Natalie recalls her first year at the University of Wisconsin-Madison as a spiral.
Now a rising senior studying community and environmental sociology, Natalie was studying Pilates and felt a duty to maintain her health and keep her body fueled. This was something she struggled to do after a condition she developed earlier in her life resurfaced.
“If anyone knew me freshman year, I wouldn’t eat before going out. And I went out like four nights a week,” she said. “Everyone’s scared to get the Freshman 15. Everyone doesn’t eat.”
Natalie, who asked that only her first name be used, said she was surrounded by a culture that validated her actions. Her relationship to food became “interpersonal”: her peers starved themselves, so she did too.
Eating disorders like the one Natalie struggles with typically begin between 18 and 21 years of age. The COVID-19 pandemic had a significant impact on the number of students seeking treatment for eating disorders and other mental health issues. The amount of students requesting care at UW-Madison’s University Health Services (UHS) has increased, and students with pre-existing conditions have also been triggered.
The National Eating Disorders Association reported a 41% increase in messages to its telephone and online help lines in January 2021 compared with January 2020.
And in a study of about 1,000 American and Dutch people with eating disorders published last July, more than one-third of subjects reported that they were restricting their diet and increasing “compensatory behaviors,” like purging and exercise.
Locally, from July 2019 to June 2020, UHS received 600 reports from individual students about eating concerns, 396 reports of issues regarding weight loss or gain and 698 reports regarding concerns about body image. Meanwhile, services that could have previously been done within a couple of weeks, like eating disorder (ED) assessments, began being booked further and further out as some students struggled to access care.
“We’ve certainly seen folks that have been stable or have made significant progress in recovery (have) their eating disorders getting activated by the events of the last year,” said Molly Caradonna, UHS’s interim eating disorder coordinator. “We have had a harder time keeping up with demand.”
The issue on campus
The National Eating Disorders Association estimates that between 10-20% of women and 4-10% of men in college suffer from an eating disorder, and rates are on the rise. In a 2019 survey of UW-Madison students, it was estimated that 9% of all students experience eating disorders.
UW-Madison’s health services are among the best in the country — The Princeton Review, which polls students, currently lists it as seventh. But with increasing wait times and a hard limit on 10 counseling sessions per 12 months, many students run into issues when trying to get the support they need.
Emerson Boettcher, a recent UW graduate with degrees in political science and economics, has dealt with an eating disorder since early middle school and has been receiving mental health treatment ever since. The 10-visit limit, she said, kept her from seeking consistent treatment.
“I went years before I sought out treatment through UHS, because I wanted to reserve my appointments, which is just a justification to keep engaging in bad behaviors,” she said. “You only get 10 per year and 20 after four years. And I think we all know that recovery from an eating disorder requires more than 20 therapy appointments for most people.”
Boettcher was admitted to a hospital for her eating disorder this past spring, in her final semester on campus. When Boettcher returned, UW Housing accommodated her new needs by providing her with a key to a dorm kitchen and an extra fridge in her room so that she wouldn’t have to rely on the dining halls. Boettcher noted that while friends, professors and residence hall staff were “outrageously kind” to her when she reached out directly, the systems put in place were less receptive.
Natalie made an appointment with UHS during her freshman year, but said she was encouraged to find more long-term care — “they said they didn’t want to start a project that couldn’t be finished there.” But she went back to UHS in March 2020 when her family lost their insurance coverage. She had no other feasible options for treatment, she said.
The process took months; by the time she got paired with a therapist, it was July. Then, Natalie found her assigned nutritionist critical and unencouraging. She was asked to keep logs of what she ate every day, which made Natalie feel like she needed to restrict her eating even more.
In December, her therapist unexpectedly left. UHS offered to transfer her to another therapist, but Natalie did not have the energy to restart the long process again, especially given her negative previous experience. She ultimately found care off-campus.
Another UW student, Sophia Slawson, noted that students are going to be on campus for “three, four, five years.”
“We should have more than 20 appointments and we should have access to things that should make us better mentally, so we can do better in other places,” said Slawson, who recently graduated with a degree in psychology while dealing with body image issues. “I feel like a lot of it’s just not deep and it’s not long-term. It’s much more surface level.”
All Big Ten universities offer eating disorder treatment as a part of their services for students. But health officials clarify that these services are not meant to be sufficient on their own.
For students whose needs are unable to be met by the university, UHS offers “care management.” Providers help students navigate outside resources and other community providers that may have the time and resources to take on students with more extensive issues. Eating disorders fall into this category.
“For most students that come in with eating concerns, we first have them go through the eating disorder assessment,” said Caradonna. “We take a really in-depth look at what they’re coming in with to really pull apart, is our model going to be a good fit for you?”
Issues with eating disorders on campus go beyond mental health services. Students allege that the institution as a whole protects a toxic culture towards body image and eating disorders. Rhetoric like the “Freshman 15” and skipping meals to “save calories” before a night of drinking have deep roots in the student community.
Students often develop disordered eating and habits through UW-Madison’s prominent drinking culture. In 2008, a term — drunkorexia — began circulating (also “alcoholimia”). Researchers in a 2019 study in the Journal of American College Health define drunkorexic as applying to “individuals who restrict their caloric intake and/or exercise excessively to mitigate the calories from alcohol consumption.” They may suffer from an eating disorder, a substance abuse disorder, or both.
Students are prime candidates to become drunkorexic, the study says, because some 40% of college students are involved in heavy drinking.
“I think UW-Madison is similar to the majority of institutions in the country in that it largely positions thinness as good and fatness as bad,” said Kate Phelps, a lecturer in UW-Madison’s Department of Gender and Women’s Studies. “Mainly through a narrative of erasure. It’s through a lack of thinking of body size as a dimension of existence that influences people’s experiences.”
