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Weight status and body image perceptions in

adolescents: current perspectives

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Adolescent Health, Medicine and Therapeutics
25 August 2015
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Dana K Voelker 1 Abstract: Adolescence represents a pivotal stage in the development of positive or negative
Justine J Reel 2 body image. Many influences exist during the teen years including transitions (eg, puberty) that
Christy Greenleaf 3 affect one’s body shape, weight status, and appearance. Weight status exists along a spectrum
between being obese (ie, where one’s body weight is in the 95th percentile for age and gender)
1
West Virginia University, College of
Physical Activity and Sport Sciences, to being underweight. Salient influences on body image include the media, which can target
Morgantown, WV, 2University of adolescents, and peers who help shape beliefs about the perceived body ideal. Internalization of
North Carolina Wilmington, College
of Health and Human Services,
and pressures to conform to these socially prescribed body ideals help to explain associations
Wilmington, NC, 3University of between weight status and body image. The concepts of fat talk and weight-related bullying
Wisconsin–Milwaukee, College of during adolescence greatly contribute to an overemphasis on body weight and appearance as
Health Sciences, Milwaukee, WI, USA
well as the development of negative body perceptions and dissatisfaction surrounding specific
body parts. This article provides an overview of the significance of adolescent development in
shaping body image, the relationship between body image and adolescent weight status, and
the consequences of having a negative body image during adolescence (ie, disordered eating,
Video abstract eating disorders, and dysfunctional exercise). Practical implications for promoting a healthy
weight status and positive body image among adolescents will be discussed.
Keywords: adolescence, eating disorders, obesity, bullying, puberty, physical activity

Weight status and body image perceptions

in adolescents: current perspectives
Body image has become a popular topic over the past 35 years. In fact, 90% of body
image studies have been published since 1980.1 Interest in this area parallels growing
public health concerns about weight status, physical inactivity, obesity, eating disorders,
and the associated spectrum of health consequences. Body image is a multidimensional
Point your SmartPhone at the code above. If you have a construct encompassing how we perceive, think, feel, and act toward our bodies2 and
QR code reader the video abstract will appear. Or use:
http://youtu.be/IR6dnYCa8_c
lies on a continuum from healthy body perceptions (ie, accurate and mostly positive)
to unhealthy body perceptions (ie, inaccurate and mostly negative).3,4 Evidence con-
sistently indicates that unhealthy body image is associated with obesity and physical
inactivity5 and plays a pivotal role in the development of eating disorders during
adolescence.6 Importantly, body image has “developmental significance” such that
Correspondence: Dana K Voelker it is not a static personal characteristic, but rather a dynamic aspect of ourselves that
Department of Sport Sciences, changes over the lifespan.1 Adolescence represents a critical period for healthy body
West Virginia University, Health
and Education Building, CPASS 207, image development due to the type and magnitude of age-related transitions occurring
PO Box 6116, 375 Birch Street, during this time. This paper will discuss the relevant literature on the significance of
Morgantown, WV 26506-6116, USA
Tel +1 304 293 0871
adolescent development in shaping body image, the relationship between body image
Email dkvoelker@mail.wvu.edu and adolescent weight status, and the consequences of an unhealthy body image during

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Voelker et al Dovepress

adolescence. Intervention strategies that address adolescent identified as a prominent source of weight- and appearance-
weight status and body image will be discussed. based pressures. In their systematic review, Webb and
Zimmer-Gembeck15 found that friends and peers influence
Adolescence as a critical period adolescent body dissatisfaction through various mechanisms,
in body image development including appearance-based teasing and criticism, modeling
A variety of cultural, social, physical, and psychological and discussing appearance concerns, making appearance
changes that characterize adolescence uniquely interact to comparisons, judging the appearance of friends, and social
shape body image between the ages of 12 years and 18 years. conflict or exclusion. Although less studied, romantic rela-
Our appearance-oriented culture often targets teens as poten- tionships also influence adolescent body image. For example,
tial consumers and has a significant negative impact on their Paxton et al16 found that body dissatisfaction among tenth
body image. In their meta-analysis, Groesz et al7 found that grade girls was strongly predicted by the belief that thinness
the greatest decline in body satisfaction occurred in girls was critical to their attraction to boys. Further, 85% of boys
under the age of 19 following exposure to overtly thin media did indeed perceive thinness as an attractive quality in girls.
images. Recent studies indicate that current diet, exercise, How adolescents perceive their bodies is strongly influenced
and beauty trends displayed in reality television shows and by their larger sociocultural context.
social media outlets can contribute to unhealthy adolescent Importantly, the influence of body ideals interacts with a
body perceptions. For example, Ashikali et  al8 found that critical period of physical change during adolescence as well.
15–18-year old girls exposed to a cosmetic surgery show Specifically, the changes that occur during puberty are among
(ie, Dr 90210) reported more weight-related and appear- the most rapid and diverse in human development, including
ance dissatisfaction than a control group exposed to a home changes in weight, height, body shape, body composition, as
improvement show (ie, Extreme Makeover Home Edition). well as primary and secondary sex characteristics. Importantly,
Tiggemann and Slater9 found that among 13–15-year old these physical changes also coincide with heightened exposure
girls, body image concerns increased with time spent on and subsequent comparisons to cultural ideals of beauty. For
the Internet and Facebook usage. Meier and Gray10 further girls, cultural expectations emphasize being thin and lean with
identified that the time spent on Facebook was less important large breasts as seen in print media, television, and online.
than the degree of exposure to appearance-specific media Thus, changes associated with puberty, such as increases
such as photo sharing, which was positively associated with in adiposity and widening of the hips, may be perceived
body image concerns. These findings suggest that in addi- negatively and seen as incongruent with the prototypical and
tion to print media, current television and Internet trends are societally valued “thin ideal.” Early maturing girls in particular,
sources of promoting unrealistic and so-called ideal images who are prone to greater puberty-related weight gain,17 have
to adolescents. As a continually evolving and ubiquitous reported a greater drive for thinness and stronger preference
source of information on body ideals, Perloff11 calls for more for a slender figure than their later maturing counterparts.18
research on the Internet, social media, and their influence on This finding suggests that early maturing girls may be espe-
body image among adolescents. cially vulnerable to developing a negative body image when
These cultural ideals and beliefs are also reinforced by they perceive their changing bodies to be misaligned with
significant others in adolescents’ immediate environments, cultural ideals. Although evidence indicates that adolescent
including family, peers, and romantic partners. Relative to boys report greater weight and appearance esteem than
family, research has shown that weight-based teasing from girls,19 boys are not immune to body image concerns during
parents and siblings is associated with body dissatisfac- adolescent development. Specifically, increases in height and
tion among girls and drive for muscularity among boys in muscle mass associated with puberty moves some boys closer
eighth and ninth grade.12 In a longitudinal study, Helfert and to cultural expectations to be tall and muscular. Late-maturing
­Warschburger13 found that the encouragement from parents to boys specifically, who have not achieved socially constructed
control weight was also linked to heightened weight concerns body ideals for men, report greater body dissatisfaction than
among high school girls and boys. Further, negative weight their early maturing counterparts.20 Thus, the perception of
talk and dieting among family members, especially from physical changes in a sociocultural context plays a critical role
mothers who serve as role models for body image, has been in shaping body image throughout adolescence.
shown to be related to body image concerns and disordered From a psychological perspective, adolescence has been
eating behaviors in adolescent girls.14 Peers have also been identified as a period of identity development in which they

