By Professor Susan Paxton FAPS, School of Psychological Sciences, La Trobe University, Melbourne
Body image problems and eating disorders sit on a continuum which ranges from healthy body image and eating patterns through disordered eating and eating behaviours, and ultimately to more severe diagnosable clinical eating disorders. In our culture, body image problems (or body dissatisfaction) are associated with concerns about shape and weight, although they may also relate to concerns about other physical features or body parts. Disordered eating refers to eating behaviours that are associated with psychological distress and physical ill-health but are not of a severity to warrant a clinical eating diagnosis. These include use of extreme weight loss behaviours (e.g., crash dieting, excessive exercise and self-induced vomiting) and binge eating. Clinically diagnosable eating disorders include: anorexia nervosa, in which relentless dieting leads to a starvation state; bulimia nervosa, in which there is regular binge eating and use of compensatory behaviours; and eating disorders not otherwise specified (EDNOS), in which eating symptoms are clinically significant but do not fit criteria for anorexia or bulimia nervosa. The most frequently occurring EDNOS is binge eating disorder in which there is regular binge eating without compensatory behaviours. Although not currently recognised as an eating disorder in its own right in DSM-IV, it most likely will be in DSM-V.
It is important to note that although all these eating-related disturbances fall on a continuum, body image problems are not in all cases the major reason for development of an eating disorder, for example, food may have become an emotional comfort or be used as a means to gain a sense of control. However, judging one’s worth by one’s appearance and experiencing body dissatisfaction is very frequently a key issue underlying disturbed eating behaviour. The focus of this article is on examining body image and disordered eating problems to enhance our understanding of the psychology of eating disturbances.
The extent of body dissatisfaction in our society is alarming. In Australia, more than 70 per cent of girls wish to be thinner and an equivalent number of boys want to be either thinner or bigger (Ricciardelli & McCabe, 2001). In adolescents, more severe body dissatisfaction has been reported in about 46 per cent of girls and 26 per cent of boys. In the most recent Mission Australia Youth Survey of over 50,000 young Australians, 34.0 per cent of female and 27.4 per cent of male participants indicated that body image was their number one personal concern. Body dissatisfaction remains at a high level into midlife, with one study reporting 43 per cent of a sample of midlife women being dissatisfied with their bodies.
Weight loss is widely believed to be the solution to body image problems and, indeed, to other sources of unhappiness in our lives. Consequently, many Australians resort to quick fix fad diet solutions and extreme weight loss behaviours that are detrimental to health, ineffective, and associated with the development of binge eating, bulimic disorders and obesity. In a representative Australian male and female sample of 15-24 year olds, 20.0 per cent reported strict dieting or fasting, 29.3 per cent reported binge eating, and 13.6 per cent reported purging for weight control. Importantly, these disordered eating behaviours continued to be observed at similarly high levels up until people were aged in their mid-fifties. Of 45-54 year old respondents, 21.4 per cent reported strict dieting or fasting, 17.4 per cent reported binge eating, and 28.6 per cent reported purging for weight control (Hay, Mond, Buttner & Darby, 2008).
To understand much of the distress associated with body image and eating, we first need to consider our society’s rigid beauty ideals. Our society currently enthusiastically endorses a very thin beauty ideal for women and a lean and athletic ideal for men. These physical attributes are believed to be associated with attractiveness, success, happiness, control and moral virtue.
On the other hand, very negative attitudes about overweight and obesity prevail. Overweight and obesity are not eating behaviours or eating disorders although they are often considered as such. Rather, these terms describe the presence of high levels of adipose tissue that may occur for a multitude of genetic, environmental and behavioural reasons, only one of which is the amount a person eats. Although there is an increased risk of morbidity associated with high levels of adiposity, this is a health issue rather than one of moral worth.
Despite this obvious fact, psychological research confirms discrimination against larger people in employment, health care, education and social settings as a result of the negative stereotypes that overweight people are unattractive, lazy, incompetent and lacking in self-control (Puhl & Heuer, 2009). Discrimination and stigma also extend to larger children who are more likely to be teased and socially isolated than their thinner peers. Our recent research shows that, even in 3-5 year old children, positive qualities (e.g., good child) are associated with a thin body size, while negative qualities (e.g., mean child) are associated with larger body sizes. It is clear that these stereotypes are established early in life, creating a framework by which to judge not only others but also the self.
