Educating Youth and Caregivers on the Severity of Eating Disorders

This is the research paper that I wrote for my Global Family Resource Management course. Throughout continuing my higher education, I integrate my passion for eating disorder recovery / treatment / protective factors into all of my course work.

Enjoy!

Introduction

       Eating disorders are the most deadly mental illness in the United States and our society is withholding the greatest tool in family resource management: failing to provide adequate education on this topic to children and their caregivers (Insel, 2012). The National Council of Family Relations (NCFR) states that family resource management is the way families utilize their resources – time, materials, community, money, and energy- in order for each member to perform at their greatest potential. Children and adults are in need of education around warning signs, importance of self-esteem, and long-term effects of eating disorders in order for families to remain emotionally accountable for the mental wellness of their community. With education comes increased dialogue; and with increased dialogue comes the ability to breakdown the stigma associated with eating disorders (Mahoney, 2019). Biological, psychological, and social components create a toxic cocktail of intrusive thoughts that develop into disordered eating behaviors and mental illness (NEDA, 2018). These three components can be identified in various parts of our society as described by the Ecological Systems Theory. This theory will assist in outlining existing barriers and tangible solutions for educating the youth and caregivers on eating disorders in our culture.

Ecological Systems Theory

The Ecological Systems Theory observes the way that an individual interacts with, and is affected by, the multiple aspects of the culture in which they are raised (Bronfenbrenner, 1977). The most intimate system is described as the microsystem: composed of family members, school peers, and teachers (Bronfenbrenner, 1977). These three groups are central in the development of an individual and are central groups that require the education of eating disorders. If family dialogue around body image is allowed, this is likely to influence the way that the child discusses their own, and their peer’s bodies. Similarly, if a child overhears peers or teachers discussing bodies, the data will innocently absorbed. These centralized group expressions of body image are crucial in the development of the child’s own emotions toward viewing the human body with a critical eye.

When a family is deciding how to best utilize their resources, it is necessary to identify the way that these groups in the microsystem interact with one another. This process of interaction is the activity that takes place in the mesosystem level of the Ecological Systems Theory (Bronfenbrenner, 1977). Involving the community in an educational based event around the triggers to eating disorders is a fundamental step in creating a trusting and open conversation around mental illness. Securing the materials, funding, and professionals in the area are all resources that a group can work together in able to provide the knowledge to all families in order to strengthen the collective growth. Involving children, caregivers, and educators in a learning experience establishes a standard to hold everyone accountable to. Beyond the more immediate, controllable environments, lay an overarching system.

The exosystem reaches out into areas that may be harder to control standards in: social and mass media, parental workplace, and services offered to community members (Bronfenbrenner, 1977). Media is loosely regulated, and overwhelmingly consumed by individuals of all ages. Utilizing the family’s resources of time, energy, and materials, is a way that a family can describe advertising and the way that imaging is manipulated throughout the media. Allowing for all members of the family to be reminded of the unrealistic standards of shape, size, and beauty that are portrayed. The workplace and community based services can be hubs for individuals to discuss their latest diet, be counting/comparing the steps on their fitness trackers, or be offering opportunities for families to lose weight, specifically targeted at the youth. Increasing exposure to these diet-culture based behaviors can infect intelligent minds and without notice, trickle into conversations that exist in the mesosystem and microsystem. The focus on eating, eating disorders, beauty standards, and diet-focused living stem from a system larger than the micro, meso, and exosystem.

Cultural standards, beliefs, and laws are described as the macrosystem (Bronfenbrenner, 1977). A family’s available resources may be influenced by their cultural identity, which will also set the universal standard for perceived ideal body shape and size. Being aware of, and bringing attention to, these various factors that set standards when educating the communities is crucial. Fasting and other restrictive diet based beliefs are rooted in culture, which would be understood in a different caliber when discussing how these standards may be interpreted through a different culture’s lens. Education through awareness of the rich cultural beliefs that make up a community is a vital role in creating dialogue around eating, eating disorders, and body standards. The chronosystem, how time and history impact the evolution of behaviors, is similar to the macrosystem in the way that it must be interpreted and processed in order to break down the education (Bronfenbrenner, 1977). Eating disorders and education about them are ever progressing and have been identified in different ways throughout the past decades. In order to establish a comprehensive and effective education around them, an individual must be up to date on the most recent research and data that is available. Trends in media and current social culture will likely be influential on the changes that come with transition in time. These changes are likely to influence the development of eating disorders in the adolescent population.

