We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist, and child development programme director at UCL. And I'm Umar Toseeb, professor of psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature and, in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways. Today, we'll be discussing eating difficulties and eating disorders. This episode is called "Problem Eating in a Community Sample: The Thin End of a Wedge." So, Umar, what brought you to this topic? Eating difficulties, I think, is interesting because it can be talked about and investigated from so many different perspectives and the close link to body image, based on my limited understanding. If I look at this from a naive, nonacademic person point of view-- I'm trying to put myself in that position-- I just think eating disorders and eating difficulties, in my head, is a teenage girl thing, but I'm not sure that it is. Was it ever a teenage girl thing? Like, was it perceived as a teenage girl thing? Yeah. But interestingly, like many of these truthy things, there is some aspect of truth to that, inasmuch as teenage girls are the demographic who are most likely to have an eating disorder. But of course, that does imply that teenage boys won't. And of course, we know that teenage boys do. It's indicative, I would say. And I think it's always good to start a question without an academic context if you like because I think often these, in quotes, "naive questions" are often the best ones because they reveal themes in the literature that may not be addressed. So I never would apologise for that. I think it's a good idea. But we are talking, I think, about a variety of different eating problems as opposed to eating disorders. And I think that's one of the most interesting things about this paper. And just to stay on that topic of populations or subgroups within a population, when I started to go to the gym probably a couple of years ago, I was amazed at how lots of-- I'm going to say men there because that's my experience, but also the men there are so obsessed with eating, eating, eating. And I wonder whether sometimes we think about eating difficulties and eating problems within a very niche, specific context. And we try and observe these behaviours in some populations, and we completely miss some other populations, because there's people at the gym where I'm like, you're physically built and muscular and all of those things. But when you describe your eating patterns to me, in my head, this is slightly problematic, the level of calorie counting, the level of macronutrient counting. I understand it's required for you to be able to do what you're doing. But in a different context, we would really consider this really problematic. Well, maybe. So why are we not thinking about it as problematic here? Because you're so obsessed with how much protein you eat, how many calories that adds up to, what the calorie deficit or the calorie surplus is. And you do that on a daily basis. And I've had conversations with people where we've pulled their phone out, and they've showed me their little spreadsheet for the day. And I'm like, oh, my god. But maybe we don't see that as problematic because it's a positive physical health thing. Well, and it does make me think about an underlying perfectionist tendency, for example, which-- I mean, I think this is interesting, though, because is problem eating-- we assume it must have some-- well, this is what we're going to ask our guest about, but have perhaps in some cases a precursor for disordered eating. But when we get into disordered eating, we're thinking about an impact on functioning. And I think if you are somebody who's a gym fanatic and obsessively tracking your eating, one might argue that you're functioning is being improved, if you like, because that's part of your community. I mean, it may have other serious repercussions, but you're not withdrawing from life. It probably allows you to be part of a community in a way that normal, inverted commas, "eating" might not. So I think it's really interesting about how context-- and I think I want to come back to this in a bit more detail, how context defines or invites our eating habits. I think it's really important. And the paper looks at eating habits in the context of schools. And I wonder if that is one of the reasons why this is revealing such interesting data. Yeah, there's a lot to get into. But yeah, I think we were talking about boy bands earlier for lots of different reasons before we started recording and thinking about how the general public and how people in the public eye are presented. And that's seen as something that's attainable through healthy habits. But one wonders if underlying that there are very unhealthy habits that we're not privy to in terms of understanding the process. Yeah. I won't name the show, but there's a popular dating show that lots of people watch. And the premise, I think, is lots of people go on an island and try to find love. So figure out what I'm talking about. I don't watch it properly. I might watch it if it's on in the background. But the reason I don't watch it properly is because I'm like, this is not realistic. It's not fair that we should have to try and aspire to be these people because nobody looks like that. And I'm making the link between eating difficulties and problems and body image and