Review of options for primary prevention of eating disturbances among adolescents

Population-level policy recommendations for the prevention of disordered weight control behaviors: A scoping review

OBJECTIVE

The aim of this scoping review was to identify recommendations and gaps in knowledge surrounding the prevention of disordered weight control behaviors (DWCBs) through policy.

METHOD

A search was conducted in several databases to identify English language articles that described an active policy, recommendation, guideline, or educational curriculum that could be implemented by governments or regulatory bodies to prevent DWCBs or related constructs (e.g., weight stigma, body dissatisfaction). Two researchers independently screened articles with oversight from a third researcher. Data were extracted from the final sample (n = 65) and analyzed qualitatively across all articles and within the domains of education, public policy, public health, industry regulation, and media.

RESULTS

Only a single empirical evaluation of an implemented policy to reduce DWCBs was identified. Over one-third of articles proposed recommendations relating to industry regulation and media (n = 24, 36.9%), followed by education (n = 21, 32.3%), public policy (n = 19, 29.2%), and public health (n = 10, 15.4%). Recommendations included school-based changes to curricula, staff training, and anti-bullying policies; legislation to ban weight discrimination; policies informed by strategic science; collaboration with researchers from other fields; de-emphasizing weight in health communications; diversifying body sizes and limiting modified images in media; and restricting the sale of weight-loss supplements.

DISCUSSION

The findings of this review highlight gaps in empirically evaluated policies to reduce DWCBs but also promising policy recommendations across several domains. Although some policy recommendations were supported by empirical evidence, others were primarily based on experts' knowledge, highlighting the need for greater research on population-level DWCBs prevention through policy.

PUBLIC SIGNIFICANCE

Our scoping review of the evidence on policies for the prevention of disordered weight control behaviors identified several recommendations across the domains of education, public policy, public health, and industry regulation and media. Although few empirical investigations of implemented policies have been conducted, expert recommendations for policies to prevent disordered weight control behaviors among populations are plentiful and warrant future consideration by researchers and policymakers alike.

Two Cases of Eating Disorders in Adolescents with Dental Braces Fitted Prior to the Onset of Anorexia Nervosa

Orthodontic treatment typically occurs during early childhood and adolescence but the wearing of dental braces is often associated with sudden changes in eating patterns that prolong treatment into the teenage years. Despite these changes, psychological assessments related to eating disorders during the course of orthodontic treatment are often ignored. Based on the findings of the present case report, it is suggested that adolescent patients who wear braces and exhibit severe weight loss should be carefully monitored for psychiatric problems, including eating disorders.

Weighing in on the issue: a longitudinal analysis of the influence of selected individual factors and the sports context on the developmental trajectories of eating pathology among adolescents

Eating disorders, and related issues (e.g., body dissatisfaction, weight control behaviors), represent pressing and prevalent health problems that affect American adolescents with alarming frequency and potentially chronic consequences. However, more longitudinal research is needed to elucidate the developmental processes that increase or maintain risk for, and that protect against, eating- and weight-related problems among adolescents. Accordingly, the current study used longitudinal data from 1,050 male and female (68.0 %) adolescents (Grades 9-11)-the majority of whom were European Americans (72.2 %)-who participated in the 4-H Study of Positive Youth Development to (a) describe trajectories of adolescents' eating pathology and body dissatisfaction, (b) identify individual and contextual correlates of these pathways, (c) examine whether trajectories of eating pathology and body dissatisfaction related to adolescents' depressive symptoms, and (d) elucidate whether sports participation moderated associations between specific trajectories of eating pathology and body dissatisfaction and adolescents' depressive symptoms. Results suggest that the diverse pathways of eating pathology and body dissatisfaction that exist across middle adolescence, in combination with adolescents' sports participation, have important implications for the positive and problematic development of our youth. In addition, the findings underscore the need to evaluate the interindividual differences that exist in regard to how sports participation may relate positively and negatively to developmental outcomes.

A controlled assessment of school-based preventive programs for reducing eating disorder risk factors in adolescent Spanish girls

This study assesses the impact of an eating disorders universal preventive program on a representative sample of Spanish adolescents in the area of Barcelona, Spain. 323 adolescent girls were assigned to three experimental conditions: complete intervention, partial intervention, and non-treatment. The program obtained a significant change in reducing the influences of the aesthetic body ideal and in improving the knowledge of nutrition. Nevertheless, attained post-treatment changes dissipate at the 6 month follow-up. In our opinion, the lack of lasting effects should be attributed to a series of considerations such as format, tests not validated for this age, or insufficient research.

