Overcoming the Unhealthy Pursuit of Thinness: Reaction to the Québec Charter for a Healthy and Diverse Body Image

Abstract

Objectives. We examined the population reach, acceptability, and perceived potential of an initiative that developed a promotional tool for a healthy body image, the Québec Charter for a Healthy and Diverse Body Image. The Charter, developed through consensus building by a multisectoral, government-led task force, outlined actions to be undertaken by organizations or citizens to reduce media pressures favoring thinness.

Methods. Six months after the Charter’s launch, we surveyed 1003 Québec residents aged 18 years or older about their knowledge of the Charter, their willingness to adhere to it, and their perceptions of its potential.

Results. After minimal prompting, more than 35% of respondents recognized the Charter. About 33.7% were very favorable toward personally adhering to the Charter and 32.7% perceived the Charter as having high potential to sensitize people to negative consequences of disordered eating. Women showed greater likelihood and people with lesser education showed lower likelihood of spontaneous recognition.

Conclusions. An initiative involving the creation of a body image Charter reaches a substantial portion of adults and is viewed as acceptable and potentially influential.

Reversing the rising tide of eating disorders is a public health priority. These include disorders characterized by the pathological pursuit of thinness (such as anorexia and bulimia nervosa) and by excessive food consumption leading to obesity.^1,2 Although numerous public health actions are aimed at reducing caloric intake and stimulating healthy food choices,^3,4 some authors have suggested that action on disordered eating has neglected to address the issue of unhealthy pursuit of thinness and corresponding maladaptive weight-control practices,^5–8 which are common risk factors for overweight, obesity, and eating disorders. Research shows that greater exposure to images promoting excessively thin body ideals can elicit maladaptive weight-control practices and disordered eating,^9–11 especially when viewers are female adolescents. Such images are markedly prevalent in Western cultures.¹² Transforming body images portrayed in the media and other public venues is therefore a relevant target for population-based initiatives.^13–15

Throughout the world, governmental and nongovernmental organizations have implemented actions to encourage refusal to subscribe to excessively thin bodily ideals. The British Fashion Council, supported by the London Development Agency, mandated a report on the health status of fashion models that was released in 2007¹⁶ and included 14 recommendations on how to promote the health of models. Similar task forces in Spain,¹⁷ Brazil,¹⁸ Italy,¹⁹ and the United States²⁰ have developed recommendations aimed at protecting the health of fashion models, and in Argentina²¹ a law was adopted to establish boundaries of action for the fashion industry. Actors in France²² and Australia²³ have promoted similar initiatives while adopting a broader focus on promoting healthy body images in society at large.

In Québec, Canada, the Ministry of Culture, Communications, and the Status of Women spearheaded an initiative to create a health promotion tool, the Québec Charter for a Healthy and Diverse Body Image,²⁴ which outlines consensual actions and principles that can be undertaken by organizations and citizens to reduce media pressures favoring thinness. The development of this Charter was based on a collaborative, educational (and noncoercive) inducement toward voluntary engagement on the part of actors in the fashion and media industries and in the health, social services, and education networks. (Figure 1 shows milestones and tasks completed in the development of the Charter.) The Charter incites organizations and people to pledge to

1. promote a diversity of body images, including different heights, proportions, and ages;

2. encourage healthy eating and weight-control habits;

3. discourage excessive weight-control practices or appearance modification;

4. refuse to subscribe to esthetic ideals based on extreme thinness;

5. remain vigilant and diligent so as to minimize the risks of anorexia nervosa, bulimia nervosa, and unhealthy preoccupations with weight;

6. act as agents of change so as to promote healthy eating and weight-control practices and realistic body images; and

7. promote the Québec Charter for a Healthy and Diverse Body Image among partners, clients, and others while actively respecting and adhering to its principles.

FIGURE 1—

Milestones and activities in the development of the Québec Charter for a Healthy and Diverse Body Image.

Note. See also the Charter’s Web site.²⁴

To our knowledge, there have been no systematic empirical efforts to date that examine the plausible outcomes of such initiatives. We therefore explored the potential contribution of the Charter to overcoming the unhealthy pursuit of thinness by collecting evidence about its population reach, acceptability, and perceived potential among Québec adults.

