The Body Project is one of three evidence-based prevention and treatment programs developed by Dr. Eric Stice and colleagues. Please see overviews below.
Body Project
4-Session Eating Disorder Prevention Program
Eating disorders affect 13-15% of females and are marked by chronicity and risk for future obesity, suicide, and mortality (Allen, Byrne, Oddy, & Crosby, 2013; Stice, Marti, & Rohde, 2013). Because 80% of individuals with eating disorders do not receive treatment (Swanson et al., 2011), effective eating disorder prevention is a public health priority.
Only three prevention programs have significantly reduced eating disorder symptom composite measures (Atkinson & Wade, 2014; Stice, Marti, Spoor, Presnell, & Shaw, 2008; Stice, Rohde, Shaw, & Marti, 2013) and only three have significantly reduced future onset of threshold or subthreshold eating disorders (Martinsen et al., 2014; Stice et al., 2008; Stice, Rohde, Shaw et al., 2013). Only one of these, the Body Project has produced effects in multiple efficacy trials conducted by independent teams and produced significantly larger intervention effects than credible alternative interventions (Becker, Smith, & Ciao, 2005; Halliwell & Diedrichs, 2014; Mitchell, Mazzeo, Rausch, & Cooke, 2007; Serdar et al., 2014; Stice, Shaw, Burton, & Wade, 2006; Stice et al., 2008).
In the Body Project, young women voluntarily critique the thin beauty ideal in verbal, written, and behavioral exercises, which theoretically generates cognitive dissonance that prompts participants to reduce their pursuit of this unrealistic ideal. In support of the intervention theory, reductions in thin-ideal internalization mediate the effects of the Body Project on symptom reductions (Seidel, Presnell, & Rosenfield, 2009; Stice, Presnell, Gau, & Shaw, 2007) and high- versus low-dissonance versions of this program produce greater symptom reductions (Green, Scott, Diyankova, Gasser, & Pederson, 2005; McMillan, Stice, & Rohde, 2011). Furthermore, the Body Project reduced objectively measured brain reward region responsivity to thin models (Stice, Yokum, & Waters, 2015). Effectiveness trials confirm that the Body Project is effective when delivered by high school and college counselors under ecologically valid conditions (Stice, Butryn, Rohde, Shaw, & Marti, 2013; Stice, Rohde, Butryn, Shaw, & Marti, 2015; Stice, Rohde, Gau, & Shaw, 2009; Stice, Rohde, Shaw, & Gau, 2011) and when delivered by undergraduate peer educators (Becker, McDaniel, Bull, Powell, & McIntyre, 2012; Halliwell, Jarman, McNamara, Rison, & Jankowski, 2015; Stice, Rohde, Durant, Shaw, & Wade, 2013).
In a recent task-shifting trial, the Body Project produced a statistically significant 58% greater reduction in future eating disorder onset with high-risk adolescent girls/young women with body image concerns when groups were delivered by peer educators versus clinicians (Stice et al., 2020).
Another recent randomized trial found that when the Body Project was delivered virtually over the Internet by peer educators, it produced a statistically significant 77% reduction in future onset of eating disorders over a 2-year follow-up compared to a placebo intervention in a representative community-recruited sample of at-risk adolescent girls/young women with body image concerns (Ghaderi et al., 2020). This is the largest eating disorder prevention effect ever observed.
In sum, the Body Project has a stronger evidence base than other eating disorder prevention programs, as it is the only one that has been found to: (1) significantly reduce future eating disorder onset over multi-year follow-ups in several trials; (2) produce significantly larger intervention effects relative to alternative credible interventions; (3) affect objective biological outcomes (e.g., fMRI-assessed brain reward region response to thin models); (4) produce effects that have replicated in trials conducted by numerous independent teams; and (5) produce effects for different race/ethnic groups (Asians, Blacks, Hispanics, Whites) in the US and in several other countries, including England, France, Sweden, Iceland, China, Mexico, and Brazil, as well as for individuals with various socioeconomic backgrounds and sexual orientations (for a review see Stice, Marti et al., 2019). The Body Project has also been adapted for males with body image concerns and has produced reductions in pursuit of the appearance ideal, body dissatisfaction, and eating disorder symptoms in trials conducted by multiple teams (Brown & Keel, 2015; Brown et al., 2017; Jankowski et al., 2017).
