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Preventing Body Image Problems
Preventing Body Image Problems: School-Based Approaches JA O’Dea, The University of Sydney, Sydney, NSW, Australia © 2012 Elsevier Inc. All rights reserved.
Glossary anorexia nervosa A serious disorder in eating behavior primarily of young women in their teens and early twenties that is characterized especially by a pathological fear of weight gain, refusal to eat, malnutrition, and excessive weight loss. body image An individual’s perceptions, beliefs, thoughts, feelings, behavior, and attitudes about his or her own body. bulimia nervosa A serious eating disorder that occurs chiefly in females, is characterized by compulsive overeating which may be followed by self-induced
Introduction Body image and eating problems among children and adoles cents are becoming increasingly targeted for school-based preventive education and school health promotion programs. The overall aim of body image programs in schools is to improve body image among children, adolescents, and young people and prevent the body image problems that may be evidenced such as eating disorders, body dissatisfaction, and weight control practices such as vomiting, fasting, laxative and steroid use, and excessive exercise. Anorexia nervosa has been found to affect 0.5–1% of adolescent girls and bulimia nervosa affects 3–5% of girls and young women, with the prevalence of subclinical partial-syndrome eating disorders being much higher, affecting 10–20% of girls and women. These findings may be inaccurate because of the very secretive nature of these disorders and because young people with eating disorders tend not to participate in research studies of the topic. The considerable physical and psychological risks of poor body image to schoolchildren and the importance of school-based body image programs are currently well sup ported by the evidence from school research studies. For example, disordered eating behaviors, including at least one of the following: fasting, skipping meals to lose weight, diet pills, vomiting, laxatives, smoking cigarettes, and binge eating, have been reported by a staggering 56% of 9th grade females and 28% of 9th grade males in the United States. Reports of dieting, fear of fatness, body image concerns, and weight loss attempts, as well as cases of more serious eating disorders, have been documented from children as young as 7 years old. Body image and eating problems have been shown to be consistently more common among girls and young women. However, more recent reports show that boys and young men are increasingly reporting these problems. Young male adoles cents are known to be concerned with their body size and shape. These males were found to undertake weight control and muscle gain behaviors (e.g., fad weight-gain diets, inap propriate weight lifting, and steroid abuse) that may be hazardous to their health. School-based body image programs
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vomiting or laxative or diuretic abuse, and is often accompanied by guilt and depression. cognitive dissonance Psychological conflict resulting from incongruous beliefs and attitudes held simultaneously. iatrogenesis Refers to sickness produced by medical activity. It is induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures. self-esteem An individual’s sustained sense of liking oneself. It is typically expressed in three ways: global self-esteem, feelings of self-worth, and self-evaluations.
therefore are now considered appropriate and relevant for young male as well as females students. Recent studies show that body dissatisfaction among young people is associated with low self-esteem and depression; in addition to the psychological and physiological consequences of body dissatisfaction and eating disorders, there are the obvious economic and social costs of treating such problems. In a large 4-year longitudinal study of adolescent females in the United States, elevated body dissatisfaction, dietary restraint, and symptoms of bulimia on study entry predicted onset of depression in initially nondepressed girls. Clearly, body image concerns and weight loss behaviors are common problems among girls and muscle gain behaviors, eating problems, and steroid use pose a serious and increasing threat to the short- and long-term physical, psychological, and social health of boys. Hence, the need for school-based pre ventive strategies among both boys and girls is well evidenced in the research literature.
Historical Trends in School-Based Programs to Promote Body Image The earliest school-based programs to improve body image were implemented in the 1980s, with a focus on providing information about the harmful effects of dieting and the prime goal of preventing eating disorders among girls. Early studies employed largely psycho-educational approaches that were traditionally based on the adaption of clinical psycholo gical techniques to be implemented in school settings, and relied heavily on the didactic presentation of knowledge and information about the dangers of weight loss techniques. These programs were often delivered by student psychologists rather than by the regular classroom teacher, making their effective ness less generalizable. Several trends are revealed when examining published school-based programs over the past three decades. A 2005 review of school-based health education strategies for the improvement of body image and prevention of eating
Encyclopedia of Body Image and Human Appearance, Volume 2
doi:10.1016/B978-0-12-384925-0.00109-7
Preventing Body Image Problems: School-Based Approaches problems examined relevant literature going back 50 years and identified 21 large, randomized controlled studies conducted in the United States, Canada, England, Australia, England, Israel, Switzerland, and Italy. The review cites the early seminal prevention studies that largely focused on providing adolescent female school students with information about eating disor ders, facts about the dangers of dieting, increased nutrition knowledge, analysis of the social construction of cultural body ideals, and construction of the stereotypical ideal female body. The outcomes of these intervention studies resulted in improved knowledge of eating disorders and weight control issues, but created little behavioral impact on body image improvement or reduction in eating disorder behaviors. Despite the lack of substantial behavior change, these early studies were instrumental in paving the way for researchers to design more innovative and successful body image interven tions. One study that was conducted in Israel introduced the innovative topics of behavior modification for weight control and skills in media analysis and assertiveness. This study resulted in reduced bulimic tendencies and improved eating patterns. Later interventions aimed to educate young people about the media’s artificial creation and perpetuation of the ‘perfect’ body via media images and stereotypes of men and women. Other studies were instrumental in broadening the preventive approaches to include an investigative critique by students of the many biological, social, and psychological influences on eating behavior and body image. Later studies were designed to be more student-centered, peer-led, and educationally interactive with a focus on improv ing body image via general self-esteem development. The ‘Everybody’s Different’ study, for instance, was successful in producing significant and long-lasting impacts among both adolescent girls and boys, including those who were at ‘high risk’ for eating disorders and those who were overweight. Other studies also produced moderate levels of success by combining various components including media literacy, self-esteem, sociocultural determinants of body shape and body image, pubertal development, nondieting approaches to weight control, hazards of dieting, genetic diversity, and coping skills. Seminal research in Canada developed a new direction for preventive research by exploring the influence of peer sup port among girls in grades 7 and 8.
Concerns and Evidence about Iatrogenesis in School-Based Programs to Improve Body Image Safety is a key underlying principle facing those involved in the planning of body image education programs that promote sensible eating and prevent body image and eating problems is safety. Teachers, health educators, dieticians, school admin istrators, nurses, sports coaches, researchers, and policymakers, as well as those who are responsible for food product develop ment, marketing, and advertising, need to pay heed to this most basic principle of modern medicine – ‘First, do no harm’. The literature presents many warnings about the poten tial to do more harm than good when attempting to prevent eating disorders and childhood overweight. In particular, obesity prevention programs may inadver tently serve to heighten awareness of body weight, and increase weight concerns and weight loss attempts among
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children and adolescents. Eating disorder prevention programs may introduce these issues to children and adolescents in a suggestive manner, especially those who directly refer to case studies or eating disorder behavior such as vomiting, starva tion, laxative abuse, diet pills, and cigarette smoking for weight control. Several published research reports confirm that teen age girls and young women have adopted smoking after receiving messages about its suppressive effect upon appetite and its potentially slimming effects. Other more recent studies discuss the creation of the muscular male ideal body via media images. No matter how well meaning prevention programs are, they may inadvertently glamorize and normalize dieting, disordered eating, and the slim ideal by using case studies of sufferers who are celebrities. Parents, teachers, sports coaches, food adverti sers, and marketers may unwittingly transfer anti-fat messages, weight prejudice, male and female body image stereotypes, and fear of food by perpetuating the ‘good foods, bad foods’ myth and creating negative, frightening messages about food and weight. Teachers may also provide incorrect or inappropriate dietary advice and hence, school-based programs to improve body image should contain a teacher and sports coach training component in order to make certain that the program is deliv ered by teachers without creating any unintentional negative effects. Within some programs, the use of negative language can contribute to the underlying fear of food, dietary fat, and weight gain which precede body image concerns and eating problems. Negative language use can occur in school-based body image and health promotion programs, when problem-based messages such as “sugar and fat are ‘bad’” are focused on and the term ‘junk food’ used. Children and ado lescents need to know that they can enjoy a variety of different foods in a balanced diet and they need to be enabled to do so in a positive, motivating atmosphere. Negative messages or those that produce guilt, shame, or fear of food are likely to do more harm than good. The need for school-based programs to properly pretest their intended messages is of great importance in such program design. For example, early investigations of adolescent girls’ reactions to posters that were supposed to improve their body image were found to be inaccurate and alarmingly negative and there is still some controversy over using guest speakers in school-based prevention. While some argue that the recogni tion of eating disorder symptoms among self and friends is critical to secondary prevention, these approaches have been found to be ineffective for primary prevention, as the normal ization and glamorization of dieting and eating disorders may lead to the adoption of potentially dangerous techniques by previously healthy individuals. It appears that researchers have become more aware of the inadvertent, potentially harmful effects of their programs and now evaluate whether or not programs have in fact done more harm than good. One such study that aimed to reduce sedentary behaviors and improve diet among adolescents through a physician-led program, specifically reported that there were no negative effects on self-esteem and body image satisfaction among adolescents who participated in the PACE + program. Regardless of the psychological implications, many schools will use guest speak ers, recovered peers, documentaries, and media reports about eating disorders to teach about these topics due to their ease of
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access. Further research in prevention needs to be made so that safe, effective, evidence-based, and easy-to-use options are available for schools to use.
