Eating Disorder Awareness

                                                                      Abstract

An awareness program for adolescent girls is developed and explored. The program educates adolescent girls and raises awareness of the prevalence and danger of eating disorders through interpersonal and interactive dialogues, formal and informal presentations and other media, small group discussions, and self-disclosure strategies. Eating disorders, their comorbidities and the confluence of factors that cause the initiation of these behaviors are presented and discussed.

The program's purpose is to educate this population on body image, body dissatisfaction, the effects of societal pressure to be thin. Further, it addresses the influence of the media in promoting manufactured images that present women unrealistically, and the marketing of thinness as beauty. The program herein has been designed and implemented under the premise that the most effective instigator of positive change is knowledge. It is designed to explore the pervasive 'thin at all costs' movement that has created destructive operational definitions of female beauty.

                                                 Eating Disorder Awareness

This program will focus on anorexia nervosa, bulimia nervosa, and binge eating disorder, which make up the eating disorders. Eating disorders are life-threatening illnesses (Herpetz et al., 2011), and they have the highest rate of death of all psychiatric disorders (Stice, Marti, & Rohde, 2013). The ten year mortality rate for people with anorexia nervosa is approximately 5%, which is ten times the mortality rate for other illnesses and disease. Over 10% of the population of young women meet the criteria for one or more eating disorders (Stice, Marti, & Rohde, 2013). Eating disorders are often accompanied by anxiety, distress, depression, suicidality, and unhealthy body weights (Stice et al., 2013). Creating awareness for girls during the initial year of high school is critical to raise awareness, that they can recognize the signs of eating disorders in themselves and in their friends, and become comfortable enough to engage in open discussions with each other as well as with their parents and other adults.

The purpose of this paper is to create a comprehensive awareness program, describe its purpose, an appropriate setting for the program, and the projected time frame in which to implement the program. In addition, this paper discusses the target population and its health factors as well as its risk factors. Three goals for the program are described and five media and other elements that were added to the program are discussed.

                                                        Program Purpose

The purpose of this program is to raise adolescent girls' awareness about eating disorders and body image issues, and the impact they have on girls, their families, and communities around the world. The program is driven by a theory that if adolescent girls learn about the life- threatening psychological and physiological effects of eating disorders, they are better prepared to arm themselves against the potential to develop such a disorder. The program has been developed to reduce the stigma that surrounds eating disorders, and to create access to information and treatment resources for adolescents with eating disorders and their families. The program was designed to provide age appropriate information, but demonstrate the fact that eating disorders are life-threatening illnesses - not a diet choice. It provides information and engages young women in discussions that promote the recognition of the pressures, cultural attitudes, and social behaviors that potentiate eating disorders.

Body dissatisfaction in young women has become so pervasive, it is considered normal (Rodin, Silberstein, & Striegel-Moore, 1985). Further, this dissatisfaction, specifically the desire to be thinner, places a tremendous burden on the young woman, including lowered self-esteem and chronic excessive dieting (Dohnt & Tiggeman, 2005). This skewed self-perception is one of the most consistent predictors of eating disorders. According to the National Eating Disorders Association (2014), 42% of first- to third-grade girls want to lose weight, 81% of 10-year-olds fear becoming overweight, and 50 to 70% of normal-weight girls believe they are overweight. Two-thirds of girls in the 5th to 12th grades said that the images in magazines influence their idea of what their bodies should look like, and about half of this age group said the pictures made them believe they should lose weight. The internet, too, functions like magazines, promoting disordered eating and body dissatisfaction (Bair, Kelly, Serdar, & Mazzeo, 2012). Certainly the media has an influence on girls as they develop a healthy or unhealthy perspective about weight, body image, and healthy eating.

                                       Health Topic: Eating Disorders

Eating disorders have become commonplace in adolescent girls (Steinhausen, Gavez & Metzke, 2005). These disorders are potentially life threatening and cause short and long-term ramifications to individuals' psychological and physiological health. In the United States alone, over 30 million people will experience a clinically significant eating disorder at some point in their lives (Wade, Keski-Rahkonen, & Hudson, 2011). According to Stice (2002), central to the development of eating disorders is body dissatisfaction. It has been estimated that 80% of women in the United States are dissatisfied with their appearance. Forty to sixty percent of girls in elementary school, between the ages of 6 and 12 become obsessed with weight and express concern about being too fat (Smolak, 2011).

