Body Image in the Integrated Prevention of Eating and Weight Disorders

  • Ottavio Bosello
  • Angiola Vanzo
  • Massimo Cuzzolaro


The rates of obesity and eating disorders (ED) continue to rise and, in the last two decades, a growing number of researchers and scientific institutions have supposed that an integrated approach to the prevention of obesity and ED could be more efficient than the only-focus-programs. An integrated prevention program is designed to provide a coordinated set of health measures aimed at avoiding a series of disturbances at the same time. The development of combined prevention programs for both weight and eating disorders began in the early 2000s. Three questions are critical: (a) is the integrated prevention model for obesity and ED theoretically well-founded? (b) is it supported by empirical research evidence of efficacy and effectiveness? (c) what is the role of body shape and weight concerns?

This chapter reviews some relevant studies that developed and evaluated integrated prevention procedures for obesity and ED. Healthy dieting and a balanced lifestyle are two plausible targets with a focus on at-risk eating behaviors. However, it seems crucial to the success of a project to consider that a negative body image is a well-known risk factor for both eating and weight disorders. Many adolescents are dissatisfied with their appearance, and the numbers are even higher in overweight teenagers. Therefore, most integrated interventions try to promote positive body image, acceptance of different body shapes and sizes, self-confidence, and coping skills with appearance-related emotions. The social stigma of obesity, media literacy, weight talk, and weight-teasing are other related issues. For selective interventions with groups at high risk, it is recommended to set the interventions on cognitive dissonance and media advocacy.


  1. 1.
    Strasser T. Reflections on cardiovascular diseases. Interdiscip Sci Rev. 1978;3(3):225–30.CrossRefGoogle Scholar
  2. 2.
    Berrios X, Koponen T, Huiguang T, Khaltaev N, Puska P, Nissinen A. Distribution and prevalence of major risk factors of noncommunicable diseases in selected countries: the WHO Inter-Health Programme. Bull World Health Organ. 1997;75(2):99–108.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Epstein FH, Holland WW. Prevention of chronic diseases in the community—one-disease versus multiple-disease strategies. Int J Epidemiol. 1983;12(2):135–7.CrossRefGoogle Scholar
  4. 4.
    Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2011;377(9765):557–67.CrossRefGoogle Scholar
  5. 5.
    N.C.D. Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet. 2016;387(10026):1377–96.CrossRefGoogle Scholar
  6. 6.
    Makino M, Tsuboi K, Dennerstein L. Prevalence of eating disorders: a comparison of Western and non-Western countries. MedGenMed. 2004;6(3):49–56.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Pike KM, Dunne PE. The rise of eating disorders in Asia: a review. J Eat Disord. 2015;3:33–46.CrossRefGoogle Scholar
  8. 8.
    Chisuwa N, O’Dea JA. Body image and eating disorders amongst Japanese adolescents. A review of the literature. Appetite. 2010;54(1):5–15.CrossRefGoogle Scholar
  9. 9.
    Austin SB. Prevention research in eating disorders: theory and new directions. Psychol Med. 2000;30(6):1249–62.CrossRefGoogle Scholar
  10. 10.
    Sanchez-Carracedo D, Neumark-Sztainer D, Lopez-Guimera G. Integrated prevention of obesity and eating disorders: barriers, developments and opportunities. Public Health Nutr. 2012;15(12):2295–309.CrossRefGoogle Scholar
  11. 11.
    Cuzzolaro M. Eating disorders. In: Sbraccia P, Finer N, editors. Obesity: pathogenesis, diagnosis, and treatment. Cham: Springer; 2017. p. 1–24.Google Scholar
  12. 12.
    Neumark-Sztainer D. Obesity and eating disorder prevention: an integrated approach? Adolesc Med. 2003;14(1):159–73.PubMedGoogle Scholar
  13. 13.
