Sunday, January 5, 2014

NEDAwareness Campaign: A Flawed Public Health Intervention to Combat Eating Disorders– Caroline Lavery

Twenty million women and 10 million men are clinically diagnosed with either anorexia nervosa, bulimia, binge-eating disorder or an eating disorder not otherwise specified (EDNOS) in the United States (1).  Additionally, the incidence of eating disorders has consistently increased over the last 7 decades since 1930 (1-3). Eating disorders are characterized by behaviors such as restricting food intake, purging, and bingeing and are often accompanied by distorted body images and intense fears of weight gain (4). The psychological illnesses negatively affect both mental and physical health and can have life-threatening consequences. Anorexia nervosa has the highest mortality rate of any psychiatric disease; the mortality rate associated with anorexia nervosa in females between the ages of 15 and 24 is twelve times that of mortality rates for any other cause of death (5-6).
Effective treatments for eating disorders exist; however, due to the complex etiology and underlying emotional disturbances that accompany the diseases treatment is difficult and often delayed. Approximately half of individuals suffering from anorexia and bulimia experience a full recovery with 30 percent achieving a partial recovery and 20 percent having no significant improvement (7-8). Additionally, many individuals with eating disorders forgo treatment for significant periods of time due to shame of discussing symptoms, denial, and various other factors (4). Due to the serious and devastating consequences of eating disorders and their resistance to treatment, prevention and early intervention are public health concerns. In response, various organizations have launched campaigns against eating disorders. One such campaign is the eating disorder awareness campaign produced by the National Eating Disorder Association (NEDA).
The NEDA organization campaigns for prevention, increased access to treatment, and research. More specifically, their NEDAwareness program strives to expand awareness of eating disorders in hopes of increasing early intervention and weakening stigmas surrounding the disorders (9). The campaign runs one week a year with the help of professionals, educators, and the general public. NEDA creates material to distribute including posters reflecting an annual theme. The public service announcements for the past two years focus on the severity and lives lost to eating disorders. They feature a graphic associated with eating disorders such as a fork and knife beside a toilet seat or a thin girl pinching skin she perceives as fat. A caption describes a characteristic aspects of anorexia nervosa and bulimia, for example “The monster isn’t under the bed it’s in the fridge.”  (9) At the bottom of the posters, in small print a few sentences display facts about the severity of eating disorders often referring to mortality statistics (9).  NEDA hypothesizes that providing the public with information on the devastating effects of eating disorders will motivate individuals to seek help or think twice about engaging in destructive eating behavior. In theory, NEDAwareness would be effective; however, the campaign makes various assumptions that are false in the target population and fails to take into consideration social influences and emotional reactions.
Flaw 1: NEDAwareness uses an ineffective individualistic model
The main flaw of the NEDAwareness campaign is its use of a simplistic individual model. NEDA based the campaign on the Health Belief Model (HBM), an intervention theory that attempts to predict and change behavior employing six constructs suggested to influence individuals’ health decisions. The model pairs perceived susceptibility with perceived severity of a condition against the perceived benefits of the health behavior and the perceived barriers. If the individual concludes that the benefits are greater than the costs, and he or she has self-efficacy, when prompted to take action he or she will engage in the health behavior (10).
The NEDAwareness campaign attempts to influence individuals with eating disorders to seek treatment by increasing the perceived severity of the illnesses. NEDA believes that if individuals know the life-threatening consequences of eating disorders, the dangers will outweigh any perceived benefits of engaging in maladaptive eating behaviors and barriers to pursuing treatment. The campaign hopes reinforcing the potential health risks of these psychiatric diseases will motivate anorexics, bulimics, and binge-eaters to receive professional help. Ideally, NEDAwareness would lead to earlier intervention, demonstrated to improve outcomes (11).
Logically, NEDAwareness would be effective; however, for complex long-term decisions such as recovering from an eating disorder, the HBM is ineffectual. For instance, anti-smoking campaigns on average decrease smoking prevalence by 2%, with long-term media campaign decreases closer to 1.5% (12-13). Although these interventions may decrease smoking, the small percentages are unlikely to have large health implications for the population. Additionally, in a study of type 1 diabetes insulin therapy compliance a relatively weak correlation of 0.5 was found between HBM motivation and overall treatment compliance (14). The HBM does not account for all factors that influence long-term complex behavior.
