.
We're looking at the '80s here,
so awareness wasn't so great with eating disorders.
I'd started school, the environment was new,
independence was being promoted,
and we'd gone from being protected in primary school.
My parents' parenting skills toughened up, teenage hormones, et cetera.
One of the common sayings in our house, unintentionally,
was, what will everybody else think?
My nature was as it was anyway, but I was developing the ideal of,
you had to be a certain person for everybody else.
It was important everybody liked you. It was important to achieve.
It was important to do all these things, and I wanted to get it right.
NORMAN: Did that include how you looked?
Looks for me came secondary. Not with everybody.
Initially for me, it wasn't about weight.
It was about anxieties for me.
As I tried harder and harder to be all for everybody,
the anxieties inside would turmoil.
That anxiety increased... I wouldn't feel hungry so I wouldn't eat.
- Anxiety put you off your food? - Initially.
- As simple as that? - Yes, pretty much.
The need for making sure everybody else was happy
created internal anxieties, which was pressure,
a lot of pressure and high expectations you put on yourself inside.
Things you cannot live up to but you think you should,
so you keep on fighting.
As this was happening, people would give you comments like -
you're growing up, you're losing your baby fat, you're looking great.
- All this feedback. - Amazing, positive feedback.
'You're great fun to have around. You're awesome at parties.'
My facade was doing a great job,
but the behaviours that I was picking up along the way
were, to me, what was creating those.
So I went along like this.
It's important to understand that eating disorders don't happen overnight.
You don't say, I'm going to wake up with an eating disorder.
It's a gradual thing.
NORMAN: Drip, drip, drip. - Yeah.
Within 12 months I'd probably halved my food intake, maybe less.
By the time I was 14 I was on very little,
and hiding all of this.
It's a very secret thing. Nobody knows about it.
Your social life starts to revolve around eating patterns.
At the time, I had a boyfriend. It was a great way to disguise things.
I'd be at home and say, I'm having lunch at his house.
I'd get to their house and say, I had lunch at home.
Socially, I'd say, I can't go for dinner.
I'm going out with so-and-so, but I'll be there after tea.
I was able to cover up, I suppose.
What's going through your head?
Can you remember what you were thinking?
It was active food avoidance?
You just got over some sort of threshold?
It becomes first and foremost about control.
I felt a great sense of control.
I was out of control in so many areas of my life,
in my own expectations of myself.
It wasn't anybody else who does it to you.
NORMAN: You weren't getting at anybody? - Yeah.
I wasn't striving for what I thought I was supposed to achieve
in my own self.
Food was one thing I could control at all costs.
I could eliminate it and nobody could stop that.
I could monitor it, nobody could stop that.
It was the one thing that I had.
It served a purpose for me.
It gave me strength where I didn't have.
I had zero self-esteem, yet everybody thought I had lots.
I was covering up all the time.
This one thing gave me a sense of rebalancing,
somewhere I could manage something.
Did you do things which sometimes people do
like turn to cooking, paradoxically, so you're actually in food preparation?
I worked at McDonald's.
NORMAN: That's enough to make you anorexic.
Which was a really great thing for me, because I'd say, I ate at work.
I had food around all the time.
I'd say, I was nibbling the whole time, so I didn't need to eat.
It's amazing what you put yourself in.
You put yourself in food-preparation zones
so people think you're dealing with food.
You comment on food.
You'll say, that lunch looks fantastic. I'd like that,
knowing darn well you might not actually get to it,
but you want people to think that you will.
There's a lot of hiding and secrecy.
Your parents must have noticed.
They're not really looking. You hide it.
There's different stages to an eating disorder.
In the early stages, you don't believe you have a problem.
There's a part of you that doesn't want anybody to know,
because if they know, then you have to deal with it.
That's not an option.
Everything else is out of control in your life,
so why would you let someone take away the one thing
that you felt good about?
In a destructive way, you feel good about it.
It's taking a voice that you don't have.
Did they ever find out about it?
When I was 15, I was rushed to hospital
with what they thought was an appendix attack.
I had to be weighed. No-one weighed you.
I had to be weighed for medication purposes.
They opened me up, and it wasn't just my appendix.
I had large ovarian cysts, and they realised I didn't have regular periods.
So I was kind of busted on top of the fact that...
NORMAN: In a fairly major way.
How much of your body weight had you lost?
I'm not really sure. They don't tell you.
Well, at that stage they didn't tell you.
I knew I was well below what I was supposed to be,
but I managed to hide that by the clothes I wore,
by my actions, different things you can do.
It depends on your situation, but I managed that.
The doctors put the big threat on me
and told me that if I didn't start eating immediately -
lack of knowledge in a big way - they would put me in a hospital ward.
I would have a sink with no basin, just a bin under it.
They would monitor when I went to the toilet.
They would give me three of these thick mixtures a day I had to drink.
NORMAN: Sounds like Guantanamo Bay.
If I didn't drink it, they would punish me.
Punishment entailed not seeing my parents, no radio, no TV.
One thing at a time, they'd take off me.
Telephone calls - the boyfriend, which was important at the time.
NORMAN: But in retrospect...
Probably the most important thing at the time. Scared me to death.
My beautiful facade. I said, sure, I'll start eating.
That will be fine.
I got away from the hospital, great. Got away from the doctors.
I thought that was very clever. But I didn't get away from my mum.
Mum was on full alert, Dad was on full alert.
NORMAN: They were on plate duty. - Absolutely.
- This is what destroys families. - Absolutely.
They start to blame themselves.
And they've got their own issues going on.
As a parent, you know you have your own issues going on.
You think, did I drop a ball somewhere? Did I miss something?
And it's not their fault.
If you have three children, how come one gets one and the other two don't?
You're brought up the same way.
It's definitely traits that go with it.
NORMAN: How did they handle it? What did they do at mealtimes and so on?
My parents handled it really badly, not intentionally.
- To be fair to them, lots do. - Also, lack of knowledge.
Without the knowledge of it, you try and do what's right, you try and fix it.
They tried to fix it.
Fixing it, probably the absolute worst thing for me, they told...
My mum did. I'm not sure about Dad, he was at work a bit more.
But Mum told people.
So, my big secret was out, and that terrified me even more.
That leaves you feeling naked and vulnerable in the street.
I don't know who knew and who didn't, but you're so afraid of judgement.
