Metaanalisis Prevencion

ANRV307-CP03-09 ARI 20 February 2007 20:46
A Meta-Analytic Review
of Eating Disorder
Prevention Programs:
Access provided by Technische Universiteit Eindhoven on 01/26/15. For personal use only.
Annu. Rev. Clin. Psychol. 2007.3:207-231. Downloaded from www.annualreviews.org
Encouraging Findings
Eric Stice,1 Heather Shaw,2
and C. Nathan Marti3
1
Oregon Research Institute, Eugene, Oregon 97403; email: estice@ori.org
2
Department of Psychology, 3 Department of Educational Administration, University
of Texas at Austin, Austin, Texas 78712; email: shaw@psy.utexas.edu,
n.marti@forum.cc.utexas.edu
Annu. Rev. Clin. Psychol. 2007. 3:207–31 Key Words

First published online as a Review in risk factors, eating disorder, prevention interventions,
Advance on December 6, 2006
meta-analysis, effect sizes
The Annual Review of Clinical Psychology is online
at http://clinpsy.annualreviews.org Abstract
This article’s doi: This meta-analytic review found that 51% of eating disorder pre-
10.1146/annurev.clinpsy.3.022806.091447
vention programs reduced eating disorder risk factors and 29% re-
Copyright c 2007 by Annual Reviews. duced current or future eating pathology. Larger effects occurred for
All rights reserved
programs that were selected (versus universal), interactive (versus
1548-5943/07/0427-0207$20.00 didactic), multisession (versus single session), solely offered to fe-
males (versus both sexes), offered to participants over 15 years of age
(versus younger ones), and delivered by professional interventionists
(versus endogenous providers). Programs with body acceptance and
dissonance-induction content and without psychoeducational con-
tent and programs evaluated in trials using validated measures and a
shorter follow-up period also produced larger effects. Results iden-
tify promising programs and delineate sample, format, and design
features associated with larger effects, which may inform the design
of more effective prevention programs in the future.
207
Contents
SIGNIFICANCE . . . . . . . . . . . . . . . . . . . 208 Coding of Effect Size
EMPIRICALLY ESTABLISHED Moderators . . . . . . . . . . . . . . . . . . . 212
RISK FACTORS . . . . . . . . . . . . . . . . . 208 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . 213
POTENTIAL MODERATORS Average Intervention Effect Sizes. . 213
OF INTERVENTION Moderators of Intervention
EFFECTS . . . . . . . . . . . . . . . . . . . . . . . 209 Effects . . . . . . . . . . . . . . . . . . . . . . . . 213
PARTICIPANT FEATURES . . . . . . . . 209 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . 220
Risk Status of Participants . . . . . . . . 209 Summary of Average Effect Sizes . . 220
Participant Sex . . . . . . . . . . . . . . . . . . . 209 Summary of Effect Size
Participant Age . . . . . . . . . . . . . . . . . . . 209 Moderators . . . . . . . . . . . . . . . . . . . 221
INTERVENTION FEATURES . . . . 210 CAVEATS OF MODERATOR

Session Format . . . . . . . . . . . . . . . . . . . 210 ANALYSES . . . . . . . . . . . . . . . . . . . . . . 222
Type of Interventionist . . . . . . . . . . . 210 POSITIVE FEATURES OF THE
Number of Sessions . . . . . . . . . . . . . . 210 EATING DISORDER
Program Content . . . . . . . . . . . . . . . . 210 PREVENTION
METHODOLOGICAL LITERATURE . . . . . . . . . . . . . . . . . . 223
FEATURES . . . . . . . . . . . . . . . . . . . . . 211 NEGATIVE FEATURES OF THE
Use of Validated Measures . . . . . . . . 211 EATING DISORDER
Length of Follow-up . . . . . . . . . . . . . 211 PREVENTION
METHODS . . . . . . . . . . . . . . . . . . . . . . . . 211 LITERATURE . . . . . . . . . . . . . . . . . . 223
Sample of Studies . . . . . . . . . . . . . . . . 211 CONCLUSIONS AND
Effect Size Estimation DIRECTIONS FOR FUTURE
Procedures . . . . . . . . . . . . . . . . . . . . 212 RESEARCH . . . . . . . . . . . . . . . . . . . . . 224
SIGNIFICANCE evaluated in controlled trials and investigates

Eating pathology, including threshold and sample, intervention, and design features
subthreshold anorexia nervosa, bulimia ner- that are associated with larger intervention
Effect size: measure
of the strength of the vosa, and binge eating disorder, is one of effects.
relation between two the more prevalent psychiatric problems for
variables used in
females, is marked by chronicity and re-
meta-analyses EMPIRICALLY ESTABLISHED
(usually correlation lapse, results in impaired psychosocial func-
tioning, and is associated with elevated risk RISK FACTORS
coefficient, r, or
Cohen’s d ) for suicide (Fairburn et al. 2000, Lewinsohn Interventionists typically seek to reduce estab-
Risk factor: a et al. 2000, Newman et al. 1996). Eating lished risk factors for eating pathology based
variable that has pathology also increases the risk for future on the logic that this should decrease cur-
been shown to depressive disorders, anxiety disorders, sub- rent and future eating disturbances. For the
prospectively predict
stance abuse, health problems, and obesity present review, we focus on risk factors that
some subsequent
pathological ( Johnson et al. 2002, Stice et al. 1999). Ac- have been supported by multiple prospec-
outcome cordingly, much effort has been devoted to tive studies conducted by independent re-
developing and evaluating prevention pro- search groups. Elevated perceived pressure to
grams for this pernicious problem. This re- be thin from family, peers, and the media,
view summarizes effect sizes for eating dis- internalization of the thin-ideal espoused for
order prevention programs that have been women by western culture, body mass, body
208 Stice · ·
Shaw Marti
dissatisfaction, and negative affect have pre- PARTICIPANT FEATURES

dicted future eating pathology in multiple
studies (e.g., Field et al. 1999, Killen et al. Risk Status of Participants
Moderator: study
1996, Stice 2001, Wertheim et al. 2001, There is evidence that universal prevention characteristics
Wichstrom 2000). Randomized experiments programs that target everyone in a sampling thought to be
have found that interventions that reduce frame produce smaller effects than selected in- associated with
thin-ideal internalization, body dissatisfac- variation in effect
terventions that target only those at high risk
sizes
tion, and negative affect result in consequent for eating pathology. Several universal eat-
reductions in eating disorder symptoms (e.g., Meta-analysis: a
ing disorder prevention programs have been
study that combines
Bearman et al. 2003, Burton et al. 2007, more effective for high-risk participants than results of several
Rosen et al. 1995, Stice et al. 2006c), pro- for the full sample (Buddeberg-Fischer et al. studies to understand
viding evidence that these may be causal risk 1998, Killen et al. 1993, Stewart et al. 2001, sample, intervention,
factors. Although dieting has predicted fu- Taylor et al. 2006, Weiss & Wertheim 2005). and design features
ture eating pathology in multiple prospec- associated with

High-risk individuals may be more motivated
variations in effect
tive studies (e.g., Field et al. 1999, Killen to engage in prevention programs, which may sizes
et al. 1996), experiments have found that as- result in greater benefits. In addition, low-risk
signment to a low-calorie weight-loss diet, individuals may have less room for improve-
versus a waitlist control condition, results ment on the outcomes. Thus, we hypothe-
in decreased bulimic symptoms in normal- sized that intervention effects would be larger
weight young women, overweight women, for selected programs versus universal pro-
obese binge-eating women, and women with grams. Because the key distinction between
threshold and subthreshold bulimia nervosa selected and universal programs is that the for-
(Burton & Stice 2006, Goodrick et al. 1998, mer are offered to high-risk individuals, we
Klem et al. 1997, Presnell & Stice 2003). It ap- use the term “risk status of participants” to
pears that the inconsistent findings emerged refer to this variable.
because the prospective studies used invalid
measures of dietary restraint (Stice et al.
2004a). Unfortunately, we know little about Participant Sex
risk factors that are specific to anorexia Females are at much higher risk for eating
nervosa, bulimia nervosa, or binge eating pathology than are males (Newman et al.
disorder. 1996). Thus, females might be expected to
be more likely to engage in eating disor-
der prevention programs than males. The
POTENTIAL MODERATORS OF low base rate of eating pathology in males
INTERVENTION EFFECTS may also produce a floor effect that makes
A unique feature of meta-analysis is that it per- it difficult to observe intervention effects.
mits an examination of moderators associated Thus, we hypothesized that intervention ef-
with variation in effect sizes, which may re- fects would be stronger for females than for
veal aspects of the participants, intervention, males.
and research design that are associated with
the strongest intervention effects. This infor-
mation may increase the yield of future pre- Participant Age
vention efforts by identifying the conditions Prospective studies suggest that eating pathol-
under which optimal prevention effects oc- ogy is most likely to emerge between the ages
cur. We investigated several potential moder- of 15 and 19 in adolescent girls and that the
ators of intervention effects that were selected rates of eating pathology are very low dur-
based on theory, prior findings, and clinical ing early adolescence. Prevention programs
experience. may be most effective when delivered during
www.annualreviews.org • Eating Disorder Prevention Programs 209

