- Email: [email protected]
Body image dissatisfaction: Prevalence and relation to body mass index among female medical students in Taibah University, 2011
Journal of Taibah University Medical Sciences (2013) 8(2), 126–133
Taibah University
Journal of Taibah University Medical Sciences www.sciencedirect.com
Student Section
Body image dissatisfaction: Prevalence and relation to body mass index among female medical students in Taibah University, 2011 Ekhlas As-Sa’edi *, Shahad Sheerah, Reem Al-Ayoubi, Ala’a Al-Jehani, Walaa Tajaddin and Hanan Habeeb Faculty of Medicine, Taibah University, Almadinah Almunawwara, Kingdom of Saudi Arabia Received 15 March 2013; revised 10 May 2013; accepted 15 May 2013
ﺍﻟﻤﻠﺨﺺ . ﻳﻌﺪ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﻣﺸﻜﻠ ًﺔ ﺫﺍﺕ ﺍﻫﺘﻤﺎ ٍﻡ ﻣﺘﺰﺍﻳﺪ ﻭ ﻣﺆﺛﺮﺓ ﻋﻠﻰ ﺍﻟﺴﻼﻣﺔ ﺍﻟﻨﻔﺴﻴﺔ. ﺃﻓﻜﺎﺭﻩ ﻭ ﻣﺸﺎﻋﺮﻩ ﺗﺠﺎﻩ ﺟﺴﺪﻩ, ﺗﻌ ّﺮﻑ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﻛـﺘﺼ ّﻮﺭ ﺍﻟﺸﺨﺺ:ﺍﻟﺨﻠﻔﻴﺔ ﺍﻟﻤﺘﺼ ّﻮﺭ ﻭ, ﻭ ﺍﺳﺘﻜﺸﺎﻑ ﺍﻟﻌﻼﻗﺔ ﺑﻴﻦ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ, ﺗﺤﺪﻳﺪ ﺍﻟﻌﻮﺍﻣﻞ ﺍﻟﻜﺎﻣﻨﺔ ﻭﺭﺍﺀﻩ, ﺗﻬﺪﻑ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﺇﻟﻰ ﺗﻘﺪﻳﺮ ﻣﺪﻯ ﺍﻧﺘﺸﺎﺭ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ:ﺍﻷﻫﺪﺍﻑ .2011 ﺍﻟﻤﺮﻏﻮﺏ ﺑﻴﻦ ﻃﺎﻟﺒﺎﺕ ﺍﻟﻄﺐ ﺑﺠﺎﻣﻌﺔ ﻃﻴﺒﺔ ﻋﺎﻡ ﺍﺳﺘﺒﺎﻧﺔ ﺗﻢ ﺗﻌﺒﺌﺘﻬﺎ ﺫﺍﺗﻴﺎ ﻟﺘﺤﺪﻳﺪ ﺍﻟﻌﻮﺍﻣﻞ, ﺍﺳُﺘﺨ ِﺪﻡ ﻣﻘﻴﺎﺱ ﺗﺼﻨﻴﻒ ﺑﺘﺴﻊ ﺻﻮﺭ ﻇﻠّﻴﺔ ﻟﺘﻘﻴﻴﻢ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ, ﻟﺠﻤﻊ ﺍﻟﺒﻴﺎﻧﺎﺕ. ﻣﺸﺎﺭﻛﺔ242 ﻫﺬﺍ ﺍﺳﺘﻘﺼﺎﺀ ﻣﻘﻄﻌﻲ ﺷﻤﻞ:ﺍﻟﻤﻨﻬﺠﻴﺔ . ﻭ ﻗﻴﺎﺱ ﻃﻮﻝ ﻭ ﻭﺯﻥ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻟﺤﺴﺎﺏ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ ﻟﺪﻳﻬﻦ,ﺍﻟﻤﺤﺘﻤﻞ ﻣﺴﺎﻫﻤﺘﻬﺎ ﻓﻲ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﺑﻴﻦ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻫﻨﺎﻙ. ﺃﻧﻔﺴﻬﻦ ﻛﺴﻤﻴﻨﺎﺕ ﺟﺪﺍ%55 ﺑﻴﻨﻤﺎ ﺗﺼﻮﺭ, ﺗﺼﻮﺭﻥ ﺃﻧﻔﺴﻬﻦ ﻧﺤﻴﻼﺕ ﺟﺪﺍ%18.6 , ﻛ ّﻦ ﺭﺍﺿﻴﺎﺕ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ%26.4 ﺑﻴﻦ ﺟﻤﻴﻊ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻓﻲ ﺍﻟﺪﺭﺍﺳﺔ؛:ﺍﻟﻨﺘﺎﺋﺞ ﺍﻟﺘﺼﻮﺭﺍﺕ ﺍﻟﻐﻴﺮ ﺣﻘﻴﻘﻴﺔ ﻋﻦ ﺍﻟﺬﺍﺕ ﻭ ﺍﻟﺸﻌﻮﺭ ﺑﻌﺪﻡ ﺗﻨﺎﺳﻖ ﺃﺟﺰﺍﺀ, ﺍﻧﺘﻘﺎﺩ ﺍﻷﺻﺪﻗﺎﺀ, ﺗﺄﺛﻴﺮ ﺍﻟﻌﺎﺋﻠﺔ, ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ:ﺭﺍﺑﻂ ﻣﻌﺘﺒﺮ ﺑﻴﻦ ﺩﺭﺟﺔ ﺍﻟﺮﺿﺎ ﻋﻦ ﺍﻟﺠﺴﺪ ﻭ ﺍﻟﻌﻮﺍﻣﻞ ﺍﻟﺘﺎﻟﻴﺔ .ﺍﻟﺠﺴﻢ ﺑﺎﻟﻐﻦ ﻓﻲ ﺗﻘﺪﻳﺮ ﺃﻭﺯﺍﻧﻬﻦ ﻭ ﺭﻏﺒﻦ ﻓﻲ, ﺃﻏﻠﺐ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻛﻦ ﻏﻴﺮ ﺭﺍﺿﻴﺎﺕ. ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﻛﺎﻥ ﻣﻨﺘﺸﺮﺍً ﺑﻴﻦ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻭ ﻣﺮﺗﺒﻄًﺎ ﺑﻤﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ:ﺍﻟﺨﺎﺗﻤﺔ ﺍﻟﻤﺰﻳﺪ ﻣﻦ. ﺍﻟﺮﻳﺎﺿﺔ ﻭ ﺍﻟﺤﻤﻴﺔ ﻫﻤﺎ ﺍﻟﺴﻠﻮﻙ ﺍﻻﻛﺜﺮ ﺷﻴﻮﻋًﺎ ﺑﻴﻦ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻟﻠﺘﺤﻜﻢ ﻓﻲ ﺍﻟﻮﺯﻥ. ﺍﻟﻌﺎﺋﻠﺔ ﻭ ﺍﻷﺻﺪﻗﺎﺀ ﻛﺎﻥ ﻟﻬﻤﺎ ﺑﺎﻟﻎ ﺍﻷﺛﺮ ﻋﻠﻰ ﻫﺬﺍ ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﻌﻤﺮﻳﺔ ﺍﻟﺤﺮﺟﺔ.ﺃﻥ ﻳﻜﻦ ﺃﻧﺤﻒ ﺁﺧﺬ ًﺓ ﻓﻲ ﻋﻴﻦ ﺍﻻﻋﺘﺒﺎﺭ ﺍﻟﻌﻼﻗﺔ ﺑﻴﻦ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭ ﺍﻟﺠﺴﺪ ﻣﻦ ﺟﻬﺔ ﻭ ﺍﻻﻛﺘﺌﺎﺏ ﻭ ﺍﺿﻄﺮﺍﺑﺎﺕ ﺍﻷﻛﻞ ﻣﻦ ﺟﻬﺔ،ﺍﻻﺑﺤﺎﺙ ﺑﺤﺎﺟﺔ ﻷﻥ ُﺗﺠﺮﻯ ﻋﻠﻰ ﻋﻴﻨﺔ ﺍﻛﺒﺮ ﻣﻦ ﺍﻟﻤﺠﺘﻤﻊ ﺍﻟﺴﻌﻮﺩﻱ .ﺃﺧﺮﻯ Abstract Background: Body image has been defined as the person’s perceptions, thoughts, and feelings about his body. Body image dissatisfaction is a problem of growing concern that affects psychological wellbeing. Objectives: This study aims to estimate the prevalence of body image dissatisfaction, identify its underlying risk factors, and explore the relation between actual, perceived and desired BMI among female medical students in Taibah University, KSA. Method: This is a cross-sectional survey that involved 242 participants. Data were collected using a nine figure silhouette rating scale for assessing body image dissatisfaction, a self-administered questionnaire for identifying possible factors contributing to dissatisfaction, and measurement of the participants’ weight and height to calculate their actual BMI.
