“Imposter.” That’s the word Kay* used to describe the way she felt while receiving treatment for an eating disorder at Lucile Packard Children’s Hospital.

“I was convinced the entire time in the hospital that I didn’t have to be there,” Kay said. “I was convinced I wasn’t sick because I knew people who had it worse.”

This feeling — of not being sick, or not sick enough — haunts many people who struggle with an eating disorder.

The eating disorder epidemic impacts a staggering number of adolescents. Data from one college, collected over a 13-year period, suggests that approximately 32 percent of college females and 25 percent of college males struggle with some form of an eating disorder.

Because eating disorders are among the most deadly mental illnesses, these statistics are particularly disconcerting. Some cases can lead to heart failure, impact brain function and damage fertility. Likelihood of recovery and survival is much higher if an individual receives help soon after developing an eating disorder. 70 percent of people with eating disorders, however, never seek out treatment.

This is partially because our society has come to define eating disorders narrowly. They are often portrayed as exclusive to upper-class adolescent females, whose eating disorders manifest as either anorexia, extreme undereating, or bulimia, over-eating and then purging. This narrow definition ignores individuals suffering from less recognized (although not necessarily less common) eating disorders, including binge eating disorder and purging disorder. It props up the false stereotype that eating disorders are cases of extreme vanity or narcissism. And it excludes men or those who are gender nonconforming.

Furthermore, our narrow conception of eating disorders entirely neglects the larger spectrum of disordered eating: Eating behaviors that may not resemble a medically defined eating disorder, but lie somewhere on the continuum of problematic eating and exercise-related behaviors. These behaviors can include calorie counting, over-exercising and over-restricting food groups.

This underbelly of less-recognized eating disorders and disordered eating needs to be acknowledged. The varied stories of Stanford students’ struggles with food and exercise demonstrate that disordered eating and eating disorders are not exclusive to a narrow definition.

The role of college

The transition from high school to college imposes certain stressors that can trigger disordered eating among all students. Students with previous problems and students with healthier attitudes toward food can be affected. According to Robyn Tepper, Medical Director at Vaden Health Center, and Cynthia Kapphahn, medical director of the Eating Disorders Program at Lucile Packard Children’s Hospital, a place like Stanford combines the standard academic and social pressures with a competitive environment that rewards both standing out and fitting in. This combination is an intoxicating draught to drink even for the most resilient of students.

“Colleges value drive and perfectionism,” Tepper and Kapphahn wrote in an email to The Daily. “[These] are qualities that can put you at risk for eating disorders.”

Donner Peer Health Educator (PHE) Julia Gillette ’20 emphasized that Stanford students may be particularly hard on themselves.

“People often strive for perfection, not only in their academic and athletic performance, but also in their self-perception regarding physical appearance [and] fitness,” Gillette wrote in an email to The Daily.

According to Kay, who says she had a positive relationship with food in high school, it was toward the end of freshman year when she first started noticing her peers’ eating and exercise habits.

“It kind of rubbed off on me in the way that it so often does,” Kay said. “I remember I didn’t know what a calorie was. And I remember people making fun of you for that. And then I went and found out what a calorie was, which was a bad thing for me to start doing.”

Kay was ultimately diagnosed with anorexia, but for some students the disordered eating behaviors they adopt may not resemble a categorizable eating disorder.

The role of athletics

Especially in athletics, disordered eating can manifest itself in behaviors that are less frequently recognized as potentially unhealthy.

Kelsey Reed ’20 took ORTHO 97Q: “Sport, Exercise, and Health: Exploring Sports Medicine,”

an introductory seminar in which one unit focused on a type of disordered eating particular to female athletes, recently named RED-S or Relative Energy Deficiency in Sport.

Reed, a member of the women’s club soccer team at Stanford, described what a person at risk of RED-S might experience. “You have weights in the morning and then class all day, and you [don’t] have time to eat. Then, you have practice after class.” At this point, Reed added, “you haven’t eaten anything all day. You eat a massive dinner where all those calories might be the official amount for the day.”