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explore possible selves and make significant life decisions For example, in a direct test, Nanu et al19 found support for
that inform aspects of their lives,21,22 including ideological the influence of internalization on the association between
(ie, occupation, religion, politics, values) and interpersonal BMI and appearance- and weight-related esteem among
domains (ie, family, friendships, romantic partnerships, and girls aged 15–20 years. Lawler and Nixon32 in a study that
gender roles).23 Although an underexplored area, preliminary included 111 boys and 129 girls between the ages of 12 and
evidence suggests that these identity development processes 19, also supported internalization as a key construct. Inter-
are linked to body image. In a study of late-adolescent nalization, along with appearance criticism and conversations
Swedish youth, Wängqvist and Frisén24 found that girls with with peers, accounted for 45.7% of variance in body dissat-
stronger interpersonal identity commitments also had more isfaction over and above BMI. Additionally, Knauss et al33
positive views of how others evaluated their appearance. reported that among 819 boys and 791 girls aged 14–16,
Similarly, boys with stronger interpersonal identity commit- internalization of body ideals represented in the media and
ments evaluated their own appearance more favorably. These perceived pressures to conform to those ideals were signifi-
findings suggest that body image may improve as adolescent’s cant predictors of body dissatisfaction after accounting for
sense of self becomes increasingly stabilized. Other research BMI. For girls in the study, the strongest predictor of body
indicates that adolescents who strongly identify with tradi- dissatisfaction was internalization. These results together
tional gender roles may invest more in media-based body suggest that the degree to which unrealistic body ideals are
ideals.25 Further investigation will help us to understand the adopted as one’s own impacts the strength of the relationship
critical role of adolescent identity exploration and commit- between body mass and body image.
ment in shaping body perceptions. There are exceptions to studies that support internaliza-
tion as a key construct in explaining the associations between
The relationship between weight status and body image. Petrie et  al,34 for example,
adolescent weight status and considered the relative contributions of various biologi-
body image cal, psychological, and social variables (eg, BMI, pubertal
The percentage of obese adolescents has quadrupled over development, pressures, internalization, social comparison,
the past 30  years.26 Recent estimates indicate that ∼17% physical fitness, physical self-concept, depression, and self-
or 12.7 million youths ages 2–19  years are obese in the esteem) to body image among 629 boys and 659 girls in
US, with higher prevalence rates found among Hispanic grades 6–8. After accounting for BMI and pubertal devel-
youth (22.4%), followed by non-Hispanic black (20.2%), opment, girls with higher BMI, greater perceived pressure
white (14.1%), and Asian youth (8.6%). Over the course of to attain a lower weight, stronger social comparison, poorer
childhood and adolescence, obesity prevalence increases perceptions of physical ability, and higher self-esteem had
(ie, 8.4% of 2–5-year olds, 17.7% of 6–11-year olds, and greater satisfaction with their bodies. For boys, stronger
20.5% of 12–19-year olds),26 which is of considerable con- perceived pressures to gain muscle and poorer physical self-
cern for health and wellness over the lifespan. concept predicted body satisfaction above and beyond BMI.
Importantly, the weight status of youth (ie, overweight Internalization, although correlated with both BMI and body
and obese) is strongly connected to body image. Specifi- satisfaction (among girls only), was not a significant predictor
cally, research consistently shows that greater body mass of satisfaction for boys or girls. Looking at similar types of
index (BMI) is associated with heightened weight concerns associations, Mitchell et al,35 in a study of 685 girls in grades
in both adolescent girls and boys.27,28 Longitudinal studies 6–8, took a slightly different approach and examined BMI as
suggest that the impact on body image are long-term such a possible moderator of the association between internaliza-
that greater BMI during adolescence strongly predicts body tion and body dissatisfaction. BMI was associated with both
dissatisfaction in young adulthood.29,30 However, while the variables but did not moderate the relationship. It is likely that
association between weight status (objective or perceived) because of the complex, multifaceted, and dynamic nature
and body image is relatively consistent in the literature, the of social and psychological influences, multiple factors must
varied psychological factors that contribute to that relation- be considered. It may be that for some adolescents, other
ship provide a more complex picture. Internalization, the variables, such as pressures and concerns, social comparison,
degree to which someone adopts a sociocultural body ideal and weight-related talk and bullying, override the influence
as his or her own,31 seems to be a particularly salient psycho- of internalization of social body ideals on the weight status–
logical factor in the weight status–body image relationship. body image relationship.

