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Body Image Disturbance and Dissatisfaction, Scorn and Stigma in Severely Obese Individuals, a Case-Control Study

Open Journal of Psychiatry, 2018, 8, 355-375
ISSN Online: 2161-7333
ISSN Print: 2161-7325
10.4236/ojpsych.2018.83028 Jul. 31, 2018 355 Open Journal of Psychiatry
Body Image Disturbance and Dissatisfaction,
Scorn and Stigma in Severely Obese Individuals,
a Case-Control Study
M. Koski1, H. Naukkarinen2,3
1The HUH Psychiatry Centre, University of Helsinki, Helsinki, Finland
2University of Helsinki, Helsinki, Finland
3Carea Hospital District, Kymenlaakso Psychiatric Hospital, Kuusankoski, Finland
: The obesity rate is rising. The aims of this study were to eluc
date the connection among body image disturbance and
dissatisfaction, scorn
and stigma in severely obese individuals using a case-control method.
: The study group consisted of 112 individuals receiving permanent dis
bility pensions primarily for obesity. The controls were selected by random
The controls were matched with the subjects by place of residence,
gender, age, the time since the pension was granted and occupation. Psychi
tric interviews and psychological assessments were conducted with all parti
ipants. The results were analyzed via chi-squared tests (χ2-
tests) and percent
distributions. The subject and control groups were compared via paired
t-tests. Conditional logistic regression analysis was also conducted.
Results: In
the Draw a Person test, we found disorganization of the body i
mage to some
degree in the subject group. Some significant differences were found between
the Machover index and the wholeness index. The Rorschach variables o
tained some differences in the responses between the subject and control
groups. Obesity was a p
roblem in all age groups. In the study group, half of
the participants thought that they were obese. Most of the participants had
endured scorn and contempt directed at them due to being overweight.
: We believe that our study provides a novel a
nd necessary overview
of the connection among body image disturbance and dissatisfaction, scorn
and stigma.
Body Dissatisfaction, Body Image, BMI, Draw a Person, Machover Index,
How to cite this paper:
Koski, M.
, H. (2018) Body Image Dis-
turbance and Dissatisfaction, Scorn and
Stigma in Severely Obese Individuals, a
-Control Study.
Open Journal of Ps
, 355-375.
April 18, 2018
July 28, 2018
July 31, 2018
Copyright © 201
8 by authors and
Research Publishing Inc.
This work is licensed under the Creative
Commons Attribution International
License (CC BY
Open Access
M. Koski, H. Naukkarinen
10.4236/ojpsych.2018.83028 356 Open Journal of Psychiatry
Obesity, Overweight, Rorschach Variable, Scorn, Stigma, Weight
Misperception, Weight Perception, Wholeness Index
1. Introduction
The biological and psychosocial backgrounds of obesity have been studied ex-
tensively. However, not many studies have been conducted on the psychiatric
problems related to obesity, such as disturbances in body image, dissatisfaction,
and the scorn and stigma due to obesity.
1.1. Body Image
According to Bruch [1], body image is a fluid concept based on all the sensory
and mental perceptions that are integrated in the central nervous system. Bruch
considered feelings of control and possession of one’s body to be essential ele-
ments of body image. Body image refers to one’s physical, emotional, and inter-
personal view of his/herself. In obesity, disturbances in body image occur, espe-
cially among individuals who become obese during childhood and adolescence.
The development of a disturbed body image in an obese child depends on
his/her parents’ attitudes toward obesity [1]. According to Powers, the emotional
aspect of body image is the sum of all the attitudes one has about his/her body
[2]. According to Stunkard [3], only two factors are involved in obesity. The first
of these factors is hyperphagia (overeating); at least one time in his/her life, each
obese individual has consumed far more calories than he/she has expended. The
other main finding among obese individuals is the presence of a disturbed body
image. This is a more common finding among individuals who have been obese
since adolescence.
Stunkard and Mendelson [4] showed that the development of body image
disturbance depends on three factors: the age at the onset of obesity, the pres-
ence of emotional disturbance, and negative attitudes expressed by others to-
ward obesity during childhood and adolescence. Such obese individuals judge
the entire world on the basis of various weights. Stunkard and Mendelson [4]
also proposed that a disturbed body image of this type requires intensive psy-
chotherapy; the individual cannot be cured otherwise. Stunkard and Burt [5]
observed that a disturbed body image was most common among individuals
who had been obese in childhood. Stunkard and Wadden [6] found that body
image disturbance rarely remits spontaneously. They examined several over-
weight persons before and after antiobesity surgery. The disturbance was most
commonly found in individuals with childhood onset of obesity. According to
et al.
[7], after surgical methods in postobesity individuals with
adult-onset obesity, body image perceptions were very similar to those of con-
trols, while in those with early-onset obesity, body image perceptions were ab-
normal. Rand and Stunkard [8] [9] found that the disturbances in body image of
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10.4236/ojpsych.2018.83028 357 Open Journal of Psychiatry
obese individuals were lessened over four years of psychoanalytic therapy.
et al.
[10] found that early-onset obesity has an adverse effect on body
image, which is independent of current BMI. Moreover, early-onset obesity in-
creases the risk of body dissatisfaction, which, in turn, impairs self-esteem [7].
