28th February 2021
Dear Mrs Murdoch,
Please let me express my enormous gratitude for the work you and your team continue to conduct in the face of the current pandemic. The NHS are demonstrating unwavering resilience and dedication that is nothing short of inspiring.
As a postgraduate student from UCL, I write in response to the recent surge in eating disorders among UK adolescents. The number of under twenties admitted to hospitals for eating disorders over the last year has topped 3,200, a figure that is 50% higher than admissions between 2019-20 (BBC 2021). This number signifies only a small proportion of the rise in cases throughout the pandemic. Yet, as pupils return to schools from 8th March in desperate need of support, I’m very concerned that the education system is ill-equipped to address the issue.
The current reductive medical definition that teaching staff apply to understand and approach eating disorders in schools, does not account for the condition’s cultural complexities (Napier et al. 2014; Lester 2019).
Such cultural complexities have only magnified throughout the pandemic as isolated adolescence turn to social media platforms as their sole means of communication. The support for those contracting eating disorders was, pre-pandemic, an area of concerning weakness. Now it is harder than ever before for those who suffer to secure the help they need (BBC 2021)
In the past, you have publicly acknowledged that early intervention to disordered eating practices is key to prevent the conditions from manifesting (Murdoch 2021). With the majority of eating disorders in the UK developing during adolescents, it follows that schools should be where these early interventions are conducted (Priority Group 2021).
Without understanding the roots and processes that facilitate the establishment, development and spread of eating disorders how can we expect teachers to provide this support? How can we expect teachers to even identify them?
By the time students start to show physical symptoms their condition is already past the point of early intervention.
I therefore implore you to facilitate a better understanding of eating disorders in our education system.
Teachers should be able to recognise the social, cultural roots characterising the emergence and spread of disorders amongst their students, empowering them to better manage the emergence of conditions going forward.
You pledged in 2018 to do your upmost to ensure that no other suffer “slips through the net” (Murdoch 2021). What I propose will go a long way to help you reach that goal.
An estimated 1.25 million people in the UK have an eating disorder (Beat 2021). This is not a figure to ignore. Anorexia, one of the main eating disorders suffered by adolescence in the UK, has the highest mortality rate of any psychiatric disorder. Global estimates suggest that one person dies every hour as a direct result of these cruel disorders (Eating Disorders Coalition, 2016). Eating disorders kill.
Mitigating the impacts and risks associated with these disorders is extremely pressing and should attract immediate attention. This is especially important in the context of the pandemic where hospital emissions are rising sharply (BBC 2021). The number of patients under twenty that seek help for eating disorders has increased by over half in the course of the pandemic (Triggle 2021). Dr Agnes Ayton, chair of the faculty of eating disorders psychiatry at the Royal College of Paediatrics has highlighted, “the tsunami [of patients] is still coming. We don’t think it has been and gone” (Marsh 2021).
Established services are already struggling to keep up. Speaking of the system as a whole, Tom Quinn, director of external affairs at the eating disorders charity Beat has highlighted that diagnosis is not happening fast enough. He argues that it takes “too long” for suffers to receive support and treatment. The majority of healthcare staff require more training to notice and diagnose the conditions early (Triggle 2021).
School children are the most vulnerable to contracting the disorders with figures from your NHS department highlighting those most vulnerable are between aged 13-15. Adolescents’ return to school is therefore the first viable opportunity to address this threat. As teachers hang on to the current framework, they remain unequipped to catch these diseases early. I implore you to equip them with the information they need to mitigate Dr Ayton’s “tsunami” of eating disorders that are “still coming” (Marsh 2021). Mrs. Murdoch, only you can make this change.
The current reductive understanding of eating disorders in our education system allows for anorexic and bulimic bodies to be viewed as machines “in need of repair” or products of individual choice (Lester 1997, 480). This painful misunderstanding not only prevents early intervention but also actively encourages the stigma that shrouds the disease (ibid). Teachers must be aware of the socio-cultural roots that propel the spread of conditions amongst adolescent populations. If they do not have fundamental information about the realities of these disorders, then how can they be expected to assist with early intervention? How can you say that you’re doing everything you can to prevent the spread of this killer disease?