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Indeed, appearance- and weight-related concerns and that appears to play a key role in adolescents’ assessment of
pressures mediate associations between body weight/ their bodies.
BMI and body image. Weight concerns and pressures are Fat talk, defined as negative body- and weight-related
experienced when individuals worry about their weight comments or conversations, is associated with body dis-
or physique, such as believing that their body is too fat or satisfaction among adolescents,39 yet research exploring the
not muscular enough, and perceive that others also believe extent to which fat talk influences the weight status–body
that their body shape or size is unacceptable. Jones and image relationship is limited. Bauer et  al40 studied 218
Crawford,36 in a study of 128 boys in grades 8–11, found mother–daughter pairs. Mothers’ scores on a measure of
that BMI was negatively associated with lack of muscularity fat talk that assessed frequency of talk directed toward their
concerns and positively associated with thinness concerns; daughters, themselves, and others were associated with
both muscularity and thinness concerns were, in turn, posi- body dissatisfaction among their daughters. These findings
tive predictors of body dissatisfaction. Thus, concerns about held even after accounting for BMI, which indicates that fat
not being muscular enough and being overweight, which are talk may be associated with dissatisfaction independent of
consistent with dominant body ideals for males, partially weight status.
accounted for variance in the relationship between body A construct associated with fat talk is weight-related
mass and body dissatisfaction. Knauss et al33 and Petrie et al34 bullying, which can include behavioral, psychological,
also supported weight pressures as a significant predictor and relational components, such as teasing and social
of body-related satisfaction beyond BMI. Petrie et al found exclusion. Overweight and obese youth are more likely to
that perceived pressure to gain muscularity was a predictor be the targets of weight-related bullying. In a meta-analysis
for boys; for girls, on the other hand, pressure to lose weight of 30 studies, van Geel et al41 found that overweight youth
was significant. Both studies found associations between are 1.19 and obese youth 1.15 times more likely to be
internalization and pressures, although Petrie et al did not find bullied compared to normal weight peers. Experiences
internalization to predict body satisfaction. Taken together, of bullying are associated with weight dissatisfaction.
these results indicate that perceived pressures may outweigh Lampard et  al 42 examined weight-related teasing as a
the influence of internalization of social body ideals as a school level variable, defined as the proportion of ado-
predictor of body image. lescent participants who reported individual teasing at
Other factors contributing to the complex relationship each school, among 20 middle and high schools. Results
between weight status and body image include social influ- from their study indicated that higher levels of girls’
ences, such as social comparison, fat talk, and weight-related body dissatisfaction were related to higher prevalence of
bullying. Social comparison, which is the tendency to com- school level teasing. Adolescents who experience weight-
pare one’s body or physique to that of others (ie, often some- related bullying report negative affect, such as sadness
one within a peer or friendship group), is especially relevant and depressed mood, as a result.43 Moreover, Fox and
among adolescents. Myers and Crowther,37 in a meta-analytic ­Farrow44 found that esteem (global and physical) and body
review of 156 studies, found that the effect of social com- dissatisfaction mediated the relationships between weight
parison on body dissatisfaction was negatively related to age, status and victimization among 195 boys and 175 girls
which supported the contention that comparing one’s body to aged 11–14 years. Thus, overweight and obese youth may
others is particularly problematic during adolescence. Petrie be particularly vulnerable to experiencing weight-related
et al34 found that engaging in social body comparison contrib- bullying when they also experience lower esteem and
uted to variance in body satisfaction among girls above and higher body dissatisfaction.
beyond what was accounted for by BMI. Similarly, Rodgers
et al38 studied 488 girls with a mean age of 12.35 years and Weight status, body image, and
found that 86% of body image concerns were accounted for the impact on health behaviors
by a model that included BMI and social comparison along The complex relationship between weight status and body
with peer teasing and internalization. Interestingly, social image is important because of its influence on adolescents’
comparison and internalization mediated the effects of social health behaviors. Negative health consequences that may
influences, but not BMI, on body image. Thus, although body result from the unique interaction of weight status and body
size, as indicated by BMI, may contribute to body image, it is image include physical inactivity, eating disorders, and
perception (eg, ­internalization, pressures, social comparison) dysfunctional exercise.

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Dovepress Weight status and body image perceptions in adolescents

