The Body Logic Program for Adolescents - CiteSeerX

BEHAVIOR MODIFICATION 10.1177/0145445503259856 Varnado-Sullivan , Zucker / BODY / November LOGIC PROGRAM 2004

The Body Logic Program for Adolescents A Treatment Manual for the Prevention of Eating Disorders PAULA J. VARNADO-SULLIVAN Southeastern Louisiana University

NANCY ZUCKER

Duke University Medical Center

The Body Logic Program for Adolescents was developed as a two-stage intervention to prevent the development of eating disorder symptoms. Preliminary results indicate that this program shows promise as an effective prevention effort. The current article provides a detailed description of the protocol for implementing Body Logic Part I, a school-based intervention. A brief review of Body Logic Part II, an intensive family-based intervention for high-risk students, is also provided. Examples of exercises are introduced and goals for practitioners are discussed. The authors hope that by providing this in-depth description of the protocol, researchers and clinicians can use this program in future prevention efforts. Keywords: prevention; eating disorders; adolescents; body image

Nothing so needs reforming as other people’s habits. —Pudd’nHead Wilson Eating disorders, in general, and anorexia nervosa, in particular, have the highest mortality rate of any psychiatric disorder (Sullivan, 1995). These disorders are often of substantial duration and incur significant emotional and financial burden to both patients and their families (Sullivan, 1995). Furthermore, eating disorders are significantly more pervasive than once believed. Although early anecdotes characterized these disorders as affecting solely the Caucasian middle and upper socioeconomic classes, empirical research has not supported BEHAVIOR MODIFICATION, Vol. 28 No. 6, November 2004 854-875 DOI: 10.1177/0145445503259856 © 2004 Sage Publications

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this claim (Arriaza & Mann, 2001; Rogers, Resnick, Mitchell, & Blum, 1997). Eating disorders are increasingly recognized across ethnic groups, economic lines, continental borders, and gender (Braun, Sunday, Huang, & Halmi, 1999; Rogers et al., 1997; Tsai, 2000). Such findings have served as the impetus for the design and implementation of eating disorder prevention programs. As will be demonstrated by this brief review and treatment manual, as our knowledge and understanding of these disorders have increased, so have the complexity of our attempts at prevention and our recognition of the continued need to enhance our efforts. Eating disorders are the result of a complex interplay of sociocultural, familial, individual, and biological factors (Mizes & Bonifazi, 2001). These factors, as well as the well-documented pervasiveness of harmful cultural attitudes toward weight and shape, imply that all of these components may need to be addressed in a successful preventive intervention (Piran, 2001). Thus, an intervention must not just impart information, but rather must create an environment in which such information can be readily received (Piran, 2001). Given this hurdle, it is not difficult to surmise why the development of eating disorder prevention efforts has been challenging. Historically, efforts to prevent eating disorders have provided information, and such information has been guided by the “diseasespecific” model of prevention (Levine, 2001). Information in these interventions was largely symptom-focused, providing information about eating disorders and the consequences of these disorders. Subsequent longitudinal risk factor studies of adolescents have provided valuable information about the relevant content for prevention programs as well as highlighting the attitudinal and behavioral factors that need to be decreased to define effective outcomes (Veron-Guidry, Williamson, & Netemeyer, 1997). Initial results from these programs were mixed (Levine, 2001), leading researchers to further speculate on factors that could improve program outcome (Neumark-Sztainer, Butler, & Palti, 1995). One recommendation stemming from these earlier trials related to the composition of the program audience. Knowledge from longitudinal risk factor studies made it possible to screen target audiences for risk

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status and thus focus interventions that were more closely matched to the needs of participants. In this manner, more efficacious utilization of resources, as well as a more potent intervention for those more in need, could be designed (e.g., Killen et al., 1993). Additional recommendations from these prevention efforts focused on the potency of the intervention. Given the pervasiveness of sociocultural attitudes toward thinness, the inclusion of relevant interpersonal influences (e.g., parents and teachers) was recommended as being necessary for attitude change and the maintenance of such change (Piran, 2001). This need was perhaps highlighted by the work of Carter, Stewart, Dunn, and Fairburn (1997). Using a skills-based approach to prevention, these authors reported an immediate postintervention decrease in attitudes and behaviors associated with eating disorders; however, changes were not maintained at a 6-month follow-up (Carter et al., 1997). The failure to maintain such gains may be a reflection of the difficulty in maintaining healthy attitudes regarding food and weight within a cultural context that conflicts with such attitudes. Such results may thus add further impetus to the need to address multiple domains of influence in a prevention program. Thus, findings from these trials highlight two potential limitations that, if addressed, may enhance the efficacy of prevention programs. First, as mentioned, targeting interventions to a more homogenous audience may prove to enhance program potency. Furthermore, as emphasized by several researchers and highlighted by the findings of Carter et al. (1997), targeting the social domains of the target audience may further enhance intervention efforts. The purpose of this article is to describe the content of an eating disorder prevention effort, the Body Logic Program, that attempted to address some of the limitations of prior studies (Varnado-Sullivan et al., 2001). The intervention sought both to include proximal domains of influence that affect adolescent attitudes (parents and teachers) and to screen individuals for level of risk status. A more intensive intervention was also designed for students identified as being at high risk of developing disordered eating. Varnado-Sullivan et al. (2001) included only a brief overview of the Body Logic Program. The pur-


