Body Image Disorders Among Men

Two studies explore this often-neglected territory.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

Eating disorders are often viewed as disorders of women, and thus men’s body image concerns tend to be “underdiagnosed, undertreated and misunderstood,” according to researchers such as Eric Strother et al. (Eat Disord. 2012. 20:346). A prime example is muscle dysmorphia, or MD, which is largely characterized by the obsessive belief that one’s body lacks sufficient muscle mass. This condition can lead to clinical distress and functional impairment among men.

Men with MD usually develop dysfunctional beliefs and behaviors similar to those of women with eating disorders; however, their concerns about body image are expressed in a very different way. Typically men attempt to increase body size and muscle development rather than the pattern more common among women, a drive for thinness.

Men with anorexia nervosa and men with MD have similar clinical profiles (Body Image. 2012. 9:193). In addition, these men adhere to strict diets high in protein and low in fat and also follow a very strict limit on daily calories. They exercise excessively and use binge eating and purging to regulate their emotions.

Several factors also get in the way of making the diagnosis of MD, according to Emilio J. Compte and colleagues in Buenos Aires and Madrid (Int J Eat Disord. 2015. 48:1092). For example, traditional diagnostic instruments assess body dissatisfaction and eating disorders from a female perspective, and the criteria for eating disorders given in the DSM-IV and DSM-5 are not particularly relevant for males with MD. 

Compte and colleagues designed a study to estimate the prevalence of eating disorders among male university students, using a two-stage format with a control group. Their secondary goal was to establish the prevalence of possible cases of MD and to compare the psychological characteristics of men at risk for developing an eating disorder or MD. The researchers found that the prevalence of eating disorders among the university male students was 1.9%, and all the men with an eating disorder had an eating disorder not otherwise specified (EDNOS). The Drive for Muscularity Scale identified possible cases of MD in nearly 7% of the male students. This suggested that drive for muscularity is the male analogue to the drive for thinness noted in women with eating disorders.

The effect of peer perceptions about muscularity

In a separate study, Linda Lin and Frank DeCusati from Emmanuel College, Boston, explored MD and how perceptions of specific peer group preferences are related to men’s body image concerns and behaviors (Am J Men’s Health. 2015. 1:11).

In this study, data on MD and the perceptions of peer muscularity norms were collected from 117 male college students ranging in age from 18 to 22. The students had an average body mass index of 25 kg/m2. Participants viewed nine male figure drawings ranging from very thin to very muscular, and were then asked to identify the drawing that most matched their current shape and also to indicate which matched their ideal shape. Then the students were given the Muscle Appearance Satisfaction Scale (Assessment. 2002. 9:351) to determine symptoms of muscle dysmorphia. This 19-item questionnaire presents statements such as “I would try anything to get my muscles to grow,” and “I must get bigger muscles by any means possible.”

The results showed that men are more likely to view their male peers as having higher standards for muscularity than their female peers and therefore may be more likely to feel inadequate when comparing their bodies with the muscularity preferences of their male peers. This might be a reflection of the different media messages about male muscularity expressed to male and female audiences. Media aimed at male audiences through action movies, video games, and male’s magazines tend to show male characters with very developed muscularity in the male leads. This contrasts with media developed for female audiences, which usually portray male characters with less developed muscularity.

One of the areas the researchers examined was how perceived muscularity preferences of men’s peers were related to symptoms of MD. Contrary to their original hypothesis, the men who perceived their close female peers as preferring greater muscularity were more likely to have symptoms of MD.

A Guided Self-Help Approach for Outpatients

The MOPED program includes a workbook with structured activities.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

As many as 73% of patients receiving outpatient care for an eating disorder drop out before treatment is completed (Clin Psychol Rev. 1998.18:391). Failure to attend outpatient appointments is a costly matter for the healthcare facility, delays treatment and exacerbates symptoms. On the other hand, patients with eating disorders who understand their condition and its treatment are more likely to comply with treatment. Since lack of motivation for recovery is also a factor in dropping out, particularly for those with anorexia nervosa, motivational interviewing techniques have been helpful for engaging patients in treatment.

Physicians at Leicestershire Adult Eating Disorders Service in the United Kingdom have recently developed a motivation and psycho-education self-help manual with structured activities (MOPED) for eating disorders outpatients. The MOPED program was developed for patients with all types of eating disorders. Dr. Nicola Brewin and coworkers compared engagement and completion of treatment rates between a group of patients on a waiting list for treatment who completed the MOPED program and those offered treatment as usual, who were given only a pamphlet describing the MOPED program (Eur Eat Disorders Rev. 20216. Published online before print. doi10.1002/erv.2431). 

The MOPED program involves a workbook with text and guided activities; it differs from other psychoeducational workbooks in that a motivational interviewing style is used throughout. All the activities are designed to increase motivation while providing psycho-education. The underlying goal is to help the patient decide whether she/he wants to change, and by doing so motivate the patient to accept help.

Dr. Brewin and colleagues’ study included 79 female patients who received MOPED after an initial assessment and who were placed on the waiting list for outpatient therapy during the study period. Because of the small numbers of male patients (n=4), no male patients were included. The 79 patients who participated in the MOPED program were then compared with 79 matched (by diagnosis) patients selected in reverse chronological order from the pool of patients assessed and placed on the waiting list for therapy before MOPED was developed. Both groups of patients were assessed by the same clinician using the Clinical Eating Disorders Rating Instrument, or CEDRI.

How well did the program work?

The MOPED manual approach significantly increased the participation of patients and reduced dropout pre-therapy while patients were on the waiting list for treatment. This was particularly true for those with anorexia nervosa. Even though the MOPED group included more students than did the second group, and students more often drop out of treatment, the self-help manual approach still significantly increased the engagement of patients and reduced dropout before therapy began.

The authors also reported that the MOPED program has been adapted for use in an online form (e-MOPED). Future studies might compare the efficacy of the paper form with the online form of the program. Future research could also involve identifying patients who may be more likely to drop out of treatment because of certain personality traits as well as tracing the efficacy of MOPED over time.

Bariatric Surgery for Severe Obesity Growing Among Teens

The Teen LABS study showed impressive results three years after surgery.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

Bariatric surgery for severe obesity has become relatively common in adults, and its use is growing among adolescents. People who have undergone or are contemplating bariatric surgery are frequently encountered by eating disorder clinicians working with adults, and this will undoubtedly be increasingly true for those working with adolescents as well.

