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ExcitingRecentDevelopmentsinPreventionMichaelP.Levine

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ExcitingRecentDevelopmentsintheFieldofPrevention

[AppearsintheApril2015Gürze-SalucoreOnlineCatalogue]

MichaelP.Levine,Ph.D.,FAED

Part1ofthisseries(Gürze-SalucoreNewsletter,March2015)exploredthe

meaningsofpreventionandthecriteriafordeterminingwhetheraprevention

programworks,whileprovidingabroadsketchoftheempiricalbasisforthe

conclusionthatEDpreventioncanindeedworkand,infact,isabsolutelynecessary.

Providingasnapshotofthecurrentstateofpreventionresearchisdifficult,

givenhowextensivelythefieldhasgrownsince2000.APsychInfosearchinmid-

Marchof2015,lookingfor“preventionorpreventing”AND“eatingdisorders”inthe

title,yielded90articlesandbookchapterspublishedinEnglishsinceJanuaryof

2010,and255sinceJanuary2000.Thus,thepurposeofthisessayistodescribea

varietyofexcitingrecentdevelopmentsinEDprevention.Presentationofprograms

isorganizedaccordingtotheirplaceontheuniversalàselectiveàindicated

(targeted)preventionspectrum(seePart1)andthelevelofage/gradeofthe

intendedaudience.

Theprogramswereselectedbecauseresearchsupports—andinsome

instancesconfirms—thatthey“work”(seePart1).Formoredetailedinformation

aboutthemandaboutotherpromisinginterventions,readersarereferredtorecent

reviews,suchasthosebyBecker(2012),Levine,McVey,andPiran(2014),Piran,

McVey,andLevine(2014),Stice,Becker,andYokum(2013),andYager,Diedrichs,

Ricciardelli,andHalliwell(2013).


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PreschoolandElementarySchool(Ages3-11)

Althoughtherearesomepromisingprograms(seereviewsbyLevine&

Smolak,2006,2009;seealsoBird,Halliwell,Diedrichs,&Harcourt,2013),todate

thereisnopreventionprogramforchildrenthatclearlyworks,usingthecriteria

discussedinPart1.

MiddleSchool(Ages12-14):Universal-SelectivePrograms

PlanetHealth

Thismultifacetedpreventionprogram,developedinBoston(USA),was

originallyintendedtopreventobesityinearlyadolescencebyalteringtheecologyof

theschooltodecreasetelevisionviewingandconsumptionofhigh-fatfoods,while

encouragingyouthtoconsumemorefruitsandvegetablesandtoincreaseboth

moderateandvigorousphysicalactivity(Austin,Field,Wiecha,Peterson,&

Gortmaker,2005).SchoolsparticipatinginPlanetHealthreceiveteacher-training

workshops,aswellaslessonsconsonantwithstate-mandatedcurriculaforphysical

educationandforawidevarietyofacademicsubjects.Projectleadersalsowork

withfamiliestomodifythehomeenvironmenttoreinforcePlanetHealth’sschool

programs.

Interestingly,intheinitialrandomizedcontrolledtrial(RCT)ofPlanetHealth

theprogramfailedtopreventdevelopment(i.e.,lowertheincidence)ofobesity,

althoughobesityprevalencewasreducedamongfemalestudents.However,Planet

Healthverysignificantlyreduced,overa2-yearperiod,initiationoftwoformsof

disorderedeatingbehavioringirls:purging(self-inducedvomiting)anduseofdiet

pills.StatisticalanalysesindicatedthatPlanetHealthcouldhaveprevented91%of


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thenewcasesofpurginganddietpillusebygirlswhowerenotdietingatbaseline

(Austinetal.,2005).Thesepositiveresultsforgirls,butnotboys,werereplicated

(preventivefraction=67%)inasecond,verylargeRCTinvolvingover1400girls

andboysingrades6and7in16Massachusettsmiddleschools(Austinetal.,2007).

