Dissemination of evidence-based body image interventions: A pilot study into the effectiveness of using undergraduate students as interventionists in secondary schools

Predictors of the sustainability for an evidence-based eating disorder prevention program delivered by college peer educators

BACKGROUND

Despite ongoing efforts to introduce evidence-based interventions (EBIs) into mental health care settings, little research has focused on the sustainability of EBIs in these settings. College campuses are a natural place to intervene with young adults who are at high risk for mental health disorders, including eating disorders. The current study tested the effect of three levels of implementation support on the sustainability of an evidence-based group eating disorder prevention program, the Body Project, delivered by peer educators. We also tested whether intervention, contextual, or implementation process factors predicted sustainability.

METHODS

We recruited 63 colleges with peer educator programs and randomly assigned them to (a) receive a 2-day Train-the-Trainer (TTT) training in which peer educators were trained to implement the Body Project and supervisors were taught how to train future peer educators (TTT), (b) TTT training plus a technical assistance (TA) workshop (TTT + TA), or (c) TTT plus the TA workshop and quality assurance (QA) consultations over 1-year (TTT + TA + QA). We tested whether implementation support strategies, perceived characteristics of the intervention and attitudes towards evidence-based interventions at baseline and the proportion of completed implementation activities during the implementation year predicted three school-level dichotomous sustainability outcomes (offering Body Project groups, training peer educators, training supervisors) over the subsequent two-year sustainability period using logistic regression models.

RESULTS

Implementation support strategies did not significantly predict any sustainability outcomes, although a trend suggested that colleges randomized to the TTT + TA + QA strategy were more likely to train new supervisors (OR = 5.46, 95% CI [0.89-33.38]). Colleges that completed a greater proportion of implementation activities were more likely to offer Body Project groups (OR = 1.53, 95% CI [1.19-1.98]) and train new peer educators during the sustainability phase (OR = 1.39, 95% CI [1.10-1.74]). Perceived positive characteristics of the Body Project predicted training new peer educators (OR = 18.42, 95% CI [1.48-299.66]), which may be critical for sustainability in routine settings with high provider turnover.

CONCLUSIONS

Helping schools complete more implementation activities and increasing the perceived positive characteristics of a prevention program may result in greater sustainment of prevention program implementation.

TRIAL REGISTRATION

This study was preregistered on 12/07/17 with ClinicalTrials.gov, ID NCT03409809, https://clinicaltrials.gov/ct2/show/NCT03409809 .

Body image of university students: a systematic review of the characteristics of interventions

BACKGROUND

Body image is the mental representation of the body and can be influenced by cognitive, biological, behavioral, sociocultural, and environmental factors. University students often encounter challenges related to it.

OBJECTIVE

This systematic review examined interventions aimed at holistically developing a positive body image within this population.

METHODS

The PRISMA 2020 guidelines and the PICO method were employed to identify, select, assess, and synthesize studies. The consulted databases included Scopus, Web of Science, and PsycINFO, with inclusion criteria targeting body image interventions for university students aged 18 to 39. Study quality was evaluated using the QATSDD tool.

RESULTS

Twenty-one relevant studies were identified, primarily from the United States, mostly employing quantitative methods, with a focus on female participants. Various intervention strategies were utilized, including cognitive-behavioral approaches, media literacy, and physical/resistance training, with a growing use of technology like mobile applications. The majority of studies reported effective outcomes, such as reduced body dissatisfaction and increased self-esteem following interventions. Nevertheless, literature gaps were identified, such as the scarcity of formative interventions and limited use of qualitative approaches.

CONCLUSION

While technology in interventions offers promising opportunities, careful assessments and judicious selection of evaluation instruments are fundamental for reliable results. Future research should focus on addressing identified gaps, such as exploring more formative interventions and incorporating qualitative methodologies to provide a more comprehensive understanding of the effectiveness of body image interventions among university students.

Evaluating a school-based body image lesson in Indonesia: A randomised controlled trial

Negative body image is a common public health concern among adolescents, globally. The aim of the current study was to evaluate the effectiveness, implementation fidelity, and acceptability of a single session, school-based universal body image intervention in Indonesia. A total of 1926 adolescents (59.4 % girls) and 12 school guidance counsellors (lesson facilitators) from nine state junior secondary schools in Surabaya, East Java took part in a two-arm open parallel cluster randomised controlled trial. In response to the changing circumstances due to the COVID-19 pandemic, half of the lessons were conducted in person and half were delivered online. Results showed that the lesson did not significantly improve adolescent body image or secondary outcomes relative to the control, though there was no evidence of harm. There were no substantive findings regarding intervention effectiveness by gender. The mode of intervention delivery (online vs. in-person) did not significantly influence the main findings. Implementation fidelity varied widely, and the lesson content and pedagogy were largely acceptable, though there was a strong preference for in-person lesson delivery. Findings have implications for researchers aiming to improve adolescent body image in low- and middle-income countries. Lessons learned can inform future school-based efforts to support adolescent body image.

A cognitive dissonance body image intervention 'Free Being Me' delivered by guide leaders to adolescent girl guides in India: A pilot and acceptability trial

This pilot study assessed the acceptability and pre-post intervention effects of a cognitive dissonance-based body image intervention, Free Being Me, delivered by Guide leaders to adolescent girls in India. Girls aged 11-14 years (Mage = 12.6, N = 117), who were members of the national scouting and guiding association of India, received the intervention across five weekly 1-hour group sessions. The primary outcome (body esteem) and secondary outcomes (self-esteem, internalisation of appearance ideals, negative and positive affect, and life disengagement) were measured pre-intervention and immediately post-intervention. The intervention was acceptable. Adolescent girls reported high levels of comfort (89%), enjoyment (90%), and perceived importance (92%) with suggestions for improvement including more interactive activities. Facilitator adherence and competence delivering Free Being Me was rated good. Significant within-groups pre-post intervention improvements in body esteem (Cohen's d = 0.28) and reductions in internalisation of appearance ideals (Cohen's d = 0.49) were identified. No changes to self-esteem, negative or positive affect, or life disengagement were observed. This study suggests that Free Being Me is acceptable for community-based delivery and Guide leader format with promising pre-post intervention effects. Going forward, a randomised controlled trial is necessary to make confident interpretations on the effectiveness of Free Being Me.

