Issue 41 | Prevention and Protective Factors

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NEDC e-Bulletin

Issue 41

Editor's Note:

Welcome to the forty-first edition of the NEDC e-Bulletin. Protective factors for eating disorders is a relatively new area of research, so this month we explore current research on the role of peers in eating disorders resilience and seek expert advice from Prof. Susan Paxton. We also shed light on the importance of media literacy in the prevention of eating disorders.

If you are interested in collaborating with the NEDC, we encourage you to join and become an NEDC member.


  1. Peers, Prevention and Eating Disorders
  2. Interview with Professor Susan Paxton
  3. Q and A: What is Media Literacy and Why is it Important?
  4. Resource:
  5. Two Weeks until the 2016 NEDC Members' Meeting

Peers, Prevention and Eating Disorders

Prevention Models

Illness prevention programs typically occur across a spectrum, from universal prevention initiatives that are delivered to general communities or entire populations, to selective programs targeted at groups who are more at risk of developing illness (NEDC, 2010). Prevention programs reduce the incidence of disease by moderating risk factors, enhancing protective factors and/or reducing early warning signs (NEDC, 2010). Recently the direction of preventative initiatives for eating disorders has moved away from providing information about eating disorders, to adopting a health promotion framework that includes cognitive dissonance and media literacy approaches. Despite these developments, there is limited research investigating the role that peers can play in the prevention of eating disorders. What research is available has typically focused on the mechanisms through which peer groups contribute to the development of eating pathologies, with only hypothetical propositions regarding how these findings can translate into protective factors.

The Significance of Peer Environments

Peers are an important source of influence, especially during transitional periods such as the transition into adulthood (Keel, Forney, Brown & Heatherton, 2013). Rayner, Schniering, Rapee, Taylor & Hutchinson (2013) note that peer relationships are a crucial aspect of adolescent life that contribute to the development of adolescents’ sense of self during a period of rapid physical, cognitive and emotional change. Peer groups and friendships can provide a range of benefits to mental/psychological health such as increased self-esteem, emotional and social support and a sense of belonging, however they can also be influential in the adoption of risky and harmful attitudes and behaviours, such as poor body image and eating disturbances (Rayner et al., 2013). Thus adolescence is an important period in for the investigation of the role of peers in the uptake of health risk behaviours, such as disordered eating.

Peers and Eating Disorders

Research finds that adolescents and young adults tend to resemble their friends in terms of body dissatisfaction (Keel et al., 2013; Rayner et al., 2013; Stice, 1998;) and disordered eating behaviour (Eisenberg & Neumark-Sztainer, 2010; Forney et al., 2012; Rayner et al., 2013; Stice, 1998).

Shomaker & Furman (2009) and Forney et al. (2013) for example, both found that friends’ comments on weight and body shape have a significant, positive association with eating pathology in adolescent males and females. That is, a higher frequency of comments made by friends about body weight and shape was correlated with higher eating pathology scores for both sexes (Forney et al., 2013). Similarly, earlier studies looking at the influence of peer groups on bulimic symptoms have found that peer modelling of the thin ideal and abnormal eating behaviour is related to bulimic pathology including the onset of binge eating and purging (Chiodo & Latimer, 1983; Stice, 1998). This similarity in behaviour between friends and peer groups is known as ‘homophily’ (Rayner et al., 2013) and can be explained using two psychological theories; selection theory and socialization theory.

Selection theory describes the tendency for friendships and peer relationships to develop between individuals with pre-existing similarities (Kandel, 1978). In the case of Rayner et al. (2013) and Forney et al. (2013) it was found that individuals who experience high levels of disordered eating and body dissatisfaction were more likely to select peers who make frequent comments, draw out more comments from their peers, and/or to be more aware of comments made by their peers about eating and weight. That is, that individuals with disordered eating patterns were more likely to seek out peers who share and voice these concerns (Forney et al., 2013; Rayner et al., 2013).

Socialization theory states that similar behaviour among peer groups is encouraged through the processes of social reinforcement and modelling (Kandel, 1980). Social reinforcement refers to the process in which people internalize definitions and display behaviours and values that are approved of by significant others (Kandel, 1980). In the context of eating disorders, social reinforcement can occur when the comments and actions of others support or promote an internalization of the thin-ideal and body dissatisfaction. These factors are thought to result in dietary restraint and negative affect, increasing the likelihood of the development of eating pathologies (Rayner et al., 2013). Indeed Stice (1998) found that family and peer social reinforcement of the thin ideal was positively correlated with bulimic symptoms. Social reinforcement of the thin ideal may also occur through criticisms of weight and/or body shape, for example Rayner et al. (2013), encouragement to diet, and exposure to media containing thin-deal images (Stice, 1998).

