Received: 12 August 2022 Revised: 26 January 2023
DOI: 10.1002/eat.23916
REVIEW
Eating disorders prevention programs in Latin American
countries: A systematic review
Karin Louise Lenz Dunker PhD 1
Ana Carolina Soares Amaral PhD
1
AMBULIM, Eating Disorders Program,
Institute of Psychiatry, University of São Paulo,
São Paulo, Brazil
2
NICTA, Body Image and Eating Disorder
Research Group, Federal University of Juiz de
Fora, Governador Valadares, Brazil
3
Federal Institute of Education, Science and
Technology of Southeast of Minas Gerais,
Barbacena, Minas Gerais, Brazil
Correspondence
Karin Louise Lenz Dunker, AMBULIM, Eating
Disorders Program, Institute of Psychiatry,
University of São Paulo, R. Dr. Ovídio Pires de
Campos, 785 - Cerqueira César, São Paulo -
SP, 05403-010, Brazil.
Email: kdunker00@gmail.com
Action Editor: Emilio Juan Compte
Int J Eat Disord. 2023;56:691–707.
Accepted: 31 January 2023
| Pedro Henrique Berbert de Carvalho PhD 1,2 |
3
Abstract
Objective: This systematic review evaluates and summarizes existing eating disorder
(ED) prevention programs in Latin American countries.
Methods: A systematic literature search was conducted using the Cochrane Con-
trolled Trial Register, PubMed, and Virtual Health Library databases up to and includ-
ing July 31, 2022. All ED prevention studies published in English, Spanish or
Portuguese were eligible, regardless of the study design, sample characteristics, and
type of prevention programs. The Cochrane Collaboration Risk of Bias criteria were
used to evaluate the quality of the included studies.
Results: Twenty-two studies were included. Most were pilot studies that were non-
randomized, had a high risk of bias, were from Mexico and Brazil, and employed
selective interventions. Dissonance-based programs and social cognitive theory were
the commonly used approaches in interventions, and most of them were tested in
adolescent girls and women. Short follow-ups were used, varying from 1 to 6 months.
Many found significant decreases after the intervention and/or at follow-up in
ED/disordered eating risk behaviors/symptoms, negative affect, body-ideal internali-
zation, and body image disturbances.
Conclusions: This review highlights promising efforts to prevent EDs among Latin
American countries. Some barriers in conducting research include funding restric-
tions, laws that do not allow remuneration or compensation for participants, and high
costs of training. Nonetheless, the outcomes of the programs developed and evalu-
ated so far are positive enough to merit further work on ED prevention. Efforts for
future researchers should recruit samples with diverse characteristics, use robust
designs and data analysis techniques, and expand the accessibility of prevention
programs.
Public Significance Statement: The development of effective eating disorder
(ED) prevention programs that can be broadly implemented is a public health priority.
Nevertheless, there is limited evidence regarding the characteristics of ED prevention
programs and their efficacy among Latin American countries. In the present study,
we reviewed existing ED prevention programs adopted in Latin America, described
their characteristics and outcomes, noted the limitations of available programs, and
discussed the implications of these findings for efforts to prevent the development
of EDs in Latin America. The outcomes of the programs developed and evaluated so
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692 LENZ DUNKER ET AL.

far are positive enough to merit the development and rigorous evaluation of future
programs and their broad dissemination in Latin American countries.
PROSPERO registration number CRD42021275245.

Abstracto
Objetivo: Esta revisión sistemática evalúa y resume los programas de prevención de
trastornos de la conducta alimentaria (TCA) existentes en los países de América Latina.
Métodos: Se realizó una búsqueda bibliográfica sistemática utilizando las bases de
datos del Registro Cochrane de Ensayos Controlados (Cochrane Controlled Trial Reg-
ister), PubMed y Virtual Health Library hasta el 31 de julio de 2022 inclusive. Todos
los estudios de prevención de TCA publicados en inglés, español o portugués fueron
elegibles, independientemente del diseño del estudio, las características de la muestra
y el tipo de programas de prevención. Se utilizaron los Criterios de Riesgo de Sesgo
de la Colaboración Cochrane para evaluar la calidad de los estudios incluidos.
Resultados: Se incluyeron veintidós estudios. La mayoría eran estudios piloto no
aleatorizados, tenían un alto riesgo de sesgo, eran de México y Brasil, y empleaban
intervenciones selectivas. Los programas basados en la disonancia y la teoría cogni-
tiva social fueron los enfoques comúnmente utilizados en las intervenciones, y la
mayoría de ellos se probaron en niñas y mujeres adolescentes. Se utilizaron segui-
mientos cortos, que variaron de uno a 6 meses. Muchos encontraron disminuciones
significativas después de la intervención y / o en el seguimiento en los síntomas de
TCA/Conductas Alimentarias de Riesgo, afecto negativo, internalización de la figura
ideal y trastornos de la imagen corporal.
Conclusiones: Esta revisión destaca los esfuerzos prometedores para prevenir los
TCA entre los países de América Latina. Algunas barreras en la realización de investi-
gaciones incluyen restricciones de financiamiento, leyes que no permiten la remu-
neración o compensación para los participantes y los altos costos de capacitación. No
obstante, los resultados de los programas desarrollados y evaluados hasta ahora son
lo suficientemente positivos como para merecer un mayor trabajo en la prevención
de los TCA. Los esfuerzos para futuros investigadores deben reclutar muestras con
características diversas, utilizar diseños robustos y técnicas de análisis de datos, y
ampliar la accesibilidad de los programas de prevención.

KEYWORDS
dissonance-based, eating pathology, Latin America, prevention programs

1 | I N T RO DU CT I O N
Eating disorders (EDs) are complex psychiatric conditions with both
medical and social-cognitive symptoms and consequences (American
Psychiatric Association [APA], 2022). Approximately 80% of individ-
uals with EDs do not receive treatment (Swanson et al., 2011), and
treatment results in lasting symptom remission for less than half of
patients (Grilo et al., 2012). Thus, EDs follow a chronic and relapsing
course and are marked by distress, impairment, and increased risk for
future obesity, depression, suicide, and mortality (Allen et al., 2013;
Arcelus et al., 2011; Stice et al., 2013) with high costs to public health
(Streatfeild et al., 2021). One barrier to mental health care is the fact
that the prevalence of EDs is more than high enough to overwhelm
the number of professionals qualified to treat and support people with
these complex disorders (Kazdin et al., 2017). Furthermore, EDs affect
individuals across cultures, ethnicities, gender identities, age, and
socioeconomic status. Thus, the development of effective ED preven-
tion programs that can be broadly implemented is a public health
priority.
In the beginning, before 2000, most, but not all, ED prevention
programs adopted a universal and curricular approach, using the class-
room as a setting in which to deliver psychoeducational material about