METHODS

Between February 18 and March 13, 2010—that is, 6 months after the launch of the Charter—we conducted a random-digit-dialing survey among 1003 adult residents (≥ 18 years old) of Québec. After being informed about the purposes of the survey and the identity of the principal investigator, respondents answered questions about the Charter and their personal characteristics.

Measures

Reach of the Charter.

After having agreed to participate in the survey, participants were first asked, “Have you heard about the Québec Charter for a Healthy and Diverse Body Image?” We then read participants a 30-second description of the Charter initiative: “The Québec Charter for a Healthy and Diverse Body Image, or Charter, is an initiative from the Minister of Communication, Culture and the Status of Women of the Government of Québec. The project led to the creation of a voluntary engagement Charter destined for the fashion industry and those groups that produce public or media messages in order to counter extreme thinness, anorexia and to promote healthy body image. The Charter invites people to voluntarily engage in performing different actions aimed at promoting a healthy and diverse body image.” We then asked participants if they now recognized the Charter. We dichotomized responses to both questions into “yes” versus “no” (with “I don’t know” answers being classified as missing), resulting in indicators of spontaneous knowledge and prompted recognition of the Charter.

Acceptability of the Charter.

We assessed acceptability of the Charter by asking all participants the extent of their willingness to personally adhere to the Charter on the basis of their knowledge of it or the description that was provided. Response options were “very favorable,” “moderately favorable,” “weakly favorable,” “not at all favorable,” and “I do not know.” We created a dichotomous variable that contrasted those who were “very favorable” to adhering to the Charter with others.

Potential of the Charter.

Three questions addressed the potential of the Charter for countering extreme thinness and promoting healthy body image, sensitizing people to the negative health consequences of extreme thinness, and sensitizing people to the negative health consequences of disordered eating behaviors and unhealthy weight-control practices. Response options were “high,” “moderate,” “low,” “none,” and “I don’t know.” Because there was good internal consistency (Cronbach α = 0.79), items were averaged and then dichotomized, to contrast people who thought the potential was high (average score = 1–1.9 on 4-point scale) with those who did not.

Perceived potential of actions proposed in the Charter.

Six questions required participants to rate their level of agreement with “if-then” statements regarding the impact of actions proposed in the Charter to reduce sociocultural pressures toward thinness (e.g., if the images and messages presented in the public eye favored the acceptance of diverse body images, including varied sizes, heights, proportions, and ages, then sociocultural pressures favoring extreme thinness would decrease). Response options were “completely agree,” “somewhat agree,” “somewhat disagree,” “completely disagree,” and “I don’t know.” Acceptable reliability was achieved across 5 items (Cronbach α = 0.71). We therefore computed an average of these items and created a dichotomous variable, contrasting stronger expressions of agreement (average score = 1–1.9 on 4-point scale) with others.

Sociodemographic and anthropometric characteristics.

Participants provided information about their height and weight, which was transformed into an estimate of body mass index (BMI; defined as weight in kilograms divided by the square of height in meters). Estimates were reclassified as underweight or normal (BMI ≤ 25 kg/m²), overweight (BMI > 25 but < 30 kg/m²), or obese (BMI ≥ 30 kg/m²). Participants also reported on their marital status (i.e., married or common law, separate or divorced, or widowed), country of birth (Canada vs elsewhere), age, education (high school or less, trade school or junior college, university or graduate degree), household income (recoded as < Can $20 000 vs ≥ Can $20 000), self-perceived class in society (recoded as significantly below average, average, significantly above average), and number of male and female children in the age brackets birth to 12 years and 13 to 17 years.

Statistical Analysis Strategy

To adjust for sampling bias, we computed unweighted and age- and sex-weighted estimates (based on data from Statistics Canada). We then examined the extent to which sociodemographic and anthropometric characteristics were associated with indicators of reach, acceptability, and perceived potential of the Charter through logistic regression analyses. We also examined whether spontaneous or prompted recognition of the Charter was associated with greater likelihood of acceptability and high perceived potential of the Charter, controlling for sociodemographic and health characteristics.

RESULTS

The response rate to the survey was 38%, a level that compares with response rates from population surveys.^25,26 A subsample of 963 participants (96.0% of the full sample) provided data on sociodemographic and outcome variables of interest (Table 1).