the developmental period when the patho- gies, whereas endogenous providers typically
logical condition emerges. Younger adoles- only deliver the intervention once per year. Fi-
cents might also possess limited insight, given nally, endogenous providers rarely receive the
Dissonance
induction: a that their abstract reasoning skills are still de- amount of specialized training and detailed
social-psychological veloping, which may constrain their ability supervision provided to dedicated interven-
approach wherein to benefit from interventions. There might tionists. Thus, we hypothesized that interven-
participants engage also be a floor effect because the rates of eat- tion effects will be significantly larger for pro-
in counterattitudinal
ing pathology are low during early adoles- grams delivered by dedicated interventionists
exercises, which
results in dissonance cence. Thus, we hypothesized that preven- versus endogenous providers.
between the original tion programs would produce larger effects
and the new attitudes for middle- to late-adolescent participants rel-
that produces an ative to preadolescent and early-adolescent Number of Sessions
attitudinal shift
participants.
toward the new Researchers have concluded that brief single-

perspective session eating disorder prevention interven-
tions, typically one hour in length, are in-
INTERVENTION FEATURES
sufficient to produce lasting attitudinal and
Session Format behavioral change (Martz & Bazzini 1999).
Multisession interventions may allow par-
Substance abuse prevention programs with an
ticipants to reflect on intervention material
interactive format have been found to pro-
between sessions, thereby maximizing inter-
duce larger intervention effects than didac-
nalization of program tenants. Multisession
tic programs (Tobler et al. 2000). Participants
interventions also give participants a chance
in interactive programs may show greater in-
to try new skills and then return to the group
tervention effects because this format helps
for troubleshooting advice. We hypothesize
them engage in the program content, which
that intervention effects would be stronger for
facilitates attitudinal and behavioral change.
longer multiple-session interventions than for
Interactive programs are also more likely to
briefer interventions.
have participants apply the skills taught in the
intervention, which should facilitate skill ac-
quisition. Thus, we predicted that interactive Program Content
programs would be more effective than didac- Intervention content should also influence
tic programs. whether a program produces effects. Inter-
ventions that target established risk factors
for eating pathology should be more effec-
Type of Interventionist tive than those that focus on nonestablished
It has been suggested that prevention pro- risk factors. More generally, prior trials sug-
grams are more effective when delivered by gest that psychoeducational content is ineffec-
dedicated interventionists versus teachers or tive in producing behavioral change (Larimer
other endogenous providers who work in & Cronce 2002). We hypothesized that pro-
school settings (Baranowski et al. 2002). The- grams that focused on increasing resistance
oretically, endogenous providers are not able to sociocultural pressures for thinness, body
to devote as much time to providing inter- satisfaction, self-esteem, and healthy weight
ventions as dedicated interventionists because management skills, as well as programs that
the former have other responsibilities (e.g., use dissonance-induction techniques to re-
teaching). Dedicated interventionists are also duce thin-ideal internalization, will produce
typically able to provide the intervention sev- larger intervention effects than programs
eral times per school year, allowing them to without this content. Conversely, we expect
develop and refine their presentation strate- that programs focusing on stress and coping
210 Stice · ·
Shaw Marti
skills will be associated with weaker effects articles, review chapters, and books, and re-
because these variables are not established eat- quested copies of unpublished trials from es-
ing disorder risk factors. We also hypothe- tablished prevention researchers. We focused
sized that psychoeducational programs would solely on prevention programs that were
be associated with smaller effects. evaluated in controlled trials. We included
trials in which participants were randomly as-
signed to an intervention or to a minimal-
METHODOLOGICAL FEATURES intervention, placebo, waitlist, or assessment-
only control condition. We also included
Use of Validated Measures
trials in which some relevant comparison
It has been suggested that use of unreliable group was used (e.g., matched controls) in
measures may result in an underestimation a quasi-experimental design. Eighteen stud-
of intervention effects in prevention trials ies without minimal-intervention, placebo,

(Kalichman et al. 1996). Reliable and valid waitlist, or assessment-only control groups
measures should be better able to detect in- were excluded. Although the use of waitlist
tervention effects because they are more sen- or assessment-only control groups does not
sitive. We hypothesized that trials that used permit one to rule out the possibility that
validated outcome measures would observe any observed effects are due to expectancies
larger intervention effects than trials that used or demand characteristics, because only six
unvalidated measures. trials used minimal-intervention or placebo
control conditions, we did not require these
types of control conditions. We focused ex-
Length of Follow-up clusively on studies that tested whether the
Given that intervention effect sizes tend to change in the outcomes over time was sig-
fade over follow-up, follow-up effect size nificantly greater in the intervention group
might be inversely correlated with length of versus the control group. Studies that only
follow-up. Accordingly, we hypothesized that tested for significant changes within condition
interventions with longer follow-up periods were not included because this type of analysis
would have smaller follow-up effect sizes than does not test whether the reductions in the in-
those with shorter follow-up periods. tervention condition are significantly greater
than the reductions in the control condition.
Authors of prevention trials that did not test
METHODS for significant differences in change in the
outcomes across conditions were asked if they
Sample of Studies could provide the results of such analyses.
To retrieve published and unpublished arti- Of 10 authors contacted, 3 provided the re-
cles, a computer search was performed on quested results so that their findings could be
PsychInfo, MedLine, Dissertation Abstracts, and included (the other 7 trials were excluded).
Cumulative Index to Nursing and Allied Health Eight studies that did not include both pretest
Literature for the years 1980–2006 (through and posttest data were excluded because it is
April) using the following keywords: eating not possible to model change in the outcomes
disorder, eating pathology, anorexia, anorexic, with this type of design. One study that did
bulimia, bulimic, binge eating, prevention, not collect information to allow the authors
preventive, and intervention. We also re- to pair pretest and posttest data was excluded
viewed the tables of content for journals that because it is not possible to model change with
commonly publish articles in this area (e.g., unmatched data. In total, we excluded 12 stud-
International Journal of Eating Disorders), ex- ies because they did not test for differential
amined the reference sections of all identified change across conditions.

