Preventing Negative Body Image and Disordered Eating: A Complicated Primer for Educators

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Preventing Negative Body Image and Disordered
EatingA Complicated Primer for Educators

• Michael Levine, Ph.D., F.A.E.D.
• Professor of Psychology, Kenyon College
• Gambier, OH 43022-9623
• March 12, 2008
• http//psychology.kenyon.edu/levine/

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GOALS AND OVERVIEW

• Why prevention?
• Definition and types of prevention
• Models of prevention and outcome research
• Conclusions about universal-selective prevention
• Implications for future research
• Selective-targeted (secondary) prevention

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Rationale for Prevention

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

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Pervasive, Unhealthy ImpactUSA, Canada, UK,
Australia, Mexico . . .

• Prevalence of eating disorders (0-4)
• Prevalence of disordered eating (2-5)
• Prevalence of negative body image and unhealthy
  dieting/nutrition (10-15, chronic)
• Use and abuse of steroids and supplements (2-5)
• Correlates of negative body image and
  calorie-restrictive dieting e.g., depression,
  binge-eating
• Rates of obesity for older children and
  adolescents nearing 20

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Multifaceted Health PromotinPrevention of
negative body image and disordered eating can be
integrated with the prevention of obesity On
Shared Ground

• 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 accordance 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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Prevention is Primary I

• Praevenire Latin - come before, anticipate,
  and/or
• forestall
• 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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3 Models of Prevention

• Social Cognitive Theory
• Non-specific Vulnerability-Stressor Theory
• Feminist Empowerment Relational Model (as a
  Critical Social Perspective)

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Disease-Specific Social Cognitive Approach

• REDUCE gt
• Slender ideal
• Negative body image
• Prejudice against fat and fat people
• Centrality of weight and shape
• Good vs. Bad foods
• Calorie-restrictive dieting
• Low self-esteem

• INCREASE gt
• Healthy eating and exercising
• Healthy weight management
• Critical thinking other
• resistance skills
• Self-acceptance
• Skepticism about dieting
• Concern with eating disorders

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Social Cognitive Approaches Key Features

• Source of Change Teacher or Mental health
  professional
• Pre-determined Lessons with at least some, if not
  a large amount of information
• Individual and group activities, e.g., videos,
  discussion, worksheets, role-playing
• Sometimes individual cognitive-behavioral work
• Sometimes integrated with information for parents
  or teacher workshops

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Best Practices in Elementary Early Middle
School Kathy Katers Program

• 10 Lessons for grades 4 through 6
• Cannot and should not try to control
• developmental changes of puberty
• impact of genetics on size and shape
• short- and long-term impact of calorie-restrictive
  dieting
• Can and should try to control
• multifaceted identity vs. appearance-focus
• moderation and variety in nutrition and
  exercising
• selection of realistic, resilient role models
• Thinking and knowing
• media literacy
• history of attitudes about bodies and body image

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Social Cognitive Programs Partial Successes

• ELEMENTARY SCHOOL
• Smolak Levine (2001) USA developmental and
  weight-related teasing
• MIDDLE SCHOOL
• Austin et al. (2005) USA Planet Health
  obesity prevention
• McVey et al. (2003) Canada life skills, peer
  support
• McVey et al. (2006) Canada school wide
• HIGH SCHOOL
• Neumark-Sztainer et al. (1995) Israel -
  nutrition
• Santonastaso et al. (1999) Italy - developmental
  
• Except for Austin et al., only one thing in
  common
• Critical evaluation of culture and the
  clash

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Non-Specific Vulnerability-Stressor Model
(Albee, 1987)

• Increasing coping and other life skills, for
  example
• decision-making, communication, coping with
  stressors, assertion
• Increasing self-esteem and positive self-image,
  especially in terms of multiple interests and
  competencies
• Increasing social support (e.g., during
  transitions)
• Reducing stressors (e.g., teasing, harassment,
  prejudice)
• Changing environments and institutions to promote
  
• support for respect, health, competence, etc.

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NSVS ApproachKey Features (ODea Abraham,
2000)

• Teacher facilitated, discovery-based
  cooperative learning
• No mention of weight, eating, nutrition, dieting
• Integrated into ongoing health curriculum
• Multiple, engaging activities for life skills,
  social, and self-esteem
• Emphasis on bringing parents, peers, and other
  adults (e.g., grandparents) into the process
• Communication skills for support and for
  appreciating and respecting appearance of self
  and other

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NSVS ProgramsPartial Successes

• ODea Abraham (2000) - Australia
• sustained improvements in concerns about physical
  appearance and acceptance from others
• limited sustained effects on body esteem
• no sustained effects on EDI subscales
• McVey et al. (2003a) Canada
• Canadian public health nurses
• GirlTalk peer support groups
• increased body esteem
• decreased dieting
• prevented increase in bulimic behavior
• but recent replication . . .

