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Body Image and Media Use

Among Adolescents
ARTICLE in ADOLESCENT MEDICINE CLINICS JULY 2005
DOI: 10.1016/j.admecli.2005.02.010 Source: PubMed

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Dina L G Borzekowski
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Angela Bayer
University of California, Los
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Adolesc Med 16 (2005) 289 313

Body Image and Media Use

Among Adolescents
Dina L.G. Borzekowski, EdD*, Angela M. Bayer, MHS
Department of Population and Family Health Sciences,
Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street,
Baltimore, MD 21205, USA

This article reviews the literature on body image and media use among adolescents. We begin by defining body image and how it is constructed, especially
among young people. We then offer information on when ones body image
perception is askew with ones perception of personal ideal, which can result in
disordered eating, including obesity, anorexia, and bulimia. Next, we describe the
research literature on media use and its relationship to adolescents body image
perceptions and discuss content analyses and correlational, experimental, and
qualitative studies. Lastly, we recommend, beyond conducting further and improved research studies, interventions and policies that may have an impact on
body image and media use.

Defining body image

What is body image and, more importantly for this discussion, what role does
it play as youth progress through adolescence? The words body and image
actually conflict. Body is definite and more objective: the physical structure
of an organism. Most responses of the body are predictable, such as reactions to
cold, pain, pleasure, and hunger. Image, conversely, is subjective, comprising
mental representation, idea, or conception [1]. Images derive from perceptions
that are influenced by personal and cultural factors. Merging the meaning of these

* Corresponding author.
E-mail address: [email protected] (D.L.G. Borzekowski).
1547-3368/05/$ see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.admecli.2005.02.010
adolescent.theclinics.com

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terms leads to body image as the internal representation of [ones] own outer
appearance [2], which reflects physical and perceptual dimensions [3]. Recent
research has established consensus that body image is a multidimensional construct that is influenced by biologic, psychologic, and social factors [36].
Body image is related highly to an individuals self-esteem and self-concept,
as well as to other key aspects of human development, including sexuality,
familial relationships, and identity [7]. Body image also has been established as a
key aspect of self-worth and mental health across the life span [4,7,8]. Poor body
image and lower self-esteem result in dissatisfaction with oneself. If these bodyrelated concerns are intense enough, they may catalyze behaviors that are aimed
at changing ones physique to reduce discontent [9]. In its extremes, this discontent manifests as disordered eating patterns or pathways toward depression
[10,11].

Adolescents construction of body image

Multiple factors impact the construction of body image; the strong association
between body image and self-esteem has a unique importance for adolescents.
Adolescence represents a critical transition period during which adolescents
face physical, cognitive, and social changes as they enter and progress through
puberty and reach adulthood. Changes in these diverse realms do not occur
independent of, but in constant interaction with, one another. Physiologic changes
include accelerated physical growth, the maturation of primary sex characteristics, and the development of secondary sex characteristics. Although growth
is a regular and regulated process, puberty marks a significant and rapid change
of pace, with a conscious participant as a fascinated, charmed or horrified
spectator [12]. Physical changes converge with feelings of sexual tension and
physical attraction, uncertainties about social relationships, and the reorganization
of cognitive structures, all of which contribute to body image being a plastic,
constantly changing concept, continuously modified by bodily growth, trauma or
decline, and significantly influenced by the ever-changing interaction with the
social environment [13]. Adolescents construction of their closely-linked body
image and self-concept can be particularly challenging because of the diverse,
rapid, and significant changes that are heightened during this period.
Because body image is self-evaluative, it is influenced by the goodness of
fit between self-evaluation of ones body, ones expectations for the physical
self, and the perceived evaluations of others [14]. This goodness of fit may
be difficult to achieve, however, because of the discrepancies between the
adolescent bodies and what is portrayed as ideal for women and men. Given
increased obesity for adolescent girls and women, the gap between the average
and the ideal has expanded; models used to weigh about 8% less than the average
woman, they now weigh 23% less [15]. Adolescent boys face a similar dilemma.
Typical growth for boys is characterized by quick gains in height, but not

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necessarily in muscle or weight. This is in striking contrast to the ideal body

