Eating Disorder Prevention: Part of a Good Education

Dianne Neumark-Sztainer, Ph.D., M.P.H., R.D., is an associate professor in the Division of Epidemiology, School of Public Health and an adjunct professor in the Department of Pediatrics at the University of Minnesota. Neumark-Sztainer is principal investigator of Project EAT, which examines eating patterns and weight-related concerns among nearly 5,000 adolescents. She is on the board of directors for the Academy of Eating Disorders and serves on the Clinical and Scientific Advisory Council of the National Eating Disorders Association.

Q. Why is prevention our best hope for lowering the prevalence of eating disorders in American youth?

A. Eating disorders are multi-faceted, involving many problematic behaviors, beliefs and symptoms. They’re also multi-factorial — that is, several risk factors conspire to make them possible.

Once someone has an eating disorder, we often say that it takes on a life of its own. The longer it persists, the more intensive the intervention has to be, and the smaller the chances of successful treatment. So our best hope in controlling eating disorders is to prevent those risk factors and problems from ever developing. Or, when we can’t do that, to identify and treat them before they progress.

Q. Are all eating disorders the result of the same risk factors?

A. No, but three types of risk factors tend to be involved: personal traits, such as poor body image and low self-esteem; socio-environmental factors, such as persistent messages that super-slim women and lean, muscular men are most attractive; and behavioral factors, such as dieting and binge eating. (1)

Q. Recent studies suggest a genetic predisposition to eating disorders. Are some people fated to develop them?

A. No. Even though there’s a great deal of debate as to whether eating disorders are primarily genetic or primarily environmental, there’s still widespread agreement that there’s never only one cause. The realization that there may be a predisposing factor we can’t control should make us more vigilant about controlling the others.

Q. If a teen at a healthy weight says she’s going on a diet because she’s “too fat,” is that cause for concern?

A. Yes. You should be concerned and find out what’s really going on. Our society’s belief that thinner females are more attractive has made it typical for girls to be dissatisfied with their bodies, a problem we call “normative discontent.” So her dissatisfaction is normal only in the sense of being typical, not of being natural or healthy. In fact, strong body dissatisfaction is one of the best indicators of risk for developing an eating disorder. Actually, just hearing my daughter say “I’m going on a diet” would be enough to concern me, since I want her to accept herself for who she is and feel comfortable with her body. Further, most teens who develop an eating disorder don’t do so without dieting first.

Q. Is that because dieting can cause an eating disorder? Or is there something wrong before you diet?

A. It’s not clear; possibly both. Dieting doesn’t lead to an eating disorder in every teenager, not even most teenagers. But if you’re vulnerable, let’s say you have low self-esteem and lack a sense of control, you might go on a diet and start receiving compliments on how you look and begin to feel that you are able to gain control over this area of your life. The dieting may serve to trigger an eating disorder, which then seems to take off on its own.

Q. Are there strategies besides dieting that we think of as good for obesity control but that can trigger a disorder?

A. Yes, and program planners have to be aware of these. Planners often assume that it’s appropriate to have overweight people be dissatisfied with their bodies, to encourage close monitoring and restriction of both type and quantity of food and to have weight reduction as the primary goal.

However, placing the focus on a child’s excessive weight and less-than-OK body may place that child at risk for unhealthy weight control behaviors. Ironically, individuals who engage in behaviors such as meal skipping or severe food restrictions may end up being very hungry and start overeating, which can actually place them at risk for weight gain.

Q.Is there any way to discourage both obesity and eating disorders?

A.We are working toward this type of approach and have had some success in addressing a broader spectrum of disordered eating behaviors and weight-related disorders than is usually done. This includes not only full-blown eating disorders, but also obesity, anorexic and bulimic behaviors, unhealthy dieting, and unhealthy eating behaviors. (6) For example, we have developed an obesity prevention program for adolescent girls that also works toward the prevention of unhealthy dieting and the promotion of a positive self-image.

Q. What does this approach entail?

A. At the student level, we focus on healthy behavioral change, not dieting or weight loss. We use increased self-acceptance, not self-rejection, as a catalyst for change. If we can get students physically active, eating fruits and vegetables, not drinking too much soda pop or eating too many sweets, limiting fat consumption, not overeating for emotional reasons, they should never even need to think about weight control. If they start off overweight, they may lose weight or prevent further weight gain without having to diet. At the environmental level, we focus on students’ behavioral change — revising school food policies so that cafeterias and vending machines provide healthy, attractive foods, not soda pop. It means integrating information about weight management and nutrition into physical education, health and biology classes. It means involving a wider range of children in recreational sports and making fewer competitive activities available.

