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Body Project

Body Project

A multi-session group intervention designed to prevent the onset of eating disorders such as anorexia, bulimia, and binge eating among female high school and college students with body image concerns.

Fact Sheet

Program Outcomes

  • Mental Health - Other
  • Physical Health and Well-Being

Program Type

  • Counseling and Social Work
  • School - Individual Strategies

Program Setting

  • Mental Health/Treatment Center
  • School

Continuum of Intervention

  • Selective Prevention

Age

  • Late Adolescence (15-18) - High School
  • Early Adulthood (19-22)

Gender

  • Female

Race/Ethnicity

  • All

Endorsements

Blueprints: Model

Program Information Contact

Paul Rohde, Ph.D.
Oregon Research Institute
1776 Millrace Drive
Eugene, OR 97403-2536
(541) 484-1108
paulr@ori.org

Program Developer/Owner

Eric Stice
Oregon Research Institute


Brief Description of the Program

Body Project is a prevention program designed for high school and college-age girls using four weekly one-hour group sessions. Groups consist of 5-10 young women. Through a series of verbal, written and behavioral exercises, the program attempts to create dissonance in participants by engaging them in a critique of the thin ideal. Participants are also engaged in body acceptance exercises and role-plays to counter thin-ideal statements and resist peer pressure. Facilitators (group leaders with Master's-level training in a clinical mental health discipline or supervised college peer educators), use activities that are counter-attitudinal to the thin ideal and use motivational enhancement, skill acquisition, social support and group cohesion to create dissonance within the participants. The Body Project is not sufficient as a stand-alone treatment for individuals meeting current criteria for an eating disorder, so attempts should be made to exclude such individuals.

Outcomes

In the first study using female high school and college students (Stice et al., 2006), the dissonance intervention relative to assessment-only or expressive writing controls produced significantly greater improvement in:

  • thin-ideal internalization at posttest, 6-month, 1-year and 2-year follow-up
  • body dissatisfaction at posttest, 6-month, 2-year and 3-year follow-up
  • dieting at posttest, 6-month and 1-year follow-up
  • negative affect at posttest, 6-month, 2-year and 3-year follow-up
  • bulimic symptoms at posttest, 6-month, 1-year and 2-year follow-up
  • risk of obesity onset over the 1-year follow-up
  • psychosocial impairment at 2-year and 3-year follow-up
  • risk for eating pathology onset over the 3-year follow-up

In the second study (Stice et al., 2003), significant differences between dissonance intervention participants and waitlist control participants were found for reductions in:

  • negative affect
  • bulimic symptoms

In the third study (Stice et al., 2001), significant differences between dissonance intervention participants and healthy weight placebo control participants were found for reductions in:

  • thin-ideal internalization

In the fourth study (Stice et al., 2009, 2011), positive effects were found for:

  • eating disorder symptoms at posttest, 6-month follow-up, 1-year and 3-year follow-up
  • thin-ideal internalization at posttest
  • body dissatisfaction at posttest, 6-month follow-up, 1-year and 3-year follow-up
  • dieting at posttest and 1-year follow-up

In the fifth study with college students (Stice et al., 2013, 2015), the following outcomes were significantly improved from baseline to 1-year follow-up and 2- and 3-year follow-ups:

  • negative affect
  • eating disorder symptoms

Regarding program effects on risk/protective factors, the following were significantly improved for the intervention participants compared to the control participants from baseline to 1-year follow-up and 2- and 3-year follow-ups:

  • thin-ideal internalization
  • body dissatisfaction
  • dieting
  • psychosocial functioning

Brief Evaluation Methodology

All five studies had a similar recruitment and randomized controlled design. The first study (Stice et al., 2006, 2007, 2008) sought to determine the effectiveness of the dissonance intervention compared to three other conditions: healthy weight intervention, expressive-writing control intervention, and assessment-only control intervention. Participants were recruited for this study from high schools and one university using mailings, flyers and leaflets that invited female participants between the ages of 14 and 19 with body image concerns to participate in the study to help them accept their bodies. The only exclusion criterion was meeting the diagnosis for an eating disorder. A total of 481 participants were randomly assigned to one of four conditions: dissonance intervention (n=115), healthy weight intervention (n=117), expressive-writing control intervention (n=123), or assessment-only control intervention (n=126). Data were collected at pretest, posttest, and at 6-month, 1-year, 2-year, and 3-year follow-ups after posttest. The mediation analysis also reported on data collected weekly from baseline to posttest.

The second study (Stice et al., 2003) sought to evaluate the effectiveness of the dissonance intervention against a healthy weight intervention and a waitlist control. Using flyers and announcements in large classes, participants were recruited from three high schools and one university. A total of 148 female students were randomized to one of three conditions resulting in the following distribution after attrition: dissonance intervention (n=48); healthy weight intervention (n=51); or, waitlist control (n=36). Data were collected at baseline, post-intervention, and 1-, 3- and 6-month follow-ups.

The third study (Stice et al., 2001) sought to evaluate the effectiveness of the dissonance intervention against a healthy weight placebo control condition. Using flyers and email messages, participants were recruited from two universities and one community college. A total of 87 female students were randomized to the dissonance intervention (n=48) and the healthy weight placebo control (n=39). Data were collected at baseline, post-intervention (week 3), and at 4-week follow-up (week 7).

The fourth study (Stice et al., 2009 and 2011) evaluated the effectiveness of the four-session version of the intervention delivered by high school nurses, teachers and counselors rather than by the investigators compared to a control condition. A total of 306 students were randomly assigned to the intervention (n=139) or control (n=167) conditions. Assessments were conducted at pretest, immediate posttest, 6-month follow-up, and at 1-, 2-, and 3-year follow-ups.

The fifth study (Stice et al., 2013, 2015) evaluated the effectiveness of the four-session, enhanced version of the intervention delivered by clinicians to female college students compared to a control condition. Participants were recruited from seven Universities in Oregon, Texas and Pennsylvania. A total of 408 students were randomly assigned to the intervention (n=203) or control (n=205) conditions. Assessments were conducted at pretest, immediate posttest, 1-year follow-up, 2-year follow-up, and 3-year follow-up.

Study 1

Stice, E., Shaw, H., Burton, E., & Wade, E. (2006). Dissonance and healthy weight eating disorder prevention programs: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 74(2), 263-275.


Study 2

Stice, E., Trost, A., & Chase, A. (2003). Healthy weight control and dissonance-based eating disorder prevention programs: Results from a controlled trial. International Journal of Eating Disorders, 33, 10-21.


Study 3

Stice, E., Chase, A., Stormer, S., & Appel, A. (2001). A randomized trial of a dissonance-based eating disorder prevention program. International Journal of Eating Disorders, 29, 247-262.


Study 4

Stice, E., Rohde, P., Gau, J., & Shaw, H. (2009). An effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescent girls. Journal of Consulting and Clinical Psychology, 77(5), 825-834.

Stice, E., Rohde, P., Shaw, H., & Gau, J. (2011). An effectiveness trial of a selected dissonance-based eating disorder prevention program for female high school students: Long-term effects. Journal of Consulting and Clinical Psychology, 79(4), 500-508.


Study 5

Stice, E., Butryn, M., Rohde, P., Shaw, H., & Marti, C. (2013). An effectiveness trial of a new enhanced dissonance eating disorder prevention program among female college students. Behaviour Research and Therapy, 51(12), 862-871.

Stice, E., Rohde, P., Butryn, M., Shaw, H., & Marti, C. N. (2015). Effectiveness trial of a selective dissonance-based eating disorder prevention program with female college students: Effects at 2- and 3-year follow-up. Behaviour Research and Therapy, 71, 20-26.


Risk Factors

Individual: Body Image Concerns*

See also: Body Project Logic Model (PDF)

Female high school and college students with body image concerns who do not meet criteria for an eating disorder.

Gender Specific Findings
  • Female
Race/Ethnicity/Gender Details

The samples across all the studies were entirely female, with the following racial make-up in Stice et al. (2006, 2007, 2008): 58% White, 19% Latino, 10% Asian, 6% Black and 7% other race/ethnicity; and the following racial make-up in Stice et al. (2003): 63% White, 16% Hispanic, 13% Asian, 2% African American, and 6% other race/ethnicity. Stice et al. (2009, 2011) had a primarily White sample and the college student sample in Stice et al. (2013, 2015) had the following racial make-up: 58% European American, 17% Asian, 13% Hispanic, 7% African American, 4% American Indian/Alaska Native, and 1% Native Hawaiian/Pacific Islander.

