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Medscape J Med. 2008; 10(5): 119.
Published online May 19, 2008.
PMCID: PMC2438482

Relationships Between Body Size Satisfaction and Weight Control Practices Among US Adults

Abstract

Context

Few studies of US adults have specifically examined body size satisfaction

Objectives

Describe correlates of body size satisfaction and examine whether satisfaction was associated with trying to lose weight or specific weight control practices among US adults using a national sample of women and men.

Design, Setting & Participants

The National Physical Activity and Weight Loss Survey (NPAWLS) was a population-based, cross-sectional telephone survey of US adults (n = 9740).

Main Outcome Measures

Participants reported their weight, height, body size satisfaction, and weight loss practices. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each dependent variable.

Results

Among women and men, higher body mass index (BMI) was significantly associated with body size dissatisfaction. Dissatisfaction, compared with being very satisfied, was positively associated with trying to lose weight among women and men. This association was modified by BMI for women (OR normal weight = 19.69, overweight = 8.79, obese = 4.05; P < .01 for interaction) but not men (OR normal weight = 8.72, overweight = 10.50, obese = 7.86; P = 0.93 for interaction). Compared with women who were very satisfied, dissatisfied women used diet more (OR = 2.03), but not physical activity/exercise (OR = 0.55) or both strategies (OR = 0.63), to try to lose weight. Men who were somewhat satisfied, compared with those who were very satisfied, were more likely to use physical activity/exercise (OR = 1.64) and both diet and physical activity/exercise (OR = 1.54) to try to lose weight.

Conclusion

These findings highlight the sex differences in body size satisfaction, actions taken to try to lose weight, and the importance of considering body size satisfaction when designing weight-management programs.

Introduction

Currently, two thirds of the US adult population is overweight, and almost one third is obese.[1] As excess weight is a risk factor for conditions such as cardiovascular disease, type 2 diabetes, cancer, and mental illness, and it is a major public health problem.[2,3] Obesity and overweight are also associated with decreased quality of life and poor body image.[4,5] Body image is a multidimensional construct central to emotional well-being.[6,7] It involves subjective evaluations of one's body, which can be related to weight-loss concern and behavior.[6,7] Satisfaction with body size is the attitudinal component of body image, indicating personal feelings and thoughts about one's body.[6,7] While most of the body size satisfaction literature addresses weight concerns, it could also encompass feelings about one's height or specific body areas.[8] Body size satisfaction is a factor associated with self-esteem, and research indicates that it is associated with health-risk behaviors such as cigarette smoking, unhealthy nutrition patterns, and physical inactivity.[8] Understanding the factors related to body size satisfaction can help improve public health messages that promote healthy weight-loss behaviors.

While many studies of US adults have assessed components of body image and related sociodemographic factors, fewer have specifically examined body size satisfaction. Most of the research has focused on women and found that lower body mass index (BMI), increasing age, and better health are generally positively associated with body size satisfaction.[9] Women typically view themselves as heavier than they actually are and desire a thinner figure,[10,11] with more reporting dissatisfaction with their bodies than men in the same BMI category.[12] While most overweight and obese women desire to lose weight, some report acceptance or satisfaction with their body size.[13,14] This has been found particularly among black women, and to a lesser extent, Hispanic women.[7,13,14]

Fewer studies have examined body size satisfaction among men. Research suggests that men tend to be more satisfied than women with their body size or weight, even if they are overweight.[12,15] While height or other body areas may influence men's body size satisfaction available studies have focused on weight. For men, body size does not appear to affect their self-perceptions or body image as much as it does for women, which may account for discrepancies between the sexes in weight-control behaviors.[16] In addition, unlike women, men who are dissatisfied with their size or weight may wish to gain muscle rather than simply lose excess fat, as the culturally ideal male body type tends to be lean and muscular.[16,17] While these studies have begun to examine men's body size satisfaction, it is an area which requires more research. As such, one of this paper's distinguishing factors is the inclusion of men in the study sample.

