mal. In a recent review, Stice (2002) concluded that there was some evidence that negative affect, perfectionism, and early menarche are potentiating factors that amplify the effects of other risk factors. He also noted that although early menarche did not emerge as a significant risk factor for eating pathology in univariate models, it did appear to interact with life stressors to predict emergence of negative affect and eating disturbances (Stice, 2002). These promising leads should be followed in future studies.

A number of factors, including perceived pressure to be thin, thin-ideal internalization, body dissatisfaction, and negative affect, have been identified as risk factors for the development of bulimic symptoms. Some studies suggest that attempted dieting is a risk factor for the development of bulimic symptoms, whereas other data indicate that actual experimentally prescribed dietary restriction is not a risk factor. It is not clear whether dysfunctional dieting, especially severe caloric restriction, is a risk factor for full-syndrome bulimia nervosa. Low self-esteem, perfectionism, early menarche, and impulsivity do not appear to be risk factors for bulimic symptoms. The conclusions from the studies of risk factors for bulimia nervosa indicate that prevention programs that target thin-ideal internalization, pressure to be thin, modeling of eating disturbances, body dissatisfaction, and negative affect may prove useful in preventing the development of bulimic symptoms. Although currently unproven, it seems logical to assume that a reduction in bulimic symptoms in a population would lead to a reduction in the incidence of full-syndrome bulimia nervosa as well.

Effective management of overweight in children and adolescents consists of diet, physical activity, and behavior change, and often requires parental participation (Goldfield, Raynor, & Epstein, 2002). Dietary change may include reduction of calorie or fat intake, or improved adherence to dietary guidelines, such as the Food Guide Pyramid (Epstein, Myers, Raynor, & Saelens, 1998). A popular approach to diet modification in youth is provided by the Stoplight Diet for Children, which classifies foods into red (stop), yellow (caution), or green (go) categories based on caloric value and nutrient density (Epstein & Squires, 1988). Typically, the initial goal is to limit intake to 1,000–1,300 calories per day, adjusted to promote a weight loss of 0.25 kg/week.

To increase physical activity, programs typically encourage structured aerobic exercise, such as swimming, jogging, or basketball, and lifestyle activity, which increases physical activity throughout the day (e.g., using the stairs rather

than escalators). Preliminary studies demonstrated that lifestyle activity was more effective than structured exercise in facilitating the maintenance of weight loss (Goldfield et al., 2002). Reducing sedentary behaviors, including watching television and playing video games, has also been shown to contribute significantly to weight management (Epstein et al., 1995).

Parental participation in treatment is critical for children and also benefits adolescents (Goldfield et al., 2002). Parents may reward changes in their child's diet or physical activity, or modify their own eating or activity habits to model healthy behaviors. Similarly, parents can limit high-fat and high-sugar foods available in the home, while increasing consumption of fruits, vegetables, and other healthy choices. One study found that using parents as the exclusive agents for their child's behavior change resulted in greater decreases in overweight than treating the child alone (Golan, Weizman, Apterm, & Fainaru, 1998).

Family-based behavioral programs reduce children's percentage of overweight by as much as 25% and produce successful weight maintenance for as long as 10 years (Goldfield & Epstein, 2002). More typical reductions in percentage overweight have ranged from 5% to 15% (Goldfield et al., 2002). Decreases in weight (or fat) have been associated with significant reductions in systolic and diastolic blood pressure, fasting serum cholesterol, triglycerides, and hyperinsulinemia, and significant increases in high-density lipoprotein serum cholesterol (Epstein et al., 1998).

A family-based behavior modification program for severe pediatric overweight (Levine, Ringham, Kalarchian, Wisniewski, & Marcus, 2001) produced an average decrease in overweight of 11% during treatment, but this reduction was not maintained approximately 8 months later. Symptoms of eating disorders were measured by the Children's Eating Attitudes Test (ChEAT), which is designed to assess attitudes toward eating and dieting behavior, perceived body image, obsessions and preoccupations with food, and dieting practices. At follow-up, preoccupation with dieting, unhealthy dieting behaviors, and concerns about being overweight decreased. Thus, neither significant weight loss nor weight regain caused an increase in eating disorder symptoms.

Epstein and colleagues evaluated an intervention in which all participants followed the standard Stoplight Diet for Children intervention (described above), and some also received problem-solving skills training (Epstein, Paluch, Saelens, Ernst, & Wilfley, 2001). Follow-up assessments, conducted 18 months after completion of treatment, indicated that percentage overweight decreased an average of 13% across conditions. Weight dissatisfaction, purging and restricting, and total symptoms of disordered eating, assessed by the Kids' Eating Disorder Survey (KEDS; Childress, Jarrell, & Brewerton, 1993), showed no significant changes over time.

