Is Your Young Adult with an Eating Disorder Ready for College?

Dr. Muhlheim is doing a live webinar for parents of high school students with eating disorders on college readiness on Saturday, Feb 25 over zoom. You can register online by clicking here.

You may be wondering: is my young adult with an eating disorder ready for college? Starting college is stressful for even the most well-adjusted young adult. Young adults with eating disorders often have trouble with transitions. Add an active eating disorder on top of the college transition, and you have a potential time bomb.

College brings a multitude of new situations to navigate: living away from parents; living with strangers; loss of personal space and privacy; unfamiliar environment; unfamiliar foods; loss of structure; drugs and alcohol; pressure to fit in; academic pressure; and social organizations and events. If a young adult has been struggling in recovery, these additional stressors typically add to the challenge.

Young adults who are not completely recovered struggle in situations that healthy adults navigate with ease. For example, consuming enough food in a dining hall can pose a big challenge for inflexible eaters. In our experience, students who are uncomfortable eating with peers or eating a variety of foods (including starches, fats, and desserts) may lose weight rapidly in this environment.

The patterns of college life can complicate the maintenance of a healthy weight. Students are likely much more active as they walk from place to place across a large campus. Different sleep patterns (including all-nighters) can also increase energy expenditure. For these reasons, the caloric needs of college students are often substantial; 3000-3500 kcal per day baseline is not unusual. This would translate to needing over 100 fat grams per day. These factors should be considered when evaluating whether your young adult can eat enough calorically dense food on their own to sustain a healthy weight or refrain from bingeing and purging.

College culture brings additional pressure on a student in recovery. Roommates and peers may be dieting, fear of the “freshman 15” may circulate, and friendships may bond around visits to the gym and yoga classes. It can be harder to refrain from exercise when it’s at the center of socializing.

Many parents want to send their young adults away to school so that they can achieve important milestones and participate in transformative experiences. However, the reality is that attending school while still plagued by intrusive eating disorder thoughts and behaviors will rob them of the very aspects of the experience you want your child to have. Offering your young adult a “normal” life too soon is a common cause of relapse, further delaying their ability to live a “normal” life.

So how do you know if your young adult is ready for college? If you can answer yes to all of the following questions—considering the last six months—then your young adult may be ready to transition. Yes, that’s right: a solid six months of recovery is recommended to ensure your young adult does not relapse. If you answer no to any of these questions, you are strongly encouraged to work with a treatment team and follow our suggestions for how to prepare your young adult.

Six months of solid recovery is needed, meaning the young adult has consistently displayed the behaviors included in the checklist over that period of time.