Pilot feasibility and acceptability trial of BE REAL's BodyKind: A universal school-based body image intervention for adolescents

Body dissatisfaction is prevalent among adolescents and a primary risk factor for eating disorders, yet there are few body image interventions for older adolescents that support development of positive body image. Therefore, we assessed the feasibility, acceptability and preliminary effectiveness of BodyKind, a four-lesson, mixed gender, teacher-led, school-based curriculum for older adolescents, that combines principles of self-compassion, compassion for others, cognitive dissonance, and social activism to address contemporary adolescent body image concerns (i.e., appearance bias, comparisons on social media) and strengthen positive body image development. The sample contained 147 adolescents, predominantly racial/ethnic minorities (>95%), 54.8% male, 41.5% female and 4.1% gender-minority students aged 15-18 years (M=16.24, SD=.96) from a low-income, inner-city high school in the Midwestern US. Two teachers received training and delivered the curriculum to students. This single arm, mixed methods trial assessed student and teacher acceptability, teacher fidelity and student intervention outcomes. Despite reasonable teacher fidelity, recruitment/attendance rates, post-intervention data loss (35% attrition) limited evaluations of program effectiveness and study feasibility. Important learnings regarding study feasibility will inform optimisation for future school-based trials. Findings demonstrate high acceptability of BodyKind among teachers and adolescents in a lower socioeconomic school setting, and further randomized controlled effectiveness trials are required.

The co-creation, initial piloting, and protocol for a cluster randomised controlled trial of a coach-led positive body image intervention for girls in sport

BACKGROUND

Globally, girls disengage from sports at an earlier age and higher rate than boys. This is, in part, due to the unique body image challenges that girls face, relative to their male peers. Existing intervention efforts that aim to reduce girls' negative body image and movement experiences have proven marginally effective, if not ineffective. This paper outlines the co-creation, initial piloting and protocol for a cluster randomised controlled trial of Body Confident Athletes (BCA); an in-person, coach-led intervention that aims to foster positive body image and sports enjoyment among girls.

METHODS

Following co-creation and an initial pilot, a two-armed cluster randomised controlled trial will assess the immediate (post-intervention) and short-term (1-month and 3-month follow-up) impact of BCA on girls' (N = 1,036; 11-17 years old) body image, sports enjoyment, and affect. Sport organisations will be randomly allocated (1:1) into either an intervention or waitlist control condition. Girls and coaches in the intervention condition will complete three 60-minute sessions over three consecutive weeks. The primary outcome will be the immediate change in girls' body esteem, with secondary outcomes assessing the immediate and short-term changes in girls' body appreciation, self-objectification, attuned self-care, sports enjoyment, and affect.

DISCUSSION

This research is the first to utilise an international multi-stakeholder partnership to co-create and evaluate an intervention that addresses the intersection of girls' body image and sport experiences. The theoretical and methodological considerations of this research have led to a feasible intervention and trial protocol, and if proven effective, BCA may assist in reducing the global gender disparity in sports participation.

TRIAL REGISTRATION NUMBER

NCT05594524 , registered 25^th October 2022.

Power, Self-Esteem, and Body Image

Abstract: We expected power – the perceived capacity to influence others – to be an antecedent of positive body image because power is closely linked to self-esteem, which in turn is linked to body image. In a cross-sectional study ( N = 318), sense of power was positively related to body appreciation and satisfaction with one’s appearance. Self-esteem partially mediated this effect. In an experimental study ( N = 114), participants assigned to a high-power group indicated more body appreciation, reported more body satisfaction, and estimated themselves to be taller than participants assigned to a low-power group. Self-esteem mediated all the effects. Altogether, power affected body image directly but also indirectly through elevated self-esteem. Implications refer to clinical prevention and intervention programs.

Sexualized Images on Social Media and Adolescent Girls' Mental Health: Qualitative Insights from Parents, School Support Service Staff and Youth Mental Health Service Providers

This research explored adults' perceptions of how sexualized images typically found on social media might influence adolescent girls' mental health, what support girls might need should they experience mental health difficulties, and how such difficulties could be prevented or reduced. Qualitative data were collected using semi-structured in-depth interviews with parents of adolescent girls (n = 11) and those who provide support to them: school support service staff (n = 7) and youth mental health service providers (n = 10) located in Perth, Western Australia. All three participant groups perceived sexualized images typically found on social media as exacerbating poor mental health among adolescent girls. Two interrelated themes, emerged with participants describing the 'potential for comparison' and 'pressure to conform' they believed girls encounter on social media that influences their mental health. Participants also explained how they perceived 'counteracting negative influences' related to sexualized images on social media could prevent or reduce the potential for mental health harms among girls, and the importance of adults and services 'keeping up to date' and being 'approachable and trustworthy' when describing the support they believed girls might need. The findings of this study have important implications for the development of health promotion programs focused on social media use and mental health among adolescent girls.

“Why don’t I look like her?” How adolescent girls view social media and its connection to body image

Background

Adolescent girls appear more vulnerable to experiencing mental health difficulties from social media use than boys. The presence of sexualized images online is thought to contribute, through increasing body dissatisfaction among adolescent girls. Sexual objectification through images may reinforce to adolescent girls that their value is based on their appearance. This study explored how sexualized images typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways.

Methods

In-depth interviews were conducted with girls aged 14–17 years (n = 24) in Perth, Western Australia. Data were analyzed using thematic analysis.