image for men, which has become increasingly muscular [16]. This trend for the
male body ideal can be observed among male print and television models and
the more successful actors. Therefore, female and male adolescents face immense
challenges as they construct their body image and address physical and psychologic changes while navigating cultural images that often are unattainable.
Variations between normal and ideal body size can result in body dissatisfaction. In a recent U.S. study, almost half of the surveyed women had negative
evaluations of their own overall appearance and were dissatisfied with their
weight and lower and mid-torso [17]. This trend is particularly marked for female
adolescents, a population which is characterized as in a state of normative
discontent because negative body image is so pervasive [17,18]. By middle
school, 20% to 50% of girls in the United States say that they feel too fat [19]
and 20% to 40% of girls feel overweight [20]. One study found that 40% of
adolescent girls believed that they were overweight, even though most of these
girls fell in the normal weight range [21]. Although past studies have examined
adolescent boys as they compare with adolescent girls, recent research has analyzed men as an independent group and identified a significant increase in body
image concerns among men [2224]. Although past studies asserted body dissatisfaction in boys at a range of 50% to 70%, which surpassed the rate for girls
[23], a recent meta-analysis on body image in boys found that boys demonstrate
less overall body concern than girls [22]. As girls tend to focus on getting thinner,
boys generally want to get bigger through increased muscle or fat, although
studies do not differentiate between the two when discussing dissatisfaction or
concerns [22].
Body dissatisfaction among adolescents is not uniform across this development period, nor youth of different genders or from different cultures. Past research demonstrated that body image undergoes changes during adolescence,
with body satisfaction scores at a given age not correlated significantly with
scores at other ages over a 5-year period [5]. Numerous studies have confirmed
that although girls body image worsens as they progress through adolescence,
boys body image improves [25,26]. Recent data indicate that this shift between
the sexes occurs between ages 13 and 15, most likely as a result of cognitive
changes that enable self-evaluation or to increased attention to body shape that is
accompanied by the significant physical changes in puberty [2628]. In this same
study, adolescents satisfaction with weight did not follow the same trajectory;
girls and boys were dissatisfied with their weight with equal frequency at 13, 15,
and 18 years of age [26].
A growing body of research now demonstrates that body image, personal
dissatisfaction with body, and perceptions of weight and attractiveness vary significantly by racial and ethnic groups within the United States and in other
countries [2932]. In the United States, African American adolescent girls have
a higher tolerance for increased adiposity compared with their white peers [29].
College-aged Asian American women are more dissatisfied with their body shape
than white women of the same age [33].

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Exploring the results of negative body image

The overwhelming dissatisfaction with body shape and weight that is
experienced by adolescents is not solely a cognitive perception or observation,
but often is linked to one of two extremes in weight-related disorders: obesity and
disordered eating. Obesity is more prevalent than the eating disorders, anorexia
nervosa and bulimia nervosa; however, all of these disorders lead to significant
negative effects on the individuals physical and psychologic health and often
impact their socioeconomic opportunities during childhood and adolescence and
into adulthood.
Another recent phenomenon, which is not explored in great detail in this
article, is the use of cosmetic surgery to alter ones appearance. In 2003, there
were 8.3 million procedures (surgical and nonsurgical) done, with 322,975 and
61,646 liposuction procedures done on women and men, respectively [34]. In the
same year, 280,401 breast enlargement procedures were done on women, a 177%
increase since 1997 [34]. More than the popular rhinoplasty surgery of previous
decades, young adults are having all types of cosmetic surgery to alter their
appearances. From 2002 to 2003, the number of girls who were 18 years of age
and younger who got breast implants increased almost 400%, from 3872 to
11,326 cases [35].
Obesity
As recognized by the World Health Organization (WHO), obesity and overweight are increasing in adult and child populations worldwide to the point
that obesity is now an epidemic [36]. Recent data show that the prevalence of
at risk for overweight among adolescents 12 to 19 years old was 30.9% in 1999
to 2002, with significantly higher prevalence for non-Hispanic blacks (36.8%)
and Mexican Americans (38.9%), as compared with non-Hispanic whites
(27.9%). The prevalence of obesity in the same age group is 16.1%, with difference by racial/ethnic group following a similar trendgreater overweight for
non-Hispanic blacks (21.1%) and Mexican Americans (22.5%) than for nonHispanic whites (14.3%) [37]. Recent estimates in Australia suggest that approximately 6% of boys and girls are obese and between 16% and 20% of boys
and girls are overweight [38]. The United Kingdom, like the United States and
Australia, also shows evidence of increasing obesity, with higher prevalence
among socially-deprived children [3941]. Obesity is not limited to developed
countries. The estimated number of obese adults increased from 200 million to
300 million in only 5 years, from 1995 to 2000. In developing countries, it is
estimated that more than 115 million people suffer from obesity-related problems [42].
Obesity in childhood and adolescence can have serious health consequences,
in the short-, intermediate- and long-term. Although most complications of
childhood obesity do not become apparent until adulthood, some children suffer
short-term consequences. Severely overweight children and adolescents are more

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likely to have orthopedic problems, intracranial hypertension, pulmonary-related

