The Active Female: Health Issues Throughout the Lifespan 2008th Edition

10. Disordered Eating Issues in Active Children and Adolescence

Maria Fernandez-del-Valle Marta Montil Jiménez  and Lesley Carraway 


Department of Health, Exercise, and Sport Sciences, Texas Tech University, Exercise and Sport Sciences Building, 3204 Main, Lubbock, TX, USA


Department of Kinesiology and Athletic Training, Universidad Europea de Madrid, Calle Tajo s/n, Villaviciosa de Odón, Madrid, 28670, Spain


Department of Health, Exercise, and Sports Sciences, Texas Tech University HESS, 43011, Lubbock, TX 79404, USA

Maria Fernandez-del-Valle (Corresponding author)


Marta Montil Jiménez


Lesley Carraway



The development of a child’s body image is strongly influenced by peers, school, family, society, and the media. While it is important for children to learn healthy eating habits and attitudes toward physical activity early in life, it is also essential that children learn to value themselves and develop a strong self-esteem. Without such positive influences, children and adolescents may develop disordered eating habits, which include the use of diet pills, laxatives, and excessive exercise. These disordered eating habits may manifest themselves as clinical eating disorders, such as anorexia and bulimia. It is of great importance that children receive support and positive influences from family, peers, and school to develop a healthy self-image and prevent the formation of disordered eating habits and eating disorders.


Disordered eatingRisk and protective factorsBody imageEating disturbances

10.1 Learning Objectives

After completing this chapter, you should have an understanding of:

·               Body image disturbances and eating disturbances and prevalence.

·               The connection between eating disorders, risk behaviors, and psychological disorders.

·               Risk and protective factors for body image and eating disturbances.

·               Promoting healthy body image and preventing eating disturbances among youth.

·               The application of Social Development Strategy in the health promotion and prevention.

10.2 Introduction

The importance of healthy habits (i.e., physical activity and diet) and their contribution to improve the quality of life and health is well known [12]. Both quality of life and health are linked to environmental influences and lifestyle of individuals. Physical Activity (PA), as well as a healthy dietary intake, is highly important during childhood and adolescence, playing a main role in the acquisition of healthy habits and behaviors through the lifespan [39]. From the environmental or social factors, family, in general, particularly parents, is the main socializing agent that stimulates healthy practices in children and adolescents [813].

Moreover, friends are important socializing agents that increase its effect during adolescence, determine the practice of PA, and promote healthy habits in the future. PA performed in school and high school determines the acquisition of adequate behavioral patterns for health and well-being [14]. Research has reported that children and adolescents show a higher PA participation, and it is during early adulthood when practice starts to decrease. This progressive reduction on PA is greater in females and depends on multiple factors related to psychological and environmental variables [1519], reflecting higher activity levels and participation in male practitioners.

The Center for Disease Control and Prevention (CDC) has identified six categories of health-risk behaviors that contribute to the leading causes of morbidity and mortality among youth and adults—alcohol and other drug use, injury and violence, tobacco use, sexual behaviors, physical inactivity, and unhealthy dietary behaviors. Not only are these behaviors linked to health problems, they also contribute to numerous educational and social problems that negatively impact our nation. These interrelated health-risk behaviors are preventable, and usually begin in childhood and persist into adulthood [20].

The Biopsychosocial (BPS) model: This model was first postulated by Gorge L. Engel at the University of Rochester [21] as, “the need for a new medical model.” The biopsychosocial model (BPS model) was termed to enclose the essential factors that trigger illnesses and disabilities in human beings, postulating three main factors: biological, psychological, and social; however, this model varies across cultures [22]. The biological component analyzes how the cause of the disease derives from the body’s functioning (physiology, genetics, etc.); the psychological component analyzes the potential psychological causes (self-control, emotional turmoil, negative thinking, self-image, self-esteem, etc.); and the social component investigates how the environment can influence health (culture, family, friends, technology, religion, or socioeconomic status) [22].

Applicability of the model: Since WHO defined Health as, “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [23], health has to be analyzed from a BPS perspective. Given that, physical, mental, and social components are vital to support health, and an open-minded point of view is required to explore the key components influencing healthy habits in a physically active population (environmental influences, physical functioning, and mental health).

