Obes Facts 2016;9:424–441

DOI: 10.1159/000454837 © 2016 The Author(s)

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Original Article

Body Dissatisfaction in Individuals with Obesity

Compared to Normal-Weight Individuals:
A Systematic Review and Meta-Analysis
Natascha-Alexandra Weinberger a, b, c Anette Kersting d
Steffi G. Riedel-Heller b Claudia Luck-Sikorski a, b, c
a Leipzig University Hospital, Integrated Research and Treatment Center (IFB)

AdiposityDiseases, Leipzig, Germany; b Institute of Social Medicine, Occupational Health and

Public Health (ISAP), University of Leipzig, Leipzig, Germany; c University of Applied Sciences
SRH Gera, Gera, Germany; d Department of Psychosomatic Medicine and Psychotherapy,
University of Leipzig, Leipzig, Germany

Key Words
Obesity · Body image · Body dissatisfaction · BMI groups · Adults

Abstract
Background: Body dissatisfaction has been identified as a psychological correlate of obesity
that is related to disordered eating, poor self-esteem, and depression. However, not all indi-
viduals with obesity are equally vulnerable to these correlates, and ‘normative discontent’ is
present in individuals with normal weight, too. In this light, the complex relationship of body
image and individual weight status seems like a worthwhile direction of research inquiry. As
such, this review aims to systematically explore the degree of body dissatisfaction in individ-
uals with obesity compared to normal-weight individuals. Methods: A systematic literature
search was conducted. All quantitative studies of adult samples reporting results regarding
differences in body dissatisfaction between individuals with normal weight and obesity were
included. Results: 17 articles were found. Across studies, individuals with obesity reported
higher body dissatisfaction than normal-weight individuals (questionnaires: d = 0.89, 95% CI
= 0.63–1.16, p < 0.001; silhouette scales: d = 1.41, 95% CI = 0.57–2.25, p < 0.001). Meta-re-
gression revealed a significant association of female gender and higher body dissatisfaction
(b = 0.60, p = 0.007). Conclusion: The findings underline the severity of body dissatisfaction
among individuals with obesity and especially among women. Future research recommenda-
tions are discussed. © 2016 The Author(s)
Published by S. Karger GmbH, Freiburg

Claudia Luck-Sikorski is the winner of the EASO New Investigator Award in Public Health 2016

Natascha-Alexandra Weinberger
University of Applied Sciences SRH Gera
Neue Straße 28–30
07548 Gera, Germany
Natascha-Alexandra.Weinberger @ medizin.uni-leipzig.de
 Obes Facts 2016;9:424–441 425
DOI: 10.1159/000454837 © 2016 The Author(s). Published by S. Karger GmbH, Freiburg
www.karger.com/ofa
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

Introduction

Obesity is widely considered to be one of the most serious public health problems of
recent times, not only increasing health care costs and risk of illness but also burdening indi-
viduals with obesity with severe psychological consequences [1]. Next to self-esteem and
emotional well-being, body image is a key concept believed to be negatively affected in obesity
[2].
Body image is a multidimensional construct and refers to a person’s perceptions and atti-
tudes, including feelings, thoughts and behaviors, regarding their own body and appearance
[3]. According to this cognitive-behavioral model of body image, personality and physical
attributes as well as interpersonal attributes and cultural socialization all play a role in how
invested individuals are in their body image and how they evaluate it [4].
One facet of attitudinal body image is referred to as body satisfaction or body dissatis-
faction [5]. It describes the subjective evaluation of the degree to which an individual has a
positive or negative regard for their body [6].
Similarly to the concept itself, measurement of body image is multidimensional as well,
a circumstance that explains why, e.g., weight dissatisfaction does not necessarily imply body
dissatisfaction [7]. Assessment tools generally include perceptual accuracy of or attitudes
regarding body image like subjective satisfaction, investment in appearance and beliefs about
the body, and avoidance behavior [8]. While the former tend to make use of figural drawing
scales and computer morphing techniques, the latter is often assessed using self-report ques-
tionnaires [9, 10].
The link between weight status and body image is complex. Schwartz and Brownell [11]
argue that body image might be affected by obesity through psychological distress, which has
an impact on quality of life. As outlined above, while body image is a subjective psychological
phenomenon, it is also largely determined by social experiences [12]. Current Western soci-
eties tend to idealize slenderness, and it is assumed that media portrayal of the ideal female
or male body has great influence on the way individuals evaluate and experience their physical
appearance [13]. These ideals are generally associated with being strong-willed and in control
of one’s body, and individuals not able to conform to this ideal face substantial stigma [12].
While the focus in women is on being thin, men are supposed to be moderately muscular as
well [14]. Past research has indeed found women to be more likely to strive for thinness [15].
Interestingly, men seem to be split between those wanting to be thinner and those who wish
to be larger and more muscular [14], a distinction that lead to recommendations of investi-
gating male and female body dissatisfaction separately from each other [16].
In light of the negative preconceptions that come with not meeting society’s bodily ideals,
it seems unsurprising that body dissatisfaction is particularly prevalent in individuals with
overweight or obesity [17] and sometimes even related to eating disorders [18]. However, it
seems that not all persons with obesity are equally vulnerable to this problem: Previous
evidence indicates lower prevalence of body image concerns in individuals with obesity who
are not seeking treatment in comparison to those who are [19, 20]. Moreover, individuals
with normal weight are far from satisfied with their body shape or size, a circumstance so
widespread among women that it has aptly been labeled as a ‘normative discontent’ [21]
which reaches well into older age categories [15, 22].
A number of individual studies have reported findings on body dissatisfaction in samples
of various weight statuses. Further, research has consistently found women to be more dissat-
isfied with their body than men [23, 24]. No comprehensive review, however, has quantified
differences in body dissatisfaction between individuals with normal weight and obesity up to
date. While this difference is commonly assumed, the magnitude of the problem still needs to
be determined. To gain a more comprehensive picture of this issue, this systematic review
 Obes Facts 2016;9:424–441 426
DOI: 10.1159/000454837 © 2016 The Author(s). Published by S. Karger GmbH, Freiburg
www.karger.com/ofa
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