Results

Participants identified body image as a major concern, reporting negative appearance comparisons when viewing images on social media. Appearance comparisons were perceived to exacerbate adolescent girls’ appearance-based concerns. Comparisons also influenced adolescent girls’ efforts to change their appearance and seek validation on social media. The importance of awareness and education from a younger age about social media and its influence on body image was emphasized, as was the need for strategies to promote positive body image and counteract negative body image.

Conclusion

The findings of this study have important implications for professionals working with adolescent girls and for the development of health promotion programs addressing social media use and body image concerns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01845-4.

Enriching sociocultural perspectives on the effects of idealized body norms: Integrating shame, positive body image, and self-compassion

Body image is an integral aspect of the psychology of the self. Idealized body images are ubiquitous in both traditional media forms (e.g., magazines, television) and social media (e.g., Facebook, Instagram). The classic sociocultural model of body image (i.e., the Tripartite Influence Model) emphasizes pathways between idealized body norms, appearance comparisons, internalization of body ideals, and body dissatisfaction and its outcomes. We summarize the model and identify some issues to be addressed in future work, particularly in light of the immense popularity of social media. We review three topics that are not included in the sociocultural model but that provide a more complete picture of the influence of societal body norms on body image: (1) body shame, (2) positive body image, and (3) self-compassion. Research on the nature, assessment, and relevance of these constructs is reviewed in detail. In terms of clinical applications of these areas of research for individuals at risk of body dissatisfaction, we suggest assessing for and targeting body shame, cultivating facets of positive body image, and teaching strategies for developing self-compassion.

A systematic review of interventions aiming to promote positive body image in children and adolescents

Evidence shows interventions can improve positive body image in adult women. This systematic review examined the evidence of efficacy of interventions that aimed to increase positive body image in children and young people aged under 18 years. The authors followed PRISMA guidelines for the review. Searches of CINAHL Plus, Medline, PsychINFO, Wiley Online Library, SCOPUS and grey literature were conducted up to February 2021 and identified 4171 papers. Thirteen studies evaluating 12 interventions, designed for children/adolescents aged 9-18 years, were eligible and evaluated using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. The studies evaluated body appreciation, body-esteem, and embodiment. Studies using cognitive dissonance, peer support, and psychoeducation had evidence of improving body appreciation and body-esteem in adolescent girls. However, evidence of efficacy for younger children and boys was lacking and the studies ranged in methodological quality. Further research should rigorously evaluate positive body image interventions using second-generation measures that assess specific components of positive body image and consider how to promote positive body image in young children and boys.

Attitudes towards cosmetic surgery among women in China and the Netherlands

Around the world, an increasing number of people, predominantly women, are choosing to undergo cosmetic surgery—despite the associated health risks. This study aimed to promote a better cross-cultural understanding of the correlates and predictors of favorable attitudes toward cosmetic surgery among women in China (an Eastern country where cosmetic surgery is increasing most rapidly) and the Netherlands (a Western country). Questionnaire data were obtained from 763 adult women; 245 were Chinese women in China (M_age = 29.71), 265 were Chinese women in the Netherlands (M_age = 25.81), and 253 were Dutch women (M_age = 29.22). Facial appearance concerns and materialistic belief were significant predictors of favorable attitudes towards cosmetic surgery for all three cultural groups. Body appreciation was a significant positive predictor among Chinese women in both China and the Netherlands, whereas age and beauty-ideal internalization were significant positive predictors only among Chinese women in China. The findings and their implications are discussed with respect to the characteristics of Chinese culture that could explain the identified differences between Chinese and Dutch women.

Body image and acceptance of cosmetic surgery in China and the Netherlands: A qualitative study on cultural differences and similarities

There is an established relationship between acceptance of cosmetic surgery and psychological factors, including body image. However, qualitative research among diverse cultural groups is needed to provide a more fine-grained understanding of the influences on women's attitudes towards cosmetic surgery. In this study, 20 Chinese and 20 Dutch women aged 18-50 years (M_Chinese = 34.20; M_Dutch = 34.70) participated in one-on-one semi-structured interviews. Data were analyzed using reflexive thematic analysis. We identified three themes that captured the factors that women perceived to foster favorable attitudes towards cosmetic surgery: (a) sociocultural pressures (e.g., normalization of cosmetic surgery, appearance-focused peers); (b) intrapersonal characteristics (e.g., beauty-ideal internalization, social comparison); and (c) benefits of beauty (e.g., attracting men, socioeconomic benefits). Conversely, two themes captured the factors perceived to reduce favorable attitudes towards cosmetic surgery: (a) intrapersonal characteristics (e.g., unconditional body acceptance, self-confidence); and (b) external considerations (e.g., health risks, financial costs). Overall, Chinese and Dutch participants shared many similarities in their opinions about what might affect cosmetic surgery consideration. The most striking cross-cultural differences concerned perceived socioeconomic benefits of beauty (mainly Chinese women) and women's conceptualization of body appreciation. This study may enable a more comprehensive understanding about the factors influencing Chinese and Dutch women's attitudes towards cosmetic surgery, and the nuances in these relationships across these cultures.

Dissonance-based eating disorder prevention among Brazilian young women: A randomized efficacy trial of the Body Project

A randomized controlled trial was conducted to assess the efficacy of the Body Project eating disorder prevention program in reducing eating disorder risk factors and symptoms in young Brazilian women. A total of 141 female university students aged 18-30 years old were randomly assigned to one of two conditions: assessment-only condition (n = 78) and Body Project condition (n = 63). Participants completed scales assessing body dissatisfaction, sociocultural influence, disordered eating attitudes and behaviors, eating disorders symptoms, body appreciation, depressive mood and negative affect at baseline, posttest, and at 1- and 6-month follow-ups. Body Project participants showed significantly greater reductions in body dissatisfaction, sociocultural influence, disordered eating, eating disorder symptoms, depressive symptoms, and negative affect, and greater increases in body appreciation (d = .35-.48) compared to assessment-only participants. Most of the effects persisted through 6-month follow-up (d = .35-.74). Results provide evidence that the Body Project is an effective intervention to reduce eating disorder risk factors and eating disorder symptoms among Brazilian young women, and that this intervention is naturally culturally adaptive.