Historically, scientists have tried to explain the behavioral process regarding specific topics, such physical inactivity, dietary habits, substance abuse, or sexual behaviors, by explanatory models or theories [2427]. Interestingly, they were focused on the psychological factors contributing to the development of unhealthy behaviors. Notwithstanding, BPS-based theories have gained ground due to the multifactorial factors involved in the origin of unhealthy behaviors [2122].

10.3 Research Findings

10.3.1 Risk and Protective Factors for a Healthy Lifestyle

There are unmodifiable and modifiable factors affecting human beings’ behaviors, and both are summarized in Fig. 10.1 [28].


Fig. 10.1

Unmodifiable and modifiable factors affecting the human behavior



These categories have a combined potential for harm or benefit when they act together. Therefore, growing research has focused in detecting risk and protective modifiable factors and changing those by presenting preventive-targeted interventions.

Numerous research studies have identified multiple risk and protective factors for body image and eating disturbances that lead to disordered eating behaviors. These can be divided into three primary categories: biological, psychological, and social (familial and cultural).

Generally speaking, if risk factors are those conditions that increase the likelihood that an individual will develop an eating problem, the protective factors are those conditions that mitigate the risk (i.e., decrease the chances that disordered eating will occur). The following discussion is not inclusive, but represents an overview of some of the key evidence-based risk and protective factors within biological, psychological, and social categories. Body image and eating disturbances are extremely complicated and appear to result from a complex interplay among a myriad of risk factors and deficient protective factors for healthy behaviors. Risk Factors

The CDC’s Youth Risk Behavior Surveillance System (YRBSS) monitors these six categories of health-risk behaviors among youth through national, state, and local data collection [29]. Data collected during September 2008–December 2009 revealed the following selected information about dietary-related behaviors among US students in grades 9–12: 45.6 % of students were trying to lose weight during the 30 days preceding the survey; 10.6 % of students had gone without eating for 24 h or more to lose weight or to keep from gaining weight during the 30 days preceding the survey; 5.0 % of students had taken diet pills, powders, or liquids without a physician’s advice to lose weight or to keep from gaining weight; and 4.0 % of students had vomited or taken laxatives to lose weight or to keep from gaining weight during the 30 days preceding the survey [29]. Those risk factors can be classified by the three components of the Biopsychosocial model:




It is important to point out that familial influences are often difficult to separate from broader sociocultural influences because most (if not all) families are influenced to some degree by current societal standards [58]. With that in mind, other cultural risk factors include societal glamorization of the thin ideal [59], media exposure promoting thinness [6061], and peer influences promoting dieting and adherence to the thin standard [5562]. It is important to note that some of these risk factors were identified through cross-sectional studies; therefore, they cannot completely meet the definition of “risk factor” until they are found to be significant in longitudinal studies [4363]. Moreover, there may be critical developmental periods during which exposure to risk factors may have greater influence on the development of eating disturbances (e.g., puberty) [44]. Protective Factors

In contrast, there is little research about protective factors and how they may buffer individuals against developing eating disturbances and clinical eating disorders (EDs) [4344]. Individual protective factors that have been suggested include the following:




In addition to positive relationships with parents [345168], other familial protective factors that have been considered include: living in a family that does not overemphasize body weight and physical attributes [6465], living in a family where parents do not misuse alcohol [73], and social support from the family [74].

Sociocultural factors that may be protective are: cultural messages that embrace different body shapes and sizes [64], participation in sports that do not emphasize thinness for successful performance [426475], close relationships with friends who do not overstress body weight [6476], and social support from peers [676874].

10.3.2 Eating Disturbances and Body Image Issues in Active Children and Adolescents

There is a broad evidence base that encompasses numerous facets of body image and eating disturbances that negatively impact the whole child. Researchers and clinicians now recognize the triad of body image difficulties, eating disorders, and obesity as an interrelated set of body weight and shape disturbances that cause substantial problems for children and adolescents [77]. In addition, many researchers have viewed eating problems on a continuum, beginning with body dissatisfaction and weight concerns and ending with clinical eating disorders [7879]. In this chapter, the term “eating disorders” (EDs) refers to anorexia nervosa (AN) and bulimia nervosa (BN). The terms “eating disturbances” and “disordered eating” are broader and refer to a range of unhealthy diet-related behaviors, such as obsession with body weight and shape, excessive restrictive eating, skipping meals, laxative and diet pill use, cycles of binge eating and dieting, self-induced vomiting, and excessive exercise with the sole purpose of “purging” calories obtained from dietary intake. The purpose of this chapter is to present an overview of some of the key findings concerning body image and eating disturbances in children and adolescents, and discuss viable avenues for promoting healthy body image and preventing eating disturbances among this population. Eating Disturbances