Social stereotypes about body size are filtered to the individual through the media, families and peers. Not surprisingly, exposure to these judgemental attitudes contributes to a strong desire to conform to the social appearance ideals. When a person endorses these ideals but perceives that they do not meet them (whether this is true or not), body image problems are likely to arise.
Environmental, individual and physical factors increase risk for the development of body image and eating problems. Environmental factors that have been shown to be particularly important are perceived pressures from peers and the media. Australian research has shown that, in 5-8 year old girls, perceived peer desire for thinness and exposure to appearance on television inversely predict appearance satisfaction one year later (Dohnt & Tiggemann, 2006). In teenage years, peer appearance conversations, friend dieting and appearance teasing have also been observed to be risk factors for the development of body image concerns and disordered eating. Further, experimental research confirms that exposure to idealised media images typically reduces body satisfaction (Wertheim, Paxton & Blaney, 2009).
In both females and males, research identifies two important links between social appearance pressures and body dissatisfaction and disordered eating: (1) internalisation of the social or media ideal; and (2) body comparison. Internalisation of the social ideal denotes the extent to which a person endorses our society’s appearance ideals. Body comparison refers to the extent to which a person compares his or her own body with the bodies of others. Social pressures increase internalisation of social ideals and body comparison tendencies, and both these attributes increase the likelihood of body dissatisfaction – especially weight and shape concerns – and disordered eating, independent of a person’s actual size. Weight and shape concerns have been identified as the strongest predictors of clinical eating disorders (Jacobi & Fittig, 2011).
Other individual attributes also increase risk for these problems. In particular, low self-esteem, depressive symptoms and perfectionistic tendencies have been observed to increase risk for body dissatisfaction and disordered eating. Individuals of larger body size are also at risk, not because of being larger per se, but rather because they are more likely to be exposed to our society’s negative judgements, as described above.
There are now psychological therapies available that are quite effective for the majority of body image and eating disorders problems, and the outlook for individuals who engage in an evidence-based treatment is good (Paxton & McLean, 2009).
For body image and subclinical eating disorders, colleagues and I have developed and evaluated manualised group interventions, facilitated by a therapist, for girls and women in different life stages. These interventions are based on cognitive behavioural principles and address factors that contribute to and maintain these problems. My Body, My Life is a six-session intervention for teenage girls who are experiencing body image and disordered eating. It provides skills for understanding and counteracting peer and other social pressures as well as ways to normalise eating patterns. The program has been evaluated using a very well received synchronous online delivery, but a face-to-face delivery approach could also be used in individual or group settings (Heinicke, Paxton, McLean, & Wertheim, 2007).
Set Your Body Free is an eight-session intervention specifically for young adults (Paxton et al., 2007). As well as developing healthy eating patterns, participants learn to question appearance ideals, reduce body comparison behaviours, and counteract avoidant behaviours associated with body dissatisfaction. Marked improvements in body dissatisfaction and disordered eating have been found using an internet delivery, but even greater improvements in these areas as well as in self-esteem and depressive symptoms were made when a group met face-to-face.
Most body image and disordered eating interventions specifically focus on the needs of young women. However, as indicated in data provided earlier, these problems continue into midlife during which the needs of women are somewhat different. In particular, lifestyles built around looking after and feeding families, as well as working, are not well suited to looking after one’s own self-care needs such as eating regular meals and having regular physical activity. Consequently, we developed Set Your Body Free – Midlife which specifically addresses these issues, and again on evaluation clinically significant gains have been demonstrated (McLean, Paxton & Wertheim, in press). These interventions are readily translated into a range of therapy settings and demonstrate the power of psychological interventions to make a real difference to the lives of women. (Manuals are available on request).
