Sunday, December 17, 2006

Deterring Unhealthy Habits or Perpetuating Them? Eating Disorder Prevention Programs through the Lens of Social Behavioral Science - Heidi Bornstein


In the past 15 years eating disorder awareness has sky-rocketed, resulting in a myriad of public health initiatives to curb to the epidemic. Most of these programs have been aimed at adolescent and post-adolescent girls as they have a high incidence rate of eating-related illness and can be easily targeted through the school system. As such courses and workshops are being held at universities; help-lines are advertised at the end of popular television programs; parenting websites are posting warning signs; and the federal government has allocated funds for prevention programs at the junior high and high school levels. Despite these efforts the prevalence of eating-related illness is still on the rise. In 1994 between 0.5 and 3% of all Americans suffered from some type of eating disorder (1). Today, as many as 3.7% of females suffer from anorexia nervosa, 1.1-4.2% of females suffer from bulimia nervosa, and 2-5% of males and females suffer from binge eating disorder (2).

In the following essay I analyze eating-disorder deterrence tactics used through the perspective of social behavioral science. I propose that public health acts of omission and commission have stunted the efficacy of prevention programs, and in some cases, have actually made the problem worse. Finally, I use social behavioral theories to suggest strategies for developing successful prevention programs in the future.

Part 1: The Media’s Influence on Dieting Behaviors

Numerous studies have shown that the media can significantly manipulate public opinion, influencing everything from purchasing patterns to the popularity of certain politicians. Perhaps the most notorious power of the media, however, is its ability to determine the norms of physical attractiveness (3). Public health academics have pounced on this notion, conducting research and writing dissertations on the evils of Hollywood imagery. The “thin-ideal” modeled in fashion magazines has been linked to the bulimia; the portrayals of thin and fat television characters has been associated with body dissatisfaction; and the Western World’s obsession with increasingly thin celebrities has been named a contributing factor to anorexia (1,4).

In response to these theories and findings most eating-disorder prevention programs have a component specially aimed to counter negative mass media messages. In most cases, the Hollywood ideal is scrutinized by the instructors who proclaim that the body types found on the screen and in magazines cannot be healthily attained by most people. The purpose of the program is to change the students’ perception of normal, and to educate them about the health risks associated with eating disorders (4). The notion is that given all the facts, individuals will react in a rational manner and abstain from behaviors which will endanger their health. The problems with these assumptions are two-fold: First, humans are not always rational. Second, a strong focus on media images can perpetuate unhealthy norms as well as countering them.
My high school health education class is a great example of a media-based prevention gone awry. Among other celebrity confessions, we watched Princess Diana admit to bulimic tendencies over and over again on a 30-inch screen. My well-meaning teacher kept exclaiming, “don’t be ashamed; it can happen to anyone!” Regrettably, not everyone received the intended message from these viewings. This became quite apparent on the last day of class when we all shared our thoughts and views regarding the course curriculum. One student said something to the effect of, “if throwing-up got Diana a prince, it can certainly land me a football player!” Several girls nodded their heads. Clearly, our instructor was not trying to endorse bulimia. By presenting a beloved heroine with an eating disorder, she was trying to create an environment where we could discuss our own dieting issues without feeling ashamed. So what went wrong?

The Social Behavioral Perspective

Thanks to tabloids, talk shows, blogs, and YouTube, the line between reality and television is becoming increasingly blurred. Celebrities are no longer mystical creatures who display their perfect figures and stay silent; many of today’s stars openly share their own experiences with fighting the fat, often teaching media consumers how to stay thin through drastic measures. This phenomenon can be explained through the tenets The Social Learning Theory, which states that people learn by observing the behaviors of others as well as the resulting outcomes of those behaviors. According to the doctrine, the more an individual respects the model, the more he or she is likely to mimic that model’s behavior, particularly when it results in an outcome which the individual finds desirable (5).

In developed societies, the mass media serves as a conspicuous and powerful model of behavior (6). Consequently, when a celebrity partakes in a dangerous behavior, or is portrayed as partaking in a dangerous behavior, she is endorsing that behavior whether she means to be or not. Teenagers are particularly prone to idolizing celebrities and mimicking their behavior. For example, say that 15-year-old “Sheila” sees her favorite actress confess to an eating disorder on a popular talk show. First, Sheila learns that this beautiful and talented woman has been throwing-up after calorie-heavy meals in order to stay trim for her sitcom role. The actress looks healthy enough, and is being praised by the talk show host for her courage in coming forward. In an attempt to be more like her role model, the adolescent begins purging twice a day, and looses 10 lbs that month. Friends and family reinforce the behavior by commenting on how great Sheila looks.

