Assessment of body-image perception and attitudes in obesity.
ABSTRACT To examine techniques that have been used to assess various aspects of body-image perception and body-image attitudes in obesity. It summarizes findings from previous review articles and reports on new research findings that have been published between August 2007 and August 2010.
Body-image perception and attitudes in obesity have been assessed using questionnaires, figural drawing scales and computer morphing or adjustment programs. Most of these techniques have been developed to assess body image in eating disorders and as such are not specific to the assessment of body image in obesity.
Body-image perception and body-image attitudes are commonly assessed in research studies on obesity. However, currently available assessment instruments have not been developed specifically for use in obese populations and not all have been validated in these populations. Researchers should be careful in selecting assessment instruments that are appropriate for use in obesity.
Assessment of body-image perception and attitudes in obesity
Charles B. Pull and Gloria A. Aguayo
Obesity as defined by a BMI of 30kg/m2or more has
become a major problem in many countries worldwide. It
isassociatedwith major physical morbidity aswell aswith
major psychopathology, including in particular major
disturbances of body image. As shown in a review by
Schwartzand Brownell , ‘socialmessagesthat being fat
reflects deficiency and personal failing are so powerful
and persistent that feeling bad about one’s body should
body dissatisfaction rises as people become more over-
weight, that negative body image is more pronounced in
obese women than obese men and that binge eating is
consistently associated with body dissatisfaction.
Body-image experts [2,3] differentiate between different
assessment measures of body image, including in particu-
lar a distinction between perceptual and attitudinal
measures. Perceptual measures pertain to the way in
which peopleperceive their body, in particular their body
size. The difference between actual body size and body
size perception is called body-image distortion. Attitu-
dinal measures have to do with the way people like or
dislike their body, in particular with regard to body size
and weight. A discrepancy between actual and desired
body size will almost always lead to body dissatisfaction.
In addition, body-image attitudes include affective dis-
tress, cognitive aspects and behavioural avoidance.
Over the years, a number of different techniques have
been developed to assess perceptual and attitudinal
aspects of body image. Assessment instruments include
single body-image-related questions and questionnaires,
static figure or figural drawing scales and computer
ments have not been developed specifically to assess
body image in obesity and not all existing instruments
have been validated in obese populations.
The present article summarizes the findings from
previous review articles and reports on new research
findings that have been published between August
2007 and August 2010 on the assessment of body-image
perception and attitudes in obesity.
PubMed was searched for research studies published from
August 2007 to August 2010, using the search words
‘assessment’, ‘body image’, ‘obesity’, ‘body-image dis-
satisfaction’ and ‘body-image disturbance’. A similar
Laboratoire des Troubles Emotionnels (LATE), Centre
de Recherche Public Sante ´, Strassen, Luxembourg
Correspondence to Charles B. Pull, Head of
Laboratory, Laboratoire des Troubles Emotionnels
(LATE), Centre de Recherche Public Sante ´, 1A, rue
Thomas Edison, 1445 Strassen, Luxembourg
Current Opinion in Psychiatry 2011, 24:41–48
Purpose of review
To examine techniques that have been used to assess various aspects of body-image
perception and body-image attitudes in obesity. It summarizes findings from previous
review articles and reports on new research findings that have been published between
August 2007 and August 2010.
Body-image perception and attitudes in obesity have been assessed using
questionnaires, figural drawing scales and computer morphing or adjustment programs.
Most of these techniques have been developed to assess body image in eating
disorders and as such are not specific to the assessment of body image in obesity.
Body-image perception and body-image attitudes are commonly assessed in research
studies on obesity. However, currently available assessment instruments have not been
developed specifically for use in obese populations and not all have been validated in
these populations. Researchers should be careful in selecting assessment instruments
that are appropriate for use in obesity.
assessment, body image, body-image attitudes, body-image dissatisfaction, body-
image disturbance, body-image perception, obesity
Curr Opin Psychiatry 24:41–48
? 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
0951-7367 ? 2011 Wolters Kluwer Health | Lippincott Williams & WilkinsDOI:10.1097/YCO.0b013e328341418c
search was conducted to find review articles published on
this topic between August 2000 and August 2010.
