The information in this article originally appeared in an Equip Academy presentation. Watch the presentation here, and register for future Equip Academy events to learn about other eating disorder-related topics and earn free CE credits.

College can be a particularly high-risk time for the development of eating disorders. Today, we’ll look at unique risk factors and common clinical presentations of eating disorders in college populations in order to arm you with the knowledge you need to identify eating disorders and help college students who may be struggling.

Eating disorders among college students

The median age of onset for eating disorders is between age 18 and 21, which overlaps almost exactly with the age range of college students. College is also a particularly vulnerable period due to several different factors, including:

• Separation from family/disruption of support system
• Being out of one’s normal routine and habits
• Normalization of diet culture and disordered eating habits
• Lack of awareness about the warning signs of disordered eating

All of these factors have the potential to trigger an eating disorder in those who are genetically or biologically predisposed to developing one. Among college students, research has shown a high prevalence of eating disorder symptoms, such as:

• Binge eating
• Restriction of food intake
• Purging behaviors
• Weight concerns

From 2013 to 2021, the prevalence of eating disorder risk increased significantly, rising from 15% to 28%. Young, female, and Hispanic students experienced the largest increases.

Given all the above, it’s very important that college students have access to eating disorder support, education, and interventions.

Identifying eating disorders in college populations

Because of the heightened risk of eating disorders among college students, it’s crucial for those who work with this population to know how to detect these illnesses. In many cases, it can be helpful to progress through several different stages when determining whether an individual has an eating disorder: screening, assessment, and identification.

Screening

To screen for an eating disorder, the SCOFF questionnaire is often helpful. This is a commonly used screener for primary care physicians and health clinics. It’s useful in that it is simple to remember and captures a full spectrum of behaviors.

The screener consists of five questions, below. Every “yes” response earns one point, and a score of two or more indicates that an eating disorder is likely and further evaluation is recommended.

SCOFF questions:

1. Do you make yourself sick because you feel uncomfortably full?
2. Do you worry that you have lost control over how much you eat?
3. Have you recently lost more than one stone (14 pounds) in a three-month period?
4. Do you believe yourself to be fat when others say that you are too thin?
5. Would you say that food dominates your life?

Assessment

Whether or not a patient presents with concerns about an eating disorder, it can be helpful to ask a few questions that can help you assess whether they may be engaging in disordered eating behaviors. These assessing questions generally center around their current behaviors and personal and family history. Questions to ask include:

• Have you made any lifestyle changes recently?
• What do you tend to eat throughout the day?
• How often during the day do you think about your weight, body shape, or food?
• Have you ever been diagnosed with an eating disorder? Has anybody in your family?

Identification

There are several valid and evidence-based measures used to identify the severity of an eating disorder. These include:

• Eating Disorder Examination Questionnaire Short (EDE-QS): Assesses key attitudes and behavioral features of an eating disorder along with a severity rating.
• Nine Item ARFID Survey (NIAS): Helps identify ARFID and its subscales: fear, picky eating, and appetite. Along with EDE-QS, this can be an excellent tool to determine the mechanisms that have caused and maintain the eating disorder.
• Compulsive Exercise Test (CET): Helps to identify the individual’s relationship to exercise, and the frequency and severity of exercise-related behavior.

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Strategies for providing support to students experiencing eating disorders

As healthcare providers, there are a number of steps we can take to support students who are struggling with eating disorders, disordered eating, or body image issues during college. Knowing and implementing the screening and diagnostic tools outlined above is one important way to help, but there are other approaches that can provide support on both an individual and campus-wide level.

Three areas that healthcare professionals can focus on are reducing stigma, increasing access, and raising awareness.

Reducing stigma

Stigma can be a major barrier to seeking treatment for mental health concerns like eating disorders. We can all work toward reducing stigma through initiatives like:

• Education
• Guest speakers
• Fundraising
• Specialty classes
• Book clubs

Increasing access

Many students don’t seek help because they don’t have access to—or aren’t aware they have access to—the support they need. We can help increase access by:

• Providing on-campus support when possible, including online options
• Having a ready referral list if there isn’t extended counseling offered on campus (there are a lot of telehealth options for treatment available now that would be less disruptive to a student)
• Referring out to eating disorder-informed registered dietitians
• Offering groups and/or peer support
• Utilizing campus-wide events to plug mental health resources on campus and in the community

Raising awareness

Many eating disorders go undiagnosed through a lack of awareness about what these illnesses look like and who they affect. We can spread education and raise awareness by:

• Partnering with nonprofits like NEDA or Project Heal to offer resources
• Developing eating disorder-related programming and education during Eating Disorder Awareness Week
• Creating and publicizing resources on the common signs and symptoms of eating disorders and where to get help
• Debunking the “Freshman 15” myth, emphasizing that it’s appropriate and fine to grow into a different body than the one students had when they were teens
• Social media campaigns
• Fliers across campus

When to refer to an eating disorder specialist

If you’re concerned that a college student might be dealing with an eating disorder, it’s a good idea to connect them to a trained eating disorder professional. Eating disorders don’t go away on their own, and early intervention is associated with better outcomes.

If and when it comes time to determine the best intervention for someone with an eating disorder, it’s important to consider the many different options that are available. The option you recommend will depend on the severity of the student’s symptoms and whether or not they have any co-occurring conditions, as well as their preferences, lifestyle, and insurance coverage.

The three primary options to consider are:

1. Outpatient treatment: Outpatient programs can be low-touch with infrequent appointments, or be quite structured and include a high frequency of appointments. Equip, for instance, offers comprehensive, multidisciplinary support that is appropriate for eating disorders of all acuity levels, as long as patients are medically stable (learn more about Equip’s level of care here). Outpatient treatment generally lasts for several months to a year depending on the individual’s symptoms and specific challenges. When referring to outpatient treatment, make sure that you choose a multidisciplinary program with multiple sessions per week.

2. Higher level of care (HLOC): This includes partial hospitalization programs (PHP) and residential treatment. You may opt for a HLOC if an individual requires daily observation because of high-risk issues like suicidal ideation, self-harm, or other complications. With residential treatment, patients receive care 24 hours a day, whereas PHP programs are usually five to 10 hours a day, five to seven days a week. Length of stay tends to be about 30 to 90 days, depending on the severity of the eating disorder.

3. Inpatient care: Inpatient care is generally only required or recommended in the case of dire medical complications and very high-risk behaviors. There is a conservative patient to provider ratio in order to ensure that providers can intervene during medical or psychiatric crises. Inpatient care is the most intense treatment option and is only meant to be used for short periods of time.

For more in-depth information on recognizing eating disorders among college students, watch my recorded Equip Academy presentation on the topic.

You can also explore past Equip Academy presentations and register for upcoming events here, and start a referral here.