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The prevalence of individuals at high risk or with clinical eating disorders (EDs) on college campuses is high. Often, students are tasked with evaluating the urgency of their needs and knowing when to seek services, which leads to delays in seeking care. Without intervention, symptoms may worsen, resulting in adverse consequences and impaired functioning. As such, early identification and reduced symptom progression for individuals across the risk/clinical continuum of ED psychopathology is urgently needed. However, effective intervention for EDs on the college campus remains a significant challenge. Counseling centers are often understaffed and overburdened, with directors reporting an average student to counselor ratio of 1,900:11. Indeed, less than 20% of students who are screened positive for EDs report receiving treatment.2
The gap in care delivery necessitates research on ways to improve the quality and efficiency of treatment delivery for symptomatic individuals and decrease the number of individuals requiring care. We propose a population-based model, for heuristic purposes, for the identification, prevention, and treatment of EDs, to reduce the incidence and prevalence of EDs on the college campus. A population-based approach allows us to move beyond treating individuals to more broadly intervene with a population, thereby increasing real-world clinical utility of ED interventions and improving the college counseling system of care for EDs.
The model is based on foundational research to develop an online screening algorithm and integrate interventions (both preventive and clinical) for ED identification and intervention (excluding anorexia nervosa), and aims to create a synergy between individual-level changes in ED attitudes/behaviors and population-level changes in community and environmental norms around body image and healthy lifestyles. The proposed model involves partnering with college counseling centers and stakeholders to implement: (a) online screening and early identification with in-person follow-up evaluation as needed; (b) tailored, evidence-based interventions, delivered online or in person based on students’ symptoms and via a stepped care approach to conserve resources and reduce cost; (c) ongoing symptom monitoring to maintain intervention gains and triage non-responders or individuals with changes in symptoms to appropriate care; and (d) community culture and policy interventions across the socio-environment to establish community and environmental norms that promote healthful behaviors. (see Figure 1).3
Hypothetically, in a sample of 1,000 female college students, we would anticipate 68–77% would screen as low risk, 20–25% would screen positive for high risk, 2–5% for subclinical, and 1–2% for clinical EDs.3 Programs would then be delivered across the continuum of ED pathology to reduce symptom progression.3 Programs targeted for high risk and subclinical students would reduce ED symptoms, improve weight/shape concerns and drive for thinness, and increase adoption of healthier lifestyles. In this model, individuals identified as low risk or overweight/obese could be offered Staying Fit™ and high risk individuals (but not clinical cases) could be offered Student Bodies–Targeted™ or equally potent, low-cost interventions. Programs for subclinical and clinical students would utilize online or therapist-delivered guided self-help approaches (e.g., Student Bodies–Eating Disorders) before offering evidence-based, in-person interventions (e.g., interpersonal psychotherapy, cognitive-behavioral therapy) to reduce ED symptoms (see Table 1 for an overview of possible interventions and Bauer & Moessner (2013, this volume) for a review of online interventions for eating disorders treatment and prevention4).
Community culture and policy interventions can establish an environment with cultural norms that promote healthful body image, decreased acceptance of risk behaviors (e.g., binge eating, purging), reduced stigma of EDs and obesity, and enhanced well being (e.g., The Whole Image™; see Table 1). Environmental changes to the quality and availability of food and activity choices on campus can help to make the healthy lifestyle choice the default choice.
This model has potential to achieve the goal of reducing incidence and prevalence of EDs, but we have identified several areas where further evaluation and research is needed.
Population-based models aim to improve treatment delivery for symptomatic individuals and decrease the number of individuals requiring care. The proposed model has the potential to increase early intervention, reduce costs, and maximize capacity to serve the entire student body, resulting in improvements in students’ overall health and well being, self image, academic performance, and quality of life. Although there is preliminary support for this approach, a programmatic line of research to better inform model implementation including long-term effectiveness and cost-effectiveness is needed. Successful implementation has potential for rapid dissemination to reach the 20 million students enrolled in US colleges and universities.
Supported by: R01 MH095748 from the National Institute of Mental Health, R01 MH064153 from the National Institute of Mental Health; R01 MH059303 from the National Institute of Mental Health; R01 MH081125 from the National Institute of Mental Health; T32 HL007456 from the National Heart, Lung, and Blood Institute; and K24 MH070446 from the National Institute of Mental Health.
The authors thank Andrea Kass, Heather Waldron, and Alison Yee for assistance with manuscript preparation, and Andrea Kass, Megan Jones, and Mickey Trockel for assistance with model development and formative evaluation.