Eating Disorders in the Adolescent Population

Eating disorders are of the top three most common disorders found in adolescents today: often becoming a chronic condition that interferes with the child’s life and activities (Herpertz-Dahlmann, 2015). The most common disorders include anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS) (Smink, van Hoeken, & Hoek, 2012).  Anorexia nervosa presents with a substantially low body weight that is accompanied by an exaggerated fear of weight gain and false perception of weight (Mayo Clinic, 2018). Individuals who struggle with anorexia associate their self worth with the thinness of their body, which can lead them to engaging in life-threatening behaviors to lose weight (Mayo Clinic, 2018). Individuals who struggle with bulimia nervosa may engage in behaviors such as binging- eating in excess without control-followed by a method of ridding the body of calories (Mayo Clinic, 2018). Engaging with behaviors such as purging, laxative abuse, excessive exercise, and periods of strict dieting are common ways that individuals try to compensate for binging episodes (Mayo Clinic, 2018). Eating disorders not otherwise specified was a term created to diagnose individuals that engage in behaviors that are present in both anorexia nervosa and bulimia nervosa (NEDA, 2018). Eating disorders are illness that harness control and are widely used as coping mechanisms to events that are occuring within their microsystem and mesosystem.

With the prevalence of the increasing number of adolescents being diagnosed and showing signs of disordered behaviors, professionals who work with this population - and caregivers - need to be conscious of how to best treat these individuals (Herpertz-Dahlmann, 2015). The average onset for eating disorders is now at 12-13 years old: around the same time that a child’s body is starting to develop through puberty (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). With the latter-end of the onset scale being around age 19, these developmental years where bodies and minds are growing rapidly, centralized attention and education should be monitored (Golden, et al., 2003). Caregivers and professionals that are interacting with this population are detrimental in noticing the warning signs and developing a treatment plan in order for the child to have the greatest success in managing this disorder (Golden, et al., 2003).

Warning signs of eating disorders can not always be noticed by assessing the way that a body looks. These signs may look like a range of physical, emotional, and behavioral actions that vary from the child’s normal behavior (National Eating Disorders Association, 2016). Physical changes may look like sudden weight gain/loss/fluctuation, constantly feeling cold and tired, and brittle skin and hair follicles (National Eating Disorders Association, 2016). Physical conditions may be more difficult to connect to a disorder, because varying disorders display different physical conditions. Emotional changes may be a critical way that caregivers and educators can identify the possibility of eating disorder warning signs. Prominent temperament traits of individuals that are susceptible to developing an eating disorder include individuals who strive for perfection, become less involved with activities they once enjoyed, and a heightened sense of awareness around bodies and food (National Eating Disorders Association, 2016). The emotional ranges are varied, but seemingly all are striving for levels of control and identifying the self. In conjunction with the emotional changes, behavioral actions are likely to be displayed stemming from the emotional source. Behavioral changes can be noted by developing rituals and forms of rules around mealtimes and with food, isolating themselves during meal-times or denying hunger, and creating compulsive actions that often distract from what is being avoided (National Eating Disorders Association, 2016).

Social Media Influence on Eating Disorders

The exosystem of individuals in the United States provides an outline of the ideal body image and what is considered beautiful. Created, curated, and distributed; the media is available for consumption at any moment. And now more than ever with the availability of technology and social media applications (Rojas, 2014). With the development of the internet, came the development of websites that specifically targeted and encouraged eating disorder behaviors (Golden, et al., 2003). These websites served as a dark example of what defines education around eating disorders. The “pro” websites educated site visitors on how to engage with restricting food intake, how to rid the body of food, and other harmful methods of body maltreatment (Golden, et al., 2003). These websites did not heavily focus on the medical side of the illnesses and rather enhanced them in a lifestyle choice light, likely attracting a wider audience (Golden, et al., 2003). With the introduction of social media, “pro” sites may not be as targeted, as users have the availability to search keywords on their applications to receive such information.

Images that promote and encourage being thin, known as thinspiration, can be found across social media platforms from Instagram to Pinterest (Ghaznavi & Taylor, 2015). Images that display quotes that influence restricting food intake such as “Nothing tastes as good as skinny feels” weave in and out of media feeds that can infiltrate the mind of the savviest user (Rojas, 2014). Thinspiration can come not only in the form of quotations, but in images that sexually enhance the family body (Ghaznavi & Taylor, 2015). This content is composed of exposed collarbones, flat and toned stomachs, and thin thighs, providing the user with the information that if one has this body they will be desirable (Ghaznavi & Taylor, 2015). Integrating the thin female body and suggestive content can be damaging to adolescents of any gender identity as they are presented with image that objectifies the body (Ghaznavi & Taylor, 2015).

