Introduction
Body image is a multidimensional construct comprised of how one thinks, acts, and feels toward their physical appearance (71). Those with poor body image may perceive themselves as unattractive or overweight, insufficiently muscular, or too thin and frail (16). As a result, these individuals are at risk for developing symptoms of depression, stress, anxiety, and signs of eating disorders, and muscle dysmorphia (1,18,41,59,78). The prevalence rates of poor body image have increased from 56% of women and 43% of men in 1997 (28) to upward of 72% of women and 61% of men in 2014 (25). Research suggests that the development and progression of poor body image can be attributed to multiple sociocultural influences, such as the mass media, parents, and peers (48,62). In particular, the Sociocultural Theory and the Social Comparison Theory are 2 theoretical frameworks proposed to help explain the development of poor body image (16,47,70).
The Sociocultural Theory proposes that poor body image can develop through the media's portrayal of the ideal physique for men and women (48) and through pressure from parents and peers who place a strong emphasis on having an attractive body (43). Individuals exposed to these messages may internalize the advantages of having an attractive body (e.g., more likely to find an attractive mate) (21) and the disadvantages of having an unattractive body (e.g., low desirability) (6). Subsequently, these individuals may engage in risky behaviors (e.g., extreme dieting and anabolic steroid use) in pursuit of a body considered ideal and attractive (2,55).
The Social Comparison Theory suggests that individuals compare themselves to either those who are considered to be further from an ideal (downward comparison), which is hypothesized to enhance positive self-perceptions or those who are considered to be closer to an ideal (upward comparison), which is hypothesized to decrease positive self-perceptions (47,70). As it pertains to body image, upward comparisons are linked to decreases in body image (47), and although some research suggests that the direction of the comparison is not always congruent with perceived body image (12), comparisons are likely an important factor, as recent evidence shows that individuals who more frequently compare their physiques to upward comparisons demonstrate the highest levels of poor body image (16).
Personality differences may also contribute to poor body image, as individuals with a poor self-concept are more likely to be influenced by threats toward their body (17). Recent research suggests that autonomy may play a role in the degree to which one internalizes the ideal physique and that an inverse relationship exists between levels of autonomy and the degree to which one is influenced by sociocultural pressures (22).
Given the adverse effects poor body image can have on physical and mental health, research elucidating the most effective treatment methods is needed. To date, educational programs, psychotherapy (e.g., cognitive behavioral therapy), and pharmacological treatments have yielded promising results (15,39,54,57). However, several barriers prevent their widespread use, such as cost, availability, and stigma (especially for men) (56). Exercise may be an effective alternative, as several studies have shown that it can improve body image (12,36,61). The hypothesized mechanisms of action include improvements in self-esteem, self-efficacy, and subjective and objective indicators of physical fitness and body composition, as well as reductions in emotional distress and symptoms of anxiety and depression (3,23,32,65,72).
Currently, the majority of this research has focused on aerobic training, with little attention given to resistance training. As a result, meta-analyses have problematically combined resistance training with other anaerobic activities (e.g., bowling, sprinting and playing sports) into a single group for analysis (36,61), although other studies have combined resistance training with other types of interventions (e.g., nutrition counseling, aerobic training, and psychological treatment) (7,8,10,19,29,31,33,37). The most recent meta-analysis compared aerobic training, resistance training, and combination interventions and found no significant differences; however, there were more than 5 times as many studies that focused on the independent effects of aerobic training (n = 36) than there were for resistance training (n = 7) (12).
These multimodal methods and interventions combined with the lack of research focus have therefore prevented an examination of the independent effects of resistance training on body image. Such an analysis is necessary given the unique benefits resistance training may provide for those with poor body image. For example, unlike other types of exercise, resistance training is well known to produce significant increases in muscular strength and mass (77); a change that is well matched to the contemporary ideal physique for men (58) and one that would clearly benefit men or women who are dissatisfied with their current level of muscularity or muscle tone. Moreover, changes that result from resistance training are not limited to just morphological transformations, as resistance training can also provide immediate feedback on one's level of muscular strength and functional capabilities. This could potentially lead to a de-emphasis on how one perceives their physical appearance (30).
