Disordered Eating, Body Image, and Healthy Weight Maintenance: Follow-Up Study

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Electronic Theses, Treatises and Dissertations The Graduate School

2011 Disordered Eating, Body Image, and Healthy Weight Maintenance: Follow Up Study Julie Schaefer

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COLLEGE OF HUMAN SCIENCES

DISORDERED EATING, BODY IMAGE, AND HEALTHY WEIGHT MAINTENANCE:

FOLLOW UP STUDY

JULIE SCHAEFER

A Thesis submitted to the Department of Nutrition, Food and Exercise Sciences in partial fulfillment of the requirements for the degree of Master of Science

Degree Awarded: Spring Semester, 2011

The members of the committee approve the thesis of Julie Schaefer defended on March 31, 2011.

______Maria Spicer Major Professor

______Pamela Keel University Representative

______Doris Abood Committee Member

Approved:

______Bahram Arjmandi Chair, Department of Nutrition, Food & Exercise Sciences

______Billie Collier Dean, College of Human Sciences

The Graduate School has verified and approved the above named committee members.

ACKNOWLEDGEMENTS

First and foremost, I would like to thank my advising committee for their time and commitment over the past two years. Your guidance and advice is invaluable and will never be forgotten.

Second, I would like to thank Dr. Amy Magnuson, who shared her research and data and helped me throughout the whole process. Dr. Magnuson is not only the motivation behind this research study, but an inspiration to me on a personal level as both a teacher and registered dietitian.

Finally, I would like to thank Dr. Mary Dolansky, a prominent researcher and personal mentor from my undergraduate institution, Case Western Reserve University. Dr. Dolansky provided me with valuable input throughout this process as well as support and encouragement.

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TABLE OF CONTENTS

List of Tables v

List of Abbreviations vi

Abstract vii

1. INTRODUCTION 1

2. LITERATURE REVIEW 5 2.1 Definitions of Eating Disorders and Co-morbidities 5 2.2 Incidence and Prevalence of Eating Disorders 7 2.3 Prevalence of Unhealthy Weight Control Behaviors 8 2.4 Factors Associated with Unhealthy Weight Control Behaviors 11 2.5 Review of Prevention Programs 15 2.6 Sustainability and Follow-up of Similar Programs 24

3. METHODS 28 3.1 Sample 28 3.2 Protection of Human Participants 29 3.3 Procedures 29 3.4 Measures 30 3.5 Data Management 32 3.6 Data Analysis Plan 32

4. RESULTS 34 4.1 Results of Data Analysis 34

5. COMMENT 38 5.1 Discussion 38 5.2 Limitations 42 5.3 Conclusions 43

APPENDICES Appendix A: Syllabus 44 Appendix B: IRB Letter of Approval 52 Appendix C: IRB Approved Informed Consent 54 Appendix D: Questionnaire 55

REFERENCES 63

BIOGRAPHICAL SKETCH 69

LIST OF TABLES

Table 1. Summary of Eating Disorder Prevention Programs 25 Table 2. Results of Repeated Measures Analysis of Variance 35 Table 3. Results of 12 Month Follow-up 37

LIST OF ABBREVIATIONS

AN – Anorexia Nervosa

BED – Binge Eating Disorder

BN – Bulimia Nervosa

BSQ – Body Shape Questionnaire

DRES – Dutch Restrained Eating Scale

DSM-IV – Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

EDE-Q – Eating Disorder Examination-Questionnaire

EDNOS – Eating Disorders Not Otherwise Specified

IBSS-R – Ideal Body Stereotype Scale-Revised

IES – Intuitive Eating Scale

ABSTRACT

Objective: The objective of this research was to investigate the sustainability of the effects of an eating disorder prevention curriculum on college women.

Participants: Participants were women enrolled in a curriculum-based eating disorder prevention program in the Fall semester of 2009 at Florida State University.

Methods: Participants completed a questionnaire on intuitive eating, body dissatisfaction, restrained eating, thin ideal internalization, and eating pathology three, six, and 12 months after the course. Results from these surveys were compared to the results obtained prior to, immediately following, and one month after the class.

Results: Analyses indicated that increased intuitive eating and decreased eating pathology, body dissatisfaction, and restrained eating were sustained through 12 months following the course. However, decreased thin ideal internalization and increased eating for physical reasons were not sustained.

Conclusions: This program was successful in improving attitudes and behaviors associated with eating disorders and unhealthy weight control behaviors. Most effects were maintained at the 12 month follow-up providing support for participation in curriculum-based eating disorder prevention programs.

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CHAPTER 1

INTRODUCTION

The prevalence of clinical eating disorders, disordered eating behaviors, and other unhealthy weight control behaviors are common, particularly in college-aged women.1-8 Personal, socio-environmental, and behavioral factors interact to result in the regular use of unhealthy weight control behaviors.5, 6, 9, 10 While disordered eating behaviors and unhealthy weight control behaviors continue to affect many women, few seek treatment regardless of the adverse outcomes. Therefore, effective prevention programs with sustainable effects, particularly for high risk populations, are necessary to address this serious public health concern. College campuses are an ideal target for these programs due to the ease of reaching large numbers of high risk women during a time of evolving values and newfound independence. There is evidence that an interactive undergraduate course addressing eating disorders, body image, and healthy eating habits can have positive effects on eating pathology in the participants.

Clinical eating disorders are serious psychiatric conditions characterized by a wide variety of mental and physical factors such as extreme obsession with food, intense fear of weight gain, distorted body image, extreme weight loss, loss of menses, binge eating, and purging according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).11 Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are estimated to affect 1.1-4.6% young women.2, 4 While these clinical diagnoses are relatively rare, subclinical eating pathology and unhealthy weight control behaviors are significantly more common. Research among teens in the Midwestern United States reveals that unhealthy weight control behaviors, such as fasting, eating very little food, taking diet pills, induced vomiting, laxative use, diuretic use, use of food substitutes, skipping meals, and smoking cigarettes with the intention of weight control, are carried out regularly by over 56% of the population.5 Furthermore, between 71.8-94% of college women report a desire to lose weight and as many as 24% of freshman women report at least one objective bulimic episode in the last month.1, 3, 12

Many factors, personal, socio-environmental, and behavioral, have been associated with the onset and persistence of unhealthy weight control behaviors. More specifically, personal

1 factors, such as depressed mood, weight concern, body dissatisfaction, importance of weight and shape, and lower self-esteem have been associated with high rates of dietary restraint, and binge eating.5, 6 Socio-environmental factors, such as parental concern about weight, peer dieting, media, perception of the effect of food on health, appearance, and performance in activities, and lack of family connectedness have been associated with girls who practice unhealthy weight control behaviors.5, 6, 13 Finally, behavioral factors, such as dietary restraint, binge eating, and emotional eating significantly increase the risk of developing an eating disorder.6, 10, 14, 15 However, it is likely that it is interaction of several or all of these factors that contributes to the development of an eating disorder or the initiation of unhealthy weight control behaviors.9, 10, 16

Several eating disorder prevention programs have been conducted on college campuses in an attempt to decrease the prevalence of these behaviors and attitudes. Many approaches to eating disorder prevention such as psychoeducation, cognitive dissonance, and media literacy have been developed. Psychoeducation occurs when information is presented on symptoms, consequences, and risk factors for eating pathology with the intention of changing the attitudes and beliefs of the group.9 Cognitive dissonance exists when an individual has inconsistent thoughts, creating a state of psychological discomfort, motivating the individual to restore consistency.9 In practice, a group may be asked to act contrary to a previously held belief. For example, in one program, a group of college women with high rates of thin ideal internalization were asked to argue against the concept. This creates cognitive dissonance between their previous beliefs and the argument they are forming, motivating the participants to restore consistency, and thus reduce their value in the thin ideal.9 Media literacy refers to educating students about the portrayal of women in the media, or more specifically, how images are often edited and how the bodies of models differ from the bodies of the majority of women in an attempt to sensitize students to the effects of constantly viewing images that support the thin- ideal.17

Initial programs in the mid-1990s focused on psychoeducation related to eating disorders, but resulted in no improvement or even exerted a negative effect on participants.18-20 Psychoeducation is meant to educate participants through the presentation of information but some of these programs seem to have backfired due to the removal of the stigma of the behavior. Due to lack of results, dissonance-based programs were developed. The cognitive dissonance

2 approach has been shown to decrease many factors associated with disordered eating behavior, such as thin ideal internalization, body dissatisfaction, dieting, negative affect, binge eating, and purging.21-24 However, these programs have had conflicting results at follow-up, and can be difficult to implement because of the need for specialists, such as clinical psychologists, graduate-level students, or intensively trained undergraduate peers.21-24 Thus, researchers implemented various computer-based programs to eliminate the need for trained facilitators.25-29 These interventions produced some desirable effects, but resulted in limited compliance due to non-mandatory participation, technological difficulties, such as computer malfunction, and various distractions, such as television or roommates.25-29

Curriculum-based college courses that employ a combination of behavior change techniques, such as psychoeducation, cognitive dissonance, and media literacy over the course of a semester have also been explored.17, 30-32 These programs have had promising results such as decreased dieting, improved body image, decreased weight concerns, and greater intuitive eating.17, 30-32 However, these studies had small sample sizes and only one included a six month follow-up.17, 30-32

At Florida State University, an IRB approved research study that integrated these programs was developed. The twelve week curriculum was offered in the Fall semester of 2010. Students voluntarily enrolled in the course entitled “Eating Disorders, Body Image, and Healthy Weight Maintenance.” The class had three objectives: first, to present current science based information about nutrition, dieting, eating disorders, and body image; second, to involve the students in taking responsibility for their own health by examining thoughts and emotions related to class topics, considering personal values and beliefs, and analyzing their current health-related behaviors; third, to help students build a sense of competence and personal power regarding nutrition, body image, and self-concept. Several approaches to eating disorder prevention including didactic presentations, discussions, readings, videos, and activities were utilized to combine cognitive behavior, cognitive dissonance, and media literacy techniques to integrate behavior change techniques. Students taking an introductory nutrition course served as the control group for this study. Pre- and immediate post-course surveys revealed that taking the course had positive effects on body dissatisfaction, restrained eating, thin ideal internalization,

3 eating pathology, and intuitive eating when compared to the control group. In fact, most positive outcomes were maintained one month after the class ended.

Because of the prevalence of eating disorders on college campuses, the immediate success of the curriculum-based intervention, and the lack of research on the long-term sustainability of the effects of the program, the purpose of this study was to determine if the effects of the eating disorders prevention program were sustained up to 12 months after the course. Will female college students who took the course “Eating Disorders, Body Image, and Healthy Weight Maintenance” sustain observed effects three, six, and 12 months following the course using the measures of intuitive eating, thin-ideal internalization, restrained eating, body dissatisfaction, and eating pathology? The hypothesis was that increased intuitive eating and decreased negative body image, restrained eating, thin ideal internalization, and eating pathology will be maintained at least 12 months following the conclusion of the course.

CHAPTER 2

LITERATURE REVIEW

Eating disorder prevention programs have been designed to minimize the occurrence of unhealthy weight control behaviors such as fasting, eating very little food, taking diet pills, induced vomiting, laxative use, diuretic use, use of food substitutes, skipping meals, and smoking cigarettes with the intention of weight control. Due to the prevalence of eating disorders and unhealthy weight control behaviors in college age women, eating disorder prevention programs have targeted this population but efficacy has been inconsistent and long-term effects have not been explored. In order to design effective programs, factors associated with unhealthy weight control behaviors as well as the sustainability of effective programs need to be considered. Based on this review, the significance of the current study is presented.

2.1 Definitions of Eating Disorders and Co-morbidities

Currently there are three clinical eating disorders recognized by the DSM-IV:11 anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS). AN is an eating disorder characterized by extreme obsession with food, intense fear of weight gain, distorted body image, extreme weight loss, and loss of menses.11 AN is associated with numerous comorbidities and has the highest mortality rate of any mental disorder. The most severe co-morbidities are cardiac effects, such as cardiac dysrhythmias, diminished cardiac mass, and congestive heart failure, as a result of severe under-nutrition.33 Other symptoms include amenorrhea, osteoporosis, anemia, and gastrointestinal complications.33 A meta-analysis of forty-two studies estimated the crude mortality rate for all causes of death in patients with anorexia nervosa at 5.9%.34 More deaths were caused by complications of the eating disorder than for any other reported reason.34 More recently, a study in Germany that followed over 100 patients with AN for twelve years reported a mortality rate of 7.7%.35 In the same study, an additional 40% were considered to have poor outcomes according to a measure based on nutritional status, menstrual function, mental state, sexual adjustment, and socio-economic

5 status. 35 Crow et al.36 examined the cause of death for more than 1800 patients treated for eating disorders between 1979 and 1997 and found a mortality rate of 4.0% for those treated for AN.

BN is characterized by periods of binging, consuming large amounts of food at one time with the feeling of a loss of control over eating, at least 2 times a week for at least 3 months, followed by compensating, or purging techniques such as self-induced vomiting, use of diuretics, laxative abuse, over-exercising, or fasting.11 Bulimic patients also place an immense value of body weight and shape on self-esteem. While mortality rates are lower than those with AN, physical manifestations are just as prominent.37 Common physical manifestations include muscle cramps, heartburn, fatigue, fainting, and impaired concentration.33 While patients may be underweight, normal weight, or overweight, many problems occur internally. Purging often leads to electrolyte imbalance such as hypokalemia, which can cause dysrhythmias and rhabdomyolysis, and hyponatremia, which can cause coma or even death.33 Furthermore, frequent binging and purging can cause gastrointestinal bleeding, ulcers, gastro-esophageal reflux, dental erosion, and in extreme cases, esophageal perforation and gastric distention.33 Crow et al.36 report a mortality rate as high as 3.9% for those patients that were treated for BN.

