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Friday, 25 May 2012

One Fat Child Inside A Perfect Storm

I write this as a psychologist specialising in obesity, childhood obesity and eating disorders; a member of the National Obesity Forum and an All-Party Parliamentary Obesity Group. I am a spokesperson for the British Psychological Society on all matters relating to eating and obesity, and I am Founder of the National Centre for Eating Disorders.

Every parent dreads getting the dreaded fat letter or a summons from the school. One such parent I know has had such a summons. Healthy schools policies now mean that schools are taking some responsibility for the wellbeing of children, by providing healthy lunches and in some cases banning high fat-sugar snacks. I applaud these policies to some extent. They are also weighing children to alert the parents about potential dangers such as increasing BMI or anorexia in older children. This is controversial and my thoughts about in-school weighing belong elsewhere. However in this case, the child aged 10 looks and is fatter than his classmates. And the parents have been told that Social Services may be invoked.

Even worse, the child himself has been told that his weight is a matter of concern. This the first time that the child has had negative feedback from an adult.

Now where a child’s weight is concerned, some parents are ignorant about what to feed their children and some try hard to feed their child a healthy diet but are thwarted by all that is out there and some parents are too lazy to bother thinking about it all. They say, let children be children and eat what they like.

Some mothers have eating problems and buy food for their children so that they have an excuse to eat it themselves. Some parents have a child who gains weight extremely easily because they were born that way. Most onlookers blame the parents if the child is fat. They think that the parent is over feeding their child.

Or they assume that the children are compulsive overeaters, sneak eaters and so on, that they are unhappy and that their weight gain signifies underlying psychological problems. They might look at the child and discover that the child is eating more than their peers. This would be normal because a fat child needs more calories than a thin child; they have more muscle as well as fat to carry around.

The parent has refused permission for the school to weigh her son. She knew that her child was large, and the diet at home is reasonably sound. I endorse her decision, since the weighing was not routine and the child would have been singled out, a horrible experience for a young person growing his wings. Now she has been told that the school is sending out for counselling for the child. The child will once again be singled out.

First do no harm. Identifying a fat child is one thing, knowing what to do about it is something else, which is why I say the following. By all means weigh children and inspect their size. But be clear that you know what to do about it so that you do not harm the child. Some children will need help and some will not. But in some cases insensitive intervention will create a tragedy. For example, is the next step to put the child on a diet? There is very strong evidence that 99% of children who are put on a diet gain weight excessively afterwards. They develop unreasonable attachments to food which is denied them; they suffer from feeling different from their peers and their self esteem can fall. My eating disorder casebooks are full of people who have been dieted or given pills as children; told that they are unacceptable and thus unlovable.

These are the circumstances for a perfect storm brewing up in which everybody could be hurt. Everyone needs to take a big step back. I would offer the following advice.

1    I would ask the school to wait, do nothing and revisit the situation in a few months time. During that time the professionals involved need to learn more about how to help fat children. They should not just swing into action with panic strategies unless there are other strong reasons for concern. They should liaise with the parents and agree together the best way to proceed.

2     The school must not be led to believe that a fat child is an unhealthy child; this is a myth. While there are health risks associated with being overweight the risks are greater for thin children who do no activity and who eat poorly at home. I would refer to the school to research the HAES research (healthy at any size). The school needs to have a written policy guided by appropriate health professionals for managing children they think have eating or weight problems.

3    The school must immediately remove any pressure on the child that would lead to him feeling different from his peers and must be open to listening to the child if he is being teased.

4   Let the parents, with some help if necessary, take a fearless inventory of the food and eating patterns at home. Even where the parent has expertise and knowledge about healthy nutrition, there are always some small improvements that can be made. This will help the child be more healthy; this will not necessarily result in weight loss. The school must be fully aware of this.

5    Neither the school nor the parents must fall into the trap of insisting that the child do more exercise if he is already doing a reasonable amount. There is no association between insisting on programmed activity that the child does not enjoy and long term weight control. Limiting TV at home is useful but not only for managing weight.