Physical inactivity Losekam et al51 found that greater weight teasing was asso-
Trends in the prevalence of physical activity among over- ciated with lower levels of physical activity among boys;
weight and obese, compared to normal weight peers, are not however this relationship was not significant among girls.
clear. Whitt-Glover et al,45 for example, examined 2003–2004 In contrast, Jensen and Steele52 reported that among girls
National Health and Nutrition Examination Survey (NHANES) with higher body dissatisfaction, weight-related criticism
data and did not find major differences in meeting physical was associated with lower levels of physical activity; how-
activity recommendations as a function of weight status. ever, this association was not found among boys with higher
Belcher et  al,46 however, found that normal weight youth body dissatisfaction. Although male and female adolescents
engaged in 16 more minutes of moderate or vigorous physical experience pressures to conform to lean body ideals, there
activity compared to obese peers. Janssen et al47 reviewed data seems to be greater social stigma and stronger psychosocial
from 34 countries and found that higher BMI was associated consequences for females. The extent to which the social
with lower levels of physical activity among 10–16-year olds. construction of gender and body ideals shapes physical activ-
It is likely that other factors, such as age, gender, race/ethnicity, ity, in association with weight status and body image must
and socioeconomic status, also interact with body image and be further studied to identify consistent patterns.
related constructs to influence physical activity levels. The negative associations between weight, body image,
Overweight and obese youth, especially those who have and physical activity are unfortunate given that the positive
body- and appearance-related concerns, are likely to avoid effects of engaging in physical activity on body image, with
physical activity. For example, Neumark-Sztainer et al48 in and without changes in body composition, are consistently
a study of 2,516 adolescents found negative associations demonstrated in the literature.53–56 Yet, many young people
between body satisfaction and physical activity. Similarly, likely experience a cycle of weight concerns, physical activity
Puhl and Luedicke43 found that among adolescents who avoidance, pathogenic weight control behaviors, weight gain
were bullied, those who experienced negative affect avoided and experiences of weight-related bias and stigma.
physical activity. The intersectionality of weight, feelings
about one’s body, and barriers to activity were highlighted Eating disorders and dysfunctional
in a systematic review of 15 qualitative research stud- exercise
ies focused on physical activity.49 Specifically, common Body image concerns for adolescents extend beyond van-
themes reported across studies indicated that overweight ity and attitudes about appearance. Body dissatisfaction
and obese youth perceive individual barriers (eg, lack of among adolescent samples has been consistently shown to
fitness associated with excess weight), social barriers (eg, be the strongest predictor of disordered eating behaviors
exclusion and teasing), and environmental barriers (eg, and clinical eating disorders across psychosocial variables,
lack of privacy in gym changing rooms). To extend previ- such as perfectionism and locus of control.57 Negative body
ous work, Greenleaf  et  al50 examined physical fitness in image among adolescents, which includes dissatisfaction
addition to self-concept, self-efficacy, and physical activity. with one’s body shape, size, or specific body part and
Their study included 1,419 middle school students, and body distortion (ie, feelings that one is larger than actual
results indicated that after accounting for BMI, gender, size), can directly impact eating behaviors in an attempt to
ethnicity, socioeconomic status and pubertal development, sculpt one’s body into a perceived ideal and gain a sense
adolescents who had experienced teasing reported lower of control.58
physical self-concept and physical activity self-efficacy. In The link between body dissatisfaction and the devel-
addition, cardiorespiratory fitness and upper body strength opment of disordered eating have been explained by the
were lower among adolescents who had been teased even reduced self-esteem and negative emotions, such as depres-
though no differences in self-reported physical activity sion, that tend to occur when body dissatisfaction is pres-
were found. The association between weight status, weight ent, but these mediators have received equivocal results
stigma experiences, and physical activity seem fairly clear; across studies.59 Therefore, recent studies have attempted to
yet, additional research is needed to better understand the examine the relationship between the importance of body
mechanisms underlying these associations and to further image (ie, salience attached to attaining the ideal body) and
explore the impact on physical fitness. ­disordered ­eating behaviors versus the effect of body dissatis-
The influence of gender on the consequences of the faction alone. These initial findings suggest that the connec-
weight status–body image relationship is somewhat unclear. tion between body image disturbances and disordered eating

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behaviors is complex and does not represent a direct, linear several months on a consistent basis. Disordered eating is
relationship.60 More research is needed to explain why body often distinguished from clinical eating disorders as being
dissatisfaction is a consistent predictor of the development of pathological while not meeting all of the DSM-5 criteria.61
clinical eating disorders and disordered eating behaviors. In some cases, adolescents who engage in disordered eating
Negative body image has been a central diagnostic fea- exhibit eating disorder symptoms (eg, restricting, vomiting,
ture for all clinical eating disorders (ie, anorexia nervosa, or use of laxatives, excessive exercise) at a lower frequency
bulimia nervosa, binge eating disorder) as outlined by the than is required for a formal diagnosis. Despite using these
Diagnostic and Statistical Manual of Mental Disorders, disordered eating behaviors at a lower frequency or for a
Fifth Edition (DSM-5).61 Although all eating disorder diag- shorter time than what is required for a clinical diagnosis and
noses have included criteria about body image disturbances being considered “sub-clinical” (ie, less severe than a clinical
in the way one’s shape or weight is experienced, symptoms eating disorder), disordered eating can still contribute to a
are manifested differently for each disorder. Anorexia myriad of health consequences. Specifically, clinical eating
nervosa involves the severe restriction of food intake to disorders and disordered eating disrupt nearly every bodily
unhealthy levels that results in caloric deprivation. By system. Not only do eating disorders represent the highest
contrast, bulimia nervosa is characterized by binge episodes mortality rate of adolescents among all psychiatric condi-
of overeating followed by compensatory purging, such as tions, eating disorders can also be associated with increased
vomiting, laxatives use, diuretics, or obligatory exercise suicide risk and self-harming behaviors. Purging behaviors
to counteract excessive caloric intake.61 This obligatory such as repetitive vomiting can place excessive strain on
exercise goes beyond what is considered “healthy exercise” the esophagus, larynx, or voice box resulting in bleeding,
and features feelings of compulsion, guilt, and rigidity with tearing, or a ruptured esophagus. Other physical compli-
regards to what “counts” as exercise.62 This exercise may cations include cardiovascular problems, amenorrhea (ie,
serve as a way to compensate for calories consumed and absence of menstrual cycle), gastrointestinal problems, tooth
an attempt to cope with feelings of guilt and negative body decay, reduced bone density, and impaired colon function.
image.63 Finally, binge eating disorder, a new classification Electrolyte imbalances create an additional risk for individu-
in the DSM-5, features binge episodes without an accom- als with eating disorders and may result in hospitalization.67
panying purging method. Shame and harsh self-criticism Unfortunately, the intended goal of achieving one’s body ideal
have been identified as underlying mechanisms for binge and feeling satisfaction is never actualized, as adolescents
eating behavior.64 often find themselves obsessively consumed with the next
Adolescent girls face considerable risk for the develop- bodily flaw or losing the next 5 pounds.68
ment of clinical eating disorders due to intense body dis- Although being physically active is usually encouraged
satisfaction and pressure from peers to “look” a particular as a health-promoting behavior, exercising compulsively and
way; however, disordered eating and dieting behaviors that excessively is a common purging strategy used to compen-
do not meet full clinical criteria for eating disorder diag- sate for caloric intake or to change one’s body weight, size,
noses are much more common.65 Dieting is popular among or shape.69 This tendency to develop disordered behaviors
teens and college students who embrace the latest fad (eg, around exercise has received numerous labels including,
Paleo diet) in an attempt to overcome desires (eg, to con- but not limited to, exercise dependence, exercise abuse,
sume sugar) that may interfere with weight-related goals.66 exercise addiction, obligatory exercise, and overexercise.70
Adolescents may initially choose to diet or restrict food It is important to note that dysfunctional exercise involves
intake (ie, dietary restraint) in attempts to change weight both the amount and quality of exercise. That is, one’s emo-
or size. They may also develop pathogenic methods for tions around exercise and psychological mindset, including
purging food that lead to unintended health consequences. motivation for exercise, are as important as the quantity of
Furthermore, adolescents who experience guilt following a exercise sessions.71
binge episode may impulsively respond by vomiting, exces- Although exercise addiction is estimated to be around
sively exercising, or using laxatives. Adolescents who view 3% of the general population,72 this prevalence increases
purging behavior as a “workaround” for dietary setback may to 30%–70% among clinical samples,73 and is estimated to
experience the addictive quality of the purge when they feel range from 33% to almost 100% of inpatient eating disorder
temporary emotional relief. This “temporary solution” can clients.74 In Dalle Grave et al’s75 study, 39% of clients with
ultimately reach clinical levels if the behavior continues for bulimia nervosa and 43% of clients with anorexia nervosa

