1. Colby Golder, M.S., R.D.N., C.D.N., Nutritionist
Roseann Neuberg, M.S.N., FNP-C, Primary Care Provider
Annette Santiago-España, Ph.D., Clinical Team Leader
Eating Disorder Team at Columbia University
Identifying and Managing Eating Disorders in Our International Students

2. Spencer Brody Weiss BMI: Perfect in every way!

3. Objectives
Recognize signs and symptoms of eating disorders in our international students.
Identify barriers /challenges to care.
Identify strategies for providing culturally sensitive and informed care.

4. Why Did We Choose This Topic?
There is an abundance of literature on culturally competent practices with international students.
It is also well documented that eating disorders are on the rise around the world.
This is an attempt to integrate culturally competent practices and eating disorders.
Explicitly define roles and expectations
Integrate other important individuals in the process
Facilitate skill building

5. Why did we choose this topic?
The number of international students in the U.S. is increasing at a rapid rate (Institute of International Education, 2017).

6. Why Did We Choose This Topic?
And as the number of international students in the U.S increases, we have a responsibility to know how to best provide culturally sensitive, integrative care for these students (Institute of International Education, 2017). ç

7. Cultural Differences in Body Image
ideal-womans-body-looks-like-in-18- countries_us_55ccd2a6e4b064d5910ac3b0
All ED’s are characterized by distorted body image, but culturally there is a very wide variation I Ideal body types

8. Eating Disorders: Patient Specific Causes and Risk Factors
Genetics and biology. Certain people may have genes that increase their risk of developing eating disorders. Biological factors, such as changes in brain chemicals, may play a role in eating disorders.
The Brain is gradually becoming more effective until age 25 and then it begins to decline.
Mayo Clinic-
(O. Bermudez, 2015). – Brain
(trimming unused connections but enhancing processing speed and effectiveness through adolescence)

9. Eating Disorders: Patient Specific Causes and Risk Factors
Psychological and emotional health Low self-esteem, perfectionism, impulsive behavior and troubled relationships.
Other mental health disorders. High comorbidity rates - anxiety disorder, depression or obsessive-compulsive disorder.
Stress. Whether it's heading off to college, moving, landing a new job, or a family or relationship issue, change can bring stress, which may increase your risk of an eating disorder.
Access to mental health services varies culturally…often taboo, and /or often not acknowledged as contributor to illness. Even if acknowledged and addressed treatment options may be limited ..

10. Patient Specific Causes and Risk Factors (cont’d)
Dieting and starvation. Dieting is a risk factor for developing an eating disorder.
Starvation affects the brain and influences mood changes, rigidity in thinking, anxiety and reduction in appetite.
Starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.

11. Family Specific Causes and Risk Factors
Family history of ED’s
Overprotective families
Parents who overvalue physical appearance
Dieting mothers and critical fathers
When parents restrict eating, children are more likely to eat when they are not hungry. The more severe the restriction, the stronger the desire to eat prohibited foods. These behaviors may set the stage for a full blown eating disorder in the future.

12. Eating Disorders On the Rise: Cultural Change Factors
Rise of global Westernization
Urbanization
Industrialization
Technology advances TV
Social media
Cit: Eating Disorders on the Rise All Around the World: An Overview .
UK study
DiNicola (1990)has argued that there is a connection between eD and culture and called this as CULTURAL CHANGE SYNDROME…that is a result of rapid economic and sociocultural change…Cultural change happens as a result of cultural evolution and human migration…Thus AN may be more prevalent during times of change and confusion and in indiv in rapidly developing countries.
TSAI- generation conflict, disintegration of extended family- growing up in rapidly westernizing Urban centers in migrating to US
More ED in urban area(Nadaoka study in Japan)
(US kids watch 21 hours- impact perceptions of ideal body image (Fiji and Pakistan, Arab and Asia - increased TV exposure)
such as Facebook, Pinterest, Instagram TV
Social media- UK study 1960 women, 20 mins of social media, increased ED Risk
China- first culture to be studied- ED before 1990 rare..
***Too much change too fast in individuals with predisposition for maladaptive coping strategies
Pike & Dunne, 2015
Rise of global Westernization (increased contact with Western views, media and norms)
Urbanization – population shift from rural to urban areas
Industrialization – social and economic changes that occur over time
Technology advances
TV (US kids watch 21 hours- impact perceptions of ideal body image (Fiji and Pakistan, Arab and Asia - increased TV exposure)
Social media such as Facebook, Pinterest, Instagram

