BRIDGING THE PREVENTION GAP: PREVENTION PROGRAMS AND SHARED
RISK FACTORS FOR OBESITY, EATING DISORDERS, AND DISORDERED EATING
by
Emily Hemendinger
BA, Hartwick College, 2012
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2015
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Emily Hemendinger
on
April 22, 2015
and approved by
Essay Advisor:
Mark Friedman, PhD
______________________________________
Assistant Professor
Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Linda Ewing, PhD, R.N.
______________________________________
Assistant Professor
Psychiatry, Psychology, and Pediatrics
Department of Psychiatry
School of Medicine
University of Pittsburgh Medical Center
ii
Copyright © by Emily Hemendinger
2015
iii
Mark Friedman, PhD
BRIDGING THE PREVENTION GAP: PREVENTION PROGRAMS AND SHARED
RISK FACTORS FOR OBESITY, EATING DISORDERS, AND DISORDERED
EATING
Emily Hemendinger, MPH
University of Pittsburgh, 2015
ABSTRACT
Obesity is an ever-growing problem in America that places a heavy burden on our
healthcare system and causes many health problems. Eating disorders, while not affecting as
large a proportion of the population as obesity, are the most deadly psychiatric illness and also
place a heavy burden on our healthcare system. Obesity and eating disorders are typically treated
as separate issues. Obesity is primarily a physical condition, while eating disorders are a physical
and psychological condition. However, a growing amount of research has shown that there are
links between obesity and eating disorders and that prevention interventions that target both have
the possibility of being more helpful than separate prevention efforts. Furthermore, obesity and
eating disorders have also been linked to disordered eating behaviors, such as excessive dieting
and fasting, using laxatives, purging, and weight cycling. Therefore the purpose of this paper is
to show that similarities between obesity and eating disorders/disordered eating exist and how
focusing on shared risk factors will facilitate prevention efforts.
This manuscript is divided into two main sections. Part I presents an overview of obesity,
eating disorders, disordered eating, and where these issues intersect. This section also provides a
theoretical background for understanding these issues and their prevention approaches. For the
iv
second part of this paper a critical literature synthesis on prevention approaches and methods was
done using PubMed and Google Scholar. After articles were collected and analyzed, a
comprehensive review of recent literature on obesity prevention, eating disorder/disordered
eating prevention, and combined prevention efforts was done.
This paper serves as a means of bringing to light the necessity of treating obesity, eating
disorders, and disordered eating as issues on a weight-related spectrum. The literature synthesis
can be used to guide public health officials in creating and implementing prevention programs
that address the shared risk factors for obesity and eating disorders/disordered eating.
v
TABLE OF CONTENTS
Part I
1.0 Introduction……………………………………......................................................................1
2.0 Background……………………………………………………………………………..........2
2.1 Obesity…………………………………………………………………………..........2
2.2 Eating disorders……………………………………………………………...............4
2.3 Disordered eating……………………………………………………………….......11
2.4 Relationship between obesity and eating disorders/disordered eating…….........13
2.5 Related theoretical models……………………………………………………........17
2.5.1 Affect/emotion regulation model…………………………………….......17
2.5.2 Biopsychosocial model………………………………………………........18
2.5.3 Brain reward pathway model………………………………………........18
2.5.4 Cognitive dissonance theory………………………………………….......19
2.5.5 Dietary restraint model………………………………………………......19
2.5.6 Dual pathway model………………………………………………….......20
2.5.7 Health belief model…………………………………………………….....20
2.5.8 Objectification/self-objectification theory…………………………........20
2.5.9 Problem-behavior theory…………………………………………….......21
2.5.10 Social-ecological model……………………………………………….....22
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2.5.11 Summary of theories……………………………………………….........22
2.6 Significance of this paper………………………………………………………......24
Part II
1.0 Methods………………………………………………………………………………….......27
2.0 Results………………………………………………………………………………….........28
2.1 Research on the prevention of obesity………………………………………….....28
2.1.1 General approaches to obesity prevention………………………….......28
2.1.2 Specific obesity prevention efforts…………………………………….....33
2.2 Research on the prevention of eating disorders/disordered
eating………………………………………………………………………………….....49
2.2.1
General approaches to eating disorder/disordered eating
prevention…………………………………………………………….....49
2.2.2
Specific eating disorder/disordered eating prevention
efforts……………………........................................................................52
2.3 Research on the prevention of obesity and eating disorders/disordered
eating.........................................................................................................................61
2.3.1
General approaches for combined prevention……………………….61
2.3.2
Specific combined prevention efforts………………………………....62
3.0 Discussion…………………………………………………………………………………..69
3.1 Potential uses……………………………………………………………………….73
3.2 Strengths and limitations………………………………………………………….74
vii
4.0 Conclusion………………………………………………………………………………….75
Appendix: Theoretical Models ……………………………………………………………….76
Bibliography……………………………………………………………………………………81
viii
LIST OF FIGURES
Figure 1: Affect/Emotion Regulation Model……………………………………………….....76
Figure 2: Biopsychosocial Model……………………………………………………………....76
Figure 3: Brain Reward Pathway Model……………………………………………………...77
Figure 4: Cognitive Dissonance Theory…………………………………………………….....77
Figure 5: Dietary Restraint Model………………………………………………………….....78
Figure 6: Dual Pathway Model………………………………………………………………...78
Figure 7: Health Belief Model……………………………………………………………….....79
Figure 8: Objectification/Self-Objectification Theory…………………………………….....79
Figure 9: Problem-Behavior Theory…………………………………………………………..80
Figure 10: Social-Ecological Model…………………………………………………………....80
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Part I
1.0 Introduction
Weight-related conditions (obesity, eating disorders, disordered eating) are a serious
public health problem because of their high prevalence among children and adolescents and their
adverse effects on growth, psychosocial development, and health outcomes (Neumark-Sztainer
& Hannan, 2000). Further, the American Journal of Public Health has labeled eating disorders
and disordered eating as the “blind spot” in the drive for obesity prevention. It indicated that
public health efforts to address obesity can no longer afford to ignore eating disorders,
disordered eating, and other related behaviors (Austin, 2011). Therefore the purpose of this
research is to compile and analyze recent literature on obesity, eating disorders, disordered
eating, stigma related to weight, and efforts to reduce obesity and prevent eating
disorders/disordered eating.
Research has already shown that there are links between obesity and eating disorders.
However, misconceptions about eating disorders/disordered eating have largely left public health
prevention and research possibilities unstudied. The information collected from this literature
synthesis will help the field of public health understand that the issue of obesity is not one-sided,
but actually on a spectrum of weight and food related issues. While obesity, eating disorders, and
disordered eating are different, they share common risk factors that allow them to be addressed
through similar prevention methods. This analysis endeavors to synthesize information in a novel
way, in hopes that the field of public health can look at these problems from an integrated
perspective. This literature synthesis will help to show that in order to prevent chronic illnesses
that increase healthcare burden, public health officials must stop singularly focusing on obesity
and instead start encouraging healthier lifestyles.
1
2.0 Background
2.1 Obesity
Obesity is a label for ranges of weight higher than ranges considered healthy. According
the Centers for Disease Control and Prevention, an adult who has a Body Mass Index (BMI)
between 25 and 29.9 is considered to be overweight and an adult who has a BMI of 30 or higher
is considered to be obese (2014). The CDC categorizes children and teens weight status using
percentile ranges based on epidemiologic data. A child is underweight if their BMI falls in a
percentile lower than the 5th percentile, a healthy weight if BMI is in between the 5th and 85th
percentiles, overweight if BMI is between the 85th and 95th percentiles, and obese if their BMI is
equal to or greater than the 95th percentile (2014). Obesity has been found to raise the risk of
death by 20-40% (Nguyen & El-Serag, 2010). Obesity has also been found to be associated with
increased risk for various chronic diseases including diabetes, hypertension, heart disease, stroke,
numerous digestive diseases, different types of cancer, and liver disease (World Health
Organization, 2015; Centers for Disease Control and Prevention, 2014; National Institutes of
Health, 2012; Nguyen & El-Serag, 2010).
Obesity is not caused by one factor, but a complex interaction of environmental, genetic,
and social factors that interact in various ways across individuals and lead to an imbalance
between energy intake and energy outtake (World Health Organization, 2015; National Institutes
of Health, 2012; Nguyen & El-Serag, 2010). Although obesity has been attributed to personal
choice and individual characteristics, the major contributor seems to be environmental factors.
The high costs of fruits, vegetables, and healthy foods, and the low cost of calorically dense
foods, are such environmental factors. Other environmental factors include the increase in
sedentary lifestyles, increase use of cars as transportation, low quality of parks, and the increase
2
usage of televisions and computers (World Health Organization, 2015; National Institutes of
Health, 2012; Nguyen & El-Serag, 2010). Gene mutations for body mass and bone structure are
genetic factors that contribute to obesity. Another genetic factor is a predisposition to diabetes.
Social networks are another factor that plays a role in the development of obesity (World Health
Organization, 2015; National Institutes of Health, 2012; Nguyen & El-Serag, 2010). According
to several studies on social networks, human interactions and whom one surrounds themselves
with can affect an individual’s health and body mass. For instance, the heavier one’s close
friends and family are, the more likely that person is to also be overweight. Social norms and
behaviors that are shared within a social network may be determinants of one’s weight and BMI.
For example when a waiter asks about dessert, some people may get dessert regardless of the
social norms of their group. However, others at a table may be influenced by those around them
(World Health Organization, 2015; Harmon, 2011).
The prevalence of obesity in the US has been rising, most notably in the past two
decades. In 1990, no states reported obesity prevalence rates greater than 15% and ten states
reported rates less than 10% (Nguyen & El-Serag, 2010). In comparison, the 2008 Behavioral
Risk Factor Surveillance System showed that five states (Alabama, Mississippi, Oklahoma,
Tennessee, and West Virginia) had prevalence rates of 30% or more and 32 states had prevalence
rates of 25% or greater (Nguyen & El-Serag, 2010). The 2011-2012 National Health and
Nutrition Examination Survey (NHANES), found that 33.1% of adults (20 years and older) were
obese and 6.4% of adults were extremely obese (Fryar, Carroll, & Ogden, 2014). Most recently
data on obesity has shown that about 17% of children and adolescents meet criteria for pediatric
obesity (Sarafrazi, Huges, Borrud, Burt, & Paulose-Ram, 2014; Sim, Lebow, & Billings, 2013)
3
and around 34.9% of adults meet criteria for adult obesity (Centers for Disease Control and
Prevention, 2014).
2.2. Eating disorders
Eating disorders are complex psychiatric disorders that involve notable disturbances in
eating behavior, weight regulation, and thinking (Fairburn & Cooper, 2014; National Institute of
Mental Health, 2014; National Eating Disorders Association, 2011). Eating disorders can result
from interpersonal, social, behavioral, biological, emotional, and psychological factors. Eating
disorders may appear to be about the preoccupation with food and weight, but those behaviors
are clearly just the tip of the iceberg. Below the surface, the food and weight control methods are
used as unhealthy coping mechanisms to deal with several issues (Fairburn & Cooper, 2014;
National Institute of Mental Health, 2014; National Eating Disorders Association, 2011).
Interpersonal factors that contribute to eating disorders include: unstable or troubled personal
relationships; difficulties expressing emotions and feelings; a history of bullying (especially
related to size or weight); and prior physical or sexual abuse (Fairburn & Cooper, 2014; National
Institute of Mental Health, 2014; National Eating Disorders Association, 2011). Social
contributors to eating disorders include: cultural pressure and glorification of thinness and/or
muscularity; the narrow definition of beauty; cultural norms that place a person’s value on
physical appearance; and stress related to discrimination or prejudice based on race, ethnicity, or
size/weight (Fairburn & Cooper, 2014; National Association of Anorexia Nervosa and
Associated Disorders, 2014; National Institute of Mental Health, 2014; American Psychological
Association, 2013; National Eating Disorders Association, 2011).
The psychological factors that contribute to an eating disorder include: low self-esteem,
feelings of lack of control in life, feelings of inadequacy, depression, anxiety; anger, stress, and
4
loneliness. Eating disorders are also caused by hormonal imbalances and neurotransmitter
imbalances especially in the chemicals that control hunger, appetite, and digestion. Eating
disorders run in families and genetics are highly at play in the development of this disease
(Fairburn & Cooper, 2014; National Association of Anorexia Nervosa and Associated Disorders,
2014; National Institute of Mental Health, 2014; American Psychological Association, 2013;
National Eating Disorders Association, 2011). Eating disorders are commonly co-morbid with
other psychiatric disorders, such as substance abuse disorders, depression and other mood
disorders, anxiety disorders, and obsessive-compulsive disorder (Fairburn & Cooper, 2014;
National Institute of Mental Health, 2014; National Eating Disorders Association, 2011). Eating
disorders also put a person at increased risk for obesity (Stice, Becker, & Yokum, 2013 ; Stice et
al., 2011; Stice et al., 2009; Stice et al., 2008b).
Anorexia nervosa is an eating disorder that involves the over-evaluation of shape and
weight (i.e. judging self-worth based on shape and weight), an intense fear of gaining
weight/being fat, and a restriction of energy intake that leads to a body weight that is considered
low in the context of age, sex, developmental phase, and physical health (i.e. typically
maintaining a body weight less than 85% of what is expected) (Fairburn & Cooper, 2014;
National Association of Anorexia Nervosa and Associated Disorders, 2014; National Institute of
Mental Health, 2014; American Psychological Association, 2013; National Eating Disorders
Association, 2011). Anorexia typically has an onset in adolescence and begins with dietary
restriction that becomes progressively more extreme, obsessive, and rigid. The restrictive diet
may be an expression of asceticism, competitiveness, control, or perfectionism. Some people
with anorexia may also over-exercise or vomit as means of further weight control. Common
symptoms of mood lability, depressive and anxious features, impaired concentration, obsessive
5
and distorted thinking generally become worse as more weight is lost. However, these symptoms
typically lessen when weight is regained (Fairburn & Cooper, 2014; National Association of
Anorexia Nervosa and Associated Disorders, 2014; National Institute of Mental Health, 2014;
American Psychological Association, 2013; National Eating Disorders Association, 2011). The
course of anorexia is often chronic, with 10-20% of cases being unremitting (Fairburn & Cooper,
2014). A majority of recovered patients will still show residual symptoms, such as over-concern
about weight and food. Factors that favor a better prognosis include an early age of onset and
short duration of the disorder (Fairburn & Cooper, 2014; National Institute of Mental Health;
National Eating Disorders Association, 2011).
Anorexia nervosa’s self-starvation causes the body to be denied nutrients needed to
function. As a result, the body slows down to try to conserve energy. This starvation mode
causes slow heart rate, low blood pressure, slow breathing, low body temperature, lanugo (i.e.
growth of fine thin hair on body), dry hair and skin, hair loss, and weakness. Anorexia nervosa
also can result in damage to the structure and function of the heart, mild anemia, muscle wasting
and loss, osteoporosis, severe constipation, severe dehydration, fatigue, heart failure, kidney
failure, fainting, brain damage, multi-organ failure, and death (National Association of Anorexia
Nervosa and Association Disorders, 2014; National Institute of Mental Health, 2014; American
Psychological Association, 2013; National Eating Disorders Association, 2011). Research has
shown that of all psychiatric disorders, anorexia nervosa has the highest mortality rate (Fairburn
& Cooper, 2014; National Association of Anorexia Nervosa and Association Disorders, 2014;
National Eating Disorders Association, 2011). In fact, the mortality rate associated with anorexia
nervosa for females between 15-24 is twelve times higher than the combined death rate
6
associated with all other causes of death for this age group (Fairburn & Cooper, 2014; National
Eating Disorders Association, 2011).
