Received: 18 February 2021 Revised: 14 June 2021 Accepted: 15 June 2021

DOI: 10.1002/eat.23571

REVIEW

Disordered eating, body image concerns, and weight control

behaviors in primary school aged children: A systematic review
and meta-analysis of universal–selective prevention
interventions

Kirrilly M. Pursey1,2,3 | Tracy L. Burrows1,2,3 | Daniel Barker3,4 |

Melissa Hart1,2,3,5 | Susan J. Paxton6

1
School of Health Sciences, College of Health,
Medicine and Wellbeing, University of Abstract
Newcastle, Callaghan, New South Wales, Objective: Body image concerns and extreme weight control behaviors frequently
Australia
2 develop in childhood indicating an important age group for the implementation of
Priority Research Centre for Physical Activity
and Nutrition, University of Newcastle, universal–selective prevention approaches. This systematic review aimed to evaluate the
Callaghan, Australia
effect of universal–selective prevention interventions addressing disordered eating, body
3
Hunter Medical Research Institute, New
Lambton Heights, New South Wales, Australia image concerns, and/or extreme weight control behaviors in children aged 6–12 years.
4
School of Medicine and Public Health, Method: Nine databases were searched up to April 2021. Studies were included if
College of Health, Medicine and Wellbeing,
they delivered a universal–selective prevention intervention to children aged 6–
University of Newcastle, Callaghan, New
South Wales, Australia 12 years and reported outcomes relating to body image, disordered eating, or weight
5
Hunter New England Mental Health, control behaviors. The review was conducted in line with the PRISMA Guidelines.
Waratah, New South Wales, Australia
6
Results: A total of 42 articles describing 39 studies included in the review, with most
School of Psychology and Public Health, La
Trobe University, Melbourne, Victoria, (n = 24; 57%) classified as neutral quality. Thirty studies implemented an eating dis-
Australia order specific universal–selective program and nine implemented lifestyle interven-
Correspondence tions plus content to address disordered eating risk factors. Meta-analysis (n = 16
Kirrilly M. Pursey, School of Health Sciences, studies) revealed an improvement in body image-related outcomes across all studies
College of Health, Medicine and Wellbeing,
University of Newcastle, Callaghan, NSW, (standardized mean difference [SMD] 0.26 [95%CI 0.01, 0.51]); with a high level of
2308, Australia. heterogeneity (I^2 = 89.9%; p < .01). Meta-analysis according to gender revealed a
Email: kirrilly.pursey@newcastle.edu.au
general improvement in body image-related outcomes for girls (SMD 0.40 [95%CI
Funding information 0.07, 0.73]), but not boys (SMD 0.23 [95%CI 0.24, 0.70]).
Hunter Medical Research Institute Greaves
Family Early Career Research Grant (KP); Discussion: By investigating child, parental and teaching interventions and including out-
NHMRC Investigator Grant (TB) comes such as weight control and disordered eating behaviors, a trend toward a reduc-
Action Editor: Kelly Klump tion in eating disorder risk factors was observed, particularly body image-related
outomes in girls. Future directions include embedded disordered eating prevention mate-
rials within existing lifestyle interventions and inclusion of more diverse samples.

Resumen
Objetivo: Las preocupaciones sobre la imagen corporal y los comportamientos de
control de peso extremo se desarrollan con frecuencia en la infancia, lo que indica un
 n de enfoques de prevencio
grupo de edad importante para la implementacio  n univer-
 n sistematica tuvo como objetivo evaluar el efecto de las
sal-selectiva. Esta revisio
 n universal-selectivas que abordan la alimentacio
intervenciones de prevencio n

1730 © 2021 Wiley Periodicals LLC. wileyonlinelibrary.com/journal/eat Int J Eat Disord. 2021;54:1730–1765.
PURSEY ET AL. 1731

disfuncional, los problemas de imagen corporal y/o los comportamientos extremos

de control de peso en niños de 6 a 12 años de edad.
Método: Se realizaron búsquedas en nueve bases de datos hasta abril 2021. Se
 n de prevencio
incluyeron estudios que habían incluido una intervencio  n universal-
selectiva en niños de 6 a 12 años de edad e informaron resultados relacionados con
 n disfuncional o los comportamientos de control de
la imagen corporal, la alimentacio
 a cabo de conformidad con los lineamientos PRISMA.
peso. El examen se llevo
Resultados: Un total de 42 artículos que describieron 39 estudios incluidos en la rev-
 n, con la mayoría (n = 24; 57%) de calidad neutra. Treinta estudios implementaron
isio
un programa selectivo universal específico de trastornos de la conducta alimentaria y
nueve implementaron intervenciones de estilo de vida mas contenido para abordar la
 n disfuncional. El metanalisis (n = 16 estudios) revelo
alimentacio  una mejoría en los
resultados relacionados con la imagen corporal en todos los estudios (DME 0,26
[IC95%: 0,00 a 0,53]); con un alto nivel de heterogeneidad (I^2 = 91,1%; p < 0,01). El
metanalisis según el sexo revelo
 una mejora general en los resultados relacionados
con la imagen corporal para las niñas (DME 0,40 [IC95%: 0,07 a 0,73]), pero no para
los niños (DME 0,23 [IC95%: 0,24 a 0,70]).
 n: Al investigar las intervenciones tanto de los padres como de la enseñanza
Discusio
e incluir resultados como el control de peso y las conductas alimentarias de riesgo, se
 una tendencia hacia una reduccio
observo  n de los factores de riesgo de los trastornos
de la conducta alimentaria. En concreto, mejoras en las variables relacionadas con la
imagen corporal, especialmente en las niñas. Las direcciones futuras incluyen
 n de la alimentacio
materiales de prevencio  n disfuncional incorporados dentro de las
 n de muestras mas diversas.
intervenciones de estilo de vida existentes y la inclusio
 n,
Palabras clave: Niños, trastornos de la conducta alimentaria y de la alimentacio
 n disfuncional, prevencio
alimentacio  n, imagen corporal, revisio
 n sistematica, metanalisis.

KEYWORDS
body image, children, disordered eating, feeding and eating disorders, meta-analysis,
prevention, systematic review

1 | I N T RO DU CT I O N
There is growing evidence that body image concerns and extreme
weight control behaviors, such as dieting, frequently develop in child-
hood and preadolescence. Body dissatisfaction has been reported in
50% of children aged 6–12 years (Dion et al., 2016; Tatangelo,
McCabe, Mellor, & Mealey, 2016). Girls and boys have also been shown
to be significantly invested in thin and muscular ideals by 5–9 years old
(Dohnt & Tiggemann, 2006; McLean, Wertheim, & Paxton, 2018;
Ricciardelli, McCabe, Mussap, & Holt, 2009; Slater & Tiggemann, 2016),
while 29% of girls aged 10–14 years have reported attempting to lose
weight (McVey, Tweed, & Blackmore, 2004). This is of concern as body
dissatisfaction and extreme weight control behaviors are among the
strongest contributing risk factors to the development of disordered
eating behaviors (Maloney, McGuire, Daniels, & Specker, 1989;
Munkholm et al., 2016; Ricciardelli & McCabe, 2001; Ricciardelli,
McCabe, Holt, & Finemore, 2003; Stice & Whitenton, 2002). Disor-
dered eating behaviors are particularly concerning in children as they
can escalate rapidly and have significant effects on growth as well as
cognitive, social, and psychological development (Bould, Newbegin,
Stewart, Stein, & Fazel, 2017). In addition, the presence of disordered
eating behaviors at the preadolescent stage confers a strong risk
for the development of an eating disorder in adolescence and early
adulthood (Bucchianeri, Arikian, Hannan, Eisenberg, & Neumark-
Sztainer, 2013; Evans et al., 2017; Kotler, Cohen, Davies, Pine, &
Walsh, 2001; Stice, Marti, Shaw, & Jaconis, 2009). Therefore, child-
hood and preadolescence are important ages for the implementa-
tion of universal and selective prevention approaches before these
behaviors and cognitions become entrenched.
Eating disorder prevention programs are broadly categorized into
three categories: (a) universal interventions, which are targeted at
whole communities independent of eating disorder risk status;
1732
(b) selective interventions, which target groups (not individuals) that
are at higher risk of developing disordered eating behaviors
(e.g., females); or (c) indicated/targeted interventions, which are
targeted at individuals displaying symptoms of eating disorders and
aim to reduce signs and symptoms associated with eating disorders
(Le, Barendregt, Hay, & Mihalopoulos, 2017). The foci of the present
review are universal and selective interventions, both of which focus
on delivering an intervention to groups independent of eating disorder
risk status. Universal–selective interventions typically aim to reduce
specific risk factors for body dissatisfaction and disordered eating
such as internalization of societal appearance ideals, peer appearance
teasing, and low self-esteem (Levine, 2017).
The majority of published universal–selective prevention inter-
ventions for disordered eating have been aimed at adolescents,
aligning with the age of peak eating disorder onset (Smink, van
Hoeken, & Hoek, 2012). In a systematic review of 16 studies,
small improvements in body image outcomes were observed in sec-
ondary school students, with the most effective programs
implemented in younger adolescents aged 12–13 years (Yager,
Diedrichs, Ricciardelli, & Halliwell, 2013). Fewer studies have evalu-
ated prevention programs in children under 12 years of age. In an
early review of universal–selective eating disorder prevention inter-
ventions in children, improvements in knowledge of nutrition and
dieting were observed, though there was insufficient evidence to sug-
gest that these programs reduced or prevented body image concerns
or problematic eating (Holt & Ricciardelli, 2008). This may be due to
the limited number of studies (n = 13) and uncontrolled designs
included in the review. More recently, a meta-analytic review
(n = 24 studies) of universal prevention programs only in a broad
range of ages from 5 to 17 years found these programs to be effec-
tive in improving body esteem, self-esteem, and internalization of
appearance ideals in children and adolescents (Chua, Tam, &
Shorey, 2020). However, this previous review synthesized data for
both children and adolescents and included only interventions spe-
cifically delivered to children and adolescents, excluding other inter-
ventions such as those involving parents and teachers which may be
more appropriate for younger groups. Given that there are signifi-
cant developmental and cognitive differences between children and
adolescents, it is timely to evaluate interventions aimed at younger
children specifically. In addition, there is a need to better understand
the effects of a broad range of interventions and implementation
strategies in this age group due to the differing peer, familial and
media influences for children. Previous reviews have focused on
body image only and there is a paucity of systematic evaluation of a
broader range of outcomes including: body image-related outcomes,
disordered eating, and weight control behaviours within a single
review, which is important to understand the effect of interventions
on a range of contributing factors to the development of disordered
eating.
While the fields of obesity and eating disorders prevention
have typically been poorly integrated, there has been increasing
scientific interest in approaches targeting both physical and
mental health in both domains due to shared underlying risk
PURSEY ET AL.
factors of the conditions, among which include unhealthy weight
control behaviors and body dissatisfaction (Sanchez-Carracedo,
Neumark-Sztainer, & Lopez-Guimera, 2012). To date, as indi-
cated above, many universal–selective eating disorder preven-
tion programs have been designed as standalone programs to
address risk factors associated with disordered eating. However,
more recent approaches have incorporated content targeted at
eating disorder risk factors (e.g., body image, weight control
behaviors) embedded as part of broader, lifestyle interventions
including aspects relating to nutrition and physical activity
(Golden, Schneider, & Wood, 2016). While there is increasing
interest in the implementation of broader lifestyle approaches,
there is a paucity of reviews synthesizing the findings of these
studies.
In summary, it is important and timely to systematically
evaluate eating disorder prevention interventions in younger
children aged 6–12 years. This unique review will assist in better
understanding the optimal prevention approaches suited to this
age group. The aim of this review was to systematically appraise
and meta-analyze the effect of universal–selective prevention
interventions addressing disordered eating, body image concerns
and extreme weight control behaviors in primary school children
aged 6–12 years, as well as moderators such as participant gender
and intervention type.
2 | METHOD
2.1 | Search strategy
A systematic search strategy was conducted from the time of
database inception to April 2021. Nine databases were searched
including CINAHL, Cochrane Database, Embase, ERIC, Medline,
Proquest Nursing and Allied Health, PsychINFO, Scopus, and Web
of Science. The search strategy is available in Supplementary
Table 1. Studies were limited to humans and publications in the
English language. The review was registered on Prospero (https://
www.crd.york.ac.uk/prospero/display_record.php?RecordID=
69503) and conducted in accordance with the PRISMA Guidelines
(Supplementary Table 2).
2.2 | Eligibility
2.2.1 | Participants
Studies were eligible for inclusion if they included boys and/or girls
6–12 years of age, or presented data stratified by age enabling extrac-
tion of data from of children 6–12 years. Exclusion criteria were chil-
dren aged under 6 years, adolescents over 12 years old and adults.
Studies were included if the age range included a small proportion of
children aged 5 or 13 years, but the sample mean and majority of par-
ticipants were within 6–12 years.
PURSEY ET AL. 1733

2.2.2 | Intervention
Articlesidentified from search Duplicates removed

Identification
strategy
Studies were included if they delivered a universal–selective preven-
n = 18,365 N = 5,661
tion intervention addressing disordered eating, body image concerns
and/or extreme weight control behaviors. In line with previous
reviews (Chua et al., 2020; Holt & Ricciardelli, 2008; Yager
et al., 2013), targeted or indicated interventions for children displaying
symptoms of eating disorders were excluded.
Articlesscreened Irrelevant studies

Screening
n = 12,704 n = 12,529

2.2.3 | Outcomes

Studies reporting postintervention changes related to body image

(e.g., body esteem, body self-esteem, muscle esteem, body image,
body dissatisfaction, body satisfaction, shape or weight concern, body Full-text articles excluded
Full-text articles assessed for

Eligibility
n = 133
acceptance) or disordered eating behaviors or extreme weight control eligibility
behaviors (e.g., dieting-related behavior, behaviors and attitudes such n = 175 n = 52 Wrong population

as restrained eating and overeating) were eligible for inclusion. n = 47 Wrong study design
While a range of other risk factors, such as self-esteem and per- n = 16 Wrong outcomes
fectionism, have been linked to the development of disordered eating
n=16 Wrong intervention
behaviors, studies reporting these outcomes were only eligible if they
Studies included n = 2 Wrong language
included one of the outcomes relating to body image, disordered eat-
Included

n = 42 articles describing n = 39
ing or extreme weight control behaviors listed above. studies

Studies included in meta -analysis

(n= 16)
2.2.4 | Study design
FIGURE 1 PRISMA flowchart
Randomized controlled trials, nonrandomized or quasi-randomized
controlled trials, cohort studies and pre–post studies were included in
the review. Study designs such as cross-sectional studies, case if there was insufficient information in the manuscript, for example,
reports, and narrative reviews were excluded. specific age of the sample (n = 1).

