Preamble

Unhealthy Body Image

Body image describes how an individual conceptualises his or her physical appearance.¹ The body image a person has results from the interaction between the person’s thoughts, beliefs, feelings and behaviours regarding their own body, and their perception of what counts as the ideal body within their own social and cultural setting.² Unhealthy body image can affect men and women, children and the elderly from all backgrounds.

While there is no single or standard definition, “unhealthy” body image can be taken to involve a dissatisfaction with one’s physical appearance leading to unhealthy responses which can include poor eating behaviours, changing levels of physical activity, substance abuse or reduced social interactions. This description emphasises that, from a health and medical point of view, the important difference between healthy and unhealthy body image is the nature of the behavioural and health-related consequences of the body image a person has.

There is potential for body image issues to arise at an early age. Evidence suggests that self-awareness starts to emerge around the age of eighteen months, though this remains an area of research and debate.³ The age or stage of development when a child begins to evaluate their body for acceptability is still being investigated.

The onset of puberty is a period of both substantial physical change and altered peer-relationships. It can be a period of major transition in a person’s body image.⁴ Body image satisfaction has been identified as the greatest single predictor of self-esteem for adolescents.⁵ Mission Australia’s National Survey of Young Australians has identified body image as one of the leading issues of concern to young Australians of both genders.⁶ Children and young people with physical and developmental disabilities can also experience body image concerns.

Unhealthy body image affects lifestyle choices and negatively affects mental and physical health, and social functioning. It can lead to unhealthy dieting, eating disorders, excessive exercise or under-exercise, substance use, and the desire for unnecessary surgical intervention. Once established, an unhealthy body image can continue through adult life. 

Eating Disorders

Eating disorders can result from unhealthy body image. Such disorders include anorexia nervosa and bulimia nervosa. The former is characterised by self imposed starvation coupled with an intense fear of weight gain (despite continued weight loss). The latter involves episodes of binge eating followed by purging (such as self-induced vomiting, laxative or diuretic misuse and excessive exercise). The health consequences of the food restriction and starvation associated with anorexia and bulimia include impairment of bone mineral acquisition leading to osteoporosis, fertility problems, kidney dysfunction, reduced metabolic rate, cardiac irregularities, muscle wasting, oedema, anaemia, stunting of height / growth and hypoglycaemia and reduced mental functioning.⁷

Eating disorders are serious psychiatric illnesses. The prevalence of eating disorders among children and adolescents is rising.⁸ While it is difficult to assess exactly how common eating disorders are (as many cases may go undiagnosed) it is estimated that one in 100 adolescent girls develop anorexia nervosa, and that it is the third most common chronic illness in girls, after obesity and asthma. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) state that eating disorders have the highest mortality rate of any psychiatric illness, with a death rate higher than that of major depression.

Cognitive Behavioural Therapy - a form of psychotherapy designed to change problematic thinking habits, feelings and behaviours – has been shown to be an effective treatment for bulimia nervosa in the Australian primary care setting. Long term follow up studies indicate that many patients with bulimia nervosa have good outcomes, with up to 50% being free of symptoms at five years or more after treatment.⁹ Unfortunately there is no evidence for a similarly effective treatment for anorexia nervosa. A major contributor to the poor prognosis for this illness is the high rate of relapse following initial treatment. This has promoted interest in interventions aimed at preventing deterioration and relapse, which may in turn lead to more effective treatments in the future.¹⁰

The Influence of the Popular Media

Research is continuing into the range of individual and social factors that might contribute to the development of unhealthy body image and eating disorders. It is generally recognised that the popular media is a significant social and cultural factor that influences the development of people’s self-perception and body image.¹¹ Young people especially, are susceptible to social pressures to conform to ideal stereotypes. The public is constantly presented in the popular print and electronic media with images of attractive, thin women and athletic, handsome men. These idealised images do not truly reflect the bodies of most people in the community, and can contribute to unrealistic perceptions about appropriate physical appearance which may lead to body dissatisfaction and eating disorders. Repeated exposure to these images could have a cumulative impact on vulnerable individuals.¹²

There is no national system of regulation relating to the portrayal of body image in the print and electronic media, nor the use of digital manipulation techniques such as airbrushing. This is despite growing community concern and debate around issues such as the use in advertising of very young and / or extremely underweight fashion models.¹³ The development of national industry standards may be an effective step along the way to responsible body image portrayal in the media.

