Journal of Taibah University Medical Sciences (2013) 8(2), 126–133

Taibah University

Journal of Taibah University Medical Sciences

www.sciencedirect.com

Student Section

Body image dissatisfaction: Prevalence and relation to body mass

index among female medical students in Taibah University, 2011

Ekhlas As-Sa’edi *, Shahad Sheerah, Reem Al-Ayoubi, Ala’a Al-Jehani, Walaa Tajaddin

and Hanan Habeeb

Faculty of Medicine, Taibah University, Almadinah Almunawwara, Kingdom of Saudi Arabia

Received 15 March 2013; revised 10 May 2013; accepted 15 May 2013

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Abstract

Background: Body image has been defined as the person’s perceptions, thoughts, and feelings about his body. Body image dis-

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satisfaction is a problem of growing concern that affects psychological wellbeing.

Objectives: This study aims to estimate the prevalence of body image dissatisfaction, identify its underlying risk factors, and

explore the relation between actual, perceived and desired BMI among female medical students in Taibah University, KSA.

Method: This is a cross-sectional survey that involved 242 participants. Data were collected using a nine figure silhouette rating

scale for assessing body image dissatisfaction, a self-administered questionnaire for identifying possible factors contributing to dis-

satisfaction, and measurement of the participants’ weight and height to calculate their actual BMI.

Corresponding address: Fourth-year Medical Students, Faculty of Medicine, Taibah University, Almadinah Almunawwara, Kingdom of Saudi

abia. Tel.: +966 530557707.

-mail: ekhlas.Assaedi@gmail.com (E. As-Sa’edi)

r review under responsibility of Taibah University.

Production and hosting by Elsevier

8-3612 � 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.

p://dx.doi.org/10.1016/j.jtumed.2013.05.001

E. As-Sa’edi et al. 127

Results: Of all participants: 26.4% were satisfied, 18.6% perceived self as too thin, while 55% perceived self as too heavy. There

has been a significant association between the degree of satisfaction and the following factors; actual BMI, family influence, friends’

criticism, unreal self-perception and feeling of disproportional body parts (at P<.05). The actual and desired BMI of the partic-

ipants in the study have been correlated to their perceived BMI at a significant level (P=.000).

Conclusion: Dissatisfaction was prevalent and associated with actual BMI. The majority of participants were dissatisfied, over-

estimating their weight and desired to be thinner. Exercise and diet were commonly used to control weight. Further researches need

to be done on this topic on a larger population of the Saudi community taking in consideration its association with depression and

eating disorders.

Keywords: Body image; Body mass index; Satisfaction; Saudi Arabia

� 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.

Introduction

Body image has been defined by many researchers over the

years as the person’s perceptions, thoughts, and feelings abouthis or her body.1 The construct of body image can be brokendown into two and often three dimensions. The first dimensionis cognitive, how an individual “thinks” he or she looks. The

second is emotional, how an individual “feels” he or she looks.Last is idealistic, how an individual “wants” to look.2 Dissat-isfaction with physical appearance appears to be more the rule

than the exception. Based on the results of a survey done byGarner and colleagues, most women (56%) and almost half(43%) of men are dissatisfied with their overall appearance.3

About 66% of Saudi women are overweight, approximately52% of the adult population in the Kingdom of Saudi Arabiais obese while 18% of adolescents and over 15% of pre-school

children are also victims of obesity.4

Abdel-Fattah et al., have conducted a study among femalesseeking treatment for obesity in Saudi Arabia and suggested ahigh frequency of depressive symptoms, and concerns with

body image among obese patients.5 It was also found that highlevels of body dissatisfaction in treatment-seeking obese indi-viduals are associated with elevated depression and decreased

levels of self-esteem.6 Al-Subaie, found an association betweenthe desire to be thinner in secondary school female students inSaudi Arabia and the exposure to Western culture as living

abroad or speaking foreign languages.7

To understand how people feel about themselves, researchershave examined self-esteemand body image satisfaction.Dissatisfac-tion with current body weight was expressed by more overweight

and underweight females than by the normal weight females.8 Falk-ner et al., found that overweight status was associated with emo-tional problems, hopelessness and suicidal thoughts in adolescent

females.9 Similar findings showed a stronger association betweenoverweight status and poor psychological health among femalesas compared to males in several other community-based, cross-sec-

tional studies of children and adolescents.10–13

Few studies have discussed body image dissatisfaction in AlMadinah Al Munwarah, KSA. This study aims to estimate the

prevalence of body image dissatisfaction, identify its underly-ing risk factors, and explore the relation between actual, per-ceived and desired body mass index (BMI) among femalemedical students in the Taibah University, KSA. We believe

that dissatisfaction is prevalent with the presence of a correla-tion between actual, perceived MI and desired BMI.

