Features

What do you see?

06 September 2019

Negative body image is an issue for children and adults alike. What’s the impact, and how can you help? Journalist Anna Scott reports.

The subject of body image (how we think and feel about our bodies) reached the House of Lords just before members went on their summer recess in July. Crossbench peer Baroness Bull, a former ballet dancer, asked the parliamentary under-secretary of state for health and social care, Baroness Blackwood, if she was confident that adequate social policies were in place to address and reduce the incidence of weight bias (TheyWorkForYou, 2019).

‘Weight-related teasing is a form of weight bias, the consequences of which can include depression, anxiety, low self-esteem, substance abuse, eating disorders, obesity and suicidality,’ she said. ‘Research shows that even health professionals are not immune to negative stereotypes that connect character and capability with weight.’

It’s not surprising that politicians are beginning to discuss physical appearance in this way, given the prevalence of negative body image among the UK population: one in five adults felt shame, just over a third felt down or low, and 19% felt disgusted because of their body image in the last year (Mental Health Foundation, 2019a). In the UK, 37% of 13- to 19-year olds felt upset in relation to their body image, and 31% felt ashamed (Mental Health Foundation, 2019a). These were some of the findings of a large survey by the charity Mental Health Foundation (MHF) earlier this year, comprising 4505 adults and 1118 teenagers. Around the same time, another survey of young people found that 67% of 2189 11- to 24-year olds said they regularly worry about the way they look (YMCA, 2019).

These are stark figures showing body image issues among multiple age groups. And these figures matter. ‘[While] body image concerns are not a mental health problem in themselves, they can make a person more likely to have mental health problems,’ explains Dr Antonis Kousoulis, director of England and Wales at the MHF. ‘At a time when the mental health of young people especially seems to be under unprecedented strain, we cannot dismiss body image as a trivial or frivolous subject.’

With the MHF report also revealing that one in eight adults have experienced suicidal thoughts or feelings because of concerns about their body image (2019a), it’s clear just how important the perceptions we hold about our bodies are.

Why is our body image so negative?

The MHF’s research highlights four areas that affect how we see our bodies: our relationships with our family and friends, how our families and peers feel and speak about bodies and appearance, exposure to images of idealised or unrealistic bodies through the media or social media, and pressure to look a certain way or to match an ‘ideal’ body type (MHF, 2019a). ‘What this ideal looks like will shift across cultures and can vary between genders,’ the report reads.

‘In the West, for most women that’s a desire to be thinner,’ says Viren Swami, professor of social psychology at Anglia Ruskin (AR) University. ‘For a lot of men that is a desire to be taller and more muscular.’

The MHF report also shows that consistently speaking about our bodies or others’ bodies in ways that imply weight or youth are central to attractiveness and value shows how many people feel about body image. For example: ‘I feel fat today’ and ‘Ugh, look at my wrinkles’ (MHF, 2019a).

Society does seem to be increasingly focused on self-image and self-awareness, says Sally Star, a SCPHN school nurse at the Hywel Dda University Health Board (see her safeguarding piece on page 22). ‘Young people are undoubtedly more media savvy and peer-aware than in previous generations and that does introduce health and emotional wellbeing risks to susceptible individuals,’ she says.

Indeed, 24% of 18- to 24-year-olds say reality TV makes them worry about their body image, reveals MHF research (2019b). The charity has concerns over the ITV2 reality show Love Island, with Antonis saying it displays body images that are ‘not diverse, largely unrealistic and presented as aspirational’.

Watching Love Island won’t automatically lead to a negative body image, says Viren, who is also an associate editor of journal Body Image. ‘Viewers are both clued-up and active users of these kinds of programmes,’ he says. ‘Most are probably actively negotiating with appearance ideals and talking about it with their friends or parents thinking, “I don’t want to look like that.”

‘But people who have pre-existing conditions such as eating disorders or body dysmorphia or a personality framework that predisposes them to such conditions may experience a negative outcome from watching these kinds of programmes. For example, people who score highly in the personality trait of narcissism are likely to view Love Island and come away with worse body image.’

Sally adds that if people have a healthy body image through ‘robust inner resource pools, the impact of current virtual and media worlds would not have such a detrimental impact’.

