Written evidence submitted by the Centre for Appearance Research (MISS0045)

The Centre for Appearance Research

The Centre for Appearance Research (CAR) is the world’s largest research group focusing on the role of appearance and body image in people’s lives. Based at the University of the West of England Bristol, CAR is a centre of excellence for psychological and interdisciplinary, patient-centred research in appearance, visible difference, body image and related studies. CAR conducts innovative research that creates and promotes knowledge and understanding about the psychosocial and cultural aspects of appearance.

To find out more about CAR:

• Website: http://www.uwe.ac.uk/car
• Podcast: http://soundcloud.com/appearance-matters

Connect with CAR on social media:

• Facebook: http://www.facebook.com/AppearanceResearch
• Twitter: http://twitter.com/CAR_UWE
• Instagram: https://www.instagram.com/car_uwe/

Contributors

Nadia Craddock

Nadia Craddock is a Research Fellow at the Centre for Appearance Research. Through her work and broader commitments, Nadia aims to empower young people to feel body confident using evidence-based methods and strives towards creating broader societal change through collaboration with the corporate sector. Nadia is currently leading the evaluation of a school-based body image curriculum in partnership with the Dove Self Esteem Project and UNICEF in Indonesia, and has recently finished her PhD exploring how big business can foster positive body image through the lens of corporate social responsibility. In addition, Nadia has a keen interest in eating disorder prevention, weight stigma, and colourism. Nadia is an engaging public speaker and is regularly invited to speak at events and panels on topics related to body image, diet culture, intersectional feminism, representation, and mental health. She also co-hosts and produces the centre’s podcast ‘Appearance Matters’ with Jade Parnell and also co-hosts the Body Protest Podcast with Honey Ross. She serves on the Diversity, Equity, and Inclusion Task Force for the Academy for Eating Disorders and is a School Governor at a local secondary school.

Phillippa Diedrichs

Professor Phillippa Diedrichs creates and evaluates evidence-based strategies to improve body image in community, education, corporate, and policy settings, and investigates psychological, social and cultural influences on body image. The evidence-based programmes that she has co-created and evaluated have been delivered in 136 countries to 20 million young people. Her research is published in over 60 peer-reviewed papers and book chapters, and has featured in the New York Times, BBC, Time.  She has advised and worked on projects alongside  Unilever’s Dove Self-Esteem Project, UNICEF, YMCA, the NHS, the World Association for Girl Guides and Girl Scouts, Cartoon Network, Getty Images, and Girl Effect. Phillippa has served as an advisor to the British Government Equalities Office, Transport for London, and parliamentary select committees. She is a Fellow of the Academy for Eating Disorders and serves on the Editorial Board for Body Image: An International Journal of Research. 

Amy Slater

Dr Amy Slater is an Associate Professor and Co-Director of the Centre for Appearance Research. Her research interest lies broadly in the area of body image, specifically body image in adolescents and children. She has particular expertise in the role of social media in the development of body image concerns, and is currently working with colleagues in Australia and the United States on the development and evaluation of a social media literacy program for adolescent girls and boys.  She has previously worked for the Australian Commonwealth Scientific and Industrial Research Organisation, and has advised both the Australian and UK Governments.  As a registered psychologist Amy has worked with children and families with speech and language difficulties, developmental delay, attachment and relationship concerns, autism, post-traumatic stress disorder, sleep disorders and chronic illnesses such as diabetes and cancer. 

Caterina Gentili

Caterina Gentili is a PhD candidate at the Centre for Appearance Research. Her main research interests include body image and gender identities when adjusting to diagnosis and treatment of cancer, and the study of health inequalities.  Her current project focuses the impact of androgen deprivation therapy on body image, masculine identity, and exercise behaviour in prostate cancer patients. Caterina has worked internationally in Italy, Netherlands, and UK. Her previous research focused on the development and testing of positive body image interventions and the study of eating disorders and unhealthy eating behaviours. Caterina also worked in a variety of psychological health settings, such as supporting patients affected by eating disorders and survivors of sexual violence.

Maia Thornton

Maia Thornton is a PhD candidate at the Centre for Appearance Research. Her main research interests include body image and psychosocial adjustment in those affected by a visible difference. Her PhD is specifically focussed on the development of support for parents and carers of children and young people with appearance affecting conditions or injuries. Her previous work has explored the experiences of body image in those who have received treatment for breast cancer. Maia has also worked in a number of psychological health settings including working with parents and children with disorders of sex difference, outpatient eating disorders services, adolescent and young people’s mental health and adult mental health.

Helena Lewis Smith

Dr Helena Lewis-Smith is a Senior Research Fellow at the Centre for Appearance Research and is known for exploring body image and developing interventions in education, community and clinical settings with children and adults. She is passionate about translating research which promotes positive body image into real-life social impact at a local, national, and global scale. Helena currently leads a team of researchers working on large-scale research projects in India, which include developing and evaluating body image interventions for adolescents in urban and rural settings. In addition, she works on several projects developing body image programmes for cancer patients and survivors. Helena is also interested in investigating risk factors for, and consequences of, body image dissatisfaction, using prospective cohort data. Helena has worked and consulted with a wide range of businesses, health organisations, and charitable trusts, such as UNICEF, Unilever, Cartoon Network, NHS England, Macmillan, Breast Cancer Care, and the British Heart Foundation.