LENZ DUNKER ET AL.
EDs and risk factors (Pearson et al., 2002; Stice & Shaw, 2004). Some
of these earlier interventions produced an increase in knowledge but
did not reduce ED symptoms or prevent future onset of EDs, while
other less didactic interventions produced encouraging results in terms
of risk factor and some symptom reductions (Neumark-Sztainer
et al., 2000; Piran, 1999; Winzelberg et al., 1998).
This situation radically changed after 2000 with the growth in the
number of intervention studies. Programs have been tested in differ-
ent populations at risk and not at risk (i.e., children, adolescents, and
women), and delivery formats (i.e., didactic, interactive, and online).
These programs have focused on resistance to sociocultural pressures
to achieve body ideals; reducing dieting, and body-ideal internaliza-
tion, and body dissatisfaction; improving self-esteem and knowledge
about nutrition and physical activity; and, in some programs, develop-
ing healthy weight-control behaviors. Programs that produced greater
effects in reducing ED risk factors and early-stage eating pathology
have been interactive and have targeted at-risk individuals (i.e., selec-
tive prevention; Stice et al., 2007; Watson et al., 2016).
There are a number of promising preventive interventions for ED
risk factors, including cognitive dissonance, cognitive behavior,
healthy lifestyle modification, psychoeducation, interpersonal psycho-
therapy, and media literacy (Harrer et al., 2020; Le et al., 2017; Stice
& Shaw, 2004, 2021; Watson et al., 2016). It must be highlighted that
not all selective prevention programs have shown statistically signifi-
cant results in reducing the future onset of EDs in adolescent and
young adult males and females (Stice et al., 2021). Healthy lifestyle
modification (i.e., Health Weight and Project Health), dissonance-
based (i.e., Body Project), and self-esteem/self-efficacy selective
prevention programs (e.g., Martinsen et al., 2014) have statistically
significantly reduced the future onset of EDs (Stice et al., 2021). In
particular, healthy lifestyle modification and dissonance-based pre-
vention programs have reduced the future onset of EDs in multiple
trials, producing a 54% to 77% reduction in future ED onset varying in
length from 2- to 4-year follow-ups (Stice et al., 2021). This highlights
the need for broad implementation of effective ED prevention pro-
grams to reduce the population prevalence of EDs.
Most of the available ED prevention programs have been
designed for and tested among primarily White, female adolescent,
and young adult samples residing in Australia/New Zealand, Europe,
or North America (Harrer et al., 2020; Le et al., 2017; Stice
et al., 2021; Watson et al., 2016). It is important to test whether pre-
ventive and treatment interventions are effective and culturally sensi-
tive for various sociocultural contexts (Stice et al., 2014). Many
factors, such as acculturation, socioeconomic status, cultural concepts
of beauty, and the cultural sensitivity of measures, could possibly
moderate intervention effects (Stice et al., 2014).
In this regard, Latin American countries' studies are underrepre-
sented in systematic reviews and meta-analyses evaluating the efficacy
and effectiveness of ED prevention programs (Harrer et al., 2020;
Watson et al., 2016). For example, one of the most comprehensive sys-
tematic reviews and meta-analyses (Watson et al., 2016) evaluating the
efficacy of universal, selective, and indicated ED prevention included
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693
102 studies, but only three randomized controlled trials were con-
ducted in Latin American countries (one universal intervention from
Venezuela: Anuel et al., 2012; and two selective interventions from

mez-Peresmitré, 2006; García et al., 2010). Harrer
Mexico: García & Go
et al. (2020) included only one integrated prevention intervention with
university students from Mexico (Castillo et al., 2019) in their system-
atic review regarding the efficacy of ED prevention programs targeting
university students. Thus, little is known about the characteristics of
ED prevention programs and their efficacy among Latin American
countries.
The present study sought to summarize and evaluate existing ED
prevention programs in Latin American countries, including studies
from previous reviews and adding other studies not included in these
reviews (prior to 2016) and those published after. Specifically, this
systematic review aimed to determine if ED prevention programs
developed in North America and similar contexts generalize to Latin
American countries in the domains of feasibility and acceptability (low
levels of attrition), and effectiveness (reduce ED risk factors/symp-
toms/onset of EDs).
2 | METHODS
This systematic review is registered in the International Prospective
Register of Ongoing Systematic Reviews (PROSPERO) database under
code CRD42021275245, and the study is reported according to the
2020 Preferred Reporting Items for Systematic Reviews and Meta-
Analysis (PRISMA) guidelines (Page et al., 2021). The PRISMA check-
list can be found in Supporting Information 1.
2.1 | Search strategy
All published ED prevention programs involving Latin American
countries were searched through the Cochrane Controlled Trial
Register, PubMed and Virtual Health Library (VHL) databases up to
and including July 31, 2022. We also reviewed the tables of contents
of journals that commonly publish ED research and the reference lists
of the identified articles.
Latin America includes 21 countries or territories: Mexico in
North America; Guatemala, Honduras, El Salvador, Nicaragua,
Costa Rica, and Panama in Central America; Colombia, Venezuela,
Ecuador, Peru, Bolivia, Brazil, Paraguay, Chile, Argentina, and Uruguay
in South America; and Cuba, Haiti, the Dominican Republic, and
Puerto Rico in the Caribbean.
The following key terms were included and combined using the
operators “AND” and “OR” in PubMed ((feeding and eating disorders)
AND (prevention) AND (body)) and in Cochrane and VHL ((eating dis-
orders) AND (prevention) AND (body)). For the VHL database,
the corresponding terms were used in Spanish and Portuguese. Given
the exploratory purpose of this review, all fields were included in the
search to ensure that as many studies as possible were found.

