Eating Disorders Information

for Middle School Personnel

BODYWISE HANDBOOK
The BodyWise Eating Disorders Information Packet for Middle School Personnel was prepared under 

U.S. Department of Health and Human Services Program Support Center Contract Number 282-97-00709,

Task Order 2, for the Office on Women’s Health. Permission to reproduce this document is granted.

Washington, DC: September 1999, 2nd ed. July 2000; 3rd ed. April 2005.
TABLE OF CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Understanding Disordered Eating and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . .4

Key Information for School Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Eating disorders and disordered eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Disordered eating affects learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Eating disorders as a mental and physical health issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

The importance of early detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Members of all ethnic and cultural groups are vulnerable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

The school community can help prevent eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Using the BodyWise Information Packet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Eating Disorders Information for Middle School Personnel 3

INTRODUCTION

The BodyWise materials seek to connect

healthy eating, positive body image, and acceptance of size diversity with favorable learning

outcomes. They also encourage school personnel to view disordered eating and eating disorders not in isolation, but in the broader context

of health and risk-taking behaviors.

Studies in the last decade show that some

disordered eating is related to other health risk

behaviors, including tobacco use, alcohol use,

marijuana use, delinquency, unprotected sexual

activity, and suicide attempts.1 The information

and suggestions provided throughout the

BodyWise packet can be easily integrated into

your existing curricula and health promotion

activities.

The BodyWise Handbook is one component of

the BodyWise packet. The handbook includes

four sections:

◆ Understanding Disordered Eating and Eating

Disorders—An overview of disordered eating and eating disorders, and a brief definition of terms.

◆ Key Information for School Personnel—Six

main messages for school personnel that

form the core of the BodyWise initiative.

◆ How To Use the BodyWise Information

Packet—A description of the materials contained within the BodyWise packet and how

they can be used by school personnel.

◆ Definitions—Detailed definitions of eating

disorders, including diagnostic criteria from

the American Psychiatric Association.

You are encouraged to reproduce the materials

in the BodyWise packet and distribute them to

other school personnel, parents, and students.

“BodyWise fits beautifully with

our Girl Power! mission. Smart

eating not only builds healthy

bodies, it is linked to better

school performance, a more

positive self-image, and a

brighter future. Recent studies

suggest that unhealthy eating

practices can begin in children

as young as 8 years old. Yet,

adults who regularly interact

with middle-school-aged children are usually not adequately

trained to recognize the potential risk factors, signs, or

symptoms of eating disorders

or disordered eating.”

—Wanda K. Jones, Dr.P.H., 

Deputy Assistant Secretary for

Health (Women’s Health)

The BodyWise Handbook was developed by the

Office on Women’s Health (OWH), of the U.S.

Department of Health and Human Services

(HHS), as a part of its BodyWise Eating

Disorders Initiative. Through this initiative, a

packet of materials designed to address eating

disorders and disordered eating among preadolescents was developed and distributed to

school personnel nationwide in the year 2000.

These materials have now been updated and

revised. A new information sheet on eating disorders and obesity has also been added to the

packet.

The BodyWise initiative was developed to provide school personnel and other adults who

interact with students ages 9 to 12 with the

information and encouragement needed to create environments, policies, and programs that

discourage disordered eating. A second objective

is to help identify youth who have warning signs

of eating disorders. The long-term goal of this

initiative is to reduce the risk factors that may

contribute to the development of eating disorders and increase factors that may prevent eating

disorders among youth, such as self-esteem, positive body image, and empathy.

The materials in this BodyWise Information

Packet on Eating Disorders for Middle School

Personnel were developed by health communications specialists in partnership with

researchers, clinicians, and educators committed to increasing awareness about eating disorders. In addition, school personnel provided

input into the development of these materials

by participating in focus group meetings conducted by OWH in ethnically and geographically diverse regions of the country.

The BodyWise packet features information

specifically directed to adults who work with

students in grades five, six, and seven. It

addresses the signs and symptoms of eating

disorders, steps to take when concerned about

students, and ways to create a school environment that discourages disordered eating.
4 BodyWise Handbook

Pre- and early adolescence is a time of physical

and psychological change. As young people

grow into adulthood, they begin to express

their unique identities. Dramatic physical

changes—increases in height, weight gains, and

sexual maturation—are often accompanied by

mood swings, wavering self-esteem, and intense

peer pressure.

During these years, young people become

increasingly concerned with their appearance.

They are exposed to media messages in music,

television, and advertising that often promote

the ideal female body as thin and the ideal male

body as muscular.

Because our society is focused on appearance,

body image becomes central to young people’s

feelings of self-esteem and self-worth—overshadowing qualities and achievements in other

aspects of their lives. Young girls start talking

about “how they look” and “how much they

hate how they look.” They may dwell on the

“cellulite” in their legs or their not-flat enough

stomach and develop a fear of fat—both in

their food and on their bodies.

Young people of all ethnic and cultural backgrounds are subject to the influences of the

dominant culture. They may associate success

or acceptance by their peers with achieving the

“perfect” physical standard portrayed by the

media. As a result, boys and girls may adopt

extreme forms of exercise and bodybuilding.

As their bodies are developing, students may

experience teasing or negative comments about

their body size or shape from family or friends.

Some may encounter sexual or racial discrimination or harassment. Consequently, they may

feel shame, dissatisfaction, embarrassment,

rejection, or even hatred toward their growing

bodies.

Young people may use food as a way of coping

with these types of stresses and other pressures

in their lives. Some students may attempt to

gain a sense of control by carefully regulating

what they eat—eating only certain foods or eating very little. Others may overeat snack foods

to reduce stress and relieve anxiety.

You may be familiar with one or more of the

following scenarios:

◆ The student who eats only a small amount

of each food on her plate because she’s

afraid of getting fat.

◆ The adolescent boy or girl who comes home

to an empty house and eats whatever snack

foods are available.

◆ The young girl who skips breakfast and

lunch, has a candy bar and diet soda after

school, finds a way to skip the evening meal

with her family—and then goes on a secret

eating binge in the evening.

◆ The wrestler who fasts for 2 days before his

match to make weight, then eats nonstop

for the next day or two.

◆ The dancer, gymnast, or cheerleader who

refuses meat, eggs, milk, or any foods she

imagines might make her fat and unable to

perform.

◆ The bright and confident class president

who is teased about the size of her body and

begins a fad diet to lose weight.

