**1. Introduction**

84 New Insights into the Prevention and Treatment of Bulimia Nervosa

Ware, J. E., Kosinski, M., Keller, S. D. (1996) A 12-item short-form health survey. *Medical* 

Whitehouse, A. M., Cooper, P. J., Vize, C. V., Hill, C., & Vogel, L. (1992). Prevalence of eating

morbidity. *British Journal of General Practice,* Vol 42, pp. 57-60.

disorders in three Cambridge general practices: Hidden and conspicuous

*Care* Vol 34, pp. 220-233.

Bulimia nervosa is an eating disorder that affects young people and causes serious damage to life quality and death in extreme cases (Affenito & Kerstetter, 1999; Cordás, 2004; Costa et al., 2008; Gucciardi et al., 2004). Since most people with the disorder have normal weight, the diagnosis of bulimia nervosa becomes a highly complex issue (Kaufman, 2000).

The etiology of bulimia nervosa has yet to be understood. However, low self-esteem, depression, social pressure on keeping oneself slim and a dissatisfaction with the body shape are factors that may be associated with the bulimia nervosa event, especially in the case of adolescents and female young adults (Affenito & Kerstetter, 1999; Alvarez-Rayon et al., 2009; Costa et al., 2008; Crosby et al., 2009; Gucciardi et al., 2004; Jauregui-Lobera et al., 2008; Thompson & Chad, 2000).

Excessive concern with weight gaining is not the only criterion for a diagnosis of bulimia nervosa. Nevertheless, adolescents with such concern have a seven-fold chance in developing some type of eating disorder (Grillo & Silva, 2004).

The fact that many young people are not satisfied with their own body shape may be an effect of pre-conceived ideas on idealized body images taken from aesthetic values transmitted by society or by the social media (Andrade & Bosi, 2003; Reato et al., 2000; Reato, 2002). The female adolescent finds herself in conflict between a fantasy-created image and her real body shape. From her perspective, there is a great difference between what is observed and what is desired. This event may lead towards dissatisfaction and low selfesteem which induces the development of eating disorders such as bulimia nervosa (Andrade & Bosi, 2003; Mond et al., 2004; Reato, 2002; Silva et al., 2003).

Many authors agree that the most prevalent aspect of female dissatisfaction occurs in issues referring to weight and appearance. Many women, including those with normal weight or even slim ones, have the impression that they are overweight or even obese. This is the reason why their body image distortion mainly affects female adolescent and young adult females (Alvarez-Rayon et al., 2009; Cordas, 2004; Costa et al.*,* 2008; Mond et al., 2004; Nunes et al., 2001).

Studies related to adolescent's psychological and eating behaviour alterations are important for the determination of factors involved in the development of eating disorders in young populations. The use of self-evaluation scales is an asset in the detection of possible eating disorders or of sub-clinic individuals (Kjelsas et al., 2004; Wichstrom, 1995).

Bulimia Nervosa and Dissatisfaction of Adolescent's Body Shape 87

advertisements featuring slim females became abundant. In fact, several massage methods were introduced to delete excesses in rounded profiles. It was during this period that a relationship between age, weight and height was established even though hard and fast

The end of the First World War brought about the female's plain and free shapes which displaced the erstwhile curve ideals. Women's wear of the 1920s abandoned the curvy outlines and corsets. Bodices were set aside. Since women started to support their breasts with vests that flattened their profile, during this period beauty was almost characterized by the absence of secondary female sexual traits. The female profile had an extended shape,

Fashion magazines of the 1920s demonstrated an association between professional life style and beauty care. Swimming became more frequent and dynamic moving half-naked bodies were exposed for anyone to look at and appreciate. Such a condition had an important influence on the concept of beauty since beauty became synonymous to a slim and muscular body with elegant and graceful movements. As a consequence, women started to maintain strict diets and extenuating physical exercises to decrease their body mass (Castilho, 2001;

In the wake of such a deep concern for weight loss the 1926 *New York Times* advertised that the New York Science Academy was calling a two-day conference to study "the explosion of food disturbances". Table 1 shows a 10-year historical series in which the ideal weight of women, height 1.60m, was suggested. The table below reveals the loss of weight trend

Table 1. Description of the ideal weight for women, height 1.60 m, at the beginning of the

Table 2 shows some measurements that the female figure, height 1.60 m, was expected to have in the 1930s, as described in the magazines *Votre Beauté* and *Marie Claire*. A trend had been introduced so that rates became smaller and smaller, corroborating the suggestion of progressive slimness (Vigarello, 2006). Progressive slimness of the female body throughout the ages may also be deduced from requirements on the agenda of Miss America Contest. In 1921 the Body Mass Index (BMI) of most of the candidates was 21.2 whereas in 1940 it decreased to 19.5. Specialized magazines exhibited the perfect body profile of film stars, and female editors were vying in giving counsels to the readers that all women may possess a

> 1938 (*Marie Claire*)

1939 (*Votre Beauté*)

legs were up for view and hairdressings were high (Castilho, 2001).

PERIOD BODY MASS January 1929 60.0 kg April 1932 54.0 kg August 1932 52.0 –53.0 kg May 1939 51.5 kg

> 1933 (*Votre Beauté*)

Table 2. Measurements of the female figure, height 1.60 m

Bosom 83 cm 85 cm 81 cm Hips 87 cm 85 cm 75 cm Waist 65 cm 60 cm 58 cm

rules were inexistent (Vigarello, 2006).

according to the magazine *Votre Beauté*.

Vigarello, 2006).

20th century

Bulimia nervosa affects males and females, although the latter are more prone to the disease. This is due to the fact that women have more conflicts related to meals, weight and body shape. Conflicts indeed change the female adolescents' emotional state; in their turn, they present a distorted body image and low self-esteem (Affenito & Kerstetter, 1999; Gucciardi et al., 2004; Mond et al., 2004). Although many bulimic syndrome cases have been reported in young women under 18 years, the occurrence of such eating disorder is also on the increase in males (Affenito & Kerstetter, 1999; Alvarez-Rayon et al., 2009; Appolinário & Claudino, 2000; Costa et al., 2008; Gucciardi et al., 2004; Jauregui-Lobera et al., 2008; Kaufman, 2000).

Several authors report that patients with bulimic events are also highly concerned with weight gain. The patient is prone to use non-appropriate compensatory methods even twice a week. Self-evaluation of body image in these patients is greatly affected by societyidealized images of body shape and weight (Alvarez-Rayon et al., 2009; Cordás, 2004; Costa et al., 2008; Gucciardi et al., 2004; Jauregui-Lobera et al., 2008; Miranda, 2000; Pedrinola, 2002; Thompson & Chad, 2000).