694
2.2 | Study selection
Following the identification of all articles, titles and abstracts were
screened for inclusion and exclusion by two authors (K.L.L.D. and
A.C.S.A.). Any disagreement between the two authors in the selection of
studies or extracted data was resolved through discussion with a third
author (P.H.B.C.) until a consensus was reached among all authors.
Studies were included if they (1) evaluated any EDs or both ED
and obesity prevention programs; (2) included samples obtained from
Latin American countries; and (3) were published in English, Spanish
or Portuguese in a peer-reviewed journal. Studies were excluded if
they (1) did not meet the requirements of a clinical trial study design
(e.g., observational studies, reviews, case reports, comments, opinions,
editorials, and protocol studies); (2) did not measure ED-related out-
comes; or (3) assessed the wrong population. For each eligible study,
relevant information was extracted, including the country, study
design, intervention arm, follow-up time-points, sample characteristics
(age, sex, and sample size), the measures used, and a description of
the main outcomes (see Table 1).
2.3 | Quality assessment
The Cochrane Collaboration Risk of Bias (Higgins et al., 2011) criteria
were used to evaluate the quality of the included studies. These criteria
cover six domains related to selection bias (random sequence generation
and allocation concealment), performance bias (blinding of participants
and personnel), detection bias (blinding of outcome assessment), attrition
bias (incomplete outcome data), reporting bias (selective reporting), and
other bias (in our study, we prespecified the use of intent-to-treat analy-
sis). For each domain, the risk of bias was categorized as a high risk of
bias, unclear risk of bias or low risk of bias. According to Higgins et al.
(2011), review authors must decide which are the key domains. Thus, for
the present systematic review, we selected selection bias, attrition bias
and the use of intent-to-treat analysis as key domains.
Regarding the random sequence generation, the study was classi-
fied as a low risk of bias when the authors described the methods
used to generate the allocation sequence (e.g., website, software) with
enough details to allow an assessment of whether they were capable
of producing comparable groups. Allocation concealment has low risk
of bias when the method used to hide the allocation was sufficiently
described and it was not possible to predict the group before or dur-
ing the enrollment (Higgins et al., 2011). Complete outcome data were
defined as having a low risk of bias when the percentage of partici-
pants lost to follow-up was low (values lower than 20%; Babic
et al., 2019) and when the authors provided clear reporting on drop-
outs and a clear statement of the reasons for dropouts. Alternatively,
the domain was also considered to exhibit a low risk of bias if there
were no statistically significant differences between dropouts versus
participants in the outcome measures (Stice et al., 2021). The last key
domain was classified as having low risk of bias whether the authors
reported the use of intent-to-treat analysis as the method of evaluat-
ing the efficacy of the intervention (Higgins et al., 2011).
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LENZ DUNKER ET AL.
The final interpretation is as follows: a low risk of bias is assumed
if all key domains were classified as of low risk; an unclear risk of bias is
assumed if the key domains received an evaluation of a low or unclear
risk of bias; and a high risk of bias is assumed when one or more key
domains were classified as of high risk. Two researchers (K.L.L.D. and
A.C.S.A.) evaluated the quality of the included studies, and unresolved
questions were discussed with the third author (P.H.B.C.).
2.4 | Synthesis of results
The present systematic review summarized and evaluated existing ED
prevention programs adopted in Latin American countries. The results
were parsed into four intervention categories: (1) selective, (2) univer-
sal, (3) indicated, and (4) integrative. The first category seeks to target
a whole population irrespective of level of risk (e.g., school-based pre-
vention for females and males). The second category aims to target a
subgroup of the population at risk of an ED (e.g., females with some
symptoms, without meeting the full diagnostic criteria for an ED). The
third category aims to target a subgroup of the population at a high to
very high risk of an ED (Gordon, 1983). The fourth category includes
programs focused on changing risk factors for EDs and obesity.
3 | RE SU LT S
3.1 | Selected studies
The systematic searches resulted in a total of 3773 studies after
the removal of 1221 duplicates. A total of 2552 studies were
retrieved, of which 2359 were excluded because they did not meet
the inclusion criteria. Of the remaining 193 studies, a total of
177 were excluded for the following reasons: the use of irrelevant
outcome measures (n = 71), research not conducted in a Latin
American country (n = 10), and an absence of pre-post follow-up
design (n = 96). Six additional studies were found via citation
searching. Twenty-two studies, described in Table 1, met all of the
inclusion criteria. A flow chart of the study selection process is pre-
sented in Figure 1.
3.2 | Study characteristics
In terms of design, 40.9% (n = 9) of the studies were pilot studies,
36.4% (n = 8) were randomized controlled trials, and 22.7% (n = 5)
were nonrandomized controlled trials. A majority of the studies were
carried out in Mexico (54.5%, n = 12), followed by studies in Brazil
(31.9%, n = 7), and with very little representation from Argentina
(9.1%, n = 2) and Venezuela (4.5%, n = 1). The sample sizes ranged
from 15 to 368. The mean age of the samples ranged from 9.9 to
20.7 years of age.
A majority of the studies involved selective interventions (54.6%,
n = 12), followed by those focused on universal (22.7%, n = 5), and
 TABLE 1 Characteristics of studies included in systematic review.

Attrition/
Study Follow-up Dropout Effect sizes
Author (year), country design Intervention arms (months) Age, % female rates Tools Significant results (η2, η2p, r or d)
Selective intervention
LENZ DUNKER ET AL.

García and Go

mez- PS 1. “BP” program (Cognitive 1 M = 14.6 (SD = .68), ISS: n = 43 CAS Girls (1, 2) reduce their use of 1.53–1.85
Peresmitré (2006), dissonance) 100% FSS: n = 20 diets with results maintained (d)a
México 2. Psycho-educational program DR: 53.5% after 1 month. Girls (1)
consider less an ideal figure
as very slim.
de Elías and Go

mez- PS 1. Media literacy program 3 M = 12.4 (SD = .38), ISS: n = 33 CAS, CIMEC Girls (1) reduced food and .47–.75
Peresmitré (2007), 2. Psycho-educational program 100% FSS: n = 19 weight concern, and (d)a
México DR: 42.4% compulsive eating after
3 months. Differences in
ideal figure and body image
dissatisfaction at post (2).
but not maintained after
3 months. There was no
difference between (1, 2).
García et al. (2010), NRT 1. Cognitive dissonance 3 M1 = 12.3 (SD = .63), ISS: n = 52 EFRATA, SS Both groups reduced body .91–.97
Mexico program M2 = 13.2 (SD = .65), FSS: n = 43 dissatisfaction and were (d)
2. Psycho-educational program 100% DR: 17.3% effective to reduce bulimic
behaviors and diet. Girls (1)
showed to be risk free in
restrictive dieting after
3 months.
Escoto Ponce de Leo
n NRT 1. “PRAIC” (Social Cognitive) No M = 15.7 (SD = 1.03), ISS: n = 15 BIAQ, BSQ, SS Girls (1) reduced body 1.48–2.75
et al. (2010), Mexico 2. Waitlist 100% FSS: n = 15 dissatisfaction and (d)a
DR: 0% avoidance of social activities
compared to (2). No changes
in body size perception.
de la Vega Morales and PS 1. Cognitive Behavioral 3, 6 M = 20.63 (SD = 2.39), ISS: n = 30 Escala de autoestima “Yo como Women (1) reduced body 1.20–2.19
Go
mez-Peresmitré program 100% FSS: No persona,” EDI-2, EFRATA, SS dissatisfaction, binge eating, (d)
(2012), México DR: No dieting, negative self-esteem
and increased positive self-
esteem. The effects
persisted through the
follow-up.
Go

mez-Péresmitré et al. NRT 1. Psycho-educational program No M = 13.4 (SD = 1.14), ISS: n = 58 EFRATA, SS Girls (1, 2) reduced variables 1.34–5.69
(2013), Mexico 2. “RVR” Program 100% FSS: No associated with body image (d)a
DR: No and disordered eating.
Decrease prevalence of
participants who were at
risk.
695

(Continues)