"I didn't want to say something and them to go outside and tell everyone": The acceptability of a dissonance-based body image intervention among adolescent girls in the UK

Cognitive dissonance-based interventions (CDIs) have been well established as effective programs for the prevention of eating disorders. However, limited research has qualitatively explored adolescent girls experience of such interventions. The present study examined the acceptability of a cognitive dissonance-based body image intervention among adolescent girls in UK secondary schools. Adolescent girls aged 14-18 years (N = 99; M_age = 14.87, SD = 0.97) who opted to participate in the intervention were invited to provide intervention feedback via open-ended questions and small focus groups. The findings suggest that the intervention was largely acceptable among adolescent girls. Peers played an important role. Despite initial concerns about sharing within the group, the groups provided a sense of belonging and participants no longer felt alone in their experience of body dissatisfaction. Participants discussed a transition from negative to positive body image following the intervention. Although acceptability was generally high, the data provides some interesting insights into potential considerations and modifications which may be advantageous in future CDIs. These include enhancing authenticity through reduced reliance on the script, inclusion of more personal content from the peer-leaders, and more interactive activities and physical movement.

Digital Bodies: A controlled evaluation of a brief classroom-based intervention for reducing negative body image among adolescents in the digital age

BACKGROUND

A growing body of research has linked social media use to negative body image.

AIMS

The present research aimed to evaluate the efficacy of Digital Bodies, a brief classroom-based intervention that aims to improve adolescents' body image.

METHODS

British adolescents (N = 290; Age M = 12.81; SD = 0.40; Range = 12-13; Female = 151) were cluster randomized to intervention or waiting list control groups. Measures of body satisfaction, appearance ideal internalization (thin and athletic ideal internalization) and self-objectification were completed at baseline (T1), 1-week post-intervention (T2) and 8-week follow-up (T3).

RESULTS

Multi-level modelling showed adolescents in the intervention group reported improved body satisfaction at T2, in comparison to the control, and crucially this effect was sustained at T3. Additionally, girls reported less thin ideal internalization at T2 relative to the control, but this effect was not sustained at T3. No other intervention effects were found.

CONCLUSIONS

Overall, the findings provide initial support for the efficacy of Digital Bodies as an intervention for improving adolescents' body satisfaction.

Evaluating the impact of a brief Health at Every Size®-informed health promotion activity on body positivity and internalized weight-based oppression

Weight-based oppression, including negative attitudes about body weight, and harassment, stigma, and discrimination based on body weight, is a widespread phenomenon that leads to considerable distress and poor health and wellbeing outcomes. Conversely, body positivity is a multi-faceted concept that encompasses body acceptance, body appreciation, and body love, and adaptive approaches protective of health and wellbeing. The aim of this study was to evaluate the impact of a brief health promotion activity informed by Health at Every Size® and critical health promotion principles on body positivity and internalized weight-based oppression in female students at Qatar University. A quasi-experimental mixed methods pre-post evaluation design was used, with quantitative assessment of body positivity and internalized weight-based oppression before the activity, immediately afterwards, and 10 weeks later, and qualitative assessment at the 10-week follow up. Measures used were the Body Appreciation Scale 2, Modified Weight Bias Internalization Scale, Fat Attitudes Assessment Toolkit Size Acceptance and Self Reflection on Body Acceptance subscales, and an open-ended questionnaire. Body acceptance and appreciation increased significantly after the activity. Qualitative results suggest that these improvements were sustained at follow up. Brief Health at Every Size® informed health promotion activities show potential to improve health and wellbeing.

Body talk in the digital age: A controlled evaluation of a classroom-based intervention to reduce appearance commentary and improve body image

This research evaluates the efficacy of a classroom-based intervention - Body Talk in the Digital Age (BTIDA) - in reducing adolescents' appearance commentary and improving body image. British adolescents (N = 314; Age Range = 12-14) were cluster randomised to intervention or waiting-list control groups. Measures of appearance commentary, appearance ideal internalisation, self-objectification and body satisfaction were completed at baseline (T1), then one-week (T2) and eight-week (T3) post-intervention. Multi-level modelling showed girls who received BTIDA reported less appearance commentary engagement and thin ideal internalisation at T2 and T3, than the control, supporting the partial efficacy of BTIDA for girls. No intervention effects were found among boys.

'Everybody's Different: The Appearance Game'. A randomised controlled trial evaluating an appearance-related board game intervention with children aged 9-11 years

This study evaluated the effectiveness of an educational board game aimed at increasing knowledge of appearance-related issues, positive body image, media literacy, and acceptance of appearance diversity with British school children. Two hundred and fifty-nine children, aged 9-11 (Mage = 10.26), from three primary schools in South-West England participated in a two-arm matched cluster randomised controlled trial. Outcome measures were collected pre-, post- and at two-week follow-up. Knowledge of appearance-related issues significantly increased in the intervention group, compared to the control group post-intervention, but was not maintained at follow-up. There were no significant differences between groups for body appreciation, media literacy or acceptance of visible difference. Of the intervention arm, 78 % (n=117) they would like to play again and 85.3 % (n=128) thought other children would like to play. Qualitative data suggests participants learned the key messages of the game. The findings suggest 'Everybody's Different: The Appearance Game' is an enjoyable way to increase knowledge of appearance-related issues. In future, researchers should consider how to increase body appreciation, media literacy and acceptance of appearance diversity, for example by increasing the dosage of the game or using it in conjunction with discussions and lessons surrounding appearance diversity and appearance-altering conditions.

