Life-Threatening Consequences – When School Boards Fancy Themselves Healthcare Providers

I met Madelyn for the first time last month in clinic. Six months prior, she was an otherwise healthy 14 year-old girl. One afternoon, Madelyn’s phys ed teacher led a gym class aimed at completing fitness and health assessments on all of the children in the grade. One at a time, each child was asked to step up and onto a scale to measure weight.  Then height and abdominal girth were measured with a tape measure. Finally, body fat composition was measured using body fat calipers. The gym teacher would do a quick calculation and then state, out loud in front of all the children, each student’s Body Mass Index and body fat composition results. Then, each student was required to perform a number of fitness challenges to assess strength, endurance, flexibility, etc.  At the end of the class, reports were handed out to each student with a list of specific goals for improving overall fitness and health. The children were then dismissed.

The students scrambled out of the gym and then formed a huddle frenetically comparing each others’ results. Madelyn (ordinarily a private and reserved child), caught up in the moment, shared her results and compared with the others. Realizing that her BMI was above average, and noting how many of her peers were thinner than she, Madelyn felt a sudden and overwhelming wave of anxiety, shame, and self-loathing.  She ran to the bathroom, locked herself in a stall and cried as she looked carefully at the information and health recommendations on her card.

Your BMI score puts you in the “overweight” category,
approximately 1 kg away from “obese”.  
To achieve a healthier
weight, it is recommended that you lose at least 6 kilos.  You can
this by exercising more each day and choosing lower
calorie food options (fruits and vegetables) 
instead of high calorie
options (fatty meats, fried foods, and items with added sugar).

6 Months later, I met Madelyn for the first time: severely malnourished, dehydrated, in cardiovascular shock and in need of an emergency hospital admission to save her life.

It turns out that Madelyn took strongly to heart the recommendations she read that day on her fitnessgram. Within a few weeks, Madelyn was skipping breakfast, eating only salad for lunch, and asking her mom to cook carb and fat-free meals for dinner.  Up at 4:30 AM every morning, she completed two hours of cardio on the basement treadmill before walking 3 miles to school.  At recess, she got special permission from the gym teacher to work out: 200 sit-ups, 100 push-ups, 200 Squats.  She walked home briskly in the hopes of arriving early enough to complete another hour of cardio before dinner. After dinner, she felt overwhelming shame for eating too much and, if no one was around, she’d force herself to vomit whatever dinner remnants might still be in her stomach not yet digested. If she wasn’t able to vomit that night, she counted the calories digested, converted them to minutes of cardio and woke up that much earlier the next morning to make them up.

The weight melted off and the more she lost the more driven she was to lose more. By the time I met her, Madelyn was 25 kilos (55 lbs) and barely alive.

Unfortunately, eating disorders programs across North America regularly care for patients with stories shockingly similar to Madelyn’s.  Often children presenting with eating disorders report life events that trigger their illness.  All too often these triggers turn out to be some form of irresponsible health message coming from school health and fitness program.  Health professionals in the eating disorders community would corroborate this as do some small-scale scientific papers

Children (along with their parents) should discuss the health implications of parameters like body weight, body height, and body fat composition with credentialed and competent healthcare practitioners, not with school educators in gymnastics classes.  Sorting out health issues relating to weight and body shape can be complex, challenging and high-risk, especially for young adolescents. Gym teachers, school principles, and class teachers simply do not have the training, experience nor expertise to assess and manage these medical problems.

I am troubled by the growing trend of health and fitness assessment programs, similar to what Madelyn experienced, that are rolling out across the United States.  “Fitnessgrams” are being handed out to children in Iowa, Texas, GeorgiaNew York and many other states.   Canada is not too far behind.  Amazingly, though school boards across America are avidly embracing this Fitnassgram model for health and fitness education in schools, there remains absolutely no evidence, whatsoever, that these programs are doing anything to help improve the health and well being of students.  The real risks, I fear, far outweigh the theoretical benefits.

For Madelyn’s sake, and for the sake of the other vulnerable adolescents like her, let’s leave childhood education to our educators and healthcare provision to our doctors and nurses.

After 1 month in hospital, Madelyn has gained back 5 kilograms, stabilized her condition and looks forward to discharge from hospital, hopefully in the next 2-3 weeks.  But only then starts what is likely to be a long and tedious battle to overcome her anorexia and earn back the life that she lost.

ADDENDUM (July 2nd, 2014)
I would encourage everyone to read the comments below. They are powerful and compelling narratives describing experiences similar to Madelyn’s.