The results of a large, multi-center cohort study of bariatric surgery in adolescents, the Teen LABS study, were recently published in the New England Journal of Medicine(NEJM. 2016. 374:113). In this study, held at 5 medical centers, 242 adolescents (mean age: 17 years) and with a mean body mass index, or kg/m2, of 53 underwent bariatric surgery at 5 centers; three-fourths were female. The authors reported three-year outcome data for weight, impact on comorbid medical problems, and complications.

Results three years after surgery

At the three-year follow-up point, the gastric bypass group had a mean 28% weight loss, compared with a mean 26% weight loss among those receiving sleeve gastrectomy. Type II diabetes mellitus remitted in 95% of those who had the disease prior to surgery. Similarly impressive rates of remission were seen for abnormal renal function (86% remission), pre-diabetes mellitus (76% remitted), hypertension (74% remitted) and elevated cholesterol or triglyceride levels (66% remitted). In addition, weight-related quality-of-life ratings improved at three-year follow-up.

There were some complications. First, low ferritin levels were seen in 57%, vitamin A deficiency developed in 16%, and 13% of participants required at least one additional abdominal surgical procedure during the three-year follow-up.

Clearly, there will be more information to come on other outcomes in the Teen LABS study, just as there was in the larger, adult-focused bariatric surgery study, LABS. This information will be valuable in assessing the diverse effects from gastric surgery, including the psychosocial impact. In the meantime, the amount of weight loss achieved at three years and the impact on co-occurring medical problems strongly suggest there will be increasing interest in the use of gastric surgery in adolescents.

Charting the Pattern of Exercise in Stages of Anorexia Nervosa

Patients were significantly more active at weight restoration than at low weight.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

One paradox in the course of anorexia nervosa (AN) is the increased levels of physical activity often reported among these very ill patients. A collaborative team of researchers from the New York State Psychiatric Institute, New York University, and Drexel University have measured physical exercise in AN patients at three time points from admission to follow-up. The researchers measured activity at low-weight, when weight was restored, and post-treatment, and compared these results with those from measured activity among age-matched heathy controls.

Loren M. Gianini, PhD, and her colleagues used a novel accelerometer to measure physical activity at these three time points in 24 women 15 to 49 years of age with DSM-5 AN and 24healthy controls (Int J Eat Disord. 2015. Dec 29. doi: 10.1002).The Intelligent Device for Energy Expenditure and Activity (IDEEA®; Minisun, Fresno, CA) is a microcomputer-based instrument that can identify at least 32 types of physical exercise, as well as the duration and intensity of walking or running. The device continually records for 24 hours, using 5 small sensors taped to the chest, thighs, and feet; the data are then transmitted to a small microcomputer on a waistband or belt.

The patients and controls wore the IDEEA at up to 3 time points: inpatient low-weight (Time 1), inpatient weight-restored (Time 2), and within 2 weeks of weight restoration (90% ideal body weight) on the impatient unit, and at follow-up (Time 3). Total activity time, including time standing and “fidgeting,” was recorded.

Sixty-one patients with AN were in the study; 45 patients wore the IDEEA for 3 consecutive days at low-weight, 35 at weight restoration, and 19 at one month after impatient discharge. Twelve wore the IDEEA at all three time points. Many healthy controls and patients with AN wore the IDEEA for 2 days but then removed it, resulting in a large amount of missing data for the third day of monitoring; thus, only data from the first two days of monitoring was used.

Physical activity across time

Contrary to the authors’ first hypothesis, patients were significantly more active at weight restoration than when they were at low weight. AN patients were also significantly more active at the one-month post-discharge point than at admission. After discharge (Time 3), patients were significantly more active than were healthy controls. The increase in physical activity, according to the authors, was primarily due to an increase in the amount of time spent on their feet, which was primarily composed of time spent standing (the device determined standing and fidgeting).

The authors also determined that elevated physical activity in AN is not directly related to the severity of the disorder or to general pathology. Another finding was that patients were more active during the day but less active at night than were controls. Some theories for this were that patients were more active during the day and then were fatigued in the evening and that patients were less socially active at all times, particularly in the evening. As for body mass index changes, the more time patients with AN spent on their feet (standing and walking), the more quickly they lost weight during the 12 months after discharge. 

This study is the first to identify a relationship between a particular type of objectively measured physical exercise and posttreatment weight. It also is the first to identify a relationship between a particular type of objectively measured physical exercise and posttreatment weight in AN patients. One suggestion from the authors is that inpatient units might develop interventions to limit standing and walking or to help patients stand and walk in a way that doesn’t lead to weight loss. Fidgeting did not differ between patients and controls and did not change with weight restoration; thus, it did not predict weight change after treatment.

Skilled Training for Caregivers May Improve Treatment for Inpatients

Two reports suggest ways to improve outcome by helping caregivers as well as AN patients. 

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

A group of British psychologists and eating disorders specialists had a theory: adding a skilled training intervention for caregivers might improve treatment outcome for inpatients with anorexia nervosa (AN). Dr. Nicholas Magill and colleagues recently reported the results of their two-year randomized study comparing treatment as usual versus adding the Experienced Caregivers Helping Others (ECHO) program to inpatient care (Eur Eat Disorders Rev. 2016. 24:122). 

Changes in the National Institute for Clinical Excellence (NICE) guidelines now recommend that inpatient care for eating disorders patients be reserved for those at high medical risk or those who do not respond to outpatient care. Because of the new guidelines, patients admitted for inpatient care may be more severely ill when they are first admitted. Although short-term interventions involving caregivers usually haven’t been very helpful for inpatients (J Psychiatr Prac. 2015. 21:49), the picture improves when family members are involved for longer than a year (PLoS One. 2012. 7, e28249). 

Testing the theory in 15 hospitals

Fourteen of the 15 hospitals that participated in the study have specialist eating disorders inpatient wards (13 adult wards and 1 adolescent ward). One group of patients was assigned to treatment as usual and a second to the ECHO group; patients in the ECHO group were given support immediately after they were randomized to treatment.

The ECHO program provides education and skills for carers through a book and 5 DVDs (3 theoretical and 2 practical), as described in a recent report (Eat Disord. 2015. 12-11. [Note: For more information and a professional version of the DVDs, see www.suceedfoundation.org.] Each family also had five 40-minute telephone coaching sessions (up to 10 per mother and father). Single caregivers had access to up to 10 coaching calls with experienced coaches, who had life experience with eating disorders or with postgraduate-level psychologists. Following the NICE guidelines for aftercare, carers in the treatment as usual arm were given contact information for a leading UK eating disorders charity and offered access to the intervention when treatment was completed.