Social media, body satisfaction and well-being among adolescents: A mediation model of appearance-ideal internalization and comparison

Despite adolescents' prolific use of social media, relationships between social media and body satisfaction and well-being are not yet well understood, especially among boys. This study tested a sociocultural model of body image within the context of social media among adolescent boys and girls. Specifically, this study examined whether appearance-ideal internalization and social appearance comparisons mediated relationships between social media engagement (intensity and appearance-focused use) and body satisfaction and subjective well-being. Australian adolescents between 11 and 17 years (N = 1,579, M_age = 13.45 years, SD = 1.15; 55.4 % boys) completed an online survey. Structural equational modelling indicated that only higher appearance-focused social media use was directly associated with lower body satisfaction and well-being. Generally, higher appearance-ideal internalization and comparisons mediated the relationships between higher social media engagement and lower body satisfaction and well-being. Multi-group analyses indicated these relationships were equivalent across gender. Findings supported the proposed model among boys and girls and extend existing theoretical knowledge to encompass male body image and well-being. Interventions which target internalization and comparisons in the context of social media are likely to be valuable in improving body satisfaction and subjective well-being in co-educational settings.

Body dissatisfaction predicts the onset of depression among adolescent females and males: a prospective study

RATIONALE

Body dissatisfaction is prevalent in mid-adolescence and may be associated with the onset of depression.

OBJECTIVE

The study assessed the influence of body dissatisfaction on the occurrence of later depressive episodes in a population-based sample of British adolescents.

METHOD

Participants were 2078 females and 1675 males from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Logistic regression was used to test if body dissatisfaction at 14 years old predicted the onset of depressive episodes at 18 years old, controlling for baseline depression.

RESULTS

Among females, body dissatisfaction predicted mild (OR=1.63, 95% CI=1.31, 2.04), moderate (OR=1.67, 95% CI=1.28, 2.18) and severe depressive episodes (OR=1.84, 95% CI=1.09, 3.12). Among males, body dissatisfaction predicted mild (OR=1.50, 95% CI=1.00, 2.25) and severe depressive episodes (OR=2.85, 95% CI=1.18, 6.87) at 18 years of age.

CONCLUSIONS

This is the first prospective study to demonstrate that body dissatisfaction in adolescence predicts the occurrence of later depressive episodes in a cohort born in the early 1990s. The findings highlight that body dissatisfaction is a public health concern.

Clinician-led, peer-led, and internet-delivered dissonance-based eating disorder prevention programs: Effectiveness of these delivery modalities through 4-year follow-up

OBJECTIVE

Independent trials have found that the dissonance-based Body Project eating disorder prevention program is efficacious and effective; the present trial provided the first test of whether delivery could be task-shifted from clinician-delivery to peer educator-delivery or Internet-delivery without loss of effectiveness through 4-year follow-up.

METHOD

Young women at high-risk for eating disorders because of body image concerns (N = 680, Mage = 22.2) recruited at 3 colleges were randomized to clinician-led Body Project groups, peer-led Body Project groups, the Internet-based eBody Project, or educational video control.

RESULTS

Participants in clinician- and peer-led Body Project groups and the eBody Project generally showed larger reductions in risk factors and eating disorder symptoms versus controls through 1- and 2-year follow-up (d = .16-.59), with some effects persisting through 3- and 4-year follow-ups (d = .28-.58). Peer-led Body Project participants showed greater reductions in some risk factors than eBody Project participants (d = .18-.19), but no other contrasts between Body Project interventions differed. Eating disorder onset over 4-year follow-up was significantly lower for peer-led Body Project participants (8.1%) than control participants (17.6%) and clinician-led Body Project participants (19.3%), and marginally lower than eBody Project participants (15.5%).

CONCLUSIONS

The evidence that all three Body Project interventions outperformed educational video controls, peer-led groups outperformed the Internet-based intervention, and peer-led groups showed lower eating disorder onset over 4-year follow-up than the other conditions are novel. Results imply that it might be optimal to task-shift Body Project delivery to peer-leaders to address implementation barriers associated with clinician-led delivery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Cognitive-behavioral roots of body image therapy and prevention

The existing array of evidence-based body image prevention and intervention approaches has evolved over time. However, the majority originated directly or indirectly from a cognitive-behavioral conceptualisation of body image pioneered by Thomas F. Cash. In this way, it is difficult to overstate the impact Tom Cash has had on body image intervention research and practice. His ground-breaking work, building on the work of Schilder and Fisher, was the first to provide a comprehensive model of body image that reflected the broad range of influences and consequences of body image. His differentiation of the components of body image as a construct and between body image traits and states allowed us to identify and influence targets for intervention. Moreover, the intervention strategies that Tom Cash employed are still used today and laid the foundations for contemporary intervention programs. There is a gap of more than 15 years between the first and last of us receiving our PhDs, yet Cash's work has been an important influence on us all. We are extremely grateful for the theoretical and practical tools that he has given to our field. In this paper, we will outline how Cash's work has informed contemporary body image intervention and prevention. We will describe Cash's theory and intervention tools before discussing how this work paved the way for subsequent research and practice.

The effectiveness of interventions aiming to promote positive body image in adults: A systematic review

Theory suggests promoting positive body image (PBI) through interventions would have a significant impact on health and well-being. However, little is known about the effectiveness of existing interventions. This review aimed to identify and assess the evidence of effectiveness of interventions to increase PBI in adults. Database searches were conducted using CINAHL Plus, Medline, PsychINFO, Wiley Online Library, and SCOPUS. Application of inclusion criteria and data extraction were conducted by two reviewers. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool, and narrative synthesis was conducted. Fifteen studies, evaluating 13 interventions, were included. Three studies, evaluating one online writing-based functionality intervention, were judged to have strong methodological quality and had evidence of improving body appreciation, body esteem, and functionality satisfaction. Six moderate quality studies found interventions using intuitive eating, CBT, self-compassion, and exercise improved PBI. There was limited evidence of effectiveness of interventions for men, suggesting future research is needed to better understand PBI mechanisms in men. Lack of heterogeneity of outcome measures is discussed as a limitation. Findings suggest existing interventions are effective at increasing aspects of PBI among women and support the development of interventions that target multiple components of PBI.