Body dissatisfaction, fear of fat, being teased,

dieting, and using food to deal with stress are

major risk factors associated with disordered

eating.

“My clothes weren’t right. My

parents were weird. I didn’t fit

in. . . I raised my hand too

often at school. . . Then, at

age 10, it seemed I woke up to

a body that filled the room.

Men were staring at me, and

the sixth-grade boys snapped

the one bra in the class. Home

after school, I’d watch TV and

pace. Munching chips. Talking

to the dog. Staring out the window. Eating macaroni. Eating

soup. Eating...”2

—Marya’s Story

UNDERSTANDING DISORDERED EATING

AND EATING DISORDERS
Eating Disorders Information for Middle School Personnel 5

DISORDERED EATING

Disordered eating refers to troublesome eating

behaviors, such as restrictive dieting, bingeing,

or purging, which occur less frequently or are

less severe than those required to meet the full

criteria for the diagnosis of an eating disorder.

Disordered eating has been termed “restrained,”

“dysfunctional,” or “emotional” eating, as well

as “chronic dieting syndrome.” It can mean not

eating enough. It can also mean eating too

much, ignoring natural feelings of fullness.

In contrast, normal eating is controlled by an

internal system that regulates the balance

between food intake and energy expenditures—so that a person usually eats when hungry and stops when full and satisfied. Normal

eating is flexible and includes eating for pleasure and social reasons. In normal eating, a

person follows regular habits—typically eating

three meals a day and snacks to satisfy hunger.

Normal eating provides nourishment for the

body, increasing energy and strength, and

enhancing health and feelings of well-being.4

Students engaged in disordered eating may

move back and forth across a continuum,

returning to normal eating after bouts of dieting or binge eating. Disordered eating can

impair a student’s ability to learn when accompanied by undernourishment or preoccupation

with thoughts of food, body image, or hunger.

Disordered eating can also be an early warning

sign of an eating disorder. Susceptible individuals may go on to develop an eating disorder

from which they cannot recover on their own.

EATING DISORDERS 

An eating disorder is a psychiatric illness with

specific criteria that are outlined in the

“Diagnostic and Statistical Manual (DSM-IVTRTM)” published by the American Psychiatric

Association (see “Definitions” section of this

handbook, pages 18 and 19).

Eating disorders have both mental and physical

components with serious medical consequences

that can disrupt growth and development.

Illnesses such as anorexia nervosa, bulimia nervosa, or binge eating disorder are among the

key health issues affecting adolescents and

young adults. Nine out of every 10 cases are

found among girls and young women. All

socioeconomic, ethnic, and cultural groups 

are affected.

Katie, now 14, was in third

grade when she began anorexic behaviors. “I compared

myself to others and to the

commercials on losing weight.

And my mom and my friends’

moms are always talking about

dieting. Then one day this boy

and I were kidding around and

he said, ‘You’re fat.’ That did

it. I just stopped eating and I

weighed myself all the time.

This went on through fourth

and fifth grades.” The summer

before sixth grade, Katie was

put in the hospital.3

DISORDERED EATING BEHAVIORS

Disordered eating encompasses

one or more of the following types

of behavior:

◆ Skipping meals. 

◆ Restricting food choices to a few

“acceptable” items.

◆ Focusing excessively on

avoiding certain foods, 

particularly foods that contain fat.

◆ Binge eating, particularly

snack foods and sweets.

◆ Self-induced vomiting.

◆ Taking laxatives, diuretics

(water pills), or diet pills.
6 BodyWise Handbook

Anorexia Nervosa

Approximately one out of every 100 adolescent

girls develops anorexia nervosa, a dangerous

condition in which people can literally starve

themselves to death.5 People with this disorder

eat very little even though they are already thin.

They have an intense and overpowering fear of

body fat and weight gain.

Bulimia Nervosa

Another two to five out of every 100 young

women develop bulimia nervosa, a pattern of

eating followed by behaviors such as vomiting,

taking laxatives or diuretics (water pills), or

overexercising to rid the body of the food or

calories consumed.6 People with bulimia 

nervosa have a fear of body fat even though

their size and weight may be normal.

Binge Eating Disorder

Binge eating disorder, characterized by frequent

episodes of uncontrolled eating, is probably 

the most common eating disorder. More than 

one-third of obese individuals in weight-loss

treatment programs report problems with

binge eating.7 The overeating or bingeing is

often accompanied by feeling out of control

and followed by feelings of depression, guilt,

or disgust.

Sari describes how her eating

disorder began. “I was on this

diet of 800 calories a day, and

I was losing lots of weight.

One day I was home alone and

I couldn’t get the chips in the

kitchen cabinet out of my

mind. I ate the whole bag—and

then half a package of chocolate-covered graham crackers.

I was so sick, I threw up. The

next time I went on a binge I

felt disgusted with myself, but

I didn’t throw up. So I stuck

my finger down my throat. It

was so easy to keep my behavior a secret. I’d eat normally in

front of everyone and binge

when my parents were working, so they never heard me

vomiting. And I worked out at

least 2 hours every day.”8

OVEREXERCISING

Overexercising, often practiced by people who have anorexia and bulimia, is

exercising frequently, intensely, or

compulsively for long periods of time,

primarily to compensate for food eaten

recently or to be eaten in the near

future. A person who overexercises

might display one or more of the following characteristics:

◆ Exercises more frequently and more

intensely than is required for good

health or competitive excellence.

◆ Gives up time from work, school,

and relationships to exercise;

likes to exercise alone.

◆ Exercises despite being injured or ill.

◆ Defines self-worth in terms of

athletic performance.

◆ Says she or he is never satisfied with

a performance or game; does not

savor victories.

Overexercising is of particular concern

when accompanied by disordered eating, body dissatisfaction, fear of fat, or

obsession with weight and food.
Eating Disorders Information for Middle School Personnel 7

KEY INFORMATION FOR SCHOOL

PERSONNEL

SIX KEY BODYWISE MESSAGES

This section summarizes key

information for school personnel,

which has been organized into

six main messages:

◆ Eating disorders may begin

with disordered eating behaviors at very young ages.

◆ Students’ ability to learn is

affected by disordered eating

and eating disorders.

◆ The problem of eating disorders is a mental health as

well as a physical health

issue. 

◆ Early detection of an eating

disorder is important to

increase the likelihood of 

successful treatment and 

recovery. 

