literature review on body image

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Literature review, current study.

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Toward an Understanding of Racial and Ethnic Diversity in Body Image among Women

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Virginia Ramseyer Winter, Laura King Danforth, Antoinette Landor, Danielle Pevehouse-Pfeiffer, Toward an Understanding of Racial and Ethnic Diversity in Body Image among Women, Social Work Research , Volume 43, Issue 2, June 2019, Pages 69–80, https://doi.org/10.1093/swr/svy033

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Body appreciation is associated with health outcomes and affects individuals across their life span, making this area of inquiry particularly relevant to social workers. Race and ethnicity have not been explored thoroughly as demographic characteristics that influence body appreciation. This study aimed to fill this gap by answering the following research questions: (a) How do favorite and least favorite body parts vary by race and ethnicity and (b) how do body appreciation, skin tone satisfaction, body size, and weight perception vary by race and ethnicity? Using Reddit, we recruited 18- through 56-year-old ( N = 497) women who identified as African American, white, Asian, Hispanic/Latina, or more than one of these (multiracial). Results suggest that abs and stomach were the least favorite body parts/features across races and ethnicities, with differences in favorite body parts/features among women of color and white women. In addition, African American women reported highest body appreciation whereas white women reported the lowest. Latina women reported highest skin tone satisfaction, with multiracial women reporting the lowest. This study suggests that women of color’s body appreciation goes beyond the traditional comparison with the white ideal and further body image research should look outside this myopic duality.

Body image significantly relates to physical ( Ramseyer Winter, O’Neill, & Omary, 2017 ), mental ( Gillen, 2015 ), and sexual health outcomes ( Ramseyer Winter, 2017 ) and affects women across the life span ( Runfola et al., 2013 ). In addition, the majority of women in western society are dissatisfied with their body ( Runfola et al., 2013 ). As such, it is likely that many social work clients are affected by body image concerns. However, a lack of inquiry regarding what influences body image, particularly positive body image, among women of color prevents researchers and social work practitioners from fully understanding these constructs and how they influence mental and physical health.

Body Image and Race and Ethnicity

White women have lower levels of body satisfaction, are more concerned about weight, have an increased drive to conceal body size with clothing, and experience increased levels of disordered eating and weight-related depression and anxiety when compared with women from other ethnic or racial groups ( Rucker & Cash, 1992 ; Wildes, Emery, & Simons, 2001 ; Yates, Edman, & Aruguete, 2004 ). Reasons for this include an increasingly thin societal beauty ideal ( Tiggemann, 2011 ) and a greater internalization of media influence to meet Eurocentric standards of beauty ( Rucker & Cash, 1992 ). However, much of the research only compares body image levels of white, Hispanic/Latina, and black women ( Cotter, Kelly, Mitchell, & Mazzeo, 2015 ; Molloy & Herzberger, 1998 ). What is less clear are the differences in body image across multiple racial and ethnic groups, including white, African American, Asian American, white or nonwhite Hispanic/Latina, and multiracial groups ( Grabe & Hyde, 2006 ).

Due to greater acceptance of larger, more curvaceous body shapes ( Cotter et al., 2015 ) and broader and more flexible beauty ideals ( Wood-Barcalow, Tylka, & Augustus-Horvath, 2010 ), African American women have low levels of weight preoccupation and disordered eating habits ( Kronenfeld, Reba-Harrelson, Von Holle, Reyes, & Bulik, 2010 ) and greater satisfaction with their bodies when compared with women in other ethnic and racial groups ( Sanderson, Lupinski, & Moch, 2013 ). It is possible that these differences in body image across race and ethnicity stem from cultural values regarding standards of beauty ( Grabe & Hyde, 2006 ; Kawamura, 2011 ). Rather than place value on these types of beauty standards, African American women report that they embrace their bodies and appreciate race- or ethnic-specific features (for example, lip size, hair grade, nose shape, body shape, and skin color) ( Bond & Cash, 1992 ; Mucherah & Frazier, 2013 ) and unique qualities such as smile, style, attitude, and ability to project pride and confidence ( Parker et al., 1995 ).

Although it appears that African American women have higher levels of body satisfaction than white women, it is not safe to assume that they are free of dissatisfaction. Altabe (1998) found that African American participants reported that they would feel better about their bodies if they had longer hair and were thinner and more toned. Other studies have demonstrated that African American college students internalize the thin ideal as much as white students ( Roberts, Cash, Feingold, & Johnson, 2006 ), especially if they attend predominately white institutions ( Hesse-Biber, 1996 ). Although it has been established that strong identification with African American culture serves as a protective factor against eating disorders, a drive for thinness, and body devaluation ( Brook & Pahl, 2005 ; Sanderson et al., 2013 ), literature in body image research is unclear as to how weight perception affects body image in African American culture. Some studies conclude that African American women are more satisfied with their weight, less likely to see themselves as overweight, and have more accurate perceptions of their weight than women in other racial or ethnic categories (see, for example, Abrams, Allen, & Gray, 1993 ). Others demonstrate that African American and white women prefer a similar ideal silhouette size and shape ( Powell & Kahn, 1995 ) and that weight is directly correlated with body satisfaction for African American women but not for white women ( Abrams et al., 1993 ). Because of these inconsistencies, it is imperative that researchers begin to inquire about weight perception and consider how sociocultural factors play a role in levels of body satisfaction and appreciation among African American women.

Although research surrounding white and African American women’s body image is heavily explored, few body image studies have uncovered specific factors that influence Asian American women’s body image ( Hall, 1995 ; Iyer & Haslam, 2003 ; Lau, Lum, Chronister, & Forrest, 2006 ). Research demonstrates that this group of women report similar levels of body dissatisfaction as white women ( Grabe & Hyde, 2006 ) due to discontentment with weight and body shape ( Altabe, 1998 ; Iyer & Haslam, 2003 ) and unhappiness with racially distinctive features (for example, eye shape, eyelid size, face shape, and nose shape) ( Evans & McConnell, 2003 ; Mintz & Kashubeck, 1999 ). In addition, many Asian American women report a desire for lighter skin ( Altabe, 1998 ).

It is not clear how body size affects Asian American women’s body image. Research demonstrates that the petite frame and low body mass index (BMI) of Asian American women serve as protective factors against body dissatisfaction and disordered eating patterns commonly found in white women ( Akan & Grilo, 1995 ). However, Asian American women experience similar levels of dissatisfaction to those of white women regarding body size ( Yates et al., 2004 ) and are more afraid to gain weight than white women ( Sanders & Heiss, 1998 ). Other studies report that Asian American women’s levels of body satisfaction is lower than white women’s and that they have higher concerns regarding overall body shape than other racial or ethnic groups ( Grabe & Hyde, 2006 ; Haudek, Rorty, & Henker, 1999 ). In fact, according to multiple studies, Asian American youths and young adults (ages 18 to 22) are least satisfied with their appearance when compared with individuals in other racial and ethnic categories ( Grabe & Hyde, 2006 ; Lee & Zahn, 1998 ).

In addition, cultural influences play a large role in determining body satisfaction levels among Asian American women. Because Asian American women are more likely to internalize a western or Eurocentric beauty standard than African American or Hispanic/Latina women ( Evans & McConnell, 2003 ), they may have more body dissatisfaction due to racially distinctive features. In addition, Asian American women may also internalize the notion of marriage as a way to measure social success ( Kawamura, 2011 ), meaning that there may be added pressure to subscribe to traditional gender roles and adopt a hyperfeminine physical appearance, both of which can contribute to body dissatisfaction among women ( Murnen & Don, 2012 ). Because collectivism is so important in Asian cultures, Asian American women may also want to assimilate to western beauty standards quickly to blend in, “enhance” their features, and avoid deviation from the “norm” ( Kawamura, 2011 ). This may be one reason why the most requested plastic surgery procedures among Asian American women include rhinoplasties (or nose reshaping) and eyelid surgery ( Man, 2006 ) and why Asian American women have high levels of body dissatisfaction.

Findings from studies that explore body image of Hispanic/Latina women (that is, women of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin) are also conflicting. Whereas some research shows that this population reports greater overall body satisfaction than non-Hispanic/Latina white women ( Barry & Grilo, 2002 ), others report that body satisfaction and appreciation levels between these two groups are comparable ( Demarest & Allen, 2000 ; Kronenfeld et al., 2010 ; Schooler & Lowry, 2011 ) and that Hispanic/Latina women desire to be taller, thinner, and have longer hair ( Altabe, 1998 ). In fact, according to a 2006 meta-analysis, there are no significant differences in body image or satisfaction between Hispanic/Latina and non-Hispanic/Latina white women ( Grabe & Hyde, 2006 ).

Hispanic/Latina women’s body image is affected by their respective cultures. For example, although many Hispanic/Latina individuals value curvy bodies, large breasts, rounded derrieres, and a generally “thick” body shape ( Goodman, 2002 ; Schooler & Lowry, 2011 ), there is more body policing and weight management practices (for example, food restriction) in Hispanic/Latina families when compared with those among other races or ethnicities ( Schooler & Lowry, 2011 ). Not only does this increase the likelihood of eating pathology for Hispanic/Latina women ( Kronenfeld et al., 2010 ; Wildes et al., 2001 ), it also increases the likelihood of depression ( Schooler & Lowry, 2011 ). One reason for this body policing and general body dissatisfaction among Hispanic/Latina women is due to possessing “dual identities”—acculturative stress ( Schooler & Lowry, 2011 ) caused by conflicting messages in the media about what the ideal body looks like in the United States ( Goodman, 2002 ). Moreover, Hispanic/Latino individuals are the ethnic group most likely to own a smartphone, are twice as likely as white individuals to stream videos online, and are more likely to download pictures and music on their mobile devices ( Pardo & Dreas, 2014 ), all of which increase exposure to media images that do not necessarily represent their body type or features ( Schooler & Lowry, 2011 ). These factors contribute to why some scholars report that increased levels of acculturation into Anglo culture in the United States directly reduces body satisfaction and appreciation for racially marginalized women ( Schooler, 2008 ; Schooler & Lowry, 2011 ).

Multiracial women are the most understudied population in body image research ( McKinley, 1999 ; Pikler & Winterowd, 2003 ; Smolak & Cash, 2011 ). Although Ricciardelli, McCabe, Williams, and Thompson (2007) found that multiracial men engage in similar rates of disordered eating as white and African American men, their research did not include women and did not measure body image. An additional study ( Ivezaj et al., 2010 ) found that multiracial women reported greater body dissatisfaction than African American women and higher levels of weight preoccupation and body-related anxiety than white or African American women. However, authors did not discuss why membership to multiple racial groups affects body image and no Hispanic/Latina or Asian American women were included in the study. Although there is a dearth of knowledge about multiracial women and body image, scholars hypothesize that this population is more likely than other racial groups to be dissatisfied with their bodies due to the “emotional and identity problems associated with straddling two cultures” ( Ricciardelli et al., 2007 , p. 601). For example, according to literature, it is more culturally acceptable for both African American and Latina/Hispanic women to have curvy or thick body shapes ( Schooler & Lowry, 2011 ; Greenberg & LaPorte, 1996 ), which is not true for white women who value Eurocentric beauty standards (for example, extremely slender body shape) ( Overstreet, Quinn, & Agocha, 2010 ; Patton, 2006 ). For multiracial women, attempting to vacillate between two different standards of beauty is both complicated and impossible, as one cannot be both waifish and thick, be both porcelain-skinned and tan, and so on. Attempting to understand how these dual identities affect mental health is necessary, as attempting to fit one specific type of body standard (let alone two diverse body standards) can cause anxiety, depression, and disordered eating ( Furnham, Badmin, & Sneade, 2002 ; Grabe & Hyde, 2006 ; Nolen-Hoeksema, 1987 ; Siegel, Yancey, Aneshensel, & Schuler, 1999 ). In addition, the role that age plays in body image perception across race and ethnicity remains underexplored. According to Grabe and Hyde (2006) , the largest variance between white and African American women’s body dissatisfaction occurs during late adolescence and continues into young adulthood with amount of variance tapering off into later adulthood. According to another study, white women’s body dissatisfaction increases with age and tapers off into late adulthood, Asian women’s body dissatisfaction peaks in adulthood, and Hispanic/Latina women’s body dissatisfaction occurs in young adulthood ( Cachelin, Veisel, Barzegarnazari, & Striegel-Moore, 2000 ). Many studies exploring body satisfaction of women rely on college-age young adults as their sample, as transition into young adulthood is a time of significant identity development and considered a relevant time to assess identification with certain beauty ideals ( Cotter et al., 2015 ). But because body image is known to change across the life span ( Cotter et al., 2015 ), comprehensive research surrounding age trends among women from diverse racial backgrounds is needed.

