This article was downloaded by: [Erciyes University] On: 30 December 2014, At: 22:56 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Where Did Universal Eating Disorder Prevention Go? Simon M. Wilksch
a
a
School of Psychology, Flinders University , Adelaide , South Australia , Australia Published online: 20 Dec 2013.
Click for updates To cite this article: Simon M. Wilksch (2014) Where Did Universal Eating Disorder Prevention Go?, Eating Disorders: The Journal of Treatment & Prevention, 22:2, 184-192, DOI: 10.1080/10640266.2013.864889 To link to this article: http://dx.doi.org/10.1080/10640266.2013.864889
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Erciyes University] at 22:56 30 December 2014
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Eating Disorders, 22:184–192, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2013.864889
THE LAST WORD
Where Did Universal Eating Disorder Prevention Go?
Downloaded by [Erciyes University] at 22:56 30 December 2014
SIMON M. WILKSCH School of Psychology, Flinders University, Adelaide, South Australia, Australia
EATING DISORDER PREVENTION: THE CURRENT STATE OF PLAY It was just 13 years ago that the future of the eating disorder prevention field appeared bleak. A 2000 review found that four studies had shown significant positive behavior change, four had shown a worsening of symptoms, while the vast majority had shown no effect at all, leading Austin (2000) to conclude a discouraging state of the field. This first wave of prevention efforts was frequently directed at universal audiences (inclusion of participants regardless of their level of risk of an eating disorder), such as intact school classes of young-adolescent girls and sometimes boys also. In the years that followed, the eating disorder prevention field moved away from evaluating programs with these universal audiences and has taken a more targeted approach with older (primarily university-aged), females screened to be at high risk of eating problems (e.g., significantly restricting food intake). This has been a fruitful shift where a 2007 meta-analysis found 51% of eating disorder prevention trials to have at least one significant beneficial impact (Stice, Shaw, & Marti, 2007) compared to just 20% of programs included in the 2000 review. Of the studies published since 2000 that were included in the 2007 metaanalysis, 20 were directed to high-risk, female-only audiences, while 12 were delivered as universal programs in school settings with only four of these including boys (Stice et al., 2007). The meta-analysis included moderators of program effect size and found significantly larger effects for programs delivered to: targeted audiences (versus universal samples); female-only Address correspondence to Simon M. Wilksch, School of Psychology, Flinders University, G.P.O. Box 2100, Adelaide, 5001 South Australia, Australia. E-mail: simon.wilksch@flinders. edu.au 184
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
185
audiences (versus mixed-gender); and, participants above 15 years of age (versus younger audiences). An Ovid search of “eating disorder prevention” since April 2006 (cut-off date for inclusion in the 2007 meta-analysis) plus additional eating disorder prevention trials of which the author was aware, found 27 trials involving high-risk, female-only audiences above the age of 15 (e.g., Becker, Bull, Smith, & Ciao, 2008; Paxton, McLean, Gollings, Faulkner, & Wertheim, 2007; Stice, Marti, Spoor, Presnell, & Shaw, 2008; Stice, Rohde, Gau, & Shaw, 2012; Stice, Rohde, Shaw & Gau, 2011b; Volker, Jacobi & Taylor, 2011), including four investigations of mediators and moderators of program outcome (e.g., Stice, Marti, Rohde, & Shaw, 2011a). A further eight trials investigated programs with low- and high-risk university students; high-risk females under the age of 15; trainee teachers; young-adult dating partners; and females under the age of 15 (e.g., Cook-Cottone, Jones, & Haugli, 2010; Heinicke, Paxton, McLean, & Wertheim, 2007; Yager & O’Dea, 2010). In contrast, ten universal, mixed-gender school-based evaluations were published over the same time frame (Cousineau et al., 2010; González, Penelo, Gutiérrez, & Raich, 2011; McVey, Tweed, & Blackmore, 2007; Pokrajac-Bulian, Zivcic-Becirevic, Calugi, & Dalle Grave, 2006; Richardson, Paxton, & Thomson, 2009; Wilksch, 2010, 2013; Wilksch, Tiggemann, & Wade, 2006; Wilksch & Wade, 2009, 2013), where four of these studies involved the same program being investigated through a pilot study (Wilksch et al., 2006), randomized controlled trial (RCT; Wilksch & Wade, 2009), supplementary analyses by participant risk status (Wilksch, 2010), and a pilot effectiveness trial of teacher delivery of the program (Wilksch, 2013). Thus, since the year 2000 there have been 47 published eating disorder prevention trials delivered to targeted high-risk, female-only audiences above the age of 15 compared to 14 published trials of programs delivered to universal, mixed-gender audiences under the age of 15 (i.e., four included in the Stice et al. meta-analysis and an additional 10 papers since). The overall quality of prevention studies in the last decade has improved on the methodological shortcomings of earlier efforts where conclusions of program efficacy were limited by: insufficient sample sizes, absence of control groups, inadequate statistical analyses; use of non-validated outcome measures, and limited duration of follow-up assessments, while prevention programs themselves were often of insufficient duration to exact significant post-intervention or follow-up effects. Many of these earlier programs were universal and given the move away from this approach since 2000, the real possibility exists that universal eating disorder prevention has yet to be adequately evaluated. By contrast, nowhere is this improvement in scientific rigor of program evaluation more apparent than amongst RCTs of targeted prevention programs with high-risk, female-only samples, conducted over substantial follow-up durations (e.g., Taylor et al., 2006). Further, programs targeting
186
S. M. Wilksch
these audiences also have been evaluated now in different countries to their original evaluation (e.g., Volker et al., 2011), direct comparison to other prevention programs rather than a no-intervention control-comparison group (e.g., Stice et al., 2008), replication efficacy trials (e.g., Becker, Bull, Schaumberg, Cauble, & Franco, 2008), and effectiveness trials involving endogenous program presenters (e.g., Stice et al., 2011b). These respective developments are extremely promising and serve as a clear set of future directions for the universal field to follow.
