Adaptation and implementation of body project as a universal body image program in Mexico and Latin America.

The Body Project (BP) intervention for body image issues is supported by extensive efficacy and effectiveness research, most of which has been conducted in the United States. The BP uses cognitive dissonance to help participants critique the ideal appearance through written, verbal, and behavioral exercises. This reduces the internalization of the appearance ideal, which in turn decreases body dissatisfaction symptoms and, in some individuals, the onset of eating disorders. To broadly implement this program in Mexico and Latin America, Comenzar de Nuevo (CdN), a non-profit organization for eating disorder treatment, partnered with the Body Project Collaborative in 2014. Together, they created a training and implementation infrastructure. This paper explores the adaptation of BP and its implementation in Mexico and Latin America. We used sustainable business, marketing, and educational models to fulfill CdN's mission to reduce eating disorder risk factors, including weight stigma, in the Latin American region. By integrating strategies to combat weight stigma within our program delivery, we strive to contribute to a more inclusive and supportive environment. We trained master trainers, regular trainers, and/or group facilitators from Argentina, Bolivia, Colombia, Costa Rica, Chile, Dominican Republic, El Salvador, Guatemala, Mexico, Panama, and Spain; and implemented the BP in 15 public schools supported by sponsorship programs. This paper provides crucial lessons learned, future directions, and implications for dissemination and implementation efforts in this region of the world.

Binge eating age of onset, frequency, and associated emotional distress among women aged 60 years and over.

Emerging research indicates that binge eating is prevalent among older adult women. This study explored the characteristics of older women (aged 60+ years) with objective binge episodes (OBE) in later-life, including age of onset, distress, and frequency of OBE. Data consist of telephone clinical interviews conducted with individuals presenting for participation in a biomedical study of older women with OBE to establish inclusion criteria. Of 71 participants interviewed, 77.5% met DSM-5 criteria for OBE (≥1/week for ≥3 months); 33.3% reported OBE onset before age 40, 17.9% reported midlife onset (ages 40-55), and 48.7% reported late-life onset (56+). Regarding distress, older women with OBE in later-life reported themes of age-related self-blame surrounding eating, loss of control, and cognitive fixation on satiation. Among older women with OBE in later-life, onset in mid- to later-life may be relatively common. Furthermore, distress regarding OBEs was significant, highlighting the need for intervention research among this population.

Psychological health among older adult women in the United States during the COVID-19 pandemic.

This study examined differences in mental health in older adult women before versus during the COVID-19 pandemic. Participants who were community dwelling (N = 227) included n = 67 women aged 60-94 in the pre-pandemic group and n = 160 women aged 60-85 in the peri-pandemic group who completed self-report measures assessing mental health and quality of life (QOL). We compared mental health and QOL indices across the pre- and peri-pandemic groups. Results indicated that the peri-pandemic group reported higher anxiety (F = 4.94, p = .027) than the pre-pandemic group. No other significant differences emerged. Given the differential effects in this pandemic across SES, we conducted exploratory analyses investigating differences by income group. Controlling for education and race, within the pre-pandemic group, women with lower income reported worse physical function compared to the mid- and high-income groups. Within the peri-pandemic group, women with lower income reported worse anxiety, poorer sleep, and poorer QOL (physical function, role limitations due to physical problems, vitality, and pain) than high-income individuals. Overall, women who reported lower income reported worse mental health and QOL than those with high-income, especially during the pandemic. This indicates that income might act as a buffer for older women against negative psychological outcomes of the COVID-19 pandemic.

Adapting the body project to a non-western culture: a dissonance-based eating disorders prevention program for Saudi women.

PURPOSE: The main aim of this study was to test the feasibility of an adapted version of the Body Project for young Saudi women as their eating and body issues are comparable to western culture and linked to internalization of westernization. The study also aims to assess predictors of attrition and preliminary effectiveness. METHOD: The intervention was adapted to local culture in collaboration with a co-director of the Body Project Collaborative. 48 Saudi undergraduate females were recruited, mean age was 19.16 years (SD = 1.23), baseline BMI was (M = 24.42, SD = 5.46). Eating pathology, body image, and comorbidities were assessed pre and post the intervention with adapted self-report measures. RESULTS: The Body Project is feasible for young Saudi women. Participants were willing to enrol, they found the intervention useful, understandable, and enjoyable. There was no difference between completers and non-completers. The preliminary effect sizes are similar or higher than other effectiveness trials in other cultures. CONCLUSION: A cognitive dissonance-based eating disorders prevention can be applicable across cultures where westernization is an influence. The effectiveness is yet to be affirmed. Future research is needed to investigate effectiveness in further robust studies and a bigger sample. EVIDENCE-BASED MEDICINE: Level IV (evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Food insecurity & dietary restraint in a diverse urban population.

