Finding Order in Disorder

Finding Order in Disorder

College and university leaders are creating a campus culture that encourages students with eating disorders to self-identify and seek treatment.
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EATING DISORDERS CONTINUE TO BE AN evergreen issue at colleges and universities. Despite what studies say about the prevalence of eating disorders among college students-some indicate that they're on the rise while others say they've stabilized-many campus health experts say they've seen little change in the number of students who have them. They have also observed a different trend-a more positive one. They've noticed that more students than ever before are seeking treatment for their eating issues.

"More students are feeling safer to come forward and receive help," says Kathleen Malara, director of student health services at <b>Fordham University</b> (N.Y.). She says the campus community has made great efforts to break down the stigma and feelings of shame and guilt that are often associated with eating disorders. Other higher ed institutions are also tackling the issue.

To put eating disorders in greater context, about 10 million females and 1 million males in the United States are battling with them, according to the National Eating Disorders Association, a nonprofit that supports research for prevention and treatment of eating disorders. Since college students are considered a high-risk group for developing eating disorders, the incidence among them is likely to be greater than the national average. In addition, people tend to underreport eating disorders, so research based on self-reporting data can be flawed.

'For a long period of time we didn't think
about identifying young men as having eating
disorders. But we're getting better at that.'
-Rob Thompson, Indiana University

In the last year, about 2 percent of college students said they have suffered from anorexia, characterized by dramatic weight loss and/or caloric restricted food intake, according to The American College Health Association's annual reference group data report. The association also reported that in the last year 2 percent have suffered from bulimia, characterized by binge eating often followed by purging. These figures have remained virtually the same over the last five years.

There's no single standard definition of eating disorders. "People use so many different descriptions for eating disorders. If you use the psychiatric way of diagnosis, many individuals do not meet the criteria for having an eating disorder," says Devdutta Sangvai, medical director of the <b>Duke</b> Eating Disorders Program. Additionally, some students get labeled with more than one diagnosis in the course of a year. They may be classified as "underweight" at one point and then "anorexic" later on.

In fact, the diagnostic threshold for eating disorders as found in the fourth edition of the <em>Diagnostic and Statistical Manual of Mental Disorders</em>, known commonly as DSM-IV-which includes anorexia, bulimia, and binge eating-has been criticized for being too restrictive, since the majority of people actually suffer from a larger spectrum of disordered eating known as EDNOS (eating disorder not otherwise specified).

"Many students have disordered eating but don't have an eating disorder," says Amy Alson, an internist and psychiatrist at the Elson Student Health Center at the <b>University of Virginia</b>. She says there is a spectrum of disordered eating. "Everybody at some point overeats or stops eating as a result of emotional stress. It's a coping mechanism, and for some people it's a phase. For others it's a lifelong struggle."

The college environment has been called a breeding ground for eating disorders. The close living quarters, combined with easy and constant access to food, competition for grades, and other factors, can make students vulnerable to eating disorders. Big life transitions can also set them off. "Other than puberty, leaving home for college is the next big transition," says Ron Thompson, a private practice psychologist and NCAA consultant to the athletic department at <b>Indiana University</b>. Additionally, he says that "college tends to draw brighter, more competitive, and perfectionist types of people."

Many students also come to college with eating disorders that were diagnosed in high school or earlier. Up to 10 percent of children have eating disorders by age 10 or younger, according to ANAD, the National Association of Anorexia Nervosa and Associated Eating Disorders.

Leaders at many IHEs are working hard to create nurturing, protective, and accepting environments for students with eating and body image issues. While institutions have their own ways of supporting students, most health experts agree that the key to effective eating disorder counseling and education is a student-centered, multidisciplinary approach. Eating disorder teams that include nutritionists, physicians, and counselors-all of whom offer a distinct perspective and expertise-are a common approach.

But there are obstacles to overcome with this kind of approach. "Different institutions have different levels of services and resources available to accommodate their students," says Sangvai at Duke, which has an on-campus, in-patient eating disorders treatment center. "Schools like Duke that are affiliated with a big medical center nearby often have more resources and can thereby provide more resources for students." Additionally, some institutions' student insurance policies are more comprehensive in coverage than others. "A student can say, 'I am willing to get help,' but the real trick is to find medical help they can afford," Sangvai says.

Some IHEs are being creative with limited resources. Health officials at Fordham, for example, tout the university's counseling resources but make it known that it's not a treatment center. "We're not looking to treat patients as if we were an in-patient psychiatric unit. We're really here to help them stay on track and complete their education in a safe way," Malara says.

