Background: Social media is a source of weight loss information for adolescents. However, engagement with image-based social media has been associated with reduced body image. This study describes weight loss imagery visible on an adolescent Instagram account. Methods: The "top" 600 images were captured from "#weightloss" on an adolescent (16 years, gender not specified) Instagram account in August 2020. Images were categorized and coded based on a predetermined ontology as food (nutrient-dense, energy-dense), people (group, individual, before/after), or text-focused by one coder (20% in duplicate, 90% agreement). Images of people were coded for sex and ethnicity and images of individuals coded for adiposity, muscularity, and pose. Results: Of 600 images, 208 (34.7%) were of individuals, predominantly females (83%) with white (37%), non-white (23%), or unclear (41%) ethnicity. Body types were thin (31%), average (43%), or higher weight (6%) with little-to-none (25%), visible (26%), or high (7%) muscularity. Almost half of images accentuated body features with a fitness/muscle accentuating (21%) or sexualized (21%) pose or both (3%). From 165 (27.5%) food images, 71% were nutrient-dense and 29% energy-dense. Of 107 (17.8%) before/after images, 90% depicted weight loss, 4% muscle building with 85% in females. From 93 (15.5%) text-focused images, 46% related to weight loss programs/products and few provided nutrition (n = 12, 13%) or exercise (n = 2, 2%) information. Conclusions: Most "#weightloss" imagery visible to adolescents on Instagram were of people, frequently females, with almost half of body-focused poses or before/after weight loss images. Few provide nutrition and exercise-related content.
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One in five participants in the delayed-image group completing the 24-week intervention achieved a clinically significant weight loss, having received only future self-images and general lifestyle advice. Timing the provision of future self-images appears to be significant, and promising for future research to clarify their efficacy.
The prevalence of obesity in developed regions has risen at an alarming rate over the past 30 years, and continues to rise despite public awareness of the associated risk of chronic disease [1]. Outside of surgical intervention, weight loss for the individual relies on lifestyle change that promotes an overall reduction of dietary caloric intake and an increase in physical energy expenditure. Being aware of the need to lose weight is usually not enough to produce sustained lifestyle change. The individual requires the initial motivation to change unhealthy dietary habits and to revise entrenched sedentary behaviours, followed by continued effort to sustain the healthy lifestyle choices.
Health professionals are often counselled for weight loss, either in response to a direct request from an individual or because of an associated illness that requires medical attention. Weight-loss counselling in the general practice setting often takes place in time-constrained consultations [2, 3]. In addition, a lack of patient motivation and failure to adhere to recommendations are often cited as a barrier to effective weight-loss intervention [4].
New technology, in the form of digital self-representations, known as Avatars, have been shown to improve health-related behaviours, including diet and exercise choices [5, 6]. Written advice that is tailored and personalised for the individual has been shown to be more effective than traditional collective advice for diet and exercise behaviour change [7, 8]. Empirical evidence from a pilot study published in 2015 suggests that self-representations in the form of computerised future self-images could enhance weight loss in women who are trying to lose weight [9]. This is consistent with the theory that a fundamental human need is to forge or maintain bonds; therefore, the prospect of a more appealing physical appearance may be a powerful motivator for behaviour change [10]. The aim of this study was to evaluate the effect of a personalised future self-image on weight change over a 6-month period, with a broader sample than the pilot study and to include both men and women of any age over 16 years.
The trial was approved by the Curtin Human Research Ethics Committee (HR 112/2013). A sample size of 150 was determined to have the power to detect a 1-kg weight difference between groups, which was the mean weight difference seen at 8 weeks in the pilot study [9]. A total of 145 participants, slightly fewer than the target number, were recruited over 8 months from November 2013 to August 2014, when the recruitment phase period concluded. Eligibility criteria required participants to be at least 16 years old, with a BMI over 25.0 kg/m2 and wanting to lose weight. Women who were pregnant or breastfeeding were ineligible. One participant was excluded due to recent thyroid surgery. During the study, one participant was withdrawn after becoming pregnant and another after opting for bariatric surgery. Participants were recruited through the Curtin University website, radio announcements, emails, and flyers. Recruitment took place at two general practices north and south of the Perth area, Curtin University, and two large employer groups located in the Perth metropolitan area.
Any weight-loss methods chosen were self-selected by the individual. Participants were asked to return once every 4 weeks for 24 weeks to record a weight measurement. The 4-week interval was chosen to minimise the impost on participants but to maintain close monitoring of their progress. Only weights recorded on the original set of scales or calibrated scales at alternative study locations were included in the final analysis. The researcher provided information on sources of advice at the time of weigh-ins, but did not provide any support in the intervening periods. At the 16-week visit participants were randomised again to either receive a second future self-image using their new weight parameters, or to continue with only the original future self-image. This step was designed to allow an estimate of the effect of repeated exposure to the image-creation process. Figure 2 summarises the study timeline.
The status of the participants was defined in three groups. Participants were deemed to have engaged in the study if they returned for the first weigh-in after recruitment. Participants who did not return for this visit are termed non-starters and were excluded from the analysis. Participants were deemed to have completed the study if they recorded a weight at either week 20 or week 24. Participants who discontinued weight measurements between week 4 and week 20 are termed dropouts and are included in the intention-to-treat (ITT) analysis.
This study has examined the rate of weight loss in adults who received a personalised image of predicted future body shape, with self-selected diet and exercise targets. On average, weight loss was modest over the 24-week period, but greater than has been recorded in other studies that have provided advice alone [14]. In this trial more than one fifth of completers in the delayed-image group lost 5% or more of their baseline weight.
A greater rate of weight loss was seen with the delayed-image group completers. This was an unexpected result. It was hypothesised that a longer period of exposure to the future self-image would result in more weight loss, favouring the early-image group. However, it may be that creation of the future self-image several weeks into a weight-loss attempt served as a greater trigger or additional reinforcement for further weight loss. An alternative explanation is that a greater number of participants in the delayed group were committed to weight-loss efforts. There was some evidence for this as a greater proportion of those in the delayed group were in the Contemplation phase of the change and a higher proportion were non-starters in this group. Failing to receive an early image may have prompted some recruits, those less committed to weight loss, to drop out early, leaving in comparison, relatively more committed recruits in the delayed-image group. We found, however, no significant interaction between initial motivational stage and percentage weight loss, and no significant effect of group allocation on continuation status, so this explanation is less plausible. Average age and baseline BMI were similar between the groups. Any apparent differences in male-to-female ratio and motivational stage would have in fact favoured weight loss in the early-image group.
Data from this study consistently demonstrated more rapid weight loss in men. Without information on individual dietary and physical activity records during the study it is not possible to confirm why this was the case, although the same pattern has been reported elsewhere [15]. Patterns of dietary change after weight-loss advice have been described in the medical literature for both men and women [16, 17]. It may be that the male participants made more effective lifestyle changes. Weight loss for men and women can be expected to be similar when energy expenditure is also comparable [18]. The difference favouring more rapid weight loss in the delayed-image group was observed for men in the ITT analysis. The reason is unclear, but suggests that there may be a disparity between genders in how the image operates.
We found no significant difference between groups for weight loss at the 8-week weigh-in where the delayed group had not yet viewed the future self-image. Comparable results between groups at 8 weeks may be because it was not a long enough period of time to produce a divergence or, as already postulated, the effect of the future self-image was less significant at the outset of a weight-loss attempt. 2351a5e196
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