Body-image-related single questions
A simple but widely used method for addressing body-
image perception and satisfaction in obesity consists in
asking participants whether they think they are over-
weight and whether they are satisfied with their body
weight or shape. Questions may ask for a simple ‘yes’ or
‘no’ answer or be presented as Likert-type items or visual
analogue scales. The procedure will be illustrated using a
few recent random examples.
A first example comes from a study comparing body-
image perception, health outlook and eating behaviour in
mildly obese versus moderately-to-severely obese ado-
lescents. In-iw et al.  asked participants whether or not
they were satisfied with their body weight and whether
obesity had an adverse impact on their self-confidence.
Participants with significant obesity had poorer self-
image than participants with only mild obesity. A second
example is a study by Rudolph et al. , in which
children’s and adolescents’ and their parents’ self-
perception of weight, desire for weight change and
weight concerns, children’s belief that their desired
weight can be achieved and parents’ perception of
their child’s weight status were assessed using questions
asking for simple ‘yes’ and ‘no’ answers. Children and
adolescents, as well as their parents, recognized over-
weight as a health problem. In the majority, weight
perception matched real body weight. Most parents at
least recognized overweight in their children.
Single questions may have also been asked in a Likert-
like format. In a cross-sectional study in seven European
countries, Mikolajczyk et al.  compared the relation-
ship between perceived body weight and BMI by simply
asking: ‘Do you consider yourself much too thin, a little
too thin, just right, a little too fat or much too fat?’
According to the results, weight ideals are rather uniform
across the European countries, with female students
being more likely to perceive themselves as ‘too fat’ at
a normal BMI, whereas male students are more likely to
perceive themselves as ‘too thin’. Another example of
this type of questions concerns a study by Truesdale and
Stevens  designed to determine whether adults accu-
rately perceived their weight status category and could
report how much they would need to weigh in order to be
classified as underweight, normal weight, overweight or
obese. On average, normal-weight women and men were
would need to weigh to be classified as obese; however,
obese women and men overestimated the amount. Only
22.2% of obese women and 6.7% of obese men correctly
classified themselves as obese. A final example is pro-
vided in a study conducted by Harring et al.  to
determine whether inaccurate body weight perception
predicts unhealthy weight management strategies and to
what extent inaccurate body weight perception is associ-
ated with depressive symptoms. Participants were asked
‘how do you describe your weight?’ using one of the
following options: very underweight, slightly under-
weight, about right weight, slightly overweight and very
overweight. The result showed that participants were
concerned with weight and that they intended to take
Over the years, a considerable number of questionnaires
have been developed for assessing body-image percep-
tion and satisfaction. Most of these questionnaires have
been developed in the eighties and nineties of the past
century but continue to be widely used up to the present.
Most have been developed for assessing body image
in patients with eating disorders without or with only
minimal consideration for weight disorders, including in
particular overweight, obese and very obese patients.
Questionnaires and other methods for assessing body-
image perception in adolescents and adults have been
reviewed by Thompson and Gardner . Questionnaires
for assessing body-image attitudes among adolescents
and adults, concerning in particular dissatisfaction with
body image, have been reviewed by Thompson and Van
den Berg  in 2002. Questionnaires for assessing body
image in children and adolescents published up to 2009
have been reviewed more recently by Yanover and
Thompson [11?]. None of the questionnaires reviewed
were specifically developed for use in obesity.
Questionnaires on body dissatisfaction have also been
reviewed more recently by Grogan , who refers to the
review by Thompson and Van den Berg and who dis-
cusses several additional questionnaires that were not
included in this review.
Recently developed questionnaires
Recently developed questionnaires include instruments
that have been validated in obese populations and in
older patients, sex-specific questionnaires and question-
naires for assessing positive body image.
Cuzzolaro et al.  have developed a 71-item question-
naire named the Body Uneasiness Test (BUT) that
consists of two parts. BUT?A measures weight phobia,
monitoring, detachment and estrangement feelings
towards one’s own body (depersonalization). BUT?B
looks at specific worries about particular body parts or
Personality disorders and neurosis
functions. Analyses confirmed a structural five-factor
model for BUT?A and an eight-factor model for BUT?B.