A controlled trial of a dissonance-based eating disorders prevention program with Brazilian girls

BACKGROUND

Given that most young women with eating disorders do not receive treatment, implementing effective prevention programs is a public health priority. The Body Project is a group-based eating disorder prevention program with evidence of both efficacy and effectiveness. This trial evaluated the efficacy of this prevention program with Brazilian girls, as no published study has tested whether this intervention is culturally sensitive and efficacious with Latin-American adolescents.

METHODS

Female students were allocated to a dissonance-based intervention (n = 40) or assessment-only (n = 22) condition. The intervention was a dissonance-based program, consisted of four group sessions aimed to reduce thin-ideal internalization. The sessions included verbal, written, and behavioral exercises. The intervention group was evaluated at pretest and posttest; assessment-only controls completed measures at parallel times.

RESULTS

Compared to assessment-only controls, intervention participants showed a significantly greater reduction in body dissatisfaction, sociocultural influence of the media, depressive symptoms, negative affect, as well as significantly greater increases in body appreciation. There were no significant effects for disordered eating attitudes and eating disorder symptoms.

CONCLUSIONS

These results suggest that this dissonance-based eating disorder prevention program was culturally sensitive, or at least culturally adaptive, and efficacious with Brazilian female adolescents. Indeed, the average effect size was slightly larger than has been observed in the large efficacy trial of this prevention program and in recent meta-analytic reviews.

TRIAL REGISTRATION

RBR-7prdf2 . Registered 13 August 2018 (retrospectively registered).

The healthy body image (HBI) intervention: Effects of a school-based cluster-randomized controlled trial with 12-months follow-up

We examined the effects of the Healthy Body Image (HBI) intervention on positive embodiment and health-related quality of life among Norwegian high school students. The intervention comprised three interactive workshops, with body image, media literacy, and lifestyle as main themes. In total, 2,446 12^th grade boys (43%) and girls (mean age 16.8 years) from 30 high schools participated in a cluster-randomized controlled study with the HBI intervention and a control condition as the study arms. Data were collected at baseline, post-intervention, 3- and 12-months follow-up, and analysed using linear mixed regression models. The HBI intervention caused a favourable immediate change in positive embodiment and health-related quality of life among intervention girls, which was maintained at follow-up. Among intervention boys, however, weak post-intervention effects on embodiment and health-related quality of life vanished at the follow-ups. Future studies should address steps to make the HBI intervention more relevant for boys as well as determine whether the number of workshops or themes may be shortened to ease implementation and to enhance intervention effects.

Eating Disorder Prevention

Thirteen percent of girls and women experience an eating disorder, yet most do not receive treatment. Thus, broad implementation of eating disorder prevention programs that reduce eating disorder symptoms and future eating disorder onset is a critical priority. This article (1) reviews risk factors that have been shown to predict future onset of eating disorders, because this should guide the content of prevention programs and high-risk subgroups to target with selective prevention programs; (2) reviews the evidence base for eating disorder prevention programs that have reduced eating disorder symptoms or future onset of eating disorders; and (3) discusses directions for future research.

Meta-analytic review of dissonance-based eating disorder prevention programs: Intervention, participant, and facilitator features that predict larger effects

Many trials have provided support for dissonance-based eating disorder prevention programs. This meta-analytic review characterized the average intervention effects and tested whether various intervention, participant, and facilitator features correlated with larger effects to guide implementation of optimally effective versions of this program. We identified 56 trials that evaluated 68 dissonance-based eating disorder prevention programs (7808 participants). Average intervention effect sizes (d) relative to minimal intervention control conditions and credible alternative interventions (respectively) were 0.57 and 0.31 for thin-ideal internalization, 0.42 and 0.18 for body dissatisfaction, 0.37 and 0.17 for dieting, 0.29 and 0.21 for negative affect, and 0.31 and 0.13 for eating disorder symptoms. As hypothesized, effects were larger for interventions with more dissonance-inducing activities, more group sessions, and larger group sizes, as well as when delivered in-person versus on-line, sessions were recorded, participation was voluntary, body dissatisfaction was required, participants were mid-adolescents or adults (versus older adolescence), there were more ethnic minority participants, groups were led by clinicians versus researchers and at least two facilitators, and when facilitators received more training and supervision. Unexpectedly from a dissonance-induction perspective, effects were larger when participants were compensated. Results offer directions for maximizing the benefits of implementation efforts with dissonance-based eating disorder prevention programs, and may hold lessons for preventing other public health problems with dissonance-based interventions.

Body Appreciation in Lesbian, Bisexual, and Queer Women: Examining a Model of Social Support, Resilience, and Self-Esteem

Purpose: There is increasing research on positive body image, but no studies to date have examined these constructs in lesbian, bisexual, and queer (LBQ) women. However, LBQ women are at increased risk for mental health concerns and disordered eating, and there is evidence that body appreciation might be both adaptive and protective. This study examined factors that could uniquely relate to body appreciation in LBQ women.

Method: Women identifying as LBQ (N=150) completed demographics and measures of social support, resilience, self-esteem, and body appreciation. We tested a hypothesized mediational model of social support leading indirectly to body appreciation through resilience and self-esteem, controlling for body mass index.

Results: All direct effects, except social support to body appreciation (p=0.696), were significant (ps=0.017–0.001), reflecting a full multiple mediation. As hypothesized, the effect of social support on body appreciation was indirect (p=0.011), through resilience and self-esteem.

Conclusion: This is the first study to investigate factors that might facilitate positive body image in LBQ women. Although preliminary, results suggest social support, resilience, and self-esteem might be important targets of body image interventions with LBQ women.

