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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 51-56

Effect of an intervention on self-esteem, body image satisfaction, and eating disorders in adolescents

Department of Community Medicine, Apollo Institute of Medical Sciences and Research, Hyderabad, Telangana, India

Date of Submission24-Sep-2020
Date of Decision25-Sep-2020
Date of Acceptance29-Jul-2021
Date of Web Publication18-Oct-2022

Correspondence Address:
Saba Syed
Sri Ram Nagar Colony, Masab Tank, Hyderabad - 500 028, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_135_20

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Background: In the area of adolescent health, there is growing evidence that effective health promotion interventions among adolescents, providing skills and knowledge, may have direct effects on a range of health outcomes. Thus, the study aimed to assess the effect of mixed-method intervention on self-esteem, body image satisfaction, eating disorders among adolescent school students. Materials and Methods: The cross-sectional study was conducted among high school students in a metropolitan city. At baseline, self-esteem, perception of body image, and pressure by media of participants were assessed using validated self-reported measures. The mixed-method intervention was a body image enhancement program conducted over 6 weeks through six 45–60 min sessions. Postintervention, participants' scores in the above-mentioned domains were assessed using the same self-reported measures. Data analysis was done using SPSS 23.0, and Fisher's exact test, paired t-test, etc., were applied as appropriate. Results: Out of 60 participants, 47% were girls and 53% were boys. Baseline self-esteem scores of girls were lower as compared to boys and were significantly higher in both postintervention. Body image satisfaction among girls improved from 53.57% to 78.57% after intervention. At baseline, higher proportion of girls had likelihood of developing an eating disorder which reduced postintervention. Conclusions: The school-based mixed-method intervention was effective in improving self-esteem, body image satisfaction, and reducing the influence of sociocultural attitudes on appearance in adolescent students.

Keywords: Adolescent, body image satisfaction, intervention, self-esteem, sociocultural attitudes

How to cite this article:
Adusumilli D, Syed S, Pattnaik S. Effect of an intervention on self-esteem, body image satisfaction, and eating disorders in adolescents. CHRISMED J Health Res 2022;9:51-6

How to cite this URL:
Adusumilli D, Syed S, Pattnaik S. Effect of an intervention on self-esteem, body image satisfaction, and eating disorders in adolescents. CHRISMED J Health Res [serial online] 2022 [cited 2022 Dec 8];9:51-6. Available from: https://www.cjhr.org/text.asp?2022/9/1/51/358811

  Introduction Top

Adolescence is a critical life stage for the development of self-confidence and self-image.[1] As puberty is associated with weight gain, adolescents frequently experience dissatisfaction with their changing bodies and body dissatisfaction is a risk factor for the development of eating disorders.[2] In a global culture that glorifies thinness, many adolescents especially girls become excessively preoccupied with their physical appearance and begin to restrict dietary intake obsessively.[3] Sociocultural factors such as peers, parents, culture-specific gender inequitable norms, and media are also hypothesized to contribute to lower self-esteem, body image dissatisfaction, and development of attitudes and behaviors related to eating disorders in adolescents.[4],[5]

Low self-esteem and negative self and body image among adolescents have been reported as the most important factors for risk-taking behavior.[6],[7] Such adolescents may become more susceptible to peer pressure and sexual abuse. They also become more prone to lifestyle-related diseases in adult life and chronic discontent with one's body hampers their well-being which may affect their adult interpersonal relationships.

Body image dissatisfaction is increasingly being recognized as an important target for public health action, and positive self-esteem has been proposed as an important defense against peer pressure and media influence.[7],[8] There is growing evidence that effective health promotion interventions providing skills and knowledge to cope with environments and challenge personal values may have direct effects on a range of health outcomes.[9],[10]

Schools can provide conducive environments to enforce and encourage health promotion strategies, especially among adolescents and can aid in improving mental health of adolescents.[11],[12],[13],[14] With the current epidemiological transition, almost universal digital and social media access and easy access to mainstream and adult content, there is an urgent need of interventions which address their unmet needs in terms of self-esteem, body image satisfaction, eating disorders, and effect of sociocultural factors on appearance. Thus, sensing a gap, the present study aimed to assess the effect of a school-based intervention on body image satisfaction, self-esteem, and eating disorders in adolescent students.

  Materials and Methods Top

Study design: Cross-sectional study

Institutional ethics committee approval was taken before initiation of the study. One government and one private school were selected randomly from a list of all private and government-aided schools. Permission was obtained from each school administration before conduction of the study. The concerned teachers were sensitized and briefed about the intervention. A group of 30 participants were selected from each participant school, in the age group of 11–15 years.

