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Eating disorders: Prevention is essential

Identifying risk factors early on means that mothers can be given guidance to avoid instilling incorrect behaviour towards food in their children. Stefania Sinesi, psychologist and psychotherapist, has founded a non-profit organisation, NEVER GIVE UP, which helps teenagers who are dealing with these illnesses.

Problems with food, weight and body image can often morph into eating disorders. Almost 4 million people in Italy suffer from anorexia or bulimia, while obesity is an increasingly widespread medical condition around the world, affecting about 11% of the Italian population. In all of these situations, re-establishing a healthy diet is essential and psychology can provide strategic assistance, especially when it comes to helping young people. Young psychologist and psychotherapist, Stefania Sinesi, having spent time studying abroad, is now an Adjunct Professor at the University of Perugia, as well as President and Scientific Director of NEVER GIVE UP, a non-profit organisation for the prevention and treatment of eating disorders founded in 2014 with a goal of intercepting risk factors in order to keep these conditions at bay. We spoke to her about how eating disorders can affect young people’s health.

How widespread are eating disorders at the moment and who is most at risk?
In Italy, eating disorders, as defined in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), are acquiring the characteristics of a real social epidemic, with increasingly early onset, sometimes emerging in children as young as 8 to 13 years. Over three million people are affected in Italy alone, and more than half of these are young people between 12 and 25 years.
The most worrying aspect is that, for this age range, anorexia nervosa and bulimia nervosa – two of the main disorders in this area – constitute the leading cause of death by illness. There are no other examples of psychiatric disorders with such an influence. For teens and pre-teens especially, it is extremely difficult for them to recognise the need for assistance and the importance of seeking professional help because of the shame, anxiety and fear of being judged. Indeed, according to data we have seen, only a tiny percentage of those suffering contact care services as a result.
It is also crucial to highlight that these illnesses are not restricted to a particular section of the population – they affect men and women, young people and adults, people from all social classes - even though, in the collective imagination, there is a very strong gender stereotype attached to these disorders.

Do these disorders tend to be caused more by biological or environmental factors?
These disorders are caused by different things and there are various risk factors: psychological, genetic, cultural or factors connected to life events, traumatic experiences, grief or role models, all of these factors can lead to the emergence of eating disorders, but they are often just the tip of the iceberg of much more profound problems.

Is it correct to put obesity in the same category of eating disorder as anorexia and bulimia? And if so, what distinguishes obesity from the other two illnesses?
Different criteria are used for the definitions and diagnosis of these disorders. The same can be said for the places they occupy in the current disease classification. Obesity is a condition defined on an anatomical basis: it is an excess of body fat, usually - but not always - associated with excess body weight and therefore a high body mass index (indeed, the diagnosis is a BMI equal to or higher than 30). This is classified by the ICD-10 (the International Classification of Diseases) in the fourth chapter (metabolic diseases) and is not featured as a disease in itself in the DSM-5 (i.e. among psychiatric and mental disorders) even though it is statistically associated with certain mental disorders such as binge eating, depression and even bipolar disorder and schizophrenia. However, genuine eating disorders are defined on a psychological and behavioural basis. Nevertheless, being obese or overweight is considered as a potential risk factor both for disorders connected to the “restriction” of food and for those characterised by binge eating followed by attempts to get rid of the food (by vomiting or using purgatives), which are typical signs of an eating disorder. It would therefore be better to have an integrated disease model, which takes into account both psychological and biological factors which would allow us to design multidisciplinary interventions rather than disconnected ones. This would allow us to adopt a coherent approach in tackling eating disorders (anorexia, bulimia and sub-threshold anomalies, i.e. behaviour which is not yet serious enough to trigger a full diagnosis, but which is nonetheless of a sufficient frequency or intensity to interfere with the person’s normal daily life) and problems linked to body weight (overweight or obesity).

You are part of the scientific committee of the non-profit organisation NEVER GIVE UP, which aims to treat problems related to food, weight and body image: how are these three things connected?
Yes, I am the founding member, President and Scientific Director of NEVER GIVE UP, a non-profit organisation targeting the prevention and treatment of eating disorders. NEVER GIVE UP features among the institutes and associations treating eating disorders in Italy, under the auspices of the Ministry of Health and the Presidency of the Council of Ministers. The scientific committee of NEVER GIVE UP is made up of professionals working at the highest levels of cutting-edge organisations in Italy and abroad in order to research and treat these disorders. One of our goals is to break down the barrier preventing people from asking for help and to detect problems with food, weight and body image early on, before they become an out-and-out disorder. Indeed, during adolescence, due to the various changes which take place, young people can experience periods of dissatisfaction with themselves. If this dissatisfaction remains, it can transform into a more serious body image problem, leading to implications and difficulties with food and body weight.
Nowadays, most teenagers who experience these problems look for information online and run the risk of ending up on the endless number of pro-anorexia and pro-bulimia websites, forums and blogs. These so-called “pro-ana” and “pro-mia” websites are real communities created by teenagers where they talk about their problems. Unfortunately, these communities can entice young people into a spiral of anorexia, self-induced vomiting and self-harming, by endorsing dangerous advice and abnormal behaviour in order to control or lose weight.
A series of English-language studies show that the motivation which leads young people to visit such communities is not one of self-destruction, but rather is the result of the need to share their problems with others without being judged. With this in mind, NEVER GIVE UP has developed a free and accessible online platform, supervised by a multidisciplinary team of professionals (psychologists and other experienced professionals) offering support based on experience which has been scientifically approved and tested in international clinical and research contexts, targeted at young people suffering from problems with food, weight and body image as well as the people close to them (family, friends, teachers). NEVER GIVE UP currently offers a help-mail service. By writing to the email address sos@never-give-up.it, NEVER GIVE UP, endeavours to reply, within 24 hours where possible, and carry out a free consultation with one of the professionals in the team or at an institute indicated on the map provided by the Ministry.

What protective factors are there against developing eating disorders? And what are the active strategies of prevention?
Various protective factors include an acceptance of one’s own body, self-esteem, resilience and positive relationships with family members.
The acceptance of your own body plays a key role from the earliest stages of development. An English-language study shows that scoring high marks on the self-esteem scale at the age of 8½ is a preventative factor which is able to suppress the development of dissatisfaction with your body and the emergence of disturbed eating behaviour in adolescence. The goal of active prevention strategies is to intercept possible risk factors and provide protection through integrated and increasingly early programmes. In particular, greater attention needs to be paid to the earliest stages of development, especially between the first 2 and 5 years of a child’s life. This period is often characterised by an attitude of rejection towards food. It is a normal stage of development where the child’s ancient protection mechanisms come to the fore, along their gradual awareness of their own existence. However, in contexts of high pathological risk, these rejections, which can be particularly violent, may trigger feelings of worry among parents, as well as anxiety, mistrust and a sense of guilt at not being able to feed their children properly. This lays the foundations for the development of these forms of anorexia, bulimia and binge eating, which could emerge later in adolescence. As a result, it is essential to create prevention programmes based on early intervention. The team at the Children’s National Medical Center in Washington D.C., led by Irene Chatoor, in which I was involved, observes and assesses the nutritional interaction between mother and child from the breast-feeding stage in order to ensure early intervention by intercepting risk factors and promoting protective factors, such as those intended to prevent the development of eating disorders in later stages of life. We would therefore hope to see prevention programmes aimed at future mothers in order to raise their awareness of the importance of adopting protective behaviour, even during pregnancy.

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