Effect Size Estimation Procedures vention effects at posttest and at follow-up

(averaging across all available follow-ups) to
We calculated effect sizes for measures of eat-
capture acute and long-term effects. When
ing pathology and established risk factors for
multiple measures of an outcome were used,
eating pathology. We included outcomes that
effect sizes were calculated for the scale with
were examined in at least 15 trials to en-
the most evidence of reliability and validity.
sure a sufficient power to detect effect size
Effect sizes were usually from analyses that
moderators. We included body mass, thin-
used all available data (completer analysis) be-
ideal internalization, body dissatisfaction, di-
cause this was the most common approach.
eting, and negative affect because these fac-
tors have predicted subsequent onset of eating
pathology in prospective risk factor studies
(Stice 2002). The correlation coefficient (r) Coding of Effect Size Moderators
was selected as the index of effect size because We considered interventions delivered to all
of its similar interpretation across different participants in intact classrooms and trials that
combinations of interval, ordinal, and nom- do not mention the intervention objective
inal variables. If effect sizes were reported in during recruitment (e.g., body acceptance)
Cohen’s d, we converted them to r with the to be universal programs (coded 0). Inter-
formula provided by Rosenthal (1991). If ef- ventions that screened participants for a risk
fects were reported as odds ratios, they were factor or that used recruitment strategies that
converted to r with the formula provided by implicitly screened participants, such as ad-
Lipsey & Wilson (2001). If no effect sizes were vertisements for a body acceptance class, were
reported, we generated them by calculating considered to be selected programs (coded
Cohen’s d with the means and standard devia- 1). We tested whether interventions offered
tions reported in the article, which were then solely to females (coded 1) were more effec-
converted to r using the Rosenthal formula, tive than those offered solely to males or those
or we reconstituted the data using weighted offered to both sexes (coded 0). Participant
probability values to estimate a χ 2 test that age was coded 1 if the mean age of the sam-
provided an odds ratio, which was then con- ple was 15 years old or greater, and 0 if the
verted to r using the Lipsey and Wilson for- mean age was below 15 years of age. Session
mula. If these options were not possible, we format was coded such that 1 = interactive
estimated effect sizes from the exact p-values program and 0 = didactic program. Interven-
reported by the authors using the formula tionist was coded such that 1 = professional
provided by Rosenthal (1991). If p-values were interventionist and 0 = endogenous provider
not reported, they were generated from the (e.g., school counselor). Number of sessions
test statistics (e.g., F ) and degrees of freedom. was coded such that one-shot interventions =
If these options were not possible, effect sizes 0 and multisession interventions = 1. We cre-
were requested from the authors. Of the 32 ated nonorthogonal content variables that re-
authors contacted, 20 provided the requested flected whether each program focused on
effect sizes. Despite these efforts, we were un- seven content areas. Program content, includ-
able to generate effect sizes for the nonsignifi- ing psychoeducational content, sociocultural
cant intervention effects from 12 trials. As the resistance skills, body acceptance, healthy
best estimate of missing nonsignificant effect weight control skills, dissonance-induction
sizes is zero (Rosenthal 1991), we assumed an procedures, self-esteem enhancement, and
r = 0.00 for these missing effects. Only 8% of stress/coping skills were coded such that 1 =
the effect sizes examined in this meta-analysis present and 0 = absent. Trials that used mea-
were set to zero because they were missing. sures with established reliability and valid-
We calculated separate effect sizes for inter- ity (minimum requirement was evidence of
212 Stice · ·
Shaw Marti
internal consistency greater than 0.70 and groups are not reported here because the few
test-retest coefficients greater than 0.60 or ev- studies that conducted such analyses focused
idence of predictive validity) for at least 50% on different high-risk subgroups. Overall, 26
of the outcomes were coded as having used (51%) of the prevention programs resulted
validated measures (coded 1) and the remain- in significant reductions in at least one es-
ing were coded as having used nonvalidated tablished risk factor for eating pathology, and
measures (coded 0). Trials with less than a year 15 (29%) of the prevention programs resulted
of follow-up were coded = 1 and those with in significant reductions in eating pathology,
a longer follow-up were coded = 0. including evidence that certain interventions
The first author coded effect sizes and both reduce extant eating pathology and pre-
the second author coded the moderators, but vent increases in eating pathology that were
consulted each other when questions regard- observed in control groups. However, there
ing the coding of particular studies arose. Al- were a wide variety of intervention effects,
though this consensus approach allowed for which suggests that it is important to exam-
a refinement of the coding system and served ine factors that moderated the effect sizes ob-
to increase inter-rater agreement, it did not served across interventions.
lend itself to the calculation of intercoder
agreement.
Moderators of Intervention Effects
We tested for significant heterogeneity in the
RESULTS effect sizes with the random effects Q-test us-
We identified 66 published and unpublished ing the SPSS macro (Lipsey & Wilson 2001).
studies that met the inclusion criteria, in In the event of significant heterogeneity, we
which 51 eating disorder prevention pro- tested whether the moderators were related
grams were evaluated in 68 separate con- to observed effect sizes with the random ef-
trolled trials (11 programs were evaluated in fects SPSS macro (Lipsey & Wilson 2001) for
more than one trial, 9 trials evaluated 2 or inverse variance weighted regression. Mod-
3 interventions simultaneously, and 2 reports erators were first examined in separate uni-
described the results from 2 separate trials). variate regression models to investigate the
In total, this resulted in 81 separate effect univariate relations between moderators and
sizes estimates for eating disorder prevention effect sizes that were not complicated by co-
programs. These effect sizes are reported in linearity. Moderators that showed significant
Table 1. effects in the univariate models were then en-
tered in a multivariate model to estimate the
unique effect of each moderator controlling
Average Intervention Effect Sizes for the effects of the other moderators with
For each outcome, we calculated the weighted significant effects. Finally, we tested whether
average random effect size. Pearson’s r ’s were there was significant residual heterogeneity in
converted to z scores (Hedges & Olkin 1985) effect sizes after the moderators were entered
and the SPSS macro developed by Lipsey & into the multivariate models. This process was
Wilson (2001) was used to estimate the overall conducted separately for posttest effects and
inverse variance weighted average effect size long-term effects. The overall tests of hetero-
for random effects models. Table 2 reports geneity and results from the univariate models
the average effect sizes (r) for the intervention are presented in Table 2.
versus the control group, which were small
to moderate in magnitude. Effect sizes re- Body mass. There was significant hetero-
flect analyses performed on the entire samples geneity in the effect sizes for body mass at
used in these studies; effects for high-risk sub- posttest. However, there was insufficient

Table 1 Effect sizes for eating disorder prevention interventions

Body Thin-ideal Body Negative Eating
Study mass internalization dissatisfaction Dieting affect pathology
(Austin et al. 2005) — — — — — 0.00 (0.09)
(Baranowski et al. 2001) — — 0.29 (0.11) 0.40∗ (0.38∗ ) 0.19 (0.14) 0.19 (0.14)
(Becker et al. 2005) — 0.12∗ (0.14∗ ) 0.26∗ (25∗ ) 0.26∗ (0.25∗ ) — 0.30∗ (0.32∗ )
Dissonance
(Becker et al. 2005) — 0.06 (0.07) 0.22∗ (0.26)∗ 0.24∗ (0.25)∗ — 0.28∗ (0.32)∗
Psychoeducational
(Bearman et al. 2003) — — 0.39∗ (0.27∗ ) 0.13 (0.11) 0.38∗ (0.28∗ ) 0.22∗ (0.20∗ )
(Brown et al. 2004) — — −0.04 (0.00) 0.18∗ (0.00) — 0.02 (0.00)
(Buddeberg-Fischer et al. — — — — — 0.05
1998)
(Butters & Cash 1987) — — 0.50∗ — 0.59∗ —

(Celio et al. 2000) — — 0.29∗ (0.17) 0.30∗ (0.47∗ ) — 0.26 (0.18)
Computer
(Celio et al. 2000) Class — — 0.13 (0.27) 0.11 (0.23) — 0.12 (0.05)
(Chase 2001) — 0.10 (0.08) 0.14∗ (0.11) 0.21∗ (0.20∗ ) 0.14 (0.02) 0.00 (0.00)
(Dalle-Grave et al. 2001) — — 0.10 (0.08) 0.01 (0.00) 0.02 (0.01) 0.21 (0.10)
(Dworkin & Kerr 1987) — — 0.21∗ — 0.18∗ —
Cognitive therapy
(Dworkin & Kerr 1987) — — 0.34∗ — 0.31∗ —
Cognitive behavior
therapy
(Elliot et al. 2004) — 0.08∗ 0.01 0.07∗ — —
(Favaro et al. 2005) 0.02 — — 0.14 — 0.19
(Franko 1998) — 0.31 0.20 — — 0.15
(Franko et al. 2005) — 0.20∗ 0.07∗ 0.00 — 0.10
(Groesz & Stice 2006) — — 0.40∗ 0.36∗ — 0.28∗
Normal dieting
(Groesz & Stice 2006) — — 0.40∗ 0.33∗ — 0.25∗
Many small meals
( Jerome 1987) — — 0.00 0.00 — 0.00
( Jerome 1991) — — 0.00 0.00 0.00 0.00
(Kaminski et al. 1996) — 0.55∗ (0.44∗ ) 0.55∗ (0.56∗ ) 0.43∗ (0.44∗ ) 0.47∗ (0.55∗ ) —
(Kater et al. 2002) Girls — 0.06 0.10 — 0.05 —
(Kater et al. 2002) Boys — 0.08 0.06 — 0.11 —
(Killen et al. 1993) 0.00 — 0.00 (0.00) 0.00 0.00 (0.00)
(Kusel 1999) — 0.20 (0.00) 0.21∗ (0.00) 0.25∗ (0.00) 0.22∗ (0.00) 0.00 (0.00)
(Low et al. 2006) Student 0.00 (0.00) (0.00) 0.00 (0.16) — — −0.10 (0.12)
Bodies program
w/moderator
(Low et al. 2006) Student 0.00 (0.00) (0.00) 0.00 (0.33∗ ) — — 0.15 (0.54∗ )
Bodies program w/o
moderator
(Continued )
214 Stice · ·
Shaw Marti
Table 1 (Continued )
(Low et al. 2006) Student 0.00 (0.00) (0.00) 0.00 (0.19) — — 0.19 (0.20)
Bodies program, no
discussion
(Mann et al. 1997) 0.15 (0.11) — 0.03 (0.21) −0.22 (0.03) 0.03 (0.08) −0.09 (0.07)
(Martz & Bazzini 1999) (0.01) (0.08) (0.00) (0.08) — —
(Martz & Bazzini 1999) (0.00) (0.08) (0.06) (0.13) — —
(Matusek et al. 2004) — 0.42∗ 0.00 — — 0.30∗
Dissonance
(Matusek et al. 2004) — 0.42∗ 0.00 — — 0.30∗
Healthy weight
(McCabe et al. 2006) — — 0.00 — 0.03