Internal consistency was satisfactory. The test–retest
correlation coefficients were highly significant. Concur-
rent validity with other tests was satisfactory. Normative
values for BUT scores in nonclinical samples of normal-
weight noneating-disordered patients, from adolescence
to old age, men and women, were calculated. The
authors conclude that the BUT is psychometrically
sound and that it can be a valuable tool for the screening
and the clinical assessment of abnormal body-image
attitudes and eating disorders.
Marano et al.  have investigated the psychometric
properties of the BUT in a large sample of obese persons
seeking treatment. Analyses confirmed a structural five-
factor model for BUT-A and an eight-factor model for
BUT-B. Internal consistency was satisfactory. The
authors calculated mean values for BUT scores in adult
patients with obesity, and evaluated the influence of sex,
age and BMI. Women obtained statistically significantly
higher scores than men in all age groups and in all classes
of obesity; patients with obesity, compared with normal-
weight patients, generally obtained statistically signifi-
cantly higher scores, but few differences could be attri-
buted to the influence of BMI. According to the authors,
the BUT can be a valuable multidimensional tool for the
clinical assessment of body uneasiness in obesity.
Ferraro et al.  developed a Body-Image Perceptions
Scale (BIPS) to assess body dissatisfaction in older
patients.TheBIPSpresents participants with eight state-
ments about various body parts (e.g. ‘I think my stomach
is ...’) that are answered on a Likert-type scale ranging
from –3 (much too small) to 0 (just the right size) to 3
(much too big). The response values are summed to
obtain the total score. Higher scores indicate greater
Ochner et al.  have developed a questionnaire to
assess body dissatisfaction in men. Called the Male Body
Dissatisfaction Scale or MBDS, the questionnaire con-
tains 25 items scored on a five-point Likert scale from
‘always’ to ‘never’ or from ‘strongly agree’ to ‘strongly
disagree’ depending upon the item. Each item is scored
1–5, with balanced keying in order to control for untrue
responding. Participants additionally rate each item on
number is divided by 10 to obtain a number from 0 to 1
(e.g. an item rated 9 would receive a 0.9 importance
rating). The importance rating is then multiplied by
the item response (1–5) to get an overall score for each
item, ranging from 0.1 to 5. The importance rating adds
weight to items participants deem as making greater
contributions to their body image. An individual’s total
scores indicating more body dissatisfaction. Initial find-
ings suggest that the MBDS is a reliable and valid
measure of body dissatisfaction that allows men to weight
particular aspects of their body image according to
Avalos et al.  have developed a questionnaire for the
assessment of body appreciation, called the Body
Appreciation Scale or BAS. Several studies supported
the instrument’s unidimensionality, construct validity,
internal consistency and reliability. According to the
authors, the BAS should prove useful for researchers
and clinicians interested in positive body-image assess-
ment. Swami et al.  examined the psychometric
properties of the German version of the BAS on a com-
munity sample of 156 women and 144 men in Austria.
Results showed good internal reliability and construct
validity for the BAS scores, as well as a unidimensional
factor structure for both women and men. The authors
conclude that the German BAS is a useful indicator of
positive body image.
image, Jakatdar et al.  developed the Assessment
of Body-Image Cognitive Distortions or ABCD and
validated their instrument in a sample of 263 college
women. The ABCD assesses eight types of distorted
thinking related to how persons process information
about their physical appearance. Two 18-item parallel
forms of the unidimensional measure were also con-
structed. All forms were highly internally consistent
and relatively free from socially desirable responding.
Convergent validity for all ABCD forms was established
using several standardized measures of body image and
eatingattitudes. Multiple regression analysis showedthat
the ABCD was predictable from body-image evaluation,
investment and overweight preoccupation. The ABCD
uniquely predicted body-image quality of life and dis-
turbed eating attitudes above and beyond other body-
more prone to body-image cognitive distortions than
were thinner women and black women.
