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Body image in obese patients before and after stable weight reduction following bariatric surgery
Journal of Psychosomatic Research, Vol. 46, No. 3, pp. 275–281, 1999 Copyright 1999 Elsevier Science Inc. All rights reserved. 0022-3999/99 $–see front matter
S0022-3999(98)00094-4
BODY IMAGE IN OBESE PATIENTS BEFORE AND AFTER STABLE WEIGHT REDUCTION FOLLOWING BARIATRIC SURGERY GIAN FRANCO ADAMI,* ANNA MENEGHELLI,† ANNALISA BRESSANI* and NICOLA SCOPINARO* (Received 24 March 1998; accepted 1 July 1998) Abstract—The role of possessing an abnormal body weight in the body image alterations of obese patients was evaluated in bariatric surgery subjects prior to and at long term after operation, when body weight and shape had become steadily normalized. Body image was assessed by the body dissatisfaction scale of the Eating Disorders Inventory, the Body Shape Questionnaire, and the Body Attitude Questionnaire. When the individuals were obese, a sharply impaired body image was observed; following operation, weight loss corresponded to normalization of body dissatisfaction, feeling of fatness, and physical attractiveness, whereas body disparagement and salience of shape, although improved in comparison to preoperative data, remained significantly different from that of controls. In the obese patients, some aspects of body image alterations are substantially accounted for by overweight status; other aspects reflect inner feelings, which are partially independent of the actual body weight and shape. 1999 Elsevier Science Inc. Keywords:
Body image; Obesity; Obesity psychology; Obesity surgery.
INTRODUCTION
In Western, developed countries, satisfaction with one’s own somatic morphology decreases as body weight increases and, consequently, in severely obese patients, sharply impaired body image and high dissatisfaction with somatic morphology are commonly observed [1–3]. However, in several studies, a clear, positive correlation between body dissatisfaction and body weight was lacking [4]: this suggests that, in obese patients, besides being overweight and having a somatic morphology far different from what is socially acceptable, other factors may influence body image [5– 7]. In most studies, body image is evaluated by ratings of ideal body figure drawings, by distorting mirrors [8–10], or by self-report questionnaires, like the body dissatisfaction scale of Eating Disorders Inventory (EDI) or the Eating Attitude Test [11, 12]. These methods are appropriate for assessing dissatisfaction with weight and shape; however, other important body image symptoms remain poorly understood. In fact, the psychometric instruments currently used only marginally assess aspects * Dipartimento di Chirugia, Facolta` di Medicina e Chirurgia, Universita` di Genova, Genova, Italy. † ASIPSE, Milano, Italy. Address correspondence to: Dr. Gian Franco Adami, Dipartimento di Chirurgia, Universita` di Genova, viale Benedetto XV 8, 16132 Genova, Italy. Phone: 39-10-3537301-39-10-3537265; Fax: 39-10502754; E-mail: [email protected]
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such as the distressing preoccupation with weight, self-disparagement, embarrassment in public, avoidance of body exposure, and importance attributed to somatic morphology in everyday life, and other aspects such as relationship with others, excessive feelings of fatness after eating, feelings of attractiveness toward other people, sense of strength, and body physical efficiency [13]. The Body Shape Questionnaire (BSQ) was developed more than 10 years ago. The BSQ measures different aspects of concern about body weight and somatic morphology and it has been used widely in the assessment of eating-disordered patients [14]; the validity and reliability of the BSQ have recently been confirmed for obese patients [13]. The Body Attitude Questionnaire (BAQ) assesses a broad range of attitudes toward the body, and its subscales address six different aspects of body experience, involving both external appearance and certain characteristics of internal functioning [15]. In this investigation, the body-image-related impact of having body weight and shape far different from the accepted standard was evaluated in a group of severely obese patients. With this purpose, the subjects were studied prior to biliopancreatic diversion [16], when they were obese. These patients had asked for bariatric surgery with the aim of losing weight and were, by consequence, preoccupied and unsatisfied with their somatic morphology. These same subjects were followed-up 3 years later when their body weight had been steadily reduced to normal or to near normal. This timeframe represents a long enough period whereby patients could adapt to having body proportions within socially accepted limits. METHOD Our investigation was carried out on 30 obese individuals (21 females) undergoing biliopancreatic diversion (BPD), ranging in age from 21 to 56 years (mean 36.8), with a preoperative mean body weight of 131 kg and a mean body mass index (BMI) of 48.7 kg/m2 (Table I). Prior to operation, the patients completed the Eating Disorders Inventory (EDI), the Body Shape Questionnaire (BSQ), and the Body Attitude Questionnaire (BAQ). Body image was assessed by the EDI’s body dissatisfaction subscale, which measures dissatisfaction with weight and shape, and by the global score of the BSQ, which reflects psychological distress with somatic morphology, embarrassment, and feeling bad about one’s own body shape and in exposing it in public, and also the worry of fatness just after eating. In addition, six subscales of the BAQ were considered: the feeling of overall fatness (feeling fat); self-disparagement or feeling of disgust with the body (disparagement); self-assessed strength and physical efficiency (strength and fitness); salience of weight and shape in a person’s everyday experience (salience of shape); self-perceived physical attractiveness (attractiveness); and the feeling of being fat, particularly in the lower part of the body (lower body fatness). These factors, although all closely centered around weight and shape, are
Table I.—Body weight (kg) and BMI (kg/m2) values in lean control individuals and in obese subjects prior to and following biliopancreatic diversion (BPD)
Body weight Mean 6 sem Range Body mass index Mean 6 sem Range
Prior to BPD
Following BPD
Control subjects
131 6 3.4a,c 104–166.5
83 6 1.9b 56–97
68 6 2.4 52–93
48.7 6 1.4a,c 36.3–165.7
30.6 6 0.7a 23.9–38.7
23.4 6 0.4 20.8–29.7
a p , 0.001 vs. control subjects. b p , 0.05 vs. control subjects. c p , 0.001 vs. following BPD subjects.
