The impact of body image on physical and mental health

Response to the call for evidence by the Health and Social Care Committee

Executive summary

• The body image can be defined as the conscious awareness of one’s body. It is multifaceted and one driver of health-related behaviours. Body image distortions characterise eating and body dysmorphic disorders.
• Research suggests that there is a strong reciprocal relationship between body image and both physical and mental health.
• Body image concerns / body dissatisfaction are associated with low self-esteem and low mental health and are predictive of eating and body dysmorphic disorders. This is especially true for those who internalise certain body ideals.
• Body image concerns drive people to make behavioural choices that impact their physical health (i.e. dieting, exercising). This can help with body image concerns but can also lead to physical ill health and psychopathologies.
• Excessive focus on patient weight, the reinforcement of the thin / muscular body ideal and the stigmatisation of obesity have unintended negative consequences on the physical and mental health of patients, both directly and indirectly by reducing patient engagement with healthcare services.
• Minor cosmetic procedures may improve body image and protect against self-harming behaviours; however, surgical procedures rarely improve body image in those with body dysmorphic disorder.

• The following recommendations are made:
• To improve knowledge of unintended consequences of reinforcing certain body ideals and stigmatisation of those outside this ideal on mental and physical health, both within healthcare settings and wider society
• To improve framing of health-related messaging because health is not best characterised by weight or appearance
• Good health campaigns should be weight-neutral but promote positive self-care and cardiovascular fitness
• To improve the balance of research funding toward (i) evidence-based programmes that optimally improve mental and physical health and (ii) media literacy interventions and tackling appearance-related bullying especially in those at risk
• To enlist cosmetic surgery providers in screening of persons at risk of body dysmorphic disorder and referral to psychological services that may better serve them

Introduction

Dr Helge Gillmeister is a Reader at the Department of Psychology, University of Essex in Colchester, UK. Her research expertise concerns body and self-awareness, which she examines with behavioural and brain imaging methods in adults with and without clinical symptoms of depersonalisation, eating and body dysmorphic disorders. She has been involved in several projects related to physical activity, weight stigma, mental health and body image across the life span. She is a board member of the British Association for Cognitive Neuroscience (BACN) for whom she acts as a membership secretary; she is also a member of the Experimental Psychology Society (EPS), European Brain and Behaviour Society (EBBS), and the European Society for Cognitive and Affective Neuroscience (ESCAN). She is a UK Science Media Centre database expert on body image and a fellow of the Higher Education Academy. For more information please see

Website: https://www.essex.ac.uk/people/GILLM41709

ORCID: https://orcid.org/0000-0001-5999-5303

The written evidence below is submitted in Dr Gillmeister’s personal capacity as expert in the field of body image, mental health and physical activity, and is based on her own research, reading and broader understanding of the topic.

Responses

• What is the relationship between people’s perception of their body image and their physical and mental health?

1) My answer to this question is based on two premises, which are well founded within psychological and cognitive neuroscience research:

i) Two broad types of mental representations of the body can be distinguished: the body schema and the body image. The body schema is a largely unconscious representation of body coordinates in space and help us interact with the environment (e.g. to grasp a cup). The body image is the conscious awareness of our body, including aspects of perception (e.g. what you look like, how your body feels to you from the inside), cognition (what you think about your body) and emotion (e.g. how positively or negatively inclined you feel toward your body). This awareness has neural correlates in the brain (e.g. Groves & Gillmeister, 2016; Coleman & Gillmeister, 2022) and drives behaviours that people engage in (e.g. less eating, more exercising, concealing their body, excessive monitoring of their body). Some of these may be defined as health-related behaviours (eating and exercising) and may be engaged in to augment the body image. Multiple facets of body image (perceptual, cognitive, emotional, behavioural) (Grogan, 2016) are affected in mental illnesses characterised by body image disturbances, such as eating and body dysmorphic disorders. These disorders are mental illnesses with childhood origins.

ii) These mental representations of our body are (a) foundational for establishing our sense of self and (b) malleable throughout the course of life. In the earliest stages of life, infants learn a basic sense of themselves as the subject of their own experiences (“I am a body”). This basic form of physical self-awareness is an anchor to higher levels (e.g. sense of agency; understanding one’s own and other minds; social skills) and is continually re-established through ongoing sensory-motor experiences (e.g. looking at yourself in the mirror, feeling your body move). This malleability makes bodily self-awareness vulnerable to distortions, which may contribute to the disturbed body image seen in eating and body dysmorphic disorders (e.g. Eshkevari et al., 2012; Provenzano et al., 2020).

