Evaluation of a Prevention Program to Address Body Focus and Negative Affect among Children

Disordered eating, body image concerns, and weight control behaviors in primary school aged children: A systematic review and meta-analysis of universal-selective prevention interventions

OBJECTIVE

Body image concerns and extreme weight control behaviors frequently develop in childhood indicating an important age group for the implementation of universal-selective prevention approaches. This systematic review aimed to evaluate the effect of universal-selective prevention interventions addressing disordered eating, body image concerns, and/or extreme weight control behaviors in children aged 6-12 years.

METHOD

Nine databases were searched up to April 2021. Studies were included if they delivered a universal-selective prevention intervention to children aged 6-12 years and reported outcomes relating to body image, disordered eating, or weight control behaviors. The review was conducted in line with the PRISMA Guidelines.

RESULTS

A total of 42 articles describing 39 studies included in the review, with most (n = 24; 57%) classified as neutral quality. Thirty studies implemented an eating disorder specific universal-selective program and nine implemented lifestyle interventions plus content to address disordered eating risk factors. Meta-analysis (n = 16 studies) revealed an improvement in body image-related outcomes across all studies (standardized mean difference [SMD] 0.26 [95%CI 0.01, 0.51]); with a high level of heterogeneity (Î2 = 89.9%; p < .01). Meta-analysis according to gender revealed a general improvement in body image-related outcomes for girls (SMD 0.40 [95%CI 0.07, 0.73]), but not boys (SMD 0.23 [95%CI -0.24, 0.70]).

DISCUSSION

By investigating child, parental and teaching interventions and including outcomes such as weight control and disordered eating behaviors, a trend toward a reduction in eating disorder risk factors was observed, particularly body image-related outomes in girls. Future directions include embedded disordered eating prevention materials within existing lifestyle interventions and inclusion of more diverse samples.

The Effects of Self-Compassion and Self-Esteem Writing Interventions on Women’s Valuation of Weight Management Goals, Body Appreciation, and Eating Behaviors

In this study, we examined the effects of body-focused daily self-compassion and self-esteem expressive writing activities on women’s valuation of weight management goals, body appreciation, bulimic symptoms, and healthy and unhealthy eating behaviors. One-hundred twenty-six women, recruited from the community and a university participant pool ( Mage = 29.3, SD = 13.6), were randomly allocated to one of the three writing conditions: body-focused self-compassion, body-focused self-esteem, or control. Women reflected on a moment within the past 24 hours that made them feel self-conscious about their bodies, eating, or exercise habits (self-compassion and self-esteem conditions) or on a particular situation or feeling that occurred in the past 24 hours (control condition) for 4–7 days. At post-treatment (24 hours after the intervention), women in the self-compassion group demonstrated decreased bulimic symptoms, while women in the self-esteem and control conditions did not. Furthermore, clinically significant changes in bulimic symptoms were associated with being in the self-compassion condition but not in the self-esteem or control conditions. Results suggest that body-focused writing interventions may be more effective in temporarily reducing eating disorder symptoms in women if they focus on harnessing self-compassion. Additional online materials for this article are available on PWQ ’s website at http://journals.sagepub.com/doi/suppl/10.1177/03616843211013465

Comparing the efficacy of a brief self-esteem and self-compassion intervention for state body dissatisfaction and self-improvement motivation

This study explored the efficacy of reflective writing tasks for reducing state body dissatisfaction and improving self-improvement motivation. Participants (N = 153) were exposed to a threatening body image scenario, after which they reported their state body dissatisfaction. Following randomisation to one of three interventions (self-esteem, self-compassion, or positive distraction control), participants completed the state body dissatisfaction measures again along with a measure of self-improvement motivation. At post-intervention, state weight dissatisfaction and appearance dissatisfaction were significantly lower and self-improvement motivation was significantly higher in the self-compassion group than in both the self-esteem and control groups. Trait body dissatisfaction moderated the efficacy of the intervention whereby the benefit of the self-compassion intervention became evident at moderate levels of trait body dissatisfaction, and was most apparent at high levels of body dissatisfaction. Self-compassion was a robust and efficacious method through which to promote immediate improvements to bodily feelings and desire to self-improve.