Few nationally representative studies have assessed the notion that body size dissatisfaction is associated with attempting to lose weight, with available studies focusing on women, clinical populations, or international samples.[1113,18] While many US women and men desire to weigh less[19] not everyone who is overweight or obese tries to lose weight.[20] The associations between body size satisfaction and weight-loss practices are complex and depend on a variety of factors, such as actual or perceived body size,[13] psychological factors,[12] and health status,[13] and they may differ by race and sex.[14,15,21] In general, more people who report high dissatisfaction with their body size are likely to indicate they are trying to lose weight than those with low or no dissatisfaction.[12,13]

Among those who are attempting to lose weight, there has been little description of how body size satisfaction influences specific practices, such as dieting and exercising. Traditionally, it has been reported that women who are dissatisfied with their body size or image tend to choose diet as a weight-loss strategy,[18] while men dissatisfied with their bodies or body image focus more on exercise and diet in order to build muscle and lose weight.[16,17] Furthermore, dissatisfaction with body size may lead women to avoid physical activity.[22] However, these findings have not been consistent in all studies, and body size satisfaction was not always the specific focus of the studies.[15,17,23]

Because past studies have generally focused on women or smaller subgroups of dieters or clinical populations and because relatively little is known of the associations between body size satisfaction and weight-loss strategies, using a population-based sample of US adults, we examined data from the National Physical Activity and Weight Loss Survey (NPAWLS), looking at women and men separately. These analyses were designed with 3 purposes in mind: (1) to describe the prevalence and correlates of body size dissatisfaction in a national sample, (2) to examine the association between satisfaction and trying to lose weight, and (3) to examine the association between satisfaction and specific weight-loss practices (diet, physical activity, or both).

Research Methods and Procedures

Survey Design

NPAWLS was an observational, nationwide, cross-sectional telephone survey conducted by the University of South Carolina Prevention Research Center from September to December 2002 that obtained data on individual physical activity and nutrition behaviors. Researchers from the Centers for Disease Control and Prevention assisted with survey design. The protocol and survey were approved by the University of South Carolina's Institutional Review Board. The survey used a list-assisted, random-digit-dial sample of telephone-equipped US households, similar to the Behavioral Risk Factor Surveillance System (BRFSS) survey.[24] In addition, a replicate design mixing telephone numbers from 3 independent samples was used to achieve target percentages for non-Hispanic black and Hispanic respondents.

Analytic Sample

NPAWLS had a total of 11,211 complete interviews, with a Council on American Survey Research Organizations response rate of 30.9%,[25] which is calculated using completed interviews in the numerator and the estimated number of eligible units in the sample in the denominator. The cooperation rate was 51.4%, which is the proportion of all respondents interviewed out of all eligible persons contacted. Of the completed interviews, 43 had a missing value or refused to answer the question on body size satisfaction, 63 had missing data on whether the respondent was trying to lose weight and what strategies she/he was using to control or lose weight, and 849 did not provide anthropometric information (height or weight). We excluded 417 persons whose socioeconomic or demographic information was incomplete and 99 women who were pregnant. We analyzed the data from the remaining 9740 adults (5436 women and 4304 men).

Measures

Body size satisfaction. Body size satisfaction was assessed using the following question, which has been used in previous studies[12,13]: “How do you feel about your body size right now? Would you say: very satisfied, somewhat satisfied, not satisfied, or don't know/not sure?” When a respondent did not wish to answer, a response of “refused” was recorded. When body size satisfaction was assessed as the dependent variable, the responses were collapsed into 2 categories: satisfied (very and somewhat satisfied) and dissatisfied.[13]

Weight control practices. Participants were asked about weight control using a question created for this survey: “Are you now trying to lose weight, gain weight, stay about the same, or are you not trying to do anything about your weight?” There were 2455 women and 1388 men trying to lose weight. If they were trying to lose weight, they were asked, “Are you using physical activity or exercise to lose weight?” (yes, no, don't know/not sure, or participant refusal) and “Are you eating either fewer calories or less fat or both to lose weight?” (yes, fewer calories; yes, less fat; yes, fewer calories and less fat; no; don't know/not sure; or participant refusal). Having any “yes” responses to this latter question was considered as using diet to lose weight. Participants who answered “yes” on the physical activity/exercise question and also “yes” on the diet question were considered as using both strategies to try to lose weight.

Covariates. General health status was assessed by measuring responses to the question: “Would you say that in general your health is: excellent, very good, good, fair, or poor, and don't know/not sure,” or participant refusal. At the end of the survey, participants were asked to report their height and weight, from which their BMI was calculated (weight in kilograms divided by height in meters squared, expressed as kg/m2). BMI was categorized as normal weight (including underweight) (BMI < 25.0), overweight (BMI 25.0–29.9), or obese (BMI >/ = 30.0).[3] Demographic and socioeconomic data were also gathered. Age was categorized into 10-year groups for those 18–69, and those aged 70 years or older were combined into 1 group. Race/ethnicity was grouped as non-Hispanic white, non-Hispanic black, Hispanic/Latino, and other. Education was grouped as less than high school, high school graduate, some college, and college graduate. Marital status was grouped as never married, currently married (also includes members of an unmarried couple), and previously married. Region of residence was grouped as Northeast, Midwest, South, and West, according to the US Census regions.[26] The questions about general health status, race/ethnicity, age, education, and marital status were the same as those used on the 2002 BRFSS.[24]