aims to systematically explore the degree of body dissatisfaction of individuals with obesity
compared to individuals with normal weight. Moreover, gender differences in body dissatis-
faction across studies are analyzed.

Material and Methods

This review was prepared according to the systematic literature review guidelines of the Centre for
Reviews and Dissemination [25] and follows PRISMA (Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) suggestions [26].

Eligibility Criteria
Eligible for inclusion in the systematic review were published articles in which an assessment of body
image was conducted and in which a quantitative outcome regarding differences in body image between
adults with normal weight and obesity was reported. The weight groups were defined according to the BMI
cut-off criteria of the WHO [27]. Journal articles published in English before December 2015 were eligible for
inclusion.

Information Sources
We searched the electronic databases Medline 1970 to present, Web of Science 1970–2015, PsycINFO
1970–2015, and Cochrane Library 1970–2015. Relevant secondary references from the bibliographies of the
selected articles were searched as well.

Search
A systematic literature search was carried out using the following strategy: [’obesity’ OR ‘overweight’]
AND [’body image’ OR ‘body dissatisfaction’ OR ‘body satisfaction’ OR ‘body image*’].

Study Selection
The first stage of screening was conducted by one author. Here, papers which were clearly not studies
about body image or quantitative studies, or about adult samples were excluded on the basis of title and
abstracts alone. In the second stage, full texts were obtained for the remaining records and screened by two
authors.
Papers were rejected which were not published in the English language, not conducted using a normal-
weight comparison group, did not include participants with obesity, and did not report separate outcomes
for participants with overweight and obesity. Taking previous findings into consideration that hint at
potential differences in body dissatisfaction among subgroups [19, 20], articles which focused on partici-
pants of weight loss, weight maintenance or weight management interventions, focused on bariatric surgery
patients or patients undergoing treatment/therapy of obesity/binge eating/eating disorders, or included/
focused on pregnant women were excluded. Also, papers were rejected which did not report separate, quan-
tifiable outcomes for the group with obesity and the comparison group. Further, to account for the multidi-
mensional nature of the body image construct, papers were excluded which did not focus on body dissatis-
faction in particular. Finally, duplicates, conference papers, editorials as well as review articles and book
chapters were rejected.
Eligible papers were tabulated and used in the qualitative synthesis. Criteria for inclusion in the meta-
analysis were more restrictive. Studies with a sample size ≤ 10 in any of the weight groups and studies using
single items to assess body dissatisfaction were excluded. Further, papers not reporting separate data for
women and men or not reporting data necessary to calculate effect size (standardized differences in means)
were not included in the meta-analyses.

Data Collection Process

Data relevant for the review and meta-analyses were collected in a datasheet. Two corresponding
authors were contacted via email for further information. The first author was asked to provide the numerical
data of two figures illustrating the percentage of participants dissatisfied with their weight. This paper was
excluded after the detailed final analysis due to its focus on weight dissatisfaction. The second author was
asked for the exact number of participants in each of the weight groups for the female and male sample. Since
we did not receive a response, the paper was not included in the meta-analysis.
 Obes Facts 2016;9:424–441 427
DOI: 10.1159/000454837 © 2016 The Author(s). Published by S. Karger GmbH, Freiburg
www.karger.com/ofa
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

Data Items
The following characteristics were extracted from the original articles and included in the review: lead
author, year of publication, country of origin of the sample, sample size, age, sex, BMI assessment method,
and body image measure as well as outcomes of body dissatisfaction (e.g., mean, SD, percentages) and effect
size. For an overview see tables 1 and 2.

