Challenging Dogma - Fall 2009

Thursday, December 17, 2009

National Eating Disorder Awareness Week: The Need For A Theoretical And Evidence-Based Approach To Eating Disorder Prevention- Amel Omari

Anorexia nervosa and bulimia nervosa are two types of eating disorders, a disease that affects 0.5% of women in their lifetime (15). Disordered eating, even when subclinical, can adversely affect an individual’s physical and psychological health long-term, particularly if they are in their early adolescence when important growth is taking place (2). Therefore the prevention and early treatment of anorexia and bulimia nervosa is an important public health goal. The National Eating Disorder Awareness Week is one such effort. NEDA, the organization at the forefront of the organization of NED Awareness Week events annually nationwide, has included in its stated mission the goal to be “a catalyst for prevention.” (9) However, NED Awareness Week lacks many of the most fundamental aspects of an effective prevention tool, including a lack of interactive, experiential activities, a selective target audience, or evidence-based or theoretically-motivated action. An intervention guided by theory, such as cognitive dissonance theory, and based on the evidence amassed from previous interventions would better address the goal of preventing eating disorders in high-risk populations.
Eating disorders are split into two main categories: anorexia nervosa and bulimia nervosa. Individuals with either type of eating disorder generally have an unhealthy goal body weight, distorted self-image, and extreme body dissatisfaction. In individuals with anorexia, this leads to severe restriction on food intake, and in those with bulimia, individuals may binge and then attempt to mitigate the effects of their food intake through vomiting, fasting, or excessive exercise (2, 13). In both these cases, long-term physical and psychological health issues can result from abnormal eating behaviors, especially in adolescents. For example, a lack of nutrients necessary for developing bone density during one’s adolescence may put one at increased risk of osteoporosis later in life(2). In addition, eating disorders result in the highest mortality rate of any mental illness (10).
National Eating Disorder Awareness Week, spearheaded by the National Eating Disorder Association, is an educational event put on annually across the nation. In 2009, the theme was “Until Eating Disorders Are History . . .” (8) and the planned theme for 2010 is “It’s Time to Talk About It.” The national association encourages local groups at universities and other organizations to arrange a week of events aimed at informing members of their community about what eating disorders are, what the signs and symptoms are, and where to get help. In addition, NEDA names a “key message” of the 2010 NED Awareness Week as media literacy, or educating people about how to critically assess the underlying message of advertisements and other media (17). They encourage actions such as writing letters in protest of ads that promote negative body image.
Events for NED Awareness Week have been organized across the nation, at large and small universities as well as at hospitals. For example, Murray State University in Murray, Kentucky organized a week of events including information tables, a “Love Your Body Fair”, and a “jeans exchange”, in which people traded their ill-fitting jeans with others in their community for ones that fit (15). At Michigan State University, NED Awareness Week featured an open mic night for attendees to share their experiences or listen to the stories of others. Free candy bars with positive messages about food and body image on them were distributed on campus (3). Finally, at Bronson Hospital in Kalamazoo, MI, informational displays were set up in the cafeteria, and a video addressing eating disorders was shown (14). The information distributed during all these events informed attendees on the nature and symptoms of the disease. They also gave information regarding where to find help, such as counselors’ or clinics’ contact or website information.
In their 2004 review of 38 interventions aiming to prevent eating disorders, Stice and Shaw identify three generations of eating disorder interventions. The first generation was universally targeted and purely information-based, the second added a component addressing societal pressures, and the third was selectively targeted toward those at high risk of developing an eating disorder and attempted to address risk factors for developing the disease (13). According to Stice and Shaw’s definitions, NED Awareness Week represents a second-generation intervention. It is a universal intervention, because it does not target a specific group, and although it is focused on educating its audience, it also addresses the pressures of society to control weight through its emphasis on media literacy.

Critique 1: Focus on didactic techniques, lack of intensive experiential component
Inviting speakers, handing out pamphlets, and exchanging jeans are all techniques to raise awareness or increase general knowledge about eating disorders. The organizers hope to help people that come to these events recognize eating disorders in themselves or their family or friends, and to educate them about help, hopefully in the process motivating them to do so. However, evidence (6) shows that interventions that are based exclusively on distributing information or on educating the public are generally not effective in changing behaviors. According to a review of 27 studies of interventions addressing eating disorders on college campuses, “information-based, cognitive behavioral, and psycho-educational approaches have been the least effective at improving body image and eating problems among university students.” (6) NED Awareness Week is focused on just these methods.
In using a didactic approach, the intervention does not make use of the evidence amassed on effective methods of changing behavior. More effective interventions include an experiential component in addition to an informational one, and attempt to engage the participants through group discussions and activities. Instead, NED Awareness Week events typically involve the direct transmission of knowledge about eating disorders through passing out literature on the subject or showing videos. Although a “jeans exchange” is an interactive activity, its aim is more symbolic than direct, and as such may make it difficult for participants to grasp its purpose.