It’s a similar story with social media. Research from the Be Real campaign – a movement to change attitudes towards body image coordinated by the YMCA – reveals that 61% of 11- to 24-year-olds feel pressure to look their best online, and 67% edit photos of themselves before posting them on social media (YMCA, 2019).

‘Social media continues to present a multitude of dangers for young people, which they have been left to navigate using their own devices,’ says Denise Hatton, chief executive for YMCA England and Wales. ‘These dangers are not just limited to the content they see, but also the pressure to emulate them. [We all] need to be conscious about the content they are posting online.’


What else can shape body image?

‘There are lots of complicating factors that affect body image, such as ethnicity, social background, gender and sexuality,’ says Viren Swami. ‘Ethnic minorities tend to be buffered against negative body image as they are not represented on TV primarily. Migrant populations tend to develop a more negative body image because of the stress of migration and trying to live up to host cultural ideals.’

Gay men often have a negative body image compared to heterosexual men because of subcultural rules about acceptable and normative body shapes and sizes, Viren explains. ‘Conversely, lesbian women tend to have a more positive body image compared to heterosexual women because there is more variance and acceptance of different body shapes and sizes,’ he adds. The MHF notes that research is mixed on this point (MHF, 2019a).

Sally Star adds: ‘The likelihood is increased in those with a diagnosed or existing mental health condition, chronic health disorder or disability, looked after children or those who have had adverse childhood experiences.’

‘Sexual harassment, rape and trauma are big triggers for negative body image and could lead to a clinical diagnosis,’ says Viren. 



Life influences

Similarly to the MHF report, Viren says: ‘There are three primary factors that tell us about standards of appearance in society: the media, parents and peers. [For instance] research shows parents who have negative body image are much more likely to pass on negative outcomes to their children.’

This issue is not often picked up by healthcare professionals, adds Saskia Waage Townsend, a health visitor at Leicestershire Partnership NHS Trust. ‘The intergenerational transmission of eating problems and the psychological meaning of eating and body difficulties is often overlooked.’

Viren also explains that influences on body image change during the course of life. ‘In childhood and up to middle adolescence, parents have the biggest impact, not just on body image but also on eating habits and how children relate to food. From middle adolescence and onwards, peers will have the biggest impact on body image. And there are many other triggers of negative body image – clothes, exercising, socialisation, teasing or bullying.’

Moving through adulthood, particular events can play a role, including pregnancy, the menopause and ageing in general. ‘The perinatal period for women tends to cause negative body image, primarily because of weight gain,’ says Viren. ‘Although during the same period women often develop a different attitude to their body and focus on what it is able to do to feed their baby, for example. So there is a tension between wanting to encapsulate this thin ideal and having respect for their bodies.’

Unaddressed issues carried over from childhood can also play a role in adults having a negative body image, says Viren. ‘Most studies suggest that negative body image becomes gendered at quite a high level at a relatively young age. Boys tend to develop negative body image slightly later in life compared to girls, but it generally exists.’ 

Body image issues don’t just disappear as we age either. ‘Body image in people in later life is informed by a lifetime of experiences throughout childhood, young adulthood and middle age,’ explains the MHF report (2019a) and so elements that can play a role in body image throughout life ‘will all have played a role in shaping how people in later life understand and experience their bodies’.

While men tend to have a more positive body image than women, just 23% feel satisfied with their body image (19% for women) (MHF, 2019a).

At what cost?

As we have already seen, poor body image can be a serious issue, and can affect behaviour, health and quality of life. ‘Body image is associated with a desire to change physical appearance and it may also affect relationships and sexual wellbeing,’ states the MHF report (2019a). ‘Increased body dissatisfaction has been linked to increased likelihood of depressive symptoms, psychological distress, disordered eating and eating disorders.’

But it’s not necessarily straightforward causation: ‘Many people with eating disorders do suffer from body image problems, and body dissatisfaction can be one of the risk factors for an eating disorder, but they are separate issues,’ says Jamie Osborn from the eating disorders charity Beat.

In the same way, body dysmorphic disorder is a mental health problem closely linked to poor body image, but they are distinct from each other.