Kirsty Garbett

Kirsty Garbett is a Research Fellow at CAR with 7 years’ experience in the design and evaluation of body image interventions for young people, particularly but not exclusively in school-based settings. She has conducted body image research with adolescents and adults in the United Kingdom, Ghana, India and Indonesia. Kirsty is due to complete her DPhil qualification at UWE Bristol in October 2021; this research is focused on maximising implementation and dissemination of body image interventions for adolescents.

Risk Factors for Poor Body Image

Body image refers to how people think and feel about the way their body looks and functions, and in turn, how they treat their bodies. Body image is shaped by psychological (e.g., negative mood, perfectionism, tendency to make comparisons to others) and societal factors (e.g., appearance ideals promoted by media and advertising, appearance-based stereotypes, and systems of oppression like racism, colourism, ableism). Poor body image is characterised by body dissatisfaction (not liking one’s appearance), excessive preoccupation with appearance, overvaluation (placing disproportionate value on one’s appearance in self evaluations of worth), and attempts to change one’s appearance due to body dissatisfaction.

Q. Who is particularly at risk of poor body image?

Scientific research has identified specific groups of people who may be at greater risk for poor body image:

Age

• Children as young as five report body dissatisfaction, however, early adolescence has consistently been identified as a particularly vulnerable period for developing and struggling with poor body image due to the physical, cognitive, and social changes characteristic of this life stage (e.g., Lacroix, Atkinson, Garbett, Diedrichs, in press).
• Poor body image tends to remain stable from adolescence through to midlife (Wang et al., 2019). However, the nature of concerns may change. For example, women have reported feeling more dissatisfied with their body shape, skin, and face, compared with when they were younger (Gagne et al., 2012).
• Older adults can also experience poor body image, yet, concerns increasingly relate to diminishing physical ability and body functionality, as opposed to physical appearance (e.g., Jankowski, Diedrichs, Williamson, Christopher, & Harcourt, 2016; Liechty, 2012).

Gender

• While men and boys experience poor body image, women and girls tend to be disproportionately affected (Bucchianeri et al., 2013; Lacroix, Atkinson, Garbett, Diedrichs, in press; Wang et al, 2019). This is often attributed to disproportionate pressure on women and girls to confirm to unrealistic societal appearance ideals, as well as more frequent experiences of sexual objectification whereby women and girls are treated and / or portrayed as passive objects rather than individuals with agency.
• Transgender individuals (i.e., people who identify across a broad spectrum of gender variance, including those who hold a non-binary identity such as genderqueer or gender fluid, as well as trans men and transwomen) are more likely to experience poorer body image than cisgender individuals (e.g., Goldhammer et al, 2019; Jones, Haycraft, Murjan & Arcelus, 2016; McClain & Peebles, 2016; Tabaac, Perrin & Benotsch, 2018).
• Higher rates of poor body image among those identify outside of the gender binary (man/woman) are thought to be a consequence of minority stress (i.e., chronic experiences of stigma, discrimination, and victimization), gender dysphoria, and broader societal appearance pressure based on binary gendered appearance ideals (Gordon et al., 2016).

Sexual Orientation

• Individuals whose sexual orientation fits within the umbrella term ‘sexual minority’ (i.e., to include those who identify as gay, lesbian, bisexual, pansexual etc.) tend to experience higher levels of body image concerns compared to their heterosexual counterparts (e.g., Austin et al., 2013; Calzo, Blashill, Brwon, & Argenal, 2017; Goldhammer et al., 2019; McClain & Peebles, 2016).
• The Mental Health Foundation 2019 survey on body image found 40% of the adults who identified as gay, lesbian, bisexual, or other said they felt shame because of their body image, compared to 18% of the heterosexual adults.
• Higher rates of poor body image among sexual minority groups may be a consequence of minority stress as well as specific community group appearance ideals.

Ethnicity

• There is evidence of poor body image being present across ethnic groups. The evidence is conflicted as to whether particular ethnic groups are at heightened risk of poor body image.
• Some studies have found that ethnic minority groups (e.g., Asian, Black, Hispanic) tend to report poorer body image than white individuals, however, this research has predominantly been conducted in the United States (e.g., Bucchianeri et al., 2013). Conversely, other studies have reported minimal differences between ethnic groups (e.g., Cheng, Perko, Fuller-Marashi, Gau & Stice, 2019; Ricciardelli, McCabe, Williams & Thompson, 2007; Schaefer et al., 2018).
• Importantly, some ethnic groups may face additional appearance pressures due to racialised appearance standards, which can lead to dissatisfaction with skin colour, hair, and facial features (Craddock, 2016). For example, research indicates poor body image among Black women is often associated with hair and skin shade (Awad et al., 2015).

Disability

• Although much of the research in the field of body image has been conducted in able-bodied individuals, there is a growing number of studies exploring body image among those with visible physical disabilities.
• Physical disabilities can be perceived as negative or associated with stigma or discrimination (Kowalski & Peipert, 2019). This can lead to the development of negative self-concept and poor body image among those with a disability (Shpigelman & Hagani, 2019).
• Women with physical disabilities have defined their body image as having both negative and positive elements, which can be fluid and change in different contexts based on their health and disability symptoms (Bailey et al., 2015; Thomas et al., 2019).
• Women with physical disabilities have also emphasised the importance of body functionality (what the body can and cannot do, encompassing physical abilities and a range of bodily processes), as a key aspect of their experience of body image (Thomas et al., 2019).

