Health Education Research Advance Access originally published online on September 8, 2006
Health Education Research 2006 21(6):770-782; doi:10.1093/her/cyl094
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Prevention of obesity and eating disorders: a consideration of shared risk factors
Division of Epidemiology and Community Health, University of Minnesota, 1300 S. Second Street, Suite 300, Minneapolis, MN 55454, USA
* Correspondence to: J. Haines. E-mail: haines{at}epi.umn.edu
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Abstract |
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 Top Abstract IntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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In response to the high prevalence of obesity, eating disorders and disordered eating behaviors among youth, researchers in both the obesity and eating disorders fields have proposed using an integrated approach to prevention that addresses the spectrum of weight-related disorders within interventions. The identification of risk factors that are shared between these weight-related disorders is an essential step to developing effective prevention interventions. This article provides preliminary support for the existence of shared risk factors for obesity and eating disorders. Specifically, the authors examined and found preliminary evidence that dieting, media use, body image dissatisfaction and weight-related teasing may have relevance for the development of the spectrum of weight-related disorders. Future etiologic research designed to specifically test these and other potentially shared risk factors is needed and would provide important insights into the relevant factors to be addressed in interventions aimed at preventing a broad spectrum of weight-related disorders.
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Introduction |
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TopAbstractIntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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Obesity, eating disorders and unhealthy dieting practices among youth are of serious public health concern due to their high prevalence and adverse effects on psychosocial [1, 2] and physical health [3–5]. The prevalence of overweight [body mass index (BMI)
95th percentile for age and sex based on Centers for Disease Control and Prevention growth charts [6]] among children and adolescents has increased steadily over the past three decades; currently, 15% of youth aged 6–19 are overweight [7]. Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating disorder, affect a much smaller percentage of the adolescent population (1–3%), but are of great concern given their serious health consequences [8, 9]. Eating disorders not meeting clear Diagnostic and Statistical Manual of Mental Disorders—fourth edition diagnostic criteria affect a much larger segment of the adolescent population, with prevalence estimates as high as 15% [10]. Furthermore, the Youth Risk Behavioral Surveillance System (YRBSS) found that >11% of high school girls and 7% of high school boys in the United States reported taking diet pills, powders or liquids to lose weight [11]. Eight percent of girls and close to 4% of boys reported vomiting or taking laxatives in the past month [11]. In response to this ‘rising tide’ [12, p. 755] of weight-related disorders, obesity and eating disorder researchers have begun calling for collaboration between the fields to address these disorders [13–17]. Researchers have provided strong empirical and practical arguments for integrating efforts to prevent obesity and eating disorders [13–15]. Empirical support for this integrated approach is provided by research suggesting that these weight-related disorders are not distinct from each other [13]. Evidence from cross-sectional studies suggests that these disorders can occur simultaneously in the same individual [13]. For example, in a large population-based survey of adolescents, Boutelle et al. [18] found that overweight adolescents are more likely than their non-overweight peers to engage in unhealthy weight control behaviors, such as diet pill use, vomiting and laxative use. Research also suggests that individuals may crossover from one condition to another [13]. Fairburn et al. [19] used a case–control design to identify factors associated with the development of bulimia nervosa and found that the odds of being obese as a child was three times higher among individuals with bulimia as compared with healthy controls. Practical reasons to simultaneously address obesity and eating disorders in prevention interventions include the economic efficiency of addressing two conditions within a single intervention [13, 15] and a reduced risk of inadvertently causing one disorder (e.g. obesity) while trying to prevent another (e.g. clinical eating disorder) [13, 14, 20].
A major challenge to developing interventions that are able to prevent both obesity and eating disorders is the identification of potent and modifiable factors that have relevance for both conditions [20]. Identification of appropriate risk factors for the condition being targeted is essential to developing effective prevention interventions [21]. The aim of this paper is to identify and explore the evidence for factors of potential relevance for obesity and eating disorders that could serve as focal points for integrated prevention interventions.