The primary aim of this study was to investigate self-reported reasons for engaging in dietary restraint (DR) in a food insecure urban population. It also tested whether DR was associated with increased eating disorder (ED) pathology when DR was broadly assessed. The initial sample (N = 503) consisted of adult clients visiting food pantries who completed the Eating Disorder Diagnostic Scale for DSM 5, the Radimer Cornell Food Insecurity Measure, and three items from the DR subscale of Eating Disorder Examination Questionnaire (EDE-Q); EDE-Q items were modified to allow participants to explain why they restricted. Analyses included participants (N = 259) who responded to one of the modified EDE-Q questions. Results indicated that participants engaged in DR for several reasons, including minimizing the effect of hunger for other family members (i.e., children), "stretching" food to make it last longer, and prioritizing medical expenses. Intentional efforts to limit food intake in this sample were correlated with increased ED pathology. Although it is not surprising that adults experiencing food insecurity engage in intentional DR, this study adds important information about why food insecure adults engage in DR and highlights the importance of assessing DR for reasons other than weight and shape concerns.

Body image in older women: a mediator of BMI and wellness behaviors.

Negative body image is prevalent among mid- and late-life women. In younger women, negative body image is associated with reduced quality of life (QOL) when controlling for body mass index (BMI), and mediates the relationship between obesity and emotional wellbeing. Yet, much remains unknown about body image in older populations. In our sample of women aged 50-86 (N = 181), negative body image mediated the relationship between BMI and sleep, all four domains of QOL, negative affect, nutritious food consumption, and psychosocial impairment, but not enjoyment of physical activity. Findings suggest negative body image impacts the wellbeing of older women.

Food Insecurity and Eating Disorders: a Review of Emerging Evidence.

PURPOSE OF REVIEW: This review summarizes emerging evidence for the relationship between food insecurity and eating disorder (ED) pathology, outlines priorities for future research in this area, and comments on considerations for clinical and public health practice. RECENT FINDINGS: Among adults, food insecurity is cross-sectionally associated with higher levels of overall ED pathology, binge eating, compensatory behaviors, binge-eating disorder, and bulimia nervosa. Evidence for similar relationships among adolescents has been less robust; however, compared to studies of adults, there have been substantially fewer studies conducted in adolescents to date. Emerging evidence consistently indicates that food insecurity is cross-sectionally associated with bulimic-spectrum ED pathology among adults. Findings emphasize the need for ED research to include marginalized populations who have historically been overlooked in the ED field. Much more research is needed to better understand the relationship between food insecurity and ED pathology and to determine effective ways to intervene.

The Female Athlete Body project study: 18-month outcomes in eating disorder symptoms and risk factors.

OBJECTIVE: To evaluate the efficacy of the Female Athlete Body project (FAB) in reducing eating disorder (ED) symptoms and risk factors. METHOD: This study was a community participatory three-site, two-arm, cluster randomized controlled trial (RCT). Female collegiate athletes (N = 481) were randomly assigned by team to the FAB intervention, a behavioral ED risk factor reduction program, or a waitlist control condition. Primary analyses examined 18-month effects for ED pathology. Secondary analyses examined risk factors and correlates (e.g., thin-ideal internalization, negative mood, Female Athlete Triad knowledge, and body mass index [BMI]). RESULTS: Linear mixed effects models with team as a cluster level variable and study condition as a between-subjects variable revealed significantly reduced dietary restraint in FAB teams relative to control teams. FAB teams also reported significantly fewer objective and subjective binge episodes than control teams. Finally, FAB teams showed significantly lower thin-ideal internalization and increased BMI at 18-months. No other significant differences were found. DISCUSSION: This RCT examined the effects of a short intervention on ED pathology and risk factors in female collegiate athletes through 18-month follow-up. This trial is one of only three trials with female athletes that have shown long-term reductions in any ED symptoms or produced positive effects on ED risk factors. The present study is the first to find such effects with athletes using a brief (i.e., 4 hr) intervention at 18-month follow-up. Although small effects were found, the current trial provides valuable lessons about future design and implementation of similar trials with athletes. TRIAL REGISTRATION: Clinical trials NCT01735994.

