First Bite: How We Learn to Eat (28 page)
Johnson and colleagues used doll play to help children start to recognize whether they were hungry. They also talked about hunger and overeating and about what empty and full bellies felt like, from the rumbling of hunger to uncomfortably full. Special dolls were brought into the nursery with nylon “stomachs” filled with varying amounts of salt. Some of the dolls had empty stomachs that were “hungry”; some were a little full; and some were very full. At snack time, the children were asked to
place their hands over their own stomachs to see how full they were and to choose the doll whose stomach felt most like their own. By the end of the intervention, children had started to spontaneously say things such as, “I’m not hungry anymore so I’m going to stop eating.” At the end of the six weeks, there were “significant improvements” in how the children ate at snack time. The overeaters started to eat less, and the undereaters ate more. Johnson’s study suggests that with the right teaching and support, “children are capable of controlling the
how much
of eating.” The first stage is learning to recognize whether the stomach is empty or not.
This is something adults can learn, too. In one weight-loss trial, it was found that giving participants lessons in mindfulness about hunger resulted in greater reductions to BMI than dieting alone. Another seven-week intervention with obese and overweight adults in the Netherlands trained them to reduce their cravings by accepting them. When these people felt assailed by food cravings, they were taught not to eat immediately, but to wait and observe what they were feeling, both in their bodies and in their minds. The psychologists doing the intervention gave the patients techniques to become more aware of their own hunger and taught them to observe whether it was physical or emotional. They were instructed in how to perform a “body scan” on themselves, methodically paying attention to different parts of the body and gauging the signs of hunger or satiety. This is not so different from playing with a doll who has a stomach full of salt. At the start of the seven weeks, many of the participants believed they had no control over their own hunger. They would say things such as, “I cannot stop eating until the bag is empty.” The training taught them ways to experience the various hungers their bodies felt without being controlled by them. They learned to accept their cravings without always giving in to them.
The latest January diets often claim that if only you follow all the steps, you will never feel hungry again. It’s taken me a long time to realize that part of eating well is making friends with hunger. We are not the starving children. To feel mildly hungry two or three times a day—when you are lucky enough to know that another meal is coming soon—is a good thing. All my life—except when I’d been attempting to lose weight—I’d responded to the gentlest of tummy rumbles as something
that needed to be urgently canceled out. It is only now that I see you can easily live with an hour or two of slight emptiness. In fact, it makes the next meal taste better (“Hunger is the best sauce,” as the proverb goes). Eating without hunger and drinking without thirst can become so habitual that you forget how good it feels to regain the proper rhythms of feeding: to earn your meals before you eat them, even if all you’ve done to earn them is to wait.
It’s like being a child, playing out on the street with your friends and losing track of time until your parents call you for dinner and you come inside, rosy-cheeked and famished.
It is a ritual so
ordinary we do not question it. Open box. Pour cereal. Pour milk. Eat. Yet the breakfast cereal habit, often acquired very early in childhood, can provide unhelpful lessons in how to satisfy hunger. It teaches us that when we feel empty, we should turn, not to a stove or to some whole food we can choose on its merits, such as a piece of fruit, but to a brightly colored box. Cereal is a medium through which we learn to confuse hunger with marketing.
Ready-to-eat cereal has become the most ubiquitous way to answer peckishness in the morning, last thing at night, and plenty of other times in between. Boxed cereal—first marketed as “Granula” in 1863 by Dr. James Caleb Jackson—was originally a quintessentially American custom. But the rest of the world is catching up. In 2013, India consumed $3.4 billion in breakfast cereal; Russia ate $3.8 billion, Brazil $4.8 billion, and China $16.7 billion. Global sales of breakfast cereal are increasing by around 10 percent per year.
Breakfast cereal tends to be one of the first foods that parents allow children to choose for themselves, as they sit wedged in a supermarket trolley. Of all the foods that we could give a child free rein over, cereal makes the least sense. Parents let children choose cereal but dictate which vegetables they eat; it should be the other way around.
Cereal also tends to be the first meal we “make” for ourselves, to fill any hungry patches in the day. Because it involves no fire or
knives, cereal is seen as a “safe” thing for children to prepare. The act of sitting at the kitchen table reading the back of a cereal box forges an emotional bond that lasts a lifetime. The cheering lettering reassures us that, despite appearances, the sugar-coated flakes will do us good, because of all those added vitamins and minerals.
