“Forty kilograms,” the ballet instructor announces. Silent agreement among faculty and other students is palpable in the studio, albeit the obvious tension. It’s an easy 4 kilograms below the number where the scale’s needle hovers — a sigh escapes, relief fills my chest. I step off and watch the needle bobble back to zero, a number I will never be.
This was my seventh grade. It was routine for me. After four hours of ballet every day, we weighed in and heard our “ideal” weights announced to the class, a public service announcement to spark incentive. A scale was kept under the piano, right by the accompanist’s feet. We were praised when we were under, condemned for every half-pound we were over. No amount of sweat — enough to wring from our leotards — was ever good enough. It was a balance between satisfaction with the reflection in the mirror and having enough fuel in your body to get through the night. It was nothing short of destructive.
I kept this mentality with me, through boarding school and part of college afterward — the pressure to conform, the ever-present desire to be liked by a choreographer, a teacher, a coach lingered in the back of my mind. In high school, I listened to my friends purging in the bathrooms, taking laxatives like candy and throwing away food without giving it a second thought.
The phases came in and out of my life, as they did for many of my friends in dance. It’s difficult to denounce a lifestyle that has been etched into your brain, diet and outlook on food. It’s consuming — present at every store, social event, relationship. You never realize how pervasive food is — the way it brings people together, maintains friendships and creates new ones.
It wasn’t until college and a pre-med curriculum that I found some peace with my body. Or made efforts to do so. The facts became harder and harder to neglect: anemia, brain defects, infertility, multiorgan failure. It quickly became apparent that the effects were long-lasting and severe. For the first time, it was real.
Over the past few decades, eating disorders have been a topic of conversation on college campuses. Universities across the country have dedicated services specifically for eating disorder treatment. The University of Michigan offers help to students battling eating disorders through programs at University Health Services and Counseling and Psychological Services, along with other smaller organizations and student-run groups like Wolverine Wellness and MBody. Michigan Medicine has a Comprehensive Eating Disorders Program, providing individualized care for patients between 8 and 24 years old.
Dr. Terrill Bravender, David S. Rosen Collegiate Professor of Adolescent Medicine, is a program physician and section chief of the University’s Comprehensive Eating Disorders program. When I interviewed him, Bravender spoke of the college campus as a stimulant of eating disorders.
“If you think about it, if you’re at risk for developing eating disorders, college culture is perfect,” he said. “You’ve got rec centers that are open 24 hours a day, you have high emphasis on appearance, you have an opportunity for 24-hour-a-day eating and all of a sudden as a college freshmen, you are responsible for creating your own structure in your life. All of these distractors can make people’s lives feel like they’re spinning out of control.”
Despite the prevalence and severity of eating disorders, there are few nationwide studies on the disease within college students. Although surveys on individual campuses and wellness centers have been conducted, there has been a lack of nationwide data on the younger 18-to-24 year-old population in general. It wasn’t until recently that two University public health researchers took matters in their own hands.
University professors Kendrin Sonneville and Sarah Lipson, assistant professors in nutritional sciences and health management and policy respectively, conducted a nationwide study on university students with eating disorders. Published in 2017, the 9,713-person study aimed to determine risk profiles for eating disorders in a diverse population. The study measured the risks of students from various backgrounds to develop an eating disorder or disordered eating habits with the long-term goal of taking preventive measures and improving current treatment.
Although eating disorders and disordered eating often result in physical symptoms, the disorder is a mental illness, characterized by an obsessive, unhealthy relationship with food. With the highest mortality rate among mental illness, eating disorders remain an insidious part of American culture. According to DSM-5, the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, there are five categories of eating disorders: anorexia, bulimia, binge-eating disorder, feeling or eating disorders not elsewhere classified (FED-NEC), and other eating disorders including body dysmorphic disorder (intrusive, imagined or inaccurate perceptions of one’s body image) and orthorexia (the fixation on overly righteous eating habits).
Researchers are studying people who do not fit into the strict criteria of the DSM-5, but nonetheless have unhealthy relationships with food. Although these people do not have full-fledged eating disorders such as anorexia or bulimia, they are characterized as having subclinical eating pathology, or “disordered eating,” which can develop into a clinical disorder. Disordered eating affects a much larger population in college communities and is now being targeted for earlier preventative measures.
“If you think about eating disorders like other conditions, it would be like saying, ‘We’re not going to treat you until you have stage 5 cancer.’” Sonneville said. “When you think about it that way, it doesn’t make any sense. There are early symptoms that if not addressed will progress to worse symptoms, and so Sarah and I took a public health approach. We looked at high levels of disordered eating behaviors that are themselves problematic, but may actually progress if unaddressed.”
