**4. Genetics**

There are many ways that genetics can play a role in the perception of external and internal beauty in individuals with eating disorders, especially anorexia nervosa. One aspect relates to the genes that determine body shape and size. I have worked with young adolescent girls who were caught up in very negative dieting and other weight control behaviors as they struggled against the set-point of their bodies. Looking at their parents, it was clear that they had genes that kept them shorter and heavier than they desired. While they would acknowledge that they couldn't control or affect their height, they believed that their weight could be manipulated and controlled. This is a belief that most people seem to share. There is truth in this up to a point. If we eat more calories than we burn, we will gain weight. However, we each have certain physical characteristics that are determined by our genes. Some individuals will be taller or shorter, thinner or heavier, large bosomed or have a smaller chest size. One challenge is that much of Western society is weight-biased and so the messages that are given to individuals affects their ability to see their larger body as beautiful. When weight bias is internalized, it can lead to a lower quality of life, such as lower self-esteem. [16] This then affects individuals' "inner beauty" as they feel less positive about themselves.

Genetics also affects temperament and can influence how individuals feel about themselves. Individuals with restrictive eating patterns and a low body mass index demonstrated a repressed form of narcissism, such that they put others' needs before their own. [17] This is important to consider. How can one recognize her own value, self-worth and thereby inner beauty, if she is always sacrificing her needs to the needs of others? This brings us back to the earlier observation about the groups that I ran when I asked individuals what they liked about themselves. They often have a hard time identifying anything positive.

#### **5. Influence of family**

Family interactions can perpetuate eating disorder behaviors and negative attitudes towards oneself, especially related to negative comments offered by other family members. Family has the most powerful influence on values and norms related to appearance. [18] Clinically, I have seen many times how a mother's focus on her body dissatisfaction influences a daughter's body image dissatisfaction. One young woman was struggling to recover from severe anorexia nervosa and had to deal with her mother constantly asking if certain clothes made her (the mother) look fat or the mother would quiz the daughter about the number of calories in a certain food because she knew her daughter had all of that information present in her mind. It was hard for my patient to disengage from her eating disorder or not worry about her body image when she was constantly fielding these questions from her mother.

While modelling behavior can influence individuals' body image and body dissatisfaction, evidence suggests that parental comments and active encouragement to diet can have an even greater influence on their child's body concerns and eating behaviors. [19] Types of comments can vary with mothers focusing on health but dads and siblings making more negative comments and participating in teasing. [20] Positive feedback can improve self-esteem of individuals with eating disorders. [21] This is important for providers to remember because often our patients are attuned to negative feedback. We need to ensure that we approach them with an encouraging attitude. Too many times, clinicians do not consider the impact that

their words will have on their patients. I have worked with clients who started down the road of an eating disorder because they were pushed to diet by a physician. We need to remember to focus on health and recognize that health can come at different sizes. Often physicians parrot the weight bias that is present in Westernized society. We need to work with families where individuals have been on the receiving end of negative comments and teasing and encourage the families to make a shift to neutral or positive comments. This can be hard but needs to be practiced. The family—especially parents—need to understand the negative effect that their comments can have on their child's self-esteem. [22]

## **6. Influence of peers**

Many clients that I see in the eating disorders clinic describe weight-related teasing prior to the development of their eating disorder. The literature does support the fact that weight-related comments lead to body dissatisfaction and negative weight control behaviors. One study looked at the long-term effect of weight related bullying and examined whether there was a difference if the bullying occurred in the family or from peers. The authors followed a group of adolescents for 15 years and found that weight-based teasing in adolescence was associated with negative weight control actions even as adults. This included eating as a coping strategy, more body dissatisfaction, higher BMI and obesity risk. [23] Within this study, the authors found that the source of teasing (whether family or peers) had the same negative effect on girls but peer teasing had an increased effect on boys. [23] They were not certain whether girls were subject to more weight-related teasing than boys within their families or whether sensitivity to societal expectations related to weight and body image made girls more susceptible to the effects of teasing. Within their study, teasing also occurred irrespective of whether the individuals were overweight, obese or even underweight. In [24], the authors found that overweight or obese children who experienced teasing by their peers struggled with more depressive symptoms and also participated in more unhealthy weight control behaviors as a result of this teasing. It is clear that weight-related teasing by peers can have significant and long-lasting effects on individuals.