◆ Students of all ethnic and cultural groups are vulnerable to

developing eating disorders. 

◆ Each member of a school

community can help create

an environment that discourages disordered eating and

promotes the early detection

of eating disorders.

These messages form the core

of the BodyWise initiative and

are included in the BodyWise

information sheets.

While only a small percentage of people who

diet or express body dissatisfaction develop

eating disorders, the beginning of an eating

disorder typically follows a period of restrictive

dieting, a form of disordered eating for youth.

Binge eating disorder is a newly recognized

condition that affects millions of people. People

with binge eating disorder have varying degrees

of obesity. Most have a long history of repeated

efforts to diet and feel desperate about their

difficulty in controlling food intake. Binge eating behaviors can begin during childhood.

The middle-school years—grades six, seven,

and eight—are opportune times to recognize

and discourage disordered eating behaviors.

Although these behaviors may not constitute a

serious illness, they are still unhealthy practices

that can affect students’ ability to learn. They

can also trigger a full-blown eating disorder in

a susceptible individual that requires intensive

treatment.

Many studies show that disordered eating

behaviors begin as early as 8 years of age, with

complaints about body size or shape. The

Harvard Eating Disorders Center (HEDC)

reports that in a study of children ages 8 to 10,

approximately half of the girls and one-third of

the boys were dissatisfied with their size. Most

dissatisfied girls wanted to be thinner, while

about half of dissatisfied boys wanted to be

heavier and/or more muscular.9

Many individuals with clinically diagnosed

anorexia nervosa and bulimia nervosa remember being teased or recall that their problems

first began when they started dieting. Similarly,

they recall experiencing body dissatisfaction

and/or fear of fat, even though they were

within the natural weight range for their age.

Eating disorders may begin as disordered eating

behaviors at very young ages
8 BodyWise Handbook

A review of research compiled by the Tufts

University School of Nutrition Science and

Policy concludes that undernutrition—even in

its “milder” forms—during any period of childhood can have detrimental effects on the cognitive development of children.10 Undernutrition

has an impact on students’ behavior, school

performance, and overall cognitive development. Undernourished students are hungry.

Being hungry—experienced by everyone on

occasion—causes irritability, decreased ability

to concentrate, nausea, headache, and lack of

energy. Students with disordered eating behaviors may experience these sensations every day.

Those who attend school hungry have diminished attention spans and may be less able to

perform tasks as well as their nourished peers.

Deficiencies in specific nutrients, such as iron,

have an immediate effect on students’ memory

and ability to concentrate. The effects of shortterm fasting on academic performance are well

documented. Numerous studies have reported

significant improvements in students’ academic

achievement just from eating breakfast.

When students are not eating well, they can

become less active and more apathetic, and

interact less with their surrounding 

environment.11 This in turn affects their social

interactions, inquisitiveness, and overall cognitive functioning. In addition, undernourished

students are tired and more vulnerable to

illness. They are also more likely to be absent

from school.

Undernourished students may be

preoccupied with thoughts of food and

weight.

Students with eating disorders share some of

the same physical and psychological symptoms

as people who have experienced starvation.

For example, preoccupation with food was documented in the Minnesota Human Starvation

study12 and, more recently, has been observed

in clinical practices with regard to eating disorders.13 One of the major effects of starvation

and semistarvation appears to be an obsession

with food.14

Students’ ability to learn is affected by disordered 

eating and eating disorders

“Girls or boys who are self-conscious about their weight and

shape, engage in restrictive

dieting or excessive exercise,

or think of their goals in terms

of pounds or fashion models

are less interested in and less

able to participate in

learning.”16

—Michael Levine, PhD,

Professor, Department of

Psychology, Kenyon College

“In our clinical practice we surveyed over 1,000 people with clinically diagnosed eating disorders.

We found that people with anorexia nervosa report 90 to 100 percent of their waking time is spent

thinking about food, weight, and

hunger; an additional amount of

time is spent dreaming of food or

having sleep disturbed by hunger.

People with bulimia nervosa

report spending about 70 to 90

percent of their total conscious

time thinking about food and

weight-related issues. In addition,

people with disordered eating,

may spend about 20 to 65 percent of their waking hours thinking about food. By comparison,

women with normal eating habits

will probably spend about 10 to

15 percent of waking time thinking about food, weight, and

hunger.”15

—Dan W. Reiff, MPH, 

Therapist and Author

“Although students with eating

disorders may display deteriorating school performance,

anorexic young women often

have perfectionist attitudes

which enable them to maintain

high levels of academic

achievement, despite their

being seriously malnourished.”

—Harold Goldstein, Ph.D.,

Former Clinical Director, Eating

Disorders Program, National

Institutes of Mental Health
Eating Disorders Information for Middle School Personnel 9

Anorexia nervosa, bulimia nervosa, and

binge eating disorder are classified as

psychiatric illnesses. 

The development of eating disorders involves a

complex interaction of factors including personality, genetics, environment (familial, social,

and cultural), and biochemistry.18 Many people

with eating disorders also suffer from other

psychiatric illnesses, such as depression, anxiety, and obsessive compulsive disorder.

The National Institute of Mental Health reports

that many people with eating disorders share

certain characteristics such as low self-esteem,

feelings of helplessness, and fear of becoming

fat. Eating behaviors in people with anorexia

nervosa, bulimia nervosa, and binge eating

disorder seem to develop as a way of handling

stress and anxieties. Those with anorexia

nervosa tend to be “too good to be true.” They

keep their feelings to themselves, rarely disobey,

and tend to be perfectionists, good students,

and excellent athletes.

Some researchers believe that people with

anorexia nervosa restrict food to gain a sense

of control in some area of their lives. Young

people with this disease often follow the wishes

of others. As a result, they do not learn how to

cope with the problems typical of adolescence,

growing up, and becoming independent.

Controlling their weight may appear to offer

two advantages, at least initially: they can take

control of their bodies and gain approval

from others.

People who develop bulimia nervosa and binge

eating disorder typically consume huge

amounts of food—often junk food—to reduce

stress and relieve anxiety. Feelings of guilt and

depression tend to accompany binge eating,

while individuals with bulimia nervosa are

impulsive and more likely to engage in risky

behaviors such as alcohol and drug abuse.

Genetic, behavioral, environmental, and

biochemical factors all play a role in the

development of eating disorders.