Different Types of School-Based Programs to Improve Body Image Most early school programs included traditional components of psycho-education, including self-esteem development, dis cussion of the origins of societal female body ideals, and practical strategies to improve girls’ body image. However, there has been a significant progression toward broader pro grams that include boys, target combined risk factors for obesity and eating disorders as well as an additional focus on the reduction of bullying and weight comparison. Another trend is an increased focus on school policy, school environ ment, and ethos, and the inclusion of parents and the community, in line with the Health Promoting Schools Framework. School-based interventions have also been tar geted toward intervention at younger age points, and are now more common in coeducational primary schools. Finally, pro grams have investigated the use of new strategies such as the performing arts, yoga, and cooking classes to improve body image as well as develop habits for life-long health behaviors.
Psycho-Educational Approaches Psycho-educational approaches to body image improvement generally employ traditional didactic pedagogical approaches and psychological counseling techniques in the classroom to impact on the way students perceive their own bodies. These programs have provided a critique of the ways in which social gender stereotypes are reinforced in Western societies. Early psychosocial interventions, delivered in the late 1980s and early 1990s were mainly implemented in secondary school populations of girls with the major objectives of providing information about the harmful effects of dieting and weight regulation; promotion of healthy nutrition and exercise and development of coping skills for resisting the sociocultural influences that are linked to the desire for thinness and dieting. Such programs also aimed to reduce moderate and extreme weight loss behaviors, disordered eating, and poor body image. In general, the early psychosocial interventions tended to improve knowledge about eating disorders, but did not pro duce significant, long term changes for measures of eating and dieting behavior, body dissatisfaction, or self-esteem. Suggested explanations for the modest impact of these pro grams was the short term nature of the intervention, the use of small numbers and the fact that body image beliefs and attitudes are already well entrenched among girls by this mid-adolescent age, suggesting that early interventions, per haps led by peer leaders, may be more successful. This early research suggested that a combination of early intervention and yearly reinforcement throughout secondary school may be more effective.
Self-Esteem Approaches The self-esteem approach to body image promotion was devel oped in the 1990s and was combined in a cooperative,
interactive, student-centered classroom that was deliberately designed to be effective at building students’ self-esteem, improving their body image and preventing eating problems than the more traditional, didactic body image program approaches. The self-esteem approach was based on the Social Cognitive Theory argument that in order to change the health damaging behaviors of adolescents, one must first change the self beliefs, values, and attitudes which precede such behaviors. Bandura’s social cognitive theory states that in particular, the self-perceptions of people must initially change in order to precipitate behavioral change. In order to reduce adolescents’ eating problems, one must therefore initially aim to improve their body image by way of improving their whole self-image and self-esteem. Self-esteem protection and enhancement is therefore appro priate and desirable for all adolescents but it is particularly relevant in the treatment and prevention of body image pro blems, eating disturbances, and obesity because low self-esteem is considered to be a potent risk factor for eating problems. Low self-esteem is common among obese adolescents. Self-esteem development and enhancement is also believed to improve the other factors known to contribute to body image and eating problems. For example, development of a positive self-image and a strong sense of self-worth are likely to help adolescents became more satisfied with their body shape and size and more resilient and resistant to the unrealistic body image ideals portrayed in the media. Adolescents with high self-esteem are better able to cope with teasing, criticism, stress, and anxiety, all of which are associated with body image problems. Further, the development of a positive self-image, which includes a broad array of aspects of the self other than physical appearance, is likely to help adolescents value their many different characteristics and those of others. This type of self-image development is likely to reduce adolescents’ obses sion with perfectionism and the belief that one must be perfect, or strive to be perfect, in order to be valued, accepted, and loved. As perfectionism is strongly associated with body image problems and eating disorders, it is believed that mod ifying this risk factor by developing self-esteem may help young people to be more self-accepting and less involved in the futile quest for perfection. The successful self-esteem intervention study ‘Everybody’s Different’ deliberately avoided any mention of food, eating disorders, dieting, or body shapes. The program aims to improve body esteem by giving the male and female students a ‘dose’ of general self-esteem. It simultaneously combines the development of a positive sense of self with a peer-led analysis and rejection of cultural body image stereotypes of males and females, media body image ideals, stress management, and acceptance of diversity in the self and among others. The 9-week program focuses on expanding grades 7 and 8 students’ self-identity and sense of self-worth by encompassing many aspects of the self and thereby decreasing the emphasis and importance of physical appearance. The program activities promote themes of self-acceptance, self-respect, self-tolerance, and reduced self expectations of perfection. The major program theme is that an individual’s uniqueness is to be expected, valued, and accepted. A strong message of the program is that
Preventing Body Image Problems: School-Based Approaches everybody is different and nobody is perfect. The educational approach features the use of student discussion, group work, team work, games, play, drama and a content-free, self-esteem building curriculum in which both the teaching style and the content of educational activities foster a positive sense of self, student involvement, self-efficacy, vicarious learning, exchange of feedback and opinion, and a safe, respectful, and positive classroom environment in which the students feel that they cannot fail. The ‘Everybody’s Different’ program significantly improved the body image of students who received this program com pared to a matched control group. Female students and those at high risk for eating problems particularly benefited from the program, showing improvements in body satisfaction, drive for thinness, physical appearance ratings, reduced dieting, and less unhealthy weight loss after the intervention. Social acceptance, which includes concepts of peer pressure and popularity, phy sical appearance, and athletic competence were shown to be less important to both male and female students after the intervention with close friendships becoming more important. Many of the improvements were still present and significant at the 12-month follow-up. A unique and interesting finding of this new self-esteem approach was the improvement in body image among both boys and girls as well as those who were overweight or at high risk of developing body image or eating problems. This is evidenced by the fact that the improvement in the body satis faction of high-risk male and female students was still statistically significant 12 months after the self-esteem pro gram. Other studies among adolescent girls that have utilized a predominantly self-esteem building and self-acceptance approach have also been successful in improving the pursuit of the thin ideal, reducing dietary restraint, shape concerns, and eating concerns, reducing dysfunctional eating behaviors and increasing body weight satisfaction. The collective positive results of these studies lend support to the school-based self-esteem approach for the improvement of body image and prevention of eating disturbances in children and adolescents.
