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Eating Disorders Prevention and Early Intervention NEDC December 2012 2

The National Eating Disorders Collaboration is funded by the Commonwealth Department of Health and Ageing December 2012 For more information about the National Eating Disorders Collaboration and this report please contact the CEO of the Butterfly Foundation at: The Butterfly Foundation 103 Alexander Street Crows Nest NSW 2065 T: (02) 9412 4499 F: (02) 8090 8196 E: [email protected]


Acknowledgements

The development of this report has been a collaborative effort involving many people from diverse sectors and organisations across Australia. The National Eating Disorders Collaboration (NEDC) gratefully acknowledges the time, effort and passion that people have brought to this process. As a project of the NEDC, the Eating Disorders Prevention and Early Intervention Report has been

developed under the expert leadership of the NEDC Steering Committee:

National Eating Disorders Collaboration Steering Committee

Prof Pat McGorry AO, Chair Claire Vickery OAM

National Standards Group Prevention and Early Intervention Group

Professional Development Group

Prof Phillipa Hay (Deputy Chair, NEDC)

Prof Susan Paxton Prof Stephen Touyz

Prof David Forbes Prof Tracey Wade Chris Thornton

A/Prof Richard Newton Dr Naomi Crafti (resigned August 2012)

A/Prof Sue Byrne

Dr Sloane Madden Dr Anthea Fursland

Collaboration and Membership Group

Clinical Reference Group Evidence from Experience Group

Elaine Painter Julie McCormack Kirsty Greenwood

Kim Ryan Prof Janice Russell Madeleine Sewell

Christine Morgan Belinda Dalton June Alexander

A/Prof Michael Kohn

Rachel Barbara‐May

Information and Resources Group

Social Messaging Group

Prof Tracey Wade A/Prof Jane Burns

Dr Hunna Watson Dr Elizabeth Scott

Particular thanks must go to the co‐chairs of the Prevention and Early Intervention Working Group,

Professor Susan Paxton, Professor Tracey Wade and Dr Naomi Crafti, who have made an

extraordinary contribution through their leadership of this group.

The consultation process has involved the members of the NEDC Prevention and Early Intervention

Working Group, workshops for teachers and other professionals working with children and young

people, and consultation with people with lived experience of eating disorders.

The Eating Disorders Prevention Cross‐Sector Advisory Group was formed with representation from

the education, sport, fitness, weight loss, and youth recreation sectors to assist in identifying the

barriers and enablers for eating disorders prevention. The NEDC gratefully acknowledges the

contribution of all members of the Advisory Group.


Prevention Cross Sector Advisory Group

Kylie Andrew Victoria Institute of Sport

Fiona Bailey Physical Activity Australia

Lisa Biffin Running Technique Coach

Hilary Bland Victorian College of the Arts Secondary School

Madeleine Campbell Victorian College of the Arts Secondary School

Naomi Crafti Turning Point

Sarah Dwyer beyondblue

Sheree Vertigan Australian Secondary Principals Association

Liz Grylls Northern Territory Institute of Sport

Laura Hart Mental Health First Aid

Kylie Hesketh Centre for Physical Activity and Nutrition Research, Deakin University

Karen Inge Jenny Craig

Nikki Jeacocke Australian Institute of Sports

Brian Martin Running Technique Coach

Susan Paxton La Trobe University (Advisory Group Chair)

Lucinda Sharp Australian Ballet School

Jaelee Skehan Hunter Institute of Mental Health

Lauretta Stace Fitness Australia

Fiona Sutherland Sports Dietitians Australia

Sally Walker New South Wales Institute of Sport


Contents

Acknowledgements Page 3

Executive Summary 6

The Prevention and Early Intervention Report 9

The National Eating Disorders Collaboration 10

About Eating Disorders 11

Chapter 1 An Urgent Issue 13

Chapter 2 Opportunities for intervention 17

Chapter 3 Approaches that work for young people 24

Chapter 4 Facilitating early help seeking 35

Chapter 5 Complementary initiatives 43

Chapter 6 Opportunities and gaps 54

Chapter 7 Prevention in a media environment 61

Chapter 8 Messages for good health 66

Chapter 9 Conclusion: Opportunities to implement effective strategies 72

References 76


Executive Summary

Eating disorders are relatively common illnesses that can lead to a lifetime of physical and mental

health problems, social isolation and reduced quality of life. The cost to individuals, families,

communities and health systems is enormous. There is however, evidence that prevention

interventions can reduce risk factors for eating disorders and early intervention in the course of the

illness can successfully reduce their duration and prevent relapse.

Some risk factors, particularly those originating in the social environment such as dieting and body

dissatisfaction, can be modified, reducing the risk of developing an eating disorder and promoting

resilience and healthy development in children and young people.

The two groups at highest risk of developing an eating disorder are children and young people, and

females of all ages. However, more specific target groups can be defined with particular

vulnerabilities and intervention needs and these must be taken into consideration in developing

prevention approaches.

While the range of evidence based prevention initiatives available in Australia is small, there are

programs and resources available, including some specifically developed for the local context.

Consistent implementation of these resources to target high risk groups, together with collaboration

between the body image, obesity and eating disorders sector for health promotion, provide

immediate opportunities for strategic intervention to stop the spiralling costs of eating disorders.

There is also a level of interest from specific sectors such as sport and fitness which provides

opportunities for the development of more targeted prevention and early intervention programs

(Chapter 6: Gaps and Opportunities, page 54). The NEDC recommends the adoption of strategies to

take advantage of these opportunities.

The long term impact of prevention messages may be strongly influenced by the social environment,

therefore to be effective prevention programs should be delivered within a broader context of

cultural change. Cultural change requires consistent responses across a wide range of

communication channels.

An integrated approach to prevention based on the shared risk factors for obesity, body

dissatisfaction and disordered eating may provide the best opportunity to reduce the impact of all of

these conditions on the health of Australians. There is an urgent need to develop integrated

prevention initiatives which encourage body esteem, healthy eating and lifestyle behaviours without

prompting engagement in fad diets, weight loss attempts and the diet‐binge cycle.

Australia is fortunate to have a mental health policy, planning and standards framework that actively

promotes prevention and early intervention.

In the interests of the health of all Australians, but especially children and young people, it is

essential that Australia undertake a national expert review of the role of dieting in obesity, body

image and eating disorders informed by all the areas of expertise including eating disorders, and

commit to implementing long term strategies to promote healthy environments.


The priority areas for action identified in this report are:

1. Consistent, Safe Community Messages Goal: A shared and consistent approach between obesity prevention, body dissatisfaction (body

image) prevention, eating disorders prevention and general mental and physical health promotion.

Strategic Opportunities for Action

An national independent task force expert review of the role of dieting in obesity, body

image and eating disorders informed by all the areas of expertise including eating disorders

Integrate body image prevention with eating disorders prevention at a policy level

Implement AED (2011) guidelines on obesity prevention in children as an interim strategy

while Australian guidelines are developed

Collaborate with health promotion campaigns to develop safe and effective approaches to

weight management with an emphasis on weight management strategies for children and

young people and developing community awareness of the dangers of dieting

Evaluation of all mental health and obesity prevention initiatives for their impact on

disordered eating is essential to open up opportunities for shared approaches to prevention

and health promotion.

2. Developing community and professional knowledge Goal: A trained and resourced professional workforce, including health professionals and

professionals in gatekeeper roles such as teachers, school counsellors and physical activity

instructors, who are able to identify and respond to people at risk


Make Mental Health First Aid training and equivalent programs accessible for adults who

intersect with people at high risk of eating disorders

Implement core competencies for frontline health professionals working with people at high

risk of eating disorders as outlined in the NEDC report: A Nationally Consistent Approach to

Eating Disorders.

Facilitate access for health professionals to basic training in eating disorders as outlined in

the NEDC report: A Nationally Consistent Approach to Eating Disorders.

3. Widespread implementation of evidence based programs Goal: Evidence based programs and resources currently available for prevention and early

intervention are made accessible on a consistent basis to high risk groups.


Make existing evidence based prevention programs, including body image programs,

available for young people on a consistent basis

Provide online access to professionally facilitated self‐guided early intervention programs

under the auspice of one or more existing eating disorders service providers


This report provides general guidance on the implementation of prevention, early intervention and early identification strategies.

Focus on modifiable risk factors of dieting, disordered eating, body dissatisfaction and the internalization of body ideals (media literacy). (Chapter 1: An Urgent Issue, page 13)

Target People at high risk or with specific vulnerabilities: (Chapter 2: Opportunities for Intervention, page 17)

Adolescents and young adults (ages 12‐25)

Females

Athletes engaging in competitive sport, fitness or dance

People seeking weight loss treatment

People with a personal or family history of eating disorders

People with additional health risks or vulnerabilities: younger children, pregnant women, males,

Indigenous communities, people with specific health conditions – diabetes, PCOS, infertility

Use evidence based programs and resources delivered by leaders/presenters who are trained and supported for this work (Chapter 3: Approaches that work for young people, page 24)

Develop supportive environments to take an integrated and safe approach to promoting good

health (Chapter 3, page 31)

Screen opportunistically during routine health and wellbeing checks, providing opportunities for disclosure and help seeking, particularly in primary health care (Chapter 4: Facilitating Early Help Seeking, page 35)

Facilitate access to mental health literacy and mental health first aid training for all adults who work

with high risk groups (Chapter 4, page 38)

Add evidence based prevention and early intervention resources to existing initiatives that target the same high risk groups (Chapter 5: Complimentary Initiatives, page 43)

Deliver programs and health messages that are safe and consistent, ensuring that initiatives for general health, mental health, body image and obesity prevention are mutually safe and supportive (Chapter 7: Prevention in a Media Environment, page 60 and Chapter 8: Messages for Good Health, page 65)

Evaluate the outcomes of prevention and early intervention initiatives to add to the evidence base,

including evaluating the impact of general health promotion and prevention initiatives on disordered eating and body satisfaction

Integrate eating disorders prevention resources with existing general mental and nutritional

health strategies (e.g. add resources to Mindmatters, Mindframe, Kidsmatter)

Collaborate with sport, fitness and dance sectors to review, update and assertively promote

information on eating disorders prevention and early identification that is relevant to the

specific physical and nutritional requirements for each sector


The Prevention and Early Intervention Report

Purpose and Scope

The purpose of the Eating Disorders Prevention and Early Intervention report is to raise awareness

of evidence based approaches for the prevention and early intervention of eating disorders.

The report identifies high risk groups, potential points for early identification, and evidence based

options for prevention and early intervention.

“Prevention” in this context refers to the reduction of risk factors associated with eating disorders

and an increase in protective factors; early intervention refers to early detection of the symptoms of

eating disorders leading to early access to treatment.

Methodology

The development of this report has involved:

A review of the research literature on prevention and early intervention for eating disorders

A review of eating disorders information resources accessible online

A review of complementary health promotion and prevention initiatives

Consultation with key stakeholders including:

o The Eating Disorders Prevention Cross‐Sector Advisory Group– this group is made up

of representatives from the education, sport, fitness, weight loss, and youth

recreation sectors. The role of the Advisory Group was to assist in identifying the

barriers and enablers for eating disorders prevention from the perspective of their

individual sectors. A full list of members appears in the Appendix of this report

o Workshops for teachers and other professionals working with young people at risk

o Members of the NEDC Prevention and Early Intervention Working Group

o People with lived experience of eating disorders and their families

A review of data collected for the NEDC Gap Analysis

National Eating Disorders Collaboration Publications

The Prevention and Early Intervention report is a key document in the suite of NEDC publications

and resources. Publications and resources developed in the current phase of the NEDC include:

An Integrated Response to Complexity: Eating Disorders National Framework (2012)

Clarity in Complexity: Strategic Communication to Support the Prevention and Early Identification of Eating Disorders (2012)

A Nationally Consistent Approach to Eating Disorders: Opportunities to Implement the

National Eating Disorders Framework (December 2012)

NEDC website and clearinghouse resources www.nedc.com.au


The National Eating Disorders Collaboration The National Eating Disorder Collaboration (NEDC) is the second phase of a project initiated and

funded by the Commonwealth Government Department of Health and Ageing (DoHA) in 2009. The

primary purpose of the NEDC is to bring together eating disorder stakeholders and experts in mental

health, public health, health promotion, education, research, and the media to develop a nationally

consistent approach to the prevention and management of eating disorders.

The projects objectives include:

Provide or facilitate access to helpful, evidence based information for young people and their

families on the prevention and management of eating disorders and healthy eating

Promote a consistent evidence based national approach to eating disorders

Develop and assist in implementing a comprehensive national strategy to communicate

appropriate evidence based messages to schools, the media and health service providers.

In working towards these objectives, the NEDC is actively pursuing the vision and goals outlined in

the first phase of the project:

1. Eating disorders are a priority mainstream health issue in Australia

2. A healthy, diverse and inclusive Australian society acts to prevent Eating Disorders

3. Every Australian at risk has access to an effective continuum of Eating Disorders prevention, care

and ongoing recovery support.

In developing all reports and resources, the NEDC draws upon research evidence and consultation

with clinicians, researchers, community based organisations, people with experience of eating

disorders and their carers and other interested stakeholders.


About Eating Disorders

Eating disorders are a group of serious psychiatric illnesses resulting in

significant physical complications and impairment. Eating disorders

include anorexia nervosa, bulimia nervosa, binge eating disorder, and

eating disorder not otherwise specified1. People with eating disorders

have disturbed eating behaviours and distorted beliefs, with extreme

concerns about weight, shape, eating and body image. Symptoms can

also include driven exercise.

Physical impairment is a result of those disturbed eating and exercise

behaviours. However, eating disorders are as much about what is

happening in the mind as they are about dealing with eating and

exercise behaviours. Importantly, they cannot be diagnosed by

appearance.

“Sufferers describe having a tyrant yelling abuse, threats and instructions in their head 24 hours a day. This tyrant began as a friend, helping protect the person from a world that, for many reasons, is

perceived as threatening.” (NEDC, 2011)

Anyone of any age, gender, cultural background or socio‐economic

group may experience an eating disorder. Eating disorders are

estimated to affect approximately 9% of the total population (males

and females of all ages). During the course of a lifetime it is estimated

that approximately 15% of Australian women experience an eating

disorder (Wade, Bergin, Tiggerman, Bulik, & Fairburn, 2006). These

estimates do not fully take into consideration the frequent under‐

reporting and under‐treatment of eating disorders, especially in men

(Hudson, Hiripi, Pope, & Kessler, 2007).

People with eating disorders experience higher rates of other mental

health disorders. Mood and anxiety disorders and substance disorders

occur quite commonly in people with all types of eating disorders.

Comorbid conditions tend to increase the severity and chronicity of

the eating disorder (Blinder, Cumella, & Sanathara, 2006).

The risk of premature death is increased for people with all types of

eating disorders (Arcelus, Mitchell, Wales, & Nielsen, 2011) in part due

to medical complications and in part due to an increased rate of

suicide (Pompili, Girardi, Tatarelli, Ruberto, & Tatarelli, 2006). Young

people with eating disorders are over ten times more likely to die

1 A more detailed description of each type of eating disorder is provided in the NEDC fact sheets on eating disorders available from the NEDC website

Myth: Eating disorders

are rare

Eating disorders are about as

common as asthma with around

9% of the population likely to be

affected at some point in their

lives. At least one quarter of the

Australian population knows and

is affected by someone with an

eating disorder.


are a choice

Eating disorders are serious

complex mental illnesses with

consequences for physical

health, quality of life and

mortality. No one chooses to

have an eating disorder.

Some of the risk factors for

eating disorders do involve

personal choices, like choosing

to go on a diet. The problem is

most people don’t know if they

have the other risks for

developing an eating disorder

until it is too late. Extreme ‘fad’

diets and weight loss techniques

are dangerous for everyone’s

health. For people at risk of

eating disorders they are a

trigger that activates a serious

illness.


prematurely than their peers without an eating disorder (Steinhausen,

2009).

The consequences of an eating disorder are not limited to acute

episodes of illness but may also be long term. The prospects for

recovery for a young person with anorexia nervosa have been described

as “often poor”. Steinhausen (2009) found that only 46% of patients

fully recovered from anorexia nervosa while 20% remained chronically

ill.

For the individual, the impact may include psychiatric and behavioural

effects, medical complications, social isolation and disability. People

who develop eating disorders in childhood or adolescence may

experience interrupted physical, educational and social development

and a long‐term risk of significant medical complications (NEDC, 2010).

“Having an eating disorder is like being in a personal hell, where no

matter what you do or don’t do, everything is wrong. It involved a lonely

isolated world of shame, guilt and a feeling of utter failure.”

For families, the impact may include caregiver stress, loss of family

income, disruption to family relationships and a high suicide risk (NEDC,

2010).

There is a prevalent myth, reinforced by media images, that the only

eating disorder of concern is anorexia nervosa and that therefore a

person must be severely underweight to have an eating disorder

(Austin, 2011). Most people with an eating disorder present with binge

eating disorder or atypical symptoms (Hay, Mond, Buttner, & Darby,

2008). These disorders are as clinically severe as anorexia nervosa and

bulimia nervosa (Hay, et al., 2010), although it is often harder to see the

impact that they have on individual health.

The rate of eating disorders in the Australian population is increasing

(Hay, et al., 2008). This trend has paralleled the increase in childhood

obesity and it is probable that there is a relationship between the

increase in concerns about obesity and an increase in extreme weight

loss behaviours and body dissatisfaction (O’Dea, 2005).

The cost of care is substantial. Eating disorders are the 12th leading

cause of mental health hospitalisation costs within Australia, and the

expense of treatment of an episode of anorexia nervosa has been

reported to come second only to the cost of cardiac artery bypass

surgery in the private hospital sector in Australia. Bulimia nervosa and

anorexia nervosa are the 8th and 10th leading causes, respectively, of

burden of disease and injury in females aged 15 to 24 in Australia, as

measured by disability‐adjusted life years (NEDC, 2010).

Myth: The only illness

to worry about is

Anorexia

Some of the symptoms of

anorexia nervosa are visible and

this is the eating disorder most

likely to require hospitalisation.

However, the other eating

disorders are also serious and

complex illnesses with a high risk

of long term health

consequences and an increased

risk of premature death.

Because they are harder to see

and less well known in the

community, people with these

eating disorders are also less

likely to get treatment.


can’t be cured

There are effective evidence

based treatments for eating

disorders. They don’t work in

the exactly the same way for

everyone but they will improve

health and quality of life. It can

take a long time to recover

completely from an eating

disorder once the illness is

established.