HealthySchools-HealthyKids

Anotherpreventionprogramdesignedtoengagestaffandstudentsin

analyzingandchangingtheecologyofamiddleschoolwasdevelopedbyGailMcVey

andcolleaguesinToronto,Canada.HealthySchools-HealthyKids(McVey,Tweed,&

Blackmore,2007)providesandcoordinatesstudentlessonsforimprovingbody

image,trainingandcurriculumguidesforteachers,andworkshopsandnewsletters

forparents.Curricularmattersarefurtherintegratedwithsmall,gender-segregated

peersupportgroups,stafftraining,student-ledpublicserviceannouncements,anda

schoolplay.

At6-monthfollow-up,girlsandboysinthe7thgradewhoparticipatedin

HealthySchools-HealthyKidsreportedlessbodydissatisfactionthanacomparison

sample,whilegirlsattendingtheinterventionschoolsalsoreportedless

commitmenttotheslenderbeauty-idealandfewerskippedmeals.UnderMcVey’s

leadership,thesepromisingresultsandthecollaborationwithlocalstakeholders

throughwhichHealthySchools-HealthyKidswasdevelopedhavegeneratedfurther

systemicdevelopments.Prominentamongthemisaweb-basedsetofresources

(matchedtocurriculumexpectationsoftheOntarioandNovaScotiaMinistriesof

Education)forteachersandpublichealthprofessionalswhoworkwithgirlsand

boysages9-12years(Levine&McVey,2012).


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MediaSmart

Notallexcitingdevelopmentsinuniversal-selectivepreventionatthemiddle

schoollevelareecologicalinnature.InAdelaide,SouthAustralia,SimonWilksch

andTraceyWade(2009)developedan8-lessonmedialiteracyprogramcalled

MediaSmart(seehttp://sparky.socsci.flinders.edu.au/researchonline/projects/5).

Thisinteractiveprogramhelpsgirlsandboystobecomeawareofandanalyzehow

massmediainfluencebodyimage,andthenencouragesstudentstogetinvolvedin

mediaactivismandadvocacy.AnRCT,conductedwithover500grade8students

(ages13-14)infourschools,revealedthat,comparedtothecontrolcondition,Media

Smartreducedweightandshapeconcernsanddietingat30-monthfollowupfor

girlsand6-monthfollowupforboys.Itappearsthat,forreasonsthatarenotyet

known,thismedialiteracyprogramhasamorepositiveeffectonstudentswhowere

initiallymoredepressed(Wilksch&Wade,2014).

ArecentlypublishedRCTwithover1,300grade7andgrade8studentsin

Australia(meanage=13.2)comparedMediaSmartnotonlytoano-intervention

controlcondition,butalsototwointerventionsfocusingonhealth-relatedlifeskills

andonthevalueofhelpingothers,respectively(Wilkschetal.,2014).Giventhefour

conditionseachforboysandgirls,andthepre-and-postassessmentsplus6-and12-

monthfollow-ups,theresultsofthis4X2X4mixeddesignarenoteasily

summarized.Itisfairtosay,however,thatMediaSmartwasthemosteffectivefor

girls,producingthehighestphysicalactivitylevelandthelowestcombinationof

weightandshapeconcerns,eatingconcerns,andperceivedsocialpressuresat

follow-up.Forboys,MediaSmartproducedthelowestinternalizationofmedia


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messagesat12-monthfollow-upandthehighestactivitylevelat6-monthfollow-up.

AsWilkschetal.(2014)noted,thiscomparativeoutcomestudysupportsfurther

investigationofthevalueofMediaSmartinreducingsimultaneouslyriskfactorsfor

EDsandobesity.

AMM-EC

Forapproximately10yearsnow,RosaRaich,DavidSánchez-Carracedo,and

colleaguesinBarcelona,Spain,havebeencarefullydevelopingandrigorously

evaluatingapreventionprogramforgirlsandboysages12-14(González,Penelo,

Gutiérrez,&Raich,2011;Raich,Sánchez-Carracedo,&López-Guimerá,2008).The

SpanishacronymAMM-ECrepresentswhatSánchez-Carracedo(personal

communication,March14,2015)translatesas"Eating,FeminineBeautyIdealand

theMedia.HowtoTrainSecondarySchoolStudentstobeCritical.”Themostrecent

versionofAMM-ECusesapproximately6.5hours(5sessionsover4-5weeks)of

interactive,multimodalinstructiontocombinenutritioneducationwithacritical

analysisofthefollowing:femalebeautyidealsacrosshistoryandacrosscultures;

thediversityofactualweightsandshapes;howbusinessandadvertisingusemass

mediatoshapeandreinforceanarrowlydefinedandslenderbeautyideal;andwhat

studentscandotomaintainacriticalperspectiveandtouseletterwritingtobe

activistsinprotestingunrealisticandunhealthyadvertising(Gonzálezetal.,2011).

