Sara Weber, LPC How to understand and respond to college students with food issues or poor body image.

1. Understanding and responding to college
students with food and body image
issues
Sara Weber, LPC
Counseling & Mental Health Center, UT Austin

2. Overview
 Binge, Purge, Starve…What’s the difference?
 Why does this happen?
 Beyond the behaviors
 College students and eating disorders
 Treatments for Eating Disorders
 The Phases of Recovery
 How to help a friend or loved one.
 Take Home Messages

4. What’s the Difference?
Eating Disorders (anorexia, bulimia and binge eating) have
many things in common even though they manifest
differently. All eating disorders:
 Seem like they are only about food and weight but it isn’t
that simple.
 Are a way of coping: using food, exercise, and weight
obsession as a way to organize life & manage emotions.
 Create a sense of security, control, predictability, etc.
 Involve an intense emotional connection with food and
weight.
 Can happen to men, women, old, and young.

5. Anorexia
Anorexia is characterized by the belief that “If I can get thin
enough, my life will be better”.
 Start off as a desire to “get thinner”, “lose some weight”
 Stability and success in life is dependent on being thin.
 Even when others believe s/he is thin enough, s/he doesn’t
“feel” thin. Perception is warped by malnutrition.
 Restricting foods, fasting, over-exercising, purging to lose
weight.
 Malnutrition can promote restriction via delusions.
 Physical complications complicate re-feeding.

6. Anorexia: Warning Signs
 Preoccupation with weight  Rapid, significant weight loss
 Relentless drive to be thin  Obsessively reading cookbooks
 Withdrawal from friends or  Cooking for other people
group activities  Intense sensitivity to criticism
 Irritability or mood swings  Intense fear of failure
 Fear of specific foods  Food rituals
 Compulsive calorie or fat gram  Rigid and compulsive
counting scheduling
 Lying about not eating  Growth of fine hair (lanugo) on
 Preoccupation with how food is arms, face, or back
prepared  Hair loss
 Perfectionist standards; high  Injuries (fractures, pulled
achievement muscles)

7. Anorexia: Medical Complications
 Weakening of the heart due to  Osteoporosis (bone loss)
malnutrition (possible heart  Lowered immune system
failure) function/ low resistance to
 Low blood pressure infection
 Low body temperature  Low blood sugar
 Low heart rate  Kidney impairment or failure
 Irregularities or loss of  Bone, ligament, and tendon
menstruation injuries due to malnutrition
 Fertility problems  Memory loss
 Dehydration  Gastrointestinal disturbance
 Electrolyte imbalance  Metabolic changes
 Anemia (low iron)

8. Bulimia
Bulimia is characterized by competing beliefs that food will solve every
problem (binge) and that it is “poisonous” and must be
avoided/eliminated (purge).
 Like Anorexia, most people start off with the desire to lose “a little” weight.
 Compensatory methods used to “purge” include: vomiting, laxatives, over-
exercise, or restricting after a binge. Purging methods are usually less effective
than the individual realizes.
 What constitutes a binge depends on the perspective of the person engaged in
the binge and the difference can be vast.
 Food is used to “numb out” but the anesthetizing effects are fleeting so the
urgent need to “get rid of” the food emerges. Purging can also feel numbing.
 Typically average to high weight with sometimes dramatic weight changes .
Underweight individuals have higher health risks.

9. Bulimia: Warning Signs
 Preoccupation with weight  Intense sensitivity to criticism
 Binge eating  Withdrawal from friends or
 Going to the bathroom right group activities
after eating  Irritability or mood swings
 Hoarding or stealing food  Swollen facial glands (chipmunk
 Overuse of laxatives, water pills, cheeks)
diet pills.  Marks on knuckles
 Secretive eating  Depression (suicidal thoughts)
 Eating when not hungry  Feeling “out of control” with
 Water retention, swollen limbs eating or life
 Self-hatred or disgust  Weight fluctuations
 Withdrawal or isolation  Perfectionist standards; high
achievement

10. Bulimia: Medical Complications
 Abnormal heart rate (possible  Lowered immune system
cardiac arrest) function/ low resistance to
 Irregularities or loss of infection
menstruation  Kidney impairment or failure
 Fertility problems  Gastrointestinal dysfunction
 Dehydration (ulceration, pain, bleeding,
 Electrolyte imbalance bloating, constipation, non-
responsive bowels)
 Anemia (low iron)
 Metabolic changes
 Esophageal bleeding or rupture
 Tooth decay
 Increased risk of throat and
mouth cancer

11. Eating Disorder NOS
Eating Disorder Not Otherwise Specified includes all other
variations of disordered eating:
 Sudden weight loss and restriction but not underweight or
hasn’t lost her menstrual cycle.
 Binge eating / purging infrequently.
 Binge eating but no purging, “binge eating disorder”.
 Chewing food and spitting it out.
 Chronic, excessive dieting, reducing quality of life.
 Orthorexia: A fixation with healthy or righteous eating.
While an anorexic wants to be thin, an orthorexic does not
desire thinness but wants to feel pure, healthy and natural.