One major flaw of the HBM that makes it ineffective at changing and predicting complex behavior is that it fails to take into consideration social influences. Using eating disorder facts and images, NEDAwareness does not account for the powerful impact media has on body image and eating disorder behavior. According to the social comparison theory, people make comparisons consciously and unconsciously between themselves and others. These comparisons can then motivate them to strive to be more similar to the admired person or desired image (15). Applying this theory to body image, individuals compare themselves to celebrities and models and are motivated to look similar to the idealized men and women. Consequently, individuals may engage in eating disorder behaviors such as restricting food or purging to achieve their goals. Further, those suffering from the illnesses may be less motivated to seek treatment because recovery can distance them from underweight media images.
A multitude of studies demonstrate the relationship between viewing media images and eating disorder behavior. In 2008, a meta-analysis of 77 studies on media and body image disturbance concluded that exposure to thin images correlates with increased body image concerns (16). More specifically, a study on the influence of television on body image disturbance found that the media accounted for 15% of the variance for drive for thinness, 17% for body dissatisfaction, 16% for bulimic behaviors, and 33% for thin ideal endorsement (17).  Additionally, image-focused Internet viewing was significantly correlated with eating pathology. College women who viewed more Internet sites featuring celebrities, fashion, and fitness scored higher on the Eating Disorder Inventory that assessed symptoms of anorexia nervosa and bulimia (18). Media images have a large impact on eating disorder development and treatment resistance. The fact that NEDAwareness fails to take this link into consideration makes the campaign flawed an unlikely to be highly successful.
In addition to failing to take into consideration social influences on eating disorders, the HBM utilized by the NEDAwareness campaign assumes that individuals with eating disorders rationally make decisions, which is not necessarily true. One of the core characteristics of eating disorders is irrational thoughts and beliefs (19). As evidenced by the Minnesota Starvation Study, significant food restriction can lead to irrational behaviors such as an intense preoccupation with food and odd food rituals including cutting food into small pieces and creating strange food combinations (20). A study with semi-starvation in college students showed similar results confirming a link between eating disorder behavior and irrational thoughts and beliefs (21). Some of the defining features of anorexia nervosa are an intense fear of weight gain even though underweight, denial of a low-body weight, and refusal to eat certain food groups due to fear of weight gain (19). An excerpt from an eating disorder story provides a clear example of irrational eating disorder thoughts. Amy was in denial of her eating disorder writing:  “Everyone was just jealous of my self-control to be thin.”(22) Her story also demonstrates irrational black and white thinking: “I would think, “if I don’t get an A, I might as well have an F,“ or, “if I’m not size zero, then I’m obese.” (22) Because individuals with eating disorders often lack the ability to think rationally, the NEDAwareness campaign that relies on rational behavior is unlikely to be highly effective.
The HBM also assumes that people value their health above other factors. The NEDAwareness campaign presumes individuals with eating disorders value health over their illness; however, health is not a strong motivating factor for many suffering these psychiatric diseases. The eating disorder is typically a top priority with other aspects of life including friends and falling to the wayside.  Amy, a recovered anorexic recalls her experience in the following quote: “All of a sudden, you don’t care about your health, your friends or your dreams. All you care about is being thin, and you don’t even really know how it happened, when, or why.” (22) Additionally, the majority of individuals suffering from eating disorders are adolescents and young adults (23). Health is not a core value in this demographic. A prospective cohort study in Minnesota found that physical appearance was valued above all other lifestyle factors and it increased in importance over time (24). Because appearance is more important to young adults than health, it is probable that many individuals with an eating disorder will value their eating disorder over their health. Consequently, NEDAwareness will be an ineffective motivator to pursue treatment.