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 TABLE 1 (Continued)
696

Attrition/
Study Follow-up Dropout Effect sizes
Author (year), country design Intervention arms (months) Age, % female rates Tools Significant results (η2, η2p, r or d)
Amaral et al. (2019), Brazil RCT 1. “BP” program (Cognitive No M = 16.25 (SD = 1.4), ISS: BAS, BSQ, CDI, EAT-26, EDDS, Girls (1) reduced body .46–.96
Dissonance) 100% n = 141 PANAS, SATAQ-3 dissatisfaction, sociocultural (d)
2. No intervention FSS: n = 62 influence of the media,
DR: 56% depressive symptoms,
negative affect, and
increased body appreciation
compared to (2). There were
no significant effects for
disordered eating attitudes
and eating disorder
symptoms.
Rutsztein et al. (2019), PS 1. “PIA” (Media Literacy 6 M = 14.5 (SD = 1.25), ISS: CIMEC-26, EDI-3 Girls (1) decreased thin-ideal .04–.14 (η2p)
Argentina + Cognitive Dissonance) 100% n = 108 internalization, body image
FSS: n = 88 concerns, influence of
DR: 18.5% advertising, drive for
thinness, bulimic attitudes
and disordered eating at
post intervention. Results for
body image concerns and
drive for thinness were
maintained at follow-up.
Almeida et al. (2021), RCT 1. “BP” program (Cognitive 1, 6 M = 20.5 (SD = 2.45), ISS: BAS-2, DMS, EAT-26, MDDI, Men (1) decreased disordered .33–1.10
Brazil Dissonance) 0% n = 180 MUS, SATAQ-4. eating, muscle dysmorphia (d)
2. No intervention FSS: symptoms, muscularity and
n = 166 body fat dissatisfaction,
DR: 7.7% drive for muscularity and
body-ideal internalization in
1- and 6-month follow -up
compared to (2). At post-
intervention only body
appreciation increased (1).
Resende et al. (2022), RCT 1. “BP” program (Cognitive 4, 6 M = 20.53 (SD = 2.51), ISS: 74 BAS-2, BSQ-8, EAT-26, IES-2, Women (1) increased intuitive .60–1.87
Brazil Dissonance +intuitive 100% FSS: 65 PANAS, RSE, SATAQ-4. eating, body appreciation (d)
eating) DR: 12.2% and self-esteem, and
2. No intervention decreased body-ideal
internalization, body
dissatisfaction and
disordered eating to post-
test, 4- and 6-month follow-
up compared to (2). Women
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 TABLE 1 (Continued)

Attrition/
Study Follow-up Dropout Effect sizes
LENZ DUNKER ET AL.

Author (year), country design Intervention arms (months) Age, % female rates Tools Significant results (η2, η2p, r or d)
(1) reduced negative affect
only at 6-month follow-up.
Hudson et al. (2021), Brazil RCT 1. “BP” program (Cognitive 1, 6 M = 20.78 (SD = 2.3) ISS: BAS, BDI, BSQ, EAT-26, EDDS, Women (1) decreased body .32–.74
Dissonance) 100% n = 141 PANAS, SATAQ-3. dissatisfaction, sociocultural (d)
2. No intervention FSS: n = 61 influence, disordered eating,
DR: 56.7% eating disorder symptoms,
depressive symptoms and
negative affect, and increase
body appreciation compared
to (2). Most of the effects
persisted at 6-month follow-
up.
Rutsztein et al. (2021), NRT 1. “PIA” (Media Literacy 6 M = 14.5 (SD = 1.25), ISS: n = 88 CIMEC-26, EDI-3 Girls (1, 2) decreased drive for .09–.15
Argentina + Cognitive Dissonance)— 100% FSS: No thinness and thin-ideal (η2p)
dieters group DR: No internalization, persisted at
2. “PIA” (Media Literacy 6-month follow-up. Bulimic
+ Cognitive Dissonance)— Attitudes decreased only
non-dieters' group among (1). No changes were
observed on body
dissatisfaction.
Universal intervention
Escoto Ponce de Leo
n PS 1. BIP (Social Cognitive— 6 M = 9.93 (SD = .44), ISS: BSQ, BULIT-O, ChEAT, Girls (1) decreased body .52–.87
et al. (2008), Mexico interactive version) 50.8% n = 120 CIMEC-26, PAI dissatisfaction, and body (d)a
2. BIP (Social Cognitive— FSS: aesthetic models. Boys (1)
didactic version) n = 120 decreased body
3. No intervention DR: 0% dissatisfaction, overeating,
and increase self-esteem.
Anuel et al. (2012), NRT 1. Cognitive program No M = 11.2 (SD = .82), ISS: BSQ Only girls and boys (1) reduced .59–.85
Venezuela 2. Positive program 36.7% n = 120 body dissatisfaction. (d)a
3. Cognitive + Positive FSS: No Statistical significance was
program DR: No maintained when controlling
4. No intervention the effect of the covariates
(age and sex).
Unikel-Santoncini et al. PS 1. “BP” program (Cognitive 12 M = 22.4 (SD = 3.5), ISS: ABF, BQDEB, CES-R Women and men (1) reduced 1.06
(2019), Mexico Dissonance) 78.9% n = 133 disordered eating behaviors, (d)
FSS: n = 74 internalization of the
DR: 44.4% aesthetic thin ideal and

(Continues)
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TABLE 1 (Continued)

Attrition/
Study Follow-up Dropout Effect sizes
Author (year), country design Intervention arms (months) Age, % female rates Tools Significant results (η2, η2p, r or d)
depression symptoms after
12-month follow-up.
Saucedo-Molina et al. PS 1. “PECANSS” (Cognitive 6 M = 16.4 (SD = No), ISS: BQDEB, DMS, IPAQ-short Girls (1) reduced disordered .02–.3
(2018), Mexico Dissonance 58.1% n = 368 eating from baseline to (η2)
+ Psychoeducation) FSS: No 6-month follow-up. Physical
DR: No activity frequency and
duration increased in
total sample over time.
Cueto-Lo

pez et al. (2022), PS 1. “PAMEF” (Media Literacy No M = 13.52 (SD = .4), ISS: n = 98 BSQ-8, CIMEC, EAT-26, Girls (1) decreased eating .27–.58
México + Psychoeducation) 100% FSS: No HADS, NUT-Q disorder risk behaviors, (r)
2. No intervention DR: No body-ideal internalization,
body dissatisfaction and
anxiety, and increase
nutrition knowledge
compared to (2).
Integrative intervention
Castillo et al. (2016), PS 1. StopOBEyTA program 3 M = 19.3 (SD = .95), ISS: n = 53 BSQ, EDE-Q, GHQ-12, MBAS, Women and men (1) improved .11–.19
Mexico (Cognitive dissonance 73.6% FSS: n = 45 MPS, SCL-90-R, RSE self-esteem, body (η2)
+ positive strenghten DR: 15.1% satisfaction, perfectionism
+ healthy habits) and reduced unhealthy
2. Study Skills weight control behaviors,
3. No intervention and levels of psycho-
pathology compared to (2)
and (3). Changes were
maintained at 3-month
follow-up.
Dunker and Claudino RCT 1. “NMP” (Social Cognitive 4 M = 13.4 (SD = .64), ISS: BSQ, RSE, UWCB No changes in girls' (1) body .08–.30
(2018), Brazil + physical activity 100% n = 270 dissatisfaction, self-esteem, (d)b
+ behavioral exercises) FSS: and use of unhealthy weight
2. No intervention n = 229 control behaviors compared
DR: 15.2% to (2).
Castillo et al. (2019), RCT 1. StopOBEyTA program 3 M = 19.8 (SD = 2.06), ISS: BSQ, EAT-26, IPAQ-Short, Women (1) reduced thin-ideal .01–.04
Mexico (Cognitive dissonance 68.4% n = 361 MBAS, MPS, RSE, SATAQ-3, internalization and (η2)
+ positive strenghten FSS: SCL-90-R. disordered eating attitudes/
+ healthy habits) n = 216 behaviors over 3-month
2. Study Skills DR: 40.2% follow-up compared (do 2,
3. No intervention 3). No effect on men.
LENZ DUNKER ET AL.

