Body image as a global mental health concern

1APPEAR, Department of Applied Psychology, Northeastern University, Boston, Massachusetts, USA

2Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHRU Montpellier, Montpellier, France

1APPEAR, Department of Applied Psychology, Northeastern University, Boston, Massachusetts, USA

3NICTA, Body Image and Eating Disorders Research Group, Federal University of Juiz de Fora, Juiz de Fora, Brazil

3NICTA, Body Image and Eating Disorders Research Group, Federal University of Juiz de Fora, Juiz de Fora, Brazil

4AMBULIM, Eating Disorders Program, Institute of Psychiatry, University of São Paulo, São Paulo, Brazil

Body image concerns related to weight or other dimensions of appearance are now prevalent on a global scale. This paper reviews the theoretical frameworks that account for the global similarities and regional differences in rates and presentation of body image concerns, as well as reviewing the extant data. Given the harmful consequences of body image concerns in terms of mental and physical health, their global burden is high. Interventions to mitigate these concerns at the individual and systemic level are warranted.

Body image concerns include preoccupation and dissatisfaction with the body’s appearance including its shape and weight as well as other characteristics. Body image concerns are present across the globe due to strong pressures to pursue appearance ideals. Although these concerns may vary with cultural context, their prevalence and association with poor mental and physical health are global. Given these high rates and the negative effects of body image concerns, it is important to increase our efforts to prevent and decrease them across the globe.

Body image is a multidimensional construct encompassing the thoughts, feelings, and behaviors of an individual related to their own appearance (Cash, 2004). Body image is often conceptualized as including both an evaluative aspect (satisfaction or concern with appearance) and an evaluation of the centrality of body image to an individual’s identity (Jarry et al., 2019). Historically, much of the empirical research has focused on body image from a deficit lens, in particular as a risk factor for poor mental health and psychopathology including eating disorders and other mental health concerns. In addition, this work has been helpful in highlighting body image concerns as a mental health concern in its own right. Nevertheless, more recently increasing attention has been focused on body image through a positive psychology lens (Tylka and Wood-Barcalow, 2015) and the ways in which positive body image can be related to well-being. As part of this focus on positive body image, more attention has been paid to nonappearance dimensions of body image such as functionality and embodiment (Piran, 2019; Alleva and Tylka, 2021).

Much of the early literature in the area of body image, up until the new millennium, stemmed from English-speaking high-income countries. In recent years, this literature has been expanded to include work from a range of countries and geographic regions. The aim of this review is to offer a critical synthesis of the literature that exists on body image at a global level. First, prevailing theoretical frameworks that have guided this work will be reviewed. Second, the existing data regarding body image at a global level will be summarized. Finally, implications and future directions will be offered.

Several theories have been developed to usefully guide investigations into body image. These frameworks place important emphasis on the role of elements at different levels, ranging from theories focusing on macro-level elements such as social discourse and institution, and those centered on the role of individual-level factors. Here, dominant theories are presented in order of narrowing lens, from the macro- to individual level.

The acceleration of highly visual culture, facilitated by digital technologies in recent years, has exacerbated the extent to which the body’s appearance is a central source of capital for individuals worldwide (Bourdieu, 2018). Body capital consists of two distinct dimensions: (1) the amount of body capital held by an individual and (2) the extent to which individuals are encouraged to invest in their body as a source of capital. Both of these dimensions are related to the matrices of power and privilege that underpin the majority of contemporary societies in which certain bodies hold more social power than others. Thus, a body that is read as holding certain identities and that is closer to social beauty standards will hold more body capital. Conversely, individuals whose identities afford them lower power and privilege, such as Black and Indigenous People of Color, and those who live in larger bodies, are more strongly encouraged to invest in their appearance as a source of capital. This perspective is relevant when considering who within a certain group is thus more likely to experience their body as related to their experiences of oppression, while concurrently experiencing it as a modifiable source of potential capital (Edmonds, 2007; Hunter, 2011).

