Beta

The skinny on Yale’s preemptive screening for anorexia

Jinjin Sun/YH

Jinjin Sun/YH

Jinjin Sun/YH

Jinjin Sun/YH

Ben Schenkel takes up an investigation during National Eating Disorders Awareness Week.

Lincoln University used to stake its fame on being the first historically black college in the U.S.—or, alternatively, on its erstwhile control over the nearby Barnes Foundation, a spatially pell-mell collection of Impressionist paintings located on the outskirts of Philadelphia. Last fall, just six years after a well-publicized standoff that resulted in a surrender of its majority share in the Barnes Foundation’s trusteeship, Lincoln University racked up criticism worldwide for a policy that had gone unnoticed for years. Starting in 2006, when this year’s graduating seniors were incoming freshmen, their waist circumferences and body mass indexes (BMI) were measured, compiled, and analyzed, as a means of guarding against obesity.

The more controversial aspect to the policy, and the explanation behind its eluding any outcry for nearly four years, was a mandatory class, “Fitness for Life,” for those Lincoln seniors whose BMIs exceeded 30, the accepted cutoff for obesity; for them, graduation hinged on completion of that extra class. In December, the faculty voted to repeal the requirement, in favor of offering the class on a voluntary basis to obese and non-obese students alike. Ostensibly, this came in response to the charges of discrimination levied against Lincoln University, but also out of concern that it would be viewed as a laughingstock rather than as a leader in the fight against obesity.

Yale, by contrast, has lacked a physical education requirement in recent memory—despite its one-time promotion of the masculinized archetype, that of a strapping gentleman swathed in blue and unmistakable for his burliness. Further contributing to that ideal’s obsolescence were the 1969 introduction of coeducation and the 1990 passage of the Americans with Disabilities Act. In certain situations, though, the powers-that-be at Yale have taken an interest in its students’ physicality. From the ’40s through the ’70s, for instance, Yale and several of its peer institutions mandated that nude photographs be taken of all freshmen, supposedly to assess the prevalence of rickets and scoliosis in the student body.

No longer subject to what some took as eugenic gestures, this generation of Yalies visibly embodies a variety of dimensions and, by extension, disabilities. But unbeknownst to the majority of Yalies, their BMIs are calculated, in isolation, from the medical records they must submit prior to matriculation.

Whereas the Lincoln seniors with a BMI deemed too high once faced obstacles to graduate, any Yale freshman with a BMI deemed too low may face obstacles merely to stay enrolled.

A self-professed early riser, Alice* greeted me chirpily from the inside of Stiles dining hall, catching me off-guard as I dawdled in the adjacent foyer about five minutes ahead of our 9 a.m. breakfast. She had already made a pass through the servery by the time I joined her, and while meditatively stabbing at the pineapple chunks strewn on her tray, she launched into a wholehearted account of what befell her last year.

A competitive gymnast since the age of seven, she turned down several offers at other schools with the understanding that she’d be representing Yale on its varsity squad. Because Alice took part in the recruitment process and was the recipient of a “likely letter” in the fall of her senior year, Yale had been sitting on her medical records for a number of months before it blindsided her with the news—a month into preseason training—that she was ineligible for competition because of her weight. “[Yale] had a responsibility to tell me about the risk,” Alice said, “as it might have influenced my decision to come here.” The decision to sideline her was apparently Yale’s alone—not the Ivy League’s or the NCAA’s.

In the hopes of being reinstated, Alice agreed to consultations twice a week at Yale University Health Services (YUHS); she was weighed, in nothing more than a paper gown, and afterwards, she would discuss her “progress” with the YUHS staff. And yet, Alice’s weight never fluctuated more than 0.2 pounds over the course of the three weeks she was required to show up. “I left feeling as though I were being treated like an in-patient,” she said. YUHS, however, didn’t monitor her eating habits off-premises.

During my conversation with her, Alice pointed out that both of her parents are naturally petite; that she is missing a “digestive enzyme which breaks down processed fats and oils;” that she had never been inhibited by her weight, but rather by a slew of injuries ranging from sore ligaments to a shattered face after a mishap on the vault; and that the majority of Olympic gymnasts—including 2008 gold medalist Nastia Liukin—share with her a BMI beneath 17.5, which she understood to be Yale’s threshold.

Alice was quick to point out the irony that food is an abiding passion of hers, both in terms of preparation and policy. Besides holding down several jobs with Yale Dining, Alice took up an internship with a non-profit devoted to eco-gastronomy this past summer. What she touted above all, as if in her defense, was her improbable victory at a recent eating contest, against the likes of a dozen brawny jocks.