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 TABLE 1 (Continued)

Attrition/
Study Follow-up Dropout Effect sizes
Author (year), country design Intervention arms (months) Age, % female rates Tools Significant results (η2, η2p, r or d)
Leme et al. (2019), Brazil RCT 1. “H3G-Brazil” program 6 M = 15.6 (SD = .05), ISS: Non-validated measures for Girls (1) reported beneficial .03–.51
LENZ DUNKER ET AL.

(Social Cognitive + physical 100% n = 253 physical activity, disordered effects for physical activity (d)
activity + nutrition) FSS: eating, binge eating, social support and healthy
2. No intervention n = 144 weighing frequency and eating strategies immediate
DR: 43.2% teasing, and body post-intervention, but an
satisfaction. adverse effect for unhealthy
weight control behaviors at
6-month follow-up. No
changes on other variables
at post-test and follow-up.
Dunker et al. (2021), Brazil RCT 1. “NMP” (Social Cognitive No M = 13.4 (SD = .64), ISS: BSQ, WCBS, RSE, non- Girls (1) reported no changes in .02–.19
+ physical activity 100% n = 270 validated eating behaviors eating behaviors. Daily (d)b
+ behavioral exercises) FSS: measure, and physical physical activity increased in
2. No intervention n = 195 activity level girls (1) with less body image
DR: 27.8% dissatisfaction and older.
Sedentary lifestyle reduced
in girls (1) with higher self-
esteem.

Note: Study design—NRT, non-randomized trial; PS, pilot study; RCT, randomized control trial. Programs—BIP, Body Image Program; BP, Body Project; H3G-Brazil, Healthy Habits, Healthy Girls-Brazil; NMP,
New Moves Program; PAMEF, Programa Alimentacio
n, modelo estético femenino y medios de comunicacio
n; PECANSS, Prevencio
n de Conductas Alimentarias No Saludables y Sedentarismo; PIA, Programa de
Prevencio
n en Imagen Corporal y Alimentacio
n; PRAIC, Programa para Reducir las Alteraciones de la Imagen Corporal; RVR, Realidad Virtual Reforzado. Attrition—DR, dropout rate; FSS, final sample size; ISS,
initial sample size; No, no reported. Tools—ABF, Attitudes toward body figure questionnaire; BAS, Body Appreciation Scale; BDI, Beck Depression Inventory; BIAQ, Body Image Avoidance Questionnaire;
BQDEB, Brief Questionnaire on Disordered Eating Behaviors; BSQ, Body Shape Questionnaire; BULIT-O, Bulimia Test's Overeating Subscale; CAS, Cuestionario de Alimentacio
n y Salud; CDI, Children
Depression Inventory; CES-R, Center for Epidemiological Studies' Revised Depression Scale; ChEAT, Children's Eating Attitudes Test; CIMEC, Cuestionario de Influência de los Modelos Estéticos Corporales;
DMS, Drive for Muscularity Scale; EAT-26, Eating Attitudes Test; EDDS, Eating Disorder Diagnostic Scale; EDE-Q, Eating Disorder Examination-Questionnaire; EDI-3, Eating Disorder Inventory-3; EFRATA,
Escala de Factores de Riesgo Asociados con Transtornos Alimentarios; GHQ-12, General Health Questionnaire; HADS, Hospital Anxiety and Depression Scale; IES-2, Intuitive Eating Scale-2; IPAQ-short,
International Physical Activity Questionnaire; MBAS, Male Body Attitudes Scale; MDDI, Muscle Dysmorphic Disorder Inventory; MPS, Multidimensional Perfectionism Scale; MUS, Muscularity and Body fat
subscales from MBAS-Revised; NUT-Q, Nutrition Questionnaire; PAI, Children's Self-Esteem Inventory; PANAS, Positive Affect and Negative Affect Scale; RSE, Rosenberg's Self-Esteem Scale; SATAQ,
Sociocultural Attitudes Towards Appearance Questionnaire; SCL-90-R, Symptom Checklist-90-Revised; SS, Silhouete Scale; UWCB, Unhealthy Weight-Control Behaviors; WCBS, Weight Control Behaviors
Scale. Effect-sizes—This column presents the range of effect sizes (minimum–maximum) for the significant effects observed.
a
Effect size calculated from the data available in the included paper.
b
Effect size calculated and given by authors of the paper.
699

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700 LENZ DUNKER ET AL.

Identification of studies via databases and registers Identification of studies via other methods
Identification

Studies identified from: Studies removed before Studies identified from:

Databases (n =3773) screening: Websites (n =0)
Registers (n =0) Duplicate studies removed Citation searching (n = 6)
(n = 1221)

Studies screened Studies excluded

(n = 2552) (n = 2359)
Screening

Studies sought for retrieval Studies not retrieved Studies sought for retrieval Studies not retrieved (n = 0)
(n = 193) (n = 0) (n = 6)

Studies excluded:
Studies assessed for eligibility Studies excluded: Studies assessed for eligibility (n = 0)
(n = 193) Wrong outcome (n = 71) (n = 6)
Wrong population (n = 10)
Wrong study design (n = 96)
Included

Studies included in review

(n = 22)

FIGURE 1 Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram.

integrative interventions (22.7%, n = 5). Studies involving indicated
intervention were not found. Half of the interventions (50%, n = 11)
used a combination of theories, for example, media literacy + cognitive
dissonance, cognitive dissonance + intuitive eating, cognitive + positive
program, cognitive dissonance + psychoeducation, media literacy
+ psychoeducation, cognitive dissonance + positive strengthening, or
social cognitive + physical activity + behavioral exercises. Dissonance-
based prevention programs were the most also frequently used (27.3%,
n = 6). Other programs emphasized social cognitive theory (9.1%, n = 2),
media literacy (4.6%, n = 1), cognitive behavioral therapy (4.6%, n = 1),
or psychoeducation (4.6%, n = 1).
Most of the interventions were aimed at only adolescent girls
(54.5%, n = 12) or only university women (13.6%, n = 3). Other stud-
ies evaluated mixed samples of adolescent boys and girls (13.6%,
n = 3) or female and male university students (13.6%, n = 3). Only
one study (4.6%) evaluated a male university sample. The majority of
interventions used a nonintervention group (54.5%, n = 12) or psy-
choeducation group (18.2%, n = 4) as a control. Four interventions
(18.2%) had no control group, and one (4.6%) used a waitlist group.
More generally, the interventions consisted of multiple sessions and
interactive formats that helped participants engage in the interven-
tions. Just under one-third of the studies conducted short follow-ups
after 1 to 4 months (27.3%, n = 6), nine studies (40.9%) involved a
6-month follow-up, and six studies (27.3%) only evaluated pre-post
intervention time points. Only one study (4.6%) followed the partici-
pants over 12 months.
The studies used several different instruments to evaluate the
impact of the interventions. Most assessed body image components
(e.g., body dissatisfaction, body size perception, and body appreciation;
82.8%, n = 18), disordered eating behaviors and ED symptoms (90.9%,
n = 20), or the sociocultural influence of media, including appearance-
ideal internalization (45.5%, n = 10), self-esteem (31.8%, n = 7), depres-
sion/anxiety/perfectionism (27.3%, n = 6), muscularity concerns (18.2%,
n = 4), levels of physical activity (18.2%, n = 4), and positive and nega-
tive affect (13.6%, n = 3). Five studies (22.7%) used two validated mea-
sures, and 14 studies (63.6%) used three or more validated measures to
evaluate the effect of a program on body image and/or ED symptoms.
Only three studies used one measure (Anuel et al., 2012; García &

