Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ
NESA Publicação oficial
ISSN: 2177-5281 (Online)
Páginas 104 a 117
Autores: Anderson Rodrigues de Sousa1; Janieiry Lima de Araújo2; Ellany Gurgel Cosme do Nascimento3
1. Bachelor's Degree in Nursing, Rio Grande do Norte State University (UERN). Pau dos Ferros, Rio Grande do Norte State, Brazil
Ellany Gurgel Cosme do Nascimento
How to cite this article
Keywords: Adolescent health, social perception, body image.
The first person to present the body image concept was Bonnier in 1905, who hypothesized it as being the sum of all feeling, coming from outside or within. Arnold Pick mentioned a mental body image in 1908, shaped through visual stimuli, tactile sensations and movement1. Today, we may say that body image is defined and influenced by reasonably complex bio-physical, psychological, environmental and behavioral components². According to Saikali et al.3, body image is divided into three components: (a) perceptive, which involves perception of physical appearance, estimated body size and weight; (b) subjective, which is related to appearance; (c) and behavioral, which are situations that people avoid due to discomfort associated with physical appearance. Social factors, cultural influences, media pressure and the quest for an ideal body standard seem to be the driving force behind the development of body image distortions, especially among adolescents4.
This behavioral or attitudinal aspect may be didactically divided into three other aspects: a) thoughts and beliefs about one´s appearance (called the evaluative component); b) emotional physical experiences (called the affective component); and c) the importance of appearance to the individual and behaviors adopted to maintain or improve it (called the investment component)5. The perceptual component corresponds to the ways in which people see or perceive their own bodies. Consequently, people who under- or over-estimate their body size are affected by perceptual distortions6. In brief, the concept of body image is initially a perceptual phenomenon, although individual judgement of what people perceive derive from cognitive, attitudinal and affective factors. However, there are controversies that must be studied to a greater extent, related to perceptual and attitudinal dysfunctions.7 The explanation for this may be a reduction in the attitudinal component of the body image related to dissatisfaction and concern about the body, which is a constraint on most studies that certainly lessens the possibility of exploring the nature of body image dysfunctions 4.
Succinctly, body image is defined as "the figure that we have in mind of the size and shape of our bodies and our feelings about these characteristics and parts"8. Body image has two main components: attitudinal and perceptual8. Consequently, body image refers to the size, shape and structure of the figure in a person´s mind9.
Based on how people see their own bodies, their own images, they try to compare them with the standards established by society. Contemporary societies, particularly in the West, have been moving towards excessive concern with beauty standards resulting in a real "divinization" of the body beautiful10. During the past few decades, the body has received doubled attention, through the proliferation of body management and care techniques, such as diets, body-building and cosmetic surgery. Men and women are investing increasingly large amounts of time, energy and money in goods and services designed to construct and maintain their outward appearances 11.
The current situation is steered by a dizzying shift driven by the unswerving wish to succeed and constant dissatisfaction. Consequently, human beings are faced by constant demands for adaptation to social contexts 12. The desired body thus becomes virtual, the object of consumption and shapeable through the deployment of scientific knowledge and new technologies. These are presented as efficient, efficacious and harmless, effortlessly allowing all kinds of changes. However, a problem arises: the body shape presented as ideal is practically unattainable 12. This situation has stepped up body image dissatisfaction, with negative effects on some aspects of people´s lives, particularly eating behaviors, in addition to psychological, social, physical and cognitive aspects, as well as self-esteem13,14.
In order to achieve effective body image satisfaction, aligned with the esthetic ideals of each culture, is increasingly clear that people are turning to diets, over-exercising, diuretics, laxatives and other resources. This paves the way for the appearance of eating disorders such as anorexia and bulimia nervosa15. Studies16-17 indicate body image a critical component in eating disorders (EA), as dysfunctional body images may lead to extreme behaviors in pursuit of an ideal of beauty that is often unattainable.
In general, studies have identified rising body image dissatisfaction rates in several age brackets, especially among adolescents18-19. With the formation of their identities and bodies constantly shifting, adolescents constitute a group that is vulnerable to social and cultural influences, tending towards concern over body weight in their pursuit of slim, lean bodies and fearing exclusion from their peer group20. Adolescents are among the most vulnerable to social pressures, in terms of aspects related to their bodies21.
Most of these adolescents idealize a body shape that is usually aligned with the slimmer and fitter standards of beauty showcased by the media. The more their real-life bodies fail to resemble this ideal, the higher the possibility of conflict and loss of self-esteem22.