277
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more complex and multidimensional than constructs such as satisfaction, and, psychometrically, they can adequately describe body image in a wide range of subjective experiences [13]. The subjects normalized or nearly normalized their body weight within the first postoperative year, and subsequently maintained a reduced body weight until the time of the study. The subjects were reassessed on the third postoperative year, on the occasion of a regular follow-up visit, when they were at normal or a nearly normal body weight for at least 2 years (Table I). All subjects reported good health and a sense of well-being, and there was no clinical or laboratory evidence of physical disturbance. A group of 30 individuals, who were never obese or had eating disorders, selected from university personnel and students, and closely matched to the obese subjects for gender and age, served as controls. Analysis was carried out with nonparametric statistical tests; the differences were evaluated by the Mann–Whitney U test for independent comparisons or with the Wilcoxon rank-sum test for paired data.
RESULTS
All patients experienced a highly satisfactory weight loss within the first postoperative year, and body weight and BMI values remained stable at both the secondand third-year follow-up visit, when the psychometric evaluation was repeated. The body weight of the lean control subjects was statistically lower than that observed at 3 years following the operation (Table I). Before BPD, the EDI body dissatisfaction, the BSQ score, and all BAQ subscale scores, except for strength and fitness, were significantly different from those observed in control subjects (Table II). Three years after the operation, by which time body weight had been steadily reduced for at least 2 years, significant decreases in the EDI’s body dissatisfaction score and the BAQ’s feeling fat and lower body fatness score were recorded, with values having become very similar to those observed in never-obese control individuals (Table II). A significant reduction in the BAQ’s disparagement and salience of shape and in the BSQ scores was also found, but with values still higher than those of controls. The BAQ’s attractiveness score rose to values very similar to those of never-obese individuals. Finally, the BAQ’s strength and fitness score remained unchanged, with both preoperative and postoperative values nearly identical to those found in the never-obese controls.
Table II.—Obese subjects prior to and following biliopancreatic diversion (BPD) and never-obese control subjects
BD FF Disp SF SS Att LBF BSQ
Prior to BPD
Following BPD
6 6 6 6 6 6 6 6
10.6 6 1.4 39.0 6 1.9 18.4 6 1.2b 16.6 6 0.8 21.8 6 0.9b 17.0 6 0.6 12.1 6 0.7 101 6 6c
16.1 47.1 21.0 17.1 25.00 15.3 14.6 123
1.0a,d 1.6a,d 0.9 0.8 0.8a,e 0.6b,e 0.5b,e 7a,e
Control subjects 9.3 35.5 13.2 17.7 18.2 18.0 12.1 75
6 6 6 6 6 6 6 6
1.2 2.5 1.8 0.7 1.3 0.5 0.7 7
Data show Mean 6 sem values of the Eating Disorders Inventory body dissatisfaction score (BD), Body Shape Questionnaire (BSQ) and also the Body Attitude Questionnaire subscale scores. FF: feeling fat; Disp: disparagement, SF: strength and fitness; SS: salience of shape; Att: attractiveness; LBF: lower body fatness. a p , 0.001 vs. control subjects. bp , 0.01 vs. control subjects. c p , 0.05 vs. following BPD subjects. dp , 0.01 vs. following BPD subjects. ep , 0.05 vs. following BPD subjects.