Bulimia nervosa is an eating disorder that involves a binge (i.e. an episode in which an
objectively large amount of food is eaten) that is followed by extreme weight-control behavior
(e.g. purging/self-induced vomiting, dietary restriction, laxative misuse). Bulimic behavior is
typically done in secret due to feelings of disgust or shame (Fairburn & Cooper, 2014; National
Association of Anorexia Nervosa and Associated Disorders, 2014; National Institute of Mental
Health, 2014; American Psychological Association, 2013; National Eating Disorders
Association, 2011). The DSM-5 states that an episode of binge eating needs to be characterized
by both eating a large amount of food in a distinct time period and feeling a lack of control over
one’s eating during a binge episode. It also denotes that in order for bulimia to be diagnosed,
there needs to be recurrent inappropriate compensatory behavior to prevent weight gain. The
binging and purging must be separate from episodes of anorexia and must occur at least once a
week over three months. Those with bulimia must also place an over-emphasis on shape and
weight (American Psychological Association, 2013; National Eating Disorders Association,
2011).
Due to the cycling of under-eating and overeating, people with bulimia are typically
found to be in a healthy weight range (BMI between 18.5 and 25.0). Oftentimes, being in the
healthy weight range will spare patients from experiencing secondary psychosocial and physical
effects of starvation and maintaining a low weight. However, bulimia nervosa’s constant
binge/purge cycles can lead to electrolyte imbalances, other chemical imbalances, irregular
heartbeat, heart failure, stroke, dehydration, and death. Other problems caused by bulimia
nervosa include chronically inflamed and sore throat, swollen salivary glands in the neck and jaw
7
area, gastric rupture from periods of binging, inflammation and possible rupture of the
esophagus, tooth decay and staining, acid reflux disorder, various gastrointestinal problems,
irregular bowel movements and constipation, peptic ulcers, and pancreatitis (National
Association of Anorexia Nervosa and Associated Disorders, 2014; National Institute on Mental
Health, 2014; National Eating Disorders Association, 2011).
Bulimia nervosa typically has its onset in late adolescence or early adulthood and can
begin as a case of anorexia nervosa. Its course is long and typically is a result of years of
disturbed or disordered eating. Some predictors related to a poor prognosis are childhood
obesity, low self-esteem, and personality disturbances (Fairburn & Cooper, 2014; American
Psychological Association, 2013; National Eating Disorders Association, 2011).
Anorexia and bulimia share the core psychopathology of the over-evaluation of shape and
weight. People with eating disorders judge their self-worth almost exclusively on the basis of
their weight, size, and ability to control the two. This over-emphasis on size and weight leads to
the fear of weight gain/being fat and the pursuit of weight loss. Those with anorexia and bulimia
will often mistake their adverse physical or emotional states as “feeling fat” and take this as
meaning that they actually are fat. Other shared symptoms of anorexia and bulimia include body
avoidance (i.e. avoiding looking at one’s body because that person thinks they look fat and
disgusting), body checking (i.e. constantly pulling at or feeling body for any change in
size/shape), and weight checking (i.e. frequent weighing of self on scale that results in obsession
with day to day fluctuations in weight) (Fairburn & Cooper, 2014; National Eating Disorders
Association, 2011).
8
Binge-eating disorder is characterized by recurrent binge eating in the absence of extreme
weight control behaviors seen in bulimia and anorexia (Fairburn & Cooper, 2014; National
Institute of Mental Health, 2014; American Psychological Association, 2013). According to the
DSM-5, these binge eating episodes must occur at least once a week for three months and must
be associated with three (or more) of the following: eating very rapidly; eating until feeling
uncomfortably full; eating large amounts of food when not feeling physically hungry; eating
alone because of feelings of embarrassment and disgust by how much one is eating; feeling
disgusted with oneself after a binge episode; and feeling depressed and/or guilty after binge
episode (American Psychological Association, 2013). The feelings of guilt, shame, and distress
that are often associated with binge-eating disorder can lead to more binge eating (Fairburn &
Cooper, 2014; National Association of Anorexia Nervosa and Associated Disorders, 2014;
National Institute of Mental Health, 2014, American Psychological Association, 2013; National
Eating Disorders Association, 2011).
Binge-eating disorder typically presents as being phasic rather than persistent, meaning
that a majority of patients have periods of many months free from binge eating (Fairburn &
Cooper, 2014). Binge-eating disorder also has a different age of presentation in comparison to
anorexia and bulimia. A large portion of binge eating disorder patients presenting for treatment
are middle-aged and one-third (or more) are male. Those who have binge-eating disorder are
typically overweight or obese and the consequences of binge-eating disorder are similar to the
health risks of being overweight and obese. Some of these consequences include high blood
pressure, high cholesterol levels, heart disease, and diabetes (National Institute of Mental Health,
2014; American Psychological Association, 2013).
9
In the DSM-5, the categories of “Other Specified Feeding or Eating Disorders” and
“Unspecified Feeding or Eating Disorders” denote a feeding or eating disorder that causes
significant distress or impairment, but does not meet criteria the other diagnoses. These disorders
can also be viewed as sub-threshold or atypical eating disorders. The psychopathology of these
disorders is similar to that seen in anorexia and bulimia, with similar duration and severity. The
category of other specified eating disorders is comprised of those cases that closely resemble
anorexia or bulimia but fail to meet the diagnostic criteria (e.g. body weight is too high for
anorexia diagnosis or binge eating frequency is too low for diagnosis of bulimia) (Fairburn &
Cooper, 2014; American Psychological Association, 2013). The other category of unspecified
eating disorders is comprised of cases that present as a combination of both anorexia and bulimia
(Barlow, 2014; American Psychological Association, 2013). Currently, data on the development
and course of these eating disorders is scarce. However, most patients have similar presenting
ages and history as patients presenting with anorexia or bulimia (Fairburn & Cooper, 2014;
American Psychological Association, 2013; National Eating Disorder Association, 2011).
Approximately 20 million women and 10 million men, or 9.4% of the population suffer
from a clinically significant eating disorder (National Association of Anorexia Nervosa and
Association Disorders, 2014; National Eating Disorders Association, 2011). In the U.S., millions
more suffer from sub-threshold eating disorders and sub-clinical disordered eating attitudes and
behavior (National Association of Anorexia Nervosa and Association Disorders, 2014; National
Eating Disorders Association, 2011). In the past, eating disorders have been perceived as being a
privileged, straight, young, white girl’s disease. Thus, previous research, prevention, and
intervention efforts focused primarily on young white girls. Many people felt that other groups
were immune to eating disorders, disordered eating, and body dissatisfaction. However, over the
10
years, cases among girls and women of all ages, sexual orientations, socioeconomic statuses, and
race/ethnicities have been identified and are increasing. The number of eating disorders among
boys and men has also been on the rise (National Association of Anorexia Nervosa and
Association Disorders, 2014; National Institute of Mental Health, 2014; American Psychological
Association, 2013; National Eating Disorders Association, 2011). In the US, the prevalence of
eating disorders has been shown to be similar among non-Hispanic Whites, Hispanics, AfricanAmericans, and Asians (National Eating Disorders Association, 2011; Stice, Ng, & Shaw, 2010).
Eating disorders can be difficult to treat and create a large amount of distress in the
person with the illness and their loved ones. Eating disorders also place a significant burden on
our country’s healthcare system (Fairburn & Cooper, 2014; National Institute of Mental Health,
2014; National Eating Disorders Association, 2011). Eating disorders cannot be cured by will or
on one’s own. They require professional treatment in order to stop the cycle of physical and
emotional destruction (Fairburn & Cooper, 2014; National Association of Anorexia Nervosa and
Associated Disorders, 2014; National Eating Disorders Association, 2011).
2.3 Disordered eating
Disordered eating is a pattern of unhealthy or disturbed eating that may lead to rigid
eating and exercise habits. These unhealthy patterns of eating can include excessive dieting (i.e.
yo-yo dieting), restrictive dieting (i.e. unbalanced eating), compulsive or binge eating, skipping
meals, vomiting after meals, steroid or creatine use, and using diet pills or laxatives (National
Eating Disorders Collaboration, 2014; National Eating Disorders Association, 2011). Disordered
eating does not always lead to an eating disorder, but it is a common indicator or precursor of an
eating disorder. Disordered eating can lead to psychological stress, guilt, depression, slowed
metabolism, decreased concentration, weight gain, obesity, fatigue and poor sleep quality,
11
headaches, muscle cramps, constipation and/or diarrhea, and mood liability (National Eating
Disorders Collaboration, 2014; National Eating Disorders Association, 2011).
According to the 2013 Centers for Disease Control and Prevention’s Youth Risk
Behavior Surveillance-United States, 16.6% of high school students were found to be
overweight. Despite this, 31.1% of high school students subjectively described themselves as
slightly or very overweight. The survey also found that in the past year, almost half of high
school students (47.7%) tried to lose weight through a variety of unhealthy weight-control
behaviors (e.g. purging, laxatives, diet pills, fasting, excessive dieting, etc.) Weight
misperception was also found in the National Health and Nutrition Examination. During 20052012, approximately 30% of children and adolescents between 8 and 15 years old
(approximately 9.1 million children and adolescents) misperceived their weight status. More than
2 million healthy weight children and adolescents considered themselves to be too fat or too thin
(Sarafrazi, Hughes, Borrud, Burt, & Paulose-Ram, 2014). Further, over 50% of young women
report body dissatisfaction (Stice, Ng, & Shaw, 2010) and 40-60% of elementary school girls (612 years old) report being concerned about their weight or about becoming too fat (National
Eating Disorders Association, 2011).
Factors that put people at risk for disordered eating are similar to contributing factors for
an eating disorder. These include, body dissatisfaction, stress, internalization of the thin-ideal,
perfectionism, weight prejudice, weight-based teasing, and family and peer group’s views and
comments about food and appearance (Smolak & Thompson, 2009). Another contributing factor
to disordered eating is “fat talk.” In our culture “fat talk” is rampant, especially among
adolescent girls and young women. This talk involves self-comparison to ideal eating and
exercise habits, fears of gaining weight and being overweight, and other talk that involves
12
appearance, food, exercise, diets, and putting oneself down. Fat talk is associated with body
dissatisfaction and disordered eating (Sharpe, et al., 2013). Body dissatisfaction has been shown
to be the best-known contributor to the development of eating disorders and disordered eating
(Wojtowicz & von Ranson, 2012; National Eating Disorders Association, 2011). Body
dissatisfaction is proving to be a central public health concern because of its role in the
development of eating disorders, along with its associations with other negative outcomes (i.e.
low mood, low self-esteem, excessive dieting, over and under exercising, obesity, and unhealthy
weight control practices) (Sharpe et al., 2013). Research has shown that the internalization of the
thin-ideal, body dissatisfaction, chronic dietary efforts/disordered eating, and eating disorder
pathology are related to increased emotional distress, functional impairment, and mental health
care utilization (Stice, Ng, & Shaw, 2010).
2.4 Relationship between obesity and eating disorders/disordered eating
The estimated prevalence of pediatric obesity is 17% (Sim, Lebow, & Billings, 2013). An
important concern is the numerous medical comorbidities associated with pediatric obesity.
Although pediatric eating disorders do not receive the same attention from the public health
field, they are serious medical and psychological conditions that affect at least 6% of youth (Sim,
Lebow, & Billings, 2013). Despite the chronic and serious nature of pediatric eating disorders,
pediatricians and other doctors often overlook weight loss in their pediatric clients, especially if
these clients have a history of obesity or being overweight. Medical providers are more likely to
identify and give referrals to adolescents for eating disorder treatment who show the more
obvious signs of emaciation and malnutrition. However, providers may not be aware of the more
subtle presentation of eating disorders. This may lead providers to misdiagnose patients who do
13
not fit the “typical” profile of someone with an eating disorder (Lebow, Sim, & Kransdorg,
2015).
Research has shown that almost half of adolescent eating disorder patients have a history
of obesity. Studies also found that in comparison to eating disorder patients without a history of
obesity, it took significantly longer for those patients with a history of obesity to be identified
and placed into treatment (Lebow, Sim, & Kransdorg, 2015; Sim, Lebow, & Billings, 2013).
Many previously obese or overweight patients have gone undetected because doctors focused
primarily on patients losing weight. However, the patient’s weight loss and methods of weight
loss are often overlooked (Lebow, Sim, & Kransdorg, 2015). For example, a sample of
overweight teenagers who had lost 25% of their premorbid weight were shown to be more
medically compromised and showed more signs of malnutrition than a sample of adolescents
with anorexia nervosa (Lebow, Sim, & Kransdorg, 2015; Sim, Lebow, & Billings, 2013). In the
samples examined, weight loss, medical issues, and malnutrition were not attributed to an eating
disorder, but instead attributed to more rare disorders such as polycystic ovary syndrome or
gastrointestinal conditions (Sim, Lebow, & Billings, 2013). Children and adolescents who have a
history of obesity or of being overweight are not exempt from eating disorders and disordered
eating. Furthermore, approximately 76% of obese adolescents girls and 51% of normal weight
girls engage in unhealthy weight control behaviors. Approximately 66% of obese girls and 38%
of normal weight girls have low levels of body satisfaction (Neumark-Szatiner et al., 2010).
There are a number of risk factors (e.g. negative body image, restrictive dieting, binge
eating, purging behaviors) that contribute to the development of clinical eating disorders that also
have been found to be present in a portion of obese individuals (Mcvey et al., 2012). Obesity and
14
eating disorders can even occur simultaneously in the same individual (Haines & NeumarkSztainer, 2006). Risk factors, such as excessive dieting, binge eating, vomiting, and use of
appetite suppressants and laxatives have also been found to be associated with an increased risk
for obesity (Smolak & Thompson, 2009). Research has even shown that overweight adolescents
are at a higher risk than their peers of engaging in self-induced vomiting and use of laxatives to
control their weight (Austin, Field, Wiecha, Peterson, & Gortmaker, 2005).
Media use has also been shown to be a contributor to both obesity and eating
disorders/disordered eating. Television appears to contribute to obesity by increasing sedentary
lifestyles and by increasing dietary intake during viewing or as a result of food advertisements.
The media’s promotion of the thin ideal causes an increase in one’s internalization of this
message, which in turn leads to increased body dissatisfaction and disordered eating (Fairburn &
Cooper, 2014; Wang, Peterson, McCormick, & Austin, 2014; Haines & Neumark-Sztainer,
2006).
Body dissatisfaction and self-esteem are the two main, shared risk factors between
obesity and eating disorders. Body dissatisfaction and self-esteem are highly correlated with
disordered eating and eating disorders, especially among adolescent girls (Wojtowicz & von
Ranson, 2012). Weight-related teasing is also associated with binge eating and other disordered
eating behaviors. When adolescents and children are teased about their weight they may also
experience body dissatisfaction and/or depressive symptoms (Haines & Neumark-Sztainer,
2006).
Despite research and evidence of the shared risk factors between eating disorders and
obesity, the two fields have chosen to work independently on prevention efforts. Of note is that
these conditions are associated with disordered eating behaviors and attitudes (e.g. body
15
dissatisfaction, body shape and weight concerns, excessive dieting, etc.) that typically precede
both conditions (Ferrari, 2011; Haines & Neumark-Sztainer, 2006). Research has also shown that
there is cross over between obesity and eating disorders. However, both of these fields continue
to promote health messages that often create confusion among the public. The promotion of
weight loss and dieting can often be misunderstood by the public, which in turn may lead some
to excessively diet or to use dangerous weight-loss methods. Current health promotion messages
have also caused an increase in weight stigmatization and an increase in those in need who avoid
health care providers. The media has also caused confusion and problems by oversimplifying
eating disorders and obesity and by blaming the individual for lacking willpower and/or being
vain (Ferrari, 2011; Puhl & Heuer, 2009).