Sociocultural theories highlight how messages from broad social discourses, relayed by proximal sociocultural agents (such as the media or the interpersonal environment), influence individuals’ beliefs regarding appearance and thereby their body image. Thus, for example, social discourses regarding the moral value of pursuing an appearance that conforms to external standards, including in terms of weight, and that encourages individuals to discipline and self-monitor their bodies have been useful (Thompson et al., 1999; Fitzsimmons-Craft, 2011). In addition, these theories have made important contributions in highlighting the increasing demands placed on individuals in terms of appearance standards, the unrealistic nature of beauty ideals, as well as their progressive globalization (Widdows, 2018). While it is true that appearance ideals vary across cultures, as well as social identities including gender and sexual orientation, it is also the case that a globalized ideal that is slender, toned yet curvy for women and muscular and lean for men, and golden in skin tone is emerging (Widdows, 2018). These theories also highlight how these socially constructed appearance standards serve political and economic goals as their inherent unattainability generates large financial profits as individuals strive to pursue them, while their perpetuation of oppressive social hierarchies contributes to maintaining the existing systems of power and privilege (Hesse-Biber et al., 2006; Rodgers, 2022 as cited in Aimé, 2022). Empirical work grounded in these theories has been useful in identifying mechanisms through which sociocultural discourses and appearance ideals are internalized by individuals, and the role of appearance comparison in the development and maintenance of body image concerns (Shroff and Thompson, 2006; Rodgers et al., 2011; Schaefer et al., 2019).

Related to the idea of body capital, Westernization, urbanization, and rapid economic growth have been posited to be linked to increased body image concerns through intensifying media and advertising pressures, as well as competition for resources and social mobility (Becker, 2004; McLaren and Kuh, 2004; Gorrell et al., 2019). From this perspective, countries that are most affluent, as well as those that are undergoing the most rapid cultural and economic transitions, are likely to be those where the highest rates of body image concerns are found.

Critical feminist theories have been useful in identifying how gendered processes that serve economic and political goals of gender majorities, including the objectification of women and gender minorities, are related to body image (Peterson et al., 2008; Roberts et al., 2018). These theories emphasize how the gendered nature of body ideals and the social value attributed to appearance serve to further protect existing gender hierarchies. Thus, for example, socializing women to be invested in achieving an unrealistically slender and highly groomed appearance diverts energies and resources away from other (political and social) activities and continues to perpetuate systems in which women’s social worth is indexed to their appearance (Widdows, 2018; Piran, 2019). In addition, these theories have highlighted how the objectification of women in society, in particular through media images, leads to women internalizing the need to self-monitor one’s body, in the form of self-surveillance and self-objectification, and how these factors are also associated with poor body image (Fitzsimmons-Craft, 2011).

A third important group of theories has highlighted how individuals who hold minoritized identities may experience and fear appearance-based discrimination (Brewster et al., 2017; Veldhuis et al., 2017; Brewster et al., 2019). These experiences and the associated anxiety lead to negative affect, a recognized risk factor for body image concerns, as well as heightened preoccupation with appearance. In addition, individuals may engage in efforts to avoid discrimination and the associated anxiety by attempting to modify their appearance through behaviors that may be harmful in the long term, as well as avoiding situations in ways that may be impairing over time.

A comprehensive integrative model of minority stress and sociocultural theory was useful to better understand how minority stressors (heterosexist discrimination, sexual orientation concealment, and internalized homophobia) were related to sociocultural influences (sociocultural pressures, thin ideal, and muscular-ideal internalization) and body image concerns and related body change behaviors (Convertino et al., 2021).

The large majority of the available research has stemmed from high-income English-speaking countries such as the USA, Canada, the UK, and Australia (Holmqvist and Frisén, 2010). In such cultural contexts, strong adherence to unrealistically slender and muscular ideals is overall found, with little variation across high socioeconomic status sites (Swami et al., 2010). In such contexts, body image concerns are highly prevalent and tend to be greatest among individuals with minoritized identities including women, sexual and gender minorities, individuals living in larger bodies, and those from minoritized racial and ethnic backgrounds (Frederick et al., 2022). Appearance ideals that are gendered, heteronormative, ableist, ageist, and Eurocentric contribute to centering concerns around weight, muscularity, youth, fairness, and related characteristics across groups.