2) There is good evidence from psychological research for a strong reciprocal relationship between body image and both physical and mental health. It is also the case that some people are far more vulnerable to these relationships. These include people with eating and body dysmorphic disorders and those at risk of developing such disorders: persons who have internalised thin/muscular body ideals, person who diet and exercise excessively as well as adolescents and young adults who are more subjected to body image-related pressures and behaviours (e.g. selfies shared on social media; appearance-related bullying) and whose sense of self and identity is changing more dramatically.

(3) I will first consider the impact of body image on mental health and vice versa. Negative body image and body dissatisfaction are associated with low self-esteem and low mental health (increased depression, anxiety) (e.g. Adams et al., 2017). Low mental health and negative self-perceptions (“I’m not worthy”, “I’m ugly”) are particularly prominent in people with eating and body dysmorphic disorders and in those who have internalised the thin / muscular body ideals prevalent in society and who therefore judge themselves largely based on their appearance. Research has shown that negative self-image and negative emotionality are risk factors for dieting and other unhealthy weight control behaviours and can prospectively predict eating disorder psychopathologies (Keel & Forney, 2013; Stice et al., 2011). Body image concerns are higher when one’s self-esteem is contingent on one’s appearance and on the approval of others (e.g., Overstreet & Quinn, 2012). My own research (Colclough & Gillmeister, in preparation) has found that appearance-contingent self-esteem is the strongest predictor of body image concerns in 18-25 year olds and may partly explain the detrimental effects of social media use on body image (e.g., Saiphoo & Vahedi, 2019). Persons whose self-esteem is relatively less contingent on appearance and others’ approval and more contingent on other dimensions of life (e.g. family, religion/ethics, achievements in other domains) may be more resilient to these effects.

(4) Body image concerns also drive people to make behavioural choices that impact their physical health (i.e. dieting, exercising). In the case of physical activity, people’s body image also benefits as a result (e.g. Reel et al., 2007), but the relationship is less clear for dieting. Body image concerns can also cause physical ill health by causing unhealthy weight control behaviours (Keel & Forney, 2013; Stice et al., 2011). One example is Muscle Dysmorphia, a body image disorder related to excessive (resistance) exercising and dieting (e.g. Cooper et al., 2020). Research in my lab (Mitchell et al., under review) has found that muscle dysmorphia symptoms increased mood disturbance due to not being able to exercise as normal during the Covid-19 lockdown. They also increased social media use and perceived pressure to “transform” one’s body through exercise while in lockdown. Similar to being prevented from going to the gym, physical limitations like ill health or physical disabilities can impact body image by reducing people’s capacity to engage in healthy behaviours (i.e. eating well, exercising).

• How can the Department of Health and Social Care and its arms’ length bodies work collaboratively across Government to tackle the health impacts of a negative perception of body image?

(1) I would urge Government to look at this issue rather broadly. This involves looking into issues related to

(i)                 Bullying, internet / social media access and mobile phone use by increasingly younger age groups. Preliminary research in my lab has found that the upset caused by appearance-related teasing in 16-25 year olds predicts greater internalisation of certain body ideals and more body dissatisfaction, which are known risk factors for body image-related disorders. Media literacy interventions have shown promise at reducing the risk for developing body image-related disorders like eating disorders (e.g. McLean et al., 2017). I would urge more attention to and research funding in these areas.

(ii)               How certain foods are priced to encourage healthier eating choices

(iii)             Investing in recreational infrastructure to promote physical and mental health through improvements in cardiovascular fitness, positive self-care and social contact.