Materials and Methods

Setting and participants

This cross-sectional survey has been carried out from Septem-ber through November 2011, at the Taibah University,

Al-Madinah Al-Munwarah, KSA. It involved 242 out of 343female medical students. Response rates were (19.8%,22.3%, 24.4%, 14.9% and 18.6%) for the 1st, 2nd, 3rd, 4th,

and 5th year students, respectively and the overall responserate was 71%. Age of participants was ranging from 19 to27 years. An informed verbal consent has been taken from

all participants. Ethics committee approval was taken.Data were collected using a nine figure silhouette rating

scale for assessing body image dissatisfaction, a self-adminis-

tered questionnaire for identifying possible factors that couldcontribute to body image (dis)satisfaction among participants,and measurement of participants’ weight and height was takenat the medical unit in the Taibah University in order to calcu-

late their actual BMI.

Study tools

The nine figure silhouette rating scale

This study used a psychological tool developed by Stunkard

et al.14 for assessing body image dissatisfaction. In this measure,silhouettes ranging from very thin to very obese are presented tothe participant, who is usually asked to choose the silhouette

closest to her own body size (perceived) and that representingher ideal size(desired). The discrepancy between the two figuresis seen as an indication of (dis)satisfaction.1 Stunkard’s figurerating scale is a valid and reliable measure of women’s weight

status, when rated as viewed either in-person or on videotapeby an unrelated observer.15 The perceived and desired figureswere related to the perceived and desired BMI using a scale

developed by Bulik and colleagues.16 The reliability of this scalehas been proved for actual BMI and self-reported BMI in malesand females. Therefore, the nine figures represented nine levels

of BMI for females (18.3–45.4).17

Calculating actual BMI

The weight and height of participants were measured at the

University’s health unit, and BMI was calculated using theequation: BMI = weight (kg)/height2 (m). Participants with

Table 1: Characteristics of participants: weight, height and body

mass index grouped into actual, perceived and desired BMI.

Range Mean±SD*

Age (years) 19–27 21.02±1.48

Weight (kg) 36.00–135.00 56.79±12.88

Height (cm) 140.00–186.00 157.72±6.72

Actual BMI 14.24–47.27 22.79±4.71

Underweight 17.19±1.13

Normal 21.48±1.83

Overweight 27.31±1.37

Obese 33.31±3.82

Perceived BMI chosen by: 17.80–40.8 22.67±4.46

Underweight 18.89±.64

Normal 21.35±2.69

Overweight 26.93±4.33

Obese 30.38±3.96

Desired BMI chosen by: 17.80–31.30 20.32±1.59

Underweight 19.93±1.30

Normal 19.97±1.19

Overweight 21.15±2.22

Obese 21.91±1.63

* Standard deviation.

128 Body image dissatisfaction

BMIs < 18.5 were considered underweight, BMIs ranging be-tween 18.5 and 24.9 were considered normal weight, BMIsranging between 25.0 and 29.9 were considered overweight,

BMIs > 30.0 were considered obese,18 the calculated BMI isconsidered as the actual BMI.

Self-administered questionnaire

Every participant was given a questionnaire that included:demographic data, possible factors that could affect body im-age (dis)satisfaction (family influence, friends’ criticism, society

pressure, unreal perception of body size, comparison to mediaicons and feeling of disproportional body parts), and partici-pants’ ideas about life aspects possibly affected by weight

changes (friends and popularity, confidence, health, beauty,femininity and attractiveness to opposite sex) have been ex-plored. Finally, the questionnaire included a survey about

the common measures used by participants to change theirweight (exercise, diet, diet pills, increasing caloric intake andothers). Ethical considerations and confidentiality wereassured.

Statistical analysis

SPSS (Statistical Package for Social Science) program was

used for statistical analysis (version 13; Inc., Chicago, IL).Data from questionnaires were entered as numerical or cate-gorical, as appropriate. Two types of statistics were done; 1.