Clinically diagnosable EDs [48] are atypical among prepubescent children [7780]; yet they rank as the third most common chronic illness among adolescent females, with an incidence of up to 5 % [8183]. EDs are related to other risk behaviors, such as tobacco use, alcohol and other drug abuse, sexual activity, and suicide attempts [48]. EDs often lead to multiple negative outcomes that affect the whole child. These outcomes may range from a preoccupation with eating that can significantly hinder healthy growth and development, to deleterious medical complications, such as severe malnutrition, osteoporosis, acute psychiatric emergencies, heart and other organ damage, and even death [84]. In fact, death rates from eating disorders are among the highest for any mental illness [85]. More specifically, the mortality rate among those with AN is approximately 12 times higher than the death rate among US females ages 15–24 from all causes of death [86].

The average age of onset for AN is 14–18 years, and younger than 13 years if early-onset of eating disorders (EOED) [87], and late adolescence or early adulthood for BN [48]. Younger children may have significant problems related to body image, eating, and weight management that do not meet the diagnostic criteria for an ED, but can increase the risk for developing an ED later. The American Academy of Pediatrics [88], and Society for Adolescent Medicine [84], assert that an ED can still exist in the absence of established diagnostic criteria. Patients who do not fully meet the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for anorexia or bulimia, but experience the same medical and psychological consequences of these disorders, usually are diagnosed with an “eating disorder not otherwise specified” (EDNOS) [89]. The majority of adolescents in ED treatment centers meet the EDNOS criteria [84].

Warning signs include obsessive thinking about food, weight, shape, or exercise; unhealthy weight management practices; and failure to maintain a healthy body weight/composition for gender and age. Similarly, along the spectrum of eating disturbances, researchers often use the terms “partial syndrome” or “sub-clinical” to indicate similar characteristics. Although most children may not meet DSM criteria for an ED, those who exhibit symptoms of EDNOS or a sub-clinical eating disturbance can still suffer considerable social and educational impairment that may require clinical intervention [77]. In fact, about the 5 % of the population of adolescents in the USA suffer from sub-clinical ED or EDNOS [90]. Even in the absence of clinical intervention, obsessive inner dialogues about body weight and shape, and the consequences of disordered eating significantly interfere with the developmental needs and resilience of children and adolescents [9192].

Eating Disturbances Comorbidity

Eating disorders often coexist with other psychological disorders, such as depression, obsessive-compulsive disorder, anxiety, bipolar disorder, substance abuse (including prescription drugs), and personality disorders (e.g., borderline personality) [488493]. In some cases, the ED is a secondary symptom to an underlying psychological disorder; and in other cases, the psychological disorder may be secondary to the eating disorder. Adding to this complexity, a young person with an ED may present other self-destructive behaviors, such as self-injury (e.g., cutting) [94].

Eating Disturbances Approach

ED are comprised of a complex array of biopsychosocial issues that should be addressed by a multidisciplinary team of medical, nutritional, mental health, and nursing professionals who have expertise in child–adolescent health and are experienced in treating Body Image disturbances (BID) and EDs [84].

Although early interdisciplinary treatment increases the likelihood of successful recovery, there are numerous barriers to this type of health care, including time, cost, and inadequate insurance benefits. In addition, patients and their families often exhibit ambivalence or resistance to the treatment process [84]. Failure to detect an ED in its early stages can exacerbate the illness and make it much more difficult to treat [8488]. Body Image Disturbances

BID, eating concerns, and weight issues clearly present major challenges for children and youth. Data reveal that, among American high school students, 25 % of girls and 11 % of boys engage in disordered eating behaviors, including bingeing, vomiting, fasting, laxative and diet pill use, and compulsive exercise [95]. Furthermore, childhood obesity in the USA has increased at an alarming rate, with approximately 12.5 million American children ages 2 through 19 classified as obese [96]. Research has indicated that American children, some as young as 6 years of age [9798], are dissatisfied with their body shapes or weights [8099100]. Up to 70 % of normal-weight adolescent girls report feeling fat and engaging in unhealthy eating practices for weight loss purposes [101]. Studies also have shown that children as young as 8 and 9 engage in dieting practices [41102104]. Moreover, girls who frequently diet are 12 times as likely to engage in binge eating as girls who do not diet [105].