(iv)             Changing away from an appearance-focused framework to a competence-focused framework (that is, to look at fitness over fatness) when considering health impacts.

(2) I do not have the expertise to name specific Government departments for each of these points but I would advocate appropriate Health and Social Care collaboration with those concerned in each area. 

• To what extent does people’s perception of their body image, and stigma around particular body images, hinder them from accessing NHS services and what could be done to address this?

(1) From my perspective, this question may concern both access to eating disorder services for persons with normal weight and access to services in general for persons who are overweight. In both cases, body weight or BMI are at the forefront of decisions about access to services. I have heard of UK cases where persons have been turned away accessing services that help with eating disorder symptoms because they are a normal weight (not “thin enough”). I am also aware of UK cases where persons have been told to lose weight before surgical procedures (to treat other problems) can be offered by the NHS.

(2) The literature overwhelmingly shows that overweight and obese people are subject to prejudice from the general public as well as from healthcare providers (Phelan et al., 2015; Rathbone et al., 2020). There are several reasons for this, but stigmatisation generally takes the form of blaming the individual for their weight. This worsens mental health (Phelan et al., 2015; Puhl & Heuer, 2009), reduces motivation to exercise (Vartanian & Novak, 2011) and, most importantly, does not achieve the intended outcome of reducing obesity but is instead predictive of weight gain (Haynes et al., 2018). Stigmatised persons (especially those who feel more vulnerable because they may suffer from mental health conditions including eating disorders) are reluctant to access services where there is a chance that their weight becomes the primary focus, they are made to feel worse about themselves, or turned down from services as a result of their weight status (e.g. Phelan et al., 2015).

• What training is needed about body image for frontline public health staff?

(1) Frontline staff could learn about the multiple reasons that cause people to be overweight (including choice, genetic factors, medication, poor health to name just a few).

(2) Frontline staff could learn about the complex relationship between stigma, mental health and obesity, especially within healthcare settings. As stated above, the approach of focusing on weight in healthcare settings can reduce mental health, increase obesity and reduce engagement with critical care for other illnesses in overweight persons. Focus on weight (and the weighing process) in diagnosis or referral can also prevent normal-weight persons from accessing the help they need for disordered eating. Focus should instead be on critical behaviours (excessive dieting, binge-eating, purging, excessive exercising, body surveillance or avoidance) and cognitive-emotional aspects of body image (body dissatisfaction, shame and self-worth contingent on appearance).

(3) Frontline staff could learn that what matters more for health (morbidity and mortality) is cardiovascular fitness rather than weight or other aspect of people’s appearance. Focusing on improving fitness rather than reducing obesity will better benefit physical (e.g. Davidson et al., 2019) and mental health (e.g. White et al., 2017). For example, exercise is likely to improve self-esteem contingent on physical competence (Biddle, 2016). Care should be taken to consider the type and intensity of physical activity that is promoted to avoid the development of exercise dependence, excessive exercising and muscle dysmorphia.

(4) It is critical that any learning occurs within a framework that is more weight-neutral than is currently the case. Interventions to reduce anti-fat attitudes in healthcare students have been largely unsuccessful and may actually worsen attitudes (Daníelsdóttir et al., 2010; Meadows et al., 2017). One reason for this may be that interventions occur within a framework that maintains that fatness is inherently problematic.

• How can the Government strike the right balance between tackling obesity in order to help prevent serious diseases, and reducing weight-based stigma that leads to mental and physical health problems?

(1) It is important to realise that physical and mental health are better served by assessing cardiovascular fitness and promoting healthy food intake and physical activity levels than by targeting weight, BMI and the concept of obesity, which focus unnecessarily on outward appearance rather than on more precise measures of health.

(2) It is well established that physical activity in particular confers protective and therapeutic benefits for both physical health problems (hypertension, heart disease, diabetes, cancers) and mental health problems (depression, anxiety, stress, as well as negative body image). It therefore stands to reason that physical activity to improve fitness should be at the core of preventing serious disease of any kind.