Statistical Analysis

SAS (Version 9.1, SAS Institute Inc., Cary, North Carolina) and SUDAAN (Release 9.0, Research Triangle Institute, Research Triangle Park, North Carolina) were used in the statistical analysis. SUDAAN was used to account for the complex sampling design. Findings were based on weighted observations that reflected the probability of selection, nonresponse, and poststratification adjustments. All significance levels were set at P < .05. Because weight loss practice and body image constructs have been shown to differ by sex,[8,27] the results are presented for women and men separately. All ORs (with 95% CIs) were adjusted for the following covariates in all models: age, race/ethnicity, education, region, general health status, and marital status.

For our first objective, we determined the unadjusted and adjusted odds of body size dissatisfaction (very and somewhat satisfied vs dissatisfied). For our second objective, we determined the unadjusted and adjusted odds of trying to lose weight in relation to body size satisfaction (very satisfied, somewhat satisfied, and dissatisfied). On the basis of previous findings,[12] we tested whether BMI (normal, overweight, and obese) modified the association between trying to lose weight and body size satisfaction. We added an interaction term to the model and this interaction was significant among women, and therefore we stratified by the 3 BMI groups. For our third objective, we determined the unadjusted and adjusted odds of using specific weight-loss strategies (dieting, exercising, and both strategies together) in relation to body size satisfaction (very satisfied, somewhat satisfied, and dissatisfied).

Results

Our study sample included 5436 (weighted percentage: 50.6%) women and 4304 (weighted percentage: 49.4%) men. Over half of the sample (56.9%) was classified as being overweight (36.2%) or obese (20.7%) (Table 1). Overall, 18.0% of the respondents reported being dissatisfied with their body size (women 23.6%; men 12.6%), 48.4% were somewhat satisfied (women 48.3%; men 48.5%), and 33.6% were very satisfied (women 28.1%; men 38.9%).

Table 1
Characteristics of the Study Population, National Physical Activity and Weight Loss Survey, 2002

Body size dissatisfaction differed by age, race/ethnicity, education, general health status, and BMI, with a greater proportion of women reporting dissatisfaction than men at all levels on each of these variables (Table 2). In adjusted analyses, older women (aged 60–69 and ≥ 70 years) showed significantly lower odds of dissatisfaction than women aged 18–29 years. Compared with men aged 18–29 years, men aged 50–59 years had significantly higher odds of dissatisfaction. Black and Hispanic/Latina women had significantly lower odds of being dissatisfied than white women (ORs: 0.68 and 0.64, respectively). The trends for Hispanic/Latino and “other” men were similar to those for black and Hispanic/Latina women, but the ORs were not significant. For women and men, after adjusting for the other variables, those with less than a high school education had significantly lower odds of dissatisfaction than college graduates. General health status was significantly inversely associated with dissatisfaction for both women and men. BMI category was the variable most strongly associated with body size dissatisfaction, with a similar positive association for women and men; as BMI increased, the odds of dissatisfaction increased.

Table 2
Prevalence and Odds Ratios of Body Size Satisfaction by S and Demographic Characteristics, Health Status, and BMI Among US Adults, National Physical Activity and Weight Loss Survey, 2002

Trying to lose weight, common among women and men, was associated with body size dissatisfaction (Table 3). For women, BMI was found to modify the association between dissatisfaction and trying to lose weight (adjusted OR normal weight = 19.69, overweight = 8.79, obese = 4.05, compared with very satisfied; P < .01 for interaction between dissatisfaction and BMI category). By contrast, trying to lose weight was not modified by BMI for men (OR normal weight = 8.72, overweight = 10.50, obese = 7.86, compared with very satisfied; P = .93 for interaction between dissatisfaction and BMI category).

Table 3
Odds of Trying to Lose Weight in Relation to Body Size Satisfaction, by BMI Category, Among US Adults, National Physical Activity and Weight Loss Survey, 2002

The associations between body size satisfaction and weight-loss strategies among those trying to lose weight are shown in Table 4 for the weight-loss strategies of diet, physical activity/exercise, and the combination of diet and physical activity/exercise, for women and men. Results were not stratified by BMI status because we were unable to statistically test for the interaction between satisfaction and BMI due to an insufficient sample size, especially dissatisfied (n = 11) and very satisfied (n = 32) normal-weight men, very satisfied obese men (n = 39), and very satisfied obese women (n = 32).

