Literature Review

Approximately 10% of young women will experience either a full-blown eating disorder or preclinical symptoms. Eating disorders are characterized by chronic problems including medical complications and impaired functioning. Young women with this condition are also at increased risk for future onset of obesity, depression, suicide attempts, anxiety disorders, substance abuse and other health problems. Only about a quarter of individuals with this disorder receive treatment and of these only 30% experience symptom remission for at least four weeks. Given these limitations of treatment programs much effort has been focused on prevention programs.

The following are the highlights of an English language review of the literature on eating disorder prevention programs and selected risk factors. Only those studies which focused solely on adolescent females were included.

Most prevention programs consisted of multiple sessions over several weeks. The formats were largely didactic with the provision of information and possibly some discussion of the material. Findings from the literature on substance abuse suggest that psycho educational interventions don’t create behaviour change. Some writers suggest inclusion of interventions which have been largely effective in substance abuse and smoking programs. These would include: social inoculation, peer-group modeling and image building. Austin reviewed 20 prevention programs and reports that four indicated positive behaviour change; seven resulted in changes in attitude, five showed an increase in knowledge but four resulted in the symptoms getting worse.

This research project addresses some gaps in the current literature. In particular, the sample is from the community and not from treatment centres; secondly, the interview schedule includes questions about women’ conflicting gender roles in contemporary society and finally the methodology employed —applied discourse analysis from a feminist perspective is unique in the field.

Although early assessments of eating disorder prevention programs provided mixed results with some researchers expressing concern that prevention programs may even have harmful effects since they increased knowledge of eating pathologies. A more recent meta-analytic review by Stice and colleagues, however, provides some positive results and no indication that these programs increase the risk of eating disorders.

Their review reports that 51% of eating disorder prevention programs reduced eating disorder risk factors and 29% reduced current or future eating pathology. The greatest change occurred for the following:

o Programs that were selected (e.g. high risk) as opposed to universal o Interactive rather than didactic o Multi-session as opposed to a single session o Offered only to females as opposed to both sexes o Participants are over 15 years of age rather than younger subjects o Programs offered by those who are professionally trained as opposed to for example, school staff; o Programs with body acceptance and dissonance-induced content versus psycho-educational content.

Research on specific risk factors that lead to eating disorders is mixed. However, there is general acceptance that the following factors are strong influences in the development of eating pathology:

o Elevated perceived pressure to be thin from family (especially parents), peers and media; o Internalization of the thin ideal; o Body mass; o Body dissatisfaction; and, o Negative affect.

Evidence is strongest for programs that reduce thin-ideal internalization, body dissatisfaction and negative affect since these have been tested by randomized control trials. In some studies dieting has predicted future onset of eating disorders, whereas in other research assignment to a low-calorie diet versus a wait-list control condition results in a decrease in bulimic symptoms for at-risk women.

There are four main categories of risk factors identified in the field—biological variables, individual factors, family dynamics and the socio-cultural context. As with most of human behaviour eating disorders are a multifactor process. An increase in the number of risk factors means an individual is more at risk for an eating disorder.

A review of the biological factors found mixed or premature results for the role of genetics; however, there is support for the role of obesity, and for the tendency of dieting to enhance overeating. There is potential for early onset of puberty to be a risk factor if it is combined with other stressful or developmental events.

Among the numerous psychological factors which have been researched, by far, body dissatisfaction is the strongest indicator of problems with eating. Self esteem does not appear to be a risk factor on its own, however, combined with other influences such as body esteem, body dissatisfaction and the way that participants’ felt about their bodies, then self-esteem definitely had an impact on eating pathology.

Other factors such as perfectionism, participation in sports that emphasize thinness and the tendency to become distressed also play a role in developing eating disorders.

The relationship between eating disorders and depression is well established but little is known about the specifics of this relationship. A team of researchers studied the reciprocal relation of eating disorders and depressive symptoms in a community sample (N= 496) over an eight year period. The study concludes that depressive symptoms contribute to eating disorders and eating disorders contribute to depression. Consequently, prevention of one disorder will also help in prevention of the other.

Aggression and the use of alcohol and illegal substances are related to bulimia or binge eating symptoms however, the relationship is not well understood. Finally, a history of childhood sexual abuse as well as childhood trauma are contributing factors in the development of eating disorders

Research on the role of family dynamics in developing eating disorders has focused primarily on parental attitudes. In addition, compared to healthy controls, women with anorexia were found to have the following risk factors: inadequate parenting, multiple house moves in childhood, high parental expectations and a parental history of eating disorders. Critical comments by both mothers and/or fathers contributed to the development of weight concerns.

In a review of the literature on parental influences, researchers found that parents are strong communicators of socio-cultural pressures. Parental influence through verbal communication and encouragement had a greater impact on their children’s body concerns and eating behaviours than parental role modeling. Both mothers and fathers were found to be an important source of influence on their offspring. More specifically, Allen et. al. found that being female and being perceived as overweight by a parent was the strongest predictor of eating disorders compared to two control groups.

In a critical review of the impact of mass media and eating disorders in adolescent females, the authors conclude that the role of media is a variable risk factor that requires further research to establish it as a causal link. One longitudinal study in approximately 7000 female adolescents found that frequent dieting and trying to look like someone in the media were independent predictors of binge eating. Another study of a program which targeted media literacy and perfectionism found that changes in perfectionism were significant but that media literacy remained the same as the control groups.

An examination of the relationship between excessive exercise behaviours, eating disordered behaviour and quality of life provides evidence that a high level of guilt over missed exercise was associated with eating pathologies and a reduced quality of life. This relationship was even more marked when exercise was undertaken explicitly to control weight or change their body shape.

Another area of study is the impact that the presenter has on program effectiveness. When someone other than a trained professional delivers the program, this is referred to as “real world conditions” or “naturalistic conditions.” Becker, Smith and Ciao have studied a program delivered by a sorority, randomized to new members. The delivery of the program by peers proved to be effective. A later replication of the study reports similar results. In another study, delivery of the program through the Internet proved effective.

In terms of teaching strategies there is strong evidence that dissonance-based activities are effective. Dissonance-based activities are a social-psychological approach in which participants engage in counter attitudinal exercises for example, write a critique of the current thin ideal and/or engage in role playing. Dissonance-based activities are particularly effective with high-risk groups. In a randomized control trial, a team of researchers found that high risk adolescent girls (with body dissatisfaction) who engaged in dissonance-based activities showed significantly greater reduction in eating disorder risk factors and bulimic symptoms than groups which undertook healthy weight promotion, expressive writing or assessment-only controls. In a later study with the same sample dissonance participants showed a 60% reduction in risk for the onset of eating disorder pathology through a 3-year follow-up.

Women represent 90% of people with eating disorders. In industrialized nations, beauty is the most salient aspect of femininity and a major source of achievement for women. Since the current standard for beauty is unrealistically thin, this results in widespread body dissatisfaction and dieting among women.