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DISCUSSION
As expected, and in full agreement with previous data, a sharp impairment of body image was observed in the severely obese patients in this study. In fact, nearly all questionnaire scores were different from those observed in the never-obese lean controls, thus indicating alterations in body satisfaction and other cognitive and affective aspects of body image as assessed by the BSQ and by BAQ subscales. After the operation, the sharp reduction of body weight and the long-term maintenance of normal or nearly normal body weight was shown to correspond to a decrease in the EDI’s body dissatisfaction score toward values similar to those of controls, suggesting a normalization of the satisfaction with one’s body shape. The body weight of never-obese subjects was lower than that of postobese individuals, whereas the EDI body dissatisfaction score was almost identical; therefore, it appears that the satisfaction with one’s own body is related more to being lean, or having become lean, than to the current value of body weight. Thus, the lack of a true negative correlation between body weight and body satisfaction is not surprising [4]. As observed by the EDI’s body dissatisfaction subscale, in the obese patients the BAQ’s feeling fat and lower body fatness scores were markedly higher than in lean controls; furthermore, despite still greater body weight, the values became closely similar after the operation. This finding reflects the correlation between the EDI’s body dissatisfaction and the BAQ’s feeling fat and lower body fatness scores [15], and indicates that the body satisfaction by itself may be considered closely related to the degree of body adiposity [15, 17]. The near normalization of body weight and somatic morphology led to normalization of the feeling of physical attractiveness, confirming its negative correlation with the BAQ subscale scores indicating fatness [15]. The widespread cultural contempt for overweight people makes obese individuals poorly accepted socially and, consequently, their human relationships are usually lacking or problematic [1, 3]. In having reduced body shape to socially acceptable limits, subjects generally increase social contacts: whatever physical appearance or psychological merits postobese persons may have, they begin to put themselves in relation with others and thus receive more positive reinforcement than when they were still fat and isolated. Furthermore, postobese individuals no longer experience the prejudice and social contempt that accompanies obesity, and thus regard themselves as similar to others. This may result in a feeling of increased physical attractiveness. Therefore, it is not surprising that, when the subject succeeds in obtaining and maintaining normal or near-normal body weight, the BAQ’s attractiveness score rises. Because postobese values became very similar to those observed in lean persons, in obese patients the lack of physical attractiveness, as a body image alteration symptom, must be considered due substantially to overweight status itself. On the contrary, other aspects of body image, such as those evidenced by the BSQ and by some BAQ subscales, appear to be, to some extent, independent of body adiposity. In accordance with previous studies, in obese patients the feeling of strength, fitness, and physical efficiency was very similar to those of lean subjects, confirming that, in this respect, the body image of overweight individuals is essentially normal [15, 17]. In fact, any inner consideration or thought about the size of one’s body may be independent of the sense of physical efficiency and, regardless of extent of over-
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weight status, obese patients may well feel as strong and as physically efficient as lean individuals. In addition, confirming the results of a previous cross-sectional investigation [17], this study demonstrates that losing a large amount of weight as a consequence of surgical intervention and maintaining a new body shape over the long term has no main effect on individual feeling of physical self-efficacy. In post-BPD subjects, maintaining body weight was mainly accounted for by intestinal malabsorption [18]. Because post-BPD individuals can maintain an essentially normal weight regardless of food consumption and/or eating behavior, a reduction in concern about weight and shape could be expected over the long term. Nevertheless, in the postobese subjects the interest in weight and shape, the importance attributed to the somatic morphology in everyday life, and the fear of regaining weight (although reduced in comparison with preoperative findings) are still greater than in never-obese subjects. In other words, post-BPD individuals, in spite of having a body weight and shape steadily within socially acceptable limits, still link deceitful psychological and emotional meanings to being overweight, and show very low confidence in the stability of their body weight, even though they maintained their nonobese weight for 2 years. A strong concern about body shape is a well-recognized feature of anorexia nervosa [19] and bulimia nervosa [20] and, in such cases, reflects true body image disturbance [21]. Because weight concern does not normalize with stable weight loss in obese patients, it can be suggested that it might reflect a body image