The effectiveness of self-compassion and self-esteem writing tasks in reducing body image concerns

This study investigated whether single-session self-compassion and self-esteem writing tasks ameliorate the body image concerns evoked by a negative body image induction. Ninety-six female university students aged 17-25 years (M_age=19.45, SD=1.84) were randomly assigned to one of three writing treatment groups: self-compassion, self-esteem, or control. After reading a negative body image scenario, participants completed scales measuring state body appreciation, body satisfaction, and appearance anxiety. They then undertook the assigned writing task, and completed the three measures again, both immediately post-treatment and at 2-week follow-up. The self-compassion writing group showed higher post-treatment body appreciation than the self-esteem and control groups, and higher body appreciation than the control group at follow-up. At post-treatment and follow-up, self-compassion and self-esteem writing showed higher body satisfaction than the control. The groups did not differ on appearance anxiety. Writing-based interventions, especially those that enhance self-compassion, may help alleviate certain body image concerns.

Healthy me: A gender-specific program to address body image concerns and risk factors among preadolescents

This study evaluated a gender-specific, school-based program to promote positive body image and address risk factors for body dissatisfaction. In total, 652 children aged 8-10 years participated (335 intervention, 317 wait-list control). Children participated in four 60min sessions and a recap session at three months post-intervention. The broad content areas were body image, peer relationships, media awareness, healthy diet, and exercise. The activities and examples for each session were gender specific. The recap session was an overview of the four sessions. Assessment measures were completed at pre-intervention, post-intervention, and after the recap. Boys and girls in the intervention demonstrated higher muscle esteem and vegetable intake at post-intervention, compared to children in the control condition. Boys and girls demonstrated higher body esteem, muscle esteem and fruit and vegetable intake at the recap. Boys in the intervention demonstrated less investment in masculine gender norms at post-intervention and at recap.

The Development of Body Image and Weight Bias in Childhood

Negative body image attitudes are related to the onset of disordered eating, poor self-esteem, general mental health problems, and obesity. In this chapter, we will review the nature of body image attitudes in girls and boys in early (approximately 3-7 years old) and later childhood (approximately 8-11 years old). The body image attitudes explored in this chapter include body image attitudes related to the self, with a focus on body dissatisfaction, and body image attitudes related to others, with a focus on weight bias. Issues of measurement of body image and weight bias will first be explored. In light of measurement considerations, the prevalence and predictors of body dissatisfaction and related concerns, and weight bias will be examined. The chapter will conclude with a review of promising directions in the prevention of body dissatisfaction and weight bias in children.

Prevention of eating disorders: A systematic review of randomized, controlled trials

OBJECTIVE

This systematic review evaluated the efficacy of universal, selective, and indicated eating disorder prevention.

METHOD

A systematic literature search was conducted in Medline, PsycINFO, Embase, Scopus, and the Cochrane Collaboration Library databases to January 2016. Studies were included if they were randomized, controlled trials (RCT) and tested an eating disorder prevention program. We retrieved 13 RCTs of universal prevention (N = 3,989 participants, 55% female, M age = 13.0 years), 85 RCTs of selective prevention (N = 11,949 participants, 99% female, M age = 17.6 years), and 8 RCTs of indicated prevention (N = 510 participants, 100% female, M age = 20.1 years). Meta-analysis was performed with selective prevention trials. As there were a limited number of universal and indicated trials, narrative synthesis was conducted.

RESULTS

Media literacy had the most support for universal prevention. Most universal approaches showed significant modest effects on risk factors. Dissonance-based was the best supported approach for selective prevention. Cognitive-behavior therapy (CBT), a healthy weight program, media literacy, and psychoeducation, were also effective for selective prevention and effects were maintained at follow-up. CBT was supported for indicated prevention and effects were maintained at follow-up.

DISCUSSION

The modest effects for universal prevention were likely due to floor effects. The evidence for selective prevention suggests that empirically supported approaches should be disseminated on a wider basis. Our findings suggest CBT should be offered for indicated populations. Overall, results suggest efficacy of several prevention programs for reducing risk for eating disorders, and that wider dissemination is required. © 2016 Wiley Periodicals, Inc.

A Meta-Analytic Review of Stand-Alone Interventions to Improve Body Image

Objective

Numerous stand-alone interventions to improve body image have been developed. The present review used meta-analysis to estimate the effectiveness of such interventions, and to identify the specific change techniques that lead to improvement in body image.

Methods

The inclusion criteria were that (a) the intervention was stand-alone (i.e., solely focused on improving body image), (b) a control group was used, (c) participants were randomly assigned to conditions, and (d) at least one pretest and one posttest measure of body image was taken. Effect sizes were meta-analysed and moderator analyses were conducted. A taxonomy of 48 change techniques used in interventions targeted at body image was developed; all interventions were coded using this taxonomy.

