Eating Disorder Prevention

Prospective risk factor studies suggest that pressure to achieve the thin beauty ideal results in an internalization of this beauty ideal, which increases risk for body dissatisfaction, which increases risk for dieting and negative affect, which increase risk for the emergence of compensatory weight control behaviors and often binge eating. This is the Dual Pathway model of bulimic-spectrum eating disorders (bulimia nervosa, binge eating disorder, and purging disorder). Unfortunately, only one prospective study has identified risk factors that predict future onset of anorexia nervosa. A low body weight during childhood and adolescence, impaired psychosocial functioning, and negative affect have predicted future onset of anorexia nervosa. Prodromal symptoms (overvaluation of weight/shape and fear of weight gain) have also predicted future onset of anorexia nervosa, but this is in a paper we just submitted. Other people think it is all genes, but we can predict onset of eating disorders with about a 70-80% accuracy from the risk factors I mentioned and no genetic findings have replicated.

It can certainly look that way, but the answer is complicated. People who report dieting don't actually eat less food that people who do not report dieting, at least when you examine objective measures of caloric intake. Dieting does not predict onset of anorexia nervosa, but it does predict onset of bulimia nervosa and binge eating disorder. My impression is that people at risk for anorexia nervosa are overly anxious and this might contribute to the low body weight. Other factors likely also contribute, but the field has only produced one study that was able to identify baseline risk factors that predicted future onset of anorexia nervosa! We/the field really need to step up our science.

Our research team has developed two different group-based eating disorder prevention programs that have produced a 54% to 77% reduction in future onset of eating disorders over 2-4 year follow-ups. If we could implement these prevention programs broadly, we could easily reduce the population prevalence of eating disorders. Indeed, for the cost it takes to successfully treat one person with bulimia nervosa (about $20,000), we could prevent about 51 cases! I strongly encourage you to do what you can to support broad implementation of one of these prevention programs.

The Body Project eating disorder prevention program provides a forum for young women to talk themselves out of pursuing an unrealistic beauty ideal and the dieting that is used to approximate that ideal. In the Body Project young women learn that other young women struggle with body image concerns and eating, and collectively convince each other out of pursuing that ideal. We always see reductions in reported dieting after completing the Body Project, which does not happen to control participants. That is, it reduces pursuit of the thin ideal, which naturally cases a reduction in body dissatisfaction and dieting.

The Body Project eating disorder prevention program has produced a 54% to 77% reduction in future onset of eating disorders among individuals who do not have an eating disorder at baseline, at least the 4 1-hour session version we created, and when it is implemented by peer educators or co-implemented by peer educators. So yes. The Body Project Collaborative is an LLC that I formed with Carolyn Becker to provide trainings in implementing the Body Project. I personally think prevention is a better solution than treatment, as treatment is very expensive and does not produce lasting symptom remission for most cases.

The Body Project body acceptance/eating disorder prevention program helps young women and men respond with more confidence and assertiveness to such pressures. Indeed, participants practice responding to pressure for thinness. Although it would be ideal if we could change our culture, we see value in helping inoculate young women and men against the pressure for a narrow beauty ideal.

I wish I knew the answer. So far, there have only been two studies to identify risk factors for future onset of anorexia nervosa. Low body weight during childhood and adolescence, negative affect, impaired social functioning, overvaluation of weight/shape, and fear of weight gain have all predicted future onset of anorexia nervosa. Next step is to design interventions that reduce these risk factors and see if it reduces future onset of anorexia nervosa. If I had a child that I was worried about I would make sure that they feel loved and accepted, help them learn how to get along well with people, and teach them that there are far more important things in life than their weight/shape. Sorry that the field has not produced a better answer to your question.

Scientists have argued that genetics explain about 50-60% of the variance in eating disorders. Unfortunately, we have not been able to identify specific genes that reliably and accurately predict who will develop an eating disorder and we have no gene therapy that we can use. Thus, the answer is almost certainly yes, but the field has not been able to get much further in answering that question. The good news is that with identified risk factors, we can predict who will develop anorexia nervosa with about an 80% accuracy (we just submitted that paper).

Malnutrition can cause immediate death or organ failure later in life. People with anorexia nervosa also have a high risk for suicide. Data suggest that about 10% of people with severe anorexia nervosa that requires hospitalization die prematurely. Milder forms of anorexia nervosa likely have a lower mortality rate.

I encourage body acceptance and appreciating beauty in many forms. Yet given that obesity is the second leading cause of death in western countries, I feel uncomfortable suggesting that obesity does not increase risk for morbidity and mortality. I think we should work to address both eating disorders and obesity because they are both important public health problems that adversely affect quality of life.

Yes. You can download the intervention script that has instructions and watch videos of people implementing the Body Project. You can also request a virtual or in-person training. The Body Project Collaborative was set up to offer training and we had someone who should be able to provide training in Australia.

If we did, I strongly suspect we would feel better about our bodies and the incidence of eating disorders would be reduced. Unfortunately, I am dubious that we can get ride of that non-useful concept because so many people are attached to that appearance idea. But we should all still do our best to get rid of the narrow beauty ideal!

We have developed two joint obesity and eating disorder prevention programs. Healthy Weight was the first, which reduced onset of overweight/obesity by about 50% and eating disorders by about 60%. We attempted to enhance it by adding activities designed to increase motivation for healthy lifestyle behaviors. It produced similar effects in a follow-up trail, and was superior to Healthy Weight for overweight/obesity prevention, but equally effective for eating disorder prevention. We have published trials in 2008, 2013, and 2018 on these interventions and the intervention script should be freely available at the Body Project Facilitators Support web page. Both are group-based prevention programs that range from 4-6 sessions.

Although I have talked to people who say it works well for them, going long periods of caloric deprivation (fasting) does increase the reward value of food, particularly energy dense foods, and the likelihood of binge eating. I personally recommend eating regular healthy meals so that the reward value of unhealthy foods does not become too great.