Eating disorders appear to run in families,

suggesting that genetic factors may predispose

some people to eating disorders. However,

other influences may also play a role. Mothers

who are overly concerned about their daughters’ weight and physical attractiveness may put

the girls at increased risk of developing an

eating disorder. In addition, girls with eating

disorders often have fathers and brothers who

are overly critical of their weight. Some

researchers link an increase in the rate of disordered eating to increased pressures on women

by the mass media, fashion, and diet industries

to pursue thinness.19

In addition, scientists have studied the biochemical functions of people with eating

disorders and found that many of the neuroendocrine system’s regulatory mechanisms are

seriously disturbed.20

“At the end of the 20th 

century, fear of fat, anxiety

about body parts, and 

expectations of perfection in

the dressing room have all 

coalesced to make ‘I hate my

body’ into a powerful mantra

that informs the social and

spiritual life of too many

American girls.”17

—Joan Jacobs Brumberg, 

The Body Project

The problem of eating disorders is a mental health as

well as a physical health issue
10 BodyWise Handbook

Eating disorders have serious physical

consequences that can begin during

adolescence.

Adolescence is a time of rapid growth and

development. Approximately 90 percent of

adult bone mass will be established during adolescence.21 Osteoporosis (“porous bones” that

break easily) can begin early in both girls and

boys who are dieting or suffering from anorexia

nervosa. An extended period of starvation or

semistarvation stunts growth, can delay the

onset of menstruation, and can damage vital

organs such as the heart and brain. One in 10

cases of anorexia nervosa leads to death from

starvation, cardiac arrest, other medical complications, or suicide.22

The vomiting that often accompanies bulimia

can erode tooth enamel and damage the esophagus. Using laxatives as a form of purging can

result in stomach and colon damage. Both

anorexia and bulimia can cause fluid and electrolyte abnormalities, including dehydration

and a deficiency in potassium resulting in muscle weakness, irritability, apathy, drowsiness,

mental confusion, and an irregular heartbeat.

The major complications caused by binge eating disorder are the diseases that accompany

obesity, such as heart disease, high blood pressure, diabetes, gall bladder disease, and certain

types of cancer.

Students engaged in disordered eating

behaviors are not well nourished.

Pre-adolescents need highly nutritious foods to

support their rapidly growing and developing

bodies. However, students with disordered eating behaviors are likely to consume much less

than the recommended daily allowances of

many essential nutrients.
Eating Disorders Information for Middle School Personnel 11

During adolescence, young people often experience variations in height and weight. A girl or

boy who puts on weight before having a growth

spurt in height may look plump, while a student who grows taller but not heavier may

appear rather thin. These changes should not

necessarily be viewed as signs or symptoms of

an eating disorder.

You should be concerned about students who:

◆ Complain about their bodies or say they are

too fat even though they appear to be of

normal weight or even rather thin.

◆ Talk about being on a diet or avoiding nutritious foods because they are “fattening.”

◆ Are overweight and appear sad.

◆ Are being teased about their weight.

◆ Are spending more time alone.

◆ Are obsessed with maintaining low weight

to enhance their performance in sports,

dance, acting, or modeling.

Students with any of these characteristics may

be at an increased risk for developing an eating

disorder. You may also want to look for other

signs and symptoms of eating disorders, such

as those listed on the following page.

Proof is not necessary—having a concern that

something may be wrong is enough to initiate a

conversation with the student or a family member. School personnel should look for signs of

possible problems and act immediately.

If you are concerned about a student, here’s

what you can do:

◆ Recognize that school personnel do not have

the skills to deal with the underlying emotional turmoil that often accompanies eating and exercise problems.

◆ Share information with other staff members

who know the student. Find out if they have

noticed similar signs.

◆ Decide together the best course of action

and who should talk to the student and

family members.

TALKING TO A STUDENT OR FAMILY

MEMBER

When talking with a student or family

member, be sure to communicate that

you care about her or him. List the

specific reasons for your concern and

recommend that the student be seen

by a health care provider knowledgeable about eating disorders. Say, “let’s

find out if there is a problem.” Remain

open to further discussion even if the

student and/or her or his family do not

wish to take your advice right away. 

Your goal is to communicate to the

student that you care and to refer her

or him to a health care provider 

knowledgeable about eating disorders. 

For more information on how to talk to

students and family members, see the

information sheet, “How To Help a

Student.”

“Middle school personnel are

less likely to see students with

a fully developed eating disorder, but you may notice students who appear to be rapidly

losing or gaining weight.

However, it is difficult to ascertain whether weight changes

that occur during puberty are

normal or are signs of eating

disorders.”

—Richard Kreipe, M.D., 

Chief, Adolescent Medicine, 

University of Rochester

Early detection of an eating disorder is important to

increase the likelihood of successful treatment 

and recovery
12 BodyWise Handbook

SIGNS AND SYMPTOMS OF 

EATING DISORDERS

In your interactions with students, you may notice one or

more of the physical, behavioral,

and emotional signs and symptoms of eating disorders.

Physical

◆ Weight loss or fluctuation in

short period of time.

◆ Abdominal pain.

◆ Feeling full or “bloated.”

◆ Feeling faint, cold, or tired.

◆ Dry hair or skin, dehydration,

blue hands/feet.

◆ Lanugo hair (fine body hair).

Behavioral

◆ Dieting or chaotic food intake.

◆ Pretending to eat, then

throwing away food.

◆ Exercising for long periods

of time.

◆ Constantly talking about food.

◆ Frequent trips to the bathroom.

◆ Wearing baggy clothes to hide

a very thin body.

Emotional

◆ Complaints about appearance,

particularly about being or

feeling fat.

◆ Sadness or comments about

feeling worthless.

◆ Perfectionist attitude. 

Your school may consider developing a protocol that provides guidelines on talking with students and family members and making referrals to health care providers knowledgeable

about eating disorders. It is also useful to have

your principal designate an eating disorders

resource person who will become acquainted

with local resources for referral.

Treatment can save the life of someone with an

eating disorder. Friends, relatives, teachers, and

health care providers all play an important role

in helping an ill person begin and continue

treatment. Early detection of an eating disorder

is important to increase the likelihood of successful treatment and recovery.

“I got noticed and was complimented on my weight loss at

first, but I got carried away.