physique. And I'm just like, this is not fair. I don't want to watch this and then feel a certain way for whatever reason. And I think if young people are watching it, I wonder what the impacts are on that. But I suppose there's a different conversation around the relationship between media and body image and also eating difficulties. There's two things that I think affect young people potentially now more so than they did in the past. And those two things are nude culture, as in sending nudes through mobile phone apps, and also weight-loss drugs. I don't know what the literature says on those things. But again, I'm making the link between eating difficulties and eating problems and body image. And I would think that this whole culture of sending nudes, for example, or having such prominent emphasis on pictures in online spaces of yourself, clothed or not, I wonder what the impact of that is on young people's eating behaviours and body image, because if you're then trying to achieve a certain body type, you then might change the way you eat and what you eat. And I think that brings a question of comparison up. I mean, certainly, we know that some young girls in particular are vulnerable to making visual comparisons using social media platforms or looking at other people's posts and making comparisons, not all, but a proportion of young people. And one of the questions that is very indicative of identifying the population that had problem eating in this paper was one of the DAWBA questions, which is a very well-established assessment. And it says, have you ever thought you were fat where other people thought you were thin? And that question has got both a self-assessment. It's got a body image disturbance in there. And it's got a comparison there. And I think this is interesting, particularly if we're talking about the teenage brain, of course, because we're talking about young people who are post-pubertal and those moment-to-moment changes. And partly, we know, particularly if we look even at the social media data, the way that teenagers experience the same post changes those intraindividual differences. And it's somewhat emblematic of early adolescence, that vacillation between different emotional states, different body images, different identities. So I'm wondering if you ask that question, that same question from the DAWBA, would a response change moment to moment, day to day, week to week, because it may feel that that comparison is very large, particularly in a school context. And I'm really interested in thinking about the school context because I think this is fascinating data because we often talk about eating in a family context, and this has shifted into a peer focus, if you like, looking at the school context. So there is some fascinating data to get into. I wonder if we should invite our very special guest in to help us? Absolutely. So today, we're joined by our very own Dr. Clara Faria from the University of Cambridge. Clara is the lead author of the paper "The Prevalence of Eating Difficulties in Children and Young People in England," a large cross-sectional school survey published in the JCPP Advances. Welcome, Clara. Thank you so much, Jane and Umar. It's a really huge honour to be here. It's a bit weird to be seated on the other chair. I'm a huge fan of your podcast, so I'm really happy to be here. And thank you so much for the lovely introduction. We're very excited about this as well because I think this is the first time that the three of us, the three of the four ACAMH podcast guests, are in the same room at the same time. And so this should be a really fun conversation. Should we start with some definitions? So we've been talking about eating difficulties, eating problems, body image, various things like that. Should we start with, what are eating disorders in the DSM, for example, and how are they related to body image? Yes, absolutely. So I'm going to use the most standard definition. So basically, we all know eating disorders are very serious mental health conditions. And you talked a lot about adolescence in the introduction. And we know also that eating disorders, they emerge mainly during adolescence. What I think is so interesting about eating disorders is that they are a very heterogeneous group of clinical presentations, but they do share the core feature of disturbed behaviours and/or perceptions towards either weight, body shape, or eating. And if you look at the DSM-5, for example, you will see several eating disorders listed. So you will see, for example, ARFID, which is Avoidant and Restrictive Food Intake Disorder. You're going to see anorexia. You're going to see bulimia nervosa. You will see OSFED, which is Other Specified Feeding or Eating Disorder. And you will see that all these clinical diagnoses, they do share the disturbed behaviour and/or perception, but they are very different. So for example, in ARFID, there is a severe restriction in food intake, but it's not motivated by body shape disturbances or by a desire to lose weight. While in anorexia, for example, we know there is also a lot of restriction, but the motivation is different. So I think from a psychology perspective, it's really interesting. Eating disorders are fascinating because you have so many different-- I forgot to mention binge eating disorder, which also has a very important externalising