Visible Difference

• A range of conditions, illnesses and injuries can result in an appearance that diverges from the “norm” (Rumsey & Harcourt, 2012), often referred to as a visible difference (or ‘disfigurement’). Visible differences can result from a congenital condition (e.g. cleft lip/palate, neurofibromatosis, congenital limb difference) or can be acquired later in life as a result of illness or injury (e.g. alopecia, scarring from a burn injury). Skin conditions such as vitiligo or prominent birth marks are also often categorised as a visible difference.
• Research on visible difference and body image is conflicted as some research has found that both adults (Rumsey & Harcourt, 2012) and young people (e.g., Jenkinson et al., 2015; Hamlet, Williamson, White, & Diedrichs, manuscript in preparation) with visible differences can struggle with poor body image more than those without a visible difference. This is more pronounced among women and girls. However, other studies have shown that some people can cope well and are not adversely affected by their visibly different appearance (Williamson et al., 2010). As a result, experts recommend that it is important to remember that we cannot judge a person’s body image, including how satisfied or dissatisfied they are with their appearance, by how they look (Rumsey & Harcourt, 2007, 2012).
• Cancer patients are particularly vulnerable to experiencing poor body image due to changes in appearance following treatment or surgery (e.g., hair loss, scarring, weight fluctuation, changes to the texture and appearance of skin). This is often most pronounced in the period immediately following treatment (e.g., Fingeret, Teo & Epner, 2014).

Higher weight

• Children, adolescents and adults who are of higher weight are at greater risk of experiencing poor body image than their lower weight peers (e.g., Algars et al., 2009; Harriger & Thompson, 2012; Hilbert, de Zwaan, & Braehler, 2012). This relationship is typically more pronounced among women than men and is understood to be the result of anti-fat weight bias, which is prevalent in society (e.g., Pearl & Puhl, 2016; Diedrichs & Puhl, 2016).

Individual Differences

• Research also indicates that individual differences affect how people think and feel about their appearance, with some people being more vulnerable than others to external appearance-related pressures irrespective of their social identities.
• People who are more likely to ‘buy-in’ or ‘subscribe’ to societal appearance ideals and engage in processes of constant upwards appearance comparisons within each group are more likely to struggle with poor body image (e.g., Barcaccia et al., 2018; Klimek, Murray, Brown, Gonzales Iv, & Blashill, 2018).
• People who strongly identify with traditional gender roles of femininity and masculinity are more likely to have poor body image (e.g., Smolak & Stein, 2010; Griffiths, Murray & Touyz, 2015).
• Some evidence indicates that personality traits might help to explain individual differences in body image. Specifically, higher levels of neuroticism and lower levels of extraversion is associated with poor body image (e.g., Allen & Walter, 2016; Roberts & Good, 2010; Swami et al., 2013).

[also see section on ‘What Contributes to Poor Body Image’]

Q. What is the impact for those with multiple protected characteristics including race, disability, sex, and sexuality?

Individuals embodying multiple protected characteristics (e.g., race, disability, gender, sexuality etc.), are exposed to heighted risk of developing body image concerns, which are likely to be specific to the combination of the person’s intersection of characteristics and identities (Tiggemann, 2015). Intersectionality is a term coined by critical race theorist and legal scholar Kimberlé Crenshaw (1989, 1991) to describe the distinctive issues that arise when a person belongs to multiple social categories that bring disadvantage in society (Carbado et al., 2013). According to intersectional theory, multiple devalued social categories interact to result in cumulative disadvantages that outweigh the disadvantage of a single social category alone. An intersectionality approach is necessary to understand and provide support for those living with multiple dimensions of disadvantage. Below are some examples of why intersectionality is relevant to body image.

• Gender x Race on Body Image: Black women’s body image issues must be considered on the base of the intersections of both gender and racial oppression. Black women are often hypersexualised in line with the ‘Jezebel’ stereotype (Lewis, Mendenhall, Harwood, & Huntt, 2016). In turn, research indicates that the experience of sexually objectifying gendered racial microaggressions is detrimental to the body image of Black women (e.g., Capodilupo & Kim, 2014; Dunn et al., 2019; Watson et al., 2019).
• Sexual Orientation x Race on Body Image: Studies find that belonging to a racial minority and sexual minority group (i.e., a double minority status) might place heighten the risk of poor body image (e.g., Austin et al., 2013; Brennan et al., 2013).
• Gender x Weight on Body Image: Weight stigma (see below) disproportionately affects women compared to men (Diedrichs & Puhl, 2016). For example, women are at greater risk of experiencing weight stigma at a lower body mass index (BMI) threshold compared to men (Puhl, Andreyeva & Brownell, 2008). In turn, weight stigma is a risk factor for poor body image (Diedrichs & Puhl, 2016).
• Skin Shade x Gender on Body Image: Colourism (see below) disproportionately affects women compared to men in relation to global appearance ideals, placing greater pressure on women to have fair skin than men (Jha, 2015).

Q. What contributes to poor body image?

Research indicates that biological, psychological, and sociocultural factors contribute to negative body image.