1.2. Dissatisfaction
Dissatisfaction with one’s own weight is very common. Here, we investigated
dissatisfaction with one’s own weight in individuals with obesity.
According to Crawford and Campbell [11], the average BMI at which women
considered themselves to be overweight was significantly lower than that for
men and was well within the acceptable BMI range. The results of the study by
et al.
[12] indicated that satisfaction with body weight and shape de-
creased as BMI increased in both genders. Women, however, showed signifi-
cantly greater body and weight dissatisfaction than men in most weight catego-
ries. Leonhard and Barry [13] demonstrated that the discrepant scores were sig-
nificantly different among the groups of females. Subjects agreed on judgments
of hypothetical normal male and female figure sizes; men in different BMI
groups agreed upon a figure representing their size and felt that their desired
size was attainable. Obese and very obese females underestimated their size and
felt that their desired size was unattainable. The disparity between ideal body
weight and real body weight is the source of emotional and physical distress for
many women. This dissatisfaction with one’s own body can lead to situations
and behaviors that reduce the health and life quality of a woman [14].
Interpersonal relations in childhood and adolescence are important for con-
sistent body dissatisfaction. The influence of family and peers is important for
reducing body dissatisfaction without depending on the media [15] [16].
In the research of [17], it was found that female university students value their
own ideal body weight as being lower than their real body weight. Most of the
female students possessed body image disturbances and dissatisfaction with their
own weight. Individuals who had undistorted body images had better nutritional
1.3. Scorn and Stigma
The rate of obesity is rising. The stigma of obesity seems to be maturing and
spreading globally [18]. The experience of being fat-shamed results in chronic
pressure, which affects millions of individuals [19]. Overwhelmingly, individuals
who are obese start to believe, internalize and project the stigma of obesity as
others do [20]. Prospective research has found that adults who have experienced
discrimination due to their weight have a 2.5 times greater risk of becoming ob-
ese. The fact is, those who have gained weight experience true difficulty in losing
weight [21].
Research has shown that social rejection and isolation causes psychosocial
stress [22]. This situation can lead to obese individuals having individuals with
M. Koski, H. Naukkarinen
10.4236/ojpsych.2018.83028 358 Open Journal of Psychiatry
similar situations within their social networks [23] [24]. This situation starts de-
veloping during childhood. [25] [26] [27] found that negative weight bias influ-
ences choices and that this bias occurs in everyday life. In working environ-
ments, females become objects of discrimination [28]. Additionally, low income
is involved in many aspects of quality of life [18] [29] [30]. [31] researched the
relationship among self-esteem, guilt and shame, which were found to be con-
nected to body and weight status. They found that women had statistically high
levels of shame and guilt regarding their own weight.
Psychosocial stress is possible in childhood because of school bullying. Social
relations could also be causes of stigma. What peers eat and take an interest in
can result in obese individuals having small social networks, which relates to the
fact that individuals with obesity are also very lonely [31] [32].
The aims of this study were to elucidate the connection among body image
disturbance and dissatisfaction, scorn and stigma in severely obese individuals.
Considering the background information presented above, we found that this
association has not yet been fully investigated. This was a case-control study.
2. Materials and Methods
The participant sample consisted of individuals living in southern Finland, each
of whom was receiving a permanent disability pension primarily due to obesity.
One hundred and fifty-two individuals met these criteria. Nineteen had been
granted a temporary pension and were excluded from the sample. Participants
who died or no longer received a pension were also excluded. The study group
consisted of 112 patients (81 women and 31 men). The control group was se-
lected from the same area and consisted of individuals receiving a disability
pension due to a different primary illness. The controls were matched with the
subjects according to place of residence and sex. The matching process also con-
sidered age, the time that the pension was granted and occupation. The occupa-
tions of the controls were either the same as the subjects or were unknown. The
controls were selected by random sampling. Because male subjects constituted a
small group, many controls were selected to ensure a reliable analysis [33].
The male and female controls were selected separately. Three controls were
selected for each female subject, and five controls were selected for each male
subject to obtain more reliable results. As mentioned previously, this study was a
case-control study. For the interview, we aimed to include at least two controls
for each female subject and three for each male subject. Overall, the study en-
listed 510 individuals, including 112 subjects and 398 controls [33].
Three letters inviting individuals to participate in the study were sent to each
subject and each control. The letters were discreetly worded and emphasized the
confidentiality of the study. Most individuals who did not participate in the
study indicated their reasons for refusal in writing. These letters are available
upon request [33].
The basic characteristics in the study and control groups is shown in the Ta-
ble 1.
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Table 1. Basic characteristics of the study participants.
