The Prevention of Eating Disorders: A Bold Look at Current Status and Future Directions

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The Prevention of Eating Disorders A Bold Look
at Current Status andFuture Directions
Michael Levine, Ph.D., FAED Department of
Psychology, Kenyon College, Gambier, OH
43022-9623 August 14, 2008, American
Psychological Association Eating Disorders --
Psychologys Role in Enacting Change and
Influencing Policy
THIS and OTHER RECENT Levine POWERPOINTS
AVAILABLE FREE at http//psychology.kenyon.edu/le
vine/
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Rationale forPrevention

• Prevalence, severity vs. person-power shortage
• Multifaceted health promotion Risk Factors and
  the principle of equipotentiality
• Obesity as Godzilla . . . .
• Evidence - sociocultural basis
• Gender and development
• Historical aspects (Silverstein Perlick, 1995)
• Other social changes in the
• USA (e.g., womens athletics)

BMI 756
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Rationale for Prevention Knowledge, and Research
If you want to truly understand something, try
to change it

• - Kurt Lewin (1890-1947)
• (no date/source, as quoted in)
• APA Policy and Planning Board.
• (2007). Who cares about APA
• Policy and does it have an impact?
• American Psychologist, 62, 491-503.

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Prevention is Primary

• Praevenire Latin - come before, anticipate,
  and/or
• forestall What are
  waiting for?
• 1. Evading or forestalling development of
  psychological disorder or unhealthy behavior
• 2. Protect and extend current states of health
  and effective functioning
• 3. Promoting greater well-being and more
  effective coping to strengthen resilience in the
  event of predictable or unforeseen stressors

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Types of Prevention

• --------------------------------------------------
  -----------------------------------------------
  Focus IOM Terminology
  Caplan (1964) Examples
  
  
• --------------------------------------------------
  ------------------------------------------
• Large groups - Universal prevention
  Primary Laws regulating
• healthy people (public health prevention)
  advertising of
  diets
• Smaller groups - Selective prevention
  Primary Programs for
• NS but HR
  children
  entering
• 
  
  elite ballet schools
• Small groups - Indicated or Targeted
  Secondary Programs for
• Very HR - prevention
  women
  with
• clear precursors
  
  severe weight
• 
  
  concerns
• --------------------------------------------------
  ------------------------------------------

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A Prevention Effect

• program is implemented as planned (fidelity is
  high)
• use of reliable and valid measures reveal that
• asymptomatic participants show a low(er) rate of
  onset of disordered eating over time as compared
  to the general population at risk
• reduced incidence of disordered eating is
  mediated by decreases in those risk
  factorsand/or increases in the protective
  factorsemphasized by the model guiding program
  development.
• comparison conditions or other arrangements
  demonstrate that the effect is probably due to
  social and psychological processes hypothesized
  to be influential components of the program.

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Conclusions About Universal-Selective and
Selective-Targeted Prevention

• Good outcome research remains limited
• There is an encouraging theoretical and research
  basis for prevention Effect sizes are small (
  .05 - .10), but significant
• it simply is not true that
• a prevention changes only knowledge, and
• b no studies have shown a long-term effect
• Value of psychoeducation as a foundation. . . .
• However, with a few exceptions, U/S programs to
  date have either not really assessed prevention
  or have had limited long-term effects

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Key Elements of Prevention ProgramsThe 5 Cs of
Preventionafter Sigall Pabst, 2000

• - Consciousness-raising
• - Competence
• - Connection
• - Change
• - Choices

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Conclusions About Universal-Selective Prevention
(continued)

• The program participation effect indicates that a
  more
• intensive, participatory, ecological perspective
  is needed
• The issue is ethics, not iatrogenesis failure
• be concerned about, but preoccupied with harm
• No systematic work on selective-targeted
  prevention for elementary and middle school
  children
• Selective-Targeted programs have demonstrated
  greater effect sizes ( .20 - .25), and some have
  had more
• consistent effects, especially over time.

