Dissonance-based eating disorder prevention delivered in-person after an online training: A randomized controlled trial for Brazilian men with body dissatisfaction

How effective are psychosocial interventions at improving body image and reducing disordered eating in adult men? A systematic review

Disordered eating and body image concerns significantly impact a growing number of men. This systematic review assessed the evidence of the effectiveness of psychosocial interventions to improve body image and eating pathology in men. Searches were conducted in December 2022 in 13 databases (PsycINFO, MEDLINE, CINAHL Plus, AMED, PubMed, Scopus, Cochrane, EMBASE, ASSIA, British Nursing Index, Wiley and OpenGrey). Studies that quantitatively evaluated psychosocial interventions and reported pre-post body image or disordered eating outcomes in men aged 18 years and over were eligible. Articles including boys, uncontrolled designs, or not in English were excluded. Findings were narratively synthesised and presented according to intervention approach. Quality was assessed using EPHPP. Eight studies including six RCTs were reviewed. Five were assessed as being moderate quality and three as weak. Evidence from moderate quality studies suggested that dissonance-based interventions showed promising improvements in body image and disordered eating for up to six months post-intervention in men with and without body dissatisfaction. Evidence for media literacy and psychoeducational interventions was limited. Findings were limited by heterogeneity in outcome measures and homogeneity of participants preventing generalisability. Robust research with longer follow-ups is needed to confirm effectiveness.

A meta-analytic review of impact of measurement choice on RCTs to reduce appearance internalization

OBJECTIVE

Prior reviews have shown that interventions targeting internalization of appearance standards are generally efficacious, though there is considerable heterogeneity in estimates across studies. This updated review of the literature evaluates whether efficacy estimates from RCTs systematically vary as a function of three related outcome measures (internalization, awareness, and perceived pressure regarding appearance standards).

METHODS

Seven electronic databases were systematically searched from inception to February 8, 2023. The Cochrane Risk of Bias tool assessed each study's risk of bias. Studies included were randomized-controlled trials evaluating body image/eating disorder prevention or intervention programs targeting internalization as a focal point of treatment. Effect sizes were meta-analyzed and meta-regression analyses were conducted investigating the impact of outcome measure choice on study effect size at post-intervention and follow-up.

RESULTS

Thirty-seven studies (N = 4809 participants) were included. The meta-analytic findings as expected found interventions efficacious at reducing internalization post-intervention (d = -0.47, 95% CI [-0.60 to -0.34], k = 44), and at follow-up (d = -0.28, 95% CI [-0.39 to -0.17], k = 43), but also highly heterogenous (I2  = 52-67%). Operationalization of internalization moderated results at follow-up but not post-intervention timepoints, with awareness measures (compared with internalization measures) producing weaker effect sizes. Exploratory analyses found bigger effects when internalization was compared with all other measurement categories combined, suggesting possible issues with statistical power in main analyses.

DISCUSSION

Mixed present findings suggest need for further evaluation of measurement effects on efficacy, and possible caution in choice of outcome measure for internalization-based interventions.

PUBLIC SIGNIFICANCE STATEMENT

This review provides some preliminary evidence that choice of survey measures used in randomized controlled trials can impact our judgments about whether a trial reduces the extent to which participants endorse unrealistic appearance standards. Accuracy in measurement of this efficacy of trials is crucial, given the role that internalized appearance standards play in onset and maintenance of eating disorders.

Goodform: A cluster randomised controlled trial of a school-based program to prevent body dissatisfaction and muscle building supplement use among adolescent boys

Although body dissatisfaction is common among adolescent boys, few intervention programs specifically developed for boys have been shown to be effective for reducing body dissatisfaction. Our study aim was to evaluate Goodform, a 4-session, teacher delivered intervention program specifically developed for boys to reduce body dissatisfaction and muscle building supplement use. The Goodform program was based on cognitive dissonance, social learning theory, and a social norms approach, and drew from two existing body image intervention programs that have shown promise among males: The Body Project- More than Muscles, and the Athletes Training and Learning to Avoid Steroids Program (ATLAS). A sample of 488 boys in grades 9 and 10 (M_age = 14.81, SD_age = 0.51) at nine secondary schools in Australia were randomly assigned to Goodform (n = 244) or control (n = 244) at the school level. Self-reported body image, supplement use, anabolic androgenic steroid (AAS) use, and attitudes around using AAS and muscle building supplements were measured at baseline, post-intervention, and eight-week follow-up. Analyses with multi-level, mixed-effect regression models revealed no changes over time attributable to the intervention. Our results have implications for researchers in the body image and eating disorder prevention fields. Lessons learned in this study can inform future school-based efforts for reducing muscle building supplement use.

Eating disorders prevention programs in Latin American countries: A systematic review

OBJECTIVE

This systematic review evaluates and summarizes existing eating disorder (ED) prevention programs in Latin American countries.

METHODS

A systematic literature search was conducted using the Cochrane Controlled Trial Register, PubMed, and Virtual Health Library databases up to and including July 31, 2022. All ED prevention studies published in English, Spanish or Portuguese were eligible, regardless of the study design, sample characteristics, and type of prevention programs. The Cochrane Collaboration Risk of Bias criteria were used to evaluate the quality of the included studies.

RESULTS

Twenty-two studies were included. Most were pilot studies that were nonrandomized, had a high risk of bias, were from Mexico and Brazil, and employed selective interventions. Dissonance-based programs and social cognitive theory were the commonly used approaches in interventions, and most of them were tested in adolescent girls and women. Short follow-ups were used, varying from 1 to 6 months. Many found significant decreases after the intervention and/or at follow-up in ED/disordered eating risk behaviors/symptoms, negative affect, body-ideal internalization, and body image disturbances.