To assess behaviours associated with body dissatisfaction
and disordered eating, Lavender and Anderson 
compared response rates to a standard self-report ques-
tionnaire that was nominally anonymous with an
unmatched count questionnaire that allowed for true
response anonymity. Five hundred and sixty-seven
undergraduate students were asked about disordered
eating and body-image-related behaviours using one of
two response formats; either a conventional true–false
questionnaire or an unmatched count questionnaire that
did not require participants to directly respond to any
sensitive questions. Both men and women had signifi-
cantly different rates of endorsement between the two
Assessing body-image in obesity Pull and Aguayo 43
methods of assessment on the majority of the questions,
suggesting that degree of anonymity and format of
response may affect endorsements of these potentially
Static figure or figural drawing scales
According to Gardner and Brown [21??], ‘figural rating
scales, also referred to as silhouette or contour-line draw-
ings consist of a series of frontal images ranging from thin
to fat’. The authors differentiate between three types of
figure or figural drawing scales. Figural drawing scales
(proper) are line drawings with or without body and
clothing detail. Silhouette scales are contour-line draw-
ings shaded in black. Pictorial scales use pictures of
persons of varying weights as the basis for the figures.
Figural drawing scales are presented on paper. They are
static or fixed, that is, they cannot be modified by
et al.  in 1983. Called the Figure Rating Scale or FRS,
the scale consists of nine schematic silhouettes ranging
from thin to very obese. The FRS continues to be widely
used up to the present to assess body image in eating and
weight disorders, including in obesity. The first figural
scale adapted specifically for use in obesity was devel-
oped by Williamson et al.  as an expansion of the
Body-Image Assessment or BIA. Called the Body-Image
Assessment for obesity or BIA-O, the expanded scale
features 18 silhouettes of men and women for body sizes
ranging from very thin to very obese in 18 increments.
During the past three decades, a considerable number of
similar figural drawing scales have been developed to
assess various aspects of body image.
Gardner and Brown [21??] have recently reviewed all
known existing paper and pencil figural drawing scales
with published reliability and validity data. Nineteen
scales with no reported measures of reliability and/or
validity were excluded from the review. The authors
summarize the psychometric properties of eight scales
for children and/or adolescents and 11 scales for adults
who meet the required criteria. For each scale, they
provide the number of separate figures present on the
scale, the test–retest reliability for both current per-
ceived size and/or desired size, the concurrent and con-
vergent validity, the sexes (men or women) represented
on the figures, whether or not the scale measures body
size distortion, whether or not the figural drawings con-
tain details about body, face, hair or clothing that might
give clues as to ethnic groups, a description of the basis of
the figural drawings (artist renderings or anthropo-
morphic data or anthropometric properties of patients
of varying weights, representation of ethnic group) and
pictorial). For the child and adolescent scales, they also
indicate the appropriate ages for which the scale was
The authors highlight a number of important problems
encountered with existing figural drawing scales for
which reliability and validity measures are available.
Most scales consist of nine or fewer figures to represent
a nearly continuous variable. Participants often select
from only a few of the available figures. Most existing
scales do not allow for the measurement of body size
distortion. Many existing scales are drawn with facial and
body features that reflect obvious Caucasian ethnicity.
Finally, nearly all existing scales have been constructed
to correspond with what the artists believe represents a
variety of weights rather than known anthropometric
body dimensions for varying weights.
Gardner et al. [24??] have recently published a new figural
drawing scale that avoids most of the shortcomings of
previous figure drawing scales. Called the Body-Image
Assessment Scale–Body Dimensions or BIAS-BD, the
scale consists of contour-line drawings of 17 men and
17 women. Dimensions of the shoulder, chest, waist, hip
breadth, thigh breadth and upper leg breadth were
determined from known anthropometric data. Facial
and body features do not reflect ethnicity. The figural
drawings correspond to a series of body weights ranging
from 60% below the known average to 140% above
average. Differences between figural drawings represent
a 5% change in body weight. Test–retest reliability as
well as concurrent validity of the BIAS-BD was deter-
mined in a sample of 207 undergraduate students, includ-
ing 66 men and 141 women. Participants selected draw-
ings that reflected their perceived size and their ideal
size. Retesting occurred after a 2-week interval and
resulted in test–retest reliability values of r¼5.86 for
actual perceived size, r¼5.72 for ideal size and r¼5.76
for body dissatisfaction. There were no significant differ-
ences in reliability values between sexes. Mean differ-
ences in perceived size, ideal size and body dissatisfac-
tion between the two test administrations were small.
Concurrent validity, measured as the correspondence
between perceived and reported size, was r¼5.76.
Participants slightly overestimated their perceived body
size, with women overestimating significantly more.
To assess body image in younger and older women, Pruis
and Janowsky  developed a pictorial Figure Rating
Scale using morphed images of women’s own bodies.