Informed consent was obtained from their parents/guardians. Baseline information on demographic variables was collected from the study participants by a questionnaire.


Self-esteem, perception of body image, drive for thinness and body dissatisfaction, and pressure by media were assessed through self-reported measures using Rosenberg's Self-Esteem Scale, body image scale (pictoral), eating disorders inventory (EDI-2 subscales), and Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3) scale, respectively.[15],[16],[17]

Rosenberg's Self-Esteem Scale is a widely used measure of global self-esteem and has been determined to be valid and reliable among students in Grades 7–12.[15] Responses to the 10 items were rated on a 4-point scale (strongly disagree to strongly agree) yielding scores between 10 and 40 with higher scores indicating higher self-esteem. The EDI-2 subscales and Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3) scale are widely used validated and reliable scales which were individually scored for each participant.[16],[17]

After obtaining baseline information, the mixed-method intervention was delivered in the form of si × 45–60 min sessions; spread over 6 weeks and integrated into the daily teaching schedule. The intervention was using the “Happy Being Me” – a co-educational body image program which had been locally adapted. Prior permission had been obtained from the authors for using their program.[12]

The sessions included ice breakers, group discussions, role plays, interactive lectures, games, videos, real-life scenarios, experience sharing, storytelling, and poster making. The adapted “Happy Being Me” student activity book was given to all participants. Sessions were conducted in a playful and friendly manner to ensure full participation. If the participants felt uncomfortable discussing any of these topics, they could approach the facilitator in a more private setting.

Session 1 – Body image

The session was designed to help the participants deal with some of the social pressures around body image and how it would help them increase good feelings about their bodies, in addition to helping others feel good about themselves.

The session involved all the participants writing down what they thought were the “ideal physical characters” a girl or boy should possess. They were then asked to reflect on what emotional, social, physical problems could result in the process of attempting to achieve those characters. They were also asked to list their favorite people and were encouraged to think which quality did they like in that particular individual, irrespective of their outward appearance.

During the conclusion of the session, each student was provided with posters and markers to write the physical qualities that they liked about their body. The take-home message was that every individual is unique and an ideal appearance does not exist.

Session 2 – Pals opposed to pressure and prejudice

Session 2 concentrated on what is meant by appearance teasing and fat prejudice. Students were told stories of children in similar age groups where appearance teasing/body shaming existed; they were encouraged to actively imagine themselves being witnesses to such a situation happening in their classroom/elsewhere and were then asked what would the right thing to do would be as a bystander/peer. They were finally asked to write down set of class rules to stop teasing and prejudice within their own classroom.

The take-home message was that singling out peers/anyone based on appearance is not acceptable and it is very important to recognize and value the unique qualities in people.

Session 3 – Fat talk

In this session, a role play was done in which two girls were sitting and complaining to each other about how fat they felt they were and that no clothes look good on them. The implication of fat talk resulting in eating disorders such as bulimia, anorexia nervosa, and decline in self-esteem was highlighted.

Session 4 – Comparison comrades

In this session, an active discussion was conducted based on the following:

  1. What physical traits do people compare?
  2. Who do people compare their bodies with?
  3. Are people stuck in the comparison trap?

The take-home message was to not fall into the comparison trap and that unhelpful appearance comparisons can contribute to body dissatisfaction, low self-esteem, and depressed mood.

Session 5 – Comparison comrades and media mates

The main purpose of this session was to bring awareness about how media can be extremely deceiving as well as unrealistic; moreover, the harm one can do to themselves in the process of attempting to look like their celebrity idol which was highlighted.

Media images of the students' favorite media figures were projected onto the board, before and after photoshopped pictures and videos were shown to impress upon the students that no one is perfect and all what you see in movies, advertisements is not real. The manipulation the images go under was shown step by step, and the “Dove-Evolution Video” transformation was one such video used to enforce this.

The take-home message was that young adults can help their friends out by refusing to take media images seriously and not being influenced by the impossible body image messages that media projects.

Session 6 – Spreading the word

The participants were told that now, their job would be to spread the word about the importance of good body image and high self-esteem to others around them by applying what they learned in the past sessions. Finally, the participants were asked to select their favorite message from all the sessions and prepare a colorful poster. After conclusion of the intervention, data collection was done using the same self-reported formats, and feedback was collected from the participants about each session.