The paucity of etiologic research investigating the shared risk factors among obesity, eating disorders and disordered eating behaviors precludes the presentation of conclusive evidence of these shared factors. Thus, this article is intended neither as a definitive nor as a comprehensive review of all risk or protective factors that may be shared between obesity and eating disorders. Instead, this article is an initial exploration of the evidence for the following factors that may have relevance for both weight-related disorders: dieting, media use, body image and weight-related teasing. These factors were selected on the basis that they are both amenable to change and suitable for addressing within prevention interventions among youth.
For each of these potential shared risk factors, a number of potential pathways by which these factors may be associated with obesity and eating disorders are described and illustrated. These pathways are not presented as conclusive causal pathways, but rather as plausible pathways that have a theoretical basis, are supported by empirical findings and are worthy of further exploration.
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Dieting |
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TopAbstractIntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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A high number of adolescents and children report dieting for weight loss. In population-based surveys with youth, dieting is often assessed using a single item (e.g. how often have you been on a diet to lose weight), which may or may not provide a brief definition of dieting (e.g. by diet, we mean change the way you eat to lose weight) [22]. In 2003, the YRBSS found that almost 60% of female and 29% of male school students were trying to lose weight [11]. Prevalence estimates for dieting among children aged 6–11 range from 20 to 56% for girls and from 31 to 39% for boys [23, 24]. Research suggests that dieting behavior may be causally linked to both obesity [25] and eating disorders [26].
Dieting and obesity
Although dieting is often touted as a solution to the rising obesity epidemic, a number of prospective studies suggest that dieting is not effective in preventing weight gain [27–29]. Furthermore, recent cross-sectional and prospective data suggest that dieting may actually be associated with an increased risk of obesity among children and adolescents. Cross-sectional data have consistently shown BMI to be positively correlated with dieting behaviors among both children [30–32] and adolescents [18, 22]. While these cross-sectional data do not provide evidence regarding the direction of the association, prospective data from three large observational studies have shown that dieting predicts weight gain among adolescents [25, 33, 34]. The largest of these three prospective studies followed 8203 girls and 6769 boys for 3 years and found that adolescents who reported dieting at baseline gained more weight than non-dieters, adjusting for baseline BMI, pubertal development, dietary intake and physical activity/inactivity [25].
The dietary restraint model, developed by Polivy and Herman [35], attempts to explain how dieting could lead to weight gain (Fig. 1). As posited by the model, dieting requires the acquisition of a ‘cognitive style’ of eating as opposed to eating in response to physiological cues of hunger and fullness [35]. Using cognitive control puts individuals at risk for disinhibited overeating, which involves loss of cognitive control over eating and is thought to occur as a result of the breakdown of prior restraint [36]. Thus, this disinhibition may increase vulnerability to bingeing and overeating. Findings from prospective studies showing that dieting predicted the development of binge eating behavior among adolescent girls provide support for the dietary restraint model [37–39].
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Dieting may also lead to an increase in metabolic efficiency (Fig. 1). Therefore, those that have restricted caloric intake for a certain period of time may alter their metabolism such that they require fewer calories to maintain their weight [40].
Another potential explanation for the association between dieting and weight gain is that individuals may engage in short-term dieting behaviors instead of more sustained eating and exercise behaviors that would likely be more effective in reducing or maintaining weight (Fig. 1). A related explanation is that self-reported dieting more aptly represents a mind-set than an actual set of behaviors. Dieters may feel that they are restricting their dietary intake; however, their actual caloric intake may not be reduced. Indeed, studies have found that dieters and non-dieters may not differ significantly with regard to their caloric intake [41, 42]. Furthermore, findings from qualitative research suggest that there is a wide variability in the behaviors that adolescents define as ‘dieting’ [43, 44]. Additional research is needed to more clearly define dieting behaviors among youth and to examine whether or not dieting behaviors are used by youth in place of more effective and sustained behavior change.
Dieting and eating disorders
Retrospective data from individuals with eating disorders provide evidence of the association between dieting and eating disorders. A number of studies involving clinical samples have found that the majority of individuals with eating disorders report that they started to diet before they initiated their disordered eating behaviors [45, 46]. Further evidence of the association is provided by prospective studies within community samples of adolescents. Among adolescents, self-reported dieting has been shown to predict increased risk of disordered eating behavior [39, 47–49] and sub-threshold eating disorders [26, 50, 51]. These results suggest that self-reported dieting among adolescents may lead to more severe eating pathology (Fig. 2).
