Challenging Dogma

...Using social sciences to improve the practice of public health

Monday, April 30, 2007

A Critique of the CFDA Health Guidelines: Addressing the Issue of Overly Thin Runway Models or Simply Paying Lip Service? - Marie Elaine Pahilan

On August 2, 2006, Luisel Ramos, a 22 year-old model from Uruguay fainted on her way to the dressing room after taking her turn on the catwalk. She died of heart failure due to anorexia nervosa. At the time of her death, the 5 foot 9 inches model weighed 98 lbs with a body mass index (BMI) of 14.5.

On October 25, 2006, Ana Carolina Reston, a 21 year-old model from Brazil was hospitalized for kidney malfunction due to anorexia nervosa and bulimia. On November 15, 2006, she died due to kidney failure. At the time of her death, the 5 foot 8 inches model weighed 88 lbs with a BMI of 13.4.

The death of Luisel Ramos, weeks before the Fall Fashion Shows, brought attention to the increasingly slim models gracing the catwalks. On September 13, 2006, Spain’s top fashion show made international headlines deciding to enact a government ban on underweight models during Madrid Fashion Week. The ban kept models with a BMI of less than 18 off the runways. The World Health Organization standard states that anyone with a BMI of less than 18.5 is underweight. (1) For a model who is 5 foot 9, the weight requirement would be 126 lbs. Over 30% of models who participated in the Madrid Fashion Show in 2005 were deemed ineligible due to the ban. In Milan, models now need to present a doctor’s certificate of good health before they will be allowed to walk in shows. Designers participating in the Milan shows agreed not to hire models younger than 16 and underage models must be chaperoned.

During New York’s Fall Fashion week in September, Tim Gunn, chairman of the fashion design department at Parsons the New School for Design commented, ‘Some of the girls caused you to gasp. When the knee joint is wider than the thigh, it can be scary.” These events and commentaries similar to Mr. Gunn’s, spurred the Council of Fashion Designers of America (CFDA) to take action.

The CFDA is a not-for-profit trade association for America’s fashion and accessory designers. It was founded in 1962 to “advance the culture of fashion design as a branch of American art and culture.” (2) Following the deaths of the two runway models and the decision in Spain to ban models who do not meet the minimum BMI, the CFDA formed the Council of Fashion Designers of America Health Initiative. The goal of this group was to address the issue of models who are unhealthily thin. The Health Initiative members included Diane von Furstenberg, designer and president of the CFDA, Susan Ice, M.D., the medical director of the Renfrew Center (a treatment center dedicated exclusively on the treatment of eating disorders), nutritionists, modeling agents and physical trainers.

On January 12, 2007 the CFDA Health Initiative presented their recommendations for the fashion industry prior to New York’s Spring Fashion Week. These recommendations included: 1) educating the industry to identify early warning signs in an individual at risk of developing an eating disorder, 2) requiring these individuals, once identified, to seek professional help, 3) developing workshops for the fashion industry on the nature of eating disorders, 4) supplying health meals, snacks, and water backstage and at photo shoots and providing nutrition and fitness education, and 5) promoting a healthy backstage environment by raising the awareness of the impact of smoking and addressing underage drinking by prohibiting alcohol. The recommendations also included keeping models under the age of 16 off the runways and not allowing models under the age of 18 to work at fittings and photo shoots past midnight. (3)

The guidelines officially introduced by the CFDA Health Initiative rely heavily on the idea of educating models and their families as a means of promoting healthy lifestyle choices. The idea of education as a means of intervention stems from the Health-Belief Model. The health-belief model is a social-behavioral model that posits that the intention to change behavior stems from a weighing of the perceived susceptibility and perceived risks of developing a disease against the perceived barriers against accomplishing the behavior change. (4) By basing their intervention on the health-belief model the CFDA Health Initiative assumes that the barriers to healthier lifestyles and eating habits outweigh the risk and perceived susceptibility of runway models. This is not necessarily the case.

To the designers, runway models are walking hangers for their designs. It is the designers who call modeling agencies and inform them of the type of models they want for their shows. Many models believe that being slim is the only way they are going to get any runway work. In 2004, Ana Carolina Reston, on her first overseas casting call in China, was told by the casting directors she was ‘too fat.’(5) At the CFDA Health Panel on February 5, 2007, model Natalia Vodianova, the face of Calvin Klein, spoke of how after giving birth to her first child, she weighed 117 lbs. Designers complained that she no longer fit the clothes and her weight dropped to 106 lbs. Following the weight loss, Ms. Vodianova became one of the fashion industry’s most sought after runway models. This creates a perception within the modeling community that not being extremely slim will prevent a model from booking shows. Health guidelines based on the health-belief model do not take into account that the potential loss of livelihood is an enormous barrier to models.

