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Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?
Have you recently lost more than 14 pounds in a three-month period?
I wonder, if I had answered these questions during my sophomore year of high school, would my anorexia have been caught earlier on? As a female ballerina with a Type A personality, I was an obvious candidate, but it took several months of starving myself before my eating disorder was diagnosed and treated.
According to a new Boston Children’s Hospital study, school screenings with questions like these could be a cost-effective way to detect eating disorders. At 35 cents apiece, a brief questionnaire could help identify and treat some of the most serious and potentially dangerous psychiatric disorders in kids.
Yet while the price is low, recent experiences with school obesity screening suggest that the issues can go beyond money.
Eating disorders, which include anorexia, bulimia and binge-eating disorder, affect at least 3.8 percent of teen girls and 1.5 percent of teen boys in the U.S. While effective therapies exist, only about 3 to 28 percent of teens actually receive treatment.
If left untreated, eating disorders can lead to serious medical complications, hospitalizations and even death. I think my own anorexia went undiagnosed for so long mainly because of the many lies I told about my diet—"I already ate," "I had a huge lunch"—and the countless hours I spent in school and dance classes, out of my parent's sight and scrutiny.
But I was lucky: I narrowly avoided hospital time. I only had to make frequent visits to my own health care trifecta—pediatrician, dietician and therapist. Had my anorexia been more severe or diagnosed even later—as is often the case—my treatment might have involved residential therapies and been much more expensive.
So could school screenings help catch the diseases earlier? The new study, published in the American Journal of Public Health, assessed whether they could help minimize both the health burdens and the cost burdens of eating disorders.
Using a computer simulation, the researchers compared the annual screening of 10- to 17-year-olds with a no-screening scenario.
The screening instrument used—the SCOFF questionnaire— is a self-administered set of five questions scored by school staff. The hypothetical students identified as being at risk for an eating disorder were referred to clinicians for further evaluation and treatment.
Compared to students receiving no screening, those who were theoretically screened received more treatment and recovered from their eating disorder more quickly.
“School-based screening would allow youth who may otherwise go undetected to access services which may significantly improve their health and quality of life,” says Dr. Kendrin Sonneville, the director of nutrition training at Boston Children's Hospital's Division of Adolescent Medicine and one of the study authors. The study finds that screening is a cost-effective way to identify high-risk youth who are often underdiagnosed and undertreated, including low-income, minority, overweight and male teens.
A recent poll found that 53 percent of adults are on board with school-based eating disorder screening.
“I do think that eating disorder screenings should be incorporated into schools,” says Beth Mayer, executive director of the Multi-Service Eating Disorders Association, a Newton-based support network and resource on eating disorder awareness and detection. “Screenings can lead to early intervention, which could potentially prevent serious and chronic eating disorders.”
"Screenings can lead to early intervention, which could potentially prevent serious and chronic eating disorders."Beth Mayer, Multi-Service Eating Disorders Association
However, mandatory school screenings are often not without controversy.
In addition to vision and hearing tests, many states require schools to conduct body-mass index (BMI) screenings, despite the lack of endorsement from the American Academy of Pediatrics. Last year Massachusetts actually banned the sending home of BMI score reports—critically coined “fat letters”—in an effort to protect children’s privacy, as well as prevent stigmatization, bullying, and risky weight loss behaviors.
“We went backwards in the eating disorder field when we began weighing kids at school,” Mayer says. “That is the job of a physician.”
As with BMI reporting, I wonder if a letter home to my parents about my eating disorder risk would have exacerbated my body image concerns or led to classmates' whispers behind my back.
“A potential consequence of mandatory eating-disorder screening can be a sense of shame in the student,” Mayer says. “Screenings should be done in total privacy so that no student has to feel ashamed or embarrassed.”
Actually, I wonder if I would have been flagged at all. Would I have answered the questions honestly or lied, as I so often did? In addition to missing students completely, there's also the risk—with all screenings—of flagging the wrong students.
“No tool can replace a clinical interview for diagnosis. Some students who screen positive and are referred to a clinician for further evaluation will not actually have an eating disorder,” Dr. Sonneville explains. “Although we account for the economic costs of such false positives in our study, we can't ignore the emotional burden this could place on the youth and families.”
As with BMI screenings and other health topics introduced in schools, Dr. Sonneville says some parent opposition is to be expected.
“Parents who have concerns about the screening should be able to opt out of screening for their child,” she says.
Despite the possible drawbacks of school screenings for eating disorders, I can’t help but imagine how my high school experience might have been different had my signs of anorexia been caught earlier on. Had my two-year disorder been shortened or prevented, perhaps I would have spent my weekends obsessing about boys and friends rather than hiding out in my room, carefully planning my meals and calculating calories.
While this study suggests that school screening is a promising option, the researchers were only able to simulate the cost-effectiveness over a 10-year period.
"More research efforts should be dedicated to assessing long-term costs and consequences of eating disorders, which will strengthen the estimated cost-effectiveness of screening programs," Dr. Sonneville says.
So will the screening be coming to a school near you anytime soon? Maybe, but it all depends on the school district's priorities. "School districts face many competing priorities and, understandably, some stakeholders may not prioritize health screenings such as eating disorders screening," Dr. Sonneville says.
In the meantime, pediatricians here in Massachusetts routinely screen children for mental and behavioral health issue—more than any other state, in fact.
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