Judgement is a massive issue,
and caring what people think and being perfect all the time.
So when someone discloses all of that, you don't know what to do.
By telling everybody when you don't want people to know,
it causes another issue.
For me, anorexia became bulimia.
I felt like I had to start eating in front of people.
I was being watched, I was being monitored.
I was told I wouldn't be driven here unless I ate this.
I wouldn't be able to do this unless I did that.
NORMAN: Was bulimia rebellion?
No, bulimia was keeping the eating disorder alive.
The eating disorder was the only thing I had control over in my own mind,
so I needed to keep it.
It was really important to me to keep it at that time.
I was at a stage where I didn't believe it was a problem. I protected it.
I would behave the way I was supposed to behave,
and almost count how long it would take me to get to the next place
so I could do what I needed to do to protect and support my eating disorder.
- So avoided battles at the meal table? - Absolutely.
When I wasn't at school, on school holidays,
I worked five to six days a week at McDonald's, double shifts.
I would go to people's houses for tea.
I had lots of different ways.
When I had to manage it in front of people, I would manage it accordingly.
Did you ever get so ill they were worried about your life?
Things were starting to falter, but I would hide things.
I had severe headaches every day. They were mind-numbing.
I would pass out at sport. Sport became a real non-event for me.
I actually liked my sport,
but I would black out if I would go for a 100k run. I'd black out.
So I would start avoiding sport.
My social life, I'd start avoiding because I was tired
and most of it revolved around food.
It definitely had its effects.
Your menstrual cycle's not normal, so you're all over the place there as well.
Your bones aren't developing properly.
I had curvature of the spine.
I was hanging upside-down on a rack
because my bones weren't forming properly.
NORMAN: Great adolescence. - Oh, awesome.
Going in to the city with your friends, I'd have to sit.
They would all go shopping, and I'd sit for an hour and a half on a seat
and go, my back hurts, I have to sit.
NORMAN: None of that created an insight for you?
It was all I knew. That's what I knew. That was my teenage years.
So, what got you out of it?
I think everybody has an 'aha' moment.
Even with all the things I've done since then,
I still see so many people and they all have these 'aha' moments.
They can be as small or as big as you like.
There is some kind of conscious awareness somewhere
that you're not doing the right thing, and you don't like it.
You absolutely detest it so often, but at the same time, you need it.
NORMAN: You're hooked on it. - Yeah.
It's keeping you alive.
It's keeping you surviving in an outside universe.
I was 19 when I had my 'aha' moment.
I was at the next boyfriend's house, who is now my husband.
His family didn't know me very well.
They were huge eaters.
I was dreading the first meal at their house. 'When are you having tea here?'
I'd say, I will, I'm just busy. I was always busy.
I sat down to this meal, and it was massive.
I felt sick, and I wanted to cry.
I thought, they're not going to like me anymore.
They're going to not accept me for who I am and it will continue.
I shuffled things around a little bit
and waited till the end.
My now mother-in-law picked my plate up from in front of me and said,
I am so sorry, Natalie. We are such big eaters.
I'll have to give you less next time.
The relief was so intense, and the acceptance of who I was was huge.
NORMAN: Had she twigged?
- Was this just a natural reaction? - She had no idea.
They are a very self-confident family.
They like who they are. They all like who they are.
They're very direct, which was quite daunting at first,
but ended up being my saviour, I think.
Just amazing human beings. They like themselves.
That was a really foreign concept.
I was so busy trying to get everybody to like me.
You did what some treatment regimes do now -
take you back to basics and almost reteach you how to eat?
Absolutely.
I have to say, a lot of my retraining and getting back from beyond,
I did myself.
That is a very rare thing.
98% of people cannot do that.
On saying that, I did have a lot of help in the people around me.
I learned what worked for me.
I learned what were the influencing factors in my life.
I learned to communicate a lot better.
The people who didn't understand,
who had gone through the whole stages with me,
they were able to re-establish what I needed.
It took probably three years, lots of baby steps, relapses.
My focus was always an ultimate goal.
There were so many things I wanted to achieve and I understood at that point
that I couldn't have any of them with the eating disorder.
I had to make a choice.
I had to say, I can have this or I can have this,
and this looked so much better.
NORMAN: And now, when you eat?
I don't think about it. There comes a stage where you...
Occasionally, if someone knows that I've recovered...
More people know now than they ever knew my whole life.
NORMAN: It's hard to keep it quiet when you go on television.
I sometimes will think, I need to go to the bathroom.
Is anybody looking over my shoulder?
It'll be a brief moment and it's gone,
and I'll think, I know I'm fine, I know I'm good.
I look at the most amazing things I've done with my life,
the things I've achieved.
I have two beautiful sons, a great husband,
fantastic relationships all over the place.
My career is great.
Everything that I could have dreamed of
has been achieved by just being who I am,
not by being who I think everybody wants me to be.
We'll come back to your story and how you're passing that on to others later.
Jenny, what are we talking about when we talk about eating disorders?
Yes, the description was really quite familiar,
the anorexia nervosa.
We have a medical disorder, we have a psychological disorder,
and it becomes an extreme psychiatric disorder.
It's a combination of problems.
The Swedes argue that it's not psychiatric at all.
It's almost described here - you go for whatever reason.
You see a model in Marie Claire who's thin, and decide to be like that
and restrict your eating, then something biological happens to you.
It's nothing psychiatric at all.
Is it fair to call it a psychiatric disorder?
It becomes psychiatric when the brain is starved,
when the brain shrinks from starvation, when you're in that starvation state.
It becomes psychiatric because the patient can't think clearly.
They can't undergo counselling
because the brain is not operating normally.
There is a genetic component.
We see identical twins with anorexia nervosa.
We see obsessive-compulsive disorder run through families.
We see these patterns in families, definitely.
There's anorexia nervosa, there's bulimia
and there's something they called EDNOS -
eating disorders not otherwise specified.
Give us a sense of what they are and how they're defined.
Anorexia nervosa is the fear of food, the refusal to maintain weight,
the refusal to gain up to a normal weight,
anxiety around food, worrying about being fat,
obsessing about being fat.
There is the restricting type,
which is the very thin girl whose mother drags her into your office
and says, she won't eat.
There is the purging type of anorexia nervosa,
which is very dangerous -
where they're not eating and they're purging.
