Public Health Impact of Social Comparison on Body Image Concerning Cognitive Processing and Disordered Eating: A Systematic Review

Introduction

Body image is how an individual perceives themselves to variables such as appearance, weight, and shape [1]. A person’s experience with body image falls on a spectrum from positive to negative, with body dissatisfaction being a facet of negative body image, and body appreciation a facet of positive body image. Where one lies on the spectrum can be influenced by factors like environment or culture. Body dissatisfaction stems from the idea that one’s appearance falls short of what is considered ideal. A way in which a negative body image can develop is through social comparison, which refers to the notion of judging one’s idea of success by the accomplishments of other people [2]. This is an instinct that provides drive and esteem to an individual to achieve more in life, however, it also can be a conduit for the development of unhealthy thoughts and behaviors towards oneself.

Participation in social comparison can occur in two distinct ways: upward comparison refers to a feeling of inferiority to another individual, while downward comparison refers to the feeling of being superior [2]. Targets of comparison are recognized as family, friends, acquaintances, or even strangers in both real life and through consumptive media forms such as television, magazines, or social media. Through these outlets, there is exposure to the thin-ideal which is a concept that thinner bodies are valued in society as more attractive than other body types [3]. This message may be internalized and become a desirable aim for those who are more vulnerable to it.

Certain individuals are more prone to participate in upward comparison than others. In terms of personality types, it has been found that neuroticism is correlated with upward comparison, and feelings of envy [2]. Those suffering from depression, among other mental health-related issues are also more vulnerable to engaging in comparisons at the risk of further worsening their condition. The pressure of attempting to achieve that idealized body contributes to damage to mental health and the creation of a negative body image.

Body dissatisfaction is unaffected by age, with an estimated 20-40% of women found to be dissatisfied with their bodies [4]. With the enormous pressure placed on women by society to maintain a specific figure while growing up, in the midst of having children, and while aging, it’s no surprise that body dissatisfaction exists at every age. However, there is a significantly higher body appreciation found in older women as opposed to those who are younger, as well as a decrease in the importance of one’s physical appearance.

Quittkat et al. (2019) also discovered that those with higher levels of body appreciation consumed fewer media promoting idealized bodies and were, therefore, less affected by it (4). Body-focused social comparisons by women have only been heightened by the presence of social media, particularly due to the staged image of confidence and portrayal of perfection posted by its users. The accessibility of social networking sites gives more opportunities today for users to be exposed to the thin-ideal, and it has been found that social media has been positively correlated with internalization [3]. It provides an environment where social comparison can easily occur, where both passively scrolling through profiles or newsfeeds, or actively engaging with users can facilitate upward comparisons [2].

With an increase in the body, dissatisfaction comes an increased risk of engaging in disordered eating behaviors to reach that standard of beauty [1]. Disordered eating behaviors are defined as maladaptive eating habits such as food restriction, or participation in binging and purging activities [5]. These behaviors are increasing rapidly among young women today. It has also been found that internalization of the thin-ideal continues during recovery from eating disorders and often leads to an increased risk of relapse [6]. Addressing the factors that contribute to thin- ideal internalization is key to preventing the domino effect of body dissatisfaction and the development of disordered eating behaviors that might be a serious and emerging public health concern. This literature review attempts to do that, in an analysis of the idealization of women’s bodies, and the effects it has on overall body image.

Methods

Using PubMed, scholarly articles were compiled on the topic. A search strategy was utilized in the database to find relevant literature by use of the Boolean operator, “AND”. Three different combinations of search terms were used to attain the appropriate information: “Social Media” AND “Body Image”, “Thin Ideal” AND “Social Comparison” AND “Body Dissatisfaction”. “Social Media” AND “Body Image” yielded a total number of 770 results. Filters were applied to narrow down search results with specific inclusion criteria depicted in Figure 1. The inclusion criteria included a publication date within the last 10 years, spanning the years between 2011 to 2021. In regards to text availability, inclusion criteria were specific for free full text. Articles that did not meet these criteria were excluded. This yielded 166 results, from which one study was chosen for analysis.

