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Body Image

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(Diet) Culture & Society

The information in this article originally appeared in an Equip Academy presentation, presented by Cara Bohon and 

 to learn about other eating disorder-related topics and earn free CE credits.

Eating disorders often involve body image concerns. Addressing these concerns is an important part of treatment, as it helps protect patients against relapse and set them up for lasting recovery. One way to do this may be to challenge harmful appearance ideals, which are often a major contributing factor to body image distress—and research suggests that cognitive dissonance theory may be a particularly effective tool for dismantling deeply ingrained appearance ideals.

Here, we’ll evaluate the origins of appearance ideals and body image pressures; examine cognitive dissonance-based body image programs and the theory behind them; and explore how to incorporate specific cognitive dissonance-based approaches to decrease body image concerns.

Body image is something we all have. In the simplest terms, body image is a person’s experience in their body. This includes their:

We often talk about “good” or “bad” body image, but it’s more nuanced than that. Body image concepts exist on a spectrum.

The concepts of “body judgment” and “body dissatisfaction” fall under the umbrella of negative body image.

, a drive for thinness, a distorted view of one’s self, body comparison, and a strong belief in appearance ideals.

Someone with a negative body image may say things like “If I looked like x, my life would be perfect,” or “I wish I was toned like you.”


The concepts of “body neutrality” and “body trust” fall under the umbrella of neutral body image.

This might show up as focusing on body function or qualities versus appearance, neutral statements about one’s body, and self-compassion.

Someone with a neutral body image may say things like, “My body is the least interesting thing about me.”

The concepts of “radical self-love” and “body liberation” fall under the umbrella of positive body image.

This might show up as body activism, challenging appearance ideals, loving every single cell, body joy, and body positivity.

Someone with a positive body image may believe strongly in these words from author and activist Sonya Renee Taylor: “Making peace with your body is your mighty act of revolution. It is your contribution to a changed planet where we might all live unapologetically in the bodies we have.”

There are a number of different appearance ideals that can inform (and often harm) someone’s body image. It’s also important to recognize that not all of us experience the same appearance ideals, as some may be more dominant than others. Race, ethnicity, socioeconomic status, disabilities, and gender identity can all influence what we are told is “ideal”.

When you think of the “perfect” girl or woman, how would you describe her?

Though answers may vary, people often respond with words like “slender,” “pretty,” “cute,” or “graceful.” We call this “look” the “feminine ideal.” It’s sometimes called the “thin ideal” because of the emphasis on overall thinness as one of the most important factors that represents femininity.

When you think of the “perfect” boy or man, how would you describe him?

Though answers may vary, people often respond with words like “strong,” “toned,” “muscular,” “lean,” or “handsome.” This is sometimes called the “muscular ideal” because of the emphasis on overall muscularity as one of the most important factors that represents masculinity.

When you think of the “perfect” non-binary person, how would you describe them?

Though answers may vary, this is sometimes called the “androgynous ideal” because of the emphasis on overall androgyny as one of the most important factors that represents being non-binary.

You might rightly wonder, where do these appearance ideals come from? It’s complex.

We have to think about these appearance ideals in the context of various systems of oppression designed to limit who has access in our society. Some of the factors that inform and shape appearance ideals include:

Appearance ideals have deep, historical roots. The ideals have changed throughout history based on what will keep institutions, businesses, and privileged individuals profiting and in power. Even as they change, they continue to stay narrow, restrictive, and unobtainable for pretty much everyone. Currently, the appearance ideals are 

shifting back to the “thin aesthetic” from the early 2000s

, with an emphasis on thin and flat stomachs.

Appearance ideals show up in our lives in many ways, including:

Comments from family, friends, colleagues, etc.

How we view, talk about, and treat ourselves

Ill-informed diagnostic criteria, biased doctors

Wellness or “lifestyle change” programs

The pursuit of appearance ideals has a significant negative impact, both on an individual and a societal level.