Two training options are provided (1-day for mental health professionals; 2-day for peer educators), in addition to hourly consultation.

1 Full-Day Training: Clinician or University/High School Staff Body Project Training
Cost: $1250 (plus trainer travel expenses) at customer's site - up to 16 participants

2 Full-Day Training: Combined Peer Leader and Train-the-Trainer Clinician Body Project Training
Cost: $2500 (plus trainer travel expenses) at customer's site - up to 16 student participants and 6 clinician participants

Recommended Post-Training Supervision:
Cost: $125 per hour

Developed using a community participatory research methodology, the 2-day training model has been repeatedly used during naturalistic clinical implementation of the Body Project and other prevention programs (i.e., has been extensively field tested). In this training, individuals are trained as Body Project facilitators while supervisors can be simultaneously trained in a “train-the-trainer” approach. Everyone is strongly encouraged to read the intervention script before the training, which includes an introduction describing the conceptual rationale for the intervention and delivery tips. A master trainer first walks everyone through the manual, reviewing the theoretical basis of the intervention, structure of the manual, and general rationale behind all major activities. Next, trainees lead an abbreviated version of the first half of the sessions, with the trainer observing and the remaining participants serving as mock participants. Trainees are encouraged to initially read directly from the script, but can closely paraphrase the material once they become familiar with it. The master trainer then supervises the trainees (and models how to provide supervision for the trainers-in-training, if applicable). Facilitators switch roles to lead the first half of sessions. This process is repeated, so that by the end of training everyone has experienced/observed all of the sessions and had an opportunity to lead these sessions at least once, with supervisory feedback. Trainees are encouraged to complete some of the home exercises between the two days of training to experience that component of the program.

In these workshops trainees gain experience in general group leadership skills (e.g., summarizing, transitions, non-verbal behaviors), how to respond to talkative and quiet participants, how to respond to participants reluctant to discuss costs of the thin ideal, how best to present the material (i.e., interacting with the group while writing on a whiteboard), and challenges of sticking to a scripted intervention while addressing ongoing group dynamics. Trainees also learn procedures to maximize homework completion, attendance, and retention, and how to arrange make-up sessions. Finally, trainees learn how to address group members who either develop or first reveal that they have an eating disorder or other mental health condition during groups.

Program Costs

Start-Up Costs

Initial Training and Technical Assistance

Results from both our efficacy and effectiveness trials are based on facilitators who have completed formal training.

Please visit the Body Project Collaborative at http://www.bodyprojectcollaborative.com/ for detailed training costs and more information. Two training options are provided (1-day for mental health professionals; 2-day for peer educators), in addition to hourly consultation.

1 Full-Day Training: Clinician or University/High School Staff Body Project Training
Cost: $1250 (plus trainer travel expenses) at customer's site - up to 16 participants

2 Full-Day Training: Combined Peer Leader and Train-the-Trainer Clinician Body Project Training
Cost: $2500 (plus trainer travel expenses) at customer's site - up to 16 student participants and 6 clinician participants

Recommended Post-Training Supervision:
Cost: $125 per hour

Curriculum and Materials

Free for download at facilitator support website: http://www.bodyprojectsupport.org/

Materials Available in Other Language: The four-session program script is available in Spanish, German, French, Portuguese, and Italian.

Licensing

None.

Other Start-Up Costs

Facilitators should have access to a room large enough to accommodate a group of 5-10 young women. Ideally, a large table for participants to write in session and a white/marker board for the group leader to present material are available.

Intervention Implementation Costs

Ongoing Curriculum and Materials

None.

Staffing

Group leaders with Master’s-level training in a clinical mental health discipline (or equivalent) should have an adequate amount of relevant experience and training to offer this intervention. Individuals who are not adequately trained for independent practice (e.g., college students, teachers who do not have a mental health background) should only conduct the Body Project under the supervision of a qualified mental health professional.

Other Implementation Costs

No information is available

Implementation Support and Fidelity Monitoring Costs

Ongoing Training and Technical Assistance

Consultation available at $125 per hour. Please contact the Body Project Collaborative at www.bodyprojectcollaborative.com/.

Fidelity Monitoring and Evaluation

Detailed checklists are available from the developers (see facilitator website) to assess intervention adherence and facilitator competence. Protocol adherence can be measured using session-specific checklists for the concepts, skills, and exercises that are outlined in the session script. Each adherence item is rated on a 100-point scale (initially a 10-point scale but expanded to 100-point using the same behavioral anchors) that covers full, partial, or minimal presentation. General facilitator competence is measured using 12 items rated on 100-point scales that assess various general indices of a competent group therapist (e.g., leader expresses ideas clearly and at an appropriate pace, leader keeps group members on task during session). In a recent effectiveness trial (Stice et al., 2013, reference below), pairs of supervisors independently rated half of the sessions selected for rating; ratings were reviewed and discrepancies resolved by consensus. Inter-rater agreement was adequate for fidelity (ICC = .65) and competence (ICC = .72).

Facilitators can self-monitor their adherence and competence as checks or sessions can be recorded and rated by supervisors or colleagues knowledgeable in CBT treatment and prevention interventions.

Post-training supervision can be provided (cost: $125/hour). For information, please visit the Body Project Collaborative at http://www.bodyprojectcollaborative.com/.

Stice, E., Butryn, M.L., Rohde, P., Shaw, H., & Marti, C.N. (2013). An effectiveness trial of a new enhanced dissonance eating disorder prevention program among female college students. Behaviour Research and Therapy, 51, 862-871.

Ongoing License Fees

None.

Other Implementation Support and Fidelity Monitoring Costs

No information is available

Other Cost Considerations

No information is available

Year One Cost Example

In this example, a high school uses its counseling and nursing staff to implement the Body Project intervention with female students. Two sessions are held each semester with 10 students per session.

Technical Assistance - 4 hours at $125/hr $500
Trainer travel expenses $1,000
On-site training $1,250
Total Year One Cost $2,750

With two sessions of 10 students each per semester, 40 female students would receive the intervention during Year One. The cost per student would be $68.75.

The actual unit cost will vary depending upon the number of sessions delivered within the school year and whether existing staff are available to deliver the program.

Funding Strategies

Funding Overview

The Body Project is a very low-cost group intervention that is typically implemented by counseling, social work, or nursing staff in high schools or postsecondary settings. The approval of staff time to implement the intervention is the key resource needed for implementation. The initial training costs can potentially be paid for within school district or university training budgets or through private fundraising.

Funding Strategies

Improving the Use of Existing Public Funds

If social workers, counselors, and nurses who are already working with adolescent and young adult girls adopt the Body Project as an intervention, they will likely use the mix of existing funding steams supporting their work to support this intervention.

Allocating State or Local General Funds

A high school or a university counseling center could potentially support the low-cost of initial training within their professional development budgets.

Maximizing Federal Funds

No information is available

Foundation Grants and Public-Private Partnerships

Foundation grants can be considered for the cost of initial training of group leaders. Initial training costs are low and could also potentially be supported through fundraising through school parent-teacher organizations, through college sorority fundraisers, or from individual donors with a particular interest in the program focus.

Debt Financing

No information is available

Generating New Revenue

No information is available

Data Sources

No information is available

Evaluation Abstract

Program Developer/Owner

Eric Stice Oregon Research Institute 1776 Millrace Drive Eugene, OR 97403-2536 USA (541) 484-2123 estice@ori.org

Program Outcomes

  • Mental Health - Other
  • Physical Health and Well-Being

Program Specifics

Program Type

  • Counseling and Social Work
  • School - Individual Strategies

Program Setting

  • Mental Health/Treatment Center
  • School

Continuum of Intervention

  • Selective Prevention

Program Goals

A multi-session group intervention designed to prevent the onset of eating disorders such as anorexia, bulimia, and binge eating among female high school and college students with body image concerns.

Population Demographics

Female high school and college students with body image concerns who do not meet criteria for an eating disorder.

Target Population

Age

  • Late Adolescence (15-18) - High School
  • Early Adulthood (19-22)

Gender

  • Female

Gender Specific Findings

  • Female

Race/Ethnicity

  • All

Race/Ethnicity/Gender Details

The samples across all the studies were entirely female, with the following racial make-up in Stice et al. (2006, 2007, 2008): 58% White, 19% Latino, 10% Asian, 6% Black and 7% other race/ethnicity; and the following racial make-up in Stice et al. (2003): 63% White, 16% Hispanic, 13% Asian, 2% African American, and 6% other race/ethnicity. Stice et al. (2009, 2011) had a primarily White sample and the college student sample in Stice et al. (2013, 2015) had the following racial make-up: 58% European American, 17% Asian, 13% Hispanic, 7% African American, 4% American Indian/Alaska Native, and 1% Native Hawaiian/Pacific Islander.

