Dr Rachel Melhem has been a DiSS clinician for two years, operating at Mount Ridley P-12 College in Craigieburn.
One of the most challenging aspects of her work is identifying students who have eating disorders and associated conditions, such as body image concerns.
This is a subject that confronts all DiSS teams. Peak body Butterfly estimates that although 1.1 million Australians live with an eating disorder, only 30 per cent seek help.
Eating Disorders Victoria quotes research showing that eating disorder cases are very heavily skewed to people aged between 12 and 19, who account for 27 per cent of cases.
Body dissatisfaction disorders affect more than four million Australians, over half of them teenagers.
Identifying students at risk is therefore important and difficult in equal measure.
Dr Melhem says that there are some behaviours she observes that are important clues.
“I’ve found these to be frequent early indicators of disordered eating or body images concerns,” she says.
This is her list:
- Questions about how to look more ‘toned’.
- Skipping meals with no reason given, or being evasive about the matter.
- Introducing new food rules, such as cutting out carbs.
- Black and white thinking about food, classifying them as good or bad.
- Tracking calories.
- Excess interest in exercise.
- Suddenly avoiding eating food at school.
- Frequent self-weighing.
“There are also some telltale clinical signs,” she adds.
“I look for postural tachycardia, inadequate weight gain between visits (particularly when we’ve reviewed a young person over a long period of time), or cool peripheries.
Dr Melhem estimated that body image concerns or eating-related issues present in school-based consultations are the primary reason for a review in between 20 and 30 per cent of her DiSS consultations. Body image concerns or eating-related issues are a contributing issue in as many as 50 per cent.
While the development of eating disorders is complex and multifactorial, she said social media emerges as a major contributor in shaping young people’s perceptions of body image, food, and exercise.
“I think social media plays a very important role, as it can normalise very narrow ideas of what bodies ‘should’ look like and encourage comparison,” she said.
“Particularly in vulnerable young people, constantly being exposed to these ideas may trigger body image concerns and eating-related issues. Less commonly, I have seen it play a positive role when the young person’s algorithm serves them more body-positive and body-neutral content.”
She added that there were some identifiable trends on social media platforms, the viewing of which may influence disordered eating in secondary school students. These include:
- ‘clean eating’
- ‘what I eat in a day’
- ‘fitspo’
- ‘cutting/bulking’
- ‘calorie tracking’
- ‘looksmaxxing’
Dr Melhem said that raising the issue of eating disorders with students was often a delicate business.
“I find taking a curious approach to my questioning has been the most effective approach,” she explained.
“For example, it’s better to say ‘tell me about how you feel when you look at yourself in the mirror or see food or do exercise’, rather than ask ‘why are you doing xyz?’.
“Especially in the early stages of meeting with a young person, I find it’s very easy to lose rapport if there’s any sense of negativity in the way I ask questions.”
Suggesting strategies with young people to support a healthier relationship with food, movement and body image is similarly difficult.
“I think it’s important to first identify what the disordered eating and body image concerns are taking away from the young person,” she said.
“For example, it might be stopping them from socialising, or inducing poor concentration, poor sport performance or impacting their mood.
“Then I can use what the young person has identified, using neutral language, to support a healthier relationship.
“So we might discuss the importance of food regularity to improve their energy. Or perhaps we’ll talk about how breaks from social media can improve mood. Sometimes we’ll chat about reducing their current movement to allow their body more energy and recovery time.”
The next steps, said Dr Melhem, involve identifying appropriate referral pathways or other supports to sustain ongoing management of eating disorders.
“I think the most important first step is to consider if this is a situation that requires parental involvement,” she said.
“This is particularly pertinent when a student has significant disordered eating impacting their cognitive function and how that affects their mature minor status. I also consider if there are any physical parameters indicating instability.
“Where there is a safe relationship with parents, I find that parental involvement is mostly a positive addition and can lead to better implementation of external support.”
School support are also important, she add. These can include observed mealtimes and check-ins with the wellbeing teams.
The school can also be a pathway to psychologists dietitians, external GP support for physical monitoring outside of DiSS terms, paediatricians, and specialist public eating disorder services such as child and youth mental health services.
“It’s really important that we as clinicians realise that recovery takes time,” she added.
“We must be patient, compassionate, and supportive during the process.”
Dr Melhem provided a checklist for DiSS clinicians to assist with managing the physical and mental health aspects of eating disorders in young people on an ongoing basis:
- Ensure regular physical examination, including blind weight, postural BP and HR, BSL and consideration of investigations (bloods and ECG) depending on the history, risk of refeeding and risk of restriction complications.
- Assess at each review eating disorder thoughts and behaviours, mood, self-harm and suicidal ideation, home and school situation and their overall motivation.
- To ensure engagement, try to tailor the consult to the young person. For example, if they’re big on watching TV shows, ask about their latest watch before launching into your history, or if they’re a soccer fan (and there’s space) kick a ball together while going through their history.
She said that being part of the DiSS program afforded a special insight into helping young people with eating disorders.
“I get to watch their progress over time,” she said. “Young people are very resilient with a big capacity change, and often I’m the one learning important life lessons through this.”
Training and resources for DiSS clinicians
- The National Eating Disorders Collaboration (NEDC), in partnership with the Victorian Department of Health, the Centre for Excellence in Eating Disorders (CEED), and Eating Disorders Victoria (EDV), is offering a suite of eLearning courses.
- NWMPHN has partnered with the National Eating Disorders Collaboration (NEDC) to codesign the Right Care Right Place: Eating disorder care in my community project.
- The Butterfly Foundation offers resources for schools and clinicians working with young people experiencing body image concerns or eating disorders.
- HealthPathways Melbourne: Health provider subscription service detailing local assessment, clinical management and referral pathways.