6   At the age of 10, the child is approaching puberty. Children tend to gain weight at this time to provide the energy for a huge amount of pending growth. It is also a time critical for developing self esteem. The parent and the school must do everything possible to support the self esteem of the child and to give them well paced information about nutrition in a sensitive way. This will put the child in a good position to make their own decisions about weight control when they are old enough to be autonomous.

7   Counselling should only be given if the child really wants it and if there are really good reasons for concern - which should be made clear in writing by the school. The parents should be open to giving assistance for weight loss only when the child asks for it. There are good and bad ways to help children lose weight and this needs to be discussed with an expert in the field. Not a doctor and definitely not a school nurse.

If anyone has a problem with a child who is fat, I am willing to act as an advocate for them. It is hard, not a crime, to be the parent of a child who is fat.

Friday, 18 May 2012

Food Addiction Vs. Compulsive Eating: The Meaning Of Overeating:

The statement I often hear that overweight people surely must be “addicted to food” is contentious and offensive.

In 2004 and subsequently in 2006, two separate NICE guidance processes, one on eating disorders and one on obesity attempted to make sense of what psychologists describe as dysregulated and disinhibited eating. Whether this eating results in weight gain depends on the restraint that a person exerts in between episodes of overeating, or the use of compensatory behaviours such as purging which accompany overeating.

Sufferers speak about irresistible drives to eat any food or certain food types such as chocolate - in the context of cravings, low mood states, excitement and a sense that their behaviour is somehow wrong / abnormal. It seems apt to apply the label “addiction” to the behaviour and its motivations because there are many shared features between substance abuse and overeating. These shared features include ways in which “using food or drugs” brings about mood relief, tolerance, withdrawal symptoms, and the activation of similar neural networks, particularly in reward centres in the brain.

Sufferers also describe their experience in the language of addiction such as “I can’t get on with things unless I have my fix”. Or, “It’s like I’m addicted to food, I wish I could just take it or leave it, but it’s never enough.”

The reason why terms such as food addiction, chocolate addiction, binge eating disorder, comfort eating and compulsive eating are used inconsistently in scientific literature are because they are not diagnostic categories. They are simply our attempts to put labels on a rich diversity in human experience and behaviour, which have different meanings to different people (1). They are useful labels because they legitimize the individual’s search for treatment for eating behaviour which they consider at least, uncomfortable and at worse, insane.

For this reason, it is dangerous and incorrect to label the uninhibited eater simply as an “addict”. There is evidence for example, (based on pre load studies with ice cream), that the eating patterns of so-called addicts is motivated more by beliefs about what they have eaten rather than the foods themselves (2). Moreover, the label “addict” is often disempowering, suggesting that you are emotionally sick, with the ever-present danger of relapse. While it is true that there is a poor record of weight loss maintenance in anyone irrespective of where they start from, there are evidence based psychological treatments of “compulsive eating” which have a good and enduring outcome (3). These treatments don’t necessarily lead to losing weight.

Ignoring for the moment the question “what is a binge?”, evidence supports the view that among obese binge eaters there is a greater than average risk of the following; history of trauma, psychiatric illness, mood disorders, history of alcohol abuse, avoidant, dependent and borderline personality disorder (4). But don’t assume that this is true for all obese binge eaters, many of who just got into bad habits, enabled in part by the people who live with them. Or alternatively there are sufferers who have not learned how to manage stress.

So this is why labelling overeaters or even compulsive eaters as “addicts” is nonsense. Careful assessment will pick out factors that may interfere with treatment for weight control. Then, using techniques such as cognitive therapy to deal with the obesity mindset, emotional resilience training, mindfulness work, trauma counselling for some people and nutritional rehabilitation, we can package together a treatment which will help even the most disinhibited of overeaters – often quickly. They will stop bingeing and they will be able to eat their forbidden foods without danger of relapse.

Personally speaking, I have found it helpful to say to my clients “I refuse to call you an addict – you simply have some things to learn which will help you to manage your life differently.”

I would only start thinking about addiction if my overeater also has existing substance abuse problems or a history of them. For sure, there are aspects of 12 step programmes which are useful for anyone with a mental health problem to help with things like self worth and forgiveness, getting help from others and taking an inventory of all ones difficulties. But first and foremost I would turn to cognitive –emotional behaviour therapy for my overeaters(5).