(3) Approaches that would strike the right balance would be weight-neutral and encouraging even of small changes and of moderate rather than intense physical activity (see Biddle, 2016). They would need to be mindful of the fact that excessive exercising, as well as dieting trends like veganism, may harbour disproportionate numbers of people at risk of developing muscle dysmorphia and disordered eating (Cooper et al., 2020; Iguacel et al., 2021; Mitchell et al., under review; Sergentanis et al., 2021). As stated previously, dieting and other unhealthy weight-control behaviours can predict psychopathologies like eating disorders.

• How best can public health campaigns tackle negative perceptions of body image?

(1) Anti-obesity campaigns have not worked well and may have even increased obesity. Weight stigma and the internalisation of the thin / muscular ideal, which are facilitated by anti-obesity campaigns, have evidently had multiple negative effects on health and wellbeing.

(2) Health campaigns may therefore consider changing direction. One approach should to move away from the focus on appearance and weight. Campaigns could directly target people’s understanding that feeling bad about one’s body (negative body image) and not looking after one’s body (low physical health and fitness) are at the root of mental and physical ill health. A good health campaign would be weight-neutral but promote positive self-care and cardiovascular fitness. In doing so, it could also try to encourage sources of self-esteem that are contingent on physical or academic competencies or on family, other social support networks and citizenship (that is, not contingent on appearance).

• To what extent are people who have a negative body image drawn to cosmetic procedures, and how do cosmetic procedures affect their body image?

(1) People are drawn to such procedures because they are increasingly acceptable, accessible and safe. An improvement in body image is desired from them in the same way as more harmless procedures like hairdressing. It is important to distinguish temporary procedures (e.g. lip fillers), minor procedures (e.g. piercings) and more extreme surgical procedures (e.g. “nose jobs”, breast augmentation, liposuction).

(2) There are some suggestions that minor procedures may be protective of body image (Claes et al., 2005; Coleman & Gillmeister, 2022; Kluger et al., 2019). People who have such procedures are no worse than those without in terms of their body image (Coleman & Gillmeister, 2022), self-esteem (Hong & Lee, 2017) and mental health history (Giles-Gorniak et al., 2015). Claes et al. (2005) even found that female eating disordered patients with piercings report less severe eating disorder symptoms than those without piercings. Body image-related reasons (desire for body ornamentation or embellishment, increased physical or sexual attractiveness) are listed among the reported motivations for piercings in general, and dominate motivations in women in particular (e.g., Kluger et al., 2019; Coleman & Gillmeister, 2022). Navel piercings, for example, which embellish an area of the body women often feel negatively about (e.g. Jansen et al., 2005), were found to improve body image in women’s retrospective reports (Coleman & Gillmeister, 2022). Facial fillers were also found to temporarily enhance body image (Sobanko et al., 2018). It can be argued that such procedures not just enhance body image but are expressions of body care that confer protection against self-harming behaviours in those at risk of such behaviours (Claes et al., 2005; Möller et al., 2018; Stirn & Hinz, 2008).

(3) The desire for dermatological and more extreme surgical procedures is a well-known dimension of disorders characterised by body image disturbances (eating disorders and body dysmorphic disorders) (Littleton et al., 2005; Mancuso et al., 2010). The majority of body dysmorphic patients desire procedures (71-76%) and most also receive them (Crerand et al., 2005; Phillips et al., 2001). While patients expect otherwise, evidence shows that procedures rarely improve body image, however, probably because the underlying insecurities are not addressed. Instead, patients merely reorient to other perceived bodily deficiencies with no change in dysmorphic concerns (Crerand et al., 2005; Phillips et al., 2001).

• Is there sufficient support and advice for people who are considering cosmetic procedures?

(1) The literature has called for body dysmorphia screening when people apply for surgical procedures and to refer those at risk to more appropriate psychological or psychiatric services (e.g., Crerand et al., 2005; Mancuso et al., 2010). Providers of cosmetic surgery procedures are ideally placed to provide such information and facilitate referrals for people seeking cosmetic procedures who might better benefit from psychological treatment for body dysmorphia instead.

