Article: The Dangerous Dance of Eating Disorders

DAYTON, Ohio -- The churning of her stomach was a good kind of pain, like the fire in her calf muscles after a vigorous workout. She was stronger than hunger, it told her, stronger than everyone else who needed food.
``Emotionally, you are on top of the world at that point in time,'' Caroline Winkler says.
The only time she felt better was when she was dancing. She loved everything about ballet the crowds, the applause, the flowers on stage, but most of all the pride of performing. Winkler the dancer was not an insecure teen-ager but a successful entertainer.

They went together like tights and a tutu, the dancing and fasting. It was obvious to her that the dancing helped keep her thin and her carrot-stick figure helped her dancing. ``You're told the costumes aren't made to fit you,'' she says. ``You're made to fit them.''

How was she supposed to know that her dedication to sleekness would jeopardize her dance career? She's only 19.

How could she be on the brink of osteoporosis, with less bone density than her grandmother?

That's what they told her earlier this year when she left her Centerville home for 17 days in a clinic for eating disorders. Doctors said the intense exercise of dancing is out, for at least a year. They also told her it wasn't such a great accomplishment after all when she weighed as little as 90 pounds at 5 feet 6 inches.

``Dance is my life,'' Winkler said before leaving the Renfrew Center, a Philadelphia women's mental health center specializing in eating disorders. ``It's what I love. It's my passion. Knowing what I've done to myself, that I took my dream away and I'm my own worst enemy, is very scary. I basically shattered my dreams right before my eyes.''

Now on medical leave from Dayton Ballet's second company, Winkler sees a new dream dawning even beyond the formidable task of beating bulimia and anorexia nervosa after six years. She wants to help others recover from eating disorders, preferably without the panic attacks, bald spots, sleepless nights and shriveled bowel that she has endured. ``I want to go around to high schools and talk,'' she says, and she's establishing a foundation to help people pay for the expensive treatment that health plans rarely cover.

The mistake people make in trying to reach those who have eating disorders is in assuming they think and reason the same way as the rest of us. For one thing, says Winkler, people think the problem is food when food is only a means for coping with the real problems. Her story is a rare insight into the thought processes behind anorexia and bulimia.

Winkler believed she had to be perfect. Her older sister's a med student, her mother owns a dancewear store, her father owns an accounting firm and she's what? A dancer? ``I always felt that I was a failure. I love my family to death, but I just felt I couldn't compare to them.''

The best thing about her eating disorder was it insulated her from those feelings. She didn't realize it at the time, of course, but anorexia subconsciously relieved her from feeling anything. ``You don't have time for feelings. You're consumed with thinking about food.''

If someone insulted or slighted her, she didn't have to respond. She could just deny herself another meal, or maybe think about the dry salad she would eat for lunch, focus all her attention on the smell and the taste and the texture.

``A mask,'' she calls her eating disorder. It hid all her problems, not just from herself but from everyone else. Nobody was going to say, ``Caroline, you really shouldn't be so hard on yourself'' or, ``Caroline, why can't you be more assertive?'' To her friends and family, her dwindling body was so obvious that they couldn't possibly notice any other problems.

Eating disorders affect about 8 million Americans, including 1 million boys and men, according to the National Association of Anorexia Nervosa and Associated Disorders,which include compulsive and binge eating as well as bulimia. Between 3 percent and 9 percent of them will die depending on the estimate, making the disorders more deadly than drug addiction.

``It's definitely not something just dancers get,'' says Kara Fowler, a registered dietitian in Cincinnati who is Winkler's nutritional therapist. Sure, it's more common among dancers, models, gymnasts, wrestlers fields driven by appearance and also among chefs and dietitians. But eating disorders ``happen across all age groups, in all types of fields,'' Fowler says.

For Winkler, dancing was another shield from those depressing human flaws. Whatever she did in school or elsewhere, she was a great anorexic and a great dancer. ``Dancers don't need to know anything,'' she told herself. ``Except how to stand on their toes.''