Risk of Bias in Individual Studies

A tool similar to the risk-of-bias assessment tool outlined in the Cochrane Handbook for Systematic
Reviews of Interventions [28] was created to account for the most common factors influencing body image
assessment [11]. The author reviewed the following aspects of all included studies: i) control for gender, ii)
control for ethnicity of sample, iii) control for weight-control behavior, iv) control for comorbidities (e.g.,
eating disorders, depression, or personality disorders), and v) assessment of other body image facets (e.g.,
appearance investment).

Data Analysis
Statistical analyses were performed using the statistical software Comprehensive Meta-Analysis,
version 3.0 (Biostat, Englewood, NJ, USA) and STATA 13.1 using the metan and metareg commands. The stan-
dardized differences in means with standard errors were calculated for relevant body dissatisfaction
outcomes for the group with obesity and the group with normal weight. A random-effects model of analysis
was used, and heterogeneity among the included studies was assessed by determining the Cochran Q and the
I2 statistic. For Cochran Q, a p value < 0.10 indicated statistically significant heterogeneity. For I2, the
percentage of observed between-study variability due to heterogeneity rather than chance was used as an
indicator. No heterogeneity was indicated by 0–30%, moderate heterogeneity was indicated by 30–50%,
substantial heterogeneity was indicated by 50–75%, and considerable heterogeneity was indicated by
75–100%. Pooled standardized differences in means for all outcomes were calculated. A two-sided p value <
0.05 was taken to indicate statistical significance.

Results

A total of 17 studies were identified for inclusion in the review, and 14 studies met the
stricter inclusion criteria for the meta-analyses. The studies excluded from the meta-analyses
either used single items to assess body dissatisfaction or had a sample size of 10 or less in any
of the weight groups or did not report data necessary to calculate standardized differences in
means [29–31]. The study selection process is illustrated in figure 1.

Characteristics of Included Studies

The characteristics of the studies meeting the eligibility criteria are summarized in
table 1.
Overall, the included studies involved 13,508 participants and varied in their samples’
country of origin and analyzed ethnic groups. Gender-specific data were present in 16 of the
17 papers. The majority of studies focused on body image and related topics such as preva-
lence of overweight and obesity, or BMI and body composition. Five studies assessed and
reported body image but also focused on a different topic, e.g. narcissism or sexuality [29,
32–35].
The reviewed papers relied on different methods to assess body dissatisfaction. Nine
studies made use of generally established and validated self-report questionnaires like the
Multidimensional Body-Self Relations Questionnaire (MBSRQ) [36]; for an overview of body
satisfaction instruments [8]. Morotti and colleagues [29] measured body dissatisfaction with
two single items, Baceviciene and colleagues [37] used the body image subscale of the WHO
Quality of Life Scale. Moreover, two studies had subjects complete body image scales developed
by the respective authors [34, 38]. Further, four studies used figure rating scales and had
Table 1. Summary of basic characteristics of studies included in the systematic review

Study N Country % female Age BMI* Body image instrument Scoring dissatisfaction Inclusion
meta-analysis?

Questionnaire
Baceviciene et al. 1,260 Lithuania 56 35–64 measured WHO QOL-100 (body image and higher scores = lower yes
[37] appearance facet; [40]) dissatisfaction
Fallon et al. [41] 1,893 USA 66 18–90 self- The Multidimensional Body-Self higher scores = lower yes
report Relations Questionnaire dissatisfaction
(MBSRQ;[36])
Herbozo et al. [32] 924 USA 100 18–25 self- The Eating Disorder Inventory- higher scores = higher yes
report 3-Body Dissatisfaction (EDI-3-BD; dissatisfaction
[42])
Hrabosky, Grilo [35] 120 USA 100 18–58 self- The Body Shape Questionnaire (BSQ; higher scores = higher yes
report [43]) dissatisfaction
Jun and Choi [44] 700 South Korea 100 20.22 ± self-reporta The Body Esteem Scale for higher scores = lower yes
1.90 Adolescents and Adults (BESAA; dissatisfaction
[45])
Lipowska and 325 Poland 100 18–35 measuredb Multidimensional Body-Self Relationshigher scores = lower yes
Lipowski [33] Questionnaire (MBSRQ; [36]); The dissatisfaction
Body Esteem Scale (BES; [46])
McCabe and 526 USA, Europe, 0 18–60 self- The Body Image Satisfaction Scale higher scores = lower yes
McGreevy [34] Australia/Oceania report [47] dissatisfaction
Morotti et al. [29] 90 Italy 100 18–35 measured how satisfied they are of their own higher scores = lower no
body and how good they felt because dissatisfaction
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Obes Facts 2016;9:424–441

of their silhouette
Streeter et al. [48] 170 Canada 54 18–25 measured The Body Esteem Scale for higher scores = lower yes (female
Adolescents and Adults (BESAA;[45]) dissatisfaction sample)
Watkins et al. [38] 188 USA 0 18–57 self- body image scale [38] higher scores = higher yes
report dissatisfaction
Silhouette scales
Benkeser et al. [49] 2,684 Ghana 100 18–99 measured The Figure Rating Scale [39] higher scores = higher yes
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dissatisfaction
Cachelin et al. [50] 276 US 100 18–52 self- The Figure Rating Scale [39] higher scores = higher yes
report dissatisfaction (lose weight)
0=satisfied lower scores =
higher dissatisfaction (gain
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

weight)
Gilbert-Diamond 671 Colombia 100 21–55 measured The Figure Rating Scale [39] higher scores = higher yes
et al. [51] dissatisfaction (lose weight)
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to