13. Why does this happen?
Contributing factors are varied:
 Physical changes in puberty
 Brain Chemistry
 Family
 Changing family roles
 Personality Characteristics
 Overwhelming events
 Cultural Factors
Dieting is a risk factor. Almost all EDs start with dieting.

14. Biology
Puberty Brain Chemistry
 Both men and women  Anxiety & depression are
experience dramatic changes in dictated by brain chemicals
their body during puberty. called neurotransmitters.
 Women need to increase body  Serotonin- Regulates hunger
fat in order to initiate and fullness. Disturbances are
menstruation. associated with binge/purge.
 Women often don’t realize the  Norepinephrine- Regulates
necessary changes of puberty mood, alertness, & response to
and resort to drastic behaviors to stress. Disturbance connected to
go back to pre-pubescent shape. Anorexia.
 Genetics are a factor.

15. Family
Family Relationships Changing Family Roles
Families of people with eating Normal development of
disorders have some independence and identity is a
commonalities: product of family’s teaching.
 Difficulty expressing Too much, too soon:
emotions. Expecting child to be
 Lack healthy bonds: Too close independent and responsibly
(enmeshed), Too distant too quickly.
(neglect) or an erratic Overprotecting: Not trusting
combination of both. the child to make good choices
Remember families are typically on their own.
doing the best that they can!

16. Personality and Life Events
Personality Characteristics Overwhelming Events
There are varied personalities in Precipitated by an event that feels
those with ED but there are some overwhelming or traumatic.
commonalities:  Leaving home for the 1st time
 Perfectionist  Death in the family/ friend
 Highly-driven  Bullying or teasing
 Ambitious  Verbal or physical abuse
 Anxious or “high strung”  Sexual trauma
 Sensitive  Moving homes
 Intuitive  Divorce
 “People pleasing”  Marriage
 Self-doubting & insecure

17. We wonder why women and men hate themselves?

18. Cultural Factors
Although it hasn’t always been this way, a person’s value
is often associated with thinness, fitness. Many of us
base our self-worth on the extent to which we can
conform to society’s idea of the “perfect” body.

19. Cultural Factors
Women: Unrealistic standards of thinness, beauty, &
shape
 Female thin-ideal: thin, toned, busty
 Thin = happy, successful, loved, accepted, desired.
Men: Unrealistic standards of strength, power, and
success
 Male “buff”-ideal: cut, lean, muscular

20. Cultural Factors
Could we be part of the problem?
 Thin Ideal worship
 Dieting
 Fat Talk

21. Do I Fat Talk?

22. The Language of Fat
1. How many times this week have you had negative
thoughts about your body or someone else’s body?
2. How many times this week have you thought about a
better life five pounds from now or when you are prettier,
sexier, more fit?
3. How many conversations have you had with other people
this week about food, weight, exercise, or dieting?
4. How many times this week have you compared yourself to
other people or to images in the media?
5. How many hours each day do you spend wishing you
looked different?

23. You can be part of the solution

24. The Eating Disorder is a life Saver!

25. Beyond the Behaviors
The eating disorder is an adaptive behavior:
self-preservation.
 Life is extremely intense for someone who develops an
ED. S/he wasn’t sure how to handle life before the ED.
 The eating disorder is a source of support.
 “Best friend” : shielding him/her from the
overwhelming parts of life that s/he can’t face alone.
 Helping “numb out” when things get to be “too much”.

26. Beyond the Behaviors
Emotions
 Feel emotions very intensely
 Lack confidence in ability to tolerate emotions
 ED behaviors “numb out” and the emotions are
avoided for the time being. “Stuffing” with food.
“Purging my feelings out”. “Starving denies I have
feelings”.
 “I feel fat” is a cover up for emotions that are hard to
face.
 Lost the ability to identify, face, and manage emotions.