Implications for Future Prevention Efforts

How can public health officials offset these negative media messages? First, they must train health educators to use social behavioral theories as a tool to help discriminate between positive and negative media images. Dangerous behaviors can often appear sexy, exciting, and worth the risks. Therefore, the utilization of magazine articles and talk show clips reflecting unhealthy habits should be kept to a minimum. Second, public health officials should invest more heavily in media campaigns featuring popular icons partaking in healthy behaviors. The mainstream media tends to focus on individuals’ bad habits, as it is more profitable. This can create the illusion that everyone behaves in an unhealthy manner. Try doing a Google search on “healthy celebrities.” You will find a bunch of sites with titles such as “do these celebs look healthy?” featuring emaciated pictures of Nicole Richie and Lindsey Lohan. This is quite disheartening. Why not create a website that actually features famous people doing things that are good for their bodies? Though these campaigns are unlikely to ever drown out the negative images shown in main-stream media, they at least give viewers a second option for behavior modeling and counter the perception that unhealthy habits are the cultural norm.

Part 2: The Deleterious Results of Current Education Approaches

Obviously, the media is not independently responsible for the high volume of eating-disorders in the Western World, and consequently, is but a single component of most prevention curriculums. Currently, most initiatives take on one of two forms: traditional or new wave. The traditional program is purely informational. It out-lines risk factors for eat-disorders, describes warning-signs and symptoms, emphasizes the prevalence of eating-disorders among certain populations, and details the health risks associated with the individual behaviors. The new wave initiatives have focused more on social relationships and have therefore experimented with interactive approaches, such as peer education and support. Regrettably, both the traditional and non-traditional approaches have done more harm than good, often perpetuating the very norms they intend to deter. The following three studies provide brief examples of prevention gone wrong.

Program A) An orientation program at a prominent California university sought to provide new students with a better understanding of the dangers of eating disorders. The workshop brought in upperclassmen that had suffered from such conditions and had them describe their experiences to the freshmen. A follow-up study found that those students indiscriminately assigned to participate in the prevention course later had a higher incidence of disordered eating in than those students who were not chosen to participate (7).

Program B) In Canada, an eating-disorder prevention study was conducted at a junior-high school in Ontario. Three hundred 7th and 8th grade girls were randomly assigned to a control group or a peer-support group developed to foster body esteem. Contrary to the hypothesis, researchers found that the girls randomly selected to participate in the active intervention were more likely to develop unhealthy attitudes and behaviors towards their weight and dieting than their peers in the control group (8).

Program C) Another research group studied the effects of an eating disorder prevention program in Norway, where random middle-school classes took part in a traditional eating disorder prevention course as part of their health curriculum. As 10th graders, the 107 graduates of the program were surveyed and interviewed. Almost all the students remembered the program accurately, and the vast majority of students strongly agreed that the program was valuable and informative. Their eating behaviors, however, told a different story. In fact, when compared to their classmates, the interviewees disproportionately attempted to loose weight, and related thinness with perfection. Furthermore, while the students believed the course provided them with the necessary tools to recognize extreme dieting behavior in their peers, they believed their own excessive dieting behaviors were under control (9).

The Role of Social Identity and other Teen Tendencies

The Theory of Social Identity offers an explanation as to why Program A and Program B failed so completely in their missions. According to this theory, part of an individual’s identity is derived from her group memberships. In essence, the individual will look to her peers, the in-group, to differentiate between appropriate and non-appropriate actions and views which she will then incorporate into her own behavioral schema (1). Keeping these principles in mind, it seems likely that the upperclassmen in Program A served as representatives of the in-group, and inadvertently gave the message that disordered eating is a cultural college norm which can be conveniently terminated by graduation. Similarly, it would seem that the peer interactions in Program B popularized the dangerous dieting behaviors it was suppose to deter. The researchers hypothesized that a few influential girls who were exhibiting unhealthy attitudes and behaviors were able to disseminate these negative feelings to their impressionable group-mates (7). In both these cases the peer groups were simply more influential than the educational messages, a common occurrence when dealing with teenagers.

Program C also failed to properly consider the psychological tendencies of adolescence. First, the course introduced new weight-loss ideas such as vomiting and laxative abuse without effectively communicating all the dangers involved. Those dangers that were addressed mainly consisted of long-term complications, which are not foremost on a young person’s mind. Vanity issues, such as rotting teeth, hair loss, and weird hair growth, were usually omitted, though most eat-disorders reflect some desire to be physically attractive. Second, the program did not take into account the risk-taking, rebellious nature of teens, or their propensity to partake in attention-seeking behaviors (9). These over-sights led to a program that did more promoting than preventing.

Suggestions for Restructuring Initiatives

It is imperative that public health officials play a larger role in school eating-disorder prevention programs by educating future program instructors. If prospective initiatives are to be more helpful than harmful, the basic tenets of social and behavioral theories cannot be dismissed. In the future, eating-disorder prevention programs should:

- Avoid in-depth descriptions of extreme weight-loss tactics. This approach simply promotes new ideas and normalizes old ones.