The current study aims to better understand body image among women who identify as African American, white, Asian American, Latina, and multiracial by seeking to answer two research questions: (1) How do favorite and least favorite body parts vary by race and ethnicity and (2) how do body appreciation, skin tone satisfaction, body size, and weight perception vary by race and ethnicity? Inclusion of a weight perception measure rather than simply asking participants for their height and weight to calculate BMI was essential, as research is unclear about how weight perception specifically affects body image across race or ethnicity. Although body size and weight perception differ across race and ethnicity, women in western society are subject to images of women as not only thin, but also athletic and toned, with small waists, large buttocks, and large breasts, a body type that is largely unattainable ( Mischke, 2014 ). Because of this ideal, all girls and women typically have weight concerns that ultimately shape body image, satisfaction, and appreciation ( Stice, Killen, Hayward, & Taylor, 1998 ).

We predicted that participants would rate various body parts differently based on their race or ethnicity. Specifically, we made four predictions: (1) Racially marginalized women would rate specific body parts (hair, eyes, smile, and so on) higher than white women due to their tendency to place value on non–body size or weight characteristics ( Cash & Smolak, 2011 ). (2) White women would have the lowest levels of body appreciation and would report being least satisfied with their body size. (3) Black women would have the highest level of body appreciation and would report to be more satisfied with their body size when compared with reports of participants in other racial or ethnic categories. (4) Hispanic/Latina women would be more satisfied with their skin tone than women in other racial or ethnic categories. (5) There would be no differences in weight perception across racial and ethnic groups, and participants would rate their hips, abdomen, or thighs as their least favorite body part due to a thin but toned ideal constantly presented in western media ( Markula, 1995 ).

Participants

Participant Characteristics and Study Indicator Descriptives by Race and Ethnicity ( N = 497)

Note: BAS = Body Appreciation Scale.

Data were collected online during the summer of 2016. Participants were required to meet the following criteria: (a) 18 years old or older; (b) identify as a woman; and (c) identify as one or more of the following: white, African American, Hispanic/Latina, or Asian American. Recruitment began after obtaining institutional review board approval from the first author’s institution. Participants clicked on the link to the study and were taken to three questions to determine their eligibility. Participants who were eligible were then shown the consent form, after which they chose whether to participate. At the end of the survey, participants were directed to another survey where they provided their e-mail address if they chose to be entered into the drawing for one of 15 $50 gift cards. Names and addresses were only collected from winners of the gift cards.

We recruited participants through Reddit ( http://reddit.com ), an online bulletin board that offers thousands of subreddits, which are online bulletin boards by topic area. To recruit a diverse sample, we posted the survey link to subreddits that specifically related to women of color. For example, we posted to /r/blackladies and /r/asianamerican subreddits. We recruited white women by posting on subreddits specifically related to women. Other than targeting race- and ethnicity-specific subreddits, we did not conduct oversampling or targeted recruiting. Data were collected online using Qualtrics.

Body Appreciation

Body appreciation was measured with the Body Appreciation Scale–2 ( Tylka & Wood-Barcalow, 2015 ), a 10-item measure with responses ranging from 1 = never to 5 = always. Sample items include “I respect my body” and “My behavior reveals my positive attitude toward my body; for example, I walk while holding my head high and smiling.” Reliability was estimated to be high with the current sample (α = .92). When split by race and ethnicity, reliability analyses revealed high reliability for each of the race groups in the current study: white (α = .92), black (α = .93), Latina (α = .91), Asian (α = .93), and multiracial (α = .91).

Skin Tone Satisfaction

Skin tone satisfaction was measured with one item ( Landor et al., 2013 ), “I like my skin color,” with response options ranging from 1 = strongly agree to 5 = strongly disagree. We reverse coded this item so that a higher score indicates a higher level of satisfaction.

Weight Perception

Weight perception was measured with one item, “How do you think of yourself in terms of weight,” with the following response options: very underweight, slightly underweight, about the right weight, slightly overweight, very overweight.

Favorite and Least Favorite Body Parts and Features

To gain a better understanding of culturally sensitive body image, we asked participants, “What are your top five favorite things about your body/appearance (these are the parts you love!)” and “What are your five least favorite things about your body/appearance (these are the parts you really do not like/want to change!).” Participants were instructed to choose up to five for each question, with the order they chose them in being inconsequential.

Response options included hair (overall, not one specific thing about your hair); hair color; hairstyle; hair texture; eyes overall (not one specific thing about your eyes); eye color; eye shape; eye lid; face; smile; lip thickness; dimples; nose overall (not one specific thing about your nose); nose width; neck; skin tone; freckles; muscles; height; overall body size (not one specific part of your body); overall body shape (not one specific part of your body); arms (overall, not one specific part of your arms); hands (overall, not one specific part of your hands); fingers; fingernails; shoulders; breasts; chest; waist; stomach/abs; back; hips; butt (overall); butt size; butt shape; vulva (the outside of female genitals); legs (overall, not one specific part of your legs); thighs; calves; ankles; feet (overall, not one specific part of your feet); size of feet; toes; toenails; tattoos and/or piercings; I do not like any parts of my body (for the former question only); and I do not dislike anything about my body (for the latter question only).

Race and Ethnicity

Race and ethnicity was collected with one item: “How do you identify your race/ethnicity ( select all that apply ).” Response options included white/Caucasian; black (African American, Caribbean American, Creole, Haitian, Jamaican, West Indian, Brazilian, Ethiopian, Somali, Kenyan, and other [please specify]); Hispanic/Latina (Mexican descent, Caribbean descent, Central American descent, South American descent, and other [please specify]); and Asian (East Asian descent [Chinese, Japanese, Korean], Southeast Asian descent [Filipino, Vietnamese, Cambodian, Hmong], South Asian descent [Asian Indian, Pakistani, Nepalese], and other [please specify]). Participants who responded with more than one race or ethnicity were categorized at multiracial.

BMI was computed from self-reported height and weight data using the CDC equation: weight (lb)/(height [in]) 2 × 703 (CDC, n.d.). BMI was collapsed into weight categories based on CDC BMI categories: under 18.5 = underweight; 18.5–24.99 = healthy, normal weight; 25.0–29.99 = overweight; and 30 and over = obese (CDC, n.d.).

Analytic Plan

To assess differences in favorite and least favorite body parts and features by race and ethnicity, we ran bivariate frequencies. We ran a series of analyses of variance, analyses of covariance (ANCOVA), and chi-square analyses to determine whether our sample differed by race and ethnicity for the following variables: body size, body appreciation, skin tone satisfaction, and weight perception. Data were not weighted.

Five Most and Least Favorite Body Parts by Race and Ethnicity ( N = 497)

The overall mean BMI for the sample was 25.90 ( SD = 7.12). Women who identified as black had the highest average BMI ( M = 27.80, SD = 8.41) and Asian women had the lowest reported BMI ( M = 23.65, SD = 5.51). The difference in mean BMI by race and ethnicity was statistically significant [ F (4, 470) = 4.81, p = .001]. Due to the significant differences in BMI, we controlled for BMI when exploring mean differences in body appreciation by race and ethnicity.

Black women reported the highest body appreciation ( M = 3.37, SD = 0.82), with white women reporting the lowest ( M = 3.13, SD = 0.74). However, body appreciation did not differ significantly by race and ethnicity [ F (4, 488) = 1.31, p = .267]. We ran ANCOVA with BMI as a covariate. While holding BMI constant, body appreciation did not vary significantly by race and ethnicity [ F (4, 471) = 0.78, p = .547].

Latina women reported the highest skin tone satisfaction ( M = 4.14, SD = 0.82), followed by black women ( M = 4.08, SD = 0.91), Asian women ( M = 3.93, SD = 0.90), white women ( M = 3.83, SD = 0.87), and women who identified as multiracial ( M = 3.78, SD = 0.95). The differences in mean skin tone satisfaction by race and ethnicity were significant [ F (4, 496) = 2.58, p = .037].

The majority of participants reported being slightly overweight or very overweight: non-Hispanic white (64.7%, n = 88), non-Hispanic black (68.1%, n = 64), Latina (68.8%, n = 44), non-Hispanic Asian American (57.6%, n = 64), and multiracial (62.4%, n = 53). However, a chi-square test revealed that the differences in weight perception by race and ethnicity were not significant: χ 2 (16, N = 490) = 21.44, p = .162.

The current study contributes to a growing body of research that calls for a broader measure of body image to fully understand the complexity of body image for all women, including women of color. Counter to some previous literature (see Roberts et al., 2006 , for a meta-analytic review), our findings suggest that women of color are not immune from negative appraisals about their physical appearance. Results of the present study illustrate that all women have concerns about their body size and shape, but women of color, in particular, seem to also place high value on non–body size and shape physical characteristics such as facial features and hair. Thus, a myopic focus on body size and shape in the research literature neglects other physical characteristics that influence body image. Without both considerations, we may never achieve a holistic understanding of the embodied experiences of all women.

The present study attempted to examine how women across different racial and ethnic groups rate various physical characteristics, including various body parts and features. Results indicate that eye color was the favorite physical characteristic for white women, whereas lip thickness was the favorite for black and multiracial women. Hair overall was the favorite physical characteristic for Latina and Asian women. Lip thickness was the second favorite physical characteristic for Latina women, whereas eyes overall was the second favorite physical characteristic for multiracial women. Last, height was the second favorite physical characteristic for white and black women. Taken together, findings suggest that women in general place a high value on non–body size and shape features. In particular, women of color place high value on physical characteristics such as facial features (for example, lips, eye color) and hair. This indicates that these physical characteristics may be equally salient to women of color as body shape and size. Facial features and hair are rarely included in positive body image scales despite a strong appreciation for these features among women of color. Although the significance of facial features and hair has been discussed in previous work ( Byrd & Solomon, 2005 ), body image research still fails to include these variables in assessments of body image. Such features may serve as buffers against body dissatisfaction for women of color, which may in turn protect women from eating disorders and other negative psychological health outcomes.

Conversely, women across all racial and ethnic groups reported that their least favorite physical characteristic was their stomach and abs. Overall body size was the second least favorite physical characteristic for all women, except for black women, who rated overall body size as their third least favorite physical characteristic. These finding are consistent with decades of past literature that document women’s dissatisfaction with their body size and shape ( Fiske, Fallon, Blissmer, & Redding, 2014 ; Grabe & Hyde, 2006 ). In addition, black women reported their breast size to be the second least favorite physical characteristic. Nose overall was the third least favorite for Latina, Asian, and multiracial women. Studies examining body dissatisfaction among racially diverse samples found that Latina and Asian women were more dissatisfied with some of their facial features, including their nose and eyes ( Frederick, Kelly, Latner, Sandhu, & Tsong, 2016 ; Warren, 2014 ). It is interesting that the physical characteristics identified as the least favorite for women across all racial and ethnic groups centered around body size and shape. These findings suggest that past research has only focused on women’s appreciation of features they seem to like the least. The danger in this approach is that it leaves out more salient culturally relevant features that are seen as attributes for women of color.

Findings demonstrate that standards of beauty are general to all women but also unique to women of color as results show that traditional body image concerns (for example, body size and shape) are not exclusive features on which women of color evaluate themselves and are evaluated by others. Thus, culturally relevant physical characteristics such as facial features and hair must be included in discussion of body image as they are meaningful aspects of the embodied experience of women of color. Women of color may be buffered from body image pathology when culturally relevant features are included in positive body image discussions to provide a more positive body image overall, though this is speculative given the study design and measure used.

Results from this investigation also revealed significant differences in BMI among racial and ethnic groups. Specifically, black women reported the highest mean BMI while also reporting the highest body appreciation evaluation, although there were no significant differences in body appreciation between groups. These results are consistent with literature that points to cultural beliefs including a general preference for larger body sizes and resistance to traditional standards of body shape ( Lovejoy, 2001 ; Webb, Warren-Findlow, Chou, & Adams, 2013 ) as an explanation for these findings. Conversely, Asian women reported the lowest mean BMI. Some literature has suggested that a cultural emphasis on thinness and criticism of body size from family may explain low BMI ( Smart & Tsong, 2014 ). Consistent with past research, we found that white women reported the lowest body appreciation ( Grabe & Hyde, 2006 ). In addition, results revealed significant differences in skin tone satisfaction such that Latina women had the highest satisfaction while multiracial women had the lowest. It is important to note, however, that African American women scored the second highest. These findings are similar to those of studies that found associations between skin tone, skin tone satisfaction, and women of color ( Landor & Halpern, 2016 ; Romo, 2011 ) and suggests that skin tone remains a salient aspect of body image in the lives of both Latina and African American women. Last, we explored racial and ethnic differences in weight perceptions. Results showed that the majority of women from all racial and ethnic groups perceived themselves as being overweight (either slightly or very). Similar results were noted in other studies ( Paeratakul, White, Williamson, Ryan, & Bray, 2002 ).