component. And even if we think about the psychopathology, it's very different from, for example, anorexia or bulimia, which are more internalising. So yeah, so eating disorders are a very diverse bag. And I think they make for a really interesting research area. Well, that's a lovely executive summary of eating disorders. So that is very helpful because pulling apart the body image aspect, which may or may not appear in certain disorders, is really, really helpful. Your paper, which I thought was superb, by the way-- and it's a really interesting and thought-provoking one, so I would encourage everyone to read it. But in your paper, you're talking about problem eating. And I want to think about how you differentiate eating difficulties and problem eating from eating disorders. And can you say something about the transition, what might predict the shift from one to another? 100%. This is something I really wanted to stress because when we talk about eating disorders, we are talking about very defined diagnostic criteria. And we're talking about eating dysfunction that is at a threshold that causes what we call impairment, so a significant impact on daily activities. And when we talk about eating problems or eating difficulties or disordered eating, we have a bit of a nomenclature problem in our field. But I think when we talk about dysfunction in eating or eating problems, which is the concept we look at in the paper, we're talking about beliefs or behaviours that will lead to an increased likelihood of broader difficulties with eating. But we're not talking about disorders, so we're not talking about sufficiently clinically impairing difficulties that would need an eating disorder diagnosis. What is interesting, though, is that we know that. People with eating disorders, they will have disordered eating. But having disordered eating alone is not enough to meet diagnostic criteria for an eating disorder. In our paper, it is important to say we didn't have access to the full diagnostic assessment. We didn't have access to the full DAWBA. So we didn't do a full diagnostic assessment because our study was part of a larger study called the OxWell Student Survey, which is led by Professor Mina Fazel. And they looked at several other things-- well-being, sleep-- in a really large population of secondary school students. And about the transitions, so that's really interesting. And I think that's the million-dollar question because-- well, we can talk about a bit of theory and also about what the quantitative studies show. So I think if we talk about a bit of theory-- well, there are several really important psychology theorists, like David Mitchell, for example, that have proposed theories on eating disorders, psychopathology, and then underlying constructs that contribute to an eating disorder. And we know that internalising difficulties and eating difficulties, for example, a lot of perfectionism and body dissatisfaction, they can contribute. So that's in the theory. But then when we look at quantitative data and what quantitative data supports, we have some really interesting recent epidemiological studies, mainly led by Professor Francesca Solmi's group, that show a clear longitudinal association between body dissatisfaction and eating disorder symptoms later in life. There are two interesting papers. Both were published at The Lancet, one by Blundell and Solmi. And then they looked at the association between childhood BMI and eating disorder symptoms and depressive symptoms later on. And then there is this other one, which was just published in this year, looking at body dissatisfaction at age 16 and later eating disorder symptoms. And the second one is really interesting because they used a twin study design. So they were also able to control for genetic and environmental confounders. So we definitely have epidemiological and longitudinal evidence that eating difficulties can represent a signal towards later eating disorder psychopathology. What we don't know that well is what mediates this transition. To be fair, we know a little bit. So in both Solmi's papers, they found that girls had twice the risk as boys to transition from body dissatisfaction to eating disorder symptoms later in life. So we know gender, it is an important factor, as Jane was mentioning in the beginning, right? It's interesting because often "common--" I'm putting in between quotes-- "common questions," they hide really interesting points. And that's not to say eating disorders don't affect boys. They do affect boys. But we know that girls are more at risk. So basically, to wrap up, the transitions question is such an interesting one because the evidence is still being built up on it. I think in terms of quantitative studies, we're still catching up with the psychological theories about eating disorder's underlying constructs and even what personality traits predict who transitions from disordered eating to an eating disorder. I don't want to dominate our discussion, but that really reminded me of a conversation I had with Dennis Ougrin for another series, Inside the Teen Brain. And we were talking about the risk factors. How do we know who's going to, let's say, move from, in this instance, self-harm to suicidal behaviour? And his comment was, we know quite a lot about the risk factors, but that really doesn't tell us