Another factor related to peers is that individuals with eating disorders often interpret ambiguous social interactions negatively. For example, when girls were asked to interpret social vignettes, those in the eating disorder group tended to attribute more hostile intent. For example, when given the situation that your best friend didn't invite you to their birthday party, the control group made the assumption that the friend, of course, expected her to come and advocated for checking out the issue by talking with the friend. Individuals with eating disorders, on the other hand, rarely picked the option of talking to the friend and made negative assumptions of the situation—that the friend had only been pretending to like her. [25] These social situations would often propel the patient group to consider using eating disorder behaviors rather than trying active ways to evaluate their negative assumptions. These concerns led to more anxiety in social situations and potentially more isolation from peers. To deal with these feelings of rejection, individuals often turn to eating disorder behaviors. This influences their sense of self and their self-esteem. Often they feel that the only thing that they have in their life that can consistently make them feel better is their eating disorder.

When considering self-esteem, we need to consider how it develops. Contingent self-esteem describes the relationship between receiving social approval and positive perception of oneself. Essentially one's self-esteem and positive feeling about oneself is dependent upon other's positive views of him/her and their approval.

*Do Individuals with Eating Disorders See Their Own External and/or Internal Beauty? DOI: http://dx.doi.org/10.5772/intechopen.97508*

This can lead to great concerns about one's weight, which can then influence body surveillance, body dissatisfaction, lower self-esteem and eating disorder behaviors. [26, 27] We need to consider how we help individuals develop their own positive self-assessment rather than always looking for social approval. That does not mean that we want people to not care at all or to try and alienate others. It does mean, though, that we have to help them recognize that we can't please everyone and that we need to feel okay about ourselves even if we meet with rejection in some social settings. In a recent session, a young woman, who suffers from an eating disorder, was struggling with how to handle her thoughts that others were always criticizing her or noticing if she gained a few pounds. She describes that she tried to handle her self-criticism by thinking why wouldn't everyone want to date her. This is a fallacy as well. We need to recognize black and white thinking and the potential sticky beliefs we can get trapped in. Just as not everyone is rejecting her because of her "perceived" flaws; she shouldn't expect everyone to overly accept her. The corollary from that would be that if someone rejects her then it is based on some aspect of her, rather than just the idea that we aren't going to mesh with everyone. I asked her if she wanted to date everyone. She doesn't. There are great people out there that for different reasons, we don't want to develop relationships with them. That does not mean that there is anything wrong with them or with us.

### **7. Other influences**

#### **7.1 Teachers, coaches and school policies**

Many others can influence how an individual perceives him/herself. In schools, more extensive weight-related teasing leads to lower self-esteem and greater body dissatisfaction in girls. [28] We need to establish safety for individuals in families and schools so that they aren't continually subjected to negative comments. That means ensuring that teachers, nurses, administrators and coaches, for example, not only monitor their own comments and ensure that they are not making weightbased comments, but also ensure that weight-based bullying is squashed. Often weight-related teasing is not included in anti-bullying policy initiatives. [29] Yet it is an important challenge. There are ways that schools are possibly perpetuating weight focus and negative weight related behaviors. While one study suggested that weight-based teasing did not increase in schools even after introduction of obesity policies, such as measuring BMI and removing vending machines from schools, the teasing still stayed at 14% for overweight to obese children. [30] Since weight-based teasing can lead to negative health behaviors that can extend even into adulthood, it is clear that we need to continue to assess the effects of any interventions. Others studies have suggested that BMI measurements in schools can potentially lead to more eating disorder behaviors, especially if not handled correctly. [31] The authors point out that the CDC did not find enough evidence to recommend BMI report cards from schools. The challenge is that BMI is one number that if reported to parents can lead to a focus on weight and dieting. A higher BMI, though, could be related to a number of situations—an impending growth spurt or increased musculature from sporting activities. If families receive information about the BMI without guidance about what it means, more unhealthy weight control behaviors could occur, which can ultimately lead to more eating disorders or future obesity. [32] One thing to consider if we are working to try and improve overall health is whether eating disorder screening should occur in schools. In [33], we find that almost 15% of girls and 4% of boys score as having a possible eating disorder using the EAT-26. Since eating disorders have the highest mortality of any psychiatric

disorders, strategies for early assessment and intervention would be useful. The SCOFF questionnaire has been suggested as a tool that could be used by school nurses to help identify children at risk for eating disorders. [34] As schools work to improve overall health and address concerns related to weight, this might be one assessment that should be implemented. With the current pandemic, the need for mental health assessment and interventions is being identified as being even more important. [35] It is incumbent on those in position of power/influence to consider the effect of their attitudes and words. Coaches can impact their athletes' view of their bodies and either inadvertently or on purpose push athletes towards negative weight control behaviors. The authors in [36] describe not only comments made to them that indicated the views and assessments of their bodies by coaches and those in power but also the objectification by others. I have worked with many young women who were encouraged to lose weight so they could be more competitive, could run faster, would look better, etc. Mary Cain in a NYTimes editorial described how she was influenced by her coaches to get thinner and thinner until her body broke down. [37] One study found that while coaches did have an understanding of eating disorders, they, at times, didn't understand the significance of some symptoms, such as amenorrhea. [38] The authors also found that coaches preferred to talk with teammates if they had a concern about an athlete rather than turning to specialists in the field of eating disorders. [38] It will be important to ensure that coaches are familiar with aspects of eating disorders and recognize the need to get athletes the care that they need.