Descriptive statistics, where Quantitative data were shown asmean, SD, range, and Qualitative data were expressed asfrequency and percent. 2. Analytical statistics, where the

Chi-square test was used to measure association between qual-itative variables. Pearson’s correlation has been used to studycorrelation between two variables having normally distributeddata. P-value was considered statistically significant when it is

less than 0.05.

Results

Results showed that mean actual BMI of participants was22.79 ± 4.71, mean perceived BMI was 22.67 ± 4.46 andmean desired BMI was 20.32 ± 1.59, and their mean age

was 21.02 ± 1.48 (Table 1).Of all participants, 55% perceived themselves as too heavy

and desired to lose weight, 26.40% were satisfied and 18.60%

perceived themselves as too thin and desired to gain weight(Figure 1). Regarding possible risk factors of dissatisfactionamong female medical students in the Taibah University, re-

sults showed a significant (P < .05) association between thedegree of (dis)satisfaction and the following factors: actualBMI (P = .000), family influence (P = .013), friends’ criticism(P = .000), unreal self-perception (P = .000), feeling of dis-

proportional body parts (P = .000), while comparison to med-ia icons, and society influence did not pose this significantassociation (P > .05). Among participants who perceived

themselves as too heavy, 86.5% stated that they feel themselvesheavier than others expressed (i.e. showed unreal self percep-tion), 78.2% feel they have disproportional body parts, while

97.8% of those feeling themselves as too thin were affectedby both the family influence and friends’ criticism (Table 2).About 79.7% of satisfied participants were of normal weightand the most interesting thing is that 54.2% of the participants

who feel themselves as too heavy were of normal weight(Figure 2).

Results indicated that there is a positive correlation be-

tween perceived BMI and both actual and desired BMI(r = .803, r = .462 at P = .000 respectively) of the studiedpopulation (Table 3/Figures 3 and 4). For underweight indi-

viduals they somewhat estimated their BMI correctly (Per-ceived = 18.89), but they still desired a heavier ideal bodyweight (ideal = 19.93). In normal weight individuals, the mean

actual and perceived BMI do not vary (21.48, 21.35 respec-tively), however they desired thinner ideal (mean = 19.97)weight. Overweight and obese individuals underestimated theiractual BMI (mean and perceived BMI = 26.39, and 30.38

respectively), but desired much thinner ideal weight (meanand Ideal BMI = 21.15 and 21.91 respectively) (Table 1). Sig-nificant differences have been found between participants (dis-

tributed by their actual BMI) regarding weight controlbehaviors (P < .05). Exercise and diet were the most com-monly used behaviors among participants to control their

weight (66.9% and 51.2%, respectively), while diet pills andchanging eating habits were minimally used by 5% and28.5% of participants, respectively (Table 4).

Discussion

Dissatisfaction is an epidemic problem of modern societies, and

it appears to bemore the rule than the exception.Women tend tobe critical of their appearance and place importance on the waythey look, it was expected that there would be a linear relation-ship between current weight status and ideal body image.

The mean age of the participants was 21.02 ± 1.48 SD,while the mean actual BMI was 22.79 ± 4.71 SD. There hasbeen a significant association between actual BMI and dissat-

isfaction (P = .000). Actual and desired BMI of the partici-pants in the study had a positive correlation to theirperceived BMI at a significant level (P = .000). In other

words; as the participants get heavier, they were aware of this

Figure 1: Prevalence of body image dissatisfaction among female medical students in the Taibah University.

Table 2: Possible risk factors of body image dissatisfaction among female medical students in the Taibah University, categorized according

to the degree of satisfaction.

Perceives self as too thin Satisfied Perceives self as too heavy Total v2 P-value

n=45 n=64 n=133 n=242

No. % No. % No. % No. %

Family influence

– No 1 (2.2) 11 (17.2) 28 (21.1) 40 (16.5) 8.66 .013*

– Yes 44 (97.8) 53 (82.8) 105 (78.9) 202 (83.5)

Friends’ criticism

– No 1 (2.2) 21 (32.8) 47 (35.3) 69 (28.5) 18.88 .000*

– Yes 44 (97.8) 43 (67.2) 86 (64.7) 173 (71.5)

Society influence

– No 7 (15.6) 10 (15.6) 18 (13.5) 35 (14.5) 0.20 .902

– Yes 38 (84.4) 54 (84.4) 115 (86.5) 207 (85.5)