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pose of the current article for this special edition of Behavior Modification is to provide a more detailed description of the program so that the information can help guide researchers and clinicians in the development of future programs. Body Logic Part I can best be described as a universal primary prevention program (Franko & Orosan-Weine, 1998). Initial efficacy for this program component was established among sixth- and seventhgrade students at two private middle schools. The second stage, Body Logic Part II, is an intensive family-based intervention for students identified as at-risk for the development of eating- and weight-related difficulties and their parents. This component was designed to provide a more intensive intervention for at-risk participants. Body Logic Part II can best be conceptualized as an indicated preventive intervention (Franko & Orosan-Weine, 1998) to prevent detectable signs and symptoms from developing into a full clinical syndrome. The Body Logic Program includes exercises designed to alter proposed risk factors for the development of an eating disorder such as body dysphoria (overconcern with body size and dissatisfaction with body shape or weight) and negative affect (Veron-Guidry et al., 1997). The program is based on reviews of existing eating disorder and other prevention protocols, information gathered from focus groups, and existing protocols for the treatment of eating disorders, body image, and childhood depression. To avoid potential iatrogenic effects, the Body Logic Program does not include educational information about eating disorders. No explanatory information is presented about restrictive eating, purgative methods, binge eating, or the physical side effects associated with these behaviors. Rather, the program focuses on improvement of body image, education about nutritional requirements, and the development of coping skills to deal with teasing and the changes associated with puberty. Consistent with reviews of the prevention literature and recent eating disorder prevention efforts (O’Dea & Abraham, 2000; Weissberg, Caplan, & Harwood, 1991), the Body Logic Program also incorporates information on such topics as communication, self-esteem, and problem solving.

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THE BODY LOGIC PROGRAM FOR ADOLESCENTS THE RESEARCH TEAM

The original Body Logic Team was composed of the authors of this article, two clinical psychologists, a registered dietitian, and two additional graduate students in clinical psychology (Varnado-Sullivan et al., 2001). Two team members led each session, with one serving as the session leader. On the basis of the initial implementation of the program, it is recommended that future session leaders have experience working with adolescents, in general, and with eating disorder treatment, in particular. To insure active and continued participation by the students, session leaders should be energetic and entertaining. The use of teachers or peers as group leaders requires further research to determine the efficacy for this type of implementation. The Body Logic Program for Adolescents was developed as a twostage program to prevent the development of eating disorders (Varnado-Sullivan et al., 2001). Body Logic Part I is a three-session school-based intervention designed to introduce the concept of body image, promote the development of coping skills to deal with sociocultural pressures for appearance, and provide educational information about nutrition and exercise. The purpose of this phase was to create a more accepting environment among students and teachers regarding body size and shape, thereby facilitating skill maintenance among the high-risk students. To this end, sessions were presented to all students in a designated grade and a workshop for educators at participating schools was conducted. Body Logic Part I

Body Logic Part I was administered to male and female students in sixth and seventh grades at two participating schools (VarnadoSullivan et al., 2001). The interventions were time lagged across schools to establish a control condition. The efficacy of the intervention was assessed with the Multiaxial Assessment of Eating Disorder Symptoms (MAEDS) (Anderson, Williamson, Duchmann, Gleaves, & Barbin, 1999) that has been validated as an outcome measure for the treatment of eating disorder symptoms. Results indicated that Body


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Logic Part I led to decreases in scores for all female participants at School 1 on the Fear of Fatness and Avoidance of Fear Foods scales of the MAEDS (Varnado-Sullivan et al., 2001). When only females identified as at-risk were examined, decreased scores on the Fear of Fatness scale were noted at School 1 (Varnado-Sullivan et al., 2001). No significant decreases were noted for participants at School 2. However, it was noted that baseline scores were higher for participants at School 2 relative to School 1. There were also some differences in the implementation of the program between the schools. For example, School 1 allowed the program to be presented over several weeks; School 2, however, opted to hold the program over three consecutive days (Varnado-Sullivan et al., 2001). We have several recommendations to improve program efficacy on the basis of this initial trial. The distribution of small prizes and a lottery of larger prizes to participating students, parents, and educators were extremely effective in enhancing participation. Given the better outcome for participants from the smaller school setting, future implementations of the Body Logic Program should consider dividing larger class sizes into smaller groups. Holding gender-specific groups should also be considered. In addition, expanding the number of sessions to insure thorough coverage of all activities of the sessions may be required. The teacher workshop. Content of the teacher workshop included a description of the Body Logic Program, basic information about eating disorders, sociocultural pressures for thinness, and other risk factors; and information about referral resources. Teachers were encouraged not only to avoid overreacting to “normal” dieting, but also not to attempt treatment of perceived difficulties on their own. Unfortunately, the efficacy of the teacher component could not be established because of insufficient sample size. Thus, detailed information about the teacher component will not be presented. Body Logic Part II