Downloaded by [Erciyes University] at 22:56 30 December 2014
THE URGENT NEED FOR EFFICACIOUS UNIVERSAL EATING DISORDER PREVENTION PROGRAMS Numerous important arguments have been proposed to meet the serious need for empirically supported universal eating disorder prevention programs (e.g., Neumark-Sztainer et al., 2006) and these reasons typically include: eating disorder risk factors are emerging in increasingly young children; there is an increase in reported incidence of pre- and early-adolescents suffering from eating disorders; it is important that prevention programs be administered prior to the age when many young people experiment with dangerous weight control behaviours (15–16 years); and there is an increasing prevalence of body dissatisfaction in adolescent boys, indicating they too need prevention programs, while girls may also benefit from having their male peers participate. A recent development highlighting the need to improve the quality of universal prevention research is the increase in corporate efforts to improve body image. While it is commendable that such organizations have taken an interest in this important area and it represents a valuable opportunity, a concerning trend is for wide-scale dissemination to occur prior to evaluation. Universal prevention researchers should view this as a call-to-action to complete quality program evaluations and assist corporations with either improving their current programs or replacing them with more empirically supported options.
UNIVERSAL PREVENTION: SIMILARITIES AND DIFFERENCES FROM TARGETED PREVENTION A positive direction across both the targeted and universal fields over the past decade has been the much greater attention given to prospectively identified eating disorder risk factors when developing program content and this has been enabled by two developments. First, the proliferation of high-quality prospective risk factor research and efforts to synthesize these findings (e.g., Jacobi & Fittig, 2010). Prospectively supported multivariate
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
187
models of how risk factors operate in conjunction with one another have been of particular value. Second, meta-analytic findings that programs targeting eating disorder risk factors do exact larger effects than those providing information about the serious nature of eating disorders (Stice et al., 2007). These developments have not only led to improved outcomes but also have moved the field away from previous suggestions of iatrogenic effects of some earlier programs (Austin, 2000), where now there has been no published trial since 2000 showing evidence of a harmful intervention effect. Thus the methodical targeting of risk factors is a considerable strength of current prevention efforts and has likely played a central role in the improved outcomes. In addition to targeting developmentally relevant risk factors and avoiding information about eating disorders, there are further similarities in how both universal and targeted programs should be developed and evaluated. Program content should follow the evidence-based principles of being interactive, having multiple session duration (i.e., sufficient intensity), and ideally initially being delivered by a health professional rather than an endogenous provider in the early stages of evaluation (Stice et al., 2007). However, the question of “what constitutes a successful outcome?” requires careful thought across the two approaches. Without question, the overall aim of eating disorder prevention research is to prevent the onset of clinical and subclinical eating disorder cases and this should be a goal of all prevention efforts regardless of audience type. However, this does require additional thought when it comes to universal, young-adolescent samples where onset of such level of pathology near the time of program delivery is often low. It is not surprising that universal programs to date have achieved smaller effect sizes than those with older, high-risk, female-only audiences. While this in part is likely due to poorer quality evaluation in the universal field, it also represents the obvious difference in baseline scores on eating disorder risk factors across the two demographics. It is apparent that the outcomes of many targeted programs include a reduction in risk factor and disordered eating scores from baseline to post-program and follow-up. While of great benefit, statistically this is a treatment effect rather than a prevention effect. By contrast, the primary goal of universal eating disorder prevention research is to prevent growth in risk factor scores over time. A treatment effect is unlikely given that baseline scores are usually not high enough to achieve such an effect by post-program relative to a control group. Instead it means adequate follow-up duration of universal programs is critical to ensure maximum opportunity to capture program effect and the follow-up period likely needs to be longer than is required in targeted programs which typically occur during the peak risk period of participants developing an eating disorder. This is currently not the case, where the longest follow-ups of universal programs have been confined to 30-months (González et al., 2011; Wilksch & Wade, 2009); with the majority of studies
188
S. M. Wilksch
Downloaded by [Erciyes University] at 22:56 30 December 2014
having follow-ups of 6 months or less. It is time for well-designed universal prevention programs to be evaluated over the entire length of the at-risk period. Further, it is increasingly recognized that while preventing clinical and subclinical eating disorder cases is critical, established eating disorder risk factors such as body dissatisfaction, over-evaluation of shape and weight, negative affect and dieting, do convey their own level of suffering (Stice et al., 2012) and as such significant effects on these variables also should be valued as highly beneficial outcomes in their own right. Thus, universal programs that can achieve a halt in risk factor growth over time are achieving a valuable outcome given that participants are usually at an age where eating disorder risk factors will likely be increasing.
