By Ralph E Carson, LD, RD, PhD
One January afternoon, Molly, a shy 10-year-old, glances into the mirror and notices her face looks a “little chubbier.” Concerned about her change in appearance, she tries on an old pair of jeans and they are a “bit snug.” Somewhat alarmed, she rushes to the bathroom scale. Her “weight is higher” than she remembers. Now she is “highly sensitive about her size and weight” and worries her friends are secretly commenting negatively about her being fat. Although her mom reassures her that she is perfect the way she is, she still feels fat and ugly. Molly is very aware that her mom is always dieting. She and her BFF spend hours leafing through Seventeen, Vogue, People, Star, etc.. They idolize thin actresses and models (Angelina Jolie and Carmen Diaz), and cringe at the weight gains of celebrities (Brittany Spears and Jessica Simpson).
Molly decides the solution to her “weight problem” is to go on a diet. She starts with simple, inconspicuous changes such as leaving off desserts and sugary beverages. Then she begins to meticulously count calories and fat grams. She announces to her family she has decided to lose weight. Her parents applaud her resolve. Molly’s friends compliment her new slender body. She, however, doesn’t notice the changes taking place and still feels fat and ugly. She is convinced she looks even fatter and now has developed a real fear of gaining weight. Her dieting escalates to progressively limited choices. Though discouraged about what she believes is her lack of success, she enjoys her newfound control and feels empowered by her ability to restrict. She resists suggestions she should gain weight and considers it jealousy over her appearance. Mom and Dad believe it’s just a phase and are not overly alarmed as Molly is well-behaved and gets excellent grades. Molly’s doctor writes it off as early signs of puberty, picky eating and testing parental boundaries. The possibility of anorexia is overlooked and not taken seriously because she is too young, not that thin and does not meet the full criteria for diagnosis.
Young girls are routinely exposed to media that promotes thinness, an older generation of chronic dieters, and a peer group that finds fault with the slightest imperfection. Overwhelmed by pressures of their world, adolescents choose excessive dieting to control their lives and act out their frustrations of never being perfect enough. There is a tendency to want to see this illness as a disorder of choice and their struggles as issues of discipline. Yet, why if 200 girls go on a diet, will only one develop anorexia? The answer has to do with one’s gene pool. Twin studies suggest anorexia is highly heritable. A young girl having a mother or sister with an eating disorder increases her chances twelvefold. Genetic tests identify personality traits that predate and persist after recovery: perfectionism; obsessiveness; harm avoidance and anxiety. But DNA only accounts for 50% of the likelihood of developing anorexia. It is the exposure to stressful life events, distorted media messages, pressure to fit in, parental influences, puberty (hormones) and dieting that trigger the emotional response (temperament) and brain dysfunction of these young girls. This latent vulnerability is often described as the “loaded gun theory;” parents provide the ammunition (genes) and life’s experiences (environment) pull the trigger.
Only a select few individuals are genetically capable of deliberately starving themselves. This genetic vulnerability reinforces the drive for thinness and extreme dieting. Caloric restriction, malnutrition and weight loss produce physical complications (low body weight, low temperature, slow heart beat, amenorrhea, electrolyte imbalances and bone loss) as well as defective behavioral responses (depression, food phobias, obsessions, compulsivity, neuroticism and distorted thinking). Anorexia is perpetuated as starvation deprives the brain cells of energy, produces nerve cell death and changes the way the young person processes information.
Eating disorders occur most frequently in females (10 times more often than males) and most often at the onset of puberty. Estrogen triggers the expression of genes that alter the brain in vulnerable anorectics. The effect is most pronounced in girls with gene variants that cause anxiety, perfectionism and obsessive behavior. The psychosocial challenges and transitions that take place during puberty create fears. Before a growth spurt it is normal for young girls to look a little chunky as their activity decreases and height has not yet caught up with their additional weight. Add developing breasts, body hair and widening hips and you have a recipe for negative self-consciousness.
