First Bite: How We Learn to Eat (23 page)

A teenage girl who suddenly switches her morning juice for coffee, goes vegetarian, and stops eating eggs for breakfast (eggs are boy food!) may find herself in trouble. Women are far more likely to be vegan or vegetar
ian than men: out of around 1 million American vegans, 79 percent are
women; among vegetarians, 59 percent are female. There are plenty of good vegetarian sources of iron, including pumpkin seeds, nuts, spices, green leafy vegetables, blackstrap molasses, dried fruits, egg yolks, pulses (such as kidney beans), bran, and whole-grain bread. The problem is that a teenager who goes vegetarian on impulse is unlikely to be in the habit of eating the correct balance of these foods. Non-meat sources of iron are also less readily absorbed by the body, so vegetarians may need even more iron than their carnivorous counterparts. The most dangerous group for girls to be in for anemia risk is the one where people are
both
dieters and vegetarians: in the 1990s, 43 percent of vegetarian British girls aged eleven to fourteen who had tried to lose weight over the past year had low hemoglobin levels in their blood, whereas only 15 percent of non-dieting vegetarians did, and 8 percent of non-dieting meat-eaters.

Surprisingly, the overweight are also at high risk for anemia. The problem is due not to the amount of food they consume, but the quality. A sample of Iranian adolescent girls confirmed this finding: despite taking in more calories than they needed, the overweight girls in the study were actually more likely to be anemic than the normal-weight girls (34.1 percent of the overweight girls were anemic as against 27.8 percent of the normal-weight girls). These girls were not getting enough iron from their carb-heavy, nutritionally imbalanced meals. There’s not much iron in pizza, or in ice cream or chips, all newly popular foods on the streets of Tehran.

It may be that iron deficiency is cause as well as consequence of being overweight. Iron deficiency seems to slow down metabolism because it causes a reduction in levels of carnitine, a compound involved in metabolizing fatty acids. Anemic women have a poor capacity for aerobic exercise, which can be reversed with iron supplements. It’s understandable if teenagers with anemia are not raring to get on a treadmill, given that lack of iron makes you feel faint and woozy, hardly able to put one foot in front of the other (or so I felt when I was anemic and white as a sheet after the birth of my first child).

Too many overweight teenage girls are being pressured by their families to lose weight when what they in fact need is better nourishment
(which would almost certainly help them to lose weight along the way).
Iron-deprived girls of every size need to be “built up,” as the reassuring old phrase had it, with soft-boiled eggs and whole-grain toast, with dark leafy greens, griddled flank steak, lamb casserole, grilled sardines, and hearty minestrone or black bean chili. In short, these girls need man food. If they still feel their bodies are crying out for chocolate, they should switch from cheap milk-chocolate bars, which are really mostly sugar and vegetable fat, to real 70 percent cocoa dark chocolate, which might actually do them some good (a small 30-gram bar of dark chocolate: 5 milligrams of iron).

But almost no one speaks of building girls up—these delicate soufflé-nibbling creatures who ought to be able to survive on air and compliments. Instead, great focus is placed on building up their brothers, stoking them with dangerous delusions about how much food they need. In the current food environment, the overfeeding of boys is no more helpful than the underfeeding of girls.

One of the biggest obstacles to any overweight or obese child
losing weight is when parents do not see that there is anything wrong. Dr. Laura Stewart runs child obesity clinics in Tayside in Scotland, which has some of the worst child health outcomes in Europe. “A lot of parents do not perceive their child has weight problems,” Stewart told a conference of health professionals I attended in October 2013. The problem, in Stewart’s view, is that the media only shows photographs of “the most exceedingly obese children” when discussing the issue, which leaves people whose children are only mildly obese thinking that they are perfectly fine. If most of the people you see around you are overweight, it starts to seem normal.