Other Risk and Protective Factors

Thin-ideal internalization, body dissatisfaction, dieting, psychosocial functioning, health care utilization and mental health care utilization were all examined as risk/protective factors.

Risk/Protective Factor Domain

  • Individual

Risk/Protective Factors

Risk Factors

Individual: Body Image Concerns*

Protective Factors

See also: Body Project Logic Model (PDF)

Brief Description of the Program

Body Project is a prevention program designed for high school and college-age girls using four weekly one-hour group sessions. Groups consist of 5-10 young women. Through a series of verbal, written and behavioral exercises, the program attempts to create dissonance in participants by engaging them in a critique of the thin ideal. Participants are also engaged in body acceptance exercises and role-plays to counter thin-ideal statements and resist peer pressure. Facilitators (group leaders with Master's-level training in a clinical mental health discipline or supervised college peer educators), use activities that are counter-attitudinal to the thin ideal and use motivational enhancement, skill acquisition, social support and group cohesion to create dissonance within the participants. The Body Project is not sufficient as a stand-alone treatment for individuals meeting current criteria for an eating disorder, so attempts should be made to exclude such individuals.

Description of the Program

Body Project (Dissonance Intervention) is a prevention program designed for high school and college-age girls using four weekly one-hour group sessions. Groups consist of 5-10 young women. Through a series of verbal, written and behavioral exercises, the program attempts to create dissonance in participants by engaging them in a critique of the thin ideal. Participants are also engaged in body acceptance exercises and role-plays to counter thin-ideal statements and resist peer pressure. Facilitators (group leaders with Master's-level training in a clinical mental health discipline or supervised college peer educators), use activities that are counter-attitudinal to the thin ideal and use motivational enhancement, skill acquisition, social support and group cohesion to create dissonance within the participants. The Body Project is not sufficient as a stand-alone treatment for individuals meeting current criteria for an eating disorder, so attempts should be made to exclude such individuals.

The four sessions include the following content:

Session 1. Participants are informed that the intervention is based on discussing the costs of the thin ideal, and a verbal commitment to the approach is obtained. The initial session is interactive with participant-driven discussion about the origin and perpetuation of the thin ideal, the impact of messages about the thin ideal, and how corporations profit from this unrealistic standard. For homework, participants are asked to write a letter to a hypothetical younger girl discussing the costs of pursuing the thin ideal and to examine their reflection in a full-length mirror, recording positive aspects of themselves.

Session 2. Following a review of the previous session, participants discuss the homework. They share their reactions to writing the letter and their main costs of pursuing the thin ideal. Additionally, they share their thoughts and feelings about the self-affirmation exercise and what they like about themselves. Then each participant engages in a role-play whereby she attempts to dissuade the group leaders from pursuing the thin ideal. For homework, participants are asked to provide three examples from their lives about pressures to be thin and generate verbal challenges to these pressures. They are also asked to create a top-10 list of things girls/women can do to resist the thin ideal.

Session 3. Participants discuss an example from their lives concerning pressure to be thin and how they might verbally challenge this pressure. They generate "quick comebacks" that challenge thin-ideal statements from peers. Participants then discuss the reasons they signed up for the intervention and identify their body image concerns. They are challenged to engage, within the next week, in a behavioral experiment related to their concerns (e.g., wearing shorts if they have avoided doing so because of body image dissatisfaction). Items are shared from the top-10 lists about ways to resist the thin ideal and participants are asked to enact one of their body activism ideas as homework.

Session 4. Participants discuss their experiences and reactions to the behavioral challenge and body activism exercises, and are encouraged to continue challenging themselves in the future. They discuss the more subtle ways in which the thin ideal is perpetuated and how to address the difficulties that arise in resisting pressures to conform to this ideal. They also learn how to talk about one's body in a positive, rather than a negative, way. Finally, for homework, participants are asked to write a letter to another hypothetical younger girl about how to avoid developing body image concerns, and to engage in another self-affirmation exercise.

Theoretical Rationale

Body Project is based on cognitive dissonance theory that the possession of inconsistent cognitions creates psychological discomfort, which motivates people to alter their cognitions to restore consistency. If girls and young women voluntarily argue against the thin ideal, this will result in a reduced subscription to this ideal and to consequent decreases in eating disorder risk factors and symptoms. Thus, this intervention involves a series of verbal, written, and behavioral exercises in which the students critique the thin ideal. Theoretically, the act of publicly critiquing the thin ideal results in cognitive dissonance among those who originally endorsed this ideal, which causes them to reduce their subscription to the thin ideal. As such, the Body Project intervention attempts to apply persuasion principles, originally identified by social psychologists, to reduce an attitudinal risk factor for eating pathology.

Theoretical Orientation

  • Cognitive Behavioral

Brief Evaluation Methodology

All five studies had a similar recruitment and randomized controlled design. The first study (Stice et al., 2006, 2007, 2008) sought to determine the effectiveness of the dissonance intervention compared to three other conditions: healthy weight intervention, expressive-writing control intervention, and assessment-only control intervention. Participants were recruited for this study from high schools and one university using mailings, flyers and leaflets that invited female participants between the ages of 14 and 19 with body image concerns to participate in the study to help them accept their bodies. The only exclusion criterion was meeting the diagnosis for an eating disorder. A total of 481 participants were randomly assigned to one of four conditions: dissonance intervention (n=115), healthy weight intervention (n=117), expressive-writing control intervention (n=123), or assessment-only control intervention (n=126). Data were collected at pretest, posttest, and at 6-month, 1-year, 2-year, and 3-year follow-ups after posttest. The mediation analysis also reported on data collected weekly from baseline to posttest.

The second study (Stice et al., 2003) sought to evaluate the effectiveness of the dissonance intervention against a healthy weight intervention and a waitlist control. Using flyers and announcements in large classes, participants were recruited from three high schools and one university. A total of 148 female students were randomized to one of three conditions resulting in the following distribution after attrition: dissonance intervention (n=48); healthy weight intervention (n=51); or, waitlist control (n=36). Data were collected at baseline, post-intervention, and 1-, 3- and 6-month follow-ups.

The third study (Stice et al., 2001) sought to evaluate the effectiveness of the dissonance intervention against a healthy weight placebo control condition. Using flyers and email messages, participants were recruited from two universities and one community college. A total of 87 female students were randomized to the dissonance intervention (n=48) and the healthy weight placebo control (n=39). Data were collected at baseline, post-intervention (week 3), and at 4-week follow-up (week 7).

The fourth study (Stice et al., 2009 and 2011) evaluated the effectiveness of the four-session version of the intervention delivered by high school nurses, teachers and counselors rather than by the investigators compared to a control condition. A total of 306 students were randomly assigned to the intervention (n=139) or control (n=167) conditions. Assessments were conducted at pretest, immediate posttest, 6-month follow-up, and at 1-, 2-, and 3-year follow-ups.

The fifth study (Stice et al., 2013, 2015) evaluated the effectiveness of the four-session, enhanced version of the intervention delivered by clinicians to female college students compared to a control condition. Participants were recruited from seven Universities in Oregon, Texas and Pennsylvania. A total of 408 students were randomly assigned to the intervention (n=203) or control (n=205) conditions. Assessments were conducted at pretest, immediate posttest, 1-year follow-up, 2-year follow-up, and 3-year follow-up.

Outcomes (Brief, over all studies)

In the first study using female high school and college students (Stice et al., 2006), the dissonance intervention relative to assessment-only or expressive writing controls produced significantly greater reductions in thin-ideal internalization, body dissatisfaction, dieting, negative affect and bulimic symptoms at posttest and 6-month follow-up; and, significantly greater decreases at 1-year follow-up in thin-ideal internalization, dieting, and bulimic symptoms.

Further, the dissonance intervention produced significantly greater decreases in thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms relative to the healthy weight intervention from pretest to posttest; and it produced significantly greater decreases in negative affect at the 6-month and 1-year follow-ups.

Additional analyses showed significantly higher reliable change rates in bulimic symptoms and lower risk of obesity onset for the dissonance intervention condition than the control groups over the 1-year follow-up.