    Neumark-Sztainer D. The interface between the eating disorders and obesity fields: moving toward a model of shared knowledge and collaboration. Eat Weight Disord. 2009;14(1):51–8.CrossRefGoogle Scholar
  14. 14.
    Haines J, Neumark-Sztainer D. Prevention of obesity and eating disorders: a consideration of shared risk factors. Health Educ Res. 2006;21(6):770–82.CrossRefGoogle Scholar
  15. 15.
    Day J, Ternouth A, Collier DA. Eating disorders and obesity: two sides of the same coin? Epidemiol Psichiatr Soc. 2009;18(2):96–100.PubMedGoogle Scholar
  16. 16.
    Krug I, Villarejo C, Jimenez-Murcia S, Perpina C, Vilarrasa N, Granero R, et al. Eating-related environmental factors in underweight eating disorders and obesity: are there common vulnerabilities during childhood and early adolescence? Eur Eat Disord Rev. 2013;21(3):202–8.CrossRefGoogle Scholar
  17. 17.
    Golden NH, Schneider M, Wood C, Committee on Nutrition, Committee on Adolescence, Section on Obesity. Preventing obesity and eating disorders in adolescents. Pediatrics. 2016;138(3):1–10.CrossRefGoogle Scholar
  18. 18.
    Damiano SR, Paxton SJ, Wertheim EH, McLean SA, Gregg KJ. Dietary restraint of 5-year-old girls: associations with internalization of the thin ideal and maternal, media, and peer influences. Int J Eat Disord. 2015;48(8):1166–9.CrossRefGoogle Scholar
  19. 19.
    Neumark-Sztainer DR, Wall MM, Haines JI, Story MT, Sherwood NE, van den Berg PA. Shared risk and protective factors for overweight and disordered eating in adolescents. Am J Prev Med. 2007;33(5):359–69.CrossRefGoogle Scholar
  20. 20.
    Neumark-Sztainer D, Wall M, Haines J, Story M, Eisenberg ME. Why does dieting predict weight gain in adolescents? Findings from project EAT-II: a 5-year longitudinal study. J Am Diet Assoc. 2007;107(3):448–55.CrossRefGoogle Scholar
  21. 21.
    Haines J, Kleinman KP, Rifas-Shiman SL, Field AE, Austin SB. Examination of shared risk and protective factors for overweight and disordered eating among adolescents. Arch Pediatr Adolesc Med. 2010;164(4):336–43.CrossRefGoogle Scholar
  22. 22.
    Lopez-Guimera G, Neumark-Sztainer D, Hannan P, Fauquet J, Loth K, Sanchez-Carracedo D. Unhealthy weight-control behaviours, dieting and weight status: a cross-cultural comparison between North American and Spanish adolescents. Eur Eat Disord Rev. 2013;21(4):276–83.CrossRefGoogle Scholar
  23. 23.
    Di Renzo L, Tyndall E, Gualtieri P, Carboni C, Valente R, Ciani AS, et al. Association of body composition and eating behavior in the normal weight obese syndrome. Eat Weight Disord. 2016;21(1):99–106.CrossRefGoogle Scholar
  24. 24.
    Sim LA, Lebow J, Billings M. Eating disorders in adolescents with a history of obesity. Pediatrics. 2013.Google Scholar
  25. 25.
    Darby A, Hay P, Mond J, Quirk F, Buttner P, Kennedy L. The rising prevalence of comorbid obesity and eating disorder behaviors from 1995 to 2005. Int J Eat Disord. 2009;42(2):104–8.CrossRefGoogle Scholar
  26. 26.
    Neumark-Sztainer D, Story M, Hannan PJ, Perry CL, Irving LM. Weight-related concerns and behaviors among overweight and nonoverweight adolescents: implications for preventing weight-related disorders. Arch Pediatr Adolesc Med. 2002;156(2):171–8.CrossRefGoogle Scholar
  27. 27.
    Stunkard A. Eating patterns and obesity. Psychiatry Q. 1959;33:284–95.CrossRefGoogle Scholar
  28. 28.
