Eating Disorder Prevention On College Campuses: Not Pulling Its Own Weight – Justin Groves

On college campuses nationwide there is a culture that provokes self consciousness and negative body image in many students. Often these feelings of inadequacy can lead to harmful behaviors such as eating disorders like anorexia nervosa or bulimia nervosa. The statistics regarding eating disorder prevalence rates in college aged respondents are staggering when compared to lifetime prevalence rates. “Nearly 20% of respondents believe that at some point they have suffered from an eating disorder, versus available research that has demonstrated lifetime prevalence rates between .05-4%” (1). With prevalence rates approaching one out of every five students, college campuses seem like, and often are, the natural point of attack to combat this growing epidemic. Although their motives are just, collegiate programs aimed at preventing students from developing eating pathologies and/or providing support for students already suffering from these afflictions often fall short due to an overwhelming amount of information given, lack of follow up, and the use of ineffective scare tactics (2-7).

Primary And Secondary Prevention
One of the many difficulties facing on campus eating disorder prevention programs is the temptation to try to accomplish both primary and secondary prevention methods in a combined setting. Primary prevention refers to the education of at risk individuals who have not yet developed an eating disorder in order to prevent them from doing so, while secondary prevention refers to encouraging students who already have an eating disorder “to seek help early on in the course of the disorder” (2,3). This dual-role type of program has become the dominant model for the majority of colleges and universities that offer such programs. Unfortunately, this combination leads to a “jack of all trades, king of none” scenario. A study was conducted by The University of Santa Clara analyzing the effectiveness of one such program at Stanford University. The Stanford prevention program that was the focus of the study consisted of “a 90-minute discussion attended by 10-20 participants at a time. It was led by pairs of Stanford students with different histories of disordered eating (one was a recovered anorexia patient, the other a bulimia patient who was not fully recovered)” (2,3). The program was split into two parts, in the first “the presenters offered information about eating disorders, such as prevalence, symptoms, how they are treated, the better prognosis for treatment if they are detected early and where to get help on campus” (2,3). The second part of the program is where the presenters “told their personal stories about developing, recognizing and then getting treatment for their eating disorders” (2,3). In order to accomplish the goals of both primary and secondary prevention, students are subjected to information directed at candidates for both types of prevention strategies. This can lead to confusion for the target audiences due to the differences in these messages. “The educational messages for primary prevention (emphasizing such things as the health dangers of eating disorders and the difficulty treating them) are very different from the messages that would be used for secondary prevention, such as reducing stigma and emphasizing treatability” (2,3). These programs also tend to overemphasize the secondary prevention component which “inadvertently gives some of the students the impression that anorexia and bulimia are fairly common, even normal” (2,3). Even with the mixed messages being presented, education of facts must lead to some form of changed behavior; the program must be accomplishing something. According to the study, something is being accomplished. It’s making the problem worse. “In terms of primary prevention, the Stanford program was a failure; it did not prevent eating disordered behavior in students who attended it. ‘In fact,’ the authors note, ‘exploratory analyses showed that students who attended the program reported slightly more symptoms of eating disorders than did students who did not attend the prevention program’" (2,3). As for secondary prevention, did the program motivate high risk students to seek help? “Only three high-risk participants reported seeking help, which was not enough, the authors say, to make any sort of comparison worthwhile. ‘To consider the intervention a success in terms of secondary prevention,’ the authors say, ‘we would have to have seen many more high-risk participants seek help.’” (2,3). Although more cost effective and less time consuming, the combination of primary and secondary prevention into a single program is not effective clinically. Both prevention methods are needed on college campuses but should be given separately to well defined student populations who would be helped most by one method or the other (2-3).

One-Shot Programs
Another problem facing eating disorder prevention programs is a lack of follow up or continual reminders of the messages provided during these programs. Like the Stanford program, most college prevention programs are of the “one-shot” variety, meaning that students attend a seminar or group discussion and then are left to deal with the issues discussed on their own unless further help or information is sought out by the student. Nearly every study conducted on the effectiveness of these types of preventions shows no significant long term decrease in pathological eating behavior, “Although customarily eating disorder prevention efforts are conducted using one-shot programs led by either professionals or trained peer educators, empirical research showing the effectiveness of such efforts is negligible.” (4) Without any sort of follow up activity, at risk individuals show an immediate increase in awareness of eating disorder behavior followed by a decrease in this behavior. Over time, however, behavior tends to return to baseline. This return to pre-prevention levels of pathological behavior is believed to be from a lack of continuity and repetition of the messages given. Without any sort of follow up, students will simply forget the messages received, out of sight, out of mind. This is a common theme in education, repetition leads to learned behaviors. There seems to be arguments and mixed conclusions when it comes to exactly how prevention programs should be designed. One promising result came from a study by C. Barr Taylor et al. In this study college aged women were enrolled in an internet based eight week cognitive-behavioral intervention named “Student Bodies” (5). They concluded that “Among college-age women with high weight and shape concerns, an 8-week, Internet-based cognitive-behavioral intervention can significantly reduce weight and shape concerns for up to 2 years and decrease risk for the onset of EDs, at least in some high risk groups.” (5) Also, to their knowledge, this prevention program is “the first study to show that EDs can be prevented in high-risk groups.” (5) The increased continuity of this program combined with a moderated online discussion group in which participants could reach out to trained professionals and others dealing with issues similar to their own from the privacy of home allowed participants to maintain normal eating patterns and non-pathological behaviors while avoiding the stigma associated with seeking treatment through more traditional channels.

