Eating disorders and disordered eating behaviours are on the rise in school. Eating disorders affect approximately 9% of the population worldwide, and although it is most commonly diagnosed in young women ages 18-24 (NIMH, 2017), the signs start early, so it helps to know what to look for!
No, It’s not up to the teacher to provide treatment to a student who appears to struggle with an eating disorder, but it is the teacher’s job to know their students well enough that they can spot the signs and refer for support. We often see our students more than anyone else in a week, and we can be the gateway for students receiving treatment. The purpose of this article is to provide you with the tools you need to see and understand an eating disorder so you can help students find the proper support to get help and heal.
Disclaimer: If you, or someone you know, is struggling with an eating disorder, or you suspect an eating disorder, please seek support from a qualified therapist. Eating disorders are the deadliest mental health crisis, second only to opioid addiction (ANAD, 2021), and approximately 26% of people with an eating disorder attempt suicide. The information in this article is not a substitute for proper medical treatment.
Diagnostic Criteria:
People often think of eating disorders as only Anorexia or Bulimia, but there’s definitely more to it! Although you are not diagnosing eating disorders, knowing the different types of eating disorders and the diagnostic criteria for each can help spot potential disordered eating behaviours in your students. So here is a cliff-notes version!
Anorexia Nervosa (American Psychiatric Association, 2013):
Restricting food intake
Fear of gaining weight, perseverating on possible weight gain, attempt to control weight through energy intake
Feelings of self-worth and esteem are deeply connected to view of their own body image, size, shape, etc.
Bulimia Nervosa (American Psychiatric Association, 2013):
Recurrent episodes of eating a large amount of food (significantly more than someone else of similar size or circumstance) in a restricted time period (within 2 hours)
Feeling a loss of control over food intake
After binging, there’s a use of compensatory behaviours, such as vomiting, laxatives, diuretics, excessive exercise, or prolonged fasting
Feelings of self-worth and esteem are deeply connected to view of their own body, image, size, shape, etc.
NOT always characterized by significant weight loss or seen as significantly underweight (unlike anorexia)
Binge Eating Disorder (American Psychiatric Association, 2013):
Recurrent episodes of eating a large amount of food (significantly more than someone else of similar size) in a restricted time period (within 2 hours)
Feeling a loss of control over food intake
Marked by feelings of distress during and after binge
NOT associated with compensatory behaviours
Avoidant/Restrictive Food intake disorder (American Psychiatric Association, 2013):
A feeding or eating disturbance (e.g. lack of apparent interest in eating food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating)
Persistent failure to meet appropriate nutritional and/or energy needs
Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
Significant nutritional deficiency.
Dependence on enteral feeding or oral nutritional supplements.
Marked interference with psychosocial functioning
Eating Disorder Demographics
Understanding eating disorders means understanding who is most affected, and particularly as a white, cis-woman, it means drawing attention to my possible blind spots. It’s crucial to have an understanding of which demographics of students may be suffering silently because of the inequity in care.
BIPOC and Eating Disorders (ANAD, 2021)
BIPOC are significantly less likely than white people to have been asked by a doctor about eating disorder symptoms.
BIPOC with eating disorders are half as likely to be diagnosed or to receive treatment.
Black and hispanic teenagers are significantly (upwards of 50%) more likely than white teenagers to exhibit bulimic behavior, such as binge-eating and purging.3
Asian American college students report higher rates of restriction compared with their white peers and higher rates of purging, muscle building, and cognitive restraint than their white or non-Asian, BIPOC peers.
LGBTQ2I+ and Eating Disorders (ANAD, 2021)
Gay and bisexual boys are significantly more likely to fast, vomit, or take laxatives or diet pills to control their weight.
Transgender college students report experiencing disordered eating at approximately four times the rate of their cisgender classmates.7
32% of transgender people report using their eating disorder to modify their body without hormones.
56% of transgender people with eating disorders believe their disorder is not related to their physical body.
Non-binary people may restrict their eating to appear thin, consistent with the common stereotype of androgynous people in popular culture.
Signs of an Eating Disorder:
Again, I’m not telling you, as the teacher, that you should be diagnosing an eating disorder, but you can keep track of the signs! Here’s a list of possible things you may notice or encounter with students who are struggling.
An unrealistic and negative view of their body that they may bring up in casual conversation.