Biological factors

• For adolescent boys and girls, lower or higher than average peer BMI is associated with later body dissatisfaction (e.g., Amaral & Ferreira, 2017; Calzo et al., 2013; Evans et al., 2017; Holsen, Jones, & Birkeland, 2012; Lewis-Smith, Bray, Salmon, & Slater, under review). For adults, higher BMI is associated with poor body image and this relationship is more pronounced among women (e.g., Algars et al., 2009). It is likely that pervasive weight bias in society (prejudice and discrimination on the basis of weight and body size) is one of the core reasons underlying the relationship between BMI and body image.
• The psychological impact of timing of puberty on body image differs by gender. While early maturing girls are more likely to experience body dissatisfaction and disordered eating (Lewis-Smith et al., under review; Slater & Tiggemann, 2012), late pubertal development has been found to predict body dissatisfaction and disordered eating among boys (de Guzman & Nishina, 2014).
• Research concerning the impact of pregnancy and postpartum on body image is contradictory. While findings indicate women can experience poor body image throughout pregnancy, with this improving in postpartum (Roomruangwong, Kanchanatawan, Sirivichayakul, & Maes, 2017), research has also suggested the opposite trend (Jenkin & Tiggemann, 1997). Despite these inconsistencies, body image during this time is associated with prior or current depression and anxiety (Roomruangwong et al., 2017).
• Menopause has been found to impact body image, whereby post-menopausal women experience greater dissatisfaction than pre-menopausal women (Deeks & McCabe, 2001); with women who have more negative attitudes towards menopause experiencing poorer body image (Erbil, 2018).

Psychological factors

• Low self-esteem is an established prospective risk factor for poor body image, particularly for girls (Murray, Rieger, & Byrne, 2013; Quick, Eisenberg, Bucchianeri, & Neumark-Sztainer, 2013; Wojtowicz & Von Ranson, 2012).

• Low mood or depressive symptoms also has been found to be a risk factor for later body dissatisfaction in adolescence and early adulthood (e.g., Sharpe et al., 2018).
• Perfectionism has been associated with increased risk for body image concerns among children and adults (e.g., Grammas & Schwartz, 2009; Nichols et al., 2018).
• People who are more likely to ‘buy-in’ or ‘subscribe’ to societal appearance ideals and engage in processes of constant upwards appearance comparisons within each group are more likely to struggle with poor body image (e.g., Barcaccia et al., 2018; Klimek, Murray, Brown, Gonzales Iv, & Blashill, 2018).
• Individuals who have a tendeny to compare their appearance to the appearance of others are also more likely to be at greater risk of body image concerns and social appearance pressures (e.g., Fardouly, Pinkus, & Vartanian, 2017).

Sociocultural factors

• Exposure to media that depicts unrealistic and narrowly defined appearance ideals is associated with significant and immediate increases in body dissatisfaction (Barlett, Vowels, & Saucier, 2008; Grabe, Ward & Hyde, 2008). See responses to questions regarding social media and advertising for more detail.
• Being teased, criticised, or bullied based on one’s weight or appearance leads to poor body image, particularly during adolescence (e.g., Menzel et al., 2010; Valois et al., 2019; Webb & Zimmer-Gembeck, 2014).
• Non-appearance based peer teasing and victimisation can also lead to poor body image among adolescents (Webb, Zimmer-Gembeck & Mastro, 2016).
• Perceived appearance pressure from parents has a significant effect on later body dissatisfaction (Helfert & Warschburger, 2011; Rodgers & Chabrol, 2009; Shomaker & Furman, 2010).

Weight Stigma

• Weight stigma refers to societal devaluation on the basis of body weight so that people of higher weight are subject to prejudice and discrimination. Examples of weight stigma are wage penalties for individuals of higher weight, reduced likelihood of promotion, overt weight-based teasing, bullying and victimisation, and stereotypes such that people of higher weight are lazy, sloppy, or unclean (Diedrichs & Puhl, 2016).
• Experiences of weight stigma and internalised weight stigma are associated with poor body image (Diedrichs & Puhl, 2016).
• In addition, decades of research have linked weight stigma and internalised weight stigma with poor outcomes such as depression, anxiety, binge eating, low self-esteem independent of sociodemographic factors and other forms of stigma (Diedrichs & Puhl, 2016; Hatzenbuehler, Keyes, & Hasin, 2009).

Colourism

• Colourism is a form of prejudice and discrimination affecting people of colour based on a hierarchical stratification of skin shade, whereby those with lighter coloured skin are afforded favour and privilege in society (Hall, 2018; Hunter, 2007). In addition to skin shade, other phenotypes are relevant to the enactment and experiences of colourism (Reece, 2016). The history of colourism is rooted in colonialism, slavery and White supremacy. Colourism is upheld, in part, by the beauty industry selling skin lightening products, and media and advertising assigning positive attributes to people of colour with lighter coloured skin and negative ones to people with darker skin shades.
• Research finds that the internalisation of colourist appearance standards predicts skin shade dissatisfaction, hair texture dissatisfaction, and skin bleaching practices among Black and Asian women (e.g., Harper & Choma, 2018).

The Impact of Poor Body Image

Q. What are the long-term effects of poor body image on people?

Q. What is the relationship between poor body image and mental health conditions including eating disorders?

As indicated above, poor body image tends to remain stable from adolescence through mid-life. This means that if an individual is struggling with poor body image as a teenager, they are likely to struggle with poor body image as an adult.