The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders.

OBJECTIVE: Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART). METHOD: The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment. RESULTS: Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge. DISCUSSION: The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.

Traumatic event exposure associated with increased food insecurity and eating disorder pathology.

OBJECTIVE: The primary aim was to investigate the association between food insecurity (FI) and eating disorders, which are nutrition-based public health problems, with traumatic event exposure in a low-income marginalized population. The study also investigated the association between traumatic event exposure, anxiety and weight stigma. DESIGN: The study used self-report surveys in a cross-sectional design. SETTING: Food pantries affiliated with the local food bank in a major US city. SUBJECTS: Participants (n 503) consisted of clients presenting to food pantries. Participants were predominantly female (76·5 %), Latino/Hispanic (64·6 %) and low-income (59 % reported earning under $US 10 000 per year). RESULTS: Results indicated that 55·7 % of participants had directly experienced a traumatic event; this increased to 61·6 % when witnessing was included. Higher levels of FI were associated with greater traumatic event exposure. Increased exposure to traumatic events correlated with worsened overall eating disorder pathology (r=-0·239), weight stigma (r=-0·151) and anxiety (r=-0·210). CONCLUSIONS: The present study is the first to investigate the association of FI, eating disorders and trauma in a low-income marginalized population. Results indicate that exposure to traumatic events is common in this civilian population and that traumatic event exposure is associated with higher levels of FI and eating disorder pathology. Results indicate that further research is warranted given that traumatic event exposure, eating disorder pathology, weight stigma and anxiety may complicate effective delivery of public health interventions in those living with FI.

Interactive medical case: wasting away.

This interactive feature presents the case of a 40-year-old woman with pain, weakness, and poor oral intake. She had had a gradual onset of bilateral flank pain spreading to her lower back, abdomen, and extremities. Test your diagnostic and therapeutic skills at NEJM.org.

Food insecurity and eating disorder pathology.

OBJECTIVE: The primary aim of this study was to investigate eating disorder (ED) pathology in those living with food insecurity. A secondary aim was to investigate whether any-reason dietary restraint, weight self-stigma, and worry increased as level of food insecurity increased. METHOD: Participants (N = 503) seeking food from food pantries completed questionnaires assessing level of food insecurity, demographics, ED pathology, dietary restraint, weight self-stigma, and worry. RESULTS: Consistent with hypotheses, participants with the highest level of food insecurity (i.e., adults who reported having hungry children in their household) also endorsed significantly higher levels of binge eating, overall ED pathology, any-reason dietary restraint, weight self-stigma, and worry compared to participants with lower levels of food insecurity. Contrary to hypotheses, compensatory behaviors also increased as level of food insecurity worsened. Overall, 17% of those in the child hunger food insecurity group reported clinically significant ED pathology. DISCUSSION: This is the first study to assess the full spectrum of ED pathology in a low-income, marginalized population with food insecurity. Given that food insecurity is a global concern, results from this study suggest that greater attention to the association between ED pathology and food insecurity is warranted by researchers around the world.

The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives.

BACKGROUND: Evidence-based practice in eating disorders incorporates three essential components: research evidence, clinical expertise, and patient values, preferences, and characteristics. Conceptualized as a 'three-legged stool' by Sackett et al. in 1996 (BMJ), all of these components of evidence-based practice are considered essential for providing optimal care in the treatment of eating disorders. However, the extent to which these individual aspects of evidence-based practice are valued among clinicians and researchers is variable, with each of these stool 'legs' being neglected at times. As a result, empirical support and patient preferences for treatment are not consistently considered in the selection and implementation of eating disorder treatment. In addition, clinicians may not have access to training to provide treatments supported by research and preferred by patients. Despite these challenges, integrating these three components of evidence-based practice is critical for the effective treatment of eating disorders. DISCUSSION: Current research supports the use of several types of psychotherapies, including cognitive-behavioral, interpersonal, and family-based therapies, as well as certain types of medications for the treatment of eating disorders. However, limitations in current research, including sample heterogeneity, inconsistent efficacy, a paucity of data, the need for tailored approaches, and the use of staging models highlight the need for clinical expertise. Although preliminary data also support the importance of patient preferences, values, and perspectives for optimizing treatment, enhancing treatment outcome, and minimizing attrition among patients with eating disorders, the extent to which patient preference is consistently predictive of outcome is less clear and requires further investigation. All three components of evidence-based practice are integral for the optimal treatment of eating disorders. Integrating clinical expertise and patient perspective may also facilitate the dissemination of empirically-supported and emerging treatments as well as prevention programs. Further research is imperative to identify ways in which this three-legged approach to eating disorder treatment could be most effectively implemented.