As the research testing the effects of resistance training on body image continues to develop, there remains a need for a detailed guide that can offer direction and guidance for future research. Thus, the primary purpose of this review was to systematically identify and appraise the most up-to-date literature that has tested the independent effects of resistance training on body image in adults. Recommendations for future research are also included.
Methods
Experimental Approach to the Problem
PRISMA guidelines were followed to conduct this systematic review (45). An electronic search of PubMed, Web of Science, PsycNET, and Scopus was performed to locate eligible studies through December 2016. The following search terms were used to locate eligible studies: “body image,” “body satisfaction,” “exercise,” “strength training,” “resistance exercise,” “resistance training,” “weightlifting,” and “weight training.” To be included, studies had to meet the following criteria: (a) written in English, (b) published in a peer-reviewed journal, (c) conducted an assessment of body image using a validated scale before and after a stand-alone resistance training intervention (i.e., not coupled with another mode of treatment), and (d) excluded participants younger than 18 years. Titles and abstracts were reviewed to remove study duplicates and those not meeting inclusion criteria. Full texts were obtained for studies that met inclusion criteria and for studies where a determination could not be made based on the abstract. The references from the included studies were reviewed as an additional search.
Included studies were assessed using the Physiotherapy Evidence Database (PEDro) scale, which is based on the Delphi questions (74). The PEDro scale measures the methodological quality of individual studies based on a set of core items devised by experts (74). Questions pertain to whether eligibility criteria is clearly specified within the manuscript, participants are randomized to different groups, allocation is concealed (i.e., sealed envelope), and subjects, therapists who administered the treatment, and assessors are blinded to which group is receiving the treatment (74). The PEDro scores range from 1 to 10, with scores of 6 or higher considered high quality and scores of less than 6 considered low quality (51).
Results
The electronic search identified 7,324 studies for screening. Of these, 7,236 were excluded after reviewing titles and abstracts, removing duplicates, and studies not meeting inclusion criteria. Of the remaining 88 studies, 11 met full inclusion criteria (Figure 1). The PEDro scores for studies in this review ranged from 3 to 7 (mean = 5), and 3 of the 11 studies were considered high quality (Table 1) (5,32,69).
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Figure 1.: Flow diagram of search results.
Table 1.: Study characteristics.*
Table 1-A.: Study characteristics.*
Study Characteristics
The 11 studies meeting full inclusion criteria were published from 1991 to 2016. There were a total of 754 participants (women = 600, 80%; men = 154, 20%), aged 18–62 years. Six studies had female-only samples (20,27,32,38,64,73), 3 studies had a mixed sample of both male and female participants (30,44,69), and 2 studies had male-only samples (5,75).
There were large variations in the resistance training program design. Intervention length ranged from 1 to 24 weeks, the total number of sessions during the intervention ranged from 1 to 48, and the intensity of sessions ranged from moderate to high. On average, participants attended sessions 2.5 days per week (range = 1–5 days) for 45 minutes (range = 30–60 minutes) per session. Characteristics of each study are highlighted in Table 2.
Table 2.: Physiotherapy Evidence Database (PEDro) ratings of included studies (n = 11).
Among the 11 included studies, 2 compared the effects of resistance training to a no-exercise group (38,44), 4 compared resistance training to another type of exercise (20,27,32,73), 3 compared resistance training to another type of exercise and a no-exercise control group (5,69,75), and 1 study compared changes in body image between men and women after resistance training (30). One study used a single-group design and did not compare resistance training to another type of exercise or between genders (64). In addition, participants in 4 studies exercised in a group (20,27,30,44), participants in 6 studies exercised independently (4,32,38,64,73,75), and it was unclear if participants in 1 study exercised in a group or independently (69). Further details of these comparisons are presented in the following section.
