Prevention programs for eating disorders abound, though many people I’ve talked to (mostly on Twitter, because that’s where I have a lot of discussions of this type) have expressed the sentiment that limited resources might be better spent on early intervention or treatment in general. Still, it isn’t hard to understand why we still optimistically aim for eating disorder prevention; of course we would rather stop eating disorders in their tracks, before they wreak havoc on the lives of people and their loved ones. I’ve written about my own take on the “is prevention possible” debate elsewhere, highlighting some of my concerns, as well as some more optimistic sentiments about truly systemic prevention efforts.
One of the things I am most concerned about is the fact that prevention tends to take place in the school context, delivered by teachers who may or may not know much about eating disorders themselves and whose “healthy eating” messages may do more harm than good. In this post I will look at 3 studies focusing on the role of teachers in delivering prevention programming.
The first, by Yager & O’Dea (2005) lays out some key points about the critical issues to consider when thinking about school-based prevention. In the second, Piran (2004) highlights how teachers might be enlisted in eating disorder prevention in a way that implicates their own lived, embodied experiences. The last, by McVey, Gusella, Tweed & Ferrari (2009) outlines results from a training program for teachers aimed at increasing their proficiency in delivering prevention programs. Together, these studies help us to scratch the surface of what researchers have to say about teachers’ impacts on eating disorder prevention, including both pitfalls and benefits.
The Role of the Teacher
Trying to implement eating disorder prevention programs in our weight-obsessed society can be challenging; for one, there is a pervasive assumption that everyone shares a definition of healthy eating and a goal of weight loss. Teachers are certainly not immune to the kind of weight stigmatizing attitudes held in popular culture; so, why do we assume that teachers will be able to deliver eating disorder prevention without thinking about their situatedness in our society?
To disentangle the potential impacts of teachers’ Yager & O’Dea explored teachers’ attitudes, knowledge, and training in the delivery of eating disorders and obesity prevention. They note that we tend to assume that teachers hold knowledge around how to deliver health curriculum; however, many teachers (like most people) hold oversimplified understandings about the relationship between weight and health. Yager & O’Dea’s review revealed that many teachers:
- Felt negatively toward obese individuals
- Believed that eating disorders could be resolved if someone just “pulled themselves together”
- Suffered role confusion around whether they should be delivering prevention or treatment
The authors also note that there is at least equivalent, if not higher, prevalence of disordered dieting and exercise among physical education teachers as in the general population. This could be interpreted in a positive or negative light, they note: having been through struggles may increase teacher empathy for eating disorders, but could also lead to modeling problematic behaviours, in the case of an active eating disorder.
Yager & O’Dea provide the following suggestions for training teachers in appropriate ways of delivering eating disorder prevention:
- More thoroughly train teachers in body image, eating disorders and obesity
- Train teachers not only in content, but also in prevention science, including techniques for prevention
- Assess teachers’ personal and professional needs in this area
Teacher Embodiment
Niva Piran (2004) provides more information about how developing body awareness and centralizing teachers’ experiences might help to mitigate the potential biases teachers can bring to prevention delivery.
Piran suggests that the lacking focus on how teachers might shape (as opposed to simply delivering) knowledge students encounter is a missing link in prevention effectiveness. Like a growing contingent of others in the field, Piran opts for an ecological (whole system) approach to prevention. Looking at the literature around teacher interest and knowledge in prevention:
- Teachers sense a gap in their knowledge around how to be a “good role model” for positive body image, and may not explore the negative consequences of dieting with students in prevention contexts (Rayman & Piran, 2002)
- Teachers may desire, but not have access to, prevention strategies and “how tos” for doing weight-related disorder prevention (Neumark-Sztainer, Story & Coller, 1999)
- The format of this information is key: teachers tend to prefer short, to the point guidelines over time-consuming books, workshops, or lesson plans (Smolak et al., 2001)
To enlist teachers in eating disorder prevention, Piran suggests:
Centralizing bodily experience by encouraging a critical exploration on teacher misconceptions and prejudicial attitudes toward certain types of bodies
For Piran, this includes:
- A critical analysis of consumer capitalist society
- The promotion of respect and care for (all kinds of) bodies
- An exploration of the structural and attitudinal barriers that diversely positioned people face in accessing health, and
- Empowering teachers to “embody prevention”
Engaging teachers in focus groups around “body-anchored experiences”
These groups would enable teachers to explore:
- How they have experienced their body in society
- See how this has impacted behaviour, and
- Leverage these experiences while delivering prevention
Brain storming about teacher-involved initiatives that could bring these body-anchored experiences into practice
For example, teachers might participate in activities that challenge often taken-for-granted misconceptions about bodies in the school context.