Modelling (or imitation) on the other hand, refers to the process whereby individuals directly copy the behaviour displayed by others (Bandura, 1969). In the context of eating disorders, individuals may be more likely to restrict and/or fast if their friends are restricting and/or fasting. This modelling effect was demonstrated in studies by Keel et al. (2013) and Nuemark-Sztainer, Haines, Story, Sherwood & van der Berg (2007) who both found that peer dieting and perceptions of peer dieting predicted the increase of disordered eating in adolescents. Other eating pathologies including binge eating, pre-occupation with body dimensions, or vomiting can also be modelled.

Long-term Influence of Disordered Eating

Interestingly, the impact that peer groups can have on body image and associated eating behaviour appears to have lasting effects into adulthood. Eisenberg and Neumark-Sztainer (2010) for example, found that both female and male adolescents, who perceived their friends as being involved in frequent dieting, were more likely to report chronic dieting, extreme weight control behaviours and binge eating five years later. Female adolescents who reported that their friends dieted ‘very much’ at the beginning of the study were twice as likely to be chronic dieters themselves five years later, compared to females who reported that their friends did not diet at the beginning of the study. Similarly, male adolescents who perceived their friends to be heavily involved with dieting were nearly four times more likely to engage in extreme weight control behaviours five years later (Eisenberg & Neumark-Sztainer, 2010). Keel et al. (2013) claim that long-term effects of peer dieting and concerns about body image are unusual given that during young adulthood, changes in life roles such as becoming a husband or wife and a mother or father, typically predict decreases in disordered eating by strengthening alternative forms of identity.

Implications for the Role of Peers in Prevention Programs

The moderating effects that peers have on body image concerns and eating behaviours of young people may partly explain why peer-led eating disorder prevention programs can be just as effective as prevention programs led by experts, particularly those that are selective in their design (Forney et al. 2012). This is because peer-led interventions enact a healthy change in peer context that can sever the tie between body dissatisfaction and disordered eating behaviours. The results of the studies discussed above also suggest that reducing or eliminating dieting behaviours in peer groups might prevent the uptake of disordered eating behaviours among adolescents (Eisenberg & Neumark-Sztainer, 2010). Indeed research looking at the benefit of peer support for other mental illnesses such as depression and schizophrenia (Davidson, Chinman, Sells & Rowe, 2006) finds that peers can play an instrumental role in the prevention and treatment of mental health problems. Despite this, however, the literature on the role that peers can play in preventing the development of eating disorders, specifically, is scarce and requires further development.


Bandura, A. (1969). Social-learning theory of identificatory processes. In D.A. Goslin (ed.) Handbook of socialization theory and research (pp. 213 – 262). Chicago: Rand McNally.

Chiodo, J. & Latimer, P.R. (1983). Vomiting as a learned weight-control technique in bulimia. Journal of Behavior Therapy and Experimental Psychiatry, 14: 131 – 135.

Davidson, L., Chinman, M. Sells, D. & Rowe, M. (2006). Peer support among adults with serious mental illness: A report from the field. Schizophrenia Bulletin, 32: 443 – 450.

Eisenberg, M.E. & Neumark-Sztainer, D. (2010). Friends’ dieting and disordered eating behaviours among adolescents five years later: Findings from project EAT. Journal of Adolescent Health, 14: 67 – 73.

Forney, J.K., Hollan, L.A., Keel, P.K. (2012). Influence of peer context on the relationship between body dissatisfaction and eating pathology in women and men. International Journal of Eating Disorders, 45: 982 – 989.

Kandel, D.B. (1978). Homophily, selection and socialization in adolescent friendships. American Journal of Sociology, 84: 427 – 436.

Kandel, D.B. (1980). Drug and drinking behaviour among youth. Annual Review of Sociology, 6: 235 – 285.

Keel, P.K., Forney, K.J., Brown, T.A. & Heatherton, T.F. (2013). Influence of college peers on disordered eating in women and men at 10 year follow up. Journal of Abnormal Psychology, 122(1): 105 – 110.

NEDC. (2010). Eating Disorders Prevention, Treatment & Management: An Evidence Review. Crows Nest, Sydney: Author.

Neumark-Sztainer, D.R., Haines, J.I., Story, M.T., Sherwood, N.E. & van der Berg, P.A. (2007). Shred risk and protective factors for overweight and disordered eating in adolescents. American Journal of Preventative Medicine, 33: 359 – 369.

Rayner, K.E., Schniering, C.A., Rapee, R.M., Taylor, A. & Hutchinson, D.M. (2013). Adolescent girls friendship networks, body dissatisfaction, and disordered eating: Examining selection and socialization processes. Journal of Abnormal Psychology, 122(1): 93 – 104.