Women faced forward with their arms about 608 out from
their sides and their feet approximately20 inapart.Head,
neck, feet and hands were cropped out of the images.
Personality disorders and neurosis
The cropped images were morphed to 35% thinner and
35% fatter than each woman’s actual size. The size
8.75%. The authors conducted a study in which each
woman saw nine images of her own body ranging from
35% thinner to 35% fatter than her actual size centred on
ideal, minimum acceptable and maximum acceptable
bodies. Body dissatisfaction and acceptable range were
calculated in the same manner as the Figure Rating Scale
with line drawings. Additionally, accuracy was calculated
as the discrepancy between their perceived current body
and their actual current body.
Another recent pictorial scale, called the female Photo-
graphic Figure Rating Scale or PFRS, was developed by
Tove ´e et al. [26,27]. The original PFRS was further
developed by Swami et al. . The scale consists of
10 photographic images of real women varying in body
mass index from emaciated to obese. All women were
grey leotards and leggings, and had their faces obscured
to avoid any impact of facial cues. The images are
presented in grey scale so as to minimize the impact of
ethnicity or skin tone. The reliability and validity of the
PFRS have been determined by Swami et al. . Based
on a sample of 208 adult women, the PFRS was shown to
have good validity in that all images were correctly rank-
ordered by BMI. In addition, construct validity was
supported by the finding that current self-ratings of body
size based on the PFRS were significantly correlated with
participants’ BMI and that body dissatisfaction was
negatively correlated with positive body image. Finally,
test–retest reliabilities showed that the PFRS remained
stable after a 3-week interval.
Computer morphing and adjustment
Computer morphing programs allow persons to modify
the size and the shape of a computer ‘morph’ of a human
body. Some programs use a digitized image of the per-
son’s own body. Programs may measure whole-body size
estimation and/or permit adjustments of individual body
Aleong et al.  have developed a computer-morphing
tool specifically designed for the testing of adolescent
body perception. The method includes an Adolescent
Body-Shape Database (AdoBSD) and an Adolescent
Body Morphing Tool (AdoBMT). The AdoBSD com-
prises real and morphed images (front and side view) of
160 adolescents (9–17 years). The AdoBMT and
AdoBSD may be used to investigate changes in body
perception during adolescence, and the role of body
perception in adolescent obesity and eating disorders.
Letosa-Porta et al.  have developed a program called
Body-Image Assessment Software or BIAS, which dis-
plays side and frontal views of a scale female human
figure that is the same size as the patient. The image can
be adjusted by independent modification of six body
parts (head, arms, breast, waist, hip and legs) in the
frontal view and five body parts (head, breast, waist,
hip and legs) in the side view, with the computer mouse.
The patient’s real body image is generated by entering
the body’s objective measurements into a database. The
program offers two visual tasks, which can be adminis-
tered together or independently. In the first, patients are
asked to modify several frontal and side views of body
parts in order to make a human figure correspond as
closely as possible to their real body image. In the second
task, patients modify frontal and side views of body parts
to make a human figure representing their ideal body
image. The discrepancy between a patient’s real and
perceived body sizes provides information about his or
her degree of perceptual distortion. The discrepancy
information about his or her degree of body image dis-
The psychometric characteristics of the BIAS have been
assessed by Ferrer-Garcı ´a and Gutie ´rrez-Maldonato ,
University of Barcelona and 51 patients with an eating
disorder. Results showed good validity and very high
reliability. Furthermore, BIAS was able to discriminate
between people who were at risk of an eating disorder
and those who were not, as well as between people with
and without a history of an eating disorder. Those at risk
of having an eating disorder and those with a current
eating disorder showed more body image distortion, that
is, overestimation of body size and higher levels of body
Stewart et al. [33??] have developed a technique called
the Body Morph Assessment, version 2.0 (which replaces
the original BMA, version 1.0 ). The BMA 2.0 is a
completely self-driven program with instructions on
board. It utilizes a computer ‘morph’ movie of a human
body. The battery consists of several morph movies
distinguished between sex and race (white or African–
American). The morph transforms from an exceptionally
thin body into an obese body or vice versa. There are a
total of 100 increments between the two endpoints of the
thin and obese bodies. By pressing a button, participants
can select the body size picture they believe corresponds
with a given instruction. For example, participants can
select their perceived current body size and ideal body
size, as well as an acceptable (able to be maintained over
time) body size. Anexportprogramcollects and organizes
the data over time and is easily transferred into other
spreadsheet and statistics programs (e.g. Microsoft Excel,
Assessing body-image in obesity Pull and Aguayo 45
SPSS) for organization and analysis of the data. The BMA
2.0 was found to have adequate reliability and validity.