sleep disorders, gallstones, insulin resistance and hyperandrogenemia, and menstrual abnormalities [4349]. Childhood and adolescent obesity has more serious
intermediate consequences during adolescence and young adulthood. Obese
boys and girls are nine to 10 times more likely to develop high blood pressure as
young adults than nonobese children [50]; overweight adolescents are 8.5 times
more likely to have hypertension as adults than nonoverweight adolescents [51].
Adolescent obesity also is associated with negative effects on total cholesterol
and low-density lipoprotein cholesterol in adulthood, particularly for boys [50]. A
new finding is particularly disconcerting; in 1994, one third of newly-diagnosed
diabetics between 10 and 19 years of age were type II diabetics. More than 90%
of these patients were obese and 40% were severely obese [52].
Childhood obesity has been identified as an independent risk factor for adult
obesity. Research suggests that childhood obesity is related to adult morbidity,
including elevated risk of heart disease for men and women, colon cancer and
gout for men, and arthritis, hip fracture, menstrual problems, and gestational
hypertension for women [53]. An association exists between childhood obesity
and adult mortality that is due to coronary heart disease and all-cause mortality,
with elevated risks of 2.0 and 1.5, respectively [54]. A recent study also demonstrated that adolescent overweight, independent of adult body-mass index (BMI),
was a more powerful predictor than adult overweight of certain types of risk in
men aged 68 to 73 years, with a relative risk of 1.8 for all-cause adult mortality
and 2.3 for adult mortality [53].
The impact of obesity extends beyond physical health consequences. Studies
show decreased high school performance in overweight adolescents and one half
of college acceptance rates to elite universities when compared with normal
weight adolescents with similar test scores [55]. A longitudinal study of 16- to
24-year-olds found that overweight women completed 0.3 years less schooling
and had lower household incomes and higher poverty rates [56]. Obese children
from certain groups tend to have lower levels of self-esteem; a recent longitudinal
study demonstrated decreased self-esteem with increased body fat [57]. Increased
BMI also is associated with a greater number of depressive symptoms in adolescent girls [58].
Society also experiences obesity-related costs. Estimates show that obesity
is responsible for 10% of health care expenditures in the United States [59]. A
recent study examined hospital discharge records to estimate the economic burden of obesity in youth; obesity-associated annual hospital costs increased from
$35 million in 19791981 to $127 million in 19971999 [60]. Obesity is the
second leading cause of death in the United States, adding 300,000 deaths
annually, compared with 434,000 deaths that are due to smoking [61,62].
Anorexia, bulimia, and eating disorder not otherwise specified
Eating disorders are no longer a condition of the daughters of well-to-do,
educated and successful families [63], as they originally were characterized, and

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have been found to affect all socioeconomic and major ethnic groups [64]. This
finding follows from the reality that eating disorders are prevalent in diverse
individuals and from the recognition that eating disorders have multiple determinants that are rooted in biologic, psychologic, and social issues. The definition
of eating disorders also has expanded, as evidenced in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, which includes anorexia
nervosa (characterized by restrictive eating patterns and significant weight loss)
and bulimia nervosa (characterized by binge-purge cycles), as well as eating
disorder not otherwise specified (ENDOS; eating disorders that do not meet the
criteria for any specific eating disorder) [65].
The prevalence of eating disorders has increased over the last 50 years [66].
Internationally, anorexia nervosa involves 0.5% to 1% of girls and women in late
adolescence and early adulthood and bulimia nervosa affects 1% to 3% of
adolescent and young adult girls/women. Studies on eating disorders frequently
look at girls or, when they have looked at boys, have grouped all adolescents
together. Recent reviews are now focusing explicitly on adolescent boys. Anorexia has been considered to be uncommon in boys, with a female/male ratio
of 10:1. A community sample that was drawn from the WHO found a much
lower female/male ratio of 2:1, when including partial syndrome [67]. In the
same WHO sample, there was a 2.9:1 female/male ratio for bulimia nervosa when
including partial syndrome. Overall, it is estimated that boys account for 5% to
15% of cases anorexia and bulimia nervosa [64]. Certain studies also found that
homosexual or bisexual orientation is a specific risk factor for eating disorders in
adolescent boys and men, particularly for bulimia nervosa, although other studies
have refuted these findings [68].
ENDOS is encountered much more commonly than anorexia or bulimia nervosa. A recent Australian study found that 12% of adolescent girls had distorted
body image and an overwhelming 77% wanted to lose weight. In the same
sample, 33% had disordered eating behaviors, 57% had unhealthy dieting practices, and 51% had attempted to lose weight in the past month [69]. A crosssectional, school-based study in the United States examined similar issues in
boys and girls in grades 5 through 12. A greater proportion of girls (45%) than
boys (20%) reported dieting at some point, and a greater percentage of girls
than boys also had disordered eating, with 13% and 7%, respectively [70].
Eating disorders often occur in conjunction with other problems, such as
anxiety disorders, depression, and substance abuse. Women who have eating
disorders experience serious morbidity and high mortality, particularly as a result
of anorexia nervosa. Morbidity concerns include myocardial impairment, osteoporosis, and amenorrhea, which often linger in the rehabilitation phase and following recovery. Mortality results from malnutrition and cardiac failure, as well
as suicide. Eating disorders, like obesity, also represent a significant burden to
society. Anorexia nervosa is the third most common chronic illness in the United
States [71]. In Australia, eating disorders are the seventh major cause of mental
disorders and treatment for anorexia nervosa represents the second highest cost
to the private hospital sector [72].

