Preventing a Continuum
of Disordered Eating:
Going Beyond the Individual
By Shelly Russell-Mayhew, Ph.D., R. Psych.
E
ating disorders are not just about food. Rather, they are complex
mental disorders as defined by the American Psychiatric
Association (APA, 1994). While full diagnosis is rare, the attitudes
and behaviors that lead up to them are common and in some
instances (such as with excessive exercise) even encouraged and
rewarded. As such, the context in which these disorders develop
needs consideration and eating disorder prevention and intervention
efforts need to promote not only healthy eating and physical activity
but also address mental health factors, such as body image.
When we have a narrow view of eating disorders (“why don’t they
just eat?”), we miss the intricacies of people’s relationships with
their bodies. It is not just people with eating disorders who struggle
with what to eat, when to eat, and how much to eat. In fact, it is a
Western cultural pastime to talk about, think about, and obsess
about how our bodies look and what we can do or not do to change
them (Choate, 2005). For women, the beauty ideal is an impossibly
thin figure with large breasts while for men it is a muscular, lean
body with six-pack abs. The quest for the ‘perfect’ body is seen as
a virtuous goal…until it goes too far. So, how does an adolescent
in this kind of environment balance on the precipice of a slippery
slope that starts off with the intent to eat healthier and be active
but then quickly moves to more extreme behaviors that lead to
disordered eating? Conversely, and perhaps more importantly,
given this context, how is it that some youth remain virtually
untouched by body image issues?
This article will examine the relationship between body image and
eating disorders to further our understanding of the continuum
of attitudes and behaviors that lead to disordered eating. To build
on the current status of eating disorder prevention, practical
strategies focusing on both individual and environmental change
will be discussed.
BRIDGE: A Framework for Understanding
“BRIDGE”: Building the Relationship between Body Image and
Disordered Eating Graph (see Figure 2.1) describes the connection
between the attitudes we hold about our bodies and the corresponding
behaviors we practice.1
Attitudes & Feelings
The horizontal axis signifies attitudes and feelings about our bodies
in a continuum that ranges from healthy to unhealthy. Body image
at its simplest is defined as the mental picture you have of your
physical appearance and the attitudes and feelings you have towards
it. Kashubeck-West and Saunders (2001) suggest that body image
should be understood from a multidimensional perspective which
includes perceptual, subjective, and behavioral components. Cash
(2004) defines body image as “the multifaceted psychological
experience of embodiment, especially but not exclusively one’s
1
The original conceptualization of BRIDGE can be found in the journal Eating
Disorders (Russell & Ryder, 2001a&b).
www.TPRonline.org
physical appearance”
(p. 1). With this
broader definition, it is clear that body image is not a singular event
but rather changes throughout time and ranges along a continuum.
Behaviors
The vertical axis contains a range of behaviors. Healthy behaviors
are nearest the intersect point and become increasingly unhealthy
as you move upward. These behaviors include:
Activity: broader than exercise, activity refers to an active lifestyle
where small changes lead to increased activity levels. Examples of
this would be taking the stairs instead of the elevator or choosing
to go dancing instead of renting a video.
Healthy eating: eating a wide variety of foods, eating when you
are hungry and stopping when you are full, and knowing that
there are no ‘good’ foods or ‘bad’ foods.
Restrictive eating/overeating: Restrictive eating refers to
limiting food and/or calorie intake (dieting) with the intention
of controlling body
It is a Western cultural pastime size. Overeating
when natural
to talk about, think about, and occurs
cues of hunger and
obsess about how our bodies
fullness are ignored
and food consumption
look and what we can do or
exceeds the body’s
not do to change them.
needs, it is often used
as a coping strategy.
Binging: eating a large quantity of food in a short period of time;
sometimes associated with feelings of being out of control (APA,
1994). Binging is often a physiological response to restrictive
eating behaviors (Bloom et al., 1999) and is placed on the graph
directly above restricting behaviors as it is often a natural
consequence of deprivation.