A third study evaluated a cognitive-behavior modification (CBM) program that taught self-regulation and problem-solving skills and promoted lifestyle change (Braet & Van Winckel, 2000). Cognitive-behavior modification was delivered in a group, individual, or summer-camp format and was compared to a one-session advice condition. At the 4.6-year follow-up assessment, percentage overweight (which did not differ between groups) had decreased an average of 11% from baseline. None of the participants had anorexia nervosa at follow-up. Assessment with the Dutch Eating Behavior Questionnaire (DEBQ; Van Strien, Frijters, Bergers, & Defares, 1986) indicated that external eating decreased and restrained eating increased between baseline and follow-up, which indicated that the program helped children control external food stimuli and develop the restraint necessary for weight control. Emotional eating, also measured with the DEBQ, did not change. Five participants (9%) scored 1 standard deviation above the reference group mean for the bulimia subscale of the Eating Disorders Inventory, which indicates a greater risk for developing an eating disorder. However, the proportion of higher-risk participants did not appear elevated when compared with community samples of adolescents.

A 10-year follow-up study, the longest to date,

evaluated outcomes for participants enrolled in one of four weight control programs during childhood (Epstein, Myers, Raynor, & Saelens, 1998). All of the interventions were family based and used the Stoplight Diet for Children. At follow-up, percentage overweight decreased an average of 10%–20% for participants in most treatment groups, whereas participants in control groups increased their percentage overweight by as much as 12%. Four percent of participants reported that they had been treated for bulimia nervosa over the course of the 10-year follow-up, and none reported treatment for anorexia nervosa. These rates are consistent with rates from community samples.

These four studies suggest that professionally administered weight loss interventions pose minimal risks of precipitating eating disorders in overweight children and adolescents. Cross-sectional studies examining the relationship between dieting and binge eating in clinical populations support this view, as past participation in diet programs does not appear to increase the occurrence of binge eating (Berkowitz, Stunkard, & Stallings, 1993). Similarly, about half of adults with binge eating disorder report that dieting did not precede the onset of their disorder (Yanovski, 2002).

Dieting and weight loss have also been identified as precipitants to adverse emotional reactions, including depression, anxiety, and irritability (Stunkard, 1957; Stunkard & Rush, 1974). Myers, Raynor, and Epstein (1998) evaluated children's psychological status, as determined by mothers' reports on the Child Behavior Checklist (CBCL; Achenbach, 1991), while they participated in a family-based behavioral program. From baseline to 1-year follow-up, participants' percentage overweight decreased an average of 20%, and during this time, global child psychopathology decreased significantly, while global competence increased. The proportion of children who met clinical criteria for at least one behavior problem decreased from 29% at baseline to 13% at follow-up. Improvements in some aspects of psychological status, including somatic complaints and so cial competence, were positively associated with weight loss.

Levine and colleagues (2001) found significant reductions in symptoms of depression and anxiety at the end of treatment that were maintained at 8-month follow-up. Epstein and colleagues (2001) observed that total behavior problems and internalizing behavior problems (as measured by the CBCL) decreased significantly at 18-month follow-up. Twelve percent of participants reported seeking treatment for depression during the decade of the Epstein, Valoski, Wing, & McCurley (1994) follow-up, a rate that does not appear high for children who have sought professional weight reduction services (Goldsmith et al., 1992). These findings, as a whole, do not indicate that dieting has a negative effect on mood (e.g., Polivy & Herman, 1985).

Professionally administered weight control programs for overweight youth do not appear to precipitate disordered eating, a finding supported by research on the effects of dieting on binge eating behaviors in obese adults (National Task Force on the Prevention and Treatment of Obesity, 2000; Wilson, 2002). Behavioral programs that prescribed moderate caloric restriction were associated with significant decreases in binge eating episodes in individuals with preexisting binge eating pathology. Studies that used very low–calorie diets (VLCDs) also generally reported improvements in binge eating, although one investigation reported an increase in this behavior (Telch & Agras, 1993). In reviewing the literature, the National Task Force on the Prevention and Treatment of Obesity (2000) concluded that dieting and weight loss, in overweight or obese adults, were not associated with the development of eating disorders, and that weight loss was associated with improvements in depression, anxiety, and related complications. The inclusion, in most programs, of behavior therapy to promote weight loss may have contributed to the observed improvements in mood (Wadden, Stunkard, & Liebschutz, 1988; Wadden, Stunkard, & Smoller, 1986). Long-term studies also found that weight regain, while up

setting to dieters, was not associated with significant increases in depression, anxiety, or binge eating (Foster, Wadden, Kendall, Stunkard and Vogt, 1996; National Task Force, 2000; Wilson, 2002).

Professionally administered weight loss programs for overweight children and adolescents generally do not increase symptoms of eating disorders and are associated with significant improvements in psychological status. Thus, concerns about the possible adverse effects of dieting should not deter our nation's growing number of overweight youth from pursuing sensible methods to lose weight or, at least, to prevent the progression of adiposity. A critical issue to address in future research is how to craft public health messages that are health promoting. Clearly approaches aimed at moderation (neither too much nor too little) could effectively target overweight children and youth who tend toward caloric restriction associated with eating disorders. Given the electricity and lack of clarity associated with the term dieting, other terminology should be sought that focuses on healthy portion sizes, moderation of intake, and healthy levels of physical activity.

Most studies evaluating universal prevention efforts target older students and use curricula designed to change the knowledge, beliefs, attitudes, intentions, and behaviors of individual students. Most programs promote healthy weight regulation, discourage calorie-restrictive dieting, and address ways in which body image