Bulimia nervosa is the binge eating, the out-of-control eating,
really quite frequent, with or without purging,
with or without something else like laxatives or diuretics.
So they're the two classics.
Eating disorders not otherwise specified
is a whole gamut of these behaviours together.
You can't make a full diagnosis of anorexia nervosa.
They may not have lost their menstrual period,
but you can't make a diagnosis of bulimia nervosa.
You have this whole array of disordered eating.
That's quite common. That's about 20% of young women.
And it's dangerous?
It's very dangerous.
The classic fainting, passing out, blacking out, low blood pressure.
Electrolytes that become upset because of the vomiting and laxative abuse.
Very dangerous.
In fact, anorexia nervosa has a high mortality rate.
NORMAN: What about eating disorders not otherwise specified?
It depends what array of symptoms they have, what sort of behaviours,
whether there's depression with it, whether there's suicidal ideation.
You have to do an assessment of each individual patient.
NORMAN: What about binge eating? - Binge-eating disorder,
also known as compulsive overeating,
where there is not a full diagnosis of bulimia nervosa,
but there's episodes of binge eating out of control, and of course, weight gain.
So if you can do a dietary history, you can talk about those binges.
And the prevalence?
Prevalence of EDNOS is about 20%.
NORMAN: In the community? - Yeah, in the young female community.
So one in five young women have an eating disorder?
Yes, yes.
That's probably an underestimate. It's probably just the tip of the iceberg.
Pretty big iceberg.
Young men as well are affected.
Anorexia nervosa, about 1 in every 200 teenage girls.
Bulimia nervosa, about 2% at least.
I had 3% of young men in my study of university men.
And EDNOS, the whole array, is at least 20%.
Gaye, you were the psychologist to the 2000 Olympics.
You've been heavily involved in sport. How does it present in young men?
I have worked for a long time in an environment
where eating disorders are statistically much higher
than what they are in the general population.
When I was doing my Masters, some of the studies I was reviewing
as part of my literature review were 20%, 30%, 40%, 50%,
depending on the sport those individuals participated in.
I would tend to see more of it in young males in the sporting environment
when it was a need to make weight.
You have categories the individual is trying to make -
for example, a lightweight rower,
or someone trying to make a category in judo, boxing, et cetera,
where there's a lot of pressure on that individual to lose weight
so they can compete in a lower category.
You would also see it in your aesthetic sports such as gymnastics, diving.
And you'll see it in endurance-based sports.
I've worked with individuals, say, from distance running, both male and female,
where they want a big motor in a small body.
There's a lot of pressure in the culture of that industry
that's very body-focused and very weight-focused.
JANE: And dancing. - Dancing is another one.
Any sort of dancers, male or female.
They say that in young men,
it's an exercise disorder rather than an eating disorder.
Is that a misconception, that it's an eating problem as well as overexercise?
I think it's more towards the exercising and body component.
The other group I've worked with over the years
are young men that have become very body-conscious,
that have wanted to build their bodies up for bulk and size.
The obsession with eating or not eating
to have the lean body weight has been part of that.
Sometimes that's been a protective mechanism
for individuals who have been bullied or abused,
and they need to feel they can physically protect themselves.
They can develop obsessive behaviour
around their body shape, image, size.
Did you notice problems in yourself when you competed at elite level?
Absolutely.
I was at 54kg and 173cm. One would say, that's pretty light.
But in my sport, I was one of the larger athletes.
I was constantly made to feel I should be thinner and I should be lighter.
That pressure was always there.
Whilst I never developed an eating disorder myself,
I struggled all the time with that internal voice,
being involved in an industry telling me all the time
that I'd run better if I was lighter. It's pervasive.
NORMAN: Less wind resistance on the bike with shaved legs.
Jane, in general practice, is the story you've heard typical, from Natalie,
or is it a different picture on average?
When a person presents, when an adolescent presents in general practice,
it's often quite a lot different to that.
You just start with the tiniest little signs,
unless you're there as a teenager brought in by a parent.
You might have a story presented by the parent,
but as a doctor, you still have to find out from the teenager
exactly what's going on.
Often we're not presented with such a thorough story as Natalie has told.
It's really being a bit suspicious, looking at size,
listening for cues around dieting behaviour, wanting to lose weight,
body image isn't what they would like of themselves,
keeping an eye on them physically.
NORMAN: Natalie, what do we know about personality traits?
- Is there a personality type? - Very much so.
Although they don't necessarily script it,
many people with eating disorders have obsessive-compulsive tendencies,
great perfectionism, a need for control - a great need for control.
Caring very much about what other people think.
Not wanting to be judged because that affects the ideal perfectionism.
Very *** themselves internally. Often high achievers.
I've heard people say, he must be so dumb to have an eating disorder.
It doesn't fit an image or an age.
It's a lot more about your nature, I think, than any of those things.
Intellect is another one.
Many people that present with eating disorders are highly intelligent.
Jenny, the stories you hear about women's magazines, body image,
what you see on television,
the father who says, you're looking a bit fat, are all those true,
or is it that the person was destined to have a disorder?
It's clearly a bit of both.
There is a genetic component, there is a social component.
In our Western society, we're all under pressure to be slim,
to fit the perfect body, to not become overweight or obese.
We're all under pressure.
If the girl has that tendency, then if she starts dieting,
it's usually the dieting that leads to the eating disorder.
Usually, there's a very clear low self-esteem.
In fact, that's one of the strongest predictors of anorexia nervosa,
is very poor self-esteem.
The girl feels that she is worth nothing.
It doesn't help to say, you're a fantastic person,
'cause you don't believe it.
Therapy is not falsely boosting self-esteem.
When they can get their weight up a little bit and feel better
and truly participate in counselling,
then that self-esteem building is very protective.
It's very protective for a child.
Gaye, is recovery a myth?
Some people say once you've got it you've always got it in some form,
it's just behind the surface.
Fortunately, it's not a myth.
If you look at anorexia nervosa, they say a good 50% will recover.
A large percentage of the remaining will learn to manage it,
but that might mean managing it throughout their lifetime.
If you look at bulimia,
they're looking a recovery rate of around 70%.
You've got the other 30% who will be learning to manage it,
and manage it throughout their lifetime.
A few years ago, an expert in anorexia nervosa and eating disorders
studied the literature, wrote it up in The Lancet and said, nothing works.
Maybe family therapy.
