Yana had always been a perfectionist. She was the valedictorian of her high school, a straight-A student at Brown and one of the few students who did all of her reading before class. When fear of gaining the infamous freshman 15 crept in during her first semester on College Hill, her reaction, like most of her freshmen girlfriends, was to start dieting.
As the semester went by, while her friends complained about the soft-serve they couldn't avoid after dinner at the Ratty, Yana (her name has been changed in this article for privacy) found herself restricting more and more of what she ate. By the spring semester, Yana was waking up before class every morning to go to the Keeney gym. By the time summer came, she was throwing the slice of bread she had grabbed for breakfast into the trash after taking a bite out of it.
"I recall thinking: 'I wanted to be a doctor before I came to Brown, now I don't. I used to be the smartest in my class, now I'm not. I had so many friends in high school, now I don't,' " she said, remembering the transition from high school to college. "So many things were changing. I was changing. Eating was the only thing I still had control of."
When she came back to Brown for her sophomore year, Yana weighed exactly 24 pounds less than she had the year before. Her friends were talking about her dramatic weight loss and her suite mates were tired of answering questions about her health, when her mother finally persuaded her to try day-treatment at a Providence psychotherapy clinic.
"I accepted just to make my mom happy," Yana said. "I didn't think I had a problem."
After three days of sitting in group therapy with drug addicts and alcoholics, Yana told her doctor she wanted to leave. The doctor proposed calling Brown Health Services so Yana could schedule a monthly checkup to make sure she didn't lose more weight. Yana took the phone and asked for a "weigh-in."
The scale at Brown Health Services said Yana weighed 98 pounds. The yardstick said she was 5 feet 7 inches. The doctor said she had to call her parents. "This is unhealthy," the doctor told her. "You can't stay in school."
Her mother flew to Providence the next morning. Yana cried as she searched her closet for an outfit that would hide her thinness when she went to see the deans. All her jeans fell off her bony hips. She used bobby pins to hold her skirt up, finally deciding on a long skirt and lots of layers on top.
The long skirt did not fool the dean - her Body Mass Index was dangerously low. She would have to take a medical leave. The dean said most students who were this underweight usually failed to gain back the weight at school.
Her mother stayed strong and calm, searching for a compromise. She and the dean agreed to sign a contract with Yana: To stay in school she would have to put on a pound every week, attend weekly meetings with University Nutritionist Heather Bell and see a therapist off campus.
"It was not about me, it was about them," Yana said of University officials. "They did not want the liability."
Yana signed the contract, unaware of the stress the weekly weigh-in sessions would cause her. "Emotionally, I was the worst I had ever been that semester," she said. "Now that I look back, I should have taken a medical leave."
The fall semester would end in eight weeks - and eight pounds. Ankle weights bought at City Sports on Thayer Street were taped to her chest under her bra, getting heavier each time she stepped on the scale at Health Services. Liters of water filled her tiny stomach and lies flowed out of her lips during the meetings with the nutritionist. "I started loving peanut butter," she told her. "I've found great friends to go to Ben and Jerry's with."
"It is very easy to deceive these people unless you want their help," Yana said. "I bullshitted during my nutritionist meetings. I never opened up to my therapist. She would ask me what could be causing my problems and I would say 'Shut the f*ck up' in my head."
Eight weeks passed by. Yana started eating less and less at the Ratty because she felt everyone was watching what she ate. She started taking out food for every meal, listening to her iPod and reading a book while nibbling on her salad in the white Ratty take-out boxes.
On her last weigh-in of the semester, the scale pointed to 122 pounds. Next morning, Yana weighed herself in her room. She was actually 110.
"Basically, I got no help," she said. "I was in complete denial. I don't know what I was thinking. I wasn't thinking."
Weighing the protocol
The clinical guidelines for the eating disorder protocol were developed by Psychological Services, the Office of Student Life and Health Services in the early part of this decade, according to Bell.