Then, no one said anything, or

if they did, it was only ‘you’re

too skinny... eat!’ Had someone said sooner that I needed

help, I may have lost only one

year to anorexia, instead 

of six.”23

—Jill, Age 22
Eating Disorders Information for Middle School Personnel 13

It is a common misperception that eating disorders occur only among white upper-class

females. However, recent research has confirmed that eating disorders occur in all socioeconomic groups and also among males and

ethnically diverse populations. The causes,

warning signs and symptoms, and consequences of eating disorders are similar for all

students.

One out of every 10 diagnosed cases of eating

disorders occurs in males, which means that

hundreds of thousands of young men have 

eating disorders that cause serious health 

problems.25

Research on the prevalence of eating disorders

among ethnically diverse youth is lacking.

However, studies suggest that disturbed eating

attitudes and behaviors occur across ethnicity,

and that acculturation toward U.S. societal

behaviors, attitudes, and values increases the

risk for body dissatisfaction and eating problems among youth.26 Because eating disorders

may not be suspected in males or females from

ethnically diverse populations, treatment may

be delayed until the illness is quite severe.27

Several information sheets in this packet

provide more facts on how eating disorders

affect different ethnic and cultural groups, as

well as boys.

Why do some students at high risk for healthcompromising behaviors successfully navigate

adolescence and avoid behaviors that make

them vulnerable to poor health and others 

do not?28

“Our body shapes are beautifully different. We need to work

hard on self-love and feeling

good about who we are on the

inside. When we don’t, food

becomes too important.”24

—Victoria Johnson, 

African American Fitness

Professional 

Students of all ethnic and cultural groups are 

vulnerable to developing eating disorders
14 BodyWise Handbook

A study reported in the Journal of the

American Medical Association found that of all

the forces that influence adolescent health-risk

behavior, the most critical are the family and

school contexts.29 Both a high expectation for

student performance and showing concern for

a student’s welfare communicate a sense of caring that is one of the major protective factors

against a variety of risky behaviors.

The protective factors that are considered most

amenable for classroom intervention are “coping and life skills,” such as problem solving,

decision making, assertiveness, communication,

and stress management.

“When girls in this culture say

‘I feel fat,’ they are trying to

tell us they are struggling with

self-esteem and identity. 

They use the term ‘fat’ as a 

symbolic expression for a

wide range of thoughts and

feelings that include feeling

out of control, anxious, 

fearful and unworthy.”31

—Craig Johnson, Ph.D.,

Director,

Eating Disorders Program,

Tulsa, Oklahoma 

In traditional Fijian culture, round,

robust figures have long been the standard for beauty. The introduction of

Western television shows seems to be

changing this cultural norm. Harvard

researchers conducted a study on Fijian

girls and found that from 1995, when

broadcast television was introduced,

indicators of disordered eating, such as

high EAT-26 scores and reports of selfinduced vomiting, dramatically

increased over a period of 3 years. Fifty

percent of the girls who watched television on three or more nights a week

described themselves as unhappy with

the size or shape of their bodies or

described themselves as “too fat.”

These same girls were also more likely

to diet than girls who watched less

television.30

Each member of a school community can help create

an environment that discourages disordered eating

and promotes the early detection of eating disorders

Media messages that equate thinness with beauty can contribute to development of negative

body images among girls. Training in media literacy can help students analyze media messages

and resist those that feature thin and unrealistic

body shapes.

Other effective strategies include conducting

mentoring programs, changing school policies

on harassment, and integrating into existing

health and science curricula information on

growth patterns in puberty and the negative

consequences of dieting.

All teachers and staff can serve as personal

agents of change, both inside and outside the

classroom, to help students avoid disordered

eating and other associated risk behaviors.

They can accomplish this by providing appropriate information and skills as well as by creating an environment that students perceive to be

caring and responsive to their needs.

A school-based study found

that discontent with body

weight and shape was directly

related to the frequency of

reading fashion magazines.

Pictures in magazines had a

strong impact on girls’ perceptions of their weight and

shape. Of the 548 5th- through

12th-grade girls, 69 percent

reported that magazine images

influenced their idea of the perfect body shape, and 47 percent reported wanting to lose

weight because of magazine

images. 32
Eating Disorders Information for Middle School Personnel 15

❐ Definitions of beauty that focus on selfrespect, assertiveness, and generosity of

spirit?

❐ Pathways to success unrelated to external

appearance?

Do we offer:

❐ Peer support groups?

❐ Adult mentoring programs?

❐ Opportunities for teachers, students, parents, and others to discuss school policies

regarding teasing, bullying, sexual harassment, and gender role constraints?

❐ Speakers or in-service programs on eating

disorders?

❐ Parent education on eating disorders and on

how nutrition and positive body image

affect learning?

❐ Partnerships in which school personnel

work with community organizations?

❐ Opportunities for students to think critically

about mass media and other sociocultural

influences on body image and eating?

Does our school:

❐ Provide teachers with information about the

signs and symptoms of eating disorders?

❐ Have a protocol that provides guidelines 

on the referral of students to health care

providers knowledgeable about eating 

disorders?

❐ Have an eating disorders resource person

who is acquainted with local and national

resources for referral?

❐ Have a list of resources for school personnel

who may want additional information on

eating disorders? 

“Providing students with positive coping and life skills education may help in discouraging eating disorders as well as

drug, alcohol, pregnancy, and

delinquency problems. Changes

in parental and teacher attitudes are important, as are

changes in school policies concerning harassment, teasing,

and being weighed in public.”

—Linda Smolak, Ph.D.,

Professor, 

Department of Psychology,

Kenyon College

Answering the following questions will give you

a snapshot of your school’s culture and help

you think about how you can integrate ways to

discourage disordered eating and promote early

detection of eating disorders into your school’s

ongoing activities.

Do we teach:

❐ The nature and dangers of dieting?

❐ Weight and size changes that occur during

puberty?

❐ Genetic effects and diversity of weight and

shape? 

❐ Media literacy skills?

❐ Problem-oriented coping skills?

❐ Assertive communication skills?

❐ Listening skills?

Do we discourage:

❐ Calorie-restrictive dieting?

❐ Weight- and shape-related teasing?

❐ Gender stereotyping?

❐ Sexual harassment?

Are we attentive to students who:

❐ Express low self-esteem, anxiety, obsessivecompulsiveness, or perfectionism?

❐ Say they are too fat?

❐ Are teased about their weight or shape?

❐ Have a family history of eating disorders,

drug abuse, or mental health problems?

❐ Experience adverse or stressful life events?