Total 301 articles were selected after the first step of exclusion. More filters were applied to limit the inclusion criteria to clinical trials, randomized controlled trials, the human species, the English language, and the female gender. The number of articles based on the second stage of exclusion (meta-analysis, reviews, systematic reviews, and studies that included males) was 202. Duplicated articles (n=22) were also excluded. A total of 77 eligible articles were further subjected to a thorough check for relevancy to the topic; and 67 articles were excluded since those were not directly related to the topic of interest. Finally, 10 scholarly articles were chosen for a detailed study and analysis as shown in the Prisma chart (Figure 1).

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Results

Findings from a few recent studies (published between 2011 to 2021) were compiled for analysis as indicated in Table 1 below, including five randomized controlled trials and two clinical trials; also includes two ecological momentary assessments and one experimental study.

Discussion

Concerning the principal focus of the scholarly articles that were analyzed, the main themes discussed were those of social comparison in the setting of social media, how social comparison can lead to the onset of disordered eating, and the cognitive processes that occur upon exposure to the thin- ideal. Concerning the setting of social media, women who posted selfies were found to feel less physically attractive compared to the control group regardless of the ability to retouch their photos [7]. This finding was in agreement with the hypothesis and demonstrated that despite the desire to present an ideal version of oneself to the public on social media, photo editing does not prevent feelings of dissatisfaction, perhaps because the act of editing by women highlights their flaws. Feelings of fatness and body size satisfaction were not affected by posting selfies, which could be attributed to the fact that selfies only show the face, as opposed to the rest of the body. The study was limited by age range, and future research can show the effects on body image posting selfies has on older women versus younger women, and also the effects that result from posting their whole body. It would also be interesting to see if specific personality types are more affected by the negative effects of posting on social media sites.

The relationship between women and their peers on social media also was supportive of the hypothesis that social comparison does decrease body image [9]. The results demonstrated that it is not just exposure to Instagram models or celebrities that leads to upward comparison, but even peers considered attractive by the participants. ASME also showed the difference between family and friends on social media sites, perhaps indicating an underlying sense of competition with attractive peers that is less often to occur with family members. Future studies can delve further into what drives social comparison with peers, and the nature of social comparison among relatives. Having participants comment on the social media of peers they considered attractive could be considered a limitation of the study, as well as the finding that participants who were in the group that commented on peers’ social media had a lower baseline body image score in comparison to those in the group commenting on family members’ social media.

Two ecological momentary assessments were conducted to evaluate the effects of upward and downward comparison on females. The results of the effort by Fitzsimmons-Craft (2017) in assessing upward and downward comparisons with strangers and close friends align with the hypothesis, that negative feelings about oneself are due to an inability to reach the expected standard of eating, exercise, and appearance based on the thin-ideal [11]. Upward exercise comparisons are most common, and more likely to be made with strangers, perhaps because it may be easier to idealize an individual from a distance, as opposed to someone with whom a direct relationship is shared. This may provide insight as to why upward body comparisons are also more often made with strangers, and upward eating comparisons are more often made with acquaintances as well.

The strict protocol of the ecological momentary assessment could be considered a limitation of the study, with questions being asked at specific times during each day as opposed to the protocol seen in the ecological momentary assessment that called for stratified random sampling which allowed for questions to be asked at random to account for more appearance-focused comparisons [11, 12]. Selection bias could have been a limiting factor as well, not only in the case of the study by Fitzsimmons-Craft (2017) but for all of the studies analyzed thus far, because while they focused specifically on the female relationship with body image, the perspectives and cognitive responses of men could give insight into the similarities and differences between the psychological and physiological processes of men and women in the setting of social comparison [11]. While typically body comparisons are the focus of eating disorder prevention programs, this data may prove useful in broadening targeted efforts of preventative programs towards eating and exercise comparisons as well.

