Re-framing the ‘perfect body’

"The perfect woman is tall like a supermodel, but also petite and dainty with hands and feet that are small and feminine… and they have to be skinny, but not too skinny because they need to have big boobs and a big bum and have an hourglass shape, and they need to have neat hair – but in an effortless way so not too neat – and also wear make-up that looks like they're wearing no make-up… and have a tan but also be fair-skinned…?" 

This is a description of what the group of adolescent girls in front of me have decided 'the perfect women' looks like. But then, it's shortly followed by what I can only describe as a lightbulb moment; a sudden, overwhelming sense of injustice at the unrealistic (and quite frankly impossible) physical standards that so many women and girls feel the pressure to meet. 

"It's impossible to be all those things at once… Why do we think we need to look like that?... This is because of the patriarchy! We're not the ones who benefit or profit from this pressure… This is not fair!"

And every time I witness a group of young women having this lightbulb moment, I can't help but feel hopeful. I feel hopeful that future generations won't have to suffer at the hands of an eating disorder like I did.

Eating disorders and related body image disorders (i.e. body dysmorphic disorder) are serious mental illnesses, and the prevention of potential risk factors is of utmost importance. Therefore, you can imagine my glee when prevention and early intervention appeared to be a priority in the Children and Young People's Mental Health Green Paper with the creation of Mental Health Support Teams (MHSTs), to bridge the gap between school-based support and specialist child and adolescent mental health services (CAMHS). One of the roles of the new MHSTs was to deliver 'group-based interventions engaging participants in critiquing the 'thin ideal', which can be effective in reducing eating disorder symptoms and body image concerns, when targeted toward high-risk adolescent girls". (Department for Education and Department for Health and Social Care. 2017: p.22) For anyone who has ever worked in or adjacent to the field of eating disorder prevention research, the type of intervention they were alluding to refers to cognitive dissonance-based interventions, which are almost synonymous with The Body Project intervention.

What is the Body Project?

The Body Project is a cognitive dissonance-based intervention which covers a critique of the thin ideal – as proposed by the green paper – and is based on the dual-pathway model (Stice, 2001). Both the intervention and the model were established by US researcher Dr Eric Stice. The dual-pathway model identified that thin-ideal internalisation leads to body dissatisfaction which subsequently leads to disordered eating via the dual pathways of negative affect and dietary restraint, and that thin-ideal internalisation was the most modifiable risk factor to address in preventive interventions (Stice, 2001).

Cognitive dissonance theory argues that psychological discomfort is created when behaviours are inconsistent with cognitions, and so individuals are motivated to change their cognitions or behaviours to restore consistency. Our intervention involves cognitive dissonance-based activities such as role plays, letter writing and behavioural challenges. For example, participants engage in verbal, written and behavioural exercises in which they critique the thin-ideal, which consequently produces cognitive dissonance that motivates participants to reduce the pursuit of this ideal (Thompson et al., 1999).

In terms of the evolution of the evidence-base for The Body Project, Stice and colleagues have tested their approach in educational settings over the last 20 years. The most rigorous trial conducted to date found that the intervention prevented 60% of the cases of eating disorders that emerged in the control condition over a 3-year follow-up, suggesting that for every 100 young women who complete this program, there should be 9 fewer young girls who develop eating disorders over the subsequent 3-year period (Stice, Onipede, and Marti, 2021)

More than muscles

However, as with most mental health research, for a long time the sampling of these trials was mainly homogenous and reflected the characteristics of the eating disorder stereotype – not the vastly diverse range of genders, sexualities and ethnicities of people who are affected by them. This is why it is promising to see that more recently, after successful efficacy trials of The Body Project, researchers have investigated its effectiveness in different groups of people. 

Researchers have adapted The Body Project to male audiences with a more nuanced intervention addressing muscle-oriented disordered eating (MODE), titled 'The Body Project: More than Muscles' (Brown et al., 2017) in addition to 'The PRIDE Body Project' which adapted the intervention to be more tailored to the risk factors for gay men (Brown and Keel, 2015). Both adaptations demonstrated acceptability as well as efficacy.

Further research evaluating the intervention effects have been conducted with some ethnic minority groups in randomised trials, such as Asian-American girls, showing equal levels of success with some modifications to the intervention (Stice et al., 2014). Cultural adaptations of the traditional Body Project were recently produced to be suitable for orthodox Jewish adolescent girls (Casasnovas et al., 2021) as well as Saudi women. Here, the role of cultural factors such as religion was identified as being a key influence in the development of eating disorders, with two studies highlighting how more religious Orthodox Jewish women reported less eating disorder pathology, supporting the idea that religion can act as a protective factor (Gluck and Geliebter, 2002). 

