Friday night, Sarah Mandl sat down to a traditional pre-race meal. Spaghetti with vegetarian sauce. Salad. Bread. A high-carbohydrate meal fit for the distance runner she is.
For the Catonsville senior, finishing that dinner was as important as finishing the race. A recovering anorexic, Mandl battles daily the disease that, two years ago, left her in pain, hospitalized and struggling to surrender the control she exerted over food.
The next morning, Mandl ran as strong as she ever has, finishing 21st in the state Class 3A championship meet, the first on her team to complete the challenging three-mile Hereford course.
"She's more muscular now than she was before," Catonsville coach Sandra Gallagher-Mohler said. "Her chest is still very thin. You can see the breastbone and her arms are thin, but she doesn't look like she's running in slow motion.
"Before, she looked like her whole frame collapsed because she didn't have the energy. Now, she just looks so much stronger."
After dropping from 120 to 102 pounds and spending two weeks in a Sheppard and Enoch Pratt Hospital inpatient program two years ago, the 5-foot-9 Mandl is now up to 115 pounds. Still, she likely will never be completely free of her battle with anorexia nervosa.
"It's a lifelong process," said Mandl, 17. "I'm still dealing with some of the monsters in my head to this day, but I can look back on the days before the hospital and know that I don't want to be there."
She also has decided that she doesn't want to be a model. Advice she received three years ago while taking modeling classes triggered her descent into anorexia.
"There were so many aspects of my life that I felt out of control in, and I think modeling was sort of the gateway to unlocking all of that. It gave me an excuse to gain control through anorexia."
Mandl always had been comfortable with her tall, slim body and her striking good looks. They drew attention from a few modeling agents at a couple of open calls. She got a few callbacks, including one from a New York agent who suggested the classes.
At first, Mandl received nothing but praise. Then, one of her advisers gave her some advice.
"He told me I could look fantastic if I lost like three inches off my hips and two inches off my waist, basically a total of five pounds."
She started running more often, doing Pilates and eating less.
The weight came off quickly. Soon, her diet and exercise regimen became an obsession. She ran at least seven miles every day, did two hours of Pilates and went horseback riding as often as possible.
She wasn't eating nearly enough to fuel all that activity, having cut back to a maximum of 500 calories a day.
"I just tried not to eat. I tried not to even think about food at all," said Mandl, who ate nothing but a few fruits and vegetables. "I would get mad at myself if I ate one little Wheat Thin."
Not wanting to eat kept her away from most social activities, because they revolved around food. She even avoided sleepovers because she didn't want to be faced with late-night snacks.
"That's one of the quagmires of having an eating disorder," said Dr. Harry Brandt, a psychiatrist and director of the Center for Eating Disorders at Sheppard Pratt, who spoke generally about the disease.
"There are some illnesses, particularly when you get into addictions - and eating disorders are different from addictions - but in addiction, you can abstain from what you're addicted to. People with eating disorders are confronted with stimuli for the disorder all the time. We need to eat."
Mandl said she has found a balance.
"From being an anorexic and having that obsession, I learned a lot about eating healthy. At this point, I know how to eat wisely when I'm out. I feel fine going out with people and being around food, like going to restaurants or movies and having popcorn."
By opting not to pursue modeling, she also has removed some of the cultural temptation to be too thin. She still runs, and though eating disorders affect many runners, Mandl said running has become therapeutic for her.
"Running, it's my high, it's my meditation," said Mandl, who enjoys running on trails near her home not far from Patapsco Valley State Park.
Mandl never thought of running as a means to lose weight. The hours of Pilates were to burn the calories, she said, while running and horseback riding were a way to escape the world.
A competitive equestrienne, she spent a lot of time riding in the state park and just being with the horses at the stables there.
Her career goal now is to become a large-animal veterinarian. A straight-A student, she's completing the admissions process and hopes to go to Alfred University in southwestern New York state, where she can study and ride. She's not sure whether she will continue to run competitively.
The transition to college won't come without stress, and Mandl said she must take care not to fall back into her anorexic habits in an effort to gain control - a lesson she has held onto for the past two years.
During her time in the hospital - two weeks inpatient and 2 1/2 weeks outpatient - in March of her sophomore year, Mandl said she learned a lot. She also got a lesson before she went into the hospital from a recovering anorexic classmate who had been hospitalized.
"She told me about the hospital and that it was scary, but she seemed really happy and it was like almost looking at a mirror, but a healthier mirror, a healthier image on the other side. She was obviously eating normally and getting help and she looked beautiful and was doing wonderfully."
By that time, Mandl knew she was in trouble. It hurt just to walk, and she passed out twice at school.
Her mother, Stacy Mandl, a registered nurse who had worked with eating disorder patients and fought her own battle with anorexia, didn't realize at first how little her daughter was eating. Still, she took her to a psychologist who dealt with eating disorders and began keeping a closer eye on her.
"She had deteriorated fairly swiftly," her mother said. "She was physiologically unstable. Sarah was at the point where she could have died in the middle of the night. The wait to get into an inpatient unit was six weeks long, but she went right to the top."
Facing her problems at the hospital wasn't easy. She refused meals and didn't find much help in group therapy, but said she did find help in art therapy sessions and in counseling with her parents.
She gained enough weight, about five pounds at first, to go home on the weekends and then to go home every night after 12 hours at Sheppard Pratt.
"There was a certain point, probably when I went from inpatient to outpatient, that I had to realize I couldn't cheat. I couldn't go out for a run, so I really focused and started to become comfortable with the fact that there really was no other way," she said.
"Going backward and becoming anorexic again would not help, and so I just let my body do its thing. I tried hard to focus on being happy and being comfortable not with my body but with the social scene and dealing with other pressures rather than the superficial ones."
Danger of exercise
She doesn't spend hours doing Pilates anymore, but she still runs and rides horses. She would like to run a marathon someday and plans to start with a half-marathon next year, but she knows she will have to watch it.
"Many people with eating disorders need to be careful about their exercise," Dr. Brandt said. "Until they approach a healthy weight, there's always a danger it can spiral out of control into a very deleterious situation. Our culture embraces exercise, but for a patient with anorexia, it can be poison."
Her cross country coach, Gallagher-Mohler, would prefer to see Mandl weigh about 130 pounds. The Metropolitan Life table states a normal weight for a small-framed 5-9 woman ranges from 129 to 142 pounds.
"Last year, when I was coaching her, that's what I weighed ," said Gallagher-Mohler, who is expecting her first child. "I asked her, 'How much do you think I weigh?' She said, '115.' I wanted her to see that 130's not fat; 130 is a strong, lean body mass. We were able to get her up to 120, but that didn't last long. It's a process. If she dips below 115, we'll talk again."
Mandl will remain vigilant.
"I have to be careful not to feel out of control and regress," she said. "I know there's always that possibility, but I feel I've also gained the courage not to let that happen. Since I've gotten out of the hospital, there have been numerous stressors and times when I've felt out of control and I've been able to get through them all. I'm doing very well and I'm happy."
Anorexia warning signs
Some common warning signs that indicate a person may be suffering from anorexia. The person:
Is thin and keeps getting thinner, losing 15 percent or more of his or her ideal body weight.
Continues to diet or restrict foods even though not overweight.
Has a distorted body image - feels fat even when thin.
Is preoccupied with food, calories, nutrition or cooking.
Denies that he or she is hungry.
Weighs himself or herself frequently.
Complains about feeling bloated or nauseated even when eating normal - or less-than-normal - amounts of food.
Loses hair or begins to experience thinning hair.
Feels cold even though the temperature is normal or only slightly cool.
SOURCE: The Renfrew Center Foundation