The results of the ecological momentary assessment by Leahey et al. (2011) support the idea that social comparison can have negative effects on body image, and goes further with its findings that upward comparisons are more dangerous to women with eating pathologies [12]. This can be attributed to a heightened sense of awareness of body-focused comparisons that are had by females with disordered eating habits. It is also worth noting how both EPHB and HB women engaging in higher amounts of upward comparisons than LB women demonstrate that women with high body dissatisfaction cognitively process body-related stimuli in a similar fashion, regardless of the presence of eating pathology.

While stratified random sampling procedures have their benefits, the methodology also has its shortcomings in that having participants write about recent experiences with social comparison instead of experiences that took place at the moment itself increases the potential for recall bias [12]. Another limitation of this study can also be applied to the ecological momentary assessment, in that the nature of these studies relies on self-reported questionnaires [11, 12]. However, the use of ecological momentary assessments allows for less recall bias to be present than seen in cases of cross-sectional studies. Future planning in regards to the structure and strategy of preventative eating disorder programs can build on these observations.

Two studies analyzed the effectiveness of preventative eating disorder programs and had participants partake in the Body Project. The data provided in the clinical research supports the idea that subscribing to the thin-ideal results in body dissatisfaction, and further, it increases the risk specifically for binging and purging behaviors within the spectrum of disordered eating [10]. There was significant overlap between predictors of sBN/BN, sBED/BED, and sPD/PD, with risk factors between the subthreshold and threshold eating disorders being similar. Both univariate and multivariate models of regression analysis highlighted body dissatisfaction as the common risk factor for all of the tested binging and purging disorders. The study was limited to the specific risk factors targeted by the program, and analysis of other factors such as negative affect or functional impairment could contribute towards research aimed at the prevention of a larger spectrum of eating disorders.

The results of the randomized controlled trial by Stice E, et al. [16] gave merit to the hypothesis that exposure to the thin-ideal lowers body image in women given the finding that a decrease in body dissatisfaction was found to be directly correlated with decreased significance cognitively placed on thin imagery [16]. The study demonstrated the positive effects of actively participating in a devaluation of the thin- ideal, proving the efforts of the Body Project to be successful. Regarding study limitations, a small sample size was used, which could have contributed to lessening the accuracy of the results. In regards to future implications of participation in the Body Project, examining the cognitive processing associated with multiple risk factors could provide more insight into how prevention programs can be used to more efficiently prevent the onset of eating disorders. The success of the program in decreasing body dissatisfaction through devaluation of the thin-ideal should increase the implementation of its principles that could prove beneficial for use in further research and practices.

Investigating the cognitive and physiologic responses following exposure to the thin-ideal was a major trend found in an analysis of the aforementioned studies. Regarding the coping mechanisms associated with exposure to thin-ideal, findings were in agreement with the hypothesis and went further in its exploration of how perfectionism attributes to a more pronounced decrease in body image and inclination towards maladaptive coping responses [13]. Females with this personality type are more affected by rumination or constant thoughts of their feelings of inferiority, and catastrophizing about weight and appearance.

Significantly, neither of the adaptive coping strategies of acceptance nor positive refocusing were found to be employed by participants [13]. Engaging in these coping strategies could prove beneficial in preventing a decrease in body image, and future research can be done on the effect of adaptive coping strategies during social comparison. Interventions can also target the engagement of negative coping mechanisms, and aim to lessen these responses to reduce their harmful consequences. In terms of limitations, the use of CERQ to measure social comparison was unique to the context of this study, and more research would be needed to substantiate its use as appropriate. It would be interesting to study other personality types and their relationship with idealized bodies as well, as previously pointed out regarding the effects on body image of posting selfies on social media [7].

