European Eating Disorders Review Eur. Eat. Disorders Rev. 9, 416426 (2001) DOI: 10.1002/erv.

410

Paper
The Relationship Between Body Size and Body Composition in Women of Different Nutritional Status
Childhood Nutrition Research Centre, Institute of Child Health, London, UK 2 Behavioural Sciences Unit, Institute of Child Health, London, UK This study analysed the relationship between weight, size, and body composition in various groups of real and fantasy women. By exploiting natural relationships between the weight and volume of human tissues, comparable data on weight, size, and body composition were obtained for healthy women from western and developing country populations, women with anorexia nervosa (AN), and fantasy gures including popular children's dolls. Women from western and developing country populations have different fatness and size despite having similar weight relative to height. Women with AN have signicantly lower fat and lean mass, and thinner size, than healthy women. Fantasy gures have body sizes similar to women with AN, implying similar body composition. In particular, children's dolls have body sizes similar to AN women at the time of death, although these effects are disguised by manipulation of body shape. Our study improves understanding of the body composition implied by manipulation of female shape and size. Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

Jonathan C. K. Wells1* and Dasha Nicholls2

1

INTRODUCTION
Clinicians are concerned with body size in women primarily in terms of two dimensions, namely body fatness and lean mass, each of which is a determinant of health. A certain level of fatness is required for healthy
*Correspondence to: J. C. K. Wells, Childhood Nutrition Research Centre, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK. Tel: 0207 242 9789 ext 2389. Fax: 0207 831 9903.

Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

European Eating Disorders Review 9(6), 416426 (2001)

Eur. Eat. Disorders Rev. 9, 416426 (2001)

Nutritional Status

menstrual function (Frisch and McArthur, 1974), while lean mass is related to skeletal mineral deposition and hence the long-term risk of osteoporosis (Kholsa et al., 1996; Ho et al., 1997). However, individuals also assess themselves in terms of overall body size and shape, and selfevaluation in these terms contributes to their sense of well-being. Concern with size/shape is most apparent in eating disorders, where dissatisfaction with weight and shape is a core feature, but it is also a source of psychological morbidity in normal teenage girls (Cooper and Goodyer, 1997; Field et al., 1999). This preoccupation with size and shape is reected in the presentation of idealized images of women by the popular media. A recent study for example reported a steady trend to lower weight relative to height in American beauty queens (Rubinstein and Caballero, 2000). Such idealized images may impact on women (and to a lesser extent men), contributing to body dissatisfaction and low self-esteem. Women may then attempt to manipulate their own shape in order to achieve the popular ideal, for example through dieting, exercise and, increasingly, plastic surgery. Interest in this issue has prompted debate as to whether the widespread publication of distorted images of body shape is a contributing factor to eating disorders (British Medical Association, 2000). Current evidence suggests that media images may be selectively misinterpreted by those susceptible to, or suffering from, eating disorders (Hamilton and Waller, 1993), but are insufcient in themselves to account for these disorders. Nevertheless, at a normal or subclinical level, attempts at weight and shape manipulation are pervasive in western culture. Little attention has been directed to the body composition that underlies different body shapes, making it difcult to evaluate the potential health risks of pursuing such idealized shapes. While the fashion and diet industries are targeted primarily at adults, exposure to idealized body images also occurs at much younger ages. Children are exposed to a range of idealized shapes, such as adult-form dolls, cartoon characters, and characters in fantasy computer games. There is little factual information available on the body composition represented by such images. However, previous research has indicated that body representations in children's toys are distorted (Sanders and Bazalgette 1994; Brownell and Napolitano 1995), which raises the possibility that exposure at comparatively young ages to such images may predispose children to accept similarly unrealistic norms for shape in later life. Furthermore, both peer pressure and media pressure favouring idealized shape have been implicated in the motivation of eating disorders in adolescent girls (Grigg et al., 1996).
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

417

J. C. K. Wells and D. Nicholls

Eur. Eat. Disorders Rev. 9, 416426 (2001)

The purpose of this paper is to investigate the relationship between nutritional status, body composition and body size in diverse categories of real and fantasy women, in order to evaluate the relative degree to which eating disorder patients and idealized gures depart from the normal range of body composition.

