EVERYBODY KNOWS THAT MASS MEDIA ARE/ARE NOT [pick one

Transcription

Journal of Social and Clinical Psychology, Vol. 28, No. 1, 2009, pp. 9-42
LEVINE AND MURNEN
Media, Negative Body Image and Disordered Eating
“Everybody knows that mass media
are/are not [pick one] a cause
of eating disorders”:
A Critical Review of Evidence
for a Causal Link between Media,
Negative Body Image, and
Disordered Eating in Females
Michael P. Levine and Sarah K. Murnen
Kenyon College
This article reviews research pertaining to mass media as a causal risk factor for
negative body image and disordered eating in females. The specific purpose is to
clarify the impact of mass media by applying seven criteria that extend those of
Kraemer et al. (1997) and Stice (2002). Although media effects clearly meet a majority of the criteria, this analysis indicates that, currently, engagement with mass
media is probably best considered a variable risk factor that might well be later
shown to be a causal risk factor. Recommendations are made for further research,
with an emphasis on longitudinal investigations, studies of media literacy as a
form of prevention, and clarification of psychosocial processes that moderate and
mediate media effects.
Numerous professionals, parents, and adolescents find the media’s
status as a cause of body dissatisfaction, drive for thinness, and eating disorders to be self-evident: “Of course, mass media contribute
to unhealthy beauty ideals, body dissatisfaction, and disordered
eating—haven’t you seen the magazine covers in the supermarket
newsstands lately? No wonder so many girls have body image issues and eating disorders.” On the contrary, a growing number of
Correspondence concerning this article should be addressed to Michael P. Levine,
Ph.D., and Sarah K. Murnen, Ph.D., Department of Psychology, Kenyon College,
Gambier, OH 43022-9623. E-mail: [email protected]; [email protected].
9
10LEVINE AND MURNEN
parents, biopsychiatric researchers, clinicians (e.g., Bulik, 2004), and
cynical adolescents find proclamations about media as a cause of
any disorder to be an irritating distraction. Their contention is, in
effect: “Of course, we know now that eating disorders, like mood
disorders and schizophrenia, are severe, self-sustaining psychiatric
illnesses with a genetic and biochemical basis. So, of course, no scientist seriously thinks that mass media and the escapades of actors,
models, and celebrities have anything to do with causing them.”
This article reviews the current status of research pertaining to
mass media as a causal risk factor for clinically significant levels of
negative body image and disordered eating in females. After considering the criteria for establishing a causal risk factor, we analyze
the evidence for the impact of mass media (e.g., fashion magazines,
television). The principal goals are to clarify (1) what is known with
relative certainty about media’s effects on females (2) what isn’t
known yet, or remains ambiguous; and (3) what methodologies and
studies are needed to advance the types of risk-factor knowledge
that should facilitate prevention, treatment, and support during recovery.
The relationships between mass media, negative body image,
and unhealthy behaviors (e.g., use and abuse of steroids and food
supplements) in males are receiving increasing attention (Pope,
Phillips, & Olivardia, 2000). This review, however, concentrates on
females. The gender differences (conservatively, 6 to 8 females for
each male) in the prevalence of anorexia nervosa, bulimia nervosa,
and eating disorder not otherwise specified (EDNOS) other than
Binge Eating Disorder are among the largest reported for mental
disorders (Fernández, Labrador, & Raich, 2007; Hoek & van Hoeken, 2003; but see Hudson, Hiripi, Pope, & Kessler, 2007).
Media as a Cause of What?—What is to Be Explained?
A Spectrum of Phenomena
Although the matter of dimensions and/or categories is complex
and unresolved (Gleaves, Brown, & Warren, 2004), substantial evidence suggests that the serious and frequently chronic conditions
recognized as the “Eating Disorders” by the DSM-IV-TR (American
MEDIA, NEGATIVE BODY IMAGE AND DISORDERED EATING
11
Psychiatric Association, 2000) are composite expressions of a set of
dimensions, such as negative emotionality, binge eating, and unhealthy forms of weight and shape management. The latter includes
restrictive dieting, self-induced vomiting after eating, and abuse of
laxatives, diuretics, diet pills, and exercise (Levine & Smolak, 2006;
Stice, Killen, Hayward, & Taylor, 1998; Tylka & Subich, 1999).
The adhesive drawing together and framing these intertwined
continua is negative body image. In most media effects research
the multidimensional construct of body image (Cash & Pruzinsky,
2002) is represented by various measures of what are essentially
perceptual-emotional conclusions (e.g., “I look too fat to myself
and others” + “I am disgusted by and ashamed of this” = “I hate
how fat I look and feel”). For females “body dissatisfaction” results
from—and feeds—a schema that integrates three fundamental components: idealization of slenderness and leanness; an irrational fear
of fat; and a conviction that weight and shape are central determinants of one’s identity (Levine & Smolak, 2006; Smolak & Levine,
1994, 1996).
“Mass” Media and Epidemiology
The effects of media designed to reach and influence huge masses of
people are certainly a salient and thus tempting explanation for four
fairly well-established findings. First, the prevalence of discontent
and problems concerning weight and shape has been so high for so
long among girls and women that for 25 years it has been considered “normative” (Ricciardelli & McCabe, 2004; Rodin, Silberstein,
& Striegel-Moore, 1985). Second, a substantial percentage, perhaps
20%, of females ages 12 through 30 have levels of negative body image and disordered eating high enough to create significant suffering for themselves and others (Cash, 2002; Levine & Smolak, 2006).
Third, weight and shape concerns, along with a “dieting mentality,”
tend to emerge in childhood for girls of varying sizes and backgrounds—and children are heavy consumers of mass media (e.g.,
TV, children’s books, and videos; Comstock & Sharrer, 2007) that are
replete with clear messages about the positive features of thinness
and the many negative aspects of being fat. Finally, while there are
certainly ethnic and sociogeographic differences in risk for negative
body image and disordered eating, the fact that “fat talk” and these
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problems are found among youth and young adults of all social
classes and ethnicities, and in many highly dissimilar geographic
locations, is consistent with a general sociocultural model that includes a proliferating, influential mass media (Cash & Pruzinsky,
2002; Gordon, 2000; Levine & Smolak, 2006; Nichter, 2000).