Though Alice appears to have emerged from the ordeal unfazed and emboldened even, she was, in her words, “legitimately devastated” when it came time to quit the team for good. She has managed to obtain solace—and leadership positions—by taking up other extracurriculars, which is why she views the outcome as a “blessing in disguise.” But those involvements didn’t stop Alice from supporting her would-be teammates at meets each weekend—watching them compete as she moved the mats.

Until the brouhaha over her weight was sorted out, she was technically prohibited from so much as entering Payne Whitney Gymnasium (PWG), let alone exercising there. Smirking deviously, Alice admitted that she sneaked into PWG regardless. “I had my head crouched down, in case they had a picture, but no one ever stopped me,” she remembered. “Not working out [would have been] a shock to my whole system.”

But as fellow yalie Stacy* can attest to, this policy of flagging—and potentially penalizing—students with suspiciously low BMIs stretches past the athlete population. For a non-athlete, the BMI cutoff is in the territory of 16 (Stacy’s estimate was 15.5)—considerably harsher than it would be for an athlete.

Sometime late in the summer, well after she’d received her rooming assignment and begun to mull over courses, Stacy got word from YUHS that she would need to make an appointment, concerning her weight, upon arrival her freshman year. That message presented her with the alternatives of taking a gap year for the sake of putting on weight, or else coming as planned and seeing how things played out. Opting for the latter, Stacy eventually fell prey to what she called a “vicious cycle,” whereby the more she stressed out about gaining weight, the more she lost her appetite.

At each of her weekly sessions with YUHS, which she now terms “weigh-ins,” Stacy was given a target weight to aim for the following week. According to Stacy, the inability to raise her BMI sufficiently, by YUHS standards, stemmed from this newly formed anxiety and a genetic predisposition toward skinniness. “Generally speaking, the women in my family are really skinny until marriage, when they start to put on padding,” Stacy joked.

Toward the end of the semester, Stacy was informed that if she kept failing to reach YUHS’ goals for her, she would be withdrawn for the following semester—no matter how superbly she was performing in other areas. Stacy’s impression of YUHS was that “there was no way to get around” its strict guidelines, not even with the help of a dean.

Luckily for Stacy, she had an advocate in the form of her aunt, a local pediatrician. In a phone interview, Stacy’s aunt recounted with relish how YUHS granted her a meeting in early December, whereupon she confronted them with photo albums and growth charts; together these served as proof that Stacy’s frailness was no aberration, but rather a lifelong condition beyond her control.

Dissatisfied with YUHS’ running line that “we go by numbers,” Stacy’s aunt remembered firing back: “[I told them] ‘You can’t lump everybody into the same category when attempting to identify an eating disorder.’” After criticizing YUHS for apparently not taking into account such factors as ethnicity, body fat, and past percentiles on the growth curve, Stacy’s aunt also noted the need for a standard if only because of liability concerns, lest the University be held accountable for “an irregularity where someone collapses randomly.”

The ultimatum was rescinded soon after the intervention, and Stacy has been enrolled ever since—without incident, but with the periodic follow-up. It didn’t hurt that, between semesters while Stacy was still being monitored, her aunt provided her with an antihistamine that would trick her appetite into wanting more.

Though she’s now in the clear, Stacy still has misgivings about the policy’s absolute application: “The most irritating part is that while they have a cutoff for people who are underweight, there is no such cutoff for people at the other end of the spectrum,” she said. Later on, she elaborated that BMI is an imperfect metric for the presence of an eating disorder because students’ BMIs are derived only once, there is no way for YUHS to detect the onset of an eating disorder after the start of freshman year, unless it’s reported to them independently.

Whatever flaws Stacy perceives in its policy, she recognizes that YUHS had a legitimate interest in seeing to her wellbeing: “I clearly knew I wasn’t at a normal weight,” Stacy said. “Ideally, if there was some way I could gain 20 pounds within a day or two, I would do it. My life would be made so much easier in terms of self-esteem, finding clothes, small things like that.”

Whereas Stacy takes issue with the policy’s severity and singularity, Calvin*, a willowy dancer who has been that way his entire life, was able in hindsight to laugh about being screened. Nothing in the way of discipline came out of Calvin’s single weigh-in last semester, as he forgot about the follow-up and YUHS has yet to chase after him.

Calvin thinks of the policy as more inconvenient to—than discriminatory against—the underweight students affected by it. However, he was bothered by the undisguised pretext that YUHS used to coax him there for a review. “[YUHS] called me on the phone because they wanted to double-check my height and weight. As they phrased it, they couldn’t ‘make out the handwriting on the form,’” Calvin said, before adding that, although the physician who saw him was unfailingly friendly, she “didn’t do anything drastic to try and cover up” her skepticism of his eating habits.