But all the other stuff that so-called experts talk about in anorexia nervosa,
my understanding is that apart from certain types of family therapy,
the only thing with randomised control-trial evidence for working
is the Swedish system, where they treat it as a biological problem
and don't treat it as a psychiatric problem, the Mandometer.
Is it as holistic as that, Jenny?
I think you would call it success
if you had someone you diagnosed with anorexia nervosa
and you kept them alive, because there's a high mortality rate.
You have to look at, what are you calling success -
keeping them alive, preventing the suicide in bulimia, for example.
NORMAN: There are certainly a lot of desperate parents
who don't feel there's much on offer.
Refeeding works.
That will save the child's life if you can get them into hospital,
refeed them and normalise their blood chemistry.
What's interesting about refeeding is, they've done studies,
looked at eating disorders, looked at prisoners of war,
looked at other people in terms of the starvation issue.
It appears it's the process of starvation
that is contributing to the psychological...
- Which is what the Swedes say. - Yes, it's what they're saying.
- The starvation process has that... NORMAN: You've got to refeed.
You have to refeed. That's first and foremost.
We're also working with a very large continuum
in terms of where individuals present to us and where they are on that scale.
And majority of them aren't at the refeeding end.
If we can pick it up earlier, work with it sooner,
we're going to get a higher turnaround in terms of individuals getting help.
NORMAN: What are the elements of family therapy?
I'm not a specialist in family therapy.
I do believe it's a really important role.
I would refer out.
Some of the aspects in family-therapy work
is that the young person really needs to feel they are validated,
that they're actually being heard.
That they're worth something. They need that self-worth.
That self-worth that comes from that family unit.
Recognising and separating out that the individual is not the disorder.
You've got Natalie, this beautiful, wonderful, gorgeous person,
then this disordered eating, and they're not two and the same.
Separating them out.
When you do that, you can empower Natalie
to see if she can take back control of her life.
Then the person can see themselves as a separate entity.
It's very easy to think you've become the eating disorder.
You have your own paranoias anyway,
but then you think, everybody thinks I am, so I am.
The family is an important part in that process.
I've got a wonderful young student
that is a peer of someone that has an eating disorder right now.
Unbelievably insightful.
Even at the age of 12 and 13, as a member of that family dynamic
working with the individual around eating disorders,
has the capacity to tell me that he knows when he's talking to the anorexia
versus when he's talking to his sister.
He has strategies for choosing not to engage in the anorexia,
which is bossy and controlling and demanding.
He has an, oh, yeah, whatever.
But he can engage and communicate with his sister.
Positive reinforcement for normal behaviour?
Absolutely, in family system. I think, isn't that beautiful?
Even a person this age can learn to be part of that healing process
within the family dynamic.
It's not deep and meaningful, historical, psychodynamic therapy,
it's here and now, cognitive-based,
reinforcing positive behaviours and not making a battlefield over dinner.
Normalising eating is the big challenge. That's what the family model does.
It tries to have the family sitting at the the table having a normal meal.
There's a few questions.
The first is from a general practitioner in Queensland -
'As a general practitioner,
what investigations are essential with eating disorders?'
With an eating disorder, you've got to look very carefully at the physical.
Investigations you're wanting to do are full blood testing -
things from absorption like iron, B12, folic acid,
which reflect throughout other absorption issues.
Looking at things like cholesterol, blood sugar,
of course, liver and kidney function.
NORMAN: Electrolytes. - Electrolytes.
You've got an idea of how the body is working.
There's also looking clinically as well - blood pressure, pulse rate,
temperature - making sure that those marry.
And then also the actual symptoms the adolescent may have.
I understand you can be hypothermic.
That's one thing that you can measure and keep an eye on.
NORMAN: The Swedish system warms you up.
- And refeeds. - Even in a hot climate.
A psychologist in Victoria asks, along the same lines -
'Shouldn't we be using BMI
as an indication of an eating disorder?' Jenny?
You can. The number we use for a fully grown adult woman would be 17.5.
Anything below that is considered to be an eating disorder.
- Really? - Yes.
- Until otherwise proven. - You can use that cut-off.
We published a paper in The Lancet about BMI and pre- and post-menarcheal girls.
Post-puberty, they're naturally going to be bigger and heavier.
I think it's more psychological - have you lost weight?
How do you feel about your weight? How would you feel about gaining weight?
They're the classic questions
that give you the answer about disordered body image.
A question for you, Jane, from a general practitioner in Wagga -
'What medications are advised with eating disorders?
Should SSRIs be used routinely?'
It's really important to make an assessment
with the person with eating disorders of anxiety and depression -
just as Natalie was saying about the incredible anxiety she feels -
and also with the low mood.
As a GP I would tend to give them an SSRI that would give them some relief.
NORMAN: You would? - I would.
I'd love to hear what the panel says.
What I'm wanting to do is to enable them to cope.
An SSRI often allows them that.
I'm the GP. I don't know what the experts would say.
In people I've spoken to,
and I had a conversation with a psychiatrist who specialises in this,
I asked him that exact question.
We know there are a lot of studies that show that if you treat depression
with anti-depressant medication, you'll also improve the bulimia.
He said that some of that is that the medication
helps them control appetite as well.
It gives back some control over the binging behaviour.
NORMAN: There have been no controlled trials. It's unknown territory.
Yes.
He also mentioned that
another thing they're now getting evidence for is omega-3,
and that being very helpful.
The anti-depressant effect of omega-3 fatty acids.
A question from Marisa Pilla in Cairns -
'Is there any use for the computer program Climate?'
And, 'Some studies show high-dose zinc and weight training helps.'
Jenny?
There have been a number of trials with online information,
online self-diagnosis, if that's what Climate is.
I'm sorry, I'm not familiar with it.
NORMAN: Anybody know what Climate is?
Anything that helps engage the patient will help.
The comment about weight training is an interesting one.
What we tried to do working through the academy
and institute programs within elite sport
was to get this shift from being skinny and thin,
and actually start working on being lean and strong.
Lean and strong was about the strength, or the weight-gaining component.
NORMAN: You've got to eat to be strong. - Yes, you do.
You might be looking more at the composition.
That was another question from a viewer -
'How do you manage the line between the perfect competitive weight
and an eating disorder in an elite athlete?'
One way of doing it is looking at what they call O-scales -
looking at the bone mass, the muscle mass, the body fat.