2.2.5 | Comparator 2.4 | Risk of bias assessment

For studies with comparator groups, any comparator was included, for
example, implementation of another intervention, no intervention or
waitlist control.
2.3 | Procedure
Titles and abstracts were screened by two independent reviewers. Full
text articles were subsequently retrieved and screened by the two
reviewers for inclusion in the review. In any cases of uncertainty about
a study's inclusion in the review, a third independent reviewer was
consulted. A data extraction table was developed for the purpose of
this review and piloted with no modifications required. Data were
extracted by one reviewer and checked for accuracy by a second
reviewer. Data extraction included study design, sample characteris-
tics, intervention details, outcomes relating to body image, disordered
eating and/or extreme weight control behaviors, follow-up duration,
and study limitations. Study authors were contacted for further details
Quality of retrieved studies was assessed by two independent
reviewers using the American Dietetic Association Quality Criteria
Checklist for Primary Research, a standardized 10-item tool that can
be applied to a broad range of study designs (Academy of Nutrition
and Dietetics, 2012). This checklist includes 10 criteria which relate
to whether the (a) research question is stated clearly, (b) selection of
study participants is free from bias, (c) study groups are comparable,
(d) methods of handling withdrawals are described, (e) blinding was
used, (f) intervention and comparators are described in detail, (g) the
outcomes are clearly defined and valid and reliable measurements
were used, (h) statistical analyses were appropriate, (i) conclusions
are supported by results and consider biases and limitations, and
(j) study funding or conflicts of interest are likely to have introduced
bias. Each item was classified as present “Yes” (high risk of bias),
“No” (low risk of bias), absent or “Unclear” for each included study.
The overall study quality was then rated as positive (i.e., low risk of
bias) if criteria 2, 3, 6, 7, and one other were yes, neutral if criteria
2, 3, 6, and/or 7 are no, unclear, or negative (i.e., high risk of bias) if
TABLE 1 Study characteristics and summary of outcomes for included studies (n = 39)
1734

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Specific
Baranowski and Nonrandomized n = 30; n = 16 Age 11–12 years. 100% Setting: Primary schools Postintervention, Reduction in dietary
Hetherington (2001); controlled trial intervention, n = 13 girls Intervention name: NR 6 months restraint following
Scotland control Ethnicity, SES and family Duration five weekly activity-based intervention and control.
income/education NR lessons lasting 1.5 hr, during school No changes in body
hours. image measures or
Content topics covered included cause eating behaviors
and consequences of dieting,
appraisal of weight/shape, thinness
and obesity stereotypes, self-esteem,
body esteem, eating disorders, and
energy regulation. Food-related
programs were chosen to match time
and type of activities.
Delivery: Children worked on an
individual level and within group.
Homework was provided. Facilitators
UC
Control: Fruit and veg intake awareness
program
Berger, Sowa, Nonrandomized 173 Age: Mean = 11.9 Setting: Schools (n = 42) Postintervention, Significant improvement in
Bormann, Brix, and controlled trial Gender: 100% girls Name of intervention: PriMa primary 3 months body self-esteem and
Strauss (2008); Ethnicity, family income/ prevention of AN eating attitudes
Germany education, SES NR Duration: nine lessons postintervention, NS
Content: The concept of the program is difference
based on a Barbie-doll character and postintervention in
show the Barbie-doll in typical actions figure dissatisfaction.
related to ED and how her family are
involved. Sessions are focused around
(a) ideals of beauty, (b) rebellion, (c)
power, (d) loss of control, (e) distorted
body image, (f) suicidal thoughts, (g)
rigid rituals of eating, (h) weight
phobia, and (i) depression.
Delivery: Guided group discussions,
visual posters, activities, and role-
plays. Lessons were delivered by
trained teachers within the normal
class schedule or as a separate
workshop.
Control group: No intervention/waitlist
control (unclear)
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Bird, Halliwell, Nonrandomized 88 (baseline) Age: Range 10–11 Setting: Primary schools (n = 2) Postintervention, Improvement in body
PURSEY ET AL.

Diedrichs, and controlled trial 85 (postintervention) Gender: 48% girls Name of intervention: Happy being me 3 months. One school satisfaction and
Harcourt (2013); UK 52 (follow-up) BMI: Mean Duration: 3  1 hr sessions over withdrew emotional eating for
± SD = 17.91 ± 3.73. 3 weeks girls and cultural
Range 14.0–32.0 Content: Session 1: Media literacy in appearance
Baseline group relation to internalization of the internalization for boys
differences: NS cultural appearance ideal. Session 2: postintervention and
Ethnicity, SES, family What are appearance-related 3-month follow-up.
income/education NR conversations and fat talk, skills for Improvement in
situations involving fat talk and appearance-related
teasing. Session 3: What is body conversations for boys
comparison, how to identify and skills and girls, appearance-
to avoid body comparison + recap. related comparisons for
Delivery: Facilitated by researchers. girls, restrained eating
Group discussions, presentations for girls, but were not
supported by visual resources, role sustained at follow-up.
playing, question and answer, Longer-term
individual and group worksheets, effectiveness not clear
homework
control: Participated in their usual
personal, social, health, and economic
lessons
Cook-Cottone, Nonrandomized 170 (baseline) N = 43 control and Setting: Two suburban and one urban Postintervention Intervention group
Talebkhah, Guyker, controlled trial 132 (postintervention) n = 127 intervention. school in New York. decreased drive for
and Keddie (2017); Age: Mean 10.1 years Name of intervention: Girls growing in thinness and body
USA (intervention) and wellness and balance: Yoga and life dissatisfaction
10.8 years (control) skills to empower compared to control
Gender: 100% girls Duration: 14 weekly 90 min sessions postintervention. NS
Ethnicity: 77% White, Content: Yoga, relaxation, and difference between
18% other, 5% prevention curriculum. The groups for bulimia
unspecified. prevention curriculum covered (a) nervosa subscale.
SES proxy parent focus on being me (internal
education level: 56% awareness, breath work, mindfulness,
completed some feelings, self-talk), (b) focus on me in
graduate school, 42% my world (assertiveness, setting
completed some boundaries, strength, empowerment),
undergraduate school, and (c) me, in my world, in this culture
3% completed some (media literacy).
high school. Delivery: Delivered during health
BMI: Mean 18.64 classes or after school, led by trained
baseline group graduate students. Group leaders and
differences: NS participant manuals provided
Control group: Waitlist.

(Continues)
1735
TABLE 1 (Continued)
1736

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Cousineau (2010); USA RCT 190 (baseline) Age: Mean ± SD = 11.7 Name of intervention: Trouble on the Postintervention, NS intervention effects on
178 (follow-up) ± 0.06 tightrope: In search of Skateboard 3 months body esteem were found
Gender: 57% girls Sam (“Skateboard Sam”) postintervention.
Ethnicity: 81% White. Duration: Worked through interactive Moderator analysis
Other ethnicities NR website program over 3   1 hr found the program was
Pubertal status: 48% of sessions. Program modules 15 min more effective in girls.
boys and 13% of girls long The program produced
prepuberty Content: Puberty, physical activity, negative results in boys.
Baseline group nutrition, self-esteem, and peer
differences: NS relations. General education and
SES, family income and targeted messages based on
education NR individual characteristics, for example,
gender, gathered from a 14 item
profile quiz.
Delivery: Games, quizzes, and videos.
Instruction sheets to guide working
through the website.
Control: Interactive science-related
websites (e.g., animal life). Number
and duration of sessions matched the
intervention group.
Dalle Grave (2001); Nonrandomized N = 106 N = 61 girls, n = 45 boys Setting: Middle schools 1 week, 6 and EDEQ and EAT scores
Italy controlled trial N = 55 intervention, Mean age 11.6 (1.2) Name of intervention: NR 12 months. decreased for both
n = 51 control years Duration: 6 group sessions during 98% retention intervention and control
Mean BMI 18.3 (3.3) school hours, weekly over 6 weeks,
SES social classes—55% 2 hr
lower, 45% middle. Content: Based on a cognitive
Ethnicity and family behavioral conceptualization of eating
income/education NR disorders. Topics included
sociocultural pressures, cognitive
distortions, effects of dieting, eating
disorders
Delivery: Included educational
materials, practical activities, group
discussions, revision of homework.
Two booster sessions after 6 months.
Delivered by psychologists.
Control: Control group included but
treatment not described
Damiano, Yager, Pre–post trial 52 (baseline) Age: Mean 6.6 (0.6) Setting: Public primary schools in 1 week Significant improvement in
McLean, and 51 (follow-up) years, range 5–8 years Melbourne, Australia (n = 2). body esteem
Paxton (2018); Gender: 49% girls Name of intervention: Achieving body postintervention. NS
Australia BMI: Mean 16.7; 60% confidence for young children (ABC- changes in weight
normal weight, 8% 4YC). stigma, internalization of
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
underweight, 10% Duration: 3  1 hr teacher led lessons appearance ideals and
PURSEY ET AL.

overweight, 22% obese delivered over 1 week appearance-based

Country of birtha: 65% Content: Focused on three key themes: teasing.
Australia, 16% Asia- (a) admiring differences and
Pacific region, 13% celebrating diversity in bodies, (b)
India, 7% other boosting body confidence through
a
Available for 31 promoting appreciation of individual
participants bodies, and (c) celebrating our brilliant
Family income/education bodies (recognizing the functional
NR qualities of bodies beyond
SES: Schools from appearance).
average to high SES Delivery: Children's book—Your body is
areas brilliant: Body respect for children.
Lesson content delivered by teachers,
guided by a handbook, children's
book, posters, class worksheets,
videos, and teacher professional
development workshops.
Control group: None
Escoto Ponce de Leon, RCT 120 (baseline) Age: Mean ± SD = 9.93 Setting: Elementary schools (n = 3) 1 week, Interactive condition
Mancilla Diaz, and 120 (follow-up) ± 0.44, range 9–11 Name of intervention: Body image 6 months showed significant
Camacho Gender: 50.1% girls program improvement in eating
Ruiz (2008); Mexico Baseline group Duration: 8  90 min weekly sessions. disorder symptoms for
differences: NS Content: Both intervention conditions girls, body
Ethnicity, family income/ received the body image program dissatisfaction for boys
education and SES NR intervention. Intervention focused on and girls and overeating
changes during adolescence, for boys. NS difference
sociocultural pressures around for didactic or control
thinness, coping with negative groups
comments about weight and shape,
body shape dissatisfaction, self-
esteem, and healthy eating, and was
based on social cognitive theory.
Delivery: Interactive condition:
Intervention delivery incorporated in-
depth discussions, guided discovery,
role-play, guided meditation, and
free-write exercises. Didactic
condition: Intervention delivery
incorporated questionnaires, analysis,
discussion, and homework.
Control: No intervention

(Continues)
1737
TABLE 1 (Continued)
1738

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Ghaderi (2007); Nonrandomized N = 164 Fifth grade, 11 years old Setting: Two schools Postintervention. 4% NS improvements in
Sweden controlled trial Schools recruited from Name of intervention: Everybody's dropout weight and shape
high and low SES different satisfaction, eating
areas, 57 and 50% of Duration: Nine consecutive weekly attitudes or behaviors.
mothers and fathers in lessons (50–80 min)
High SES areas had Content: Topics included dealing with
more qualified work stress, self-image, factors that make
positions compared to people unique, examining
25 and 21% in lower stereotypes.
SES. Delivery: Delivered in school via
53% girls teacher. Teachers provided with
Ethnicity NR. materials and support by two
NS differences control graduate psychology students.
and intervention at Control: Control group used but
baseline except for treatment not detailed
housing
Haines, Neumark- Pre–post quasi- Intervention n = 70, Intervention group Setting: Elementary schools Postintervention NS change in body
Sztainer, Perry, experimental design control n = 72 Boys, n = 37, girls n = 42 Name of intervention: V.I.K. (very satisfaction, dieting
Hannan, and Age, mean (SD) 10.3 important kids) behavior or unhealthy
Levine (2006); USA Ethnicity White n = 15; Duration: 20 sessions weight control behaviors
African American Content: Designed based on social post program.
n = 31; Hispanic cognitive theory. Topics included
n = 10 body satisfaction, internalization of
Asian American n = 17; media messages, unhealthy weight
American Indian n = 1; behaviors and constructs associated
other n = 5. BMI with teasing behaviors.
percentile BMI <15th Delivery: Individual component of the
n = 2; BMI >15th intervention included after school
<85th n = 40; BMI sessions (n = 10) and theatre program
>85th <95th n = 17; and production sessions (n = 10).
BMI >95th n = 20 Environmental component—school-
Control group based intervention consisting of: (a)
Boys n = 34, girls n = 38 school staff training for half day, (b)
Age, mean (SD)—10.0 no teasing campaign developed by
(1.0) students, (c) book of the month on
Ethnicity White n = 18; youth experience with teasing, (d)
African American theatre production for all staff and
n = 34; Hispanic n = 4; students. Family based intervention
Asian American n = 6; components consisted of: (a) family
American Indian n = 2; nights n = 2 held at school; (b) parent
other n = 8. BMI postcards; (c) parent teacher night to
percentile BMI <15th respond to parent questions; and (d)
n = 1; BMI> 15th theatre production.
<85th n = 36; BMI Control: Assessment only control
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
>85th <95th n = 17;
PURSEY ET AL.