Stewart told us of an experiment she did in Tayside in 2010 that was aimed at finding out what it would take to make parents see that their child has a weight problem. Parents were shown photographs of children and asked to group them into “normal” and “overweight.” It was as if they couldn’t grasp what was in front of them. These parents could only recognize a problem with weight when the child in the picture was actually
“significantly obese.” All of the photos of children who were overweight,
rather than obese, were seen as “normal.” There is a lot of collective denial when it comes to children and weight. It is even there among some of the doctors and nurses whose job it is to deal with it. Around half of those employed by the National Health Service (NHS) in Great Britain are now overweight or obese, making it seem normal for them, too. After Stewart had finished talking, a health worker in the audience put up her hand and criticized Stewart for using the body mass index system in evaluating children. “You could have a fat but fit child! On the BMI system, a body builder could be classified as obese!” Stewart collects herself and smiles. “I’ve never once had a fit muscular child referred to my clinic. You do have to use your eyes.”

The problem of “weight misperception” has consistently been shown to be worse with boys than with girls. Numerous studies have shown that parents are less likely to think a brother is overweight than a sister, perhaps because a boy’s figure is seen as less of a social issue than a girl’s. Parents often become very defensive when a nurse or dietician points out that, based on the weight and height charts, their child is obese. They protest that their child is “big-boned,” that they only eat healthy food, that there’s something wrong with the chart. This defensiveness is seen in parents of girls as well as boys, but with boys, the parents seem almost proud of their son’s large physique. An obese boy may be described as “solid” or “chunky,” which sounds healthier than “fat.” A low-income mother whose preschool son was borderline obese told researchers, “I can look at him, and he might weigh a lot, of course, but that could be just all muscle. ’Cause he is a strong kid.”

When parents under-assess a boy’s weight and over-assess his food requirements, it may form his self-image and the way he eats for the rest of his life. A large-scale study of weight perception among more than 16,000 American adults found that under-assessment of one’s weight was two to three times more common in men than in women. Nearly 43 percent of the American men who were overweight (but not obese) said that their weight was “about right.” Nearly 12 percent of obese men said their weight was about right. Similar results have been seen among Australian men and women, where about the most men would admit to was that
they were “a little overweight,” when they were actually “biomedically
obese.” This is worrying, given that you are unlikely to do anything about your weight problem if you don’t even recognize that you have one.

There is an equally disquieting trend for a large segment of healthy-weight or underweight women to misdiagnose their weight in the opposite direction and wrongly label themselves as obese. A 2003 study of more than 2,000 undergraduates across six American campuses found that fully 72 percent of the women believed their “thighs were too fat” in comparison with just 11 percent of the men. It transpires that, regardless of actual weight, college-age women are more uncomfortable about being weighed in public than their male equivalents. Female body dysmorphia—exaggerated and perfectionist beliefs about one’s own body flaws—is an anxiety that is not confined to those who suffer from a full-blown eating disorder. Research suggests that in our society, such worries afflict the majority of postpubescent girls.

This discrepancy between the self-image of girls and of boys is a problem for both sexes. It means that public health messages about the “obesity crisis” and ways to eat more healthily are probably heard by the wrong people and not by those who might benefit. It’s like when a teacher loses his or her temper with the persistent troublemakers and decides the best approach is to tell off the whole class to make them see how they are squandering their future. The good, quiet children listen to the angry lecture and feel upset, thinking it applies to them, when it doesn’t. The troublemakers at the back don’t think the teacher has anything of relevance to say to them, so they doze off or continue to make trouble. When anti-obesity campaigns tell us we are sleepwalking into a terrible future, significant numbers of healthy-weight women think the words are a direct criticism of their own upper arms, and significant numbers of obese men think it has nothing to do with them.

As a general rule, women seem to be more compliant with dietary guidelines—more likely to at least attempt to eat healthily, even if they do not manage it. Over the course of childhood, the trend is for boys to eat declining quantities of vegetables and fruits, while girls increase their intake very slightly. A recent study of British children showed that 70 percent of boys aged four to six ate apples, but this declined to 39 percent
of those aged fifteen to eighteen; as we have seen, parents feel reluctant
to push older boys on the question of healthy eating. But with girls, the consumption of salad went up: only half of the four- to six-year-olds ate it, but 66 percent of teenage girls did, maybe because they saw it as something they were meant to eat. Either way, many boys could benefit from learning to eat more like a girl. In Thailand, girls eat many more fruits and vegetables than boys, and twice as many boys are obese. Yet survey data suggest that Thai mothers do not view their sons’ lack of vegetables as a problem.