Scientific research evidence indicates poor body image is a risk factor for:

• Eating disorder onset and disordered eating (e.g., Bornioli et al., 2019; Micali et al., 2015; Stice & Desjardins, 2018)
• Depression and depressive symptoms (e.g., Sharpe et al., 2018)
• Anxiety disorders and anxiety symptoms (e.g., Vannucci & Ohannessian, 2017)
• Self-harm (e.g., Bornioli et al., 2019)
• Low self-esteem (Paxton et al., 2006)
• Risky behaviours such as smoking, high-risk drinking, and substance misuse (e.g., Bornioli et al., 2019; Calzo et al., 2015)
• Use of anabolic steroids among boys/men (Jenssen & Johannessen, 2015)
• Suicide ideation and behaviour (du Rocoät, Legleye, Guignard, Husky & Beck, 2016)
• Reduced quality of life on markers of psychological wellbeing, academic, emotional, and social functioning (Griffiths et al., 2016, 2017)
• Curtailed academic and career aspirations and performance (Halliwell, Diedrichs & Orbach, 2015).
• Opting out of important life activities including going to the doctor, joining a club, giving an opinion, raising a hand in the classroom (e.g., Atkinson & Diedrichs, under review; Dove Global Girls Beauty and Confidence Report, 2017)

Social Media and Poor Body Image

Q. What is the effect of the following on people’s body image when using social media?

The dramatic increase in social media use in the last decade has led to much research investigating the impact of social media use on body image concerns. A number of systematic reviews have highlighted that engagement with social media is associated with poor body image (e.g., Rounsefell et al., 2020; Saiphoo & Vahedi, 2019; Holland & Tiggemann, 2016; Mingoia et al., 2017). In addition, longitudinal research indicates that greater social media usage predicts poor body image and the desire to undergo cosmetic surgery (de Vries, Peter, de Graaf & Nikken, 2016; de Vries, Peter, Nikken & de Graaf, 2014).

The internal processes of appearance ideal internalisation and the tendency to make appearance-based comparisons are important mechanisms that help to explain the relationship between social media and body image concerns (Fardouly & Vartanian, 2016; Holland & Tiggemann, 2016). 

However, social media use is complex and nuanced.  People engage with social media use in many different ways, for different reasons and in different settings. Recent research attention has focused on understanding the impact of different aspects of social media use.   

Adverts

There is very little research on the specific impact of social media advertising on body image. An early study examining advertising on websites aimed at adolescents (not social media) reported that adverts on these sites perpetuated the stereotypical ideal of feminine beauty and could have a detrimental impact on body image (Slater et al., 2012). 

User-generated content (posts from friends)

Like traditional media, social media is often appearance-focused, with users likely to encounter a stream of highly idealised images that portray narrow appearance and body standards. However, while in traditional media these images would typically be of celebrities and models, social media presents the additional opportunity for users to view content generated by their peers. Social comparison theory (Festinger, 1954) states that people are more likely to make comparisons to similar others, which suggests that peer comparisons on social media may be particularly influential.

• Research supports this, reporting that women are more likely to make appearance comparisons through social media than traditional media, and that these comparisons are associated with less appearance satisfaction (Fardouly, Pinkus & Vartanian, 2017).
• Similarly, a tendency to compare one's appearance to others (particularly to one's peers) mediated the relationship between Facebook usage and poor body image (Fardouly & Vartanian, 2015).

User-generated content (posts from influencers/celebrities/models)

While the primary focus of many social networking services is to facilitate peer networks, these platforms are also particularly popular with celebrities, many of whom share aspects of their lives with millions of followers. Many people follow the accounts of celebrities and some will form strong connections and may begin to feel they have special relationships with them, a connection referred to as celebrity worship (Maltby et al., 2005). 

• Two studies have reported a significant relationship between celebrity worship and negative body image (Maltby et al., 2005; Swami et al., 2011). 
• An experimental study by Brown & Tiggemann (2016) compared the impact of viewing celebrity images, peer images and travel images from Instagram on women’s body image. Exposure to both celebrity and peer images increased body dissatisfaction compared to travel images, with no difference observed between viewing celebrity or peer images.  However, women who had higher levels of celebrity worship felt more dissatisfied after viewing celebrity images than women with lower levels of celebrity worship. This study demonstrates that acute exposure to thin and attractive female celebrity images has an immediate negative effect on women’s body image.  Interestingly, exposure to similarly thin and attractive unknown peers had a similar detrimental impact on body image. 
• A correlational study by Cohen et al. (2017) found that women who reported following celebrity accounts on Instagram (e.g., the Kardashians) also reported poorer body image (greater thin-ideal internalisation and body surveillance).      

Content promoting eating disorders

Pro-eating disorder content can be found on social media platforms (including Instagram, Facebook, YouTube, Twitter, Pinterest) as well as designated pro-eating disorder websites. Pro-eating disorder content can include thinspiration (images and messages idolizing thinness), bonespiration (images and messages idolizing emaciation whereby bones, e.g., hipbones, ribs, spine, are clearly visible) and hints and tips to avoid eating / maximise weight loss.

• Viewing pro-eating disorder content may exacerbate pre-existing negative body image and disordered eating and may lead to the development of negative body image and disordered eating among vulnerable individuals (Rodgers et al., 2015).
• Despite actions from some social media platforms to suppress pro-anorexia content, evidence suggests this type of content is still uploaded and available (Harmon & Rudd, 2019).

Content promoting diet culture

Content promoting diet culture is ubiquitous on social media, including in celebrity content and advertising. ‘Fitspiration’ is one particular social media trend that consists of images and messages designed to encourage people to exercise and pursue a healthier lifestyle. The digital trend of “clean” eating (e.g., encouraging the consumption of low-calorie and often raw food) seems interconnected with pro-ana, thinspiration, and fitspiration discourses online.

