CONDITIONS & DISORDERS
BODY IMAGE AND EATING BEHAVIOURS Nikki Brierley Specialist Dietitian and CBT Therapist
Nikki has been a HCPC Registered Dietitian for eight years and more recently gained BABCP accreditation as a CBT Therapist. She currently works in a dual role within the Adult Community Eating Disorder Service at Cheshire and Wirral Partnership NHS Foundation Trust.
Body image dissatisfaction can negatively impact on an individual’s health and wellbeing and directly influence eating behaviours. With a reported 50% of the UK population suffering with a negative body image,1 it is clear that this is a subject which needs further discussion and better understanding/ management. The idea of body image (BI) was first developed by neurologists, whilst research was undertaken to understand how the brain interprets information received from different parts of the body. The term BI now refers to how an individual perceives their physical body (i.e. height, shape, weight, size and general appearance) and the thoughts/ feelings that this creates. This results in an internalised sense of what the individual thinks they look like. The subjective appearance may or may not accurately match the objective appearance (i.e. how they appear to others). As such, BI can be described as positive/ healthy or negative/dissatisfied (briefly summarised in Table 1 overleaf), and this can change over time.2 DEVELOPMENT OF BODY IMAGE
The development of BI is understood to be complex and influenced by individual and environmental factors.1 Babies and very young children appear to show little awareness of their own or others’ appearance; however, by the age of around seven, children are able to discriminate between ‘good’ and ‘bad’ appearance. This is reinforced by childhood literature that commonly links goodness with beauty and evil with ugliness.2 Adolescence is a time when the vulnerability to BI concerns increases, as the physical body endures many changes and becomes associated with sexual attractiveness. It is common for teenage girls to worry about their 24
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appearance and strive to the ideal ‘weight and shape’, it is also not uncommon for young males to develop concerns that their appearance differs from the projected ideal of ‘strong and muscular’. This is also a time when the risk of bullying increases and as physical appearance is obvious, any variation form the average is common a target. In addition, mainstream media continues the theme that was commenced in childhood and portrays attractiveness as being linked to success and happiness.2 There can be the assumption that with age, BI concerns reduce and individuals become less concerned with their appearance; however, the very lucrative ‘anti-aging’ market would strongly suggest otherwise. It is also true that if someone’s sense of self-worth has been largely dependent on their appearance, this is unlikely to change with age alone.2 NEGATIVE BODY IMAGE
There is no denying that physical appearance does hold some importance and that first impressions are partly formed due to the judgements made on how someone looks. Indeed, wanting to be attractive makes good sense as it conveys evolutionary and social advantages, with evidence suggesting that attractive children and adults are treated more favourably. However, the way someone feels about their body has a greater influence on the quality of life than how physically attractive they actually are.3
Table 1: A brief comparison of positive and negative body image Positive body image
Negative body image
• Accurate perception of body and physical appearance
• Negative/distorted perception of body and physical appearance
• Appreciate and accept own unique body
• Dissatisfied and frequent negative comparison to others
• Self-concept/value/worth is drawn from a variety of sources (i.e. friends/family, work/education, hobbies and physical appearance) • Comfortable and confident in own body
• Self-concept/value/worth is based largely on physical appearance (i.e. importance of physical appearance is overvalued)
• Don’t spend an unreasonable amount of time worrying about diet, weight and exercise
• Uncomfortable, ashamed, self-conscious, anxious about own body
• Changes to diet and/or exercise may be present, focus on improvements to health rather than based mainly on changing physical appearance
• Excessive worry about diet, weight and exercise
• Realistic/obtaining goals relating to appearance • Understand a person’s body size/shape says little about their character and values
• Attempts to diet and/or exercise in order to alter physical appearance (sometimes to the detriment of health and wellbeing) • Unrealistic/unobtainable goals relating to appearance • View ability to control body size/shape sign of personal success/failure
Source: Information collected from references 1, 2 and 3
Table 2: The glorification of thinness/leanness3 Thinness/leanness
Fatness
• Attractiveness
• Ugliness
• Success and status
• Failure/lack of
• Fitness
• Laziness
• Health
• Unhealthy
• Happiness
• Unhappiness
It is also essential that the importance of physical appearance is kept in perspective, as an excessive preoccupation with appearance can be very unhelpful and lead to distress and interfere with daily activities. When the significance of appearance becomes overvalued, this gives rise to a negative BI and BI dissatisfaction.2 Worryingly, recent findings suggest that 50% of the UK population suffer with negative BI and, furthermore, that one in four individuals are depressed about their bodies.1 Culture is described as the most powerful influence on BI, with the media’s portrayal of the ‘glorification of thinness’ (summarised in Table 2) cited as significantly contributing to body dissatisfaction. Over the past 30+ years, as the general population has increased in size and weight, the projected ideal has become thinner/ leaner and, as such, can only be obtained by extreme diets/exercise/other behaviours. It is also evident that increasingly drastic measures
(including cosmetic surgery) are being viewed as normal behaviours, as populations buy into the ‘myth of personal transformation’ (i.e. if you try hard enough these goals can be attained). What this does not take into account is the natural diversity of body shape and size and that for some, these ideals are completely unrealistic. What further compounds the problem is that many of the images used to project these ideals have also been digitally manipulated, making them simply unobtainable.3 When comparisons are inevitably made and efforts to change appearance do not deliver the required changes/long-term results, this places individuals at an increased risk of anxiety about their appearance and, for some, this results in excessive worry and a negative/dissatisfied BI. Although certain groups are more at risk of developing BI concerns, it is important to understand that it can affect all society, regardless of age, ethnicity, gender, sexuality, disability, body size or shape.3 www.NHDmag.com June 2017 - Issue 125