How results were measured

All participants, patients and caregivers, completed self-report questionnaires and or/blinded interview assessments by mail or telephone at admission, and upon discharge from the inpatient unit, and then at intervals over a 2-year period after the patient was discharged. All patients also completed a short monthly telephone assessment of their core eating symptoms. A total of 268 adult caregivers (178 primary caregivers and 90 secondary caregivers) were recruited, including 144 mothers, 81 fathers, 28 partners, 7 siblings, 5 friends and 3 other relatives. Most carers (69%) lived with the patient. 

How well did the intervention work?

A small-to-moderate degree of improvement was reported among the ECHO group, but this was not statistically significant because of loss to follow-up. Thirty-three percent (59) patients were lost to follow-up at 24 months.

There was a small drop in body mass index (BMI, mg/kg2) after discharge; overall, BMIs were lowest at the 6-month point but had increased above discharge BMIs by 15 months. At the 24-month follow-up point, patients treated in the ECHO group were estimated to have a higher weight, lower levels of eating disorder psychopathology, and lower levels of general distress. 

Once again, none of these differences were statistically significant. Patients in the treatment as usual group had significantly lower BMIs at discharge but the BMIs were comparable in both groups on admission. Some 20% of patients were readmitted for treatment after discharge, and there were 2 deaths during the study.

The authors concluded that providing carers with skills to manage eating disorder symptoms and to provide support following inpatient care is effective for reducing severe malnutrition and for providing respite. Over the long term, educating caregiver may lead to improvement of symptoms in most AN patients. 

Interventions for caregivers

Interventions that equip families and close others with skills to manage eating disorder behavior are showing good potential for improving treatment outcome, according to Dr. Janet Treasure and Dr. Bruno Palazzo Nazar, of King’s College, London (Curr Psychiatry Rep. 2016. 18:16). Dr. Treasure, one of authors of the ECHO report, and Dr. Palazzo concluded this after an extensive literature review on caring/parenting interventions for people with eating disorders.

The authors’’ research showed that carers play a very important role early on, before the person with the eating disorder recognizes that he or she is ill, but when the family has become aware of it. Social aspects may then come into play. For example, family members may unwittingly collude with the eating behaviors by organizing family around eating disorders rules, to cover up the negative consequences of the behaviors. These behaviors also can divide family members, making some shoulder more of the burden while others turn away. Another complication is that interventions often have a selective focus on improving the well-being of the carers or the patient, but not both.

Drs. Treasure and Nazar suggest that interventions for caregivers need to take into account the stage of illness and whether certain interpersonal behaviors that may maintain the disorder, such as accommodation, expressed emotion, or family divisions, are present. Some promising approaches include family-based therapy, the New Maudsley approach, which addresses some maintaining interpersonal behaviors (J Eat Disord. 2013. 1:13), and new interventions that specifically target partners (Int J Eat Disord. 2011. 44:19) are all promising. They also suggest that since most of the work has focused on patients with AN, more work is needed to understand caregiving for patients with bulimia nervosa and binge eating disorder.

UPDATE: Bariatric Surgery Patients Often Have Depression, BED

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

According to the results of a study at the University of California, Los Angeles, a sizeable number of persons undergoing bariatric surgery also have depression and/or binge-eating disorder (BED). Dr. Aaron Dawes, a general surgery resident at UCLA, recently reported that an analysis of 68 studies found that almost one-fourth of candidates for gastric bypass or gastric sleeve techniques had a mood-related disorder, usually depression. Another 17% had BED. Dr. Dawes reported his findings in the January 12, 2016 issue of the Journal of the American Medical Association. These figures for depression and BED are both twice as common as in the general U.S. population.

While having a diagnosis of BED might seem to preclude an individual from undergoing bariatric surgery, since food intake has to be strictly limited, people with the disorder fare as well as other patients, Dawes said. That might be partly because some get therapy for their binge-eating, Wolfe said, but added that the surgery also has effects on the nervous and hormonal systems that may help ease bingeing.

Based on the review, people with depression can also improve after surgery. Across seven studies, prevalence of depression dropped by anywhere from 8% to 74% after surgery. The severity of patients' depressive symptoms also fell by 40% to 70%.

Things you can do to support your loved one in need

Studies show the presence of a solid support system is a huge predictor of eating disorder recovery. In fact, research on Family-Based Therapy, where family is not only supportive, but also actively involved in a direct way with restoration of an adolescent, has been shown to be by far the strongest and most effective evidence-based treatment.

But whether you're an adolescent or adult, the presence of support from family and loved ones is likely to be one of the most important factors in recovery. We know that no one gets better alone. We know that our ability to connect helps us recover in every way.

For many people, our family and sometimes our closest friends are the people who form the basis of our support and community that will help us recover. Always remember, eating disorders are an illness. Families do not cause them, but rather they can help cure them.

If you are the support system, there are things you can do to help your loved one suffering from an eating disorder.

1. The person is not the disorder. They remain the same person, regardless of how they suffer. Loving by itself does not, however, create a cure. We must always remember that love is a necessary component, but love alone will not make someone better.

2. If we're helping someone with an eating disorder, we must get support for ourselves. In the same way we must accept that our loved one has an illness, we must accept that our lives are burdened by this illness. Support for us will make us stronger and better able to function.

3. We must be willing to be fully and actively engaged, especially if our family members are adolescents. We must know about the meal plans and treatment strategies for our family members. We must know honesty, transparency and respect are all keys to communicating with loved ones who have this illness. We must be sensitive, firm and avoid all comments about food, body and appearance.

In addition, we must be willing to distract loved ones from the pains of treatment. Our loved ones depend on us to help us create a life worth living and to start building that life at whatever stage of the eating disorder we find ourselves in.

In addition to psychological and family roles, eating disorders are a tremendous financial burden. We need to make sure people have the best possible insurance and understand their benefits. The eating disorder will affect their lives and ours, and sacrifices will be necessary.

On a larger level, we help loved ones by becoming a part of the eating disorder community and working with organizations that support mental health and are committed to increasing high-quality treatment options for everyone.

Wherever you are and whatever you're doing, if you have a loved one with an eating disorder, remember you are their greatest advocate and may be the most important person in their life. Never underestimate your strength and power to help your loved one get the help they need.