Scare Tactics
A popular methodology used in eating disorder prevention programs on college campuses is the use of so called “scare tactics” to strike fear in the hearts of the students in the hope that the information delivered in this manner will not be forgotten. Horror stories by presenters who are recovering or have recently recovered, pictures and videos of sickeningly skinny people, death rates, and health risks, all of these, among others, are devices used in prevention programs in attempts to scare the students onto the straight and narrow path of non-pathological eating behavior. Often, however, these scare tactics backfire in an unexpected way. If a student does not feel that they are at risk for the targeted behavior, the message will simply fly right over their head. Without some sort of connection to the message, it is meaningless. The student must feel threatened in order for these scare tactics to be effective, “When threat is low, there is NO response to the message (it's not even processed, efficacy is not considered.” (7) Conversely, many college aged females do not feel they are at risk or are threatened by these messages. On college campuses there is increasing pressure on women to be attractive, and in today’s society attractive often equates to thin, “college is a time in which dating serves an important social function, the pressure on young women to be attractive may be particularly salient during these years” (4). This is also a time in which many young women must be forced to try to “fit in” with certain crowds, “this time of life may present pressures for young women to look their most attractive to appeal to friends and potential romantic partners.” (4) This pressure combined with negative attitudes toward body image can often lead to development of an eating disorder. This being the case, it stands to reason that if a female has developed an eating disorder due to the pressures of fitting in with the “thin” crowd, then all of her friends look just like she does. Therefore the previously described scare tactics do not strike fear into the student, they see this as the way a girl should look.

The public health approach to eating disorders on college campuses fails on several levels. Whether it be because of a complete overload of information forced on students who are not the target audience, a complete lack of follow up and continuity of programs leading to a relapse in behavior, or the use of ineffective and often counterproductive scare tactics, prevention programs are not getting the job done and must be altered to reflect the changing attitudes of and problems faced by today’s youth. There is also a complete void in research devoted to finding successful methods for these programs. What little research there is empirically shows that these types of interventions are not effective, but somehow this message is ignored by the organizers of these programs. Benjamin Franklin once said that “the definition of insanity is doing the same thing over and over and expecting different results.” Better prevention methods need to be implemented right now.

REFERENCES
1. National Eating Disorders Association. National Eating Disorders Association Announces Results of Eating Disorders Poll On College Campuses Across the Nation. Seattle, WA: National Eating Disorders Association.
2. American Psychological Asssociation (1997, April 30). Eating Disorder Prevention Programs At Universities May Be Doing More Harm Than Good, Study Suggests. ScienceDaily. Retrieved April 22, 2008, from http://www.sciencedaily.com­ /releases/1997/04/970430140126.htm
3. Mann T, Nolen-Hoeksema S, Huang K, Burgard D, Wright A, Hanson K. Are Two Interventions Worse Than None? Joint Primary and Secondary Prevention of Eating Disorders in College Females. Health Psychology 1997; 16:215-225
4. Martz, D. M.; Bazzini, D. G. Eating disorders prevention programming may be failing: Evaluation of 2 one-shot programs. Journal of College Student Development 1999; 40:32-42
5. C. Barr Taylor, MD; Susan Bryson, MA, MS; Kristine H. Luce, PhD; Darby Cunning, MA; Angela Celio Doyle, PhD; Liana B. Abascal, MA; Roxanne Rockwell; Pavarti Dev, PhD; Andrew J. Winzelberg, PhD; Denise E. Wilfley, PhD. Prevention of Eating Disorders in At-Risk College-Aged Women. Arch Gen Psychiatry 2006; 63; 881-888
6. Jacqueline C. Carter, D. Anne Stewart, Valerie J. Dunn, Christopher G. Fairburn. Primary prevention of eating disorders: Might it do more harm than good?. International Journal of Eating Disorders 1997; 22; 167-172
7. Witte K. Use of Fear Appeals in Public Health Campaigns and in Patient/Provider Encounters. Baltimore, MD: Johns Hopkins University. http://www.comminit.com/en/node/212290