• Content analyses find that fitspiration images of women are often also thin (i.e., low in body fat) as well as lean (Deighton-Smith & Bell, 2017; Talbot, Gavin, van Steen & Morey, 2017), while images of men are lean and muscular (Gültzow et al., 2020).
• Fitspiration content on social media often contains guilt-inducing messages, stigmatises weight and body fat, and emphasises dieting and restrictive eating (Boepple et al., 2016; Boepple & Thompson, 2016; Tiggemann & Zaccardo, 2015).
• Exposure to Instagram fitspiration images leads to increased negative mood and body dissatisfaction and decreased state appearance self-esteem relative to appearance-neutral images (e.g., Tiggemann & Zaccardo, 2015).

• Women who follow “health food”, “clean eating” or “fitness” accounts on Instagram demonstrate higher levels of disordered eating and orthorexic tendencies such as extreme dietary restrictions and preoccupation with health than the general population (Cohen et al., 2017; Turner & Lefevre, 2017).

Content promoting cosmetic procedures

There is very limited research to date examining the impact of social media content promoting cosmetic surgery or procedures. 

• A recent experimental study examining whether exposure to social media images depicting facial cosmetic enhancement found increased the desire for cosmetic surgery in young women (Walker et al., 2019).
• Several studies have found that viewing content on traditional media promoting cosmetic procedures results in elevated body dissatisfaction. In one study, viewing cosmetic surgery television shows increases dissatisfaction with weight and appearance compared to a control group viewing a neutral non-appearance related show (Ashikali et al., 2014). Other studies have found that viewing cosmetic surgery advertising is also detrimental to women’s body image (e.g., Ashikali, Dittmar, & Ayers, 2016; 2017).

Media and Corporate Responsibility

Q. What are the responsibilities of companies and the media in ensuring diversity in the images we see?

Like all business, companies in fashion, beauty, advertising and the media have a social responsibility to not cause social or public harm through their business actions (Carroll, 1999; Craddock et al., 2019; McWilliams, Siegal, & Wright, 2006).

Focusing specifically on imagery, the evidence is clear that exclusively promoting thin, white, gendered appearance ideals is detrimental to body image. Studies have systematically documented an over-representation of these types of appearance ideals in advertising and media (Barlett, Vowels, & Saucier, 2008; Grabe, Ward & Hyde, 2008; Slater et al., 2012). Accordingly, companies and media have a responsibility to break this mould and be more inclusive in their imagery.

Studies have also systematically documented the prevalence of stereotypes and prejudice in media and advertising based on appearance, including race, age, weight, presence of a visible difference (e.g., scar or birth mark), and sexual identity (e.g., Croley, Reese, & Wagner, 2017; Diedrichs & Puhl, 2016; Jerald et al., 2017; Kroon et al., 2018; Nölke, 2018). Evidence clearly demonstrates this perpetuates significant health and social inequities, and has a detrimental effect on health, relationships, education and safety in addition to body image. Therefore, companies and media have a responsibility to avoid harmful appearance stereotypes and ensure that efforts to include more diverse images go beyond tokenistic gestures.

Notably, research indicates there is a business case for fostering positive body image. In a study with 45 business executives working in fashion, beauty, advertising and media in the UK and USA, the authors found that businesses actions to foster positive body image were beneficial for profits, employee satisfaction and corporate reputation (Craddock et al., 2019).

Based on the evidence outlined in this submission, all companies and media have a responsibility to:

• Have a diverse workforce, including at the leadership level to ensure that they are making decisions in the best interests of diverse stakeholders and consumers. People of colour ought to be creating the narrative of characters of colour, for example.
• Not mislead consumers through digital editing and enhancement techniques which serve to create unrealistic appearance standards that do not exist in reality.

• Activity work to dispel harmful stereotypes based on appearance, including skin colour, age, body weight, disability, gender and sexual identity (e.g., scars = a villain; larger body size = lazy; Black person = ghetto, criminal; a person with a disability = victim or superhero etc.).
• Show complexity in character for underrepresented groups. For example, the story arch for a person larger in size needs to go beyond the pursuit of weight loss or obsessive eating.
• Avoid stigmatising images of marginalised groups. For example, headless torsos of people of higher weight.

• Ensure there is a connection with imagery and stock. It is disingenuous if, for example in fashion, a campaign shows a size 16 model, but size 16 clothes are not available in store or online. Similarly, in beauty, if models of colour are shown in campaigns but there are no products suitable for darker skin shades available, efforts to show diverse images are tokenistic and can be perceived as virtual signalling.

Q. Which adverts or campaigns have had a negative impact on body image? 

Adverts or campaigns that exclusively promote unrealistic societal appearance ideals are harmful to body image. This is supported by decades of research that has documented the negative impact of exposure to idealised appearance imagery on traditional media (such as magazines and television) has on people's body image (Barlett, Vowels, & Saucier, 2008; Grabe, Ward & Hyde, 2008). This includes experimental and prospective studies that have demonstrated casual effects.

Adverts and campaigns promoting weight loss, weight management, muscle building or other body shape transformations contribute to diet culture which collectively harms how people think and feel about the way their body looks and how in turn, they behave towards their body (Austin, Yu, Tran, & Mayer, 2017; Or, Kim, Simms, & Austin, 2019).