Criteria for Evaluating the Status
of a Mass Media as a “Cause”
Causes and Risk
Researchers in many fields have stopped thinking about “the” cause
of a disorder as “the agent” that directly brings about the undesirable outcome. Instead, there is an emphasis on variables that are
reliably and usefully associated with an increase over time in the
probability of a subsequent outcome. Such variables are called risk
factors (Kraemer et al., 1997).
Common Risk Factors and
Relatively Rare Conditions
Thinking in terms of risk factors has two major implications for investigating mass media as a “cause” of eating disorders. The first
concerns the oft-heard “relative rarity” argument: How could mass
media be a cause when the vast majority of girls and young women
are exposed to ostensibly toxic influences, but only a small percentage develop eating disorders? This critique dissolves when one
considers multiple risk factors as multiplicative probabilities. Assume, conservatively, that 35% of adolescent girls are engaged with
those mass media containing various unhealthy messages. Assume
also that three other risk factors—such as peer preoccupation with
weight and shape; family history of overweight/obesity; and being socialized by parents and older siblings to believe firmly that
a female’s identity and worth are shaped primarily by appearance
(Smolak & Levine, 1996)—each have a probability of .35 of occurring
in the population. The probability of co-occurrence for these four
unweighted risk factors is .354 = .015, which is roughly the preva-
13
lence of anorexia nervosa and bulimia nervosa among females in
the age range at greatest risk (Hoek & van Hoeken, 2003). Behavior
geneticists have long accepted that the presence of fairly common
risk factors in a population can account for fairly rare and extreme
conditions (Hanson, 2004).
Criteria for Determining a Causal Risk Factor
Second, if mass media constitute a causal risk factor (Kraemer et al.,
1997; Stice, 2002) for the spectrum of negative body image and disordered eating, then the following will be the case. Cross-sectional
studies will show that the extent of exposure to mass media, or to
various specific forms of mass media, is a correlate of that spectrum. Longitudinal studies will demonstrate that exposure to mass
media precedes and predicts development of negative body image and disordered eating. Laboratory experiments should show that
well-controlled manipulation of the media risk factor (independent
variable) causes the hypothesized changes in “state” body satisfaction and other relevant dependent variables, while controlled analog
(laboratory) or field experiments should demonstrate that prevention
programs designed to combat known risk factors do indeed reduce
or delay the onset of disordered eating.
These criteria are demanding in and of themselves (Stice, 2002).
Nevertheless, it is also important to incorporate the contributions
to knowledge of two further sources: common sense and people’s
"lived experience." Specifically, if mass media are a causal risk factor, then content analyses should document that media provide the
raw material from which children and adolescents could readily extract and construct the information, affective valences, and behavioral cues necessary to develop the components of disordered eating. Similarly, surveys and ecological analyses will reveal that engagement with mass media is frequent and intensive enough to provide
multiple opportunities for this type of social-cognitive learning.
Finally, surveys and qualitative studies should find that, beginning at
the age where they can think critically about themselves in relation
to personal and outside influences, children and adolescents will
report that mass media are sources of influence, and even pressure,
on themselves, their peers, and others.
14LEVINE AND MURNEN
Thus, this review uses seven criteria to evaluate the status of mass
media as a causal risk for negative body image and disordered eating. Content and exposure are foundational, so we will consider
them criteria 1 and 2. The Kraemer-Stice standards are criteria 3
through 6, and the existence and impact of subjective experiences of
media pressures and influence constitute criterion 7.
Criteria 1 and 2: Content and Exposure
Media Exposure and Use
Mass media are a major part of the lives of many children, adolescents, and adults (Comstock & Scharrer, 2007; Harris, 2004). People of all ages select and use media for many purposes, including
entertainment and distraction, but also exploration of significant
developmental issues pertaining to curiosity, education, popularity, identity, gender roles, and sexuality (Arnett, 1995; Comstock &
Scharrer, 2007).
Mass Marketing
Appearance, status, sexuality, and buying and consuming are, for
many reasons (including the power of mass media), very important
aspects of life throughout many countries. Consequently, the content of mass media provides daily, multiple, overlapping, and, all
too often, unhealthy messages about gender, attractiveness, ideal
body sizes and shapes, self-control, desire, food, and weight management (Bordo, 1993; Currie, 1999; Spitzer, Henderson, & Zivian,
1999). These messages sometimes intentionally, sometimes incidentally indoctrinate developing girls and boys with the following easily extracted themes: (a) being sexually attractive is of paramount
importance; (b) the sources of ideals about attractiveness (“being
‘hot’!”), style, and the best, most competitive practices for becoming
and staying beautiful are obviously located outside the self; and (c)
mass media are the most important and inherently enjoyable “external” source of the information, motivation, and products neces-
15
sary to be attractive and fashionable (Ballentine & Ogle, 2005; Labre
& Walsh-Childers, 2003).
Mass Media and the Thinness Schema
Thus, with respect to the cultural foundations of negative body image and disordered eating, even girls (and boys) as young as 4 or 5
have no trouble finding in mass media the raw materials for various
maladaptive but entirely normative media-based schemata concerning gender and attractiveness (Levine & Harrison, 2004; Smolak &
Levine, 1994, 1996; Smolak & Murnen, 2004, 2007). The “thinness
schema” for females is a set of assumptions, “facts,” and strong feelings that are organized so as to establish a readiness to think and
respond in terms of, for example, the following themes: (1) Women
are “naturally” invested in their beauty assets and thus beauty is a
woman’s principal project in life; (2) a slender, youthful attractive
“image” is really something substantive, because it is pleasing to
males and it demonstrates to females that one is in control of one’s
life; and (3) learning to perceive, monitor, and indeed experience
yourself as the object of an essentially masculine gaze is an important part of being feminine and beautiful.
Transnational Idol: The Exaltation
of Thinness and the Vilification of Fat
There is a wealth of evidence from content analyses that the ideal
female body showcased on television, in movies, in magazines, and
on the internet reflects, indeed embodies, the proposition that “thin
is normative and attractive” (Harrison & Hefner, 2006; Levine &
Smolak, 1996; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999).
While (because?) American girls and women are becoming heavier,
the current body ideal (idol) for women has become and remains
unrealistically thin (Grabe & Hyde, 2006; Sypeck, Gray, & Ahrens,
2004). In fact, mass media are one of many sociocultural sources
for the normative prejudice that fat is “horrible and ugly,” and that
“getting fatter” is a sign of at least 4 of the classic “7 deadly sins”—
extravagance, gluttony, greed, sloth, and, maybe, pride (see, e.g.,
research by Fouts & Burggraf, 2000, and Klein & Shiffman, 2006;
16LEVINE AND MURNEN
see reviews by Greenberg, Eastin, Hofschire, Lachlan, & Brownell,
2003, and Puhl & Latner, 2007).
