FEWO Committee Report

FACTORS CONTRIBUTING TO THE DEVELOPMENT OF AN EATING DISORDER

Although the exact causes of eating disorders are not fully understood,[35] research suggests that they are complex illnesses with a biological or neurobiological basis influenced by a multitude of genetic, psychological, social and cultural factors.[36] The relative influence of contributing factors might vary between males and females with eating disorders,[37] and possibly across age groups.[38] This section of the report discusses some of the known or suspected factors contributing to the development or maintenance of eating disorders without attempting to rank them in order of their relative contribution.

A. Genetic Factors

Developments in genetic research are advancing our knowledge of the causes of eating disorders.[39] The Committee heard that the heritability for anorexia nervosa is about 75%, which is higher than many illnesses commonly understood to be genetically determined, such as schizophrenia, with a heritability of about 50% and type II diabetes, at about 70%. According to Dr. Blake Woodside, Medical Director for the Program for Eating Disorders at the Toronto General Hospital, in the case of anorexia nervosa, “genetics loads the gun; environment pulls the trigger.” Bulimia nervosa is also believed to have a strong genetic basis.[40] Noelle Martin, a professor at Brescia University College, Western University, and President of Registered Dietitian Services, described the genetic predisposition of certain individuals to eating disorders as a “ticking time bomb,” waiting to be triggered by any of a complex array of social, cultural, and environmental factors.[41]

B. Biological and Psychological Factors

An in-depth discussion of the physiology of eating disorders is beyond the scope of this report, but many witnesses emphasised the biological nature of eating disorders.[42] For instance, Dr. Joy Johnson, Scientific Director of CIHR, noted that factors such as early puberty or obesity in girls could predispose them to eating disorders.[43] Merryl Bear, Director of the National Eating Disorder Information Centre (NEDIC), noted that emphasising the multiplicity of factors is important because it moves away from “blaming” parents for “causing” eating disorders in their children by mentioning their child’s weight or eating habits.[44] It might also help parents understand the reason for their child’s disturbed behaviour:

I understood what was happening in the brain. This made it easier for me to exhibit patience. My daughter was exhibiting a typical fight-or-flight response to an anxious situation. From a neurobiological standpoint it made sense.[45]

Some witnesses emphasised the complex interplay of biological and psychological factors. Therapist Carly Lambert-Crawford noted that while certain psychological factors may predispose individuals to eating disorders, the starvation of the brain that results from food restriction negatively affects cognition.[46] The lack of nutrition associated with food restriction can lead to increased obsessiveness, which in turn fuels the perceived need to diet, exercise or purge.[47] Thus, eating disorders function in a manner similar to obsessive compulsive disorder, where the obsessive thought is “I am eating too much, I’m gaining too much weight” and the compulsive behaviours used to alleviate stress are restricting food, purging and/or exercising.[48] Dr. Blake Woodside of Toronto General Hospital noted that chronic dieting – which has biological and psychological implications – can predispose individuals to developing eating disorders.[49]

From a psychological perspective, witnesses described certain personality traits or mental health problems as being factors that predispose individuals to eating disorders. For instance, high levels of anxiety may predispose children to eating disorders, as can depression and mental illness generally.[50] Young people with obsessive, perfectionist or anxious personality style might also be predisposed.[51] Marla Israel, Acting Director General of the Centre for Health Promotion and Chronic Disease Prevention Branch of PHAC, explained that inadequate coping mechanisms in some children – meaning their inability to respond appropriately to stressful situations – could contribute to the development of eating disorders.[52] Dr. Wendy Spettigue, psychiatrist with CACAP, described food restriction as a means that patients use to cope with intolerable feelings of fear, sadness, worry, guilt, anger and stress.[53] Dr. Monique Jericho, a psychiatrist and Medical Director of the Calgary Eating Disorder Program with Alberta Health Services, cautioned that despite their presentation, eating disorders are not in fact about food; the food restriction and other behaviours associated with eating disorders are symptoms of more complex underlying issues.[54] Several witnesses noted that physical and sexual abuse might predispose individuals to eating disorders.[55]