THE RELATIONSHIP BETWEEN VOLUME AND COMPOSITION OF THE BODY

The relationships between nutritional status, size and body composition can be explored using well-established relationships between tissue masses and volumes. Nutritional status is generally assessed using body mass index (BMI) which represents an index of weight adjusted for height. This measure cannot however quantify the relative proportions of body weight that are fat mass (FM) and fat-free mass (FFM), which together comprise what is known as the two-component model of body composition. The two tissues FM and FFM have well established densities, namely 0.90 kg/l and 1.10 kg/l respectively (Siri, 1961; Fuller et al., 1992). This means that measurements of the two components allow calculation of total body volume, while in the reverse direction, measurement of body volume in conjunction with weight allows calculation of the relative proportions of the two components in body weight, using Archimedes principle (Siri, 1961). One of the oldest methods of assessing body composition in humans is therefore densitometry, whereby body volume is measured by underwater weighing. An alternative technique for body volume measurement, whole body air-displacement plethysmography (Dempster and Aitkens, 1995), has also been developed. However, a variety of other techniques are now available for measurement of FFM and FM, including isotope dilution, total body electrical conductivity, magnetic resonance imaging, and dual-energy X-ray absorptiometry. Whichever measurement method is used, the derived information can always be expressed in terms both of masses and of volumes. Because fat is distributed primarily around the exterior of the human body, fatness can also be predicted with reasonable accuracy using anthropometric measurements, such as skinfold thickness or circumference measurements (Steinkamp et al., 1965). Although accuracy of these equations is reduced in the middle of the range of fatness, it tends to improve at the extremes of the range. Furthermore, the equations tend to be accurate when applied to groups, and they can therefore be used for statistical modelling purposes alongside other techniques.
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

418

Eur. Eat. Disorders Rev. 9, 416426 (2001)

Nutritional Status

Using a combination of these same techniques, we have derived a method whereby the body composition of idealized gures can be assessed. Volume of such gures can be measured either by water displacement, or potentially in larger gures by three-dimensional photographic scanning (Wells et al., 2000). Volumes can then be scaled to the size of real women, with a correction made for lung volume using published equations. At this stage, weight of the gure remains unknown, but it can be predicted by adding in further anthropometric measurements which predict fat mass. This information can then be used to derive the volume of fat present, and together with total volume, the fat-free volume and mass can then be obtained. Full details of this process are given in the next section. By combining these approaches, it is possible to obtain compatible data on body size and body composition in both real and idealized women for comparative purposes. It is then necessary to select an appropriate approach for this comparison. Traditionally, to compare individuals and groups, data on body composition have been expressed in terms of percentage fat. Since this is a ratio expression, it fails to exploit all the available information relating to the two body compartments, and is a misleading way of comparing individuals in terms of fatness. Two subjects can differ in percentage fat either if they have the same FFM but different FM, or if they have the same FM but different FFM. Instead, both FFM and FM should be normalized for body size by dividing by height-squared (Van Itallie et al., 1990), so that the fat-free mass index (FFMI) and the fat mass index (FMI) are calculated separately as FFM/height2 and FM/height2 respectively. It is then possible to compare both fatness and relative lean size, relative to height, in both individuals and groups.

SUBJECTS AND METHODS

Body composition was calculated for several categories of real and fantasy women, using the various approaches described above. Data on real women were used in the study only if body fatness had been measured (e.g. by underwater weighing, isotope dilution, DXA or multicomponent modelling) rather than predicted from simpler methods. Data on healthy women from western industrialised countries (n ve studies), were taken from the literature (Mayo-Smith et al., 1989; Fuller et al., 1992; Russell et al., 1994; Scal et al., 1997; Polito et al., 1998). In four of these studies, the women were control groups in studies of eating disorders, while the other group (Fuller et al., 1992) were selected from a normal healthy population. Data on healthy women
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

419

J. C. K. Wells and D. Nicholls

Eur. Eat. Disorders Rev. 9, 416426 (2001)

from developing country populations and engaged in subsistence agriculture (n ve studies) were also collated (India, Satwanti et al., 1977; New Guinea, Norgan et al., 1982; The Gambia; Lawrence et al., 1988; Benin, Schultink et al., 1992; Guatemala, Imminck et al., 1992). Based on mean BMI values, nine of these populations fell within the normal range of 2024.99 kg/m2 (Garrow and Webster, 1985), while the Indian women were just outside the range with a mean BMI of 19.5 kg/ m2. For each population a mean value of FFMI and FMI was calculated as described above. Data on women with anorexia nervosa (AN) were likewise taken from the literature (n six studies) (Mayo-Smith et al., 1989; Hannan et al., 1993; Russell et al., 1994; Probst et al., 1996; Scal et al., 1997; Polito et al., 1998). FFMI and FMI were again calculated. Data on children's dolls (Barbie; Mattel Inc, California; Sindy; Vivid Imaginations Ltd, Essex) were obtained as follows. The subjects were sealed with silicone sealant, any structural gaps in the body shape being lled in to provide a smooth body surface. Body volume was assessed using water displacement, and arm and thigh circumferences and height measured. All measurements were scaled to a height of 1.60 m, the average height of the real women described above. FM was predicted from thigh and arm circumferences (Steinkampf et al., 1965) and converted to fat volume. Fat-free volume was calculated by difference of body volume (corrected for predicted lung volume (Crapo et al., 1982) and fat volume, and converted to FFM. Finally, body mass index of a fantasy computer game character (Lara Croft, Tomb Raider, Eidos Interactive Games, www.eidos.com) was calculated using values for weight and height published on the internet (http:/ /volc.ctimes.net/prole.html). All body composition data were plotted on Hattori graphs (Hattori et al., 1997), which compare FFMI on the x-axis with FMI on the y-axis. Diagonal lines crossing the graph indicate units of BMI and percentage fat. Between-group comparisons were made using t-tests. All analyses were performed using a Minitab Release 10.51 Xtra (Minitab Inc, Philadelphia, USA) software package.