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Dovepress Weight status and body image perceptions in adolescents

who used purging methods engaged in excessive exercise social comparisons, and address the influence of traditional
behaviors. Importantly, dysfunctional exercise during treat- gender roles on body image development. A review of
ment and at the time of discharge is one of the strongest 16 classroom-based body image programs in secondary
predictors for eating disorder relapse.76 Like other disordered schools revealed that the most effective programs were mul-
eating behaviors, dysfunctional exercise is associated with tisession interventions targeted toward younger adolescents
physical and psychological health consequences, including between 12 years and 13 years of age that focused on media
poor concentration, fatigue, mood disturbances (eg, depres- literacy, boosting self-esteem, and building peer support.80
sion, irritability), overuse injuries (eg, stress fractures, pres- An emerging body of research suggests that the strengths
sure sores), social isolation, and impaired relationships.69 of social media, including its interactivity and networking
capabilities, may be a valuable forum for promoting body-
Practical implications positive messages. Perloff11 cautions that such social media
The importance of developing a healthy body image during interventions should be systematic, grounded in theory,
adolescence should be emphasized given the associated tailored to the unique needs of the intended audience, and
health consequences. In light of the rising obesity rates among empirically evaluated.
adolescents and the attention given to obesity as a public Although promising, these interventions are not without
health priority, schools and communities tend to focus on limitations. For example, Yager et al80 noted that fewer than
obesity prevention and weight loss alone. However, interven- 20% of classroom-based body image programs had lasting
tions that emphasize these objectives without consideration effects. Specifically, most programs that yielded body image
for body image may have unintended consequences. For improvements immediately following the intervention did not
example, Irving and Neumark-Sztainer77 assert that many sustain these improvements in the follow-up. Further, inter-
obesity interventions reinforce and normalize body dissat- vention programs have largely targeted adolescent girls,81,82
isfaction because of being overweight. In contrast, eating while intervention programs for adolescent boys are only
disorder interventions often emphasize self-acceptance and beginning to be developed and evaluated.83 Finally, other
health at every size. Irving and Neumark-Sztainer recom- researchers have emphasized the importance of attending to
mend that interventions be integrated to address the broad the design and target audience when developing body image
spectrum of eating- and weight-related concerns (ie, obesity interventions. For example, O’Dea84 found that two widely
and eating disorders) in ways that equally promote a healthy distributed body image education posters were perceived
body image. Neumark-Sztainer et al78 further suggest that negatively by adolescent girls in that they aroused body
interventions aimed to improve physical activity should image concerns and fueled social comparisons with girls
avoid strategies that may have a negative impact on the shown in the poster. O’Dea emphasized the importance of
body image of adolescents, such as unrealistic weight goals, first pilot-testing interventions on a small scale and soliciting
critical weight-related comments, and weigh-ins. Instead, the feedback from the intended audience. These efforts will
physical activity promotion should additionally include a help to guard against unintended consequences of a well-
means of increasing body satisfaction, especially when body intended initiative.
satisfaction may buffer against symptoms associated with A key example of an effective body image intervention
other mental health concerns in overweight adolescents, is The Body Project developed for adolescent and young
including depression, anxiety, and anger.79 Such integrated adult women with body image concerns.85 Participants in
approaches not only acknowledge the full spectrum of eat- this program critique the thin ideal through verbal, written,
ing- and weight-related concerns during adolescence, but also and behavioral activities to create cognitive dissonance with
consider the preponderance of evidence suggesting that the thin ideal messages and images and ultimately encourage
point of intervention should include improving body percep- positive perceptions of their own bodies. A growing body
tions versus weight status alone. of evidence has demonstrated the effectiveness of a face-to-
Grogan4 provided evidence supporting the effectiveness face group and internet version of this program.86,87 In their
of programs aimed to promote a healthy body image among meta-analysis of eating disorder prevention programs, Stice
both adolescent boys and girls. Specifically, she discussed et al88 found that the largest effects were identified for those
the importance of interventions that target the psychological that were delivered by expert interventionists to a selected
correlates of poor body image (eg, low self-esteem), buffer target audience for which the intervention was designed;
the internalization of thin and muscular body ideals, reduce were offered only to women versus a mixed-gender group;

