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How can we improve dissemination of universal eating disorder risk reduction programs?
EATBEH-01058; No of Pages 4 Eating Behaviors xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Eating Behaviors
How can we improve dissemination of universal eating disorder risk reduction programs? Simon M. Wilksch School of Psychology, Flinders University, GPO Box 2100, Adelaide, 5001, South Australia, Australia
a r t i c l e
i n f o
Article history: Received 3 November 2015 Received in revised form 15 March 2016 Accepted 30 March 2016 Available online xxxx Keywords: Prevention Eating disorders Commentary Risk factors Universal Dissemination
1. Overview A recent commentary provided an overview of the current state of the eating disorder prevention field, where a case was made for an urgent increase in the output of quality universal prevention research (Wilksch, 2014). Suggested future directions included: an increase in the number of methodologically rigorous efficacy RCTs similar to what the targeted prevention field has done so well in recent years; greater collaboration with obesity prevention researchers to evaluate if programs can prevent both problems; increased collaboration with prevention researchers in related fields (e.g., depression prevention) to see if individual programs can prevent more than one problem; and, an increased focus on younger audiences (specifically pre-adolescents and even pre-school children). In the brief period since, there have been publications in the field that reflect greater attention to most of these areas and this needs to continue (e.g., Fairweather-Schmidt & Wade, 2015; Hart, Damiano, & Paxton, 2015; Wilksch et al., 2015). Two of these three studies focused on much younger children than usually targeted in our field, where Hart, Damiano, Chittleborough, Paxton, and Jorm (2014) evaluated parenting resources for promoting positive body image and healthy eating behaviours for parents of 2- to 6-year olds, whilst Fairweather-Schmidt and Wade evaluated a new program targeting perfectionism in 11-year-olds. Wilksch et al. (2015) completed a large RCT of 3 programs with N = 1316 Grade 7 and 8 girls and boys and found one program (Media Smart) halved the rate of onset of
E-mail address: simon.wilksch@flinders.edu.au.
clinical concerns about shape and weight at 12-month follow-up compared to control girls, whilst also lowering obesity risk factors such as screen time. On further reflection, there is also a need for greater attention to be given to the dissemination of universal programs that have been found to significantly lower eating disorder risk over multiple, well-designed RCTs (e.g., random assignment to condition, inclusion of control group, statistical adjustment for baseline levels of eating disorder risk, adequate follow-up of 12-months minimum). Thus whilst the need for increased output in high quality universal efficacy RCTs remains (Wilksch, 2014), we also need to be able to ‘offer something now’ to schools and other settings who are increasingly desperate to address the issues of body image and eating disorders. Given dissemination research from the medical field suggests an average lag of 17 years to translate original research into routine clinical practice, we cannot afford to wait this long (Brownson, Colditz, & Proctor, 2012). This paper addresses three areas related to this: a need to rethink some prevention strategies that have been essentially discarded of late but that might make dissemination more readily achieved (i.e., single session programs); the importance of being clear in what our programs seek to prevent (or reduce) and how measurement of clinically relevant features of disordered eating could assist the case for dissemination; and, a discussion of how dissemination could best occur in the universal context. 2. Is there a place for single session programs? Meta-analyses by Stice and colleagues have been invaluable in guiding the development and evaluation of eating disorder prevention programs in recent years (Stice & Shaw, 2004; Stice, Shaw, & Marti, 2007). These publications have contributed to a notable shift in the overall scientific quality of our field with most researchers now conducting studies that include many features found to be associated with larger effect sizes and thus better outcomes. One feature of interest from these papers was the finding that singlesession programs produce smaller effect sizes than multiple session programs (Stice & Shaw, 2004; Stice et al., 2007). This makes sense given the importance of consolidating learned content, practicing skills, and time for interactive learning activities. As a result of these findings, the field has now largely moved away from evaluations of single session programs. However, it is important to remember that some of these earlier programs included in the meta-analyses had multiple features that might
http://dx.doi.org/10.1016/j.eatbeh.2016.03.036 1471-0153/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article as: Wilksch, S.M., How can we improve dissemination of universal eating disorder risk reduction programs?, Eating Behaviors (2016), http://dx.doi.org/10.1016/j.eatbeh.2016.03.036
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S.M. Wilksch / Eating Behaviors xxx (2016) xxx–xxx
have led to smaller effect sizes. For example, the majority of singlesession interventions in these reviews were psychoeducational in nature rather than targeting prospective eating disorder risk factors. We know this is associated with smaller effect sizes (Stice et al., 2007). Similarly, many were delivered in a didactic rather than interactive manner, which has also been shown to be associated with smaller effect sizes. Thus there were several aspects of program design and delivery that might have led to less beneficial outcomes. It is important that the universal prevention field has “another think” about what we are trying to achieve. If we have programs that are known to reduce eating disorder risk but program lengths (or requirements on presenters) are such that schools and other settings are discouraged from taking them on board, then we need to look at ways to improve uptake. One such way is to investigate if shorter or even single-session versions of longer programs that target prospectively identified eating disorder risk factors can actually have a beneficial effect. A recent trial by Diedrichs and colleagues compared a single 90minute session that was delivered by teachers versus the same content delivered by expert researchers versus a class as usual control group (Diedrichs et al., 2015). Analyses revealed improvements for intervention students in the teacher-delivered group relative to controls at post-program in body esteem, negative affect, dietary restraint, and for both intervention groups for life engagement. This provided evidence that some immediate benefits can be achieved from a single session, leading the authors to conclude that single session interventions might provide a “more acceptable and feasible intervention option in schools” (p. 100) than longer programs. In short, just as we should not take the meta-analytic findings by Stice and Shaw (2004) and Stice and colleagues (2007) to mean that only targeted (and not universal) programs, with females-only (rather than both girls and boys) who are 15-years and older (rather than early or pre-adolescents) are worthy of research attention, we need to reconsider if single session (or brief) programs can be of value. It seems that the universal field has yet to rigorously investigate single session programs that are designed in a way that includes other features associated with larger effect sizes, thus maximizing the likelihood of being efficacious. That is: being interactive in learning content; avoiding psychoeducational content about eating disorders; targeting developmentally-relevant risk factors; and evaluated with validated outcome measures. A single-session intervention that has been well evaluated, shown to have benefits and likely increases and organization's willingness to pursue further content, would be a very valuable, pragmatic tool in the overall pursuit of dissemination of evidence-based interventions.