alteration similar to that of eating-disordered patients. However, only the former have shown somatic morphology far different from normal, have been teased and blamed for overeating and being overweight, and have directly experienced the very harmful psychosocial effects of being obese; therefore, it is easy to understand why, regardless of body image alteration, postobese subjects are more afraid of again becoming obese than those never experiencing obesity. Furthermore, weight loss, without any other specific therapy, has itself caused some improvement of salience of shape, whereas, in eating-disordered patients, changes in body weight usually do not have an effect on weight/shape concern. Finally, the high salience of shape found in the postobese subjects could be simply accounted for by a body weight still slightly higher than that observed in the lean controls. For these reasons, the high levels of weight concern in postobese subjects must be considered as a psychological construct substantially different from the high weight concern of anorexia and bulimia nervosa patients; that is, the salience of shape of obese people appears to be related mainly to social contempt against being overweight, whereas body weight overconcern in eating-disordered patients might reflect true body image alteration. Three years after BPD only a slight, nonsignificant reduction of the BAQ’s body disparagement subscale was found; however, the data are still significantly different from those of lean subjects, thus confirming the previous cross-sectional findings [17] and suggesting that body disparagement may be partly intrinsic to obese patients’ personality traits. A psychological construct similar to the BAQ’s body disparagement has been described previously in relation to patients seeking treatment for obesity [22, 23]. On the contrary, in this investigation body disparagement greater than that of lean subjects was observed in both obese surgery patients and in individuals who have already had successful treatment for obesity, and have been in touch only for routine follow-up. Therefore, it appears that the BAQ’s body dis-
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paragement subscale might reflect a still unclear aspect of body image, which in any case is independent of both body weight and help-seeking for weight loss. Regardless of the presence of a true eating disorder, persons with mood disturbances can negatively distort their body image [24] and, in some obese patients, physical selfdisparagement could reflect psychological discomfort not related to overweight status and, consequently, in the absence of any specific therapy, can remain unchanged after weight loss. In addition, in severely obese patients, striking alexithymic elements and a high degree of symbolic functional inhibition have been described [25, 26]: when faced with psychological difficulties, subjects could not reliably identify and label their emotions, and had the tendency to transfer their discomfort to overweight status — thus seeking help for weight loss. It is most likely that the psychological discomfort of these patients would not subside with stable weight loss: consequently, in postobese subjects the physical self-disparagement, which characterizes obese patients seeking weight loss [22, 23], might well continue to be higher than in lean individuals, whereas body weight is steadily reduced. The sharp postoperative reduction of BSQ score and the lack of normalization of the data are fully understandable. The BSQ substantially measures both the feeling of fatness and body shape concern [13, 14]: the postoperative normalization of the feeling of fatness corresponds to the sharp reduction of the BAQ score, whereas a residual salience of shape higher than that of controls would account for BSQ values still greater than those of lean individuals who were never obese. This study confirms that the body image of severely obese patients seeking bariatric surgery is sharply impaired. The questionnaire data suggest that the recovery from obesity (i.e., the steady normalization or near normalization of body weight) obtained following bariatric surgery results in the recovery of some aspects of body image: the subjects have become more satisfied with their own body and the feelings of fatness and of physical attractiveness have decreased and increased, respectively. Other body image symptoms, such as distressing preoccupation with weight and excessive importance attributed to somatic morphology in everyday life and in relation with others, are improved , but have not reached complete normality. Therefore, it can be hypothesized that, within the body image construct, some psychological aspects are strictly related to body weight and shape, and in this respect body image alterations in obese patients are substantially accounted for by overweight status itself. Other aspects, such as the distressing preoccupation with body weight and shape, body dissatisfaction, and self-disparagement, might reflect inner feelings, which in obese patients become partially independent from actual somatic morphology and which do not normalize with the stable body weight and shape. In conclusion, the overall improvement after stable weight reduction indicates that, in obese patients, body image alterations—although they may involve similar behaviors, may reflect a similar cognitive pattern, and may be shown by the same psychometric instrument—are completely different from those of eating-disordered patients.