FUTURE DIRECTIONS FOR UNIVERSAL EATING DISORDER PREVENTION Previous discussions of eating disorder prevention often have focused on the question of which is the better approach—universal or targeted eating disorder prevention? This is unlikely to be a helpful way in which to view the field and the argument of a universal versus targeted approach to eating disorder prevention is not an exclusive one. We require a stepped, developmentally appropriate approach to eating disorder prevention where efficacious universal programs act as the first-line of prevention efforts while targeted programs can be delivered to high-risk samples. However, at the current time this is only a hope rather than a reality. While there have been some notable positive findings in universal eating disorder prevention RCTs, it is apparent that the field as a whole has considerable ground to gain if it is to become a scientifically supported presence on the eating disorder prevention landscape. It is therefore proposed that five key directions need to be followed: 1. The universal prevention field needs to learn from the targeted prevention field in regard to the methodical and thorough evaluation of programs. This includes efficacy RCTs of appropriate scientific quality, replication trials, and where indicated, effectiveness trials. A noteworthy feature here is that it appears more energy needs to go into evaluation rather than the development of new programs, with a focus on longer follow-up evaluations than have previously been completed. 2. Eating disorder prevention research needs to evaluate whether programs actually are preventing cases of clinical eating disorders. While this might seem obvious, it is an area where both targeted and universal program researchers need to improve. While some targeted trials have investigated this (e.g., Stice et al., 2008; Taylor et al., 2006), many have focused on
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
189
continuous measures of disordered eating beahviours without reporting outcomes for actual cases, while universal trials have generally evaluated risk factor outcomes without directly assessing eating disorder behaviours. Both targeted and universal fields need to improve as it is only by gaining evidence of actual reduced onset of cases that eating disorder prevention researchers can make considerable progress towards the overarching goal of broader sustainability of programs through wide-scale dissemination and adoption of evidence-based programs by government authorities. 3. Build partnerships with prevention experts targeting other mental health problems. Just as eating disorder prevention programs have found significant benefit for risk factors for other mental health problems, such as depression (Wilksch & Wade, 2009), it is feasible that programs seeking to prevent depression also could have benefit for eating disorder risk factors, given their relevance to disordered eating. Of course this would need to be guided by selecting programs that target known eating disorder risk factors. However, the inclusion of well-chosen risk factor and behavioural measures in prevention trials for other mental health problems represents a cost-effective opportunity to increase the quantity and quality of efficacy trials, as well as exploring novel program options. 4. Greater collaboration with obesity prevention experts. This is not a new suggestion (e.g., Neumark-Sztainer et al., 2006), however within the universal prevention field there remains just two studies to investigate the effect of a program on both disordered eating and obesity (Austin, Field, Wiecha, Peterson, & Gortmaker, 2005; Wilksch & Wade, 2013). There are numerous reasons for taking a combined approach: obesity is a risk factor for disordered eating; some with disordered eating are more likely to gain weight over time; the risk of confusing messages to young people if they participate in separate programs; a desire to avoid inadvertent harm to the other problem; and, a realization that preventing one problem is likely to have flow-on benefits to preventing the other problem. But the most important reason is the increasingly common finding that there is overlap in the risk factors for both problems. Specifically, risk factors such as dieting, body dissatisfaction, media, depressive symptoms, perfectionism, shorter sleep duration, and difficulties with emotion regulation, have been found to increase the risk of both disordered eating and weight gain (e.g., Neumark-Sztainer et al., 2007). As such, an intervention that can reduce these risk factors could have a preventative effect for both eating disorders and obesity. Indeed, in the targeted prevention field, the Healthy Weight program has significantly reduced the risk the onset of both problems (Stice et al., 2008). 5. We need evidence-based programs for children as well. In addition to not turning our backs on prevention trials with young-adolescents, increased research attention needs to be directed to developing and evaluating ageappropriate programs with pre-adolescent children. We cannot ignore the
190
S. M. Wilksch
ever growing body of research regarding the young age at which body dissatisfaction and other risk factors begin to emerge. In addition, we have the many concerns that accompany technology use in children where cross-sectional data have found significant positive associations between social media use and body dissatisfaction in young-adolescent females (Tiggemann & Slater, 2013).
Downloaded by [Erciyes University] at 22:56 30 December 2014
CONCLUSION The eating disorder prevention field has advanced considerably since the turn of the century. The most notable positive directions include the systematic targeting of prospectively identified eating disorder risk factors, much improved scientific rigor in prevention trials, and progressing to the next stage of research including replication and effectiveness trials. On closer inspection however, the vast majority of this research activity has been with programs delivered to targeted, high-risk young-adult female audiences. While such programs are of critical value in the overall efforts to prevent eating disorders, numerous universal prevention programs have been developed without adequate evaluation. The field needs to improve as we cannot afford to only have effective programs available to deliver to participants older than 15-years of age already displaying concerning eating attitudes and behaviours.
FUNDING Simon Wilksch holds a research fellowship funded by the South Australian Centre for Intergenerational Health.
REFERENCES Austin, S. B. (2000). Prevention research in eating disorders: Theory and new directions. Psychological Medicine, 30, 1249–1262. Austin, S. B., Field, A. E., Wiecha, J., Peterson, K. E., & Gortmaker, S. L. (2005). The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls. Archives of Pediatrics & Adolescent Medicine, 159, 225–230. Becker, C. B., Bull, S., Schaumberg, K., Cauble, A., & Franco, A. (2008). Effectiveness of peer-led eating disorders prevention: A replication trial. Journal of Consulting and Clinical Psychology, 76, 347–354. Becker, C. B., Bull, S., Smith, L. M., & Ciao, A. C. (2008). Effects of being a peerleader in an eating disorder prevention program: Can we further reduce eating disorder risk factors? Eating Disorders, 16, 444–459.