3. Adding clarity to our science: The importance of accurately articulating what universal programs seek to achieve The terms “body image program” and “eating disorder prevention program” are often used interchangeably in the universal field. To some degree this is not of concern, body image and eating disorders are clearly related and indeed all scientific efforts to develop efficacious programs should be welcomed. But it does provide a hint of a more broad issue: what are our programs seeking to achieve - Improving body image? Reducing eating disorder risk? Preventing eating disorders? Whilst a widely used shorthand phrase, the use of the term “eating disorder prevention” programs in universal settings is still fraught as no universal program has been found to significantly reduce eating disorder onset. This is an issue that Carolyn Black-Becker has recently written about and has helpfully recommended the term “eating disorder risk factor reduction trials” for those RCTs that measure prospectively identified risk factors but not diagnostic criteria (Becker, 2015). This seems a very appropriate recommendation and one that the field would benefit from using.
Also at the core of this discussion are the risk factor targets of our programs. Weight concerns is widely considered the most proximal eating disorder risk factor (Jacobi & Fittig, 2010) after being identified in a number of high quality prospective risk factor studies (e.g., Cooper & Goodyer, 1997; Killen et al., 1996). The concept of weight concerns differs in a subtle but important manner from body image and body dissatisfaction more broadly. Whilst body image could be thought of as one's perception of one's physical body and often includes items such as “I think that my thighs are too large” (Garner, 1991), weight concerns contains a more evaluative component (e.g., “Has your weight influenced how you think about (judge) yourself as a person?”: Fairburn & Beglin, 1994). It has been proposed that body dissatisfaction is heavily influenced by mood and is thus of a more labile nature whilst weight concerns are a more stable construct that includes the value placed on one's body weight and shape to an individual's self-worth (Cooper & Fairburn, 1993). Finally, weight concerns and overvaluation of weight and shape are clinical and diagnostic features of patients with an eating disorder. It is of course clear that poor body image is associated with many negative outcomes such as lower mood, depression, unhealthy weight control practices, disordered eating (Neumark-Sztainer, Paxton, Hannan, Haines, & Story, 2006) and that poor body image conveys suffering in its own right and is thus a worthy target of prevention programs (Wilksch, 2014). However we do need to remember that many people who experience body dissatisfaction will never progress to developing an eating disorder. Cognitive behavioral models would posit that this is due to having sufficient other components to self-worth (e.g., friendships, academic, other interests etc.) that prevent an excessive importance being placed on one's shape and weight despite having moments of not liking aspects of one's body (Fairburn, Cooper, & Shafran, 2003). In essence it seems that this is the message that is seeking to be taught in current efficacious universal programs — that simply there is more to our individual value than our weight and shape and to thus be skeptical of messages that place great importance on these elements (Wilksch & Wade, 2009). Thus whilst all prevention efforts in our field should be encouraged, the universal field is more likely to gain greater scientific traction and thus increased likelihood of wide scale dissemination if a stronger scientific case can be made that our programs reduce the onset of the core features of the illnesses we are seeking to prevent (Wilksch et al., 2015). As such, it would be valuable for all universal programs to include a weight concerns measure, most likely from the EDE-Q (Fairburn & Beglin, 1994), to further improve the clinical relevance of outcomes. This would also allow an investigation of if universal programs can prevent the onset of clinical levels of concern of weight and shape as was the case in a recent RCT at 12-month follow-up (Wilksch et al., 2015). Indeed it would be valuable to take this further and to include all four EDE-Q scales (Restraint, Eating Concern, Shape Concern, Weight Concern) to obtain a Global EDE-Q score as an indicator of disordered eating (Fairburn & Beglin, 1994). Given relevant prospective risk factor research (Jacobi & Fittig, 2010; Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004; Stice, 2002), it would be prudent to also measure negative affect, perceived pressure to be thin (or muscular for boys), media internalization, and, weight-related comments. Whilst body image programs are valuable in their own right, we cannot assume that they are having flow on benefits to key eating disorder risk factors and indeed clinical concerns without measurement of these features. Thus we need both greater clarity in the terminology used to describe our programs, and increased use of clinically relevant outcome measures. 4. How should dissemination occur? Prevention scientists are in a constant tension between pursuing methodologically rigorous scientific research whilst also being well aware of the ‘real world’ limitations in which this work is conducted. Nowhere is this more apparent than in universal, school-based research.