* Corresponding address: Fourth-year Medical Students, Faculty of Medicine, Taibah University, Almadinah Almunawwara, Kingdom of Saudi Arabia. Tel.: +966 530557707. E-mail: [email protected] (E. As-Sa’edi) Peer review under responsibility of Taibah University.
Production and hosting by Elsevier 1658-3612 Ó 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jtumed.2013.05.001
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Results: Of all participants: 26.4% were satisfied, 18.6% perceived self as too thin, while 55% perceived self as too heavy. There has been a significant association between the degree of satisfaction and the following factors; actual BMI, family influence, friends’ criticism, unreal self-perception and feeling of disproportional body parts (at P<.05). The actual and desired BMI of the participants in the study have been correlated to their perceived BMI at a significant level (P=.000). Conclusion: Dissatisfaction was prevalent and associated with actual BMI. The majority of participants were dissatisfied, overestimating their weight and desired to be thinner. Exercise and diet were commonly used to control weight. Further researches need to be done on this topic on a larger population of the Saudi community taking in consideration its association with depression and eating disorders. Keywords: Body image; Body mass index; Satisfaction; Saudi Arabia Ó 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.
Introduction
Materials and Methods
Body image has been defined by many researchers over the years as the person’s perceptions, thoughts, and feelings about his or her body.1 The construct of body image can be broken down into two and often three dimensions. The first dimension is cognitive, how an individual “thinks” he or she looks. The second is emotional, how an individual “feels” he or she looks. Last is idealistic, how an individual “wants” to look.2 Dissatisfaction with physical appearance appears to be more the rule than the exception. Based on the results of a survey done by Garner and colleagues, most women (56%) and almost half (43%) of men are dissatisfied with their overall appearance.3 About 66% of Saudi women are overweight, approximately 52% of the adult population in the Kingdom of Saudi Arabia is obese while 18% of adolescents and over 15% of pre-school children are also victims of obesity.4 Abdel-Fattah et al., have conducted a study among females seeking treatment for obesity in Saudi Arabia and suggested a high frequency of depressive symptoms, and concerns with body image among obese patients.5 It was also found that high levels of body dissatisfaction in treatment-seeking obese individuals are associated with elevated depression and decreased levels of self-esteem.6 Al-Subaie, found an association between the desire to be thinner in secondary school female students in Saudi Arabia and the exposure to Western culture as living abroad or speaking foreign languages.7 To understand how people feel about themselves, researchers have examined self-esteem and body image satisfaction. Dissatisfaction with current body weight was expressed by more overweight and underweight females than by the normal weight females.8 Falkner et al., found that overweight status was associated with emotional problems, hopelessness and suicidal thoughts in adolescent females.9 Similar findings showed a stronger association between overweight status and poor psychological health among females as compared to males in several other community-based, cross-sectional studies of children and adolescents.10–13 Few studies have discussed body image dissatisfaction in Al Madinah Al Munwarah, KSA. This study aims to estimate the prevalence of body image dissatisfaction, identify its underlying risk factors, and explore the relation between actual, perceived and desired body mass index (BMI) among female medical students in the Taibah University, KSA. We believe that dissatisfaction is prevalent with the presence of a correlation between actual, perceived MI and desired BMI.
Setting and participants This cross-sectional survey has been carried out from September through November 2011, at the Taibah University, Al-Madinah Al-Munwarah, KSA. It involved 242 out of 343 female medical students. Response rates were (19.8%, 22.3%, 24.4%, 14.9% and 18.6%) for the 1st, 2nd, 3rd, 4th, and 5th year students, respectively and the overall response rate was 71%. Age of participants was ranging from 19 to 27 years. An informed verbal consent has been taken from all participants. Ethics committee approval was taken. Data were collected using a nine figure silhouette rating scale for assessing body image dissatisfaction, a self-administered questionnaire for identifying possible factors that could contribute to body image (dis)satisfaction among participants, and measurement of participants’ weight and height was taken at the medical unit in the Taibah University in order to calculate their actual BMI. Study tools The nine figure silhouette rating scale This study used a psychological tool developed by Stunkard et al.14 for assessing body image dissatisfaction. In this measure, silhouettes ranging from very thin to very obese are presented to the participant, who is usually asked to choose the silhouette closest to her own body size (perceived) and that representing her ideal size(desired). The discrepancy between the two figures is seen as an indication of (dis)satisfaction.1 Stunkard’s figure rating scale is a valid and reliable measure of women’s weight status, when rated as viewed either in-person or on videotape by an unrelated observer.15 The perceived and desired figures were related to the perceived and desired BMI using a scale developed by Bulik and colleagues.16 The reliability of this scale has been proved for actual BMI and self-reported BMI in males and females. Therefore, the nine figures represented nine levels of BMI for females (18.3–45.4).17 Calculating actual BMI The weight and height of participants were measured at the University’s health unit, and BMI was calculated using the equation: BMI = weight (kg)/height2 (m). Participants with
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BMIs < 18.5 were considered underweight, BMIs ranging between 18.5 and 24.9 were considered normal weight, BMIs ranging between 25.0 and 29.9 were considered overweight, BMIs > 30.0 were considered obese,18 the calculated BMI is considered as the actual BMI. Self-administered questionnaire Every participant was given a questionnaire that included: demographic data, possible factors that could affect body image (dis)satisfaction (family influence, friends’ criticism, society pressure, unreal perception of body size, comparison to media icons and feeling of disproportional body parts), and participants’ ideas about life aspects possibly affected by weight changes (friends and popularity, confidence, health, beauty, femininity and attractiveness to opposite sex) have been explored. Finally, the questionnaire included a survey about the common measures used by participants to change their weight (exercise, diet, diet pills, increasing caloric intake and others). Ethical considerations and confidentiality were assured.
Table 1: Characteristics of participants: weight, height and body mass index grouped into actual, perceived and desired BMI. Age (years) Weight (kg) Height (cm) Actual BMI Underweight Normal Overweight Obese Perceived BMI chosen by: Underweight Normal Overweight Obese Desired BMI chosen by: Underweight Normal Overweight Obese *
Statistical analysis SPSS (Statistical Package for Social Science) program was used for statistical analysis (version 13; Inc., Chicago, IL). Data from questionnaires were entered as numerical or categorical, as appropriate. Two types of statistics were done; 1. Descriptive statistics, where Quantitative data were shown as mean, SD, range, and Qualitative data were expressed as frequency and percent. 2. Analytical statistics, where the Chi-square test was used to measure association between qualitative variables. Pearson’s correlation has been used to study correlation between two variables having normally distributed data. P-value was considered statistically significant when it is less than 0.05. Results Results showed that mean actual BMI of participants was 22.79 ± 4.71, mean perceived BMI was 22.67 ± 4.46 and mean desired BMI was 20.32 ± 1.59, and their mean age was 21.02 ± 1.48 (Table 1). Of all participants, 55% perceived themselves as too heavy and desired to lose weight, 26.40% were satisfied and 18.60% perceived themselves as too thin and desired to gain weight (Figure 1). Regarding possible risk factors of dissatisfaction among female medical students in the Taibah University, results showed a significant (P < .05) association between the degree of (dis)satisfaction and the following factors: actual BMI (P = .000), family influence (P = .013), friends’ criticism (P = .000), unreal self-perception (P = .000), feeling of disproportional body parts (P = .000), while comparison to media icons, and society influence did not pose this significant association (P > .05). Among participants who perceived themselves as too heavy, 86.5% stated that they feel themselves heavier than others expressed (i.e. showed unreal self perception), 78.2% feel they have disproportional body parts, while 97.8% of those feeling themselves as too thin were affected by both the family influence and friends’ criticism (Table 2). About 79.7% of satisfied participants were of normal weight and the most interesting thing is that 54.2% of the participants
Range
Mean±SD*
19–27 36.00–135.00 140.00–186.00 14.24–47.27
21.02±1.48 56.79±12.88 157.72±6.72 22.79±4.71 17.19±1.13 21.48±1.83 27.31±1.37 33.31±3.82 22.67±4.46 18.89±.64 21.35±2.69 26.93±4.33 30.38±3.96 20.32±1.59 19.93±1.30 19.97±1.19 21.15±2.22 21.91±1.63
17.80–40.8
17.80–31.30
Standard deviation.