Conclusion
Criteria 1 and 2 are fulfilled. Mass media are saturated with potentially unhealthy messages, and citizens of virtually all ages are motivated to use and be engaged with these media on a regular basis.
Criterion 3: Cross-Sectional Correlates
of Exposure to Mass Media
The presence of a positive correlation between level of exposure to
mass media, or to certain types of mass media, and the spectrum
of disordered eating is a necessary but not sufficient condition for
determination of causal agency. However, absence of a positive correlation negates the argument for causality.
Television
Consistent with Criterion 3, cross-sectional studies show that the
average amount of time adolescent girls spend viewing appearancefocused media such as soap operas and music videos is positively
correlated with body dissatisfaction, drive for thinness, internalization of the thin ideal, endorsement of surgery to attain a bust size
that is neither small nor too large, and bulimic symptomatology,
although there is conflicting evidence as to whether this relationship applies to White as well as non-White girls (Borzekowski, Robinson, & Killen, 2000; Botta, 2000; Harrison, 2003; Tiggemman, 2005;
Tiggemann & Pickering, 1996). Yet, there is substantial variability
in the survey-based empirical findings (Levine & Harrison, 2004,
in press; Murnen, Levine, Groesz, & Smith, 2007). To draw general
conclusions, we turn to two recent meta-analytic evaluations of the
relationship between exposure to television, body image, and disordered eating.
Grabe, Ward, and Hyde (2008) located 12 studies yielding 21 independent effect sizes. Although these investigators did not calculate
17
TABLE 1. Media Exposure (Survey-Based) and Disordered Eating in Females: Effect Sizes
k
n
r
Heterogeneity: r Larger for
Thin Ideal
16
4606
0.21
Age < 18; non-US samples
Body Dissatisfaction
31
9398
0.12
None of the variables coded
Wt/Shape control
17
5927
0.19
Sample is < 80% White;
Disordered eating
20
11834
0.13
U.S. samples; sample is > 80%
White
Thin Ideal
10
3917
0.02
Age < 18; non-U.S. samples
Body Dissatisfaction
30
8212
0.09
age > 18
Wt/Shape control
17
5557
0.05
age > 18; sample is > 80%
White; assessed with EDI-DT
Disordered eating
21
9345
0.06
assessed with EDI-BU or EAT
Exposure to
Magazines
Television
Note: All rs (effect sizes) are statistically significant, p < .01. Except for the correlations between TV
viewing and disordered eating (ns) and magazine reading and body dissatisfaction (p < .05), all heterogeneity statistics are significant at p < .01. ES = effect size. EDI-DT and EDI-BU = Drive for Thinness
and Bulimia subscales, respectively, of the Eating Disorders Inventory. EAT = Eating Attitudes Test.
the 4 individual ds from the complete cross of magazines versus
TV and correlational versus experimental design, the ds for the relationship between TV exposure and body dissatisfaction ranged
from -.20 to +.61 (n = 11), while the ranges for internalization of the
thin ideal and for disordered eating were -.08 to +.43 (n = 4) and
+.12 to +.47 (n = 3), respectively. According to Grabe et al. (2008),
their meta-analysis definitely supports a positive relationship, with
“small to moderate effect sizes,” between TV exposure and body
dissatisfaction, thin-ideal internalization, and self-reported disordered eating.
We also conducted a meta-analysis (Murnen et al., 2007; see Table 1). Given that our focus was on media exposure as evaluated in
survey-based correlational research, many more unpublished and
published studies were identified (k = 30). We found smaller but
still statistically significant correlations (effect size rs range from between +.02 and +.09; ds = +.04 to +.18) for the relationship between
TV exposure in general and sets of criterion variables categorized
as thin ideal internalization, body dissatisfaction, weight and shape
control, and disordered eating.
18LEVINE AND MURNEN
Magazines
According to studies of undergraduate women and adolescent girls,
the extent of exposure to magazines that feature and glamorize
the thin ideal is positively correlated with disordered eating, even
when controlling for the young woman’s level of personal interest
in fitness and dieting (Harrison & Cantor, 1997; Thomsen, Weber, &
Brown, 2002). A path analytic study by Jones, Vigfusdottir, and Lee
(2004) found that for girls 11 through 14 the extent of exposure to
appearance-related magazines and to appearance conversations by
peers each predicted body dissatisfaction through the mediator of
internalization of the thin beauty ideal.
Grabe et al.’s (2008) meta-analysis identified 18 survey-based
studies of the correlates of magazine exposure, yielding 33 effects.
The ds for body dissatisfaction ranged from -.22 to +.63 (n = 12),
while those for internalization of the thin ideal and for disordered
eating were +.03 to +.81 (n = 9) and +.08 to +.63 (n = 9), respectively.
Once again, Grabe et al. concluded that, in general, there is a small
to moderate positive correlation between magazine exposure and
the key variables. We note, however, that the relationship between
magazine exposure and thin-ideal internalization may be stronger
than that. Of the 9 relevant ds, only one was < +.35, and 6 were >
+.55.
Our meta-analysis (Murnen et al., 2007) of over 30 studies found
that the effect size rs (+.12 to +.21, equivalent to ds between +.24 and
+.44) were appreciably higher for magazines than for TV (see Table
1). Consistent with the findings of Grabe et al., we also discovered
that, compared to the other criterion measures, thin ideal internalization was more strongly correlated with magazine reading and
TV viewing, especially for children and adolescents under age 18.
Conclusion
Meta-analytic studies show that there is a small to moderate positive correlation between level of exposure to mass media such as
TV and magazines and each of the important triad of body dissatisfaction, thin-ideal internationalization, and disordered eating. This
fulfills Criterion 3.
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The two meta-analyses (Grabe et al., 2008; Murnen et al., 2007)
found a lack of consistency in potential moderators within and
across the two types of media. This suggests we have a lot to learn
about the relationship between frequency and intensity of naturalistic media exposure and disordered eating.
Criterion 4: Longitudinal Correlates
of Exposure to Mass Media
A causal risk factor precedes and predicts development of a problem. Consequently, longitudinal studies are critically important for
identifying causal risk factors.
