Last month the American Academy of Pediatrics released its first comprehensive guidelines in 15 years for addressing childhood obesity. Increasing concerns about the short and long-term consequences of being significantly overweight, especially the risk of diabetes and cardiovascular disease, prompted the organization to recommend a much more aggressive treatment approach. The problem is so serious that for the first time ever the organization recommended offering weight loss medications and bariatric surgery along with dietary and lifestyle interventions to children as young as 12.

We don’t often think of unhealthy and/or excessive eating as an eating disorder, and for most people eating issues never rise to the level of a diagnosable disorder. At the same time, a broader perspective about the ways in which children develop unhealthy relationships with food seems warranted. Eating disorders have the highest mortality rate of any mental health diagnosis, and mounting data suggest that overweight children are significantly at risk for developing a variety of chronic and life-threatening diseases.

Eating Disorders Awareness Week

The National Eating Disorders Association (NEDA) and other US-based advocacy and treatment organizations have designated February 27 to March 5 as 2023’s national Eating Disorders Awareness Week. During this annual public awareness campaign, eating disorder professionals and advocates conduct, and support others who want to conduct, educational outreach programs aimed at both preventing eating disorders and helping those already suffering with the physical and emotional consequences of this cluster of diagnoses.

Eating Disorders Awareness Week is the ideal time for school districts to use their considerable reach to educate staff, students, and parents about offering students help with eating disorders and to help students cultivate healthier relationships with food. It is also a good time to examine and challenge societal stereotypes of “the perfect body” and to foster acceptance of different body shapes and sizes.

Based on diagnostic interview data collected between 2001 and 2004, the National Institutes of Mental Health (NIMH) have reported that the lifetime prevalence of eating disorders among U.S. adolescents aged 13 to 18 years is 2.7%. Not surprisingly, given that one of the most significant environmental factors contributing to eating disorders is society’s subtle and not-so-subtle messages about physical appearance, these conditions are more than twice as prevalent among females (3.8%) than males (1.5%). That said, boys are likely under-diagnosed because many incorrectly assume that boys do not get eating disorders and do not succumb to body image concerns.

As reported by NEDA, “Body image concerns often begin at a young age and endure throughout life. By age 6, girls especially start to express concerns about their own weight or shape, and 40-60% of elementary school girls (ages 6-12) are concerned about their weight or about becoming too fat. (Smolak, 2011). Furthermore, over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.” (Neumark- Sztainer, 2005).

Understanding the Common Types of Eating Disorders

Eating disorders symptoms can hide in plain sight: when we see people who look painfully thin, we might wonder if they have cancer or some other medical condition, and perhaps overlook the possibility that disordered eating might be to blame. Even harder to detect are the eating disorder struggles of those who appear to be of average weight, or even of those who are overweight since our society often judges overweight people as weak, lazy, or lacking in self-control rather than as suffering from a medical or mental health condition.

There are many types of disordered eating patterns and unhealthy relationships with food, but the most common eating disorders that are formally recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include:

• Anorexia Nervosa is characterized by the extreme restriction of food intake, lower than expected body weight, highly distorted body image, and the fear of gaining weight. Anorexia nervosa can also be found in individuals who fall within expected weight ranges, and while it is perhaps the best known, it is actually the least common eating disorder.
• Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by behaviors meant to compensate for the calories consumed, including purging (vomiting), fasting, excessive exercise, and laxative use to avoid gaining weight.
• Binge Eating Disorder is characterized by repeated episodes of consuming a large amount of food in a short amount of time. It is typically accompanied by feelings of loss of control and intense shame and is most often found among people of larger body sizes.
• Other Specified Feeding and Eating Disorder is a catch-all category that is used when an individual shows disordered eating behaviors that do not meet the specific criteria for one of the above disorders. People with these “sub-clinical” eating disorders will often go on to develop full blown eating disorders.
• Avoidant/Restrictive Food Intake Disorder involves restricted food intake that causes individuals to fall short of their nutritional and/or energy needs, but it typically is not accompanied by body image problems.

Although not characterized as an eating disorder per se, Body Dysmorphic Disorder can be a significant risk factor for the development of one of the above disorders. Body Dysmorphic Disorder is characterized by a preoccupation with one or more perceived defects or flaws in one’s physical appearance, “flaws” that are imperceptible or seem slight to others. It is accompanied by feelings of embarrassment and shame, anxiety in and possible avoidance of social situations, and repetitive behaviors like mirror checking and reassurance seeking because of appearance concerns. Some individuals go so far as to seek numerous cosmetic procedures to try to “fix” the perceived flaw, although often these procedures offer only temporary relief.

Body image disturbances range in severity and frequently co-occur with self-esteem issues, depression, eating disorders, or post-traumatic stress. Warning signs of a body image disturbance include:

• The inability to accept a compliment.
• Constant comparisons of self to others.
• An ever-present fear of gaining weight, regardless of body size.
• An overriding sense of shame about oneself and one’s body.
• Frequent disparaging references to the self: I am “gross,” “disgusting” or “ugly.”
• Frequent requests for reassurance that his/her looks are acceptable.
• Distortions related to one’s body or body parts.
• Extreme and consistent perfectionism.
• The persistent tendency to equate thinness with beauty, success, perfection, happiness, confidence, and self-control.