Q. What children should be in school-based prevention programs?

A. So many of our youth are displaying some type of eating or weight-related disorder — obesity, unhealthy eating practices, unhealthy weight control practices, body dissatisfaction or a full-blown eating disorder — that we need to be addressing these conditions with all school children, both boys and girls.

All children should participate in what we call a primary prevention program that fosters healthy attitudes and behaviors. Students at particular risk of developing eating disorders should also participate in more intensive prevention activities at the school.

Students found to have eating disorders should be referred for specialized help.

Q. At what age should eating disorder prevention start?

A. At a very young age, with ongoing reinforcement. The early messages can be as simple as learning how to feel good about your body, how to handle teasing, how not to tease others.

Q. Studies have shown that a few minutes of exposure to models or celebrities with “ideal” bodies can make a person feel less content with his or her body. Do repeated messages reinforce that feeling?

A. Yes. Anne Becker’s study of young people in Fiji is a classic example. She looked at weight-related concerns before and after television, with its Western ideals, was introduced. After TV arrived, many more youths were dieting and expressing body dissatisfaction and had eating disorders.

Q. Is there any way to protect children from these media messages?

A. We can help our children see those messages for what they are so that they are less vulnerable to them, and the children can consciously reject them.

We ran a program, “Free to Be Me,” where we took the first steps toward critical analysis of the media and media advocacy. (9) We worked with pre-teen Girl Scouts, who wrote letters to magazines or advertisers saying, “We liked your article for this reason” or, “We didn’t like your advertisement for this reason.” At the end of the program, we found that the girls were less likely to be passive recipients of potentially harmful media messages. They also felt more like they could have a positive impact on these messages. Many stopped reading a popular magazine that focuses primarily on teen fashion and beauty.

Q. Do peers have a role in prevention?

A. Yes. It’s really important to have a peer culture in which a child’s peers are aware of the kinds of things they’re saying, and aware of their impact. Also, if they see that a friend has a problem, they can let the friend know they care, point out specific behaviors that concern them. Then they should turn to an adult who can do something — a teacher, a nurse, a parent. Kids should never feel that by taking action, they are betraying their friend.

Symptoms and Consequences of the Major Eating Disorders

Bulimia Nervosa (10)

Major Symptoms: Binge eating (eating large quantities of food in short periods of time), often in secrecy, while feeling out of control and without regard to hunger or fullness. Following binges with one or more compensatory behaviors, such as purging (self-induced vomiting, laxative or diuretic abuse), fasting or compulsive exercise. Extreme concern with weight and body shape.

Health Consequences: Heart irregularity or failure due to electrolyte imbalances and dehydration; gastrointestinal problems, such as stomach rupture, esophageal inflammation or rupture, irregular bowel movements and ulcers; tooth decay and staining.

Anorexia Nervosa (7)

Major Symptoms: Refusing to maintain body weight at or above a minimally normal weight for height. Extreme concern with weight and body shape. Intense fear of weight gain. Feeling fat despite dramatic weight loss. Loss of menstrual periods in girls who have reached puberty.

Health Consequences: If no purging behaviors are present: muscle loss and weakness; slowed heart rate and low blood pressure, due to weakening or loss of heart muscle; osteoporosis; severe dehydration with possible kidney failure; fatigue and general weakness; dry hair and skin; hair loss on head but growth of downy hair (lanugo) all over body. If purging is present: add consequences listed under “bulimia nervosa.”

Binge-Eating Disorder (11)

Major Symptoms: Binge eating, as in bulimia nervosa. Feelings of shame, disgust or guilt after a binge (but no compensatory behaviors).

Health Consequences: Same as obesity in general, including increased risk of type 2 diabetes, hypertension and heart disease.

For More Information
The National Eating Disorders Association warns that “Prevention efforts will fail, or actually encourage eating disorders, if they concentrate solely on warning the public about the signs, symptoms, and dangers of eating disorders.” (12) Such a focus, experts explain, ignores the underlying factors that need to be addressed. In addition, it may inadvertently glamorize eating disorders and provide details regarding unhealthy behaviors that lead to, instead of discourage, their adoption. (13)

For more information, as well as suggestions for what to do and where to go when you suspect an eating disorder, visit the Web sites of the National Eating Disorders Association, the National Institutes of Health and the Academy of Eating Disorders.

Prevention Tips

Concerned adults who want to know what to do to prevent eating disorders can visit the Web site of the National Eating Disorders Association, where they’ll find two sources of practical prevention tips.