Media Literacy Approaches Several recent research studies have found a link between the negative influences of the mass media upon the body image of young people. The impact of media messages contributes to a critical, negative body image, body dissatisfaction, a desire for the slim ideal among females and the muscular ideal among males and the onset of dieting and disordered eating. The key element of the effect of media is the creation of social comparison among boys and girls, where they begin to compare themselves with the ‘perfect’ images of young men and women portrayed in the media. Those who endorse the use of a media literacy approach for the improvement of body image and the prevention of eating problems argue that young women and men become highly self-critical after view ing impossibly ‘perfect’ images of other young women and men in the media. Consequently, this form of social compar ison results in a damaging sense of failure, inadequacy, and, often, a futile life-long pursuit of the unachievable ideal body. The major aim of media literacy education is to help stu dents understand how media messages are constructed, how the messages often reflects a commercial aim, how different
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people interpret different media messages, and how media can have powerful uses in education and social change. In regard to body image education, media literacy is helpful in teaching students how to critique the media messages and then reject the stereotypical body image ideals that are con stantly promoted in the media. The major objectives of classroom-based media literacy lessons are to discover how media messages create social norms in our society; examine stereotypes of males and females in our society; and under stand that we do not have to conform to stereotypes and understand that everybody is an individual, with a unique appearance. A recent review of health-promoting media literacy educa tion found that, of the 21 interventions using this approach, 10 were aimed at improving body image or eating disorders, fol lowed by six to improve violence, three to reduce tobacco smoking, and two to reduce alcohol consumption. In the ‘Everybody’s Different’ program, male and female students in school grades 7 and 8 in Australian schools were involved in media literacy activities to teach them how to explore and critically analyze the portrayal of stereotypes in popular magazines. The aims of media literacy education were for students to develop an awareness of how gender stereotypes and ‘bodies’ are created and portrayed in the media and to employ critical thinking skills to analyze the content and meaning of media messages. Students are also encouraged to question how media messages operate to sell products, messages, and ideas and to discover how media images are created, retouched, airbrushed, and made to look ‘perfect’. Finally, the media literacy component of the program aimed to allow the students to reject inappropriate and unhealthy media messages and to adopt the message that ‘Everybody is Different’ and to promote the idea that diversity and uniqueness is valued and respected. The most recent and effective school-based body image program that has used media literacy is the ‘MediaSmart’ program. Once only media literacy lessons from this pro gram were found to be effective in reducing internalization of the media ideals of thinness and muscularity which is an achievement, as one-shot programs are not generally known to be effective. In addition, media literacy is suggested to be a particularly appropriate way of approaching body image programs among boys and young men, as it uses a balanced approach to examining media stereotypes in order to reduce body dissatisfaction.
Programs Targeting Boys The only program specifically developed for boys was devel oped by Stanford and McCabe (2005) and it focused on development of issues important to boys including develop ment of self-identity and self-esteem; understanding that people have bodies of different shapes and sizes; analysis of media messages about the ideal male body; and discussion of possible responses to boys’ body image concerns. The program produced an increased satisfaction with muscles, improved self-esteem, and lower negative affect. Later studies conducted among boys recommend the deliberate targeting of boys with body image concerns or those most at risk of adopting health risk behaviors, rather than the application of universally tar geted programs.
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Dissonance Approaches Prevention programs based on cognitive dissonance and the use of the Internet have been widely and successfully imple mented among female college models, but their use has not yet filtered down to the school setting. Cognitive Dissonance Theory has generally been used with at-risk women, and out side of the school setting. This approach intersects nicely with models of interactive and student-centered learning as well as fitting with the principles of developing media literacy, making it a good fit for the school setting. The focus on public sharing of attitudes that contradict societal body standards could potentially be useful for all students, with and without body image problems, as it would assist in creating healthier peer norms that would extend the benefits of the program beyond the time in which it is presented. Trials among at-risk adoles cent girls (17 years) outside the school setting have been effective and suggest that dissonance-based approaches could potentially be trialed in schools with older year levels (15 years and over), provided that teachers or facilitators were well trained in the use of this approach. The Internet offers a broad range of opportunities for pro grams designed to improve body image in a range of populations and such approaches could potentially be broadly disseminated at very low cost, and with minimal teacher train ing, making them an exciting new possibility for school-based prevention. The use of the Internet offers the additional benefit of enabling both a universal and targeted program as initial activities can include screening for risk factors and tailoring the subsequent content. For example, ‘Student Bodies’ is an 8-week psycho-educational eating disorder prevention program that was developed in the United States and trialed among female adolescents (mean age 15.1 years) and their parents. It is recommended that future research investigate the use of cogni tive dissonance and Internet-based approaches in schools.
Whole School Approaches Development of student self-esteem and media literacy skills for the improvement of body image and the prevention of eating problems would be very naïve if confined to the indivi dual or to the school classroom. An adolescent’s body image, self-esteem, and sense of self-worth, whilst certainly affected by school curricula and teaching style, are also impacted by peers (e.g., teasing), attitudes of family, teachers and coaches, school environment, community factors (including the media, adver tising, and sports involvement), and culture (such as feminist issues, cultural stereotypes, and social norms and stigma about weight and shape). Positive school policy changes, such as anti-teasing and anti-bullying policies, are very powerful ways of changing the whole school environment to promote a greater diversity in body shapes and a greater tolerance of individual differences. An holistic environmental approach to the prevention of body image and eating problems as well as prevention of over weight in children, such as the Health Promoting Schools Framework, theorizes that whole communities need to be involved in fostering overall health within school and commu nity environments. Several facets of prevention need attention when focusing on body image improvement using a whole
school approach, including school curricula, school ethos, school policies, and school community links.
Government Initiatives In Australia, the current national government has developed a strategic approach to body image improvement and prevention of eating problems by initiating some widespread policy sugges tions. The National Advisory Group on Body Image has recommended that to progress the development of a National Strategy on Body Image, the Australian Government engage with and support existing expertise, resources, and organizations. Specifically, the government initiatives recommended for malization of information sharing among the federal and state and territory governments to ensure research, best practice initiatives, and resources are shared. National initiatives to address body image are supported by all levels of government and the creation of a national register of interested parties as a means of creating a network of concerned people from the public, industry, community organizations, academics, and health practitioners. This government initiative also developed and supported a ‘Voluntary Industry Code of Conduct on Body Image’. This initiative came with the proviso that, if, after a sustained period of continued development, government sup port, and promotion, there is a broad failure among industry to adopt good body image practices, the Australian Government should look to review the voluntary nature of the code. Another interesting government development to arise from the national advisory group on body image was the suggestion to introduce standardized clothes sizing. As part of the intro duction of standardized sizing, the Australian government was to consider consulting body image experts and the Textile, Clothing and Footwear Industries representatives concerned with body image issues to ensure sizing labels do not encou rage competitive weight loss. It is also suggested that Government communications about positive body image mes sages be distributed to consumers and industry at the time of introducing standardized sizing. Public Advocacy initiatives were also developed by the group to enable and inform mem bers of the public of mechanisms they can use to raise concerns regarding body image messages. The national body image consultation process was sup ported by a briefing paper prepared by the Australian Government Office for Youth. The paper outlines the issue of negative body image in the community, including factors that contribute to its development, and existing measures to address it. Similarly, in 2006, the Italian government and fashion industry created a voluntary code of conduct requiring models to show medical proof that they do not suffer from eating disorders. The code bans models younger than 16 from the catwalks and calls for a commitment to add larger sizes to fashion collections. The Italian Ministries of Health and Sports are directing the project at schools and the media, pro viding guidelines for magazines, television, radio, and Internet sites to discourage ultrathin beauty ideals. Spanish government authorities have developed similar guidelines to attempt to reduce underweight and unhealthy models acting publicly as unhealthy role models for young women.
Preventing Body Image Problems: School-Based Approaches
Summary of Programs and Outcomes in Grade Schools, Middle Schools, and High Schools Initially, body image improvement programs were implemented in secondary schools, at the age at which young people (in particular, girls) were considered to be most at risk of devel oping eating disorders. More recently, programs have been developed for much younger co-educational cohorts as research ers realize the importance of implementing programs with boys, preadolescents, and well before body image problems arise. Many well-designed and effective programs to improve body image have now been conducted in primary schools. ‘Very Important Kids’ and ‘Healthy Schools-Healthy Kids’ are two examples of programs that have been conducted with boys and girls aged 10–12 years, and over the entire school year. These programs have had a broader focus, and included themes of size acceptance, reduction of weight-based teasing, and healthy living throughout several aspects of the formal and informal curricu lum. Shorter programs have also been found to be effective in improving body image with young audiences, including the innovative use of the storybook ‘Shapesville’ and puppetry among children as young as 5 years of age. Ideally, programs to improve body image would be given throughout a child’s school career and would target developmentally appropriate risk factors and behaviors. The crowding of the school curriculum and the increased competition for implementation of interventions of many kinds have required the development of combined programs with a broader health promotion focus to improve body image as well as a range of other areas of young people’s well-being. The most common of these combinations has been the dual focus on risk factors common to both obesity and eating dis orders to reduce the broad spectrum of weight problems. Examples of such programs include ‘New Moves’, as well as new developments ‘5-2-1-Go!’ ‘Healthy Buddies’ and ‘Healthy Schools-Healthy Kids’. These combined approaches draw upon theory from the Social and Emotional Learning and Positive Psychology literature, as well as the eating disorder and obesity prevention research.