Adverts and campaigns that perpetuate racism, weight stigma, the objectification of women or other forms of oppression on a marginalised group also contribute to harming people’s body image (Aubrey, 2010; Betz & Ramsay, 2017; Diedrichs & Puhl, 2016; Halliwell et al., 2011).

Q. Which adverts or campaigns stand out in promoting a positive body image?

Adverts or campaigns that show appearance diversity and dispel negative appearance stereotypes serve to create a social landscape that fosters positive body image. Studies have documented the beneficial impact of consumers viewing diverse appearances and body positive content in media (e.g., Diedrichs & Lee, 2011; Cohen et al., 2019; Halliwell et al., 2006).

Some brands that have consistently take action to represent greater appearance diversity and/or promote body positive or body neutral messages include Dove, Aerie, Fenty, Good American, Universal Standard, Teatum Jones, Christina Siriano, GabiFresh x Swimsuits for All, Nike, ASOS.

Examples of campaigns and brands that have been systematically researched by scientists to establish their positive impacts on body image, include:

• Aerie Real (e.g., Convertino, Rodgers, Franko & Jodoin, 2019; Rodgers et al., 2019)
• This Girl Can (e.g., Mulgrew et al., 2018)
• Dove and the Dove Self-Esteem Project (e.g., Halliwell, Easun & Harcourt, 2011; Diedrichs et al., 2015; Atkinson, Diedrichs, Garbett, & Leckie, 2015).

Regulation

Q. Has Government policy had an impact on improving body image?

Aside from one study investigating public perceptions of a body positive initiative by the Quebec Government (Gauvin & Steiger, 2012), overall, government policy in relation to improving body image has not been systematically evaluated (Paxton, 2015).

Some politicians, policymakers and advocacy groups have suggested that adding warning or disclaimer labels to digitally altered media images (e.g., “This image has been airbrushed”) might be helpful in reducing the body dissatisfaction that often accompanies exposure to media images. However, a significant body of research has demonstrated that the addition of such warning labels is not effective in reducing body dissatisfaction on traditional media images (e.g., Bury et al., 2016; Tiggemann et al., 2013; McComb & Mills, 2020) or on social media (Fardouly & Holland, 2018). Furthermore, public opinion on this approach is mixed, but there is clear public support for promoting greater appearance diversity in media (Paraskeva, et al., 2017).

Q. What strategy should the Government take to encourage healthy body image for young people?

1. Adopt an evidence-based approach to inform and evaluate policy initiatives.

To operate ethically and to avoid wasting time, human resources and public funds on ineffective approaches (e.g., disclaimer labels on retouched images or ineffective resources for parents and schools), and to ensure measurable and positive effects of any actions taken, it is critical that government adopts an evidence-based approach and consults with a range of stakeholders, including scientists, prior to developing policy and interventions and evaluates the outcomes of any actions implemented.

2. Connect and unify existing groups and initiatives in relation to body image to ensure a strategic and consistent approach across social policy actions.

In recent years, there have been multiple government, APPG and third sector inquiries and initiatives in relation to body image. However, there has not been a consistent or integrated approach to these efforts. A fractured approach likely undermines timely and effective action to foster positive body image.

For example, multiple All Party Parliamentary Groups are currently discussing issues related to body image, but there appears to be no ostensible overlap or collaboration (e.g., the APPGs on Beauty, Aesthetics, and Wellbeing; Corporate Responsibility; Eating Disorders; Textiles and Fashion; Obesity; Social Media; Sport; Young People’s Health).

Furthermore, APPGs, select committees, government and other community organisations have conducted numerous inquiries, evidence reviews, and round table discussions on the topic of body image in recent years with similar findings and recommendations. Unfortunately, these reports have yet to lead to any systematic or substantial collective action to introduce social policies to foster positive body image in a meaningful, measurable and consistent way.

For example, see:

1. 2012, APPG Inquiry Report on Body Image, “Reflections on Body Image”;
2. 2013, Government Equalities Office. Body Image – A rapid evidence assessment of the literature.
3. 2017, British Youth Council’s Youth Select Committee Report, “A Body Confident Future”, 2017.
4. 2017, Royal Society for Public Health Report on social media and body image “#StatusofMind”
5. 2019, Mental Health Foundation Report, “Body image: How we think and feel about our bodies”.
6. 2019, Royal Society for Public Health Report on social media and body image “#NewFilters”.
7. 2020, Kings College Weight Stigma campaign recommendations and report.

A more unified approach to cross-sector and government initiatives is critical to future progress. It is also imperative that effort is made to move on from discussion to concrete actions and social policy as the evidence across these existing reviews collectively and consistently demonstrates that body image is an important public health, gender equality, and social justice issue that requires urgent attention and uptake of the recommendations made by previous inquiries and reports.

3. Introduce mandatory evidence-based body image curriculum in schools.

Governments could usefully focus on promoting evidence-based body image interventions and including them in the curriculum for primary and secondary schools to promote positive body image, reduce unhealthy weight control behaviours and better mental health more broadly. There are a number of existing school-based programmes available that have demonstrated their effectiveness in rigorous research in improving young people’s body image and are readily available (e.g., Me U & Us for adolescent girls, Sharpe et al., 2013; Dove Confident Me for mixed gender groups Diedrichs et al., 2015, under review; Media Smart Australia for mixed gender groups Wilksch et al., 2013, 2016). Unfortunately, in the past Government has endorsed and helped to disseminate media literacy and body image programmes that have not been evaluated sufficiently to determine if they are effective or not, or in some cases have been shown to be ineffective and unacceptable to students (e.g., MediaSmart UK; Paraskeva, Diedrichs, Yager & Halliwell, 2013).

