Girls as young as six are watching their weight -- and starving their way to
serious eating disorders
by Sarah McNaught
"I don't eat birthday cake. It makes you fat." "Don't drink the milk in the
red carton because it's bad; it's fat milk."
When Amy Purcell, a Cambridge teacher, began to hear these kinds of comments
from her students, she knew there was something wrong.
So Purcell began to question the students. She sat at a table with 18 kids at
the Shady Hill School as they discussed how they saw themselves and what they
believed they "should" look like. Purcell was amazed at what she heard,
particularly from the girls.
"They wanted to look like Barbie. They refused to eat cake during birthday
parties. They were throwing entire lunches in the trash, untouched," she says.
"I realized that telling my students about the importance of eating healthy
foods was not enough. They had set standards for themselves that they couldn't
Many people know that eating disorders are a widespread problem. But who would
guess that Purcell's troubled students are third graders?
Research is making it increasingly clear that trouble with food starts very
early. Many girls between the ages of 6 and 12 are dieting and building
unhealthy expectations about their bodies. Such beginnings can lead to a spiral
of low self-esteem and, eventually, self-destructive behavior. By the time
girls reach adolescence, eating disorders are the third-most-common chronic
illness afflicting them, according to the American Medical Association. Yet
little is known about how the cycle starts in the very young -- and little is
being done to prevent it.
Boston public schools spokesperson Gretchen O'Neil says that according to the
school system's director of health services, eating disorders and dieting are
not topics school nurses mention in meetings. "Body-image issues are white-girl
issues, not black-girl ones," O'Neil says. "And you have to realize only
16 percent of the girls in our school system are white, so the issue just
doesn't come up." But, she adds, "obesity is a big factor."
Catherine Steiner-Adair and Lisa Sjostrom, of the Harvard Eating Disorders
Center, say that distorted eating can't be isolated to any one class or race.
However, they agree that among lower-income black girls, obesity may be a
larger problem than excessive dieting. "Binge-eating disorders -- when people
eat obsessively -- are huge problems in lower-income black families," says
Firsthand experience has taught Esther Spillane, Charlestown High School's
nurse, that inner-city black girls do suffer from binge eating. "They may not
be starving themselves, but they are suffering from eating disorders of another
kind," explains Spillane. "The simple fact is that eating disorders are
widespread and know no class or color."
Becky Thompson, a Jamaica Plain resident and associate professor of sociology
at Simmons College, has written a book about eating disorders among black,
white, and Latino women, and has traveled the country giving lectures and
conducting workshops concerning African-American women and eating disorders.
"The problem is, African-American women have not been studied enough," says
Thompson, who believes eating disorders are a growing problem in the black
community. "In 1984, Glamour conducted a survey of their readers
concerning their opinion of eating disorders and their own appearance. In 1994,
Essence -- a predominantly black magazine -- conducted a similar survey,
and the women who responded to Essence scored higher as potential
victims of eating disorders."
Black or white, rich or poor, obsession with one's appearance is hitting girls
at a much younger age. "I'm amazed at how many girls who come to see me have
issues with their figures before they even have figures," says Bob Sege, a
pediatrician at the New England Medical Center. "People just don't understand
the seriousness. I mean, I have kindergartners -- four- and five-year-olds --
talking about being fat and how to be thin. We have a problem here, a real
Last month, University of Minnesota researchers released a study of nearly
10,000 Connecticut grade-school students. Of girls between the ages of 8 and
12, 17 percent said that they had induced vomiting or used laxatives or
diet pills. Last month, another study appeared in the Archives of Pediatrics
and Adolescent Medicine, stating that of North Carolina students in grades
six to eight, an overwhelming 92 percent said that they had dedicated a
substantial amount of thought to dieting and diet-pill use. A recent Stanford
University study concluded that 57 percent of fourth- and fifth-grade
girls have weight concerns.