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Influences on body image and disordered eating

Although media often is portrayed as the sole culprit in adolescent formation
of body image and eating attitudes and behavior, research has demonstrated that
family and peers also are main sources of influence [73]. Research in this area has
focused primarily on girls; however, recent studies have examined the impact of
media, parents, and friends on boys perceptions of body image.
The family acts as a primary socialization agent by transmitting certain messages to adolescents, often differentially according to gender [74]. Family members may provide the first set of external criteria against which girls evaluate
themselves as women [75]. Teasing and criticism at a young age can mediate the
relationship between weight status and self-concept [76]. Adolescent girls descriptions of parental relationships as more conflictual were associated with increased dieting and poorer body image, and girls who had eating disorders often
perceived their families as less warm and cohesive and more conflictual [77,78].
Strong evidence exists regarding the influence of mothers as role models and
transmitters and reinforcers of social messages around body image and eating for
their adolescent daughters [79]. Another body of research confirms that mother
daughter relationships that are characterized by poor attachment patterns and low
warmth are associated with greater levels of eating disorders [33]. Less work has
been done on the influence of fathers and siblings on their adolescent daughters
and sisters body image and eating attitudes and behaviors. One study found that
fathers influence their daughters body dissatisfaction, but not their eating practices [79]. Another study showed some evidence that sisters may play the same
role as mothers in affecting the girls body image and eating patterns [80]. One
recent small study examined the role of parents, friends, and the media on body
image and body change methods in adolescent boys [24]. Mothers exerted a
stronger influence on the body image of their adolescent sons than other family
members, peers, or the media. Given that most messages from mothers are positive, this may explain why boys tend to have higher levels of body satisfaction. Fathers and brothers, however, have a larger impact on boys body change
methods, such as exercise.
Peers also are important socialization agents in shaping body image and eating
patterns, particularly because adolescence marks a period when girls and boys
begin to spend less time with parents and more time with friends. Studies show
that body image plays a much greater role in peer relationships and adaptation to
the social environment than previously believed [81]. Girls who compare their
appearance with that of their female peers have a greater risk of body dissatisfaction and body change methods, such as dieting. This influence increases as
girls get older; same-sex peers have a greater influence than mothers on the eating
attitudes and behaviors of older adolescent girls [80]. Two recent studies on high
school girls, one in Canada and one in Australia, confirmed that peer pressure
significantly relates to body image concerns, eating behaviors, and dieting manifestation [82,83]. A study on adolescent boys found trends that paralleled the
influence of mothers, fathers, and brothers, based on the gender of the peer.

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Although the positive comments of female friends influence the body satisfaction
of boys, the perceptions of their male friends has a greater impact on boys body
change methods [24].
Even after considering these important interpersonal factors, medias influence
on adolescent body image, eating attitudes, and behaviors persists and continues
to dominate, especially in the publics attention. Medias effect on adolescent
girls is strikingly strong, with media considered to be the loudest and most
aggressive purveyors of images and narratives of ideal slender beauty [84]. As
with all research on body image and eating patterns, much less is known about
the effect of media on boys. A recent study found that media affects the body
satisfaction of boys, and that its most sizeable effect on this population is its
encouragement of exercise and other body change methods [24].
Media can have a direct influence on its audiences and it can affect audiences
indirectly by altering ones perceptions of social norms. A recently proposed and
presented model, the Presumed Influence Model, suggests that young people
perceive that media messages are received by and influence their peers. This
heightens medias effect on the individual (Gunther et al, submitted for publication, 2005). Applying this model to body image and media, one can imagine an
adolescents attitudes and behaviors concerning weight control being impacted by
the messages that she observes through media and through the belief that many of
her peers are seeing these same messages. Research that confirms the presumed
influence models role in body image has not been conducted; however, relevant
studies suggest that adolescents perceptions of others opinions interact with the
relationship between media use and self-appraisals [85].

Media use by adolescents

The typical adolescent lives in a media-rich environment. Although adolescents watch less television than their younger peers, their media consumptionor
screen timeoften is greater, because adolescents use a variety of media with
great frequency. Traditional and new media technologies appeal to adolescents,
with ownership and use being pervasive among youth [86]. Even in developing
countries, young people own and use print media, radio, and television on a
regular basis (Borzekowski and Hill, submitted for publication, 2005).
Teen magazines, either in print or online, are extremely popular with adolescent boys and girls. Twelve- to 19-year-olds spend approximately $175 billion
annually on magazines [87]; approximately 60% of 15- to 18-year-olds report
that they read magazines daily [88]. Seventeen remains the most popular teen
magazine; however adult-to-teen crossovers, like Teen People, CosmoGirl!, Elle
Girl, and Teen Vogue have notable circulation among adolescent girls. In contrast
to the homogenous magazines that reach young women, there is great diversity
in the magazines that are read by adolescent boys. Boys read magazines that
appeal to niche markets, such as electronic gaming (GamePro), sports (Sports
Illustrated), music (Spin, Vibe), and cars (Road and Track) [89].

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Many teen magazines have companion web sites, that often serve as a communication platform and additional resource between print issues [90]. The more
interactive features of the Internet can enhance the magazine reading experience;
online magazines offer visitors unlimited access so that they can contribute to
online polls, gather additional information, or express their opinions and experiences on online message boards [90].
Young people enjoy and use the Internet more so than members of any other
age group [91]. Although the primary reason why adolescents log on to the
Internet is social (e-mailing, instant messaging), approximately two thirds have
gone online to get health information, either for personal or academic reasons
[92]. In the United States, the average adolescent is on the Internet daily, and 74%
of households with children have access to the Internet [93].