27. Beyond the Behaviors
Self-Concept
Loss of identity: interests, personality, etc. Focus on food and
appearance as the solution to problems, prevents normal
development of self-concept and eats away at existing identity.
Life is the ED.
Negative self-concept: never good enough, smart enough, pretty
enough. Arguably a way to appease their drive (perfection) but it
actually sabotages success in life.
Perfection: “Be perfect, or be nothing”.
Innate inadequacy: Fraud myth- “one day, pe0ple will discover the
truth and abandon me”.
Body Image: Bases self-worth on body size.

28. Beyond the Behaviors
Relationships
 Relating to others can be confusing, frightening, and distressing.
 Values relationships greatly.
 People pleasing and very good at reading others’ needs and
responding to them.
 Doesn’t accept help/love very easily b/c of fear of being
vulnerable.
 Vulnerability is debilitating so they often end relationships
before they get too close.
 Doubts of their worth and fear of abandonment prevent them
from feeling safe or secure in relationships.

30. College Survey ~ 1,000 students
● 20% of respondents believe that at some point they have suffered
from an eating disorder . National research says it is only .05-4%.
● More than half of those polled said they know at least one
person who has struggled with an eating disorder.
● Almost 80% of students have dieted & avoided or skipped meals.
● 45% of the students know someone who compulsively exercises,
almost 40% know someone who purges by vomiting, and 25%
know someone who abuses laxatives.
● Among those who confirmed they have had an eating disorder or
still suffer from it, nearly 75% of that group never received
treatment.
National Eating Disorders Association, 2007

31. College- Unique Challenges
 Significant transition- academically, socially, time-
management, responsibility (bills, car, health), self-care (eating,
sleeping).
 Communal eating. Eating schedule may depend on peers.
Roommates influence eating and body image.
 Consistent interpersonal challenges- constant social interaction.
 Getting “lost in the crowd”: Once the big fish in a little pond
but now a little fish in a big pond. Losing identity from high
school (sports, cheerleader, popular, best at…etc.)
 Coping with and managing long-distance family & friend
relationships.

32. College- Unique Challenges
The college environment is especially toxic for body image:
 Body change between age 18-22 years is normal yet
unexpected for most college students.
 Fear of the freshman 15
 Shopping together, sharing clothes, high pressure fashion
bubble.
 Events focused on body image: Rush, “socials”, football,
parties, “going out”.
 Prime-time for dating creates an incubator for dialogue &
concern about body and appearance.
 Going back to home town during break encourages
comparison of body changes with peers from high school.

34. Treatment
Eating Disorder specialists are necessary.
Choose a team from the beginning:
 Psychotherapist – license not as important as training.
 Dietitian – Using nutrition info for good and not evil
 Physician – Medical monitoring is key!
 Psychiatrist – Optional (as needed)
 Group – Reducing shame, not feeling alone.
 Family therapy- If needed, crucial for some people.

35. The Mindful Eating Program
 Outpatient “light”
 Assessment focused
 “Academic Success” is our main goal
 Strength-based
 Not a treatment program.
 Recovery support.
 Services:
 Bi-weekly therapy
 group counseling, and
 medical monitoring.

36. ME: Assessment & Referral
Students are asked to complete a thorough assessment.
 Psychological
 Medical
 Dietetic
 Sometimes psychiatric and/or off-campus specialists
(cardiologist) are required for the full assessment.
After this assessment we provide feedback about the next steps
and offer guidance in developing a treatment plan.
If a student is outside of our scope of care, they are given
treatment recommendations by the team.
 Off-campus, outpatient treatment team (weekly, ongoing)
 Intensive Outpatient Therapy
 Inpatient treatment

37. The Phases of Recovery
Stabilization: Medical, behavioral, nutritional, &
psychological (anxiety/depression, insight, communication,
changing thinking, working with emotions).
Exploring: gaining a deeper understanding of how the
ED functions in their life. Developing healthier coping
strategies. Addressing body image.
Recovering life: 1) maintain progress, 2) resume life
activities & develop new ones, 3) become fully engaged
in life without relapse.

38. When a friend or a loved one is facing eating issues.

39. As a professional, you can help…
 Know about eating disorders
 Warning signs
 Health risks
 Costs (personal, financial, emotional) of the struggle
 Bring it up (if it is your role)
 “Do you have any concerns about your relationship with food or
exercise?”
 Do not focus on weight
 Focusing on weight, size, or good/bad eating is not helpful. Instead the
focus should be on health behaviors- movement, nutrition, self-care.
 Listen and don’t judge
 Remind yourself that they are struggling with an eating disorder
because they are trying to manage something that must be very
challenging for them right now. Have compassion for their struggle.
 Acknowledge your emotions & take care of yourself