REFERENCES 1. Allon N. Self-perception and stigma of overweight in relation to weight losing patterns. Am J Clin Nutr 1979;32:470–480.
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2. Offman HJ, Bradley SJ. Body image of children and adolescents and its measurements: an overview. Can J Psychiatry 1992;37:417–422. 3. Stunkard AJ, Wadden TA. Psychological aspects of severe obesity. Am J Clin Nutr 1992; 55(suppl):524S–532S. 4. Foster GD, Wadden TA, Vogt RA. Body image in obese women before, during and after weight loss treatment. Health Psychol 1997;16:226–229. 5. Abram M. The eating disorder inventory as a predictor of compliance in a behavioral weight-loss program. Int J Eat Disord 1991;10:355–360. 6. Chandarana P, Holliday R, Conlon P, Deslippe T. Psychosocial considerations in gastric stapling surgery. J Psychosom Res 1988;32:85–92. 7. Adami GF, Gandolfo P, Campostano A, Bauer B, Cocchi FH, Scopinaro N. Eating Disorder Inventory in the assessment of psychosocial status in the obese patients prior to and at long term following biliopancreatic diversion for obesity. Int J Eat Disord 1994;15:267–274. 8. Williamson DA, Davis CJ, Bennett SM, Gorenczy AJ, Gleaves DH. Development of a simple procedure for assessing body image disturbances. Behav Assess 1989;22:433–446. 9. Ben-Tovim DI, Walker MK. Women’s body attitudes: a review of measurement techniques. Int J Eat Disord 1991;10:155–167. 10. Rosen JC. Body image assessment and treatment in controlled studies of eating disorders. Int J Eat Disord 1996;20:331–343. 11. Garner DM, Garfinkel PE. The Eating Attitude Test: an index of symptoms of anorexia nervosa. Psychol Med 1979;9:273–279. 12. Garner MG, Olmsted MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord 1984;2:15–24. 13. Rosen JC, Jones A, Ramirez E, Waxman S. Body Shape Questionnaire: studies of validity and reliability. Int J Eat Disord 1996;20:315–319. 14. Cooper PJ, Taylor M, Cooper Z, Fairburn CG. The development and validation of the Body Shape Questionnaire. Int J Eat Disord 1987;6:485–494. 15. Ben-Tovim DI, Walker MK. The development of the Ben-Tovim Walker body attitudes questionnaire (BAQ), a new measure of women’s attitudes toward their own bodies. Psychol Med 1991; 21:775–784. 16. Scopinaro N, Gianetta E, Adami GF, Friedman D, Traverso E, Marinari GM, Cuneo S, Vitale B, Ballari F, Colombini M, Baschieri G, Bachi V. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996;119:261–268. 17. Adami GF, Gandolfo P, Campostano A, Meneghelli A, Ravera G, Scopinaro N. Body image and body weight in obese patients. Int J Eat Disord 1998;24:299–306. 18. Scopinaro N, Adami GF, Marinari GM, Gianetta E, Traverso E, Friedman D, Camerini G, Baschieri G, Simonelli A. Biliopancreatic diversion. World J Surg 1998;22:936–946. 19. Bruch H. Eating disorders: obesity, anorexia nervosa and the person within. New York: Basic Books 1973. 20. Cooper PJ, Faiburn CG. The Eating Disorder Examination: a semistructured interview for the assessment of the specific psychopathology of eating disorders. Int J Eat Disord 1987;6:1–8. 21. Garfinkel PE. Evidence in support of attitudes to shape and weight as a diagnostic criterion of bulimia nervosa. Int J Eat Disord 1992;11:321–325. 22. Stunkard AJ, Burt V. Obesity and body image. II. Age at onset of disturbance in the body image. Am J Psychiatry 1967;123:1443–1447. 23. Stunkard AJ, Mendelson M. Obesity and the body image. Characteristics of disturbances in the body image of some obese persons. Am J Psychiatry 1967;123:1296–1300. 24. Noles SW, Cash TF, Winstead BA. Body image, physical attractiveness, and depression. J Consult Clin Psychol 1985;53:88–94. 25. Legorreta G, Bull RH, Kiely MC. Alexithymia and symbolic function in the obese. Psychother Psychosom 1988;50:88–94. 26. Clerici M, Albonetti S, Papa R, Penati G, Invernizzi G. Alexithymia and obesity. Study of the impaired symbolic function by the Rorschach test. Psychother Psychosom 1992;57:88–93.
S0022-3999(98)00094-4
BODY IMAGE IN OBESE PATIENTS BEFORE AND AFTER STABLE WEIGHT REDUCTION FOLLOWING BARIATRIC SURGERY GIAN FRANCO ADAMI,* ANNA MENEGHELLI,† ANNALISA BRESSANI* and NICOLA SCOPINARO* (Received 24 March 1998; accepted 1 July 1998) Abstract—The role of possessing an abnormal body weight in the body image alterations of obese patients was evaluated in bariatric surgery subjects prior to and at long term after operation, when body weight and shape had become steadily normalized. Body image was assessed by the body dissatisfaction scale of the Eating Disorders Inventory, the Body Shape Questionnaire, and the Body Attitude Questionnaire. When the individuals were obese, a sharply impaired body image was observed; following operation, weight loss corresponded to normalization of body dissatisfaction, feeling of fatness, and physical attractiveness, whereas body disparagement and salience of shape, although improved in comparison to preoperative data, remained significantly different from that of controls. In the obese patients, some aspects of body image alterations are substantially accounted for by overweight status; other aspects reflect inner feelings, which are partially independent of the actual body weight and shape. 1999 Elsevier Science Inc. Keywords:
Body image; Obesity; Obesity psychology; Obesity surgery.