In two quite different cultures, the Ukraine and Fiji, institution
of a market-based mass media was followed by increases in internalization of the slender beauty ideal and in body dissatisfaction
among adolescent girls (Becker, Burwell, Gilman, Herzog, & Hamburg, 2002; Bilunka & Utermohlen, 2002). In Fiji, 3 years after introduction of television the level of disordered eating and self-induced
vomiting to control weight was significantly greater (Becker et al.,
2002).
Compared to cross-sectional studies, longitudinal research linking media exposure with body image is sparse. The few published
studies do suggest that early exposure to thin-ideal television predicts a subsequent increase in body-image problems. For a sample
of Australian girls aged 5 to 8, viewing of appearance-focused television programs (but not magazines) predicted a decrease in appearance satisfaction 1 year later (Dohnt & Tiggemann, 2006). For
European American and African American girls ages 7 through 12
greater overall television exposure predicted both a thinner ideal
adult body shape and a higher level of disordered eating 1 year later
(Harrison & Hefner, 2006). The results of both studies were valid
regardless of whether the children were heavy, or perceived themselves to be thin or heavy, at the outset of the research. The thrust of
these two studies is consistent with Sinton and Birch’s (2006) finding that, among the 11-year-old American girls they studied, awareness of media messages about thinness was related to the strength
of appearance schemas a year later.
The importance of a longitudinal design is revealed in recent
studies of older children and young adolescents conducted by
20LEVINE AND MURNEN
Tiggemann (2006) and by Field and colleagues (1999, 2001, 2008).
In a sample of 214 Australian high school girls (mean age = 14),
Tiggemann found that the only measure of television exposure, including total hours of exposure, to produce meaningful cross-sectional and longitudinal correlations was the self-reported extent of
watching soap operas. Cross-lagged correlational analyses showed
that Time 1 exposure to soap operas predicted, to a small but significant degree, internalization of the slender ideal and level of appearance schema at 1-year follow up (Time 2). Time spent reading
appearance-oriented magazines, but not other magazines, at Time 1
predicted, also to a small but significant degree, Time 2 levels of internalization, appearance schema, and drive for thinness. However,
none of the media exposure variables was a significant longitudinal
predictor of body dissatisfaction. Moreover, hierarchical regressions
controlling for Time 1 level of each of the four criterion variables
(e.g., internalization) found that none of the media exposure measures added significantly to prediction of the Time 2 criteria.
Although Field and colleagues used only single-variable measures of media exposure, their longitudinal research also casts
doubt on exposure as a causal risk factor for older children and
younger adolescents. Field et al. investigated a sample of over 6900
girls who were ages 9 through 15 at the 1996 baseline. Preliminary
cross-sectional work did produce the expected positive linear association between frequency of reading women’s fashion magazines
and intensity of weight concerns (Field et al., 1999). However, subsequent longitudinal research revealed that over a 1-year period the
key predictor of the development of weight concerns and frequent
dieting was “making a lot of effort to look like same-sex figures in
the media” (Field et al., 2001, p. 54). A 7-year follow-up showed that
initiation of binge-eating, but not purging, in (now) adolescent and
young adult females was predicted independently by frequent dieting and by Time 2 (1997) level of attempting to look like persons in
the media (Field et al., 2008).
The only longitudinal investigation of young adult women we
could locate was Aubrey’s (2006) 2-year panel study of college-age
women. In support of Criterion 4, the extent of exposure to sexually
objectifying media at Time 1 predicted level of self-objectification at
Time 2, especially in women with low self-esteem. Measures of the
tendency to self-objectify are positively correlated with eating disorder symptoms such as misperceptions of weight and shape, body
21
shame, drive for thinness, and restrictive dieting (see, e.g., Smolak
& Murnen, 2004; Tylka & Hill, 2004).
Conclusion
Evidence from a very small number of longitudinal studies indicates that for children and very young adolescents, extent of media
exposure does appear to predict increases in negative body image
and disordered eating. Tiggemann’s (2006) suggests that by early
adolescence the causal risk factor is not media exposure, or even
internalization of the slender beauty ideal, but rather the intensity
and extent of “core beliefs and assumptions about the importance,
meaning, and effect of appearance in an individual’s life” (p. 528).
Field et al.’s extensive work concurs, pointing to schematic feature
of paying attention to, and trying to look like, models and celebrities in the mass media. In all, there is little support for Criterion 4 as
it applies to adolescence, and preliminary but inconclusive support
for this criterion in regard to children and college students.
Criterion 5: Experimental Manipulation of Media
Exposure Experimental Evidence: Laboratory
Research and the Contrast Effect
Laboratory experiments cannot settle the question of correlation
and causal agency in a developmental sense. However, experimentation can help determine whether, as predicted by a causal risk factor model, concentrated media exposure actually makes girls and
women feel immediately worse or better about their bodies and
their selves.
In a meta-analysis of 25 published and unpublished experiments
appearing between 1979 and 2000, Groesz, Levine, and Murnen
(2002) examined the effects of experimental exposure to media content on body dissatisfaction in female samples. Thirty-five (81%) of
the 43 d values were negative, and the overall d value was -0.31 (r =
-.65). Compared to participants randomly assigned to control conditions, participants exposed to thin-ideal images from the media
experienced a moderately large drop in body satisfaction. The aver-
22LEVINE AND MURNEN
age effect size was slightly greater for participants not yet in college
(d = -.36), suggesting heightened sensitivity among adolescents.
Grabe et al.’s (2008) meta-analysis identified an additional 19 experimental studies of magazine-based images and an additional 8
studies of images from TV shows and commercials. Sixteen of 19
magazine studies and all of the TV studies were published after the
Groesz et al. (2002) article went to press. Of the 24 magazine effect
sizes involving body dissatisfaction, half were over -.45 and four
were greater than -1.00. For the 9 TV effect sizes, the range was -.15
to -1.63, and four were greater than -.45. Grabe et al. (2008) also reported that, although there was substantial heterogeneity, the ds for
experimental effects (across magazines and TV) on internalization
and eating behaviors and beliefs were -.21 and -.36, respectively.
Conclusion
The meta-analyses by Groesz et al. (2002) and Grabe et al. (2008)
provide strong support for Criterion 5. In this regard, multimethod
studies by Hargreaves and Tiggemann (2002, 2003, 2004) in Australia produced compelling evidence for the contention that mass
media have negative and cumulative effects on body image in girls
and young women. The adolescent girls whose body image was
most negatively affected by experimental exposure to 20 television
commercials featuring the thin ideal tended to have greater levels of
body dissatisfaction and drive for thinness 2 years later, even when
initial level of body dissatisfaction was controlled statistically.
