Body of Research
As a researcher who studies eating disorders, Kenyon psychology professor Linda Smolak has heard some very disturbing stories in her career. One in particular haunts her more than most.
Two years ago, Smolak and her colleague psychology professor and associate provost Sarah Murnen were working on a study in which a group of girls ages six to twelve were shown pictures of scantily clad women singers known as much for their thin bodies as for their voices. When asked if they wanted to look like these women, the majority of the girls said yes. When asked what they would need to do to look that way, one first grader paused, then responded matter-of-factly, "Either eat and throw up the food or don't eat at all."
"We were just dumbfounded. How would a first grader know that?" asks Smolak, a twenty-year veteran of eating-disorders research. "It's worrisome because I know we didn't find the only first grader in the U.S. who knows this."
If statistics are any indication, her worries are well founded. Many eating disorder clinics report a younger patient roster than ever before, adding a sense of urgency to studies by Smolak, Murnen, and fellow Kenyon psychology professor Michael Levine. Individually and in collaboration, these three professors have earned national recognition for their contributions to the understanding of the developmental, psychological, and cultural aspects of eating disorders. Their work, frequently undertaken together with students, has resulted in dozens of journal articles, several books, and curricular guides for teachers. They regularly deliver talks at professional conferences and are frequently invited to address schools and civic groups. Popular magazines seek them out for expert commentary. When Smolak, Levine, and Murnen first began their research, eating disorders were rarely diagnosed and largely misunderstood. Now, health professionals have a better grasp of the issue and an arsenal of prevention and treatment techniques developed in large part from the work done at Kenyon.
"They, together, have been the conscience of the field of prevention," says Douglas W. Bunnell, the president of the National Eating Disorders Association, on whose Clinical and Scientific Advisory Council both Levine and Smolak serve. "Their scholarship and passion about this issue have kept the field focused on the development of better prevention strategies."
Adds Laura Hill, chief executive officer of the Center for Eating Disorders in Worthington, Ohio, "The body-image work that specialists provide nationally, if not internationally, is constantly impacted by their work." Smolak and Levine have both served on the board for the center, which provides treatment and prevention services and conducts research on eating disorders and body image.
Hill says she and other professionals who work in the area of
eating-disorder treatment and prevention continue to look toward Kenyon as a center for new insights. Those insights are perhaps more important now than ever, Hill notes, given the increasing number of people who struggle with the problem: 11 million adults and children suffering with anorexia or bulimia (or both) and another 25 million with binge-eating disorder, also called compulsive overeating. Due in part to this alarming trend, the Kenyon professors are expanding the scope of their research. What role do peers, parents, and the media play in shaping how people feel about their bodies? How do these perceptions affect boys as well as girls? And, perhaps most important, why do some people strive for what society bills as the "perfect" body at all costs, while others seem to be immune to that pressure?
Developing an interest
Kenyon's history as a center for eating-disorders research began in 1983, when Levine, then in his fourth year on the College faculty, joined the board of the mental health association in Mount Vernon. He and other board members were sitting around the office one day, trying to come up with a theme around which they could build an awareness week filled with seminars and community outreach activities. Tracy Schermer, longtime director of the College's Health and Counseling Center, happened to be in the building (for reasons Levine can't recall) and overheard the group's conversation. He told them that college campuses around the country, Kenyon included, were seeing an upsurge in anorexia among female students. Why not make that the topic?
Levine was skeptical. During graduate school at the University of California-Santa Barbara in the mid-1970s, most of his psychology professors dismissed eating disorders as a minor problem that the students likely would never see in clinical practice or in their studies. "The only eating disorder that was known or even talked about was anorexia nervosa," says Levine, and that was covered only briefly in texts in a category his professors dubbed "esoteric disorders you'll probably never encounter."
But Schermer's arguments were persuasive, and Levine and his fellow board members decided to meet with officials at the National Anorexic Aid Society, a center in Worthington, Ohio. The society embraced the idea, and in October 1983, the world's first Eating Disorders Awareness Week was held at the YMCA in Mount Vernon, attracting more than a hundred participants. Among other important activities, two experts from the society conducted a training session for professionals. The society ultimately took over the project, and now institutions in countries around the world observe an awareness week at various times during the year. (Kenyon's is in late winter.)
Over the next several years, Levine's interest in eating disorders awareness and prevention grew, and he began working on a book on the topic for the National Education Association. In the early 1980s, he and Smolak, who had joined the faculty in 1980, started team-teaching a course on childhood psychopathology, an experience that gave them a strong sense that the field of eating disorders needed to be better informed by the field of developmental psychology and the emerging field of developmental psychopathology. By the late 1980s, they were at work on studies that examined the relationship between normative developmental factors, body image, dieting, and disordered eating.
As they combed through journals and books, they were dismayed by the limited amount of research on the developmental aspects of eating disorders. Smolak's training is in developmental psychology, a field focusing on the nature of different life stages, childhood through adolescence to adulthood, and the transitions from one to the next. She was convinced that efforts to treat and prevent eating disorders would be successful only if experts had a better understanding of how the problem and its onset were related to adolescent development.
