Screening For Survival: A Legal Framework For Addressing Anorexia Nervosa

For nearly 60 years, anorexia nervosa (AN) has been the mental illness with the highest mortality rate in the country.[1] A 2011 meta-analysis of 36 studies from 1966 to 2010[2] and a 2025 meta-analysis of 49 studies from 2010 to 2024[3] found that anorexia nervosa has the highest mortality rates compared to other mental illnesses. Overall, “5% of patients with AN die within the first 4 years of diagnosis,” and when the “illness lasts for more than 20 years, the mortality rate (as a direct result of the illness) is 20%.”[4] AN is particularly common during adolescence since 70% of adolescent girls and 45% of adolescent boys experience body dissatisfaction.[5] Yet, despite the severity of AN, federal law contains no mandated prevention or screening requirements for eating disorders in schools. Therefore, Congress should enact a structural, school-based prevention mandate for anorexia nervosa.

The two steps of AN treatment are renourishment (consisting of weight restoration in a residential, inpatient, or family-based therapy setting) and maintenance, which involves at least one year of outpatient therapy to prevent relapse.[6] However, since treatment occurs only after the disorder has manifested, traditional individual approaches are insufficient. This supports the need for a structural public health intervention that the federal government should implement to help address AN in adolescence: a mandated anorexia nervosa school-based prevention program. Schools are a uniquely effective setting for early, population-level intervention, since schools already shape norms, routines, and health behaviors for nearly all U.S. adolescents. Similar federal structural interventions (such as tobacco-prevention curricula and nutrition standards under the Healthy, Hunger-Free Kids Act) demonstrate that school-based health mandates are legally and practically feasible.

A mandated school-based AN prevention program would directly reach children both before and during adolescence. Federal education law already incorporates health requirements, such as school meal nutrition standards, disability-related services under the Individuals with Disabilities Education Act (IDEA), and physical-education reporting provisions. Constitutionally, Congress would rely on the Spending Clause to condition federal education funds on state compliance with screening and prevention protocols. Under South Dakota v. Dole,[7] such conditions are valid if they are clear and in pursuit of the general welfare. An AN prevention mandate would satisfy this test.

This school-based prevention program should span a child’s entire 13 years of public schooling. It should consist of (1) healthy eating workshops in elementary school, (2) body image education in middle school, and (3) early screening and intervention using surveys in middle and high school. Since AN rarely begins before puberty,[8] the program should begin by educating elementary school students on healthy behaviors and mindsets as a preventative measure, focusing later on identification and intervention once children reach puberty.

Stage 1 should center on healthy eating through experiential garden-enhanced nutrition education. A 2015 study found that hands-on approaches like garden-based learning had the strongest positive effects on healthy food consumption.[9]

Stage 2 should focus on body image and self-esteem education. A three-month study found that teaching children to take pride in their work, reframe negative thoughts into positive solutions, and respond constructively to criticism significantly improved self-esteem in children who previously experienced low self-esteem issues.[10]

Stage 3 would involve mandated eating disorder screening surveys in middle and high schools. Specifically, the SCOFF questionnaire should be incorporated into routine health assessments, which currently focus on monitoring mobility, height, and obesity prevention.[11] The SCOFF questionnaire is a brief, five-item screening tool with yes-or-no questions: “Do you make yourself sick because you feel uncomfortably full? Do you worry you have lost control over how much you eat? Have you recently lost more than 14 pounds (one stone) in a three month period? Do you believe you are fat, when others say you are thin? Would you say food dominates your life?”[12] Each “yes” response receives 1 point, with a score of 2 or more indicating a likely diagnosis of anorexia nervosa or bulimia.[13] Implementing this survey would effectively enable timely intervention by allowing schools to notify parents and refer students to relevant health services or agencies for further evaluation when appropriate. Also, since SCOFF results would qualify as “education records” under FERPA,[14] they would be subject to established access, confidentiality, and parental-notification requirements, providing a built-in privacy framework.

A limitation of the proposed intervention is that it would require federal funding, oversight, and coordination with school districts, which will likely be costly for taxpayers. Another limitation of this intervention is that it would necessitate cooperation from parents, schools, and students for it to be effective. Students and staff may not take the surveys seriously, thus preventing necessary change from occurring. A third limitation is that discussions regarding health and body image can be seen as intrusive, increasing the possibility of parental pushback. Finally, a school-based prevention program like the one proposed must be inclusive and thoughtfully designed to be effective, which is a challenging goal. Specifically, it is essential to account for cultural differences, stereotypes, and varying socioeconomic backgrounds when building the curriculum. This will ensure that all students are represented and supported without unrealistic expectations, such as assuming that a student who lives in a food desert can easily access healthy food options.