Results

The literature search identified 62 tests of interventions (N = 3,846). Interventions produced a small-to-medium improvement in body image (d₊ = 0.38), a small-to-medium reduction in beauty ideal internalisation (d₊ = -0.37), and a large reduction in social comparison tendencies (d₊ = -0.72). However, the effect size for body image was inflated by bias both within and across studies, and was reliable but of small magnitude once corrections for bias were applied. Effect sizes for the other outcomes were no longer reliable once corrections for bias were applied. Several features of the sample, intervention, and methodology moderated intervention effects. Twelve change techniques were associated with improvements in body image, and three techniques were contra-indicated.

Conclusions

The findings show that interventions engender only small improvements in body image, and underline the need for large-scale, high-quality trials in this area. The review identifies effective techniques that could be deployed in future interventions.

Do children emotionally rehearse about their body image?

This study examined the association between propensity for emotional rehearsal, body image self-perception and weight status in Chinese Hong Kong pre-adolescents. Children 8-12 years of age (n = 278) completed measurement of body mass index, body image and emotional rehearsal. Multinomial regression analyses revealed that body mass index was positively associated with body image dissatisfaction and a significant predictor of body size estimation. However, only body size underestimation was associated with lower rehearsal tendencies. The prevalence of body image dissatisfaction and body size estimation was also reported for this population. Future research is suggested for greater understanding of emotional coping in body image dissatisfaction in young children.

Depression and self-concept in girls with perception of pubertal onset

PURPOSE

Early pubertal timing in girls is associated with psychological and behavioral problems. This study aimed to evaluate the psychological features of girls who perceived breast development beginning by analyzing their depression levels and self-concept.

METHODS

From March 2007 to December 2012, 93 girls were enrolled and assigned to a pre-8 (younger than 8 years, n=43) or post-8 (8 years and older, n=50) group according to the age at onset of perceived breast development, and their height, body weight, body mass index, bone age (BA), Tanner stage, and luteinizing hormone and follicle-stimulating hormone levels were examined. We investigated their psychological state with the Korean Children's Depression Inventory (CDI) and Piers-Harris Children's Self-Concept Scale (PHCSC) to evaluate depression levels and self-concept, respectively.

RESULTS

The pre-8 group had a significantly greater height standard deviation score, (0.5±1.01 vs. 0.11±0.86, P = 0.048) and more advanced BA (2.07±1.02 years vs. 1.40±0.98 years, P = 0.004) compared to the post-8 group. There were no statistically significant intergroup differences for the CDI and PHCSC scores; however, the pre-8 group scored higher than the post-8 group in the physical appearance and attributes domain of the PHCSC (9.93±2.57 vs. 8.52±3.03, P = 0.017).

CONCLUSION

The timing of perceived breast development among girls who thought puberty to begin did not affect depression levels and self-concept. There was no correlation between Tanner stage and depression levels and self-concept despite the perception of pubertal onset. The pre-8 group had a more positive view of their physical appearance than the post-8 group.

The reporting of fidelity measures in primary prevention programmes for eating disorders in schools

OBJECTIVE

The aim of this paper was to examine the extent to which controlled trials of face-to-face school-based primary prevention for eating disorders report their strategies for maintaining fidelity.

METHOD

A systematic review located 38 articles eligible for inclusion. These studies were assessed using 18 criteria for reporting fidelity maintenance strategies based on those recommended by the Treatment Fidelity Workgroup of the National Institute of Health Behavior Change Consortium.

RESULTS

Fidelity reporting was generally poor. The studies reported between 22% and 56% of fidelity criteria. Detailed reporting of curriculum-as-usual control conditions was generally lacking, as were methods to ensure high-quality training and mechanisms to assess provider adherence to intervention protocol.

DISCUSSION

Poor fidelity assessment and reporting is a problem in school-based primary prevention programmes for eating disorders. Recommendations for improving fidelity maintenance and reporting practices are provided.

Brief report: maltreatment in childhood and body concerns in adulthood

OBJECTIVE

We examined the relationship between maltreatment in childhood and body concerns in adulthood.

METHOD

A community sample of 156 women and 143 men completed measures of maltreatment - frequency of sexual abuse, physical abuse, physical neglect, emotional abuse and emotional neglect - in childhood. They also reported current dissatisfaction with body weight and shape and drive for thinness and drive for muscle.