anything. We need to know about what stops someone from moving into that path. And that really made me think about, as you were saying, we know a little bit. We know girls are more likely to move into that disordered category, if you like, or the disordered dimension. But we don't know anything, really, about what stops you moving into that position because, I guess, when we know the protective factors, it points towards intervention in a way that the risk factors may not. I mean, it can be the obverse of a risk factor, but not always. So that's really interesting. I hadn't quite appreciated the lack of data on that transition. I love that you brought in the self-harm analogy because I think it's such a good comparison because with self-harming behaviours, for example, we know they're more common among teenage girls. But we do know that not everybody-- and this is something I see so much in clinic as well. So we know lots of patients self-harm. Not everyone who self-harms will have suicidal ideation or will attempt suicide, although we know those phenomenon are interlinked. So yeah, it's really important to know, as you said, what stops someone from transitioning, right? And I think moving back to the eating disorders versus disordered eating issue, eating is such a complex behaviour. And as Umar was talking about it earlier, it's influenced by so many dimensions of life, like peer-to-peer comparison, what you watch on TV, what you watch when you're scrolling past your Instagram every day, and the concepts and the parameters you internalise as normal. So yeah, it's a really interesting question. What are some examples of eating difficulties in general, but also the ones that you investigated in your study? So in our study, we used the DAWBA screening items. So they are five items that ask about disordered eating behaviours. And when they were created, actually, the intention of creating them was using them as a screening tool in the general population because, basically, the DAWBA full interview is quite an extensive assessment, and it takes a lot of time. So especially when you talk about using very large populations, general population samples and outside of a clinical context, they wanted something that could screen people to who was more likely to have a disorder. The DAWBA was invented, I want to say, 1999. I'm pretty sure it's 1999, their first [INAUDIBLE] paper. And I think basically, our understanding of eating disorders back then was much more limited. So in 1999, there was no ARFID, if you stop to think about it, because ARFID only became a diagnosis in the DSM-5-- in the DAWBA, we ask about five eating difficulties. So we ask about, we can say, body dissatisfaction with the first question that Jane mentioned. Have you ever thought you were fat while others thought you were thin? We ask about guilt. So we ask about if you ever felt guilty with overeating. And I'm not saying the specific wording in the question. But yeah, there is a question about guilt or shame regarding to your weight. And then there is a third question, which is, I think, my favourite question because I think it's a more discriminatory question, about, have you ever self-induced your own vomit in order to lose weight? And then we also have two other questions about disordered eating behaviours. But we don't have questions, for example, on restrictive eating in terms of-- when I say restrictive eating, I'm saying more thinking about ARFID-like behaviours. So we don't have questions in the DAWBA, for example, about restricting your eating because of sensory issues, which is really important for ARFID. So yes, we did investigate five eating difficulties, but we didn't investigate all of them. And I just wanted to flag this limitation. You've mentioned one of them that I think is particularly interesting here, making yourself deliberately vomit. And in your study, I think you found that 17.7% of the sample reported that they had engaged in that behaviour. That seemed very high to me. And one of the things that I was thinking was, of those 17.7% of young people who have engaged in that behaviour, is it all problematic, or are there situations in which that's totally OK? If you're feeling sick and you're feeling unwell, I'm not suggesting people should do this, but I've had conversations with people where they say you feel instantly relief after you've thrown up. And so is there a situation where people would deliberately make themselves throw up in a "I'm feeling unwell" way rather than "I'm experiencing eating difficulties" way? Yeah, you've touched on a really important point. So we always thought, and we still think, but I've always thought that the third question about deliberate vomiting was the most discriminatory one, because the DAWBA was also used in several other studies, so, for example, looking at the Mental Health of Children and Young People national survey and looking at the percentages they found for the same eating difficulties. The third item was always the least endorsed one. But we were surprised as well to see the 17%. And I think you've raised a very likely possible explanation, that actually when we talk-- because with children, this is less likely, right, like with younger children. But when we talk about secondary school students, actually, it is much more likely that you may induce your vomit because