The fields of obesity and eating disorders would benefit by working together. A
collaborative approach to these issues would be economically efficient and reduce the risk of
accidentally causing one disorder while trying to prevent the other (Haines & Neumark-Sztainer,
2006). However, there are various challenges to collaboration between these fields. The goals of
treatment and prevention for both issues may seem contradictory. For example, behaviors like
weight management, monitoring weight, food and activity logs, and food restriction are keys to
obesity prevention and treatment, but when taken to the extreme, these behaviors can be seen as
symptoms of an eating disorder. Another issue hindering collaboration between these fields is the
lack of appreciation for the issues facing each field. For instance, professionals in the obesity
field may not see body dissatisfaction or excessive dieting as being problems on the same level
of hypertension (Haines & Neumark-Sztainer, 2006; Neumark-Sztainer, 2005). Both fields view
themselves as separate entities and often do not communicate with one another. They each have
their own publications and conferences (Neumark-Sztainer, 2005). This lack of communication
16
may be the result of the public health field not seeing eating disorders and disordered eating as
public health issues. Another issue is that while obesity is not a psychological condition, it can
cause significant psychological impairment (Haines & Neumark-Sztainer, 2006; NeumarkSztainer, 2005). Professionals within the obesity and eating disorder fields must focus on shared
risk factors and develop collaborative strategies to help those with eating disorders, disordered
eating, and those who are categorized as being obese.
Both these fields have the goal of promoting healthier lifestyles. They also share the
goals of promoting regular meal eating and listening to one’s body cues of hunger and satiety.
Eating disorders, disordered eating, and obesity are complex issues that are affected by and affect
various physiological, psychological, socio-economical, and socio-cultural factors. There is no
single or simple solution to properly address both problems. Obesity, disordered eating, and
eating disorders must be viewed on the same spectrum of weight-related problems. Collaboration
between these fields is necessary for successful prevention efforts.
2.5 Related theoretical models
Below are several models and theoretical concepts that can assist in understanding the
topics of disordered eating, obesity, and eating disorders, along with some of the prevention
efforts discussed later in this paper.
2.5.1 Affect/emotion regulation model: Affect regulation can be defined as one’s
attempt to control or influence the emotions one experiences. If affect regulation is hindered or
unsuccessful, self-regulation in other areas of one’s life may also fail (Leehr et al., 2015). This
model posits that people will often binge eat as a way to obtain comfort and distraction from
negative emotions. Those who binge are said to have major difficulties regulating their negative
emotions (Leehr et al., 2015; Rohde, Stice, & Marti, 2014). Research with adolescents has shown
17
that those reporting social pressure to be thin, weight and calorie preoccupation, and body
dissatisfaction were at higher risk for disordered eating and the onset of threshold or
subthreshold bulimia or binge eating disorder (Rohde, Stice, & Marti, 2014). Although obesity is
not an eating disorder, obese individuals can be diagnosed with binge eating disorder (Leehr et
al., 2015). This model suggests that obesity may, in part, be due to self-regulation issues and
emotional eating (Leehr et al., 2015) (See Figure 1 in Appendix).
2.5.2 Biopsychosocial model: This model can be used to examine body dissatisfaction as
resulting from a combination of sociocultural, biological, and psychological factors. In the
current environment, energy-dense foods are abundant, physical activity is not viewed as
necessary, and the ideal body type is a thin and unattainable standard for women and men.
Someone in this environment who has a low stress threshold, is a perfectionist, or has low
emotion regulation skills will be more vulnerable for the development of weight-related
problems. This person will be even more vulnerable if someone in their family has or had
weight-related problems (Rodgers, Paxton, & McLean, 2014; Neumark-Sztainer, 2005). This
model is similar to the social-ecological model because it focuses on interactions between
various factors (See Figure 2 in Appendix).
2.5.3 Brain reward pathway model: This model suggests that eating
disorders/disordered eating and obesity affect similar pathways and areas of the brain. These
pathways affect one’s reward system and how one experiences satiety and pleasure. This model
also posits that stress can cause overeating or under-eating (Hasan & Hasan, 2011; Berridge, Ho,
Richard, & DiFeliceantonio, 2010) (See Figure 3 in Appendix).
18
2.5.4 Cognitive dissonance theory: This theory describes what individuals do when
confronted with information that does not agree with their current beliefs and behavior (Butryn,
2014; Stice et al., 2013; Stice et al, 2012; Stice et al., 2011b; Stice et al., 2011a; Becker, 2009;
Stice et al., 2009; Stice, et al., 2008a; Stice et al., 2008b). The dissonance theory proposes that
when one possesses thoughts/cognitions that are not aligned with one’s current beliefs, values,
behaviors, and attitudes, psychological discomfort is created. This discomfort may serve to
motivate the person to alter their cognitions and behavior to lessen the discomfort and create
consistency. Evidence has shown that people may change future behavior in an effort to decrease
cognitive dissonance (Stice et al., 2013; Stice et al, 2012; Stice et al., 2011b; Stice et al., 2011a;
Stice et al., 2009; Stice, et al., 2008a; Stice et al., 2008b). Dissonance can be a motivator for
change, which is very important to health promotion. Main constructs in the dissonance theory
are motivation and persuasion, which both play a role in behavior and cognition change. It has
been suggested that dissonance-based interventions and exercises can be helpful in the treatment
of obesity, eating disorders, reducing the risk for eating pathology, body dissatisfaction, and the
thin-ideal internalization (Stice et al. 2008b) (See Figure 4 in Appendix).
2.5.5 Dietary restraint model: This model is used as a means to explain how dieting can
lead to weight gain. Dieting is not only a behavior, but also a cognitive style; it involves thoughts
about eating and restriction, instead of eating in response to physiological cues of hunger and
fullness. This self-enforced cognitive control puts an individual at risk for binge eating, which
can be said to be a loss of cognitive control over eating as a result of prior restraint. This
disinhibited eating may increase overeating and binge episodes, thus leading to weight gain
(Holmes, Fuller-Tyszkiewicz, Skouteris, & Broadbent, 2015; Andres & Saldana, 2014; Haines &
Neumark-Sztainer, 2006) (See Figure 5 in Appendix).
19
2.5.6 Dual pathway model: This model proposes that the level of internalization of the
thin-ideal, elevated BMI, and one’s perception of the pressure to be thin contribute to body
dissatisfaction. Body dissatisfaction leads to increased dieting and negative affect, which in turn
can lead to binge eating (Rohde, Stice, & Marti, 2014). Overemphasis on weight/body size
results in dieting which increases the risk for binge eating. This binge eating worsens the
weight/body size concerns, thus furthering dieting and compensatory behaviors (Rohde, Stice, &
Marti, 2014; Kroon Van Diest & Perez, 2012; Stice et al. 2008b) (See Figure 6 in Appendix).
2.5.7 Health belief model: This model posits that a person’s belief about a health
problem, their perceived susceptibility to the problem, the perceived severity of the problem, the
perceived benefits of action, the perceived barriers to action, and self-efficacy explain
engagement (or lack of engagement) in health promoting behaviors. In the case of obesity and
eating disorders/disordered eating, there is a notable lack of perceived susceptibility or risk.
Obesity and eating disorders are associated with many health issues, yet many people think they
are immune to these conditions or do not need help. Eating and exercising in a healthful way are
both important behaviors that are difficult to promote in the obesity and eating
disorder/disordered eating populations (Akey, Rintamaki, & Kane, 2013; Garcia & Mann, 2003)
(See Figure 7 in Appendix).
2.5.8 Objectification theory/self-objectification theory: The objectification theory
states that because women’s bodies are regularly objectified, women begin to engage in selfobjectification where they internalize the outside perspective and ideas of the ideal body. If a
female’s body and the standard ideal body that she uses to judge her body by do not align, she
engages in negative self-evaluation. In societies, especially in western culture, where the ideal
body for a woman is much thinner than the average woman and is quite unattainable (e.g. large
20
breasts, tiny waist, low body fat), negative self-views and habitual self-monitoring (i.e. selfsurveillance) of one’s body and appearance are common (Becker et al., 2013). One’s own image
and degree of self-objectification is influenced by environmental factors, such as media,
interpersonal encounters, and family and peers. In order to reach the “perfect” body, many
people will engage in unhealthy eating practices and disordered eating, which can eventually
lead to obesity or weight gain, and serious medical and psychological issues (Kroon Van Diest
& Perez, 2012 ). These issues of self-objectification and body dissatisfaction are associated with
appearance anxiety, body shame, disordered eating, decreased mental resources, decreased
performance on cognitive tasks, decreased motivational states, and various psychological
disorders (e.g. depression, sexual dysfunction, and eating disorders). People who are obese or
overweight, may feel even more pressure to look a certain way, which may in turn cause them to
overeat more or become depressed (Becker et al., 2013; Kroon Van Diest & Perez, 2012).
Although this model is typically applied to females, the growing number of males with body
image issues and eating disorders/disordered eating shows that this model can also be applied to
some males (See Figure 8 in Appendix).
2.5.9 Problem-behavior theory: This theory states that participating in one risky or
health-compromising behavior is associated with engaging in other problem behaviors. These
behaviors do not necessarily cause one another, but instead are a cluster of problem behaviors.
For example, someone with an eating disorder can become obese later in life or they may abuse
various substances. Another example is that someone who is obese could practice disordered
eating behaviors, which may in turn lead to an eating disorder (Dong, & Ding, 2012; Eichen,
Conner, Daly, & Fauber, 2012). This theory is important to examine because it shows that
21
overeating, obesity, and eating disorders can lead to other problem behaviors (See Figure 9 in
Appendix).
2.5.10 Social-ecological model: The social-ecological model examines the complex
interactions between systems at different personal and environmental levels. Due to the many
factors that influence obesity and eating disorders/disordered eating, the social-ecological model
is useful in understanding these issues. Factors that influence the development of weight-related
behaviors are individual factors (i.e. demographics, psychosocial factors, thin-ideal
internalization, body dissatisfaction, perfectionism), interpersonal factors (i.e. relationships with
parents, peers, teachers, whether critical comments about weight/size are being made),
behavioral settings where individuals take part in weight-related behaviors (i.e. homes, schools,
neighborhoods), sectors of influence that influence weight-related behaviors (i.e. media,
education, government, and fashion, entertainment and cosmetic surgery industries), and the
sociocultural context (i.e. social and cultural norms and values about ideal body size) (Wang,
Peterson, McCormick, & Austin, 2014; Mcvey, et al., 2012). There are several opportunities for
integrating obesity and eating disorder prevention efforts through environmental approaches (See
Figure 10 in Appendix).
2.5.11 Summary of theories: Although there are many more theories involved in
understanding obesity, eating disorders, and disordered eating, those listed and described above
are the most prominent in the field. After conducting extensive research on the most prominent
theories that address obesity, eating disorders and disordered eating, it was found that several
theories support prevention efforts based on shared risk factors. For example, the brain reward
pathway model helps to explain how eating disorder, disordered eating, and obesity affect similar
pathways and areas of the brain that involve one’s reward system and experience of satiety. The
22
dietary restraint model explains that dieting and restrictive eating taxes one’s cognitive
resources. With less control over one’s cognitions, binge eating may occur which can lead to
weight gain or unhealthy compensatory behaviors (e.g. purging, over-exercising, etc.). The dual
pathway model explains disordered eating and eating disorders by purposing that one’s level of
thin-ideal internalization and perception of pressure to be thin can lead to body dissatisfaction.
This body dissatisfaction can lead to increased negative affect, dieting, and unhealthy
compensatory behaviors. The overemphasis on weight/body size, body dissatisfaction, and
constant dieting can lead to binge eating and this binge eating can lead to excessive weight gain,
which in turn causes more body dissatisfaction and unhealthy compensatory behaviors.
The theories above describe which prevention efforts can be implemented to decrease
obesity and prevent eating disorders and disordered eating behaviors. For example, the
affect/emotion regulation model shapes prevention efforts by focusing on mood regulation and
coping skills. By teaching people self-regulation and healthy ways to deal with their emotions,
binging, purging, or other disordered eating behaviors can be prevented. Prevention efforts that
use the biopsychosocial model and socio-ecological model are successful because they target
multiple levels. These theories posit that various levels and systems of society interact and
influence one another. By changing factors within one system, other systems will be affected.
The problem-behavior theory illustrates that eating disorders and disordered eating are risky
behaviors related to other risky behaviors. This information can be used to develop prevention
programs that target not just drug and alcohol use, but also disordered eating behaviors and
eating disorders. The health belief model, which involves a person’s perceived susceptibility or
risk, can be used to examine obesity, eating disorders and disordered eating. This model can be
23
utilized when assessing the level and type of targeted health education needed on the topics of
obesity, eating disorders, and disordered eating.
Prevention efforts that have used the cognitive dissonance theory typically focus on
creating inconsistency between one’s behavior, values, and attitudes regarding dieting, media
viewing, and body image. The objectification and self-objectification theories inform prevention
efforts that focus on body image. These theories provide several explanations why people are
dissatisfied with their bodies. Body dissatisfaction is one factor that many prevention efforts find
measurable and usable, so theories such as the objectification/self-objectification and cognitive
dissonance theories are used to guide prevention efforts focused on reducing body
dissatisfaction. Taken together, the outlined theories can contribute to the development of shared
prevention efforts focused on disordered eating behaviors, obesity, and eating disorders.
2.6 Significance of this paper
Obesity and eating disorders are critical public health issues due to their association with
death and chronic disease. Dr. Rebecca Grief, a clinical psychologist and the clinical director at
Mt. Sinai Hospital’s Eating and Weight Disorder Program believes that eating disorders and
disordered eating need to be taken more seriously. She has stressed the importance of education
and awareness in the general public, but especially among pediatricians, clinicians, and those in
the field of public health (R. Greif, personal communication, October 25, 2014). A common
belief in our society is that eating disorders and disordered eating are not important enough to
warrant prevention efforts or to cause worry. There are not many evidence-based treatments and
insurance companies will often not cover the full, most effective, and necessary treatment needed
for a better and long-lasting outcome (NEDA, 2011; Franco & Erb, 1998). Although eating
disorders affect a small portion of the population, they can be very deadly. Eating disorders have
24
severe side effects and many medical complications. Eating disorders are costly for the
individual, family, and for society as a whole. For one individual, eating disorder treatment costs
at least $30,000 per month (Parker-Pope, 2010) and the burden on a society (lost production and
loss to society) is estimated to be more than $69 billion per year (Eating Disorders Review,
2015). Someone who has an eating disorder has a very low quality of life and their illness is
typically chronic. Missed days of school/work and health care utilization create an immense
burden on our health care system (R. Greif, personal communication, October 25, 2014). Obesity
also places a heavy burden on our healthcare system (Nguyen & El-Serag, 2010). Healthcare
expenses related to obesity alone are approximately $190 billion per year (Harvard School of
Public Health, 2015) and the quality of life for those who are obese is negatively impacted by
their weight and health status. A public health prevention approach that encompasses both eating
disorders and obesity is needed to address the heavy burden on the healthcare system.
Although clinically significant eating disorders may affect a small number of the
population, many in our society are affected by negative body image and/or disordered eating.
Many people in our culture also suffer from sub-threshold eating disorders, including chronic
dieting and over-exercising. These individuals may not even know they are suffering because of
the normalcy of these unhealthy practices. Dr. Greif believes that prevention efforts need to
focus on changing the overall toxic environment that our society has surrounding food and
dieting (R. Greif, personal communication, October 25, 2014).
The following section will review strategies to prevent obesity, eating disorders, and
disordered eating. The critical literature synthesis will review obesity prevention efforts to
identify previous efforts that have included eating disorders and/or disordered eating. This next
section will critique the prevention literature to see how incorporating eating disorder/disordered
25
eating prevention and education into obesity prevention and education will improve current
prevention efforts.
