by Wilson, Bee
Overcoming selective eating is even harder for older children and adults than for younger children, but it can still be done. Tyler was a sixteen-year-old boy with Asperger syndrome. His food restriction was so acute that for nine years he had been fed by gastrostomy tube. He had the height of a ten-year-old and the weight of a nine-year-old. Tyler ate just three foods: ham steak, cereal, and pasta (which had to be bowtie-shaped: farfalle). Without the tube, he would not have received enough calories to survive. Previous attempts to improve his eating had been unsuccessful. Over a two-week course of treatment, therapists at Penn State Hershey created a modified version of “Plate A–Plate B” for Tyler involving a system of token rewards that he could put toward “arcade” time on his laptop, DVD player, and game consoles. For each meal, Tyler was asked to choose six foods, some easy and some “difficult.” The more difficult Tyler considered a food to be, and the more bites he ate, the more time he could earn on his screens. The difficult foods all started off the size of a grain of rice and got gradually bigger. By the last three days of treatment, he was happily eating full-sized portions of normal meals: a main course, plus three or four side dishes.
By the end of treatment, Tyler had a repertoire of seventy-eight different foods, and several months after discharge he was willingly adding new foods to his diet. He was now free of the wretched tube-feeding. On cost grounds alone, Tyler’s cure was a triumph: a year of tube-feeding cost a minimum of $16,000 at 2007 prices, whereas his treatment cost less than $500 a day: $7,000 total. But the greatest gain was to Tyler’s health and well-being. His parents reported that family meals were now actually enjoyable, and he was gaining weight faster than he ever had on the tube. Tyler had left behind the loneliness of tube nutrition and was now enjoying the social interaction of a shared meal.
Keith Williams believes that, with the right motivation for change, it would be possible to use taste exposure to treat selective eating at any age. The greatest obstacle is that most selective eaters—and their parents—view their condition as incurable, and therefore do not really believe there is any point in treatment. Their reluctance in the face of new food is so great that they would rather organize their lives around the disorder—like the girl who chose the college that offered pizza twice a day—than fight the disorder and try to buy themselves a new life. It is even harder to treat selective eating in adults than in children. The adults may not cry and gag and spit, but they are less open-minded than the children about their potential to learn a new trick. Most would prefer to keep their condition as an embarrassing secret rather than contact a feeding disorders clinic.
There are exceptions. Over the years, Williams has worked with several adult picky eaters who desperately wanted not to be so limited in and fearful about their eating. When the motivation to change is there, Williams finds that taste exposure works just as well on adults as on children. He was once contacted by a primary-school teacher who wanted to become a missionary in Asia, but knew she would not be able to make it in a foreign country unless she could teach herself to eat differently. At the time, she ate only ketchup sandwiches, Oreo cookies, and instant noodles. Unless something changed, she would never be able to cope with the food in the Far East: it wasn’t just the thought of the pungent flavors, such as soy sauce, ginger, scallions, and Sichuan pepper. She didn’t even eat plain white rice. Slowly and gradually, using taste exposure and tiny morsels, she built up the foods she could tolerate. That teacher is now working in the Philippines, land of vinegar and garlic.
When your beautiful baby is first handed to you by the doctor or midwife and you see a whole future in those blurry eyes, it’s unlikely you’d imagine that he or she might become a person who ate only ketchup sandwiches, Oreos, and instant noodles. What parents do spend a lot of time pondering, particularly if the baby is a girl, is how awful it would be if their child developed anorexia. What misery: to watch this person you have fed so tenderly just waste away, rejecting your meals and, by implication, your love. You would do anything to avoid it, for your own sake as well as theirs.