Getting help as early as possible

is the best way to reduce the

severity and duration of illness.

However treatment is

worthwhile at any stage of

illness. For the people who

develop an ongoing illness,

engagement in treatment will

reduce symptoms, reduce the

risk of mortality, and improve

quality of life.


Chapter 1 An Urgent Issue

A brief introduction to the need for prevention and early intervention for eating disorders and the

definitions of prevention, early identification and early intervention used in this report

Prevention and early intervention are critical components of a continuum of health care. The

purpose of prevention and early intervention is to reduce the incidence of illness and the impact of

illness on individuals, families, communities and health care systems.

Eating disorders are illnesses that typically need treatment for recovery to occur. While eating

disorders can be treated successfully they can also have a lifelong impact on health and wellbeing.

Only about half of the people with anorexia nervosa and bulimia nervosa will fully recover, while

20%–30% will continue to experience persistent subclinical symptoms, 20%–25% will have a severe

and enduring disorder, and up to 10% may die as a result of the disorder (Steinhausen, 2009).The

increased risk of premature death is due in part to medical complications and in part to an increased

risk of suicide (Pompili, et al., 2006).

Eating disorders are estimated to affect approximately 9% of the total population (males and

females of all ages). This is a conservative estimate. At least two studies have indicated that only

about one tenth of bulimia nervosa cases are detected.

The Economic Impact of Eating Disorders without Early Intervention

A recently released report from Deloitte Access Economics (2012) estimates the total annual

expenditure on eating disorders in 2012 at $99.9 million, based on AIHW reports for 2008‐

2009. These health system costs are primarily borne by the Australian government ($42.6 million)

and state, territory and local governments ($26.4 million). Individuals contribute $10.4 million, while

family/friends and carers make up the remaining $20.5 million.

The cost of long term illness with an eating disorder however is much higher for everyone involved.

Added to the need for repeated access to treatment for the disorder and for treatment for all of the

physical health consequences of the disorder over many years, are the costs of loss of productivity,

loss of quality of life, health impacts on family and carers and out of pocket expenses. The Deloitte

Access Economics report estimates the productivity impacts of eating disorders in 2012 to be $15.1

billion, similar to the productivity impacts of anxiety and depression which were estimated at $17.9

billion in 2010.

The “burden of disease” from eating disorders is estimated as $52.6 billion, which is comparable to,

the estimated value of the burden of disease for anxiety and depression of $41.2 billion, and for

obesity at $52.9 billion (Access Economics, 2012).

Prevention

The risk and protective factors for eating disorders occur within the context of everyday life,

heritable risk, perinatal influences, family relationships, interpersonal relationships, the home


environment, schools, workplaces, recreational and sport activities, media and social influences, the

health of the individual and the health of the community. The complex interplay of biological,

psychological, social, environmental, cultural, economic and political factors support the use of

population health approaches to eating disorders prevention.

Research suggests that weight concern and body dissatisfaction, and dietary restraint constitute

early stages in the development of eating disorders (Stice, Ng, & Shaw, 2010). Therefore, the

prevention of eating disorders focuses on building factors that contribute to healthy body

satisfaction and relationships with food, and reducing factors that contribute to body dissatisfaction

and dieting. Independent meta‐analysis studies have found prevention initiatives to be effective in

influencing eating disorder related knowledge, attitudes and behaviours (Fingeret, Warren, Cepeda‐

Benito, & Gleaves, 2006). These effects may be increased and become more sustainable when

prevention is delivered in a context of environmental and social support for these changes.

Early Intervention Individuals who are identified and treated early in the course of an eating disorder have a better

chance of recovery compared to those with a longer history of illness (Berkman, Lohr, & Bulik, 2007;

Steinhausen, 2009).

Early intervention provides interventions that are appropriate for, and specifically target, people

displaying the early signs and symptoms of eating disorders. Interventions can be:

1. Prevention focussed ‐ targeting individuals beginning to show the early signs and symptoms

of a problem (indicated primary prevention) with the goal of arresting any further

development along the pathway to a clinical eating disorder

2. Treatment focussed ‐ targeting individuals experiencing a first episode of mental illness (secondary prevention). Treatment focussed early intervention requires an intensive, multi disciplinary treatment approach supported by expertise in eating disorders treatment.

Initiatives and strategies to lower the severity and duration of an illness through early intervention,

include early detection and early treatment. These interventions can occur at any stage of life, from

childhood to older age. The distinguishing feature is that intervention occurs early in the pathway to

mental ill‐health.

Early Identification

For early intervention to occur strategies are required to enable people to recognise when an illness

is developing and access treatment and support at the earliest point in illness and whenever needed

for the duration of the illness. At present, this frequently does not occur. Early identification is

therefore included in the spectrum of initiatives to prevent or intervene early in the development of

eating disorders.

It is important to note that early identification can only achieve positive outcomes when there are

accessible and appropriate services for people to be referred to.


Breaking the Developmental Cycle of Eating Disorders

Biological, psychological and social factors all contribute to the development of an eating disorder.

However, the triggers for the onset of an eating disorder are typically nutritional stress as a result of

a diet (or by exercise or illness in anorexia nervosa) which occurs in the context of a stressful or

difficult life event (Southgate, Tchanturia, & Treasure, 2005).

Prevention focuses on the modifiable risk factors that precede the development of illness. Reducing

causal risk factors for an illness is expected to break the developmental sequence leading to a

reduction in the frequency and intensity of the illness (Jacobi, Hayward, de Zwaan, Kraemer, &

Agras, 2004).

Risk factors for eating disorders include body dissatisfaction and dieting. There is strong support for

internalization of the thin body ideal as a causal risk factor for both body dissatisfaction and dieting

(Wilksch, Tiggemann, & Wade, 2006; Blowers, Loxton, Grady‐Flesser, Occhipinti, & Dawe, 2003) and

this is therefore the focus of many prevention initiatives (Richardson & Paxton, 2010).

Dieting as a Common Risk Factor

“You can’t get an eating disorder if you don’t diet” (Steiger, 2012)

To prevent eating disorders it is essential to pay proper regard to the importance of ‘diet’ (Steiger,

2012). Adolescents who diet and develop disordered eating behaviours carry these unhealthy

practices into young adulthood and beyond (Neumark‐Sztainer, Wall, Larson, Eisenberg, & Loth,

2011). Even modest levels of dieting alter brain activity (Goodwin, Fairburn, & Cowen, 1987; Cowen,

Clifford, Walsh, Williams, & Fairburn, 1996) and being underweight or malnourished alters the

processes of normal development (DNA methylation) (Ehrlich, et al., 2010).

Disordered eating describes a disturbed eating

behaviour that is not sufficient to meet the current

clinical criteria for a clinical disorder but nonetheless

constitutes a serious health problem. It includes

unhealthy and extreme weight control behaviours

and/or binge eating. Disordered eating can result in

significant impairment, mentally, physically and

socially, and significantly increases suicidal thoughts

and behaviours in adolescents. Girls who start dieting

before the age of 15 are more likely to experience

depression and are more likely to engage in

disordered eating (Lee, 2001). A study of young

Australian women with subclinical levels of disordered

eating has found that even minor levels of illness have

a significant impact on health and quality of life for

the long term (Wade, Wilksch, & Lee, 2012).

Dieting

In the context of eating disorders the term “dieting”

describes eating behaviours such as a reduction in

energy intake below daily requirements, fad dieting,

rigid eating patterns and cutting out whole food

groups mainly for the purposes of weight loss.

As such, dieting is distinct from healthy eating which

includes a variety of foods sufficient to meet daily

energy and nutritional requirements, supported by

a relaxed attitude to eating that can accommodate

flexibility and adaptation of eating patterns in

response to changing needs.


Reducing the incidence and impact of eating disorders

1. Reduce the social and environmental risk factors including the social emphasis on dieting and

unrealistic body ideals supported by community attitudes and behaviours (fat talk, bullying)

2. Increase protective factors through evidence based prevention programs that target

modifiable risk factors and develop protective factors

3. Skill adults (professionals and parents) who intersect with high risk groups to identify eating

disorder symptoms, promote help seeking, and model appropriate attitudes and behaviours.

4. Support access to early self‐help through information resources and online indicated

prevention programs

5. Improve access to eating disorders specific treatment early in the course of illness and early

in the help seeking process (i.e. when the person is motivated for change)

Disordered eating is increasing, and many studies show that disordered eating is now normative in

Australian society. One study in South Australia found that disordered eating behaviour, including

binge eating, purging, strict dieting and fasting, had doubled for both males and females within the

past decade(Hay, et al., 2008).

This upward trend is apparent for both males and females, and cuts across age groups from youth

through to older adults. A recent study drawing on data from the National Eating Disorder Screening

Program in the US, found that nearly 12% of females and 3% of males reported vomiting to control

their weight and 17% of females and 10% of males reported binge eating. Approximately 24% of

females and 8% of males reported being preoccupied with being thinner (Haines, et al., 2011).

An Australian Institute of Family Studies report has identified that approximately 50% of children

between the ages of 10 and 11 want to lose weight and 75% have attempted to diet in the previous

twelve months (AIF, 2012).

Weight concern and Body Dissatisfaction: A Risk Factor for Dieting and Eating Disorders

Body dissatisfaction expressed as concern about weight or shape is the most potent risk factor for

the development of an eating disorder (Jacobi & Fittig, 2010). Research suggests that body

dissatisfaction and concern with weight gain begin in childhood but that this pattern of thinking

remains open to change making it a primary target for prevention initiatives (Neugebauer, Roubin,

Mack, & Curiel, 2011).

Body dissatisfaction, mainly focused on weight concerns, is prevalent among young males and

females (Yager and O’Dea, 2008), particularly among overweight or obese girls (Sonneville, et al.,

2012). In general, lower body satisfaction predicts the use of disordered eating behaviours

(Neumark‐Sztainer, Paxton, Hannan, Haines, & Story, 2006). Studies of body dissatisfaction in

adolescence have found varying but consistently high levels. Body dissatisfaction has been identified

in up to 70% of adolescent girls (Levine & Smolak, 2002). Body dissatisfaction has been consistently

identified in the Mission Australia Youth Survey as one of the top ranked issue of concern for young

people for several years.


Identified risk factors include:

• Adolescence • Early maturation • Negative self‐evaluation • Body dissatisfaction (weight and shape

concerns) • Stressful life events • Depression, anxiety disorders, substance

and/or alcohol abuse

(Extract from Jacobi, et al., 2011)

Chapter 2 Opportunities for Intervention

Identifying risk factors, high risk groups and key opportunities for early intervention

People at risk

Eating disorders can occur in any population within Australia; both males and females; in children,

adolescents, adults and older adults; in all socio‐economic groups; and from all cultural backgrounds.

However, across this broad demographic, certain groups have been identified as being at higher risk:

Adolescents and young adults (ages 12‐25)

Females

Athletes engaging in competitive sport, fitness or dance



The identification of at risk populations provides opportunities for targeted prevention and early intervention measures. Adolescents and Young Adults The peak period for the onset of eating disorders is between

the ages of 12 and 25 years, with a median age of around 18

years (Hart, Jorm, Paxton, Kelly, Kitchener, 2009). This is a

period in which the body and brain undergo significant

changes and development. It is also a period of emotional

adjustment, identity formation and significant behavioural

change.

Adolescents are particularly prone to risk‐taking behaviour.

Heightened self‐awareness during youth makes adolescents

more vulnerable to self‐doubt and unfavourable social

comparison. Socio‐cultural pressures related to appearance

and success activate feelings of inadequacy making identity formation and self‐acceptance a difficult

task (Shure et al., 2009). Disordered eating behaviours and eating disorders may result from both

risk taking behaviour (the willingness to try extreme methods without consideration of risk) and the

struggle for identity formation in a stressful environment.

Opportunities for Intervention

School‐based universal prevention interventions for all young people

Screening as part of routine health checks carried out by GPs, in schools, sports associations

and youth health clinics

Specific eating disorders early intervention initiatives delivered through youth health

services such as headspace

Targeted screening and access to prevention/early intervention programs in tertiary

education


Online access to information and links to relevant youth services and eating disorders

services

In addition to information and screening process for children and young people, it is important that

relevant services are also available.

Females

Being female has been consistently identified as a risk factor for the development of eating disorders

(Jacobi & Fittig, 2010). Most research findings have focused on the incidence of eating disorders,

particularly anorexia nervosa and bulimia nervosa in females. For women, the lifetime risk of

developing an eating disorder that requires clinical intervention is estimated at 15%. The risk of

premature death for women with anorexia nervosa is well documented, with estimates of risk at 6‐

12 times higher (AED, 2011) than the general population and “much higher” than other psychiatric

disorders (Arcelus, et al., 2011).

The risk of developing an eating disorder is not limited to adolescence. Eating disorders and

disordered eating are emerging as issues for adult women, with particular vulnerability associated

with stressful life changes such as transition to tertiary education or work, marriage, pregnancy,

menopause, and divorce (Pereira & Alvarenga, 2007). Research shows that bulimia nervosa is as

likely to emerge after the age of 18 years as before (Lewinsohn, Striegel‐Moore, & Seeley, 2000).

There is a growing body of evidence that maladaptive eating attitudes and behaviours are common

in midlife and older women. Eating disorder symptoms are present in middle to older age women

and are similar in severity to those of younger individuals. The estimated point prevalence rate for

clinical eating disorders in women over 45 years is 4.5% (Keel, Eddy, Thomas, & Schwartz, 2010). A

study of women aged 60 to 70 years found that 80% were trying to control their weight, 3.8% met

criteria for an eating disorder and 4.4% reported a single episode of eating disorder (Mangweth‐

Matzek, et al., 2006). Similarly, a study of 200 women aged 35‐65 years identified that 17% probably

had an eating disorder (McLean, Paxton, & Wertheim, 2010). Levels of bulimia nervosa have been

found to be similar in a comparative study of women over 45 years and younger women (Procopio,

Holm‐Denoma, Gordon, & Joiner, 2006).

A study in Western Australia found that 25% of patients from a community sample experienced

onset of their eating disorder after the age of 30 (Fursland, Allen, Watson, & Byrne, 2010). Hay and

colleagues (2008) found an increase in disordered eating reported by women over the age of 45.

Gadalla (2008) concluded that women over the age of 50 years should be routinely screened for

symptoms of disordered eating and associated psychiatric comorbidity.

Opportunities for intervention

School‐based selective prevention interventions that target girls only

Screening as part of routine health checks carried out by GPs and other medical professionals at

key points of vulnerability, such as pregnancy and menopause

Special eating disorder early intervention initiatives delivered through women’s health services.


Identified Risk Factor

• Participation in weight‐related social or professional subculture (dancer, model, athlete, gymnasts, etc.) (Jacobi & Fittig, 2010)

Disordered Eating can affect every aspect of

the student‐athlete’s life, including:

• Academic, especially concentration • Athletic, due to malnutrition and

dehydration, which lead to insufficient energy stores and muscle weakness

• Psychological, especially causing negative moods

• Social, leading to withdrawing from others

(NCAA Coaches Handbook)

Athletes and Eating Disorders

Eating disorders and disordered eating may occur in people who are regarded by society as being

extremely fit and healthy. Both males and females engaged in competitive physical activities,

including sports, fitness and dance, have increased rates of body dissatisfaction, disordered eating

and eating disorders (Weltzin, et al., 2005). Physical activity and sporting environments play an

important role in influencing how people perceive their own bodies.

High levels of exercise have been identified as a

potential risk factor for eating disorders (Jacobi, et al.,

2004). A study of adolescent athletes (mean age

14.0 ± 2.2 years) found that changes in the desire to be

leaner to improve sports performance were associated

with changes in disordered eating. Athletes are more

at risk for disordered eating if they believe it is possible

to enhance their sports performance through weight

regulation (Krentz & Warschburger, 2011). Disordered

eating more frequently affects athletes in sports that

emphasize a thin size or a low weight, than in other

sports, but no sports are exempt.

Disordered eating has the potential to cause negative

health outcomes in female athletes. Low energy

availability that may have been caused by disordered

eating can lead to menstrual dysfunction and impaired

bone health, and has become known as the Female

Athlete Triad (Nattiv, et al., 2007). “Dieting” or “dietary restriction” is recognised as a precursor for

eating disorders. While some instances of disordered eating may directly relate to the sport, more

often the individual athlete has other risk factors in their lives and may have been likely to engage in

disordered eating without participation in a sport (NCAA Coaches Handbook).

While there appear to be circumstances under which sports participation is a risk factor for eating

problems, there are also situations where participating in sport may be a protection against body

dissatisfaction and eating problems. For example, young people engaging in non‐elite sports,

especially in high school, have shown a reduced risk of eating problems compared to their peers

(Smolak, Murnen, & Ruble, 2000) and body image has been found to differ significantly among girls

participating in different types of sport, and between those who participate in sport and those who

do not (Abbott & Barber, 2011). Encouraging females to participate in physical activity which focuses

on what the body can do (function) rather than on appearance has been found to enhance body

satisfaction (Abbott & Barber, 2011).

Opportunities for Intervention

Introduction of specific policies regarding eating disorders, their risk factors and prevention

in sport, fitness and dance organisations and programs


Identified risk factors include

• Higher BMI • Dieting • High weight and shape concerns • Exposure to appearance based

criticism (bullying, teasing) • Internalization of the thin ideal

(unrealistic appearance goals) • Body dissatisfaction


Screening for compulsive exercise or excessive exercise as a means of weight control and

nutritional imbalance

Training programs that take age and body shape into consideration

Support for open dialogue about unrealistic appearance expectations

Focus in sport on functional achievement rather than appearance

Regular health checks for children and adolescents engaged in competitive sport including

screening for eating disorders


It is estimated that 30% of people seeking weight loss treatment have binge eating disorder (Hill,

2007).

Only about 17‐31% of people with eating disorders seek or receive treatment specifically for their

disorder (Hart, Granillo, Jorm, & Paxton, 2011). By comparison, between 30 and 73% will contact

health professionals or weight loss centres for help with their weight (Hay et al, 2010).

People with bulimic eating disorders and binge eating disorder most frequently present to primary

health care for help with weight loss (Hay, Marley, & Lemar, 1998) and generalised psychological

distress (Mond, Myers, Crosby, Hay, & Mitchell, 2010).

