Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

Prevention of Eating Disorders: Failing to Protect Young Women from the Thin-ideal. – Marissa L. Garofano

The prevalence of eating disorders is growing problem, and over the past 50 years the number of cases has steadily increased. Eating disorders; anorexia and bulimia, affect a small proportion of people in the United States, 0.5% - 1% and 1 – 2% respectively and possibly as much as 10% (1, 2) However, they are costly to treat and effective prevention methods are necessary. At least an additional 10% of women and girls in late adolescents have eating disorder symptoms at any given time (2). Health care professionals recognize the importance of primary prevention due to the difficult nature of treating eating disorders (3). In addition, only the small proportion of people who have a clinically diagnosable eating disorder will receive treatment, an unknown amount of others who have some symptoms receive no treatment.

There are a multitude of risk factors that may lead to the development of an eating disorder. The factors that receive the most attention in prior prevention efforts are individual factors which include: child abuse, having been teased, perfectionism, obsessive thoughts, and body dissatisfaction among others (1). In addition to individual risk factors, sociocultural influences including parents, peers and the media are being shown to have an effect on the development of eating disorder (1,4). There is a relationship between the two but there has been a greater emphasis on individual risk factors rather than social ones.

There has been an inverse relationship to the amount of available food and ideal body of certain groups of people; as there begins to be a surplus of food, the ideal body size tends to become smaller (1). The media norms, on television and in magazines, have helped to accelerate this process. American women depicted in the media have become steadily thinner in the past 50 years, and more than half meet the criteria for anorexia nervosa (5). The media sends constant messages to children and adolescents about what it means to be beautiful, successful, feminine, attractive and desirable: for women this comes with slenderness (6).

The Thin-Ideal and Drive for Thinness

The media is the greatest contributor to a culture’s thin ideal. The media creates a social norm that girls feel they need to live up to. Many young girls aspire to be actresses or models that are greatly admired by Western cultures and have a high status and a lot of money. Currently most every show on television and fashion magazines depicts thinness as the norm (4, 6). Slender, airbrushed women with very little fat, and no wrinkles or pimples are shown on television or fashion magazines. These images set the standards for women so high that failure is inevitable.

In addition to the glorification of slenderness in the media being fat is also looked down upon (6). Because of this and due to the amount of exposure to these ideals on the media, girls may begin to compare themselves to the slender actresses and develop a negative view of their own bodies (6). Today, children under the under the age of six spend around two hours a day watching television, or movies (7). Between the ages of eight and eighteen children spend around four hours watching television and an additional two in front of a computer (7). The amount of time older children and teens spend in front of a screen is nearly one fourth of their day. From this, it is evident how the media is able to instill these ideals in youth. It is the internalization of the thin-ideal that has been associated with weight concerns and disorder eating habits (8)

Current prevention methods have failed and this is demonstrated by the growing number of cases of eating disorders and increasing prevalence of dieting and unhealthy eating behaviors. The failure of current eating disorder prevention methods is due to the ineffectiveness of current education programs, the failure to alter social norms, and the media’s promotion of the thin ideal.

Current Education Methods are Ineffective

It has been shown that preventing eating disorders through changes in knowledge, attitude, and behavior via education is difficult and often unsuccessful (9). The majority of previous educational interventions have included information on the nature and consequences of eating disorders and dieting (10, 11). Many of these studies have shown an increase in knowledge but no change in eating behavior (11). Interventions of this nature use the health belief model (HBM) for behavior change. This model assumes that increasing the knowledge about the benefits of eating healthy and consequences of dieting and eating disorders will lead a person to weigh the risks and benefits of change against what they perceive to be the severity of eating disorders and how susceptible they feel they are to them. If the benefits of change are high along with the severity and susceptibility, this will lead to the intention to change, and then the adoption of a healthy behavior change (12). Prevention methods based upon the HBM address individual factors and does not account for outside social factors that influence a behavior. Also, the HBM is most effective when used for short term change or one time decision, as demonstrated by how soon after an intervention their was a greater change in attitudes but after time had passed the strength of theses attitudes decreased (10). Maybe the first night when these facts are still fresh in her memory, a girl may not eat a large tub of ice cream and then purge or fast afterwards. However, three months later, during a stressful time period, this may not be the case. The HBM suggests that teenage girls make rational decisions, and highly value their health over being accepted by their peers.