In sum, our study demonstrates that body image measures that centralize the thin ideal provide an incomplete picture of the embodied experiences of women of color. Even when white samples are not included in studies, women of color are implicitly compared with their white counterparts as the measures reflect white standards of beauty. Studies continue to examine body image issues among women of color using measures that have been developed and validated with predominately white samples. Such measures may be no longer sufficient. Our findings indicate that women of color struggle to navigate issues around white standards of beauty and their own cultural attitudes around other physical characteristics salient to their body image. This conflict is important to note.

Findings also underscore social work’s ethical foundation. The social work code of ethics states that “social justice” and “competency” be incorporated by social workers at all times ( National Association of Social Workers, 2017 ). Studies that increase understanding of how body image affects historically underresearched races and ethnicities is imperative to moving body image research forward in a way that is culturally competent. A recent study found that clinical practitioners do not feel equipped to assess for body image in female clients. This study also found that practitioner would like further training and information on how body image affects mental health ( Ramseyer Winter, Brett, Pevehouse, O’Neill, & Ellis-Ordway, 2018 ). Lack of diverse body image research makes creating training and providing tools to practitioners nearly impossible, perpetuating the continued gap in knowledge surrounding body image’s effect on clients across cultures, which according to the social work guidelines is unethical.

This research also highlights the need to continue to explore the various body image concerns for all racial and ethnic groups rather than painting with a broad brush. The experiences and perceptions of women from different racial and ethnic groups are different and should be treated as such.

Limitations

The current study has many strengths, but also several important limitations. First, the cross-sectional design does not allow us to determine causality and the findings are not generalizable. All measures are self-reported, which could result in biased data. Furthermore, the measure of favorite and least favorite body features is crude and will require refinement and psychometric testing if it is used in future research. Although this article explores body image by race and ethnicity in much more depth than most, it is important to note that we were unable to account for diversity within heterogeneous racial and ethnic groups. In addition, the use of Reddit to collect data as the sole source of data collection is a limitation.

Based on the notion that women of color are buffered from body image concerns, social work practitioners may choose not to discuss body image issues with these women. Our results suggest that practitioners should avoid such assumptions and consider expanding the scope of the discussion to other relevant physical characteristics such as facial features and hair. In addition, findings further demonstrate the need for researchers and practitioners to include aspects of physical appearance aside from body size and shape in measurement of body image of women of color. In fact, it seems critical for future body image studies to include variables related to physical characteristics (for example, hair, lips, eye color) to more comprehensively understand the lived reality of all women. Understanding what characteristics promote body satisfaction and a positive body image differentially across various racial and ethnic groups could be a salient tool in the development of tailored interventions designed to prevent eating and psychological disorders. Future research should consider the interactions of other social identities such as social class, age, racial or ethnic identity, and sexual orientation as they may also be associated with the body image of women of color. In addition, given the dearth of research on body image issues within racial and ethnic minorities, qualitative studies using in-depth interviews should be conducted to investigate the influence of culturally relevant physical characteristics on how racial and ethnic minority women view their bodies.

Virginia Ramseyer Winter, PhD, is assistant professor, School of Social Work, University of Missouri, 705 Clark Hall, Columbia, MO 65211; e-mail: [email protected] . Laura King Danforth, PhD, is assistant professor, University of Arkansas at Little Rock. Antoinette Landor, PhD, is assistant professor, Department of Human Development and Family Science, University of Missouri, Columbia. Danielle Pevehouse-Pfeiffer, MSW, is case manager, Care Coordination, University of Missouri Hospital, Columbia.

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[Body image; literature review]

Affiliation.

• 1 Facultad de Ciencias de la Actividad Física y el Deporte, Universidad Católica de San Antonio, Guadalupe, Murcia.
• PMID: 23808427
• DOI: 10.3305/nh.2013.28.1.6016

Abstract in English, Spanish

Introduction: Nowadays, in developed countries there are standards of beauty based on pro-thin models, which are internalized by adolescents and young people especially in the case of women, assuming it as risk factor for developing changes in body image and perception.

Objective: To analyze the current state of research in relation to body image, the sociodemographic variables that influence it, the relationship between body composition, conducting diets, eating disorders, sports and intervention programs and prevention, and the body image.

Methods: It was searched in Medline, Isi Web of knowledge and Dialnet as well as a manual search among the references of selected studies and in different libraries.

Results and discussion: A increased socio-cultural influence is associated with a greater perception of body fat, greater body image dissatisfaction and lower self assessment of overall fitness. This leads to a lot of teenagers and young adults to abuse to the restrictive diets and to suffer eating disorders. Numerous studies have analyzed the relationship between sports practice with body image disturbance; there are conflictive results. Moreover it is necessary to design objective tools to detect changes and enhance the design of prevention and intervention programs in order to avoid distortion of body image, especially in those age ranges where the population is more vulnerable to this phenomenon.

Conclusions: The excessive current preoccupation about body image has resulted in the realization of diets and changes as eating disorders. There are other factors that influence body image and perception as the realization of physical exercise, although the results about the relationship between these factors are contradictory. Therefore, further work is needed on the issue by creating tools to detect changes and enhance the design of prevention and intervention programs.

Introducción: En los países desarrollados existen en la actualidad unos estándares de belleza basados en modelos prodelgadez, que son interiorizados por los adolescentes y los jóvenes, sobre todo en el caso de las mujeres, suponiendo un factor de riesgo para el desarrollo de alteraciones de la imagen corporal y su percepción. Objetivo: Analizar el estado actual de las investigaciones sobre la imagen corporal, las variables sociodemográficas que influyen sobre ella y su relación con la composición corporal, la realización de dietas, los trastornos de la conducta alimentaria, el deporte y los programas de intervención y prevención. Metodología: Se realizó una búsqueda bibliográfica en Medline, Isi Web of Knowlegde y Dialnet, así como una búsqueda manual entre las referencias de los estudios seleccionados y en diferentes bibliotecas. Resultados y discusión: Una mayor influencia sociocultural está asociada a una mayor percepción de la grasa corporal, a una mayor insatisfacción con la imagen corporal y a una menor valoración del autoconcepto físico general. Esto lleva a una gran cantidad de adolescentes y jóvenes a abusar de dietas restrictivas y a sufrir trastornos de la conducta alimentaria. Numerosos estudios han analizado la relación de la práctica deportiva con las alteraciones de la imagen corporal, encontrando resultados contradictorios. Por otra parte, es necesario crear herramientas objetivas para detectar las alteraciones y profundizar en el diseño de programas de prevención e intervención con el fin de evitar la distorsión de la imagen corporal, sobre todo en aquellas franjas de edad donde la población es más vulnerable a este fenómeno. Conclusiones: La excesiva preocupación sobre la imagen corporal trae como consecuencia la realización de dietas y alteraciones como los trastornos de la conducta alimentaria. Existen además otros factores que influyen sobre la imagen corporal y su percepción como es la realización de ejercicio físico, aunque los resultados sobre la relación de ambos factores son contradictorios. Por esto, es necesario profundizar más en el tema, creando herramientas para detectar las alteraciones y profundizar en el diseño de programas de prevención e intervención.

Copyright © AULA MEDICA EDICIONES 2013. Published by AULA MEDICA. All rights reserved.

Publication types

• English Abstract
• Beauty Culture
• Body Image*
• Feeding and Eating Disorders / psychology
• Socioeconomic Factors
• Young Adult

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Body Image Problems in Individuals with Type 1 Diabetes: A Review of the Literature

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• Published: 26 August 2021
• Volume 7 , pages 459–498, ( 2022 )

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• Alda Troncone 1 ,
• Crescenzo Cascella 1 ,
• Antonietta Chianese 1 ,
• Angela Zanfardino 2 ,
• Anna Borriello 1 &
• Dario Iafusco 2  

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Despite type 1 diabetes' (T1D) potential influence on adolescents' physical development, the occurrence of body image problems of adolescents with diabetes remains unclear. No research synthesis has yet addressed this issue. This study aims to systematically evaluate the empirical evidence concerning body image in individuals with T1D in order to provide an overview of the existing literature. Using PRISMA methodology, 51 relevant studies that fulfilled the eligibility criteria were found, the majority of them (N = 48) involving youth. The findings varied across studies: 17 studies indicated that in youth with T1D, body dissatisfaction was common and that body concerns were generally greater in youth with T1D than in controls; nine studies did not find any differences in body image problems between participants with and without T1D; three studies described higher body satisfaction in youth with diabetes than in controls; and three studies reported mixed results. Body concerns in individuals with T1D were often found to be associated with negative medical and psychological functioning. The variability and limits in assessment tools across studies, the overrepresentation of female subjects, and the fact that most research in this field is based on cross-sectional data are stressed in the interpretation of these mixed findings. Future research directions that could improve the understanding of body image concerns and clinical implications are discussed.

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Introduction

For individuals with type 1 diabetes (T1D), specific features of the illness and its management—such as dietary restrictions, weight variation, perception of living in an unhealthy body, and focus and attention on the body—are thought to contribute to the development of a negative body image (Colton et al., 1999 ; Shaban, 2010 ). Concerns and lack of satisfaction with their body, especially during adolescence, may lead to the development of unhealthy eating attitudes that could seriously increase the risk of poor glycemic control and long-term complications (Hanlan et al., 2013 ; Young et al., 2013 ). However, no general agreement has been reached as to whether body image problems are always found in individuals with T1D and whether significant differences exist between individuals with and without T1D in terms of body image. To date, no research synthesis has addressed this issue; therefore, this study aims to offer a systematic review that summarizes and analyzes the peer-reviewed literature over time on this topic.

It is worth noting that a great deal of literature has reported that body image is significantly associated with psychological functioning in general. In particular, body image has been found to meaningfully affect quality of life, self-esteem, sexual functioning (Grossbard et al., 2009 ; Nayir et al., 2016 ; O'Dea, 2012 ; Weaver & Byers, 2006 ; Woertman and van den Brink 2012 ). Additionally, some authors argue that negative body image has a negative effect on mood and on social anxiety and interpersonal/psychosocial functioning (Cash et al., 2004 ; Choi & Choi, 2016 ; Davison & McCabe, 2006 ; Holsen et al., 2001 ; Pawijit et al., 2017 ), in addition to promoting health-compromising behaviors (e.g., dieting, binge eating, lower levels of physical activity, unhealthy weight control behaviors), particularly during a time of difficult transition such as adolescence (Neumark-Sztainer et al., 2006 ). The generally-demanding process of maturation toward adulthood, the changes in the body due to pubertal development and growth, and the growing importance of appearance may favor a tendency toward problematic perceptions and dissatisfaction with their body size and shape during this critical time (Davison & McCabe, 2006 ; Paxton et al., 2006 ; Wertheim & Paxton, 2011 ). Several studies have identified the key role of body dissatisfaction in the development of disordered eating behaviors (DEBs), both in youth from the general population and in adolescents with T1D (Amaral & Ferreira, 2017 ; Araia et al., 2020 ; Girard et al., 2018 ; Striegel-Moore & Bulik, 2007 ). Recently, a meta-analysis was conducted of the results of 479 samples from 330 studies comparing body image in children and adolescents with chronic conditions to that in healthy controls (Pinquart, 2013 ). However, while this review examined a broad range of conditions (e.g., arthritis, cerebral palsy, visual impairment, cancer, epilepsy, spina bifida, hearing impairment, cystic fibrosis, inflammatory bowel disease), its focus on individuals suffering from T1D was limited (approximately 34 Footnote 1 /330 studies).

Current Study

Given the relevance of body image problems to the psychological functioning of youth, including those with T1D, and in order to obtain a more comprehensive understanding and a systematic evaluation of this issue, the present study seeks to identify existing main findings on body image in youth with T1D, along with current gaps in the literature that may serve as a guide for future investigations. In particular, this review attempts to answer the following research questions: what are the general demographics (e.g., gender, age), sample composition, and research design of the studies? What measures are used to assess body image problems? Which studies examining youth with T1D describe body image problems, and what demographic-/anthropometric-related differences are reported? How frequently are body image concerns reported as being related to eating problems? What other (illness-related and psychological) factors were described as being associated with body image problems? Critical summaries of each article (description of the study’s design, aims, sample, measures of body image, major findings and limitations) are provided in Table 1 . Studies explicitly comparing adolescents with adults, as well as those focusing solely on adults, are summarized at the end of Table 1 .

