I was very wary of approaching students about weight issues," says Mark Griffiths, educational therapist at The Ash technology college, in Ashford, Middlesex. "But after the first couple of kids I started to get bolder. I'd just say: 'I've got this health club, so and so is in it, do you want to join?' And they'd say: 'I'm glad you said this, I'm worried about my weight and nothing I do seems to work.'"
Weight and appearance are so personal that raising the subject of someone's size can seem intrusive or taboo. There is an emotional underlay to extremes of shape - the mysterious intensity of self-starvation, the abandonment of severe obesity - which can arouse wonderment and disgust in onlookers.
These extremes also prompt a degree of helplessness among adults in positions of authority. You can neither force a child to eat, nor prevent them from eating, says Jenny Dover, an educational therapist from therapeutic teaching organisation the Caspari Foundation, who works with secondary school children in London.
"Eating problems often touch teachers, particularly women, deeply. They can remind them of their own worries, when they need to stay detached."
Yet schools can be a great help. Through vigilant observation, sound knowledge of symptoms and identification of students in difficulty they can bring the issue into the open. Then they need to maintain trusting, supportive relationships with sufferers while helping them seek treatment.
EATING DISORDER FACTS
About one teenager in 100 has anorexia nervosa, the self-starvation disease. About two in 100 have bulimia nervosa, in which the sufferer's weight is kept at a fairly constant level by alternate overeating and purging, using laxatives or self-induced vomiting. Binge eating is probably more common still. Many more females than males are affected by eating disorders. (Perhaps because of this, anorexia or bulimia in boys can often go undiagnosed.) The most common age for developing an eating disorder is 14-15, though it can be as young as eight. Both anorexia and bulimia can be triggered by dieting and stressful life events, such as family breakdown or bullying.
Controlling food intake and size is one way a young person can keep something in their life under control.
These children are often sensitive, highly diligent, perfectionist students who have given little trouble in the past. Anorexia sufferers develop an unrealistic self-image: no matter how thin they become they still see themselves as fat.
Although obesity is not officially an eating disorder, it is clearly related: it flourishes where there is tension between hunger, satisfaction, self-control, self-image and the relationship between food and feelings.
Most obese people have low self-esteem and are depressed.
Recent statistics show obesity in Britain has trebled in 20 years: almost one-in-ten 6-year-olds and one-in-seven 15-year-olds are clinically obese.
MONITORING AND SYMPTOMS
By watching for students who are anxious, diligent, dieting and stressed, schools should be able to identify at least some who are at risk from an eating disorder, says Jenny Dover.
In some ways they are better placed than families: weight loss that happens gradually over the summer holidays can be missed at home, but is striking in the classroom on the first day of the autumn term. Since the earlier an eating disorder is diagnosed the more hopeful its outcome, vigilant schools can help prevent hospitalisation and permanent damage, and save lives.
(Between 5 and 20 per cent of people with anorexia die from it; more will suffer irreversible bone and kidney damage.) Key symptoms are:
* preoccupation with food: talking about it, picky or secret eating, frequent self-weighing
* obsessive exercising
* tiredness, dizziness, hypersensitivity to cold or heat, easy bruising
* reduced concentration, irritability, missing school
* frequent visits to the toilet, particularly during or after meals, laxative use, toothmarks or abrasions on knuckles from self-induced vomiting.
Some staff are better placed than others to detect physical change and unusual eating behaviours. Lunchtime staff, both catering and supervising, should be trained to watch for students who often throw lots of food away, who drink large quantities of water to fill themselves up, who only ever take salads, or who invariably return for second helpings.
PE staff are most likely to see children's bodies. (Anorexic students notoriously dress in baggy clothes to hide their diminishing size. Obese students, on the other hand, may suffer bullying if they cannot fit into a normal school uniform.) They can also observe falling energy or fitness levels.
Since eating disorders are markedly more common among young people with high aspirations in certain sports - distance running, dancing, gymnastics and horse-racing - teachers and coaches in these sports have a responsibility beyond monitoring. They may find themselves asked by normally-built or slender teenagers whether they should lose more weight; they may be asked to praise students for losing weight; they may find young female athletes and dancers in particular competing for thinness among themselves.
To combat this, the Eating Disorders Association says sports coaches should never encourage weight loss among this group of students: instead they should emphasise healthy eating and the weakness weight loss will bring.
SPORT AND OBESITY
PE can be physically difficult and emotionally painful for heavy children, who feel exposed and humiliated, particularly if children are permitted to pick teams. Yet sensitive sports staff may be well-placed to support children who want to lose weight, says Mary Rudolph, professor of paediatrics at Leeds University and founder of a Leeds-wide exercise and weight reduction programme called Watch-It (see resources).