### **7.2 Media**

The effect of television and Westernization has been established through many studies. When television was introduced to Fiji, body image dissatisfaction and disordered eating behaviors increased. [39] This was replicated in Bhutan, which was the last country exposed to television. When this occurred, it led to a subsequent pressure to get thinner, look thinner and regulate one's appearance based on media images rather than compared to one's peer group. [40] Media has a strong influence, not only on distorted perceptions and expectations, but on how role models are perceived. Intense celebrity worship by young teens can have a negative influence on their body image. [18, 41] It isn't clear which comes first—does obsession with a celebrity lead to poor body image or do individuals with poor body image gravitate towards celebrity fixation. Interestingly one study looked at body dissatisfaction, restrained eating and compared congenitally blind women, acquired blind women and sighted women. They found that these issues increased related to the extent of visual media exposure so that congenitally blind women had overall better body image because they had not been faced with the media's distorted expectations. [42] In the tools, we will discuss the importance of media literacy which can help with body dissatisfaction. One program, ARMED, which offered a two session media literacy course demonstrated that 8 weeks after participating in the course, women who were at high risk for developing an eating disorder had less body dissatisfaction. A change was not noted for women at low risk for developing an eating disorder but they may be less influenced in their sense of self and their body image as compared to those at higher risk. [43]

#### **7.3 Objectification**

"Objectification theory posits that girls and women are typically acculturated to internalize an observer's perspective as a primary view of their physical selves." ([44], p.173) This can lead to habitual body monitoring, which increases shame

#### *Do Individuals with Eating Disorders See Their Own External and/or Internal Beauty? DOI: http://dx.doi.org/10.5772/intechopen.97508*

and anxiety for many women. Seeing oneself as an external viewer of one's body can also decrease awareness of internal body states. [44] We have seen that the connection with one's body and reliable interpretation of internal body states can be affected for individuals who struggle with eating disorders. They often monitor their bodies and perform numerous body checking activities to evaluate how they should be feeling about their body. I worked with one young woman who agreed to not weigh herself but turned instead to measuring and recording the size of many of her body parts—circumference of thighs, etc. As with the objectification theory—she was seeing herself as just the sum of her parts, which is how the authors discuss their theory. "The common thread running through all forms of sexual objectification is the experience of being treated as a body (or collection of body parts) valued predominantly for its use to (or consumption by) others." ([44], p. 174).

This objectification not only affects how they see and monitor their physical bodies but also how they function in their overall lives. "Again, though, the habitual self-conscious body monitoring that results from self-objectification might best be viewed as a strategy many women develop to help determine how other people will treat them, which has clear implications for their quality of life." ([44], p. 180) Because they recognize that they are being objectified by others, they constantly need to scan themselves to assess how they will be perceived. Rather than being in the moment and living their lives, they are viewing and measuring themselves. It has also been demonstrated that women do not have to be personally targeted to experience the negative effects of objectification. [5] One mediating factor appeared to be that when individuals feel part of a group, they can experience less negative self-esteem stemming from sexism. [45] Feeling part of a group can be a larger challenge for individuals struggling with eating disorders. As we discussed earlier, they may have more negative evaluations of interpersonal interactions, which can leaving them feeling not a part of a group and turning more to their eating disorder. [25] This can affect this described mediating factor.

This objectification can be even more difficult for young girls as they progress through puberty. "Far beyond the idea that adolescent girls simply do not like the size and shape of their maturing body, girls learn that this new body belongs less to them and more to others." ([44], p. 193) For many of my patients, going through puberty led to increased negative feelings about themselves. If they went through puberty earlier than others, they were often targeted for comments and felt selfconscious because their bodies looked different than others who were the same age. One patient described that when she went through puberty, her family made fun of her changing body—often it was her brothers but her parents did not intervene and on occasion, her father made comments. Now it is hard for her to gain weight; it is hard for her to develop curves or breasts. Others have commented about similar situations. After hearing her brother and father comment consistently on women's breasts, a young woman feels very ambivalent and self-conscious about gaining weight and developing the same physical attributes that garnered so much attention from the men in her life.