Search Strategy and Study Selection

A systematic search was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009 ; Moher et al., 2009 ). A search for relevant literature was conducted in December 2020 and January 2021 to identify peer-reviewed articles evaluating body image in individuals with T1D. In order to detect all potential publications, no date ranges or limits were established. The following electronic databases were used in this search: PsycInfo, PsycArticles, PsycCRITIQUES, Pubmed, and Scopus. The search strategy utilized search terms for diabetes (i.e., “type 1 diabetes”, “diabetic”, “insulin dependent diabetes mellitus”) combined with terms for body image (i.e., “body image”, “body shape”, “body dissatisfaction”, “body concerns”, “body image disturbances”, “body image attitudes”). In addition, a manual search of relevant journals was carried out. Specifically, a carefully examination of the reference sections of articles was conducted to identify additional, potentially relevant records. Additionally, just before this paper was submitted, the searches were repeated in order to identify any new studies published in the relevant literature after the initial search.

The initial database search identified 635 articles (plus 10 articles identified through other sources) (Fig.  1 ). After duplicates (N = 361) were removed, 284 articles were then further considered and screened by their titles. Through title screening, articles reporting qualitative, case report, or treatment studies were excluded, along with commentaries, letters to editors, editorials, non-original studies (e.g., reviews and meta-analyses), books chapters, and study protocols (N = 52). The title screening step identified 232 full-text articles, which were retrieved and assessed for inclusion in this review based on the following inclusion criteria: (1) the original research was in English; (2) the study examined body image (and related aspects) in individuals with T1D; (3) the study presented quantitative data; (4) the full text was published in English.

PRISMA flow chart describing the study selection process

Studies were excluded if they: (1) only measured body image in type 2 diabetes (T2D); (2) were not fully relevant (e.g., studies that focused exclusively on weight loss or nutrition and not on body image aspects). Titles and full texts were screened by two independent reviewers (AB, CC). A third independent reviewer (AT) was consulted in cases of uncertainty in order to reach agreement on the eligibility of the study. After an examination of 232 full texts, 181 studies were excluded because they did not include T1D samples (N = 116), did not focus on psychological dimensions (N = 8) or on body image (N = 11), had an inadequate design (N = 1), were not in English (N = 24), did not report quantitative data (N = 18) or relevant evidence (N = 2), or the full text was not available (N = 1) (Fig.  1 ). (All excluded studies are listed in Online Appendix 1.) Consequently, a total of 51 articles met all of the selection criteria and were included in the review (Fig.  1 ).

Synthesis of Study Characteristics

The number of participants with T1D across studies ranges from 13 (Herpertz et al., 2001 ) to 629 (Baechle et al., 2014 ). Of the 51 papers included in this literature review, three studies were conducted with adults (19 years and older) (Herpertz et al., 2001 ; Mcdonald et al., 2021 ; Rockliffe-Fidler & Kiemle, 2003 ); 14 had samples comprising both adolescents [according to the WHO’s ( 1986 ) definition from ages 10 to 19] and adults (e.g., Bachmeier et al. 2020 ; Rancourt et al., 2019 ; Robertson et al., 2020 ); 27 studies were conducted with adolescents only (e.g., Araia et al., 2020 ; Hartl et al., 2015 ; Peterson et al., 2018 ; Wilson et al., 2015 ); six studies used a sample comprising both children and adolescents (e.g., Olmsted et al., 2008 ; Peducci et al., 2019 ); and one study sample consisted exclusively of children (Troncone et al., 2016 ). In terms of gender, 12 studies were conducted with only female participants (e.g., Gawlik et al., 2016 ; O'Brien et al., 2011 ), and 38 with both male and female participants (e.g., Benioudakis, 2020 ; Verbist & Condon, 2019 ; Wilson et al., 2015 ). Only one study (Svensson et al., 2003 ) was conducted exclusively with male participants. The majority of the studies (n = 29) were cross sectional in design (e.g., O'Brien et al., 2011 ; Philippi et al., 2013 ; Powers et al., 2017 ); 18 were case–control studies (e.g., Falcão & Francisco, 2017 ; Troncone et al., 2020a ) and four were longitudinal studies (e.g., Hartl et al., 2015 ; Troncone et al., 2018 ). In terms of sample composition, 24 studies had a sample consisting only of individuals with T1D (e.g., Blicke et al., 2015 ; de Wit et al., 2012 ); 14 studies had samples with both T1D and control participants (e.g., Baechle et al., 2014 ; Falcão & Francisco, 2017 ); four studies had samples of T1D adolescents and their parents (e.g., Eilander et al., 2017 ; Troncone et al. 2020b ); three studies had participants with T1D and T2D (Bachmeier et al. 2020 ; Herpertz et al., 2001 ; Rockliffe-Fidler & Kiemle, 2003 ); and six studies had participants with T1D and other illnesses (e.g., individuals with rheumatic arthritis, bone-fracture patients, individuals with an amputation, individuals with an eating disorder -ED) (e.g., Kaminsky & Dewey, 2013 , 2014 ; Mcdonald et al., 2021 ).

Measurement of Body Image

A range of screening and assessment methods have been developed and used to identify body image perception and to measure several aspects of body image problems. Therefore, the ways in which body image was conceptualized and assessed varies across studies. Of the 51 studies included in this literature review, the majority (n = 30) used subscales and items from existing tools (e.g., Body Dissatisfaction subscale from the Eating Disorder Inventory; Shape and Weight Concern subscales from the Eating Disorder Examination-Questionnaire) (e.g., Eilander et al., 2017 ; Peducci et al., 2019 ; Peterson et al., 2018 ) or used individual self-report tools (n = 10) designed for the general population (e.g., Body Image Scale; Body Image Disturbance Questionnaire; Sociocultural Attitudes Towards Appearance Questionnaire) (e.g., Gawlik et al., 2016 ; Troncone et al. 2020a , b ). Additionally, six studies developed questionnaires/items specifically for the study (e.g., Bachmeier et al. 2020 ; Benioudakis, 2020 ). Overall, in these studies, body image problems were mainly defined—and therefore assessed—as thoughts or judgments about one’s body (or body parts) or evaluations and perceptions of one’s general appearance (i.e., body shape/weight concerns, body dissatisfaction, body image disturbances/distortions, weight perception and satisfaction, concern with body development, body pride); as facets of self-concept (i.e., body image concept, physical self-evaluative and motivational salience, physical self-concept, negative body self, body esteem, self-perception and body awareness); or as the internalization of the thin ideal and the perceived sociocultural appearance-related pressures or positive/negative feelings about their body.

Additionally, eight studies used body silhouette charts (e.g., Body Image Assessment, Stunkard figure rating scales, Collins’s body image silhouette chart) (e.g., Araia et al., 2017 , 2020 ; Falcão & Francisco, 2017 ) designed to generally measure size accuracy (perception of current body size and own weight category) and body satisfaction (difference between perceived body size and ideal body size) ; four studies used projective tests (e.g., drawing tests, Rorschach) or items evaluating general body image impairment and disturbances (e.g., Fällström & Vegelius, 1978 ; McCraw & Tuma, 1977 ); and one study used two open-ended questions exploring personal experience of body image concerns along with a self-reported body image measure (Verbist & Condon, 2019 ).

Body Image Problems

Thirty-three studies (out of 51) sought either to directly evaluate the presence of body image problems or to subsequently measure other variables. Of these 33 studies, 18 (one of which focused on adults) reported body concerns in diabetes patients, while 12 did not and three reported mixed results. Specifically, 11 studies described significant body image problems—viewed as body image dissatisfaction (e.g., Eilander et al. 2017 ; Philippi et al., 2013 ), weight and shape concerns (Bachmeier et al., 2020 ; Peducci et al., 2019 ), perceived damaged/inadequate body image (Swift et al., 1967 ), and body size misperception (Troncone et al., 2018 )—in adolescents with T1D. Shape and weight concerns were especially present in adolescents and adults with T1D with high diabetes distress compared to those with low/moderate distress (test values NR, p  < 0.001) (Powers et al., 2017 ). Of these 11 studies, one was conducted with adults with T1D and similarly indicated that participants were dissatisfied with their body (Rockliffe-Fidler & Kiemle, 2003 ). Moreover, seven case–control studies reported greater body dissatisfaction, shape concerns, and an attitude of negative body image in individuals with T1D (mainly samples of female children and adolescents) than in healthy peers or controls without T1D (e.g., Markowitz et al., 2009 ; Troncone et al. 2020b ).

Conversely, nine studies found no significant differences in body image problems between participants (mainly adolescents of both genders) with and without T1D (e.g., Falcão & Francisco, 2017 ; Kaminsky & Dewey, 2013 , 2014 ). Particularly, in one study, male adolescents with T1D did not show higher body dissatisfaction than control participants (test value NR, p  > 0.05) (Svensson et al., 2003 ). Three studies (Ackard et al., 2008 ; Baechle et al., 2014 ; Meltzer et al., 2001 ) reported that adolescents with T1D of both genders (in Meltzer et al., 2001 , only girls) even had a higher body level of body satisfaction than controls without T1D. In terms of the three studies reporting mixed results, one study indicated that female adolescent participants with T1D showed higher weight concerns, dissatisfaction (test value NR, all p  < 0.01), and concerns-body development (perceiving themselves as overweight, χ 2  = 11.8, p  < 0.01) than female participants without T1D, while male participants with T1D did not differ from male controls (χ 2  = 0.4, p  > 0.05) (Neumark-Sztainer et al., 1996 ). In another study, children with T1D (t = 5.603, p  < 0.001) and controls (t = 11.140, p < 0.001) showed similar levels of underestimation and dissatisfaction (t = − 0.962, p  < 0.01) with body size; additionally, girls with T1D were more accurate in their perception of body size than the control group (F = 4.654, p  < 0.05) (Troncone et al., 2016 ). In another study, while adolescents with T1D reported higher body dissatisfaction than controls (t = 4.219, p  < 0.0001), they did not display more body image problems (as thin ideal internalization and appearance pressure) (test value NR, p  > 0.05) than controls did; female participants with T1D were found to be more pressured than female controls by family (t = 2.258, p  = 0.025) but less by media (t = − 2.308, p  = 0.022) to improve their appearance and to attain a thin body (Troncone et al., 2020a ).

The 18 studies (out of 51) that did not directly evaluate the presence of body image problems mainly: explored body image so as to identify any association with other variables (HbA1c values, diabetes adjustment, family climate, maladaptive eating behaviors, BMI, quality of life, etc.) (e.g., Blicke et al., 2015 ; O'Brien et al., 2011 ); carried out comparisons among youth with T1D grouped by gender, presence of EDs, type of insulin therapy, etc. (e.g., Powers et al., 2012 ; Wilson et al., 2015 ); evaluated body image as a mediator of psychological outcomes (Hartl et al., 2015 ); or assessed changes in body image dissatisfaction in adults with T1D (Herpertz et al., 2001 ). It is worth noting that among these, two studies focused on the impact of diabetes insulin devices in adolescents and adults with T1D, describing higher negative body representation (as insulin pump use effect) in multiple daily injection users than in continuous subcutaneous insulin infusion (CSII) users (U = 2363, p  < 0.0001) (Benioudakis, 2020 ) or finding no differences in body image dissatisfaction between technology (CSII, continuous glucose monitoring—CGM) users and nonusers (CGM/CSII z = − 0.68/0.10, p  > 0.05) (Robertson et al., 2020 ).

Gender Differences

Of the 12 studies looking at gender differences and clearly comparing male and female individuals with T1D, most (n = 11) showed that girls/women had significantly higher rates of body image dissatisfaction and body weight and shape concerns than boys/men (e.g., Araia et al., 2017 , 2020 ; Bachmeier et al. 2020 ). Although no direct mean comparisons were carried out, in other studies, dissatisfaction with weight means reported by girls with T1D (13.9 ± 4.0) were higher than those reported by boys with T1D (5.4  ± 2.7) (Ackard et al., 2008 ); girls reported higher body dissatisfaction (22.9%) than boys (8.3%) (Baechle et al., 2014 ); both girls (11.20 < χ 2  < 32.33, 0.001 <  p  < 0.05) and boys (although less pronounced) (17.91 < χ 2  < 34.78, 0.001 <  p  < 0.003) with chronic illness (including T1D) reported higher body image problems—as weight dissatisfaction, body pride, and concern with body development—than those without chronic illness (Neumark-Sztainer et al., 1995 ). In contrast, another study found no gender differences in body satisfaction (t = 1.96, p  = 0.053) in a sample of 103 Dutch adolescents with T1D (Eilander et al. 2017 ), as well as in a sample of 23 Finnish adolescents with T1D ( p  = NR) (Erkolahti et al., 2003 ).

