During the summer that she became anorexic, Evlyn Carlin began each morning with a five-mile run, followed by a 250-lap swim in the pool.
Then she got serious.
Five days a week, Carlin spent the next six to eight hours at her local health spa, taking aerobics and fitness classes and lifting weights almost without rest.
Starving herself on a diet of 600 calories a day on top of the exercise regimen, Carlin transformed herself in three months from a 125-pound UC San Diego freshman to a sickly, 95-pound "basket case" whose clothes hung from her bones.
"I was definitely distraught if I couldn't do my exercise," said Carlin, who seven years later has recovered from the disorder, anorexia nervosa. "And I was more weight-conscious. I couldn't eat."
Less well-known than the self-starvation of anorexia nervosa or the binge-purge syndrome of bulimia, such exercise compulsions are a significant facet of the eating disorders that affect millions of women, and might be growing more common with the increasing popularity of fitness regimens, experts say.
"I think that we're seeing it more because there's more of a focus in the culture at this point on being strong instead of just skinny," said Judith Brisman, a psychologist and director of training at Bulimia Treatment Associates in New York City. "You're going to see it more."
Eating disorder therapists are focusing more attention on this driven, joyless activity and wondering whether it is linked to women's recent entry into the competition of traditionally male career roles.
"This is linked to the change in women's roles," said Susan Wooley, co-director of the eating disorders clinic at the University of Cincinnati Medical College. "Women reaching maturity today are expected for the first time I can think of to model their roles not after their mothers but after their fathers.
"Body type has become a strong symbol of that. The body type that women are aspiring to have now is male," she said.
More than 50% of anorexics use calorie-burning exercises such as running, bicycling and aerobics classes as part of the self-starvation process that characterizes the occasionally fatal disorder, during which women lose at least 25% of their ideal body weight. About 1% of teen girls, usually those from middle- and upper-class homes, become anorexic, said Michael Strober, a UCLA psychologist and editor of the International Journal of Eating Disorders.
Anorexics can be very tenacious in their quest to exercise, driven by a fear of fat that seems unreasonable to those viewing their shrunken physiques. At the Balance Program, one of two major San Diego eating disorder programs, nurses once caught a 70-pound hospitalized anorexic running in place with feeding and intravenous tubes still hooked to her body.
"It's not uncommon for families (of anorexics) to tell me that they'll wake up at two in the morning and hear their kid exercising," said Jackie Beck, a licensed clinical social worker and director of the Balance Program, which is at Harbor View Medical Center. Carlin, now a 25-year-old therapist at Balance and an assistant to a private psychologist, said she had no hint of eating disorders through her high school years, and never thought twice about indulging her yen for full meals and midnight snacks. But once she started college at UCSD, friends began lecturing her about avoiding "freshman spread," and peer pressure slowly began to change her eating habits.
Spending the summer at home in Rolling Hills Estates on the Palos Verdes Peninsula, she soon found herself focusing on food and exercise.
"It wasn't anything where I said, 'I'm going to get anorexia nervosa, and I'm not going to eat anymore,' " she said. "It's more like I didn't have anything to focus on. It became very easy for me to become obsessed with food."
Carlin began to adopt the ritualized behavior of anorexics, weighing and measuring food to determine its calories and memorizing the number of calories in everything she ate.
"Friends, I didn't have time for, unless they wanted to exercise with me," she said. "Some would come to the spa with me. But if you don't run your five miles a day, you really freak out."
Concentrating on imagined fat on her thighs, Carlin would do hundreds upon hundreds of leg lifts, in addition to endless repetitions with small amounts of weight and aerobic exercise to burn calories off the rest of her body. She never enjoyed it, but was powerless to stop.
"I hate this," Carlin told herself almost every day. "Why am I doing this?"
The answer is that exercise provides a sense of mastery over their own bodies for anorexics bedeviled by the feeling that they are losing control, as well as a convenient escape from emotions such as anger or helplessness they feel prevented from expressing, Beck said.
Anorexics are usually perfectionist overachievers but suffer from low self-esteem. Many become convinced that they can eliminate their anxiety by whipping their bodies into shape, Beck said. "I felt that the less I weighed, the happier I'd be," Carlin said. "My self-esteem got tied up with my weight and the numbers on the scale."
Though no one really knows why some anorexics take to exercise and others don't, some research indicates that there may be a physiological connection between exercise and the disorder.
Anorexics may actually become addicted to exercise. Preventing them from satisfying that craving may produce the same kind of withdrawal symptoms that afflict drug addicts and alcoholics, said Dr. Joel Yager, professor of psychiatry and director of the Adult Eating Disorders Clinic at UCLA.
Less studied, but perhaps more common today, is a phenomenon that some therapists have dubbed "exercise bulimia." Bulimia, sometimes called bulimia nervosa, is characterized by periodic, sizable eating binges followed by attempts to "purge" the body of that food, usually by self-induced vomiting or by taking laxatives and diuretics.
It is also primarily a women's disorder, affecting between 2% to 2.5% of women from 15 to 30, according to Strober. Another study put the rate at 19% of the women in one liberal arts college.
Instead of vomiting or taking laxatives, however, some bulimics purge by burning off calories with huge amounts of exercise.
