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. 2002;2002(2):CD002891.
doi: 10.1002/14651858.CD002891.

Interventions for preventing eating disorders in children and adolescents

B M Pratt  1 , S R Woolfenden
Affiliations

Interventions for preventing eating disorders in children and adolescents

B M Pratt et al. Cochrane Database Syst Rev. 2002.

Abstract

Background: Eating disorders represent an extremely difficult condition to treat and patients consume an enormous amount of mental health energy and resources. Being young, female, and dieting are some of the few identified risk factors that have been reliably linked to the development of eating disorders, and several prevention eating disorder prevention programs have been developed and trialed with children and adolescents. The purpose of this systematic review is to evaluate the effectiveness of eating disorder prevention programs for children and adolescents both in the general population and those determined to be at risk.

Objectives: 1. To determine if eating disorder prevention programs are effective in promoting healthy eating attitudes and behaviours in children and adolescents; 2. To determine if eating disorder prevention programs are effective in promoting psychological factors that protect children and adolescents from developing eating disorders; 3. To determine if eating disorder prevention programs are effective in promoting satisfactory physical health in children and adolescents; 4. To determine if eating disorder prevention programs have a long-term, sustainable, and positive impact on the mental and physical health of children and adolescents; and, 5. To determine the safety of eating disorder prevention programs in terms of possible harmful consequences on the mental or physical health of children and adolescents.

Search strategy: Relevant trials are identified through searching the Cochrane Controlled Trial Register (CCTR) and relevant biomedical and social science databases. All terms necessary to detect prevention programs and the participant groups are used. A strategy to locate randomised controlled trials is used. Other sources of information are the bibliographies of systematic and non-systematic reviews and reference lists from articles identified through the search strategy. In order to identify unpublished studies, experts in the field are contacted by letter and/or electronic mail.

Selection criteria: Randomised controlled trials (RCT) with a major focus on eating disorder prevention programs for children and adolescents, where there is no known DSM-IV diagnosis of an eating disorder, are eligible for inclusion in the review. Trials must include a control group and at least one objective outcome measure (eg. BMI) or a standardised psychological measure used with the intervention and control group, pre- and post-intervention.

Data collection and analysis: A total of 1379 titles have been identified through the search to date. 13 studies were located that reported use of a randomised controlled trial methodology and were critically appraised by two independent reviewers. Five (5) studies were excluded as data were not reported in a useable form or useable data could not be obtained from the trial authors, one dissertation could not be obtained, one study had no "true" no-treatment or usual treatment control group, and one study did not use a pre-test outcome measure. Eight (8) studies met the selection criteria outlined above.

Main results: Only one of eight pooled comparisons of two or more studies using similar outcome measures and similar intervention types demonstrated the statistically significant effect of a particular type of eating disorder prevention program for children and adolescents. Combined data from two eating disorder prevention programs based on a media literacy and advocacy approach indicate a reduction in the internalisation or acceptance of societal ideals relating to appearance at a 3- to 6-month follow-up (Kusel, unpublished; Neumark-Sztainer2000) [SMD -0.28, -0.51 to -0.05, 95% CI]. However, there is insufficient evidence to conclude that this approach also demonstrated a significant impact on awareness of societal standards relating to appearance. There is insufficient evidence to support the effect of four programs designed to address eating attitudes and behaviours and other adolescent issues on body weight, eating disorder symptoms, associated eating disorder psychopathology or general psychological and physical well-being in the general sample or those classified as being at high risk for eating disorder (Buddeberg-F 1998; Killen 1993/1996; Santonastaso 1999; Zanetti 1999). Given only one program used a psychoeducation approach to prevent bulimia nervosa (Jerome, unpublished) and only one program adopted a focus on self-esteem (O'Dea 2000), the effect of these approaches could not be evaluated via meta-analyses. In relation to potential harmful effects, there is not sufficient evidence to suggest that harm resulted from any of the prevention programs included in the review.