0=satisfied lower scores =

higher dissatisfaction (gain
© 2016 The Author(s). Published by S. Karger GmbH, Freiburg

weight)
Santos Silva et al. 1,720 Brazil 56 20–59 measured The Figure Rating Scale [39] higher scores = higher yes (female
[52] dissatisfaction sample)
428

Table 1 continued on next page

Table 1. Continued

Study N Country % female Age BMI* Body image instrument Scoring dissatisfaction Inclusion
meta-analysis?
Both measures
Johnstone et al. [31] 60 UK 50 20–55 measuredc Silhouette: The Figure Rating Scale silhouette: higher scores = no
[39]; digital body image technique lower dissatisfaction
[53]
Questionnaire: Body image Ideals questionnaire: higher scores
Questionnaire (BIQ; [54]) = higher dissatisfaction
Kakeshita and Sousa 106 Brazil 54 18–55 measured Silhouette: The contour drawing silhouette: FRS & computer no
Almeida [30] scale (three scoring methods; [30]) method: higher scores =
higher dissatisfaction (lose
weight) 0=satisfied lower
scores = higher
dissatisfaction (gain weight)
Questionnaire: The Body Shape questionnaire: higher scores
Questionnaire (BSQ; [43]) = higher dissatisfaction
Vieira et al. [20] 1,795 Portugal 100 18–99 measured Silhouette: Body Image Assessment silhouette: higher scores = yes
Questionnaire (silhouettes; [55]) higher dissatisfaction
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Questionnaire: The Body Shape questionnaire: higher scores

Obes Facts 2016;9:424–441

Questionnaire (BSQ; [43]) = higher dissatisfaction

*Division of BMI groups according to WHO criteria if not stated otherwise.
aAsian criteria of WHO: normal (18.0 kg/m2 ≤ BMI < 25.0 kg/m2); obese (BMI ≥ 25.0 kg/m2).
b
Ideal group: BMI = 21.7–22.7 kg/m2; obese group: BMI > 30.0 kg/m2.
cObese group = BMI > 30.0 kg/m2; normal-weight group = BMI < 23.0 kg/m2.
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WHO = World Health Organization; QOL = quality of life; FRS = figure rating scale.
Normal-Weight Individuals: A Systematic Review and Meta-Analysis
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
© 2016 The Author(s). Published by S. Karger GmbH, Freiburg
429
Table 2. Outcomes and summary of results of included studies

Study N Outcome Results Comment d r, SE

dissatisfaction

Questionnaire
Baceviciene et female: M (SD) ob > nw results adjusted for age; both genders dissatisfied, but female: –1.31 female: –0.55, 0.10
al. [37] ob = 277, nw = 192 (both genders) women especially; in men no difference between body male: –0.63 male: –0.3, 0.12
male: image scores of nw & ow subjects
ob = 145, nw = 148
Fallon et al. female: M (SD) ob > nw post hoc: no significant BMI group differences for any of female: female:
[41] ob = 240, nw = 673 (both genders; the body image dependent variables; compared to men BS: –1.36 BS: –0.56, 0.08
male: BS & AE subscale) women had sig. lower body area satisfaction; no AE: –1.70 male: AE: –0.65, 0.09 male:
ob = 147, nw = 262 difference was found in appearance evaluation; BS & AE: BS: –0.91 BS: –0.42, 0.11
in the ow & obese category men consistently report more AE: –1.26 AE: –0.53, 0.11
positive body image than women
Herbozo et al. female: M (SD) ob > nw no test of differences reported 1.32 0.55, 0.11
[32] ob = 105, nw = 580
Hrabosky and Black females: M (SD) ob > nw / Black: 1.27 Black: 0.54, 0.35
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Grilo [35] ob = 28, nw = 15 (both ethnic Hispanic: 0.96 Hispanic: 0.43, 0.38
Obes Facts 2016;9:424–441

Hispanic females: groups)

ob = 20, nw = 13
Jun and Choi female: M (SD) ob > nw / –0.49 –0.24, 0.21
[44] ob = 25, nw = 530
Lipowska and female: M (SD) ob > nw no sig. difference in AO – all participants scored moderateAE: –0.80 AE: –0.37, 0.15
Lipowski [33] ob = 72, nw = 168 (AE subscale) in the MBSRQ and no sig. difference between ob & nw in
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sexual attractiveness subscale