RESULTS
Comparison of women from western and developing country populations showed that despite having similar BMI values (see Table 1), the proportion of weight that was FFM and FM differed. The developing country women had greater FFMI (p 0.08) and lower fatness (p < 0.01)
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

420

Eur. Eat. Disorders Rev. 9, 416426 (2001)

Nutritional Status

Table 1. Body composition and BMI in western women, developing country women, and women with anorexia nervosa
FFMI Mean Western Developing country Anorexia nervosa 15.7 16.2 13.1 y SD 0.4 0.5 0.5 FMI Mean 5.8 4.2 * 2.4 y SD 0.5 0.6 0.3 BMI Mean 21.5 20.5 15.5 y SD 0.9 0.7 0.3

*Western versus developing country (p < 0.01). y Anorexia nervosa versus western or developing country (p < 0.005).

for their height. These differences in body masses translate into volume differences, so that the western women were on average 3.4% heavier, but had 5.0% greater volume, for their height. The AN women had signicantly reduced FFMI and FMI compared to both western and developing country populations (p < 0.005 for all comparisons, see Figure 1), and therefore had much reduced BMI values, ranging from 15.1 to 16.8 kg/m2 (p < 0.001). Volume relative to

Figure 1. Body composition in western, developing country and anorexic women, and in children's dolls. Fat mass index (FMI) is plotted on the y-axis, fat-free mass index (FFMI) on the x-axis. Diagonal lines represent percentage fat and body mass index.
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

421

J. C. K. Wells and D. Nicholls

Eur. Eat. Disorders Rev. 9, 416426 (2001)

Table 2. Anthropometry and body composition of Barbie and Sindy dolls, scaled to a height of 1.60 m
Weight (kg) Barbie Sindy 32.8 31.1 BMI (kg/m2) 12.4 11.8 FFM (kg) 28.1 29.3 FM (kg) 4.7 1.8

height was reduced by 28.2% compared to the western women, and by 24.6% compared to the developing country women. The small sample size for the children's dolls precludes formal statistical analysis. However, Table 2 shows that the dolls have BMI values considerably lower than the AN women, at around 10 to 12 kg/m2. Graphic analysis (Figure 1) indicates that their FFMI and FMI are both reduced compared to AN women, due to their volumes relative to height being on average 23.4% lower. The difference in fatness between the two dolls is due almost entirely to the smaller arm circumference of Sindy. The fantasy computer game character Lara Croft has a BMI value of 16.9 kg/m2, which is comparable to that of the women with AN. No data on volume or body composition were available, but she can be seen to lie very close to the line representing the BMI value of 17 kg/m2. Her volume must be reasonably close to that of the women with AN, depending on how much of her weight is FM and FFM.

DISCUSSION
We have utilized well-known relationships between body mass, body size and body composition in humans to provide independent indices of body fatness, relative lean mass, and size in real and fantasy women. In adults, BMI is used to distinguish undernutrition through the denition of chronic energy deciency (BMI < 18.5 kg/m2) (James et al., 1988). Starvation, wasting diseases and eating disorders are associated with BMIs well below 18.5, with a theoretical lower limit compatible with life of around 10 or 11. If the eating disorder AN were to be classied solely on the basis of size, then the idealized images considered here would all qualify for the diagnosis. In contrast, the women from developing countries, though leaner than their western counterparts, are well above the threshold for malnutrition. Comparison of nutritional status and body composition reveals that women from developing countries have a different body composition and volume compared to western women for a similar
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

422

Eur. Eat. Disorders Rev. 9, 416426 (2001)