Those of us who squandered too much of our youth on stupid diets may feel especially determined not to “give” our children an eating disorder. We tie ourselves in knots trying to save them from it. “There’s no such thing as perfect,” was my mantra when my daughter was little and she scrunched up a piece of her artwork. My fear was that her high artistic standards might seep dangerously into body hatred. I would then forget my own words and praise her for doing something “perfectly,” at which point she would correct me, saying it couldn’t be perfect: no such thing. I tried to promote her self-esteem by saying, “Goodnight, beautiful girl,” every night; and then I stopped, fearing that she would equate beauty with self-worth. I watched her vigilantly for signs of wariness around cake. “It’s fine to have a slice. Or two if you are hungry.” No food, I insisted, was absolutely healthy or unhealthy, not even salad. I talked a lot about how it was good to be normal-sized rather than skinny or chubby, but a bit of chubbiness was fine, too, especially in teenagers. I showed her exposés of how models in magazines were Photoshopped, so that she wouldn’t be taken in by those deceitfully lovely images.
So far (she is twelve), no eating disorder. But it’s unlikely to have been all my little preventive measures that have saved her (if, indeed, they have helped at all). It’s an extremely good thing for families to promote sanity around bodies and food, as far as they can, but in the end, our attempts to save our children from anorexia are pieces of magical thinking, like throwing salt over your shoulder to blind the devil. There is no charm that can absolutely ward off anorexia. The current evidence on this puzzling and eerie disease is that the causes are more biological than social. While there is no single anorexic gene, up to 85 percent of the risk of developing it is genetic.
There has been a real sea change in clinical thinking about anorexia over the past two decades. The prevailing view among those who treat it now is that it is a largely heritable condition of the brain rather than a symptom of having an overbearing mother or seeing too many ads featuring thin models. Scientists have identified a cluster of anorexic genes that have to do with the drive for perfection, the need for control, and low self-esteem. Research in 2013 by a team of Cambridge scientists led by Simon Baron-Cohen found that adolescent girls with anorexia showed elevated autistic traits on cognitive tests compared to a control group. The suggestion is that the characteristic brain structure of anorexic patients (the neural phenotype) is strongly inclined toward systems, like the brains of autistic children. Many studies on anorexia have shown that sufferers display a high degree of social anxiety and difficulty interacting with others. Both autism and anorexia are associated with social anhedonia: an inability to find pleasure in many of the social interactions that others find enjoyable. The theory is not that anorexia and autism are the same—or that every anorexia sufferer is socially withdrawn—but that they share certain neural traits that are expressed in different ways. It is striking that whereas the male-to-female ratio is roughly 10:1 for autism, with anorexia the situation is reversed, with a male-to-female ratio of 1:9. Baron-Cohen noted that the rigid mental attitudes of anorexia mirrored the narrow and repetitive behavior of autism “but in anorexia happen to focus on food or weight.”
Patients with anorexia have brains that work slightly differently from the rest of the population, although whether the brain dysfunction is cause or consequence of starvation is not so clear. Neuroimaging has revealed various forms of cognitive impairment in anorexic patients. In particular, anorexics have a poorly functioning insula, a part of the brain that helps regulate anxiety. The insula is also crucial for flavor recognition. Some of this brain malfunction may be a response to a lack of food. But it seems that the insula of anorexics is still impaired after recovery, suggesting a structural flaw that predates the onset of the illness. One study measured the brain response of sixteen recovered anorexics to the pleasant taste of drinking sugar wat
er. In contrast to a control group, these women had reduced activity in the insula when they drank the sugar water. It was as if their brains had difficulty recognizing pleasure.
As with any genetic inheritance, however, having an “anorexic brain” is not enough to give you an eating disorder. You might have anorexic genes but never get ill. Carrie Arnold, who is both a recovering anorexic and a biologist, describes the condition as arising from “a complex interaction between malfunctioning hunger signals, anxiety, depression, and difficulties with decision making.” If the causes of anorexia are more biological than social, this could be taken as good news for parents. It absolves the families of anorexic children from the crushing sense of guilt that affects so many. Arnold notes that her own parents were relaxed around food and never counted calories or pressured her to lose weight. In most cases—though there are exceptions, where eating disorders are triggered by abuse or cruelty—parents are not “to blame” after all, except insofar as they have passed on their genes. A family history of anxiety or depression places children at a markedly higher risk of developing an eating disorder. The downside to this is that if parents are not primarily to blame, there may be little that parents can do to prevent their children from becoming ill.