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Seemingly conflicting results have been found in experimental studies with females, which have shown that assignment to a prescribed low-calorie diet was associated with greater decreases in eating disorder symptoms as compared with controls [52–56]. A plausible explanation for these apparent inconsistent findings is that the experimental interventions, which typically involve education sessions promoting healthy dietary behaviors (i.e. eating a balanced diet, eating regular meals), result in participants engaging in more healthful weight loss behaviors than are typically practiced in the general population.
Collectively, findings from the cross-sectional and prospective studies investigating associations between dieting and weight gain and between dieting and disordered eating behaviors suggest that interventions aimed at preventing youth from engaging in dieting behaviors have the potential to reduce the incidence of obesity and eating disorders. Given the strong influence that peers and families can have on the dieting behaviors of youth [57–59], interventions that include strategies focused on changing peer and family norms, such as educating parents that the comments they make about their own weight or their child's weight can be counterproductive to obesity prevention efforts and implementing anti-dieting campaigns in school settings, may be effective in reducing dieting among youth. In addition, providing youth with the skills and support for healthy alternatives to dieting, (i.e. healthy eating and regular physical activity) may also be effective in reducing dieting behavior among youth [60, 61].
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Media |
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TopAbstractIntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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Media are ubiquitous in American society. A recent study surveyed a nationally representative sample of youth and found that, on average, youth spend 6.5 hours per day watching television and videos, using print media, playing video games, using computers and listening to CDs, MP3 players, tapes and the radio [62]. Media use and the internalization of the messages promoted by the media have been explored as putative risk factors for both obesity [63, 64] and eating disorders [65, 66].
Media and obesity
In general, cross-sectional studies have shown a positive association between media use and BMI in children and adolescents [64, 67–72]. While several prospective studies [56, 66, 67, 68] have found a positive association between television viewing and obesity, others have found no association [76]. Stronger evidence of this association between television use and obesity is provided by two school-based obesity intervention trials, which found that reducing television use predicted decreases in obesity prevalence among middle school girls [60] and BMI among elementary schoolchildren [77].
Television has been proposed to contribute to obesity through two main mechanisms: by reducing energy expenditure due to displacement of physical activities and by increasing dietary intake during viewing or as a result of food advertising (Fig. 3) [63, 78]. Evidence is strongest for this second mechanism [79]. Children view 
40 000 advertisements per year [80], the majority of which are for sugared cereals, candy and fast food [81]. In a recent review of the literature examining the effect of television on children's consumption patterns, Coon and Tucker [82] conclude that exposure to food advertisements significantly increases the likelihood that a child will select or request the advertised product. Cross-sectional studies have found associations between television viewing and higher intakes of fast foods [83] and soda pop [84], suggesting that a higher exposure to advertisements for unhealthy foods may increase intake of those foods.
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Media and eating disorders
Due to the ubiquitous nature of media in our culture and its relentless promotion of the thin beauty ideal, media has long been identified as a potential risk factor for eating disorders [65, 66]. A key tenet of sociocultural theories of eating disorders is that society, through avenues including mass media, pressures individuals to conform to the cultural ideal for size and shape [85]. This cultural ideal has changed throughout history, becoming increasingly thin for females [86] and increasingly lean and muscular for males [87]. Theoretically, media's pressure to conform to the ideal promotes internalization of this ideal [88, 89]. Internalization, in turn, leads to body dissatisfaction because the cultural ideal is unattainable for most people [89]. Body dissatisfaction then leads to disordered eating and negative affect, which may lead to an increased risk for eating disorders (Fig. 4) [88]. Findings from cross-sectional, prospective and experimental studies provide evidence in support of this model.
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Several cross-sectional surveys have found a positive association between media use and body dissatisfaction and disordered eating behavior among both children and adolescents [90–94]. Evidence from a recent prospective study provides further support for this association; Vaughan and Fouts [95] found that decreases in magazine reading over 16 months were associated with decreases in eating disorder symptoms among a sample of adolescent girls.