Study group
Control group
Significance (
n = 112 n = 262 p = 0.0894
Unmarried 10.7% 15.7%
Married 62.7% 59.6%
Widowed 14.7% 13.5%
Divorced 6.7% 10.7%
Common law marriage 5.3% 0.6%
n = 22 (m)
n = 53 (f)
n = 66 (m)
n = 112 (f)
p = 0.901 (m)
p = 0.5930 (f)
Technical, scientific,
sociological, and artistic work
m = 0%
f = 0%
total = 0%
m = 0%
f = 4.5%
total = 2.2%
Accounting and clerical work
m = 4.5%
f = 5.7%
total = 5.1%
m = 1.5%
f = 2.7%
total = 2.1%
Commercial work
m = 4.5%
f = 17.0%
total = 10.8%
m = 4.5%
f = 10.7%
total = 7.6%
Agriculture, forestry, and
m = 0%
f = 7.5%
total = 3.7%
m = 3.0%
f = 7.1%
total = 5.1%
m = 27.3%
f = 7.5%
total = 17.4%
m = 24.2%
f = 4.5%
total = 14.3%
Industrial work
m = 50.1%
f = 17.0%
total = 33.5%
m = 48.6%
f = 21.4%
total = 35.0%
Service work
m = 13.6%
f = 45.3%
total = 29.5%
m = 18.2%
f = 49.1%
total = 33.7%
m = 100%
f = 100%
total = 100%
m = 100%
f = 100%
total = 100%
According to Bruun’s
social classification
(Bruun K. Social class
division, fin, 1954)
p = 0.050 (m)
p = 0.936 (f)
I = First social class
4.2% 2.3%
II = Second social class 12.5% 17.7%
III = Third social class 50.0% 57.7%
IV = Fourth social class 33.3% 22.3%
Figure 1 shows the amount of participants and the distribution of gender.
BMI was calculated as weight (kg) divided by height (m2). According to the
WHO guidelines, the weight categories were defined as follows: overweight, BMI
25 ≤ 29; obese, BMI 30 ≤ 34; severely obese, BMI 35 ≤ 40; and morbidly obese,
BMI > 40. In this material the body mass index is larger in the study group than
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10.4236/ojpsych.2018.83028 360 Open Journal of Psychiatry
the control group. In the paired T-test the value of p is 0.000 and the p < 0.001 is
statistically highly significant. Figure 2 shows these results.
Due to the age-standardisation of the study subjects and controls, there were
no considerable differences in age. The majority of the study subjects fell within
the age group of 60 - 64 years, cf. Figure 3 below.
Figure 1. Study overview.
Figure 2. Body mass index values of the subjects and controls in the study group.
Figure 3. The age distribution of the study group.
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10.4236/ojpsych.2018.83028 361 Open Journal of Psychiatry
2.1. Occupations
The standard occupational classifications of the Social Insurance Institution
(1982) were used.
2.2. Psychiatric Interview
All subjects and controls were interviewed using structured psychiatric forms.
During each interview, attention was drawn to the development of obesity, in
addition to how much the individual would like to weigh and how satisfied
he/she was with his/her weight. Specifically, we paid attention to the kinds of
memories and recollections the respondents had about the scorn and contempt
directed at them because of their weight.
Psychological Tests
The Draw a Person test
: The Machover index [34] measures distortions pertain-
ing to perceptions of the human body. The higher the index value, the more dis-
torted the perception. In regard to the integrity of the perception of the human
body, this index is based on the Kalliopuska and Siimes index [35], which meas-
ures the integrity of an individual’s perception of the human body. The higher
the index value, the more integrated the perception. Separate variables were also
used for various features of the drawings, such as type, size, gender, and general
impression of the developmental degree of the perception of the body.
The Rorschach test
: The Rorschach test is a projective diagnostic personality
test consisting of ten cards with inkblot designs. Klopfer’s scoring methods and
other scoring systems were applied [36]. The method applied by [37] was used.
The variable that was used on the Rorschach record forms was the bar-
rier-penetration index, which measures body image boundaries. A large number
of barrier responses indicates that an individual has an established picture of
his/her own body and that he/she is able to cooperate with this well-integrated
self-esteem. A low number of barrier responses indicates that the boundaries of
the body of an individual are poor and he/she is working as other individuals
say. A large number of penetration responses also indicates penetration of the
2.3. Statistical Methods
The statistical methods used in this study included percentage distributions,
t-tests, means and a conditional logistic linear model. Because the material was
matched, it was analyzed not only with figures and percentages but also by cal-
culating the means for the subjects and controls using a matched control ap-
proach; these two classes were then compared using paired t-tests. Variables for
which statistically significant results were detected were further analyzed using
the logistic linear model. The results that remained significant after the logistic
linear analysis were assessed to determine risk ratios and the upper and lower
confidence limits. The statistical analyses were performed on a computer using
SPSS, the Statistical Package for the Social Sciences (for Windows 18/Windows,
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Chicago, IL, USA). The conditional logistic analyses were performed with the
GLIM program [38]. The GLIM analysis is quite straightforward, provided that
the data are arranged in a convenient individual-by-individual format, which
typically corresponds to the method of compilation. The major advantages of
this technique is that it is easy to use and has inherent flexibility; thus, to make
the most of this advantage, it is recommended that all the data for each individ-
ual be attached to this program whenever possible. The observations in each set
were case matched with 0 - 5 controls. Hence, because these observations could
be considered counts, the error distribution could be considered as following a
Poisson distribution, and the link function could be considered the logarithmic
function. Thus, the model is a special form of a log-linear model. The linear pre-
dictor in the systematic part of the model for each observation is a (linear) func-
tion of the observed exposure variables for each individual, plus a constant (set)
term, which may vary between matched sets. In the literature, concerning the
analysis of case-control data, this model is termed “conditional logistic regres-
sion” (a description of the data analysis that may be misleading to those familiar
with generalized linear model terminology). These groups were used for the sta-
tistical analysis. Although the group of subjects would have remained small with
this method, missing controls were replaced by the nearest controls. The
matched control approach meant that the data from some of the subjects who
had agreed to participate were excluded from the statistical analysis because a
control was not available for them. In some cases, multiple specific variables
were lacking, which further reduced the number of observations available for
comparison [39]. A difference between the groups was considered highly statis-
tically significant when the probability (p) of error in rejecting the null hypothe-
sis was < 0.001 (***), statistically significant when p was < 0.01 (**), and nearly
statistically significant when p was < 0.05 (*).
