Our nation’s health has reached a point of crisis. According to the American Obesity Association, 65% of adults and 30% of children are overweight, and 30% of adults and 15% of children meet the criteria for obesity (1). Rarely playing outdoors, children spend their days chatting online or watching TV while snacking on nutritionally empty foods. The average child spends 4 hours per day watching TV, and only 1 hour per day completing homework (2). Similarly, the adult workplace has become more and more sedentary.

At the same time, rates of some eating disorders in women, such as anorexia nervosa and bulimia nervosa, are rising (3), and increasing numbers of men are seeking treatment as well (4). Patients are being referred at progressively younger ages (5). There is a significant dichotomy between society’s idealized rail-thin figure and the more typical American body. The reasons for this are complex and likely involve the interplay of media pressure to be thin, family eating and exercise patterns, and a relative surplus of non-nutritious food. Dietary restriction leads to a repetitive pattern of self-deprivation, which can result in bingeing, weight gain, and worsening self-image.

Although it is tempting to blame today’s media for perpetuating and glorifying unrealistic standards of physical beauty, the truth is far more complicated. Throughout history, the dominant political climate and cultural ideals always have shaped the public’s perception of the ideal female body type. However, today’s culture is unique in that the media (including television, Internet, movies, and print) is a far more powerful presence than ever before. This article gives examples of changing ideals over time, explores possible explanations for the relationship between obesity rates and the prevalence of eating disorders (including anorexia nervosa, bulimia nervosa, and binge eating) and identifies possible avenues for prevention and change.

Ideal Body Type Throughout History

Throughout history, the standard of female beauty often has been unrealistic and difficult to attain. Those with money and higher socioeconomic status were far more likely to be able to conform to these standards. Women typically were willing to sacrifice comfort and even endure pain to achieve them.

In colonial times, the harsh environment and lack of comfortable surroundings required that all family members contribute to survival. Large families were preferred as children could help tend to the land and household chores. For these reasons, communities valued fertile, physically strong and able women. However, in the 19th century, ideals shifted and women with tiny waists and large bustles came to be valued. It was desirable for an upper-class man to be able to span a woman’s waist with his hands (6). If women were too frail to work, plantation owners could justify the use of slaves (7). Indeed, much emphasis was placed on female fragility, which then made a woman a more attractive candidate for marriage. The ideal wealthy woman of the time was sickly and prone to headaches; the fine art of fainting was taught in finishing schools throughout the country. Women of significant financial means would go as far as having ribs removed to further decrease their waist size. Despite being painful and causing health problems, such as shortness of breath (which could lead to pneumonia) and dislocated visceral organs, corsets became the height of fashion (6).

Some have said that the invention of the corset was the main impetus for the feminist movement at the beginning of the 20th century (8). Women turned up their noses at complicated dresses, instead favoring pants, which were comfortable and did not restrict movement. They cut their hair short, bound their breasts, took up cigarette smoking, and fought for the right to vote. At this point, it was fashionable to be angular, thin, and boyish-looking, and manufacturers routinely featured pictures of “flappers” in their advertisements.

During the Second World War, ideals changed yet again. With their husbands overseas, young women went to work so that industry could thrive. In their spare time, some of them formed professional sports teams. Again, society valued competent, strong, and physically able women. However, things changed after the war. The men came home and cultural values shifted again to emphasize traditional family and gender roles. Women took to wearing dresses and skirts. Again highlighting the importance of fertility (this time period marked the beginning of the Baby Boom era), the population favored a more curvaceous frame like that of Marilyn Monroe (9).

In the 1960s, major changes were in the works. Along with people of color, women were again fighting for equality both in the home and in the workplace. The advent of the birth control pill afforded increased sexual freedom (9); women burned their bras. Similar to the trends found during the suffrage movement at the beginning of the century, women of the decade idealized thin and boyish bodies like that of the emaciated supermodel Twiggy.

Current Media Influence

The current media culture is complicated and very confusing. Women are told that they can and should “have it all.” They expect family, career, and home to be perfect, and Martha Stewart tells them how to do it. The media inundates them with mixed messages about what is sexy, making it difficult to choose a role model. The heroin chic waif made popular by Kate Moss in the early 1990s competes with the voluptuous Baywatch babe personified by Pamela Anderson and the athletic soccer stars who celebrated a World Cup victory by tearing their shirts off. Though it is highly unlikely for a rail-thin woman to have natural DD-cup size breasts, toy manufacturers set this expectation by developing and marketing the Barbie doll, whose measurements are physiologically impossible. Thankfully, Barbie’s designers revamped her figure back in the late 1990s (10). However, with increased availability of plastic surgery, today’s women are faced with similarly unrealistic expectations every time they open a fashion magazine.

