National Eating Disorders Association

Prevention is any systematic attempt to change the circumstances that promote, initiate, sustain, or intensify problems like eating disorders. Eating disorders arise from a variety of physical, emotional, and social issues, all of which must be addressed for effective prevention and treatment. 

Records of eating disorders exist throughout history and in cultures around the world. Since the 1950s, however, reports of all eating disorders have increased dramatically, especially in Western cultures. At the same time, people in these same cultures have increased dieting for weight loss and the amount of attention they pay to the food they eat and their body size and shape. This suggests that these factors may play a role in the development of eating disorders. Scientists believe that if they can reduce the risk factors for eating disorders, then they can reduce the chances that a person will go on to develop an eating disorder.

Prevention efforts may involve reducing negative risk factors, such as body dissatisfaction, depression, or basing self-esteem on appearance; or increasing protective factors, such as a non-appearance-oriented self-definition and replacing dieting and body snarking with intuitive eating and appreciation for the body’s functionality. 

Although it’s too soon to say that any specific prevention program can reduce the rates of diagnosable eating disorders, these programs do show benefits in reducing risk factors for eating disorders, such as fasting, purging, and other unhealthy weight loss behaviors, as well as in decreasing disordered eating.

What are Prevention Programs?

Prevention programs are systems and trainings developed in order to prevent eating disorder onset in a population. Prevention programs vary based on the size and nature of the group for whom the programming is intended. The Mental Health Intervention Spectrum, developed by the National Academy of Sciences (Committee on the Prevention of Mental Disorders, 2009), classifies different types of prevention programs according to their goals, methods and audiences:

Universal/primary prevention: These are programs or interventions aimed at all people in a population (e.g., all adolescents in New York City, or all students in a health class). Designed to change public policy, institutions and normative cultural attitudes and practices. The aim is to prevent the development of eating disorders in large groups with varying degrees of risk. Universal prevention may involve education, policy or legal action, and other environmental and larger social actions.

Selective prevention: Intended to prevent eating disorders by targeting individuals who do not yet have symptoms of a disorder and are at risk for an eating disorder due to biological, psychological or sociocultural factors (e.g., girls aged 10 to 13 who are facing puberty, experience sociocultural pressure for thinness, and have a parent with a history of an eating disorder). Selective prevention typically involves multisession, interactive curriculum.   

Indicated/targeted prevention: Targets people who are at high risk due to warning signs (e.g., mild ED symptoms) and/or clear risk factors (e.g., high levels of body dissatisfaction). The audience does not yet have an eating disorder. The goal is to stop the development of a serious problem and is aimed at the individual, rather than at effecting change in social policies, systems, or interpersonal behavior. Indicated prevention overlaps with traditional steps of clinical treatment: case identification to intervention to aftercare.

Does Eating Disorders Prevention Work?

There are many studies evaluating a variety of eating disorders and disordered eating prevention programs. Some of the major findings are:

General Findings

  • Prevention programs can alter knowledge, attitudes and behaviors associated with eating disorders and disordered eating. 
  • Various programs have successfully discouraged the development of eating problems in children, adolescents and young adults.
  • Much more research is needed concerning prevention. We are particularly lacking information about prevention programs that work with children, with males, and with people from a variety of ethnic groups.

Findings on Program Types

  • Universal, selective and indicated/targeted prevention programs have enjoyed some success, though targeted programs may have had more success. Universal prevention is often difficult to research due to its focus on large-scale policy and normative attitudinal changes.
  • There is particularly good evidence that targeted programs using a social learning theory, cognitive behavioral, media literacy and cognitive dissonance approaches are effective with adolescents and young adult women from various ethnic groups.
  • The cognitive dissonance approach encourages girls and women to question the media and cultural messages by asking them to speak out against the thin ideal or other eating disorder risk factors through verbal, written and behavioral exercises. The conflict between one’s beliefs and actions creates psychological discomfort, motivating the individual to change their beliefs to match their actions.
  • Programs that have shown some success include, but are not limited to, programs that adopt an ecological approach, involving not only individual change but also changing the environment of teacher and peer behavior; media literacy programs; and programs that emphasize health. 

References:

Ahern, A. L., Bennett, K. M., & Hetherington, M. M. (2008). Internalization of the ultra-thin ideal: positive implicit associations with underweight fashion models are associated with drive for thinness in young women. Eating Disorders, 16(4), 294-307. 

Cash, T., & Smolak, L. (2011). Body image: A handbook of science, practice, and prevention (2nd ed.). NY: Guilford.

Levine, M.P., & Smolak, L. (2006). The prevention of eating problems and eating disorders: Theory, research, and practice. Mahwah, NJ: Lawrence Erlbaum.

Juarascio, A. S., Forman, E. M., Timko, C. A., Herbert, J. D., Butryn, M., & Lowe, M. (2011). Implicit internalization of the thin ideal as a predictor of increases in weight, body dissatisfaction, and disordered eating. Eating behaviors, 12(3), 207-213.

Loucas, C. E., Fairburn, C. G., Whittington, C., Pennant, M. E., Stockton, S., & Kendall, T. (2014). E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis. Behaviour research and therapy, 63, 122-131.

Neumark-Sztainer D. (2005). Can we simultaneously work toward the prevention of obesity and eating disorders in children and adolescents? International Journal of Eating Disorders, 38, 220-227.

Smolak, L., & Thompson, J.K. (2009). Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (2nd edition). Washington, DC: American Psychological Association.

Stice, E., Shaw, H., & Marti, C. N. (2007). A meta-analytic review of eating disorder prevention programs: progress at last. Annual Review of Clinical Psychology, 3, 233-57

Stice, E., Marti, C. N., Spoor, S., Presnell, K., & Shaw, H. (2008). Dissonance and healthy weight eating disorder prevention programs: long-term effects from a randomized efficacy trial. Journal of consulting and clinical psychology, 76(2), 329.