Body Logic Part II is an intensive family-based intervention for students identified as at risk for the development of an eating disorder and their parents. Body Logic Part II is conducted in a smaller group

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format, and includes exercises to further develop coping skills introduced during the school-based intervention. Efforts to implement Body Logic Part II were unsuccessful because of a lack of participation by students and their parents (Varnado-Sullivan et al., 2001). Only one family opted to attend the program. Although their feedback was positive and the student demonstrated further decreases in attitudes and behaviors, this limited information does not allow for elaboration of the efficacy of the program. The following sections will present in detail the protocol and treatment manual of Body Logic Part I, and provide a brief description of Body Logic Part II.1 PROTOCOL AND TREATMENT MANUAL FOR BODY LOGIC PART I SESSION 1

The primary goals for Session 1 are to define the concept of body image, discuss the influence of sociocultural pressures on body image ideals, and discuss the relationship between body image and selfesteem (see Figure 1). Session 1 begins with leader introductions and an explanation of the program. We are all constantly flooded by messages from our friends and families, from what we read in magazines, and from what we see on television, movies, and the internet about what to look like, how to eat, and how we should act. Such messages sometimes promise that doing these things will make us happy, popular, or healthy. Sometimes the messages we get from different sources tell us exactly the opposite things. Sometimes the things that we are told to do seem impossible. The purpose of the Body Logic Program is to teach you how to be in control of the messages around you. This program will teach you how to pick out good advice from bad, to learn how to like the way you look, and to treat your body in a healthy way. This program will also teach you some things that make you feel either good or bad about the way you look. Today we are going to talk about the way you feel about your physical appearance, and the things that cause people to like or dislike their body.

Group leaders begin a discussion of the concept of body image. The session outline lists the definitions used (see Figure 1) as well as ques-


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tions to prompt discussion by the participants. Students are encouraged to provide input into this discussion, such as providing examples of who might be considered a current body image ideal. The session leaders stress that the development of a negative body image is not “wrong,” but may create some difficulties. Body Logic provides ways to promote a more positive body image and self-concept. Following the basic overview of body image terms, session leaders enact several skits. The skits demonstrate the cognitive model of body image and serve to initiate discussions of potential contributing factors to the development of a negative body image. The twin body image scenario (see Figure 2) is designed to demonstrate the difference between a “positive” and a “negative” body image by demonstrating how two persons could react differently to the same stimulus event. Session leaders enact the skit and prompt a discussion of how thought processes can affect mood, self-esteem, and body image. During the initial efficacy study, students generally discussed contributory factors such as personality characteristics, self-esteem, and thought processes as leading to the different interpretations of the twins. Session leaders guide the discussion to a brief review of the cognitive-behavioral model (Williamson, White, York-Crowe, & Stewart, 2004 [this issue]). The concept of challenging or modifying a distorted or negative thought process is then introduced. Session leaders stimulate a discussion of the influence of selfesteem, teasing, peer comparison of body size and shape, early pubertal onset, and sociocultural pressures in the development of a negative body image. To help generate this discussion, the “Becky” skits are enacted by the session leaders (see Figure 1). The participants are prompted to discuss ways in which Becky could cope with these incidents. Leaders lead the discussion to suggestions, such as talking about how the incidents made her feel or challenging negative body image beliefs Becky may have. Session leaders provide information about factors that may contribute to the development of a negative body image, such as teasing or media influences. It is vital to promote a discussion by the participants of how to discourage teasing within the school environment, as well as how to cope when individually teased by peers. Challenging negative body image thoughts and assertive behaviors are presented as strategies to manage teasing from peers.

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Body Logic Program Part I In each of the session outlines, tasks, statements, or questions intended for the session leaders are printed in plain text. Items in italics represent participant responsibilities or likely responses.

Session 1

1. Introductions and explanation of program. 2. What is body image? “Body Image is the picture that we have of what we look like in our heads. A body image ideal is how we wished we looked.” Ask students to provide examples of body image ideals. Likely responses include: Popular singers Actors 3. Define positive and negative body image. “People that have a positive body image like the picture of their bodies in their minds. People that have a negative body image do not feel really good about the picture of their bodies in their minds. Neither is right or wrong.” 4. Review cognitive model through skits. Materials needed: props, twin body image handout. A. Twin body image scenario a. How is it possible that 2 people who look exactly alike can feel so differently about their appearance? b. How can you explain their different interpretations? c. What might contribute to people’s different reactions? Likely responses: What they are thinking. How they feel about themselves. B. Becky skits. Use props. a. Becky asks to borrow clothes from a friend, but the friend tells Becky she is too big to fit in them. b. Becky is at home with her boyfriend; he points to a model and says, “Can you look like that.” c. Becky calls to her dad, and he responds, “Hey chipmunk cheeks.” 5. Development of body image.