C. Culture and Body Image

Although witnesses generally discussed cultural influences on body image and social pressures to conform to a particular ideal as triggers, rather than causes, of eating disorders,[56] they emphasised that these pressures can be huge burdens for women, and young girls particularly.[57] Factors such as a pervasive acceptance of an unrealistically thin ideal,[58] a rise in celebrity culture,[59] and society’s tendency to objectify women,[60] contribute to girls’ development of unhealthy expectations about their own body. One potentially damaging message that girls receive is that if they try hard enough, they can all attain a particular body type, when in fact some girls’ genes may dictate a different body type.[61] Witnesses also noted that societal pressures to be thin can mask the symptoms of eating disorders because people are encouraged to lose weight or praised for losing weight.[62] Further, because society equates beauty with power, and the predominant beauty ideal implies thinness, it may be difficult for some individuals to fully appreciate the potential danger of pursuing thinness.[63]

In addition to the societal pressure to be thin, there is an even greater pressure to avoid becoming fat. Some witnesses described a “moral panic” that has led to the stigmatization of fatness.[64] People perceived as being fat face discrimination and stereotypes; they may be considered unattractive, unhealthy, immoral or lazy.[65] The Committee heard that even preschool-aged girls have internalized society’s collective rejection of fatness; when presented with fat or thin figures, girls aged three to five years were more likely to describe the thin figures as “nice, smart, cute, neat and quiet, while heavier figures were characterized as mean, stupid, friendless, sloppy, ugly and loud.”[66] In the words of Jarrah Hodge of Women, Action and the Media Vancouver, if the pursuit of thinness acts as a carrot, the policing and shaming of fatness acts as a stick.[67]

These dangerous messages are affecting young girls and women.[68] Dr. Wendy Spettigue, psychiatrist with CACAP, cited a study in which researchers found that 61% of Canadian girls in grades 7 and 8 were trying to lose weight. She cited another study of 700 children in Edmonton in grades 5 to 7, in which researchers found that 15% were purging or over-exercising, 16% were binge eating, and 19% were restricting their food intake to one meal per day or less.[69] Adult women are also vulnerable to pressures to be thin; research shows that as many as 87% of adult women are dissatisfied with their bodies and 70% are dieting to lose weight.[70]

Witnesses characterised schools as potentially toxic environments for messaging about weight and appearance. Dr. Spettigue noted that many teenaged girls do not eat lunch at school out of fear that they would be judged by other students, particularly boys. She also noted the popularity in schools of apps that allow users to rate images of girls and women.[71] Dr. Valerie Steeves, associate professor of the Department of Criminology at the University of Ottawa, noted the focus in high schools on “thigh gap”; girls with a gap between their thighs are envied and subjected to jealous taunts, while girls without them are considered fat and ugly.[72] Because many young people spend more time with their peers than with their families, parents may struggle to counteract this barrage of negative messages in the time they have with their child.[73] Witnesses explained that this was yet another area where parental support and communication is key. Witnesses had repeatedly explained that fostering good body image and confidence, and helping people through eating disorders, is more effective with familial support.

The Public Health Agency of Canada works to counteract some of the negative messages that witnesses warned against. The agency advised the Committee that fostering a positive sense of self, with feelings of control and self-esteem among girls and boys can protect against eating disorders.[74]

D. Mainstream Media and Advertising

As specific examples of cultural influences that could trigger behaviours related to eating disorders, witnesses discussed the fashion and entertainment industries, as well as advertising in general, and the advertising of diet products in particular. These industries convey “very specific messages about what [young women’s] bodies should look like.”[75] The images of beauty that the entertainment industry presents are quite unrealistic; although an average healthy body mass index (BMI)[76] for a young woman is about 21, typical models and celebrity actresses have a BMI closer to 16 or 17.[77] Dr. Giorgio A. Tasca, Research Chair in Psychotherapy Research at the University of Ottawa and the Ottawa Hospital, noted that as television and the Internet were introduced into communities that had previously had little access to these forms of media, rates of eating disorders increased dramatically.[78] Merryl Bear, Director of NEDIC, commented that many behaviours associated with eating disorders – such as highly restrictive eating, excessive exercise and guilt about eating – are highlighted or even “glamourized” by the media.[79] Further, meta-analyses of studies on eating disorders suggest that increased media consumption is associated with eating disorder symptoms.[80]

