Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

A Failed Eating Disorder Intervention For Young Girls: Why Telling Girls To Stop Being Anorexic Just Doesn’t Work—Anonymous

In 1978, Hilde Bruch’s seminal book “The Golden Cage: The Enigma of Anorexia Nervosa” first described anorexia as “the relentless pursuit of excessive thinness,” appropriately placing emphasis on the individual’s psychological state rather the disease’s physical manifestations (1, 2). Her book was one of the first attempts to truly understand the psychology behind anorexia; it went beyond the conventional wisdom of the day, which was blaming the girls themselves for not eating and “treating” them by telling (or forcing) them to eat (1). The disease was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, and the most recent edition of the manual gives four diagnostic criteria to identify anorexia: [1] refusal to maintain appropriate bodyweight, [2] intense fear of gaining weight, even if underweight, [3] disturbance in how bodyweight/shape is experienced or denying seriousness of low bodyweight, [4] absence of at least three consecutive menstrual cycles (3).

While by definition a mental illness, anorexia manifests itself through starvation and is thus marked by a wide array of physical health problems (4-5). These range from the relatively benign (inability to think clearly, excessive facial hair) to the extremely serious and possibly fatal (osteoporosis, stunted sexual development, kidney problems, arrhythmia, stroke, and cardiac atrophy) (5-6). The disease is both more common and more fatal than one might suppose. The DSM-IV estimates that one in every 250 girls will suffer from the disease, and in 2001, the National Institutes of Health estimated anorexia’s mortality rate at .56% per year (5-6). This makes anorexia the biggest killer of American teenage girls—the rate is said to be “12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population” (6).

This brief overview of anorexia has already shown that it is an incredibly serious disease. This paper will continue to explain why any intervention which attempts to help those suffering from it will need to respect the fact that it is a psychological disorder with a variety of causes, not the least of which are societal. The Face the Issue commercial fails to do this. The animated commercial was aired on television stations catering to teenage viewers, such as MTV, and is currently available online (7). The commercial, called “You’ll be dead before you’re thin enough,” is narrated by Julianne Moore, a well-known, very attractive, and skinny actress. It lists the negative effects of anorexia, including baldness, infertility, inability to think clearly, and death. The narrator concludes by saying: “it’s not cool and it’s not pretty. You’ll be dead before you’re thin enough. Your choice.” The commercial ends with a link to the sponsoring organization’s website, which is simply a forum for girls to talk—it does not provide any guidance for how to go about obtaining treatment for yourself or a loved one. Since the commercial’s narrator directly addresses anorexic girls, its intent does not appear to be agenda setting, but rather a genuine desire to change behavior.

There are three crucial problems with this intervention, each of which will be discussed in more detail. The first is that the commercial’s apparent reliance on the health-belief model does not accord with the psychological underpinnings of the disease. The second is that the commercial fails to promote self-efficacy because it does not provide feasible first steps towards recovery for those who suffer from the disease, nor does it provide guidance on how to help a loved one get the proper treatment. Last, the commercial ignores the cultural and social influences behind anorexia.

This Commercial Fails Young Girls by Relying on the Fallacies of Choice and Intentional Action

The Health Belief Model (HBM) has long been a basis for public health interventions, and the underlying assumptions made in this commercial indicate that its creators had this model in mind. HBM theorizes that for an individual to take action to avoid a disease, she would need to believe: [1] that she is personally susceptible to it, [2] that the occurrence of the disease would have at least moderate severity on some component of her life, [3] that taking a particular action would be beneficial by reducing her susceptibility to the condition or its severity if the disease occurs, and [4] that it would not entail overcoming important psychological barriers such as cost, convenience, pain, or embarrassment (8). In layman’s terms, the model is based on the theory that people thoughtfully consider the “pluses” and “minuses” of a certain health behavior and rationally decide whether they would like to adopt that behavior; they then act in accordance with that intention. This intervention is the embodiment of HBM because it is premised on the idea that anorexic girls make the rational choice to engage in this self-destructive behavior. The commercial provides a litany of anorexia’s negative effects in an attempt to make the perceived costs outweigh the perceived benefits, and thus change the intention to engage in anorexic behavior. This reliance on HBM shows a lack of understanding of the psychological forces behind anorexia. First, those suffering from anorexia do not make the rational choice to become anorexic, and second, even if someone who was suffering from the disease desired to become healthy, the nature of the disease is not such that intention can be expected to result in a change of behavior without receiving a wide range of therapies (1,2).