13. Cultural Change Factors (cont’d)
Migration patterns
Experiences of acculturation
Shift in gender roles and identities
Shift in traditional family structure
Conflicting information about healthy diet and exercise
Cultural differences in the approach and management of specific health conditions
Stress of War/terrorism
CHANGE is rapid and can be stressful….predisposing anxiety, depression, OCD,
Migration patterns – within or across countries
Experiences of acculturation (e.g., bi-cultural vs mono-cultural identities)
Shift in gender roles and identities
Shift in traditional family structure
Conflicting information about healthy diet and exercise – from one country to the next
Cultural differences in the approach and management of specific health conditions (e.g., low weight due to restriction vs. metabolic issue)
Stress of War/terrorism (e.g., country of origin and 9/11)
And many others

14. Eating Disorders Team At Columbia University
Multi-disciplinary and diverse team
5 Psychologists
1 Licensed Clinical Social Worker
1 Nurse Practitioner
2 Medical Doctors
1 Nurse
1 Registered Dietician
1 Psychiatrist
Patients of concern with a ED then referred to ED team for further assessment and treatment
Our own experience at CU Health has been that our International students have been some of our most acutely ill patients. We have had patients from India, China, South America, Russia, Switzerland, Italy, Japan. We have been forced to navigate some unique challenges with patients from abroad.

15. ED Team Function
The ED Team meets 1x/week to coordinate care for high risk patients
Refer to APA Practice Guidelines for the Treatment of Patients with Eating Disorders
The intensity and duration of treatment depends on:
Severity and duration of disorder
Mental Health Status
Co-existing medical or psychological disorders
Resources available – insurance, proximity to where student lives
Motivation and timing
2017 systematic review by Hilbert and Hoek and Schmidt compared international evidenced based clinical treatment guidelines –Comparison demonstrated notable commonalities
Many indicviduals do NOT receive evidenced based care-Goal interntional coordination of guidelines

16. The Clinicians Role Consider and identify ED’s
Engage peers, family, significant others
Team up with outside multi- disciplinary providers
Collaborate with other university offices at the highest level
Assess and manage students at varying levels of severity of eating disorders
Picture of ED Team-
But first line intervention is educating all clinicians to include ED in the differential dx…
Res Life, Athletics, Deans office, Legal Counsel, Religious affairs, Student organizations, Ombuds office, International Student Office

17. Recognizing Signs and Symptoms: What to look for and How to ask
First Step is to consider Eating Disorders on your differential. Once thought to be an affliction of upper class, White women, we now know that ED’s do NOT discriminate.
All staff need to be mindful of a potential ED dx, not just those on the Ed team…look for clues in Hx and PE, labs
Once suspected, can phrase questions to get info to support your suspicion
Bulimia more common in Latin American countires, AN more common in women than men
With many ED patients, physical appearance may not provide the necessary clue.

18. Medical Signs and Symptoms of Possible Eating Disorder
Fatigue
Difficulty Concentrating
Fainting
Dizziness
Constipation/Bloating
Nausea
Irregular Periods\Vaginal Symptoms\Fertility Concerns
The exception is the patient that comes in with a CC of ED…more common complaints include-

19. Medical Signs and Symptoms of Possible Eating Disorder (cont’d)
Fear of getting weighed
Orthostasis
Thin Hair, Pale Dry Skin, Lanugo
Prominent Parotids
Absent Gag Reflex
Bloating\Hypoactive Bowel Sounds
Atrophic Vaginitis
On Physical exam, findings that may support a ED concern include:
Cultural differences in personal space, comfort during exam/revealing skin- African pts sit proudly naked on the exam table/…
Weight …fear of knowing wt…reorting they don’t have a scale, fear of getting weighed…surprise at weight.?Is this what you expected?
Rate of wt loss important info…rapid, unexplained loss could indicate medical diagnosis (ie., thyroid disorder, infection,cancer)

20. Medical Signs and Symptoms: Assessment
Complete Blood Count/Ferritin/B12
Chemistry
FSH, LH, Prolactin, Thyroid panel, HCG (In Amenorrheic Patients)
Vitamin D
Urinalysis
Dexa for BMD
****Hepatitis B Serologies/H. Pylori/TB****
Standard labs regardless of cultural background. Additionally, Foreign born students from Asia, Africa, Latin America should also have Hep B, H. pylori and TB serologies , as incidece is HIGH in those countries and can impact wt

21. Psychological Considerations
Are you coming yourself or because someone else referred you?
Does anyone know about your behaviors?
Any significant changes in your eating habits recently?
Have you ever been in counseling and/or treated for an ED?
Does anyone in your family have a problem with food/weight?
What messages did you receive from your family about food, eating or weight?
Did your family ever comment on your food habits or body shape/weight?
How to begin the conversation/ask the questions when pt presents to counseling service
Culturally competence includes expressing a curiosity about the following:

22. Psychological Considerations (cont’d)
Has your family been involved/supportive?
How long have you lived in the U.S.?
Do you have a support system here in the U.S.?
How has the adjustment been since arriving in the U.S.?
To what extent have you been able to make friends and build a support system?
What is your living situation?
When was the last time you saw a medical provider? Did they know you have an ED? Was the provider in the U.S. or in your home country?
Do you eat alone or with others in social settings?
NICKNAMES….HOW DOES YOUR BODY COMPARE WITH OTHERS FROM YOUR CULTURE?