Issues Related to Success or Failure of Programs and Approaches The school environment is particularly challenging for pre vention research due to issues of appropriateness and relevance of program content, teacher’s adherence to program content, and effectiveness of standardized measures in ‘normal’ populations or those not particularly at risk. Additionally, evaluation instruments tend to be suitable for use among females and are not necessarily effective for mea suring body image in males.
Issues of Program Fidelity and Program Delivery Barriers to program fidelity include the fact that teachers may deviate from the intended program content or may have inadequate training to effectively carry out the program. A number of past school-based body image prevention
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programs have been developed and delivered by psycholo gists and/or research staff with little formal educational training or background. Very few past school-based body image programs have provided teacher training and this may impact on program delivery. In the school-based delivery of body image programs, teachers need to be trained to develop specific skills to deliver prevention programs, such as being able to facilitate student reflective discussion. The Canadian program ‘Student Body: Promoting Health at Any Size’ is the first web-based training tool designed to assist teachers and public health officials to deliver programs to improve body satisfaction in schools. Teachers (especially those who are young and female) may be experiencing body image issues themselves. It is thus sug gested that teachers undergo specific training that addresses their personal and professional needs both during undergrad uate training and once in the workforce.
The Universal Versus Targeted Program Debate and Issues of Measurement of Program Effectiveness Most school-based body image improvement programs to date have been universal, or universal-selective according to the WHO definitions of health promotion. Targeted programs, or those focused on engaging high-risk participants, are acknowl edged as being more effective in statistical terms, and increased outcome effects occur when programs are conducted with high-risk females rather than ‘normal’ populations who tend to have low baseline scores for body image concerns. However, universal-selective interventions provide a clear opportunity for the widespread, sustainable implementation of body image intervention programs in schools. Several researchers have commented that there is little room for movement in research data scores, as most study outcome measures have been developed for clinical use with females and hence, allow very little room for improvement in baseline scores among ‘normal’ populations, or those not at risk. This issue is exacerbated by the move toward school-based prevention in younger and younger audiences without the development of appropriate standardized mea sures to capture changes in attitudes and behavioral intentions among such young participants. Even the best program cannot be properly evaluated, or will not seem to be effective, without appropriate measurement tools, espe cially when using female focused instruments to investigate body image in boys. It is recommended that researchers develop validated gender-specific scales that provide a more accurate depiction of change among preadolescent and ‘nor mal’ participants.
Inclusion of Males in School-Based Body Image Programs Early body image interventions conducted in the 1980s and 1990s tended to include only girls, but more recent studies have realized the importance of including boys in the
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educational programs as well as in the research evaluations. Boys certainly have body image concerns, as several recent research studies have shown. Boys may have a significant role to play in balancing coeducational classroom discussions about gender stereotypes. Most researchers and educators now agree that males need to be included in school-based body image programs, but the discussion of whether they should be included into coeduca tional programs with girls, or to have gender-specific programs still remains. The most successful mixed gender program that improved male body satisfaction was ‘MediaSmart’, which took a media literacy approach and used a male researcher to facilitate the program. Either of these factors may have led to males finding the program more relevant and engaged with the activities to a greater level, resulting in improved outcomes. The ‘Everybody’s Different’ program also reported significant improvements in male body dissatisfaction and this program also included a media literacy component. It may be that the reaction and discussion between males and females over body image ideals and the resultant realization of more reasonable peer norms may be more powerful than the program content itself. The development of male focused program materials and the theoretical frameworks for body image improvement among males are urgently required in order for this research to continue. Empirical evidence is required to guide future programs in regard to whether these programs should be con ducted among same-sex or mixed groups, and by male or female facilitators.
Recommendations for Future Research and Programs Future school-based body image programs should include both genders, using suitable instruments for females and males and should focus on the early prevention of body image concerns by further developing programs that are aimed at younger coeducational groups of children and those that use age-appropriate engaging approaches such as musicals, puppetry, and story books. Programs specific to targeted groups, such as high-risk populations, require further investiga tion. Online and Internet-based programs may be effective in reaching a broader array of participants. The incorporation of broader whole school approaches and combination with obe sity and healthy living interventions appears to be a new approach that not only utilizes available resources, but also harnesses expertise from both fields. Utilizing the powerful role of parents, government policy, and whole school and community environments are also salient in planning future research designs.
See also: Body Image Change and Prevention: DissonanceBased Approaches; Body Image Development – Adolescent Boys; Body Image Development – Adolescent Girls; Body Image Development – Adult Men; Body Image Development – Adult Women; Body Image Development – Boy Children; Body Image Development – Girl Children; Body Image: Familial Influences; Body Image in Dance and Aesthetic Sports; Body Image: Peer Influences; Body Weight and Body Image in Children and Adolescents; Internalization of Thin-Ideal and Muscular-Ideal; Measurement of Body Image in Adolescence and Adulthood; Measurement of Body Image in Childhood; Measurement of Perceptual Body Image; Preventing Body Image Problems: Digitally Delivered Interventions; Preventing Body Image Problems: Ecological and Activism Approaches; Preventing Body Image Problems: Public Policy Approaches; Social Comparison Theory and Body Image; Sociocultural Perspectives on Body Image; Teasing, Appearance-Related.
Further Reading Bergsma, L. J., and Carney, M. E. (2008). Effectiveness of health-promoting media literacy education: A systematic review. Health Education Research 23, 522–542. Dohnt, H. K., and Tiggemann, M. (2008). Promoting positive body image in young girls: An evaluation of ‘Shapesville’. European Eating Disorder Review 16, 222–233. Haines, J., Neumark-Sztainer, D., Perry, C. L., et al. (2006). V.I.K. (Very Important Kids): A school-based program designed to reduce teasing and unhealthy weight-control behaviors. Health Education Research 21, 884–895. McCabe, M. P., Ricciardelli, L., and Karantzas, G. (2010). The impact of a healthy body image program among adolescent boys on body image negative affect and body changes strategies. Body Image 7, 117–123. McVey, G. L., Tweed, S., and Blackmore, E., (2007). Healthy schools-Healthy kids: A controlled evaluation of a comprehensive universal eating disorder prevention program. Body Image 4, 115–136. Neumark-Sztainer, D., Story, M., Hannen, P. J., and Rex, J. (2003). New Moves: A schoolbased obesity prevention program for adolescent girls. Preventive Medicine 37, 41–51. O’Dea, J. A. (2007). Everybody’s Different: A Positive Approach to Teaching about Health, Puberty, Body Image, Nutrition, Self-Esteem and Obesity Prevention. Melbourne, VIC: Australian Council for Educational Research (ACER). O’Dea, J. A., and Yager, Z. (2011). School-based psychoeducational approaches to prevention. In: Cash, T. F., and Smolak, L. (eds.), Body Image: A Handbook of Science, Practice, and Prevention, 2nd ed., pp. 434–441. New York: Guilford Press. Paxton, S. (2002). Research Review of Body Image Programs: An Overview of Body Image Dissatisfaction Prevention Interventions. Melbourne, VIC: Victorian Department Government Department of Human Services. Stice, E., Rohde, P., Gau, J., and 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, 825–834. Wilksch, S. M., Tiggemann, M., and Wade, T. D. (2006). Impact of interactive school based media literacy lessons for reducing internalization of media ideals in young adolescent girls and boys. International Journal of Eating Disorders 39, 385–393.