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Empowerment-Relational Model(Piran, 1999, 2001)

• Emphasis on gender and the experience of being
  in, or disconnected from, ones body
• Based on girls and womens experiences in
  specific contexts, not didactic lessons
• Empowerment within dialogue within relationships
• Girls and women as authorities, not the experts
• Body as a site of power and transformation, not
  private shame
• Transforming the personal into the political
  Activism and systemic change

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Critical Social Perspectives Programs Successes
Partial Successes

• Piran (1999) Canada (Elite Ballet School)
• reduction in incidence of eating disorders
• Neumark-Sztainer et al. (2000) USA Girl Scouts
• reduced internalization of slender beauty ideal
• increased self-efficacy for activism in regard to
  weight-related norms
• no sustained effect on dieting or body-size
  acceptance
• Steiner-Adair et al. (2002) Full of Ourselves -
  USA middle school girls
• sustained improvements in body satisfaction
• no sustained effect on internalization of beauty
  ideal
• no effects on weight management such as dieting

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Universal-Selective Prevention Recent
Meta-Analyses

• Stice and Shaw (2004)
• Interactive (vs. didactic) and focus on
  developing skills for
• -- resisting unhealthy sociocultural
  influences
• -- increasing body satisfaction tend to have
  stronger effects
• Universal-selective programs had small but
  statistically significant prevention effect sizes
  (rs range from .06 to .09) at follow-up for
• -- eating pathology and
• -- risk factors of body dissatisfaction and
  internalization of
• the slender beauty ideal (similar to
  targeted)
• No evidence that prevention programs are
  inadvertently harmful.
• Fingeret et al. (2006) - universal and selective
  (including universal-selective) programs continue
  to be promising

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Conclusions About Universal-Selective Prevention

• Good outcome research remains limited
• There is an encouraging theoretical and research
  basis for prevention 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, programs to date
  have either not really assessed prevention or
  have had limited long-term effects

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Conclusions About 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
• elementary and middle school children

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Implications of Current Research Need for
Well-Designed Outcome Studies

• Random assignment (at some level, e.g., schools)
  and sufficient power
• Program is implemented as planned fidelity is
  high
• Program participants as a group show a low(er)
  onset, that is, incidence, of disordered eating
  over time as compared to the population incidence
• Comparison conditions demonstrate that the effect
  is probably due to the processes hypothesized to
  be influential components of the program
• Reduced incidence of disordered eating is
  mediated by decreases in the risk factorsand/or
  increases in the protective factorsemphasized by
  the guiding model
• Reliable, valid measurement of disordered eating,
  risk factors, and protective factors

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Implications of Current ResearchAn Ecological
Perspective

• Of or pertaining to the totality or pattern of
  relations between organisms and their environment
• Sociocultural factors
• A spectrum of problems
• Limits of classroom programs
• Lessons from other areas of prevention
• Definitions and models of prevention

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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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The Ecological PerspectiveHealth Promoting
Schools

• School ethos
• School curriculum
• School-community partnerships

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School Ethos - Action Committee

• Resource person
• Dialogue and needs assessment
• Action committee, with administrative support
• School policies
• What is the mission?
• What are the principles?
• Policies and procedures
• teasing and harassment
• IAR Identification, assessment, referral

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School Ethos - Action Committee IAR

• Policies and support
• Community preparation
• and collaboration
• Purposes
• Dos and Donts

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Health Promoting Schools Ethos (for example)

• Teacher and staff assessment training
• Ecological review
• posters, contests, practices
• multiple opportunities for success in ways that
  de-emphasize appearance for girls
• emphasis on various forms of helping, including
  reaching out to peers, community service
• Food Service
• Educational needs of teachers, library, coaches

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Health Promoting Schools Ethos Staff as Role
Models

• Dressing with style and individual expression
  regardless of shape and weight
• Refusing to avoid activities because of body
  image issues
• Enjoying a variety of foods in front of students
• No fat talk
• Exercising for the 4 Fs Fun, fitness,
  friendship, function
• Practice talking back to culture

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Implications of Current ResearchAn Ecological
Perspective Means That Prevention Should Involve
Boys and Men in Various Ways
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Implications of Current ResearchAn Ecological
Perspective means that we can learn a great deal
from the prevention of cigarette smoking and
other substance use/abuse