The body project 4 all: A pilot randomized controlled trial of a mixed-gender dissonance-based body image program.

OBJECTIVE: The Body Project is a cognitive dissonance-based body image improvement program with ample research support among female samples. More recently, researchers have highlighted the extent of male body dissatisfaction and disordered eating behaviors; however, boys/men have not been included in the majority of body image improvement programs. This study aims to explore the efficacy of a mixed-gender Body Project compared with the historically female-only body image intervention program. METHOD: Participants included male and female college students (N = 185) across two sites. We randomly assigned women to a mixed-gender modification of the two-session, peer-led Body Project (MG), the two-session, peer-led, female-only (FO) Body Project, or a waitlist control (WL), and men to either MG or WL. Participants completed self-report measures assessing negative affect, appearance-ideal internalization, body satisfaction, and eating disorder pathology at baseline, post-test, and at 2- and 6-month follow-up. RESULTS: Linear mixed effects modeling to estimate the change from baseline over time for each dependent variable across conditions were used. For women, results were mixed regarding post-intervention improvement compared with WL, and were largely non-significant compared with WL at 6-month follow-up. Alternatively, results indicated that men in MG consistently improved compared with WL through 6-month follow-up on all measures except negative affect and appearance-ideal internalization. DISCUSSION: Results differed markedly between female and male samples, and were more promising for men than for women. Various explanations are provided, and further research is warranted prior to drawing firm conclusions regarding mixed-gender programming of the Body Project. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:591-602).

Reducing eating disorder risk factors: A pilot effectiveness trial of a train-the-trainer approach to dissemination and implementation.

OBJECTIVE: Impediments limit dissemination and implementation of evidence-based interventions (EBIs), including lack of sufficient training. One strategy to increase implementation of EBIs is the train-the-trainer (TTT) model. The Body Project is a peer-led body image program that reduces eating disorder (ED) risk factors. This study examined the effectiveness of a TTT model at reducing risk factors in Body Project participants. Specifically, this study examined whether a master trainer could train a novice trainer to train undergraduate peer leaders to administer the Body Project such that individuals who received the Body Project (i.e., participants) would evidence comparable outcomes to previous trials. We hypothesized that participants would evidence reductions in ED risk factors, with effect sizes similar to previous trials. METHOD: Utilizing a TTT model, a master trainer trained a novice trainer to train undergraduate peer leaders to administer the Body Project to undergraduate women. Undergraduate women aged 18 years or older who received the Body Project intervention participated in the trial and completed measures at baseline, post-treatment, and five-month follow-up. Primary outcomes included body dissatisfaction, thin ideal internalization, negative affect, and ED pathology. RESULTS: Participants demonstrated significant reductions in thin ideal internalization, ED pathology and body dissatisfaction at post-treatment and 5-month follow-up. At 5 months, using three different strategies for managing missing data, effect sizes were larger or comparable to earlier trials for 3 out of 4 variables. DISCUSSION: Results support a TTT model for Body Project implementation and the importance of utilizing sensitivity analyses for longitudinal datasets with missing data.

Effectiveness of a peer-delivered dissonance-based program in reducing eating disorder risk factors in high school girls.

OBJECTIVE: This pilot study investigated the feasibility, acceptability, and effectiveness of a peer-led dissonance-based eating disorders (ED) prevention/risk factor reduction program with high school girls. METHOD: Ninth grade girls (n = 50) received the peer-led program within the school curriculum. A quasi-experimental design was used to assess changes in ED risk factors preintervention and postintervention compared with waitlist control. Participants were followed through 3-month follow-up. RESULTS: Peer-leader adherence to an intervention manual tailored for this age group was high. The intervention was rated as highly acceptable, with a large proportion of participants reporting that they enjoyed the program and learned and applied new information. Intervention participants exhibited significantly greater pre-post reductions in a majority of risk-factor outcomes compared to waitlist controls. When groups were combined to assess program effects over time there were significant pre-post reductions in a majority of outcomes that were sustained through 3-month follow-up. DISCUSSION: This pilot study provides tentative support for the effectiveness of using peer leaders to implement an empirically supported ED risk factor reduction program in a high school setting. Additional research is needed to replicate results in larger, better-controlled trials with longer follow-up.