So, she and Levine decided to tackle the topic themselves. For their first study, they recruited Murnen, who had joined the Kenyon faculty in 1988, for a project to examine the perception of body image and the prevalence of dieting and eating disorders in 454 girls in sixth, eighth, ninth, and tenth grades in schools in Knox County, Ohio. The research was published in 1990 in the International Journal of Eating Disorders, and the lead author was Sarah Gralen '89, who had worked with Smolak on a senior honors thesis. The results suggested that girls' reactions to what Levine calls "concrete events" of adolescence-menstruation, changes in social structure, and so on-can serve as predictors for disordered eating in the younger girls in the study. However, in the ninth and tenth grades, girls' own opinions of beauty and their bodies served as predictors. The findings pointed to changes in views on body image and dieting that paralleled changes which occurred through adolescent development.
"That was one of the things that hooked us into continuing to do this, because it suggested that there was a place for looking at these phenomena developmentally," Levine says. Had it not been for Smolak, he notes, they might not have chosen to take the developmental approach. "Linda Smolak was one of the first people to take a hard look at the phenomena of body image, dieting, and disordered eating from a developmental viewpoint."
Social pressures, cultural cues
The 1990 study was the first of many to come out of Kenyon that sought to explore how the turmoil of even normal adolescent development might leave a girl vulnerable to problems. Over the course of the next several years, Smolak, Levine, and Murnen authored or coauthored a number of articles revealing that girls with low self-esteem, a drive for perfection, a need for external validation, and an unhealthy obsession with thinness were predisposed to the type of body dissatisfaction that often precedes the onset of an eating disorder.
Then, in 1994, Levine and Smolak published a study of 382 middle-school-age girls to learn more about their attitudes toward weight and eating habits, the impact of peer and parental pressure to have a certain body size, their dating history, and academic-related stress. The findings, published in the International Journal of Eating Disorders, suggested that a combination of pubertal anxiety, social pressure, and unrealistic views of thinness may prove to be too much for girls with characteristics such as low self-esteem.
While analyzing other data from the same study, Levine and Smolak unearthed another finding that would come to be a focus for much of Levine's future work. Influenced by the work of one of their students, Helen Hayden Wade '91, whose undergraduate interest in the impact of mass media has shaped her own career as a clinical psychologist specializing in eating disorders and obesity, they included a set of questions on the survey that asked the girls about the magazines they read and how those publications influenced their opinions of what makes someone attractive. The study, published in the Journal of Early Adolescence, found that 42 percent of the participants read fashion magazines frequently and used them as a primary source of information about beauty and fitness. What's more, 13 percent had a "high degree" of interest in looking like the women in the magazines.
"This suggested to us that there was a relationship between reading magazines and a drive for thinness and a disordered pattern of eating," says Levine, lead author of that paper. "There's no question that mass media is one of the social influences that glorifies slenderness and either vilifies fat or ignores it completely. There's also no doubt from our research that fashion magazines and, to some extent, television and movies make it crystal clear that the most important thing for a girl or a young woman is her looks."
While Levine and Smolak are reluctant to lay all the blame for body dissatisfaction on mass media, they contend that magazines, television, movies, and the Internet certainly contribute to the problem. "Media doesn't necessarily tell you what to think," Levine says. "It tells you what to think about. It tells you to mistrust your own body and your own eyes and your own sense of what may look good and focus instead on external cues that are forever telling you that you are falling short of perfection."
All in the family
"The range of what is acceptable is so unrealistic and impossible for more than 95 percent of the population," says Helene Keery '95, a clinical psychologist at the Methodist Hospital Eating Disorders Institute in Minneapolis, Minnesota. For her senior honors thesis at Kenyon, Keery did a literature review on eating disorders and anxiety disorders, one of dozens of students who have pursued research projects under the guidance of Levine, Smolak, and Murnen. Today, she works with people ages twelve to thirty who suffer from eating disorders. While she was drawn to psychology out of a curiosity about human behavior, Keery's focus on body image and eating disorders is far more personal.
"I was the perfect demographic for what people think of as the typical eating-disorder patient," she says. She comes from an upper middle class home and is an overachieving perfectionist with successful parents. "I was surrounded by all these people who were just like me who had eating disorders. Why did they wind up with a problem and I didn't? In theory, it could have been me, but why wasn't it?"
Keery has learned from her work and from studies by her Kenyon mentors that answering that question is no easy task. One thing they have come to realize, however, is that mass media isn't the only cultural factor at play. Pressure from peers and parents also exerts influence. A 1999 study led by Smolak surveyed 131 mothers and 89 fathers of fourth- and fifth-grade boys and girls to learn more about how parents' comments affect a child's self-image, dieting habits, and overall views on body shape. Published in theInternational Journal of Eating Disorders, the findings suggested that the things parents say have a powerful influence on how children-especially girls-feel about their own bodies.