Statistical analysis

Data were analyzed using SPSS 22.0 (IBM Corp., Armonk, NY). Descriptive statistics were used for sociodemographic data. Significance of difference in the mean scores was analyzed using paired student's t-test, and significance of difference in proportions of participants scoring low/moderate/high before and after the intervention was calculated using Fisher's exact test. P <0.05 was considered significant.

  Results Top

Demographic characteristics

The present study was conducted with 60 students. The mean age of the participants was 12.58 years. Majority of participants, i.e. 23 (38.33%) and 21 (35%) participants were 13 years and 12 years of age, respectively. Seven (11.67%) participants were 14 years, 6 (10%) were 11 years, 2 (3.33%) were 15 years, and 1 (1.67%) was 10 years of age. The study participants comprised of 28 (47%) girls and 32 (53%) boys. The study population was homogenous with respect to age and gender (P > 0.05).


The overall preintervention mean self-esteem score in girls was lower (18.01) indicative of low self-esteem than the mean self-esteem score (24.69) indicative of moderate self-esteem in boys and the difference was found to be significant (P < 0.05).

The postintervention mean self-esteem score was observed to increase to 31.43 in girls and 35.31 in boys indicative of high self-esteem. The pre- and postintervention mean self-esteem scores were significantly higher in both boys and girls (P < 0.05).

The categories of self-esteem scores both pre- and postintervention among the study participants are depicted in [Table 1].
Table 1: Categories of pre- and post-intervention self-esteem scores of the study participants

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Furthermore, girl and boy participants from the government school had a significantly lower preintervention mean self-esteem score (16.33 and 21.84, respectively) as compared to the private school (19.69 and 27.53, respectively) (P < 0.05). The postintervention mean self-esteem score was observed to increase significantly in both girls and boys to 29.86 and 34.22, respectively, in government school and to 33 and 36.4, respectively, in private school (P < 0.05).

Body image satisfaction

Before the intervention, of 28 girl participants, 15 (53.57%) were satisfied with their body image and 13 (46.43%) were not satisfied with their body image. Of the 32 boy participants, more boys 28 (87.5%) were satisfied with their body image and 4 (12.5%) were not satisfied with their body image. The difference in preintervention body image satisfaction among boy and girl participants was not significant statistically (P > 0.05).

Postintervention, improvement in body image satisfaction, was observed in both boy and girl participants where 22 (78.57%) girls and 30 (93.75%) boys were satisfied with their body image. The improvement in body image satisfaction postintervention did not approach statistical significance (P > 0.05).

The pre- and postintervention body image satisfaction among the study participants is depicted in [Table 1].

  Eating disorders survey results Top

Before the intervention, among the girl participants, 8 (28.57%) had thoughts/actions linked to an eating disorder in the past 4 weeks, and none of the boy participants had thoughts/actions linked to an eating disorder in the past 4 weeks. Of the above 8 girl participants, 6 (75%) were attending government school and 2 (25%) were in the private school.

Postintervention, of the eight girl participants, 4 (14.29%) girl participants had thoughts/actions linked to an eating disorder in the past 4 weeks of which 3 (37.5%) girl participants were attending government school and 1 (12.5%) girl was from the private school.

The categories of self-esteem scores both pre- and postintervention among the study participants are depicted in [Table 1].

Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3)

The mean preintervention Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3) score in boy participants was 30.37 and was 34.57 in girls indicating perception of participants that “Sociocultural factors always influence appearance.” The postintervention mean (SATAQ-3) score was 40.38 in girls and was 38 in boys indicating perception of study participants that sociocultural factors sometimes influence appearance. Differences in Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3) scores were not significant in the government and private school study participants.

The categories of Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3) results both pre- and postintervention among the study participants is depicted in [Table 1].

  Discussion Top

The present cross-sectional study assessed the effect of a school-based mixed-method intervention adapted to Indian context on self-esteem, body image satisfaction, likelihood of developing eating disorder, and influence of sociocultural attitudes on appearance. It was conducted through 6 sessions over 6 weeks, to the best of researcher's knowledge, this is the first time this has been addressed in Indian adolescent school students.


Overall, girls had lower self-esteem scores before the intervention. Postintervention, however, there was a 46.43% increase in the girl participants and 37.52% increase in the boy participants who had high self-esteem. Gender significantly influences adolescents' self-esteem, especially in gender inequitable societies. Adolescent girls appear to be more vulnerable than boys to negative stress and present with symptoms of depression, low self-worth, and eating disorders as reported by other studies.[14]

Adolescence is a period of constant conflict with oneself, low self esteem , confidence and an adolescent may indulge in behavior which may prove detrimental to his/her health and well being. Moreover, with the social media revolution, unrestrained advertising and obsession of a section of media in diligently documenting daily events of film celebrities globally adolescents have become more vulnerable to “desirable body images.” However, adolescents' self-esteem can be enhanced effectively through sensitively planned and delivered interventions as is evident in other studies and the present study.