Numerous laboratory-based experiments have also examined the short-term effects of exposure to media images of the thin fashion models among samples of adolescent and young adult women. A recent meta-analysis of these laboratory-based experiments suggests that exposure to thin-ideal images causes a modest, acute increase in body dissatisfaction [96]. Randomized experiments have also shown that exposure to thin-ideal images results in increases in negative affect [97–99]. Among males, experimental research examining exposure to media images and body satisfaction has produced mixed results. Some studies have found that exposure to muscular ideals has acute negative effects on body build satisfaction in young men [100–102], while others have found no association [103, 104].
Findings from prospective research provide evidence for the hypothesized association between thin-ideal internalization and eating disorder symptoms. Thin-ideal internalization has been shown to predict body dissatisfaction [49] and disordered eating behaviors [39, 47]. In one study, Field et al. [47] found that girls who reported at baseline trying to look like females in the media were almost two times more likely to report purging behavior one year later than those that did not report trying to look like figures in the media, after adjustment for age and BMI.
The implications of these findings are that interventions aimed at decreasing media use and increasing children's critical viewing skills through media literacy may be effective in reducing the incidence of obesity and eating disorders in youth. Practitioners and interventionists could implement strategies that encourage parents/caregivers to restrict youth's media viewing times and access by taking televisions out of bedrooms and limiting the types of magazines that are available in the home. Schools and community-based organizations that serve youth could implement media literacy interventions that strive to educate youth about the advertising process and provide them with skills to critically analyze the media they consume [105–108].
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Body dissatisfaction |
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TopAbstractIntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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Body dissatisfaction is common among children and adolescents. Approximately 50% of girls and 30% of boys report that they are dissatisfied with their bodies [22, 109, 110]. Body image dissatisfaction may have relevance for the development of obesity due to its association with binge eating [100] and lower levels of physical activity [101]. Body image dissatisfaction is also an established risk factor for eating disorders [111].
Body dissatisfaction and binge eating
A number of prospective studies have shown body dissatisfaction to be predictive of binge eating behavior (Fig. 5) [38, 112, 113]. For example, Johnson and Wardle [112] followed a sample of 960 adolescent girls for 10 months and found that girls who were dissatisfied with their body were at 1.5 times the odds of initiating binge eating as compared with those who were satisfied with their body. This association between body dissatisfaction and binge eating may be mediated by dieting behavior, which may lead to hunger, followed by overeating [38, 39, 114]. Alternatively, the association between body dissatisfaction and binge eating may be mediated by negative affect [38], since body image plays a central role in adolescents' overall feelings of self-worth [115].
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Body dissatisfaction and physical activity
Researchers have hypothesized that body image dissatisfaction may conceivably be beneficial for individuals with average or above-average BMI values because it may be a motivating factor to engage in healthy weight management behaviors [116, 117]. However, results from qualitative, cross-sectional and prospective studies examining the association between body image and physical activity among adolescents suggest that body dissatisfaction may not be a motivator for physical activity and that it may actually be associated with decreased participation in physical activities (Fig. 5) [113].
Olafson [118] conducted individual interviews and three focus groups with adolescent girls to investigate adolescent girls' experiences in physical education classes. Not liking how they felt about their bodies was identified by the girls as a major obstacle to engaging in physical activity. Cross-sectional findings similarly suggest that lower levels of body satisfaction are associated with lower levels of physical activity [119–121].
Prospective findings from a large, population-based study suggest that lower levels of body image satisfaction are predictive of lower levels of physical activity among both male and female adolescents, after controlling for baseline level of physical activity and demographic variables [113]. When BMI was added to the model, the association remained significant among the girls, but not among the boys. Thus, it appears that the association between body image satisfaction and physical activity may differ by gender [113]. Given the paucity of longitudinal research examining the association between body image and physical activity and the potential importance this association may have for obesity risk among youth, additional studies are needed to further elucidate the association between body dissatisfaction and physical activity levels among adolescents.