who feel themselves as too heavy were of normal weight (Figure 2). Results indicated that there is a positive correlation between perceived BMI and both actual and desired BMI (r = .803, r = .462 at P = .000 respectively) of the studied population (Table 3/Figures 3 and 4). For underweight individuals they somewhat estimated their BMI correctly (Perceived = 18.89), but they still desired a heavier ideal body weight (ideal = 19.93). In normal weight individuals, the mean actual and perceived BMI do not vary (21.48, 21.35 respectively), however they desired thinner ideal (mean = 19.97) weight. Overweight and obese individuals underestimated their actual BMI (mean and perceived BMI = 26.39, and 30.38 respectively), but desired much thinner ideal weight (mean and Ideal BMI = 21.15 and 21.91 respectively) (Table 1). Significant differences have been found between participants (distributed by their actual BMI) regarding weight control behaviors (P < .05). Exercise and diet were the most commonly used behaviors among participants to control their weight (66.9% and 51.2%, respectively), while diet pills and changing eating habits were minimally used by 5% and 28.5% of participants, respectively (Table 4). Discussion Dissatisfaction is an epidemic problem of modern societies, and it appears to be more the rule than the exception. Women tend to be critical of their appearance and place importance on the way they look, it was expected that there would be a linear relationship between current weight status and ideal body image. The mean age of the participants was 21.02 ± 1.48 SD, while the mean actual BMI was 22.79 ± 4.71 SD. There has been a significant association between actual BMI and dissatisfaction (P = .000). Actual and desired BMI of the participants in the study had a positive correlation to their perceived BMI at a significant level (P = .000). In other words; as the participants get heavier, they were aware of this
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Figure 1: Prevalence of body image dissatisfaction among female medical students in the Taibah University.
Table 2: Possible risk factors of body image dissatisfaction among female medical students in the Taibah University, categorized according to the degree of satisfaction. v2
Perceives self as too thin
Satisfied
Perceives self as too heavy
Total
n=45
n=64
n=133
n=242
P-value
No.
%
No.
%
No.
%
No.
%
Family influence – No – Yes
1 44
(2.2) (97.8)
11 53
(17.2) (82.8)
28 105
(21.1) (78.9)
40 202
(16.5) (83.5)
8.66
.013*
Friends’ criticism – No – Yes
1 44
(2.2) (97.8)
21 43
(32.8) (67.2)
47 86
(35.3) (64.7)
69 173
(28.5) (71.5)
18.88
.000*
Society influence – No – Yes
7 38
(15.6) (84.4)
10 54
(15.6) (84.4)
18 115
(13.5) (86.5)
35 207
(14.5) (85.5)
0.20
.902
(82.2) (17.8)
34 30
(53.1) (46.9)
18 115
(13.5) (86.5)
89 153
(36.8) (63.2)
78.22
.000*
(37.8) (62.2)
15 49
(23.4) (76.6)
33 100
(24.8) (75.2)
65 177
(26.9) (73.1)
3.39
.183
(71.1) (28.9)
30 34
(46.9) (53.1)
29 104
(21.8) (78.2)
91 151
(37.6) (62.4)
38.02
.000*
(51.1) (46.7) (2.2) (0.0)
12 51 1 0
(18.8) (79.7) (1.5) (0.0)
2 72 39 20
(1.5) (54.2) (29.3) (15.0)
37 144 41 20
(15.3) (59.5) (16.9) (8.3)
104.18
.000*
Unreal self perception – No 37 – Yes 8 Comparison to media icons – No 17 – Yes 28 Feeling of disproportional body parts – No 32 – Yes 13 Actual BMI – Underweight – Normal – Overweight – Obese *
23 21 1 0
Significant association; P value<.05.
Figure 2: Actual BMI of participants distributed by their degree of body image (dis)satisfaction.
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Table 3: Correlation between perceived and both desired and actual body mass indices of the studied population. Perceived BMI
Desired BMI Actual BMI *
r
P-value
.462 .803
.000* .000*
Significant association; P value<.05.
weight gain which was accompanied by increasing levels of dissatisfaction for being far from the slender ideal body images. They desired slimmer bodies even though their ideals were larger than their thinner counterparts; which states that the ideal weight was proportional to their weight. Similarly, in a study done among Jamaican adolescents in 2011, there were significant positive correlation between participants actual and perceived BMI (r = 0.61, P < 0.01), and between perceived and desired BMI (r = 0.29, P < 0.01).17 Kostanski et al., have also found that actual BMI was strongly related to dissatisfaction (P < .05).19 Another research, done by Alipoor et al., found a significant correlation between score of dissatisfaction and actual BMI (r = .95, P = .0001).2 In Spain, large proportion of students (67.7%) chose an ideal body weight lower than actual weight.20 A tendency of female students to over-estimate their body weight has been established in a similar study.21 Perhaps this similarity is due to the effect of the common age group, but still this association has proven to be significant in middle aged women. A study
made by Cachelin et al., on middle aged women showed that current figures were significantly larger than the ideal figure (P = .0001).22 Although western and non-western cultures are distinct, dissatisfaction seems to be a common problem. Significant differences in body shape perception among Australian born women were reported with greater degree of dissatisfaction.23 On the other hand, Mahmud et al., made a study showing that dissatisfaction is more pronounced in western compared to eastern cultures as Australian females expressed significantly higher levels of dissatisfaction once they are paired to Pakistani females.24 Of all participants in our study: 26.4% were satisfied, 18.6% perceived self as too thin (desired to gain weight), while 55% perceived self as too heavy (desired to lose weight). These findings are in line with these related studies: a Polish study showed that only 34.4% of female pharmacy students were satisfied.21 Among the dissatisfied individuals in a Pakistani research, 45.6% of the respondents perceived self as too heavy whereas 54.4% perceived self as too thin.25 The prevalence of dissatisfaction was 47.3% among female university students in Florianopolis, Brazil.26 In Jamaica, Huffman et al., reported that the study participants underestimated their weight in obese and overweight categories, but still desired smaller bodies.17 These closely related results are probably because thinness has the most influential impact on body image dissatisfaction nowadays. Our study concludes that there is a significant association between the degree of satisfaction/dissatisfaction and the following risk factors: participants’ actual BMI, Family influence
Figure 3: Correlation between perceived and desired body mass index among the study participants.
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Figure 4: Correlation between perceived and actual body mass index among the study participants.
Table 4: Behaviors for weight control among participants distributed by their actual BMI. Under weight n=37
Normal n=144
No.
%
Exercise – No – Yes
19 18
51.4 48.6
52 92
Diet – No – Yes
23 14
62.2 37.8
Diet pills – No – Yes
30 7
Eat more – No – Yes
17 20
*
Over weight
No.
n=41 %
Obese
Total
n=20
v2
P-value
n=242
No.
%
No.
%
No.