BMI >95th n = 18
Family income/
education, SES NR
Halliwell et al. (2016); RCT 144 (baseline) Age: Mean ± SD Setting: Primary school Postintervention, The intervention
UK 133 (follow-up) girls = 9.46 ± 0.50, Name of intervention: Body image in 3 months significantly improved
boys = 9.49 ± 0.53 the primary school body image concerns in
Gender: 51.4% girls Duration: 6  1 hr lessons over girls but not in boys. NS
Ethnicity: 92% White. 6 weeks. difference media
Other ethnicities NR Content: The curriculum focuses on 4 internalization,
BMI: Mean ± SD key themes related to appearance— awareness or perceived
girls = 17.87 ± 3.89, valuing diversity, celebrating one's pressure.
boys = 17.68 ± 4.14 own unique appearance, managing
Baseline group teasing, and developing resilience to
differences: NS media and peer pressure.
Family income/ Delivery: Classes incorporated
education, SES NR brainstorming exercises, class
discussion, pair and small group work,
role play, and viewing film clips.
Control: No intervention
Halliwell (2018); UK RCT 344 (baseline) Age: Mean 9.3 (0.7) Setting: Primary schools in south West 1 and 6 weeks Body image improved
NR (follow-up) years, range 9– England (n = 4). across both intervention
11 years Name of intervention: NR and control with NS
Gender: 54% girls Duration: 1  40 min session per week differences between
Baseline group for 4 weeks groups. The yoga
differences: NS Content: Based on the embodiment intervention was not
Ethnicity: Reports theory/model. more effective than
predominantly white Delivery: Participation in yoga in place usual PE classes.
but no information of usual PE class. Delivered by
provided. certified yoga instructor
Family income/ Control group: Usual PE class
education, SES NR
Hinz (2017); Germany, RCT 972 (baseline) Age: Mean 10.5 years, Setting: Elementary schools in Germany Postintervention Significant improvement in
France 906 (postintervention) fourth and fifth (n = 40) and France (n = 2) body dissatisfaction,
graders. 25 classes Name of intervention: My body and I body shape concerns,
intervention (n = 591), Duration: 6  45 min school lessons. and desired body shape.
17 classes control Intervention duration unclear.
(n = 381) Content: Pubertal development and
Gender: 50% girls media literacy
15 rural and 7 urban/ Delivery: Integrated into the regular
suburban schools. class schedule. Guided meditation and
Baseline group relaxation exercises were central
differences: NS elements of lessons. Text and video/
1739

(Continues)
TABLE 1 (Continued)
1740

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Ethnicity, family income/ image materials provided. Delivery/
education, SES NR implementation unclear.
Control group: NR
Huon, Roncolato, Pre–post trial n = 100 SES recruitment schools Setting: Primary schools Postintervention, NS change in eating
Ritchie, and covering upper-middle, Name of intervention: 6 months behaviors or body image
Braganza (1997), middle, and lower Duration: Six weekly 1 hr lessons. postintervention
Australia socioeconomic areas of Content: Personal development, health,
Sydney. physical education syllabus. Body
All students were in Year image and healthy eating
5. components. Initial 4 weeks covered
100% girls broad topics of individual self and
Mean age = 10.9 food, food messages, body images. F
(SD = 5 months) children prepared a magazine based
Ethnicity, family income/ off the first 4 weeks learning.
education NR Delivery: Students worked in
collaboration with teachers.
Interactive exercises individual and
group work. Educational posters
around classroom. Homework was set
for each lesson.
Control: Nil control
Irving (2000); USA Pre–post trial n = 45 First grade—18%; second Setting: Elementary schools 1 week Greater acceptance of
grade—19%; third Name of intervention: EDAP puppet body shape post
grade—35%; fourth program program
grade—27% Duration: Performance 15–20 min, 10–
47% of students were 20 min of question time.
girls. Content: Body acceptance, dieting,
45 fifth grade students emotional distress, body shapes.
completed the figure Delivery: Life-sized multicultural
rating scale. puppets. The program includes three
Additional demographic scripts—one for grades K-3; two for
data was not collected Grades 4–5, with an additional
or reported. presenters manual. School teachers
have additional educational material
and follow-up class activities to
reinforce messages from the scripts.
Questions answered by the puppets.
Control: Nil control
Kater, Rohwer, and Nonrandomized n = 415; intervention Upper elementary school Setting: Elementary schools, public and 1 week NS improvement in body
Londre (2002); USA controlled trial n = 357, control children 9–—13 years private image postintervention.
n = 58 of age Name of intervention: Healthy body Improvements in media
Public schools (n = 4), image: Teaching kids to eat and love literacy
private school (n = 1). their bodies, too! postintervention.
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Fourth graders (n = 182); Duration: 11 lesson curriculum.
PURSEY ET AL.

fifth graders (n = 79); Content: Nature of body size, shape and

sixth graders (n = 154) composition and four lessons
Ethnicity White—95%; emphasize positive factors of weight,
Asian American- 2.5%; body image and well-being. Topics:
Native American Appearance changes during puberty;
Intervention Grades 4, 5, genetic diversity; internal weight
and 6 regulation; biology of hunger
Girls (n = 183), boys deprivation; satisfaction of hunger
(n = 174). and wholesome food; limit sedentary
Control Grades 4 and 5 activity and increase physical activity;
Girls (n = 23), boys balanced attention to identity; choose
(n = 35) realistic role models, tools for coping
Family income/ with changes in appearance, cultural
education, SES NR perspective on changes in body image
attitudes, interpretation and critical
thinking around media.
Delivery: Delivered through curriculum
Control: Control received nil
intervention
Kater, Rohwer, and Pre–post trial n = 222 Fourth graders (n = 166) Setting: Elementary schools Postintervention Intervention had more
Levine (2000); USA Sixth graders (n = 56) Name of intervention: Healthy body positive attitudes
Boys and girls, proportion image: Teaching kids to eat and love toward body image and
NR their bodies too! controlling body weight
SES lower-middle to Duration: Ten separate lessons over postintervention.
upper-middle 6 weeks.
socioeconomic class Content: First four lessons emphasize
Ethnicity: Predominantly what cannot be controlled about
White, no other body shape, size and hunger. Four
information provided lessons cover what factors influence
weight and body image. Two
sociocultural lessons cover historical
body image attitudes and skills to
understand and resist media
messages.
Delivery: Curriculum comprised of
objectives, rationales, elaboration on
background concepts, and lesson
scripts. Lessons include stories,
humor, games, activities, and
discussions. Implemented by
classroom teacher, no training.
Control: Nil control

(Continues)
1741
TABLE 1 (Continued)
1742

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Lee et al. (2018); Korea Single-arm prospective Study 1:169 (baseline) Study 1: Age: Mean 12.3 Setting: One elementary school in Study 1: Significant improvement in
and Kwag (2020), cohort study 165 (0.3) years, sixth grade Korea Postintervention, body satisfaction and
Korea (postintervention) Gender: 51% girls Name of intervention: Me, you and us 1 month body esteem,
164 (follow-up) BMI: Mean 19.6 (3.1) Duration: 6  1 hr weekly sessions Study 2:3 years particularly in girls and
Study 2: n = 133 Study 2:51% girls Content: Three risk areas; societal risk, those at higher risk of
Age 15.4 (0.3) peer group risk and individual risk ED.
BMI: 20.8 (3.2) Delivery: Delivered by mental health At 3-year follow-up, there
Ethnicity, family income/ social workers. Included instruction were no decreases in
education, SES NR manual, workbooks, power point body esteem in boys
slides, images, and videos, which were compared to
translated from English to Korean postintervention;
Control group: None. however, some
decreases in body
esteem were observed
in girls at 3-year follow-
up compared to
postintervention.
McCabe, Connaughton, RCT 652 Gender intervention 49% Setting: School based Postintervention, Improvement in body
Tatangelo, Mellor, girls, control 53% girls Name of intervention: Healthy me 3 months esteem at follow-up and
and Busija (2017); Age intervention Duration: Four weekly sessions for 1 hr muscle esteem
Australia 8.8 + 0.69, control in groups of 12–30 children and a postintervention and
8.77 + 0.72 (NS). 3-month recap session. 3-month follow-up in
Baseline differences: Content: Healthy Me uses a strengths- intervention compared
Intervention group based approach and a social cognitive to control. NS
higher body esteem approach. Program targets differences body change
and fruit and veg sociocultural pressures that impact strategies
intake, control group beliefs, attitudes and behaviors- postintervention or
higher pressure from improving peer relationships, media follow-up.
peers, parents, the awareness including media literacy
media and negative and role models, parent education,
affect. healthy diet and exercise behaviors,
Ethnicity NR. Family and challenging masculine
income/education NR stereotypes for boys.
SES SEIFA range 946– Delivery: Discussion and activities
1,053. regarding the acceptance of diversity,
identification and critical appraisal of
influences of body esteem,
identification of nonappearance-
related personal strengths and
discussion of healthy eating and
exercise behaviors. Activities to
improve self-concept across school
and home environments. Children
given workbooks and homework
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
tasks to complete with parents.
PURSEY ET AL.

Parents were given a tip sheet to

assist their child to develop a positive
body image. Program run separately
for boys and girls and provided
gender specific content within same
themes. Intervention conducted by
psychologists.
Control: Waitlist
McCabe (2006); Pre–post trial n = 368 Intervention group Setting: Primary schools Postintervention NS difference in body
Australia Mean age boys = 10.25 Name of intervention: Active children dissatisfaction between
(SD = 1.13); and esteem study—ACE kids intervention and control
girls = 10.08 Duration: 8 weekly, 40 min sessions. over time.
(SD = 1.11). BMI: boys Content: Content on a range of
grade 3–4 = 17.54 different types of physical activity and
(SD = 2.90); girls grade sports, body image, body diversity
3–4 = 18.78 and focus on internal qualities, self-
(SD = 2.81); boys esteem and peer relationships
grade 5–6 = 19.51 components including coping with
(SD = 5.77); girls grade peer rejection and awareness of their
5–6 = 17.47 actions on others
(SD = 2.83) Delivery: Run in school time.
Control group Control: No intervention.
Mean age boys = 10.23
(SD = 1.02);
girls = 9.96
(SD = 1.04). BMI boys
grade 3–4 = 18.16
(SD = 3.38); girls grade
3–4 = 17.63
(SD = 1.77); boys
grade 5–6 = 18.51
(SD = 2.62); girls grade
5–6 = 18.67
(SD = 4.69)
Ethnicity, family income/
education, SES NR
McVey (2004); Canada Nonrandomized N = 258 (n = 182 100% girls Setting: Schools 1 week, 6 and 12 months Improvement in body
controlled trial intervention, n = 76 Mean age 11.8 years, Name of intervention: Everybody is a image satisfaction in
control) grade 6 somebody intervention compared
Ethnicity 44% White, Duration: 6  50 min weekly sessions. to control
20% south Asian, 13% Content: Topics included media postintervention, but
Asian, 9% African influences, enhancing self-esteem and not sustained at 6 and
body image, body size acceptance, 12-month follow-up.
1743

(Continues)
TABLE 1 (Continued)
1744

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Canadian, 3% Native healthy living, stress management, Improvement in dieting
Canadian positive relationships. scores postintervention
BMI: 17.98 (3.02) Delivery: Weekly classroom activities, in intervention
NS differences group discussions, slide, and video compared to control that
intervention and presentations were sustained at
control Control: Control group included but follow-up
Family income/education treatment not clear
NR. Reports schools
were matched on SES
but no information
reported
Neumark-Sztainer, RCT Girls girl scouts (n = 226) 226 girls (mean Setting: Girl Scout Troops Postintervention, NS change in dieting
Paxton, Hannan, IG (n = 115) and CG age = 10.6 years, Name of intervention: Free to be me 3 months behaviors or body
Haines, and (n = 111). SD = 0.7) from 24 girl Duration: Six 90 min sessions satisfaction
Story (2006); USA scout troops. Content: Focus on media literacy and postintervention.
29% of the girls were advocacy skills, to improve body
trying to lose weight. acceptance and resist destructive
Ethnicity participants images of women in the media.
were predominantly Delivery: Sessions were delivered
White (91.7%), other during consecutive bi-weekly troop
ethnicities NR meetings. Activities completed were
Majority of participants about body development, medias
were in fifth or sixth effects on body image and self-
grade (96%) esteem. Parental component involved
Family income/ weekly mail outs, involving take home
education, SES: NR activities, healthy snack recipes, and
previous session's messages. Troop
leaders delivered intervention
following 3 hr training session.
Control: CG received this after 3-month
follow-up.
Norman, Sodano, and Nonrandomized 156 (baseline) Age: 9–12 years old fifth Setting: Public and private middle Postintervention Significant improvement in
Cook-Cottone (2014); controlled trial 118 (postintervention) grade girls, M = 10.06 schools (n = 3) drive for thinness and
USA Ethnicity 76% White name of intervention: The girls growing body dissatisfaction for
European—American, in wellness and balance: A school- intervention compared
6% African American/ based mental health development to controls
black, 5% Asian, 1% program postintervention.
Hispanic, 12% of other Duration: 90-min weekly sessions, 12
or mixed race. sessions over 12 weeks
Baseline group Content: Breathing techniques,
differences: NR assertiveness, stress management,
Family income/education girls identity, self-care, and media
NR literacy
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
SES: representative of Delivery: Weekly sessions were held
PURSEY ET AL.

upper middle after school or during the child's

socioeconomic groups health and wellness class period.
Three-part interactive group sessions
beginning with active yoga practice
oriented around a theme for the
week. Guided discussion and
activities. Group leaders (trained
graduate students from the
university) led the session using a
manual. Each session ended with
guided relaxation and meditation.
Control: The control group received no
additional treatment beyond their
typical school day.
Norwood, Murray, Pre–post trial 77 Age: Grades 5 and 6. M Setting: Public school (n = 1) 1 week Significant improvement in
Nolan, and age = 10.86. Name of intervention: Beautiful from body image satisfaction
Bowker (2011); Gender: 53% girls the inside out and awareness of
Canada English speaking Duration: Five consecutive 80 min sociocultural attitudes
Ethnicity NR. English sessions conducted over 1 week for boys and girls
speaking Content: Session topics: (a) introduction postintervention.
Family income/ to self-esteem and support systems, Significant improvement
education, SES NR (b) media literacy, (c) real vs. artificial in physical appearance
beauty collages, (d) exploring esteem for boys
individuality of self and peers, and (e) postintervention.
communication skills.
Delivery: Students were involved in
activities, games, lessons, and group
discussions designed to promote
overall feelings of self-esteem and
positive body image.
Control: Nil control group due to time
constraints and teacher request to
provide intervention to all students
Ross (2013); Australia Nonrandomized N = 60 Gender: 100% girls Setting: Co-ed primary schools (n = 5), 1 week Significant improvement in
controlled trial Age: Grade 6 girls, mean private and public body satisfaction, ideal
age of 11.25 (range of Name of intervention: Y's girl perceived body size,
11–12) years. Duration: 6  60 min structured thin ideal internalization
Intervention: Age (SD) sessions over 3 weeks and body comparisons
11.24 (0.44), control: Content: Friendships and team building, in intervention
(SD) = 11.26 (0.43), sociocultural attitudes toward beauty, compared to control
country of birth Australia positive peer talk and relationships, postintervention. NS
(90%), 5% New communication skills, influence of change in disordered
media on concept of beauty, positive eating. Changes in body
1745