Do we promote:

❐ Role models of all sizes and shapes who 

are praised for accomplishments, not

appearance?
16 BodyWise Handbook

The BodyWise information packet includes a

set of materials that you can reproduce and distribute to other school personnel, including

teachers, coaches, school nurses, counselors, the

principal, and other administrators. We suggest

that you keep the originals and make copies for

members of your school staff and, as needed,

for parents and students.

The packet consists of the items listed below.

INFORMATION SHEETS

Information Sheets for School Personnel

These information sheets provide practical

information for teachers, school nurses and

counselors, administrators, and physical education teachers, coaches, and dance instructors

about disordered eating and eating disorders.

Suggestions are provided to enable school personnel to respond effectively to warning signs

and help create a positive school culture. The

sheets feature quotes and stories that highlight

the experiences of students and school personnel. Each sheet concludes with a list of additional available resources.

How To Help a Student

This information sheet provides suggestions on

how to approach a student who may have an

eating disorder.

How To Help a Friend

Students will often notice the signs of a possible eating disorder before school personnel or

parents. This information sheet can be reproduced and given to students who express their

concerns about a friend.

Special Student Populations

Information sheets addressing how eating disorders affect boys and ethnically diverse girls

are included in the packet to help dispel the

myth that eating disorders are only a problem

among middle- and upper-income white girls.

Information Sheets for Parents and Other

Caregivers

Two information sheets are included for parents. The first provides basic information on

eating disorders, how to detect them, and how

to discourage disordered eating and support

the development of a positive body image. The

second, written in Spanish, provides basic

information for parents and suggestions on

how to seek assistance when concerned about

their children. The information sheet also

addresses the impact of acculturation and

media exposure on the body image and eating

behaviors of Hispanic children.

INFORMATION SHEET ON EATING

DISORDERS AND OBESITY

This information sheet describes the links

between eating disorders and obesity and provides ideas for parents and other adult caregivers on how to promote healthy attitudes and

behavior related to eating among adolescents.

RESOURCE SHEETS

The BodyWise packet includes resource sheets

developed specifically for middle school personnel. The resource sheets list the following:

◆ Professional books for school personnel that

discuss girls’ health issues and eating disorders and offer specific recommendations 

relevant for school personnel.

◆ Curricular support materials that teachers

may use for planning classroom lessons.

◆ Young people’s reading lists for individual

and classroom reading, including both fiction and nonfiction titles.

“Students learn by what they

see and hear. Parents and

teachers who model good eating behavior reinforce what

they learn in class. Students

also need the help of school

policy makers who affect their

environments. Policy makers

can ensure that a choice of

healthy menu items exists in

the school cafeteria and place

limits on the access to

unhealthy snacks and beverages in vending machines and

from fund raising activities.”33

—Kweethai Neill, Ph.D., CHES,

Council for Food and Nutrition,

American School Health

Association

USING THE BODYWISE

INFORMATION PACKET
Eating Disorders Information for Middle School Personnel 17

◆ Videos on body image, eating disorders, and

media literacy that may be used for continuing education for school personnel and

shown to middle-school students and

family members.

◆ Educational organizations that provide

information on preadolescent health, eating

disorders, and media literacy.

The BodyWise materials are available for

downloading from:

www.4woman.org/BodyImage

SUPPLEMENTAL MATERIALS

For more information on women’s and adolescent girls’ health, refer to Office on Women’s

Health Web sites listed below.

Office on Women’s Health

U.S. Department of Health and Human

Services

200 Independence Ave., SW

Washington, D.C. 20201

Tel: (800) 994-9662 

TDD: (888) 220-5446 

Web sites: www.4woman.gov

www.4girls.gov
Abnormal eating patterns can vary in severity.

It is important to distinguish between the

terms “eating disorder” and “disordered eating.”

An eating disorder is a psychiatric illness with

specific criteria that are outlined in the

“Diagnostic and Statistical Manual” (DSM-IVTRTM) published by the American Psychiatric

Association.

In contrast, disordered eating has not been

strictly defined. For the purposes of this handbook, disordered eating may include the following behaviors, particularly when a student

also expresses body dissatisfaction, fear of gaining weight, or feeling anxious or stressed:

◆ Skipping meals.

◆ Restricting food choices to a few “acceptable” items.

◆ Focusing excessively on avoiding certain

foods, particularly foods that contain fat.

◆ Occasionally bingeing, particularly on snack

foods, sweets, and sodas.

◆ Self-induced vomiting, or taking laxatives,

diuretics (water pills), or diet pills-to lose

weight.

ANOREXIA NERVOSA 

Anorexia nervosa is characterized by:34

◆ Self-induced weight loss or failure to make

expected weight gain during periods of

growth—resulting in body weight less than

85 percent of that expected.

◆ Intense fear or dread of gaining weight or

becoming fat—even though underweight.

◆ Disturbance in one’s perception of body

weight or shape, undue influence of body

weight or shape on self-evaluation, or

denial that the current low body weight

is serious.

◆ Amenorrhea in females—onset of menses is

delayed or arrested (the absence of at least

three consecutive menstrual cycles).

There are two subtypes of anorexia nervosa,

namely restricting type and binge-eating/purging

type. Individuals with the restricting subtype

accomplish weight loss primarily through dieting, fasting, or excessive exercise. Individuals

with the binge-eating/purging subtype regularly engage in binge eating and purge through

self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Some people in this

subtype do not binge eat, but do purge after

eating small amounts of food.

DEFINITIONS

18 BodyWise Handbook
— Eating alone because of being embarrassed by how much one is eating.

— Feeling disgusted with oneself, depressed,

or very guilty after overeating.

— Marked distress regarding binge eating is

present.

— The binge eating occurs, on average, at

least 2 days a week for 6 months.

Binge eating is frequently experienced by

people diagnosed with bulimia nervosa and

sometimes experienced by people diagnosed

with anorexia nervosa. However, binge-eating

disorder is not associated with the use of

inappropriate compensatory behaviors (e.g.,

purging, fasting, excessive exercise).

OVEREXERCISING

Overexercising, often practiced by those with

anorexia and bulimia, is exercising frequently,

intensely, or compulsively for long periods of

time in order to control weight. A person who

overexercises might display one or more of the

following characteristics:

◆ Exercises more frequently and more

intensely than is required for good health

or competitive excellence.

◆ Gives up time from work, school, and

relationships to exercise.

◆ Exercises despite being injured or ill.

