Have you ever seen a normal-sized seven-year-old turn down a hot chocolate with marshmallows because she thinks she's fat? I have. And it's scary. It's as if the normal order of life has been reversed. It's as unnatural as a five-year-old having a heart attack because of stress. Or an eight-year-old developing breast cancer. Something that should only exist in the realms of adulthood has slipped through the net.
This sounds dramatic, but with the British National Health Service reporting that 2,000 children under the age of 18 were hospitalised for eating disorders in the past three years - 200 of whom were between the ages of five and 12 - eating disorders have become something all parents need to be aware of.
Before you turn the page thinking, ‘This isn't relevant to me - my kids would live on chocolate if they could', it's worth knowing that eating disorders can develop gradually and without you even noticing. It's also worth knowing that they affect boys as well as girls, and that they can be life-threatening.
A family affair
Rebecca*, 32, knows all too well how quickly and silently an eating disorder can slip into a child's psyche, having witnessed her younger sister struggle with anorexia. She says, "I was 15 and my little sister Sam* was 13 when we both started losing weight. We lived in a very fat-phobic, upper-middle-class society where there was a lot of pressure to be thin - a lot of the girls at school had eating disorders. We were both very into sports, so it was easy to lose weight and we got lots of positive comments about it.
"I don't know when it turned from being dieting to an eating disorder for Sam, but I suddenly noticed that she had lost a lot of weight. My mother must have noticed, too, because she took Sam to the doctor, who said that Sam had to start gaining weight. The whole family got involved: we started eating together more and being conscious about what we were saying in front of Sam.
"Just after Christmas of that year, Sam was hospitalised. She was in denial about her weight and we were trying to help her, but we couldn't. It was hard feeling so powerless, and the fact it was serious enough for her to be hospitalised was scary. She was in for about two months and it was a horrible time for all of us. When she came out of hospital, she seemed to be getting better, but she went downhill again and was re-admitted for another month. By the next September she was back at school. She was still being monitored and having counselling, but she was much better."
Sam pulled herself out of the depths of anorexia and is now leading a healthy, normal adult life, but Rebecca still gets emotional talking about the experience and believes that it has had a major effect on her own life. She says, "My parents didn't talk to us about it that much back then, but we know now that Sam nearly died because of it. The whole thing sent me on a massive ten-year women's studies rampage. I felt so sad for such a long time about how girls, and women, waste so much energy trying to be skinny. It annoys me when you hear people equating beauty with being thin."
Why does it happen?
There's no one reason that causes a child, or an adult, to develop an eating disorder. Dr Tara Wyne, clinical director at LightHouse Arabia, says, "Some people have a genetic predisposition to eating disorders. Genetic studies show that as much as 80 per cent of the risk is biological." According to Dr Wyne, other risk factors are age (puberty is a high risk time), stress (such as parental conflict, moving country, exams), feeling out of control, and having low self-esteem. "I read somewhere that 90 per cent of teenagers hate their bodies. If you're low on self-esteem because you hate your body, feeling like you are in control of it could seem like a good boost."
Jared Alden, psychotherapist at the German Neuroscience Center (www.gnc-dubai.com) agrees that a major factor in a young person's eating disorder can be feeling out of control, and that it's not necessarily to do with choosing what to wear, or where to go on the weekend, but often about feeling pressured by parents' expectations. He says, "Parents are often shocked about this - they never wanted to control their child, they only wanted to guide them, to protect them from the pitfalls of life and to pass on their wisdom and experiences. But this can mean that children never make mistakes, which is a natural part of growing up. Children can contribute to this by wanting to please their parents and to be like them. The trouble arises when they don't feel they can do it."
Clare Smart, counsellor at LifeWorks Counselling and Development Centre Dubai (www.counsellingdubai.com), says that having a weight-conscious family can also be a risk factor - especially for girls. She says, "With most of the young girls I've seen, their mother, or older sister, has been dieting. Family plays a huge role."
A new shift
In addition to these ‘traditional' risk factors, there are new societal changes that are causing an increase in the number of children becoming obsessed with their weight. Dr Justin Thomas, a psychologist and assistant professor at Zayed University, has carried out multiple research projects on eating disorders in the UK and here in the UAE. He says that although he has other fields of interest, eating disorders is one that he keeps coming back to - partly because they are ‘pathoplastic', meaning they change nature based on social and cultural influences. "As society changes and shifts, eating disorders change and shift too. High levels of bulimia stemmed out of a 1980s' consumerism message: ultra-thin women on billboards eating chocolate and burgers... the messages were at odds. Now there is a new chapter on eating disorders, in terms of it affecting children at a younger age." We look at some of the societal changes that are partly to blame:
Change one: fear of obesity
Changes in lifestyle in the 1980s and 1990s led to higher rates of obesity, which, a decade or two later, led to lifestyle diseases, such as diabetes. Raising awareness about obesity has been high on the agenda of every government, newspaper and school for the past ten years and the importance of eating healthily is drummed into children from all angles, all day, every day. The danger is that the other end of the eating spectrum gets very little airtime. Dr Thomas says, "There are books out there with titles like How to Have Skinny Kids and you can't open a magazine without people banging on about obesity. But in the same way that fear of skin cancer has perhaps contributed to wide-spread vitamin-D deficiency, fear of obesity may lead some to eating disorders."
According to Dr Thomas, experts in the medical community believe that obesity should be recognised as an eating disorder. That way, the message could be anti-eating disorder, rather than just anti-eating. "Being obese is a predictor of health problems later in life," he says. "But having a BMI of less than 17 is a predictor of issues right now. Kids don't die of being fat, but they do die of eating disorders. Those two risks need to be connected, otherwise they undermine each other."