INTRODUCTION
In Western, developed countries, satisfaction with one’s own somatic morphology decreases as body weight increases and, consequently, in severely obese patients, sharply impaired body image and high dissatisfaction with somatic morphology are commonly observed [1–3]. However, in several studies, a clear, positive correlation between body dissatisfaction and body weight was lacking [4]: this suggests that, in obese patients, besides being overweight and having a somatic morphology far different from what is socially acceptable, other factors may influence body image [5– 7]. In most studies, body image is evaluated by ratings of ideal body figure drawings, by distorting mirrors [8–10], or by self-report questionnaires, like the body dissatisfaction scale of Eating Disorders Inventory (EDI) or the Eating Attitude Test [11, 12]. These methods are appropriate for assessing dissatisfaction with weight and shape; however, other important body image symptoms remain poorly understood. In fact, the psychometric instruments currently used only marginally assess aspects * Dipartimento di Chirugia, Facolta` di Medicina e Chirurgia, Universita` di Genova, Genova, Italy. † ASIPSE, Milano, Italy. Address correspondence to: Dr. Gian Franco Adami, Dipartimento di Chirurgia, Universita` di Genova, viale Benedetto XV 8, 16132 Genova, Italy. Phone: 39-10-3537301-39-10-3537265; Fax: 39-10502754; E-mail: [email protected]
275
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such as the distressing preoccupation with weight, self-disparagement, embarrassment in public, avoidance of body exposure, and importance attributed to somatic morphology in everyday life, and other aspects such as relationship with others, excessive feelings of fatness after eating, feelings of attractiveness toward other people, sense of strength, and body physical efficiency [13]. The Body Shape Questionnaire (BSQ) was developed more than 10 years ago. The BSQ measures different aspects of concern about body weight and somatic morphology and it has been used widely in the assessment of eating-disordered patients [14]; the validity and reliability of the BSQ have recently been confirmed for obese patients [13]. The Body Attitude Questionnaire (BAQ) assesses a broad range of attitudes toward the body, and its subscales address six different aspects of body experience, involving both external appearance and certain characteristics of internal functioning [15]. In this investigation, the body-image-related impact of having body weight and shape far different from the accepted standard was evaluated in a group of severely obese patients. With this purpose, the subjects were studied prior to biliopancreatic diversion [16], when they were obese. These patients had asked for bariatric surgery with the aim of losing weight and were, by consequence, preoccupied and unsatisfied with their somatic morphology. These same subjects were followed-up 3 years later when their body weight had been steadily reduced to normal or to near normal. This timeframe represents a long enough period whereby patients could adapt to having body proportions within socially accepted limits. METHOD Our investigation was carried out on 30 obese individuals (21 females) undergoing biliopancreatic diversion (BPD), ranging in age from 21 to 56 years (mean 36.8), with a preoperative mean body weight of 131 kg and a mean body mass index (BMI) of 48.7 kg/m2 (Table I). Prior to operation, the patients completed the Eating Disorders Inventory (EDI), the Body Shape Questionnaire (BSQ), and the Body Attitude Questionnaire (BAQ). Body image was assessed by the EDI’s body dissatisfaction subscale, which measures dissatisfaction with weight and shape, and by the global score of the BSQ, which reflects psychological distress with somatic morphology, embarrassment, and feeling bad about one’s own body shape and in exposing it in public, and also the worry of fatness just after eating. In addition, six subscales of the BAQ were considered: the feeling of overall fatness (feeling fat); self-disparagement or feeling of disgust with the body (disparagement); self-assessed strength and physical efficiency (strength and fitness); salience of weight and shape in a person’s everyday experience (salience of shape); self-perceived physical attractiveness (attractiveness); and the feeling of being fat, particularly in the lower part of the body (lower body fatness). These factors, although all closely centered around weight and shape, are
Table I.—Body weight (kg) and BMI (kg/m2) values in lean control individuals and in obese subjects prior to and following biliopancreatic diversion (BPD)
Body weight Mean 6 sem Range Body mass index Mean 6 sem Range
Prior to BPD
Following BPD
Control subjects
131 6 3.4a,c 104–166.5
83 6 1.9b 56–97
68 6 2.4 52–93
48.7 6 1.4a,c 36.3–165.7
30.6 6 0.7a 23.9–38.7
23.4 6 0.4 20.8–29.7
a p , 0.001 vs. control subjects. b p , 0.05 vs. control subjects. c p , 0.001 vs. following BPD subjects.
277
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more complex and multidimensional than constructs such as satisfaction, and, psychometrically, they can adequately describe body image in a wide range of subjective experiences [13]. The subjects normalized or nearly normalized their body weight within the first postoperative year, and subsequently maintained a reduced body weight until the time of the study. The subjects were reassessed on the third postoperative year, on the occasion of a regular follow-up visit, when they were at normal or a nearly normal body weight for at least 2 years (Table I). All subjects reported good health and a sense of well-being, and there was no clinical or laboratory evidence of physical disturbance. A group of 30 individuals, who were never obese or had eating disorders, selected from university personnel and students, and closely matched to the obese subjects for gender and age, served as controls. Analysis was carried out with nonparametric statistical tests; the differences were evaluated by the Mann–Whitney U test for independent comparisons or with the Wilcoxon rank-sum test for paired data.
RESULTS
All patients experienced a highly satisfactory weight loss within the first postoperative year, and body weight and BMI values remained stable at both the secondand third-year follow-up visit, when the psychometric evaluation was repeated. The body weight of the lean control subjects was statistically lower than that observed at 3 years following the operation (Table I). Before BPD, the EDI body dissatisfaction, the BSQ score, and all BAQ subscale scores, except for strength and fitness, were significantly different from those observed in control subjects (Table II). Three years after the operation, by which time body weight had been steadily reduced for at least 2 years, significant decreases in the EDI’s body dissatisfaction score and the BAQ’s feeling fat and lower body fatness score were recorded, with values having become very similar to those observed in never-obese control individuals (Table II). A significant reduction in the BAQ’s disparagement and salience of shape and in the BSQ scores was also found, but with values still higher than those of controls. The BAQ’s attractiveness score rose to values very similar to those of never-obese individuals. Finally, the BAQ’s strength and fitness score remained unchanged, with both preoperative and postoperative values nearly identical to those found in the never-obese controls.
