“Healthy Habits, Healthy Girls—Brazil”: an obesity prevention program with added focus on eating disorders
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To evaluate the immediate post-intervention and 6-month post-intervention effects of a Brazilian school-based randomized controlled trial for girls targeting shared risk factors for obesity and disordered eating.
Total of 253 girls, mean of 15.6 (0.05) years from 1st to 3rd grades of high school participated in this 6-month school-based cluster randomized controlled trial. “Healthy Habits, Healthy Girls—Brazil (H3G-Brazil)”, originally developed in Australia, emphasized 10 key nutrition and physical activity (PA) messages delivered over 6 months. Disordered eating prevention procedures, i.e., prevention of weight-teasing, body satisfaction, and unhealthy weight control behavior, were added to the intervention. Body dissatisfaction, unhealthy weight control behaviors and social cognitive-related diet, and physical activity variables were assessed at baseline, immediate post-intervention, and 6-month post-intervention. Intervention effects were determined by one-way analysis of covariance or logistic regression, after checking for the clustering effects of school. The control group did not receive intervention prior to follow-up assessment. A conservative significance level was set at p < 0.01.
Beneficial effects were detected for PA social support (F = 6.005, p = 0.01), and healthy eating strategies (F = 6.08, p = 0.01) immediate post-intervention; and healthy eating social support (F = 14.731, p = 0.00) and healthy eating strategies (F = 5.812, p = 0.01) at 6-month post-intervention. Intervention group was more likely to report unhealthy weight control behaviors (OR = 1.92, 95% CI 1.15–3.21, p = 0.01) at 6-month post-intervention. No other significant immediate or 6-month post effects were detected.
H3G-Brazil demonstrated positive 6-month effects on some social cognitive variables but an adverse effect on unhealthy weight control behaviors. Thus, this study was not able to achieve synergy by combining obesity and disordered eating prevention procedures in an intervention among low-income girls in Brazil.
Level I: cluster randomized controlled trial
KeywordsAdolescence Girls Eating disorders Obesity Prevention Social cognitive theory
Body mass index
Healthy Habits, Healthy Girls—Brazil
Low- and middle-income countries
Social cognitive theory
The authors thank the participant schools and adolescent girls for the value contribution. We also thank FAPESP twice: for AL post-doctoral training in Brazil (process no. 2015/20852-7) and for the grant to conduct the research internship at Baylor College of Medicine, Children’s Nutrition Research Center, Houston, Texas to AL (process no. 2016/21144-9).
All authors truly contributed to the development of this study. AL: participated in study concept and design, acquisition of data, analysis and interpretation of data, drafting the manuscript, critical revision of the manuscript for intellectual content and statistical analysis. SP: senior research of this project, participated in study concept and design, acquisition of data, drafting the manuscript and critical revision of the manuscript for important intellectual content. DT: participated in drafting the manuscript, critical revision of the manuscript for intellectual content and statistical analysis. TN: participated in drafting the manuscript, critical revision of the manuscript for intellectual content and statistical analysis. TB: participated in analysis and interpretation of data, drafting the manuscript, critical revision of the manuscript for intellectual content and statistical analysis.
No funding was received.
Compliance with ethical standards
Conflict of interest
The authors do not have any particular conflict of interest. Author ACBL received a post-doctoral scholarship from the São Paulo Research Foundation (Fundação de Amparo à Pesquisa—FAPESP).
This research received ethical approval from the School of Public Health, University of São Paulo (FSP-USP) ethics committee under the protocol number 01658112.6.0000.5421.
The parents/caregivers of the girls and the school principals provided written informed consent, as well as the girls provided assent forms for participation prior to data collection.