Dancing added the benefit of letting her be somebody else. Even if she didn't deserve much attention and applause the rest of the time, she always got it when she took the stage. She knew she deserved it there, too. She liked Caroline the dancer, and so did everyone else.

``You're so pretty,'' people would tell her. ``You have a great body. I can tell you're a dancer.'' That became her identity, thin and a dancer, ``and that's what I loved.''

Not that she necessarily agreed about being pretty. Even when Winkler weighed 105 pounds, wearing size 1 or children's clothing, she couldn't bear the sight of that blob in the mirror. ``I don't see bones. I see fat all over my body,'' she says even now at 114 pounds.

``My stomach was flat, but never flat enough. My hip bones stuck out. It still wasn't flat enough.''
Her stomach, her thighs, her rear end, ``even my face is too fat.'' She can accept the muscular calves and biceps from dancing, but her ankles? ``Way too big for me.'' So are her fingers. Her wrists, as her weight creeps up, ``are getting a little big, too.''

Worst of all is her lower back. She can't see her ribs there anymore. ``It's so scary.''
Winkler went on her first diet at 13, the age her caretakers mark as the beginning of her eating disorder. She threw up her first meal on purpose at 16. She'll never forget what her dance instructor told the class that day. The guest choreographer had told them to take a break, but when the teacher came back to the studio, she hollered, ``Get up off your fat, lazy, Centerville-snobby asses.''

The instructor was right, Winkler told herself. ``I am fat and lazy. I probably need to start losing weight.'' She threw up her dinner that night, and soon she was taking diet pills and laxatives.

She still ate McDonald's and pizza with the rest of the kids. ``I would just get rid of it.'' Eventually all she had to do was go to the restroom and bend over, without even sticking her finger down her throat.

``I usually kept about one meal a day and maybe a snack down,'' she says.
Sometimes she couldn't sneak off by herself, but that's why she carried laxatives in her purse. ``I popped three or four of those puppies in and the same thing happened.''

This bulimic routine was not painless, Winkler says. Her esophagus hurt almost constantly, and the retching tortured her stomach.

``Almost every time I threw up, I threw up blood,'' she says. ``But it didn't matter what I did to my body.'' Anything she did to stay thin was worth it.

Winkler's fear of gaining weight rarely loosened its choke hold from that first bulimic night at 16. ``That would have been, as I saw it, killing myself,'' she says. Not literally. She never was suicidal. But if anything ever kept her from dancing, that would be ``killing my identity.''

It could happen, she was sure. She had seen other dancers put on probation for gaining weight, and she never lacked for weight-loss techniques.

Among dancers, she says, calories, carbohydrates and resisted cravings are standard shop talk.
Winkler's fear was scarred into her mind like gasoline spilled on the lawn by the time she earned a spot with Dayton Ballet II, the amateur apprentice troupe. Freshly graduated from Centerville High School in 1997, she made her career choice expecting to hear even more emphasis on weight. She was surprised to hear the instructors there talk about better conditioning instead of less weight.

``Our issue is fitness, not thinness,'' says Dermot Burke, Dayton Ballet's executive director. These are high-performance athletes, he says, and they can't function any better on an empty stomach than pro football players.
From Burke's perspective, that's the attitude at most elite dance companies. He thinks dance directors are probably more sensitive to eating disorders than other athletic instructors because anorexia and bulimia have been so closely associated with dance. They're learning to say, ``You're out of shape,'' for example, instead of

``You're fat.''

But that enlightenment hasn't necessarily trickled down to youth instructors, he acknowledges, and they're at the level where dancers

``start to equate goodness with thinness.'' Then when a young dancer starts wasting away, even the most loving friends and family members don't quite know how to bring up the skeleton in the living room. Most of the time, Burke says they don't allow themselves to see it.

Winkler's mother, Susan, missed the signs for the longest time even though she had experienced mild anorexia in her dancing days. Looking back, she can't believe the conversation she once had with a friend of hers as they watched their daughters practice. They were talking about other girls on weight probation, and they decided their
daughters had ``just figured out how to lose weight.''