• Engaging students
• Normative expectations
• Critical thinking
• Life Skills
• Peer involvement
• School policies
• classroom work
• Community
• programming

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Goldberg et al. (2000) The Adolescents Training
Learning to Avoid Steroids (ATLAS) Program

• Education, media literacy, media advocacy,
  refusal skills, nutrition strength training
• HS football players (vs. controls) 1 year FU
• -- greater knowledge (exercise, AS)
• -- less investment in images of use
• -- less intent to use
• -- less new use
• -- saw coaches as less tolerant
• ATHENA for girls
• http//www.ohsu.edu/hpsm/atlas.html

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Implications of Current ResearchEducation is a
Foundation

• Content
• The Clash
• Critical analysis
• Gender and identity
• Health and performance ? well-being
• Action and activism
• Media and cultural literacy

• Processes
• Dialogue
• Discovery
• Teaching
• Social norms
• Integration

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The 5 Cs of Preventionafter Sigall Pabst,
2000

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

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Cultural Literacy, the Critical Perspective, and
Prevention
Sociocultural influences
Unhealthy Messages
Negative Effects
Consciousness- raising Choice
Competence Connection Change

• Analysis
• Fair?
• Function?
• Who benefits?

Activism Advocacy
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Media Literacy and the 5 As The Cycle
Embedded in a Sociocultural Context...
Critical Awareness Analysis in a Relational
Context
Fat is bad/ Thin is good
Unhealthy relationship to food
Consciousness-raising through Connection Competenc
ies Choices for Change
Actions May involve gaining Access to mass media
Competition between women
Rigid, limited gender roles
Advocacy Access Including actions taken USING
media
Activism Including actions taken TOWARD media
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Its Time to Dream Envisioning An Example of
Ecological Change

• Mental Health Association
• Education
• Advocacy
• Prevention

• Peers
• Decreasing teasing
• objectification
• Collaboration
• Social marketing

Microsystems
Exosystems

• Religious Organizations
• Self-respect
• Tolerance
• Health
• Leadership and
• service

• Youth Organizations
• (e.g., Scouts, 4-H)
• Peer leadership training
• Programs with awards
• Media literacy for adults

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Targeted Prevention

• Universal-selective programs can be useful with
  older adolescents. Nevertheless, as children and
  young adolescents get older, one is more likely
  to be addressing and identifying participants who
  already show body image or eating problems and
  hence are appropriate audiences for
  selective-targeted prevention.

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Targeted Prevention

• Group Interventions
• Stices cognitive dissonance
• Stices healthy weight program
• Paxtons Set Your Body Free
• Computer Assisted Psychoeducation Programs (CAPP)
• Student Bodies
• Food, Mood, and Attitude

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Selective-Targeted PreventionRecent
Meta-Analyses

• Stice and Shaw (2004) - Controlled prevention
  outcome studies - targeted (which they referred
  to as selected) for high-risk participants is
  more effective than universal prevention,
  especially for people ages 15 or older.
• Stice and Shaw (2004) - Effect sizes at follow-up
  - small to moderate for
• internalization of the slender beauty ideal (r
  .21)
• body dissatisfaction (r .25)
• dieting (r .24)
• eating pathology (r .22)
• Fingeret et al. (2006)
• targeted prevention programs had greater effects
  on thin-ideal internalization and body
  dissatisfaction than universal or selective
• although selective programs were more effective
  at reducing dieting

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Implications of a Sociocultural PerspectiveAn
Ecological ApproachA 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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Conclusions

• Prevention is absolutely necessary
• There is evidence to support the effectiveness of
  prevention efforts
• There is no single approach that works but
  theory and evidence point to the value of a
  Critical Social Perspective and the 5 Cs of
  Prevention

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Conclusions

• An ecological perspective Absolutely necessary,
  bewilderingly absent
• There is help for this effort in the fields of
  psychology and public health (e.g., substance
  abuse prevention)
• Selective-targeted (more secondary) prevention
  is, thus far, more efficacious (i.e., has better
  outcomes) than universal-selective (more primary)
  prevention, but it cannot be the answer
• Prevention is potentially harmful if done poorly,
  but so is wood-working, therapy, medicine,
  marriage. . . .

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A Bolder Model of Prevention (Irving, 1999)
"Each of us must be the change we want to see in
the world Mohandas K. Gandhi Everything
is advocacy! Michael Moore (husband of Ruth
Striegel-Moore

• Personal
• Professional
• Political