Eating Disorders

The Journal of Treatment & Prevention

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Prevention of eating disorders: 2018 in review

Michael P. Levine

To cite this article: Michael P. Levine (2019): Prevention of eating disorders: 2018 in review,
Eating Disorders, DOI: 10.1080/10640266.2019.1568773

To link to this article: https://doi.org/10.1080/10640266.2019.1568773

Published online: 31 Jan 2019.

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EATING DISORDERS
https://doi.org/10.1080/10640266.2019.1568773

Prevention of eating disorders: 2018 in review

Michael P. Levine
Department of Psychology, Kenyon College, Gambier, Ohio, USA

ABSTRACT
This article reviews the 10 prevention-related publications in Eating
Disorders: The Journal of Treatment & Prevention during 2018. Two
models frame this analysis. This first is the Mental Health
Intervention Spectrum from health promotion → types of preven-
tion → case identification and referral → treatment (recovery).
The second parses the phases of prevention into rationale, theory,
and methodology → clarification of risk factors, including very high
risk, shading into warning signs → implications for specific preven-
tive interventions → design innovation and feasibility (pilot)
research → efficacy and effectiveness research → program disse-
mination. Collectively, the articles illustrate how complex and
demanding the field of prevention is, with respect to, for example,
phases of program development, the multidimensional ecology of
interventions, and methodological requirements for demonstrat-
ing that a program deserves to be designated “evidence-based.”
A subset of the articles also illustrates how far the increasingly
broad and dynamic field of prevention has advanced. Examples
include models of eating disorder development in high-risk popu-
lations such as people with type 1 diabetes; prevention program-
ming for young children; and after-school preventive interventions
that combine dissonance-based lessons with empowering partici-
pation in community advocacy and activism.

Implications for Prevention Practice

● The Mental Health Intervention Spectrum facilitates understanding of forms
of prevention and the relationship between health promotion, prevention,
and treatment.
● Risk factor research in service of prevention should be guided by multi-
dimensional etiological models with clear implications for prevention.
● More program innovation and evaluation research is needed for prevention
of ED risk factor development in young children.
● More program innovation and evaluation research—especially effectiveness
studies—are needed for after-school and other community-based preventive
interventions that increase critical social consciousness and engagement in
constructive social change.

CONTACT Michael P. Levine Levine@kenyon.edu Department of Psychology, Kenyon College, Gambier,

OH 43022, USA
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/uedi.
© 2019 Taylor & Francis
2 M. P. LEVINE

Table 1. Phases of prevention research and the 10 prevention-related articles in the 2018 issues
of Eating Disorders: The Journal of Treatment & Prevention (Volume 26).
Important 2018 Non-EDJTP
Prevention Phase 2018 EDJTP Article(s) Articles and Book Chapters
Prevention rationale, -None - Taylor, Fitzimmons-Craft, & Goel
theory, and 2018
methodology

Clarification of risk and (1) Haynos, Wang, & Fruzzetti 2018; (2) Hazzard, Stice & Desjardins; Vartanian
of very high risk or Borton, Bauer, K. W., & Sonneville; (3) Watson et al. 2018; Graham et al. 2018
warning signs et al. 2018(4) De Paoli & Rogers 2018; (5) Higgins
& Cahn 2018; (6) Worsfold & Sheffield

Implications for specific (7) Damiano, Yager, McLean, Paxton 2018 Austin, Liu, & Tefft 2018; Pennesi
preventive & Wade 2018
interventions

Design innovation (8) Damiano, Yager, McLean, Paxton 2018 Green et al. 2018; Pennesi &
Wade 2018

Efficacy research and (9) Eickman et al. 2018 Golan & Ahmad 2018; Rodgers
et al. 2018; Warschburger &
Zitzmann 2018

Effectiveness research - None - Stinson, Perez, Ohrt, Von Schell,

& Bruening 2018; Wilksch,
O’Shea, Taylor, et al.

Program dissemination (10) Green & Venta 2018; (11) McAndrew & Ciao, Ohls, & Pringle 2018; Le,
Menna 2018 Hay, & Mihalopoulos 2018; Lee
et al. 2018

● Valid and practical measures for screening large populations are needed to
link individual levels of ED risk to confidential and individually tailored
referrals for levels of prevention or treatment.