In addition, socioeconomic status also influences self-esteem in adolescents as observed in the present study, wherein the private school, both pre- and postintervention self-esteem scores for both boys and girls' participants were significantly higher than the government school participants. Previous studies have also reported similar observations.[18] Low socioeconomic status combined with low literacy rates could be the reasons why the parents/guardians of these adolescents are often not able to guide them in combating adolescent issues.

Eating disorder

At baseline, among the boys, no participant had any thought/action linked to an eating disorder in the past 28 days. However, 29% of the girl participants had thoughts/actions linked to an eating disorder which reduced to 14% after the intervention. Few studies of eating disorders include men, yet our findings suggest that a substantial minority of men also report eating disorder symptoms. Keywords: binge eating, eating disorders, body mass index, gender difference eEating disorders such as anorexia nervosa and bulimia nervosa are more common among females, and studies have reported that girls are more likely than boys to report weight dissatisfaction, engage in extreme dieting, and use purgatives which are corroborated by findings of the present study.[19],[20],[21],[22]

Findings of the present study could be indicative of rising trend of adolescent girls with eating disorders and/abnormal eating attitudes in India also; even though the prevalence of eating disorders among adolescent females may be lower in Asian countries when compared to western countries.[23]

Body image satisfaction

In the present study, body image satisfaction was lower, i.e. 54% among girls than (88%) among boys which improved significantly to 79% in girls and 94% in boys, postintervention. Other studies have also shown positive short-term benefits for girls' body image, dietary restraint, and for eating disorder symptoms among girls and boys. However, relatively long-term interventions may be needed for sustained improvement in body image perception.[21],[22],[24]

Influence of sociocultural factors on appearance

Before intervention, all 60 (100%) participants in the present study felt sociocultural factors either sometimes/always influenced appearance and postintervention 9 (28.13%) boys and 17.86% girls felt sociocultural factors never influenced their appearance. Baseline findings could be indicative of the effect of families, peers, print and social media, movies, and television on adolescents, especially to look a certain way. One of the methods of intervention in the present study was a video sharing technique attempted to enhance the awareness of the participants how models and actors enhanced their looks through make-up, camera, and computer manipulations.[24]

Similar studies assessing effects of interventions on adolescents' have been conducted globally but there is a paucity of Indian studies on interventions addressing the aforementioned areas in adolescent mental health despite the huge gap.[25],[26],[27] In the present study, low self-esteem, body image dissatisfaction, perception of effect of sociocultural factors on appearance and thoughts/actions linked to eating disorder were observed more in girl participants. The “Indian cultural milieu” causes unprecedented stress in the lives of adolescents through their “well-meaning” immediate, extended families and acquaintances. The major burden of which is still borne by girls who are unknowingly falling prey to the “fair, slim, tall and beautiful” to “marry an eligible bachelor” syndrome by which Indian society is afflicted with irrespective of caste, religion, and socioeconomic status aided by the omnipresent advertisements and mainstream media glorifying a certain body type.

The Indian family (the cocoon) too is becoming frayed and unable to handhold and adolescents assuredly into adulthood. Boys are also not spared where becoming the next hot sports/film celebrity has become aspirational and those who do not conform are left with feelings of inadequacy which have an effect on their own and their future families' health and well-being.

A gender-equitable adolescent with good self-esteem will mostly make the right health and well-being-related choices for him/herself and their families. Interventions addressing self-esteem, body image satisfaction, eating disorders, and effect of sociocultural factors on appearance among adolescents can be effective as evident in the present study and are indicative of potential areas for further research in the area of adolescents' well-being.

Strengths of the present study

The study adds to the evidence base on effectiveness of school-based interventions on mental health of adolescents in India in terms of relatively neglected but crucial areas of self-esteem, body image satisfaction, and effect of sociocultural attitudes on appearance.

Limitations of the present study

The study was a cross-sectional study with a limited sample size; prospective multicentric studies with larger sample size would be more effective in assessing effectiveness and impact of similar interventions among adolescents.

  Conclusions Top

The school-based mixed-method intervention was effective in improving the self-esteem, body image satisfaction, and reducing the influence of sociocultural attitudes on appearance in adolescent school students.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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