Please cite this article as: Wilksch, S.M., How can we improve dissemination of universal eating disorder risk reduction programs?, Eating Behaviors (2016), http://dx.doi.org/10.1016/j.eatbeh.2016.03.036
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Universal prevention scientists need to find an appropriate balance between quality efficacy research, whilst also not taking years to accrue this (Austin, 2015). We have clear evidence in Australia and other countries that body image is an important issue to school-aged girls and boys (Mission Australia, 2015). Whilst it must be acknowledged that the research support for universal programs is not at the same level as that for targeted prevention programs, we do have an emerging evidence base for two programs (e.g., Espinoza, Penelo, & Raich, 2013; González, Penelo, Gutiérrez, & Raich, 2011; Wilksch et al., 2015; Wilksch & Wade, 2009) with confirmation that these programs 1) have shown significant benefits to participants in more than one study; 2) where the impact was evaluated over a minimum 12-month follow-up period; and 3) there was no evidence of harm. First, a media literacy program from Spain led students to report significantly lower scores on a measure of disordered eating attitudes and behaviors at 2.5-year follow-up (González et al., 2011). Results also showed that, following media literacy training, participants reported greater body satisfaction than was seen in the control group at 2.5year follow-up (Espinoza et al., 2013). An effectiveness RCT was then conducted with program participants experiencing significantly greater reductions in disordered eating attitudes and weight-related teasing at 12-month follow-up (Sánchez-Carracedo et al., 2016). Second, Media Smart (Australia) has been evaluated in two major RCTs, totalling over N = 2000 participants, where girls who received the program had significantly lower shape and weight concern at 2.5year follow-up than controls (Wilksch & Wade, 2009), whilst in the second trial Media Smart girls had half the rate of onset of clinical concerns about shape and weight, as compared to control girls at 12-month follow-up (Wilksch et al., 2015). Significant reductions in a range of other risk factors was also found (e.g., negative affect, weight-related teasing), whilst supplementary moderator analyses found indications of benefits to participants at both high- and low- baseline risk of an eating disorder (Wilksch, 2010; Wilksch & Wade, 2014). Despite promising findings the truth is that by and large these programs are currently not making it into school classrooms on a large scale. What remains a real concern is what is that we know little about what is being taught to students in schools in the absence of these evidence-based programs (Becker, Plasencia, Kilpela, Briggs, & Stewart, 2014). One of the few studies to document how eating disorder prevention is being taught in education settings found that the most common occurrence was: a recovered eating disorder sufferer giving information about eating disorder symptoms with a focus on their personal journey rather than skill building (Mann et al., 1997). In other words, the exact opposite of what we now know to be effective. Whilst this study of US universities was conducted nearly 20 years ago and we would hope that this is managed differently now, the truth is that we don't know what is being done in schools and universities to address body image and eating disorder prevention. This is an extremely concerning as it seems increasingly clear that building skills without raising awareness of body image pressures is the most effective approach in young-early adolescent audiences (Wilksch et al., 2015; Wilksch, in press). We need to give serious thought to how dissemination of effective risk reduction programs could best be achieved. The targeted prevention field has progressed from efficacy trials to effectiveness research to investigate the impact of programs when delivered by peer and other non-specialist presenters under ‘real-world’ conditions (e.g., Stice, Butryn, Rohde, Shaw, & Marti, 2013; Stice, Rohde, Shaw, & Gau, 2011). This is to be commended and does seem a logical next step for the universal field also (Wilksch, 2014) despite only having been tested in limited capacity to date (e.g., Sánchez-Carracedo et al., 2016; Wilksch, 2015). However, given the time required to conduct effectiveness RCTs of teacher-delivered programs as well as previous findings that up to 75% of non-specialist presenters (e.g., school teachers) either omitting core program learning activities or generating their own topics (Levine,
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Smolak, & Schermer, 1996), we do need to have other strategies for dissemination (Becker et al., 2014). As discussed above, brief programs that can be delivered by experts are one option (Diedrichs et al., 2015). It also seems likely that some schools prefer even multiple session programs to be delivered by external providers (Richardson, Paxton, & Thomson, 2009). This will likely require partnerships between prevention scientists who have developed efficacious programs and commercial or government organizations. However the value of having efficacious programs delivered in their entirety by specialist presenters avoids the risk of a diluted, less effective program experience for participants. Whilst a less scalable approach, it is likely to be more efficacious, particularly for children and young-adolescent audiences where we know there is a real nuance required in the presenter to build skills in participants without increasing awareness of appearance pressures (Diedrichs et al., 2015). Finally, is the question of whether there can be a role for the internet in universal program delivery? This is another direction the targeted eating disorder prevention field is taking with both established online programs (Taylor et al., 2006) and trialing adapted versions of efficacious group programs into an online format (Stice, Durant, Rohde, & Shaw, 2014). Whilst there has been one online program with preadolescent girls and boys that targeted pubertal development and body dissatisfaction (Cousineau et al., 2010), to date online delivery is largely unexplored in universal, young-adolescent audiences. Whilst of course the internet is such a key form of media and appearancebased pressures to young people that development of effective programs for this audience is important, it is also more complex given that such an online program would require much more active engagement by the young person compared to receiving a program in a classroom setting as part of usual schooling. Further, a key feature of efficacious universal programs does appear to be the interactive learning content involving working with peers (Stice et al., 2007; Wilksch, in press). It is unlikely this could be so readily achieved in an online setting. A better option might be for classroom-based programs to include a greater focus on online content when developing media literacy skills. 