This article reviews the 10 prevention-related publications in Eating

Disorders: The Journal of Treatment & Prevention during 2018 (see Table
1). Each is summarized and connected to established phases of prevention
research, and in the Reference section, they are preceded by an *. I conclude
by considering their implications for theory, practice, and research. Space
limitations prevent (no pun intended) analysis of important prevention
reviews or research published in other journals in 2018, but recommended
samples for each phase are included in Table 1.
 EATING DISORDERS 3

Definitions and frameworks

Prevention refers to sociocultural, interpersonal, and personal factors that
head off entirely the occurrence of a disorder or substantially delay its
development. Because disorder often emerges in response to cumulative
stressors, another aspect of prevention is enhancing resilience by promoting
components of effective coping, including social support (Levine, 2017).
The Mental Health Intervention Spectrum helps to integrate health
promotion, prevention, and treatment (National Academies of Sciences,
Engineering, and Medicine, 2016; National Research Council and Institute
of Medicine, 2009; see Figure 1). It runs from general health and resilience
promotion → universal prevention → selective prevention → indicated
(targeted) prevention → screening/assessment for case identification →
intervention → aftercare. Universal programs change cultural attitudes
and practices, public institutions, and social policies in order to prevent
eating disorders (EDs) in extremely large groups of people at varying
degrees of risk. Selective interventions also seek to change the developmen-
tal ecologies of participants, but these programs are designed for large
groups of symptom-free people who are at risk due to different combina-
tions of biological, psychological, and sociocultural factors. The prototypi-
cal “universal” classroom-based curriculum potentially available to large
groups of mixed-risk students falls between universal and selective preven-
tion (Levine & Smolak, 2006).

Figure 1. The mental health intervention spectrum.

Source. Reprinted with permission, courtesy of the National Academies Press, from National
Academies of Sciences, Engineering, and Medicine (2016). Preventing bullying through science,
policy, and practice (p. 180). Washington, DC: The National Academies Press. DOI: 10.17226/23482
4 M. P. LEVINE

Indicated (an adjective that avoids the hostile connotations of “targeted”)

programs are designed for people at high or very risk for ED onset. Exhibiting
warning signs (e.g., mild symptoms) or well-documented precursors (e.g.,
high levels of weight/shape concerns) “indicates” need for an intervention.
Such distinctions are often difficult to apply. Prevention research programs
recruiting people who want help with body dissatisfaction (a well-
documented risk factor) are likely to generate a sample of people at high
risk, very high risk, and in transition to an ED. Consequently, although the
program may be labeled “selective” or “indicated,” it is more accurately
categorized as selective-indicated.
The organization of Table 1 reflects one useful way to parse the phases in
creating, evaluating, refining, and disseminating a preventive intervention:
Prevention rationale, theory, and methodology → clarification of risk factors,
including very high risk, shading into warning signs → implications for
specific preventive interventions → design innovation and feasibility (pilot)
research → efficacy and effectiveness research → program dissemination,
including evaluation and modeling of cost-effectiveness, plus illumination of
internal and external obstacles to participating (Becker & Stice, 2017; Becker,
Stice, Shaw, & Woda, 2009; Levine, 2017).

Important 2018 articles outside the purview of this review

This framework does not capture every important aspect of prevention scholar-
ship. Universal prevention necessarily focuses on improving populations (Levine
& Smolak, 2006), so the relationship between translational prevention science and
transformations in social policy is especially relevant (Biglan, 2018; see also Austin,
2016). The interplay between theory, program development, evaluation, and
dissemination is featured in recent reviews of ED prevention that is mindfulness-
based (Beccia, Dunlap, Hanes, Courneene, & Zwickey, 2018) or Internet-based
(Wade & Wilksch, 2018). Similarly, integration of ED and obesity prevention is the
focus of two studies by Stice, Shaw, and Rohde (see, e.g., Stice, Rohde, Shaw, & Gau,
2018). In this regard, also noteworthy are evaluations of Internet-based programs –
one for adolescents (Bell et al., 2018) and one for adult women (Nacke et al.,
2018) – that match different levels of risk in a large audience, as determined by
screening, to specific types of ED prevention or treatment that also address
unhealthy weight status. Finally, a recent article by Leadbeater et al. (2018),
commissioned by the Society for Prevention Research (www. preventionre
search.org), provides much-needed attention to a neglected topic in the field of
ED prevention: ethics.
 EATING DISORDERS 5