(Continues)
TABLE 1 (Continued)
1746

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Zealand, and 5% South attitudes and actions toward health satisfaction were
East Asia. and well-being, positive self-talk, moderated by initial
BMI: Intervention mean resilience. levels of risk-factors.
BMI (SD) = 19.02 Delivery: Group interactive activities
(2.68), control: BMI such as role-plays and movement, led
(SD) =18.60 (3.57) by a trained honors level researcher.
Baseline group Control: Control received nil
differences: NS intervention
Family income/education
NR
SES: Schools located in
similar middle income
areas
Russell-Mayhew, Nonrandomized n = 493 elementary Age: Elementary school Setting: Elementary and junior high 1 month NS difference in
Arthur, and controlled trial students, (1,095 8–11 years. schools (n = 11) disordered eating
Ewashen (2007); students overall), 114 Gender: 58% girls Name of intervention: Student between intervention
Canada parents and 92 baseline group intervention It's What's inside that approaches for
teachers. differences: NR counts: Promoting healthy body elementary students.
Ethnicity NR image and self-esteem; parent
Family income/education intervention building blocks to a
NR positive body image: A session for
SES: Ranged from parents in the prevention of eating
schools in affluent to disorders; teacher intervention
low socioeconomic building a body-positive environment
areas in schools: A session for educators in
the awareness and prevention of
eating disorders.
Duration: One off puppetry play or
workshop
Content: Overall message was around
accepting diversity in body image and
rejecting pressures to achieve a
“perfect” body
Delivery: Three components to
intervention—Student, parent and
teacher intervention.
Elementary student intervention—30 min
puppetry play performed by
professional actors. Students also
provided with a study guide.
Parent intervention—1.5 hr interactive
workshop facilitated by a psychologist
and a health educator. Provided
PURSEY ET AL.
TABLE 1 (Continued)
Author, year Study design
Scime and Cook- Combined results from
Cottone (2008); USA four separate pre–post
design studies and one
non-RCT
Stewart, Goddard, Quasi experimental case
Cakir, Hall, and controlled comparison
Allen (2020); UK trial; non inferiority
trial
n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
supplemental handouts and referral
PURSEY ET AL.
information.
Teacher intervention—1 hr interactive
workshop facilitated by a psychologist
and a health educator. Supplemental
handouts and referral information.
Teachers were also provided
classroom activities and encouraged
to implement.
Control: Waitlist
144 (baseline) Age: Fifth grade, age NR. Setting: Middle school (n = 1) Postintervention Significant improvement in
135 (post) Gender: 100% girls Name of intervention: Girls' Group body dissatisfaction and
BMI: Mean ± SD Duration: Five separate 10-session bulimia nervosa
intervention group over 10 consecutive weeks, subscale for intervention
group = 18.12 ± 4.32, weekly basis after school for 90 min compared to control
control group = 18.49 Content: Each session consisted of a postintervention. NS
± 3.61 mind and body component, as well as differences drive for
Ethnicity: 73% White, 7% an integration piece. Topics included thinness.
African American, 8% competence, coping and attribution
Asian American style, self-esteem, nutrition, body
SES: 92% parental dissatisfaction, and sociocultural
education >1–3 years pressures from media
Baseline group Delivery: Mind component: Group
differences: Ethnicity discussions around risk and protective
p < .05, social self- factors for disordered eating
concept scale higher in behavior. Body component:
control p < .05, future Participating in yoga. Integration
intentions scale higher component: Relaxation exercises
in intervention p < .05 combined with visualization. At the
completion of the intervention,
groups prepared a project (magazine
or DVD) to summarize the
information learned.
Control: No intervention or waitlist
N = 172 intervention, Age 11.7 (0.33) Setting: Secondary school, single sex Postintervention; Body satisfaction
n = 197 control; 174 90% girls and co educational 3 months. 90% follow- improved
teacher led trial SES and ethnicity: Name of intervention: Happy being me up control and postintervention and at
Recruited schools Duration: 6 sessions, 50 min intervention follow-up in intervention
serve a diverse SES Content: Manualized program that uses compared to control in
and ethnic background. a peer based interactive approach and the facilitator led
45% local population comprises dissonance inducing intervention. NS change
black, Asian and activities, empowerment and active in eating disorder
minority ethnic challenging of culturally reinforced symptoms in
norms. Targets body dissatisfaction, intervention compared
1747
(Continues)
TABLE 1 (Continued)
1748

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
ethnicities. No other internalization of the thin ideal, body to control. NS changes
information reported comparisons and self-esteem in body satisfaction or
Delivery: Class activities and discussion, disordered eating
didactic presentations, pair work, behaviors in the teacher
work sheets, individual work and led intervention.
homework, film clop presentation. Significant improvement
Delivered during PHDPE school in thin ideal
lesson. Clinicians specialized in eating internalization in teacher
disorder treatment delivered led group
intervention.
Study 2 teachers were responsible for
delivering intervention. Observed a
trained facilitator delivering the
program, discussed the manual and
were offered supervision and
consultation.
Control: Usual PE class
Wick et al. (2011) and Pre–post controlled trial Study 1:887 (baseline) Study 1: Age: Setting: Schools (n = 92) Study 1: Significant improvement in
Adametz (2017); with (post hoc) parallel 706 (follow-up) Mean = 12 years, Name of intervention: PriMa Postintervention, body self-esteem
Germany group assignment. Study 2: n = 100 (7% range 10–13, sixth Duration: 9  45 min lessons. 3 months postintervention in
response rate) grade Content: The concept of the program is Study 2: intervention compared
Gender: 100% girls based on a Barbie-doll character who 7–8 years to control, not sustained
BMI: Intervention group is developing anorexia nervosa.. at 3 months. NS
mean ± SD = 19.1 Beauty ideals and expectations, differences eating
± 3.4, control group attention gaining behaviors (e.g., behaviors or anorexia
mean ± SD = 18.7 rebellion against authority, nervosa subscale
± 3.3 perfectionism, superiority), self- postintervention or
Baseline group esteem, body image and awareness, 3-month follow-up.
differences: NS healthy eating/over evaluating diet, Disordered eating
Study 2: Mean age at coping strategies (e.g., family remained stable at 7- to
follow-up 19.8 years problems, dealing with emotions), 8-year follow-up.
Ethnicity, family income/ recognizing disordered eating Increases in body
education, SES NR behaviors, the course of AN, getting esteem in the
help. intervention group were
Delivery: Lessons delivered by usual sustained at 7- to 8-year
classroom teachers following a follow-up.
training session. Teachers are
encouraged to incorporate interactive
components within sessions, for
example, role playing.
Control: Control group but intervention
not specified
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Yeh, Liou, and Quasi-experimental, 366 (baseline) Fifth and sixth grades Setting: Elementary schools in Taipan Postintervention, Significant improvement in
PURSEY ET AL.

Chien (2012); nonrandomized 314 (follow-up) Experimental group (n = 2) 3 months body satisfaction
Taiwan controlled trial Mean age—10.72, girls— Name of intervention: NR postintervention and
53.6%, SES: High Duration: 8  40 min weekly sessions 3-month follow-up. NS
40.0%, medium 29.4%, over 8 weeks differences perception
low 30.6% Content: Program sessions covered of body size, dieting or
BMI—18.57 body image, self-esteem, media vomiting behaviors.
control group literacy, stress management, friendly
mean age—10.62, girls environment, and interpersonal
55.4%; SES: High communication
45.6%, medium 31.9%, Delivery: Methods of delivery included
low 22.5% lecture, role play, games, video,
BMI: 18.86 discussion, drawing, practical
Baseline group activities and homework activities.
differences: NS Intervention was delivered by the
Family income/ lead researcher.
education, Ethnicity Control group: Attended usual school
NR classes
Lifestyle
DeBate, Pettee Gabriel, Pre–post trial Total study sample Age: Range 8–15 Setting: Various community Postintervention Significant improvement in
Zwald, Huberty, and 2,233 (baseline) (outcomes for organization facilities body image in those
Zhang (2009); USA 1,034 (postintervention) <10 years reported Name of intervention: Girls on the run <10 years
N = 467 8–10 year olds separately) (third-fifth grade), girls on track postintervention.
with pre and post data Gender: 100% girls (sixth—Eighth grade)
Ethnicity: 61.0% White, Duration: 2  1.5 hr sessions per week
7.5% African American, for 12 weeks
7.0% Hispanic, 5.6% Content: Weeks 1–4: Assess current
other behaviors and learn how to change
Participation in GOTR behavior, importance of nutrition and
intervention: 60.0% PA in health, emotional health and
first time, 25.6% dealing with emotions, learn about
second time, 10.5% inner and outer beauty. Weeks 5–8:
third time or greater Cooperation, negative consequences
Family income/ of bullying and negative talk about
education, SES NR others, and developing a positive
attitude toward others. Weeks 9–12:
Responsibility within the community,
analyzing cultural and social messages
from the media, stereotyping and
discriminatory behavior, and create
and implement a community service
project + the 5 km running event is
held in Week 12.

(Continues)
1749
TABLE 1 (Continued)
1750

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Delivery: The program involves training
for a 5 km running event combined
with experiential learning around
promoting positive emotional, social,
mental and physical development.
Control: Nil
DeBate and Pre–post trial N = 322 Girls Setting: 28 program sites Postintervention, 85% Improvement in dieting
Thompson (2005); 8–12 years of age, mean Name of intervention: Girls on the Run retention rate behaviors,
USA age 10 years Duration: 12 week program, 2  1 hr preoccupation with
Ethnicity 81% White, 4% sessions weekly. weight and body size
African American, 3% Content: Learning activities include self- dissatisfaction
Asian, 12% Latino esteem, body image, positive postintervention.
Family income/ attitudes/ behaviors with eating and a
education, SES NR sense of community
Delivery: Experiential learning program
combining running and curriculum
based activities to encourage
emotional, social, mental and physical
health. Taught by certified coaches of
the program.
Control: Nil
Dowdy et al. (2013); Pre–post trial 58 (baseline and follow- Age: Mean ± SD = 11.62 Setting: Primary school (private, 1 week, Significant improvement in
USA up) ± 0.56, range = 10–13, religious) 1 month body image at follow-
sixth grade Name of intervention: Empower U up.
Gender: 43.1% girls Duration: 1  45 min session per week
Ethnicity predominantly for 4 weeks
White, no other Content: Exercise, nutrition, self-esteem
information reported and body image, smoking
Family income/education Delivery: Exercise session—physical
NR activity education (types of exercise,
SES: Upper middle SES, nutrition during exercise, health
no other information benefits) and exercise. Nutrition
provided session—education (food pyramid,
food labels, counting calories, daily
requirements, food groups and
healthy choices), group question and
answer, visual resources, and
interactive games. Self-esteem and
body image session—presentation on
societal views of attractiveness and
how this has changed over time,
group discussion regarding views of
attractiveness and media influence on
ideals of beauty, facilitators
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
reinforced acceptance of different
PURSEY ET AL.

styles and standards of beauty.

Smoking session control: Nil control
group
Eldridge et al. (2016); Cluster RCT 150 parents (baseline) Age: Mean ± SD = 10.6 Setting: Unclear Postintervention, Small decrease in weight
USA (semirandom) 136 (postintervention) ± 1.35, Gender: 70.5% Name of intervention: 4- health 6 months dissatisfaction across
105 (follow-up) # kids girls, Ethnicity: 98.1% educational program both groups, and a small
White, 1% American Duration: 10  90 min face-to-face but significant
Indian or Alaskan sessions over 8 months improvement in body
Native. BMI: 18.9% Content: Nutrition: Nutrition esteem at the 6-month
overweight, 16.9% recommendations, practicing healthy follow-up for both
obese eating and eating as a family, avoiding genders.
Family income $<35,000 unhealthy weight control practices.—
10.5%, $35,000– Physical activity: Recommendations,
75,000 65.4%, > creating an environment to promote
$75,000 24% an active lifestyle and exercising as a
family.—body image: Size and body
acceptance, understanding media and
environmental influences on body
image, teaching and modeling healthy
self-esteem, respect, and confidence.
Delivery: Parents received the
intervention. This topic was
supported by take home information,
group discussions, presentations, and
scenario-based activities (e.g.,
practicing conversations with
children) as well as goal-setting—
Parenting and family communication
control/minimal intervention group:
Printed intervention materials on
nutrition (topics as above but without
instruction of how to implement
changes) and body image (tips for
talking to your child about body
image).
Pettee Gabriel, Quasi-experimental 877 Age—≤9 years 44.3%, Setting: Public elementary schools Postintervention, Improvement in body size
DiGioacchino longitudinal study 10 years 33.3%, (n = 15) 5 months discrepancies in girls
DeBate, High, and >11 years 22.4% Name of intervention: Girls on the run newly exposed to the
Racine (2011); USA Race/ethnicity White Duration: 1.5 hr sessions over 12 weeks program.
45.3% black/ Africa- Content: Weeks 1–4: Focus is on
American 20.8%, enhancing self-awareness and self-
12.6% Hispanic, 7% care. Weeks 5–8: Participants learn
Asian/Native American about cooperation, team building,
1751

(Continues)
TABLE 1 (Continued)
1752

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Categorized as never social support, and developing a sense
(67.3%), newly (14.9%) of community. Weeks 9–12:
and previously (17.8%) Participants learn about responsibility
exposed to the girls on within the community, awareness of
the run program negative messages from media and
Family income/ peers + the 5 km running event is
education, SES NR held in Week 12.
Delivery: Training for a 5 km running
event combined with a curricula on
positive youth development.
Intervention delivered by trained
coaches.
Control: Nil
Santos et al. (2014); Cluster RCT 647 students (baseline) Age: Range 6–12 years, Setting: Elementary schools (n = 19), 38 Postintervention NS differences in dieting
Canada 584 (follow-up) intervention group classrooms behaviors or thoughts
mean = 9.3, control Name of intervention: Healthy buddies postintervention.
group mean = 8.8 Duration: 21 lessons delivered across
Gender: 48% girls the 10-month school year
BMI: 36% overweight or Content: Physical activity, healthy
obese eating and a healthy body image, with
Baseline group the overall messages of go move, go
differences: NR. 49% fuel, and go feel good.
attended rural schools. Delivery: Teachers attended a training
Ethnicity, family income/ seminar to learn the program. Older
education, SES NR students (9–12 years) attended a
45 min lesson each week delivered by
their teachers. Older school students
then delivered a 30 min lesson each
week of the same content to their
younger (6- to 8-year-old) student
buddies. These sessions included
identifying healthy and unhealthy
foods, valuing themselves and others
based on individuality and facilitating
social skills, self-esteem and social
responsibility, and 2  30 min
sessions of aerobic fitness each week
completed in their buddy pairs.
Control: Waitlist
Scime, Cook-Cottone, Pre–post trial N = 45 Fifth grade Setting: After school group Postintervention. 7 drop Significant improvement in
Kane, and Age: 4% 9 years, 67% Name of intervention: Girls group outs body dissatisfaction and
Watson (2006); USA 10 year olds, 29% Duration: 10 weekly sessions, 90 min drive for thinness.
11 year olds each
100% girls
PURSEY ET AL.
TABLE 1 (Continued)

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
BMI range 12.51–34.17 Content: Topic covered included
PURSEY ET AL.

