The Efficacy of a Universal School-Based Prevention Program for Eating Disorders among German Adolescents: Results from a Randomized-Controlled Trial

A systematic review of weight stigma and disordered eating cognitions and behaviors

Weight stigma is persistent across contexts and is associated with disordered eating cognitions and behaviors. This systematic review aimed to examine the existing literature that has explored the relationship between weight stigma and disordered eating cognitions and behaviors. We specifically examined three dimensions of weight stigma - experienced, anticipated, and internalized - and adopted an inclusive conceptualization of outcomes related to disordered eating (including constructs such as binge eating, body dissatisfaction, and other cognitions and behaviors such as dietary restraint, unhealthy weight control behaviors, and drive for thinness). We searched PubMed, Embase, CINAHL, Web of Science, Sociological Abstracts, and PsycINFO for English-language, peer-reviewed articles and dissertations with quantitative methodology published through October 2023. The search resulted in 242 articles meeting inclusion criteria. A narrative review found a consistent relationship between greater weight stigma and more disordered eating cognitions and behaviors. Methodological and theoretical limitations are discussed, as are critical avenues for future research and potential clinical implications stemming from this body of research. Given the widespread nature and impact of weight stigma on disordered eating, it is imperative that we intervene to address weight stigma at all levels, from the structural to the intrapersonal.

Perfectionism and eating disorders in children and adolescents: A systematic review and meta-analysis

There is a consistent link between perfectionism and eating disorders, however no meta-analysis to date has synthesized this literature in children and adolescents. We hypothesized that there would be significant, small pooled correlations between perfectionism dimensions and eating disorder symptoms in children and adolescents. Published, peer-reviewed articles with standardised measures of perfectionism and eating disorder symptoms were included. Articles were excluded if the age range was over 18 years. Overall, 39 studies were included (N = 13,954 participants, M age = 13.7 years). Total perfectionism (r = 0.25), perfectionistic strivings (r = 0.21), and perfectionistic concerns (r = 0.31) had significant positive associations with eating disorder symptoms. Most studies were rated as fair or good quality. Limitations included high heterogeneity, insufficient studies to investigate age as a moderator, the inclusion of only English articles, and predominately cross-sectional studies which precluded causal inference. Higher perfectionism was associated with greater eating disorder symptoms in children and adolescents. Future research should focus on longitudinal studies of eating disorder symptoms in children and adolescents.

Normative body image development: A longitudinal meta-analysis of mean-level change

This meta-analysis synthesized longitudinal data on mean-level change in body image, focusing on the constructs of body satisfaction and dissatisfaction, body esteem, perceived attractiveness, valuation, self-objectification, and body shame. We searched five databases and accessed unpublished data to identify studies that assessed body image at two or more time points over six months or longer. Analyses were based on data from 142 samples representing a total of 128,254 participants. The age associated with the midpoint of measurement intervals ranged from 6 to 54 years. Multilevel metaregression models examined standardized yearly mean change, and the potential moderators of body image construct, gender, birth cohort, attrition rate, age, and time lag. Boys and men showed fluctuations in overall body image with net-improvements between ages 10 and 24. Girls and women showed worsening body image between ages 10 and 16, but improvements between ages 16 and 24. Change was greatest between ages 10 and 14, and stabilized around age 24. We found no effect of construct, birth cohort, or attrition rate. Results suggest a need to revise understandings of normative body image development: sensitive periods may occur somewhat earlier than previously believed, and body image may show mean-level improvements during certain age ranges.

Prevention and early intervention in eating disorders: findings from a rapid review

BACKGROUND

Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

METHODS

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

RESULTS

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

CONCLUSIONS

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

School-Based Interventions Improve Body Image and Media Literacy in Youth: A Systematic Review and Meta-Analysis

Body ideals conveyed by the media and by body comparisons often result in body dissatisfaction, which can cause risky health behaviours and eating disorders, especially in adolescents. We conducted a meta-analytic review of existing school-based interventions designed to enhance media literacy in order to reduce body dissatisfaction and to promote a positive body image. We included controlled trials examining children and adolescents from grade five to nine (age 10-15 years) after a manual search and a comprehensive literature search using PsycINFO, Medline, Web of Science, and CENTRAL. We computed average weighted effect sizes (Hedges' g) with the help of a random effects model and identified seventeen different programme evaluations with 7392 participants. We found a significantly larger effect on positive body image and media literacy in the intervention compared to control groups. However, heterogeneity was substantial for both outcomes. Results suggest that media literacy interventions have the potential to improve media literacy and reduce body dissatisfaction. Interventions that worked with the principle of induction of cognitive dissonance were the most effective.

Effect of modified physiology laboratory sessions on the awareness and knowledge of obesity of health-related university students

BACKGROUND:

Obesity is a global health problem of immense magnitude. Increased awareness and knowledge about obesity in health-care providers are essential to addressing this global issue. The aim of the present study was to assess the baseline knowledge on obesity of university students in health-related programs and evaluate the effectiveness of modified physiology laboratory (MPL) sessions in enhancing the awareness of obesity of these students by repeated exposure to physiological differences between normal weight (NW) and overweight or obese (OW/OB) individuals.