Patients with EDNOS are those who have manifestations of an eating disorder severe enough to qualify as a clinical condition, but do not completely meet the diagnostic criteria for AN or BN, for example, binge eating disorder (BED).33 BED is proposed in the DSM-IV as a particular type of EDNOS characterized by binge eating in the absence of compensatory behaviors seen in BN.11, 38 BED is associated with high rates of obesity and related problems as well as psychiatric conditions like mood and anxiety disorders.38 According to the DSM-IV, binge eating is defined as an episode of eating an unusually large amount of food accompanied by a sense of loss of control.11 Other forms of EDNOS include subthreshold and partial eating disorders.7 Subthreshold eating disorder refers to those who experience all of the symptoms of a particular eating disorder but experience one or more symptom at a subthreshold level, for example, a patient who meets all the criteria for BN but does not binge 2 times a week for at least 3 months. Partial syndrome eating disorder refers to a subset of symptoms of a particular eating disorder at a threshold level, for example, a patient who meets all of the criteria for AN except for loss of menses. Crow et al.36 found the mortality rate for EDNOS to be 5.2%, the highest among the eating disorders.

2.2 Incidence and Prevalence of Eating Disorders

Incidence and prevalence are commonly used to measure disease frequency. Incidence is the number of new onset cases in the population over a specified period of time and prevalence is the total number of cases in the population over a specified period of time. One study estimated rates of AN over a 50 year period in the mid-1900s (1935-1984) by reviewing over 13,500 medical records from the Rochester, Minnesota area, applying the current diagnostic criteria.39 The researchers found the incidence of AN per 100,000 person-years for women aged 10-14, 5- 19, and 20-24 were 25.7, 69.4, and 27.6 respectively.39 Furthermore, the incidence rate in women aged 15-24 years revealed a highly significant increasing linear trend over the 50 year period and represented over 60% of all of the cases reported.39 The same study also reported no increase in the incidence of AN for women over 25 years of age.39 According to data from diverse populations, including a nationally representative survey and populations of young women in Italy and Australia, it is estimated that 0.9-2.0% of all women are affected by AN in their lifetime.2, 4, 8 In the same populations, BN has been estimated to affect 1.5-4.6% of all women.2, 4, 8 The incidence of BN per 100,000 person-years was found to be 13.5 between 1980 and 1990.40 Likewise, BED has been estimated to affect 2.9-3.5% of all women.4, 8 In the nationally representative survey, the prevalence rate for women 18-29 years of age was found to be 1.1% for AN, 2.2% for BN, and 4.2% for BED.4 The study that was conducted in Italy with more than 930 women concluded that 2.0% of those 18-25 years of age were affected by AN, 4.6% were affected by BN, and 11.0% developed any type of eating disorder.2 When women in urban areas of Italy were compared to those in suburban areas, estimated prevalence increased to 2.9% for AN, 6.2% for BN, and 12.8% for developing any type of eating disorder.2 When researchers in the United Kingdom sought to investigate rates of eating disorders, they found that AN affected 4.7 per 100,000 people.41 This would indicate a stable rate of the incidence of AN during the study period of 1994 to 2000.41 The same study found that BN affected 6.6 per 100,000 people, a rate much lower than previous reports.41 There is further evidence that the prevalence of BN has significantly decreased between the years 1982 and 2002 in college cohorts.42

Other forms of EDNOS, such as subthreshold and partial eating disorders, affect even more young women. Stice et al.7 conducted annual diagnostic interviews for nearly 500 young

7 women over an eight year period. The authors found that by 20 years of age, subthreshold AN affected 0.6% of girls, subthreshold BN affected 6.1% of girls, and subthreshold BED affected 4.6% of the women.7 Another subthreshold eating disorder, purging disorder, is estimated to affect 4.4% of girls by age 20.7 Rates of partial AN have been reported in 2.6-4.3% of women, 2, 8, 16 3-6% for partial BN, 2, 7, 16 and 4% for an EDNOS characterized by a manifestation of binge eating episodes, followed by compensatory behaviors (vomiting, laxative use, or exercise) with the intention of preventing weight gain, accompanied by an immense concern and preoccupation with body weight and shape or loss of control over eating.13 Rates of partial syndrome of EDNOS have been reported in the American public as high as 5.3% and EDNOS characterized by driven exercise or fasting without binge eating is prevalent in about 4.3%.8

Research indicates that eating disorders primarily affect the young female adult population. The average peak of onset for the three eating disorders is 18.9-21.7 years of age for AN, 19.7 years of age for BN, and 25.4 years of age for BED.4, 39 A higher mortality rate was also found in young adults between the ages of 20 and 30 than any other age group for patients treated for eating disorders.36 A review by Hoek and van Hoeken43 reports that AN is rarely reported in male populations and probably affects less than 0.5 males per 100,000 per year and BN affects about 0.8 males per 100,000 per year. This translates to greater than a 10:1 female to male ratio for the occurrence of eating disorders.43 Moreover, on average, AN persists for about 1.7 years whereas BN and BED persist for an average of 5.9-8.0 and 12.6 years respectively, even when treatment is sought.4, 44 Longer duration of symptoms has also been associated with worse long-term outcome.44

2.3 Prevalence of Unhealthy Weight Control Behaviors

While severe clinical eating disorders affect a relatively small percentage of the population, a high percentage of young adults engage in similar behaviors to try to control weight. Project EAT (Eating Among Teens) was initiated in 1998 to investigate the eating habits and associated factors of a large cohort of middle- and high-school students in the Midwestern United States.5, 6, 45 Participants completed questionnaires at two time points, five years apart. Project EAT-I refers to the original survey of 4746 adolescents from 31 schools and Project

EAT-II refers to the five year follow-up survey completed by 2516 adolescents from the original population. One third of the population was in middle school during the first survey (average age 12.8 years at time one and 17.2 years at time two) and two thirds of the population was in high school during the first survey (average age 15.8 years at time one and 20.4 years at time two).6 Several analyses have been carried out using the data from Project EAT on the prevalence, initiation, and persistence of several unhealthy weight control behaviors in this adolescent population.

In 2009, Linde et al.5 assessed the prevalence and persistence of unhealthy weight control behaviors including fasting, eating very little food, taking diet pills, induced vomiting, laxative use, diuretic use, use of food substitutes, skipping meals, and smoking cigarettes more than usual with the intention of weight control.5 At the initial analysis, 56.1% of the girls regularly engaged in at least one unhealthy weight control behavior.5 Five years later, 43.3% of the original sample was still carrying out the reported behavior.5 Upon examining the same population, Neumark- Sztainer et al.6 identified the prevalence of a broader spectrum of weight-related problems: overweight, binge eating, and extreme weight control practices. Among the girls who participated, 44% had at least one of the three problems examined and 13.4% had more than one6. Prevalence of overweight, binge eating, and extreme weight control practices were 27.5%, 10.5%, and 22.1% respectively.6 An alarming 9.4% of the girls engaged in recurrent purging behaviors such as vomiting, laxative use, or excessive exercise.45 More than 41% of all the girls and 18% of underweight girls had body image disturbance, meaning, for example, rating their weight as “overweight” when their BMI is classified as “normal.”45 Furthermore, 36.4% placed a great deal of importance of body weight on self-esteem.45

Literature reveals alarming rates of maladaptive eating patterns on college campuses, particularly in women. Up to 71.8-94% of women in college have reported a desire to lose weight, although there is evidence of a significant decrease in the number of students reporting a desire to lose weight since 1982.1, 3, 42 According to data from the National College Health Assessment (NCHA), a survey of over 90,000 college students, 55.8% of the respondents were exercising to lose weight and 35% were dieting to lose weight.46 The authors also reported that over 46% perceived their BMI to be higher than it actually was.46 Of these students, females were significantly more likely to utilize unhealthy weight control behaviors such as dieting,

9 vomiting, and taking diet pills.46 This study supports the previous findings of Cooley and Toray1 who reported that the average difference between actual and ideal weight in their sample of women entering college was more than 14.5 pounds. Similar to the Project EAT population, distorted weight standards are common in the college population. Delinskey and Wilson47 found that a significant number of college women are likely to classify themselves as being overweight when in actuality their weight is normal. In fact, distorted body image may worsen after beginning college. Vohs et al.48 surveyed 342 young women during their senior year of high school and then again during their first year of college and found that significantly more girls categorized their weight as overweight after entrance into college as opposed to when they were asked to do the same, months earlier, in high school. The same girls were also significantly less satisfied with their bodies after entering college as opposed to when they were still in high school.48

Reports of dieting are high across all classification of weights, especially in the college population. In the college population, about 43% of underweight women, 67-80% of normal weight women, 87-91% of overweight women, and about 86% of obese women report dieting to lose weight.12, 14 More than one third of undergraduate women report skipping breakfast every day and another one third report eating breakfast only sometimes.3 Malinauskas et al.12 report that in their sample of 185 undergraduate females, 51% consciously eat less than they would like, 40% count calories as a means of weight control, 35% use meal replacement drinks, and 26% use weight loss supplements. Heatherton et al.3 report that 28.2% of undergraduate women regularly binge eat and more than 19% report fasting. Furthermore, about 2-5% regularly uses diuretics, laxatives, or vomiting to control weight and 3.5% regularly use diet pills.3, 12

Subclinical bulimic pathology is also prevalent on college campuses. Among 336 women who were followed through their freshman year, about 30% report at least one subjective bulimic episode in the past month and 7.4% of women report vomiting as a means of weight control.47 In the same study, about 24% of freshmen women report at least one objective bulimic episode in the last month and 4.7% reported at least eight objective bulimic episodes in the last month.47 Furthermore, a few studies used data to classify undergraduate women across a spectrum of eating pathology and conclude that 23-26% are dieters, 15-20% are problem dieters, 6-11%

10 could be classified as having a subclinical eating disorder, and 3.5-8% could be diagnosed with a clinical eating disorder.3, 48

2.4 Factors Associated with Unhealthy Weight Control Behaviors

It is important to identify factors associated with unhealthy weight control behaviors in order to develop effective programs to prevent and reverse these behaviors. Many factors have been found to be associated with the initiation, or onset of these actions, as well as the persistence, or continuation, of these actions. Personal factors that contribute to both the onset and continuation include depressed mood, weight concern, body dissatisfaction, importance of weight and shape, and lower self-esteem.5, 10 Socio-environmental factors include parental concern about weight, peer dieting, media, perception of the effect of food on health, appearance, and performance in activities, and lack of family connectedness.10 Finally, behavioral factors, such as dieting, binge eating, and emotional eating, have also been linked to initiation and persistence of unhealthy weight control behaviors. It is likely, however, that it is a combination of these factors that contributes to both the initiation and persistence of eating pathology.

Personal factors, such as depressed mood, weight concern, body dissatisfaction, importance of weight and shape, and lower self-esteem have been associated with both the initiation and persistence of unhealthy weight control behaviors.5, 6, 10 Personal factors associated with higher rates of subclinical eating disorders include greater body dissatisfaction, drive for thinness, and perfectionism.13 Project EAT data reveal that only 18% of adolescent girls reported high body satisfaction.49 Furthermore, lower body satisfaction is associated with higher rates of dieting, unhealthy and very unhealthy weight behaviors, as well as binge eating that persists at least through a five year period.49 In their study that surveyed over 1,100 teenage girls, Johnson and Wardle15 found that dietary restraint, low self-esteem, and depression are completely mediated by body dissatisfaction, concluding that this factor should be the target in addressing eating pathology.

Socio-environmental factors associated with increased likelihood of initiation of unhealthy weight control behaviors in the Project EAT population were parental concern about weight, peer dieting, weight-loss article reading, perception of the effect of food on health,

11 appearance, and performance in activities, and lack of family connectedness.5 During the five year follow-up period, increase in weight concerns, such as desire to be thinner and fear of gaining weight, were the strongest predictors of initiation, as well as persistence of unhealthy weight control behaviors.5 There is also evidence that girls with higher measures of weight concerns are significantly more likely to develop a partial syndrome eating disorder.13 Neumark- Sztainer et al.6 expanded the research on risk factors to other weight-related problems with the Project EAT population. The authors found that other socio-environmental factors, such as maternal weight concerns, being teased about weight, and exposure to magazines on weight loss, were also associated with overweight, binge eating, and extreme weight control practices.6 Girls who reported being teased about weight at the initial assessment were twice as likely to be overweight and about 1.5 times as likely to binge eat at the five year follow-up.6

Socio-environmental factors associated with persistence of unhealthy weight control behaviors were similar, including peer dieting, weight teasing, weight loss article reading, and greater parental weight concern.5 Cooley and Toray1 followed women entering college for three years to study the factors associated with persistence of unhealthy weight control behaviors. The researchers found that the factor with the most impact on persistence of unhealthy weight control behaviors was the severity of the actual behaviors at the beginning of the study, which means that the more severe the behavior, the more likely the individual was to continue.1 Furthermore, women with higher scores of bulimic symptoms or dietary restraint at the beginning of their first year of college were more likely to experience worsening eating disorder symptoms and behaviors throughout the year.1 This finding is consistent with Johnson and Wardle15 who report that girls with higher levels of dietary restraint and body dissatisfaction at baseline were more likely to experience more abnormal attitudes toward weight and eating and worsening bulimic symptoms, emotional eating, self-esteem, and depressive symptoms. For both the initiation and persistence of unhealthy weight control behaviors, the personal factors, such as body dissatisfaction and weight concerns had greater explanatory value than the socio-environmental factors.5

Behavioral factors that predict weight-related behavior problems include dieting, binge eating, and diet soda intake.6 There is strong evidence that restricted eating and dieting are strong predictors of eating disorders and eating pathology. As previously discussed, reports of dieting in

12 an attempt to lose weight are prevalent among college women. Furthermore, frequency of dieting is associated with more eating disorder symptoms as well as the severity of these habits.10, 14, 15 Higher rates of dieting are also associated with more severe body dissatisfaction and drive for thinness, as well as negative body image in various aspects of weight concerns such as ideal body mass index, current weight, and preferred weight.10, 14, 15 Furthermore, higher rates of dieting were also reported among those women who have an emotional attachment and preoccupation with exercise as well as those women who report more frequency and intensity of exercise.14

Among a population of adolescent girls who developed an eating disorder, 65% were previously identified as moderate dieters and 32% were previously identified as severe dieters.16 In the same study, girls who dieted at a severe level were 18 times more likely to develop an eating disorder, equating to about a 1 in 5 chance over a 12 month period.16 Those who dieted at a moderate level were 5 times more likely to develop an eating disorder, equating to about a 1 in 40 chance over a 12 month period.16 In contrast, adolescent girls who reportedly never dieted had less than a 1 in 500 chance of developing an eating disorder over a 12 month period.16 Among the Project EAT population, dieting was significantly related to reported use of extreme weight control practices and diagnosis of an eating disorder.50 In addition, those who reporting dieting at the initial assessment were twice as likely to engage in extreme weight control practices at the five year follow-up compared to those who did not report any dieting.50