Mark Warren, MD

Shapesville – Book Interview

Authors Andy Mills and Becky Osborn joined us for an interview on their book, Shapesville (illustrated by Erica Neitz). What follows are our questions in italics, and their thoughtful answers.

Shapesville is a very special children’s book. It’s a wonderful intersect of healthy messages and children’s literature. Published by Gürze in 2003, you all were in your early 20’s at the time. How did this book come about?

Andy had just completed a research study looking at “awareness” and “internalization” of ideal body images for young boys and young girls. The results of the study proved to be somewhat shocking. When Andy asked his professors, Drs. Linda Smolak and Sarah Murnen, what they were going to do with the results they explained they would all write an article and work to get it published in a major journal. Andy was excited about that opportunity, but something was still missing for him. He spent some time talking to Dr. Smolak and she asked him what he wanted to do. He said, “I want to write a children’s book to help kids, teachers, and parents discuss body image issues.” She encouraged Andy to meet with Becky Osborn to discuss his idea. Becky, had been working with young girls studying how puberty was impacting their self-esteem and body image. She was interested/concerned that these seemingly “adolescent” issues were emerging at younger and younger ages (Kindergarten/first grade) rather than closer to pre-adolescence, which seemed like a complex culmination of media, home environment, peer pressure, etc. It took one meeting with Andy and Becky to discuss the idea of creating a book called, “ShApeSviLLe.” They then went to Dr. Michael Levine with the idea and said they wanted to create an independent study called, “Writing a Children’s Book,” and have him as their advisor. He was intrigued to say the least, but extremely supportive. He had one question. How do I grade you on this assignment if you don’t write a book? Becky and Andy both responded, “then we fail.” Needless to say it was an exciting few months and we were able to connect with Erica Neitz, an artist who had recently graduated from Kenyon. Erica donated her time and talent to help us with our assignment.

In addition to size, shape, and color acceptance, you managed to incorporate positive self-esteem messages and the value of nutrition. Please tell us more.

Based on Andy’s and my work during college in the local elementary schools and with the school counselor, in addition to being steeped in body image literature at the time (courtesy of Levine/Smolak/Murnen), it become immediately clear that the issues with which young (even very little) children struggled around self-image and body image were inextricably bound with a complex host of other variables including (but not limited to) the actual nutrition available to them in their house/community, what other people around them looked like, their immediate family/support culture around food, and also peer culture/mass media. It blew our minds that even the littlest of people (1st-5th graders) understood from watching Brittany Spears (at that time) or similar media figures that there was a specific “norm” to obtain, with respect to shape, size, color, and, that regardless of how someone obtained that image (whether it was healthy or not), those that didn’t look like the images they saw felt “less worthy” by comparison. The fact that 1st-5th graders were being imbued with such strong social norm messages relating to all these areas was deeply concerning and clearly complex and so it seemed only natural to address as many factors that went into contributing to this complex picture for children as possible, since they were present regardless. This wasn’t just for girls either, it was for boys, too.

The role of the media was noted when you wrote, “So tell all your friends whatever sHaPe they may be, that what matters most may not be on TV.” Can you please comment on your sense of the media’s role now regarding children and body image?

Unfortunately, despite all the wonderful research and social efforts to clearly prove from a public health (including physical and social/emotional health) standpoint that the role of the media is massive in influencing kids’ self-image, worth, and even behavioral choices, I would say we have not made enough progress. As a mom of little girls, I worry deeply about the fact that even many children’s cartoons now look and speak far more like “little adults” than ever before, and images in the mass media of women seemingly has not gotten much better. There are some great role models like Meghan Trainor who speak openly about embracing and loving body size and shape, but the vast majority of celebrities, even if they start out at a normal size/look, end up being literally reduced to almost nothing. Public figures like Kelly Clarkson, Queen Latifah, and Adele are jumped on immediately by the media for any weight gain/loss, and even stars who claim to be healthy and eat, still look a part that for the vast majority of kids, young people, and adults is impossible to attain (without millions and a personal trainer). Also, as a public health professional, I think the obesity epidemic combined with increasing health disparities and income inequality, particularly in the United States, is very complexly related to the very issue at the core of Shapesville, that of self-worth and acceptance; as many folks who struggle with weight have deeper challenges, such as mental health issues, addiction, socio-economic barriers to access healthy food, and safety issues like walking in neighborhoods that would facilitate regular exercise. And, at the end of the day there are some very specific policy level changes (the Rudd Center out of UConn has been a pioneer in this area) that need to be put in place with respect to marketing companies targeting children in low-income communities for specific products, empowering more folks to serve on zoning boards in their cities/towns to create safe places for kids to play, and adults to exercise, and a far greater investment in and integration of mental health services both in primary care and also public health services (preventive, pro-active) to help folks attain a positive sense of self-worth, which is really at the heart of many of the major health and public health challenges our country faces.

You offer discussion questions for parents, teachers, and children at the end of Shapesville. What are some points you want children to know about themselves and their peers?

At the core of Shapesville is an intent to inspire self-acceptance and self-love, and acceptance, tolerance and love of others. A subtle difference to notice is that even the word ShaPesVille is never spelled the same in the book to reiterate how we are all different even if we seem the same. If nothing else, we hope the book encourages children along with their adult role models to consider how important it is to love oneself, and in doing so, reflect on how humans of all ages can actually seek to accomplish this in their lives.

I’m guessing you are aware that Dr. Susan Paxton and her colleagues with Confident Body, Confident Child (CBCC), an evidenced-based resource that is designed to promote healthy eating, positive body image, and healthy weight in children aged 2 – 6 years, includes Shapesville in its CBCC resource pack. How do you feel about the reach of your book?

The reach of Shapesville is truly incredible, and has exceeded every expectation that Andy and I hoped and dreamed it would. This book was created, not because we thought we would live off the royalties but because we believed this book could serve a need and potentially improve the lives’ of children and adults alike by encouraging conversations around some really challenging issues that deeply impact the human experience in an increasingly complex world.

What kind of feedback have you received from the children who have read or who have had Shapesville read to them?

The feedback has been amazing. Kids are smart. They notice things about each character and they relate those unique qualities to themselves. When we first started writing the book we talked to several child psychologists about our concept. One in particular said that kids wouldn’t be able to relate shapes to themselves, especially based on how unique each character was in our book. We tested it and found the exact opposite. The fact that each character was so much different than “human” characters, the children were able to talk more freely and focus on the unique qualities and talents Robbie, Tracy, Cindy, Sam, and Daisy had. With each classroom we visit, we are constantly amazed by the new things kids notice and how they relate the characters to themselves.