Reed explained that the “energy deficient period” that this behavior creates while exercising can be damaging to the body. “You don’t necessarily have an eating disorder in the typical sense, but you’re not taking in enough calories to offset the amount of exercise you’re doing,” she said.

RED-S is just one example of disordered eating that might not be recognized for what it is. Particularly in a Stanford context, where student-athletes juggle enormous athletic responsibilities with the hectic reality of the quarter system, RED-S can surface, alongside other forms of disordered eating.

Reed also raised concerns about how disordered eating in student-athletes should be addressed. “Do you try to tell your athletes that they can’t play until they improve their eating habits?” she asked rhetorically of coaches and other leaders in Stanford athletics.

The answer is not simple, but it’s clear that the typical construction of eating disorders is too limited to encompass the full range of problems, especially those particular to student-athletes. This insufficiency becomes especially dangerous if these athletes don’t even realize that they may be damaging their bodies. They are just doing what they can to survive the day-to-day.  

Getting help

Kay’s best friend eventually convinced her to get help during her sophomore year. Kay called Counseling and Psychological Services (CAPS), but she was told she would not be able to see someone for another four-to-six weeks. CAPS told her to begin seeing a doctor to get her vitals taken once a week in the meantime to treat the health problems the eating disorder was causing.

Tepper and Kapphahn acknowledged the urgency of both mental and physical health services in the treatment of eating disorders.

“Although therapy plays an essential role in any student’s recovery from an eating disorder, the medical and nutritional problems that result from eating disorders, must be treated, not only for safety reasons, but due to the significant impact the medical and nutritional consequences have on an the individual’s ability to recover,” they wrote.

Even after starting counseling, however, Kay did not feel like she was getting better. Eventually, after her vitals dipped below a certain threshold, Kay spent two weeks in the hospital.  

“It was just helping me become more self-aware of what my problem was, but I was like I know what my thought processes are a little bit more … but I had no power to stop,” Kay said.

Kay credits the resources she received in both inpatient and outpatient treatment as significantly helping her recovery, but she says that she could have received more resources earlier.

“I wish that they’d done a lot of things sooner rather than later,” Kay said.

For someone whose problem does not lead to visibly extreme weight loss or significantly depressed vitals, it might not be possible to get the inpatient and outpatient care that person needs to recover. In less extreme situations, it can also be difficult for friends and support networks to know when to step in.

“I don’t want to upset them or presume that I know better than they do,” Reed said. “How do you balance trying to figure out when, as a friend, you should say something or not say something?”  

Especially when the current definition of eating disorders excludes people who are counting calories, skipping meals and over-exercising, it’s hard to know when to bring up the issue. But if these problems go unrecognized, and therefore untreated, they can persist and, in some cases, become more severe.

The experience of those who suffer from anorexia and bulimia should not be discredited or diminished. However, our discussion of eating disorders and disordered eating must begin to acknowledge this gray area. No one should feel as if there is a voice in their head telling them they don’t deserve food. No one should feel as if this voice is normal.

Inherent in most individuals who experience disordered eating or an eating disorder is the sense that they do not deserve food. Maybe that means skipping all meals except one. Maybe that means counting calories, and then stopping at 500 or 200 or 100. Maybe that means only eating fruits and vegetables — no protein, no carbs.  

In contrast, Reed told us: “Food, as it is, makes me happy.”

Even if that sentiment doesn’t currently describe a student’s relationship with food, working toward it first requires an acknowledgment of difficulty. The gray area between a medically catastrophic eating disorder and a fully healthy relationship with food is legitimate, real and challenging to navigate.  

Gillette encouraged anyone who may struggle with these less defined behavioral ticks or negative thoughts to seek out the numerous resources available on Stanford campus.

“Thankfully there are really great athletic nutritionists and psychological resources for athletes alongside CAPS and nutritionists in Vaden that are available for any student,” she said.

*Name changed to protect privacy.

Contact Claire Dinshaw at cdinshaw ‘at ’ stanford.edu and Emily Elott at elotte ‘at’ stanford.edu.