In 2002, actress Jamie Lee Curtis famously posed for More magazine, both in typical “glammed up” attire and then in her sports bra and shorts. The reality is that most magazines airbrush photos and use expensive computer technology to correct blemishes and hide figure flaws. In fact, in Jamie Lee’s own words, she has “… very big breasts and a soft, fatty little tummy … and … back fat” (11). She felt that women should know that the figures portrayed by the media are rarely real. Granted, celebrities can afford to hire personal trainers and nutritionists to assist in their weight loss endeavors. Stylists select fetching outfits and tailors wait on standby to make sure that clothes fit like second skin. Before awards ceremonies, attendees routinely fast and endure tight-fitting undergarments to flatten their stomachs for unforgiving evening gowns.

Celebrities are no less susceptible to eating disorders than the rest of the population. Mary-Kate Olsen was hospitalized with anorexia nervosa, and the weekly gossip magazines have speculated consistently about the health of Lindsay Lohan and Nicole Richie. Their concern for the well-being of these young women is tainted by additional articles in the same issues of their publications which criticize singer-actress Jennifer Lopez’s ample bottom and praise supermodel Heidi Klum for being “runway ready” merely 4 weeks after giving birth to her second child. Twenty-five years ago, the average fashion model was 8% thinner than the average woman. Today, that number has risen to 23% (12), likely reflecting a combination of rising obesity rates in the general population and progressively thinner ideals. Even health and fitness magazines are not above scrutiny. Articles tout the importance of moderate diet and exercise, but pages are filled with advertisements for appetite suppressants and diet supplements. The diet industry is a multibillion dollar business (13). Women are consistently given the message that they are not pretty enough or thin enough.

No discussion of body image and the media would be complete without referencing Becker’s landmark study comparing rates of eating disorders before and after the arrival of television in Fiji in 1995 (14). Ethnic Fijians have traditionally encouraged healthy appetites and have preferred a more rotund body type, which signified wealth and the ability to care for one’s family (15). Strong cultural identity is thought to be protective against eating disorders; there was only one case of anorexia nervosa reported on the island prior to 1995. However, in 1998, rates of dieting skyrocketed from 0 to 69%, and young people routinely cited the appearance of the attractive actors on shows like “Beverly Hills 90210” and “Melrose Place” as the inspiration for their weight loss (14). For the first time, inhabitants of the island began to exhibit disordered eating.

Television shows continue to feature impossibly thin actors in lead roles. More recently, reality shows such as “The Swan” and “Dr. 90210,” which feature plastic surgery and major makeovers, have been criticized for promoting unhealthy body image. In “The Swan,” young women are separated from family and friends for several weeks to undergo an intensive diet and exercise plan. Hair stylists recommend hair extensions and highlights, and plastic surgeons perform breast augmentation, facelifts, and Botox and collagen injections. The end results are showcased in a beauty pageant, where formerly “ugly ducklings” compete against each other for the title of “The Swan.”

Effects on Health

According to a recent study, children exposed to excessive TV viewing, magazines, and movies are at higher risk of obesity. When other variables are controlled, TV exposure independently increases the odds of becoming overweight by 50% for both men and women (16). Furthermore, the type of exposure, not the amount, is correlated with negative body image. Specifically, rates of exposure to soap operas, movies, and music videos were associated with higher rates of body dissatisfaction and drive for thinness (17). Excessive media consumption also may be correlated with the rate of childhood depression. This could be a function of negative body image, or may reflect the tendency of depressed kids to spend more time in front of the TV because of diminished energy.

As highlighted in a recent Newsweek article, classic eating disorders such as anorexia and bulimia are being diagnosed at younger ages (some as young as eight or nine), and with higher frequency (18). A 1994 survey found that 40% of 9-year-olds have been on a diet (19). Clinicians now believe that eating disorders, previously ascribed to dysfunctional family dynamics, are multifactorial in origin. While family dynamics are certainly important, so too are biological predisposition to anxiety and mood disorders, interpersonal effectiveness skills, and cultural expectations of beauty. The development of proanorexia (pro-ana) and probulimia (pro-mia) websites on the Internet has been particularly concerning. Here, people who have made a “life style choice” to engage in eating-disordered behavior post messages detailing their weight loss progress and provide tips, support, and encouragement for their peers. Pictures of emaciated women resembling concentration camp victims serve as “thinsperation” (20).

Although fewer men meet criteria for anorexia and bulimia than do women, more men are becoming concerned with shape and weight (21, 22). While some of the manifestations are similar to the disordered eating found in women, there are some important differences as well. Men too are bombarded by media pressure. Pictures of thin, muscular, and perfectly coiffed “metrosexual” models appear in men’s magazines. Gay and straight men alike are shelling out significant sums of money for gym memberships, styling products, salon haircuts, manicures, and waxing treatments. Duggan and McCreary found that reading muscle and fitness magazines correlated with levels of body dissatisfaction in both gay and straight men (23). Unlike Barbie, whose shape has become more realistic in recent years, action figures have become increasingly muscular and devoid of body fat (24). In the “Adonis Complex,” a phenomenon with similarities to body dysmorphic disorder and anorexia nervosa, young men become obsessed with bulk and muscle mass, which can lead to overexercise, dietary restriction, and abuse of anabolic steroids (25).

