Rethinking the Freshman Fifteen

Helen (not her real name), a recent Yale graduate who has suffered from anorexia, got used to seeing nutrition facts displayed at New York chain restaurants when she took a semester off last fall. But when she returned to Yale in the spring, she was shocked to find cards detailing calorie information all over her residential dining hall. "They're very triggering if you're in recovery from an eating disorder," Helen says of calorie counts. "I felt almost violated that Yale had done this."

With more than 30 percent of college students falling into the American College Health Association's obese or overweight categories, Yale is not the only school trying to help students make smart food choices. But experts say the emphasis on calorie counts can backfire and lead to disordered eating, even among students with no history of food issues.

Dr. Richard Kreipe, a specialist in adolescent medicine whose research centers on eating disorders, says that while he has seen fewer cases of classic eating disorders like restrictive anorexia nervosa and bulimia nervosa in the past several years, the number of patients with eating disorders not otherwise specified (EDNOS) has "almost doubled" nationally in the midst of America's obesity epidemic. (An EDNOS, also called disordered eating, is an eating disorder that doesn't meet the strict diagnostic criteria for a full-blown eating disorder, but may include drastic weight loss, caloric restriction, binging, and purging.) Since 2000, the number of college students dieting, vomiting, or taking laxatives to lose weight has jumped from about 28 to 38 percent, according to the American College Health Association's annual surveys. Well-balanced caloric intake, with regular meals and physical activity—not dieting—is the best way to avoid obesity, says Kreipe, a professor at the University of Rochester Medical Center. That's why, in his view, calorie information doesn't benefit students. "Nutrition is not a simple thing that can be distilled down into a label," he says. "There's a tendency for people to overinterpret what a specific number means."

Last fall, Harvard removed cards with calorie information from dining halls. Writing about the decision on his blog, Ted Mayer, executive director of Harvard's dining services, noted that his staff needed to address "the challenge a quiet and surprisingly large contingent of our community faces with eating disorders." The dining staff now makes the information available on the Internet and at kiosks in the dining halls.

Going away to college makes all students vulnerable to weight gain and disordered eating, often at the same time. Students tend to experience a loss of structure when they go from high school to college. Studies have found that college students are less likely to eat breakfast or regular meals, and snack foods account for many often-unrecognized calories. All-you-can-eat dining halls and easy access to alcohol also make college students more susceptible to weight gain. At the same time, anxiety about gaining the "freshman 15" can trigger disordered eating—often well beyond the freshman year. Kreipe says that in a new setting surrounded by new people, college students are more likely to develop body-image issues, which can also lead to disordered eating.

Even overweight students, the prime targets of obesity-awareness programs, may get the wrong message. In a recent study, Dianne Neumark-Sztainer, a professor at the University of Minnesota School of Public Health, found that about 40 percent of overweight college-age women and roughly 20 percent of overweight college-age men engaged in disordered eating behaviors in an attempt to get thin. "People are concerned about the fat kids being fat and the thin kids having anorexia," she says. "But people aren't concerned about the disordered eating among the overweight kids." For under- and overweight people alike, eating disorders can lead to a host of health issues, including electrolyte imbalances, fertility problems, impaired brain development, bone loss, and, in severe cases, death. The study also showed that disordered eating behavior leads to further weight gain over time.

Colleges that focus solely on calorie counts are over-simplifying nutrition, says Neumark-Sztainer, who encourages collaboration between the eating disorder and obesity fields. More comprehensive information—like a nutrient density score—would better serve students. Such data would distinguish between items like a Coke, which is high in calories but low in nutrients, and avocado, which is rich in both calories and nutrients. Neumark-Szainer says the focus at college should be less on what people eat then how they eat. For example, students who eat with others are more likely to make healthy food choices and less likely to develop disordered eating—either eating too much or too little—than those who eat alone, she says.

There are other ways that schools can help students avoid unhealthy weight gain without provoking eating disorders. Colleges should provide opportunities for healthy physical activity that don't necessarily involve being on a sports team or going to the gym, Kreipe says. For example, schools might create walking trails or organize activities and social groups that focus on physically activity. Kreipe also recommends that schools make more healthy options—both in dining halls and vending machines—available. Above all, he says, colleges should be emphasizing portion size.

Some schools have tried to do just that. Last fall, Penn State converted one of its all-you-can-eat dining halls into a so-called "healthy dining hall," free from French fries, deep-fried chicken, or white bread. For each meal, Penn State's healthy dining hall features a model-portion plate, which consists of 50 percent fruits and vegetables, 25 percent grains, and 25 percent proteins. (The program is modeled on one at the University of North Texas.)

Still, Penn State provides caloric breakdowns in its healthy dining hall and in all other cafeterias on campus. "Healthy entrees," designated as those that container fewer than 400 calories and 10 grams of fat, are identified by a special check on the cards. Lisa Wandel, Penn State's residential-dining director, says it's the college's responsibility to notify students about what's in their food. "Would you pull labels off all the items in a grocery store?" she says. "We can't hide the fact that food has calories. I think it's better to provide that information so students can make educated choices."

Despite objections from students like Helen, Yale also plans to continue posting calorie counts in its dining halls this year. Rafi Taherian, executive director of Yale dining, says he expects that students will one day have access to real-time information about food through their cell phones or laptops. "I don't think we can hold the information back from them," he says. In fact, Rafi predicts that colleges, like some states and cities, will soon be required to provide students with nutritional data.

More important, it seems, is giving students the context to understand that information and making sure their education focuses on healthy behavior, not numbers on a scale.