In order to achieve effective satisfaction with body images aligned with the esthetic ideals of their cultures, people may turn to diets, over-exercising, and taking diuretics and laxatives, among other options that may lead to eating disorders such as anorexia, bulimia nervosa and other important public health problems 15.
Consequently, the objective of this study is to describe how the issue of self-image among adolescents is presented in publications during the past few years, as well as exploring which factors are selected in order to assess high-risk behavior.
This is a systematic review of papers addressing the issue of body image perceptions among adolescents, correlated to a factor predisposing them to high-risk behaviors. Research for the papers was conducted in the Medline/PubMed, Scientific Electronic Library Online (SciELO-BR) and Latin American and Caribbean Literature in the Health Sciences (LiLACS) databases in January 2015. The search terms used in Medline/PubMed were: adolescent health, with perception and body image. For both SciELO-BR and LiLACS, the keywords used were: adolescent health, perception and body image. For this discussion, only Brazilian papers were selected as, although this is a worldwide collective health problem, these discussions would be closer to the realities surrounding the youngsters selected as the target public of the study, due to cultural and social standards, among other aspects.
The following inclusion criteria were used: full texts available, written in Portuguese; with body image as the main topic; research projects encompassing boys and girls; adolescent public.
Consequently, this review did not include papers not available in full, texts not written in Portuguese, non-adolescent or single-gender samples, and addressing topics other than body image perception and the health-disease process.
The search of the PubMed database resulted in a total of 2,091 papers, and after screening through the selection process outlined above, eleven papers remained, of which only five were selected on the basis of their titles, used in the review presented in paper. The search of the SciELO-Brazil database found no papers using the terms adolescent health and body image perception. Consequently, only the terms body image and perception were used, resulting in 51 papers, of which seven were selected by their titles, as they encompassed the objective of the discussion in view. The LiLACS database initially produced 856 papers, of which 23 remained after screening through the selection process described above. After using the Titles filter, ten papers remained, several of which had already been located in previous searches of other databases. As a result, 22 papers were finally selected that discuss the issue of adolescent perceptions of their body images, with their results indicating that this is a predisposing factor for health-hazardous high-risk behaviors (Table 1).
Analysis showed that that concern over body image is solidly present in all post-puberty age brackets, although more clearly during adolescence, with many factors contributing to this situation.
To an increasing extent, this issue is being addressed by research projects all over the world, as the attitudes adopted by youngsters in attempts to change their appearance are rated as a worldwide public health problem. In Brazil, the studies found were conducted mainly in the South, followed by the Southeast and Northeast. No papers were found for the North and Center-West regions (Table 2 and Figure 1). The research projects consisted mainly of cross-sectional studies (Table 3).
Figure 1. Publication regions of papers on Body Image Perceptions among Adolescents: 2006 and 2014, 2015.
The age bracket of the study participants varied from adolescent to adult. More specifically, twenty papers focused on adolescents were found, compliant with the age bracket established by the World Health Organization (WHO). In terms of sample size, representative studies were found with a sample of 17,525 adolescents in several States.
In order to organize and present the results more efficiently, a Table was drawn up listing the selected studies, together with their: authors, year of publication, year of study, geographical region / nationwide, study type, subject age and sample size (Table 4).
Based on the content of the selected papers, it was possible to divide this study into three theme-specific axes: body image and the health-disease process (7 papers); body image and educational qualifications (6 papers); and social factors (9 papers). Based on this division, each paper was analyzed, assessing which factors underpinned body image dissatisfaction in adolescents, as well as possible intervention strategies that might combat this public health problem (Table 5).
Body image and the health-disease process
The number of adolescents stating dissatisfaction with their body image is a matter for concern, topping 50% of the samples in several studies in this review, with some exceeding 70%. This problem does not affect a single gender or just one age bracket, but is apparent at all ages during adolescence, with boys and girls both clearly much affected by this problem. In terms of gender, girls are clearly concerned about losing weight, while boys want exactly the opposite: bulking up. In other words, girls try to avoid body fat, while boys want more muscle mass. We must consequently bear in mind that body dissatisfaction does not appear homogeneously during adolescence23,24.
This problem has a direct influence on the health disease process among adolescents. As is already known, youngsters dissatisfied with their own images tend to seek methods that are somewhat or very unhealthy for controlling weight, building up muscle, etc. In addition to seriously harming their health, these practices may result in the appearance of other pathologies, such as anorexia or bulimia nervosa25.