mez-Peresmitré, 2006) or non-validated measures (Leme et al., 2019).
Go
Most of the studies that evaluated disordered eating risk behav-
iors and ED symptoms (i.e., dieting, bulimic symptoms, and binge eat-
ing) found statistically significant decreases after the intervention
(80%, n = 16) and verified clinically relevant changes in at least one of
the body image components (66.7%, n = 12). Half of these studies
(n = 11) found an effect size from medium to large in at least one of
these measures (d = .32–1.1; η2 = .02–.19; r = .27–.58). Five pro-
duced a large effect (d = .91–5.69), two a small to medium
(d = .01–.51), and three studies did not find any significant changes in
these measures. All studies that evaluated the sociocultural influence
of media (e.g., thin-ideal internalization) (45.5%, n = 10) and positive
and negative affect (13.6%, n = 3) found statistically significant
decreases at postintervention and/or follow-up time points. A major-
ity of the studies that evaluated depression/anxiety/perfectionism
(83.3%, n = 5) and approximately half of the studies evaluating
self-esteem (57.1%, n = 4) and physical activity (50%, n = 2) also
demonstrated statistically significant changes. Only one study found

LENZ DUNKER ET AL.
statistically significant changes in muscularity concerns. Iatrogenic
effects were not found in any of the studies included in this review.
3.3 | Risk of bias assessment
In general, most trials (72.7%) had a high risk of bias. The risk of bias
was evident from a lack of information about the randomization pro-
cess (31.8%, n = 7), the use of nonrandomized studies (36.4%, n = 8),
and an absence of intention-to-treat analysis (72.7%, n = 16) (please
see Figure 2 and Table 2 for a summary).
FIGURE 2 Risk of bias summary.
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701
4 | DI SCU SSION
The aim of this study was to summarize and evaluate the published lit-
erature assessing ED prevention programs adopted in Latin American
countries. To our knowledge, this is the first systematic review of pre-
vention programs in this context. Our literature search identified
22 published studies that provided information about programs con-
ducted with diverse populations using randomized and nonrando-
mized designs and different intervention approaches. The results
show promising efforts to prevent EDs among Latin American
countries.

702
Low-risk of bias Unclear risk of bias
n % n %
Random sequence generation 7 31.8 8 36.4
Allocation concealment 8 26.4 9 40.9
Blinding of participants - 0 - 0
Blinding of personnel - 0 - 0
Blinding of outcome assessment 3 13.6 14 63.7
Incomplete outcome data 9 40.9 5 22.7
Selective reporting 22 100 - 0
Intent-to-treat analysis 6 21.3 - 0
The results demonstrate a predominance of two countries in con-
ducting prevention studies, namely, Mexico and Brazil. Additionally,
the first article that we identified dates from 2006, when numerous
investigations into prevention programs on other continents, such as
Europe, Oceania (especially Australia) and North America (Le
et al., 2017; Watson et al., 2016), had already been conducted. The
results suggest that these efforts are still incipient in most countries in
Latin America, as studies from only four among the 22 Latin American
countries were included in this review. In this regard, it is important to
mention some difficulties in conducting research in these countries,
especially the historical and current funding restrictions incurred by
Latin American researchers (Dunker et al., 2018; Verstraeten
et al., 2012). Moreover, the rules for longitudinal studies in these
countries are notable. In Brazil the law prohibits participants from
receiving any kind of remuneration or compensation (Conselho Nacio-
nal de Saúde Brasil, 2012), which makes it difficult for volunteers to
adhere, especially those allocated to the assessment-only control
condition.
Regarding the sample characteristics, the samples for most of the
studies were adolescent girls and/or young women. Historically,
research on EDs has focused on these groups, since they are at higher
risk than males for the onset of an ED (Stice et al., 2013). However,
recent studies (e.g., Almeida et al., 2021; Harrer et al., 2020) have
pointed out the importance of more investigations into risk factors
and prevention strategies for EDs in males. Our review identified only
one trial that focused on male samples (Almeida et al., 2021). Other
eligible trials conducted interventions with mixed samples (i.e., males
and females in the same group). Theoretically, heterogeneous samples
may attenuate the ability to detect effects. Stice et al.'s (2007, 2021)
trials with mixed-sex settings indicated that the presence of males
increased the incidence of ED onset over follow-up and thus sensitiv-
ity to detect preventive effects. Despite this, of the studies with
mixed samples (n = 6) that were reviewed in the present study, half
reported statistically significant effects on the outcomes. In one study
of adolescents, a reduction in scores for overeating and the influence

n
of body aesthetic models was found (Escoto Ponce de Leo
et al., 2008), and two studies of university students showed a
decrease in disordered eating behaviors (Castillo et al., 2016;
Saucedo-Molina et al., 2018). Thus, there are promising effects of
mixed-sex ED interventions in non-Latin American countries. The
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LENZ DUNKER ET AL.
TABLE 2 Risk of bias.
High-risk of bias
n %
7 31.8
5 22.7
22 100
22 100
5 22.7
8 26.4
- 0
16 72.4
Australian program “Happy Being Me Co-educational” compared out-
comes for girls when the program was delivered as a universal (co-
educational) or selective (single-sex), and observed significant
improvements in body dissatisfaction and psychological risk factors
for ED (i.e., thin-ideal internalization, appearance-based comparisons,
and self-esteem in both conditions; Dunstan et al., 2016). Another
program “In Favour of Myself,” conducted with adolescents from
Israel, demonstrated that mixed-sex group had statistically significant
improvement in body-esteem, as well as reduction in perceived cur-
rent body image, and in the difference between current and ideal
body image (positive change) (Agam-Bitton et al., 2018).
Most of the programs evaluated a selective intervention. The
results of these trials show significant reductions in ED risk factors,
such as dieting, body dissatisfaction, sociocultural influences
(e.g., thin-ideal internalization), disordered eating behaviors, low
self-esteem, and depressive symptoms (e.g., negative affect), with
effect sizes ranging from medium to high (see Table 1). Furthermore,
it is important to note that the only selective intervention that
included a sample of young men (Almeida et al., 2021) found signifi-
cant effects for almost all outcomes, including disordered eating,
muscularity concerns, and muscle dysmorphia symptoms. Selective
preventions have demonstrated better efficacy and effectiveness,
showing improvement in several risk factors at postintervention and
longer follow-ups, with larger effect sizes (Ciao et al., 2014; Stice
et al., 2021).
On the other hand, universal approaches often produce weaker
effects (Stice & Shaw, 2004; Stice et al., 2007). This is in part a statisti-
cal artifact. The target groups of these interventions are a mix of par-
ticipants who are not at risk and those who are at risk, and perhaps at
high risk. Therefore, their typical scores on baseline measures of risk,
including disordered eating, are lower and thus less capable of positive
change (Schwartz et al., 2019). Nevertheless, the universal prevention
programs included in this review achieved important results. Among
the included trials that evaluated universal interventions, most had

pez et al.'s
mixed samples (i.e., girls and boys), except for Cueto-Lo
(2022) study, which evaluated a sample composed of adolescent girls.
In general, these trials also showed significant differences in the out-
comes for those who participated in the interventions, including a
decrease in disordered eating, body dissatisfaction, and thin-ideal
internalization, with medium effect sizes (see Table 1).