A recent phenomenon: the Internet, body image, and disordered eating

Messages about body weight and appearance, long prevalent in the mass
media, also have begun to be disseminated through the Internet. Although there
are many sites that convey positive health messages to young people, such as
those that encourage healthy diets and physical activity (eg, www.kidshealth.org,
www.teenhealthfx.com, www.cdc.gov), several web sites contain health-related
information that can be harmful. A disturbing new phenomenon is the emergence
of sites that portray disordered eating in a positive light. Classified as pro-ana
(proanorexia), pro-mia (probulimia), or a combination of both, these sites
characterize anorexia and bulimia as a lifestyle choice, not a clinical disease over
which individuals may have little control [94]. The sites present themselves as a
environment where likeminded individuals can share information and boost their
motivation. Many sites acknowledge that individuals who have eating disorders
may be harmed by the offered online content; some sites provide explicit messages to this effect. These messages vary substantially; however, some may be
construed as posing a personal challenge to individuals [94]. For instance, one
reads I am not responsible for your actions. . .leave if you cant handle it [94].
These messages are, at best, ineffective and, at worst, harmful by encouraging
some adolescents to enter the website as a personal challenge.
The general attitude and environment that are projected by pro-ana and promia sites is one of superiority, empowerment and pride [94] where young
women encourage one another to engage in anorexic and bulimic behaviors to
demonstrate self-control and reject weak societal values. One pro-ana site highlights this approach in a striking manner, claiming that anorexics seek
sympathy and die, whereas rexies gain respect through their lifestyle choice. A
position paper that was released by the National Eating Disorder Association
identifies proanorexia and probulimia web sites as promoting damaging behaviors among people who are seriously ill, while providing dangerous support
to dissuade these individuals from seeking treatments [95].

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Typical features of pro-ana and pro-mia sites include bulletin boards and chat
rooms for discussions and sharing of experiences, as well as photo galleries,
where very thin models are featured as thinspiration [94,96]. Andrist [96] did a
content analysis of messages that were posted on a pro-ana website and identified
two groups of visitors to the site: young, overweight women who wanted to lose
weight and young women who had eating disorders and other mental health
problems, including drug addiction, depression, cutting, and attempted suicide.
Most pro-ana and pro-mia sites are unmonitored and do not offer medical
assistance; instead, they adhere to denial of the need for recovery or help. When
messages seem dire, however, others respond by encouraging the person in need
to seek help [96]. Given these sites negative portrayal of anorexics and bulimics
who cannot control their condition, it is likely that seeking help signifies an even
greater failure for those who are seeking help. The imbalanced dynamic of selfcontrol and independence within the sites and the seriousness of disordered eating
is evidenced further in the followinga significant minority of sites are left
unattended because the controller can no longer attend to the site. One site was
being maintained from a hospital bed [94,96].

Research that explores the relationship between media use and body image
Content analyses
Women who exemplify societys beauty ideal, from Playboy centerfolds to
Miss America contestants and winners to magazine cover models, often have
BMIs that are well below normal [9799]. For women, the current body ideal
features a very slender body with large breasts, often attained through the use of
cosmetic surgery (Fig. 1). Whereas the ideal female has become progressively
thinner over the last 30 years, the male ideal has become increasingly dense and
muscular. Playgirl centerfolds, mega-movie stars, and even G.I. Joe action
figures often have unattainable physiques; depicted chests, arms, and legs could
only promote the use of anabolic-androgenic steroids among young men who
wish to resemble these archetypes (Fig. 2) [16,100].
Television strongly conveys the body ideal message. Content analyses of
programming indicate that there are few characters who are overweight; female
characters usually are thin [101103]. In sharp contrast to actual prevalence rates,
33% and 60% of female television characters are below or average weight,
respectively, and only 7% seem to have above average weights [103]. Male
characters are likely to make positive comments about the weight, shape, and
bodies of thinner female characters [103]. Commercial breaks offer no haven,
because many advertisements depict slender models promoting the use of
appearance-enhancing items [104]. Young viewers are encouraged to buy new
and improved products that will make their hair shinier, teeth brighter, and skin
glow more (but not too much). Commercials for these appearance-enhancing
items are juxtaposed next to advertisements that promote foods which may be

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Fig. 1. (A, B) Fashion advertising that targets adolescent girls. These models typify the female
body ideal.

Fig. 2. Action figures from the Star Wars movie series. Luke Skywalker (left) and Hans Solo (right)
are shown in their earlier lean and more contemporary buff versions.

