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Eating Disorders in Malta

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Eating disorders such as anorexia and bulimia are usually associated with teenage women. However, eating disorders can affect anyone, irrespective of gender or age. A local study examines eating disorders in those aged between 10 and 16 years.

Do Maltese people have eating disorders?

Until a few years ago, eating disorders were seen as a first-world problem, something that young women brought upon themselves. While some conservative pockets of the population still hold on to this view, the vast majority has recognized that eating disorders are psychological disturbances and rarely have anything to do with food. 

Prior to 2012, very few services that tackled eating disorders existed in Malta. However, a study conducted that same year (carried out by the National Statistics Office) examined a representative sample of 15- to 50-year-olds in the general population. The results found that the prevalence of eating disorders in Malta was comparable to that in other European countries, with a lifetime prevalence of anorexia at 2.4%, 0.8% for bulimia and 2.6% for binge eating. This study led to the opening of Dar Kenn Għal Saħħtek (Centre for the Treatment of Obesity and Eating Disorders) in 2014. 

Shortly after it opened, Dar Kenn Għal Saħħtek noticed something peculiar about its patients. A substantial number were under 15 years old. The lack of empirical data in this age group led the Centre to commission a new study, one that examined the prevalence of eating disorders in 10- to 16-year-olds. This research is the first of its kind in Malta. 

Annabel Cuff, one of the leading researchers of the study and a Research Support Officer with the Faculty for Social Wellbeing at the University of Malta (UM), explains how ‘while female adolescents are the most at-risk group, eating disorders can affect men, older women, and children. The average age of onset is between 10 and 19 years. These are crucial years for physical and psychological development, and the presence of an eating disorder at this developmental stage tends to disrupt natural growth. More importantly, the way you treat a 12-year-old isn’t necessarily how you would treat a 50-year-old.’ Darleen Zerafa, Director at Dar Kenn Għal Saħħtek and Prof. Anton Grech, Clinical Chairman of the Department of Psychiatry in the Ministry of Health and also Chairman of Dar Kenn Għal Saħħtek have worked tirelessly in the area and contributed to this study through their guidance and advice.

What are eating disorders?

Eating disorders are never about food. Food is the outward appearance of the eating disorder. Food is what can be controlled or what is to be feared.

Annabel Cuff

According to the DSM (Diagnostic and Statistical Manual of Mental Disorders), eating disorders are classified as a psychological disturbance. More often than not, eating disorders are not about eating. They usually appear because of emotional problems and arise from a desire to control food intake that spirals out of control for some innate reason. According to Cuff, ‘Eating disorders are never about food. Food is the outward appearance of the eating disorder. Food is what can be controlled or what is to be feared.’ 

There are four main eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant/restrictive food intake disorder (ARFID). 

Anorexia

Due to its high mortality rate, Anorexia is seen as the most dangerous of eating disorders. It is characterised by an extreme fear of gaining weight, an abnormally low body weight, and a distorted perception of weight. Anorexia is not just about restricting calories but removing them by any means. No matter how much weight is lost, sufferers remain fearful of weight gain and experience a constant desire to lose more weight. 

Bulimia

Bulimia is characterised by frequent and uncontrollable episodes of overeating or binges followed by purging. These binges usually consist of consuming thousands of calories in a single sitting, accompanied by extreme efforts to avoid gaining weight such as throwing up, exercise, laxatives, and medication. 

Binge Eating Disorder

Binge eating disorder involves uncontrollable urges to eat. However, it is distinct from bulimia as it does not include purging behaviours. As a result, sufferers are highly likely to be overweight or obese.

ARFID

ARFID is a type of extreme picky eating or food phobia in which the sufferer avoids certain types of food. Often this is due to sensory issues or fear of certain foods; as a result, sometimes whole food groups are excluded. ARFID is not about body image but rather involves a psychological block tied to certain types of food. Usually it develops into the patient only eating a very specific type of food, such as a particular brand of pasta.

Usually there isn’t one, single cause of eating disorders, but a number of factors. These could be psychological or emotional reasons, a history of abuse, genetics, as well as family make-up. A consequence of the disorders is that sufferers lead blunted, subpar lives, and make costly and high-volume use of health services, not to mention suicide attempts.