The Role of Medical Practitioners

According to the World Health Organisation Collaborating Centre for Mental Health and Substance Abuse, medical practitioners have an important role in fostering healthy beliefs about body weight and shape by challenging unrealistic thoughts, beliefs and values, providing education and providing referral for therapy.¹⁴ Medical practitioners play an important role in the early detection and management of individuals at risk of developing unhealthy body image or eating disorders.¹⁵ Doctors can identify symptoms of eating disorders or body image problems which would otherwise appear unrelated. Early intervention may lead to a more complete recovery, and reduce the risk of an eating disorder becoming chronic.¹⁶ Doctors have opportunities to educate patients on the benefits of healthy eating and appropriate physical activity, and to advise parents about healthy eating and healthy weight for children and adolescents. Doctors are aware of the complex processes of behaviour change needed to establish and maintain a healthy weight, and can advise those with body image concerns about the risks and likely successes of various weight control ‘diets’.¹⁷

For those individuals who have an established eating disorder, general practitioners are often responsible for coordinating referral to, and care by, consulting tertiary services and local dietetic and psychological services.¹⁸ In the management of eating disorders, doctors recognise the potentially long-term nature of the illness and the need for continuity of care and coordinated multi-disciplinary management. Because there are often long-term care relationships between doctors and patients, doctors will be aware of the adverse impacts of eating disorders on families, friends and colleagues, and will often be a source of important support for patients and their families during a very disruptive and psychologically disturbing time.

In some cases, people turn to medical procedures or cosmetic surgery to achieve their ideal body. Advertising and other promotions which appeal to youth can encourage cosmetic surgery as an easy solution to personal issues, including body image dissatisfaction. Doctors can provide impartial advice to people on cosmetic procedures, including whether they are medically indicated, and the potential health risks that may be involved. This also applies to drugs and other substances that individuals may use to enhance or change physical appearance. Evidence-based medical counselling can help individuals develop realistic views about their need for cosmetic procedures, and what can be achieved by them.

The AMA Position

The AMA believes that the following measures and proposals will contribute to reducing the impacts of unhealthy body image and eating disorders.

A National Approach

• The AMA believes that a nationally coordinated approach is necessary in order to develop effective and consistent practices in preventing and addressing the incidence of unhealthy body image and eating disorders. To achieve this, a peak national network of researchers, educators, policy-makers and industry stakeholders should be established to coordinate this national approach to body image and eating disorders.

Media Portrayals of Body Image

• While acknowledging the impact of other social pressures to conform to idealised body types, the AMA recommends that the ‘media industry’ (ie., publishers, programmers and advertisers) depicts a more realistic range of body images and role models. This should happen at a national and industry-wide level, through conformity with appropriate standards that are developed by industry in conjunction with experts and stakeholders in the area of body image issues. If the Australian media industry can neither develop nor abide by such standards, then the AMA believes that government regulation should be considered.
• The advertising and media industry should not portray normal bodily changes, such as those associated with ageing, as abnormal or problematic.
• Direct to consumer advertising of pharmaceutical products designed to play on body image and weight concerns is an unacceptable practice.

Schooling and Public Education

• The school system can play a very important role in helping children and young adults build and maintain a healthy body image. There is a need for increased understanding of how school curricula and other aspects of school life can impact positively and negatively on the development of body image and eating disorders. In particular, schools should:
  • incorporate issues around development of healthy body image into its health curriculum programs (including recognition of the impacts that bullying may have on body image);
  • develop programs in media literacy, and integrate media literacy skills into other curriculum areas so that young people can critically evaluate media content and messages pertaining to ideals about body type, and develop realistic views of self and society;
  • develop and monitor their physical activity programs to be aware of the risk of unhealthy body image developing, and associated excessive exercise. An emphasis on team based sports can be an effective vehicle to promote healthy lifestyles and to deter disordered eating and athletic enhancing behaviours;¹⁹
• There is a need for increased government commitment to appropriately targeted public education on the association between diet, physical activity and health, and the health risks associated with eating disorders.

Cosmetic and Restorative Surgery

• Medical procedures to modify or enhance physical appearance should not be provided to young people under 18 years of age, unless those procedures are in a person’s medical and/or psychological interests.
• The AMA discourages the marketing and advertising of cosmetic surgery as an easy solution to individuals’ personal or social problems.
• The AMA supports the need for measures to ensure safety and quality of practice in cosmetic surgery, and that the interests of the patient are always paramount. It is essential for people considering cosmetic surgery to discuss the risks and potential benefits with their doctor.
• The AMA recognises the importance of restorative surgery in cases where accident, injury or surgery has a significant impact on body image satisfaction.