At the 2- and 3-year follow-ups (Stice et al., 2008), compared to assessment-only controls, dissonance intervention participants showed significantly lower thin-ideal internalization, body dissatisfaction, negative affect, bulimic symptoms and psychosocial impairment at the 2-year follow-up and significantly lower body dissatisfaction, negative affect and psychosocial impairment at the 3-year follow-up.

Compared to expressive writing controls, dissonance intervention participants showed significantly lower thin-ideal internalization and body dissatisfaction at the 2-year follow-up and significantly lower body dissatisfaction and psychosocial impairment at the 3-year follow-up. Further, dissonance participants showed significantly greater reductions in psychosocial impairment than healthy weight participants by the 3-year follow-up.

Lastly, dissonance participants showed significantly lower risk for eating pathology onset than assessment-only controls over the 3-year follow-up.

In the second study (Stice et al., 2003), significant differences between dissonance intervention participants and waitlist control participants were found for two of the five outcomes: reductions in negative affect and bulimic symptoms.

In the third study (Stice et al., 2001), significant differences between dissonance intervention participants and healthy weight placebo control participants were found for one of the eight outcomes: reductions in thin-ideal internalization.

In the fourth study (Stice et al., 2009, 2011), eating disorder symptoms were significantly improved at posttest and this effect was sustained at 6-month follow-up, at one-year follow-up and three-year follow-up, but not at 2-year follow-up. Regarding program effects on risk/protective factors, thin-ideal internalization, body dissatisfaction and dieting were significantly improved for the intervention participants compared to the control participants at immediate posttest. Some, but not all, of these differences were maintained at 1-year and 3-year follow-up.

In the fifth study (Stice et al., 2013), negative affect and eating disorder symptoms were significantly improved from baseline to 1-year follow-up. Regarding program effects on risk/protective factors, thin-ideal internalization, body dissatisfaction, dieting and psychosocial functioning were significantly improved for the intervention participants compared to the control participants from baseline to 1-year follow-up. At the 2- and 3-year follow-up, the primary negative affect and eating disorder symptoms continued to show a significant intervention effect. However, among risk and protective factors, only psychosocial impairment continued to show significant improvement among the treatment group as compared to the control group.

Outcomes

In the first study using female high school and college students (Stice et al., 2006), the dissonance intervention relative to assessment-only or expressive writing controls produced significantly greater improvement in:

  • thin-ideal internalization at posttest, 6-month, 1-year and 2-year follow-up
  • body dissatisfaction at posttest, 6-month, 2-year and 3-year follow-up
  • dieting at posttest, 6-month and 1-year follow-up
  • negative affect at posttest, 6-month, 2-year and 3-year follow-up
  • bulimic symptoms at posttest, 6-month, 1-year and 2-year follow-up
  • risk of obesity onset over the 1-year follow-up
  • psychosocial impairment at 2-year and 3-year follow-up
  • risk for eating pathology onset over the 3-year follow-up

In the second study (Stice et al., 2003), significant differences between dissonance intervention participants and waitlist control participants were found for reductions in:

  • negative affect
  • bulimic symptoms

In the third study (Stice et al., 2001), significant differences between dissonance intervention participants and healthy weight placebo control participants were found for reductions in:

  • thin-ideal internalization

In the fourth study (Stice et al., 2009, 2011), positive effects were found for:

  • eating disorder symptoms at posttest, 6-month follow-up, 1-year and 3-year follow-up
  • thin-ideal internalization at posttest
  • body dissatisfaction at posttest, 6-month follow-up, 1-year and 3-year follow-up
  • dieting at posttest and 1-year follow-up

In the fifth study with college students (Stice et al., 2013, 2015), the following outcomes were significantly improved from baseline to 1-year follow-up and 2- and 3-year follow-ups:

  • negative affect
  • eating disorder symptoms

Regarding program effects on risk/protective factors, the following were significantly improved for the intervention participants compared to the control participants from baseline to 1-year follow-up and 2- and 3-year follow-ups:

  • thin-ideal internalization
  • body dissatisfaction
  • dieting
  • psychosocial functioning

Mediating Effects

The mediation analysis (Stice et al., 2007) used three of the conditions, comparing both dissonance intervention and healthy weight to expressive writing and excluding the no treatment control group. The sample size of 355 was assessed at four time points from baseline to posttest: before the intervention (baseline), after session 1, after session 2, and after session 3 (posttest). The analysis did not use the follow-up data.

The mediation model for the dissonance condition tested thin-ideal internalization as a mediator of four outcomes – body dissatisfaction, dieting, negative affect, and bulimic symptoms – that were linked theoretically to the program goals.

The results indicated that thin-ideal internalization partially mediated the effects of the intervention on the outcomes. Specifically, 1) the intervention group experienced significantly greater improvement in all four outcomes, 2) the intervention group experienced significantly greater improvement in the mediator, 3) changes in thin-ideal internalization significantly affected the outcomes, and 4) the effect of the intervention on the outcomes was significantly reduced after controlling for change in the mediator which accounted for 26% to 48% reduction in the main effects.

Effect Size

Effects sizes were small to medium across all studies.

Generalizability

The sample for the first study was taken from one city and one university; the sample for the second study was taken from three high schools and one university in the same city. The fourth study drew the sample from one city resulting in mostly white students with educated parents. The fifth study drew a sample from 7 states but was still limited to university women and those with body concerns.

Limitations

Study 1 (Stice et al., 2006, 2007, 2008) had:

  • Limited generalizability due to drawing the sample from one city and one university.

Study 2 (Stice et al., 2003) had the following limitations:

  • Lack of information on recruitment sample size.
  • Study may not have adhered to the intent-to-treat principle.
  • No information on implementation fidelity.
  • No long-term follow-up.

Study 3 (Stice et al., 2001) had the following limitations:

  • Lack of information on recruitment sample size.
  • The study may not have adhered to the intent-to-treat principle. It is not clear whether it attempted to follow up with attriters.
  • No long-term analysis conducted.
  • Only one of eight measures was significantly different between conditions at posttest.

Study 4 (Stice et al., 2009, 2011) had the following limitations:

  • Two significant differences in outcome variables were found at baseline.
  • Sample was drawn from one city resulting in mostly white students with educated parents.

Study 5 (Stice et al., 2013, 2015) had the following limitations:

  • Sample was limited to university women and those with body concerns.
  • Analysis of differential attrition does not include tests for condition by outcome

Notes

In some of the evaluations, the dissonance intervention was compared to a Healthy Weight intervention, which is included as a separate program in this database.

Endorsements

Blueprints: Model

Peer Implementation Sites

Marisol Perez
Dept of Psychology
Arizona State University
950 S McAllister Ave, room 230
Tempe, AZ 85287-1104
office: 480-727-2717
marisol.perez00@gmail.com

Program Information Contact

Paul Rohde, Ph.D.
Oregon Research Institute
1776 Millrace Drive
Eugene, OR 97403-2536
(541) 484-1108
paulr@ori.org

References

Study 1

Certified Stice, E., Shaw, H., Burton, E., & Wade, E. (2006). Dissonance and healthy weight eating disorder prevention programs: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 74(2), 263-275.

Stice, E., Marti, C., Spoor, S., Presnell, K., & Shaw, H. (2008). Dissonance and healthy weight eating disorder prevention programs: Long-term effects from a randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76(2), 329-340.

Stice, E., Presnell, K., Gau, J., & Shaw, H. (2007). Testing mediators of intervention effects in randomized controlled trials: An evaluation of two eating disorder prevention programs. Journal of Consulting and Clinical Psychology, 75(1), 20-32.

Stice, E., Shaw, H., Burton, E., & Wade, E. (2006). Dissonance and healthy weight eating disorder prevention programs: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 74(2), 263-275.

Study 2

Certified Stice, E., Trost, A., & Chase, A. (2003). Healthy weight control and dissonance-based eating disorder prevention programs: Results from a controlled trial. International Journal of Eating Disorders, 33, 10-21.

Stice, E., Trost, A., & Chase, A. (2003). Healthy weight control and dissonance-based eating disorder prevention programs: Results from a controlled trial. International Journal of Eating Disorders, 33, 10-21.

Study 3

Certified Stice, E., Chase, A., Stormer, S., & Appel, A. (2001). A randomized trial of a dissonance-based eating disorder prevention program. International Journal of Eating Disorders, 29, 247-262.

Stice, E., Chase, A., Stormer, S., & Appel, A. (2001). A randomized trial of a dissonance-based eating disorder prevention program. International Journal of Eating Disorders, 29, 247-262.