Two years ago, the US Department of Health's Task Force on Eating Disorders
announced the results of its own survey: 80 percent of girls between
grades three and six feel bad about their bodies, and 70 percent of them
are on diets at any given time. The accompanying report had a simple message:
the country needs a comprehensive curriculum for children ages 6 to 12 that
focuses on preventing the known precursors to eating disorders.
"What people need to realize is that girls don't just wake up one day and
decide to starve themselves," says Lisa Sjostrom. "There is a definite
progression beginning in grade school with dieting and leading to full-blown
eating disorders, oftentimes in high school. And at that point, prevention is a
Eating disorders begin with what researchers call "distorted thinking," and
this can start quite young. Thirty-one percent of 10-year-old girls say they
are afraid of being fat, according to studies conducted by the Harvard Eating
Disorders Center. And 52 percent of 14-year-old girls report feeling
better about themselves if they are on a diet.
The media, of course, play a role. Young girls thumb through issues of
Vogue and Mademoiselle, taking in the scantily clad, impossibly
thin models who are praised for their concave abdomens, pencil-thin arms, and
bony pelvises. These same models can be seen in TV advertisements for
cosmetics, clothing, and hair color. Although studies show that the weight of
an average model is 23 percent lower than that of an average woman, some
eight- and nine-year-old girls still believe that look is a reasonable goal,
says Roslyn G. Weiner, director of the Child and Adolescent Eating Disorders
Clinic at the New England Medical Center's Floating Hospital. It is a pervasive
idea. "In a children's movie called Matilda, a joke is made in which the
character says not to worry about having a stomach bug, because at least if you
throw up you lose weight," says Catherine Steiner-Adair.
But imitation of everyday adult behavior is also an important factor, explains
Weiner, who has worked with young eating-disorder sufferers for 10 years. "Mom
and Dad comment on weight issues -- `I was so bad today and ordered dessert at
lunch,' " she says. "Kids want to be approved of by their parents and they
want to be like their parents, so they hear comments like that and internalize
them as the way they should be acting." (See "What to Do?", right.)
What to do?
though a grade-school child's obsession with appearance may sometimes be hard
to detect, there are preventive measures beyond monitoring meals that parents
can take. The Massachusetts Eating Disorders Association offers a list of do's
and don'ts for parents.
Remind your child that everyone is born a different shape and size. Talk
with your child about genetic differences in body types. Go through a family
album and ask your child to find the body type he or she most closely shares.
Be a good model of healthy eating and exercise: eat a variety of foods and
exercise for fun, not to punish yourself for eating.
Talk to your child about the advertisements in magazines, television, and
newspapers. Explain that these pictures are unrealistic and that a process
called computer imaging helps the models achieve the appearance of
Don't use food as a reward or punishment. Don't ever deprive a child of food
in response to behavior problems.
Don't limit your child's diet unless a physician calls for it.
Don't comment on your child's body shape or weight. Don't comment on anyone
else's body in front of your child, either.
Don't use mealtimes to discuss discipline problems, financial troubles, or
other stressful issues.
For more information on distorted eating habits and eating disorders,
contact any one of the following:
The Harvard Eating Disorders Center: 1-888-236-1188
The Massachusetts Eating Disorder Association, Inc.: (617) 738-MEDA
The Child and Adolescent Eating Disorders Clinic at Floating Hospital: (617)
The American Anorexia/Bulimia Association, Inc.: (212) 575-6200
at the American Medical Association
Anorexia Nervosa and Related
Eating Disorders, Inc.
The psychological roots can go even deeper. Home lives in which there is
sexual or physical abuse, drug use, or absent parents can lead children to
criticize themselves. They may conclude that if they change their appearance,
their problems will go away. "Oftentimes I work with children who are troubled
and show it through behavior like distorted eating," says Weiner. "It may sound
silly, but when children are full of emotional distress, there is no room for
food. . . . Some of us don't eat when we are upset or angry,
just as others eat more." Studies conducted by the American Medical Association
have even shown that chronically ill children are at a greater risk for
developing an eating obsession of some form.