In the past, our academy in the ACT was one of the first
to throw out skin-fold testing.
They used to just measure people's body fat.
You do that to teenagers, whose bodies are changing,
they were exacerbating the issue.
We requested that that be ceased, and it was at the academy.
We had individuals we were trying to re-educate
and get the shift from skinny to lean and strong.
Looking at O-scales could be helpful and beneficial.
I interviewed somebody at Stanford,
in their eating disorders clinic last year.
They said, red light flashing - online.
Often kids are referred to online, but there are sites
which actually bolt them on.
There are pro-anorexia sites.
You think your kids are getting therapy, but they're bolted onto their problem.
To parents, I would say, keep your eyes wide open.
The Foundation of Victoria, I'm sure there are others,
but they have a chat room which is very strongly moderated.
They're only allowed to discuss positive ways of managing your eating disorder,
bringing out issues.
NORMAN: Not being proud of it. - Yeah.
Or competing, or finding new techniques for purging.
We're working every day at ways of stopping these sites.
But it's a big, big task.
NATALIE: Parents need to be aware of what their kids are.
It's not just their friends they're talking to,
it's somebody across the world, giving them new tricks.
There are... (Speaks indistinctly)
Let's go to our first case study. Jim is a 45-year-old dairy farmer.
Things have been tough during the drought,
and Jim's wife has made a appointment with you, Jane, as your patient.
She's increasingly become concerned
because he's lost a lot of weight in six months and he's eating little.
In a case like Jim, the first thing is that
loss of weight doesn't necessarily mean an eating disorder.
Somebody of that age in a rural area, where we know there's droughts,
increasing inflation, an increase in petrol -
probably enormous reasons to be depressed and anxious.
That can affect his appetite.
The other thing, as a GP, you want to make sure that physically he's alright -
there's no illness affecting it and no malignancy or any other thing.
If it talks like a duck, looks like a duck, walks like a duck, it is a duck.
He's more likely to be depressed than anything else.
There might be a few questions - make sure he's not dieting and things,
but it's not the first thing I would think of.
If he's 22?
JANE: 22 would be a bit different.
It would depend.
NORMAN: And buffed.
That's what I was going to say.
It would depend about his appearance and his presentation and his concerns.
If he's concerned he may not have lost enough weight,
that his physique isn't right, is he doing enough exercise,
and when you inquire that he's doing four, five hours a day,
those are things that would alert me
that it might be something other than depression.
But also in rural boys, we do see depression and anxiety.
That may result in some weight loss as well.
Let's stick with boys for a moment.
Gaye, you've got a 22-year-old male
with an exercise analogue of anorexia nervosa, an eating disorder.
How would you assess him, what would you do about him, how would you help him?
The behaviours I tend to have seen more, thinking of individuals I've worked with
more along the binging, bulimia side of it, the purging behaviours...
Purging behaviours will often be training in sweats to lose body fluid,
they would be excessive overtraining -
doing additional training on top of what they're supposed to be doing.
They would be engaged in vomiting behaviour.
They would be engaged in trying to use laxatives and diuretics,
although diuretics give a positive blood test
and could turf you out of competition.
A number of things with working with individuals like that is,
you've actually got to look at the motivation in the first place.
It's very difficult, if they're trying to make a weight category
to compete in a particular competition,
and you're concerned that what they're doing
is not healthy for their wellbeing.
You've got a duty-of-care responsibility.
NORMAN: Coaches need to watch out. - Coaches need to be aware,
and anyone else involved in that individual's life.
The team or the crew often are people that might alert you
that they're concerned about a fellow athlete or competitor.
We need to hear that through a third party.
Often they're more aware.
Working with them, I've also found that a lot of these individuals
end up with a form of depression, a physiologically driven depression.
The demands that are being placed on them to compete hard, to train hard
and to do so with a really light body weight
can also spiral them off into having a depressive episode.
I've worked with individuals for up to two years to correct that,
post them having retired.
There are a number of individuals
that you have to look at the decision matrix - why are you doing this?
The benefits from it and the costs from it.
There are individuals I've helped both in sport and in dance
move out of that industry because of what it does for them.
You hear of young men who,
the six pack is the analogue for the sylphlike female model.
That's what they're striving for, and they're not really involved in sport.
Jenny, what do you do about that situation?
Talking to them, finding out what they're doing.
If they're doing more than two hours of exercise a day
that's not related to their career or their sport, that's probably too much.
NORMAN: Does it go with steroid abuse? - It does.
It goes with the gym environment, the peer group.
They spend their lives there.
I had a patient who would quite like to be married,
but he spends his whole life at the gym lifting weights with his mates.
And made himself impotent with steroids.
Very boring - you know, no conversation at all.
It does go along with that drive for muscularity.
It goes along with steroid use. They're rife.
I had boys in my study who were injecting insulin to try to gain weight.
I have boys who are taking all sorts of pills.
They couldn't tell me what the pills were.
Some drug dealer at a gym had sold them these pills to bulk them up.
It's a dangerous pattern.
It's harder for them to see a problem than somebody in Natalie's situation.
That's right. It's not abnormal.
Men are supposed to be big and tough and muscular.
Everyone at the gym uses steroids.
One approach that I do use
is not to necessarily focus on what they're doing as being all negative.
I might look at the strengths and qualities it's taken this person.
They've got to be determined, focused, they've set goals.
Try and pull out the positives.
NORMAN: And redirect them. - Redirect it.
Say, it's not because you're muscular or you're thin that you're this person.
It's because you have these qualities or abilities in the first instance
that you've been able to channel them here.
Where else would you like to channel them?
Where else can you use them in a useful way in your life?
Make them aware of those strengths.
You're taking something positive
out of what could initially be seen as dysfunctional.
Do you get many calls, Natalie, from boys?
Last week I had four clients that were male,
all different ages and stages.
That's something you brought up before when we were talking about Jim,
saying that he was he was in his 40s.
Then we went on to younger, and we had this big conversation.
It's important to know that eating disorders don't discriminate with age.
- You could have a 45-year-old. - Yes.
We often do think, they're too old for that.
They're not necessarily.
Although it might not be the first thing on your mind...
NORMAN: Why did they call?
Why did they call?
What made them lift the phone?
Most people who get to that point have gone through the denial part.
They get to a stage where they want to start acting.
