Challenging Dogma

...Using social sciences to improve the practice of public health

Monday, April 30, 2007

Framing Eating Disorders Matters: Why Health Belief Model Based Programs On College Campuses Are Failing To Have An Impact – Morgan Kutzman

In the United States, 9.3 million adults reported having had suffered from an eating disorder some time in their life, 4.5% of the population (1). Eating disorders are prevalent on the cover of celebrity gossip magazines most every month. Usually a woman is portrayed starving herself obsessed with the desire to be thin, right next to a headline about dieting secrets. It is no wonder people are confused about eating disorders.

The public tends to perceive Anorexia Nervosa as loss of appetite or fear of food, which is a gross over simplification of a complex psychological disease. In reality, very few people with Anorexia Nervosa actually have a loss of appetite (2). Patients with eating disorders suffer from obsessive thoughts and behaviors resulting from depression or anxiety that lead to starvation behaviors (3). Although the media portrays eating disorders with extremely skinny women the medical diagnostic criteria for Bulimia and Binge-Eating disorder do not include the requirement for low body weight; patients of these diseases can appear to have normal body weight (4). Moreover, one fourth of people suffering from the disorders are male (1). The public might believe weight controlling behaviors in eating disorder patients result from an obsession with appearance, in reality these behaviors are how the depression or anxiety the patient is suffering from is managed. Eating disorders result from a complex pathway of risk factors including genetic, neurochemical, psychodevelopmental and sociocultural (4). Similar to any other disease, these risk factors combine into the pathology of eating disorders. Whitaker uses an example of heart disease, which develops from physical factors: production of cholesterol, behavioral factors: smoking and dietary, and psychological factors: type A vs. type B personality. These all contribute to the development of the disease. Although behavioral factors contribute to heart disease it is never portrayed as an individual’s responsibility (5). In comparison eating disorders have many risk factors, but they are portrayed mostly as being an individual’s responsibility.

The college social environment is complex; many students may feel overwhelmed by the responsibility of being on their own, handling difficult course work, pressure to fit in and find a social group. This can lead to feelings of loss of control, which for some can be fulfilled by controlling weight and restricting diet (6). The shift in student’s social context can be triggering to those already at risk for the development of an eating disorder. Behaviors such as restricting diet, use of diet pills, and excessive exercise are common among college students, 61% have reported these behaviors (6). There is a line between the psychological illness of an eating disorder with behavioral and clinical profiles, and eating disordered behaviors (5). When college students are surrounded by these behaviors, it can be difficult to distinguish a psychological illness (6). The prevalence of these disordered eating behaviors, and the social context of college life contributes to the high prevalence of eating disorders on college campuses.

Eating disorders, which affect 5-7% of college students, have underlying factors, including the need for control, anxiety, and depression, that are not usually recognized (6). Intervention programs for eating disorders on college campuses are mainly centered on the Health Belief Model and aim to impact individuals’ behaviors by influencing their attitudes and intentions about eating disorders. Most of the programs frame eating disorders as a concern with food, body image, and a desire to appeal to the opposite sex. Research has shown this approach is ineffective; moreover, the prevalence of eating disorders among college students is increasing (7, 8). Some researchers argue that intervention programs that implement a social model and present how one feels with a healthy body image may improve success (7). Eating disorders are about more than food; they have complex underlying factors. Reframing the diseases can help redesign college campus intervention programs.

Society frames eating disorders as an obsession with food, a woman’s fear of being fat, obsessions with appearance, and desire to appeal to the opposite sex. The public then perceives the diseases as an individual’s responsibility or something they have control over. This frame does not address the underlying issues of depression, the need for control, and anxiety. People’s understanding of the diseases and the way interventions are designed are based on the frame. A frame is a “label the mind uses to find what it knows” (9), which is a powerful tool in public health because the language used by public health practitioners to frame a problem can generate support or lack thereof. In addition, the frame dictates what people perceive to be the truth, thus facts about a certain disease will be ignored unless they fit in the frame (10). Eating disorders are framed as personal responsibility, which requires public health practitioners to develop interventions that focus solely on individual’s behavior change (9).

The public’s perception of eating disorders is reflected in the designing of prevention and interventions programs. The first goal in planning an intervention for college students should be to understand the social environment of the student, then the disease (6). Traditional interventions on college campuses serve to educate about the diseases and where to go for help, but may only change an individuals’ intentions and attitudes about eating disorders (7). Education alone does not provide them with the motivation to change their behaviors; it does not address the underlying depression, anxiety or loss of control the students are suffering from. The programs may even make some more aware of their body image, further perpetuating eating disorder behaviors (11). Intervention programs succeed at increasing knowledge about eating disorders, but a study by Carter shows knowledge does not correlate with behavior change. Furthermore, at the six month follow up participants has significantly increased their eating disorder related behaviors (11).

Martz studied interventions for college students designed to provide education about eating disorders and referral resources. The educational sessions were preceded by information on perceived body size, and techniques for increasing ones own body image. Results of the study showed minimal effects. Additionally, the intervention was redesigned implementing emotional persuasive content, but was repeated with no improvement. The researchers felt that the interventions should have focused on showing how it feels to have a healthy body image, and clarified the distinction of improving body image vs. improving physical appearance (7).

A different study, by Becker focused on interventions targeting individuals’ awareness of the risks associated with eating disorders. Results showed after the intervention, 81% of participants reported being aware of the disease and were confident about accessing recourses for treatment, yet only one half of the subjects recommended for treatment followed through. The authors found it concerning participants who felt educated and had access to care, decided not to pursue treatment. The presumed barriers: lack of information and treatment resources, did not factor into individuals seeking care (8). The model used for the interventions made the programs insufficient; it educated the participants on the dangers of eating disorders but could not influence their health behaviors.

