Investigating Body Image Disturbance in Anorexia Nervosa Using Novel Biometric Figure Rating Scales: A Pilot Study

Exploring weight bias and negative self-evaluation in patients with mood disorders: insights from the BodyTalk Project

Background

Negative body image and adverse body self-evaluation represent key psychological constructs within the realm of weight bias (WB), potentially intertwined with the negative self-evaluation characteristic of depressive symptomatology. Although WB encapsulates an implicit form of self-critical assessment, its exploration among people with mood disorders (MD) has been under-investigated. Our primary goal is to comprehensively assess both explicit and implicit WB, seeking to reveal specific dimensions that could interconnect with the symptoms of MDs.

Methods

A cohort comprising 25 MD patients and 35 demographically matched healthy peers (with 83% female representation) participated in a series of tasks designed to evaluate the congruence between various computer-generated body representations and a spectrum of descriptive adjectives. Our analysis delved into multiple facets of body image evaluation, scrutinizing the associations between different body sizes and emotionally charged adjectives (e.g., active, apple-shaped, attractive).

Results

No discernible differences emerged concerning body dissatisfaction or the correspondence of different body sizes with varying adjectives. Interestingly, MD patients exhibited a markedly higher tendency to overestimate their body weight (p = 0.011). Explicit WB did not show significant variance between the two groups, but MD participants demonstrated a notable implicit WB within a specific weight rating task for BMI between 18.5 and 25 kg/m2 (p = 0.012).

Conclusions

Despite the striking similarities in the assessment of participants' body weight, our investigation revealed an implicit WB among individuals grappling with MD. This bias potentially assumes a role in fostering self-directed negative evaluations, shedding light on a previously unexplored facet of the interplay between WB and mood disorders.

Body evaluation in men: the role of body weight dissatisfaction in appearance evaluation, eating, and muscle dysmorphia psychopathology

BACKGROUND

Body image dissatisfaction is a significant concern among men, influencing appearance evaluation, eating behaviors, and muscle dysmorphia psychopathology. However, research on these correlations is notably deficient in men, largely because body image concerns are unevenly distributed between genders. Therefore, this study aims to assess the various dimensions of concerns about body image in men and explore their associations with characteristics such as sexual orientation.

METHODS

A cross-sectional study was conducted with 251 adult men from fitness centers in the Veneto Region, Italy. Participants completed self-report questionnaires, including the Eating Attitudes Test (EAT-26), the Appearance Schemas Inventory-Revised (ASI-R), and the Muscle Dysmorphic Disorder Inventory (MDDI). Body weight perception and dissatisfaction were evaluated using a Figure Rating Scale (FRS) with 12 male biometric silhouettes.

RESULTS

Participants were divided into three subgroups based on the experienced levels of body weight dissatisfaction: those who rated a smaller body (BWsmaller), those who rated a larger body (BWlarger) more highly relative to their own estimated body size, and those who reported implicit neutrality with their current weight (BWneu). BWsmaller participants reported higher levels of eating-related concern, while BWlarger participants exhibited higher levels of muscle dysmorphia. Additionally, the BWlarger group showed the highest degree of quantitative perceptual underestimation of their body weight. Sexual orientation was found to have an impact on body weight dissatisfaction, with bisexual men more likely to desire an increase in weight and gay men more likely to desire a decrease.

CONCLUSIONS

Body weight dissatisfaction significantly impacts appearance evaluation, eating behaviors, and muscle dysmorphia psychopathology in males. Tailored interventions that consider individual differences can support the well-being of men. The study provides useful insight into male body image issues, warranting further exploration to inform effective interventions and promote positive body image and mental health in this population.

Transgender body image: Weight dissatisfaction, objectification & identity - Complex interplay explored via matched group

In the context of body image and mental health, transgender individuals face distinctive challenges stemming from the complexities of their gender identity journey, societal expectations, and body norms. However, the existing line of research on this topic remains limited. This study explores the complex relationship in transgender individuals between body objectification, body weight dissatisfaction, and eating concerns. A sample of 154 individuals (77 transgenders paired with 77 cisgenders) was recruited via LGBTQ+ groups' mailing lists. Participants completed various questionnaires assessing body image, eating psychopathology, depression, and body objectification. Propensity score matching was performed with different variables: age, current BMI, years of education, current self-identified gender, and sexual orientation. The results revealed that transgender individuals experienced higher levels of body objectification, body weight dissatisfaction, and eating concerns compared to their cisgender counterparts. Additionally, age emerged as a protective factor, as older transgender individuals demonstrated improved body acceptance and self-esteem. Logistic regression analyzes indicated that bulimic behaviors, depressive symptoms, and appearance control beliefs were specific factors significantly associated with being transgender. Our findings highlight the unique challenges faced by transgender individuals in navigating their gender identity and body image, underscoring the importance of targeted interventions and support systems.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

The role of sexual orientation in the relationships between body perception, body weight dissatisfaction, physical comparison, and eating psychopathology in the cisgender population

PURPOSE

Body weight dissatisfaction (BWD) and visual body perception are specific aspects that can influence the own body image, and that can concur with the development or the maintenance of specific psychopathological dimensions of different psychiatric disorders. The sexual orientation is a fundamental but understudied aspect in this field, and, for this reason, the purpose of this study is to improve knowledge about the relationships among BWD, visual body size-perception, and sexual orientation.