While education has very little effect on positive behavior change it may also have a negative effect on behavior and will lead to more unhealthy eating behaviors. It has been shown that providing detailed information about the symptoms of eating disorders to children and adolescents can increase the amount of disordered eating habits that occur (10, 13). While behavior and attitudes may change positively right after the implementation of an intervention, months later the girls may be back to their original views and behaviors, or they may have developed more negative views and have more disordered eating behaviors (10). The idea of providing teachers and faculty at schools with a detailed overview of the causes and symptoms of eating disorders has also been suggested (14). However this knowledge may create false accusations of students and stigmatization of them if not enough information is provided. If a stigma is created the student may fall into a self-fulfilling prophecy where she engages in disordered eating behaviors because others already accept it from her (15).

Current interventions for prevention are typically being implemented in adolescence or young adulthood. The time at which most educational interventions have been implemented are at or around the onset of puberty (11). By this time many disorders attitudes towards eating habits my have developed as by the time girls are 10, 81% are afraid of being fat (16). Also, by adolescence one’s views are already set and it is more difficult to alter these opinions. This suggests that intervention should be implemented at a younger age when children are more malleable and absorb the most information.

In addition current educational interventions fail to account for important influences on behavior; social and contextual factors (12). Education assumes that people want to be healthy rather than fit in with social norms. Also it fails to address the reasons for why these behaviors were adopted in the first place.

Failure to Alter Social Norms

The occurrence of dieting and the desire to be thin are extremely common among women and girls and begin at a very young age, as young as six. Forty-two percent of 1st through 3rd graders want to be thinner (16). It is common that when with a group of young women you will hear talk about current diets, being too fat, and needing to lose their excess weight. Trends in dieting are discussed as frequently as trends in fashion. Women will attempt to conform to the current definitions of what is beautiful and attractive in order to fit in with their social group (15). However, what women perceive as normal may not coincide with actual societal norms. They perceive that the most attractive figure to men is one that is very slender (18) when men actually prefer a more curvaceous woman with muscle tone to one who is super skinny and mostly bone. Women envision an ideal body shape that is smaller than their current one, feeling that they need to lose weight, to achieve that of what is perceived as attractive and what their peers hold as ideal (17). An attempt to achieve this ideal and fit in with their peer’s norm, may lead girls to begin methods of unhealthy methods to achieve the perceived ideal. The CDC found that, in 2000, 37.5% of girls trying to lose weight did so in an unhealthy manner (18). A study of high school girls showed that an increase in an individual’s unhealthy eating habits was correlated with perception of her friends dieting habits (19) which suggests that eating behaviors are not solely based on individual factors and the weighing of risks and benefits but group level factors as well.

Prevention methods that stress education do not account for perceived social norms or group level factors. Facts may be provided about the average size of a woman and comparing her to the average model but there is a lack of discussion regarding the perceived norms the girls have and how they feel about them. Marketing theory suggests that focus groups need to be created to determine what the girls think would be effective and what their current ideals are (20). After creating an intervention with the girls concerns in mind the outcomes will be more successful, as education does address these concerns and the programs are not created with the help of the girls who are affected by the norms.

The Social Networking theory gives insight as to how these ideals and practices have become normal. The theory relies on the relationships and interactions of the individuals within a group (21). If you have a group that consists of high school girls and analyze the relationships of them you will most likely see the thin girls who comply with society’s norm in the middle with the most friends and the heavier girls who are perceived as unattractive will be marginalized (21). Body shape will also dictate who will be in the subgroups or cliques in the network. The heavier girls will have less interpersonal contacts within the group. Social norms provided by the media suggest that people who are heavy are outsiders, and possess undesirable qualities and therefore it is acceptable to not interact with them and avoid contact (5). In order to change this social network one of two things would have to occur, either a change in norms to accept heavier people as attractive or, more likely, the heavier girls will adopt disordered eating behaviors to try to move to the center of the network and gain acceptance from peers.

Also in the social network would be parents and family members, neighbors, teachers and all other people the girls interact with (22). Parents and teachers play an important role in teaching the children to accept everyone for who they are and to help develop a positive self image (3, 21).

The Media’s promotion of the Thin Ideal

While there is a strong correlation between the idealization of thinness and occurrence of eating disorders, little has been done to protect children, especially girls, from this ideal. With nearly ¼ of a child’s or teen’s day spent in front of a computer or television, then combined with the amount of time spent reading fashion magazines, it is evident how the media can impact a person’s views on what it normal (7). Media awareness interventions that have been tested have not demonstrated much success at changing attitudes about eating and body image. Suggesting that the length of previous interventions were inadequate and long term programs may be more effective.