In her eight years at Fordham, Malara has formed an eating disorder committee made up of nutritionists and counselors to monitor students' eating disorders. She has also created a statement of expectations for students to sign before they begin counseling. "They must agree to be counseled, see a nutritionist, and seek further help if their weight drops or if they fall off course," she says. The statement's purpose is twofold: it empowers the student to take ownership for managing his or her health and gives the university "a safety net if students don't comply," she says. Students don't have to sign the statement of expectations, but most do. "When someone comes to our attention, they usually want to be helped," Malara says.

Large institutions also have a unique set of challenges. One is that they serve a much greater volume of students and therefore have much more data to manage. Health services staff at <b>Cornell University</b> (N.Y.) formed an interdisciplinary group called CHEP (Cornell Healthy Eating Program) in 2001 that serves about 450 students (both undergraduate and graduate) who struggle with some aspect of eating or nutrition or body image. The number of students served by CHEP, which provides integrated medical, counseling, nutrition, and health promotion services, has increased by 150 percent in the past seven years, according to Janet Corson-Rickert, MD, executive director of the university's Gannett Health Services.

"We're doing a better job of identifying students and engaging them in a discussion," Corson-Rickert says. Each week, the group discusses 60 to 70 students and shares its expertise on best practices management for each individual. Each student typically meets with about three to four members of the team. "We can only take good care of students using a multidisciplinary approach, since eating disorders have both a physical and mental component," she says.

To help identify students who are struggling, CHEP also provides educational resources to the entire campus community, including janitors and the facilities and fitness center staff. Despite the volume of students they counsel, most of the students they see do graduate. "It's pretty incredulous to think they can still succeed at a place like Cornell. I think that's a credit to the support they get here," says A.J. Rubineau, a physician at Gannett Health Services.

The University of Virginia also uses an integrated care model, in which a nutritionist, physician, and counselor work in concert to care for an individual patient. They find group therapy to be very effective. "Eating disorders are complex, and the people who have them are complex. Having support from a number of like-minded people is a pretty powerful experience," says Alson at UVA.

The university has developed a 35-person coalition to address eating disorders and exercise concerns that includes students, faculty, and staff. "It's a proactive approach to promoting a healthy body image. That's critical when we think of prevention," says Paula Ciavarella Caravati, RD, a nutritionist who works with Aramark in UVA Dining and is a member of the coalition. Nutritional and wellness counseling is free for any student on a meal plan, and she sees about five students each week. "My role is not only to get information out to students but to ensure that there are a lot of healthy items on the menu."

The coalition also develops programming to educate the entire campus community on broader body image and eating issues. It recently sponsored a series titled "Celebrate Every Body" that included a speaker from The Renfrew Center, the nation's first freestanding facility exclusively dedicated to the treatment of eating disorders. The team has also hosted a help-a-friend initiative; "Perfect Illusions," a vigil to celebrate and honor those in recovery or struggling with eating disorders; and a "Day without Mirrors," in which they removed mirrors from the bathrooms in residence halls and athletic facilities. "We wanted to show students that image isn't the only thing that defines a person," Alson says.

The prevalence of eating disorders is arguably even higher among college athletes. When the pressures of athletic competition are added to the cultural emphasis on thinness, the risks for eating disorders increase. Those playing sports where thinness is valued-such as distance running, diving, and gymnastics-are particularly susceptible. "Low-weight body shape is often considered advantageous in terms of performance," says Thompson of Indiana University.

Data backs up the connection between sports and eating disorders. A 2002 study by Katherine Beals, associate professor of nutrition at <b>The University of Utah</b>, found that 43 percent of 425 female college athletes interviewed said that they were terrified of being or becoming too heavy, and 55 percent reported experiencing pressure to achieve or maintain a certain weight. Most said the pressure was self-imposed, but many also felt pressure from coaches and teammates. A 2005 study of 325 athletes published in the <em>Journal of Applied Sport Psychology</em> found eating disorders in 5.1 percent of female athletes and 1.8 percent of male athletes.

Thompson adds that he is a firm believer in a team approach. "It increases the likelihood of treatment. We need to cover every aspect of the problem-both the emotional and the nutritional issues."'

Campus health experts recently attended the second annual Eating Disorders Conference, hosted by Duke this year. It was started by a group of campus nutritionists and mental health professionals to address eating concerns on college campuses and achieving excellence in the care of eating disorders. "We learned that we all have common issues but have a variety of ways of addressing those issues," says Sangvai, who attended the conference. "We're working toward a multidisciplinary approach and identifying insurance plans that provide comprehensive coverage for students."

<em>Alana Klein is a former editor at</em> University Business.


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