One of the many scary things about anorexia is how young the sufferers sometimes are. A 2011 survey of eating disorders in Britain found that, while the incidence of the illnesses was stable overall, it was increasing in younger children. Out of all the new cases of children with eating disorders, 59 percent—whether boys or girls—were preadolescent. It was not uncommon for them to be as young as ten or eleven. Some—though this was far more unusual—were eight, or seven, or six. It scarcely seems possible that a child so young could have the distorted body image and fear of fatness of anorexia. Part of the magic of childhood for most of us, looking back, was the sensation of freedom in your own body—the feeling that these legs were made for skipping. How cruel that any seven-year-olds, who should be eating popsicles in the park without a care in the world, should be calculatedly starving themselves.
The obvious explanation for anorexia arising in children so young is that something has gone hideously wrong in our culture. There’s no doubt that anorexia and bulimia are most common in Western or Westernized societies that revere thinness, while pushing foods that make it very difficult to be thin. Anorexia usually starts with a period of dieting. Maybe a child decides to cut out dessert because she has been told at school that sugar is unhealthy, or maybe she has been teased for the way she looks in a swimsuit. The ideal female body type depicted in advertisements in glossy magazines is estimated to be possessed by just 5 percent of women, leaving the other 95 percent feeling potentially unworthy. As for boys, the ideal superhero body—quads like tree trunks, a small waist, and an ability to fly around skyscrapers—belongs to precisely no one. Little kids hear their parents talking about how they wish they could lose weight, or calling pudding “naughty,” or using “skinny” as a compliment; and anorexia would seem to be one logical response.
But eating disorders are not just a creation of modern life. If our culture causes anorexia, how could there have been documented cases of anorexia as long ago as the 1890s? In 1895, a doctor at an English children’s hospital described “A Fatal Case of Anorexia Nervosa” in an eleven-year-old girl. “She had a wild, hysterical appearance, was very restless, and refused all food,” recorded the doctor. He tried to feed her beef tea, brandy, and milk, but after fifteen days in the hospital, she came down with a fever and died.
One hundred years later, in the mid-1990s, a seven-year-old girl, “VE,” was admitted to Massachusetts General Hospital. She weighed just 57 pounds (26 kilograms), but stated to doctors that other children would “like her more” if only she could get down to 50 pounds. She no longer ate regular meals, and she drank nothing but water. She was fearful of eating, or even of chewing her own fingernails, for fear of gaining weight. She spoke in an “infantile manner,” yet would also make comments about her thighs and stomach being too fat. She was under the impression that folds of fat hung down over her pajamas, when in fact her tiny body was “engulfed” by her clothes. Before her hospitalization, VE was involved in competitive dancing, figure skating, and gymnastics. Her mother had wanted to be a dancer herself, and said she could imagine VE dancing on Broadway. There were conflicts in her parents’ marriage. VE’s mother had a tendency to become enraged, whereas her father would withdraw and leave the room rather than argue.
At first glance, this sad case looks like strong confirmation of the view that parents and culture cause anorexia. It’s a lot of pressure for a seven-year-old to be engaged in not one but three highly competitive individual activities—skating, dancing, and gymnastics—all of which place a premium on being thin. Four months before VE was hospitalized, her mother had discouraged her request to give up dance lessons.
But the assumption that ballet and elite sports “cause” anorexia has been questioned. Prima facie, children who do physical activity for several hours every day already look pretty similar to sufferers of anorexia athletica, who engage in compulsive exercise. Disciplines that emphasize leanness have a higher prevalence of eating disorders than endurance or ball sports. In one study, more than 80 percent of female ballet dancers were estimated to have an eating disorder over a lifetime, yet other studies suggest that the prevalence is lower than 10 percent. Recently, experts have been rethinking the role of physical activity in eating disorders. In old-style treatment, anorexics were discouraged from exercising, in case it aggravated their illness. A major review of medical databases in 2013, however, found that supervised exercise could actually aid the recovery of anorexics, by building strength and cardiovascular fitness and alleviating the symptoms of depression.