Relevant Websites http://www.youth.gov.au – Australian Government Action on Body Image Policy.
http://www.cbc.ca – Italian Government Initiative.
http://findarticles.com – Spanish Government Initiative.
Glossary anorexia nervosa A serious disorder in eating behavior primarily of young women in their teens and early twenties that is characterized especially by a pathological fear of weight gain, refusal to eat, malnutrition, and excessive weight loss. body image An individual’s perceptions, beliefs, thoughts, feelings, behavior, and attitudes about his or her own body. bulimia nervosa A serious eating disorder that occurs chiefly in females, is characterized by compulsive overeating which may be followed by self-induced
Introduction Body image and eating problems among children and adoles cents are becoming increasingly targeted for school-based preventive education and school health promotion programs. The overall aim of body image programs in schools is to improve body image among children, adolescents, and young people and prevent the body image problems that may be evidenced such as eating disorders, body dissatisfaction, and weight control practices such as vomiting, fasting, laxative and steroid use, and excessive exercise. Anorexia nervosa has been found to affect 0.5–1% of adolescent girls and bulimia nervosa affects 3–5% of girls and young women, with the prevalence of subclinical partial-syndrome eating disorders being much higher, affecting 10–20% of girls and women. These findings may be inaccurate because of the very secretive nature of these disorders and because young people with eating disorders tend not to participate in research studies of the topic. The considerable physical and psychological risks of poor body image to schoolchildren and the importance of school-based body image programs are currently well sup ported by the evidence from school research studies. For example, disordered eating behaviors, including at least one of the following: fasting, skipping meals to lose weight, diet pills, vomiting, laxatives, smoking cigarettes, and binge eating, have been reported by a staggering 56% of 9th grade females and 28% of 9th grade males in the United States. Reports of dieting, fear of fatness, body image concerns, and weight loss attempts, as well as cases of more serious eating disorders, have been documented from children as young as 7 years old. Body image and eating problems have been shown to be consistently more common among girls and young women. However, more recent reports show that boys and young men are increasingly reporting these problems. Young male adoles cents are known to be concerned with their body size and shape. These males were found to undertake weight control and muscle gain behaviors (e.g., fad weight-gain diets, inap propriate weight lifting, and steroid abuse) that may be hazardous to their health. School-based body image programs
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vomiting or laxative or diuretic abuse, and is often accompanied by guilt and depression. cognitive dissonance Psychological conflict resulting from incongruous beliefs and attitudes held simultaneously. iatrogenesis Refers to sickness produced by medical activity. It is induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures. self-esteem An individual’s sustained sense of liking oneself. It is typically expressed in three ways: global self-esteem, feelings of self-worth, and self-evaluations.
therefore are now considered appropriate and relevant for young male as well as females students. Recent studies show that body dissatisfaction among young people is associated with low self-esteem and depression; in addition to the psychological and physiological consequences of body dissatisfaction and eating disorders, there are the obvious economic and social costs of treating such problems. In a large 4-year longitudinal study of adolescent females in the United States, elevated body dissatisfaction, dietary restraint, and symptoms of bulimia on study entry predicted onset of depression in initially nondepressed girls. Clearly, body image concerns and weight loss behaviors are common problems among girls and muscle gain behaviors, eating problems, and steroid use pose a serious and increasing threat to the short- and long-term physical, psychological, and social health of boys. Hence, the need for school-based pre ventive strategies among both boys and girls is well evidenced in the research literature.
Historical Trends in School-Based Programs to Promote Body Image The earliest school-based programs to improve body image were implemented in the 1980s, with a focus on providing information about the harmful effects of dieting and the prime goal of preventing eating disorders among girls. Early studies employed largely psycho-educational approaches that were traditionally based on the adaption of clinical psycholo gical techniques to be implemented in school settings, and relied heavily on the didactic presentation of knowledge and information about the dangers of weight loss techniques. These programs were often delivered by student psychologists rather than by the regular classroom teacher, making their effective ness less generalizable. Several trends are revealed when examining published school-based programs over the past three decades. A 2005 review of school-based health education strategies for the improvement of body image and prevention of eating
Encyclopedia of Body Image and Human Appearance, Volume 2
doi:10.1016/B978-0-12-384925-0.00109-7
Preventing Body Image Problems: School-Based Approaches problems examined relevant literature going back 50 years and identified 21 large, randomized controlled studies conducted in the United States, Canada, England, Australia, England, Israel, Switzerland, and Italy. The review cites the early seminal prevention studies that largely focused on providing adolescent female school students with information about eating disor ders, facts about the dangers of dieting, increased nutrition knowledge, analysis of the social construction of cultural body ideals, and construction of the stereotypical ideal female body. The outcomes of these intervention studies resulted in improved knowledge of eating disorders and weight control issues, but created little behavioral impact on body image improvement or reduction in eating disorder behaviors. Despite the lack of substantial behavior change, these early studies were instrumental in paving the way for researchers to design more innovative and successful body image interven tions. One study that was conducted in Israel introduced the innovative topics of behavior modification for weight control and skills in media analysis and assertiveness. This study resulted in reduced bulimic tendencies and improved eating patterns. Later interventions aimed to educate young people about the media’s artificial creation and perpetuation of the ‘perfect’ body via media images and stereotypes of men and women. Other studies were instrumental in broadening the preventive approaches to include an investigative critique by students of the many biological, social, and psychological influences on eating behavior and body image. Later studies were designed to be more student-centered, peer-led, and educationally interactive with a focus on improv ing body image via general self-esteem development. The ‘Everybody’s Different’ study, for instance, was successful in producing significant and long-lasting impacts among both adolescent girls and boys, including those who were at ‘high risk’ for eating disorders and those who were overweight. Other studies also produced moderate levels of success by combining various components including media literacy, self-esteem, sociocultural determinants of body shape and body image, pubertal development, nondieting approaches to weight control, hazards of dieting, genetic diversity, and coping skills. Seminal research in Canada developed a new direction for preventive research by exploring the influence of peer sup port among girls in grades 7 and 8.
Concerns and Evidence about Iatrogenesis in School-Based Programs to Improve Body Image Safety is a key underlying principle facing those involved in the planning of body image education programs that promote sensible eating and prevent body image and eating problems is safety. Teachers, health educators, dieticians, school admin istrators, nurses, sports coaches, researchers, and policymakers, as well as those who are responsible for food product develop ment, marketing, and advertising, need to pay heed to this most basic principle of modern medicine – ‘First, do no harm’. The literature presents many warnings about the poten tial to do more harm than good when attempting to prevent eating disorders and childhood overweight. In particular, obesity prevention programs may inadver tently serve to heighten awareness of body weight, and increase weight concerns and weight loss attempts among
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children and adolescents. Eating disorder prevention programs may introduce these issues to children and adolescents in a suggestive manner, especially those who directly refer to case studies or eating disorder behavior such as vomiting, starva tion, laxative abuse, diet pills, and cigarette smoking for weight control. Several published research reports confirm that teen age girls and young women have adopted smoking after receiving messages about its suppressive effect upon appetite and its potentially slimming effects. Other more recent studies discuss the creation of the muscular male ideal body via media images. No matter how well meaning prevention programs are, they may inadvertently glamorize and normalize dieting, disordered eating, and the slim ideal by using case studies of sufferers who are celebrities. Parents, teachers, sports coaches, food adverti sers, and marketers may unwittingly transfer anti-fat messages, weight prejudice, male and female body image stereotypes, and fear of food by perpetuating the ‘good foods, bad foods’ myth and creating negative, frightening messages about food and weight. Teachers may also provide incorrect or inappropriate dietary advice and hence, school-based programs to improve body image should contain a teacher and sports coach training component in order to make certain that the program is deliv ered by teachers without creating any unintentional negative effects. Within some programs, the use of negative language can contribute to the underlying fear of food, dietary fat, and weight gain which precede body image concerns and eating problems. Negative language use can occur in school-based body image and health promotion programs, when problem-based messages such as “sugar and fat are ‘bad’” are focused on and the term ‘junk food’ used. Children and ado lescents need to know that they can enjoy a variety of different foods in a balanced diet and they need to be enabled to do so in a positive, motivating atmosphere. Negative messages or those that produce guilt, shame, or fear of food are likely to do more harm than good. The need for school-based programs to properly pretest their intended messages is of great importance in such program design. For example, early investigations of adolescent girls’ reactions to posters that were supposed to improve their body image were found to be inaccurate and alarmingly negative and there is still some controversy over using guest speakers in school-based prevention. While some argue that the recogni tion of eating disorder symptoms among self and friends is critical to secondary prevention, these approaches have been found to be ineffective for primary prevention, as the normal ization and glamorization of dieting and eating disorders may lead to the adoption of potentially dangerous techniques by previously healthy individuals. It appears that researchers have become more aware of the inadvertent, potentially harmful effects of their programs and now evaluate whether or not programs have in fact done more harm than good. One such study that aimed to reduce sedentary behaviors and improve diet among adolescents through a physician-led program, specifically reported that there were no negative effects on self-esteem and body image satisfaction among adolescents who participated in the PACE + program. Regardless of the psychological implications, many schools will use guest speak ers, recovered peers, documentaries, and media reports about eating disorders to teach about these topics due to their ease of
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access. Further research in prevention needs to be made so that safe, effective, evidence-based, and easy-to-use options are available for schools to use.