People who are overweight are at risk of developing eating

disorders (Jacobi, et al., 2004). Although the majority of

overweight or obese individuals do not have an eating disorder,

the risk of presenting with binge eating disorder or bulimia

nervosa increases with obesity. There is evidence that obesity is a

serious and common outcome for people with bulimic eating

disorders and binge eating disorder (Fairburn, Cooper, Doll,

Norman, & O'Connor, 2000).

People seeking assistance for weight loss who are in the healthy

BMI range may also be at risk of or have symptoms of an eating

disorder.

A number of recognised risk factors for eating disorders are weight related and therefore people

who are concerned about their weight represent a high risk group and a potential target group for

screening and prevention.


Screening for risk factors as a routine part of assessment for weight loss treatment


Eating disorders are significantly more likely to occur in people who have parents or siblings who've

had an eating disorder. A family history of eating disorders is an identified risk factor for the

development of eating disorders (Jacobi, et al., 2011).


Identified risk factors that may be apparent in

childhood include:

• Problem eating • Feeding and digestive problems • Anxiety disorders


People who have experienced an episode of eating disorder are at high risk of a recurrence of the

same or a related disorder. For example, a diagnosis of bulimia nervosa in early adolescence leads to

a 20‐fold increase in risk for the development of bulimia nervosa as an adult (Kotler, Cohen, Davies,

Pine, & Walsh, 2001).

The presentation of an eating disorder may vary over time (Wade, et al., 2006). Approximately half

of individuals with anorexia will experience bulimia or EDNOS at a later stage in life. The

presentation of people with bulimia and binge eating disorder may also change over time to EDNOS

(Steinhausen, 2009). It is therefore not safe to limit monitoring to symptoms of the same eating

disorder that a person experienced at an earlier stage in life.


Screening for people presenting with related health conditions – resource kits required by

relevant health professionals to promote screening

People with additional health risks or vulnerabilities

Some groups in the community who may not be identified as having a high statistical risk of

developing eating disorders, experience specific health issues and vulnerabilities when they do

experience an eating disorder that need to be taken into consideration. These groups include:

Younger children

Pregnant women

People with specific health conditions – diabetes, PCOS, infertility

Males

Indigenous communities

Younger Children

Younger children are increasingly concerned about their body size (Neugebauer, et al., 2011) and

there has been a rise in the number of young children diagnosed with eating disorders, body

dissatisfaction or dietary restraint (Nicholls, Lynn, & Viner, 2011).

Eating disturbances in young children can result in

serious medical consequences, including growth delay,

even in the absence of apparent weight loss (Pinhas,

Morris, Crosby, & Katzman, 2011).

The presence of eating problems in early childhood is a

strong predictor of eating disorders in later life (Kotler,

et al., 2001).

Eating Disorders in Pregnancy and parenting

Unfavourable outcomes have been found for infants of women with sub‐threshold anorexia nervosa

or bulimia nervosa, including growth retardation, low birth weight, increased incidence of congenital


anomalies, increased risk of premature birth and higher peri‐natal mortality. The use of laxatives and

diuretics in purging behaviour has been implicated in the development of cancers in the foetus

(Newton & Chizawsky, 2006). Given the potential severity of risk to the both mother and foetus,

Newton and Chizawsky (2006) recommend screening for eating disorders as a routine part of

obstetrical assessments.

Eating disorders in adult women not only have an impact on the individual concerned but influence

their children and the way in which they respond to eating disorder prevention initiatives presented

to their children. The prevalence of disordered eating and eating disorders in adult women is

therefore a relevant issue for professionals working with children and young people as well as health

professionals working directly with adult women.

People with specific health conditions

Specific groups in the community may also be at increased risk including people with diabetes

(Pereira & Alvarenga, 2007), people who are obese (Darby, et al., 2009) and women with Poly Cystic

Ovary Syndrome (PCOS) and opportunistic screening as part of routine health examinations is

recommended for these groups.

The peak age of onset for Type 1 diabetes in Australian girls is between the ages 10 and 14 which is

also a peak period for the onset of disordered eating (Starkey & Wade, 2010). Adolescents with

diabetes may have a 2.4‐fold higher risk of developing an eating disorder, particularly bulimia

nervosa and binge eating than their peers (Pereira & Alvarenga, 2007).When diabetes and eating

disorders occur together they can severely compromise physical health (Starkey & Wade, 2010). For

females with anorexia nervosa and diabetes, there is a 15.7‐fold increase in mortality rates when

compared with females with diabetes alone (Pereira & Alvarenga, 2007).

Adult women with Polycystic Ovarian Syndrome (PCOS) are also at increased risk of binge eating and

bulimia nervosa (Jahanfar, Eden, & Nguyent, 1995; McClusky, Lacey, &Pearce, 1992). PCOS affects

between 5% and 10% of women of reproductive‐age and is the leading cause of infertility (Azziz, et

al., 2004). Women with PCOS need to learn effective ways to manage their physical and mental

health. Strategies which focus on developing appropriate eating and exercise habits rather than

weight loss are most appropriate for women with symptoms of both PCOS and eating disorders

(Morgan, 1999).

Males and Eating Disorders

Awareness of the risk for females has tended to distract from the prevalence of eating disorders in

men. Current research suggests that males make up approximately 25% of people with anorexia or

bulimia and 40% of people with binge eating disorder (Hudson, et al., 2007; Weltzin, et al., 2005). In

a recent study (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011), lifetime prevalence

estimates for anorexia nervosa in adolescents aged 13 – 18 years found no difference between

males and females.


Warning signs:

A significant amount of weight lost, or rapid weight loss

Excessive gym attendance – consistently or in bouts of extreme activity

Exercise despite injury or obvious illness

A reduction in performance

‘Dizzy spells’ or fainting whilst exercising

Difficulties concentrating or remembering

Signs of purging

Indications from others who are concerned

There is an increase in reports of body

dissatisfaction and eating problems in young males

including the use of weight control and weight gain

behaviours that may be injurious to their health

(O’Dea, 2005). Male students are also increasingly

adopting health‐damaging, body‐image related

behaviours such as excessive weight lifting, body

building and steroid abuse (Yager & O’Dea, 2008).

Studies have found that up to 50% of boys want to

change the size of their body (Weltzin, et al.,

2005). Eating disorder symptoms were found in a

study of boys aged less than ten years, with 10%

reporting binge eating and 4.2% reporting self‐

induced vomiting (Pearson, Combs, & Smith, 2010).

A key issue for males is the stigma associated with mental illness and the expectation that eating

disorders ‘only affect females’. Sensitivity is required in listening to health issues identified by males

in order to be able to identify and respond to symptoms of eating disorders.

One unique difference between males and females with eating disorders is that men more typically

engage in compulsive exercise as a compensatory behaviour, “meaning that male eating disorders

may be oriented towards the acquisition of muscularity and not exclusively towards the pursuit of a

more slender body” (Dr Stuart Murray, Interview with NEDC).

Indigenous Communities

Little is known about the incidence of eating disorders in Indigenous Communities; however a

number of risk factors for eating disorders are well recognised as health problems for Aboriginal and

Torres Strait Islander peoples including obesity, mental illness, self‐harm and substance disorders. A

small study of Indigenous people living in urban areas in Australia has identified that eating disorder

symptoms are at least as common, or more common, in these communities as in non‐indigenous

Australians (Hay & Carriage, 2012).

An investigation of body image issues amongst Indigenous young people has found that Indigenous

young people may think about body image in different ways to other groups in Australia. This is

closely related to pride in their heritage, their experience of family and their experience of

discrimination. It is also related to their access to health care, with issues such as poor dental health

directly affecting their body satisfaction and confidence (Flaxman, Skattebol, Bedford, & Valentine,

2012).

Approaches to prevention for Indigenous people must be developed in collaboration with

Indigenous communities, taking an inter‐generational approach. They must also be flexible in taking

in to consideration a broader range of health and well‐being factors, for example access to dental

treatment.


Chapter 3 Approaches that Work for Young People A review of evidence based approaches to prevention suitable for delivery in schools and tertiary

education targeting the high risk groups of children, adolescents and young adults.

To be effective, eating disorders prevention programs should focus on reducing modifiable risk

factors such as thin‐ideal internalization, body dissatisfaction,

negative affect, pressure to be thin and perfectionism. They

should also work to increase protective factors, such as social

support and self‐esteem (Stice, 2002). Prevention trials indicate

that interventions that take this focus can significantly improve

knowledge and reduce unhealthy eating attitudes and behaviours

(Fingeret, et al., 2006; Neumark‐Sztainer, et al., 2006; Stice, et al.,

2010).

Successful Approaches for Prevention Programs

Successful approaches to teaching a range of content for eating disorders prevention include:

Dissonance‐based education

Dissonance‐based approaches are based on the idea that when there is an inconsistency

between an individual’s health beliefs and behaviours, the resulting psychological discomfort will

motivate them to change their attitude or behaviours to reduce this inconsistency. Dissonance‐

based approaches for selective populations have achieved consistent success in reducing thin‐

ideal internalization, body dissatisfaction, dieting and disordered eating behaviours (Stice, Marti,

& Durant, 2011; Yager & O’Dea, 2008). Informed by cognitive dissonance theory and its

application in fields such as substance abuse and obesity, it was reasoned that encouraging

young women with high levels of thin‐ideal internalization to argue against the thin ideal would

produce psychological discomfort as a result of the inconsistency between the new and the

original attitude. The result would be a reduction in thin ideal internalisation and subsequent

reduction in body dissatisfaction, dieting and related risk factors.

Psychoeducation

Psychoeducation involves teaching about eating disorders and their risks. The psychoeducation

program ‘Student Bodies’ discussed later in this chapter, has been extensively researched and

demonstrated to be an effective strategy for older adolescents and young adults. For young

people aged 15 to 25 years, information on eating disorders may contribute to recognition of

risk factors in themselves and others and the development of supportive community

environments. Information on eating disorders is supported by information on positive

behaviours for good health and self‐esteem. Psychoeducation has not been demonstrated to be

an effective approach for younger adolescents and children. Wilksch and Wade (2009) suggest

that programs targeting universal populations younger than 15 years of age should avoid

discussion of disordered eating behaviours so as to ensure young people did not learn eating

disordered behaviours from the program.

Modifiable Risk Factors

• Low self esteem • High weight and shape concerns • Dieting • Internalization of the thin ideal • Perfectionism

(Extract from Jacobi & Fittig, 2010)


Psycho‐educational programs usually address aspects of the

following content areas:

o Normal changes in body shape and physiology at puberty

o Cultural influences on body image and eating behaviour,

and changes over time

o Suggestions for building a positive body image

o Unrealistic and unhealthy body image ideals promoted in

the media

o Manipulation of female images in the media

o Weight‐based discrimination

o The dangers of short‐term crash dieting

o The nature and symptoms of disordered eating and how to

get help if required

o Healthy weight management

o Understanding the relationship between feelings and

eating (Paxton, 2002)

Media literacy There is evidence to suggest that print, broadcast, electronic and social media all present and reinforce the value of the thin ideal for women and the muscular ideal for men. Health education programs based on developing media literacy are based on the assumption that promoting a critical evaluation of the media will reduce its credibility and persuasive influence (Irving & Berel, 2001). Media literacy education can have a lasting beneficial impact, reducing long‐term self‐reported disordered eating attitudes and internalisation of the thin body ideal in both males and females in high school aged adolescents (Gonzalez, Penelo, Gutierrez, & Raich, 2011; Wade, Davidson, & O’Dea, 2003;Wilksch & Wade, 2009; Wilksch, 2010). A new study in Australia (McLean, Paxton, & Wertheim, 2012) provides clear evidence for a relationship between media literacy and a reduction in risk factors for eating disorders in adolescent girls. These findings are consistent with studies which have shown media literacy to be positively related to a reduction in other risk behaviours in adolescents, including smoking and use of alcohol.

Cognitive Behavioural Therapy (CBT)

CBT principles have been used in a range of prevention initiatives

for people with body dissatisfaction and a high risk of developing

an eating disorder. CBT based approaches have shown successful

outcomes in random controlled trials over many years (e.g. Fisher

et al. 1994, Heinicke et al. 2007, Jacobi et al. 2007, Jacobi et al.

2012, McLean et al. 2011, Paxton et al. 2007, Taylor et al. 2006)

What kind of

Media literacy?

The media have the potential to

exert a wide range of potentially

negative effects on individuals.

A study of vulnerable young

people including Indigenous

youth and homeless youth has

found that the use of social

networking sites is common and

that this exposes people to body

image pressure, cyber bullying

and derogatory comments. The

view that personal popularity

was related to social networking

‘friends’ seems to be prevalent

amongst young people with low

self‐esteem and poor body

image and this is the group most

likely to be vulnerable to cyber

bullying (Flaxman, et al., 2012).

The purpose of media literacy is

to help people to protect

themselves from those negative

effects. New forms of media are

constantly being developed and

media literacy should be

developed across all forms of

media (Potter, 2010).


Promising Interventions

Addressing peer interactions

The peer environment has been shown to impact upon body dissatisfaction and disordered

eating. For example, environments in which there is high attention paid to appearance, high

frequency of talk about dieting and weight issues (“fat talk”) or teasing about weight and shape

can increase risk for these problems. One intervention that helps young adolescents girls

understand and change peer interactions has been shown to reduce body dissatisfaction and

other risk factors for disordered eating over a three month period (Richardson & Paxton, 2010).

The same program has been adapted for preadolescent co‐educational school settings with

positive body image outcomes for girls (Diedrichs, Bird, & Halliwell, 2012).

Perfectionism

Targeting perfectionism represents a promising prevention option that requires further

investigation in children of mid‐adolescence age, and further investigation is required to

determine the demographic most likely to benefit from media literacy (Wilksch, Durbridge, &

Wade, 2008).

Self Esteem

Low self‐esteem is a risk factor for body dissatisfaction, dieting, and eating disorders as well as a

general risk factor for other mental health issues. Health education and health promotion

programs that are based on the improvement of self‐esteem have achieved success in the

reduction of body dissatisfaction, dietary restraint and disordered eating (Yager & O’Dea, 2008).

Approaches to the prevention of eating disorders do not necessarily include specific reference to

eating disorders. Children under the age of 15 do not need information about eating disorders in

order to benefit from prevention initiatives.


Delivering Effective Prevention Programs

Effective prevention programs are timed appropriately, are socio‐culturally relevant to their target

populations, have well‐trained staff and include outcome evaluation (Nation, et al., 2003).

The delivery style and the selection of participants may be as important as the program content

(Jacobi, et al., 2011). In addition to content that targets modifiable risk factors, design strategies

which enhance program effectiveness include:

Multi‐sessional designs (Jacobi, et al., 2011; Starkey & Wade, 2010)

Multiple session programs produce larger effect sizes than single‐session programs.

Continuing reinforcement of messages through ‘booster sessions’ is also suggested to

sustain new behaviours (Wade, Mamerow, & Wilksch, 2010). While prevention programs are

usually evaluated as one‐off interventions, it is anticipated that the cumulative effect of

developmentally appropriate interventions will be more effective in the long term (Paxton,

2002)

Programs that are interactive (Jacobi, et al., 2011; Starkey & Wade, 2010; Stice, Shaw, &

Marti, 2007)

A review of school‐based eating disorder prevention programs has found interactive

interventions in which students learnt experientially produced more positive effects than

didactic interventions that employed an information‐based approach (Hellings & Bowles,

2007)

Internet based education with moderated group discussion (Heinicke, Paxton, McLean, & Wertheim, 2007; Yager & O’Dea, 2008)

Technology‐based interventions, such as internet prevention programs, internet‐assisted

CBT, online consulting, and text messaging have all shown promise in assisting in the early

intervention treatment of eating disorders (Fichter, et al., 2012).

Attention should also be paid to how to teach such programs. Evidence to date supports the use of a trained presenter (Wade, et al., 2010).

Leadership

When prevention programs are delivered in schools there is wide variety in the gender, profession,

knowledge and personality of the program facilitators. Similarly, the location of the program, the

number of sessions, the number and age of participants and other factors may have an impact on

the success of the program (Richardson, Paxton, & Thomson, 2009). Further research is required to

investigate the impact of teaching style and classroom environment on the outcomes of prevention

programs (Richardson, et al., 2009; Wade, et al., 2003).

Two different types of intervention leadership have been identified as successful:


The “voice” of the program needs to be

“authentic” if they are going to be heard by

the student. Clever material and a smart

approach won’t connect (and the bridge

won’t be built) if the voice is not authentic. (NEDC Consultation with Teachers, 2010)

Delivery by an eating disorders sector professional (Stice, et al., 2007)

Delivery of dissonance based programs by trained peer leaders for interventions for university undergraduates (Becker, Bull, Schaumberg, Cauble, & Franco, 2008)

A study of body dissatisfaction, disordered eating and

eating disorders among trainee educators found that both

males and females training for health or physical education

roles had significantly poorer body image and higher levels

of body dissatisfaction, dieting and disordered eating than other education trainees. Health and

physical education trainees were also more likely to engage in over exercise which very few self‐

identified as a problem. The authors of the study (Yager & O’Dea, 2009) recommend screening and

training for all educators involved in health education, nutrition education, sport and obesity

prevention programs.

Given the potentially important role of teachers and other educators (including health educators,

school nurses, school counsellors, school psychologists, and sports coaches) in contributing to the

prevention of eating disorders and child obesity, it is essential to ensure that these professionals are

skilled and supported to carry out prevention initiatives (Yager & O’Dea, 2005).

The important role of the presenter has been identified in other prevention initiatives. Initiatives to

reduce adolescent use of alcohol and tobacco, such as the Aussie Optimism program, have been

found to be successful only when implemented by teachers who received training in the delivery of

the program (Roberts, et al., 2011).Evaluation of MindMatters programs has identified that many

teachers believe they lack knowledge in the area of mental health and mental illness. This indicates

the possibility of limited availability of teachers in each school who feel that they do have adequate

knowledge to teach prevention programs (Ainley, Withers, Underwood, & Frigo, 2006).

These findings support the importance of training and supporting teachers who are expected to

deliver prevention programs, or sourcing external presenters with expertise in the prevention of

eating disorders. Providing professional development for teachers directly linked to programs and

resources will increase the likelihood that programs will be implemented in schools in a whole of

school approach.