Critique 2: Lack of selective target audience
Adolescent girls comprise the population most at-risk for developing an eating disorder. However, other populations are also at risk. One to 4.2% of women university students have eating disorders, and damaging behavior related to body-image in men is also becoming more prevalent (17). In addition, interventions regarding eating disorders traditionally focus on women, although men are increasingly at risk for behaviors associated with body dissatisfaction and are not immune to developing this disease. (17)
NED Awareness Week is a general event, not targeted to a certain population but rather aimed at educating a wide population of an entire campus or an entire community, depending on who organizes the events. Several previously completed intervention programs designed for university campuses were aimed at the entire student body rather than screening for or advertising toward high-risk students, and whether or not these studies were successful was unclear (13). A universal rather than selective focus makes NED Awareness Week highly inefficient—it may reach many people who may not use the information while missing those who do. In those that already exhibit symptoms of eating disorders, there may be a level of denial about having the disease (3), and as such may avoid an informational event that is not targeted toward them. In addition, studies have shown that “selected programs that were provided to high-risk individuals produced significantly larger intervention effects than did universal programs that were provided to unselected samples.” (11)

Critique 3: Lack of theory-based or evidence-based intervention methods
The combination of the lack of evidence-based action and the lack of theory to guide the efforts of the orchestrators of NED Awareness Week events in any location makes it a relatively aimless approach to the prevention of eating disorders. Evidence shows that multiple sessions are more effective than brief, one-time sessions, that selective programs are more effective than universal programs, that “psychoeducational content is ineffective in producing behavioral change” (13), and that interactive programs are more effective than informational ones (13). One study has also shown that interventions that try to both prevent asymptomatic individuals from developing disordered eating and to encourage symptomatic individuals to get help at the same time may unintentionally normalize disordered eating behaviors, harming the asymptomatic students instead of helping them. (5) NED Awareness Week seems to have disregarded current scientific knowledge based on findings from studies over two decades, and continues to organize an event based on only the most limited advances in knowledge regarding the etiology of eating disorders. Put eloquently by Stice and Shaw,
. . . the early programs focused on providing information about eating pathology, despite the fact that etiologic models do not posit that a lack of information concerning the ill effects of eating pathology is a risk factor for development of these conditions. (13)

In other words, this intervention does not take into account the actual underlying causes of eating disorders in its effort to prevent them.
Further, in addition to disregarding the actual causes of the disease, it seems to lack a theoretical motivation for its efforts to change individuals’ behaviors. While successful interventions based on cognitive dissonance theory have been identified (17), NED Awareness Week apparently does not follow the guidance of theory to design its approach. In addition to making the event disorganized in nature, this lack of a theoretical foundation limits the evaluation potential of the intervention. Without a hypothesis to test, it is impossible to determine whether the intervention is achieving its stated goals, and as such we cannot know whether NED Awareness Week is helping, hurting, or doing nothing at all to affect the rate of disordered eating behavior in attendees. As such, an intervention of any kind should include some sort of control group with which to compare the effects of the actions taken.