“What are some of the things that may have lead to Becky’s feelings about her body?” Likely responses: Teasing. Media. “How could Becky cope with these incidents?” Tell them off. Tell Dad that it hurts her feelings. Talk about how it feels. 6. Slide Show. Materials needed: Slides/images of historical and current ideals. “The slides we are about to show you demonstrate different ways in which people have tried to change their bodies at different times in history. While you're watching them, try to think of ways that people use today to change their body size and shapes.” a. What is your initial impression when you look at this picture? b. Are you surprised that this picture represents the ideal of beauty during a period of history? c. Is this picture considered fashionable now? Do you think it could ever be again? Why or why not? Likely responses: EEEW or laughter. No way I would do that. 7. Body image concern. “Why do people think so much about their weight and body size?” Ask class what deodorant, a wig, a corset, colored contacts, hair color dye, control-top pantyhose, steroids, tanning, and weight lifting have in common. Students discuss sociocultural pressures. 8. Homework. Materials needed: Great Debate worksheet. Students gather materials for debate.

Figure 1. Outline for Session 1.

The next exercise in Session 1 focuses on sociocultural influences on body image ideals. A slide presentation demonstrating differing standards for attractiveness over time is presented. The slide show used in the initial efficacy study was adapted from a media-focused psychoeducational program developed by Stormer and Thompson


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Imagine two identical twins, Brittney and Courtney. They’re identical so they look exactly the same (Get it?). They are walking down the hall in their school and a friend of theirs walks past them without saying “hi.” They both then walk past a group of boys who play on the football team who are laughing. If we could put a microphone to the heads of these twins and listen to their thoughts, this is what we would hear:

Boy, our friend Jennifer must have a lot on her mind. It looked like she didn’t even see us. I’ll call her later to see if she’s O.K. That football player on the end is cute. I think he may have been checking me out.

Jennifer must be mad at me. I look so gross today she’s probably afraid to acknowledge she’s my friend. I look so stupid, even those boys were laughing at me.

Now imagine a pair of male identical twins, Jack and Mac who are walking down the hall and both just found out that they didn’t make the varsity football team. If we could put a microphone to the heads of these twins and listen to their thoughts, this is what we would hear.

If only I had worked out harder, I would have been big enough to make the team. No wonder the coach didn’t want me - I must look like a total weakling. I’ll probably never get a date.

Guess this means I’ll have a lot more time to learn to play the guitar. You know, women go crazy over musicians - this could be the start of something.

Figure 2. The identical twin exercise from Lesson 1 to demonstrate the cognitive basis of body image.

(1998). The slides include portraits of historical figures, photographs of methods used to alter appearance (e.g., corsets), and photographs of popular models/actors from the 1950s to the present.

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Following the slide show, the session leaders provide information about the current ideals presented in the media, the lengths that models/actors go to achieve a certain appearance, and the ability to technologically alter these images. The students are prompted to discuss the changing ideals presented in the slide show. Students typically responded to the slides with amazement at the methods used historically to alter appearance. Leaders question the students if they believe that current methods used to alter appearance will be considered as silly in the future, as past methods seem today. As a conclusion, group leaders stress that one of the factors that has changed over the past several decades is the degree of discrepancy between the body image or attractiveness ideals of today and the average person. This leads to a discussion of the message from the media that if one just works hard enough, any body size can be achieved. Information is then provided about the average heights and weights of persons today as compared to the average height and weight of a model. Leaders stress that what is presented in the media is not achievable for most people. The session ends with instructions about an exercise for the next session, the Great Debate. The debate centers on the following points: (a) whether one should accept the current ideal presented in the media and (b) if one chooses to accept this ideal, whether body shape and size can be altered to whatever appearance one desires. Each student is instructed to bring materials to argue for both sides of the debate as teams will not be decided until the day of the debate. The students are given a worksheet to help in gathering the materials, as well as an information sheet to promote discussion of the project with their parents (see Figure 3). It is important that students gather materials for both sides of the debate as the goal of this exercise is to promote questioning of the ideal presented in the media. At the close of the session, a summary of the main points of Session 1 and a preview of Session 2 are provided. Group leaders take suggestions and questions from the participants. SESSION 2

The goals of this session are to (a) have the students question the idea that bodies are infinitely malleable and rewards await those who


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can achieve the ideal (Brownell, 1991) and (b) develop coping skills to deal with sociocultural pressures for thinness. As can be seen in the session outline (see Figure 4), the session begins with introductions and a brief recap of the session preceding the Great Debate. During the development of the Body Logic Program, the researchers were acutely aware that having the students examine evidence and argue for acceptance or promotion of the current thin body image ideal presented in the media could reinforce maladaptive beliefs. However, two-sided arguments tend to be more effective in persuasive arguments when trying to affect attitude change. The goal is that by having the students examine both sides of this issue, attitude change will be promoted. This format is designed to lead to an active, problem-solving approach for the participants to develop coping strategies to deal with pressures to achieve the current body image ideal. Following the introductory information, participants are divided into teams and allowed preparation time. Our experience was that some students did not actively gather materials for the debate, although many did. Session leaders should be prepared to provide supplemental materials. Students did actively participate in the debate. The teams present main arguments, and the opposing team is allowed to make a rebuttal. Leaders should remain conscious of the purpose of the debate, which is to promote questioning of ideals presented in the media and to help generate a discussion of how this affects the participants. The group leaders lead the discussion to the crucial final argument that current ideals presented in the media are not achievable for most people. Information about the diversity of body shapes and sizes, as well as educational information about the impact of genetics on height, weight, and body shape, is reviewed. Session leaders should promote discussion and problem solving of how to deal with sociocultural pressures. The impact of puberty on body image and self-esteem is the next component of this session. Educational information about pubertal changes is presented, particularly differing rates of development, and session leaders discuss how concern about these changes can affect self-esteem. The group leaders should use examples to prompt student participation, such as their own experiences with pubertal development.

