Information Resource

Eating Disorders and Schools

E
ating can become disordered. Serious eating disorders can disable and lead to
death. Because many adolescents with eating disorders actively try to hide their
“dieting” behaviors, diagnosis is often late in the development of the problem. In
general, effective treatment for chronic problems is difficult to accomplish.
Therefore, prevention and early intervention are of critical importance, and as with so
many problems experienced by youth, schools are seen as an important venue for these
forms of action.
As an aid for school personnel and those in the home, this brief resource provides
information on the following:
o What are eating disorders and how do we recognize them?
o Why and how should schools intervene?
In addition, we list some organizations focusing on eating disorder and offer a few
additional resources for garnering information.

What are eating disorders and how do we recognize them?

Diagnostic manuals differentiate eating disorders using the terms Anorexia Nervosa,
Bulimia Nervosa, and eating disorder not otherwise specified.

Anorexia Nervosa is defined as the refusal to maintain body weight at or above a

minimally normal weight (American Psychiatric Association, 2013). Those manifesting
Anorexia Nervosa display intense fear of gaining weight even though their body weight
is usually less than 85% of the expected weight. They have distorted body image of
themselves and deny being seriously underweight. For many postmenarcheal females,
amenorrhea (the absence of at least three consecutive menstrual cycles) is a symptom.
The disorder has been categorized into two subtypes:
1) Restricting Type: The person has not engaged in binge-eating or purging behavior
but rather just strictly restricts calorie intake.
2) Binge Eating/Purging Type: The person regularly engages in binge eating or
purging behavior.

Bulimia Nervosa is largely characterized by recurrent episodes of binge eating followed

by recurrent inappropriate compensatory behavior to prevent weight gain (American
Psychiatric Association, 2013). Binge eating is described as either eating an amount of
food that is larger than most people would eat in certain time period or a sense of lack of
control over eating. Compensatory behavior commonly includes induced vomiting,
misuse of laxatives, diuretics, enemas, fasting, or excessive exercise. The disorder has
been categorized into two subtypes:
1) Purging Type: The person regularly engages in self-induced vomiting or the
misuse of laxatives, diuretics, or enemas.
2) Nonpurging Type: The person uses other compensatory behavior instead of
engaging in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

*The material in this document was culled from the literature and drafted by Da Eun Suh as part
of her work with the national Center for Mental Health in Schools at UCLA.
The center is co-directed by Howard Adelman and Linda Taylor and operates under the auspices
of the School Mental Health Project, Dept. of Psychology, UCLA, Phone: (310) 825-3634 Email:
[email protected] Website: http://smhp.psych.ucla.edu Send comments to [email protected]
Feel free to share and reproduce this document
Eating Disorder not otherwise specified includes disorders that do not fit under the above
descriptions. Following are those that might be so-categorized:

1. For female patients, all of the criteria for Anorexia Nervosa are met except that
the patient has regular menses.
2. All of the criteria for Anorexia Nervosa are met except that, despite significant
weight loss, the patient's current weight is in the normal range.
3. All of the criteria for Bulimia Nervosa are met except that the binge eating and
inappropriate compensatory mechanisms occur less than twice a week or for less
than 3 months.
4. The patient has normal body weight and regularly uses inappropriate
compensatory behavior after eating small amounts of food (e.g., self-induced
vomiting after consuming two cookies).
5. The patient engages in repeatedly chewing and spitting out, but not swallowing,
large amounts of food.
6. Binge-eating disorder: recurrent episodes of binge eating in the absence if regular
inappropriate compensatory behavior characteristic of Bulimia Nervosa.

Finally, it should be noted that disorders such as avoidant personality disorder, obsessive-
compulsive personality disorder, borderline personality disorder, depression, panic
disorder all have been associated with eating disorders (Robertson 2013).

Commonly Cited symptoms of eating disorder

skipping lunch at school

seeking out snacks frequently
throwing away food
avoiding food in social situations
playing with or taking apart foods (removing cheese from pizza)
secrecy around eating
using the restroom immediately after eating
weight loss
frequent attempts at dieting
excessive exercise
continually talking about food, weight, and body image
calluses or scars on the knuckle
soft, downy hair present on the body
menstrual irregularities or loss of menstruation (amenorrhea)
(As Cited by Muhlheim, 2012)
Prevalence Rates Increasing

Eating disorders commonly are diagnosed during the early teen years. In community
samples, 24-55% of adolescent girls report that they are unhappy with their weight and
shape and peers become an important source of influence during the adolescence in
shaping their viewpoint (Stice & Whitenton, 2002). According to the National
Association of Anorexia Nervosa and Associated Disorders (2014) Anorexia is the third
most common chronic illness among adolescents. Bulimia is seen as an underreported
condition because the weight of individuals with the problem often appears normal.