In addition to putting women at risk for unhealthy weight control behaviors, the literature reveals that dieting is an ineffective approach to weight loss. For diet programs such as very low calorie, low fat, or low carbohydrate diets, attrition rates are high and weight loss is rarely maintained.51-53 As a result, many health professionals are turning to a non-diet alternative to help people adopt a healthy lifestyle.52 One such model of a non-diet approach to weight management is the Health at Any Size (H@AS) Paradigm.54 This model proposes that restrictive dieting leads to abnormal eating patterns and psychological distress, but that removal of dietary restrictions will lead to healthier eating patterns and a normal body weight with the absence of eating pathology and a better overall quality of life.54 As opposed to the traditional strategy for weight loss that suggests that restricting intake is the only way to lose weight, the H@AS model asserts that a healthy weight can result as a product of behavior and lifestyle independent of body

13 weight.54 The authors argue that chronic dieting and obsession with weight mask the ability to identify internal cues of hunger and fullness and the desire to exercise for enjoyment rather than weight loss.54

There is evidence that the H@AS model can help chronic dieters make lasting lifestyle changes. After a six month intervention, the H@AS model decreased drive for thinness, binge eating habits, and body dissatisfaction and increased ability to recognize internal cues in obese women with a history of chronic dieting. The control group followed a traditional diet approach and saw no change from baseline to the two year follow-up.51 Furthermore, those in the non-diet program maintained an improved lipid panel, better blood pressure, and more physical activity at the two years follow-up compared to those in the traditional diet group.51 In another study, 24 obese women followed either a traditional weight loss plan or a non-diet approach that involved moderate behavior changes that can be comfortably implemented and maintained.53 The women in the traditional weight loss plan were prescribed a 1200 calorie diet and the women following the non-diet were prescribed an 1800 calorie diet.53 At the end of the study, self-reported adherence revealed that those who followed a non-diet approach reported consuming less than the 1800 calories that was recommended while those who followed the traditional diet plan reported consuming more than the recommended 1200 calories.53 As a result, the women in the non-diet group continued slow weight loss through the 12 month follow-up while the traditional diet group experienced an initial weight loss followed by a regaining trend.53 Overall, there is evidence that a non-diet approach to weight management lead to a better psychological state, gradual weight reduction, and maintenance of lifestyle and behavior change.51, 53-55

Research suggests that the cause of unhealthy weight control behaviors is likely a combination of personal, socio-environmental, and behavioral factors. Stice9 found significant evidence for his proposed model of bulimic pathology, termed the dual-pathway model, that theorizes that bulimic pathology begins with pressure to be thin from family, peers, and friends and the internalization of the thin ideal.9, 10 This, in turn, fosters body dissatisfaction, which promotes both dieting and negative affect.1, 9, 10, 15 Dieting then causes further negative affect due to the failure to control weight despite efforts and the impact of caloric deprivation on mood.9, 14 Negative affect, such as depressive symptoms and low self-esteem, have been associated with unhealthy weight behaviors.6, 10, 15 Finally, dieting and negative affect lead to bulimic

14 pathology.9, 10, 14 Dieting encourages bulimic pathology because it often leads to binge eating to counteract the effects of caloric deprivation or as a result of disinhibited eating from breaking strict dietary rules.9, 10, 50 Negative affect will promote bulimic pathology because of the common belief that food provides comfort and escape from negative feelings that often results in binge eating.9, 10, 15, 56 This theory was coined the dual-pathway model because it is based on the assumption that dieting and negative affect lead to bulimic symptoms.9 This is similar to the findings of Cooley and Toray1 who found higher levels of disordered eating habits associated with higher levels of both body dissatisfaction and feelings of ineffectiveness; women were more likely to report loss of control of eating at a time of heightened emotion. Stice9 also concludes that the course of anorexia nervosa and bulimia nervosa begin with the same pathway, but that anorexics become very successful dieters whereas bulimics do not. Anorexics experience a powerful cognitive reinforcement of positive feelings with caloric restriction and negative feelings with food and eating that people who carry out unhealthy behaviors do not experience.9

2.5 Review of Prevention Programs

Integrated prevention programs are needed to simultaneously prevent weight problems while helping girls abandon and replace unhealthy behaviors. The university is an ideal setting for such prevention programs. College-age women are at increased risk for disordered eating behaviors. This age is also a time of developing values and character as well as a new-found independence. Since many eating disorders develop in late adolescence and the median age of onset ranging from 18-21, the university setting provides the target population for prevention programs.4, 39 Several approaches have been explored in developing prevention programs such as cognitive dissonance-based education, computer-based programs, and college curriculum.

Dissonance-based Education

Some of the first eating disorder prevention programs were centered on psychoeducation. Psychoeducation refers to the presentation of the symptoms, risk factors, and consequences of disordered eating behavior with the intention of changing the beliefs and actions of the group.

While these programs did increase awareness and knowledge, they failed to decrease dieting or other eating disorder behaviors.18-20 Furthermore, there is evidence that these programs may have been counterproductive, resulting in increased dietary restraint and other eating disorder symptoms.18, 19 Undergraduate students may also respond better to other approaches, as there is evidence of students rating psychoeducation less favorably.57 Stice, Mazotti, Weibel, and Agras23 developed a cognitive dissonance-based program targeted to undergraduate women with elevated body image concerns. Cognitive dissonance refers to a state of inconsistent thoughts that creates psychological discomfort, which would motivate the individual to restore consistency.9

Based on the dual-pathway model, the authors hypothesized that using a cognitive dissonance approach to decrease thin ideal internalization and pressure to be thin would decrease body dissatisfaction, dieting, negative affect, and ultimately, unhealthy weight control habits.9, 23, 24 Participants were recruited via fliers and emails that advertised a research study evaluating an intervention designed to improve body image.23 The study attracted women with elevated body image concerns and served as a targeted prevention program. The intervention consisted of three one-hour sessions in which 10 undergraduate women were assigned to develop a program for improving body image in high school girls.23 Since many of the women had highly internalized the thin ideal, taking a stance against it created psychological inconsistency and caused the women to alter their own beliefs.

The participants experienced a significant decrease in their own thin ideal internalization, body dissatisfaction, dieting, negative affect, and binging and purging behaviors at the end of the third session.23 At the one month follow-up, effects on the thin ideal, body dissatisfaction, and negative affect were maintained, but dieting measures had returned to baseline scores and the effect on bulimic symptoms were deteriorating.23 Conversely, binging and purging behaviors in the control group had significantly increased, so in comparison, the intervention may have protected against worsening symptoms.23 The authors also conclude that prevention programs targeted to high risk populations may be more beneficial than universal programs.23, 24

These findings were promising, but limited in the small sample size. Consequently, Stice et al.24 replicated the study with a larger sample size of 48 women in the intervention group. Similarly, this study attracted women with significantly elevated body image issues.24 The intervention mirrored that of the previous study and similarly, participants experienced

16 significantly decreased thin ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms.24 Moreover, all effects remained significant at the one month follow-up, suggesting that programs such as this one not only result in healthy behavior change, but may have lasting effects.24 While the intervention group addressed the thin ideal particularly, the control group focused on developing a program for high school girls that emphasized a healthy lifestyle in general.24 Interestingly, Stice et al.24 also saw a decrease in body dissatisfaction, dieting, negative affect, and binging and purging behaviors in the control group. The authors proposed that the control group resulted in positive effects because all participants were high risk whether they were assigned to intervention or control, but because the control group did not address thin ideal internalization, however, effects on thin ideal were more pronounced in the intervention group.24 Furthermore, this was the first eating disorder prevention program to actually decrease bulimic behaviors in participants. The authors attribute this effect to a non- psychoeducational approach that targeted high risk populations.24 However, a similar cognitive dissonance intervention has been observed to reduce body dissatisfaction, restraint, and eating pathology in both high- and low-risk college women.21, 22

Due to the success of this approach compared to psychoeducation, Becker et al.22 wanted to compare cognitive dissonance to another interactive approach. In this study, members of a college sorority participated in either a cognitive dissonance intervention of similar structure or a media advocacy intervention.22 The media advocacy group addressed the portrayal of women in the media, the attainability of the thin ideal, and strategies to resist media messages. The cognitive dissonance group discussed the consequences of pursuing the thin ideal and was assigned counter-attitudinal projects, such as standing in front of a mirror and noting positive mental, physical, and emotional attributes about themselves or trying to convince an herbal supplement enthusiast and an excessive dieter to abandon their unhealthy habits.22 Ninety new sorority members agreed to participate in the program and were assigned to one of the two groups.22 Eight months following the intervention, those in the cognitive dissonance group had sustained a moderate to large effect on decreased thin ideal internalization, body dissatisfaction, and restraint in addition to eating pathology, while the media advocacy group experienced little to no effect on these measures.22 Furthermore, these focus groups were led by peer facilitators, demonstrating that a highly trained professional may not be necessary to achieve desired results in this setting.

When this study was replicated and expanded to include about twice as many women, the authors found that both the cognitive dissonance and media advocacy groups both experienced a decrease in thin ideal internalization, body dissatisfaction, restraint, and bulimic symptoms at the eight month follow-up.58 When high-risk women were compared to low-risk women, however, only the cognitive dissonance intervention had positive effects on the low-risk women, suggesting that cognitive dissonance can have positive effects on all women regardless of risk level.58 Once again, the sessions were led by peer facilitators who had previously participated in the program. These positive outcomes support the use of cognitive dissonance-based interventions facilitated by trained peers.

Roehrig et al.59 proposed that the program by Stice et al24 was dissonance-based but also included both psychoeducation and behavior strategy components. Thus, Roehrig et al.59 conducted a study to investigate whether it was the cognitive dissonance or the combination of cognitive dissonance with psychoeducation that produced desired effects. The 78 participants were randomized into either a full treatment condition or a treatment condition with only dissonance induction.59 The full treatment condition was an exact replication of Stice et al.23 program that employed education on the thin ideal, pressure from family and friends, effects on self-esteem and health in addition to counter-attitudinal assignments such as writing an essay about the costs of pursuing the thin ideal, discussing how high school students can resist pressure, and role-playing to counter thin ideal statements.23 The dissonance induction group focused solely on the counter-attitudinal activities. The undergraduate women in both groups experienced significant decreases in thin ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms by the end of the intervention.59 The findings support previous research on cognitive dissonance and the authors conclude that the dissonance- induction component may be the essential element effective eating disorder prevention programs.

Overall, the cognitive dissonance approach has been shown to decrease thin-deal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms fairly regularly. When compared to psychoeducation and media literacy, cognitive dissonance seems to be the only approach that effectively decreases internalization of the thin ideal.21-24, 59 While these programs have had highly successful outcomes, the rapidly growing use of technology in the college population motivated researchers to explore another approach. Computer-based

18 eating disorder prevention programs provide an alternative venue for implementing eating disorder prevention programs with a widespread reach.

Computer-based Programs

With the increasing use of computers and the internet that continues to grow, computer- based technology has great potential for disseminating prevention programs. In 1998, Winzelberg et al.28 developed the computer program Student Bodies, a psychoeducational intervention using software to address body dissatisfaction, weight and shape concerns, and dieting or restrained eating.28 The program addressed four units, eating disorders, healthy weight regulation, nutrition, and exercise, through video presentations and taught cognitive-behavioral techniques.28 Women were recruited through the campus newspaper, fliers, and an electronic bulletin board. Fifty-seven women were randomly assigned to the intervention program, Student Bodies, or a control group. The software program significantly improved body image in participants, but not thin ideal internalization, bulimic symptoms, or weight and shape concerns.28 These findings encouraged Winzelberg et al.60 to implement a prevention program employing Student Bodies, conducted via internet to allow for an online discussion group component. Although no significant differences were found immediately following the end of the program, intervention participants were found to have significantly decreased thin ideal internalization and improved body image at the three month follow-up.60

Low et al.26 implemented the online Student Bodies program with undergraduate women, but had a longer follow-up period. Eight months following completion of the program, the 61 intervention participants had significantly decreased drive for thinness and body dissatisfaction, but the program had no effect on bulimic behaviors.26 At follow-up, weight and shape concerns remained the same in the intervention participants while increasing in the control group.26 Taylor et al.27 implemented the same program with a larger sample size, about 200 undergraduate women. During this cycle of Student Bodies, the intervention significantly decreased weight concerns, disordered eating, drive for thinness, and bulimic behaviors.27 All of the effects were sustained at the one year follow-up except for bulimic behaviors.27 The program targeted high- risk women by setting eligibility criteria of scoring high on a weight concerns scale, reporting

19 moderate or intense fear of gaining three pounds, or reporting that weight is the most important thing in life.27 At the two year follow-up, the median score for the measure of weight concerns was higher than the threshold set for entry in the study, indicating that the program could not sustain positive effects on weight concerns.27

Franko et al.25 examined the effects of a computer-based program on first year college women. The CD-ROM program Food, Mood, and Attitude (FMA) was designed using multiple behavior-change strategies to decrease disordered eating behaviors and attitudes. FMA addressed interpersonal issues, such as being accepted by peers and feeling attractive, taught cognitive behavior strategies, such as restructuring thoughts and addressing distortions, and employed interactive tools, such as providing feedback to reported behaviors.25 In contrast to the Student Bodies program, participants were required to complete the two-hour sessions of the program.25 The study recruited 240 first year students who were randomly assigned to the intervention or control group after being screen for risk of developing an eating disorder so each group would have equal numbers.25 All women, regardless of risk, in the intervention group increased their knowledge and awareness of thin ideal internalization.25 Compared to high-risk women in the control group, high-risk women in the intervention group decreased their weight and shape concerns significantly but did not decrease restrained eating.25 Compared to low-risk women in the intervention group, high-risk women in the intervention group experienced significantly increased knowledge and decreased internalization of the thin ideal, but did not decrease weight and shape concerns or restrained eating.25

Zabinski et al.29 also implemented a prevention program via the internet to address unhealthy eating habits and body image in undergraduate women. The pilot program consisted of a weekly reading followed by an online chat discussion, summary of the discussion, and a homework assignment.29 Through the program, students were taught cognitive behavior techniques to aid in behavior and attitude change. These techniques included identifying, challenging, and restructuring thoughts surrounding evaluation of body weight.29 The intervention led to decreased drive for thinness, weight and shape concerns, and restricted eating, but had no effect on bulimic symptoms.29 The program had promising results, but findings were limited due to the small sample size of four participants. Researchers then expanded this study by conducting a similar program with 60 women and an additional live online discussion instead of

20 a discussion board led by a moderator.61 The moderator posed questions related to the weekly reading, allowed participants to practice skills, ask questions, and discuss barriers, and ensured equal participation.61 Participants experienced significantly decreased eating and weight concerns, but not shape concerns or restrained eating.61

There are several benefits associated with computer-based programs. For example, these programs require fewer resources and are cost-effective.25, 60 Furthermore, programs can be completed independently and anonymously.25 Computer-based programs also have the potential to be used frequently for brief periods of time to avoid scheduling conflicts.60 However, there are limitations to the computer-based studies. Compliance is difficult to control since the students complete the programs from their own computers in their own time. Also limiting was the technological difficulties with the computers and internet access and lack of control over distractions in the students.28, 29, 60, 61 Overall, these computer-based prevention programs succeeded in improving body image and decreasing weight and shape concerns and thin ideal internalization, but do not sustain behavior change relative to dietary restraint or bulimic pathology.