Another factor linking body dissatisfaction to the health-disease process is that dissatisfaction is often triggered by a health problem such as obesity or overweight, which may, in turn, be the outcome of poor eating habits, sedentary lifestyles, and other factors. It thus becomes clear that it is vital to address body image dissatisfaction, even before it appears26.
A matter of concern is the 'getting fit' discourse mentioned by many teens. In general, these youngsters tend to view health from merely the physical side. This means that having a slim, strong body that looks good means being healthy, regardless of the ways in which this is achieved. Fitness is then used as an excuse for deploying unhealthy methods in the pursuit of a specific standard of beauty7.
Perhaps due to fear of discrimination, persecution or judgement, many youngsters use this 'getting fit' discourse to disguise their real interest in physical exercise and the use of substances or methods that modify their bodies, bringing them steadily closer to the reigning standards. Although it has been proven that youngsters tend to link health to something physical and palpable, it is quite clear that in actual fact, health is edged into the background. The main real goal of pursuing certain practices is body modification. This hampers the identification of at-risk youngsters by practitioners and their families, while also making it hard for they themselves to define the boundaries between right and wrong in their pursuit of their ideal silhouette7.
Encouraging healthy life habits - such as eating properly and regular exercise - can prevent the appearance of body dissatisfaction and many other associated morbidities. This is very clear in some of the studies analyzed.26 However, introducing preventive measures designed to underscore the importance of healthy living habits is praiseworthy, together with the culture of the body, the way it is seen and the ways it must be treated. It is vital to remember that different approaches must be used for boys and girls, as this dissatisfaction appears in different ways. Parental participation in some types of activities would also be very important, as they strongly influence the lifestyles of their offspring27.
However, investigation in greater depth is required of everything involved in the health-disease process and related to this issue of body image dissatisfaction and its consequences, in order to design better strategies for dealing with this problem24.
Body image and educational qualifications
The issue of body image is being discussed and researched all over the world to an increasingly wider extent, as this is a relatively recent problem that is unfortunately becoming more and more evident among young people.
In both the government and private teaching networks, body image dissatisfaction is found among adolescents with some specific characteristics - such as body satisfaction and perceptions - varying by social and economic status. Generally, the higher the social and economic status, the greater the body dissatisfaction. This is probably related to greater exposure to the media, disseminating large numbers of distorted images of reality that tend to reshape body perceptions among adolescents and children, in addition to establishing new standards among them of what constitutes a beautiful, perfect and ideal body28,29. However, with the steady spread of globalization, it is illusory to think that this problem does not also affect the less privileged classes30.
In addition to exposure to the media, which many people rate as the main factor triggering discontent with body image, it is known that this dissatisfaction is actually multi-factor, related to how individuals interact with their surroundings and how they perceive them. Consequently, culture, family and friends wield massive influence and are extremely important for whether or not feelings of body dissatisfaction arise. This means that schools are a crucial venue for working on this issue, as it is at school that the vast majority of youngsters are most exposed to influences that shape their chosen definition of a specific body model. Through this, people may define the ways in which they view their own bodies, as well as some cognitive and emotional aspects31,30.
Most adolescents indicated that the opinions of their schoolmates and friends of their bodies is important, positive and constructive, highlighting aspects that could be improved in their appearance and physique12, even if these assessments focus only on a specific body part (thighs, stomach, arms)30.
This is already reflected in the discourse of some youngsters who state that they see their bodies as 'something' or a 'thing' that must be cared for properly and well 'prepared', in order to be shaped to the interests of its owner. For them, the body is responsible only for movements and actions, serving as a type of 'cover' or 'model'12,11.
Consequently, this means that schools are crucial places for working on body image perceptions and the risks behind the standards of beauty headlined in the media. As noted, youngsters tend to define their identities and perceptions of things - including themselves and their own bodies - by the values to which they are exposed. This means that even eutrophic teenagers may feel fat or skinny30. At this time, body identity falls between the ethical and the esthetic12. Adolescents often view themselves against standards of beauty designed for adults, which may interfere to an even greater extent in the functioning of their body dynamic and growth and development processes28.
Concern over appearance was the main reason for body dissatisfaction among the youngsters in these studies11. This may be related to weight increases noted throughout almost the entire population, with sedentary lifestyles linked to poor diets packed with sugars and fats stepping up the numbers of overweight and obese people. Adolescents form a large proportion of this group, as fast foods are already part of their dietary culture.
The outcome is that adolescents become dissatisfied with their own images due to increased body fat9. As suggested by some studies, overweight and obese people tend to be 2.87 times more likely to be dissatisfied with their own bodies9,32.