    Fairburn CG, Wilson GT. Binge eating: definition and classification. In: Fairburn CG, Wilson GT, editors. Binge eating nature assessment and treatment. New York: The Guilford Press; 1993. p. 3–14.Google Scholar
  29. 29.
    Hudson J, Pope H, Wutman J. Bulimia in obese individuals. J Nerv Ment Dis. 1988;176:144–52.CrossRefGoogle Scholar
  30. 30.
    Mitchell JE, Pyle RL, Eckert ED, Hatsukami D, Soll E. Bulimia nervosa in overweight individuals. J Nerv Ment Dis. 1990;178(5):324–7.CrossRefGoogle Scholar
  31. 31.
    Rotella F, Castellini G, Montanelli L, Rotella CM, Faravelli C, Ricca V. Comparison between normal-weight and overweight bulimic patients. Eat Weight Disord. 2013;18(4):389–93.CrossRefGoogle Scholar
  32. 32.
    Bulik CM, Marcus MD, Zerwas S, Levine MD, La Via M. The changing “weightscape” of bulimia nervosa. Am J Psychiatry. 2012;169(10):1031–6.CrossRefGoogle Scholar
  33. 33.
    Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014;48(11):977–1008.CrossRefGoogle Scholar
  34. 34.
    Lebow J, Sim LA, Kransdorf LN. Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders. J Adolesc Health. 2015;56(1):19–24.CrossRefGoogle Scholar
  35. 35.
    Fairburn CG, Welch SL, Doll HA, Davies BA, O'Connor ME. Risk factors for bulimia nervosa: a community-based case-control study. Arch Gen Psychiatry. 1997;54(6):509–17.CrossRefGoogle Scholar
  36. 36.
    Fairburn CG, Harrison PJ. Eating disorders. Lancet. 2003;361(9355):407–16.CrossRefGoogle Scholar
  37. 37.
    Herzog DB, Thomas JG, Kass AE, Eddy KT, Franko DL, Lowe MR. Weight suppression predicts weight change over 5 years in bulimia nervosa. Psychiatry Res. 2010;177(3):330–4.CrossRefGoogle Scholar
  38. 38.
    Wildes JE, Marcus MD. Weight suppression as a predictor of weight gain and response to intensive behavioral treatment in patients with anorexia nervosa. Behav Res Ther. 2012;50(4):266–74.CrossRefGoogle Scholar
  39. 39.
    Venditti EM, Wing RR, Jakicic JM, Butler BA, Marcus MD. Weight cycling, psychological health, and binge eating in obese women. J Consult Clin Psychol. 1996;64(2):400–5.CrossRefGoogle Scholar
  40. 40.
    Utzinger LM, Gowey MA, Zeller M, Jenkins TM, Engel SG, Rofey DL, et al. Loss of control eating and eating disorders in adolescents before bariatric surgery. Int J Eat Disord. 2016;49(10):947–52.CrossRefGoogle Scholar
  41. 41.
    Herget S, Rudolph A, Hilbert A, Bluher S. Psychosocial status and mental health in adolescents before and after bariatric surgery: a systematic literature review. Obes Facts. 2014;7(4):233–45.CrossRefGoogle Scholar
  42. 42.
    Sondike SB, Pisetsky EM, Luzier JL. Development of significant disordered eating in an adolescent following gastric bypass surgery. Eat Weight Disord. 2016;21(1):133–6.CrossRefGoogle Scholar
  43. 43.
    Segal A, Kinoshita Kussunoki D, Larino MA. Post-surgical refusal to eat: anorexia nervosa, bulimia nervosa or a new eating disorder? A case series. Obes Surg. 2004;14(3):353–60.CrossRefGoogle Scholar
  44. 44.