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questionable. A recent television advertising campaign by the empire McDonalds

suggests that eating at their fast-food restaurant can be part of a healthy lifestyle,
complete with wholesome, high-quality food menu options [105]. Instead
of ordering the well-known quarter pounder with cheese (510 calories, 25 g of
fat), customers may order the California Cobb salad with grilled chicken and
Newmans Own Cobb dressing for a healthy 390 calories and 20 g of fat
[105]. A content analysis that focused on television that is popular with African
American audiences found that there were more overweight characters featured
on the programs and a greater number of food commercials within the programs,
compared with that watched by general audiences [106].
A growing phenomenon that should be monitored is the great increase in
reality television shows, based primarily on competitions that feature appearance and body image issues. In shows such as NBCs The Biggest Loser,
ABCs Extreme Makeover, and FOXs The Swan, real people compete and
change their appearances, sometimes through drastic cosmetic surgery. As a
first step in examining the impact of these reality shows, content analyses should
be performed to understand better the messages that are conveyed through
these programs.
Correlational studies: cross-sectional and longitudinal research
Studies from the United States, Britain, and New Zealand offer evidence that
increased media use, especially more hours of television per day, is associated
with greater BMI and greater risk of obesity among children and adolescents
[107,108]. The likely explanation of this association is not that children are more
sedentary when they use media [109], but rather that they are persuaded to
consume fast foods; soft drinks; and high-calorie, high-fat, low-nutritional value
snacks because of repeated exposure to persuasive commercial messages [110].
On the other end of this scale, a simple bivariate relationship; girls who read
beauty and fashion magazines frequently and compare themselves with the
slender models, are more likely to limit their intake to 1200 or less calories per
day, and have greater body dissatisfaction and drive for thinness [111].
Among young gay and heterosexual men, those who read muscle and fitness
magazines often have higher levels of body dissatisfaction [112]. Frequent
magazine readers, usually adolescent girls, also are more likely to engage in
anorexic and bulimic behaviors, such as taking appetite control or weight-loss
pills [113]. Controlling for participants body size, as well as parent and peer
pressures to lose weight, path analyses show that sociocultural influences
significantly add to the prediction of body dissatisfaction [114]. Longitudinal
studies also show that girls who wish to look like women on television, in
movies, and magazines are likely to have a higher risk of using vomiting or
laxatives for weight control [115]. Research suggests that several factors contribute to harmful attitudes and behaviors, but exposure and desire to resemble
media ideals are significant factors that must be considered [114,115]. Conclusive
directionality of this relationship remains unknown, however. One study found

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that adolescent girls who increased their eating disorder symptomatology also
increased their exposure to television and fashion magazines over a 16-month
period [116].
Positive effects have also been observed within the results of correlational
studies on media use and body image. Adolescents who have greater exposure to,
and interest in, sports media are more likely to participate in physical activities
[117]. Those who wish to look like television, movie, and magazine celebrities
are more likely to spend more hours per week engaging in a physical activity [118].
Experimental studies
To conduct an experiment to see if increased exposure to media would result
in higher BMI would not be feasible (no Human Research Committee would
approve such a study plan); however, recent experimental work has considered
the reverse. One study focused specifically on reducing television, videotape, and
video game use among elementary school children. Boys and girls in the intervention group demonstrated decreased television viewing, number of meals eaten
in front of the television, and decreased body fatness measures [119].
Experiments that examined the impact of media exposure on body image
showed inconsistent findings regarding the association between media use and its
immediate effect on ones self-perceptions. A meta-analysis of 25 studies found a
small, but significant, effect, where body image was judged more negative after
viewing thin images of models among young female participants [84]. A recent
study of young men who were exposed to ideal male models were more depressed and had higher levels of muscle dissatisfaction compared with those who
were exposed to neutral male models [120].
A longitudinal experiment showed that after a successful manipulation, those
adolescent girls who had increased exposure to fashion magazines were not more
likely to demonstrate thin-ideal internalization, body dissatisfaction, dieting, negative affect, or bulimic symptoms compared with those who had less exposure.
Participants who were more vulnerable at the beginning of this 15-month experiment were affected negatively, however. Girls who had higher levels of body
dissatisfaction and less social support at baseline were significantly more likely
to have increased body dissatisfaction, dieting, and bulimic symptoms at the
conclusion of the experiment compared with those who were less vulnerable at
baseline [121].
Qualitative research
A handful of qualitative studies has considered the relationship between media
use and body perceptions [85,122124]. In one Australian study, researchers
systematically analyzed discussions that were held by adolescent girls to inform
how media effects and body image contribute to the construction of self-image
[122]. The girls suggested that a variety of cultural influences affect their desire to

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be thin, but media was offered most frequently and strongly as the source of the
thin ideal. Many of the participants comments were strikingly sophisticated and
perceptive; however, the complex processes that lead to their attitudes were not
understood completely. One girl remarked The media portrays the image of
girls, how we want to be, like skinny or whatever, and I dont know it just kind of
takes over our mind, we dont think properly. . ..we forget other things like we
dont think about inside, like personality and the inner self [122]. In another
Australian qualitative study, girls associated the medias portrayal of the thin
ideal with pressure to be thin [124]. A U.S. study in which white and minority
girls were interviewed found that white girls see media ideal images as important
because their peers, and especially boys, are affected by the images. In contrast,
minority girls were less affected by the media because they believed that
significant others did not subscribe to these images [85].
Across studies, the strongest media impact appears among those who are most
vulnerable; from cross-sectional to experimental designs, the groups who are
most affected by thin-ideal media images are those who already are at risk for
weight concerns and eating disorders. Adolescents who already feel pressure
from family and peers to be thin may be more susceptible to the social comparison process that is promoted by print and video images of body-ideal men
and women [121,125].