◆ Defines self-worth in terms of athletic

performance.

◆ Says she or he is never satisfied with a performance or game; does not savor victories.

Overexercising is of particular concern when

accompanied by disordered eating, body

dissatisfaction, fear of fat, or obsession with

weight and food.

BULIMIA NERVOSA

Bulimia nervosa is characterized by:35

◆ Recurrent episodes of binge eating characterized by:

— Eating in a discrete period of time (e.g.,

within any 2-hour period) an amount of

food that is definitely larger than most

individuals would eat under similar circumstances.

— A sense of lack of control over eating

during the episode (e.g., a feeling that

one cannot stop eating or control what

or how much one is eating).

◆ Recurrent inappropriate compensatory

behavior to prevent weight gain. These

behaviors are either:

— Purging: self-induced vomiting or misuse

of laxatives, diuretics (water pills), or 

enemas.

— Nonpurging: fasting or excessive exercise.

◆ Binge eating and inappropriate compensatory behaviors that both occur, on average, at

least twice a week for 3 months.

◆ Self-evaluation that is unduly influenced by

body shape and weight.

Bulimia nervosa can occur in those with

anorexia nervosa or it can occur as a separate

condition.

BINGE EATING DISORDER

Binge eating disorder is characterized by:36

◆ Recurrent episodes of binge eating (see

definition provided in first bullet under

“Bulimia Nervosa” above) 

◆ The binge eating episode is associated with

three (or more) of the following:

— Eating much more rapidly than normal.

— Eating until feeling uncomfortably full.

— Eating large amounts of food when not

feeling hungry.

Eating Disorders Information for Middle School Personnel 19
20 BodyWise Handbook

END NOTES

1 Neumark-Sztainer D, Story M, French SA. Covariations of

unhealthy weight loss behaviors and other high-risk behaviors among adolescents. Archives of Pediatric Adolescent

Medicine, 1996, vol. 150, no. 3, pp. 304-308; and National

Institute of Mental Health. Eating disorders, 1994.

2 The McKnight Foundation. The McKnight Foundation

program for research and training in the diagnosis, treatment,

and prevention of eating disorders. Minneapolis, MN:

Author, 1994, p.9.

3 Arbetter, S. The As and Bs of eating disorders. Current

Health, 1994, vol. 21, no. 1, pp. 6-12. Published with permission from Weekly Reader Corporation.

4 Berg, F. Afraid to eat: Children and teens in weight crisis.

Hettinger, ND: Healthy Weight Publishing Network, 1997.

5 National Institute of Mental Health, Eating disorders,

1994; and Piran N, Levine MP, Steiner-Adair C (eds.).

Preventing eating disorders: A handbook of interventions and

special challenges. Philadelphia: Brunner/Mazel, 1999, p.

xviii.

6 Ibid.

7 Yanovski, S.Z. "Binge eating in obese persons." In

Fairburn, C.G., Brownell, K.D. (eds) Eating Disorders and

Obesity 2nd ed. New York: Guilford Press, 403-407, 2002.

8 Arbetter, S. The As and Bs of eating disorders.

9 Harvard Eating Disorders Center Web site www.hedc.org,

1999; and Collins ME. Body figure perceptions and preferences among preadolescent children. International Journal

of Eating Disorders, 1991, vol. 10, no. 2, pp. 199-208.

10 Tufts University School of Nutrition Science and Policy.

Statement on the link between nutrition and cognitive

development in children. Boston: Center on Hunger,

Poverty and Nutrition Policy, 1998. The statement may be

obtained by calling (617) 627-3956.

11 Ibid.

12 Keys A, et al. The biology of human starvation, vols. 1 and

2. Minneapolis: University of Minnesota Press, 1950 (cited

in Reiff & Lampson-Reiff, 1999).

13 Reiff D, Lampson-Reiff KK. Eating disorders: Nutrition

therapy in the recovery process. Mercer Island, WA: Life

Enterprises, 1999.

14 Ibid.

15 Reiff D, Lampson-Reiff KK. Eating disorders: nutrition

therapy in the recovery process, p. 285.

16 Personal conversation with Michael Levine, Ph.D., member of the Office on Women’s Health Eating Disorders

Steering Committee, June 1999.

17 Brumberg JJ. The body project. New York: Random

House, 1997, p. 130.

18 National Institute of Mental Health. Eating disorders,

1994.

19 Nasser M, Katzman M. Eating disorders: Transcultural

perspectives inform prevention. In N Piran, MP Levine, C

Steiner Adair (eds.), Preventing eating disorders: A handbook

of interventions and special challenges. Philadelphia:

Brunner/Mazel, 1999, p. 28.

20 National Institute of Mental Health. NIMH Workshop

on Research in Eating Disorders. December 7-8, 1998.

21 National Institute of Child Health and Human

Development. Child and adolescent nutrition fact sheet,

May 1998.

22 National Institute of Mental Health. Eating disorders,

1994.

23 Personal conversation, January 21, 1999.

24 Crute S (ed.). Health and healing for African Americans.

Emmaus, PA: Rodale Press, 1998.

25 Andersen AE. Eating disorders in males. In CG Fairburn,

KD Brownell (eds.). Eating disorders and obesity: A comprehensive handbook, 2nd ed. New York: Guilford Press, 2002,

pp.188-192.

26 Dounchis JZ, Hayden HA, Wifley DE. Obesity, eating

disorders, and body image in ethnically diverse children

and adolescents. In JK Thompson, L Smolak (eds.), Body

image, eating disorders and obesity in children and adolescents: Theory, assessment, treatment, and prevention.

Washington, DC: American Psychological Association,

2001, pp.67-98.

27 Carlat DJ, Carmargo CA Jr, Herzog DB. Eating disorders

in males: A report on 135 patients. American Journal of

Psychiatry, 1997, vol. 154, no. 9, pp. 1127-1132; Andersen

AE. Eating disorders in males. In KD Brownell, CG

Fairburn (eds.), Eating disorders and obesity: A comprehensive handbook. New York: Guilford Press, 1995; and Root

MPP. Disordered eating in women of color. Sex Roles,

22(7/8), 525-536, 1990.

28 Resnick MD, Bearman PS, Blum RW, Bauman KE,

Harris KM, Jones J, Tabor J, Beuhring T, Sieving RE, Shew

M, Ireland M, Bearinger LH, & Udry JR. Protecting adolescents from harm. Findings from the National Longitudinal

Study on Adolescent Health. JAMA, 1997, vol. 278, no. 10,

pp.823-32.