It is not unheard of for a bulimic to ingest 10,000 calories in a single binge, eating almost to the point of unconsciousness, experts said. In response, some subsequently work off as much as 2,000 calories through exercise, Beck said.
Phyllis Price, intake coordinator at the Rader Institute for eating disorders at Mission Bay Hospital, was such a person. At age 17, Price would rise at 4 a.m. to hit tennis balls against a backboard at her parents' Coronado home for two hours, then go bicycling for an hour. After school, she would jog the beach near her home. The exercise was coupled with the self-starvation of an anorexic.
But within a few years, the disorder evolved into bulimia, a pattern that is not infrequent. Price would alternate eating binges with vomiting and huge amounts of exercise.
At 18, Price was taking four to six aerobics classes a day. At 19, she had become a certified aerobics instructor and was teaching three, four and five classes a day.
"I was real into self-abuse," said Price, now 27. "I'd want to teach the advanced (classes)."
There was "no sense of having fun. The fun was gone," Price explained in terms similar to those used by Carlin. "It was work." Also like Carlin, Price sought acceptance and escape from internal stresses, and reasoned that a thinner body was the key.
But her disorder differed because Price's problems also included heavy drinking and cocaine use. At the worst point, she consumed a fifth of vodka or a full bottle of wine each day, she said. Inevitably, those habits took their toll, making it impossible for Price to exercise.
Many exercise bulimics have difficulty maintaining their pace over long periods of time, falling victim to physical injury, exhaustion and the damage that other forms of purging do to the body, experts said. (Some very driven women will continue to exercise despite serious injuries such as strained ligaments or stress fractures).
Exercise is also a somewhat less efficient way of burning calories, and bulimics sometimes turn to better methods.
Of Brisman's patients, only 5% used exercise as their sole method of purging, and a much larger number used it in combination with vomiting or laxatives.
More impulsive and subject to wider mood swings than anorexics, bulimics usually appear normal in body weight. But their behavior is driven by emotional problems similar to anorexics.
"What underlies a lot of exercise bulimia is the wish to feel triumphant over something, the wish to feel triumphant over one's body," said Mary Anne Cohen, director of the New York Center for Eating Disorders in New York City. "The body is used as a way of feeling in control because one is really feeling shaky in other areas of one's life."
As with anorexia, no one knows exactly why some bulimics choose exercise and others do not. But it is clear that social approval of exercise is at least one factor that makes it attractive to some bulimics.
"Most of the people that are exercise bulimics don't come into treatment," Brisman said. "They'll binge and they'll exercise, and it'll look more normal than someone standing over a toilet. The only time you'll see them is when they mess up a kneecap."
Therapists note that heavy exercise is not the only criteria determining whether someone has an eating disorder, and that regular exercise is important to staying healthy. Some people enjoy strenuous exercise as part of their everyday lives. Some indulge when training for a marathon or a triathlon. Some are professional athletes or physical education instructors.
Such people will take care of themselves by eating well and cutting down on exercise when they are injured or sick. The exercise does not come before friends and family. And they do not become obsessed with the concept, lighting up when they talk about their workouts.
"For some people it's enjoyment. For some people it's their career," Price said. "For some people, it's a manifestation of an emotional problem."
Carol Sullivan, a 41-year-old fitness instructor at the Center for Sports Medicine who exercises about four hours a day, believes that her regimen is no more than a healthy and pleasurable part of her day. She exercises with her husband, eats a low-fat diet and has never suffered from any of the symptoms of anorexia or bulimia, she said.
Sullivan and her husband awake at 3 a.m. to go running, primarily because her husband, a contractor, must be at work early in the morning. After a two- to three-mile run, she does about 30 minutes on a stationary bicycle before heading to a gym to lift weights for about two hours. Sullivan said she lifts very small amounts of weight to maintain trimness, not add muscle. Her workout ends about 7 a.m.
"I love to work out," said Sullivan, who admits she has kept up her training regimen while injured. "I don't see it as a compulsion. When I wake up, I know that I'm going to go running, and I like looking at the stars. I'm not racing like a wild woman."
Women like Carlin and Price, however, need help with their disorders. After life-threatening bouts of alcoholism that included lengthy blackouts, Price sought treatment at age 22 for her drinking problem. Even during her first hospitalization, she secretly continued her practice of self-induced vomiting and eventually checked herself out against medical advice.
But during a second stay as an in-patient, Price revealed her eating disorder and ultimately received help with the disorder in a halfway-house for alcoholics.
Unlike Carlin, she considers herself to be perpetually "recovering" from the disorder, never completely free of the possibility of a relapse. But today she speaks to teachers, coaches and exercise instructors about responsible exercise and how to spot someone with an eating disorder.
Carlin, who spent three years in the grip of anorexia, actually began to acknowledge her problem that first summer, when she broke down sobbing during an argument with her parents over her eating habits. Locking herself in a bathroom, she was shocked by the sight of herself in a mirror.
"They're standing out there screaming at me," she said of her parents, "and I'm swinging from the towel rack screaming for them to go away. And I said, 'Oh my God, look at me, I'm a basket case.' "
Gradually, with some help from friends and psychotherapists, she pulled herself back to a healthy 125 pounds, the weight she maintains today.
"I wanted to check back into life," she said. "I wanted to have a life again."