%
36.1 63.9
7 34
17.1 82.9
2 18
10.0 90.0
80 162
33.1 66.9
15.74
.001*
79 65
54.9 45.1
10 31
24.4 75.6
6 14
30.0 70.0
118 124
48.8 51.2
17.36
.001*
81.1 18.9
144 0
100.0 .0
38 3
92.7 7.3
18 2
90.0 10.0
230 12
95.0 5.0
24.37
.000*
45.9 54.1
109 35
75.7 24.3
30 11
73.2 26.8
17 3
85.0 15.0
173 69
71.5 28.5
14.94
.002*
Significant association; P value<.05.
and friends’ criticism, unreal self-perception and feeling of disproportional body parts (P < .05). Family and friends influenced 83.5% and 71.5% of all participants respectively. About 63.2% of participants reported feeling heavier than other expressed to them (unreal self-perception) and nearly 62.4% stated the feeling of disproportional body parts. Approximately more than half of participants who perceive themselves as too heavy were influenced by these factors. Lawler et al., showed that BMI, peer criticism and internalized appearance emerge as significant predictors of body image
dissatisfaction.27 Another research done by BibiGerner, also found this correlation with peer acceptance (r = .23 at P = .001).28 In a study made on Chinese females, 2010, reported pressure from peers and adult relatives to lose weight.29 This similarity in results can be partially explained by participants’ critical age group which can make them more affected by others’ opinion. A study made on Pakistani students found a significant association between high media exposure and body image dissatisfaction (P < .05).25 Another study done by O’Dea and
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Abraham, demonstrated that body weight was also an important aspect of social acceptance.30 Among Spanish adolescents, mass media exposure was associated with body dissatisfaction.31 Unexpectedly, our results found insignificant association between dissatisfaction and both media and society influence (p > .05). The lower exposure to media and less sociability of medical students might clear up this contradiction. In this study, among the 64 (26.4%) of satisfied participants, 79.7% were of normal weight, 18.8% and 1.5% were of underweight and overweight respectively. None of the obese participants was satisfied. The results of this study are in keeping with those of a previous study made by Sarwer, which showed that the majority of obese women demonstrated body image dissatisfaction related to obesity.6 However, a study conducted in 2005, found that there’s a little relationship between the degree of obesity and the intensity of dissatisfaction among North American population.32 This controversy can be explained by the cultural differences in viewing obesity. Among behaviors used to control weight: Exercise and diet were the most commonly used behaviors among participants (66.9% and 51.2%, respectively) while diet pills were used only by 5% of them. Increasing caloric intake to gain weight was used by 28.5% of all participants. McDonald et al., also showed that Women’s motivation of exercise was related to weight.33 Moreover, Sarwer et al., reported that dissatisfaction might be a motivator to lose weight by changing dietary habits and physical activity.32 A study made in Qatar, 2006, stated that 47.1% of overweight and obese female adolescents were on diet.34 This resemblance is owed to the fact that diet and exercise are the most accessible means of controlling weight. Limitations The results would have been enhanced if a larger sample of college students was taken in consideration, and if it included both sexes in this group. That is a limitation we have been forced to, because of the short duration of research we were obliged to while conducting. Recommendation Further studies need to be done on a larger population of the Saudi community taking into consideration the association between body image dissatisfaction and depression as well as eating disorders. Universities may also consider carrying awareness campaigns on this issue and planning for intervention programs in nutrition clinics in their facilities. Conclusion Results indicate that dissatisfaction is prevalent among female medical students in the Taibah University and associated with their actual BMI. More than half of participants of all weight categories were dissatisfied about their weight. There was a tendency to over-estimate weight even among normal-weight participants. This led to behavioral changes in an attempt to controlling weight. In addition, it was strongly influenced by family and friends’ criticism, feeling of disproportional body parts and unreal self perception. This highlights the importance of conducting nutritional health education campaigns
in this group of young university students to correct their wrong thoughts toward the ideal body image, orient them by the criteria and importance of a healthy diet, and provide free nutritional consultations. References 1. Morgan S. Body image: understanding body dissatisfaction. Routledge; 2008. 2. Alipoor S et al. Analysis of the relationship between physical selfconcept and body image dissatisfaction in female students. J Social Sci January 2009; 5(1): 60–66. 3. Garner DM, Garfinkel Paul E, Schwartz Donald, Thompson Michael. Cultural expectations of thinness in women. Psychol Rep 1980; 47. 4. Roche. Obesity threatens the Saudi community. Saudi Arabia Business Press Releases 2001. 5. Abdel-Fattah Moataz M, Abdel-Rahman Asal A, Tamer Mohamed M, Makhlouf Mohamed M. Depression and body image disturbances among females seeking treatment for obesity in Saudi Arabia. Eur J Psychol 2008; 4(3). 6. Sarwer DB, Wadden TA, Foster GD. Assessment of body image dissatisfaction in obese women: specificity, severity, and clinical significance. J Consult Clin Psychol 1998; 66: 651–654. 7. Al-Subaie AS. Some correlates of dieting behavior in Saudi schoolgirls. Int J Eat Disord 2000; 28: 242–246. 8. Rasheed Parveen. Overweight status: body image and weight control beliefs and practices among female college students. Ann Saudi Med 1999; 19(4). 9. Falkner NH, Neumakr-Sztainer D, Story M, Jeffery RW, Beuhring T, Resnick MD. Social, educational and psychological correlates of weight status in adolescents. Obes Res 2001; 9: 32–42. 10. Datar A, Sturm R. Childhood overweight and elementary school outcomes. Int J Obes 2006; 30: 1449–1460. 11. Erickson S, Robinson T, Haydel F, Killen J. Are overweight children unhappy? Arch Pediatr Adolesc Med 2000; 154: 931–935. 12. Mond JM, Hay PJ. Functional impairment associated with eating disorder behaviors in a community sample of women and men. Int J Eat Disord 2007; 40: 391–398. 13. Needham BL, Crosnoe R. Overweight status and depressive symptoms during adolescence. J Adolesc Health 2005; 36: 48–55. 14. Stunkard AJ, Sorensen TI, Schulsinger F, editors. Use of the Danish Adoption Register for the study of obesity and thinness. New York: Raven Press; 1983, Biomed central, http://www.biomedcentral.com/1471-2458/11/835/figure/F1?highres=y. 15. Cardinal Tiffany M. The figure rating scale as an index of weight status of women on videotape. Obes Res 2006; 14: 2132–2135. 16. Bulik CM, Wade TD, Heath AC, Martin NG, Stunkard AJ, Eaves LJ. Relating body mass to figural stimuli: population based normative data for caucasions. Int J Obes 2001; 25(10): 1517–1524. 17. Barrett SC, Huffman FG. Comparison of self-perceived weight and desired weight versus actual body mass index among adolescents in Jamaica. Rev Panam Salud Publica 2011; 29(4): 267–276. 18. Health Canada. BMI Chart. http://www.hc-sc.gc.ca/index-eng. php accessed November 2011. 19. Kostanski Marion, Gullone Eleonora. Adolescent body image dissatisfaction: relationships with self-esteem, anxiety, and depression controlling for body mass. J Child Psychol Psychiatry February 1998;255–262. 20. Arroyo M, Basabe N, Serrano L, Sa´nchez C, Ansotegui L, Rocandio AM. Prevalence and magnitude of body weight and image dissatisfaction among women in dietetics majors. Arch Latinoam Nutr June 2010; 60(2): 126–132. 21. Jaworowska Agnieszka, Bazylak Grzegorz. An outbreak of body weight dissatisfaction associated with self-perceived BMI and
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dieting among female pharmacy students. Biomed Pharmacother November 2009; 63(9): 679–692. Lewis DM, Cachelin FM. Body image, body dissatisfaction, and eating attitudes in midlife and elderly women. Eat Disord 2001; 9: 29–39. Lake Amelia J., Stager Petra, Glowinski Huguett. Effect of western culture on women attitude to eating and perception of body shape, School of Psychology, Deakin University, Melbourne, Australia; 1999. Mahmud Nargis, Crittenden Nadia. A comparative study of body image of Australian and Pakistani young females. Br J Psychol 2007; 98: 187–197. Khan Amad N, Khalid Salema, Khan Hussain, Jabeen Mehnaz. Impact of today’s media on university student’s body image in Pakistan: a conservative, developing country’s perspective. BMC Public Health 2011; 11: 379. Costa Lda C, de Vasconcelos Fde A. Influence of socioeconomic, behavioral and nutritional factors on dissatisfaction with body image among female university students in Florianopolis, SC. Rev Bras Epidemiol Braz J Epidemiol December 2010; 13(4): 665–676. Lawler M, Nixon E. Body dissatisfaction among adolescent boys and girls: the effects of body mass, peer appearance culture and internalization of appearance ideals. J Youth Adolesc January 2010; 40(1): 59–71.