                                       Awareness Program for Schools

This program is designed to be implemented during the regular school day. The length of each session is 2.5 hours, with a fifteen minute break with snacks, halfway through the program. It is designed to be held once or more for each grade level, depending on the number of students, and will be held in the auditorium or another room that can hold at least 100 students at one time. During the first part of the program, the presenter will provide the participants with the facts and statistics along with the health risks and long-term effects of eating disorders. The adolescents will be shown a short video about the superficiality of image and how the media constructs images into a representation of women that is unrealistic and impossible to attain. An interactive discussion about body image and their experiences will follow. Another four minute video will be shown, after which there will be another interactive discussion. After the first hour, there will be a break after which the adolescents will break into smaller groups of 8-10 students.

After the break, the smaller group sessions will begin. During this part of the program, the participants will be encouraged to express their experiences with disordered eating, the pressure they have experienced to be thin, and their personal body dissatisfaction, and other experiences pertaining to body weight, peer pressure and eating habits, and stress they experience because of the social pressure to be thin.

                                             Targeting Adolescent Girls
Health Factors

This program targets adolescent girls because this population experiences the greatest impact of eating disorders, which are developed during adolescence more than any other time in life (Steinhausen, Gavez, & Metzke, 2005; Stice et al., 2013). Forty-four percent of all female high school students are trying to lose weight. Even in fourth grade, one half of the girls are on a diet. In addition, the adolescent population is prone to risk-taking behaviors (Gardner & Steinberg, 2005; Steinberg, 2011; Roaten & Roaten, 2012). Brain changes that take place during adolescence have a profound impact on adolescents thoughts, feelings, and behaviors. For adolescent girls, this can mean dieting dangerously and utilizing starvation, binging and purging, and laxatives to prevent them from gaining weight.

                                                                     Health Risks

Risk-Taking Behavior in Adolescents

 The adolescent brain changes dramatically, which effects the behaviors, emotions, and thoughts in the adolescent population (Gardner & Steinberg, 2005; Steinberg, 2011; Roaten & Roaten, 2012). These changes are partly the result of decreased synaptic connections, which compels this age group to seek new information, and contributes to adolescent risk-taking behavior (Roaten & Roaten, 2012). The pre-frontal cortex, which drives decision making, is one of the last parts of the brain to fully complete the reorganization process that enables adult decision making abilities (Gardner & Steingerg, 2005; Steinberg, 2011; Roaten & Roaten, 2012). As the pre-frontal cortex develops, the brain part most relied upon for decision making and managing challenges is the amygdala, which is partly responsible for the emotional outbursts and risk-taking behavior characteristic of this age group (Steinberg, 2011). Adolescent girls' undeveloped emotional processing system causes them to make emotional decisions and engage in dangerous behaviors, such as eating disorders, that they believe will help them be thin.

Health Risks in Anorexia Nervosa
As a result of self-starvation, there is an increase in health risks for individuals with anorexia nervosa because the body slows its metabolism in an effort to conserve energy. Changes in the heart muscle, which increases the risk for heart failure, are evidenced by slowed heart rate and lowered blood pressure. Osteoporosis is the result of the body's lack of essential nutrients, when the body leaches minerals and nutrients from the bones, which is one of the last reserves of these elements in the body. When women initiate anorexic behavior in adolescence, they are far more prone to osteoporosis later in life compared to their healthy counterparts, even after several years of recovery from the eating disorder (Misra, 2008). In anorexia nervosa, especially, severe dehydration can cause kidney failure, and overall weakness and fatigue are chronic and constant symptoms of anorexia and the other eating disorders as well. Some evidence suggests women with a history of anorexia nervosa or bulimia nervosa experience a greater degree of infertility problems (How Eating Disorders Affect Fertility and Pregnancy, 2012).

Health Risks in Bulimia Nervosa

There are two types of bulimia nervosa; the purging type, in which the individual uses self-induced vomiting, laxatives, diuretics, or enemas, and the non-purging type wherein the individual uses inappropriate compensatory behaviors, such as excessive exercise or fasting, but does not engage in self-induced vomiting, using laxatives, diuretics or enemas. The chronic use of binging and purging behavior can cause a variety of health problems including tooth decay, swollen gums or gum disease, osteoporosis, electrolyte imbalances, dehydration, and swollen salivary glands. In addition, bulimia nervosa has comorbidities including depression, substance abuse, social anxiety disorder, panic disorder, panic attacks, and borderline personality disorder.

Comorbidities with Eating Disorders

Psychiatric and medical comorbidities are common in adolescent girls with eating disorders. Psychiatric disorders such as alcohol and substance abuse (Harrop & Marlatt, 2010), depression and mood disorders (Mangweth et al., 2003), and obsessive-compulsive disorder are most commonly reported (Altman & Shankman, 2009). In adolescents with bulimia nervosa, 25% had attempted suicide or inflicted self harm. Eating disorders have become more common with each passing year. These disorders represent a significant public health concern, not only because of the dramatic increase in the number of adolescents initiating disordered eating behaviors, but also because eating disorders are frequently comorbid with other psychopathologies and because the eating disorder becomes the primary concern, the comorbidities often go untreated or under-treated.