CONCLUSIONS

This review highlights promising efforts to prevent EDs among Latin American countries. Some barriers in conducting research include funding restrictions, laws that do not allow remuneration or compensation for participants, and high costs of training. Nonetheless, the outcomes of the programs developed and evaluated so far are positive enough to merit further work on ED prevention. Efforts for future researchers should recruit samples with diverse characteristics, use robust designs and data analysis techniques, and expand the accessibility of prevention programs.

PUBLIC SIGNIFICANCE STATEMENT

The development of effective eating disorder (ED) prevention programs that can be broadly implemented is a public health priority. Nevertheless, there is limited evidence regarding the characteristics of ED prevention programs and their efficacy among Latin American countries. In the present study, we reviewed existing ED prevention programs adopted in Latin America, described their characteristics and outcomes, noted the limitations of available programs, and discussed the implications of these findings for efforts to prevent the development of EDs in Latin America. The outcomes of the programs developed and evaluated so far are positive enough to merit the development and rigorous evaluation of future programs and their broad dissemination in Latin American countries. PROSPERO registration number CRD42021275245.

Expert peer facilitation of the EVERYbody Project: A randomized-controlled evaluation of a diversity-focused, dissonance-based, universal body image program for college students

OBJECTIVE

A novel peer facilitation model was used to deliver a two session, dissonance-based, inclusive body image intervention that critically examines how internalized size-based oppression intersects with race, class, gender, sexuality, and ability.

METHOD

The EVERYbody Project was open to all college students and delivered by "expert" peer facilitators with body image and diversity experience and advanced facilitation skills. Recruitment was halted due to COVID-19; 90 students in the Northwest US (M age = 19.83 years, SD = 2.38; 80% female-identified, 13% male-identified, 7% gender expansive) were randomized to receive the EVERYbody Project or a video-based, low-dissonance comparison intervention.

RESULTS

Around half of students (56%) held one or more specific socially marginalized identity (26% with a racial or ethnic identity other than white and non-Hispanic, 39% with a sexual identity other than straight, 7% with a gender identity other than cisgender). The EVERYbody Project produced greater reductions in three outcomes associated with poor body image (internalized appearance norms, body dissatisfaction, and negative affect) compared to the video intervention through 3-month follow-up (ps < .003) with medium between group effects. Both conditions experienced small reductions in eating disorder psychopathology over time.

DISCUSSION

Expert peer facilitation may be a viable delivery model for inclusive, diversity-focused dissonance-based body image programs.

PUBLIC SIGNIFICANCE

This study explored a novel facilitation approach for a diversity-focused body image program for college students. A brief (4 h) dissonance-based program was open to all college students and delivered by "expert" diverse peer leaders who were screened for facilitation readiness. Body image and related outcomes were improved through 3-month follow-up relative to a comparison condition, suggesting that expert peer facilitation may be a viable option for delivering universal, inclusive body image programming.

Body image as a global mental health concern

Body image concerns related to weight or other dimensions of appearance are now prevalent on a global scale. This paper reviews the theoretical frameworks that account for the global similarities and regional differences in rates and presentation of body image concerns, as well as reviewing the extant data. Given the harmful consequences of body image concerns in terms of mental and physical health, their global burden is high. Interventions to mitigate these concerns at the individual and systemic level are warranted.

Short forms of the Body Appreciation Scale-2 (BAS-2SF): Item selection and psychometric evaluation

The 10-item Body Appreciation Scale-2 (BAS-2; Tylka & Wood-Barcalow, 2015) is a widely used contemporary measure of positive body image that assesses one's love for, acceptance and appreciation of, and respect for their body. Given the need for abbreviated measures to reduce participant burden and study cost, we aimed to generate a short form of the BAS-2 (BAS-2SF). Two versions of the BAS-2SF emerged: a 3-item version derived deductively from theory (items selected based on their unique contribution to the body appreciation construct), and a 2-item version generated empirically (items selected based on a genetic algorithm approach). Psychometric evidence was garnered across five studies, totaling 3114 participants. Both BAS-2SF versions correlated highly (rs = .93-.97) with the original 10-item BAS-2 and demonstrated internally consistent and stable scores. Factor analyses revealed high item-factor loadings, unidimensionality, and gender invariance of the 3-item BAS-2SF. Correlations with construct validity measures, as well as model pathways, were similar between both BAS-2SF versions and the 10-item BAS-2. BAS-2SF versions also evidenced incremental validity. Both BAS-2SF versions retain the psychometric integrity of the BAS-2 and are recommended for use; however, the 3-item BAS-2SF is an ideal option for researchers who wish to estimate a body appreciation latent factor.

Prevention of eating disorders: 2021 in review

This review of 19 prevention-related publications in Eating Disorders during 2021 is framed by four models: (1) Mental Health Intervention Spectrum: health promotion → types of prevention → case identification/referral → treatment; (2) the prevention cycle: rationale and theory, shaped by critical reviews → clarifying risk and protective factors → program innovation and feasibility studies → efficacy and effectiveness research → program dissemination; (3) links between disordered eating (DE) and eating disorders (EDs); and (4) Kraemer and Jacobi's criteria for variable, causal risk factors (RFs). Twelve articles demonstrated the strengths and limitations of cross-sectional investigations of RFs for DE and EDs: five explored the role of trauma in activating genetic and psychological RFs (e.g., anxiety and experiential avoidance), while five suggest other variables meriting further evaluation: ergogenic supplement use, "feeling fat," internalized weight bias, food insecurity, and compulsive exercising. One article presents a pilot program that reduced risk factors in a high-risk group: professional ballerinas. Implications of the absence of efficacy, effectiveness, dissemination, and advocacy studies, along with the need to develop tailored programs for various high-risk groups, are discussed.