Factor structure and psychometric properties of the Body Appreciation Scale-2 among adolescents and young adults in Danish, Portuguese, and Swedish

In recent years, the study of body image shifted from focusing on the negative aspects to a more extensive view of body image. The present study seeks to validate a measure of positive body image, the Body Appreciation Scale-2 (BAS-2; Tylka & Wood-Barcalow, 2015a) in Denmark, Portugal, and Sweden. Participants (N = 1012) were adolescents and young adults aged from 12 to 19. Confirmatory factor analyses confirmed the one-dimensional factor structure of the scale. Multi-group confirmatory factor analyses indicated that the scale was invariant across sex and country. Further results showed that BAS-2 was positively correlated with self-esteem, psychological well-being, and intuitive eating. It was negatively correlated with BMI among boys and girls in Portugal but not in Denmark and Sweden. Additionally, boys had higher body appreciation than girls. Results indicated that the BAS-2 has good psychometric properties in the three languages.

Out of "Objectification Limelight"? The Contribution of Body Appreciation to Sexual Adjustment in Midlife Women

According to objectification theory, women become culturally desexualized during midlife and have the opportunity to let go of their propensity to self-objectify. In young women, self-objectification is negatively related to sexual adjustment. Yet little is known about what could ameliorate this relationship or whether it continues after midlife. Body appreciation (i.e., acceptance and positive regard for the body) has been substantiated as a contributor to improved sexual adjustment in young and older women alike. Hence, this study was designed to examine whether it helps mitigate the deleterious effect of self-objectification on sexual function, satisfaction, and distress in women over the age of 50 (n = 193). Path analyses revealed that self-surveillance is related to body shame and appearance anxiety, the latter of which was related to body self-consciousness during sex. In turn, body self-consciousness during sex mediated the relationship between body shame, appearance anxiety, and all three indicators of sexual adjustment. Furthermore, high body appreciation attenuated the negative associations between self-objectification constructs, body self-consciousness during sex, and sexual satisfaction and distress. Overall, this study supports the use of objectification theory in midlife and older women. Sex therapy interventions that incorporate mindfulness and body appreciation principles are discussed.

A pilot controlled trial of a cognitive dissonance-based body dissatisfaction intervention with young British men

This pilot study evaluated a body image intervention for men, Body Project M. Seventy-four British undergraduate men took part in two 90-min intervention sessions, and completed standardised assessments of body image, bulimic pathology, and related outcomes at baseline, post-intervention, and 3-month follow-up. Fifty-three other men completed the questionnaires as an assessment-only control group. Per-protocol analysis showed that Body Project M improved men's dissatisfaction with body fat and muscularity, body appreciation, muscularity enhancing behaviours, appearance comparisons, and internalization (ds=0.46-0.80) at post-intervention. All except dissatisfaction with muscularity and internalization were sustained at 3-month follow-up. No effects were found for bulimic pathology. Post-intervention effects for dissatisfaction with muscularity and internalization only were retained under intention-to-treat analysis. Participants were favourable towards the intervention. This study provides preliminary evidence for the acceptability and post-intervention efficacy of Body Project M. Further development of the intervention is required to improve and sustain effects.

Clinician-led, peer-led, and internet-delivered dissonance-based eating disorder prevention programs: Acute effectiveness of these delivery modalities

OBJECTIVE

Because independent trials have provided evidence for the efficacy and effectiveness of the dissonance-based Body Project eating disorder prevention program, the present trial tested whether clinicians produce the largest intervention effects, or whether delivery can be task-shifted to less expensive undergraduate peer educators or to Internet delivery without effect size attenuation, focusing on acute effects.

METHOD

In this study, 680 young women (Mage = 22.2 years, SD = 7.1) recruited at colleges in 2 states were randomized to clinician-led Body Project groups, peer-led Body Project groups, the Internet-based eBody Project, or an educational video control condition.

RESULTS

Participants in all 3 variants of the Body Project intervention showed significantly greater reductions in eating disorder risk factors and symptoms than did educational video controls. Participants in clinician-led and peer-led Body Project groups showed significantly greater reductions in risk factors than did eBody Project participants, but effects for the 2 types of groups were similar. Eating disorder onset over 7-month follow-up was significantly lower for peer-led Body Project group participants versus eBody Project participants (2.2% vs. 8.4%) but did not differ significantly between other conditions.

CONCLUSIONS

The evidence that all 3 dissonance-based prevention programs outperformed an educational video condition, that both group-based interventions outperformed the Internet-based intervention in risk factor reductions, and that the peer-led groups showed lower eating disorder onset over follow-up than did the Internet-based intervention is novel. These acute-effects data suggest that both group-based interventions produce superior eating disorder prevention effects than does the Internet-based intervention and that delivery can be task-shifted to peer leaders. (PsycINFO Database Record

Adapting the Body Appreciation Scale-2 for Children: A psychometric analysis of the BAS-2C

Positive body image among adults is related to numerous indicators of well-being. However, no research has explored body appreciation among children. To facilitate our understanding of children's positive body image, the current study adapts and validates the Body Appreciation Scale-2 (BAS-2; Tylka & Wood-Barcalow, 2015a) for use with children. Three hundred and forty-four children (54.4% girls) aged 9-11 completed the adapted Body Appreciation Scale-2 for Children (BAS-2C) alongside measures of body esteem, media influence, body surveillance, mood, and dieting. A sub-sample of 154 participants (62.3% girls) completed the questionnaire 6-weeks later to examine stability (test-retest) reliability. The BAS-2C displayed a unidimensional factor structure and evidence of internal consistency, test-retest reliability, and construct, criterion-related, and incremental validity. Additionally, the results suggest adaptive properties of body appreciation for body-related and emotional well-being among children. The BAS-2C could serve as an essential component within research to understand and estimate children's positive body image.

Participant feedback from peer-led, clinician-led, and internet-delivered eating disorder prevention interventions

OBJECTIVE

This article examines qualitative participant feedback to clinician-delivered groups, peer-delivered groups, and an Internet version of a dissonance-based eating disorder prevention program from a controlled trial. These data have not been systematically examined and can inform the refinement and implementation of eating disorder prevention programs.