Elaine Stevenson, long-time advocate on behalf of people with eating disorders and co-administrator of the Alyssa Stevenson Eating Disorder Memorial Trust, expressed dismay that negative images in the media are fuelling the “very powerful, multi-billion dollar” diet industry.[81] This industry promises that thinness will bring “health, happiness, sexiness, and acceptance by society,” when in fact, she argued, pursuing thinness may cause serious harm.[82]

Witnesses expressed particular concern about marketing specifically aimed at girls. Dr. Valerie Steeves, associate professor, noted that there has been a significant change in her lifetime; when she was young, adolescents and children were off-limits for most advertisers, but this market now appears wide open.[83] Further, advertisers may be specifically targeting young women with potentially dangerous messages. Dr. Steeves shared her experience of visiting educational websites on eating disorders with sponsored links; the advertisements were for plastic surgery and diet products.[84]

Recommendation 1

The Committee recommends that the Government of Canada consider supporting research on the impact of media messaging and marketing directed toward children and the impact and consequences of society’s current, narrow definition of beauty.

Recommendation 2

The Committee recommends that the Government of Canada encourage academic institutions to promote media literacy for young children to help them to view media content critically and question the messages therein.

E. Social Media

Our society appears to be increasingly focused on individuals’ appearance, and this focus is particularly strong in the online context.[85] This emphasis on image can lead to a perception that one’s identity – which might otherwise comprise personality, intellect and other aspects of oneself – is “reduced to our physical identity.”[86] In turn, this can cause people to distance themselves from their bodies and to judge their visual identities while knowing that others are judging their visual identities too.[87] Witnesses pointed to Facebook and social media to help explain this phenomenon.

Facebook allows users to construct their visual identities.[88] It also allows other people to comment on a user’s visual identity.[89] Dr. Valerie Steeves, associate professor, described some of her recent research in which she interviewed young women about their Facebook practices.[90] She described girls dieting then posting images of themselves in lingerie, and waiting to see if they received enough “likes” for their picture in the short time after they posted an image. If they did not receive enough “likes” in that time, they felt humiliated and took down their picture. Dr. Steeves explained that while social media “provides a snapshot of teen life” because of its public-private nature, the emphasis on body image and the pressure to be thin are not unique to social media. Rather, she argued, they arise from media and culture generally.[91]

F. Public Health Messages about Weight

The Committee was told that although public health messages about weight and healthy eating may be “very well-intended,” they may be dangerous for certain populations.[92] There are widely publicized campaigns to fight a childhood obesity “epidemic,” but some witnesses questioned whether such an epidemic exists.[93] Dr. Gail McVey, of the Hospital for Sick Children and OCOPED, told the Committee that research indicates that childhood obesity and eating disorders are actually linked and that public health “attention to preventing one does not have to mean neglect of the other.”[94]

The Committee heard that adults are unintentionally “transmitting a kind of panic” to children about obesity. Psychiatrist Dr. Wendy Spettigue, of CACAP, told the committee that public health messaging about obesity actually increases the incidence of eating disorders.[95] Dr. Leora Pinhas a psychiatrist from the Department of Psychiatry at the Hospital for Sick Children, noted that studies show that children would rather lose an arm, be hit by a truck or have a parent die of cancer than be fat.[96]

Some witnesses warned against the current approach to education about eating disorders in schools (discussed in greater detail later in the report). While these awareness-raising messages may be well-intentioned, they can act as triggers for eating disorder-related behaviours.[97] Joanna Anderson, Executive Director of Sheena’s Place, shared the following experience:

I worked with a young 13-year-old boy who was hospitalized after someone had come into his class to educate them about healthy eating. In that talk it had been said that fat was bad, that fat should be cut out of diets. Within six weeks this child was in a tertiary health care centre on a heart monitor after he had lost so much weight as a result of receiving that message.