you're feeling unwell, especially if you're 17 or drink too much at a party or something like that. So yeah, I think that's a very valid alternative explanation. That being said, and this is something we found looking at MHCYP data, that usually people who endorse the third item, they are more likely to then-- because I should probably explain this better. In the MHCYP data set, we actually had the full eating disorder interview. So we were able to see and to correlate, what screening items were you positive for, and what diagnoses did you have in the end? So we did see a stronger predictive validity for the third item because we had the eating disorder diagnostic interviews. So we knew what was the [INAUDIBLE] eating disorder status in the end. But yeah, because in this study, where we just looked at a general school population and we were talking about a big cohort of students, yeah, definitely. That's a possible explanation. What I'm getting there is-- I think my understanding of what you're saying is there could possibly be some people within this 17.7% that are not doing this in a problematic way or have not done this in a problematic way. But that question itself is quite good at predicting who then goes on to have a diagnostic label for this kind of thing or problematic behaviours that become a diagnosis. Is that a fair assessment? Yes, that's a totally fair assessment. So my clinical work is often with young people who have neurodevelopmental conditions, and tics in particular. And during COVID, there was a surge in functional tics and other medically unexplained symptoms, not just functional tics, for example, medically unexplained epilepsy and so on. So I'm wondering, because I think we're all surprised by the levels of numbers, how much import should we give COVID to your particular cohort's findings? And could that teach us anything about possible environmental interventions? Well, first I want to say I think the COVID question is such an interesting one, right, because I know, Jane, you're based at the Great Ormond Street. And there is a really nice study, actually, that came out during the pandemic, basically using the electronic health care records of GOSH and also other electronic health care records that showed a spike in eating disorder-related admission to general paediatric units. And you can clearly see the trends during the pandemic. So we know this happened, right? And how this is relevant to this paper? So this paper, the data were collected in 2023. So it was post-pandemic, and school life had already largely returned to normal standards. But I think when we think about what happened during COVID, it's just so interesting because there was such a huge disruption in everyone's environmental circumstances. And there's another paper. Speaking of environmental circumstances during COVID and OxWell data, there is another paper. The first author Emma Soneson. And the title is very nice. It's called "Happier During Lockdown." And it doesn't look at eating difficulties in particular, but it looks at well-being and depressive symptoms during lockdown using OxWell data. And actually, what it found was that during COVID, for some people, lockdown was actually beneficial, and it had increased levels in well-being. So just thinking with my clinical hat on, you've mentioned you work a lot with neurodiversity. And we know, for example, that for neurodiverse people, certain environments, especially the school environment, depending on what type of school they go to and what sense support is available or not, can be very challenging. So I can imagine that if they have a supportive family that understands their needs, lockdown may have been a wonderful thing for them because they were able, then, to be in a more supportive environment. So I think when we apply that to eating difficulties and eating disorders, and when we think about things like comparison-- and this is all speculative because we don't really have that good-- again, we don't have that transition data during COVID yet. So when we think about behaviours that people may have engaged in during the pandemic and things like just comparing yourself in social media time, for example, and looking at-- as Umar saying in the beginning, I loved-- and you as well. I loved the reality show comparison just because it is so true. There is another famous reality show that I'm not going to name, but it's about finding partners without initially looking at their appearance. And I thought that, so you can guess what I'm talking about. It's very popular in the UK. But what I thought was fascinating, that although the show has this premise, the other day, I was reading an interview with a few of the show's candidates, and they were just describing all the amount of static procedures they went through prior to joining the show. And this is just an example to say that, I mean, especially young adults and teenagers, they care a lot about appearance, right? So I imagine that staying-- I mean, just conjecturing at this point, but staying at home and increasing your screen time and comparing yourself all the time to images and bodies you're seeing online that may or may not be representative of reality can't have done good in terms of body satisfaction. And that might be a good point to point out that we did an episode with Lisa Henderson on the