Can you please provide a quick update on where each of you are in your lives today?

Becky (Osborn) Lewis MSW, MPH, is living in Western Massachusetts. I work as a department chair at a community college where I oversee a health careers program, and also continue to do consulting in public health on the side. I am married with two wonderful little girls, and another one on the way in June 2016! Although I mostly work with college students now, I see, on a daily basis, the impact of media and other social issues on young people’s self-esteem and self-image and am constantly trying to inspire them through their career pathways and personal passions to address the things they are passionate about and to keep reaching for the moon.

Andy Mills is living in Columbus, Ohio and co-owns a commercial brokerage company called Elford Realty and is a Partner with Elford Development. Outside of his work, Andy is an active community volunteer spending time volunteering at Nationwide Children’s Hospital, Rotary International, and as a 2nd grader tutor every Wednesday at Stephenson Elementary School in Grandview Heights, Ohio.  Andy still reads Shapesville to several classrooms each year throughout Columbus. He is engaged and planning a May 21, 2016,wedding to a beautiful and amazing woman, Mary Curphey.

Please speak to your audience today. What would you like Shapesville fans to know?

That we are so grateful that this book has been widely used and accepted and hope that people keep letting us know how it has helped them and if there are any other ways we can help continue to spread the basic message of Shapesville more globally. Also, that it is so important in an increasingly complex world, for people of all ages to have a voice and to advocate for things that are important to them and to see one another as whole humans not as pieces.

Feeding Our Families in Our Diet-Centered Culture

By Anna Lutz, RD, CEDRD

Feeding. It can feel like the most basic part of raising a child.  One of the very first things we do for our child, feeding is instinctual to mothers’ and babies’ bodies. However, feeding our families in our society has become confusing and complicated because of the concern about the obesity epidemic. There is fear-based, restrictive nutrition advice everywhere. Children come home from school with rules about what can and cannot be brought in their lunch box. There are public school weigh-ins and BMI report cards. There are books geared to toddlers about lifting weights and “not being so chubby.” I fear that the casualties of the “War on Obesity” are our children,1 children that are more likely to diet, be unsatisfied with their weight, and be at risk for developing eating disorder behaviors.2

As a mother and a Registered Dietitian that specializes in eating disorders, I am passionate about how children are fed. We know that many, many factors, genetics included, play a role in the development of an eating disorder. While feeding practices certainly do not cause eating disorders, the approach to food in a household may be protective. We know that children who diet are more likely to have eating disorder symptoms.3 Since our mainstream culture and our healthcare system seem to have fully adopted a diet mentality and dieting messages are truly everywhere, how can we feed our children in a sound, healthy, protective way? It’s a daunting task, but there are four truths that come to mind that I try to remember as I’m navigating my own family feeding. I certainly do not have it figured out and there are many days I’m fearful that I’m “doing it wrong.” Some of these truths may be common-sense parenting, but the food rules, nutrition lessons, weight-management clinics, BMI charts, and nutrition picture books, have gotten things way off track.

Truth #1: Children’s bodies can be trusted.

It is not a parent’s job to control a child’s weight, nor is a child’s weight a reflection of the quality of parenting. We are born with the ability to regulate our intake.4 We can observe this first hand when taking care of an infant.  Babies know when they are hungry, and when they are not. With no external interference, children can retain this innate ability to self-regulate as they grow older. Children grow predictably along growth curves. Some children are more interested in food and may eat more and some may eat less, but both of these type children will grow predictably if given the opportunity to continue to listen to their bodies. Parents may follow well intended advice and begin to interfere with a child’s natural hunger cues by attempting to control how much their child eats.

Ellyn Satter’s Division of Responsibility (sDOR) is a model that can assist parents in feeding so that a child can keep (or recover) their innate ability to self-regulate and have a healthy relationship with food.5,6 In Satter’s Division of Responsibility, the parents’ jobs are to decide when it is time to eat, what is served, and where it is served. The child’s job is to decide if he’s going to eat and how much. Parents can do their jobs of putting together balanced, nutritious meals and assisting children in coming to the table hungry by having set meal and snack times. After the parent does his/her job, s/he can (try to) relax and trust the child’s body. This doesn’t mean a child won’t overeat or undereat at a meal. It means that with some structure, children’s bodies can be trusted to self regulate over time. I use this framework in my own home and find it extremely supportive. If I start to wonder what the best thing to do is, I take a deep breath and ask myself what my jobs are.

Truth #2: Bodies come in all sizes. 

Just as there are many different colors of eyes, hair, and skin, there are many different shapes of bodies. Weights and heights are truly on a bell curve and are generally determined by genetics. The nutrition and weight messages aimed at our children are teaching them that being bigger/chubbier/fatter is something that should be avoided at all costs. It makes me so sad that well intended teachers, healthcare professionals, and parents are teaching children that some people’s natural body type is not acceptable. I, unfortunately, have seen this play out with our culture supporting size-based bullying of children from their peers and even from adults. In our society, body size seems to predict how children feel about their bodies and how they eat. One study showed that girls that are in the “at-risk-for-overweight” category at age 5 are more likely to restrict their food and have body dissatisfaction at age 9.7 In this study, as dietary restraint increased, there were greater increases in BMI. Not only does our diet culture seem to accept bullying children with larger bodies, we may be actually causing weight gain, presumably the very thing the war on obesity soldiers are trying to prevent.

This topic is a bit tricky for me as a parent. The one thing I seem to be able to do most consistently is to not have my children hear me comment on my own body or how other bodies look. I have to believe that this example is something that subconsciously is having an influence on them. Certainly, my children have described others as fat. When they were in preschool, it was a descriptive term, with no judgement. As they’ve become school aged, I can hear the effect of society and the word fat contains a judgement. I try to acknowledge that their observation is true –there are fat people and fat is a descriptive term–and at the same time teach them through example, that this is a neutral, descriptive term. I may say something like, “I see that. What else do you know about her?” We may have no immediate control over the outside environment, but we can demonstrate acceptance of all bodies within our home.

Truth #3: We want things we cannot have. 

It’s human nature to want things we cannot have. Developmental psychological experiments have shown this over and over, whether it’s a toy, a job, or a food, we want the thing that seems forbidden or harder to get. We know that maternal restrictive feeding is predictive of children eating when they are not hungry and having increased BMI;8 again, presumably the exact things the parents are trying to avoid. An interesting study showed that girls that were restricted from highly palatable snack foods in their family ate more of these foods when they were not hungry, compared with girls that were not restricted from these foods.9 These studies highlight that for many children, if they are not allowed to have these foods or told these foods are forbidden, they will overeat them when their parents aren’t looking.