Research has suggested that levels of body image concerns in high-income English-speaking countries, particularly in the USA, are among the highest globally, with the exception of pockets of very affluent and Westernized areas, such as within Asia (Holmqvist and Frisén, 2010). It is also within such contexts that research focusing on positive body image has received the greatest attention (Halliwell, 2015), as well as research aiming to refine explanatory models of body image concerns that account for interindividual variations (Pachankis et al., 2020).

In the USA and in other English-speaking high-income countries, negative body image has been associated with eating disorders (Drummond, 2002; McLean and Paxton, 2019), as well as depression and postpartum depression (Brausch and Gutierrez, 2009; Silveira et al., 2015), and poor psychosocial functioning (Davison and McCabe, 2006). Effective interventions to decrease body image concerns have been developed, in particular those that increase understandings of the socially constructed nature of appearance ideals and decrease adherence to them (Marchand et al., 2011; Lewis-Smith et al., 2019). Notably, sometimes these interventions address eating disorders as the main outcome and body image as a risk factor (Marchand et al., 2011). However, these interventions need to be embedded more systematically into existing networks and systems, and efforts to decrease universal risk need to be increased (Bell et al., 2016).

Studies in European non-English-speaking countries have overall evidenced findings that are similar to those in high-income English-speaking countries, although overall rates of body image concerns tend to be lower than in the USA (Frederick et al., 2007; Holmqvist and Frisén, 2010). Within Europe, variations exist in terms of body image, for example, individuals from Belgium and Portugal have reported lower rates of body size satisfaction as compared to Norway and Denmark (Kvalem et al., 2020).

Latin countries such as Portugal and Spain tend to place more emphasis on appearance, which is accompanied by higher rates of cosmetic surgery and body image concerns (Stefanile et al., 2015). Consistent with the theories described previously, high rates of appearance investment and anxiety in Cyprus, as compared to other European countries, were interpreted as being related to the lower economic power of the area and recent rapid urbanization and change (Koutsantoni et al., 2020).

Among European samples, body image has been found to be associated with mental health concerns including internalizing symptoms (Ramos et al., 2019), eating disorder symptoms (Rodgers et al., 2011), and poor psychological functioning (Corry et al., 2009; Træen et al., 2016). Given the preliminary evidence for the burden of body image concerns in Europe, continuing to develop efforts toward prevention is critical (Barbosa, 2021).

Body image disturbances and physical appearance concerns are prevalent in most Latin American countries (McArthur et al., 2005; Silva et al., 2011; Forbes et al., 2012; Amaral and Ferreira, 2017; Swami et al., 2020: Bolívar-Suárez et al., 2021; León-Paucar et al., 2021). Research points to several sociocultural factors related to body image concerns in Latin American samples, such as pressure to achieve socially prescribed body ideals and the internalization of appearance ideals (Austin and Smith, 2008; Mellor et al., 2008; Forbes et al., 2012; de Carvalho et al., 2017; de Carvalho and Ferreira, 2020), unique pressures to meet unrealistic standards of beauty (Forbes et al., 2012; Gruber et al., 2022), thin-ideal awareness (Moreno-Domínguez et al., 2019), negative appearance-related messages from family members (Rivero et al., 2022), acculturative stress (Quiñones et al., 2022), and acculturation (Marquez and Benitez, 2021).