The study protocol was approved by the ethics committees of Hespe-
ria/Aurora Hospital (Community Psychiatric Hospital in Helsinki) and La-
pinlahti Hospital (Psychiatric Clinic of Helsinki University)/Psychiatric Cen-
trum of Helsinki University. Informed consent was signed by the individuals,
and the ethical principles of the Declaration of Helsinki were followed
The results of the individuals who refused personal interviews were removed
from the register. Thirty-seven individuals refused to participate, namely, nine
men and 28 women. The mean age of the men who did participate in the study
was 59 years, and the mean age of the women was 61 years. Thirty-one individu-
als in the group had a primary school education, whereas 34 had no vocational
education of any kind. The individuals who refused to participate in the study
were as poorly educated as those who did; the age distribution and gender dis-
tribution were also identical (Figure 1). Of the women, 65% (53) of the subjects
and 68% (111) of the controls agreed to participate in the study; among the men,
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10.4236/ojpsych.2018.83028 363 Open Journal of Psychiatry
74% (23) of the subjects and 71% (66) of the controls agreed to participate,
yielding a total of 253 participants. One of the male subjects could not be con-
tacted for follow-up, and one female subject withdrew from the study before the
psychological test. In addition, one of the female controls refused to continue the
interview after the first few questions.
3. Results
At the start of the pensions, the mean weight of the subjects was 106.6 kg, and
the corresponding mean weight of the controls was 70.2 kg. Figure 4 shows the
body mass distribution between study and control group.
Of the female subjects, 20.5% had been overweight during childhood. Most of
them (72.7%) had become more overweight as adults. Of the male subjects,
42.1% had gained excess weight during childhood, and 52.6% had as adults. Of
the female controls, only 26.0% had been overweight during childhood. Of the
male controls the same number were 22.9%. Table 2 shows these important
Table 2. Weight measurements of the different BMI groups in the study and control
BMI <24.9 25 - 29.9 30 - 34.9 35 - 39.9 >40 Total
In childhood
case 11.1% 22.2% 22.2% 44.4% 20.5%
control 16.7% 55.6% 16.7% 11.1% 26.09%
In adolescence
case 100.0% 4.5%
control 55.6% 22.2% 11.1% 11.1% 13.04%
In adulthood
case 3.1% 31.3% 34.4% 31.3% 72.7%
control 23.8% 52.4% 21.4% 2.4% 60.87%
Total case 4.5% 27.3% 29.5% 36.4% 100.0%
Total control 57.1% 37.8% 3.1% 2.0% 100.0%
BMI <24.9 25 - 29.9 30 - 34.9 35 - 39.9 >40 Total
In childhood
case 12.5% 25.0% 37.5% 25.0% 42.1%
control 12.5% 50.0% 25.0% 12.5% 22.85%
In adolescence
case 100.0% 5.3%
control 100.0% 2,85%
In adulthood
case 10.0% 60.0% 30.0% 52.6%
control 7.7% 53.8% 30.8% 7.7% 74.3%
Total case 5.3% 5.3% 15.8% 47.4% 26.3% 100.0%
Total control 36.5% 42.9% 19.0% 1.6% 100.0%
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Figure 4. Body mass index values of the subjects in the study group.
3.1. Body Image
3.1.1. Results of the Psychological Tests
In this study, we used psychological tests to estimate the disturbances in body
Regarding the results of the Draw a Person test, we found some differences in
the Machover and wholeness indices. The findings are presented in Table 3 and
Table 4.
On the basis of the means for the indices measuring the wholeness of the body
image reflected by the Draw a Person test, there were, in fact, no differences be-
tween the subjects and controls. The drawings of both the subjects and the con-
trols showed some unclarity and inaccuracy in the figures. In both groups, there
were relatively many drawings of abnormal sizes. Similarly, in both groups, it
was rather common that the gender of the figure in the drawing could not be
determined. Abnormal and grotesque figures were somewhat common among
the drawings of both groups, although the level of disturbance in body image, as
measured by the Machover index, remained low [34].
The findings of the Draw a Person test are classified into six groups in Table
4. In all, 11.4% of the participants in the study group did not want to perform
this test. The ages of the human figures approached statistical significance. Re-
garding the question of the perception of bodily proportions, 50% of the partici-
pants in the study group exhibited poorly proportioned findings.
Body perception according to the Rorschach test
. The mean number of barrier
responses was 1.92 among the subjects and 1.75 among the controls. The mean
number of penetration responses was 1.38 among the subjects and 1.72 among
the controls. The values measuring the firmness and permeability of the boun-
daries of the body by means of barrier and penetration indices revealed no sig-
nificant differences between the subjects and the controls.