Risk factors informing prevention

There are no necessary or sufficient conditions for the development of an
ED. Consequently, theorists and researchers committed to prevention con-
sider risk factors (RFs). The truism “correlation does not equal causality”
obscures the fact that lack of correlation does indeed mean lack of causality.
Establishing correlation, especially in the context of predictions based on
a model, is a necessary but not sufficient step in RF research. Beyond that, an
RF is a correlate with predictive utility; it is a variable that is reliably and
meaningfully associated with an increase over time in the probability of
a negative outcome. Successful prevention by averting or reducing risk factor
X establishes that variable as a causal risk factor (Kraemer et al., 1997).
In many people with an ED, dietary restraint functions to manage emotional
distress, which itself may be compounded by an inability to differentiate and
label specific feelings and needs. However, this conjunction does not mean that
emotional dysregulation, such as under-control, constitutes an RF for over-
restrictive eating in people without an ED. Haynos et al.’s (2018) cross-
sectional survey of a small sample of female and male U.S. undergraduates
provided initial support for this hypothesis. Even controlling for age, gender,
BMI, and score on the EDE-Q’s dietary restraint subscale, there were significant
relationships between components of the Difficulties in Emotional Regulation
Scale (DERS) and a clinically validated, single-item measure of dietary restric-
tion status: whether in the past month the person was “consuming objectively or
contextually too little in order to impact body image” (p. 6). Most telling, the two
very strong predictors were DERS total score and the dimension of self-reported
problems in dealing with emotional distress.
Two other articles published in Eating Disorders during 2018 also used
survey research to examine stressors, distress, and maladaptive coping via
unhealthy weight control behaviors (UWCBs) that themselves are RFs for
EDs and part of ED syndromes. Watson et al. (2018) examined UWCBs
reported by approximately 18,500 sexually active youth from the 1998, 2004,
and 2010 waves of the Minnesota Student Survey. Previous studies indicate
that youth who report bisexual or homosexual experiences in the past year
would be at risk for UWCBs because they experience threatening, distressful
social stigma, in addition to pervasive sociocultural pressures pertaining to
objectification, glorification of thinness, and vilification of fat.
Consistent with other findings, and with the ultimate objectives of pre-
vention, the prevalence of UWCBs self-reported by sexually active males and
females in high school declined over the years (Watson et al., 2018).
Nevertheless, as predicted by a stressor-maladaptive coping model of dis-
ordered eating (DE), in all three surveys sexual minority boys were signifi-
cantly more likely to pursue weight loss through fasting, use of diet pills, and
self-induced vomiting. Interestingly, girls reporting bisexual experiences, but
6 M. P. LEVINE

not girls reporting homosexual experiences, were significantly more likely

than girls with a heterosexual orientation to pursue weight loss through diet
pills and intentional vomiting. If replicable, these findings raise a number of
testable hypotheses, including exclusively lesbian sexual experiences are less
stigmatized and thus less stressful, generating lower levels of UWCB; and, for
males as well as females, sexual relationships in the presence of the male gaze
produces more self-objectification, leading to greater UWCB.
Hazzard, Borton, Bauer, and Sonneville (2018) analyzed data from over 3,343
emerging adults ages 18 through 26 who participated in Wave III (2001–2002) of
the National Longitudinal Study of Adolescent to Adult Health, which began in
the mid-1990s. After controlling for self-reported femininity, self-esteem, risk-
taking, depression, and various demographic factors (e.g., age, sexual orienta-
tion), for men higher levels of masculinity were associated with significantly
greater use of diet pills, legal performance-enhancing substances (PES), and illicit
PES. Contrary to what many readers would likely predict, for women, there were
no significant associations between dietary and muscle-enhancing product use
and either masculinity or femininity. This study has two implications for future
investigations of RFs for DE and EDs. First, the developmental effects of mascu-
linity need to considered in terms of weight and shape management, not just
drive for a muscular appearance (Smolak & Murnen, 2008). Second, as Hazzard
et al. (2018) note, a better understanding of the impact of gender and identity
requires important distinctions between self-descriptions of one’s gender-linked
traits and one’s endorsement of gender roles and gendered behavior (see
Griffiths, Murray, & Touyz, 2015).