The study sought to observe other potentially influential characteristics like age, degree-level, gender, sexual orientation, race and ethnicity, and citizenship. After extensive analysis, the two researchers concluded undergraduate student status, non-straight men, and overweight or obese students were at the highest risk for developing an eating disorder.
“There’s been appreciation in my field of public health and descriptive epidemiology about what is the face of eating disorders,” Sonneville said. “There’s this long-standing myth that eating disorders affect skinny, white, affluent girls. … We are seeing it across socioeconomic spectrum and across racial, ethnic groups. What we’re realizing is that the face of eating disorders — the stereotypical notion of what eating disorders look like — is not true.”
Sonneville and Lipson reported a startling 49 percent of female students engaging in binge-eating behaviors and 30 percent in men engaged in these behaviors. Female students were also more likely to engage in compensatory behaviors like food restriction and dieting compared to men — 31 percent to 29 percent.
“We wanted to get a sense of who is actually struggling and suffering on campus, because unless you understand who is suffering, it’s really hard to understand how you target early intervention, how you target prevention efforts,” Sonneville said.
Based on these findings, the two researchers urge universities to take preventative actions by conducting earlier and more regular eating disorder screenings.
“What we found is that eating disorder pathology is really common on college campuses. We saw even smaller sex differences than others find — with compensatory behaviors like self-induced vomiting and compulsive exercising to be almost the same among males and females in our sample,” Sonneville said.
The ever-rising, incessant presence of social media in college culture often perpetuates the existing problem. The risks of exposure to idealized body types through social media is an emerging field of research. Bravender spoke about unrealistic body images being projected through media like Instagram.
“When we saw photoshopped or digitally altered images 10 years ago, it was because a beauty company or fashion company or diet company was trying to sell us a product. Now, if we see a digitally altered image, it might be our friends on social media using filters or other things,” Sonneville said. “It used to be for-profit industries that were trying to propagate this ideal, and now, we’re all trying to do it. That is a totally new phenomena in eating disorder risk factors.”
Former U-M rower Traci Carson is now a Ph.D. candidate in the School of Public Health. Having personally experience with disordered eating, Carson spoke about the role of social media in her college and graduate school life.
“Being somebody that is constantly comparing myself to other people, I have seen how social media can be damaging for my own thoughts about food and thoughts about my body,” Carson said. “In the last few months, I’ve made a conscious effort to make sure that the people I’m seeing on social media are not people who are feeding into my disorder. I will delete or unfollow people as soon as I see anything that triggers me to want to restrict or go exercise more or feel shame about the way that I look.”
Shannon Nulf, a School of Music, Theatre & Dance freshman studying dance, echoed Carson’s sentiments.
“When there’s a medium that’s usually edited, polished and filtered, I definitely think that plays into a mental self-loathing. When you see all of this perfection in social media, that can mess with your head,” Nulf said.
She also spoke about the dangers of certain social media. Some contain blogs or accounts acting as instruction manuals for someone at risk or in the midst of an eating disorder. Nulf spoke about finding information on specific social media sites that encouraged unhealthy habits and eating disorders.
“When I was in the throes of anorexia, I was trying to find other people like me and see what I was doing,” Nulf said. She spoke about using social media sites like Tumblr to see how other people with anorexia were restricting their food intake and cutting weight—She often compared their methods to her own or looked for ideas on how to continue losing weight. “There are Tumblrs on how to have an eating disorder. … It was all there for me, it was a resource that I wish I hadn’t had.”
Perhaps our next steps may involve using this pervasive medium to reach large groups of people and encourage more constructive ways of thinking about food. Bravender spoke about the dangers of teenagers and young adults viewing social media’s idealized body types as direct messages to them.
“If you’re looking at these Instagram feeds of perfection and you believe that that’s speaking to you and telling you how you should be, then it significantly raises your risk for developing an eating disorder,” Bravender said. “If you’re able to push that off to the side and be a savvy media consumer and realize that these perfect images aren’t possible and realize they’re just images and just a brand someone is trying to sell you, then that doesn’t confer risk of an eating disorder.”
However, social media doesn’t seem to be entirely negative. Nulf and Carson raised similar ideas of filtering content by unfollowing or selectively choosing accounts. Kinesiology freshman Maddie Ross has proactively incorporated social media into her path to recovery, posting on an Instagram account the food she makes.