In the hospital it became clear that VE’s perfectionist tendencies predated and went beyond her recent involvement in dance, skating, and gymnastics. From her earliest years, her parents had found her to be “difficult” and highly competitive with her peers. She seemed to greatly fear any sign of weakness in herself, and she was distraught about some recent poor scores in math at school. In the hospital, she worked hard to show that she was a good patient, and she was needy for praise from staff. Anorexia sufferers often say that, long before they started attempting to lose weight, they remember feeling anxious, fearful, socially vulnerable, and obsessive in various ways. Around two-thirds of people with anorexia also suffer from an anxiety disorder. While neither of VE’s parents had an eating disorder, both suffered from bouts of depression. Her mother had twice been hospitalized with postnatal depression and had been treated for OCD.
Without all the pressure surrounding skating and gymnastic competitions, VE’s anorexia might have taken longer to manifest itself. In addition to refeeding her, VE’s cure involved switching her hobbies to team sports and other group activities, such as soccer and Girl Scouts. But her anorexia was not “about” the sports or the skating or dancing. Plenty of people do manage to become elite athletes or top dancers without developing eating disorders. With the family history of depression and OCD, VE had a biological makeup that would have made her vulnerable to eating disorders even without those activities.
Anorexia tends to occur when someone who is genetically predisposed to the illness suffers some kind of stress or trauma. But often the trauma is nothing more or less than puberty. The natural weight gain that occurs as children’s bodies change into adult ones can prompt body dissatisfaction: Are these strange, swelling limbs really mine? Anorexia may be a way for girls to desexualize themselves and return to the safety of prepubescence: as the weight falls, breasts and hips melt away and periods stop. The hormones of puberty also seem to play a role in triggering anorexia in some people. New data from twin studies indicate that estradiol, the female sex hormone, can “switch on” the genes that predispose some individuals to anorexia.
With the falling age of puberty, it follows that the age at which
children develop eating disorders is also dropping. Susan Ringwood, the director of Beat, the leading eating disorders charity in Britain, confirms that rising numbers of younger children are calling the Beat helpline. “We’re not quite sure what is doing it,” she says. One possibility, however, is the younger onset of puberty. “The average age of puberty has dropped by about five years in the last fifty years,” notes Ringwood. Given that we know that the onset of puberty increases the risk of developing anorexia, it would be surprising if there were not some link between this much earlier puberty and the early anorexia.
If there is a link, then some of the current childhood anorexia, paradoxically, has its roots in the obesity crisis. The causes of early puberty are not easy to unravel, but there does seem to be a correlation in girls between higher BMI and earlier onset of periods and breasts. “It’s primarily driven by weight,” says Ringwood. “Forty-two kilos [about 92 pounds] and you are in.” In 2000, it was found that 1 in 6 girls in Britain were showing signs of puberty as early as eight. One in 14 boys had pubic hair by the age of eight, compared to 1 in 150 for their father’s generation. “We know that the biological mind of puberty starts to develop around two years before the physical effects,” says Ringwood. There is a domino effect: from child obesity to premature puberty, from premature puberty to eight-year-old anorexics. “It’s the double whammy,” she adds. “You are starting to develop an adult body when you have even less of an adult mind.” When young children become gripped by anorexia, the illness seems to escalate faster than it does with teenagers. A comparison of child and adolescent anorexics found that the children lost weight faster and were likely to have a lower percentage of their ideal bodyweight at the time they—or their parents—sought medical help. This was all the more worrying, given that they were still of an age when they needed the best possible nutrition to help them grow and develop long-term bone density.