Only three prevention programs have significantly reduced eating disorder symptom composite measures (Atkinson & Wade, 2014; Stice, Marti, Spoor, Presnell, & Shaw, 2008; Stice, Rohde, Shaw, & Marti, 2013) and only three have significantly reduced future onset of threshold or subthreshold eating disorders (Martinsen et al., 2014; Stice et al., 2008; Stice, Rohde, Shaw et al., 2013). Only one of these, the Body Project has produced effects in multiple efficacy trials conducted by independent teams and produced significantly larger intervention effects than credible alternative interventions (Becker, Smith, & Ciao, 2005; Halliwell & Diedrichs, 2014; Mitchell, Mazzeo, Rausch, & Cooke, 2007; Serdar et al., 2014; Stice, Shaw, Burton, & Wade, 2006; Stice et al., 2008).
In the Body Project, young women voluntarily critique the thin beauty ideal in verbal, written, and behavioral exercises, which theoretically generates cognitive dissonance that prompts participants to reduce their pursuit of this unrealistic ideal. In support of the intervention theory, reductions in thin-ideal internalization mediate the effects of the Body Project on symptom reductions (Seidel, Presnell, & Rosenfield, 2009; Stice, Presnell, Gau, & Shaw, 2007) and high- versus low-dissonance versions of this program produce greater symptom reductions (Green, Scott, Diyankova, Gasser, & Pederson, 2005; McMillan, Stice, & Rohde, 2011). Furthermore, the Body Project reduced objectively measured brain reward region responsivity to thin models (Stice, Yokum, & Waters, 2015). Effectiveness trials confirm that the Body Project is effective when delivered by high school and college counselors under ecologically valid conditions (Stice, Butryn, Rohde, Shaw, & Marti, 2013; Stice, Rohde, Butryn, Shaw, & Marti, 2015; Stice, Rohde, Gau, & Shaw, 2009; Stice, Rohde, Shaw, & Gau, 2011) and when delivered by undergraduate peer educators (Becker, McDaniel, Bull, Powell, & McIntyre, 2012; Halliwell, Jarman, McNamara, Rison, & Jankowski, 2015; Stice, Rohde, Durant, Shaw, & Wade, 2013).
In a recent task-shifting trial, the Body Project produced a statistically significant 58% greater reduction in future eating disorder onset with high-risk adolescent girls/young women with body image concerns when groups were delivered by peer educators versus clinicians (Stice et al., 2020).
Another recent randomized trial found that when the Body Project was delivered virtually over the Internet by peer educators, it produced a statistically significant 77% reduction in future onset of eating disorders over a 2-year follow-up compared to a placebo intervention in a representative community-recruited sample of at-risk adolescent girls/young women with body image concerns (Ghaderi et al., 2020). This is the largest eating disorder prevention effect ever observed.
In sum, the Body Project has a stronger evidence base than other eating disorder prevention programs, as it is the only one that has been found to: (1) significantly reduce future eating disorder onset over multi-year follow-ups in several trials; (2) produce significantly larger intervention effects relative to alternative credible interventions; (3) affect objective biological outcomes (e.g., fMRI-assessed brain reward region response to thin models); (4) produce effects that have replicated in trials conducted by numerous independent teams; and (5) produce effects for different race/ethnic groups (Asians, Blacks, Hispanics, Whites) in the US and in several other countries, including England, France, Sweden, Iceland, China, Mexico, and Brazil, as well as for individuals with various socioeconomic backgrounds and sexual orientations (for a review see Stice, Marti et al., 2019). The Body Project has also been adapted for males with body image concerns and has produced reductions in pursuit of the appearance ideal, body dissatisfaction, and eating disorder symptoms in trials conducted by multiple teams (Brown & Keel, 2015; Brown et al., 2017; Jankowski et al., 2017).
Project Health
6-Session Obesity/Eating Disorder Prevention Program
Nearly 70% of US women and men are overweight or obese, resulting in 300,000 deaths and $150 billion in health-related expenses yearly (Flegal et al., 2012). Prevention may be the most effective way to combat obesity because most treatments rarely result in lasting weight loss. However, most prevention programs have not prevented future increases in weight and overweight/obesity onset (Plotnikoff et al., 2015). One exception is the Healthy Weight obesity and eating disorder prevention program that produced a 53% reduction in obesity onset and a 60% reduction in eating disorder onset over 3-year follow-up versus assessment-only controls for female adolescents with body image concerns and greater reductions in BMI gain and eating disorder symptoms through 3-year follow-up versus controls and two alternative interventions (Stice et al., 2008).
In Healthy Weight, participants make small incremental healthy lifestyle changes to gradually balance caloric intake and expenditure; we encourage gradual dietary changes to minimize metabolic slowing, which attenuates weight loss. The lifestyle change plan is participant-driven to promote internalization of the health goals. Healthy Weight is delivered in groups because it increases accountability and support for lifestyle change goals and is cost effective. Compared to educational brochure controls, a 4-hour version of Healthy Weight resulted in significantly greater reductions in BMI gain and eating disorder symptoms in young women with weight concerns, prevented BMI gain through 1-year follow-up for initially overweight participants, and produced a 60% reduction in eating disorder onset over 2-year follow-up (Stice et al., 2012, 2013).
