The Prevention of Eating Problems and Eating Disorders

Theories, Research, and Applications

Michael P. Levine, Linda Smolak

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781315401041
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

In a detailed analysis of the field of eating problems and disorders, this book highlights the connections between the prevention of eating problems and disorders, and theory and research in the areas of prevention and health promotion. It also looks at models of risk development and prevention, specific issues and challenges, the status of current prevention research, and lessons for prevention program development.

In this unique text Levine and Smolak draw on a range of interdisciplinary perspectives, including prevention science, developmental psychology, public health, and neuroscience, to provide a thorough review, history, and critique of the topic in light of a range of empirical studies. The only authored volume with a broad, detailed and integrated view of theories, research, and practice, this expanded, fully revised, and updated new edition features new chapters on dissonance-based approaches, public health, biopsychiatry and neuroscience, gender, culture(s), technology, obesity, protective factors, and ecological approaches.

The Prevention of Eating Problems and Eating Disorders: Theories, Research, and Applications is essential reading for clinicians, academics, researchers, graduate students, upper-level undergraduates, and activists and advocates involved in work pertaining to eating disorders, disordered eating, prevention, health promotion, body image, obesity and biopsychosocial perspectives.

Part I

Introduction

Chapter 1

Introduction to Prevention

This book addresses the prevention of eating disorders (EDs) and eating problems that we will call disordered eating (DE). In the course of examining prevention of EDs and DE, we will necessarily be engaged with the role of body image and body image problems. The nature and relationship of the EDs and DE, as well as the distinctions between them, are examined in more detail in Chapter 2.

By definition, EDs and DE encompass significant problems with eating. However, to understand and prevent them, we need to acknowledge their multidimensional nature, including their relationship to body image. In general, both refer to a combination of disability, distress, disconnection, and deviance from social and/or personal norms that is attributable to a set of interwoven (1) eating patterns; (2) weight management practices; (3) beliefs, feelings, and behaviors—that is, attitudes—in regard to food, weight, body shape, and being in or out of control; (4) struggles with identity and self-control; and (5) disruptions in the neurobiological processes underlying hunger, satiety, pleasure, anxiety, and anger (Levine, Piran, & Jasper, 2015). To advance the field of prevention, it is also very useful to think of EDs as severe and integrated forms of attitudes that are common, if not normative, in many industrialized countries (see Chapter 2; Table 2.2).

EDs, DE, and body image problems create a substantial amount of misery, dysfunction, and financial hardships for those afflicted, their families, and society at large. For many people with EDs and DE, these conditions tend to be severe and long lasting, if not chronic, and they are costly in multiple ways. Reflecting this burden of suffering, testimonies from recovered ED patients and their families, as well as reflections from sensitive clinicians, often include the statement “if only”—if only she had developed a stronger sense of self, if only she had never been sexually assaulted, if only he had not been teased so mercilessly about his weight and body shape, then perhaps their ED would never have developed. If only people who cared had done things differently at an earlier point in the person’s life, then it is likely that the ED would have been prevented. Similar wishes are also expressed by people whose adolescent and adult years have been bound up with DE. This desire for the types of changes subsumed under prevention may be particularly strong as they begin to raise their own children.

The rationale for prevention is apparent when we consider the prevalence and severity of EDs (see Chapter 2) and the limited availability of effective treatment. Galmiche, Déchelotte, Lambert, and Tavolacci (2019) reviewed 94 epidemiological studies published in English or French between 2000 and 2018. The weighted averages (range) of lifetime ED prevalence for women and men were 8.4% (3.3–18.6%) and 2.2% (0.8–6.5%), respectively. Moreover, the weighted average point prevalence more than doubled from 3.5% over 2000–2006 to 7.8% for the 2013–2018 period.