InthemostrecentinaseriesofRCTs,Gonzálezetal.(2011)foundthat,

comparedtoano-interventioncondition,at30-monthfollow-uptheAMM-EC

programresultedinsignificantlylowerscoresondisorderedeatingattitudesand


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behaviors,andonavalidatedmeasureofinternalizationofthepotentiallyvery

unhealthyweightandshapemessagesemanatingfrom“differentsocialagents

(advertising,verbalmessages,socialmodelsandsocialsituations)”(p.351).

SubsequentstatisticalanalysesbyEspinoza,Penelo,andRaich(2013)showedthat

theAMM-ECprogram,withorwithoutthenutritioneducationcomponent,produced

greaterbodysatisfactionthanwasseeninthecontrolgroupat30-monthfollow-up.

MiddleSchool:Selective-TargetedPrograms

and

HighSchool(Ages14–18):Universal-SelectivePrograms

Onceagain,althoughtherehavebeensomepromisingdevelopments(Levine

&Smolak,2006,2009;Yageretal.,2013),asyetthereisnoselective-targeted

preventionprogramforstudentsages12-14andnouniversal-selectiveprogramfor

highschoolstudents(ages14-18)thatclearlywork,usingthecriteriadiscussedin

Part1.

HighSchool:Indicated/TargetedPrograms

Stice’sBodyProject

Thebestknown,themostwidelyresearched,andthemostrigorously

evaluatednewprogramforEDpreventionisthedissonance-basedapproach

developedbyEricSticeandcolleaguesattheOregonResearchInstitute(USA).The

BodyProjectwasoriginallydesignedtoreduceriskfactorsandEDsymptomsin

youngwomen(ages18-25)whovolunteertoparticipatebecausetheyhavehigh

levelsofbodyimageconcernsorbulimicsymptoms.Thetheory,theextensive

evidencebase,andtheindividuallessonsforthisindicated(or“targeted”)


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interventionarepresentedindetailina290-pagefacilitatorguide(Stice,Rohde,&

Shaw,2013).

Briefly,TheBodyProject’slessonsandhomeworkassignmentsseekto

generate“cognitivedissonance”byhavingparticipants—workinginfrontofagroup

andwithminimalinducementbyleadersorpeers—voluntarilywrite,make

statements,andbehaveinwaysthatcontradictandchallengeourculture’s(and

theirown)entrenchedinternalizationoftheslenderbeautyideal.Variousfocused

exercisescreatenumerousopportunitiesforparticipantstoengageinacritical

analysisofthenature,origins,andsocioculturalmechanisms,including“fattalk,”

thatpromotethisideal.Toreducedissonance,groupleadersusecognitive-

behavioralexercisesduringgrouptimeandhomeworkassignmentstoguideeach

participantandthegroupinaneffortfulcommitmenttocreatingandenacting

counterargumentstosociety’sglorificationofslendernessandvilificationoffat.One

paramountgoalistohelpparticipantstoresistimpossiblestandardsofself-

managementbybecoming“bodyactivists”(Becker,2012,p.174).

AnRCTconductedbyStice,Rohde,Shaw,andGau(2011)foundthat,

comparedwithcontrols,highschoolgirlswhoparticipatedintheBodyProject

showedgreaterdecreasesinbodydissatisfactionat2-yearfollowupandED

symptomsat3-yearfollowup.FurtheranalysesofthesedatabyStice,Marti,Rohde,

andShaw(2011)indicatedthattheCDprogramworkedbyreducingboth

internalizationofthethinidealandbodydissatisfaction.

