European Eating Disorders Review Eur. Eat. Disorders Rev. 9, 416±426 (2001) DOI: 10.1002/erv.
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 signi®cantly 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
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), 416±426 (2001)
such as adult-form dolls. and selfevaluation in these terms contributes to their sense of well-being. Field et al. 9.. exposure to idealized body images also occurs at much younger ages. Eat. Little attention has been directed to the body composition that underlies different body shapes. There is little factual information available on the body composition represented by such images. attempts at weight and shape manipulation are pervasive in western culture. increasingly. Ho et al. making it dif®cult to evaluate the potential health risks of pursuing such idealized shapes. individuals also assess themselves in terms of overall body size and shape. Children are exposed to a range of idealized shapes. However. 2000). 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. 1999). Disorders Rev. plastic surgery. 1974). Ltd and Eating Disorders Association. cartoon characters.
Copyright # 2001 John Wiley & Sons. but it is also a source of psychological morbidity in normal teenage girls (Cooper and Goodyer.. Current evidence suggests that media images may be selectively misinterpreted by those susceptible to. However.Eur. and characters in fantasy computer games. both peer pressure and media pressure favouring idealized shape have been implicated in the motivation of eating disorders in adolescent girls (Grigg et al. Brownell and Napolitano 1995). eating disorders (Hamilton and Waller. 1996. A recent study for example reported a steady trend to lower weight relative to height in American beauty queens (Rubinstein and Caballero. 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. but are insuf®cient in themselves to account for these disorders. Concern with size/shape is most apparent in eating disorders. or suffering from. at a normal or subclinical level. Such idealized images may impact on women (and to a lesser extent men). for example through dieting. While the fashion and diet industries are targeted primarily at adults.
. where dissatisfaction with weight and shape is a core feature. Women may then attempt to manipulate their own shape in order to achieve the popular ideal.. while lean mass is related to skeletal mineral deposition and hence the long-term risk of osteoporosis (Kholsa et al. 1997).. 1996). 1993). contributing to body dissatisfaction and low self-esteem. Furthermore. 2000). exercise and. Nevertheless. 416±426 (2001)
menstrual function (Frisch and McArthur. This preoccupation with size and shape is re¯ected in the presentation of idealized images of women by the popular media. previous research has indicated that body representations in children's toys are distorted (Sanders and Bazalgette 1994. 1997.
and dual-energy X-ray absorptiometry.90 kg/l and 1. the derived information can always be expressed in terms both of masses and of volumes. whole body air-displacement plethysmography (Dempster and Aitkens. measurement of body volume in conjunction with weight allows calculation of the relative proportions of the two components in body weight. Fuller et al. 9.
. and they can therefore be used for statistical modelling purposes alongside other techniques. K. Because fat is distributed primarily around the exterior of the human body. 1961.10 kg/l respectively (Siri. using Archimedes principle (Siri.
Copyright # 2001 John Wiley & Sons. which together comprise what is known as the two-component model of body composition. Furthermore. This measure cannot however quantify the relative proportions of body weight that are fat mass (FM) and fat-free mass (FFM). it tends to improve at the extremes of the range. 416±426 (2001)
The purpose of this paper is to investigate the relationship between nutritional status. 1992). One of the oldest methods of assessing body composition in humans is therefore densitometry. This means that measurements of the two components allow calculation of total body volume. a variety of other techniques are now available for measurement of FFM and FM. Disorders Rev. An alternative technique for body volume measurement. total body electrical conductivity. Nutritional status is generally assessed using body mass index (BMI) which represents an index of weight adjusted for height. in order to evaluate the relative degree to which eating disorder patients and idealized ®gures depart from the normal range of body composition. fatness can also be predicted with reasonable accuracy using anthropometric measurements. Eat. size and body composition can be explored using well-established relationships between tissue masses and volumes.J. whereby body volume is measured by underwater weighing. Although accuracy of these equations is reduced in the middle of the range of fatness. 1961). Nicholls
Eur. 1995). has also been developed. magnetic resonance imaging. while in the reverse direction. body composition and body size in diverse categories of real and fantasy women. including isotope dilution.
THE RELATIONSHIP BETWEEN VOLUME AND COMPOSITION OF THE BODY
The relationships between nutritional status.. 1965). The two tissues FM and FFM have well established densities. Wells and D. namely 0. the equations tend to be accurate when applied to groups. Ltd and Eating Disorders Association.. However. such as skinfold thickness or circumference measurements (Steinkamp et al. Whichever measurement method is used. C.
2000). Disorders Rev.. Data on real women were used in the study only if body fatness had been measured (e. using the various approaches described above. Ltd and Eating Disorders Association. Eat. This information can then be used to derive the volume of fat present.. with a correction made for lung volume using published equations. the women were control groups in studies of eating disorders. Volumes can then be scaled to the size of real women.. 9. or potentially in larger ®gures by three-dimensional photographic scanning (Wells et al. Two subjects can differ in percentage fat either if they have the same FFM but different FM. In four of these studies. were taken from the literature (Mayo-Smith et al. weight of the ®gure remains unknown. 1992) were selected from a normal healthy population.. 1992. Since this is a ratio expression. By combining these approaches. It is then possible to compare both fatness and relative lean size. it fails to exploit all the available information relating to the two body compartments.