High-risk shades into detection and referral for intervention

As shown in Figure 1, there is a portion of the Mental Health Intervention
Spectrum where indicated prevention for people at very high-risk shades into
case identification and referral – therapeutic intervention is probably “indi-
cated” in order to prevent a more severe disorder, likely compounded by
comorbid conditions. Key issues are education of people in a position to
detect EDs; development of accurate screening; effective communication that
facilitates referral and evaluation; understanding of obstacles to identification
and help-seeking; and resources for knowledgeable evaluation and treatment.
In 2018 Eating Disorders published three articles in this category. De Paoli
and Rogers (2018) conducted the first systematic review of research examin-
ing the relationships between insulin-dependent (type 1) diabetes (IDD), DE,
EDs, and insulin restriction. Males and females with IDD, which typically has
a childhood onset, are at high risk for DE in adolescence and EDs in young
adulthood, and both significantly worsen their diabetic condition and prog-
nosis. RFs include identity disruption, frequent challenges to control one’s
body and behavior, weight fluctuations, and negative affect due to family
 EATING DISORDERS 7

conflicts over disease management. People with IDD have at their disposal
a particularly dangerous method of weight loss via purging. Insulin avoid-
ance or under-dosing disinhibits impaired glucose utilization and thus gen-
erates the breakdown of fat (and protein) stores, as well as many
complications.
De Paoli and Rogers (2018) demonstrate that DE and insulin restriction or
omission in IDD can be comorbid with any form of ED. According to their
transdiagnostic, biopsychosocial model, some children with IDD have
a negative, unstable sense of self that is both intensified by feeling different
and tryannized by perfectionist standards. This generates over-valuation of
the control of weight, shape, and eating, which is amplified by the demands
and stressors of managing diabetes, including weight gain via insulin injec-
tion and the need to control one’s insulin levels by eating (following one’s
“diet”) and exercising “properly.”
In adolescence, these factors enter into unhealthy transactions with family
conflicts, emotional upheaval, and, of course, fluctuations in glucose levels.
These stressors, a fierce focus on diet, control issues, and the emotional instabil-
ity produced by IDD combine with normative developmental factors in adoles-
cence – particularly for maturing girls – to increase the probability of three
mutually reinforcing behaviors: dietary restraint, binge eating, and purging,
possibly via insulin restriction (De Paoli & Rogers, 2018). Further, hypoglycemia
elevates the propensity to eat sugary (“bad” or “forbidden”) foods, which can
disinhibit binge eating, particularly in the presence of cognitive rigidity, negative
affect, and insulin overdosing. Disordered eating and its health complications
can become fixed in a destructive positive feedback loop incorporating low self-
esteem; family stressors; negative affect and emotional instability; intense anxiety
about weight gain and poor hypoglycemic control; wounded autonomy; and
overvaluation of eating, weight, and shape.
De Paoli and Rogers’ (2018) review is a powerful reminder that professionals
seeking to prevent and treat EDs need to be aware of IDD, just as medical
personnel involved in diabetes care must be alert to signs of EDs. Higgins and
Cahn (2018) also address mental health literacy. Given anorexia nervosa’s (AN)
negative health consequences, primary care physicians (PCPs) are well posi-
tioned for early detection and referral. However, in an online study that pre-
sented videotaped vignettes, supplemented by blood count and lipid panel data,
to 160 young PCPs in a major U.S. city, only 61% were able to recognize AN in
a young woman. Correct diagnosis was unrelated to whether the “patient” was
Asian American or White, whether the PCP was female or male, or how
experienced the PCP was. Disturbingly, of those correctly detecting AN, only
40% intended to refer for psychiatric or psychological treatment. In all, <25% of
the PCPs were both sufficiently informed about AN and willing to refer the
woman for therapy.
8 M. P. LEVINE

In another online vignette study of mental health literacy, Worsfold and

Sheffield (2018) examined the ability of 115 psychologists, naturopaths (e.g.,
herbalists, nutritionists without dietetics training), and fitness instructors in
Australia to detect, in a young woman, an OSFED variant of bulimia nervosa
without purging but with excessive, compensatory exercising. A clear major-
ity of professionals in each category saw “Sarah’s” problems as common and
“very-to-extremely distressing,” but only ~20% of the fitness instructors and
~30% of the naturopaths correctly diagnosed an ED. Indeed, they were more
likely to invoke low self-esteem. Although, as expected, psychologists were
more attuned to the presence of an ED, nearly 40% failed to diagnose an ED.
Overall, nearly two-thirds of the professionals felt the issue was not an ED,
and nearly 37% of the fitness instructors perceived Sarah’s condition as
desirable in some respects, particularly her weight loss.