Phelps noted common items in educational settings, like desks and chairs, are built with a narrow range of bodies in mind. That has a real impact on people living in bodies outside of that range.
Phelps said if “health” was the focus of these institutions, those structures would look different. Not only would healthcare change, but agricultural and pharmaceutical systems would as well.
“The ‘wellness system’ is not invested in our wellness,” said Phelps. “Everybody is doomed in the system (of diet culture) because it’s a system that relies on the perpetual investment in our confusion and unwellness.”
Diet culture is the widespread belief that body size is an indicator of health and moral value, and that everyone should strive towards a thin body no matter the cost. This can be deadly — unhealthy diets can lead to malnourishment, body dysmorphia and eating disorders such as anorexia, bulimia and binge-eating disorder.
According to the National Eating Disorders Association (NEDA), these diets often make people sicker and perpetuate a harmful cycle where larger bodies are pathologized and don’t get the care they need.
This culture is pervasive. Caradonna noticed little messages spread around campus, like calorie counts at the dining call, or “motivational” posters that undermine real wellness. UW’s wellness facilities, RecWell, scheduled “Active Badger Day,” during which students are encouraged to participate in physical activity to improve overall wellness, on the same day as World Obesity Day.
“Even at UHS, there are signs outside the elevator … ‘You would burn blah blah blah calories by taking the stairs,’” Caradonna said.
“I’ve been compelled to put sticky notes on them (that say) ‘Do what you need to do today.’”
To combat this narrative, Caradonna suggests thinking about health and wellness from a holistic perspective. Focusing on food intake and exercise, but not taking into account the mental and emotional impact of certain “health behaviors,” promotes a rigid sense of morality. This rigidity is enforced by labeling and tracking every traditional measure of health.
“Take numbers out of everything. Numbers are not helpful,” she said.
A broader problem
College is among the riskiest times to develop an eating disorder. It’s often the first point in a person’s life when they are living on their own, beginning to develop a real sense of independence and self. An increased workload, less structure and more focus on peers, plus potential anxieties, poor-self esteem or learning issues, can create a “perfect storm” for a person to develop an eating disorder.
Students “start to make dietary changes and restrictively eat, and then those actions are reinforced,” said Dr. Peggy Scallon, a clinical assistant professor in psychiatry at the School of Medicine and Public Health.
“People will tell them they look good, or ask them if they feel better after they’ve lost a little bit of weight. … It gains momentum from there. That can be hard to stop.”
Those disordered habits may vary, from fad dieting to “clean” eating or over-exercising.
According to NEDA, 35% of ‘normal’ dieters progress to unhealthy dieting, and of those, 20-25% develop partial or full-syndrome eating disorders. To be diagnosed, the habit must be sustained over a long period of time and create dangerous or unmanageable situations.
Natalie, the senior studying Pilates, developed orthorexia, an eating disorder characterized by an obsession with “healthy” eating and exercise. This obsession can lead to detrimental behaviors including social isolation, anxiety, and a loss of ability to eat. She had never even heard of orthorexia until she was diagnosed with it.
“Diet culture, in general, doesn’t call disordered eating (by name),” she said. “It’s called dieting or fasting. It has all these non-threatening terms.”
Due to the increasing number of people being diagnosed and the emergence of different disordered eating habits, Scallon said it’s important that people continue to be made aware of both the prevalence of eating disorders and their long-standing effects. Without proper care, sufferers may be at risk of bone loss and strain on the heart and reproductive organs. Cardiovascular, gut and even neurological damage are also real possibilities.
“Education about proper nutrition is helpful, so is coming up with a healthy, consistent meal plan,” Scallon said. “Psychotherapy is often needed to look at body image concerns and negative or self-critical thoughts. Usually, there’s a combination of work with a nutritionist, pediatrician, therapist and psychiatrist.”
Students still need solutions
Students see room for improvement at UW-Madison and its health services. But many realize that larger changes to the system will have to be made before certain mental illnesses and disorders can be fully addressed and de-stigmatized.
The university’s own wellness culture could be one place to start. “RecWell” stands for recreation and wellbeing, Natalie said, but “they see wellness as a completely physical thing.”
“If they’re going to preach about wellness, why don’t they offer cooking classes?” she said. “Why don’t they offer all of these other things that can help, all in the realm of wellness? Why is it just exercise?”
In response, RecWell said it is beginning to offer opportunities that advance students’ mental wellbeing, in addition to current programs like group fitness classes, intramural sports, sport clubs and education courses. They consider their offerings to be “complementary” to UHS programs.
RecWell plans to launch a peer wellness coaching program this fall, which will allow students to focus on their own wellness goals in a collaborative, peer-led environment.
“It is well-documented that physical activity not only improves physical health but also mental health by reducing anxiety, depression, and negative moods,” Abby Diehl, RecWell’s assistant director of wellbeing, said via email. Physical activity “also helps build a sense of community and decrease social withdrawal.”
Natalie does see a silver lining to her experiences. Her professors and TAs have been considerate about her limitations, and have made accommodations for her because of it. And this spring, Natalie found a therapist and nutritionist outside UHS, both of whom she feels are more stable and better equipped to treat her. She feels optimistic about taking in-person classes in the fall.
Students can combat dangerous habits with education and a support system, she said. She hopes fellow students with eating issues can allow themselves “grace and patience.”
“Find friends on this campus that practice safe party habits, like eating before going out,” she said. Friends that have healthy relationships with food are out there, and “they’re looking for people like you too.”
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