SUBJECTS AND METHODS
Body composition was calculated for several categories of real and fantasy women. or if they have the same FM but different FFM. Data on healthy women
Copyright # 2001 John Wiley & Sons. DXA or multicomponent modelling) rather than predicted from simpler methods. it is possible to obtain compatible data on body size and body composition in both real and idealized women for comparative purposes. to compare individuals and groups. Russell et al.g. 1998). Data on healthy women from western industrialised countries (n ®ve studies). so that the fat-free mass index (FFMI) and the fat mass index (FMI) are calculated separately as FFM/height2 and FM/height2 respectively. in both individuals and groups. Full details of this process are given in the next section. and is a misleading way of comparing individuals in terms of fatness. isotope dilution.. At this stage. the fat-free volume and mass can then be obtained.
.Eur. but it can be predicted by adding in further anthropometric measurements which predict fat mass. 1990). while the other group (Fuller et al. we have derived a method whereby the body composition of idealized ®gures can be assessed. It is then necessary to select an appropriate approach for this comparison. by underwater weighing. 1997. Polito et al. 416±426 (2001)
Using a combination of these same techniques. and together with total volume.. Scal® et al.. data on body composition have been expressed in terms of percentage fat. Traditionally. both FFM and FM should be normalized for body size by dividing by height-squared (Van Itallie et al. 1989. Fuller et al. relative to height. Instead. 1994.. Volume of such ®gures can be measured either by water displacement.
Copyright # 2001 John Wiley & Sons. All measurements were scaled to a height of 1. and arm and thigh circumferences and height measured...51 Xtra (Minitab Inc. Data on children's dolls (Barbie. USA) software package. 1982) and fat volume. 1988. Philadelphia. 1977. while the Indian women were just outside the range with a mean BMI of 19.. 1982. Fat-free volume was calculated by difference of body volume (corrected for predicted lung volume (Crapo et al. 1996. All body composition data were plotted on Hattori graphs (Hattori et al. All analyses were performed using a Minitab Release 10. Imminck et al.99 kg/m2 (Garrow and Webster.. 1992.. Based on mean BMI values..5 kg/ m2. FM was predicted from thigh and arm circumferences (Steinkampf et al.60 m. Essex) were obtained as follows.ctimes. body mass index of a fantasy computer game character (Lara Croft. The subjects were sealed with silicone sealant. FFMI and FMI were again calculated. Guatemala.. The Gambia. For each population a mean value of FFMI and FMI was calculated as described above. C. Wells and D.. Polito et al. Tomb Raider. 9.
.. Satwanti et al. Ltd and Eating Disorders Association.com) was calculated using values for weight and height published on the internet (http:/ /volc. Russell et al. Hannan et al. 1993. Data on women with anorexia nervosa (AN) were likewise taken from the literature (n six studies) (Mayo-Smith et al.
Comparison of women from western and developing country populations showed that despite having similar BMI values (see Table 1).. California. 1965) and converted to fat volume. Eidos Interactive Games. Scal® et al. 1998). Body volume was assessed using water displacement. www. Vivid Imaginations Ltd.net/pro®le. Disorders Rev. the proportion of weight that was FFM and FM differed. Nicholls
Eur. Schultink et al. nine of these populations fell within the normal range of 20±24. Between-group comparisons were made using t-tests.. the average height of the real women described above. 1985).. Norgan et al.eidos. 1992). 1989. 1997). Probst et al..html). which compare FFMI on the x-axis with FMI on the y-axis. K.. and converted to FFM. The developing country women had greater FFMI (p 0. 416±426 (2001)
from developing country populations and engaged in subsistence agriculture (n ®ve studies) were also collated (India. New Guinea. Diagonal lines crossing the graph indicate units of BMI and percentage fat. 1994. Finally. any structural gaps in the body shape being ®lled in to provide a smooth body surface. Eat.J. Lawrence et al. Mattel Inc. Sindy. Benin. 1997.08) and lower fatness (p < 0.
so that the western women were on average 3. y Anorexia nervosa versus western or developing country (p < 0.0% greater volume.6 0.01). and in children's dolls.Eur.9 0.005 for all comparisons. Eat. ranging from 15. developing country women.7 0.8 kg/m2 (p < 0.
Copyright # 2001 John Wiley & Sons.5 FMI Mean 5. see Figure 1). and women with anorexia nervosa
FFMI Mean Western Developing country Anorexia nervosa 15. and therefore had much reduced BMI values. Volume relative to
Figure 1.4 0.7 16.005). 416±426 (2001)
Table 1.1 y SD 0.001).2 13.4 y SD 0.5 15.2 * 2.1 to 16.5 0. Disorders Rev.5 0. The AN women had signi®cantly reduced FFMI and FMI compared to both western and developing country populations (p < 0.3 BMI Mean 21. These differences in body masses translate into volume differences.
for their height. Ltd and Eating Disorders Association.