Despite all of these shortcomings, the event effectively improves media literacy. One of NEDA’s “key messages” that it hopes to communicate to its audience during the 2010 NED Awareness Week is how to be aware and critical of the messages the media sends regarding body image (17). By advocating letter-writing events protesting ads promoting negative body image, NEDA encourages the organizers of the event to educate their audience about how to recognize media that promotes negative body image. In this way, NED Awareness Week moves beyond first-generation eating disorder interventions by addressing the societal pressures that contribute to risk factors for eating disorders such as body dissatisfaction.
However, the intervention needs to go a few steps further to engage its attendees with an interactive element. Further, an effective intervention should target at-risk individuals and address specific risk factors. I will explore more effective methods for designing and implementing a successful public health intervention with the goal of reducing the prevalence of eating disorders, addressing each of the criticisms made against NED Awareness Week.
Improvement 1: Inclusion of an intensive experiential component while removing emphasis on didactic techniques
An ideal intervention to address eating disorders would be interactive and engaging, and its main focus would be to address the risk factors of body dissatisfaction, negative body image, and others rather than to inform the attendees about the illness. As such, the information conveyed would focus on issues relating to risk factors rather than on signs and symptoms of eating disorders. Instead of passively reading pamphlets or listening to lectures, the information would be delivered in a variety of ways. One method of delivery may include an internet component, based on studies showing the success of online interventions. (16) The intervention would also include small-group discussion and anonymous online forums, such that the participants would be able to actively engage with the topic in an interactive way in person as well as within a non-threatening safe space online. Finally, the intervention would include an active component in which participants could publicly express their beliefs about these issues and perhaps use what they learned to help younger adolescents avoid unhealthy behaviors and boost confidence. This kind of intervention, in which participants develop and change their beliefs about eating and body image, and then use their knowledge to help younger students, has been shown to change behaviors. This relates to cognitive dissonance theory, and will be expanded upon later.

Improvement 2: Targeting a select audience
Instead of creating an event universally targeted, an ideal intervention would be highly targeted to high-risk individuals. The highest priority population to access would be adolescent girls. To reach them, advertisements for the program would be targeted toward their demographic, through creative design techniques as well as by advertising in places that adolescent girls frequent: high schools, malls, and on websites that they may be interested in.
Other risk factors apart from sex and age could be assessed using questionnaires. In this manner, other high-risk populations could be identified. Other risk factors may include low self-esteem, dieting, perfectionism, and others. (17) Advertising to attract participants in the intervention would be changed to accommodate the different populations, as well as the intervention design itself. For example, the language used to convey information might be different for a group of high-school aged girls versus a group of college-aged women, and topics for discussion might change somewhat as well. In addition, the intervention might attempt to attract a higher proportion of high-risk populations to participate through the use of incentives.
Furthermore, a separate intervention would ideally be designed to target men who may be at high risk for eating disorders, since the prevalence of eating disordered behavior among men is on the rise. (17) However, men may need an intervention designed differently than more traditional approaches designed for women, since societal expectations for male bodies is different from that of women’s bodies. According to Yager and O’Dea, men are engaging in different types of damaging behaviors related to negative body-image than women, including steroid abuse. As such, the part of the intervention focused on media literacy may need to be entirely redesigned to address the expectations the media imposes on men with regards to their bodies.

Improvement 3: Using theory-based and evidence-based intervention methods
In order to craft an effective intervention aimed at preventing eating disorders, a public health practitioner would have to delve into the studies that have already been done to see what works and what does not. Which methods have actually succeeded in reducing the prevalence of eating disorders among at-risk populations? Based on Stice and Shaw’s review analyzing the success of several studies, an effective intervention would have multiple sessions rather than a single session (13). As mentioned before, the intervention would target high-risk individuals, would be interactive, and would engage the participants (13). A few studies have shown that delivering the message of the intervention via the Internet may particularly effective, and as such online material should be considered as a possible addendum or alternative to the method of carrying out the intervention. (16)
Furthermore, the intervention should include some sort of control group in order to assess whether it was successful or not, and to contribute to the wider effort to reduce the prevalence of eating disorders overall. If it was successful, the method should be repeated elsewhere, and if it was not successful or if it was deleterious, those negative effects should not be inflicted upon another population. Because it is impossible to assess the success or failure of an intervention without a control group, the omission of one is in fact an irresponsible and negligent act on the part of the public health practitioner.
In addition to experimental evidence, an effective intervention should also look for guidance from theory in order to develop a logical course of action. Leon Festinger published A Theory of Cognitive Dissonance in 1957. Festinger posits that people favor sets of consistent attitudes and beliefs over inconsistent ones. If a person recognizes that their attitudes are inconsistent, this person experiences a tension caused by cognitive dissonance and is likely to change their attitudes and behavior in order to render these sets of cognitions consistent (1).
Previous studies have looked to cognitive dissonance theory to address eating disorders. (17, 12) For example, Stice and his colleagues undertook a study in 2000 to see if a dissonance-based approach to disordered eating prevention might reduce risk factors in an at-risk population. They designed their intervention to convince high-risk women to voluntarily assume a perspective that was opposite to a thin-body ideal. To this end, Stice et al asked this group of women to help them design a program to reduce thin-body ideal internalization in high school girls. In this way, Stice and his colleagues hoped to induce cognitive dissonance between the women’s stated perspective (against the thin-body ideal) and their behaviors and internal beliefs. This state of dissonance would then theoretically cause a tension which the women would attempt to reduce by changing their attitudes or behaviors. The researchers found a “decrease in thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptomology,” (12) all of which are risk factors for the development of disturbed eating. (4) This method was theoretically guided and its effectiveness was corroborated by successful experimental results. As such, it may be useful to take a similar approach when designing interventions at universities and hospitals to see if these results are generalizable beyond the community in which the authors worked.