Recommendations
More research
As presented through various methodologies and studies, statistically significant relationshipsalthough small in magnitudeexist between adolescents;
media use and body image attitudes and behaviors. The body of research, although
growing, is not complete. As Irving [126] suggested, further work in this area
should explore how medias influence: (1) interacts with individual factors, (2) affects those who are most vulnerable, and (3) interrelates with other socio-cultural
factors to have an effect on body image and eating attitudes. The authors recommend, beyond the conduct of more research, that interventions and policy be
used to lessen medias impact on the risk for obesity and disordered eating [126].
Interventions
To alter the impact of media on adolescents body image, numerous prevention
programs have been developed and implemented. To date, there is limited evidence to show that such programs are effective [127]. Furthermore, some studies
demonstrated that some prevention programs actually increase problem behaviors
[128,129]. A meta-analysis of randomized clinical trials focused on eating disorder prevention programs in adolescence by groups in various industrialized
countries, including Australia, Canada, Norway, the United Kingdom, and the

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United States [130]. This meta-analysis identified four types of interventions:

psychoeducation; class discussion of eating attitudes and behaviors, eating disorders and general adolescent issues; media literacy and advocacy skills; and
programs that focused on promoting self-esteem, with no direct focus on eating
attitudes, behaviors, or disorders. This review suggested that programs that include a media literacy and advocacy approach will be more successful [130]. In
one such study, fourth-, fifth-, and sixth-grade girls learned to recognize deceptive media techniques, critically analyze media messages, and evaluate people in
ways other than by appearance. At follow-up, girls in the intervention group,
compared with those in the control group, decreased their levels of body distortion and increased their awareness of body stereotypes [131]. Another study
analyzed the media-related attitudes and behaviors of fifth- and sixth-grade girls
before and following six 90-minute media literacy and advocacy sessions. The
researchers observed a significant positive influence on media-related attitudes
and behaviors and a modest effect on body-related knowledge and attitudes [70].
The meta-analysis findings are bolstered by two subsequent studies that
showed success with reducing eating disorders through well-designed, mediabased intervention programs [130]. The first examined the effect of school-based
media literacy versus self-esteem programs for reducing eating disorder risk
factors on eighth-grade boys and girls in the United States. The male and female
adolescents who participated in the adapted version of the GO GIRLS! Program
for media literacy showed reduced levels of weight concern when compared
with the self-esteem and control groups [132,133]. The second study involved an
Internet-delivered eating disorder prevention program for tenth-grade girls and
their parents; this was the first educational intervention to allow parents to
address individual and familial risk factors. Student participants in the Student
Bodies intervention demonstrated significantly reduced eating restraint and
greater increases in knowledge in comparison with the control group, although
these differences did not remain at the 3-month follow-up. Parent participants
showed significant decreases in critical attitudes toward shape and weight; however, the results are questionable because many parents in the intervention group
did not comply fully with the intervention [134]. Another recent study did not
focus on eating disorders, but instead looked at dieting. After being exposed to
videos that showed dieting prevention messages, approximately one third of the
seventh- and eighth-grade female participants in Australia felt less likely to go on
a diet. Higher dieting, body dissatisfaction and negative effect, however, were
associated with lower persuasive ratings of the video messages. This demonstrated the importance of implementing the intervention before the onset of
dieting behavior [135].
Obesity-prevention programs are becoming more common as obesity becomes
more pervasive among youth. Three recent meta-analyses of obesity examined
prevention programs; one focused specifically on the importance of physical
activity in overweight and obesity [136139]. The reviews highlight the role of
increased physical activity and decreased sedentary behavior in the prevention of
obesity; two specifically mentioned the positive impact of limiting television to

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reduce excess weight gain [136,137]. Two key studies looked at the combined
effects of long-term dietary education and physical activity interventions on
obesity [56,139]. One study examined the effect of a behavioral choice intervention, Planet Health, which promotes physical activity and aims to modify
dietary intake and reduce sedentary behaviors, with a focus on reduced television
watching. Among the sixth- to eighth-grade participants, the girls demonstrated
lower obesity when compared with controls at the 2-year follow-up, although
there was no significant difference for boys. Change in television watching
was the only variable that mediated the intervention effect, although decreased
viewing was associated with reduced obesity prevalence only for girls [56]. A
second combined intervention study provided a school-based health promotion
course to 5- to 7-year-old children and their parents that was based on nutrition
education and emphasized keeping active and decreasing television viewing. The
only statistically significant change at the 1-year follow-up was reduced fat mass
in the intervention group [139].
The paucity of studies on obesity-prevention programs demonstrates the need
for further research, with a focus on reducing obesity without increasing weight
concerns and eating disorders. Two of the researchers who were cited above
(Mueller and Robinson) are carrying out follow-up studies, which should provide
important evidence on the relationship between weight concerns and media use.
Finally, one recent article promotes the integration of intervention programs
for eating disorders and obesity [140]. The investigators propose this union
because of the overlap of the two disorders as part of a spectrum of food- and
weight-related problems that are symptoms of a cultural context that inhibits the
development of healthy patterns of eating and physical activity and discourages a
healthy respect for diverse body weights and shapes [140]. They also propose
that integrated intervention programs could address personal, sociocultural and
behavioral factors using a media literacy/advocacy approach. They promote this
approach due to medias instructive role, its demonstrated promise in changing
health-relevant attitudes, its easy integration into the curriculum, its pervasiveness
in Western society, and its entertainment qualities. The investigators recognize
the differences between eating disorders and obesity, as well as the philosophical
differences and sociopolitical obstacles that such efforts encounter, and
recommend that the integration of the two might be most appropriate for primary
prevention or as a component in secondary or tertiary prevention programs. They
conclude that such integration is important given the high prevalence and
potential seriousness of disordered eating and obesity, the overlap between the
conditions, the potentially harmful consequences of addressing only one of these
conditions, and limited time, financial, and human resources [140].
Policy
Although the time and funding investment that intervention programs require
usually is substantial, their impact usually is limited to a small target population.
How is it possible to improve body image and lessen the negative impact of