Comparisons
Resistance Training vs. No Exercise
There were 2 studies that compared resistance training to no exercise, and both were considered low quality based on their PEDro score (38,44). Participants in both studies were enrolled into a resistance training or no-exercise control group without random assignment. One study reported that participants had a mean age of 23.8 years (44), and the other study had a mean age of 45.5 years (38). The resistance training protocols used in the 2 studies ranged from 16 to 24 weeks and 2–3 sessions each week for between 30 and 60 minutes. Body image was assessed in one study with the Body Cathexis Scale (44) and in the other study with the Body Satisfaction Scale (38). Results from both studies found that body image did not significantly improve for the resistance training or control group.
Resistance Training vs. Other Exercise
A total of 4 studies were included in this category (20,27,32,73), and only 1 study was considered high quality based on its PEDro score (32). The studies by Tucker and Mortell (73) and Martin Ginis et al. (32) used random assignment, the study by Depcik and Williams (20) enrolled participants into a resistance training or active control group without random assignment, and Gammage et al. (27) used a single-session crossover design. Participants in the 3 longitudinal studies ranged in mean age from 21.5 to 42.5 years. The resistance training protocols ranged from 8 to 13 weeks and 2–3 sessions each week. Only Depcik and Williams (20) and Martin Ginis et al. (32) reported on the session length, which ranged between 45 and 50 minutes each session. The control group participants in one study performed non-resistance training exercise (20) and those in the other 2 studies did aerobic training (32,73). To assess changes in body image, 1 study used the Body Cathexis Scale (73); 1 study used the Appearance Evaluation Scale, the Body Areas Satisfaction Scale, and the Social Physique Anxiety Scale (32); and 1 study used the Body Cathexis Scale and the Body Shape Questionnaire (20). Two of the 3 longitudinal studies found that body image significantly improved after resistance training compared with the active control group (20,73). The other study found that aerobic training was more effective than resistance training at reducing social physique anxiety and at improving appearance evaluation (32).
The average age of the participants in the study that used a crossover design was 18.9 years (27). Participants completed a single session of resistance training and hatha yoga in a counterbalanced fashion for 30 minutes each. Body image was assessed before and after each session with the Body Image States Scale and the State Social Physique Anxiety Scale. There was a significant reduction in social physique anxiety in response to both types of exercise, but only hatha yoga was found to improve state body image (27).
Resistance Training vs. Other Exercise vs. No Exercise
Three studies were included in this category (5,69,75) and 2 were considered high quality based on their PEDro score (5,69). The studies conducted by Anderson et al. (5) and Taspinar et al. (69) used random assignment, and the study by Waldorf et al. (75) used a quasi-experimental, single-session crossover design. Participants in the 2 longitudinal studies ranged in age from 18 to 40 years (5,69). The resistance training protocols ranged from 6 to 7 weeks and included 3 sessions each week for between 30 and 50 minutes. The active control group in one study did aerobic training (5) and those in the other study did hatha yoga (69). Both studies also included a no-exercise control group. To assess changes in body image, one study used the Body Cathexis Scale (69), and the authors of the other study developed their own visual analog scale (5). Taspinar et al. (69) found that body image significantly improved for the resistance training and hatha yoga group compared with the no-exercise control group but improved more for the resistance training group. Anderson et al. (5) found that body image did not significantly improve for any group.
The average age of the participants in the study that used a crossover design was 24.9 years (75). Participants completed a single session of resistance training, cycling, and no exercise. Body image was assessed before and after each session, and 24 hours after each session with the Body Image States Scale and a perceived body fat and muscularity silhouette measure (75). The results revealed significant differences in body image state scores after intervention between resistance training and no exercise but not for cycling. In addition, resistance training, but not cycling or the no-exercise control, led to significant increases in perceived muscularity. Finally, perceived body fat was significantly reduced after resistance training and cycling but not after no-exercise. All scores returned to baseline after the 24-hour postsession period.
Men vs. Women
One study was included in this category (30), and it was considered low quality based on its PEDro score. The study examined gender differences in changes in body image in response to a 12-week, 5 sessions per week, resistance training intervention. Body satisfaction, social physique anxiety, drive for muscularity, and subjective and objective measures of body composition and muscular strength were assessed in 28 men and 16 women (mean age = 21.6 years, SD = 2.4). Significant improvements in body satisfaction (F = 35.50, p < 0.001) and significant decreases in social physique anxiety (F = 5.21, p ≤ 0.05) were seen for both genders, but significant reductions in muscular dissatisfaction were seen for men only (F = 14.33, p < 0.001). For men, improvements in body image were significantly correlated with subjective changes in body composition. For women, improvements in body image were significantly correlated with both subjective changes in body composition and objective changes in muscular strength.
