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The Efficacy of a Universal School-Based Prevention Program for Eating Disorders among German Adolescents: Results from a Randomized-Controlled Trial

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Abstract

Disordered eating is highly prevalent during adolescence and has a detrimental effect on further development. Effective prevention programs are needed to prevent unhealthy developmental trajectories. This study evaluated the efficacy of the POPS-program (POtsdam Prevention at Schools), a universal school-based eating disorder prevention program for adolescents. In a cluster-randomized design, we compared the intervention group receiving the prevention program to a waiting control group. Outcomes included indicators of disordered eating and relevant risk factors for eating disorders (body dissatisfaction, internalization of the thin ideal, perceived media pressure, perfectionism, emotional element of exercise, social comparison, and perceived teasing). Questionnaires were administered at the start of the intervention, 3 and 12 months post intervention. At baseline, 1112 adolescents aged 10 to 16 years participated (49% girls; 51% intervention group). Intention-to-treat analyses with the complete data set and per-protocol analyses as a completer analysis were performed. The intervention group showed a more favorable course compared to the control group regarding all observed risk factors for eating disorders except for perceived teasing. Effect sizes were small but comparable to other primary prevention programs. At 1-year follow-up, a small but significant effect on disordered eating was observed. Results of the per-protocol analyses were mostly confirmed by the intention-to-treat analyses. Results were promising for both genders although girls benefited more regarding disordered eating and internalization of the thin ideal. Further studies are warranted examining successful program elements and whether gender-specific programs are needed.

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References

  • Aschenbrenner, K., Aschenbrenner, F., Kirchmann, H., & Strauß, B. (2004). Störungen des Essverhaltens bei Gymnasiasten und Studenten. Psychotherapie, Psychosomatik, Medizinische Psychologie, 54, 1–13.

    Article  Google Scholar 

  • Bakalar, J. L., Shank, L. M., Vannucci, A., Radin, R. M., & Tanofsky-Kraff, M. (2015). Recent advances in developmental and risk factor research on eating disorders. Current Psychiatry Reports, 17(6), 42.

    Article  PubMed  Google Scholar 

  • Baker, J. H., Thornton, L. M., Lichtenstein, P., & Bulik, C. M. (2012). Pubertal development predicts eating behaviors in adolescence. International Journal of Eating Disorders, 45(7), 819–826.

    Article  PubMed  PubMed Central  Google Scholar 

  • Baranowski, T., Cullen, K. W., Nicklas, T., Thompson, D., & Baranowski, J. (2003). Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity Research, 11, 23–43.

    Article  Google Scholar 

  • Beato-Fernandez, L., Rodriguez-Cano, T., Belmonte-Llario, A., & Martinez-Delgado, C. (2004). Risk factors for eating disorders in adolescents. A Spanish community-based longitudinal study. European Child & Adolescent Psychiatry, 13(5), 287–294.

    Article  Google Scholar 

  • Botvin, G. J., Eng, A., & Williams, C. L. (1980). Preventing the onset of cigarette smoking through life skills training. Preventive Medicine, 9(1), 135–143.

    Article  PubMed  Google Scholar 

  • Bucchianeri, M. M., Arikian, A. J., Hannan, P. J., Eisenberg, M. E., & Neumark-Sztainer, D. (2013). Body dissatisfaction from adolescence to young adulthood: Findings from a 10-year longitudinal study. Body Image, 10(1), 1–7.

    Article  PubMed  Google Scholar 

  • Ciao, A. C., Loth, K., & Neumark-Sztainer, D. (2014). Preventing eating disorder pathology: Common and unique features of successful eating disorders prevention programs. Current Psychiatry Reports, 16(7), 453.

    Article  PubMed  PubMed Central  Google Scholar 

  • Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review: What we have learned about the causes of eating disorders - a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 56(11), 1141–1164.

    Article  PubMed  Google Scholar 

  • Dion, J., Hains, J., Vachon, P., Plouffe, J., Laberge, L., Perron, M., et al. (2016). Correlates of body dissatisfaction in children. Journal of Pediatrics, 171, 202–207.

