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 sororities and fraternities. If a young adult has been struggling in recovery, these additional stressors typically make life even harder.
Young adults who are not completely recovered struggle in situations that healthy adults navigate with ease. Consuming enough food in a dining hall can pose a big challenge to students with eating disorders characterized by inflexible eating. In our experience, students who are not comfortable eating with peers and not comfortable eating a variety of foods (including starches, fats, and desserts) lose weight rapidly in this environment.
The patterns of college life can make it harder to maintain a healthy weight. Students are likely much more active as they walk from place to place over a large campus. Different sleep patterns (all-nighters among them) 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 the 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 to a student in recovery. Roommates and peers may be dieting, there is fear of the “freshman 15,” and friendships may bond around visits to the gym and yoga classes. It can be harder to refrain from exercise when it is the place that socializing occurs.
Many parents want to send their young adults to school so as not to have them miss out on common milestones and universal 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 them to have. Returning to a “normal” life too soon is a common cause of relapse, further delaying their ability to live a “normal” life.
From our experiences with the preparation of high school seniors to go off to college and the reception of incoming freshman from other eating disorder teams, we have developed the following list of questions for parents to ask when deciding whether a young adult is prepared for a healthy transition to college:
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 menstruated consistently (if female-bodied) for six months?
- Has your young adult been free of eating-disordered behaviors such as bingeing, purging, laxative use, and excessive exercise for six months?
- Is your young adult able to independently and consistently prepare/choose meals (in a variety of settings) that contain enough energy-dense foods to maintain this weight?
- Is your young adult able to serve themselves snacks and desserts?
- Does your young adult consume beverages other than water (juice, milk, lattes)?
- Is your young adult able to eat at a variety of restaurants, ordering and eating a balanced meal that is not simply the lowest calorie item on the menu?
- Is your young adult able to go into a cafeteria and eat from the different food stations comfortably (sandwich bar, grill, etc.) and not just from the salad bar?
- Is your young adult comfortable eating hot breakfasts (other than oatmeal)?
- Does your young adult use condiments comfortably (dressing with fat, ketchup, mayonnaise, etc.)?
- Is your young adult comfortable eating with friends?
- Does your young adult eat at a normal pace?
- Has your young adult reincorporated the majority of previously feared and avoided foods?
- Is your young adult able to go without exercise at least every other day, or not at all if medically contraindicated?
- If your young adult has returned to exercise, do they understand the need to add additional fuel following exercise?
- 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.)
- Will your young adult be able to cope with potentially having a scale in the room and roommates who weigh themselves and discuss weight/dieting?
- 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 24- to 36-hour period.
- Is your young adult able to increase their daily calories substantially to account for mileage logged when walking around campus?
- Can your young adult be restful? Does he or she sit when everyone else is sitting?
- Is your young adult able to be alone around processed and highly-palatable foods without having an urge to binge?
- Has your young adult demonstrated an ability to tolerate anxiety without resorting to restriction, bingeing, or purging?
- Does your young adult openly acknowledge their eating disorder and have insight about the need to construct a life and schedule that supports recovery?
- 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?
- Does your young adult understand that alcohol calories “do not count” towards energy needs?
- Are temperamental traits (perfectionism, rigidity, comparing, etc.) acknowledged and appropriately managed?
- Are you, the parents, willing to step in and pull your young adult out if needed? Remember, even though your young adult is over 18 you are still responsible for them and 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.”
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 them in different self-serve cafeteria-type settings including a variety of restaurants for breakfast, lunch, and dinner. Good options include Souplantation, Indian restaurants that have lunch buffets, and hospital cafeterias. Have them 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 them practice walking five miles per day for a week (to simulate the amount of physical activity they’re likely to have on a college campus) and adding sufficient calories to keep weight steady.
- Do ‘surprise’ food exposures for a few months – at random times take your young adult to unexpected food locales/situations and make sure they can tolerate it. For example, make a spontaneous stop at Cold Stone Creamery and offer them a snack.
- Do a week of sauces and butter on everything.
- It is a good idea to have a college contract in place. This is an agreement between the parents and the student that specifies criteria required for staying in college (things like maintaining a healthy weight, not engaging in eating disorder behaviors, and having regular weigh-ins) and what the parents will do if these things are not met (for example, increase supervision, bring the 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 their starting than to have them start and get overwhelmed by their 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 she or he is fully recovered. By contrast, sending them to college when they are not ready may reduce their chance for a full recovery.
For an update on how COVID is impacting the college experience, read about additional considerations.
Thanks to Rebecka Peebles, MD, Therese Waterhous, PhD/RDN, CEDRD, and JD Ouellette for their helpful feedback and contributions to this piece.
Download copy of article here: Is your young adult ready for college?