Table 4
Odds of Using Different Weight-Loss Strategies in Relation to Body Size Satisfaction Among US Adults Trying to Lose Weight, National Physical Activity and Weight Loss Survey, 2002

The unadjusted odds of using diet among dissatisfied and somewhat satisfied women and men were significantly greater than the odds for the very satisfied referent groups (Table 4). After adjusting for covariates, however, these associations remained significant only for women (OR dissatisfied = 2.03, OR somewhat satisfied = 2.11). The use of physical activity/exercise to try to lose weight differed by sex, mainly among those who were very satisfied with their body size. In that category, 75.5% of women but only 67.3% of men used physical activity/exercise to try to lose weight. Women who were dissatisfied, compared with those who were very satisfied, had significantly lower odds of using physical activity/exercise (OR = 0.55), while men who were somewhat satisfied, compared with those who were very satisfied, had significantly higher odds of using physical activity/exercise (OR = 1.64). The patterns of association for using both diet and physical activity/exercise to try to lose weight were similar to those found for using physical activity/exercise only.

Discussion

This study of adult Americans showed that women were around twice as likely as men to be dissatisfied with their body size. Having worse general health and a higher BMI were factors associated with dissatisfaction, and dissatisfaction differed by race/ethnicity among women. Body size dissatisfaction was positively associated with trying to lose weight, and this relationship was modified by BMI for women but not for men. Assessment of weight-management strategies found that among those trying to lose weight, women who were dissatisfied with their body size were more likely than those very satisfied to use diet to try to lose weight, but comparable findings were not obtained for using physical activity/exercise or both strategies. A different pattern emerged for men: those who were somewhat satisfied, compared with those very satisfied, were more likely to try to lose weight using physical activity/exercise or diet and physical activity/exercise together. By determining these weight-loss strategy patterns among men, this study adds to the body size satisfaction literature, which often does not include men in study samples.

In examining the prevalence and correlates of body size satisfaction, the first goal of this study, we obtained results similar to findings from other studies.[7,9,1215,18,21,22] Our findings are consistent with previous research that has found women to have greater dissatisfaction than men across age, racial, or educational groups.[12,15] An interesting pattern that emerged in looking at age was that women showed less dissatisfaction with older age, whereas men showed greater dissatisfaction at older ages. This finding could speak to the notion that men may hold on to the muscular, lean body ideal as they age, whereas women may be less focused on body size satisfaction as they age. Our results also indicated that patterns of body size satisfaction varied by race among women, but not men. Consistent with previous findings,[12,21,28] black women in our study showed greater body size satisfaction than white women. Hispanic/Latina women were also more satisfied with their bodies or body image than white women, which agrees with some[28,29] but not all[30] earlier studies, although these studies mainly examined body image rather than body size satisfaction. Some studies have observed that black and Hispanic/Latino men are also more satisfied with their bodies or body image,[10,14] while others have shown no ethnic differences among men.[30]

One apparently paradoxical finding from our study was that, compared with white women, black and Hispanic/Latina women were more likely to be satisfied with their bodies even though, as seen in other national surveys, they are more likely to be overweight or obese. Estimates from 1999–2004 were that 81.6% of black women and 75.4% of Mexican American women in the United States were overweight or obese, in contrast to 58.0% of white women.[1] This contrast between satisfaction and actual size implies that women can be overweight and obese without having a negative body image or dissatisfaction with body size. In the present study, we found that dissatisfaction with body size was associated with trying to lose weight, and there was an interaction between satisfaction and BMI for women but not for men. One issue to point out is that it is possible that height was a factor associated with body size satisfaction, particularly for men. However, in our data, it did not appear that people were answering the body size satisfaction question based on height. As the magnitude of the association between dissatisfaction and trying to lose weight was not as great among obese women as it was among normal weight and overweight women, we might conclude that other factors such as comorbidities contribute to the high prevalence of trying to lose weight among obese women who are very satisfied with their body or body image.[12,31] However, given the high prevalence of dissatisfied women and men trying to lose weight, particularly those overweight and obese, dissatisfaction appears to be a strong motivator for weight loss. Thus, when planning weight-loss programs for overweight and obese women and men, paying attention to the degree of body size dissatisfaction as a motivating factor may be an important and useful consideration for successful interventions.