Study 4

Certified Stice, E., Rohde, P., Shaw, H., & Gau, J. (2011). An effectiveness trial of a selected dissonance-based eating disorder prevention program for female high school students: Long-term effects. Journal of Consulting and Clinical Psychology, 79(4), 500-508.

Certified Stice, E., Rohde, P., Gau, J., & Shaw, H. (2009). An effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescent girls. Journal of Consulting and Clinical Psychology, 77(5), 825-834.

Stice, E., Rohde, P., Gau, J., & Shaw, H. (2009). An effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescent girls. Journal of Consulting and Clinical Psychology, 77(5), 825-834.

Stice, E., Rohde, P., Shaw, H., & Gau, J. (2011). An effectiveness trial of a selected dissonance-based eating disorder prevention program for female high school students: Long-term effects. Journal of Consulting and Clinical Psychology, 79(4), 500-508.

Study 5

Certified Stice, E., Rohde, P., Butryn, M., Shaw, H., & Marti, C. N. (2015). Effectiveness trial of a selective dissonance-based eating disorder prevention program with female college students: Effects at 2- and 3-year follow-up. Behaviour Research and Therapy, 71, 20-26.

Certified Stice, E., Butryn, M., Rohde, P., Shaw, H., & Marti, C. (2013). An effectiveness trial of a new enhanced dissonance eating disorder prevention program among female college students. Behaviour Research and Therapy, 51(12), 862-871.

Stice, E., Butryn, M., Rohde, P., Shaw, H., & Marti, C. (2013). An effectiveness trial of a new enhanced dissonance eating disorder prevention program among female college students. Behaviour Research and Therapy, 51(12), 862-871.

Stice, E., Rohde, P., Butryn, M., Shaw, H., & Marti, C. N. (2015). Effectiveness trial of a selective dissonance-based eating disorder prevention program with female college students: Effects at 2- and 3-year follow-up. Behaviour Research and Therapy, 71, 20-26.

Study 1

Evaluation Methodology

Design: Using a randomized controlled design, researchers sought to determine the effectiveness of the dissonance intervention (Body Project) compared to three other conditions: healthy weight intervention, expressive-writing control intervention, and assessment-only control intervention. The healthy weight intervention had the same structure as the dissonance intervention but used motivational interviewing, behavior modification, journalizing and goal setting to challenge the thin-ideal, find benefits for, and reinforce, lifestyle changes, and provide solutions to barriers encountered when changing. The expressive writing condition consisted of 3 weekly 45-minute individual writing sessions.

Participants were recruited for this study from high schools and one university using mailings, flyers and leaflets that invited female participants between the ages of 14 and 19 with body image concerns to participate in the study to help them accept their bodies. The only exclusion criterion was meeting the diagnosis for an eating disorder.

A total of 566 female participants were assessed for eligibility, 44 (7.7%) refused to participate and 41 (7%) did not meet criteria. The remaining 481 participants were randomly assigned to one of four conditions: dissonance intervention (n=115), healthy weight intervention (n=117), expressive-writing control intervention (n=123), or assessment-only control intervention (n=126). Data were collected at pretest, posttest, and at 6-month, 1-year, 2-year, and 3-year follow-ups after posttest. The mediation analysis also reported on data collected weekly from baseline to posttest.

Attrition was low with only 5% of participants not completing assessments through the 3-year follow-up.

Sample Characteristics: The sample was adolescent girls with a mean age of 17 years and with the following racial identities: 10% Asian/Pacific Islander, 6% African American, 19% Hispanic, 58% White, and 7% who specified other or mixed racial heritage. Parental education ranged from high school graduate or less (17%) to graduate/professional degree (28%).

Measures: Eight areas were measured in Stice et al. (2006). In the long-term follow-up results (Stice et al., 2008), dieting and health service utilization were left out of the tables and social functioning was renamed psychosocial impairment. Assessments were conducted through self-report and interview using assessors blinded to the condition. The mediation analysis (Stice et al., 2007) examined two other mediating variables – healthy eating and physical activity.

Thin-ideal internalization was assessed using The Ideal-Body Stereotype Scale-Revised which uses a response format ranging from 1 = strongly disagree to 5 = strongly agree. This scale has shown internal consistency (α = .91), test-retest reliability (r = .80), and predictive validity for bulimic symptom onset.

Body dissatisfaction was assessed with 8 items from of the Satisfaction and Dissatisfaction with Body Parts Scale that assesses body parts that are often of concern to females (e.g., stomach, thighs, and hips). Participants indicate their level of satisfaction with body parts on scales ranging from 1 = extremely satisfied to 6 = extremely dissatisfied. This scale has shown internal consistency (α = .94), 3-week test-retest reliability (r = .90), and predictive validity for bulimic symptom onset.

Dieting was assessed using The Dutch Restrained Eating Scale (DRES) where participants indicate the frequency of dieting behaviors using scales ranging from 1 = never to 5 = always. The DRES has shown internal consistency (α = .95), 2-week test-retest reliability (r = .82), convergent validity with self-reported caloric intake, and predictive validity for bulimic symptom onset.

Negative affect was assessed with the sadness, guilt, and fear/anxiety subscales from the Positive Affect and Negative Affect Scale-Revised (PANAS-X). Participants reported the extent to which they had felt various negative emotional states on scales ranging from 1 = very slightly or not at all to 5 = extremely. This scale has shown internal consistency (α = .95), 3-week test-retest reliability (r = .78), convergent validity, and predictive validity for bulimic symptom onset.

Bulimic symptoms were assessed using the diagnostic items from the Eating Disorder Examination (EDE), a semi-structured investigator-based interview. Items assessing the symptoms in the past month were summed to create an overall bulimic symptom composite for each assessment point. The adapted symptom composite showed internal consistency (α = .86 at pretest) and 1-month test-retest reliability for assessment-only controls (r = .81).

BMI was used to reflect obesity and adiposity and was calculated from height (measured to the nearest millimeter using stadiometers) and weight (assessed to the nearest 0.1 kg using digital scales). Two measures of each were obtained and averaged.

Social functioning (or psychological impairment) was assessed using items adapted from the Social Adjustment which demonstrated internal consistency (α= .76) at pretest.

Health service utilization was measured using two items assessing the frequency of visits to health and mental health care providers (e.g., How often have you seen a doctor (physician) because of illness, injury, long-term health problems, or for regular check-ups in the last 6 months). The items showed 1-year test-retest reliability for assessment-only controls (r= .82 and r= .89 respectively).

Healthy eating was measured using four items that were averaged to form an overall healthy eating composite. This scale was internally consistent (α = .82) at pretest and temporally reliable (1-month test-retest r = .63 for assessment-only controls).

Physical activity was measured using two items assessing weekly frequency and duration of exercise and the two items were multiplied to form a quantity × frequency measure of exercise behavior at each assessment. This scale was temporally reliable (1-month test-retest r = .61 for assessment-only controls).

Analysis: Stice et al. (2006) used omnibus repeated measures ANOVA models to test whether there were differential changes in the outcomes across the four conditions up to one-year follow-up (condition was a 4-level between-subjects factor and time was a 4-level within-subject factor). Next, the researchers examined ANOVA models that contrasted pairs of conditions at each of the follow-up periods to determine precisely which groups differed significantly and how long these significant differences persisted. In each of these repeated measures models condition was a 2-level between-subjects factor and time was a 2-level within-subjects factor (pretest to posttest, pretest to 6-month follow-up, and pretest to 1-year follow-up). Full information maximum likelihood estimation was used to impute missing data.

Stice et al. (2008) examined outcomes at 2- and 3-year follow-ups using mixed model analyses that included all five waves of post-intervention data as dependent variables (posttest, and follow-ups at 6-month, 1-year, 2-year and 3-year). Independent variables included condition, wave, condition × wave interaction, pretest level of the outcome, the pretest of the outcome × wave interaction, posttest to one-year slope of the outcome, and the posttest to one-year slope × wave interaction. There were 5 contrasts that tested for the hypothesized effects at both 2-year follow-up and 3-year follow-up in each model: dissonance vs. assessment only, dissonance vs. expressive writing, healthy weight vs. assessment only, healthy weight vs. expressive writing, and dissonance vs. healthy weight. Baseline versions of the outcomes and change in the outcomes from post-test to 1-year follow-up were controlled for in an effort to ensure that differences in the marginal means at 2- and 3-year follow-up were a result of the interventions rather than these covariates.

Stice et al. (2007) used multilevel analysis and multiple imputation of missing data but included a full mediation analysis.