Certain children may be especially vulnerable to these messages. Witnesses remarked that a single comment from a teacher, a coach or a family doctor, or information from a health class or school project could trigger dangerous behaviours.[98] Dr. Pinhas noted that these messages are particularly unhelpful for younger children because they may not be able to process all the nutritional information that is being conveyed, and further, they have limited control over their diets because their parents buy food and make meals.[99]

When Jadine Cairns, President of the Eating Disorders Association of Canada (EDAC-ATAC), mentioned to one of her clients with an eating disorder that she would be appearing before this Committee, they discussed public health campaigns about weight. The patient said “yes, please tell them that it’s really hard on us.”[100] Dr. Spettigue shared similar concerns:

[T]here are a lot of very compliant, self-conscious, perfectionistic, anxious little girls who are trying to be very, very good, and avoiding all the bad foods. Many of them get to the point where they're hospitalized for medical instability because they’re only eating vegetables because they’ve heard so many messages about the bad foods: the fats, the sodium, and the sugar. We somehow need to create an atmosphere that's more about moderation and balance that applies to everybody. We also need to figure out how to treat obesity without causing eating disorders because for all of the patients who are getting the messages about the need to diet and watch your eating and all of that, they’re creating a whole bunch of young patients who are coming into our hospital terrified of eating, terrified of gaining weight.[101]

A representative from Health Canada noted that the department’s nutrition messaging emphasises health and well-being rather than weight and calorie counting,[102] and witnesses supported this approach; this approach is also an important part of prevention, as discussed below.[103]

Recommendation 3

The Committee recommends that the Government of Canada collaborate with the provinces and territories to consider adjusting medical criteria for defining normal weights beyond quantitative measures such as Body Mass Index.

Recommendation 4

The Committee recommends that the Government of Canada review the information it provides on nutrition to encompass greater sensitivity in its guidelines on “good” and “bad” foods with the goal of helping to prevent unintended consequences, such as children as young as five years old developing eating disorders, which have been alleged to arise from the current guidance.

G. Prevention

The Committee was told that the development of effective prevention strategies is a critical step in reducing cases of eating disorders. Effective prevention initiatives must address the range of contributing factors described above with the goal of changing the circumstances that promote, initiate, sustain or intensify eating disorders.[104] Noelle Martin, professor at Brescia University College and President of Registered Dietitian Services, highlighted the importance of prevention strategies:

Eating disorders are mental illnesses related to one's relationship with body, food, and others. We know that there's often a genetic link… Then, we have social, cultural, and environmental factors that may cause the gene to be expressed. For example, it could be a comment from a parent, friend, coach, or teacher that triggers a new thought in one's mind. It could be an article in a magazine, a commercial, or the content of a movie or a show. It can be obvious, or it can be very subtle. We cannot pinpoint just one thing that is the cause for eating disorders. Because of this, we need to look at prevention strategies that target a variety of areas.[105]

Prevention strategies can be targeted (aimed at a subset of a population) or take a more universal approach (e.g., national or school-wide level).[106] Witnesses stated that prevention campaigns with a more universal approach can address more than just eating disorders; such campaigns can have the wider goal of changing society’s attitudes about weight and appearance and reducing stigma for individuals at risk of developing an eating disorder.[107] From a public health perspective, such a widespread prevention campaign can promote the development of a solid foundation in terms of mental well-being, self-confidence and self-esteem.[108] As well, such universal prevention efforts can focus on healthy eating and balanced nutrition, without discussing dieting, calorie-counting and weight.[109]

For example, Dr. Hasan Hutchinson, Director General of the Office of Nutrition Policy and Promotion at the Health Products and Food Branch of Health Canada, said that “nutrition promotion policies, programs, and messages such as those developed by Health Canada, which focus on health and well-being and not on weight and calories, play an important role in the prevention of disordered eating.”[110]

Among targeted prevention strategies, the Committee learned that prevention can focus on the general promotion of healthy eating, with the goal of stopping eating disorders before they develop, or prevention can focus on assisting individuals who may be showing eating disorder symptoms, with the aim of providing early identification and early treatment.[111]