Reviewer's conclusions: The one significant pooled effect in the current review does not allow for any firm conclusions to be made about the impact of prevention programs for eating disorders in children and adolescents, although none of the pooled comparisons indicated evidence of harm. From a clinical perspective, the development and refinement of prevention programs is complicated by a lack of knowledge about risk factors associated with eating disorders and the need to strike a balance between delivering preventive interventions for eating disorders and considering the potential to cause harm. From a research perspective, the idea of "thresholds" for identifying young people at risk of developing eating disorders has been raised, and denial of concern or denial of illness represents a further issue complicating early identification in relation to eating disorder symptomatology. Longer-term effects of the intervention approaches will need to be monitored across development in order to demonstrate a decline in the incidence of eating disorders and associated risk factors.

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Conflict of interest statement

None.

Figures

1.1
1.1. Analysis
Comparison 1 "Eating Attitudes/Behaviours & Adolescent Issues" approach (5 studies), Outcome 1 Body Mass Index (BMI) at 12‐ to 14‐month follow up.
1.2
1.2. Analysis
Comparison 1 "Eating Attitudes/Behaviours & Adolescent Issues" approach (5 studies), Outcome 2 Body Mass Index (BMI) (hi‐risk) at 12‐ to 14‐month follow up.
1.3
1.3. Analysis
Comparison 1 "Eating Attitudes/Behaviours & Adolescent Issues" approach (5 studies), Outcome 3 Eating Attitudes Test (EAT) Total at 6‐ to 12‐month follow‐up.
1.4
1.4. Analysis
Comparison 1 "Eating Attitudes/Behaviours & Adolescent Issues" approach (5 studies), Outcome 4 Eating Attitudes Test (EAT) Total (high‐risk) at 6‐ to 12‐month follow‐up.
1.5
1.5. Analysis
Comparison 1 "Eating Attitudes/Behaviours & Adolescent Issues" approach (5 studies), Outcome 5 Eating Disorder Inventory (EDI) "Bulimia" at 12‐ to 14‐month follow‐up.
1.6
1.6. Analysis
Comparison 1 "Eating Attitudes/Behaviours & Adolescent Issues" approach (5 studies), Outcome 6 Eating Disorder Inventory (EDI) (hi‐risk) "Bulimia" at 12‐ to 14‐month follow‐up.
2.1
2.1. Analysis
Comparison 2 "Media Literacy & Advocacy" approach (3 studies), Outcome 1 Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ) "Awareness" at 3‐month follow‐up.
2.2
2.2. Analysis
Comparison 2 "Media Literacy & Advocacy" approach (3 studies), Outcome 2 Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ) "Internalization" at 3‐month follow‐up.
2.3
2.3. Analysis
Comparison 2 "Media Literacy & Advocacy" approach (3 studies), Outcome 3 Social Perception Profile (SPA & SPPC) "Global Self Worth" at 3‐month follow‐up.
2.4
2.4. Analysis
Comparison 2 "Media Literacy & Advocacy" approach (3 studies), Outcome 4 Body Image Assessment (BIA: Silhouettes) at 3‐months.
3.1
3.1. Analysis
Comparison 3 "Self‐esteem" approach (2 studies), Outcome 1 Social Perception Profile (SPA) "Close Friendships" at 3‐month follow‐up.
3.2
3.2. Analysis
Comparison 3 "Self‐esteem" approach (2 studies), Outcome 2 Social Perception Profile (SPA) "Social Acceptance" at 3‐month follow‐up.
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References