The Timing for Prevention

As for other mental illnesses which develop in adolescence, childhood is the critical period for

primary preventive efforts and the development of resilience; adolescence and young adulthood is

the stage when early intervention strategies may be required (McGorry & Purcell, 2009). However,

for eating disorders, different approaches to prevention seem to be more effective for different age

groups.


Early universal prevention

initiatives such as media

literacy implemented

before the age of 13 years

are an important part of a

prevention strategy.

Young Families

The behaviours, attitudes and beliefs that contribute to vulnerability to eating disorders are

established early in life and are reinforced by the person’s social environment. The risk and

protective factors for eating disorders occur within the context of everyday life – family and peer

relationships, school and workplace cultures, recreational and sport activities, media and social

influences. The complex interplay of biological, psychological, social, environmental, cultural,

economic and political factors supports the use of a universal population health approach to eating

disorders prevention for families with young children. However, research has yet to explore this

option.

Children and Adolescents in the Middle School Years

Research suggests that there is a marked increase in body image and eating

concerns in young people while they are between school years 7 and 8

(Wertheim, Koerner, & Paxton, 2001) and that intervention at late primary

school and early high school represents an opportunity for prevention of the

development of body image problems (Paxton, 2002).

Evidence suggests that a media literacy and advocacy approach is indicated as best practice with the

12 to 14 year old group. (Wade, et al., 2010).Evidence based prevention programs such as Media

Smart and Happy to Be Me have demonstrated successful outcomes for universal groups of both 13

year old males and females (Wilksch & Wade, 2009).

Some issues such as body dissatisfaction affect males and females at different ages. Body

dissatisfaction is a risk factor for both depressive mood and low self‐esteem in girls in early

adolescence and in boys in mid adolescence(Paxton, Neumark‐Sztainer, Hannan, & Eisenberg,

2006).Prevention of body dissatisfaction must begin early and should be considered as a component

of both obesity and eating disorder prevention programs (Sonneville, et al., 2012).

Media literacy has not been found to be effective with 15 year olds indicating that media literacy

may be most appropriate for younger adolescents or older children (Starkey & Wade, 2010)

Older Adolescents and Young Adults

There is a high prevalence of body dissatisfaction and related eating disorder problems in university

age women. At this stage indicated prevention interventions are usually required. The goal of these

interventions is to reduce body dissatisfaction and disordered eating behaviour that are already

present (Paxton, 2002). Typically, individuals volunteer to participate in this type of program or are

referred by a health professional.

Evidence suggests that prevention programs which target people who are known to be at high risk of

developing eating disorders produce larger effects than universal programs (Fingeret, et al., 2006;

Jacobi, et al., 2011; Stice, et al., 2010). This involves targeting prevention programs at people over


the age of 15 years who have high weight and shape concerns, a history of critical comments about

eating, weight or shape and negative affect (Jacobi, et al., 2011).

For older adolescents and young adults internet‐based interventions structured around a cognitive

behavioural approach or cognitive dissonance have been shown to be effective (Wade, et al., 2010).

Amongst university students, dissonance based education, incorporating health education activities

that build self‐esteem have been shown to be more successful than psycho‐educational approaches

(Yager & O’Dea, 2008).

There will always be adolescents and young adults who develop body image and eating disorder

problems despite earlier prevention interventions. So there will continue to be an urgent need for

targeted interventions for young adults (Paxton, 2002).

At all ages, it is important that students who have been exposed to a peer who has an eating

disorder have access to prevention programs and support (Hellings & Bowles, 2007).

Finding a Place in the Curriculum

It is frequently suggested that the prevention of eating disorders should be integrated with the

national Personal Development Health and Physical Education (PDHPE) syllabus.

The aim of PDHPE “to develop students’ capacity to enhance personal health and wellbeing” and the

learning outcomes, including “exploring the relationship between body image and gender and the

impact of the media” align with evidence based approaches to eating disorders prevention.

Disordered eating and body image are identified in the topic content for mental health and healthy

food habits (Note: the aims and outcomes and topic content are based on the NSW PDHPE Syllabus Years 7‐10).

The same learning outcome includes content on drug use, sexual health and road safety making this

a diverse and crowded topic area. Evaluation of MindMatters has found that mental health

education is competing for time within a crowded curriculum (MindMatters, 2005) in either PDHPE

or pastoral care. Time for planning, lesson development and the provision of appropriate support

after learning are all required to ensure that eating disorders prevention messages are safe and

effective.

There is no evidence that current approaches to teaching PDHPE have actually had a preventative

effect for eating disorders or that PDHPE teachers are consciously using the syllabus to prevent

eating disorders.

Possible issues that may inhibit the effectiveness of PDHPE syllabus as a complementary initiative:

The teacher’s knowledge and beliefs about eating disorders and the prioritization of other

issues within the same topic area such as alcohol abuse. Eating disorders prevention

requires teachers who have been trained in eating disorders mental health literacy


Individual teaching programs utilize resources that are accessible and of relevance to the

teacher or school and this may not include eating disorder information. Developing and

promoting eating disorders content relevant to the syllabus could overcome this issue.

PDHPE is a subject with assessment and examination and as such learning in this context is

somewhat different to learning for behavioural change

To change behaviour on a long term basis, lessons learned in PDHPE would need to be

supported by the school environment, the family environment and the sport environment;

the lack of emphasis in the community on the dangers of dieting and widespread

engagement in ‘fat talk’ would both tend to decrease the effectiveness of PDHPE

information relevant to eating disorders

While current opportunities for health education appear in the PDHPE curriculum and for media

literacy in the English curriculum, for years 7 to 9(Education Services Australia, 2011) there is a need

for a broader ‘whole of school approach’ to the integration of eating disorders prevention into

school activities.

Whole of School Approaches

Platform 2 of the Ottawa Charter encourages a socio‐environmental approach to promoting health.

Relevant environments for young people include the home, school and sports team (Rickwood,

2011). The school setting has the potential to provide an environment that fosters resilience and a

coordinated whole of school approach is frequently identified as an effective means of addressing

multiple risk factors for adolescent health concurrently(CEED & EDV, 2004).

School‐based interventions have the advantage of reaching a very high risk population for eating

disorders. For primary age children, there is the potential for genuine prevention before problem

thinking and behaviours have become entrenched (Paxton, 2002). In later years, there are

opportunities to sustain resilience through a healthy school environment and intervene early for

young people with symptoms of eating disorders.

A number of different approaches have been investigated in Australia to address the specific issue of

negative body image. Conclusions support a ‘whole of school approach’ based on four key elements:

taught curriculum, staff training and development, school environment and policy, and partnerships

with parents and services.

Perceived challenges to the implementation of a whole of school approach are identified as:

Strategies to include parents

An already crowded general curriculum and the difficulty in finding time for body image

curriculum

A strong need for more curriculum resources to teach about body image, particularly for

males

Monitoring of food provision

Participation in physical education


Checklist for a Whole of School Approach Policy

Include a statement in the school mission about providing a body image friendly environment and celebrating diversity.

Prohibit appearance‐related teasing, including cyber‐bullying in school policy.

Ensure that there is no weighing, measuring or anthropometric assessment of students in any context.

Provide an opportunity for all students to engage in regular physical activity in a non‐competitive, non‐weight‐loss focused, safe and secure environment.

Provide a balance of food options from all food groups in the canteen.

Display public material and posters that include a wide diversity of body shapes and sizes and ethnicity.

Workforce Development

Train all relevant teaching staff in the early identification and referral of students with serious body image concerns and eating disorders

Provide all teachers with training and information about eating disorders, their impact on the wellbeing of young people and ways that risk factors are reinforced by social environments.

Train teachers to use body friendly language in their interactions with students. Curricula

Provide developmentally appropriate teachings at every year level. Engaging Parents

Make available up‐to‐date printed information about how parents can support their child to develop a positive body image and a healthy relationship with food

Provide parents with links to information about body image and eating disorders on the school website Present talks and information nights for parents about eating disorder issues.

(Adapted from the Checklist for Body Image Friendly Schools, Commonwealth of Australia, 2009)

‘Getting everyone on board’ and consistency of approach across a range of school

stakeholders.

The proposed National Strategy on Body Image (Commonwealth of Australia, 2009) provides a

checklist on whole of school approaches to promote positive body image which includes many of the

same recommendations. The following edited list of recommendations may contribute to the

prevention of eating disorders in a whole of school context.


Resources to support a ‘whole of school approach’

There is a wide range of resources available to teachers to assist in media literacy, healthy body

image promotion ranging from text books (for example Everybody's Different: A positive approach

to teaching about health, puberty, body image, nutrition, O’Dea, 2005) and teacher resource kits (for

example Eating Disorders Resources for Schools, CEED & EDV, 2004) to websites designed

specifically to appeal to children and young people (see for example Completely GORGEOUS

http://completelygorgeous.com.au/).

These resources should be used within an evidence‐based and planned approach to promoting

health and preventing eating disorders.

Prevention Initiatives in Schools

Schools are making a commitment to health and wellbeing and implementing a variety of strategies

to promote mental health and positive body image including state and federal policy initiatives and

locally derived strategies. However, schools experience significant barriers in supporting mental

health including time constraints; potential conflict between the instructional and social

development roles expected of teachers; and limited access to health services for referral of

students.

While schools provide a convenient place for connection with children, young people and parents,

they are not always best placed to influence the thinking and behaviours that may contribute to

eating disorders. Parent attitudes may be the most important influence. Parent attitudes can be

affected by the perceived expertise of other professionals working with their children or directly

with the adults in the family including sports coaches, dance teachers and weight loss consultants.

Prevention approaches should consider the full spectrum of opportunities to influence adult

attitudes and behaviours as well as connecting with young people. There are many initiatives at a

local level developed and disseminated by youth and family services and eating disorder support

services that provide a platform for further development. These initiatives are largely unevaluated

and have developed separately from each other. Creating links between these services and with

researchers to improve sharing of resources and information and implementation of evaluation will

enhance outcomes.


Evidence Based Interventions for school aged children and young people

Prevention programs are not all equally successful. Stice and colleagues (2011) found that 51% of eating

disorder prevention programs actually reduced eating disorder risk factors and 29% reduced current or

future eating pathology. The following list highlights a selection of programs which are supported by

research evidence:

Media Smart

For early high school (grades 7 and 8), Media Smart is an 8 session program and addresses media

and peer issues in interactive class‐room activities. This is a universal program for girls and boys

unselected for risk factors. Long term follow‐up shows reduction in risk factors for eating disorders

(Wilksch & Wade, 2009).

Happy Being Me This program is an interactive school‐based program specifically for grade 7 girls unselected for risk factors. This 3 session program addresses both media and peer issues. Activities about peer interactions include ones that increase understanding of the role of body comparisons, fat talk and teasing in maintaining body dissatisfaction and disordered eating (Richardson & Paxton, 2010).

The Body Project

The Body Project is a two‐part group intervention program for adolescent girls and young women at

risk of developing eating disorders. Using a cognitive dissonance approach, in the first part of the

program participants learn skills that increase body satisfaction, decrease unhealthy weight control

behaviours and prevent eating disorder symptoms. In the second part participants learn to make

gradual lifestyle changes to achieve a healthy body weight. The program is supported by a facilitator

guide and is designed to be delivered by school counsellors, nurses and teachers (Stice & Presnell,

2007).

Student Bodies For older female students in upper high school and tertiary education, Student Bodies is an online

psycho‐educational intervention program designed to help women establish and maintain a positive

body image and to engage in healthy eating behaviours. The program was designed as an 8‐week,

Internet‐based, structured intervention program with scope for booster sessions. Student Bodies

focuses on four areas: eating disorders, healthy weight regulation, nutrition, and exercise (Beintner,

Jacobi, & Taylor, 2012; Jacobi, Volker, Trockel, & Taylor, 2012; Taylor, et al., 2006). Student Bodies is

a targeted program for girls who identify themselves as having body image concerns. People self‐

select to participate (unlike the class‐room based interventions described above).

Student Bodies has also been shown to be effective in reduction of body mass index (BMI) and self‐

reported dieting (Stice, Rohde, Shaw, & Marti, 2012).

For Teachers: Student Bodies, delivered as a web based program, has also been identified as a

successful approach for the education of primary school teachers, improving knowledge concerning

weight and dieting issues and how weight bias can trigger body image concerns among students

(McVey, Gusella, Tweed, & Ferrari, 2009).


Chapter 4 Facilitating Early Help Seeking

The role of early identification in enabling early intervention and evidence based approaches to

improving the capacity for early identification

The ability to engage with appropriate help at an early stage in illness is widely regarded as a

protective factor for mental health.

There is no known way to completely prevent the development of eating disorders in all vulnerable

people. It is therefore helpful to be able to detect the development of symptoms as early as possible

in order to shorten the course of the illness. Early intervention critically depends on early detection

of risks and symptoms (McGorry & Yung, 2003; Marshall, Lockwood, Lewis, & Fiander,

2004).Individuals who are identified and treated early in the course of an eating disorder have a

better chance of recovery compared to those with a longer history of illness (Berkman, et al., 2007;

Steinhausen, 2009).

Long delays in seeking treatment, are related to poorer long‐term outcomes (Gilbert, et al., 2012;

Haines, et al., 2011).

There is a prevalent myth, reinforced by media images, that eating disorders only refer to anorexia

nervosa and that therefore a person must be severely underweight to have an eating disorder

(Austin, 2011). Although published statistics often only reflect the diagnoses of anorexia nervosa and

bulimia nervosa most people with an eating disorder present with atypical symptoms that do not fit

either of these diagnostic categories. In an Australian study, the most common eating disorder

diagnoses in 2005 were found to be binge eating disorder or other ‘‘eating disorders not otherwise

specified’’ (Hay, et al., 2008). These disorders are considered to be as clinically severe as anorexia

nervosa and bulimia nervosa (Hay, et al., 2010).

Eating disorders are not self‐limiting illnesses and early identification and prompt intervention,

based on appropriate, multi‐disciplinary approaches, are required to reduce the severity, duration

and impact of the illness. This has been described as the ‘ideal standard of care” (AED, 2011). For

early intervention to occur strategies are required to enable people to recognise when an illness is

developing, and access and engage with treatment and support, at the earliest point in illness or

episode and whenever needed for the duration of the illness.

Seeking Help for Eating Disorders

People with eating disorders often do not seek help, or only seek help after a long period of illness

(Kelly, Jorm, & Wright, 2007; Hart, et al., 2011). Evidence suggests there is an average delay of

approximately 4 years between the start of disordered eating symptoms and first treatment. For

some people, this delay can extend to 10 or more years (Gilbert, et al., 2012).It is proposed that

shortening this time between the onset of symptoms and first treatment will improve individual

health and quality of life (Austin, Ziyadeh, Forman, Keliher, & Jacobs, 2011).


Raising awareness of eating disorders in people who have or are at risk of developing an eating

disorder is important but is not sufficient to improve patterns of help seeking or contribute to early

intervention. Despite experiencing severe symptoms, less than 25% of people specifically seek

treatment for their eating disorder and only about 45% of people actively seek help from health care

providers for related conditions (Hudson, et al., 2007). Some individuals live for 10 or more years

with the illness before receiving a correct diagnosis (Oakley Browne, Wells, Scott, & McGee, 2006)

Factors which inhibit help seeking for people with eating disorders include:

Stigma associated with mental illness

Stigma and reluctance to seek help has been identified as a general issue for people with

various mental health problems. Young people, who are identified as a population with the

greatest need for mental health interventions, are also the least likely group to actually seek

help. Males of all ages are less likely to seek help than females (Rickwood, Deane, & Wilson,

2007).

Stigma associated with eating disorders

People with eating disorders experience the stigma related to specific misconceptions or

lack of awareness of eating disorders in the community. Stigma may be an external

experience, in the form of teasing, bullying, criticism or exclusion from social groups all of

which are identified as risk factors for the development of eating disorders. Stigma may also

be an internal experience in which the person adopts the dominant ideas of their culture

and these ideas combine with other personal risk factors for eating disorders, such as low

self‐esteem or perfectionism, to create a fear of rejection by others (Newton & Chizawsky,

2006).

Lack of recognition of the seriousness of the condition

A characteristic of eating disorders is that they are ego‐syntonic (Newton & Chizawsky,

2006) which is often expressed as lack of recognition of the seriousness of the condition or

concealment of behaviours (Tury, Gulec, & Kohls, 2010; Vandereycken &Van Humbeeck,

2008). Hepworth and Paxton (2007) identify the person’s ability to recognise that their

behaviour is a problem is an important precursor to help seeking. Vandereycken and Van

Humbeeck (2008) found that people with eating disorders were aware of eating disorders as

an illness but did not apply the concept to their own experience.

Socio‐economic factors

Other factors which reduce help seeking include rural location, lower education levels and

lack of sufficient financial resources.

A study of high school students with eating disorders in the US (Austin, et al., 2011) identified the

most common reasons for not seeking help as:

Felt they could handle problems on own (girls 49%; boys 32%)

Decided they did not have a problem (girls 48%; boys 43%)

Were too embarrassed to discuss it with anyone (girls 25%; boys 15%)


Thought the problem would get better by itself (girls 22%)

Were not sure who to talk to (girls 21%) or did not think anyone could help or would be

trustworthy (boys 30%)

It is therefore very important to engage people who are in influential roles, including family,

partners, peer groups, health professionals and other frontline professionals who are positioned to

act as gatekeepers in the process of early identification of eating disorders.

Knowledge of the signs of an eating disorder, where to seek help, what effective treatments are

available and when it is best to seek them, are all aspects of mental health literacy that can facilitate

help seeking.

Identification of Eating Disorders by Health Professionals

The process of identification by health professionals is a key problem for eating disorders.

International and Australian studies have found very low rates of identification of people with

eating disorders in health care settings (Hay, et al., 1998, Mond, et al., 2010) and delayed

presentation of the seriously ill to specialist services (Madden, Morris, Zurynski, Kohn, & Elliot,

2009).

The majority of people with eating disorders have contact with health professionals but do not

specifically talk about their eating problems. The majority of adolescents with eating disorders

(72.6% to 88.2%), have contacted services for emotional problems (Swanson, et al., 2011). A variable

but significant proportion of people with eating disorders (30% to 73%) contact health professionals

for help with their weight (Hay, et al., 2010).