Together, these actions encourage teachers to explicitly position themselves as not just vessels for the delivery of neutral information (and we know that information about bodies, food, and weight are never neutral) but as part of prevention efforts.
So, both of these articles build evidence for the case that we need to be taking the role of teachers seriously when designing and implementing prevention efforts. However, we also know that time and resources are limited. How effective are strategies that encourage teachers to embody prevention, and what has been tried?
Teacher Training
Gail McVey has been at the helm of many Canadian initiatives aiming to more thoroughly train teachers and health care professionals in eating disorders and body image issues. Here, I’ll briefly describe an article from 2009 in which she and colleagues detail experiences testing an online prevention program with 78 teachers and 89 public health practitioners in 2 provinces.
McVey et al. note that in the wake of an uptick in anti-obesity messaging and general concern about children’s health, there is a particular need to provide teachers with more information about how to provide students with balanced and helpful information about weight and shape.
They tested a curriculum and training tool called The Student Body: Promoting Health at Any Size, a 6-module, online program for teachers and other school professionals. They wanted to find out if teachers were comfortable with the program, whether the program provided an effective way to give teachers information about prevention that they felt able to use to work against weight biases in the school environment.
Participants were divided into intervention and control groups; both health practitioners and teachers were involved, but for the purposes of this post I’ll focus on the results related to teachers in particular. Those in the intervention group improved in their knowledge of:
- Restrictive dieting (e.g. that diets may lead to weight gain)
- Peer influences on weight bias (e.g. that peers may actively or passively encourage dieting amongst one another)
Unfortunately, despite being satisfied with the program, teachers did not feel more able to fight weight bias upon completion of the modules. The authors suggest that to bring increases in knowledge into practice, teachers need more support in developing strategies to counter weight bias.
Unlike some other articles I’ve seen on the subject, McVey et al.’s article provides a detailed outline of topics covered in the intervention. They also define “healthy eating,” which is surprisingly rare in prevention articles. This kind of transparency could hopefully help in other trials for the program, or tweaks to make the intervention more effective.
So, what does it mean?
It is encouraging to see prevention programs focused on making changes in the broader environment rather than focusing on the individual. McVey et al.’s article helps to provide evidence against a common refrain one might encounter when arguing for the need to provide more training opportunities for teachers: that it requires too much time and effort to train teachers how to do prevention. Counter to this argument, this study showed how teachers were satisfied with a program delivered online and aligned with curriculum.
I also enjoyed how Piran’s article in particular highlighted that if we want to make cultural change around weight, bodies, and food, in schools and beyond, we need to critique not only “thin ideal internalization” (which places the onus on the individual) but the broader consumer capitalist society in which we live. Instead of assuming that “media literacy” in a traditional sense (i.e., awareness of airbrushed models, etc.) this extends into the realm of being critical about why and in whose interests (hint: not mine or yours, but certainly the pocket books of large corporations) these standards are produced.
Together, these articles underline the necessity of approaching prevention from beyond the individual. They encourage us to make changes at a systemic level (i.e. the school as a system) to support a more body-, food- and weight-positive environment for children. Whether changes in teacher training help to: a) prevent iatrogenic (unintended negative) impacts of prevention programs for children exposed to prevention and b) actually prevent eating disorders remains to be seen. At the very least, this could be a positive step toward less weight-stigmatizing environments that could be more supportive for students, teachers, and others.
References
McVey, G., Gusella, J., Tweed, S., & Ferrari, M. (2009). A controlled evaluation of web-based training for teachers and public health practitioners on the prevention of eating disorders. Eating disorders, 17 (1), 1-26 PMID: 19105058
Piran, N. (2004). Teachers: on “being” (rather than “doing”) prevention. Eating disorders, 12 (1), 1-9 PMID: 16864300
Yager, Z., & O’Dea, J.A. (2005). The role of teachers and other educators in the prevention of eating disorders and child obesity: what are the issues? Eating disorders, 13 (3), 261-78 PMID: 16864532
I do not believe that teachers are suited or qualified to address this issue.There are eating disorder professionals who volunteer their time to run free weekly or monthly support groups,speak in the community at various places,etc. Why not reach out to eating disorder professionals and put out a request for volunteer speakers?I know mental health professionals who do this on other topics.What about school psychologists,guidance counselors and nurses?
