Eating Disorders Prevention With Adolescents and Young Adults
Heather Shaw and Eric Stice
Approximately 10% of young women have anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified (EDNOS), which includes binge eating disorder and subthreshold eating disorders (EDs; Hudson, Hiripi, Pope, & Kessler, 2007; Stice, Marti, Shaw, & Jaconis, 2009; Wade, Bergin, Tiggemann, Bulik, & Fairburn, 2006). Threshold EDs and EDNOS are marked by chronicity, relapse, distress, functional impairment, and risk for future obesity, depression, suicide attempts, anxiety disorders, substance abuse, and morbidity (Arcelus, Mitchell, Wales, & Nielsen, 2011; Crow et al., 2009; Le Grange et al., 2006; Schmidt et al., 2008; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). The standardized mortality ratio (observed deaths in a population divided by expected deaths on the basis of demographics) was 1.7 for anorexia nervosa, 1.6 for bulimia nervosa, and 1.8 for EDNOS (comparable increases for suicide were 4.7, 6.5, and 3.9, respectively; Crow et al., 2009). Indeed, EDs show stronger relations to suicide attempts, outpatient and inpatient treatment, and functional impairment than virtually all other psychiatric disorders (Newman et al., 1996).
Importance of Prevention
Although most individuals with EDs have some contact with mental health services (80% of those with threshold EDs; 67% of those with EDNOS), few seek ED treatment (20% with threshold ED; 3% with EDNOS; Swanson et al., 2011). Furthermore, treatments of choice result in lasting symptom remission for only 35% to 45% of treated patients (e.g., Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Lock et al., 2010), and treatments are typically less effective when delivered in real-world clinical settings
(Weersing & Weisz, 2002), where dropout rates are higher (Merrill, Tolbert, & Wade, 2003). ED treatment is also very expensive, often costing more than $10,000 (Striegel-Moore et al., 2000), with residential treatment costs estimated at an average of $956 per day with an average stay of 83 days (Frisch, Herzog, & Franko, 2006). These issues surrounding treatment point to why preventing EDs is at the forefront of considerable research efforts. Prevention programs may be particularly successful for EDs, relative to other psychiatric conditions, because the peak risk period for onset of these disorders occurs between the ages of 16 and 19 (Hudson et al., 2007; Lewinsohn et al., 2000; Stice, Marti, et al., 2009). These data imply that if efficacious programs were widely implemented during this period, they could reduce the incidence of EDs. Moreover, it is more ethical to prevent the emergence of these debilitating disorders than to wait for them to develop and attempt treatment. Thus, broadly implementing effective ED prevention programs is a public health priority.
Prevention scientists recognize three qualitatively different types of prevention programs: universal, selective, and indicated. Universal prevention describes interventions that are offered to all individuals in a particular population, such as high school students. Selective prevention programs are offered only to individuals at elevated risk for a particular psychiatric condition, such as young women or those with established risk factors for eating pathology (e.g., body image or weight concerns). Indicated prevention programs are offered to individuals with initial symptoms of the psychiatric condition, such as those who endorse binge eating or other ED symptoms. Although several prevention programs have significantly reduced putative risk factors for EDs, such as body dissatisfaction, only a small handful have significantly reduced ED symptoms or disorders through follow-up.
In the following sections, we provide an overview of research evaluating ED prevention programs and describe examples of effective universal, selective, and indicated programs. We then describe the Body Project, a dissonance-based eating disorder prevention program, in greater detail, because it has received the most empirical support of the ED prevention programs that have been evaluated to date.