Eating disorders can be hard to diagnose and treat, and it can take five years to get to grips with anorexia once treatment starts, writes SHEILA WAYMAN
WHO DOESN’T have some sort of issue with food these days? It’s not surprising when we’re bombarded with advice on what we should or shouldn’t eat; regularly presented with “miracle” diets endorsed by some glamorous celebrity, and it’s deemed “news” when a pop singer is spotted wearing her size eight jeans days after giving birth.
Children are affected by this image-obsessed world from an early age. A US study found 40 per cent of six year olds wish they were thinner. In Ireland, a study of the eating habits of more than 3,000 people under 18, which was published last year, shows that more than of a third of them are dieting.
But why do some youngsters go from having normal concerns about food and weight to developing complex and dangerous eating disorders? The reasons are varied – and sometimes unknown.
It is estimated that at least 200,000 people in Ireland are affected by eating disorders, although there has been no State-funded research on the extent of these conditions. The three main types are anorexia nervosa, bulimia nervosa and binge eating disorder (see panel).
Eating disorders endanger both physical and mental health, with anorexia having the highest mortality rate of all psychiatric illness.
“The mortality rate is higher than schizophrenia or depression put together,” says consultant child and adolescent psychiatrist Prof Fiona McNicholas, author of the above-mentioned study on children’s eating habits. “Half of the deaths occur by medical complication and the other half occur by suicide.”
For a third of people who experience anorexia, it starts between the ages of 11 and 15; while for half of them, symptoms first occur between the ages of 16 and 20.
The services for people affected by eating disorders in Ireland are scant. There are only three public beds for the treatment of eating disorders in the Republic. These are in St Vincent’s Hospital in Dublin and are for over 18s.
There are eight private beds in St John of God Hospital, Dublin, for people aged over 16 with anorexia, and also a small number in St Patrick’s Hospital, Dublin, for those over 14.
The provision of four regional units of six adult beds for the specific treatment of eating disorders was recommended in a policy document drawn up for the Department of Health in 2006, entitled A Vision for Change.
“The same report recommended the development of a specialised centre for the treatment of eating disorders in children and adolescents, to be attached to one of the national children’s hospitals,” points out Jacinta Hastings, the chief executive officer of the eating disorders support and information charity, Bodywhys. “There has been no progress on these recommendations to date.”
The best option for people with eating disorders is outpatient treatment, says McNicholas, sitting in the library of the Lucena Clinic on Orwell Road in Rathgar, Dublin. She divides her working time between here and Our Lady’s Children’s Hospital in Crumlin. Hospital care is reserved for the very unwell, or where the outpatient approach has not worked.
However, recovery from anorexia takes a long time. Only a third of cases will get better within five years of seeking intervention.
For a third, getting better means it is as if they never had the illness, explains McNicholas. Another third will always be vulnerable to stress by over-focusing on weight and they may be the sort of person who will never finish their meal.
“Then there is another sad third who have a chronic form of the illness, where their life is preoccupied by their desire to achieve this never achievable low weight and ultimately they end up with physical complications and mental health difficulties.”
The earlier the condition is identified, the greater the chance of overcoming it. So how, as a parent, do you distinguish between a child’s “pickiness” about food, combined with natural growing awareness of how they look, and the beginnings of an eating disorder which could ruin their life for many years to come?
“The age of the child, the gender of the child and the child’s other personality factors would help alert you to whether there is a possibility,” says McNicholas. “It’s absolutely normal as people get a little bit older that they become focused on their body image, body shape and the way they look, whether they are dressed in peer-appropriate clothes.”
When that starts to become obsessive and negatively affect other areas of their life, there is cause for concern. The child may be very critical of his or her appearance and place undue emphasis on weight, shape and size.
“What might have started out as a health approach, cutting out junk food and a little bit of exercise, which would be recommended and encouraged, they start over-doing it, at the expense of other things,” says McNicholas.
The danger signs are if it is affecting their social life with their peers, their school work, family life at home and their mental health. “They may become a lot more miserable and depressed.”
However, adolescents who suffer anorexia are typically high achievers, very competitive, have loads of energy, are very organised and very academically able, she points out.
“Sometimes for a long time their mood isn’t depressed; they are invigorated by their efforts to succeed in losing weight, which they do. So it may take longer for somebody with anorexia to suffer the negative impact of the eating disorder.”
It is also a matter of observing what and how your child is eating. People with an eating disorder will say they’re not hungry, may try to hide the fact that they’re not eating and become very ritualistic about the way they eat.
“They may hide their physique as well, wearing baggy clothes to avoid people seeing just how thin they’ve become,” says McNicholas. “Sometimes parents will say, ‘it is only when I saw her getting dressed for gym, or in the shower, that I noticed’.
“But not all anorexics hide their body,” she stresses. “I work with some young children who, despite being emaciated, will wear little tank tops. They delight in this bony image.”
The youngest patient she has seen was aged just eight.
Some people who have difficulty controlling their diet will binge and then there will be tell-tale signs of vomiting after a meal, or use of laxatives. They may over-exercise too, running up and down the stairs hundreds of times, in addition to going to the gym, swimming and walking the dogs. Parents should ask themselves is it a normal amount of exercise or does it seem a bit pathological?
A child’s ability to cope with emotions may also make them vulnerable to an eating disorder, says McNicholas. “If they internalise a lot of upsetting events and they have no way of dealing with it, they may suddenly latch on to something that they think they can control, which is their weight. So in an indirect way they are dealing with upsetting feelings by dieting; it kind of numbs your body for a while and you don’t have emotional feelings while you’re starving yourself.”
If you think your child does have an eating disorder, what should you do?
“If you suspect anything, the easiest thing to do with your child is just ask them how they are feeling and try to develop discussions around your emotions. You needn’t even talk about food,” says McNicholas.
However, if the child says there are not any worries, or is in that slightly elated phase where the diet is going really well, you won’t get anywhere with that.
Then it is a matter of observing your child’s weight and shape over time.
If you are concerned that both behaviour and the facts are showing that your daughter is losing weight, or failing to gain weight, a visit to the GP is always the best bet, she advises.
“For a discussion yourself: you don’t have to even mention it to your daughter. Educating yourself is always very, very helpful.”
For anorexic adolescents who have lost a lot of weight, the initial step is medical treatment for weight gain before embarking on therapy to tackle the underlying cause of the eating disorder.
Research shows that family-based treatment for anorexia is best for those under the age of 18. “You empower the parents to refeed their own child,” she says. “It is only when the child starts to eat normal amounts that you can start dealing with the other adolescent issues that will be there, as in all children – autonomy, going out socially, the child’s own concerns about their inner turmoil,” McNicholas explains.
She believes psycho-education could have a considerable impact on preventing the development of eating disorders; if people could learn how to avoid over-focusing on physical image.
“If people would put food and weight concerns in their right place and try to promote in children diversity, how it’s good to be different and not be all the same in our Ugg boots and our Abercrombie jackets. It’s nice if somebody is pear-shaped, somebody else is dead skinny straight while somebody else is curvy.”
McNicholas would also like to see children being taught in school how to cope with emotional turmoil. “It’s about promoting positive mental health; eating disorders are a tiny bit in a much bigger piece.”
As part of National Eating Disorders Awareness Week, Prof Fiona McNicholas and Jacinta Hastings will give a talk tonight (Feb 24th) on Eating Problems in Adolescents, at the Lucena Clinic in Rathgar, Dublin, at 7pm. To register: tel 01-4923596.