RESULTS AND CONCLUSIONS

Childhood maltreatment was associated with drive for muscle in women and body dissatisfaction and drive for thinness in men. The results provide some evidence that adverse conditions in childhood can be associated with gender-atypical body concerns in adulthood.

Trajectories of weight disturbances during adolescence in relation to gender in a Swedish cohort

AIM

To explore developmental trajectories among adolescents of thinness and overweight in relation to gender.

METHODS

A group-based procedure was used to determine patterns of weight disturbances in a school-based sample of 3020 Swedish adolescents followed from age 11 to 18. A sensitivity analysis was performed to compensate for an increasing number of missing height and weight data after grade 8.

RESULTS

Six trajectories represented the best description of developmental weight disturbances with the exception of thinness among boys, which was best described by four trajectories. Concerning thinness, 5.9% of girls and 4.2% of boys developed this condition during the study period, while 1.9% of girls and 3.0% of boys recovered from their initial thinness. For overweight, (including obesity) 1.5% of girls and 3.1% of boys developed this weight disturbance during the study period, while 10.1% of girls and 9.3% of boys recovered from overweight/obesity. Non-reporting of height and weight was biased towards an underestimation of the true prevalence of overweight and obesity in girls and of thinness in boys.

CONCLUSIONS

Developmental trajectories provide a novel method to describe the dynamics of weight disturbances during adolescence. Similar patterns were found for overweight and thinness in boys and girls but group sizes varied between genders. Non-reporting of height and weight was found in a gender-specific pattern.

Body esteem in Chinese adolescents: Effect of gender, age, and weight

This study examined the associations of body esteem with gender, age, and Body Mass Index (BMI) among 905 Hong Kong adolescents using the Body-Esteem Scale (BES). Older age, male gender and lower BMI were associated with better body esteem. Multiple regression analyses indicated significant main effects of gender, age and weight on BES-Total. Significant interaction effects of gender × BMI and gender × age × BMI were also found on BES-Weight (beta = −0.149, p = .028) and BES-Total (beta = −0.139, p = .044). Improvement of body esteem with age may be associated with age-related BMI differences.

A cluster-randomized controlled trial to reduce sedentary behavior and promote physical activity and health of 8-9 year olds: the Transform-Us! study

BACKGROUND

Physical activity (PA) is associated with positive cardio-metabolic health and emerging evidence suggests sedentary behavior (SB) may be detrimental to children's health independent of PA. The primary aim of the Transform-Us! study is to determine whether an 18-month, behavioral and environmental intervention in the school and family settings results in higher levels of PA and lower rates of SB among 8-9 year old children compared with usual practice (post-intervention and 12-months follow-up). The secondary aims are to determine the independent and combined effects of PA and SB on children's cardio-metabolic health risk factors; identify the factors that mediate the success of the intervention; and determine whether the intervention is cost-effective.

METHODS/DESIGN

A four-arm cluster-randomized controlled trial (RCT) with a 2 × 2 factorial design, with schools as the unit of randomization. Twenty schools will be allocated to one of four intervention groups, sedentary behavior (SB-I), physical activity (PA-I), combined SB and PA (SB+PA-I) or current practice control (C), which will be evaluated among approximately 600 children aged 8-9 years in school year 3 living in Melbourne, Australia. All children in year 3 at intervention schools in 2010 (8-9 years) will receive the intervention over an 18-month period with a maintenance 'booster' delivered in 2012 and children at all schools will be invited to participate in the evaluation assessments. To maximize the sample and to capture new students arriving at intervention and control schools, recruitment will be on-going up to the post-intervention time point. Primary outcomes are time spent sitting and in PA assessed via accelerometers and inclinometers and survey.

DISCUSSION

To our knowledge, Transform-Us! is the first RCT to examine the effectiveness of intervention strategies for reducing children's overall sedentary time, promoting PA and optimizing health outcomes. The integration of consistent strategies and messages to children from teachers and parents in both school and family settings is a critical component of this study, and if shown to be effective, may have a significant impact on educational policies as well as on pedagogical and parenting practices.

TRIAL REGISTRATION

ACTRN12609000715279; Current Controlled Trials ISRCTN83725066.