Change two: media diet
Not only are children exposed to media more these days, but the media content is more adult-orientated. Research on communities experiencing the arrival of media for the first time have found that it's not necessarily the amount of TV a child watches that boosts their risk of an eating disorder, but how many people in their immediate social circle watch TV. The take-home message here is that it is not so much to do with a child's media intake as a community's ideals of beauty. Dr Thomas says, "A study on Disney characters found that each decade, the characters' body shapes become less and less realistic. Snow White was definitely chunkier than Pocahontas." According to Dr Wyne, a similar study on Barbie and Ken dolls, found that, if Barbie's proportions were attributed to a woman of average height, she would have a waist only slightly wider than her head, and shoulders and hips slightly larger than that. She says, "Then you have Hannah Montana, High School Musical… everyone's skinny, pretty and perfectly groomed. With these role models, you don't even have to talk about genetics and childhood pressure to understand why so many young people feel dissatisfied with their body shape." Dr Raymond H Hamden, director of the Human Relations Institute, says, "If parents are infatuated with the media and with body image, it will influence their child's perception. In the media, beauty has become a mark of acceptance, and something to strive for."
Change three: body-esteem
Image has always been an important part of a person's identity, but with identities going global on social networking sites 24-hours-a-day, and the self-branding involved in this, image has become a pivotal factor in how young people feel about themselves. Self-esteem has been replaced by body-esteem. Dr Wyne and Sarah Queen, nutritionist at Nutrition Matters Arabia, both express concerns over the aesthetic nature of Facebook - the constant uploading of photos and commenting on those photos. This doesn't necessarily mean that Facebook is to blame for eating disorders. It's just that the success of Facebook is another symptom of society's obsession with image, which is partly to blame for the increase in eating disorders.
According to Sarah, if a child develops an unhealthy obsession with exercise, it could be an indicator of weight obsession. She recalls a talk she was asked to give at a UAE school - the school nurse asked her to come in as she was concerned that a lot of the sporty girls were feeling faint from lack of food. "At the end of the workshop, I spoke to the girls individually," says Sarah. "The main question from them was, ‘What's the best way to lose weight?'"
Providing an antidote
Now armed with this knowledge, what can parents do to help prevent their kids from falling into the eating disorder trap?
Separating a child's self-worth from their physical appearance is a good first step, says counsellor Clare. "Praise them on the kind things they do, the positive aspects of their personality, and the skills they have, not just on how they look." Another antidote is to be a good ‘healthy body image' role model. Dr Thomas says, "If you have a desire for an unrealistic body shape, your kids will pick up on that. Parents should be aware of what they discuss and the language they use around their children. If children feel people are celebrated for being thin, when they feel down, they will think that losing weight will make them feel good." Clare agrees: "If you are constantly commenting on people's physical imperfections, children will notice that."
Balancing the constant feed of body-consciousness streaming in from the media, and other sources, is also important. Clare says, "Tell your children that what they are seeing is not achievable. Have discussions as a family; you can even talk about it in the background when they are within earshot." Dr Wyne says, "Parents need to counteract the media, school, friends and Facebook photos, so their children get the information in a healthy way, and they should be doing so from the word go."
Building a healthy eating environment for your child can also help protect them from eating disorders. Dr Hamden recommends eating as a family, never skipping meals, never forcing your child to finish everything on their plate, not mentioning body shape or size, keeping their lifestyle active and engaging in all of these as a family. He also advises not telling children they need to eat to be big and strong, but instead to say that eating healthily will give them the chance to feel good, and the energy to do their best. Jared says, "Parents should teach their children that all food is good food in moderation. Put time into family meals and try not to eat on the go. Be active as a family and chill out a bit to give your children some space. Does it matter if the house gets a bit messy once in a while?"
Of utmost importance is being there for your child emotionally, says Sarah. "There's a misunderstanding that eating disorders are all about food," she says, "but they are psychological illnesses - they're about emotions and control. If a child doesn't feel they are getting the approval, or attention they deserve, or doesn't feel able to speak openly, the emotions can turn into something unhealthy. Be there for your child - hear them, see them, be emotionally available to them - because once they're stuck in the middle of an eating disorder, it's often too late to do that."
* Names have been changed.
Here are some warning signs that your child may be developing an unhealthy attitude to their body and weight:
- Weight loss - however, some eating disorders, such as bulimia, are not always characterised by weight loss
- Skipping meals or fussiness about food
- Excessive exercise
- Becoming private about their body
- If a girl's periods stop
- Using laxatives
- If your child wants to go on a diet
- Teeth marks on the knuckles - they could be making themselves sick
The types of eating disorders
Anorexia: People with anorexia nervosa have an intense fear of being fat, distorted body image and will avoid eating. Body weight is likely to be thin.
Bulimia: People with bulimia will often eat a lot of food at one time, even when they're not hungry, which they will follow up with purging, either through vomiting, laxatives or exercise. They may be very secretive about their binging, and may feel ashamed of it. Body weight is likely to be thin to normal.
Binge Eating Disorder: The same as bulimia but without purging. Instead, they may eat little when around other people, but binge in private. Body weight is likely to be normal to obese.
Eating Disorder Not Specified (EDNOS): People with EDNOS may have some symptoms of any of the above three eating disorders, or symptoms from more than one type.
Six things you didn't know about eating disorders
- Bulimia is the most prevalent, with 20 cases per 1,000 people
- Eating disorders have the highest mortality rate of any mental illness, with up to 20 per cent of patients dying prematurely
- Anorexia is the rarest with four cases per 1,000 people
- Up to 20 per cent of eating disorder cases are boys and men
- 1.6 million people in the UK are affected by eating disorders
- Not all eating disorder sufferers are skinny