Not long before she graduated, Winkler told her sister, Valerie, about the bulimia. She must have wanted to quit throwing up, she says now. She even kept the appointments with her school counselor and the Undereaters Anonymous group that Valerie made for her, even though she knew her bulimia problems were over.
``I decided I just wouldn't eat,'' she says.

That summer, a trip to the dentist clinched her decision. She had 25 cavities in 11 teeth from all the stomach acid she had thrown up.

But anorexia was harder to hide from her friends and family. She couldn't go out to dinner and order coffee with a parsley sprig. ``I didn't want people to know,'' she says. They just would have nagged her about eating.
So when she moved into an apartment two summers ago, she went back to bulimia. Not until March 1998, when she returned to her parents' house after foot surgery, did she settle on anorexia exclusively.

The high was what hooked her on anorexia, a light-headed feeling like an exercise high. She'd feel intensely hungry about four times a day, but the pangs would leave after 10 minutes and the high would last for two or three hours. ``But after a while, I had no hunger, and I still had the highs.''

She ate enough, she figured. She had lots of light yogurt and fruit, especially apples and cantaloupe. She knew anorexics died of potassium depletion, so she ate a banana every day.

She had the impression it burned 100 calories to digest an 80-calorie egg, so that was her protein source.
``I wanted to protect my muscles,'' she says. But carbohydrates, starches, dairy products besides light yogurt? Not a chance. After a few months, she always knew how many calories were in her body. She could figure it out in her head.

She suppressed her hunger every day with six gallons of water. She supplemented that with the diuretics in caffeinated Diet Coke and coffee.

When she came home and her parents offered a meal, she would say she had eaten out. ``I lied a lot,'' she says.
She also shopped a lot, oddly. She'd come home with bags of groceries, but she gave them all away. Or she baked. Cookies, pies, cakes, and she always told people she had sampled them while she was cooking.
``The way I satisfied myself was watching them eat, and asking, `What does that taste like? Is it good? Describe it to me.'''

She volunteered to make the lunch runs for her co-workers, and she usually brought everyone back something extra. That was satisfying, too. ``I was stronger than they were,'' she says. ``They were weak. They ate that cookie.''

So it wasn't that Winkler didn't care about food. ``It's all I thought about,'' she says.

She dreamed about the half a cantaloupe she would gorge on for breakfast.

Where others express their emotions by singing or painting or writing poetry, she obsessed about the food she would not eat.

Winkler's parents were alarmed about her weight even before she went to Puerto Rico on a dance tour last June and July. They had argued about her lack of eating. She was down to 105 pounds.

Looking back, Susan says the biggest mistake she made was trying to deal with it herself. She had been through anorexia, both her own and her brother's. She knew what to do. She'd cook Caroline's favorite meals, she'd sit with her at the table, as long as it took, giving her moral support through the meal.

It didn't help.

All Caroline ate was fruit, dry English muffins, unbuttered corn, salmon and crab legs, and not a lot of those.
``We lost real precious time before we got professional help,'' Susan says.

At least Caroline was traveling with her private dance instructor, another recovering anorexic. The coach assured Susan she'd help Caroline gain weight in Puerto Rico. But when she came off the plane in Dayton, Susan knew right away Caroline had lost more weight.

``Her upper arms were so small I could pretty much put my fingers around them,'' Susan says. ``Her legs were tiny and fragile.''

Caroline started spending seven hours a day at the gym and dance studio. She had a chance to get her body fat measured and it was 8 percent. Normal for a healthy female is 18 percent to 24 percent, says Fowler, the dietician at Nutrition Access. Anything below 14 percent is considered dangerously low.
``I thought it was so cool,'' Caroline says.

Her parents felt helpless. ``We didn't know where to turn,'' Susan says, and they couldn't stop wondering what they had done to cause this horror for their daughter, ``what you've said in the past. Did you make comments
that she needed to lose weight? What was going to happen to her? It was awful.''