Numerous research studies show that high numbers of Caucasian American children experience body dissatisfaction [80]. However, there is evidence that body dissatisfaction may be increasing among girls in minority ethnic groups. For example, Neumark-Sztainer and colleagues [106], found high levels of dieting and disordered eating among all ethnic groups. They also discovered that, although dieting was more prevalent among adolescents from higher socioeconomic families, disordered eating was widespread in adolescents from lower socioeconomic families as well. Other research has shown that African American adolescent females have reported being more comfortable with their bodies than those among other ethnic groups, but they also have exhibited a high drive for thinness [99]. In addition, there are indications that Mexican-American female adolescents desire to be thinner [107].

There also are developmental trends in body image and weight concerns, and these trends vary by gender and across ethnic groups. For example, research suggests that body dissatisfaction and weight concerns increase with age, particularly among females [6880108109]. These trends are important because there is evidence that body dissatisfaction in young girls can lead to eating problems [3680110], and early-onset depression [111112], later.

In terms of assessing body image, most researchers focus on two separate components of BID—perceptual body-size distortion and the affective (attitudinal) aspect. Perceptual body-size distortion is comprised of inaccurate perceptions of one’s body size (e.g., individuals with eating disorders often overestimate their actual body size). The affective element relates to dissatisfaction with one’s body size, shape, or some other aspect of physical appearance [113]. Although most studies have focused on the distortion component, greater consistency has been found by using attitudinal measures. Moreover, these two components appear to function independently [114]. Therefore, body image is considered multidimensional, and the assessment of BID requires a variety of methods and techniques [115]. There are a variety of assessment instruments, most of which have been developed with adult samples [116]. Banasiak and colleagues [116] examined reliability in numerous assessments that measured dietary restraint and body concerns. Their findings suggest that many of the instruments developed on adults can be used with middle adolescent girls (ninth grade) when proper steps have been taken to ensure that girls understand the terminology used in the instruments [117]. For example, glossaries can be developed for assessment instruments to improve their reliability for use with adolescents. Reliable and valid measures of BID and ED symptoms in preadolescents are also needed. To help fill the gap in terms of measuring body image in children and adolescents, Veron-Guidry and Williamson [117] conducted a study in which they extended the Body Image Assessment (BIA) procedure for adults [118], to children and adolescents, developed norms, and evaluated reliability and validity of the adapted BIA procedure. Their data supported the validity of the BIA-C (children) and BIA-P (preadolescents) procedures and confirmed results from the adult BIA procedure [118]. Generally speaking, instruments used to measure body image and BID in children and adolescents should have sound psychometric properties (e.g., a test–retest reliability of at least 0.70) and be evidence-based. In addition, researchers have supported the use of video distortion methods, which have been successfully implemented with children as young as 5 and 6, as well as custom computer software for measuring body size estimations [113].

Body Image Comorbidity

The term body image is the subjective depiction of physical appearance [119], and is comprised of behavioral, perceptual, cognitive, and affective experiences [120]. Numerous studies have shown a connection between BID and low self-esteem, psychosocial distress, and early-onset depression [80]. In addition, the relationship between body image dissatisfaction and BID has been strongly linked to eating disorders, such as anorexia nervosa and bulimia nervosa [80]. As mentioned earlier, body dissatisfaction has been seen in children as young as 6. As age increases, ideal body size generally becomes progressively thinner [121122]. Therefore, body image and BID in children and adolescents command attention in both research and practice [80113].

Body Image Approach

Although the research literature concerning body image in children and adolescents has provided an enlightening knowledge base, Smolak [123], points out that there are salient research questions that still need to be addressed, such as: (a) how body dissatisfaction varies at different ages for different genders and across different ethnic and socioeconomic groups; (b) the need to develop more accurate measurements of body image, particularly in young children and adolescents from various ethnic and socioeconomic groups; and (c) developmental trends in body image development. In addition, more research needs to target body image importance (overestimated views about body shape and weight) and its role in the development of body dissatisfaction, weight loss strategies, and disordered eating [124125]. Likewise, there is a need to investigate whether childhood body dissatisfaction, high body mass index, and eating disturbances are risk factors for later development of eating disorders, obesity, or depression [100].