Nutritional Status

body mass. Their greater FFM may be attributable to the greater activity levels required by subsistence agriculture, so that the western women are fatter but not heavier. These differences indicate that on average the western women have a slightly larger volume for a given weight and therefore appear slightly larger for the same BMI. We have shown that the BMI values of children's dolls are not only far lower than those of both western and developing country women, but also signicantly lower than those of AN women. The BMI values are close to those of AN women at the time of their death (Moller-Madsen et al., 1996; Herzog et al., 1997). Figure 1 indicates that the paucity of FFM is even more extreme than that of FM. The computer game character Lara Croft also has a BMI within the range characteristic of AN women, despite her `reputation' for vigorous health and activity levels. Our study indicates that in terms of volume, fantasy women are as thin as, or thinner than, women with severe eating disorders. Paradoxically, the gures look slim but not chronically ill. It is necessary to consider therefore how this manipulation has been achieved. There are two reasons: rst, the waist and thighs appear less deformed than they actually are because the hips have also been reduced (Sanders and Bazalgette 1994); second, the emaciated condition is belied by generous bust sizes. No real woman could reproduce similar proportions if her total body fatness were so low. Thus the idealized images have been selectively deformed to make them look slim yet apparently healthy. The ridiculously thin limbs do not appear to be wasted because of the manipulation of key torso dimensions, so the effect of this distortion is to make the body look tall and slim. The larger hip size, relative to height, of real women makes this kind of slimness unattainable. Previous studies of children's dolls have identied the distortion of body proportions, but have been unable to express the consequences of these effects in conventional terms of nutritional status. Our study has attempted to resolve this issue, by using established relationships between body composition and size to calculate the fatness and lean size represented by fantasy gures. Our study conrms that the distortions of body size represented by idealized images are not trivial, but are equivalent to serious malnutrition. Furthermore, we emphasize that idealized shapes impact as much on lean size as on fatness, implying that in women seeking to emulate these ideals there may be important long-term clinical implications. However, the distortion of size is partially camouaged by manipulation of key aspects of shape. We do not know whether children or adults can distinguish size ideals from shape ideals, and we suggest that further research is needed on the impact that such images may have on children's subsequent attitudes to their own bodies.
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

423

J. C. K. Wells and D. Nicholls

Eur. Eat. Disorders Rev. 9, 416426 (2001)

REFERENCES
British Medical Association. 2000. Eating Disorders, Body Image and the Media. British Medical Association: London. Brownell KD, Napolitano MA. 1995. Distorting reality for children: body size proportions of Barbie and Ken dolls. International Journal of Eating Disorders 18: 295298. Cooper PJ, Goodyer I. 1997. Prevalence and signicance of weight and shape concerns in girls aged 1116 years. British Journal of Psychiatry 171: 542544. Crapo RO, Morris AH, Clayton PD, Nixon CR. 1982. Lung volumes in healthy non-smoking adults. Bulletin Europeen de Physiopathologie Respiratoire 18: 419425. Dempster P, Aitkens S. 1995. A new air displacement method for the determination of human body composition. Medicine and Science in Sports and Exercise 27: 16921697. Field AE, Cheung L, Wolf AM, Herzog DB, Gortmaker SL, Colditz GA. 1999. Exposure to the mass media and weight concerns among girls. Pediatrics 103: E36. Frisch RE, McArthur JW. 1974. Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset. Science 185: 949951. Fuller NJ, Jebb SA, Laskey MA, Coward WA, Elia M. 1992. Four-component model for the assessment of body composition in humans: comparison with alternative methods, and evaluation of the density and hydration of fat-free mass. Clinical Science 82: 687693. Garrow JS, Webster J. 1985. Quetelet's index (W/H2) as a measure of fatness. International Journal of Obesity 9: 147153. Grigg M, Bowman J, Redman S. 1996. Disordered eating and unhealthy weight reduction practices among adolescent females. Preventive Medicine 25: 748756. Hamilton K, Waller G. 1993. Media inuences on body size estimation in anorexia and bulimia: an experimental study. British Journal of Psychiatry 162: 837840. Hannan WJ, Cowen SJ, Freeman CP, Wrate M. 1993. Can bioelectrical impedance analysis improve the prediction of body fat in patients with eating disorders? European Journal of Clinical Nutrition 47: 741746. Hattori K, Tatsumi N, Tanaka S. 1997. Assessment of body composition using a new chart method. American Journal of Human Biology 9: 573578. Herzog W, Deter H-C, Fiehn W, Petzold E. 1997. Medical ndings and predictors of long-term physical outcome in anorexia nervosa: a prospective, 12-year follow-up study. Psychological Medicine 27: 269279. Ho SC, Wong E, Cha SG, Lau J, Chan C, Leung PC. 1997. Determinants of peakbone mass in Chinese women aged 2140. III. Physical activity
Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