Different Types of School-Based Programs to Improve Body Image Most early school programs included traditional components of psycho-education, including self-esteem development, dis cussion of the origins of societal female body ideals, and practical strategies to improve girls’ body image. However, there has been a significant progression toward broader pro grams that include boys, target combined risk factors for obesity and eating disorders as well as an additional focus on the reduction of bullying and weight comparison. Another trend is an increased focus on school policy, school environ ment, and ethos, and the inclusion of parents and the community, in line with the Health Promoting Schools Framework. School-based interventions have also been tar geted toward intervention at younger age points, and are now more common in coeducational primary schools. Finally, pro grams have investigated the use of new strategies such as the performing arts, yoga, and cooking classes to improve body image as well as develop habits for life-long health behaviors.
Psycho-Educational Approaches Psycho-educational approaches to body image improvement generally employ traditional didactic pedagogical approaches and psychological counseling techniques in the classroom to impact on the way students perceive their own bodies. These programs have provided a critique of the ways in which social gender stereotypes are reinforced in Western societies. Early psychosocial interventions, delivered in the late 1980s and early 1990s were mainly implemented in secondary school populations of girls with the major objectives of providing information about the harmful effects of dieting and weight regulation; promotion of healthy nutrition and exercise and development of coping skills for resisting the sociocultural influences that are linked to the desire for thinness and dieting. Such programs also aimed to reduce moderate and extreme weight loss behaviors, disordered eating, and poor body image. In general, the early psychosocial interventions tended to improve knowledge about eating disorders, but did not pro duce significant, long term changes for measures of eating and dieting behavior, body dissatisfaction, or self-esteem. Suggested explanations for the modest impact of these pro grams was the short term nature of the intervention, the use of small numbers and the fact that body image beliefs and attitudes are already well entrenched among girls by this mid-adolescent age, suggesting that early interventions, per haps led by peer leaders, may be more successful. This early research suggested that a combination of early intervention and yearly reinforcement throughout secondary school may be more effective.
Self-Esteem Approaches The self-esteem approach to body image promotion was devel oped in the 1990s and was combined in a cooperative,
interactive, student-centered classroom that was deliberately designed to be effective at building students’ self-esteem, improving their body image and preventing eating problems than the more traditional, didactic body image program approaches. The self-esteem approach was based on the Social Cognitive Theory argument that in order to change the health damaging behaviors of adolescents, one must first change the self beliefs, values, and attitudes which precede such behaviors. Bandura’s social cognitive theory states that in particular, the self-perceptions of people must initially change in order to precipitate behavioral change. In order to reduce adolescents’ eating problems, one must therefore initially aim to improve their body image by way of improving their whole self-image and self-esteem. Self-esteem protection and enhancement is therefore appro priate and desirable for all adolescents but it is particularly relevant in the treatment and prevention of body image pro blems, eating disturbances, and obesity because low self-esteem is considered to be a potent risk factor for eating problems. Low self-esteem is common among obese adolescents. Self-esteem development and enhancement is also believed to improve the other factors known to contribute to body image and eating problems. For example, development of a positive self-image and a strong sense of self-worth are likely to help adolescents became more satisfied with their body shape and size and more resilient and resistant to the unrealistic body image ideals portrayed in the media. Adolescents with high self-esteem are better able to cope with teasing, criticism, stress, and anxiety, all of which are associated with body image problems. Further, the development of a positive self-image, which includes a broad array of aspects of the self other than physical appearance, is likely to help adolescents value their many different characteristics and those of others. This type of self-image development is likely to reduce adolescents’ obses sion with perfectionism and the belief that one must be perfect, or strive to be perfect, in order to be valued, accepted, and loved. As perfectionism is strongly associated with body image problems and eating disorders, it is believed that mod ifying this risk factor by developing self-esteem may help young people to be more self-accepting and less involved in the futile quest for perfection. The successful self-esteem intervention study ‘Everybody’s Different’ deliberately avoided any mention of food, eating disorders, dieting, or body shapes. The program aims to improve body esteem by giving the male and female students a ‘dose’ of general self-esteem. It simultaneously combines the development of a positive sense of self with a peer-led analysis and rejection of cultural body image stereotypes of males and females, media body image ideals, stress management, and acceptance of diversity in the self and among others. The 9-week program focuses on expanding grades 7 and 8 students’ self-identity and sense of self-worth by encompassing many aspects of the self and thereby decreasing the emphasis and importance of physical appearance. The program activities promote themes of self-acceptance, self-respect, self-tolerance, and reduced self expectations of perfection. The major program theme is that an individual’s uniqueness is to be expected, valued, and accepted. A strong message of the program is that
Preventing Body Image Problems: School-Based Approaches everybody is different and nobody is perfect. The educational approach features the use of student discussion, group work, team work, games, play, drama and a content-free, self-esteem building curriculum in which both the teaching style and the content of educational activities foster a positive sense of self, student involvement, self-efficacy, vicarious learning, exchange of feedback and opinion, and a safe, respectful, and positive classroom environment in which the students feel that they cannot fail. The ‘Everybody’s Different’ program significantly improved the body image of students who received this program com pared to a matched control group. Female students and those at high risk for eating problems particularly benefited from the program, showing improvements in body satisfaction, drive for thinness, physical appearance ratings, reduced dieting, and less unhealthy weight loss after the intervention. Social acceptance, which includes concepts of peer pressure and popularity, phy sical appearance, and athletic competence were shown to be less important to both male and female students after the intervention with close friendships becoming more important. Many of the improvements were still present and significant at the 12-month follow-up. A unique and interesting finding of this new self-esteem approach was the improvement in body image among both boys and girls as well as those who were overweight or at high risk of developing body image or eating problems. This is evidenced by the fact that the improvement in the body satis faction of high-risk male and female students was still statistically significant 12 months after the self-esteem pro gram. Other studies among adolescent girls that have utilized a predominantly self-esteem building and self-acceptance approach have also been successful in improving the pursuit of the thin ideal, reducing dietary restraint, shape concerns, and eating concerns, reducing dysfunctional eating behaviors and increasing body weight satisfaction. The collective positive results of these studies lend support to the school-based self-esteem approach for the improvement of body image and prevention of eating disturbances in children and adolescents.
