A proposed intervention to counter the National Eating Disorder Association’s media campaign for eating disorders- Jennifer LeDoux

Introduction to the Issue: Eating Disorders as a Mental Health Disease

Eating disorders cover a spectrum of mental health disorders characterized by extreme eating behaviors, such as eating very small amounts or having severe stress regarding body weight, shape, or size¹. Oftentimes, eating behaviors that are considered more “normal” and “acceptable”, such as dieting, can spiral downwards and progress into more severe, restrictive eating behaviors. While eating disorders (ED’s) are most common in adolescent females, they can occur in any age, race, ethnicity, or gender. Everyone is at risk for an eating disorder. In fact, about 1 in 100 Americans develop an eating disorder at some point in their life¹, with the average age of onset for Anorexia Nervosa at 19 years of age and the average age of onset for Bulimia Nervosa at 20 years of age². Given the complex, multidimensional foundations of these diseases, those with an ED often struggle with their eating behaviors throughout their entire lifetime. In fact, over 75% of individuals with eating disorders report that the illness can last 15 years or longer³. Many never receive treatment. In fact, an average of only 1 in 10 individuals with an ED receives some form of treatment for their disease⁴.

The spectrum of eating disorders covers several conditions, though individuals may suffer from more than one at any given time. Anorexia Nervosa (AN) the most widely known and is characterized by extreme thinness, an inability or unwillingness to achieve a healthy body weight, severe fear of gaining weight, a poor self-esteem that encourages a distorted body image, and extremely restricted eating⁵. Eating, or not eating, often becomes an obsession for the patient with Anorexia Nervosa and can be combined with additional restrictive behaviors such as extreme exercise, use of laxatives, or vomiting⁵. Individuals with Anorexia Nervosa tend to be of a very low body weight, which incurs a plethora of unhealthy physical symptoms and health issues. For instance, these individuals may suffer from osteopenia/osteoporosis, anemia and muscle wasting, gastrointestinal disturbances, and decreased immune functioning^5,6.

Another common eating disorder is Bulimia Nervosa (BN), which is characterized by binge-eating unusually large amounts of food. Patients with this disorder subsequently feel shame and lack of control and engage in compensatory behaviors to regain control, such as use of laxatives, excessive exercise, fasting, or vomiting. Though most patients with Bulimia Nervosa appear to be of average or slightly above average weight, these individuals also face a host of physical symptoms and health issues related to their behaviors. Individuals with Bulimia may suffer from a chronically inflamed throat, poor dentition and oral health, gastrointestinal complications, acid reflux disorder, and severe dehydration^5,6. Other conditions that are considered eating disorders include Binge-Eating Disorder (BED) and Eating Disorders Not Otherwise Specified (EDNOS). However, far less research exists regarding these particular conditions.

Eating Disorders are, at their core, a mental health disease. Like many other mental health conditions, ED’s may develop from a combination of factors, including biological, socioeconomic, cultural, and psychological factors⁷. For instance, while an individual may be genetically predisposed to an eating disorder or other mental health condition, he or she may also develop the ED as a result of societal pressure to be thin or cultural norms and standards of beauty. Oftentimes, ED’s develop during the adolescent years, when girls and body are particularly susceptible to peer pressure, social expectations and norms, and body image issues¹. In addition, many adolescents feel the need to gain more independence over their lives and their bodies and see restrictive eating behaviors as a way to do this. Eating disorders often co-occur with other mental health issues like depression or obsessive-compulsive disorder (OCD). Given the wide spectrum of symptoms, signs, causes, and conditions involved with ED’s, diagnosis and treatment can be a challenge. Currently, several national organizations are sponsoring research efforts and national awareness campaigns to help lower the number of individuals in the United States who suffer from an Eating Disorder. Despite these attempts, the number of ED cases in the U.S. continues to rise⁸. Eating Disorders are now the third most common chronic illness in the adolescent female population⁹. Despite the rise in the number of ED’s, there is hope to reduce the lifelong negative effects of this mental illness. Eating disorders can be treated with multidisciplinary efforts that combine medical care, psychiatric care, nutrition education, and more¹.

