Media influence may lead adolescents to internalize patterns of physical beauty, resulting in dissatisfaction with their own bodies when they are unable to match up to these patterns. In the constant search for an 'ideal body', adolescents may begin to develop risk behaviors for the development of eating disorders (ED). The object of this study was to analyze the influence of the mass media on body dissatisfaction (BD) and on ED in adolescents, comparing sexes. We also analyzed the influence of BD on the risk of developing unsuitable eating behaviors, with the risk of ED, comparing sexes. A cross-sectional study was carried out with 1011 adolescents: 527 girls and 484 boys. The BMI of each adolescent was determined and the instruments EAT-26, SATAQ-3, and BSQ were applied. For statistical analysis, we used Student’s t-test, the chi-square test, Pearson's correlation test, and the Odds Ratio. The influence of the mass media contributes to a negative self-image, especially in girls, increasing the likelihood of adolescents presenting BD and eating disorders risk. An increase in BD is responsible for the increased risk of developing ED in adolescents of both sexes but is more expressive in girls than in boys.
Keywords: body image; mass media; eating disorders; adolescents
1. Introduction
Body image (BI) refers to the perceptions, thoughts, and feelings of a person with respect to his/her body [1]. When a person has a negative view of his/her body, or there is a discrepancy between one's own body evaluation and an 'ideal body, this results in body dissatisfaction (BD) [1,2]. BD among adolescents is a serious public health problem because it generates a series of damaging conditions [3,4], such as compromised emotional well-being, low self-esteem, symptoms of depression, and disordered eating [3]. BD affects adolescents of both sexes in different ways: boys tend to suffer sociocultural pressure encouraging them to have bigger, more muscular bodies [5], while girls are under pressure to have a thin or ultra-thin body [6]. The pressure may come from parents, friends, boys- or girlfriends, or even from the media, which appear to exercise a strong influence on adolescents. The mass media (MM) define the 'ideal body', emphasizing thinness for women and muscular bodies for men; they also often associate professional and personal success with the 'perfect body. Many women aspire to the pattern of beauty stipulated by the MM, however, it tends to be unachievable for most, resulting in constant dissatisfaction with their body image [7,8]. A distorted image of the 'ideal body' associated with a feeling of dissatisfaction with oneself may trigger behaviors that jeopardize the health of adolescents who act to achieve this ideal imposed by the media.
Grabe et al. [9], in a meta-analysis, observed that women and adolescents exposed to the media spent more money on improving their appearance and were more susceptible to eating disorders (ED) because they felt dissatisfied with their body image. High susceptibility to developing unsuitable eating behavior may be related with an attempt to achieve a pattern of beauty promoted by the MM. Skipping meals, exercising obsessively, causing vomiting, and using laxatives or diuretics have been recognized as sub-clinical symptoms of ED and as predictors of the start of the clinical range of ED [10]. Adolescence is a period of vulnerability, especially for girls. This can determine a greater risk of developing ED as adolescents begin to focus on their body image during this stage as a result of changes related with puberty, including a sudden weight increase [11]. In industrialized countries, ED are the third most common chronic disease in female adolescents [12]. In western countries, the rate of anorexia (AN) is 0.3% and of bulimia (BN) is 1% [13]. Previous studies have shown that BD is one of the most consistent risks for developing eating disorders (ED) [14,15], and is one of the 10 principal causes of disability in young women [16]. BD and ED may be determined by different variables and are strongly related with social and cultural norms and ethnic groups [17]; the causes of ED in each population, therefore, need to be identified.
Identifying the factors which cause adolescents to feel dissatisfied with their body image, and identifying the factors which increase the susceptibility of adolescents to developing ED, are important for the creation of prevention and support programs for these adolescents. The objectives of this study were, therefore: (1) to analyze the influence of the mass media on BD and ED, comparing adolescents of both sexes; (2) to analyze the influence of BD on ED, comparing adolescents of both sexes.
2. Method
2.1.Participants
We carried out a descriptive, observational, cross-sectional study. The sample size was calculated from the white population of the city of Fortaleza, Brazil, with 93,837 secondary school students in public and private schools [18]. We used the formula, where is the first approach to the sample size and is the tolerable sample error. With a sample error of 4%, n was 621 students; our total sample was larger. The study included 1011 secondary school students in the city of Fortaleza, Brazil, aged between 14 and 18 years, of both sexes (527 girls and 484 boys). Informed consent was obtained from all individual participants included in this study. Adolescents were excluded if their parents refused their informed consent. This study was carried out in accordance with the Helsinki Declaration and was approved by the Ethics Committee for Research on Human Beings, file number 2.193.376.