The health-belief model is one that focuses on the individual and does not take into account the outside forces that affect an individual’s behavior. Many runway models come from poor backgrounds. By modeling they become the breadwinners for their entire family. Ana Carolina Reston’s father was diagnosed with Parkinson’s and Alzheimer’s when she was a young teen. After winning a beauty contest at 14, she signed with Ford Modeling Agency and provided for the rest of her family. (5) Natalia Vodianova presented a similar story of growing up poor in Russia at the CFDA Health Panel. (6) Responsibilities to families are another barrier that may prevent models from adopting a healthier lifestyle.

The CFDA Health Initiative guidelines also do not take into account that many of these models are extremely young. At 16, models can take to the runway. These guidelines do not take into account that adolescents respond to health matters in a way that is not always rational. The health-belief model assumes that an individual will always make rational decisions. Adolescents do not always respond rationally when presented with the potential outcomes of their actions. Adolescents respond better to short-term negative effects as opposed to long-term negative effects. (7) Telling a 16 year-old that if she is too skinny she may suffer kidney failure and heart problems is not sufficient. These are abstract dangers. It would be more effective to emphasize that being extremely thin will cause her hair to fall out.

The approach for change outlined by the CFDA relies wholly on education. This type of approach for changing human behavior is an empirical-rational strategy. (8) The two main assumptions in this type of strategy are that humans are rational beings and that once the rational course is revealed to them; people will adopt the behavior change. I have already discussed how assuming rational responses in the modeling population, especially from teen models, is not a proper assumption; further showing how the guidelines put forth by the CFDA do not effectively address the problem of overly thin models.

Another strategy is a normative-re-educative approach (8), which uses the power of persuasion to change behavior. To see this behavior change, it is necessary to change the social norms of the population, a change in attitudes and values in addition to education. Simple persuasion would not be enough for models, because even if they can be persuaded, even if they believe that changing their eating habits is the best choice, the standard body type in the modeling community is not decided by the models themselves. For such an attitude and value change to occur in the fashion industry, the CFDA would have to focus their intervention on the designers and persuade them to use size 4 and size 6 dress forms in creating sample clothing as opposed to the current norms of size 0 and size 2 samples. Thus far, designers have been resistant in changing sample sizes.

In this scenario, the most effective strategy for change is a power-coercive approach (8). This approach demands the compliance of the target population, by enacting laws or enforcing bans to bring about changes in behavior. This is the path the Spanish government has taken. Ban models whose BMI is below the WHO standard from the runway. In an atmosphere where education is not enough to change behavior and persuasion is useless if other parties will not help the modeling community in achieving a healthier lifestyle, the option you are left with is coercion. If models are banned from the runway when they are anorexic and overly thin, designers will have to change their standards; otherwise they will no longer be able to show their designs.

The CFDA should be commended for addressing the issue of overly thin models. While I do not feel that the guidelines are enough to protect models and promote healthier lifestyles, it is the first step the American Fashion Industry has taken. A ban on models with a BMI lower than the WHO standards would be another step in the correct direction. If, as I argue, the problem with the guidelines is that they incorrectly assume that the barriers to healthier lifestyle decisions do not outweigh the risks of being overly thin because the potential loss of livelihood is too great a barrier, then setting a minimum BMI would completely remove that barrier. Unless they are a healthy weight, their livelihood would be gone. If fashion designers continue to produce clothing for overly thin models and a ban is in place, they will soon find themselves without models to show their clothes and will also find their livelihood gone.

It is important that the Fashion Industry continue to move away from the overly thin model as the ideal. Fashion and the models the industry employ set the standard of beauty that the public strive for. The image portrayed on the runway will affect the decisions of the teenage girl reading Vogue and Cosmopolitan, watching Project Runway and America’s Next Top Model (9, 10).

On February 13, 2007, Eliana Ramos, an 18 year-old model from Uruguay, was found dead in her grandparents’ home. Preliminary examinations indicate the cause of death was heart attack due to malnutrition. She was the younger sister of Luisel Ramos.


1. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. Geneva, Switzerland: WHO Technical Report Series, 1995.

2. Council of Fashion Designers of America.

3. Council of Fashion Designers of America. Council of Fashion Designers of America Health Initiative. New York, NY: Council of Fashion Designers of America, 2007.

4. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs 1974; 2:328-335.

5. Phillips T. Everyone knew she was ill. The Observer. January 14, 2007.

6. Karimzadeh, M. At CFDA Health Panel, A Model’s Story. Women’s Wear Daily. February 6, 2007.

7. Kunter L. Holiday drinking opens adolescents’ eyes to alcohol. The New York Times 1991; p.C9.

8. Chin R, Benne KD. General strategies for effective change in human systems (pp. 22-45). In Bennis W et al. eds. The Planning of Change (3rd edition). New York: Holt, Rinehart and Winston, 1976.

9. Botta RA. Television Images and Adolescent Girls’ Body Image Disturbance. Journal of Communication, 1999.

10. Field AE, et al. Exposure to the Mass Media and Weight Concerns Among Girls. Pediatrics 1999; 103:36-40.

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