Unlike the other two categories of eating disorders, bulimia and overeating, anorexia is distinguished by its starvation dynamics, pointed out Dr. William Sledge. (Presently the Medical Director at Yale New Haven Psychiatric Hospital, and formerly the master of Calhoun, Sledge once studied under Hilde Bruch, author of the seminal manual The Golden Cage: The Enigma of Anorexia Nervosa.) Sledge provided a litany of the potential byproducts of a too-low BMI: hair loss; muscular atrophy; electrolyte imbalances; depression and fatigue; cessation of menstruation, which can lead to sterility; an impaired immune system; cardiac arrythmia, due to changes in circulatory flow; and even stunted cognition.

“That’s why it may seem that some of the policies are heavy-handed,” Sledge said, “because they don’t want the individuals to get nutritionally compromised.” He noted further challenges inherent to spotting and addressing eating disorders. For one, they are not a “unitary condition” afflicting people for the same reason, or in the same manner. The main issue in treatment is that the people who need it are usually resistant, denying that there’s anything wrong with them; this could be due to the perfectionist tendencies that sometimes give rise to the eating disorder, or simply to not sensing its underlying ill effects. No matter which, the “medical dilemma,” to borrow Sledge’s phrase, is a standoff between provider and patient that gives way to a misplaced sympathy for the latter’s “plight,” as if they’re being spoon-fed a standard that is out of reach for them.

Christina Roberto, GRAD ’12, a fourth-year PhD candidate in both clinical psychology and at the School of Public Health, studied eating disorders as a psychology major at Princeton. Immediately after graduation, she embarked on a two-year stint at a pro bono clinic run through Columbia University (the only one of its kind in the country, for in-house treatment of anorexia).

“Eating disorders have heritability rates comparable to other mental disorders that are traditionally viewed as more biological in nature,” Roberto told me. “It’s a misconception people have that eating disorders are easier to develop, or that they’re problems of vanity.” Despite their strong genetic component, eating disorders can also be influenced by environmental factors. The transition to college can promote disordered eating behaviors, owing to a cocktail of factors like academic pressure, irregular scheduling, accessibility of snacks (Roberto, though a grad student, knew to cite “butteries”), group living, and increased discussion of body image.

Because college students are so vulnerable to eating disorders, Roberto was nonplussed by my mention of those constitutionally thin students, like Alice and Stacy, whom the YUHS policy may be embracing unfairly.

“If you have a BMI below 15.5, it’s good that the University is concerned for you,” Roberto admonished. Self-deception (the word she used was “ego-syntonic”), she said, can interfere with an appropriate diagnosis. Referring to those who grapple with acknowledging an eating disorder, Roberto said: “Many of them seem high-functioning, but you don’t know what’s going through their heads.”

When pressed for comment, the officials at YUHS itself were highly receptive and forthcoming. In an email, Chief of Student Medicine Dr. James Perlotto, ES ’78, wrote that “[disordered eating] is very common at Yale and in wealthy, developed societies such as ours.”

“Each case of a possible eating disorder is, of course, handled on an individual basis, [but] once a BMI falls below 18, it can be cause for concern. Only “if no cause can be found, and if the student does express concerns about conflicts with eating, or worrying about weight,” would Perlotto involve his colleagues at Mental Health.

Registered dietitian Lisa Kimmel, who works simultaneously for the Student Medicine and Mental Health and Counseling teams at YUHS, emphasized, in an email to me, a holistic battery that “includes a full medical evaluation, lab work, an EKG, nutritional assessment, and mental health evaluation.”

“Our ultimate focus is on the health and well-being of our students,” Kimmel wrote. “Care plans and goals are therefore individualized between the student and health care team. It’s not just about ‘putting on a few pounds.’”

Save for Kimmel, every one of the experts made sure to mention, emphatically, that anorexia has the highest mortality rate of any psychiatric condition (and that other strains of eating disorders pose dangers of their own, sometimes fatal).

Though she’s appreciative of the dangers to an eating disorder, Rebecca*, another undergrad, had an unfounded “weigh-in” experience of her own, starting the first day of her freshman year. Originally, Rebecca felt that YUHS’ overtures were a “nuisance,” since she does not have an eating disorder. But she maintains that the staff was “very cordial and warm,” and that they “were willing to adjust their rules for particular cases.” Never was Rebecca under the impression that she risked being suspended, if her weight weren’t brought up to a certain level.

“I think that at the worst, it’s a minor inconvenience that people should bear for the larger purpose it serves,” Rebecca said, referring to her weekly appointments at YUHS. “In the end, that’s a small cost to pay for a safety net that potentially serves a greater purpose. It’s clear that there are a significant number of students with eating disorders at Yale, and I think YUHS is doing what it can, without being too much of a big-brother type figure, to better help those students.”

Cover design by Jinjin Sun.

*These people’s names have been changed to protect their identities.