(McVey & Davis 2002) — — −0.07 — — −0.02
(McVey et al. 2004) — — 0.13∗ (0.15∗ ) 0.15∗ (0.14∗ ) 0.15∗ (0.13∗ ) 0.17∗ (0.10)
(McVey et al. 2003) — — 0.23∗ (0.23∗ ) 0.17∗ (0.27∗ ) — 0.18∗ (0.27∗ )
(Moreno & Thelen 1993) — — — — — —
(Moreno & Thelen 1993) — — — — — —
(Mutterperl et al. 2002) 0.03 (0.03) 0.01 — — — 0.06 (0.06)
(Nebel 1995) — — 0.05 — 0.07 0.21∗
(Neumark-Sztainer et al. 0.09 (0.13∗ ) — 0.03 (0.03) 0.09 (0.07) 0.00 (0.05) 0.15∗ (0.15∗ )
1995)
(Neumark-Sztainer et al. — 0.05 (0.14∗ ) 0.10 (0.06) 0.07 (0.04) — 0.03 (0.05)
2000)
(Nicolino et al. 2001) — (0.15) (0.02) (0.20) (0.08) —
(O’Dea & Abraham (−0.11∗ ) 0.02 (0.13∗ ) 0.14∗ (0.05) 0.03 (0.05) 0.05 (0.05) 0.05 (0.05)
2000)
(Outwater 1990) — — 0.08 (0.08) — 0.01 (0.01) —
(Paxton 1993) (0.03) (0.10) (0.05) (0.13) (0.04) (0.17)
(Presnell et al. 2003) 0.40∗ — — 0.12 0.20 0.32∗
(Richman 1993) — — 0.24∗ 0.00 — 0.05
(Richman 1997) — — 0.15∗ (0.07) 0.11∗ (0.05) — 0.03 (0.08)
(Rosen et al. 1989) — — 0.50∗ (0.32∗ ) — — —
(Santonastaso et al. 1999) (0.01) — (0.14) — (0.11) (0.10)
(Shepard 2001) — 0.04 (0.04) 0.03 (0.02) — — 0.13 (0.11)
(Smolak et al. 1998a) — (0.18∗ ) (−0.05) (0.00) — —
(Smolak et al. 1998b) — (0.00) (−0.05) (0.00) — —
(Steiner-Adair et al. — 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) — —
2002)
(Stewart et al. 2001) — — 0.11∗ (0.06) 0.19∗ (0.08∗ ) 0.06 (0.04) 0.12∗ (0.10∗ )
(Stice et al. 2006a) 0.35∗ (0.35∗ ) 0.29∗ (0.25∗ ) 0.13 (0.30∗ ) 0.01 (0.32∗ ) 0.12 (0.09) 0.29∗ (0.34∗ )
(Stice et al. 2006b) — 0.25∗ (0.09) 0.23∗ (0.08) 0.25∗ (0.11) 0.18∗ (0.12) 0.27∗ (0.15)
(Stice et al. 2000) — 0.40∗ (0.43∗ ) 0.46∗ (0.42∗ ) 0.36 (0.27) 0.42∗ (0.32) 0.37∗ (0.37∗ )
(Stice & Ragan 2002) 0.32∗ 0.38∗ 0.25∗ 0.31∗ 0.14 0.34∗
(Continued )

Table 1 (Continued )
(Stice et al. 2006) 0.05 (0.15∗ ) 0.31∗ (0.17∗ ) 0.28∗ (0.30∗ ) 0.18∗ (0.18∗ ) 0.23∗ (0.11) 0.17∗ (0.16∗ )
Dissonance
(Stice et al. 2006) Healthy 0.12 (0.12) 0.20∗ (0.21∗ ) 0.16∗ (0.24∗ ) 0.05 (0.13) 0.16∗ (0.04) 0.20∗ (0.17∗ )
weight
(Stice et al. 2003) — 0.24 (0.15) 0.23 (0.13) 0.17 (0.09) 0.27∗ (0.26∗ ) 0.23∗ (0.21∗ )
Dissonance
(Stice et al. 2003) Healthy — 0.25 (0.20) 0.12 (0.15) 0.06 (0.13) 0.34∗ (0.23∗ ) 0.31∗ (0.22∗ )
weight
(Taylor et al. 2006) 0.00 (−0.02) — 0.38∗ (0.21)∗ — 0.08 (0.10) 0.11∗ (0.06)
(Varnado et al. 2001) — 0.43∗ — 0.05 0.06 0.28∗

Girls
(Varnado et al. 2001) Boys — 0.21∗ — 0.10 0.31∗ 0.12
(Wade et al. 2003) Media — — 0.16 (0.06) 0.18 (0.03) 0.03 (0.17) —
(Wade et al. 2003) Esteem — — 0.05 (0.05) 0.03 (0.00) 0.11 (0.07) —
(Weiss & Wertheim 2005) — 0.00 0.03 0.00 0.06 0.02
(Winzelberg et al. 1998) 0.11 (0.22) — 0.32∗ (0.31∗ ) — — 0.10 (0.20)
(Winzelberg et al. 2000) — — 0.17 (0.35∗ ) — — 0.16 (0.23)
(Wiseman et al. 2004) — — — 0.00 0.00 —
(Withers et al. 2002) — — 0.04 (0.03) 0.00 (0.00) — —
(Wolf-Bloom 1998) — 0.04 0.07 — 0.01 0.01
(Zabinski et al. 2004) 0.00 (0.00) — 0.25∗ (0.16) — 0.00 (0.27∗ ) —
(Zabinski et al. 2001) 0.07 — 0.01 — — —
Note: Effect sizes for pre-effects to post-effects are presented first; effect sizes for pre-analyses to follow-up analyses are presented in parentheses
when relevant. A dash indicates that we did not estimate the models because there was no significant heterogeneity in effects.
variability in self-esteem content and model (χ 2 [14] = 17.20, n.s.). Because there
stress/coping content for these moderators was no significant heterogeneity of effect
to be examined. Significantly smaller effects sizes for body mass at follow-up, it was not
occurred for programs with psychoeduca- appropriate to test for moderators of effect
tional content (Mr = 0.06, p < 0.05) than size in univariate or multivariate models.
those without this content (Mr = 0.19,
p < 0.001). Programs emphasizing sociocul-
tural resistance skills (Mr = 0.02, n.s.) had Thin-ideal internalization. There was sig-
significantly smaller effects than programs nificant heterogeneity of effect sizes for
without this content (Mr = 0.17, p < 0.001). thin-ideal internalization at posttest. A uni-
Intervention effects were significantly larger variate model indicated that selected pro-
in programs that focused on body acceptance grams produced significantly larger de-
(Mr = 0.14, p < 0.001) versus those that did creases in thin-ideal internalization (Mr =
not (Mr = 0.01, n.s.). In the multivariate 0.24, p < 0.001) than universal programs
model, the effect for sociocultural resistance (Mr = 0.10, p < 0.05). Significantly larger
skills content (z = −2.26, p < 0.05) remained effects were observed for trials focusing
significant. There was no significant het- on participants over age 15 (Mr = 0.23,
erogeneity of effect size in this multivariate p < 0.001) than for trials focusing on younger
216 Stice · ·
Shaw Marti
ANRV307-CP03-09
Table 2 Overall average effect sizes, overall tests of heterogeneity, and univariate effects for moderators
Thin-ideal
ARI
Study Body mass internalization Body dissatisfaction Dieting Negative affect Eating pathology
Overall models
Average effect size (r) 0.10∗∗∗ (0.04) 0.18∗∗∗ (0.14∗∗∗ ) 0.14∗∗∗ (0.11∗∗∗ ) 0.12∗∗∗ (0.09∗∗∗ ) 0.12∗∗∗ (0.09) 0.13∗∗∗ (0.13∗∗∗ )
Test of heterogeneity (x2) 37.3∗∗ (22.3) 93.1∗∗∗ (30.41) 196.80∗∗∗ (74.71∗∗ ) 99.09∗∗∗ (64.49∗∗ ) 81.91∗∗∗ (29.23) 112.05∗∗∗ (66.99∗∗ )
Moderators
20 February 2007
Risk status of participants 1.11 (—) 2.77∗∗ (—) 5.26∗∗∗ (6.13∗∗∗ ) 4.19∗∗∗ (4.97∗∗∗ ) 4.71∗∗∗ (—) 5.71∗∗∗ (4.18∗∗∗ )
Sex 0.98 (—) 1.27 (—) 0.82 (2.82∗∗ ) 1.50 (2.29∗ ) 1.01 (—) 1.53 (1.30)
Age 1.44 (—) 2.29∗ (—) 2.44∗ (4.38∗∗∗ ) 1.76 (3.22∗∗ ) 2.32∗ (—) 3.22∗∗ (2.83∗∗ )
20:46
Session format 1.76 (—) 0.54 (—) 2.40∗ (2.21∗ ) 2.67∗∗ (2.54∗∗ ) 2.18∗ (—) 3.21∗∗ (2.33∗∗ )
Interventionist 1.06 (—) 1.75 (—) 2.35∗ (3.17∗∗ ) 2.09∗ (1.97∗ ) 2.29∗ (—) 1.79 (0.84)
One-shot intervention −0.11 (—) −0.65 (—) 1.74 (−0.20) 3.15∗∗ (0.36) 1.95 (—) 1.14 (0.06)
Psychoeducational content −2.60∗∗ (—) −2.18∗ (—) −4.71∗∗∗ (−1.43) −3.17∗∗ (−1.11) −5.53∗∗∗ (—) −4.07∗∗∗ (−2.53∗∗ )
Sociocultural content −4.17∗∗∗ (—) −0.29 (—) −0.69 (−1.02) 0.27 (−0.32) −0.98 (—) −0.33 (−0.03)
Healthy weight content −0.72 (—) 0.74 (—) −1.05 (−0.18) 0.15 (0.02) −0.71 (—) −0.10 (−0.64)
Stress and coping content NA −2.05∗ (—) −0.81 (−0.55) −0.31 (0.20) −0.38 (—) −0.53 (−0.29)
Self-esteem content NA −0.35 (—) −0.87 (−0.69) −1.12 (−0.03) −1.03 (—) −1.48 (−0.96)
Body enhancement content −2.08∗ (—) 2.82∗∗ (—) 1.73 (0.98) 1.96 (2.29∗ ) 2.07∗ (—) 1.29 (0.81)
Dissonance content −0.57 (—) 2.22∗∗ (—) 2.10∗ (1.38) 2.78∗∗ (1.80) 2.39∗∗ (—) 3.11∗∗ (2.44∗ )
Validated measures 0.51 (—) 2.23∗ (—) 1.65 (2.68∗∗ ) 1.33 (1.55) 0.82 (—) 1.40 (0.76)
Length of follow-up — (—) — (—) — (−0.25) — (0.90) — (—) — (2.45∗ )
∗
= 0.05, ∗ ∗ = 0.01, ∗ ∗∗ = 0.001.
Note: Effects for moderators for pre to post-analyses (z-scores) are presented first; effects for moderators for pre-analyses to follow-up analyses are presented in parentheses when relevant. A
dash indicates that we did not estimate the models because there was no significant heterogeneity in effects. NA indicates that the models did not converge because of the limited number of
effect sizes for body mass index.
www.annualreviews.org • Eating Disorder Prevention Programs