    Marino JM, Ertelt TW, Lancaster K, Steffen K, Peterson L, de Zwaan M, et al. The emergence of eating pathology after bariatric surgery: a rare outcome with important clinical implications. Int J Eat Disord. 2012;45(2):179–84.CrossRefGoogle Scholar
  45. 45.
    Cuzzolaro M. Eating and weight disorders: studies on anorexia, bulimia, and obesity turns 19. Eat Weight Disord. 2014;19(1):1–2.CrossRefGoogle Scholar
  46. 46.
    American Medical Association House of Delegates. Report of the Council on Science and Public Health (CSAPH). Recognition of obesity as a disease. Resolution. 420 (A-13). 2013. Accessed 11 Nov 2014, 25 June 2013.
  47. 47.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders, DSM-5. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.CrossRefGoogle Scholar
  48. 48.
    Hill AJ. Obesity and eating disorders. Obes Rev. 2007;8(Suppl 1):151–5.CrossRefGoogle Scholar
  49. 49.
    Brownell KD, Rodin J. The dieting maelstrom. Is it possible and advisable to lose weight? Am Psychol. 1994;49(9):781–91.CrossRefGoogle Scholar
  50. 50.
    Ferrari M. Understanding the feasibility of integrating the eating disorders and obesity fields: the beyond obesity and disordered eating in youth (BODY) study. Eat Weight Disord. 2015.Google Scholar
  51. 51.
    Piran N. New possibilities in the prevention of eating disorders: the introduction of positive body image measures. Body Image. 2015;14:146–57.CrossRefGoogle Scholar
  52. 52.
    Piran N, Mafrici N. Preventing body image problems: ecological and activism approaches. In: Cash TF, editor. Encyclopedia of body image and human appearance. 2nd ed. Amsterdam: Elsevier Academic Press; 2012. p. 674–9.CrossRefGoogle Scholar
  53. 53.
    Paxton S. Preventing body image problems: public policy approaches. In: Cash TF, editor. Encyclopedia of body image and human appearance. 2nd ed. Amsterdam: Elsevier Academic Press; 2012. p. 680–5.CrossRefGoogle Scholar
  54. 54.
    O’Dea J. Preventing body image problems: school-based approaches. In: Cash TF, editor. Encyclopedia of body image and human appearance. 2nd ed. Amsterdam: Elsevier Academic Press; 2012. p. 686–92.CrossRefGoogle Scholar
  55. 55.
    Piran N. Prevention of eating disorders: a review of outcome evaluation research. Isr J Psychiatry Relat Sci. 2005;42(3):172–7.PubMedGoogle Scholar
  56. 56.
    Becker CB, Bull S, Schaumberg K, Cauble A, Franco A. Effectiveness of peer-led eating disorders prevention: a replication trial. J Consult Clin Psychol. 2008;76(2):347–54.CrossRefGoogle Scholar
  57. 57.
    McVey G, Tweed S, Blackmore E. Healthy Schools-Healthy Kids: a controlled evaluation of a comprehensive universal eating disorder prevention program. Body Image. 2007;4(2):115–36.CrossRefGoogle Scholar
  58. 58.
    Neumark-Sztainer D, Flattum CF, Story M, Feldman S, Petrich CA. Dietary approaches to healthy weight management for adolescents: the New Moves model. Adolesc Med State Art Rev. 2008;19(3):421–30, viii.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Neumark-Sztainer D, Story M, Hannan PJ, Rex J. New Moves: a school-based obesity prevention program for adolescent girls. Prev Med. 2003;37(1):41–51.CrossRefGoogle Scholar
  60. 60.
    Neumark-Sztainer DR, Friend SE, Flattum CF, Hannan PJ, Story MT, Bauer KW, et al. New moves-preventing weight-related problems in adolescent girls. A group-randomized study. Am J Prev Med. 2010;39(5):421–32.CrossRefGoogle Scholar
  61. 61.