College Curriculum

Programs reviewed in this paper have been successful but were limited in small sample size, inconsistent participation, and insufficient intensity, as none of the interventions met more than three times. It is possible that a more intense program of a longer duration may be necessary to produce optimal effects and the university setting may be ideal for such programs.17 Thus, there has been some research to investigate the effects of an intensive college course implementing a variety of behavior change techniques. Such an approach could allow for groups to meet multiple times a week for an entire semester. The students would receive credit for the course and would enroll voluntarily, which would encourage attendance and participation.

The first college course offered as a disordered eating intervention consisted of an undergraduate course that met for two hours a week for ten weeks. The course addressed issues related to body image such as media, history of beauty, cosmetic surgery, eating disorders, and culture.31 Each week, the 24 students were required to write a two to three page reaction paper to

21 that week’s topic.31 At the end of the course, the women had significantly decreased body dissatisfaction, weight and shape concerns, drive for thinness, and bulimic behaviors.31 The authors attribute the success of the program to many factors, including the multi-dimensional, academic, and non-personal nature of the ten-week course, although there was no control group for comparison.31 The course addressed the cultural, historical, and psychological components of body image without addressing personal change, which removed the stigma associated with personal concerns and avoided resistance to discussing these topics.31 The researchers did not determine if this approach had long-term effects.31

These promising findings encouraged Stice and Ragan17 to develop a similar program. The 15-week course addressed pathology and consequences of eating disorders and risk factors for eating pathology, as outlined by the dual-pathway model, which asserts that pressure to be thin from family, peers, and friends and the internalization of the thin ideal which fosters body dissatisfaction that promotes both dieting and negative affect.9, 17 Dieting then causes further negative affect due to the failure to control weight despite efforts and the impact of caloric deprivation on mood, leading to bulimic pathology.9 The course required the 17 students to attend lectures, write three essays, and complete one presentation analyzing a topic of their choice at the end of the semester and write a ten page paper on the same topic.17 These women reported significantly decreased thin ideal internalization, body dissatisfaction, dieting behaviors, and eating disorder symptoms at the end of the semester.17

To improve their previous study, the authors replicated the program and expanded it to include a six month follow-up.32 Again, the course used both psychoeducational and dissonance- based approaches to decrease thin ideal internalization.32 Impressively, the 25 participants reported significantly better outcomes at the six month follow-up than immediately after the intervention.32

Hawks et al.30 implemented a similar college course that focused on body image, self- esteem, eating disorders, dieting, and obesity. The design was based on the Health Belief Model, which asserts that the likelihood of changing behavior is dependent upon several factors including perceived susceptibility and seriousness to eating pathology, demographic and sociocultural variables, perceived benefits and barriers, and cues to action.30 The instructors tried to motivate change, or cues to action, in the form of small group discussions, peer-support

22 sessions, journal writing, and guided imagery assignments.30 Unlike the previous courses, this included a measure of intuitive eating.30 This is an important addition because it indicates eating based on intrinsic cues of hunger and fullness and anti-dieting attitudes. At the end of the semester, the 29 women reported significantly less dieting, improved body image, decreased weight concerns, and greater intuitive eating.30 This study, however, did not examine eating disorder behaviors other than dieting and did not conduct a follow-up.30

A similar program was offered in the form of the college course “Eating Disorders, Body Image, and Healthy Weight maintenance.” The instructor utilized psychoeducation, cognitive behavior techniques, cognitive dissonance, and media literacy to decrease disordered eating attitudes and behaviors. Analyses revealed that participants increased intuitive eating and decreased eating pathology, body dissatisfaction, thin ideal internalization, and dieting after the course. One month follow-up data indicated that all results were sustained at one month except for decreased thin ideal internalization. This class also attracted many high risk participants who experienced more pronounced benefits from the course.

One advantage of the college course approach is that participation is voluntary, students register for the class out of choice.17, 31 Students are motivated to participate to earn a passing grade. Furthermore, these programs were not advertised as eating disorder prevention programs, which may have allowed for the women to be less defensive and more open to alternate perspectives on body image.17 Baseline measures also indicate that these courses attract women with elevated eating disturbance.17, 32 While the effects of these college courses were encouraging, some limitations existed. Most of the programs had relatively small sample sizes and only one program included a six month follow-up.17, 31, 32

In the Fall semester of 2010, students at Florida State University enrolled in a three credit-hour course entitled “Eating Disorders, Body Image, and Healthy Weight Maintenance.” The class met twice a week for a total of three hours a week for 12 weeks. The course had three objectives: first, to learn about nutrition, dieting, eating disorders, and body image; second, to encourage students to take an active role in their health by examining thoughts and emotions related to class topics, consider personal values and beliefs, and analyze current health-related behaviors; finally, to enable students to build a sense of competence and personal power regarding nutrition, body image, and self concept. The course used a combination of approaches

23 to eating disorder prevention including didactic presentations, discussions, readings, videos, and activities such as identifying irrational beliefs, challenging negative talk, completing an art therapy activity, differentiating between a healthy ideal and the thin ideal, and role playing. The instructor was the first researcher to use the combination of cognitive behavior, cognitive dissonance, and media literacy techniques to conduct an eating disorders prevention program in an academic setting.

Over the course of 12 weeks, the students completed six homework assignments, five in- class activities, seven quizzes, and a five-page paper with a short presentation. The syllabus for the course can be found in Appendix A. Cognitive behavioral techniques included keeping a 24- hour food journal and identifying emotional links to food, discussing a handout regarding how students contribute to others’ eating disorders, challenging irrational beliefs about thinness, identifying and counteracting negative self-talk, and listing strategies that could be used to cope with anxiety, distress, and panic. Cognitive dissonance techniques included identifying examples of pressure to be thin and verbal challenges to that pressure and listing reasons that adolescent girls should avoid thin-ideal thinking, though many of the participants highly internalized the thin ideal. Media literacy was implemented by viewing Jean Kilbourne’s “Killing Me Softly III” which addressed media as a source of the thin ideal, effects of media on the negative body image of women, and the history of beauty in the media, followed by discussion and a reaction paper.

Students completed a survey on the first day of class, at the end of the twelve week curriculum, and four weeks after the conclusion of the course. Results indicated that female students who took the course had increased intuitive eating and decreased eating pathology, body dissatisfaction, thin ideal internalization, and dieting. All effects were sustained at the four week follow-up with the exception of thin ideal internalization. Furthermore, female students identified as high risk demonstrated more pronounced effects than those identified as low risk. The purpose of this study was to investigate the long-term effects of this course.

2.6 Sustainability and Follow-up of Similar Programs

In this review, 18 college eating disorder prevention programs were reviewed with reasonable success. However, few programs have included a substantial follow-up period to

24 determine whether effects are sustained. Lack of a follow-up period has been identified as a limitation in the evaluation of prevention programs. In an extensive review of 27 undergraduate eating disorder prevention programs that took place from 1987 to 2007, Yager and O’dea62 found that only 52% included any follow-up. A summary of the studies reviewed in this paper with follow-up periods and findings are reported in Table 1. Three of the 18 programs reviewed did not have any follow-up.17, 30, 31 All three resulted in decreased body dissatisfaction and

Table 1. Summary of Sustainability of Prevention Programs

Study Follow-Up Findings

Winzelberg et al., 199828 3-month Improved body image sustained; no effect on thin ideal internalization, bulimic symptoms, or weight and shape concerns Springer et al., 199931 None Improved body image, weight and shape concerns, drive for thinness, and bulimic symptoms post-intervention Stice et al., 200023 1-month Decreased thin ideal internalization, body dissatisfaction, bulimic symptoms, and negative affect sustained; Decreased dieting post-intervention, but not maintained at follow-up Winzelberg et al., 200060 3-month No significant differences post-intervention, but decreased thin ideal internalization and improved body image at follow-up; no effect on bulimic symptoms or weight and shape concerns Stice et al., 200124 1-month Decreased thin ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms sustained Zabinski et al., 200129 10-week Decreased drive for thinness, weight and shape concerns, and restricted eating sustained; no effect on bulimic symptoms Stice and Ragan, 200210 None Decreased thin ideal internalization, body dissatisfaction, dieting, and eating disorder symptoms post-intervention Matusek et al., 200457 4-week Decreased thin ideal internalization, body dissatisfaction, and eating pathology sustained Zabinski et al., 200461 10-week Decreased eating and weight concerns sustained; no effect on restrained eating or shape concerns Becker et al., 200521 1-month Decreased thin ideal internalization, body dissatisfaction, restraint, and eating pathology sustained Franko et al., 200525 3-month Increased knowledge and awareness of thin ideal sustained; decreased weight and shape concerns sustained Becker et al., 200622 7-week & 8- Decreased thin ideal internalization, body dissatisfaction, month restraint, and bulimic symptoms Low et al., 200626 8-month Decreased drive for thinness and body dissatisfaction sustained; no effect on bulimic symptoms or weight and shape concerns Roehrig et al., 200659 1-month Decreased thin ideal internalization, body dissatisfaction, dieting, and bulimic symptoms sustained; decreased negative affect not sustained 25

Table 1 Continued

Study Follow-Up Findings

Taylor et al., 200627 1 & 2 years Decreased weight concerns, disordered eating, drive for thinness at 1 year; effects on weight concerns not sustained at 2 years Stice et al., 200632 6-month Decreased thin ideal internalization, body dissatisfaction, dieting, and eating disorder symptoms sustained or greater at follow-up Becker et al., 200858 7-week & 8- Decreased thin ideal internalization, restraint, body month dissatisfaction, and bulimic pathology sustained; thin ideal internalization effects faded slightly at 8-months but other effects sustained Hawks et al., 200858 None Increased intuitive eating and decreased dieting, body dissatisfaction, and weight concerns post-intervention Magnuson (unpublished) 1-month Increased intuitive eating and decreased dieting, body dissatisfaction, thin ideal internalization, and eating pathology sustained

disordered eating habits, but it is unknown whether or not these effects are endured over time.17, 30, 31 Ten of the 18 programs reviewed conducted a follow-up between one and three months.21, 23-25, 28, 29, 57, 59-61 The majority of these programs demonstrated limited effectiveness, often sustaining some effects on risk factors like thin ideal internalization or body dissatisfaction, but usually not the behavior change like binging or purging.23, 28, 29, 59-61 Only four had successful effects that were sustained.21, 24, 25, 57 Three of these four studies had a one month follow-up and only one had a three month follow-up.

Five undergraduate eating disorder prevention programs were conducted with a follow-up of at least six months.22, 26, 27, 32, 58 One of these studies had varied results with decreased thin ideal internalization and body dissatisfaction sustained, but the program had no effect on bulimic behaviors or weight and shape concerns.26 This was one of the programs that utilized the psychoeducational software program Student Bodies. Another study that used the Student Bodies software program included one and two year follow-ups.27 At one year, decreased weight concerns, disordered eating, and drive for thinness persisted. However, the authors reported that effect on weight concern was not sustained at two years and did not report any other findings from the two year follow-up.27 The other three programs successfully sustained decreased thin

26 ideal internalization, body dissatisfaction, dieting, and bulimic symptoms for at least six months.22, 32, 58 All three of these programs employed the cognitive dissonance approach.22, 32, 58

Many undergraduate women have adopted various harmful habits from dieting and fasting to purging and diet pills to try to control body weight. These behaviors stem from a combination of personal factors (i.e. body dissatisfaction, body shape concerns, and preoccupation with weight), socio-cultural factors (i.e. parental attitudes, peer behavior, and media influence), and behavioral factors (i.e. dieting and binge eating). Due to the high prevalence and wide range of disordered eating behaviors, programs are needed to both prevent the eating disorders and to reverse unhealthy behaviors and attitudes. Extensive research has been conducted to develop programs on college campuses to change harmful attitudes and behaviors. Many of these programs were able to increase knowledge and change attitudes and some were even able to alter behavior. However, many programs failed to study the sustainability of positive effects. Therefore, the purpose of this research is to answer the question: Will female college students who took the course “Eating Disorders, Body Image, and Healthy Weight Maintenance” sustain observed effects three, six, and 12 months following the course using the measures of intuitive eating, thin-ideal internalization, restrained eating, body dissatisfaction, and eating pathology?

CHAPTER 3

METHODS

Female students who took the course “Eating Disorders, Body Image, and Healthy Weight Maintenance” experienced increased intuitive eating and decreased eating pathology, body dissatisfaction, thin ideal internalization, and dieting immediately at the end of the course. All effects were sustained at the four week follow-up with the exception of thin ideal internalization. The purpose of this study was to investigate the long-term effects of this course. The hypothesis was that increased intuitive eating and decreased negative body image, restrained eating, thin ideal internalization, and eating pathology will be maintained at least 12 months following the conclusion of the course. In this chapter, the sampling procedure, survey instrument, data management and statistical approaches to test this hypothesis are discussed.