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
191
Cook-Cottone, C., Jones, L. A., & Haugli, S. (2010). Prevention of eating disorders among minority youth: A matched-sample repeated measures study. Eating Disorders, 18, 361–376. Cousineau, T. M., Franko, D.L., Trant, M., Rancourt, D., Ainscough, J., Chaudhuri, A., & Brevard, J. (2010). Teaching adolescents about changing bodies: Randomized controlled trial of an internet puberty education and body dissatisfaction prevention program. Body Image, 7, 296–300. González, M., Penelo, E., Gutiérrez, T., & Raich, R. M. (2011). Disordered eating prevention programme in schools: A 30-month follow-up. European Eating Disorders Review, 19, 349–356. Heinicke, B. E., Paxton, S. J., McLean, S. A., & Wertheim, E. H. (2007). Internetdelivered targeted group intervention for body dissatisfaction and disordered eating in adolescent girls: A randomized controlled trial. Journal of Abnormal Child Psychology, 35, 379–391. Jacobi, C., & Fittig, E. (2010). Psychosocial risk factors for eating disorders. In W. S. Agras (Ed.), The Oxford handbook of eating disorders (pp. 123–136). New York, NY: Oxford University Press. McVey, G., Tweed, S., & Blackmore, E. (2007). Healthy Schools-Healthy Kids: A controlled evaluation of a comprehensive universal eating disorder prevention program. Body Image, 4, 115–136. Neumark-Sztainer, D., Levine, M. P., Paxton, S. J., Smolak, L., Piran, N., & Wertheim, E. H. (2006). Prevention of body dissatisfaction and disordered eating: What next? Eating Disorders: The Journal of Treatment & Prevention, 14, 265–285. Neumark-Sztainer, D., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E., & van den Berg, P. A. (2007). Shared risk and protective factors for overweight and disordered eating in adolescents. American Journal of Preventive Medicine, 33, 359–369. Paxton, S. J., McLean, S. A., Gollings, E. K., Faulkner, C., & Wertheim, E. H. (2007). Comparison of face-to-face and internet interventions for body image and eating problems in adult women: An RCT. International Journal of Eating Disorders, 40, 692–704. Pokrajac-Bulian, A., Zivcic-Becirevic, I., Calugi, S., & Dalle Grave, R. (2006). School prevention program for eating disorders in Croatia: A controlled study with six months of follow-up. Eating and Weight Disorders, 11, 171–178. Richardson, S. M., Paxton, S. J., & Thomson, J. S. (2009). Is BodyThink an efficacious body image and self-esteem program? A controlled evaluation with adolescents. Body Image, 6, 75–82. Stice, E., Marti, C., Rohde, P., & Shaw, H. (2011a). Testing mediators hypothesized to account for the effects of a dissonance-based eating disorder prevention program over longer term follow-up. Journal of Consulting and Clinical Psychology, 79, 398–405. Stice, E., Marti, C., Spoor, S., Presnell, K., & Shaw, H. (2008). Dissonance and healthy weight eating disorder prevention programs: Long-term effects from a randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76, 329–340. Stice, E., Rohde, P., Gau, J., & Shaw, H. (2012). Effect of a dissonance-based prevention program on risk for eating disorder onset in the context of eating disorder risk factors. Prevention Science, 13, 129–139.
Downloaded by [Erciyes University] at 22:56 30 December 2014
192
S. M. Wilksch
Stice, E., Rohde, P., Shaw, H., & Gau, J. (2011b). An effectiveness trial of a selected dissonance-based eating disorder prevention program for female high school students: Long-term effects. Journal of Consulting and Clinical Psychology, 79, 500–508. Stice, E., Shaw, H., & Marti, C. N. (2007). A meta-analytic review of eating disorder prevention programs: Encouraging findings. Annual Review of Clinical Psychology, 3, 207–231. Taylor, C., Bryson, S., Luce, K., Cunning, D., Doyle, A., Abascat, L., . . . Wilfley, D. (2006). Prevention of eating disorders in at-risk college-age women. Archives of General Psychiatry, 63, 881–888. Tiggemann, M., & Slater, A. (2013). NetGirls: The Internet, Facebook, and body image concern in adolescent girls. International Journal of Eating Disorders, 46, 630–633. Volker, U., Jacobi, C., & Taylor, C. (2011). Adaption and evaluation of an Internet-based prevention program for eating disorders in a sample of women with subclinical eating disorder symptoms: A pilot study. Eating and Weight Disorders, 16, e270–e273. Wilksch, S. M. (2010). Universal school-based eating disorder prevention: Benefits to both high- and low-risk participants on the core cognitive feature of eating disorders. Clinical Psychologist, 14, 62–69. Wilksch, S. M. (2013). School-based eating disorder prevention: A pilot effectiveness trial of teacher-delivered Media Smart. Early Intervention in Psychiatry. doi: 10.1111/eip.12070 Wilksch, S. M., Tiggemann, M., & Wade, T. D. (2006). Impact of interactive schoolbased media literacy lessons for reducing internalization of media ideals in young adolescent girls and boys. International Journal of Eating Disorders, 39, 385–393. Wilksch, S. M., & Wade, T. D. (2009). Reduction of shape and weight concern in young adolescents: A 30-month controlled evaluation of a media literacy program. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 652–661. Wilksch, S. M., & Wade, T. D. (2013). Life Smart: A pilot study of a school-based program to reduce the risk of both eating disorders and obesity in young adolescent girls and boys. Journal of Pediatric Psychology. doi: 10.1093/jpepsy/jst036 Yager, Z., & O’Dea, J. (2010). A controlled intervention to promote a healthy body image, reduce eating disorder risk and prevent excessive exercise among trainee health education and physical education teachers. Health Education Research, 25, 841–852.
Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Where Did Universal Eating Disorder Prevention Go? Simon M. Wilksch
a
a
School of Psychology, Flinders University , Adelaide , South Australia , Australia Published online: 20 Dec 2013.
Click for updates To cite this article: Simon M. Wilksch (2014) Where Did Universal Eating Disorder Prevention Go?, Eating Disorders: The Journal of Treatment & Prevention, 22:2, 184-192, DOI: 10.1080/10640266.2013.864889 To link to this article: http://dx.doi.org/10.1080/10640266.2013.864889
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Erciyes University] at 22:56 30 December 2014
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Eating Disorders, 22:184–192, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2013.864889
THE LAST WORD
Where Did Universal Eating Disorder Prevention Go?
Downloaded by [Erciyes University] at 22:56 30 December 2014
SIMON M. WILKSCH School of Psychology, Flinders University, Adelaide, South Australia, Australia
EATING DISORDER PREVENTION: THE CURRENT STATE OF PLAY It was just 13 years ago that the future of the eating disorder prevention field appeared bleak. A 2000 review found that four studies had shown significant positive behavior change, four had shown a worsening of symptoms, while the vast majority had shown no effect at all, leading Austin (2000) to conclude a discouraging state of the field. This first wave of prevention efforts was frequently directed at universal audiences (inclusion of participants regardless of their level of risk of an eating disorder), such as intact school classes of young-adolescent girls and sometimes boys also. In the years that followed, the eating disorder prevention field moved away from evaluating programs with these universal audiences and has taken a more targeted approach with older (primarily university-aged), females screened to be at high risk of eating problems (e.g., significantly restricting food intake). This has been a fruitful shift where a 2007 meta-analysis found 51% of eating disorder prevention trials to have at least one significant beneficial impact (Stice, Shaw, & Marti, 2007) compared to just 20% of programs included in the 2000 review. Of the studies published since 2000 that were included in the 2007 metaanalysis, 20 were directed to high-risk, female-only audiences, while 12 were delivered as universal programs in school settings with only four of these including boys (Stice et al., 2007). The meta-analysis included moderators of program effect size and found significantly larger effects for programs delivered to: targeted audiences (versus universal samples); female-only Address correspondence to Simon M. Wilksch, School of Psychology, Flinders University, G.P.O. Box 2100, Adelaide, 5001 South Australia, Australia. E-mail: simon.wilksch@flinders. edu.au 184
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
185
audiences (versus mixed-gender); and, participants above 15 years of age (versus younger audiences). An Ovid search of “eating disorder prevention” since April 2006 (cut-off date for inclusion in the 2007 meta-analysis) plus additional eating disorder prevention trials of which the author was aware, found 27 trials involving high-risk, female-only audiences above the age of 15 (e.g., Becker, Bull, Smith, & Ciao, 2008; Paxton, McLean, Gollings, Faulkner, & Wertheim, 2007; Stice, Marti, Spoor, Presnell, & Shaw, 2008; Stice, Rohde, Gau, & Shaw, 2012; Stice, Rohde, Shaw & Gau, 2011b; Volker, Jacobi & Taylor, 2011), including four investigations of mediators and moderators of program outcome (e.g., Stice, Marti, Rohde, & Shaw, 2011a). A further eight trials investigated programs with low- and high-risk university students; high-risk females under the age of 15; trainee teachers; young-adult dating partners; and females under the age of 15 (e.g., Cook-Cottone, Jones, & Haugli, 2010; Heinicke, Paxton, McLean, & Wertheim, 2007; Yager & O’Dea, 2010). In contrast, ten universal, mixed-gender school-based evaluations were published over the same time frame (Cousineau et al., 2010; González, Penelo, Gutiérrez, & Raich, 2011; McVey, Tweed, & Blackmore, 2007; Pokrajac-Bulian, Zivcic-Becirevic, Calugi, & Dalle Grave, 2006; Richardson, Paxton, & Thomson, 2009; Wilksch, 2010, 2013; Wilksch, Tiggemann, & Wade, 2006; Wilksch & Wade, 2009, 2013), where four of these studies involved the same program being investigated through a pilot study (Wilksch et al., 2006), randomized controlled trial (RCT; Wilksch & Wade, 2009), supplementary analyses by participant risk status (Wilksch, 2010), and a pilot effectiveness trial of teacher delivery of the program (Wilksch, 2013). Thus, since the year 2000 there have been 47 published eating disorder prevention trials delivered to targeted high-risk, female-only audiences above the age of 15 compared to 14 published trials of programs delivered to universal, mixed-gender audiences under the age of 15 (i.e., four included in the Stice et al. meta-analysis and an additional 10 papers since). The overall quality of prevention studies in the last decade has improved on the methodological shortcomings of earlier efforts where conclusions of program efficacy were limited by: insufficient sample sizes, absence of control groups, inadequate statistical analyses; use of non-validated outcome measures, and limited duration of follow-up assessments, while prevention programs themselves were often of insufficient duration to exact significant post-intervention or follow-up effects. Many of these earlier programs were universal and given the move away from this approach since 2000, the real possibility exists that universal eating disorder prevention has yet to be adequately evaluated. By contrast, nowhere is this improvement in scientific rigor of program evaluation more apparent than amongst RCTs of targeted prevention programs with high-risk, female-only samples, conducted over substantial follow-up durations (e.g., Taylor et al., 2006). Further, programs targeting
186
S. M. Wilksch
these audiences also have been evaluated now in different countries to their original evaluation (e.g., Volker et al., 2011), direct comparison to other prevention programs rather than a no-intervention control-comparison group (e.g., Stice et al., 2008), replication efficacy trials (e.g., Becker, Bull, Schaumberg, Cauble, & Franco, 2008), and effectiveness trials involving endogenous program presenters (e.g., Stice et al., 2011b). These respective developments are extremely promising and serve as a clear set of future directions for the universal field to follow.