Rebecca Lester (1997; 2019), an anthropologist who specialises in this space, has proposed a more suitable framework for their understanding. She suggests that rather than considering eating disorders as isolated within individuals, they should be recognised as existing and developing “between people” and their environments (Lester 2019, 9). Such a framework facilitates recognition of the social dynamics that are fundamental to the development of the conditions including:
- Our cultural construction of the self
- Eating disorders’ transmissible nature
- Adolescents’ desire for control
This letter will hopefully demonstrate and justify the significance of each of these conditions in turn. I also draw from my recent experience which brought this issue to my attention. This experience will further validate the significance of this response.
Last July, my 13-year-old cousin shared with me the content of her TikTok homepage. Exclaiming with glee, “look at this girl isn’t she sooooo cool” she proceeded to show me a video of one of her favourite influencers acting out the “what-I-eat-in-a-day” video trend.
The video in question showed the girl consuming a total of under 800 calories throughout the day. Mrs Murdoch, I do not need to tell you that this amount is well below the recommended calorie intake for toddlers.
This was just one of the many videos admired and shared by my cousin, her peers, and thousands of other adolescent followers on the platform.
Whilst this sort of video is neither new nor a-typical of content that can be found online, the structure of the TikTok algorithm is such that enables these videos to be transmitted and shared at a much faster rate than ever before. Moreover, the uptake of the platform amongst adolescents the pandemic and isolation of its users bolsters the need for concern about their rapid circulation and ever-increasing reach. On average, over the pandemic, the amount of time adolescence spend on social media has more than doubled (Marketing Charts, 2020). Situated as such, the damaging messages they communicate are more accessible and powerful than ever.
‘I am my body’: the cultural construction of the self.
Anthropologists have worked to demonstrate that our relationship with ourselves and our bodies is a product of our culture (O’Connor and Van Esterik 2015). They explain that our bodies today are “no longer just a body, or even” entirely our own (ibid,152). Instead, we interpret our bodies as representations of our moral and social selves (Lester 2019, 1997). This cultural reality makes “fertile ground” for the development of eating disorders, particularly amongst adolescents who are already trying to make sense of themselves as they develop (O’Connor and Van Esterik 2015, 152).
The increasing focus on healthy eating in popular culture has only contributed to the moralisation of our bodies (O’Connor and Van Esterik 2015; MacDonald 2000). Slim bodies are now privileged in all spheres of life. Even the measure of health, BMI, favours the slim physique (Greenhalgh and Carney 2014; Yates-Doerr 2014). We need to be able to acknowledge the repercussions of this.
Culturally, the slim body has been found to act as communication of virtue within contemporary society, conveying the following messages … “I take care of myself,’ ‘I live right,’ ‘I make smart choices,’ ‘I’m healthy,’ and ‘I’m in charge” (Stinson 2001, 202-207; Mintz 1993; O’Connor and Van Esterik 2015). With this in mind, it is not surprising that the majority of anorexia nervosa sufferers in rehab associate their eating patterns with their ability to be a “good person” (O’Connor and Van Esterik, 2015, 157). Nor is it surprising that a “failure to attain” the slim, “normative” body can lead suffers to “internalise the identity of bad citizens” and assume “personal responsibility for their [perceived] failure” (Greenhalgh and Carney 2014, 267).
Teachers need to be able to recognise this relationship and the vulnerability this promotes. It is no coincidence that my cousins and her friends expressed admiration for this girl, describing her as “cool” and “on-it,” and expressing remorse they were not “smashing it” by looking like her.
By acknowledging the established links between cultural virtues, the body, and the mind and recognising their capacity to function as a “gateway to anorexia” and other disorders, teachers will be able to engage more closely with the risks facing their students (O’Connor and Van Esterik 2015, 165).
With this understanding, teachers would be able to navigate positive engagement with future problematic trends, mitigate the risks, and prevent disordered eating from manifesting in their students.
Looking for control.
You will be aware that adolescents are the most vulnerable to the development of eating disorders. This vulnerability must also be acknowledged and understood if it is to be addressed.
It is, in part, a result of the “identity politics” of adolescents, which intensifies the value placed on aesthetic appearance (O Connor and Van Esterick 2015, 176). The vulnerability also has to do with creating a sense of control during this identity-forming period (Lester 1997).
