Monthly Archives: May 2008
June 6, 2008 — More than 10% of adolescent girls and 3% of boys binge eat or purge at least once a week, according to a new study published in the June issue of the Archives of Pediatric and Adolescent Medicine.
The frequency of this disordered eating is surprising and concerning, said 1 of the study authors, Alison E. Field, ScD, associate professor of pediatrics, in the division of adolescent medicine at Children’s Hospital, Boston, in Massachusetts. “I would believe that 10% [of girls] would at least experiment with these behaviors, but once a week is quite severe.”
Dr. Field and her colleagues analyzed data from 6916 girls and 5618 boys who were part of the Growing Up Today Study (GUTS). The subjects, who were aged 9 to 15 years at the start of the study, were children of women participating in the Nurses’ Health Study II. The younger participants filled out questionnaires every 12 to 18 months from September 1, 1996 to November 11, 2003, and in 2004, a questionnaire was sent to their mother.
The study found that more girls started to purge at least weekly (5.3%) than started to binge eat (4.3%). In contrast, among boys, binge eating, at 2.3%, was more common than purging, at 0.8%. Interestingly, very few youngsters in the study engaged in both disordered-eating behaviors.
Purging On People’s Radar Screen
Dr. Field found the extent of the binge eating to be disturbing, especially with the country facing an obesity epidemic. But perhaps of more concern was the phenomenon of purging. “It’s very serious if someone is binge eating weekly, but it’s probably much more serious if someone is purging at least weekly,” she said. “The purging group is really coming onto people’s radar screen right now, and our data suggest it’s a really important group to consider.”
The study also investigated risk factors for developing these behaviors and found that among girls, frequent dieting, especially in those younger than 14 years, was a predictor of starting to purge or binge eat, as was concern about weight.
Predictors of Purging and Binge Eating Among Girls
Rates of some eating-disordered behavior varied by age. For example, girls younger than 14 years whose mother had a history of an eating disorder were almost 3 times more likely than their peers to start purging at least weekly (OR, 2.8; 95% CI, 1.3 – 5.9), although maternal history of an eating disorder was not related to an elevated risk among older teens.
Teasing Important Area to Focus On
Teasing was a factor in increased risk for disordered eating, according to the study. Although negative comments about weight from a mother, father, or female friends were not related to binge eating or purging among girls, teasing about their weight by boys did increase their risk of starting to purge. “Influences early in life such as teasing by boys seem to be scaring events,” said Dr. Field. Among boys, if their fathers made negative comments about their weight, they were twice as likely to binge eat.
Teasing might be considered a “normal rite of passage,” she added, but the study results “suggest that this is an important area to focus on, because you might be able to prevent some children from becoming disordered eaters.”
A first step might be for parents to watch what they say about weight issues in front of all their children. “A lot of parents may realize they shouldn’t make comments to their daughter about her weight, but our results also suggest they shouldn’t make comments to their son about his weight,” said Dr. Field.
As for physicians, Dr. Field stressed the importance of considering bulimic behaviors among male as well as female patients and of talking with all their overweight patients. “It’s important to find out if the children are being teased and what’s going on in their lives.”
It is also important for parents and physicians to stress healthy behaviors and not overemphasize the issue of weight. “There are a lot of reasons why kids should eat a healthy diet and get rid of the soda and junk food at home,” but weight loss should not be the main goal, said Dr. Field.
Media Images Unattainable
The media also play a role in influencing dieting behavior in young people. Girls in the study who strove to look like figures in magazines, on television, and in the movies were about twice as likely to binge eat and were also significantly more likely to purge. “It’s really important for young people to realize the print images they see have almost all been touched up, so what they’re looking for is completely unattainable,” said Dr. Field.
It is an important issue for boys, too, as more and more images of scantily clad males with six-pack abs appear in magazines and on billboards, added Dr. Field.
Approaches to preventing these behaviors might include media literacy and other approaches to make young people less susceptible to the media images they see, the authors write.
The researchers hope to get a better handle on which girls who start to binge or purge continue this behavior, Dr. Field told Medscape Psychiatry. “We’re trying to understand now who are the young people who just experiment with the behavior — say, do it for 1 year and then stop — vs those who go on to have a very persistent problem.”
The researchers are interested in looking more closely at the possible role of genetics in eating disorders and plan to collect DNA from this cohort to try to get some answers, said Dr. Field.
Arch Pediatr Adolesc Med 2008;162:574-579.
The Weekend Australian
Health editor Adam Cresswell | May 31, 2008
IT took a while for Sydney mother Jan to realise something wasn’t quite right with her daughter Ashleigh, then aged 13 1/2.
At that stage weighing 62 kilograms, Ashleigh was sensitive about her weight – which was perfectly healthy, but towards the upper end of the normal range. Ashleigh mentioned to Jan (not their real names) that she wanted to shed a bit of the “puppy fat” that was making her unhappy.
For the next couple of months, until about October 2006, all seemed to be going well. Ashleigh continued to eat well, was sporty, healthy and – so it seemed – happy. Her mother noticed a bit of weight had come off, but nothing to cause concern.
Slowly, that changed.
