I struggle struggle struggle to explain why I worry about "prevention" work in eating disorders. I shock and upset people with this, as if I'm defending poor body image and weight stigma and bullying. I hit upon an analogy that MAY help this morning.
There is no doubt in anyone's mind, is there, that smoking isn't a great move. I am sure that no one thinks kids should start smoking, and it is obvious that smoking can and often does lead to lung cancer. Reducing smoking in the population is an important public health prevention for lung cancer.
But. Does that mean that someone with lung cancer smoked? No. Does it mean that they just need to stop smoking to treat the cancer? Does it follow that the only reason to stop smoking is to prevent lung cancer?
These latter are the mistakes I believe we are making in eating disorder language when we concentrate on preventing body image distress and disordered eating as a way to prevent eating disorders.
I would argue that the fuzziness of the distinction between unhealthy ideas and behaviors vs. mental illness would be analogous to equating smoking with lung cancer. Sure, they're related for the majority of people. No question: we need to keep trying to end smoking and we need to keep kids from starting. But equating lung cancer with smoking isn't going to work as a treatment, and isn't going to help those who have cancer from radon exposure or genetic predisposition or other triggers. When someone has lung cancer already, it doesn't matter very much what caused it. Once someone has an eating disorder although their treatment will often need to include work on disordered eating and body image those can not be the whole picture - or even most of the picture.
When someone is smoking, their health and quality of life are usually compromised even if they don't get lung cancer. Same with poor body image and disordered eating behaviors.
I'm not convinced that public health efforts to "prevent" eating disorders are effective or effective enough to matter. At this point it strikes me that there are far more direct early interventions, such as pediatricians (and parents) tracking weight concern, history of anxiety and OCD, and flagging for any failure to maintain normal growth. I wonder how many eating disorders would be caught early or even prevented if track coaches refused to schedule meets and travel that preclude eating, or if the system of weighing for wrestling was entirely revamped. What if we banned BMI report cards and lining kids up to be weighed at school in front of their peers? I'd like to see a study on rates of eating disorders being triggered and maintained in schools with anti-obesity campaigns, or in schools where "health" teachers show "Super Size Me." What if parents were coached to use safety seats, bike helmets, and family meals? What if we even just added to every childhood obesity message an equal concern for undernourishment and unhealthy dieting behaviors?
What if we're treating body image and disordered eating in the population as the greatest risk factor when it is really not, or it is really something so immutable it isn't a reasonable target? What if work to change those factors was more like trying to prevent depression by banning death or talk of death? Uh-oh, that's a whole different analogy.