- Provide a certain amount of supervision over discussion sections to ensure that the right messages are being reinforced.

- Focus more on positive health behaviors than negative health behaviors whenever possible.

- When discussing health risks, emphasize the imminent dangers that will resonate most with the audience.


Educational efforts to prevent eating-disorders have generally been unsuccessful despite large investments of both time and money. Social and behavioral theories offer a myriad of explanations for these failures, as well as potential strategies for future endeavors. Concepts from The Social Learning Theory and The Social Identity Theory provide particularly good insight for developing effective prevention workshops for the adolescent audience, though hundreds of other worthy concepts exist. The key is that public health officials and educators must be open to these ideas in order to utilize them. By actively seeking out social science resources, and using these resources to experiment with new initiatives, public health officials can eventually develop a model for successfully fighting eating disorders.

Works Cited:

1) Harrison, Kristen. Joanne Cantor. “The Relationship Between Media Consumption and Eating Disorders.” The Journal of Communication. 47, 1. Winter 1997.
2) Ice, Susan. M.D. “Statistics.” Eating Disorders Coalition. accessed 12/3/06.
3) Anastasio, Phyllis A. Karen C. Rose, and Judith Chapman. “Can the Media Create Public Opinion? A Social-Identity Approach.” American Psychological Society. 8, 5. October 1999.
4) Harrison, Kristen. “The Body Electric: Thin-Ideal Media and Eating Disorders in Adolescents.” The Journal of Communication. 50, 3. Summer 2000.
5) Ormond, J.E. Human Learning. Upper Saddle River, Prentice Hall: 1999.
6) DeFleur, Lemvin L. Theories of Mass Communication (fifth edition). London, Longman Inc.: 1989.
7) Mann, T., S. Nolen-Hoeksema, K. Huang, D. Burgard, A. Wright, K. Hanson. “Are two interventions better than none? Joint primary and secondary prevention of eating disorders in college females.” Health Psychology. 16, 3. May 1996.
8) McVey, Gail L., Melissa Lieberman, Nancy Voorberg, Diana Wardrope, Elizabeth Blackmore, and Stacy Tweed. “Replication of a Peer Support Program Designed to Prevent Disordered Eating: Is a Life Skills Approach Sufficient for All Middle School Students?” Eating Disorders. Taylor & Francis Inc.: 2003.
9) Rosenvinge, Jan H. “Is Information about Eating Disorders Experienced as Harmful? A Consumer Perspective on Primary Prevention.” Eating Disorders. Taylor & Francis Inc.: 2004.


Anonymous Anonymous said...


7:43 AM  
Blogger Michael Siegel said...

This is an outstanding paper - Heidi - and a great way to start out the blog. It brings up some very important considerations that we often ignore in school health education, and it transcends this issue.

I've observed a lot of drug education programs in schools where they bring in upperclassmen like successful athletes who have used drugs and then became drug-free. While intended to deter drug use, the message sent to students is that if you use drugs, you will end up being successful and you can always stop using them, just like these athletes.

Thanks for paving the way!

8:08 AM  
Blogger Leah said...

This is a great critique of current eating disorder prevention programs. As a health educator at the college level- I will keep this in mind as we prep our eating disorder presentation for next year.

8:48 AM  
Anonymous Stephanie said...

Hi Heidi,

Good job on your paper. It's a great topic to write about, since eating disorders are definitely on the forefront of the public agenda, especially given the recent deaths of top fashion models caused by anorexia and bulimia.
Another thing to think about is the lack of self-esteem as a risk factor for developing an eating disorder. I am not familiar with the research in this area, but I wonder if this topic has ever been explored. The reason I bring it up is because the women I've known throughout my life who have become afflicted with eating disorders had extremely low self- esteem and little or no sense of self worth. In addition, I believe the concept of control could have a significant influence on eating disorders. Perhaps some of these women are looking for something in their lives which they can personally drive and have control over, and if that is eating (or lack thereof), they are successful in fulfilling that need (especially, as you stated, when they see their role models doing it). Perhaps public health could also address the issues of self-esteem and control when intervening in the problem. I look forward to continuing the discussion on this topic. Quite interesting.

11:35 AM  
Anonymous Anonymous said...

Hi Stephanie,
Yor are absolutely right- self-esteem and control issues are an integral part of an eating-disorder prevention program, and there is an abundance of literature supporting the importance of these concepts. Perfectionism is also linked to anorexia, and being a "pleaser" is linked to bulimia. The problem lies with how these concepts are applied to the curriculum. In hindsight, I should have made ths much more clear, and given credit for the good things that these programs are doing. Thanks for the feedback!

7:56 AM  

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