In his book “Anatomy of Anorexia,” Steven Levenkon identifies four stages of anorexia (5). The first stage is familiar to almost all women—it is simply dieting, prompted by a desire to be thin and “socially acceptable.” It is at this stage that those who are predisposed towards anorexia become, in a sense, addicted to the “declarations of praise, admiration, and envy from others.” These people proceed to the second stage, where the compulsion to lose weight essentially becomes a life-absorbing obsession. The third stage is marked by “assertiveness”; since girls who develop anorexia tend to be non-assertive, a girl who develops this disease realizes this is her first real act of assertiveness and she develops a sense of defiance, but it’s only with respect to this one thing—her anorexia. Thus to give up anorexia would be to give up her assertiveness. Last is the “pseudo-identity” stage, where the girl feels as though she has achieved a special identity for herself because her appearance and actions have caused all those around her to react—this “pseudo-identity fills in the emptiness she has secretly felt about herself for some time.”

As this framework makes clear, one does not truly “choose” to become or stay anorexic; it is instead a process that one who is genetically or psychologically predisposed to anorexia may go through when prompted by outside circumstances (5). That is, while someone who develops this disease may initially choose to diet, anorexia as a disease does not exist until the compulsion to lose weight becomes an obsession, at which point the idea of simply choosing to eat more is clearly unrealistic. Further, since anorexia is not about health, and, once the disease has officially presented itself, is not even about “coolness,” appeals to the detrimental health and social effects of anorexia are bound to fail (1,2). While perhaps it could be argued that the commercial was trying to target girls still in the first stage of dieting, it still managed to disregard a large part of the social sciences’ literature about how that first stage of anorexia is initiated.

This four stage framework also shows why HBM’s theory that intention, once developed, can be expected to result in a change of behavior is particularly ill-suited to a problem such as anorexia. Even if the commercial did prompt someone who was suffering from anorexia to desire avoiding the negative side effects listed and thereby creates an intent to eat (and that’s a very serious “if”), the psychological nature of the disease means there is no reason to think intent will necessarily translate into action (2,4,8). Levenkon’s four stages establish that someone suffering from anorexia is not only in the midst of obsessive behavior, but giving up that behavior is also giving up an entrenched, defining and (to herself) highly valued part of her personality (5). Clearly, she cannot act on an intent to start eating the same way that someone can act on an intent to get a mammogram. This model does not allow for a situation where one intends something intellectually (e.g., to eat) but is still psychologically incapable of that action without serious mental health treatment (1,2). As the experience of one female anorexia patient, as described by her doctor, illustrates: “Despite developing intellectual insight about [how her preoccupation with her thinness obsession prevented her from achieving her real goals], she had great difficulty letting go of her obsession to be thin. She saw the anorexia as an ogre who had an unyielding hold on her” (9).

This Commercial Fails to Promote Self-Efficacy to Seek Help

Social cognitive theory posits that self-efficacy is an important predictor of change, and this idea was adopted by the health belief model to explain how intention transforms into action (10-11). Self-efficacy is “the conviction that one can successfully execute the behavior required to produce the outcomes” (11). Thus, in the anorexia context, whether or not a young girl or woman ceases engaging in self-destructive anorexic behavior depends on her belief that she is capable of taking the necessary steps.

This commercial fails to recognize the role self-efficacy plays in enabling change by trying to do too much too soon. The commercial essentially tells girls not to be anorexic (which, as the previous section shows, anorexic girls may not believe they are capable of doing) instead of telling girls to make a phone call to a hotline (which can provide initial counseling and references to appropriate resources) or to talk to a friend about how they’re feeling. These latter actions are ones girls may believe they are actually capable of performing, and therefore providing these feasible first steps towards recovery seems like a much more effective approach. By gaining confidence through these first few steps they may be able to get themselves the help they need to really work towards recovery. According to the self-efficacy theory, conquering small steps is one of the ways that an individual can build self-efficacy for the task as a whole (10). Treatment for anorexia may require an overwhelming array of therapies, including interpersonal therapy, family and group therapy, an internist, a nutritionist, an endocrinologist, and a psychopharmacologist (2). To think that someone could even contemplate beginning this process by going to the website provided by the commercial is simply absurd.