5. Closing The universal eating disorder risk reduction field is continuing to advance and there have been many valuable steps forward in recent years (e.g., Diedrichs et al., 2015; Fairweather-Schmidt & Wade, 2015; González et al., 2011; Hart et al., 2014; Richardson & Paxton, 2010; Wilksch et al., 2015). Whilst the field needs to continue with quality scientific output (Wilksch, 2014), we also need greater attention towards dissemination of programs with an evidence-base (Austin, 2015). Strategies including investigating shorter programs, developing a clearer case for prevention of core eating disorder features and weighing up effectiveness research versus specialist program delivery on a broad scale are all likely to help. In the end, the main aim of our research is to benefit as many young people as possible. We thus must give greater attention to how this can be achieved. References Austin, S. B. (2015). Accelerating progress in eating disorders prevention: A call for policy translation research and training. Eating Disorders, 1–14. Becker, C. B. (2015). Our critics might have valid concerns: Reducing our propensity to conflate. Eating Disorders, 1–11. Becker, C. B., Plasencia, M., Kilpela, L. S., Briggs, M., & Stewart, T. (2014). Changing the course of comorbid eating disorders and depression: What is the role of public health interventions in targeting shared risk factors? Journal of Eating Disorders, 2, 15. Brownson, R. C., Colditz, G. A., & Proctor, E. K. (2012). Dissemination and implementation research in health: translating science to practice. Oxford University Press. Cooper, P. J., & Fairburn, C. G. (1993). Confusion over the core psychopathology of bulimia nervosa. International Journal of Eating Disorders, 13, 385–389. Cooper, P. J., & Goodyer, I. (1997). Prevalence and significance of weight and shape concerns in girls aged 11–16 years. British Journal of Psychiatry, 171, 542–544. Cousineau, T. M., Franko, D. L., Trant, M., Rancourt, D., Ainscough, J., et al. (2010). Teaching adolescents about changing bodies: Randomized controlled trial of an internet puberty education and body dissatisfaction prevention program. Body Image, 7, 296–300.
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Diedrichs, P. C., Atkinson, M. J., Steer, R. J., Garbett, K. M., Rumsey, N., et al. (2015). Effectiveness of a brief school-based body image intervention ‘Dove Confident Me: Single Session’ when delivered by teachers and researchers: results from a cluster randomised controlled trial. Behaviour Research and Therapy. Espinoza, P., Penelo, E., & Raich, R. M. (2013). Prevention programme for eating disturbances in adolescents. Is their effect on body image maintained at 30 months later? Body Image, 10, 175–181. Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or selfreport questionnaire? International Journal of Eating Disorders, 16, 363–370. Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41, 509–528. Fairweather-Schmidt, A. K., & Wade, T. D. (2015). Piloting a perfectionism intervention for pre-adolescent children. Behaviour Research and Therapy, 73, 67–73. Garner, D. M. (1991). EDI-2: Eating disorder inventory professional manual. Odessa, FL: Psychological Assessment Resources, Inc. González, M., Penelo, E., Gutiérrez, T., & Raich, R. M. (2011). Disordered eating prevention programme in schools: A 30-month follow-up. European Eating Disorders Review, 19, 349–356. Hart, L. M., Damiano, S. R., Chittleborough, P., Paxton, S. J., & Jorm, A. F. (2014). Parenting to prevent body dissatisfaction and unhealthy eating patterns in preschool children: A Delphi consensus study. Body Image, 11, 418–425. Hart, L. M., Damiano, S. R., & Paxton, S. J. (2015). Confident body, confident child: A randomised controlled trial evaluation of a parenting resource for promoting healthy body image and eating patterns in 2- to 6-year old children. International Journal of Eating Disorders (n/a-n/a). Jacobi, C., & Fittig, E. (2010). Psychosocial risk factors for eating disorders. In S. Agras (Ed.), The Oxford handbook of eating disorders (pp. 123–136). New York, NY: Oxford University Press; US. Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., & Agras, W. (2004). Coming to terms with risk factors for eating disorders: Application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin, 130, 19–65. Killen, J. D., Taylor, C., Hayward, C., Haydel, K., Wilson, D. M., et al. (1996). Weight concerns influence the development of eating disorders: A 4-year prospective study. Journal of Consulting and Clinical Psychology, 64, 936–940. Levine, M. P., Smolak, L., & Schermer, F. (1996). Media analysis and resistance by elementary school children in the primary prevention of eating problems. Eating Disorders: The Journal of Treatment & Prevention, 4, 310–322. Mann, T., Nolen-Hoeksema, S., Huang, K., Burgard, D., Wright, A., et al. (1997). Are two interventions worse than none? Joint primary and secondary prevention of eating disorders in college females. Health Psychology, 16, 215–225. Mission Australia (2015). National survey of young Australians. (Sydney, Author). Neumark-Sztainer, D., Paxton, S. J., Hannan, P. J., Haines, J., & Story, M. (2006). Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health, 39, 244–251.