A disconcerting phenomenon is the number of preteens struggling with eating disorders. The average age for the onset of anorexia used to be 13 – 17. Today that age range is 9 to 12. There are reports of children as young as six being diagnosed. The Agency for Healthcare Research and Quality reported that between 1999 and 2006, the number of children hospitalized for eating disorders doubled. More than 60% of elementary and middle school teachers reported that eating disorders are a problem in their schools. While the vast majority of children do not develop eating disorders, experts are concerned about the rise in incidence in this age group.
There are several important reasons to diagnose anorexia at an early age and provide immediate treatment. Children lose weight more rapidly, have a lower body mass to begin with and enter a state of starvation rather quickly. Failure to treat in a timely fashion could result in irreversible effects on organ development (heart, liver, kidney), stunt linear growth; impede the natural progression of puberty, cause detrimental brain alterations and lead to severe bone loss. The longer an individual has anorexia the more challenging it is to intervene.
Some professionals in the field are concerned that schools in their enthusiasm to address the war on childhood obesity may wrongly endorse dieting, establish inappropriate weight goals and trigger food and weight obsessions. One study found the following disturbing results:
• Nearly one-third of 3 – 6 year old girls said they would change something about their physical appearance.
• Forty percent of elementary school children want to be thinner.
• 81% of ten year olds are afraid of becoming fat.
• 40% of nine year olds have already dieted.
Children are internalizing the idea of not being okay with their physical appearance and dieting is a way to change that poor self-image. In the meantime, the percentage of overweight children in the United States is growing at an alarming rate. One out of three children and adolescents are now considered overweight or obese. One does not have to have anorexia for weight to lead to poor self-esteem. Negative attitudes are already established in preschool children towards those considered overweight. When children are insecure in their bodies and dissatisfied with their weight they often feel inadequate, doubt they are loveable, and believe they don’t deserve happiness. The stigmatization begins early and the scars are long lasting. With low self-esteem come social anxiety, school failures, depression and violence. Too often poor self-esteem can lead to substance abuse or eating disorders.
What is desperately needed is a shift in focus away from weight loss to improvements in health and self-esteem. For children, the approach should be to maintain their current weight or to keep weight stable as linear growth proceeds (most importantly avoid dieting). Through these developmental years it is important for parents to reassure their children they are important, valued and loved unconditionally regardless of weight. Parents should encourage children to express their feelings and emotions and listen to what their children are telling them. Size acceptance should be promoted. Parents may want to provide information about the media’s influence, social biases and peer pressure. Weight is a delicate and private issue. Children know if they are heavy, so parents should not pretend it is not an issue, but instead encourage open dialogue. Parents should avoid the blame game and yelling, nagging, criticizing, bribing, threatening or punishing. Children should be complemented for their successes such as choosing healthy snacks, spending time in physical activities, watching less television and practicing healthy eating. Parents should avoid power struggles, constant policing and over monitoring of what is consumed. At the same time they should introduce boundaries and set goals. Kids need their parents to be involved in their lives and look to them for the attention they need and deserve. They should be encouraged to believe in themselves. The underlying message from their parents should always be that “it’s what’s on the inside that counts, not outside appearance.”
Note: “A Body to Die For” was abbreviated due to space constraints. To read the article by Dr. Ralph Carson in its entirety, including references, visit www.wellbeingmag.com/category/image-beauty.
Ralph Carson, LD, RD, PhD has been involved in the clinical treatment of addictions, obesity and eating disorders for more than thirty-five years using a neuropsychobiological approach. He is a consultant to The Women’s Center Eating Disorder and Addiction Program @Pine Grove, Hattiesburg, MS. Dr. Carson is also an active board member of the International Association of Eating Disorder Professionals and author of The Brain Fix: What’s the Matter with Your Gray Matter and Harnessing the Healing Power of Fruits.