TABLE 1—

Characteristics of Participants in a Survey About the Québec Charter for a Healthy and Diverse Body Image: Québec, Spring 2010

Characteristic	Unweighted Value, No. (%)	Weighted Estimates, %a
Sex
Male	443 (46)	49.4
Female	520 (54)	50.6
Age, y
18–29	132 (13.7)	19.6
30–39	187 (19.4)	16.6
40–49	205 (21.3)	19.0
50–59	220 (22.8)	18.8
≥ 60	219 (22.7)	26.0
Education
≤ high school	377 (39.1)	39.7
College or trade school	232 (24.1)	23.8
University or graduate degree	353 (36.7)	36.4
Income, Can $
< 20 000	101 (10.5)	10.8
≥ 20 000	748 (77.7)	77.2
Missing	114 (11.8)	12.0
Self-perceived social class
Significantly above average	50 (5.2)	4.8
Average	886 (92.0)	92.4
Significantly below average	27 (2.8)	2.8
Marital status
Married	566 (58.8)	56.7
Single	248 (25.8)	28.1
Divorced or separated	148 (15.4)	15.1
Children of different ages and sex
Has ≥ 1 girl birth–12 y	156 (16.2)	14.9
Has ≥ 1 boy birth–12 y	152 (15.8)	14.7
Has ≥ 1 girl 13–17 y	89 (9.2)	8.2
Has ≥ 1 boy 13–17 y	79 (8.2)	7.0
Country of birth
Canada	876 (91.0)	90.7
Elsewhere	87 (9.0)	9.3
Weight status
Normal or underweight	516 (53.6)	54.3
Overweight	308 (32.0)	31.7
Obese	139 (14.4)	14.0

Note. Total sample was 963 Québec residents.

^aEstimates were weighted for sex and age according to information from Statistics Canada.

As shown in Table 2, unweighted and weighted estimates revealed that just over 7% spontaneously recognized the Charter and that an additional 28.5% recognized the Charter after being prompted. More than one third of respondents indicated that they were very favorable to personally adhering to the Charter. About one third indicated that the Charter, as a health promotion tool, had high potential to sensitize people in the population to issues of body image and disordered eating, but only about 14% reported that potential actions proposed in it had high potential to reduce sociocultural pressures favoring thinness.

TABLE 2—

Reach, Acceptability, and Perceived Potential of the Québec Charter for a Healthy and Diverse Body Image: Québec, Spring 2010