3.1 Sample

The intervention group included 76 undergraduate women who participated in “Eating Disorders, Body Image, and Healthy Weight Maintenance” class at Florida State University in the Fall semester of 2010. Men were excluded from the study to avoid non-valid results. The mean age of the sample was 19.36 ± 2.56 years; the mean height was 64.75 ± 2.46 inches; the mean weight was 133.28 ± 21.21 pounds; the mean body mass index (BMI) was 22.35 ± 3.25, which is a healthy body weight according to the Centers for Disease Control and Prevention (CDC). The class consisted of a diverse group of Caucasian (69%), African American (11%), Hispanic (11%), and Asian (4%) women, with the remainder reporting ethnicity as “other” (5%). High risk participants were identified using the Body Shape Questionnaire (BSQ), as in previous studies.21, 29, 58, 60, 63 Those participants who scored above the median for the BSQ were considered to be at “high risk” for developing an eating disorder while those who scored below the median were considered to be at “low risk” for developing an eating disorder. The median score in this group was 84, characterizing 36 (47.4%) students as “low risk” and 40 (52.6%) students as “high risk.”

All students were approached during the last class and recruited for participation in the current long-term follow-up study. The curriculum was taught to 100 students, both male and female. Of these students, 90 signed the informed consent. Of these, 76 female students participated in the pre- and post intervention study. Of the 76 students, 41 students (53.9%) responded to at least one of the follow-up surveys in this study. The three month follow-up attracted 33 participants (43.4%); the six month follow-up attracted 22 participants (28.9%); the 12 month follow-up attracted 21 participants (27.6%) despite the incentive of a gift card drawing for participation. Only ten students responded to all three of the follow-up surveys in this study. All available data was used for analysis. Use of missing data (wave non-response) is addressed in the statistical analysis section.

3.2 Protection of Human Participants

At the four week follow-up, students were solicited to participate in this follow-up study. Students were assured that their participation was voluntary. Approval was obtained from the Institutional Review Board at Florida State University (Appendix B) and all agreeable participants signed an approved informed consent prior to participation in the follow-up surveys (Appendix C). This study had little risk to those participating. Surveys were conducted anonymously and no personal identifiers were collected. This study may have benefited participants by prompting recollection of the nutrition knowledge, positive attitudes, and healthier lifestyle behaviors discussed in class. The only risk was the possibility of discomfort associated with responding to questions about body image and eating attitudes for those who continue to struggle with these topics. Students were provided contact information for the University Counseling Center, Thagard Student Health Center, and the Nutrition Clinic at Florida State University and encouraged to seek help if this did occur.

3.3 Procedures

Students completed a survey before the twelve weeks of curriculum, which served as a baseline measure, and a post survey during the last class. Students also completed a follow-up

29 survey, four weeks after the conclusion of the course. Data for the current study will be compared to the data for these 76 women. Students who agreed to participate were contacted via email at three, six, and 12 months following the course and prompted to complete the anonymous surveys using an online survey software program, Qualtrics. Students were asked to give the last four digits of their cellular phone number on their survey in order to compare the surveys at the different time points. As incentive for participation, students who participated in the twelve month survey were entered into a drawing to win a $50 gift card to a local grocery store.

3.4 Measures

At each time point, participants were asked to report descriptive data such as age, height, weight, ethnicity, and gender. Data was analyzed for female participants only. The questionnaire (Appendix D) was consistent throughout the study so that results could be compared to determine effects of the curriculum over a 12 month follow-up. The questionnaire included the following surveys: the Eating Disorder Examination–Questionnaire (EDE-Q), the Dutch Restrained Eating Scale (DRES), the Ideal Body Stereotype Scale-Revised (IBSS-R), the Body Shape Questionnaire (BSQ), and the Intuitive Eating Scale (IES). The purpose of each measure is discussed along with a description of the questions, scoring, internal consistency, and test retest reliability. Internal consistency refers to whether the similar items in each survey produce similar scores. Cronbach’s alpha was used to measure internal consistency. This statistic can range from 0 to 1. A score of 0.6-0.7 indicated acceptable consistency and a score of 0.8 or higher indicated good consistency. Test re-test reliability refers to the degree to which a questionnaire can produce similar results if given to the same participants twice. A score of 0.7 or higher is considered good test re-test reliability.

The EDE-Q was used to measure eating pathology in the form of dietary restraint, eating concerns, shape concerns, and weight concerns.11, 64 This questionnaire consists of 28 items using a Likert scale ranging from 0 (no days) to 6 (everyday). The EDE-Q has four subscales (Restraint, Eating Concern, Shape Concern and Weight Concerns) computed by adding the subscale items together and dividing by the total number of items. A sample item from the EDE-

Q is “have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?” A decrease in these scores would indicate decreased eating pathology or increased healthy attitudes and behaviors. The EDE-Q has good internal consistency reliability (EDE-Q restraint α = .84),58, 59 (EDE-Q weight & shape concerns α = .79-.80),31, 65 (EDE-Q eating concerns and (EDE-Q bulimic subscale α = .79-.85).58, 59 The parent study also found good internal consistency on the subscales: EDE-Q restraint α = .89, eating concerns α = .88, shape concerns α = .91, and weight concerns α = .87.

The DRES was used to measure dieting behaviors.66 This survey consists of ten items; for example, “if you put on weight, did you eat less than you normally would?” The DRES uses a Likert scale ranging from 1 (never) to 5 (always). The scores from each item are added and divided by ten to obtain an average score. A decrease in this score would indicate decreased dieting and restrictive behavior. The DRES has yielded good internal consistency (α = .95) and test-retest reliability (r = .82).67 The parent study also found good internal consistency reliability (α = .92).

The IBSS-R was used to measure thin-ideal internalization. This questionnaire consists of eight items; for example, “slim women are more attractive.” The IBSS-R uses a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scores from each item are added together and divided by eight to obtain an average. A decrease in this score would indicate decreased thin ideal internalization. The IBSS-R has a good internal consistency (α = .91)67 and (α = .81)32 and test-retest reliability (r = .80).67 The parent study also found good internal consistency (α = .82).

The BSQ was used to measure body dissatisfaction.68 This questionnaire consists of 34 items; for example, “have you felt so bad about your shape that you have cried?” The BSQ uses a Likert scale ranging from 1 (never) to 6 (always). The BSQ score is determined by the sum of all of the items, therefore, scores can range from 34 to 204. Furthermore, it was used in the parent study to identify high risk participants, as in previous studies.21, 29, 58, 60, 63 Those participants who scored above the median for the BSQ were considered to be at “high risk” for developing an eating disorder while those who scored below the median were considered to be at “low risk” for developing an eating disorder. It has good test-retest reliability (α = .88) and

31 compares well to other measures of body satisfaction.69 The instrument also demonstrated good internal consistency in the parent study (α = .97).

The IES was used to measure intuitive eating, or, intrinsic, hunger-based eating behaviors.70 The IES consists of 21 items; for example, “I follow eating rules or dieting plans that dictate what, when, and/or how much to eat.” The IES uses a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The questionnaire is scored by calculating a total IES score, which is the average of the 21 items, as well as three subscales: unconditional permission to eat (average score of nine items), eating for physical rather than emotional reasons (average score of six items), and reliance on internal hunger/satiety cues (average score of six items). An increase in these scores would reveal increased intuitive eating. Initial testing of the IES among a college population yielded a wide range of internal consistency coefficients (α = .42-.93) and test-retest reliability for each subscale (.56-.87).30 Validity has been established as higher scores have been associated with intrinsic eating principles.30 This tool is important because the purpose of the program was not only to decrease disordered eating behaviors, but to replace them with healthier behaviors.

3.5 Data Management

A spreadsheet was created to record participation in the three, six, and 12 month follow- up surveys. The only identifier reported was the last four digits of the participants’ phone number; this code was used to identify who completed the follow-up study as well as to match the data to previous surveys. Exploratory analysis was conducted, in the form of scatterplot diagrams and descriptive statistics, to check for data entry errors, irregularities, and outliers. Assumptions for the statistical tests were tested. The two assumptions for paired t tests are normal distribution and equal variance. The assumption for repeated measures analysis of variance (ANOVA) is sphericity, or the equality of variances of the differences between conditions.

3.6 Statistical Analysis

Data were analyzed using statistical software (PASW Statistics 18). A paired t-test was carried out to determine the effects on intuitive eating, eating pathology, dieting, thin ideal internalization, and body dissatisfaction between baseline and 12 months following the conclusion of the course. Repeated measures ANOVA were conducted to investigate change in the measures over the 12 month period. This determined what effects were sustained up to a year after completing the eating disorders, body image, and healthy weight maintenance curriculum. While improvements were more pronounced for students identified as high risk in the original study, risk level was not assessed in this study due to the lack of a control group.

Wave non-response (missing data) occurred during data collection, which means that some participants completed surveys for some but not all waves of data collection, but not for others. However, because repeated measurements for a participant tend to be correlated, it is recommended to use all available data rather than only data from those who responded to all three waves of data collection.71 In a longitudinal study, the best method to impute missing data is the statistical procedure of maximum likelihood (ML) which utilizes an expectation- maximization (EM) algorithm using the missing data module for PSAW.71 This method is superior to other methods of imputing missing data such as case deletion, reweighting, averaging available items, and single imputation.71 Thus, this method was used in the ANOVA of the longitudinal data.

CHAPTER 4

RESULTS

The purpose of this study was to investigate the sustainability of the effects of a curriculum-based eating disorder prevention program on the following measures: intuitive eating, restrained eating, body dissatisfaction, thin ideal internalization, and eating pathology. Students were approached during their last “Eating Disorders, Body Image, and Healthy Weight Maintenance” class. Ninety students agreed to participate and signed the IRB approved informed consent. They provided their email addresses so that they could be contacted to complete the anonymous surveys at three, six, and 12 months following the end of the course. The 76 females who participated in the intervention completed the initial set of questionnaires prior to the class, immediately after the course, and one month following the conclusion of the course. Follow-up surveys were compared to these results.

4.1 Results of Data Analysis

After imputation of missing data, repeated measures ANOVA was carried out for the 76 participants at the six time points (Table 2). In repeated measures ANOVA, the assumption of sphericity was addressed before interpreting the results. Sphericity refers to the equality of variances of the differences between conditions. PASW 18.0 ran Mauchly’s test to test the hypothesis that the variances of the differences between conditions were equal. If Mauchly’s test of sphericity reveals a statistically significant value, less than the critical value of 0.05, then the variances of the difference between levels are significantly different, or the assumption of sphericity has been violated. If sphericity is violated, an adjusted statistic should be used. As recommended by Field, if the two corrections give rise to the same conclusion, the more conservative statistic, the Greenhouse-Geiser, should be used.72 If the two corrections give rise to different conclusions, the Greenhouse-Geisser and the Huynh-Feldt should be averaged; if the average is significant, the significant statistic should be reported and vice versa.72 All 12 measures violated sphericity, but in all cases, both corrections offered the same conclusion; thus,

34 results of the Greenhouse-Geiser analysis were reported. Results indicate there was significant change over time for all effects measured in the questionnaire.

Table 2. Results of Repeated Measures Analysis of Variance (n=33)

Scale Baseline Post 1 Month 3 Month 6 Month 12 Month p for Trend Total IES 3.21(.53) 3.63(.54) 3.61(.64) 3.47(.40) 3.51(.35) 3.35(.45) p<.001*

IES 2.87(.65) 3.54(.66) 3.51(.76) 3.34(.47) 3.45(.42) 3.36(.50) p<.001* Unconditional Permission to Eat IES Eating 3.20(.89) 3.51(.75) 3.48(.88) 3.21(.52) 3.30(.46) 3.18(.54) p=.001* for Physical Reasons IES Eating 3.71(.60) 3.89(.59) 3.90(.64) 3.93(.43) 3.82(.34) 3.52(.43) p<.001* Based on Internal Cues EDEQ 1.99(1.35) .79(.84) .82(.99) 1.77(.86) 1.23(.59) 1.44(.74) p<.001* Restraint Subscale EDEQ Eating 1.15(1.36) .57(.81) .68(.91) 1.03(.81) .72(.58) 1.23(.73) p<.001* Concerns Subscale EDEQ Shape 2.54(1.44) 1.74(1.29) 1.75(1.23) 2.32(.86) 1.64(.67) 2.13(.88) p<.001* Concerns Subscale EDEQ 2.15(1.53) 1.45(1.22) 1.59(1.22) 1.83(.78) 1.20(.61) 1.82(.86) p<.001* Weight Concerns Subscale EDEQ Global 1.96(1.30) 1.14(.93) 1.21(.96) 1.74(.78) 1.22(.55) 1.66(.76) p<.001* Subscale Dutch 2.76(.83) 2.19(.74) 2.09(.73) 2.28(.56) 2.19(.41) 2.12(.45) p<.001* Restrained Eating Scale Ideal Body 3.58(.50) 3.36(.58) 3.43(.64) 3.59(.32) 3.45(.30) 3.55(.30) p=.001* Stereotype Scale Revised Body Shape 91.37(34.38) 76.02(25.88) 75.43(27.32) 81.05(20.40) 67.89(13.63) 82.89(23.07) p<.001* Questionnaire *Indicates statistical significance (p<.05); an increase in all measures of the IES would indicate increased intuitive eating; a decrease in all measures of the EDEQ would indicate a decrease in eating pathology; a decrease in the DRES would indicate a decrease in dieting behavior; a decrease in the IBSS-R would indicate a decrease in thin ideal internalization; a decrease in the BSQ would indicate a decrease in body dissatisfaction

To further explore the data, a paired t test was carried out to investigate which effects remained significantly improved 12 months following the conclusion of the course (Table 3). Immediately following the course, students experienced significantly increased intuitive eating and decreased eating pathology, dieting, thin ideal internalization, and body dissatisfaction. All results were maintained at the one month follow-up with the exception of thin ideal internalization, for which improvement was diminishing, but was still lower than baseline. At 12 months, scores for the total IES, IES unconditional permission to eat, IES eating based on internal cues, all measures of the EDEQ, DRES, and BSQ remained significantly improved from baseline. While IES eating for physical reasons and IBSS-R scores were not significantly improved from baseline, they still remained below baseline scores.