MATERIALS AND METHODS:

It was a quasi-experimental study in which three regular physiology laboratory exercises were modified (MPL) to address different aspects of obesity. A total of 319 students (181 male and 138 female) from health-related colleges taking the physiology course during academic session 2011–2012 were included in the study. A questionnaire on obesity served as a measure of prior knowledge and improvement of evolution of student knowledge. The questionnaire was administered thrice: Beginning of the first MPL session (pretest), at the end of the second session of the first MPL (posttest-1), and the end of second session of the final MPL (posttest-2). Correct knowledge (CK), perceived knowledge (PK), and accuracy of knowledge (KA) were evaluated. Students gathered and analyzed physiological data in these sessions to explore the differences between NW and OW/OB subjects.

RESULTS:

The students' level of PK on obesity was high, but KA was low in pretest. The three knowledge indices improved significantly (P <0.001) from pretest (PK = 77.2%; KA = 52.8%; CK = 40.5%) to posttest 1 (PK = 93.5%; KA = 70.1%; CK = 65.9%). However, from posttest 1 to posttest 2, only small but significant increments were observed in CK (10.5%) and KA (8.7%).

CONCLUSION:

The awareness and knowledge on obesity of health-related undergraduate university students at baseline were low, but significantly improved after MPLs. The students' knowledge did not only increase but also improved in accuracy. This increase in awareness and knowledge of obesity is expected to directly impact on the students' lifestyles and boost their confidence to counsel others on obesity.

Research Review: Effectiveness of universal eating disorder prevention interventions in improving body image among children: a systematic review and meta-analysis

BACKGROUND

Increasingly, children are at risk of developing eating disorders. A systematic review and a meta-analysis were conducted to examine the effectiveness of universal eating disorder prevention interventions in improving body image, internalization of appearance ideals, and self-esteem among children aged 5-17 years old.

METHODS

Nine electronic databases were systematically searched from each database's point of inception to March 2019. The Cochrane Risk of Bias tool assessed each study's risk of bias, while the GRADE approach judged the overall evidence for each review outcome. A meta-analysis was conducted using the random-effect model to obtain standardized mean differences with 95% confidence intervals under the inverse variance method. Heterogeneity was assessed using I² statistic and Cochran's Q chi-squared test. Publication bias was assessed using funnel plots.

RESULTS

A total of 24 studies (22 trials) were included in this review. Universal interventions were found to be effective in improving children's body esteem, self-esteem, and internalization of appearance ideals at postintervention and at follow-up timepoints. Subgroup analyses found that girls benefited more from these interventions than boys. Multisessional interventions with an optimal duration of approximately one month were found to be more effective.

CONCLUSIONS

The findings encourage the incorporation of universal preventive interventions into school curricula to benefit most children. Laypeople such as teachers can deliver these interventions, but content experts should address topics on body dissatisfaction. Due to the low quality of evidence, as accorded by the GRADE approach, current findings should be validated by future research.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Exploring the reciprocal relationships between adolescents' perceptions of parental and peer attachment and disordered eating: A multiwave cross-lagged panel analysis

OBJECTIVE

This prospective study explored bidirectional associations between attachment quality towards mother, father, and peers and disordered eating among a large population-based sample of boys and girls in the transition from preadolescence to adolescence. Specifically, we examined whether insecure attachment relationships emerged as a risk factor for or as an outcome of disordered eating.

METHOD

A population-based sample of 904 adolescent girls and boys was assessed four times, at baseline (T1; M_age  = 10.8 years) and at 2-, 4-, and 6-year follow-up (T2, T3, and T4). Prospective data were analyzed using cross-lagged panel models for each attachment figure (i.e., mother, father, peers) in a multigroup design to compare genders.

RESULTS

Better attachment to the mother led to less pronounced disturbed eating in girls across the entire age range and in boys across two time periods. In girls, more pronounced disordered eating at T3 predicted worse attachment to the mother at T4 and better attachment to the father at T1 predicted less disturbed eating at T2. In boys, disordered eating at T1 predicted better attachment to the father at T2. Concerning peer attachment, better attachment at T1 predicted disordered eating at T2, in boys only. No other significant cross-lagged effects emerged.

DISCUSSION

These findings highlight the differential and gender-specific contribution of attachment figures to the development of disordered eating in adolescence. Programs aimed at improving communication and trust in the relationship with parents might be promising in the prevention of disordered eating and the subsequent deterioration of parent-child attachment relationships.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

Prevention of eating disorders: 2018 in review

This article reviews the 10 prevention-related publications in Eating Disorders: The Journal of Treatment & Prevention during 2018. Two models frame this analysis. This first is the Mental Health Intervention Spectrum from health promotion → types of prevention → case identification and referral → treatment (recovery). The second parses the phases of prevention into rationale, theory, and methodology → clarification of risk factors, including very high risk, shading into warning signs → implications for specific preventive interventions → design innovation and feasibility (pilot) research → efficacy and effectiveness research → program dissemination. Collectively, the articles illustrate how complex and demanding the field of prevention is, with respect to, for example, phases of program development, the multidimensional ecology of interventions, and methodological requirements for demonstrating that a program deserves to be designated "evidence-based." A subset of the articles also illustrates how far the increasingly broad and dynamic field of prevention has advanced. Examples include models of eating disorder development in high-risk populations such as people with type 1 diabetes; prevention programming for young children; and after-school preventive interventions that combine dissonance-based lessons with empowering participation in community advocacy and activism.