Do we not owe it to our clients to “label” them as potentially normal as the rest of us?


1 Fitzgibbon and Kirschenbaum (1999). Heterogeneity of clinical presentation among obese individuals seeking treatment. Addictive Behaviours 15, 291-295

2 Wilson T. (1993). Binge Eating And Addictive Disorders, in Binge Eating, Nature Assessment and Treatment. Eds Fairburn, C. and Wilson, T. Guildford Press.

3 Gladis, Wadden et al. (1998). Behavioural treatment of obese binge eaters, do they need different care? Journal of Psychosomatic Research 44 375-384.

4 Yanovski, Nelson, Dubbert & Spitzer (1993). Association of Binge Eating Disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry December (12):1910

5 Smith, Marcus & Kaye (1992). Cognitive behavioural treatment of obese binge eaters. International Journal of Eating Disorders 12, 257-262

Sunday, 6 May 2012

Vogue Bans Under Age Catwalk Models - Is The Tide Turning?

Alexandra Schulman is banning models who are under 16 years of age or "who are showing obvious signs of an eating disorder" from her pages. She castigates designers who only provide sample sizes in size 2 which means that she has to seek the very thinnest models from the agencies who sell their girls to the media.

This follows on from a gentle but increasing wave of editorial changes taking place in Israel, in France and Italy. They are finally cottoning on to the notion that they have some resonsibility for the epidemic of poor body image and weight anxiety that is afflicting their readers.

Two anorexic women writing in the Daily Mail, May 5th 2012 described how their anorexia was induced by their obsession at looking the skinny models in fashion magazines. Is this true?  This is not a good argument for banning skinny models. As I have written in an earlier post, skinny models don't cause anorexia; if they did millions of women would have anorexia. Thinspiration and obsessional looking at fashion pics simply reinforce an illness which is already there. Women who are obsessed by looking at fashion magazines need to have an hour with an expert to show how these images are digitally altered. The pictures by and large aren't real.

The big challenge is, how we can teach our girls and our boys how to look at these fabulous icons, these long legs, skinny thighs, plasticated boobs and chiselled stomachs without automatically coming to the conclusion that "I am ugly". Just try this, step out into the street and count how many perfect bodies you will see. Not all that many.

There will always be someone you can find who is thinner than you, or stronger with bigger muscles or nicer hair. Even though I'm an eating disorder therapist who should fully understand, I am sometimes at a loss about addiction to fashion magazines,  images of perfection and people who covet boobs made of industrial plastic.

We have an internal mirror that only needs to be taken out from time to time. If we keep on looking into it and sighing, like Narcissus, we will fade away and die.

Compassion Versus Coldness in Eating Disorder Treatment:

On Linked-In a therapist asked should an eating disorder therapist be compassionate or “cold and rigid”?

This is a huge question; boundaries are important because they foster trust and engagement; many of our patients lack boundaries and we need to model good boundaries for them. Treatment requires compassion, speaking the language of the eating disorder using "hip pocket patient thinking" to show people we "get them”. But too much compassion may mean that we collude with eating disorder thinking and behaviour so it is not sufficient for recovery to take place, we also need to do some hard work shoulder to shoulder with our people, insist on home assignments and even use "blackmail strategies" such as a 10 minute interview instead of an hour of therapy if a client engages in treatment resistant behaviour. So, sometimes being provocative and challenging too. I once did a 2 hour presentation for an NHS service in the UK on therapist qualities for eating disorder treatment and (only) one of the conclusions is that a sense of humour helps too.

Compassion is important, yet bear in mind that often a client becomes more interested in their relationship with the therapist rather than doing the work because of early attachment problems with their parents or a history of neglect and abuse. This is a vulnerable client group. I don’t think that we can do much unless we have a good relationship which becomes a template for other relationships in a sufferer’s life, which involves learning skills for managing conflict and a good balance between avoidance and dependency.

Psychotherapists have to be on guard against NEEDING to be liked by our patients, and always having to be too kind, which can interfere with their treatment and which puts us at risk of colluding with the eating disorder. This is, I guess, why I am not scared of being controversial and at times making people angry with me.