Flaw 2: NEDAwareness Creates Psychological Reactance
The NEDAwareness campaign posters create psychological reactance, motivation to restore freedom perceived to be threatened (25). A clear example of a violation of psychological reactance theory stems from anti-smoking ads. Adolescents perceive anti-smoking advertisements as a threat to their freedom. As age increased until the 10th grade, perceived threat also increased. Further, ads that were perceived as a threat to freedom were evaluated more negatively as adolescents experienced reactance. (26) Psychological reactance has been observed within the mental health field. In the schizophrenic population, patients were found to be less compliant with medications if they perceived the treatment to be a threat to their freedom (27). Campaigns and treatments that advise people to perform or not to perform a specific behavior are viewed as a threatening and can have the opposite effect as intended (25).
Similar to anti-smoking campaigns and demands to take prescribed medication, NEDAwareness posters have the potential to evoke psychological reactance. The public service announcements indirectly instruct individuals to stop engaging in eating disorder behaviors. For instance, one ad depicts a toilet seat centered between a fork and knife. The caption reads: “What’ll we lose on this diet? Lots of people every year”(9).  Although not directly stating do not purge, the message is strongly implied, stop purging or you will die. According to psychological reactance theory, when individuals with anorexia or bulimia see this poster, they perceive NEDA’s suggestion as a threat to the freedom to purge.  In response, eating disorder sufferers will strive to regain their freedom by restricting food, purging, or bingeing.
Psychological reactance created by the NEDAwareness ads is likely to be relatively strong. First, psychological reactance is amplified in individuals that demonstrate denial, mistrust, dominance, and independence (28). Individuals with eating disorders often exhibit denial and engage in eating disorders to gain a sense of control placing them at increased risk for reactance (21,29). Second, eating disorders are very important to individuals often becoming part of their identity (30). Psychological reactance theory states that threats made to freedoms that are important to individuals evoke more reactance (25). Because NEDAwareness campaign threatens a freedom that is highly valued and the eating disorder population exhibits traits that are more responsive to psychological reactance, the ads are likely to create a boomerang effect and increase eating disorder behavior.
Flaw 3: NEDAwareness Violates Terror Management Theory
A third flaw with the NEDAwareness campaign is that the messages and facts provided on the posters violate terror management theory. This theory suggests that when individuals are reminded of their mortality consciously or unconsciously they experience intense anxiety. To resolve this terror, people strive to bolster their belief that they are valuable members of society by improving self-esteem (31).  When an individual’s self-esteem is enhanced by the undesirable behavior, prompting thoughts of death may have unintended consequences. The advertisements can backfire provoking the actions they strove to inhibit. For instance, anti-smoking public service announcements with mortality-salient messages led to more favorable views of smoking in smokers who believed smoking was a source of self-esteem (32). Further, advertisements that focus on the lethal effects of smoking increased smoking cravings and smoking intensity (33).
Similar to anti-smoking advertisements, NEDAwareness posters may also produce opposite effects than intended. Individuals with eating disorders often use food and weight control to bolster self-esteem. They often attempt to relieve anxiety, depression, or insecurity by changing their external appearance or controlling food as encouraged by the Western society (34). Eating disorders can make people feel worthy when they have low self-efficacy in other areas of life such as friendships, school, or work. Further, the withdrawal from activities can increase the need to find self-acceptance through the eating disorder (35). Additionally, eating disorder behaviors are frequently used as a method to reduce anxiety and cope with stress. Individuals with lower coping self-efficacy and prone to an avoidance coping styles are more likely to have eating disorder attitudes and behaviors (36). The eating disorder population possesses both components that cause mortality messages to motivate unhealthy behavior: eating disorders are a source of self-esteem and a coping mechanism. Consequently, NEDAwareness posters that feature mortality statistics may provoke anorexics, bulimics, and binge eaters to engage in eating disorder behavior to cope with evoked anxiety.