- 1.Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, Abraham JP, Abu-Rmeileh NME, Achoki T, AlBuhairan FS, Alemu ZA, Alfonso R, Ali MK, Ali R, Guzman NA, Ammar W, Anwari P, Banerjee A, Barquera S, Basu S, Bennett DA, Bhutta Z, Blore J, Cabral N, Nonato IC, Chang J-C, Chowdhury R, Courville KJ, Criqui MH, Cundiff DK, Dabhadkar KC, Dandona L, Davis A, Dayama A, Dharmaratne SD, Ding EL, Durrani AM, Esteghamati A, Farzadfar F, Fay DFJ, Feigin VL, Flaxman A, Forouzanfar MH, Goto A, Green MA, Gupta R, Hafezi-Nejad N, Hankey GJ, Harewood HC, Havmoeller R, Hay S, Hernandez L, Husseini A, Idrisov BT, Ikeda N, Islami F, Jahangir E, Jassal SK, Jee SH, Jeffreys M, Jonas JB, Kabagambe EK, Khalifa SEAH., Kengne AP, Khader YS, Khang Y-H, Kim D, Kimokoti RW, Kinge JM, Kokubo Y, Kosen S, Kwan G, Lai T, Leinsalu M, Li Y, Liang X, Liu S, Logroscino G, Lotufo PA, Lu Y, Ma J, Mainoo NK, Mensah GA, Merriman TR, Mokdad AH, Moschandreas J, Naghavi M, Naheed A, Nand D, Narayan KMV, Nelson EL, Neuhouser ML, Nisar MI, Ohkubo T, Oti SO, Pedroza A, Prabhakaran D, Roy N, Sampson U, Seo H, Sepanlou SG, Shibuya K, Shiri R, Shiue I, Singh GM, Singh JA, Skirbekk V, Stapelberg NJC, Sturua L, Sykes BL, Tobias M, Tran BX, Trasande L, Toyoshima H, van de Vijver S, Vasankari TJ, Veerman JL, Velasquez-Melendez G, Vlassov VV, Vollset SE, Vos T, Wang C, Wang X, Weiderpass E, Werdecker A, Wright JL, Yang YC, Yatsuya H, Yoon J, Yoon S-J, Zhao Y, Zhou M, Zhu S, Lopez AD, Murray CJL, Gakidou E (2014) Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384(9945):766–781. https://doi.org/10.1016/s0140-6736(14)60460-8 CrossRefPubMedPubMedCentralGoogle Scholar
- 5.APA (2017) Eating disorders. What are eating disorders? American Psychiatric Association. https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders Accessed 9 Sep 2017
- 11.Campos-Uscanga Y, Gutierrez-Ospina G, Morales-Romero J, Romo-Gonzalez T (2017) Self-regulation of eating and physical activity is lower in obese female college students as compared to their normal weight counterparts. Eat Weight Disord EWD 22(2):311–319. https://doi.org/10.1007/s40519-016-0338-9 CrossRefPubMedGoogle Scholar
- 16.Bucchianeri MM, Fernandes N, Loth K, Hannan PJ, Eisenberg ME, Neumark-Sztainer D (2015) Body dissatisfaction: do associations with disordered eating and psychological well-being differ across race/ethnicity in adolescent girls and boys? Cult Divers Ethn Minority Psychol. https://doi.org/10.1037/cdp0000036 Google Scholar
- 18.Stephen EM, Rose JS, Kenney L, Rosselli-Navarra F, Weissman RS (2014) Prevalence and correlates of unhealthy weight control behaviors: findings from the national longitudinal study of adolescent health. J Eat Disord 2:16. https://doi.org/10.1186/2050-2974-2-16 CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Leme AC, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST (2016) Preventing obesity among Brazilian adolescent girls: Six-month outcomes of the Healthy Habits, Healthy Girls-Brazil school-based randomized controlled trial. Prev Med 86:77–83. https://doi.org/10.1016/j.ypmed.2016.01.020 CrossRefPubMedGoogle Scholar
- 28.Kass AE, Jones M, Kolko RP, Altman M, Fitzsimmons-Craft EE, Eichen DM, Balantekin KN, Trockel M, Taylor CB, Wilfley DE (2017) Universal prevention efforts should address eating disorder pathology across the weight spectrum: implications for screening and intervention on college campuses. Eat Behav 25:74–80. https://doi.org/10.1016/j.eatbeh.2016.03.019 CrossRefPubMedGoogle Scholar
- 29.Leme A, Baranowski T, Thompson D, Nicklas T, Philippi S (2018) Sustained impact and behavioral mediators of waist circumference in the “Healthy Habits, Healthy Girls—Brazil” school-based randomized controlled trial for adolescents living in low-income communities. Prev Med Rep (in press) Google Scholar
- 30.Philippi S, Leme A (2018) Weight-related teasing: body dissatisfaction mediates weight-control behaviors of Brazilian adolescent girls from low-income communities? Cadernos de Saúde Coletiva 35 (in press) Google Scholar
- 31.Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG (2010) CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ 340:c869. https://doi.org/10.1136/bmj.c869 CrossRefPubMedPubMedCentralGoogle Scholar