    Article  PubMed  Google Scholar 

  • Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175–191.

    Article  PubMed  Google Scholar 

  • Fichter, M. M., & Quadflieg, N. (2016). Mortality in eating disorders—results of a large prospective clinical longitudinal study. International Journal of Eating Disorders, 49(4), 391–401.

    Article  PubMed  Google Scholar 

  • Garner, D. M., & Garfinkel, P. E. (1979). The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9(2), 273–279.

    Article  PubMed  Google Scholar 

  • Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12(4), 871–878.

    Article  PubMed  Google Scholar 

  • Garner, D. M., Olmstead, M. P., & Polivy, J. (1983). Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. International Journal of Eating Disorders, 2(2), 15–34.

    Article  Google Scholar 

  • Grave, R. D., DeLuca, L., & Campello, G. (2001). Middle school primary prevention program for eating disorders: A controlled study with a twelve-month follow-up. Eating Disorders, 9(4), 327–337.

    Article  Google Scholar 

  • Herpertz-Dahlmann, B., Wille, N., Hölling, H., Vloet, T. D., & Ravens-Sieberer, U. (2008). Disordered eating behaviour and attitudes, associated psychopathology and health-related quality of life: Results of the BELLA study. European Child & Adolescent Psychiatry, 17(1), 82–91.

    Article  Google Scholar 

  • Hoffmann, S., & Warschburger, P. (2017). Weight, shape, and muscularity concerns in male and female adolescents: Predictors of change and influences on eating concern. International Journal of Eating Disorders, 50(2), 139–147.

    Article  PubMed  Google Scholar 

  • Hölling, H., & Schlack, R. (2007). Eating disorders in children and adolescents. First results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz, 50(5-6), 794–799.

    Article  PubMed  Google Scholar 

  • Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358.

    Article  PubMed  Google Scholar 

  • Kansi, J., Wichstrøm, L., & Bergman, L. R. (2005). Eating problems and their risk factors: A 7-year longitudinal study of a population sample of Norwegian adolescent girls. Journal of Youth and Adolescence, 34(6), 521–531.

    Article  Google Scholar 

  • Keel, P. K., & Forney, K. J. (2013). Psychosocial risk factors for eating disorders. International Journal of Eating Disorders, 46, 433–439.

    Article  PubMed  Google Scholar 

  • Keery, H., van den Berg, P. J., & Thompson, K. (2004). An evaluation of the Tripartite Influence Model of body dissatisfaction and eating disturbance with adolescent girls. Body Image, 1(3), 237–251.

    Article  PubMed  Google Scholar 

  • Klauer, K. (1993). Denktraining für Jugendliche. Ein Programm zur intellektuellen Förderung. Handanweisung [Cognitive training for adolescents. A training program. Manual.]. Göttingen: Hogrefe.

    Google Scholar 

  • Kromeyer-Hauschild, K., Wabitsch, M., Kunze, K., Geller, F., Hesse, V., von Hippel, A., et al. (2001). Perzentile für den Body-mass-Index für das Kindes- und Jugendalter unter Heranziehung verschiedener deutscher Stichproben [Percentiles of body mass index in children and adolescents evaluated from different regional German studies]. Monatsschrift Kinderheilkunde, 149(8), 807–818.

    Article  Google Scholar 

  • Le, L. K.-D., Barendregt, J. J., Hay, P., & Mihalopoulos, C. (2017). Prevention of eating disorders: A systematic review and meta-analysis. Clinical Psychology Review, 53, 46–58.

    Article  PubMed  Google Scholar 

  • Levine, M., & Smolak, L. (2013). Toward a model of the developmental psychopathology of eating disorders: The example of early adolescence. In L. Smolak, R. Striegel-Moore & M. Levine (Eds.), The developmental psychopathology of eating disorders: Implications for research, prevention, and treatment (pp. 59–80). London: Routledge.

