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.
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