According to Deloitte, appearance-based discrimination (defined as the unjust, prejudicial treatment of somebody purely based on their appearance) has a high cost. Their data shows that in a given year:

Appearance-based discrimination (defined as the unjust, prejudicial treatment of somebody purely based on their appearance) leads to $269 billion in financial costs and $233 billion in lost well-being

Weight discrimination affected 34 million people and cost $206 billion

Skin shade discrimination affected 27 million people in the Black community and cost $63 billion

Natural hair discrimination affected 5 million people in the Black community

Body dissatisfaction (defined as having a severe and persistent negative attitude toward one’s own physical appearance, which has been caused by harmful beauty ideals) led to $84 billion in financial costs and $221 billion in lost well-being

Diet culture thrives on body image concerns, which are fueled by appearance ideals. In our diet culture-informed society, body image distress is extremely common among all populations.

41% of men think they are “too heavy” and are self-conscious about weight

60% of women think they are “too heavy” and are self-conscious about weight

80% of young teenage girls report fears of becoming fat

82% of adults believe weight loss is their responsibility

95% of people who diet regain weight they lost within 5 years

$71 billion spent on dieting and weight loss in 2020

Not all people who struggle with body image will develop an eating disorder, but a significant subset will, and body image distress is often a contributing factor to (and symptom of) an eating disorder. In this year alone, 5.5 million people living in the United States will develop an eating disorder, and only 20% of them will receive treatment; an even smaller fraction will get evidence-based care that works.

Body image concerns, intense pressure to fit the appearance ideals, and the harsh reality of how many people will experience an eating disorder in their lifetime left researchers wondering: What if we could decrease negative body image concerns and prevent eating disorders from developing in the first place?

How appearance ideals can lead to an eating disorder

Eating disorders emerge out of a confluence of different genetic, biological, environmental, social, and other factors. Some common traits that predict the onset of an eating disorder are:

As researchers explored the emergence of eating disorder traits, a theory developed. Thin-ideal internalization (coupled with sociocultural pressure) starts the cascade effect contributing to body dissatisfaction, then dieting and negative affect, ultimately leading to eating disorder symptoms.

They wondered: If we could reduce thin-ideal internalization first, would the other risk factors decrease too?

Research shows that education-based prevention programs are not very effective in creating attitudinal and behavioral change. The theory was put forth that cognitive dissonance could be effective in creating shifts in both beliefs and behaviors.

Learning information can feel good and helpful at first, but there is a difference between educating and empowering people to change. Research shows that disclaimers and warnings on photoshopped pictures or ads are unsuccessful at mitigating the body image distress created by unrealistic images in the first place. We often want to wait for our thoughts or emotions to change first before we alter our behaviors, but experiencing dissonance can actually empower us to act now.

Cognitive dissonance theory rests on the notion that as humans, we want to maintain consistency between our beliefs, values, and actions. When there’s a conflict between our beliefs and actions, we experience dissonance: mental distress like frustration, guilt, shame, discomfort, anxiety, etc. Dissonance is uncomfortable, so we seek out ways to reduce the conflict and return to a state of consistency. We might do this in one of a few different ways:

add in more affirming beliefs to override the conflicting belief/behavior

attempt to decrease the importance of the conflicting belief/behavior

 change and adapt toward the new belief or behaviors

Consider this example: Drew, an eco activist, bought their dream car: a Chevy truck with a diesel engine—and their sister just showed them a graph of how high diesel emissions are and says Drew’s car is awful. To reduce cognitive dissonance, Drew could:

by going to chevysRthebest.com and reading how Chevy trucks aren’t bad for the environment because they R the best.

: by saying their car might not be the best for the environment, but Drew recycles and takes short showers so it all works out fine for their carbon footprint (and their car still totally rocks).

: by turning their car into a dealership and leaving with an eco-friendly truck, realizing their diesel Chevy wasn’t the best car for them because they care about their environmental impact.

It’s important to note that the amount of dissonance that you experience can be influenced by how highly you value a belief or the degree to which your beliefs are inconsistent. For instance, Drew might experience decreased dissonance if his best friend Betty, who died last year, also loved driving a diesel Chevy truck and they bonded over that belief, making this a deeply held value for Drew. On the other hand, his dissonance might increase if this was the eighth time Drew heard new information on why diesel Chevys aren’t the best cars, so they had a larger drive to change cars.

