The Influences of Mental Health and Culture on Weight and Eating Disorders - Preventing Eating Disorders

Conventional public health definitions describe primary prevention as the prevention of new cases and secondary prevention as the prevention of recurrence of a disease or prevention of its progression. Primary prevention measures fall into two categories—actions to protect against disease and disability and actions to promote health such as good nutrition and hygiene; adequate exercise and rest; and avoidance of environmental and health risks. Health promotion also includes education about other interdependent dimensions of health known as wellness. Examples of health promotion programs aimed at preventing eating disorders include programs to enhance self-esteem, nutrition education classes, and programs to support children and teens to resist unhealthy pressures to conform to unrealistic body weight.

Secondary prevention programs are intended to identify and detect disease in its earliest stages when it is most likely to be successfully treated. With early detection and diagnosis it may be possible to cure the disease, slow its progression, prevent or minimize complications, and limit disability. An example of secondary prevention of eating disorders are efforts to identify affected individuals in order to intervene early and prevent the development of serious and potentially life-threatening consequences.

Tertiary prevention programs aim to improve the quality of life for persons with various diseases by limiting complications and disabilities; reducing the severity and progression of the disease; and providing rehabilitation (therapy to restore function and self-sufficiency). Unlike primary and secondary prevention, tertiary prevention involves actual treatment for the disease, and in the case of eating disorders is conducted primarily by medical and mental-health practitioners rather than public health or social service agencies. An example of tertiary prevention is a program that monitors persons with eating disorders to ensure that they maintain appropriate body weight and adhere to healthy diets and other prescribed medication or treatment. Since treatment of eating disorders is not always effective or lasting, many health professionals contend that initiatives directed at controlling or eliminating the disorders by treating each affected individual or by training enough professionals as interventionists are ill advised. Instead, they advocate redirecting time, energy, and resources to primary and secondary prevention efforts.

Table 3.2 lists the basic principles for the prevention of eating disorders prepared by the National Eating Disorders Association. These principles underscore the complexity of addressing the problem and the need for comprehensive, community-wide prevention programs that address the social and cultural issues promoting the rise of these disorders. The National Eating Disorders Association also urges parents to spearhead efforts to prevent eating disorders by practicing positive, healthy attitudes and behaviors and encouraging children to resist media stereotypes about body shape and weight. Table 3.3 outlines the philosophies and actions parents can adopt and the behaviors they can model to help their children cultivate healthy attitudes about food, eating, exercise, and body weight.

Changing Social and Cultural Norms

Cultural idealization of thinness as a standard of female beauty and worth and the societal acceptance of dieting as a female ritual have been widely cited as socio-cultural TABLE 3.2
Eating disorders can be prevented!

What is eating disorders prevention?

Prevention is any systematic attempt to change the circumstances that promote, initiate, sustain, or intensify problems like eating disorders.

• Primary prevention refers to programs or efforts that are designed to prevent the occurrence of eating disorders before they begin. Primary prevention is intended to help promote healthy development.

• Secondary prevention (sometimes called "targeted prevention") refers to programs or efforts that are designed to promote the early identification of an eating disorder—to recognize and treat an eating disorder before it spirals out of control. The earlier an eating disorder is discovered and addressed, the better the chance for recovery.

Basic principles for the prevention of eating disorders

1. Eating disorders are serious and complex problems. We need to be careful to avoid thinking of them in simplistic terms, like "anorexia is just a plea for attention," or "bulimia is just an addiction to food." Eating disorders arise from a variety of physical, emotional, social, and familial issues, all of which need to be addressed for effective prevention and treatment.

2. Eating disorders are not just a "woman's problem" or "something for the girls." Males who are preoccupied with shape and weight can also develop eating disorders as well as dangerous shape control practices like steroid use. In addition, males play an important role in prevention. The objectification and other forms of mistreatment of women by others contribute directly to two underlying features of an eating disorder: obsession with appearance and shame about one's body.

3. Prevention efforts will fail, or worse, inadvertently encourage disordered eating, if they concentrate solely on warning the public about the signs, symptoms, and dangers of eating disorders. Effective prevention programs must also address:

• Our cultural obsession with slenderness as a physical, psychological, and moral issue.