Enhancing health and quality of life for all children and adolescents is a desired outcome of health promotion and prevention programs. Health is not a static condition, but a dynamic interplay among the dimensions of physical, mental, emotional, social, and spiritual health. Consistent with this view of health, the promotion of healthy body image and the prevention of eating disturbances among children and adolescents should focus on the “whole child.” For example, undernutrition, which often occurs with eating disturbances, can have detrimental effects not only on children’s physical health (e.g., growth retardation and delayed maturation) [126], but also on their cognitive development [127]. Undernourished students often experience irritability, decreased concentration, nausea, headache, lack of energy, and increased susceptibility to illness [127]. Therefore, it is very difficult for these youth to focus their energy on mastering important developmental tasks, such as succeeding in academics and developing social–emotional skills and a positive identity.

10.3.3 Promoting Healthy Model: Strategies and Programs Approaching a Healthy Model

Research about the determinant factors affecting healthy habits during childhood and adolescence focuses in the analysis of the individual, family, sociocultural groups, schools, and peers factors. From this research, the promotion of a healthy model can be approached from different points and by different people and organizations.

As the social learning theory postulates, children imitate adults (family), and it is during adolescence when they reinterpret those social behaviors by comparing them to other social patterns (friends or school). This process lasts throughout life (peers), in spite of its extreme importance during childhood [128]. Therefore, these influences are key to developing and establishing healthy habits during life [129130]. Strategies and Programs

Primary Prevention

Primary prevention focuses on keeping body image and eating disturbances from developing among children and adolescents (i.e., stopping the problem before it starts). Due to the varied tasks that comprise healthy development across childhood and adolescence, prevention programs must not only be age and developmentally appropriate, but must also address the relevant skills and challenges for each stage of development [131]. Because body dissatisfaction and inappropriate weight management practices start early and can lead to more serious body image and eating problems later, prevention should begin at an early age (e.g., elementary school years) [80].

Health education promoting healthy body image along with healthy eating and physical activity is a principal tool for primary prevention. Health education can be implemented both formally and informally in a variety of settings, including homes, schools, health care facilities, and the wider community. Primary prevention is effective when it incorporates strategies that emphasize multifarious components, including, but not limited to:








A crucial aspect of prevention that targets the individual is the development of self-esteem, which has emerged as a significant predictor of eating problems in numerous research studies [43132133].

Branden [133], defines self-esteem as possessing two components—self-respect and self-efficacy. Among the hallmarks of self-respect are an individual’s assurance of his/her value and basic right to experience a fulfilling life, plus comfort in appropriately asserting thoughts, wants, and needs [133]. A caring adult can foster a child’s self-respect through increasing the individual’s sense of positive uniqueness (i.e., characteristics that set her apart from others in a way that brings honor and a healthy sense of pride). Self-respect does not arise from physical characteristics, but rather from internal attributes. A child also needs to feel significant and a distinct sense of belonging. This sense of significance and belonging should begin in the family, but also can be fostered through other settings, such as the school and other community-based groups. For example, a school-based prevention program called Everybody’s Different [134] focuses on an individual’s uniqueness. Initial findings revealed that boys and girls and those students who were overweight or at high risk of developing body image or eating problems experienced significantly improved body image compared to controls [132].

Self-efficacy is a person’s belief or confidence that she/he can successfully accomplish a task [133]. A sense of competence (power) is foundational for sound mental and emotional health and preventative against the development of negative body image and eating problems. For example, Troop and Treasure [135], found that women who reported experiencing more feelings of helplessness and lower levels of mastery in childhood were more likely to develop EDs in adulthood.

One avenue for instilling a sense of competence in children and adolescents is to help them develop health literacy, which is comprised of these four competencies: effective communication, self-directed learning, critical thinking and problem solving, and responsible, productive citizenship [136]. Health literate individuals are more likely to be resilient and make healthy, life-affirming choices. In terms of preventing body dissatisfaction and eating problems, health literacy competencies are imperative. For example, critical thinking and problem solving are integral skills youth need to effectively counter the barrage of unrealistic, “thin” sociocultural messages they frequently encounter from a variety of sources.

