Effects of a Prototype Internet Dissonance-Based Eating Disorder Prevention Program at 1- and 2-Year Follow-up

Between 10-13% of young women meet DSM-IV (Hudson, Hiripi, Pope, & Kessler, 2007) or DSM-5 criteria for eating disorders (Stice, Marti, & Rohde, 2013b), which are marked by chronicity, relapse, distress, impairment, and future obesity, depression, suicide attempts, anxiety disorders, substance abuse, and mortality (Arcelus, Mitchell, Wales, & Nielsen, 2011; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). Thus, researchers have sought to develop effective eating disorder prevention programs. Although several prevention programs have produced significant reductions in eating disorder symptoms that persist through at least 6-month follow-up in single trials (Jones et al., 2008; McVey, Tweed, & Blackmore, 2007; Stewart, Carter, Drinkwater, Hainsworth, & Fairburn, 2001), more trials conducted by more research teams have provided support for a selective dissonance-based eating disorder prevention program (Body Project) in which young women with body image concerns critique the thin ideal in verbal, written, and behavioral exercises (Stice, Shaw, Burton, & Wade, 2006a). Criticizing the thin ideal publically theoretically reduces thin-ideal internalization because people seek to maintain consistency between their behaviors and attitudes, which putatively decreases body dissatisfaction, unhealthy weight control behaviors, negative affect, and eating disorder symptoms. Participants assigned to the Body Project have shown greater reductions in eating disorder risk factors, eating disorder symptoms, functional impairment, and eating disorder onset through 3-year follow-up than participants assigned to assessment-only control conditions or alternative interventions in efficacy trials (e.g., Stice et al., 2006a; Stice, Marti, Spoor, Presnell, & Shaw, 2008). Similar effects have emerged in efficacy trials conducted by independent researchers (Becker, Smith, & Ciao, 2005; Becker et al., 2010; Halliwell & Diedrichs, 2013; Matusek, Wendt, & Wiseman, 2004; Mitchell, Mazzeo, Rausch, & Cooke, 2007). Consistent with the intervention theory for the Body Project, reductions in thin-ideal internalization appear to mediate the effects of the intervention on change in the other outcomes (Seidel, Presnell, & Rosenfield, 2009; Stice, Presnell, Gau, & Shaw, 2007a) and participants assigned to versions of this intervention designed to maximize dissonance-induction show greater reductions in eating disorder symptoms than those assigned to versions that minimize dissonance-induction (Green, Scott, Divankova, Gasser, & Pederson, 2005; McMillan, Stice, & Rohde, 2011). Participation in the Body Project also eliminated the negative effect of exposure to supermodels on body dissatisfaction in adolescent girls observed in participants who did not complete this prevention program, which was assessed in an ostensively independent study, reducing the impact of demand characteristics (Halliwell & Diedrichs, 2013). Effectiveness trials indicate that this prevention program produces similar effects when high school and college counselors recruit female students with body image concerns and deliver the intervention under ecologically valid conditions, including significant reductions in eating disorder symptoms that persist through 3-year follow-up (e.g., Stice, Butryn, Rohde, Shaw, & Marti, 2013a; Stice, Rohde, Shaw, & Gau, 2011). Despite the encouraging evidence-base for the Body Project, experience suggests it can be difficult to identify school clinicians who have the time and expertise to competently deliver the program. For instance, in 40% of the high schools approached in an effectiveness trial we were unable to convince even one clinician at the school to receive free training to deliver the interventionand the program and were unable to locate a school clinician with experience leading group-based interventions, despite approaching all school counselors and nurses at each school. Clinician turnover has also caused implementation and sustainability challenges in high schools and colleges. For example, 32% of clinicians trained at eight colleges in our effectiveness trial took positions at another institution or lost their job during the intervention delivery phase of our trial. Thus, we developed an Internet version of the Body Project to overcome these dissemination barriers to facilitate broad implementation given that over 95% of adolescent girls/young women have access to the Internet (Odell et al., 2008). This decision was based on the encouraging results from trials that evaluated the cognitive behavior therapy-based Student Bodies Internet eating disorder prevention program, which has reduced eating disorder risk factors in multiple trials(e.g., Celio et al., 2000; Winzelberg et al., 2000; Zabinski et al., 2004). However, this team had to add 8 hours of clinician-led asynchronous chat room interchanges and in-person meetings with the clinician to observe significant reductions in eating disorder symptoms (Low et al., 2006; Taylor et al., 2006). As noted, our effectiveness trials revealed that a key dissemination barrier is that many schools do not have clinicians available to deliver prevention programs, whether in person or via a facilitator-supported Internet-based intervention. Our prototype Internet intervention sought to conserve the key elements of the group dissonance-based Body Project. We therefore translated each of the key activities from the Body Project into a parallel activity that could be conducted on the Internet (Stice, Rohde, Durant, & Shaw, 2012). In the present trial, 107 female college students with body image concerns were randomly assigned to the new Internet-based eBody Project, the group-based Body Project, an educational video control condition, or to an educational brochure control condition. The educational video control condition, which provided information on body image and eating disorders, was included to control for the medium used to deliver the new eBody Project and is a more rigorous active comparison condition than the control conditions used in past trials of Internet-based eating disorder prevention programs. The educational brochure control condition was included to allow us to benchmark the effects from this trial against the effects from Body Project groups delivered by school counselors in our effectiveness trials that used this control condition. The acute phase report from this trial indicated that eBody Project and Body Project participants showed greater pre-post reductions in eating disorder risk factors and symptoms than video controls (M d = .47 and .54 respectively) and brochure controls (M d = .75 and .72, respectively), with many effects reaching significance in this pilot that was only powered to detect a d = .65, which is between a medium and large effect (Stice et al., 2012). Acute phase effects did not differ significantly for Internet versus group participants (M d = -.13). Pre-post effect sizes for the eBody Project were similar to those previously observed for group-based Body Project. The current report describes effects at 1- and 2-year follow-up. Aim 1 was to test whether the eBody Project would produce significantly larger reductions in eating disorder risk factors and symptoms than educational video and brochure control conditions. Aim 2 was to test whether the eBody Project produced reductions in outcomes that were similar to those observed for the group Body Project conducted by college counselors, which was also expected to produce larger effects than the two control conditions. Aim 3 was to report the effects of the eBody Project and Body Project interventions on change in body mass index (BMI), given calls for prevention programs that produce significant intervention effects for eating disorder symptoms and unhealthy weight gain (Brownell & Fairburn, 1995; Irving & Neumark-Sztainer, 2002).