For a parent, this means that having all kinds of foods as part of your family’s life teaches children how to deal with highly palatable foods in a healthy way. This doesn’t mean a free-for-all on highly processed snacks and sweets. Remember, Satter’s Division of Responsibility; you decide the what and when. You are demonstrating what balance looks like, day to day. We can choose mostly nutrient dense foods, and occasionally include some so-called “junk foods” in our family’s meals and snacks to show children their bodies can manage a variety of different foods. Children don’t need strict rules for this or to be told these foods aren’t “good for them.” Children learn by example; if we don’t have chips at every meal, they learn it must not be what we eat a lot of. If we have a fruit or a vegetable at every meal, they learn that fruits and vegetables must be an essential part of a meal. They need the opportunity to eat these less nutrient dense foods alongside other food, without them being moralized. Chips are just chips; we need not fear or judge them. We don’t need to tell our young children these words, they learn it by experience. Then, when they go to a slumber party, chips are not a big deal and they don’t feel naturally compelled to overeat them just because they are not allowed to eat them when mom or dad are around. Decreasing the power and allure of these foods in this way also leaves room for children to discover a genuine liking for more nutritious foods, not having learned that “healthy” foods like fruits and vegetables are fundamentally different from their “junk food” counterparts.

Truth #4: Nutrition education needs to be age appropriate.

Just like sex education, age appropriateness is important to consider in nutrition education. We don’t tell a 5-year-old all the details of the birds and the bees. Similarly, a 5-year-old does not need to know all the details of nutrition, information that is extremely nuanced and subject to highly individual factors. Young children are concrete thinkers, they cannot think abstractly until middle school or beyond. One must be able to think abstractly on some level to understand nutrition. Adults can understand that a slice of cake may not be nutrient dense, but that our health is not affected if we have a slice of cake every once in awhile. We can also understand that carrots contain a lot of vitamin A, which is good for our eyes, and that not eating carrots doesn’t make us go blind (which I truly have been asked by a child). Parents can use nutrition information to guide their meal and snack planning (deciding the “what”), but they can consider the larger picture of several days or weeks of meals constituting overall nutritional balance. Children often cannot make that abstract leap. Inappropriate nutrition education is either just not understood accurately by children10 or in some cases can cause harm. One report documented four case studies in which healthful living programs by a health professional, such as myself, appear to have triggered a child to develop an eating disorder.11 One response to the obesity epidemic has been to teach children, even preschool children, specific nutrition information, typically including “good/green light/always foods” and “bad/red light/rarely foods.” Appropriate feeding is a parent’s job and a very risky burden to put on our children. Age appropriate nutrition education for young children would include where particular foods come from, food and culture, and cooking. As a child gets older, middle and high school aged, they can begin to learn more about nutrition information and how to put meals and snacks together.

Parenting in general today can be an amazingly daunting task. Because of what I do, I am most fearful of the restrictive and diet messages my children already come in contact with daily. They hear little comments, like an adult saying she’s not going to eat the pizza at a birthday party because she’s being “good” today or a teacher commenting on what a child has in her lunch. I cannot protect them from those comments, but I can work towards having an environment within our family that models balanced eating and values all bodies. It can sometimes feel like an impossible task. I certainly make many mistakes and have moments I do not know what to say to my children. But I always try to come back to these basic tenets, knowing that if I do my jobs well most of the time, I can trust my children’s bodies to grow and thrive.

About the author:

Anna Lutz is a Registered Dietitian with Lutz, Alexander & Associates Nutrition Therapy in Raleigh. NC.  She specializes in eating disorders and pediatric/family nutrition. Anna received her Bachelor of Science degree in Psychology from Duke University and Master of Public Health in Nutrition from The University of North Carolina at Chapel Hill. She is a Certified Eating Disorders Registered Dietitian through the International Association of Eating Disorders Professionals.  Anna previously worked at Children’s National Medical Center in Washington, DC, and on the Eating and Body Image Concerns Treatment Team at Duke Student Health.  In addition to her private practice nutrition therapy, Anna provides presentations and trainings to other professionals, school personnel, student, and parents. Anna has three young children and enjoys supporting and coaching parents about family feeding.

References: 

1. Zavodni K and Lutz A, “Non-Diet’itians – Integrating Eating Disorder Wisdom in All That We Do,” Renfrew Foundation Conference, Philadelphia, PA, 15 Nov 2014.
2. Neumark-Sztainer DR, Wall MM, Haines JI, Story MT, Sherwood NE, van den Berg PA. Shared risk and protective factors for overweight and disordered eating in adolescents. American Journal of Preventative Medicine. 2007 Nov;33(5):359-369.
3. Patton GC, Selzer R, Coffey C, Carlin JB, Wolfe R. Onset of adolescent eating disorders: population based cohort study over 3 years. BMJ. 1999 Mar 20; 318(7186): 765–768.; Stice E, Presnell K, Spangler D. Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psychol 2002; 21: 131–8.
4. Fomon SJ. Recommendations for feeding normal infants. In: Fomon SJ, ed. Nutrition of Normal Infants. St. Louis, MO: Mosby-Year Book, Inc.; 1993:455-458.
5. Ellyn, S. Child of Mine: Feeding with Love and Good Sense. Boulder: Bull City Publishing, 2000.
6. ellynsatterintitute.com
7. Shunk JA, Birch LL. Girls at risk for overweight at age 5 are at risk for dietary restraint, disinhibited overeating, weight concerns, and greater weight gain from 5 to 9 years. Journal of the American Dietetic Association. 2004 Jul;104(7):1120-6.
8. Fisher JO, Birch LL; Restricting Access to Foods and Children’s Eating. Appetite. 1999; Vol 32:3, 405-419., Birch LL, Davison KK, Fisher JO. Learning to over- eat: Maternal use of restrictive practices promotes girls’ eating in the absence of hunger. Am J Clin Nutr. 2003;78:215-220.
9. Fisher JO, Birch LL; Restricting Access to Foods and Children’s Eating. Appetite. 1999; Vol 32:3, 405-419.
10. Lytle, Leslie et al. Children’s Responses to Dietary Recommendations: A Qualitative Study.  Minnesota Department of Education, 1993.
11. L, McVey G, Walker KS, Norris M, Katzman D, Collier S. Trading Health for a Healthy Weight: the uncharted side of healthy weight initiatives. Eating Disorders. 2013; 21(2):109-115.