Self-efficacy also can be promoted through goal setting, particularly short-term goals, so that children and youth can take “baby steps” of progress. In turn, they can experience multiple increments of success, thereby developing confidence in their abilities. In addition, repeated opportunities for rehearsal of essential life skills help youth increase a sense of mastery. This sense of competence empowers them to persist in spite of setbacks, and press forward to learn new skills.

Positive social support is another critical element for fostering self-efficacy that can be derived from the family, peers, and caring adults and mentors (e.g., school personnel, health care providers, and other members of the community). These significant relationships provide opportunities for children to cultivate resilience and emulate positive role models and mentors.


As primary caregivers in the early years of life, parents are considered the main teachers and socializing agents for a child’s interaction with the larger environment [137]. Families are a major health and social influence in the lives of children and adolescents; therefore, strong family involvement is essential to health promotion and prevention.

There are numerous strategies that the family can employ to promote positive body image and healthy eating and physical activity habits in children and youth. First of all, positive, nurturing relationships are integral to family health. Parents/caregivers should make it an utmost priority to invest time in building strong, loving, and supportive relationships with their children. In addition, parents/caregivers should be intentional in building self-esteem and fostering resilience in children, starting at a very early age. Parents also should encourage and model essential life skills such as clear communication, problem solving, decision making, and stress management. Even preschool-aged children can be taught about the value of eating healthy foods and being physically active for health and wellness, the importance of respecting different body types, and how to effectively communicate feelings and needs. All children, regardless of their weight and size, should feel that they are unconditionally loved and accepted by the family.

Studies have shown that family involvement plays a key role in a variety of school-based health promotion efforts targeting children and youth, including cardiovascular health promotion [138140], fruit and vegetable consumption [141], and alcohol prevention [142]. The family also can play a powerful role in preventing negative body image and eating problems in children and adolescents [98100137143], yet few school-based prevention programs have included a family involvement component [137], such as home-based activities that the family completes together, family fun nights at the school, parent education workshops, and experiential “role play” activities for skill development.

If a family suspects that a child is engaging in restrictive eating and/or other maladaptive behaviors, they should seek help from a qualified professional [For a more comprehensive list of suggestions, see Levine] [144].

Sociocultural Groups

Progress is lagging in terms of altering cultural norms concerning thinness, body image, and weight management practices. Experts contend that sociocultural changes must occur in order to experience a decline in the growing numbers of children and adolescents with body image problems and disordered eating [7788]. Sociocultural influences encompass schools, peers, health care providers, media, and the larger society, all of which interact dynamically in the prevention of body image and eating disturbances.






Other credible prevention strategies and programs that address various sociocultural influences can be located online. In addition to BodyWise [154], the National Eating Disorders Association (www.​edap.​org) provides an array of prevention information and tips. Positive Youth Development

Numerous researchers and practitioners have recognized the importance of positive youth development in promoting health-enhancing behaviors and preventing health-risk behaviors among youth. In a comprehensive study of positive youth development programs in the USA, Catalano and colleagues [164], found that various youth development approaches can result in positive youth behavior outcomes (e.g., enhanced relational skills and quality of peer and adult relationships, improved problem solving and self-efficacy) and prevention of youth risk behaviors (e.g., drug and alcohol use, smoking, school misbehavior, and risky sexual behavior). Data from longitudinal studies over the past 30 years have identified similar risk and protective factors in individuals, peer groups, families, schools, and neighborhoods that can accurately predict diverse youth problem behaviors [165170]. However, exposure to ever-increasing numbers of protective factors has been found to prevent problem behaviors in spite of the presence of multiple risks [171172].

As a forerunner in the research and implementation of positive youth development, the Social Development Research Group emphasizes the importance of a comprehensive approach to preventing youth problem behaviors by addressing both risk and protective factors. The framework for guiding the positive youth development process is Social Development Strategy (SDS), which is part of a comprehensive model of behavioral development—The Social Development Model [167]. SDS organizes protective factors into a framework for promoting positive youth development, despite the presence of risk. Additionally, SDS focuses on the outcome of health-enhancing behaviors through exposing children and adolescents to two critical protective factors: (1) pro-social bonding to family, school, and peers and (2) healthy beliefs and clear standards for behavioral norms. The mechanisms that help create these protective factors are: opportunities for meaningful participation in productive pro-social roles, life skills to facilitate participation in these roles, consistent systems of recognition and positive reinforcement for pro-social involvement, and individual characteristics.

