For a long time, a 50-meter swimming pool was Aubrey Wall’s temple. She mimicked coaches’ instructions and pushed herself to live well, body and mind.

Wall started synchronized swimming at 6. She remembers the sound of her coach giving counts and critiques through a microphone, the voice clouded by the splashes of the shallow end and wet feet hitting rubber flooring.

As the team’s routine began, Wall used her weight to sink. The water cleared the sounds from above as speakers below carried her coach's counts. Wall’s movements connected to those next to her.

She was good. One of the best on the team, whether that was the outdoor recreation pool as a kid or when she joined the Bozeman Stingrays.

Wall left Bozeman before her senior year with the goal of collecting college scholarships. She joined a bigger team in Denver and moved in with a host family. Thanks to her performance and grades, about 75 percent of her tuition was covered at Lindenwood University in Missouri.

Somewhere between the 6-year-old learning how to tread water and the college freshman competing nationally, Wall began negotiating with food.

Dinner plans with friends might mean she had chicken broth for lunch. Eventually, missing a run meant she didn’t deserve to eat.

It didn’t matter she felt weak.

It didn’t matter that tracking calories and workouts replaced time with people.

It didn’t even matter that teammates noticed Wall go from 155 pounds to 110.

“It was working,” she said.

***

Nothing about Wall feels small.

The 25-year-old is 5-foot-8. Her voice carries, her laugh even more so. The sides of her head are buzzed with her hair long enough on top to run her fingers through it. She has tattoos along her arms and scattered over her body. She’s quick to give an opinion or to smile.

She’s a perfectionist — even through her anorexia and compulsive exercising.

As Wall's meals dropped, she’d try to guess what number would come up each time she stepped on a scale.

“There was never a specific goal. It was always just less,” she said. “If I was above what I expected, I’d eat less food. If I weighed less, I was proving to myself I could lose more,”

She weighed herself at least once a day. The days she tried to avoid the scale felt louder as numbers clicked through her mind like a stereoscope.

“I never thought I would have an eating disorder,” Wall said. “I was that kid who would say, ‘I don’t understand how anyone would ever not eat. That’s so sad.’”

At least 30 million Americans suffer from an eating disorder at some point in their life. Yet the complicated illness remains underestimated.

Tomoko Udo, a health policy, management and behavior professor with the University at Albany in New York, said part of the reason why is there’s limited population-based data on the prevalence of eating disorders. In part, it’s hard to study.

“People often engage in eating disorders behind a door,” Udo said. “Society still struggles to talk about it.”

Udo’s the lead author of a study published in Biological Psychiatry in May that revised estimates of the prevalence of eating disorders. It was the first update for the numbers since 2007 and took into account stories from 36,306 adults — the largest sample ever pulled on the topic in the U.S.

The findings estimate that 0.8 percent of U.S. adults will be affected by anorexia in their lifetime, 0.28 percent will experience bulimia and 0.85 percent will have a binge eating disorder.

“It’s common for any race, any gender, any age,” Udo said.

Udo said part of the reason the update was warranted was because scientists changed the thresholds for diagnosing eating disorders, widening the definitions and adding for the first time binge eating to the list.

It was the scientific world acknowledging what people living with a disorder already knew: They don’t fit into a narrow category.

Udo said that’s a start, but more studies need to follow to either confirm the latest stats or fill in gaps of information they missed. Without that research as evidence of the issue, she said it’s hard to compete for grants to further understand the disorders’ roots and train the medical world to recognize them.

***

Walking through the doors of her doctor’s office, Wall wondered whether she was skinny enough for anyone to notice. At the time, she capped her calories at about 1,000 a day.

When she gained weight her senior year in high school, people let her know.

“As I got skinnier and skinnier, I’m sure people talked about it,” Wall said. “But they never said anything to me. Strangers would, but all in positive ways.”

Routine doctor appointments meant she stepped on a scale in front of a nurse or doctor, in a hall with people walking by.

“I thought they’d have to notice. They never did,” she said.

Paige Reddan, a Bozeman nutritionist, said that’s not surprising.

While doctors tend to ask patients whether they smoke, drink or experience symptoms of depression, she said it’s rare to ask people about their relationship with food.

“There are few in Montana that know eating disorders,” Reddan said. “They see a fit athlete, great pulse and heart rate instead of understanding this person’s low heart rate could mean their heart is small due to low weight.”