26
Part II
1.0 Methods
This section is a critical literature synthesis, which entailed a comprehensive literature
review and analysis. Data was collected from the online databases PubMed and Google Scholar.
Some of the initial terms that were used to search for articles were: “eating disorders”, “obesity”,
“disordered eating”, and “prevention.” To narrow down article choices, articles needed to be
about eating disorder/disordered eating and/or obesity prevention interventions. Articles that
were excluded were studies that took place outside of the United States or Canada. Eventually
other terms were used to narrow the search. These terms included: “weight stigma”, “fat
shaming”, “war on obesity”, “obesity epidemic”, “body image”, “chronic dieting”, “food
industry”, “diet industry”, “BMI”, and “body mass index.” Other articles and references were
obtained from the original articles’ reference and citation sections. Overall 92 different articles
were used to examine different prevention approaches, methods, and interventions. When
accounting for multiple usage of articles, the breakdown of these 91 articles was: 38 articles on
obesity prevention methods, approaches, and interventions (7 about weight stigma and
discrimination, 2 about BMI/BMI report cards, 6 about weight loss and dieting, 5 about bariatric
surgery, 5 about VERB campaign, 3 about the CORD program, 6 about school-based
interventions, and 4 about the Let’s Move initiative); 45 about eating disorder and disordered
eating prevention methods, approaches, and interventions (9 about general, physician, and
parental approaches to prevention, 9 about general school-based approaches to prevention, 3
about yoga and mind-body approaches, 5 about media literacy and Media Smart, 2 about Student
Bodies, 15 about the Body Project, and 2 about the Healthy Weight intervention); and 22 about
27
combined prevention approaches, methods, and interventions (7 about general combined
prevention approaches, 4 about New Moves, 2 about interpersonal therapy (IPT), 4 about Planet
Health, and 5 about on the Health at Every Size (HAES) approach).
2.0 Results
2.1 Research on the prevention of obesity
The field of public health has tried various approaches to reduce the obesity epidemic.
These include education, food labeling and advertising, food assistance programs, health care
and training, transportation and urban development, taxation, and policy development. The
results of these prevention efforts have been mixed (Callahan, 2012).
2.1.1 General approaches to obesity prevention
1.) Weight stigmatization and weight bias: One method of obesity prevention that public
health officials have been known to use is weight stigmatization. Weight stigma is a specific type
of disease stigma, which is when groups of people are blamed for their illnesses or conditions
because society views them as immoral, unclean, or lazy (Major, Eliezer, & Rieck, 2012; Puhl &
Heuer, 2010). In the media, messages about the personal responsibility of obesity and personal
solutions for obesity far outnumber coverage on societal causes for obesity. This perpetuates the
current societal message that both the cause and solution for obesity are within the individual.
However, research has shown that genetic, biologic, environmental, and societal factors all play
significant roles in the development of obesity.
Overweight and obese individuals who are victims of weight stigma or who perceive
themselves as being discriminated against based on their weight, experience increased stress and
reduced self-control. Weight stigma is also threatening to the identity of overweight and obese
individuals. This threat causes individuals to undergo an overwhelming amount of negative
28
emotions, cognitions, behaviors, and biological responses. Weight stigma is different from
stigma based on race, ethnicity, and gender, because weight is typically perceived as
controllable. This causes people to hold others, and themselves, responsible for having a certain
weight identity, despite the fact that for the majority of people, long-term weight loss is
unsuccessful (Major, Eliezer, & Rieck, 2012; Puhl & Heuer, 2010). Weight stigma is also
different from other types of stigma because unlike other stigma, where one can celebrate their
identity and have the support of family and friends, individuals who are overweight are often
shunned and treated poorly by family, friends, and the general public (Major, Eliezer, & Rieck,
2012; Puhl & Heuer, 2010).
Similar to the stigmatization of tobacco smoking, public health officials have tried to
make being obese and/or overweight a taboo trait. Weight stigma is one of the only forms of
stigma often found to be socially acceptable because of the view that obese individuals are to
blame for their weight. Public health officials feel that weight stigmatization is even necessary
for promoting behavioral change. These public health officials feel that weight stigma serves as
an essential way of motivating obese individuals to embrace healthier lifestyles and healthier
behaviors (Major, Eliezer, & Rieck, 2012; Puhl & Heuer, 2010). Despite claims that weight
stigma is a justifiable and useful tool for obesity prevention and intervention, research has
continuously shown that weight stigma is not a beneficial public health tool for reducing obesity
and that current approaches need to be reevaluated (Puhl & Heuer, 2010).
Weight stigma is pervasive in our society. Employers, coworkers, teachers, physicians,
nurses, medical students, dietitians, therapists, peers, and family members often discriminate
against individuals based on their weight (Puhl & Heuer, 2010). Weight stigmatization endangers
health, increases health disparities, and impedes effective obesity prevention and intervention
29
efforts. Weight stigma and bias increase psychological stress and decrease physical health within
individuals. One study found that overweight women who thought their weight was visible to
those in a room with them, showed increased stress and cognitive depletion (Major, Eliezer, &
Rieck, 2012). Another study found that when exposed to weight stigma, overweight women
consumed more calories and had reduced perception of their dietary control (Major, Hunger,
Bunyan, & Miller, 2014). Research has also shown that weight discrimination is associated with
many psychiatric disorders and can be detrimental to an individual’s mental health treatment and
recovery. One study found that those participants who perceived that they were experiencing
weight discrimination had the highest levels of stress (Hatzenbuehler, Keyes, & Hasin, 2009).
Weight stigma increases anxiety and can lead to chronic stress, which in turn impacts an
individual’s physical wellbeing (Major, Hunger, Bunyan, & Miller, 2014). Research has also
shown that weight stigma puts obese and overweight individuals at a significant disadvantage in
employment settings and interpersonal relationships (Puhl & Heuer, 2010). Obese and
overweight individuals receive less adequate and quality care by physicians, largely due to
physicians’ attitudes that these individuals are lazy and non-compliant (Hulzinga, Bleich, Beach,
Clark, & Cooper, 2010; Puhl & Heuer, 2009). However, lack of quality care is also a result of
physicians and health providers’ beliefs that they were not equipped to treat obesity (Puhl &
Heuer, 2009). This lack of quality and perception of weight bias in health care settings leads to
overweight and obese individuals avoiding going to the doctor (Puhl & Heuer, 2009). Weight
stigma also decreases the effectiveness of weight loss programs (Carels et al., 2009). Overall,
weight stigma increases unhealthy eating behaviors, unhealthy weight control methods, and
lower levels of physical activity, all of which worsen obesity and weight gain (Puhl & Heuer,
2010).
30
2.) Weight-loss and dieting: Recommendations regarding the obesity epidemic include
telling those who are overweight and obese to lose weight through lifestyle modification
methods including diet and exercise. Weight loss can be beneficial, in that it has been associated
with several favorable clinical outcomes. Moderate weight loss has been found to be associated
with significant reductions in type 2 diabetes and blood pressure levels. Weight loss in women
has been associated with improvement in fertility and increased menstrual regularity and
ovulation. Other reports have shown that weight loss results in decreased knee and joint pain and
that weight loss may also benefit one’s mental health (Kramer, 2015; Centers for Disease
Control and Prevention, 2014).
The recommendation to lose weight has shown some success, but the majority of
individuals are unable to maintain weight loss over the long term (Bacon & Aphramor, 2011).
Even when intensive efforts in various weight loss programs are made or individuals make
improvements on their own, success rates for weight loss and the decrease of obesity are low
(Callahan, 2012). Initial weight losses of 5-10% of one’s body weight can be achieved and help
prevent chronic diseases. However, reports have shown that within 5 years, lost weight is
typically regained (Thomas, Bond, Phelan, Hill, & Wing, 2014). However, it has been shown
that weight-loss maintenance is possible for some people over a 10-year course (Thomas, Bond,
Phelan, Hill, & Wing, 2014). Some studies have shown that larger weight losses and longer
duration of maintenance of the new weight were associated with better long-term outcomes.
Meanwhile, decreases in leisure-time physical activity, dietary restraint, and frequency of selfweight and increases in percentage of energy intake from fat and disinhibition were associated
with greater weight regain. Although these studies showed that weight-loss can be a successful
31
tool in the long-run for some people, as stated above, most people regain the weight they had lost
(Thomas, Bond, Phelan, Hill, & Wing, 2014).
This approach has been shown to be associated with food and body preoccupation,
repeated cycles of weight loss and regain, distraction from other personal health goals, reduced
self-esteem, eating disorders, other health issues, and weight stigmatization and discrimination
(Bacon & Aphramor, 2011). Dieting and weight loss have also been found to be associated with
depressed mood, anxiety, irritability, heightened weight concerns, and eating disorder
symptomology (Austin, Field, Wiecha, Peterson, & Gortmaker, 2005). Some studies have shown
that dieting is actually associated with an increased risk of obesity among children and
adolescents. Dieting among children and adolescents has also been associated with weight gain,
binge eating, disinhibited eating, and issues with their metabolism (Haines & Neumark-Sztainer,
2006).
Weight loss and obesity research does not go through as rigorous clinical standards for
publishing as compared to certain other types of research. This has caused some misconceptions
and exaggerations in our society regarding weight loss and dieting. For example, BMI weakly
predicts one’s longevity. Most epidemiological studies have found that people who are
overweight or obese live at least as long as normal weight people, and sometimes even longer
(Callahan, 2012; Bacon & Aphramor, 2011). The Americans’ Changing Lives study found that
when controlling for socioeconomic and other risk factors, obesity is not a significant risk factor
for mortality. This study also found that people who are 55 years of age or older, being
overweight or obese decreases one’s risk of mortality (Bacon & Aphramor, 2011). Evidence has
found that a significant problem among those who are obese, is that of weight cycling. Weight
cycling is the constant attempt to lose weight and then regaining weight. This cycle repeats over
32
and over again. Weight cycling results in increased inflammation, hypertension, and insulin
resistance. Therefore some researchers have proposed that the issues associated with obesity are
actually caused by weight cycling (Bacon & Aphramor, 2011; (Austin, Field, Wiecha, Peterson,
& Gortmaker, 2005).
Weight loss guidelines put forth the idea that anyone who is truly determined can lose
weight and maintain a healthy weight through healthy diet and exercise behaviors. The
assumption that weight loss is the answer for everyone also discredits genetic, environmental,
and socioeconomic factors that are related to obesity.
2.1.2 Specific obesity prevention efforts
1.) VERB campaign: The VERB campaign was one of the earliest population-based
prevention interventions that Congress funded to promote physical activity among youth. The
VERB campaign’s aim was to increase physical activity in children between 9-13 years old,
through paid media campaigns that used television, radio, and print ads. After one year of the
campaign, effects were found in free-play physical activity, especially among younger children
and girls (Dietz, 2015; Huhman et al., 2010).
In the initial campaign years, higher awareness and understanding of the campaign were
found in girls, children aged 12-14 years old, Caucasian children, children from moderate or high
income households, and children who had at least one parent with a college degree (Huhman et
al., 2010; Huhman, Bauman, & Bowles, 2008). In subsequent years, the campaign focused on
increasing awareness among boys, younger tweens, and ethnic and racial minorities. Boys were
targeted through the development of messages that promoted sports participation and
emphasized boys’ interest in competition. The campaign also increased the media time on
channels that were targeted more toward boys and enlisted professional sports leagues to
33
promote the campaign (Huhman, Bauman, & Bowles, 2008). Younger tweens were targeted
through messages from popular cartoon characters and events sponsored by these cartoon
characters (Huhman, Bauman, & Bowles, 2008). In later years, the VERB campaign also began
to emphasize inclusiveness and diversity through television messages specifically targeted at
African American and Hispanic youth. The campaign also increased awareness among these
groups by increasing VERB community-based promotions through schools and recreation and
youth centers (Huhman, Bauman, & Bowles, 2008).
As a means for surrounding tweens with positive messages regarding physical activity,
the VERB campaign also targeted parents as a secondary audience. Through viewing of
television messages and targeted messages in magazines, the campaign used an educational
strategy to raise parental awareness of the VERB campaign. Parents’ awareness of the campaign
increased with each year of the campaign. The higher the level of parental awareness of the
campaign, the higher the levels of positive attitudes about physical activity for their own child.
These higher levels were also associated with the number of days parents were physically active
with their child (Price, Huhman, & Potter, 2008).
Between 2001 and 2005, children who were aware of this campaign (about 75% of
children in the age group) did report engaging in more physical activity than those who were not
aware of this campaign (Dietz, 2015; Huhman et al., 2010; Banspach, 2008). This increase in
physical activity persisted after two years and into adolescence (Huhman et al., 2010; Banspach,
2008). The more children were exposed to the campaign, the more likely they were to believe in
the benefits of being physically active, their self-efficacy to be physically active increased, and
social influences on their physical activity were present (Huhman et al., 2010).
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The VERB campaign brought together the field of public health and commercial
marketing to target children with healthy messages. Although funding was reduced each year of
the campaign, the campaign still was popular among target children, achieved a high level of
brand awareness, and increased physical activity among targeted children (Huhman et al., 2010).
2.) Bariatric surgery: Providers often consider bariatric surgery to prevent obesity (Bour,
2015). Clinicians typically use bariatric surgery when weight loss and lifestyle interventions are
thought to have failed. Bariatric surgery patients lose significant amounts of excess weight and
experience noticeable improvement in several other obesity-related comorbidities. Some studies
have shown that patients can achieve weight loss between 70%-75% of their body weight within
18 to 24 months (Bour, 2015). However, there are various costs and side effects that keep many
people from getting bariatric surgery (Callahan, 2012). This medically complex procedure can
lead to many complications and issues including pneumonia, pulmonary embolism, band
slippage, abdominal hernias, development of gallstones, dumping syndrome, nutritional
deficiencies, anemia, osteoporosis, hair loss, anastomosis leakage, and even death (Bour, 2015;
Trilk & Kennedy, 2015).
Weight loss following bariatric surgery is variable. In one sample of 1,456 adults who
underwent bariatric surgery, weight loss ranged from 4.1% to 60.9% (Trilk & Kennedy, 2015).
The range in success of bariatric surgeries has been attributed to preoperative eating behaviors,
quality of life, and psychological factors. The initial weight loss seen in bariatric surgery patients
has been related to factors such as greater diet soda intake and greater water intake (Trilk &
Kennedy, 2015).
The benefits of bariatric surgery are still being debated. In comparison of the above
study, another study found bariatric surgery to be partially successful. This study examined two
35
different types of bariatric surgeries, Roux-en-Y (RYGB) and laparoscopic adjustable gastric
banding (LAGB). Of the obese participants who underwent bariatric surgery, 1,739 participants
underwent RYGB and 610 participants underwent LAGB. This study found that there was
substantial weight loss 3 years following the surgery, with the maximum weight loss occurring
during the first year after the surgery. The participants who received RYGB had a median weight
loss of 41 kg and a 31.5% baseline weight loss and the participants who received LAGB had a
median weight loss of 20 kg and a 15.9% baseline weight loss (Courcoulas et al., 2013).
A retrospective outcome study looked at 127 participants who underwent LAGB and 105
participants who underwent RYGB. The study found that after 4 years of consistent weight loss
and BMI loss, these measures stabilized between 5 and 7 years. After 7 years, those who
underwent RYGB had a 58.6% excess weight loss and those who underwent LAGB had a 46.3%
excess weight loss. This study also measured the failure rate of these procedures. Participants
failed if they removed their gastric bands and/or had less than 25% excess weight loss. After 7
years, the failure rate for LAGB participants was 48.3% and 10.7% for RYGB participants. At
10 years, the failure rate for LAGB participants increased to 51.1%. This study found that at 10
years, 52.8% of LAGB participants and 41% of RYGB participants experienced adverse effects
from their bariatric surgery. Finally, the results showed that 8.6% of RYGB participants and
none of the LAGB participants experienced serious and potentially life-threatening
complications. These results show that bariatric surgery can be successful, some procedures are
more successful than others, and some procedures are more risky than others (Spivak,
Abdelmelek, Beltran, Ng, & Kitahama, 2012).