Positive youth development programs usually strive to achieve one or more of the following objectives: foster resilience; promote healthy bonding; promote social, emotional, cognitive, behavioral, and moral competencies; foster self-determination; foster self-efficacy; foster clear and positive identity; cultivate spirituality; foster belief in the future; provide recognition for positive behavior; provide opportunities for pro-social involvement; and foster pro-social norms [164]. Although positive youth development programs can target youth in one particular setting, the majority of successful programs capitalize on the resources of multiple settings (family, schools, community) [164].

Positive youth development that is guided by SDS can be considered a viable framework for promoting healthy body image and preventing eating disturbances among children and adolescents. In order to develop positive body image and healthy eating behaviors, all children and adolescents must be enveloped in environments that consistently provide the protective factors depicted in Fig. 10.1. Youth who live with multiple risk factors for developing body image and eating problems can benefit from all of these steps and need to be even more fully immersed in protective environments. For positive youth development to be successful, families and communities must identify healthy beliefs and clear standards for healthy body image and eating behaviors. Then, they must foster those healthy beliefs, and communicate the standards in multiple arenas of a young person’s life—at home and school, in peer groups, within youth-serving and faith-based organizations, and in all segments of the larger community. Children and adolescents must have numerous opportunities to cultivate strong, relational bonds with those who embrace and model positive body image along with other health-promoting behaviors, such as healthy eating and PA. These protective bonds can be created through providing youth meaningful opportunities for participation/involvement in a variety of pro-social activities (e.g., advocacy efforts aimed at changing cultural norms promoting the thin ideal). In addition, children and adolescents need repetitive opportunities to develop crucial cognitive, social-emotional, and behavioral skills to help them successfully accomplish these activities, as well as important developmental tasks. They also need to be consistently recognized and affirmed for their pro-social involvement at all levels. Finally, recognizing and nurturing individual strengths can enhance children’s resilience and provide a foundation for external protective factors to optimally function.

10.4 Contemporary Understanding of the Issues

A number of factors, including peer groups, schools, family, media, and society, greatly affect children’s and adolescents’ body-image perceptions. In a time when the media have such a strong influence on how we feel we should look, it is essential that we treat these issues seriously, as the consequences could be deadly. The best defenses we have against eating disorders and body-image disturbances are early prevention, through family support and positive influences, and, for those already affected by these disorders, timely diagnosis and treatment. It is crucial, now more than ever, that a child develops a positive self-image and self-esteem at a young age and that his or her sense of self-worth is fostered into adolescence and young adulthood.

10.5 Future Directions

There are several prevention questions that deserve further study. For example: Which protective factors should be targeted and enhanced to reduce the incidence of body image and eating disturbances among children and adolescents from different age and ethnic groups? Which interventions are more effective—universal or targeted ones? How long should interventions last, and what are the most cost-effective approaches? [143] How can high-risk youth be reached, and what interventions are most effective with this group? [84143] Future studies also need to directly compare promising prevention programs in randomized trials, particularly in ecologically valid settings where large numbers of children and adolescents can be reached (e.g., schools) [173]. There is an additional need to further explore the pathogenesis of early-onset eating disorders, and enhance the current diagnostic system to address the “unique spectrum of early-onset eating disorders and the development of effective treatments for adolescent eating disorders” [84]. Finally, research is needed to determine whether positive youth development programs that employ SDS can produce positive outcomes in terms of decreasing body image and eating disturbances among children and youth.

10.6 Concluding Remarks

Body image and eating disturbances are highly complex and wield a harsh blow to our nation in terms of health care costs, diminished quality of life, and tragic loss of life. Youth, parents, school personnel, health care providers, and entire communities can be effective change agents for the prevention of body image and eating disturbances among children and adolescents. Health promotion and prevention efforts need to be multifaceted and encompass the whole child by addressing physical, mental, emotional, social, and spiritual health. Furthermore, these efforts should target interests, skills, and challenges that are distinctive for particular stages of development [137]. No individual should underestimate his or her ability to make a positive difference in the prevention of body image and eating disturbances in children and adolescents. Even small changes have the capacity to produce a powerful ripple effect that can transform society. When individuals, families, and communities unite and engage in proactive endeavors to promote health and quality of life for children and adolescents, they create a legacy of tremendous impact and enduring value [174].



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