• What form should a regulatory regime for non-surgical cosmetic procedures take in order to improve patient safety?

I am not responding to this point.

References

Adams, K. E., Tyler, J. M., Calogero, R., & Lee, J. (2017). Exploring the relationship between appearance-contingent self-worth and self-esteem: The roles of self-objectification and appearance anxiety. Body image, 23, 176-182.

Biddle, S. (2016). Physical activity and mental health: evidence is growing. World Psychiatry, 15(2), 176.

Claes, L., Vandereycken, W., & Vertommen, H. (2005). Self‐care versus self‐harm: Piercing, tattooing, and self‐injuring in eating disorders. European Eating Disorders Review: The Professional Journal of the Eating Disorders Association, 13(1), 11-18.

Colclough, I. & Gillmeister, H. (in preparation). Contributions of Social Media use and Contingent Self-Worth to Body Surveillance, Body Shame and Disordered Eating. Preprint available on request.

Coleman, C., & Gillmeister, H. (under review). Body image and self-perception in women with navel piercings. PLoS ONE. Preprint available https://osf.io/atuz6/?view_only=25e583488631414c815710148a9cde67

Cooper, M., Eddy, K. T., Thomas, J. J., Franko, D. L., Carron‐Arthur, B., Keshishian, A. C., & Griffiths, K. M. (2020). Muscle dysmorphia: A systematic and meta‐analytic review of the literature to assess diagnostic validity. International Journal of Eating Disorders, 53(10), 1583-1604.

Crerand, C. E., Phillips, K. A., Menard, W., & Fay, C. (2005). Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics, 46(6), 549-555.

Daníelsdóttir, S., O'Brien, K. S., & Ciao, A. (2010). Anti-fat prejudice reduction: a review of published studies. Obesity facts, 3(1), 47-58.

Davidson, L. E., Hunt, S. C., & Adams, T. D. (2019). Fitness versus adiposity in cardiovascular disease risk. European journal of clinical nutrition, 73(2), 225-230.

Eshkevari, E., Rieger, E., Longo, M. R., Haggard, P., & Treasure, J. (2012). Increased plasticity of the bodily self in eating disorders. Psychological medicine, 42(4), 819-828.

Giles-Gorniak, A. N., Vandehey, M. A., & Stiles, B. L. (2016). Understanding differences in mental health history and behavioral choices in a community sample of individuals with and without body modifications. Deviant Behavior, 37(8), 852-860. https://doi.org/10.1080/01639625.2015.1060798

Grogan, S. (2016). Body image: Understanding body dissatisfaction in men, women and children, 3rd ed. Routledge, London. https://doi.org/10.4324/9781315681528

Groves, K., Kennett, S., & Gillmeister, H. (2017). Evidence for ERP biomarkers of eating disorder symptoms in women. Biological Psychology, 123, 205-219.

Haynes, A., Kersbergen, I., Sutin, A., Daly, M., & Robinson, E. (2018). A systematic review of the relationship between weight status perceptions and weight loss attempts, strategies, behaviours and outcomes. Obesity Reviews, 19(3), 347-363.

Iguacel, I., Huybrechts, I., Moreno, L. A., & Michels, N. (2021). Vegetarianism and veganism compared with mental health and cognitive outcomes: a systematic review and meta-analysis. Nutrition reviews, 79(4), 361-381.

Jansen, A., Nederkoorn, C., & Mulkens, S. (2005). Selective visual attention for ugly and beautiful body parts in eating disorders. Behaviour research and therapy, 43(2), 183-196.

Keel, P. K., & Forney, K. J. (2013). Psychosocial risk factors for eating disorders. International Journal of Eating Disorders, 46(5), 433-439.

Kluger, N., Misery, L., Seité, S., & Taieb, C. (2019). Body Piercing: A National Survey in France. Dermatology, 235(1), 71-78.

Littleton, H. L., Axsom, D., & Pury, C. L. (2005). Development of the body image concern inventory. Behaviour Research and therapy, 43(2), 229-241.