Richardson, S. M., & Paxton, S. J. (2010). An evaluation of a body image intervention based on risk factors for body dissatisfaction: A controlled study with adolescent girls. International Journal of Eating Disorders, 43, 112–122. Richardson, S. M., Paxton, S. J., & Thomson, J. S. (2009). Is BodyThink an efficacious body image and self-esteem program? A controlled evaluation with adolescents. Body Image, 6, 75–82. Sánchez-Carracedo, D., Fauquet, J., López-Guimerà, G., Leiva, D., Puntí, J., et al. (2016). The MABIC project: An effectiveness trial for reducing risk factors for eating disorders. Behaviour Research and Therapy, 77, 23–33. Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128, 825–848. Stice, E., & Shaw, H. (2004). Eating disorder prevention programs: A meta-analytic review. Psychological Bulletin, 130, 206–227. Stice, E., Butryn, M. L., Rohde, P., Shaw, H., & Marti, C. N. (2013). An effectiveness trial of a new enhanced dissonance eating disorder prevention program among female college students. Behaviour Research and Therapy, 51, 862–871. Stice, E., Durant, S., Rohde, P., & Shaw, H. (2014). Effects of a prototype Internet dissonance-based eating disorder prevention program at 1- and 2-year follow-up. Health Psychology, 33, 1558–1567. Stice, E., Rohde, P., Shaw, H., & Gau, J. (2011). An effectiveness trial of a selected dissonance-based eating disorder prevention program for female high school students: Long-term effects. Journal of Consulting and Clinical Psychology, 79, 500–508. Stice, E., Shaw, H., & Marti, C. N. (2007). A meta-analytic review of eating disorder prevention programs: Encouraging findings. Annual Review of Clinical Psychology, 3, 207–231. Taylor, C., Bryson, S., Luce, K. H., Cunning, D., Doyle, A. C., et al. (2006). Prevention of eating disorders in at-risk college-age women. Archives of General Psychiatry, 63, 881–888. Wilksch, S. M. (2010). Universal school-based eating disorder prevention: Benefits to both high- and low-risk participants on the core cognitive feature of eating disorders. Clinical Psychologist, 14, 62–69. Wilksch, S. M. (2014). Where did universal eating disorder prevention go? Eating Disorders: The Journal of Treatment & Prevention, 22, 184–192. Wilksch, S. M. (2015). School-based eating disorder prevention: a pilot effectiveness trial of teacher-delivered Media Smart. Early Intervention in Psychiatry, 9, 21–28. Wilksch, S. M. (2016). Evidence-based prevention program delivery. In T. D. Wade (Ed.), Encylopedia of feeding and eating disorders. Singapore. Singapore: Springer (in press). Wilksch, S. M., & Wade, T. D. (2009). Reduction of shape and weight concern in young adolescents: A 30-month controlled evaluation of a media literacy program. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 652–661. Wilksch, S. M., & Wade, T. D. (2014). Depression as a moderator of benefit from Media Smart: A school-based eating disorder prevention program. Behaviour Research and Therapy, 52, 64–71. Wilksch, S. M., Paxton, S. J., Byrne, S. M., Austin, S. B., McLean, S. A., et al. (2015). Prevention across the spectrum: A randomized controlled trial of three programs to reduce risk factors for both eating disorders and obesity. Psychological Medicine, 45, 1811–1823.
Please cite this article as: Wilksch, S.M., How can we improve dissemination of universal eating disorder risk reduction programs?, Eating Behaviors (2016), http://dx.doi.org/10.1016/j.eatbeh.2016.03.036
Contents lists available at ScienceDirect
Eating Behaviors
How can we improve dissemination of universal eating disorder risk reduction programs? Simon M. Wilksch School of Psychology, Flinders University, GPO Box 2100, Adelaide, 5001, South Australia, Australia
a r t i c l e
i n f o
Article history: Received 3 November 2015 Received in revised form 15 March 2016 Accepted 30 March 2016 Available online xxxx Keywords: Prevention Eating disorders Commentary Risk factors Universal Dissemination
1. Overview A recent commentary provided an overview of the current state of the eating disorder prevention field, where a case was made for an urgent increase in the output of quality universal prevention research (Wilksch, 2014). Suggested future directions included: an increase in the number of methodologically rigorous efficacy RCTs similar to what the targeted prevention field has done so well in recent years; greater collaboration with obesity prevention researchers to evaluate if programs can prevent both problems; increased collaboration with prevention researchers in related fields (e.g., depression prevention) to see if individual programs can prevent more than one problem; and, an increased focus on younger audiences (specifically pre-adolescents and even pre-school children). In the brief period since, there have been publications in the field that reflect greater attention to most of these areas and this needs to continue (e.g., Fairweather-Schmidt & Wade, 2015; Hart, Damiano, & Paxton, 2015; Wilksch et al., 2015). Two of these three studies focused on much younger children than usually targeted in our field, where Hart, Damiano, Chittleborough, Paxton, and Jorm (2014) evaluated parenting resources for promoting positive body image and healthy eating behaviours for parents of 2- to 6-year olds, whilst Fairweather-Schmidt and Wade evaluated a new program targeting perfectionism in 11-year-olds. Wilksch et al. (2015) completed a large RCT of 3 programs with N = 1316 Grade 7 and 8 girls and boys and found one program (Media Smart) halved the rate of onset of
E-mail address: simon.wilksch@flinders.edu.au.