“Ten Things Parents Can Do to Prevent Eating Disorders” challenges parents to closely examine their dreams and goals for their children and to pass on healthy, positive attitudes. (15)

“Prevention Guidelines and Strategies” lists 50 things that parents, educators, coaches and others can do to help protect young people from eating disorders, including 21 pointers specifically developed for men and fathers. (16)

Interview:

Good Sports: Preventing Anorexia Athletica

Roberta Trattner Sherman, Ph.D., is cofounder and codirector of the Eating Disorders Program at Bloomington Hospital in Bloomington, Ind., and serves as a clinician and consultant to the Indiana University Department of Intercollegiate Athletics. She is co-author of the books Bulimia: A Guide for Family and Friends and Helping Athletes with Eating Disorders and co-chair of the Athlete Special Interest Group of the Academy for Eating Disorders. She serves on the editorial board of Eating Disorders: The Journal of Treatment and Prevention.

Q. Why isn’t anorexia athletica as well known as anorexia nervosa or bulimia nervosa?

A. Anorexia athletica isn’t a formal psychiatric diagnosis, the way anorexia nervosa or bulimia nervosa is. Instead, this eating disorder — which is unique to athletes — gets grouped under “eating disorders, not otherwise specified” for diagnostic purposes. So many people know of the problem, but call it something else — for example, “female athlete triad” when it affects a woman, or simply “anorexia.”

Q. Are anorexia athletica and anorexia nervosa similar?

A. The criteria for anorexia athletica recommended by the researcher who coined that name, Jorunn Sundgot-Borgen, are similar to those for anorexia nervosa, but not always as severe. For example, body weight must be 15 percent below the expected level for anorexia nervosa, but only 5 percent below expected for anorexia athletica.

Q. What are the other defining characteristics of anorexia athletica?

A. According to Sundgot-Borgen, excessive fear of becoming obese, gastrointestinal complaints, restriction of caloric intake and the absence of a medical or mood disorder that could explain weight loss.

Q. Is compulsive exercise the same as anorexia athletica?

A. No, compulsive exercise is activity that the individual feels compelled to do and is often related to what we call “compensatory behavior.” The goal is to reduce anxiety by burning off what the person believes is excessive calorie intake. Compulsive exercise is very often, but not always, a feature of anorexia athletica.

Q. Are athletes more or less vulnerable than the general population to eating disorders?

A. We don’t have much data, but what we have indicates that eating disorders are at least as common, if not more common, among athletes than in the general population.

Q. Are athletes who develop anorexia athletica and other eating disorders vulnerable before getting involved in athletics? Or do they come to athletics with a fairly clean slate, and things go wrong as a result of the activity?

A. Athletics will not create an eating disorder in a person who is not already at risk. But it’s possible for athletics to trigger an eating disorder in a person who is already vulnerable.

Let’s say a coach says, “You need to lose weight. You should go on a diet.” We know that dieting is the No. 1 risk factor for developing an eating disorder. One kid will shrug his or her shoulders and say, “I’m OK just the way I am.” But a vulnerable kid is going to take the same information and run with it to the extreme.

Unfortunately, just by looking at a child, you might not see the vulnerability.

Q. Are there any clues that a child is vulnerable?

A. Low self-esteem, a history of being teased a lot about weight or shape, a sense of self-worth that’s tied up in body appearance or level of accomplishment — any of these can be red flags for high risk.

A child who has “all or nothing” thinking, only seeing extremes, is at risk; if she gets the message that fat is bad, she’ll think, “If I don’t want to be fat, then I have to be really thin.” Kids who have a hard time talking about conflict, emotions, depression or stress are vulnerable, too.

Q. Are certain activities particularly likely to trigger an eating disorder?

A. Any sport that emphasizes thinness or small size, either for appearance or for performance, is a more likely trigger. Sports that are judged, like gymnastics, versus refereed, like basketball, carry more risk. Any sport where there’s a weight class, like wrestling or rowing, is higher risk.

Q. Let’s say you have a child who seems to be at risk for developing an eating disorder and wants to learn gymnastics. Would you discourage, even prohibit participation?

A. That depends on the circumstances. If a kid is at super high risk and I know that the coach is very competitive and prefers very slight build, I would strongly discourage participation and steer the child in another direction.

But if the child wasn’t high risk, and I knew the coach saw the activity as a way for children to have fun regardless of their build, I might say OK and monitor the situation closely.

Q. If a child shows signs of being headed for an eating disorder while engaged in a physical activity, is it necessary to stop the activity?

A. Sometimes a sport is so intimately related to the eating disorder that it’s almost impossible to get well unless participation stops.