Mancuso, S. G., Knoesen, N. P., & Castle, D. J. (2010). The Dysmorphic Concern Questionnaire: A screening measure for body dysmorphic disorder. Australian & New Zealand Journal of Psychiatry, 44(6), 535-542.

McLean, S. A., Wertheim, E. H., Masters, J., & Paxton, S. J. (2017). A pilot evaluation of a social media literacy intervention to reduce risk factors for eating disorders. International Journal of Eating Disorders, 50(7), 847-851.

Meadows, A., Higgs, S., Burke, S. E., Dovidio, J. F., van Ryn, M., & Phelan, S. M. (2017). Social dominance orientation, dispositional empathy, and need for cognitive closure moderate the impact of empathy-skills training, but not patient contact, on medical students' negative attitudes toward higher-weight patients. Frontiers in Psychology, 8, 504.

Mitchell, J., Reed, K. E., & Gillmeister, H. (under review) Restrictions during the COVID-19 pandemic disproportionately affected physical activity levels in gym members with access to less home equipment. PLOS ONE. Preprint available on request.

Möller, J., Peregrinova, L., Badde, S., Oddo, S., Unterhorst, K., & Stirn, A. (2018). Childhood abuse and neglect in intimately pierced individuals. International journal of culture and mental health, 11(3), 237-247.

Overstreet, N., Quinn, D. (2012). Contingencies of self-worth and appearance concerns: do domains of self-worth matter? Psychology of Women Quarterly, 36, 314-325.

Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. obesity reviews, 16(4), 319-326.

Provenzano, L., Porciello, G., Ciccarone, S., Lenggenhager, B., Tieri, G., Marucci, M., ... & Bufalari, I. (2020). Characterizing body image distortion and bodily self-plasticity in anorexia nervosa via visuo-tactile stimulation in virtual reality. Journal of clinical medicine, 9(1), 98.

Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: a review and update. Obesity, 17(5), 941.

Rathbone, J. A., Cruwys, T., Jetten, J., & Barlow, F. K. (2020). When stigma is the norm: How weight and social norms influence the healthcare we receive. Journal of Applied Social Psychology.

Reel, J. J., Greenleaf, C., Baker, W. K., Aragon, S., Bishop, D., Cachaper, C., ... & Hattie, J. (2007). Relations of body concerns and exercise behavior: a meta-analysis. Psychological reports, 101(3), 927-942.

Saiphoo. A., Vahedi, Z. (2019). A meta-analytic review of the relationship between social media use and body image disturbance. Computers in Human Behaviour, 101, 259-275.

Sergentanis, T. N., Chelmi, M. E., Liampas, A., Yfanti, C. M., Panagouli, E., Vlachopapadopoulou, E., ... & Tsitsika, A. (2021). Vegetarian Diets and Eating Disorders in Adolescents and Young Adults: A Systematic Review. Children, 8(1), 12.

Stice, E., Marti, C. N., & Durant, S. (2011). Risk factors for onset of eating disorders: Evidence of multiple risk pathways from an 8-year prospective study. Behaviour research and therapy, 49(10), 622-627.

Stirn, A., & Hinz, A. (2008). Tattoos, body piercings, and self-injury: Is there a connection? Investigations on a core group of participants practicing body modification. Psychotherapy Research, 18(3), 326-333.

Sobanko, J. F., Dai, J., Gelfand, J. M., Sarwer, D. B., & Percec, I. (2018). Prospective cohort study investigating changes in body image, quality of life, and self-esteem following minimally invasive cosmetic procedures. Dermatologic Surgery, 44(8), 1121-1128.

Vartanian, L. R., & Novak, S. A. (2011). Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise. Obesity, 19(4), 757-762.

White, R. L., Babic, M. J., Parker, P. D., Lubans, D. R., Astell-Burt, T., & Lonsdale, C. (2017). Domain-specific physical activity and mental health: a meta-analysis. American journal of preventive medicine, 52(5), 653-666.