The studies adhered with the intent-to-treat principle by gathering data and analyzing results from all participants, regardless of dose of intervention received.

Outcomes

Implementation Fidelity: Facilitators received a detailed and scripted manual for each of the intervention conditions (dissonance and healthy weight) as well as training and direct observation by the first author. A random sample of sessions (10%) were audio taped and coded by research assistants who were blinded to intervention condition to determine whether the facilitators covered the main exercises listed in the relevant treatment manual and did not cover the main exercises listed in the other treatment manual (each session contains 4–6 main exercises). Results indicated that group leaders covered 100% of the main exercises from the relevant manual and included 0% of exercises from the other manual.

Further, the study reported that session attendance was high and did not differ across conditions. Among dissonance participants, 91% attended all three sessions, 6% attended two sessions, and 3% attended one session. Parallel attendance rates were 91%, 6%, and 3% for the healthy weight intervention and 98%, 1%, and 1% for the expressive writing condition. The proportion of participants who completed the homework assignments was not significantly different in the dissonance (80%) versus the healthy weight condition (87%).

Baseline Equivalence: The four groups did not differ significantly on any of the demographic or outcome variables.

Differential Attrition: The study reported low levels of attrition (4% at 1-year follow-up and 5% at 3-year follow-up) and reported that the attriters did not differ from participants who completed all the assessments on any demographic or outcome variables at pretest. Further, the study reported that attrition did not differ across conditions. The mediation analysis examined a shorter time span and had attrition of 4%. Checks showed no differences across dropouts and completers.

Posttest and 1-year follow-up (Stice et al., 2006): Across all four conditions, significantly differential change over time was found for thin-ideal internalization (p < .001, r = .20), body dissatisfaction (p < .001, r = .20), dieting (p = .001, r = .14), negative affect (p = .006, r = .13), and bulimic symptoms (p < .007, r = .13). When looking at specific contrasts, the dissonance intervention relative to assessment-only or expressive writing controls produced:

  • significantly greater reductions in thin-ideal internalization, body dissatisfaction, dieting, negative affect and bulimic symptoms at posttest and 6-month follow-up
  • significantly greater decreases at 1-year follow-up in thin-ideal internalization, dieting, and bulimic symptoms

Further, the dissonance intervention produced significantly greater decreases in thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms relative to the healthy weight intervention from pretest to posttest; and it produced significantly greater decreases in negative affect at the 6-month and 1-year follow-ups.

Additional analyses showed significantly higher reliable change rates in bulimic symptoms and lower risk of obesity onset for the dissonance intervention condition than the control groups over the 1-year follow-up.

2- and 3-year follow-up (Stice et al., 2008): Compared to assessment-only controls, dissonance intervention participants showed significantly lower thin-ideal internalization, body dissatisfaction, negative affect, bulimic symptoms and psychosocial impairment at 2-year follow-up and significantly lower body dissatisfaction, negative affect and psychosocial impairment at 3-year follow-up.

Compared to expressive writing controls, dissonance intervention participants showed significantly lower thin-ideal internalization and body dissatisfaction at 2-year follow-up and significantly lower body dissatisfaction and psychosocial impairment at 3-year follow-up.

Further, dissonance participants showed significantly greater reductions in psychosocial impairment than healthy weight participants by the 3-year follow-up.

Lastly, dissonance participants showed significantly lower risk for eating pathology onset than assessment-only controls (p = .022) over the 3-year follow-up.

Mediation Analysis (Stice et al., 2007): The mediation analysis used three of the conditions, comparing both dissonance intervention and healthy weight to expressive writing and excluding the no treatment control group. The sample size of 355 was assessed at four time points from baseline to posttest: before the intervention (baseline), after session 1, after session 2, and after session 3 (posttest). The analysis did not use the follow-up data.

The mediation model for the dissonance condition tested thin-ideal internalization as a mediator of four outcomes – body dissatisfaction, dieting, negative affect, and bulimic symptoms – that were linked theoretically to the program goals.

The results indicated that thin-ideal internalization partially mediated the effects of the intervention on the outcomes. Specifically, 1) the intervention group experienced significantly greater improvement in all four outcomes, 2) the intervention group experienced significantly greater improvement in the mediator, 3) changes in thin-ideal internalization significantly affected the outcomes, and 4) the effect of the intervention on the outcomes was significantly reduced after controlling for change in the mediator which accounted for 26% to 48% reduction in the main effects.

Study 2

Evaluation Methodology

Design: Using a randomized controlled design, researchers sought to evaluate the effectiveness of the dissonance intervention (Body Project) against a healthy weight intervention and a waitlist control. Using flyers and announcements in large classes, participants were recruited from three high schools and one university. A total of 148 female students were randomized to one of three conditions, however 14 students dropped out during the intervention resulting in the following distribution: dissonance intervention (n=48); healthy weight intervention (n=51); or, waitlist control (n=36). No information was provided on the number recruited to obtain the initial sample size of 148. Further, even though the study reports that 14 students (9%) dropped out during the intervention leaving a sample size of 134, the analyzed sample size included 135 students. Data were collected at baseline, post-intervention, and 1-, 3- and 6-month follow-up.

Sample Characteristics: The sample of adolescent girls had a mean age of 17.4 years and the following racial identities: 13% Asian/Pacific Islander, 2% African American, 16% Hispanic, 63% White, and 6% who specified other. Parental education ranged from high school graduate or less (2% of fathers and 1% of mothers) to advanced degree (20% of mothers and 39% of fathers).

Measures: Five measures previously used in other studies were gathered in this study:

Thin-ideal internalization was assessed using the Ideal-Body Stereotype Scale-Revised, which uses a response format ranging from 1 = strongly disagree to 5 = strongly agree. This scale has shown internal consistency (α = .89), test-retest reliability (r = .63), and predictive validity.

Body dissatisfaction was assessed with 8 items from of the Satisfaction and Dissatisfaction with Body Parts Scale that assesses body parts that are often of concern to females (e.g., stomach, thighs, and hips). Participants indicate their level of satisfaction with body parts on scales ranging from 1 = extremely satisfied to 6 = extremely dissatisfied. This scale has shown internal consistency (α = .94), 3-week test-retest reliability (r = .90), and predictive validity.

Dieting was assessed using the Dutch Restrained Eating Scale (DRES), where participants indicate the frequency of dieting behaviors using scales ranging from 1 = never to 5 = always. The DRES has shown internal consistency (α = .95), 2-week test-retest reliability (r = .82), convergent validity with self-reported caloric intake, and predictive validity.

Negative affect was assessed with the sadness, guilt, and fear/anxiety subscales from the Positive Affect and Negative Affect Scale-Revised (PANAS-X). Participants reported the extent to which they had felt various negative emotional states on scales ranging from 1 = very slightly or not at all to 5 = extremely. This scale has shown internal consistency (α = .95), convergent validity, and predictive validity for bulimic symptom onset.

Bulimic symptoms were assessed using the diagnostic items from the Eating Disorder Examination (EDE), a semi-structured investigator-based interview. Items assessing the symptoms in the past month were summed to create an overall bulimic symptom composite for each assessment point. The adapted symptom composite showed internal consistency (α = .84 at pretest) and test-retest reliability (r = .89).

Analysis: Repeated measures ANOVA models were used to test whether participants in the intervention conditions improved over time across the five measures compared to waitlist control participants. In separate follow-up models, condition was a three-level between-subjects factor and time was a four-level within-subjects factor.

The study may not have adhered to the intent-to-treat principle. It is not clear whether it attempted to follow up with attriters.

Outcomes

Implementation Fidelity: No information was provided on implementation fidelity.

Baseline Equivalence: No significant differences between conditions were found for demographic or outcome variables.

Differential Attrition: The study reported that the attriters did not differ from completers on any demographic or outcome variables at pretest. Further, the study reported that attrition did not differ across conditions.

Posttest: Significant differences between dissonance intervention participants and waitlist control participants were found for two of the five outcomes: reductions in negative affect (p=.001) and bulimic symptoms (p=.015). It is unclear if the significant group-by-time coefficients produced statistically significant differences at all four time points.

The study reported r coefficients of .25 and .21 for the significant interactions but did not interpret the coefficients in terms of strength.

Study 3

Evaluation Methodology

Design: Using a randomized controlled design, researchers sought to evaluate the effectiveness of the dissonance intervention (Body Project) against a healthy weight placebo control condition. Using flyers and email messages, participants were recruited from two universities and one community college. A total of 87 female students were randomized to the dissonance intervention (n=48) and the healthy weight placebo control (n=39). Data were collected at baseline, post-intervention (week 3), and at 4-week follow-up (week 7). The attrition rate was 10%; 9 participants dropped out of the study and did not complete posttest or follow-up surveys.