The most vulnerable girls may well have a self-schema dominated by the core importance of physical appearance. In a study of girls
ages 15 through 18 Hargreaves and Tiggemann (2002) found that
appearance-focused TV commercials did activate an appearancerelated self-schema, as reflected in several measures of cognitive
set. Moreover, as predicted, appearance-focused commercials generated greater appearance dissatisfaction for those girls who began
the study with a more extensive, emotionally charged, self-schema
for appearance. Interestingly, the negative impact of the thin-beauty
ideal in television commercials was, unlike previous findings with
magazine images, unaffected by either the girls’ initial level of body
dissatisfaction (see Groesz et al., 2002) or whether their viewing
23
style was more personal (self-focused) or more detached (imagefocused; see next section).
Positive (Assimilation) Effects. Durkin and Paxton (2002) found that
32% of the 7th grade girls and 22% of the 10th grade Australian girls
who were exposed to images of attractive models from magazines
exhibited an increase in state body satisfaction. Similarly, two studies
of Canadian college students found that restrained eaters showed
moderate to large increases in body satisfaction following exposure
to similar magazine images, whereas unrestrained eaters had very
large decreases in body satisfaction (Joshi, Herman, & Polivy, 2004;
Mills, Polivy, Herman, & Tiggemann, 2002).
Two studies in the United States by Wilcox and Laird (2000) suggest that young women who focus on the slender models in magazines while defocusing attention on themselves are more likely to
identify with the models and thus to feel better about their own
bodies. Conversely, women who self-consciously divide their attention between the models and themselves are more likely to evaluate
themselves and reach a conclusion that leaves them feeling inferior
and worse. This finding is supported by research showing that selfevaluative processes, as opposed to self-improvement motives, are
more likely to reflect and activate “upward” social comparison processes, which themselves tend to generate negative feelings about
one’s body (Halliwell & Dittmar, 2005).
Pro-Ana Web Sites. The internet offers many pro-anorexia (proana) and pro-bulimia (pro-mia) web sites. Some of the most prominent pro-ana sites defiantly and zealously promote AN as a sacred
lifestyle rather than a debilitating psychiatric disorder (Norris, Boydell, Pinhas, & Katzman, 2006). Their ”thinspirational” images of
emaciation and their explicit behavioral instructions for attaining
and sustaining the thin ideal are intended to reinforce the identity
and practices of those already entrenched in AN or BN.
If concentrated exposure to typical images of slender models have
negative experimental effects, then we might well expect the images and messages from pro-anorexia web sites to have even more
negative effects. Two recent experiments by Bardone-Cone and Cass
(2006, 2007) examined the effects of a web site that they constructed
to feature the prototypical content of pro-ana sites. As predicted, exposure to this site had a large number of negative effects on young
women, independent of their dispositional levels of thin ideal inter-
24LEVINE AND MURNEN
nalization and disordered eating. At present, we do not know what
effects pro-ana and pro-mia sites have on the adolescent girls and
young women who avidly seek them out because they already have
a full-blown eating disorder.
Criterion 6: Experimental Evidence:
Prevention Studies
Media Literacy: Laboratory Investigations
If media effects are a causal risk factor, then reduction or elimination of negative media influences should reduce or prevent negative body image and other processes that eventually result in eating
disorders. One way to test this proposition is to evaluate the impact
of interventions designed to promote “media literacy.” Media literacy (ML) is a set of knowledge, attitudes, and skills that enable
people to work together to understand, appreciate, and critically
analyze the nature of mass media and one’s relationships with them
(Levine & Harrison, 2004, in press; Levine & Piran, 2004; Levine &
Smolak, 2006). Systematic investigations of ML can be categorized
into analog laboratory studies, brief interventions, and longer, more
intensive programs.
Analog Studies
This research has been reviewed in detail elsewhere (Levine, Piran,
& Stoddard, 1999; Levine & Smolak, 2006, chapter 13; Levine &
Smolak, 2008). Several controlled experiments show that very brief
written or video interventions can inoculate college-age women, including those who already have a negative body image, against the
general tendency to feel worse about their bodies and themselves
after viewing slides or video containing media-based images of the
slender beauty ideal. The most effective ML “inoculation” highlights the clash between the artificial, constructed nature of the slender, flawless, “model look” versus two stark realities: (1) the actual
shapes and weights of females (and males) naturally vary a great
deal across a population; and (2) dieting to attain an “ideal” and
25
“glamorous” weight/shape that is unnatural for a given individual
has many negative effects, including risk for an eating disorder.
Brief Curricular Programs
Three doctoral dissertations completed in the U.S. from 1998 to 2000
taught ML to girls ages 9 through 14 (see Levine & Smolak, 2006,
chapter 13). The content of these programs varied, but, consistent
with the findings of analog research, each emphasized the narrow
and constructed nature of beauty ideals, as well as the futility and
health costs of seeking to actualize this artificial “perfection.” These
projects demonstrated that ML lessons ranging in length from 40 to
135 minutes can have a number of positive effects lasting several
months, such as improving girls’ body image and reducing both the
glorification of thinness and social comparison tendencies.
Several programs for high-school and college-age females used
slide presentations or Jean Kilbourne’s video Slim Hopes (http://
www.mediaed.org/videos/MediaAndHealth/SlimHopes) to help
participants consider the history of changing, but consistently restrictive, beauty ideals and then to answer some fundamental questions: Do real women look like the models in advertising? Will buying the product being advertised make me look like this model?
These programs emphasize how fashion models, working with the
production staffs of magazines and movies, use “cosmetic” surgery,
computer graphics, and other technologies to construct idealized
images. Participants are encouraged to explore how these manipulations are carefully orchestrated to stir up the desire to purchase
products, many of which will supposedly reduce the discrepancy
between such unreal, “perfect” images versus the body shapes and
weights of normal, healthy females.
These ML programs are brief, so positive effects are necessarily
limited. Nevertheless, it is noteworthy that they tend to reduce, at
least in the short run, one important risk factor for disordered eating (Thompson & Stice, 2001): internalization of the slender beauty
ideal.