	Unweighted Value, No. (%)	Weighted Estimates, %a
Charter’s reach
Spontaneous knowledge of Charter
Yes	73 (7.6)	7.3
No	887 (92.1)	92.4
I don’t know	3 (0.3)	0.3
Prompted recognition of Charter
Yes	344 (35.9)	35.1
No	619 (64.3)	64.9
I don’t know	0 (0.0)	0.0
Charter’s acceptability
Willingness to personally adhere to Charter
Very favorable	332 (34.5)	33.7
Moderately favorable	334 (34.7)	35.0
Weakly favorable	115 (11.9)	12.2
Not at all favorable	158 (16.4)	16.5
I don’t know	24 (2.5)	2.5
Degree of acceptability
High	332 (34.5)	33.7
Not high	607 (63.0)	63.8
I don’t know	24 (2.5)	2.5
Perceived impact of Charter
Charter’s potential to counter extreme thinness and promote healthy body image
High	154 (16.0)	15.7
Moderate	541 (56.2)	56.4
Low	135 (14.0)	14.4
None	61 (6.3)	6.3
I don't know	72 (7.5)	7.3
Charter’s potential for sensitizing people to negative health consequences of extreme thinness
High	224 (23.3)	23.1
Moderate	475 (49.3)	49.5
Low	162 (16.8)	17.0
None	40 (4.2)	4.2
I don't know	62 (6.4)	6.2
Charter’s potential for sensitizing people to negative health consequences of disordered eating behaviors and unhealthy weight control practice that lead to extreme thinness
High	255 (26.5)	26.9
Moderate	445 (46.2)	45.9
Low	165 (17.1)	17.4
None	45 (4.7)	4.6
I don't know	53 (5.5)	5.2
Composite indicator of Charter’s sensitization potential
High	312 (32.4)	32.7
Other	615 (63.9)	63.7
Missing	36 (3.7)	3.6
Agreement with specific statements regarding potential of actions proposed in Charter
“If the images and messages presented in the public eye favored the acceptance of diverse body images, including varied sizes, proportions and ages, then sociocultural pressures toward thinness would be reduced.”
Completely agree	139 (14.4)	14.4
Somewhat agree	367 (38.1)	38.4
Somewhat disagree	197 (20.5)	20.9
Completely disagree	242 (25.1)	24.4
I don’t know	18 (1.9)	1.9
“If the images and messages presented in the public eye favored healthy eating practices and healthy weight control practices, then sociocultural pressures toward thinness would be reduced.”
Completely agree	151 (15.7)	15.8
Somewhat agree	403 (41.8)	41.3
Somewhat disagree	255 (26.5)	27.3
Completely disagree	140 (14.5)	14.1
I don’t know	14 (1.5)	1.4
“If the images and messages presented in the public eye dissuaded excessive weight control or image modification practices, then sociocultural pressures toward thinness would be reduced.”
Completely agree	114 (11.8)	11.8
Somewhat agree	324 (33.6)	33.1
Somewhat disagree	270 (28.0)	28.6
Completely disagree	229 (23.8)	23.8
I don’t know	26 (2.7)	2.7
“If the images and messages presented in the public eye did not favor beauty ideals based on extreme thinness, then sociocultural pressures toward thinness would be reduced.”
Completely agree	359 (37.3)	36.6
Somewhat agree	315 (32.7)	33.2
Somewhat disagree	161 (16.7)	16.8
Completely disagree	106 (11.0)	11.0
I don’t know	22 (2.3)	2.3
“If the images and messages presented in the public eye favored a more vigilant attitude aimed at decreasing the risks of anorexia, bulimia, and unhealthy preoccupation with weight, then sociocultural pressures toward thinness would be reduced.”
Completely agree	121 (12.6)	12.3
Somewhat agree	260 (27.0)	27.1
Somewhat disagree	274 (28.5)	28.7
Completely disagree	283 (29.4)	29.3
I don’t know	25 (2.6)	2.5
“If the images and messages presented on the public eye displayed health and realistic body images, then sociocultural pressures toward thinness would be reduced.”
Completely agree	100 (10.4)	10.3
Somewhat agree	293 (30.4)	30.5
Somewhat disagree	279 (29.0)	29.8
Completely disagree	268 (27.8)	27.1
I don’t know	23 (2.4)	2.3
Composite indicator of potential of actions proposed in Charter to reduce pressures toward thinness
High	138 (14.3)	13.9
Other	816 (84.7)	85.2
I don’t know	9 (0.9)	0.9

Note. Survey participants were 963 Québec residents.

^aEstimates were weighted for sex and age according to information from Statistics Canada.

In final multivariate logistic regression models (available from the first author upon request), education and sex were consistently and strongly associated with outcomes. Compared with people who had completed a university degree, people with lower educational achievement were less likely to spontaneously recognize the Charter (for high school education or less [HS], odds ratio [OR] = 0.35; 95% confidence interval [CI] = 0.19, 0.64 and for only trade school or junior college degree [Trade], OR = 0.39; 95% CI = 0.20, 0.76) or to recognize the Charter following prompting (OR_HS = 0.62; 95% CI = 0.45, 0.85 and OR_Trade = 0.69; 95% CI = 0.48, 0.98). People in the less-educated group were also less likely to express willingness to personally adhere to the Charter (OR_HS = 0.53; 95% CI = 0.38, 0.75). Compared with people with a university education, however, people with lower educational achievement were more likely to indicate that the Charter had high potential to sensitize people to issues of body image and disordered eating (OR_HS = 1.44; 95% CI = 1.03, 2.02 and OR_Trade = 1.45; 95% CI = 1.00, 2.09) and that the actions proposed in the Charter would result in reductions in sociocultural pressures toward thinness (OR_HS = 2.67; 95% CI = 1.67, 4.27). In addition, women were more likely to spontaneously recognize the Charter (OR = 1.77; 95% CI = 1.05, 2.98), to report being very favorable to personally adhering to it (OR = 1.72; 95% CI = 1.29, 2.29), and to indicate that the Charter had high potential for sensitizing people (OR = 1.39; 95% CI = 1.05, 1.85). For the high school or less, trade school, and university education categories, estimated proportions with spontaneous knowledge of the Charter were 6.9%, 7.4%, and 17.5% for women and 4.0%, 4.3%, and 10.7% for men, respectively.

