Principle 3: Thinking in Terms of a Population Means That Focusing All or Even Most of Our Prevention Efforts on High-Risk Individuals Is a Limited Strategy

Trying to prevent EDs in people at high risk, as indicated by some sort of screening, is a logical extension of the classic detect-an-illness-then-treat-it approach in medicine (Rose, 1985; Chapter 1). The many advantages and disadvantages of selective-indicated prevention will be explored in Chapter 21. A mistaken assumption generated by the very concept of high risk is that people placed (correctly or incorrectly) in this categoiy should be the primary focus of prevention programming.

The paradox here, which bears Rose’s name, is that the extremely large number of people at low to moderate risk yields a higher number of cases of disorder than a small number of people at high risk. This statistical phenomenon is at the heart of a population-based, public health approach to prevention (Austin, 2001; Rose, 1985; see Levine, 2017c, for a numerical example). Noting that “group” or “people” can refer to an aggregate of individuals or a collection of ecological entities like schools. Austin (2001) provided two applications of the Rose Paradox. First, in a secondary analysis of a University of Minnesota cross-sectional study of dieting frequency and pinging (e.g., self-induced vomiting, laxative use) in over 17,000 girls ages 13 through 18, 21% of high-risk, constant dieters reported purging, but 63% of those who purged were those who dieted less frequently. At the microsystem level (see Chapter 4), Austin’s (2001) analysis of data from the large-scale Planet Health obesity prevention study (Gortmaker et al., 1999; see, e.g., Austin, Field, Wiecha, Peterson, & Gortmaker, 2005, 2007; Chapters 15 and 17 through 19) demonstrated that (1) 56% of “cases” of pathogenic weight management via diet pill use or purging came from schools with moderate to low levels of dieting; and (2) if prevalence of dieting could be reduced by 10% in all 10 schools in the sample (range of average dieting in the schools = 8-45%), more than a third of those cases could be prevented.

Principle 4: We Must Think About Environmental, Institutional, and Other Sociocultural Factors Created by and Affecting Populations

Chapters 6, 7, and 18 confirm that selective and indicated programs that increase individual resistance to unhealthy sociocultural messages about ideal bodies and necessary weight management have the potential to prevent a spectrum of DE, at least over a 2- to 3-year period in adolescence or young adulthood. In light of the Rose Paradox operating for normally distributed risk factors, the public health model seeks to reduce the number of new cases by shifting the entire risk distribution to the left, in the direction of a lower mean risk for the population. To accomplish this shift and thereby facilitate longterm improvements in the conditions in which people live, the public health approach insists we pay attention, not just to mass media and school environments but also to business interests, media practices, public policies, legislation, and other structural features of society (Wang, Peterson, McCormick, & Austin, 2013). To do otherwise and solely insist that individuals are ultimately responsible for resisting toxic social forces that are powerful, pervasive, and persistent has been criticized as unethical (Austin, 2016). Nevertheless, as noted by McLaren and Piran (2012), in most prevention programs to date, an implicit, untested, and naive assumption is that a “bottom-up” change in individual (or school-wide) attitudes and behaviors will lead to changes in group nonns (e.g., among peers), institutions (e.g., schools), and policies (e.g., state or provincial public education).

Principle 5: Health Is Defined More Broadly Than Simply the Absence of Disease

The first of the nine principles of the constitution of the World Health Organization (WHO, 2014), formulated in 1946, is that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p. 1). This reinforces our emphasis on the relationship between health promotion, resilience, and prevention (Chapter 1, Figure 1.1; see also Chapters 4 and 16).