424

Eur. Eat. Disorders Rev. 9, 416426 (2001)

Nutritional Status

and bone mineral density. Journal of Bone and Mineral Research 12: 262271. Imminck MDC, Flores A, Diaz EO. 1992. Body mass index, body composition and the chronic energy deciency classication of rural populations in Guatemala. European Journal of Clinical Nutrition 46: 419427. James WPT, Ferro-Luzzi A, Waterlow JC. 1988. Denition of chronic energy deciency in adults. European Journal of Clinical Nutrition 42: 969981. Kholsa S, Atkinson EJ, Riggs BL, Melton LJ. 1996. Relationship between body composition and bone mass in women. Journal of Bone and Mineral Research 11: 857863. Lawrence M, Thongprasert K, Durnin JVGA. 1988. Between-group differences in basal metabolic rates: an analysis of data collected in Scotland, The Gambia and Thailand. European Journal of Clinical Nutrition 42: 877891. Mayo-Smith W, Hayes CW, Biller B, Klibanski A, Rosenthal H, Rosenthal D. 1989. Body fat distribution measured with CT: correlations in healthy subjects, patients with anorexia nervosa, and patients with Cushing Syndrome. Radiology 170: 515518. Moller-Madsen S, Nystrup J, Nielsen S. 1996. Mortality of anorexia nervosa in Denmark during the period 19701987. Acta Psychiatrica Scandinavica 94: 454459. Norgan NG, Ferro-Luzzi A, Durnin JVGA. 1982. The body composition of New Guinean adults in contrasting environments. Annals of Human Biology 9: 343353. Polito A, Cuzzolaro M, Raguzzini A, Censi L, Ferro-Luzzi A. 1998. Body composition changes in anorexia nervosa. European Journal of Clinical Nutrition 52: 655662. Probst M, Goris M, Vandereycken W, van Coppenolle H. 1996. Body composition in female anorexia nervosa patients. British Journal of Nutrition 76: 639647. Rubinstein S, Caballero B. 2000. Is Miss America an undernourished role model? Journal of American Medical Association 283: 1569. Russell JD, Mira N, Allen BJ, Stewart PM, Vizzard J, Arthur B, Beumont PJ. 1994. Protein repletion and treatment in anorexia nervosa. American Journal of Clinical Nutrition 59: 98102. Sanders T, Bazalgette P. 1994. You Don't Have to Diet. Transworld Publishing Ltd.: London. Satwanti KM, Bharadwaj H, Singh IP. 1977. Relationship of body density to body measurements in young Punjabi women: applicability of body composition prediction equations developed for women of European descent. Human Biology 49: 203213. Scal L, Bedogni G, Marra M, Di Biase G, Caldara A, Severi S, Contaldo F, Battistini N. 1997. The prediction of total body water from bioelectrical impedance in patients with anorexia nervosa. British Journal of Nutrition 78: 357365. 425

Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

J. C. K. Wells and D. Nicholls

Eur. Eat. Disorders Rev. 9, 416426 (2001)

Schultink WJ, Lawrence M, van Raaij JMA, Scott WM, Hautvast GAJ. 1992. Body composition of rural Beninese women in different seasons assessed by skinfold thicknesses and bioelectrical impedance measurements and by a deuterium oxide dilution technique. American Journal of Clinical Nutrition 55: 321325. Siri WE. 1961. Body composition from uid spaces and density: analysis of methods. In Techniques for Measuring Body Composition, Brozek J, Henschel A, (eds). National Academy of Sciences NRC: Washington, DC. Steinkamp RC, Cohen NL, Gaffey WR, McKey T, Bron G, Siri WE, Sargent TW, Isaacs E. 1965. Measures of body fat and related factors in normal adults II. A simple clinical method to estimate body fat and lean body mass. Journal of Chronic Diseases 18: 12911307. Van Itallie TB, Yang M, Heymseld SB, Funk RC, Boileau RA. 1990. Heightnormalised indices of the body's fat-free and fat mass: potentially useful indicators of nutritional status. American Journal of Clinical Nutrition 52: 953959. Wells JCK, Douros I, Fuller NJ, Elia M, Dekker L. 2000. Assessment of body volume using three-dimensional photonic scanning. Annals of the New York Academy of Sciences (in press).

Copyright # 2001 John Wiley & Sons, Ltd and Eating Disorders Association.

426

Copyright of European Eating Disorders Review is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.