Sally agrees there is a strong correlation between a negative body image and poor emotional and mental health, but ‘not all young people who experience poor mental and emotional health will have issues with their body image’. When young people are unable to see themselves as others can see them, it can affect their perception of their own weight, body shape and skin colour. ‘This can lead to behaviours such as self-harm and substance misuse,’ she says. ‘It can exacerbate mental and emotional health conditions such as anxiety and depression and make suicidal thoughts more likely.’

Poor body image can affect the way people behave too. ‘It can potentially affect social factors, such as increasing isolation and reducing friendships,’ says Sally.

Viren adds: ‘In women, negative body image is associated with social exclusion – they are less likely to go out with friends, and they might make poor sexual health decisions, and have poor breast care, especially when they have a negative image regarding breast size,’ he says. ‘Use of anabolic steroids by men is another example.’

Antonis says: ‘People may try to hide certain parts of their body, bringing their shoulders forward instead of having a confident body posture. They may avoid wearing certain clothes.’


Recommendations for public health

  • Frontline health practitioners should receive training which includes information about how parents and carers can, from a very early age, positively influence their children’s feelings about their bodies through their behaviours and attitudes.  
  • Children and adults in distress should receive fast and empathetic support when they need it, regardless of where they live in the country.  
  • Public campaigns on nutrition and obesity should avoid the potential to create stigma and indirectly contribute to appearance-based bullying. They should focus on healthy eating and exercise for all members of the population, regardless of weight.  
  • A co-produced body image and media literacy toolkit (by the government with input from young people) should be a compulsory element in schools. This should include the development of a charter for achieving a healthy and positive body image. MHF, 2019a.

 

64% of 11- to 24-year-olds regularly worry about the way they look-YMCA, 2019

Your role

The likelihood that community practitioners (CPs) will come into contact with someone with a poor body image is extremely high, given its prevalence, says Viren. ‘Certain groups might need additional care – mums in the postnatal period, for example. HVs might need to have conversations about looking after the body by shifting the focus away from aesthetics onto body functionality.’

Saskia adds that early intervention is key with pregnant women to minimise the impact on both parent and baby. ‘If midwives and HVs could routinely talk with pregnant women about these issues, it would help to identify causes of distress and unease and legitimise asking for help if parents feel they want and need it,’ she adds.

‘For CPs, the most important thing is to be able to engage with people,’ says Antonis. ‘A question such as “Obviously your body is changing [pregnancy or adolescence, for example], how do you feel about that?” can be invaluable. It’s also important to normalise it – millions of people have gone through and are going through this.’

Poor posture is one of the signs you can look out for if you suspect someone has negative body image, says Antonis. ‘Some people might joke about their bodies, especially pregnant women and teenagers. Is this a self-defence mechanism? On the other hand, people may also never talk about their body image, which could be a sign.’

Viren has advice for when it comes to school children: ‘It’s important to look out for things like bullying, or “fat talk” – when young girls in particular talk to each other about their body fat – and working out what interventions might be needed. The other thing to think about is media literacy interventions in schools – to give children the tools to critically appraise what they are watching on TV – because that doesn’t come naturally.’

Sally believes that children are not provided with enough opportunity to develop good health and emotional literacy. ‘If we don’t teach children about positive healthy emotions, self-worth and relationships, then the adult that they become won’t have a healthy self-image.’

As a school nurse, Sally is often called upon to address established problems with young people. ‘Our intention is to help the development of emotional literacy and positive associations with the triggers, such as food and physical fitness,’ she says. ‘Ideally, we work with partners in the primary mental health team, healthy schools practitioners and education staff to provide a whole-school approach, promoting positive body image across the curriculum, throughout the school and beyond.

‘Collaborating with parents/carers is vital and we will meet individually with young people and families if it’s needed, either at home or in school.

‘Depending on the specific needs we can signpost them to resources, provide interactive programmes for home, prescribe recommended reading or refer to specialist services if intensive intervention is required to safeguard the young person.’

Staying positive

Of his work, Viren says: ‘We [AR University] have been developing interventions focused on things like spending time in nature, which is good for mental health in general and helps to promote a positive body image.’ Interestingly, he says, it’s been shown that activities such as life drawing can be particularly effective among teenage children. ‘It can help expose them to the idea that people come in all different shapes and sizes, and we can be happy irrespective of what we look like.’