relationship between young people's development and their engagement with digital media like smartphones and social media. So check that out if you haven't already done so. I wonder whether we should have a bit of the conversation here about whether eating disorders and eating difficulties should be thought of as internalising problems, externalising problems, and what that looks like, because we often make that distinction on this show, but also in the literature. And lots of these things might fit nicely into internalising and externalising, but some of them don't. And there is that. And I think we were talking about that earlier. There's a really nice Mitchell review asking the question about whether eating disorders should be internalising or externalising. I mean, it's something you touched on earlier, Clara. Perhaps there's something in your DAWBA data that you could contextualise some of these eating difficulties within that. So if you were going to throw your money one side or the other, what would you say? Oh, my god. It's such a difficult but important question. And I think when we look at the DAWBA screening items, the last question hints a bit at externalising behaviours. So the last question is, If you eat too much, do you blame yourself a lot? which is kind of nodding to binge eating-like behaviours. But when we look at the other four questions-- well, the vomiting one, we could also say it's externalising behaviours. But when we look at the other three questions, especially the, Have you ever thought you were fat while others thought you were thin? and the question about shame and guilt, it's talking more about internalising things. I don't want to give a 50/50 answer. But I think, well, if we look at the overall understanding of eating disorders and most of the work that's been done so far on personality traits, for example, that are associated with eating disorders, the overall consensus is definitely that we're talking about mainly internalising disorders. However, I think there's a very interesting point to be made, that because eating disorders are so heterogeneous and because when we look at presentations like binge eating, for example, that it's mainly about the loss of control over your eating that is not driven by necessarily a desire to lose weight. And it doesn't come with compensatory behaviours. So we're talking about people that lose control over eating and eat a lot in very short periods of time. So when we look at binge eating, it's very externalising behaviour, right? And if you think about other externalising disorders in psychiatry and psychology, it's more similar, for example, to someone who has a substance use disorder and uses substances uncontrollably. Or if we think about the cognitions that drive anorexia, for example, and that desire to be thin at all costs, the cognition, we're talking about more internalising disorders. But then again, if you think about the behaviour-- sorry, if you think about the behaviour and then the actions that are coming as a consequence of those cognitions, I suppose you could even frame it as externalising. It's really difficult. It's a really difficult question. What are your thoughts on it, Jane and Umar? I'm really interested because you are the psychology experts. Oh, so I would say that it's-- yeah, I think, like you say, it's complex, and it's difficult. I would say this distinction of internalising and externalising assumes that it has to be one or the other. But actually, it might be a bit of one and a bit of the other as well. I think that's probably the most pragmatic and reasonable answer here. Maybe it's not easy to get to an answer because you can't put them into one camp or the other. And there might be parts of it that is internalising and parts of it that is externalising, I think is probably what I think. But I thought. Umar, you'd be delighted with that because I think it does question some of the diagnostic framework questions, the broader theoretical issues, about how we categorise or our failures in categorising different conditions. So I'm sure you're delighted. I love that, Clara. But on the other hand, and then there's this. And that is the sign of a really informed person who can consider something from all sides. I think that's a really nice answer, so thank you. I wanted to turn and think a little bit about intervention because, obviously, from my point of view, I'm interested in the sort of, What now? question. And what we know from eating disorders-- and of course, we're not talking about eating difficulties. We're talking about eating disorders-- is that family-based treatment has an impressive evidence base. So there are five tenants in that, including empowering parents, separating eating disorder from the child, having a sort of pragmatic and nonjudgmental approach. So you're not looking for a reason why. You're dealing with what's in front of you and so on. Do you think there's anything to be learned from that approach, understanding that we are pushing the data somewhat? But is there anything to be learned from that approach that might be applied to a school support programme, or do you think there is a different requirement entirely? 