Roy and Forest  have developed a computerized tool
to measure body-image distortion named the Quantifi-
cation of Body Image Distortion or Q-BID. The tool
pertains to the perceptual component of body image. It
uses a whole-body image procedure which allows for the
quantification of body-image distortion in absolute rather
than relative terms. It consists of morphological silhou-
ettes that were generated by more than 100 anthropome-
trical measurements taken from a representative sample
of Canadian men and women. Patients are invited to
modify the silhouettes in two steps. In the first step, they
modify the shoulders/hips ratio and breast development
such that the silhouettes become as similar as possible to
the perceived size. In the second step, patients modify
the weight of the silhouettes until they correspond to the
perception of their own body. Although the procedure
was initially developed and validated for use in patients
with anorexia nervosa, the authors are confident that
it can be used in any research involving body-image
Based on a method developed by Stewart et al. ,
Johnstone et al.  have developed a digital morphing
technique to assess body image in obesity. The tech-
nique implies taking a digital still photograph of the
patient dressed in swimwear, standing with palms for-
ward, arms abducted to approximately 458 and legs
abducted with feet approximately 0.5m apart. The
uncropped digital image is downloaded to a computer,
and the image extracted from the background using
delineation software in which the operator placed a series
of 131 landmark points, located in a systematic manner
around the feature margins of the image. Delineated
images are then uploaded into an interactive distortion
based on perpendicular vectors from body region mid-
points,whichproduces atwo-dimensionalwarping effect.
All images have the head masked from view. The body is
divided into left and right arms, thighs and calves and the
torso divided into chest, rib and hip areas, which can be
manipulated in real-time via the user interface. Using
interactive slider controls, patients can restore what they
believe to be the true shape from the given distorted
outline or create an ideal body.
The authorshave compared the results of their technique
with those of two standard paper questionnaires in three
categories of patients: lean, obese and lean regular exer-
cisers. Obese patients displayed poorer body perception
than their lean counterparts, with both sexes significantly
overestimating their actual body size. There was a sig-
nificant correlationfor body-image
between the digital technique and the questionnaires.
Gutie ´rrez-Maldonado et al.  have studied the effect of
virtual-reality exposure to situations that are emotionally
significant for patients with eating disorders on the
stability of body-image distortion and body-image dis-
satisfaction. A total of 85 patients and 108 controls were
randomly exposed to four experimental virtual environ-
ments: a kitchen with low-calorie food, a kitchen with
high-calorie food, a restaurant with low-calorie food and a
restaurant with high-calorie food. In the interval between
the presentation of each situation, body-image distortion
and body-image dissatisfaction were assessed. Eating
disorder participants had significantly higher levels of
body-image distortion and body-image dissatisfaction
after eating high-calorie food than after eating low-calorie
food, while control participants reported a similar body
image in all situations. The results suggest that body-
image distortion and body-image dissatisfaction show
both trait and state features. On the one hand, eating
disorder patients show a general predisposition to over-
estimate their body size and to feel more dissatisfied with
their body image than controls. On the other hand, these
body-image disturbances fluctuate when participants are
exposed to virtual situations that are emotionally relevant
As pointed out by Thompson , ‘body image is a
dimensions’. As such, assessing body image remains a
difficult task, and clinicians as well as researchers need to
very carefully consider the psychometric properties of
available instruments before deciding on the most appro-
priate measures. Thompson outlines 10 strategies to
improve assessment of body image for applied and
research purposes: specification of the dimension that
is being investigated, use of multiple measures, use of
measures with established reliability and validity, use of
the measures with appropriate samples, assessment
of reliability and validity in a given sample, adaptation
of measures to the purposes of the study, determination
oftheneedtomeasure stateortraitcharacteristics, carein
determining the instructional protocol, consideration of
diversity and analysis by pertinent participants’ charac-
teristics and evaluation of data in terms of norms and
clinical versus statistical significance. Among the caveats
emphasized by Thompson, special attention should be
given to the question of whether the measure is adequate
for use in obesity as a whole and in different degrees of
obesity, including severe and very severe types of obesity
More recently, Cafri et al.  have outlined a number of
potential methodological problems that may arise when
body dissatisfaction is measured by taking the difference
between self and ideal figures on contour-drawn figural or
Personality disorders and neurosis
silhouette scales. Problems include reduced reliability,
ambiguity, confounded effects, untested constraints and
dimensional reduction. The authors consider several
methodological criticisms of the use of difference scores
tive data-analytic framework that involves polynomial
regression and response surface methods.
