Background
In epidemiologic and public health research, non-fatal health conditions are deemed to constitute a public health problem to the extent that they are both prevalent and disabling [
1]. Disability is often assessed using one or more measures of health-related quality of life, that is, measures of the perceived effect of an individual’s health on his or her everyday functioning [
2,
3], although individuals’ subjective satisfaction with different facets of their lives - including, but not limited to, their health status - is considered equally important by many authorities [
4,
5]. Individuals’ subjective satisfaction with their lives may be referred to as subjective quality of life, although it needs to be recognized that all quality of life measures are subjective to some extent and that there are no universally accepted definitions of such terms [
5,
6]. Both health-related quality of life and subjective quality of life have been found to be strongly predictive of more objective indices of health status, including chronic disease and mortality, as well as health service utilization, hence their utility as measures of disease burden [
7‐
9].
There is no doubt that body dissatisfaction (BD) is prevalent. Findings from epidemiological studies have consistently shown that many, if not most, younger women in industrialized nations are at least moderately dissatisfied with their body weight or shape [
10]. The term “normative discontent” was introduced in the 1980’s to describe the pervasiveness of this phenomenon and it is no less apposite today [
10,
11]. BD remains less common in men, although the gap may be closing [
10,
12].
Whether and to what extent BD should be considered disabling is less clear. On the one hand, there is good evidence that BD is associated with - and predictive of - a range of adverse health outcomes, including low self-esteem, depressive mood and eating disorder symptoms [
13‐
15]. There is also good evidence that BD mediates the association between obesity and emotional well-being, in young women at least [
12,
16]. On the other hand, attention has focused, almost without exception, on the status of BD as a risk factor for other, “more serious” mental health problems rather than as a public health problem in its own right [
13,
17,
18]. As a consequence, little is known about the effects of BD on quality of life. Given the demonstrated links between BD and impairment in emotional well-being [
13‐
15], adverse effects of BD on quality of life might be expected to be most pronounced for items tapping perceived impairment in mental health and psycho-social functioning, whereas impairment in physical health might be expected to be less pronounced and due, at least in part, to the positive association between BD and body weight [
12]. However, the available evidence does not permit any firm conclusions in this regard.
Meland and colleagues [
19] found, in a large, general population sample of adolescents, that perceived negative health was more common among girls than among boys and that this was accounted for by higher levels of BD - and a stronger association between BD and perceptions of health - among girls. However, findings from this study are difficult to interpret because the assessment of perceived health was confined to a single item, namely, “How healthy do you think you are?”, that presumably encompassed perceived impairment in both physical and mental health [
20]. Further, no attempt was made to control for body weight in exploring the associations between BD and perceptions of health.
Muennig and colleagues [
21] found, in a general population sample of women and men, that the difference between actual and desired weight was a better predictor of self-reported “unhealthy” days in the past month than actual body weight and that this was the case for both physical and mental health. Further, and consistent with the findings of Meland et al. [
19], poor self-reported health was more common in women than in men and this was accounted for, at least in part, by higher levels of BD, and a stronger association between BD and perceived impairment, in women.
Of note is that there was no assessment of eating disorder symptoms, namely, the “undue influence of weight or shape on self-evaluation” and the occurrence of binge eating and/or extreme weight-control behaviors [
20,
22], in either of these studies. Given the strong links between BD and eating disorder symptoms [
18], and given that eating disorder symptoms are associated with marked impairment in quality of life [
20,
22‐
24], it would be helpful to consider the potential role of these symptoms in accounting for any observed associations between BD and quality of life impairment. In a community-based study of quality of life impairment associated with eating disorder symptoms in women, Vallance and colleagues [
25] found moderate negative correlations between BD and both physical and mental component summary scales of the (36-item) Medical Outcomes Study Short Form (SF-36) in preliminary (bivariate) analysis. Whether these associations might have been due to an association between BD and eating disorder symptoms was not, however, considered.