Age Differences

Of the 14 studies with samples comprising both adolescents and adults with T1D, only four directly compared adolescents with adults. Of these four studies, two did not detect differences between age groups (test value NR, p  = 0.755, Philippi et al., 2013 ) (test value NR, p  = NR, Verbist & Condon, 2019 ), one found body image dissatisfaction to be higher in adults than in adolescents ( p  < 0.001, n 2  = 0.05) (Rancourt et al., 2019 ), and one indicated that 13–14 year old girls’ body dissatisfaction was lower than that of the other age groups (older adolescents and young adults), regardless of diabetes (data NR) (Khan & Montgomery, 1996 ). Similarly, when different age groups of adolescents with T1D were directly compared, teens reported higher shape (t = 6.11, p  < 0.00001) and weight (t = 5.72, p  < 0.00001) concerns than preteen participants (Peducci et al., 2019 ). Of the three studies conducted with adults with T1D (19 years and older), two focused directly on the presence of body image problems, finding high frequency of dissatisfaction with their body (Rockliffe-Fidler & Kiemle, 2003 ) and no worsening of body dissatisfaction after 2 years (test value NR, p  > 0.05) (Herpertz et al., 2001 ). The remaining study focused less on the occurrence of body image problems, instead evaluating body image as a mediator and a predictor of psychological outcomes (Mcdonald et al., 2021 ).

Researchers have shown that body dissatisfaction (or body image satisfaction) was positively (or negatively) correlated with higher BMI in both girls and women with T1D (e.g., Kichler et al., 2008 ) and in youth of both genders (Rancourt et al., 2019 ). In fact, BMI was described as higher in girls with T1D with shape and eating concerns (F = 3.47, p  = 0.046) and less positive body image (t = − 0.46, p  = 0.03) (Kaminsky & Dewey, 2014 ; Wilson et al., 2015 ). Similarly, in both genders (although more so for female than male participants), a higher BMI was found to be a significant predictor of greater body dissatisfaction (female: R 2  = 0.271 p  < 0.0001; male: R 2  = 0.103, p  < 0.03) (Meltzer et al., 2001 ), and body image satisfaction was also predicted by BMI (R 2  = 0.232; b = − 0.466, p  < 0.01) (Verbist & Condon, 2019 ). In line with these findings, other evidence indicated higher body dissatisfaction in overweight adolescents and adults with T1D compared to those with normal weight (test value NR, p  < 0.001) (Philippi et al., 2013 ); similarly, it was found that in children with T1D and in control participants, those with higher weight underestimated their body size more (F = 30.238, p  < 0.001) and are more dissatisfied than those with lower weight (F = 25.766, p  < 0.001) (Troncone et al., 2016 ). Only one study, evaluating a sample of Turkish adolescents with T1D, found no significant body dissatisfaction correlation with BMI (r = − 0.192, p  > 0.05) (Pinar, 2005 ); additionally, another study found a lack of correlation in boys (but not in girls) (Kaminsky & Dewey, 2014 ).

Body Image Problems and Disordered Eating Behaviors

Several studies (n = 12) clearly described body image problems (defined as body image dissatisfaction, perceived physical appearance, weight and shape concerns, and pressure to conform to societal norms about body image) in youth with T1D as one of the main predictor of DEBs, both in female-only samples (e.g., Falcão & Francisco, 2017 ; Verbist & Condon, 2019 ) and in samples of both genders (e.g., Araia et al., 2017 , 2020 ). One study described weight dissatisfaction as a predictor of binge eating and purging behaviors in female (but not male) adolescent participants with T1D (B = 0.32, p  < 0.001) and without T1D (B = 0.11, p  < 0.05) (Neumark-Sztainer et al., 1996 ). Similarly, concerns about body image/weight dissatisfaction were found to be higher in adolescents with T1D and DEBs (Eilander et al., 2017 ) and positively correlated to DEBs (Neumark-Sztainer et al., 2002 ; Rancourt et al., 2019 ), EDs (Kaminsky & Dewey, 2013 ), bulimic symptoms in both genders (Peterson et al., 2018 ) and dietary restraints (Rancourt et al., 2019 ). Girls reporting higher rates of body dissatisfaction were more likely to engage in unhealthy weight control behaviors than those with lower rates of body dissatisfaction (test value NR, p  = 0.005) (Neumark-Sztainer et al., 2002 ).

Two studies found higher negative body image (Grylli t = − 3.4, p  < 0.001; Maharaj F = 60.42, p  = 0.0005) and poorer self-concept about their physical appearance (Maharaj F = 19.45, p  = 0.0005) in adolescent girls with T1D and a diagnosed ED than in girls with T1D but no ED. Another study reported greater shape and weight concerns among male and female adolescents with T1D with any ED than those with no ED (test value NR, p  < 0.003) (Wilson et al., 2015 ). Adolescents with T1D and DEBs were found to show higher levels of body dissatisfaction (t = 2.578, p  = 0.011) and body image problems conceptualized as thin ideal internalization and appearance pressure problems (2.703 ≤ t ≤ 4.603, 0.001 ≤  p  ≤ 0.010), than adolescents with T1D but no DEBs (Troncone et al. 2020b ). Further evidence indicated higher body dissatisfaction in adolescents and adults with T1D at risk of ED compared to those not at risk of ED (test value NR, p  < 0.001)—as well as being higher in those who omitted insulin (test value NR, p  < 0.001) (Philippi et al., 2013 ).

One study reported that participants (adolescents and adults) with an ED and T1D did not differ in body distortion (test value NR, p  = 0.097), weight concerns (test value NR, p  > 0.05), and body dissatisfaction (test value NR, p  > 0.05) from patients with an ED and no diabetes, but they saw themselves as heavier and desired a thinner physique less frequently and reported fewer shape concerns than patients with an ED and no diabetes (test value NR, p  = 0.047) (Powers et al., 2012 ). Conversely, another study reported that body dissatisfaction did not correlate with attitudes to restricting eating (when faced with external cues that prompt eating) (test value NR, p  > 0.05) and did not differ between those who omitted insulin and those who did not (test value NR, p  > 0.05) (Khan & Montgomery, 1996 ). Similarly, no significant body dissatisfaction correlation with EDs in Turkish adolescents with T1D (r = − 0.155, p  > 0.05) and in controls (r = − 0.080, p  > 0.05) was found (Pinar, 2005 ).

Other Factors Associated with Body Image Problems

Other factors that have been found to be associated with body image concerns in youth with T1D include both diabetes-related aspects (e.g., glycemic control) and general psychological dimensions (e.g., self-esteem, comorbidity, illness adjustment, quality of life).

Diabetes Management

The results of the systematic review suggest that body image problems are correlated with diabetes control. More specifically, body awareness (Blicke et al., 2015 ) and satisfaction (de Wit et al., 2012 ; Peterson et al., 2018 ; Rancourt et al., 2019 ) were found to be inversely correlated with HbA1c values, suggesting that youth who felt satisfied and comfortable in their bodies had significantly better metabolic control. Similarly, previous evidence revealed that the more damaged the self-perception, the worse the diabetes control (r = NR, p  = 0.03)—and conversely, the better the body image, the better the control (r = NR, p  = 0.001) (Swift & Seidman, 1964 ; Swift et al., 1967 ). Another study indicated that for single (not involved in a romantic relationship) adolescents, a negative family climate was positively associated with poorer body image (r = 0.56, p  < 0.001), which in turn predicted worse glycemic control (beta = − 0.24, p  = 0.007) (Hartl et al., 2015 ). Body image perception was found to be generally related to diabetes management as well. In particular, one study found that the extent to which girls and women with T1D define their self-worth by their physical appearance was positively related to disease control (r = 0.28, p  < 0.001) and negatively to diabetes quality of life (r = − 0.40, p  < 0.001), particularly for younger individuals (Gawlick et al. 2016). Other evidence indicated that higher adjustment in body image areas is positively correlated with a positive attitude toward diabetes (r = 0.29, p  < 0.01), a dependence/independence attitude (r = 0.27, p  < 0.01), and general adjustment to diabetes (r = 0.77, p  < 0.05) (Sullivan, 1979 ).

Psychological Dimensions

Body image concerns have been found to be associated with several psychological variables. In female adolescents with T1D, body dissatisfaction was found to be positively (moderately) correlated with diabetes distress, anxiety symptoms, and depressive symptoms, and negatively correlated with emotional well-being, diabetes-related resilience, and quality of life (± 0.34 < r <  ± 0.43, all p  < 0.001) (Araia et al., 2020 ). Similarly, in youth and young adults of both genders with T1D, body dissatisfaction was described as positively correlated with depressive symptoms (r = 0.71, p  < 0.01) (Peterson et al., 2018 ) and with greater diabetes-specific negative affect (b = 0.05, p  < 0.01) (Rancourt et al., 2019 ). For adults with diabetes (T1 and T2), body image experience, psychological investment in physical appearance, and self-ideal discrepancy predicted psychosocial outcomes such as anxiety, depression, and quality of life (χ 2  = 48.80, p  = 0.003; estimate = 0.102) (McDonald et al., 2021 ). Individuals with T1D with high diabetes distress reported greater shape (test value NR, p  < 0.001) and weight (test value NR, p  < 0.001) concerns than those with low or moderate distress, regardless of age; among these individuals, those younger than 18 years with high distress perceived a larger current body shape than those with low or moderate distress (test value NR, p  < 0.001) (Powers et al., 2017 ).

Other significant associations were also described. In children with T1D, self-perception (as damaged and mutilated person) was positively associated with a dependence–independence attitude (test value NR, p  = 0.001) (Swift & Seidman, 1964 ). A more positive adolescent body image positively correlated to a higher powerful external locus of control (r = 0.41, p  = 0.01) (Kaminsky & Dewey, 2013 ). Body dissatisfaction was positively associated with female adolescents’ perceptions of their mother’s frequency of dieting behavior (b = 0.522, p  < 0.001) and their mother’s belief that she/her daughter is heavier than ideal (b = 0.275/0.313, p  = 0.020/0.009, respectively), and it was negatively associated with family cohesion (b = − 0.247, p  = 0.036) (O'Brien et al., 2011 ). In a sample of adolescents and adults with T1D, participants with body image dissatisfaction were more likely to be frequent social network users (χ 2  = 5.58, p  = 0.02), and body image dissatisfaction was found to be predicted by social network use (b = − 0.266, p  < 0.01) (Verbist & Condon, 2019 ).

Other studies described body image as a mediator of the relationship between psychological and diabetes-related variables. In particular, one study found that, in girls with T1D, body dissatisfaction was positively correlated with negative perceptions of familial and peer communication (r = 0.62, p  < 0.01) and moderated the relationship between negative communication and maladaptive eating attitudes and behaviors (z = 2.64, p  < 0.01) (Kichler et al., 2008 ). Other evidence indicated that adolescents’ self-concept in the area of physical appearance mediated both the link between maternal weight and shape concerns and adolescent eating disturbances (pr = 0.42, p  = 0.00005) as well as the link between mother–daughter relationships and adolescent eating disturbance status (pr = 0.25, p  = 0.003) (Maharaj et al., 2003 ). For adult individuals with diabetes, body image disturbances mediated the relationship between personal investment in appearance and psychosocial outcomes (estimate = 0.102) and partially mediated the relationship between self-ideal discrepancy and psychosocial outcomes (estimate = 0.185) (χ 2  = 48.80, p  = 0.003) (McDonald et al., 2021 ). For single (not involved in a romantic relationship) adolescents, body image was found to mediate the association between family climate and changes in glycemic control (b = 0.24, p  = 0.007) (Hartl et al., 2015 ).

No general agreement has been reached that body image problems are always reported in youth with T1D. Despite the role of body image problems in increasing unhealthy eating behaviors and in affecting general well-being in individuals with T1D, especially during adolescence, little attention has been paid to understanding and synthetizing the existing findings on this issue from the current body of literature. Drawing from PRISMA guidelines, the present study systematically and comprehensively evaluated the empirical literature on body image problems in individuals with T1D up to January 2021 and summarized the principal findings. As the large majority of results came from studies involving youth, this study is able to provide a valuable contribution to the developmental literature on this issue. A good deal of evidence was beyond the scope of the present review and thus was excluded.