Noncomparisons
Single Group
One study was included in this category, and it was considered low quality based on its PEDro score (64). Seguin et al. (64) tested the effects of resistance training on 6 different dimensions of body image (Health Orientation, Subjective Weight, Fitness Orientation, Fitness Evaluation, Health Evaluation, and Weight Preoccupation). Participants were 341 women with a mean age of 62 years (SD = 12) who were part of a community-based strength training program known as The Strong Women Program. Participants attended sessions over a period of 4–12 weeks, with the average being 10 weeks. Significant changes in body image were found on 5 of the 6 subscales, with the exception of weight preoccupation (64).
Discussion
The purpose of this review was to systematically identify and appraise the currently published peer-reviewed literature that has tested the independent effects of resistance training on body image in adults. Eleven studies were included in this review, and the majority (8 of 11) of studies concluded that resistance training can significantly improve multiple dimensions of body image. Importantly, only 3 of the 11 studies were considered high quality based on their PEDro score (5,32,69), of which, 2 showed significant improvements in body image with resistance training (32,69), and 1 of those 2 showed greater improvements with aerobic training when compared with resistance training (32).
A major strength of the current research is that it has provided preliminary guidelines for a resistance training prescription for improving body image. For example, resistance training sessions held 2–3 days per week may be optimal, as this would allow for 24–48 hours of rest in between sessions to ensure that muscular soreness can resolve before the next session. In addition, total body routines that take between 30 and 60 minutes may also be ideal, as this was enough time in most studies to complete 2–3 sets of 8–12 repetitions per exercise at a moderate to high intensity. However, the current evidence is inconclusive with regard to the optimal length or dose of an intervention and how long its effects last. For example, although some studies found body image to significantly improve after just a single session (27,75), others found no significant improvements after 6 weeks (5), 16 weeks (44), or 24 weeks (38), and only 1 study conducted a follow-up assessment of body image in the postintervention period (75).
Another strength of the current literature is the continued improvement of the assessment of body image. The earliest studies testing the effects of resistance training on body image were conducted over 20 years ago, during which time improvements have been made in the way researchers measure the multidimensional components of body image (14). For example, studies conducted within the last 15 years have more rigorously measured the detrimental effects of poor body image (e.g., appearance intolerance, social physique anxiety, perceived body fat/muscularity), including how resistance training might be able to improve these different dimensions. For example, resistance training has been reported to improve the various dimensions of body image, including the subjective (20,27,30,32,64,69,73,75), affective (20,27,30,32,64), perceptual (30,64,75), behavioral (30,64,75), and cognitive dimensions (32,64). These improvements in the assessment of poor body image provide important details on potential mechanisms of action that could help explain why resistance training can improve body image and provide guidance in the development of future interventions that can target these specific mechanisms. Notably, it is unclear if resistance training can improve one dimension more so than others, but the current research has predominately favored the assessment of the subjective dimension (36).
Importantly, researchers must also be aware that several limitations of this literature exist. First, there remains a heavy focus on women, as the aggregate sample in this review was 80% female. Such a bias skews the results and prevents a clear understanding of how resistance training might be effective for improving body image in men. This is not just a limitation of the research done on resistance training and body image, however, as it is more widespread and extends to the overall literature on various types of exercise and body image (12,36,61). Given that rates of poor body image in men are increasing (50) and may be as high as 61% in the male population (25), it will be important to expand the research in this area and conduct more studies targeting and including men.