Itisnoteworthythat,intheUnitedKingdom,EmmaHalliwellandPhillippa

Diedrichs(2014)havecreatedamodifiedversionofTheBodyProjectasauniversal-


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selectiveclassroompreventionprogramfor12-to-13-year-oldgirls.Comparedtoa

wait-listcontrolcondition,thisrelativelybriefintervention(fourweekly20-min

sessions)didnotaffectself-reporteddietaryrestraint.However,itdidreduceboth

bodydissatisfactionandinternalizationofathinbodyidealbytheendofthe

intervention.Moreover,amonthlatergirlslearningthecriticalsocialperspective

thatisanessentialpartofTheBodyProjectwereabletoresisttheimmediate

negativeeffectsofmediaimagespresentedinthecontextofaseparateexperiment.

UniversityandCollege(Ages18-25):Universalà SelectivePrograms

Becker’sBodyProjectProgram

Sincetheearly2000s,CarolynBeckerandcolleaguesatTrinityUniversityin

SanAntonio,Texas(USA)havebeendevelopingauniversal-selectiveversionofthe

dissonance-basedBodyProjectpreventionprogram.Theirlineofprogram

developmentandoutcomeevaluationdiffersfromSticeetal.’sworkinfour

importantways(Becker,2012;Becker,Plasencia,Kilpela,Briggs,&Stewart,2014).

First,itwasdesignedtointegratepreventionwithBecker’sroleasprofessorin

teachingundergraduatesandpromotingundergraduateresearch.Second,it

expresslyfocusesonpreventioneffectiveness(vs.efficacy;seePart1ofthisseries)

inreal-lifesettings,includingminimalinvolvementofcostly,sometimesinfeasible

professionaltimecoupledwithlimitedavailabilityoffunds.Focusingon

effectivenesshasmadeiteasiertotrainavarietyofinterestedpartiesinthebasics

oftheprogramandhowtotransportittocollegiatesettingsthatdifferfromTrinity

University.


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Third,Beckeretal.’sadaptationofTheBodyProjectaddsanecological

perspectivebyengagingyoungwomeninthecollegecommunity(e.g.,sorority

members)aspartnersinleadingtheprogramsandindetermininghowtheprogram

ispresentedinparticularsettings,andhowtheresultingknowledgeisused.Finally,

thisversionofTheBodyProjectalsoembodiesanecologicalapproachbyworking

hardtopromotesustainablechangesinpeerinteractions,healthypeernorms,and

peerleadership.Forexample,professionaland/orsororitypeerleaderswillhave

youngwomen,workingingroupsof7or8drawnfromdifferentsororities,apply

basicelementsoftheBodyProject.Leadershelpthewomentogenerate—and

advocatefor—suggestionsforpolicychangeswithinindividualsororitiesandthe

sororitysystem.Inthisregard,Beckerandcolleaguesrecentlydemonstratedthat

theyhavedevelopedaneffectiveinterventioninwhichtwocriticallyimportant

tasks—groupleaderforprogramimplementationandtrainerofsubsequentpeer

leaders—canbeshiftedfromveryexperiencedprofessionals(e.g.,Becker)toeither

graduatestudentsorundergraduatepeerleaders(Kilpelaetal.,2014).

Programcontent,includingthe9-hourtrainingforpeer-facilitators,andthe

resultsoftheverysuccessfulinitialevaluationstudiesaredescribedindetail

elsewhere(Becker,2012;Becker,Stice,Shaw,&Woda,2009;Beckeretal.,2014).

Morerecently,ithasbeenshownthatamodifiedversionofTheBodyProject

designedforgroupsoffemaleintercollegiateathletes(atvariouslevelsofriskfor

ED)producedsignificantreductionsinbulimicsymptoms,weightandshape

concerns,andnegativeemotionalityat1-yearfollow-up(Becker,McDaniel,Bull,

Powell,&McIntyre,2012).FurtherevaluationofTheBodyProject’seffecton


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collegiatewomenwhoarenotathletesindicatesthat,aspredicted,long-term

reductionsinriskofEDsymptomsaremediatedbyreductionsinbody

dissatisfaction,whichinturnreflectreductionsinboththin-idealinternalization

andself-objectification(KroonVanDiest&Perez,2013).