                                                               Program Goals

Creating Awareness

The primary goal of this program is to create an awareness of the prevalence and danger of eating disorders through interpersonal dialogues, formal presentations, including Ted Talks, PowerPoint presentations, and other media, small group discussions, and self-reflection strategies. To increase ongoing awareness, the program will establish a network between the girls by having them share personal stories and experiences. The goal of the small group session is to break down the barriers between the girls by having them share universal feelings and experiences of body image and body dissatisfaction. In addition, it is hoped that they will feel less self-conscious about sharing personal experiences and these discussions will help them understand the importance of standing together rather than placing undue pressure on each other. Girls who experience greater levels of peer and parental pressure to be thin are more apt to initiate disordered eating behaviors (Huon & Walton, 1999).

Establishing a stronger network between the girls has the potential to put them on the same side of the fight against the pressure to be thin and to utilize their newly established network as a personal strategy to increase self-esteem and to develop healthier interpersonal relationships with other young women. Sharing personal experiences will be encouraged fostered by encouraging discussions of personal experiences of the pressure to be thin and how they affect overall self-esteem and sense of self.

Bring Eating Disorders Out of the Closet

A second goal of the program is to engage girls in open discussions about their experiences, fears, and concerns over eating disorders, and how they can help each other contend with and manage the pressure to be thin. This has the potential to create solidarity between the girls and help them recognize symptoms of the disorder and become more aware of each other's struggles. The small group portion of the program is designed so the girls feel comfortable enough to express their own struggles with thinness and eating. Especially during adolescence, girls have a powerful influence on each other in regards to body dissatisfaction and dieting (Dohnt & Tiggemann, 2005).

This program will utilize peer influence since this age group is particularly susceptible to that influence (Gardner & Steinberg, 2005; Jaccard, Blanton, & Dodge, 2005; Thorlindsson & Bernburg, 2006). Because of the dramatic brain changes (and an increase in the number of mirror neurons in the adolescent brain), they are far more vulnerable to the vicarious experiences of their peers (Roaten & Roaten, 2012). The small group sessions are designed to promote openness and the expression of personal experiences that have the potential to deeply affect the girls. Adolescents, with their increased vulnerability to vicarious experience are sensitive to the emotions and struggles of their peers. Some research has found that teens can relate to protecting their friends more readily than they comprehend the need to protect themselves (Roaten & Roaten, 2012).

Create an Awareness of the Power of Media
Societal pressure to be thin and the influence of the media in promoting eating disorders is a significant psychological burden among girls of this age group, and a primary contributing factor in body dissatisfaction and disturbed eating . The media is influential for women of all ages, and its power is insidious and often goes unrecognized, although its effects are evident (Ahern, Bennett, & Hetherington, 2008). It pressures girls intentionally, and perpetuates an ignorance and acceptance of unreasonable beauty and body expectations for girls and women. This program seeks to create an awareness of this silent crime against the female gender and educate girls on the marketing of thinness as beauty.

Over the last three decades, models have gone from thin to severely underweight, and simultaneously the rate of eating disorders in young girls, young women, and women of all ages has continued to increase. Between 1980 and 1996, models weighed 8 percent less than average women. In 2008, they weighed 23 percent less than average women. Approximately 10% of Playboy centerfolds and 17% of beauty pageant participants have a body mass index that fits criteria for anorexia nervosa (Ahern et al., 2008). Today, the media is a commonly utilized information source for adolescent girls, and its influence is more powerful than it has previously been. Rather than retrieving information from friends and family, adolescents are bombarded with far more images that present women in unrealistic and unreasonable contrived female images (Ahern et al., 2008).

Ahern and colleagues (2008) found that the real damage lies in the length of time and number of exposures to media that present women as underweight models. The more a girl is exposed to such models, the higher her desire is for thinness, which is, according to Ahern and colleagues (2008), "a cardinal symptom in eating disorders" (p. 305). After extended exposure to the contrived images of underweight models, girls believe the models are reflective of the real world. This program was designed in part to inform adolescent girls that the media presentations are not real world; they are contrived and heavily manufactured according to what the image is enticing the consumer to purchase.

