Deadly diets

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 possibly attain."

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 Steiner-Adair.

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 problem."

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 moot point."

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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.

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 perfection. 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) 636-0132 The American Anorexia/Bulimia Association, Inc.: (212) 575-6200 KidsHealth at the American Medical Association Eating Disorders Shared Awareness Anorexia Nervosa and Related Eating Disorders, Inc.

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.)

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.

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.

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.

"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."

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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 says.

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 their own.

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 smcnaught[a]phx.com.