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media on larger numbers of youth? One possible vehicle involves policies and
legislation, particularly those that are related to governmental regulatory groups.
Such policies are difficult to formulate because the free market rights of media
corporations can conflict with the public health of the diverse populations to
whom they appeal. In previous decades, government policy regarding media
usually was modified when children were involved; however, this no longer
seems to be the case, at least in the United States [141,142]. Given the laissezfaire trend of current federal agencies, a call-for-action is even more critical.
Industry guidelines and legislation do exist for some media. Since 1992, television networks have had voluntary standards to limit the portrayal of violence
[143]. In 1997, the Federal Communication Commission implemented requirements for educational and informational programming for children [144]; but
observance of these rules has been questionable and no television station has lost
its license for noncompliance [145]. Another mechanism, the use of ratings systems, is favored strongly by parents and public health organizations [93,146,147].
The movie ratings system was established by the Motion Picture Association of
America in 1968, and around 3 decades later, in 1996, the television industry
developed a similar system. In this same year, the Television Communications
Act mandated that new television sets be manufactured with a micro computer
chip (the V-chip) that could read these ratings [147]. Although age-based ratings
have been supplemented with content-based ratings, the system works poorly
[143]. Producers are inconsistent in program ratings and parents self-report
that they do not use the ratings and V-chip system, even when it is available
[93,142,148]. The video and computer game and music industries also have
developed ratings, both of which resemble, but are not identical to, those for
movies and television. The gaming industry ratings system is based on age [149]
and the music industry considers the explicitness of the lyrics [150].
One public health area that is noticeably absent from current industry guidelines, policies, and rating systems concerns body image and disordered eating.
Although it may be challenging to develop a rating system around these issues,
policies that are targeted at the mass media could take one of two forms: restrictions on negative body image and eating attitudes and behaviors, or the
general promotion of positive body image and eating attitudes and behaviors. The
first set of policies aims to restrict the portrayal of stereotypical body image (eg,
overly thin women and very muscular men) and the presentation of unhealthy
eating attitudes and behaviors (eg, dieting). The second group of policies focuses
on promoting healthy body image through the depiction of healthy-weight men
and women and targets the prevention of disordered eating and body change
methods by increasing awareness of their existence and the dangers that they
represent. These two types of policies are not exclusive, but represent the ideal
components in a continuum of restricting current, negative practices and replacing them with positive alternatives, in an effort to make media part of the
solution for adolescents.
Even if official policies do not materialize, it is possible and essential to make
media more accountable, whether this impetus emerges from subscribers and

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viewers, contributors (eg, writers and artists), institutions (eg, nongovernmental

agencies), or the media companies themselves. One example of a governmentdriven initiative to encourage the restriction of stereotypical body image is the
Body Image Seminar that was held by the British government following the
release of the report, Eating Disorders, Body Image & The Media [151]. At
the seminar, editors from leading womens and teen magazines announced the
adoption of a voluntary code to prohibit the publication of pictures of ultra-thin
models and celebrities [152]. VANS, Inc., a company that designs active-casual
footwear, clothing and accessories for the youth market, provides a strong example of company-driven efforts to promote positive body image in its customers.
VANS philosophy is to use real athletes instead of models to represent the
companys roots in action sports (S.B. Stanger, personal communication, 2004).
As a result, this companys advertisements portray healthy-looking youth, rather
than the emaciated models that are featured in other advertisements (Fig. 3).

Fig. 3. VANS, Inc. has a commitment to using average-looking models in their advertising.

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Research should continue to monitor the relationship between media and body
image, but interventions and policy are two measures that can be used to lessen
medias negative impact. Teaching media literacy and advocacy skills to youth
are successful in altering body image and eating disorders. The growing literature
in this area suggests that to counteract youths unhealthy attitudes and behaviors
regarding food and weight, integrated programs that address obesity and eating
disorders are recommended. Although interventions typically focus on smaller
target populations, policy has the opportunity to impact audiences on a wider
scale. Rather than censor media, the public ought to be made more aware of and
praise the mass media that feature and promote positive, healthy body images.

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