Intervention: An Anti-Industry Movement Against the Thin Ideal
NEDAwareness is a flawed campaign; however, methods exist to invent a more efficacious intervention taking into consideration social factors while avoiding reliance on rational thinking, health, messages that threaten freedom, and mortality statistics. A successful youth anti-smoking campaign successfully decreased smoking using an anti-industry approach known as the “truth” campaign. Using youth input, commercials were filmed attacking the manipulation of the tobacco industry rather than focusing on health effects of smoking. A rebellion was created providing adolescents with the independence they desire (37). The “truth” campaign decreased smoking in Florida by 40% in middle school students and by 18% in high school students (38). A similar anti-industry intervention could also be used to address eating disorders.
A group level model campaign that produces a movement against the social thin ideal may be efficacious in decreasing the prevalence and incidence of eating disorders. Videos could feature healthy weight young men and women rebelling against aspects the fashion industry and Hollywood such as digitally manipulating photographs in magazines. The advertisements would end with messages of self-acceptance and positive body image asking the public to join the anti-industry movement. Young adults and adolescents can identify with the created brand and stand for real beauty, not artificial industry beauty.
A potential video could begin with a group of young women watching a modeling photo shoot. The clip would focus on how lighting and cosmetics are used to fake a flawless image. Next, the commercial could show how the picture is edited to slim and perfect the model’s body. The camera could zoom in on one member of the group and she could say: “Don’t believe everything you see. Choose to be real”. The group would then leave the set laughing hands around each other’s shoulders. The ad would end with a slogan “Be Real. Don’t Let Deception Define You” with symbol featuring a “NO” symbol over a camera.
A campaign against the fashion industry incorporating self-love and acceptance avoids many of the flaws of the NEDAwareness campaign. The anti-industry ad utilizes group level models that incorporate social influences, irrationality of human behavior, and strong core values. The proposed anti-industry campaign utilizes marketing and advertising theory principles along with psychological reactance theory to create an intervention that has the potential to decrease the power of the thin ideal and increase the desire to recover from eating disorders.
First, the proposed intervention incorporates social influences that NEDAwareness fails to take into consideration. The campaign recognizes the societal pressures to be extremely thin. It directly attacks the fashion industry and Hollywood by showing how the images provided to society are manipulated. Additionally, the campaign attempts to use group theories to change social norms to desire a healthy weight. According to marketing theory, one can mold behavior by discovering what the target population craves and packaging the desired behavior to fulfill those wants (39). Individuals with eating disorders and those susceptible to developing the disorders often engage in maladaptive eating to fulfill a desire to be accepted and belong (34). The anti-industry campaign fulfills these wants and needs using a healthy weight and self-acceptance. The videos provide evidence by showing visual examples of healthy weight peers that love their body while having friends and radiating happiness and peace.
Another flaw of NEDA’s awareness campaign corrected with the proposed intervention is the HMB’s assumption that individuals act rationally. The anti-industry intervention escapes this flaw by using advertising theory. This group model uses irrationality to change behavior. Advertising theory states that making large promises based on core values backed by emotional and visual support are effective at influencing behavior. Further, the more preposterous the promise, the more effective the advertisement as long as sufficient support is provided (40). The anti-industry campaign promises that one will experience core values of self-acceptance, friendship, and happiness if he or she rebels against the thin ideal. The promise is supported by anecdotal videos of people at healthy weights having fun with friends. Although it may not be rational to believe that refusing to follow the stick figure ideal will lead to friendships and self-acceptance, the large promise and strong emotional visual support may decrease eating disorder behavior.
Marketing and advertising theory also allow the anti-industry campaign to avoid the assumption that the individual must value health. Unlike NEDAwareness, the proposed campaign does not mention health or use it as a core value. Instead, the intervention utilizes the strong core values of acceptance, belonging, and freedom. Adolescents and young adults do not need to value health to want to join the movement against the thin ideal. For the anti-industry advertisements to be effective, the audience must value acceptance, belonging, and freedom, which are common values among younger populations where the majority of eating disorder occurs (2).