217
participants (Mr = 0.11, p < 0.05). Programs providers (Mr = 0.09, p < 0.001). Programs
with psychoeducational content (Mr = 0.14, with psychoeducational content (Mr = 0.09,
p < 0.001) had significantly smaller ef- p < 0.001) had significantly smaller effects
fects than those that did not (Mr = 0.25, than those with no psychoeducational content
p < 0.001). Intervention effects were signif- (Mr = 0.25, p < 0.001). Intervention effects
icantly larger in programs that focused on were significantly larger for programs with
body acceptance (Mr = 0.28, p < 0.001) ver- dissonance content (Mr = 0.24, p < 0.001)
sus those that did not (Mr = 0.13, n.s.). relative to those without this content (Mr =
Studies that focused on stress and coping 0.13, p < 0.001). In the multivariate model
skills (Mr = 0.07, n.s.) showed significantly with the five moderators that showed sig-
smaller effects than programs without this nificant univariate effects, the effects for
focus (Mr = 0.21, p < 0.001). Intervention selected versus universal programs (z =
effects were significantly larger for pro- 3.50, p < 0.001), participant age (z = −1.97,
grams with dissonance content (Mr = 0.28, p < 0.05), and psychoeducational content (z =
p < 0.001) relative to those without this con- −2.15, p < 0.05) remained significant. There
tent (Mr = 0.15, p < 0.001). Interventions was no significant residual heterogeneity in
produced significantly larger effect sizes for effect sizes (χ 2 [48] = 49.53, n.s.) when these
thin-ideal internalization in trials that used six predictors were entered into the model.
validated measures (Mr = 0.22, p < 0.001) There was significant heterogeneity of ef-
than in trials that used unvalidated measures fect sizes for body dissatisfaction at follow-
(Mr = 0.06, n.s.). No moderators remained up. A univariate model indicated that selected
significant in the multivariate model; how- programs produced significantly larger de-
ever, the residual variance did not differ from creases in body dissatisfaction (Mr = 0.19,
zero (χ 2 [19] = 30.68, p < 0.05), which indi- p < 0.001) than universal programs (Mr =
cates that these moderators accounted for the 0.05, p < 0.001). Significantly larger decreases
variability in effect sizes. Because there was in body dissatisfaction were observed for in-
no significant heterogeneity of effect sizes for terventions offered to female-only samples
thin-ideal internalization at follow-up, we did (Mr = 0.13, p < 0.001) than for interventions
not test for moderators of effect size. offered to samples containing males (Mr =
0.03, n.s.). Significantly larger effects were ob-
Body dissatisfaction. There was significant served for trials focusing on participants over
heterogeneity of effect sizes for body dis- age 15 (Mr = 0.16, p < 0.001) than for trials
satisfaction at posttest. A univariate model with participants with an average age under
indicated that selected programs produced 15 (Mr = 0.05, p < 0.001). Interactive pro-
significantly larger decreases in body dissat- grams produced significantly larger decreases
isfaction (Mr = 0.22, p < 0.001) than univer- in body dissatisfaction (Mr = 0.12, p < 0.001)
sal programs (Mr = 0.06, p < 0.001). Signif- than studies that used didactic programs
icantly larger effects were observed for trials (Mr = 0.04, n.s.). Interventions adminis-
focusing on participants over age 15 (Mr = tered by trained professionals (Mr = 0.14,
0.18, p < 0.001) than for trials focusing on p < 0.001) had significantly larger effects than
younger participants (Mr = 0.08, p < 0.001). those administered by endogenous providers
Interactive programs produced significantly (Mr = 0.05, p < 0.01). Interventions pro-
larger decreases in body dissatisfaction (Mr = duced significantly larger effects in trials
0.16, p < 0.001) than studies that used didac- that used validated measures (Mr = 0.12,
tic programs (r = 0.06, p < 0.01). Programs p < 0.001) than in trials that used unvalidated
administered by an interventionist (Mr = measures (Mr = 0.03, n.s.). In the multivari-
0.18, p < 0.001) had significantly larger ef- ate model with the seven variables that showed
fects than those administered by endogenous significant univariate effects, only the effect
218 Stice · ·
Shaw Marti
for selected versus universal focus (z = 3.43, (Mr = 0.03, n.s.). Significantly larger effects
p < 0.001) remained significant. There was were observed for trials focusing on partic-
no significant residual heterogeneity in effect ipants over age 15 (Mr = 0.14, p < 0.001)
sizes (χ 2 [39] = 33.36, n.s.) when these seven than for trials focusing on younger partici-
predictors were entered into the model. pants (Mr = 0.05, p < 0.01). Interactive pro-
grams produced significantly larger effects
Dieting. There was significant heterogene- (Mr = 0.11, p < 0.001) than studies that used
ity of effect sizes for dieting at posttest. didactic programs (r = 0.03, n.s.). Prevention
A univariate model indicated that selected programs administered by an intervention-
programs (Mr = 0.20, p < 0.001) produced ist (Mr = 0.12, p < 0.001) had significantly
significantly larger decreases in dieting than larger effects than those administered by en-
universal programs (Mr = 0.06, p < 0.01). dogenous providers (Mr = 0.06, p < 0.01).
Interactive programs produced significantly Intervention effects were significantly larger