Schomaker, L.B. & Furman, W. (2009). Interpersonal influences on late adolescent girls and boys disordered eating. Eating Behaviour, 10: 97 – 106.

Stice, E. (1998). Modelling of eating pathology and social reinforcement of the thin-ideal predict onset of bulimic symptoms. Behaviour Research and Therapy, 36: 931 – 944.

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Interview with Professor Susan Paxton

We spoke with Professor Susan Paxton to seek expert advice on eating disorders protective factors. Susan is a professor in the School of Psychological Science at La Trobe University Melbourne with a longstanding interest in body image, disordered eating and clinical eating disorders. She has been involved with the NEDC since its inception and is a past president of the Australian and New Zealand Academy for Eating Disorders (ANZAED) and a past President of the Academy of Eating Disorders. Susan is committed to ensuring the translation of research into practice and supports public health initiatives to facilitate the prevention and early intervention of eating disorders.

Eating disorders are increasingly prevalent in Australia. What do you think may be contributing to this rise?

It is hard to gain a clear picture of the epidemiology of eating disorders in Australia as there are few recent population studies and, unfortunately, effective assessment of eating disorders is often omitted in mental health surveys. However, it is likely that there is an increase in the prevalence of Other Specified Feeding and Eating Disorders (OSFED). These are not less serious eating disorders than Anorexia Nervosa and Bulimia Nervosa, but are eating disorders that don’t fit ‘neatly’ into other diagnoses. As with all eating disorders, there is no single cause, and genetic, temperament and socio-environmental factors are likely to be involved. It is possible that changes in socio-environmental factors, perhaps in interaction with genetic factors, may contribute to an increased prevalence of eating disorders. In relation to these environmental factors, appearance pressures on both males and females remains very strong. Appearance based social media may create an increased pressure to conform to appearance ideals in young women. In addition, we live in an environment in which ready availability of food and sedentary lifestyles promote weight gain. These factors most likely result in increased weight and shape concerns and use of extreme weight control behaviours, risk factors for the development of eating disorders.

High self-esteem has been recognised in research as a protective factor against eating disorders. From your experience, how can environments such as schools, workplaces and homes promote positive self-esteem?

Specific public health programs to build self-esteem have generally not had great success. However, on an individual level, it is highly likely that if a young person is encouraged to value themselves for their personal qualities, rather than appearance related qualities this is likely to help build resilience. In addition, it is likely that teasing of any kind, but especially related to appearance is likely to undermine self-esteem.

What type of social skills and social support structures help prevent the onset of an eating disorder?

It is important to note that although we have identified some ways that are potentially helpful in reducing risk factors and thereby should reduce the development of eating disorders, there is little data to show that we can consistently prevent the onset of an eating disorder at this time. The development of social skills within socially supportive environments is likely to protect against a range of mental health problems. In addition, strong friendship environments which are not appearance-focused and in which a person feel valued for themselves protect against the development of risk factors for eating disorders.

How can media literacy assist in protecting an individual from developing an eating disorder?

Media literacy has been defined as the ability to access, analyse, evaluate and understand media. It has been suggested that actively responding to media images using critical examination and analysis reduces the degree to which media exposure contributes to body dissatisfaction. Media literacy can enable images to be perceived as inappropriate for appearance related comparisons and less acceptable as standards of beauty to be internalised. This notion is supported by recent research suggests that actively responding to media images using critical examination and analysis is associated with more positive body image. In addition, a number of school-based interventions designed to increase appearance-related media literacy have been shown to reduce risk factors for body dissatisfaction and eating disorders.

Parents and families play a pivotal role in the development of young people. What can parents and families do to help protect children/ adolescents from disordered eating behaviours?

This is an interesting question to which there isn’t a clear-cut answer. Families can play a central role in providing a non-judgemental appearance environment in which their children feel valued for themselves and in which neither appearance concerns nor weight bias attitudes are modelled. However, young people are inevitably exposed to a range of media and peer influences over which families have little control and despite best intentions, parents may not be able to protect their children against these influences.

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Q and A: What is Media Literacy and Why is it Important?

By Danni Rowlands - Education Manager, The Butterfly Foundation

The 21st century is a time where we are bombarded, more so than ever before, with perfect, manipulated, filtered and digitally enhanced images. One of the consequences of this intense exposure to media is that many people, of all ages and genders, are in full pursuit of these beauty and appearance ideals. There has never been a greater need for media literacy education than now.

A common misconception is that media causes eating disorders. This is not true and to suggest it trivialises the complexity of how an eating disorder develops. However, as supported by research, being exposed to the beauty and appearance ideals presented in the media can increase body dissatisfaction, encourage weight loss practices and can increase the internalisation of the thin ideal, all of which are known modifiable risk factors of eating disorders. What research also confirms is that these factors can positively be addressed with evidence based and evaluated media literacy programs.