  • Amy Cunningham

    Thank you for this important article. As a mom of a now 12 year old girl who is recovering from anorexia I feel that the ‘healthy eating’ phenomenon has caused more harm than good. Children are not fully grown until age 25 and yet we try to manipulate their bodies from as young as 7 with inappropriate information and signals. My family is predisposed biologicall to eating disorders, but my girl’s anorexia was triggered by a desire for ‘healthy eating’. Our story is similar to Madelyn’s. Eating disorders are biologically based brain disorders and are triggered by rapid weight loss. It is as if the child is on a slippery slope when they begin any food or weight restriction regime. We are a group of parents and survivors united by our common experiences and working against extreme diets and negative portrayals of ED in social/media. Please join us at International Eating Disorder Action on FB and #IEDAction on Twitter. Thanks agin for the great article!

  • Thank you for this wonderful article. Although my children have never been weighed at school or received a “fitnessgram”, I know parents of children who have. I think it’s a disgusting practice and one that can only cause harm.

    Eating disorders are biologically based brain illnesses that can be triggered by a variety of factors, healthy eating being one. I know this was one of the causes of my daughter’s eating disorder. Eating disorders are vastly misunderstood, misrepresented and underfunded in Canada and the U.S., yet are the #1 reason for death of all mental illnesses.

    I, too, belong to a group of parents on Facebook and Twitter, using social media as a way to educate people about eating disorders and to put aside old fashioned stigmas attached. Our children are suffering and our families have been greatly affected by this deadly disease. International Eating Disorder Action on facebook and #IEDAction on twitter.

  • This important article describes exactly what my daughter’s school did, and still does, and which was a MAJOR trigger for her developing a life threatening eating disorder in 7th grade. The public weigh in and BMI calculation imposed during gym class was the first time she and many of her peers were exposed to unnecessary and harmful judgment about their weight. This common practice in schools is complicit in triggering an astronomical number of deadly eating disorders in children with a biological disposition to the disease. This has ruined and even ended the lives of so many children, and yet school districts continue to do it anyway! I find it unbelievably disturbing that schools still haven’t even admitted and taken responsibility for their role in this and ended the practice. Due to my family’s experience, I now work together with a group of parents and survivors who share our family’s devastating experience of an eating disorder triggered, in most cases, by the same school practice that lead to my daughter’s eating disorder. Our group, #IEDAction on Twitter and International Eating Disorder Action on Facebook addresses this practice, extreme diets, often labeled as “healthy” and inaccurate information about eating disorders in society and social media. These issues are very important to us because they lead to and maintain a deadly disease in people, including many of our members and our children and prevent so many from receiving timely and appropriate treatment. Thank you so much for addressing this very serious problem.

  • This is a very important piece and I will share widely in my work with Mothers Against Eating Disorders (#MAEDVocates) and International Eating Disorder Actions (#IEDAction). One thing we’d like to do is have our members go straight to school boards to protest weighing/BMI calculation and to advocate for nutrition education that promotes moderation rather than rigid, black and white rules.

    I have been telling people our families are canaries in the coal mine for these destructive, non evidence-based practices. Arkansas has been doing an anti-obesity campaign since 2002 and obesity has risen. It doesn’t work for anyone’s purposes and has, as you point out, devastating unintended consequences.

  • Amy. Julie Evelyn, Jennifer – Thank you so much for your powerful comments and for advocating so strongly for these children.

  • I am a psychologist who specializes in the treatment of eating disorders in children through young adults. I can say with absolute certainty that in my practice, the biggest trigger for children and adolescents to “begin to diet” has been one thing – the assignment that they get in health class to track their intake to become more “healthy”. This seems to especially be a phenomenon that often occurs in the 5th grade curriculum, at least here in Pennsylvania. So, it is not just when these vulnerable children get weighed in school that they often fall down the hole of an eating disorder but also when they are told to ‘track” their intake and make “better choices”. Something so innocent like this type of assignment can become deadly for so many in that once they learn to “be more healthy”, they can not turn the switch off and end up experiencing a deadly disease that they can no longer control.

  • The issue raised here is critical. I am a member of Mothers Against Eating Disorders (#MAEDVocates) and International Eating Disorder Actions (#IEDAction) and also someone who is currently doing very well in recovery from Anorexia. I know first hand how devastating and destructive this disease is, and it is imperative that we take that into consideration before implementing/teaching lessons and messages to the millions who are genetically vulnerable to developing a potentially dangerous and life threatening disease as a result. Personally, my Anorexia was triggered in large part to me adapting a “healthier” lifestyle simply because I thought it would be good for me. Though weight loss was not my intention, it happened VERY rapidly and nearly cost me my life. Thank you so much for this excellent and educational article!

  • Axa

    Thank you so much for this article. My daughter was 8 when she started a healthy eating club with her friend. She had heard in school, during PE’s President’s Fitness Program, that she needed to eat healthy and not eat junk food. She took it to heart and slowly started cutting out deserts and junk food. By the age of 9 she was eating lettuce and fruit and was diagnosed with restrictive anorexia and compulsive exercise. It took two years to get her to her normal weight and it was a nightmarish process. She has been in remission/recovery for 6 years but to this day exhibits brain changes as a result of the anorexia. We need more medical providers writing articles like this.