The presence of pro-eating disorder sites, thinspiration, and images that equate the thin body with sexual desire are all toxic information that is readily available to adolescents through media use. Consistent use of social media has a direct correlation to decreasing body image in adolescent women, noting the more time that users spend on the sites, the lower their self esteem drops (Fardouly & Vartanian, 2016). The most powerful action that is taken amongst the youth as they spend their time on social media is the action of comparing themselves with images that are presented (Fardouly & Vartanian, 2016). Comparison becomes more difficult to navigate as more images are being edited to shrink, lift, tighten from individuals fingertips (Kleemans, Daalmans, Carbaat, & Anschutz 2016). Individuals are consistently drawn to retouched images and often find it difficult to determine acts of retouching on bodies, however, filters and lighting techniques are more easily noted (Kleemans, Daalmans, Carbaat, & Anschutz, 2016). Direct correlation between viewing retouched images- even when consumers were told they were observing an edited photo- and negative self body image are found (Kleemans, Daalmans, Carbaat, & Anschutz, 2016).

The correlation between comparison on media and decreased body image have been documented, but not all who experience negative body image will develop eating disorders (Rojas, 2014). A high number of individuals will not meet diagnosable criteria, but will likely fall onto a continuum that struggle with chronically low self-esteem. While media is an influential part of the culture, it is stated that consumption of it will not be sole reason that an individual develops an eating disorder: there are biological, social, and environmental factors as well (NEDA, 2018). With the infiltration of media in different forms, the education around eating disorders to youth and caregivers will vary in some dimensions than it has in the past decades.

How Past Decades Educated on Eating Disorders

From the 1970’s to the early 2000’s, the amount of eating disorders documented rose dramatically, reaching 5% of the population in the United States (Tenore, 2001). Once believed to only affect specific socioeconomic classes and genders - affluent white women - the stereotypes were broken down with the exposure of individuals varying in races, ages, and socioeconomic standings developing disorders (Tenore, 2001). Social media may not have been introduced, but our society has long been influenced by various other types of media throughout the years. Notably, body image ideals shifting from the 1940’s/50’s boasting a curvy Marilyn Monroe, to “Twiggy” in the 1960’s as a representation of the now desirable, super-thin body (Tenore, 2001). Educational information about the ever changing body expectations came, devastatingly, with the death of Karen Carpenter in 1983 due to complications of her anorexia nervosa (Tenore, 2001). After the death, eating disorders and the research conducted began to become more focalized around the severity, leading to standards for education to be implemented (Tenore, 2001).  

When viewing eating disorder education from a chronosystem view, looking into the 1980’s, there were implementations made with the scarce knowledge that was available. The Food and Agriculture Organization of the United Nations was able to craft an educational guide to be implemented in school systems to combat the rising rates of documented eating disorders (Levine, 1987). Educational documents that were curated held information regarding sociocultural influences on the disorders, key characteristics of popular behaviors, and an outline of how to discuss eating disorders and recognize them in the classroom (Levine, 1987). Referral programs and guides were also made available to the schools that were to receive the instructional guide (Levine, 1987). This guide was found to be rather comprehensive in the amount of information that it provided. Throughout the past decades, materials, like the ones made following Karen Carpenter’s death,  have been provided in hopes that educational materials would help families managing their resources.

Medical attention has become more specified and curated over the past years as there has been more discussion, awareness, and funding around the research of eating disorders (Mahoney, 2019). These medical implementations of practice have improved the quality of educational materials that are available to the public via medical and eating disorder awareness sites. However, these materials may not be introduced in a proficient timeframe: acquiring literature when a disorder has already been diagnosed instead of having the materials from an earlier date to monitor and understand behaviors with a child (Mahoney, 2019). Looking to overall transitions in education, there should be a focus on not only historical information, but the implementation of  importance of eating disorder education as the disorder continues to thrive and take more lives.