78% White, 7% African competence, coping and attribution

American, 7% Asian style, physical self-esteem and
American, 4% Native nutrition, body dissatisfaction and
American, 2% Hispanic. sociocultural values from the media.
Family education (SES Delivery: Built from a positive
proxy): High school psychology framework and focuses
father 4%, 16% on wellness and mind body
mother, 1–3 years integration including a yoga
college fathers 20%, component. Sessions included yoga,
mothers 13%, college songs or poems, journal writing,
graduates fathers 40%, interactive activities, and guided
mothers 31%, graduate relaxation. Facilitated by psychologist,
school fathers 33%, counselor, and two graduate students.
mothers 36%. Control: Nil
Sifers and Shea (2013); Pre–post trial 111 (pre and post) Age: Grades 3–8, mean Setting: After school program at Postintervention Sig improvement in
USA ± SD = 9.69 ± 1.44, multiple sites in the community physical appearance
range 8–13 Name of intervention: Girls on the self-perception
Gender: 100% girls run/girls on track postintervention. NS
Ethnicity, family income/ Duration: 2  weekly sessions over difference body image.
education, SES NR 12 weeks
Content: Training for a 5 km running
event combined with a curricula on
teaching life skills and a community
service project. Developing self-
understanding, goals and values,
sharing with peers, positive attitudes,
gratitude, and avoiding over
commitment; team building, positive
friendship, and peer interactions; the
world around you, contributing to the
community, dealing with negative
media.
Delivery: Sessions involved discussion
of the relevant topics, exercise
involving running and sharing a
healthy snack. Intervention delivered
by girls on the run trained coaches,
plus participation in the 5 km run and
conducting the community service
project.
Control: Nil comparison/control that did
not participate in the evaluation

(Continues)
1753
TABLE 1 (Continued)
1754

Author, year Study design n Sample characteristics Intervention details Follow-up duration Summary of outcomesa
Smolak, Levine, and Pre–post trial n = 222 253 children completed Setting: Elementary school 1–4 months after NS change in body esteem
Schermer (1998) and pretest (boys n = 115, Name of intervention: Eating smart, program, or dieting
Smolak and girls n = 138. eating for me 2 years postintervention. At
Levine (2001); USA 222 children completed Duration: Ten lessons 2-year follow-up, higher
posttest (boys n = 102, Content: (a) Growth, change and body esteem in girls in
girls n = 120). nutrition, (b) nutrition for growth: My the intervention group.
Family income/ body… My choice, (c) myths about fat,
education, SES NR (d) body shape: tolerance of
Predominantly White, no differences, (e) positive body image,
other information (f) eating and exercising for you and
about ethnicity your Health (two parts), (g) dieting, (h)
provided media literacy, (i) what is for lunch,
and (j) eating and exercising for you
and your health.
Delivery: Delivered by classroom
teachers. Teachers were provided
with instructions on how to deliver
the program. Material and homework
was tailored to young children (fourth
and fifth graders). Homework
included parental involvement (one
per lesson). All material required for
assignments was provided to
students. Parents received
newsletters (n = 9), which related to
the lessons.
Control: Three classrooms were
controls.

Abbreviations: NR, not reported; NS, nonsignificant; RCT, randomized controlled trial.
a
Outcomes highlighted in the outcome summary column were significantly different at postintervention and/or follow-up.
PURSEY ET AL.
PURSEY ET AL.
six or more criteria were no. In any cases of uncertainty regarding
the quality assessment, a third reviewer was consulted.
2.5 | Descriptive synthesis
Study characteristics were synthesized descriptively. Studies were
grouped according to the intervention type for synthesis, specifically,
(a) universal–selective eating disorder prevention designed specifically to
target body image concerns, disordered eating and/or extreme weight
control behaviors, and (b) broader lifestyle interventions that focused on
physical activity, healthy eating incorporating content relating to body
image, disordered eating, or extreme weight control behaviors.
2.6 | Meta-analysis methods
Studies that reported preintervention and postintervention changes in
body image-related outcomes, as listed in the Section 2.2.3 above,
were combined into a meta-analysis (n = 16). Hedges' G was calcu-
lated from the difference between the control and intervention
groups preintervention and postintervention and used as the effect
size. The Hedges' G along with the SE was used in a random effects
model to determine the pooled effect size from the studies. To
account for the heterogeneity between treatment effects, a random
effects model and the DerSimonian–Laird estimate was used
(DerSimonian & Laird, 1986). Subgroup analyses were conducted by
study type (specific universal–selective eating disorder prevention
programs or lifestyle interventions) and gender (girls, boys and those
including both boys and girls specific). There were insufficient studies
to conduct subgroup analyses according to age. Publication bias was
investigated using funnel plots. Analysis was performed in R 4.0.2.
Due to the small number of studies reporting disordered eating and
weight control behavior outcomes, and significant heterogeneity
within these outcomes, a meta-analysis could not be performed.
3 | RESULTS
3.1 | Description of included studies
The search strategy retrieved 12,704 studies. Of these, 42 articles
describing 39 studies were deemed eligible for inclusion in the review
(Figure 1). Reasons for exclusion in descending order included wrong
population (n = 52), wrong study design (n = 47), no relevant outcomes
(n = 16), wrong intervention (n = 16), and published in a language other
than English (n = 2). The majority of studies were conducted in the
United States (n = 17), followed by Australia (n = 5), Canada (n = 4),
the United Kingdom (n = 4), and Germany (n = 2) (Table 1). A range of
study designs were used including randomized controlled trial (n = 13),
nonrandomized controlled trial (n = 7), pre–post study (n = 14), semi-
randomized controlled trial (n = 3), cohort (n = 1), quasi-experimental
case-controlled trial, and one study combining data from four pre–post
1755
studies and one nonrandomized controlled trial. Comparators included
no intervention, usual school lessons and waitlist; however, the com-
parators were not well described across studies.
3.2 | Participants across included studies
A total of 12,673 participants were included across studies, ranging
from 30 to 972 participants per study (Table 1). The majority of studies
investigated older primary school aged children, with 22 studies sam-
pling participants of a mean age >10 years, while 6 studies investigated
children with mean age <10 years, and in 11 studies mean age was not
reported. Twenty-four studies included both boys and girls, fifteen
studies recruited girls only and no studies exclusively studied boys. Par-
ticipants were predominantly White (range 44–99%); however, race
and ethnicity were not consistently reported across studies. Few stud-
ies reported socioeconomic status or a proxy for socioeconomic status
(e.g., parental income or education) (n = 14). In addition, the measures
used to ascertain socioeconomic status were not clear. For example, in
11 studies, it was reported that participants were recruited from high,
middle, and lower socioeconomic areas; however, the method of deter-
mining socioeconomic status was not reported. The duration of inter-
vention follow-up ranged from immediately post program to 8 years
post program with the most common duration being 3 months. Seven-
teen studies reported the BMI of participants (range 12.51–34.17 kg/
m2; n = 14 reporting BMI in the specific prevention program interven-
tions and n = 3 in the lifestyle interventions). Outcome measures and
tools used across studies were variable. Outcome measures were pre-
dominantly self-reported by the children; however, the validity of the
tools for younger children specifically was not reported in many studies.
3.3 | Risk of bias assessment
Study quality is reported in Table 2. Most articles (n = 24) were classi-
fied as neutral quality, followed by positive quality (n = 18). No stud-
ies were deemed as negative quality. The quality criteria that were
commonly deemed at risk of bias or unclear included participant selec-
tion (n = 20), whether the study samples were comparable (n = 12),
methods of handling withdrawals (n = 22), use of blinding (n = 38),
and funding sources (n = 14).
3.4 | Description of intervention programs
Thirty studies reported on specific universal–selective prevention pro-
grams to address disordered eating, body image concerns, and/or
weight control behaviors (Table 1). Nine studies reported on lifestyle
programs incorporating nutrition and/or physical activity, with embed-
ded content to address disordered eating, body image concerns
and/or extreme weight control behaviors.
Participants were recruited and programs conducted in schools in
33 studies, while four programs were conducted in community settings
TABLE 2 Risk of bias assessment (n = 42 articles)
1756

Q6. Were
intervention/
therapeutic
regimens/
exposure
factor or
procedure Q9. Are
and any Q8. Was the conclusions
Q2. Was the comparison(s) statistical analysis supported by
selection of Q4. Was Q5. Was described in Q7. Were appropriate for results with
Q1. Was the study method of blinding used detail? Were outcomes clearly the study design biases and Q10. Is bias due
research participants/ Q3. Were handling to prevent intervening defined and the and type of limitations taken to study's funding
question patients free study groups withdrawals introduction factors measurements outcome into or sponsorship
clearly stated? from bias? comparable? described? of bias? described? valid and reliable? indicators? consideration? unlikely? Quality
Adametz (2017) Y Y Y Y N Y Y Y Y Y +
Baranowski and Y UC UC N N Y Y Y N Y 0
Hetherington (2001)
Berger et al. (2008) Y UC N/A N N Y Y Y Y Y 0
Bird et al. (2013) Y UC Y Y N Y Y Y Y Y 0
Cook-Cottone Y UC N Y N Y Y Y Y UC 0
et al. (2017)
Cousineau (2010) Y Y Y N N Y Y Y Y Y +
Dalle Grave (2001) Y Y Y N N Y Y Y Y Y +
Damiano et al. (2018) Y Y N/A Y N Y Y Y Y Y +
DeBate and Y Y N/A N N Y Y Y Y UC +
Thompson (2005)
DeBate et al. (2009) Y UC N/A Y N Y Y UC Y Y 0
Dowdy et al. (2013) Y Y N/A Y N Y Y Y Y Y +
Eldridge et al. (2016) Y UC UC N Y Y Y Y Y Y 0
Escoto Ponce de Leon Y Y Y Y N Y Y Y Y Y +
et al. (2008)
Ghaderi (2007) Y UC Y N N Y Y Y Y Y 0
Haines et al. (2006) Y UC Y Y N Y Y Y Y Y 0
Halliwell et al. (2016) Y Y UC Y N Y Y Y Y Y 0
Halliwell (2018) Y Y Y N N Y Y Y Y UC +
Hinz (2017) Y Y Y Y N Y Y Y Y Y +
Huon et al. (1997) Y UC N/A N N Y Y Y Y Y 0
Irving (2000) Y UC N/A N N Y UC Y Y UC 0
Kater et al. (2002) Y Y N N N Y Y Y Y UC 0
Kater et al. (2000) Y UC N/A N N Y UC UC Y UC 0
Kwag (2020) Y Y N/A Y N Y Y Y Y Y +
Lee et al. (2018) Y Y N/A Y N Y Y Y Y Y +
PURSEY ET AL.
TABLE 2 (Continued)

Q6. Were
intervention/
PURSEY ET AL.

therapeutic
regimens/
exposure
factor or
procedure Q9. Are
and any Q8. Was the conclusions
Q2. Was the comparison(s) statistical analysis supported by
selection of Q4. Was Q5. Was described in Q7. Were appropriate for results with
Q1. Was the study method of blinding used detail? Were outcomes clearly the study design biases and Q10. Is bias due
research participants/ Q3. Were handling to prevent intervening defined and the and type of limitations taken to study's funding
question patients free study groups withdrawals introduction factors measurements outcome into or sponsorship
clearly stated? from bias? comparable? described? of bias? described? valid and reliable? indicators? consideration? unlikely? Quality
McCabe (2006) Y Y Y N N Y Y Y Y Y +
McCabe et al. (2017) Y UC N N N Y Y Y Y UC 0
McVey (2004) Y Y Y N N Y Y Y Y Y +
Neumark-Sztainer Y Y Y N N Y Y Y Y UC +
(2000)
Norman et al. (2014) Y Y N Y N Y Y Y Y UC 0
Norwood et al. (2011) Y N N/A N N Y Y Y Y Y 0
Pettee Gabriel Y UC N Y N Y Y Y Y Y 0
et al. (2011)
Ross (2013) Y UC Y Y N Y Y Y Y UC 0
Russell-Mayhew Y Y UC N N Y Y Y Y Y 0
et al. (2007)
Santos et al. (2014) Y Y Y Y Y Y Y Y Y Y +
Scime et al. (2006) Y Y N/A Y N Y Y UC Y UC +
Scime and Cook- Y UC N Y N Y Y Y Y UC 0
Cottone (2008)
Sifers and Shea (2013) Y UC N/A N N N Y Y Y UC 0
Smolak et al. (1998) Y UC UC N N Y Y Y Y Y 0
Smolak and Y UC UC N N Y Y Y Y UC 0
Levine (2001)
Stewart et al. (2020) Y Y Y Y Y Y Y Y Y Y +
Wick et al. (2011) Y Y Y N N Y Y Y Y Y +
Yeh et al. (2012) Y N Y Y N N Y Y Y Y 0