To improve the efficacy of Healthy Weight, we added activities that promote cognitive dissonance about lifestyle behaviors that drive excess weight gain. We created a 6-hour dissonance-based version of Healthy Weight, referred to as Project Health, that added verbal, written, and behavioral exercises to create dissonance regarding unhealthy lifestyle behaviors (e.g., discussing costs of an unhealthy diet), which theoretically increases the likelihood that participants will align their attitudes with their perspectives taken in the sessions, resulting in healthier lifestyle choices.
In the first trial evaluating Project Health (Stice et al., 2018), young adults at risk for weight gain randomized to Project Health showed smaller increases in BMI through 2-year follow-up versus participants who completed Healthy Weight and obesity education video controls, and a 41% and 42% reduction in overweight/obesity onset over 2-year follow-up relative to Healthy Weight participants and obesity education controls, respectively; they also showed a reduction in eating disorder symptoms and a marginal 60% reduction in future eating disorder onset relative to controls.
In the second trial (Stice et al., 2021), we experimentally manipulated two factors theorized to improve the body fat gain prevention effects of Project Health. First, given that Healthy Weight produced weight gain prevention effects when implemented in female-only groups but not when implemented in mixed-sex groups, we hypothesized that Project Health would also be more effective when implemented in single-sex groups. The second idea for improving the effectiveness of Project Health was to add food response inhibition and attention training using computer training tasks.
Using a 2x2 factorial design, 261 young adults (mean age = 19.3, 79% female; 64% White) were randomized to single- or mixed-sex groups that completed food- or generic- response inhibition/attention training. Body fat (primary outcome), eating disorder symptoms and other outcomes were assessed at pretest and posttest. Body fat reduction had a significant interaction with the two manipulated factors (d = -.28), as well as significant main effects for sex composition of groups (d = -.18) and food response inhibition and attention training (d = -0.17), with the largest body fat loss occurring for single-sex groups implemented with food response inhibition and attention training. Although the two manipulated factors did not affect change in the other outcomes, there was a significant reduction in eating disorder symptoms across the conditions (within-participant d = -.78), converging with prior evidence that Project Health produced significantly larger reductions in eating disorder symptoms than educational controls. In sum, delivering Project Health in single-sex groups with food response inhibition and attention training appears to produce the largest body fat loss effects, as well as significant reductions eating disorder symptoms. We are currently completing an evaluation of this optimized version of Project Health compared to video control with 2-year follow-up.
In Healthy Weight, participants make small incremental healthy lifestyle changes to gradually balance caloric intake and expenditure; we encourage gradual dietary changes to minimize metabolic slowing, which attenuates weight loss. The lifestyle change plan is participant-driven to promote internalization of the health goals. Healthy Weight is delivered in groups because it increases accountability and support for lifestyle change goals and is cost effective. Compared to educational brochure controls, a 4-hour version of Healthy Weight resulted in significantly greater reductions in BMI gain and eating disorder symptoms in young women with weight concerns, prevented BMI gain through 1-year follow-up for initially overweight participants, and produced a 60% reduction in eating disorder onset over 2-year follow-up (Stice et al., 2012, 2013).
To improve the efficacy of Healthy Weight, we added activities that promote cognitive dissonance about lifestyle behaviors that drive excess weight gain. We created a 6-hour dissonance-based version of Healthy Weight, referred to as Project Health, that added verbal, written, and behavioral exercises to create dissonance regarding unhealthy lifestyle behaviors (e.g., discussing costs of an unhealthy diet), which theoretically increases the likelihood that participants will align their attitudes with their perspectives taken in the sessions, resulting in healthier lifestyle choices.
In the first trial evaluating Project Health (Stice et al., 2018), young adults at risk for weight gain randomized to Project Health showed smaller increases in BMI through 2-year follow-up versus participants who completed Healthy Weight and obesity education video controls, and a 41% and 42% reduction in overweight/obesity onset over 2-year follow-up relative to Healthy Weight participants and obesity education controls, respectively; they also showed a reduction in eating disorder symptoms and a marginal 60% reduction in future eating disorder onset relative to controls.