Sample Characteristics: The sample of female participants had a modal age of 19 years and the following racial identities: 13% Asian/Pacific Islander, 5% African American, 17% Hispanic, 59% White, and 6% who specified other. Parental education ranged from high school graduate or less (2%) to advanced degree (13%).

Measures: Eight measures, several used in other studies, were gathered in this study:

Thin-ideal internalization was assessed using the Ideal-Body Stereotype Scale-Revised, which uses a response format ranging from 1 = strongly disagree to 5 = strongly agree. This scale has shown internal consistency (α = .91), test-retest reliability (r = .80), and predictive validity.

Body dissatisfaction was assessed with 8 items from of the Satisfaction and Dissatisfaction with Body Parts Scale that assesses body parts that are often of concern to females (e.g., stomach, thighs, and hips). Participants indicate their level of satisfaction with body parts on scales ranging from 1 = extremely satisfied to 6 = extremely dissatisfied. This scale has shown internal consistency (α = .94), 3-week test-retest reliability (r = .90), and predictive validity.

Dieting was assessed using the Dutch Restrained Eating Scale (DRES), where participants indicate the frequency of dieting behaviors using scales ranging from 1 = never to 5 = always. The DRES has shown internal consistency (α = .95).

Negative affect was assessed with the sadness, guilt, and fear/anxiety subscales from the Positive Affect and Negative Affect Scale-Revised (PANAS-X). Participants reported the extent to which they had felt various negative emotional states on scales ranging from 1 = very slightly or not at all to 5 = extremely. This scale has shown internal consistency (α = .95), convergent validity, and predictive validity for bulimic symptom onset.

Bulimic symptoms were assessed using the diagnostic items from the Eating Disorder Examination (EDE), a semi-structured investigator-based interview. Items assessing the symptoms in the past month were summed to create an overall bulimic symptom composite for each assessment point. The adapted symptom composite showed internal consistency (α = .84 at pretest).

Fat consumption was assessed using an adapted version of the Fat-Related Diet Habits Questionnaire which asks participants to rate how often they eat high-fat food using a 5-point scale ranging from never or almost never to five or more times a week. This scale had a Cronbach's alpha of .79 at baseline and a 3-week test-retest coefficient of .76.

Body Mass was measured using BMI calculated based on self-reports of height and weight.

Exercise behavior was assessed with an adapted form of the Past Year Leisure Physical Activity Scale, which asks participants to indicate how many days they did nine activities for at least 20 minutes at a time. Items use an 8-point response format ranging from 0 days to 7 days. The 3-week test-retest coefficient was .61.

Analysis: Repeated measures ANOVA models were used to test whether participants in the intervention conditions improved over time across the outcomes compared to placebo control participants. In the models, condition was a two-level between-subjects factor and time was a three-level within-subjects factor.

The study may not have adhered to the intent-to-treat principle. It is not clear whether it attempted to follow up with attriters.

Outcomes

Implementation Fidelity: All groups were audiotaped and reviewed by a research assistant blind to the condition. The study reported that all sessions covered the material contained in the manual for the intervention and placebo control conditions.

Baseline Equivalence: No significant differences between conditions were found for demographic or outcome variables.

Differential Attrition: The study reported that the attriters did not differ from completers on any demographic or outcome variables at pretest. Further, the study reported that attrition did not differ across conditions.

Posttest: The analysis referred to tests for fat consumption, BMI, and exercise as manipulation checks for the quality of the control condition, and the tests for the other outcomes as analysis of intervention effects. Significantly better results for dissonance intervention participants relative to healthy weight placebo control participants were found for one of the eight outcomes: reductions in thin-ideal internalization (p<.001). The authors attributed the limited effects in part to the unexpected improvement in the Healthy Weight control group.

Limitations

  • The study may not have adhered to the intent-to-treat principle. It is not clear whether it attempted to follow up with attriters.
  • No long-term analysis conducted.
  • Only one of eight measures was significantly different between conditions at posttest.

Study 4

Evaluation Methodology

Design:

Recruitment/Sample size: Between April 2005 and November 2007, high school students were recruited using mailings and flyers from three school districts. The recruitment targeted female students between the ages of 14 and 19 with body image concerns. A total of 386 students (9.2% of the population) responded to the recruitment effort and were assessed for eligibility. Students were excluded if they did not have body image concerns (n=43) or met criteria for an eating disorder (n=2). An additional 35 students (9%) refused to participate in the study resulting in participation of 306 students (79.3%).

Study type/intervention: Researchers used a randomized controlled design in this evaluation. The 306 students were randomly assigned to the intervention (n=139) or control (n=167) conditions. Unlike previous evaluations, the intervention was delivered in four sessions by high school nurses, teachers and counselors rather than the investigators. A minimal intervention psychoeducational brochure was used as the control condition.

Assessment/Attrition: Assessments were conducted at pretest, immediate posttest, 6-month follow-up, and at 1-, 2-, and 3-year follow-ups by evaluators blind to the condition. Attrition rates at each assessment were as follows: 3% at posttest, 7% at 6-month follow-up, 8% at 1-year follow-up, 10% at 2-year follow-up and 16% at 3-year follow-up.

Sample Characteristics: The sample of girls had an average age of 15.7 years, mean BMI of 24.9, and was 2% Asian/Pacific Islander, 2% African American, 9% Hispanic, 81% Caucasian, and 6% who specified other or mixed racial heritage. Parental education was 17% high school graduate or less, 24% some college, 38% college graduate, and 21% advanced graduate/professional degree.

Measures: Six measures, several used in other studies, were gathered in this study.

Thin-ideal internalization was assessed using the Ideal-Body Stereotype Scale-Revised, which uses a response format ranging from 1 = strongly disagree to 5 = strongly agree. This scale has shown internal consistency (α = .91), test-retest reliability (r = .80), and predictive validity.

Body dissatisfaction was assessed with 8 items from the Satisfaction and Dissatisfaction with Body Parts Scale that assesses body parts that are often of concern to females (e.g., stomach, thighs, and hips). Participants indicate their level of satisfaction with body parts on scales ranging from 1 = extremely satisfied to 6 = extremely dissatisfied. This scale has shown internal consistency (α = .94), 3-week test-retest reliability (r = .90), and predictive validity.

Dieting was assessed using the Dutch Restrained Eating Scale (DRES), where participants indicate the frequency of dieting behaviors using scales ranging from 1 = never to 5 = always. The DRES has shown internal consistency (α = .95).

Depressive symptoms was assessed using the Center for Epidemiologic Studies Depression Scale, where participants select among four response options reflecting increasing levels of symptom severity (0=never/less than 1 day in past week to 3=most of the time/5–7 days in the past week). The CESD has shown internal consistency (α =.74 –.91) and reliability (test–retest r= .57–.59).

Eating pathology was examined using the Eating Disorder Diagnostic Interview, a semi-structured interview adapted from the Eating Disorder Examination which assesses DSM–IV eating disorder symptoms. Items assessing the symptoms in the past month were summed to form an overall eating disorder symptom composite for each assessment. The symptom composite showed internal consistency (α =.92) and 1-week test–retest reliability (r= .90).

Body Mass was measured using BMI calculated based on height and weight measures taken using stadiometers and digital scales.

Stice et al. (2011) reported gathering two additional measures:

Functional impairment was examined using items from the Social Adjustment Scale, which measures psychosocial functioning in the family, peer group, school, and work spheres.

Health care utilization during the previous 6 months was examined using two items: the number of times a person saw a doctor because of illness, injury, long-term health problems, or regular check-ups; and the number of times a person saw a psychologist, psychiatrist, or counselor/therapist because of mental health problems. Responses to these two items were averaged.

Analysis: Omnibus repeated measures analyses of variance were conducted to test whether changes in outcomes for the two conditions were significantly different from baseline to 1-year follow-up and from baseline to 3-year follow-up. This was followed by repeated measure ANOVA models for each of the assessment points. Reliable change score analysis was conducted to examine the clinical significance of changes in eating disorder symptoms.

The study complied with the intent-to-treat principle by including all available data from participants regardless of dosage received. It used all subjects in the analysis with full information maximum likelihood estimation.

