The Last Word on Eating Disorders Prevention

Leigh Cohn

• Publisher: Taylor & Francis
• Year: 2018
• eBook ISBN: 9781134978069
• Edition: 1
• Topic: Medicine
• Subtopic: Nutrition, Dietics & Bariatrics

For the first time in one volume, many of the world's most esteemed eating disorders prevention experts share their opinions and recommendations about future directions for the field. Employing "The Last Word" format of writing concise editorials about a focused area of research, authors from four countries contribute thirteen chapters with diverse points of view. The approaches range from large scale, macro-environmental calls for change through public policy to the more intimate promotion of positive youth identity for buffering against eating disorders. Included are retrospective looks at the development of prevention programs with an eye toward best practices moving forward, calls for integrating eating disorders interventions with existing efforts in the obesity and health promotion fields, examples of successful change through public policy and social justice, and a cry for gender inclusiveness, which has missing in female dominated strategies. More personal-level recommendations look at the efficacy of mindfulness, yoga, intuitive eating and exercise, and the importance of forming healthy self-identity. Informed by decades of investigation, the authors—all of whom have conducted numerous studies, programs, and research projects—offer the insights they've learned and the lessons that they each believe will make a difference in reducing eating disorders. This book was originally published as a special issue of Eating Disorders: The Journal of Treatment and Prevention.

Accelerating Progress in Eating Disorders Prevention: A Call for Policy Translation Research and Training

S. Bryn Austin^a,b

^aDepartment of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA; ^bDivision of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States

The public health burden of eating disorders is well documented, and over the past several decades, researchers have made important advances in the prevention of eating disorders and related problems with body image. Despite these advances, however, several critical limitations to the approaches developed to date leave the field far from achieving the large-scale impact that is needed. This commentary provides a brief review of what achievements in prevention have been made and identifies the gaps that limit the potential for greater impact on population health. A plan is then offered with specific action steps to accelerate progress in high-impact prevention, most compellingly by promoting a shift in priorities to policy translation research and training for scholars through the adoption of a triggers-to-action framework. Finally, the commentary provides an example of the application of the triggers-to-action framework as practiced at the Strategic Training Initiative for the Prevention of Eating Disorders, a program based at the Harvard T. H. Chan School of Public Health and Boston Children’s Hospital. Much has been achieved in the nearly 30 years of research carried out for the prevention of eating disorders and body image problems, but several critical limitations undermine the field’s potential for meaningful impact. Through a shift in the field’s priorities to policy translation research and training with an emphasis on macro-environmental influences, the pace of progress in prevention can be accelerated and the potential for large-scale impact substantially improved.

Background

The wide-ranging medical and psychosocial consequences of eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating disorders, and related subdiagnostic conditions, have been widely reported (Arcelus, Mitchell, Wales, & Nielson, 2011; Crow, 2005) and the global burden of disease documented in developed and emerging economies (Kessler et al., 2013; Treasure, Claudino, & Zucker, 2010; Whiteford et al., 2013). The economic consequences of eating disorders are also substantial, with high treatment costs and lost work productivity and wages (Lynch et al., 2010; Mond & Hay, 2007; Samnaliev, Noh, Sonneville, & Austin, 2015; Stuhldreher et al., 2012). Given the profound impact the disorders can have on all systems of the body and myriad domains of social and economic life, the work of prevention scientists is vital for the field and for population health.

Over the past nearly 30 years, an increasing number of preventive interventions addressing eating disorders and poor body image have been developed, with over a hundred approaches published in the literature (Coelho, Gomes, Ribeiro, & Soares, 2014; Holt & Ricciardelli, 2008; Levine, McVey, Piran, & Ferguson, 2012; Newton & Ciliska, 2006; Rodgers & Paxton, 2014; Stice, Becker, & Yokum, 2013; Stice, Shaw, Becker, & Rohde, 2008; Stice, Shaw, & Marti, 2007; Yager, Diedrichs, Ricciardelli, & Halliwell, 2013; Yager & O’Dea, 2008). These interventions have included universal, selective, and targeted prevention strategies. They have been designed for young children, adolescents, and adults in school and community settings and online. They have targeted self-esteem, body dissatisfaction, thin-ideal internalization, media literacy, healthful nutrition and physical activity, and other indicators (Coelho et al., 2014; Holt & Ricciardelli, 2008; Levine et al., 2012; Newton & Ciliska, 2006; Rodgers & Paxton, 2014; Stice et al., 2007, 2008, 2013; Yager et al., 2013; Yager & O’Dea, 2008). Over 60 preventive interventions have been evaluated in controlled studies, the vast majority of which were efficacy trials (Stice et al., 2013). Importantly, there have been a number of notable successes from these trials documenting preventive effects on onset of eating disorders-related psychological and behavioral symptoms and/or body image problems (Austin et al., 2007; Neumark-Sztainer et al., 2010; Stice et al., 2013; Wilksch et al., 2014; Yager et al., 2013).