With media pressure to be thin and a multibillion dollar dieting industry at our disposal, higher rates of eating disorders in the population seem concerning, but are also understandable. While cultural standards of beauty are certainly not new, today’s media is far more ubiquitous and powerful. However, the reasons behind the growing obesity epidemic are not entirely clear.

For the most part, members of society strive to lead healthy lives. In addition to preaching the cosmetic appeal of weight loss, news reports warn of the risks of obesity, including heart disease and stroke (26). Frightened and inspired, overweight individuals begin strict diet and exercise regimens. They may even lose weight. However, our society is unique in that there is a surplus of cheap, micronutrient-dense food available, which is being advertised by the same media outlets advertising thinness and warning of the risks of obesity (27). After restricting too heavily, dieters often feel deprived. They binge on the unhealthy foods seen in advertisements, gain weight, feel poorly about themselves, and perpetuate the cycle. Less than 5% of individuals who have lost 20 pounds are able to keep it off for 5 years (28). In short, dieters pin all of their hopes on overly restrictive diets that were doomed to fail from the start. This, combined with a relatively sedentary life style, is likely responsible for increasing rates of obesity and disordered-eating behavior, such as dietary restriction, bingeing, and purging.

Baby Steps Toward Change

Clearly, the problem is complicated and there are no easy solutions. Parents and health care providers alike have a responsibility to talk with children about media messages and healthy life styles. Parents can limit exposure to television and talk with children about the messages portrayed on TV shows and in advertising. The American Academy of Pediatrics’ current guidelines suggest that children watch no more than 1 to 2 hours of quality television per day and that parents watch programs with their children so they can discuss the content together (29).

A strong cultural identity is thought to be protective against eating disorders, and families can use this to their advantage by teaching children about the history of their ethnic or religious group. Furthermore, families can eat dinner together on a daily basis. In addition to ensuring that all family members are getting a nutritionally balanced dinner, parents have the opportunity to inquire about children’s experiences at school, and the family can brainstorm together when problems arise.

In addition to providing regular family meals, parents need to take responsibility for providing healthy meals and snacks spaced at regular intervals throughout the day. They also need to allow for a reasonable number of treats so that kids do not feel deprived. Clinical experience consistently shows that individuals overeat when they are hungry or emotionally stressed; skipping meals during the day can lead to overeating at night. Moreover, studies have shown that children’s eating behavior is influenced by the habits modeled by their parents (30) and that parental concern about a child’s weight can negatively affect a child's self-evaluation (31). Families can plan fun outdoor activities, which increase physical activity without subjecting children to shame about their physical shortcomings. Studies consistently have shown that life style changes are most effective when undertaken by the entire family (32).

Health care providers should be quick to address concerns about obesity but must be careful to adopt an empathic, nonshaming approach. It is important not to restrict what children eat, but to encourage a healthy amount of physical activity and a moderate, healthy diet. Parents and clinicians should discourage dieting, as it rarely works in the long term. In addition, they should try not to focus too much on appearance or weight, as perceived pressure to be thin can lead to disordered eating. Most importantly, parents, teachers, and members of the health care community can encourage children to develop strengths such as music, art, or sports to foster healthy self-esteem. It is important for children to focus on mastery of an activity rather than comparing themselves to others (33). When adults suspect mood disorders or eating problems, children should be referred promptly for diagnosis and treatment.

Finally, the government needs to allocate funds to produce exciting, media-driven advertising campaigns to provide information to kids and families about good nutrition, exercise, and healthy self-esteem. Messages need to be visible at school, on TV, and online. Media is a formidable opponent precisely because advertising firms have the financial resources to produce clever advertisements that convince consumers to buy their products. Advertising executives are paid hefty salaries to try to find a way into the consumer’s psyche. Magazine editors need to find ways to incorporate images of average-sized adults and teenagers into their publications. In addition, they need to find ways to resist publishing advertisements featuring emaciated models.

Adults need to take responsibility for teaching children healthy habits, and one of the best ways to do so is by modeling healthy eating and exercise. However, the process will likely be a slow one, and we will need to be patient. As any parent can tell you, it is nearly impossible to get a child to agree to have an apple for a snack when they’ve just seen a compelling ad for the newest flavor of potato chips. Perhaps if children got consistent healthy messages from “cool” media sources at school, online, on TV, and at home, the messages would be more effective. The media is a formidable force, and one that is not going to change easily. However, it is not the only culprit; parental behaviors and family values play an important role in shaping children’s development. The onus is on adults to find a way to harness media power for good instead of evil.