Table II.—Obese subjects prior to and following biliopancreatic diversion (BPD) and never-obese control subjects
BD FF Disp SF SS Att LBF BSQ
Prior to BPD
Following BPD
6 6 6 6 6 6 6 6
10.6 6 1.4 39.0 6 1.9 18.4 6 1.2b 16.6 6 0.8 21.8 6 0.9b 17.0 6 0.6 12.1 6 0.7 101 6 6c
16.1 47.1 21.0 17.1 25.00 15.3 14.6 123
1.0a,d 1.6a,d 0.9 0.8 0.8a,e 0.6b,e 0.5b,e 7a,e
Control subjects 9.3 35.5 13.2 17.7 18.2 18.0 12.1 75
6 6 6 6 6 6 6 6
1.2 2.5 1.8 0.7 1.3 0.5 0.7 7
Data show Mean 6 sem values of the Eating Disorders Inventory body dissatisfaction score (BD), Body Shape Questionnaire (BSQ) and also the Body Attitude Questionnaire subscale scores. FF: feeling fat; Disp: disparagement, SF: strength and fitness; SS: salience of shape; Att: attractiveness; LBF: lower body fatness. a p , 0.001 vs. control subjects. bp , 0.01 vs. control subjects. c p , 0.05 vs. following BPD subjects. dp , 0.01 vs. following BPD subjects. ep , 0.05 vs. following BPD subjects.
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DISCUSSION
As expected, and in full agreement with previous data, a sharp impairment of body image was observed in the severely obese patients in this study. In fact, nearly all questionnaire scores were different from those observed in the never-obese lean controls, thus indicating alterations in body satisfaction and other cognitive and affective aspects of body image as assessed by the BSQ and by BAQ subscales. After the operation, the sharp reduction of body weight and the long-term maintenance of normal or nearly normal body weight was shown to correspond to a decrease in the EDI’s body dissatisfaction score toward values similar to those of controls, suggesting a normalization of the satisfaction with one’s body shape. The body weight of never-obese subjects was lower than that of postobese individuals, whereas the EDI body dissatisfaction score was almost identical; therefore, it appears that the satisfaction with one’s own body is related more to being lean, or having become lean, than to the current value of body weight. Thus, the lack of a true negative correlation between body weight and body satisfaction is not surprising [4]. As observed by the EDI’s body dissatisfaction subscale, in the obese patients the BAQ’s feeling fat and lower body fatness scores were markedly higher than in lean controls; furthermore, despite still greater body weight, the values became closely similar after the operation. This finding reflects the correlation between the EDI’s body dissatisfaction and the BAQ’s feeling fat and lower body fatness scores [15], and indicates that the body satisfaction by itself may be considered closely related to the degree of body adiposity [15, 17]. The near normalization of body weight and somatic morphology led to normalization of the feeling of physical attractiveness, confirming its negative correlation with the BAQ subscale scores indicating fatness [15]. The widespread cultural contempt for overweight people makes obese individuals poorly accepted socially and, consequently, their human relationships are usually lacking or problematic [1, 3]. In having reduced body shape to socially acceptable limits, subjects generally increase social contacts: whatever physical appearance or psychological merits postobese persons may have, they begin to put themselves in relation with others and thus receive more positive reinforcement than when they were still fat and isolated. Furthermore, postobese individuals no longer experience the prejudice and social contempt that accompanies obesity, and thus regard themselves as similar to others. This may result in a feeling of increased physical attractiveness. Therefore, it is not surprising that, when the subject succeeds in obtaining and maintaining normal or near-normal body weight, the BAQ’s attractiveness score rises. Because postobese values became very similar to those observed in lean persons, in obese patients the lack of physical attractiveness, as a body image alteration symptom, must be considered due substantially to overweight status itself. On the contrary, other aspects of body image, such as those evidenced by the BSQ and by some BAQ subscales, appear to be, to some extent, independent of body adiposity. In accordance with previous studies, in obese patients the feeling of strength, fitness, and physical efficiency was very similar to those of lean subjects, confirming that, in this respect, the body image of overweight individuals is essentially normal [15, 17]. In fact, any inner consideration or thought about the size of one’s body may be independent of the sense of physical efficiency and, regardless of extent of over-
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weight status, obese patients may well feel as strong and as physically efficient as lean individuals. In addition, confirming the results of a previous cross-sectional investigation [17], this study demonstrates that losing a large amount of weight as a consequence of surgical intervention and maintaining a new body shape over the long term has no main effect on individual feeling of physical self-efficacy. In post-BPD subjects, maintaining body weight was mainly accounted for by intestinal malabsorption [18]. Because post-BPD individuals can maintain an essentially normal weight regardless of food consumption and/or eating behavior, a reduction in concern about weight and shape could be expected over the long term. Nevertheless, in the postobese subjects the interest in weight and shape, the importance attributed to the somatic morphology in everyday life, and the fear of regaining weight (although reduced in comparison with preoperative findings) are still greater than in never-obese subjects. In other words, post-BPD individuals, in spite of having a body weight and shape steadily within socially acceptable limits, still link deceitful psychological and emotional meanings to being overweight, and show very low confidence in the stability of their