Note: N = No, N/N = not applicable, UC = Unclear, Y = Yes. + = positive quality, = negative quality, 0 = neutral quality.
1757
1758
(Table 1). In two studies, the setting was unclear. Program duration
ranged from 1 week to 10 months, with 12-week programs most com-
mon (n = 5). Most studies delivered face-to-face interventions, excluding
one online study where participants worked through an interactive
website program. The majority of interventions were delivered by trained
facilitators (e.g., graduate students; n = 14), with teachers delivering inter-
ventions in seven studies, parents and families in two studies, scout troop
leaders in one study, a yoga teacher in one study, and intervention deliv-
ery by student peers in one study. In one study comparing the efficacy of
a trained facilitator compared to teacher implementation, implementation
by a trained facilitator was found to be more efficacious in improving
body satisfaction. The one online intervention was self-facilitated, and
the person delivering the intervention was unclear in 12 studies.
Interventions covered a range of topics related to disordered eating
risk factors including body image (27 studies), cultural ideals (16 studies)
individual characteristics (6 studies), media literacy (24 studies), and eat-
ing behaviors (13 studies). Programs also commonly covered physical
activity (8 studies), healthy eating (8 studies), and mental health such as
stress management, breathing techniques, relaxation, self-care, and posi-
tive attitudes (2 studies). Strategies commonly incorporated in programs
included group discussions (15 studies), role playing (4 studies), goal set-
ting and planning (2 studies), workbooks and worksheets (4 studies),
homework (8 studies), and video clips (6 studies).
3.5 | Specific eating disorder universal–selective
prevention programs
3.5.1 | Body image-related outcomes
There was a statistically significant improvement in self-reported body
image in 14 out of 16 studies (Baranowski & Hetherington, 2001; Bird
FIGURE 2 Treatment effects and standardized mean differences of body image-related outcomes for all studies (n = 16)
PURSEY ET AL.
et al., 2013; Cook-Cottone et al., 2017; Escoto Ponce de Leon
et al., 2008; Halliwell et al., 2016; Hinz, 2017; Kater et al., 2000;
Kater et al., 2002; Lee et al., 2018; McVey, Davis, Tweed, &
Shaw, 2004; Norman et al., 2014; Norwood et al., 2011; Scime &
Cook-Cottone, 2008; Stewart et al., 2020; Yeh et al., 2012), and body
esteem in eight out of nine studies (Baranowski & Hetherington, 2001;
Berger et al., 2008; Damiano et al., 2018; DeBate & Thompson, 2005;
Lee et al., 2018; McVey, Davis, et al., 2004; McVey, Tweed, &
Blackmore, 2004; Norwood et al., 2011; Wick et al., 2011) in the inter-
vention group (Table 1). One study each included outcomes of muscle
esteem (McCabe et al., 2017) and eating attitudes (Berger et al., 2008),
with significant improvements reported for both. Regarding weight-
and shape-related outcomes, one study reported significant improve-
ment in body shape concerns and desired body shape (Hinz, 2017),
while in two studies no differences were found for perception of body
size (Yeh et al., 2012) and weight stigma (Damiano et al., 2018).
3.5.2 | Extreme weight control and eating behavior
outcomes
There was a significant improvement in eating behavior outcomes
(including restrained eating, emotional eating, and/or overeating) in
three studies (Baranowski & Hetherington, 2001; Bird et al., 2013;
Escoto Ponce de Leon et al., 2008); however, seven studies found no
difference postintervention in these outcomes (Ghaderi, Mårtensson, &
Schwan, 2005; Haines et al., 2006; Huon et al., 1997; Russell-Mayhew
et al., 2007; Stewart et al., 2020; Wick et al., 2011; Yeh et al., 2012).
With respect to eating disorder symptoms, significant improvements
were reported in two studies for the bulimia scale (Cook-Cottone
et al., 2017; Scime & Cook-Cottone, 2008), while in three studies no
differences were found for eating disorders symptoms or scales of
PURSEY ET AL. 1759

F I G U R E 3 (a) Treatment effects and standardized mean differences of body image-related outcomes for girls (n = 13). (b) Treatment effects
and standardized mean differences of body image-related outcomes for boys (n = 7)