Compulsive exercise: when the primary motivation for exercising
is to control or manipulate body size. Exercise is an obligation
not a choice toward health.
Disordered eating: when a number of unhealthy behaviors related
to eating and exercise coincide. Examples of this include the use
of steroids to increase muscle mass, tobacco use for weight loss
or control, and occasional binging, purging, or fasting behaviors.
Binge eating disorder: eating enormous amounts of food in short
periods of time with no compensatory behaviors. Binges are
associated with feelings of disgust, shame, and lack of control due
in part to the frequency and intensity of the episodes (APA, 1994).
Bulimia nervosa: an eating disorder characterized by frequent
binge eating episodes, followed by compensatory behaviors such
as vomiting, over-exercising, or laxative and/or diuretic use
(APA, 1994). A person with bulimia is preoccupied with body
shape and weight.
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Preventing a Continuum of Disordered Eating: Going Beyond the Individual
Anorexia nervosa: an eating disorder in which food intake is so
severely limited that a person does not meet minimum weight
requirements for height and age (APA, 1994). People with anorexia
nervosa fear fat and the perception of their own body size is so
distorted that it is difficult for them to recognize the seriousness
of their condition.
The 3 Circles: The Relationship Between
Attitudes and Behaviors
The circles represent the intersect points on the graph and bring
knowledge, attitude, and behaviors together on a continuum from
healthy (body awareness) to unhealthy (body paralysis).
Body awareness and acceptance: an area bound by healthy
attitudes and healthy behaviors. There is an overall acceptance
of our bodies and an understanding that how we look is only one
part of who we are.
Body preoccupation: an over-concern with our bodies, particularly
around weight and shape. There are a number of factors that
contribute to a preoccupation with our bodies, including the beauty
ideals of thinness and/or muscularity. A related factor is the
damaging myths about what it means to be fat in our culture
(Herndon, 2002). Of course, a certain amount of body preoccupation
during puberty is normal. It is not uncommon for body image to
become an issue during adolescence since all of the physiological
changes which happen during this developmental phase are a lot
to manage. However, when youth start to experiment with
dangerous behaviors like dieting, it is important to intervene.
Body paralysis: associated with the unhealthiest attitudes, body
paralysis is the experience of being immobilized by how we feel
about and take care of our bodies. It develops when controlling
the body becomes the primary focus in life. It consumes so much
time and energy that it takes priority over everything else. In its
extreme, people with body paralysis restrict their activities and
their quality of life suffers.
Most people can relate to all three ovals represented in the graph
at certain times in their lives and do not develop eating disorders.
In fact, we might imagine that these ovals “accordion” in and out
from healthy to the extremely unhealthy. Diagnosable eating
disorders are rare but the behaviors that can lead to them are not.
Eating Disorder Prevention
Population-based studies have documented disordered eating
(such as using diet pills or vomiting) among 26% of
female and 10% of male high school students (FormanFigure 2.1
Hoffman, 2004). Neumark-Sztainer and colleagues
BRIDGE Graph
(2002) found 46% of adolescent girls reported body
dissatisfaction and 57% had engaged in unhealthy
weight loss behaviors within the past year. Boys are
The Relationship Between
also dissatisfied with their bodies and increasingly at
levels comparable with girls if muscularity is considered
&
(McCabe & Ricciardelli, 2004). So while diagnosable
eating disorders are rare, the spectrum of body-imageAnorexia
Nervosa
related concerns from negative body image to disordered
BODY
PARALYSIS
Bulimia
eating are common in adolescence and need to be
Nervosa
addressed through prevention efforts. Recent reviews
Binge Eating
of the state of eating disorder prevention make a number
Disorder
of recommendations (Neumark-Sztainer et al., 2006);
three are described below.