“I started this food Instagram account at the beginning of my recovery because I found other people who were in recovery on Instagram,” Ross said. “There are nutrition blogs that focus on intuitive eating and health at every size. You have to find the positive pockets in social media, because there is so much negative. You have to realize where the negative is and put your blinders on when you see it or get away from it. It’s much easier said than done.”
Despite the abundance of these “communication” channels for photos and videos, many illness narratives and experiences are left untold.
Ross spoke about the onset of her anorexia when she was in middle school and high school.
“I felt like I had no control over my friendships or anything, but eating was the one place I could control. I thought that I was being healthy,” she said.
Nulf’s story followed a similar pattern of downward spiral and loss of control.
“It was all rooted in a big, body dysmorphic view I had of myself. Then, it just spiraled and spiraled,” she said. “My hair started falling out and I just wanted to sleep. I started to fight with my friends and parents. I couldn’t sleep. I lost my period — a lot of medical effects.”
Students, myself included, are often unaware of exactly how ubiquitous the issue is. For how widespread and lethal the consequences are, the lack of dialogue on campus is striking.
“Eating disorders in general are diseases of denial and secrecy,” Sonneville said. “There is shame, there is fear, there are a lot of underlying emotional things for someone who is actively struggling.”
Eating disorders, like other mental illnesses, generally lack dialogue on campus, there is a smaller subpopulation within the community that is often overlooked: athletes.
According to Bravender, there are three types of athletic endeavors that put students at particular susceptibility for developing eating disorders or disordered eating.
The first group are athletes who may experience an initial improvement in performance from weight loss. These often include cross-country or long-distance runners.
“In people who are at risk, there’s a little click that happens, and thinks, ‘Well if I lose five pounds and I improved a little bit, maybe if I lose 10 pounds I’ll improve more,’ and they try that,” Bravender said. “Of course, there’s a point of diminishing return, and as you lose more weight, your running worsens. And in those who are at particular risk, they’ll think, ‘Well, I need to lose more weight,” and it becomes a self-perpetuating spiral downwards of worsening physical condition.”
The second group of athletes are those engaging in aesthetic sports where performance is judged subjectively. Dancers, gymnasts and figure skaters are common for this category of susceptibility.
“There’s no free-throw percentage or soccer goal being scored. You are performing for a judge, and because it’s a performance where all eyes are on you, it increases the self-consciousness of appearance and raises your risk of developing an eating disorder,” Bravender explained.
The third group includes sports that divide its competitors into weight classes like wrestling, judo and rowing. According to Bravender, this is a massive issue, in which athletes feel pressured to reduce to their lowest weight for competitive advantage. It wasn’t until multiple tragic deaths of collegiate wrestlers that the National Collegiate Athletic Association made regulations in 2012 and has since, not observed any deaths from unhealthy weight cutting practices.
However, the tensions around body image and weight remain high among college athletes. The shielded nature of the topic makes it particularly hard to speak about in competitive settings.
“I think it came from the Type A nature that is Michigan, that is Michigan sports, that is a Michigan student-athlete. I definitely did not see it across my whole team, and I can only speak from my own experience that it started much earlier for me than rowing,” Carson said.
Carson’s sports career started with soccer and then cross-country, until she began rowing at the University.
“You can usually pick out a rower because they are significantly taller than other athletes and have strong, beautiful shoulders. I wouldn’t say that it was my sport involvement that lead to my desire to fit my desired body image that was smaller than what I was,” she said. “I think for me, it started much earlier. I had already had that mentality and the disordered frame of thinking.”
Nulf’s story shared similar elements of disorder and conformity. She traced the beginnings of her abnormal relationship with food to her earlier figure-skating career.
“I definitely had skating coaches who made comments and put pressure on kids in our skating clubs to look a certain way and be a certain way,” she said.
At the beginning of high school, she began cross-country and then dance. With the stress of college auditions for dance programs, the anorexia morphed into something else.
“That stress made me snap and I really started binge-eating, but to compensate for that, I began binging and purging. It was a one-time thing, then it was a two-time thing, and then a once-a-week thing, until it progressed and progressed to a multiple-times-daily thing,” Nulf said.
When thinking about the heightened risk for eating disorders and disordered eating among athletes, I question my own habits. Maybe it’s something in the regimented training that permits this sort of body-mind detachment to occur. I remember thinking my decisions around food were promoting my artistic career and therefore saw no negative consequence in straining my body — in fact, I was proud of my achievements in weight loss. However, the balance between performance and body image is a constant, underlying current of tension.