They've decided something's really wrong, but they want to prepare it.
They don't want to just go in head-first.
So they'll ring up, and often I'm their first port of call.
They've never disclosed to anybody.
- Rehearsing the path to recovery? - Pretty much.
I've had people ring who have kept it hidden for 40-odd years.
It's such a hidden secret.
NORMAN: This is part of the control? - Absolutely.
- They want to map it out. - How to fix it.
I'll often get calls from someone who says,
nobody knows, I don't want anybody to know.
You were asking if my parents knew.
I speak to people who have been married for 15, 20 years,
and their partner has no idea that they've had an eating disorder.
That's why the GP is so important, because they will go to the GP
and say, I want to move on with my life. I want to change, can you help me?
That relationship with the GP is perfect.
I had an elderly aunt who was 80 who I reckoned had anorexia nervosa
and wouldn't admit it to the family.
Let's go to our next case study.
Ellie's mother consults the school counsellor - you, Gaye -
about her 16-year-old daughter.
Ellie's competitively dieting with other kids at school
and has lost a noticeable amount of weight in the last few months.
It's not unusual to start in that age group.
Young women hit puberty and oestrogen kicks in
and they get hips and *** and their body is changing.
At the same time all those body changes are occurring,
they're trying to figure out who they are, where they fit in in the world
and trying to establish some sort of identity for themselves.
For some, that identity may be linked in with,
if I can't be the smartest girl in the school or the best musician
or the best athlete, I can be the thinnest.
That seems to be an aspect they can get hooked in to,
that they focus and put a lot of energy into.
It gives them some definition of who they are.
As Natalie mentioned, there's a lot of kudos.
Natalie talked about the fact that when she started losing weight,
she got comments about how great she looked.
It's very much reinforced.
The first thing I'd do is reassure Mum that it isn't unusual.
We're not stigmatising it or making Mum feel bad.
Then we'd probably start looking at what we might be able to do.
Given that this is a potentially fatal disorder,
what assessment are you going to do quickly to make sure she's not at risk?
The first thing I would do in that instance
is ask Mum to connect back with the GP
and to have the GP have a look at her daughter
with respect to some basic physiological assessments.
NORMAN: You'd deal with the head and allow the GP to deal with the body?
You've first got to make sure the individual is physically safe,
that their physical wellbeing is safe. That's the first port of call.
NORMAN: That Jane was talking about earlier?
I would refer her to the GP.
Then I would want to communicate in liaison with support from the GP
and the parents, in terms of what we might do with the child.
And also look at what the school can do in terms of supporting that individual.
Natalie spoke to us about a lot of her anxieties.
If any of these anxieties are school-based,
we want to know what we can put in place in terms of pastoral-care support
to reduce some of those anxieties while they're in the school environment.
Then there's the family work as well.
I have young people who are hesitant to speak to me.
Maybe Mum or Dad has come in.
I might do a number of sessions with Mum and/or Dad
before the young person even comes through my door.
That family-therapy idea we spoke about - reinforcing the positive.
Supporting the parents to understand what's going on,
how they might open up communication with their daughter.
NORMAN: What's the advice for mealtimes?
For mealtimes? When you get to someone that is at that end
in terms of concerns with it,
I would look at referring them back to consultation with the GP.
Where are we at right now? How far at risk?
The parents will ask, what do we do at mealtimes if she doesn't eat?
Normalise mealtimes.
You don't want the family to adjust their eating
to accommodate the disordered eating.
You want to normalise the young person into the family environment,
but you've also got to set small, realistic goals.
There's no point standing over the individual,
making them have the same food the family has.
Family therapists say, the child has to attend, even if they don't eat a lot.
Yes, that's correct.
- But you don't have a battle over it. - It's the socialisation around it.
It's not the eating per se, it's the format and the structure.
You're talking about control again.
Having that structure at a certain part of the day, it's therapy in itself.
If the child says, I'm not coming to dinner?
NATALIE: Who's the parent?
Oh!
Obviously you'll have your sporting and your jobs,
and it's not always ideal to sit down at table.
But if you establish a routine in your household...
You put food in front of her or him
and if it's not eaten, you take the plate away at the end of the meal?
Sometimes the parents are sitting there for a long period of time.
There's a minimum amount the individual needs to eat to stay physically safe.
The consequences Natalie shared with us -
we'll force you to go to hospital and have this amount of food
and take privileges away are very real
if these minimum amounts aren't consumed.
They need to be done in consultation with the young person.
- They need to be realistic. NORMAN: Jenny?
With the family, trying to get them to come to a table
might be something that they never do.
So getting them to eat together, just to role-model that eating,
and giving the girl or boy lots of encouragement
and positive feedback - that's good, you're getting better.
It will stop your fainting, you'll perform better at sport,
your brain will operate better at school.
This food is going to be good for you.
It's not the enemy, it's going to help you.
NORMAN: You've still got to cross that threshold to start eating.
JENNY: Three peas, and that's excellent.
That's important, what Jenny just said then.
It's about looking at what stage they're at
and encouraging that stage.
If you say to someone who hasn't eaten in a long time,
here's a three-course meal. Eat this. Off we go.
If they eat three peas on their plate, that's something to congratulate.
They've eaten it, they've kept it down.
If they can establish that pattern for a couple of weeks,
that's something to celebrate, not - you still haven't eaten much.
What you say around that is huge.
It's something they can manage.
If you're asked to run a marathon next week
and you've done no training, can you do it?
It's not humanly possible, and it's overwhelming.
Let's look at Holding On, a DVD produced by Natalie's organisation,
the Eating Disorders Foundation of Victoria.
I ate as an instinctive thing,
to cover up lots of feelings as I was growing up -
fear, hatred, hurt, pain.
When I was hurt, I would eat.
I didn't understand what was happening.
I didn't understand why I was doing that.
That emotional thing became a habit,
and that habit became problematic in my life.
I would use it every day, all day to deal with things.
I don't know how to describe the relationship I had with food.
It was a love-hate relationship.
It was my best friend, my lover, it was comfort.
It made me feel good about myself.
It made me feel different and special, I suppose.
That's certainly not the way that I see it now.
The way I see it now is, it doesn't make you special at all.
It steals who you are.
There's no you left anymore. There was no me left.
The one thing my parents could not control is what I ate, I guess.