100%. I think that based on our findings, but also based-- as you said, it's a bit pushing our data. But based on everything we know and based on these really interesting new studies about the association between body dissatisfaction and eating disorder symptoms, what we can say about the five tenants is definitely the nonjudgmental approach, I think for me personally, is the most important one when we think about school interventions. And we have a few interventions out there already for disordered eating. So I think a very interesting one is called The Body Project. Hannah Lewis does a lot of work on it. So The Body Project does a lot about empowering as well young people to be more accepting of their bodies and teaching them about different body formats. So I think that's empowering. And when we think about at the school level, things that schools can do, I think the nonjudgmental approach is really important, mainly because another very important problem and that I know that schools are very interested in at the moment and invested is obesity in childhood, which is a totally separate topic. But it is very relevant because we have a lot of healthy weight interventions in schools at the moment. And we know there are a lot of behavioural interventions for encouraging children to lose weight. So while-- just make that very clear-- obesity is not an eating disorder, those things, they are interlinked. Obesity and eating disorders are interlinked. And you can't talk about weight-loss interventions for children without also considering the risks of encouraging, for example, excessively restrictive eating patterns and a judgmental approach towards your body. So I think it's important to be really careful when we talk about these things. And definitely, a nonjudgmental approach helps a lot. I mean, I guess it's hard to find a situation in which that wouldn't be helpful. And I guess we do have that debate about whole school interventions or whole school ideas that for a very small proportion it may not be a helpful approach. But it's hard to consider how that framework could not be helpful if we're thinking about young people in school who may have problematic eating. Yeah, that's an interesting one. OK, so let's call it a day there. And so what we'll do is we'll thank you for your time, Clara. That's been an amazing conversation and lots for us to reflect on. And Jane and I will just have a chat after you go and see what we think. Thank you so much, Jane and Umar. Yeah, thank you so much. It's been lovely to be here today. And I really appreciate the invite. No, thank you. It's been great. Thank you. Thanks. See you. Bye. Bye. Bye. Well, we covered a lot of ground, but it raised a lot more questions for me as well. And I think that, as is the case with lots of the episodes that we do, there's just more stuff that needs to be discussed. And now I just think we should have a separate episode on body image and ideal. I think as Clara was talking, one of the things that I was thinking was, I wonder how body ideals change through development, because if I think back to my younger years and teenage years, thin was the ideal. And now in my late 30s, I'm like, oh, thin, in my head, isn't the ideal anymore. And I wonder whether that's because I'm now older or whether that's because society has shifted in general. I think it's so interesting how there is a fashionable body shape, if you like, that becomes the aspired body shape because I think culture-- and whether that's a broad culture or your local community-- is really highly relevant to eating problems. And I think in part, I'm thinking about my clinical experience here, where particular schools, for example, have some requirements, if you like, in terms of the fashionable shape. And there are schools that may have clusters of problematic eating and disordered eating. So I can see that in clinical practise sometimes, that there are patterns where there are clusters of schools. So the fact that this study was assessed within schools, I think, makes it slightly different from other population assessments, inasmuch as we're asking a question about body shape in the context of school. So does that mean that the comparison might be greater? And does that mean that the intervention should be school-based? I mean, one of the best practises I've ever seen in a school was where teachers went into the school hall and had lunch with the pupils. So they're really getting into the social space. They were modelling good social behaviour, using food as a social tool, if you like. I think the only problem with that is we're adding something else to teachers' lists. And it cannot be considered a lunch break for a teacher because, of course, they are very much managing a psychosocial aspect of their pupils. But I think that allowing that sort segue into what a social space and eating in a social space might do is quite important because I think that cultural experience is where a lot of the difficulties and the comparisons potentially happen. Yeah, but I think it's really interesting. Whether it's a cohort or context effect, eating patterns are so vulnerable to our environmental experience. And you might not have the answer to this. It's just putting the question out there, is whether there are evidence-based approaches to addressing eating difficulties in schools, or the one that you've just mentioned, for example. And the reason I say that is because I was speaking to someone last week, I think it was. And this is not my idea