To our knowledge, no other research has examined the association between BD and impairment in quality of life in a general population sample. This is regrettable because population-based research addressing impairment in quality of life associated with BD, when taken with findings relating to prevalence, has the potential to highlight the significance of BD as a public health problem - and, in turn, the need for a public health response - in the same way that findings from epidemiological studies of disability associated with the more common mental health problems have highlighted the public health burden of these conditions [
3,
23,
26].
The goal of the present study was, therefore, to examine impairment in quality of life associated with the spectrum of BD that occurs at the population level, using measures of both health-related and subjective quality of life. Although the existing evidence did not permit any firm a priori hypotheses, it was reasonable to surmise that adverse effects of BD on quality of life would be most pronounced for items tapping perceived impairment in or dissatisfaction with mental health and psycho-social functioning, whereas impairment in physical health associated with BD would be expected to be less pronounced and due, at least in part, to the association between BD and body weight. A secondary aim of the study was to determine whether any observed associations between BD and quality of life impairment could be accounted for by an association between BD and eating disorder symptoms.
Results
As can be seen in Table
1, BD was common in this sample with most participants (86.9%) reporting some degree of dissatisfaction with their weight or shape and more than one third (36.6%) reporting moderate to marked dissatisfaction.
Table 1
Mean (
SE
) scores on measures of health-related quality of life (SF-12 Physical and Mental Component Summary scales; SF-12 PCS, MCS) and subjective quality of life (WHOQOL-BREF Psychological and Social Functioning subscales; QOL-P, QOL-S) among participants (n=4,892) reporting each of 7 levels of body dissatisfaction (BD0-BD6)
i
n
| 674 | 1264 | 647 | 687 | 594 | 598 | 695 | | | | |
% | 13.1 | 24.5 | 12.5 | 13.3 | 11.5 | 11.6 | 13.5 | | | | |
|
Mean (
SE
)
|
Mean (
SE
)
|
Mean (
SE
)
|
Mean (
SE
)
|
Mean (
SE
)
|
Mean (
SE
)
|
Mean (
SE
)
|
F
|
p
|
Post-Hoc
ii
|
Effect Size
iii
|
SF-12 PCS | 49.63 (.38) | 49.79 (.27) | 50.41 (.36) | 50.46 (.35) | 50.10 (.39) | 49.75 (.38) | 48.64 (.38) | 2.74 | < .05 | 2,3>6 | .01 |
SF-12 MCS | 50.90 (.46) | 49.04 (.33) | 47.44 (.44) | 44.79 (.43) | 45.47 (.47) | 41.25 (.46) | 38.59 (.47) | 81.47 | < .01 | 0>1,2>3,4>5>6 | .11 |
QOL-P | 3.98 (.03) | 3.82 (.02) | 3.77 (.03) | 3.63 (.02) | 3.60 (.03) | 3.38 (.03) | 3.14 (.03) | 107.57 | < .01 | 0>1,2>3,4>5>6 | .14 |
QOL-S | 4.08 (.03) | 3.92 (.02) | 3.85 (.03) | 3.71 (.03) | 3.65 (.04) | 3.48 (.03) | 3.33 (.03) | 53.21 | < .01 | 0>1,2,3>4>5>6; 1>3 | .07 |
Also shown in Table
1 are mean scores on each of the four summary QoL measures for participants reporting different levels of BD. As can be seen, higher levels of BD were associated with lower scores on all four summary scale measures, SF-12 PCS, SF-12 MCS, QOL-P and QOL-S, although the effect size for the difference between groups on the SF-12 PCS was small. The rank order correlations between BD and scores on SF-12 PCS, SF-12 MCS, QOL-P, and QOL-S, were, respectively, -.10, -.30, -.36 and -.26. The correlation between BD and BMI was .47.
Results of the ordinal logistic regression analyses are summarised in Table
2. As can be seen, all levels of BD were associated with impairment in at least some aspects of quality of life, after controlling for BMI and other potential covariates. Further, the number of items for which BD was associated with increased likelihood of quality of life impairment increased proportional to the level of BD reported.