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28. BibiGerner. The relationship between friendship factors and adolescent girls’ body image concern, body dissatisfaction, and restrained eating. Int J Eat Disord 2005; 37: 313–320. 29. Xu X, Mellor D, Kiehne M, Ricciardelli LA, McCabe MP, Xu Y. Body dissatisfaction, engagement in body change behaviors and sociocultural influences on body image among Chinese adolescents. Body Image 2010; 7(2): 156–164. 30. O’Dea Jennifer A, Abraham Suzzane. Association between selfconcept and body weight, gender, and pubertal development among male and female adolescents. Adolescents (Academic Research Library) Spring 1999;69. 31. Calado Marı´ a, Lameiras Marı´ a, Sepulveda Ana R, Rodriguez Marı´ a V, Carrera Marı´ a V. The association between exposure to mass media and body dissatisfaction among Spanish adolescents. Women’s Health Issues 2011; 21(5): 390–399. 32. Sarwer DB, Thompson J Kevin, Cash Thomas F. Body image and obesity in adulthood. Psychiatr Clin N Am 2005. 33. McDonald Karen, Thompson J Kevin. Eating disturbance, body image dissatisfaction, and reasons for exercising: gender differences and correlational findings. Int J Eat Disord 1992; 11(3): 289–292. 34. Bener A, Tewfik I. Prevalence of overweight, obesity, and associated psychological problems in Qatari’s female population. Obes Rev 2006;139–145.
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Body image dissatisfaction: Prevalence and relation to body mass index among female medical students in Taibah University, 2011 Ekhlas As-Sa’edi *, Shahad Sheerah, Reem Al-Ayoubi, Ala’a Al-Jehani, Walaa Tajaddin and Hanan Habeeb Faculty of Medicine, Taibah University, Almadinah Almunawwara, Kingdom of Saudi Arabia Received 15 March 2013; revised 10 May 2013; accepted 15 May 2013
ﺍﻟﻤﻠﺨﺺ . ﻳﻌﺪ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﻣﺸﻜﻠ ًﺔ ﺫﺍﺕ ﺍﻫﺘﻤﺎ ٍﻡ ﻣﺘﺰﺍﻳﺪ ﻭ ﻣﺆﺛﺮﺓ ﻋﻠﻰ ﺍﻟﺴﻼﻣﺔ ﺍﻟﻨﻔﺴﻴﺔ. ﺃﻓﻜﺎﺭﻩ ﻭ ﻣﺸﺎﻋﺮﻩ ﺗﺠﺎﻩ ﺟﺴﺪﻩ, ﺗﻌ ّﺮﻑ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﻛـﺘﺼ ّﻮﺭ ﺍﻟﺸﺨﺺ:ﺍﻟﺨﻠﻔﻴﺔ ﺍﻟﻤﺘﺼ ّﻮﺭ ﻭ, ﻭ ﺍﺳﺘﻜﺸﺎﻑ ﺍﻟﻌﻼﻗﺔ ﺑﻴﻦ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ, ﺗﺤﺪﻳﺪ ﺍﻟﻌﻮﺍﻣﻞ ﺍﻟﻜﺎﻣﻨﺔ ﻭﺭﺍﺀﻩ, ﺗﻬﺪﻑ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﺇﻟﻰ ﺗﻘﺪﻳﺮ ﻣﺪﻯ ﺍﻧﺘﺸﺎﺭ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ:ﺍﻷﻫﺪﺍﻑ .2011 ﺍﻟﻤﺮﻏﻮﺏ ﺑﻴﻦ ﻃﺎﻟﺒﺎﺕ ﺍﻟﻄﺐ ﺑﺠﺎﻣﻌﺔ ﻃﻴﺒﺔ ﻋﺎﻡ ﺍﺳﺘﺒﺎﻧﺔ ﺗﻢ ﺗﻌﺒﺌﺘﻬﺎ ﺫﺍﺗﻴﺎ ﻟﺘﺤﺪﻳﺪ ﺍﻟﻌﻮﺍﻣﻞ, ﺍﺳُﺘﺨ ِﺪﻡ ﻣﻘﻴﺎﺱ ﺗﺼﻨﻴﻒ ﺑﺘﺴﻊ ﺻﻮﺭ ﻇﻠّﻴﺔ ﻟﺘﻘﻴﻴﻢ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ, ﻟﺠﻤﻊ ﺍﻟﺒﻴﺎﻧﺎﺕ. ﻣﺸﺎﺭﻛﺔ242 ﻫﺬﺍ ﺍﺳﺘﻘﺼﺎﺀ ﻣﻘﻄﻌﻲ ﺷﻤﻞ:ﺍﻟﻤﻨﻬﺠﻴﺔ . ﻭ ﻗﻴﺎﺱ ﻃﻮﻝ ﻭ ﻭﺯﻥ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻟﺤﺴﺎﺏ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ ﻟﺪﻳﻬﻦ,ﺍﻟﻤﺤﺘﻤﻞ ﻣﺴﺎﻫﻤﺘﻬﺎ ﻓﻲ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﺑﻴﻦ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻫﻨﺎﻙ. ﺃﻧﻔﺴﻬﻦ ﻛﺴﻤﻴﻨﺎﺕ ﺟﺪﺍ%55 ﺑﻴﻨﻤﺎ ﺗﺼﻮﺭ, ﺗﺼﻮﺭﻥ ﺃﻧﻔﺴﻬﻦ ﻧﺤﻴﻼﺕ ﺟﺪﺍ%18.6 , ﻛ ّﻦ ﺭﺍﺿﻴﺎﺕ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ%26.4 ﺑﻴﻦ ﺟﻤﻴﻊ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻓﻲ ﺍﻟﺪﺭﺍﺳﺔ؛:ﺍﻟﻨﺘﺎﺋﺞ ﺍﻟﺘﺼﻮﺭﺍﺕ ﺍﻟﻐﻴﺮ ﺣﻘﻴﻘﻴﺔ ﻋﻦ ﺍﻟﺬﺍﺕ ﻭ ﺍﻟﺸﻌﻮﺭ ﺑﻌﺪﻡ ﺗﻨﺎﺳﻖ ﺃﺟﺰﺍﺀ, ﺍﻧﺘﻘﺎﺩ ﺍﻷﺻﺪﻗﺎﺀ, ﺗﺄﺛﻴﺮ ﺍﻟﻌﺎﺋﻠﺔ, ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ:ﺭﺍﺑﻂ ﻣﻌﺘﺒﺮ ﺑﻴﻦ ﺩﺭﺟﺔ ﺍﻟﺮﺿﺎ ﻋﻦ ﺍﻟﺠﺴﺪ ﻭ ﺍﻟﻌﻮﺍﻣﻞ ﺍﻟﺘﺎﻟﻴﺔ .ﺍﻟﺠﺴﻢ ﺑﺎﻟﻐﻦ ﻓﻲ ﺗﻘﺪﻳﺮ ﺃﻭﺯﺍﻧﻬﻦ ﻭ ﺭﻏﺒﻦ ﻓﻲ, ﺃﻏﻠﺐ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻛﻦ ﻏﻴﺮ ﺭﺍﺿﻴﺎﺕ. ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭﺓ ﺍﻟﺠﺴﺪ ﻛﺎﻥ ﻣﻨﺘﺸﺮﺍً ﺑﻴﻦ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻭ ﻣﺮﺗﺒﻄًﺎ ﺑﻤﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﺪ ﺍﻟﻔﻌﻠﻲ:ﺍﻟﺨﺎﺗﻤﺔ ﺍﻟﻤﺰﻳﺪ ﻣﻦ. ﺍﻟﺮﻳﺎﺿﺔ ﻭ ﺍﻟﺤﻤﻴﺔ ﻫﻤﺎ ﺍﻟﺴﻠﻮﻙ ﺍﻻﻛﺜﺮ ﺷﻴﻮﻋًﺎ ﺑﻴﻦ ﺍﻟﻤﺸﺎﺭﻛﺎﺕ ﻟﻠﺘﺤﻜﻢ ﻓﻲ ﺍﻟﻮﺯﻥ. ﺍﻟﻌﺎﺋﻠﺔ ﻭ ﺍﻷﺻﺪﻗﺎﺀ ﻛﺎﻥ ﻟﻬﻤﺎ ﺑﺎﻟﻎ ﺍﻷﺛﺮ ﻋﻠﻰ ﻫﺬﺍ ﺍﻟﻤﺮﺣﻠﺔ ﺍﻟﻌﻤﺮﻳﺔ ﺍﻟﺤﺮﺟﺔ.ﺃﻥ ﻳﻜﻦ ﺃﻧﺤﻒ ﺁﺧﺬ ًﺓ ﻓﻲ ﻋﻴﻦ ﺍﻻﻋﺘﺒﺎﺭ ﺍﻟﻌﻼﻗﺔ ﺑﻴﻦ ﻋﺪﻡ ﺍﻟﺮﺿﺎ ﻋﻦ ﺻﻮﺭ ﺍﻟﺠﺴﺪ ﻣﻦ ﺟﻬﺔ ﻭ ﺍﻻﻛﺘﺌﺎﺏ ﻭ ﺍﺿﻄﺮﺍﺑﺎﺕ ﺍﻷﻛﻞ ﻣﻦ ﺟﻬﺔ،ﺍﻻﺑﺤﺎﺙ ﺑﺤﺎﺟﺔ ﻷﻥ ُﺗﺠﺮﻯ ﻋﻠﻰ ﻋﻴﻨﺔ ﺍﻛﺒﺮ ﻣﻦ ﺍﻟﻤﺠﺘﻤﻊ ﺍﻟﺴﻌﻮﺩﻱ .ﺃﺧﺮﻯ Abstract Background: Body image has been defined as the person’s perceptions, thoughts, and feelings about his body. Body image dissatisfaction is a problem of growing concern that affects psychological wellbeing. Objectives: This study aims to estimate the prevalence of body image dissatisfaction, identify its underlying risk factors, and explore the relation between actual, perceived and desired BMI among female medical students in Taibah University, KSA. Method: This is a cross-sectional survey that involved 242 participants. Data were collected using a nine figure silhouette rating scale for assessing body image dissatisfaction, a self-administered questionnaire for identifying possible factors contributing to dissatisfaction, and measurement of the participants’ weight and height to calculate their actual BMI.