METHODS

A total of 1033 individuals participated in an online survey. Physical comparison, depression, and self-esteem was evaluated, as well as sexual orientation and the presence of an eating disorder. A Figure Rating Scale was used to assess different valences of body weight, and mediation analyses were performed to investigated specific relationships between psychological aspects.

RESULTS

Bisexual women and gay men reported significantly higher BWD than other groups (p < 0.001); instead, higher body misperception was present in gay men (p = 0.001). Physical appearance comparison mediated the effect of sexual orientation in both BWD and perceptual distortion. No difference emerged between women with a history of eating disorders and without, as regards the value of body weight attributed to attractiveness, health, and presence on social media.

CONCLUSION

This study contributes to understanding the relationship between sexual orientations and body image representation and evaluation. Physical appearance comparisons should be considered as critical psychological factors that can improve and affect well-being. The impact on subjects with high levels of eating concerns is also discussed.

LEVEL OF EVIDENCE

Level III: case-control analytic study.

Methods to develop figure rating scales (FRS): A systematic review

BACKGROUND AND AIMS

Figure Rating Scales (FRS) are psychometric instruments developed to measure individual's perception of physical appearance and subsequently, to determine the level of body dissatisfaction. The following systematic review summarizes existing FRSs and the techniques used to development them.

METHODS

A systematic search was conducted in the following databases; PubMed®, Web of Science®, Scopus® using key words "figure rating scale" AND "Stunkard".

RESULTS

From 466 potentially relevant articles, 24 publications were included, 22 publications reporting original FRSs with the other two scales being modifications of the original for children and babies. Fifteen were figural drawings or silhouettes and nine were developed by photographic techniques, video methods or using computer software. Most of the figural scales were applicable for adults and consisted of nine images. Ten of the 15 figural scales were without facial features and four scales had minimal facial features. Technological advancements including 3D modeling have played a pivotal role in the development of FRSs.

CONCLUSIONS

FRSs have been developed by a mix of traditional and modern techniques. The development and validation of ethnic specific FRSs using modern technology should be the priority for future studies.

Weight bias and linguistic body representation in anorexia nervosa: Findings from the BodyTalk project

OBJECTIVE

This study provides a comprehensive assessment of own body representation and linguistic representation of bodies in general in women with typical and atypical anorexia nervosa (AN).

METHODS

In a series of desktop experiments, participants rated a set of adjectives according to their match with a series of computer generated bodies varying in body mass index, and generated prototypic body shapes for the same set of adjectives. We analysed how body mass index of the bodies was associated with positive or negative valence of the adjectives in the different groups. Further, body image and own body perception were assessed.

RESULTS

In a German-Italian sample comprising 39 women with AN, 20 women with atypical AN and 40 age matched control participants, we observed effects indicative of weight stigmatization, but no significant differences between the groups. Generally, positive adjectives were associated with lean bodies, whereas negative adjectives were associated with obese bodies.

DISCUSSION

Our observations suggest that patients with both typical and atypical AN affectively and visually represent body descriptions not differently from healthy women. We conclude that overvaluation of low body weight and fear of weight gain cannot be explained by generally distorted perception or cognition, but require individual consideration.

How do patients with eating disorders perceive and evaluate food portion sizes? A systematic review

OBJECTIVE

The selection of adequate portion sizes plays a key role in the nutritional treatment of eating disorders (EDs). There is limited knowledge concerning the estimation of portion sizes in individuals with EDs.

METHOD

We performed a systematic review according to the PRISMA statement to synthesise current evidence in this field. Of N = 584 hits, four full-texts were included in the qualitative synthesis.

RESULTS

While patients with anorexia nervosa (AN) tend to overestimate the size of energy-dense food items and small to medium sized meal portions, they do not show a different estimation compared to healthy controls when judging the amount of food pieces. Large portion sizes were associated with increased anxiety in patients with AN.

DISCUSSION

The overestimation of food portion sizes seems to be driven by attitudinal and/or higher cognitive factors associated with AN. Differences between the studies are discussed and suggestions for future studies are given.

Comparison of body image evaluation by virtual reality and paper-based figure rating scales in adolescents with anorexia nervosa: retrospective study

PURPOSE

Assessment of the symptoms of body image disorder (BID) is crucial in anorexia nervosa (AN). Recent technological advancements such as virtual reality (VR) have improved the visual perception with 3D avatars and the feeling to be the avatar with the immersive conditions. This retrospective study examines the hypothesis that VR with standardized 3D avatars would improve body image perception and then body image evaluation by adolescents with AN, compared to the paper-based figure rating scales (FRS).

METHODS

Data of 31 female adolescents with AN were retrospectively studied. Paired data of perceived and desired body forms in addition to body perception index (BPI) (p = 0.2) and body dissatisfaction (p = 0.6), obtained by both VR and FRS were compared. Furthermore, correlation with validated psychometric questionnaires was also studied. Head-tracking technology allowed for the implicit measurement of explicit choices of patients.