26LEVINE AND MURNEN
Intensive Programs
Well-controlled studies of multi-lesson, multifaceted media literacy
programs that unfold over 1 to 2 months have shown that media
literacy training can help girls and boys ages 10 through 14 to reduce
risk factors such as internalization of the slender or muscular ideal,
while increasing the potentially protective factors of self-acceptance, self-confidence in friendships, and confidence in their ability
to be activists and thus affect weight-related social norms (Levine
& Smolak, 2006). In addition to spending considerable time working on the same components as those in the analog and brief interventions, intensive ML programs address the process and costs of
social comparison. They also get participants involved in working
within their ML groups, their school, and their larger community
to translate their increasing literacy into peer education, consumer
activism, and creating and promoting new, healthier media.
Recent investigations with college students also show ML to be a
promising form of prevention (Levine & Harrison, in press; Levine &
Smolak, 2007, 2008). For example, Watson and Vaughn (2006) developed a 4-week, 6-hour intervention consisting of psychoeducation
about the nature and sources of body dissatisfaction; group-based
content analysis of beauty ideals in popular women’s magazines;
discussion of media ideals and beauty enhancement techniques;
and a brief cognitive intervention designed to help participants
dispute negative beliefs and feelings activated by media images of
the thin ideal. Compared to a 1-day, 90-min version of this intervention, a one-time viewing of a 34-min media literacy film, and
a no-intervention control, the extended intervention was the most
successful in reducing the following risk factors for disordered eating: unhealthy social attitudes, internalization of the slender ideal,
and body dissatisfaction.
Conclusion
At present there have been no direct, long-term studies of whether
media literacy in particular can prevent development of negative
body image and the spectrum of disordered eating. At this point
it seems fair to say that there is “some” encouraging evidence for
27
Criterion 6 in that (1) brief forms of a critical social perspective can
mitigate the immediate negative effects of exposure to the thin ideal; and (2) more systematic interventions over days or weeks can reduce one important risk factor: internalization of the slender ideal.
Criterion 7: Subjective Influence: Motives,
Pressures, and Ideals
One sensible way to add to our understanding of media effects is
to ask people about their experiences with media “pressures” and
“influences.”
Desiring the Media’s Ideal Shape
Field et al.’s (1999) survey of nearly 550 working class girls ages 11
through 19 revealed that almost 70% reported that the “pictures”
in magazines have an influence on their conception of the “perfect
body shape.” Over 45% indicated that those images motivated them
to lose weight, and the greater the frequency of reading “women’s
magazines,” the more likely these adolescent girls were to report
being influenced to think about the perfect body, to be dissatisfied
with their own body, to want to lose weight, and to diet.
As noted previously, subsequent cross-sectional and longitudinal research by Field and colleagues revealed that “wanting to look
like” celebrities and models in the media was a strong predictor of
weight concerns, dieting behavior, and binge eating. A similar study
of nearly 800 Australian adolescent girls found that 88.5% said they
desired the “slender media-promoted ideal body shape” (Grigg,
Bowman, & Redman, 1996). Further, those who definitely and enthusiastically desired this shape had significantly higher levels of
extreme dieting and disordered eating. This finding is quite consistent with the results of Levine, Smolak, and Hayden’s (1994) survey
of nearly 400 American girls ages 10 through 14. In this study the extent to which magazine articles and advertisements were important
to a young adolescent girl’s concept of the perfect body and how to
obtain it was very strongly correlated with greater investment in
thinness, use of weight management techniques, and level of disordered eating. In a survey of college women Harrison (1997) found
28LEVINE AND MURNEN
that “interpersonal attraction” (a composite variable representing
liking, wanting to be like, and feeling similar) to thin media personalities predicted disordered eating beyond mere media exposure.
Internalization of the Slender Ideal and
Perceived Media Pressures
Cross-Sectional Studies. Social-cognitive models of media influence,
including the prominent “cultivation theory” (see Levine & Smolak,
1996, for an application to body image and eating disorders), argue
that normative beliefs about the social world, as emphasized in mass
media, become beliefs and attitudes about the self. The most valid
and widely used measure of both passive awareness, and active internalization, of the media’s thin body ideal for females is the Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ). In the
original version seven of the eight items forming the internalization
factor (subscale) pertained directly to the mass media (e.g., “I tend
to compare my body to people in magazines and on TV”; Smolak,
Levine, & Thompson, 2001). Two validation studies of the most recent version (SATAQ-3; Thompson, van den Berg, Roehrig, Guarda,
& Heinberg, 2004) demonstrated that, for undergraduate women,
self-reported levels of perceived pressure from media and of internalization of the slender beauty ideal were (1) highly correlated with each
other; and (2) strong predictors of precursors of disordered eating.
In addition, as hypothesized, scores on those two subscales, as well
as that assessing awareness of the media’s thin ideal, all significantly
differentiated eating disordered women from among nondisordered
controls. Engeln-Maddox (2006) recently found that, as predicted,
some young women have the clear and strong expectation that looking like a media ideal will transform their lives in multiple, positive
ways. Of that group, those who have internalized the media ideal of
slender beauty tended to have greater body dissatisfaction.
Internalization of the thin ideal is certainly understandable—
and probably rational and adaptive—in the current cultural context (Gordon, 2000; Smolak & Levine, 1996). However, it is far
from harmless. For example, Smolak et al. (2001) found that, in 200
girls ages 11 through 14, only 7% of the variation in weight control
techniques was accounted for by body mass. However, when the
SATAQ awareness and internalization subscales were added to the
29
regression equation, variance accounted for rose to 48%. Further, in
the final equation using all three variables, only internalization was
a statistically significant predictor of weight control behaviors.
A recent study of 14 to 16-year-old Swiss girls (Knauss, Paxton,
& Alsaker, 2007) also found that internalization, perceived pressure
from the media, and body dissatisfaction were highly intercorrelated (all rs > .61). This finding adds to a large body of research
demonstrating three key facts for girls and young women ages 8
through 22. First, perceived media pressure to be thin is correlated with increased weight- and body-dissatisfaction (Cusumano &
Thompson, 2000; Van den Bulck, 2000). Second, this experience of
pressure involves exposure to, and internalization of, the slender
ideal, which in turn increases the probability of various eating and
emotional problems (Blowers, Loxton, Grady-Flesser, Occhipinti,
& Dawe, 2003; Cusumano & Thompson, 1997; Thompson & Stice,
2001; Thompson et al., 2004). Third, in support of these correlationbased findings, level of thin-ideal internalization has consistently
been identified in experimental studies as a moderator of media effects. In fact, several studies found that only “high internalizers”
experience heightened body dissatisfaction after exposure to thin
media models (Dittmar & Howard, 2004; Halliwell & Dittmar, 2004;
Heinberg & Thompson, 1995).