Overall, this systematic review replicates and expands the results of a previous meta-analysis (Pinquart, 2013 ), which included a lower number of studies (34 vs. 51 in the current study) and indicated that young individuals with chronic physical diseases (especially those with scoliosis, cystic fibrosis, growth hormone deficits, asthma, spina bifida, cancer, and diabetes) had generally less positive body image then their healthy peers. In the current review, the findings on body image problems are somewhat mixed, and the occurrence of such problems varied across studies. In line with this previous meta-analysis (Pinquart, ( 2013 ), a number of studies (n = 17) described here indicated that in youth with T1D, body dissatisfaction was commonly experienced and body concerns were generally greater in those with T1D than in the general population; however, several studies (n = 9) did not find any difference in body image problems between adolescents with and without T1D. In addition, some studies (n = 3) even described higher body satisfaction in adolescents with T1D than in healthy peers.

In terms of gender differences, studies that differentiated male and female individuals with T1D revealed a higher likelihood of girls/women having a body image problems than boys/men, mirroring the findings of the general literature across different age groups (Bearman et al., 2006 ; Phares et al., 2004 ). When assessed, boys/men with T1D reported higher dissatisfaction with their bodies than controls without T1D, which is also in line with evidence from general population (Cohane & Pope, 2001 ). Few studies directly compared different T1D age groups, and these provided mixed results, showing older participants with greater body image problems than younger ones or no differences at all. With respect to problems that are frequently found to be associated with body image disturbance, this literature review indicated that the primary issue can result in adverse physical and psychological health effects. Body image problems were found to be associated with negative medical outcomes—such as elevated glycosylated hemoglobin, poorer diabetes management, and higher BMI—as well as with psychological variables—such as anxiety, depression, poorer quality of life, and higher distress. Furthermore, body image concerns have also been frequently found to be associated with DEBs, confirming the key role of body dissatisfaction in the development of DEBs, as largely supported by studies with the general population as well as with adolescents with chronic illness (Amaral & Ferreira, 2017 ; Girard et al., 2018 ; Neumark-Sztainer et al., 2002 ; Striegel-Moore & Bulik, 2007 ).

Interpretations of these findings—especially the results on the occurrence of body image problems and on gender differences—require that two general methodological issues be taken into account. First, the variation in tools used across studies may contribute to discrepancies in findings on body image problems. As shown in Table 1 , a range of tools has been used in samples with T1D individuals; therefore some differences—or lack thereof—may be the result of the measures adopted. For example, it was reported that adolescents with T1D showed greater body dissatisfaction than controls on the EDI Footnote 2 Body Dissatisfaction subscale, but in the same study, no differences were found when the body image problems of thin ideal internalization and appearance pressure were measured (Troncone et al., 2020a ). Consequently, with regard to findings supporting the presence body image problems, it could be hypothesized that diabetes-related factors and difficulties—e.g., recurring weight variation, perception of living in an unhealthy body, focus on body functioning, dietary restrictions, daily need for injections, etc.—may explain the development of a negative body image (Colton et al., 1999 ; Shaban, 2010 ). At the same time, inconsistencies in the results lead us to wonder the extent to which the findings directly stem from differences in and the limits of the measures adopted.

Second, it should be acknowledged that girls/women (and youth) were overrepresented across the included studies. Given that several studies measured body image and subsequently measured eating problems, this overrepresentation of female participants may be attributable to the largely-recognized higher prevalence of DEBs in girls and women in general and in the T1D population (Colton et al., 2015 ; Neumark-Sztainer et al., 2011 ; Wisting et al., 2013 ), as well as to convenience sampling across studies. In this regard, it should be noted that all studies finding no differences between adolescents with T1D and control participants in terms of body image problems were conducted with samples composed of male and female—or, in one study, only male—adolescent participants (e.g., Baechle et al., 2014 ; Falcão & Francisco, 2017 ; Svensson et al., 2003 ). In contrast, all studies conducted with exclusively-female samples reported higher body image problems in the T1D group than the control group, giving the impression that body image problems are a specifically women’s or girls’ issue (e.g., Markowitz et al., 2009 ).

Limitations across body image measures due to gender bias should also be taken into consideration when interpreting such results. Existing tools often focus on body image concerns that are salient to women and girls (e.g., belief of being fat, concerns about specific aspect/shape of body parts such as thighs or hips) and focus less on symptoms recognized as more central to men and boys (e.g., desire for a muscular and athletic physique, concern about muscle mass and shoulder width) (Cafri & Thompson, 2004 ). Therefore, it cannot be ruled out that because of these methodological issues, the true levels of body dissatisfaction among boys with T1D are probably not well estimated.

The present review has a number of strengths. One main strength is that it undertakes a systematic review of all existing studies that address body image problems in T1D samples and then summarizes the state of research and provides a comprehensive picture of the main findings and of the methods used in investigations of this topic. The structured search and analysis procedure, along with the predefined inclusion and exclusion criteria to ensure the scientific relevance of the studies under examination, strengthen the overall quality of the review. It is worth noting that a quite extensive body of literature—composed of a relatively high number of studies with more-or-less sophisticated research designs—attempted to collect evidence about the presence and features of body image problems in individuals (mostly youth) with T1D, revealing a certain amount of attention paid to this topic. Several factors (gender, BMI, DEBs, etc.) were also frequently analyzed as potential salient variables. Nevertheless, the understanding of the development of body image problems in individuals with T1D is restricted by the limitations of the present review and of the field.

Limitations and Implications for Future Directions

Several limitations in this systematic review should be noted. To start, the results of this review are limited by the study’s inclusion criteria; thus, they are limited to English peer-reviewed journal articles indexed in electronic database resources, and the gray literature was not consulted. It may be possible that some studies could have been missed; for example, non-original studies (e.g., comments, book chapters, case reports, etc.) published in other languages were ignored, and potential additional insight on the topic could have been missed. Furthermore, another limitation is related to the search terms used in this review: it is possible that they did not capture all relevant studies. For example, the use of search terms for T1D might have overlooked some studies on chronic illness that also included participants with diabetes. This limitation was partially accounted for by a hand search of the included reference lists. In addition, the research in this review was of a quantitative nature; future research could adopt a qualitative or mixed-method approach to more deeply investigate how body image problems in youth with T1D develop and how they manifest.

Similarly, several limitations can be found within the studies examined in the current review, which need to be addressed in order to obtain a more comprehensive picture of body image concerns in people with T1D. To start with, future research should strive to accurately measure body image: to date, the majority of measures adopted consist of self-report instruments assessing body image as a single and undifferentiated construct, ranging from dissatisfaction with body shape and weight, shape concerns, and level of satisfaction with (or significance of) their physical appearance to body image disturbances or facets of self-concept. Fewer studies adopted measures based on body silhouettes evaluating the level of body size accuracy and the satisfaction with one’s physical appearance as the difference between actual and ideal size. Multidimensional assessment should start from the assumption that body image is a multi-faceted construct consisting of self-perceptions, attitudes, beliefs, feelings, and behaviors related to one’s body and is dynamically related to the social environment (Calogero & Thompson, 2010 ; Cash & Pruzinsky, 1990 ), and such assessments should be more frequently adopted as a measurement approach that can recognize the multiple aspects of body image.

Additionally, as already argued for ED pathology (Murray et al., 2017 ), a more gender-sensitive approach to examining body image problems is needed—one that includes constructs that resonate more with the male experience. Therefore, future studies should ensure they consider gender differences when assessing body image ideals and body image dissatisfaction (i.e., desire for thinness in women vs. desire for a muscular physique in men; girls typically wanting to be thinner vs. boys frequently wanting to be bigger). In particular, they should address body image concerns that may be more pertinent to boys and take into account guidelines and methods that are purposely designed to more effectively assess male body image (Cafri & Thompson, 2004 ). Moreover, given the cross-sectional nature of the results and the dearth of follow-up studies, longitudinal research is needed to further explore the relationship between body image issues and clinical and psychological variables.

Given the other limitations in studies’ designs (e.g., limits in the representativeness of the samples, potentially salient/confounding variables not examined, frequent absence of control group), additional research on this topic that is more methodologically robust is needed to draw more solid conclusions. Future work should also focus on identifying key predictors of body image problems in youth with T1D, should more deeply explore differences between adolescents and adults, between different adolescent age groups (i.e., early, middle, late), and should address body image concerns in children.

Clinical Implications

Given the well-known associations between body image problems and EDs/DEBs and between body image problems and negative psychological outcomes—as well as the higher vulnerability of youth with T1D to psychological problems—continuous psychological monitoring is needed to periodically evaluate adolescents’ overall psychosocial well-being, diabetes-specific quality of life and distress, psychosocial and mental health problems, and developmental adjustment to diabetes management (ADA, 2018 ; Buchberger et al., 2016 ; Delamater et al., 2018 ; Hagger et al., 2016 ). For such psychological evaluations, dedicated screenings and specific assessments of body image problems can be incorporated into routine practice. Specifically, given the harmful effects of DEBs on health and diabetes management (Goebel-Fabbri, 2009 ; Nielsen, 2002 ; Starkey & Wade, 2010 ), such unhealthy eating behaviors need particular attention. An accurate evaluation of the onset and characteristics of the body image problems is a crucial first step in realizing appropriate intervention or prevention strategies. Therefore, it is important to combine screening measures with the use of diagnostic interviews, carried out by experienced clinicians, to appropriately target the interview questions in order to ensure that body image problems (and related issues, such as DEBs) are accurately screened. Once assessed, the body image concerns of individuals with T1D need to be addressed through educational and intervention programs before the problems become more severe. Collecting and analyzing such data can significantly enrich knowledge and the progress of research in this area.

Body image problems in individuals with T1D have been associated with a number of negative psychosocial and behavioral outcomes. Despite the scholarly attention that has been paid to the presence of body image problems in youth with T1D, no summary of either the state of current research or its gaps had been performed. The present study addresses the need for a systematic review of the existing empirical evidence on body image problems in individuals with T1D. This review reveals evidence both for and against the idea that body image problems are more frequently found in youth with T1D than in healthy peers. Overall, studies indicating that body dissatisfaction is more common and generally greater in youth with T1D than in controls outnumber studies that do not find differences between these groups. In addition, body concerns are often found to be associated with negative medical and psychological functioning. Taken together, the available empirical data indicate that, given the major issues that adolescents face in general (i.e., rapid and dynamic cognitive, developmental, and emotional changes, impact of body changes, searching for acceptance by peers, etc.) combined with the burden of the illness, its management, and the relative adaptation to emerging development needs, psychological care should be integrated into diabetes care in order to periodically monitor for psychological conditions and possible problematic signs (such as body image concerns). However, this topic needs to be examined further, with the methodological limits that characterize existing research especially taken into account, in order to expand the existing knowledge on body image problems in diabetes patients during such a critical developmental phase as adolescence. An important next step is conducting empirical studies in which different and age/gender-specific aspects of body image problems are investigated, as well as longitudinal studies that verify causal relationships between body image and psychological and medical variables.

It was difficult to define the exact number of studies, because unpublished studies were also included and some were unavailable; therefore, it was not possible for the authors to verify the inclusion of diabetes patients.

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Acknowledgements

The authors wish to thank Dr. Maria Cascone, who assisted in the literature analysis of the manuscript.

Open access funding provided by Università degli Studi della Campania Luigi Vanvitelli within the CRUI-CARE Agreement. The research leading to these results received funding from the project, DiabEaT1, which received funding from University of Campania “Luigi Vanvitelli” through the programme V:ALERE 2019, funded with D.R. 906 del 4/10/2019, prot. n. 157264, October 17, 2019. University of Campania had no role in study design, collection, analysis, or interpretation of data, writing the manuscript, or the decision to submit the manuscript for publication.

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AT conceived of the study, participated in its design and coordination, conducted data analysis and drafted the manuscript; CC, AB, AC, AZ performed the literature search, data screening and extraction, provided summaries of research studies and participated in data analysis; DI critically revised the work with support from all authors. All authors contributed to and approved the final manuscript.

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Troncone, A., Cascella, C., Chianese, A. et al. Body Image Problems in Individuals with Type 1 Diabetes: A Review of the Literature. Adolescent Res Rev 7 , 459–498 (2022). https://doi.org/10.1007/s40894-021-00169-y

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Social Media Use and Body Image Disorders: Association between Frequency of Comparing One’s Own Physical Appearance to That of People Being Followed on Social Media and Body Dissatisfaction and Drive for Thinness

Barbara jiotsa.

