How Should Eating Disorder Recovery Stories Be Shared? Q&A with Dr. Quatromoni

This is part of a Q&A series with leading expert in eating disorders and sports, Paula Quatromoni. For more Q&As click here.

Q: How should eating disorder recovery/stories be shared in presentations? How do we share properly, avoid triggers, address concerns, and raise awareness?

A (Paula Quatromoni, DSc, MS, RD, LDN): I was recently looking for something on-line and came across some “guidelines” for eating disorder prevention talks in schools and one of the top recommendations was to not bring in an individual to tell their recovery story. I wish I could remember the source of that ‘tip,’ but clearly, I dismissed it because in my opinion, “it depends” entirely on the audience and also on the individual sharing their story.

I do not believe in making a hard and fast “no, don’t do it” declaration. At the same time, I would not give an unconditional, “do this!” recommendation either. What works for one person and in one setting may not work for another. There are never any guarantees that what we deliver in an educational session will meet everyone in the audience’s needs. One speaker may do a great job and a different speaker may not do the topic justice at all. That is true in any educational setting and the same can be said of teachers, in general. It is also true of counselors, therapists, dietitians, doctors, etc. Some patients or clients may describe their interactions with a health professional as “outstanding” or “super helpful,” but others may find their interactions to be not very therapeutic, effective or individualized to their personal needs.

What we do need to ensure is that first, we “do no harm.” So there are some important considerations and a need for heightened sensitivity when a recovery speaker is planning to address a school community.

Pictures, weights and calorie counts could be triggering for some people in the audience, so speakers need to plan for what is appropriate to share depending on the audience.

I would argue that weights and calories should not be shared in the presentation; they just aren’t necessary and they encourage comparisons which are harmful. But let’s be honest – pictures on magazine covers of celebrities, pictures on social media (not just of celebrities but also of other students and peers all over social media), and pictures of professional athletes’ bodies are at the fingertips of students 24/7/365.

Like it or not, these pictures are everywhere in our society. Just open the Victoria’s Secret catalog or the Sports Illustrated magazine that comes in your mailbox . . . The difference is, someone sharing their story responsibly is standing before the audience talking about it, breaking the silence, and giving the issues air space for honest discussion about what is going on with the man/woman in the pictures on the screen. Social media, on-line posts and magazine pictures are not doing that! In fact, they are sending conflicting messages, claiming to be the secret to a successful, healthy, happy life if you look like the person in the bikini or follow the dieting tips endorsed by celebrities on social media.

Pictures embedded in an educational program and surrounded by the opportunity to ask questions of the speaker, with teachers, counselors, nutrition professionals and/or school nurses also participating in the program provide the opportunity to fully address the issues behind the pictures. A responsible speaker will not just show pictures; they will tell their recovery story, identify how they connected to and worked with professionals who guided their recovery journey, and provide direct links to trusted individuals at the school and in the local community who can help anyone in the audience who needs help.

Students should be given the opportunity to opt out of an eating disorder discussion at school.

I saw one school articulate this perfectly. Any student who was uncomfortable with the topic of the guest speaker was allowed to opt out and not attend the presentation. Any student who attends but becomes uncomfortable or gets triggered by a picture or a comment has the opportunity to get up and walk out of the conference room. A teacher or counselor should be on hand to assist in this case. As discussed, a presenter should be trying to avoid this by thoughtfully and carefully crafting their presentation; but it can happen. We cannot predict every individual’s response and reaction to this topic. We must anticipate and plan for this.

School counselors and teachers should plan to debrief with students and schedule some follow-up activities to help students process the speaker experience and messages heard.

These trusted school officials can add their professional lens to the conversation to have small group discussions with students in class later that day or the next day. This is the responsibility of the school community. A school should not be offering an event like this in isolation, especially to a middle or high school audience. They can also plan a conversation before the invited speaker’s talk to clearly articulate ground rules for students (about their ability to opt out and/or walk out of the lecture hall, letting them know that counselors will be available if they need to talk) to set expectations and create a positive, open, learning environment.

By hosting events and conversations about tough topics like this, a school is telling its students “this is an important topic and we want to give this space in our curriculum.”

Bringing in a guest speaker in isolation may not be the right thing for any given school. But tying it to other curriculum components and debriefing or follow up activities led by teachers and counselors makes the guest lecture just one piece of a more comprehensive unit to address the topic in the school’s health & wellness curriculum.

One school official recently voiced a concern that a recovery speaker could “motivate students to enter into an eating disorder.” To that, I will remind readers that an eating disorder is not a matter of “motivation.” It is not a “choice” to enter an eating issue. Eating disorders are psychiatric illnesses. They are not precipitated by showing a photograph or telling a story. There is far more to it than that.

