BY MARY TANTILLO, PhD, PMHCNS-BC FAED
“Everybody’s body is different, so you will find the right things for your own body like food and exercise…All movie stars are like eating one egg and gum all day. That is horrible for you…You have to balance it out.”
-Sage advice from a middle school girl
The sage counsel above comes from the mouth of a brave middle school girl who was interviewed as part of a recent body image research project. Her advice to have a balanced mindset in relation to intake, exercise, and other self-care activities could have come from our grandparents. However, given the increasingly toxic Western cultural values emphasizing perpetual youthfulness, thinness, overall physical appearance, and the achievement of success and control through dieting, her advice is actually very countercultural. American culture is especially toxic for vulnerable adolescents who are already experiencing a myriad of bodily, psychological, and social changes. The number of children and adolescents with eating disorders (ED’s) has greatly increased over the past 50 years,¹-² and during the past decade the prevalence of obesity in children and adolescents has also dramatically increased.³-⁶ The data in Table 1 show the prevalence of both conditions, associated behaviors, and body dissatisfaction in youth. Both teen girls and boys are increasingly dissatisfied with their bodies including teens who are average or underweight.⁵,⁷
Historically, ED’s and obesity have been viewed as completely separate conditions requiring separate prevention approaches. However, recent research findings no longer support these notions. This article will discuss research findings that support an integrated approach for understanding and preventing ED’s and obesity. It will end with the highlights from a study the author developed with middle school students to understand their subjective experiences of what helps them feel good and bad about their bodies. Their voices clearly create a call to action.
Research About Eating Disorders and Obesity as Weight-Related Disorders
In a five-year longitudinal study of adolescents⁸ weight-teasing and dieting in girls, weight concern in boys and girls, and unhealthy weight control practices in boys predicted all three of the following weight-related outcomes: overweight, binge eating and extreme weight control behaviors. These findings and others⁴-⁵,⁷,⁹-¹¹ support attempts to integrate an understanding of risk and protective factors associated with ED’s and obesity and view these conditions on a continuum of weight-related disorders. The findings discourage a primary focus on weight loss, BMI, the number on the scale, and dieting because these efforts can actually increase youth weight concern and stigmatization of obesity. ⁵,¹¹ Instead, the findings support development of prevention programs that focus on wellness, healthy eating behaviors, moderate physical activity, and especially positive body image.
An emphasis on development of positive body image in prevention programs could potentially have a synergistic effect on prevention of obesity, ED’s, and other adolescent behavioral health problems. Body dissatisfaction is closely linked to self-esteem, especially in adolescence, and is a robust predictor of disordered eating, unhealthy weight control practices, and eating disorders in adolescents. For example, weight concern (reflective of body dissatisfaction) predicted extreme weight control practices, binge eating, and overweight problems in both genders in Neumark-Sztainer et al.’s (2007) research⁸. Other studies have also shown that body dissatisfaction is correlated with obesity.⁵ Body dissatisfaction is prevalent during adolescence,⁵ is associated with negative affect and other high risk behaviors such as sexual behavior and substance abuse.⁵,¹²-¹⁵ It predicts depression and suicide and can interfere with development of a healthy self-concept.¹³-¹⁵ Eating disorders commonly emerge with the transition to high school or college, often after a prolonged period of body image dissatisfaction or distortion during middle school years.⁵,¹⁴,¹⁶ All these findings support promotion of positive body image as part of our prevention efforts, as well as development of prevention programs that simultaneously attend to the broad spectrum of eating, activity, and weight-related problems.⁵
A Youth-Informed Participatory Approach to Prevention of Weight-Disorders
Research shows that when prevention programs produce sustained results in relation to eating, activity, and body image, their effectiveness seems related to the degree that interventions are participatory in nature and “ecologically-informed,” i.e., how well they are informed and developed by the particular school, parents, students, and surrounding community.¹⁶-²¹ What follows are the highlights from a recent study²² developed for and with middle school students in a suburb of Monroe County. The study was the first step in crafting a participatory and ecologically-informed prevention approach for ED’s and obesity. In this study students were engaged as “co-investigators,” and the author initially spoke with two smaller focus groups (12 students each) of middle school students about the study. They helped develop the research interview questions and methods that were used with peers in two subsequent larger focus groups including 45 students ages 11-14 in grades 6-8. The larger groups were predominantly Caucasian, with subgroups of Asian American (11%), Latino (2%); African-American (2%), and Other/Multi-Ethnicity (5%).
theory approach. This approach seeks to develop a theory regarding middle school body image built from themes gleaned from a systematic analysis of student subjective experiences. Table 2 lists the processes contributing to positive and negative body image in middle school students.
A main take away from these findings is that body esteem, self-esteem, and connection with peers are intimately intertwined. The findings suggest that adolescents face a painful developmental dilemma. At the same time they are trying to develop their own identities and an acceptance of their own bodies, they simultaneously feel a strong pressure to fit in and avoid being perceived as different. The latter may lead to peer criticism, isolation, and negative self-concept, e.g., “So, if you’re not skinny, you are kind of out.” Depending on the interaction of genes, environmental stress, and supports, one child may emerge from this mix relatively unscathed, while another may initiate unhealthy weight control practices to feel less inadequate and fit in. This path can lead to eating disorders and/or obesity in adolescents who are vulnerable due to the interaction of genes and environmental and developmental stressors.
Another take away is that middle school youth experience a 2:1 ratio of processes contributing to negative vs positive body image. Some of these processes are experienced before and during middle school, e.g.,” perceiving and responding in extreme ways,” and some are experienced mainly during middle school, e.g.., “conforming to fit in.” A number are also experienced in several domains, e.g., “feeling the futility of being fat” within the individual, in school and in the culture. Study findings supported findings in the broader literature linking factors such as peer weight teasing, peer dieting, internalized desire for thinness, low self-esteem, and parental messages about weight/shape with increased body dissatisfaction.¹⁴, ²³
One main message from the study is that middle school youth feel positive about their bodies and themselves when they feel confident about being who they are and feel validated for this. One girls says: “Be yourself. Stick to your gut…Don’t change yourself if you like your style”…“Good parents…[and real friends] want you to feel good about yourself regardless of what you look like.” This finding encourages partnerships among parents and school personnel to create home and school environments that reinforce these processes. This work includes ensuring connections at home and school wherein peers and caring adults provide validation and foster safety for teens to identify their similarities with and differences from peers. It also involves explicitly discouraging the quest for perfection; encouraging a balanced mindset with regard to expectations of oneself and one’s body; fostering development of life skills to learn adaptive coping in the face of emotional vulnerability; maintaining a zero tolerance policy for weight teasing; and quickly naming hurtful processes like peer weight teasing and intervening in a timely way to facilitate repair. Given these findings it would be inefficient and ineffective to approach prevention of obesity and eating disorders in a separate silo way. Body dissatisfaction can contribute to development of obesity, eating disorders and/or other behavioral health problems. A focus on wellness, balance, diversity, authenticity, validation, and home-school connectedness seems relevant for prevention of ED’s and obesity in teens. As one middle school boy says, Dr. Seuss taught him all these things very early on. In one focus group he shared the following: “Be who you are and say what you feel because those who matter don’t mind, and those who mind don’t matter.”
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