LENZ DUNKER ET AL.
In addition, although the effects of integrative prevention on ED
risk factors are promising, only two studies (Castillo et al., 2016, 2019)
found the desired effects on body dissatisfaction and disordered eat-
ing risk behaviors, with effect sizes from small to medium (see
Table 1). Two studies did not found significant effects for these mea-
sures, but had a small to medium effect size for physical activity prac-
tice (Dunker et al., 2021; Leme et al., 2019). Given these results,
further research is strongly recommended because integrative preven-
tion programs may be more cost-effective, reducing the costs related
to the development of two separate prevention programs and avoid-
ing the iatrogenic effects of conflicting messages from obesity and
ED-only prevention programs (Ferrari, 2015; Leme et al., 2019; Sán-
chez-Carracedo et al., 2012).
Trials that had significant effects (d = .91–2.75) on measures of
body image and/or ED risk factors were based on interactive programs

mez-Peresmitré, 2012;
with multiple sessions (de la Vega Morales & Go

n et al., 2010; García & Go
Escoto Ponce de Leo
mez-Peresmitré, 2006;
García et al., 2010; Resende et al., 2022; Unikel-Santoncini
et al., 2019), meeting recommendations for the development of ED
prevention programs (Stice et al., 2019). Regarding the content of the
interventions, we highlight the frequent use of cognitive dissonance

mez-Peresmitré, 2006; García et al., 2010; Resende
(García & Go
et al., 2022; Unikel-Santoncini et al., 2019). Dissonance-based pro-
grams are based on group definitions of body ideals, discussions about
the costs of pursuing this ideal, and behavioral exercises and chal-
lenges, including role plays (Stice et al., 2013). As also noted by other
reviews (e.g., Stice et al., 2019), cognitive dissonance programs
(e.g., Body Project) have shown greater reductions in several ED risk
factors and symptoms, including the onset of EDs (Stice et al., 2021),
than both alternative interventions and assessment-only control condi-
tions. Several of these effects extended through long follow-ups (up to
3–4 years; Stice et al., 2021). These effective results were confirmed in
trials with significant medium/large effect size (d = .32–1.87: Almeida
et al., 2021; García et al., 2010; Hudson et al., 2021; Resende
et al., 2022; η = .02–.19: Castillo et al., 2016; Rutsztein et al., 2019,
2
2021; Saucedo-Molina et al., 2018) included in this review that tested
cognitive dissonance programs through short follow-ups (3–6 months),
strongly suggesting that the ease of cultural adaptation of script con-
tent guarantees that dissonance elements are maintained even in other
sociocultural contexts.
Psychoeducational interventions and programs derived from
social cognitive theory were also tested in the included studies. These
approaches involve offering content that generates participants' iden-
tification of problems related to food, as well as proposed activities
that challenge negative thoughts about the overvaluation of weight
and shape (Baranowski et al., 2002). Among the main results found,
these interventions significantly reduced body dissatisfaction, food
and weight concerns, and other ED risk factors (d = .59–5.69: Anuel

mez-Peresmitré, 2012; Escoto
et al., 2012; de la Vega Morales & Go

n et al., 2008, 2010; García & Go
Ponce de Leo
mez-Peresmitré, 2006;

mez-Péresmitré et al., 2013).
García et al., 2010; Go
The integrated Brazilian version of the “New Moves” (Dunker &
Claudino, 2018) also uses this approach with adolescent girls, with
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703
sessions based on nutrition, social support, and physical activity.
Although the researchers did not find significant changes for ED risk
factors, in a secondary analysis Dunker et al. (2021) found that girls
with less body image dissatisfaction reported higher daily physical
activity levels. Therefore, the authors suggest that engagement in
physical activity could be a protective factor against body dissatisfac-
tion, given that it has been inversely associated with several risk fac-
tors for EDs and other psychological benefits.
It is also important to point out that none of the studies included
in the present review used an online model of delivery; all of them
were delivered in person. Only one study included an innovative
approach. The selective program named “Realidad Virtual Reforzada,”

mez-Péresmitré et al. (2013) with Mexican
designed and tested by Go
adolescent students, showed the positive effects of using software
that allows participants to manipulate avatars that represent their cur-
rent, ideal and real figures, interacting in a virtual medium while
reflecting on negative thoughts about her own body. The researchers
found a significant decrease in body dissatisfaction scores and a
reduction in the prevalence of participants who were at risk of
developing ED.
The use of new technologies is strongly encouraged to broadly
disseminate prevention programs. One of the trials (Almeida
et al., 2021) exemplifies the use of these strategies in facilitator train-
ing that was carried out virtually. Considering the difficulty and high
cost of such training, we consider it an important direction for broad
dissemination, as well as the use of virtual platforms to deliver
interventions.
Regarding the maintenance of effects, most of the trials included
shorter follow-ups than studies conducted in other countries (Stice
et al., 2020). Long follow-ups are strongly recommended for several
reasons. The primary reason for a longer follow-up is the need to
demonstrate that the intervention creates changes that last well
beyond the period in which the program is in effect. Furthermore, lon-
ger follow-ups in ED prevention programs allow for demonstrating
that program-induced changes in risk factors ultimately contribute to
a significant comparative reduction in ED onset (Stice et al., 2021).
Another important question regarding outcomes concerns the
diversity of tools used, which makes it difficult to compare the results.
Moreover, there is no pattern in the selection of outcomes, as evi-
denced by the results of the present review. It is notable that several
tools related to the screening of EDs and their risk factors were cre-
ated in countries such as the USA, Australia, and European nations.
However, many of them are not available in Spanish or Portuguese
for use in the Latin American context, making it difficult for
researchers in these countries to choose validated measures. This
highlights the need for a measurement adaptation and harmonization
to improve the outcome comparability of these Latin American stud-
ies with Western studies.
Importantly, the results from the trials included in this review
show promising reductions in body dissatisfaction, body-ideal inter-
nalization, depressive symptoms, and ED symptoms. These findings
confirm the value of prevention initiatives, as they produce effective
results that could prevent the development of EDs. This is especially

