Information for Educators

Eating disorders typically first appear during the teen years or young adulthood with approximately 6-8% of adolescents developing an eating disorder before age 18.^1,2 The rates are even higher when looking at the prevalence of subclinical eating disorder symptoms, with 22% of children and adolescents worldwide showing signs of disordered eating.³ This early age of onset is associated with a 25-year reduction in life span.⁴ Given the prevalence of eating disorders among school-age children and adolescents as well as the life threatening nature of these illnesses, educators are in a critical position to raise awareness, identify eating disorder symptoms as early as possible, and help their students to receive additional support and treatment when needed.⁵

The Role of Educators

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The role of an educator in a student’s life allows them to not only identify eating disorder symptoms (often before others do), but also to raise awareness about eating disorders and implement strategies that may prevent disordered eating and body image issues from progressing to a full-blown eating disorder. Here are some ways that educators can work towards creating a school environment that promote a healthier relationship with body image and eating and perhaps prevent these harmful behaviors from progressing to a more chronic and severe state:⁶

• Learn as much as you can about eating disorders. Know the difference between facts and myths so that you can identify the early signs of eating disorders and be prepared to discuss your concerns with a student, their parent/guardian and/or school mental health professional(s).⁴ 
• Educate students about eating disorders and body image issues to increase awareness, combat stereotypes, and decrease stigmatization.⁴ Studies show that educating students about body acceptance, the risks of weight control behaviors and eating disorders decreases the likelihood of engaging in disordered eating.⁷ Furthermore, students cite a lack of awareness about eating disorders as a barrier to disclosing eating disorder concerns to school staff.⁸

• Combat weight stigma and create a school environment where people of all sizes feel safe and accepted. The message that thinner is better is everywhere in our society and researchers have shown that exposure to this “thin-ideal” can increase body dissatisfaction, which can lead to the development of disordered eating behaviors or a full blown eating disorder.⁹ Here are some ways that you can combat weight stigma:
  • Be a positive role model for body acceptance and a balanced relationship to eating. Examine your own attitudes about body image, nutrition, exercise and eating. How have you internalized the message that thinner is better? Are you inadvertently promoting weight based stigma through your words or actions? 
  • Pay attention to how students and faculty around you talk about bodies, nutrition, exercise and eating etc. Educate those who may be promoting the thin-ideal about the dangers of weight based stigma.  
  • Identify any school policies that may promote the thin-ideal and advocate for policies and curriculum that are size inclusive.⁵ For example, some schools have mandatory weight or BMI reporting which has been found to increase body dissatisfaction (a leading risk factor for eating disorders).¹⁰
• Ensure that a protocol is in place for students to report teasing, bullying, or harassment based on weight or appearance. Being teased or bullied – especially about weight – is emerging as a risk factor in many eating disorders.⁸ Be clear with students that bullying, especially about one’s weight, is not acceptable.¹¹
• Teach students skills to become critical viewers of the media to combat narrow and harmful definitions of beauty and acceptability (i.e., media literacy lessons).¹² Research has linked media use, specifically exposure to the thin ideal in the media, to body dissatisfaction, internalization of the thin ideal, and disordered eating.^13,14

There are also several prevention programs that have been implemented in schools which have proven effective in reducing the onset of eating disorders in students who exhibit early signs of disordered eating. One such program is called The Body Project which is a group-based intervention that provides a forum for high school girls and college aged women to confront unrealistic appearance ideals and develop healthy body image and self-esteem. Learn more about the Body Project and facilitator training here.

Learn more about the prevention of eating disorders here.

Warning Signs of Eating Disorders in a School Setting

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Eating disorders can have profound effects on cognitive and emotional functioning and may have a negative impact on student behavior and school performance. Eating disorders can decrease the ability to concentrate and focus, make students less active and more apathetic, and lead them to be withdrawn, and engage in fewer social interactions. They can also impair the immune system and make students more vulnerable to illnesses. The chance for recovery increases the earlier an eating disorder is detected, therefore, it is important to be aware of the signs of an eating disorder so that you can identify students who may be in trouble and take steps to get them the help they need as early as possible. The following list are some of the signs and symptoms that could indicate a student is at risk, however this is not a comprehensive list and not every person with an eating disorder will experience all or any of these symptoms- only an expert can diagnose:

Emotional and behavioral signs:¹⁶

• Preoccupation with weight loss, food, calories, and dieting
• Refuses to eat certain foods, and often eliminates whole food groups (carbohydrates, fats, etc.)
• Develops food rituals (i.e., eating foods in certain orders, excessive chewing, rearranging food on a plate)
• Drinks excessive amounts of water or non-caloric beverages  
• Makes excuses to avoid mealtimes or situations involving food (i.e., avoids cafeteria)
• Maintains an excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury 
• Extreme concern with body size and shape
• Frequent checking in the mirror for perceived flaws in appearance
• Experiences weight based bullying¹⁷
• Hides body with baggy clothes
• Withdraws from friends and previously pleasurable activities and becomes more isolated and secretive.
• Extreme mood swings (i.e., becoming more irritable, anxious or depressed)
• Changes in academic performance (i.e., homework completion, attention in class etc.).^4,18 It is important to note that eating disorders are more common among students with high academic achievement and that they often feel pressure to maintain this high level of performance despite their compromised physical and mental status.^19.20
• Displays rigid and inflexible thinking style and has difficulty adapting to change or transitioning from one task to another.
• Perfectionism, low self-esteem, impulsivity particularly when combined with body dissatisfaction.²¹
• Overvalues self-sufficiency, is fearful of losing control and is reluctant to ask for help
• Denies there is a problem and/or does not perceive the severity of their disordered eating and symptoms²¹
• Increased absenteeism due to psychological and physical impairments related to eating disorders.⁴

Physical signs:¹⁵

• Difficulties with concentrating, focus, memory loss, and/or information processing
• Dizziness, especially upon standing
• Fainting/syncope
• Muscle weakness
• Feeling cold all the time
• Noticeable fluctuations in weight, both up and down
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Cuts and calluses across the top of finger joints (a result of inducing vomiting)
• Dry skin and hair, and brittle nails
• Fine hair on body (lanugo)
• Cold, mottled hands and feet or swelling of feet
• Poor wound healing
• Impaired immune functioning which may make them more vulnerable to illness

Learn more about the warning signs of eating disorders here.

What Should an Educator Do When They First Suspect a Student has an Eating Disorder?

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• Early detection and intervention can greatly improve treatment outcomes. If you suspect a student may have disordered eating or an eating disorder do not delay addressing your concerns and seeking help.¹⁷
• Check if your school has specific guidelines on referrals for students suspected of having an eating disorder or other mental health issues. 
• Be prepared to refer students and families to appropriate eating disorder resources and professionals who can assess, diagnose, and develop a treatment plan.
• Help the student and/or their guardians/parents to understand more about eating disorders and emphasize the importance of early intervention. 
• If a student discloses that they may have an eating disorder, consider the setting in which the disclosure has occurred. If it is during class or another setting where others are present, practice protective interrupting. (i.e., “Thank you for sharing that…I’d like to follow up with you about this after [class, recess, gym].”)
• Be aware that a student who has divulged very personal concerns has chosen the particular teacher or staff person to divulge for a reason. Acknowledge to the student how difficult disclosing personal concerns can be.
• Ask the student with the eating disorder privately how they would like teachers (and others) to respond when asked about how the student is doing and how they would like to be supported. 
• Avoid promises or setting expectations that you cannot or will not uphold. For example, “I promise not to tell your parents.”
• Identify who at the school is the appropriate person to reach out to the student’s parents/guardians to discuss your concerns. The school psychologist, counselor, nurse or equivalent is generally the most appropriate person to communicate with parents/guardians.⁴

How to Talk to Parents/Guardians About a Student’s Suspected Eating Disorder?

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• Before you approach the student’s parent/guardian, consider the family dynamics and any cultural or social issues that may make it difficult to discuss your concerns.
• When you start a conversation with parents/guardians, focus on empathy and concern. Listen to what they say without interrupting, judging, or making pronouncements or promises. 
• Be clear about policies regarding confidentiality and your duty of care as a mandated reporter. Parents/guardians may feel frustrated at a perceived lack of communication so it is important to explain the ethical and legal regulations that guide what you can and cannot divulge to a student’s parent/guardian. It is also important to let them know about your legal obligations as a mandated reporter should there be concerns that a guardian is not taking the appropriate steps to ensure their child is receiving necessary medical and mental health treatment.
• Begin by telling the parents/guardians that you are concerned about the student AND offer specific, factual observations about the student’s behavior to illustrate your concerns. Don’t interpret what the behavior could mean—just state the facts of the observed behaviors. (i.e., “We are concerned about your child because we’ve noticed they have been making a lot of comments about feeling unhappy about their weight and have been throwing their lunch away. I was wondering if you had any concerns or noticed anything recently?”)
• Don’t make a diagnosis, only a professional is qualified to do so.
• Be clear about the support the school can offer and the services available through the school (i.e. school counseling, accommodations to support the student’s recovery etc.). 
• Encourage the family to access support, information, or treatment from external sources and have resources available to refer them to. 
• Try and decide collaboratively on the next steps the school will take with the student and parents/guardians together.
• Follow up oral conversations with a written summary of the conversation and action steps agreed upon, and send the summary to the parent/guardian to check there is mutual understanding of what was discussed.
• Don’t persist with a conversation that isn’t going well. This may damage future communication. Validate that this is a difficult topic to discuss, reiterate the school’s concern, leave the door open to future conversations and let them know you will be reaching out to check-in and provide any additional updates on their child’s wellbeing. 
• Consider what action you are permitted to take if parents/guardians deny there is a problem and you feel the student is in crisis. If there is suspected medical neglect of the eating disorder, take the appropriate steps to report the situation to child protective services.