* Corresponding address: Fourth-year Medical Students, Faculty of Medicine, Taibah University, Almadinah Almunawwara, Kingdom of Saudi Arabia. Tel.: +966 530557707. E-mail: [email protected] (E. As-Sa’edi) Peer review under responsibility of Taibah University.
Production and hosting by Elsevier 1658-3612 Ó 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jtumed.2013.05.001
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Results: Of all participants: 26.4% were satisfied, 18.6% perceived self as too thin, while 55% perceived self as too heavy. There has been a significant association between the degree of satisfaction and the following factors; actual BMI, family influence, friends’ criticism, unreal self-perception and feeling of disproportional body parts (at P<.05). The actual and desired BMI of the participants in the study have been correlated to their perceived BMI at a significant level (P=.000). Conclusion: Dissatisfaction was prevalent and associated with actual BMI. The majority of participants were dissatisfied, overestimating their weight and desired to be thinner. Exercise and diet were commonly used to control weight. Further researches need to be done on this topic on a larger population of the Saudi community taking in consideration its association with depression and eating disorders. Keywords: Body image; Body mass index; Satisfaction; Saudi Arabia Ó 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.
Introduction
Materials and Methods
Body image has been defined by many researchers over the years as the person’s perceptions, thoughts, and feelings about his or her body.1 The construct of body image can be broken down into two and often three dimensions. The first dimension is cognitive, how an individual “thinks” he or she looks. The second is emotional, how an individual “feels” he or she looks. Last is idealistic, how an individual “wants” to look.2 Dissatisfaction with physical appearance appears to be more the rule than the exception. Based on the results of a survey done by Garner and colleagues, most women (56%) and almost half (43%) of men are dissatisfied with their overall appearance.3 About 66% of Saudi women are overweight, approximately 52% of the adult population in the Kingdom of Saudi Arabia is obese while 18% of adolescents and over 15% of pre-school children are also victims of obesity.4 Abdel-Fattah et al., have conducted a study among females seeking treatment for obesity in Saudi Arabia and suggested a high frequency of depressive symptoms, and concerns with body image among obese patients.5 It was also found that high levels of body dissatisfaction in treatment-seeking obese individuals are associated with elevated depression and decreased levels of self-esteem.6 Al-Subaie, found an association between the desire to be thinner in secondary school female students in Saudi Arabia and the exposure to Western culture as living abroad or speaking foreign languages.7 To understand how people feel about themselves, researchers have examined self-esteem and body image satisfaction. Dissatisfaction with current body weight was expressed by more overweight and underweight females than by the normal weight females.8 Falkner et al., found that overweight status was associated with emotional problems, hopelessness and suicidal thoughts in adolescent females.9 Similar findings showed a stronger association between overweight status and poor psychological health among females as compared to males in several other community-based, cross-sectional studies of children and adolescents.10–13 Few studies have discussed body image dissatisfaction in Al Madinah Al Munwarah, KSA. This study aims to estimate the prevalence of body image dissatisfaction, identify its underlying risk factors, and explore the relation between actual, perceived and desired body mass index (BMI) among female medical students in the Taibah University, KSA. We believe that dissatisfaction is prevalent with the presence of a correlation between actual, perceived MI and desired BMI.
Setting and participants This cross-sectional survey has been carried out from September through November 2011, at the Taibah University, Al-Madinah Al-Munwarah, KSA. It involved 242 out of 343 female medical students. Response rates were (19.8%, 22.3%, 24.4%, 14.9% and 18.6%) for the 1st, 2nd, 3rd, 4th, and 5th year students, respectively and the overall response rate was 71%. Age of participants was ranging from 19 to 27 years. An informed verbal consent has been taken from all participants. Ethics committee approval was taken. Data were collected using a nine figure silhouette rating scale for assessing body image dissatisfaction, a self-administered questionnaire for identifying possible factors that could contribute to body image (dis)satisfaction among participants, and measurement of participants’ weight and height was taken at the medical unit in the Taibah University in order to calculate their actual BMI. Study tools The nine figure silhouette rating scale This study used a psychological tool developed by Stunkard et al.14 for assessing body image dissatisfaction. In this measure, silhouettes ranging from very thin to very obese are presented to the participant, who is usually asked to choose the silhouette closest to her own body size (perceived) and that representing her ideal size(desired). The discrepancy between the two figures is seen as an indication of (dis)satisfaction.1 Stunkard’s figure rating scale is a valid and reliable measure of women’s weight status, when rated as viewed either in-person or on videotape by an unrelated observer.15 The perceived and desired figures were related to the perceived and desired BMI using a scale developed by Bulik and colleagues.16 The reliability of this scale has been proved for actual BMI and self-reported BMI in males and females. Therefore, the nine figures represented nine levels of BMI for females (18.3–45.4).17 Calculating actual BMI The weight and height of participants were measured at the University’s health unit, and BMI was calculated using the equation: BMI = weight (kg)/height2 (m). Participants with
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BMIs < 18.5 were considered underweight, BMIs ranging between 18.5 and 24.9 were considered normal weight, BMIs ranging between 25.0 and 29.9 were considered overweight, BMIs > 30.0 were considered obese,18 the calculated BMI is considered as the actual BMI. Self-administered questionnaire Every participant was given a questionnaire that included: demographic data, possible factors that could affect body image (dis)satisfaction (family influence, friends’ criticism, society pressure, unreal perception of body size, comparison to media icons and feeling of disproportional body parts), and participants’ ideas about life aspects possibly affected by weight changes (friends and popularity, confidence, health, beauty, femininity and attractiveness to opposite sex) have been explored. Finally, the questionnaire included a survey about the common measures used by participants to change their weight (exercise, diet, diet pills, increasing caloric intake and others). Ethical considerations and confidentiality were assured.
