France has cracked down on its modeling industry, but experts say personality traits, life experiences, and cultural messages are also causes.

When Anne Becker first arrived in Nadroga, Fiji, in 1995, anorexia was nearly unheard of.

But another thing also arrived in Nadroga that year: broadcast television.

By 1998, more than 97 percent of the population reported they watched at least some television. Among teenage girls, three years’ exposure to Western imagery was enough to make a difference.

On the island, Becker noticed that negative attitudes toward body image and eating had more than doubled in those three years. The percentage of teens who made themselves throw up to control their weight had risen from zero to more than 11 percent.

Teens living in households with a television were more than three times as likely to have such unhealthy attitudes.

Images of ultrathin models and actresses have been blamed for decades for eating disorders, especially among teen girls.

In France, legislation was approved last December to crack down on underweight girls in the modeling industry.

But is the barrage of images of skinny people in today’s media-conscious world really the prime culprit?

Experts say eating disorders usually arise from a combination of complex factors, and media overload is just one of them.

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Anxiety, perfectionism, and other personality traits lie at the core of eating disorders.

After all, most people who consume Western media haven’t been diagnosed with anorexia or bulimia. But for some people, idealized imagery serves as a trigger to activate tendencies lurking within them already.

“The reality is that eating disorders are not just about being thin, they’re complex disorders with a biopsychosocial axis to it,” said Sondra Kronberg, director of the Eating Disorder Treatment Collaborative, and spokesperson for the National Eating Disorders Association (NEDA), in an interview with Healthline, “There are people who have healthy BMI who are eating disordered, and there are people who have unhealthy BMI who are not eating disordered. So it’s not the greatest measure of whether one has an eating disorder or not. The degree to which one’s … thoughts about food, weight, and body image, how it interferes with their life and social relationships, is a better measure of one’s eating disorder.”

For Ruth, age 35, from Phoenix, perfectionism was her undoing.

“I grew up doing gymnastics,” she told Healthline. “That’s a sport that’s very focused on perfectionism and you have to think about your body and your weight. You’re judged aesthetically, and how much you weigh determines how fast you can flip and things like that. It’s the nature of the beast.”

Kronberg said this is a common recipe for an eating disorder.

“Those people who have brains that are more genetically predisposed to being obsessive, perfectionist, depressed, [and] ritualistic are more predisposed to developing some form of restrictive eating disorder,” she explained. “In a mind that is very detail-oriented, and very perfectionistic, and an underlying core of self-loathing, one of the ways that an anorexic mind can feel better about itself is to restrict, get thinner, eat less.”

Ruth also experienced trauma, which shook her sense of control over her life.

“One of the ways I tried to cope was by being very depressed, very anxious, and very focused on perfectionism,” Ruth said. “A perfectionist person, who’s a gymnast … you’re probably creating the perfect storm to have someone with an eating disorder.”

Control was also important to Kristina, age 22, of Brooklyn, New York.

“I [used] food as a Band-Aid for my emotions, filling my stomach instead of my heart and proving to people that I wasn’t under their control,” she said. “After a traumatic event in college, I developed the opposite obsession — eating as little as possible and proving to myself that … I was capable of controlling myself even if I couldn’t control anything else in my life.”

Many people with an eating disorder share a history of trauma in childhood or young adulthood, such as an assault or a parental divorce. In some cases, this triggers a desperate attempt to regain control.

“While trauma reactions are very individualized, the attempt to maintain control is often a piece of this picture,” said Ramani Durvasula, a professor of psychology at California State University, Los Angeles, and a licensed clinical psychologist. “Anything that contributes to a sense of vulnerability can place a young person at risk for attempting to either numb their feelings or attempting to get control over them.”

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Media images can be another trigger point for those predisposed to an eating disorder.

And depictions of slim celebrities certainly do play a role in the development of anorexia.

Today, people in the United States consume more than 10 hours of media a day. In that time, they are exposed to hundreds of images of people, many of whom are professional models or actors with low body mass index (BMI), scores. BMI is a rough measurement of body fat.

The National Institutes of Health (NIH) defines a healthy BMI as between 18.5 and 24.9 — so, according to the guidelines, the minimum healthy weight for a person who is 5 feet 7 inches tall would be 118 pounds.

When a fashion show in Madrid applied this minimum standard to its models in 2006, they wound up turning away 30 percent of those who had participated in the previous event, according to CNN.

Meanwhile, the average American has a BMI around 26.5. In addition, the average women in the United States is 5 feet 4 inches tall and weighs 166 pounds. The average model is 5 feet 10 inches tall and weighs 107 pounds.

This vast rift between what Americans look like and the images they see isn’t without consequence. The prevalence rates of anorexia and bulimia reached 0.6 percent by 2007, meaning that nearly 2 million Americans will experience one of these eating disorders in their lifetimes.

One study found that 44 percent of adolescent girls felt they were overweight, and 60 percent were trying to shed some pounds, even though the majority of them were already at a healthy weight.

As many as 90 percent of American women report they feel dissatisfied with their bodies, says Durvasula.

“There is a push to achieve a societally valued state,” she told Healthline. “It is a cultural paradigm.”