In light of the severity of body image and eating disorders, it would be ideal if effective prevention strategies could be identified. The major principle guiding recent prevention approaches is that if the development of influential risk factors for body image and eating disorders can be prevented or reduced, then movement along the continuum from health to disorder is less likely. Consequently, recent prevention interventions have sought to teach skills to manage social appearance pressures, and to reduce internalisation of appearance ideals, body comparison, body dissatisfaction and use of extreme weight loss behaviours.
In the mental health area, three kinds of prevention approaches are usually identified. Universal prevention is prevention provided to the general public or whole population without consideration of the presence of risk factors (e.g., billboard advertising or programs delivered to a whole school). Selective prevention targets at-risk population subgroups (e.g., teenage girls), but does not target participants on the basis of presence of individual risk factors. Indicated prevention is specifically for high risk individuals who are showing early symptoms of the problem (e.g., a program for girls with body image or eating concerns).
A universal prevention program for delivery in co-educational early high school classes that had particular promising outcomes is a media literacy program, MediaSmart (Wilksch & Wade, 2009). A universal approach is particularly useful in schools as it does not require the class to be divided and enables all students to be involved. MediaSmart aims to raise awareness of the unrealistic, manipulative nature of media images in an interactive way, and thereby reduce the risk factor internalisation of the media ideal.
A selective prevention program specifically for early high school girls that has positive outcomes is a peer risk factors focused program, Happy Being Me (Richardson & Paxton, 2010). The goal of this program is to help participants learn about the negative impact of appearance conversations and appearance teasing on internalisation of the thin ideal and self-esteem, and to learn ways to change these environmental risk factors.
Indicated prevention approaches have been shown to be especially helpful in later teen years. In these programs, young women with elevated body dissatisfaction and eating concerns are invited to participate. A cognitive dissonance approach – in which participants engage in exercises to argue against attitudes about the importance of thinness which they themselves hold – has been shown to be effective in reducing internalisation of the thin ideal, body dissatisfaction and eating disorder symptoms at a two year follow-up (Stice, et al., 2008).
\Public policy refers to actions at local, State or federal levels of government. Avenues open to governments to bring about change include legislation, promotion of non-binding industry codes, social marketing, and providing financial support for community and school-based initiatives. In Australia, no legislative approaches have been used. However, the Victorian and Federal Governments have promoted voluntary media and industry codes of conduct. Media and fashion leaders have been asked to endorse a code to not digitally alter images and to promote diversity of body shapes within their industry. Although non-binding codes clearly don’t bring about rapid change and industry endorsement has been modest at best, they do serve an awareness raising role and popular teen magazines have altered the ways in which they present many images. One magazine has taken the initiative to identify unaltered images (of which there are a reasonable number) with a symbol stating ‘Retouch Free Zone’. Actions such as this may serve a media literacy role.
The Victorian Government has promoted two social marketing campaigns. The first was a billboard campaign, backed with website information, named ‘Fad Diets Won’t Work’. The campaign aimed to raise awareness of the dangers of fad dieting, with one caption reading ‘Fad dieting helped me go from a size 14 to a size 12, back to a size 16’. Although an excellent message, the campaign only ran for one month in 2007 and consequently had very low reach. Another creative social marketing campaign by the Victorian Government ran on MySpace and was titled ‘Real life doesn’t need retouching: Take a stand against digital manipulation’. In an innovative series of images, glamorous advertising images were contrasted with the real worlds of young people. Although it had potential as a tool for media literacy, it was also only shown for one month and could not be expected to have had much impact in this time.
Importantly, the Federal Government is currently supporting the development of evidence-informed prevention resources for distribution to schools. In the future, public policy initiatives such as this may have a widespread impact.
While extremely rigid weight and shape body image ideals prevail, a large proportion of the population will compare themselves with these ideals, find themselves wanting, engage in disordered eating, and develop subclinical and clinical eating disorders. Looking ahead, we need to find ways to reduce pressure to conform to these ideals and ensure that the risks associated with extreme weight loss behaviours are well understood. We need to work to achieve a society that is accepting of diversity of body weights and shapes. In the meantime, psychologists can play very positive roles in guiding prevention and providing evidence-based interventions for body dissatisfaction and disordered eating. n
The author can be contacted at Susan.Paxton@latrobe.edu.au .