Although usually associated with females, approximately 10% of those coming to mental
health professionals for eating disorders are male. Moreover, many professionals suggest
the number is an underrepresentation because the misconceptions about eating disorders
among males tend to allow many to go unnoticed. Also, males are seen as feeling more
shame about having such a problem and thus even more likely than females to avoid
seeking treatment (Anderson 1992).
About Cause

The exact causes of eating disorders are not known. However, genetic, biological,
psychological, social and cultural factors, alone and in combination, have been discussed
(e.g., Hirst, 1998, Mayo Clinic, 2012). Correlational studies abound. For example:
biologically-focused researchers report that individuals who have a first degree relative
with an eating disorder are eight times more likely to suffer from an eating disorder.
Other research suggests abnormalities in the activity of neurotransmitters, such as
serotonin, norepinephrine, dopamine. From a psychological perspective, constructs such
as perfectionism, low self-esteem, and approval seeking all have been implicated. With
respect to societal and cultural factors, the focus has been on the “thin ideal” image
emphasized in Western society (e.g., pressure from the media, family, and peers that
equates “thinness” with beauty) and on competitive or athletic activities that emphasize
avoiding gaining weight.

Why and how should schools intervene?

In addition to a cultural emphasis on thinness, increasing public health attention to
obesity has called on schools to address attitudes about weight gain and to focus on
socializing healthful eating habits. Thus, schools already are pursuing some activity to
promote health and prevent problems and to contribute to efforts to address problems
when they are identified. The special value of schools for intervening early is a
continuous theme in the literature.

As with many problems, the importance of early intervention for eating disorders is
supported by research (Loeb, 2012). For example, early intervention improves prognosis.
Research on Bulimia Nervosa suggests that treatment within the first 5 years of diagnosis
produces a recovery rate of 80% as compared to a recovery rate of 20% for those not
treated until after 15 years (Muhlheim, 2012).

Schools vary considerably in their direct concern for eating disorders. Some schools try
to ensure their personnel learn about eating disorders and how to identify and refer
students affected. Some include the problem as part of a health education curriculum.
Student support staff often play a special role in all this, and they certainly are needed in
assisting those students who are unwilling or unable to discuss their eating problems.
Schools often can bridge the communication gap between students with eating problems
and their families. The National Association of Anorexia Nervosa and Associated
Disorders offers a variety of resources, including their School Guidelines for Educators
to support education and prevention efforts (http://www.anad.org/get-information/school-
guidelines/).

Note: From the perspective of our Center at UCLA, addressing specific

problems, such as eating disorders, should be done within the broader context of
improving how schools address barriers to learning and teaching. Our Center
stresses that failure to embed such interventions into a unified and
comprehensive system of learning supports risks making the efforts just one
more fragmented and marginalized approach to addressing major and multiple
problems confronting many students. A unified and comprehensive system
enables schools to provide a broad range of other student and learning supports
that are essential in ensuring that all students have an equal opportunity to
succeed at school. See What Is a Unified and Comprehensive System of
Learning Supports? ( http://smhp.psych.ucla.edu/pdfdocs/whatis.pdf ).

*******************************************************
A Few Examples of How Schools Might Enhance
Education About Eating Disorders

Adapting ideas from a variety of resources, here are a couple of ways a school might
begin to enhance its educational role related to addressing the problem of eating disorders.

Provide an Educational Session about Eating Disorders

In contrast to the high level of daily exposure to media and social pressure that might
push students to take extreme measures to be thin, there is little exposure to interventions
designed to help them internalize warnings about the dangers of eating disorders. It seems
reasonable to suggest that health education curricula should focus on this matter. While
not a panacea, it is worth noting that data support the effectiveness of comprehensive sex
education in reducing teen pregnancy (Kohler et al.). Given this, at least one class during
the school year to educate and inform students about the dangers of eating disorders
should be implemented and evaluated. Available guidelines suggest that such a class
would include exploration of

what eating disorders are and are not

the harmful consequences of eating disorders
the role of media and social pressures in distorting body image
healthy diet and eating habits
good vs. excessive exercise

Note: Often recommended are videos such as

>Body Talk by Body Positive,
http://www.bing.com/videos/search?q=Body+Talk+by+Body+Positive+video%2c
&qpvt=Body+Talk+by+Body+Positive+video%2c&FORM=VDRE
>Killing Us Softly 3 by Jean Kilbourne
http://www.mediaed.org/cgi-bin/commerce.cgi?preadd=action&key=206
>America the Beautiful by Darrel Roberts
http://www.bing.com/videos/search?q=America+the+Beautiful+by+Darrel+Rober
s+video&qs=n&form=QBVR&pq=america+the+beautiful+by+darrel+robers+vid
eo&sc=0-33&sp=-1&sk=
Provide Guidelines for Teachers

Example: “As with all students, it is important to watch for signs of problems, but don’t
rush to diagnose and label their problems. Here are four immediate strategies to
consider:
(1) Be open to students and families who may be seeking information, guidance, and
support.
(2) Talk with the student individually and try to determine what’s wrong. Start off
exploring general matters. Encourage full expression of concerns, but don’t rush
to talk about eating disorders. If the student is reluctant, bring up what has been
observed that is of concern. When the student starts talking about problems, listen
and don’t interrupt; just reflect back about what is said so the student feels
positively heard.
Things not to do in talking with students:
avoid focusing on their weight/food - try to focus on feelings instead
avoid commenting on how they look
avoid demanding changes
avoid giving simple solutions
don’t make promises about confidentiality

(3) If you haven’t the time or feel uncomfortable talking with students about such
matters, ask a member of the school’s student support staff (e.g., the school’s
counselor, psychologist, social worker) to come to the class and find natural
opportunities to observe, interact, and talk with the student about what’s wrong.