Despite its challenges, the strengths of this proposal outweigh its limitations. As outlined above, a school-based prevention program will target adolescents, the group at the highest risk for developing AN.[15] Embedding the intervention within the school system would also facilitate implementation, making it more sustainable over time and reaching a broad and diverse population: the approximately 49.6 million children from a wide range of socioeconomic and cultural backgrounds who attend school in the United States.[16] Most importantly, a school-based prevention program would provide a multi-level approach to support students throughout their 13-year educational journey by addressing the key factors of structural intervention: social structures and cultural/media messages. By doing so, the program would promote early detection of AN symptoms and equip students with the tools and knowledge to foster a healthy mindset and prevent the onset of those symptoms.

Anorexia nervosa (AN) is the deadliest mental illness[17] often beginning in adolescence[18] and presenting significant challenges to long-term recovery.[19] Therefore, its prevention and early detection must be a public health priority. A federally mandated school-based prevention program would offer a structural solution by embedding these efforts within schools, the institutions that have the most consistent and direct access to adolescents. The potential long-term effects of such a program far outweigh the potential limitations. By equipping students with the tools to build a healthy relationship with food and body image and implementing standardized screening, this intervention has the power to improve individual outcomes and influence broader social norms.

[1] Rindahl, K. (2017). A Systematic Review of Literature on School Screening for Eating Disorders. International Journal of Health Sciences, 5(3), 1–9. https://doi.org/10.15640/ijhs.v5n3a1

[2] Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724–731. https://doi.org/10.1001/archgenpsychiatry.2011.74

[3] Krug, I., Liu, S., Portingale, J., Croce, S., Dar, B., Obleada, K., Satheesh, V., Wong, M., & Fuller-Tyszkiewicz, M. (2025). A meta-analysis of mortality rates in eating disorders: An update of the literature from 2010 to 2024. Clinical Psychology Review, 116. https://www.sciencedirect.com/science/article/pii/S0272735825000133

[4] Meczekalski, B., Podfigurna-Stopa, A., & Katulski, K. (2013). Long-term consequences of anorexia nervosa. Maturitas, 75(3), 215–220. https://doi.org/10.1016/j.maturitas.2013.04.014=

[5] Yager, Z., Diedrichs, P., Ricciardelli, L., & Halliwell, E. (2013). What works in secondary schools? A systematic review of classroom-based body image programs. Body Image, 10(3), 271–281. https://doi.org/10.1016/j.bodyim.2013.04.001

[6] Steinglass, J. (2024). Mechanism to treatment in anorexia nervosa. NYU Langone Department of Child and Adolescent Psychiatry Grand Rounds. https://med.nyu.edu/departments-institutes/child-adolescent-psychiatry/education/grand-rounds

[7] South Dakota v. Dole

[8] Klein, D., & Walsh, T. B. (2004). Eating disorders: clinical features and pathophysiology. Physiology & Behavior, 81(2), 359–374. https://doi.org/10.1016/j.physbeh.2004.02.009

[9] Dudley, D., Cotton, W., & Peralta, L. (2015). Teaching approaches and strategies that promote healthy eating in primary school children: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 12(28). https://doi.org/10.1186/s12966-015-0182-8

[10] Sharma, S., & Agarwala, S. (2015). Self-Esteem and Collective Self-Esteem Among Adolescents: An interventional approach. Psychological Thought, 8(1), 105–113. https://psyct.swu.bg/index.php/psyct/article/view/121/pdf

[11] Rindahl, K. (2017). A Systematic Review of Literature on School Screening for Eating Disorders. International Journal of Health Sciences, 5(3), 1–9. https://doi.org/10.15640/ijhs.v5n3a1

[12] Rindahl, K. (2017). A Systematic Review of Literature on School Screening for Eating Disorders. International Journal of Health Sciences, 5(3), 1–9. https://doi.org/10.15640/ijhs.v5n3a1

[13] Rindahl, K. (2017). A Systematic Review of Literature on School Screening for Eating Disorders. International Journal of Health Sciences, 5(3), 1–9. https://doi.org/10.15640/ijhs.v5n3a1

[14] Family Educational Rights and Privacy Act

[15] Yager, Z., Diedrichs, P., Ricciardelli, L., & Halliwell, E. (2013). What works in secondary schools? A systematic review of classroom-based body image programs. Body Image, 10(3), 271–281. https://doi.org/10.1016/j.bodyim.2013.04.001

[16] National Center for Education Statistics. (2024). Back-To-School Statistics. Nces.ed.gov. https://nces.ed.gov/fastfacts/display.asp?id=372

[17] Rindahl, K. (2017). A Systematic Review of Literature on School Screening for Eating Disorders. International Journal of Health Sciences, 5(3), 1–9. https://doi.org/10.15640/ijhs.v5n3a1

[18] Yager, Z., Diedrichs, P., Ricciardelli, L., & Halliwell, E. (2013). What works in secondary schools? A systematic review of classroom-based body image programs. Body Image, 10(3), 271–281. https://doi.org/10.1016/j.bodyim.2013.04.001

[19] Steinglass, J. (2024). Mechanism to treatment in anorexia nervosa. NYU Langone Department of Child and Adolescent Psychiatry Grand Rounds. https://med.nyu.edu/departments-institutes/child-adolescent-psychiatry/education/grand-rounds