Media Literacy Approaches Several recent research studies have found a link between the negative influences of the mass media upon the body image of young people. The impact of media messages contributes to a critical, negative body image, body dissatisfaction, a desire for the slim ideal among females and the muscular ideal among males and the onset of dieting and disordered eating. The key element of the effect of media is the creation of social comparison among boys and girls, where they begin to compare themselves with the ‘perfect’ images of young men and women portrayed in the media. Those who endorse the use of a media literacy approach for the improvement of body image and the prevention of eating problems argue that young women and men become highly self-critical after view ing impossibly ‘perfect’ images of other young women and men in the media. Consequently, this form of social compar ison results in a damaging sense of failure, inadequacy, and, often, a futile life-long pursuit of the unachievable ideal body. The major aim of media literacy education is to help stu dents understand how media messages are constructed, how the messages often reflects a commercial aim, how different
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people interpret different media messages, and how media can have powerful uses in education and social change. In regard to body image education, media literacy is helpful in teaching students how to critique the media messages and then reject the stereotypical body image ideals that are con stantly promoted in the media. The major objectives of classroom-based media literacy lessons are to discover how media messages create social norms in our society; examine stereotypes of males and females in our society; and under stand that we do not have to conform to stereotypes and understand that everybody is an individual, with a unique appearance. A recent review of health-promoting media literacy educa tion found that, of the 21 interventions using this approach, 10 were aimed at improving body image or eating disorders, fol lowed by six to improve violence, three to reduce tobacco smoking, and two to reduce alcohol consumption. In the ‘Everybody’s Different’ program, male and female students in school grades 7 and 8 in Australian schools were involved in media literacy activities to teach them how to explore and critically analyze the portrayal of stereotypes in popular magazines. The aims of media literacy education were for students to develop an awareness of how gender stereotypes and ‘bodies’ are created and portrayed in the media and to employ critical thinking skills to analyze the content and meaning of media messages. Students are also encouraged to question how media messages operate to sell products, messages, and ideas and to discover how media images are created, retouched, airbrushed, and made to look ‘perfect’. Finally, the media literacy component of the program aimed to allow the students to reject inappropriate and unhealthy media messages and to adopt the message that ‘Everybody is Different’ and to promote the idea that diversity and uniqueness is valued and respected. The most recent and effective school-based body image program that has used media literacy is the ‘MediaSmart’ program. Once only media literacy lessons from this pro gram were found to be effective in reducing internalization of the media ideals of thinness and muscularity which is an achievement, as one-shot programs are not generally known to be effective. In addition, media literacy is suggested to be a particularly appropriate way of approaching body image programs among boys and young men, as it uses a balanced approach to examining media stereotypes in order to reduce body dissatisfaction.
Programs Targeting Boys The only program specifically developed for boys was devel oped by Stanford and McCabe (2005) and it focused on development of issues important to boys including develop ment of self-identity and self-esteem; understanding that people have bodies of different shapes and sizes; analysis of media messages about the ideal male body; and discussion of possible responses to boys’ body image concerns. The program produced an increased satisfaction with muscles, improved self-esteem, and lower negative affect. Later studies conducted among boys recommend the deliberate targeting of boys with body image concerns or those most at risk of adopting health risk behaviors, rather than the application of universally tar geted programs.
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Dissonance Approaches Prevention programs based on cognitive dissonance and the use of the Internet have been widely and successfully imple mented among female college models, but their use has not yet filtered down to the school setting. Cognitive Dissonance Theory has generally been used with at-risk women, and out side of the school setting. This approach intersects nicely with models of interactive and student-centered learning as well as fitting with the principles of developing media literacy, making it a good fit for the school setting. The focus on public sharing of attitudes that contradict societal body standards could potentially be useful for all students, with and without body image problems, as it would assist in creating healthier peer norms that would extend the benefits of the program beyond the time in which it is presented. Trials among at-risk adoles cent girls (17 years) outside the school setting have been effective and suggest that dissonance-based approaches could potentially be trialed in schools with older year levels (15 years and over), provided that teachers or facilitators were well trained in the use of this approach. The Internet offers a broad range of opportunities for pro grams designed to improve body image in a range of populations and such approaches could potentially be broadly disseminated at very low cost, and with minimal teacher train ing, making them an exciting new possibility for school-based prevention. The use of the Internet offers the additional benefit of enabling both a universal and targeted program as initial activities can include screening for risk factors and tailoring the subsequent content. For example, ‘Student Bodies’ is an 8-week psycho-educational eating disorder prevention program that was developed in the United States and trialed among female adolescents (mean age 15.1 years) and their parents. It is recommended that future research investigate the use of cogni tive dissonance and Internet-based approaches in schools.
Whole School Approaches Development of student self-esteem and media literacy skills for the improvement of body image and the prevention of eating problems would be very naïve if confined to the indivi dual or to the school classroom. An adolescent’s body image, self-esteem, and sense of self-worth, whilst certainly affected by school curricula and teaching style, are also impacted by peers (e.g., teasing), attitudes of family, teachers and coaches, school environment, community factors (including the media, adver tising, and sports involvement), and culture (such as feminist issues, cultural stereotypes, and social norms and stigma about weight and shape). Positive school policy changes, such as anti-teasing and anti-bullying policies, are very powerful ways of changing the whole school environment to promote a greater diversity in body shapes and a greater tolerance of individual differences. An holistic environmental approach to the prevention of body image and eating problems as well as prevention of over weight in children, such as the Health Promoting Schools Framework, theorizes that whole communities need to be involved in fostering overall health within school and commu nity environments. Several facets of prevention need attention when focusing on body image improvement using a whole
school approach, including school curricula, school ethos, school policies, and school community links.
Government Initiatives In Australia, the current national government has developed a strategic approach to body image improvement and prevention of eating problems by initiating some widespread policy sugges tions. The National Advisory Group on Body Image has recommended that to progress the development of a National Strategy on Body Image, the Australian Government engage with and support existing expertise, resources, and organizations. Specifically, the government initiatives recommended for malization of information sharing among the federal and state and territory governments to ensure research, best practice initiatives, and resources are shared. National initiatives to address body image are supported by all levels of government and the creation of a national register of interested parties as a means of creating a network of concerned people from the public, industry, community organizations, academics, and health practitioners. This government initiative also developed and supported a ‘Voluntary Industry Code of Conduct on Body Image’. This initiative came with the proviso that, if, after a sustained period of continued development, government sup port, and promotion, there is a broad failure among industry to adopt good body image practices, the Australian Government should look to review the voluntary nature of the code. Another interesting government development to arise from the national advisory group on body image was the suggestion to introduce standardized clothes sizing. As part of the intro duction of standardized sizing, the Australian government was to consider consulting body image experts and the Textile, Clothing and Footwear Industries representatives concerned with body image issues to ensure sizing labels do not encou rage competitive weight loss. It is also suggested that Government communications about positive body image mes sages be distributed to consumers and industry at the time of introducing standardized sizing. Public Advocacy initiatives were also developed by the group to enable and inform mem bers of the public of mechanisms they can use to raise concerns regarding body image messages. The national body image consultation process was sup ported by a briefing paper prepared by the Australian Government Office for Youth. The paper outlines the issue of negative body image in the community, including factors that contribute to its development, and existing measures to address it. Similarly, in 2006, the Italian government and fashion industry created a voluntary code of conduct requiring models to show medical proof that they do not suffer from eating disorders. The code bans models younger than 16 from the catwalks and calls for a commitment to add larger sizes to fashion collections. The Italian Ministries of Health and Sports are directing the project at schools and the media, pro viding guidelines for magazines, television, radio, and Internet sites to discourage ultrathin beauty ideals. Spanish government authorities have developed similar guidelines to attempt to reduce underweight and unhealthy models acting publicly as unhealthy role models for young women.
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Summary of Programs and Outcomes in Grade Schools, Middle Schools, and High Schools Initially, body image improvement programs were implemented in secondary schools, at the age at which young people (in particular, girls) were considered to be most at risk of devel oping eating disorders. More recently, programs have been developed for much younger co-educational cohorts as research ers realize the importance of implementing programs with boys, preadolescents, and well before body image problems arise. Many well-designed and effective programs to improve body image have now been conducted in primary schools. ‘Very Important Kids’ and ‘Healthy Schools-Healthy Kids’ are two examples of programs that have been conducted with boys and girls aged 10–12 years, and over the entire school year. These programs have had a broader focus, and included themes of size acceptance, reduction of weight-based teasing, and healthy living throughout several aspects of the formal and informal curricu lum. Shorter programs have also been found to be effective in improving body image with young audiences, including the innovative use of the storybook ‘Shapesville’ and puppetry among children as young as 5 years of age. Ideally, programs to improve body image would be given throughout a child’s school career and would target developmentally appropriate risk factors and behaviors. The crowding of the school curriculum and the increased competition for implementation of interventions of many kinds have required the development of combined programs with a broader health promotion focus to improve body image as well as a range of other areas of young people’s well-being. The most common of these combinations has been the dual focus on risk factors common to both obesity and eating dis orders to reduce the broad spectrum of weight problems. Examples of such programs include ‘New Moves’, as well as new developments ‘5-2-1-Go!’ ‘Healthy Buddies’ and ‘Healthy Schools-Healthy Kids’. These combined approaches draw upon theory from the Social and Emotional Learning and Positive Psychology literature, as well as the eating disorder and obesity prevention research.