704
important for Latin American countries because of the limited avail-
ability of centers for specialized treatment of EDs and the difficulty in
accessing these services, which are often only available in large cities.
4.1 | Limitations
The risk of bias for the trials included in this review ranged from low
to high, with 16 trials (72.7%) being rated at high risk and six being
rated as at low risk of bias. First, in eight studies, there was no ran-
domization of participants, while seven other studies did not report
sufficient information about the randomization process used. This is a
key domain of any intervention study, as the randomization process
produces groups that are highly likely to be unbiased with respect to
the dependent variables at baseline and with known and unknown
confounding variables (McCoy, 2017). In addition, some trials did not
have a control group, which could compromise the outcomes and
produce bias.
Another key domain evaluated in the quality assessment was the
use of intent-to-treat analysis. Only six studies (27.27%) used this
form of analysis. According to McCoy (2017), such an analysis allows
the researcher to draw unbiased conclusions regarding the effective-
ness of an intervention, as all participants are included in the analysis.
Use of this strategy is very recent among the included trials, as the
first study that used this approach dates from 2018. However, even

pez et al., 2022; Rutsztein
some more recent trials (Cueto-Lo
et al., 2021) did not use intent-to-treat analysis.
The sample size is also a concern among the investigations. Most
of the studies did not perform power-based sample size calculations,
and many included a small number of participants. The sample size
directly influences the precision of estimates and the capacity for a
study to draw conclusions. Nonetheless, researchers are often
tempted to study a small sample due to convenience, time concerns,
and available resources (Nayak, 2010).
Another important question that deserves to be highlighted is
the risk of bias in blinding of participants and treatment providers
(performance bias). All the included studies have high risk of bias in
this domain. We understand that this is a potential bias in the stud-
ies, but it is also an inherent aspect of these interventions. Previous
systematic reviews have chosen not to include this domain as a
quality assessment criterion, because it is not easy to avoid the per-
formance bias in psychological in-person interventions (e.g., Stice
et al., 2021; Watson et al., 2017). On the other hand, Juul et al.
(2021) argue that, despite the challenges of implementing blinding
procedures for participants and personnel, it is possible to blind
both in psychological interventions. For example, the providers may
be kept blinded if they are not informed about the specific therapy
(i.e., the name and the theory), and the participants if they do not
know their allocation and could not distinguish the experimental
condition from the control. However, as pointed out by the authors,
this kind of blinding could potentially compromise the effects of the
active components of the psychological interventions and conse-
quently affect the effective delivery of the intervention. Also, as
psychological intervention may require extensive training of
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LENZ DUNKER ET AL.
providers, the implementation of this kind of blinding is even more
difficult.
In addition to the methodological limitations of the included studies,
we must also consider the limitations of the present review. Despite
efforts made to capture all of the literature on the topic, gray literature
and dissertation/thesis data were not included. We did not include these
data because they are generally not peer reviewed, and their internal
validity (i.e., risk of bias) may be difficult to assess due to poor reporting
of trials. Additionally, the identification of relevant unpublished study
data or data published in the gray literature and their inclusion in a sys-
tematic review can be particularly challenging due to the excessive time,
effort and costs involved. Although one might argue that systematic
reviews and meta-analyses not including unpublished or gray literature
results are likely to overestimate treatment effects, Schmucker et al.
(2017) found that this is only the case for a minority of reviews.
Another limitation concerns our decision to not conduct a meta-
analysis. The studies included in this review showed a high risk of bias
(i.e., 72.7% of reviewed studies), showed high levels of heterogeneity,
and used a variety of ED measures. We also found a lack of standardi-
zation of information between studies (in terms of, e.g., sample sizes,
time points follow-ups, and data reports). Also, as noted above, many
studies did not perform a power analysis, so, we cannot assume that
these trials were adequately powered. We reviewed existing ED pre-
vention programs regardless of study designs and target populations
(i.e., intervention categories, sex, and race/ethnicity). Given the scar-
city of ED interventions tested among Latin American countries, we
decided to include and summarize the results of heterogeneous pub-
lished and peer-reviewed studies.
4.2 | Future directions
Based on this set of limitations, it will be critical for future studies to
adopt procedures to systematically contribute to the field of ED pre-
vention in Latin America. First, the results show that most of the ini-
tiatives included only adolescent girls and young women, with some
of them using mixed samples and only one focusing on men. It is
important to conduct investigations specifically targeting men and
sexual and gender minorities to provide a suitable framework for pre-
vention efforts among these groups. Furthermore, the inclusion of
new technologies in interventions is recommended. Trials from other
world regions have already evaluated the efficacy of some of the pre-
ventive programs discussed in this review when delivered virtually
(i.e., v-Body Project; Ghaderi et al., 2020), and other protocols are
under evaluation in European countries (Bauer et al., 2019; Bell et al.,
2019; Nacke et al., 2019). Including new technologies in ED preven-
tion programs (e.g., interventions delivered virtually) may help broadly
disseminate these interventions. It is also recommended that preven-
tion programs in Latin America place more emphasis on improving
protective factors. Some trials showed that prevention programs can
improve body appreciation (Almeida et al., 2021; Amaral et al., 2019;
Hudson et al., 2021; Resende et al., 2022) and intuitive eating
(Resende et al., 2022). It would also be optimal to use more robust
designs (i.e., randomized controlled trials) and analysis (i.e., intent-to-

LENZ DUNKER ET AL.
treat analysis) and longer follow-ups to produce more informative
intervention effects (i.e., to demonstrate that program-induced
changes in risk factors ultimately contribute to a significant compara-
tive reduction in ED onset). Finally, we recommend that future studies
in Latin American countries strive to avoid sources of bias by being
more attentive to the importance of randomization to groups, use of
power calculations to establish appropriate sample sizes, application
of intent-to-treat analyses of outcomes, and blinding of participants,
personnel, and assessors.
AUTHOR CONTRIBUTIONS
Pedro Henrique Berbert de Carvalho: Conceptualization;
methodology; writing – original draft; writing – review and editing.
Ana Carolina Soares Amaral: Conceptualization; investigation; meth-
odology; project administration; writing – original draft; writing –
review and editing. Karin Louise Lenz Dunker: Conceptualization;
investigation; methodology; project administration; writing – original
draft; writing – review and editing.
FUND ING INFORMATION
This study was not funded.
CONF LICT OF IN TE RE ST ST AT E MENT
The authors have no conflict to declare.
OPEN RE SEARCH BADGES
This article has earned Open Data, Open Materials and Preregistered
Research Design badges. Data, materials and the preregistered design
and analysis plan are available at https://osf.io/g4uhs/?view_only=
188b85b53a934b2a97acbef9ac151912.
DATA AVAI LAB ILITY S TATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Karin Louise Lenz Dunker https://orcid.org/0000-0002-8686-7611
Pedro Henrique Berbert de Carvalho https://orcid.org/0000-0002-
4918-5080
Ana Carolina Soares Amaral https://orcid.org/0000-0003-2485-
9111
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SUPPORTING INF ORMATION
Additional supporting information can be found online in the Support-
ing Information section at the end of this article.
How to cite this article: Dunker, K. L. L., Carvalho, P. H. B. d.,
& Amaral, A. C. S. (2023). Eating disorders prevention
programs in Latin American countries: A systematic review.
International Journal of Eating Disorders, 56(4), 691–707.
https://doi.org/10.1002/eat.23916