The more realistic role that self-efficacy plays in the anorexia context, however, is with respect to the friends and family members of those who suffer from the disease—they must believe there is something they can do to help. Anorexia is unique in that perhaps the best intervention is not one targeted to the person whose actions the intervention is attempting to change because those who suffer from anorexia often do not realize they have a problem (9). One patient treated by Dr. Lucas and described in his book “Demystifying Anorexia Nervosa,” is quoted as saying that “[d]enial was another big part of my anorexia. Although people commented daily that I was too thin or sick...I never saw myself as thin. I denied everything and wondered how everyone else could be so wrong and blind”(9). She continued that it took “forceful efforts from [her] parents and friends to get [her] professional help, because [she] truly didn’t think [she] was eating disordered”(9). Dr. Lucas noted that this experience is typical (9). Thus, it is truly incumbent upon family and friends to seek the necessary help. As organizations such as the American Dietetic Association and Anorexia Nervosa and Related Eating Disorders Inc., make clear when encouraging parents and friends to intervene, this is not an easy task because even the very first step of confrontation can be enormously difficult (12-14). However, as one guidebook to eating disorders notes, “[h]ealth-care professionals can’t afford to wait until the person with the problem is willing to seek help”(4). The Face the Issue intervention ignores the role of family and friends altogether, and therefore obviously fails to promote self-efficacy amongst those groups.

This Commercial Fails to Account for the Cultural and Social Influences Behind Anorexia

Three categories of factors are currently recognized as contributing to the development of anorexia: genetic predispositions, psychological predispositions (e.g. traits of perfectionism and compulsiveness, anxiety disorders), and cultural and social influences (3). The first two factors are stable individual-level factors which a media-based intervention is never going to be able to influence. The proper role for a media-based intervention is to try to change the cultural and social norms surrounding thinness in women. The commercial’s meek attempt at showing that anorexia isn’t “cool” is hardly forceful enough to counteract the powerful messages regarding the import of thinness that girls constantly receive from society. Moreover, the fact that the message is delivered by an actress who is remarkably skinny arguably undermines the legitimacy of the message. This section discusses how society has contributed towards the growth of anorexia and concludes that interventions like the Face the Issue commercial are doomed to fail because they neglect these societal causes.

One clear way that society influences the development of eating disorders is by glorifying thin women through the media. Over a decade ago, one expert on advertising and gender issues noted that ‘[t]he current emphasis on excessive thinness for women is one of the clearest examples of advertising’s power to influence cultural standards and consequent individual behavior. Body types, like clothing styles . . . are promoted by advertising” (19). Further supporting this link between the media and anorexia, a Harvard study found that Fijian women who started watching American TV such as Melrose Place and Xena Warrior Princess at least three times a week were 50% more likely to see themselves as too fat and 30% more likely to diet, even though their culture traditionally valued rounder women (17). The effect of thinness in the media has become so profound that even the fashion industry is starting to recognize the harmful role it can play: last year a Madrid fashion show took the step of prohibiting women with very low BMIs from participating so as to not promote unsafe eating behaviors (18).

External social rewards embrace and affirm the media’s glorification of thin women. For instance, the stereotypes that overweight people are lazy and that thin people are in control of their lives has been found to extend to the business world, where thinner people are said to have an easier time getting jobs and being promoted, and are generally found to experience greater success than those who are overweight (4). If fact, one author has gone so far as to say that obesity may cause poverty, rather than vice-versa (21). The author came to this conclusion after discovering a study which found that thin women tend to have upward social mobility while overweight women experience the opposite trend of downward social mobility (lower income than their parents). She considered this trend in conjunction with several other studies exploring how obesity affects the chances of getting into a better college and marrying wealthier men, and concluded that “fat people are systematically denied economic success” (21). One of the foremost doctors in treating eating disorders remarks in his book that “[a]norexia is unique among obsessional disorders because society invites girls and women to try to lose more weight than is healthy,” and notes that women at dinner parties joke to him about “getting some of that anorexia” (5).