#### **7.4 Trauma**

Trauma can affect an individual and her sense of beauty and herself. It can be associated with disordered eating; this is often because of negative emotions and thoughts. [46] I have certainly worked with individuals who blamed themselves for the attacks. This led to not only negative feelings but also the use of disordered eating to try and gain back a sense of control or to numb the negative feelings related to the trauma. The authors [46] also see these effects of trauma. Disordered eating can be a way to avoid unwanted attention and the individual may feel this is a way to keep them safe. [46] One woman whom I worked with had recovered from her eating disorder but was then a victim of a sexual assault. She began her pattern of restricting again. She described to me that if she was assaulted when she looked "healthy" and had curves, she needed to make sure she didn't have that happen again. Others have described working to disappear. There is often an ambivalence should I be thinner/smaller so that I am not noticed or since thinness is often associated with sexual objectification, will that draw more attention? It can put women in conflicted and negative associations with their bodies.

Emotional abuse contributes to negative self-perception, which then can contribute to disordered eating, including night eating syndrome and binge eating disorder. [47] One study found that adolescent girls who were exposed to traumatic life events or who had to navigate difficult family situations were at an elevated risk of becoming obese and in engaging in unhealthy weight control behaviors. [48] One study found that patients with bulimia were more likely to have a history of trauma as compared to other eating disorder diagnosis [49] What is even more significant from this study is that almost 35% of the adolescents being treated for eating disorders had a history of trauma. [49] A systematic review demonstrated an association between adverse life experiences and obesity and binge eating disorder. [50] Adults who have experienced one adverse childhood experience (ACE) were likely to have suffered multiple other adverse experiences during childhood. [51] This is important because ACES appear to have a cumulative effect such that as the number of events increases so does the effect on mental health. [52] It seems fairly obvious how abuse can undermine an individual's perception of herself. This can lead to the use of food or disordered eating to try and control negative emotions. It can also influence acceptance of self and recognition of both external and internal positive qualities. I have worked with fabulous young women who do not seem to recognize any of their positive attributes because of being criticized and belittled by other's in their lives—often family members. When working with clients with disordered eating, it is helpful to assess their perception of themselves and any history of emotional or other types of abuse.

## **8. Tools to help**

	- Consider your body's needs and rhythms. If someone was going to move into your body for the day, what important information would they need to know about it? What guidelines would you need to provide related to rest, feeding, watering, light/outdoors, physical activity, touching, soothing, healing--what keeps it functioning well?
	- A letter From Your Body to Yourself. Our bodies hear everything we think/ say about ourselves…if it could write a letter to you, what would it say?
	- List three women/men you would like to be for a day and explain why it would be a great experience to be them. She finds that usually patients

include individuals based on positives in their stories or their accomplishments and not often focused on appearance.


are having negative or critical thoughts about themselves. Sometimes this can occur so routinely that they don't even stop to examine their thoughts or they believe that everyone harbors this internal self-criticism. It is important to clarify the patients' thoughts and work to help them recognize them and challenge them. Is there another way to reframe the thought? For example, if someone is critical of themselves because of past abuse, can they instead view their resilience as a strength? Are there better ways to frame things—if they describe themselves as "stupid" because they didn't do well on an exam, can you help them put this in a reasonable context? We all make mistakes or can fail at something but that does not make us total failures. Are they overgeneralizing? Are they turning one small setback into a catastrophe? One tool that I find helpful when faced with patients who harbor negative thoughts or self-criticism is to ask them if they would tell those same comments to a friend or family member. Typically they would not. The question then is why they feel that they should tell it to themselves. This can help them start to recognize when an interior monologue is helpful or when it is perpetuating a negative cycle.


#### *Do Individuals with Eating Disorders See Their Own External and/or Internal Beauty? DOI: http://dx.doi.org/10.5772/intechopen.97508*

photo-shopping. It reminds us that the expectations that we are comparing ourselves to are not realistic. Can this have an impact? Yes, it can. When presented to a group of young women who watched music videos, it was demonstrated that this simulated commercial break had the potential to disrupt the detrimental effects of social comparisons with the idealized models. [62] All young women should understand that when they encounter the media, they are comparing themselves to manipulated and often unobtainable images.


who are struggling with trying to navigate middle school and high school. The desire for social approval in light of shifting alliances and bullying make it challenging for everyone but in particular those individuals who link their sense of self-worth to the approval of others. If we can provide tools to help our adolescents navigate these unsettling years, it can help improve self-confidence and positive coping strategies. *Expand Your Horizon* is a program than can help focus on body functionality, which we have discussed can improve body appreciation and decrease disordered eating. [70]