  • This is such an important conversation to have. My son’s obsession with food restriction leading to anorexia was triggered not from wanting to lose weight but from fear of becoming fat, and also fear of “disease causing” unhealthy food. He was already thin, and our family already ate healthily, but he noticed puberty turn the bodies of previously thin people into what he perceived as “fat”. The messages from within and without of the school of eat less fat and sugar, and fat is bad became something he felt he need to focus on. Further complicating things was a family member fighting breast cancer who was following an extreme diet that involved eliminating so called “cancer causing foods” and eating only so called “anti-cancer” foods. What resulted was a fear of not just junk food, processed food and foods high in fat and sugar but a fear of all “unhealthy” or “disease causing” foods, including healthy foods containing any amount fat, sugar or salt and all meat. Even now he is weight restored fear of “bad” foods persists and is a barrier to recovery. All the healthy eating messages did not teach my, then 12 year old, to make good food choices, it bombarded him with messages that made him afraid of bad choices, taught him that food makes you “fat” and food makes you “sick”. What we are doing is not working, many kids are not going home and using these messages to eat better and therefore maintain a “healthy” weight, they are just feeling guilty, confused and overwhelmed and in cases like my sons, a previously healthy, strong and fit boy now has his health compromised by osteoporosis and anorexia. There is no worse time to send these confusing and fat shaming messages to our kids than in the school years when the body needs extra fuel and fats for growth and development and healthy bones.

  • Fran

    This smart, thoughtful article is an excellent example of why a child’s nutritional needs, weight/height ratio, and overall general health be left as a private conversation between the parents and the child’s pediatrician.

    Our daughter, was a cross country/track runner in HS. The fall of her senior year, her coach had a nutritionist visit and talk to her team. This woman told the group “The Snicker Bar you eat on Tuesday WILL effect the race you run on Saturday.” From that moment, our daughter’s life, and our family, were never the same. She began her restricting that afternoon. It seemed like each month more and more was being restricted and the running became excessive. By March she was running 60-70 miles/week and spending less and less time with friends. (This remark had the same impact on another girl the following spring. She was on the tennis team.) These are not elite athletes. These are our children just wanting to have fun. She was still developing, and like most teens her body, moods, and dreams changed frequently.

    Her restricting began the fall of 2005. It is now the summer of 2014. As a family we have been blessed with being able to afford the best treatment for her, and to her credit, she has never lapsed in her commitment to therapy. Nevertheless, this struggle and the urge to restrict continues.

    We pray every day that a miracle will pull her from this black hole. How sad is that? Families should not have to rely on miracles for recovery.

  • Thank you so very much for all of these important and powerful stories.

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  • Belinda Caldwell

    Exactly our experience and of many I have met in this journey – far more common than going on a diet to get thin or look like a modelFamilies have now been shown to be an important element of the recovery process for eating disorder sufferers but the process of caring for this specific illness is extremely challenging, requiring enormous emotional reserves and new parenting skills for many. In addition, it can result in financial challenges with family members unable to work and, at times, a need for strong advocacy on behalf of your family member in a health system which can appear fragmented and confusing!
    Our daughters school measured BMI and did beep test comparisons etc. She was also taught about healthy eating messages and national guidelines for physical activity which she took on verbatim. Our kids have a biological and personality make up which makes them very good at adhering to rules and guidelines while wanting to be good at everything and please people. My daughter was thin before all this started. There is no evidence that these programs work to reduce obesity but many of us know there heartbreak of the hellish and long journey that a diagnosis of anorexia nervosa is.

  • Anonymous

    I appreciate this article very much, and agree that it is reckless for schools to be promoting these kinds of poorly thought-out practices. I wanted to chime in as someone recovering from 7+ years of an eating disorder. While comments about food and weight and competition amongst peers can certainly (and often do) trigger eating disorders, I firmly believe that an eating disorder is never caused by only one thing, be that genetic loading, or school or family environment. While the salience of the obesity panic that exploded while I was an adolescent certainly influenced my predilection for anorexia in that it made me starving myself more socially acceptable (and thus my weight loss wasn’t noticed until it was severe), I would never list this as the cause of the anorexia. I really do appreciate the sentiment of this post, but I wanted to share my thoughts because too often eating disorders are put down to being caused “by society”. I wish that were the case; it would have made recovering a lot easier.
    Again, thanks for blogging about this.

  • Ana

    My son is only one, so I have some time to develop a strategy around food. However, my husband and I are both obese and it runs in both families. I thought that I would teach my son about “healthy choices,” but after reading this post perhaps I should frame it as “tasty and fun” food and leave the other characteristics for adult only conversations. Thank you for the information.