Barriers to Accessing Care Rooted in Lack of Education

There are reasons why more than 75 percent of individuals living with an eating disorder will not seek or receive care (“CBS Interview”, 2018). There is a severe lack of information distributed to individuals about what eating disorders are and that there is care available (“CBS Interview, 2018). Individuals may not know that what they are struggling with is classified as a disorder, and that there is a biological based component: without educational guidelines, this individual would be put at high risk without knowledge of support. If/when an individual becomes aware of an issue, there is a continued stigma around reaching out for help (“CBS Interview, 2018). Especially with the misconception that eating disorders are a choice when in reality they are an illness that require support and connection in order to find recovery (“CBS Interview”, 2018). Providing educational materials to the youth and caregivers directly works to eliminate these socially established barriers. Increasing the availability of information to a wider range of people-not just those who seek it out-is a key proponent in improving the understanding of eating disorders and therefore, eliminating the associated stigmas. The range of individuals who are receiving education need to be inclusive and understanding of the cultural backgrounds of many of the families residing in the United States.

Due to culturally induced barriers, specific demographics may have a more difficult time finding applicable information about their experience. There is a concern around the lack of bilingual care available for eating disorders and the lack of information that Latino individuals receive (Reyes-Rodriguez, Ramirez, Davis, Patrice, & Bulik, 2013). Emotional barriers around stigmatization and fear of being misunderstood within their families are profound limitations on receiving access to education within these communities as well (Reyes-Rodriguez, Ramirez, Davis, Patrice, & Bulik, 2013). In addition to being misunderstood by their families, ethnic minorities face being undetected for mental health related issues at the hands of medical professionals (Becker, Arrindell, Perloe, Fay, & Striegel-Moore, 2009). In comparative studies, African-American women were receiving care for eating disorder behaviors at a significantly lower rate than that of white women in the same geographical area (Becker, Arrindell, Perloe, Fay, & Striegel-Moore, 2009). With a mandatory disbursement of resources, the youth and caregivers of all racial and ethnic cultures will be supported and informed of the severity of these illnesses in their families. Education will liberate individuals in their ability to identify the mental health issues they are facing. And encourage the development and inclusion by the medical professionals responsible for caring for their diverse clientele.  

Establishing Eating Disorder Education Standards

        Schools foster learning in a variety of forms and throughout the last few decades, there has been an increase in the conditions – whether implicit or not- that are placed on the body, wellness, and how an individual identifies themselves (Rich, Evans, & Holroyd, 2010). Health-based programs - that are components of family resource management including materials and community based services- can offset behaviors of individuals who are at risk for developing an eating disorder (Rich, Evans, & Holroyd, 2010). An educational facility with curriculum structured around healthy or “right” based eating, exercise, and standard body size is not catering to the mental and physical wellness of all students. A system that focuses on labeling bodies – especially in groups of adolescents- and obsessions with obesity puts a focus of fear in the minds of caregivers and the youth when identifying their self (O’Dea, 2005). When initially establishing programs that deal with eating disorder behaviors, it is necessary for the professional to be intentional about the outcomes of the program.

Creating boundaries that are careful to not instill food or body fears and glorifying dieting, while at the same time not minimizing the effects of binge-eating disorder on the body are essential in production of educational events (O’Dea, 2005). In recent decades, following the trend in availability of media in the exosystem, programs have been implemented throughout a range of communities. The programs that yield the best results: youth reporting lower cases of body dissatisfaction and higher self-esteem- share a series of regulated strategies. These strategies include; involving caregivers in the practice, interactive lessons, a focus on self esteem building, and education on media practices (O’Dea, 2005). Utilizing the objective of family resource management, implementing structured programs are eating disorder education can be a way for families to integrate materials and community members into their time to increase the awareness of the importance of this issue amongst a variety of age groups. Increasing the way that members of an adolescent’s mesosystem engage with and discuss their perception of their bodies and others. Having a foundation of rules and a set of outcomes hoped to be achieved directly outlined when implementing the programs can offer guidelines to staying on the path to protective factors and education (FREED, 2019).

Solutions in Mandated Eating Disorder Education

Eating disorder education is rooted in how families manage their resources. With the implication of allocating time, energy, materials, community members, and money; caregivers, youth, and educators will be able to have a comprehensive and effective understanding of eating disorders. When creating these programs some of the barriers  identified may be not having adequate resources: but there are educational guides and materials that are available for free from eating disorder awareness based sites (NEDA, 2018). These materials are worded in a way that describes the best practices on how to identify, encourage discussion, and steps to take in acquiring further research in an approachable manner (NEDA, 2018). An educator or community representative would not need a background in eating disorder treatment education in order to successfully distribute and engage in a discussion around the topic. Additional resources for individuals who seek further knowledge are routinely provided at the end of the educational guides (NEDA, 2018). If an educator, caregiver, or community member is more interested in learning about the disorders, there are opportunities to have a professional come speak at an event.