The cereals marketed for children are consistently the most sugary and highly processed in the whole cereal aisle. A child’s choice isn’t determined by the sensory properties of the cereal—which are hidden inside the box. As a kid, you pick the one that promises you the most stuff: the most bizarre shapes, the coolest cartoon character, the best free gift or promotion, the most added chocolate. This habit offers a bad lesson in how to choose food. When you encounter a genuinely filling breakfast food, such as oatmeal or scrambled eggs, it is hard to shake off the feeling that there is something missing.
Rebeca only liked to eat the damp earth of the courtyard
and the cake of whitewash that she picked off the
walls with her nails. It was obvious that her parents, or
whoever had raised her, had scolded her for that habit
because she did it secretively and with a feeling of guilt.
Gabriel
García
Márquez,
One Hundred Years of Solitude
D
iane was a forty-eight-year-old woman with a full-time
job as an office manager, with no outward signs of medical problems, aside from being overweight. She had never sought or received professional treatment for any kind of eating disorder. Yet in 2014, her case came to the notice of researchers studying adults in a deprived borough of the Midlands in the United Kingdom who identified themselves as “picky eaters.” Diane was one of the participants recruited through local libraries and recreation centers. In all, the researchers spoke to twenty-six families, interviewing them at length in cafés and at home. The picky eaters were also asked to keep a detailed photo diary of everything they ate over a four-day period, showing where they ate it and with whom. This exercise built up a picture of apparently normal people who nevertheless ate in deeply abnormal ways. All of the adult picky eaters said they had been eating this way since childhood. At the age of nearly fifty,
Diane’s diet consisted mostly of cheese, processed potato products, sliced bread, and cereal.
Despite having the skills and confidence to cope with her job, Diane was passive and childlike about food. She spoke of guilt about the way she ate, and she still felt she had let her mother down by not being more accommodating. Diane’s eating was limited not just by ingredients but also by temperature. The only vegetables she could tolerate were very cold salad vegetables, sliced thin, and with no dressing, in minuscule quantities. Cooked food had to be very hot or she would not touch it. She went with one of the researchers to a café, where she ordered egg and toast, but she had to stop eating it halfway through because when it got cold it “turned her stomach,” she said.
The way Diane ate made it difficult for her to eat at the houses of friends, as she was apt to refuse the food they cooked for her and couldn’t prevent the look of abject disgust on her face. Diane recognized her eating to be a problem; and yet, from her point of view, it would have been more problematic still for her to try to consume any of the foods that she did not want to eat. She hated cooking, she said. Occasionally, she would attempt to eat a more balanced diet, but she couldn’t bring herself to “crave” anything but “junk.” “Well, I’m 48 now so I’m not going to be able to change am I, really?”
This case does not sound like what we imagine to be a typical eating disorder. Diane was not a teenager; she didn’t—so far as we know—obsess over fashion magazines or do ballet; and she wasn’t overly preoccupied with having a flatter stomach. Indeed, she recognized that she would be healthier if she could bring herself to eat different foods. Diane was not avoiding food as a way of limiting her calorie intake, but because she just couldn’t bear to eat certain things. Yet there is no doubt that her life—and her health—suffered profoundly because of her eating. Diane’s case shows just how distorted eating can become and still not quite count as an “eating disorder” in clinical terms.
There are many misconceptions about eating disorders. One is that they are all about trying to lose weight, like anorexia or bulimia. Another is the view that they have nothing to do with the rest of us. In fact, eating disorders—whose forms are as numberless as snowflakes—
are
best understood as extreme versions of the dilemmas and pitfalls that all of us face in learning how to eat.
Those whose eating disorders are so acute that they—or their parents—seek help from an eating or feeding disorders clinic are the tip of an iceberg that extends deep into our food culture: a far-reaching edifice of low-level unhappy eating that manifests in countless ways. Think of the office worker who compensates for a hard day—every day—with comfort snacks in front of the TV, or the child who is afraid to drink anything that doesn’t taste sweet. There are the grown men who still feel sickened by greens, and grown women who won’t allow themselves to order a dessert, only to eat the equivalent of a double portion from everyone else’s plates. Most ubiquitous are the yo-yo dieters, stuck on an unremitting treadmill of losses and gains, who own two separate wardrobes, the fat clothes and the thin ones. Such behavior is so common that we do not recognize how dysfunctional it is. In a survey of 2,000 college students in the United States, 41 percent of the women and 18 percent of the men said they were currently “on a diet.”