Keery also examined this subject as part of her graduate studies at the University of South Florida. For her dissertation, she led a study of 372 middle school girls that looked at the impact of teasing by parents and siblings. Twenty-three percent of the girls reported teasing by a parent, and 12 percent were teased specifically about their weight. Fathers teased more than mothers, and that teasing had a harsher impact. Girls whose fathers made fun of them were far more likely to be dissatisfied with their bodies and to exhibit bulimic behaviors, have low self-esteem, and suffer from depression. Keery is about to begin another study in Minnesota involving about 100 patients thirteen to eighteen years old, in an effort to further examine the role between parental teasing and body image and the risk of eating disorders.
It comes as little surprise to learn that pressure from friends and family can have a devastating effect on a child's or young adult's self-esteem, Smolak says. But their studies suggest that it's the combination of pressure from family, friends, and mass media images that has the most dangerous impact on an individual's risk of developing an eating disorder. That's something she and Levine learned from their 1994 studies of girls in sixth through tenth grades.
"There was a subset of girls who reported receiving messages about the importance of slenderness and dieting from magazines, from peers, and from family, and those girls had extremely high scores on the measure of disordered eating," Levine says. While traumatic events such as sexual harassment or abuse may play a role in the development of eating disorders, he notes, it's clear that everyday "normal" influences, in combination, can contribute significantly.
"We're not blaming adolescent development," Levine is quick to add. "Many people have friends and peer groups who talk about weight. Many people have families who also convey those kinds of messages. Many people read these magazines and pay close attention to the pictures and articles. We're saying that for certain people, the coinciding of these three influences may be feeding a pattern of disordered eating."
Another area of study advanced in part by the work done at Kenyon is the role that gender plays in the onset of eating disorders. Murnen, an expert in women's studies, has had a particular interest in the question of gender. Studies at the College and elsewhere have suggested that girls and women are far more likely than boys or men to judge themselves by their bodies and have historically gone to greater lengths to achieve what they believe to be the perfect body shape. (This remains true despite the recent rise in steroid use among boys and men.) Murnen felt that further research would benefit from feminist theory, which posits that society constructs gender, an array of roles and attributes attaching to the labels "male" and "female," with far-reaching consequences.
Feminist theory suggests that gender difference in eating disorders can be explained largely by the "lived experiences" of girls and women. "These 'lived experiences' include growing up in a culture which emphasizes an unrealistically thin body type as the societal ideal, limited achievement opportunities, and sexual abuse and harassment as normative experiences," wrote Murnen and Smolak in a chapter for Eating Disorders: New directions for research and practice, a book published in 2001 by the American Psychological Association.
Murnen and her colleagues have explored these "lived experiences" through studies that span the last fifteen years, including a close look at the link between sexual harassment or childhood sexual assault and eating disorders. In 1997, Murnen and Smolak analyzed sixty-nine previously published papers on sexual harassment and found evidence of a link to eating disorders. In 2000, Murnen designed her own study to further explore that connection. She and Smolak enrolled seventy-three children in grades three through five for the project, the first study to examine sexual harassment in children that young. Eleven scenes depicting a realistic form of sexual harassment for that age group (being stared at, verbally teased, pinched, pushed, etc.) were read to the kids. Many of the girls said that the victims in the scenarios would be frightened, while most of the boys thought the victims would be flattered by the attention. Those girls who said the victim would be scared also were likely to have a poor body image.
In another study, published in 2002 in the International Journal of Eating Disorders, Murnen and Smolak analyzed fifty-three published research articles about the link between sexual abuse and eating disorders and found that victims of child sexual abuse are more likely to develop an eating disorder later in life.
The implication, Murnen says, is clear. "You won't prevent eating disorders, in my opinion, unless you take the gendered aspects into account and look at things like sexual harassment, dating violence, and body image."
The researchers now are moving in several new directions. Smolak and Murnen recently published a study of 383 middle-school boys that found that the same sociocultural influences that affect girls' body image-peers, parents, and the media-figure in the way boys view their bodies, particularly with regard to the use of steroids and food supplements to build muscle.
"We're still at a point where the pressure on boys is not equal to the pressure on girls, but it's growing, and this is a time when we could stop it," Smolak says. "We should take a lesson from what we've learned about girls and not let it happen to boys."
Murnen also has turned her attention to the area of prevention. She recently completed a study of 100 boys and girls in sixth, seventh, and eighth grades that examined the influence parents can have in reversing the sociocultural factors that often contribute to poor body image. She hopes to help parents develop a "critique of culture that they can teach their kids." Levine, too, is interested in developing tools to help kids and parents make better distinctions between reality and what they see in magazines, on television, and in movies. But prevention will only succeed, he suggests, if people work to change a culture that promotes unrealistic and unhealthy ideals.
"It's really impossible to develop a sociocultural theory about the origins of the continuum of eating disorders without thinking about how society and culture can change," Levine says. "To say it's 'sociocultural' is to offer hope, a sense of possibility to change society and to change prejudices. It's not easy, but it's certainly possible."
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