as in other weight disorders. Very few of the currently
available measures have been developed for use in
obesity. Not all have been validated in obesity, especially
in the more severe degrees of the condition, and as such
may not be adequate for use in this field. Researchers are
advised to carefully investigate the psychometric proper-
ties of the measures they consider using in obesity before
starting their investigations.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 83–84).
of special interest
of outstanding interest
Schwartz MB, Brownell KD. Obesity and body image. Body Image
assessment methods of eating behaviours and weight related problems.
Thousand Oaks, CA: Sage; 1995. pp. 119–144.
Pruzinsky T, Cash TF. Understanding body images: historical and contem-
porary perspectives. In: Cash TF, Pruzinsky T, editors. Body image: a
handbook of theory, research,and clinical practice. New York: Guilford Press;
2002. pp. 3–12.
In-iw S, Manaboriboon B, Chomchai C. A comparison of body-image percep-
tion, health outlook and eating behavior in mildly obese versus moderately-to-
severely obese adolescents. J Med Assoc Thai 2010; 93:429–435.
Rudolph H, Blu ¨her S, Falkenberg C, et al. Perception of body weight status: a
case–control study of obese and lean children and adolescents and their
parents. Obes Facts 2010; 3:83–91.
Mikolajczyk RT, Maxwell AE, El Ansari W, et al. Relationship between
perceived body weight and body mass index based on self-reported height
and weight among university students: a cross-sectional study in seven
European countries. BMC Public Health 2010; 10:40.
Truesdale KP, Stevens J. Do the obese know they are obese? N C Med J
Harring HA, Montgomery K, Hardin J. Perceptions of body weight, weight
management strategies, and depressive symptoms among US college stu-
dents. J Am Coll Health 2010; 59:43–50.
Thompson JK, Gardner RM. Measuring body image perception among
adolescents and adults. In: Cash TF, Pruzinsky T, editors. Body image: a
handbook of theory, research,and clinical practice. New York: Guilford Press;
2002. pp. 135–141.
10 Thompson JK, Van den Berg P. Measuring body image attitudes among
adolescents and adults. In: Cash TF, Pruzinsky T, editors. Body image: a
handbook of theory, research,and clinical practice. New York: Guilford Press;
2002. pp. 142–154.
Yanover T, Thompson JK. Assessment of body image in children and
and obesity in youth: assessment, prevention, and treatment, 2nd ed.
Washington: American Psychological Association; 2009 . pp. 177–192.
Excellent review on the assessment of body image in children and adolescents.
12 Grogan S. Understanding body dissatisfaction in men, women and children.
2nd ed. Routledge, New York: Psychology Press; 2008.
13 Cuzzolaro M, Vetrone G, Marano G, Garfinkel PE. The Body Uneasiness Test
(BUT): development and validation of a new body image assessment scale.
Eat Weight Disord 2006; 11:1–13.
14 Marano G, Cuzzolaro M, Vetrone G, et al., QUOVADIS Study Group.
Validating the Body Uneasiness Test (BUT) in obese patients. Eat Weight
Disord 2007; 12:70–82.
15 Ferraro FR, Muehlenkamp JJ, Paintner A, et al. Aging, body image, and body
shape. J Gen Psychol 2008; 135:379–392.
16 Ochner CN, Gray JA, Brickner K. The development and initial validation of
a new measure of male body dissatisfaction. Eat Behav 2009; 10:197–
17 Avalos L, Tylka TL, Wood-Barcalow N. The Body Appreciation Scale:
development and psychometric evaluation. Body Image 2005; 2:285–
18 Swami V, Stieger S, Haubner T, Voracek M. German translation and psycho-
metric evaluation of the Body Appreciation Scale. Body Image 2008; 5:122–
19 Jakatdar TA, Cash TF, Engle EK. Body-image thought processes: the devel-
opment and initial validation of the assessment of body-image cognitive
distortions. Body Image 2006; 3:325–333.