and not my thought specifically. And they were arguing for less school-based mental health interventions and more clinical-based mental health interventions during adolescence. And their rationale was we actually don't know what works within the context of school settings. We have no good evidence for what works within a whole-school approach. But we have good evidence of what works within the clinical settings. So why are we investing time, effort, and resource into school-based stuff when we don't know if it works, and we actually know what works outside of school within clinical settings? So why don't we just push that more? And that was an interesting take. So I wonder whether that applies here. Do we know what works in schools? I actually don't know. I mean, there may be. I haven't looked at the literature properly. There may be. But what I do know in terms of healthy eating in schools is that there's some really nice reviews looking at how to deliver healthy eating information to adolescents. So there's a variety of different paradigms, if you like. And in one context, school information-- now I'm just trying to remember who did the study. But in one condition, all the young people were given information about taking sugar out, eating healthily, and so on. In the other condition, young people were given the information, but they were asked to educate one another. And the way that they delivered it made a huge difference to eating choices. In other words, a didactic teaching will not work with most adolescents. Healthy behaviour is most likely to happen in peer-to-peer context, albeit facilitated, so thinking about why sugar is bad for you, why companies may be profiting from sugar, and so on and so on, is the way to allow young people to educate one another. So I do think you've got a point. We don't know about the vector, if you like, how we deliver these data. But I guess the question is, who does that? And actually, as you're saying, it made me think about having almost like a well-being practitioner group, so a low-intensity group of practitioners who are thinking about prevention and some informed mental health background, but not necessarily at the level of dealing with disordered or more high-intensity difficulties. And we're about to launch a new BSC, MSci programme at UCL, and it's called child health sciences. And the graduates from that would be the perfect person to do this. So they are going to be informed across a whole range of child health issues, including psychology as one of their specialisms and mental health within that. So having a group of informed mentors or informed mental health professionals who aren't quite at that level of intensity might be the ideal group. But it's a fair point. I don't know if school-based interventions are the best place. And we know that there are some questions about whole-group interventions for good reason. What's your takeaway? So I was really struck by the conversation that we had about the 17% of people in the sample deliberately made themselves vomit and what that's actually measuring. And I suppose it made me reflect on when we're asking questionnaire-based items within schools or within any context, it's, what are we intending to measure, and does it measure what we are intending to measure, and actually, what might be some of the sources of noise within the response that you get? So the headline figure of 17% sounds very problematic. And I'm sure that it is. But I think like we discussed, there will be some reasons underneath that that might not be as problematic. And that's not to take away from that particular finding. It's just me trying to demonstrate that when we're asking a question, there'll be layers of bias and sources of noise within the responses that we should just be mindful of. Yeah. Aware of. This paper really me-- because eating disorders was something I used to work in some time ago. So it really made me revisit some of the interesting concepts and ideas in a wonderful way because, of course, things have moved on. But it brought me back to the Fairburn, Cooper, and Shafran paper, which was published over 20 years ago. But it's still a really important paper because it asks us to think about the underlying psychological processes. So it's sort of related to what you were talking about, the things that might cut across eating disorders or may mask or may conflate the data in some instances. So the Fairburn paper talked about perfectionism, low self-esteem, emotional regulation, and interpersonal difficulties as really the latent variables, if you like, underlying eating disorders. So my takeaway, I guess, would be to think about exploring these as the area of leverage. So perhaps that's a way of diverting the problem eaters away from a disordered outcome. And I think that would be an interesting area to look at. But I really enjoyed this paper because it really prompted a rediscovery of some ideas in the context of these data having moved on with another layer of understanding. So it's interesting. I think the data are thought-provoking. And perhaps they're pointing to a thin end of a very big wedge. Who knows? Join us again next week when our guests will be Xiaolan Liao and Elizabeth Skowron as we discuss how the amount of parent-child interaction therapy affects outcomes for child welfare families. [MUSIC PLAYING]