Lauren and Katie’s College Readiness Checklist

Has your young adult maintained a steady weight in the healthy range (according to childhood growth records) and (if female-bodied) menstruated consistently for six months?	☐ Yes ☐ No
Has your young adult been free of eating disorder behaviors such as bingeing, purging, laxative use, and excessive exercise for six months?	☐ Yes ☐ No
Is your young adult able to independently and consistently prepare and choose meals that contain enough energy-dense foods to maintain this weight?	☐ Yes ☐ No
Is your young adult able to serve themselves snacks and desserts?	☐ Yes ☐ No
Does your young adult consume beverages other than water (juice, milk, lattes)?	☐ Yes ☐ No
Is your young adult able to eat at a variety of restaurants, ordering and eating a balanced meal that is not the lowest-calorie item on the menu?	☐ Yes ☐ No
Is your young adult able to confidently eat from the different food stations at a cafeteria (sandwich bar, grill, etc.) and not just from the salad bar?	☐ Yes ☐ No
Is your young adult comfortable eating hot breakfasts (other than oatmeal)?	☐ Yes ☐ No
Does your young adult use condiments comfortably (dressing with fat, ketchup, mayonnaise, etc.)?	☐ Yes ☐ No
Is your young adult comfortable eating with friends?	☐ Yes ☐ No
Does your young adult eat at a normal pace?	☐ Yes ☐ No
Has your young adult reincorporated the majority of previously feared and avoided foods?	☐ Yes ☐ No
Is your young adult able to go without exercise at least every other day, or not at all if medically contraindicated?	☐ Yes ☐ No
If your young adult has returned to exercise, do they understand the need to add additional fuel following exercise?	☐ Yes ☐ No
Is your young adult able to eat in front of other people who aren’t eating? (There is no guarantee roommates will not be eating disordered, so taking care of one’s own needs and handling the self-consciousness inherent in doing so is an important recovery skill.)	☐ Yes ☐ No
Would your young adult be able to cope with having a scale in the room and roommates who weigh themselves and discuss weight or dieting?	☐ Yes ☐ No
If your young adult misses a meal for any reason at all, are they able to make it up that day or the next day at the latest? (Making it up may mean having larger portions at other meals, two extra snacks, or the equivalent of an extra meal across a twenty-four- to thirty-six-hour period.)	☐ Yes ☐ No
Is your young adult able to increase his or her daily calories substantially to account for mileage logged when walking around campus?	☐ Yes ☐ No
Can your young adult be restful? Do they sit when everyone else is sitting?	☐ Yes ☐ No
Is your young adult able to be alone around processed and highly palatable foods without having an urge to binge?	☐ Yes ☐ No
Has your young adult demonstrated an ability to tolerate anxiety without resorting to restriction, bingeing, or purging?	☐ Yes ☐ No
Does your young adult openly acknowledge their eating disorder and have insight about the need to construct a life and schedule that supports recovery?	☐ Yes ☐ No
Have you discussed with your young adult that any situation that puts them in a state of negative energy imbalance or weight loss could trigger a relapse?	☐ Yes ☐ No
Does your young adult understand that alcohol calories do not count toward energy needs?	☐ Yes ☐ No
Are temperamental traits (perfectionism, rigidity, comparing, etc.) acknowledged and appropriately managed?	☐ Yes ☐ No
Are you willing to step in and pull your young adult out of school if needed? (Remember, even though your young adult is over eighteen, you are still responsible for them. It is unrealistic to expect their college to, in the words of Laura Collins, “provide the kind of accountability and monitoring and personal support that a parent provides and an eating disorder patient deserves.”)	☐ Yes ☐ No

How to Prepare a Young Adult for College

If your young adult meets most of the above criteria and there is still time before they are expected to leave for college, there are things you can do to prepare them.

• Practice eating with your young adult in different self-serve cafeteria-type settings, as well as a variety of restaurants, for breakfast, lunch, and dinner. Good options include Indian restaurants that offer lunch buffets and hospital cafeterias. Have your young adult practice building a meal that will meet their dietary needs. Revisit the same places again with the expectation that they will choose different options.
• Have your young adult practice walking five miles per day for a week (to simulate the amount of physical activity they are likely to have on a college campus) and add sufficient calories to keep weight steady.
• Arrange “surprise” food exposures for a few months. At random times take your young adult to unexpected food locales and make sure they can tolerate it. For example, make a spontaneous stop at an ice cream parlor.
• Do a week of sauces and butter on everything, simulating more typical cafeteria meals (e.g., meats with gravy or sauce, pasta with cream sauces, salads already dressed).
• Enter into a college contract. This is an agreement between you and your young adult that specifies the criteria required for staying in college (such as maintaining a healthy weight, not engaging in eating disorder behaviors, and having regular weigh-ins) and what you will do if these things are not met (for example, increase supervision, bring your child home, etc.). A sample college contract is available here.
• Make sure they have a meal plan that includes three meals per day in the dining hall.

If your young adult does not meet the criteria listed above, then please consider having them defer college, or start at a local college while living at home. It is better to delay starting college than to have them start only to get overwhelmed by symptoms and need to drop out. Life is not a race. College can wait. Your young adult will get more out of the experience when they are fully recovered. By contrast, sending them to college before full readiness may reduce chances for a full recovery.

For an update on how COVID is impacting the college experience, read about additional considerations.

Thanks to Katie Grubiak, RDN, who co-authored this piece in its initial form, and Rebecka Peebles, MD, Therese Waterhous, PhD/RDN, CEDRD, and JD Ouellette for their helpful feedback and contributions to this piece.

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EDTLA therapists are available to work with you on getting your young adult ready for college. Learn more about our eating disorder services for college students.