3.1.2. Dissatisfaction
Thirty-one percent of the subjects and 50% of the controls said they were fully
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satisfied with their present weight, but 53% of the subjects and 46% of the con-
trols reported having occasional weight problems. When asked whether being
overweight constrained their human relationships, 30% of the subjects gave af-
firmative responses. Expectedly, the corresponding figure among the controls
was very low. These results finds out from Table 5.
3.1.3. Scorn and Stigma
The attitude of the subjects’ spouses toward overweight was positive in the case
of 17% of the subjects and 7% of the controls. A negative attitude on the part of
the spouse was found to be the case in 11% of the subjects and 7% of the con-
Table 6 shows that seven percent of the subjects reported that being over-
weight had been a problem even before they reached school age. Being over-
weight at the school age was a problem for 10% of the subjects. Sixty-one of the
subjects had been subjected to derision because of being overweight, but 33%
had not. Six percent of the subjects could not give a positive or negative answer
to this question. Fifty percent of the subjects regarded themselves as being
grossly obese. Five percent of the subjects and 40% of the controls regarded their
weight as normal, while 4% of the subjects regarded themselves as considerably
Table 3. Results of the Machover index and the wholeness index.
Variables Study
Statistical sign.
paired t-test
Machover index
n = 70
n = 157
Means 3.98 4.31
In the point
position p = 0.0300 3.3 1.9 - 5.7
The missing
division p = 0.0447 0.3 0.1 - 0.8
The wholeness index
n = 70
n = 157
Means 17.35 18.02 p = 0.290
between the groups
p = 0.0571
In the drawing of
lines p = 0.0839
Table 4. Results of the Draw a Person test.
Variables Study group Control group Statistical sign.
Distribution of the types of
n = 77
n = 176
No drawing 11.4% 5.6%
Stick figure 8.5% 5.6%
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Snowman, ghost, Santa Claus 5.6% 5.1%
A mere head 1.4% 6.8%
No abnormality 73.6% 67.0%
A baby - 1.1%
Distributions of the human
n = 70
n = 157
Small 24.3% 22.3%
Large 5.7% 8.9%
Normal 70.0% 68.8%
Age of the human figures
n = 70
n = 157
Age could not be determined 47.1% 32.5%
A child 14.3% 12.1%
An adult of the same age as the
person examined 38.6% 55.4%
Perception of bodily proportions
n = 70
n = 157
Poorly proportioned 50.0% 38.2%
Averagely proportioned 35.7% 42.7%
Normally proportioned 14.3% 19.1%
Table 5. The point in life when obesity was acknowledged in the study group and the
control group.
Study group
n = 74
Control group
n = 176
Statistical significance
How does the respondent
describe his/her present weight?
p = 0.0000
very underweight
4.1% 0%
somewhat underweight 1.4% 5.7%
normal 5.4% 40.3%
slightly overweight 39.2% 43.8%
heavily overweight 50.0% 10.2%
How does the respondent feel
about his/her weight and
p = 0.0002
perfectly satisfied, no problems
30.7% 50.3%
occasional problems with the size
of his/her own body 53.3% 45.8%
continual feelings of inferiority
because of his/her own looks and
9.3% 4.0%
the respondent continually feels
utterly unfit and is unsatisfied
with himself/herself
6.7% 0%
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Table 6. Scorn and stigma in the study and control group.
Study group
n = 74
Control group
n = 176
Has being overweight ever been a
yes no yes no
before school age
7.1% 92.7% 0.6% 99.4% p = 0.0111
when at school age (7 - 17 years)
10.0% 90.0% 1.1% 98.9% p = 0.0033
during youth (16 - 20 years)
14.3% 85.7% 2.3% 97.7% p = 0.0008
What kinds of memories and
recollections does the respondent
have about the scorn and contempt
directed at him/her because of
his/her being overweight as an
n = 74
n = 176
p = 0.0000
61.4% 32.9% 12.0% 62.7%
Many 0% 0.6%
Cannot say 2.9% 3.6%
Does not want to talk about it 2.9% 1.2%
The respondent has not been
overweight 0% 19.9%
4. Discussion
4.1. Statement of Principal Findings
At the start of the pensions, the mean weight of the subjects was 106.6 kg. Body
mass index values of most women were ≥ 40. On men group the body mass in-
dex value were 35.0 - 39.9. In both subject groups (men and women) many were
overweight during the childhood.
The level of disturbance in the body image was measured by the Machover
index. We found statistically significant differences in terms of the point posi-
tion and the missing division.
The wholeness index mean values were similar between the groups; however,
the chi-squared test showed that there was a significant difference between the
groups. Some degree of body image disorganization was found among the sub-
jects in the Draw a Person test.
The number of barrier responses pertaining to body image firmness was
slightly low among the subjects. The distributions of the responses to the barrier
and penetration responses given by both the subjects and the controls were sim-
Obesity had been a problem for some of the subjects in childhood and for
some in adolescence. In this study, obesity was a problem in all age groups; be-
tween the study group and the control group, there was a statistically significant
difference. Half of the participants in the study group thought that they were
obese. In the study group, 1/3 of the individuals were perfectly satisfied with
M. Koski, H. Naukkarinen
10.4236/ojpsych.2018.83028 368 Open Journal of Psychiatry
their weight. A large part of the study group described the scorn and contempt
directed at them for being overweight. The partners did not have any negative
comments to say about obesity.