For many people with eating disorders, their first attempt at seeking treatment is a test of attitudes

and responses. If the first help seeking is a positive experience then the person is more likely to

engage successfully with future treatment. The knowledge of the clinician is a key to this

engagement process. People who have a positive first encounter with health professionals note the

benefits of having a knowledgeable and non judgemental therapist (Schoen, et al., 2012)

Recognition requires knowledge of the illness and warning signs as well as knowledge of pathways to

access appropriate professional intervention, positive attitudes towards people with eating

disorders and a belief that acting on this knowledge will have a positive outcome (Jorm, et al., 1997).

Both prevention and early intervention require a skilled frontline workforce with knowledge of

eating disorders, and skill to recognise warning signs, screen and assess for risk, and implement

appropriate evidence based prevention programs. The frontline workforce include professionals

from health and other sectors including General Practitioners, Nurse Practitioners, School

Counsellors, Teachers, Youth Workers, Social Workers, and people engaged in physical activity

instruction.

The frontline workforce reflects the attitudes and beliefs of the wider community. A greater level of

community education is required to raise the level and accuracy of knowledge and beliefs about


eating disorders in order to support prevention, early identification and help seeking (Hart, et al.,

2009).

Mental Health Literacy

Members of the community are generally able to recognise the behavioural characteristics of

anorexia however there appear to be misconceptions about the nature of the illness, with some

people regarding it as a manifestation of low self‐esteem rather than a serious mental illness (Darby,

Hay, Mond, & Quirk, 2010).

In a survey conducted by the NEDC as part of a gap analysis process in 2012, clinicians indicated that

they were able to identify the behaviours of anorexia nervosa and bulimia nervosa and to a lesser

extent behaviours related to binge eating and other eating disorders not otherwise defined.

However, few were able to identify factors that would put their clients at risk of an eating disorder.

Mental Health First Aid Training

It is vital that adults who frequently connect with and influence children and young people, including

parents, teachers, sports coaches and youth leaders; have accurate and up‐to‐date knowledge about

eating disorders and appropriate strategies to support positive body image and nutrition.

Training in mental health first aid has been shown to be effective in increasing mental health literacy

and supportive behaviours in the social networks of individuals with mental health problems.

Training in mental health first aid is identified as a suitable intervention for increasing community

knowledge of and support for people with eating disorders to seek appropriate help (Hart, Jorm, &

Paxton, 2012).

Mental Health First Aid training has been successfully adapted for high school teachers,

demonstrating positive effects on teachers’ mental health knowledge, attitudes and confidence

(Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010)

Providing access to training is only the first step in ensuring that people are equipped to recognise

and respond to eating disorders. It is also essential that primary health care providers are trained

and resourced to screen for, diagnose, refer and support people with eating disorders.

The role of General Practitioners

The role of GPs in prevention has been recognised by the Council of Australian Governments (COAG,

2007) and GPs are consistently identified in eating disorder research as the primary source of initial

diagnosis and assistance.

Research suggests that the most common first points of professional contact are GPs (Sim, et al.,

2010). GPs acknowledge that they have an important role in the detection and management of

mental illness (RACGP,2012)


The general community identifies GPs as the most appropriate first point of contact for treatment of

eating disorders. Most people who receive treatment for an eating disorder have been identified by

their GP (Darby, et al., 2010). However, recognition and confidence among GPs in the treatment of

eating disorders is often poor (Hay, De Angelis, Millar, & Mond, 2006).

Improving eating disorders mental health literacy and eating disorders screening and assessment

skills in GPs is vital to support early intervention. Improving eating disorders mental health literacy is

equally important for paediatricians (Rosen, 2010) dieticians and counsellors. While the general

community recognises the potential roles of dietitians and counsellors in the treatment of eating

disorders, evidence suggests that the eating disorders literacy among these groups and their

confidence to treat is limited (Hay, Darby, & Mond, 2007).

People from specific high risk groups may first seek help from professionals in very different fields,

for example, athletes may first seek help from specialists in sports medicine or physiotherapy, whilst

people who frequently use self‐induced vomiting purging techniques may first be identified and

access help through a dentist.

For specific at‐risk groups, specialist health service providers may represent the first point of

contact. For example, for women presenting with eating disorder symptoms later in life, the first

point of contact may be a gynaecologist or midwife (Newton & Chizawsky, 2006); men and women

may present for infertility treatment (Ogg, Millar, Pusztai, & Thom, 1997); for people seeking

treatment for diabetes or obesity, an endocrinologist or a diabetes educator may be the first point of

contact (Pereira & Alvarenga, 2007).

The majority of people with eating disorders have contact with health professionals but they do not

specifically talk about their eating problems. This means that many people are not diagnosed with

eating disorders at an early stage because they present with apparently unrelated complaints.

Common health presentations include emotional problems, weight loss, and gastro‐intestinal

problems.

Gilbert, and colleagues (2012) explored how and when women with eating disorders first disclosed

their eating problems and how this affected their help seeking. This study confirmed that women are

more comfortable help‐seeking for related problems or consequences of the eating disorders (for

example, anxiety, depression, gastrointestinal problems, weight loss and concerns about weight).

Although they may not volunteer information about specific eating problems in health care

appointments many would welcome questions from health care providers about eating behaviours.

All professions which regularly intersect with people at high risk of developing an eating disorder

require a basic level of mental health literacy and the knowledge and skill to screen, assess and refer

people with eating disorders appropriately.

Preventing Eating Disorders in General Practice

Screening for eating disorders involves asking a small number of evidence based screening questions

of individuals on an opportunistic basis when the patient presents for other reasons. This would

include patients who:


Are identified as having a high risk of eating disorders or for whom an eating disorder would

potentially exacerbate risks associated with other health conditions e.g. adolescents, young

adults, women, people with a personal or family history of eating disorders

Present with recurring gastrointestinal complaints (e.g. bloating, perceived delay in gastric

emptying, IBS symptoms)

Present for the treatment of potential symptoms of eating disorder including weight related

concerns, depression or anxiety

Present for prevention advice on youth mental health, nutrition or exercise

While the screening questions for eating disorders have been developed and tested in the specific

context of this group of illnesses, they are equally appropriate for people with other health

conditions that involve investigation of the patient’s nutritional, exercise or mental health status.

Asking about eating habits and a person’s relationship with food and exercise fits well with the

current recommendations to GPs for general preventive screening (RACGP, 2012):

Preventive activities in children and young people

Guidelines recommend the use of frequent contact with the GP during childhood to screen

for a range of health conditions and promote health e.g.

o All age groups to be screened for nutrition and physical activity

o 6‐19 years to be screened for family functioning, social and emotional wellbeing and

weight and height

o 14‐19 years to be screened for major depressive disorder

Prevention of chronic disease

SNAP (smoking, nutrition, alcohol, physical activity) risk factors include physical activity and

dietary change. GP screening processes include as a first step asking the patient in a

systematic way about their nutrition, alcohol consumption and physical activity. Preventive

screening for risk factors for chronic disease include:

o BMI and waist circumference

o Asking about fruit and vegetable consumption

o Asking about alcohol and other substance consumption

Advice for women preconception

Preventive practice with women pre‐conception includes discussion of weight management,

nutrition (including assessment of nutritional deficiencies and dietary practices) and

periodontal disease. All of these assessments are compatible with screening for eating

disorders.

Psychosocial

Guidelines identify that GPs have an important role in the detection and management of

mental illness. Screening focuses on depression and anxiety, both of which co‐occur in

people with eating disorders. At this stage the guidelines do not mention eating disorders.


One study found that the best individual

screening questions are:

Does your weight affect the way you

feel about yourself?

Are you satisfied with your eating

patterns? (Cotton, Ball, & Robinson, 2003)

Opportunistic screening for eating disorders is a simple, safe and inexpensive approach that has the

potential to enhance general health in patients who are screened as well as identifying people who

have or are at high risk of developing an eating disorder

Initiating Disclosure

Initiating a disclosure may lead to earlier access to treatment for individuals with eating disorders.

Expedient access to specialist services has been associated with disclosures that involved either a GP

or a family member (Gilbert, et al., 2012).

Screening questions may help to initiate disclosure and talk about their body dissatisfaction or

disordered eating with a health professional leading to earlier access to treatment (Gilbert, et al.,

2012).

Berg, Peterson and Frazier (2012) recommend that assessment of eating disorder symptoms should

be conducted for all clients presenting for psychological counselling. Similarly, NSW Health

guidelines for screening of psychiatric patients include the recommendation to screen for eating

disorder pathology as part of standard assessments.

Screening questions for eating disorders can be

as simple as the five questions in the Eating

Disorders Screen for Primary Care (ESP) and

SCOFF screening tools. The questionnaires do not

diagnose eating disorders but identify the

possible presence of an eating disorder and

prompt a more detailed assessment. Routine

screening of adolescents is recommended as part

of regular health examinations. An investigation

of the use of SCOFF screening questions with adolescent school students found that 81% of the

students who self‐reported eating disorder symptoms in response to the SCOFF questions would

have remained undetected if the questions had not been used (Hautala, et al., 2009).

Rapid Access to Treatment

Disclosure & Help Seeking

Information


Eating Disorder Screen for Primary Care (ESP)

Are you satisfied with your eating patterns? (A “no” to this question is classified as an abnormal response).

Do you ever eat in secret? (A “yes” to this and all other questions is classified as an abnormal response).

Does your weight affect the way you feel about yourself?

Have any members of your family suffered with an eating disorder?

Do you currently suffer with or have you ever suffered in the past with an eating disorder?

SCOFF

S – Do you make yourself Sick because you feel uncomfortably full?

C – Do you worry you have lost Control over how much you eat?

O – Have you recently lost more than 6.35 kg in a three‐month period?

F – Do you believe yourself to be Fat when others say you are too thin?

F – Would you say Food dominates your life?

An answer of ‘yes’ to two or more questions indicates the need for a more comprehensive

assessment. A further two questions have been shown to indicate a high sensitivity and specificity

for bulimia nervosa.

1. Are you satisfied with your eating patterns?

2. Do you ever eat in secret?

Additional screening tools may be used to identify compulsive exercise. Compulsive exercise

describes a rigid, driven urge to exercise. This is a serious health concern that often requires the

intervention of someone close to the individual, such as a family member, friend or coach who

recognises these warning signs and encourages professional help. The CET is a screening

questionnaire of 24 questions (1 page) which asks people to rate their own behaviour and emotions

in relation to exercise. The CET can be used with adolescents.


“The problems that young people have to deal

with have become “all mixed up”. Depression,

distorted self‐images and self‐harm, lack of

sleep, obesity, alcohol are all major issues that

have become all mixed up together.” (NEDC Consultation with Teachers, 2011)

Chapter 5 Complementary Initiatives Identifying health initiatives that have the potential to complement approaches to eating disorders

prevention and early intervention

The challenges for eating disorders prevention and early

intervention are similar to those for other mental health

issues, particularly those affecting young people. Mental

illnesses typically have their onset between the ages of

12 and 25 years and yet these age groups are the least

likely to seek help from conventional health services.

Some of the risk factors and socio‐environmental

stressors for eating disorders are shared with other mental illnesses. Low self‐esteem, stress,

bullying, body dissatisfaction, risk taking, self‐harm, substance misuse, disordered eating and

depression frequently occur in some combination in the lives of young people.

The most promising approaches for reducing multiple risk factors simultaneously address multiple

domains of risk, focusing on increasing resilience and promoting positive home and school

environments (Jackson, Henderson, Frank, & Haw, 2012). In the development of this report, the

NEDC has investigated whether general mental or physical health initiatives, particularly those

targeting young people, are likely to be complementary to eating disorders prevention and early

intervention.

There has been significant recent investment in mental health initiatives for people aged 12–25

years (Rickwood, Raphael, & Pilgrim, 2011) and in promotion of general physical health and obesity

prevention. In this context there have been a number of potential initiatives to be investigated from

an eating disorders perspective. Only a small selection appears in this report.

The range of initiatives reviewed for this report included:

General mental health literacy and promotion

Youth access to mental health services

Body image programs

Nutrition and obesity prevention initiatives.

To be complementary to eating disorders prevention and early intervention an initiative needs to

provide an established platform for engagement with a high risk group. To directly contribute to

eating disorders prevention and early intervention an initiative needs to target known risk factors for

eating disorders through the provision of evidence based content and approaches directly related to

eating disorders.

The criteria used to assess whether initiatives are complementary to or contribute to eating

disorders prevention include that the initiative:

Targets and effectively engages with a high risk group for eating disorders

Addresses modifiable risk factors for eating disorders


Is evidence base demonstrating efficacy in changing target behaviours

For prevention initiatives, includes content that directly addresses one or more of:

o Media literacy

o Body satisfaction/respect for body diversity

o Healthy relationship with food

For early intervention initiatives, provides or directly links to evidence based early

intervention approaches supported by professionals with knowledge and skill in the delivery

of eating disorders early intervention

Promoting youth mental health

General mental health promotion initiatives reviewed include:

MindMatters

Mindframe

Aussie Optimism

Confident Kids

MindMatters provides resources and professional development programs to support secondary

schools to promote mental health and suicide prevention (Rickwood, 2011).The MindMatters

program targets a high risk group for eating disorders at a critical time for prevention initiatives but

does not specifically include eating disorders prevention or early intervention resources at this time.

Implementing eating disorders prevention programs

An evaluation of MindMatters determined that the initiative is used in some way in two thirds of

secondary schools (Ainley, Withers, Underwood, & Frigo, 2006) providing a potentially useful

platform for the future dissemination of information resources and prevention programs for eating

disorders.

The evaluation found that programs and professional development activities are identified by

teachers as the most important components of the initiative. This is consistent with the

implementation of evidence based programs for eating disorders prevention and the provision of

training for teachers as presenters of these programs. Using MindMatters as a platform could

prioritize eating disorders prevention in schools that are already engaged with MindMatters.

Supporting early intervention for eating disorders

MindMatters has identified that schools experience problems referring students for help with

mental illness due to lack of services particularly in rural communities, limited access to bulk‐billing

and long waiting lists to access mental health services. This is expected to be true for eating

disorders as well as other types of mental illness. The implementation of workforce capacity

building, outlined as a strategic option in the NEDC report ‘A Nationally Consistent Approach to

Eating Disorders’ must be considered as an essential component of an effective early intervention

strategy, working with the implementation of resources and professional development programs

through initiatives such as MindMatters.


Mindframe

Mindframe National Media Initiative aims to encourage responsible, accurate and sensitive

representation of mental illness and suicide in the Australian mass media. Mindframe focuses on

promotion and prevention for mental health primarily to audiences in the communications and

media sector. Program activities include national leadership, resource development and national

dissemination, and ongoing contribution to the evidence‐base in this area.

Mindframe has the potential to play an important role in the development of community awareness

of eating disorders.

Raising awareness of eating disorders

Mindframe has launched a new information resource on communicating about eating disorders in

2012, developed in collaboration with the NEDC, demonstrating the practical opportunities for the

eating disorders sector to work with Mindframe to develop community awareness of and

appropriate attitudes towards eating disorders.

Mindframe provides pre‐service training for teachers in their role in promoting mental health. The

pre‐service training for secondary school teachers is due for re‐development and this would provide

an opportunity to integrate eating disorders information into this teacher education approach.

Eating disorders are a distinct group of psychiatric disorders with important differences to other

mental illnesses. These distinctions must be communicated to professionals, the media and the

general community. There is also a need to clearly demonstrate the relationship between eating

disorders and other mental illnesses. Mindframe provides one potential platform to integrate

evidence based information on eating disorders into the mainstream promotion of mental health

and mental health literacy.

Aussie Optimism Program

The Aussie Optimism Program (AOP) is a universal mental health promotion program for primary

school grades 6 and 7 that focuses on the development of social skills, social problem solving and

challenging unhelpful thoughts through a combination of school and family based activities. The

program has also been adapted for use in secondary schools (Grade 8).

Evaluation of AOP has shown it to be effective in reducing depression and anxiety in rural school

children (Roberts, Kane, Bishop, Matthews, & Thomson, 2004) and in reducing the internalisation of

problems in young adolescents (Roberts, et al., 2010). AOP has also been found to be effective in

reducing levels of alcohol and tobacco usage (Roberts, et al., 2011).

The evaluation of AOP’s impact on alcohol and tobacco usage noted that the program was only

effective when implemented by teachers who received training and support in the delivery of the

program (Roberts, et al., 2011). This is consistent with the view that teacher knowledge and

attitudes directly influence the outcomes of prevention programs.


Confident Kids

The Confident Kids program aims to reduce children's behavioural and emotional difficulties through

a group program for primary school children. The program has also been adapted for secondary

school students. Evaluation of the program has identified that parents report significant

improvements in children’s internalising of difficulties (Trinder, Soltys, & Burke, 2008) which may be

of relevance to internalisation related to the development of eating disorders.

Multi‐risk factor approaches to eating disorder prevention

Both AOP and Confident Kids show promise as models to address multiple risk factors and develop

resilience in children and both programs target important groups for universal prevention of eating

disorders. Risks and behaviours for eating disorders have not been evaluated as an outcome of these

programs and it is therefore not possible to say whether this type of program would contribute to

prevention of eating disorders. Further research would be required to identify the potential of these

and similar mental health promotion initiatives to contribute to eating disorders prevention.

Facilitating Access to Mental Health Information and Support

The following initiatives promoting early access to mental health information and referral have been

reviewed:

Mind Health Connect

Reachout

Young and Well CRC

Online tools

headspace

Mind Health Connect

The Mind‐health‐connect website provides a gateway to mental health information and services to

enable people to make informed choices regarding their mental health concerns. Mind‐health‐

connect is a general access service for adults. As part of the national e‐mental health strategy, there

are plans to link the service to a ‘Virtual Clinic’ which will provide access to free therapy, either

online or by phone.

Mind‐health‐connect currently provides information on and links to depression, anxiety and general

youth mental health. The focus for the Virtual Clinic will also be on mild to moderate anxiety and

depression.

Early intervention that is specific to eating disorders

While anxiety and depression are common amongst people with eating disorders, eating disorders

have distinct characteristics and treatment requirements. Therefore, addressing these conditions

without also addressing the eating disorder is unlikely to result in favourable outcomes.


The Mind‐health‐connect model has the potential to expand to include links to organisations which

provide information and support for eating disorders and this would be a positive step towards

improving access to early intervention.

Reach Out.com

ReachOut.com, an initiative of the Inspire Foundation, provides evidence based information and

support for young people on mental health issues that are accessible online, including mobile‐

friendly forums and specific apps (refer to online tools below).