From distorted thinking, a child can move to the next phase of trouble:
distorted eating. This runs the gamut from avoiding fatty foods, skipping
meals, and throwing away portions of lunch to inducing vomiting, bingeing on
junk food and then fasting for days, and replacing meals with large quantities
of laxatives and diuretics. According to studies conducted by the Harvard
Eating Disorders Center, 9 percent of nine-year-olds have tried vomiting
to avoid gaining weight. The American Medical Association has also reported
that the onset of puberty -- which brings acne, menstruation, and other body
changes -- can often trigger distorted eating habits.
From here, it doesn't take much to reach the third phase -- a full-blown
eating disorder. (See "What Are Eating Disorders?", below left.) And by the time
kids reach this phase, it is too late to convince them that their appearance is
fine. "I have a high no-show rate among the young girls who are referred to me,
because by the time they reach the point where they have an eating disorder,
they spend most of their time shying away from admitting it to me and to
themselves," says Beth Rinaldi, a nutritionist at the Bowdoin Street Health
Center, in Boston.
According to the Massachusetts Eating Disorders Association (MEDA),
7 percent of female adolescents and adult women, and 3 percent of
men, have eating disorders. Fifteen percent of all young women, according to
MEDA, show some symptoms of disorders.
Eating disorders are devastating, and their effects can be terrifying --
even fatal. According to a report released in August by the National Institute
of Mental Health, 20 percent of people with serious eating disorders die
if they aren't treated. Several years ago, Glamour magazine carried a
story informing readers that people with bulimia have died of cardiac arrest,
respiratory arrest, laxative overdose, and suicide. Similarly, Contemporary
Psychology reported that one in 10 cases of anorexia leads to death from
starvation, cardiac arrest, other medical complications, or suicide.
What are eating disorders?
More than five million Americans suffer from eating disorders, according to the
New York-based American Anorexia/Bulimia Association, Inc. There are three main
eating disorders, but some sufferers show symptoms of more than one.
In anorexia nervosa, an exaggerated preoccupation with thinness leads
to excessive weight loss. The danger signals are losing a significant amount of
weight; continuing to diet and feel fat after losing weight; preoccupation with
food, calories, nutrition, and cooking; a preference to diet in isolation; and
compulsive exercising. The physical complications associated with anorexia
range from hair loss, dry skin, bruising, poor circulation, insomnia, and
constipation to loss of menstrual cycle, osteoporosis, depression, suicidal
tendencies, kidney failure, and even death.
Bulimia nervosa involves frequent episodes of binge eating, almost
always followed by purging and intense feelings of guilt. Some of the danger
signals are fasting, abuse of laxatives or diuretics, frequent trips to the
bathroom after meals, and dental problems. Physical complications associated
with bulimia include gastrointestinal problems, damaged or discolored teeth,
lung irritation, and chronic loss of bodily fluids that can result in muscle
spasms, irregular heartbeat, or kidney disease. Bulimia can also be fatal.
The third type of eating disorder is binge or compulsive eating.
Sufferers eat uncontrollably, often in private, and binges are often
accompanied by depression and other psychological problems. The danger signals
of binge eating are eating when not physically hungry, frequent dieting,
inability to stop eating, weight fluctuations, and attributing social and
professional failures or successes to weight gain or loss. Possible
complications are weight-related hypertension, fatigue, nausea, weight gain,
diabetes, high blood pressure, and forms of cancer associated with obesity.
"One of the most important things to remember about young girls' bodies in
grade school is that they are still growing," explains Roslyn Weiner.
"Nutrition is key to a child's growth, whether it be organs, bone density,
healthy blood, or a number of other things. Without food, your body fails and
you die. That shouldn't come as a surprise to anyone, but it's a message some
children don't always get."
