Body image satisfaction: A gratitude pilot
intervention for at-risk adolescents in Singapore
Samantha S. Ng
REACH (West)
National University Hospital, Singapore
Contact: samantha_sy_ng@nuhs.edu.sg
Dr. Albert K. Liau
Psychological Studies
National Institute of Education
Nanyang Technological University, Singapore
Contact: albert.liau@nie.edu.sg
What is body image satisfaction?
Body image and adolescence
Implications of poor body image
Straits Times, October 13, 2013
Traditional interventions targeting
poor body image
Applying positive psychology to BIS
Development of the
BIS-gratitude intervention
Purpose of the study
1. Examine the effectiveness of the BISgratitude intervention in an Asian
context on the following outcomes:
• General well-being
• Body image
2. Examine factors that mediate the impact
of the BIS-gratitude intervention
Method
Pretest-Posttest Experimental Design
44 participants (18 male, 26 female)
Mean age = 12.95
Experimental Group (22 participants)
- Wrote about 3 things they
appreciated about their bodies
Control Group (22 participants)
- Wrote about their past week
Measures
Well-being:
• PA: Positive Affect; NA: Negative Affect
•
20-item PANAS (Watson et al., 1988)
• Gratitude
•
5 gratitude-related items (grateful, glad, appreciative,
thankful & understood; Emmons & McCullough, 2003;
Froh et al., 2008)
• OLS: Overall Life Satisfacton
•
6-item Brief Multidimensional Students’ Life Satisfaction
scale (Froh et al., 2008)
Measures
Body image:
• BA: Body Appreciation
•
13-item Body Appreciation Scale (Avalos, Tylka, & WoodBarcalow, 2005)
Procedure of the Study
T1
T2
T3
Pretest data
collection
Session 2
Posttest 2
data
collection
Session 1
Posttest 1
data
collection
Gratitude condition
There are many things in our lives, both large and
small, that we might be grateful about. Think about
your health and the different parts of your body,
such as your eyes, arms and legs. Write down three
parts of your body you are thankful for, and why
you are thankful for each of them. You can write in
any language you want. Don't worry about spelling
or grammar.
Control condition
Think about your past week. These might include
what happened in your family, what your schedule
was like, what you liked and did not like, what you
thought about, and what your classes were like. On
this paper, write what you can think of. You can
write in any language you want. Don't worry about
spelling or grammar.
Results
Results
Preliminary Analyses
• There were no significant differences in all
the outcomes between the experimental
and control group
• Gender was not associated with condition
• In general, no gender differences in the
outcomes except for T1 PA
Results
Data Analyses Plan
2 X 3 MANOVA for repeated measures
• (condition by time)
• Time by group interaction effect
2 X 3 ANOVAs for each outcomes
• Time by group interaction effect
• Parameter estimates group effects @ T1,T2,T3
Post hoc analyses
• Within groups
• Changes from T1 to T2, & T1 to T3
Results
Data Analyses Plan
2 X 3 MANOVA for repeated measures
• Significant time main effect
• Significant time by group interaction effect
2 X 3 ANOVAs for each outcomes
• Significant time effects for NA & BA
• Significant time by group interaction effects for PA, LS
& Gratitude
Post hoc analyses
• Please see graphs
Results
Intervention Effects
There was a significant difference between groups at T2
(t=2.12, p=.04, d=.64)
Post hoc analyses indicated a significant decrease from T1 to T2
for the control group, and no changes for the experimental group.
Results
Intervention Effects
There was a significant difference between groups at T2
(t=3.06, p=.004, d=.92)
Post hoc analyses indicated a significant increase from T1 to T2
& Tt to T3 for the experimental group, & no changes for the
control group.
Results
Intervention Effects
There was a significant difference between groups at T2
(t=2.56, p=.01, d=.77)
Post hoc analyses indicated a significant increase from T1 to T2
& Tt to T3 for the experimental group, & no changes for the
control group.
Results
Intervention Effects
There was a significant difference between groups at T2
(t=2.17, p=.04, d=.65)
Post hoc analyses indicated no significant changes for the
experimental and control groups.