Evaluation has identified that ReachOut.com has a wide reach and is effectively engaging young

people, including those who are experiencing high levels of psychological distress (Collin, et al.,

2011).

ReachOut.com includes resources on body image and on eating disorders which are evidence based

and which have recently been reviewed in consultation with the NEDC. However, evaluation results

indicate that only 4% of the young people using ReachOut.com were seeking help for eating

disorders.

Information that is specific to eating disorders

ReachOut is effectively connecting with a high risk target audience for eating disorders prevention.

It provides a valuable resource for young people however evaluation results suggest that alternative

methods may be required to reach young people with eating disorders. Many people in the general

community do not understand eating disorders to be mental health problems and will therefore not

turn to mental health services such as ReachOut and Mind‐health‐connect for help.

Building the capacity for existing initiatives to promote early help seeking for eating disorders is an

important step in eating disorders prevention however there will continue to be a need for eating

disorders specific portals to achieve effective reach to high risk groups.

Young and Well Cooperative Research Centre

The Young and Well Cooperative Research Centre (YAW‐CRC)investigates the role of technology in

young people’s lives, and how it can be used to improve the mental health and wellbeing of young

people aged 12 to 25.

Eating disorder organisations, including the Butterfly Foundation and the NEDC are actively involved

with the YAWCRC to identify effective ways of engaging this high risk target group for eating

disorders prevention.

Current initiatives, such as Keep it Tame, focus on inappropriate behaviour and bullying using social

media. Social media has been shown to have a significant influence on the body image of vulnerable

young people (Flaxman, et al., 2012).


The YAW‐CRC project provides essential opportunities for the development of innovative and

evidence based approaches to the prevention of eating disorders and the promotion of early help

seeking.

Online Tools

Online tools provide an acceptable and easily accessible format for dissemination of mental health

resources. Online tools are potentially cost effective, have a wide reach and are continuously

accessible. The use of such tools forms part of an average young person’s normal daily social activity.

The following apps and online programs of potential relevance to people with eating disorders have

been promoted on the YAWCRC website.

iCope: offering alternatives to deliberate self‐harm by providing practical and easy steps to

distract, displace and seek‐help

Body Beautiful: promotes positive body image and self‐esteem among women and girls

iCounselor: Incorporates strategies for managing a range of conditions, including anger,

obsessive‐compulsive disorder (OCD) and depression

MoodGYM: an online CBT based intervention designed to prevent depression and reduce

anxiety. Scientific trials of MoodGYM show that it can be effective in reducing symptoms of

depression and anxiety.

ReachOut.com provides online training and games including:

ReachOutCentral.com.au a game to test and develop life skills

SmilingMind offers meditation techniques and exercises to reduce stress

WorkOut provides online training to improve mental ‘fitness’

Youth mental health service, headspace, has recently partnered with Facebook to launch an online

campaign to reduce bullying: Be Bold Stop Bullying.

All of these initiatives have the advantage of being easily accessible and in an acceptable format for

young people. With the exception of Body Beautiful, none of them specifically addresses eating

disorder issues. With the exception of MoodGYM, none has been subjected to rigorous evaluation at

this stage. None have been evaluated for their impact on eating disorders.

Research is essential

Evaluation of youth mental health initiatives in collaboration with the eating disorders sector would

provide valuable insights into the effectiveness of these initiatives in the prevention of eating

disorders.

headspace

The National Youth Mental Health Foundation, headspace, provides health advice, information and

support to people aged 12 to 25 years and their families in the areas of general health, mental


health, education and employment, and alcohol and other drug issues. These services are provided

through a website, the e‐headspace telephone and online support service, a school support program

and headspace centres in various locations around Australia.

The range of services provided by each headspace centre varies. Provided at a community level by a

local consortium of services, the expertise and service range within each headspace centre reflects

local workforce capacity and interest, funding opportunities and perceived local needs.

The issues that headspace regularly deals with include self‐harm, depression, anxiety and alcohol

and other drug use.

headspace acknowledges that to be effective the early intervention clinical stream of services needs

to be able to respond quickly to young people who have complex needs, working collaboratively as

part of the broader network of health services, and that there needs to be ongoing assistance for

young people with high prevalence disorders.

The headspace School Support provides long term post‐intervention support and resources to school

communities that have been affected by suicide. The approach recognises that while standardised

toolkits are helpful, individual personal contact and the development of prevention and post‐

intervention plans that are specific to the needs of individual schools are essential. The headspace

school support model is consistent with consultation feedback on effective approaches to eating

disorders prevention programs in schools and could provide a useful basis for developing ‘whole of

school approaches’ to eating disorders.

As a source of both general and mental health information and early intervention, headspace

centres have the potential to effectively engage with a high risk group for eating disorders.

Consultation with headspace suggests that at present clinical staff do not consistently have expertise

in working with people with eating disorders. There is an opportunity to build capacity into the

existing e‐headspace and headspace centre workforces to enable them to identify and respond to

people with symptoms of eating disorders.

A model has been developed by the Butterfly Foundation of a potential early intervention approach

to eating disorders that can be embedded in headspace centres. This model builds on the

infrastructure, reputation and communication networks of headspace to reach young people who

are affected by or at risk of developing an eating disorder. The approach would involve the

engagement of eating disorders teams to work from headspace centres providing an early

intervention and low intensity outpatient program on one or two days a week. It would also inform

outreach in local schools and support development of eating disorders knowledge and skills in local

frontline clinicians.

This is one potential approach to building capacity into the workforce in selected areas to provide

eating disorders early intervention treatment.


Promoting positive body image

Research suggests a strong link between body dissatisfaction and disordered eating. Behaviourally

body dissatisfaction is reflected in unhealthy weight loss practices in people in all weight ranges and

in binge eating (Paxton, 2002). In addition to eating disorders, body dissatisfaction is associated with

depression and unhealthy weight gain.

Schools and community organisations have made a variety of positive responses to the promotion of

healthy body image, usually in the form of resources that can be used by the whole school or by

individual teachers.

Curriculum resources include:

South Australia ‐ Absolutely Every Body which aims to raise awareness of the importance of

healthy body image and help schools implement a whole of school approach to promoting

health body image

New South Wales ‐ No Body Is Perfect, a resource for years 7‐10 which provides teachers

with a series of teaching and learning activities which they can incorporate into their PDHPE

program.

Victoria – See Me www.seeme.org.au provides interactive, online media literacy curriculum

resources that address body image concerns.

Stand alone programs designed by experts outside education include:

Free to BE – a resource for years 3 to 12 which aims to address the various factors that

influence body image. This resource was developed by the Butterfly Foundation as a part of

the Australian Government’s National Body Image Strategy

Y’s Girls – an affordable curriculum resource for girls in primary school designed to be

delivered by teachers, which has demonstrated promising results in improving body

dissatisfaction, thin ideal internalisation, self esteem and disordered eating (Ross, Rodgers,

& Paxton, 2012)

Evidence based approaches to reducing body dissatisfaction and enhancing healthy body image,

such as Free to BE and Y’s Girls, form an essential part of the prevention of eating disorders.

Planning for the delivery of these interventions should be done in collaboration with eating disorders

prevention planning.

Recommendations from the National Strategy on Body Image (2009) are also appropriate for the

prevention of eating disorders.


Promoting nutritional health

Although eating disorders are mental illnesses it is attitudes towards body shape, weight and dieting

which provide the context that triggers eating disorders for many people. Therefore programs which

focus on nutrition and prevention of overweight and obesity are of relevance to eating disorders

prevention.

Nutrition in Schools

Schools have an important role in promoting healthy eating and physical activity to students and

providing an environment that supports a healthy lifestyle.

Move Well Eat Well

Move Well Eat Well, an initiative of the Tasmanian Department of Health and Human Service,

promotes healthy eating and physical activity by providing information for early childhood services,

primary schools, families, health and community workers.

The aim is to help children aged 0‐12 develop healthy habits for life and provide opportunities for

optimal learning and development.

Healthy School Canteen Initiatives

Most states and territories have implemented initiatives to promote healthy food provision from

school canteens that are consistent with the Australian Dietary Guidelines for Children and

Adolescents.

A healthy school canteen models the positive nutrition messages that are taught in the classroom

and may introduce students to new foods that they have not experienced. School canteens can also

provide a substantial proportion of a child’s daily nutritional intake if both lunch and snacks are

regularly purchased from the school canteen.

Fresh Tastes Toolkit (NSW) to support implementation of the NSW Healthy School Canteen

Strategy

Right Bite Easy Guide supports implementation of the Healthy Food and Drink Supply for

South Australian Schools and Preschools

smart CHOICES supports implementation of the Queensland Health, Healthy Food and Drink

Supply Strategy

Nourish the Facts: The Food in ACT Schools, provides guidelines for children in preschool to

Year 12

Potential for Unintended Harm

These initiatives are a useful component of a whole of school approach to body image and eating

disorders prevention. To be safe and effective the messages (both direct and indirect) provided to

children and young people through these initiatives would avoid:


An overemphasis on weight as a physical parameter of health. A focus on weight detracts

from an understanding of health in its broader sense as a state of physical, social, and

mental well‐being and absence of disease, and fails to optimise personal and sociocultural

health solutions. It may promote weight bias and weight stigmatisation, body dissatisfaction,

and weight concern and preoccupation, and through these various mechanisms may

increase risk of future weight‐related conditions, including overweight, obesity, disordered

eating, and eating disorders

Moralisation of eating, for example by labelling foods as ‘good’, ‘bad’, ‘junk’, and food

choices as ‘right’ or ‘wrong’, which may foster a rigid approach to eating that is inconsistent

with guidelines for nutritional health; preclude an understanding of dietary balance; foster

guilt and other negative emotions about dietary choices; and at the extreme, perpetuate

cycles of restriction, food avoidance, and binge eating

Awareness‐raising initiatives that focus on the consequences of childhood obesity, without

appropriate information and support for effective lifestyle changes. This may be

misinterpreted by obese children and their parents as cues to engage in dieting, such as fad

or restrictive dieting. This is unsuitable for growing children and may have detrimental

consequences for health and physical growth.

(Source: Evaluating the Risk of Harm of Weight‐Related Public Messages, NEDC 2011)

Measure Up Campaign

This universal media campaign encourages people to make positive lifestyle changes (specifically in

the areas of nutrition and physical activity). The primary target group was people aged 25 to 50

years which may include parents of young children who are a key target audience for eating

disorders awareness and prevention messages.

The campaigns’ focus on weight and waist measurement does not align with the recommendations

of the Evaluating the Risk of Harm of Weight Related Public Messages guidelines (refer above).

One measure of success for this campaign was the number of people who had attempted to lose

weight in the six months preceding the evaluation study. 60% of the primary audience had

attempted to lose weight. By contrast, only 9% of the primary audience reported improving their

daily consumption of fruit and vegetables to the recommended five serves per day. Respondents in

the evaluation expressed reservations about their ability to sustain lifestyle and diet changes in the

long term (Social Research Centre, 2010).

There is a “substantial body of evidence from the eating disorder literature” demonstrating a connection between an emphasis on appearance and weight control and the development of eating disordered behaviours (AED, 2011).

These results raise concerns that adults may be attempting quick weight loss diets that are not

nutritionally balanced and should not be sustained in the long term. Not only does this increase the

risk of developing an eating disorder in these adults, but as the primary role models for children and

young people parents have a significant impact on their children’s beliefs about weight, body image


and their eating behaviours. Role modelling unhealthy behaviours or attitudes potentially places

children at risk.

The Australian Institute of Family Studies report on Australian families (2011) found that 50% were

consciously trying to lose weight, 75% had dieted in the last twelve months and yet only 18% (aged

8‐9) were overweight and 7% were obese. Research evidence indicates that young people who start

to engage in non‐medically supervised dieting before the age of 15 are more likely to experience

depression, binge eating and eating disorders (Lee, 2001).

"The difficulty with young people is that even if they are moderately overweight, they are still growing height‐wise and are at risk of over‐interpreting public health messages of 'low fat is good' to suggest that 'no fat is better'. (Source: Professor Susan Sawyer, Media Article, February 11, 2012)

The key to integration of obesity prevention and eating disorders prevention is shifting the focus

from weight to behaviours that can be maintained on an ongoing basis (Neumark‐Sztainer, 2009).

Complementary Initiatives

There are a number of mental and physical health initiatives targeting children, young people and

their parents, that could provide useful platforms for the dissemination of evidence based eating

disorders prevention programs.

There is no evidence at this stage that these programs currently have the capacity to prevent eating

disorders or contribute to early identification or early intervention for eating disorders.

There is a need to add eating disorders expertise and evidence based resources to existing programs

to ensure effective prevention of eating disorders. Key areas for the addition of eating disorder

specific knowledge include:

Professional development for teachers and others presenting body image, media literacy

and eating disorder prevention programs

Professional development for frontline clinicians, including psychologists and nurses working

in schools and clinicians in youth health centres, to ensure that young people have access to

knowledgeable clinicians able to identify, assess and refer people with eating disorders

Programs and resources, ensuring that eating disorders and body image programs that have

been evaluated as successful are available to all young people

Design and evaluation of general mental health and nutritional health initiatives to ensure

that these reduce the risk of harm and that they are evaluated for their impact on

disordered eating.


Chapter 6 Opportunities and Gaps

Opportunities to apply the evidence for prevention and early intervention to all high risk groups

including athletes, older women, men and people seeking help for weight loss

There are a small number of evidence based prevention and early intervention programs

predominantly developed for delivery in schools and universities. Additional prevention approaches

are required to meet the needs of all of the high risk groups, particularly men, athletes, older

women, people seeking weight loss and vulnerable communities.

Each of these interest sectors has implemented initiatives to either prevent the development of

eating disorders or to support identification of people with early symptoms. These initiatives have

developed in isolation from each other and therefore without the opportunity to learn from and

replicate effective approaches.

Coordination and evaluation of initiatives to prevent eating disorders is required to enable sectors to

replicate successful tools and approaches in settings other than schools.

Physical Activity – Sport, Fitness and Dance

Awareness of eating disorders appears to be increasing in sport, fitness and dance. This may be the

result of an increased awareness of eating disorders among young people and the general

community.

The key to prevention for people engaged in competitive physical activity is identified as education

and support for the coaches, teachers, parents and other adults who work with people at high risk.

Training in eating disorders is not usually included in the accreditation training for sports coaches,

fitness instructors or dance teachers.

As with programs delivered in schools, prevention in the context of physical activity requires

teachers/leaders that are knowledgeable about the issue and able to role model healthy attitudes

and behaviours. Sports coaches and dance teachers who believe that weight loss is an indicator of

successful training or an essential aesthetic for a specific activity will influence the behaviour of

young people and their parents.

The perceived complexity of eating disorders and the associated stigma may be a barrier to

identification. Coaches, instructors and teachers are concerned that they lack knowledge about how

to respond to situations, and are concerned for the consequences if an athlete is ‘labelled’ as having

an eating disorder. This contributes to a culture of ‘not noticing’ potential eating disorder risks and

symptoms.

Training for coaches, instructors and teachers should include a strong focus on proactive strategies

to promote resilience rather than focusing solely on identification of people with eating disorders.

There is also a need for screening tools, adapted for the different needs of individual activities, to


assist early identification.

For any prevention initiative to be successfully implemented on a consistent basis it requires the

support of the whole organisation or sporting code and therefore must be integrated into policy,

training and measurement of outcomes. This is the equivalent of a ‘whole of school approach’. As

part of this approach, the following issues should be taken into consideration:

Timing prevention activities for high risk periods

Three key periods have been identified as representing increased risk for people involved in

competitive physical activity: the development stage, non‐competition periods, and retirement or

cessation of intense physical activity.

Broad concerns have been expressed in NEDC consultations about sub‐elite athletes and dancers

who aspire to the body shape of elite performers but do not have access to the medical and

nutritional support services to help them achieve this in a safe and healthy way.

Other specific risk periods for people participating in sport and dance were identified as retirement,

when people are no longer in a regulated environment, and non‐competition periods when some

people gain weight which they subsequently have to lose in order to compete.

Choosing the right activity

Sports and dance often require very specific body shapes or weights. People who do not naturally

have those body shapes but who strive to attain them are at greater risk of developing an eating

disorder. Matching physical activity to body shape would presumably reduce some of the risks.

In order to enable parents to support their children there is also a need for parents to understand

the culture and physical requirements of any specific sport or dance activity that their children

engage in. Parents need to be equipped to help their children select appropriate activities.

Peer pressure

Peer pressure can contribute to both risk and protective factors. It is an issue for anyone engaging in

group training where body comparison becomes a part of the group culture. In this context, advice

given to one person about exercise or weight loss may be transferred to all members of the group,

leading to people engaging in inappropriate activities for their health needs. For example, when one

person receives advice to lose weight this may lead to all members of a group trying to lose weight

regardless of their need to do so.

Peer pressure may also provide an opportunity to prevent eating disorders if all members of a team

or group are provided with relevant training. It is possible to build positive body image and healthy

relationships with food into a team culture.


Developing Prevention Responses for Physical Activity Sectors Mental health first aid training could be appropriate for coaches, teachers, fitness instructors,

parents and young adult athletes providing immediate access to an evidence based training

program.

There are also a number of evidence informed resources available which could be utilized as the

basis of prevention interventions in physical activity, such as Fitness First Australia’s “Fitness

Australia Guidelines” (Marks & Harding, 2004).

However, NEDC investigation has demonstrated that generic resources are not being extensively

integrated into practice and resources developed for other sectors are not being transferred and

adapted.

Information on eating disorders and prevention must be interpreted in ways that can integrate with

the existing practices of a sector or code of sport. The degree of difference is not simply between

sectors such as sport and education. The language and expectations of each sporting code and each

type of dance are different. These differences must be reflected in the way that eating disorders are

communicated and this can only be achieved through a partnership approach between eating

disorders expertise and each sector to develop the resources that they need.

Physical activity as a complementary initiative for eating disorders prevention

Physical activity and sporting environments play an important role in influencing how people

perceive their own bodies. While there appear to be circumstances under which sports participation

is a risk factor for eating problems, there are also situations where participating in sport may be a

protection against body dissatisfaction and eating problems. For example, young people engaging in

non‐elite sports, especially in high school, have shown a reduced risk of eating problems compared

to their peers (Smolak, Murnen, & Ruble, 2000) and body image has been found to differ

significantly among girls participating in different types of sport, and between those who participate

in sport and those who do not (Abbott & Barber, 2011). Encouraging females to participate in

physical activity which focuses on what the body can do (function) rather than on appearance has

been found to enhance body satisfaction (Abbott & Barber, 2011).