Many bariatric surgeries are being done without proper follow-up care and behavioral
interventions. Another issue is that although healthcare companies may cover bariatric surgery,
36
they will often not cover both bariatric surgery and lifestyle/behavioral interventions. Both of
these issues affect how successful bariatric surgery is in the long run. Over 64% of bariatric
surgery patients regain weight if they do not have proper lifestyle and behavioral modification
(Bour, 2015; Trilk & Kennedy, 2015).
3.) BMI/BMI report cards: Body Mass Index (BMI) is the health measurement standard
when it comes to obesity. While having a higher BMI is associated with chronic health issues,
the health system’s current focus on BMI is problematic. One main issue with BMI is that it does
not differentiate between fat weight and muscle weight. Thus, two men of the same height and
weight could both be diagnosed as obese, despite the fact that one may be a chronic video game
player and chip eater and the other an Olympic athlete. BMI has also been at the center of a
public health initiatives for combating childhood obesity through obesity surveillance and
screening programs (Ruggieri & Bass, 2015; Vogel, 2011).
Legislation for BMI surveillance and screening programs has been passed in 25 states.
However, these programs have been at the center of several ethical debates about confidentiality
and privacy, school-to-parent communication, and safety and self-esteem issues for students.
BMI surveillance programs focus on group data and are far less controversial than BMI
screening programs, such as BMI report cards. BMI screening programs are individualized and
the report cards may conflict with the protection of privacy of students (Ruggieri & Bass, 2015;
Vogel, 2011).
BMI report cards (also known as “fat letters”) are part of school-based programs that
send parents report cards or letters about their child’s weight, BMI, and risk for obesity (Ruggieri
& Bass, 2015; Vogel, 2011). The overall aim of this program is to help parents who may be in
denial about their child. These reports are focused on getting parents to seek a medical diagnosis
37
for their child or to make behavioral changes in their child’s life, such as decreasing television
time. Some people feel that these report cards are important for getting children the help they
need to live healthier lives. Other people feel that this school screening will increase and promote
bullying, weight stigma, negative body image, and unhealthy dieting and attitudes about weight
(Vogel, 2011).
One of the primary concerns of BMI report cards is that of confidentiality during the
measurement process and when communicating results. Most parents would support these
screening programs if respect for student privacy was maintained at all levels. Many schools do
not provide the necessary privacy. BMI assessments are typically done in hallways, classrooms,
or the gymnasium where students are measured in front of one another. Many people feel that
this violation of privacy may cause children to feel uncomfortable or lead to increases in teasing
and bullying (Ruggieri & Bass, 2015; Vogel, 2011).
Another issue with these screening programs is expense. The main costs for program
implementation include measurement equipment, privacy protection, computers and software for
records, staff-related expenses, and mailing supplies. Costs for program implementation range
from as low as $60-$500 in total to as high as $14-$36 per student per year (Ruggieri & Bass,
2015). Resources for these programs may be unaffordable for many schools, which could lead to
unequal experiences across school districts. Critics feel that this financial burden is
overwhelming for many school districts and that money should be spent on more positive
interventions such as physical education and nutrition programs. Supporters feel that the costs of
these screening programs are low compared with the costs and burden of childhood obesity
(Ruggieri & Bass, 2015; Vogel, 2011).
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The BMI report cards have also caused many issues by diagnosing girls going through
puberty and children who are muscular as being obese. These children may not be obese, but this
label may cause them to be bullied or teased. Weight-related teasing and bullying have been
found to be associated with psychosocial complications, such as decreased self-esteem and lower
academic performance. These complications are found in children as young as preschool age and
are experienced by approximately one third of overweight girls and boys (Ruggieri & Bass,
2015). Critics of BMI report cards state that overweight children will experience increased
teasing and bullying, especially during the screening process. However, early evaluation data
from BMI screening programs has shown that weight-related teasing and bullying have not
increased in schools (Ruggieri & Bass, 2015; Vogel, 2011).
Parents take issue with these programs because they feel that the school does not need to
tell them how to take care of their child. The term obese for children is often offensive to parents
and children. CDC categories for diagnosing children have also been found to be confusing for
parents. Parents have also voiced concern over screening children’s weights and BMIs on a
standardized scale because children grow at varying rates (Ruggieri & Bass, 2015; Vogel, 2011).
Overall, little is known about the long-term positive or negative effects of these reports.
For example, data from Arkansas, one of the states that has implemented BMI report cards,
suggests that progress is being made. Since this prevention program has been launched, obesity
rates among students have plateaued at 20% and awareness of weight issues among students and
parents have improved by as much as 4% (Vogel, 2011). However, this program was initiated at
the same time as several other obesity prevention efforts. Therefore, improvements cannot be
attributed to BMI report cards. In the Arkansas schools, the majority of parents are not following
up with doctors after receiving the report card nor have they changed the meals they are serving.
39
Students have also not reported significant changes in their dietary habits (Vogel, 2011).
Findings have shown that BMI report cards alone cannot reduce rates of obesity among students.
BMI report card and screening programs can be somewhat effective in the promotion of health
lifestyles in schools, but only if implemented with other school-based prevention programs
(Ruggieri & Bass, 2015; Vogel, 2011).
4.) The Childhood Obesity Research Demonstration (CORD) project: The CORD
project is a multi-setting, multilevel approach to integrating primary healthcare and public health
prevention efforts in the fight against childhood obesity that includes three phases over four
years (Foltz, Belay, Dooyema, Williams, & Blanck, 2015). The CORD project was created based
on the assumption that the health behavior of children is influenced by factors in multiple
environments (e.g. home, educational, community, and healthcare settings) (Foltz, Belay,
Dooyema, Williams, & Blanck, 2015). This program focuses on improving BMI and obesityrelated behaviors in underserved 2-12 year olds. The CORD project assumes that order for
change to occur in childhood obesity trends, both prevention and treatment interventions across
various settings, programs, and systems are needed (Foltz, Belay, Dooyema, Williams, &
Blanck, 2015).
In 2009, the Children’s Health Insurance Program (CHIP) Reauthorization Act
authorized the CORD project and in 2010, the CORD project was funded by the Affordable Care
Act. CHIP authorized this project because children utilizing CHIP’s services typically have
higher rates of obesity and lower access to care. The CORD project officially began in 2011 and
three demonstration sites were set up to test this program. These demonstration sites partnered
with state and local agencies, community organizations, school districts, healthcare settings,
primary care organizations, and community organizations. This model implements evidence-
40
based interventions for obesity prevention in each setting. The CORD model works to support
existing state and community efforts that encouraged children’s healthy eating, active living, and
obesity prevention. This model also uses community health workers to provide education and
counseling to children and families, link families to resources in their communities, and facilitate
community-wide healthy lifestyle behaviors (Foltz, Belay, Dooyema, Williams, & Blanck,
2015; Williams, Dooyema, Foltz, Belay, & Blanck, 2015).
The CORD project focused on creating policy, system, and environmental changes in an
effort to improve and increase behavior change and population-level obesity prevention efforts.
The sites where the CORD model was implemented focused on changing children’s health
behaviors through the involvement of children, parents, other family members, and the
communities in which they live. Although each site’s individualized interventions have different
approaches to the prevention and management goals, the varying perspectives produce unique
results that can be used to make geographically and demographically-tailored population
interventions. CORD builds on each community’s existing work and programs. The CORD
project also uses a community’s stakeholders and state and local infrastructure (Blanck &
Collins, 2015). The CORD project is fairly new and is still in the evaluation stage. However,
initial results have shown this program to be a promising prevention effort in the field of
childhood obesity (Blank & Collins, 2015; Foltz, Belay, Dooyema, Williams, & Blanck, 2015).
5.) School-based obesity prevention: Schools are a primary setting for implementing
childhood obesity prevention and intervention programs. These programs focus on the
environmental and societal factors that affect food intake and physical activity. Previous schoolbased prevention efforts have added healthier food items to the cafeteria menu and vending
machines. These changes have been somewhat successful in maintaining weight loss and
41
behavioral changes (Hung et al., 2015; Kelishadi & Azizi-Soleiman, 2014). On the other hand,
educational programs taught in schools that are consistent with the Dietary Guidelines for
Americans have proven to be more successful. A recent meta-analysis of school-based obesity
prevention showed that structured interventions in schools that focus on lifestyle factors for
obesity prevention, like online resources for students and parents and physical activity education
and programs for students and parents are shown to be more successful than other school-based
obesity prevention interventions (Hung et al., 2015).
Successes of school-based programs were measured by decreases in the prevalence of
obesity in the schools. However, when BMI or skinfold thickness were used as outcome
measurements, results typically were mixed (Hung et al., 2015; Kelishadi & Azizi-Soleiman,
2014). Many programs showed BMI to be unaffected. Overall, the most effective school-based
programs targeted children rather than adolescents and included nutrition and physical activity
components, along with cognitive elements (Hung et al., 2015). Children have more adaptable
and flexible minds; they are still growing and developing behaviors. This may be one of the
reasons why prevention interventions are more successful with children than with adolescents.
There are a large number of school-based obesity prevention interventions. The following
are just two examples of these prevention interventions:
Choice, Control and Change: This intervention is based on the assumption that body size
is the result of complex interactions between biological, environmental, and personal behavioral
factors. The main goals of this prevention intervention are to foster motivations and skills in
middle school so that they can become adept in navigating the current food system and sedentary
environment and personalize how they interact with food and physical activity in the world
(Gray, Contento, & Koch, 2015; Contento, Koch, Lee, Calabrese-Barton, 2010).
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This approach to obesity prevention is focused on helping youth develop a rationale and
motivation for taking action. The Choice, Control and Change program consists of twenty-four
45 minutes lessons. Example activities and lessons include: understanding that food and activity
choices help the body function; drawing self-portraits; observing food items in neighborhood
stores; analyzing television advertisements; demonstrating the importance of balancing energy in
and energy out; learning about body systems; and collecting and analyzing personal food and
activity data in order to set personal goals (Gray, Contento, & Koch, 2015; Contento, Koch, Lee,
Calabrese-Barton, 2010). These lessons are taught by science teachers for 8 to 10 weeks.
Teachers receive one intensive, 3-hour professional development session and one session in the
middle of the program (Gray, Contento, & Koch, 2015; Contento, Koch, Lee, Calabrese-Barton,
2010).
Intervention students, compared with controls, drank less sweetened beverages and had
smaller sizes of sweetened beverages as time progressed. Intervention students also consumed
fewer packaged and processed snacks and decreased the sizes of snacks over time. Students in
the intervention did not reduce the amount of times they ate at fast-food restaurants. However,
they did report ordering much smaller sized meals from fast-food restaurants. Intervention
students also walked more and more often intentionally took the stairs (Gray, Contento, & Koch,
2015; Contento, Koch, Lee, Calabrese-Barton, 2010). This intervention program also increased
students’ self-efficacy for all targeted behaviors. Intervention students felt an increase in their
motivation for making healthy food choices and being physically active (Gray, Contento, &
Koch, 2015; Contento, Koch, Lee, Calabrese-Barton, 2010).
HEROES Initiative: The HEROES (Health, Energetic, Ready, Outstanding, Enthusiastic,
Schools) Initiative is a multilevel, school-based childhood obesity prevention intervention based
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in states with some of the highest obesity rates (King et al., 2014). The HEROES Initiative
facilitates change within schools by increasing healthy lifestyle habits among students, their
families, and school staff. This intervention aims to create a culture of wellness by bringing
schools and community agencies together. This intervention provides local oversight, substantial
funding, prescribed implementation strategies that can be tailored based on needs. Schools must
commit to three years of involvement and plan on sustaining changes once the funding period
has ended. The HEROES Initiative can be implemented in elementary, middle, and high schools,
along with private and public schools and schools in rural and urban communities. This
intervention’s focus on schools allows each individual school to take ownership and utilize their
own strategies for change (Lederer, King, Sovinski, Seo, & Kim, 2015; King et al., 2014).
The five components related to childhood obesity prevention that the HEROES Initiative
focuses on are health education, physical education, nutritional services, health promotion for
staff, and family and community involvement (Lederer, King, Sovinski, Seo, & Kim, 2015; King
et al., 2014). Intervention efforts include increasing opportunities for physical activity and
healthy eating among students and staff; integrating health and wellness education into academic
curriculum; engaging parents and community-based organizations in supporting healthy
environments inside and outside of school; and empowering schools to develop and implement
healthy lifestyle policies for students, their families, and school staff (Lederer, King, Sovinski,
Seo, & Kim, 2015; King et al., 2014). Funding for the HEROES Initiative goes towards a stipend
for a part-time school wellness coordinator, program materials, and upgrades for gym and
physical activity equipment (Lederer, King, Sovinski, Seo, & Kim, 2015; King et al., 2014).
Findings on the HEROES Initiative have shown that this program has been successful in
reducing the percentage of overweight children in schools, along with modifying children’s
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dietary, physical activity, and sedentary behaviors (Lederer, King, Sovinski, Seo, & Kim, 2015;
King et al., 2014). Initial evaluation has shown that the HEROES Initiative is associated with
students’ increased intake of vegetables and fruits. Unhealthy eating behaviors and soda
consumption were decreased over an 18-month evaluation period. Physical activity-related
behaviors were increased and television and computer screen time were noticeably decreased
(Lederer, King, Sovinski, Seo, & Kim, 2015; King et al., 2014).
6.) Let’s Move! initiative and the Obama administration: The Let’s Move! initiative was
founded during the first Obama administration with Michelle Obama leading the campaign. This
campaign came out of the Task Force on Childhood Obesity, which focused on developing
interventions for early childhood, empowering parents and caregivers, ensuring that healthy food
was in schools, ensuring that children had access to healthy and affordable food, and increasing
physical activity. The Let’s Move! initiative became the foundation for many of the Obama
administration’s legislative and regulatory activities aimed at implementing the Task Force on
Childhood Obesity’s recommendations (Bumpus, Tagtow, & Haven, 2015; Dietz, 2015; Katz,
2012; Wojcicki, & Heyman, 2010).
One of the first steps of Let’s Move! was to partner with the Health Weight Commitment
Foundation to lower calories in the food supply. The partnership worked to engage companies
that supplied more than 30% of the calories in the US food supply to reduce 1.5 trillion calories
in the daily food supply by 2015. By 2014, the companies reported that they had reduced 6.4
trillion calories in the daily food supply (Dietz, 2015).
Michelle Obama’s role in the Let’s Move! initiative was especially important to this
campaign’s success. As a parent, herself, she was able to personalize the situation and relate to
the challenges that parents face when trying to promote healthy diets and physical activity to
45
their children. Michelle Obama appeared on various media outlets to promote the message,
which increased the visibility of the campaign and awareness of the obesity epidemic (Bumpus,
Tagtow, & Haven, 2015; Dietz, 2015; Katz, 2012; Wojcicki, & Heyman, 2010).
The Let’s Move! initiative also has several smaller programs that have been implemented
over the past five years. “Let’s Move! Cities Towns and Counties” involves a partnership
between the National League of Cities (NLC), Department of Human and Health Services
(HHS), the United States Department of Agriculture (USDA), the National Association of
Counties, and several other nonprofit groups. The goal of this initiative is to encourage and
support elected officials in making policy and environmental changes to prevent childhood
obesity. As of 2014, over 450 sites that represent more than 70 million people have taken part.