Ex. Spending a great deal of time posing in front of the mirror or phone, criticizing photos taken of themselves
Restrictive food intake, such as turning down school snacks, skipping breakfast/lunch, turning down class birthday cakes or treats that were brought in
Saving treats rather than eating in front of others
Avoiding eating at all in front of others
“Rules” around food intake, such as won’t eat anything pre-packaged, suddenly becomes vegan, avoiding certain ingredients, imposing certain standards around food intake (organic, non GMO, etc.), not taking food from others, rules around how to eat certain foods (won't eat anything with their hands, that needs a a spoon, etc.)
Extreme dieting and fad dieting, such as intermittent fasting (as a weight loss tool), keto, calorie counting, liquid diet, etc.
Immediately excusing themselves after eating to use the bathroom
Excessive time spent on Instagram and making body comparisons
Guilt around food intake, such as “I can’t believe I just ate that…”
Using exercise to “burn” the food consumed
Following “pro-ana” sites (these are extremely dangerous pro-anorexia sites and IG feeds that promote and support disordered eating).
Celebrating weight loss and always having “only 5lbs to go”
Often comorbid with other mental health diagnoses, such as anxiety, depression, personality disorders, etc. (NIMH, 2017).
Treatment:
So, once you’ve referred a student to the school counselor, who likely refers them to community resources, what would treatment look like? It can feel like you’re doing everything to help, but then you don’t actually get to know what that looks like! Which can make referring scary, and can leave students fearful too, if you can’t explain what next steps might look like before the referral to the counselor! Knowing what to expect means you can tell students what to expect and help them be on board with you referring onwards. (Refer anyway, but the best way to maintain the relationship is to have their blessing!)
There are a few ways that therapists address eating disorders, though most eating disorder teams will involve a clinical therapist, a psychiatrist, and a dietician/nutritionist. This is sometimes inpatient hospital treatment, depending on severity, though it can also be outpatient care, in which the student will have multiple appointments a week (please be accommodating to these appointments!).
The clinical therapist usually acts as case-manager, and facilitates treatment, where the psychiatrist supports prescriptions and med review on a bi-monthly (sometimes more, sometimes less) basis. The nutritionist will often provide menu plans and help the youth and their family track intake to ensure the individual’s dietary and nutrient needs are being met.
The therapist may use a few modalities for therapeutic intervention, but the most common and evidence based are CBT (Cognitive Behavioural Therapy) or DBT (Dialectical Behaviour Therapy). (For more info on CBT, review my article here)
DBT has proven effective to treat a myriad of mental health diagnoses, such as eating disorders, bipolar disorder and borderline personality disorder, addictions, and mood disorders.
Although it shares some treatment methods with CBT, it’s more focused on, specifically, balancing and regulating mood and emotions.
DBT practice includes mindfulness, distress tolerance, relationship building and boundary setting, and emotional regulation (Schimelpfening, 2021).
DBT encourages folks to acknowledge their anxiety or dysregulation, and practice ways to find themselves in the present moment. It can support folks with eating disorders to eat mindfully, focus on nourishing their bodies, and pay attention to the things that trigger the emotional dysregulation (such as Instagram or food brought in by others). It then encourages small steps toward healing and stepping out of their comfort zone to engage in healthier responses and behaviours around food.
Conclusion:
Eating Disorders are complicated, scary, and above all, isolating. We never want to be the person to comment on a student’s body, and I absolutely discourage you from doing that! However, early intervention in disordered eating behaviors can be critical in creating a community of safety around the student and helping them feel supported and loved through the process.
I suggest taking a stance of observation, and pointing out any concerning behaviours you notice. Come from a place of trying to understand, question their food rules or other behaviours you notice, and gauge level of concern and then talk to the student first and let them know you are going to seek other support for them. You can be their person without being their person and make sure they understand the importance of getting proper care early on.
I hope the above information has helped you feel more aware of eating disorders and the ways to support your students who may be struggling!
* Want more on this conversation? Check out the follow-up podcast episode that reviews both elements of the article and provides some more in-depth info!
Works Cited:
ANAD (2021), Eating Disorder Statistics. https://anad.org/get-informed/about-eating-disorders/eating-disorders-statistics/
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
NIMH (National Institute of Mental Health) (2017). Eating Disorders. https://www.nimh.nih.gov/health/statistics/eating-disorders
Schimelpfening (2021), What is Dialectical Behavioural Therapy (DBT)? https://www.verywellmind.com/dialectical-behavior-therapy-1067402