1 Addictology and Liaison Psychiatry Department, Nantes University Hospital, 44000 Nantes, France; [email protected] (B.J.); [email protected] (B.N.); [email protected] (B.R.)

Benjamin Naccache

Mélanie duval.

2 Public Health Department, Nantes University Hospital, 44000 Nantes, France; [email protected]

Bruno Rocher

Marie grall-bronnec.

3 Inserm UMR 1246, Nantes and Tours Universities, 44200 Nantes, France

Associated Data

The data presented in this study are available on request from the corresponding author.

(1) Summary: Many studies have evaluated the association between traditional media exposure and the presence of body dissatisfaction and body image disorders. The last decade has borne witness to the rise of social media, predominantly used by teenagers and young adults. This study’s main objective was to investigate the association between how often one compares their physical appearance to that of the people they follow on social media, and one’s body dissatisfaction and drive for thinness. (2) Method: A sample composed of 1331 subjects aged 15 to 35 (mean age = 24.2), including 1138 subjects recruited from the general population and 193 patients suffering from eating disorders, completed an online questionnaire assessing social media use (followed accounts, selfies posted, image comparison frequency). This questionnaire incorporated two items originating from the Eating Disorder Inventory Scale (Body Dissatisfaction: EDI-BD and Drive for Thinness: EDI-DT). (3) Results: We found an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and body dissatisfaction and drive for thinness. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. (4) Discussion: The widespread use of social media in teenagers and young adults could increase body dissatisfaction as well as their drive for thinness, therefore rendering them more vulnerable to eating disorders. We should consequently take this social evolution into account, including it in general population prevention programs and in patients’ specific treatment plans.

1. Introduction

Body image is defined as one’s perception, thoughts, and emotions revolving around one’s own body. It is the depiction of one’s body representation, including their mirror reflection, and it reflects social constructs, which depend on a society’s culture and norms. This conception is created using body ideals, substantially communicated via media, family, and peers.

For the last 30 years, media have been over-exposing people to thinness ideals, starting from a young age [ 1 ], turning this ideal into a new reference standard [ 2 ]. Young women, who are most sensitive to thinness ideals, tend to liken them to beauty and success [ 3 ]. Thus, etiologic models incorporating environmental factors consider social pressure about physical appearance to be a determining factor in developing eating disorders (EDs) [ 4 , 5 ].

However, even though this social pressure is indisputable, not all people are vulnerable to it. It is the degree with which they will relate to these thinness standards, namely how they internalize this ideal, that will help to predict the risk of developing an ED [ 6 ]. Indeed, internalizing thinness standards can lead to an alteration in body image, resulting in body dissatisfaction and exaggerated concerns about body and weight [ 4 ]. Body dissatisfaction is characterized by an inconsistency between one’s real body and the idealized body. It is one of the most studied psychological constructs in body image disorders literature [ 4 , 7 , 8 , 9 ]. According to the literature, it is often linked to psychological distress [ 10 , 11 ] and is a proven risk factor for developing an ED [ 12 , 13 ], through, in particular, the implementation of food restriction that can lead to anorexia nervosa (AN) [ 14 , 15 ] or to the onset of binge eating episodes (with or without compensatory behaviors to prevent weight gain). According to several authors, body dissatisfaction found in AN patients differs from that of control subjects by a greater feeling of inconsistency between their actual body and the desired body [ 16 ]. Indeed, in addition to overestimating the size of their actual shape, AN patients seek to resemble an ideal significantly thinner than subjects without EDs do. People with AN and bulimia nervosa share the same body image obsession, with the pervasive fear of gaining weight [ 4 ]. Finally, subjects with binge eating disorders tend to be overweight, or even obese, which can reinforce body dissatisfaction [ 17 ].

Social comparison, combined with the internalization of ideals, is one of the main mechanisms participating in one’s body image perception. These two mechanisms are instrumental in developing body dissatisfaction [ 1 , 18 , 19 ]. Several studies have shown that individuals who compare their physical appearance to that of others they considered to be more attractive than them, such as models or celebrities, had a higher chance of being dissatisfied with their body image and developing an ED [ 20 , 21 , 22 , 23 ].

Although historically speaking, body norms have been mainly conveyed through traditional media (TV, radio, newspaper, magazines), the last few years have borne witness to the rise and expansion of social media use. The term “social media” refers to every website and online mobile app with user-generated content. They enable their users to participate in online exchanges, broadcast self-made content, and join virtual communities. They are mostly used by teenagers and young adults, and the most common ones are Facebook, Instagram, Snapchat, and Twitter. Several studies have suggested that social media exposure could foster body dissatisfaction and result in risky eating behaviors by broadcasting thinness ideals individuals thus long for [ 18 , 24 , 25 ]. Among the identified mechanisms that explain this outcome, the most common ones are social comparison based on physical appearance and thinness ideals’ internalization through daily exposure to idealized bodies. Indeed, physical appearance holds a central place in social media today [ 26 ].

There is, to this day, a lack of scientific data, and in particular French data, about the association between the use of social media and risky eating behaviors [ 27 ]. In this context, this study’s main objective was to study the association between, on one hand, daily exposure to idealized bodies through social media and, on the other hand, the presence of two dimensions fostering body image disorders: body dissatisfaction and drive for thinness. A secondary objective was to compare two populations, one with a risk of suffering from ED, and the other one free of that risk, using different variables. The hypothesis was that at-risk participants were more dissatisfied with their physical appearance, had a higher drive for thinness, and compared themselves more often to social-media-conveyed images.

2. Materials and Methods

2.1. study design and ethics statements.

This is a transversal observational study. Participants had to answer a questionnaire available online. Since it was an investigation involving the health field, but with an objective that did not involve the developing of biological or medical knowledge, it not fit in the French Jardé legal framework (and thus, approval from an ethics committee was not required). Data collection was made anonymously, was digitalized, and was realized outside of a care setting. Answering the questionnaire was interpreted as consent for data use, as it displayed that the results would be used in a survey, but that the participation would be anonymous, and that there were no data that would lead them to be recognized should they decide to participate.

2.2. Participants Recruitment

The study’s general population participants were enlisted via a social media publication (Facebook, Instagram, Twitter) and via posters in gyms. These posters were also sent to health workers with a practice in Nantes and in different French cities (psychiatrists, GPs, psychologists, etc.), who were tasked with informing their ED patients about this study. The Fédération Française Anorexie Boulimie (FFAB, French Federation for Anorexia and Bulimia), which is an association regrouping professionals working in the ED field, helped to broadcast the questionnaire using mailing lists, social media, and websites. Recruitment occurred between September 2019 and December 2019.

The inclusion criteria were as follows: using their Facebook and/or Instagram account daily and being 15 to 35 years old. This age range was chosen in light of the current literature, which shows that use of social media and body image concerns involved mainly teenagers and young people [ 28 , 29 ]. Moreover, participants recruited via a health professional had to register their ED diagnosis for which they were treated.

2.3. Evaluation

2.3.1. general data.

The questionnaire’s first part was designed to register sex, age, degrees, and current height and weight to measure body mass index (BMI).

2.3.2. Social Media Use

The questionnaire’s second part interrogated the participants about their use of social media: platform, frequency (number of uses per day), time spent (hours per day), frequency of comparing one’s physical appearance to that of people followed on social media, and the frequency of posting “selfies” (a photograph that you take of yourself).

2.3.3. Body Image

The questionnaire’s third part evaluated body image perception, using the Eating Disorder Inventory-2 (EDI-2) scale, translated and adapted in French [ 30 , 31 ]. It is a self-rated questionnaire evaluating psychological characteristics and symptoms associated with ED, using 11 subscales. We used the “Drive for Thinness” subscale (EDI-DT), composed of 7 questions (score of 0 to 21), and “Body Dissatisfaction” subscale (EDI-BD), composed of 9 questions (score of 0 to 27). The subscales are presented in Table 1 .

Drive for Thinness and Body Dissatisfaction subscales of Eating Disorder Inventory-2.

2.3.4. ED Screening

The questionnaire’s last part aimed at screening ED, using the Sick-Control-One Stone-Fat-Food (SCOFF) self-questionnaire. It is a simple survey of 5 questions used to screen eating disorders in general population [ 32 ]. The French validation depicted this questionnaire to be as efficient and relatable as the original, with a great sensitivity and specificity in diagnosing ED when a patient has a score of 2 or over [ 33 ]. It enabled us to sort the population sample into two groups depending on their risk of having an ED: when their score was ≥2, they were sorted in the “SCOFF positive” group, and when their score was <2, in the “SCOFF negative” group. The SCOFF questionnaire is presented in Table 2 .

Sick-Control-One Stone-Fat-Food (SCOFF) questionnaire.

Yes = 1 point; score of ≥2 suggests an eating disorder.

2.4. Statistical Analysis

A descriptive statistical analysis was conducted for the entire sample. Continuous variables are described by means and standard deviations, while categorical variables are presented as numbers and percentages.

We asked all participants to complete the SCOFF questionnaire, so that they were sorted into two groups depending on their results: the “SCOFF+” group gathering all participants with a SCOFF score of 2 or over, and therefore with the risk of suffering from an ED, and the “SCOFF−” group gathering all participants with a SCOFF score under 2. These two groups were then compared based on all collected variables. We applied a Student’s t -test for quantitative variables (“age”, “EDI-BD”, “EDI-DT”, and “average BMI”), a Chi-squared test for qualitative variables (“sex”, “level of education”, “social media use frequency”, “time spent”, “body comparison”, “groups of BMI”), and Fisher exact test for multimodal qualitative variables whose theoretical headcount did not allow the use of the Chi-squared test (“posting selfies”).

Then, we looked for an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and the scores measured using the EDI Body Dissatisfaction and Drive for Thinness subscales. We thus performed two linear regressions with adjustment for two potential confounding factors (BMI and level of education). Confounding factor status was assessed by searching for an association of the two variables with EDI subscores on the one hand and with the frequency of comparing one’s own physical appearance to that of people followed on social media on the other hand.

The significance threshold for all these analyses was set at p = 0.05 (α risk of 5%).

Statistical analyses were done using the SPSS software (Statistical Package for Social Science, IBM, Armonk, NY, USA).

3.1. Population Description

In total, 1407 questionnaires were completed, and 1331 were analyzed. A total of 1138 subjects were from the general population, and 193 were ED patients recruited via health workers. Seventy-six completed questionnaires (5.4%) were excluded from the analysis because they did not match the age criteria or because their ED diagnosis was not communicated (for ED patients recruited via health workers). Figure 1 represents the study’s flowchart.

Flow chart of subjects’ inclusion.

The participants’ age ranged from 15 to 35 (M = 24.2, σ = 4.2). Most were women (97.7%). They had, for the most part, a Bachelor’s degree. Mean BMI was 22.3 (σ = 4.2).

Table 3 presents the final sample’s characteristics.

Final sample characteristics and comparison between SCOFF+ and SCOFF− groups.

Note. BDI: body mass index; EDI-IC: Eating Disorder Inventory—Body Dissatisfaction; EDI-RM: Eating Disorder Inventory—Drive for Thinness. *: p < 0.05; **: p < 0.01; ***: p < 0.001. According to the International Classification of Diseases, anorexia nervosa is associated with a BMI < 17.5.

Most participants declared using Facebook (93%) and Instagram (92.8%). Other social media were less frequently used: Snapchat (68.4%), Twitter (29.1%), and Tiktok (2.5%).

In total, 57.3% of participants had a private account and 42.7% an account open to the public. Users declared that they used social media mainly to “like posts” (82.7%) and to “observe content, as ghost followers (bots or inactive accounts)” (65.4%). In total, 92.7% said that they used social media to “follow friends and acquaintances”, “follow healthy food content” (68%), “follow the news” (67%), and “follow fitness content” (61.2%).

Regarding participants recruited via health workers for whom data were analyzed (N = 193), the most frequently reported ED was anorexia nervosa restricting type (41%), followed by anorexia nervosa purging type (28%), binge eating disorder (16%), bulimia nervosa (12%), and unspecified feeding or eating disorder (9%).

3.2. Comparing Participants Based on Their ED Screening

The final sample was sorted into two groups according to the SCOFF’s results ( n = 953 in the SCOFF+ group; n = 378 in the SCOFF− group). These groups were compared using all described variables, and the results are showcased in Table 3 .

SCOFF+ group subjects had a significantly higher social media use (regarding both frequency and time spent), a significantly higher frequency of comparing their physical appearance to that of people they followed, and of posting selfies.