    Haines J, Neumark-Sztainer D, Perry CL, Hannan PJ, Levine MP. V.I.K. (Very Important Kids): a school-based program designed to reduce teasing and unhealthy weight-control behaviors. Health Educ Res. 2006;21(6):884–95.CrossRefGoogle Scholar
  62. 62.
    Wade TD, Wilksch SM, Paxton SJ, Byrne SM, Austin SB. Do universal media literacy programs have an effect on weight and shape concern by influencing media internalization? Int J Eat Disord. 2017;50(7):731–8.CrossRefGoogle Scholar
  63. 63.
    O’Dea JA. Prevention of child obesity: “First, do no harm”. Health Educ Res. 2005;20(2):259–65.CrossRefGoogle Scholar
  64. 64.
    O’Dea J. Body image and self-esteem. In: Cash TF, editor. Encyclopedia of body image and human appearance. 1st ed. Amsterdam: Elsevier Academic Press; 2012. p. 141–7.CrossRefGoogle Scholar
  65. 65.
    Ghaderi A, Martensson M, Schwan H. “Everybody’s different”: a primary prevention program among fifth grade school children. Eat Disord. 2005;13(3):245–59.CrossRefGoogle Scholar
  66. 66.
    Austin SB, Yu K, Tran A, Mayer B. Research-to-policy translation for prevention of disordered weight and shape control behaviors: a case example targeting dietary supplements sold for weight loss and muscle building. Eat Behav. 2017;25:9–14.CrossRefGoogle Scholar
  67. 67.
    Atkinson MJ, Wade TD. Mindfulness-based prevention for eating disorders: a school-based cluster randomized controlled study. Int J Eat Disord. 2015;48(7):1024–37.CrossRefGoogle Scholar
  68. 68.
    Atkinson MJ, Wade TD. Does mindfulness have potential in eating disorders prevention? A preliminary controlled trial with young adult women. Early Interv Psychiatry. 2016;10(3):234–45.CrossRefGoogle Scholar
  69. 69.
    Austin SB, Field AE, Wiecha J, Peterson KE, Gortmaker SL. The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls. Arch Pediatr Adolesc Med. 2005;159(3):225–30.CrossRefGoogle Scholar
  70. 70.
    Doyle AC, Goldschmidt A, Huang C, Winzelberg AJ, Taylor CB, Wilfley DE. Reduction of overweight and eating disorder symptoms via the Internet in adolescents: a randomized controlled trial. J Adolesc Health. 2008;43(2):172–9.CrossRefGoogle Scholar
  71. 71.
    Rohde P, Auslander BA, Shaw H, Raineri KM, Gau JM, Stice E. Dissonance-based prevention of eating disorder risk factors in middle school girls: results from two pilot trials. Int J Eat Disord. 2014;47(5):483–94.CrossRefGoogle Scholar
  72. 72.
    Rohde P, Stice E, Shaw H, Gau JM, Ohls OC. Age effects in eating disorder baseline risk factors and prevention intervention effects. Int J Eat Disord. 2017;50(11):1273–80.CrossRefGoogle Scholar
  73. 73.
    Stice E, Chase A, Stormer S, Appel A. A randomized trial of a dissonance-based eating disorder prevention program. Int J Eat Disord. 2001;29(3):247–62.CrossRefGoogle Scholar
  74. 74.
    Stice E, Shaw H, Burton E, Wade E. Dissonance and healthy weight eating disorder prevention programs: a randomized efficacy trial. J Consult Clin Psychol. 2006;74(2):263–75.CrossRefGoogle Scholar
  75. 75.
    Stice E, Rohde P, Shaw H, Marti CN. Efficacy trial of a selective prevention program targeting both eating disorders and obesity among female college students: 1- and 2-year follow-up effects. J Consult Clin Psychol. 2013;81(1):183–9.CrossRefGoogle Scholar
  76. 76.