Disordered
Eating
Environmental Approaches
A recent, systematic review on interventions for
Compulsive
preventing eating disorders in children and adolescents
Exercise
reported on 12 randomized controlled studies involving
BODY
PREOCCUPATION
samples with no known eating disorder diagnosis (Pratt
Binging
& Woolfenden, 2006). All 12 interventions targeted the
individual. Examples included promotion of healthy
eating and training in media literacy. However, it is
Restrictive
Eating/
becoming increasingly clear that sociocultural variables
Overeating
like media messages and peer teasing contribute to the
development of body-image issues (Neumark-Sztainer
et al., 2006). Thus, current recommendations from
Healthy Eating
BODY AWARENESS
experts include focusing on environmental approaches
& ACCEPTANCE
that reach beyond the individual and include interventions
Activity
like modifying food options in schools, changing
advertising at fitness centers to focus on wellness not
weight loss, and exposure to role models with diverse
body sizes and shapes. Table 2.1 presents examples of
Attitudes & Feelings
UNHEALTHY
HEALTHY
KNOWLEDGE
individual and environmental approaches to eating
About Our Bodies
disorder prevention.
Wellness Not Illness
Not to be reproduced without written consent of the author. © 1999, Shelly Russell in collaboration with Sabine Ryder.
Experts in the eating disorder field recommend
HEALTHY
Behaviors
UNHEALTHY
Body Image
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September 2007 • Volume 14(3) • The Prevention Researcher
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Table 2.1
Broad and Specific Topics for Eating Disorder Prevention
Broader
Protective Factors
Examples of Illness-Specific Topics
Individual Focus
Environmental Focus
Appreciate all body sizes and shapes, recognizing that we are more
than our appearance. It is not only about having a healthy body,
but also having a healthy attitude and accepting who we are.
Create an environment of ‘belonging.’ For example, a
school where students are cherished and want to attend.
Critique media messages around gender, body size, and shape.
For example, examining attitudes and beliefs toward obesity and
the thin ideal.
Support media campaigns that use regular models (i.e., Spain
banishing the use of ultra-thin models) and focus on aspects
other than outer beauty (e.g., DOVE campaign for real beauty).
Write letters to discourage offensive marketing. Support
policies that limit youth’s exposure to advertising about
food products.
Educate about the dangers of trying to change one’s body through
dieting or other behaviors, like steroid use.
Change food policy in schools. Advocate and lobby for
healthy options at fast food restaurants. Work with food
manufacturers and distributors.
Understand the dangers of compulsive exercise. Encourage
participation in life-long activities and sport that is not only
about competition.
Encourage fitness centers to be holistic and health focused.
Petition for pedestrian-friendly communities (i.e., sidewalks).
Promote acceptance of self and others in terms of body size and
appearance. Provide students with basic skills that promote healthy
relationships (‘I’ statements, eye contact, assertiveness).
Create positive peer and family networks for youth. Model
working collaboratively with others so students can witness
the sum being greater than the parts. Build community
partnerships.
Tolerance
Acceptance of other people’s bodies and physical abilities (e.g., the
belief that bodies can be healthy at any size, the inappropriateness
of weight-related teasing or comments). Recognize that jokes and
put-downs about bodies are a form of harassment.
Hire diverse body shapes and sizes. Give equal opportunity
regardless of weight, size, shape, or physical attractiveness.
Create a culture where differences are acknowledged and
celebrated and are seen as a contribution and strength.
Emotional Health/
Coping and
Communication
Skills
Identify and appropriately deal with feelings. Decode ‘fat’ and ‘diet’
talk, for example, “I feel fat” or “I need to go on a diet” is a ‘teachable
moment’ and an opportunity to explore what feelings are being
inappropriately attributed to the body. Attempts to change the
body will not resolve the negative feeling.
Create policies and reward/compensation systems that focus
on life balance (i.e., find balance between extracurricular
sport, clubs, and academic pursuits).
Puberty Changes/
Normal
Developmental
Stages
Understand how pubertal changes, body types, genetics, and
metabolism affect our bodies. Prepare and normalize tweens for
physiological changes.
Recognize, limit and advocate against age-inappropriate
exposure to ideas and images.
Problem-Solving
and Decision-Making
Skills
Strategize about how to counteract the impact of the messages
(implicit and explicit) around food, bodies, and size promoted by
family, friends, school environments, and the larger culture.