Research shows a decline in physical activity levels during adolescence, particularly among females.

Reported barriers to participation include: feeling self‐conscious or uncomfortable (Biscomb,

Matheson, Beckerman, Tungatt, & Jarret, 2000) about their bodies; lack of confidence, influence of

peers, parents and teachers, and body‐image issues (Dwyer, Allison, Goldenberg, Fein, Yoshida,

Boutilier, 2006).

The perceived barriers to participation in sport and the association with body dissatisfaction suggest

that social‐environmental strategies to promote engagement in both formal and informal sporting

activity could be helpful in reducing the risk of body dissatisfaction and disordered eating provided

that sports and other physical activities also adopt appropriate eating disorder prevention

responses.


Engaging Parents

While not a high risk group themselves, parents are consistently identified as the most influential

group for children and young people and are therefore a primary target audience for prevention and

early identification messages.

Family interactions shape the views that young people have of their bodies and appearance and

their understanding of healthy relationships with food. This pattern has been noted across cultural

and socio‐economic groups, including very vulnerable populations of young people (Flaxman, et al.,

2012). Families have also been identified as a young person’s first point of reference for health

information.

It is therefore essential that parents gain an understanding of eating disorders and how family

activity can positively influence mental health. Mental health first aid training provides one evidence

based option for parents. Specific training programs have been developed for parents, particularly in

the area of body image, either as integral parts of prevention initiatives involving both children and

parents (e.g. Neugebauer, et al., 2011) or as standalone information sessions.

Both in program evaluations and anecdotally, parent participation in body image and eating

disorders workshops has been consistently low. NEDC consultation has identified both the

importance of engaging parents and the difficulties in realizing this goal. It appears that parents are

not prioritizing these issues and this most probably relates to broad community misperceptions of

eating disorders. It was noted in consultation that parents often do not recognise the problems of

overweight or obesity and disordered eating in their children because these traits appear normal in

their environment.

NEDC consultation suggests that in some instances the parent, teacher or other adult in a young

person’s life projects their own body concerns and aspirations onto the young person.

The adults in a young person’s life reflect the broad values of their culture. While communication

may be usefully targeted at specific groups such as teachers, sports coaches or parents, it must also

be supported by broader community awareness in order to be effective. Strategies that target

limited groups of adults are unlikely to have the necessary impact on their own.

Communication needs to focus on disordered eating rather than the diagnosis of an eating disorder

in order to gain general public attention. This approach will help people to connect eating disorders

issues with their own experience.

Adult Early Interventions

There is an increasing identification of eating disorders in older adults. For some this is a late onset

possibly related to stress associated with physical changes such as pregnancy, menopause, weight

gain and ageing, and also to stressful life events. For others this is an identification of a long standing

illness which may have started in adolescence but has not previously been treated.


Early intervention for adults – early in the development of illness or early in the current episode of

illness – is a vital prevention strategy both for the individual adults concerned, reducing the impact

and duration of illness, and for the other people they may influence such as children and

grandchildren.

Few prevention interventions have been directed towards alleviating body image or disordered

eating issues in the adult community. Innovative approaches have been successfully trialled in the

fitness sector (e.g. Lousie Wigg and Body Image and Health Inc approach to changing the culture in

gyms: Wigg, 2001) and amongst chronic dieters (Higgins & Gray, 1998).

Some interventions designed for children and adolescents have been shown to have positive effects

for adults as well. For example, Student Bodies, discussed in chapter 3 of this report, has been

shown to be effective in improving knowledge for teachers and this may include improving the

participants own weight and dieting issues. As an online intervention, this approach could have

broad appeal and accessibility for adults if appropriately promoted.

Anecdotally, parents who participate in prevention workshops designed for their children frequently

comment on the impact these have on their own attitudes and behaviours.

While successful, these approaches have not been widely adopted. Broader implementation of

targeted interventions to adults is likely to be very valuable (Paxton, 2002).

People Seeking Help for Weight Loss

Weight issues and obesity are serious and common outcomes for people with bulimia nervosa and

binge eating disorder (Fairburn, et al., 2000). People with these disorders are more likely to seek

help for weight loss than for psychological distress (Mond, et al., 2010).

However, people of healthy or low weight also seek assistance for weight loss and this can be an

indication that the person is at risk of or has an eating disorder.

Of particular concern is the impact of non‐medically supervised weight loss programs on children

and young people, whether it is the child who engages in the diet or the parent who role models the

dieting behaviour.

There is evidence that professionally designed and administered weight management programs for

children and adolescents have the potential to reduce both weight and eating pathologies (Hill,

2007). However, without an appropriate level of expert involvement from both physical and mental

health sectors, dieting represents a risk for young people

Two key issues are identified for the promotion of prevention and early intervention for eating

disorders for people seeking help with weight loss:

The lack of training and ability to use evidence based screening tools; particularly in weight

loss consultants who are not health professionals has an immediate impact on early

identification and longer term implications for those vulnerable to eating disorders who

engage unsuccessfully in weight loss programs. While no specific training has been identified


for these professionals, Mental Health First Aid for Eating Disorders and introductory

professional training in eating disorders (e.g. CEED online training) may provide an initial

basis for improving workforce capacity in this sector. Training for staff would need to be

supported by policies and procedures within each organisation or centre that aligned with

the principles of eating disorder prevention.

The lack of regulation of the weight loss industry, particularly in regard to the promotion of

‘quick fix’ diet products and diet plans raises considerable concern. Unlike pharmaceuticals,

diet products do not have to prove their effectiveness. Failure to lose weight leads product

users to blame themselves rather than the product leading to low self‐esteem and the

potential for increased health risks (Hill, 2007). There is scope for regulation of the way in

which diets and diet products are promoted.

Gaps in Access to Prevention and Early Intervention

Innovative approaches should be encouraged and evaluated

There is an urgent need to replicate some of the innovative approaches to prevention and treatment

that have been developed to meet local, regional and specific sector needs in Australia. These

innovative approaches are evidence‐based but have not yet generated evidence of their own

effectiveness.

Approaches to prevention must include evaluation strategies. This applies to the implementation of

eating disorders prevention programs, the adaptation of these programs to new contexts, to general

health initiatives that are intended to build resilience and to early access initiatives intended to assist

people to seek help early in illness.

Flexible approaches

Prevention approaches must be flexible and adaptable to the context in which they will be delivered.

No two schools or sports, and no two adult work or recreation contexts, could be expected to need

or be able to utilize exactly the same thing. There is a need to work with each sector to develop their

approaches rather than simply providing them with already determined guidelines. Prevention

initiatives should be developed in close consultation with the target audiences and sectors.

Coordination is as important as new resources

There are identifiable gaps in prevention and early intervention support services but equally

important are the gaps in linkages between these existing resources. Positive actions are being taken

in every state and in both private and public health and education but there are few links between

these initiatives. Resources are used to effectively ‘reinvent the wheel’ with each new initiative

rather than capitalizing on what has already been achieved.

Sharing of information, replication and up‐scaling of current initiatives and coordination between

initiatives will be an important part of any future approach to preventing eating disorders. A

common and coordinated approach to evaluating effectiveness could significantly enhance the

development of a uniquely Australian approach.


Gaps in Knowledge

There are population groups for which no reliable evidence is available to guide prevention and early

intervention. The indicators of risk suggest that Indigenous people are at high risk of eating disorders

but there is no evidence as yet on the most appropriate way to assist Indigenous communities to

address these issues. This is a priority for further investigation.

Consistent Prevention Messages

Most prevention initiatives provide a short term program delivered once in a child or adolescent’s

school life, or on a more targeted basis, delivered once to young adults with very high risk. The

information, beliefs and behaviours developed during these short term interventions must compete

with a barrage of other messages received through the media, the school or work environment and

family and peer relationships.

To be most effective, prevention initiatives must be delivered consistently over time as part of a long

term and coordinated approach to prevention and early intervention for eating disorders.


Words that create barriers to healthy change

Diet

What diet means to one person is not the same as to another.

To a health professional interested in promoting healthy

weight, it may mean a sensible eating plan leading to a modest

weight loss of 5‐10%; in eating disorders literature it is

shorthand for taking extreme measures to lose weight

whether or not weight loss is actually required.

To most people in the community, based on media coverage of

the issue, it seems to mean a short term significant reduction

in food intake in order to rapidly lose weight or a longer term

extreme ‘make over’ of western eating habits (e.g. the Paleo

diet; the raw food diet) in order to address broader health

issues, often without any scientific basis.

Chapter 7 Prevention in a Media Environment

Prevention messages for eating disorders, like prevention messages for other health issues such as

obesity, are understood within a broader context of social communication which may reinforce the

key message or undermine it. Influences on health behaviours such as culture, media and fashion

must be addressed (Jackson, et al., 2012) if prevention messages are to have a long term effect in

people’s lives.

The evidence on contributory factors for eating disorders points to vulnerabilities and triggers which

are beyond individual control (Steiger,

2012) and cannot necessarily be identified

before exposure to risk. Prevention

initiatives must therefore include broad

social and environmental actions rather

than focusing solely on individual

responsibility.

Based on media reporting and surveys, the

Australian community holds some

mistaken beliefs about dieting, obesity and

eating disorders (Cook & Lewandowsky,

2011). Well crafted health promotion

messages and research results find a

different interpretation when they are

translated in popular media. A focus on

reducing obesity has translated in popular

culture and media into a focus on restrictive diets that promise short term weight loss and a

competitive culture of body comparison.

Seeing Messages through the Eyes of Children

In promoting dieting, society is effectively encouraging children and young people to take significant

health risks at a stage in their development where they are prone to engage in risk behaviours and

least likely to be able to understand that risk in perspective. Unhealthy weight control is associated

with other types of risk‐taking behaviour such as substance misuse and unprotected sex (Hill, 2007).

Many different weight‐loss strategies are currently being promoted and although some are

considered healthy, many may be dangerous to the health of vulnerable individuals. Research shows

that overweight adolescents are the people most likely to select high risk, extreme and unhealthy

weight loss behaviours and that this is associated with poor psychological health (Hill, 2007).

Any action that further stigmatizes obesity is likely to increase child and adolescent weight concerns

and the risks for eating disorders (Hill, 2007).


To prevent eating disorders it is essential to pay careful attention to the way in which ‘diet’ and

weight are portrayed in popular media.

Print Media

Print media has been the primary focus of previous campaigns for responsible portrayal of bodies,

body image, weight and eating behaviours. It appears those campaigns have been somewhat

successful in shifting the intentions, and in some cases, actions of print media.

For example, the November 2012 issue of popular women’s magazine ‘Cleo’ includes an interview

with the Butterfly Foundation CEO Christine Morgan as part of an article on photo‐shopping in their

magazine, an un‐manipulated swimwear fashion shoot and an article on body‐shape which

advocates positive body image and not dieting.

Magazines with a weekly publication schedule and a focus on celebrity news and information appear

less likely to promote positive body image and mindful eating. Online content for these publications

provides unique management challenges, with older articles being easily accessible, all articles being

searchable for particular content, e.g. ‘diet’ and editorial scrutiny being somewhat less stringent to

meet the different timeframes and publishing pathways in online media. Online content is also often

subject to comments from public users.

Recent examples from websites of Australian magazines include:

Articles which give specific daily kilojoule targets and suggest disordered eating behaviours as

part of short term weight‐loss plans

Several diet plans which follow a high protein, low carbohydrate eating model for a duration of

two weeks or less

Published comments from public users which perpetuate community myths and negative

stereotypes about eating disorders.

It is important that continued collaboration with the print media industry continues, and is extended

and focused towards:

a wider range of print media, including health/fitness magazines, weekly publication‐cycle

magazines, pregnancy magazines and bridal magazines

online publications and the online content of print magazines originating in Australia

“There are no short cuts to improving health and no magic bullets. Eating a wide variety of good food

but not too much, keeping physically active, stopping smoking and making sure you don’t drink too

much alcohol, are the best approaches” (Source: Chris Del Mar, Professor of Public Health, Bond

University; opinion piece in the Conversation, 30 November 2012)


Social Media

Social media is currently one of the most important spheres of influence in a young person’s life and

social media websites are perceived as a common source of body image pressure. Many young

people report awareness of cyber bullying and derogatory comments on social network sites.

The advent of social media on the internet has given rise to many new and innovative ways for

people with or at risk of an eating disorder to access information and support. It also provides a

unique environment to disseminate population‐wide and targeted messaging about healthy eating

and body image.

However, this also provides a forum for people to share their unhealthy views on eating and body

image, and provide a community of acceptance and support for symptoms of eating disorders. It

also allows for the easy spread of misinformation about healthy eating, body image and eating

disorders.

The following are some examples of the information contained in social media;

Facebook; the social networking site has many pages devoted to ‘thinspiration’, unhealthy

eating behaviours and weight‐loss programs, some with over 300,000 fans. These pages

often perpetuate misinformation about eating disorders and support dangerous, restrictive

dieting behaviours

Twitter; a review of twitter hashtags and the accounts that have frequently used them

highlights a pervasive use of twitter updates to share thoughts and experiences on

disordered eating behaviour. It also provides communities of ‘support’ for people engaging

in unhealthy eating behaviours. While these updates seem to be specific to people already

suffering from disordered eating and thinking regarding body image, they are often also

tagged with more general terms such as #fat and #loseweight, which gains them a wider

audience with people engaging in general weight conversations

Tumblr; This free personal blog media website includes pages which contain graphic images

of underweight men and women along with personal experiences of eating disorders and

self‐harming behaviours, explicit information on how to engage in disordered eating

behaviours and derogatory language towards people who are not restricting and/or purging

their food intake. Many of the people responsible for these pages purport to be young

women, often under the age of 18.

Awareness, prevention and early intervention campaigns should have an active, well monitored

presence in social media spaces and look at the roles and risks of social media as part of prevention

and early intervention programs with young people.

Evidence Based Eating Disorders Information Online There has been a strong uptake of mental health information online, especially amongst young

people (Rickwood, 2011). There are indications that it is people with the greatest well‐being

problems who are searching online for health information (Drentea, Goldner, Cotten, & Hale,


2008).Health professionals also use online search engines to find medical literature (Cummings,

2009).

The Australian Government E mental health strategy seeks to capitalize on this trend by improving

access to professional, reliable mental health information, support and therapy through online

portals.

Evidence based information on eating disorders can be accessed from a wide variety of online sites

including eating disorders and body image support services, private clinical practices, youth mental

health services such as ReachOut.com.au and headspace and the NEDC website.

The volume of information on eating disorders and body image is now so great that selecting the

right information can be confusing. The credibility of the website should assist people in the

selection process however; websites have not been shown to consistently meet quality standards. A

review of websites on diet and anorexia or bulimia using Google as a search engine, has found that

the credibility of websites covering these issues is still poor. Factors such as identifying authorship,

referencing of content and updating of content were identified as areas for improvement

(Guardiola‐Wanden‐Berghe, Gil‐Perez, Sanz‐Valero, & Wanden‐Berghe, 2011).

Investigation of trends in mental health ‘Googling’ in the UK and Ireland has shown that there is one

search for ‘pro ana’ for every three searches for ‘anorexia’ (Cummings, 2009).

In addition to credibility, the following factors have been identified by this review:

Accessing information at times of stress

Usage patterns for the NEDC website indicate that while people may enthusiastically search

the website for resources, they do not necessarily remember those resources at later times

when the information would be of immediate use. There is a need to either assertively

disseminate information (e.g. through email) or to provide more personal information (e.g.

through telephone support)

When the right information is not the answer

Information that promotes help seeking for medical treatment is not always welcome. Many

people prefer not to seek medical help and people with eating disorders experience

additional barriers to help seeking including failure to recognise their condition as a health

problem, reluctance to change, and fear of the stigma associated with eating disorders. In

this context the solutions offered by less credible sites may be more appealing than the right

answer.

Referral and early intervention options

The most frequently recommended course of action in credible online resources on both

body image and eating disorders is to seek help from a GP. The NEDC analysis of gaps in

current approaches to eating disorders has identified that GPs and other frontline health

professionals often do not recognise or respond appropriately to patient’s with eating

disorders. People with lived experience of an eating disorder identify the positive support of

a GP as one of the most helpful factors in getting treatment. Unfortunately, more people


experience long delays in getting treatment because they are not correctly diagnosed or

referred by their GP. It is essential that information on how to seek help is matched by

strategies to provide early intervention treatment and support.

Organisations and initiatives providing online information about eating disorders must continuously

review and develop their resources in order to maintain their currency and quality.

Opportunities to improve the dissemination of information about eating disorders to support

prevention, early identification and access to early intervention include:

Coordination of quality websites to link to each other

Coordination of the development of resources to ensure that initiatives act synergistically

and the development of clear links between credible sites may enhance access to reliable

information

Provision of opportunities for personal contact

One study has shown that 68% of young people would use online mental health information

if they needed it, however the same study found that 79.4% would still prefer face to face

support (Horgan & Sweeney, 2010). People accessing information about eating disorders do

so in the context of the complexity of eating disorders, difficulties in accessing

knowledgeable primary care and early intervention, and the barrier of stigma and

misconceptions about eating disorders. Providing access to information in a personalized

way that can answer an individual’s specific questions may be an essential component of an

early intervention approach. Building capacity into community based support services and

youth health services such as headspace may provide one option to achieve this. The

provision of telephone and email support services, such as the Butterfly Teleweb Counselling

Service, may also provide an accessible and cost effective alternative.


Disordered eating and overweight may perpetuate each other's development.

(Urquhart & Mihalynuk, 2011)

Healthy Eating & Exercise

Problem beliefs and behaviours

about appearance, eating and exercise

Clinical Health Problems: Eating Disorders and

Obesity

Chapter 8 Messages for Good Health

Research indicates that the prevalence of eating disorder behaviour in Australia, particularly binge

eating, is increasing in parallel with the increase in obesity.

Obesity in adolescents has increased by 75% in the past three decades (Daee, et al., 2002). In parallel

with this increase, the development of comorbid obesity with eating disorder behaviours has

increased at a faster rate than that of either obesity or eating disorders alone. Research on

adolescent girls has found that those suffering obesity have high rates of disordered eating (Darby,

et al., 2009). A population survey conducted in South Australia found that one in five people

suffering obesity also suffered from disordered eating, mainly in the form of binge eating, but also

evident in episodes of strict dieting and purging (Darby, et al., 2009).Research conducted by Hay and

colleagues in Australia (2008) found evidence of an increase in incidence in binge eating disorder and

EDNOS over a ten year period, and speculated that this may be associated with rising public

concerns over the increase in obesity.