Of the participating sites, 20 sites have been recognized nationally for their efforts (Bumpus,
Tagtow, & Haven, 2015). “Let’s Move! Faith and Communities” and “Let’s Move! Museums
and Gardens” are other programs under the Let’s Move! initiative. “Let’s Move! Faith and
Communities” is a partnership with HHS that involves encouraging faith, neighborhood, and
community-based organizations to create and coordinate activities that promote the wellness of
children and their families. “Let’s Move! Museums and Gardens” is a program through which
children’s museums, public gardens, science museums, art and history museums, and zoos work
to encourage healthy living. Some examples of steps this program has taken include interactive
exhibits, outdoor spaces and gardens for families, and programs that encourage families to eat
healthy and increase their physical activity (Bumpus, Tagtow, & Haven, 2015; Dietz, 2015).
“Let’s Move! In Indian Country” is a program that aims to improve the health of
American Indian and Alaskan Native children through collaboration and health eating and
physical activity program planning. These two groups have some of the highest rates of
46
childhood obesity in the country. “Let’s Move! Child Care” is a program that works with early
care education providers, children, and their families to increase physical activity, reduce
television and computer screen time, offer healthy beverage choices, serve healthy food, and
support infant feeding. These best practices are taught through free online trainings that discuss
strategies for implementation. Through this program, early care education providers can also
obtain continuing education and professional development credits (Bumpus, Tagtow, & Haven,
2015; Dietz, 2015).
“The Healthy Lunchtime Challenge” program is a contest where children can submit
original recipes that are considered to be both healthy and delicious. Winners of this contest are
invited to attend a Kids’ State Dinner at the White House. Winning recipes are collected and
compiled into a Healthy Lunchtime Challenge Cookbook. This program inspired a collaboration
called “Kids and Chefs Cook for Success” which involves the winners and local chefs partnering
to teach other children about health cooking (Bumpus, Tagtow, & Haven, 2015; Dietz, 2015).
“Let’s Move! Active Schools” is a program that works with schools to promote physical activity
among children. A customized action plan is created to incorporate physical activity before,
during, and after school for at least 60 minutes and day. The main goal of this program is create a
culture where physical activity is a foundation to academic success (Bumpus, Tagtow, & Haven,
2015; Dietz, 2015).
“Let’s Move! Salad Bars to Schools” and “Chefs Move to Schools” are two school-based
programs that help increase healthy food choices in the school environment, while staying within
the school’s budget. This program encourages gardening, menu and recipe development, culinary
training for staff, cooking demonstrations, and education in the classroom about healthy eating
and cooking (Bumpus, Tagtow, & Haven, 2015; Dietz, 2015). “Let’s Move! Outside” is a
47
program that encourages children and their families to be active outside and to explore the “great
outdoors.” “Let’s Read, Let’s Move!” is a program that aims to reduce summer reading loss and
childhood obesity. Celebrities, politicians, and other famous figures read to children and take
part in physical activities (Bumpus, Tagtow, & Haven, 2015; Dietz, 2015). This initiative and its
smaller programs have shown some initial success. However, the initiative and programs are all
still being evaluated (Dietz, 2015).
The Obama administration has also partnered with the Department of Human and Health
Services, the United States Department of Agriculture, and the US Treasury to fund the Healthy
Food Financing Initiative. This initiative focuses on getting retailers to build grocery stores in
“food deserts,” neighborhoods that lack grocery stores. The Obama administration also created
the Partnership for a Healthier America, which allowed direct contractual commitments to be
made between the PHA and various industries. Other important policies and standards that the
Obama administration put into place include: supporting breastfeeding in businesses and
including it in the Affordable Care Act; menu labeling, creating standards for meals; and
developing the Healthy Hunger-Free Kids Act (Bumpus, Tagtow, & Haven, 2015; Dietz, 2015;
Katz, 2012; Wojcicki, & Heyman, 2010).
Overall, the Obama administration and the Let’s Move! initiative has shown some
success. A national survey found there has been a statistically significant decrease in the
prevalence of obesity in children 2-5 years old (Dietz, 2015). However, the main area of success
has been the creation and increase of public awareness about childhood obesity. Presently, 55%
of Americans feel that childhood obesity is the most important national health concern (Dietz,
2015). This increased awareness of obesity, especially childhood obesity, has caused many
Americans to change their behavior, namely though decreased consumption of sugar drinks and
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fast food (Bumpus, Tagtow, & Haven, 2015; Dietz, 2015; Katz, 2012; Wojcicki, & Heyman,
2010).
Many are worried that the next presidential administration will not be focused on the
obesity epidemic or that the Obamas will not continue to campaign against childhood obesity,
which in turn may reverse the progress that has been made. Moving forward, it has been
suggested that a shift in the current obesity paradigm is needed. People feel that focusing on
weight and obesity is negative and that there needs to be a move towards promoting overall
wellness. This wellness paradigm would focus not only on nutrition and physical activity, but
also on other areas related to obesity, such as mental health (Bumpus, Tagtow, & Haven, 2015;
Dietz, 2015; Katz, 2012; Wojcicki, & Heyman, 2010). In order to keep moving forward with
obesity prevention, there needs to be a common agenda, shared measurements, shared
reinforcing activities, continuous communication, and structural support from the government,
companies, and other institutions.
2.2 Research on the prevention of eating disorders/disordered eating
2.2.1 General approaches to eating disorder/disordered eating prevention
Interventions that have been most successful in reducing eating disorders and disordered eating
among adolescent girls focus on reducing body dissatisfaction. These selective prevention
programs also focus on reducing the internalization of the thin-ideal, reducing pressure to be
thin, and creating a more balanced view of food and dieting (Stice et al., 2013; Stice, Ng, &
Shaw, 2010). Prevention programs that target adolescents with high levels of body dissatisfaction
and those with high thin-ideal internalization have been proven to reduce body dissatisfaction,
eating disorder pathology, and risk for subthreshold and clinically diagnosed eating disorders
(Stice, Ng, & Shaw, 2010). Other modifiable factors that eating disorder/disordered eating
49
programs address include the pressure to be thin and the pursuit of the thin ideal. Programs that
address these factors have also been shown to reduce eating disorder symptoms and pathology
(Stice, Ng, & Shaw, 2010). Community-partnership research and interventions increase the
dissemination of interventions such as the dissonance-based interventions created for eating
disorders. By engaging community members and partners in decision-making and power,
knowledge about the health problem can spread and improvements can be made through
interventions. (Becker et al., 2009).
Prevention programs that use a social-ecological approach and target not only the
individual, but the environment, have also been successful in eating disorder and disordered
eating prevention (National Eating Disorders Association, 2011). When the environment is
modified, there is a chance for a positive impact on people who are not enrolled in a specific
prevention program. Environmental prevention programs need to focus on reducing the
objectification of women, along with the social pressures for men to be extremely muscular.
Both of these factors play a role in body dissatisfaction and the development of eating
disorders/disordered eating. Thus, environmental prevention approaches need to deal with issues
of the gendered nature of body image concerns and self-esteem. Environmental prevention
programs also need to focus on the impact of ethnicity and gender on body image and weightrelated issues (Neumark-Sztainer et al., 2006).
Prevention programs for eating disorders and disordered eating have been primarily
psychoeducational. However, newer interventions focus on decreasing risk factors (e.g. the thinideal, body dissatisfaction, dieting) and increasing protective factors (e.g. stress management,
critical use of the mass media). One of the successful interventions is Body Image Cognitive
Behavioral Therapy in which dysfunctional thoughts, feelings, and behaviors are modified
50
through psychoeducation, self-monitoring, cognitive restructuring, and other CBT methods
(Cash & Smolak, 2011). The success of these programs and interventions has been small,
especially in comparison to the currently widespread use of dissonance-based interventions
(Stice, Becker, & Yokum, 2013; Stice et al., 2012; McMillan et al., 2011; Stice et al., 2011a;
Stice et al., 2011b; Stice et al., 2008b).
1.) Role of the physician in prevention: Physicians play a key role in eating disorder
prevention. Important primary prevention methods for physicians include promoting positive
body image, promoting effective communication, especially within families, healthy
encouragement of physical activity, and guiding parents and their children through the various
challenges of growing up and individuation. Secondary prevention methods for physicians
include noticing changes in a patient’s physical appearance (i.e. weight, vital signs, growth),
sharing concerns about their change in appearance, and providing initial counseling. Other
secondary prevention methods include educating the patient about the importance of adequate
nutrition and healthy living and working with the patient’s school, athletic organizations, and
other social groups. Tertiary prevention methods for physicians include referring patients to
appropriate treatment/therapy by being knowledgeable about resources in the area, breaking the
patient’s denial by giving them a historical perspective of their behavior, educating the patient
about the consequences of an eating disorder and the benefits of treatment, and monitoring the
patient’s medical status. Other important tertiary prevention methods include setting a positive
example for the patient regarding needing others’ help by collaborating with mental health
professionals and advocating for appropriate care for the patient (National Eating Disorders
Association, 2011; Neumark-Sztainer, et al., 2006).
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2.) Role of a parent in prevention: Parents also play an important role in eating
disorder/disordered eating prevention. Parents influence how their children socialize, eat, and
respond to stress. Parents also influence their child’s food environment and how the child feels
about weight, food, dieting, and body image in general and their own self-image. Parents’ dieting
behaviors and teasing or critical comments about their child’s weight are related to how the child
relates and feels about food and their body later in life (National Eating Disorders Association,
2011; Neumark-Sztainer, et al., 2006).
3.) School-based approaches to eating disorder/disordered eating prevention: Schoolbased interventions that are interactive and engaging have been shown to produce positive peer
norms and create media literacy, resistance skills, stress management, and other helpful life
skills. These skills reduce the risk of disordered eating and body dissatisfaction among young
women and girls. Interventions that have been most successful focused on changing the culture
around food, dieting, and body image in schools (Mcvey et al., 2012; Cash & Smolak, 2011;
Berger et al., 2008).
2.2.2 Specific eating disorder/disordered eating prevention efforts
1.) Yoga and mind-body strategies: Mind-body strategies are important to eating
disorder/disordered eating prevention primarily because of the components of self-acceptance
and being in the moment. Mind-body strategies that have been used with adolescents and young
adults include interactive discourse, yoga, and relaxation. Results on these mind-body strategies
are mixed, but do show some promise in reducing disordered eating attitudes and behaviors
(Neumark-Sztainer, 2014; Scime & Cook, 2008).
Early research has suggested that yoga may be effective in decreasing risk factors and
increasing protective factors for eating disorders and disordered eating. Yoga is the practice of
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physical postures, mindfulness, and meditation, in which one can explore the mind-body
connection and find acceptance of the self. Yoga has also been found to be helpful in the
treatment of eating disorders. Yoga is a good prevention method because it is accessible and not
too costly. Researchers recommend that either eating disorder prevention be integrated into
ongoing yoga classes or that yoga be integrated into existing eating disorder prevention
programs. Incorporating eating disorder and disordered eating prevention messages into yoga
classes will allow prevention experts to teach those in the yoga class about the risks and
behaviors of eating disorders/disordered eating. Positive body image and self-acceptance can
also be incorporated in the practice of yoga, since yoga’s message is one of self-acceptance and
being in the moment (Neumark-Sztainer, 2014; Scime & Cook, 2008).
One notable study that examined the relationship between eating disorders and disordered
eating and yoga was conducted with 1030 men and 1257 women (30% early young adults and
70% older young adults). This study found that young women who participated in yoga/Pilates
were less likely to report body dissatisfaction than those who did not practice yoga/Pilates
(36.1% vs. 51.4%). However, young men who practiced yoga/Pilates displayed higher levels of
extreme and unhealthy weight control behaviors than young men who did not practice
yoga/Pilates (17.0% vs. 7.4%). Overall, both women and men practiced unhealthy weight control
methods regardless of their participation in yoga. More research needs to be done in this area, but
results from this study show that yoga/Pilates is a promising means to increase body satisfaction
(Neumark-Sztainer, Eisenberg, Wall, & Loth, 2011).
2.) Media literacy interventions: Interventions that involve teaching the public media
literacy skills have been used in eating disorder/disordered eating prevention. Media literacy
focuses on critical thinking and viewing of media. These prevention efforts are based on the
53
belief that the environment and societal pressures to be thin or look a certain way affect how
someone feels about their body. Family, peers, and the media all affect how one thinks and feels
about weight and appearance in general. This model posits that a person’s body image and selfesteem depend on how much a person internalizes this beauty standard and thin-ideal (Coughlin
& Kalodner, 2006; Hesse-Biber, Leavy, Quinn, & Zoino, 2006).
These prevention programs encourage people to become active and conscientious
consumers of media (Coughlin & Kalodner, 2006). Media literacy programs teach participants
how to critically analyze media messages and develop ways of putting their own message into
the multi-media networks. Media literacy also focuses on examining the strategies that the media
uses and ways in which participants can question the images and messages they receive. This
development of critical thinking and viewing can assist in decreasing the internalization of
unhealthy messages (Hesse-Biber, Leavy, Quinn, & Zoino, 2006).
One of the main aims of these prevention efforts is to promote healthy lifestyle changes
and behaviors through media literacy. It is important that these interventions include an
assessment of one’s knowledge, attitudes, and behaviors in regards to the media, body image,
weight management, and eating patterns. Studies have shown that a brief version of a media
literacy intervention combined with psychoeducation before one is exposed to certain media,
reduces the negative effects of the media images (Hesse-Biber, Leavy, Quinn, & Zoino, 2006;
Neumark-Sztainer et al., 2006).
Some of those in the eating disorder/disordered eating field feel that media literacy
efforts, such as anti-dieting or anti-PhotoShop campaigns, would be key prevention efforts for
the general population. Others in the field feel that media literacy is only effective as a secondary
prevention effort for eating disorders (Coughlin & Kalodner, 2006).
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A study that examined the effects of the thin-ideal media and a media-literacy
psychoeducation program on young college women found that the media-literacy
psychoeducation program reduced negative body image concerns in women with high thininternalization levels (Yamamiya, Cash, Melnyk, Posavac, & Posavac, 2005). The study also
found that just being exposed to thin-ideal media for five minutes, results in negative body image
thoughts and beliefs in young women and those levels of body dissatisfaction are amplified with
the level of thin-ideal internalization (Yamamiya, Cash, Melnyk, Posavac, & Posavac, 2005).
One example of a tested and replicated media literacy intervention is Media Smart. Media
Smart is a school-based prevention program for eating disorders and has been shown to be
effective with young adolescents. This program was developed to focus on media and thin ideal
internalization (i.e. muscular ideal for boys but referred here as thin ideal). Media and thin ideal
internalization are main risk factors for eating disorders and disordered eating. These factors can
lead to body dissatisfaction which also leads to eating disorders and disordered eating. Media
Smart is an eight-week program that focuses on stereotypes, digital altering of images, pressures
that young people experience and how to confront those pressures, group presentations, and
activism activities such as writing to advertising agencies about negative advertisement
messages. Media Smart, like most other eating disorder prevention efforts, has been shown to
have good efficacy, but effectiveness of this and other eating disorder programs has not been
researched properly (Wilksch, 2015; Wilksch, & Wade, 2014).
An efficacy randomized-controlled trial (RCT) of Media Smart was conducted with 540
eighth grade girls and boys. Eleven classes were given the Media Smart intervention and 13
classes received no-intervention to serve as the control. The RCT showed a significant reduction
55
in shape and weight concerns and body dissatisfaction scores, even at the 2.5-year follow up
(Wilksch, 2015; Wilksch & Wade, 2014). A more recent study of Media Smart found that for
shape and weight concerns, there was a non-significant difference of small to moderate effect
size that showed favor to the Media Smart group; both boys and girls in the Media Smart
condition scored lower on weight and shape concerns at follow-up. Although the decrease in
weight and shape concerns in the intervention group was not significant in this study, the effect
size was similar to that seen in the prior RCT (Wilksch, 2015; Wilksch & Wade, 2014). This
similarity shows that in order to see the same effect as the RCT, more research and possibly a
larger sample followed over a longer period of time is needed.