4. Address weight stigma by removing weight-focused initiatives from all schools, fostering collaboration between obesity, eating disorder, and public mental health fields, and adopt a health-centric vs. weight-centric approach to government public health campaigns and initiatives.

‘Anti-obesity’ language and campaigning are stigmatising. Weight-focused public health and school initiatives also risk perpetuating weight stigma, disordered eating and health inequalities by focusing on weight as a metric for health. A substantial body of scientific evidence demonstrates that weight stigma independently predicts a range of negative health and quality of life outcomes, including weight gain, weight cycling, poor mental health, unhealthy weight control practices, and disordered eating and exercise behaviours (Diedrichs & Puhl, 2016).  

Leading professional societies and the scientific community have stressed the detrimental impact of anti-obesity and weight stigma approaches. They have also made clear recommendations for government, health professionals, businesses and the public on how to reduce the harmful impact of weight stigma. For example, see the Academy for Eating Disorders position statement “The Nine More Truths about Eating Disorders: Weight and Weight Bias” and International Consensus Statement for ending stigma of obesity (Rubino et al., 2020). 

5. Include weight and disfigurement as protected characteristics in the Equality Act 2010.

Due to the overwhelming evidence (already outlined) the widespread prevalence of prejudiced attitudes and discriminatory behaviours towards higher weight individuals (including weight-based teasing during childhood and adolescence), and the concomitant negative impacts of weight stigma on health, employment, and education outcomes, weight should be added as a protected characteristic.

We also support calls from Changing Faces, the national charity that supports represents people who have a condition, scar or mark that affects their appearance, to include disfigurement (i.e., those with a distinctives appearance due to an appearance-altering condition or injury) as a protected characteristic.

6. Ban the sale and promotion of diet pills and muscle-building supplements to minors.

In line with a bill in the US state of Massachusetts, the sale of diet pills and muscle-building supplements to minors under 18 years old should be prohibited (see Harvard STRIPED “Out of Kids’ Hands).

7. Regulate media and advertising to avoid body shaming and increase representation of the diverse British public.

Due to the overwhelming evidence (already outlined) documenting the lack of diverse representation of appearances in advertising and the media, and the concomitant  well-established negative impacts of this on consumers’ health and well-being, greater regulation of media and advertising is critical to avoid body shaming and increase diverse depictions in media.

In 2016, Transport for London successfully introduced a section in their Advertising Policy in which they will not approve any advertisements on their advertising estate that “ could reasonably be seen as likely to cause pressure to conform to an unrealistic or unhealthy body shape, or as likely to create body confidence issues particularly among young people".  This policy has been successfully implemented while not affecting the revenue of the TfL estate, thus demonstrating that media and advertising regulation in relation to body image and appearance diversity is possible and commercially viable.

Q. Is there enough research and data to support the Government in creating policy surrounding body image and social media?

Yes (see evidence outlined above). We propose the next step is for the government to work with researchers, clinicians and scientists as well as business and social media platforms to inform an evidence-based approach to policy development. It is also important to sufficiently evaluate policy actions to ensure an ethical approach and the judicious use of resources to underpin the implementation of such initiatives.

Q. Would proposals in the Online Harms White Paper protect people from potential harm caused by social media content in regard to body image?

Many of the proposals (e.g., statutory duty of care for social media companies, developing tools to monitor potentially harmful content) could be useful strategies to apply to body image, however, further consultation with experts and the scientific evidence-base is necessary to ensure any proposals are specific and targeted enough to foster positive body image.

Q. What is the role of the Advertising Standards Authority (ASA) in promoting diversity and a positive body image in:

Due to the overwhelming evidence (outlined above) documenting the lack of diverse representation of appearances in advertising and the media, and the concomitant  well-established negative impacts of this on consumers’ health and well-being, greater regulation of media and advertising by the ASA is critical to avoid body shaming and increase diverse depictions in media. In accordance with their remit on gender stereotyping and sexualisation and harmful content, the evidence indicates that it would be judicious for the ASA to expand their policies to specifically include body image and appearance-based prejudice.

In 2016, Transport for London successfully introduced a section in their Advertising Policy in which they will not approve any advertisements on their advertising estate that “could reasonably be seen as likely to cause pressure to conform to an unrealistic or unhealthy body shape, or as likely to create body confidence issues particularly among young people".  This policy has been successfully implemented while not affecting the revenue of the TfL estate, thus demonstrating that media and advertising regulation in relation to body image and appearance diversity is possible and commercially viable.

Q. How successful is the ASA at protecting the public from adverts that have a negative impact on body image?

To date, the ASA has had limited impact on protecting the public from adverts that negatively harm body image. This is likely due to the fact that while they address gender stereotyping and sexualisation, the ASA does not specifically address body image and appearance-based prejudice in its policies and guidelines.

Furthermore, like many regulatory bodies, the ASA currently reviews problematic adverts on a case-by-case basis. This does not sufficiently address the potential harm caused by the cumulative effect of seeing numerous advertisements on a daily basis that perpetuate appearance ideals and stereotypes.

On the basis of decades of research demonstrating the negative impact of advertising that perpetuates narrowly defined appearance ideals and stereotypes, we would welcome the inclusion of specific policies and standards from the ASA on advertising and body image.

June 2020

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