2.2. Demographic and anthropometric measures
The equipment used to take anthropometric measurements were an electronic scale (Filizola®-110), a stadiometer (Sanny®), and an anthropometric tape (Sanny®). To assess body fat, the body mass index (BMI) was used, defined as the body mass divided by the square of the body height, expressed in units of kg/m2, and analyzed by gender. BMI was calculated by the following formula: BMI = mass / height2. The BMI diagnosis was sub-divided into Accentuated thinness (BMI between 16.0-16.99), Thinness (BMI between 17.00-18.49) Normal (BMI between 18.5-24.9), Overweight (BMI between 25.0 and 29.9), Obese (BMI=30.0)
2.3. Measurements
The Sociocultural Attitudes Towards Appearance Questionnaire-3 (SATAQ-3) was developed to refine the measurement of internalization as well as to evaluate the distinctiveness and utility of other dimensions of media influence [19]. This questionnaire has been used previously in a Brazilian population, and its validity has been examined [20]. It consists of 30 items to measure four dimensions of media influence: Subscale 1- Internalization-General (INT-GEN); Subscale 2- Internalization-Athletic (INT-ATH); Subscale 3- Pressure (PRESS); and Subscale 4- Information (INFO). The two internalization subscales evaluate the incorporation of appearance norms promoted by the media into the individual’s own identity, up to the point at which he/she desires or strives to match the ideals. INT-GEN was classified as low (≤23 points), middle (23-28 points), and high (≥29 points). INT-ATH was classified as low (≤12 points), middle (13-16 points), and high (≥17 points). The PRESS subscale contains items that index a subjective sense of pressure from exposure to media images and messages to modify one’s appearance. PRESS was classified as low (≤15 points), middle (16-21 points), and high (≥22 points). The INFO subscale captures the recognition that information regarding appearance norms is available from media sources [21]. INFO was classified as low (≤26 points), middle (27-30 points), and high (≥31 points). The result is given by the sum of the responses from each element; the higher the score, the greater the internalization of the media messages specific to the element. The total score for mass media influence was classified as: small influence (≤77 points), regular influence (78-94 points), and large influence (≥95 points).
The Body Shape Questionnaire (BSQ) is an instrument designed to measure dissatisfaction with body image [22]. A Brazilian version of the BSQ for adolescents of both sexes has been previously validated [23].
The questionnaire contains 34 questions on a 6-point Likert scale, ranging from 1 (never) to 6 (always), spread over 4 subscales: 1. Self-perception of body shape (22 questions); 2. Comparative concern (5 questions); 3. Attitude (5 questions), and 4. Severe alterations (2 questions), to give a score ranging between 34 and 204 points. The higher the score, the greater the dissatisfaction. Based on their BSQ results, the subjects were divided into four levels of dissatisfaction with physical appearance, following the model validated for Brazilian adolescents by Conti and Latorre [23]: score ≤79 (no dissatisfaction with BI); score ≥80≤109 (slight dissatisfaction with BI); score ≥110≤140 (moderate dissatisfaction with BI); score ≥140 (severe dissatisfaction with BI).
Eating Attitudes Test (EAT-26) is a self-reporting questionnaire that analyses unsuitable eating behaviors; it has been validated for Brazilians [24,25]. It contains 26 items with answers on a Likert-type scale (0=never, hardly ever, or occasionally; 1= sometimes; 2=often; 3=always). There are three subscales: 1. diet, related with a pathological rejection of foods with high-calorie content and concern with physical appearance; 2. bulimia and concern with foods, referring to episodes of compulsive eating followed by purgative behavior for bodyweight loss/control; 3. oral self-control, referring to self-control with respect to food, to evaluate the impact of environmental and social factors on food ingestion. Scores ≥ 20 indicate risk behavior for triggering eating disorders.