Introduction to the Public Health Campaign: National Eating Disorder Association Media Campaign

The National Eating Disorder Association (NEDA) is a non-profit organization devoted to supporting individuals affected by eating disorders. NEDA‘s goals are to provide information, resources, and action-oriented advocacy for the eating disorder community. The organization also campaigns for prevention efforts, improved access to quality healthcare, and increased research funding in order to better understand, prevent, and treat all eating disorders¹⁰.

While NEDA’s website provides general information and resources for both professionals and the general population, it is designed for those who are seeking information. The media campaigns that that the organization launched last year are instead designed to get attention from those who may be unaware of the prevalence of eating disorders or who may not know where to find information to help with one. The recent media campaign falls under the common slogan “Until Eating Disorders are History…” and incorporates print ads, online ads, and video public service announcements ^10,11. Several designs exist for the print and online ads in this media campaign- each consists of a bold color background with a single image in the center and bold-faced type. Short, succinct lines are designed to draw attention and questions from the general population. One ad, for example, is bright blue and has an image of a toilet seat (in the place of a plate) in between a fork and knife. Below the image, the line reads “What’ll we lose on this diet? Lots of people every year”¹¹. Another ad for the campaign features a bright yellow background with a largely oversized strawberry skewered on an average-sized fork and reads “The monster isn’t under the bed- it’s in the fridge”¹¹. In addition to the print and online ads, several videos were released with NEDA’s media campaign. The most popular video (“Questions”) is shot in black and white and shows several young girls (all pre-adolescent in age) asking the camera questions relating to self-esteem, body image, dieting, and weight, such as “Am I pretty enough to be noticed?” and “Will they love me if I go on a diet?”¹². The video is intended to create an emotional response to the feelings and questions that many people with eating disorders undergo on a daily basis. It is also intended to show that eating disorders can develop early in a child’s life, before one would think an individual would be at risk.

The ads and videos in NEDA’s media campaign surely are intended to bring awareness and education to individuals suffering from eating disorders¹¹. The organization feels that the campaign should encourage individuals with ED’s to recognize their behaviors as unhealthy and seek treatment. In this way, NEDA hopes that the media campaign will help to lower the rates of ED’s in the United States. Recent evidence shows that media campaigns such as this one have fallen flat and that the numbers of individuals with ED’s are only growing^3,4. Though well-intentioned, NEDA’s media campaign falls short in several areas. Insert a set-up paragraph to the 3 critiques

Critique 1: The unsuccessful use of fear to encourage behavior change

The ads in NEDA’s print campaign are designed to grab the audience’s attention with bold, frightening statements and references to some of the very negative aspects of eating disorders. For example, the ad with the strawberry describes the “monster” that the eating disorder patient faces at every meal. The ad with the toilet seat informs the audience that eating disorders may result in death. The print ads in this media campaign provide some insight into the mental and physical health costs of eating disorders. However, the ads do little more than that. They provide “shock value” but minimal information for individuals who are suffering from ED’s . The sole incentive to change disordered eating behavior in these advertisements is fear of the potential outcomes; the ads provide no information as to the benefits of changing disordered eating habits to healthy eating habits.

