Body Image and Eating Disorders

What's the Connection?

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Body image distress is often seen as a symptom of an eating disorder. However, not every person with an eating disorder has a problematic body image and many people who do not have eating disorders have poor body image. So how can we understand the relationship between body image and eating disorders?

What Is Body Image?

Body image is the subjective image people have of their own body, which is distinct from how their body actually appears.

Body image is a complex construct and is made up of beliefs, thoughts, perceptions, feelings, and behaviors. The way we see ourselves and our bodies has an impact on our health, on our mental health, and on our relationships. A healthy body image involves having an objective perception of one’s appearance and an ability to separate one’s value as a person from the way one looks.

Negative Body Image

Negative body image is often characterized by a dissatisfaction with appearance and engaging in behaviors such as dieting, checking, and/or avoidance, in an attempt to ameliorate the dissatisfaction. Negative body image often emerges during childhood. Studies show that approximately 50 percent of preadolescent girls and 30 percent of preadolescent boys dislike their body, and that 60 percent of adult women and 40 percent of adult men have a negative body image.

The term “normative discontent” was first used by Rodin and colleagues in 1984 to describe dissatisfaction with body size and shape.

It was found to be so widespread among women that it was determined to be “normative” or normal. A recent large scale study of 18- to 79-year-old Icelanders showed that nearly 43 percent were dissatisfied with their body weight and over 71 percent thought they needed to lose weight. Even though average BMI was higher among males, more females than males were dissatisfied with their body weight in every age group.

Body Image Issues in Eating Disorders

Eating disorders are complex mental illnesses caused by genetic as well as environmental factors—negative body image is just one potential contributor. However, negative body image is prominent in eating disorders because many people with eating disorders place a high value on their body shape and weight when determining their own self-worth.

This “overevaluation of shape and weight” is a symptom of some, but not all, eating disorders. One’s self-evaluation being disproportionately influenced by body shape and weight is consistent with a diagnosis of either anorexia nervosa or bulimia nervosa.  A diagnosis of anorexia nervosa is additionally consistent with a disturbance in the way one’s body weight or shape is experienced or an inability to recognize the seriousness of the current low body weight.

Overevaluation of shape and weight is not a required feature of binge eating disorder (BED), the most common eating disorder. Research indicates that only about 60 percent of BED patients met criteria for overevaluation of shape and weight. However, it appears that patients with BED who experience a preoccupation with shape and weight may have a more severe form of BED.

Patients with the eating disorder avoidant restrictive food intake disorder (ARFID) do not typically experience any preoccupation with shape and weight at all.

Negative Body Image and Other Disorders

Body dissatisfaction may lead to dieting and disordered eating, which can be gateway behaviors to an eating disorder. Body dissatisfaction is not only a risk factor for or symptom of an eating disorder, it can also be a risk factor for depression, anxiety, and low self-esteem. Thus, it is a common target for prevention efforts.

Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is another psychiatric disorder, classified as a type of obsessive-compulsive and related disorders.

People who have BDD are preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance, which can include body shape. In order to be diagnosed with BDD a person must engage in repetitive behaviors (such as checking or reassurance-seeking) related to the preoccupation and it must cause impairment in functioning. However, if the individual’s body image concerns only occur within the context of an eating disorder, only the eating disorder is diagnosed. It is not uncommon for patients to have both an eating disorder and BDD (the latter focusing on concerns other than weight or body fat).

Body weight and size dissatisfaction has long been recognized as an issue among females, but it has in recent years been identified as an increasing problem among males. One type of body dysmorphic disorder, muscle dysmorphia, affects primarily males who desire to be more muscular. Because many patients with muscle dysmorphia engage in exercise and changes in eating designed to influence body weight and shape, several researchers believe that muscle dysmorphia is actually a version of anorexia nervosa more closely aligned with traditional male gender norms.

Treatment for Negative Body Image

Research shows that body image is often one of the last symptoms of an eating disorder to improve during treatment. Even accounting for different treatments and symptoms between patients, the stages of recovery from an eating disorder follow a fairly similar pattern. Almost universally, weight recovery and behavioral changes appear to precede psychological recovery. And some degree of body image distress and preoccupation may persist after recovery of an eating disorder, since it is not normal for people in our society to be entirely free of body image concerns.

A variety of interventions have been designed to target negative body image. These interventions fall into several broad categories including cognitive-behavioral therapy, fitness training, media literacy, self-esteem enhancement, psychoeducation, and gratitude. In many cases, treatments incorporate more than one category of intervention. For example, cognitive-behavioral treatments and media literacy programs often include psychoeducation.

Cognitive-Behavioral Interventions

Cognitive-behavioral interventions are those most frequently utilized to address body image. These interventions help individuals modify dysfunctional thoughts, feelings, and behaviors that contribute to negative body image. The techniques use include self-monitoring, cognitive restructuring, body size estimation training, exposure to triggers, and mirror exposure. One of the best known cognitive-behavioral programs to address body image is the Body Image Workbook by Thomas Cash.

Fitness Training

Fitness training interventions include exercise geared at improving physical capabilities such as muscle strength. Objective improvements in physical fitness are not as important as perceived improvements. Fitness training can also improve body image by encouraging individuals to focus more on the functionality of their body and less on their appearance.

Media Literacy Interventions

Media literacy interventions teach individuals to critically evaluate and challenge the media images and messages that can contribute to negative body image. For example, images of very thin models and messages such as “Thin is beautiful” can be challenged. Techniques used in media literacy interventions include education and advocacy training.

Self-Esteem Interventions

Self-esteem strategies used in the treatment of negative body image focus on identifying and appreciating individual differences both in regards to body image and internal qualities and talents. Strategies also focus on building healthy coping skills.