When we use the term ‘Media Literacy’ we are referring to someone’s ability to critically access, analyse, evaluate and create media. Someone who is media literate will also be able to better understand and in turn challenge the often complex messages concealed within the many media mediums; television, magazines, books, music and music videos, video games, the internet and social media.

This is particularly important for our body image, our eating behaviours and our values around weight, shape and appearance. Effective media literacy education empowers the development of critical thinking that supports, particularly young people, to:

  • Understand the role media plays in shaping our society views on beauty, health and appearance
  • Identify how marketing and advertising works and the persuasive techniques used
  • Recognise the bias, misinformation and the ways they can be manipulated
  • Develop media messages that are positive and helpful
  • Become an advocate for media justice
  • Apply critical thinking to a wide range of issues.

Media literacy provides educators and those working with young people an incredibly enjoyable, relatable and effective platform to address challenging topics in a positive and helpful way. It is recommended that educators or those working with young people refer to existing evidence based and evaluated programs.

Media literacy can be extended and incorporated well beyond a classroom or youth setting. People, of all ages, in other environments such as the home, peer/friendship groups and workplace can benefit when media messaging is challenged.

More Information

Mindframe have developed guidelines to assist professionals in effectively reporting on and communicating about mental health. These guidelines are also beneficial for those wishing to share their stories in a safe and effective way.

To read more, click here.

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A plethora of research indicates that individuals, particularly young people, access the internet as an initial reference for information on Mental Health. In light of this, the NEDC have developed an interactive online platform to assist individuals in accessing evidence-based information about eating disorders and advice on help seeking. provides guidance on challenging topics such as; understanding when there may be something wrong, how to speak to a loved one who has an eating disorder, and where to seek support for treatment and recovery.

With reference to the youth generated user experience guidelines and goals from the NEDC’s Eating Disorders & Online Resources for Young People report, this resource has been designed to be relevant and engaging to people who are either at risk of or experiencing an eating disorder or who want to access online resources to help a friend or family member.

You can explore this resource at:

Who can use this resource?
  • General Practititoners
  • Families/ Carers
  • Teachers
  • School Counsellors
  • People at risk of/ or experiencing an eating disorder

If you are interested in finding out more about how to implement this resource into your workplace or home environment, please email the NEDC.

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Two Weeks until the 2016 NEDC Members' Meeting

The 2016 NEDC Members' Meeting is fast approaching!

The National Eating Disorders Collaboration are looking forward to their 2016 NEDC Members’ Meeting to be held on Friday 17th June 2016 at the Royal Brisbane and Women’s Hospital, Brisbane QLD. This is a free forum showcasing the collective impact of knowledge building and research in eating disorders.

Members’ Meetings are held by the NEDC, to enable our diverse and invaluable membership to come together, share ideas and discuss current evidence-based knowledge and initiatives relating to eating disorders. This year’s forum will follow the theme of ‘Where to Next?’ in the context of eating disorders research, prevention, treatment and recovery. The Meeting presents opportunities for professional development, collaboration, knowledge-sharing and contribution.

We are pleased to have secured two Keynote Speakers for the event:

  • Mrs. Lucinda Brogden, Mental Health Commissioner at the National Mental Health Commission
  • Prof. Phillipa Hay, Chair of Mental Health at Western Sydney University


Visit the forum webpage for more information and online registration. Registration closes Friday 10th June.

Not a member but wish to attend? Not a problem!

Become an NEDC member by filling out our online membership form and register for the event. Membership is free!

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See also

Issue 80: Culture change in the sports system

Editor’s Note AIS-NEDC Eating Disorders in Sport training Interview with John Worsfold and video Interview with Kate Wensley and video Q&A Interview with Nikki Jeacocke Upcoming Events and training Editor’s note An essential part of NEDC’s role in building the system of care for people experiencing eating disorders is starting the conversations and taking the steps required to change the culture.

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Issue 52 | Happy Easter

NEDC e-Bulletin Editor’s Note: Wishing you all a safe and happy Easter!

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Issue 64 | Members' Meeting and Peer Work Guide

NEDC e-Bulletin Editor's Note: It is strange to reflect on the 10th anniversary NEDC Members’ Meeting 2020, held only a month ago on February 27-28 in Melbourne, with the knowledge of the drastic changes made to society due to the COVID-19 pandemic.

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Issue 21 | NEDC Resources

NEDC e-Bulletin Issue 21 | April 2014 Introduction: Welcome to the April edition of the NEDC e-Bulletin.

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