Results
Intervention Effects
There was a significant difference between groups at T3
(t=-3.45, p=.001, d=1.04)
Post hoc analyses indicated a significant increase from T1 to T3
for the control group; no changes for the experimental group.
Results
Mediating Effects
• To help us understand better the
processes of change in the study from
the pretest to the posttest (T1 to T2),
change scores in the main outcomes from
the pretest to the posttest were
calculated.
Results
Mediating Effects
Changes in
Gratitude
Changes in
Outcome
Intervention
Changes in Body
Appreciation
Results
Mediating Effects
• Product-of-coefficients approach of testing
indirect effects
• SPSS Macro Indirect (Preacher & Hayes,
2014)
• Allows testing of multiple mediators
• Analyses focused on change scores from
T1 to T2
Results
Mediating Effects
Changes in
Gratitude
Intervention
Changes in LS
Changes in Body
Appreciation
Changes in BA mediated the effects of the intervention on changes
in LS (bootstrap mean=.17, SE=.09, 95% CI=.03,.40)
Results
Mediating Effects
Changes in
Gratitude
Intervention
Changes in PA
Changes in Body
Appreciation
Changes in Gratitude & BA mediated effects of the intervention on
changes in PA (bootstrap mean=1.92,SE=1.25,95%CI=.20,5.26;
bootstrap mean=1.34,SE=.81,95%CI=.19,3.55, respectively)
Discussion
The BIS-Gratitude
intervention was able
to improve
adolescents’ body
appreciation more
than a control
condition
Significant results are
similar to that of longer
programmes
Discussion
BIS-gratitude
intervention was able
to improve
adolescents’ life
satisfaction more than
a control condition.
Results are generally
consistent with
previous research
findings that showed
improvements in
positive feelings,
gratitude, and life
satisfaction at postintervention
(Chan, 2010; 2013; Froh et al.,
2008; Senf & Liau, 2012).
Discussion
Significant findings at
post-intervention were
not sustained at 1week follow-up.
Programme duration
Lack of maintenance
effects in many CBT
interventions without
booster sessions.
Discussion
However, there was a
significant difference in
negative affect.
Consistent with other
research in Asian
contexts where
positive psychology
interventions influence
negative affect not
positive affect
(Liau, Neihart, Teo, Lo,
2014)
Discussion
Body appreciation and
Gratitude mediated
the effects of the
intervention on
positive affect.
Body appreciation
mediated the effects of
the intervention on life
satisfaction.
The mediation results
are consistent with
Broaden-and-Build
Theory that positive
emotions elicited
through a BIS-gratitude
exercise can lead to
improved well-being.
Acknowledgments
• Conference travel was funded by the Ministry of Health,
Singapore, and the National Institute of Education, NTU
• Thank you to all who were involved in the study, i.e. CARE
Singapore, and the schools, teachers, and students involved.
• Thank you for listening!
• samantha_sy_ng@nuhs.edu.sg
• albert.liau@nie.edu.sg
Selected References
Allen, K. L., Byrne, S. M., Oddy, W. H., & Crosby, R. D. (2013). DSM-IV-TR and DSM-5 eating disorders in
adolescents: prevalence, stability, and psychosocial correlates in a population-based sample of male and
female adolescents. Journal of Abnormal Psychology, 122(3), 720-732.
Apter, A., Gothelf, D., Orbach, I., Weizman, R., Ratzoni, G., Har-Even, D., & Tyano, S. (1995). Correlation of
suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. Journal
of the American Academy of Child and Adolescent Psychiatry, 34(7), 912-918.
Blowers, L. C., Loxton, N. J., Grady-Flesser, M., Occhipinti, S., & Dawe, S. (2003). The relationship between
sociocultural pressure to be thin and body dissatisfaction in preadolescent girls. Eating Behaviors, 4(3),
229-244.
Cattarin, J. A., & Thompson, J. K. (1994). A three-year longitudinal study of body image, eating
disturbance and general psychological functioning in adolescent females. Eating Disorders: The Journal of
Treatment and Prevention, 2(2), 114-125.
Davis, C. (2000). Exercise abuse. International Journal of Sport Psychology, 31, 278-289.