What to do When a Parent/Guardian Discloses a Student has an Eating Disorder Diagnosis?

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• Check if your school has guidelines for how to support a student diagnosed with an eating disorder. 
• Meet with the student and parents/guardians to determine what their needs are and how the school can support the student throughout the recovery process.⁴ 
• Help the student and family with obtaining any necessary accommodations including creating a 504 plan.⁶ A 504 plan is part of an anti-discriminatory law in the United States which ensures that students who have mental or physical illnesses that significantly impair their daily functioning receive the accommodations/services they require to meet their educational needs.²³ 
• Coordinate with a multidisciplinary team of professionals, school personnel and family members to ensure the student receives appropriate medical monitoring, nutrition supervision and psychological interventions as needed.⁶
• Specify who at the school will be a family liaison so that the family has the opportunity to develop a supportive relationship with a school staff member and to coordinate effectively to support the student’s recovery.

Guidance for Schools on Education Plan for a Student in Treatment

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• Meet with the student and parents/guardians before the student returns to school to discuss the supports that may be needed.⁴
• Be aware of the effects of eating disorders on cognitive abilities so expectations are realistic.
• Work with parents/guardians, the treatment team and the school to ensure the reintegration plan takes the student’s medical, psychological, and academic needs into account, including creating a 504 plan (i.e., upon re-entry, students may need supportive counseling, medical monitoring, release from physical education classes, meal monitoring, and ongoing communication between the treatment team and family etc.)
• Develop a realistic educational plan for the student. Be flexible while balancing realistic workloads, deadlines, and the school’s responsibility to ensure the student fulfills important learning goals (i.e., reduced workload, alternative assignments for physical education requirements, extended time on assignments/tests, peer tutoring, copies of class notes from missed days, and access to a quiet study location, as needed).⁴
• Discuss how to support students with any anxiety they may be experiencing about transitioning back to school, resuming classwork, engaging in social interactions and/or encountering triggers to their disordered eating.⁴
• Consider the timing of potentially stressful decisions (i.e., discussing if the student needs to repeat the grade)
• Advocate for the student (i.e., help students negotiate scheduling conflicts between school and doctor appointments; educate school staff about the effects of eating disorders on cognitive abilities and the side effects of the student’s medications)
• Provide in-school counseling (relaxation techniques, supportive and reflective listening, short-term solution-focused problem solving for in- school issues)
• Consult with the school nurse who may need to conduct periodic assessments and follow-up: pulse and blood pressure checks, medication dispensing, managing medical releases and restriction forms for activities and meals, and/or monitoring the student during meals.
• Decide which staff will take responsibility for monitoring and communicating changes in a student’s well being through appropriate channels to the students parents/guardians and/or treatment team.

Supporting Students Who Know a Fellow Student With an Eating Disorder

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• When supporting the student’s classmates, protect confidentiality and privacy by providing general information about how to be supportive to a friend who is experiencing an eating disorder.
• Remind the student that they are not responsible for their friend’s eating disorder or recovery and that they cannot “fix” their friend.
• Support friends and fellow students by providing information and opportunities to talk about:
  • Emotions they may be experiencing
  • Coping with the changes in their friend (i.e., behavioral and social changes such as increased agitation or social isolation)
  • Strategies to support their friend (i.e., avoidance of triggering topics like body size, appearance, eating behaviors)
  • Strategies to support themselves (taking time-out, talking with the school counselor, or going to a peer support group)
• The friends of the student with an eating disorder can be supportive by learning basic information about eating disorders. Such information could be integrated into health education classes, if those classes are available for students.

Resources For Educators

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• The NEDA Educator Toolkit is a resource for educators, staff who work in a school setting, or those who work with youth outside of school. If you want to understand more about eating disorders, if you’d like to know how to support students and young people who may be affected, this information will help you.
• Campus Warriors is an outreach initiative designed to engage colleges and universities across the United States to raise awareness about eating disorders and fundraise for NEDA.
• NEDA’s eating disorders screening tool assesses warning signs of an eating disorder and can help determine if it’s time to seek professional help. This screening is not a replacement for clinical evaluation.
• Learn more about treatment here.
• Learn more about finding treatment providers in your student’s area here.
• Additional mental health resources for educators:
  • Mental Health Resources for K-12 Schools handout offers a list of resources to address mental health in schools including continuing education for staff, best practice guidelines, and class curriculums.