College Can Be a High-Risk Transition for People with Eating Disorders. Here’s How to Prepare.

March 22, 2023

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When it was time for Equip Family Mentor Laura Cohen to help her daughter navigate college applications, she had one rule: recovery would always take priority. “My daughter started college two years into her recovery,” Cohen says. “Even during the application process, her recovery was in the front seat. We and her team were very clear that just because she got into a college didn’t mean she could go that fall. Recovery was first and foremost and if that meant a gap year was needed, we wouldn't have hesitated.”

Transitions are a tricky time for those with eating disorders, and starting college is one of the biggest transitions there is. For many students, the sudden shift in environment, expectations, and schedule can be jarring, and is compounded by anxieties around academics and social status. Even for those who aren’t moving away from home, the change in structure and responsibility can be a lot to handle. And for anyone prone to or in recovery from an eating disorder, all of these changes—combined with the endless food choices and diet talk that are both hallmarks to college culture—can cause considerable stress and potentially trigger a problem or relapse. Given all this, it's no coincidence that the median age of eating disorder onset tends to coincide with the typical age of college enrollment, according to research.

“This is a time of great developmental change. Young adults are focusing on individuation from their family of origin, deciding who they are, and developing intimacy in significant relationships,” says Equip VP of Medical Care, Jennifer Derenne, who has edited two books on transitioning from adolescent to adult mental health care. “All of this change can be exciting and exhilarating while also overwhelming and destabilizing. They may change their eating or activity behaviors to manage their stress and anxiety, or out of a fear that they’ll gain the ‘Freshman 15.’”

But while all these risk factors can make this time particularly precarious, eating disorders in college are not inevitable. With the right information, resources, and support, families can help their child prioritize recovery and make this time of transition exciting rather than overwhelming.

Why the college transition can be so tough for those in recovery

While any type of transition can be triggering for people prone to eating disorders, starting college can be particularly tough for a number of reasons. In addition to the universal stressors of school life and potentially leaving home for the first time, students also run up against challenges around food, exercise, and eating socially.

“College is a time of increased independence, and if someone can’t adequately eat on their own, it can be very easy to relapse,” Cohen says. “With more independence comes increased responsibility. Being comfortable eating with others and making sure you’re comfortable choosing food in a big and loud dining hall is essential.”

Ah, the dining hall. It’s a place defined by seemingly endless food choices, big crowds, and social dynamics on full display; and while this environment is fun for many college students, eating in a dining hall can be incredibly challenging for someone vulnerable to or in recovery from an eating disorder. For some, the pressure of eating in front of a large group can be overwhelming, and for others, the unfamiliar foods themselves can prove problematic. At home, the pantry and fridge were full of your go-to brands and family staples, and now you’re surrounded by a self-serve frozen yogurt machine, an omelet station, five kinds of pizza and a salad bar the length of your whole house; the overwhelming amount of choices and presence of potential “fear foods” can be paralyzing for many struggling with eating disorders.

What’s more, a number of college dining halls now display nutrition information (or the arguably more problematic “traffic light” labeling, in which “healthy” foods are marked with green and “unhealthy” foods with red) for the food they provide. This type of nutritional labeling can be potentially triggering for those in recovery who are working not to judge food as “good” or “bad. “You need to be comfortable choosing adequate meals even while the calorie contents are often listed all over the dining hall,” Cohen says.

“And if you’re eating with others, you need to be comfortable doing so and choosing meals that are recovery-minded, which may differ from some of your friends who may be entrenched in diet culture,” Cohen adds. “College is an easy place to hide an eating disorder and it’s very easy to relapse.” Equip Registered Dietitian Stephanie Kile adds that one of the biggest potential triggers for college students is peer pressure. “College life has so much diet culture and it is easy to slip into these behaviors that will then derail progress and increase risk of relapse,” Kile says. “Being able to have a clear plan and steps to prevent this from happening is key.”

How to prepare for the college transition while prioritizing recovery

While it’s impossible to anticipate all the potential obstacles or challenges college can bring, experts strongly recommend building a strong recovery foundation as early as possible. “The key is to be very prepared heading into the process,” Derenne says. “I advise families to think about the transition much sooner than they might think is necessary, and even consider these things as they are going on college visits and filling out applications.”

Here are some helpful ways to prepare and make the transition to college one that supports recovery:

Do a trial run

Derenne, Kile, and Cohen all advocate for “practice runs” prior to the start of the semester, or allowing the person in recovery to slowly take on more responsibility while still having the structure and safety net of home. This may mean allowing them more freedom around meal planning, giving them the opportunity to make their own doctor’s appointments, or having meals in unfamiliar and public settings, like a mall food court.

“A good idea is to test ‘food independence’ the summer before college,” Cohen says. “This could look like having your loved one plan and prepare their meals so if they have a wobble, they can navigate getting back on track.”

Create a contract

Cohen is a big advocate of the summer behavior contract, in which families write out what is expected of their loved one before they leave to show that they are ready. She also recommends extending that contract into the start of college to help those in recovery stay accountable.

While every family may choose to use the contract differently, Cohen believes having a target recovery weight range is important, as it helps loved ones keep close tabs on potential backtracks. “A contract should also include what is expected in terms of appointments with providers—virtually or in-person—and if weights and vitals will be needed,” she says. “The campus health center can do this and may need your outpatient team to request what is needed. You can also add limitations around exercise, and I strongly suggest adding something about what to do if a scale is accessible to prevent obsessive weighing.”

Having a contract also ensures that there will be swift, serious consequences if recovery starts to fall by the wayside. “Families and treatment teams need to consistently enforce and follow through on contingencies,” Derenne says. “If someone isn't attending their treatment sessions or appears to be deteriorating, sound the alarm sooner rather than later to get things back on track and prevent a full-blown relapse. Support the student getting connected to appropriate (re)evaluation or treatment as soon as possible. If it isn't possible to arrange that on campus, consider bringing the student home or having a family member travel to them to help navigate the system and provide support around improving nutrition and stopping behaviors.”

Put a team in place

Establishing a solid care team on or off campus is critical, and this will require some advanced research. “All schools are different in terms of the mental health and medical services offered,” Derenne says. “Families also need to think about logistics such as the availability of medical or psychiatric hospitals in the event of an emergency, transportation and ease of getting to appointments, and distance from home. How long would it take a family member to get there if there is a problem? Will they live alone or with roommates who can reach out if there is a concern?”

Set up check-ins

Experts also recommend setting a schedule for regular check-ins with family to keep everyone on the same page of recovery. “Having regular calls and texts can help everyone stay accountable,” Kile says. “Set up a time so everyone knows it’s coming and can be prepared. Also make sure that your loved one has a trusted family member they can reach out to when highly triggered and in need of immediate support. Having someone on campus that they can turn to when they need someone quickly is also a great thing to set up: a counselor, the health center, or a family member nearby who can be there quickly to help in those heightened moments would be beneficial.”

Be honest with yourself

Finally, it’s important to recognize the reality of a young person’s current recovery. If they aren’t ready for a major life change, it may be best to press pause on college and focus on rebuilding health. “I see loved ones send their kids to college because they are too scared to hold them back and that can be a recipe for disaster,” Cohen says. “Many parents can’t imagine pulling their loved ones out of school, but it’s often the thing that is more important than any grade. College is not going anywhere!”

If you’re struggling to decide whether your loved one can go to college without compromising their recovery, here are 12 questions to help you make your decision.

Citations:

Treatment & Recovery