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emphasized cognitive-dissonance and body acceptance; and 9. Tiggemann M, Slater A. Netgirls: the internet, facebook, and body image
concern in adolescent girls. Int J Eat Disord. 2013;46(6):630–633.
promoted active engagement across multiple sessions versus 10. Meier EP, Gray J. Facebook photo activity associated with body image
those that were merely didactic and psychoeducational.88 disturbance in adolescent girls. Cyberpsychol Behav Soc Netw. 2014;
As a critical theme, tailoring the intervention to the specific 17(4):199–206.
11. Perloff RM. Social media effects on young women’s body image
participant demographic (eg, age, gender, developmental concerns: theoretical perspectives and an agenda for research. Sex
period) is essential in program design. These guidelines may Roles. 2014;71(11–12):363–377.
12. Schaefer MK, Salafia EHB. The connection of teasing by parents,
be used and refined in the development of other intervention siblings, and peers with girls’ body dissatisfaction and boys’ drive for
programs that show promise in improving body image among muscularity: the role of social comparison as a mediator. Eat Behav.
adolescents. 2014;15(4):599–608.
13. Helfert S, Warschburger P. A prospective study on the impact of peer
and parental pressure on body dissatisfaction in adolescent girls and
Conclusion boys. Body Image. 2011;8(2):101–109.
14. Neumark-Sztainer D, Bauer KW, Friend S, Hannan PJ, Story M,
Adolescence is a critical period for body image development Berge JM. Family weight talk and dieting: how much do they matter
because of the various social, cultural, physical, and psy- for body dissatisfaction and disordered eating behaviors in adolescent
chological changes occurring between the ages of 12 years girls? J Adolesc Health. 2010;47(3):270–276.
15. Webb HJ, Zimmer-Gembeck MJ. The role of friends and peers in
and 18 years of age. The relationship between weight status adolescent body dissatisfaction: a review and critique of 15 years of
and body image is complex, such that additional variables research. J Res Adolesc. 2014;24(4):564–590.
16. Paxton SJ, Norris M, Wertheim EH, Durkin SJ, Anderson J. Body
must be considered when explaining this association, dissatisfaction, dating, and importance of thinness to attractiveness in
including internalization of body ideals, weight-related adolescent girls. Sex Roles. 2005;53(9–10):663–675.
pressures and concerns, and a range of social influences 17. Lee JM, Appugliese D, Kaciroti N, Corwyn RF, Bradley RH,
Lumeng JC. Weight status in young girls and the onset of puberty.
(eg, social comparison, fat talk, and weight-related teasing Pediatrics. 2007;119(3):e624–e630.
and bullying). Consequences associated with having a nega- 18. Ackard DM, Peterson CB. Association between puberty and disordered
eating, body image, and other psychological variables. Int J Eat Disord.
tive body image for adolescents include physical activity 2001;29(2):187–194.
avoidance, eating disorders, and dysfunctional exercise. 19. Nanu C, Tăut D, Băban A. Appearance esteem and weight esteem in
Therefore, promotion of a healthy body image should be adolescence. Are they different across age and gender? Cogn Brain
Behav. 2013;17(3):189–200.
integrated across all interventions aimed to address obesity, 20. McCabe MP, Ricciardelli LA. A Longitudinal study of pubertal timing
eating disorders, and other health-related concerns among and extreme body change behaviors among adolescent boys and girls.
Adolescence. 2004;39(153):145–166.
adolescents. 21. Erikson EH. Identity: Youth and Crisis. New York, NY: Norton; 1968.
22. Marcia JE. Development and validation of ego identity status. J Pers
Disclosure Soc Psychol. 1966;3:551–558.
23. Balistreri E, Busch-Rossnagel NA, Geisinger KF. Development and
The authors report no conflicts of interest in this work. preliminary validation of the ego identity process questionnaire.
J Adolesc. 1995;18(2):179–192.
24. Wängqvist M, Frisén A. Swedish 18-year-olds’ identity formation:
References associations with feelings about appearance and internalization of body
1. Markey CN. Why body image is important to adolescent development. ideals. J Adolesc. 2013;36(3):485–493.
J Youth Adolesc. 2010;39(12):1387–1391. 25. Smolak L, Stein JA. A longitudinal investigation of gender role and mus-
2. Cash TF. Body image: past, present, and future. Body Image. 2004;1(1): cle building in adolescent boys. Sex Roles. 2010;63(9–10):738–746.
1–5. 26. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood
3. Cash TF, Phillips KA, Santos MT, Hrabosky JI. Measuring ‘negative and adult obesity in the United States, 2011–2012. J Am Med Assoc.
body image’: validation of the body image disturbance questionnaire in 2014;311(8):806–814.
a nonclinical population. Body Image. 2004;1(4):363–372. 27. Calzo J, Sonneville KR, Haines J, Blood EA, Field AE, Austin SB.
4. Grogan S. Promoting positive body image in males and females: The development of associations among body mass index, body dis-
contemporary issues and future directions. Sex Roles. 2010;63(9–10): satisfaction, and weight and shape concern in adolescent boys and girls.
757–765. J Adolesc Health. 2012;51:517–523.
5. Harriger JA, Thompson JK. Psychological consequences of obesity: 28. Caccavale LJ, Farhat T, Iannotti RJ. Social engagement in adolescence
weight bias and body image in overweight and obese youth. Int Rev moderates the association between weight status and body image. Body
Psychiatry. 2012;24(3):247–253. Image. 2012;9(2):221–226.
6. Rohde P, Stice E, Marti CN. Development and predictive effects of eat- 29. Quick V, Eisenberg ME, Bucchianeri MM, Neumark-Sztainer D. Pro-
ing disorder risk factors during adolescence: implications for prevention spective predictors of body dissatisfaction in young adults: 10-year
efforts. Int J Eat Disord. 2015;48(2):187–198. longitudinal findings. Emerg Adulthood. 2013;1(4):271–282.
7. Groesz LM, Levine MP, Murnen SK. The effect of experimental presenta- 30. Bucchianeri MM, Arikian AJ, Hannan PJ, Eisenberg ME, Neumark-
tion of thin media images on body satisfaction: a meta-analytic review. Sztainer D. Body dissatisfaction from adolescence to young adulthood:
Int J Eat Disord. 2002;31(1):1–16. findings from a 10-year longitudinal study. Body Image. 2013;10(1):1–7.
8. Ashikali E-M, Dittmar H, Ayers S. The effect of cosmetic surgery real- 31. Thompson JK, van den Berg P, Roehrig M, Guarda AS, Heinberg LJ.
ity tv shows on adolescent girls’ body image. Psychol Pop Media Cult. The Sociocultural Attitudes Towards Appearance Scale-3 (SATAQ-3):
2014;3(3):141–153. development and validation. Int J Eat Disord. 2004;35(3):293–304.