clinical concerns about shape and weight at 12-month follow-up compared to control girls, whilst also lowering obesity risk factors such as screen time. On further reflection, there is also a need for greater attention to be given to the dissemination of universal programs that have been found to significantly lower eating disorder risk over multiple, well-designed RCTs (e.g., random assignment to condition, inclusion of control group, statistical adjustment for baseline levels of eating disorder risk, adequate follow-up of 12-months minimum). Thus whilst the need for increased output in high quality universal efficacy RCTs remains (Wilksch, 2014), we also need to be able to ‘offer something now’ to schools and other settings who are increasingly desperate to address the issues of body image and eating disorders. Given dissemination research from the medical field suggests an average lag of 17 years to translate original research into routine clinical practice, we cannot afford to wait this long (Brownson, Colditz, & Proctor, 2012). This paper addresses three areas related to this: a need to rethink some prevention strategies that have been essentially discarded of late but that might make dissemination more readily achieved (i.e., single session programs); the importance of being clear in what our programs seek to prevent (or reduce) and how measurement of clinically relevant features of disordered eating could assist the case for dissemination; and, a discussion of how dissemination could best occur in the universal context. 2. Is there a place for single session programs? Meta-analyses by Stice and colleagues have been invaluable in guiding the development and evaluation of eating disorder prevention programs in recent years (Stice & Shaw, 2004; Stice, Shaw, & Marti, 2007). These publications have contributed to a notable shift in the overall scientific quality of our field with most researchers now conducting studies that include many features found to be associated with larger effect sizes and thus better outcomes. One feature of interest from these papers was the finding that singlesession programs produce smaller effect sizes than multiple session programs (Stice & Shaw, 2004; Stice et al., 2007). This makes sense given the importance of consolidating learned content, practicing skills, and time for interactive learning activities. As a result of these findings, the field has now largely moved away from evaluations of single session programs. However, it is important to remember that some of these earlier programs included in the meta-analyses had multiple features that might
http://dx.doi.org/10.1016/j.eatbeh.2016.03.036 1471-0153/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article as: Wilksch, S.M., How can we improve dissemination of universal eating disorder risk reduction programs?, Eating Behaviors (2016), http://dx.doi.org/10.1016/j.eatbeh.2016.03.036
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have led to smaller effect sizes. For example, the majority of singlesession interventions in these reviews were psychoeducational in nature rather than targeting prospective eating disorder risk factors. We know this is associated with smaller effect sizes (Stice et al., 2007). Similarly, many were delivered in a didactic rather than interactive manner, which has also been shown to be associated with smaller effect sizes. Thus there were several aspects of program design and delivery that might have led to less beneficial outcomes. It is important that the universal prevention field has “another think” about what we are trying to achieve. If we have programs that are known to reduce eating disorder risk but program lengths (or requirements on presenters) are such that schools and other settings are discouraged from taking them on board, then we need to look at ways to improve uptake. One such way is to investigate if shorter or even single-session versions of longer programs that target prospectively identified eating disorder risk factors can actually have a beneficial effect. A recent trial by Diedrichs and colleagues compared a single 90minute session that was delivered by teachers versus the same content delivered by expert researchers versus a class as usual control group (Diedrichs et al., 2015). Analyses revealed improvements for intervention students in the teacher-delivered group relative to controls at post-program in body esteem, negative affect, dietary restraint, and for both intervention groups for life engagement. This provided evidence that some immediate benefits can be achieved from a single session, leading the authors to conclude that single session interventions might provide a “more acceptable and feasible intervention option in schools” (p. 100) than longer programs. In short, just as we should not take the meta-analytic findings by Stice and Shaw (2004) and Stice and colleagues (2007) to mean that only targeted (and not universal) programs, with females-only (rather than both girls and boys) who are 15-years and older (rather than early or pre-adolescents) are worthy of research attention, we need to reconsider if single session (or brief) programs can be of value. It seems that the universal field has yet to rigorously investigate single session programs that are designed in a way that includes other features associated with larger effect sizes, thus maximizing the likelihood of being efficacious. That is: being interactive in learning content; avoiding psychoeducational content about eating disorders; targeting developmentally-relevant risk factors; and evaluated with validated outcome measures. A single-session intervention that has been well evaluated, shown to have benefits and likely increases and organization's willingness to pursue further content, would be a very valuable, pragmatic tool in the overall pursuit of dissemination of evidence-based interventions.
3. Adding clarity to our science: The importance of accurately articulating what universal programs seek to achieve The terms “body image program” and “eating disorder prevention program” are often used interchangeably in the universal field. To some degree this is not of concern, body image and eating disorders are clearly related and indeed all scientific efforts to develop efficacious programs should be welcomed. But it does provide a hint of a more broad issue: what are our programs seeking to achieve - Improving body image? Reducing eating disorder risk? Preventing eating disorders? Whilst a widely used shorthand phrase, the use of the term “eating disorder prevention” programs in universal settings is still fraught as no universal program has been found to significantly reduce eating disorder onset. This is an issue that Carolyn Black-Becker has recently written about and has helpfully recommended the term “eating disorder risk factor reduction trials” for those RCTs that measure prospectively identified risk factors but not diagnostic criteria (Becker, 2015). This seems a very appropriate recommendation and one that the field would benefit from using.