The social networking theory described above is dictated by societal norms, and these norms are greatly influenced by the media. The media depicts thin as being the right way and fat people, when shown in the media, are often shown as undesirable and lazy (5). The desire to be considered as beautiful and attractive is one that is highly sought out by girls and women young and old. With the influence of the media the attempt to achieve the ideal and avoid being considered lazy and undesirable may lead to an increase disordered methods of obtaining them. Becker, et al. (2002) conducted a study in Fiji where girls had not been exposed to the thin ideal media and where a larger figure was considered desirable and the norm (23). The study showed an increase in disordered eating habits and a shift in the ideal body over a three year period of time after the introduction and exposure to thin ideal media (23). These findings can be generalized to give insight as to how the United States and westernized cultures may have adopted this view.

The media may counteract any improvements made through education because it dictates what is perceived as both ideal and normal (2, 15, 23). As time passes there is less focus on being healthy and more on social ideals and now girls have the information on how to achieve this ideal because of an increased knowledge symptoms and unhealthy eating habits. The media has the ability to create a norm in which all sizes are accepted, and because of this there is a need to regulate what is shown on the media and diversify the images of women seen (6).

Most of the studies previously conducted on the relationship between the media and eating behaviors have been quantitative in nature and have not asked the how and why questions (23). Marketing theory would suggest that for an intervention to be successful one needs to determine the needs of the consumers (21). In this circumstance to discuss with adolescent girls how they are affected by the media, why they think this way, the changes they would like to see, etc. From the answers received by the girls a program can be developed that is specifically designed to influence the needs of this target population, something has not been considered when using educational methods.

However a reduction in the internalization of the thin ideal has been associated with positive outcomes suggesting that it is possible to significantly reduce these ideals if an effective method is discovered. (8).

There is a need to prevent eating disorders since they are costly to treat and have poor health outcomes. Also, as the prevalence of anorexia and bulimia increases there is an increased need for an effective public program. Current eating disorder prevention interventions have failed due to the overemphasis on education, lack of attention to the influence of social norms, and the influence of thin ideal media. The effects of education do not last over an extended period of time and may actually create more disordered eating habits than they prevent. Current social norms support these disordered behaviors in order to achieve the ideal body type valued by society. The media dictates these social norms and is a responsible for interacting with other risk factors to increase the prevalence of disordered eating behaviors.

These reasons for failure suggest that there is a need to reform the prevention methods that are used. New prevention methods should include the voice of girls to determine what they want and there opinions on these topics. New prevention measures should attempt to change the societal norm to one that does not focus on one ideal body but rather the acceptance of all healthy bodies.

Implications for future prevention methods

To improve upon the flaws of prior eating disorder prevention methods, new approaches must be implemented to improve upon the failures of past intervention because of their focus on education, lack of acknowledgment of social norms, and the media’s influence on the ideal. The new intervention would take place over a long time period and would use theories not typically used in the public health field, using mostly theories about marketing, social influence, and social networks. The basic structure of the new prevention program would consist of mapping a social network of teen girls in a representative area to determine the following: who is marginalized, who is heavy or thin, and who engages in disordered eating behaviors.

Next, girls who would fall into one or more of the above categories would be interviewed in focus groups with other girls similar to them to determine why they engage in certain behaviors, how other girls who are in their peer group influence them, and how the media influences them (24). Using the information collected, healthy eating behaviors can be marketed to this population in a way that shows this as the norm. The girls’ feedback on the media can be used to create media awareness campaigns, and regulations of the media that will create size acceptance and minimize the thin ideal.

Moving beyond education

New interventions would address education’s inability to produce long term change in the eating behaviors of teen girls. The use of marketing theory will take into consideration the needs and wants of the target population instead of coming from the point of view of health care professionals (24). As health professionals will focus more on the clinical aspects that are important to them rather than social ones which are more important to adolescent girls. The idea of gaining insight, through focus groups, as to why a consumer engages in a certain behavior is beneficial when determining the best way to “sell” healthful eating (24). Questions need to be asked to find out why the girls engage in a certain behavior at surface level and then continue to question them to discover the true motives for this behavior that are not at the surface level (24). Questions asked may include: how it makes them feel afterwards? How they usually feel before? Are there any external pressures they feel to engage in this behavior? Do the girls engage in healthy eating behaviors and if so why, what to they gain or lose through this action?

