Feasibility and Acceptability of the BE REAL Let's Eat Curriculum in Middle Schoolers

Rationale: There is widespread, harmful 'diet culture' messages which state that one needs to have the ideal body to be happy, healthy, and desirable and the way you achieve that is through a restrictive dieting. It has been well-studied that these messages apply pressure on adolescents to conform to unrealistic ideals which have been associated with body dissatisfaction, disordered eating, and lower well-being. Of salience to the present study, school is an important environment that can promote 'diet culture' messages, and specifically in health or physical activity or gym classes. For instance, in one study, researchers interviewed 150 adolescents who received medical treatment for anorexia nervosa and found that health education was attributed as a trigger to the eating disorder in 14% of the sample and their eating disorder was more likely to start younger with health education. Moreover, 2018 Health Textbooks have been found to teach students to count calories, log food, promote "good" versus "bad" foods all of which have been associated with disordered eating and eating disorders.

Furthermore, middle school is a sensitive period for developing one's eating behavior as they are experiencing changing social environments (i.e., elementary to middle school), increased autonomy and perceived independence, and cognitive and affective changes stimulated by puberty, which further sensitize individuals to learning new behaviors. To expand on adolescent changes with puberty, the changes in some students' physical bodies add another area in which 'diet culture' can influence adolescents' eating behaviors. The adolescent's eating behaviors can also vary by gender identity and cultural practices of eating. For example, in a qualitative study involving boys and girls discussing their food habits, both genders discussed anti-fat attitudes; however, girls described more societal pressures to be thin as a motivation for food restriction than boys. Another example is the differences in food choices and preferences based on cultural diets, such as the typical dishes prepared by parents from different ethnic backgrounds. In summary, adolescence is an important period to intervene, and given the known presence of diet culture in many of the current school programs, the Be Real 'Let's Eat' Curriculum is a novel approach to eating that does not include 'diet culture' messaging and is culturally sensitive to diverse youth experiences.

Let's Eat program:

BE REAL's Let's Eat is an evidence-informed schools-based curriculum that was developed in a multinational collaboration of established researchers with expertise in adolescent body image, disorder eating, nutrition and health education, and public health professionals. Let's Eat teaches "tuned-in eating," a holistic eating practice informed by intuitive and mindful eating, and how to apply it within the state and federal guidelines for nutrition education. The main goals of "tuned-in eating" are for adolescents to learn about physiological and emotional signals and experiences related to eating and learn how to make food choices based on their body's needs and preferences. Students are also exposed to the importance of eating for pleasure or enjoyment and of the social or community aspects of eating. This is a gender-neutral, inclusive curriculum that also addresses the role of culture with food and addresses the other messaging around food such as 'diet culture.' The program is a 3 lesson, teacher-led program delivered to 6th \& 8th graders [See Attachments for an outline of the program].

This is the first trial of this multi-component eating and nutrition curriculum that may prevent against eating disorders and improve nutrition in adolescents.

Aim/objectives:

The purpose of this study is to evaluate the feasibility and acceptability of 'Let's Eat' and its capacity to change eating behavior and body appearance/functionality considerations in adolescents aged 11-14 years. This pilot study aims to ascertain whether the 'Let's Eat' curriculum a.) is considered acceptable by adolescents and their teachers, b.) is feasible for delivery as part of the middle school health curriculum, c.) preliminary efficacy of the curriculum to increase intuitive eating, eating competence, body acceptance, and well-being, d.) met the nutrition knowledge goals of select federal and state nutrition curriculum standards.

Theoretical rationale: The program teaches "tuned-in" eating which is based on intuitive eating. Intuitive eating emphasizes integrating the body's physical cues to eat (i.e., hunger and fullness cues) along with the individual's energy needs, community, and/or food preference to decide on what and how much food to eat. Intuitive eating is a proposed alternative to restrictive diets and longitudinal research has demonstrated that greater intuitive eating in adolescence predicts lower depressive symptoms, disordered eating, and body dissatisfaction in young adulthood. It is theorized with the acceptance model of intuitive eating, that increasing individual's trust and reliance on internal body cues also transfers to overal increase in body satisfaction and well-being since eating serves as an essential example of a positive body functioning. Therefore, the proposed intervention may improve eating behaviors, body image, and overall well-being.

Hypotheses: It is anticipated that the curriculum will be evaluated as acceptable by students and teachers, feasibly delivered, and that there will be statistically significant changes in outcome measures among adolescents who receive the curriculum; specifically we would expect significant increases in intuitive eating, eating competence, body acceptance, nutrition knowledge, and well-being between pre and post intervention.

Overall, the study seeks to provide some evidence of proof-of-concept for the curriculum to teach state and federally designated nutrition information without an emphasis on weight and diet culture in it. Additionally, to note how the curriculum goes above in improving other related domains of well-being and body image, which can be negatively impacted by the current, weight-focused curriculum (i.e., increase the risk of disordered eating post-exposure).