anorexia nervosa or bulimia nervosa symptoms (Escoto Ponce de Leon
et al., 2008; Norman et al., 2014; Wick et al., 2011).
3.5.3 | Other outcomes
There were significant improvements in outcomes relating to the inter-
nalization of appearance ideals in six studies (including cultural appear-
ance internalization, media influence internalization, drive for thinness,
internalization of thin ideals/muscular ideals) (Bird et al., 2013; Halliwell
et al., 2016; Kater et al., 2002; Norman et al., 2014; Norwood
et al., 2011; Scime et al., 2006); however, no difference was found in
one study for body aesthetic models influence (Escoto Ponce de Leon
et al., 2008). Significant improvements were reported for appearance-
related comparison and conversation outcomes in one study (Bird
et al., 2013), one study found a significant decrease in teasing (Haines
et al., 2006), while no differences were found for appearance-related
teasing in two studies (Bird et al., 2013; Damiano et al., 2018).
1760
3.6 | Lifestyle interventions incorporating content
to address disordered eating, body dissatisfaction,
and/or weight control behaviors
3.6.1 | Body image-related outcomes
Of the nine studies that evaluated lifestyle interventions, a parent only
obesity prevention program reported improvements in child body
esteem, appearance attitudes, and overweight dissatisfaction (Eldridge
et al., 2016) (Table 1). In two physical activities, nutrition and body image
interventions, one study reported an improvement in body image
(Dowdy et al., 2013). In five studies evaluating the Girls on Track/Girls
on the Run intervention, incorporating physical activity plus content
around emotional, mental and physical development, there was a statisti-
cally significant improvement in body image postintervention in two
studies (DeBate et al., 2009; DeBate & Thompson, 2005; Pettee Gabriel
et al., 2011; Scime et al., 2006), improvement in body satisfaction and
eating behaviors in one study (DeBate & Thompson, 2005), a decrease in
body dissatisfaction and desire for thinness in one study (Scime
et al., 2006). However, no significant differences were observed in
another study (Sifers & Shea, 2013).
3.6.2 | Extreme weight control and eating behavior
outcomes
No significant differences in dieting behavior or thoughts were
observed following an intervention including physical activity and
body image content (Santos et al., 2014).
3.6.3 | Other outcomes
One study showed improvements in children's nutrition knowledge
and positive attitudes to body types (Smolak et al., 1998; Smolak &
Levine, 2001).
Although positive effects in body image, weight control and
disordered eating behaviors were reported at postintervention in
many studies, the maintenance of effects was variable at follow-
up. Positive changes were sustained at 1 to 3 months in five pro-
grams, while positive effects of the intervention were not
maintained in another eight programs at follow-up ranging from
3 to 12 months. In one study of longer-term follow-up (7 to
8 years), body esteem improvement following the intervention was
maintained at follow-up.
3.7 | Meta-analysis
Sixteen studies that reported preintervention and immediately
postintervention changes in body image-related outcomes were
included in the meta-analysis. For all studies, the standardized
mean difference (SMD) was 0.26 [95%CI 0.01, 0.51], indicating an
PURSEY ET AL.
improvement in body image-related outcomes across interventions
when compared to control (Figure 2). There was a high level of
heterogeneity across all studies (I^2 = 89.9%; p < .01). Similarly,
for the specific universal–selective eating disorder prevention pro-
grams (14 studies), the standardized mean difference was 0.27
[95%CI 0.02, 0.55], indicating an SMD favoring intervention
compared to control for changes in body image-related variables.
However, this was not statistically significant and there was a high
level of heterogeneity for the specific universal–selective
prevention programs (I^2 = 92.1%; p < .01). There were an insuffi-
cient number of studies in the lifestyle intervention group for
meta-analysis.
For girls (13 studies), the standardized mean difference was 0.40
[95%CI 0.07, 0.73], indicating an improvement in the body image-
related outcomes across studies for the intervention when compared
to control (Figure 3). There was a high level of heterogeneity between
studies (I^2 = 92.6%; p < .001). For boys (seven studies), the standard-
ized mean difference was 0.23 [95%CI 0.24, 0.70], indicating that
while the results favored an improvement in body image-related out-
comes in the intervention compared to control, this was not statisti-
cally significant and there was a high level of heterogeneity
(I^2 = 87.8%; p < .001) (Figure 3b). The funnel plot was asymmetric
for the girls, with smaller studies mainly showing an improvement in
body image-related outcomes.
4 | DI SCU SSION
To the author's knowledge, this review extends previous research
through synthesis of a broad range of universal–selective prevention
interventions targeting risk factors for the development of eating dis-
orders in younger children aged 6–12 years. The descriptive synthesis
found that most interventions showed an improvement in one or
more outcomes relating to body image or weight control behaviors,
such as body esteem, body image, and restrictive or overeating behav-
iors. Meta-analysis revealed an improvement in body image-related
outcomes across all studies; however, there were a wide range of
effects and a substantial level of heterogeneity across studies. This
may be due to the considerable variability in the types of interven-
tions, topics delivered, and implementation strategies across included
studies. This is consistent with a previous review combining both chil-
dren and adolescents, which showed a small but significant improve-
ment in body satisfaction (SMD 0.07) and body esteem (SMD 0.25)
along with significant heterogeneity (Chua et al., 2020). Improvements
in disordered eating and weight control behaviors were less consis-
tent, which may be related to the variable outcome measures used
across studies.
Broadly, those studies that were gender specific in their delivery
or reporting of outcome measures and reported including interactive,
active learning components as part of the intervention appeared to
be more effective in children. In contrast, those studies where the
interactive learning opportunities were unclear, as well as those
studies that did not report gender-specific strategies or outcomes,
PURSEY ET AL.
appeared to be less promising. In many cases, the amount of content
provided about specific education topics was not outlined in detail.
However, it appears that approaches such as media literacy, diversity
of bodies, sociocultural pressures, body size acceptance, and positive
eating behaviors were among those that yielded positive effects.
Program duration was variable with no clear trends toward program
efficacy based on duration or number of sessions.
The majority of studies recruited both girls and boys with a large
proportion recruiting girls only. This may be reflective of selective
interventions targeted at girls given the higher rates of disordered eat-
ing in girls compared to boys (Smink et al., 2012). No studies recruited
boys exclusively; however, outcomes were reported separately for
boys in six studies. Analysis according to participant gender revealed a
statistically significant improvement in body image-related variables in
girls but not in boys, consistent with previous research (Chua
et al., 2020). This may be due to prevention materials being more tai-
lored to girls than boys. However, in many of the interventions includ-
ing both boys and girls, the use of gender-specific content and
delivery including gender-specific sessions was not clear. In one study
including gender specific content with sessions run separately for
boys and girls, there were significant improvements in muscle esteem
in boys specifically, which may indicate the value of providing gender
tailored content within broader interventions. As there appears to be
considerable gender differences in weight, shape, and eating concern
from an early age (Forsén Mantilla, Birgegård, & Clinton, 2017), the
delivery of targeted content in specific sessions suited to gender
(e.g., small group discussion approach in girls) may be useful to
improve engagement and allow for discussion of relevant topics.
However, the feasibility of this may depend on the specific study set-
ting. Although girls have been shown to be at higher risk for the
development of disordered eating behaviors, the prevalence is
increasing in boys (Galmiche, Déchelotte, Lambert, & Tavolacci, 2019).
Future studies should consider tailored recruitment to appeal to larger
numbers of boys and interventions specifically designed with gender-
specific content and reporting of outcomes.
Although most studies included in the meta-analysis were specific
universal–selective interventions targeting eating disorder risk factors,
in the descriptive synthesis, lifestyle interventions incorporating nutri-
tion, and physical activity as well as content to address disordered
eating also demonstrated efficacy in improving body image-related
outcomes such as body esteem, body image and body satisfaction.
There is sound rationale for incorporating content relating to eating
disorder risk factors alongside healthy eating and physical activity
interventions, given that body dissatisfaction in preadolescence has
been associated with the development of obesity, reduced physical
activity, and dieting (Neumark-Sztainer et al., 2006). While lifestyle
programs offer a promising opportunity, it is also important to con-
sider the potential risk of harm for body dissatisfaction and extreme
weight control behaviors in the context of the primary prevention of
obesity. In children and adolescents undergoing obesity treatment,
short-term improvements in body image were observed (Gow
et al., 2020). Improvements in body image and physical appearance
have been observed in physical activity interventions (Annesi, 2007;
1761
Christiansen et al., 2018; Olive, Byrne, Cunningham, Telford, &
Telford, 2019) while improvements in body esteem were also observed
in a nutrition and physical activity intervention (Kolotourou et al., 2015).
In addition, a School Nutrition Policy Initiative for overweight and obe-
sity saw no change in body dissatisfaction postintervention, indicating
no adverse effects of the intervention on these outcomes (Foster
et al., 2008). Due to the ubiquitous nature of obesity prevention pro-
grams, future directions may include embedding materials addressing
known risk factors for disordered eating such as body image within exis-
ting diet and lifestyle interventions for younger children.
The majority of studies were classified as neutral quality with the
areas of participant selection (e.g., clear specification of inclusion and
exclusion criteria for recruitment, representativeness of the sample),
methods of handling withdrawals (e.g., reporting of characteristics of
withdrawals, reasons for dropouts), and use of blinding needing more
careful reporting in future studies. This is similar to previous reviews,
where included studies were found to be of low quality evidence
(Chua et al., 2020). In most cases, outcomes relating to body image
and extreme weight control behaviors were reported by children, as
opposed to parental report. While the validity of tools for younger
children were reported in some cases, many studies did not report
validity for this age group specifically. Future studies should use tools
validated for children specifically.
The majority of studies reported intervention effects immediately
post program only, with few studies reporting longer-term effects.
Positive short-term changes could be driven by demand characteris-
tics or recency effect. In addition, in many cases, positive effects
immediately postintervention were not sustained at follow-up ranging
from 3 to 12 months. However, it is possible that other factors such
as environmental exposures could have influenced the findings at
longer-term follow-up. Given the lack of long-term positive changes,
it is unclear if the resource investment required to implement such
programs on a larger scale is warranted. Therefore, further research is
needed including health economics data to determine the resource
investment and longer-term effects of such interventions to support
meta-analysis of follow-up outcomes. Given the consistent exposure to
cultural ideals and social media during childhood and adolescence,
long-term studies are warranted to determine if intervention effects
are sustained over time as well as whether ongoing intervention is
required over different developmental life stages. Future studies should
also consider other exposures over the duration of follow-up to sub-
stantiate whether the changes in body image outcomes, disordered
eating and extreme weight control behaviors are related to the inter-
vention specifically rather than other external factors or education.
Most studies recruited older children (>10 years of age). Due to
the lack of studies conducted in younger participants and heterogene-
ity of interventions in the younger age group, the optimal age of
implementation is difficult to ascertain. However, in the six studies
conducted in younger children (<10 years), there were variable effects
of interventions. In two lifestyle interventions, no positive
effects were reported for the outcomes assessed, while in the specific
interventions there were positive effects body esteem for boys and
girls in one study (Damiano et al., 2018) and an improvement in body
1762
image concerns in girls but not boys in another study (Halliwell
et al., 2016), and no significant difference in body esteem in another
two studies. Given the inconsistent findings in younger children,
implementation in those aged 10–12 years may be more efficacious;
however, further studies are needed to substantiate this. Develop-
mentally appropriate programs for younger children should be
explored further in future research, which will allow for potential
meta-analysis according to age in future reviews. Future directions
also include qualitative approaches to better understand the most
appropriate prevention approaches including content and implemen-
tation strategies for children due to the unique needs that may pre-
sent across this life stage. Future research is also required better
understand the scope of disordered eating and associated risk factors
in younger children to better inform potential prevention approaches.
The majority of interventions included in the review were delivered
in school settings, which are widely recognized as appropriate settings
for implementation in children and adolescents. Trained facilitators such
as graduate students and researchers delivered most interventions,
with only seven interventions implemented by teachers, which may
limit scalability and wide-scale dissemination. Teachers are well placed
to support the delivery of prevention programs due to their interactions
with students and opportunities to facilitate positive discussion around
nutrition and body image. However, it is also important to note the lim-
ited time in the school curriculum and competing schedules for educa-
tion and professional development for teachers, which may act as a
barrier to implementation (Yager & O'Dea, 2005). In addition, the
knowledge and perceptions of teachers may influence their delivery of
programs leading to more variation compared to trained researchers or
facilitators. In one recent study, the implementation of a teacher led
intervention was less efficacious in improving body satisfaction com-
pared to the same intervention delivered by trained clinicians (Stewart
et al., 2020). Therefore, the inclusion of trained facilitators alongside
teachers is an important consideration as well as potential opportunities
to embed content relating to eating disorder risk factors as part of exis-
ting interventions to lessen the burden on teachers. Further research is
required to better understand the perceived training and resource
needs for teachers to implement such interventions.
Given the ubiquitous nature of technology in the classroom and
social environment for children, exploring technology-based options
to support intervention delivery may be an important step in future
interventions. However, the one study that included web-based deliv-
ery did not yield significant improvements in body esteem, indicating
that technological approaches should be integrated as part of face-to-
face interventions, which showed greater efficacy in the reviewed
studies. Delivery via online platforms also may assist in scalability of
future interventions to complement the current curriculum rather
than adding to current teaching workloads.
Compared to previous reviews, this review includes a larger num-
ber of studies and adds important insights into the efficacy of a
broader range of interventions applicable to primary school aged chil-
dren aged 6–12 years, including parental, teacher, and child-focused
interventions. The current review extends previous findings on body
image by including investigation into other eating disorder risk factors
PURSEY ET AL.
such as weight control and eating disorder behaviors. In contrast to
previous reviews, this review found a significant improvement in body
image-related variables in primary school aged children aged 6–
12 years. This may be due to differences in populations and
interventions included in the reviews, with a previous review including
only universal interventions aimed at children and adolescents aged
5–17 years (Chua, 2020), while the current review evaluated univer-
sal–selective interventions that were specific to younger children aged
6–12 years.
Strengths of this review include the comprehensive search strat-
egy across nine databases and inclusion of a broad range of interven-
tions to give insight into the scope of available interventions for
younger children. This review is limited by the restriction of studies in
the English language. It is also limited the population groups studied
across the included studies, with samples being predominantly girls
>10 years of age and drawn from predominantly White populations.
This may make findings of this review less generalizable to boys, other
ethnicities, and those from the younger ages. The collection and
reporting of socioeconomic status were vague, with the method of
reporting not described in most cases. This precludes recommenda-
tions for programs according to socioeconomic status. Future studies
should clearly report the method of collecting socioeconomic data to
allow for practical recommendations based on socioeconomic status
of children. Future studies should consider the inclusion of a broader
range of populations to improve the representativeness and diversity
of samples as well as facilitate subanalyses by characteristics such as
socioeconomic status and ethnicity.
5 | CONC LU SIONS
Across reviewed studies, there was a trend toward a reduction in eat-
ing disorder risk factors, more specifically, an improvement in body
image-related outcomes following the implementation of universal–
selective eating disorder prevention interventions in children; how-
ever, there was a wide range of effects across studies. Analysis
according to participant gender revealed positive effects in girls, with
a statistically significant improvement in body image-related variables
in girls but not in boys. Improvements in disordered eating and weight
control behaviors were less consistent across studies. The types of
interventions, topics delivered and implementation strategies across
studies were variable; however, those studies that included interactive
learning opportunities and gender-specific delivery or outcomes
appeared to be more promising in children. Future directions include
the use of high quality, controlled study designs including more
diverse samples, as well as consideration around the scalability of
interventions including embedding eating disorder prevention content
in existing lifestyle intervention frameworks.
ACKNOWLEDG MENTS
The review team would like to thank M Whatnall and K Cochrane for
