Healthy Schools-Healthy Kids: A controlled evaluation of a comprehensive universal eating disorder prevention program
Introduction
Society's current norm for overvaluing female thinness and equating that thinness with beauty, success, and happiness has led to widespread body dissatisfaction among women and adolescent girls (Paquette & Raine, 2004) as well as among some girls as young as 6 years of age (Davison, Markey, & Birch, 2003). Body dissatisfaction among children and adolescents can have significant weight-related health implications. For example, in their longitudinal study, Neumark-Sztainer, Paxton, Hannan, Haines, and Story (2006b) found that lower body satisfaction among both adolescent males and females was predictive of higher levels of dieting and binge eating, placing those individuals at an increased risk of poor overall health. Body dissatisfaction has also been associated with depression and poor self-esteem (Stice & Bearman, 2001). Given these findings, it is not surprising that experts have advocated that interventions should strive to increase levels of body satisfaction (Neumark-Sztainer et al., 2006b).
Although targeted eating disorder prevention interventions (those targeting at-risk individuals) have shown promising results (see Fingeret, Warren, Cepeda-Bento, & Gleaves, 2006; Stice & Shaw, 2004 for reviews) there remains a need to assess the outcome of untargeted interventions. In universal prevention, the goal is to foster resilience and reduce risk among nonsymptomatic populations (i.e., the entire student body). In the short-term, universal prevention programs are expected to increase resiliency and decrease risk factors. In the long term, it is expected that those changes will lead to fewer eating problems and fewer cases of eating disorders.
Universal prevention approaches have several advantages. First, a population-based approach has the potential to help those at-risk while also helping to prevent the development of new cases. Second, an inclusive broad-based approach to prevention can help children learn to cope with the sociocultural influences that have been linked with the development of body image dissatisfaction (Stice & Whitenton, 2002). For example, the thin ideal is transmitted and reinforced via parents, peers, and the media. Studies have shown that children whose parents transmit messages about the importance of thinness, either through role modeling or direct comments, are more likely to develop concerns with their own weight and shape (Davison & Birch, 2001; Smolak, Levine, & Schermer, 1999). Moreover, prospective research has shown that perceptions of peers’ desire for thinness and watching appearance-focused television are associated with girls’ desire for thinness, appearance satisfaction, and self-esteem (Dohnt & Tiggemann, 2006). Similarly, weight-based teasing by peers and parents has also been linked to body dissatisfaction in children and youth (Eisenberg, Neumark-Sztainer, & Story, 2003; Lieberman, Gauvin, Bukowski, & White, 2001).
Teaching children and youth how to support one another through positive peer modeling, mutual respect, and acceptance (regardless of size or shape) can foster a healthy and more equitable environment. This approach can help to offset the development of disordered eating as well as other risky behaviours (e.g., drug use, depression). Before conclusions are drawn about the usefulness of universal prevention within the field of eating disorders, however, there is a need to broaden the scope of the intervention work. This requires targeting multiple sociocultural influences and evaluating their effectiveness using high-quality research.
Presently, strategies used by researchers conducting primary prevention work fall into one of three distinct categories (Levine & Smolak, 2006). First, some researchers have drawn on social cognitive theory (Bandura, 1986) or cognitive-behavioural theory to develop prevention programs. According to Social Cognitive Theory (SCT), behaviour is influenced by the interplay between cognitive and emotional processes within the person, behavioural patterns, and the environment. Within the eating disorder literature, particular attention is given to the sociocultural factors that create or maintain disordered eating, as previously described. The focus of SCT-driven prevention programs is on decreasing risk factors associated with disordered eating such as the idealization of slenderness, drive for thinness, or fear of fatness (using cognitive-behavioural techniques), while also fostering protective factors such as healthy eating attitudes and behaviours. Levine and Smolak (2006) refer to this as the Disease-Specific (DS) pathways approach to prevention. Second, the Non-Specific Vulnerability-Stressor (NSVS) approach to prevention fosters generic life-skills such as stress management, assertion, decision-making, social competency and resiliency. A third approach, entitled the Feminist Empowerment-Relational (FER) model, emphasizes developing critical thinking towards the gendered issues contributing to negative body image and promotes new norms of relating, acceptance, support, and power using a participatory approach (Piran, 1999a, Piran, 2004; Levine & Piran, 2001).