It is noteworthy that poor mental health has been associated with body image concerns in Latin American countries, including low self-esteem (Amaral and Ferreira, 2017; Bolívar-Suárez et al., 2021), depressive symptoms (Amaral and Ferreira, 2017; Delgado-Floody et al., 2021; León-Paucar et al., 2021), poor psychological well-being (Amaral and Ferreira, 2017; Lemes et al., 2018; Matias et al., 2020), mental health concerns (Pinheiro et al., 2007; Silva et al., 2011), and eating disorder symptoms (Compte et al., 2015; Amaral and Ferreira, 2017; de Carvalho et al., 2017; de Carvalho and Ferreira, 2020). Although effective interventions to decrease body image concerns have been developed for Latin Americans (Castillo et al., 2019; Almeida et al., 2021; Rutsztein et al., 2021; Resende et al., 2022), there is still a critical need to position body image as a priority in public mental health policies, and again several of these programs address body image as a risk factor within eating disorder prevention. This may be particularly challenging in Latin America countries, given difficulties faced in their operationalization, financing, and adaptation to sociocultural realities (Leiva-Peña et al., 2021).

Beauty ideals in Asia and South-East Asia have been described as centering around being small-bodied as well as a particular emphasis on facial features (Mellor et al., 2013) and skin tone (Prusaczyk and Choma, 2018). Asia is a very diverse area in terms of affluence and cultural groups, and unsurprisingly, these differences have been found to be associated with variations in body image concerns. Thus, for example, in highly Westernized and affluent parts of Asia, levels of body image concerns are among the highest in the world (e.g. Shih and Kubo, 2005; Jung et al., 2009).

As in other cultures, support has been found for the role of media influence in body image across Asian countries including in Singapore (Chang et al., 2019), Taiwan (Chang et al., 2013), Korea (You and Shin, 2020), Hong Kong and China (Rochelle and Hu, 2017), and Japan (Ando et al., 2021), as well as the role of the internalization of appearance ideals (Omori et al., 2017; Hsu et al., 2021). In addition, work has been accumulating from a positive body image perspective, suggesting that these constructs are relevant to these groups (Swami and Jaafar, 2012; Todd and Swami, 2020).

As documented in other cultural contexts, in Asian countries body image concerns have been associated with eating disorder symptoms (Yamamiya et al., 2008; Chisuwa and O’Dea, 2010; Kaewpradub et al., 2017), depression (Prusaczyk and Choma, 2018), and poorer quality of life (Santhira Shagar et al., 2021). In very recent years, prevention efforts have been extended to affluent and developing areas of Asia (Craddock et al., 2021; Danthinne et al., 2022; Garbett et al., 2022); however, more work is needed.

Body image concerns are present in the Middle East; however, much of the existing work has focused on women, with rare exceptions (Melki et al., 2015; Saghir and Hyland, 2017). A study among women from Bahrain, Egypt, Jordan, Oman, and Syria revealed that in each country 32–39% of women reported being dissatisfied with their body weight, and 17–22% reported a preference for the body shape of Western models (Musaiger, 2015). In another study among women from southwestern Saudi Arabia, 77% indicated a discrepancy between their actual, perceived, and ideal weights (Khalaf et al., 2015).

Similar to findings in other settings, urbanization has been associated with a preference for thinness (Jackson et al., 2003), and research has pointed to the role of sociocultural factors in body image concerns, including the role of media (Tayyem et al., 2016; Saghir and Hyland, 2017) and the internalization of appearance ideals (Melki et al., 2015; Zainal et al., 2020). Perhaps in this geographic area more than others, the role of cultural and religious values and behaviors has been explored, with findings suggesting that the relationships are complex and require further disentangling (Al-Mutawa et al., 2019; Sidi et al., 2020).

Again, as in other contexts, body image concerns have been associated with eating disorder symptoms in students from Iran (Naeimi et al., 2016) and with depression among students in Turkey (Tayfur and Evrensel, 2020). These findings suggest that here too, body image may be accompanied by significant mental health burden, and that tailoring and extending prevention efforts to these settings would be important.