The level of avoidance coping strategy demonstrated by participants in the study by Cho, et al. showed how oversized bodies elicit a physiological response to a stimulus considered by women to be threatening [14]. Those in the High Avoidance group were more affected by oversized body stimuli they considered to be aversive and responded through compensatory attentional bias towards thin bodies they considered more attractive. This physiologic response supports the hypothesis due to the idea that there is a negative response to bodies that stray from the socially acceptable thin ideal. The aversive nature towards oversized body stimuli seen among those in the High Avoidance group could be a risk factor in the development of eating disorders.

Small sample size was considered a limitation of the study, also seen previously in the randomized controlled trial conducted by Stice, et al. [16]. In the future, more research can be done on the relationship between avoidance coping strategies and eating disorders. An effort should be made to understand what tools can be used to change the behavior of individuals who demonstrate high avoidance coping strategies to reduce their negative reactions toward oversized bodies and prevent the onset of disordered eating.

Avoidance coping strategies can also be used in support of the hypothesis in the study by McComb, et al. of how awareness of photo editing techniques through self- disclaimer captions impacted body image [8]. The idea that participants were less likely to compare themselves with the bodies of other women after viewing thin-ideal images can be attributed to using avoidance as a protective mechanism from the harmful effects that can come from upward comparison. It was also interesting that women with high photo manipulation techniques similarly were less likely to participate in social comparison, which may come from the knowledge they have of the editing allowing for them to be less impacted by the effect it has on body image.

Given that the study was based on Instagram photos, it was a limitation that the photos were not presented in the general format seen in daily life with likes and comments underneath them [8]. Because it was found that self- disclaimer captions were not effective in preventing a decrease in body image or likelihood to participate in social comparison, future efforts should be made towards finding new strategies to prevent the dangerous effects that come with exposure to idealized bodies on social media.

Alternatively, to the physiological response seen in the Korean study, the findings of Humbel et al. could not support the hypothesis due to no change demonstrated in physiologic responses upon exposure to the thin-ideal [14, 15]. HF-HRV and salivary cortisol were not found to be correlated with the ERD elicited by exposure to thin imagery. Attempting to link the stress response from thin-ideal exposure to the autonomic nervous system has proved ineffective. The emotional response elicited by participants from idealized bodies may have been limited by the lack of a strong enough trigger for the activation of physiologic processes. Future studies should focus on determining the level of intensity of the given stimulus that would be more likely to set off the autonomic system.

Social comparison on body image concerning cognitive processing and disordered eating has a serious public health impact which is considered to be emerging in the recent time. The impact might be many fold in near future since there is a an increasing access and also usage of information on social media, especially by public who do not have adequate awareness of education regarding the harmful effects and those who can easily get biased. The public health impact of the emerging problem of social comparison is presented in Table 2.

Public Health Impact Recommendation

Regarding the overall study limitations of this literature review, while the majority of articles used for analysis were randomized controlled trials and clinical trials, the qualitative analysis of ecological momentary assessments could be considered a lesser level of clinical evidence used for exploration. However, as stated earlier, their use is stronger in preventing recall bias than traditional cross- sectional studies. In accordance with the past literature, social comparisons are also activated by situational cues [17]. In a study on adolescents’ body image perceptions based on social comparison, it has been reported that a better understanding of enhancement appraisals should be used to guide health promotion efforts on an individual’s body image. These factors have not been taken into consideration in the reviewed studies.

Conclusion

The primary goal of this literature review was to evaluate how social comparison can increase body dissatisfaction in women. After a thorough evaluation of several earlier done studies, the resulting analysis successfully concluded that exposure to the thin-ideal decreases body image in women through social comparison. In regards to social media and body image, there is still much more clinical research to do, however, in terms of clinical findings related to eating disorder prevention programs, there is much to be hopeful for in treatment and prevention strategies against disordered eating in the future.

Acknowledgment

The authors would like to thank Dr. James P. Bruzik and the Research Literature Review Analysis (RLRA) committee at the Medical University of the Americas, Nevis for critical comments during the review writing project as a part of the requirements for Christina George to complete her pre- clerkship program in Medicine.