larger effects (Mr = 0.14, p < 0.001) than in programs with a body acceptance com-
didactic programs (r = 0.02, n.s.). Inter- ponent (Mr = 0.13, p < 0.001) versus those
ventions delivered by an interventionist without (Mr = 0.05, p < 0.01). Selected pro-
(Mr = 0.15, p < 0.001) had significantly gram was the only moderator effect that
larger effect sizes than those delivered by remained significant (z = 2.76, p < 0.01) in
endogenous providers (Mr = 0.07, p < 0.05). the multivariate model; there was no signif-
Multisession programs produced significantly icant residual heterogeneity in effect sizes (χ 2
larger effects (Mr = 0.14, p < 0.001) than [30] = 34.45, n.s.) when these predictors were
single-session programs (Mr = −0.05, n.s.). entered simultaneously.
Programs with psychoeducational content
(Mr = 0.09, p < 0.001) had significantly Negative affect. There was significant het-
smaller effects than those that did not erogeneity of effect sizes for negative af-
(Mr = 0.20, p < 0.001). Intervention effects fect at posttest. A univariate model in-
were significantly larger for programs with dicated that selected programs produced
dissonance content (Mr = 0.25, p < 0.001) significantly larger decreases in negative af-
relative to those without this content fect (Mr = 0.20, p < 0.001) than did uni-
(Mr = 0.11, p < 0.001). In the multivari- versal programs (Mr = 0.06, p < 0.001). Sig-
ate model, effects for selected programs nificantly larger effects were observed for
(z = 2.03, p < 0.05), trained intervention- trials focusing on participants over age
ist (z = 2.49, p < 0.05), and multisession 15 (Mr = 0.16, p < 0.001) than for trials
programs (z = 2.60, p < 0.01) remained focusing on younger participants (Mr =
significant. There was no significant residual 0.06, p < 0.001). Interactive programs pro-
heterogeneity in effect sizes (χ 2 [34] = 40.26, duced significantly larger effects (Mr = 0.13,
n.s.) when these predictors were entered into p < 0.001) than didactic programs (Mr =
the model. 0.03, n.s.). Programs delivered by an inter-
There was significant heterogeneity of ventionist (Mr = 0.16, p < 0.001) had signif-
effect sizes for dieting at follow-up. A icantly larger effects than those delivered by
univariate model indicated that selected endogenous providers (Mr = 0.07, p < 0.01).
programs (Mr = 0.18, p < 0.001) produced Programs with psychoeducational content
significantly larger decreases in dieting than (Mr = 0.06, p < 0.001) produced significantly
universal programs (Mr = 0.04, p < 0.01). smaller effects than programs without this
Significantly larger effects were observed for content (Mr = 0.21, p < 0.001). Interven-
interventions offered to female-only sam- tion effects were significantly larger in pro-
ples (Mr = 0.11, p < 0.001) than for inter- grams that focused on body acceptance (Mr =
ventions offered to samples containing males 0.15, p < 0.001) versus those that did not

(Mr = 0.07, p < 0.001). Intervention effects up. A univariate model indicated that se-
were significantly larger for programs with lected programs produced significantly larger
dissonance content (Mr = 0.21, p < 0.001) decreases in eating pathology (Mr = 0.19,
relative to those without this content (Mr = p < 0.001) than universal programs (Mr =
0.10, p < 0.001). In the multivariate model, 0.07, p < 0.001). Significantly larger effects
more of the univariate effects remained sig- were observed for trials focusing on partic-
nificant. There was no significant resid- ipants over age 15 (Mr = 0.16, p < 0.001)
ual heterogeneity in effect sizes (χ 2 [26] = than for trials focusing on younger par-
33.14, n.s.) when all seven predictors were ticipants (Mr = 0.08, p < 0.001). Interactive
entered simultaneously. Because there was programs produced significantly larger ef-
no significant heterogeneity of effect sizes fects (Mr = 0.14, p < 0.001) than did didac-
for negative affect at follow-up, it was tic programs (Mr = 0.04, n.s.). Programs that
not appropriate to test for moderators of contained psychoeducational content (Mr =

effect size in univariate or multivariate 0.11, p < 0.001) had significantly smaller ef-
models. fects than those without this content (Mr =
0.19, p < 0.001). Intervention effects were
Eating pathology. There was significant significantly larger for programs with dis-
heterogeneity of effect sizes for eating pathol- sonance content (Mr = 0.21, p < 0.001) rel-
ogy at posttest. A univariate model indi- ative to those without this content (Mr =
cated that selected programs produced signif- 0.11, p < 0.001). Programs that had a follow-
icantly larger decreases in eating pathology up period of less than one year (Mr = 0.15,
(Mr = 0.21, p < 0.001) than universal pro- p < 0.001) exhibited significantly larger effect
grams (Mr = 0.06, p < 0.001). Significantly sizes than those with a longer follow-up pe-
larger effects were observed for trials focus- riod (Mr = 0.07, p < 0.001). In the multivari-
ing on participants over age 15 (Mr = 0.17, ate model with the six variables that showed
p < 0.001) than for trials focusing on younger significant univariate effects, none of the mod-
participants (Mr = 0.07, p < 0.001). Interac- erators were significant predictors individu-
tive programs produced significantly larger ally. There was no significant residual hetero-
effects (Mr = 0.16, p < 0.001) than did di- geneity in effect sizes (χ 2 [31] = 38.20, n.s.)
dactic programs (Mr = 0.03, n.s.). Signifi- when these five predictors were entered into
cantly smaller effects occurred for programs the model.
with psychoeducational content (Mr = 0.10,
p < 0.001) than those without this content
(Mr = 0.22, p < 0.001). Intervention effects DISCUSSION
were significantly larger for programs with
dissonance content (Mr = 0.25, p < 0.001)
Summary of Average Effect Sizes
relative to those without this content (Mr = This meta-analytic review found that 51%
0.11, p < 0.001). In the multivariate model of eating disorder prevention programs re-
with the four variables that showed signifi- duced eating disorder risk factors and that
cant univariate effects, the effects for selected 29% reduced current or future eating pathol-
programs (z = 2.43, p < 0.05) and program ogy. The overall percentage of prevention
format (z = 2.47, p < 0.05) remained signifi- programs that produced effects for eating
cant. There was no significant residual hetero- pathology compares favorably to the suc-
geneity in effect sizes (χ 2 [45] = 49.87, n.s.) cess rates of prevention programs for other
when these six predictors were entered into public health problems, including obesity
the model. (21%; Stice et al. 2006d) and HIV (22%;
There was significant heterogeneity of ef- Logan et al. 2002). Although it is encourag-
fect sizes for eating pathology at following that the average effect sizes were at least
220 Stice · ·
Shaw Marti
statistically significant, given that early eat- engage more effectively in the prevention pro-
ing disorder prevention programs were gram and the lower levels of eating pathology
unsuccessful at reducing risk factors for in unselected samples may attenuate interven-
eating disorders or eating pathology, the tion effects.
average effects were small. Fortunately,
the individual effect sizes from the pre- Participant sex. Intervention effects were
vention trials ranged from nonexistent to significantly larger for programs that focused
large, and the moderation analyses iden- solely on females versus those that included
tified several factors that were associated males, but only for two of the six outcomes.
with larger effects. Certain prevention pro- Theoretically, effects are more pronounced
grams produced very promising effects. For for females because the elevated body image
example, a number of interventions have and eating disturbances that occur for this sex
produced medium-sized effects for eating may motivate them to engage more effectively
pathology that persisted through follow-up in the intervention and because there may be
(e.g., Becker et al. 2005, Low et al. 2006). floor effects for samples containing males.
Other programs reduced risk for onset of
threshold or subthreshold eating disorders Participant age. Intervention effects were
(Stice et al. 2004b, Taylor et al. 2006). One significantly larger for samples in which par-
program reduced risk for future onset of both ticipants were over, versus under, 15 year of
eating disorder symptoms and obesity and re- age for five of the six outcomes. Interven-
sulted in improved psychosocial functioning tions may be more effective for the former
and reduced mental health care utilization because they were delivered during the period
(Stice et al. 2006c). of greatest risk for emergence of eating dis-
turbances, because younger adolescents may
have limited insight, or because of a floor ef-
Summary of Effect Size Moderators fect caused by the low levels of eating pathol-
Risk status of participants. Selected pro- ogy during early adolescence.
grams produced larger intervention effects
than did universal programs for five out of Program format. Intervention effects were
the six outcomes. It was noteworthy that only significantly stronger for interactive versus
selected interventions prevented the future didactic programs for four of the six out-
increases in eating pathology observed in con- comes. Other prevention researchers have
trol groups because this suggests that the ef- concluded that psychoeducational interven-
fects are not merely resulting because the tions are less effective than interventions that
programs decrease initial elevations in eating actively engage participants and teach new
disturbances. Mirroring the pattern of find- skills (Larimer & Cronce 2002). We posit that
ings across studies, several universal preven- an interactive format helps participants en-
tion programs were more effective for sub- gage in the program, which likely facilitates
groups of high-risk participants than for the acquisition of concepts and promotes attitu-
full sample (Buddeberg-Fischer et al. 1998, dinal and behavioral change.
Killen et al. 1993, Stewart et al. 2001, Stice
et al. 2004b, Weiss & Wertheim 2005). Meta- Type of interventionist. Prevention pro-
analytic reviews have found that selected pre- grams delivered by trained interventionists
vention programs produce larger effects than were more effective than those delivered
universal prevention programs for obesity and by endogenous providers (e.g., teachers) for
depression (Horowitz & Garber 2006, Stice three of the six outcomes. Effects may be
et al. 2006d). The distress that characterizes smaller for endogenous providers because
high-risk individuals may motivate them to they have other responsibilities that make