4.2. Strengths and Weaknesses
The undisputed advantage of this study was its nonselective sample of severely
obese individuals. The subjects were not obtained from a diet group, as with
most obesity research, which also augmented the validity of the study. This study
concentrated on a group of individuals receiving disability pensions due to obes-
ity. All the subjects were interviewed individually, which tends to improve the
reliability of a study. The interviews were conducted such that the interviewer
did not know whether the individual was a subject or a control. This double-blind
approach increased the validity of the study. The study group was successfully
matched with the control group. The occupational and social statuses in both
groups were nearly identical. The influence of the subjects’ life situations was
minimized because the members of the control group had also been receiving a
pension for the same duration. The fact that the controls were selected by ran-
dom sampling from data from the Social Insurance Institution of Finland added
value to the findings. Researchers who have studied the psychopathology of ob-
esity [1] [40] have stated that, with respect to a considerable proportion of obese
individuals, we know only what the statistics tell us. It can be said that the ma-
terial studied here was also, at least in part, a sample that is not often the object
of research.
4.3. Strength and Weakness in Relation to Other Studies,
Particularly Any Differences in the Results
4.3.1. Body Image
Stunkard and Wadden [6] found that obese individuals have body image distur-
bances, with Adami
et al.
[7], Hill and Williams [41] and Buddeberg-Fischer
[42] being of the same opinion. According to Sarwer
et al.
[43], the vast ma-
jority of obese women demonstrate body image dissatisfaction related to their
obesity, with almost half reporting the greatest dissatisfaction with their waist or
abdomen compared to other body regions. On average, they reported signifi-
cantly more body image dissatisfaction than the controls.
4.3.2. Dissatisfaction
A range of different methodologies have shown that the majority of women and
girls perceive themselves as too fat and are dissatisfied with their body shapes
[44]. However, Rand and Resnick [45] produced different results, with a large
majority (87%) of their subjects considering their actual weight socially accepta-
et al.
[46] found that a high percentage of overweight kids experience
teasing because of their weight. The history of teasing and social norms have an
effect on body dissatisfaction. BMI appeared to have no effect. Moreover,
M. Koski, H. Naukkarinen
10.4236/ojpsych.2018.83028 369 Open Journal of Psychiatry
self-efficacy has an influence on beginning to eat healthy, and self-confidence
should be heightened.
According to Demarest and Langer [47], body shape dissatisfaction was
greatest for overweight women and was approximately the same for average
weight women as it was for overweight men. Men of average weight and under-
weight women were fairly satisfied with their current shapes. Both men and
women had distorted views of the shape that the opposite gender found most at-
Christensen [48] studied obesity in childhood. He found that parents who are
living in cultural cities and who have higher education levels have children who
are less overweight. The parents tend to overestimate their daughters’ weight
and they underestimate their sons’ weight.
According to Carels
et al.
[49], weight bias among individuals who are at-
tending weight-loss groups is associated with psychological maladjustment and a
disturbance in their ability to obtain optimal health and well-being. Docteur
[50] found that severely obese individuals perceived themselves as being more
corpulent than obese individuals.
This study (M.K.) focused on a group of adults. The study included a very he-
terogenous group of women and men. In this study, there were few changes in
weight status, and most of the persons had been obese for a very long time [1]
[4]; 1/3 of the subjects were fully satisfied with their present weight [6] [51].
The results of the present study (M.K.) did not lend support to the theory that
disturbed body image is more frequent among individuals who have been obese
in their youth [5].
4.3.3. Scorn and Stigma
According to Brewis
et al.
[18], the mainstream U.S. society has negative views
toward the overweight and obese. Mocking obese individuals is common in both
institutional and interpersonal relationships. In particular, how other women
perceive themselves to be judged by their weight and the opinions of people in
their social networks affects them. This result (M.K.) was in line with the find-
ings of Drewnowski and Yee [52]. Among the subjects, obesity had been a prob-
lem during pre-school age much more often than among the controls. This
finding was in agreement with those of previous reports in the literature [4] [5].
Most studies have assessed the pathological changes in a rather vaguely de-
fined variable, and there have been few theoretical or empirical attempts to im-
prove the concept of body image or to develop more suitable alternatives. It
has become increasingly clear that a distinction must be made between measures
of body size perception and measures of body attitude or body satisfaction [53]
[54]. The fact that these two groups of variables are often only weakly intercor-
related and that there is no theory of body imageto explain this finding has led
at least one group to conclude that the concept of body imageis little more
than a heading for research activities on perceptions, emotions and cognitions
relating to one’s own body [55] [56].
M. Koski, H. Naukkarinen
10.4236/ojpsych.2018.83028 370 Open Journal of Psychiatry
4.4. Meaning of the Study: Possible Mechanisms and
Implications for Clinicians and Policymakers
According to Harriger and Thompson [57], there have only been a few studies
that focused on the psychological causes of childhood obesity, specifically in
terms of body image disturbance. Legenbauer
et al.