In this way, the print ads in NEDA’s media campaign are a prime example of incorrect use of the Health Belief Model. The model postulates that positive behavior change in an individual is influenced by his or her perception of the costs of a health problem and the value associated with actions aimed at reducing the threat. In other words, the model describes the likelihood of an individual to change their behavior in a positive way based on his or her perceived costs of the current behavior and perceived benefits of the changed behavior^13,14. The NEDA campaign ads attempt to demonstrate the severity of the health costs associated with eating disorders. The ads do this well; however, it is not always a successful method for inducing behavior change. Public health interventions designed to reduce a variety of negative lifestyle behaviors from drunk driving to cigarette smoking have been criticized for the use of fear to provoke behavior change. Research shows that these types of interventions are not always successful and may incur further negative responses from the targeted audience^{15, 16, 17}. Previous research surrounding the use of the Health Belief Model in individuals with low self-esteem shows that the use of fear and information on the negative consequences of an unhealthy behavior may actually backfire and make the individual more likely to engage in the behavior¹⁸. While the ads use fear in an attempt to draw attention and induce behavior change, they do not provide information on the benefits of seeking treatment for eating disorders. The ads should tell the eating disorder patient why they should change their behavior, not why they shouldn’t continue their current behavior. In order to be more successful in encouraging the eating disorder population to seek help and change their unhealthy eating habits, the ads should focus on positive messages describing the benefits of healthy eating habits and maintaining a healthy body weight.

Critique 2: Lack of empowerment and disregard for the concept of self-efficacy

Central to several public health theories and models is the concept of self-efficacy, or one’s sense of control over one’s environment and behavior. According to Albert Bandura’s Social Cognitive Theory for behavior change, self-efficacy is considered a direct predictor of behavior change¹⁹. In other words, individuals with a greater feeling of self-efficacy are more likely engage in positive change. Self-efficacy beliefs can help to determine not just whether or not an individual will change his or her behavior but also how much effort he or she will expend, how long he or she will persist, and how high his or her goals will be^20,21. Self-efficacy is a component to several other public health models and is thus a crucial consideration in any successful public health intervention.

Several past public health interventions in areas ranging from weight loss to smoking cessation have used the idea of self-efficacy to successfully encourage positive behavior change in study participants. One study on school-aged girls found that participants with greater measured exercise self-efficacy were more likely to engage in both moderate and vigorous physical activity²². Another study aimed at improving nutrition status in study participants found that self-efficacy for fruit and vegetable intake predicted a 24-hour recall of fruit and vegetable intake. Participants with a greater self-efficacy consumed more fruit and vegetables²³. Another study of teenage girls with high rates of sexual activity found that the participants who had a greater sense of control over their sex practices were more likely to use contraceptives effectively²⁴.

Self-efficacy has been demonstrated to be an accurate predictor of behavior change and has been used in many public health interventions, particularly in the population that is most at risk for eating disorders (adolescent females). Public health interventions have proven that by encouraging a sense of self-efficacy, the individual is more likely to engage in positive behavior change. In the NEDA media campaign, the costs and results of eating disorders are made apparent. The advertisements and personal service announcement may successfully draw attention in this way but they will not be successful in encouraging individuals to change their behavior. The ads in no way create a feeling of being able to change one’s view of oneself and change one’s eating behaviors. The campaign creates no sense of empowerment in a target population that is particularly at risk for low self-esteem and low self-efficacy^1,2. Instead of instilling fear into individuals afflicted with eating disorders, the media campaign should instead instill a feeling of confidence to change one’s behavior.

Critique 3: Perpetuation of negative labeling for patients with a mental health disorder

Howard Becker developed Labeling Theory to help explain deviant or risk behavior in individuals. He posited that it is not the behavior itself that is deviant but society’s view of the behavior. He argues that the “deviant” behavior is constant but that society’s view of it may change^{25, 26}. People in power, whether it’s an individual, a group, or a movement, can help to label a certain behavior as “deviant”. In light of the current topic, disordered eating is considered “deviant” behavior by our current society. As with many other mental health disorders, people who suffer from eating disorders suffer from a negative social stigma²⁷.

With society telling individuals who suffer from eating disorders that they are abnormal, individuals often internalize these messages and inflict a self-stigmatization as well. If one is repeatedly being told that one is not normal, the message will eventually stick with the individual. Recent literature describes the impact of stigmatization on individuals with mental health disorders as being twofold- it encompasses both social stigma from others and self-stigma from oneself ²⁸. Another study showed that labeling an individual as having a particular mental illness endorsed negative stereotypes of the individual and changed the way the public reacted to the individual²⁹.