But that’s not always the case. For example, if the real trigger is too much stress in the child’s life, it may be possible to reduce that stress without stopping the activity. Of course, if the child’s physical health has been compromised, sport participation may need to be curtailed until the physical problem is remedied.

Q. Are there things to avoid as we encourage children to be more involved in sports, things that might push the vulnerable children into full-blown eating disorders?

A. Several. We have to be aware of “all or nothing” thinking. We seem to understand moderation where sleep is concerned, realize that a certain amount is safe but too little or too much is no good, and discourage the extremes. But we don’t seem to grasp moderation when it comes to activity or exercise.

We also need to downplay getting involved in athletics for the sake of excelling or winning and emphasize getting involved for health and enjoyment. And we have to become more tolerant of a broader range of body sizes and shapes.

Q. You mentioned that dieting is a major risk factor for eating disorders. What about gently approaching the subject of weight loss if children are overweight or obese?

A. Dieting and weight loss are inappropriate topics if we want to protect our children from eating disorders. I would say the same thing to all the children, regardless of weight: “Let’s respect and value our bodies, treat them well. That means giving them exercise, so let’s think of some fun ways to do that. And let’s talk about giving ourselves nutritious food.”

I’d explain that “giving ourselves nutritious food” means making good food choices, getting a good number of servings each day of different kinds of food. But not measuring food or counting calories. And making those choices because of the good things they do, things that have nothing to do with weight, like helping develop strong muscles.

If children engage in good exercise and good nutrition, the excess pounds will take care of themselves.

Q. Should dieting and weight loss be taboo topics even when children are involved in competitive sports where appearance affects scoring?

A. Yes. When they become more seriously competitive, the coach can say, “You’re moving to a level where you have to decide whether or not you want to be an elite athlete. If you do, you’re going to have to treat your body with the utmost care and respect. So, among other things, I want you to work with the dietitian and get on a meal plan.” And the resulting weight and percent body fat should be treated as what’s right for that child.

Q. Is this part of becoming more tolerant of differences in body sizes and shapes?

A. That, and treating each child as an individual. I encourage coaches and athletes alike to see past our stereotypes, tell them that not everyone performs best at the same weight or percent body fat. I often use examples of excellent athletes who are outside the traditional boundaries. One woman I spoke with, a swim coach, told me she was always the biggest one at swimming competitions. That’s potentially embarrassing; swimmers wear skimpy suits and bend over on the blocks. But you know what? She won several medals in international competition.

Q. So performance should trump appearance?

A. That’s the idea. And that brings up another thing coaches need to change: assuming that weight is the problem when athletes don’t perform well. Instead, a coach should look at physical conditioning, strength training and skill attainment. Be sure that mental and emotional conditioning is good. Looking at those things won’t put athletes at risk; fixating on weight will.

Q. You mentioned working with a dietitian. Do you recommend that?

A. We work with dietitians all the time, because many coaches simply don’t have a correct concept of what a healthy weight or healthy eating is.

Dietitians understand that you’re born with a certain type of body. It can be modified, but it’s not worth aiming for some ideal if the way to get there is unnatural or unhealthy.

Q. Like taking steroids?

A. Exactly. We know that if elite athletes take steroids, they can run faster, jump higher. But we have decided, as a society, that steroids put the user at too much physical risk.

We should feel the same way about starvation: It’s unacceptable because of the health risks involved. In the short run, occasionally it will enhance performance. But in the long run, never. Starving children don’t develop normally. Their bones become brittle, their muscles break down, their internal organs get damaged and so on.

Q. What are some other things that coaches can change to help protect young athletes from eating disorders?

A. Eliminate group weigh-ins, which create competition and can be very humiliating and degrading. Only weigh athletes when there is a valid reason, such as determining weight class or checking for dehydration during hot-weather practice sessions.

Also, discourage what we call unhealthy subcultural aspects among the athletes, including body talk. For example, discourage wrestlers in locker rooms who brag about how much weight they can cut before competition and in how short a time.

Q. Do physical education teachers and coaches get trained on eating disorders?

A. Unfortunately, teachers and coaches below the level of elite competition may hear little or nothing about eating disorders. Their training needs to include more about prevention and detection.

As things are now, coaches almost never ask children about things they should know, in order to spot the ones at high risk or who already have problems.

Q. Is lack of awareness responsible?

A. I think discomfort factors in, too. If a male coach isn’t comfortable asking about menstrual cycles, he won’t know if a young woman has gone months without one, which is a danger signal.