    Wilksch SM, Paxton SJ, Byrne SM, Austin SB, McLean SA, Thompson KM, et al. Prevention across the spectrum: a randomized controlled trial of three programs to reduce risk factors for both eating disorders and obesity. Psychol Med. 2015;45(9):1811–23.CrossRefGoogle Scholar
  77. 77.
    Watson HJ, Joyce T, French E, Willan V, Kane RT, Tanner-Smith EE, et al. Prevention of eating disorders: a systematic review of randomized, controlled trials. Int J Eat Disord. 2016;49(9):833–62.CrossRefGoogle Scholar
  78. 78.
    Le LK, Barendregt JJ, Hay P, Mihalopoulos C. Prevention of eating disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2017;53:46–58.CrossRefGoogle Scholar
  79. 79.
    Becker CB. From efficacy to global impact: lessons learned about what not to do in translating our research to reach. Behav Ther. 2017;48(5):718–30.CrossRefGoogle Scholar
  80. 80.
    Stice E, Yokum S, Waters A. Dissonance-based eating disorder prevention program reduces reward region response to thin models; how actions shape valuation. PLoS One. 2015;10(12):e0144530.CrossRefGoogle Scholar
  81. 81.
    Sánchez-Carracedo D, López-Guimerà G, Fauquet J, Barrada JR, Pàmias M, Puntí J, et al. A school-based program implemented by community providers previously trained for the prevention of eating and weight-related problems in secondary-school adolescents: the MABIC study protocol. BMC Public Health. 2013;13:955.CrossRefGoogle Scholar
  82. 82.
    Sanchez-Carracedo D, Fauquet J, Lopez-Guimera G, Leiva D, Punti J, Trepat E, et al. The MABIC project: an effectiveness trial for reducing risk factors for eating disorders. Behav Res Ther. 2016;77:23–33.CrossRefGoogle Scholar
  83. 83.
    Wilson JF. Can disease prevention save health reform? Ann Intern Med. 2009;151(2):145–8.CrossRefGoogle Scholar
  84. 84.
    Russell LB. Preventing chronic disease: an important investment, but don’t count on cost savings. Health Aff. 2009;28(1):42–5.CrossRefGoogle Scholar
  85. 85.
    da Luz FQ, Sainsbury A, Mannan H, Touyz S, Mitchison D, Hay P. Prevalence of obesity and comorbid eating disorder behaviors in South Australia from 1995 to 2015. Int J Obes. 2017;41(7):1148–53.CrossRefGoogle Scholar
  86. 86.
    Sharif Ishak SI, Chin YS, Mohd Taib MN, Mohd SZ. School-based intervention to prevent overweight and disordered eating in secondary school Malaysian adolescents: a study protocol. BMC Public Health. 2016;16(1):1101.CrossRefGoogle Scholar
  87. 87.
    Goldschmidt AB, Wall MM, Loth KA, Neumark-Sztainer D. Risk factors for disordered eating in overweight adolescents and young adults. J Pediatr Psychol. 2015;40(10):1048–55.CrossRefGoogle Scholar
  88. 88.
    Wang LY, Nichols LP, Austin SB. The economic effect of Planet Health on preventing bulimia nervosa. Arch Pediatr Adolesc Med. 2011;165(8):756–62.CrossRefGoogle Scholar
  89. 89.
    Austin SB, Kim J, Wiecha J, Troped PJ, Feldman HA, Peterson KE. School-based overweight preventive intervention lowers incidence of disordered weight-control behaviors in early adolescent girls. Arch Pediatr Adolesc Med. 2007;161(9):865–9.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Ottavio Bosello
    • 1
  • Angiola Vanzo
    • 2
  • Massimo Cuzzolaro
    • 3
  1. 1.Department of MedicineUniversity of VeronaVeronaItaly
  2. 2.Department of Food Hygiene and NutritionULSS 8 BericaVicenzaItaly
  3. 3.Formerly Medical Pathophysiology Department, Eating Disorders and Obesity UnitSapienza University of RomeRomeItaly

Personalised recommendations