Journal of Public Health

, Volume 19, Issue 4, pp 357–365 | Cite as

Primary prevention of eating-related problems in the real world

  • Uwe BergerEmail author
  • Katharina Wick
  • Christina Brix
  • Bianca Bormann
  • Melanie Sowa
  • Dominique Schwartze
  • Bernhard Strauss
Original Article



As known from meta-analyses, prevention programs for eating disorders yield significant effects under ideal conditions. However, it is still unclear how these programs can be more widely disseminated. Since 2004 in Thuringia, Germany, several programs for preadolescent girls and boys (aged 10 to 15 years) covering a wide geographical range have been developed in order to prevent eating-related problems.

Subjects and Methods

Over 3,500 pupils and more than 100 schools participated in the internal evaluation following the three-step standard of the Society of Prevention Research (SPR). To examine the program efficacy (step 1) and effectiveness (step 2), we conducted pre-post design studies with control groups. In order to describe the implementation process and the program dissemination (step 3), the Health Promoting School Approach (HEPS) was applied.


Girls (6th grade) showed significant improvements in eating attitudes and self esteem about their bodies, whereas boys only improved their knowledge about eating and physical activity. The evaluations of the programs for 7th and 8th graders are still pending. On the HEPS checklist, our health promotion concept fulfilled 64 points out of a maximum of 74, which indicates a high intervention quality.


Broad dissemination of prevention programs requires methodological compromises and organizational flexibility. Quality assurance should be considered to be as important as the optimal level of evidence, which depends on the needs of all stakeholders and could not be derived from the standards for clinical studies. Furthermore, health promotion needs political support that is independent of legislative periods and the turnover of institutional staff.


Eating disorders Prevention program Health promotion 



We thank the Federal Ministry for Education and Research for financial support (BMBF: project no. 01EL0602, term 2006–2009).

Furthermore, we thank our practice partners, Thuringian Ministry TMBWK and ThILLM, especially Jutta Beinersdorf und Margrit Luedecke, for didactic counseling and competently providing teacher training sessions, and all girls, boys, parents and teachers for patiently filling out the questionnaires.