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The Great Debate Attention parents! We are going to have a debate and your child is in charge of gathering some materials to defend both sides of the following arguments. The purpose of the debate is to generate discussion of the pressures your child feels to obtain a certain appearance or look a certain way. The Body Logic team will discuss how to cope with these pressures following the debate.

SIDE 1

Argument 1: We should not accept the body type currently presented in the media. Argument 2: We cannot usually make our body shape look any way we want it to even if we work really hard at it.

SIDE 2

Argument 1: We should accept the body type that the media presents. Argument 2: We can make our body shape look any way we want it to if we work hard enough. We will randomly divide the children into two teams on the day of the debate so your child will find out on that day which argument he/she will be making. In the meantime he/she should be prepared to defend either side. The following materials are suggestions of things your child can try and gather for each side:

SIDE 1 articles about successful people who don’t look “just right” find an interview of an actor who worries about appearance

SIDE 2 ads in newspapers for health clubs pictures or actors from magazines

Figure 3. Homework sheet for the Great Debate in Session 2.

The “silly things we do during puberty” component focuses on the concept of a negative body image or excessive concern with appearance leading to difficulties, such as restricting food consumption because of fears of gaining weight. Group leaders segue to a discussion of the consequences of excessive concern about shape and how such excessive concern would interfere with significant domains of the individual’s life. Students were quite adept at detailing how excessive concern would affect someone. Leaders should stress that although everyone wants to look one’s best and be healthy, excessive concern interferes with one’s life. Group leaders stress that if individuals listen to their body’s internal cues for hunger and rest and remain physically active, a healthy body weight will naturally follow. To develop coping strategies to manage sociocultural pressures, the students take part in the survival skills exercise (see Figure 5). Follow-


Session 2

1. Introductions. 2. The Great Debate. Materials needed: supporting materials, worksheets, prizes A. Divide into groups and allow them time to organize their strategies. Help with planning. Suggested strategies: Pro adopting team. (a) Photos of models. (b) Attractive people are more popular, admired, etc. Anti-adoption team. (a) Photos to demonstrate that people come in all shapes and sizes. (b) Story about a very thin or fit person who is not “happy.” (c) Photos of people who are not the “ideal” yet are admired, respected, successful, etc. Students present arguments then rebuttal. B. Conclusion: (a) People come in all shapes and sizes. (b) Our shape and size is determined a great deal by genetics. (c) Most of us cannot achieve the ideals presented in the media. (d) Emphasize that the pressures to look a certain way are real and that there are ways to help cope with these pressures. 3. Diversity of body shapes and sizes. Materials needed: Body shapes worksheet. Emphasize role of genetics, as well as environment. 4. The impact of pubertal changes on selfesteem and body image. “People’s bodies go through pubertal changes at different rates. Girls usually begin puberty earlier than boys. For boys, pubertal changes start a little later, but last longer. Sometimes we think there is something wrong with them when their bodies are going through changes at a rate that is different from their peers. Just remember that there is no right or wrong way for our bodies to change during this time!” A. Skit or Role Play. What sorts of things might someone who grows and develops slower or faster than their peers encounter? Likely responses: Teasing. Worrying about appearance.

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B. Problem Solving. Discussion of what could the person in that situation do, say, or think, so that he or she does not feel bad. Students problem-solve. C. What things would you miss out on if you worried about your appearance all day long? Likely answers: Spending time with friends and family. Talking on the phone, listening to music... 5. Silly things that people do doing puberty. “Sometimes we get so worried about the changes that are happening to our bodies that we do things that may cause problems. For example, when our body is growing it needs more energy. We get energy from food. We may be hungrier or eat more than before. Some worry about becoming fat. If you develop healthy habits like eating a variety of foods and being physically active, your body will stay at the weight that’s most healthy for you. For now, remember one simple rule: listen to your body.” 6. Lunch Skits or Role-play. Set up scenario of a student commenting about how much another student is eating. Ask how the student would feel. Likely responses: Bad Self-conscious A. Problem Solving. Students generate a discussion of what could the person could do, say, or think to themselves, to not feel bad. 7. Survival Skills. Materials needed: Survival Skills worksheet. A. Questions to promote: (a) What are ways to like our appearance and ourselves more? (b) What are things that we may do either on purpose or by accident that may make people feel badly? (c) What are the qualities that are most important to you in a friend? 8. Homework. Materials Needed: Interview Sheet. Students interview several adults whom they admire and ask about their rate of growth during puberty.


ing the skits and role-plays for this exercise, leaders assist students in brainstorming how to handle these situations. In addition, questions such as those listed on the session outline (see Figure 4) can be used to promote construction of the survival skills worksheet. Session leaders