Diener, E., Lucas, R. E., & Oishi, S. (2002). Subjective well-being: The science of happiness and life
satisfaction. In C. R. Snyder, & S. J. Lopez (Eds.), Handbook of Positive Psychology (pp. 63-73). New York:
Oxford University Press, Inc.
Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. E. (1999). Subjective well-being: Three decades of progress.
Psychological Bulletin, 125(2), 276-302.
Dittmar, H., Halliwell, E., & Ive, S. (2006). Does Barbie make girls want to be thin? The effect of
experimental exposure to images of dolls on the body image of 5-8-year-old girls. Developmental
Psychology, 42(2), 283-292.
Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: an experimental
investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social
Psychology, 84(2), 377-389.
Emmons, R. A., & Mishra, A. (2011). Why gratitude enhances well-being: What we know, what we need to
know. In K. Sheldon, T. Kashdan, & M. F. Steger (Eds.), Designing the future of positive psychology: Taking
stock and moving forward (pp. 248-262). New York: Oxford University Press.
Fredrickson, B. (1998). What good are positive emotions? Review of General Psychology, 2(3), 300-319.
Fredrickson, B. (2001). The role of positive emotions in positive psychology. The American Psychologist,
56(3), 218-226.
Fredrickson, B. (2004). The broaden-and-build theory of positive emotions. Philosophical Transactions of the
Royal Society of London Series B – Biological Sciences, 359(1449), 1367-1377.
Gable, S. L., & Haidt, J. (2005). What (and why) is positive psychology? Review of General Psychology, 9(2), 103110.
Gralen, S. J., Levine, M. P., Smolak, L., & Murnen, S. (1990). Dieting and disordered eating during early and middle
adolescence: Do the influences remain the same? International Journal of Eating Disorders, 9(5), 501-512.
Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women, and children (2nd ed.). East
Sussex: Routledge.
Herzog, D. B., Greenwood, D. N., Dorer, D. J., Flores, A. T., Ekeblad, E. R., Richards, A., . . . Keller, M. B. (2000).
Mortality in eating disorders: A descriptive study. International Journal of Eating Disorders, 28, 20-26.
Holland, L. A., Brown, T. A., & Keel, P. K. (2014). Defining features of unhealthy exercise associated with
disordered eating and eating disorder diagnoses. Psychology of Sport and Exercise, 15(1), 116-123.
Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., & Agras, W. S. (2004). Coming to terms with risk factors for
eating disorders: Application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin,
130(1), 19-65.
Katzman, D. K. (2005). Medical complications in adolescents with anorexia nervosa: A review of the literature.
International Journal of Eating Disorders, 37(S1), S52-S59.
Keel, P. K., Dorer, D. J., Franko, D. L., Jackson, S. C., & Herzog, D. B. (2005). Postremission predictors of relapse in
women with eating disorders. American Journal of Psychiatry, 162(12), 2293-2268.
Lay, B., & Schmidt, M. H. (1999). Relapses in the course of anorexia nervosa. Z Kinder Jugendpsychiatr Psychother,
27, 207-129.
Lee, H. Y., Lee, E. L., Pathy, P., & Chan, Y. H. (2005). Anorexia nervosa in Singapore: An eight year retrospective
study. Singapore Medical Journal, 46, 275-281.
Liau, A., Maureen, N., Teo, T. & Lo, C (2014). Effects of the Best Possible Self Activity on Subjective Well-being: An
experimental study with an examination of moderating factors. Paper presented at the 2014 Australian Positive
Psychology Conference, Melbourne.
Lyubomirsky, S., King, L., & Diener, E. (2005). The benefits of frequent positive affect: Does happiness lead to
success? Psychological Bulletin, 131, 803-855.
McCullough, M. E., Emmons, R. A., & Tsang, J. (2002). The grateful disposition: A conceptual and empirical
topography. Journal of Personality and Social Psychology, 82(1), 112-127.
Milos, G., Spindler, A., Hepp, U., & Schnyder, U. (2004). Suicide attempts and suicidal ideation: Links with
psychiatric comorbidity in eating disorder subjects. General Hospital Psychiatry, 26(2), 129-135.
Murnen, S. K., Smolak, L., Mills, A., & Good, L. (2003). Thin, sexy women and strong, muscular men:
Grade-school children's responses to objectified images of women and men. Sex Roles, 49(9-10), 427-437.