Unreal self perception

– No 37 (82.2) 34 (53.1) 18 (13.5) 89 (36.8) 78.22 .000*

– Yes 8 (17.8) 30 (46.9) 115 (86.5) 153 (63.2)

Comparison to media icons

– No 17 (37.8) 15 (23.4) 33 (24.8) 65 (26.9) 3.39 .183

– Yes 28 (62.2) 49 (76.6) 100 (75.2) 177 (73.1)

Feeling of disproportional body parts

– No 32 (71.1) 30 (46.9) 29 (21.8) 91 (37.6) 38.02 .000*

– Yes 13 (28.9) 34 (53.1) 104 (78.2) 151 (62.4)

Actual BMI

– Underweight 23 (51.1) 12 (18.8) 2 (1.5) 37 (15.3) 104.18 .000*

– Normal 21 (46.7) 51 (79.7) 72 (54.2) 144 (59.5)

– Overweight 1 (2.2) 1 (1.5) 39 (29.3) 41 (16.9)

– Obese 0 (0.0) 0 (0.0) 20 (15.0) 20 (8.3)

* Significant association; P value<.05.

Figure 2: Actual BMI of participants distributed by their degree of body image (dis)satisfaction.

E. As-Sa’edi et al. 129

Table 3: Correlation between perceived and both desired and

actual body mass indices of the studied population.

Perceived BMI

r P-value

Desired BMI .462 .000*

Actual BMI .803 .000*

* Significant association; P value<.05.

130 Body image dissatisfaction

weight gain which was accompanied by increasing levels of dis-

satisfaction for being far from the slender ideal body images.They desired slimmer bodies even though their ideals were lar-ger than their thinner counterparts; which states that the idealweight was proportional to their weight.

Similarly, in a study done among Jamaican adolescents in2011, there were significant positive correlation between partic-ipants actual and perceived BMI (r= 0.61, P < 0.01), and be-

tween perceived and desired BMI (r= 0.29, P < 0.01).17

Kostanski et al., have also found that actual BMI was stronglyrelated to dissatisfaction (P < .05).19 Another research, done

by Alipoor et al., found a significant correlation between scoreof dissatisfaction and actual BMI (r = .95, P = .0001).2 InSpain, large proportion of students (67.7%) chose an idealbody weight lower than actual weight.20 A tendency of female

students to over-estimate their body weight has been estab-lished in a similar study.21 Perhaps this similarity is due tothe effect of the common age group, but still this association

has proven to be significant in middle aged women. A study

Figure 3: Correlation between perceived and desired

made by Cachelin et al., on middle aged women showed thatcurrent figures were significantly larger than the ideal figure(P = .0001).22

Although western and non-western cultures are distinct,dissatisfaction seems to be a common problem. Significant dif-ferences in body shape perception among Australian born wo-

men were reported with greater degree of dissatisfaction.23 Onthe other hand, Mahmud et al., made a study showing that dis-satisfaction is more pronounced in western compared to east-

ern cultures as Australian females expressed significantlyhigher levels of dissatisfaction once they are paired to Paki-stani females.24

Of all participants in our study: 26.4% were satisfied,

18.6% perceived self as too thin (desired to gain weight), while55% perceived self as too heavy (desired to lose weight). Thesefindings are in line with these related studies: a Polish study

showed that only 34.4% of female pharmacy students were sat-isfied.21 Among the dissatisfied individuals in a Pakistani re-search, 45.6% of the respondents perceived self as too heavy

whereas 54.4% perceived self as too thin.25 The prevalenceof dissatisfaction was 47.3% among female university studentsin Florianopolis, Brazil.26 In Jamaica, Huffman et al., reported

that the study participants underestimated their weight in ob-ese and overweight categories, but still desired smallerbodies.17 These closely related results are probably becausethinness has the most influential impact on body image dissat-

isfaction nowadays.Our study concludes that there is a significant association

between the degree of satisfaction/dissatisfaction and the fol-

lowing risk factors: participants’ actual BMI, Family influence

body mass index among the study participants.

Figure 4: Correlation between perceived and actual body mass index among the study participants.

Table 4: Behaviors for weight control among participants distributed by their actual BMI.