UniversityandCollege:Selectiveà Indicated/TargetedPrograms

StudentBodiesTM

StudentBodiesTM(SB)isa6-week,8-lessonmultimediaon-lineprogramfor

collegewomenwhoareatmoderatetohighriskforED.SBisonecomponentofover

20yearsofpreventionprogramdevelopmentandresearchledbyC.BarrTaylorand

colleaguesatStanfordUniversity(California,USA)andbyCorinnaJacobiatthe

TechnischeUniversität(Dresden,Germany;seeBeinter,Jacobi,&Taylor,2012;

Sinton&Taylor,2010).Anexcitingaspectofthisworkisanongoingattemptto

makeSBpartofacampus-wideprogramthatusesavalidatedscreeningtoolto

identifyeachstudent’slevelofriskandthentailorsforthatstudenttheappropriate

levelofpreventionortreatment(Jones,Kass,etal.,2014)

SBisdesignedtopromotehealthyeatingandexercisingandtoreduce

prominentriskfactorssuchasbodydissatisfaction,perceivedpressurestobethin

emanatingfrompeersandmedia,internalizationoftheslenderideal,andweight

andshapeconcerns.Guidedbysocialcognitive,cognitive-behavioral,andfeminist-

criticalmodels,SBoffersinteractivepsychoeducationandcognitive-behavioral

exercises,whileencouragingparticipantstogiveandreceivesocialsupportin

moderatedon-linediscussions.


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NumerousRCTsintheUSAandGermanyhaveshownthatSBandsimilar

interactiveInternet-basedprogramsareeffectiveoverfollow-upperiodsofupto2

years(Beintneretal.,2012;Sinton&Taylor,2010).Thestatisticalstrengthofthe

reductionsinbodydissatisfactionanddisorderedeatingattitudesandbehaviors

tendtobesmalltomoderate,andthussmallerthanthosetypicallygeneratedbyThe

BodyProject.Nevertheless,SBisparticularlyeffectiveforcollegeoruniversity

femalesathighriskforEDs(Sinton&Taylor,2010).

AnexpandedversionofSBhasbeendevelopedasatargetedprogramfor

integratingpreventionofobesityanddisorderedeatinginoverweightadolescents

(Jonesetal.,2008).StudentBodies-BingeEatingDisorders(SB-BED)features8more

lessonsthatconstituteacognitive-behavioralapproachtoweightreduction,

includingmanagementofover-andbingeeating.Theweb-basedSB-BEDhasbeen

usedsuccessfullywithoverweightadolescentsages14through16asastand-alone

program(Jonesetal.,2008)andaspartofaschool-and-family-basedecological

intervention(StayingFit)foradolescents,regardlessofweight,whohavehighlevels

ofweightandshapeconcerns(Jones,Lynch,etal.,2014).

Stice’sBodyProject

Asnotedabove,TheBodyProjectwasdevelopedforandvalidatedwith

femalecollegestudentsathighriskforED.Itspositiveeffects,sustainedovertime,

havebeendemonstratedinefficacyandeffectivenessstudiesbyresearchteamsat

differentuniversitiesandwithAfricanAmerican,AsianAmerican,Hispanic,and

Whiteparticipants(see,e.g.,Stice,Marti,&Cheng,2014).Severalstudiessupport,

butdonotconclusivelydemonstrate,thatdissonanceinductionanddissonance


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reductionarepartlyresponsibleforthesepositiveeffects(Becker,2012;Levineet

al.,2014;Sticeetal.,2013).