2.4. Procedure
Scales to assess the influence of the media (SATAQ-3), level of satisfaction with body image (BSQ), and Eating attitudes (EAT-26) were applied to the adolescents. In addition, the BMI of each adolescent was calculated. The result of each instrument was analyzed. The correlations between Media influence × Body image; Media influence × Eating attitudes; Media influence × BMI, Body image x Eating attitudes risk were calculated. For this study, a comparison was made of the results between the sexes.
2.5. Data analysis
Descriptive statistics are presented as mean ± standard deviation (± SD), range, and frequency (% values). The student’s t-test was used for comparison between the sexes. A chi-square test was used for qualitative variables. Pearson's correlation and the Odds Ratio were applied between the variables analyzed. Statistical analysis was carried out using SPSS for Windows, version 20.0. Statistical significance was set at p≤ 0.05.
3. Results
Table 1 shows the general characteristics of the adolescents by sex. 54.7% of the adolescents suffered a slight influence from the MM, 27.3% moderate influence, and 18.0% strong influence. A larger number of girls than boys was found to suffer strong influence from the MM (Table 2). We observed that the values for all the subscales of SATAQ-3 were higher for girls than boys, showing that they are more strongly influenced by the media. Both sexes presented regular influence in INT-GEN and low influence in INT-ATH and INFO. In the PRESS subscale, the girls presented significantly higher values than the boys, experiencing regular influence (Table 1).
Table 1. Comparison of quantitative variables in adolescents aged between 14 and 18 years, by sex.
Variables
Values
Sex
Female
Male
Age (years)
Mean (SD)
15.6 (1.0)
15.7 (1.1)
p-value
0.105
BMI
21.8 (3.5)
22.0 (3.7)
0.468
Body image (score)
(BSQ)
78.6 (34.9)
63.0 (27.3)
≤0.001
Eating attitudes (score)
(EAT-26)
Diet
7.74 (7.61)
5.12 (5.58)
Bulimia
3.18 (2.97)
2.08 (2.54)
Oral control
4.41 (3.86)
3.57 (3.36)
Total
15.3 (10.9)
10.7 (8.6)
Media influence
(SATAQ-3)
INT-GEN
24.4 (8.4)
23.2 (7.4)
0.011
INT-ATH
12.0 (4.7)
12.7 (4.9)
0.016
PRESS
17.4 (7.2)
14.9 (6.0)
INFO
25.1 (7.1)
24.3 (6.5)
0.088
81.2 (23.3)
77.2 (20.5)
0.004
SD: Standard Deviation
28.7% of the adolescents presented BD: 15.1% slight BD, 7.8% moderate BD, and 5.7% severe BD (Table 2). A higher percentage of girls (19.6%) presented some degree of BD than boys (9%); boys presented a lower score than girls in the BSQ, showing greater body satisfaction (Table 1). 73.7% of the adolescents presented normal BMI. Being overweight was slightly more frequent in girls while obesity was slightly more frequent in boys (Table 2). 6.8% of the adolescents presented unsuitable eating behaviors with a risk of developing ED; the percentage was significantly higher in girls than in boys (Table 2). Furthermore, girls presented higher scores than boys in all the subscales of EAT-26 (Table 1).
Table 2. Classification of adolescents for eating disorders risk, BMI, Body dissatisfaction, and mass media influence, by sex.
Instruments
Classification/p value
Girls
Boys
Eating attitudes (EAT-26)
No ED risk
46.9%
46.3%
93.2%
ED risk
5.4%
1.5%
6.8%
Accentuated thinness
0.3%
1.0%
1.3%
0.006
Thinness
0.4%
1.4%
Normality
39.3%
34.4%
73.7%
Overweight
9.3%
8.0%
17.3%
Obesity
1.1%
2.8%
3.9%
Severe obesity
1.2%
2.5%
Body image
No dissatisfaction
32.4%
38.9%
71.3%
Slight dissatisfaction
9.9%
5.2%
15.1%
Moderate dissatisfaction
2.6%
7.8%
Severe Dissatisfaction
4.5%
5.7%
Low
26.4%
28.3%
54.7%
Regular
14.0%
13.3%
27.3%
High
11.7%
6.3%
18%
3.1. Media influence x BMI
Greater media influence was observed in boys with overweight and obesity than in normal-weight and thin boys. 85% of thin girls presented low media influence; greater influence was observed when their weight was higher, with 56% of overweight girls and 63% of obese girls feeling that they suffered regular or high media influence. A very low significant positive correlation was observed between BMI and SATAQ-3.