References to studies included in this review

Buddeberg* 1998 {published and unpublished data}
    1. Buddeberg‐Fischer B, Klaghofer R, Gnam G, Buddeberg C. Prevention of disturbed eating behaviour: A prospective intervention study in 14‐ to 19‐year‐old Swiss students. Acta Psychiatrica Scandanavica 1998;98(2):146‐55. - PubMed
Dalle Grave 2001 {published and unpublished data}
    1. Dalle Grave R, Luca L, Campello G. Middle school primary prevention program for eating disorders: A controlled study with a twelve‐month follow‐up. Eating Disorders 2001;9:327‐337. - PubMed
Jerome 1991 {unpublished data only}
    1. Jerome lW. Primary intervention for bulimia: The evaluation of a media presentation for an adolescent population. Dissertation Abstracts International B: The Sciences & Engineering 1991;52(6‐B):3296.
Killen 1993 {published data only}
    1. Killen JD. Development and evaluation of a school‐based eating disorder symptoms prevention program. In: Smolak L, Levine MP, Striegel‐Moore R editor(s). The developmental psychopathology of eating disorders: Implication for research, prevention and treatment. Mahwah, NJ: Lawrence Erlbaum & Associates, 1996.
    1. Killen JD, Taylor CB, Hammer LD, Litt I, Wilson DM, Rich T, et al. An attempt to modify unhealthful eating attitudes and weight regulation practices of young adolescent girls. International Journal of Eating Disorders 1993;13(4):369‐84. - PubMed
Kusel 1999 {unpublished data only}
    1. Kusel AB. Primary prevention of eating disorders through media literacy training of girls. Dissertation Abstracts International B: The Sciences & Engineering 1999;60(4‐B):1859.
Neumark* 2000 {published and unpublished data}
    1. Neumark‐Sztainer D, Sherwood N, Coller T, Hannan P. Primary prevention of disordered eating among preadolescent girls: Feasibility and short‐term effect of a community‐based intervention. Journal of the American Dietetic Association 2000;100(12):1466‐73. - PubMed
O'Dea 2000 {published and unpublished data}
    1. O'Dea JA, Abraham S. Improving the body image, eating attitudes and behaviors of young male and female adolescents: A new educational approach which focuses on self‐esteem. International Journal of Eating Disorders 2000;28(1):43‐57. - PubMed
Olmsted 2002 {published data only}
    1. Olmsted MP, Daneman D, Rydall AC, Lawson ML, Rodin G. The effects of psychoeducation on disturbed eating attitudes and behavior in young women with Type 1 Diabetes Mellitus. International Journal of Eating Disorders 2002;32:230‐239. - PubMed
Santonastaso 1999 {published data only}
    1. Santonastaso P, Zanetti T, Ferrara S, Olivotto MC, Magnavita N, Favaro A. A preventive intervention program in adolescent schoolgirls: A longitudinal study. Psychotherapy & Psychosomatics 1999;68(1):46‐50. - PubMed
Stice 2003 {published data only}
    1. Stice E, Trost A, Chase A. Healthy weight control and dissonance‐based eating disorder prevention programs: Results from a controlled trial. International Journal of Eating Disorders 2003;33(10‐21). - PubMed
Wade 2003 {published and unpublished data}
    1. Wade TD, Davidson S, O'Dea JA. A preliminary controlled evaluation of a school‐based media literacy program and self‐esteem program for reducing eating disorder risk factors. International Journal of Eating Disorders 2003;33:371‐383. - PubMed
Zanetti 1999 {unpublished data only}
    1. Zanetti T, Ferrara S, Favaro A, Santonastaso P. Teaching teachers prevention interventions. European Council on Eating Disorders, Stockholm, 15‐17 September. 1999:19.