Encourage social awareness and responsibility. Help youth
to find meaning in helping others so that the focus is not on
changing one’s own body or weight but rather enhancing
the lives of others.
Self-Esteem
Critical Thinking/
Analysis Skills
Healthy Eating
Physical Activity
Healthy
Relationships/
Interpersonal Skills
avoiding: 1) a focus on eating disorder signs and symptoms
(O’Dea, 2004); and 2) detailed descriptions of ‘recovery’ from an
eating disorder for fear of teaching disordered eating behaviors or
glamorizing these serious illnesses (Russell & Ryder, 2001b).
Rather, the consensus from a review of the eating disorder
prevention literature over the past 20 years (Neumark-Sztainer et
al., 2006) suggests combining a focus on broad protective factors,
such as self-esteem and communication skills, with illnessspecific risk factors, such as weight-related teasing and the dangers
of dieting (See Table 2.1 for a list of topics). Overall, discussions
about healthy attitudes and behaviors should dominate over those
about illness and disorder.
www.TPRonline.org
Stakeholders
In eating disorder prevention programs, a participatory approach
is encouraged in which all stakeholders (for example, adolescents,
parents, teachers, families, counselors, policy-makers, and food
distribution companies) are invested in changes that create a
positive environment for every ‘body.’ For example, a one-time
wellness-based eating disorder prevention program with students,
which has in the past shown to be minimally effective may be more
effective in changing attitudes and behaviors when teachers and
parents are involved (Russell-Mayhew, Arthur, & Ewashen, 2007).
When you involve all people (even those without body image
issues) and collaborate with industries (like fashion and fast food),
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Preventing a Continuum of Disordered Eating: Going Beyond the Individual
there is potential to positively impact everyone involved as well as
change the environment.
Conclusion
Without recognizing that body-image issues are socially constructed
and maintained, prevention efforts will likely fall short because we
need to look at transforming the system that created the problems
in the first place (Speight & Vera, 2004). Body image issues and
eating disorders shift our attention from the social conditions that
produce them, to the individual that carries the weight (literally)
of our social plight (O’Neill, 2004). Prevention and intervention
efforts need to be connected to the systemic roots that determine
people’s relationships with food and their bodies. The larger issue
is social responsibility in a context where there is little relief from
the pressures around weight and body shape, whether these pressures
lead to the development of eating disorders or not. Professionals
working with adolescents are in a prime position to commit to the
prevention of body image issues. This can be as simple as inviting
discussion about these issues by hanging up a poster in your office
to using tools like the Body Image Kits (www.bodyimageworks.com)
to facilitate body image discussions within a school setting. a
Shelly Russell-Mayhew, Ph.D., R. Psych, Assistant Professor, Division of Applied
Psychology, Faculty of Education, University of Calgary. Shelly’s research
interests center around the prevention of weight-related issues. Current projects
include the development and evaluation of health promotion resources for
schools; exploring the connection between eating disorders and social justice;
determining mental health factors in the prevention of obesity; studying the
interprofessional collaborations within an obesity network and examinations
of media messages around food and appearance.
Copyright © 2007, Integrated Research Services, Inc.
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Cash, T.F. (2004). Body image: Past, present, and future. Body Image, 1, 1–5.
Choate, L.H. (2005). Toward a theoretical model of women’s body image
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UPCOMING TOPIC FOR NOVEMBER 2007
Immigrant and Refugee Youth
Currently more that 20% of all youth in the U.S. are immigrants or children of immigrants. While these
youth have many of the same needs as their non-immigrant peers, they also have unique challenges and
strengths. Experiences prior to and during migration, strength of family, and the acculturation experience,
as well as school and community climate all impact the needs of these youth and how well they do in our
society. The November 2007 issue of The Prevention Researcher is devoted to the topic of immigrant and
refugee youth with the goal of understanding how immigration affects youth and how to build on their
unique strengths to assist them in making a successful transition.
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September 2007 • Volume 14(3) • The Prevention Researcher
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