McCabe and male: M (SD) ob > nw / UB: –0.35 UB: –0.17, 0.12 LB:
McGreevy ob = 102, nw = 205 LB: –0.22 –0.11, 0.12
[34]
Morotti et al. female: M (SD) ob > nw both groups are satisfied, ob just less so body: –0.86 body: –0.40, 0.27
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

[29] ob = 21, nw = 47 silhouette: –1.30 silhouette: –0.54, 0.29

Streeter et al.female: M (SD) ob > nw weight esteem was more heavily influenced by higher female: –1.06 female: –0.47, 0.34
[48] ob = 12, nw = 46 (both genders) BMI than appearance esteem in both sexes, but more so
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to

male: in women.
ob = 9, nw = 44
© 2016 The Author(s). Published by S. Karger GmbH, Freiburg

Watkins et al. male: M (SD) ob > nw / BD: 0.88 BD: 0.40, 0.23
[38] ob = 26, nw = 79 total: 0.42 total: 0.20, 0.23

Table 2 continued on next page

430
Table 2. Continued

Study N Outcome Results Comment d r, SE

dissatisfaction

Silhouette
Benkeser et al. female: prevalence ob > nw almost 3/4 of women dissatisfied; the majority of the 0.30 0.15, 0.06
[49] ob = 973, nw = 828 satisfied 1/4 were overweight or obese; obese more
likely to desire weight loss; results independent of age,
wealth & education
Cachelin et al. female: M (SD) ob > nw results independent of age, SES & dependent on 1.35 0.56, 0.16
[50] ob = 70, nw = 123 acculturation
Gilbert– female: M (SD) ob > nw results independent of SES & education 1.63 0.63, 0.13
Diamond et al. ob = 78, nw = 390
[51]
Santos Silva et female: odds ratio ob > nw results independent of skin color, education & income; female: 1.75 male:female: 0.66, 0.26
al. [52] ob = 155, nw = 493 dependent of age; more women than men dissatisfied 1.61 male: 0.63, 0.21
male: by being heavier than ideal; more men than women
ob = 115, nw = 346 dissatisfied by being lighter than ideal
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Both measures
Johnstone et al. female: M (SED) ob > nw results indicate that females had a greater body / /
[31] ob = 10, nw = 10 (all measures) dissatisfaction score than males
male:
ob = 10, nw = 10
Kakeshita and NA M (SD) ob > nw results independent of age; questionnaire: women had / /
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Sousa Almeida (all measures, both higher dissatisfaction scores compared to men;
[30] genders) difference scores: women had higher dissatisfaction
scores compared to men, but only in the nw group
Vieira et al. female: M (SD) ob > nw participants seeking treatment (not included in this BIAQ: 2.05 BSQ: BIAQ: 0.72, 0.13 BSQ:
[20] ob = 74, nw = 798 (both measures) review) reported significantly higher body image 0.78 0.36, 0.12
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

dissatisfaction compared to women in the non–clinical

group [normal–weight women excluded].
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to

d = Cohen’s d effect size, r = correlation; SE = standard error; M = mean, SD = standard deviation; ob = obese, nw = normal–weight, ow = overweight, NA = no data
available; BS = body satisfaction; AE = appearance evaluation; AO = appearance orientation; UB = upper body; LB = lower body; SES = socioeconomic status; SED = standard
© 2016 The Author(s). Published by S. Karger GmbH, Freiburg

error of the difference; BIAQ = Body Image Assessment Questionnaire.

431
 Obes Facts 2016;9:424–441 432
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Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

Fig. 1. Flow diagram of study selection. Adapted from [26].

participants chose the silhouette that represented how they would like to look (ideal) and
how they currently look (current). Body dissatisfaction was then measured by calculating the
difference between ideal and current silhouette, with greater discrepancies indicating greater
dissatisfaction [39]. In addition to a body image questionnaire, two studies used figure
drawing scales [20, 30]. One study made use of a digital body image technique comparing
both a figure drawing scale and a questionnaire [31].
Finally, while the majority of studies using figure drawing scales measured participants’
weight and height, studies using self-report questionnaires often relied on the subjects’ self-
reported anthropomorphic data (table 1).