“It’s a huge regret that I have,” Carson said. “In college, what my body looked like became more important than what my performance looked like. … I wanted to be the best athlete I could, but at that time, the disordered thoughts were stronger than my rational thoughts.”
Carson spoke about being clouded by her disordered thoughts that she had convinced herself she was aiding her performance.
“I kept losing weight through my years, and my physical performance went down with my weight,” she said. “It’s hard for to look back at that time because I was putting my body through so much physical and emotional stress, all for what I now know was wanting to look a certain way.”
As a dancer of 19 years, this performance-versus-body sacrifice is something that resonates deeply. Sonneville explained this tug of war as a common pressure among young athletes.
“There is a real trade-off, in order to maintain a particular body type for some people is going to require disordered eating,” she said. “People who have a skill and ability in a sport will face a moment in their career that says, in order to maintain this body type, this is a real sacrifice I have to make — I cannot have both things.”
Sonneville emphasized the difficulty in this decision, especially when athletes are surrounded by people who praise them for their sport, have parents who have invested time and energy, or even a coach that reinforces unhealthy messages of eating.
She urges coaches to cultivate a team culture that is a safe space. “A place where people disclose, a place where people are allowed to suffer and struggle,” she said. “I think you have to model vulnerability if you are in a position of authority. Be particularly mindful of who your athletes are, who your students are and what they’re at risk of.”
As a former U-M athlete, Carson reiterates the necessity for fostering the right environment for students.
“Seeing help-seeking as a strength and not a weakness — I think that’s something sports struggle with is viewing mental health as a weakness and it’s not,” Carson said. “At the end of the day, your mental health is more important than your physical performance. But when you’re in the culture of athletics, it doesn’t feel that way. Even when I was in that place, it didn’t feel that way: the team, the team, the team.”
However, there is extensive work being done to better treat and prevent eating-related disorders among athletes. The NCAA has implemented various eating disorder research and prevention programs like The Female Athlete Body Project — an interactive series of verbal, written and behavioral exercises to promote a healthier lifestyle and mindset. Carson stresses the importance of mental health and pushes for annual screenings earlier on in athletes’ careers.
“I really think the athletic department could better serve its athletes by allocating some more funding to this area,” Carson said. “I think that mental health, which includes eating disorders, should be a bigger priority. Because without mental health, you can’t be a great student, a great athlete, a great friend, a great teammate.”
The urgency for better prevention and intervention is apparent. Eating disorders are a physical and mental problem in need of attention and appropriate care. It isn’t a diet pill or exercise plan you can unsubscribe to. It’s much more complex.
Sometimes I wonder what my body would be like without the scale under the piano and the traumatizing embarrassment of a target weight too far below the actual. I wonder if I wouldn’t have stopped growing and could’ve been taller like my brother. Sometimes I wonder if sacrificing my health for my craft was worth it — and I still don’t have a clear answer.
So where do we being? How do we tackle this illness, this stigma, this fine balance between sacrifice and well-being?
“I’m hoping we are going towards a more holistic approach to prevention,” Sonneville said. “Right now, there’s a lot of money and research dedicated to obesity prevention and there’s this idea that this has to be different from eating disorder prevention. … We are working towards the same goal, but we get stuck in these silos with this messaging that is off-putting to the other field. If we are addressing obesity with the expense of increasing weight stigma, body dissatisfaction and disordered eating, that’s a real problem.”
As a researcher, former athlete and subject of disordered eating, Carson hopes to see greater efforts into redefining the face of eating disorders.
“Eating disorders are not about the size of your body, they’re about your thoughts. I think it’s really good for people to be aware of that — you may have friends and family members who may not look like what you see on a TV show, but it’s really not about your size or your BMI,” Carson said. “It’s about this obsessive thought process around food. I always thought I couldn’t have an eating disorder — I’m not small enough, I’m not thin enough. It’s not about that.”
Bravender pushes for eating disorders to be recognized as the medical conditions they are.
“You can look at that as having a glass of wine with dinner is normal, but if the emphasis becomes so much on the drinking that you become an alcoholic, we treat that as an illness,” he said. “We don’t treat that as just an annoying behavior, there is something wrong that needs specific treatment.”
Like addiction, like any mental illness, eating disorders and disordered eating should be treated the same way.
“The right thing to do is to get treated, just as if you had diabetes or cancer or a broken leg, you’d seek treatment,” he said. “And there’s no stigma attached to those other medical issues, why should there be for eating disorders?”