Conducting qualitative research instead of generating quantitative data is useful especially for studying a behavior and determining the reasons for a particular behavior. Quantitative research just discusses how common an event is (25). Discussing in small groups of girls who are either centralized or marginalized within a social network will provide a great deal of insight into the reasons for such behaviors prior quantitative research was unable to do this, however it is necessary to know the reasons for why one engages in behaviors to know how to intervene and prevent them. Education about the consequences of eating disorders, and their symptoms, as well as what foods are healthy and which ones are not should be discarded as it has not been proven effective in the past and may be causing more harm than good (10).

Additionally, another way marketing and social network theory improve upon education through the Health Belief Model, is how they do not assume that behaviors are made through a rational weighing of the risk and benefits (12). Unlike education methods based upon the Health Belief Model, they take into consideration the influence of outside forces through marketing theory and social networking theory in this new intervention would able to create effective programs to influence the healthy and unhealthy eating behaviors of teenage girls (19, 24).

Altering social norms

Currently society places normality on being thin and because of this there has been a marginalization of overweight and obese people (19). Social norms are extremely influential on adolescents, as they are still gaining a sense of self and have a strong desire to fit in with their peers. The current social network needs to be altered so that there is a mixture of thin and heavy people through out the group and there is not one group who is favored above the other. New prevention methods should focus on altering social norms by creating size acceptance and promoting the importance of healthy eating and how to do this. Decreasing the pressures to be thin will have a great impact on the amount of disordered eating behaviors in which a girl engages. If the social norms that influence whether or not a girl will engage in unhealthy eating behaviors are altered or reduced than the eating behaviors that follow will also be reduced through the role of social norms on how they depict what peer influences will impact other girls (19).

By changing the social influences on adolescent girls through the creation of size accepting norms there will be less marginalization of overweight individuals who would not fit in with the ideal body that is currently portrayed. If a second network was mapped of a similar group of teen girls after the alteration of social norms occurred, its structure would show a mixture of heavy and thin people centralized and those who are extremely obese or engage in disordered eating habits would be marginalized and seen on the outskirts of the social network. Social network analysis believes that actions are interdependent on others in an environment and not based upon an individual behaving in an independent manner (21). This analysis would demonstrate a norm for being healthy and not approving of unhealthy eating behaviors, such as dieting, purging, excessive exercise, fasting, and others. The media can be used to alter the social norms regarding ideal body.

Combating the media’s influence

The media is one of the most powerful tools in creating social norms and has the great impact on youth. Currently the media helps to create unrealistic and unhealthy standards for female physical appearance which American culture has come to accept, support, and strive for. Social norms about weight have fluctuated over time suggesting that it may be possible to shift the desired body to one of a healthier curvy figure. Americans need to become educated consumers about what is depicted on television and in fashion magazines, and how it is neither normal, healthy, or real (6). It is possible that media education can be integrated in to the classroom setting and be taught similar to that about alcohol use and violence (6, 16).

Through use of the focus groups used to collect data on the eating behaviors of teen girls can also be used to collect opinions about the media and the influence it has on the decision making of these girls (24). For instance what types of shows are currently watched and which ones were watched when the girls were younger. After learning what aspects of shows have had the greatest impact on the girls, it may be possible to implement some regulations in the media to alter this affect; such as the times when certain body types can be portrayed as ideal, the body types that are portrayed in children’s shows. Currently on television shows, overweight individuals are rarely portrayed and when they are it is usually in a negative manner where they are being depicted as clumsy, lazy, stupid, and unsuccessful (5, 6). If social networks of shows in the media do not marginalize heavier people than this will influence the setup of teen social networks. Becker, (2002) demonstrated how the introduction of thin ideal media can change a society’s ideal from a heavier set on to an extremely thin one and how the pressures from the thin ideal lead to an increase in disordered eating behaviors (23). This also suggests that if the media were to introduce shows in which different sizes of people are shown, the thin ideal could be reduced and one regarding a healthy body can be created.

Using the media to alter social norms in a way that would suggest eating healthy and being of a healthier weight is seen in a positive manner and as more attractive to men. The qualitative data collected through use of marketing theory could also be used to create effective campaigns by addressing what is important to adolescent girls and portray these messages in a way that will actually impact them more than someone telling them what they should do.


In the past the ideal shape for a woman’s body has been curvy and heavier than the current societal ideal suggesting that it is possible to alter current norms (16). If it is possible to gain insight as to why girls begin to engage in disordered eating behaviors, then it will be more likely that they can be prevented. By focusing on external factors rather than individual ones eating disorder prevention is more likely to be successful. New prevention measures need to improve upon the failures in past approach in that they should not focus on education but rather the impact of social norms and the media on disordered eating behaviors.


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