Body dissatisfaction and eating disorders
Body dissatisfaction is one of the most consistent and robust risk factors for eating disorders [111]. Body dissatisfaction is hypothesized to lead to increased risk of eating disorders via three mechanisms (Fig. 6). The first proposed mechanism suggests that body dissatisfaction leads to elevated attempts to reach the thin ideal using dieting behaviors, which in turn increases the risk for eating pathology [26, 47]. The second hypothesized mechanism is that body dissatisfaction contributes to negative affect (anxiety or depression), which, in turn, is thought to increase the risk of binge eating and the use of radical compensatory behaviors, such as purging behavior [49]. Third, body dissatisfaction may directly promote the development of eating disorders [111].
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There is a substantial support for the role of body dissatisfaction in the development of dieting behaviors. Cross-sectional studies have shown that children and adolescents with higher levels of body dissatisfaction also engage more frequently in dieting behaviors [122–124]. Prospective studies involving adolescent girls have found that elevated body dissatisfaction at baseline were significantly associated with dieting behaviors at follow-up 8 months later [114], 9 months later [125] and 20 months later [49]. There is also evidence from prospective studies that body dissatisfaction predicts negative affect [126–128]. Numerous prospective studies have found body dissatisfaction to predict bulimic behaviors [39, 47, 129] and eating pathology [50, 114].
Findings from cross-sectional and prospective research investigating the association between body dissatisfaction and binge eating, body dissatisfaction and physical activity and body dissatisfaction and eating disorders suggest that interventions aimed at improving body satisfaction may have implications for the prevention of obesity and eating disorders among youth. Body image dissatisfaction is more commonly addressed in eating disorder interventions than in obesity prevention interventions [130, 131]. However, the findings presented here suggest that body image dissatisfaction could be a potential risk factor rather than just a consequence of weight gain and obesity. Therefore, thought needs to be given to how to address issues of body image within obesity prevention programs. Incorporating intervention strategies that enhance body satisfaction will likely be more effective than motivating adolescents toward behavioral change via decreasing their comfort with their bodies [113]. Strategies that may effectively promote a positive body image among youth include individual-level strategies, such as psychoeducational activities that provide youth with opportunities to learn about and challenge sociocultural ideals of body size and shape [e.g. 132], and environmental-level activities, such as working with peer groups to reduce the level of body comparison and negative body talk that occurs among youth [e.g. 133].
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Weight-related teasing |
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TopAbstractIntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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Weight-related teasing is prevalent among adolescents and children with overweight youth reporting higher levels of weight-related teasing compared with their average weight peers [134–137]. Weight-related teasing has been shown to be associated with both binge eating and other disordered eating behaviors (e.g. purging, restricting), suggesting that it may have a potential relevance for the development of both obesity and eating disorders.
Teasing and binge eating behavior
A large, cross-sectional survey of adolescents found that among overweight adolescents, those who experienced weight teasing had two times the odds of engaging in binge eating behavior as compared with youth who did not report teasing [135]. Data from a case–control study by Brown et al. [138] provide further support for the hypothesis that teasing is associated with binge eating behavior. Brown et al. [138] compared a sample of adolescent female binge-purgers with a matched group of female controls and found that binge-purgers were more likely than controls to report that peers had made fun of them or rejected them because of their appearance during childhood. Longitudinal evidence of an association between weight teasing and binge eating is provided by a large study of adolescents, which found that weight teasing was predictive of binge eating among both females and males after adjustment for age, race/ethnicity and socio-economic status [139]. When BMI was added to the model, the association remained significant among males and was marginally significant among females [139].
Given the importance placed on body shape and size in the US culture and the important role weight plays in how adolescents feel about themselves, it is possible that being teased about weight may result in depressive symptoms or body dissatisfaction [140–142], which may lead to binge eating behavior [38]. Being teasing about weight may also cause an individual to diet in an attempt to avoid future weight-related stigmatization, which may lead to binge eating behavior. Binge eating, in turn, can lead to an increased risk for weight gain and obesity [33], as depicted in Fig. 7.
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Teasing and eating disorders
Teasing has also been shown to be associated with disordered eating behaviors, such as purging and restricting behaviors. Among adult populations, studies have examined the relation of retrospective reports of teasing and use of disordered eating behaviors and found that women who were teased about their appearance as children demonstrate higher levels of restrictive eating patterns than women who did not report being teased [134, 143–145].