One way to get around that is to tell the team, “I’m really concerned about your health. You’re going to perform best if your health is at its best. And one of the indicators we use for good health is your menstrual cycle. You don’t have to report to me every month, but if you go two or three months without a period, you need to let me know, so we can be sure that everything is OK.”

Q. It seems that the traits often valued in athletes are similar to signs of risk for eating disorders. Does that make it hard to spot children at risk?

A. Yes, the traits can be similar. So when an athlete trains excessively, denies pain, complies with every request from the coach, accepts nothing short of perfection and is willing to restrict food intake dramatically to attain a certain build, you have to ask: Is this a good athlete? Or someone with a serious problem? You can’t know until you find out what makes that child tick.

Athletes and Eating Disorders: A Parent’s Guide to Risk Reduction

Athletic involvement, while broadly encouraged for young people, can be a place where eating disorders emerge. “Concerned parents often wonder what to look for that might be a warning sign that an eating disorder could develop in their teenager,” notes Pauline S. Powers, M.D., director of the University of South Florida College of Medicine’s Psychosomatic Medicine Division and co-author of the National Collegiate Athletic Association Study on Athletes and Eating Disorders. Powers encourages parents of teen athletes to watch for these 12 red flags: (14)

1. Excessive weight loss after beginning a sport if a teen falls off his or her usual growth curve as a result.

2. Re-setting weight goals — that is, revising a weight goal downward after an initial modest weight-loss goal has been achieved.

3. Loss of menstrual periods. Whether due to stress or a eating disorder, loss of menses in adolescence can lead to early osteoporosis. Parents should find out what’s wrong.

4. Excessive (compulsive) exercise. If a teen exercises more than is expected by his or her sport or level in that sport, parents should talk with the child or the coach.

5. Use of exercise to purge. Regular exercise after eating may indicate that a child is exercising to burn off what is perceived as excessive food intake.

6. Inappropriate dieting behavior. Parents should be alert for extreme or unusual dieting practices — including use of diet pills, fat-burning aids, laxatives and diuretics — in young athletes.

7. Intense use of exercise or pursuit of a sport after a significant disappointment, such as a breakup with a boyfriend or girlfriend.

8. Avoidance of tasks of adolescent development. A teen who is so preoccupied with exercise, to the point that he or she is no longer socializing, achieving in school or engaged in the process of emancipation from parents, may be using exercise as an inappropriate solution to a developmental problem.

9. Negative comments from a coach or trainer. If a teen’s coach makes negative comments about weight, shape or performance, parents should ask the coach to refrain from such remarks.

10. The belief that weight loss in itself will improve athletic performance.

11. Participation in high-risk sports. Before parents let a teen get involved in sports where both performance and appearance are judged, they should find out what the coach’s attitudes are and how much he or she knows about eating disorders.

12. Unrealistic sport achievement expectations. If a child wants to become an elite athlete, parents, coach and child should work together to get a realistic appraisal of his or her potential. Parents should encourage that goal only if the potential is there.

The Research

Bibliography

1. Irving, L.M. and Neumark-Sztainer, D. (2002) Integrating the prevention of eating disorders and obesity: Feasible or futile? Preventive Medicine 34, 299-309.

2. National Alliance for the Mentally Ill. NAMI HelpLine fact sheet: Anorexia nervosa.

3. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Mental Health. (2001) Eating disorders: facts about eating disorders and the search for solutions.

4. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. (2001) Binge eating disorders.

5. KidsHealth. (2001) Eating disorders.

6. Neumark-Sztainer, D. (1996) School-based programs for preventing eating disturbances. Journal of School Health 66(2), 64-71.

7. National Eating Disorders Association. Anorexia nervosa.

8. Neufield, S. Eating disorders linked with risky behavior.

9. Neumark-Sztainer, D., Sherwood, N.E., Coller, T and Hannan, P.J. (2000) Primary prevention of disordered eating among preadolescent girls: Feasibility and short-term effect of a community-based intervention. Journal of the American Dietetic Association 100(12), 1466-1473.

10. National Eating Disorders Association. Bulimia nervosa.

11. National Eating Disorders Association. Binge eating disorder.

12. National Eating Disorders Association. Eating disorders can be prevented!

13. Thompson, R.A. and Trattner Sherman, R. (1999) Athletes, athletic performance, and eating disorders: Healthier alternatives. Journal of Social Issues 55(2), 317-337.

14. Powers, P.S. (1999) Athletes and eating disorders. Eating Disorders: The Journal of Treatment and Prevention. 7, 249-255.

15. National Eating Disorders Association. 10 things parents can do to prevent eating disorders.

16. National Eating Disorders Association. Prevention guidelines and strategies.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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