Most studies have focused on adolescent women; however, eating disorders have also been found in other demographics, especially in marginalised communities, men, and LGBTQ+.

For example, anorexia in men is usually about muscle mass. The ideal male body is presented as a muscle frame on social media. Achieving this requires hard work, exercise, and dietary control, which can easily spiral into an obsession that starts to take over many aspects of the person’s life. 

While personality is generally thought to have a relationship to eating disorders, the debate remains as to whether and to what extent: whether personality is causal to eating disorders, predisposes an individual to an eating disorder, or generates complications during the course of the disorder.

Eating disorders in today’s children

The study conducted by the UM Faculty in collaboration with Dar Kenn Għal Saħħtek took a stratified random sample of 400 children between 10 and 16 years old. Participants took part in an anonymous telephone survey; it included questions aimed at the children themselves, as well as questions aimed at their guardians. 

The most widely used questionnaire for investigating eating disorders is the Eating Attitudes Test (EAT); however, this is aimed at adults. The researchers used an adaptation of EAT which is aimed at children. ChEAT (Children’s Eating Attitudes Test) has been widely tested, boasts good reliability and validity, and has been translated and used in several languages, making it ideal for the local study. The language used is simple enough for children to understand and is easily translatable. In fact, it was translated into Maltese to fit the local context, and the translation was tested to ensure it was a true reflection of the English original.

The results suggest that although the vast majority of 10 to 16 year olds in Malta do not have an eating disorder, there is a substantial minority who do. Of the 5.5% who are affected, 3.25% are female and 2.25% are male. Within the general population of 10 to 16 year olds in Malta, this translates to 1675 youngsters affected by eating disorders, of whom, potentially, 990 are female and 685 are male. 

While more females than males were affected, the male/female ratio was higher than expected. With ChEAT, scores above 20 indicate a possible eating disorder; of these, for the males who scored above or equal to 20, the average was higher than the equivalent average for females. This suggests that males within this age group may be more severely affected than females. Additionally, the study found that, for this age group and cohort, there are no significant associations for age, gender, or socio-economic status. Eating disorders cut right across the socio-economic strata.

The study is a nationally representative study and shows that the split between male and females (in 10 to 16 year olds) is essentially 50/50. This suggests that, within this age group, gender does not play a role in the likelihood of an eating disorder.  

Road to Recovery

There is a huge stigma associated with eating disorders. They are often seen as ‘putting on airs’ or a self-imposed condition. This stigma usually means that many patients will hide their condition, which, in turn, could delay their treatment. For many, these psychological disturbances are an attempt to achieve an ‘ideal’ body image. Oftentimes, these ‘ideal’ body images are compounded by media representations. Cuff points out that, ‘Being thin or having a “good” figure is seen as socially desirable, and many people try hard to achieve this. Especially in an age where the number of likes on your social media photos count for self-validation. Not all people who strive to look good will go on to develop an eating disorder of course; however, body image and achieving the impossible “ideal figure” remains a factor.’

Annabel Cuff. Photo by Sarah Zammit

Cuff goes on to add, ‘When you are in the grip of an eating disorder, it rules you and controls your compulsions. It becomes a driver in your life. Especially for people with anorexia, if the patient has had it for several years, it becomes a part of your identity.’ Treating eating disorders requires a holistic approach. It essentially involves ‘rewiring’ the way the patient lives their life, the way they view food, and in extreme cases, their entire sense of self. 

By better understanding eating disorders in younger age groups, the study will not only help inform public policy but will also aid in the development of services for Dar Kenn Għal Saħħtek’s service users. Cuff leaves us with one, final piece of advice: ‘If somebody suspects that a loved one has an eating disorder, the best thing is to look for information and not be afraid to help and support them. Research shows that having adequate support is usually the most effective approach for treatment.’ The Dean of the Faculty for Social Wellbeing, Prof. Andrew Azzopardi states that ‘these studies serve to enlighten us but also provide evidence-based data that can be used to enhance our social policy. We are an effective faculty when we manage, through our scholarship and community outreach, to help bring about changes.’

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