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use questions such as the ones described on the session outline to promote this discussion. For each of the questions, students are asked to write down responses, and group leaders randomly pick some for group discussion. Responses to the questions are used to solve problems and generate potential coping strategies, or survival skills. Students participated actively in this process, but leaders should be prepared to supplement the discussion. Students are instructed to use the survival skills as needed. At the close of the session, a review is provided and suggestions are requested. Homework for this session is to interview parents or another adult whom they admire and ask about his or her experience with puberty. Students are provided a worksheet and potential questions, such as “Were you teased as an adolescent?” or “What advice would you give a developing adolescent?” SESSION 3

This component includes a review of the Adult Interview, basic educational information about nutrition and exercise, and the “how to recognize a fad diet” exercise (see Figure 6). The first exercise is a review of the Adult Interview. Group leaders ask for volunteers to discuss their interviews, with an emphasis placed on what was learned from the exercise. Our experience was that many of the students completed the interview, and were willing to discuss the exercise. Participants are encouraged to discuss advice given by the interviewed adult, and whether suggestions could be incorporated into their survival skills sheets. Leaders underscore the differing rates of development experienced by the interviewed adults. Students are asked about using their survival skills, and ways to implement the skills that are provided. Following the homework review, the overview of nutrition and exercise guidelines begins. The leaders discuss the bombardment of information presented in the media, especially information about weight loss products. To enable questioning of these messages by group participants, the session leaders use the “forest creature” example to illustrate the importance of relying on internal cues about hunger. This analogy is detailed in Figure 6. The group leaders emphasize the importance of listening to one’s body and eating regularly. Session leaders review side effects of skipping meals and use the forest-creature


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Remember that teasing is never a good or fun thing to do. It can hurt other’s feelings and it hurts mine. Remember that we come in all sorts of shapes and sizes; it would be boring if we all looked alike. Make a list of all my good qualities so that I can remember them when I am feeling bad. When I see someone else being teased, I can try to help stop it. I can tell them that it’s not nice or let a teacher know what is going on. Write a list of things I like about my friends. Looks are not what matter to me about my friends, why would they matter to them? Try to “talk back” when I start beating myself up. Remember that we can’t all look like movie stars and the ideal presented in the media changes. Remember that pictures in magazines are touched up. Eat healthy. Talk to my friends when I feel bad. Figure 5. Completed survival skills worksheet.

analogy to review the concept of energy stores being depleted, which could lead to overeating. Participants are questioned about the frequency of skipping meals, and reasons for doing so. Many students responded that lunch meals were regularly skipped. Leaders promote developing solutions to skipping meals. Dietary information is reviewed in a game show format with students competing for prizes. Sample questions are listed in the session outline (see Figure 6). Leaders should provide the correct answer, as well as supplemental information about the concept covered by the question. Following the Nutrition and Exercise Game, the group leaders introduce basic nutrition and exercise guidelines via a review of

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Session 3

1. Introductions and Review of Homework. Review adult interview sheets. Focus on what was learned and advice that can be used for survival skills work sheet. Students discuss interviews. 2. Critical examination of media messages about food and nutrition. “In the past few sessions, we’ve talked about the importance of having a positive body image, the influences that define what is considered the “ideal” way to look, and how the media can misinform us about health and dietary practices. Today we are going to get down to basics: how to critically examine messages about how much you are “supposed” to weigh; how to eat and exercise in a healthy way; and how to critically examine diet programs.” A. Information. Ask where they obtain information about how much to eat?Likely responses: Classes. Media. Parents. B. Forest creature analogy. “I want you guys to use your imagination for a minute. Think about animals in the natural environment. Have you ever seen an overweight animal in the woods? How do they determine when it is time to eat? C. Regular eating. Lead into a discussion of the importance of eating at least 3 meals per day plus snacks. Ask how many skip lunch and why? What would make it “not cool” to skip lunch? Students problem solve. Discuss depletion of energy stores and how this may lead to overeating. 3. Dietary guidelines. Materials needed: Nutrition and exercise game. “Dietary and exercise guidelines provide basic general rules for guiding someone’s eating and

lifestyle habits. Because adolescence is a time of growth and intensified nutritional needs, following these guidelines is especially important.” A. Game. Examples of questions: (a) Who knows how many servings of milk is recommended daily?; (b) What are the potential benefits of exercise?; (c) Which food is a good source of Vitamin D?; and (d) Which foods are good sources of fiber and what does fiber do? Students compete for prizes individually or as a team. B. “Because of the growing emphasis on thinness in our society, many adolescents get frightened by an increase in appetite that they experience during adolescence because they fear gaining weight. TRUST YOUR BODY!!!” 4. Review food pyramid and guidelines. Materials needed: Food pyramid handouts, how to follow guidelines handout. Points to stress: (a) Discuss the importance of eating a variety of foods and not eliminating any food group. (b) Maintain a comfortable weight for you, don’t focus on numbers. (c) Pay attention to your body’s signals. Eat when hungry, not because of external cues (remind about 3 meals per day). (d) Foods that are rich in complex carbohydrates such as fruits, vegetables, breads, and pastas are an important source of energy for your muscles. Try to eat fruits and vegetables as snacks to increase these in your diet. (e) Everything in moderation. Too much or too little fat, sugar, or sodium can lead to difficulties later on. 5. How to recognize a fad diet. Materials needed: Everybody’s dieting and designing a healthy diet worksheet. A. Education. Provide educational information about an appropriate weight loss program. B. Advertisement. Have students create an advertisement that outlines a healthy approach to dieting. Review ads students develop.