Galmiche et al.’s (2019) lifetime prevalence figures are consistent with conservative estimates of a current or past-year ED prevalence of approximately 8% for females and 1–2% for males ages 15 through 30 living in the United States and Europe who meet the diagnostic standards for either anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), or other EDs (see Chapter 2; Hoek, 2016; Keski-Rahkonen & Mustelin, 2016; cf. Udo & Grilo, 2018). According to the latest available figures from the U.S. Census Bureau’s (2012) Statistical Abstracts, the number of females and males ages 15 through 29 in the United States in 2010 was approximately 31.5 million and 33 million, respectively. This suggests that at any given point the number of people ages 15 through 29 in the United States who have an ED is approximately 3 million.

Various statistics attest to the seriousness of EDs. For example, working with samples from a large-scale longitudinal study of adolescents, Micali et al. (2015) found that 2 years later those with EDs at ages 14 or 16 are at high risk for problems with depression, anxiety, self-harm, and substance abuse. According to a review by Brown, Klein, and Keel (2015), even after 5 to 7 years, 40–45% of people with AN who have sought treatment remain ill. Further, approximately 15–20% of people with AN never recover, and in as many as 10% that condition is “severe and enduring” in ways that compromise their lives to a degree comparable to schizophrenia (Brown et al., 2015; Lacey & Sly, 2015). A meta-analytic review by Arcelus, Mitchell, Wales, and Nielsen (2011) indicated that people with AN were nearly six times more likely to die than an age-and-sex-matched comparison group, while those with BN or eating disorder not otherwise specified (EDNOS) were approximately 1.9 times more likely to die. The risk of premature death for those with AN is especially high during the first 10 years of their illness (Brown et al., 2015).

The outlook is better for BN, but not as rosy as many people assume. For 10% the disorder will be chronic, while at long-term follow-up 30% will still be struggling with binge eating, purging, and anxiety about weight and shape (Brown et al., 2015). It is worth noting that some experts (e.g., Lacey & Sly, 2015) feel that these statistics are too optimistic. They point to a well-known study by Von Holle et al. (2008) indicating that 15 years after the onset of the illness, only 16% of those with AN and 25% of those with BN met strict criteria for recovery.

There is no question that EDs are a significant social and economic issue for industrialized and developing societies around the world (Ágh et al., 2016; Erskine, Whiteford, & Pike, 2016). The 2013 Global Burden of Disease Study commissioned by the Institute of Health Metrics and Evaluation found that together AN and BN were the twelfth leading cause (among over 300 physical and mental disorders in 188 countries) of years lost to ill health or premature death in females ages 15 through 19 living in high-income countries (Erskine et al., 2016). In low-to-middle-income countries, these two EDs were the forty-sixth leading cause. Note that these estimates do not reflect the impact of the disorder on functioning at work, within the family, or in the community.

The financial and social burdens become apparent when we consider two points. First, the rates of comorbidity with disabling conditions such as depression are high (Hudson, Hiripi, Pope, & Kessler, 2007). Second, it is likely that only a third receive treatment (Hart, Granillo, Jorm, & Paxton, 2011; Merikangas et al., 2011), intensifying the already substantial challenges and stressors for family members and other caregivers (Zabala, Macdonald, & Treasure, 2009). Third, the annual cost of treatment is perhaps an average of $5,000 USD/2016 (Stuhldeher et al., 2012)—if not much more (Ágh et al., 2016)—per person for outpatient or inpatient services. Consequently, a very conservative estimate of the yearly economic costs to the United States just for people ages 15 through 30 who have an ED and who have access to and receive treatment is $5.5 billion. If, as a minimum expectation in a modern and civilized society, treatment were acceptable and available to even half of those in that age range who have an ED, the minimum annual cost would likely be $7.5 billion USD.

In summary, EDs are disturbingly prevalent; they are often extremely serious; and they tend to be very difficult, time-consuming, and expensive to treat, even with multidisciplinary and expert intervention. Even in countries such as the United States, Canada, and Australia, which have resources many less developed countries can only dream of, there simply are nowhere near enough mental health professionals qualified to meet this challenge, let alone provide treatment for other prominent disorders such as depression. In 2017 in the United States there were approximately 450,000 mental health professionals with at least a master’s degree (Grohol, 2019). Diagnosis and effective treatment of EDs require specialized training (see, e.g., Brownlow et al., 2015). So let’s make the very generous assumption that 1 in 20 of those mental health professionals receives that training and is both able and willing to apply it. This yields approximately 22,500 mental health professionals able to provide effective, ethical care for at least 3 million people with EDs, and, after all, we know the latter figure is an underestimate because people under 15 and over 30 have EDs. At best, there would be one capable mental health professional for every 130 people with an ED.