References to studies excluded from this review

Abascal 2003 {published data only}
    1. Abascal L, Bruning Brown J, Winzelberg AJ, Dev P, Barr Taylor C. Combining universal and targeted intervention for school‐based eating disorder programs. International Journal of Eating Disorders 2004;35:1‐9. - PubMed
Ghaderi 2003A {published data only}
    1. Ghaderi A, Scott B. Pure and guided self‐help for full and sub‐threshold bulimia nervosa and binge eating disorder. British Journal of Clinical Psychology 2003;42(3):257‐269. - PubMed
Heinze 2000 {published data only}
    1. Heinze V, Wertheim EH, Kashima Y. An evaluation of the importance of message source and age of recipient in a primary prevention program for eating disorders. Eating Disorders: The Journal of Treatment & Prevention 2000;8(2):131‐45.
McVey 2002 {published data only}
    1. McVey GL, Davis R. A program to promote positive body image: A 1 year follow‐up evaluation. Journal of Early Adolescence 2002;22(1):96‐108.
McVey 2004 {published data only}
    1. McVey GL, Davis R, Tweed S, Shaw BF. Evaluation of a school‐based program designed to improve body image satisfaction, global self‐esteem, and eating attitudes and behaviors: A replication study. International Journal of Eating Disorders 2004;36:1‐11. - PubMed
McVey submitted {unpublished data only}
    1. McVey GL, Davis R, Tweed S, Shaw BF. Parental involvement in the prevention of eating disorders: Findings from a 1‐year evaluation study. Eating Behaviors (submitted for publication).
Neumark* 1995 {published data only}
    1. Neumark‐Sztainer D, Butler R, Palti H. Eating disturbances among adolescent girls: Evaluation of a school‐based primary prevention program. Journal of Nutrition Education 1995;27(1):24‐31.
Phelps 2000 {published and unpublished data}
    1. Phelps L, Sapia J, Nathanson D, Nelson L. An empirically supported eating disorder prevention program. Psychology in the Schools (Special Issue: Empirically validated interventions in school psychology) 2000;37(5):443‐52.
Rosen 1989 {published and unpublished data}
    1. Rosen JC. Prevention of eating disorders. National Anorexic Aid Society Newsletter 1989;Apr‐Jun:1‐3.
Steiner‐Adair 2002 {published data only}
    1. Steiner‐Adair C, Sjostrom L, Franko DL, Pai S, Tucker R, Becker AE, Herzog DB. Primary prevention of risk factors for eating disorders in adolescent girls: Learning from practice. International Journal of Eating Disorders 2002;32:410‐411. - PubMed