    Google Scholar 

  • Lloyd, S., Fleming, C., Schmidt, U., & Tchanturia, K. (2014). Targeting perfectionism in anorexia nervosa using a group-based cognitive behavioural approach: A pilot study. European Eating Disorders Review, 22, 366–372.

    Article  PubMed  Google Scholar 

  • McCabe, M. P., Ricciardelli, L. A., & Salmon, J. (2006). Evaluation of a prevention program to address body focus and negative affect among children. Journal of Health Psychology, 11(4), 589–598.

    Article  PubMed  Google Scholar 

  • McCreary, D. R., & Sasse, D. K. (2000). An exploration of the drive for muscularity in adolescent boys and girls. Journal of American College Health, 48(6), 297–304.

    Article  PubMed  Google Scholar 

  • McLean, S. A., Paxton, S. J., & Wertheim, E. H. (2016). The role of media literacy in body dissatisfaction and disordered eating: A systematic review. Body Image, 19, 9–23.

    Article  PubMed  Google Scholar 

  • Meermann, R., & Vandereycken, W. (1987). Therapie der Magersucht und Bulimia nervosa: Ein klinischer Leitfaden für den Praktiker [Treatment of anorexia and bulimia nervosa: A clinical guide for the practitioner]. Berlin: De Gruyter.

    Google Scholar 

  • Micali, N., Solmi, F., Horton, N. J., Crosby, R. D., Eddy, K. T., Calzo, J. P., et al. (2015). Adolescent eating disorders predict psychiatric, high-risk behaviors and weight outcomes in young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry, 54(8), 652–659.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nagl, M., Jacobi, C., Paul, M., Beesdo-Baum, K., Höfler, M., Lieb, R., et al. (2016). Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults. European Child & Adolescent Psychiatry, 25(8), 903–918.

    Article  Google Scholar 

  • Neumark-Sztainer, D., Levine, M. P., Paxton, S. J., Smolak, L., Piran, N., & Wertheim, E. H. (2006). Prevention of body dissatisfaction and disordered eating: What next? Eating Disorders, 14(4), 265–285.

    Article  PubMed  Google Scholar 

  • Neumark-Sztainer, D., Wall, M., Larson, N. I., Eisenberg, M. E., & Loth, K. (2011). Dieting and disordered eating behaviors from adolescence to young adulthood: Findings from a 10-year longitudinal study. Journal of the American Dietetic Association, 111(7), 1004–1011.

    Article  PubMed  PubMed Central  Google Scholar 

  • O’Dea, J. A. (2004). Evidence for a self-esteem approach in the prevention of body image and eating problems among children and adolescents. Eating Disorders, 12(3), 225–239.

    Article  PubMed  Google Scholar 

  • Paul, T., & Thiel, A. (2005). EDI-2. Eating Disorder Inventory-2. Göttingen: Hogrefe.

    Google Scholar 

  • Rainer, G., & Rathner, B. (1997). EAT-Normen für deutschsprachige weibliche Jugendliche: Eine populationsgestützte Studie. Zeitschrift für Klinische Psychologie, Psychopathologie und Psychotherapie, 45(3), 16–35.

    Google Scholar 

  • Rodgers, R. F., Paxton, S. J., & McLean, S. A. (2014). A biopsychosocial model of body image concerns and disordered eating in early adolescent girls. Journal of Youth and Adolescence, 43(5), 814–823.

    Article  PubMed  Google Scholar 

  • Sehm, M., & Warschburger, P. (2016). Prospective associations between binge eating and psychological risk factors in adolescence. Journal of Clinical Child and Adolescent Psychology, 11, 1–15.

    Article  Google Scholar 

  • Shisslak, C. M., & Crago, M. (2001). Risk and protective factors in the development of eating disorders. In J. Thompson & L. Smolak (Eds.), Body image, eating disorders, and obesity in youth. Assessment, prevention, and treatment (pp. 103–125). Washington, DC: American Psychological Association.

