My Experience with Atypical Anorexia
By: Valentine Esposito Everyone gets 1 ¾ breadsticks.
Every time my mom would make spaghetti and meatballs for dinner, which always came with requisite breadsticks, I would make a painfully deliberate point to announce the equitable distribution of carbs to my Italian family of six. Being the oldest sister, I probably could have just taken two breadsticks because birth order does bestow one these kinds of inherent rights, but I let my sense of justice supersede my profound love for bread (love you, Oprah).
Even back when I was little, before the advent of Instagram models and a formal conceptualization of calories, food was always about numbers. But I liked numbers. School and grades were about numbers. The interest collecting on my Holy Communion savings account was about numbers. Numbers were good, except for when they timed the mile in gym because that shit was fucking miserable. And eventually, I became a number: my weight.
I distinctly remember looking in the mirror before school one morning in sixth grade and thinking to myself, “Wow, my butt looks fat.” Now, given the matching sweat suit I was sporting regularly, my transition lens Harry Potter glasses, and the fact that I carried my saxophone around with me all day (obviously I wasn’t going to stop at my band locker and then be late to class, I’m a scholar after all), my ass was the least of my problems. And hell, was maybe even my best feature back then. But rational thought is lost on middle schoolers, or at least it was on me.
And from there, I just kept going. Feeling fat became my baseline and on a typical day, I hated nearly every inch of my body (I always did like my eyes though- thanks, Grandpa Brooklyn). By the end of high school, I had tried virtually every diet I could get my hands on. None of the diets worked though. I always had a supremely difficult time losing weight, and this is likely because I never needed to lose weight. My body looked different than those of many of my peers (which makes sense since all bodies are different), and it certainly never looked the way I wanted it to, but I was never clinically overweight; I was just always heavier than I wanted to be.
Wanting to be thinner, lighter, to take up less space, is a powerful thing. But my ambitions were usually more powerful. I never entered Eating Disorder territory because I always had a more pressing goal in front of me: Medical School. I didn’t have the time to exercise excessively, and I needed food to fuel my brain so that I could ace my never-ending exams. I just couldn’t have an eating disorder - my schedule and professional aspirations wouldn’t allow it. To be clear, this is not to say that having an eating disorder is a choice. Like all other illnesses, eating disorders do not discriminate and no one chooses to have an eating disorder. However, for me personally, my eating disorder was sparked and facilitated by having the time to fixate on my appearance and regularly perform eating disorder behaviors after a lifetime of predisposing risk factors.
But when did I have the time to have an eating disorder? Great question. That would be my third year of medical school during my protected Step 1 study period. For any medical students and doctors reading this, you’re probably laughing right now. For non-medical readers, Step 1 is the defining licensing exam for medical students. This one test more or less determines which type of doctor you will be and where you will be able to train for residency (I think this is ludicrous, but that is a rant for another time).
While I studied hard for Step 1, I felt like I had all the time in the world. For the first time since preschool, I had blocked off my entire schedule to devote myself to one goal and one goal only - this fucking test. Previously, I ran around doing a million different things, so this felt like a vacation in an odd way. Before this "vacation," like any medical student, I would just eat whatever I carried in my short white coat and tried to fit in a workout when I could. But in Step 1 Land, everything fell away, and I could make time around studying to eat and exercise in a way that I felt was finally perfect.
I started cycling which isn’t exactly a problem in it of itself, but my attitude towards it became an issue. While cycling was ironically the hobby I picked up to prevent an eating disorder, I had decided to start focusing on what my body could do instead of how much it weighed- I quickly began abusing this form of exercise once I discovered how many calories it burned. On top of the viciously strict diet I had been keeping the entire year prior, I began skipping meals.
When I finished my test, I realized that I may have a problem. I felt profoundly guilty when my regularly scheduled life wouldn’t let me cycle for hours a day and eat meticulously. This imperfection of food and exercise added to my baseline anxiety, which I had felt to be worse than usual at the time. I knew this wasn't healthy, but "knowing better" didn't stop me from hurting myself.
I decided to turn myself in. I told my doctors that I thought I had an eating disorder, even though I knew I didn’t meet criteria for an eating disorder given my body weight wasn’t low enough. And this is where, again, I discover that I don’t actually know everything there is to know about medicine. Admittedly, I never believed I knew everything, not for a second, but I knew enough medicine to be perpetually dangerous to myself.
It turns out that I met criteria for atypical anorexia, a formally recognized eating disorder in the DSM-5, grouped under Feeding or Eating Disorders Not Elsewhere Classified. Did anyone else have no idea this existed? Prior to this knowledge, I had been operating under the false assumption that I didn’t have an eating disorder because I simply didn’t look like I had one.
And everyone agreed. Everyone told me how skinny and fit and “healthy” I looked, healthcare providers and medical school peers included. I was endlessly commended for getting in shape and losing weight, but no one ever inquired on how I did it because the result was more important than the process and because the result, a "normal" BMI, didn’t suggest pathology. Maybe if someone had, I would have fessed up sooner.
Realistically, I most likely would have bullshitted my way through any inquiries into the mechanisms behind my weight loss because I didn’t particularly want to get caught. “I just finally found an exercise I love.” “Oh, you know, it’s just Step 1 stress. But I’m feeling great now!” “IT’S NOT A DIET, IT’S A LIFESTYLE MOTHERFUCKER.”
But again, no one asked how.
I wished someone had asked me how.
Peers in medicine, we need to stay curious. We need to ask our patients how. And not just about weight loss. We need to make the time to inquire about how our patients are achieving their health goals, often times the same ones we work with them to craft. It is insufficient to only applaud patients for losing weight, lowering their A1c, or quitting smoking. Your patients very well may be skipping meals, ceasing payment for their hypertension medications to afford their insulin, or picked up another abusive substance to quit smoking. We won’t know - we can’t know - unless we ask.
Instead of being so quick to be supportive cheerleaders and advocates for our patients (which I will say is my favorite job in the world), we need to be patient-centered critical thinkers first. It is imperative that we look beyond general appearance and beyond numbers and commit ourselves to taking a thoughtful 360 view of our patients’ health, to seeing the people behind patients. We owe it to them to ask the delicate, but life-saving, questions of how, because if we don’t, there is a chance no one else will.
Understanding HOW is our job, and, frankly, we need to do it better.