The Body Project: using cognitive dissonance to challenge appearance ideals

Dr. Eric Stice and team developed the dissonance-based eating disorder prevention program The Body Project. The Body Project includes verbal, written, and behavioral exercises designed to position girls to argue against the appearance ideals, as well as discussion-based groups with Socratic questions to highlight costs of pursuing the thin ideal for girls. It was the first prevention program to reduce eating disorder symptoms, and Initial trials showed reduced risk factors and eating disorder symptoms over a short period follow-up.

After many years of research and multiple iterations, large efficacy trials revealed The Body Project as the most effective compared to seven other credible interventions in reducing eating disorder symptoms, including thin internalization. Many research teams have replicated these results across languages, countries, and program audience adaptations: The PRIDE Body Project, More Than Muscles, The EVERYbody Project, etc.

The “high dissonance” version of the project showed greater reductions in risk factors and eating disorder symptoms, leading to new program updates, like increased voluntariness of participation, public accountability, and difficulty of exercises. The three- to four-hour intervention produced significant reductions in symptoms that remained three and four years after the intervention was completed. Additionally, fMRI imaging revealed The Body Project participants had decreased activation in reward response (Caudate) when shown thin models compared to the control group.

Applying cognitive dissonance theory in practice

There are a number of different strategies you can employ to apply the learnings of this research with your own patients.

Fildes, Alison et al. “Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records.” 

Frederick, David A et al. “The swimsuit issue: Correlates of body image in a sample of 52,677 heterosexual adults.” 

Kearney-Cook, Ann et al. “Body Image Disturbance and the Development of Eating Disorders.” In The Wiley Handbook of Eating Disorders (eds L. Smolak and M.P. Levine). 

https://doi.org/10.1002/9781118574089.ch22

Pearl, Rebecca L et al. “Prevalence and correlates of weight bias internalization in weight management: A multinational study.” SSM - population health vol. 13 100755. 17 Feb. 2021, 

How Cognitive Dissonance Can Challenge Appearance Ideals in Eating Disorder Patients 

The information in this article originally appeared in an Equip Academy presentation. Watch the presentation 

Screening for eating disorders is essential to ensuring that patients don’t slip through the cracks and that everyone who is struggling gets the support they need. However, many providers aren’t equipped with the knowledge and tools required to properly screen for these illnesses. Today, I’ll explain everything providers should know about screening for eating disorders.

First, let’s define what screening is and why it’s important. At their broadest definition, screenings are medical tests used to check for diseases and health conditions before there are any signs or symptoms. 

According to the World Health Organization

, “the purpose of screening is to identify people in an apparently healthy population who are at higher risk of a health problem or a condition, so that an early treatment or intervention can be offered and thereby reduce the incidence and/or mortality of the health problem or condition within the population.”

Some examples of screening options include:

Routine testing of blood, vitals, imaging, etc.

Screening is essential for eating disorders for a few reasons. First, the lag between the onset of eating disorder symptoms and treatment is on average five to seven years. We know that early detection and swift entry into treatment can improve outcomes, and so this lag is significant.

And secondly, misconceptions and stereotypes about eating disorders mean that many people with these illnesses go undiagnosed—just 20 to 25% of patients with an eating disorder actually get treatment, and this number is even smaller for marginalized groups. Eating disorders are still thought of as a niche issue, despite prevalence similar to other mental health disorders, and newer diagnoses like 

 are identified less often. More screening would shed light on the millions of people with eating disorders and make clear that more accessible treatment is needed.

There are a number of different options for screening for eating disorders in patients. Below, we’ll go through some of the screening tools used for different patient populations.

The SCOFF questionnaire is a series of five questions. An answer of “yes” to

two or more questions indicates the need for a more comprehensive assessment.

 stone (6.35 kg) in a three-month period?

The SCOFF’s strengths are that there is lots of research on it; it is accurate at distinguishing those with an eating disorder from those without an eating disorder; it’s brief and easy to score; and there’s a low likelihood of false alarms.

Its limitations are that it is primarily focused on 

, other specified feeding or eating disorder (OSFED), or avoidant/restrictive food intake disorder (ARFID); it only raises a red flag after symptoms have started; it is only validated in adults; it is less accurate in studies that include men; and it does not pick up on disordered exercise behaviors.