Skipping the stereotypes

These trials demonstrate some progress in addressing the historic sampling bias in the field of mental health and psychology, where research has mainly been conducted with a homogenous group that perpetuates the 'eating disorder stereotype' i.e., white, adolescent, girls with solely restrictive disordered eating (Gordon, Perez, and Joiner, 2002). It also inspired my recent PhD project, where I have been exploring how body dissatisfaction and disordered eating are experienced by the second largest demographic group in the UK – those from a South Asian background. 

A big focus of this research project was to evaluate the relevance of the current intervention content of The Body Project with this group, and there are clear recommendations emerging on how this intervention could be culturally adapted i.e. to encompass more elements than weight and shape as part of the appearance ideal, to accommodate how to respectfully challenge elders and their comments in a collectivist society, and to acknowledge the cultural importance of food and religion. The most important part of this work was speaking with people from a South Asian background with lived-experience of body image and eating disturbance, hearing their experiences and insights, and collaboratively working on modifications to the current evidence-base which will be more inclusive. 

What needs to change for a successful roll-out across all schools?

Despite the success of The Body Project in the US and globally, there is limited evidence to demonstrate the intervention's generalisability in the UK. Examples of The Body Project being delivered and evaluated in a UK setting are limited and have exclusively taken place in the South-West of England (Halliwell and Diedrichs, 2014; Diedrichs, Halliwell and Paraskeva, 2015; Halliwell et al., 2015).These studies explored the effectiveness of The Body Project with 12–13-year-old girls (Diedrichs, Halliwell and Paraskeva, 2015); 14-15-year-olds (Halliwell et al., 2015) and older teenagers (Mean age 19.6; Halliwell and Diedrichs, 2014). Two of these three studies reported on the ethnicity of participants, however, the majority were reported as White.

Whilst these studies did show some positive effects in body appreciation and body satisfaction (Halliwell et al., 2015) and decreased body dissatisfaction and thin-ideal internalisation (Halliwell and Diedrichs, 2014)., a qualitative evaluation of The Body Project revealed that participants experienced 'awkwardness' and found the intervention too scripted and 'artificial', as well as too 'static and still' (Jarman, Treneman-Evans, and Halliwell, 2021). In addition, a small number of participants (5%) would have appreciated content that went beyond weight and shape and covered different body parts and skin colour (Jarman, Treneman-Evans, and Halliwell, 2021).

The suggestion to include skin colour as a factor in the appearance ideal is an important consideration when looking at UK implementation, as people from an Asian ethnic background – namely South Asian (Indian, Bangladeshi, Pakistani and Sri-Lankan) – are under-represented in specialist services for problems related to body image disturbance, despite some studies indicating similar or higher prevalence rates in this group (Wales et al., 2017; Chowbey, Salway, and Ismail. 2012). Therefore, it is important that preventive interventions are inclusive of the needs of ethnically diverse adolescent girls, and that MHSTs are equipped to deliver these culturally appropriate interventions. 

At the beginning of my PhD, I held a series of stakeholder engagement conversations with a number of MHST practitioners across the country. Here, they emphasised how they were struggling to navigate the increased prevalence of body image anxiety and demand from schools to address this post-Covid-19 pandemic, when there was no training provided in the Educational Mental Health Practitioner (EMHP) curriculum. In addition, I was told how there were blurred boundaries and scope between specialist CAMHS eating disorder outreach teams – which were unprecedently overstretched – and the remit of the MHST model, which was initially intended to address mild to moderate cases of low mood and anxiety – the latter of which was prioritised throughout the pandemic. 

We explored how we could overcome these initial barriers, such as using language which clarifies that eating disorder prevention doesn't have to fall within the remit of specialist services, such as 'body acceptance intervention' or 'an intervention that alleviates body image anxiety'. Secondly, reinforcing that the evidence-based nature of this intervention fits within the fidelity of the MHST model. Finally, the advantage of close multi-agency working was emphasised, with MHSTs sharing that collaboration with research institutions or the charity sector could lead to greater impact.

What the future could look like…

Despite the hurdles, the future for the implementation of The Body Project in the UK is looking promising. Prof Philippa Diedrichs, an eating disorders prevention expert, created training with the aim to rapidly translate evidence-based insights and interventions into social impact. Alongside working with industry on community impact programmes and more inclusive business practices, they have established a scalable and sustainable dissemination model for The Body Project in the UK. A cohort of Master Trainers – including myself – have been trained to deliver in-person and online training in how to deliver The Body Project to community providers (e.g., NHS Trusts, universities, schools, charities). 

Using a sustainable train-the-trainer model, the training provided by Master Trainers equips community providers with the skills and information to build up their own teams of Body Project Trainers and Facilitators. The goal is to see UK-wide delivery of the project and to prevent eating disorders in an evidence-based, co-ordinated, sustainable and cost-effective way.

