Gail McVey, Ph.D., C.Psych.
Young adolescence has been identified as a period of high risk for the development of body image concerns and disordered eating because of the common stressors that girls face, such as normal increases in weight and fat associated with puberty, increased importance of peer acceptance and changes in academic and social expectations. Increasingly, body image and eating problems are being seen in younger school children.
New Trends in Primary Prevention
A recent trend in the primary prevention of these concerns involves adopting health promotion programs designed to promote overall wellness, and alter some of the predisposing risk factors (e.g., low self-esteem) related to disordered eating. This approach contrasts the traditional health education approach of teaching adolescents the defining characteristics, behaviours and dangers associated with eating disorders.
Given the potentially adverse effects of health education strategies, researchers in the field underscore the need for safe and effective approaches for the prevention of eating problems in children and adolescents. In order to prevent harm, has been suggested that school-based education programs should change their focus from highlighting negative, problem-based issues (e.g., glamorization of eating disorders, suggestive information about weight control techniques, negative language around food messages). Rather, their focus should turn to helping young people enjoy healthy, active lifestyles without developing a fear of food, and to build self-esteem. In this way, universal prevention may address a number of issues, such as self- esteem, media literacy, healthy eating, and active living. An advantage to using the self-esteem approach is that it can have a positive effect on other health-related outcomes (e.g., depression, anxiety, sexual risk-taking, substance abuse, obesity).
The Need for Comprehensive Programs
To date, most of the prevention work has been conducted with female youth. The need to develop comprehensive programs that target multiple factors has been emphasized. For example, the inclusion of males in prevention has potential benefits. First, the health promotion messages may help to protect male adolescents from body image concerns and unhealthy eating and physical activity practices. Second, sensitizing male students to the pressures that female students face, and instituting school policies to reduce or eliminate harassment and weight and shape teasing, might help to create a healthier and more positive environment for female youth. This is especially noteworthy given the research evidence that suggests that boys are more likely than girls to initiate weight-based teasing and harassment of other children. Addressing the negative impact of harassment and weight-based teasing with boys in single-sex sessions and helping them develop more equitable life skills is an initiative which warrants further investigation. Parents, teachers, school support staff and coaches should also be included in school-based interventions, given their important roles in young people’s social environment. It is important that everyone understand their own beliefs and behaviours regarding weight, food and dieting, so that a comprehensive approach towards healthy eating and active living can be obtained.
Schools As Sites of Prevention
Schools are an important arena for health promotion and prevention efforts. Ideally, preventive intervention would be implemented in a stepped fashion, i.e. elementary through high school, matching the prevention level to the developmental level of students. For example, in Kindergarten through grade 4, the focus could be on raising awareness with parents, teachers, and school support staff about their own beliefs and behaviours with respect to dieting and slimness, as well as creating a school climate that fosters over-all child health. Health promotion would be introduced with students as early as grade 4 and continue throughout high school, e.g., booster sessions, incorporating the prevention material into the school curriculum across various topics. In addition, peer support groups would be offered to students approaching the high-risk period of early adolescence (grades 5-7) to help them combat weight and shape teasing and peer pressures to diet. Given the higher prevalence of disordered eating among high school students, selective or targeted intervention strategies could be implemented with students who exhibit early symptoms of an eating disorder. The support groups and interventions could be facilitated by trained school support personnel or public health nurses with direct referrals to specialized health services in the community.
In addition to serving as a place for universal prevention, the school setting is also suitable for the delivery of targeted prevention programs for students at risk. It has previously been reported that most adolescents with eating disorder symptoms do not seek treatment until it is medically necessary. The school setting however, has the advantage of providing specialized care to students who may otherwise not seek treatment for their eating disorder symptoms. In addition to being available in an accessible and familiar environment, a school-based targeted program may reach students before their eating disorder symptoms worsen or may even motivate them to seek professional treatment. Motivation and readiness to change have been identified as key factors in the successful treatment of adolescent eating disorders. It has been recognized that some students may prefer not to attend such school-based programs, given that this ‘singling out’ makes them more vulnerable to an environment already riddled with peer pressures and teasing. However, the study of the school setting as a potential environment for more targeted prevention should not be abandoned, especially given its positive effect on eating disordered behaviours, as demonstrated in the literature. In a truly comprehensive approach, where the entire school environment is offered differing levels of prevention to promote self and size acceptance, the hope is that all students, including those at higher risk, will become more comfortable approaching their school staff for help.
Comprehensive Approaches to Prevention
A comprehensive approach also includes the implementation of school-wide policies such as: (a) sensitizing teachers and school support staff about the genetic influences of weight and shape, the common factors that influence body image and eating behavior, e.g., physical changes in puberty, as well as their own beliefs and behaviours with respect to dieting, self-esteem, slenderness and weight, (b) reducing or eliminating weight and shape teasing and sexual harassment, (c) discouraging starve-a-thons as fundraising techniques, (d) providing opportunities for healthy eating at school, e.g., a wide variety of food choices, (e) discouraging lunch-room talk that promotes unhealthy eating, and (f) replacing fat-caliper testing and group weigh-ins with the promotion of physical activity that is inclusive to students of all sizes and shapes.
It is crucial to work with governments to incorporate evidence-based practices of prevention into the school curriculum. In fact, integrating broad-based prevention strategies in the field of eating disorders with other adolescent health concerns such as substance abuse, depression and anxiety, obesity, diabetes, cardiovascular disease, and some cancers, is an innovative way to address health concerns of adolescents as well as capitalize on the available resources, e.g., the limited time of teachers. In particular, there is a current debate in the literature regarding how best to integrate eating disorder and obesity prevention work. For example, current concerns about childhood obesity have increased the focus on the importance of teaching youth about healthy eating and active living. However, advice about what to eat to stay healthy can increase girls’ preoccupation with foods and serve to undermine their own control and confidence about eating. Similarly, advice about physical activity can lead some girls to engage in excessive exercise, particularly if they are going through the early adolescent period of high-risk for body image concerns and disordered eating. The development of health promotion programs designed to prevent obesity, without promoting weight and shape preoccupation in children, will require further collaboration among stakeholders who work with youth.
The Role of Parents and Educators
Parents and educators can help reduce weight and shape preoccupation by (a) reflecting on what messages they might be sending to youth, e.g., Am I a person who goes on diets? Do I think overweight people are out of control? , (b) providing support during the time of normal physical and psychological pubertal changes, (c) including all children in sports and physical activities regardless of their weight and shape, and (d) helping children combat weight and shape teasing. Addressing these issues with parents and educators can be extended to all appearance based teasing in a similar way that enhancing self-esteem in young adolescents can address a number of high-risk behaviours.
What, Then, Do We Know?
While the study of the prevention of body image problems and disordered eating is still relatively new, there have been promising results. Universal prevention, specifically those models using a life skills, participatory approach, has been successful in changing the attitudes and knowledge around body image, size acceptance, media literacy, and disordered eating in children and young adolescents. It’s effect on eating behaviours in the long-term are less clear and require further investigation. Targeted prevention in the school setting, however, has been successful in altering disordered eating behaviours in those at higher risk. Given the complexity of issues involved in developing body image concerns and disordered eating, it is likely that a model of prevention will be equally as complex. This model will include a comprehensive approach that encompasses the entire school climate (i.e. all students, teachers, school-support staff), and offers prevention materials specific to the developmental and symptom level of the students.
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