Since the onset of the COVID-19 pandemic, we have seen increases in the rates of disordered eating and eating disorders among youth, as well as rising fear of weight gain and weight stigma. Part of this rise has been attributed to language used in lay media in reference to gaining the “quarantine 15” and diets claiming to help us get our “pre-pandemic bods” back. And while our language as health care providers can have a positive, empathetic impact on patients, it can also contribute to misconceptions and stereotypes that interfere with obtaining quality mental health care.
Extending beyond the clinic room, the language used by health care providers spreads to patients, their families, and beyond, which can help reduce stigma and encourage help-seeking behavior. Given the increasing prevalence and visibility of these issues, there is a clear need to discuss our language around body image to ensure clear and accurate communication by health care providers.
As clinician-scientists steeped in eating disorder assessment and treatment, we hope this primer on common terms used to discuss body, weight, and shape concerns, can help standardize language between providers, caregivers and children, policymakers and those who engage with youth when discussing solutions for our current eating disorder crisis among youth.
Body image is an individual’s own subjective experience of their body. It is a complex construct that involves our perception, feelings, and thoughts about our body as well as one’s behaviors in reaction to our perception, thoughts, and feelings about our own body (e.g., avoiding situations where our body can be seen or exposed). Our body image may be neutral, negative, positive or a mixture of these on any given day, time, or situation.
Clinical, research, and media attention typically focuses on negative, or poor, body image. Negative body image can involve a distorted perception of size or shape, like seeing parts of one’s body, or whole body, as different than it objectively is, as well as more global feelings of discomfort, dissatisfaction, shame or anxiety about one’s body. Poor body image is often a predictor of low self-esteem, anxiety, depression, stress, dieting and eating disorders in adolescents.
Positive body image is generally considered to encompass a more accurate perception of one’s body size and/or shape as well as comfort or acceptance of one’s body. Enjoying, respecting and taking care of the body are typically considered part of holding positive body image. Importantly, positive body image does not imply always liking or loving one’s body. Instead, we often encourage youth to think of positive body image to be living a meaningful life without having to change their eating, activities, or behavior due to thoughts or feelings about their body.
Body dissatisfaction is a subcomponent of negative body image, usually referring to holding negative thoughts or feelings about one’s body image. Individuals who are dissatisfied with their body typically describe a discrepancy between their subjective perception of their body and their ideal body image. Body dissatisfaction and negative body image are common in youth and may relate to dissatisfaction with not only one’s shape or weight but can also refer to dissatisfaction with height, general appearance or individual body parts. Being dissatisfied with one’s shape or weight can put someone at risk of engaging in disordered eating or developing a clinical eating disorder. However, body dissatisfaction alone is not enough to be diagnosed with an eating disorder.
BODY IMAGE DISTURBANCE
Body image disturbance is defined as a distorted perception of how someone sees their own body. This differs from dissatisfaction alone—a teenager can be dissatisfied with their body while still having an accurate perception of their body. Body image disturbance has historically been considered a hallmark of clinical eating disorders and is related to poorer treatment outcomes and relapse. Although body image disturbance is perceptual, this misperception is often influenced by our thoughts, feelings and attention. Importantly, it is possible for someone to be diagnosed with an eating disorder even if they do not express body image disturbance or overvaluation of shape and weight.
OVERVALUATION OF SHAPE AND WEIGHT
Overvaluation of shape and weight refers to the importance someone places on shape and weight for their identity, sense of self and self-worth. Unlike body image dissatisfaction, which may fluctuate based on mood or thoughts, overvaluation of shape and weight is stable across situations. While it is possible for someone to overvalue shape or weight and not develop an eating disorder, it does increase the likelihood of disordered eating and/or unhealthy exercise behaviors.
Often used by the public and media to express body dissatisfaction or body image disturbance, body dysmorphia is an attribute of body dysmorphic disorder. Someone with body dysmorphic disorder has obsessive thoughts with a perceived flaw in their appearance that others do not see, e.g., believing one’s nose is deformed, skin is scarred/discolored or other body part is disfigured. Importantly, the perceived flaw cannot be solely weight or shape-related. Those with body dysmorphic disorder often go to extreme lengths to manage distress related to their appearance, such as cosmetic surgery or avoiding social situations, and often spend hours worrying or checking their appearance. Muscle dysmorphia is a subtype of body dysmorphic disorder where one is preoccupied with being insufficiently muscular, engages in compulsive muscle building behavior, and experiences significant distress related to their physique.
The nuances of these terms and concepts are incredibly important in our efforts to effectively diagnose and treat body image and eating difficulties in youth. Accurate language is a key first step in helping families connect with the care they need and is also critical in the development of strategies to train educators and caregivers to support in identifying youth with eating disorders. Accurate language lays the groundwork for identifying solutions—policy, clinical and educational—to address the eating disorder crisis we are now facing.