Discussion

Given the clear signs of progress, should we stay the course and continue to develop the prevention field along the same path as has been followed so far? The answer is no. Several critical limitations to the approaches developed to date leave the field far from achieving the large-scale impact on population health that is needed. One, in the eating disorders and body image literature as a whole, preventive intervention studies make up only a small proportion of published research. A recent evaluation of all articles appearing in the International Journal of Eating Disorders, the leading journal in the field, and Eating Disorders: The Journal of Treatment and Prevention from 2005–2010 found that articles describing preventive intervention studies made up only 3% of articles in the former journal and 8% of papers in the latter journal (Austin, 2012). In contrast, more than half of the articles in both journals were focused on diagnosis, treatment, and course of illness. This gross imbalance suggests prevention is ranked very low among the field’s priorities, but were the field to reallocate scientific attention and resources, even to a modest degree, for prevention research and training of emerging scientists, likely productivity would increase appreciably.

Two, only a small proportion of the preventive intervention studies produced so far have moved beyond the efficacy trial stage to be evaluated in effectiveness (Austin et al., 2007; Becker, Smith, & Ciao, 2006; Becker et al., 2010; Matusek, Wendt, & Wiseman, 2004; Perez, Becker, & Ramirez, 2010; Stice et al., 2013) and dissemination (Austin et al., 2012; Kilpela et al., 2014) studies. Large-scale impact of behavioral interventions on population health necessitates progression through the phases of evaluation from efficacy to effectiveness to dissemination (Brownson & Jones, 2009; Flay, 1986; Glasgow, Lichtenstein, & Marcus, 2003). Furthermore, preventive interventions by and large have been dominated by selective and targeted approaches, with only a minority using universal strategies (Wilksch, 2014). No doubt the reliance on selective and targeted approaches is in part a consequence of the documented prominence of clinical disciplines and the comparative quiescence of public health or similar disciplines in the eating disorders prevention field (Austin, 2012). In addition, nearly all evaluated preventive interventions (with a rare exception [Gauvin & Steiger, 2012]) to address eating disorders and poor body image are targeted at the individual level (Gauvin & Steiger, 2012; Levine et al., 2012; McLaren & Piran, 2012; Sanchez-Carracedo, Neumark-Sztainer, & Lopez-Guimera, 2012). While individual-level behavior change should be a key element in the field’s overall preventive strategy, an exclusive focus on the individual without seeking to change the larger societal conditions that produce illness has been widely rejected by public health professionals across a range of health concerns—including mental health, cancer, obesity, substance use, accidental injury, and more—both as needlessly limited in the potential to have a meaningful impact and even unethical, placing the burden solely on individuals while leaving toxic environments and societal bad actors unchallenged (Austin, 2000, 2011; Braveman & Gottlieb, 2014; Braveman et al., 2011; Colditz, Emmons, Vishwanath, & Kerner, 2008; Levine et al., 2012; McLaren & Piran, 2012; Piran, 2010; Schwartz & Brownell, 2007).