156 submit your manuscript | www.dovepress.com Adolescent Health, Medicine and Therapeutics 2015:6
Dovepress
Dovepress Weight status and body image perceptions in adolescents

32. Lawler M, Nixon E. Body dissatisfaction among adolescent boys and 52. Jensen CD, Steele RG. Brief report: body dissatisfaction, weight
girls: the effects of body mass, peer appearance culture and internaliza- criticism, and self-reported physical activity in preadolescent children.
tion of appearance ideals. J Youth Adolesc. 2011;40(1):59–71. J Pediatr Psychol. 2009;34(8):822–826.
33. Knauss C, Paxton SJ, Alsaker FD. Relationships amongst body dis- 53. Monteiro Gaspar MJ, Amaral TF, Oliveira BMPM, Borges N. Protective
satisfaction, internalisation of the media body ideal and perceived pres- effect of physical activity on dissatisfaction with body image in
sure from media in adolescent girls and boys. Body Image. 2007;4(4): children – a cross-sectional study. Psychol Sport Exercise. 2011;12(5):
353–360. 563–569.
34. Petrie TA, Greenleaf C, Martin S. Biopsychosocial and physical cor- 54. Goldfield GS, Mallory R, Parker T, et al. Effects of modifying physical
relates of middle school boys’ and girls’ body satisfaction. Sex Roles. activity and sedentary behavior on psychosocial adjustment in over-
2010;63(9–10):631–644. weight/obese children. J Pediatr Psychol. 2007;32(7):783–793.
35. Mitchell SH, Petrie TA, Greenleaf CA, Martin SB. Moderators of the 55. Huang JS, Norman GJ, Zabinski MF, Calfas K, Patrick K. Body
internalization – body dissatisfaction relationship in middle school girls. image and self-esteem among adolescents undergoing an intervention
Body Image. 2012;9(4):431–440. targeting dietary and physical activity behaviors. J Adolesc Health.
36. Jones DC, Crawford JK. Adolescent boys and body image: weight and 2007;40(3):245–251.
muscularity concerns as dual pathways to body dissatisfaction. J Youth 56. Lindwall M, Lindgren E-C. The effects of a 6-month exercise inter-
Adolesc. 2005;34(6):629–636. vention programme on physical self-perceptions and social physique
37. Myers TA, Crowther JH. Social comparison as a predictor of body anxiety in non-physically active adolescent Swedish girls. Psychol Sport
dissatisfaction: a meta-analytic review. J Abnorm Psychol. 2009;118(4): Exerc. 2005;6(6):643–658.
683–698. 57. Wertheim EH, Koerner J, Paxton SJ. Longitudinal predictors of restric-
38. Rodgers RF, Paxton SJ, McLean SA. A biopsychosocial model of tive eating and bulimic tendencies in three different age groups of
body image concerns and disordered eating in adolescent girls. J Youth adolescent girls. J Youth Adolesc. 2001;30(1):69–81.
Adolesc. 2014;43:814–823. 58. Stice E, Shaw HE. Role of body dissatisfaction in the onset and mainte-
39. Sharpe H, Naumann U, Treasure J, Schmidt U. Is fat talking a causal risk nance of eating pathology: a synthesis of research findings. J Psychosom
factor for body dissatisfaction? A systematic review and meta-analysis. Res. 2002;53(5):985–993.
Int J Eat Disord. 2013;46(7):643–652. 59. Heywood S, McCabe MP. Negative affect as a mediator between body
40. Bauer KW, Bucchianeri MM, Neumark-Sztainer D. Mother-reported dissatisfaction and extreme weight loss and muscle gain behaviors.
parental weight talk and adolescent girls’ emotional health, weight J Health Psychol. 2006;11(6):833–844.
control attempts, and disordered eating behaviors. J Eat Disord. 60. Brechan I, Kvalem IL. Relationship between body dissatisfaction and
2013;1:45–45. disordered eating: mediating role of self-esteem and depression. Eat
41. van Geel M, Vedder P, Tanilon J. Are overweight and obese youths Behav. 2015;17:49–58.
more often bullied by their peers? A meta-analysis on the relation 61. American Psychiatric Association. Diagnostic and Statistical Manual
between weight status and bullying. Int J Obes (Lond). 2014;38(10): of Mental Disorders. Fifth ed. Washington, DC: American Psychiatric
1263–1267. Association; 2013.
42. Lampard AM, MacLehose RF, Eisenberg ME, Neumark-Sztainer D, 62. Reel JJ. The relationship between exercise and eating disorders: a double-
Davison KK. Weight-related teasing in the school environment: associations edged sword. In: Andersen MB, Hanrahan SJ, editors. Doing Exercise
with psychosocial health and weight control practices among adolescent Psychology. Champaign, IL, US: Human Kinetics; 2015:259–273.
boys and girls. J Youth Adolesc. 2014;43(10):1770–1780. 63. De Young KP, Anderson DA. The importance of the function of exercise
43. Puhl RM, Luedicke J. Weight-based victimization among adolescents in the relationship between obligatory exercise and eating and body
in the school setting: emotional reactions and coping behaviors. J Youth image concerns. Eat Behav. 2010;11(1):62–64.
Adolesc. 2012;41(1):27–40. 64. Duarte C, Pinto-Gouveia J, Ferreira C. Escaping from body image
44. Fox CL, Farrow CV. Global and physical self-esteem and body dis- shame and harsh self-criticism: exploration of underlying mechanisms
satisfaction as mediators of the relationship between weight status and of binge eating. Eat Behav. 2014;15(4):638–643.
being a victim of bullying. J Adolesc. 2009;32(5):1287–1301. 65. Croll JK, Neumark-Sztainer D, Story M, Ireland M. Prevalence and
45. Whitt-Glover MC, Taylor WC, Floyd MF, Yore MM, Yancey AK, risk and protective factors related to disordered eating behaviors among
Matthews CE. Disparities in physical activity and sedentary behav- adolescents: relationship to gender and ethnicity. J Adolesc Health.
iors among US children and adolescents: prevalence, correlates, and 2002;31(2):166–175.
intervention implications. J Public Health Policy. 2009;30(Suppl 1): 66. Radtke T, Kaklamanou D, Scholz U, Hornung R, Armitage CJ. Are
S309–S334. diet-specific compensatory health beliefs predictive of dieting intentions
46. Belcher BR, Berrigan D, Dodd KW, Emken BA, Chou C-P, and behaviour? Appetite. 2014;76:36–43.
Spruijt-Metz D. Physical activity in US youth: effect of race/ethnicity, 67. Katzman DK. Medical complications in adolescents with anorexia
age, gender, and weight status. Med Sci Sports Exerc. 2010;42(12): nervosa: a review of the literature. Int J Eat Disord. 2005;37(Suppl):
2211–2221. S52–S59.
47. Janssen I, Katzmarzyk PT, Boyce WF, et  al; Health Behaviour in 68. Burt NM, Boddy LE, Bridgett DJ. Contribution of temperament to eat-
School-Aged Children Obesity Working Group. Comparison of over- ing disorder symptoms in emerging adulthood: additive and interactive
weight and obesity prevalence in school-aged youth from 34 countries effects. Eat Behav. 2015;18:30–35.
and their relationships with physical activity and dietary patterns. Obes 69. Hausenblas HA, Cook BJ, Chittester NI. Can exercise treat eating
Rev. 2005;6(2):123–132. disorders? Exerc Sport Sci Rev. 2008;36(1):43–47.
48. Neumark-Sztainer D, Paxton SJ, Hannan PJ, Haines J, Story M. Does 70. Calogero RM, Pedrotty-Stump KN. Incorporating exercise into eating
body dissatisfaction matter? J Adolesc Health. 2006;39:244–251. disorder treatment and recovery: cultivating a mindful approach. In:
49. Stankov I, Olds T, Cargo M. Overweight and obese adolescents: what turns Maine M, McGilley BH, Bunnell DW, editors. Treatment of Eating
them off physical activity? Int J Behav Nutr Phys Act. 2012;9:53–53. Disorders: Bridging the Research – Practice Gap. San Diego, CA, US:
50. Greenleaf C, Petrie TA, Martin SB. Relationship of weight-based teasing Elsevier Academic Press; 2010:425–441.
and adolescents’ psychological well-being and physical health. J Sch 71. Taranis L, Meyer C. Associations between specific components of
Health. 2014;84(1):49–55. compulsive exercise and eating-disordered cognitions and behaviors
51. Losekam S, Goetzky B, Kraeling S, Rief W, Hilbert A. Physical activ- among young women. Int J Eat Disord. 2011;44(5):452–458.
ity in normal-weight and overweight youth: associations with weight 72. Sussman S, Lisha N, Griffiths M. Prevalence of the addictions: a problem
teasing and self-efficacy. Obes Facts. 2010;3(4):239–244. of the majority or the minority? Eval Health Prof. 2011;34(1):3–56.