Individuals with eating disorders do not need to suffer further from the negative stigmatization of having a mental illness. However, the NEDA media campaign ads and public service announcement show clear pictures of the stereotypes of individuals with eating disorders. The ad with the toilet seat perpetuates the idea that all individuals with eating disorders purge their food. The ad with the strawberry shows the intense fear of food that individuals with anorexia feel. The public service announcement describes the self-conscious thoughts of an individual with an eating disorder. All of these play a role in further perpetuating the label of an eating disorder. In turn, the NEDA media campaign only increases the social stigma faced by these individuals.

Outline for the proposed intervention: Moving Forward to Healthy Eating

In order to counter the flaws in NEDA’s well-intentioned but poorly designed media campaign to combat the prevalence of eating disorders, a new intervention is proposed that will use similar media strategies to reach out to the target audience. The proposed intervention will be called “Moving Forward to Healthy Eating”, a title which encompasses the three central provisions of the intervention that are discussed below. Namely, the title should instill a positive message (that one can move forward from an ED), should create a greater sense of empowerment and self-efficacy (that the individual has the ability to control his or her body and environment and change his or her behavior), and should avoid negative labeling and stigmatization (not using a mental illness label such as “anorexic”).

The proposed intervention will be a media campaign utilizing print ads, video, and audio. All of the media materials will be designed to reach out to the target audience: individuals with eating disorders and their families. As stated in the introduction, a large proportion of individuals with ED’s are adolescent aged females, so the materials will be designed to reach this population in particular. Print ads may be posted in places where they will be seen by the target audience, such as: popular magazines and newspapers, coffee shops and college campuses, and even on streets in urban areas. Urban areas will be particularly important to reach out to as recent evidence shows that rates of certain eating disorders, like bulimia nervosa, are higher in urban areas³⁰. Video ads will be posted on popular websites such as YouTube and may air on certain television stations that have a large percentage of viewers in the target population. Audio ads will be played on radio stations popular with the target population, such as ones playing pop and alternative music hits. The audio ads will help to reach out to adolescent females living in urban areas and will strengthen the portfolio of media items in the campaign.

In order to encompass the three central suggestions for the intervention, the media campaign will utilize components from several public health models, including: Health Belief Model, Social Cognitive Theory, and the Labeling Theory. Marketing and advertising efforts for the media campaign will also be largely important in broadcasting the media campaign successfully to the correct audience. Below is a more detailed description of the three suggestions that make up the intervention proposal and how these suggestions will improve the success of the intervention.

Suggestion 1: Encouraging behavior change through the use of positive messages

As discussed above, the NEDA media campaign uses messages in its print ads that are designed to create fear of the possible costs of eating disorders. In several studies, this tactic has been shown to draw attention but inadvertently make individuals more likely to engage in the negative behavior^15-18. This is particularly true for individuals with low self-esteem, which is a factor for many individuals with eating disorders.

According to the Health Belief Model, individuals weigh both the potential costs of their current behavior and the potential benefits of changing their behavior^13,14. Thus, according to this model, an intervention could instead focus on the potential benefits of changing one’s behavior. Focusing on the positive results of behavior change through positive messages in the media campaign would help to create hope in individuals with eating disorders. Instead of describing a “monster”, or mortality risks, the media campaign will focus on achieving confidence, self-esteem, a healthy body weight, and healthy hair, skin, and nails³¹. The campaign will demonstrate that changing disordered eating behaviors results in a healthier, happier, more beautiful individual. Some potential slogans for the intervention might be: “I judge myself though my eyes, not anyone else’s. I am beautiful.” and “I love my body. I love food. I love being healthy. I love (period)”. These messages are all positive and encourage behavior change by showing some of the benefits of behavior change, such as higher levels of self-esteem and confidence.