Nonprofit and for-profit organizations specializing in eating disorders have created educational programs that send a professional to a school to speak with schools. The Foundation for Research and Education in Eating Disorders (FREED) hosts a program with a licensed professional to provide a preventative educational experience to groups of educators and adolescents with three major focuses (FREED, 2019). To increase awareness around disordered behaviors, to raise levels of protective factors in order to decrease risk, and to encourage individuals to support and reach out for support (FREED, 2019). These components of their methodology have been proven through research to yield results that document having an expert in the field lead these presentations allowed for greater levels of comfort in asking questions, an objective look at the population being addressed, and providing skills that can benefit multiple health related issues (FREED, 2019). A nonprofit in Denver, The Eating Disorder Foundation (EDF), follows a similar method to that of FREED, in that they provide a speaker to attend educational institutions and educate on the components of eating disorders. However, these presentations differ as they are presented by volunteers who offer their time and knowledge to the topic and are free of charge for the recipients (EDF, 2019). Presentations have been given at mental health focused days on high school campuses and in a psychology course in a local high school within the past few weeks (EDF, 2019). Having access in the area and free of charge can provide resources and knowledge to individuals who do  not have any frame of reference of disorders, but have been struggling. Practices like these are largely organized by schools, and a few states have begun to implement mandatory mental health education in their curriculum.

New York and Virginia have been the first states to make a mandatory law that mental health information be provided during the health classes that are provided in the schools (Lou, 2018). With an increasing number of students being diagnosed and coming forward asking for help, these states have required that information around protective factors, negative coping mechanisms, addiction and based disorders be administered in the school setting (Lou, 2018). The states practices look different in regards to the variety of the information being taught. As the districts are to consult with a mental health professional to integrate their knowledge into the class structure (Lou, 2018). These two states have made a groundbreaking entry to the discussion of mandated mental health education. And there can be more done to educate and support the youth as the numbers of teenage suicides due to mental health related disorders continue to rise (Lou, 2018).

For the youth and caregivers to be given the greatest chance at identifying warning signs and implementing protective factors to support themselves and their communities, New York, Virginia, and the remaining 48 states, need to implement mandatory training on eating disorders. The documented programs offer both paid for and free programs that can be available to communities with the allocation of a few family resources. Making time to make mental health a priority of the family doesn’t need to be a major investment: an hour long discussion can be enough to provide the family with available educational materials (FREED, 2019). A multitude of educational programs are available, however, they need to be sought out by individuals in order to bring them to communities. In order for these practices to reach individuals that may not know about the services-and need them-the programs need to be assigned as non-negotiable lessons throughout adolescent education.With a central focus on inclusion of the caregivers in interactive activities to bring these methods into home discussions as well as in the educational setting (O’Dea, 2005). These need to be implemented so that they can act as protective factors, and not reactive factors, to an individual developing an eating disorder. Incorporating eating disorder education into an event that encourages participation amongst an individual's microsystem and mesosystem, will likely influence change amongst the cultural exosystem and macrosystem.


Conclusion

Education around eating disorders should not only be available to those who seek out the information on their own. Programs will be designed to best fit the boundaries that families have regarding resource management. Families taking the time and energy to bring the awareness of a societal issue into an educational model in their communities will encourage the growth and discussion beyond into the greater systems. Addressing the known barriers and from there, creating standards and solutions of how a community can best implement practices to support the members serves as a foundation for mental wellness.

The rate of diagnosed eating disorders is continuing to rise, and while it is not likely that education will be able to influence the biological and psychological components, taking a step towards the break down of the social component is mandatory (Mahoney, 2019). Educational programs will inform the youth and caregivers on the biological and psychological components so that they are able to monitor growth and establish healthy measures of body image, self-esteem, and self-identity. Socially, the youth and caregivers are not being aided in how to best support their families and help each member reach their maximum potential when it comes  awareness around eating disorders. The creation and implementation of eating disorder focused educational events will integrate available family resources in able to make the program as influential and obtainable to the diverse family systems within in the United States.

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Lydia Rhino