    Chapter  Google Scholar 

  • Smolak, L., & Levine, M. P. (2001). A two-year follow-up of a primary prevention program for negative body image and unhealthy weight regulation. Eating Disorders, 9(4), 313–325.

    Article  PubMed  Google Scholar 

  • Steck, E. L., Abrams, L. M., & Phelps, L. (2004). Positive psychology in the prevention of eating disorders. Psychology in the Schools, 41(1), 111–117.

    Article  Google Scholar 

  • Steffen, J. J., & Brehm, B. J. (1999). The dimensions of obligatory exercise. Eating Disorders, 7(3), 219–226.

    Article  Google Scholar 

  • Stice, E., Marti, C. N., & Rohde, P. (2013). Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. Journal of Abnormal Psychology, 122(2), 445–457.

    Article  PubMed  Google Scholar 

  • Stice, E., & Shaw, H. (2004). Eating disorder prevention programs: A meta-analytic review. Psychological Bulletin, 130(2), 206–227.

    Article  PubMed  Google Scholar 

  • Stice, E., Shaw, H., & Marti, C. N. (2007). A meta-analytic review of eating disorder prevention programs: Encouraging findings. Annual Review of Clinical Psychology, 3, 207–231.

    Article  PubMed  Google Scholar 

  • Tchanturia, K., Larsson, E., & Adamson, J. (2016). Brief group intervention targeting perfectionism in adults with anorexia nervosa: Empirically informed protocol. European Eating Disorders Review, 24, 489–493.

    Article  PubMed  Google Scholar 

  • Thompson, J. K., Cattarin, J., Fowler, B., & Fisher, E. (1995). The Perception of Teasing Scale (POTS): A revision and extension of the Physical Appearance Related Teasing Scale (PARTS). Journal of Personality Assessment, 65(1), 146–157.

    Article  PubMed  Google Scholar 

  • Thompson, J. K., Heinberg, L. J., Altabe, M., & Tantleff-Dunn, S. (1999). Exacting beauty: Theory, assessment, and treatment of body image disturbance. Washington, DC: American Psychological Association.

    Book  Google Scholar 

  • Thompson, J. K., Heinberg, L., & Tantleff, S. (1991). The Physical Appearance Comparison Scale (PACS). The Behavior Therapist, 14, 174.

    Google Scholar 

  • Thompson, J. K., & Pasman, L. (1991). The Obligatory Exercise Questionnaire. The Behavior Therapist, 14, 137.

    Google Scholar 

  • Thompson, J. K., van den Berg, P., Roehrig, M., Guarda, A. S., & Heinberg, L. J. (2004). The Sociocultural Attitudes Towards Appearance Scale-3 (SATAQ-3): Development and validation. International Journal of Eating Disorders, 35(3), 293–304.

    Article  PubMed  Google Scholar 

  • Thompson, M. A., & Gray, J. J. (1995). Development and validation of a new body-image assessment scale. Journal of Personality Assessment, 64(2), 258–269.

    Article  PubMed  Google Scholar 

  • Uzunian, L. G., & Vitalle, M. Sd. S. (2015). Social skills: A factor of protection against eating disorders in adolescents. Ciencia & Saude Coletiva, 20(11), 3495–3508.

    Article  Google Scholar 

  • Wade, T. D., Davidson, S., & O’Dea, J. A. (2003). A preliminary controlled evaluation of a school-based media literacy program and self-esteem program for reducing eating disorder risk factors. International Journal of Eating Disorders, 33(4), 371–383.

    Article  PubMed  Google Scholar 

  • Wagner, G., Zeiler, M., Waldherr, K., Philipp, J., Truttmann, S., Dür, W., et al. (2017). Mental health problems in Austrian adolescents: A nationwide, two-stage epidemiological study applying DSM-5 criteria. European Child & Adolescent Psychiatry, 26(12), 1483–1499.