29 Ibid.

30 Becker AE, Burwell RA, Gilman SE, Herzog DB,

Hamburg P. Eating behaviors and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls. British Journal of Psychiatry, 2002, vol. 180,

pp.509-514; Becker AE. Body, self, and society: The view

From Fiji. Philadelphia: University of Pennsylvania Press,

1995.

31 Personal conversation with Craig Johnson, Ph.D, member of the Office on Women’s Health Eating Disorders

Steering Committee, July 1999.

32 Field AE, Cheung L, Wolf AM, Herzog DB, Gortmaker

SL, Colditz GA. Exposure to the mass media and weight

concerns among girls. Pediatrics, 1999, vol. 103, no. 3, p.

e36.

33 Personal conversation with Kweethai Neill, Ph.D, member of the Office on Women’s Health Eating Disorders

Steering Committee, May 1999.

34 American Psychiatric Association. Eating disorders.

Diagnostic and statistical manual of mental disorders (4th

ed., DSM-IV-TRTM), 2000.

35 Ibid.

36 Ibid.
The following persons were involved in the

original production of the BodyWise packet

in 1999. The packet was reprinted in 2000

and updated in 2005.

Office on Women’s Health

U.S. Department of Health and Human

Services

Wanda K. Jones, Dr.P.H.

Deputy Assistant Secretary for Health

(Women’s Health)

Jonelle C. Rowe, M.D., M.A.

Medical Advisor, Project Officer

Susan M. Clark, M.A.

Director, Division of Program Management

Carol Krause, M.A.

Director, Division of Communications

Anna L. Kinderman, J.D.

Public Health Analyst

Meena Gupta, M.P.H.

Project Assistant

Steering Committee Members

Jennifer Biely, J.D., Executive Director

Eating Disorders Awareness and Prevention,

Inc., Seattle, WA

Jeanine Cogan, Ph.D., Congressional Fellow

Office of Representative Diana DeGette

Washington, DC

Steven Crawford, Ph.D., Associate Director

St. Joseph Medical Center, Center for Eating

Disorders, Towson, MD

Diana Everett, Ph.D., Director of Public Affairs

Texas Association for Health, Physical

Education, Recreation and Dance, Austin, TX

Harold Goldstein, Ph.D., Clinical Director

Eating Disorders Program, National Institute

of Mental Health, Rockville, MD

Barbara Hartigan, Teacher

Kingswood Oxford Middle School

West Hartford, CT

David Herzog, M.D., Director

Harvard Eating Disorders Center, Boston, MA

Craig Johnson, Ph.D., Director

Eating Disorders Program at Laureate

Psychiatric Clinic and Hospital, Tulsa, OK

Dean Krahn, M.D., Chief of Psychiatry

William S. Middleton Veteran’s Hospital

Madison, WI

Richard Kreipe, M.D., Chief, Division of

Adolescent Medicine, Children’s Hospital at

Strong, Rochester, NY

Michael Levine, Ph.D., Professor

Department of Psychology, Kenyon College

Gambier, OH

Anita Sinicrop Maier, M.S.W.,

Executive Director, Pennsylvania Educational

Network on Eating Disorders, Allison Park, PA

Rebecca Manley, Executive Director

Massachusetts Eating Disorder Association

Newton, MA

Saralyn Mark, M.D., Medical Advisor

Office on Women’s Health

Washington, DC

Sabrina Matoff, M.S., Public Health Analyst

Health Resources and Services Administration,

Women’s Health

Vivian Hanson Meehan, R.N., D.Sc., President

National Association of Anorexia Nervosa and

Associated Disorders, Chicago, IL

Charles Murkofsky, M.D., President

American Anorexia Bulimia Association, Inc.,

New York, NY

Kweethai Neill, Ph.D., Professor of Health and

Kinesiology, Sam Houston State University

Huntsville, TX

Judith Robinson, Ph.D., R.N., Executive

Director, National Association of School

Nurses, Scarborough, ME

Catherine Shisslak, Ph.D., Associate Professor

Arizona Prevention Center, University of

Arizona, Tucson, AZ

Meg Small, Ph.D., School Health Advisor

U.S. Department of Education

Safe and Drug-Free Schools Program 

Washington, DC

Linda Smolak, Ph.D., Professor

Department of Psychology, Kenyon College

Gambier, OH

Catherine Steiner-Adair, Ed.D., Director,

Education, Prevention, and Outreach

Harvard Eating Disorders Center 

Boston, MA

ACKNOWLEDGMENTS

Ruth Striegel-Moore, Ph.D., Chair of

Psychology, Wesleyan College 

Middleton, CT

Mary Vernon, M.D., Chief,

Special Populations Program Section,

Centers for Disease Control,

Atlanta, GA

Violet Woo, M.S., M.Ph., Program Analyst,

Office of Minority Health, HRSA,

Rockville, MD

Educational Services, Inc.

Mary Lou Rife, Ph.D.

Project Director

Sandy Lundahl, M.P.H.

Catalina Vallejos-Bartlett, M.A.

Health Communications Specialists

Emily Albright

Jill L. Johnson

Chloe Plaunt

Project Assistants

Magdala P. Labre, M.A.

Senior Editor/Graphic Design

Elena Cohen, M.Ed., M.S.W.

Writer, Spanish-Language Materials

Lara Beaudry Byer

Illustrator

Consultants and Reviewers

OWH Regional Women’s Health Coordinators

Members of the OWH Minority Women’s

Health Panel of Experts

Jocelyn L. Ancheta

Frances Berg, M.S.

Carol Bloom, Ph.D.

Lynne Doner, M.A.

Jennifer Zoler Dounchis

Helen A. Hayden, M.A.

Dennis Henning

Niva Piran, Ph.D.

Dan Reiff, M.P.H., R.D.

Kirsten Reitter

Tom Shiltz, M.S.

Denise E. Wilfley, Ph.D.
The Office on Women’s Health

(OWH) of the U.S. Department of

Health and Human Services (HHS)

is the Government’s focal point for

women’s health issues. The mission

of OWH is to improve the health of

women across the life-span by

directing, developing, stimulating,

and coordinating women’s health

research, health care services, and

public and health professional 

education and training across HHS

agencies and offices; and with other

Government agencies, public 

and private organizations,

and consumer and health care 

professional groups.