assisting with the review and E. Nolan for assisting with the meta-
analysis. T. L. B. is supported by an NHMRC Investigator Grant. K. M.
PURSEY ET AL.
P. is supported by the Hunter Medical Research Institute Greaves
Family Early Career Research Grant.
CONF LICT OF IN TE RE ST
The authors declare no conflict of interest.
DATA AVAI LAB ILITY S TATEMENT
Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
ORCID
Kirrilly M. Pursey https://orcid.org/0000-0001-7615-7280
Daniel Barker https://orcid.org/0000-0002-9707-4465
RE FE R ENC E S
Academy of Nutrition and Dietetics. (2012). Evidence analysis manual: Steps
in the academy evidence analysis process. Chicago, IL: Academy of Nutri-
tion and Dietetics Retrieved from http://www.adaevidencelibrary.com/
files/Docs/2012_Jan_EA_Manual.pdf
Annesi, J. J. (2007). Relations of age with changes in self-efficacy and
physical self-concept in preadolescents participating in a physical
activity intervention during afterschool care. Perceptual & Motor Skills,
105(1), 221–226. https://doi.org/10.2466/pms.105.1.221-226
Baranowski, M. J., & Hetherington, M. M. (2001). Testing the efficacy of
an eating disorder prevention program. International Journal of Eating
Disorders, 29(2), 119–124.
Berger, U., Sowa, M., Bormann, B., Brix, C., & Strauss, B. (2008). Primary
prevention of eating disorders: Characteristics of effective
programmes and how to bring them to broader dissemination.
European Eating Disorders Review, 16(3), 173–183. https://doi.org/10.
1002/erv.861
Bird, E. L., Halliwell, E., Diedrichs, P. C., & Harcourt, D. (2013). Happy
Being Me in the UK: A controlled evaluation of a school-based body
image intervention with pre-adolescent children. Body Image, 10(3),
326–334. https://doi.org/10.1016/j.bodyim.2013.02.008
Bould, H., Newbegin, C., Stewart, A., Stein, A., & Fazel, M. (2017). Eating
disorders in children and young people. BMJ, 359, j5328.
Bucchianeri, M. M., Arikian, A. J., Hannan, P. J., Eisenberg, M. E., &
Neumark-Sztainer, D. (2013). Body dissatisfaction from adolescence
to young adulthood: Findings from a 10-year longitudinal study. Body
Image, 10(1), 1–7. https://doi.org/10.1016/j.bodyim.2012.09.001
Christiansen, L. B., Lund-Cramer, P., Brondeel, R., Smedegaard, S., Holt, A.-
D., & Skovgaard, T. (2018). Improving children's physical self-
perception through a school-based physical activity intervention: The
move for well-being in school study. Mental Health and Physical Activ-
ity, 14, 31–38. https://doi.org/10.1016/j.mhpa.2017.12.005
Chua, J. Y. X., Tam, W., & Shorey, S. (2020). Research review: Effective-
ness of universal eating disorder prevention interventions in improving
body image among children: A systematic review and meta-analysis.
Journal of Child Psychology and Psychiatry, 61(5), 522–535. https://doi.
org/10.1111/jcpp.13164
Cook-Cottone, C., Talebkhah, K., Guyker, W., & Keddie, E. (2017). A con-
trolled trial of a yoga-based prevention program targeting eating disor-
der risk factors among middle school females. Brunner-Mazel Eating
Disorders Monograph Series, 25(5), 392–405. https://doi.org/10.1080/
10640266.2017.1365562
Dalle Grave, R., De Luca, L., & Campello, G. (2001). Middle school primary
prevention program for eating disorders: A controlled study with a
twelve-month follow-up. Eating Disorders, 9(4), 327–337.
Damiano, S. R., Yager, Z., McLean, S. A., & Paxton, S. J. (2018). Achieving
body confidence for young children: Development and pilot study of a
1763
universal teacher-led body image and weight stigma program for early
primary school children. Brunner-Mazel Eating Disorders Monograph Series,
26(6), 487–504. https://doi.org/10.1080/10640266.2018.1453630
DeBate, R. D., Pettee Gabriel, K., Zwald, M., Huberty, J., & Zhang, Y.
(2009). Changes in psychosocial factors and physical activity fre-
quency among third- to eighth-grade girls who participated in a devel-
opmentally focused youth sport program: A preliminary study. Journal
of School Health, 79(10), 474–484. https://doi.org/10.1111/j.1746-
1561.2009.00437.x
DeBate, R. D., & Thompson, S. H. (2005). Girls on the run: Improvements
in self-esteem, body size satisfaction and eating attitudes/behaviors.
Eating & Weight Disorders: EWD, 10(1), 25–32.
DerSimonian, R., & Laird, N. (1986). Meta-analysis in clinical trials. Con-
trolled Clinical Trials, 7(3), 177–188.
Dion, J., Hains, J., Vachon, P., Plouffe, J., Laberge, L., Perron, M., …
Leone, M. (2016). Correlates of body dissatisfaction in children. The
Journal of Pediatrics, 171, 202–207. https://doi.org/10.1016/j.jpeds.
2015.12.045
Dohnt, H. K., & Tiggemann, M. (2006). Body image concerns in young girls:
The role of peers and media prior to adolescence. Journal of Youth and
Adolescence, 35(2), 141–151. https://doi.org/10.1007/s10964-005-
9020-7
Dowdy, S., Alvarado, M., Atieno, O., Barker, S., Barrett, S., Carlton, A., …
Williamson, L. (2013). Empower U: Effectiveness of an adolescent out-
reach and prevention program with sixth-grade boys and girls: A pilot
study. Journal of Pediatric Nursing, 28(1), 77–84. https://doi.org/10.
1016/j.pedn.2012.03.028
Eldridge, G., Paul, L., Bailey, S. J., Ashe, C. B., Martz, J., & Lynch, W. (2016).
Effects of parent-only childhood obesity prevention programs on BMIz
and body image in rural preteens. Body Image, 16, 143–153. https://
doi.org/10.1016/j.bodyim.2015.12.003
Escoto Ponce de Leon, M. C., Mancilla Diaz, J. M., & Camacho Ruiz, E. J.
(2008). A pilot study of the clinical and statistical significance of a pro-
gram to reduce eating disorder risk factors in children. Eating & Weight
Disorders: EWD, 13(3), 111–118.
Evans, E. H., Adamson, A. J., Basterfield, L., Le Couteur, A., Reilly, J. K.,
Reilly, J. J., & Parkinson, K. N. (2017). Risk factors for eating disor-
der symptoms at 12 years of age: A 6-year longitudinal cohort
study. Appetite, 108, 12–20. https://doi.org/10.1016/j.appet.2016.
09.005
Forsén Mantilla, E., Birgegård, A., & Clinton, D. (2017). Factor analysis of
the adolescent version of the Eating Disorders Examination Question-
naire (EDE-Q): Results from Swedish general population and clinical
samples. Journal of Eating Disorders, 5, 19–19. https://doi.org/10.
1186/s40337-017-0140-8
Foster, G. D., Sherman, S., Borradaile, K. E., Grundy, K. M., Vander
Veur, S. S., Nachmani, J., … Shults, J. (2008). A policy-based school
intervention to prevent overweight and obesity. Pediatrics, 121(4),
e794–e802. https://doi.org/10.1542/peds.2007-1365
Galmiche, M., Déchelotte, P., Lambert, G., & Tavolacci, M. P. (2019). Preva-
lence of eating disorders over the 2000–2018 period: A systematic lit-
erature review. The American Journal of Clinical Nutrition, 109(5),
1402–1413. https://doi.org/10.1093/ajcn/nqy342
Ghaderi, A., Mårtensson, M., & Schwan, H. (2005). "Everybody's different":
A primary prevention program among fifth grade school children. Eat-
ing Disorders., 13(3), 245–259.
Ghaderi, A., Mårtensson, M., & Schwan, H. (2005). "Everybody's differ-
ent": A primary prevention program among fifth grade school chil-
dren. Eating Disorders, 13(3), 245–259. https://doi.org/10.1080/
10640260590932869
Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing obesity and
eating disorders in adolescents. Pediatrics, 138(3), e20161649.
https://doi.org/10.1542/peds.2016-1649
Gow, M. L., Tee, M. S. Y., Garnett, S. P., Baur, L. A., Aldwell, K., Thomas, S.,
… Jebeile, H. (2020). Pediatric obesity treatment, self-esteem, and
1764
body image: A systematic review with meta-analysis. Pediatric Obesity,
15(3), e12600. https://doi.org/10.1111/ijpo.12600
Haines, J., Neumark-Sztainer, D., Perry, C. L., Hannan, P. J., & Levine, M. P.
(2006). V.I.K. (very important kids): A school-based program designed
to reduce teasing and unhealthy weight-control behaviors. Health Edu-
cation Research, 21(6), 884–895.
Halliwell, E., Yager, Z., Paraskeva, N., Diedrichs, P. C., Smith, H., &
White, P. (2016). Body image in primary schools: A pilot evaluation of
a primary school intervention program designed by teachers to
improve children's body satisfaction. Body Image, 19, 133–141.
https://doi.org/10.1016/j.bodyim.2016.09.002
Halliwell, E., Jarman, H., Tylka, T. L., & Slater, A. (2018). Evaluating the
impact of a brief yoga intervention on preadolescents’ body image
and mood. Body Image., 27, 196–201.
Hinz, A. (2017). Improving body satisfaction in preadolescent girls and
boys: Short-term effects of a school-based program. Electronic Journal
of Research in Educational Psychology, 15(2), 241–258. https://doi.org/
10.14204/ejrep.42.17030
Holt, K. E., & Ricciardelli, L. A. (2008). Weight concerns among elementary
school children: A review of prevention programs. Body Image, 5(3),
233–243. https://doi.org/10.1016/j.bodyim.2008.02.002
Huon, G. F., Roncolato, W. G., Ritchie, J. E., & Braganza, C. (1997). Preven-
tion of dieting-induced disorders: Findings and implications of a pilot
study. Eating Disorders, 5(4), 280–293. https://doi.org/10.1080/
10640269708249235
Irving, L. M. (2000). Promoting Size Acceptance in Elementary School Chil-
dren: The EDAP Puppet Program. Eating Disorders., 8(3), 221–232.
Kater, K. J., Rohwer, J., & Levine, M. P. (2000). An elementary school
project for developing healthy body image and reducing risk factors
for unhealthy and disordered eating. Eating Disorders: The Journal of
Treatment & Prevention, 8(1), 3–16. https://doi.org/10.1080/
10640260008251208
Kater, K. J., Rohwer, J., & Londre, K. (2002). Evaluation of an upper ele-
mentary school program to prevent body image, eating, and weight
concerns. The Journal of School Health, 72(5), 199–204. https://doi.
org/10.1111/j.1746-1561.2002.tb06546.x
Kolotourou, M., Radley, D., Gammon, C., Smith, L., Chadwick, P., &
Sacher, P. M. (2015). Long-term outcomes following the MEND 7-13
child weight management program. Childhood Obesity, 11(3), 325–330.
https://doi.org/10.1089/chi.2014.0092
Kotler, L. A., Cohen, P., Davies, M., Pine, D. S., & Walsh, B. T. (2001). Lon-
gitudinal relationships between childhood, adolescent, and adult eating
disorders. Journal of the American Academy of Child & Adolescent Psy-
chiatry, 40(12), 1434–1440. https://doi.org/10.1097/00004583-
200112000-00014
Kwag, K. H., Han, S. W., Cho, J. Y., Ko, M., Park, E. J., & Kim, Y. R. (2021).
A school-based eating disorder prevention program (Me, You & Us) for
young adolescents in Korea: A 3-year follow-up study. International
Journal of Eating Disorders.
Le, L. K.-D., Barendregt, J. J., Hay, P., & Mihalopoulos, C. (2017). Preven-
tion of eating disorders: A systematic review and meta-analysis. Clini-
cal Psychology Review, 53, 46–58. https://doi.org/10.1016/j.cpr.2017.
02.001
Lee, G. Y., Park, E. J., Kim, Y. R., Kwag, K. H., Park, J. H., An, S. H., …
Treasure, J. (2018). Feasibility and acceptability of a prevention pro-
gram for eating disorders (me, you and us) adapted for young adoles-
cents in Korea. Eating & Weight Disorders: EWD, 23(5), 673–683.
https://doi.org/10.1007/s40519-017-0436-3
Levine, M. P. (2017). Universal prevention of eating disorders: A concept
analysis. Eating Behaviors, 25, 4–8. https://doi.org/10.1016/j.eatbeh.
2016.10.011
Maloney, M. J., McGuire, J., Daniels, S. R., & Specker, B. (1989). Dieting
behavior and eating attitudes in children. Pediatrics, 84(3), 482–489
Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0-
0024452132&partnerID=40&md5=a6671ac521f1f568b8f63c81b7ac4a95
PURSEY ET AL.
McCabe, M. P., Connaughton, C., Tatangelo, G., Mellor, D., & Busija, L.
(2017). Healthy me: A gender-specific program to address body image
concerns and risk factors among preadolescents. Body Image, 20, 20–
30. https://doi.org/10.1016/j.bodyim.2016.10.007
McCabe, M. P., Ricciardelli, L. A., & Salmon, J. (2006). Evaluation of a pre-
vention program to address body focus and negative affect among
children. Journal of Health Psychology, 11(4), 589–598.
McLean, S. A., Wertheim, E. H., & Paxton, S. J. (2018). Preferences for
being muscular and thin in 6-year-old boys. Body Image, 26, 98–102.
https://doi.org/10.1016/j.bodyim.2018.07.003
McVey, G., Tweed, S., & Blackmore, E. (2004). Dieting among preadoles-
cent and young adolescent females. Canadian Medical Association Jour-
nal, 170(10), 1559–1561. https://doi.org/10.1503/cmaj.1031247
McVey, G. L., Davis, R., Tweed, S., & Shaw, B. F. (2004). Evaluation of a
school-based program designed to improve body image satisfaction,
global self-esteem, and eating attitudes and behaviors: A replication
study. International Journal of Eating Disorders, 36(1), 1–11.
Munkholm, A., Olsen, E. M., Rask, C. U., Clemmensen, L., Rimvall, M. K.,
Jeppesen, P., … Skovgaard, A. M. (2016). Eating behaviours in preado-
lescence are associated with body dissatisfaction and mental
disorders—Results of the CCC2000 study. Appetite, 101, 46–54.
https://doi.org/10.1016/j.appet.2016.02.020
Neumark-Sztainer, D., Paxton, S. J., Hannan, P. J., Haines, J., & Story, M.
(2006). Does body satisfaction matter? Five-year longitudinal associa-
tions between body satisfaction and health behaviors in adolescent
females and males. Journal of Adolescent Health, 39(2), 244–251.
https://doi.org/10.1016/j.jadohealth.2005.12.001
Norman, K., Sodano, S. M., & Cook-Cottone, C. (2014). An exploratory
analysis of the role of interpersonal styles in eating disorder preven-
tion outcomes. Journal for Specialists in Group Work, 39(4), 301–315.
https://doi.org/10.1080/01933922.2014.948234
Norwood, S. J., Murray, M., Nolan, A., & Bowker, A. (2011). Beautiful from
the inside out: A school-based programme designed to increase self-
esteem and positive body image among preadolescents. Canadian
Journal of School Psychology, 26(4), 263–282. https://doi.org/10.1177/
0829573511423632
Olive, L. S., Byrne, D., Cunningham, R. B., Telford, R. M., & Telford, R. D.
(2019). Can physical education improve the mental health of children?
The LOOK study cluster-randomized controlled trial. Journal of Educa-
tional Psychology, 111(7), 1331–1340 No Pagination Specified.
https://doi.org/10.1037/edu0000338
Pettee Gabriel, K. K., DiGioacchino DeBate, R., High, R. R., & Racine, E. F.
(2011). Girls on the run: A quasi-experimental evaluation of a develop-
mentally focused youth sport program. Journal of Physical Activity &
Health, 8(Suppl 2), S285–S294 Retrieved from http://ezproxy.
newcastle.edu.au/login?url=http://ovidsp.ovid.com?T=JS&CSC=Y&
NEWS=N&PAGE=fulltext&D=med7&AN=21918243
Ricciardelli, L. A., & McCabe, M. P. (2001). Children's body image concerns and
eating disturbance: A review of the literature. Clinical Psychology Review,
21(3), 325–344. https://doi.org/10.1016/S0272-7358(99)00051-3
Ricciardelli, L. A., McCabe, M. P., Holt, K. E., & Finemore, J. (2003). A
biopsychosocial model for understanding body image and body
change strategies among children. Journal of Applied Developmental
Psychology, 24(4), 475–495. https://doi.org/10.1016/S0193-3973
(03)00070-4
Ricciardelli, L. A., McCabe, M. P., Mussap, A. J., & Holt, K. E. (2009). Body
image in preadolescent boys. In Body image, eating disorders, and obe-
sity in youth: Assessment, prevention, and treatment (2nd ed., pp. 77–
96). Washington, DC: American Psychological Association.
Ross, A., Paxton, S. J., & Rodgers, R. F. (2013). Y's Girl: increasing body sat-
isfaction among primary school girls. Body Image., 10(4), 614–618.
Russell-Mayhew, S., Arthur, N., & Ewashen, C. (2007). Targeting students,
teachers and parents in a wellness-based prevention program in
schools. Brunner-Mazel Eating Disorders Monograph Series, 15(2), 159–
181. https://doi.org/10.1080/10640260701190709
PURSEY ET AL.
Sanchez-Carracedo, D., Neumark-Sztainer, D., & Lopez-Guimera, G.
(2012). Integrated prevention of obesity and eating disorders: Barriers,
developments and opportunities. Public Health Nutrition, 15(12),
2295–2309. https://doi.org/10.1017/s1368980012000705
Santos, R. G., Durksen, A., Rabbanni, R., Chanoine, J. P., Lamboo
Miln, A., Mayer, T., & McGavock, J. M. (2014). Effectiveness of peer-
based healthy living lesson plans on anthropometric measures and
physical activity in elementary school students: A cluster randomized
trial. [Erratum appears in JAMA Pediatr. 2015 Jan;169(1):96]. JAMA
Pediatrics, 168(4), 330–337. https://doi.org/10.1001/jamapediatrics.
2013.3688
Scime, M., & Cook-Cottone, C. (2008). Primary prevention of eating disor-
ders: A constructivist integration of mind and body strategies. Interna-
tional Journal of Eating Disorders, 41(2), 134–142. https://doi.org/10.
1002/eat.20480
Scime, M., Cook-Cottone, C., Kane, L., & Watson, T. (2006). Group preven-
tion of eating disorders with fifth-grade females: Impact on body dissat-
isfaction, drive for thinness, and media influence. Eating Disorders, 14(2),
143–155. https://doi.org/10.1080/10640260500403881
Sifers, S. K., & Shea, D. N. (2013). Evaluations of girls on the run/girls on
track to enhance self-esteem and well-being. Journal of Clinical Sport
Psychology, 7(1), 77–85.
Slater, A., & Tiggemann, M. (2016). Little girls in a grown up world: Expo-
sure to sexualized media, internalization of sexualization messages,
and body image in 6–9 year-old girls. Body Image, 18, 19–22. https://
doi.org/10.1016/j.bodyim.2016.04.004
Smink, F. R., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating
disorders: Incidence, prevalence and mortality rates. Current Psychiatry
Reports, 14(4), 406–414. https://doi.org/10.1007/s11920-012-0282-y
Smolak, L., & Levine, M. P. (2001). A two-year follow-up of a primary prevention
program for negative body image and unhealthy weight regulation. Eating
Disorders, 9(4), 313–325. https://doi.org/10.1080/106402601753454886
Smolak, L., Levine, M. P., & Schermer, F. (1998). A controlled evaluation of
an elementary school primary prevention program for eating problems.
Journal of Psychosomatic Research, 44(3–4), 339–353.
Stewart, C., Goddard, E., Cakir, Z., Hall, R., & Allen, G. (2020). Can more
people be "Happy Being Me"? Testing the delivery of a universal body
satisfaction program by clinicians and school staff. Eating Disorders, 1–
28. https://doi.org/10.1080/10640266.2020.1771165
Stice, E., Marti, C. N., Shaw, H., & Jaconis, M. (2009). An 8-year longitudinal
study of the natural history of threshold, subthreshold, and partial eating
1765
disorders from a community sample of adolescents. Journal of Abnormal
Psychology, 118(3), 587–597. https://doi.org/10.1037/a0016481
Stice, E., & Whitenton, K. (2002). Risk factors for body dissatisfaction in
adolescent girls: A longitudinal investigation. Developmental Psychol-
ogy, 38(5), 669–678. https://doi.org/10.1037/0012-1649.38.5.669
Tatangelo, G., McCabe, M., Mellor, D., & Mealey, A. (2016). A systematic
review of body dissatisfaction and sociocultural messages related to
the body among preschool children. Body Image, 18, 86–95. https://
doi.org/10.1016/j.bodyim.2016.06.003
Wick, K., Brix, C., Bormann, B., Sowa, M., Strauss, B., & Berger, U. (2011).
Real-world effectiveness of a German school-based intervention for pri-
mary prevention of anorexia nervosa in preadolescent girls. Preventive
Medicine, 52(2), 152–158. https://doi.org/10.1016/j.ypmed.2010.11.022
Yager, Z., Diedrichs, P. C., Ricciardelli, L. A., & Halliwell, E. (2013). What
works in secondary schools? A systematic review of classroom-based
body image programs. Body Image, 10(3), 271–281. https://doi.org/10.
1016/j.bodyim.2013.04.001
Yager, Z., & O'Dea, J. A. (2005). The role of teachers and other educators
in the prevention of eating disorders and child obesity: What are the
issues? Eating Disorders, 13(3), 261–278.
Yeh, M. C., Liou, Y. M., & Chien, L. Y. (2012). Development and effective-
ness of a school programme on improving body image among elemen-
tary school students in Taiwan. Journal of Advanced Nursing, 68(2),
434–443. https://doi.org/10.1111/j.1365-2648.2011.05735.x
SUPPORTING INF ORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of this article.
How to cite this article: Pursey, K. M., Burrows, T. L., Barker,
D., Hart, M., & Paxton, S. J. (2021). Disordered eating, body
image concerns, and weight control behaviors in primary
school aged children: A systematic review and meta-analysis
of universal–selective prevention interventions. International
Journal of Eating Disorders, 54(10), 1730–1765. https://doi.
org/10.1002/eat.23571
Copyright of International Journal of Eating Disorders is the property of John Wiley & Sons,
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.