Surely they are better qualified to address eating issues than are teachers,who are not qualified to address this at all. I am a Hurricane Sandy victim.The government,in a well meaning effort to help trauma survivors,set a number of programs in my area,which had been virtually obliterated by Sandy.One of these projects was called “Project Hope”.I came to refer to it as “Project Hopeless”. What the government had done,was to take a group of people who were not mental health professionals,give them a crash course in trauma counseling,and send them out into a community of severely traumatized individuals.These”Trauma counselors”made comments in response to some of the things we Sandy Victims shared that had us in tears.Then a program was set up within the visiting nurse program.We Sandy victims were offered free”Natural Disaster Oriented C.B.T. sessions.”Someone would come to our homes,and help us.It sounded wonderful.A nice young man came into my home,who had been initially assigned to “Project Hope” and “re-trained”to do “C.B.T. “. He was reading straight out of a C.B.T.manual at times.
I have training in C.B.T. He had no idea what he was doing.At one point,when I was talking about the trauma I had undergone,he interrupted me because he was supposed to cover a certain amount of C.B.T. from his manual.A psychologist who is trained in C.B.T. would NEVER interrupt a client who is discussing the water climbing her stairs during Sandy,because she wasn’t keeping pace with his 10 session program.As I am from a community that was completely underwater during Sandy,where EVERYONE is a trauma survivor, we Sandy survivors discussed these programs on Facebook support group pages,(which were a heck of a lot more helpful and supportive to us that the “trauma counselors”ever were).The consensus was that these people
were doing us more harm than good.I contrast that with a Hurricane Sandy that was set up at our local Jewish Community Center which was funded by U.J.A. Federation and offered both support groups and individual counseling given by actual social workers. THAT group was helpful.Those sessions were helpful to an extent,though the social workers were not trained to deal with trauma victims. The “trauma counselors”trained by the government received more training that I imagine teachers will be given re eating disorders.Of course, we were already traumatized,and the proposal is that teachers will be involved in prevention,rather than in treating those who are already suffering from eating disorders.Still, I do not believe they are qualified.and many students are suffering from eating disorders from early childhood. The body size of the teacher,or anyone addressing eating disorders,is important.I saw an obese teacher being interviewed on T.V.in regards to such an education initiative.The body size of teachers and mental health professionals is relevant,but is not addressed.I walked into Renfrew,and the head of the program in Manhattan was obviously anorexic.She had a doctorate in psychology,but no credibility as far as I am concerned.This is a problem in the eating disorder professional community overall.There is a preponderance of eating disorder therapist and of nutritionists who specialize in eating disorders who are suffering from eating disorders.I have a friend who is an eating disorder therapist who is actively bulimic.She is probably a marvelous therapist,but I always wonder what will happen if she runs into a client,fresh from purging in a restaurant bathroom.I have finally found help with a male therapist.I never thought a male therapist could help me with my eating disorder,but in additional to be an incredibly skilled psychologist and wonderful person,I don’t compare my body to his,which is immensely helpful,though he is a bit overweight and had gone up and down during the course of treatment.He has the healthiest attitude toward eating and body size of any mental health professional I’ve encountered ,and I’ve seen all too many regarding my eating disorder.I hope the schools can bring in some professionals.I know there are professionals who would volunteer their time.My therapist would.I think that would serve students better.Overall,I believe that it is parents who hold the key,but so many parents have eating issues that this is a problem.I didn’t get my messages about body size from the media.My mother told me “You can never be too rich or too thin” & “Fat people can’t have class”when I was a small child.The first message was easily understandable. I did not know what “Class” meant,at young age,but I got the message.My niece decided that her thighs were fat when she was a small child,because she’s heard her mother say that her own thighs were fat.
My apologies for the length of my comment.At this point,it’s not that cohesive.I greatly appreciate your blog. and all the effort you go . I find what you write to be more helpful than much I have read in professional journals, the media,and elsewhere.You are providing a great service.Thank you.Hmm. Here’s a thought.Doctoral and Masters students such as yourself going into the schools. Thanks again. Deborah
Good grief.I had no idea my comment was so long.It’s longer than you post.I think you should probably take it down for that reason.My apologies.I feel strongly about this subject,obviously.
Appreciate the fact you waded in. I am one of the many who finds prevention campaigns unappealing when treatment options are abysmal.
I agree that a tangible step might be addressing the fact that media literacy is not actually methodically addressed with young children in schools. My son was asked in grade four to pick out a product he liked and to develop an advertising spread on the product. At no point in that teaching unit was there any classroom discussion or didactic section on how advertising messages are created to generate dissatisfaction and anxiety. Some of the most successful anti-smoking campaigns in the US for children and adolescents (until they were squashed by the payout agreements from the tobacco companies) focused on how the viewer was being manipulated by tobacco advertising (and yes, these were measured outcomes of the campaigns in question).