Pilot studies
Illumination of risk and protective factors guides development and initial
testing of innovative prevention, such as the program described by Damiano,
Yager, McLean, and Paxton (2018). Susan Paxton, a distinguished RF
researcher, prevention specialist, and advocate for prevention-related social
policies, is the founder of the EMBodIED Research Team at La Trobe
University in Melbourne. This pilot study is related to their Confident
Body, Confident Child resource pack and website (http://www.confident
body.net/).
Many ED risk factors (e.g., body dissatisfaction) have their foundation in
early childhood. Nonetheless, very little prevention has been designed for
young children and none that is (1) based clearly on theory and evidence-
based risk factors; (2) reliably effective; and (3) intended to be implemented
by teachers alongside their daily educational lessons (Damiano et al., 2018).
Thus, using the prevention literature and an in-depth needs assessment of
elementary school teachers, Damiano et al. (2018) developed the Achieving
Body Confidence for Young Children (ABC-4-YC) program. Its three lessons
(1 hr each) focus on the “school peer environment to improve body satisfac-
tion and reduce weight stigma, internalization of appearance ideals, and
appearance-based teasing in 5- to 8-year-old children….(p. 490).” ABC also
represents three central program components: Admiring Differences (cele-
brating diversity, e.g., in size, shape, weight); Boosting Body Confidence
(appreciating each child’s unique body); and Celebrating Our Brilliant
Bodies (using the children’s book by Iceland’s foremost prevention expert,
Sigrun Daníelsdóttir, 2014, to help children recognize and respect the body’s
many functional qualities). ABC-4-YC consists of a professional development
workshop for teachers, a teacher’s handbook, the children’s book, short
videos, and activity worksheets.
 EATING DISORDERS 9

Damiano et al.’s (2018) pilot study with 50 children found that ABC-4-YC
significantly increased body esteem (large effect size) one week after the
program. There were no changes in weight stigma, and the desired reduc-
tions in internalization of appearance ideals and in appearance-based teasing
(small effect sizes) were not statistically significant. The teachers did deliver
ABC-4-YC as intended, found it to be engaging, and reported all 15 activities
to be either moderately or highly valuable. Overall, ABC-4-YC shows enough
promise to warrant refinement and more rigorous evaluation.

Efficacy studies
Researchers distinguish between a program’s efficacy under ideal and highly
controlled conditions, and its effectiveness under less well-controlled and more
varied real-world conditions. The only prevention efficacy trial published in Eating
Disorders last year was Eickman et al.’s (2018) RCT of the REbeL after-school peer
education program for adolescents ages 11 through 18 (see http://re-bel.org/). In
this universal-selective intervention REbeL staff train school personnel and peer
leaders to follow a manual and foundational principles in working with volunteer
students who meet after school throughout the year to complete modules and
activities. Emphasizing empowerment, activism, and community, this extracurri-
cular program gives participants the tools to “rebel” against a weight- and shape-
obsessed culture. REbeL is dissonance-based (Becker & Stice, 2017) but features
components of Niva Piran’s feminist empowerment relational model (Levine &
Smolak, 2006, chapter 8; Piran, 2010). Participants take an active role in organizing
their groups, in selecting and applying manual-based material (e.g., weight bias,
media literacy, promoting positive body image), and in collaborating with local
college students and other community volunteers to conduct prevention-oriented
advocacy projects. REbeL is readily disseminated because it is flexible and partici-
patory in ways that allow it to be easily integrated into and sustained within school
systems or other community organizations.
Following two successful pilot studies (e.g., Breithaupt, Eickman, Byrne, &
Fischer, 2017), Eickman et al. (2018) conducted a yearlong RCT with 48
students (~80% female) in two U.S. high schools (ages 14–18) participating in
weekly REbeL chapter meetings throughout the school year. Although weight
bias was unaffected, there was substantial support for REbeL’s efficacy. At
both high schools the program was more successful than the control program
(moderate to very large effect sizes) in reducing ED psychopathology;
unhealthy dietary restraint; maladaptive concerns with eating, weight and
shape; and body checking. At one high school the program also reduced
internalization of unhealthy body ideals (moderately large effect size) and
increased a sense of empowerment (very large effect size).
10 M. P. LEVINE