the food pyramid. Group leaders present the daily serving requirements and an explanation of a serving size. It is stressed that eating a variety of foods is essential to help insure that one is consuming a balanced diet, that is, “everything in moderation.” The importance of


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exercise, the general recommendations, and ways to increase physical activity is included in this component as well. The final exercise in Session 3 is how to recognize a fad diet (see Figure 6). Group leaders provide pointers such as “healthy” weight loss guidelines, and the importance of not eliminating whole food groups from the diet. Students are asked to design their own advertisement for a “healthy” weight loss program. Group leaders stress that an appropriate weight loss program includes behavior modification, educational information, a balanced diet, and exercise. In addition, group leaders review findings that many who feel overweight and report dieting are actually within the normal weight range. Therefore, discussing plans to diet with a physician and parents is an important part of deciding whether to diet. The group leaders stress that eating in a healthful manner and exercising regularly will lead to maintaining an appropriate weight. At the close of the session, group leaders review the main points of Body Logic Part I. All students are invited to attend Body Logic Part II and are given contact information for this program. BODY LOGIC PART II (THE INTENSIVE FAMILY-BASED PROGRAM)

Although further research is necessary to determine the effectiveness and best method of implementation for this component, a brief description will be provided. To avoid stigmatization of students identified as at-risk, all students and their parents are provided information about the program and invited to attend. Participants identified as at risk for the development of eating disorder symptoms receive an additional phone call and letter inviting them to the program. Body Logic Part II consists of four weekly sessions, which were designed to provide more in-depth interventions for the targeted adolescents and their parents. Parent and adolescent sessions are held concurrently, but separately, with the groups merging at the close of each session. Body Logic Part II consists of the following content areas. Two sessions are devoted to the concept of body image. The Development of Negative Body Image component includes information and exercises reviewing the development of body image. Thought monitoring and challenging negative self-talk are introduced in the first session. The

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second session of Body Logic Part II, How to Improve a Negative Body Image, is designed to promote the development of coping strategies for dealing with a negative body image, and a continuation of cognitive interventions to improve a negative body image and selfesteem. The third session of Body Logic Part II, Nutrition Education provides more detailed information about nutritional guidelines. This session includes exercises on the recognition of fad diets, and resisting peer pressure to diet. Parents and adolescents also discuss mealtime problems, and meal planning is introduced. The final session consists of an overview of communication skills and problem solving. DISCUSSION

Since the initial publication of the Body Logic Program (VarnadoSullivan et al., 2001), we have had the benefit of receiving commentaries from several experts in the eating disorder prevention field regarding ways to enhance program efficacy and acceptability. Such insights will hopefully prove useful for the refinement of the Body Logic Program as well as in the development of future programs. The intent of the Body Logic Program was to teach students skills to enhance their resiliency to sociocultural pressures of thinness. However, commentaries regarding the program repeatedly emphasized the need to not only target the individual, but also to target the environment the individual must navigate (Franko, 2001; Levine, 2001; Piran, 2001). One of the foremost challenges of eating disorder prevention is to create a social environment that is receptive to the messages presented in program curricula. We addressed this issue by providing information to and including parents and teachers in the intervention. However, such efforts would have perhaps been more readily received if additional steps had been taken. One such step includes working with parents and teachers regarding their own prejudices and insecurities prior to program implementation (Piran, 2001). In this manner, there is an increased likelihood that parents and teachers echo the messages the participants are being taught in the school program.


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The best way to create an accepting environment within the school system is an area of continued exploration. Conceptually, the school system should be regarded as a microcosm in which an environment accepting of diversity and intolerant of teasing and discrimination should be the goal. Piran (1999) reported success with such a systemic approach in a high-risk residential school setting. Creating such an environment for the Body Logic Program in the public school system could include implementing body image workshops for faculty, scrutinizing health curricula regarding the presentation of pubertal change, and altering physical education target goals to emphasize personal improvement rather than beating nationally set criteria. Obviously, this only superficially taps the many vast areas for intervention. As we have learned and other researchers have described, there is usually a conflict between what researchers deem an ideal intervention and the logistical reality of implementing such a program within the overtaxed and overburdened academic system (Franko, 2001). Eating disorders are but one of many problems with which a school system must contend. Thus, programs that teach skills that have a broader applicability will probably also have more appeal to the school system (Franko, 2001). Although skills such as communication and problem solving were part of Body Logic II, the intervention would have perhaps been more readily received if such skills were part of the initial program that was described as a “life skills” intervention. In sum, the degree to which we can create an accepting environment prior to intervention implementation and the degree to which our goals match the goals of the school system will enhance our efforts at intervention. In the end, it is important to remember that we all share the same goals: to raise healthy and happy children. The challenge comes from acknowledging, appreciating, and incorporating each party’s vision of how such goals are best attained. NOTE 1. Further details about this program including program content outlines can be obtained from the first author.