“I started to notice that she was making different choices about food,” says Jan. “There was always an excuse – ‘No, I don’t want a salad sandwich, I’ll just have the salad without the bread’.”
So began a near year-long ordeal during which mother and daughter consulted their GP, then waited weeks to see a psychologist and dietitian, before Ashleigh was finally taken to the eating disorders unit at the Children’s Hospital at Westmead, Sydney.
At the time of her admission, Ashleigh had lost over 20kg. Her periods had ceased eight months earlier. Her hair was falling out, and was being replaced by a soft fuzz similar to that on baby’s heads. Her teeth were brittle and chipping, her skin was breaking out and she had dark circles under her eyes.
Whereas a normal heartbeat would have been somewhere between 60 and 70 beats per minute, Ashleigh’s scarcely rose above 42.
“They had to tube her immediately, and put her under heat lamps for three to four days,” her mother recalls. “She was tubed for a week.”
Anorexia nervosa is a lethal disease that kills 20 per cent of those affected – a higher mortality rate than for either depression or schizophrenia.
There is a paucity of research comparing different treatments for anorexia, but there is a push in Australia to widen the availability for a treatment method that has the most research evidence to back it up.
Called the Maudsley Approach, it is suitable for people who have had anorexia for less than three years. Contrary to previous treatment protocols – many of which have involved hospitalising the patient when they become dangerously ill, effectively separating them from their families for weeks on end – the Maudsley Approach puts parents in the front line by teaching them how to handle the problem at home.
Once patients are well enough to leave hospital if they initially required inpatient treatment, phase one of the three-stage treatment focuses on weight restoration. A therapist works with the family, emphasising to the anorexic patient the severe health dangers associated with starvation, and coaching the parents on how to insist the child eats.
Siblings are also involved to be a support for the patient.
Once the adolescent has accepted the need to eat and weight is returning, the treatment moves into phase two, when the therapist and parents help the child take more control over their own eating, gradually trusting them to take more meals unsupervised. Phase three starts when the adolescent can maintain their weight above 95 per cent of their ideal weight, and is aimed at establishing a healthy identity.
The three phases usually take one year.
Trial results show between 60 and 70 per cent of adolescent patients have recovered by the end of the year-long treatment, while 75 to 90 per cent have regained their normal weight five years later.
The method is not without its critics, who say not all parents are able to give up work in order to supervise children all day. They also question the effect on siblings of being sidelined, and having nightly dinnertime confrontations – sometimes including, as in Ashleigh’s case, threats of suicide – played out nightly near or in front of them.
One of the main international advocates of the approach, Daniel le Grange from the University of Chicago – who helped develop it further after it was first developed at the Maudsley Hospital in London, where he once worked – has been in Australia for the past several weeks, briefing health workers on how the program works and what training is required.
The program is non-drug-based and has negligible commercial links. The main outlay for parents and health workers is a text book on what to do, costing about $20 and $50 respectively. It has now been adapted for treatment of bulimia, which is more common than anorexia but does not have such serious outcomes.
After a slow takeup by a handful of centres in Sydney and Melbourne, and a few in Victoria, availability of the Maudsley Approach for anorexia may soon widen more rapidly thanks to a more enthusiastic backing from NSW Health.
For many families, it’s a better option than some in-patient treatment programs, which can be extremely expensive and which in some cases have forced families to sell their homes to finance it.
Even so, it’s not for the faint-hearted.
Jan remembers her daughter “screaming, arguing, (and) my husband and I sitting on either side of her at the table so she couldn’t escape. We would be at the table for three hours so she would eat something – not one night, but night after night after night.”
Le Grange concedes the program can be “gruelling”, but counters criticism that it’s not a realistic option for those parents who can’t afford to take several weeks off work to give the sick child the care and supervision required.
“If parents don’t have that luxury, we can look for grandparents or aunts,” le Grange says. “You just have to be creative as clinicians.”
The only other reason why someone might not be suitable, says le Grange, other than having anorexia for more than three years, is that they are too sick. The cut-off is if someone is below 75 per cent of their healthy weight, a category that covers about 20 per cent of patients presenting with anorexia.
Stephen Touyz, professor of clinical psychology at the University of Sydney, and co-director of the Peter Beumont Centre for Eating Disorders at the Wesley Private Hospital, says the Maudsley Approach received the top rating of any treatment for anorexia from Britain’s National Institute for Health and Clinical Excellence, which assesses the cost-effectiveness of therapies for the UK’s National Health Service.
Touyz, who is working on a tool that will allow doctors to grade a patient’s anorexia by severity – much as cancers are currently graded from one to four – says the strength of Maudsley is that it encourages early intervention in anorexia.
“The message is: if you think your child has anorexia, you want to get in early, and treat it early,” he says. “Because if it becomes chronic, it’s very hard to treat … and Maudsley does have highly successful outcomes.”
Ashleigh, meanwhile, has stabilised her weight at 52kg. Jan, who says she would recommend the Maudsley Approach to others, says the next milestone will be when Ashleigh’s periods restart, which the doctors think could be within three months if she can keep her weight up.
“It’s not a quick fix. But we’re absolutely stronger as a family. We always were strong.”