RESULTS

Participants with AN overestimated own body size regardless of the assessment tool used. BPI and body dissatisfaction did not differ significantly between FRS and VR. VR-based evaluation was correlated with the psychometric parameters BID and body dissatisfaction. Head tracking revealed significantly longer participant engagement with avatars representing malnutrition and underweight states, while those least engaged corresponded to obesity.

CONCLUSIONS

Results of BID evaluation by VR standardized 3D avatars are comparable to those obtained by paper-based FRS. These findings suggest that comparable results obtained by both tools of evaluation reflect primarily the role of affective-cognitive perturbation in BID. The perceptive component could be better evaluated using biometric-enhanced assessment tools.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study (evaluation data retrospectively studied).

An update on gastrointestinal disturbances in eating disorders

Eating disorders, namely anorexia nervosa, bulimia nervosa and binge eating disorder are frequent diseases and often complicated by comorbidities, e.g. psychiatric or cardiovascular comorbidities. It is to note that also gastrointestinal symptoms/complications are frequently observed in patients with eating disorders. These diseases will be presented in the current review along with - where known - possible underlying mechanisms. Lastly, gaps in knowledge will be highlighted.

Is an obesity simulation suit in an undergraduate medical communication class a valuable teaching tool? A cross-sectional proof of concept study

OBJECTIVE

With the growing prevalence of overweight and obesity, medical students should be prepared to engage in weight management and obesity-related communications in order to prevent patients from having stigmatising experiences. In addition, medical students should have training to reduce anti-fat prejudices.

DESIGN

Cross-sectional proof of concept study.

SETTING

University Hospital Tuebingen, Germany.

PARTICIPANTS

246 participants (207 second-year medical students, 13 standardised patients (SPs) and 22 teachers) took part in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the assessment of degree of reality of the encounter with the SP wearing an obesity simulation suit (OSS). The secondary outcome was the evaluation of students' awareness and prejudice against patients with obesity in a simulated role play. Additionally, a description of the advantages and disadvantages when using such a teaching tool is delivered.

RESULTS

The OSS contributed to a realistic perception of the patient group depicted in a role play according to students, teachers and SPs. OSS body mass index estimation by students, teachers and SPs correctly was over 30 kg/m²-thus in the range of obesity. In a selected subscale of the Anti-Fat Attitudes Test, students showed significantly stronger anti-fat stigmatisation compared with teachers and SPs.

CONCLUSIONS

An OSS worn by an SP is a valuable teaching tool to raise awareness about patients with obesity. It gives a realistic picture of the encounter. Stigmatisation was low in general but was especially present in the students. Further research should include intervention studies to address this issue.

Perceptual Not Attitudinal Factors Predict the Accuracy of Estimating Other Women's Bodies in Both Women With Anorexia Nervosa and Controls

Disturbance in how one's body shape and size is experienced, usually including over-estimation of one's own body size, is a core feature of the diagnostic criteria of anorexia nervosa (AN). Is this over-estimation specific to women with AN's judgments of their own body? Or is it just a general feature of their judgments about all bodies? If the latter, it would be consistent with a general error in the perception of body size potentially linked to the use of a different set of visual cues for judging body size. If the former, then this suggests that the over-estimation of own body size has a strong attitudinal component and may be part of the psycho-pathology of their condition. To test this hypothesis, 20 women with AN and 80 control observers estimated the body size of 46 women. The results show a strong effect of perceptual factors in estimating body size for both controls and women with AN. This result is consistent with size over-estimation of own body in AN having a strong attitudinal basis and being a core feature of the psycho-pathology of the condition.

Assessing the Relationship Between Attitudinal and Perceptual Component of Body Image Disturbance Using Virtual Reality

Body image disturbance (BID) affects quality of life even in the absence of clinically diagnosable eating pathology, and numerous studies have shown its crucial role in the emergence and maintenance of eating disorders. This study aimed at exploring attitudinal and perceptual components of BID using a novel virtual reality (VR)-based paradigm. A community sample of women (N = 27) recreated in VR their perceived body in both an allocentric (third-person view) and egocentric (first-person view) perspective. Specifically, women were able to choose between a wide range of three-dimensional bodies spanning body mass index 12.5-42.5 kg/m². Attitudinal indexes of BID (body dissatisfaction, body uneasiness, and body image avoidance) were assessed through questionnaires. Attitudinal components predicted the perceptual BID only in the allocentric perspective. Specifically, overestimation was predicted by body image avoidance, while underestimation was predicted by body uneasiness. Furthermore, a common predictor of underestimation and overestimation was body dissatisfaction. In line with the allocentric lock hypothesis, the current results seem to confirm the presence of two different mechanisms underlying BID: one related to real-time perception-driven inputs (egocentric frame) and one related to abstract knowledge, beliefs, and attitudes related to a person's body (allocentric frame). These findings contribute to a better understanding of the nature and mechanisms underlying BID and provide additional evidence about the suitability of using VR for exploring and assessing body image-related components and disturbances.