Eating Disorder Screen for Primary Care (ESP)

In this screener, responses are classified as normal or abnormal. A “no” to question one is classified as an abnormal response, and a “yes” to questions two through five is classified as an abnormal response. Any abnormal response indicates that the patient needs further assessment. Research shows that the best individual questions for ruling out an eating disorder are questions one and three.

1. Are you satisfied with your eating patterns?

3. Does your weight affect the way you feel about yourself?

4. Have any members of your family suffered with an eating disorder?

5. Do you currently suffer with, or have you ever suffered in the past, with an eating disorder?

The strengths of the ESP are that it is conversational, short, has simple scoring, and there is a high likelihood of not missing any cases. Its limitations include the fact that it is only used in one study and a few case studies, so there is less validation, and it is prone to more false positives.

In this screener, each item is scored one if present, and a score of two or more is predictive of the presence of an eating disorder.

1. Do you often feel the desire to eat when you are emotionally upset or distressed?

2. Do you often feel you cannot control what or how much you eat?

3. Do you sometimes make yourself throw up (vomit) to control your weight?

4. Are you often preoccupied with the desire to be thinner?

5. Do you believe yourself to be fat when others say you are thin?

The strengths of the SDE screener are that it is brief, and similar to SCOFF but with questions that improve accuracy for BED. Its limitations include the fact that there are still no questions that would catch 

; it is only used in adults; and it only picks up after more severe symptoms have started.

Eating Disorder Examination Questionnaire-7 (EDEQ-7)

, but pared down to focus on dietary restraint, shape and weight valuation, and body satisfaction.

1. Have you been consciously trying to limit the amount of food you eat to influence your shape or weight?

2. Have you attempted to avoid eating any foods which you like in order to influence your shape or weight?

3. Have you attempted to follow definite rules regarding your eating in order to influence your shape or weight; for example, a calorie limit, a set amount of food, or rules about what or when you should eat?

4. Has your weight influenced how you think about (judge) yourself as a person?

5. Has your shape influenced how you think about (judge) yourself as a person?

6. How dissatisfied have you felt about your weight?

7. How dissatisfied have you felt about your shape?

The strengths of the EDEQ-7 are that it is briefer than the full EDE-Q, but still maintains the quality and validation of the full questionnaire. Its limitations are that it is lower in accuracy than the full EDE-Q, so may miss some cases; it also does not include questions about ARFID.

Stanford-Washington University Eating Disorder Screen (SWED)

The SWED is primarily for college-age women. It is embedded into 

Its strengths are that it is comprehensive; has lots of good validation; and is tested most widely across diagnoses. Its limitations are that it is only applicable to a subset of those with eating disorders; accuracy is lower for 

; has very little data in men and racial or ethnic minority groups; and is lengthy and somewhat complex to score.

The NEDA screener has a wide reach, with 71,362 people taking the screener. Of that group, 86.3% screened positive for a possible clinical or subclinical eating disorder—but only 14% report receiving treatment.

Brief Assessment of Stress and Eating (BASE)

The BASE screener is based on the full Eating Pathology Symptoms Inventory (EPSI), but is pared down to focus on specific behaviors and cognitions. It is for student healthcare and college research settings.

Its strengths are that it is brief, captures a more diverse range of behaviors, and has strong outcomes in men and gender diverse populations. Its main limitation is that it only applies to a select population of young adults.

This screener distinguishes between ARFID subtypes: selective eating, lack of interest/low appetite, and fear of aversive consequences. Scores of >9 or 10 indicate a potential diagnosis.

Its strengths are that it is brief, provides clarity on presentation types, is validated in youth and gender diverse groups, and is translated into multiple languages. Its main limitation is that it doesn’t rule out other eating disorders.

Pica, ARFID, Rumination Disorder Interview - ARFID - Questionnaire (PARDI-AR-Q)

 is a 32-item questionnaire based on the diagnostic interview. Its strengths are that it can provide information on ARFID subtypes, has a screening algorithm, is comprehensive, and there’s a patient version as well as a parent version for kids as young as age four. Its limitations are that it’s a longer survey, has complicated scoring, and there are no validation studies yet for screening.

Below is a sampling of the questionnaire.

