When Charlotte Stoute is anxious about a test, she struggles to control her mind before her disordered thoughts do.
The past two weeks have been the longest the freshman has abstained from binging and purging to relieve her stress in as long as she can remember. On her worst days, she used to purge up to 15 times per day-her throat burning and shedding blood. She described her eating disorder as a "crutch" she leaned on when everything else seemed uncontrollable.
"It's such an excellent distraction because you have to face food every single day," she said. "For people who have a dysfunctional family or have traveled a lot, an eating disorder serves as an event or hobby that is constant throughout your life."
Stoute's experience with anorexia nervosa began when she was a preteen, as a dancer in Panama. She starved herself, and no longer had enough energy to dance.
"Just smelling food would make me feel like I'd gain weight," she said. "[When you have an eating disorder], you're scared of food as if it's a toxin, like it's going to corrupt your life. And when it's in you, you just want to peel your skin off.... I'd wake up in the middle of the night, thinking there's something I've eaten that I should have thrown up."
Not alone
Stoute is not the only Duke student who has developed an eating disorder.
According to the results of the 2006 American College Health Association National College Health Assessment, 2.8 percent of Duke students out of the 22 percent who responded said they have been diagnosed with anorexia nervosa.
This figure is roughly the same as the national statistic, said Franca Alphin, director of health promotion at Duke Student Health.
Although it has not been documented in formal research studies, Alphin said counselors at Student Health and Counseling and Psychological Services perceive that about 80 percent of Duke students experience an unhealthy relationship with food at some point in college.
Katherine Zavodni, adviser for the peer educator group Educating Students to Eliminate Eating Misconceptions, explained that unhealthy eating occurs when thoughts about food interfere with everyday life. On the "eating behavior continuum," she said, anorexia is on one side and involves drastically limiting calorie intake. On the other is bulimia, which involves eating large amounts of food and purging excess calories.
In between these extremes are individuals who display similar behaviors, but they might not be diagnosed with an eating disorder if they do not exhibit a minimum frequency of unhealthy behaviors.
"A healthy body image is about being accepting of what your body looks like and not having negative thoughts. It lets you lead a fulfilling life, but there are times when people don't like their bodies," Alphin said.
Stoute's eating disorder took the form of bulimia nervosa when she was in high school, causing her parents to send her to a psychiatric clinic. Not wanting to return to Panama after the treatment, Stoute enrolled in a Danish boarding school, where she vowed to make a fresh start.
About a year after she left treatment, however, her eating disorder assumed a new disguise. She began running for two hours each day, which developed into a seven-hour-a-day habit. She strove to burn at least 4,000 calories daily while only consuming 2,000.
"I can still tell you how many calories are in everything," she said. "This is one area where being smart can kill you. The disease uses it to empower itself."
Before she came to Durham in August, she told herself she was going to put an end to her eating disorder. But the stress of her first semester pushed her back.
She said she has felt pressured to conform to a norm at Duke-one that expects students "not to be too liberal, to speak intelligently, act appropriately, be very kind, be liked by professors, to do really well in classes and exams." Physically, she said she has felt the need "to have thin legs, nice skin, nice hair" and be "athletic-looking."
Paula Scataloni, coordinator of eating disorder and body image concerns for CAPS, said many students do not identify with having an eating disorder due to the social stigma, but noted a high prevalence of disordered eating on campus.
She counsels students-predominantly women-who express a variety of disordered behaviors, including "yo-yo dieting" and a preoccupation with weight. The number of women seeking her counseling spikes before sorority rush and then again before Spring Break, she said.
"There is a culture of dieting at Duke," she noted. "People are looked up to if they can control their weight and maintain the idealized body."
But Scataloni does not view these issues as unique to Duke. Rather, she said American culture in general places too much value on narrowly defined standards of beauty.
An unreal ideal
The specific pressure for Duke women is the "effortless perfection" ideal, Scataloni said, because Duke attracts women who excel in all areas of life and will not accept failure in the area of being thin.
At Duke and in American society in general, being overweight is associated with not being in control, Alphin said.
"It's ironic-people think people who have it together on the outside are put together on the inside, but people who have it together on the outside are usually the ones falling apart on the inside," she added.
The 2006 NCHA results indicate that this desire is common. Nine percent of Duke student respondents said they thought they were underweight, while 30 percent said they were slightly overweight. To the question "Are you trying to lose weight?", 44 percent responded that they were. This indicates that about 10 percent of respondents think they should lose weight, even though they are of normal weight, Alphin explained.
Sophomore Anna Brown, a member of ESTEEM, said she perceives a general pressure for Duke women to frequent the gym and display an image that is very "put together." She does not pinpoint the expected norm to any one sub-group of campus culture.
Amanda Boston, a junior, said she has not experienced body image issues but she recognizes a general obsession with physical fitness, which she said crosses racial and gender barriers.
Brown added that pressure to conform to the fitness ideal can manifest itself in everyday life. Many students, in part because they are health-conscious and also because they seek social approval, will only order items from The Loop that are labeled "lite," she said.
"As a female, if you order a salad, that is seen as a more positive choice," she said. "To a person who burns a lot of calories working out, they may need a burger for the protein and carbs, but they feel pressured to choose another item."
Crossing the gender divide
Both men and women may feel the need to adopt a "fit" lifestyle, yet the ideal physique splits along gender lines.
"There's definitely a greater focus on muscularity for guys-many girls here shun the thought of gaining any muscle mass, which I believe promotes much more unhealthy behaviors in girls than guys," a male junior, who asked not to be named, wrote in an e-mail. "Many girls will do strictly cardiovascular exercise all the time with no thought of how much they're eating just so they can reduce their total weight, even if it causes them to lose muscle in the process of losing fat."
He added that he believes women are held to stricter beauty standards than men, which are revealed through the types of clothing acceptable-form-fitting jeans or leggings for women versus baggy jeans and a polo shirt for men. There is also a wider array of acceptable body shapes for men, ranging from "very thin yet lean to rather hefty but muscular," he said.
Stoute said she recognizes that not only women are concerned with their bodies.
"I think in essence, guys are subject to the same amount of perfectionism as women, but can express it through other means," she said. "Guys are concerned with their bodies, but expressing that would make them seem vain and girly."
Stoute said her own body image and eating habits have improved through CAPS workshops, a 12-step recovery program and the support of her friends. She can now look at her legs and feel content.
But every day her newfound mental liberation is tested when she is stressed about an exam or if someone tells her she looks thin-which promotes a desire in her to begin restricting her intake again.
"It's always there, and it's always haunting me. But I decide that just for today, I'm not going to resort to my eating disorder to distract myself from life," she said. "I wake up every day, and I tell myself I am going to be serene and comfortable with whatever life gives me."
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