Belinda Johnson, the director of Psychological Services, said these guidelines describe the course of action the University suggests for students with unhealthy Body Mass Indexes (a metric where weight in kilograms is divided by the square of one's height in meters) while "leaving enough room for an individual evaluation of every student's situation." Each year Psych Services sees about 75 students with "diagnosable eating disorders," Johnson said.
Diagnosable eating disorders manifest themselves primarily as anorexia nervosa, bulimia nervosa and binge eating disorder, which affect both men and women. Because denial often clouds the students' condition, whether they are suffering from anorexia, bulimia, binge eating or other types of eating disorders, diagnosis is a complicated process.
Director of Health Services Edward Wheeler agreed in an e-mail to The Herald that, along with BMI, factors such as medical status, behavioral patterns and psychiatric status play into the University's decision about a student.
"Medical leave is never decided based on weight or BMI alone," he wrote in an e-mail. For example, one student told The Herald she consulted deans about taking a medical leave for binge eating disorder because it was disrupting her life at Brown, even though her BMI was within normal range.
If the University were to set a specific BMI under which students would be required to leave, Wheeler wrote, some students might be aware of the cutoff and would work to maintain that minimal BMI. If they reached it, they would be unlikely to even come to Health Services, he wrote.
Health Services physician Marsha Miller said most guidelines suggest that patients with a BMI below 15 should be hospitalized. According to the American Psychiatric Association, patients at or below 75 percent of healthy weight meet the requirement for immediate hospitalization, even if the patient displays no other clinical problems. The World Health Organization classifies a BMI of 18.5 to 25 as "optimal weight" and below 16 as "severe thinness."
Yana, having lost 20 percent of her original weight between freshman and sophomore year, had a BMI of 15.6 when she was first weighed at Health Services and was told by the provider to put on a pound a week if she wanted to stay at Brown.
Miller said she is usually pretty certain if someone has an eating disorder. "It's a disease we see so often that we're familiar with it," she said. Miller said disorders are apparent in assessments of the student's BMI, exercise habits and, for women, regularity of menstruation.
"There's not one recipe," Miller said. "It's a medical judgment." Health Services physicians like Miller cannot enforce a leave but can put a student on a pound-per-week program without notifying the deans.
Because of medical confidentiality, it's possible for students to see a physician and agree to a recovery plan without the Office of Student Life even knowing about it, said Mary Greineder, assistant dean in the Office of Student Life.
Even though students can agree to take a medical leave with only a physician's consent, when students are unwilling to take a leave and resist Health Services' diagnosis, they end up in the deans' offices.
"The University has the right to place the student on medical leave if she (or he) is a danger to herself or to others," said Associate Dean of Student Life Carla Hansen. Student life deans generally make these decisions based on the recommendation of the provider.
Yana's case was rare, Johnson said, as the University does not typically sign contracts obliging a student to gain weight on a consistent basis. "It must have been that she was at a point where the administrators were willing to work with her to keep her on campus."
According to Hansen, the pound-per-week rule is recommended when the student's situation is "not at a point to force" leave but close enough.
Many students react negatively when the University imposes these policies on their behavior, Hansen said. "As a Brown student, they want to run their own show. We are dealing with students who are saying 'No, I can't leave. I succeeded at everything, I can't fail at this.' "
Johnson said the University is well aware that students can be deceptive if, like Yana, they are determined to stay on campus. Student life officials learn more and more about the lengths students will go to stay on campus, Hansen said, but there is nothing they can do to prevent it. Such denial requires full-time supervision away from campus, where a student can be closely monitored.
Johnson agreed. "Sometimes you just have to say, I'm sorry, whether you like or not you're taking a leave," she said. "It's very unpleasant for everyone but that's what needs to happen."
Taking a medical leave to undergo more intense treatment increases an individual's chances of recovery, Wheeler said. The University's guidelines on medical leaves for eating disorders are supported by the American Psychiatric Association's findings that patients who lose more than 15 percent of their healthy body weight have trouble gaining weight without a highly structured program, he added.