ArecentstudybyStice,Durant,Rohde,andShaw(2014)demonstrateshow

farthislineofresearchhasadvanced.FemalecollegestudentsatriskforEDdueto

highlevelsofbodydissatisfactionwererandomlyassignedtooneoffourconditions:

TheBodyProject,anInternet-basedversionofTheBodyProject(eBodyProject),or

oneoftwoconditionsthatcontrolledfortheimpactofrelevanteducation.As

comparedtocontrolconditions,theeBodyProjectreducedEDriskfactorsand

symptomsatboth1-and2-yearfollow-up,althoughthesmalltomoderateeffectsof

theInternetprogramweresignificantlylessthanthehigh-moderateeffectsofthe

standardBodyProject.AsStice,Durant,etal.(2014)note,thefindingthattheeBody

Projectproducedlargeweightreductioneffectsrelativetocontrols,andgreater

effectsthanTheBodyProject,haspotentiallyimportantimplicationsforcombined

obesityandEDprevention,

HealthyWeightIntervention

Sticeandcolleaguesinitiallydevelopedahealthyweightmanagement

intervention(HWI)toserveasastrongplacebo-controlinRCTsevaluatingthe

effectsofTheBodyProjectoncollegewomenatriskforED.TheHWIuses

psychoeducation,motivationalinterviewing,andbehaviormodificationtechniques

tofacilitatemodestbutsustainedchangesinknowledge,attitudes,andbehavior

thattogethercanreplacerestrictivedietingandchaoticeatingwithabalanceddiet

andregularexercise.


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Aseriesofstudies(seeBeckeretal.,2009,e.g.,forareview)demonstrated

that,likeTheBodyProject,at1-yearfollow-uptheHWIproducessignificant

reductionsinEDriskfactors,EDsymptoms(includingbingeeating),andthe

probabilityofbecomingobese.AsisthecaseforTheBodyProject,theHWIalso

reducestheincidenceofclinicallysignificanteatingpathologyat3-yearfollow-up.

AlthoughthecomparativeeffectivenessofTheBodyProjectandtheHWIisa

complicatedissue(Levineetal.,2014),itappearsthattheHWIistheindicated

preventionprogramofchoiceforat-riskadolescentgirlsandemergingadultwomen

whoatprogramoutsethaveahigherBMIandatendencytowardemotionaleating

(Stice,Marti,Shaw,&O’Neill,2008).

IntheBeckeretal.(2012)studydescribedabove,femaleintercollegiate

athletesatvaryinglevelsofEDriskparticipatedinapeer-ledversionoftheHWI.

Thepreventionresultswerejustaspositiveat1-yrfollow-upasthoseforBecker’s

modifiedformoftheBodyProject,butthemodifiedHWIprogramwasmore

acceptabletoathletes.AsBeckeretal.(2012)observed,thisgreateracceptanceof

theHWImayreflecttheathletes’greaterfocusonperformance,relativetobody

imageandtosport-specificornon-specificthinideals.

ConclusionsandFutureDirections

WhatWorks?

Thisreviewsupportsthefollowingbasicconclusions,drawingonPart1’s

extensiveandstrictcriteriafordeterminingwhetherapreventionprogram“works”:


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• Therearecurrentlyseveraleffectivepreventionprogramsformiddleschool

girlsandboys(ages12-14).Thesecanreasonablybecategorizedas

universal-selectiveinterventions(seePart1).

• TheBodyProject,adissonance-basedprogram,iseffectiveforhighschool

females(age14-18)whoareatriskforanEDduehigherlevelsofnegative

bodyimage.Giventhegirls’age,theirgender,andourculturalstandards,

coupledwiththeirlevelofrisk,thisprogramcanreasonablybecategorized

asaselective-indicatedintervention.

• TheBodyProject,deliveredinatraditionalgroupformalorovertheweb,is

oneofthreeselective-indicatedpreventionprogramsthatareeffectivefor

femaleundergraduateswhoareathighriskforanED.Theothertwoare

StudentBodiesandtheHealthyWeightIntervention.

• Becker’speer-led,ecologicalversionofthedissonance-basedTheBody

Projectisaneffective,practicalpreventionprogramforgroupsof

undergraduatewomeninsororitiesandonintercollegiateathleticteams.

Thesewomenatelevatedriskforavarietyofdevelopmentalandperhaps

environmentalreasons,sothisprogramisprobablybestcategorizedas

universal-selective.