                                         Additions to PowerPoint Presentation

Poster-What You Weigh Shouldn't be Who You Are!
The Theme for the program will be 'What you weigh shouldn't be who you are!' They will present the idea that eating disorders can destroy lives, and are destroying the lives of their friends or their sisters. The posters will be brief with graphics, and enough information (facts and statistics) to compel the girls to want to understand more about eating disorders. Posters will be placed on bulletin boards in hopes to stimulating discussion prior to the program. The posters will be geared to an adolescent's point of view and will be 'cool' rather than a traditional adult poster. It will be inviting, informative, and stimulating.

Handouts: Be a Voice, not an Echo!

Patterned after the National Association of Anorexia Nervosa and Associated Disorders' 2014 National Eating Disorders Awareness Week, the handouts provided at the program will encourage the girls to maintain ongoing discussions about eating disorders between themselves, with their parents, or a healthcare professional. The handouts will encourage them to voice their personal strengths, talents, and standard of beauty, and to stop perpetuating media's unreasonable and unrealistic standards for beauty. They will promote ongoing discussions about eating disorders that will help girls get the help they need. The handouts will point out that keeping quiet about eating disorders gives more strength and influence to the current skewed standards of thinness and beauty. They will provide a list of resources for girls who want help but are afraid to talk about it.

Information Brochure for Parents

A brochure will be provided for the girls who want to provide information for their parents. The theme of the brochure will be: It's time to talk about it. The girls will be encouraged to take the brochure home, but told that it is not necessary and they should only take the information if they want it. It is hoped that the brochure will raise awareness of eating disorders among parents. If parents can become more aware of the problems and pressures that adolescent girls face, it may encourage open discussions about eating disorders between adolescents and their parents. In addition, raising parents' awareness will provide them with the information they need to help their daughters or other adolescent girls struggling with weight issues, body dissatisfaction, and eating disorders. The brochure will be informative and factual, and will provide a list of resources for families struggling with a child with an eating disorder.

Dove Patches Video
https://www.youtube.com/watch?v=EGDMXvdwN5c#aid=P-gscX4o03E

The company that created Dove products created this video to show women that beauty is a state of mind rather than the fulfillment of unreasonable and unrealistic beauty standards. It is a four minute you tube video that was designed to help women discover how a change in perspective has the potential to incite a personal experience of beauty, the power of which lies within each person. The women in this video are invited to try a beauty patch that would help them to see themselves in a more beautiful light. They are instructed to wear it for two weeks and keep a diary on the changes they experience. The results were life-changing. After discussing the changes they experienced, the doctor explained the ingredients in the patch. There were none. It was a placebo that had a powerful effect on the way they perceived themselves. It is an enjoyable and empowering.

Ted Talks:

https://www.ted.com/talks/cameron_russell_looks_aren_t_everything_believe_me_i_m_a_model

This is a short, ten minute talk about the superficiality of physical beauty, the power of

image, and how the media uses it to make women believe they should look a certain way. The speech is done by Cameron Russell, who has been a model for over ten years. She discusses the time and energy that goes into creating the images that are seen in magazines, on television, and that have become the basis of the cultural expectations and beauty standards for women. In addition, she helped the audience understand that the pictures seen in magazines and other media are not real women, they are contrived and manufactured images tailored to sell a product or enhance the written word.

                                               Instigating Positive Change

This program was designed and implemented under the premise that the most effective instigator of positive change is knowledge. When people understand an issue, they have the power to influence the course of its effects, and the effect it has on them, their community, and the world. This program will instigate positive change simply by presenting the prevalence, health risks, and factors that may instigate the initiation of disordered eating. In addition, it encourages this age group to establish new and more realistic expectations of body image and standards of beauty.

The pervasive 'thin at all costs' movement has created a destructive definition of female beauty that is harming generations of young women, especially in Western culture. Although the United States has the highest rates of obesity, it also has the highest rates of eating disorders in the world. It is important to educate adolescent girls on the media, which is one of the most influencing factors in the creation of the images and beliefs held by this age group. Educating them on the creation of these images may help them more effectively differentiate between the construed and manufactured images from the pages of magazines, and images that are representative of real world bodies and beauty.

Conclusion

Eating disorders continue to increase, and the initiation of this behavior most commonly begins in adolescent girls. Eating disorders are complex, and their initiation is usually a confluence of factors, and no genetic reason has been identified to explain this behavior. It seems important to educate young women about the societal messages associated with body image, the unreasonable and ridiculous standards of beauty perpetuated by the media and the fashion industry, and the misconstrued and unfair values women place on themselves and other women. The program for adolescent girls described herein aims to raise awareness of eating disorders and explicate the confluence of social factors that contribute to body dissatisfaction and disordered eating.

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