On the factors of feelings of ineffectiveness and weight-related teasing, there were
significant main effects of moderate size that favored the Media Smart group. Girls in the Media
Smart group scored significantly lower than the control group on participating in weight-related
teasing and girls in the Media Smart group also showed increased self-esteem after the
intervention. Boys in the Media Smart group showed the largest effect sizes for decreased
feelings of ineffectiveness and participation in weight-related teasing (Wilksch, 2015).
3.) Student BodiesTM: This 8-week online intervention was created for college women
with high levels of weight and shape concerns. The prevention intervention focuses on
improving body image, health weight management, psychoeducation, and nutrition. Student
BodiesTM uses cognitive-behavioral strategies to increase body satisfaction, while reducing
weight and shape concerns. These strategies include self-monitoring, goal setting, journaling,
and online discussion groups. This prevention intervention has been shown to reduce body
dissatisfaction, drive for thinness, and eating disorder pathology in participants (Ciao, Loth, &
Neumark-Sztainer, 2014; Kass et al., 2014). Student BodiesTM was conducted as a large RCT
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with 480 college women who displayed high levels of weight and shape concerns. Compared to
the waitlist control group, those who received the intervention experienced noticeable reductions
in body dissatisfaction, drive to be thin, and eating disorder pathology at post-intervention and at
the 1-year follow-up (Ciao, Loth, & Neumark-Sztainer, 2014; Kass et al., 2014).
Although originally designed for college women, two adapted versions of Student
BodiesTM have been developed for sub-threshold eating disorders. One modified program is for
overweight high school girls and boys with sub-threshold binge eating and the other modified
program is for college women with subclinical eating disorders. Both of these programs also
resulted in a greater reduction in eating disorder pathology compared to the waitlist control
through the 5-to-6-month follow-up (Ciao, Loth, Neumark-Sztainer, 2014; Kass et al., 2014).
4.) Dissonance-based interventions: Limited efficacy of previous eating disorder
interventions led to the development of dissonance-based interventions that use the principle of
dissonance-based persuasion to make lasting change in body dissatisfaction and disordered
eating (Stice et al., 2008b; Berger et al., 2008). Dissonance-based interventions have been shown
to be the most effective in reducing body dissatisfaction, disordered eating, and eating disorder
symptomatology and pathology. These dissonance-based interventions focus on creating
cognitive dissonance in regards to the thin-ideal female standard of beauty through exercises
where participants speak, write, and act against the thin ideal through homework and group
activities (Stice et al., 2013; Becker et al., 2013; Kroon Van Diest & Perez, 2012; Becker et al.,
2009). With dissonance-based interventions, there are typically 2-4 sessions that last 3-4 hours.
These sessions focus on creating dissonance (i.e. psychological discomfort), which will motivate
participants to reduce the internalization of the thin ideal and in turn decrease body
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dissatisfaction, disordered eating, negative affect, eating disorder symptoms, and risk for future
eating disorders (Becker et al., 2009).
Dissonance-based interventions for eating disorders have high efficacy and have also
been tested to show high effectiveness with young woman and young girls (Becker et al., 2009;
Stice et al., 2009). Dissonance-based interventions for body dissatisfaction and disordered eating
have also proven to be effective cross-culturally. One study showed that a dissonance-based
intervention reduced disordered eating and eating disorder pathology among Caucasian, AsianAmerican, and Hispanic participants significantly and equally across these ethnic groups
(Rodriguez, Marchand, Ng, & Stice, 2008).
The Body Project is the leading dissonance-based body acceptance program for young
girls and young women. This intervention has more research supporting it than any other body
image program. It has been found to reduce the onset of eating disorders, the internalization of
the thin ideal, disordered eating, body dissatisfaction, unhealthy weight control and dieting
patterns, and negative affect among girls in middle school, high school, and college. The Body
Project has also been found to reduce the risk of obesity and mental health care utilization (Stice
et al., 2008a). This 3-4 hour intervention has participants partake in a series of verbal, written,
and behavioral exercises where they critique the thin ideal. The Body Project has been
implemented in school districts across the country. There are several variations of the original
intervention, including an Internet intervention and a peer-led group version (Butryn et al., 2014;
Stice et al., 2013; Stice et al., 2012; Stice et al., 2011a; Stice et al. 2011b; Stice, Ng, & Shaw,
2010; Stice et al., 2009).
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In effectiveness and efficacy trials, the Body Project has produced statistically significant
and clinically meaningful 60% reductions in eating disorders over a 3-year follow-up (Stice,
Becker, & Yokum, 2013; Stice et al., 2011a; Stice et al., 2011b; Stice et al., 2009; Stice et al.
2008a). In several studies on the Body Project, the results suggested that for every 100 young
women who complete the Body Project intervention, 9 fewer would show the onset of eating
disorder and disordered eating pathology (Stice et al., 2009; Stice et al., 2008a). The Body
Project was compared with the Healthy Weight intervention, an expressive writing control
intervention, and an assessment-only control condition. The results of the experimental analysis
showed that The Body Project produced the most significant changes and improvements in body
satisfaction and in the reduction of disordered eating (Stice, Becker, & Yokum, 2013; McMillan
et al., 2011; Stice et al., 2008a). The Body Project has been repeatedly shown to reduce the risk
of eating disorder pathology over multi-year follow-ups (Cia, Loth, & Neumark-Sztainer, 2014;
Stice, Becker, & Yokum, 2013).
5.) The Healthy Weight intervention: The Healthy Weight program was originally
created to be used as a comparison intervention in the Body Project research trials. The Healthy
Weight program focuses on achieving body satisfaction among young women, by promoting
enduring healthy improvements to dietary intake and exercise. Originally used for eating
disorder and disordered eating prevention, it has also been applied to obesity prevention (Stice et
al., 2008a). The Healthy Weight intervention attempts to reduce the risk for unhealthy weight
control patterns and eating disorder pathology. Lifestyle change in diet and weight, along with
education are the key components of this intervention (Ciao, Loth, & Neumark-Sztainer, 2014;
Stice et al., 2008a). Participants learn about determinants of weight and shape, along with how to
create a personal lifestyle change plan that involves gradual health improvements to their diet
59
and activity level (Ciao, Loth, & Neumark-Sztainer, 2014; Stice et al., 2008a). This intervention
can be done as a two, three, or four session program (Ciao, Loth, & Neumark-Sztainer, 2014).
Several studies comparing the Healthy Weight intervention with a control group showed
that intervention participants showed significant reductions in thin-ideal internalization, negative
affect, and eating disorder pathology at the post-test, the 3-month follow-up, the 6-month follow
up, and the 2-to-3 year follow-up. These studies found that Healthy Weight intervention
participants showed a 61% reduction in disordered eating pathology and a 55% reduction in risk
for obesity (Ciao, Loth, & Neumark-Sztainer, 2014; Stice et al., 2008a; Stice et al., 2008b).
Overall, the Healthy Weight program promotes moderate and healthy physical activity, delivers
healthy weight management education, and reduces the risk of eating disorder pathology (Ciao,
Loth, & Neumark-Sztainer, 2014).
6.) Proud2BMe: Proud2BMe is an online community for adolescents focused on
promoting positive body image and encouraging healthy attitudes about food and weight.
Proud2BMe was founded by Rivierduinen, a mental health organization in the Netherlands. In
2011, the United States-based organization, the National Eating Disorders Association (NEDA)
was licensed the concept of Proud2BMe and has since taken over this website and concept. This
website has information about eating disorders, disordered eating, body image, media literacy,
advocacy, stories of hope, events, fashion and beauty news, and culture and entertainment news.
This website serves as a place where adolescents can learn how to empower themselves and
others, while building their confidence and self-esteem (Aardoom, Dingemans, Boogaard, & Van
Furth, 2014; Proud2BMe, 2011).
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2.3 Research on the prevention of obesity and eating disorders/disordered eating
2.3.1 General approaches for combined prevention Eating disorders and obesity are
linked in multiple ways, thus campaigns for obesity reduction and prevention need to focus on
both issues (Austin, 2011). Since disordered eating, media influences, and weight-stigma play a
role in someone becoming overweight and/or obese, it has been suggested that socialecologically based interventions could be good starting points for the prevention of obesity and
eating disorders/disordered eating (Mcvey et al., 2012). At the individual level, the factors of the
thin-ideal internalization, body dissatisfaction, and perfectionism can be examined and targeted;
at the interpersonal level, an adolescent’s family and peers can be targeted (e.g. critical
comments about weight/size); and on a socio-cultural level, factors such as gender inequality,
weight stigma and prejudice, ethnocultural bias, and classism can be targeted. School-based
prevention programs that focus on changing peer norms and increasing involvement of teachers
and parents, have also been shown to reduce risky behaviors and disordered eating issues
(Mcvey, et al., 2012).
Prevention programs that reduce the thin-ideal internalization have been designed for
young girls and have been shown to reduce eating disorder pathology, body dissatisfaction, and
risk for eating disorders (Stice, Ng, & Shaw, 2010). Targeting girls in high school has been
shown to have more positive responses to prevention programs that focus on reducing and
preventing body dissatisfaction (Wojtowicz & von Ranson, 2012). School-based interventions
that are interactive and engaging have been shown to produce positive peer norms and create
resistance, stress management, and other helpful life skills. These skills reduce the risk of
disordered eating and body dissatisfaction (Mcvey et al., 2012; Cash & Smolak, 2011).
Interventions like cognitive dissonance exercises, media literacy, education about the hazards of
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dieting, teaching coping skills like art therapy and yoga, and coming up with non-dieting
approaches to weight control could all be successful in reducing disordered eating and body
dissatisfaction (Cash & Smolak, 2011; Stice et al., 2008b). The prevention interventions that
have been most successful focused on changing the culture around food, dieting, and body image
in schools (Mcvey et al., 2012; Cash & Smolak, 2011; Berger et al., 2008).
Media literacy, the Healthy Weight intervention, the Body Project, yoga and mind-body
strategies, along with several other eating disorder prevention interventions can also be used for
an integrated prevention approach between eating disorders/disordered eating and obesity. This
is primarily because of the shared risk factors between conditions of body dissatisfaction, low
self-esteem, and level of thin ideal internalization. There are also combined prevention efforts
and interventions that have shown some success in addressing eating disorders, disordered
eating, and obesity.
2.3.2 Specific combined prevention efforts
1.) New Moves: This integrated 16-week prevention intervention is a school-based
program for high school girls who are overweight or at risk of becoming overweight. New Moves
incorporates strategies from both eating disorder and obesity prevention by promoting behavioral
change. Program strategies include, psychoeducation for students and their parents, physical
education classes involving moderate and non-competitive physical activities, discussion
regarding social support, self-empowerment, and a non-dieting approach to nutrition, individual
counseling for goal setting and motivational activities, and lunch meetings to practice healthy
eating while socializing (Ciao, Loth, & Neumark-Sztainer, 2014; Friend, Flattum, Simpson,
Nederhoff, & Neumark-Sztainer, 2014; Neumark-Sztainer et al., 2006). New Moves promotes
moderate and healthy physical activity and self-empowerment through school-based classroom
62
curriculum. Although New Moves focuses on reducing obesity through healthy weight
management, this goal can directly benefit the prevention of extreme weight control behaviors
and disordered eating. (Ciao, Loth, & Neumark-Sztainer, 2014; Neumark-Sztainer et al., 2006).
Original research on New Moves showed that although program effects were modest,
New Moves was positively received by girls, parents, and school staff. Girls who participated in
this research stated that they had experienced increased self-efficacy and positive changes in how
they perceived themselves (Neumark-Sztainer, et al., 2006). New Moves was also evaluated in a
RCT of 356 high school girls and was compared to a control condition of an all-girls physical
education class. New Moves did not lead to any significant changes in participants’ body fat
percentage or BMI. However, improvements were seen in sedentary activity, eating patterns,
unhealthy weight control behaviors, self-efficacy, and body image (Neumark-Sztainer et al.,
2010). Results from the 9-month follow-up showed that in comparison to the control group, girls
in the intervention group decreased their sedentary behaviors by 30-minutes block day and
increased their food portion control behaviors (Neumark-Sztainer et al., 2010). At the 9-month
follow-up, girls in the New Moves intervention groups showed improvements in body image and
self-worth. Another finding at the 9-month follow-up showed that the percentage of participants
using unhealthy weight control behaviors decreased by 13.7% (Ciao, Loth, & Neumark-Sztainer,
2014; Neumark-Sztainer, et al., 2010).
New Moves does not focus on weight loss goals, but rathe healthy behavioral change. It is
a novel approach that focuses on creating a supportive environment where girls of all sizes and
shapes can be comfortable being physically active and healthy (Neumark-Sztainer et al., 2010).
The Substance Abuse and Mental Health Service Administration (SAMHSA) and the National
Cancer Institute at the National Institutes of Health have recognized New Moves as an evidence-
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based program that can produce positive behavioral and psychosocial results (Ciao, Loth, &
Neumark-Sztainer, 2014; Friend, Flattum, Simpson, Nederhoff, & Neumark-Sztainer, 2014).
2.) Interpersonal Therapy: A 12-week interpersonal psychotherapy (IPT) targeted
prevention program was created for adolescent girls at high risk for obesity and eating disorders.
This program involved a 1.5 hour individual meeting with participants, which was followed by
weekly 90 minute group sessions. Studies have shown that targeted prevention approaches for atrisk subgroups of youth have greater effects than weight-management programs (TanofskyKraff, et al., 2014; Tanofsky-Kraff, 2010).
When IPT was given to girls at-risk for excess weight gain with loss of control eating,
greater reductions in loss of control eating episodes was found in comparison to those in the
health education control group. Another finding was that girls, regardless of whether they had
previously experienced loss of control eating, in the IPT intervention group were shown to be
less likely to increase their BMI as expected for their age and BMI percentile (Tanofsky-Kraff et
al., 2010). Interpersonal psychotherapy has also shown short and long term efficacy with adults
in reducing binge eating and loss of control eating. In several follow-ups, IPT was shown to be
more efficacious than health education at reducing out of control eating (Tanofsky-Kraff, et al.,
2014). After going through this program, participants experienced decreases in expected BMI
gain and disinhibited eating. This program also proved to be more effective than healtheducation programs (Tanofsky-Kraff, et al., 2014).
3.) Planet Health: Planet Health is a multifaceted environmental and school-based
prevention intervention (Neumark-Sztainer et al., 2006). Although it was originally developed to
prevent obesity among middle school girls and boys, this program has also been shown to be
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useful in preventing eating disorders and disordered eating behaviors (Ciao, Loth, & NeumarkSztainer, 2014; Austin, Field, Wiecha, Peterson, & Gortmaker, 2005). This prevention
intervention promotes behavioral changes in media viewing, physical activity, and nutritional
choices. Classroom teachers give 32 program lessons over a 2-year time period. This prevention
strategy also includes physical activity and nutrition checks that are integrated into physical
education classes (Ciao, Loth, & Neumark-Sztainer, 2014; Austin, Field, Wiecha, Peterson, &
Gortmaker, 2005).
Planet Health has shown positive effects on BMI and other weight-related outcomes for
girls. It has also shown decreases in eating disorder pathology and unhealthy weight control
behaviors. Girls who participated in Planet Health reported decreases in their purging and diet
pill usage compared to girls in control groups (Ciao, Loth, & Neumark-Sztainer, 2014). Planet
Health has shown both efficacy and effectiveness with reducing unhealthy weight control
behaviors in middle school girls (Ciao, Loth, & Neumark-Sztainer, 2014; Neumark-Sztainer et
al., 2006).