So how can providers incorporate these screeners into clinical practice? There are few important things to keep in mind when it comes to using the screeners outlined above. Some tips and tools to remember:

Integrate behavioral health screeners into existing medical screeners, like growth charts

Recognize that screening doesn’t mean diagnosis, and further assessment is always needed

The SBIRT model is also an important concept to understand. SBIRT stands for Screen, Brief Intervention, and Referral to Treatment. If the screening is positive, the healthcare professional asks further questions to assess level of use. For high-risk use, a brief intervention is recommended; for severe use, a 

 is recommended. The SBIRT approach has been shown to be valid for identifying and improving outcomes for people who have high risk use of alcohol and drugs.

 is a novel screening tool for adults in primary care. After screening, the tool walks you through a brief intervention and resources for referral.

We need more research on eating disorder screening. There are currently no validated screeners for youth, and evidence for adult and adolescent screening (among asymptomatic patients) has been deemed insufficient, despite the many screeners that are available. The current state of eating disorder screening is considered insufficient for a few reasons:

There are no studies directly assessing the benefits and harms of screening, which is needed

They are mostly assessed in adult women, and available data lack information about underrepresented groups

Treatment trials did not recruit screen-detected participants from primary care settings

Limited generalizability to populations who would be detected by routine screening

In addition to refining and further researching screening tools, it’s also important that screening begin earlier. Eating disorders often peak in childhood or adolescence, making youth a high-risk time for onset—yet there are no screeners developed for kids 12 and under. There are limited validated screening tools for adolescents, but many of the adult ones are used with teens. A tool for youth needs to focus on catching early symptoms of an eating disorder, and be relevant to the symptoms we expect to show up in this age group (e.g., ARFID). It’s likely that parents or other caregivers may be the best source for administering these screeners.

There are currently a number of in-progress studies looking to create clinically-validated screeners for youth. These include studies from Equip, AED/AAP Workgroup, and The CARE Lab at the University of Kansas.

For more information on screening for eating disorders, as well as in-depth information about the Equip research team’s pediatric ED screener, watch my 

 on the topic. You can also explore past Equip Academy presentations and register for upcoming events 

Screening programmes: a short guide. Increase effectiveness, maximize benefits and minimize harm. Copenhagen: WHO Regional Office for Europe; 2020.

Hamilton A, et al. Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders. Aust N Z J Psychiatry. 2022 Mar;56(3):248-259. 

Penwell TE, et al.. Eating Disorder Treatment Access in the United States: Perceived Inequities Among Treatment Seekers. Psychiatric Services [Internet]. 

https://psychiatryonline.org/doi/full/101176/appi.ps.20230193

. American Psychiatric Publishing; 2024 May 8 [cited 2024 Jul 14];0(0).

Graham AK, et al., A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women. J Am Coll Health. 2019 May-Jun;67(4):357-366. 

https://www.nationaleatingdisorders.org/screening-tool/

Never Miss a Diagnosis: Screening for Eating Disorders

Eating disorders affect people of all ages, but there are certain stages of life that are higher risk than others. Because of hormonal fluctuations, body changes, societal pressure, and many other factors, pregnancy can be one of those high-risk times. In order to better understand how this plays out, we conducted a comprehensive survey looking at the relationship between disordered eating and the entire reproductive journey, including fertility, 

We surveyed 645 American women over the age of 18 who self-reported a history of an eating disorder or disordered eating habits. The survey itself included a thorough set of questions that explored fertility, pregnancy, and the postpartum period. We looked into how respondents’ eating disorders or disordered eating habits impacted their efforts to conceive, their pregnancy experience, their body image after pregnancy, and more.

Here’s the breakdown of our survey respondents:

610 respondents with a history of disordered eating, 553 of whom had tried to conceive within the past 10 years

35 respondents with a history of a diagnosed eating disorder, 30 of whom had tried to conceive within the past 10 years

The majority of respondents were 30-39 year-old cisgender women

When we set out to conduct the survey, we assumed that both 

 habits would have some impact on women’s fertility and pregnancy experience, but we didn’t know what that would look like. Below are some of our most important findings, several of them quite eye-opening.

Here are some of the most notable things we learned about how eating disorders and disordered eating impact the fertility and conception experience of women:

45% of women with a history of an eating disorder or disordered eating 