Additional references

APA 1994
    1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV). 4th Edition. Washington, DC: American Psychiatric Association, 1994.
Baranowski 2001
    1. Baranowski MJ, Hetherington MM. Testing the efficacy of an eating disorder prevention program. International Journal of Eating Disorders 2001;29(2):119‐24. - PubMed
Ben‐Tovim 1990
    1. Ben‐Tovim DI, Morton J. The epidemiology of anorexia nervosa in South Australia. Australian & New Zealand Journal of Psychiatry 1990;24(2):182‐6. - PubMed
Campbell 2002
    1. Campbell K, Waters E, O'Meara S, Summerbell C. Interventions for preventing obesity in children. The Cochrane Library 2002, Issue 1.
Carter 1997
    1. Carter JC, Stewart DA, Dunn VJ, Fairburn CG. Primary prevention of eating disorders: Might it do more harm than good?. International Journal of Eating Disorders 1997;22(2):167‐72. - PubMed
Dalle Grave 2003
    1. Dalle Grave R. School‐based prevention programs for eating disorders: Achievements and opportunities. Dis Manage Health Outcomes 2003;11(9):579‐593.
Emans 2000
    1. Emans SJ. Eating disorders in adolescent girls. Pediatrics International 2000;42(1):1‐7. - PubMed
Fairburn 1997
    1. Fairburn CG, Welch SL, Doll HA, Davies BA, O'Connor ME. Risk factors for bulimia nervosa: A community‐based case‐control study. Archives of General Psychiatry 1997;54(6):509‐17. - PubMed
Fairburn 1999
    1. Fairburn CG, Cooper Z, Doll HA, Welch SL. Risk factors for anorexia nervosa: Three integrated case‐control comparisons. Archives of General Psychiatry 1999;56(5):468‐76. - PubMed
Friedman 1996
    1. Friedman SS. Girls in the 90's. Eating disorders: The Journal of Treatment & Prevention 1996;4(3):238‐44.
Friedman 1998
    1. Friedman SS. Girls in the 90s: A gender‐based model for eating disorder prevention. Patient Education & Counseling 1998;33(3):217‐24. - PubMed
Garner 1991
    1. Garner DM. The Eating Disorder Inventory (EDI‐2). 2nd Edition. Psychological Assessment Resources, 1991.
Ghaderi 2003B
    1. Ghaderi A. Structural modeling analysis of prospective risk factors for eating disorder. Eating Behaviors 2003;3:387‐396. - PubMed
Gresko 1998
    1. Gresko RB, Rosenvinge JH. The Norwegian school‐based prevention model: Development and evaluation. In: Vandereycken W, Noordenbos G editor(s). The prevention of eating disorders. London: Athlone Press, 1998:75‐98.
Grigg 1996
    1. Grigg M, Bowman J, Redman S. Disordered eating and unhealthy weight reduction practices among adolescent females. Preventive Medicine 1996;25(6):748‐56. - PubMed
Huon 1997
    1. Huon GF, Roncolato WG, Ritchie JE, Braganza C. Prevention of dieting‐induced disorders: Findings and implications of a pilot study. Eating disorders: The Journal of Treatment & Prevention 1997;5(4):280‐93.
Lucas 1991
    1. Lucas AR, Beard CM, O'Fallon WM, Kurland LT. 50‐year trends in the incidence of anorexia nervosa in Rochester, Minn.: A population‐based study. American Journal of Psychiatry 1991;148(7):917‐22. - PubMed
Maloney 1989
    1. Maloney MJ, McGuire J, Daniels SR, Specker B. Dieting behavior and eating attitudes in children. Pediatrics 1989;84(3):482‐9. - PubMed
Mathers 2000
    1. Mathers CD, Vos ET, Stevenson CE, Begg SJ. The Australian burden of disease study: Measuring the loss of health from diseases, injuries and risk factors. Medical Journal of Australia 2000;172(12):592‐6. - PubMed
Neumark 2000
    1. Neumark‐Sztainer D, Hannan PJ. Weight‐related behaviors among adolescent girls and boys: Results from a national survey. Archives of Pediatrics & Adolescent Medicine 2000;154(6):569‐77. - PubMed
Patton 1999
    1. Patton GC, Selzer R, Coffey C, Carlin JB, Wolfe R. Onset of adolescent eating disorders: Population based cohort study over 3 years. BMJ 1999;318(7186):765‐8. - PMC - PubMed
Piran 1995
    1. Piran N. Prevention: Can early lessons lead to a delineation of an alternative model? A critical look at prevention with school children. Eating disorders:The Journal of Treatment & Prevention 1995;3(1):28‐36.
Piran 1996
    1. Piran N. The reduction of preoccupation with body weight and shape in schools: A feminist approach. Eating Disorders: The Journal of Treatment & Prevention 1996;4(4):323‐33.
Rosenvinge 1997
    1. Rosenvinge JH, Gresko RB. Do we need a prevention model for eating disorders? Recent developments in the Norwegian school‐based prevention model. Eating disorders: The Journal of Treatment & Prevention 1997;5(2):110‐8.
Shisslak 1998
    1. Shisslak CM, Crago M, Renger R, Clark‐Wagner A. Self‐esteem and the prevention of eating disorders. Eating disorders: The Journal of Treatment & Prevention 1998;6(2):105‐18.
Smolak 1998
    1. Smolak L, Levine MP, Schermer F. A controlled evaluation of an elementary school primary prevention program for eating problems. Journal of Psychosomatic Research 1998;44(3‐4):339‐53. - PubMed
Stewart 2001
    1. Stewart A, Carter JC, Drinkwater J, Hainsworth J, Fairburn CG. Modification of eating attitudes and behavior in adolescent girls: A controlled study. International Journal of Eating Disorders 2001;29(2):107‐18. - PubMed
Stice 2004
    1. Stice E, Shaw H. Eating disorder prevention programs: A meta‐analytic review. Psychological Bulletin 2004;130(2):206‐227. - PubMed
Striegel‐Moore 1997
    1. Striegel‐Moore RH. Risk factors for eating disorders. In: Jacobson MS, Rees JM, et al. editor(s). Adolescent nutritional disorders: Prevention and treatment. New York, NY: New York Academy of Sciences, 1997:98‐109. - PubMed
Szmukler 1986
    1. Szmukler G, McCance C, McCrone L, Hunter D. Anorexia nervosa: A psychiatric case register study from Aberdeen. Psychological Medicine 1986;16(1):49‐58. - PubMed
Turnbull 1996
    1. Turnbull S, Ward A, Treasure J, Jick H, Derby L. The demand for eating disorder care: An epidemiological study using the General Practice Research Database. British Journal of Psychiatry 1996;169:705‐712. - PubMed

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