Assessment of body image: Psychometric properties of the Body Image Questionnaire

This study investigated the psychometric properties of the Body Image Questionnaire (QÜIC) in Spanish adolescents. The sample comprised 254 girls and 189 boys, aged 12–15. Principal component analyses showed that the 18 satisfaction items could be summarized using two moderately interrelated dimensions, torso and head/limbs, with satisfaction with chest/breast and genitals loading on a different factor for boys (torso) and girls (head/limbs). The QÜIC measures of body satisfaction, body problems, general physical appearance and conformity with weight and height presented satisfactory test-retest reliability, internal consistency and convergent validity. Our findings support the use of the QÜIC when assessing body image.

Effects of Exercise Interventions on Body Image

Our meta-analysis examined the impact of exercise interventions on body image; and participant, intervention, and design features associated with larger effects. We identified 57 interventions (with pre-and post-data for the exercise and control groups) examining the effects of exercise on body image. A small random effect indicated that exercise intervention conditions had improved body image compared to control conditions; and that participant (age), design (year of publication), and intervention (exercise frequency and specificity) features moderated the effect size. Research examining the mechanisms and the exercise dose-response required for body image change is needed.

Social comparison and body image in adolescence: a grounded theory approach

This study explored the use of social comparison appraisals in adolescents' lives with particular reference to enhancement appraisals which can be used to counter threats to the self. Social comparison theory has been increasingly used in quantitative research to understand the processes through which societal messages about appearance influence adolescents' body image. Little is known about the comparison processes used in their daily lives-to whom individuals compare (the target), on what individuals compare (the attribute) and how they compare (comparison appraisal). Based on the analysis of 20 in-depth grounded theory interviews with 12- to 14-year old boys and girls, we suggest that comparison processes are used for the purpose of identity development (core category). Given the opportunity, adolescents spontaneously describe a variety of targets, comparison attributes and comparison appraisals. Peers play an important part in making sense of media images and messages and provide comparison targets themselves. Adolescents are aware of societal standards and pressures and use a range of enhancement appraisals. The positive impact of these might depend on individual characteristics. Findings suggest that enhancement appraisals might have a protective function and should be considered in designing health promotion and prevention programmes.

Weight concerns among elementary school children: a review of prevention programs

There is increasing evidence that children display high levels of weight and muscle concerns, which include body dissatisfaction and problem eating. In order to address these issues, researchers have designed and implemented prevention programs for this age group. Thirteen published studies were located and reviewed, with children aged 8-12 years from elementary schools, or equivalent. Overall, the programs were shown to be effective in improving children's knowledge at post-test and at follow-up assessments. However, there is limited evidence to show that the programs reduced or prevented body image concerns and/or problem eating. Too few studies have examined muscle concerns so no conclusions can yet be drawn about this domain. Limitations of the studies and suggestions for future prevention efforts are discussed.

Ecological strategies to promote healthy body image among children

BACKGROUND

Personal habits of children and adolescents related to healthy body image (BI) are influenced by various determinants in the micro- and macroenvironment. These include attitudes and behaviors about eating; exercise and physical appearance modeled by parents, teachers, and peers; as well as opportunities to learn new habits and social praise for healthy choices. The coordinated school health program (CSHP) is compatible with the 5 levels of an ecological approach to developing new health behaviors.

METHODS

Authors systematically applied the ecological model to all 8 components of coordinated school health. Next, strategies for each of the components were developed using the professional literature as well as author expertise in the areas of health education, exercise science, and dietetics.

RESULTS

For each strategy, applicable health and physical education standards, as well as goals for each strategy and additional Web resources, were provided to assist educators and administrators in supporting healthy BI among students.

CONCLUSIONS

Educators may effectively use a coordinated approach to guide multiple intervention activities aimed at increasing healthy habits among adolescents and their families. The strength of the CSHP is its collaborative nature with active participation by students, faculty members, family caregivers, agency professionals, community residents, and health care providers.

A Meta-Analytic Review of Eating Disorder Prevention Programs: Encouraging Findings

This meta-analytic review found that 51% of eating disorder prevention programs reduced eating disorder risk factors and 29% reduced current or future eating pathology. Larger effects occurred for programs that were selected (versus universal), interactive (versus didactic), multisession (versus single session), solely offered to females (versus both sexes), offered to participants over 15 years of age (versus younger ones), and delivered by professional interventionists (versus endogenous providers). Programs with body acceptance and dissonance-induction content and without psychoeducational content and programs evaluated in trials using validated measures and a shorter follow-up period also produced larger effects. Results identify promising programs and delineate sample, format, and design features associated with larger effects, which may inform the design of more effective prevention programs in the future.