Julie Curley, a teacher's aide in New Hampshire, has one daughter in third
grade and another in seventh. Curley says she was very worried when her seventh
grader began to worry about her body two years ago. "She heard a group of girls
talking at school about their bodies and she came home and asked me if she
looked okay," recalls Curley. "She was looking for approval."
Fortunately for Curley, her daughters' school, the Beaver Meadow Elementary
School, in Concord, New Hampshire, had a curriculum in place to teach students
about eating disorders. "They held in-depth discussions and even offered a
cooking session where the kids could learn about good nutrition," Curley
Curley still worries about what will happen as the girls go through their teen
years, but she says at least she knows they have sound information.
There have been several attempts to integrate nutrition and self-esteem issues
into the classroom at the grade-school level. Last fall, Sjostrom and
Steiner-Adair launched a pilot program in which 13- and 14-year-old girls were
taught how to connect with their bodies, deal with teasing at school and at
home, and resist distorted media messages; they also learned about good
nutrition and the dangers of disordered eating. The program was field-tested at
12 sites around Boston, with 500 girls participating. The teenagers, in turn,
became mentors to fourth- and fifth-grade girls. "We know that fourth- and
fifth-graders are growing increasingly concerned with their appearance,"
explains Steiner-Adair. "And we know that these younger girls look up to
teenagers," adds Sjostrom. "So it seemed logical that instead of adults
lecturing young girls, let peers work with peers." The program is going to be
replicated across New England and in Oklahoma.
But according to Gretchen O'Neil, the Boston school system currently has no
permanent programs to confront the early stages of eating disorders. In
neighboring towns like Cambridge, Charlestown, and Revere, individual teachers
have integrated their own nutrition and self-esteem curriculums into classes on
On a national level, Kathy Kater, an eating-disorder treatment specialist from
Minnesota, has developed a curriculum specifically for fourth- and sixth-grade
girls. Kater says she recognized the need for such a program when her own
fourth-grade daughter came home from school one day and told Kater that her
best friend was afraid she was fat. "It was then that I realized that there are
programs for middle-school girls and none for younger girls," says Kater. "But
by middle school it's too late. These girls are already in the thick of it."
The pilot program involved 222 boys and girls in Minnesota public schools, who
took a 30-question survey prior to the course so that researchers could
determine the children's preconceived beliefs about food, appearance, and
self-esteem. Eleven lessons covered subjects ranging from how genetics
determine a person's height and weight and how bodies change through puberty to
how to eat right and how to differentiate between realistic role models and
what kids see on television.
The kids were given in-class assignments as well as handouts to share with
their parents. To measure the effectiveness of the curriculum, the kids
completed the same survey at the end of the program that they took at the
beginning. The results were encouraging.
For example, the percentage of students who answered "true" to the
sentence "I feel good about how my body is growing" jumped from 36 percent
before the course to 64 percent afterward. Where just 56 percent felt
sure their bodies were growing normally before the lessons, 80 percent
felt that way afterward. And the number of children who believed it was "false"
that "thin people have more to offer or are more admirable than fat people"
increased from 23 percent to 58 percent.
One of the biggest problems is recognizing that there is a problem. "Some
parents don't realize their daughters are suffering with appearance issues,
because their kids spend most of their time in school," explains Weiner. "And
oftentimes schools are not aware because girls camouflage their concerns by
saying they don't feel well or they ate at home."
Tom Vorenberg, a sixth-grade teacher at the Shady Hill School, knows firsthand
how such issues can be overlooked. In his six years there, he has encountered
four 11-year-old students with eating disorders. And when he has contacted the
parents, some have reacted defensively.
"Eating disorders are considered nasty, self-inflicted social diseases that
the sufferers as well as their families are ashamed of," explains Vorenberg.
"The twisted thing is, dieting is praised as one of the trendiest, hippest
things to do. People need to realize that, for insecure adolescent girls, one
lends itself to the other."
Sarah McNaught can be reached at firstname.lastname@example.org.