What Causes Eating Disorders?

The exact causes of eating disorders are unknown, but the results of various research studies suggest that a person’s risk is related to a combination of genetic, biological, psychological, and social factors.

The NEDA website offers a comprehensive list of risk factors in each of the above categories:

• Biological/genetic factors include a history of dieting; having a family member with an eating disorder; and a diagnosis of Type I diabetes.
• Psychological factors include perfectionism; inflexible thinking; a co-occurring anxiety disorder; and body image dissatisfaction.
• Social factors include a history of bullying or teasing about weight or appearance; the pervasiveness of “weight stigma” in our society that reinforces the belief that “thinner is better” and that there is a “perfect body”; the stress of acculturation; and the presence of intergenerational trauma.

How Can School Professionals Help?

Educators spend a lot of time with young people and often are the first ones to detect that something is wrong. Early intervention is critical, so school professionals should consider involving school-based mental health or medical staff and/or notifying parents if they notice that a student:

• Is showing significant weight loss or gain.
• Always wears clothing that hides the shape of the body.
• Never brings lunch to school, throws away most of his/her lunch, refuses to eat in front of others, or shows extreme pickiness about food (although the latter can also be a sign of neuro-diversity, e.g., autism or sensory issues).
• Consistently spends a lot of time in the bathroom, especially after lunch.
• Is increasingly tired and distracted, perhaps the sign of a malnourished brain.
• Frequently expresses dissatisfaction with his/her body or how he/she looks.
• Shows persistent and extreme perfectionism.
• Frequently expresses feelings of being out of control.

Apart from guiding individual students and their families toward assessment and eating disorders treatment, the biggest contribution that school professionals can make is in the area of prevention. This involves actively pushing against the many forces that can affect the development of body image disturbances and unhealthy relationships with food. Districts can consider several educational and school culture interventions to accomplish these goals:

• With all students, regardless of whether an eating disorder is known or suspected, it is advisable to avoid talking about eating habits, weight, or physical appearance. Exceptions to this, of course, would be health, science, and physical education classes that teach nutritional concepts and an appreciation for the miracle that is the human body. In nutrition classes avoid labeling foods as “good” or bad”.
• In anti-bullying discussions and interventions specifically label body-shaming comments and behavior that contributes to weight stigma as unacceptable.
• Engage students and families in conversations about the hazards of buying into “diet culture” and our society’s relentless messages about striving to achieve the “perfect” body size and shape. Help students identify and actively resist cultural messages that promote weight stigma and the idealization of thinness.
• Help students and families reduce negative risk factors that contribute to disordered eating (e.g., body dissatisfaction, depression, self-esteem based on appearance) by advocating and referring for mental health services.
• Help students and families increase protective factors, e.g., by fostering non-appearance-based ways of defining oneself. Encourage students to recognize and value characteristics such as hard work, honesty, kindness, creativity, etc. in themselves and others.
• Use SEL and other classes to teach and practice various self-regulation and self-soothing strategies as many emotional factors (e.g., anxiety, anger, frustration, boredom) can trigger eating in the absence of actual physical hunger.
• Re-evaluate food offerings in the school cafeteria and in vending machines.
• Develop a list of community resources that offer healthy food for families struggling economically and/or who live in “food deserts” where affordable fruits, vegetables, and other healthy foods are largely unavailable.
• Find ways to creatively introduce movement into the school day.
• Keep in mind that certain groups of students might be particularly vulnerable to eating disorders, such as student athletes in weight focused sports (e.g., wrestling and gymnastics) and those engaged in the performing arts (e.g., ballet and theater). Coaches and other extracurricular instructors should de-emphasize weight, body shape, and appearance goals and strive for inclusion in both athletic and other enrichment activities.

For help with eating disorders contact the NEDA Helpline at Eating Disorders Helpline | Chat, Call, or Text | NEDA (nationaleatingdisorders.org) or call 1-800-931-2237. NEDA also offers an Educator Toolkit that contains a variety of suggestions for school professionals to consider.

Resources:

• Eating Disorders: Definition, Symptoms, Traits, Causes, Treatment (verywellmind.com)
• What Is Weight Stigma? (verywellmind.com)
• Obesity in kids: American Academy of Pediatrics pushes for more aggressive treatments up to drugs and surgery – cleveland.com
• National Eating Disorders Association
• EducatorToolkit.pdf (nationaleatingdisorders.org)
• Risk Factors | National Eating Disorders Association
• https://renfrewcenter.com/10-steps-to-help-professionals-make-a-difference-in-schools/
• https://renfrewcenter.com/negative-body-image-9-tips-for-improving-body-esteem-updated/