23. Nutritional Considerations
Do you prepare your own food? How many meals?
Are you familiar with the foods offered in the dining hall?
What were your favorite foods growing up at home?
Are there any foods that you avoid?
Does anyone in your family have issues with food or weight?
Were there family meals growing up?
Were parents on a diet? Do they maintain rituals/traditions around food?
Many patients on “special diets” for religious/ethical/health reasons- “vegan/gluten free/vegetarian/low carb… must explore motivation for restricitons/avoidance

24. Barriers to Care DACA/Immigration/Visa Issues
Ensure confidentiality to alleviate fear of deportation
Work closely with International Student Office (ISO) and write letters of support for medical leaves which protects student status
DACA student support group
Provide education about Leave Policy
If she was going to continue with yoga in limited amounts, what would a yoga teacher look like? Strong? Meeting where she was at. Eating enough to sustain this. Source of income for patient.
Body Mass Index and Self-rated Health across four east Asian countries (Noh, et al., 2017)

25. Barriers to Care Fear of Being Sent Home
Explore their culture, their concept of health and expectation of therapeutic, medical, and nutrition encounters.
Be mindful of underlying feeling of distrust in Western interventions
Use of treatment contracts
Use of ED Team Administrative Letter
International students are here on Academic visas- if they leave school, their status here may be in jeopardy.
Sense of responsibiity to stay here if family members have made sacrifices for education
“HOME” may be contributing to the problem, may not have treatment options available…
Drive to succeed academically maked ED treatment less of a priority

26. Barriers to Care Financial - Cost of Care
Since 2017, all international students are required to enroll in the university student health plan
All students pay a health fee for access to on campus services
ED Team evaluates level of care, provides short term treatment and surveillance

27. Barriers to Care Language
Explore linguistic skills early and then decide on need for interpreters. Let students know they can bring a friend, use multilingual staff member or make use of Translation Service (Language Line Services: )
Be mindful of metaphors
Allow longer visit times due to information gaps/language barriers
Be aware of variations in non-verbal communication
Put plan into writing
Google translate
Put plan into writing/ to pt – can look up words at home to ensure understanding
Language Line Services
(e.g., sense of personal space, idioms of distress, eye contact)
(e.g., burning of the stomach) for describing distress differ between cultures and are often a way to speak about atrocities (e.g., sexual assault)

28. Barriers to Care Acculturation/Assimilation
Explore patient and family competency, strengths, skills and limitations
Take into consideration level of acculturation/degree of cultural dissonance
Personal self care vs. responsibilities to family
Loyalty to family and/or religion
AS with all ED patients, need to assess whether family members are a support or a contributor to problem. Special considerations with International students include information gaps in care, opportunities for treatment in birth country, sense of responsibility to family over self, religious and cultural views around food, mental health care etc…
(Thompson, 1994) Eating problems may begin as survival strategies and sensible acts of self-preservation in response to injustices such as stress of acculturation.

29. Barriers to Care Lack of Social Support
Recognize there might be an underlying feeling of distrust in medical and mental health professionals
Identify and integrate social and professional support services locally and at home
Explore the shame associated with having an eating disorder and the importance of social support in recovery
Encourage student to participate in ED support group or International Student support group
Consult with religious leaders (e.g., Rabbi, Priest, Minister)
Lack of support
Lifetime prevalence of mental health utilization lower among minority and international populations

30. Barriers to Care: Cultural Food Variations
Recognize distinct eating patterns and quantities of different food groups
Acknowledge there may be a stigma associated with American food portions
Consider cost
Flexibility is the key!

31. Barriers to Care Cultural Food Variations
In 1993, Oldways , in partnership with the Harvard School of Public Health and the WHO, created the multicultural food pyramids to reflect dietary patterns across the world
We’re lucky to be in NYC where we can accommodate all cuisines – easy access

32. Food Pyramids Around the World
Useful tools when meal planning

33. Food Pyramids Around the World (Cont’d)

34. The Balance Between Self-care And Religious Practices
Religious fasting
Cultural/religious dress (hijab)
Praise from family for not eating
Just pray to God
Bigger family meals after fasting
Guilt about preparing meals when family is fasting
Ramadan 18 hrs

35. Readmission Procedures For International Students
Documentation of treatment and readiness to return from providers both locally and abroad
Expect 3 months of treatment, regular labs, and healthy weight
If documentation (e.g., medical reports with low BMI or irregular labs) does not support readiness to return, student is encouraged to take additional time
Schedule readmission evaluation with ED team at Columbia (Psychological, Medical, and Nutrition)
Set realistic expectations about the readmission process
Make recommendation to Dean
Encourage student to remain in close contact with Dean
Dean makes final decision about whether student can return to school
Need to define criteria of acceptable care with pts.