Among adolescents and children, cross-sectional research has shown that being teased about weight is associated with higher levels of disordered eating behaviors [90, 135, 146, 147]. Fewer prospective studies have examined the effects of teasing on the development of disordered eating behaviors. Cattarin and Thompson [142] followed a sample of adolescent girls for 3 years and found that teasing was directly associated with the level of appearance dissatisfaction, which in turn predicted use of restrictive and bulimic behaviors. Wertheim et al. [114] found that weight-related teasing predicted subsequent levels of bulimic behaviors among adolescent girls. Conversely, Field et al. [47] found that weight-related teasing was not related to subsequent purging behaviors, after accounting for other relevant factors.
Gardner et al. [148] followed a sample of children aged 6–14 for 3 years, and observed that teasing predicted higher eating disorder scores among males but not females. Similar gender differences were seen in longitudinal analyses of a large sample of adolescents [139]. It is possible that because females receive more messages about achieving the ‘thin ideal’ from a larger range of sources than their male counterparts, weight teasing does not independently explain as much of the variance in these behaviors in females as it does in males.
Taken together, the cross-sectional and prospective research on the impact of teasing on dieting and disordered eating behaviors suggests that being teased about weight may function directly or indirectly through body/appearance dissatisfaction to influence the use of dieting and disordered eating behaviors. As discussed previously, dieting and use of unhealthy weight control behaviors may increase the risk for developing an eating disorder (Fig. 8) [26, 47].
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Although prospective research examining the association between weight teasing and these behaviors is limited, the evidence from the existing cross-sectional and prospective studies suggest that being teased about weight is positively associated with binge eating and other disordered eating behaviors (e.g. purging, restricting). Thus, interventions aimed at reducing weight-related teasing in youth may have relevance for obesity and eating disorders. Strategies that may be effective in reducing weight-related teasing among youth include (i) the implementation of clear no-teasing policies at schools and community-based organizations that serve youth and (ii) intervention activities focused on reducing verbal harassment and improving conflict resolution and communication skills among youth.
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Conclusion |
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TopAbstractIntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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As a result of the high prevalence of obesity, eating disorders and disordered eating among youth and the evidence suggesting these disorders may not be distinct from one another, there has been increasing interest among obesity and eating disorder researchers to utilize an integrated approach to the prevention of these disorders. Identification of risk factors that are shared among these weight-related disorders is an essential step to developing effective prevention interventions. This article provides preliminary support for the existence of shared risk factors for obesity and eating disorders. Specifically, this article examined and found preliminary evidence that dieting, media use, body image and weight-related teasing may have relevance for the development of the spectrum of weight-related disorders.
This information can be used to inform future etiologic research and intervention design. Prospective studies can be designed to specifically test the pathways proposed in this article. These associations can also be examined using experimental research, such as community-based trials, which would provide stronger evidence of causality than can be achieved with prospective studies. In addition to the factors and pathways highlighted here, other potential shared risk and protective factors that may be worthy of further etiologic inquiry include self-esteem, depression, dietary intake patterns (e.g. meal patterns), the role of parental encouragement or role modeling of weight-related behaviors and the role of a home environment that is supportive of healthy eating and physical activity behaviors.
The findings from this review also have implications for the development of prevention interventions. This review provides preliminary evidence of factors that are amenable to intervention and that may have relevance for both obesity and eating disorders. Thus, these factors may serve as important focal points for an intervention aimed at simultaneously addressing both obesity and eating disorders.
Many of the factors reviewed in this paper are more commonly addressed in interventions focused on the prevention of eating disorders rather than obesity. However, as evidenced by this review of the literature, many of these factors, including dieting, body dissatisfaction and teasing, can lead to increased weight gain and obesity. Thus, the effectiveness of obesity prevention programs may be improved by including messages that address these risk factors, in addition to the typical obesity prevention messages of increased physical activity and improved dietary intake. Interventions that use this more integrated approach may also have the added benefit of reducing the risk of eating disorders among youth.
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Conflict of interest statement |
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TopAbstractIntroductionDietingMediaBody dissatisfactionWeight-related teasingConclusionConflict of interest statementReferences |
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None declared.
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References |
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