Results of Individual Studies and Quality Assessment

Across the studies, individuals with obesity reported higher body dissatisfaction than
individuals with normal weight. Notably however, Lipowska and Lipowski [33] found no
significant difference between women with obesity and women with normal weight in their
Table 3. Risk of bias assessment of included studies

Study Separate Separate ethnic Weight-control BI comorbidities Other BI relevant factors Other BI facets
gender group behavior

Questionnaire
Baceviciene et al. yes Lithuanian no no none no
[37]
Fallon et al. [41] yes yes no no failure to complete items of overweight preoccupation,
demographics or MBSRQ* fitness & health evaluation (via
MBSRQ; [36])
Herbozo et al. [32] female only yes (but not in no no verbal commentary on shape concern, weight concern
results) physical appearance (via EDE-Q; [56])
Hrabosky and Grilo female only yes (Black, Hispanic)eating- & weight depression (via BDI; none shape concern, weight concern
[35] patterns [57]) (via EDE-Q; [56]); distress with
specific body areas (via PASTAS;
[58])
Jun and Choi [44] female only South-Korean weight-control self-rated depression incomplete or missing weight esteem, external
behavior [59] answers* attribution (via BESAA; [45])
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Lipowska and female only Polish practicing sports on a anorexia* (via DSM-IV; appearance orientation (via
Obes Facts 2016;9:424–441

Lipowski [33] professional basis* [60]) MBSRQ; [36]); sexual

attractiveness, weight concern,
physical condition (via BES;
[46])
McCabe and male only yes (but not in binge eating behavior; no not heterosexual* body image importance, ideal
McGreevy [34] results) body change strategies body internalization,
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to lose weight/to sociocultural influences on body

increase muscle size image & body change strategies
Morotti, et al. [29] female only Italian exercise intensely on a neurological*, not married or in a stable perception
regular basis psychiatric*, relationship*; childbirth*,
disorders*, depression pregnancy*; use of
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

(via BDI; [57]) psychoactive or recreational

substances*; (…)
Streeter et al. [48] yes Canadian (Caucasianno no none weight esteem, external
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to

only) attribution (via BESAA; [45])

Watkins et al. [38] male only yes (but not in no no none weight/shape concern
© 2016 The Author(s). Published by S. Karger GmbH, Freiburg

results)

Table 3 continued on next page

433
Table 3. Continued

Study Separate Separate ethnic Weight-control BI comorbidities Other BI relevant factors Other BI facets
gender group behavior

Silhouette
Benkeser et al. [49] female only Ghanaian no no pregnancy*, time post-partum perception
< 3 months*
Cachelin et al. [50] female only Mexican American no no acculturation; pregnancy*, time perception
only post-partum < 4 months*
Gilbert-Diamond et female only Colombian no no high income* perception
al. [51]
Santos Silva et al. yes Brazilians of no no none perception (data not shown)
[52] different skin colors

Both measures
Johnstone et al. [31] no (but test NA diet; weight loss*; no chronic health complains* perception
for group unstable weight (+ 2kg
effect) in the previous 3
months)*; exercise
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regime to change body

shape*
Kakeshita and Sousa yes Brazilian BMI < 18,5 no none perception
Almeida [30] or > 40,0
Vieira et al. [20] female only Portuguese non-clinical sample: no pregnancy*, being (post) investment in BI,
Enrollment in a formal menopausal* preoccupation (both via BSQ;
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weight loss treatment [43])

program*; present
attempt to lose weight
clinical sample:
treatment level*
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

*Listed as exclusion criteria in original article.

BI = body image, EDE-Q = Eating Disorder Examination Questionnaire, BDI = Beck Depression Inventory, PASTAS = Physical Appearance State and Trait Anxiety Scale.
Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
© 2016 The Author(s). Published by S. Karger GmbH, Freiburg
434
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Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

estimation of their sexual attractiveness. They also note that all participants scored moderate
in the MBSRQ and subjects of both groups did not differ in the extent of investment their
appearance. Moreover, Morotti and colleagues [29] reported both groups to be satisfied, with
obese women being more dissatisfied. Further, Benkeser and colleagues [49] found three-
quarters of their sample to be dissatisfied with their body. Interestingly, the majority of the
subjects reporting satisfaction with their body were overweight or obese.
Regarding gender differences, women generally reported being more dissatisfied with
their body image than men [30, 31]. In addition, Fallon and colleagues [41] found men with
overweight and obesity to consistently report more positive body image than women in both
body area satisfaction and the appearance evaluation. Similarly, Baceviciene and colleagues
[37] report both genders to be dissatisfied, particularly the women. They also found no
difference between body image scores of male subjects with normal weight and overweight.
Further, Streeter and colleagues [48] found weight esteem to be more heavily influenced by
higher BMI than appearance esteem in both sexes, but again more so in women. Santos Silva
and colleagues [52] report more women than men to be dissatisfied by being heavier than
ideal, but more men than women being dissatisfied by being lighter than ideal.
Per assessment method, an overview of body dissatisfaction results is provided in table 2.
All of the studies controlled for gender, and a majority either analyzed only one or
reported separate results for different ethnic groups. Moreover, in the majority of question-
naire studies, body image dissatisfaction was assessed using validated instruments that
accounted for the multidimensionality of the construct. Although all studies reported inclusion
or exclusion criteria as well as control variables, body image-related influence factors such as
eating disorders could not be fully ascertained for all of them. Particularly, weight control
behavior and comorbidities such as eating disorders and depression were not collected in a
large proportion of studies. The details of the risk-of-bias assessment are illustrated in table 3.