People with daughters aged 13 to 17 years were more likely to recognize the Charter following prompting (OR = 1.74; 95% CI = 1.07, 2.82) and to report being very favorable to personally adhering to the Charter (OR = 1.88; 95% CI = 1.15, 3.09). Parents with sons aged 13 to 17 years (OR = 0.57; 95% CI = 0.33, 0.98) and people not wishing to report whether they had children (OR = 0.47; 95% CI = 0.31, 0.70) were less likely to recognize the Charter after prompting, whereas parents of boys aged birth to 12 years were more likely to report being very favorable to personally adhering to the Charter (OR = 1.76; 95% CI = 1.17, 2.63). Oddly, parents of girls aged birth to 12 years were less likely (OR = 0.36; 95% CI = 0.18, 0.74) to indicate strong agreement that actions proposed in the Charter would have an impact.

Both spontaneous recognition (OR = 2.26; 95% CI = 1.51, 4.00) and prompted recognition of the Charter (OR = 1.34; 95% CI = 1.05, 1.82) were predictive of greater likelihood of being very favorable to personally adhering to the Charter. Proportions of respondents who expressed being very favorable were as follows: 55.5% of those who spontaneously recognized it versus 33.6% of those who did not, and 40.1% of those who recognized it after prompting versus 32.8% of those who did not. Other associations observed previously remained unchanged, although people born outside of Canada were now less likely to report spontaneous (OR = 0.47; 95% CI = 0.27, 0.82) or prompted recognition (OR = 0.47; 95% CI = 0.27, 0.82) of the Charter. Furthermore, we observed that spontaneous knowledge of the Charter was not associated with perceptions of the potential of the Charter to sensitize people, nor with perceptions of the potential effects of Charter actions to reduce sociocultural pressures toward extreme thinness. Intriguingly, people reporting prompted recognition of the Charter had a lower likelihood (OR = 0.67; 95% CI = 0.50, 0.89) of reporting that the Charter had potential to sensitize people to body image and disordered eating issues.

DISCUSSION

To gauge the contribution of an initiative to overcome the unhealthy pursuit of thinness, we examined the population reach, acceptability, and perceived potential of a body image Charter aimed at reducing pressures favoring extreme thinness. Findings showed that, seizing upon a few media events and without a population-wide campaign, the Charter reached a substantial portion of the adult population, with over 35% recognizing the Charter following minimal prompting. We believe these data show that this initiative had good infiltration in the population. However, other findings indicate that to have a population impact, campaigns must reach a greater proportion of the population.^27,28

Findings also show that the reach and acceptability of the Charter were not uniform across the population. Women and people with higher education appeared to be more easily reached by, and more favorable toward, the Charter, whereas men and people with less education were more difficult to reach. These latter results are consistent with previous findings showing that health-education and advocacy efforts are less likely to reach people with lower education.^29,30 Given the significance of increasing reach (especially in lower education groups) and of ensuring acceptability and perceived value of the Charter to overcome the unhealthy pursuit of thinness, additional actions seem to be warranted. These include continued advocacy with media and industry players to effect actual changes in the images portrayed in the media and social marketing campaigns to disseminate information about the causes and consequences of disordered eating. Our belief in the potential of further dissemination efforts is bolstered by the finding that people who report spontaneous knowledge or prompted recognition of the Charter are more likely to report being very favorable to adhering to the Charter—suggesting that greater reach might also lead to stronger endorsement of actions proposed in the Charter.

This study has limitations. Because the data were self-reported, it is difficult to ascertain whether people were actually recognizing the Charter (rather than being agreeable), and whether acceptability and perceived potential will translate into actions to overcome the unhealthy pursuit of thinness. In addition, the study presents a snapshot of public opinion about the Charter taken 6 months after its launch. The population’s views may evolve across time. Continued surveillance is required to fully understand reach, acceptability, and perceived potential of the Charter and the extent to which this type of initiative may actually shift societal perceptions.

In conclusion, this study shows that a Charter aimed at encouraging healthy and diverse body images in the media, created through consensus building among interested parties and disseminated through accessible media events, can reach a substantial (but selected) portion of the adult population. Despite the extent to which overvaluation of thinness may be entrenched in our culture, the notion of mounting a social effort to reduce population pressures favoring thinness is remarkably palatable to a substantial segment of the population.