Tied into these ideas of the media’s glorification of thin women and external social rewards for thinness is the age-old concern of peer pressure and the desire to belong. Desire to look attractive for a significant other and desire to gain membership into social organizations such as sororities and cheerleading squads can instigate unhealthy dieting amongst females (4). This desire can even cause girls to emulate anorexia to be “cool.” The medical director at the Western New York Comprehensive Care Center for Eating Disorders recently stated in an interview that some teenagers think if they get very skinny or develop an eating disorder they’ll become popular (22).

These cultural and societal factors are precursors for anorexia, and an intervention which targets those factors could be successful. This commercial, however, commits what Sharon Schwartz refers to as a “Type III error,” which is confusing the reasons behind the distribution of a public health problem across a population with the causes for that health problem’s increase in the general population over time (23). For instance, obesity has been linked with genetic predisposition, but that cannot be the cause for the increased rates of the disease because genetic variation can’t change that quickly, and thus it is the environmental factors that will explain any variation in obesity’s distribution over time. As this paper has shown, anorexia works the same way—there are genetic and psychological predispositions, but they are unlikely to explain the increased rates of anorexia over the past few decades. Thus, if anorexia interventions are based on individual-level factors (as this commercial is), then they are bound to be ineffective because “the cause of the rate increase is left unaddressed” (23). The causes of anorexia’s rate increase are likely the factors previously discussed—society’s overvaluation of thinness and punishment of the overweight. The Face the Issue intervention’s failure to address those factors in any meaningful way, deciding instead to oversimplify the issue and urge girls not to “choose” anorexia, is a serious deficiency which likely renders the intervention useless.


The Face the Issue anorexia intervention may have all the same tools as mainstream media—a web page, catchy graphics, and celebrity power, but this superficial similarity is simply not enough to stop the harmful behavior it’s targeting. Unlike successful commercial advertisements, the intervention’s creators failed to conduct the psychological and sociological research necessary to understand what drives anorexic behavior in young girls and how they ultimately get on the path to recovery. Further, its message that anorexia is somehow a choice may do more harm than good. If young girls who start dieting believe it’s a choice, will they think they can “try out” anorexia for a bit and then stop when they decide it’s time? Will girls who recognize they have a problem blame themselves because they don’t feel like they can stop? Even more disturbing, there’s evidence that some education-type methods of eating disorder interventions actually promote the disease (2). Will this commercial increase interest in anorexia, and will healthy girls who visit the website, which is a forum for girls who have the disease to talk, have a desire to gain their sense of community? These are all questions that the Face the Issue intervention seems have entirely ignored, to the detriment of healthy and anorexic girls alike. This intervention desperately needs to reevaluate its methods and find a model that accommodates for the unique barriers to recovery that anorexia presents.

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7. Face the Issue. Dying to be Thin.
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10. Edberg, M. Essentials of Health Behavior. Sudbury, MA: Jones and Barlett Publishers, 2007.
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13. Anorexia and Related Eating Disorders, Inc. For Parents, Partners, and Other Family Members.
14.American Dietetic Association. Helping a Friend with an Eating Disorder.
15. U.S. Department of Health and Human Services, Office on Women’s Health. Eating Disorders.
16. The Klarman Eating Disorders Center at McLean Hospital. Harvard Medical School Affiliate.
17. Harvard Medical School Office of Public Affairs. Sharp Rise in Eating Disorders in Fiji Follows Arrival of TV. 1999.
18. Skinny Models Banned From Catwalk. Sept. 13, 2006.
19.Kilbourne, J. Still Killing Us Softly: Advertising and the Obsession with Thinness (395-418). In: Fallon, P. et al eds.
Feminist Perspectives on Eating Disorders. New York: The Guilford Press, 1994.
20. Wolf, N. The Beauty Myth. New York: Harper Perennial, 2002.
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22. USA Today. Bauman, V. “Wannarexic” Girls Yearn for Eating Disorders. August 4, 2007.
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Research. American Journal of Public Health. 1999; 89: 1175-80.

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