Synthesis of Results
Questionnaires Body Dissatisfaction
A random-effects model of analysis was used and significant heterogeneity was found
(Q = 117.12, df = 10, p < 0.001; I2 = 91.5%). The overall analysis showed body dissatisfaction
to significantly afflict the group with obesity over the normal-weight group (pooled stan-
dardized difference in means = 0.89, 95% CI = 0.63–1.16, p < 0.001). Based on the literature,
we decided to conduct gender-specific analyses as shown in figure 2.
The pooled effect size of body dissatisfaction for men was 0.58 (95% CI = 0.31–0.85)
compared to 1.18 (95% CI = 0.97–1.40) in women. Subsequent meta-regression revealed a
significant association of female gender and higher body dissatisfaction (b = 0.60, p = 0.007).

Questionnaires Appearance Evaluation

Four studies assessed Appearance Evaluation in women. Again, significant heterogeneity
(Q = 49.4, df = 4, p < 0.001, I² = 93.3%) existed, and a random-effects model was run. The
overall effect size was 1.02 (95% CI = 0.37–1.67).

Figure Drawing Scales

Four studies assessed body dissatisfaction in women with a figure drawing scale. A
random-effects model of analysis was used, and significant heterogeneity was found (Q =
231.5, df = 4, p < 0.001; I2 = 98.3%). The overall analysis showed body dissatisfaction to signif-
icantly more afflict the group with obesity than the normal-weight group (pooled stan-
dardized difference in means = 1.41, 95% CI = 0.57–2.25, p < 0.001).
 Obes Facts 2016;9:424–441 436
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Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

Fig. 2. Meta-analysis of differences in body dissatisfaction questionnaire scores between individuals with
obesity and normal-weight among male and female samples. Abbreviations: 1 = male; 2 = female; SMD = stan-
dardized mean difference; CI = confidence interval; LB = lower body; UB = upper body.

Risk of Bias across Studies

Considering that each meta-analysis performed included less than 10 studies, no sensi-
tivity analysis or assessment of publication bias was performed.

Discussion

This review aimed at systematically exploring the degree of body dissatisfaction in indi-
viduals with obesity compared to individuals with normal weight as well as analyzing gender
differences in body dissatisfaction across studies. In total, 17 studies met the eligibility criteria
for inclusion, and 14 of them provided suitable data for meta-analysis. Meta-analyses showed
body dissatisfaction to significantly more afflict the group with obesity than the normal-
weight group in both studies using questionnaires as well as in those using figure drawing
scales. Further, participants with obesity rated their bodily appearance significantly more
negative in comparison to normal-weight participants. Effect sizes ranged from small to large
in the male samples (d = 0.22–0.89) and from medium to large in the female samples (d =
 Obes Facts 2016;9:424–441 437
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Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
Normal-Weight Individuals: A Systematic Review and Meta-Analysis

0.77–1.37). The meta-regression revealed the difference in body dissatisfaction between