Identification and Treatment in Obstetrical Patients

Eating disorders are well defined in females ages 14 to 24, and consist primarily of anorexia nervosa (AN) and bulimia nervosa (BN). Collectively, these two eating disorders are characterized by severe disturbances in eating behaviors and acute distress over body shape and weight. In AN, fear of weight gain coupled with a distorted body image leads to refusal to maintain a minimally accepted body weight (American Psychiatric Association [APA], 1994). Although women with BN also overvalue body size and shape, this disorder is characterized by episodes of binge eating followed by efforts to undo the binge episode (oral purging is the most widely known effort) (APA, 1994). Developmental, psychological, socioenvironmental and behavioral factors contribute to the complex development and persistence of AN and BN (Rosen & Neumark-Sztainer, 1998).

Internet-based innovations for the prevention of eating disorders: a systematic review

The objective of this systematic review was to compare the results of studies of Internet-based eating disorder prevention programs. Eight electronic bibliographic databases, three key journals, and study reference lists were searched. This method yielded five published studies: four experimental and one quasi-experimental. A meta-analysis of the study results indicated no statistical significance for pooled study outcome data. No robust evidence exists on the impact of Internet-based prevention strategies on eating disordered symptomatology and on putative factors that contribute to eating disorder development. Further intervention development and consideration to study design are needed to move this field forward.

Can collaboration between education and health professionals improve the identification and referral of young people with eating disorders in schools? A pilot study

In this pilot study, a number of different methods of identifying young people with eating disorders in schools were compared. Pupils aged 16-18 years from 3 schools in the South West of the UK participated (389 boys and 374 girls in total). A self-report questionnaire (EDE-Q) was found to be the most effective method of case identification. However, very few of these cases accepted the offer of help and it was strongly suspected that other cases went undetected despite teacher, parent and school nurse guidance. Implications for future early intervention studies are discussed.

"Everybody's Different": a primary prevention program among fifth grade school children

The aim of the present study was to assess the efficacy and effectiveness of the primary prevention program "Everybody's Different" among fifth grade school children. Pre and post measurements were made in both the intervention and control groups regarding body image, weight concern, emotional well-being, attitudes and behaviors associated with disordered eating, self-esteem, anxiety, and depression. The study did not result in any significant improvements regarding self-esteem, eating attitudes, or body image. The prevention program does not seem to be effective for children in grade five in its present form. Further research on and development of primary prevention programs is needed.

Are family meal patterns associated with disordered eating behaviors among adolescents?

PURPOSE

To examine associations between family meal patterns (frequency, priority, atmosphere, and structure of family meals) and disordered eating (unhealthy weight control behaviors, binge eating, and chronic dieting) in adolescent girls and boys.

METHODS

Survey and anthropometric data were collected from 4746 ethnically diverse adolescents from public middle and senior high schools who participated in the Project EAT study (Eating Among Teens). Variables of interest included family meal patterns and disordered eating behaviors. Logistic regressions were performed to examine associations between family meal patterns and disordered eating behaviors adjusting for body mass index, sociodemographic characteristics, family connectedness, and weight pressures within the home.

RESULTS

In general, adolescents who reported more frequent family meals, high priority for family meals, a positive atmosphere at family meals, and a more structured family meal environment were less likely to engage in disordered eating. For example, 18.1% of girls who reported 1-2 family meals/week engaged in extreme weight control behaviors compared with 8.8% of girls who reported 3-4 family meals/week. Making family meals a priority, in spite of scheduling difficulties, emerged as the most consistent protective factor for disordered eating. Associations between family meal patterns and disordered eating behaviors tended to be stronger among girls than among boys. Family meal patterns were more consistently associated with unhealthy weight control behaviors than with chronic dieting and binge eating. Although associations between family meals and disordered eating were weakened after adjusting for more global familial factors, including family connectedness and weight-specific pressures within the home, a number of the associations remained statistically significant, suggesting an independent relationship between family meals and disordered eating.

CONCLUSION

Family meals have the potential to play an important role in the prevention of unhealthy weight control behaviors among youth. Findings suggest that attention needs to be directed toward increasing family meal frequency and creating a positive environment for family meals.