Automatically, by taking that power away,
I guess I began to live my own life.
It was a control issue for me.
I was most concerned about keeping on with the disease.
It was part of my life and something I really wanted,
as strange as that sounds.
I didn't want anybody to threaten it.
Anorexia, bulimia unfortunately became a tool
as to how I dealt with everyday life.
If something was difficult, I ran to anorexia and bulimia nervosa.
I would binge-eat and vomit, make myself sick
and wouldn't have to worry about my day.
I was doing well at school, I had great friends.
Family life was as it should be.
There was nothing out of the ordinary for me.
This was a release for any feelings of self-doubt I had.
I thought I was being really brilliant.
I could think of a way to lose weight, which was just to vomit.
Eat as much as I wanted and throw it all up again.
I thought I was really clever.
I just thought I had a healthy exercise habit and a healthy food habit.
To think I got so ill so quickly didn't even figure.
Self-esteem, confidence, in control.
And they're three things that I've always struggled with.
Before I got to my teen years, I'd always been a performer.
Somebody only had to say one thing to me and I'd just curl up into my shell.
I was very sensitive.
Someone would make a genuine criticism and I'd take it to heart
and curl up in a little ball.
I was always a perfectionist at school.
My mum's got pictures of me when I was, like, three years old,
and I've got my socks pulled up perfectly level.
She said I had to have my pigtails equal and my socks level.
That was the thing - perfection.
If I couldn't get what I wanted, it made me really angry.
In a way, making yourself sick is a kind of self-harm thing.
It's a punishment as well.
So while it did make me feel better, I was punishing myself on occasions.
Holding On, the video from the Eating Disorders Foundation of Victoria.
Jenny, what can a general practitioner do to encourage this weight issue?
This is a question from a general practitioner in Victoria.
The relationship with the GP needs to be strong and ongoing
from childhood right through to adolescence.
If you have a young person in your office,
they love to have their height done.
They like that reinforcement from the doctor that they're growing nicely.
This is your stage of puberty, this is where you're headed.
You will become rounder and more voluptuous, and that's normal.
Your body is growing very beautifully. That's a very positive thing.
- Permission to have body fat. JENNY: Yes.
Do you do that, Jane?
I wish I did.
NORMAN: You will now. - I will definitely now.
There is that positive reinforcement,
making sure you have a relationship with the young woman, the teenager,
that is positive, non-judgemental, supportive and caring.
Tell me what you do in a country town
when you've got one you're losing the plot on.
This can be very difficult.
It's wonderful tonight to be able to listen to everybody here.
Often if you're in a remote rural or inland area,
you don't have a lot of facilities that you can call on.
Generally there's a community health service.
There will be a dietician with that and a social worker
and maybe a psychologist.
If you're in a larger regional area,
there probably will be more people you can draw on.
There might be private practitioners.
Then you can use things like your EPCs and mental-health care plan.
So you can start building teams.
Just to be brave enough as a GP to hang in there,
no matter if you don't know what to do next.
NORMAN: Keep the child alive. - As soon as you can, ring somebody up.
There's always an expert somewhere, and I've always found them supportive.
A mother watching in New South Wales comments
that her daughter had bulimia and anorexia for ten years with a BMI of 16.
Nothing worked, but the Swedish system did, the Mandometer.
They've moved to Victoria, the Swedish system. What's your view?
The Swedish system has had more studies behind it than most of the others.
For people who don't know anything about it,
I referred to it obliquely, but it's warming, it's fixing up the teeth.
There is counselling - cognitive behavioural therapy.
There's refeeding, which is speed and content, on a computerised system.
That's right.
It's interesting because they don't believe it's psychological at all.
Everybody has their own views on that one.
Yet they do use psychological practices.
When you speak to them, they do.
The one thing they do that nobody else does is,
they monitor them for years afterwards.
Going through all those - control, perfectionism, et cetera -
these guys will often keep working at it
because they know someone's going to pull them up later on it
and say, how are you going?
They're not going out of the system and being forgotten about
until they're recommitted.
They're doing for weight gain what other people do for weight loss.
NATALIE: That's it.
Another question - 'Is *** or emotional abuse
connected with eating disorders?' Jenny?
There are a few studies that talk about the high risk in homosexual men,
that there's high pressure to be thin and to have a perfect body.
Nothing conclusive.
This is talking about abuse rather than orientation.
Yes. There's strong links with *** abuse.
You can see the emotion, the psychological problems
coming out in the eating disorder.
There is a relationship with *** abuse.
Gayelene, a question from a general practitioner in Queensland.
It seems that many Australian coaches need to be educated
about the impact of their activities on weight and eating disorders.
Is there much education going on in sport,
particularly school and club-sport level?
I would absolutely agree that we need to do a lot more of it.
The Australian Coaching Council in the past
used to include it as part of training for its athletes,
but I don't know whether that's still up and running.
I would think, generally speaking,
we do a reasonably good job with our teachers,
but we don't necessarily include it as a requirement for coach education
at the different levels the coaches might go through.
I'd like to see more of it too.
There's another question here, Natalie, about websites
from a pharmacist in South Australia.
Websites - which ones to avoid and whether schools should block these
and whether parents should be blocking them.
Anything that is pro-anorexic, pro-eating disorder,
in other words, promoting the behaviours, talking about them.
Often, when people are in the throes of an eating disorder, they want new ideas
on how they can support it.
They will source it out if they need it.
This is where awareness has to be on people who don't have eating disorders.
Most of the eating-disorders foundations in the different States,
they're pretty safe.
You're looking at people
who are working with people with eating disorders every day.
If you're not sure, ring the help lines
and they'll lead you in the right direction.
Schools and parents should definitely block the sites.
They're really pernicious sites.
They encourage the eating disorder.
They're called pro-ana sites or pro-mia sites.
They might be promoting anorexia nervosa, promoting bulimia.
They say it's just a lifestyle choice.
A general practitioner in New South Wales
has a very close friend who's a dentist who sees the erosions with bulimia.
How can we share information about this? Have you got any suggestions, Jane?
Communication between all health professionals is a great thing.
It doesn't always happen.
Even if they can ask that person, talk about it, as can be done.
Just ask them to see their doctor.
Perhaps just bring up that they've noticed it
and why it may occur, their experiences in the past.
Communication is good.
We're running out of time, but we must touch base with bulimia.
