Innocence lost — health messages are not always healthful

The current focus on teaching children “healthy” eating is popularly believed to be so healthful, helpful and necessary, that confirmation bias cannot let us see the evidence that suggests it isn’t. A major 3-year study found disturbing clinical evidence that children are being harmed by such initiatives… children as young as five. Yet, not only has the media not widely report this important study, even its authors missed the biggest story in its findings.

What was reported

A small troubling piece in the Australian news reported that children as young as five are suffering from eating disorders and being hospitalized with life-threatening malnutrition. They are “literally starving themselves to death.”

Dr. Sloane Madden, child and adolescent psychiatrist at Children’s Hospital at Westmead, Sydney, said that they’ve seen a 50 percent increase in children aged 10-12 and younger needing hospitalization for eating disorders, an increase not seen among older teens.

These young children are critically ill by the time they arrive at the hospital, he said, and are medically unstable, with very low blood pressure, heart rate and temperature and are so malnourished they need tube feedings. In fact, he said, during the three years of their study, children were in increasingly critical condition by the time a diagnosis is made. That’s a concern because it means that disordered eating is going undiagnosed until children’s health and lives are in danger.

According to Dr. Madden, the children say “they believe they are fat and want to be thinner, and they have no insight into the fact that they are malnourished and they are literally starving themselves to death.” “The number of cases is expected to rise,” Dr. Madden said, “unless there is a change in the media's obsession with fat and weight.”

Because of the way the study was reported, it might have been easy to dismiss it. Readers may have thought that it was the experience of a single medical center offering pediatric anorectic services and a matter of more children coming to their center, not a nationally representative trend. But that wasn’t the case.

The study

The study, published in the Medical Journal of Australia, reported the findings of the first national prospective study of early-onset eating disorders (EOEDs) in young children. It was based on active surveillance data from the Australian Paediatric Surveillance Unit from July 2002 to June 2005, which gathered data from physicians, primarily paediatric Fellows of the Royal Australasian College of Physicians, of all Australian children aged 5-13 years who had received a diagnosis of EOED. The definition was developed in consultation with paediatric EOED specialists, and “was based on existing diagnostic criteria from the DSM-IV; the International classification of diseases, 10th revision (ICD-10); and the Great Ormond Street Hospital for Children Feeding and Eating Disorders Service.”

The authors from Children’s Hospital at Westmead, the Department of Paediatrics and Child Health at the University of Sydney and the Australian Paediatric Surveillance Unit in Sydney received detailed reports on a sampling of 101 children, about 90 percent of those diagnosed with EOED. What may be surprising, they found “no significant differences between boys and girls in terms of age, presenting symptoms, psychological comorbidities, family history or outcome.”

Eating disorders are most recognized as beginning during adolescence, the authors noted, when they’re the third most common chronic illness in women. “Eating disorders have the highest lifetime mortality rate of any psychiatric disorder (up to 20%), and mortality rates are 12 times higher for women with eating disorders than for unaffected women,” they wrote.

Children with eating disorders, however, continue to get younger. It was only in 2003 that Australian news had reported that the average age of young people being hospitalized for eating disorders across the country had dropped from 14 years in 2001 to 12.

In this study, three out of four young people diagnosed with eating disorders were female and the average age was 12.2 years. But nearly one in five patients were under the age of ten.

Disordered eating in young people and teens who are still growing puts them at special risk of complications that can have serious implications for their health and futures, such as “growth retardation, impaired bone health, cognitive impairment, disruption of pubertal development, infertility, depression, anxiety and death,” the authors noted.

How myths can be deadly

Of those children who had to be hospitalized, nearly two-thirds (61%) had life-threatening complications of malnutrition, yet only 37% had met the DSM-IV official diagnostic criteria of anorexia nervosa. The most significant failure of the commonly used definition of anorexia nervosa was that half of children suffering disordered eating — so severe that their malnutrition was even life-threatening — appeared ‘overweight’. Weight is a poor measure of eating disorders or health. Only 51% of those hospitalized and 23% of outpatients were under 85% on the BMI growth curves. As we’ve seen, failing to understand the natural diversity among people and believing the myth that fat people are fat because they overeat, means that children who are seriously below a weight that’s natural for them and who are failing to grow and develop normally per their individual growth curves, can look fat or even a ‘normal, healthy’ weight. You cannot tell from looking at people which ones are starving.

“Our study also highlights the absence of a threshold body weight or body mass index in children below which medical compromise occurs,” Dr. Madden and colleagues wrote. They cautioned that any young person who is falls off his/her growth curve should be taken seriously. Rapid weight loss is more likely to result in life-threatening complications. Of the young people who required hospitalization, nearly all of them had lost weight (89%) or failed to gain weight (8%), “as would be expected during normal growth,” the authors reported.

Among the young people diagnosed with eating disorders, half of which were potentially life-threatening, about three-fourths (74%) presented with fear of gaining weight or of being fat and preoccupation with their weight (73%).