Shapesville as Performance Art: Exploring Body Image through Dance

By Sandra Perez, BA, MA, CMA

I first discovered the book Shapesville from a student research paper through a course I teach entitled Body Image Through History. This course is an exploration of what body image is and how it affects us personally and globally through the lens of the arts. This section of the course was comprised of dance majors and this student was also pursuing a dance teaching certification in preK-12. Her thesis was to discover the factors that contribute to the development of body image in children, at what age this begins to develop and how we can promote a more positive body image. Through this research she discovered a study by Dohnt and Tiggemann, entitled Promoting Positive Body Image in Young Girls: an Evaluation of ‘Shapesville’. Shapesville was successfully used to change negative body image perception in young girls. As a dancer and dance educator I have seen the effect of a negative body image on the dreams of the dancer, eating disorders among them. The idea that a book could target body image at an early age intrigued me; educators know that the early years of life are some of the most formative. In addition, I had used the art of dance to communicate and express since I was five and took my first tap class, virtually my whole life. As an arts integration specialist, reading and writing stories are of equal importance to me. The ability to communicate through the arts translates easily to the written and spoken word, as they are both languages, forms of literacy. I also know that as a shy child, reading was the place where I began to find the magic in words. Reading and dancing took me to other places where I could be anything or go anywhere. In performing classical ballets, I began to find stories of my own through the roles I danced, swans that could fall in love, birds with magical powers and sprites that had womanly guiles. I also found an identity as an interpretive artist, a dancer. So it is not surprising that as an artist educator my research would become intertwined with storytelling, dance, performing, teaching and learning; performance art. Sally O’Reilly in her book, The Body In Contemporary Art, sees performance art as  “any form of work that combines the artist’s body and a live action event”. (as qtd.in Pembleton 40 ) It has also been viewed from the perspective that the processes surrounding the creation of the art become equally as important as the product and oftentimes becomes a part of the performance. In this project the process was more important to me than the product, although the goal was always high quality art. The processes did not become a part of the performance but informed its creation throughout. Having already choreographed several educational dances when I discovered Shapesville, I saw its enormous potential to become a dance that could entertain, teach, and heal, my definition of educational choreography. The message of Shapesville about loving yourself and accepting others is important and the delightful illustrations of characters lend themselves toward movement, drama, dance, and imagination, the perfect combination for creating educational dance/art. These ideas led me to seek permission from the publisher, Leigh Cohen, to adapt the book into a dance. This generous permission led to development of a project entitled Shapesville Where You Can Be U: A Community Project. This article will discuss the adaptation of Shapesville into performance art and outline the collaborative, creative processes used in developing the piece that simultaneously explored the students’ own definitions of body image and subsequent view of themselves.

My choreographic research explores the creation of art through a collaborative creative process which I define as a process in which both the choreographer or director and the interpretive artist (the dancer) become equally valuable and significant in forming the final art product; in this case the dance of Shapesville. For this project, I worked with five college age students of varying dance abilities. None were currently pursuing dance as a career. All but one had danced for some time in high school and one was just beginning to dance at the non-major college level. Each came with individual goals ranging from expressing for relaxation, increased body conditioning, and having more confidence by increasing what they can do and improving how they dance. They comprised a course entitled Modern Repertory. While at first I was disappointed that I would not be working with more trained dancers, I quickly realized how fortunate I was to work with dancers who had no preconceived ideas about this collaborative process of learning dance repertory. The lack of expectations allowed them to remain open to my experimental ideas of choreographing the piece collaboratively and improvisationally, using journal writing, discussion, and somatic practices. I also saw that the message of Shapesville, “ It’s not the size of your ShapE or the shApe of your size, but what’s in your heart that deserves first prize” might be extremely effective in improving the body image of these young artists who were not highly trained or muscularly developed dancers, but young people struggling with their own identities, abilities, and body structures. Through writing, structured dance improvisations, discussions, and exchanging ideas we began to develop the five characters of Shapesville; Robbie the Rectangle who is an artistic star with many friends; Cindy the Circle, a movie star with beaucoup self confidence; Tracy the Triangle who’s “a little bit shy” but a basketball star who holds her head up high; Sam the Blue Square who’s a musical star and happy inside; and finally, Daisy the Diamond an academic star with beauty in her heart. (Shapesville) Although improvisation is often characterized as having little or no preparation before acting, structured improvisation can offer a pathway into discovering expressive movement that might otherwise not be uncovered. My job as the facilitator of learning and creativity was to develop structured activities that would lead the dancer toward discovering the depth of each character while finding personal meaning and voice through this process.

We began with a reading of the book and careful observation of the bodies of the characters and of ourselves through the illustrations. Through this body level exploration we quickly discovered the characters’ whimsical figures, while not realistic in adult terms, offered numerous possibilities of “doing.” Seeing the possibilities in these characters led us to discover the possibilities of “doing” with our own bodies when we don’t limit our notions of what a body can do. A rectangle with many arms could embrace numerous friends; springs as legs could help us jump, be free, be strong and accomplished; reading and being smart can bring beauty to our hearts; and music and the arts can make us happy and self confident, all ideas the illustrations revealed to us. I challenged my students to find their own character within themselves as developing young adults and to try to meet their fears that they or their creations would not be good enough. Through journal writing I heard their fears, but more importantly I confronted them on the dance studio floor. I watched the dancers struggle with my requests to try different, difficult, unfamiliar movement and partnering as seen in this quote from a student journal entry, “I need to recognize positive things are learned from making mistakes, confront fears, focus on process and not the end results, and avoid all or-none thinking. I need to stop watching others in the dance mirror and look inward.” Another commented, “After practice for a time I became better at it. Personally that is an important part of my body image because I am challenging myself and pushing my body to do things that I want to be able to do.” I also asked them to write about what they loved about their bodies. This served as a moment of turning inward for self-awareness, but in a positive way. These body level explorations and improvisations of the characters then forced me to see the need for deeper somatic connections to their self in order for the dancers to embody their characters more deeply and authentically.