The importance of campaign saliency as a predictor of attitude and behavior change: A pilot evaluation of social marketing campaign Fat Talk Free Week.

Fat Talk Free Week (FTFW), a social marketing campaign designed to decrease self-disparaging talk about body and weight, has not yet been evaluated. We conducted a theory-informed pilot evaluation of FTFW with two college samples using a pre- and posttest design. Aligned with the central tenets of the Elaboration Likelihood Model (ELM), we investigated the importance of FTFW saliency as a predictor of fat talk behavior change. Our analytic sample consisted of 118 female participants (83% of original sample). Approximately 76% of the sample was non-Hispanic White, 14% Asian, and 8% Hispanic. At baseline, more than 50% of respondents reported engaging in frequent self fat talk; at posttest, this number dropped to 34% of respondents. Multivariable regression models supported campaign saliency as the single strongest predictor of a decrease in self fat talk. Our results support the social diffusion of campaign messages among shared communities, as we found significant decreases in fat talk among campaign attenders and nonattenders. FTFW may be a promising short-term health communication campaign to reduce fat talk, as campaign messages are salient among university women and may encourage interpersonal communication.

Eating disorder prevention: current evidence-base and future directions.

OBJECTIVE: This narrative review sought to (a) characterize prevention programs that have produced reliable, reproducible, and clinically meaningful effects in efficacy trials, (b) discuss effectiveness trials that have tested whether prevention programs produce intervention effects under ecologically valid real-world conditions, (c) discuss dissemination efforts and research on dissemination, and (d) offer suggestions regarding directions for future research in this field. CONCLUSION: A literature revealed that 6 prevention programs have produced significant reductions in eating disorder symptoms through at least 6-month follow-up and that 2 have significantly reduced future eating disorder onset. Effectiveness trials indicate that 2 prevention programs have produced effects under ecologically valid conditions that are only slightly attenuated. Although there have been few dissemination efforts, evidence suggests that a community participatory approach is most effective. Lastly, it would be useful to develop programs that produce larger and more persistent reductions in eating disorder symptoms and eating disorder onset, focus more on effectiveness trials that confirm that prevention programs produce clinically meaningful effects under real-world conditions, conduct meditational, mechanisms of action, and moderator research that provides stronger support for the intervention theory of prevention programs, and investigate the optimal methods of disseminating and implementing evidence-based prevention programs.

Fat talk, old talk, or both? Association of negative body talk with mental health, body dissatisfaction, and quality of life in men and women.

BACKGROUND: Little research has investigated the harmful effects of old talk-negative age-related body talk-on mental health and quality of life despite substantial research examining fat talk. Old talk also has only been evaluated in women and in relation to few outcomes. Of note, old talk and fat talk are strongly correlated, suggesting possible overlap in elements that drive negative outcomes. Thus, the primary aim of this study was to investigate the extent that old talk and fat talk contribute to negative mental health and quality of life outcomes when examined in the same model and when interacting with age. METHODS: Adults (N = 773) ages 18-91 completed an online survey assessing eating disorder pathology, body dissatisfaction, depression, aging anxiety, general anxiety, quality of life, and demographics. RESULTS: While fat talk and old talk were correlated with almost all outcome variables, fat talk was more commonly significantly associated with poorer outcomes than old talk. Additionally, the relationship between fat talk and old talk with poorer mental health was affected by age in men, but not women. CONCLUSIONS: Future research is warranted to decipher the individual effects of old talk and fat talk on mental health and quality of life across the adult lifespan.

The term "negative body talk" is used to describe the negative things people sometimes say about their bodies and appearance. Two kinds of negative body talk are fat talk (critical and negative talk about weight-related body image) and old talk (negative body talk focused on changes due to aging). Fat talk has been widely studied and found to be related to poorer mental health, including body dissatisfaction and eating disorders. However, old talk has been much less studied though it is both similar and distinct from fat talk. The current study examined how both old talk and fat talk related to mental health and quality of life in adults across the lifespan. We found that both were correlated with poorer mental health, but when compared to one another, fat talk was more related to mental health in both men and women. Of note, age appears to impact these relationships in men, but not in women. It is important for future research to examine why age seems to influence the impact old talk and fat talk have on mental health and further evaluate the similarities and differences between these two types of negative body talk.