Downloaded by [Erciyes University] at 22:56 30 December 2014
THE URGENT NEED FOR EFFICACIOUS UNIVERSAL EATING DISORDER PREVENTION PROGRAMS Numerous important arguments have been proposed to meet the serious need for empirically supported universal eating disorder prevention programs (e.g., Neumark-Sztainer et al., 2006) and these reasons typically include: eating disorder risk factors are emerging in increasingly young children; there is an increase in reported incidence of pre- and early-adolescents suffering from eating disorders; it is important that prevention programs be administered prior to the age when many young people experiment with dangerous weight control behaviours (15–16 years); and there is an increasing prevalence of body dissatisfaction in adolescent boys, indicating they too need prevention programs, while girls may also benefit from having their male peers participate. A recent development highlighting the need to improve the quality of universal prevention research is the increase in corporate efforts to improve body image. While it is commendable that such organizations have taken an interest in this important area and it represents a valuable opportunity, a concerning trend is for wide-scale dissemination to occur prior to evaluation. Universal prevention researchers should view this as a call-to-action to complete quality program evaluations and assist corporations with either improving their current programs or replacing them with more empirically supported options.
UNIVERSAL PREVENTION: SIMILARITIES AND DIFFERENCES FROM TARGETED PREVENTION A positive direction across both the targeted and universal fields over the past decade has been the much greater attention given to prospectively identified eating disorder risk factors when developing program content and this has been enabled by two developments. First, the proliferation of high-quality prospective risk factor research and efforts to synthesize these findings (e.g., Jacobi & Fittig, 2010). Prospectively supported multivariate
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
187
models of how risk factors operate in conjunction with one another have been of particular value. Second, meta-analytic findings that programs targeting eating disorder risk factors do exact larger effects than those providing information about the serious nature of eating disorders (Stice et al., 2007). These developments have not only led to improved outcomes but also have moved the field away from previous suggestions of iatrogenic effects of some earlier programs (Austin, 2000), where now there has been no published trial since 2000 showing evidence of a harmful intervention effect. Thus the methodical targeting of risk factors is a considerable strength of current prevention efforts and has likely played a central role in the improved outcomes. In addition to targeting developmentally relevant risk factors and avoiding information about eating disorders, there are further similarities in how both universal and targeted programs should be developed and evaluated. Program content should follow the evidence-based principles of being interactive, having multiple session duration (i.e., sufficient intensity), and ideally initially being delivered by a health professional rather than an endogenous provider in the early stages of evaluation (Stice et al., 2007). However, the question of “what constitutes a successful outcome?” requires careful thought across the two approaches. Without question, the overall aim of eating disorder prevention research is to prevent the onset of clinical and subclinical eating disorder cases and this should be a goal of all prevention efforts regardless of audience type. However, this does require additional thought when it comes to universal, young-adolescent samples where onset of such level of pathology near the time of program delivery is often low. It is not surprising that universal programs to date have achieved smaller effect sizes than those with older, high-risk, female-only audiences. While this in part is likely due to poorer quality evaluation in the universal field, it also represents the obvious difference in baseline scores on eating disorder risk factors across the two demographics. It is apparent that the outcomes of many targeted programs include a reduction in risk factor and disordered eating scores from baseline to post-program and follow-up. While of great benefit, statistically this is a treatment effect rather than a prevention effect. By contrast, the primary goal of universal eating disorder prevention research is to prevent growth in risk factor scores over time. A treatment effect is unlikely given that baseline scores are usually not high enough to achieve such an effect by post-program relative to a control group. Instead it means adequate follow-up duration of universal programs is critical to ensure maximum opportunity to capture program effect and the follow-up period likely needs to be longer than is required in targeted programs which typically occur during the peak risk period of participants developing an eating disorder. This is currently not the case, where the longest follow-ups of universal programs have been confined to 30-months (González et al., 2011; Wilksch & Wade, 2009); with the majority of studies
188
S. M. Wilksch
Downloaded by [Erciyes University] at 22:56 30 December 2014
having follow-ups of 6 months or less. It is time for well-designed universal prevention programs to be evaluated over the entire length of the at-risk period. Further, it is increasingly recognized that while preventing clinical and subclinical eating disorder cases is critical, established eating disorder risk factors such as body dissatisfaction, over-evaluation of shape and weight, negative affect and dieting, do convey their own level of suffering (Stice et al., 2012) and as such significant effects on these variables also should be valued as highly beneficial outcomes in their own right. Thus, universal programs that can achieve a halt in risk factor growth over time are achieving a valuable outcome given that participants are usually at an age where eating disorder risk factors will likely be increasing.