Under weight Normal Over weight Obese Total v2 P-value

n=37 n=144 n=41 n=20 n=242

No. % No. % No. % No. % No. %

Exercise

– No 19 51.4 52 36.1 7 17.1 2 10.0 80 33.1 15.74 .001*

– Yes 18 48.6 92 63.9 34 82.9 18 90.0 162 66.9

Diet

– No 23 62.2 79 54.9 10 24.4 6 30.0 118 48.8 17.36 .001*

– Yes 14 37.8 65 45.1 31 75.6 14 70.0 124 51.2

Diet pills

– No 30 81.1 144 100.0 38 92.7 18 90.0 230 95.0 24.37 .000*

– Yes 7 18.9 0 .0 3 7.3 2 10.0 12 5.0

Eat more

– No 17 45.9 109 75.7 30 73.2 17 85.0 173 71.5 14.94 .002*

– Yes 20 54.1 35 24.3 11 26.8 3 15.0 69 28.5

* Significant association; P value<.05.

E. As-Sa’edi et al. 131

and friends’ criticism, unreal self-perception and feeling of dis-

proportional body parts (P < .05). Family and friends influ-enced 83.5% and 71.5% of all participants respectively.About 63.2% of participants reported feeling heavier thanother expressed to them (unreal self-perception) and nearly

62.4% stated the feeling of disproportional body parts.Approximately more than half of participants who perceivethemselves as too heavy were influenced by these factors.

Lawler et al., showed that BMI, peer criticism and internal-ized appearance emerge as significant predictors of body image

dissatisfaction.27 Another research done by BibiGerner, also

found this correlation with peer acceptance (r = .23 atP = .001).28 In a study made on Chinese females, 2010, re-ported pressure from peers and adult relatives to lose weight.29

This similarity in results can be partially explained by partici-

pants’ critical age group which can make them more affectedby others’ opinion.

A study made on Pakistani students found a significant

association between high media exposure and body image dis-satisfaction (P < .05).25 Another study done by O’Dea and

132 Body image dissatisfaction

Abraham, demonstrated that body weight was also an impor-tant aspect of social acceptance.30 Among Spanish adolescents,mass media exposure was associated with body dissatisfac-

tion.31 Unexpectedly, our results found insignificant associa-tion between dissatisfaction and both media and societyinfluence (p > .05). The lower exposure to media and less

sociability of medical students might clear up thiscontradiction.

In this study, among the 64 (26.4%) of satisfied partici-

pants, 79.7% were of normal weight, 18.8% and 1.5% wereof underweight and overweight respectively. None of the obeseparticipants was satisfied. The results of this study are in keep-ing with those of a previous study made by Sarwer, which

showed that the majority of obese women demonstrated bodyimage dissatisfaction related to obesity.6 However, a studyconducted in 2005, found that there’s a little relationship be-

tween the degree of obesity and the intensity of dissatisfactionamong North American population.32 This controversy can beexplained by the cultural differences in viewing obesity.

Among behaviors used to control weight: Exercise and dietwere the most commonly used behaviors among participants(66.9% and 51.2%, respectively) while diet pills were used only

by 5% of them. Increasing caloric intake to gain weight wasused by 28.5% of all participants. McDonald et al., alsoshowed that Women’s motivation of exercise was related toweight.33 Moreover, Sarwer et al., reported that dissatisfaction

might be a motivator to lose weight by changing dietary habitsand physical activity.32 A study made in Qatar, 2006, statedthat 47.1% of overweight and obese female adolescents were

on diet.34 This resemblance is owed to the fact that diet andexercise are the most accessible means of controlling weight.

Limitations

The results would have been enhanced if a larger sample ofcollege students was taken in consideration, and if it included

both sexes in this group. That is a limitation we have beenforced to, because of the short duration of research we wereobliged to while conducting.

Recommendation

Further studies need to be done on a larger population of theSaudi community taking into consideration the association be-

tween body image dissatisfaction and depression as well as eat-ing disorders. Universities may also consider carryingawareness campaigns on this issue and planning for interven-

tion programs in nutrition clinics in their facilities.

Conclusion

Results indicate that dissatisfaction is prevalent among femalemedical students in the Taibah University and associated withtheir actual BMI. More than half of participants of all weight

categories were dissatisfied about their weight. There was atendency to over-estimate weight even among normal-weightparticipants. This led to behavioral changes in an attempt tocontrolling weight. In addition, it was strongly influenced by

family and friends’ criticism, feeling of disproportional bodyparts and unreal self perception. This highlights the impor-tance of conducting nutritional health education campaigns

in this group of young university students to correct theirwrong thoughts toward the ideal body image, orient them bythe criteria and importance of a healthy diet, and provide free

nutritional consultations.

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