    Article  Google Scholar 

  • Warschburger, P. (2009). Körperunzufriedenheit und gestörtes Essverhalten bei Jugendlichen. Praxis Klinische Verhaltensmedizin und Rehabilitation, 85(3), 152–158.

    Google Scholar 

  • Warschburger, P., Helfert, S., & Krentz, E. M. (2011). POPS: A school-based prevention programme for eating disorders. Journal of Public Health, 19(4), 367–376.

    Article  Google Scholar 

  • Watson, H. J., Joyce, T., French, E., Willan, V., Kane, R. T., Tanner-Smith, E. E., et al. (2016). Prevention of eating disorders: A systematic review of randomized, controlled trials. International Journal of Eating Disorders, 49(9), 833–862.

    Article  PubMed  Google Scholar 

  • Webb, H. J., & Zimmer-Gembeck, M. J. (2014). The role of friends and peers in adolescent body dissatisfaction: A review and critique of 15 years of research. Journal of Research on Adolescence, 24(4), 564–590.

    Article  Google Scholar 

  • Wilksch, S. M. (2015). School-based eating disorder prevention: A pilot effectiveness trial of teacher-delivered Media Smart. Early Intervention in Psychiatry, 9(1), 21–28.

    Article  PubMed  Google Scholar 

  • Wilksch, S. M., Durbridge, M. R., & Wade, T. D. (2008). A preliminary controlled comparison of programs designed to reduce risk of eating disorders targeting perfectionism and media literacy. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 937–947.

    PubMed  Google Scholar 

  • Wilksch, S. M., & Wade, T. D. (2009). Reduction of shape and weight concern in young adolescents: A 30-month controlled evaluation of a media literacy program. Journal of the American Academy of Child and Adolescent Psychiatry, 48(6), 652–661.

    Article  PubMed  Google Scholar 

  • Wilksch, S. M., & Wade, T. D. (2013). Life smart: A pilot study of a school-based program to reduce the risk of both eating disorders and obesity in young adolescent girls and boys. Journal of Pediatric Psychology, 38(9), 1021–1029.

    Article  PubMed  Google Scholar 

  • Wirtz, M. (2004). On the problem of missing data: How to identify and reduce the impact of missing data on findings of data analysis. Rehabilitation, 43(2), 109–115.

    Article  PubMed  Google Scholar 

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Acknowledgements

We are grateful to the students, parents and teachers who agreed to participate in the study. Special thanks to Susanne Helfert and Eva-Maria Krentz, who were involved in the conceptualization of the POPS-program and the evaluation study. Thanks to Diana Peitz for her support in the statistical analyses. Thanks to the Federal Ministry of Education and Research for funding the project.

Authors’ Contributions

PW conceived and coordinated the study, developed the statistical data analysis plan, performed the statistical analysis, and participated in the interpretation of the data; JZ performed the statistical analysis, drafted the manuscript, and participated in the interpretation of the data. All authors read and approved the final manuscript.

Funding

This project was funded by the Federal Ministry of Education and Research (BMBF; Registr.nr: 01EL0607; Prof. Dr. P. Warschburger).

Data Sharing Declaration

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

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  1. Department of Psychology, University of Potsdam, Karl-Liebknecht-Str. 24-25, Potsdam, 14476, Germany

    Petra Warschburger & Jana Zitzmann

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  1. Petra Warschburger
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Correspondence to Petra Warschburger.

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The authors declare that they have no conflict of interest.

Ethical Approval

Written informed consent was obtained from all individual participants included in the study as well as from their parents. The privacy rights of human subjects were observed. The study was approved by the University Ethics Board prior to survey administration. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards

Informed Consent

Written informed consent was obtained from all individual participants included in the study as well as from their parents. The privacy rights of human subjects were observed

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Warschburger, P., Zitzmann, J. The Efficacy of a Universal School-Based Prevention Program for Eating Disorders among German Adolescents: Results from a Randomized-Controlled Trial. J Youth Adolescence 47, 1317–1331 (2018). https://doi.org/10.1007/s10964-018-0852-3

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