Psychoeducation

Psychoeducational strategies teach individuals about issues related to negative body image including its causes and consequences. Psychoeducational strategies are often used in combination with one of the other types of interventions.

Gratitude-Based Interventions

A newer line of body image interventions includes gratitude-based strategies such as gratitude journals, lists, reflections, and meditations. Such interventions seek to increase appreciation for non-appearance based aspects of oneself.

Strategies to Try at Home

Here are some self-help strategies based on some of the interventions above that you can do on your own to improve body image:

  • Keep a body gratitude journal. A daily routine that includes self-deprecating comments about your body is likely making you feel worse. In order to come to a more balanced perspective, it is important to start to shift your attention and appreciate good things about your body. One way to achieve this is to keep a body gratitude journal. Try to write something daily that is positive about your body. You can include things like, “I had a good hair day,” “My legs allowed me to hike up the canyon,” or “My arms allowed me to hug my child.” At first It may be hard, but it will get easier with practice.
  • Clean your social media feed. We are all barraged on a daily basis with images and messages emphasizing thinness and/or the attainment of an ideal physique. To counteract these messages, it is important to find messages that support body acceptance and the inclusion of a range of bodies. Instead, read body-positive blogs and follow body positive role models. Some excellent posts are: Body Image Booster: A Powerful Reminder by Margarita Tartakovsky and What the Dying Regret by Kerry Egan. You may want to create a body positive Pinterest board. It’s also a good idea to stop following social media sites that promote the thin or fit ideal.
  • Buy clothes that fit now. Many people resist buying clothes that fit and either wear shapeless clothes or dangle themselves the reward of shopping or fitting into old clothes “when they lose the weight.” This misguided exercise increases misery in the present and does nothing to increase motivation. Instead, buy at least a few basic items that fit now and that make you feel good. Most people find that this leads them to feel more confident and reduces anxiety and self-disparagement when getting dressed.
  • Challenge avoidance and stop body checking. Avoidance and body checking have been implicated in the persistence of eating disorders. Avoidance can involve the complete covering up, refusing to wear appropriate clothes for the situation (wearing a hoody in the summer, refusing to wear shorts or a sleeveless top on a summer day, refusal to swim because of anxiety over wearing a swim suit) or complete avoidance of doctors who might weigh them. Body checking is the repeated checking of one’s shape and weight and takes a variety of forms from repeated weighing, measuring (with a tape measure or by touch), or obsessive checking in the mirror. Avoidance and body checking only perpetuate anxiety. The goal should be moderation. Those who avoid should practice exposure, and those who obsessively check should stop. If checking is an issue, try keeping track of the number of times you check and then try to gradually cut that back. Exposure can also be gradual. For example, one can first wear sleeveless shirts around the apartment for increasing lengths of time before eventually venturing outside wearing them.
  • Act out against the thin ideal. Some of the most effective eating disorder prevention programs, such as The Body Project, are based on the principle of cognitive dissonance. Cognitive dissonance is the idea that when attitudes and behaviors are in conflict, a person experiences discomfort and tries to align attitudes with behaviors. Individuals are encouraged to engage in activities that actively resist cultural pressures toward the thin ideal. Such activities include writing a peer or young girl a letter that encourages her to embrace a more diverse range of beauty or writing a company that has engaged in fat shaming or thin-centric behaviors a letter that explains why that bothers you.
  • Change negative body language. Engaging in typical “fat talk”—negative and judgmental comments or conversations that are focused on weight and appearance—is detrimental to body image. Avoiding such judgments (e.g., “I’m so fat!”) can improve body image. Consider taking a pledge to not engage in fat talk.

A Word From Verywell

There are numerous movements suggesting people should aim to love their bodies. This may not be possible. A more reasonable goal for some might be to work toward appreciating and accepting their bodies. Body image is not likely to improve without effort, and the activities above need to be performed over time. Improving body image is an appropriate goal for therapy, whether or not an individual is experiencing disordered eating. If employing these strategies independently is not helping over time and body image is having a negative effect on overall well-being or daily functioning, don’t hesitate to seek help from a professional.

Sources:

Alleva JM., Sheeran P, Webb TL, Martijn C, & Miles E. “A Meta-Analytic Review of Stand-Alone Interventions to Improve Body Image.” 2017. Plos One. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0139177.

Cash, T.F. (2008). The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks (2nd ed.). Oakland, CA: New Harbinger Publications.

Clausen, L. 2004. “Time Course of Symptom Remission in Eating Disorders.” The International Journal of Eating Disorders 36 (3): 296–306. doi:10.1002/eat.20043.

Grilo, CM., Crosby RD, Masheb RM, et al,. 2009. “Overvaluation of Shape and Weight in Binge Eating Disorder, Bulimia Nervosa, and Sub-Threshold Bulimia Nervosa.” Behaviour Research and Therapy 47 (8): 692–96. doi:10.1016/j.brat.2009.05.001.

Matthiasdottir E, Jonsson SH, and Kristjansson AL. 2012. “Body Weight Dissatisfaction in the Icelandic Adult Population: A Normative Discontent?” European Journal of Public Health 22 (1): 116–21. doi:10.1093/eurpub/ckq178.

Paxton, SJ, Neumark-Sztainer, D, Hannan PJ, & Eisenberg ME. “Body Dissatisfaction Prospectively Predicts Depressive Mood and Low Self-Esteem in Adolescent Girls and Boys: Journal of Clinical Child & Adolescent Psychology: Vol 35, No 4.” 2017. http://www.tandfonline.com/doi/abs/10.1207/s15374424jccp3504_5.

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