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Targeted Prevention is important -- but its not
the only or even the principal answerA
Simplified Look at the Rose Paradox (Austin,
2001 Rose, 1995)

• Number Risk - Disorder N___
  
• 10,000 High
  12 1200
• 90,000 Lower
  2 1800
• 100,000 total Low-mod? 3
  3000

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Necessary Advances I Learn a lot from the
prevention of cigarette smoking and other
substance use/abuse(Biglan et al., 2000
Cuijpers, 2002 Levine Smolak, 2006)

• Interactive engagement with students
• Normative expectations
• Social influence Critical thinking
• resistance training
• Life Skills (multifaceted
• competence enhancement)
• Peer involvement
• School policies curricula
• Community programming
• Supporting families

Ecstacy E or X
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Hard-won Gains and Lessons from the Prevention of
Substance Abuse and Other Problems

• Beware the justs - Be careful about
  oversimplification
• Lot of things are risky if done poorly - Value
  of
• education dangers of relying solely on it
  (Hansen, 1992)
• Prevention is not a luxury - It is a necessity
  and
• it can work, i.e., it is possible (Tobler et
  al., 2000)
• It takes more than a village, but thats a
  start -
• An ecological perspective is at the heart of our
  work
• Key components and reciprocal determinism
• Methodology is critical as an aspect of research,
• advocacy, and, ultimately, theory (Biglan et
  al., 2000)

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We can learn a lot from the prevention of
cigarette smoking and other substance
use/abuse(Biglan et al., 2000 Stith et al.,
2006 Winters et al., 2007)

• Community readiness
• Collaboration and coalition-building
• Planning for FES fidelity, evaluation, and
  sustainability (staffing, fund-raising,
  relationship-building

• Expending meaningful amounts of resources in
  engaging the target populations
• Broad-based involvement in bottom-up and
  consensus-oriented decision-making

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The Ecological Perspective Reminds Us Prevention
is Primary

• Cowen (1973, 1983) -- broad but distinct concept
• 1. targets a group, not individuals
• 2. targets those who are well, although they may
  be at risk
• by virtue of life circumstances
• 3. has a more impersonal focus on changing
  groups, institutions, and communities
• 4. intentional intervention that applies
  knowledge to strengthening
• psychological health and forestalling
  maladjustment.

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Necessary Advances II Integrating prevention of
negative body image and disordered eating with
prevention of obesity On Shared Ground(based
on Neumark-Sztainer and colleagues)

• Body dissatisfaction ?life dissatisfaction
• Disturbances of interoceptive awareness
• Unhealthy dieting
• Maladaptive weight management
• Binge-eating and chaotic food consumption
• Inadequate nutrition
• Dealing with culture(s) and cultural change
• Unhealthy relationships with media and
  activity/exercise

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Multifaceted Health PromotionNegative body
image, disordered eating, and obesity On
shared ground HAES Philosophy (Robison, 2003)

• Self and diversity acceptance, supported
  supported by people who care about you as a whole
  person
• Enjoying physical activity and a more active
  lifestyle in accord-ance with needs and rights
• Making more peaceful, social, and celebratory
  relationships with nutritious, nourishing food
• Living better through critical consciousness and
  everyday acts of rebellion

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Necessary Advances III A Bolder Model
of Prevention (Irving, 1999 Levine, Piran,
Stoddard, 1999 Levine Smolak, 2006 Maine,
2000 Piran, 2001 Sigall Pabst, 2005)


5 Components of Effective Prevention
Cultural Literacy
Collaboration Consciousness-Raising Competencies
Choices and Changes adapted from gender
literacy work of Sigall Pabst
Awareness Analysis Activism and
Advocacy Access (e.g., to media)
Personal Professional
Political
You must be the change You wish to see in the
world - Ghandi
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Some Things are Like PreventionHard to
Understand How it Could Happen,But It Needs to
be Done
Bring it!
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Challenge and Hope of Prevention
Piran, 1999

• Austin et al., 2005

Goldberg, Elliot, and colleagues
Neumark-Sztainer et al. (2000)
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What are We Waiting For?Its Time, No?

• At the age of six I wanted to be a cook. At
  seven I wanted to be Napoleon. And my ambition
  has been growing steadily ever since.
• Salvador Dali

Soft Watch at the Moment of First Explosion, 1954