Park, N., Peterson, C., & Seligman, M. E. (2004). Strengths of character and well-being. Journal of Social
and Clinical Psychology, 23(5), 603-619.
Pomeroy, C. (2004). Assessment of medical status and physical factors. In J. K. Thompson (Ed.), Handbook
of eating disorders and obesity (pp. 81-111). Hoboken, NJ: John Wiley & Sons, Inc.
Preacher, K.J. & Hayes, A.F. (2008). Asymptotic & resampling strategies for assessing & comparing indirect
effects in multiple mediator models. Behavior Research Methods, 40, 879-891.
Ricciardelli, L. A., & McCabe, M. P. (2001). Children’s body image concerns and eating disturbance: A
review of the literature. Clinical Psychology Review, 21(3), 325-344.
Smolak, L. (2004). Body image in children and adolescents: Where do we go from here? Body Image, 1(1),
15-28.
Seligman, M. E., Reivich, K., Jaycox, L., & Gillham, J. (1995). The optimistic child. New York: Houghton
Mifflin.
Skemp-Arlt, K. M. (2006). Body image dissatisfaction and eating disturbances among children and
adolescents: Prevalence, risk factors, and prevention strategies. Journal of Physical Education, Recreation
and Dance, 77(1), 45-51.
Smolak, L., & Levine, M. P. (2001). Body image in children. In J. K. Thompson, & L. Smolak (Eds.), Body
image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (pp. 41-66).
Washington, DC: American Psychological Association.
Stice, E., Cameron, R. P., Killen, J. D., Hayward, C., & Taylor, C. B. (1999). Naturalistic weight-reduction
efforts prospectively predict growth in relative weight and onset of obesity among female adolescents.
Journal of Consulting and Clinical Psychology, 67(6), 867-974.
Stice, E., Hayward, C., Cameron, R. P., Killen, J. D., & Taylor, C. B. (2000). Body image and eating
disturbances predict onset of depression among female adolescents: a longitudinal study. Journal of
Abnormal Psychology, 109(3), 438-444.
Swinbourne, J. M., Hunt, C., Abbott, M., Russell, J., St Clare, T., & Touyz, S. (2012). The comorbidity
between eating disorders and anxiety disorders: Prevalence in an eating disorder sample and anxiety
disorder sample. Australian and New Zealand Journal of Psychiatry, 46(2),
Tan, R. (2013, October 13). More youngsters diagnosed with eating disorders. The Sunday Times, p. 10.
Tylka, T. L. (2011). Positive psychology perspectives on body image. In T. F. Cash, & L. Smolak (Eds.), Body
image: A handbook of science, practice, and prevention (pp. 56-64). New York: The Guilford Press.
Wood, A. M., Joseph, S., & Maltby, J. (2009). Gratitude predicts psychological wellbeing above the Big Five
facets. Personality and Individual Differences, 46(4), 443-447.
Wood-Barcalow, N. L., Tylka, T. L., & Augustus-Horvath, C. L. (2010). "But I like my body": Positive body
image characteristics and a holistic model for young adult women. Body Image: An International Journal
of Research, 7(2), 106-116.
Results
Mediation Effects
• Change in Gratitude was related to changes in PA (Positive
Affect)
• Change in BA (Body Appreciation) was related to changes in PA
and LS (Life Satisfaction)
Significant difference between groups at T2 (t=3.46, p=.001,
d=1.04)
Post hoc analyses indicated a significant increase in the
experimental group, and a significant decrease in the control
group from T1 to T2.
Results
Intervention Effects
• Body Preference (BP):
• chi-square test for independence conducted to test for changes
in the proportions of participants who desired to gain weight,
remain the same size, or lose weight.
Discussion
There was a significant
difference in positive
affect.
However, this is due to
a reduction in the
control group, and not
an increase of the
experimental group.
The participants are in
Grade 7 which is a
transition to the first
year of secondary
school. Hence, there
are new academic &
social demands.
Discussion
BIS-gratitude
intervention did not
have an effect on the
proportion of
participants who
desired to remain the
same size (body
preference).
Possibly an objective
need for to either lose
weight or gain weight.