“The cost of it is the consequence to the body,” added Kronberg. “And it’s accelerated in this culture by a message that says thin is better, smaller sizes are better. Body image dissatisfaction is one of the primary risk factors for the development of an eating disorder. What those cultural messages do is create body image dissatisfaction.”

That was the experience for Kristina from Brooklyn.

“We live in a society that lauds skinny people for their body type — how could I not see that and be envious sometimes?” she told Healthline.

Kristina struggled with binge eating disorder throughout her teenage years. Later, after a traumatic experience in college, she resorted to food restriction, eating as little as possible.

“I went from size 14 to size 4. There is nothing like the addiction that comes from watching pounds melt away, the euphoria that comes from people saying, ‘Oh my God, you look so skinny, you look amazing!’ The media has trained us to believe that skinny is better than strong, and that being skinny is better and more important than being compassionate, driven, successful, or kind,” Kristina said.

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While most coverage of eating disorders focuses on women, about 10 to 15 percent of people with anorexia and bulimia are male.

Media imagery of men also exaggerates a sexual ideal, showing levels of muscle definition that are hard to achieve at a healthy body weight.

“When young, vulnerable men and women live with this, it sort of deciphers for them what makes them popular, or what makes them acceptable in this culture,” said Kronberg. “If acceptable in this culture is to have a six-pack, then unless they have a six-pack, they’re not OK.”

Brian, age 24, from Flanders, New Jersey, struggled with his body image and anorexia as he tried to understand his sexual orientation.

“The media portrays the homosexual lifestyle and gay men in a distorted way most of the time,” he told Healthline. “All the gay men I had seen in the media were ‘perfect,’ with muscular bodies, chiseled abs, the perfect amount of body hair. I felt an extreme pressure to live up to these standards. I desperately wanted to be accepted as being gay, and I thought having a ‘perfect’ body was the only way.“

“It sounds silly to me now that I think of it,” Brian added,” that I once thought all gay men were in perfect shape, but the media portrayed them this way, and I was fooled.”

Media imagery wasn’t the only thing that drove Brian to restrict his eating — so did pressure from within.

“Anxiety was a huge factor in developing my eating disorder,” he said. “I developed an eating disorder as a way to cope with the anxiety these pressures put on me, and to deal with the anxiety that came along with them.”

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Other than continuing to improve access to mental health services for at-risk people, there’s not much that can be done about personality traits that make teens vulnerable to eating disorders.

Media imagery, on the other hand, is subject to regulation.

“For example, the Public Health Cigarette Smoking Act of 1969 requires cigarette packages to carry a warning that they are dangerous to health.”

Today, legislators and the courts are hashing out a series of cases on whether it’s permissible to require cigarette packs to carry larger graphic warnings.

Israel decided to tackle the eating disorder issue in 2012 when it passed a law requiring models to have a BMI of at least 18.5.

France followed suit last December. Lawmakers passed legislation that would impose fines or jail time on modeling agencies or individuals who employ models with a BMI lower than 18.

The new French legislation also restricts websites that promote anorexia, and requires altered images of models to list a disclaimer that the image has been retouched.

A few weeks after France passed the new laws, researchers published a paper in the American Journal of Public Health (AJPH) that stated that an average fashion model has a BMI of less than 16. That, they said, is considered dangerously thin under World Health Organization (WHO) guidelines.

The researchers urged U.S. health officials to take steps to address this problem.

But would such legislation fly in the United States?

“The current Supreme Court approaches all speech restrictions with great suspicion, and legal interventions that would be acceptable in most other countries around the world may fall under judicial review in the U.S.,” said Michelle Mello, a professor of law at Stanford Law School, and a professor of health research and policy at the Stanford University School of Medicine, in an interview with Healthline.

“It’s very difficult to restrict speech,” added David Greene, an adjunct professor at the University of San Francisco School of Law, in an interview with Healthline. “If there’s a public health concern, it has to be something really critical, and that the restrictions be the only way of addressing this seriously critical public health concern.”

While the connection between cigarettes and health problems is indisputable, Greene says, a causal connection between media imagery and eating disorders is harder to prove.

“That would require the government to prove that the preponderance of these types of advertising actually causes the harm it’s trying to address,” he said. “And I think it’s going to have a hard time doing that.”

Durvasula thinks restrictions might help, but they’d miss the bigger picture.

“The media images are an easy target, but they are but one of many determinants of anorexia nervosa, which is a psychological/psychiatric disorder that has numerous predictors,” she said.

Still, Kronberg says that NEDA has been working to bring about restrictions on who can be an actor or model.

“Our original plan was to have screenings in schools and in the agencies — a full-blown screening for an eating disorder, not just BMI,” she said. “The existence of an eating disorder would make them not eligible for a particular job. Just like if they were alcoholic or using drugs, they would not be eligible for a particular job. I do not believe that would be discriminating.”

Whether such restrictions ever catch on in the United States remain to be seen. However, there are still ways to help.

“If you suspect that somebody has a problem related to eating, don’t ignore it,” urged Ruth. “Especially if you’re talking about a child, that person needs help.”

The original story was published on April 14, 2015, and was updated by David Mills on September 1, 2016.