A vulnerable individual who is predisposed to an eating disorder may be triggered by a photograph, a story, or a comment. The source of that trigger could come from a recovery speaker, but it could also come from a sitcom on TV, a comment from a parent, sibling or coach, a social media post from a classmate, a bullying experience, or a lecture in health or science class. We have evidence of all of these, and more, as being triggers for eating disorder onset.

Triggers are everywhere; some of us are more vulnerable to them and others are more resilient. So the bigger issues are vulnerability and predisposition, not necessarily the photo. We cannot protect students from photos. We cannot protect them from the diet-crazed, thin ideal society we live in. But we CAN help them to understand their own personal vulnerability, learn to examine their own behaviors, learn about the warning signs of an eating or exercise concern, and learn who can help because help is available. THAT is the education that the right presenter with a real-life recovery experience can help schools provide to their students and parents.

Allowing a recovery speaker after carefully vetting the person and their presentation is certainly a responsible strategy for a school community.

This allows your speaker to share an authentic story that showcases eating disorder recovery from the lens of the lived experience, and that can be very powerful for students and other members of the school community.  

After all, what is the alternative? 

  • Only allowing a health education teacher, school nurse or counselor to deliver educational programming on this topic?
  • Not doing eating disorder prevention programming in school at all?

If a school or organization is afraid to include the topic of eating disorders on its agenda because they believe it will cause eating disorders, or because they do not have in-house expertise to know how to approach this topic, they would be well-served to connect with an eating disorder professional to better understand how to move forward. By choosing not to address it, they are choosing to perpetuate the silence, keep the topic taboo, and keep the students uninformed. However, students will never be unexposed to eating disorder triggers. And some students are vulnerable and predisposed. A choice not to educate only heightens the risk for eating disorders in an already high-risk population without raising conscious awareness of the risk factors, identifying any solutions, or connecting students to helpers in their community. 

That is an unfortunate choice, but not too difficult to imagine. Choosing not to include education on this topic in school leaves eating disorders in the darkness of silence. Sometimes a school or athletic community will only respond to eating disorders when they are forced to; when a case develops that requires intervention, but not in the realm of education and prevention. Those in charge do not necessarily understand the risks of death or suicide associated with eating disorders and the co-existing depression and desperation. Or, they simply don’t know how to talk about this very difficult and sensitive topic. They may be unaware of where to turn for help, so it is tempting to prioritize other pressing health and wellness topics in the curriculum, those with easily identifiable solutions.

Finally, I will say this – there have been serious cases of eating disorders triggered and reinforced by well-intentioned teachers and coaches who are employed in schools. I have had adolescents referred to me who literally stopped eating carbs or adopted severely restricted diets and developed eating disorders after being taught about “healthy eating” in health class in school. There are some science teachers out there who are promoting ketogenic diets and intermittent fasting in their science classrooms. There is no guarantee that teachers (or coaches) are giving accurate information and are not bringing their own personal biases or distortions to what they communicate to students or role model in the school setting. I speak from experience; we have many teachers in our eating disorder treatment programs who have debilitating eating and compulsive exercise concerns of their own, and there are plenty of examples of coaches giving dieting advice to athletes that contributes to the onset of eating disorders. The school is not necessarily having oversight over these individuals in regards to how they teach and talk about diet, nutrition, or weight in their daily interactions with students. We are all liable for our words; not just recovery speakers, but teachers, coaches, and others too. It is a shared responsibility to ensure that our words and advice are accurate and “do no harm.”

For all these reasons and more, we need high quality eating disorder education and prevention programming in schools!

Paula Quatromoni, DSc, MS, RD is a registered dietitian, academic researcher, and one of the country’s leading experts in the prevention and treatment of eating disorders in athletes. Dr. Quatromoni is a tenured associate professor of Nutrition and Epidemiology, and Chair of the Department of Health Sciences at Boston University where she maintains an active program of research. She publishes widely on topics including clinical treatment outcomes and the lived experiences of athletes and others with and recovering from eating disorders. In 2004, she pioneered the sports nutrition consult service for student-athletes at Boston University, and in 2016, she led the creation of the GOALS Program, an athlete-specific intensive outpatient eating disorders treatment program at Walden Behavioral Care where she serves as a Senior Consultant. Dr. Quatromoni is an award-winning educator. She earned her B.S. and M.S. degrees in Nutrition from the University of Maine at Orono, and her Doctorate in Epidemiology from the Boston University School of Public Health.