There is a “substantial body of evidence from the eating disorder

literature” demonstrating a connection between an emphasis on

appearance and weight control and the development of eating

disordered behaviours (AED, 2011). Overweight adolescents are at

higher risk than their healthy‐weight peers for disordered weight‐

control behaviours and binge eating, behaviours (Austin, 2011). Dieting that is not clinically

supervised is associated with onset of disordered weight control behaviours, eating disorders, and

weight gain (Neumark‐Sztainer, et al., 2007). Among girls who diet, the risk of obesity is greater than

for non‐dieters (Daee, et al., 2002; O’Dea, 2005).

Unhealthy weight loss dieting is associated with other health concerns including depression, anxiety,

nutritional and metabolic problems, and, contrary to expectation, with an increase in weight

(Paxton, 2002).

Adolescents who diet and develop disordered eating behaviours carry these unhealthy practices into

young adulthood and beyond (Neumark‐Sztainer, et al., 2011) influencing their own long term health

and potentially the health of any children they may care for.

Obesity and eating disorders are often

seen as separate problems and yet eating

disorders, weight and shape preoccupation

and obesity often co‐occur over time and

share common risk and protective factors.

Adolescent girls, in particular, may suffer

from more than one condition (e.g., binge

eating and obesity), or they may move

from one eating disorder to another

depending on the severity and stage of


Radically Different

For some people it is the unrealistic desire to radically

alter body shape and appearance and to do this quickly

that drives unhealthy behaviours.

People are becoming bigger but at the same time

striving for an ideal body size and shape.

their illness.

Obesity and eating disorders may be viewed as occurring at the same end of a spectrum from

healthy beliefs, attitudes, and behaviours at one end to problematic beliefs, attitudes, and

behaviours at the other end (AED, 2011).

Factors that have been identified as contributing to both eating disorders and obesity include dieting, media use, body dissatisfaction and weight‐related teasing (Haines & Neumark‐Sztainer, 2006).

Integrated messages require a shift in focus ‐ from weight or shape to health; from comparison to

individual identity and self‐worth; from negative motivators such as fear or social exclusion to

positive motivators of personal wellbeing and achievement.

Fears about weight gain develop within a

cultural context that promotes the pursuit of

thinness and engagement in dieting behaviours,

both of which contribute to body dissatisfaction

(Neugebauer, et al., 2011).Wherever people

look in the media, appearance criticism and

dieting are popular topics. Regardless of the

intention of health promotion messages

encouraging weight loss, it is in the context of popular media that these messages are interpreted

and internalized.

It is not possible to fully address eating disorders prevention without also revisiting approaches to

obesity prevention.

There is an urgent need to develop integrated prevention initiatives which encourage body esteem,

healthy eating and lifestyle behaviours without prompting engagement in fad diets, weight loss

attempts and the diet‐binge cycle (Darby, et al., 2009; Neumark‐Sztainer, 2005; O’Dea, 2005;

Russell‐Mayhew, Arthur, & Ewashen, 2007).

Focusing on the risk and protective factors that are common to eating disorders and obesity

presents an opportunity to collaborate and redirect people in a positive direction. Targeting

unhealthy socio‐cultural beliefs and behaviours, combined with education for healthy living may be

the most effective strategy for reducing the prevalence of disordered eating and obesity among

females (Urquhart & Mihalynuk, 2011).


The ideal body size for women has become progressively smaller over the past half century while in the same time period the actual female body size has increased (Urquhart & Mihalynuk, 2011). Popular media emphasizes apparent arguments between the obesity

sector and the eating disorders sector particularly in regard to the risks

and benefits associated with dieting. While the eating disorder sector

represents dieting as a risk, a defining feature of illness and a

maintaining behaviour, the obesity sector, supported by popular

media, presents dieting as a solution to a significant health problem

(Hill, 2007).

Eating disorders represent the activation by dieting of non‐specific

vulnerabilities in susceptible individuals. You can’t get an eating

disorder if you don’t diet. (Howard Steiger, NEDC National Workshop,

2012)

The term ‘dieting’ as used here refers to a broad range of eating

behaviours and cognitions that are unhealthy and potentially harmful

from a physical and psychological standpoint. Examples include overly

restrictive eating (i.e., excessively low calorie intake, cutting out entire

food groups), strict and rigid food rules, and dietary changes that are

not practical or sustainable long‐term. Dieting can be distinguished

from healthful dietary practices and cognitions, such as having a

balanced diet, aiming to eat the recommended serving of fruits and

vegetables, being flexible about food choices, and engaging in practical

and sustainable dietary practices.

While the primary focus for eating disorders prevention is on extreme

weight loss strategies, it should be noted that there is evidence that

the use of common weight control techniques by young females who

are of healthy weight can produce subtle levels of chronic under‐

nutrition (Guest, et al., 2010) at an important time in their physical,

social and learning development. Dieting of all types amongst children

and young people is potentially a health risk unless prescribed and

supervised as part of a medical health intervention.

The NEDC Communication Strategy ‘Clarity in Complexity’ and the

NEDC guide to healthy weight related messages (www.nedc.com.au)

identify the following negative strategies as leading areas of concern in

health promotion:

Measurement (e.g. of weight/BMIs) as standalone indicators

of health

Shared risk factors:

Being overweight in

childhood

Weight bias and

stigmatisation

Childhood weight‐related

teasing

Amount of time spent

watching television/using

the internet/playing video

games

Media and marketing

exposure

Dieting and disordered

eating

Poor body image

Depressive symptoms and

anxiety

Family talk about weight,

parent weight‐concern and

weight‐related behaviours

(e.g. dieting)

Shared protective

factors:

Enjoying physical activity

Positive body image

High self‐esteem

Eating breakfast, lunch and

dinner every day

Family modelling of healthy

behaviours (e.g. avoiding

unhealthy dieting, engaging

in physical activity, having

regular and enjoyable family

meals)


Focus on dieting dangers

In response to the question “How can we convince young people of the risks of dieting?’ professionals

consulted by the NEDC gave this response:

Give them the facts that it actually doesn’t work!

Young people are all about stats and facts – and they DON’T want to put on weight.

Moralisation of eating e.g. labelling foods as ‘good’ or ‘bad,’ and food choices as ‘right’ or

‘wrong’

Weight bias and stigmatisation including criticism of the appearance of individuals

Food fears and unhealthy dieting

Body dissatisfaction, dieting, and use of unhealthy weight control practices

Positive Health Messages

The aim of health promotion activities is to shape the knowledge and behaviours of community

members to prevent disease and improve health. At present, the health promotion strategies for

obesity and eating disorders tend to be conducted separately; however, there is growing evidence to

suggest that a shared approach could be of benefit.

Efforts to prevent both obesity and eating disorders would benefit from a reduction in the negativity

that obesity attracts in the popular media (Hill, 2007). High levels of body dissatisfaction have not

been shown to motivate people to engage in healthy weight loss strategies.

Failure to achieve or maintain weight loss contributes to the sense of personal failure which may

trigger binge eating or purging behaviours.

People respond most favourably to health promotion messages that involve multiple positive health

behaviours and do not directly mention obesity or related health risks. Messages with stigmatising

content generally receive the lowest level of participants complying with the program.

Shifting the focus from weight to good health, representing the diversity of healthy body shapes and

sizes and promoting the modest weight loss goals (5‐10% of starting body weight) that health

professionals are recommending for people who are identified as being at risk of weight related

illness, may provide a formula for successful reduction in the incidence of obesity and disordered

eating (Hill, 2007; Neumark‐Sztainer, 2009).

According to Professor Newton of the Austin / BETRS (Body Image Eating Disorders Treatment and

Recovery) program "We need to be giving healthy weight messages that don't vilify fatness, but

actually encourage health,"(Source: Sun Herald Interview, February 2012).

This approach has been tested and there are a number of evidence based prevention programs

which have been successful in addressing both weight and eating disorder risk factors in children and

young people. Implementation of such programs on a consistent basis may provide one opportunity

to address both obesity and eating disorders prevention.


Evidence Based Integrated Programs

The 5‐2‐1 Go! intervention (Planet Health obesity prevention curriculum plus School Health

Index for Physical Activity and Healthy Eating: A Self‐ Assessment and Planning Guide,

Middle/High School Version) produced positive outcomes that support the effectiveness of an

integrated obesity prevention and disordered eating behaviour prevention intervention for

pre‐adolescent and early adolescent girls (Austin, et al., 2007).

The Healthy Weight program outlined in the book The Body Project, includes various

techniques to discourage unhealthy dieting behaviours (e.g., calorie‐counting or food

deprivation) while facilitating guidance for achieving a healthier lifestyle, including regular

exercise and a healthy diet. Particular attention is paid to factors which may have led to

failure of previous diet goals and participants receive nutritional information specific to their

individual diet plans, in order to prevent prospective failures.

The Body Project, discussed earlier as an evidence based prevention approach for eating

disorders, also addresses health body weight. In the second part of the program participants

learn to make gradual lifestyle changes to achieve a healthy body weight (Stice & Presnell,

2007).

There is no evidence to support a ‘single solution’ to obesity or eating disorders. There are no simple

solutions to the complex and inter‐related problems of obesity, body dissatisfaction and eating

disorders. Each condition is influenced by a complex interplay of biological, social and environmental

factors. The way in which each condition is addressed influences the social environment in which the

other conditions develop.

There has been considerable debate in both academic and popular media in recent years about the

best approaches to take to reduce levels of overweight and obesity. If the single ‘magic bullet’

approaches are dismissed, the consensus seems to come down in favour of promoting healthy

eating, activity and body satisfaction through multiple social environmental channels.

“There are no short cuts to improving your health and no magic bullets. Indeed, there’s no avoiding

the fact that eating a wide variety of good food (lots of colours, more vegetables and fruit than dairy

and meat) but not too much, keeping physically active, stopping smoking and making sure you don’t

drink too much alcohol, are best. Boring, isn’t it?” (Chris Del Mar, Professor of Public Health at Bond

University, 2012)

“ Measures that will make a difference are engaging children and young people in solutions,

normalising healthy environments and understanding the needs of parents and families, making links

between industry and the learning environment transparent, and leadership and advocacy that pays

attention to evidence. Anything else is a waste of time, money and public attention.” (Waters, de

Silva‐Sanigorski, Gibbs & Pettman, 2012)


This is consistent with the approach to eating disorders prevention and with the findings of the

Academy of Eating Disorders (AED, 2010) in the development of guidelines for the prevention of

obesity in children.

An integrated approach to prevention based on the shared risk factors for obesity, body

dissatisfaction and disordered eating may provide the best opportunity to reduce the impact of all of

these conditions on the health of Australians.

Universal prevention initiatives, delivered as part of such an integrated approach should include:

A focus on a developing healthy lifestyles and a healthy relationship with food

Promotion of modest, achievable health and weight goals

Clear messages about the risks of restrictive and extreme dieting

Development of media literacy and critical thinking

Healthy body satisfaction and respect for body diversity

Such messages would have the greatest impact if supported by more targeted initiatives in schools, and primary health care, including implementation of evidence based prevention programs. Strategic options include Implementation of the AED guidelines for obesity prevention in children.

These guidelines provide a sound and evidence informed starting place for the construction of safe,

effective obesity prevention initiatives that are safe for children and young people (Danielsdottir,

Burgard & Oliver‐Pyatt, 2009).

Screening of people seeking weight loss treatment within the context of a more regulated weight

loss industry would also contribute to early identification and early intervention for people with

eating disorders with no discernible negative consequences for the reduction of obesity.


essential that Australia undertake a national expert review of the role of dieting in obesity, body

image and eating disorders informed by all the areas of expertise including eating disorders, and

commit to implementing long term strategies to promote healthy environments.


Chapter 9 Conclusions

Opportunities to implement effective strategies to improve approaches to the prevention and early

intervention of eating disorders

Australia is fortunate to have a National Mental Health Policy, National Mental Health Plan and

National Mental Health Service Standards that all prioritize prevention and early intervention. This

provides the policy framework for strategic action for eating disorders.

This report identifies strategic opportunities to improve prevention and early intervention for eating

disorders in three broad priority action areas that are consistent with and will support the

implementation of this policy framework.

1. Consistent, Safe Community Messages

A national priority for eating disorders prevention is the adoption of an integrated cross

sector approach to address the complex and inter‐related problems of eating disorders,

body dissatisfaction and obesity.

Addressing the complex socio‐environmental risk factors for eating disorders will require a

shared and consistent approach between obesity prevention, body dissatisfaction (body

image) prevention, eating disorders prevention and general mental and physical health

promotion. A committed collaboration is required across these sectors to ensure consistency

of messaging. Evaluation of all mental health and obesity prevention initiatives for their

impact on disordered eating is essential to open up opportunities for shared approaches to

prevention and health promotion.


essential that Australia undertake a national expert review of the role of dieting in obesity,

body image and eating disorders informed by all the areas of expertise including eating

disorders, and commit to implementing long term strategies to promote healthy

environments.

2. Community and professional knowledge

Ensuring that all adults who intersect with high risk groups have access to training at an

appropriate level for their role. For parents, teachers, youth workers and others who

influence young people, this would include access to Mental Health First Aid training. For

health professionals with responsibility for the diagnosis and referral of people with early

symptoms of eating disorders this would include access to training that achieves the core

competencies for eating disorders treatment as outlined in the NEDC report: A Nationally

Consistent Approach to Eating Disorders.

Early intervention is dependent on the capacity of community members, both professionals


and lay people, people with symptoms of eating disorders and their supporters, to recognise

and act on the health problem. A trained and resourced professional workforce, including

health professionals and professionals in gatekeeper roles such as teachers, school

counsellors and physical activity instructors, who are able to identify and respond to people

at risk is essential as is extensive community education to develop mental health literacy

about eating disorders

3. Widespread implementation of evidence based programs

Ensuring that the evidence based programs and resources currently available for prevention

and early intervention are made accessible on a consistent basis to high risk groups. Existing

complementary mental and physical health initiatives that target the same high risk groups

should be utilized as platforms to ensure dissemination of resources.

Immediate Strategic Opportunities

Immediate opportunities based on effective utilization of existing resources are outlined below.

Policy

Integrate body image prevention with eating disorders prevention at a policy level

Implement NEDC guidelines on safe, healthy weight related messages for all weight related

health promotion strategies

Implementation of Existing Resources

Implement existing evidence based prevention programs, including body image programs,

on a consistent basis using existing mental health promotion initiatives as a platform for

dissemination

Provide training in the delivery of evidence based prevention programs for teachers, sport

coaches and other professionals working with young people

Make Mental Health First Aid training and equivalent programs accessible for all adults who

intersect with people at high risk of eating disorders



Integrate eating disorders prevention resources with existing general mental and nutritional

health strategies (e.g. add resources to Mindmatters, Mindframe, Kidsmatter)

Development Opportunities

The following opportunities require the development of new resources in collaboration with other

sectors. These medium term initiatives can be developed from existing evidence based and evidence

informed resources and have the potential to effectively address gaps in the current resources for

eating disorders prevention and early intervention.




Cross sector research and evaluation including the development of an independent task

force representing expertise in obesity, eating disorders and body image to investigate and

report on the evidence‐based health benefits and risks of dieting and the impact of popular

interpretations of dieting, including the weight loss industry practices, on the current health

status of Australians

Develop information packs for parents and schools that integrate information and advice for

mental health, physical health (obesity prevention) and eating disorders prevention

Develop and assertively promote information packs on eating disorders screening,

assessment and referral for health professionals who intersect with people at high risk

including GPs, paediatricians, obstetricians, diabetes educators, dietitians, physiotherapists,

dentists, and emergency department personnel

Develop regulations and support systems for the commercial weight loss sector to ensure

that a) eating advice and service conform to safe standards and b) that people are medically

screened for risk of eating disorders

Collaborate with sport, fitness and dance sectors to review, update and assertively promote

information on eating disorders prevention and early identification that is relevant to the

specific physical and nutritional requirements for each sector

Collaborate with health promotion campaigns to develop safe and effective approaches to

weight management with an emphasis on weight management strategies for children and

young people and developing community awareness of the dangers of dieting

Collaborate with media to develop guidelines on reporting on weight and on

Investigate the information, prevention and early intervention needs of specific vulnerable

communities including Indigenous communities

General Recommendations for Implementation of Programs

Preventive and early intervention initiatives should include evaluation requirements that are

designed to advance the level of evidence for the selected strategy

Implementation and evaluation of prevention and early intervention initiatives should

monitor and ensure implementation fidelity

Preventive initiatives should be strongly and consistently implemented over an extended

timeframe

Preventive initiatives for children and young people should address the developmental

stage, with each component of prevention building on the foundation of earlier stages in

development

Coordinated multiple strategies to prevent, identify and intervene early in the course of

eating disorders are required

Multi level interventions are required that target the socio‐cultural environment as well as

individuals

Priority areas for action outlined in the NEDC gap analysis report ‘A Nationally Consistent Approach’

(2012) will also have an impact on prevention and early intervention.


Workforce capacity building – roll out and assertively promote online and face to face

training opportunities for health professionals in eating disorders recognition, screening,

assessment, referral and management

Early intervention – promote teleweb and local community access points for information,

professional advice and support to enable help seeking by young people, parents, adults

with eating disorders and clinicians

Equity of access – develop eating disorders service models to ensure access to eating

disorders services in all Medicare local regions

Responses to these strategic opportunities would contribute to achievement of key priorities and

actions within the Fourth National Mental Health Plan (2009). Eating disorders should be specifically

referenced in action plans to address:

Improve of community and service understanding and attitudes through a sustained and

comprehensive national stigma reduction strategy.

Work with schools, workplaces and communities to deliver programs to improve mental

health literacy and enhance resilience

Implement targeted prevention and early intervention programs for children and their

families through partnerships between mental health, maternal and child health services,

schools and other related organisations.

Expand community based youth mental health services which are accessible and combine

primary health care, mental health and alcohol and other drug services. Provide education

about mental health and suicide prevention to front line workers in emergency, welfare and

associated sectors (Fourth National Mental Health Plan, 2009)


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