What is an eating disorder?
Eating disorder describes difficulties people suffer in their attitudes towards food, eating, weight and body shape. It is not a helpful term as these difficulties have their roots in problems of emotional communication and distorted views of the self, rather than eating per se. As an umbrella term it includes anorexia nervosa, bulimia and binge eating. Clinicians do not consider compulsive eating, selective eating - Marmite sandwiches and ice-cream for every meal, for instance - and food phobias as eating disorders, although they can cause acute anxiety and long-term difficulties.
What is the difference between anorexia and bulimia?
Distinguishing between the two can be difficult as anorectics go through bulimic phases, and vice versa. Basically, anorectics are successful starvers; bulimics failed starvers. Both think about food and calories all the time, but anorectics rarely eat fat or carbohydrates and will try to skip meals. They suffer extreme weight loss; periods may stop in girls, they develop a growth of downy hair on the body, have difficulty sleeping, and often feel dizzy. They feel fat even when underweight; may exercise excessively; may get hooked on ritual behaviours (such as cutting up food into tiny pieces, or constantly washing their hands); lie about eating meals and insist on cooking cakes and meals for the family.
Bulimics binge, then attempt to maintain a normal weight by vomiting, obsessive exercising or laxative abuse. They experience ravenous hunger and eat to cure a terrible feeling of emptiness, then feel severe guilt and shame, which leads to vomiting in an attempt to relieve those feelings. While bulimics can suffer from heart disease and ruptured stomachs, which in rare cases can lead to death, anorexia is a life-threatening disorder with a higher mortality rate than leukaemia and the highest mortality rate of all psychiatric conditions - at around 13 to 20 per cent a year, according to the Eating Disorders Association (EDA).
What does it look like and who does it affect?
Anorectics tend to be fastidiously clean and tidy, high-achieving and perfectionist about their studies, the teacher's dream student who puts in the overtime on homework. The illness was once perceived as the province of middle and upper-class, highly intelligent children. Now specialists recognise that it strikes the conscientious, fastidious and eager-to-please across the social spectrum. Anorectics become increasingly withdrawn, and avoid social gatherings likely to involve food. They stop smiling. They also tend to withdraw from team sports and take up more solitary pursuits such as jogging. They can be bright-eyed and hyperactive. They lose weight when already very thin and tend to compensate by wearing baggy clothes.
Bulimics are difficult to spot, but tell-tale signs include disappearing for long periods after a meal; swollen glands and hamster-cheeks (because the glands around their face and throat become enlarged); tooth decay (stomach acids rot the enamel); dry or poor skin; dehydration; unkempt appearance; violent mood swings and self-harm; frequent shopping trips or shoplifting if their money has run out.
The historical perspective Some authors suggest anorexia has existed for centuries under other names, for example, "fasting saints" or circus performers professing to "live on air". Physician and minister John Reynolds wrote about a disorder resembling anorexia in 1669, as did philosopher Thomas Hobbes in 1688. An accurate description by Richard Morton appeared in his 1694 Treatise on Consumption. Anorexia nervosa was first formally described as a medical condition in 1873 by Charles Lasegue (as "l'anorexie hysterique"), and in 1874 by William Gull. Bulimia nervosa was not recognised as a clinical condition until Gerald Russell's paper in 1979, though it probably has a much longer history.
Is it really on the increase?
Nobody knows. Relevant studies are difficult, time-consuming and expensive so have not been done. Around one person in 60 may suffer from an eating disorder, a similar level to diabetes. In 1992, the Royal College of Psychiatrists estimated that about 60,000 people might be receiving treatment for anorexia or bulimia at any one time, although the EDA believes the current number to be nearer 90,000. The prevalence of anorexia among young adult women has been estimated at between 1 and 2 per cent; bulimia at 1 to 3 per cent. Specialists also believe anorexia is occurring at an ever younger age, even in primary school. Dr Andrew Hill, a psychologist at Leeds University who has written extensively on body dissatisfaction and dieting in children, says issues of body shape and weight are "alive and kicking" among children as young as seven or eight.
What about the boys?
Males account for one person in 10 with an eating disorder. Of these, about 20 per cent identify as gay. Among adolescents, the overall figure rises to 25 per cent. Some boys tend to focus their body image on muscularity rather than weight, so their eating disorder is often expressed in over-exercising (biggorexia) combined with insufficient food intake to fuel this exercise. Others starve and exercise to lose weight, rather than gain muscle, because they are afraid of manhood.
Dr John Morgan, an eating disorders specialist at St George's medical school in London, who has focused on boys, says that because fat is "clearly a feminist issue, men have been written out of the equation". GPs are slow to spot anorexia in boys, often misdiagnosing their weight loss as depression, and it's relatively difficult for boys to access treatment.