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. Berger U (2008) Essstörungen wirkungsvoll vorbeugen—Die Programme „PriMa“, „TOPP“ und „Torera“ zur Prävention von Magersucht, Bulimie. Fressattacken und Adipositas, Kohlhammer, StuttgartGoogle Scholar
  2. Berger U, Sowa M, Bormann B, Brix C, Strauss B (2008) Primary prevention of eating disorders: Characteristics of effective programs and how to bring them to broader dissemination. Eur Eat Disord Rev 16:173–183. doi: 10.1002/erv.861 PubMedCrossRefGoogle Scholar
  3. Bulik CM, Sullivan PF, Tozzi F, Furberg H, Lichtenstein P, Pedersen NL (2006) Prevalence, heritability and prospective risk factors for anorexia nervosa. Arch Gen Psychiat 63:305–312PubMedCrossRefGoogle Scholar
  4. Brandt S, Moß A, Berg S, Wabitsch M (2010) Schulbasierte Prävention der Adipositas: Wie sollte sie aussehen? Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 53:207–220. doi: 10.1007/s00103-009-1017-z CrossRefGoogle Scholar
  5. Caplan G (1964) Principles of preventive psychiatry. Basic Books, New YorkGoogle Scholar
  6. Dadaczynski K, Paulus P, de Vries N, de Ruiter S, Buijs G (2010) HEPS inventory tool—An inventory tool including quality assessment of school interventions on healthy eating and physical activity. Accessed 6 October2010
  7. Daniels SR, Arnett DK, Eckel RH et al (2005) Overweight in children and adolescents: Pathophysiology, consequences, prevention, and treatment. Circulation 111:1999–2012. doi: 10.1161/01.CIR.0000161369.71722.10 PubMedCrossRefGoogle Scholar
  8. Flay BR, Biglan A, Boruch RF, Castro FG, Gottfredson D, Kellam S, Moscick EK, Schinke S, Valentine JC, Ji P (2005) Standards of Evidence: Criteria for Efficacy, Effectiveness and Dissemination. Prev Sci 6:151–175. doi: 10.1007/s11121-005-5553-y PubMedCrossRefGoogle Scholar
  9. Frey KS, Hirschstein MK, Guzzo BA (2000) Second step: Preventing aggression by promoting social competence. J Emotional Behav Disord 8:102–112CrossRefGoogle Scholar
  10. Grilo MG (2006) Eating and Weight Disorders. Psychology Press Taylor and Francis Group, HoveGoogle Scholar
  11. Gonzalez-Suarez C, Worley A, Grimmer-Somers K, Dones V (2009) School-Based Interventions on Childhood Obesity. A Meta-Analysis. Am J Prev Med 37:418–427. doi: 10.1177/106342660000800206 PubMedCrossRefGoogle Scholar
  12. Haug E, Rasmussen M, Samdal O et al (2009) Overweight in school-aged children and its relationship with demographic and lifestyle factors: results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) Study. Int J Pub Health 54:167–179. doi: 10.1007/s00038-009-5408-6 CrossRefGoogle Scholar
  13. Hoek HW, van Hoeken D (2003) Review of the prevalence and incidence of eating disorders. Int J Eat Disorder 34:383–96. doi: 10.1002/eat.10222 CrossRefGoogle Scholar
  14. Kurth BM, Schaffrath Rosario A (2007). The prevalence of overweight and obese children and adolescents living in Germany. Results of the German health interview and examination survey for children and adolescents (KiGGS). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 50, 736–743. doi:  10.1007/s00103-007-0235-5
  15. Jacobi C, Abascal L, Taylor CB (2004) Screening for eating disorders and high-risk behavior: Caution. Int J Eat Disorder 36:280–295. doi: 10.1002/eat.20048 CrossRefGoogle Scholar
  16. Levine MP, Smolak L (2006) The prevention of eating problems and eating disorders: Theory, research, and practice. Erlbaum, Mahwah, NJGoogle Scholar
  17. Puhl RM, Heuer CA (2010) Obesity Stigma: Important Considerations for Public Health. Am J Pub Health 100:1019–1028. doi: 10.2105/AJPH.2009.159491 CrossRefGoogle Scholar
  18. Ricciardelli LA, McCabe MP (2004) A biopsychosocial model of disordered eating and the pursuit of muscularity in adolescent boys. Psychol Bull 130:179–205PubMedCrossRefGoogle Scholar
  19. Roehrig M, Thompson JK, Brannick M, van den Berg P (2005) Dissonance-based eating disorder prevention program: A preliminary dismantling investigation. Int J Eat Disorder 39:1–10. doi: 10.1002/eat.20217 CrossRefGoogle Scholar
  20. Schaffrath Rosario A, Kurth BM, Stolzenberg H, Ellert U, Neuhauser H (2010) Body mass index percentiles for children and adolescents in Germany based on a nationally representative sample (KiGGS 2003–2006). Eu J Clin Nutr 64:341–349. doi: 10.1038/ejcn.2010.8 CrossRefGoogle Scholar
  21. Schulz KF, Altman DG, Moher D, for the CONSORT Group (2010) CONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomised Trials. PLoS Med 7:e1000251. doi: 10.1371/journal.pmed.1000251 PubMedCrossRefGoogle Scholar
  22. Schwartze D, Sowa M, Bormann B, Brix C, Wick K, Strauss B, Berger U (2011) Efficacy of the ‘Teenage Obesity Prevention Program’ (TOPP) for the prevention of overweight and low physical activity in boys attending 6th grade. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 54:349–356. doi: 10.1007/s00103-010-1233-6
  23. Steinhausen HC (2002) The outcome of anorexia nervosa in the 20th century. Am J Psychiat 159:1284–1293PubMedCrossRefGoogle Scholar
  24. Stewart-Brown S (2006) What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Copenhagen, WHO Regional Office for Europe. Health Evidence Network report. Accessed 6 October 2010
  25. Stice E, Shaw H, Marti CN (2007) A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu Rev Clin Psycho 3:207–231CrossRefGoogle Scholar
  26. Stice E, Trost A, Chase A (2003) Healthy weight control and dissonance-based eating disorder prevention programs: Results from a controlled trial. Int J Eat Disorder 33:10–21. doi: 10.1002/eat.10109 CrossRefGoogle Scholar
  27. Swinburn B, Egger G (2004) The runaway weight gain train: too many accelerators, not enough brakes. BMJ 329:736–739. doi: 10.1136/bmj.329.7468.736 PubMedCrossRefGoogle Scholar
  28. Treasure J, Claudino AM, Zucker N (2010) Eating Disorders. Lancet 375:583–593. doi: 10.1016/S0140-6736(09)61748-7 PubMedCrossRefGoogle Scholar
  29. Wick K, Brix C, Bormann B, Sowa M, Strauß B, Berger U (2011) Real-world effectiveness of a German school-based intervention for primary prevention of anorexia nervosa in preadolescent girls. Prev Med 52:152–158. doi: 10.1016/j.ypmed.2010.11.022 PubMedCrossRefGoogle Scholar
  30. WHO (2000) Obesity. Preventing and managing a global epidemic. Report of a WHO Consultation. WHO Technical Report Series, GenevaGoogle Scholar
  31. Zipfel S, Loewe B, Reas DL, Deter HC, Herzog W (2000) Long-term prognosis in anorexia nervosa: Lessons from a 21-year follow-up study. Lancet 355:721–722. doi: 10.1016/S0140-6736(99)05363-5 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Uwe Berger
    • 1
    Email author
  • Katharina Wick
    • 1
  • Christina Brix
    • 1
  • Bianca Bormann
    • 1
  • Melanie Sowa
    • 1
  • Dominique Schwartze
    • 1
  • Bernhard Strauss
    • 1
  1. 1.Institute of Psychosocial Medicine and PsychotherapyJena University Hospital, Friedrich Schiller University JenaJenaGermany

Personalised recommendations