40. As a friend, you can help…
 Learn about eating disorders
 Talk to him/her
 Be and stay aware
 Break through secrecy
 Listen
 Help him/her get support
 Acknowledge your emotions
 Take care of yourself
 Focus on life beyond the illness
 Encourage authenticity

41. You can help!

42. Don’t Diet…
• Avoid categorizing foods as “good/safe” vs. “bad/dangerous.”
Remember, we all need to eat a balanced variety of foods.
• You will not be happier just because you are thin, busty, or
fit. Look around and consider examples of thin people who are
miserable and large people who are happy.
• Dieting harms your body- yes even so-called “healthy”
diets. Your body needs variety and nutrition- don’t sacrifice your
health to be thin.
• Larger people can be healthy too. Eating nutritious foods and
staying active is the prescription for health- regardless of your
size.
• Encourage a culture that values a healthy relationship with
food. Slow down, enjoy food, & listen to your body.

43. Fat Talk – Stop it!
Begin listening more closely to the language other women
and men are using to speak to each other and the language
you are using with yourself.
Decide to avoid judging others and yourself on the basis
of body weight or shape. Turn off the voices in your head
that tell you that a person’s body weight says anything
about their character, personality, or value as a person.
Pay attention to the media messages that reinforce Fat Talk.
Begin to explore the emotions that are going on “behind” Fat
Talk…are you feeling scared, ashamed, vulnerable?
Request honesty and intimacy with others- change the
subject when the Fat Talk takes over your conversations.

45. What you need to know!
 Anyone can recover from an eating disorder.
 Recovery is a tough road but a journey worth taking!
 College is a prime time to develop an eating disorder
(or for an old struggle to come back).
 Professionals can offer compassion for patients so that
the patients can have compassion for themselves.
 Talk about eating disorders, weight, and food in ways
that challenge the status quo & change the paradigm.
 Reach out to people you see struggling- you might
plant a seed, you might save a life.

47. Why She Feels Fat by McShane & Paulson
www.gurze.com
www.austineds.com
www.edin-ga.org
www.nationaleatingdisorders.org
www.endfattalk.com
www.somethingfishy.org
www.eatingrecoverycenter.com
www.cmhc.utexas.edu/mindfuleating.html

48. As a friend, you can help…
 Learn about eating disorders
 Talk to him/her
 Be and stay aware
 Break through secrecy
 Listen
 Help him/her get support
 Acknowledge your emotions
 Take care of yourself
 Focus on life beyond the illness
 Encourage authenticity

49. You can help…
 Learn about eating disorders
 Websites, books, talking to a therapist and someone
who has been through it before.
 Talk to him/her
 Remember that they feel the ED is vital to their survival
and will feel threatened if you criticize it.
 Use I statements, “I feel… when you…” or “I am worried
about ….(specific behavior)”.
 Remind him/her that you are there to listen and check
in occasionally so that s/he doesn’t feel like you are
ignoring the issue now that you brought it up.

50. You can help…
 Be and stay aware
 Keep your eyes open for subtle improvements
 Stay tuned into possible relapse behaviors and bring them up
the same way you did when you initially confronted him/her.
 Break through secrecy
 There is a strong drive to hide the ED, even after admission
that s/he wants to recover. Talk about this struggle to keep
the ED a secret and offer compassion for this desire while also
challenging him/her to be as transparent as possible.
 Listen
 Listening is one of the most important things you can do.
This is hard if you don’t know how to help or don’t
understand what they are going through but listening openly
is still a valuable support to offer.

51. You can help…
 Help him/her get support
 Offer your support in any way possible. Ask often if there is
anything you can do for him/her.
 Help him/her find things to enjoy again- hobbies, activities,
interests. Encourage putting time and energy into things s/he
might enjoy and offer to go too.
 Acknowledge your emotions & Take care of yourself
 It can be maddening to be in a support position of someone
with an ED. Take care of yourself and get support when
needed.
 It is ok if you can’t be the primary support person all the time.
 You can model emotional awareness and self-care.
 Rely on your own support system.

52. You can help…
 Focus on life beyond the illness
 Plan activities and enjoy time together that isn’t related to the
ED at all. These may need to be non-food events.
 Don’t put life on hold for the ED (although be mindful of
limitations of recovery length, e.g. don’t start a new degree).
 Focus on aspects of your friend or loved one that were there
before the ED took over (personality or interests)
 Encourage authenticity
 There is a tendency to deny that they are really struggling so
look ways s/he may be trying to look “fine” and intervene to
offer help and challenge them to acknowledge their struggles.

53. http://www.youtube.com/watch?v=QSqtVDIwnHo