Table 1: Characteristics of participants: weight, height and body mass index grouped into actual, perceived and desired BMI. Age (years) Weight (kg) Height (cm) Actual BMI Underweight Normal Overweight Obese Perceived BMI chosen by: Underweight Normal Overweight Obese Desired BMI chosen by: Underweight Normal Overweight Obese *
Statistical analysis SPSS (Statistical Package for Social Science) program was used for statistical analysis (version 13; Inc., Chicago, IL). Data from questionnaires were entered as numerical or categorical, as appropriate. Two types of statistics were done; 1. Descriptive statistics, where Quantitative data were shown as mean, SD, range, and Qualitative data were expressed as frequency and percent. 2. Analytical statistics, where the Chi-square test was used to measure association between qualitative variables. Pearson’s correlation has been used to study correlation between two variables having normally distributed data. P-value was considered statistically significant when it is less than 0.05. Results Results showed that mean actual BMI of participants was 22.79 ± 4.71, mean perceived BMI was 22.67 ± 4.46 and mean desired BMI was 20.32 ± 1.59, and their mean age was 21.02 ± 1.48 (Table 1). Of all participants, 55% perceived themselves as too heavy and desired to lose weight, 26.40% were satisfied and 18.60% perceived themselves as too thin and desired to gain weight (Figure 1). Regarding possible risk factors of dissatisfaction among female medical students in the Taibah University, results showed a significant (P < .05) association between the degree of (dis)satisfaction and the following factors: actual BMI (P = .000), family influence (P = .013), friends’ criticism (P = .000), unreal self-perception (P = .000), feeling of disproportional body parts (P = .000), while comparison to media icons, and society influence did not pose this significant association (P > .05). Among participants who perceived themselves as too heavy, 86.5% stated that they feel themselves heavier than others expressed (i.e. showed unreal self perception), 78.2% feel they have disproportional body parts, while 97.8% of those feeling themselves as too thin were affected by both the family influence and friends’ criticism (Table 2). About 79.7% of satisfied participants were of normal weight and the most interesting thing is that 54.2% of the participants
Range
Mean±SD*
19–27 36.00–135.00 140.00–186.00 14.24–47.27
21.02±1.48 56.79±12.88 157.72±6.72 22.79±4.71 17.19±1.13 21.48±1.83 27.31±1.37 33.31±3.82 22.67±4.46 18.89±.64 21.35±2.69 26.93±4.33 30.38±3.96 20.32±1.59 19.93±1.30 19.97±1.19 21.15±2.22 21.91±1.63
17.80–40.8
17.80–31.30
Standard deviation.
who feel themselves as too heavy were of normal weight (Figure 2). Results indicated that there is a positive correlation between perceived BMI and both actual and desired BMI (r = .803, r = .462 at P = .000 respectively) of the studied population (Table 3/Figures 3 and 4). For underweight individuals they somewhat estimated their BMI correctly (Perceived = 18.89), but they still desired a heavier ideal body weight (ideal = 19.93). In normal weight individuals, the mean actual and perceived BMI do not vary (21.48, 21.35 respectively), however they desired thinner ideal (mean = 19.97) weight. Overweight and obese individuals underestimated their actual BMI (mean and perceived BMI = 26.39, and 30.38 respectively), but desired much thinner ideal weight (mean and Ideal BMI = 21.15 and 21.91 respectively) (Table 1). Significant differences have been found between participants (distributed by their actual BMI) regarding weight control behaviors (P < .05). Exercise and diet were the most commonly used behaviors among participants to control their weight (66.9% and 51.2%, respectively), while diet pills and changing eating habits were minimally used by 5% and 28.5% of participants, respectively (Table 4). Discussion Dissatisfaction is an epidemic problem of modern societies, and it appears to be more the rule than the exception. Women tend to be critical of their appearance and place importance on the way they look, it was expected that there would be a linear relationship between current weight status and ideal body image. The mean age of the participants was 21.02 ± 1.48 SD, while the mean actual BMI was 22.79 ± 4.71 SD. There has been a significant association between actual BMI and dissatisfaction (P = .000). Actual and desired BMI of the participants in the study had a positive correlation to their perceived BMI at a significant level (P = .000). In other words; as the participants get heavier, they were aware of this
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Figure 1: Prevalence of body image dissatisfaction among female medical students in the Taibah University.
Table 2: Possible risk factors of body image dissatisfaction among female medical students in the Taibah University, categorized according to the degree of satisfaction. v2
Perceives self as too thin
Satisfied
Perceives self as too heavy
Total
n=45
n=64
n=133
n=242
P-value
No.
%
No.
%
No.
%
No.
%
Family influence – No – Yes
1 44
(2.2) (97.8)
11 53
(17.2) (82.8)
28 105
(21.1) (78.9)
40 202
(16.5) (83.5)
8.66
.013*
Friends’ criticism – No – Yes
1 44
(2.2) (97.8)
21 43
(32.8) (67.2)
47 86
(35.3) (64.7)
69 173
(28.5) (71.5)
18.88
.000*
Society influence – No – Yes
7 38
(15.6) (84.4)
10 54
(15.6) (84.4)
18 115
(13.5) (86.5)
35 207
(14.5) (85.5)
0.20
.902
(82.2) (17.8)
34 30
(53.1) (46.9)
18 115
(13.5) (86.5)
89 153
(36.8) (63.2)
78.22
.000*
(37.8) (62.2)
15 49
(23.4) (76.6)
33 100
(24.8) (75.2)
65 177
(26.9) (73.1)
3.39
.183
(71.1) (28.9)
30 34
(46.9) (53.1)
29 104
(21.8) (78.2)
91 151
(37.6) (62.4)
38.02
.000*
(51.1) (46.7) (2.2) (0.0)
12 51 1 0
(18.8) (79.7) (1.5) (0.0)
2 72 39 20
(1.5) (54.2) (29.3) (15.0)
37 144 41 20
(15.3) (59.5) (16.9) (8.3)
104.18
.000*
Unreal self perception – No 37 – Yes 8 Comparison to media icons – No 17 – Yes 28 Feeling of disproportional body parts – No 32 – Yes 13 Actual BMI – Underweight – Normal – Overweight – Obese *
23 21 1 0
Significant association; P value<.05.
Figure 2: Actual BMI of participants distributed by their degree of body image (dis)satisfaction.
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Body image dissatisfaction
Table 3: Correlation between perceived and both desired and actual body mass indices of the studied population. Perceived BMI
Desired BMI Actual BMI *
r
P-value
.462 .803
.000* .000*
Significant association; P value<.05.
weight gain which was accompanied by increasing levels of dissatisfaction for being far from the slender ideal body images. They desired slimmer bodies even though their ideals were larger than their thinner counterparts; which states that the ideal weight was proportional to their weight. Similarly, in a study done among Jamaican adolescents in 2011, there were significant positive correlation between participants actual and perceived BMI (r = 0.61, P < 0.01), and between perceived and desired BMI (r = 0.29, P < 0.01).17 Kostanski et al., have also found that actual BMI was strongly related to dissatisfaction (P < .05).19 Another research, done by Alipoor et al., found a significant correlation between score of dissatisfaction and actual BMI (r = .95, P = .0001).2 In Spain, large proportion of students (67.7%) chose an ideal body weight lower than actual weight.20 A tendency of female students to over-estimate their body weight has been established in a similar study.21 Perhaps this similarity is due to the effect of the common age group, but still this association has proven to be significant in middle aged women. A study
made by Cachelin et al., on middle aged women showed that current figures were significantly larger than the ideal figure (P = .0001).22 Although western and non-western cultures are distinct, dissatisfaction seems to be a common problem. Significant differences in body shape perception among Australian born women were reported with greater degree of dissatisfaction.23 On the other hand, Mahmud et al., made a study showing that dissatisfaction is more pronounced in western compared to eastern cultures as Australian females expressed significantly higher levels of dissatisfaction once they are paired to Pakistani females.24 Of all participants in our study: 26.4% were satisfied, 18.6% perceived self as too thin (desired to gain weight), while 55% perceived self as too heavy (desired to lose weight). These findings are in line with these related studies: a Polish study showed that only 34.4% of female pharmacy students were satisfied.21 Among the dissatisfied individuals in a Pakistani research, 45.6% of the respondents perceived self as too heavy whereas 54.4% perceived self as too thin.25 The prevalence of dissatisfaction was 47.3% among female university students in Florianopolis, Brazil.26 In Jamaica, Huffman et al., reported that the study participants underestimated their weight in obese and overweight categories, but still desired smaller bodies.17 These closely related results are probably because thinness has the most influential impact on body image dissatisfaction nowadays. Our study concludes that there is a significant association between the degree of satisfaction/dissatisfaction and the following risk factors: participants’ actual BMI, Family influence
Figure 3: Correlation between perceived and desired body mass index among the study participants.