Effectiveness studies
Effectiveness trials evaluate a program as it might be implemented by various
stakeholders – and not by the program’s developers – within multiple com-
munities that differ, sometimes greatly, from the setting(s) in which the
program was developed and initially validated. There were no prevention
effectiveness trials published in Eating Disorders last year. Over the past
10 years, though, there has been increased attention to investigating the
effectiveness of programs constructed for widespread and sustainable disse-
mination (Austin, 2016; Becker et al., 2009; Beintner, Jacobi, & Taylor, 2012;
Taylor, Fitzsimmons-Craft, & Goel, 2018).
For example, Wilksch et al. (2018) conducted an RCT of the comparative
effectiveness of adaptations of two evidence-based programs: Student
BodiesTM and a version of Media Smart, revised for indicated (targeted)
prevention. Participants were a community sample of young women in
Australia and New Zealand. Many had OSFED, and the rest were at high
or very high risk for EDs. Both interventions were delivered online by the
weekly release of nine modules in a self-help format without a key feature of
Student BodiesTM: moderation by a therapist.
The results illustrate the difficulty of determining whether an intervention
“works” under rigorous experimental but “real world” conditions.
Approximately a third of those in the Media Smart-Targeted or Student
BodiesTM conditions chose not to access even the first module. And, of those
completing module 1, only a small percentage completed their program, with
women receiving Media Smart-Targeted much more likely to do so (41% vs.
3%). Moreover, compared to assessment-only and Student BodiesTM partici-
pants, women receiving Media Smart-Targeted who completed the 12-month
follow-up assessment reported significantly lower levels of (a) DE (small effect
sizes); (b) negative affect and feelings of ineffectiveness (small to moderate effect
sizes); and (c) clinical impairment (small to moderate effect sizes). Media Smart-
Targeted was also significantly more effective (small effect size) at 6-month
follow-up in reducing internalization of media pressures for achievement of
the thin ideal.

Dissemination: resources and obstacles

To have a broad impact and thereby reduce the incidence of EDs, effective
programs must be disseminated. Evidence-based programs overseen by pro-
fessional researchers need to be publicized, tailored to stakeholders’ needs,
affordable in terms of training and materials, demonstrably cost-effective,
and ultimately accepted and sustained as part of local systems (Austin, 2016;
Becker & Stice, 2017; Becker et al., 2009; Graham et al., 2018).
 EATING DISORDERS 11

Green and Venta’s (2018) survey of 169 first-year students at a U.S. public
university found that, across various types of high schools, not one student was
exposed to ED prevention programming, while only 29% reported any exposure to
information about EDs. Given the prevalence of DE and EDs, there is a need for
mental health literacy that would increase receptivity to dissemination of evidence-
based ED prevention. This type of education requires careful construction. An
experiment by McAndrew and Menna (2018) yielded evidence of the fundamental
attribution bias when young women in college interpret signs of DE. Compared to
women who read a fictional vignette about another woman who exhibited DE,
women who read the same vignette but from the perspective of themselves were
less likely to perceive barriers to getting ED treatment, but less likely to consider the
possibility of an ED and less likely to see a need for professional help because one
could cope with the mental health issues alone. The studies by McAndrew and
Menna (2018) and Wilksch et al. (2018) suggest that young women at very high
risk or with early signs of ED are not all that receptive to many forms of prevention.