In the second trial (Stice et al., 2021), we experimentally manipulated two factors theorized to improve the body fat gain prevention effects of Project Health. First, given that Healthy Weight produced weight gain prevention effects when implemented in female-only groups but not when implemented in mixed-sex groups, we hypothesized that Project Health would also be more effective when implemented in single-sex groups. The second idea for improving the effectiveness of Project Health was to add food response inhibition and attention training using computer training tasks.
Using a 2x2 factorial design, 261 young adults (mean age = 19.3, 79% female; 64% White) were randomized to single- or mixed-sex groups that completed food- or generic- response inhibition/attention training. Body fat (primary outcome), eating disorder symptoms and other outcomes were assessed at pretest and posttest. Body fat reduction had a significant interaction with the two manipulated factors (d = -.28), as well as significant main effects for sex composition of groups (d = -.18) and food response inhibition and attention training (d = -0.17), with the largest body fat loss occurring for single-sex groups implemented with food response inhibition and attention training. Although the two manipulated factors did not affect change in the other outcomes, there was a significant reduction in eating disorder symptoms across the conditions (within-participant d = -.78), converging with prior evidence that Project Health produced significantly larger reductions in eating disorder symptoms than educational controls. In sum, delivering Project Health in single-sex groups with food response inhibition and attention training appears to produce the largest body fat loss effects, as well as significant reductions eating disorder symptoms. We are currently completing an evaluation of this optimized version of Project Health compared to video control with 2-year follow-up.
Body Project Treatment
8-Session Eating Disorder Treatment Program
Eating disorders (EDs) affect 13-15% of females and 5% of males (Allen et al., 2013; Dakanalis et al., 2017; Stice et al., 2013), but 80-97% of individuals with EDs do not receive treatment (Swanson et al., 2011), and even those who receive treatment usually do not receive evidence-based care (Lilienfeld et al., 2013).
We developed a brief 8-session group treatment for a broad spectrum of DSM-5 EDs appropriate for outpatient care, called Body Project Treatment (BPT). The theory for this treatment is that overvaluation of the thin appearance ideal (which applies to both women and men) and unhealthy weight control behaviors used to pursue this ideal maintain EDs. BPT uses dissonance induction to reduce variables theorized to maintain EDs. In the treatment sessions and home exercises, participants collectively explore the negative effects of pursuing the thin appearance ideal, overvaluation of weight/shape, body dissatisfaction, dieting, unhealthy compensatory weight control behaviors and binge eating in a variety of exercises, some of which specifically target each participant’s ED behaviors.
Four randomized controlled trials have provided support for BPT. In the first trial, 72 women with a DSM-5 ED were randomized to BPT or usual care control. Those randomized to BPT showed significantly larger reductions in valuation of the thin ideal (d = .79), dissonance about perpetuating the thin ideal (d = .65), body dissatisfaction (d = 1.14), negative affect (d = .55), and ED symptoms (d = .94) compared to a usual care control condition (Stice, Rohde et al., 2015).
In the second trial, 84 women with a DSM-5 ED were randomized to BPT or a supportive mindfulness group typical of that offered at colleges that was matched on modality and number of sessions. Compared with controls, participants randomized to BPT showed significantly larger reductions in dissonance about affirming the thin ideal (d = .32), body dissatisfaction (d = .62), negative affect (d = .48), impaired psychosocial functioning (d = .36), and remission of ED diagnoses (77% vs. 60%; Stice, Rohde et al., 2019). The larger reductions in thin-ideal valuation (d = .55), ED symptoms (d = .53), or abstinence from binge eating and purging behaviors (55% vs. 39%, respectively) did not, however, reach statistical significance (Stice, Rohde et al., 2019).
In the third trial, 100 women with a DSM-5 ED were randomized to BPT or waitlist control and completed fMRI scans to assess brain-related measures of target engagement. Relative to waitlist controls, BPT participants showed significantly greater reductions in fMRI-assessed responsivity of regions implicated in reward valuation (dorsolateral prefrontal cortex [r = .47] caudate [r = .53]) and attention (precuneus [r = .41]) to thin versus average weight models, valuation of the thin ideal (d = .72), and increased attractiveness ratings of average weight models (d = .44). In addition, they showed significantly greater reductions in body dissatisfaction (d = .83), negative affect (d = .76), and ED symptoms (d = .59) and marginally greater abstinence from binge eating and purging compared to waitlist controls (39% vs. 21%, respectively; Stice, Yokum et al., 2019). To improve the reproducibility of the fMRI findings, we recruited an additional 38 participants. Results from the larger sample confirmed that BPT participants showed significantly greater reductions in reward (caudate) and attention (precuneus) region response to thin models versus average weight models, as well as significantly larger reductions in ED symptoms (d = .61) and significantly greater reductions in abstinence from binge eating and purging (41.1% vs. 25.0%). There was no clear evidence that BPT produced greater reductions in reward region response to high-calorie binge food images (vs. low-calorie food images), which was the second investigated intervention target.