Treatment Services

• Services for eating disorder patients vary widely in their accessibility, availability and the type of care provided to patients and their carers. This variability is most pronounced for those living in rural and regional areas.²⁰ A greater focus is needed on ensuring appropriate access to early intervention and treatment services for young people in rural and remote locations.
• A ‘one size fits all’ approach to the treatment of eating disorders does not adequately cater for the needs of all those who have eating disorders or body image problems. Mechanisms need to be in place to allow health and medical professionals to readily access recent information about best-practice for the identification, diagnosis and treatment of body image and eating disorder problems.

Fitness and Health

• The AMA advises against the use of fad or crash “diets” which make claims of dramatic weight loss, weight gain, or performance enhancement.
• The AMA recommends that individuals engage in healthy eating habits and an active lifestyle   in accordance with evidence-based dietary guidelines and physical activity recommendations.
• Safe and supportive environments should be available to facilitate access, increase participation, and  a willingness to engage in a range of healthy physical activities by people with body image concerns. Having an unhealthy body image can also limit physical activity, as those who feel self-conscious about their body may be less likely to participate for fear of exposing their body.
• The AMA encourages the fitness industry to actively promote participation in physical activity as a preventative health strategy rather than to achieve the 'ideal' body. 

Research

• Adequate funding should be provided for further research into:
  • the impact of media on body image, particularly among children and adolescents;
  • the risk factors for developing eating disorders;
  • the protective factors that may reduce the incidence of eating disorders;
  • the health impacts of unhealthy body image and eating disorders across all population groups, and the effective interventions and treatments for them, particularly regarding anorexia nervosa. 

References:

1. Thompson JK. Body Image Disturbance: Assessment and Treatment. 1990. New York: Pergamon Press.

2. Cash, TF. Body Image: Past, Present and Future. Body Image 2004. vol1: 1-5

3. Brownell, CA., Zerwass, S. & Ramani GB. “So Big”: The Development of Body-Self-Awareness in Toddlers.  Child Development. 2007. vol 78:142-1440

4. Wood, KC., Becker JA., Thompson JK. Body Image Dissatisfaction in Preadolescent Children. Journal of Applied Development Psychology. 17: 85-100.

5. Wood KC, Becker JA and Thompson JK. Body Image Dissatisfaction in Preadolescent Children. Journal of Applied Developmental Psychology. 1996 17: 85–100

6. Mission Australia. National survey of young Australians 2007: Key and emerging issues. Located at: http://www.missionaustralia.com.au/document-downloads/doc_details/48-nat...

7. Eating Disorders Foundation of Victoria Inc. Physical and Psychological effects. Located at: http://www.eatingdisorders.org.au/content/view/18/37/

8. Gonzalez, A., Kohn, MR., Clarke, SD. Eating disorder in adolescents. Australian Family Physician vol. 36. No. 8. 2007

9. Hay, PJ. Understanding bulimia. Australian Family Physician. Vol 36. No. 9. 2007

10. Walsh T, Kaplan AS, Attia E et al. Fluoxetine after Weight Restoration in Anorexia Nervosa: A Randomised Control Tiral. JAMA. 2006;2605- 2612

11. The Bronte Centre. Located at: www.brontecentre.com

12. Government Response to the Parliamentary Inquiry into Issues Relating to the Development of Body Image Among Young People and Associated Effects on Their Health and Wellbeing. (Victorian Government: Family and Community Development Committee) – January 2006

13. For example, the 2008 Senate Standing Committee Inquiry into the Sexualisation of Children in the Contemporary Media Environment.

14. Treatment Protocol Project. Management of Mental Disorders. 2000. World Health Organisation Collaborating Centre for Mental Health and Substance Abuse. 

15.  Gonzalez, A., Kohn, MR., Clarke, SD. Eating disorder in adolescents. Australian Family Physician vol. 36. No. 8. 2007

16. Abraham, SF. Dieting, body weight, body image and self esteem in young women: doctors dilemmas. MJA 2003; 178: 607-611

17. Dieting is so prevalent in our society that Australians spend about $1 million a day on weight loss attempts. Unfortunately, nine out of ten weight-loss diets are unsuccessful or may actually be harmful or eventually increase weight gain. Vic Health. Parliamentary Inquiry into issues relating to the development of body image among young people and associated effects on their health and wellbeing. 2004 Vic Health Response.

18. Gonzalez, A., Kohn, MR., Clarke, SD. Eating disorder in adolescents. Australian Family Physician vol. 36. No. 8. 2007

19. Elliot DL et al. Preventing Substance Use and Disordered Eating: Initial Outcomes of the ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternatives) Program. Arch Pediatr Adolesc Med. 2004;158:1043-1049

20. Government Response to the Parliamentary Inquiry into Issues Relating to the Development of Body Image Among Young People and Associated Effects on Their Health and Wellbeing. (Victorian Government: Family and Community Development Committee) – January 2006