Conclusions and implications

The 10 articles published last year in Eating Disorders illustrate how complex
and demanding the field of prevention is, in regard to terminology, the
Mental Health Intervention Spectrum, phases of program development, the
need for multidimensional interventions, and methodological requirements
to earn the vaunted adjective “evidence-based” (Becker & Stice, 2017; Levine,
2017; Levine & Smolak, 2006; Piran, 2010). It is not surprising that, of 39
articles published in 2018 in a “Journal of Treatment & Prevention,” its co-
editors-in-chief identified only 25.6% as “prevention” (n = 6) or “informing
prevention” (n = 4). And yet those articles advance our understanding of,
and commitment to, prevention in four significant ways, while highlighting
important future directions for theory and research.
First, the three risk factors studies (Haynos et al., 2018; Hazzard et al.,
2018; Watson et al., 2018) confirm the importance of subjecting conventional
wisdom to empirical scrutiny, whether the issue is the function of dietary
restraint, the relationship between masculinity and unhealthy weight man-
agement, or distinctions between sexual behavior, sexual orientation, and sex
roles. Longitudinal investigations, including prevention studies, are needed to
determine whether emotional dysregulation, or masculine gender role, or
bisexual behavior, is a variable, causal risk factor for DE or EDs (Kraemer
et al., 1997). To increase its validity, this research should be guided by
predictions derived from multivariate developmental models such as De
Paoli and Rogers’ (2018) explanation of how childhood onset IDD creates
risk for DE and EDs. De Paoli and Rogers’ (2018) review also highlights the
likely importance of identity development and identity disruption in risk for
12 M. P. LEVINE

EDs, and therefore in shaping future prevention programs (see Vartanian,

Hayward, Smyth, Paxton, & Touyz, 2018).
Second, the three studies (De Paoli & Rogers, 2018; Higgins & Cahn, 2018;
Worsfold & Sheffield, 2018) relevant to ways in which indicated prevention
shades into case identification (see Figure 1) emphasize the need for
increased eating disorders literacy in health professionals, as well as other
professionals in a position to observe and influence mental health.
Sociocultural foundations for EDs and for obstacles to identification, referral,
and treatment are well documented, so, training and ongoing professional
development of culturally significant professionals continues to be an area
desperately in need of research and program development.
A third theme is that Damiano et al.’s (2018) pilot study and Eickman
et al.’s efficacy research (2018) are inspiring as well as informative. The
evolution of ABC-4-YC shows that a team-oriented, patient, and long-term
commitment to analyzing the literature regarding risk factors, prevention
and developmental psychology, and to collaboration with school personnel
professionals, can produce a novel and promising universal program for
young children (Damiano et al., 2018). In addition, teachers administer this
program, which is consonant with established curricular policies and profes-
sional development for educators. ABC-4-YC could be readily disseminated,
should efficacy and effectiveness research demonstrate preventive effects and
cost-effectiveness.
Eickman et al.’s (2018) demonstration that an after-school program can be
efficacious is compelling for different reasons. REbeL originated in the skills and
passion of a clinical psychologist in a U.S. community (not the academy), so its
components are a practical blend of expert-driven, dissonance-based lessons with
a “grassroots,” participatory empowerment structure. Eickman et al.’s (2018)
research augments Golan and Ahmad’s (2018) Israeli study showing the efficacy
of an extracurricular version of In Favour of Myself. These studies affirm the need
for more community-oriented programs designed to increase critical social con-
sciousness and constructive social change (Piran, 2010).
Finally, there were no effectiveness studies published in Eating Disorders in
2018 and very limited – and indirect (see, e.g., McAndrew & Menna, 2018) –
attention to a closely related topic, dissemination. This dearth strongly suggests
that ED prevention researchers revisit and follow the Body Project model (Becker
& Stice, 2017). We need to investigate more intensively and extensively the
nature of, and links between, the following aspects of dissemination: prevention
receptivity; collaboration with stakeholders to identify specific community needs,
strengths, and vulnerabilities in regard to prevention; and adaptation and eva-
luation of programs tailored to those communities. Green and Venta’s (2018)
study leaves no doubt that high schools – and, by extension, middle schools – are
unaware of or resistant to (a) the need to prevent EDs, DE, and comorbid
 EATING DISORDERS 13

conditions; and (b) the existence of effective programs (Becker & Stice, 2017;
Levine, 2017; Levine & Smolak, 2006; Taylor et al., 2018).
Consideration of the mental health intervention spectrum (Figure 1) raises
one more topic that, hopefully, will appear in future issues of Eating
Disorders. Valid and practical measures for screening large populations,
such as all Girl Scouts in a region, are needed to determine individual levels
of risk for EDs. The results would be used to tailor individual, confidential
referrals to appropriate starting levels of prevention or treatment. One testa-
ment to how far the ED prevention field has come since its inception 30 years
ago is that models to guide such ambitious but necessary work through the
phases of prevention research are readily available (Bauer & Moessner, 2013;
Graham et al., 2018; Wilfley, Agras, & Taylor, 2013).

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