Also at the core of this discussion are the risk factor targets of our programs. Weight concerns is widely considered the most proximal eating disorder risk factor (Jacobi & Fittig, 2010) after being identified in a number of high quality prospective risk factor studies (e.g., Cooper & Goodyer, 1997; Killen et al., 1996). The concept of weight concerns differs in a subtle but important manner from body image and body dissatisfaction more broadly. Whilst body image could be thought of as one's perception of one's physical body and often includes items such as “I think that my thighs are too large” (Garner, 1991), weight concerns contains a more evaluative component (e.g., “Has your weight influenced how you think about (judge) yourself as a person?”: Fairburn & Beglin, 1994). It has been proposed that body dissatisfaction is heavily influenced by mood and is thus of a more labile nature whilst weight concerns are a more stable construct that includes the value placed on one's body weight and shape to an individual's self-worth (Cooper & Fairburn, 1993). Finally, weight concerns and overvaluation of weight and shape are clinical and diagnostic features of patients with an eating disorder. It is of course clear that poor body image is associated with many negative outcomes such as lower mood, depression, unhealthy weight control practices, disordered eating (Neumark-Sztainer, Paxton, Hannan, Haines, & Story, 2006) and that poor body image conveys suffering in its own right and is thus a worthy target of prevention programs (Wilksch, 2014). However we do need to remember that many people who experience body dissatisfaction will never progress to developing an eating disorder. Cognitive behavioral models would posit that this is due to having sufficient other components to self-worth (e.g., friendships, academic, other interests etc.) that prevent an excessive importance being placed on one's shape and weight despite having moments of not liking aspects of one's body (Fairburn, Cooper, & Shafran, 2003). In essence it seems that this is the message that is seeking to be taught in current efficacious universal programs — that simply there is more to our individual value than our weight and shape and to thus be skeptical of messages that place great importance on these elements (Wilksch & Wade, 2009). Thus whilst all prevention efforts in our field should be encouraged, the universal field is more likely to gain greater scientific traction and thus increased likelihood of wide scale dissemination if a stronger scientific case can be made that our programs reduce the onset of the core features of the illnesses we are seeking to prevent (Wilksch et al., 2015). As such, it would be valuable for all universal programs to include a weight concerns measure, most likely from the EDE-Q (Fairburn & Beglin, 1994), to further improve the clinical relevance of outcomes. This would also allow an investigation of if universal programs can prevent the onset of clinical levels of concern of weight and shape as was the case in a recent RCT at 12-month follow-up (Wilksch et al., 2015). Indeed it would be valuable to take this further and to include all four EDE-Q scales (Restraint, Eating Concern, Shape Concern, Weight Concern) to obtain a Global EDE-Q score as an indicator of disordered eating (Fairburn & Beglin, 1994). Given relevant prospective risk factor research (Jacobi & Fittig, 2010; Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004; Stice, 2002), it would be prudent to also measure negative affect, perceived pressure to be thin (or muscular for boys), media internalization, and, weight-related comments. Whilst body image programs are valuable in their own right, we cannot assume that they are having flow on benefits to key eating disorder risk factors and indeed clinical concerns without measurement of these features. Thus we need both greater clarity in the terminology used to describe our programs, and increased use of clinically relevant outcome measures. 4. How should dissemination occur? Prevention scientists are in a constant tension between pursuing methodologically rigorous scientific research whilst also being well aware of the ‘real world’ limitations in which this work is conducted. Nowhere is this more apparent than in universal, school-based research.
Please cite this article as: Wilksch, S.M., How can we improve dissemination of universal eating disorder risk reduction programs?, Eating Behaviors (2016), http://dx.doi.org/10.1016/j.eatbeh.2016.03.036
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Universal prevention scientists need to find an appropriate balance between quality efficacy research, whilst also not taking years to accrue this (Austin, 2015). We have clear evidence in Australia and other countries that body image is an important issue to school-aged girls and boys (Mission Australia, 2015). Whilst it must be acknowledged that the research support for universal programs is not at the same level as that for targeted prevention programs, we do have an emerging evidence base for two programs (e.g., Espinoza, Penelo, & Raich, 2013; González, Penelo, Gutiérrez, & Raich, 2011; Wilksch et al., 2015; Wilksch & Wade, 2009) with confirmation that these programs 1) have shown significant benefits to participants in more than one study; 2) where the impact was evaluated over a minimum 12-month follow-up period; and 3) there was no evidence of harm. First, a media literacy program from Spain led students to report significantly lower scores on a measure of disordered eating attitudes and behaviors at 2.5-year follow-up (González et al., 2011). Results also showed that, following media literacy training, participants reported greater body satisfaction than was seen in the control group at 2.5year follow-up (Espinoza et al., 2013). An effectiveness RCT was then conducted with program participants experiencing significantly greater reductions in disordered eating attitudes and weight-related teasing at 12-month follow-up (Sánchez-Carracedo et al., 2016). Second, Media Smart (Australia) has been evaluated in two major RCTs, totalling over N = 2000 participants, where girls who received the program had significantly lower shape and weight concern at 2.5year follow-up than controls (Wilksch & Wade, 2009), whilst in the second trial Media Smart girls had half the rate of onset of clinical concerns about shape and weight, as compared to control girls at 12-month follow-up (Wilksch et al., 2015). Significant reductions in a range of other risk factors was also found (e.g., negative affect, weight-related teasing), whilst supplementary moderator analyses found indications of benefits to participants at both high- and low- baseline risk of an eating disorder (Wilksch, 2010; Wilksch & Wade, 2014). Despite promising findings the truth is that by and large these programs are currently not making it into school