Planet Health’s original RCT used an assessment-only control group with 1295 middle
school children. This initial trial showed positive effects on BMI and other weight-related
outcomes for girls involved in the study. A secondary analysis, with a subset of 480 girls, also
showed positive effects on eating disorder pathology. For example, girls who participated in the
intervention program were less likely to report purging and diet pill use than those girls in the
control group. An effectiveness trial with 1551 middle school children found that girls in the
intervention group were less likely to use unhealthy weight control behaviors in comparison to
an environmental-intervention control group.
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One study that used the Planet Health program found that after the intervention, 14
(6.2%) of 226 girls in the control group and 7 (2.8%) of 254 girls in the intervention group
reported purging or using diet pills to control their weight. Girls who participated in the
intervention were also less than half as likely to report purging or using diet pills at follow-up
when compared with girls in the control groups. This study also estimated that the Planet Health
program prevented 59% of new cases of disordered weight-control behaviors among girls in the
intervention group (Austin,Field, Wiecha, Peterson, & Gortmaker, 2005).
An intervention that involved the Planet Health program and a self-assessment planning
guide for healthy eating and physical activity was implemented in Massachusetts. This crosssectional study found that students with higher levels of exposure to the Planet Health program
had lower rates of disordered eating and weight control behaviors after three years (Ciao, Loth,
& Neumark-Sztainer, 2014; Austin et al., 2007). At the follow-up, it was found that the number
of girls in the intervention groups partaking in unhealthy weight control behaviors was reduced
by two thirds compared with girls in control schools (Austin et al., 2007).
Overall, Planet Health promotes moderate and healthy physical activity and reduced
television and computer screen time (Ciao, Loth, & Neumark-Sztainer, 2014).
4.) Health at Every Size (HAES): This prevention intervention is a weight-neutral
approach that has an overall focus on holistic health (Bombak, 2014; Watkins, 2013; Provencher
et al., 2009). HAES is a wellness to obesity approach that also addresses disordered eating
behaviors and eating disorders. This prevention intervention decentralizes the focus on weight
and dieting as intervention targets. Instead HAES focuses on health behavior change through the
assessment of metabolic variables and psychosocial variables, like body image (Bombak, 2014;
Watkins, 2013; Bacon & Aphramor, 2011; Provencher et al., 2009). HAES also promotes the
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message that there are various body shapes and sizes that can be considered healthy. The
message is also that thin bodies are not necessarily healthy and the only body type considered
attractive. This prevention strategy includes endorsing body self-acceptance, intuitive eating (i.e.
eating in response to hunger rather than external cues), and engaging in physical activity for
pleasure rather than just for calorie-burning purposes (Bombak, 2014; Watkins, 2013; Bacon &
Aphramor, 2011). The main aim of HAES is to empower people to lead healthy, fulfilling lives
while caring for the body they have now, regardless of its size. Weight loss may occur during the
intervention’s time period, but weight is not the main focus (Watkins, 2013; Bacon & Aphramor,
2011).
HAES is more effective than dieting interventions because dieting interventions are
associated with continuous ineffectiveness, weight regain, and physical and psychological risks.
Instead of dieting, HAES focuses on physical activity as a means for being healthy (Bombak,
2014; Watkins, 2013; Bacon & Aphramor, 2011; Provencher et al., 2009). Research has shown
that weight loss has only had modest success in obesity prevention. Researchers have found that
improved nutrition and physical activity were the main mediators in improving health physically
and mentally. Not only do physical measures like blood pressure improve, but psychological
measures like body satisfaction also improve (Bombak, 2014; Watkins, 2013; Bacon &
Aphramor, 2011).
In order to test the effects of a HAES intervention, one study randomly assigned women
to a HAES group (n = 48), a social support group (n = 48), or a control group (n = 48). Scores for
susceptibility to hunger (an important factor related to overeating) were significantly lower at the
1-year follow-up in both the HAES and social support group. Situational susceptibility to
overeating was also significantly lower at the 1-year follow-up in HAES participants than in
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control participants. Rigid dietary restraint is one factor that plays a role in overeating and
disinhibition. In comparison, flexible restraint of caloric intake has been associated with longterm weight maintenance. Another finding of this study was that approximately two thirds of the
women participating in the HAES intervention maintained a lower-body weight at the 1-year
follow-up when compared to their baseline weight. This study showed that participants in the
HAES group showed more flexible restraint than rigid restrain compared to the control
participants. The results suggested that when HAES is compared to a control group, a HAES
intervention could have long-term benefits on eating behaviors related to disinhibition and
hunger. However, the study did not show significant effects between the HAES intervention and
social support intervention (Provencher et al., 2009). In an effort to enhance a HAES
intervention, a social support intervention piece could possibly be added to a HAES intervention.
The results of this study showed that a HAES approach could possibly have better results in
changes related to better body weight maintenance (Provencher et al., 2009).
Another study compared a HAES intervention program with a diet program. This study
involved six months of weekly group intervention meetings for the HAES group and diet
program group, which were followed by six months of monthly aftercare group support. Along
with any change in weight, there were five factors that made up the intervention and were
measured as outcomes: body acceptance, eating behavior, nutrition, activity, and social support.
HAES group members were able to maintain weight, improve in all the outcome factors, and
sustain their improvements. Participants in the diet group lost weight and showed improvement
in outcome factors initially, but weight was later regained and little improvement was sustained.
One hundred percent of participants in the HAES intervention felt that their involvement in the
HAES program helped them feel better about themselves and only 47% of participants in the diet
68
group felt that their program helped them feel better about themselves. In comparison to zero
percent of HAES participants expressing feelings of failure after the program, 53% of
participants in the diet group expressed feelings of failure. Overall, the encouragement of size
acceptance, reduction in dieting behavior, and heightened awareness and response to body
signals resulted in improved health for participants in this study (Bacon, Stern, Van Loan, &
Keim, 2005).
HAES is not only a strategy used in the obesity field, but is also becoming a standard
practice in the eating disorders field (Watkins, 2013; Bacon & Aphramor, 2011). Messages of
encouraging body acceptance, intuitive eating, and physical activity as a pleasurable activity
(Bombak, 2014; Watkins, 2013; Bacon & Aphramor, 2011) are key points the eating disorder
field have been trying to get across to the public. With the support of the obesity field and the
eating disorder field, HAES has the potential to be a successful, integrated, and holistic
prevention effort.
3.0 Discussion
This literature synthesis reviewed prevention efforts and methods for obesity, eating
disorders, and disordered eating. Finding articles and information about combined prevention
efforts proved to be difficult and actual programs that target obesity and eating
disorders/disordered eating are scarce. Programs, such as the Body Project and the Healthy
Weight, created for eating disorder and disordered eating prevention, were also shown to reduce
obesity. New Moves and the Planet Health program were school-based prevention interventions.
However, future research could work to adapt and test these interventions in community settings.
School-based interventions are very important, but are not sufficient. More community-based
prevention interventions that combine obesity and eating disorders/disordered eating need to be
69
implemented and disseminated. Awareness and education about obesity and eating
disorder/disordered eating prevention need to be increased among physicians and healthcare
workers. Families also need to be educated about the shared risk factors for these conditions.
In regards to combined prevention, more programs that target males and females need to
be created. Most of the research in this review showed significant results in only females. Of the
prevention efforts reviewed, only the Planet Health program targeted both males and females.
Males also suffer from body dissatisfaction, disordered eating, and eating disorders. With more
awareness and sensitivity surrounding male weight-related concerns, prevalence of these issues
has been growing. Prevention programs that can focus just on boys or work with both males and
females are important in moving forward.
Based on the successes of obesity and eating disorder prevention programs, this review
found that coordinated, multi-level prevention would be impactful. The main focus of the
combined prevention programs was the promotion of healthy and balanced living. When
physical activity was being promoted in New Moves, it was being promoted through selfempowerment techniques and social support. HAES focused on promoting physical exercise as a
means of pleasure and overall health, not as something that people feel obliged or burdened to
do. While IPT gives a more clinical and psychological approach to obesity and eating disorders,
it provides the public health field with a strategy to address those cases of obesity that are
associated with disinhibition and loss of control eating episodes. Planet Health provided a
prevention intervention that was for middle school students and promoted health and moderate
physical activity, nutritional choices, and media viewing. All of these interventions were shown
to be successful, although research on these programs is still not adequate. Articles and studies
on these programs were difficult to find and general research on combined prevention was even
70
more difficult to find. More research needs to be done on these programs and on new combined
prevention interventions.
Important program and policy implementations need to be developed for the public, but
especially for schools, on weight-based teasing, stigma, and victimization. Health care
professionals are often the first point of contact for those who are obese or are suffering from an
eating disorder. It is important for health care professionals to be educated about all of the types
of weight-related problems, from obesity to eating disorders (Sim, Lebow, & Billings, 2013;
Wilfley, Vannucci, & White, 2010). This will allow them to treat their patients with best care
practices and avoid “doing harm” to their patients.
Policies and programs that address eating disorders, disordered eating, obesity, and
weight stigma are being increasingly called for in our society. While advocates and researchers
in the obesity field call for policies regarding the display of calories on menus, taxes on fast food
and soda, and BMI report cards in schools, those in the eating disorder and disordered eating
fields are calling for multiple policy interventions and regulations, such as achieving equitable
treatment and insurance coverage for eating disorders, implementing school-based screenings for
eating disorders, placing government restrictions on access to over-the-counter drugs and
supplements for weight control by youths, requiring policies to address eating disorders in
college athletic programs, curtailing weight-related mistreatment and bullying in schools, and
implementing legal protections against weight discrimination (Puhl, Neumark-Sztainer, Austin,
Luedicke, & King, 2015; Puhl & Heuer, 2010). Policy and legal initiatives for eating disorders
are much less popular than those regarding obesity. However, policy actions regarding weight
stigma and eating disorders are slowly beginning to emerge. Research from this study has shown
that policies on both sides of the weight-related issues spectrum need to be implemented.
71
This review and analysis of prevention efforts has shown that body dissatisfaction and
dieting are risk factors for obesity, eating disorders, and disordered eating. These results are
important for understanding people’s views about factors underlying body dissatisfaction and
dieting. Some of the factors that can be targeted areas of prevention are peer acceptance, social
media use and social comparison online, pressure from family, and pressure from the media and
fashion industries. Programs that help people build sources of support, teach people to be critical
of the media, provide psychosocial skills training, monitor the school and other gyms, work with
parents, provide psychoeducation about eating disorders/disordered eating, and provide people
with resources and referrals if they need help will be successful in targeting factors that underlie
body dissatisfaction and dieting (Sharpe, Damazer, Treasure, & Schmidt, 2013; Haines &
Neumark-Sztainer, 2006).
Other important research-based recommendations for health care providers to prevent
obesity and eating disorders among youth include, discouraging unhealthy dieting and instead
encouraging and supporting healthy eating and physical activity behaviors that can be
maintained, promoting positive body image, encouraging frequent and enjoyable family meals,
encouraging families to focus less on weight and calories and instead promoting healthy family
eating and physical activity, and addressing and discouraging weight-related teasing and
mistreatment in families (Neumark-Sztainer, 2009; Haines & Neumark-Sztainer, 2006). To
further efforts of integrating eating disorder/disordered eating prevention into obesity prevention,
both fields need to recognize that each problem is equally important. It is important for
professionals in each field to realize that, at this point, the best way to move forward and make
progress is to work together.
72
3.1 Potential uses
A key use for these findings will be to create healthy-lifestyle initiatives that focus on
systems-level change. Through this research, more healthful communities can be created that
support and empower people to practice healthy behaviors. These healthy lifestyle initiatives will
incentivize people and communities to have a more healthy relationship with food and their
bodies. Initiatives will focus on encouraging individuals and communities to eat meals that are
nutritionally balanced and foods that are diverse. Regular patterns of physical activity will also
be promoted. These measures will be implemented in a way that helps individuals and
populations maintain their health and prevent unhealthful weight gain/weight loss, chronic
diseases, and disordered eating. The findings from this research may help to create a society
where healthy behaviors and healthy relationships with food and our bodies are normalized,
while chronic dieting, restricting food groups, shape obsession, and other unhealthy behaviors
are de-normalized.
Changing our cultural perception and views on obesity, dieting, and the standard of
beauty are key to reducing disordered eating patterns in our nation. Prevention efforts should not
just focus on obesity, they should focus on all types of disordered eating, eating disorders, and
dietary restraint. These findings could be used to create policies and environments that promote
healthy lifestyles among all racial, ethnic, and socioeconomic status populations. Fostering a
supportive culture of wellness that normalizes healthy behaviors and relationships with food and
one’s body will be more likely to produce sustainable changes. These findings can help to
promote this culture by creating interventions that focus on giving individuals the chance to
obtain and modify health-related personal skills. By analyzing the findings from this research,
the field of public health may also be able to start to create a system that focuses less on BMI,
73
calorie counting, and fat shaming, and focuses more on fueling one’s body and feeling good both
physically and mentally.
3.2 Strengths and limitations
This research included multiple perspectives on the issues of obesity and eating
disorders/disordered eating prevention. A strength of this research is the fact that this topic is
largely understudied. The lack of information, although a limitation, was also a strength because
it shows the novelty and necessity of this research. One limitation was that not all prevention
interventions could be reviewed for this paper. This paper only provides a portion of the public
health prevention strategies for obesity and eating disorders/disordered eating. More limitations
of this research largely stemmed from a lack of information on the focus of this research.
Although information on obesity is plentiful, information regarding eating disorders, disordered
eating, and weight stigmatization is much less abundant. However, the bigger issue was finding
information and articles where obesity and eating disorders and/or disordered eating were
analyzed together as being problems of public health significance. Another limitation was that
most eating disorder/disordered eating prevention research has only been done with girls and
young women. As increasing data surfaces, researchers are becoming more aware that eating
disorders/disordered eating do not discriminate by gender, race/ethnicity, or socioeconomic
status. It is important for future researchers and public health officials to include males and
minorities in body image, self-esteem, and eating disorder programs.
Finally, one limitation for this research may be that some in the public health field will
not find this issue of public health significance. However, the belief that this topic is not of
public health significance helps to prove that this is an area of public health that does not have
74
enough research available, therefore showing the novelty and importance of research regarding
our nation’s unhealthy dietary patterns.
4.0 Conclusion
Prevention interventions that focus on overall health, not weight, are most helpful. As the
field of public health moves away from weight and diet focused prevention efforts, it is
important that these prevention efforts be labeled as “health promotion” and not “obesity
prevention.” Instead of focusing just on personal responsibility, public health officials need to
look at all determinants of health that may lead to unhealthy behaviors and conditions. New
prevention efforts also need to focus on promoting self-esteem, body satisfaction, and healthy
body size diversity.
In order for the public health community to fully and successfully address the issue of
obesity, it must also include eating disorders, disordered eating, and other weight-related
conditions. By doing so, prevention efforts will reach a wider audience, be more holistic, and
more successful.
75
Appendix
Theoretical Models
(Source: Tufts University, 2014)
Figure 1: Affect/Emotion Regulation Model
(Source: Suffolk County Department of Health Services, 2013)
Figure 2: Biopsychosocial Model
76
(Source: Nature Medicine, 2010)
Figure 3: Brain Reward Pathway Model
(Source: PreMedHQ, 2014)
Figure 4: Cognitive Dissonance Theory
77
(Source: Diapedia, 2014)
Figure 5: Dietary Restraint Model
(Source: University of Texas, 2014)
Figure 6: Dual Pathway Model
78
(Source: Wikimedia, 2014)
Figure 7: Health Belief Model
(Source: Fredrickson & Roberts, 1997)
Figure 8: Objectification/Self-Objectification Theory
79
(Source: DocStoc, 2014)
Figure 9: Problem-Behavior Theory
(Source: University of Victoria, 2014)
Figure 10: Social-Ecological Model
80
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