Children get anorexia too, including boys
Think ‘eating disorder’ and you’re likely to imagine a supermodel or emaciated, waif-like teenage girl. But this stereotype could be blinding professionals to the plight of primary-school aged children suffering from eating disorders, especially boys.A study published in the Australian Medical Journal in April this year found that boys suffering an eating disorder were more likely than girls to remain undiagnosed until they experienced potentially life-threatening medical complications. “Doctors are not expecting to see boys with eating disorders so they are picked up later,” suggests Dr Sloane Madden, lead study author and child psychiatrist at Westmead Children’s Hospital.
The Australian study found that between July 2002 and June 2005, 101 five to 13 year-old children were newly diagnosed with an eating disorder. About two thirds were affected by anorexia nervosa. The remaining third were experiencing ‘food avoidant emotional disorder’ – a condition unique to children that involves extreme weight loss driven by high anxiety levels, rather than wanting to be thin.
By the time these children received treatment for their condition the majority were experiencing life-threatening complications such as low body temperature, low blood pressure and slowed heart rate.
This trend rings alarm bells with eating disorder specialists who know the shocking consequences of an eating disorder left unchecked in children. These include the potentially lethal effects of starvation, impaired fertility, stunted growth and thinning of the bones, in some cases to the point of osteoporosis.
“When kids are starved their brains shrink, they’re more likely to get depressed and anxious, their thinking slows down and memory falters,” says Madden. “All of this affects their relationships with their friends. The effects can be reversed with re-feeding, but not always.”
These serious complications can be prevented if children at risk are picked up early. “If children get the right treatment early, 70 to 80 per cent get well in 12 months and 90 per cent are better in five years. This is much better than in adults where the recovery rate at five years is less than 50 per cent,” says Madden. The Maudsley Model of family based treatment is currently the treatment of choice for children. It involves the family working together over a year to overcome the anorexia their child is experiencing.
Unfortunately, significant gaps in community awareness and in the health care system conspire toward late diagnoses.
“Worried parents are often wrongly reassured by a health professional that their child is OK,” says Madden. “This reflects the limited education that general practitioners and medical specialists are getting. Most psychiatric trainees have limited contact with eating disorder patients, and GPs have even less. It’s not unusual to go through training without ever seeing an eating disorder client.”
Training programs for paediatricians and primary care health workers are being developed. Meanwhile, although eating disorders in children are still rare, hospital admission rates are increasing around the country. Professor Susan Sawyer, Director of the Centre for Adolescent Health, Royal Children’s Hospital in Melbourne says that over the last five years she’s seen a dramatic increase in the number of young people of all ages presenting with eating disorders, especially amongst the 10 to 13 year age group.
Despite appearances, eating disorders are not about food. “If you look behind the dieting behaviour, you’ll find high levels of stress and anxiety,” says Westmead’s paediatrician Dr Michael Kohn. “I suspect that the increased stress levels I’m seeing in young children are making them more vulnerable to picking up on dieting strategies and media messages about weight and appearance.”
Whether or not an eating disorder can take hold and thrive seems to rest in the balance of risk and protective factors that a person experiences. In the last few decades, the increasing number of risk factors experienced by children – such as stress, anxiety, dieting, body image worries, and exposure to media images and messages that equate fat loss with happiness - may be creating an unhealthy tipping point.
Once a sanctuary from food and body-shape obsessions, the primary school playground is now a site for body image, fat-loss and muscle-gain conversations. Research reviews indicate that up to half of primary school girls and about a third of boys say they are dieting to lose weight, and almost half of boys are trying to gain muscle.
Two thirds of girls in grade one believed that being thin would make them more popular, according to a 2003 study of 135 South Australian children conducted by Professor Marika Tiggemann, School of Psychology, Flinders University. Even more believed that weight gain would attract teasing.
One in four children affected by an eating disorder were male, according the recent Australian study, which is notably higher than the one in 10 ratio found in adults.
“This may be because boys are more reliant on dietary restriction to achieve a lean look,” says Madden. “Older males can use other methods such as steroids and the gym.”
Body image expert Dr. Murray Drummond is Associate Professor of Education at Flinders University. In his current interviews with grade five and six boys about masculinity, he’s encountering a groundswell of body-based issues for boys.
“Young boys will readily describe the ideal male body as muscular, without being hyper-muscular, devoid of fat (but not skinny), ‘cut’ or ‘ripped’ with a six pack, athletic looking and no body hair,” says Drummond. “These boys are also very aware of the commercial benefits of looking good. One young boy in a recent JJJ radio interview said the way his body looked would propel him much further than his intellect ever would.”
Sexy calendars of male sporting heroes associate looks with performance and boys seem to absorb this connection. “While the girls say they don’t want to be fat, the boys say they want to ‘be cut’ believing they’ll be better at sport if they lose body fat,” says Kohn of his eating disorder patients.
The media comes under fire, not as the cause of eating disorders, but as a potent ‘enabler’ of fat-phobia, body-discontent and restrictive eating in young people.
Beauty advisor and body image activist Gregory Landsman, says children have told him about their “Biggest Loser” parties where they see who can remain hungry the longest before giving in to eating cake.
Ironically, health messages can also nudge children along an unhealthy pathway.
Helen Frank, Family Support Officer for the Eating Disorder Foundation of Victoria, is concerned about the way some health education programs are conducted in schools. “A mother contacted me recently about a lunchbox survey conducted in her nine-year-old son’s class. Her son’s lunchbox was held up in front of the class as an example of what you shouldn’t eat,” says Frank. “The boy was absolutely mortified. His mother observed that since then he’s become very self-conscious of what he eats in front of others, and lot more restrictive at home.”
Kohn agrees that children are being influenced by anti-obesity messages. “Vulnerable children hear them in the wrong way and take them to the extreme. Then a physiological mechanism kicks in which reinforces the behaviour. Eating less and losing weight dampens down the serotonergic mechanism in our brain that processes our emotional responses. This makes the children feel better – calmer and less reactive. Their behaviour improves and they get positive feedback, so locking in the dieting behaviour.”
The insidious nature of eating disorders can also delay help-seeking for children in need. “Eating disorders can creep into a persons life with no clear starting point,” says Leah Collins, psychologist for the eating disorder program, Centre for Adolescent Health in Melbourne. “It can be hard for parents to know when food refusal and fussy eating, not uncommon in children, become the first signs of an eating disorder. When dieting is a harmless experiment or a danger sign, or when going vegetarian is a smokescreen for adopting obsessive food restrictions versus being a legitimate choice for a young person to make.”
“If your child is not growing and gaining weight then something is wrong and you need to get it checked out, ” urges Kohn who believes that parental instinct is the best front-line defence against childhood eating disorders. “Parents know their children best. They will be the first to see the earliest changes that could lead their child down a slippery slope. Trust your instincts and if you are worried seek help. If your concerns aren’t answered pursue other avenues – try your GP, a dietitian, psychologist or community support organisation such as the Butterfly Foundation.”
Copyright Thea O'Connor
Published in Sydney Morning Herald, June 18, 2009 Health and Science Pages