Preventing Eating-Related and Weight-Related Disorders: Collaborative Research, Advocacy, and Policy Change

2. Prevention of Disordered Eating through Structural Change: The Population Health Framework and Lessons from Case Studies in Intensive Community-Based Intervention

chapter two Prevention of Disordered Eating through Structural Change: The Population Health Framework and Lessons from Case Studies in Intensive Community-Based Intervention Lindsay McLaren, University of Calgary Niva Piran, Ontario Institute for Studies in Education, University of Toronto Body dissatisfaction, disordered eating behaviour, and eating disorders have been linked with numerous correlates or risk factors operating at various levels, including the individual level (e.g., the internalization of thinness, body dissatisfaction, perfectionism; see Stice, 2001); the level of one’s family or peer group (e.g., critical comments about body weight/ shape from parents or peers, see McLaren, Kuh, Hardy, & Gauvin, 2004; Wertheim, Paxton, & Blaney, 2004); and the broader socio-cultural environment (e.g., gender inequity, see Piran, 2001a; Piran, 2001b; Piran & Thompson, 2008; and weight prejudice and its intersection with classism or ethno-cultural bias, see Anderson-Fye & Becker, 2004; Bowen, Tomoyasu, & Cauce, 1999; Piran, 2001b). One might expect this breadth of influences to translate into a similar breadth of targets for prevention strategies. In general, this is not the case. Although there is increasing recognition of the need for an ecological approach to preventing eating disorders (McVey, Tweed, Blackmore, 2007; Neumark-Sztainer, Sherwood, Coller, & Hannan, 2000; Neumark-Sztainer et al., 2006; Piran, 1995), whereby individual and contextual systems and their interaction are emphasized (Bronfenbrenner, 1979; McLaren & Hawe, 2005), the focus of most existing prevention efforts has ultimately been the individual, and it has typically entailed some variant of provision of information . To illustrate, Pratt and Woolfenden (2009) conducted a Cochrane 4 5 4 6 L i n d s a y M c La r e n , N i v a P i r a n systematic review of interventions (all evaluated using a randomized controlled design) to prevent eating disorders in the general population or in high-risk samples. Although socio-cultural factors (e.g., social pressures to be thin) were acknowledged by the study’s authors, the intervention target in all twelve studies was the individual, who was the recipient––via didactic or interactive means––of health promotion messages around healthy eating, coping skills, and media literacy. In other words, the implicit or explicit approach was to build individuals’ resistance to broader sociocultural influences rather than to tackle these broader influences themselves ––either directly or indirectly by articulating a process through which individual knowledge/skills may translate into broader socio-cultural change. Pratt and Woolfenden (2009, p. 16) concluded their review by stating that “there is insufficient support for the effectiveness of any specific type of eating disorder prevention program for children and adolescents.” By way of explanation, the authors commented that “the impact of the media and the peer group on a developing adolescent’s belief systems are very strong and appear quite resistant to short-term individual or small group therapeutic intervention,” a sentiment that has been echoed elsewhere (Neumark-Sztainer et al., 2006). A tendency to revert to the individual level as the target for prevention strategies is not unique to the eating disorders field and, in fact, is apparent in many areas of health, where intervention effectiveness is similarly low, such as obesity prevention (for example, Summerbell et al., 2006). In their important article entitled “Prevention of body dissatisfaction and disordered eating: What next?” Neumark-Sztainer and colleagues (2006, p. 267) comment that, given the important contribution of cultural factors to the development of body dissatisfaction and disordered eating, “efforts to change the environment are likely to be critical.” The question is: how do we accomplish this? Some guidance is needed. The population health framework can provide this guidance, and the objective of the present chapter is to convey the framework’s implications for the prevention of eating disorders and related outcomes (e.g., disordered eating). The chapter is divided into two major sections. In the first section, we introduce the population health framework and identify how it could apply to disordered eating prevention. In the second section, which looks towards bridging the population health framework with the existing research literature on disordered eating prevention, we consider an initiative that has elements of a population health approach and that has produced notable and sustained preventive effects in a school setting. We conclude by offering several suggestions for achieving such a pronounced and longer-term impact from disordered eating prevention efforts. P r e v e n t i o n o f d i s o r d e r e...