The present study used classroom curriculum and nurse-facilitated peer support groups (McVey, Davis, Tweed, & Shaw, 2004; McVey, Lieberman, Voorberg, Wardrope, & Blackmore, 2003a) as a starting point in the development of a longer and more intensive comprehensive program within an ecological approach. Those previously tested strategies were shown to improve body satisfaction and body esteem by way of helping girls critically analyze messages and develop general life-skills and healthier peer norms. Elements from all three models described previously were included (i.e., DS, NSVS, and FER-models). An ecological approach was considered for the present study because it takes into consideration the interaction of multiple systems and their potential influences on a person's behavior (personal competencies, peer, parent and media influences, school characteristics, etc.) (Bronfenbrenner, 1979). The present intervention drew also from the comprehensive Health-Promoting School Framework (HSF); a framework used in intervention research designed to improve school health in general (Leger, 1999) and eating attitudes in particular (Anderson & Piran, 1999; Neumark-Sztainer, 1996; Neumark-Sztainer et al., 2006a; O’Dea & Maloney, 2000). The HPS framework focuses on three key elements including school curriculum, school environment/climate, and school-community relationships, all of which are expected to function as an interactive system.
Varnado-Sullivan et al. (2001) implemented one of the first comprehensive eating disorder prevention programs, entitled the Body Logic Program. This included in-class curriculum (three sessions with students), a teacher workshop, and information sessions for parents. Participants were male (n = 130) and female (n = 157) students in Grades 6 and 7 drawn from two private schools. The Body Logic program was found to have a positive influence on female, but not male participants (e.g., as measured by reductions in scores on the fear of fatness scale). While this study contributed important findings to the prevention literature, the generalizability of Varnado et al.'s findings to diverse groups was limited due to the inclusion of a relatively small, predominantly Caucasian (91%), and upper middle class (i.e., private school setting) sample of students. In another study, Austin, Field, Wiecha, Peterson, and Gortmaker (2005) developed and evaluated the effectiveness of a multi-level school-based obesity prevention program targeting disordered eating in early adolescent girls (N = 480, aged 10–14 years). Students from 10 middle schools were matched and randomly assigned to the intervention or control condition and the obesity prevention program was implemented over two school years. Both girls and boys from Grades 6 and 7 (primarily Caucasian) were enrolled in the Planet Health program, however, only the females were included in the evaluation of the program. The intervention, which focused on reducing television viewing and the consumption of high fat foods, while also increasing physical activity and fruit and vegetable consumption, included classroom lessons with extensive teacher input (from across different disciplines), training for teachers, wellness sessions, and fitness funds. The program had a positive impact on reducing purging behavior and diet-pill use in females. Most recently, Haines, Neumark-Sztainer, Perry, Hannan, and Levine (2006) developed and evaluated the effectiveness of a multi-component, school-based intervention designed to prevent teasing and unhealthy weigh-control behaviours. Like Austin et al. (2005), the program lasted 8 months. However, the study by Haines et al. was conducted with a slightly smaller (intervention group n = 79, control group n = 72), younger (Grades 4 through 6), and more culturally diverse sample. Components included an after-school program (a theatre program), school environment components (school staff training, no-teasing campaign, book of the month), and a family-component (family nights, parent postcards, booth at parent–teacher night, and theater production). The intervention was associated with a reduction over time in the number of students who reported being teased, but no changes in weight control behaviours were reported.