Suggestion 2: Encouraging behavior change through a greater sense of empowerment and self-efficacy

Another shortcoming of the NEDA media campaign is that it does not attempt to empower individuals with eating disorders to change their behavior and it does not account for the effects of self-efficacy in the target population. The Social Cognitive Theory by Albert Bandura discusses the concept of self-efficacy as the level of control an individual feels over his or her environment and body. Individuals with a greater sense of self-efficacy are more likely to engage in behavior change and follow through with the change^19,20. Several other public health models account for the concept of self-efficacy (or a similar concept), such as the Transtheoretical Model and the Theory of Reasoned Action²¹. By not taking self-efficacy into account and not attempting to empower individuals with eating disorders to change their behavior, the NEDA media campaign is eliminating what is considered a direct predictor of behavior change.

The proposed intervention will account for the concept of self-efficacy by empowering individuals with eating disorders to change their behavior. The print ads, audio ads, and video ads will all use slogans and themes that encourage the individual to change their behavior and that make them feel as if this is a feasible task. Slogans such as “It’s you versus the eating disorder. You can win. X number of women already have.” may be used to show individuals with eating disorders that they are not alone and that they can treat their eating disorder. In addition, video ads with women who had eating disorders and are now receiving treatment would be utilized in the media campaign. The videos would show the benefits of changing disordered eating behavior. Women could discuss the ways in which they have come to accept their bodies, treat their bodies well, and engage in healthy eating and exercise. It could highlight individuals who have gone on to lead successful lives in business, science, sports, family, and other areas. Having positive messages and examples of individuals who have successfully treated their condition would help to empower individuals with eating disorders and improve their feeling of self-efficacy.

Suggestion 3: Encouraging behavior change by avoiding negative labeling and social stigmatization

The last way in which the proposed intervention will account for the mistakes of the NEDA campaign will be by avoiding the negative labeling and social stigmatization of eating disorders. Labeling Theory, as developed by Howard Becker, describes that it is society that labels a particular behavior as risky or “deviant”. While the deviant behavior remains constant, it is society’s views of the behavior that change^25-27. Over the past few decades, mental health disorders have suffered from public scrutiny and negative labeling. Individuals with eating disorders suffer from the negative labeling and social stigma associated with mental illnesses. Research shows that people react differently to individuals with certain mental illnesses^{28, 32}. In turn, this differential treatment may contribute to an individual’s lack of confidence, self-esteem, or self-efficacy and may reduce the chance that he or she will stop engaging in the negative behavior³³.

The NEDA media campaign actually helped to perpetuate the negative labeling and stigma associated with eating disorders by using some of the stereotypical symptoms and behaviors of eating disorder patients in their print ads. In addition, the public service announcement highlighted some common self-esteem and body image themes that are common in eating disorder patients. In showcasing these aspects of the disease, the NEDA campaign made it clear they were talking about a mental illness and that people with this illness are not normal. The campaign perpetuated the stereotypes of eating disorders and, in doing so, reduced the effectiveness of the intervention. Instead of using common aspects of the disease or perpetuating stereotypes, the proposed intervention would avoid the use of negative labels to reduce social stigma and to make individuals with eating disorders feel more comfortable about their condition and their ability to change their behavior. The media campaign of the proposed intervention would not highlight common behaviors, stereotypes, or ideas about eating disorders and it would not use terms like “anorexic” or “binge-purge”. Instead, it would avoid use of specific labels and would focus on the improved mental and physical outcomes in individuals who have treated their eating disorder and now engage in healthy eating habits and have positive self-esteem.

Conclusion

Eating disorders encompass a variety of conditions that may develop from exposure to several factors, including genetic susceptibility, socioeconomic status, and cultural beliefs. At its core, an eating disorder is a mental illness which must be treated using a multidisciplinary method to cure the mind and the body. The National Eating Disorder Association created a media campaign intervention to reduce the number of individuals with eating disorders; however, this campaign failed due to a lack of awareness of several social science theories. By utilizing key concepts from the Health Belief Model, the Social Cognitive Theory, and the Labeling Theory, a new intervention is proposed that would more successfully encourage individuals with eating disorders to change their behavior and seek treatment.

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