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msJAMA
November 7, 2001

Body Image in the Balance

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JAMA. 2001;286(17):2159. doi:10.1001/jama.286.17.2159-JMS1107-3-1

You have been weighed in the balance and found wanting. Daniel 5:27

While 21st century Americans are more concerned about being found ample than wanting, the emotional impact of the scale's judgment is as powerful today as it was in Biblical times. Across the weight spectrum, as many as 66% of women and 52% of men report feelings of dissatisfaction or inadequacy regarding their body weight.1 Once considered to be a mere side effect of weight gain, body image distress is increasingly being recognized as a medical and psychological problem in its own right.

Although body image distress among men appears to be on the rise, the problem still predominantly affects women.2 In part, this may be due to the perpetuation of idealized and unrealistic female body images by the mass media in the United States and other Western countries. For example, since 1922, the body mass index of Miss America winners has steadily decreased to a level that, for most winners in the past 3 decades, lies within the range of undernutrition.3 In a recent study, prolonged exposure to Western television was found to give rise to dramatically increased rates of weight concern and disordered eating in Fijian adolescent girls.4

Current research suggests that the prevalence of pathological weight loss behaviors is increasing as a result of increasing body weight dissatisfaction. Some 35% of dieters in the United States engage in pathological dieting, and one quarter of pathological dieters go on to develop sub-threshold or full-syndrome eating disorders.5 Excessive dissatisfaction with body shape and weight may also cause patients to engage in self-destructive behavior such as abuse of diet pills, fad diets, or compulsive exercise.

Practitioners who treat patients with eating disorders are acquainted with the phenomenon of body image distress across the weight spectrum, including underweight patients with anorexia nervosa, normal-weight patients with bulimia nervosa, and obese patients with binge eating disorder. An individual's belief that her weight and shape are central to her worth as a person, along with an assessment that her current weight as unsatisfactory, leads to the classic eating disordered mind set. The rigid and unforgiving nature of this belief system, combined with the fact that weight cannot be easily or quickly modified, creates a barrier to the positive self-regard that energizes healthful living.

At the same time, some degree of body image dissatisfaction is normative and perhaps even useful for those who could benefit from weight loss. Researchers have suggested that the distinction between pathological distress and normative discontent with one's appearance is largely one of degree. Heinberg and colleagues propose an "inverted U" model for determining the amount of body image distress that is optimal for producing significant, but not pathological, behavioral change.6 Obese patients who have too little body image distress may not be sufficiently motivated to practice the taxing dietary and exercise routines necessary for weight loss. Conversely, those with too much distress are at risk of engaging in self-destructive measures or may be "paralyzed" by the seeming impossibility of the task.

For the individual whose self-definition is overly dependent on weight and shape, the amelioration of body image distress may be a prerequisite to ongoing healthy lifestyle change.7 Cognitive behavioral therapy has been shown to improve body image even in the absence of weight loss and can complement behavioral and dietary strategies in weight management.8 Self-acceptance and healthy change are not contradictory ideals; rather they are mutually reinforcing principles in the journey toward health.9

The physician's challenge, then, is to assess the patient's attitudes toward her body and to assist her in negotiating the delicate balance between acceptance and change. A heightened awareness of media influences and their impact on the target audience may increase the clinician's ability to empathize with his or her patients' concerns.

While less precisely measurable than blood pressure, lipid profile, or fasting glucose, the patient's self-regard is a key component of her overall health and well-being. When excessive or pathological, body image distress is a problem in its own right, and the intentional or unwitting reinforcement of this distress, even in the service of a laudable goal, can have serious consequences for the patient.

References
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Becker  AE Body, Self, and Society: The View From Fiji.  Philadelphia, Pa University of Philadelphia Press1995;
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Shisslak  CMCrago  MEstes  LS The spectrum of eating disturbances. Int J Eat Disord. 1995;18209- 219Article
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Heinberg  LJThompson  JKMatzon  JL Body image dissatisfaction as a motivator for healthy lifestyle change: is some distress beneficial? Streigel-Moore  RHSmolak  Leds.Eating Disorders: Innovative Directions in Research and Practice Washington, DC American Psychological Association2001;215- 232
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Kearney-Cooke  AStriegel-Moore  R The etiology and treatment of body image disturbance. Garner  DMGarfinkel  PDeds.Handbook of Treatment for Eating Disorders 2nd ed. New York, NY The Guilford Press1997;295- 306
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Rosen  JCOrosan  PReiter  J Cognitive behavioral therapy for negative body image in obese women. Behav Ther. 1995;2625- 42Article
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Wilson  GT Acceptance and change in the treatment of eating disorders and obesity. Behav Ther. 1996;27417- 439Article
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