In the present study, prevention curriculum (Seaver, McVey, Fullerton, & Stratton, 1997) was implemented in all classes including Health Education, Math, Science, English and Drama to ensure the delivery of a consistent school-wide message. In addition, training was offered to teachers (and school administrators) and parents to help make them aware of their own potential weight-based biases and the issues that influence body image. It was felt that subtle forms of body discrimination (or weight based teasing) could go unnoticed by parents or teachers if they themselves were “fat-phobic” or invested in current sociocultural ideals of thinness. Other elements of the HPS included in the present intervention were the (a) setting of goals that where based on identifiable community needs (e.g., surveys conducted by local public health units revealed that eating and body image issues were considered high priority issues facing the schools), (b) involvement of members of the community in the development (a public health nutritionist, student enrolled in teacher's college, a high school intern, members of provincial and national nutrition and physical activity organizations) and the delivery (teachers, local public health nurses, local Drama and English teachers, local high school drama students) of the intervention, and inclusion of school staff, students, parents, and local public health staff as targets of the intervention. Male students were also included in both the implementation and evaluation of the intervention in light of evidence showing that they too experience body dissatisfaction and pressures to conform to a lean, “bulked up” physique that is being touted as “ideal” (McCabe and Ricciardelli, 2001, McCabe and Ricciardelli, 2003; McCreary & Sasse, 2000; Neumark-Sztainer, Story, Falkner, Beuhring, & Resnick, 1999; Smolak, Levine, & Schermer, 1998). Furthermore, evidence suggests that boys are more likely than girls to initiate weight-based teasing and harassment of other children (Stein, 1999). This multi-dimensional approach has shown promising results in school-based drug abuse and tobacco use prevention programs (Biglan, Ary, Duncan, & Black, 2000; Pentz et al., 1989).
The present study adds to the existing body of work investigating the effectiveness of an ecological approach to the prevention of disordered eating by using a randomized controlled trial to test the effectiveness of an intensive (8-month intervention) comprehensive, multi-level intervention conducted with a large and multi-cultural sample of students drawn from lower to middle class neighbourhoods. Male and female students were involved in both the intervention and the evaluation process. Student outcome variables included body satisfaction, internalization of media ideals, body size acceptance, weight-based teasing, disordered eating, and weight loss and muscle gaining behaviours. The effectiveness of the intervention on teachers’ body satisfaction, internalization of media ideals, and eating attitudes and behaviours were also assessed, as well as its impact on their perceptions of the school climate. Middle school students were a selected group for this universal prevention study because of the normative developmental stressors that trigger disordered eating during this stage of early adolescence (e.g., natural increases in body fat and weight associated with puberty, increased desire for peer acceptance, onset of romantic interests, changes in academic expectations) (Smolak & Levine, 1996).
The overall aim of the present study was to examine the influence of the comprehensive, universal-selective intervention in improving body satisfaction and size acceptance and in reducing the internalization of media ideals, weight-based teasing, disordered eating and weight-loss or muscle-gaining behaviours. It was hypothesized that the participants of the Healthy Schools-Healthy Kids (HS-HK) intervention would show significantly greater improvements over time in body satisfaction and size acceptance, and significantly greater reductions in the internalization of media ideals, weight based teasing, disordered eating and weight loss and muscle-gaining behaviours, compared to controls. The intervention was expected to have a greater impact on female students, given their propensity for eating problems (and their risk factors) to affect them more than males. Similar hypotheses were predicted for the teachers’ scores on these same measures. In addition, teachers’ perceptions of the school climate were expected to show improvements over time among those in the intervention group compared to those in the comparison group.
Section snippets
Students
The initial study sample measured at baseline included 982 students in Grades 6 (n = 526) and 7 (n = 456) (M age = 11.27 years, SD = .67) drawn from four middle schools that were matched on geographic location, size, and cultural make-up. While the study was open to all students within each of the four schools, the overall response rate was 52% (slightly lower than reported by Austin et al., 2005), reflecting the number of parents who returned an active consent form for their child to complete the
Preliminary analyses
To examine whether attrition-bias was present, comparisons were made between those students who dropped out of the study and those who had data at all three measured time points. Using Chi-square analyses, those who dropped out of the study did not differ from those with complete data on factors of gender, grade, specific school attended, condition (intervention versus comparison), or cultural background (p > .05). Using one-way analyses of variance (ANOVAs), however, comparisons between
Discussion
In the present study, the effectiveness of a universal-selective program, using an ecological approach, was assessed with students in Grades 6 and 7 attending middle school. The HS-HK intervention evolved from previous prevention work conducted with middle school students (McVey et al., 2003a, McVey et al., 2003b, McVey et al., 2004). However, in the present study, the existing classroom curriculum (McVey et al., 2004) and peer support group model (McVey et al., 2003a) previously implemented
Acknowledgments
This study was supported by a Women's Health Council grant of Ontario (Grant # 000–45) to Gail L. McVey. The Council is fully funded by the Ontario Ministry of Health and Long Term Care. This research does not necessarily reflect endorsement by the Ministry of Health and Long Term Care. Gail L. McVey currently holds a mid-career award from the Canadian Institutes of Health Research—Institute of Gender and Health and the Ontario Women's Health Council. The authors thank the adolescents and their
References (75)
- et al.