But to believe that eating disorders are just about fat and weight is to miss the much more serious findings in this study — findings with wide implications: how today’s “healthy eating and physical activity” messages, largely driven by the war against obesity, are affecting young people. Yet, even the authors didn’t see them.

“I think that there needs to be a move away from this focus on weight and numbers and body fat, and a focus on healthy eating and exercise,'” Dr. Madden told reporters.

The study, however, found that compared with weight and fat, far more children were preoccupied with food and trying to avoid eating foods — foods they believed were unhealthy or feared were bad for them or would make them fat — 98% of these young children were avoiding foods and 90% were preoccupied with foods. Another worrisome finding was that more than half of the youngsters (54%) were already exhibiting excessive exercise, another anorectic behavior.

This study provided important indications that the incessant messages being given to children about healthy eating and exercise to prevent obesity are having serious adverse consequences. The evidence certainly provides no support that children need more of the same. Yet, the belief in healthy eating and activity has become so strong, the cognitive disconnect isn’t recognized. This is an example of one of the most common fallacies of logic, known as confirmation bias.

The evidence not seen through the cognitive disconnect

This study is not the first to suggest that healthy eating and activity interventions to address an “epidemic of childhood obesity” are not only groundless, but harming young people. The largest, most comprehensive statewide program ever enacted in our country, the Arkansas Act 1220, is one such example of a program that has failed children.

Confirmation bias doesn’t just lead advocates to design evaluation tools to support what they believe, or want us to believe, is true, but to report the findings in such a way, too. As we saw last fall, when the fourth annual report of the Arkansas 1220 was quietly released, this immense program was shown to have had no effect on children and adolescent weight classifications and to have failed to demonstrate improved health outcomes. Meanwhile, troubling evidence of its unintended consequences is growing. The results of this major healthy eating and activity intervention for children showed the importance of not looking at what we are teaching children, but what they are learning.

Beginning with children’s programming and Saturday morning cartoons, toddlers and preschoolers cannot escape the nonstop barrage of ‘eat right and exercis’ messages. They proliferate on Nickelodeon’s “Lazy Town,” PBS' “Boohbah” and the Disney Channel's “JoJo's Circus.” Ronald McDonald is pushing fitness and even the Cookie Monster on Sesame Street and Barney tells kids about eating “right” and that his favorite treat should only be a “sometime food.” Children’s programming is filled with examples of fat children being ridiculed. The messages to eat healthy and be active to prevent child overweight become even more pronounced once they start school.

Child nutrition and eating experts have been cautioning for years that even “positive” nutritional messages are beyond children’s understanding and disregard their developmental ability to grasp the complexities or to apply such concepts as “moderation.” Children are black-and-white thinkers and when they are told sweets or fats should be “sometimes foods” and eaten in moderation, they take that to mean all sweets or fats must be bad. By 1995, for instance, more than eight out of ten American children, aged 9-15, already believed healthy meant avoiding all high-fat foods. And a recent British Heart Foundation poll of 1,100 UK children, 8- to 15-years old, reported that a quarter of the youngsters believed “bad” foods would shorten their lives. And nearly half of the kids polled said they believed that ‘junkfood’ would make them fat and unpopular, cause their teeth to decay and their skin to break out.

According to the research of international child nutrition and eating expert, Jennifer O’Dea, MPH, Ph.D., from the University of Sydney in Australia, health education messages and government dietary guidelines since the 1970s, with their “control your weight” messages, have resulted in an exponential rise in disordered eating and most young people have mistakenly come to believe that they are eating “healthy,” when they are actually dieting. Food fears and unsound beliefs about healthy eating continue into adulthood, with many suffering lifelong disordered relationships with food.

Yet it’s been recognized for decades, such as research from the Centre for Adolescent Health at the University of Melbourne, Australia, that restrictive eating and dieting behavior among girls is associated with five to 18 times greater risk of developing an eating disorder. So, the increase in eating disorders seen among children exposed to increasingly intense healthy eating and exercise messages should not really be a surprise at all.

Saddest of all, is that children have never grown up in a safer world. — Most have enough to eat, safer foods and better diets, not nearly as bad as some are trying hard to convince us to believe. They are as fit and active as ever. They have better access to medical care and immunizations that have enabled far more to survive infancy and childhood; and far fewer to spend their childhoods sickly, with childhood illnesses, foodborne illnesses and nutritional deficiencies. Children are healthier and have the longest life expectancies of any time in our history. There is no credible science that the diets of today’s children are shortening their lives or causing them to develop adult diseases. There is no credible scientific support that low-fat, low-sugar, low-salt foods define healthier foods for youngsters, prevent heart disease or obesity, or lead to longer lives. [Background: here, here, here, here, here and here.]

This should be the best time to be a child. Instead, today’s young people are surrounded by scares about their foods, their bodies, their futures and the world they live in. Kids as little as five years old are being hospitalized for starvation because they’re afraid to eat. What is wrong with this picture? When will adults see past their own biases and the special interest scare mongering, and see what is being done to their children… and give kids back their childhoods?