Watch-it takes place once a week in sports centres. It combines individual weight monitoring and advice with fun group exercise. Professor Rudolph says she deliberately did not base it in schools "because the bullying problem for these children is enormous".
The Ash's health club, however, quickly became a high-status activity for children once Mark Griffiths set it up with the help of Surrey University.
A minibus-load of students travelled to the university twice a week for 10 weeks, setting off half-an-hour before school ended. They tried new forms of physical activity, such as climbing and boxercise, as well as learning about healthy diet. The aim was lifestyle change rather than dramatic weight loss, which is never recommended for children and young people.
Once news of the glamorous university facilities spread through the school, Griffiths found other students tried to persuade him they were obese, so they could join what they inevitably called Fat Club.
All 10 club members lost weight, some substantially. "I think what made it work was the emotional support. They had an sense of team spirit and they felt safe," Griffiths says.
While schools have taken on the healthy eating and exercise message for prevention, they still find it extremely hard to help children who are already obese, says Professor Rudolph.
"I think no one knows how to treat these children. The management of obesity in childhood is such a new thing. We are aware that there are health and emotional issues, but we are far from having effective solutions as to how to get children to lose weight and how to support them."
TALK ABOUT EATING
Once adults in a school suspect a student has an eating disorder, it must be raised with them, says Jade McEwen, youth education and training officer of the Eating Disorders Association, which runs regular courses for teachers and others working with children. Pastoral staff are best placed to start the conversation. They may take advice from the school nurse, or from their local child and adolescent mental health service, which will probably provide treatment.
Trust and sensitivity are very important. "Be very honest about your concerns," says McEwen. "Say something like, 'I've noticed you have been a bit dizzy lately, do you want to talk about things with me?' Or, 'I couldn't help but notice you're not eating much, is there anything I can help with?' Do it very calmly and sensitively, in an appropriate environment, and avoid accusations."
Young people with eating disorders are often frightened and defensive; many will protest that nothing is wrong, and will insist their parents are not informed of the school's concerns, says Jenny Dover. "But if you have a real feeling that a child is at risk of harm, then you have a duty of care to that child to contact their parents, and you might have to spell that out to them."
This is equally true when students are suspected of self-harming, a condition that often accompanies eating disorders and which can become addictive.
Students generally self-harm outside school, says Ron Best, professor of education at Roehampton University, who recently completed a pilot study on the subject.
Experts agree that the burning and cutting these students inflict on their bodies is not attention seeking, but an attempt to express the pain they feel inside. As with self-starvation, the feelings this disorder can arouse in adults responsible for a child can be overwhelming.
"Teachers have told me about feeling panic, distress, anxiety and bewilderment," says Professor Best. "They want to hand over the problem to someone else, which isn't necessarily best; sometimes it's better for the school counsellor to help a trusted teacher supporting the child. On the other hand, I've had a teacher tell me how a pupil she was remonstrating with pulled up her sleeve to show her scarred arm and said: 'Look, this is what people like you make me do.'"
WHAT TO DO
Once a child has a diagnosed eating disorder and is being treated, generally with psychotherapy, relaxation and weight monitoring, in severe cases as an in-patient but otherwise at home, the school's role needs to be clearly defined.
"You want to encourage the bit of the child that wants to get better and not the bit that doesn't," says Jenny Dover. "You don't want to be the enemy who forces her to eat, but someone who understands the difficulties."
Schools have to tread a delicate path between supplying work but not pressurising the student, and providing support that does not leak into pseudo-therapy or stoke up emotional volatility. Experts say you should be encouraging in general, but don't specifically praise a child for putting on weight as that can feel threatening. Don't cast a net of awe and wonder over the disorder. Don't allow staff to see themselves as saviours or victims of the child. Don't get into arguments or battles of wills.
Schools need to know the limitations of what they can do, says Jade McEwen - a view with which Jenny Dover agrees. "You can get well-meaning teachers who feel they need to get these children to eat, but that doesn't help.
Saying to a child, 'You are beginning to look like a skeleton,' won't help," she says.
"These are very hard children to treat, and there's not a huge amount schools can do other than be very supportive and understand that it's an illness and not just kids being bloody minded."
TRAINING AND RESOURCES
* The Eating Disorders Association (www.edauk.com) offers training courses for staff, leaflets and an educational resource pack and video, It's not about food it's about feelings (price pound;19.99). It has helplines for adults (0845 634 1414), and under-18s (0845 634 7650)
* www.nutrition.org.uk offers healthy eating materials
* www.rcpsych.ac.uk has background information and links
* www.selfharm.org.uk offers advice for young people from National Children's Bureau
* Young Minds (www.youngminds.org.uk) offers leaflets on self-harm and a parents' information service (0800 018 2138)