But given that schools depend more heavily upon corporate sponsorships for many fund raising activities I don’t suppose that true media literacy education is high up on the priority list.
Yes, I think that’s the prevailing sentiment amongst advocates online- that prevention seems like a lower priority than fixing the broken-ness that is our treatment system. I agree that media literacy needs to be better addressed; further, I think there needs to be a recognition that media literacy is not immunity to poor body image. I think there is a tendency for media literacy to be touched on briefly, in passing, and then a dusting-of-the-hands and saying “well, covered that!” I fear that media literacy does little to actually change the system (I supposed unless enough media-literate folks get together and demand change) and leaves people fighting a battle that often leaves one feeling deflated. Personally, the “love your body” glossing that media literacy sometimes takes on actually provokes a feeling of not-good-enough if there is a day where I do, in fact, feel kind of crummy about myself. A compounded guilt that comes from knowing I should know better! Interesting, how the onus on feeling good about oneself is so easily pushed onto the individual…
I am one who is highly skeptical of elevating pursuit of prevention above physician education for early diagnosis and access to treatment.
I am a teacher, and one who has taught media literacy. I am also a parent who raised my children on poetry and literature along the lines of Marge Piercy’s Barbie Doll. The who and the why of advertising, Photoshop, etc. were oft-discussed topics in our home. The youngest of my four children still developed anorexia.
The underpinnings of prevention seem to me to be predicated on a linear equation–decrease body image issues which will decrease disordered eating which will decrease incidence of eating disorders. This model doesn’t seem to account for the strong genetic and biological pieces and the myriad triggers of EDs. Again, to me, this effort hurts us AT THIS POINT (may not be that way in a few years) by reinforcing the idea that EDs are a result of choice and vanity.
One last point as an educator and parent–our children should not function as guinea pigs and the recent rise in non evidence-based school-based anti-obesity and ED-prevention programs assign them that function.
Thank you so much for exploring this topic, I look forward to further reading.
I certainly agree that media literacy is an insufficient measure unto itself to prevent eating disorders. From my read of the prevention literature, the idea behind it is to target one of the “modifiable risk factors” for EDs (following Stice et al., 2000- http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1098-108X(200003)27:2%3C206::AID-EAT9%3E3.0.CO;2-D/abstract I suspect it comes from a good place, i.e., one of “well, we can’t change the other things so we might as well try this.” I agree, though, that it has led to an all-too-common choice discourse around eating disorders, which we know are not choices and are caused by a complex mixture of factors including genetics. I tend to favour prevention efforts that aim to promote positive self-esteem not linked to eating disorders specifically, for that reason. Given the context within which we are working (i.e., one that problematically positions restriction as a good thing, anti-obesity messaging, etc.), I think it is worth having a look at health curricula to flag for content that might be problematic for those who are predisposed to eating disorders (similar to Pinhas et al., 2013: http://www.ncbi.nlm.nih.gov/pubmed/23421694 and looking at weight bias & weight based bullying within the school context, to avoid doing harm. And yes, I agree that more effort might be devoted to improving early intervention & access to treatment. Interestingly, “early intervention” sometimes fits into a prevention schema (i.e. under public health prevention models, seeing tertiary, targeted prevention as early intervention by making appropriate referrals for help, stopping behaviours, etc.), so maybe more effort on that end of the spectrum and less around universal “positive body image” style prevention, for prevention scientists…
I cite the Pinhas study constantly and absolutely agree with you. I was heartened to have Carolyn Becker assert, in a session at NEDA last year, that her work on prevention is intended only for universal body-image work, not as ED prevention. Sadly, a Google search reveals that it is being billed as prevention by many.
Both as a teacher and a parent, I think we’d get more mileage out of ensuring teachers know signs of eating disorders rather than them being roped into prevention work they are neither trained for, nor is their evidence for currently.
The fact that all the programs/authors are so preoccupied with body image highlights how confused their thinking is. IMO, to think you can prevent anorexia by promoting positive body image is to completely mix up cause and effect. It’s a bit like thinking you can prevent OCD by encouraging everyone to enjoy a little dirt, to love not having things in straight lines and to celebrate just checking once if something is locked. These concerns are symptoms of the condition, not its cause. But no-one seems to be able to grasp this principle when it comes to EDs.
I personally doubt whether a prevention program could work. However, if there is to be such a program it would ideally address EDs completely separately from body image, dieting etc. Perhaps teach that certain thought processes (for example, being driven to lose more and more weight but believing that you have got nowhere and are just as fat as you were at the start) are actually symptoms of a mental illness and one that is very difficult to escape from on your own. But kids can be so suggestible that even that may potentially do more harm than good.