While specific appearance ideals and body image concerns vary across contexts throughout Sub-Saharan Africa, traditional standards of beauty for women often reflect a preference for a larger body size and a fuller, curvier shape (Furnham and Baguma, 1994; Tovée et al., 2006; Naigaga et al., 2018). These traditional standards of attractiveness and beauty continue to exert influence on body image ideals today, with women and men at higher weights endorsing greater appearance satisfaction than those at lower weights (Otakpor and Ehimigbai, 2016; Tuoyire et al., 2018).

Consistent with this, cross-cultural work has supported that body image satisfaction, including as related to weight and muscularity, is higher among groups from African countries as compared to similarly aged groups from countries such as China, Indonesia, and Ecuador (Blum et al., 2021), and the UK (Thornborrow et al., 2020).

However, globalization has brought increasing pressures to achieve Eurocentric beauty ideals and a greater desire for smaller hips, larger buttocks, straight hair, lighter skin tones, and slimmer noses among African women (Balogun-Mwangi et al., under review; Eddy et al., 2007; Kaziga et al., 2021). Consistent with theories regarding the role of accelerating modernity, among women in South Africa, Cameroon, and Uganda, higher levels of desire for thinness and preference for smaller bodies have developed (Dapi et al., 2007; Prioreschi et al., 2017; Kaziga et al., 2021), as well as a preference for Eurocentric beauty ideals among women from Nigeria versus Kenya (Balogun-Mwangi et al., under review). Thus, appearance ideals may be changing in African countries and pressures to pursue mainstream globalized appearances may be increasing.

As predicted by sociocultural theories, these pressures, including pressures from social media, which represents a principal source of globalized appearance pressures, have been found to be associated with body size dissatisfaction (Michels and Amenyah, 2017), desire for a thinner body (Terhoeven et al., 2020), and poorer overall body image (Kaziga et al., 2021) in Ghana, Burkina Faso, and Uganda, respectively. Although multiple factors may be at play, increased exposure to Western (but not Zimbabwean) media was found to account for poorer body image among Zimbabwean women (Swami et al., 2012). The literature pertaining to body image among men in Africa is more scarce. Nevertheless, emerging research has suggested that while dissatisfaction with muscularity may be present in men, rates are lower than in other cultural contexts such as the USA (Frederick et al., 2007).

Consistent with findings from around the globe, in Africa greater body image concerns have been associated with poorer mental health outcomes, including eating disorders (Prioreschi et al., 2017; Terhoeven et al., 2020), depression and anxiety (Corona et al., 2019), lower quality of life (Ejike, 2015), and general psychiatric morbidity (Otakpor and Ehimigbai, 2016). Again, efforts to prevent this burden would be important.

Although differences exist, the literature has also highlighted commonalities across countries at the global level in terms of appearance ideals (Lipinski and Pope, 2002; Swami et al., 2010), the nature of body image concerns, and potential risk factors in the development of these concerns. Support has been found for media exposure, and particularly Westernized media exposure, as a correlate of poorer body image among adults across 26 countries in 10 world regions (Swami et al., 2010; Schaefer et al., 2019). Similarly, among adolescents from 24 countries across Europe, Canada, and the USA, the role of parental influence in body image has been supported (Al Sabbah et al., 2009). These findings provide strong support for continuing to ground work in sociocultural models that account for these pathways.

In addition, the literature has supported the fact that immigration from a lower income and less Westernized area to a higher income, urban, and Westernized area is frequently accompanied by increased body image concerns (Toselli et al., 2016). This increase may be related to greater exposure to Western media, as well as increased minority stress, and a loss of capital that may lead to body capital becoming more salient.

Importantly, the consistent findings regarding the association between body image and multiple indicators of poor mental health including eating disorders, mood disorders, and general impaired functioning highlight the critical nature of body image concerns. Coordinated efforts should be made to address this global issue.