This is extremely complex and controversial. There is no single cause, but the fact that the peak age of onset for anorexia and bulimia is in the teenage years strongly supports the notion that the disorder is due to difficulties in negotiating the developmental hurdles of adolescence. There may be genetic traits that, with early environmental influences, lead to the development of a vulnerable personality. For example, according to Dr Jill Welbourne, a retired eating disorders specialist and patron of the EDA, anorectics are invariably the daughters of "grade A worriers". Sociocultural factors are also considered influential, given that eating disorders are much commoner in societies where material goods - including food - are more readily available and where thinness, especially in females, is valued highly.
According to Dr Morgan, the average female fashion model has a "bodyfat ratio inconsistent with a regular hormonal cycle". Young women often, therefore, aspire to thinness at puberty, when their bodies naturally lay down fat to support fertility.
But neither the media nor genetics can be blamed alone. Not all children with anxious parents, nor all who wish to be thinner, develop eating disorders. There have to be "trigger" factors as well, such as stress caused by puberty, moving school or exams, or more traumatic events such as parental divorce or emotional, physical or sexual abuse. Bullying by peers is a notorious trigger, as is insensitivity by teachers about body shape, ability or character either in remarks or actions (such as making an overweight child wear skimpy clothing during PE). There may also be unconscious rewards in having the illness, such as receiving attention within a busy family or bringing parents who were drifting apart back together again. Such factors can make sufferers fearful of recovery.
How can teachers help?
By being good listeners. You may be approached first by peers worried about a friend. Take this kind of approach seriously; early intervention greatly enhances chances of recovery. By showing your concern you cannot make the condition worse, and by initiating practical steps to help, you have a chance of making things better. Do not focus the concern on food. The pupil is likely to be frightened off and clam up. Ask if there is something worrying them rather than why they're not eating. Try to maintain their trust but make sure the pupil is aware that there are limits to confidentiality. If the pupil denies there is a problem, try to keep the door open for further talks. Tackle the low self-esteem, not the eating pattern. Show children that you value their particular gifts. Research shows that the support of family and friends and schools is crucial; that unconditional love is a major contributing factor to recovery. Consult other staff to see if they have picked up signs of a disorder. In particular, try to pick up any bullying issues. Do not act in isolation. Encourage pupils to see the school nurse or a counsellor, or to contact the EDA.
Cleaners and dinner staff are a good source of information. They will have spotted if somebody is avoiding food or is leaving food or sick bags around the school. Realise that failing to gain weight can be a sign that a child is suffering. Children need to gain weight to grow and often a rounded, pudgier physique is a necessary precursor to growth spurts. Be aware that many of you will also be dieting and may not have resolved your own attitudes towards food. Analyse your own prejudices about shape and weight and be aware that raising eating disorders as a PSE issue can glamorise the condition in the minds of vulnerable children and lead to copycat behaviour. It might be better to deal with topics that develop self-esteem, rather than the end results of not having it.
Realise that there is no one effective approach. Each situation is unique but the illness can last a long time with many setbacks - the mean duration of anorexia is five years - so consistent and continuing support is vital.
What you shouldn't say
If a child tells you, "I'm fat", never dismiss it or contradict it - the pupil is likely to feel chastised and close off lines of communication. Never praise a child for losing weight or comment on his or her body shape. Do not make personal comments that undermine self-esteem. Never say anything such as, "Come on! Eat up". Sarcasm, according to Dr Welbourne, should be a criminal offence. Never say, "It's just a phase." It's not a phase, it's an illness.
How to support parents
If you are seriously concerned about a child's health, parents must be informed, though they do not need to know everything. Discuss with colleagues who should make the initial contact. Parents have an unspoken contract with the school and have a right to know; if the child had broken his or her leg, you wouldn't hesitate. You can help families by encouraging pupils to tell their parents about their problems. A child may want to hang on to a disorder and so retain control by playing adults off against each other. If parents refuse to acknowledge that there is a problem, allow some time, then try again. An eating disorder cannot be left to chart its own course.
There is no one effective treatment. What works for one child can be a nightmare for another. The first contact for further help must be the GP, who will refer on for specialist intervention. A range of therapies - family, art therapy, drama therapy, counselling, psychotherapy - can be brought into play. A child may have to be admitted to hospital if the condition becomes life-threatening and may have to be fed through a naso-gastric tube. In cases of non-cooperation, a court order may have to be obtained. This is not considered force-feeding; there is still considerable debate about forcing food into a child's mouth.
Dr David Wood, a consultant in child and adolescent psychiatry who runs the Ellernmede Centre for eating disorders in north London, says any such traumatic intervention is seen as further damaging self-esteem and can reinforce a child's determination to lose weight. To be effective, therapy must address self-esteem, so Dr Wood believes the sensitivity of the therapist and the nature of the child's relationship with that therapist is the key to success.