[58] measured various com-
ponents to assess body image disturbances in obese individuals. In a group of
individuals with binge eating disorders, the problems were bigger than in a
group of obese individuals. Obesity prevention and treatment programs should
take into consideration psychological, biological and behavioral factors to de-
crease obesity prevalence rates [59].
Researchers [32] found that the understanding of body size varies depending
on BMI in the female group. This concept must be remembered when we choose
effective treatments for overweight and obese young women.
Some researchers think that the stigma alone can largely explain the popula-
tion [60].
4.5. Unanswered Questions and Future Research
We studied body image in a group of very rare, severely obese individuals. We
have found that body image definitions and measurement methods are very dif-
Pull and Aguayo [61] found that the currently available assessment instru-
ments do not measure body image perception or body image attitudes in obesity.
According to Karasu [62], psychological factors are neither primarily etiological
nor even necessarily predominant in obesity. Cultural differences should be
taken into account when managing obese and overweight individuals in the fu-
ture [63]. In continuing research, we should be more often be researching the
connection between psychiatric diseases and core weight.
5. Conclusion
We believe that our study provides a novel and necessary overview of the con-
nection among body image disturbance and dissatisfaction, scorn and stigma.
We hope that this overview will provide insights that will help to revise and up-
date the current knowledge of obesity. Our findings prove that this research is
very important. We believe that this study provides encouraging possibilities for
research on the potential health effects of severe obesity and its development.
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Full-text available
Presentación que ponde manifiesto la importancia del YO corporal y el valor semiológico del cuerpo. Cuadros clínicos en los que hay que tener especial cuidado en el campo de las Técnicas de Cirugía estética y reparadora.
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Background: Obesity has a multifaceted etiology that involves genetic, biological and behavioral factors, body growth, eating habits, energy expenditure and the function of adipose tissue. The present study aimed to expand upon knowledge about the relationships among obesity, emotions and eating habits in severely obese individuals using a case-control method. Methods: The subject group consisted of 112 individuals (81 females and 31 males) receiving a permanent disability pension primarily for obesity. The control subjects were randomly selected from the same area and were receiving a disability pension for a different primary illness. The controls were matched with the subjects by the place of residence, sex, age, the time since the pension was granted and occupation. Psychiatric interviews were conducted on all participants. The results were analyzed using the chi-squared test (χ(2)-test) and the percent distribution. The subject and control groups were compared using the t-test for paired variables. Conditional logistic regression analysis was also conducted. Results: The emotional state of eating was significantly associated with quarrels and feelings of loneliness. The subjects suffered from night eating syndrome, which was associated with an increased risk of early retirement. Binge eating syndrome was observed more frequently in the study group. The subjects reported feeling increased hunger compared with the controls. A significant percentage of the subjects had a body mass index of ≥ 40. No differences in eating habits were observed between the groups. Conclusion: This study provides information on the relationship between emotions and eating habits in obesity, which is a rarely studied topic. We believe that our study provides a novel and necessary overview of the associations among severe obesity, emotions and eating habits.
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Purpose: The purpose of this study was to examine the differences among actual body size, perceived body size, and ideal body size in overweight and obese young adult women. Methods: Actual body size was assessed by body mass index (BMI), while self-perceived and ideal body sizes were assessed by the Body image assessment tool-body dimension. Descriptive statistics were calculated and analysis of variance (ANOVA) was performed on actual BMI as a function of perceived BMI. Results: Of the 42 participants included in the study, 12 were overweight (25 ≤ BMI < 30), 18 were obese 1 (30 ≤ BMI < 35), and 12 were obese 2 (35 ≤ BMI ≤ 39.48). The mean ideal body size of participants was 25.34 ± 1.33. Participants in general perceived their body size (BMI: 35.82 ± 1.06) to be higher than their actual body size (32.84 ± 0.95). Overweight participants had a significantly higher mean body size misperception than obese 2 individuals (µ dif = -6.68, p < .001). Conclusion: Perception accuracy of body size differs in women by BMI. Weight loss programs need to be tailored to consider body size misperception in order to improve treatment outcomes for overweight and obese young women.
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Purpose: Recent studies have shown that body image perception is an important factor in weight management and can be influenced by several social or cultural factors in Western or non-Western societies; however, body image perception and its nutritional and demographic determinants in Iran have not been extensively studied. In the current study, we aimed to evaluate body image perception and its socio-demographic and nutritional determinants among female university students in Tabriz City of Iran. Methods: In the current cross-sectional survey, 184 female students aged 18-35 years from Tabriz, Iran, were enrolled. Anthropometric variables including weight, height, waist and hip circumference were measured and body mass index (BMI) and waist to hip ratio (WHR) were calculated. Body image perception and distortion were assessed by Figure Rating Scale (FRS) developed by Stunkard consisting of nine silhouettes. Nutrition intake was assessed by a 3-day 24-h dietary recall method and analyzed by Nutritionist IV software. Results: Most of the participants in the underweight (41.66 %), normal weight (67.71 %) and overweight (57.14 %) categories of BMI selected the thinnest figure as their desirable or ideal body image perception. The total prevalences of body image dissatisfaction and distortion were 51.63 % and 64.13 %, respectively. Subjects who had undistorted body image perception consumed more time for physical activity and had more night sleeping hours compared with others (P < 0.05). Subjects who perceived themselves as being of normal weight had significantly lower intake of total fat and saturated fatty acids and higher intakes of monounsaturated fatty acids (MUFAs) compared with other groups (P < 0.05). Conclusions: According to our findings, female participants had a higher tendency to consider thinness as the preferred body image style. Persons with undistorted body image perception had healthy nutritional status compared with others. Due to high prevalence of body image dissatisfaction, the need for appropriate interventional programs to prevent the associated co-morbidities is emphasized.