Three, not only do preventive interventions insufficiently address the macro environment, but even the observational literature on determinants of eating disorder symptoms and poor body image has generally overlooked macro-environmental factors (McLaren & Piran, 2012; Paxton, 2012; Wang, Peterson, McCormick & Austin, 2013). A recent systematic review of research on environmental influences on eating disorders and body image identified 93 observational studies in the English-language, peer-reviewed literature from 1994–2012, covering nine environmental constructs (Wang et al., 2013). More than half of the studies defined environment as family, a quarter as peer relationships, a tenth as media, and small percentages of the remaining examined other behavioral settings, sociocultural or interpersonal factors, and twin environments. None of the studies identified in this review examined policy or built and consumer industry environments (Wang et al., 2013). It is important to note that other areas of public health have long ago moved away from an exclusive focus on individual and interpersonal level determinants and behavior change strategies, instead directing valuable scientific attention and resources to building an expansive body of research on environmental determinants of health, such as in the areas of cancer prevention, tobacco and alcohol use, nutrition, and many others, generating a powerful array of environmentally targeted preventive intervention approaches to maximize large-scale impact on population health (Colditz et al., 2008; Gostin, 2000; Institute of Medicine, 2000; Schwartz & Brownell, 2007; Swinburn, Egger, & Raza, 1999). In sum, though important advances in the prevention of eating disorders and poor body image have been made over the past nearly 30 years, several critical limitations described above profoundly undermine the field’s potential to make a difference in population health. Bluntly stated, if we keep doing more of the same over the next 30 years of research, we will continue to earn only the same type of small-scale victories with little promise of substantial impact on population health. How can we speed up our progress toward meaningful impact? We must make a shift in our field’s priorities to policy translation research and training guided by a triggers-to-action framework, as described below.

Keys to Accelerating Progress in Prevention

For well over a decade, translation—which in the simplest terms can be described as systematic and deliberate processes using research findings to inform changes in policy and practice to improve population health—has become increasingly central to the missions of health sciences and of major government and foundation funders of health research (Alfano et al., 2014; Lomas, 2000; McGinnis, Williams-Russo, & Knickman, 2002; Rubio et al., 2010; Sung et al., 2003; Zerhouni, 2005). Subsequent to the U.S. Institute of Medicine (IOM) Clinical Research Roundtable’s 2003 publication on translational research, which described translational research in two phases (T1 and T2) (Sung et al., 2003), scholars have expanded on the phases to include T3 and T4 to delineate types of translation occurring in the public health and policy sectors with the potential to improve population health on a large scale (Alfano et al., 2014; Khoury et al., 2007). In addition, the IOM further extolled the importance of policy translation, urging scientists in its 2011 report For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges to engage in active policy research to identify promising innovations for high impact (Institute of Medicine Committee on Public Health Strategies to Improve Health, 2011).

Echoing the IOM’s call, Kessler and Glasgow challenged health researchers to ask the question, “Will this research generate data likely to result in policy or practice improvement within three to five years?” (Kessler & Glasgow, 2011). This question, which is no less applicable for researchers focused on eating disorders and body image, must be followed with the pragmatist’s question: “If yes, how?” How do we make sure our work is aptly designed and targeted for policy translation and macro-environmental change to maximize impact on population health? Progress in prevention in eating disorders and body image problems can be accelerated through two pivotal types of changes: One involves changes in study designs and the study methods given priority and a second involves adoption of a triggers-to-action framework to guide research and training activities.

Shift Priorities in Research Designs and Methods

A number of other fields (...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Citation information
• Notes on Contributors
• Introduction to “The Last Word on Prevention”
• 1. Accelerating progress in eating disorders prevention: A call for policy translation research and training
• 2. Optimizing prevention programs and maximizing public health impact are not the same thing
• 3. Eating disorders prevention: Looking backward, moving forward; looking inward, moving outward
• 4. The role of protective factors in the prevention of negative body image and disordered eating
• 5. How to block the ways to eating disorders
• 6. A call for social justice and best practices for the integrated prevention of eating disorders and obesity
• 7. Building partnerships with prevention experts targeting other mental health problems
• 8. The implementation of evidence-based eating disorder prevention programs
• 9. Our critics might have valid concerns: Reducing our propensity to conflate
• 10. Integrating exercise and mindfulness for an emerging conceptual framework: The intuitive approach to prevention and health promotion (IAPHP)
• 11. Embodied self-regulation and mindful self-care in the prevention of eating disorders
• 12. Re-thinking eating disorder prevention: The case for prioritizing the promotion of healthy identity development
• 13. Including the excluded: Males and gender minorities in eating disorder prevention
• Index