Building on previous delivery in Gloucestershire, in a collaboration between the Community Eating Disorder Service and the University of Gloucestershire, The Body Project intervention is being delivered funded by the Gloucestershire Integrated Care Board in 2023. The dream is that over the next 18-months, myself together with colleagues at the University of Gloucestershire can establish a 'blueprint' for implementation and roll-out, and continue to share our findings to other regions in the future on how to deliver the intervention to as many people as possible and adapt it to suit different at-risk groups such as men and boys, LGBTQIA+ communities, and people from diverse ethnic and cultural backgrounds.  

If after reading this article, you would like to explore how to get The Body Project delivered in your school or community, or you would like to be trained as a facilitator, don't hesitate to contact me on [email protected] 

Hannah Lewis, PhD Candidate at Queen Mary University of London & Research Associate, University of Gloucestershire 

References

Al-Shebali M, Becker C, Kellett S, AlHadi A, Waller G. 2021. 'Adapting the body project to a non-western culture: a dissonance-based eating disorders prevention program for Saudi women'. Eating and Weight Disorders. 
Brown TA, Forney KJ, Pinner D, Keel PK. 2017. A randomized controlled trial of The Body Project: More Than Muscles for men with body dissatisfaction. Int J Eat Disord. 50(8):873-883

Brown TA, Keel PK. 2015. A randomized controlled trial of a peer co-led dissonance-based eating disorder prevention program for gay men. Behav Res Ther. 74, pp: 1-10.

Casasnovas, A.F, Huryk, K.M., Levinson, D., Markowitz, S., Friedman, S., Stice,E. & Loeb, K.L. 2019. 'Cognitive dissonance-based eating disorder prevention: pilot study of a cultural adaptation for the Orthodox Jewish community', Eating Disorders: The Journal of Treatment and Prevention

Chowbey, P., Salway, S., and Ismail, M. 2012. 'Influences on diagnosis and treatment of eating disorders among minority ethnic people in the UK'. Journal of Public Mental Health. Vol. 11 No.2. pp. 54-64

Department for Education and Department for Health and Social Care. 2017. Transforming Children and Young People's Mental Health Provision: a Green Paper. [Online] Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf

Diedrichs PC, Halliwell E, Paraskeva N. Extending the evidence base for eating disorders prevention: the impact of a dissonance-based intervention on positive body image, intuitive eating and self-objectification. J Eat Disord. 2014 Nov 24;2(Suppl 1):O38

Gluck ME, Geliebter A. Racial/ethnic differences in body image and eating behaviors. Eat Behav. 2002 Summer;3(2):143-51; Latzer Y, Orna T, Gefen S. Level of religiosity and disordered eating psychopathology among modern-orthodox Jewish adolescent girls in Israel. Int J Adolesc Med Health. 2007 Oct-Dec;19(4):511-21

Gordon, K.H., Perez, M., Joiner, T.E. Jr. (2002) The impact of racial stereotypes on eating disorder recognition. Int J Eat Disord, 32(2) pp: 219-224. 

Halliwell, E., & Diedrichs, P.C. (2014). Brief report: Testing a dissonance body image intervention among young girls. Health Psychology, 33, pp: 201-204

Halliwell, E., Jarman, H., McNamara, A., Risdon, H., and Jankowski, G. (2015) Dissemination of evidence-based body image interventions: A pilot study into the effectiveness of using undergraduate students as interventionists in secondary schools, Body Image, 14, pp: 1-4

Jarman HK, Treneman-Evans G, Halliwell E. 2021. "I didn't want to say something and them to go outside and tell everyone": The acceptability of a dissonance-based body image intervention among adolescent girls in the UK. Body Image.38: pp:80-84

Stice E. 2001. A prospective test of the dual-pathway model of bulimic pathology: mediating effects of dieting and negative affect. J Abnorm Psychol.110(1), pp:124-35 

Stice, E., Marti, C.N. and Cheng, Z.H. (2014). Effectiveness of a dissonance based eating disorder prevention program for ethnic groups in two randomised control trials. Behav Res Ther, 55, pp:54-64.

Stice E, Onipede ZA, Marti CN. A meta-analytic review of trials that tested whether eating disorder prevention programs prevent eating disorder onset. Clin Psychol Rev. 2021 Jul;87:

Stice, E., Marti, C.N. and Cheng, Z.H. (2014). Effectiveness of a dissonance based eating disorder prevention program for ethnic groups in two randomised control trials. Behav Res Ther, 55, pp:54-64.

Thompson, J. K., Heinberg, L. J., Altabe, M., & Tantleff-Dunn, S. (1999). Exacting beauty: Theory, assessment, and treatment of body image disturbance. Washington, DC: American Psychological Association

 Wales, J., Brewin, N., Raghavan, R. and Arcelus, J. 2017. 'Exploring barriers to South Asian help-seeking for eating disorders'. Mental Health Review Journal, Vol. 22 No. 1, pp. 40-50;