.8 4. developing country and anorexic women. fat-free mass index (FFMI) on the x-axis. Fat mass index (FMI) is plotted on the y-axis.3
*Western versus developing country (p < 0.4% heavier.5 y SD 0. Diagonal lines represent percentage fat and body mass index. 9. but had 5.5 20. Body composition and BMI in western women. for their height. Body composition in western.
the women from developing countries. 9. The small sample size for the children's dolls precludes formal statistical analysis.
We have utilized well-known relationships between body mass.
. Starvation. 416±426 (2001)
Table 2.1 BMI (kg/m2) 12. In adults.9 kg/m2. BMI is used to distinguish undernutrition through the de®nition of chronic energy de®ciency (BMI < 18. Nicholls
Eur. No data on volume or body composition were available. though leaner than their western counterparts. which is comparable to that of the women with AN. depending on how much of her weight is FM and FFM. then the idealized images considered here would all qualify for the diagnosis.8
height was reduced by 28.60 m
Weight (kg) Barbie Sindy 32.J. wasting diseases and eating disorders are associated with BMIs well below 18. and size in real and fantasy women.5 kg/m2) (James et al. 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. In contrast. Table 2 shows that the dolls have BMI values considerably lower than the AN women. 1988). scaled to a height of 1. Her volume must be reasonably close to that of the women with AN. Ltd and Eating Disorders Association.1 29. Disorders Rev.8 FFM (kg) 28. Eat. If the eating disorder AN were to be classi®ed solely on the basis of size. due to their volumes relative to height being on average 23.5. However. The difference in fatness between the two dolls is due almost entirely to the smaller arm circumference of Sindy.6% compared to the developing country women. at around 10 to 12 kg/m2. K. C. Graphic analysis (Figure 1) indicates that their FFMI and FMI are both reduced compared to AN women. Wells and D. but she can be seen to lie very close to the line representing the BMI value of 17 kg/m2. and by 24.4% lower.4 11..3 FM (kg) 4. with a theoretical lower limit compatible with life of around 10 or 11.8 31.7 1. are well above the threshold for malnutrition. body size and body composition in humans to provide independent indices of body fatness. The fantasy computer game character Lara Croft has a BMI value of 16.2% compared to the western women. Anthropometry and body composition of Barbie and Sindy dolls. relative lean mass.
women with severe eating disorders. 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. Thus the idealized images have been selectively deformed to make them look slim yet apparently healthy. 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. No real woman could reproduce similar proportions if her total body fatness were so low. or thinner than. implying that in women seeking to emulate these ideals there may be important long-term clinical implications. by using established relationships between body composition and size to calculate the fatness and lean size represented by fantasy ®gures. The computer game character Lara Croft also has a BMI within the range characteristic of AN women. relative to height. 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. Our study has attempted to resolve this issue. 9. The larger hip size. Paradoxically. the ®gures look slim but not chronically ill. the waist and thighs appear less deformed than they actually are because the hips have also been reduced (Sanders and Bazalgette 1994). Figure 1 indicates that the paucity of FFM is even more extreme than that of FM. 1996. The BMI values are close to those of AN women at the time of their death (Moller-Madsen et al. Herzog et al. Ltd and Eating Disorders Association.
. Disorders Rev. so the effect of this distortion is to make the body look tall and slim. second. Their greater FFM may be attributable to the greater activity levels required by subsistence agriculture. Our study indicates that in terms of volume. fantasy women are as thin as. There are two reasons: ®rst. but are equivalent to serious malnutrition. so that the western women are fatter but not heavier. the distortion of size is partially camou¯aged by manipulation of key aspects of shape. It is necessary to consider therefore how this manipulation has been achieved. but have been unable to express the consequences of these effects in conventional terms of nutritional status. Our study con®rms that the distortions of body size represented by idealized images are not trivial. but also signi®cantly lower than those of AN women.Eur. Eat. the emaciated condition is belied by generous bust sizes. despite her `reputation' for vigorous health and activity levels. The ridiculously thin limbs do not appear to be wasted because of the manipulation of key torso dimensions.
Copyright # 2001 John Wiley & Sons.. Previous studies of children's dolls have identi®ed the distortion of body proportions. However. Furthermore.. 1997). we emphasize that idealized shapes impact as much on lean size as on fatness. We do not know whether children or adults can distinguish size ideals from shape ideals. 416±426 (2001)
body mass. of real women makes this kind of slimness unattainable.
1997. Physical activity
Copyright # 2001 John Wiley & Sons. 9. Gortmaker SL. Lung volumes in healthy non-smoking adults. Assessment of body composition using a new chart method. Tanaka S. Hannan WJ. 1992. 416±426 (2001)
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