The medium to large effect sizes for the cross-sectional correlation
of internalization of the media-based thin ideal and negative body
image seen in the Smolak et al. (2001) and Knauss et al. (2007) studies appear to be representative of a general trend. Cafri, Yamamiya,
Brannick, and Thompson’s (2005) meta-analysis of 31 effect sizes
from 18 studies found an r of .50 (d = 1.15) for thin ideal internalization and negative body image, which was significantly greater than
the r of .29 (d = .61, based on 25 effect sizes) for awareness of the
thin ideal. Although it is based on only 7 effects from 6 studies, the
composite effect size for the relationship between pressures experienced from the media and body image was nearly the size of that
for internalization, r = .48 (d = 1.09).
Longitudinal Studies. It is difficult to evaluate the status of evidence
from longitudinal studies of internalization of the media-based thin
ideal. The Cafri et al. (2005) meta-analysis included only crosssectional studies, citing a paucity of longitudinal research with the
SATAQ. Stice’s own measure of “ideal body internalization,” while
30LEVINE AND MURNEN
reliable and valid, is not directly connected to media ideals, and its
items load on the SATAQ awareness factor, not the internalization
factor (Thompson et al., 2004).
With those caveats in mind, Stice’s (2002) meta-analysis of 8 longitudinal studies (including 6 of his own) found that, over follow-up
periods of 9 months to 5 years, thin-ideal internalization did predict
increases in body dissatisfaction, dieting, and bulimic pathology.
For example, Stice and colleagues have found that both internalization of the slender beauty ideal and perceived pressure to be thin
(emanating from family, friends, dating partners, and media) predicted significant, short-term increases in body dissatisfaction in
girls ages 14 to 17. These factors were also concurrently associated
with body dissatisfaction, which in turn predicted increases in dieting and negative affect (Stice, 2001; Stice & Whitenton, 2002; but see
Bearman, Presnell, Martinez, & Stice, 2006).
Conclusion
Several other longitudinal studies by Stice and colleagues (see, also,
e.g., McCabe & Ricciardelli, 2005) cast some doubt on the causal
role of mass media. For example, Stice (1998) found that neither perceived pressure from media nor observational learning of unhealthy
weight-shape concerns played a role in the onset of bulimic symptoms in adolescents and young adults. Nevertheless, Stice’s (2002)
own meta-analysis of longitudinal studies and the meta-analysis
of cross-sectional studies by Cafri et al. (2005) collectively provide
evidence consistent with Criterion 7. More longitudinal research is
needed, but it appears that, in support of media as a causal risk factor, the following are consistent predictors of negative body image
and, to some extent, disordered eating: awareness of the importance
of the thin ideal in society; internalization of that ideal; and perceived pressure from the media to be thin.
Presumed Influences on Others
In thinking about the subjective experiences of media pressures
and influences, it is worth examining more closely the construct of
“awareness” of the thin ideal. The perception that peers and people
31
in general (e.g., employers) are influenced by thin-ideal media can
itself be a form of subjective pressure that motivates young people
to diet in an attempt to meet that ideal (Milkie, 1999). In fact, it appears that the mere presumption of media effects on others may
exert its own effect, at least on older females. Park’s (2005) path analytic study of over 400 undergraduates found that the more issues
of beauty and fashion magazines a young woman reads per month,
the greater the perceived prevalence of the thin ideal in those magazines. The greater this perceived prevalence, the greater the presumed influence of that ideal on other women; and in turn the greater the perceived influence on self, which predicted the desire to be
thin. More research of this type with younger samples is needed to
test this “cultivation of perceived social norms” hypothesis: Greater
consumption of beauty and fashion magazines or of appearance-focused TV and internet content will foster stronger, more influential
beliefs that the slender ideal is ubiquitous and normative for peers.
This logic will, in turn, be a source of pressure and inspiration for
the person’s own desire to be thin(ner).
Conclusions and Recommendations
Are Mass Media a Causal Risk Factor?
Based on the weight of the empirical evidence in relation to criteria
1, 2, 5, and 7, a defensible conclusion is that the content, use, and
experience of mass media—in and of themselves, and in the context
of synergistic messages from peers, parents, and coaches—renders
them a possible causal risk factor. Further, although the strength
of the relationship is relatively weak to modest, the extent of exposure to mass media in general and to thinness-depicting media
(Harrison & Cantor, 1997) in particular is correlated concurrently
and prospectively with negative body image and disordered eating (criteria 3 and 4). In fact, because the hypothesized paths of influence between media exposure (engagement) and the outcomes
of interest are mediated and moderated by several variables, we
should probably expect effect sizes that are modest at best. Stronger
evidence (criterion 5) for a causal relationship between mass media,
negative body image, and disordered eating comes from the extensive experimental literature (Grabe et al., 2008; Groesz et al., 2002).
32LEVINE AND MURNEN
And, yet, in light of the important research by Tiggemann (2006)
and by Field et al. (1999, 2001, 2008) there remains a need to demonstrate more conclusively that either (1) direct engagement with
mass media or (2) media effects that are mediated by parents and/
or peers precede development of the more proximal risk factors such
as negative body image (criterion 4). Similarly, despite the preliminary but encouraging evidence from media literacy interventions of
varying intensities, to date no studies have tested the deceptively
simple proposition (see criterion 6) that prevention programs can
increase media literacy and thereby reduce or eliminate negative
media influences—and in turn reduce or delay development of
proximal risk factors (e.g., internalization of the thin ideal, social
comparison tendencies) and attendant outcomes such as EDNOS.
In sum, of the 7 criteria, there is strong evidence for Criteria 1, 2, 5,
and 7, and solid evidence for Criterion 3. However, the evidence for
two of the most important criteria—4 (factor precedes and predicts)
and 6 (reducing the risk factor prevents the disorder)—is encouraging but complicated, preliminary, and inconclusive. Consequently,
engagement with mass media is probably best considered a variable risk
factor that might well be later shown to be a causal risk factor (Kraemer
et al., 1997; Stice, 2002).