And if there were, somehow, the necessary number of trained personnel, two significant obstacles would still remain, both of which underpin the striking disparity between the prevalence of EDs and the number of people receiving treatment. First, EDs tend to be shrouded in anxiety, secrecy, rigidity, and shame. Second, we have long known that many poor people, many women and children, minority groups, people living in rural areas, the LGBTQ community, and other marginalized groups are not being well served by private or community-based mental health specialists (Cowen, 1983; United States Office of the Surgeon General, 1999; see Chapter 20).

Prevention is the focus of this book because it is the only viable solution to EDs as an international public health problem affecting at least a quarter of the world’s nearly 200 countries (Levine & Smolak, 2010). Making effective care available for those who have significant problems is very important. Nevertheless, we join theorists in many areas of public health, community psychology, and psychosomatic medicine who have long argued for a shift in research emphasis and financial resources away from the “detect it—treat it” medical model to a more integrated ecological and behavioral model focusing on personal and environmental changes, broadly conceived, that contribute to health and thus to the prevention of illness (Albee & Gullotta, 1997). The overwhelming success of public health programs to inoculate children against diseases such as polio, mumps, and measles and the significant reduction of the onset of tooth decay by the intentional, controlled introduction of fluoride into public drinking water suggest that prevention is potentially a powerful solution to health promotion on a mass scale.

Although the state of affairs in preventing mental disorders in general and EDs in particular is not so straightforward, significant progress has been made in the ED field in the 15 or so years since we completed the research and writing for the first edition of this book (Levine & Smolak, 2006). We are pleased to note that the ratio of programming, speculation, and controversy to solid research, to borrow a phrase from Emory Cowen (1973), has been substantially reduced. One major purpose of this revision is to examine carefully the theories, programs, empirical data, and importantly, unresolved issues that comprise the current, more hopeful state of affairs in the prevention of negative body image, DE, and EDs in children, adolescents, and young adults.

Prevention Steps and Processes

There is no simple or accepted way to describe the processes involved in creating a prevention program; evaluating its effects; and, if there is robust evidence that it “works,” getting it into the hands of many people who need it, can implement it, and can also sustain its use while continuing to evaluate and refine it (Price, 1983; Glascow et al., 2012; Spoth et al., 2013). This is one focus of Chapter 3. A useful starting point is Price’s (1983) perspective, which divides the prevention process into four large-scale components. These are best understood as partially overlapping, nonlinear steps, such that, for example, it is best to design a novel prevention program with the challenges of evaluation and cost-effective, large-scale dissemination in mind (Spoth et al., 2013).

The first step in Price’s (1983) model is a full description of the problem, including precise definitions, prevalence and incidence, correlates, and risk factors. This phase requires a variety of quantitative and qualitative methods from multiple disciplines, ranging from epidemiology to ethnography. Risk factors that are modifiable help determine the nature of Price’s (1983) second component, design innovation. In the third phase field research carefully implements the innovative program and then arranges for rigorous quantitative and qualitative evaluation of its short- and long-term positive and negative effects. The final component in Price’s (1983) scheme is diffusion, that is, dissemination and distribution of the innovative development in ways that will have a large-scale impact on public health.

Major Questions Shaping This Book

In light of this perspective on the steps and processes involved in prevention, this second edition addresses the field’s ongoing attempts to answer or at least clarify many of the same basic questions that formed the foundation of the first editio...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Preface
• Acknowledgments
• PART I Introduction
• PART II Guides to Prevention: Models and Risk Factors
• PART III Guides to Prevention: Specific Issues and Challenges
• PART IV Review of Prevention Research
• PART V Prevention Theory and Research: Lessons From the Field
• Appendix
• References
• Index