Because we don’t believe obesity in boys to be as much of an issue as it is for girls, we also don’t see just how unhappy it can make them. Kuwait has some of the highest rates of adolescent obesity anywhere, with nearly half of those aged fourteen to nineteen overweight or obese. Kuwaiti teenagers are significantly fatter than those in other Arab countries. One study found that among fifteen- to eighteen-year-olds, more than twice as many of the boys were obese or overweight in Kuwait as in Syria or Libya. Kuwait had a more rapid “nutrition transition” than other parts of the Middle East, meaning that Kuwaitis were exceptionally quick to adopt Western fast foods. For generations, Kuwaitis have eaten a cuisine far heavier in meat and fat than the people of other nearby Arab countries, such as Lebanon, where family meals center on vegetable-based
mezze
: eggplant-based dip,
fattoush
(herb and bread salad), and the like. In Kuwait, a typical family dish is
makbous dajaj
, where a whole chicken is first boiled and then deep-fried and served with rice simmered in the fatty cooking water. When American-style fried chicken and hamburgers arrived in Kuwait City, local palates were already primed to enjoy them.

Kuwait’s obesity crisis is another case of traditional ideas about feeding going badly wrong in a modern prosperous food supply. Hospitality is a crucial concept in Kuwait, and it is sometimes remarked that every family gathering is treated as if it were Thanksgiving. Claudia Roden, the great expert on Middle Eastern food, notes that to be a good guest in traditional Arab cultures, “if one feels satiated, one should nevertheless continue to nibble at a dish from which others are eating, since if one person stops eating, everyone else may feel compelled to stop too.” Oil money has made Kuwait one of the richest countries in the world per
capita, with vast shopping malls, a culture of eating out, going to these
places in luxury cars, and having plenty of disposable cash for snacking. The wealth of Kuwait means that excess food has become affordable to many, hence the fact that weight gain has been far more rapid there than in poorer countries of the Middle East, such as Syria or Algeria.

Kuwait has also suffered an epidemic of “disordered eating,” particularly among boys. Professor Abdulrahman O. Musaiger, a leading expert on nutrition in the Arab world, found that eating disorders were becoming widespread throughout the region, and the teenagers with the most disordered attitudes of all were Kuwaiti boys. Musaiger tested for eating disorders using the EAT-26 test, which asks respondents to rate the frequency with which they engage in behavior such as “eating binges where you feel you may not be able to stop,” and thoughts such as, “I feel that food controls my life,” or “I feel extremely guilty after eating.” A full 47 percent of the Kuwaiti teenage boys who performed the test came out as having “disordered eating attitudes” (a lot of Kuwaiti girls had disordered eating too: 43 percent). Musaiger concluded that this might be because Kuwaiti boys have “cultural adjustment difficulties.” Despite its economic modernity, the country is socially more conservative than many other Middle Eastern countries. As recently as 2013, a survey of nearly 2,000 college students found that only 70 percent of young Kuwaitis—male or female—believed that men and women were equal. The survey also found that many students claimed to dislike the Western “consumer culture.” Kuwaiti boys hear relatives speak of the Gulf crisis of 1990 and may view America as the enemy.

Yet even as they denounce American culture, they participate in it when they grab a Super Supreme at Pizza Hut (which has forty-nine branches in Kuwait), or a platter of spicy ribs at Applebee’s. Many Kuwaiti boys eat the enemy’s food and sip the enemy’s soda every day. In Musaiger’s analysis, these young men are torn between the values of East and West, “caught between the influence of Western culture on dietary behavior and body size preferences that encourage thinness on the one hand and traditional cultural norms that favor customary food habits and normal or plump body size on the other.” Traditionally, it is a boy’s prerogative to eat as much as he wishes. In a Kuwaiti family where all the brothers are obese—and most of the adults around them, too—the parents may
look at their boys and think they are fine. But judging from Musaiger’s research, they are absolutely not fine, either physically or mentally.