METHOD

Feedback was collected from body dissatisfied young women (N = 680; M age = 22.2, SD = 7.1) randomized to a clinician-led group, peer-led group, Internet version of this prevention program or to an educational video.

RESULTS

Clinician and peer-led group participants reported the group setting, feeling that they were not alone, and the letter exercise as most valuable; the most common response of what was less valuable was "none." Many participants of the Internet version suggested increasing community support.

CONCLUSIONS

Findings suggest the importance of considering the therapeutic value of group membership, and that online prevention programs could be enhanced by providing a mechanism for community support, such as an online forum. Results also inform selective prevention and suggest that screening potential participants to determine which delivery method best suits them should be considered. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1087-1092).

Dismantling prevention: Comparison of outcomes following media literacy and appearance comparison modules in a randomised controlled trial

A dismantling study of body dissatisfaction prevention was conducted. Adolescent girls ( N = 260) were randomly allocated to a media literacy (Happy Being Me – Media Literacy) or appearance comparison (Happy Being Me – Appearance Comparison) intervention or healthy eating behaviour control (Happy Being Me – Healthy Eating Behaviour) condition. In the Happy Being Me – Appearance Comparison condition, improvements from baseline to post-programme and follow-up for upward appearance comparison and fear of negative appearance evaluation were observed. In the Happy Being Me – Media Literacy condition, improvements were observed from baseline to post-programme for upward appearance comparison and realism scepticism. Findings were similar in a high-risk subsample and overall are moderately supportive of appearance comparison-based interventions, but less supportive of a stand-alone media literacy intervention.

Predicting body appreciation in young women: An integrated model of positive body image

This study examined a range of predictors, based on previous theoretical models, of positive body image in young adult women. Participants were 266 women who completed an online questionnaire measuring body appreciation, activity participation, media consumption, perceived body acceptance by others, self-compassion, and autonomy. Potential mechanisms in predicting body appreciation assessed were self-objectification, social appearance comparison, and thin-ideal internalisation. Results indicated that greater perceived body acceptance by others and self-compassion, and lower appearance media consumption, self-objectification, social comparison, and thin-ideal internalisation were related to greater body appreciation. An integrated model showed that appearance media (negatively) and non-appearance media and self-compassion (positively) were associated with lower self-objectification, social comparison, and thin-ideal internalisation, which in turn related to greater body appreciation. Additionally, perceived body acceptance by others was directly associated with body appreciation. The results contribute to an understanding of potential pathways of positive body image development, thereby highlighting possible intervention targets.

Perceiving beauty in all women: Psychometric evaluation of the Broad Conceptualization of Beauty Scale

Women's ability to broadly conceptualize beauty (i.e., perceive many looks, appearances, body sizes/shapes, and inner characteristics as beautiful) has been identified as a facet of positive body image in qualitative research. A scale is needed to be able to assess this construct within quantitative research. Therefore, we developed the Broad Conceptualization of Beauty Scale (BCBS), which measures the extent women define female beauty widely within external and internal characteristics, and examined its psychometric properties among four community samples totaling 1086 women. Exploratory and confirmatory factor analyses revealed a unidimensional structure with nine items. The internal consistency, test-retest reliability, and construct (convergent, discriminant, and incremental) validity of its scores were upheld. Researchers and clinicians can use the BCBS alone to assess women's perceptions of female beauty, or they can use the BCBS alongside women's perceptions of self-beauty to more comprehensively explore women's ability to broadly conceptualize beauty for others and themselves.

New possibilities in the prevention of eating disorders: The introduction of positive body image measures

Delineating positive psychological processes in inhabiting the body, as well as quantitative measures to assess them, can facilitate progress in the field of prevention of eating disorders by expanding outcome evaluation of prevention interventions, identifying novel mediators of change, and increasing highly needed research into protective factors. Moreover, enhancing positive ways of inhabiting the body may contribute toward the maintenance of gains of prevention interventions. Integrated social etiological models to eating disorders that focus on gender and other social variables, such as the Developmental Theory of Embodiment (Piran & Teall, 2012a), can contribute to positive body image intervention development and research within the prevention field. Using the Developmental Theory of Embodiment as a lens, this article explores whether existing prevention programs (i.e., Cognitive Dissonance and Media Smart) may already work to promote positive body image, and whether prevention programs need to be expanded toward this goal.

Future directions for positive body image research

The emergence of positive body image research during the last 10 years represents an important shift in the body image literature. The existing evidence provides a strong empirical basis for the study of positive body image and research has begun to address issues of age, gender, ethnicity, culture, development, and intervention in relation to positive body image. This article briefly reviews the existing evidence before outlining directions for future research. Specifically, six areas for future positive body image research are outlined: (a) conceptualization, (b) models, (c) developmental factors, (d) social interactions, (e) cognitive processing style, and (f) interventions. Finally, the potential role of positive body image as a protective factor within the broader body image literature is discussed.

What is and what is not positive body image? Conceptual foundations and construct definition

A decade ago, research on positive body image as a unique construct was relatively nonexistent, and now this area is flourishing. How and why did positive body image scholarship emerge? What is known about this contemporary construct? This article situates and contextualizes positive body image within Cash's scholarship, eating disorder prevention efforts, feminist influences, strength-based disciplines within psychology, and Buddhism. Extracting insights from quantitative and qualitative research, this article demonstrates that positive body image is (a) distinct from negative body image; (b) multifaceted (including body appreciation, body acceptance/love, conceptualizing beauty broadly, adaptive investment in appearance, inner positivity, interpreting information in a body-protective manner); (c) holistic; (d) stable and malleable; (e) protective; (f) linked to self-perceived body acceptance by others; and (g) shaped by social identities. Complementing what positive body image is, this article further details what positive body image is not to provide a more nuanced understanding of this construct.