Interpersonal influence and disordered eating behaviors in adolescent girls. The role of peer modeling, social reinforcement, and body-related teasing
Eating Behaviors
(2001) - et al.
Reliability testing of a children's version of the Eating Attitude Test
Journal of the American Academy of Child and Adolescent Psychiatry
(1988) Preventing the broad spectrum of weight-related problems: Working with parents to help teens achieve a healthy weight and a positive body image
Society for Nutrition Education
(2005)- et al.
Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males
Journal of Adolescent Health
(2006) - et al.
Primary prevention of disordered eating among preadolescent girls: Feasibility and short-term effect of a community-based intervention
Journal of the American Dietetic Association
(2000) - et al.
Sociodemographic and personal characteristics of adolescents engaged in weight loss and weight/muscle gain behaviours: Who is doing what?
Preventive Medicine
(1999) - et al.
Sociocultural context of women's body image
Social Science & Medicine
(2004) - et al.
A controlled study evaluation of an elementary school primary prevention program for eating problems
Journal of Psychosomatic Research
(1998) - et al.
Development and implementation of the Body Logic Program for adolescents: A two-stage prevention program for eating disorders
Cognitive and Behavioral Practice
(2001) - et al.
Health promoting schools
The Canadian Association for Health, Physical Education, Recreation, and Dance
(1999)
The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls
Archive of Pediatric Adolescent Medicine
Social foundations of thought and action: A social cognitive theory
A randomized controlled trial of a community intervention to prevent adolescent tobacco use
Tobacco Control
Toward an experimental ecology of human development
American Psychologist
Weight status, parent reaction, and self-concept in five-year-old girls
Pediatrics
A longitudinal examination of patterns in girls’ weight concerns and body dissatisfaction from ages 5 to 9 years
International Journal of Eating Disorders
The contribution of peer and media influences to the development of body satisfaction and self-esteem in young girls: A prospective study
Developmental Psychology
Associations of weight-based teasing and emotional well-being among adolescents
Archives of Pediatric and Adolescent Medicine
Relation between dieting and weight change among preadolescents and adolescents
Pediatrics
Eating disorder prevention research: A meta-analysis
Eating Disorders: The Journal of Treatment & Prevention
The validity of the distinction between bulimia with and without anorexia nervosa
American Journal of Psychiatry
The Eating Attitudes Test: Psychometric features and clinical correlates
Psychological Medicine
“Everybody's Different”: A primary prevention program among fifth grade school children
Eating Disorders: Journal of Treatment and Prevention
In a different voice
Prevention of anabolic steroid use
Reducing obesity via a school-based interdisciplinary intervention among youth: Planet health
Archives of Pediatric Adolescent Medicine
V.I.K. (Very Important Kids): A school-based program designed to reduce teasing and unhealthy weight-control behaviors
Health Education Research
Development and validation of the Sociocultural Attitudes Towards Appearance Questionnaire
International Journal of Eating Disorders
Can dieting cause an eating disorder?
Psychological Medicine
The Silencing the Self Scale
Psychology of Women Quarterly
Empowering adolescent girls: Examining the present and building skills for the future with the GO GRRRLS Program
The opportunities and effectiveness of the health promoting primary school in improving child health: A review of the claims and evidence
Health Education Research
The prevention of eating disorders: Towards a participatory ecology of knowledge, action, and advocacy
Associated health risks of adolescents with disordered eating: How different are they from their peers? Results from a high school survey
Child Psychiatry and Human Development
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