Among prevention campaigns geared to adolescents, the population at greatest risk of developing an eating disorder, the Committee was informed that organizations should be cautious when designing campaigns to teach youth about eating disorders. Research indicates that poorly-designed campaigns can provide “how-to” information and can trigger an eating disorder among individuals at risk.[112] Dr. Gail McVey, of the Hospital for Sick Children and OCOPED, explained that having speakers present on the topic of eating disorders to youth is “ineffective as a prevention strategy” and can “glorify eating disorder symptoms among impressionable youth.” She noted: “For example, it is well documented that following such presentations youth are at risk of adopting dangerous [eating disorder] techniques including laxative use, starvation, self-induced vomiting.”[113]

As well, as discussed above, the Committee was told that obesity prevention campaigns can be equally harmful; for example, programs that measure youth’s BMI end up stigmatizing different body sizes and creating a sense of fear over weight gain.[114]

The Committee was told by Dr. McVey that prevention strategies can adopt a “lifespan approach” which is “heavily anchored in mental health promotion designed to foster healthy coping skills to fend off stressors that lead to eating disorders.”[115] Prevention campaigns can also include long-term media literacy components, which help youth to build confidence and resilience, combat social pressure and improve critical thinking related to media messages.[116]

The Committee was informed that while evidence indicates that prevention targeted at adolescents is most effective, there is “a total absence of targeted prevention for Canadian adolescents” and “this gap in service, or death valley, coincides with the highest period of risk for the development of eating disorder symptoms and their associated mental health concerns.”[117]

Josée Champagne, Executive Director of Anorexia and Bulimia Quebec (ANEB Quebec), said that prevention programs in schools should be more prevalent, and she recommended training “peer helpers” to assist students at risk of developing eating disorders.[118] However, Dr. McVey recommended that only qualified mental health experts be responsible for leading eating disorder prevention as they have the appropriate knowledge and expertise to “deliver high quality, sophisticated, clinically-sensitive prevention programming.”[119] Prevention strategies targeted at children, often with the aim of providing nutritional information, have begun to shift towards targeting parents and other adult role models or authorities, as these people have direct control over the lifestyles and eating habits of the children.[120] Dr. Leora Pinhas, psychiatrist at the Hospital for Sick Children, said that teaching children about nutrition can have a limited impact, as it is the parents who prepare meals; she suggests instead creating “a lunch program” to ensure children are eating balanced meals.[121] Laura Beattie, Co-chair of F.E.A.S.T. Canada Task Force, recommended that schools provide adequate time and supervision for lunch and nutrition breaks to promote healthy eating.[122]

The Committee also heard about certain types of prevention[123] that should be targeted primarily at parents, health care professionals, teachers, coaches and any other adult who may recognize early onset symptoms of an eating disorder. Dr. McVey explained that evidence indicates the effectiveness of targeted prevention in the early identification of disordered eating habits, and that this serves to stop early onset symptoms from escalating into full eating disorders.[124] These programs must have consistent messages that are directed at multiple levels, across sectors in health, education, sport and more.[125]

A challenge in the creation and delivery of prevention programs and strategies is the need for funding.[126] Ms. Beattie suggested the diet industry be financially responsible for the cost of certain prevention programs.[127]

Dr. McVey suggested establishing a “prevention strategy” for Canada.[128] However, the Committee was informed that efforts to prevent eating disorders are valuable, but not always sufficient. As was explained by Lisa LaBorde, parent of a daughter with an eating disorder:

Our home environment was probably as close to an experiment in eating disorder prevention as one could get. There was no scale in our home. We did not have cable. I'd never been on a diet in my life, and I grew up in a culture that did not internalize the thin ideal. I worked to pass that on to my children also. We consciously spoke about healthy bodies of any size, and I raised them to be conscious and critical of media messages. Still, [my daughter] got an eating disorder.[129]

Recommendation 5

The Committee recommends that the Government of Canada collaborate with the provinces and territories to consider developing a health and well-being education and awareness campaign, including both in-school and social media content, to foster a positive sense of self to protect against eating disorders, and to include media literacy components to counteract images portrayed in mainstream media.