Gaye, what's the story with bulimia that parents and GPs should look out for?
The sort of presentation I would normally see
is a young girl in her teenage years.
She might be in her last two years at school, so 11 and 12.
There's a lot of pressure around academic performance and exams.
She's likely also got a talent in music or dance or sport
or some interest she's also endeavouring to perform well in.
She might be involved in school reviews, things like that.
You've got young people with a lot happening, a lot of stress,
high expectations, and they start to feel out of control.
Slipping into bulimic behaviour
can be one way of trying to find some aspect of their life
that they can feel in control of.
What are they doing, Natalie? What's recognisable?
Is it leaving after every course and disappearing to the toilet?
It can vary.
Usually, if they go off on their own, whether it be to the toilet or...
But it doesn't have to be immediately after.
Sometimes, especially if they think they're being watched,
they'll hold on till they think they're in a safe zone.
If they've got a time limit,
if they know everybody's leaving the table in 20 minutes,
they'll wait for 20 minutes because everybody leaves.
You might look at other things, like changes in mood swings,
in energy levels, whether there's a change in their ability to concentrate
and focus on things.
Are they isolating themselves from situations
where they would normally meet friends and have a meal?
They're behaviours that might indicate that something could be going on.
What do we do, Jenny? What's the assessment and what's the management?
Differential diagnosis is really important for the GP.
You're trying to work out what you're dealing with.
You're trying to work out if you're dealing with anorexia nervosa
or bulimia nervosa or a whole array of eating disorders.
Interviewing, doing good histories,
getting a handle on what you think you're dealing with is very important.
Checking the bloods and the blood pressure regularly.
Keeping the patient coming back to you regularly
so you don't lose track of them.
That's the important thing for treatment.
It's gonna take a long time. Tell the parents it's going to take a long time.
NORMAN: What's the therapy that works? Is there any? Just hand-holding?
If you have a 13-year-old girl who's lost so much weight
that she's passing out, you need to put her in hospital.
That's more anorexia than bulimia, isn't it?
The treatment for bulimia, it's psychological.
It's cognitive behavioural therapy.
The classic sign with bulimia is they simply cannot stop eating.
It's totally out of control.
They'll come to you because they've gained weight.
The therapist, the counsellor is trying to find those triggers
that trigger out-of-control eating behaviour.
You're looking at trying to regulate thoughts and emotions.
We know that how we think can affect how we feel can affect what we do,
and can go back the other way.
Working with a young person suffering from bulimia,
you're looking for the psychological and emotional links
that trigger the purging behaviour in the first instance.
JENNY: It's the binging behaviour.
I meant to say, binging behaviour.
You're also looking at factors such as
helping them develop some life skills and strategies
about other choices they might have to deal with those periods of anxiety
which trigger the behaviour.
You're trying to help increase their awareness.
You start looking at what are their mental processes?
We've got to start listening to ourselves internally.
Then we try and make the links between when an event might occur
in that young person's life that might then trigger off a binging behaviour.
You're trying to get awareness happening first,
then upskill them with a range of different things
that give them alternative choices about which approach they might take
to deal with issues that are causing them distress.
To add to that, you cannot change another human being's mind.
If these guys are in a head set where they're not ready yet,
they're still listening all the time.
Everybody has 'aha' moments.
Most people have 'aha' moments where something just clicks.
Although you cannot make somebody start to get better from an eating disorder -
you're saying, holding hands - you can create awareness.
You can bring out communication. You can educate yourself.
- You can give them options. - Give them lots of options.
The more options they have, the more they realise
they can control something they're not ready to let go of yet.
They can see there's other ways to maintain control
without having to be destructive.
You're empowering them to make smarter choices or decisions.
By giving them lots of options,
you're letting them fit what best suits them.
There's no one technique you would teach a young person with bulimia,
but you would look at a range of possibilities.
The individual will know what will fit best with them
or what they feel might work for them.
Jane, finally, we heard from Jenny
about what she thinks is the role of the GP
from early childhood, to prepare the child
for the growing-up process,
and that it's a normal thing to become more rounded, et cetera.
What do you think is the role of the GP in terms of prevention,
early detection and intervention?
Often as a GP, you are in that position where you are seeing young teenagers.
You're able to perhaps to pick up on changes in diet, changes in behaviour,
fainting or not coping with sport.
You can see that in the whole picture.
You don't have to be thinking - eating disorder.
But you can be thinking about getting good information.
You might just make sure you monitor it, make sure you get them back regularly.
It's really important as GPs, listening to what everyone was saying,
is that often we don't know what to do.
If it's a severe case, it can be very daunting, as a GP.
But if we just stay with it and see that person regularly,
we at least give them an environment
where they can gain information if they want.
They can fail, they can come back.
As long as they know that that's alright
and we're not going to get angry with them...
As a GP, it's really hard when people don't get better!
Then we're doing the most important thing we can.
It's lovely to have that extra input today about little things we can do
in terms of behavioural stuff.
Gaye, what's your takeaway message for those watching?
Trying not to be judgemental,
and separating the illness out from the person
and recognise that they're two separate entities
so you can keep the self-confidence,
self-esteem and value of the individual intact.
NORMAN: Natalie?
I would say that eating disorders do not discriminate.
That's really important to hold onto.
Also that inside, the strength that keeps and supports an eating disorder
is the same strength that will get you through recovery
and maintaining it forever.
NORMAN: Jenny? - Take-home message?
I guess that...
Buy your book.
Yes, buy my book.
And make sure your local high school is doing sensible things in health classes.
One message for GPs, certainly Jane has hit on it,
is that you're a worthy person.
Keep coming back and seeing me.
Your worth is not about your weight.
Thank you very much. A very important program.
I hope you've enjoyed the program on eating disorders tonight.
If you're interested in obtaining more information on issues raised,
there are a number of resources available
on the Rural Health Education Foundation's website:
And here's the number of the Eating Disorder Foundations of Victoria,
which you can ring from anywhere in Australia:
Don't forget to complete and send in your evaluation forms,
and please register for CPD points by completing the attendance sheet.
Our thanks to the Department of Health and Ageing
for making the program possible.
Thanks to you for taking time to attend and contribute.
I'm Norman Swan. From all of us, bye for now.
Captions by Captioning & Subtitling International
Funded by the Australian Government Department of Families, Housing,
Community Services and Indigenous Affairs