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Looking good and feeling bad

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Grotesque after the ‘Gram: the perfect lives many social media users try to project end up fuelling depression and anxiety

The harmful effects of TV and social media on mental health are becoming increasingly recognised1. In particular, young people are perpetually facing pressures to look a certain way which is adversely affecting their mental wellbeing. Only last month, NHS England chief executive, Simon Stevens, raised his concerns about popular TV programme Love Island having breast enlargement adverts aired during the show.

‘We have to think about the whole environment children are exposed to, some of that is social media but even if you take a show like Love Island, look at the adverts that are being shown alongside it,’ he argued.

‘You’ve got explicit adverts being aimed at young women around breast cosmetic surgery. That is all playing in to a set of pressures around body image that are showing up. The time has come to think long and hard about whether we should be exposing young people to those kinds of pressures.’

Poor body image is a significant health risk for young people2 – it is a trigger that can initiate eating disorders, depression, anxiety, and body dysmorphic disorder. Studies have shown that only 36% of girls in the UK had high body esteem, and those with low body esteem struggle to be assertive.2,3 Symptoms of poor body image can be subtle, therefore primary care nurses should be vigilant and refer care to protect the patient’s mental health.

‘There has definitely been an increase in service users accessing help with a presenting symptom being concerns around body image,’ says Mandy Scott, mental health nurse at Personalised Eating Disorder Support (PEDS).

‘The use of social media, in particular Instagram and Facebook, has made it very difficult for young people to avoid the pressures associated with the “perfect profile picture” with users being exposed to daily comments detailing weight loss, alterations to the body and foods eaten or resisted.’

Poor body image triggers

‘Body image’ is how a patient sees themselves, it encompasses what they believe about their own appearance, how they feel about their body (including height, shape and weight), and how they control their body while moving.4 While is it most prominent in young adults and adolescents, it also seen in children.

This sense of self is established before the age of 6, this is when children become aware of their own appearance and the social biases against certain physical features. For example, children become aware of obesity and its associated stigma of being lazy, undisciplined and unhealthy. Overweight children can internalise this message very early on in their development.5

‘The continuing emphasis upon health and beauty within western cultures has tended to centre very strongly upon youth and body schema. Whilst there have been initiatives within the fashion industry to celebrate people with fuller figures, fashion designers by and large have been resistant to this,’ says Bob Price, independent health services training consultant and author of Body Image: Nursing Concepts and Care.

‘So the picture is mixed. Some drivers set up unrealistic expectations and some others have accented coping strategies. What remains certain is that the emphasis on the body as representative of the self remains.’

The Royal Society for Public Health6 has named Instagram the worst social media platform for fuelling depression, anxiety, loneliness, bullying and poor body image. Additionally, researchers have shown that seeing a peer’s curated social media content is more likely to induce feelings of shame and guilt compared to images of celebrities or models – and engaging in activity on Facebook results in a negative mood particularly among young women.1

However, some research has reported that the effects of social media can be mixed. While it’s true that seeing photographs of beautiful people can increase the pressure to look the same, studies have also proven that interacting with people online can boost confidence.3

Advising patients to stay away from all social media may not be a realistic recommendation, however, limiting their time spent online and reminding themselves that the images which they might compare themselves to are heavily curated and unrealistic can be beneficial.6

Related health conditions

According to the Mental Health Foundation, more than 725 000 people in the UK are affected by eating disorders, with anorexia having the highest death rate of any mental illness – 20% of people with the condition will die prematurely as a result.7 Notably, this is not just a problem in women as it is estimated that between 10% and 25% of those with eating disorders are men.7

What differentiates BDD are more specific concerns, such as anxiety over a particular facial feature rather than body weight only, which is typical in those with eating disorders.

‘Historically body image problems have been seen as sequelae to physical problems, after burns, after cancer, after surgery, skin conditions etc. But there is I think a growing understanding that self-conception problems, mental illness, can prompt problems running the other way,’ says Mr Price.

‘Body dysmorphia can lead to self-harm, suicide, social isolation, depression amongst other mental health problems. The mechanisms by which altered body image increase risk and distress seem to be associate with what the Canadian-American sociologist Erving Goffman argued back in the 1960s. Briefly, that we use public reaction to our appearance to judge self-worth. Damage to self-esteem then undermines the motivation to wrestle with illness, to self-care and to negotiate healthy relationships, those that facilitate a sense of wellbeing.’

Body image in practice

A compulsive behaviour of BDD is constant comparison with models, celebrities on social media and people in public spaces. Young people are particularly vulnerable as they spend more time on social media than any other demographic.8

‘Poor body image results in individuals less likely to fulfil their full potential and an increased risk of developing an eating disorder. The risk is further enhanced if a family member is constantly on a diet, talks negatively about food or body image,’ says Ms Scott.

‘The individual is less likely to look after themselves physically, eat a well-balanced diet, exercise for health or make the best of themselves. A poor body image can contribute to low mood, low self-esteem and confidence issues. If an eating disorder develops, this can become life-threatening.’

Recognition and early intervention are key factors in responding to body image concerns. There are several things to look out for in patients: becoming socially isolated, not wanting to eat in public, avoiding exposing the body (e.g. swimming), having difficulty accepting compliments, putting oneself down, and having a pre-occupation with social media promoting ‘ideal body’ types.

‘Supporting the individual to focus on positive qualities is important, as is the need to nourish the body and mind in order to get the best out of it. How can you expect a car to run properly if you don’t fuel it efficiently? The same applies for a body in relation to food and the need for all food groups,’ says Ms Scott.

‘Helping patients to recognise that there is always hope and that someone with a negative body image does not have to stay that way. Helping someone to change their mindset is important with daily activities that can, over time, increase body confidence. It can also be useful to acknowledge that not everyone with a poor body image will go on to develop an eating disorder and whilst it is important to recognise eating disorder symptoms, we can be at risk of misdiagnosing. Therefore, it is vital if you are concerned that someone is suffering from an eating disorder that they are seen by their GP and signposted accordingly.’


Poor body image is linked to serious mental health conditions. As young people are experiencing this more and more, raising awareness of its cultural triggers, such as TV and social media, is becoming especially important. Mental health problems affect one in ten children and young people, and 70% of those do not receive appropriate interventions,9 therefore recognising poor body image early on is a vital preventative measure to reduce the risk of future diagnoses of mental illness.


1. Fardouly J, Diedrichs P, Vartanian E. Social comparisons on social media: the impact of Facebook on young women’s body image concerns and mood. Body Image. 2015;13:38-45.

2. 2017 Dove Global Girls Beauty and Confidence Report. Dove; 2017.

3. Siddique H. Poor body image makes girls less assertive and risks health, study finds. The Guardian; 2017. (accessed 30 July 2018)

4. National Eating Disorders Association. Body image. 2018. (accessed 30 July 2018)

5. Bolton M, Lobben I, Stern T. The impact of body image on patient care. Prim Care Companion. 2010;12(2):10r00947.

6. Royal Society for Public Health. #StatusofMind. (accessed 30 July 2018)

7. Mental Health Foundation. Eating disorders. 2018. (accessed 30 July 2018)

8. Campbell D. British teenagers among world’s most extreme internet users, report says. The Guardian. 2017. (accessed 30 July 2018)

9. Mental Health Foundation. Children and young people. 2018. (accessed 30 July 2018)

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