At this point in the project, while the students were still grappling with physical insecurities, I saw building self-awareness to promote self-confidence as important in order to facilitate the openness necessary to continue to create and perform. I also realized that I had to build a community for this project not only for developing the community of Shapesville but also a community within the class. Without the trust of one another that solid, nurturing, reciprocal communities offer, the students would not be able to make themselves open to criticism and ultimately growth and accomplishment that presumably would lead to an increase in self-esteem. The artist must constantly take feedback in order to perfect the art for sharing in the performing arena. The dancer or any performing artist who must make their body and creative ideas visible and open to scrutiny, by themselves as well as by others, on a daily basis will experience vulnerability and will need to cope with its effects on self-esteem and body image. In order to accomplish both inner awareness and build a sense of community at the same time, I began with breathing techniques and an exploration of breath patterns as they contribute to our emotions. Without breath we have no life; breath supports our movement and our emotions. “It is possible to influence breath through conscious intention. Thus, breath can be an ally in any approach to change.“ (Hackney 52) It has been my experience that through conscious breathing we can influence our reactions to stressful situations thus opening our being to change and ultimately creativity. Brodie and Lobel state in their book, Dance and Somatics: Mind Body Principles of Teaching and Performance, “Developing awareness of breathing patterns can provide insight into the emotional and physical states of the body, and changing these patterns can help us begin to change habitual ways of using the entire being” (57). Peggy Hackney explains further, “Conscious cultivation of breath is recognized in many cultures to be an important part of attuning to a spiritual connection between the individual and the universe” (52). This supports my belief that conscious breathing can build connection to self and to the community. Hackney adds, “Attuning to another’s breath pattern is one of the best ways to connect” (54). The following quote from one student’s journal further supports this, “The breathing experiences connect us as a class but they help me to connect with myself and my own surroundings too. It’s always interesting when we begin breaths together and everyone starts off differently and then tries to connect.” Another mentioned breathing techniques as a way to “convey inspirations.” Through becoming aware of their own breath patterns we began to connect to what the breath patterns of their characters might be as translated into movement. This did help them to create movement motifs that were stylized but still seemed incomplete to me as the director. The next step became an exploration of the Laban Movement Analysis (LMA) Effort Factors and Elements. I am a Certified Movement Analyst (CMA) through the Laban Institute of Movement Studies (LIMS). (www.limsonline.org) Laban Movement Analysis (LMA) is a framework of analyzing how we move. Through careful analysis of the movement qualities of each character, we explored expression and quality of movement.

Effort as understood in LMA is compromised of four factors as they relate to energy use. These factors are Weight, how we use our weight in movement for expression, the relative freedom or inhibition of Flow within our movement and its relationship to expression, the Spatial Intent or where the movement is directed in space, and finally, the speed of the movement or Time. These factors combine together to create expression in movement.

(Raphael) 

Through analyzing the factors and their combinations, dancers and choreographers can create clear, expressive, dynamic movement and also create combinations of Effort Factors that elicit new choreographic ideas. We explored the emotions and strengths of the characters and each student’s own movement preferences. For example, a Light Weight and Free Flow movement Indirectly expanded in space and at a Quick tempo illustrates the character of Sam in this piece as she wrote, “I still cannot decide if Sam’s character is strong (weight) or light. I think he does not have to be that strong because he is already happy and carefree.” I also asked the dancers to create a character that symbolized the book’s intent, but also embodied the personality of the performer and interpretive artist, themselves. In this project, the student was both a performing artist and creator, thus combining the need to be true to the book’s character as the creator but also to bring their own movement preferences and emotions to the role as the interpretive artist. Daisy wrote, “The movement phrases we come up with have been constructed into choreography, which we firmly believe these entities make us think and feel. When we present our dance as a form of dance education we will serve as a universal communication for diverse learners”. This Effort exploration helped to solidify the characters’ movement traits, allowing for further development as they continually performed and grew the piece. This analytic use of the Effort Factors also allowed the dancers to reveal themselves in a scientific way that seemed to make them less vulnerable. “I love the fact the Daisy sees beauty as an internal factor. This has caused me to think deeply about portraying a character from a book and my own exploration of body image.” “If we were to deconstruct the misconceptions of beauty in the eye of the beholder, this could be a valuable tool for body image and self-esteem.” (Daisy) These reactions and newfound understandings illustrate the power of this work. I also saw unique movements created through this exploration that contributed greatly to the development of the characters as larger than life. The students became less afraid to be animated and exaggerated, as the piece called for, and to reveal themselves to the audience.

Finally, the piece was combined the following semester with eleven young girls, ages 6-11, from a community arts center who work-shopped with me for 10 sessions. They explored the book and ultimately developed characters of their own that were added to the book’s adaptation. The five college students had grown in their body image, self-esteem, and physical conditioning and through this interaction with the children built community and shared their triumphs with the younger students by being confident dancers. The young ladies, in turn, were able to embrace the characters and become their friends while also growing in their own positive body images, a subsequent article.

I would like to close with the words of the dancers themselves. These quotes sum up what was experienced and learned through this collaborative project. Tracy the triangle expressed this thought, “It is awesome we are all able to be interpretive artists and choreographers in this piece. So when we encourage each other I think we are being consistent. We are observing our different qualities which when combined makes us a stronger team”. Daisy said, “I continue to gain strength and improve in areas where I never before imagined. I cannot wait to look back on this journey of this collaborative project”. “I really appreciate the time I’ve spent with everyone in the class. I’ve learned a lot about myself and everyone else through this project. I plan to take what I have learned and continue to use it for the project and my other classes.” (Tracy)

“Instead of feeling defeated or giving up, my “think I can” attitude makes me feel like I can rise up and accomplish any goal. When facing challenges now I am less likely to doubt my own abilities.” (Daisy) Sam wrote, “I have learned that it is ok to be the way I am or anybody else is.” “Letting everything go by expressing whatever I feel makes me free and easy.”

Finally, Tracy replied post project, “Being part of the process from start to finish provided me with a new experience. Professor Perez’s compassionate and eloquent guidance comforted us and strengthened our goals. Through creating the dance and rehearsals I gained more confidence when I challenged myself to master new movements. The journal assignments and class discussions allowed me to focus more on things I like about myself and what makes me unique.” I was touched and continue to be by this book called ShApeSvillE. I am still carrying on the project and recently had a successful performance with high-school students. The children who watch are intrigued and each time I travel to Shapesville with my dancers their growth in self-esteem and belief in their own bodies’ abilities astounds me. Performance art does have the power to teach, entertain, and heal. Please take a moment to watch a short tease from the first performance, Shapesville Where You Can Be U: A Community Project with the Chesapeake Arts Center.   https://youtu.be/M79zFIBz8xU