Second, only 3 studies in this review included middle-aged and older adults (38,64,73), and all 3 used a female-only sample. Similar to the poor inclusion of men, the current research is biased by a strict focus on young adults, despite the research that suggests that middle-aged and older adults can also experience poor body image as a result of changes in their physical appearance (e.g., skin wrinkling, body fat redistribution, muscle loss), physical functioning (e.g., decline in mobility, muscular strength), and overall health (9,42). Specifically, research suggests that as individuals age, women's body image is more likely to decrease as a result of changes to their physical appearance, whereas men's body image is more likely to decrease as a result of a decline in their physical functioning (9). Regardless, given the lack of research in this area, it is not clear how or if age is a factor and whether resistance training could be helpful for improving the body image of older populations.
Additional limitations of the studies in this review include the use of a weak study design, a lack of rigorous sampling methodology, and the lack of theory-guided interventions. For example, only 4 of the 11 studies were randomized controlled trials (5,32,69,73) and only 3 studies were considered high quality based on their PEDro score (5,32,69). In addition, 2 studies used convenience samples, such that participants currently enrolled in university weightlifting courses were recruited to make up the resistance training groups (20,44). Finally, only 1 study tested a theoretical model. Martin Ginis et al. (32) applied the Exercise and Self-Esteem Model as a conceptual framework in an effort to examine the potential mechanisms of action (e.g., changes in physical fitness, self-efficacy, and self-perceptions) that likely support the positive relationship between resistance training and body image.
Future research should first address the several limitations that consume the current literature. Specifically, more theoretically driven, tightly controlled, randomized controlled trials that focus on, or at least include, adult men of all ages are needed. In addition, researchers should target other understudied populations who may also benefit from resistance training. For example, the rates of poor body image and body dissatisfaction are particularly high among a subset of gay men (79). Research suggests that these men place a greater emphasis on physical attractiveness, and more specifically, on levels of muscularity (46), making them an ideal target for a resistance training intervention. Similarly, transgendered individuals, and in particular female-to-male transgendered individuals, could also benefit from resistance training, as objective improvements in muscle strength and subjective improvements in muscle size resulting from resistance training could compliment their existing habits aimed at achieving a more masculine body (24). Resistance training might also be helpful for individuals living with chronic disease (e.g., cancer, HIV/AIDS) who experience poor body image in response to negative physical side effects associated with their disease (e.g., scarring, lipodystrophy) (40,66). In addition to reducing some of these negative physical side effects, resistance training can improve multiple aspects of mental health (e.g., quality of life, mood) (53,63), which could ultimately lead to an improvement in body image via enhanced self-perceptions (23).
Practical Applications
Results of this review suggest that resistance training has the potential to improve body image in adults. However, much more work will be needed before effective prescriptions can be recommended. More specifically, a better understanding of the mechanisms of action underlying the effects of resistance training on body image is required to move the field forward. Currently, some evidence suggests that subjective improvements in perceived body composition after resistance training may provide the most influential impact on body image in men. In contrast, it seems that subjective improvements in body composition and objective improvements in muscular strength and endurance are particularly important to women. As such, resistance training programs structured to support and promote increases in muscle size may be most effective to improve body image in men (67,75), whereas training programs targeting physical function may be the most effective to improve body image in women (30).
In addition, despite the research indicating that athletes have a more positive body image than non-athletes (35), some athletes, such as those who are required to wear revealing or tight-fitting uniforms (e.g., volleyball, swimming, and gymnastics), may be at an increased risk (68). Moreover, significant concerns about body image can ultimately become a distraction, leading to a reduction in performance, a cessation in participation, or an increase in risky health behaviors (e.g., extreme dieting) (26,68). Therefore, coaches should be aware of their organization or institution's guidelines on how to properly identify the signs and symptoms of poor body image and the process of providing support. Such an awareness could result in more immediate support and referral for those in need (11).
Finally, fitness professionals should consistently assess their clients' motivations for exercise, as individuals who primarily exercise to improve physical appearance are more likely to have poor body image (49,60). Furthermore, it is important to monitor clients who excessively exercise, who only want to work out alone, or who show extreme fluctuations in body weight, as these could also be signs of poor body image (34,52). Overall, readers are referred to established guidelines on how to safely manage and improve body image, such as those by Wilhelm (76) and Cash (13). In severe cases, referrals to mental health professionals will be necessary.
Acknowledgments
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to disclose.
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