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REFERENCES Anderson, D. A., Williamson, D. A., Duchmann, E. G., Gleaves, D. H., & Barbin, J. M. (1999). Development and validation of a multifactorial treatment outcome measure for eating disorders. Assessment, 6, 7-20. Arriaza, C. A., & Mann, T. (2001). Ethnic differences in eating disorder symptoms among college students: The confounding role of body mass index. Journal of American College Health, 49, 309-315. Braun, D. L., Sunday, S. R., Huang, A., & Halmi, K. A. (1999). More males seek treatment for eating disorders. International Journal of Eating Disorders, 25, 415-424. Brownell, K. D. (1991). Dieting and the search for the perfect body: Where physiology and culture collide. Behavior Therapy, 22, 1-12. Carter, J. C., Stewart, D. A., Dunn, V. J., & Fairburn, C. G. (1997). Primary prevention of eating disorders: Might it do more harm than good? International Journal of Eating Disorders, 22, 167-172. Franko, D. L. (2001). Rethinking prevention efforts in eating disorders: Commentary on “Development and Implementation of the Body Logic Program for Adolescents.” Cognitive and Behavioral Practice, 8, 265-270. Franko, D. L., & Orosan-Weine, P. (1998). The prevention of eating disorders: Empirical, methodological, and conceptual considerations. Clinical Psychology: Science and Practice, 5, 459-477. Killen, J. D., Taylor, C. B., Hayward, C., Wilson, D. M., Haydel, K. F., Hammer, L. D., et al. (1993). An attempt to modify unhealthful eating habits and weight regulation practices of young and adolescent girls. International Journal of Eating Disorders, 13, 369-384. Levine, M. P. (2001). Commentary on Varnado-Sullivan et al.’s “Development and Implementation of the Body Logic Program for Adolescents.” Cognitive and Behavioral Practice, 8, 271-276. Mizes, J. S., & Bonifazi, D. Z. (2001). Primary prevention of eating disorders: A noble calling or an unrealistic ideal? Cognitive and Behavioral Practice, 8, 246-248. Neumark-Sztainer, D., Butler, R., & Palti, H. (1995). Eating disturbances among adolescent girls: Evaluation of a school-based primary prevention program. Journal of Nutrition Education, 27, 24-31. O’Dea, J. A., & Abraham, S. (2000). Improving the body image, eating attitudes, and behaviors of young male and female adolescents: A new educational approach that focuses on selfesteem. International Journal of Eating Disorders, 28, 43-57. Piran, N. (1999). Eating disorders: A trial of prevention in a high risk school setting. Journal of Primary Prevention, 20, 75-90. Piran, N. (2001). The Body Logic Program: Discussion and reflections. Cognitive and Behavioral Practice, 8, 259-264. Rogers, L., Resnick, M. D., Mitchell, J. E., & Blum, R. W. (1997). The relationship between socioeconomic status and eating-disordered behaviors in a community sample of adolescent girls. International Journal of Eating Disorders, 22, 15-23. Stormer, S. M., & Thompson, J. K. (1998, November). An evaluation of a media-focused psychoeducation program for body image. Poster session presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Washington, DC. Sullivan, P. F. (1995). Mortality in anorexia nervosa. American Journal of Psychiatry, 152, 10731074. Tsai, G. (2000). Eating disorders in the Far East. Eating and Weight Disorders, 5(4), 183-197.


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Varnado-Sullivan, P. J., Zucker, N., Williamson, D. A., Reas, D., Thaw, J., & Netemeyer, R. G. (2001). Development and implementation of the Body Logic Program for adolescents: A two-stage prevention program for eating disorders. Cognitive and Behavioral Practice, 8, 248-259. Veron-Guidry, S., Williamson, D. A., & Netemeyer, R. G. (1997). Structural modeling analysis of risk factors for eating disorders in children and preadolescents. Eating Disorders: Journal of Treatment and Prevention, 5, 15-27. Weissberg, R. P., Caplan, M., & Harwood, R. L. (1991). Promoting competent young people in competence-enhancing environments: A systems-based perspective on primary prevention. Journal of Consulting and Clinical Psychology, 59, 830-841. Williamson, D. A., White, M. A., York-Crowe, E., & Stewart, T. (in press). Cognitive-behavioral theories of eating disorders. Behavior Modification, 28(6), 711-738.

Paula J. Varnado-Sullivan earned her Ph.D. from Louisiana State University. She completed a 1-year internship in 1995 at the University of Mississippi/Virginia Consortium in psychology. She is now an assistant professor of psychology at Southeastern Louisiana University, where she has been employed in a full-time position since 1998. Her research has focused on body image, eating disorders, and the prevention of eating disorders. She has published research journal articles and book chapters on such topics as eating disorders, obesity, and behavioral medicine. Nancy Zucker earned her Ph.D. from the Louisiana State University in Baton Rouge, LA. She completed a 1-year internship at Duke University Medical Center in 2000. She is now the director of the Duke Eating Disorder Outpatient Program at Duke University Medical Center. Her research has focused on obesity and eating disorders, and she has published several journal articles and book chapters on these topics.