• The roles of men and women in our society.

• The development of people's self-esteem and self-respect in a variety of areas (school, work, community service, hobbies) that transcend physical appearance.

4. Whenever possible, prevention programs for schools, community organizations, etc., should be coordinated with opportunities for participants to speak confidentially with a trained professional with expertise in the field of eating disorders, and, when appropriate, receive referrals to sources of competent, specialized care.

SOURCE: Michael Levine and Margo Maine, "Eating disorders can be prevented!," National Eating Disorders Association, Seattle, WA. © 2002, National Eating Disorders Association. All Rights Reserved. [Online] http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=286&Profile_ID=41169 [accessed January 7, 2004]

causes of eating disorders. The widespread misperception that the body is readily reshaped and that one can, and should, strive to change its size and form to conform with aesthetic preferences also contributes to distorted perceptions and unrealistic expectations.

Media images that create, reflect, communicate, and reinforce cultural definitions of attractiveness, especially female beauty, are often acknowledged as factors that contribute to the rise of eating disorders. They exert powerful influences on values, attitudes, and practices for body image, diet, and activity. The role of the media, in conjunction with the fashion and entertainment industries, especially those targeting women and girls, in promoting unrealistic standards of female beauty and unhealthy eating habits has been named as a causative factor for body dissatisfaction, unhealthy dieting behavior, and the rise of eating disorders.

TABLE 3.3
10 things parents can do to help prevent eating disorders

1. Consider your thoughts, attitudes, and behaviors toward your own body and the way that these beliefs have been shaped by the forces of weightism and sexism. Then educate your children about

(a) the genetic basis for the natural diversity of human body shapes and sizes, and

(b) the nature and ugliness of prejudice.

• Make an effort to maintain positive, healthy attitudes & behaviors. Children learn from the things you say and do!

2. Examine closely your dreams and goals for your children and other loved ones. Are you overemphasizing beauty and body shape, particularly for girls?

• Avoid conveying an attitude which says in effect, "I will like you more if you lose weight, eat so much, look more like the slender models in ads, fit into smaller clothes, etc."

• Decide what you can do and what you can stop doing to reduce the teasing, criticism, blaming, staring, etc. that reinforce the idea that larger or fatter is "bad" and smaller or thinner is "good."

3. Learn about and discuss with your sons and daughters (a) the dangers of trying to alter one's body shape through dieting, (b) the value of moderate exercise for health, and (c) the importance of eating a variety of foods in well-balanced meals consumed at least three times a day.

• Avoid categorizing foods into "good/safe/no-fat or low-fat" vs. "bad/dangerous/fattening."

• Be a good role model in regard to sensible eating, exercise, and self-acceptance.

4. Make a commitment not to avoid activities (such as swimming, sunbathing, dancing, etc.) simply because they call attention to your weight and shape. Refuse to wear clothes that are uncomfortable or that you don't like but wear simply because they divert attention from your weight or shape.

5. Make a commitment to exercise for the joy of feeling your body move and grow stronger, not to purge fat from your body or to compensate for calories eaten.

6. Practice taking people seriously for what they say, feel, and do, not for how slender or "well put together" they appear.

7. Help children appreciate and resist the ways in which television, magazines, and other media distort the true diversity of human body types and imply that a slender body means power, excitement, popularity, or perfection.

8. Educate boys and girls about various forms of prejudice, including weightism, and help them understand their responsibilities for preventing them.

9. Encourage your children to be active and to enjoy what their bodies can do and feel like. Do not limit their caloric intake unless a physician requests that you do this because of a medical problem.

10. Do whatever you can to promote the self-esteem and self-respect of all of your children in intellectual, athletic, and social endeavors. Give boys and girls the same opportunities and encouragement. Be careful not to suggest that females are less important than males, e.g., by exempting males from housework or childcare. A well-rounded sense of self and solid self-esteem are perhaps the best antidotes to dieting and disordered eating.