Health Services is re-evaluating its guidelines as research shows that the likelihood of recovery is greater when patients are given intense treatment at the early stages of a disorder. In an e-mail, Wheeler wrote that Health Services is examining whether "they should be advocating leaves earlier and more forcefully," as well as the requirements for students before their return from leave.
Bell likened treating an eating disorder to chemotherapy. "Nobody wants to have chemo," she said. "But it's the only thing that will give cancer patients a chance to be cured."
Taking the campus' pulse
While the University is busy "revamping" the eating disorder protocol, a group of students have begun questioning the resources available to those dealing with disordered eating.
One of these students is Leslie Roos '09. A psychology and visual arts double concentrator, Roos has organized a group independent study project titled "Eating Disorders at Brown," advised by Adjunct Professor of Psychology Brian Hayden, who teaches PSYC 1330: "Abnormal Psychology" and PSYC 0300: "Personality."
Roos and the other GISP members, Mollie West '09, Sandhya Dhir '08, Sarah Goodman '09 and Helena Sullivan '09, hope to assess available resources for students with eating disorders and then recommend how the University could improve its policies.
West is currently working with the Office of Residential Life to post permanent signs on the back of bathroom doors that would inform students of available resources.
The group is working with Brown's nutritionist on the project and is in frequent touch with deans, administrators and Health Services and Psych Services staff about the GISP. The students have met with President Ruth Simmons and voiced their interest in a new dean's position,dedicated solely to eating disorders.
Researching resources at universities such as Dartmouth, Duke, Harvard, Notre Dame and the University of California-Davis has helped the girls evaluate what could be improved at Brown. Each week, group members conduct about two interviews and then discuss their findings with Hayden.
Still, what the group needs most is Brown students' first-hand experiences. "In order to do that, we decided to send out a private message to all of our friends through the Facebook," Roos said.
During a meeting in the first floor lobby of the Sciences Library, the five girls sat around a round table, composing the message. "Hey girls, hope your semesters are going well," Roos read out loud. "We are doing an independent study on disordered eating, eating disorders and body image at Brown. Basically, we think the University has a pretty poor institutional approach to addressing these issues. We want to improve the way Brown deals with eating disorders and the way disordered eating is perceived on campus."
In the Office of Student Life, Hansen said she would be happy to see the GISP's proposals and talk over what they should be improving. "The students' common perception (is) that we are iron-clad," she said. "But I hope that I am open to criticism."
"This is not an easy part of our job, and we don't think it's finished at any point. That's why the protocols are revised," Hansen added. "We're not hell-bent on sticking to something."
Nearly half a year ago, Roos was already questioning how the University handles eating disorders, taking the first steps toward the GISP. She sent a similar message to all of her Facebook friends, inviting them to discuss eating disorders at Brown.
"Please don't laugh at the corny first few lines of it," she said about the message. "It was 3 a.m. when I wrote it."
"So tonight, I had this 'Revelation,' and it is physically impossible for me to fall asleep unless I send this out," the message read. Roos wrote that she wanted to create a clinic for young people to get help, information and counseling for eating disorders, but first she wanted to spark discussion at Brown. She explained that her motivation sprang "from a number of experiences including personal eating issues, friends' eating issues and living with boys."
Though Roos is now embarrassed by what she wrote in the message, she was excited when more than 40 people showed up at 7 p.m. on a Wednesday night to watch the HBO documentary "Thin" in her suite's common room.
What seemed like a casual line in her message, "living with boys," was actually one of the main reasons Roos found herself immersed in the issue of body image. Social life at Brown, Roos explained, "led me to see how girls viewed their bodies and how their bodies were viewed and judged by guys."
"I would be sitting at the Ratty with eight boys, and one of them would say 'Damn, check her out. She has hot hip bones,' or 'Yeah, that whole group used to be the hot girls on campus, but over the summer they all got fat,' " she said.
"I knew this group of girls who got so stuck in a dieting routine together that their 'have a diet/work-out buddy' system turned into eating the same thing together, every day, asking for permission to take a bite out of a cookie and then going to a two-hour workout," Roos said.