Table 2
Results of ordinal logistic regression analyses showing odds ratios (
OR
s) and confidence intervals (
CI
s) for poorer quality of life on items of the WHOQOL-BREF and SF-12, according to participants’ (n=4,892) level of body dissatisfaction (BD)
i-iii
WHOQOL-BREF items
| | | | | | |
Psychological Functioning
iv
| | | | | | |
Positive Feelings | 1.22 (0.98, 1.52) | 1.49 (1.18, 1.87)** | 1.86 (1.44, 2.41)*** | 2.02 (1.59, 2.58)*** | 3.23 (2.47, 4.21)*** | 4.04 (3.12, 5.22)*** |
Spirituality | 1.45 (1.18, 1.78)*** | 1.70 (1.37, 2.11)*** | 2.27 (1.78, 2.89)*** | 2.54 (2.02, 3.20)*** | 3.39 (2.63, 4.36)*** | 4.98 (3.90, 6.36)*** |
Thinking | 1.29 (1.04, 1.59)* | 1.37 (1.10, 1.70)** | 1.80 (1.40, 2.32)*** | 2.00 (1.58, 2.53)*** | 2.93 (2.26, 3.79)*** | 4.21 (3.28, 5.41)*** |
Self-esteem | 1.84 (1.47, 2.30)*** | 2.60 (2.07, 3.27)*** | 3.89 (3.01, 5.04)*** | 5.00 (3.91, 6.38)*** | 9.35 (7.15, 12.23)*** | 24.58 (18.83, 32.07)*** |
Negative feelings | 1.52 (1.22, 1.88)*** | 1.72 (1.37, 2.15)*** | 2.41 (1.87, 3.10)*** | 2.83 (2.23, 3.59)*** | 4.45 (3.43, 5.77)*** | 8.47 (6.56, 10.94)*** |
Social Relationships
v
| | | | | | |
Personal relationships | 1.53 (1.24, 1.89)*** | 1.64 (1.32, 2.04)*** | 2.18 (1.70, 2.78)*** | 2.81 (2.23, 3.54)*** | 3.79 (2.93, 4.89)*** | 4.33 (3.38, 5.55)*** |
Sexual activity | 1.34 (1.10, 1.65)** | 1.68 (1.36, 2.07)*** | 1.91 (1.51, 2.42)*** | 2.39 (1.91, 2.99)*** | 3.22 (2.52, 4.11)*** | 3.78 (2.98, 4.81)*** |
Social support | 1.26 (1.02, 1.54)* | 1.63 (1.32, 2.02)*** | 1.94 (1.53, 2.47)*** | 2.06 (1.64, 2.58)*** | 2.63 (2.05, 3.38)*** | 3.81 (2.99, 4.85)*** |
Overall quality of life
vi
| 1.26 (1.02, 1.57)* | 1.38 (1.10, 1.72)** | 1.69 (1.31, 2.18)*** | 2.06 (1.62, 2.62)*** | 2.55 (1.96, 3.31)*** | 3.60 (2.78, 4.65)*** |
SF-12 items
| | | | | | |
Physical Health
vii
| | | | | | |
General health | 1.25 (1.02, 1.53)* | 1.37 (1.11, 1.69)** | 1.52 (1.20, 1.93)** | 1.90 (1.51, 2.38)*** | 2.17 (1.70, 2.77)*** | 3.75 (2.95, 4.77)*** |
Accomplish less | 1.00 (0.78, 1.28) | 1.01 (0.79, 1.31) | 1.34 (1.01, 1.77)* | 1.40 (1.07, 1.82)* | 1.43 (1.07, 1.91)* | 2.44 (1.86, 3.21)*** |
Limited in kind | 1.00 (0.77, 1.31) | 1.08 (0.82, 1.42) | 1.00 (0.73, 1.36) | 1.12 (0.84, 1.50) | 1.43 (1.06, 1.95)* | 1.73 (1.30, 2.32)*** |
Moderate activities | 0.71 (0.53, 0.95)* | 0.67 (0.49, 0.91)* | 0.62 (0.44, 0.89)** | 0.64 (0.46, 0.89)** | 0.87 (0.62, 1.22) | 1.03 (0.75, 1.41) |
Climb several flights | 0.87 (0.65, 1.16) | 0.82 (0.61, 1.11) | 0.91 (0.66, 1.27) | 0.95 (0.70, 1.29) | 1.30 (0.94, 1.78) | 1.58 (1.17, 2.14)** |
Pain-interfere | 1.23 (1.00, 1.52) | 1.20 (0.97, 1.49) | 1.36 (1.07, 1.74)* | 1.59 (1.27, 2.01)*** | 1.51 (1.17, 1.95)** | 2.12 (1.66, 2.70)*** |
Mental Health
viii
| | | | | | |
Accomplish less | 1.23 (0.95, 1.60) | 1.77 (1.36, 2.31)*** | 2.64 (1.98, 3.54)*** | 2.33 (1.77, 3.08)*** | 4.10 (3.05, 5.52)*** | 6.25 (4.67, 8.36)*** |