Predominant theories that have been useful for conceptualizing body image concerns include those that highlight the importance of sociocultural identities, particularly from an intersectional and minority stress standpoint. The majority of the work that has been conducted outside of high-income Western countries has focused on sociocultural elements including pressures toward thinness and internalization of media ideals (e.g. Moreno-Domínguez et al., 2019; Zainal et al., 2020; Hsu et al., 2021). This represents an important gap, as theories that can account for the ways in which appearance is tied to power and privilege are likely particularly useful ones in such contexts. Future work at the global level should seek to explore these facets to a greater extent. It is notable, however, that the work grounded in sociocultural theories suggested that these frameworks and their related constructs are still applicable outside of affluent Western contexts. Together, these findings suggest that additional attention should be focused on extending theories to be culturally informed and sensitive to cultural variations as well as integrating important elements of minority and intersectionality theory.

From a practice perspective, findings highlight three important elements. First, the prevalence of body image concerns worldwide is high. Second, these concerns are robustly linked to mental health concerns. Third, prevention efforts are limited by their failure to be embedded in existing structures (e.g. school curriculum, etc.) and by the fact that some of the programs that have received the greatest research attention target body image in the context of eating disorder prevention. Together, these three elements point to an urgent need to elevate the seriousness of appearance concerns at a global level and to continue efforts to develop universal and targeted interventions with a broad reach that can be easily disseminated, for example through embedding them in existing services for youth or by leveraging the reach of digital technologies. These efforts should build on additional work extending theoretical frameworks that can identify cross-cultural core intervention targets (such as internalization of appearance ideals) as well as culturally specific ones.

Although initially constricted to high-income English-speaking countries, the empirical literature focused on body image has started to extend to a global level, making important contributions to our knowledge of the global burden of body image concerns. Despite these contributions, several areas of future research emerge.

Replicating the ways in which the body image literature developed within the field, the majority of the extant literature from areas such as Africa or the Middle East has to date largely focused on women and thinness-related concerns. Moving forward, it will be important to extend this work to more diverse groups in terms of gender, sexual orientation, age, and ability. Moreover, while important work has been conducted on the role of urbanization, it will be important to better understand how low socioeconomic status may place individuals at greatest risk for body image concerns and unhealthy behaviors in urban settings. Finally, using an intersectional lens will enrich the literature and provide a more fine-grained understanding of the way vulnerability to these concerns is distributed through the population (Burke et al., 2020).

As described above, a large amount of the existing literature has centered on body weight and shape, with a predominant focus on thinness and to some extent on muscularity. Evidence for the importance of other aspects of appearance in body image exists, however (Lowy et al., 2021). Future research should seek to better characterize the aspects of appearance that may be particularly central to body image in different groups so as to conduct culturally sensitive research.

In addition, greater focus on positive elements of body image will help to shift conceptualizations toward a strengths-based model and to increase understanding of the unique strengths certain cultural groups may have in terms of positive body image. In particular, exploring settings in which appearance is less salient may be helpful for understanding how to decenter appearance in affluent and highly Westernized contexts.

Finally, given the global rates and commonalities of body image concerns, greater efforts should be made to prevent and decrease these concerns. Although scalable interventions have started to emerge across the globe (Marchand et al., 2011; Craddock et al., 2021; Garbett et al., 2022), this work is still in its infancy. In addition to developing such programs, working with stakeholders and policymakers is crucial to decreasing universal risk for body image concerns effectively at a global level, with Western media emerging as a particularly important target (Bell et al., 2016).

The findings from this review highlight how body image concerns constitute a burden at the global level, with higher levels of risk among already vulnerable groups. The oppressive nature of appearance ideals, combined with their function to maintain social hierarchies and generate profit, contributes to explaining this increased risk. The variations in risk observed at the global level, which map onto levels of economic development and international power, are to some extent replicated within countries (such as within the USA where minoritized groups experience greater concerns) and geographic areas (e.g. in Europe, where lower income countries report higher levels of body image concerns). However, countries in which Westernized appearance ideals are still only gaining ground, and where the social emphasis on appearance is lower, may still be protected from body image concerns to some extent (Frederick et al., 2007).

To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2023.2.

All authors contributed to reviewing the relevant research, drafting the first version of the manuscript, and final editing.

The authors have no conflicts of interest to report.