 The second flaw of the NEDAwareness campaign, evoking psychological reactance is minimized in the new proposed intervention. Psychological reactance cannot be entirely avoided due to the inherent goal of interventions to suggest behavior change; however, various techniques exist to lessen the degree of reactance. Explicitly stating intent, decreasing dominance, increasing support, and having the actor be similar to the target population all decrease reactance (41-42). The anti-industry campaign lessens reactance by incorporating all of the above characteristics into its videos. The desired behavior is explicitly stated; rebel against the industry artificial thin ideal. Second, the campaign uses peers to increase similarity while decreasing dominance. Lastly, the advertisements provide ample support to go against unhealthy societal trends and maintain a healthy body by displaying thriving healthy weight young women and men surrounded by loving friends. Psychological reactance is probably low in the proposed campaign.
Lastly, the anti-industry campaign avoids terror management by eliminating mortality statistics. Nowhere the campaign mentions the negative effects of eating disorders or the possible tragic outcomes. Consequently, the ads do not create anxiety and terror in those with eating disorders or at-risk for eating disorders decreasing the likelihood viewing the ads will increase eating disorder behavior. In place of mortality-salient messages, the proposed intervention highlights the benefits of life without eating disorders such as acceptance and belonging.
 Eating disorders are a pubic health concern due to the severity of health consequences and rising incidence. Using the HBM, NEDA created posters that reinforce the devastating effects of eating disorders in hopes that perceived severity would outweigh perceived benefits of maladaptive eating and barriers to treatment. The campaign failed to take into consideration social influences, irrational behavior, and low value of health, psychological reactance, and terror management. Instead of NEDAwareness, a group level anti-industry campaign attacking the thin ideal may avoid many of the above-mentioned flaws resulting in a greater impact on the population. To prevent eating disorders and increase early intervention, public health professionals must take the focus off health and create interventions that enhance self worth in the absence of the thin ideal.


1.       Wade TD., Keski-Rahkonen A., Hudson J. Epidemiology of eating disorders (pp. 343-360). In M. Tsuang and M. Tohen eds. Textbook in Psychiatric Epidemiology (3rd ed.). New York, NY: Wiley, 2011.
2.       Hoek HW., van Hoeken D. Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders 2003; 34(4): 383-396.
3.       Hudson JI., Hiripi E., Pope HG Jr., Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry 2007; 61: 348-358.
4.       Becker AE., Grinspoon SK., Klibanski A., Herzog DB. Eating disorders. New England Journal of  Medicine 1999; 340:1092-1098.
5.       Arcelus J., Mitchell AJ., Wales J., Nielsen S. Mortality rates in patients with Anorexia Nervosa and other eating disorders. Archives of General Psychiatry 2011; 68(7): 724-731.
6.       Sullivan PF. Mortality in anorexia nervosa. American Journal of Psychiatry 1995; 152(7):1073-4.
7.       Steinhausen HC. Treatment and outcome of adolescent anorexia nervosa. Hormone Research 1995; 43:168-170.

8.       Keel PK., Mitchell JE. Outcome in bulimia nervosa. American Journal of Psychiatry 1997; 154:313-321.
9.       National Eating Disorder Association. National Eating Disorder Awareness Week. New York, NY: National Eating Disorder Association.
10.    National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896). Available at:
11.    Le Grange D., Loeb K. Early identification and treatment of eating disorders: Prodrome to syndrome. Early Intervention in Psychiatry 2007; 1: 27–39.
12.    Dwyer T., Pierce JP., Hannam CD., Burke N. Evaluation of the Sydney “Quit. For life” anti-smoking campaign. Part 2. Change in smoking prevalence. Medical Journal of Australia 1986; 144(7): 344-347.
13.    Pierce JP., Macaskill P., Hill D. Long-term effectiveness of mass media led antismoking campaigns in Australia. American Journal of Public Health 1990; 80(5): 565-569.
14.    Bloom Cerkoney KA., Hart LK. The relationship between the Health Belief Model and compliance of persons with diabetes mellitus. Diabetes Care. 1980; 3(5): 594-598.
15.    Festinger, L. A theory of social comparison processes. Human Relations 1954; 7: 117–140.
16.    Grabe S., Ward LM., Hyde JS. The role of media in body image concerns among women: a meta-analysis of experimental and correlational studies. Psychological Bulletin 2008; 134(3): 460-476.