it difficult to deliver the prevention pro- tive affect, and eating pathology than did pro-
gram with fidelity, have fewer opportunities grams without this content, providing support
to practice intervention delivery relative to for the utility of this attitudinal change ap-
trained interventionists, and do not receive proach. Sociocultural content was associated
as much specialized training and detailed su- with smaller effects for body mass, and a stress
pervision. This finding suggests that preven- and coping focus was associated with weaker
tion programs that have emerged as effica- effects for thin-ideal internalization, but the
cious may not be effective when delivered effects of these moderators was limited. It is
under ecologically valid conditions by en- important to note, however, that the content
dogenous providers. of the 15 programs that produced intervention
effects for eating pathology varied dramati-
Number of sessions. Results provided lim- cally, including programs that focused on pro-
ited support for the hypothesis that brief moting self-esteem, stress management skills,
single-session programs would be less effec- body acceptance, healthy weight control be-
tive than longer multisession programs, in haviors, and critical analysis of the thin-ideal,
that the latter only produced significantly which suggests that there are multiple meth-
stronger intervention effects for one of the ods to successfully prevent eating pathology
six outcomes. We had postulated that multi- or that nonspecific factors account for much
session interventions might produce stronger of the intervention effects.
effects because it is useful for participants to
reflect on intervention material between ses- Use of validated measures. There was some
sions and because intersession periods give support for the hypothesis that intervention
them a chance to try new skills and return to effects would be larger for trials that used val-
the group for troubleshooting advice. idated outcome measures, but only for two of
the six outcomes. Presumably, validated mea-
Program content. Certain program content sures are more sensitive in detecting inter-
was associated with intervention effects, but vention effects. Results imply that researchers
other content was not (e.g., content focus- should only use measures with established re-
ing on healthy weight control skills and self- liability and validity for the population under
esteem). Psychoeducational content was asso- study.
ciated with weaker effects for all six outcomes,
providing support for the assertion that psy- Length of follow-up. There was little sup-
choeducational content is ineffective in pro- port for the expectation that prevention trials
ducing behavioral change (Larimer & Cronce with longer follow-ups would produce weaker
2002). There was also evidence that interven- effects, in that follow-up length only moder-
tions focusing on body acceptance were more ated the effects of one of the six outcomes ex-
effective than programs without this focus. amined. This finding probably emerged be-
This effect may have emerged because body cause prevention effects tend to fade over
dissatisfaction increases risk for a variety of time, which may be unavoidable given the
problems, including unhealthy dieting, neg- ubiquitous sociocultural pressures for thin-
ative affect, and eating-disordered behavior ness in our culture.
(e.g., vomiting for weight control) and that
a reduction in body dissatisfaction results in
decreases in these downstream disturbances. CAVEATS OF MODERATOR
Programs with dissonance-induction content ANALYSES
designed to reduce thin-ideal internalization First, because our power to detect modera-
produced larger effects for thin-ideal inter- tors was limited by the fact that we only had
nalization, body dissatisfaction, dieting, nega- a moderate number of effect sizes for certain
222 Stice · ·
Shaw Marti
outcomes, null findings should be interpreted and can be considered to be effective inter-
with caution. Second, evidence that a mod- ventions. Finally, select prevention programs
erator is associated with intervention effect have produced intervention effects for both
sizes does not establish causality. It is possible eating pathology and obesity (Planet Health,
that a particular effect is due to some other Healthy Weight), which is desirable because
variable that was not modeled (e.g., perhaps programs that impact multiple public health
the prevention programs for those under the problems are more desirable from a dissemi-
age of 15 are less effective because they are nation perspective than those that just impact
less likely to target causal risk factors). Third, a single problem.
many of the conclusions regarding modera-
tors of intervention effects are based on the-
oretical considerations rather than on direct NEGATIVE FEATURES OF THE
EATING DISORDER
empirical evidence. For instance, although we

posit that selected programs produce large ef- PREVENTION LITERATURE

fects because the distress that may character- There are also several areas of concern regard-
ize high-risk samples leads them to engage ing the eating disorder prevention literature.
more effectively in the program content, no First, even the effect sizes for the most promis-
trials have directly confirmed this speculation. ing programs could be larger, which suggests
that it will be vital to explore methods of pro-
ducing larger and more persistent effects. It is
POSITIVE FEATURES OF THE our impression that greater use of persuasion
EATING DISORDER principles from social psychology may prove
PREVENTION LITERATURE useful in this regard, but other alternatives
A number of positive developments have oc- should also be explored, such as the use of
curred in the eating disorder prevention field. booster sessions, adjunctive bibliotherapy, or
First, several prevention programs have re- school-wide interventions that challenge un-
duced current and future eating disorder healthy norms.
symptoms, which has been an elusive goal. Second, few studies have examined the me-
Second, the positive effects of certain eating diators that account for intervention effects,
disorder prevention programs have now been which is vital for testing the intervention the-
replicated in multiple trials conducted by the ory specific to each program and for explor-
same lab (Girl Talk, McVey et al. 2003; Stu- ing the effects of nonspecific factors. The
dent Bodies, Taylor et al. 2006) and some have fact that several interventions did not produce
been replicated by trials conducted by inde- significantly stronger effects than minimal-
pendent labs (Body Project, Stice et al. 2006c; intervention control conditions (e.g., Celio
Healthy Weight, Stice et al. 2006c). Third, et al. 2000, Mutterperl & Sanderson 2002,
several prevention programs have now been Nicolino et al. 2001; but see also Becker et al.
found to significantly outperform active al- 2007, Dworkin & Kerr 1987, Rosen et al.
ternative interventions (Body Project, Healthy 1989, Stice et al. 2006c) suggests that nonspe-
Weight). Thus, a handful of prevention pro- cific factors should be examined as potential
grams can now be considered empirically mediators. Refinement of the theory regard-
established prevention programs (e.g., effica- ing factors that mediate intervention effects
cious interventions). Fourth, certain preven- may facilitate the design of more effective
tion programs have been shown to be effective interventions.
when delivered by endogenous providers un- Third, only a handful of studies have exam-
der ecologically valid conditions (Body Project; ined moderators of intervention effects (e.g.,
Girl Talk; Planet Health, Austin et al. 2005; Taylor et al. 2006). These types of analyses
Weigh to Eat, Neumark-Sztainer et al. 1995) may provide important information regarding

the types of participants who show the best interventions are effective when endogenous
response to extant prevention programs and providers are responsible for recruitment of
suggest future directions for designing pro- participants and intervention delivery. It was
grams for those who do not respond to current also worrisome that many researchers did not
interventions. test for differential change in outcomes across
Fourth, randomized prevention trials offer intervention condition, which is essential for
a unique opportunity to provide experimental the proper interpretation of intervention ef-
tests of etiologic theory. Prevention programs fects. Finally, many researchers did not report
that focus on reducing a sole putative risk fac- effect sizes, which makes it difficult for readers
tor provide a strong test of the effect of that to properly interpret the findings.
factor on eating pathology, particularly when
a placebo control condition is used to control
CONCLUSIONS AND
for nonspecific factors. Experimental tests of

etiologic theory are vital because there is al- DIRECTIONS FOR FUTURE
ways a possibility that some confounding vari- RESEARCH
able explains the relation between a risk factor This review revealed that a number of promis-
and future eating pathology from prospective ing eating disorder prevention programs have
studies. For example, it was noteworthy that been developed. Several have decreased cur-
three of the interventions that reduced eating rent eating pathology and the risk for future
disorder symptoms increased dietary restric- increases in eating pathology. The majority
tion (Groesz & Stice 2006, Presnell & Stice decreased risk factors for eating pathology.
2003, Stice et al. 2006c)—a variable that is Certain intervention effects persisted as long
widely accepted to be a risk factor for eating as two years and were superior to minimal-
pathology. These results suggest the need for intervention control conditions. The het-
refinement of one of the most widely accepted erogeneity in the content of the successful
etiologic risk factors for eating pathology. In programs implies that there may be several
addition, trials indicating that a program re- approaches to preventing eating disturbances,
duced a putative risk factor, but not eating dis- but it appeared that successful programs of-
order symptoms, might suggest that said risk ten decreased attitudinal risk factors and pro-
factor is not a causal risk factor. moted healthier weight control behaviors.
Fifth, there are a number of general There was evidence that larger intervention
methodological limitations of this literature. effects occurred for programs that were se-
Many prevention trials did not include a con- lected (versus universal), interactive (versus
trol group, which makes it impossible to sep- didactic), multisession (versus single-session),
arate the effects of the intervention from the solely offered to females (versus both sexes),
effects from the passage of time, regression offered to participants over age 15 (versus
to the mean, or measurement artifacts. Vir- younger participants), and delivered by pro-
tually all trials have not used placebo or al- fessional interventionists (versus endogenous
ternative intervention control groups, making providers). Further, programs with body ac-
it impossible to separate intervention effects ceptance and dissonance-induction content
from effects arising from nonspecific fac- and without psychoeducational content and
tors, demand characteristics, or expectancies. programs evaluated in trials using validated
Numerous eating disorder prevention trials measures and a shorter follow-up period also
did not include a measure of eating disorder produced larger effects.
symptoms or diagnoses, which limits what can We hope that the next generation of eat-
be learned from these trials. Few prevention ing disorder prevention trials will build upon
programs have been evaluated in effectiveness these promising emerging results and will ad-
trials that attempt to determine whether these dress the limitations of extant programs and
224 Stice · ·
Shaw Marti
trials. It would be useful for future studies important to conduct independent replica-
to refine the most efficacious interventions tions of the most promising prevention tri-
in an effort to increase the yield of these als. Greater attention should also be devoted
programs. It will also be important to con- to developing general prevention techniques
duct more detailed examinations of medi- that are independent of the specific content
ators and moderators of intervention ef- of the intervention, such as strategic self-
fects. Another vital direction will be to begin presentation, motivational interviewing, and
conducting effectiveness trials that evaluate other persuasion techniques from social psy-
whether interventions produce effects when chology. We believe that a commitment to
delivered under ecologically valid conditions methodologically rigorous and programmatic
and to conduct studies that begin to eluci- studies will allow the next generation of stud-
date barriers to successful dissemination of ies to bring us closer to the goal of reducing
the most promising interventions. It will be the prevalence of eating disorders.