women with obesity and normal weight to be significantly higher than in men.
The two major results of the current systematic review and meta-analyses seem to be in
line with past findings on the topic: body dissatisfaction is greater in persons with obesity
than in normal-weight persons, and compared to their respective normal-weight peers,
women with obesity are more dissatisfied with their bodies than men with obesity. These
differences appear hardly surprising considering that societies’ emphasis on thinness and
beauty particularly affect girls and women [12]. Accordingly, past research shows that
physical appearance seems to be of more importance to females than males [61]. Moreover,
women report significantly higher body dissatisfaction, even if their BMIs are lower than
those of men [62]. This finding was affirmed by a recent cross-national study that reports that
25% of girls were undertaking some measure to lose weight, like dieting, and that they were
more likely to think of themselves as ‘fat’ even though overweight and obesity was higher in
boys [63] Furthermore, a number of studies have concluded that body dissatisfaction in
women seems to be stable across the life span [15].
Due to past research having focused on women, the picture of body dissatisfaction in men
is less clear and as such the subject of a rising number of studies. McCreary and Sasse [64] for
example report that men and boys also seem to increasingly report body dissatisfaction and
that body image is a concern for males over the lifespan [14]. Similarly to women, body dissat-
isfaction in men is linked to low self-esteem, depression, and eating disorders [65], but also
to the use of bodybuilding drugs like anabolic steroids or human growth hormone [66].
Moreover, it is hypothesized that males with overweight or obesity might protect themselves
from body dissatisfaction by considering themselves as ‘big and strong’ rather than ‘fat’ [11].
As a consequence, nuanced approaches to further investigate the relationship between
male gender, weight status and body image are required.
Regarding body dissatisfaction in populations with obesity, our findings are in accor-
dance with previous assumptions, especially concerning women with obesity [11, 19]. Inter-
estingly, not all studies of women with obesity find a relationship between BMI and body
dissatisfaction [8]. Certain factors like weight-related teasing or stigmatizing experiences
appear to play a role in increased body image concerns in this population as well [67].
An important practical implication of these negative obesity-related consequences
pertains to treatment options. Schwartz and Brownell [11] theorize that many individuals
with obesity might consider weight loss to be the optimal way to improve their body image.
Generally, studies examining body image before and after weight loss treatment find improved
body image as a person loses weight and deterioration if the individual regains weight [68].
One particular exception constitutes massive weight loss following bariatric surgery: Body
dissatisfaction due to hanging skin is common and often entails body contouring surgery to
alleviate this ‘new’ dissatisfaction [69]. However, individuals with extreme obesity seeking
bariatric surgery underscore the importance of body dissatisfaction as a motivating factor as
these individuals are impelled by improvements in appearance rather than improvements in
health [8]. Moreover, previous research suggests that, unlike the experience of stigma and
discrimination, a certain level of body dissatisfaction might motivate healthy behavior
changes like increased physical activity [70]. In turn, improved body image is theorized to
facilitate use of psychosocial resources and lead to better adherence to weight management
[71].
Thus, intervention and prevention measures that also take into account the heteroge-
neity of the population with obesity seem to be a promising approach to not only mitigate
negative psychological consequences but also – due to body dissatisfaction’s association with
vital health behaviors – contribute in the treatment against obesity itself.
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Naturally, the current review has limitations. The number of studies that we were able to
include is limited. It seems likely that studies reporting null findings or results contradicting
the general consensus might have been susceptible to publication bias. Moreover, the current
research does not include papers not written in English. Considering the rising prevalence of
obesity in developing nations and cultural differences in body image that may be a promising
approach for prevention and intervention measures [50], insufficient inclusion of potential
findings regarding body image among samples of different ethnicities is particularly unfor-
tunate.
As with any overview, the samples and assessment tools are not identical across studies.
Especially, the use of different measures to determine body dissatisfaction makes compar-
isons rather difficult. While some studies used validated scales, others relied on single items
or figure rating scales to assess body dissatisfaction. Even though past research has shown
high correlations between figure rating scores and body dissatisfaction questionnaires [72],
not all lines of action of psychological research assume self and ideal ratings to be distinct
causes of body dissatisfaction [73]. Next to conceptual differences, there is also debate
regarding the use of difference scores as a measure of body image due to potential method-
ological problems like ambiguity or dimensional reduction (see [74] for details).
Further, we agree with past studies that encourage researchers to make use of measures
developed for and validated in samples with obesity [10].
Another critical point pertains to the assessment of anthropometric data (particularly
subjects’ height and weight). The majority of included studies used self-reported height and
weight data to calculate BMI and determine consequent group assignment. However, while
self-report data may be more time- and cost-effective in comparison to measurement of
weight and height, research shows trends of participants underestimating their weight and
BMI and overestimating their height [75]. This is particularly problematic if the self-reported
BMI is a primary variable of interest and used for example in classification of BMI groups or
evaluations of prevalence of obesity or overweight [76]. Thus, the use of measured anthropo-
metric data is recommended especially in studies analyzing participants with overweight and
obesity [77].
Moreover, possible influences of comorbid conditions in the included studies could not
be controlled for completely. As illustrated in table 3, not all studies explicitly excluded partic-
ipants engaging in weight control behavior or seeking or already undergoing treatment for
weight management. In addition, comorbidities like eating disorders or depression were not
controlled for in all included papers, making conclusions about potential differences in body
dissatisfaction between subsamples with and without comorbid conditions extremely
difficult. Taken together with the fact that the majority of studies analyzed a sample that was
not representative of the respective population, the current findings should be interpreted
with care.
The current review is the first to attempt to quantify differences in body dissatisfaction
between individuals with normal weight and obesity. As such, it gives a first estimation as to
the magnitude of the problem. Our results underline the severity of body dissatisfaction
among individuals with obesity and especially among women.
This is particularly concerning since the prevalence of obesity is increasing worldwide
[78] and consequently puts more individuals at risk of suffering its negative physical and
psychological consequences. As outlined above, interventions to improve body image are not
just beneficial to obesity management but also to psychological well-being in general. Consid-
ering that body dissatisfaction and body perception are associated with partly unfavorable
obesity-related behaviors, like excessive weight loss attempts and binge eating [79], not just
the development of prevention and intervention measures but also their implication in
practice is essential. Furthermore, to account for the complexity of the issue in this group,
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Weinberger et al.: Body Dissatisfaction in Individuals with Obesity Compared to
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more research regarding body image in men and particularly in men with obesity is required.
Also, in light of its multidimensionality, a closer look at other body image facets like body
image perception and their relationship with individual’s weight status seems worthwhile.
Finally, future research on the topic should also include and analyze individuals of different
classes of obesity.

Funding

This work was supported by the Federal Ministry of Education and Research (BMBF), Germany, FKZ:
01EO1501.

Disclosure Statement

All authors declare no conflict of interest.

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