Table 3. Results of 12 Month Follow-up (n=76)

Scale Baseline 12 Month Significance

Total IES 3.21(.53) 3.35(.45) P=.023*

IES Unconditional 2.87(.65) 3.36(.50) p<.001* Permission to Eat IES Eating for Physical 3.20(.89) 3.18(.54) p=.873 Reasons IES Eating Based on 3.71(.60) 3.52(.43) p=.006* Internal Cues EDEQ Restraint Subscale 1.99(1.35) 1.44(.74) p=001*

EDEQ Eating Concerns 1.15(1.36) 1.23(.73) p=.519 Subscale EDEQ Shape Concerns 2.54(1.44) 2.13(.88) P=.013* Subscale EDEQ Weight Concerns 2.15(1.53) 1.82(.86) p=.043* Subscale EDEQ Global Subscale 1.96(1.30) 1.66(.76) p=.033*

Dutch Restrained Eating 2.76(.83) 2.12(.45) p<.001* Scale Ideal Body Stereotype Scale 3.58(.50) 3.55(.30) p=.654 Revised Body Shape Questionnaire 91.37(34.38) 82.89(23.07) p=.028*

*Indicates statistical significance (p<.05); an increase in all measures of the IES would indicate increased intuitive eating; a decrease in all measures of the EDEQ would indicate a decrease in eating pathology; a decrease in the DRES would indicate a decrease in dieting behavior; a decrease in the IBSS-R would indicate a decrease in thin ideal internalization; a decrease in the BSQ would indicate a decrease in body dissatisfaction

CHAPTER 5

COMMENT

Female students who participated in the curriculum-based eating disorder prevention program “Eating Disorders, Body Image, and Healthy Weight Maintenance” experienced significantly increased intuitive eating and significantly decreased negative body image, restrained eating, thin ideal internalization, and eating pathology immediately following the course. The questionnaire used in this study was the same used to analyze the effects of the curriculum prior to the course, immediately following the course, and one month after. All effects were sustained at the one month follow-up with the exception of thin ideal internalization which was diminishing. The purpose of this study was to investigate the sustainability of these effects at three, six, and 12 months following the conclusion of the course. Results indicate that most improvements were sustained. Interpretation and meaning of these results is presented in the following section.

5.1 Discussion

Intuitive eating is a key component of the non-diet approach that has been associated with healthy weight management.51, 54, 55 An increase in the total and subscale measures would indicate a positive change toward increased intuitive eating. The total IES measures the interrelationship between eating foods that are desired, eating for physical reasons, and reliance on internal cues. Results indicated that after taking the course, students sustained increased intuitive eating for at least 12 months. The IES subscale of unconditional permission to eat reflects the degree to which an individual eats when they are hungry and does not restrict amounts or types of food.70 A significant increase in this measure would indicate a decreased tendency to place conditions on when and how much to eat which, in turn, could reduce feelings of deprivation and preoccupation with food.70, 73 This improvement was also sustained for at least 12 months following the course. The IES subscale of eating for physical reasons reflects the degree to which an individual uses food to satisfy a physical hunger rather than a coping

38 mechanism for emotions and stress.70 While an improvement in this measure was observed at the one month follow-up, positive effects diminished by the 12 month follow-up. The IES subscale of eating based on internal cues measures an individual’s ability to rely on hunger and satiety cues to determine when and how much to eat. Positive effects observed after the course were sustained according to this measure through the 12 month follow-up.

All positive effects measured by the EDEQ were sustained through the 12 month follow- up. The subscales of the EDEQ measure eating pathology and include restraint, eating concerns, weight concerns, shape concerns, and a global scale, which is an average of the previous four subscales. This is an important outcome because the EDEQ is designed to address eating disorder pathology as outlined by the DSM-IV.11 For example, restraint is prevalent in patients with AN as well as used as a purging technique in those with BN. The eating concerns subscale addresses preoccupation and obsession with food. The weight and shape concerns subscales address the degree to which one values weight and shape, determines self-esteem based on these factors, and has an intense fear of weight gain. Through the follow-up period, students who participated in the class maintained decreased levels of eating pathology.

The positive effect measured by the BSQ was also sustained 12 months following the conclusion of the intervention. The BSQ is used to measure level of body dissatisfaction, or concern with body weight and shape. Higher rates of body dissatisfaction are associated with higher rates of subclinical eating disorders, dieting, binge eating, depression, and low self- esteem.13, 15, 49 Students were able to maintain decreased levels of body dissatisfaction. Furthermore, this finding is consistent with the results of the EDEQ subscales of weight concerns and shape concerns, which were also sustained.

At the one month follow-up, the decrease in thin ideal internalization, measured by the IBSS-R, was diminishing. The average score at the 12 month follow-up, however, remained below the baseline score, although the decrease was not statistically significant. According to Stice’s dual-pathway model, bulimic pathology begins with thin ideal internalization that fosters body dissatisfaction, dieting, and negative affect that ultimately lead to bulimic pathology.9 The intervention may have protected against an increase in thin ideal internalization, but this cannot be determined without a control group.

Results indicated that the positive effect measured by the DRES after the intervention was sustained for 12 months following the conclusion of the course. The DRES measures dieting behavior or the degree to which an individual eats less than desired. Frequency of dieting is associated with more severe eating disorder symptoms, body dissatisfaction, thin ideal internalization, weight concerns, and emotional attachment to exercise.10, 14, 15 There is also evidence that dieting is highly associated with increased risk of developing an eating disorder.16 After taking the course, students experienced a significant decrease in dieting behavior that was sustained at 12 months. This finding coincided with the EDEQ restraint subscale, which was also sustained. This was a significant finding, demonstrating a sustained change in disordered eating behavior.

Overall, students maintained a majority of the positive effects from participation in the curriculum. Students maintained positive effects on most aspects of intuitive eating, eating pathology, body dissatisfaction, and dieting. The only measure that was sustained at the one month follow-up that was not maintained through 12 months was the IES subscale of eating for physical reasons. Finally, while decreased thin ideal internalization was not maintained post- intervention, the scores remained below baseline at the 12 month follow-up. These outcomes are comparable to similar studies.

Of the four curriculum-based eating disorder prevention programs, only one included follow-up data.32 In this study, intervention students had significantly sustained a decrease in thin ideal internalization, body dissatisfaction, dieting, depressive symptoms, and eating disorder symptoms six months following the intervention.32 In the current study, results revealed a sustained decrease in body dissatisfaction, body dissatisfaction, and eating disorder symptoms, but not thin ideal internalization.

Two cognitive dissonance-based eating disorder prevention programs conducted eight month follow-ups.22, 58 Both of these programs found decreased thin ideal internalization, body dissatisfaction, restraint, and bulimic symptoms that were sustained at the eight month follow-up. The current study found a sustained decrease in body dissatisfaction and restraint, but not thin ideal internalization and did not include a measure of bulimic symptoms.

Two computer-based eating disorder prevention programs utilized the software program Student Bodies conducted at least an eight month follow-up.26, 27 The first had varied results with decreased thin ideal internalization and body dissatisfaction sustained, but the program had no effect on bulimic behaviors or weight and shape concerns.26 The current study found decreased body dissatisfaction, but did not demonstrate a sustained decrease in thin ideal internalization. However, the current study did observe a sustained decrease in weight and shape concerns. The second conducted one and two year follow-ups.27 At one year, decreased weight concerns, disordered eating, and drive for thinness were sustained.27 However, the authors reported that effect on weight concern was not sustained at two years and did not report any other findings from the two year follow-up.27 At one year, the current study reported sustained decrease in weight concerns and eating pathology, but not in drive for thinness.

While interventions that produce any positive attitude and behavior change are a step in the right direction, maintenance of these changes is equally important. Most of the positive effects were sustained over time, but modifications could be made to the course to maximize benefit. The design of this program was favorable for using a combination of behavior change techniques. Programs that have been able to sustain effects used techniques not utilized in this program. For example, two cognitive dissonance-based programs previously discussed were successful in sustaining positive effects.22, 58 These programs consisted of two cognitive dissonance-based sessions led by trained peers.22, 58 While the program in this study did implement cognitive dissonance, perhaps it was the dissemination of the technique that helped sustain effects. The instructor could employ a similar technique by having students who took the course in a previous semester lead class sessions. Other programs had success in using computer programs.26, 27 These programs also included an online moderated discussion group. This program could implement an abbreviated computer program as a homework assignment and could utilize the class website for anonymous discussion. There is also evidence that conducting booster sessions following intervention is effective in maintaining behavior change.74 While it may not feasible to bring students back for booster sessions after the conclusion of a course, a similar technique could be implemented. The instructor could produce a newsletter reviewing material covered in class, discussing relevant media headlines, presenting new research on course topics that could be emailed or posted on the course website. Former students could also blog or offer feedback and support to current students on the website. Although most results

41 were sustained, small adjustments could be made to the course to maximize maintenance of positive attitude and behavior change.

5.2 Limitations

While data analysis revealed promising outcomes to the eating disorder prevention course, two notable limitations to this study exist. One limitation was the response rate. Wave nonresponse occurred during data collection, which means that some participants were present for some waves of data collection, but not for others. However, because it is recommended to use all available data rather than only those who responded to all three waves of data collection, the missing data module was used to impute missing data.71 The other major limitation to this study was the lack of a control group. Time constraints did not allow for the control participants from the original study to be recruited for this study. It remains unknown how follow-up scores for intervention students would compare to those of the control students. At the one month follow- up for a cognitive dissonance-based eating disorder prevention program, Stice et al.23 found that while effects of decreased binging and purging behaviors were deteriorating, binging and purging behaviors in the control group had significantly increased. Therefore, the authors propose that the intervention may have protected against the worsening of symptoms.23 In a curriculum-based eating disorder prevention program, Stice et al.32 found a significant increase in thin ideal internalization in the control group six months following the conclusion of the course, while intervention students sustained a significant decrease in the same measure. Results of the current study exhibited a similar finding in which a decrease in thin ideal internalization was not sustained but also did not appear to worse. Thus, it is possible that the intervention could have had a protective effect, but this remains unknown without a control group for comparison.

All curriculum-based eating disorder prevention programs have produced significant changes in disordered eating attitudes and behaviors. This was only the second of these studies to conduct a follow-up period to determine if effects are sustained. While this follow-up study produced successful results, similar research needs to be conducted that maximizes response rate and includes a control group to draw further conclusions.

5.3 Conclusion

The hypothesis of this study was that increased intuitive eating and decreased negative body image, restrained eating, thin ideal internalization, and eating pathology will be maintained at least 12 months following the conclusion of the course. Overall, results suggest that students who participated in this college course sustained significant improvements in various aspects of intuitive eating, eating pathology, body dissatisfaction, and dieting behavior. Analysis also revealed, however, that positive effects on eating for physical reasons and thin ideal internalization were not sustained 12 months following the course. These findings suggest that most of the positive effects of this curriculum-based eating disorder prevention program were sustained at least 12 months following the conclusion of the intervention. Furthermore, outcomes were similar to other eating disorder prevention programs. This is the first curriculum-based prevention program to conduct a 12 month follow-up and only the second to conduct any follow- up. Although the program was highly successful, minor adjustments could be made to the course to maximize effects of participation. In addition, to further understand the benefits of this type of program, future research is necessary using an experimental design.

APPENDIX A

Syllabus

PET 3932 (2) Eating Disorders, Body Image & Healthy Weight Maintenance (3 credit hrs) Fall 2009 Mon Wed 1:25 – 2:40 pm 115 Bellamy

Amy Magnuson, MS, RD Office Hours: 402 Thagard Student Health Center Thurs 12:00-3:00 pm Other times by appointment

Course Objectives The first objective of this course to present current science based information about nutrition, dieting, eating disorders and body image. A second objective is to involve you in taking responsibility for your health. You are invited to examine your thoughts and emotions about the issues under discussion, to consider your personal values and beliefs, and to analyze your health-related behaviors. The third objective is to enable you to build a sense of competence and personal power regarding your nutrition, body image and self-concept.

Course Requirements There is no required text for this course but there are required readings. All required readings will be posted on blackboard.

Attendance and Participation: Your regular, punctual attendance is required. If you are late on 3 occasions, you will be charged with an absence. I am aware that sometimes you may need to miss class for reasons other than health problems, therefore you are granted 2 absences.

Absences beyond the 2 that are allowed will result in a 3 point loss for each that occurs. Absences are excused for medical reasons or personal problems that can be documented. Vacations, weddings, early holiday departures, having to see an advisor, work-related problems, etc., will not be excused. You are expected to join in class discussions and exhibit active listening.

CELL PHONES, PAGERS, OR WATCH ALARMS MUST BE TURNED OFF DURING CLASS

ASSIGNMENTS

Points will be deducted for improper grammar, spelling, or failure to proofread.

LATE ASSIGNMENTS WILL NOT BE ACCEPTED. Late submissions are those that occur any time after the class session in which the assignment is due. If you are ill and must miss class, your assignment is still due on the date indicated on your syllabus. You may submit it electronically or have a friend drop it off.

TENTATIVE CLASS SCHEDULE

This schedule may change due to the natural pace and rhythm that is inherent in any class. This flexibility may require either speeding up or slowing down. You will be apprised in advance of any changes.