36. Recovery 8 out of 10 will recover from their eating disorder
The probability of recovery increases with cognitive maturation
Evidence based treatments are emerging showing increased and quicker recovery rates
Prevention and awareness strategies are improving
Research funding is increasing
Our best discoveries are ahead of us, not behind us
2017 article by Hilbert- Evidence-based clinical guidelines for eating disorders: international comparison

37. In the Works
American Psychological Association – guidelines for best practices when working with international students
International coordination of evidence-based clinical guidelines for eating disorders

38. ED Resources https://oldwayspt.org/programs
Inspiring Good Health Through Cultural Food Traditions
Go Ask Alice! Body Image Q&As
Something-Fishy.org
About-Face is dedicated to media literacy.
Body Positive is dedicated to fostering self-esteem and a positive relationship to food and our bodies.
Proud2BMe is a body acceptance site.
Gurze Books offers resources on eating disorders.
National Eating Disorders Association has information on the origins, prevention, and treatment of eating disorders.
Mayo Clinic offers a summary of many weight control issues and concerns.
American Psychological Association has information on the treatment of eating disorders.
Eating Disorder Referral and Information Center

39. References
Bernal, G., Jimenez-Chafey, M. I., & Rodriguez, M. M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40,
Bhugra, D., Bhui, K., & Gupta, K. R. (2000). Bulimic disordered and sociocentric values in north India. Soc Psychiatry Psychiatr Epidemiol, 35,
Cheng, P. H., & Merrick, E. (2017). Cultural Adaptation of Dialectical Behavior Therapy for a Chinese Internationa Student with Eating Disorder and Depression. Clinical Case Studies, 16,
Davis, C., & Katzman, M. A. (1999). Perfection as acculturation: A study of the psychological correlates of eating problems in Chinese male and female students living in the United States. International Journal of Eating Disorders, 25,
Gerbasi, M. E., Richards, L. K., Thomas, J. J., Agnew-Blais, J. C., Thompson-Brenner, H., Gilman, S. E., & Becker, A. E. (2014). Globalization and eating disorder risk: Peer influence, perceived social norms, and adolescent disordered eating in Fiji. International Journal of Eating Disorders, 47,
Gitau, T. M., Micklesfield, L. K., Pettifor, J. M., Norris, S. A. (2014). Changes in Eating Attitudes, Body Esteem and Weight Control Behaviors during Adolescence in a South African Cohort. PLoS ONE, 9, 10.

40. References (cont’d)
Jung, J., Forbes, G. B., & Lee, Y. (2009). Body dissatisfaction and disordered eating among early adolescents from Korea and the U.S. Sex Roles, Spring Science + Business Media on-line publication, LLC.
Kolar, D. R., Rodriguez, D. L., Chams, M. M., & Hoek, H. W. (2016). Epidemiology of eating disorders in Latin America. 29, 6.
Makino, M. Tsuboi, K., & Dennerstein, L. (2004). Prevalence of Eating Disorders: A comparison of Western and Non-Western Countries. MedGenMed, 6, 49.
Mammen, P., Russell, S., & Russell, P. S. (2007). Prevalence of Eating Disorders and Psychiatric Co-morbidity among children and adolescents. Indian Pediatrics, 44,
Pike, K. M. & Borovoy, A. (2004). The rise of eating disorders in Japan: Issues of culture and limitations of the model of westernization. Culture, Medicine and Psychiatry, 28,
Rathner, G., & Rainer, B. (1997). Annual treatment rates and estimated incidence of eating disorders in Austria. Wien Klin Wochenschr. 109,
Thompson, B.W. (1994). A hunger so wide and so deep: A multiracial view of women’s eating problems. Minneapolis: University of Minnesota Press.
Ung, E. K. (2003). Eating disorders in Singapore: a review. Ann Acad Med Singapore, 32,

41. Questions/Comments

42. Presenter Contact Information
Annette Santiago-España, Ph.D. Psychologist Counseling & Psychological Services Columbia Health Lerner Hall, 5th Floor 2920 Broadway New York, NY
Roseann Neuberg, FNP-C
Nurse Practitioner
Medical Services
Columbia Health
John Jay Hall, 4th Floor
Mail Code 3601
519 West 114th Street,
New York, NY 10027