WhyandHowPreventionWorks

Itislikelythat,ingeneral,effectiveEDpreventionprogramsworkby

reducingkeyproximalriskfactorssuchasinternalizationoftheslenderbeauty

ideal,bodydissatisfaction,andnegativeemotionality.Morespecifically,dissonance-

basedprogramsprobablyworkinavarietyofways,buttheycertainlyexerttheir


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positiveeffectbygeneratingdissonanceandthenprovidingparticipantswith

cognitive-behavioralskillsforreducingdissonanceandforincreasingresistanceto

negativesocioculturalmessagesglorifyingthinnessandvilifyingbodyfatandfat

people.

Areviewoftheeffectiveprogramshighlightedinthisessay,coupledwitha

reviewofpromisingprogramsdevelopedduringtheyears1990-2005(Levine&

Smolak,2006),indicatesthatthereisgreatvarietyinthenatureofsuccessful

programs.Thismakesithardtogeneralizeabouttheirkeyingredients.Usinga

prototypicalapproach,mycolleaguesandIbelievethatthemoresuccessful

programsreviewedhereandelsewhere(e.g.,Levine&Smolak,2006;Piran,2010)

tendtohave4ormoreofthefollowing7Cs(Levineetal.,2014):

• TheprogrampromotesaCriticalSocialPerspectivethatfostersawareness

andanalysisofsocioculturalriskfactorsoperatingatthecultural(e.g.,

media),subcultural(e.g.,sportsordance),peer,andfamilylevels.

• Ithelpschildren,youth,andyoungadultsdevelopvariousCompetenciesfor

resistingunhealthysocioculturalinfluencesandforpromotinghealthand

resilience.

• ItbuildsConnections(e.g.,fosteringdialogue)betweenparticipants

themselvesandbetweenparticipantsandbothpeerleaders,influential

adults,andthecommunity.


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• Itenablesenablesparticipantstousetheircriticalsocialperspective,their

developingcompetencies,andtheirconnectionstomakeChoicesaboutways

toChangenegativesocioculturalinfluences.

• IthelpsyoungpeopledevelopandextendtheConfidencenecessarytomake

health-promotingchangesinthemselves,theirpeerrelationships,andtheir

cultures.Theprogram,inessence,helpsyoungpeopleandthosewho

supportthemtofindtheCouragetopursuepositivegoals,despiteongoing

anxietyanddoubt,andinthefaceofinevitablecriticism.

FutureDirections

Itisnowaclichétostatethatthereisstillmuchtobedoneindevelopingand

evaluatingprogramsforpreventingEDs.Yet,itsrepetitiondoesnotmakeitanyless

true.Thisreviewsuggeststhat,ataminimum,highpriorityareasforfurtherwork

arefurtherdevelopmentofeffective(1)prevention,acrossthespectrum,forpre-

schoolandelementaryschoolchildren;(2)selective-targetedpreventionformiddle

schoolstudents;(3)universal-selectivepreventionforhighschoolstudents;and(4)

prevention,acrossthespectrum,foryoungadultsinthemilitary,inthefitnessand

bodybuildingworlds,andinnon-collegiatecommunitiesingeneral.Thisdoesnot

meanthattherearenotheoreticalorempiricalguidelinesforpreventioninthese

areas(Levine&Smolak,2006,2009;Yageretal.,2013).Itmeansthatwearefar

fromhavingprogramsthatclearlyworkaccordingtostrictscientificcriteria(see

Part1).


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Whateverthefocusofnewdevelopments,threeotherareasshouldbehigh

priorities.First,weneedtocontinuecreatingprogramsformalesaswellasfemales.

Second,weneedtoblendcurrentecologicalapproachestoprevention(Beckeretal.,

2009;McVeyetal.,2007;Piran,2010)withapublichealthperspectivesoasto

emphasizetheimportanceofcollectiveactionandsocialjusticeintransforming

dominantculturalbeliefsandpracticesintohealthierpracticesregardingweight,

shape,gender,andself-management(Levine&McVey,2012;Piranetal.,2014).The

thirdareafollowsfromthesecond.Sincesimilarpsychosocialfactorsareoperating

inothermentalhealthproblems,weneedworkonpreventionprogramsthatseek

tochange,forexample,depressionandsubstanceabuse,alongwitheatingdisorders

(Beckeretal.,2014;Levine,2014).


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