- 32.Lubans DR, Morgan PJ, Dewar D, Collins CE, Plotnikoff RC, Okely AD, Batterham MJ, Finn T, Callister R (2010) The nutrition and enjoyable activity for teen girls (NEAT girls) randomized controlled trial for adolescent girls from disadvantaged secondary schools: rationale, study protocol, and baseline results. BMC Public Health 10:652. https://doi.org/10.1186/1471-2458-10-652 CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Bandura A (1986) Social foundations of thought and action: a social cognitive theory. Prentice-Hall, Englewood CliffsGoogle Scholar
- 36.Neumark-Sztainer DR, Friend SE, Flattum CF, Hannan PJ, Story MT, Bauer KW, Feldman SB, Petrich CA (2010) New moves-preventing weight-related problems in adolescent girls a group-randomized study. Am J Prev Med 39(5):421–432. https://doi.org/10.1016/j.amepre.2010.07.017 CrossRefPubMedPubMedCentralGoogle Scholar
- 38.Heck R, Thomas S, Tabata L (2010) Multilevel and longitudinal modeling with IBM SPSS. Routledge, New YorkGoogle Scholar
- 39.Tabachnick BG, Fidell LS (2007) Multilevel linear modeling. Using multivariate statistics. Pearson Education Inc., BostonGoogle Scholar
- 41.de Boer MR, Waterlander WE, Kuijper LD, Steenhuis IH, Twisk JW (2015) Testing for baseline differences in randomized controlled trials: an unhealthy research behavior that is hard to eradicate. Int J Behav Nutr Phys Act 12:4. https://doi.org/10.1186/s12966-015-0162-z CrossRefPubMedPubMedCentralGoogle Scholar
- 45.Lopez-Guimera G, Neumark-Sztainer D, Hannan P, Fauquet J, Loth K, Sanchez-Carracedo D (2013) Unhealthy weight-control behaviours, dieting and weight status: a cross-cultural comparison between North American and Spanish adolescents. Eur Eat Disord Rev 21(4):276–283. https://doi.org/10.1002/erv.2206 CrossRefPubMedGoogle Scholar
- 47.Lubans DR, Morgan PJ, Okely AD, Dewar D, Collins CE, Batterham M, Callister R, Plotnikoff RC (2012) Preventing obesity among adolescent girls: one-year outcomes of the nutrition and enjoyable activity for teen girls (NEAT Girls) cluster randomized controlled trial. Arch Pediatr Adolesc Med 166(9):821–827. https://doi.org/10.1001/archpediatrics.2012.41 CrossRefPubMedGoogle Scholar
- 48.Dewar DL, Morgan PJ, Plotnikoff RC, Okely AD, Collins CE, Batterham M, Callister R, Lubans DR (2013) The nutrition and enjoyable activity for teen girls study: a cluster randomized controlled trial. Am J Prev Med 45(3):313–317. https://doi.org/10.1016/j.amepre.2013.04.014 CrossRefPubMedGoogle Scholar
- 49.Wilksch SM, Paxton SJ, Byrne SM, Austin SB, O’Shea A, Wade TD (2017) Outcomes of three universal eating disorder risk reduction programs by participants with higher and lower baseline shape and weight concern. Int J Eat Disord 50(1):66–75. https://doi.org/10.1002/eat.22642 CrossRefPubMedGoogle Scholar
- 51.Tanofsky-Kraff M, Shomaker LB, Wilfley DE, Young JF, Sbrocco T, Stephens M, Brady SM, Galescu O, Demidowich A, Olsen CH, Kozlosky M, Reynolds JC, Yanovski JA (2017) Excess weight gain prevention in adolescents: three-year outcome following a randomized controlled trial. J Consult Clin Psychol 85(3):218–227. https://doi.org/10.1037/ccp0000153 CrossRefPubMedGoogle Scholar
- 57.Stice E, Shaw H, Marti CN (2007) A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu Rev Clin Psychol 3:207–231. https://doi.org/10.1146/annurev.clinpsy.3.022806.091447 CrossRefPubMedGoogle Scholar
- 64.Tanofsky-Kraff M, Shomaker LB, Wilfley DE, Young JF, Sbrocco T, Stephens M, Ranzenhofer LM, Elliott C, Brady S, Radin RM, Vannucci A, Bryant EJ, Osborn R, Berger SS, Olsen C, Kozlosky M, Reynolds JC, Yanovski JA (2014) Targeted prevention of excess weight gain and eating disorders in high-risk adolescent girls: a randomized controlled trial. Am J Clin Nutr 100(4):1010–1018. https://doi.org/10.3945/ajcn.114.092536 CrossRefPubMedPubMedCentralGoogle Scholar
- 65.Lubans DR, Smith JJ, Plotnikoff RC, Dally KA, Okely AD, Salmon J, Morgan PJ (2016) Assessing the sustained impact of a school-based obesity prevention program for adolescent boys: the ATLAS cluster randomized controlled trial. Int J Behav Nutr Phys Act 13:92. https://doi.org/10.1186/s12966-016-0420-8 CrossRefPubMedPubMedCentralGoogle Scholar