Dear Reader,

Your friend is lucky to have a friend like you, who observed a change that concerned you enough to ask for help and learn more about what could be going on. A twenty-five pound weight loss in one month is definitely cause for concern. Losing that much weight in such a short period of time could indicate a medical problem. Has your friend seen a health care provider recently? If not, you may consider urging her to schedule an appointment with a medical provider for a physical exam to make sure she is okay. This may or may not be an easy thing for you to do. Strategies to consider when encouraging a friend to see a health care provider include:

Validating your friendship

Convey that you care for her and that your concern is genuine. You can say, "I value our friendship, and I hope you know that I care about you."

Thinking about your approach

Plan what you will say. Be direct with your concern, and focus on your friend's health rather than on her weight. Sometimes it's easier to identify an aspect of someone's health or behavior. For example, "I've noticed that you seem tired all the time"; or, "I've noticed that you seem kind of blue lately." If she's an athlete, you might be able to comment on her decreased performance. Whatever you choose to say, keep the emphasis away from weight, appearance, and food, because sometimes the most seemingly innocent statement can be misinterpreted and unwittingly close a door you had planned to open.

Offering a plan with options

Sometimes it's not enough to express concern. Follow up your observation with action-oriented ideas. For instance, "Is there a health care provider you feel comfortable scheduling an appointment with? If not, I'd be happy to help you find one." Or, "I can go with you to your appointment with the health care provider, if you like, or perhaps there is someone closer to you whom you might like to go with instead."

Recognizing your own limitations

Perhaps going to a health care provider with your friend is outside of your comfort zone. That's okay. It's important to know what you feel comfortable with so you avoid overextending yourself. Maintain whatever boundaries you need to so as not to get stressed out. Choosing to stay within your limits doesn't mean you're not supporting your friend.

It is not clear whether or not your friend has bulimia; however, you have noticed that she is in a serious situation and needs to be seen medically, since her health may be at risk. If you think your friend has an eating disorder, consider the following:

• Individuals with bulimia nervosa tend to be of normal to slightly overweight range. Bulimia typically involves regular and repeated, often secretive binge eating bouts followed by purging, or other compensatory behaviors, to prevent weight gain. In general, purging is accomplished by self-induced vomiting and/or misuse of laxatives, diuretics, or enemas (purging type). People with bulimia may resort to other extreme behaviors, such as excessive physical activity or self-induced starvation (non-purging type) to avoid weight gain. Bulimia is highly correlated with substance abuse. People with bulimia often have a history of misusing alcohol and/or other substances.
  
  
• Anorexia nervosa is characterized by an unwillingness and inability to maintain a healthy body weight. Typically, someone with anorexia is at 85 percent or less of her/his healthy body weight. S/he has a severe fear of fat and weight gain, and has a distorted body image. The seriousness of the significant weight loss is often denied by someone with anorexia.
  
  
• Binge eating disorder is similar to bulimia nervosa in that it is typically characterized by regular and repeated binge eating episodes. An episode of binge eating involves rapidly and uncontrollably eating a large amount of food in a single time period at one sitting until uncomfortably full. Unlike bulimia nervosa, binge eating disorder does not include purging or other compensatory behaviors. Affected individuals are usually obese and have had problems with fluctuations in their body weight. For a majority of these individuals, binge eating begins during a diet.
  
  
• Eating Disorders Not Otherwise Specified (EDNOS) describes individuals who show signs of anorexia and/or bulimia, but do not fully exhibit the behaviors necessary to be clinically diagnosed with anorexia or bulimia. Someone with EDNOS may purge but not binge eat, or binge eat less than twice per week. So someone with disordered eating may not fit into the category of anorexia or bulimia, but still have an eating disorder that requires treatment.

A medical problem can trigger such significant weight loss in a short period of time, and so can depriving and/or ridding one's body of calories. Body weight remains stable when people eat just enough food to give their bodies the energy (calories) that they need for daily activity — calories taken in or ingested need to equal calories out or expended for weight maintenance. People gain weight if they consume more calories than their bodies need and use. If people eat fewer calories than they need and use, their bodies will take the energy from their storage, body fat, and will lose weight. Significant weight loss indicates that there may be multiple factors involved.

Based on your observations, the sooner you take action, the better. If you're comfortable, consider your approach if/when you talk with your friend. Timing is important, so choose when you two can sit in a relaxed environment that allows enough time to talk. Think about what you will say without coming across in a threatening or accusatory manner. Use "I" statements to express your feelings about what you've noticed that seems to be happening with her: "I'm worried that something is going on with your health." Try not to let the discussion turn into an argument or power struggle. If the conversation becomes hostile, back off and resume after you both have had time to calm down and think. Be prepared for rejection the first, fifth, or tenth time you express your concern with her. Persistence could pay off at some point, as the road to recovery is a process. If your friend denies she has a problem, a common reaction, don't take it personally; at least your friend now knows that she can come to you if/when she's ready to ask for or to get help.

If you're a college student, you can get help and support for your friend and even for you in dealing with your friend, from your resident adviser (RA) or residence hall director (RD), dean, advisor, or from someone in the Counseling Department. If you are at Columbia, you can reach out to the Health Services' Eating Disorders Team, Counseling and Psychological Services (CPS) at x4-2878, or a nutritionist or medical provider at Primary Care Medical Services at x4-2284. As you can see, there are many opportunities to begin to get the help you need to be able to help your friend. It is important to remember that she needs medical care, and that you alone cannot fix her. She's lucky to have someone like you who cares enough to reach out.

In an emergency situation, however, you need to involve your friend's RA, RD, and/or dean to make sure she gets appropriate help immediately. Signs that indicate an urgent situation include sleeping all day, blacking out, suicidal thoughts or attempts, or significant weight loss, such as in this case. You may feel reluctant to blow the whistle on your friend, but you will be a better friend by helping her get the assistance she needs than by respecting her privacy in this specific situation.

Alice

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