To find out whether other Brown students had similar experiences, the GISP surveyed Hayden's "Abnormal Psychology" students about their personal experience with eating disorders. Though the survey didn't provide them with reliable data, it was a first attempt at figuring out how Brown's population is affected by eating disorders.
National studies, like the 2006 National Eating Disorders Association poll, have found that eating disorders disproportionately affect college students. Nearly 20 percent of students polled on American college campuses reported believing that at some point they had suffered from an eating disorder, though previous research shows lifetime prevalence rates are as low as 0.05 to 4 percent, according to the NEDA poll. Nearly 75 percent of those who reported having dealt with an eating disorder were never treated.
A band-aid on an open wound
Elizabeth's disordered eating began during her freshman year at Brown. With the stress of leaving her home and family, the fear of gaining the freshman 15 and the overwhelming all-you-care-to-eat of the dining halls, Elizabeth (her name has been changed in this article for privacy) started limiting her diet and eventually went for days without eating.
Suffering from malnourishment, she would stay up all night reading a single chapter. She had no patience for schoolwork, much less making new friends.
Especially for freshmen who are dealing with the transition, Elizabeth said, developing an eating disorder on a college campus can be unfortunately easy. "Everybody is somebody you can compare yourself to," she said. "The comparison game is dangerous in eating disorders." When she realized she was having a nervous breakdown, Elizabeth saw a therapist at Psych Services.
Elizabeth's eating disorder came out one day when she hadn't eaten and was feeling unwell during a Psych Services session. "I kind of went through what I had eaten that day, and she said it wasn't normal. I had convinced myself that it was fine," she said. The therapist referred her to a physician at Health Services.
Elizabeth said she was honest with the physician, telling the doctor what she was - and was not - eating. After weighing her and checking her vital signs, the physician told Elizabeth she had an eating disorder. "It was obvious that I was not healthy," Elizabeth said. "My pulse was between 45 and 50, while it was supposed to be 75."
The physician told Elizabeth she wanted her to stay at Brown, but not in this condition. "She told me if I gained a pound per week, I would be able to stay," Elizabeth said. Upon hearing the doctor's ultimatum, Elizabeth burst into tears. "I hated her at the time," she said. "I despised her."
But Elizabeth tried to cooperate with the program. She started to see an off-campus therapist and the University nutritionist and attempted to eat foods with high caloric content.
"I would put cheese on my veggie burger and put peanut butter on my banana, but I would end up taking out the cheese and avoiding the peanut butter," she said. "I was trying, but not hard enough."
When Elizabeth failed to gain weight, she agreed with the physician that taking a medical leave was the only option left. After only a month at Brown, she headed home to recover, without even seeing the deans. She didn't come back for a year.
Though the pound-a-week program didn't work for Elizabeth or Yana, Greineder said lack of success with two students does not suggest the program is ineffective. Hansen said she believed other students can successfully gain a pound each week and recover at Brown. "It is for them," she said, "that we have the opportunity for all students to do it."
Elizabeth criticized the approach for not teaching students how to cope with the triggers of the disease."It's just a temporary fix, like putting a band aid on an open wound," she said. "You have to devote yourself to healing without doing anything else."
Hansen said it was possible to see the pound-per-week rule as a band-aid on an open wound. But, she said, the alternative is to say " 'We're not going to put on a band-aid on an open wound - you're going to the hospital this afternoon.' "
To keep students at a critical level on campus, weight gain must start immediately, she said. "We're talking about a student whose body is about to shut down and make changes that are very hard to reverse."
Now back at Brown as a sophomore, Elizabeth said she felt "much better" being on campus.
Elizabeth's sentiments are not unusual, according to Hansen. "I have never had a student come back and say, 'I can't believe you put me on medical leave, it ruined my life.' " Instead, she added, students have always told her upon returning to Brown, "I'm so glad I had to leave."
"I am so grateful to (the doctor) for making me do it," Elizabeth said. "I couldn't have made that decision myself."