What We Need to Know But Don’t Know Yet
This review suggests five principal gaps in our knowledge about
mass media as a potential causal risk factor for the spectrum of
disordered eating. The first three are derived from the conclusion
immediately above. First, there is a need for longitudinal research
(see, e.g., Tiggemann, 2006) that examines the predictive validity
of media exposure, motives for media use, and the subjective experience of media influences. Second, as noted by an anonymous
reviewer of this manuscript, there remains a dearth of information
about whether it is the thinness-depicting aspects of magazine, TV,
and other media content that exert negative effects. Thus, surveybased longitudinal investigations of media exposure should strive
to determine as precisely as possible not only frequency and intensity of consumption, but also the nature of the images, articles, programs, and such to which participants are exposed (again, see, e.g.,
Tiggemann, 2006). Third, there is a need for prevention research
33
that capitalizes on and extends the promising findings of extended
media literacy interventions.
The fourth research direction concerns the relationship, particularly from a developmental perspective (Smolak & Levine, 1994,
1996; see also Levine et al., 1994), between engagement with mass
media and other causal risk factors. We need to learn much more
about the ways in which body image disturbance and disordered
eating are influenced by perceived social norms (Park, 2005), by the
confluence of media, family, and peer messages about weight and
shape (Levine et al., 1994; Peterson, Paulson, & Williams, 2007), and
by indirect media exposure, such as acquisition of body ideals and
eating behaviors via interactions with family, peers, and significant
adults (e.g., coaches) who learned them directly from television and
magazines (Clark & Tiggemann, 2006; Harrison & Hefner, 2006;
Krayer, Ingledew, & Iphofen, 2007). Direct media effects may be
small to modest (Groesz et al., 2002; Murnen et al., 2007), but the
combination of direct and indirect effects, that is, the cumulative
media effect, may be substantial (Harrison & Hefner, 2006; Levine
et al., 1994).
Finally, the transactions between the developing child (or adolescent) and media constitute another set of important research questions to address. A cross-sectional study by Gralen, Levine, Smolak,
and Murnen (1990) indicated that the correlates of negative body
image and disordered eating in young adolescents tended to be
more concrete and behavioral (e.g., onset of dating, pubertal development, teasing about weight and shape), whereas the predictors
in middle to later adolescence were more psychological, such as
the experience of a discrepancy between perception of one’s own
shape versus an internalized ideal shape. More recently, a longitudinal study by Harrison (2000) found that the number of hours that
children ages 6 through 8 watched television per week predicted
an increase in disordered eating without predicting idealization of
a slender body. This raises the interesting and testable proposition
that exposure to various salient media messages, including those
contained in the onslaught of advertisements for diet-, fitness-, and
weight-related products, might have little effect on the “thinness
beliefs” of young children, while leading them to vilify fat, glamorize dieting as a grown-up practice, and yet still think of fattening, non-nutritious foods as desirable in general and useful for as-
34LEVINE AND MURNEN
suaging negative feelings (Harrison, 2000; Harrison & Hefner, 2006;
Levine & Harrison, in press).
With respect to the transformation of relevant psychological processes over late childhood, early adolescence, and later adolescence,
Thompson and colleagues have developed and validated various
features of the Tripartite Model in which media, family, and peers
influence directly internalization of the slender beauty ideal and
social comparison processes (Keery, van den Berg, & Thompson,
2004; Thompson et al., 1999; van den Berg et al., 2007). This valuable
model reminds us that, after nearly 25 years of research on media
and body image, we still know relatively little about the automatic,
intentional, and motivational processes involved in the role of social comparison in media effects (Halliwell & Dittmar, 2005; Levine
& Harrison, 2004; Trampe, Stapel, & Siero, 2007). Basic questions
remain: What dispositional and situational factors determine when
people will make upward social comparisons with highly dissimilar fashion models whose “image” has been constructed by cosmetic surgeons, photographers, and computer experts? And under
what circumstances will such comparisons result in negative effects
(contrast) or positive effects (assimilation)?
Multidimensional models such as Thompson’s also emphasize
the need to determine when and how in the developmental process
a number of important mechanisms such as appearance schematicity, thin-ideal internalization, social comparison processes, and selfobjectification begin to play key roles (see also Tiggemann, 2006).
Further experimental and longitudinal studies of these mediators
will be a very positive step toward understanding the emergence,
particularly around puberty, of attentiveness and vulnerability to
thin-ideal media images and to the many other potentially negative
influences that emanate from family, peers, and influential adults
such as coaches (Smolak & Levine, 1996; Thompson et al., 1999).
How Can We Go About Learning
What We Need to Know?
Since the publication of our earlier reviews (see, e.g., Groesz et al.,
2002; Levine & Harrison, 2004; Levine & Smolak, 1996), there has
been an exciting, if daunting, upsurge in studies of the role of various media in the development of negative body image, weight and
35
TABLE 2. Important Methodological Issues in the Improvement of Media Effects Research
• Articulation, in text and with visual figures, of the model demonstrating how mass media
influences mediators and outcomes, and how mass media is influenced by moderators such
as family and peer factors
• Attention to validity of constructs such as media exposure and state body dissatisfaction
• Careful consideration of demand characteristics in regard to use of pre-post designs to
investigate phenomena (e.g., impact of pictures of the slender beauty ideal) that are wellknown to participants
• Development of control conditions to rule out confounds, such as that between the slenderness (or muscularity) of a model in an advertisement and the model’s perceived attractiveness
• In investigations of media literacy-as-prevention, careful measurement of the chain of
mediators (was literacy increased? Was internalization of the thin ideal reduced?) and
arrangement for long-term follow-up to determine if onset of target problems was indeed
prevented.
• Precise description, in the Method section, of how ethical issues were addressed, notably
the risks posed by (1) experiments that present vulnerable people with images known to
have negative effects; (2) the deceptions that are often necessary to address threats to internal validity; and (3) the desirability paradox recently identified in connection with media
literacy training (Austin, Pinkleton, & Funabiki, 2007)
shape management, and disordered eating (see Grabe et al., 2008).
This dramatic growth has brought with it a number of important
improvements in attention to methodology. We encourage researchers to continue to follow the lead of research programs such as those
of (in alphabetical order) Dittmar and Halliwell, Durkin and Paxton, Hargreaves and Tiggemann, Harrison, Mills, Neumark-Sztainer, Stice, and Thompson in paying careful attention to the methodological issues listed in Table 2. Stronger methodology, in connection with clearly articulated theories and well-developed, practical
interventions is critically important for clarifying whether mass media are in fact a causal risk for the spectrum of disordered eating.
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