In the fourth trial (which is ongoing), 60 women with DSM-5 EDs were randomized to BPT or an 8-session group-delivered version of Interpersonal Psychotherapy (IPT). Compared to IPT, women randomized to BPT showed significantly greater reductions in ED symptoms at posttest (d = .88) and 6-month follow-up (d = 1.24). Although the within-condition posttest reductions in ED symptoms was large for IPT (d = .71), BPT produced significantly larger symptom reductions (d = 1.26). BPT participants showed higher (although nonsignificant) abstinence from binge eating and purging behaviors than IPT participants (54% vs. 38%). We are currently recruiting and treating the rest of this sample for greater statistical power.
We developed a brief 8-session group treatment for a broad spectrum of DSM-5 EDs appropriate for outpatient care, called Body Project Treatment (BPT). The theory for this treatment is that overvaluation of the thin appearance ideal (which applies to both women and men) and unhealthy weight control behaviors used to pursue this ideal maintain EDs. BPT uses dissonance induction to reduce variables theorized to maintain EDs. In the treatment sessions and home exercises, participants collectively explore the negative effects of pursuing the thin appearance ideal, overvaluation of weight/shape, body dissatisfaction, dieting, unhealthy compensatory weight control behaviors and binge eating in a variety of exercises, some of which specifically target each participant’s ED behaviors.
Four randomized controlled trials have provided support for BPT. In the first trial, 72 women with a DSM-5 ED were randomized to BPT or usual care control. Those randomized to BPT showed significantly larger reductions in valuation of the thin ideal (d = .79), dissonance about perpetuating the thin ideal (d = .65), body dissatisfaction (d = 1.14), negative affect (d = .55), and ED symptoms (d = .94) compared to a usual care control condition (Stice, Rohde et al., 2015).
In the second trial, 84 women with a DSM-5 ED were randomized to BPT or a supportive mindfulness group typical of that offered at colleges that was matched on modality and number of sessions. Compared with controls, participants randomized to BPT showed significantly larger reductions in dissonance about affirming the thin ideal (d = .32), body dissatisfaction (d = .62), negative affect (d = .48), impaired psychosocial functioning (d = .36), and remission of ED diagnoses (77% vs. 60%; Stice, Rohde et al., 2019). The larger reductions in thin-ideal valuation (d = .55), ED symptoms (d = .53), or abstinence from binge eating and purging behaviors (55% vs. 39%, respectively) did not, however, reach statistical significance (Stice, Rohde et al., 2019).
In the third trial, 100 women with a DSM-5 ED were randomized to BPT or waitlist control and completed fMRI scans to assess brain-related measures of target engagement. Relative to waitlist controls, BPT participants showed significantly greater reductions in fMRI-assessed responsivity of regions implicated in reward valuation (dorsolateral prefrontal cortex [r = .47] caudate [r = .53]) and attention (precuneus [r = .41]) to thin versus average weight models, valuation of the thin ideal (d = .72), and increased attractiveness ratings of average weight models (d = .44). In addition, they showed significantly greater reductions in body dissatisfaction (d = .83), negative affect (d = .76), and ED symptoms (d = .59) and marginally greater abstinence from binge eating and purging compared to waitlist controls (39% vs. 21%, respectively; Stice, Yokum et al., 2019). To improve the reproducibility of the fMRI findings, we recruited an additional 38 participants. Results from the larger sample confirmed that BPT participants showed significantly greater reductions in reward (caudate) and attention (precuneus) region response to thin models versus average weight models, as well as significantly larger reductions in ED symptoms (d = .61) and significantly greater reductions in abstinence from binge eating and purging (41.1% vs. 25.0%). There was no clear evidence that BPT produced greater reductions in reward region response to high-calorie binge food images (vs. low-calorie food images), which was the second investigated intervention target.
In the fourth trial (which is ongoing), 60 women with DSM-5 EDs were randomized to BPT or an 8-session group-delivered version of Interpersonal Psychotherapy (IPT). Compared to IPT, women randomized to BPT showed significantly greater reductions in ED symptoms at posttest (d = .88) and 6-month follow-up (d = 1.24). Although the within-condition posttest reductions in ED symptoms was large for IPT (d = .71), BPT produced significantly larger symptom reductions (d = 1.26). BPT participants showed higher (although nonsignificant) abstinence from binge eating and purging behaviors than IPT participants (54% vs. 38%). We are currently recruiting and treating the rest of this sample for greater statistical power.
