Eating disorders are particularly difficult to treat because they are associated with a low level of help-seeking, commonly exist among the general population in sub-threshold levels, and respond to even the most efficacious of treatments less than half of the time . Given the pervasive nature of these disorders in combination with the physical and psychological toll they pose, early prevention and intervention efforts are key to any mental health effort tackling them . Prevention programs are ideal in addressing this cluster of disorders because they occur before adulthood and show a pervasive, persistent course throughout one’s life. Unfortunately, few programs have been effective in reducing risk for eating disorders, with a recent meta-analysis showing only 6 out of 38 programs produce sustained reductions in symptoms at their six month follow-up . These programs have shown marked improvement in factors associated with eating disorders including: initial levels of belief in a cultural thin-ideal, perceived pressure to be thin, body dissatisfaction, self-reported dieting, and negative affect.
Interestingly, of the six effective programs, indicated prevention programs, programs targeting high-risk individuals proved to be most successful. This is a reassuring finding as it suggests that individuals not yet diagnosed have a good chance of avoiding a future diagnosis if provided with proper intervention.
The Body Project is one such program; it is the only eating disorder prevention program considered an efficacious intervention by the American Psychological Association with prolonged improvements in eating disorder pathology documented at their three year follow-up [2, 4]. This program is based on the cognitive dissonance theory since it specifically targets dissatisfaction and thin-ideal internalization . The program focuses on these two targets because literature supports that they are fundamentally involved in the dual pathway of bulimia and are also strongly associated with all other forms of eating disorders. Unlike other eating disorder prevention programs, The Body Project focuses on reducing didactic presentation; focusing on in-session exercises such as between-session homework, motivational enhancement exercise, and group activities. These aspects of the program are meant to uniquely engage participants, facilitate skill acquisition, maximize motivation, and improve social support behaviors.
The original version of the Body Project consists of three weekly sessions each about one hour long. During this time, participants engage in various activities aimed at helping identify their internalized thin-ideal and then combat it by acknowledging aspects of their appearance they appreciate. According to dissonance theory, this should create discomfort in participants because their cognitions are inconsistent; on the one hand they are aspiring to an impossible thin-ideal, while on the other acknowledging that they are attractive despite not meeting this ideal. This dissonance then creates discomfort in the participants which can only be alleviated by restoring consistency to their cognitions. The fundamental basis of The Body Project is that participants will resolve this dissonance by refusing to aspire to the thin-ideal and, instead, form a greater appreciation of their appearance as is. To further engrain these notions of the thin-ideal being unattainable and toxic for mental well-being, the program focuses on having participants exchange advice on how to deal with societal pressures of aspiring to the thin-ideal in the future and how they might help someone else suffering from body dissatisfaction.
One unique aspect of this program is that it relies on community group leaders. By training members of the community to lead discussions, they are drastically reducing the community resources needed to implement the program. Typically, group leaders are trained in the program and then are provided with additional support from a trained professional if needed. However, once a team leader has had some experience with the program, they could take the place of the trained professional, thus making this program a self-sustaining community effort. By removing the eventual need of trained professionals, this program is superior to other similar interventions because it allows a community to maintain the program long after the research team has finished it.
To further acknowledge the need to meet community needs, The Body Project has been altered and evaluated with various populations under different research teams particularly focusing on high-risk groups including college sorority members and athletes [2, 6, 7]. Most of these studies have found The Body Project to be superior to other commonly respected preventative eating disorder programs. Of these, the research on adapting this intervention to sororities has been more positive than with college female athletes though their adaptations have been successful as well [6, 7]. In fact, the only reason the sorority adaptation was considered more effective by the authors was because the feedback they received from participants in the college athlete study was more favorable towards a different prevention program known as Health Weights (though both programs were equally effective).
When critically evaluating a prevention program, it is important to consider how easily adaptable it is to different populations. One could make the argument that female college athletes are both at highest risk of developing an eating disorder and greatest resistance towards intervention. Research has shown that female athletes are at almost double the risk of developing clinical levels of eating pathology as compared to their non-athletic peers . There are several reasons for this; there exists a pressure in the sports world to continue to compete regardless of the risk for serious physical harm along with the general appreciation for excessively unhealthy eating and exercising behaviors. Furthermore, this group is considered especially resistant to prevention efforts because of the pressure from coaches and a culture that believes low body fat enhances performance. As such, examining the effectiveness of an adaptation to this particularly complex group is a good indication of how amenable the overall program can be to different populations. Considering that the original research on The Body Project examined less severe cases of adolescent girls suffering from varying levels of body dissatisfaction, an effective adaptation with a more difficult/at-risk population is a good indicator of the range of applicability of this intervention. Having said that, it is important to note that the steps taken to adapt an intervention are paramount to its success; this was certainly the case in the adaptation of The Body Project for college female athletes.
To remodel the intervention for this particular group, the researchers consulted with local coaches on how to best serve their athletes. By involving the community, they were better able to assess the aspects of the intervention that were most applicable to the new population while also adding new paradigms to best address the unique needs of this population. More specifically, through their collaboration, the research team decided to break up athletes by team as coaches suggested each particular team faces different pressures on conforming to the thin-ideal, and segregating teams would also foster within-sport team building. Furthermore, the coaches did not want to exclude any individual from the benefits of being involved in a program; so, there was no wait-list control group (as is considered general practice). Instead, the research team tested the effectiveness of two different prevention interventions against each other and conducted the study over two years. In the first year, participants were randomly assigned to one intervention and then assigned to the other. Again, although this is not a typical research design, it best fit the needs of the community and allowed members to experience two different (productive) interventions thus improving their chances of benefitting from at least one.
Impressively, by acknowledging the needs of their intended population, the research team was able to get a 94% volunteer participation rate with an exceptionally low drop-out rate. According to qualitative data collected by the research team, these interventions were so effective that 7 athletes (a statistically significant amount from the sample) came forward to coaches over concerns with their unhealthy weight. Though not traditionally viewed as a measure of success in empirical research, this signified an important outcome of the intervention as it was unprecedented in the entire career of the coach. Furthermore, other qualitative reports showed that peer-leaders became instructive in helping their team members maintain a healthy weight outside of the confines of the study. Though the authors do not mention which of the two prevention programs produced these qualitative results, it is clear from quantitative results that both programs were effective and that further analysis need to be conducted to tease apart whether both programs also produce similar qualitative results. Conducting research that allows for these types of qualitative findings is very important in community tailored prevention research because of the rich results regarding efficacy that may not be reflected in quantitative analysis.
One final aspect of the adaptation of The Body Project that was consistent with good practice for program adaptation was a qualitative analysis of participant and team leader satisfaction. Results from this analysis were very informative and the need for this approach in future adaptations cannot be stressed enough. In this particular study, although quantitative analysis found both The Body Project and Healthy Weights programs to be equally effective, qualitative reports showed a much greater dissatisfaction among both participants and team leaders with The Body Project. This is not to say that they did not gain anything from participating in The Body Project as they simply preferred the Healthy Weight Project. Although this may seem like a discouraging finding, it is actually a great starting point for a further adaptation of The Body Project to this population. Although not specifically mentioned in the article, a more detailed analysis of the aspects that were preferred from Healthy Weights may be useful as it would allow for the incorporation of those aspects into The Body Project. Combined with a more detailed quantitative examination of the key aspects of both programs. This information could be used to further enhance both the efficacy and appeal of both programs.
In sum, The Body Project seems to hold up as a well-researched and supported intervention program for eating disorders. The few adaptations that exist have proven it to be equally or more effective than other types of eating disorder interventions and applicable across some of the highest-risk populations.
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