Much has yet to be discovered in the field of eating disorder prevention. A standard design and implementation method of a highly effective intervention to that end does not yet exist. However, the only way to continue to improve is to build on past research, test hypotheses, and refine methodology based on the results. NED Awareness Week is information-based, universally targeted, and lacking in a theoretical foundation. The National Eating Disorders Association needs to consider evidence from the past two decades of research on the topic, and change these fundamental aspects of its program in order to effectively reduce disordered eating.

1. Chapanis, N and A Chapanis. 1964. Cognitive Dissonance. Psychological Bulletin, vol. 61: p. 1-22.
2. Dibden, L, E Goldberg, KM Leslie, A Lynk, R Tonkin, M Westwood. 1998. Eating Disorders in Adolescents: Principles of diagnosis and treatment. Pediatric Child Health, vol.3: p.189-92.
3. Gowers, SG and B Palmer. 2004. Eating disorders: assessment and strategies. Women's Health Medicine, vol. 1: p. 11-16.
4. Killen, JD, CB Taylor, C Hayward, D Wilson, K Haydel, L Hammer, B Simmonds, T Robinson, I Litt, A Varady, and H Kraemer. 1994. Pursuit of thinness in a community sample of adolescent girls: A three-year prospective analysis. International Journal of Eating Disorders, vol. 16: p. 227-238.
5. Mann T, S Nolen-Hoeksema, K Huang, D Burgard, A Wright and K Hanson. 1997. Are Two Interventions Worse Than None? Joint Primary and Secondary Prevention of Eating Disorders in College Females.” Health Psychology, vol. 16: p. 215-225.
6. McClain, S. “Be a part of MSU Eating Disorders Awareness Week.” 2007. Murray State University News. Murray State University.
7. “National Eating Disorders Association Wages War Against Eating Disorders During 2009 NED Awareness Week.” 2009. Medical News Today.
8. “NED Awareness Week 2010, February 21-27: Key Messages.” 2009. National Eating Disorders Association.

9. “NEDA is committed to providing help and hope to those affected by eating disorders.” 2009. National Eating Disorders Association.
10. “NED Awareness Week: Until Eating Disorders are History.” 2009. MSU Bodyline Blog. Michigan State University.
11. Sepúlveda AR, JA Carrobles, A Gandarillas, J Poveda and V Pastor. 2007. Prevention program for disturbed eating and body dissatisfaction in a Spanish university population: A pilot study. Body Image, vol. 4: p. 317-328.
12. Stice, E, L Mazotti, D Weibel, and SW Agras. 2000. Dissonance prevention program decreases thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms: a preliminary experiment. International Journal of Eating Disorders, vol. 27: p. 206–217.
13. Stice, E and H Shaw. 2004. Eating disorder prevention programs: A meta-analytic review. Psychological Bulletin, vol. 130: p. 206–227.
14. “The Tiger in the Jungle: Identifying Eating Disorders.” 2009. Kalamazoo Eating Disorders Professional Coalition.
15. Vitiello, B and I Lederhendler. 2000. Research on eating disorders: current status and future prospects. Biological Psychiatry, vol. 47: p. 777-786.
16. Winselberg, AJ, D Eppstein, KL Eldredge, D Wilfley, R Dasmahapatra, P Dev, and CB Taylor. 2000. Effectiveness of an Internet-Based Program for Reducing Risk Factors for Eating Disorders. Journal of Consulting and Clinical Psychology, vol. 68: p.346-350.
17. Yager, Z and JA O’Dea. 2008. Prevention programs for body image and eating disorders on university campuses: A review of large, controlled interventions. Health Promotion International, vol. 23: p. 173-189.

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