Principle 6: Disparities in Health Are Created by the Intersections of Class, Race, Ethnicity, and Gender; Consequently, We Must Reach Out to Previously Ignored and Underserved Populations

Although principle 3 emphasizes differences in risk between populations, the public health model acknowledges the need to examine differences within a society that contribute to differential rates in the onset of, and the response to, the problems on which we are focusing. We have known for over 30 years that within a population such that of the United States there are specific and nonspecific risk factors for BD, DE, and EDs (see, e.g., Connors, 1996). Thus, one approach to illuminating the sotu ce of health disparities was addressed in the first version of this book (Levine & Smolak, 2006, Chapter 7) when we considered the nonspecific vulnerability-stressor model (NVSM). The foundation of this model is the following fact, demonstrated by research in many disciplines. Mental disorders, behavioral problems, and ill health in general flourish where people have too much stress; too little respect for themselves and for others; too few meaningfill relationships and too little perceived social support; and too few personal, social, and physical resources for meeting their needs (Albee & Gullota, 1997). It follows that prevention will be facilitated when stress, prejudice, social exploitation, alienation, and powerlessness are reduced while coping skills, self-esteem, meaningfill interactions, and opportunities for competence and meaningfill work are increased.

Within the public health model this line of theory and research points to the need to understand inequalities in the experience of, and expenditures for, BD, potentially unhealthy weight management, DE, and EDs (Chapters 9, 11, 12, 19, and 20). In the United States, where race, sexuality, class, weight, and shape are extremely important in determining identity and power, there is a wide range of groups and subcultures demonstrating the negative effects of inequality. Examples emphasized by public health research include transgender youth (Guss, Williams, Reisner, Austin, & Katz-Wise, 2017), poor households headed by women (Austin, Yu, Liu, Dong, & Tefft, 2017a), and people stigmatized by the “war on the obesity epidemic” and the idealization of slenderness (Vartanian & Smyth, 2013; Chapters 5, 13, and 15).

Principle 7: Specific Types of Research Are Needed to Maximize Impact at the Population Level

“Translation” is an important concept for thinking about the process of prevention, and especially dissemination. It refers to “systematic and deliberate processes using research findings to inform changes in policy and practice to improve population health” (Austin, 2016, p. 9). Type 1 translation involves converting research findings from multiple sources into testable and ultimately efficacious and effective programs (Chapter 3). Type 2 translation extends this work to research that facilitates development of guidelines for the widespread, collaborative dissemination and implementation of effective programs (Glasgow et al., 2012; Spoth et al., 2013; see, e.g., Becker’s work in Chapter 7). Translation is a very prominent issue in medicine, where there is typically a large gap between optimal treatment, as determined by a solid foundation of controlled research, and what people with a condition are actually receiving from physicians, if anything (Glasgow et al., 2012).

Since the mid-2000s, researchers have extended the type 1 and type 2 distinction (Austin, 2015,2016; Glasgow et al., 2012). Type 3 translations extend dissemination and implementation research by studying political, community, institutional, and other structural processes and practices that inhibit or facilitate collaboration, training, adoption, and implementation of evidence-based prevention. Type 4 translations investigate the impact, including direct and indirect costs, as well as negative consequences, of the prevention efforts on various measures of health in the population.

Together, these translations encourage researchers to think in terms of generating findings that can be readily and relatively quickly translated into policy changes and other macroenvironmental changes that affect healthcare and population health (Austin, 2015, 2016; Austin, Yu, Tran. & Mayer, 2017). Although translation research types T1 through T4 are described in a linear fashion, they can be best understood as nodes in an interconnected web (see Glascow et al., 2012, Figure 1, p. 1275). Roberto and Brownell (2017) refer to this type of policy-oriented research and its communication to policy makers via concise and clear policy briefs, as well as academic articles, as “strategic science.”

Principle 8: Multisector Collaborations Between Researchers, Advocates, and Citizens Are Necessary for Changing the Macroenvironment by Changing Public Policy

Phases 2 through 4 of translation are facilitated when researchers design and implement their studies in collaboration with community stakeholders, policy makers, economists, lawyers, and various lay and professional people with expertise in professional standards, education, and advocacy (Austin, 2012, 2015, 2016; Chapters 7, 19, and 20). Prevention science will be more strategic when researchers work with agents of social change early in the research process to identify the most relevant research questions and information needs (Roberto & Brownell, 2017; Chapter 19). An extended example of how the translation and collaborative processes unfold in efforts to prevent disordered eating is provided in the next section