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CONDITIONS & DISORDERS Table 3: Potential effect of negative BI •
Emotional distress
•
Excessive worry
•
Low self esteem
•
Unhealthy eating behaviours
• Malnutrition •
Gastrointestinal disturbances
• Anxiety • Depression •
Eating disorders
•
Social withdrawal
•
Avoidance of activities that require to show body (i.e. exercise, sex, going to the doctors, swimming)
Source: Information collected from references 1, 2 and 3
Experiencing a negative BI (summarised in Table 1) can range from mild feelings of unattractiveness to severe obsessions with physical appearance that impairs normal functioning.3 BI dissatisfaction can impact on certain areas and/or the general quality of life and is associated with an increased risk of a variety of physical and mental health conditions. It can also impact on relationships and social engagement (Table 3 lists the potential effects of a negative BI). IMPACT ON EATING BEHAVIOURS
Inevitably, a negative BI can result in attempts to change the body by altering eating behaviours and/or increasing exercise. The combination of the distorted view of the body, unrealistic/ unobtainable ideals and the level of importance associated with the success of achieving the desired body, can give rise to extreme dieting, over exercising and other body changing behaviours. This results in an increased risk of disordered eating and eating disorders (ED). Indeed, BI dissatisfaction is a fundamental feature in the aetiology and maintenance of an ED. Conversely, a positive BI is associated with a reduced risk in developing an ED. Furthermore, improving BI can help to break the cycle of ED behaviours.3 The attempts to restrict intake to obtain a thinner/leaner body can increase the risk of malnutrition, nutritional deficiencies and/ or subsequent over eating/bingeing. This can further intensify the feelings of failure and dissatisfaction and a cycle can easily become established (as demonstrated in Figure 1). 26
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IMPROVING BODY IMAGE
It is clear that cultural changes are required to cultivate a positive BI and that the promotion of body respect, appreciation and importantly acceptance are required at a society level to reduce the prevalence of BI dissatisfaction. There is a variety of campaigns and organisations that are challenging the current practises including the ‘Be Real campaign for body confidence’ (www.berealcampaign. co.uk/the-campaign.html) that promotes education, health and diversity and ‘Health at Every Size UK’ (www.healthateverysize.org. uk) an approach that promotes not pursuing a specific weight, but instead the health benefits that can practically be achieved by the individual. It is, however, recommended that additional research and evidence is needed to ensure that these approaches are effective.1 Cognitive Behavioural Therapy (CBT) has been clinically proven to enhance BI by challenging negative thoughts, utilising mindfulness, adopting a non-judgemental stance and fostering self-compassion.2,3 There are self-help programmes available (i.e. Overcoming Body Image Problems, 2009) that include an evidence-based, step-by-step package that can be followed independently or with the support of a CBT therapist. The British Association for Behavioural and Cognitive Psychotherapist provides further details regarding CBT and how to access an accredited CBT therapist (www.babcp.com/ Default.aspx).
Figure 1: Cycle restriction and/or over eating
ROLE OF THE DIETITIAN AND OTHER HEALTH PROFESSIONALS
It is essential that as dietitians and health professionals (HPs) we are aware of the potential risks of negatively impacting on individuals BI. It seems vital that we actively aim to promote a positive/healthy BI in everyone we encounter and, thus, ensure that we are part of the solution and not indeed adding to the problem. In order to do this, we too need to adopt and model the behaviour of acceptance, non-judgement and compassion. This may require changes in the way healthcare is provided and the focus of the outcomes measured/goals that are set (i.e. health-based outcomes, not weight-based goals). It may also require us to look at the language that is currently used when referring to weight, shape and size (i.e. ‘ideal weight’) and the impact that this can potentially have on an individual who is not within the ‘ideal range’. This seems especially relevant given that we are regularly aiming to assist individuals in making positive changes to their diet and lifestyles and if we indivertibly contribute to the development of a negative BI, the opposite may occur (extreme/ over restricted diets and overeating).
SUMMARY
Recent reports suggest that 50% of the UK population experience a negative BI. The development of a negative BI appears to be complex and involves personal and environmental factors. The effects can range from mild to severe and can drastically impact on normal functioning and overall quality of life. Furthermore, they are associated with an increased risk of a number of physical and mental health conditions. A negative BI can also directly impact on eating behaviours and increases the risk of developing disordered eating patterns and indeed eating disorders. It is clear that a cultural shift is required to prevent the promotion of a negative BI and there are a number of campaigns that aim to influence society and promote body confidence and acknowledge the natural diversity of body shape and size. CBT is an evidence-based and clinically proven method to improve BI, by adopting acceptance, non-judgement and selfcompassion. It seems important that HPs are aware of the prevalence and risk of a negative BI and that an approach that at least does not further contribute to the problem is adopted.
References 1 Reflections on Body Image (May 2012). All Party Parliamentary Group on Body Image. YMCA Central 2 Overcoming Body Image Problems (Jan 2009). Veale, Wilson and Clarke. Constable and Robinson Ltd 3 Overcoming Body Image Disturbance: A Programme for people with Eating Disorders (Feb 2008). Bell and Rushworth. Routledge
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