Week Day Discussion Assignment

Course Introduction: Schedule, objectives, In class assignment – what are your Aug 24 organization & assignments, discussion of interests? interests

Nutrition & Exercise Objectives Students will be able to: List your top (10) reasons for pursuing a healthy lifestyle (positive 1 1. Identify functions of protein, carbohydrates & & negative motivations) (5 pts) fats. Aug 26 Begin Homework #1: 24 hour food 2. List consequences of low carbohydrate diet & exercise journal (5 pts), enter into mypyramid.gov (5 pts) & discuss 3. Identify the Dietary Guidelines for Americans brief summary on your experience (10 pts) 4. Identify guidelines for physical activity

Nutrition & Exercise Objectives Aug 31 (continued) Homework #1 due (25 pts)

Intuitive Eating Objectives

Students will be able to: In class activity #1 (5 pts) 1. Define intrinsic eating Reading (1) for 9/9: Tribole, 2 2. Identify components of ―normal eating‖ Evelyn, and Elyse Resch. Intuitive Sept 2 Eating : A Revolutionary Program 2. Identify principles to help with healthy eating that Works. New York: St. Martin's Griffin, 2003. Ch 2 pg 8-19 3. Identify principles to help ensure adequate exercise

4. Differentiate between ―mindful eating‖ and ―dieting‖

3 Sept 7 Labor Day

Intuitive Eating Objectives Quiz #1 on Tribole & Resch reading (1), ch 2 (5 pts) Sept 9 (continued) Reading (2) for 9/14: Tribole & Resch, Chapter 3, pg 20-29

Intuitive Eating Objectives Quiz #2 on Tribole & Resch reading (2), ch 3 (5 pts) 1. (continued) Readings (3) for 9/16: Mann, T, Tomiyama, J., Westling, E., Lew, A.M., Samuels, B., Chatman, J. Sept 14 (2007). Medicare’s Search for Effective Obesity Treatments. American Psychologist, 220-232 and Fletcher, A.M.(2003). Renewed Hope for Self-Change. American 4 Psychologist, 822-823.

Dieting Objectives Quiz #3 on Mann et al.(2007)& Students will be able to: Fletcher (2003) (5 pts) 2. 1. Briefly discuss the short & long term effects Sept 16 Reading (4) for 9/21:Handout: of ―dieting.‖ (Provide at least 5 effects) 3. 2. Provide strategies to assist with long-term ―Comparing traditional and non-diet health vs simply education. approaches to eating & weight 3. Define & differentiate between ―non-diet‖ vs loss.‖ ―diet‖ thinking

Dieting Objectives Quiz #4 (5 pts)

(continued) Reading (5) for 9/23:Stice, E., Davis, K., Miller, N.P. & Marti, C.N. 5 Sept 21 Discuss handout ―Comparing traditional & non- (2008) Fasting Increases Risk for diet approaches to eating and weight loss Onset of Binge Eating and Bulimic Pathology: A 5-year Prospective Study. Journal of Abnormal Psychology, 117, 941-946.

Eating Disorders Objectives

Students will be able to: Quiz #5 on Stice, Davis, Miller & Marti (2008) (5 pts) 1. Identify criteria for anorexia nervosa, bulimia, binge eating disorders, EDNOS & Sept 23 body dysmorphic disorder. Begin Homework #2 (Tribole & 2. Identify risk factors for binge eating and Resch (2003) chapter 15 pg. 214- bulimia (fasting, ―cheating on weekends,‖ etc) 241) (reading 6)

 4. Identify what we say that may contribute to eating disorders Eating Disorders Objectives

(continued) Sept 28 In class activity #2 (5 pts) Discuss handout ―How do we contribute to an

6 ED?‖ Eating Disorders Objectives Homework #2 due (10 pts) (from reading 6) Sept 30 (continued)

Homework #2 discussions

Eating Disorders Objectives Homework # 3 due (5 pts) (continued) Oct 5 In class activity #3 (5 pts) Small group discussions (raising children in a

diet-obsessed culture)

Self Awareness Objectives In class activity #4 (5 pts)

Students will be able to: Identify & challenge your own irrational beliefs about thinness. 1. Identify ways individuals undermine their own self-esteem. Identify negative body talk or self- 7 talk and identify positive counter 2. Differentiate between positive and negative statements. energy Oct 7 Art & mindfulness activities (UCC)

Reading (7) for 10/12: Thompson, Guest presenter: University Counseling Center J.K. & Stice, E.(2001). Thin-Ideal Internalization: Mounting Evidence for a New Risk Factor for Body- Image Disturbance and Eating Pathology. Current Directions in Psychological Science, 10, 181- 183.

Cultural & Societal Emphasis on Thinness Quiz #6 on Thompson & Stice (2001) (reading 7) (5 pts) Students will be able to:

1. 1. List factors that contribute to the thin-ideal. Begin Homework #4 2. 2. Define ―thin-ideal internalization‖ according Oct 12 to Thompson & Stice, 2001. 3. 3. List costs or negative health effects that may occur as a result of thin-ideal internalization according to Thompson & Stice, 2001. 4. 4. Differentiate between ―healthy ideal‖ and 8 ―thin ideal.‖ 5. 5. List consequences in attempting the thin ideal. Cultural & Societal Emphasis on Thinness

(continued) Homework #4 due (10 pts) Oct 14 Discuss homework #4

Identify at least 8 ―volunteers‖ for next weeks’ activity

Cultural & Societal Emphasis on Thinness In class activity #5 (5 pts)

(continued) 2nd set of pp slides Reading (8) for 10/21: Grabe, S., Ward, L.M., & Hyde, J.S. (2008). 9 Oct 19 (Role play) class activity The Role of the Media in Body Image Concerns Among Women: A Meta-Analysis of Experimental and Correlational Studies. Psychological Bulletin, 134, 460-476.

The Role of the Media in Body Image Concerns

Students will be able to:

1. List the media as a source of the thin-ideal

2. Define and differentiate between ―experimental‖ & ―correlational‖ research.

3. Identify that brief exposure to media images Quiz #7 on Grabe, Ward, Hyde Oct 21 with the thin-ideal often leads to negative body (2008) reading (8) (5 pts) image in women, according to Grabe et al., 2008.

4. Identify that media use is related to increased eating disorder symptoms.

5. Identify techniques used by the media to create ideal images

6. Summarize the history of the thinning standards of beauty in the media

The Role of the Media in Body Image Concerns Oct 26 Homework #5 due (5 pts)

Discuss homework #5 10 The Role of the Media in Body Image In class activity #6 (5 pts) Concerns Oct 28 View and discuss Jean Kilbourne’s film ―Killing Us Soft Softly III‖

Coping Strategies & Re-lapse Prevention Homework #6 due (10 pts) Nov 2 Identify helpful coping strategies In class activity #7 (5 pts) 11 Student presentations Papers due (20 pts) Nov 4 Presentation of paper (5 pts)

Student presentations Presentation of paper (continued) Nov 9 (5 pts) 12 Survey

Nov 11 Veteran’s Day- no class

Nov 16- No class

Dec 2

Friday, Final Final (10 pts) Dec 11

7:30 am- 9:30 am

Paper (20 pts): Choose a problem or issue that we discussed in class. Why did you choose this topic. Argue why this is a problem. Be sure to propose a clear argument. Include as many reasons as possible why this is a problem. Is it a problem in our society? Is it a problem for individuals? How is it harmful? What does it contribute to? Discuss possible solutions or ideas. (You will be presenting a brief <5 minute presentation about your argument in class). (~5 pgs)

Grading: The grading system will be based on the percentage of total points you score on in-class activities, homework, quizzes, your paper & presentation. This grading system is based on traditional cut- off points.

Average percent score Total Points

A 90-100 160-144

B 89- 80 128-143

C 79- 70 112-127

D 69- 60 96-111

F 59 and below <96

Students with learning or other disabilities: Accommodations will be made for you whether it is for test taking or modifications to the classroom environment. Please register with the Office of Student Disabilities and bring the appropriate documentation to me for appropriate action on your behalf.

For more information about services available to FSU students with disabilities, contact the:

Student Disability Resource Center 874 Traditions Way 108 Student Services Building Florida State University Tallahassee, FL 32306-4167 (850) 644-9566 (voice) (850) 644-8504 (TDD) (850) 644-7164

50 [email protected] http://www.disabilitycenter.fsu.edu/

ACADEMIC HONOR POLICY:

The Florida State University Academic Honor Policy outlines the University’s expectations for the integrity of students academic work, the procedures for resolving alleged violations of those expectations, and the rights and responsibilities of students and faculty members throughout the process. Students are responsible for reading the Academic Honor Policy and for living up to their pledge to. . . be honest and truthful and . . . [to] strive for personal and institutional integrity at Florida State University. (Florida State University Academic Honor Policy, found at http://dof.fsu.edu/honorpolicy.htm.)

College of Human Sciences: A Breathe Easy Zone (smoking policy) In accordance with the mission and vision of the College of Human Sciences—―to improve the health, development, and economic well-being of individuals, families, and communities‖, the Florida Clean Indoor Air Act designed to protect people from the health hazards of secondhand some, and the Florida State University Healthy Campus 2010 Goals, the College of Human Sciences is an established ―Breathe Easy Zone‖. There shall be no smoking in the Sandels Building, at any entrance to the building including the loading zone, or within 50 feet of the exterior of the building. A smoking area with seating, designated by a green post and green receptacle, is available adjacent to the patio along Legacy Way at the junction of sidewalks between Sandels, Jennie Murphree Hall, and Cawthorne Hall. This area is accessible from the south exit of level one. The success of this policy depends upon the good will of the college community. Both tobacco users and non-users have a collective responsibility to ensure compliance. Any person found out of compliance should be referred to the campus smoking cessation program at Thagard Health Center.

APPENDIX B

IRB Letter of Approval

Office of the Vice President For Research Human Subjects Committee Tallahassee, Florida 32306-2742 (850) 644-8673 · FAX (850) 644-4392

APPROVAL MEMORANDUM

Date: 11/30/2009

To: Julie Schaefer

Dept.: NUTRITION FOOD AND MOVEMENT SCIENCES

From: Thomas L. Jacobson, Chair

Re: Use of Human Subjects in Research : Eating Disorders, Body Image, and Healthy Weight Maintenance Follow-Up Study

The application that you submitted to this office in regard to the use of human subjects in the proposal referenced above have been reviewed by the Secretary, the Chair, and two members of the Human Subjects Committee. Your project is determined to be Expedited per 45 CFR § 46.110(7) and has been approved by an expedited review process.

The Human Subjects Committee has not evaluated your proposal for scientific merit, except to weigh the risk to the human participants and the aspects of the proposal related to potential risk and benefit. This approval does not replace any departmental or other approvals, which may be required.

If you submitted a proposed consent form with your application, the approved stamped consent form is attached to this approval notice. Only the stamped version of the consent form may be used in recruiting research subjects.

If the project has not been completed by 11/29/2010 you must request a renewal of approval for continuation of the project. As a courtesy, a renewal notice will be sent to you prior to your expiration date; however, it is your responsibility as the Principal Investigator to timely request renewal of your approval from the Committee.

You are advised that any change in protocol for this project must be reviewed and approved by

52 the Committee prior to implementation of the proposed change in the protocol. A protocol change/amendment form is required to be submitted for approval by the Committee. In addition, federal regulations require that the Principal Investigator promptly report, in writing any unanticipated problems or adverse events involving risks to research subjects or others.

By copy of this memorandum, the Chair of your department and/or your major professor is reminded that he/she is responsible for being informed concerning research projects involving human subjects in the department, and should review protocols as often as needed to insure that the project is being conducted in compliance with our institution and with DHHS regulations.

This institution has an Assurance on file with the Office for Human Research Protection. The Assurance Number is IRB00000446.

Cc: Maria Spicer, Advisor HSC No. 2009.3534

APPENDIX C

IRB Approved Informed Consent

If you are 18 years old or older, then you are invited to participate in a research study which will evaluate the sustainability of the effects of a 12-week Eating Disorder, Body Image and Healthy Weight Maintenance curriculum on eating attitudes & behaviors of college students. This curriculum is this course, PET 3932, Eating Disorder, Body Image and Healthy Weight Maintenance.

Participation in the study only requires you to complete a brief (10-15 min) survey in March, June and December, 2010. The survey will be similar to the one previously taken in class. The information you provide will be confidential to the extent allowed by law. You will be asked for your e-mail address in order to receive a link to the online survey. Your names WILL NOT be collected and no link will be made between you and your surveys. The aggregate survey data will be entered into a statistical analysis program for data analysis. There will be no hard copy of the data. The researcher is the only individual who will have access to the information you provide.

Your participation in this study is voluntary – you are free to refuse to take part and there is no penalty for nonparticipation. You can withdraw from the research at any time and this will NOT affect your grade in the course. There are little to no risks in participating. This study may benefit you by prompting recollection of the nutrition knowledge, positive attitudes, and healthier lifestyle behaviors discussed in class when the follow-up surveys are conducted. There is a small possibility of discomfort associated with responding to questions about body image, eating, etc. If you feel you need to talk to someone or need counseling, I encourage you to seek additional resources that are available to you on FSU’s campus including:

 University Counseling Center (644-2003)  Thagard Student Health Center (644- 4567)  Nutrition Clinic at Thagard Student Health Center (644-8871)

Signing this consent form will indicate your agreement to participate. Whether or not you choose to participate will have no bearing on your grade in this class. At this time, if you would like to participate, please read and sign the informed consent. After you turn in the form, please write down the e-mail address that you believe you can be contacted at for the next 12 months. Thanks for your consideration.

Please contact Julie Schaefer if you have any questions regarding this study. You may also contact Dr. Maria Spicer in the Department of Nutrition, Food and Exercise Sciences at 644-1784. Additionally, any questions regarding your treatment or rights as a participant in this research project please contact:

Institutional Review Board (Human Subjects Committee) 2035 E. Paul Dirac Drive, Box 15 100 Sliger Building, Innovation Park Tallahassee, FL 32310 644-8836 (Hotline Information)

I agree to participate in this study.