For this study's third and perhaps most innovative goal, we found that dissatisfied women, compared with very satisfied women, used diet more, but used physical activity/exercise and both strategies less. By contrast, we found that men who were somewhat satisfied, more than those very satisfied, tended to report using physical activity/exercise and both diet and physical activity/exercise. Our results for using both strategies appear to be driven by the use of physical activity/exercise. Our study found that dissatisfied women and men both used diet at a high rate (92.1% and 89.7%, respectively), percentages similar to a previous finding.[17] In addition, we found that the use of physical activity/exercise was similar between dissatisfied and somewhat satisfied women and men, which contrasts with other studies' findings that women may use physical activity/exercise to a greater degree than men.[15] Somewhat to our surprise, in our study, women who were very satisfied with their body size had a higher prevalence of using physical activity/exercise (75.5%) than men who were very satisfied (67.3%). Because of the cross-sectional nature of the paper, we cannot determine whether the use of physical activity/exercise has led to greater body size satisfaction.

An important question for future research will be to understand why women who are less satisfied with their body size are more likely to diet but not use physical activity/exercise or both strategies to try to lose weight. Research has shown that women with lower body image perception tend to diet more and engage in physical activity/exercise less than men of the same body image category.[32] To our knowledge, however, no studies have directly assessed the link between why body size satisfaction is differentially associated with specific weight-loss strategies. Understanding these interrelationships could prove useful in future research and interventions. Once more is known about why body size dissatisfaction may act as a barrier to exercising for women, or as a catalyst for dieting, more effective weight-loss interventions can be created according to varying levels of satisfaction. Effective weight-loss strategies may be different depending on levels of body size satisfaction.

This study has at least 4 limitations, some of which are inherent in the survey's methodology. First, the survey was administered by telephone, and so those without landline telephones and those living in institutions were not part of the sampling frame.[25] Furthermore, telephone surveys may undersample ethnic minorities and low-income persons.[13] However, to address these issues, NPAWLS was conducted in English and Spanish, and it was designed to oversample black and Hispanic populations.[25,33] The survey's large sample and the fact that it was population based lend credibility to the results. Next NPAWLS had a low response rate (30.9%), which could limit the generalizability of these results.[4,33] However, our findings of overweight (36.9%) and obesity (20.7%) in 2002 are consistent with those of the 2002 BRFSS,[24] the “gold standard” telephone survey (37.0% overweight, 22.1% obesity). Third, all data were self-reported, which may have led to misclassification of height, weight, and physical activity/exercise behaviors, as self-reported height and physical activity/exercise tend to be overestimated and weight underestimated.[34,35] The verbal response to the question on body size satisfaction, while suitable for a large-scale telephone survey, may be limited in its ability to assess a global view of body image; future studies could use it along with other measures of body size satisfaction and body image that assess the multidimensional nature of these constructs, such as the Multidimensional Body-Self Relations Questionnaire,[36] silhouette rating scales of perceived vs ideal body shape,[37] and reasons for wishing to lose weight.[23]

Finally, while we observed that there were associations between body size satisfaction and weight-loss practices, we are unable to determine the direction of association from these cross-sectional survey data. It is unclear whether body size dissatisfaction leads to trying to lose weight or whether trying to lose weight gives rise to feelings of dissatisfaction. Future longitudinal studies could better address the directionality of the associations.

With the high prevalence of obesity in the United States and its negative physical and mental health consequences,[2] it is important to understand the factors associated with feelings about body size and related weight-loss behaviors. Accounting for the effects of peoples' attitudes about their body size should be considered important in future surveys, interventions, and public health efforts to reduce obesity. If people are dissatisfied with their body size, they may be ready to lose weight, particularly by dieting. Goals of future interventions should not be to increase body size dissatisfaction, but to work with those who are dissatisfied to promote appropriate weight-control behaviors and remove barriers to weight loss and the attainment of a healthy weight.

Acknowledgements

The authors would like to thank Deborah A. Jones for her oversight of the project and Heather Bowles for data management.

Notes

Disclaimer

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Abbreviation Notes

National Physical Activity and Weight Loss Survey (NPAWLS), body mass index (BMI), Behavioral Risk Factor Surveillance System (BRFSS), odds ratio (OR), confidence interval (CI), standard error (SE)

Footnotes

Reader Comments on: Relationships Between Body Size Satisfaction and Weight Control Practices Among US Adults See reader comments on this article and provide your own.

Readers are encouraged to respond to the author at ude.hpshj@etsllimr or to George Lundberg, MD, Editor in Chief of The Medscape Journal of Medicine, for the editor's eyes only or for possible publication as an actual Letter in the Medscape Journal via email: ten.epacsdem@grebdnulg

Contributor Information

Rachel A. Millstein, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia.

Susan A. Carlson, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia.

Janet E. Fulton, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia.

Deborah A. Galuska, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia.

Jian Zhang, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia.

Heidi M. Blanck, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia.

Barbara E. Ainsworth, Department of Exercise and Wellness, Arizona State University, Mesa, Arizona.

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