She said that’s especially frustrating in places like Bozeman where athletes gather.

“No one is running 5ks anymore, they’re doing 55ks and running the Ridge. There’s nothing wrong with that, but there’s never enough,” Reddan said. “For some, as they continue to push their body beyond what feels possible, food becomes part of that.”

Reddan is the lead dietitian with the Eating Disorder Center of Montana, which she said opened about five years ago.

The center offers individual, family and group psychotherapy on an outpatient basis along with an intensive outpatient program and a partial hospitalization program day treatment.

The center gets patients from throughout Montana. For the most part, people arrive at the center because they’ve lived with the illness for years and aren’t getting better.

“They come with stories of a doctor's office or emergency room that don’t grasp the psychological piece of it,” she said. “They need education around, 'Why is the same girl coming back in every couple weeks for an IV for potassium? Why isn’t she eating and just getting on with her life?'”

Like any symptoms, Reddan said eating disorders are an attempt to fix an underlying psychical crisis tied to psychological, biological and social factors.

She said the need in Montana for treatment outgrew the center. So they hired more providers and added a dinner program for intensive outpatient treatment when the lunch hours overbooked.

“There’s many, many more out there struggling and suffering,” she said. “There's still a prejudice about body image. We’re all so conflicted about how a woman and everyone, really, is supposed to look.”

***

Wall didn’t know what fix she wanted but knew something had to change. After her first year in college, she left synchronized swimming and transferred to Montana State University to return home.

She tried therapy for a year but continued to struggle with body dysmorphia — like a funhouse mirror, the reflection she saw didn’t match reality.

“Mental disorders are not a logical thing. You get so deep into it, it’s really hard to come out of it on your own as the chemistry of your brain changes,” Wall said.

After about a year at home, she landed in a chair across from Reddan.

“I remember her being kind of snarky, like, ‘Prove it to me that I need to change,’” Reddan said. “It never fit, her looking like a waif, you know, skinny and scrawny. It didn’t fit her personality at all. She was strong and powerful. The mental piece had hijacked her brain.”

Reddan told Wall if she continued to starve her body of nutrition, her bones would grow weaker, “like a 90-year-olds.”

Wall announced she would refuse to stop exercising, but took Reddan’s meal plan and began restoring her body. She missed competing, missed having a reason outside of her image to train.

She worked through the program for six months.

“I would by no means say I had recovered. But one day I was reading ‘Well-built Triathlete.’ It said don’t count calories, eat to perform,” she said.

She’d heard it before. But this time it came from one of the most successful triathlon coaches of the country. And she started to listen. She was ready to listen. 

***

Soon after she returned to Bozeman, Wall joined the Stingrays again as head coach as she continued to live with her disorder.

On a recent afternoon, Wall gave count and landed corrections as the high school team of Stingrays followed her direction. Wall said her focus is to help girls on the team be what she calls “effective people.” She wants them to pick up the skills to cope with stress and life and learn to commit to goals that are scary — the same things that pulled her into athletics in the first place.

“I never want any of them to ever go through what I did. I think about it all the time,” she said.

Though she coached, it took Wall years to return to water as a swimmer. The first time she got back in for laps, she soaked in the sounds she hadn’t realized she missed: her breath against the surface, the rhythm of her stroke, the water’s ripple off her arms.

Today, Wall is training to be a professional triathlete. And she looks it.

She recently returned from the Ironman World Championships in Kona, Hawaii, where she ran toward the ocean with more than 2,000 competitors for a 140.6-mile race. After a 2.4-mile swim, 112-mile bike ride and a 26.2-mile run, she finished in the top 15 in her age group among women.

She said she struggled with her disorder for about three years, though there’s not really an exact starting or ending point.

The last time Wall weighed herself more than a year ago she was 155 pounds — the same weight she was when her disorder trickled into her life. But she’s proud of each muscle and what it took to form her strength.

“I don’t think you ever heal from an eating disorder totally. The voices get quieter and you figure out how to control it a little bit more, but it never goes away forever,” she said. “Now it’s about the way my body’s performing and what I can do — I train to be strong, not skinny.”

Katheryn Houghton can be reached at khoughton@dailychronicle.com or at 406-582-2628. Follow her on Twitter @K_Hought.