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Weight discrimination is prevalent in American society. Although associated consistently with psychological and economic outcomes, less is known about whether weight discrimination is associated with longitudinal changes in obesity. The objectives of this research are (1) to test whether weight discrimination is associated with risk of becoming obese (Body Mass Index≥30; BMI) by follow-up among those not obese at baseline, and (2) to test whether weight discrimination is associated with risk of remaining obese at follow-up among those already obese at baseline. Participants were drawn from the Health and Retirement Study, a nationally representative longitudinal survey of community-dwelling US residents. A total of 6,157 participants (58.6% female) completed the discrimination measure and had weight and height available from the 2006 and 2010 assessments. Participants who experienced weight discrimination were approximately 2.5 times more likely to become obese by follow-up (OR = 2.54, 95% CI = 1.58-4.08) and participants who were obese at baseline were three times more likely to remain obese at follow up (OR = 3.20, 95% CI = 2.06-4.97) than those who had not experienced such discrimination. These effects held when controlling for demographic factors (age, sex, ethnicity, education) and when baseline BMI was included as a covariate. These effects were also specific to weight discrimination; other forms of discrimination (e.g., sex, race) were unrelated to risk of obesity at follow-up. The present research demonstrates that, in addition to poorer mental health outcomes, weight discrimination has implications for obesity. Rather than motivating individuals to lose weight, weight discrimination increases risk for obesity.
The development of the Dutch Eating Behaviour Questionnaire (DEBQ) with scales for restrained, emotional, and external eating is described. Factor analyses have shown that all items on restrained and external eating each have high loadings on one factor, but items on emotional eating have two dimensions, one dealing with eating in response to diffuse emotions, and the other with eating in response to clearly labelled emotions. The pattern of corrected item-total correlation coefficients and of the factors was very similar for various subsamples, which indicates a high degree of stability of dimensions on the eating behavior scales. The norms and Cronbach's alpha coefficients of the scales and also the Pearson's correlation coefficients to assess interrelationships between scales indicate that the scales have a high internal consistency and factorial validity. However, their external validity has yet to be investigated.
The objective was to describe some features of obese patients that consulted at our Department. In our sample (74 patients), anxiety and depression symptoms stand out and patients show characteristics of ego- weakness, emotions constriction, dependent attachment and a non-appropriate performance to self resources. It would be necessary to consider these aspects into the multidisciplinary approach of the pathology.
Individuals who are overweight or obese report body image concerns and lower self-esteem. However, little is known about the mechanisms underpinning these associations. The objective of this study was to test body-related shame and guilt as mediators in the association between weight status and self-esteem. Young adult participants (n = 790) completed assessments of self-esteem and body-related guilt and shame, and weight status indicators were measured by trained technicians. Findings from multiple mediation analyses suggest that body-related shame mediates the relationship between weight status and self-esteem. If replicated in longitudinal studies, these findings suggest that reducing body-related emotions may have important implications for improving self-esteem in clinical weight management. © The Author(s) 2015.
The development of the Dutch Eating Behaviour Questionnaire (DEBQ) with scales for restrained, emotional, and external eating is described. Factor analyses have shown that all items on restrained and external eating each have high loadings on one factor, but items on emotional eating have two dimensions, one dealing with eating in response to diffuse emotions, and the other with eating in response to clearly labelled emotions. The pattern of corrected item-total correlation coefficients and of the factors was very similar for various subsamples, which indicates a high degree of stability of dimensions on the eating behavior scales. The norms and Cronbach's alpha coefficients of the scales and also the Pearson's correlation coefficients to assess interrelationships between scales indicate that the scales have a high internal consistency and factorial validity. However, their external validity has yet to be investigated.
Objective: The objective is to evaluate whether physician body mass index (BMI) impacts their patients' trust or perceptions of weight-related stigma. Methods: We used a national cross-sectional survey of 600 non-pregnant overweight and obese patients conducted between April 5 and April 13, 2012. The outcome variables were patient trust (overall and by type of advice) and patient perceptions of weight-related stigma. The independent variable of interest was primary care physician (PCP) BMI. We conducted multivariate regression analyses to determine whether trust or perceived stigma differed by physician BMI, adjusting for covariates. Results: Patients reported high levels of trust in their PCPs, regardless of the PCPs body weight (normal BMI=8.6; overweight=8.3; obese=8.2; where 10 is the highest). Trust in diet advice was significantly higher among patients seeing overweight PCPs as compared to normal BMI PCPs (87% vs. 77%, p=0.04). Reports of feeling judged by their PCP were significantly higher among patients seeing obese PCPs (32%; 95% confidence interval (CI): 23-41) as compared to patients seeing normal BMI PCPs (14%; 95% CI: 7-20). Conclusion: Overweight and obese patients generally trust their PCP, but they more strongly trust diet advice from overweight PCPs as compared to normal BMI PCPs.