• By Laura Whybra
  • Posted on Monday 13th October, 2014

Preventing eating disorders: time to take the bull by the horns in schools?

strong>Could schools play a more active part in preventing eating disorders as children reach adolescence? Research from Germany’s “Torera” project suggests a positive answer when teachers are equipped with well-conceived program materials and training.A one-year evaluation of the intervention for school students aged 11 to 13, demonstrated improvements in problem eating behavior and also young people’s self-esteem relating to body image. Change for the better was most marked among girls and those whose eating habits had been especially risky at the start. With costs of implementing the program estimated at just €2.50 per student, the study suggests that universal approaches can play a valuable part in “real world” efforts to tackle the spread of debilitating conditions such as anorexia nervosa and bulimia nervosa, alongside more targeted approaches.Health and preventionTorera was purpose-designed for schools in the central German state of Thuringia and reflects the particular requirements for the study that were stipulated by its Ministry of Education. These included developing a comprehensive prevention and health program, rather than targeting a particular eating disorder, and producing materials that could be taught by teachers, as opposed to external specialists.The authorities also insisted that any school interested in implementing the new program should be allowed to do so. A randomized controlled trial was ruled out, resulting in an evaluation using a quasi-experimental design. This assessed children just before the nine-session Torera program was implemented and a year after baseline measurements were taken.The research design made it possible to compare results from 188 students in the 10 schools that agreed to take part in the program with those from 345 students in schools that declined. All young people in the intervention group had taken part the previous year in either a program for pre-adolescent girls focused on preventing anorexia nervosa or an obesity prevention program for boys. However, the comparison group was sub-divided between “pre-treated” students who had participated in one of the two previous programs and those from schools that had not. “Facing the bull”The Torera program began with a half-day training session for teachers, who had all been involved with the earlier interventions. They were equipped with a 76-page teaching manual and workbooks.The nine 90-minute sessions used instruction, role-play and videos to address known risk factors for eating disorders, including binge eating, unhealthy foods, negative body image, lack of physical activity, being teased, feeling of shame and social isolation. Prompted by the program’s name, young people were urged to “face the bull” of risky eating.For the evaluation, eating behavior was assessed using two standardized tests known as SCOFF and EAT. These included questions about purging, recent weight loss, and feelings of control over food. Body self-esteem was measured with a sub-scale from the German Body Experience Questionnaire.Based on their scores, the research team classified young people as either high or low risk for eating disordered behavior. Overall, girls and students whose assessments at baseline had been high risk showed significant improvement after the course (“small to “medium” effect sizes) when compared with the two comparison groups. Further analysis suggested that improved levels of self-esteem among the girls had led to more positive eating behaviors.The only significant finding among boys was that their eating attitudes improved (a “small” effect size). This was not entirely surprising, given that boys, before the intervention, had reported higher body self esteem and fewer negative eating behaviors than girls. It is, therefore, likely that the difference in effectiveness of eating disorder prevention interventions for boys and girls was due to differences in their body related self-esteem.Given that there have been previous examples of interventions for preventing unhealthy behavior among young people can have unanticipated negative consequences, it is also important to note that the research found no equivalent side effects.In Europe, school based programs are not easily transferable across the different educational systems, so developers often have to start from scratch. The development and reporting of Torera provides a useful template for program developers.The German research team report which aspects of Torera were constructed from the evidence base on how to reduce eating disorders, and which aspects were tailored to specific Thuringian policies. This helps researchers in other countries who may want to implement the program understand which parts of the intervention help change behavior – and should therefore stay the same – and which parts of the program can be customized without reducing the impact of the intervention. *********References:Berger, U., Schaefer, J-M., Wick, K., Brix, C., Bormann, B., Sowa, M., Schwartze, D. & Strauss, B. (2013). Effectiveness of Reducing the Risk of Eating-Related Problems Using the German School-Based Intervention Program, “Torera”, for Preadolescent Boys and Girls, Prevention Science. doi: 10.1007/s11121-013-0396-4

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