body weight, even though they maintained their nonobese weight for 2 years. A strong concern about body shape is a well-recognized feature of anorexia nervosa [19] and bulimia nervosa [20] and, in such cases, reflects true body image disturbance [21]. Because weight concern does not normalize with stable weight loss in obese patients, it can be suggested that it might reflect a body image alteration similar to that of eating-disordered patients. However, only the former have shown somatic morphology far different from normal, have been teased and blamed for overeating and being overweight, and have directly experienced the very harmful psychosocial effects of being obese; therefore, it is easy to understand why, regardless of body image alteration, postobese subjects are more afraid of again becoming obese than those never experiencing obesity. Furthermore, weight loss, without any other specific therapy, has itself caused some improvement of salience of shape, whereas, in eating-disordered patients, changes in body weight usually do not have an effect on weight/shape concern. Finally, the high salience of shape found in the postobese subjects could be simply accounted for by a body weight still slightly higher than that observed in the lean controls. For these reasons, the high levels of weight concern in postobese subjects must be considered as a psychological construct substantially different from the high weight concern of anorexia and bulimia nervosa patients; that is, the salience of shape of obese people appears to be related mainly to social contempt against being overweight, whereas body weight overconcern in eating-disordered patients might reflect true body image alteration. Three years after BPD only a slight, nonsignificant reduction of the BAQ’s body disparagement subscale was found; however, the data are still significantly different from those of lean subjects, thus confirming the previous cross-sectional findings [17] and suggesting that body disparagement may be partly intrinsic to obese patients’ personality traits. A psychological construct similar to the BAQ’s body disparagement has been described previously in relation to patients seeking treatment for obesity [22, 23]. On the contrary, in this investigation body disparagement greater than that of lean subjects was observed in both obese surgery patients and in individuals who have already had successful treatment for obesity, and have been in touch only for routine follow-up. Therefore, it appears that the BAQ’s body dis-
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paragement subscale might reflect a still unclear aspect of body image, which in any case is independent of both body weight and help-seeking for weight loss. Regardless of the presence of a true eating disorder, persons with mood disturbances can negatively distort their body image [24] and, in some obese patients, physical selfdisparagement could reflect psychological discomfort not related to overweight status and, consequently, in the absence of any specific therapy, can remain unchanged after weight loss. In addition, in severely obese patients, striking alexithymic elements and a high degree of symbolic functional inhibition have been described [25, 26]: when faced with psychological difficulties, subjects could not reliably identify and label their emotions, and had the tendency to transfer their discomfort to overweight status — thus seeking help for weight loss. It is most likely that the psychological discomfort of these patients would not subside with stable weight loss: consequently, in postobese subjects the physical self-disparagement, which characterizes obese patients seeking weight loss [22, 23], might well continue to be higher than in lean individuals, whereas body weight is steadily reduced. The sharp postoperative reduction of BSQ score and the lack of normalization of the data are fully understandable. The BSQ substantially measures both the feeling of fatness and body shape concern [13, 14]: the postoperative normalization of the feeling of fatness corresponds to the sharp reduction of the BAQ score, whereas a residual salience of shape higher than that of controls would account for BSQ values still greater than those of lean individuals who were never obese. This study confirms that the body image of severely obese patients seeking bariatric surgery is sharply impaired. The questionnaire data suggest that the recovery from obesity (i.e., the steady normalization or near normalization of body weight) obtained following bariatric surgery results in the recovery of some aspects of body image: the subjects have become more satisfied with their own body and the feelings of fatness and of physical attractiveness have decreased and increased, respectively. Other body image symptoms, such as distressing preoccupation with weight and excessive importance attributed to somatic morphology in everyday life and in relation with others, are improved , but have not reached complete normality. Therefore, it can be hypothesized that, within the body image construct, some psychological aspects are strictly related to body weight and shape, and in this respect body image alterations in obese patients are substantially accounted for by overweight status itself. Other aspects, such as the distressing preoccupation with body weight and shape, body dissatisfaction, and self-disparagement, might reflect inner feelings, which in obese patients become partially independent from actual somatic morphology and which do not normalize with the stable body weight and shape. In conclusion, the overall improvement after stable weight reduction indicates that, in obese patients, body image alterations—although they may involve similar behaviors, may reflect a similar cognitive pattern, and may be shown by the same psychometric instrument—are completely different from those of eating-disordered patients.
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