But, as is often the case, resources are an issue for CPs. ‘We don’t have the opportunity for formal supervision regarding general emotional and mental health concerns,’ says Sally. ‘Some of the team, like myself, share an office with other SNs who will provide informal support and share resources. However, due to the rural locality [in Wales], some SNs are quite isolated and don’t have that instant support, although they can obviously phone the team leader and others.’

Increasing training and resources will, according to Saskia, give CPs the confidence and knowledge to discuss body image and its impact on wellbeing with their clients.

Addressing the issues

The government’s Online harms white paper sets out its plans for online safety legislative and non-legislative measures to make companies more responsible for users’ safety online, especially children and other vulnerable groups (HM Government, 2019).

As mentioned in the May issue of Community Practitioner (Fuller, 2019), the white paper (the consultation closed in July) proposes establishing a new duty of care towards users, to be overseen by an independent regulator. It also wants companies to be held to account for tackling behaviours including harmful body image representations (HM Government, 2019).

‘The white paper should address harms relating to the promotion of unhelpful or idealised body image online,’ says the MHF report. It also recommends: ‘Social media companies should sign the Be Real campaign’s body image pledge and investigate new ways of using their platforms to promote positive body image and to ensure that a diversity of body types is presented positively to users’ (MHF, 2019a).

The MHF is also calling on greater guidance and training for healthcare professionals (see Recommendations for public health, opposite page), along with effective regulation of how body image is portrayed, and has specific recommendations for the national governments (MHF, 2019a).

For example, the NHS, governments and public health bodies across the UK should actively consider the effects of the increased attention paid to people’s weight and size when developing messaging on obesity (MHF, 2019a).

As can often be the case when changes in attitude are required, collective responsibility is needed, says Viren. The MHF report (2019a) shares this conclusion, stating that instead of striving towards a single body ideal, we should all, in our different and complementary ways – individually, professionally and corporately – strive to shape a society that embraces and champions the diversity of the human race’.

For CPs, particularly SNs seeing body image issues in children, more time, resources and training are needed, says Sally. ‘We should be part of a multi-agency team delivering research-based culturally and gender sensitive interventions using differentiated methods and quality resources within an alternative curriculum.

Viren says: ‘There are difficult conversations to be had about the nature of beauty structures and societies that tell both women and men that they are not good enough in terms of their appearance. We need a broader societal shift in terms of how we relate to people and how we talk about appearance.’

Better body image, it seems, is on all of us.

Image credit| Alamy Images


Resources:

  • The MHF Body image report, including advice for children, adults and professionals bit.ly/MHF_body_image  
  • The Be Real campaign has a pledge with businesses, charities and experts, showing how everyone can bring about responsible change bit.ly/be_real  
  • Body Image is an international, peer-reviewed journal bit.ly/BI_journal  
  • Advice for children and young people struggling with a poor body image bit.ly/YM_BI_advice  
  • Guidance from the Personal, Social, Health and Economic Association for teaching children bit.ly/PSHE_body_image  
  • A toolkit by Beat and KCL’s Institute of Psychiatry for those working with young people bit.ly/beat_KCL_body_image 

References:

Fuller G. (2019) Time for a screen break? See: https://www.communitypractitioner.co.uk/node/1222 (accessed 8 August 2019).

HM Government. (2019). Online Harms White Paper. See: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793360/Online_Harms_White_Paper.pdf (accessed 14 August 2019).

Mental Health Foundation. (2019a) Body image: How we think and feel about our bodies. See: bit.ly/MHF_body_image (accessed 14 August 2019).

Mental Health Foundation. (2019b) Mental Health Foundation criticises new series of Love Island as it releases new statistics about body image and reality TV. See: https://www.mentalhealth.org.uk/news/mental-health-foundation-criticises-new-series-love-island-it-releases-new-statistics-about (accessed 14 August 2019).

TheyWorkForYou. (2019) Mental Health: weight and shape-related bullying question. See: www.theyworkforyou.com/lords/?id=2019-07-22b.529.2#g529.5 (accessed 14 August 2019).

YMCA. (2019) The Curate Escape: a report investigating young people’s body confidence and the content they post on social media. See: https://www.ymca.org.uk/wp-content/uploads/2019/05/The-Curate-Escape-v2.0.pdf (accessed 14 August 2019).


 

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