20 Lavender JM, Anderson DA. A novel assessment of behaviors associated
with body dissatisfaction and disordered eating. Body Image 2008; 5:399–
Excellent review of static figural drawing scales for the assessment of body image.
Gardner RM, Brown DL. Body image assessment: a review of figural drawing
scales. Pers Indiv Differ 2010; 48:107–111.
22 Stunkard AJ, Sorensen T, Schulsinger T. Use of the Danish Adoption Register
for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis
23 Williamson DA, Womble LG, Zucker NL, et al. Body image assessment for
obesity (BIA-O): development of a new procedure. Int J Obes Relat Metab
Disord 2000; 24:1326–1332.
Gardner RM, Jappe LM, Gardner L. Development and validation of a new
figural drawing scale for body-image assessment: the BIAS-BD. J Clin
Psychol 2009; 65:113–122.
State-of-the-art figural drawing scale for assessing body image in eating and
weight disorders, including obesity.
25 Pruis TA, Janowsky JS. Assessment of body image in younger and older
women. J Gen Psychol 2010; 137:225–238.
26 Tove ´e MJ, Maisey DS, Emery JL, Cornelissen PL. Visual cues to female
physical attractiveness. Proc R Soc Lond 1999; 266:211–218.
27 Tove ´e MJ, Cornelissen PL. Female and male perceptions of female
physical attractiveness in front-view and profile. Br J Psychol 2001;
28 Swami V, Salem N, Furnham A, Tove ´e MJ. The influence of feminist ascription
on judgements of women’s physical attractiveness. Body Image 2008;
29 Swami V, Salem N, Furnham A,Tove ´e MJ. Initial examination of the validity and
reliability of the female photographic figure rating scale for body image
assessment. Pers Indiv Differ 2008; 44:1752–1761.
30 Aleong R, Duchesne S, Paus T. Assessment of adolescent body perception:
development and characterization of a novel tool for morphing images of
adolescent bodies. Behav Res Methods 2007; 39:651–666.
31 Letosa-Porta A, Ferrer-Garcı ´a M, Gutie ´rrez-Maldonado J. A program for
assessing body image disturbance using adjustable partial image distortion.
Behav Res Methods 2005; 37:638–643.
32 Ferrer-Garcı ´a M, Gutie ´rrez-Maldonado J. Body Image Assessment Software:
psychometric data. Behav Res Methods 2008; 40:394–407.
Stewart TM, Allen HR, Han H, Williamson DA. The development of the Body
Image 2009; 6:67–74.
State-of-the-art program for assessing body image in eating and weight disorders,
34 Stewart TM, Williamson DA, Smeets MA, Greenway FL. Body morph assess-
ment: preliminary report on the development of a computerized measure of
body image. Obesity Res 2001; 9:43–50.
35 Roy M, Forest F. Assessment of body image distortion in eating and weight
36 Stewart AD, Benson PJ, Michanikou EG, et al. Body image perception,
satisfaction and somatotype in male and female athletes and nonathletes:
results using a novel morphing technique. J Sports Sci 2003; 21:815–
Assessing body-image in obesity Pull and Aguayo47
37 Johnstone AM, Stewart AD, Benson PJ, et al. Assessment of body image in
obesity using a digital morphing technique. J Hum Nutr Diet 2008; 21:256–
38 Gutie ´rrez-Maldonado J, Ferrer-Garcı ´a M, Caqueo-Urı ´zar A, Moreno E.
Body image in eating disorders: the influence of exposure to virtual-
reality environments. Cyberpsychol Behav Soc Network 2010; 13:521–
39 Thompson JK. The (mis)measurement of body image: ten strategies to
improve assessment for applied and research purposes. Body Image
40 Cafri G, van den Berg P, Brannick MT. What have difference scores not been
telling us? A critique of the use of self-ideal discrepancy in the assessment of
body image and evaluation of an alternative data-analytic framework. Assess-
ment 2009; 17:361–376.
Personality disorders and neurosis