In the development of an eating disorder, “food” and “eating” can become vectors to “carefully control” an adolescent’s sense of self (Lester 2019, 9). Through this control, individuals feel they can elicit some structure and purpose to address the distress they feel in their daily adolescent life (Mattingly 2010; O’Connor and Van Estrick 2015).
At its most extreme, when eating disorders become severe, the perceived control can become the “gravity that holds [them] together” (Lester 2019, 76).
In the context of the current crisis, the chaos of adolescence has only been exacerbated, leaving suffers increasingly vulnerable. It is no wonder that the “stars” of TikTok have become so popular in this climate. Their videos provide a treasure trove of instructions that cut through the chaos and noise, promoting a ‘successful and ‘happy’ life, encouraged by controlled eating practices. In linking such rhetoric’s of success and control to the establishment of eating disorders, the videos problematic nature is evident.
Schools must be aware of the relationship between eating disorders and this need for control.
This would be particularly prudent in the context of the current pandemic where student’s primary means of communication has been through social media platforms. Teachers are the ones who will see first-hand the effects of this isolation. Yet if teachers are to be prepared to tackle the development of eating disorders going forward and establish strategies to de-glamorise the messages of these influences, they must understand their full impact.
Eating disorders are transmissible.
The current biomedical framework for understanding eating disorders also negates that eating disorders can are transmissible (Seeberg and Meinert 2020). This is a highly misleading rejection that accelerates the stigma surrounding the condition and the blame of sufferers (O’Connor and Van Estrick 2015).
In reality, the cultural dynamics that facilitate the emergence of eating disorders enable the conditions to “move within, across and outside social networks” spreading and clustering in social milieus (Seeberg and Meinert 2020, 62; Christakis and Fowler 2007).
The current rise in cases amongst adolescents should be understood as a social cluster, not the product of individual choice.
With this recognition, teachers would be able to work against the stigma and blame associated with eating disorders. By understanding and acknowledging the patterns facilitating and encouraging their spread, teachers will be equipped to interrupt the early establishment of disordered eating practices.
To neglect cultural roles in the spread and development of eating disorders in our adolescent population is the “single biggest barrier” to early intervention and prevention of the conditions (Napier et al., 2014, 1630). With the current framework, teachers are unable to fulfil their duty of care to their students and eating disorders will continue spreading at this unprecedented rate. If teachers are empowered to approach eating disorders as cultural issues, they will be better placed to respond to them.
Culture, by its very nature, is not static (Napier et al., 2014). You must ensure that teachers, therefore, embrace this cultural framework whilst recognising that the factors impacting the development of disorders are “always in the making” (ibid,1614). Teachers do not require “technical skills” to ensure that their understanding of eating disorders develops in line with their pupil’s experience of them. Instead, they must build upon this framework by developing and sustaining “elective affinities” with their students (Kleinman and Benson 2006, 1676). These may be established through regular teacher-led group sessions where social media trends or content such as that found on TikTok is openly explored and its implications unravelled. With such affinities in place, teachers will be able to identify and address signs of disordered eating in their infancy.
Mrs. Murdock, the current eating disorder figures – not to mention their inter-relation with other psychiatric issues – speak for themselves in outlining the challenge that lies ahead for you and your team (Lester 2019).
As the head of the Mental Health Team at the NHS, you are the only one who can call for and enforce the educational shift required. Whilst what I have suggested is no panacea for the multitude of issues you face, I implore you to recognise its significance. To ignore it would be to establish a partnership with the current, rising rates of transmission (Singer 1994). As eating disorders have the “highest mortality rates of any psychiatric disorder,” the threat to the population that the current rate of transmission presents cannot be overestimated (Beat 2021; Lester 2019).
With the overwhelmed NHS, empowering our teachers to prevent further spread is not only prudent but essential. I hope this letter helps you to realise this and encourages you to act. The empowerment process could start by taking small but significant educational steps, sharing with schools across the UK the information I’ve given you today.
Last year you wrote, “the NHS has adapted services in response to current challenges, but we should not be expected to pick up the pieces from lives damaged by avoidable harm”; if you are to stay true to this, you will have to work to mitigate the avoidable harm sustained by a current lack of awareness (Murdoch, 2020, 1)
I would welcome an opportunity to discuss this further and demonstrate how this could be rolled out to pre-suppose your long-term plan of addressing mental health issues in schools (NHS 2021).
I look forward to your response.
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