Sometimes, in a black humor, dieters say they envy anorexia sufferers their “discipline.” Or, since the difficulties faced by someone who has pared down her consumption to almost nothing seem so far removed from the more everyday disordered eating of the rest of us, we might treat eating disorders as irrelevant. Who would choose to spend time thinking about laxative abuse or starvation-induced organ failure when we could be dreaming about cake? We avert our gaze from anorexics in the gym changing rooms, not wanting to draw attention to their jutting collarbones and gaunt legs, though whether we are sparing their feelings or our own is not clear. Yet if we look closer—and preferably make eye contact—we might find that eating disorder sufferers have something to teach the rest of us about food. For one thing, they show just how high the stakes become when eating goes wrong. More importantly, eating disorders offer a model for how eating habits can be relearned from scratch, even by people whose genetic disposition makes eating naturally more difficult.
Under the right circumstances and with the right kind of help, some people manage gradually to replace destructive food habits with ones
that
sustain and delight. Anorexia has terrifying mortality rates, with as many as 20 percent of all sufferers dying prematurely. Anorexics have suicide rates fifty-seven times higher than the general population. And yet most sufferers do survive, and some even recover. In one study, researchers followed a large cohort of women with anorexia or bulimia for seven and a half years. At the end of that period, 83 percent of those with anorexia had achieved at least a partial recovery, and 33 percent had managed a full recovery (recovery was defined as the “absence of symptoms” for at least eight consecutive weeks). The bulimia patients had even better rates of improvement, with 99 percent enjoying at least a partial recovery and 74 percent a full recovery. Think what this means: the vast majority of those whose meals had once been a maelstrom of bingeing and purging had now succeeded in learning how to eat food and digest it in a normal way.
The first step in recovering from an eating disorder is recognizing that there is a problem. There are more people than we might imagine who have an eating disorder without fitting the expected model of anorexic teenage girls. I have a male friend whose childhood in the 1970s was blighted by an untreated eating disorder. At the age of around seven, after the birth of a sibling, family meals started to make him nauseous, and he would spend several days each week home from school, vomiting. His weight plummeted, but the local hospital pronounced that his symptoms were “only” psychosomatic, not physical. His parents interpreted this to mean that he was making it up and did nothing further to help him. After his parents divorced, he slowly recovered, by himself.
The ways in which eating can go wrong in early life cover a rich spectrum, spilling out beyond the official categories and definitions. Anorexia is not in fact the most common childhood eating disorder. Nor is bulimia. That honor goes to EDNOS: Eating Disorder Not Otherwise Specified—“other,” for short. Our fertile minds are very good at concocting our own idiosyncratic eating disorders, with a bit of binge eating here, a smattering of purging there, and skipped meals in between.
Some children are morbidly obsessed with certain foods; others have trouble summoning much of an appetite for anything. Eating may go wrong because a child is hypersensitive to touch: for some, lumps in the
mouth are actively painful. Others are hypersensitive to smell: the odor in the school cafeteria may make a child feel unable to eat. There are children who can’t swallow anything that isn’t soft, and children who vomit at the thought of a new food. Some (this is called
pica
) eat things that are not food—ranging from dirt to baby powder. Some chew food repeatedly and regurgitate it (this is
rumination
), and then decide whether to chew the regurgitated food again or spit it out. One ruminant explained his thought process. “If it’s a good slice of pizza, I’m not going to waste it. But if it was spinach to begin with, of course I’m going to spit it out.”