classrooms on a large scale. What remains a real concern is what is that we know little about what is being taught to students in schools in the absence of these evidence-based programs (Becker, Plasencia, Kilpela, Briggs, & Stewart, 2014). One of the few studies to document how eating disorder prevention is being taught in education settings found that the most common occurrence was: a recovered eating disorder sufferer giving information about eating disorder symptoms with a focus on their personal journey rather than skill building (Mann et al., 1997). In other words, the exact opposite of what we now know to be effective. Whilst this study of US universities was conducted nearly 20 years ago and we would hope that this is managed differently now, the truth is that we don't know what is being done in schools and universities to address body image and eating disorder prevention. This is an extremely concerning as it seems increasingly clear that building skills without raising awareness of body image pressures is the most effective approach in young-early adolescent audiences (Wilksch et al., 2015; Wilksch, in press). We need to give serious thought to how dissemination of effective risk reduction programs could best be achieved. The targeted prevention field has progressed from efficacy trials to effectiveness research to investigate the impact of programs when delivered by peer and other non-specialist presenters under ‘real-world’ conditions (e.g., Stice, Butryn, Rohde, Shaw, & Marti, 2013; Stice, Rohde, Shaw, & Gau, 2011). This is to be commended and does seem a logical next step for the universal field also (Wilksch, 2014) despite only having been tested in limited capacity to date (e.g., Sánchez-Carracedo et al., 2016; Wilksch, 2015). However, given the time required to conduct effectiveness RCTs of teacher-delivered programs as well as previous findings that up to 75% of non-specialist presenters (e.g., school teachers) either omitting core program learning activities or generating their own topics (Levine,
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Smolak, & Schermer, 1996), we do need to have other strategies for dissemination (Becker et al., 2014). As discussed above, brief programs that can be delivered by experts are one option (Diedrichs et al., 2015). It also seems likely that some schools prefer even multiple session programs to be delivered by external providers (Richardson, Paxton, & Thomson, 2009). This will likely require partnerships between prevention scientists who have developed efficacious programs and commercial or government organizations. However the value of having efficacious programs delivered in their entirety by specialist presenters avoids the risk of a diluted, less effective program experience for participants. Whilst a less scalable approach, it is likely to be more efficacious, particularly for children and young-adolescent audiences where we know there is a real nuance required in the presenter to build skills in participants without increasing awareness of appearance pressures (Diedrichs et al., 2015). Finally, is the question of whether there can be a role for the internet in universal program delivery? This is another direction the targeted eating disorder prevention field is taking with both established online programs (Taylor et al., 2006) and trialing adapted versions of efficacious group programs into an online format (Stice, Durant, Rohde, & Shaw, 2014). Whilst there has been one online program with preadolescent girls and boys that targeted pubertal development and body dissatisfaction (Cousineau et al., 2010), to date online delivery is largely unexplored in universal, young-adolescent audiences. Whilst of course the internet is such a key form of media and appearancebased pressures to young people that development of effective programs for this audience is important, it is also more complex given that such an online program would require much more active engagement by the young person compared to receiving a program in a classroom setting as part of usual schooling. Further, a key feature of efficacious universal programs does appear to be the interactive learning content involving working with peers (Stice et al., 2007; Wilksch, in press). It is unlikely this could be so readily achieved in an online setting. A better option might be for classroom-based programs to include a greater focus on online content when developing media literacy skills. 5. Closing The universal eating disorder risk reduction field is continuing to advance and there have been many valuable steps forward in recent years (e.g., Diedrichs et al., 2015; Fairweather-Schmidt & Wade, 2015; González et al., 2011; Hart et al., 2014; Richardson & Paxton, 2010; Wilksch et al., 2015). Whilst the field needs to continue with quality scientific output (Wilksch, 2014), we also need greater attention towards dissemination of programs with an evidence-base (Austin, 2015). Strategies including investigating shorter programs, developing a clearer case for prevention of core eating disorder features and weighing up effectiveness research versus specialist program delivery on a broad scale are all likely to help. In the end, the main aim of our research is to benefit as many young people as possible. We thus must give greater attention to how this can be achieved. References Austin, S. B. (2015). Accelerating progress in eating disorders prevention: A call for policy translation research and training. Eating Disorders, 1–14. Becker, C. B. (2015). Our critics might have valid concerns: Reducing our propensity to conflate. Eating Disorders, 1–11. Becker, C. B., Plasencia, M., Kilpela, L. S., Briggs, M., & Stewart, T. (2014). Changing the course of comorbid eating disorders and depression: What is the role of public health interventions in targeting shared risk factors? Journal of Eating Disorders, 2, 15. Brownson, R. C., Colditz, G. A., & Proctor, E. K. (2012). Dissemination and implementation research in health: translating science to practice. Oxford University Press. Cooper, P. J., & Fairburn, C. G. (1993). Confusion over the core psychopathology of bulimia nervosa. International Journal of Eating Disorders, 13, 385–389. Cooper, P. J., & Goodyer, I. (1997). Prevalence and significance of weight and shape concerns in girls aged 11–16 years. British Journal of Psychiatry, 171, 542–544. Cousineau, T. M., Franko, D. L., Trant, M., Rancourt, D., Ainscough, J., et al. (2010). Teaching adolescents about changing bodies: Randomized controlled trial of an internet puberty education and body dissatisfaction prevention program. Body Image, 7, 296–300.
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Please cite this article as: Wilksch, S.M., How can we improve dissemination of universal eating disorder risk reduction programs?, Eating Behaviors (2016), http://dx.doi.org/10.1016/j.eatbeh.2016.03.036