The Health Belief Model links the three example studies. The model caused the interventions to be focused on individuals’ health behaviors and their perceptions of eating disorders. The programs, through education about the costs and benefits of eating disorders, should have provided individuals with motivation to change their behavior (12). The Health Belief Model leaves no room to account for the influences of the individuals’ objective environment (13). The environment college students live in is associated with the diseases, but it is not addressed in interventions based on the Health Belief Model (6). Interventions that focus on “blaming the individual,” and do not include community level factors have a small effect (13). Framing eating disorders at the individual level causes innervations on college campuses to focus on changing individuals’ behavior with out regard to the social context of the diseases.

On college campuses, most of the behaviors associated eating disorders are socially accepted and not recognized as being the development of diseases (6). When unhealthy behaviors are thought to be the norm in a social group, such as college campuses, the urge to conform affects behaviors. Social Norm Theory aims to promote accurate norms of health and safety (14). In contrast to the Health Belief Model, this allows for the interventions to address the social context of the diseases. The Health Belief Model focuses on the individual, without regard to the individuals’ social experience (15). College students are at increased risk for feelings of anxiety and loss of control, especially freshmen because of their new social environment (6). Eating disorders often develop out of these underlying risk factors; individuals find control by controlling food intake and their weight (16). In the social context of college, behaviors associated with eating disorders are not recognized as diseases, supported by the misperception that “everyone” partakes in food and weight control (6).

Social Norm Theory accounts for individuals’ perception of social norms in their group. Health behaviors perceived to be the norm influence individuals’ actions (14). High-risk groups can be targeted with comprehensive programs using positive messages and normative feedback, and important aspect of the theory (17). Eating disorder behaviors thought to be common and socially accepted among college students adds to the problem of misperception.

Eating disorders are framed by the public as diseases only about food and an individuals struggle to control their weight. The public’s perception of the diseases influences how interventions are designed. When public health practitioners consider eating disorders an individual issue, interventions target individuals’ behavior. Significantly higher prevalence of the diseases exists on college campuses partially because social factors of college life can contribute to the development of the diseases. Health Belief Model based interventions fail to address the social context in which eating disorders occur rendering them ineffective on college campuses. Social Norm Theory takes into account the influences of the social group with regards to individuals’ health behaviors. In order for the public health community to successfully design interventions for eating disorders on college campus, perceptions of the disease must first change. Reframing eating disorders in the correct way, having interventions focus on increasing awareness about the underlying issues, and including the contribution from social factors; may help to decrease the prevalence of eating disorders on college campuses.


1. Gellene, Denise. “Eating disorders a guy thing too, study finds.” Los Angeles Times February 1, 2007.

2. Halmi, Katherine. “Psychopathology of Anorexia Nervosa.” International Journal of Eating Disorders 37 S20-S21, 2005.

3. Sodersten, Per, Cecilia Bergh, and Michel Zandian. “Understanding eating disorders.” Hormones and Behavior; 50:572-578 (2006).

4. Becker, Anne, Steven Grinspoon, Anne Klibanski, and David Herzog. “Eating Disorders.” New England Journal of Medicine; 340:1092-1098 (1999).

5. Whitaker, Leighton. “The Bulimic College Student: Evaluation, Treatment and Prevention.” Haworth Press Inc., NY 1989.

6. Knowlton, Kerry. “The Beast Within: An Exploration into Eating Disorders among College Women.” Journal of Student Affairs; 10:2000-2001. Accessed February 13, 2007 .

7. Martz, Denise M. “Eating disorders preventions programming may be failing: Evaluation of 2 one-shot programs.” Journal of College Student Development; Jan/Feb 1999. Accessed February 2007 .

8. Becker, Anne, Debra Franko, Karin Nussbaum, and David Herzog. “Secondary Prevention for Eating Disorders: The Impact of Education, Screening, and Referral in a College-Based Screening Program.” International Journal of Eating Disorders 36: 157-162, 2004.

9. Dorfman, Lori, Lawarnce Wallack and Katie Woodruff. “More than a message: Framing Public Health Advocacy to Change Corporate Practices.” Accessed March 2007. .

10. Chua, Kao-Ping. “Introduction to Framing.” Accessed March 2007 .

11. Carter, JC. “Primary prevention of eating disorders: Might it do more harm then good?” International Journal of Eating Disorders; 22:167-172, 1997.

12. Salazar, Mary Kathryn. “Comparison of Four Behavioral Theories.” AAOHN Journal; 39: 128-135, 1991.

13. Marks, David. “Health Psychology in Context.” Journal of Health Psychology; 1:7-21, 1996.

14. Haines, Michael. “Best Practices Social Norms.” Accessed March 2007 .

15. Thomas, Linda. “A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education.” Journal of Professional Nursing; 11:246-252.

16. Walter H. Kaye, M.D., Cynthia M. Bulik, Ph.D., Laura Thornton, Ph.D., Nicole Barbarich, B.S., Kim Masters, B.S. and the Price Foundation Collaborative Group. “Co morbidity of Anxiety Disorders With Anorexia and Bulimia Nervosa.” American Journal of Psychiatry; 161:2215-2221, 2004.

17. Berkowitz, Alan. “Higher Education Center: The Social Norms Approach: Theory, Research and Annotated Bibliography.” Accessed March 2007 .

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