Looking more closely, it may be noted that beauty and physical appearance have become highly valued assets, with the body viewed as an incomplete object that must be worked on, upgraded and molded, shaped to the wishes of its 'manager', in fact pursuing standards laid down by society and disseminated by the media. In other words, the body becomes an object of consumption and investment11.
This may be explained by the fact that contemporary society showcases slim bodies as a sign of success and a symbol of sexual attraction and recognition, while overweight or fat is viewed as sloppiness, lack of will power, greed and others9,11.
Many other factors directly related to how people view their own bodies and rate them include: low self-esteem, social and economic status, age, maturation, gender, thinness, overweight, race and ethnicity. Some of these aspects may also serve as protective factors, including race and ethnicity18. However, there are environmental factors that also contribute to body dissatisfaction, such as fear of being excluded from the group, peer rejection and denigration11. This has been proven through interviews in which overweight respondents admit to discrimination at work, social exclusion, poor service at stores, rejection, etc18.
The pursuit of the ideal body is aligned with requirements in place that have been created and maintained in and by society. The standards of beauty appreciated by society, spotlit and disseminated by the media, have a strong influence on the teen public, reflected in packed gyms and changes in eating habits, some harmless (choosing diet and light options), others harmful (lengthy fasts, taking laxatives or diuretics, bulimic and anorexic behaviors)11,33,34.
In this case, it is vital that wholesome diets be encouraged among young people, with incentives to adopt healthy eating habits and take regular exercise, in order to achieve a better quality of life while also preventing the appearance of body image dissatisfaction, as these simple practices can help improve physical appearance 32,33. This could be done through using the schools as strategic venues offering easier access to fruit, vegetables and exercise33.
Another point to be taken into consideration when drawing up strategies for dealing with this problem is the fact that it must be addressed differently for each gender. According to these studies33,34,35, dissatisfaction appears differently among boys and girls. Among girls, weight (fat) loss is pursued, while boys want to bulk up their bodies (muscle mass). There is also a difference in the way that they perceive their own bodies, with girls tending to overestimate how much they weigh, while boys underestimate their body size.
Inter-sector approaches - or rather joint efforts by the healthcare sector working closely with the education sector - and also family interventions are vital for the success of steps dealing with this issue9,33. This triple-pronged approach may be extended through school boards and government entities working with healthcare (Municipal Health Councils and universities)35. The earlier these practices are introduced at schools, the better the outcomes, particularly for the teen public and even younger children, as the results may well be more satisfactory. Finally, as this matter is rated as a public health problem, public policies are required that reach out to teenagers in order to intervene effectively in this field34.
When preparing this review, it was noted that discussions of body image perceptions among adolescents constitute an escalating topic that is expanding steadily in the scientific field. Perhaps due to changes in youngster profiles, this problem has reached sufficient proportions to now be rated as a public health problem.
However, some constraints were noted in the analyzed papers, such as the cross-sectional approach adopted by most of the studies. Sample sizes and age brackets endow the studies with good quality in their discussions, effectively portraying the Brazilian situation in this field. Some records presented overviews of the international context. However, few of them linked this problem to factors such as the influence of families and friends. And some of these studies also related practices to specific eating disorders, although without investigating the influence of the other factors.
It is apparent that body image dissatisfaction is, in brief, dissatisfaction with the real body compared to the ideal standards showcased in the media. This is now a severe public health problem, as its existence may lead to people engaging in health-hazardous types of behavior associated with discourses that associate health with 'staying in shape', fueled by fears of denigration and exclusion from groups. As shown by some authors, the teen public is one of the segments most severely affected by this problem. Among all the age brackets, these youngsters pursue changes most eagerly, seeking what they feel is the 'ideal body'. According to the studies listed here, more than half of these youngsters are unhappy about their body shapes, with appearance, self-esteem and health being the main reasons underpinning body image dissatisfaction among adolescents.
On this basis, the importance of the parents, teachers and healthcare practitioners is quite clear, for observing, identifying and working on body image dissatisfaction among the teen public, always on the alert for danger signs and alerts. Schools and families are very favorable settings for working on body identity and the incompatibility of these standards of beauty with healthy lives, with this quest possibly exposing them to risks that are hazardous to their health.
It is consequently recommended that health education and promotion practices be undertaken in schools, involving pupils and their parents. The sooner these links are built up among families, schools and healthcare facilities, the better the outcomes in terms of combating health problems that could threaten these youngsters every day of their lives through pursuing unrealistic standards of beauty.
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