FUTURE DIRECTIONS FOR UNIVERSAL EATING DISORDER PREVENTION Previous discussions of eating disorder prevention often have focused on the question of which is the better approach—universal or targeted eating disorder prevention? This is unlikely to be a helpful way in which to view the field and the argument of a universal versus targeted approach to eating disorder prevention is not an exclusive one. We require a stepped, developmentally appropriate approach to eating disorder prevention where efficacious universal programs act as the first-line of prevention efforts while targeted programs can be delivered to high-risk samples. However, at the current time this is only a hope rather than a reality. While there have been some notable positive findings in universal eating disorder prevention RCTs, it is apparent that the field as a whole has considerable ground to gain if it is to become a scientifically supported presence on the eating disorder prevention landscape. It is therefore proposed that five key directions need to be followed: 1. The universal prevention field needs to learn from the targeted prevention field in regard to the methodical and thorough evaluation of programs. This includes efficacy RCTs of appropriate scientific quality, replication trials, and where indicated, effectiveness trials. A noteworthy feature here is that it appears more energy needs to go into evaluation rather than the development of new programs, with a focus on longer follow-up evaluations than have previously been completed. 2. Eating disorder prevention research needs to evaluate whether programs actually are preventing cases of clinical eating disorders. While this might seem obvious, it is an area where both targeted and universal program researchers need to improve. While some targeted trials have investigated this (e.g., Stice et al., 2008; Taylor et al., 2006), many have focused on
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
189
continuous measures of disordered eating beahviours without reporting outcomes for actual cases, while universal trials have generally evaluated risk factor outcomes without directly assessing eating disorder behaviours. Both targeted and universal fields need to improve as it is only by gaining evidence of actual reduced onset of cases that eating disorder prevention researchers can make considerable progress towards the overarching goal of broader sustainability of programs through wide-scale dissemination and adoption of evidence-based programs by government authorities. 3. Build partnerships with prevention experts targeting other mental health problems. Just as eating disorder prevention programs have found significant benefit for risk factors for other mental health problems, such as depression (Wilksch & Wade, 2009), it is feasible that programs seeking to prevent depression also could have benefit for eating disorder risk factors, given their relevance to disordered eating. Of course this would need to be guided by selecting programs that target known eating disorder risk factors. However, the inclusion of well-chosen risk factor and behavioural measures in prevention trials for other mental health problems represents a cost-effective opportunity to increase the quantity and quality of efficacy trials, as well as exploring novel program options. 4. Greater collaboration with obesity prevention experts. This is not a new suggestion (e.g., Neumark-Sztainer et al., 2006), however within the universal prevention field there remains just two studies to investigate the effect of a program on both disordered eating and obesity (Austin, Field, Wiecha, Peterson, & Gortmaker, 2005; Wilksch & Wade, 2013). There are numerous reasons for taking a combined approach: obesity is a risk factor for disordered eating; some with disordered eating are more likely to gain weight over time; the risk of confusing messages to young people if they participate in separate programs; a desire to avoid inadvertent harm to the other problem; and, a realization that preventing one problem is likely to have flow-on benefits to preventing the other problem. But the most important reason is the increasingly common finding that there is overlap in the risk factors for both problems. Specifically, risk factors such as dieting, body dissatisfaction, media, depressive symptoms, perfectionism, shorter sleep duration, and difficulties with emotion regulation, have been found to increase the risk of both disordered eating and weight gain (e.g., Neumark-Sztainer et al., 2007). As such, an intervention that can reduce these risk factors could have a preventative effect for both eating disorders and obesity. Indeed, in the targeted prevention field, the Healthy Weight program has significantly reduced the risk the onset of both problems (Stice et al., 2008). 5. We need evidence-based programs for children as well. In addition to not turning our backs on prevention trials with young-adolescents, increased research attention needs to be directed to developing and evaluating ageappropriate programs with pre-adolescent children. We cannot ignore the
190
S. M. Wilksch
ever growing body of research regarding the young age at which body dissatisfaction and other risk factors begin to emerge. In addition, we have the many concerns that accompany technology use in children where cross-sectional data have found significant positive associations between social media use and body dissatisfaction in young-adolescent females (Tiggemann & Slater, 2013).
Downloaded by [Erciyes University] at 22:56 30 December 2014
CONCLUSION The eating disorder prevention field has advanced considerably since the turn of the century. The most notable positive directions include the systematic targeting of prospectively identified eating disorder risk factors, much improved scientific rigor in prevention trials, and progressing to the next stage of research including replication and effectiveness trials. On closer inspection however, the vast majority of this research activity has been with programs delivered to targeted, high-risk young-adult female audiences. While such programs are of critical value in the overall efforts to prevent eating disorders, numerous universal prevention programs have been developed without adequate evaluation. The field needs to improve as we cannot afford to only have effective programs available to deliver to participants older than 15-years of age already displaying concerning eating attitudes and behaviours.
FUNDING Simon Wilksch holds a research fellowship funded by the South Australian Centre for Intergenerational Health.
REFERENCES Austin, S. B. (2000). Prevention research in eating disorders: Theory and new directions. Psychological Medicine, 30, 1249–1262. Austin, S. B., Field, A. E., Wiecha, J., Peterson, K. E., & Gortmaker, S. L. (2005). The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls. Archives of Pediatrics & Adolescent Medicine, 159, 225–230. Becker, C. B., Bull, S., Schaumberg, K., Cauble, A., & Franco, A. (2008). Effectiveness of peer-led eating disorders prevention: A replication trial. Journal of Consulting and Clinical Psychology, 76, 347–354. Becker, C. B., Bull, S., Smith, L. M., & Ciao, A. C. (2008). Effects of being a peerleader in an eating disorder prevention program: Can we further reduce eating disorder risk factors? Eating Disorders, 16, 444–459.