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Figure 4: Correlation between perceived and actual body mass index among the study participants.
Table 4: Behaviors for weight control among participants distributed by their actual BMI. Under weight n=37
Normal n=144
No.
%
Exercise – No – Yes
19 18
51.4 48.6
52 92
Diet – No – Yes
23 14
62.2 37.8
Diet pills – No – Yes
30 7
Eat more – No – Yes
17 20
*
Over weight
No.
n=41 %
Obese
Total
n=20
v2
P-value
n=242
No.
%
No.
%
No.
%
36.1 63.9
7 34
17.1 82.9
2 18
10.0 90.0
80 162
33.1 66.9
15.74
.001*
79 65
54.9 45.1
10 31
24.4 75.6
6 14
30.0 70.0
118 124
48.8 51.2
17.36
.001*
81.1 18.9
144 0
100.0 .0
38 3
92.7 7.3
18 2
90.0 10.0
230 12
95.0 5.0
24.37
.000*
45.9 54.1
109 35
75.7 24.3
30 11
73.2 26.8
17 3
85.0 15.0
173 69
71.5 28.5
14.94
.002*
Significant association; P value<.05.
and friends’ criticism, unreal self-perception and feeling of disproportional body parts (P < .05). Family and friends influenced 83.5% and 71.5% of all participants respectively. About 63.2% of participants reported feeling heavier than other expressed to them (unreal self-perception) and nearly 62.4% stated the feeling of disproportional body parts. Approximately more than half of participants who perceive themselves as too heavy were influenced by these factors. Lawler et al., showed that BMI, peer criticism and internalized appearance emerge as significant predictors of body image
dissatisfaction.27 Another research done by BibiGerner, also found this correlation with peer acceptance (r = .23 at P = .001).28 In a study made on Chinese females, 2010, reported pressure from peers and adult relatives to lose weight.29 This similarity in results can be partially explained by participants’ critical age group which can make them more affected by others’ opinion. A study made on Pakistani students found a significant association between high media exposure and body image dissatisfaction (P < .05).25 Another study done by O’Dea and
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Abraham, demonstrated that body weight was also an important aspect of social acceptance.30 Among Spanish adolescents, mass media exposure was associated with body dissatisfaction.31 Unexpectedly, our results found insignificant association between dissatisfaction and both media and society influence (p > .05). The lower exposure to media and less sociability of medical students might clear up this contradiction. In this study, among the 64 (26.4%) of satisfied participants, 79.7% were of normal weight, 18.8% and 1.5% were of underweight and overweight respectively. None of the obese participants was satisfied. The results of this study are in keeping with those of a previous study made by Sarwer, which showed that the majority of obese women demonstrated body image dissatisfaction related to obesity.6 However, a study conducted in 2005, found that there’s a little relationship between the degree of obesity and the intensity of dissatisfaction among North American population.32 This controversy can be explained by the cultural differences in viewing obesity. Among behaviors used to control weight: Exercise and diet were the most commonly used behaviors among participants (66.9% and 51.2%, respectively) while diet pills were used only by 5% of them. Increasing caloric intake to gain weight was used by 28.5% of all participants. McDonald et al., also showed that Women’s motivation of exercise was related to weight.33 Moreover, Sarwer et al., reported that dissatisfaction might be a motivator to lose weight by changing dietary habits and physical activity.32 A study made in Qatar, 2006, stated that 47.1% of overweight and obese female adolescents were on diet.34 This resemblance is owed to the fact that diet and exercise are the most accessible means of controlling weight. Limitations The results would have been enhanced if a larger sample of college students was taken in consideration, and if it included both sexes in this group. That is a limitation we have been forced to, because of the short duration of research we were obliged to while conducting. Recommendation Further studies need to be done on a larger population of the Saudi community taking into consideration the association between body image dissatisfaction and depression as well as eating disorders. Universities may also consider carrying awareness campaigns on this issue and planning for intervention programs in nutrition clinics in their facilities. Conclusion Results indicate that dissatisfaction is prevalent among female medical students in the Taibah University and associated with their actual BMI. More than half of participants of all weight categories were dissatisfied about their weight. There was a tendency to over-estimate weight even among normal-weight participants. This led to behavioral changes in an attempt to controlling weight. In addition, it was strongly influenced by family and friends’ criticism, feeling of disproportional body parts and unreal self perception. This highlights the importance of conducting nutritional health education campaigns
in this group of young university students to correct their wrong thoughts toward the ideal body image, orient them by the criteria and importance of a healthy diet, and provide free nutritional consultations. References 1. Morgan S. Body image: understanding body dissatisfaction. Routledge; 2008. 2. Alipoor S et al. Analysis of the relationship between physical selfconcept and body image dissatisfaction in female students. J Social Sci January 2009; 5(1): 60–66. 3. Garner DM, Garfinkel Paul E, Schwartz Donald, Thompson Michael. Cultural expectations of thinness in women. Psychol Rep 1980; 47. 4. Roche. Obesity threatens the Saudi community. Saudi Arabia Business Press Releases 2001. 5. Abdel-Fattah Moataz M, Abdel-Rahman Asal A, Tamer Mohamed M, Makhlouf Mohamed M. Depression and body image disturbances among females seeking treatment for obesity in Saudi Arabia. Eur J Psychol 2008; 4(3). 6. Sarwer DB, Wadden TA, Foster GD. Assessment of body image dissatisfaction in obese women: specificity, severity, and clinical significance. J Consult Clin Psychol 1998; 66: 651–654. 7. Al-Subaie AS. Some correlates of dieting behavior in Saudi schoolgirls. Int J Eat Disord 2000; 28: 242–246. 8. Rasheed Parveen. Overweight status: body image and weight control beliefs and practices among female college students. Ann Saudi Med 1999; 19(4). 9. Falkner NH, Neumakr-Sztainer D, Story M, Jeffery RW, Beuhring T, Resnick MD. Social, educational and psychological correlates of weight status in adolescents. Obes Res 2001; 9: 32–42. 10. Datar A, Sturm R. Childhood overweight and elementary school outcomes. Int J Obes 2006; 30: 1449–1460. 11. Erickson S, Robinson T, Haydel F, Killen J. Are overweight children unhappy? Arch Pediatr Adolesc Med 2000; 154: 931–935. 12. Mond JM, Hay PJ. Functional impairment associated with eating disorder behaviors in a community sample of women and men. Int J Eat Disord 2007; 40: 391–398. 13. Needham BL, Crosnoe R. Overweight status and depressive symptoms during adolescence. J Adolesc Health 2005; 36: 48–55. 14. Stunkard AJ, Sorensen TI, Schulsinger F, editors. Use of the Danish Adoption Register for the study of obesity and thinness. New York: Raven Press; 1983, Biomed central, http://www.biomedcentral.com/1471-2458/11/835/figure/F1?highres=y. 15. Cardinal Tiffany M. The figure rating scale as an index of weight status of women on videotape. Obes Res 2006; 14: 2132–2135. 16. Bulik CM, Wade TD, Heath AC, Martin NG, Stunkard AJ, Eaves LJ. Relating body mass to figural stimuli: population based normative data for caucasions. Int J Obes 2001; 25(10): 1517–1524. 17. Barrett SC, Huffman FG. Comparison of self-perceived weight and desired weight versus actual body mass index among adolescents in Jamaica. Rev Panam Salud Publica 2011; 29(4): 267–276. 18. Health Canada. BMI Chart. http://www.hc-sc.gc.ca/index-eng. php accessed November 2011. 19. Kostanski Marion, Gullone Eleonora. Adolescent body image dissatisfaction: relationships with self-esteem, anxiety, and depression controlling for body mass. J Child Psychol Psychiatry February 1998;255–262. 20. Arroyo M, Basabe N, Serrano L, Sa´nchez C, Ansotegui L, Rocandio AM. Prevalence and magnitude of body weight and image dissatisfaction among women in dietetics majors. Arch Latinoam Nutr June 2010; 60(2): 126–132. 21. Jaworowska Agnieszka, Bazylak Grzegorz. An outbreak of body weight dissatisfaction associated with self-perceived BMI and
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