Not careful | 1.21 (0.91, 1.60) | 1.62 (1.21, 2.16)** | 2.57 (1.88, 3.50)*** | 2.29 (1.70, 3.08)*** | 3.53 (2.58, 4.82)*** | 5.09 (3.75, 6.89)*** |
Peaceful | 1.53 (1.24, 1.87)*** | 1.95 (1.58, 2.42)*** | 2.62 (2.06, 3.32)*** | 2.94 (2.35, 3.69)*** | 4.34 (3.40, 5.56)*** | 6.71 (5.27, 8.55)*** |
Energy | 1.25 (1.02, 1.53)* | 1.50 (1.22, 1.85)*** | 2.09 (1.65, 2.64)*** | 2.36 (1.89, 2.95)*** | 3.98 (3.11, 5.08)*** | 5.95 (4.68, 7.56)*** |
Blue/sad | 1.57 (1.27, 1.94)*** | 1.86 (1.49, 2.32)*** | 2.51 (1.96, 3.22)*** | 2.78 (2.20, 3.50)*** | 4.55 (3.53, 5.87)*** | 7.49 (5.85, 9.61)*** |
Social-time | 1.12 (0.90, 1.39) | 1.33 (1.06, 1.66)* | 1.96 (1.53, 2.52)*** | 1.71 (1.35, 2.16)*** | 2.55 (1.98, 3.28)*** | 4.163.25, 5.34)*** |
As is also apparent in Table
2, increased likelihood of quality of life impairment associated with BD was more likely to be observed for items of the SF-12 tapping mental health than those tapping physical health, although greater BD was strongly associated with increased likelihood of impairment for certain aspects of physical health. In particular, participants who reported marked BD were 3.75 times more likely to report poorer perceived general health than those who reported no BD, after controlling for age, BMI and socio-demographic characteristics.
As would be expected, individuals with eating disorder symptoms (n=482, 9.2%) were over-represented among participants with moderate (BD = 5: 19.2%) and marked (BD = 6: 43.3%) BD, whereas the prevalence of eating disorder symptoms was low in the remainder of the study population, ranging from 0.4% among participants with no BD to 3.8% among participants with moderate BD (χ
2
= 1300.0, p < .01). As would also be expected, effect sizes for some associations were reduced when the regression analysis was repeated controlling for the occurrence of eating disorder symptoms. For example, the odds ratio for the SF-12 PCS General Health item for participants who reported marked BD changed from 3.75 to 3.50, whereas the odds ratio for the SF-12 MCS Blue/Sad item for participants who reported marked BD changed from 7.49 to 5.79. However, the pattern of findings was unchanged and all previously significant effects remained significant.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
JM was responsible for the design and conduct of the research as well as data processing, initial data analysis and manuscript preparation. DM conducted supplementary data analysis and assisted with interpretation of this analysis. BR, PH and CO contributed to the design and conduct of the research and to critical revision of an earlier version of the manuscript. BR contributed to data analysis and interpretation. All authors read and approved the final manuscript.