Downloaded by [Erciyes University] at 22:56 30 December 2014
The Last Word
191
Cook-Cottone, C., Jones, L. A., & Haugli, S. (2010). Prevention of eating disorders among minority youth: A matched-sample repeated measures study. Eating Disorders, 18, 361–376. Cousineau, T. M., Franko, D.L., Trant, M., Rancourt, D., Ainscough, J., Chaudhuri, A., & Brevard, J. (2010). Teaching adolescents about changing bodies: Randomized controlled trial of an internet puberty education and body dissatisfaction prevention program. Body Image, 7, 296–300. González, M., Penelo, E., Gutiérrez, T., & Raich, R. M. (2011). Disordered eating prevention programme in schools: A 30-month follow-up. European Eating Disorders Review, 19, 349–356. Heinicke, B. E., Paxton, S. J., McLean, S. A., & Wertheim, E. H. (2007). Internetdelivered targeted group intervention for body dissatisfaction and disordered eating in adolescent girls: A randomized controlled trial. Journal of Abnormal Child Psychology, 35, 379–391. Jacobi, C., & Fittig, E. (2010). Psychosocial risk factors for eating disorders. In W. S. Agras (Ed.), The Oxford handbook of eating disorders (pp. 123–136). New York, NY: Oxford University Press. McVey, G., Tweed, S., & Blackmore, E. (2007). Healthy Schools-Healthy Kids: A controlled evaluation of a comprehensive universal eating disorder prevention program. Body Image, 4, 115–136. Neumark-Sztainer, D., Levine, M. P., Paxton, S. J., Smolak, L., Piran, N., & Wertheim, E. H. (2006). Prevention of body dissatisfaction and disordered eating: What next? Eating Disorders: The Journal of Treatment & Prevention, 14, 265–285. Neumark-Sztainer, D., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E., & van den Berg, P. A. (2007). Shared risk and protective factors for overweight and disordered eating in adolescents. American Journal of Preventive Medicine, 33, 359–369. Paxton, S. J., McLean, S. A., Gollings, E. K., Faulkner, C., & Wertheim, E. H. (2007). Comparison of face-to-face and internet interventions for body image and eating problems in adult women: An RCT. International Journal of Eating Disorders, 40, 692–704. Pokrajac-Bulian, A., Zivcic-Becirevic, I., Calugi, S., & Dalle Grave, R. (2006). School prevention program for eating disorders in Croatia: A controlled study with six months of follow-up. Eating and Weight Disorders, 11, 171–178. Richardson, S. M., Paxton, S. J., & Thomson, J. S. (2009). Is BodyThink an efficacious body image and self-esteem program? A controlled evaluation with adolescents. Body Image, 6, 75–82. Stice, E., Marti, C., Rohde, P., & Shaw, H. (2011a). Testing mediators hypothesized to account for the effects of a dissonance-based eating disorder prevention program over longer term follow-up. Journal of Consulting and Clinical Psychology, 79, 398–405. Stice, E., Marti, C., Spoor, S., Presnell, K., & Shaw, H. (2008). Dissonance and healthy weight eating disorder prevention programs: Long-term effects from a randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76, 329–340. Stice, E., Rohde, P., Gau, J., & Shaw, H. (2012). Effect of a dissonance-based prevention program on risk for eating disorder onset in the context of eating disorder risk factors. Prevention Science, 13, 129–139.
Downloaded by [Erciyes University] at 22:56 30 December 2014
192
S. M. Wilksch
Stice, E., Rohde, P., Shaw, H., & Gau, J. (2011b). An effectiveness trial of a selected dissonance-based eating disorder prevention program for female high school students: Long-term effects. Journal of Consulting and Clinical Psychology, 79, 500–508. Stice, E., Shaw, H., & Marti, C. N. (2007). A meta-analytic review of eating disorder prevention programs: Encouraging findings. Annual Review of Clinical Psychology, 3, 207–231. Taylor, C., Bryson, S., Luce, K., Cunning, D., Doyle, A., Abascat, L., . . . Wilfley, D. (2006). Prevention of eating disorders in at-risk college-age women. Archives of General Psychiatry, 63, 881–888. Tiggemann, M., & Slater, A. (2013). NetGirls: The Internet, Facebook, and body image concern in adolescent girls. International Journal of Eating Disorders, 46, 630–633. Volker, U., Jacobi, C., & Taylor, C. (2011). Adaption and evaluation of an Internet-based prevention program for eating disorders in a sample of women with subclinical eating disorder symptoms: A pilot study. Eating and Weight Disorders, 16, e270–e273. Wilksch, S. M. (2010). Universal school-based eating disorder prevention: Benefits to both high- and low-risk participants on the core cognitive feature of eating disorders. Clinical Psychologist, 14, 62–69. Wilksch, S. M. (2013). School-based eating disorder prevention: A pilot effectiveness trial of teacher-delivered Media Smart. Early Intervention in Psychiatry. doi: 10.1111/eip.12070 Wilksch, S. M., Tiggemann, M., & Wade, T. D. (2006). Impact of interactive schoolbased media literacy lessons for reducing internalization of media ideals in young adolescent girls and boys. International Journal of Eating Disorders, 39, 385–393. Wilksch, S. M., & Wade, T. D. (2009). Reduction of shape and weight concern in young adolescents: A 30-month controlled evaluation of a media literacy program. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 652–661. Wilksch, S. M., & Wade, T. D. (2013). Life Smart: A pilot study of a school-based program to reduce the risk of both eating disorders and obesity in young adolescent girls and boys. Journal of Pediatric Psychology. doi: 10.1093/jpepsy/jst036 Yager, Z., & O’Dea, J. (2010). A controlled intervention to promote a healthy body image, reduce eating disorder risk and prevent excessive exercise among trainee health education and physical education teachers. Health Education Research, 25, 841–852.