17.    Botta RA. Television images and adolescent girls’ body image disturbance. Journal of Communication 1999; 49(2): 22-41.
18.    Bair CE., Kelly NR., Serdar KL., Mazzeo SE. Does the internet function like magazines? An exploration of image-focused media, eating pathology, and body dissatisfaction. Eating Behaviors 2012; 13(4):398-401.
19.    National Eating Disorder Association. General Information. New York, NY: National Eating Disorder Association.
20.    Keys A., Brozek J., Henschel A., Mickelsen,O., Taylor, HL. The Biology of Human Starvation (Vol. II). Minnesota: Minnesota Press, 1950.
21.    Hagan MM., Tomaka J., Moss DE. Relation of Dieting in College and High School Students to Symptoms Associated with Semi-starvation. Health Psychology 2000; 5: 7.
22.    Ketley Mental Health Resource Center. Amy’s Story. Vancouver, BC: Ketley Mental Health Resource Center.
23.    National Institute of Mental Health. Eating Disorders. Rockville, MD: National Institute of Mental Health.
24.    Prokhorov AV., Perry CL., Kelder SH., Klepp KI. Lifestyle values of adolescents: results from Minnesota Heart Health Youth Program. Adolescence 1993; 28(111): 637-647.
25.    Brehm J. A Theory of psychological reactance. New York, NY: Academic, 1966.
26.    Grandpre J., Alavaro EM., Burgoon M., Miller CH., Hall JR. Adolescent reactance and anti-smoking campaigns: a theoretical approach. Health Communication 2003; 15(3): 349-366.
27.    Moore A., Sellwood W., Stirling J. Compliance and psychological reactance in schizophrenia. British Journal of Clinical Psychology 2000; 39: 287-295.
28.    Burgoon M., Alvaro E., Grandpre J., Voloudakis M. Revisiting the theory of psychological reactance: Communicating threats to attitudinal freedom. (pp. 213-232). In: Dillard JP., Pfau M. eds. The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage, 2002.
29.    University Counseling Service. Eating Disorders. Cambridge , England: University of Cambridge.
30.    Halmi KA. Perplexities of treatment resistance in eating disorders. BMC Psychiatry 2013; 13(1): 292.
31.    Goldenberg JL,, Arndt J. The implications of death for health: A terror management health model for behavioral health promotion. Psychological Review 2008; 115:1032-1053.
32.    Hansen J., Winzeler S., Topolinksi S. When death makes you smoke: A terror management perspective on the effectiveness of cigarette on-pack warnings. Journal of Experimental Social Psychology 2010; 26(1): 226-228.
33.    Arndt J., Vail K., Cox C., Goldenberg J., Piasecki T., Gibbons F. The interactive effect of mortality reminders and tobacco craving on smoking topography. Health Psychology 2013; 32(5): 525-532.
34.    Anorexia and Related Eating Disorders. Who is at risk for developing an eating disorder. Anorexia and Related Eating Disorders.
35.    De Groot JM. Women, eating disorders and self-esteem. Toronto, OR. National Eating Disorder Information Centre.
36.    Macneil L., Esposito-Smythers C., Mehlenbeck R., Weismoore J. The effects of avoidance coping and coping self-efficacy on eating disorder attitudes and behaviors: A stress-diathesis model. Eating Behavior 2012; 13(4): 293-296.
37.    Hicks J. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10: 3-5.
38.    Bauer U., Johnson T., Hopkins R., Brooks R. Changes in youth cigarette use and intentions following implementation of a tobacco control program. Journal of the American Medical Association 2000; 284(6): 723-728.
39.    Siegel M. Marketing Theory. [class lecture]. Boston University; Boston, MA; October 31, 2013.
40.    Siegel M. Advertising Theory. [class lecture]. Boston University; Boston, MA; October 24, 2013.
41.    Siegel M. Psychological Reactance Theory. [class lecture]. Boston University; Boston, MA; November 11, 2013.

42.    Silvia P. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(30): 277-284.

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