Issues Related to Success or Failure of Programs and Approaches The school environment is particularly challenging for pre vention research due to issues of appropriateness and relevance of program content, teacher’s adherence to program content, and effectiveness of standardized measures in ‘normal’ populations or those not particularly at risk. Additionally, evaluation instruments tend to be suitable for use among females and are not necessarily effective for mea suring body image in males.
Issues of Program Fidelity and Program Delivery Barriers to program fidelity include the fact that teachers may deviate from the intended program content or may have inadequate training to effectively carry out the program. A number of past school-based body image prevention
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programs have been developed and delivered by psycholo gists and/or research staff with little formal educational training or background. Very few past school-based body image programs have provided teacher training and this may impact on program delivery. In the school-based delivery of body image programs, teachers need to be trained to develop specific skills to deliver prevention programs, such as being able to facilitate student reflective discussion. The Canadian program ‘Student Body: Promoting Health at Any Size’ is the first web-based training tool designed to assist teachers and public health officials to deliver programs to improve body satisfaction in schools. Teachers (especially those who are young and female) may be experiencing body image issues themselves. It is thus sug gested that teachers undergo specific training that addresses their personal and professional needs both during undergrad uate training and once in the workforce.
The Universal Versus Targeted Program Debate and Issues of Measurement of Program Effectiveness Most school-based body image improvement programs to date have been universal, or universal-selective according to the WHO definitions of health promotion. Targeted programs, or those focused on engaging high-risk participants, are acknowl edged as being more effective in statistical terms, and increased outcome effects occur when programs are conducted with high-risk females rather than ‘normal’ populations who tend to have low baseline scores for body image concerns. However, universal-selective interventions provide a clear opportunity for the widespread, sustainable implementation of body image intervention programs in schools. Several researchers have commented that there is little room for movement in research data scores, as most study outcome measures have been developed for clinical use with females and hence, allow very little room for improvement in baseline scores among ‘normal’ populations, or those not at risk. This issue is exacerbated by the move toward school-based prevention in younger and younger audiences without the development of appropriate standardized mea sures to capture changes in attitudes and behavioral intentions among such young participants. Even the best program cannot be properly evaluated, or will not seem to be effective, without appropriate measurement tools, espe cially when using female focused instruments to investigate body image in boys. It is recommended that researchers develop validated gender-specific scales that provide a more accurate depiction of change among preadolescent and ‘nor mal’ participants.
Inclusion of Males in School-Based Body Image Programs Early body image interventions conducted in the 1980s and 1990s tended to include only girls, but more recent studies have realized the importance of including boys in the
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educational programs as well as in the research evaluations. Boys certainly have body image concerns, as several recent research studies have shown. Boys may have a significant role to play in balancing coeducational classroom discussions about gender stereotypes. Most researchers and educators now agree that males need to be included in school-based body image programs, but the discussion of whether they should be included into coeduca tional programs with girls, or to have gender-specific programs still remains. The most successful mixed gender program that improved male body satisfaction was ‘MediaSmart’, which took a media literacy approach and used a male researcher to facilitate the program. Either of these factors may have led to males finding the program more relevant and engaged with the activities to a greater level, resulting in improved outcomes. The ‘Everybody’s Different’ program also reported significant improvements in male body dissatisfaction and this program also included a media literacy component. It may be that the reaction and discussion between males and females over body image ideals and the resultant realization of more reasonable peer norms may be more powerful than the program content itself. The development of male focused program materials and the theoretical frameworks for body image improvement among males are urgently required in order for this research to continue. Empirical evidence is required to guide future programs in regard to whether these programs should be con ducted among same-sex or mixed groups, and by male or female facilitators.
Recommendations for Future Research and Programs Future school-based body image programs should include both genders, using suitable instruments for females and males and should focus on the early prevention of body image concerns by further developing programs that are aimed at younger coeducational groups of children and those that use age-appropriate engaging approaches such as musicals, puppetry, and story books. Programs specific to targeted groups, such as high-risk populations, require further investiga tion. Online and Internet-based programs may be effective in reaching a broader array of participants. The incorporation of broader whole school approaches and combination with obe sity and healthy living interventions appears to be a new approach that not only utilizes available resources, but also harnesses expertise from both fields. Utilizing the powerful role of parents, government policy, and whole school and community environments are also salient in planning future research designs.
See also: Body Image Change and Prevention: DissonanceBased Approaches; Body Image Development – Adolescent Boys; Body Image Development – Adolescent Girls; Body Image Development – Adult Men; Body Image Development – Adult Women; Body Image Development – Boy Children; Body Image Development – Girl Children; Body Image: Familial Influences; Body Image in Dance and Aesthetic Sports; Body Image: Peer Influences; Body Weight and Body Image in Children and Adolescents; Internalization of Thin-Ideal and Muscular-Ideal; Measurement of Body Image in Adolescence and Adulthood; Measurement of Body Image in Childhood; Measurement of Perceptual Body Image; Preventing Body Image Problems: Digitally Delivered Interventions; Preventing Body Image Problems: Ecological and Activism Approaches; Preventing Body Image Problems: Public Policy Approaches; Social Comparison Theory and Body Image; Sociocultural Perspectives on Body Image; Teasing, Appearance-Related.
Further Reading Bergsma, L. J., and Carney, M. E. (2008). Effectiveness of health-promoting media literacy education: A systematic review. Health Education Research 23, 522–542. Dohnt, H. K., and Tiggemann, M. (2008). Promoting positive body image in young girls: An evaluation of ‘Shapesville’. European Eating Disorder Review 16, 222–233. Haines, J., Neumark-Sztainer, D., Perry, C. L., et al. (2006). V.I.K. (Very Important Kids): A school-based program designed to reduce teasing and unhealthy weight-control behaviors. Health Education Research 21, 884–895. McCabe, M. P., Ricciardelli, L., and Karantzas, G. (2010). The impact of a healthy body image program among adolescent boys on body image negative affect and body changes strategies. Body Image 7, 117–123. McVey, G. L., Tweed, S., and Blackmore, E., (2007). Healthy schools-Healthy kids: A controlled evaluation of a comprehensive universal eating disorder prevention program. Body Image 4, 115–136. Neumark-Sztainer, D., Story, M., Hannen, P. J., and Rex, J. (2003). New Moves: A schoolbased obesity prevention program for adolescent girls. Preventive Medicine 37, 41–51. O’Dea, J. A. (2007). Everybody’s Different: A Positive Approach to Teaching about Health, Puberty, Body Image, Nutrition, Self-Esteem and Obesity Prevention. Melbourne, VIC: Australian Council for Educational Research (ACER). O’Dea, J. A., and Yager, Z. (2011). School-based psychoeducational approaches to prevention. In: Cash, T. F., and Smolak, L. (eds.), Body Image: A Handbook of Science, Practice, and Prevention, 2nd ed., pp. 434–441. New York: Guilford Press. Paxton, S. (2002). Research Review of Body Image Programs: An Overview of Body Image Dissatisfaction Prevention Interventions. Melbourne, VIC: Victorian Department Government Department of Human Services. Stice, E., Rohde, P., Gau, J., and 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, 825–834. Wilksch, S. M., Tiggemann, M., and Wade, T. D. (2006). Impact of interactive school based media literacy lessons for reducing internalization of media ideals in young adolescent girls and boys. International Journal of Eating Disorders 39, 385–393.
Relevant Websites http://www.youth.gov.au – Australian Government Action on Body Image Policy.
http://www.cbc.ca – Italian Government Initiative.
http://findarticles.com – Spanish Government Initiative.