OUTCOMES

Implementation Fidelity: A total of 67% of dissonance participants attended all four sessions, 18% attended three sessions, 5% attended two sessions, and 10% attended one session. Implementation fidelity ratings (10-point scale) had a mean of 6.9 and facilitator competence ratings (10-point scale) had a mean of 6.2.

Baseline Equivalence: The study reported no differences in demographic variables between conditions. Significant differences between conditions were found at baseline for two outcome variables: students in the control condition reported significantly higher thin-ideal internalization scores and significantly lower body dissatisfaction scores.

Differential Attrition: The study reported that the participants who did not complete the assessments through the 3-year follow-up did not differ from the 84% of participants retained in the trial on any demographic or outcome measures at pretest, and attrition did not differ significantly across conditions.

Posttest: Of the three outcomes examined in the study (depression, eating disorder symptoms, BMI), eating disorder symptoms were significantly improved at posttest and this effect was sustained at 6-month follow-up.

Program Effects on R&P Factors: Of the five risk/protective factors examined in the study, three were significantly improved at posttest. Thin-ideal internalization, body dissatisfaction and dieting were significantly improved for the intervention participants compared to the control participants at immediate posttest; however the effect was sustained at the 6-month follow-up only for body dissatisfaction.

Long-term Follow-up: Differences in improvement in eating disorder symptoms between conditions was significant at one-year follow-up and three-year follow-up, but not at 2-year follow-up.

Program Effects on R&P Factors: Differences in improvement in body dissatisfaction and dieting between conditions were significant at one-year follow-up. At two-year follow-up, only differences in body dissatisfaction were maintained, however these differences were not significant at 3-year follow-up.

Study 5

Evaluation Methodology

Design:

Recruitment/Sample size: Between October 2009 and October 2011, female students at seven universities in Oregon, Texas and Pennsylvania were recruited by facilitators using emails and posters. The recruitment targeted female students with body image concerns. A total of 682 women responded to the recruitment effort and were screened for eligibility. Respondents were excluded (10%) if they did not have body image concerns (n=33), were not affiliated with a university (n=29) or met criteria for an eating disorder (n=4). An additional 208 respondents (30%) refused to participate in the study, resulting in participation of 408 students (60%).

Study type/Randomization/Intervention: Researchers used a randomized controlled design in this evaluation. The 408 students were randomly assigned to the intervention (n=203) or control (n=205) conditions. The intervention differed from previous evaluations in the following three ways: facilitators were trained using more role-plays and received feedback to improve delivery; supervision of the facilitators was improved; and, participation, effort and accountability for taking an anti-thin-ideal perspective were more strongly emphasized in the curriculum. A minimal intervention psychoeducational brochure was used as the control condition.

Assessment/Attrition: Assessments were conducted at pretest, immediate 4-week posttest, and 1-year, 2-year, and 3-year follow-ups (although it is unclear if the follow-up periods lasted from baseline or the end of the 4-week program). Attrition rates increased over time: 1.0% at posttest, 4.7% at 1-year follow-up, 8% at the 2-year follow-up, and 15% at the 3-year follow-up.

Sample Characteristics: The sample of female participants had an average age of 21.6 years, mean BMI of 24.4, and was 58% European American, 17% Asian, 13% Hispanic, 7% African American, 4% American Indian/Alaska Native, and 1% Native Hawaiian/Pacific Islander. Parental education was 14% high school graduate or less, 25% some college, 32% college graduate, and 28% advanced graduate/professional degree.

Measures: Ten measures, several used in other studies, were gathered from subjects in this study. All assessments were conducted by evaluators blind to the condition.

Thin-ideal internalization was assessed using the Ideal-Body Stereotype Scale-Revised, which uses a response format ranging from 1 = strongly disagree to 5 = strongly agree. This scale has shown internal consistency (α = .91), test-retest reliability (r = .80), and predictive validity.

Body dissatisfaction was assessed with 8 items from of the Satisfaction and Dissatisfaction with Body Parts Scale that assesses body parts that are often of concern to females (e.g., stomach, thighs, and hips). Participants indicate their level of satisfaction with body parts on scales ranging from 1 = extremely satisfied to 6 = extremely dissatisfied. This scale has shown internal consistency (α = .94), 3-week test-retest reliability (r = .90), and predictive validity.

Dieting was assessed using the Dutch Restrained Eating Scale (DRES), where participants indicate the frequency of dieting behaviors using scales ranging from 1 = never to 5 = always. The DRES has shown internal consistency (α = .95).

Negative affect was assessed using the Beck Depression Inventory, which has shown internal consistency (α =.73 –.95) and reliability (test–retest r= .60–.90).

Eating disorder symptoms were examined using the Eating Disorder Diagnostic Interview, a semi-structured interview adapted from the Eating Disorder Examination which assesses DSM–IV eating disorder symptoms. Items assessing the symptoms in the past month were summed to form an overall eating disorder symptom composite for each assessment. The symptom composite showed internal consistency (α =.74) and 1-week test–retest reliability (ICC= .95).

Body Mass was measured using BMI calculated based on height and weight measures taken using stadiometers and digital scales.

Unhealthy weight transitions were also examined as an outcome variable and were coded if participants made unhealthy changes in BMI (i.e., from healthy weight to overweight or obese and from overweight to obese).

Psychosocial impairment was examined using items from the Social Adjustment Scale, which measures psychosocial functioning in the family, peer group, school, and work spheres.

Health care utilization was assessed using the Patterns of Help Seeking Behavior where participants were asked the number of hours they spoke with a doctor or nurse in the past month.

Mental health care utilization was assessed using the Patterns of Help Seeking Behavior where participants were asked the number of hours they spoke with a psychiatrist, a therapist, psychologist, or other counselor, or attended a support group in the past month.

Analysis: Multilevel, linear and logistic mixed effects models were used to analyze the data. An effect for site (level 3) was found for dieting and eating disorder symptoms only and therefore these two outcomes were modeled with three levels (time, person, and site) and the rest with two levels (time and person). Tests examined group-by-time interactions that controlled for baseline outcomes.

The study complied with the intent-to-treat principle by including all available data from participants regardless of dosage received. It used all subjects in the analysis with multiple imputation of missing data.

OUTCOMES

Implementation Fidelity: A total of 62% of dissonance participants attended all four sessions and 5% attended less than two sessions; participants attended an average of 3.4 sessions. Participants completed 87% of the assigned homework exercises. Implementation fidelity ratings (10-point scale) had a mean of 7.37 and facilitator competence ratings (10-point scale) had a mean of 7.12. Very low rates of inadequate fidelity (1.6%) or competence (2.3%) were found.

Baseline Equivalence: The study reported no differences in demographic or outcome variables between conditions.

Differential Attrition: Attrition was minimal at posttest (1%) and was 4.7% at 1-year follow-up. After the 2-year and 3-year follow-ups, when attrition was higher, the study reported that none of the pretest outcomes were significantly associated with missingness. However, the results did not test for differential attrition across conditions

Results: Of the four outcomes examined in the study (negative affect, eating disorder symptoms, BMI, unhealthy weight transitions), negative affect and eating disorder symptoms were significantly improved from baseline to 1-year follow-up (p’s<.001, d = -.38 to -.40).

Program Effects on R&P Factors: Of the six risk/protective factors examined in the study, four were significantly improved at posttest. Thin-ideal internalization, body dissatisfaction, dieting and psychosocial functioning were significantly improved for the intervention participants compared to the control participants from baseline to 1-year follow-up. Effect sizes ranged from -.32 to -.54. The other two, health care utilization and mental health care utilization, were not significantly improved.

Long-term Follow-up: Similarly to the posttest, the study reported significant improvement in the treatment group as compared to the control group for negative affect (p<.001) and eating disorder symptoms (p<.001) through the 3-year follow-up. Effect sizes ranged from -.22 to -.39.

Long-term effects on R&P Factors: The study reported 7 risk and protective factors, of which 4 were significantly improved through the 3-year follow-up. Thin-ideal internalization, body dissatisfaction, dieting, and psychosocial impairment continued to show significant improvement among the treatment group as compared to the control group. Effect sizes ranged from -.07 to -.54.

Contact

Blueprints for Healthy Youth Development
University of Colorado Boulder
Institute of Behavioral Science
UCB 483, Boulder, CO 80309

Email: blueprints@colorado.edu

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Blueprints for Healthy Youth Development is
currently funded by Arnold Ventures (formerly the Laura and John Arnold Foundation) and historically has received funding from the Annie E. Casey Foundation and the Office of Juvenile Justice and Delinquency Prevention.