______Signature Date

APPENDIX D

Questionnaire

EATING ATTITUDES & BEHAVIOR SURVEY: August 2009

Last 4 digits of phone # _____ Age____ Ethnicity

Major ______Height____ Asian___ Native American _____ Weight____ Black___ White___ Year in college _____ Gender ____ Hispanic___ Other ___

For each item, please circle the answer that best Strongly disagree neutral agree Strongly characterizes your attitudes or behaviors. disagree agree

1. 1. I try to avoid certain foods high in fat, carbohydrates, or 1 2 3 4 5 calories. 1. 2. I stop eating when I feel full (not overstuffed). 1 2 3 4 5

1. 3. I find myself eating when I’m feeling emotional (e.g., 1 2 3 4 5 anxious, depressed, sad), even when I’m not physically hungry. 1. 4. If I am craving a certain food, I allow myself to have it. 1 2 3 4 5

1. 5. I follow eating rules or dieting plans that dictate what, 1 2 3 4 5 when, and/or how much to eat. 1. 6. I find myself eating when I am bored, even when I’m not 1 2 3 4 5 physically hungry. 1. 7. I can tell when I’m slightly full. 1 2 3 4 5

1. 8. I can tell when I’m slightly hungry. 1 2 3 4 5

1. 9. I get mad at myself for eating something unhealthy. 1 2 3 4 5

1. 10. I find myself eating when I am lonely, even when I’m not 1 2 3 4 5 physically hungry. 1. 11. I trust my body to tell me when to eat. 1 2 3 4 5

1. 12. I trust my body to tell me what to eat. 1 2 3 4 5

1. 13. I trust my body to tell me how much to eat. 1 2 3 4 5

1. 14. I have forbidden foods that I don’t allow myself to eat. 1 2 3 4 5

1. 15. When I’m eating, I can tell when I am getting full. 1 2 3 4 5

1. 16. I use food to help me soothe my negative emotions. 1 2 3 4 5

2. 17. I find myself eating when I am stressed out, even when 1 2 3 4 5 I’m not physically hungry. 1. 18. I feel guilty if I eat a certain food that is high in calories, 1 2 3 4 5 fat, or carbohydrates. 2. 19. I think of a certain food as “good”or “bad” depending on its 1 2 3 4 5 nutritional content. 3. 20. I don’t trust myself around fattening foods. 1 2 3 4 5

1. 21. I don’t keep certain foods in my house/apartment because 1 2 3 4 5 I think that I may lose control and eat them.

Please circle the response that reflects your agreement Strongly disagree neutral agree Strongly with these statements: disagree agree

1. Slim women are more attractive 1 2 3 4 5

2. Tall women are more attractive 1 2 3 4 5

3. Women with toned bodies are more attractive 1 2 3 4 5

4. Women who are in shape are more attractive 1 2 3 4 5

5. Slender women are more attractive 1 2 3 4 5

6. Women with long legs are more attractive 1 2 3 4 5

7. Curvy women are more attractive 1 2 3 4 5

8. Shapely women are more attractive 1 2 3 4 5

Circle the best response to describe your behavior over the never seldom sometimes often always last week:

1. If you put on weight, did you eat less than you normally would? 1 2 3 4 5

2. Did you try to eat less at mealtimes than you would like to eat? 1 2 3 4 5

3. How often did you refuse food or drink because you were 1 2 3 4 5 concerned about your weight?

4. Did you watch exactly what you ate? 1 2 3 4 5

5. Did you deliberately eat foods that were slimming? 1 2 3 4 5

6. When you ate too much, did you eat less than usual the next 1 2 3 4 5 day?

7. Did you deliberately eat less in order not to become heavier? 1 2 3 4 5

8. How often did you try not to eat between meals because you 1 2 3 4 5 were watching your weight?

9. How often in the evenings did you try not to eat because you 1 2 3 4 5 were watching your weight?

10. Did you take into account your weight in deciding what to eat? 1 2 3 4 5

How have you been feeling about your appearance over the PAST FOUR WEEKS? Read each question and circle the appropriate number.

never rarely sometimes often very always often 1. Has feeling bored made you brood about 1 2 3 4 5 6 your shape? 2. Have you been so worried about your 1 2 3 4 5 6 shape that you have been feeling that you ought to diet? 3. Have you thought that your thighs, hips, 1 2 3 4 5 6 or bottom are too large for the rest of you? 4. Have you been afraid that you might 1 2 3 4 5 6 become fat (or fatter)? 5. Have you worried about your flesh not 1 2 3 4 5 6 being firm enough? 6. Has feeling full (e.g, after eating a large 1 2 3 4 5 6 meal) made you feel fat? 7. Have you felt so bad about your shape 1 2 3 4 5 6 that you have cried? 8. Have you avoided running because your 1 2 3 4 5 6 flesh might wobble? 9. Has being with thin women made you feel 1 2 3 4 5 6 self-conscious about your shape? 10. Have you worried about your thighs 1 2 3 4 5 6 spreading out when sitting down? 11. Has eating even a small amount of food 1 2 3 4 5 6 made you feel fat? 12. Have you noticed the shape of other 1 2 3 4 5 6 women and felt that your own shape compared unfavorably? 13. Has thinking about your shape 1 2 3 4 5 6 interfered with your ability to concentrate (e.g., while watching television, reading, listening to conversations)? 14. Has being naked, such as when taking a 1 2 3 4 5 6 bath, made you feel fat? 15. Have you avoided wearing clothes 1 2 3 4 5 6 which make you particularly aware of the shape of your body? 16. Have you ever imagined cutting off 1 2 3 4 5 6 fleshy areas of your body? 17. Has eating sweets, cakes, or other high 1 2 3 4 5 6 calorie food made you feel fat? 18. Have you not gone out to social 1 2 3 4 5 6 occasions (e.g., parties) because you have felt bad about your shape? 19. Have you felt excessively large and 1 2 3 4 5 6 rounded? 20. Have you felt ashamed of your body? 1 2 3 4 5 6 21. Has worry about your shape made you 1 2 3 4 5 6 diet? 22. Have you felt happiest about your shape 1 2 3 4 5 6

when your stomach has been empty (e.g., in the morning)? 23. Have you thought that you are the 1 2 3 4 5 6 shape you are because lack of self control? 24. Have you worried about other people 1 2 3 4 5 6 seeing rolls of flesh around your waist or stomach? 25. Have you felt that it is not fair that other 1 2 3 4 5 6 women are thinner than you? 26. Have you vomited in order to feel 1 2 3 4 5 6 thinner? 24. 27. When in company have you worried 1 2 3 4 5 6 about taking up too much room (e.g., sitting on a sofa or a bus seat)? 28. Have you worried about your flesh being 1 2 3 4 5 6 dimply? 29. Has seeing your reflection (e.g., in a 1 2 3 4 5 6 mirror or shop window) made you feel bad about your shape? 30. Have you pinched areas of your body to 1 2 3 4 5 6 see how much fat there is? 31. Have you avoided situations where 1 2 3 4 5 6 people could see your body (e.g., communal changing rooms or swimming baths)? 32. Have you taken laxatives in order to feel 1 2 3 4 5 6 thinner? 33. Have you been particularly self- 1 2 3 4 5 6 conscious about your shape when in company of other people? 34. Has worry about your shape made you 1 2 3 4 5 6 feel you ought to exercise?

What is your weight at present (please give your best estimate). ______

What is your height? (Please give your best estimate). ______

If female: Over the past three-to-four months have you missed any menstrual periods? ______

If so, how many? ______

Have you been taking the “pill?” ______

Have you received counseling for eating behaviors and/or body image issues in the past 6 months?

○yes ○no How many counseling sessions have you attended in the past 6 months? ______

Who provided the counseling?

○Friend ○parent ○psychotherapist ○health professional ○nutritionist ○Other

Questions 1 to 12: Please circle the appropriate number on the right. The questions only refer to the past four weeks (28 days).

On how many of the past 28 days . . . No days 1-5 days 6-12 13-15 16-22 23-27 Every- days days days days day 1. Have you been deliberately trying to limit 0 1 2 3 4 5 6 the amount of food you eat to influence your shape or weight (whether or not you have succeeded)? 2. Have you gone for long periods of time (8 0 1 2 3 4 5 6 waking hours or more without eating anything at all in order to influence your shape or weight? 3. Have you tried to exclude from your diet 0 1 2 3 4 5 6 any foods that you like in order to influence your shape or weight (whether or not you have succeeded)? 4. Have you tried to follow definite rules 0 1 2 3 4 5 6 regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)? 5. Have you had a definite desire to have an 0 1 2 3 4 5 6 empty stomach with the aim of influencing your shape or weight? 6. Have you had a definite desire to have a 0 1 2 3 4 5 6 totally flat stomach? 7. Has thinking about food, eating or 0 1 2 3 4 5 6 calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? 8. Has thinking about shape or weight made 0 1 2 3 4 5 6 it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? 9. Have you had a definite fear of losing 0 1 2 3 4 5 6 control over eating? 10. Have you had a definite fear that you 0 1 2 3 4 5 6 might gain weight? 11. Have you felt fat? 0 1 2 3 4 5 6 12. Have you had a strong desire to lose 0 1 2 3 4 5 6 weight?

Questions 13- 21: Please fill in the appropriate number in the boxes on the right. Remember that the questions only refer to the past four weeks (28 days).

1. 13. Over the past 28 days, how many times have you eating what other people would regard as an unusually large amount of food (given the circumstances)? ______

14. On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating?) ______

1. 15. Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e., you have eaten an unusually large amount of food and have had a sense of loss of control at the time)? ______

1. 16. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight? ______

1. 17. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight? ______

1. 18. Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat, or to burn off calories? ______

Questions 19 to 21: Circle the appropriate number. Please note that for these questions the term “binge eating” means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating. The following questions are concerned with the past four weeks (28 days) only.

No days 1-5 days 6-12 13-15 16-22 23-27 Every- days days days days day 19. Over the past 28 days, on how many 0 1 2 3 4 5 6 days have you eaten in secret (ie. furtively)? . . . . Do not count episodes of binge eating. None of A few of Less Half of More Most of Every the times the times than half the than the time times half time 20. On what proportion of the times that you 0 1 2 3 4 5 6 have eaten have you felt guilty (Felt that you’ve done wrong) because of its effect on your shape or weight? . . . . Do not count episodes of binge eating. Not at all Slightly Moder- Mark- ately edly 21. Over the past 28 days, how concerned 0 1 2 3 4 5 6 have you been about other people seeing you eat? . . . .Do not count episodes of

61 binge eating.

Questions 22 to 28: Please circle the appropriate number on the right. The questions only refer to the past four weeks (28 days).

Not at all Slightly Moder- Mark- ately edly 22. Has your weight influenced how you 0 1 2 3 4 5 6 think about (judge) yourself as a person? 23. Has your shape influenced how you 0 1 2 3 4 5 6 think about (judge) yourself as a person? 24. How much would it have upset you if 0 1 2 3 4 5 6 you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks. 25. How dissatisfied have you been with 0 1 2 3 4 5 6 your weight? 26. How dissatisfied have you been with 0 1 2 3 4 5 6 your shape? 27. How uncomfortable have you felt seeing 0 1 2 3 4 5 6 your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)? 28. How uncomfortable have you felt about 0 1 2 3 4 5 6 others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)?

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BIOGRAPHICAL SKETCH

Education: Florida State University, Tallahassee FL Dietetic Intern, Registration Eligible

Florida State University, Tallahassee FL –Graduation: April 2011 Degree: Master’s in Food and Nutrition Science Thesis: Eating Disorders, Body Image, and Healthy Weight Maintenance: A Follow-up. GPA: 3.5

Case Western Reserve University, Cleveland OH – Graduation: May 2009 Major: Bachelor of Science in Nutrition GPA: 3.6

Scholarships and Awards: 2010 – Pao-Sen Chi Memorial Scholarship Recipient 2010 – Omnicron Pi Chapter of Kappa Omnicron Nu Honors National Honors Society Member in the Human Sciences

Publications: Dolansky MA, Zullo M, Schaefer J, Hassanein, S. (submission July 2010). Cardiac Rehabilitation in a Skilled Nursing Facility: Need, Feasibility, and Current Services. Heart & Lung.

Peer-reviewed Published Abstracts: Dolansky, MA, Zullo M, Boxer R, Schaefer J, Moore SM (2009). Transitional rehabilitation using self- management techniques (TRUST) in a skilled nursing facility. The Gerontologist, 49(52), 279.

Presentations:  Dolansky MA, Zullo M, Boxer RS, Schaefer J, Moore SM (2009). Transitional Rehabilitation in Skilled Nursing Facilities. Poster presented at the Gerontological Society of America, November, Atlanta Georgia.  Boxer RS, Dolansky MA, Schaefer J, Hitch JA, Piña IL (2009). Managing Heart Failure Patients in the Long Term Care and Skilled Nursing Facility Bridge Project. Poster presented at Case Western Reserve University Research Showcase, Cleveland, Ohio

Work Experience: Canopy Cove Eating Disorder Treatment Facility Dietary Assistant Tallahassee, FL September 2009 – May 2010  Lead nutrition education sessions  Prepare meals according to client meal plan  Monitor and encourage clients at meals  Grocery shopping for all clients at the facility  Alter meal plan per client preferences and needs  Assist clients with menu planning

Case Western Reserve University Research Assistant Cleveland, OH January 2008 – July 2009  Work as an project coordinator on a National Institutes of Health study  Worked with the principle investigator on developing participant questionnaires  Coordinate meetings with staff members  Scheduled travel itineraries  Create and publish documents for various aspects of the study  Orient new staff members to the study  Create database and enter data using statistical software

Case Western Reserve University Research Assistant Cleveland, OH May – September 2007  Worked as a project coordinator  Obtained medical records for 80 subjects  Performed detailed data abstraction from the medical records  Transferred the information into a statistical software package  Performed preliminary and final data analyses

Completion of Senior Capstone Project (Case Western Reserve University)  Design, Implement, and carry out a research project  Write a report of the research in scientific format

Great Lakes – Quicksilver Volleyball Club Head Coach Cleveland, OH October 2008 – May 2009  Organize and run practice sessions  Teach volleyball skills and techniques  Lead the team at tournaments  Develop individual qualities such as leadership, respect, punctuality, and maximum effort in young adults  USA Volleyball Increased Mastery and Professional Application of Coaching Theory (IMPACT) Certified (2008)

Leadership Experience: Varsity Volleyball Team (Case Western Reserve University) Captain (2008) Member: Fall 2005 – Fall 2008  Captain of the 2008 Varsity Volleyball team  Scholar Athlete Award 2005 – 2008  American Volleyball Coaches Association Team Academic Award (2007 Season)  Participated in annual community service projects

Case Association of Student Athletes Member: Fall 2005 – May 2009  Vice President Fall 2008 – 2009  Chair of the Programs Committee Fall 2005 – Spring 2008  Varsity Volleyball Representative Fall 2005 – 2009

Professional Organizations:  American Dietetic Association (ADA) Student Member ID #01044560  Sports, Cardiovascular, and Wellness Nutrition (SCAN) Member