(4) Severe problems call for immediate action. Encourage the student to seek help.
Unless the student is willing and able to access help, a conference with the family
must be called to discuss the problem and what to do. Let the student know that a
family conference will be scheduled. Ask a member of the school’s student
support staff to participate and add their expertise at the conference. Parents may
need specifics that support the school’s concern; they will need information about
what to do and where to go for help.

In talking with students (and family members), the process should be private and the
atmosphere should be non-judgmental.”
*******************************************************

Organizations Focusing on Eating Disorders

National Institute of Mental Health (NIMH) -- http://www.nimh.nih.gov

National Mental Health Information Center -- http://mentalhealth.samhsa.gov

Academy for Eating Disorders -- http://www.aedweb.org

National Association of Anorexia Nervosa and Associated Disorders --

http://www.anad.org
National Eating Disorders Association -- http://www.nationaleatingdisorders.org
 A Few Additional Resources
Understanding and Learning about Student Health
o http://www.columbia.edu/itc/hs/medical/residency/peds/new_compeds_sit
e/pdfs_new/school_based_health/Eating_Disorders.pdf
Five Things Teachers Should Know About Eating Disorders…
o http://www.eatingdisordersblogs.com/eating_disorders_in_schoo/2011/11/
five-things-teachers-should-know-about-eating-disorders-.html
Eating Disorders – Information for Teachers/Youth Workers
o http://www.bodywhys.ie/m/uploads/files/TeachersLeaflet.pdf
Discovery Education lesson plans- Overcoming Disorders
o http://www.discoveryeducation.com/teachers/free-lesson-
plans/overcoming-eating-disorders.cfm
A Lesson for Teachers in Addressing the Eating Disorder Bully
o http://www.nationaleatingdisorders.org/lesson-teachers-addressing-eating-
disorder-bully
For parents: Cleveland Center for Eating Disorders
o http://www.maudsleyparents.org/
For more, see our Center’s Online Clearinghouse Quick Find on Eating Disorders
-- http://smhp.psych.ucla.edu/qf/p3006_01.htm

References Cited and Drawn From

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders,
5th Edition: DSM-5. Arlington, VA: Author.
Anderson, A. E. (1992). Eating disorders in males: Critical questions. In R. Lemberg (Ed.),
Controlling eating disorders with facts, advice and resources (pp. 20-28). Phoenix, AZ: Oryx
Press.
Hirst, J. (1998). Biological causes of anorexia nervosa and bulimia nervosa.
http://serendip.brynmawr.edu/bb/neuro/neuro98/202s98-paper3/Hirst3.html
Kohler, P.K. et al. (2008). Abstinence-only and comprehensive sex education and the initiation of
sexual activity and teen pregnancy. Journal of Adolescent Health, 42, 344-351.
Loeb, K.L. (2012). Early intervention for eating disorders: What, why, and how.
http://www.slideshare.net/MaudsleyParents/early-intervention-for-eating-disorders-what-
why-and-how-11759143
Loeb, K.L.& Le Grange, D. (2009). Family-based treatment for adolescent eating disorders:
Current status, new applications and future directions. International Journal of Child and
Adolescent Health, 2, 243-54.
Mayo Clinic (2012). Eating disorders. Causes. http://www.mayoclinic.org/diseases-
conditions/eating-disorders/basics/causes/CON-20033575
Mulheim, L. (2012). Eating disorders in middle and high schools. Milwaukee, WI: F.E.A.S.T.
http://www.feast-
ed.org/Resources/ArticlesforFEAST/EatingDisordersinMiddleandHighSchools.aspx
National Association of Anorexia Nervosa and Associated Disorders (nd). ANAD School
Outreach & Guidelines. http://www.anad.org/get-information/school-guidelines/
Smith, M., Robinson, L. & Segal, J. (2014). Helping someone with an eating disorder: advice for
parents, family members, and friends. Helpguide.org.
http://www.helpguide.org/mental/eating_disorder_self_help.htm
Stice, E. & Whitenton, K. (2002). Risk factors for body dissatisfaction in adolescent girls: A
longitudinal investigation. Developmental Psychology, 38, 669–678.

University of Maryland Medical Center (2013). Eating Disorders.

http://umm.edu/health/medical/reports/articles/eating-disorders