Problems with eating can be placed in one of two big categories. There are the “feeding disorders” of little kids, and the “eating disorders” of older children and adults. Anorexia, for instance, is a classic eating disorder, whereas a classic feeding disorder would be some kind of phobia of food or extreme pickiness. Too often, feeding disorders aren’t taken as seriously as eating disorders. Until 2013, the guidelines in the official manual aimed at clinicians who treat mental health said that it was only a “feeding disorder” if the onset was in a child younger than six years old. The idea was that pickiness—even extreme pickiness—is a developmental stage, something that children will grow out of as they get older. A feeding disorder can look like a form of extreme childishness—and indeed, some of the forms that it takes do involve children who won’t consume anything but milk or baby food. An eating disorder, by contrast, involves intense preoccupation with one’s bodyweight, like a warped version of the adult activity of dieting. It is often associated with depression, anxiety, obsessive-compulsive disorder (OCD), and suicidal thoughts.
It isn’t true, though, to say that “feeding disorders” are only for infants, and “eating disorders” are for teenagers and adults. To study disorders of eating is to see that we live in an era when some children are old before their time, and some adults are forever juvenile. There are prepubescent children—as young as six or seven—who have already started to limit their food intake to dangerously low levels because of fears that they are not “skinny” enough. Equally, there are grown-ups holding down jobs and paying mortgages who will eat nothing but canned baked beans—the so-called adult picky eaters, most of whom slip under the radar and are never treated by the medical profession.
Whether they affect adults or children, eating disorders and feeding disorders are two very different types of conditions. Those with an eating disorder may be scared of eating a French pastry, such as a
pain au raisin
, rich buttery layers of pastry, sugar, and fruit, because they think eating it will make them fat. Someone trapped in a habit of selective eating—the main kind of feeding disorder—may also be afraid of a raisin pastry, though they are not afraid it will make them fat. They instead may be afraid of the raisins themselves: the sight, smell, texture, and color of them, and, above all, the very thought of them.
There are certain things, however, that the eating and feeding disorders on this vast spectrum have in common. While the causes and experience of these conditions can be very different, for example, the treatment can be remarkably similar. Structured meals, at which a wide range of foods are offered in a firm but loving way, are a key part of the cure for any eating disorder (along with various talking cures and medications to help with anxiety or depression). Family meals, used to “refeed” the child, are now the gold standard for treating childhood anorexia (assuming the patient is not in need of hospitalization). The treatment for feeding disorders involves slowly building up a child’s repertoire of foods through repeated tasting sessions. All the members of the family will probably need to rethink portion sizes (smaller for binge eaters and larger for anorexics) and where and how they eat. Often, an eating disorder has become so difficult for the rest of the family to manage that the child is in the habit of eating alone. Recovery happens when the child is happy to be included in the social life of mealtimes, and when the rest of the family is happy to have them there. Whether the disorder is anorexia or restrictive eating, recovery involves learning how to eat all over again.
For people with eating disorders, food is both the poison and
the remedy, but this is true for the rest of us as well. Food is an inescapable fact of life, and the task for each of us is to find a way to make our peace with it. Disordered eating is very different from alcohol addiction, whose cure is sobriety. When eating goes wrong, the antidote is not a life with
out food, but figuring out how we can bring ourselves to eat new foods in new ways.
It is one of the great clichés about eating disorders that they aren’t really “about” food. This is a fairly senseless remark. You might just as well say that hay fever isn’t really “about” pollen. It’s certainly true that there is far more going on in anorexia and bulimia than just the surface eating behavior: starving and purging are physical manifestations of some deep depression or a cognitive malfunction. These are mental illnesses, and the causes, as we will see, are as much genetic as environmental. But by the time someone is in the grip of anorexia, it is very much “about” the food: the devouring of cookbooks; the meager meals of a single piece of fruit, slowly eaten; the way a brain changes in the absence of nourishment.
Selective eating is first, second, and last about the food. It’s about the distress of being offered orange food when you only eat yellow. It’s about the subtle differences between the brand of yogurt you can tolerate and the one that makes you gag. Some children are so sensitized to the smell of the “wrong” foods that they cannot even sit with family members when they are eating it. Because this kind of extreme eating usually goes along with other underlying conditions, such as autism, and is often coupled with behavioral difficulties at the dinner table—terrible tantrums and rage or sadness—it is easy to assume that a failure to eat all but a narrow range of foods is primarily a way of acting out some deeper problem, and that it would be trivial to pay too much attention to the eating itself. Yet the evidence points in the opposite direction. Whatever their core condition may be, these children cannot behave at the table because the food is causing them such distress. If people kept serving you dinners that made you retch, wouldn’t you be angry, too?