Eating Disorders

HEALTH ISSUE: Eating disorders are an increasing public health problem among young women. Anorexia and bulimia may give rise to serious physical conditions such as hypothermia, hypotension, electrolyte imbalance, endocrine disorders, and kidney failure. KEY ISSUES: Eating disorders are primarily a problem among women. In Ontario in 1995, over 90% of reported hospitalized cases of anorexia and bulimia were women. In addition to eating disorders, preoccupation with weight, body image and self-concept disturbances, are more prevalent among women than men.Women with eating disorders are also at risk for long-term psychological and social problems, including depression, anxiety, substance abuse and suicide. For instance, in 2000, the prevalence of depression among women who were hospitalized with a diagnosis of anorexia (11.5%) or bulimia (15.4 %) was more than twice the rate of depression (5.7 %) among the general population of Canadian women. The highest incidence of depression was found in women aged 25 to 39 years for both anorexia and bulimia. DATA GAPS AND RECOMMENDATIONS: Hospitalization data are the most recent and accessible information available. However, this data captures only the more severe cases. It does not include the individuals with eating disorders who may visit clinics or family doctors, or use hospital outpatient services or no services at all. Currently, there is no process for collecting this information systematically across Canada; consequently, the number of cases obtained from hospitalization data is underestimated. Other limitations noted during the literature review include the overuse of clinical samples, lack of longitudinal data, appropriate comparison groups, large samples, and ethnic group analysis.

Half of rural girls aged 8 to 17 years report weight concerns and dietary changes, with both more prevalent with increased age

OBJECTIVE

Determine body image satisfaction, weight concerns and dieting behaviors, Tanner index, and dietary adequacy in young women and girls.

DESIGN

A cross-sectional, self-selected comparative survey was completed.

SUBJECTS/SETTING

Rural white women and girls (N=333) aged 8 to 17 years, completed a weight concerns and dieting behavior questionnaire, a body image assessment, and a self-rating of sexual maturity, and 230 subjects completed 3-day diet diaries. ANALYSES PERFORMED: Correlational analysis identified relationships between variables among age groups (8 to 10 years, 11 to 14 years, and 15 to 17 years). Analysis of variance examined differences among variables. Multiple regression analysis measured the influence of variables on diet quality. A mean adequacy ratio (MAR) was computed to express dietary adequacy.

RESULTS

More than half (52%) of the subjects reported 1 or more weight concerns and dieting behaviors. This pattern increased with age. Friends dieting positively influenced scores (P=.0001) for 8- to 14-year olds, and a dieting family member meant higher scores (P=.04) for all ages studied. Although most wanted to be smaller, there was little body image dissatisfaction. Girls (aged 11 to 17 years) who dieted had greater body dissatisfaction (P=.0001) and significantly lower (P=.002), but adequate diets (MAR=76) compared to those who did not diet (MAR=81). Inverse relationships were found for the 11- to 14-year olds with diet adequacy and the following variables: body image dissatisfaction (-2.7, P<.01) and weight concerns and dieting behaviors (-3.7, P<.001). These variables accounted for 34% (P=.0001) of the variance in the MAR.

APPLICATIONS/CONCLUSIONS

Dietitians, partnering with school and health clinic personnel, need to educate girls younger than age 11 years about attaining the dietary adequacy needed to support expected growth. This age is important because it appears that actual weight and dieting concerns begin earlier, and by age 11 years, negatively affect diet quality.

Dietary trends among Scottish schoolchildren in the 1990s

BACKGROUND

In recent years, healthy eating messages have sought to highlight the advantages of a healthy balanced diet, but there is little evidence that the recommendations have been translated into sustained behavioural change. In Scotland, the national diet has become a major focus in key policy documents, and the diet of children and young people has been consistently highlighted as an area of particular concern. This paper reports on dietary trends among Scottish schoolchildren during the 1990s.

METHODS

Data were collected from a representative sample of Scottish schoolchildren as part of the WHO Cross-national Health Behaviour of School-aged Children (HBSC) study. Three consecutive national surveys were undertaken in Scotland, in 1990, 1994 and 1998, using self-completion food frequency questionnaires with 11-, 13- and 15-year-old school pupils.

RESULTS

Between 1990 and 1998, fruit and vegetable consumption increased among Scottish schoolchildren, especially among girls, but levels of consumption fell below current dietary recommendations. There has been a concomitant increase in consumption of high-fat and high-sugar foods, and consumption of these foods is higher among boys and children from lower socio-economic groups.

CONCLUSION

The findings emphasize the need for continued health promotion efforts to improve the diet of schoolchildren in Scotland especially among lower socio-economic groups.

BRIDGE 2 (Building the Relationship Between Body Image and Disordered Eating Graph and Explanation): interventions and transitions

BRIDGE 2 (Building the Relationship Between Body Image and Disordered Eating Graph and Explanation): Interventions and Transitions, builds upon the framework presented in the first publication of BRIDGE. BRIDGE 2 moves beyond increasing the understanding of the relationship between body image and eating disorders and encourages a movement into action. First, it suggests the appropriate point of intervention for both parents and teachers. Second, the continuum of health care from promotion to prevention, to early intervention, and to basic and specialized treatment services is positioned on the BRIDGE framework. This added dimension offers a new level of understanding specific to eating disorders by utilizing concepts from mental health promotion and mental illness prevention literature.