SOURCE: Michael Levine and Linda Smolak, "10 things parents can do to help prevent eating disorders," National Eating Disorders Association, Seattle, WA. © 2002, National Eating Disorders Association. All Rights Reserved. [Online] http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=286&Profile_ID=41171 [accessed January 7, 2004]

The National Eating Disorders Association reported a research finding that women's magazines contained 10.5 times more advertisements and articles promoting diet and weight loss than were found in men's magazines. It also reported that a study of 4,294 network television commercials revealed that one out of every 3.8 commercials conveyed some sort of attractiveness message—advising viewers about qualities that were attractive or unattractive.

While media messages portraying thinness as a desirable attribute do not directly cause eating disorders, they help to create the context within which people learn to place a value on the size and shape of their body. To the extent that media advertising defines cultural values about that which is beautiful and desirable, the media have potent power over the development of self-esteem and body image. Even if the media were to present more diverse and realistic images of people, this change would be unlikely to immediately reduce or eliminate eating disorders. However, many observers do believe it would reduce the pressures to conform to one ideal, and in the process, reduce feelings of body dissatisfaction and ultimately decrease the potential for eating disorders.

According to many health professionals and media observers, in addition to promoting unrealistic, unattainable body weights, media coverage of health, nutrition, diet, overweight, and inactivity does not fulfill its potential to educate the public about how to make healthful changes in their lives. At the November 2002 annual meeting of the American Public Health Association, investigator Vickie Collie and her colleagues from the Health Communication Research Laboratory at the Saint Louis University School of Public Health in Missouri presented the results of their research about how obesity and weight loss are discussed in the media. The investigators analyzed the content of one year of newspaper and television news stories on obesity and diet or physical activity (from June 1999 to June 2000) to determine whether when obesity was mentioned, recommendations were included about weight loss, diet, nutrition, or physical activity. Recommendations were defined as describing specific foods and serving sizes or specific exercises and amount of time for exercise.

The investigators found that fewer than one-third (30 percent) of obesity stories from television news programs included recommendations for diet, 37 percent offered recommendations for physical activity, and 13.3 percent contained recommendations for both. Newspaper stories on obesity were less likely than those on television to include recommendations—9.1 percent gave dietary advice, 50 percent offered recommendations for physical activity, and just 10 percent provided both. The investigators concluded that television and newspaper stories about obesity were missing opportunities to educate the public about specific weight-loss strategies. They stated that the "prospect exists for the public health community to collaborate with the media to increase and improve their coverage of obesity as a public health problem."

The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity (U.S. Department of Health and Human Services, 2001), a report that outlined strategies to address the increasing prevalence of overweight and obesity in America, identified the media as having a key role in prevention efforts. The report recommended a range of proactive interventions intended to educate the public and change Americans' eating behavior and exercise patterns. It took direct aim at preventing eating disorders by calling for media actions to "Promote the recognition of inappropriate weight change" and enumerated the efforts necessary to reorient the media including:

• Communicating to media professionals that the primary concern of overweight and obesity is one of health rather than appearance.
• Informing media professionals about the prevalence and burden of overweight and obesity in low-income and racial and ethnic minority populations and the need for culturally sensitive health messages.
• Communicating the importance of prevention of overweight through balancing food intake with physical activity at all ages.
• Building awareness of the importance of social and environmental influences on making appropriate diet and physical activity choices.
• Providing professional education for media professionals on policy areas related to diet and physical activity.
• Emphasizing to media professionals the need to develop uniform health messages about physical activity and nutrition that are consistent with the Dietary Guidelines for Americans.

The Call to Action also described specific actions the media could take to help Americans change their attitudes and behaviors, including:

• Launching a national campaign to increase public awareness of the health benefits of regular physical activity, healthful dietary choices, and maintaining a healthy weight, based on the Dietary Guidelines for Americans.
• Educating consumers about realistic and reasonable goals for weight-loss programs and weight-management products.
• Incorporating messages about proper nutrition, including eating at least five servings of fruits and vegetables a day, and regular physical activity in youth-oriented TV programming.
• Training nutrition and exercise scientists and specialists in media advocacy skills that will enable them to disseminate their knowledge to a broad audience.
• Encouraging balance between advertising campaigns that encourage consumption of excess calories and inactivity with messages promoting the benefits of healthy diets and exercise.
• Advocating that media celebrities use their considerable influence as role models to demonstrate eating and physical activity lifestyles for health rather than for appearance.
• Encouraging the media to employ actors of diverse sizes.