SUMMARY POINTS
1. This meta-analysis identified moderators of eating disorder prevention programs that
produced the largest intervention effects.
2. Programs that tended to produce larger intervention effects were selective, interactive,
multisession, offered only to females, offered to participants over age 15, delivered by
professional interventionists, incorporated body acceptance and dissonance-induction
content, evaluated in trials using validated measures, lacked psychoeducational con-
tent, and had a shorter follow-up period.
3. There are several empirically established eating disorder prevention programs, some
of which have also been shown to be effective when delivered by endogenous providers
under ecologically valid conditions.
4. Some of these prevention programs have produced intervention effects for both eating
pathology and obesity, which is promising from a public health standpoint.
FUTURE DIRECTIONS
1. Programs need to be further refined to produce larger intervention effects. Adopting
social psychological persuasion principles, using booster sessions, adjunctive biblio-
therapy, or school-wide interventions that challenge unhealthy norms are possible
directions to take to reach this goal.
2. Additional research is needed to elucidate the mediators of intervention effects, which
is crucial for testing intervention theories specific to each program and for exploring
the effects of nonspecific factors.
3. Randomized prevention trials that manipulate individual risk factors and use placebo
comparison groups to control for nonspecific factors are needed to rule out the possi-
bility that the relation between a risk factor and future eating pathology from prospec-
tive research is due to a confounding variable.

4. Effectiveness trials that are delivered under ecologically valid conditions and that can
elucidate barriers to successfully disseminating promising interventions are needed.
5. The development of general prevention techniques that are independent of the con-
tent of the intervention is also needed.
ACKNOWLEDGMENTS
Preparation of this manuscript was supported by research grants (MH/DK61957 and
MH70699) from the National Institutes of Health. We are grateful to Krista Heim and Emily
Wade for their assistance with the preparation of this article. Thanks also go to the numerous
authors who were kind enough to provide effect sizes or conduct additional analyses when
requested.
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AR307-FM ARI 2 March 2007 14:4
Annual Review of
Clinical Psychology
Contents Volume 3, 2007

Mediators and Mechanisms of Change in Psychotherapy Research

Alan E. Kazdin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
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Drug Abuse in African American and Hispanic Adolescents: Culture,
Development, and Behavior
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and Daniel A. Santisteban p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 77
Depression in Mothers
Sherryl H. Goodman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p107
Prevalence, Comorbidity, and Service Utilization for Mood Disorders
in the United States at the Beginning of the Twenty-first Century
Ronald C. Kessler, Kathleen R. Merikangas, and Philip S. Wang p p p p p p p p p p p p p p p p p p p p p137
Stimulating the Development of Drug Treatments to Improve
Cognition in Schizophrenia
Michael F. Green p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p159
Dialectical Behavior Therapy for Borderline Personality Disorder
Thomas R. Lynch, William T. Trost, Nicholas Salsman,
and Marsha M. Linehan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p181
A Meta-Analytic Review of Eating Disorder Prevention Programs:
Encouraging Findings
Eric Stice, Heather Shaw, and C. Nathan Marti p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p207
Sexual Dysfunctions in Women
Cindy M. Meston and Andrea Bradford p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p233
Relapse and Relapse Prevention
Thomas H. Brandon, Jennifer Irvin Vidrine, and Erika B. Litvin p p p p p p p p p p p p p p p p p p p257
vii
AR307-FM ARI 2 March 2007 14:4
Marital and Family Processes in the Context of Alcohol Use and

Alcohol Disorders
Kenneth E. Leonard and Rina D. Eiden p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p285
Unwarranted Assumptions about Children’s Testimonial Accuracy
Stephen J. Ceci, Sarah Kulkofsky, J. Zoe Klemfuss, Charlotte D. Sweeney,
and Maggie Bruck p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p311
Expressed Emotion and Relapse of Psychopathology
Jill M. Hooley p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p329
Sexual Orientation and Mental Health
Gregory M. Herek and Linda D. Garnets p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p353

Coping Resources, Coping Processes, and Mental Health

Shelley E. Taylor and Annette L. Stanton p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p377
Indexes
Cumulative Index of Contributing Authors, Volumes 1–3 p p p p p p p p p p p p p p p p p p p p p p p p p p p403

Cumulative Index of Chapter Titles, Volumes 1–3 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p405
Errata
An online log of corrections to Annual Review of Clinical Psychology chapters (if any)
may be found at http://clinpsy.AnnualReviews.org
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ANRV307-CP03-09 ARI 20 February 2007 20:46

Annu. Rev. Clin. Psychol. 2007. 3:207–31 Key Words

INTERVENTION FEATURES . . . . 210 CAVEATS OF MODERATOR

SIGNIFICANCE evaluated in controlled trials and investigates

dissatisfaction, and negative affect have pre- PARTICIPANT FEATURES

ture eating pathology in multiple prospec- associated with

www.annualreviews.org • Eating Disorder Prevention Programs 209

toward the new Researchers have concluded that brief single-

of intervention effects in prevention trials ies without minimal-intervention, placebo,

www.annualreviews.org • Eating Disorder Prevention Programs 211

Effect Size Estimation Procedures vention effects at posttest and at follow-up

www.annualreviews.org • Eating Disorder Prevention Programs 213

Table 1 Effect sizes for eating disorder prevention interventions

(Butters & Cash 1987) — — 0.50∗ — 0.59∗ —

(McCabe et al. 2006) — — 0.00 — 0.03

www.annualreviews.org • Eating Disorder Prevention Programs 215

(Varnado et al. 2001) — 0.43∗ — 0.05 0.06 0.28∗

www.annualreviews.org • Eating Disorder Prevention Programs

Interactive programs produced signiﬁcantly Intervention effects were signiﬁcantly larger

www.annualreviews.org • Eating Disorder Prevention Programs 219

not appropriate to test for moderators of contained psychoeducational content (Mr =

www.annualreviews.org • Eating Disorder Prevention Programs 221

empirical evidence. For instance, although we

posit that selected programs produce large ef- PREVENTION LITERATURE

www.annualreviews.org • Eating Disorder Prevention Programs 223

for nonspeciﬁc factors. Experimental tests of

the most promising interventions. It will be the prevalence of eating disorders.

www.annualreviews.org • Eating Disorder Prevention Programs 225

Favaro A, Zanetti T, Huon G, Santonastaso P. 2005. Engaging teachers in an eating disorder

www.annualreviews.org • Eating Disorder Prevention Programs 227

meta-analytic chol. Bull. 128:851–85

lescent girls: a 1 year follow-up. Health Educ. Res. 8:43–51

www.annualreviews.org • Eating Disorder Prevention Programs 229

intervention. Int. J. Eat. Disord. 31:159–71

Stice E, Rohde P, Bohon C, Heim K. 2006b. A Randomized Effectiveness Trial of a Dissonance-

www.annualreviews.org • Eating Disorder Prevention Programs 231

Contents Volume 3, 2007

Mediators and Mechanisms of Change in Psychotherapy Research

Marital and Family Processes in the Context of Alcohol Use and

Gregory M. Herek and Linda D. Garnets p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p353

Coping Resources, Coping Processes, and Mental Health

Cumulative Index of Contributing Authors, Volumes 1–3 p p p p p p p p p p p p p p p p p p p p p p p p p p p403

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