In addition, they declared having significantly higher EDI-BD and EDI-DT scores than SCOFF− subjects ( p < 0.001), and they more frequently had BMI both in the lower and higher ranges.

3.3. Association between the Frequency of Comparing One’s Own Physical Appearance to That of People Followed on Social Media and EDI Body Dissatisfaction and Drive for Thinness

In the search for confounding factors associated with both the frequency of comparing one’s own physical appearance to that of people followed on social media and EDI-BD and EDI-DT scores, we found a significant association between the level of education and the frequency of comparing one’s own physical appearance to that of people followed on social media ( Table 4 ). Similarly, we observed an association between the modality “Level of education ≥12” and EDI-BD: participants with a level of education ≥12 had a mean EDI-BD score 2.5 points lower compared to that of participants with a level of education <12 ( Table 5 ). We also found a similar association between the modality “Level of education ≥12” and EDI-DT: participants with a level of education ≥12 had a mean EDI-DT score 3 points lower compared to that of participants with a level of education <12 ( Table 6 ).

Association between level of education and frequency of comparing one’s own physical appearance to that of people followed on social media.

Note. **: p < 0.01.

One-way ANOVA results looking for a link between EDI-BD score and level of education.

Global p -value = 0.1338. Note: The modality “Less than level 12” was chosen as the reference modality for this analysis. *: p < 0.05; ***: p < 0.001.

One-way ANOVA results looking for a link between EDI-DT score and level of education.

Global p -value = 0.0016. Note: The modality “Less than level 12” was chosen as the reference modality for this analysis. ***: p < 0.001.

Furthermore, we did not find any significant association between BMI and the frequency of comparing one’s own physical appearance to that of people followed on social media ( Table 7 ). A significant but very weak correlation (<0.3) was found between the BMI and the two EDI subscores ( Table 8 ). In view of these results, we did not retain BMI as a confounding factor for the following analysis.

One-way ANOVA results looking for a link between BMI and frequency of comparing one’s own physical appearance to that of people followed on social media.

Global p -value = 0.4368. Note: The modality “Never” was chosen as the reference modality for this analysis. ***: p < 0.001.

Results of association between BMI and EDI scores.

Note. EDI-BD: Eating Disorder Inventory—Body Dissatisfaction. **: p < 0.01; ***: p < 0.001.

The results of the search for an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and EDI Body Dissatisfaction and Drive for Thinness scores are presented in Table 9 and Table 10 . As showcased in Table 9 , the “Sometimes”, “Often”, and “Always” frequency of comparing modalities were significantly associated with the EDI-DT score. Participants who sometimes compared their own physical appearance to that of people followed on social media had a mean EDI-DT score 2.0 points higher than that of those who never compared themselves; those who often compared themselves had a mean EDI-DT score 5.3 points higher; and those who always compared themselves had a mean EDI-DT score 8.4 points higher.

Linear regression looking for a link between EDI-DT score and frequency of comparing one’s own physical appearance to that of people followed on social media.

Global p -value <2.2 × 10 −16 ***. Note: Modalities “Less than level 12” and “Never” were chosen as the reference modalities for this analysis. *: p < 0.05; **: p < 0.01; ***: p < 0.001.

Linear regression looking for a link between EDI-BD score and frequency of comparing one’s own physical appearance to that of people followed on social media.

Global p -value <2.2 × 10 −16 ***. Note: Modalities “Less than level 12” and “Never” were chosen as the reference modalities for this analysis. *: p < 0.05; ***: p < 0.001.

In addition, according to Table 10 , the “Often” and “Always” frequency of comparing modalities were significantly associated with the EDI-BD score. Participants who often compared their own physical appearance to that of people followed on social media had a mean EDI-BD score 5.6 points higher than that of those who did not, and those who always compared themselves to social media images had an average EDI-BD score 9.2 points higher than that of those who never did.

4. Discussion

4.1. discussing the main results.

Our survey aimed to study the links between social media use, body image disorders, and ED prevalence in a teenage and young adult population.

First, we found that ED or at-risk of ED subjects presented significantly different results concerning all social media use parameters. Using platforms such as Facebook and Instagram has been particularly associated with a higher body dissatisfaction and the appearance of ED symptoms [ 27 , 34 ]. As was expected, in ED or at-risk of ED patients, Body Dissatisfaction rates were higher, as was their Drive for Thinness. A common ED assumption is that ED patients develop a cognitive structure that focalizes on weight, combined with, most of the time, a mistaken perception of their own body image, especially in anorexia nervosa. These subjects tend to yearn for a thinner body ideal than the general population, thus creating a substantial inconsistency between what they think they look like and what they yearn to look like [ 35 ]. Leahey and her colleagues in 2011 [ 36 ] found that, in addition to increasing body dissatisfaction, social comparisons have an influence on negative effects, guilt, as well as diets and physical-activity-centered thoughts.

Participants in general were seldom prone to posting selfies. Ridgway and her colleagues [ 37 ] conducted in 2018 a study on Instagram and posting selfies, which showed that a higher body image satisfaction was associated with an increase in posting selfies. This could explain the low percentage of self-promoting subjects found in this study.

Second, we confirmed the existence of a significant association between, on one hand, the frequency of comparing one’s own physical appearance to that of people followed on social media and, on the other hand, Body Dissatisfaction and Drive for Thinness scores measured using the EDI scale. It seems that the more the subjects compared themselves to the images, the more they increased their body dissatisfaction and their drive for thinness. However, this association can work two ways. Indeed, it could be that the depth of body dissatisfaction and the drive for thinness increase the inclination to compare oneself to images. Our results are in accordance with those found in the literature, which identified a link between social media use and body image disorders [ 26 , 38 , 39 ]. It has also been found that subjects who often compared their physical appearance to that of idealized images were more dissatisfied with their body and had a higher drive for thinness than those who compared themselves less often [ 40 , 41 ]. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. Indeed, the relation between frequency of comparing one’s own physical appearance to that of people followed on social media on the one hand and EDI DT and BD subscores on the other hand is modified by the level of education, starting from a level corresponding to a Bachelor’s degree (>12 + 3 years).

Self-assessment is a fundamental reflexive analysis tool [ 42 ]. It plays an essential part in self-positioning among others and oneself. This self-evaluation must resort to social comparisons, which have a direct link to self-esteem. Body image’s sociocultural construct takes shape using body ideals that are broadcasted through, in particular, media, family, and peers and are thereafter internalized by individuals [ 43 ]. Reaching these body norms is usually perceived as proof of self-control and success, which leads one to stand out from the crowd in a positive way [ 44 ]. Internalizing body ideals thus creates an authentic concern for one’s physical appearance, which will be observed and judged by others [ 45 ]. This can trigger body dissatisfaction, which usually involves feeling inadequate in one’s body, estranged from the ideal one pursues [ 43 ]. Fear of gaining weight can be exacerbated when thinness is one of narcissism’s only tools. It can lead to behaviors such as food restriction, excessive physical activity, with the aim of modifying one’s appearance and thus fit into social standards. This excessive self-surveillance can bring about emotional and psychological consequences, including shame about one’s own body, self-bashing, anxiety, and depression, up to ED [ 46 ].

Finally, although estimating ED prevalence in a young adult population was not an objective determined beforehand, we must point out that most participants had a SCOFF+ result (71%), suggesting they might suffer from an ED. This questions whether a more systematic ED screening should be done in teenage and young adult populations, which are ED’s main targets. Several studies in which teenagers were interviewed have shown that they often are dissatisfied with their bodies, feeling like they are “too fat”, and most of them have already followed a diet [ 47 , 48 , 49 ]. These diets can include ingesting smaller portions, eating healthier food, up to major food restrictions and complete removal of some types of food, which can be found in ED.

4.2. Study’s Strengths and Weaknesses

There are several limits to this study. First, it is a transversal study, which cannot prove the existence of a causal relationship between the studied variables. Therefore, longitudinal studies are necessary in finding out how this association works. Second, the online questionnaire was not designed to collect data that could be considered as indicators of individual or family vulnerabilities for ED, which did not allow for stratified analyses. Third, measuring the time spent on social media and how often participants used it was done through self-reported data, which could induce a declaration bias, thus limiting the data’s precision. Future studies could use technologies such as data tracking (virtual counter measuring connection frequency and time spent) in order to have more precise data and thus be more confident in the data’s reliability. Fourth, the participants’ recruitment induced a selection bias. Indeed, having used daily use of social media as an inclusion criterion leads to selecting a certain type of population and renders irrelevant any extrapolation to the general population. Moreover, recruiting via gyms may have led to selecting individuals with a specific concern for their body image. We can assume that these subjects, who paid specific attention to their physical appearance, might have certain demands concerning themselves, which might involve body dissatisfaction and an exaggerated drive for thinness. The daily use of social networks could also be a reflection of excessive body concerns, which could lead to more body dissatisfaction and a more pronounced drive for thinness compared to subjects who are less exposed to these kinds of media. Fifth, our participants recruited via health workers may not be representative of all ED patients for several reasons: ED diagnosis was self-reported, anorexia nervosa restricting type was overrepresented in our sample, and the most severe patients may not be psychologically available to participate in a study like this one. Finally, the SCOFF questionnaire is a screening tool and not a diagnostic one. It does not enable discriminating between anorexia nervosa, bulimia nervosa, or binge eating disorder among participants, but we can assume that all types of ED were present in the SCOFF+ group, as the participants in this group more frequently had BMI both in the lower and higher ranges.

However, these limits are balanced by the study’s strengths. First, the sample rallied a significant number of participants, and their sorting into two groups after ED screening was quite proportionate, which ensured the statistical analyses’ power. Second, EDs were screened using a validated tool for the general population, and the Body Dissatisfaction and Drive for Thinness dimensions were evaluated using a self-questionnaire whose psychometric characteristics have been validated in clinical populations. Finally, to the extent of our knowledge, this type of study had never been conducted in France, thus bringing forth unprecedented data.

4.3. Perspectives

This study’s results open new avenues for clinicians to explore social media use and cognitive pathways in ED. Indeed, social media exposure and, in particular, exposure to edited and idealized images could contribute to inaccurate thought processes about body image, internalizing what is socially valued on social media as a personal goal. Since we know that cognitive pathways play an important part in ED development and continuation [ 50 ], it seems relevant to explore patients’ use of social media and the cognitions associated. This could contribute to increasing psychotherapy’s efficacy, enriching prevention programs using cognitive dissonance, therapies that have been proven to be effective in reducing ED symptoms’ intensity [ 51 ]. A way to implement this could be to encourage the development of the ability to question social media, encouraging patients to think of arguments that go against posting idealized photos on social media [ 27 ].

When considering the general population, when we see how important social comparison based on physical appearance is in developing body dissatisfaction, prevention programs could be useful. It seems relevant to encourage teenagers, particularly those with the tendency to compare themselves to their peers, to evaluate their body using health criteria instead of using other peoples’ bodies as a standard. Additionally, it would be interesting to intervene by deconstructing the “ideal body” myth, with the goal of diminishing the comparison to “idols”. Finally, it seems relevant to inform people that some role models’ BMI and body type are not representative of those of most of the population and that trying to reach their body type could be harmful. ED screening in this population should thus be more systematic.

5. Conclusions

To summarize, we found an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and body dissatisfaction and drive for thinness. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. The widespread use of social media in teenagers and young adults could increase body dissatisfaction as well as their drive for thinness, therefore rendering them more vulnerable to eating disorders.

Acknowledgments

The authors would like to thank the French Federation for Anorexia and Bulimia (Fédération Française Anorexie-Boulimie (FFAB)), who allowed the broadcasting of the questionnaire to its members, ED-specialized health workers.

Author Contributions

Study concept and design: B.J., B.R., and M.G.-B. Analysis and interpretation of data: B.J., B.N., B.R., and M.G.-B. Statistical analysis: M.D. Study supervision: B.R. and M.G.-B. Investigation (data collection): B.J., B.R., and M.G.-B. Writing—original draft: B.J. and B.N. Critical revision: M.D., B.R., and M.G.-B. Writing—revised version of the manuscript: B.J., M.D., and M.G.-B. All authors have read and agreed to the published version of the manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Institutional Review Board Statement

Since the study was an investigation involving the health field, but with an objective that did not involve the development of biological or medical knowledge, it not fit in the French Jardé legal framework. The approval from an ethics committee was not required according to the current French legislation.

Informed Consent Statement

Data collection was made anonymously. According to the current French legislation, answering the questionnaire was interpreted as consent for data use.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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