Adolescent Health, Medicine and Therapeutics 2015:6 submit your manuscript | www.dovepress.com
157
Dovepress
Voelker et al Dovepress

73. Mond JM, Calogero RM. Excessive exercise in eating disorder patients 81. Richardson SM, Paxton SJ. An evaluation of a body image intervention
and in healthy women. Aust N Z J Psychiatry. 2009;43(3):227–234. based on risk factors for body dissatisfaction: a controlled study with
74. Kiezebrink K, Campbell D, Mann E, Blundell J. Similarities and differ- adolescent girls. Int J Eat Disord. 2010;43(2):112–122.
ences between excessive exercising anorexia nervosa patients compared 82. Halliwell E, Diedrichs PC. Testing a dissonance body image interven-
with DSM-IV defined anorexia nervosa subtypes. Eat Weight Disord. tion among young girls. Health Psychol. 2014;33(2):201–204.
2009;14(4):e199–e204. 83. McCabe MP, Ricciardelli LA, Karantzas G. Impact of a healthy body
75. Dalle Grave R, Calugi S, Marchesini G. Compulsive exercise to control image program among adolescent boys on body image, negative affect,
shape or weight in eating disorders: prevalence, associated features, and and body change strategies. Body Image. 2010;7(2):117–123.
treatment outcome. Compr Psychiatry. 2008;49(4):346–352. 84. O’Dea J. Can body image education programs be harmful to adolescent
76. Steinglass JE, Sysko R, Glasofer D, Albano AM, Simpson HB, females? Eat Disord. 2002;10(1):1–13.
Walsh BT. Rationale for the application of exposure and response 85. Stice E, Shaw H, Burton E, Wade E. Dissonance and healthy weight
prevention to the treatment of anorexia nervosa. Int J Eat Disord. 2011; eating disorder prevention programs: a randomized efficacy trial.
44(2):134–141. J Consult Clin Psychol. 2006;74(2):263–275.
77. Irving LM, Neumark-Sztainer D. Integrating the prevention of eat- 86. Stice E, Rohde P, Durant S, Shaw H. A preliminary trial of a prototype
ing disorders and obesity: feasible or futile? Prev Med. 2002;34(3): internet dissonance-based eating disorder prevention program for young
299–309. women with body image concerns. J Consult Clin Psychol. 2012;80(5):
78. Neumark-Sztainer D, Goeden C, Story M, Wall M. Associations between 907–916.
body satisfaction and physical activity in adolescents: implications 87. Stice E, Butryn ML, Rohde P, Shaw H, Marti CN. An effectiveness trial
for programs aimed at preventing a broad spectrum of weight-related of a new enhanced dissonance eating disorder prevention program among
disorders. Eat Disord. 2004;12(2):125–137. female college students. Behav Res Ther. 2013;51(12):862–871.
79. Cromley T, Knatz S, Rockwell R, Neumark-Sztainer D, Story M, 88. Stice E, Shaw H, Marti CN. A meta-analytic review of eating disorder
Boutelle K. Relationships between body satisfaction and psychological prevention programs: encouraging findings. Annu Rev Clin Psychol.
functioning and weight-related cognitions and behaviors in overweight 2007;3:207–231.
adolescents. J Adolesc Health. 2012;50(6):651–653.
80. Yager Z, Diedrichs PC, Ricciardelli LA, Halliwell E. What works in
secondary schools? A systematic review of classroom-based body image
programs. Body Image. 2013;10(3):271–281.

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