Association of Body Image and Body Mass Index with psychological outcomes in obese patients.

Purpose The purpose of this study was to test whether higher dissatisfaction with one's own body image, majorly than the body mass index (BMI), may be associated with higher levels of psychopathological aspects, hopelessness feelings, and psychophysical health. Methods Fifty-nine patients undergoing bariatric surgery lled out the Symptom Checklist-90-Revised, the Body Uneasiness Test, the 12-item Short Form Survey, the Beck Inventory Scale II, and the Beck Hopelessness Scale. Correlations and multiple regressions between measures were performed. Results Dissatisfaction with the perception of one's own body image was strongly correlated with a worse psychophysiological health. On the contrary, BMI showed no signicant correlation with the previous variables. Furthermore, the perception of one's own body image signicantly predicted the state of psychological health. The ndings of the present study showed a more relevant role of body image compared to the BMI in the association with psychological outcomes suggesting the importance to consider body image in the assessment and treatment of obese patients.


Introduction
Bariatric surgery is currently the gold standard for the treatment of morbid obesity and its comorbidities, leading to an improvement in psychophysical wellbeing [1]. Concerns about body image can signi cantly affect an individual with obesity and it is expected to have a negative clinical impact in uencing their behaviour, quality of life and psychological health [2]. These can be some of the main motivations for weight loss in individuals with obesity [3] and a factor that motivates the decision for in treatment-seeking.
Many previous studies investigated the association between the weight and the psychological aspects in obese patients. Most of the studies showed a correlation with psychological aspects as anxiety, depression, low self-con dence, alexithymia, and eating disorders in overweight and obese patients [4][5][6][7][8].
Furthermore, the literature focuses on the perception of one's own body image after bariatric surgery, reporting different results. One recent study [9] examined psychological well-being and body image in a sample of pre-bariatric surgery patients and in those with 1-year follow-up, showing a body image and psychological well-being improved in most patients. In general, obese patients pre or post bariatric surgery showed a clear association between body image perception and psychological state [10][11][12][13].
Instead, a recent review [14] on the goal of examining body image changes in patients with obesity pre and post bariatric surgery, shows that in most cases the perception of one's body image does not change between pre and post bariatric surgery suggesting that body image is not directly associated with the The correlational analyses (Pearson's r) among the weight, BMI and BUT with the psychological outcomes (SCL-90-R, SF-12, BDI II and BHS) are reported in Table 2. p= Weight was only negatively correlated with SCL-90-R subscale of somatisation, while BMI was negatively correlated with Global Severity Index of SCL-90-R, and SCL-90-R subscales of somatisation, obsessiveness-compulsiveness, and depression (see Table 2).
BUT-A Global Severity Index and most of its subscales were positively correlated with all SCL-90-R scales, BDI II and BHS and was negatively correlated with SF-12 scales (see Table 2). Also, BUT-B Positive Symptom Distress Index, similarly to the BUT-B Positive Symptom Total, was positively correlated with all SCL-90-R scale, and BDI II, however it did not show signi cant correlation with BHS. Moreover BUT-B Positive Symptom Total was negatively correlated with SF-12 scales (see Table 2).
The multiple regression analyses performed on the psychological outcomes (SCL-90-R Global Severity Index, SCL-90-R Positive Symptom Total, SF-12 Physic Health, SF-12 Mental Health, BDI II, and BHS) with BMI, BUT-A Global Severity Index and BUT-B Positive Symptom Distress Index as predictors showed the following results. As regard to the SCL-90-R Global Severity Index, the regression model was signi cant, and the BUT-A Global Severity Index was a signi cant predictor (see Figure 1). As regard to the SCL-90-R Positive Symptom Total, the regression model was signi cant, and the BUT-A Global Severity Index was a signi cant predictor (see Figure 1). As regard to the SF-12 Physical Health, the regression model was not signi cant (see Figure 1). Instead, as regard to the SF-12 mental Health, the regression model was signi cant, and the BUT-A Global Severity Index was a signi cant predictor (see Figure 1). As regard to the BDI II, the regression model was signi cant, and the BUT-A Global Severity Index was a signi cant predictor (see Figure 1). Finally, as regard to the BHS, the regression model was signi cant, and the BUT-A Global Severity Index was a signi cant predictor (see Figure 1).

Discussion
This study investigated the association between the perception of one's own body image in relation to aspects of psychophysical health in a preliminary phase of bariatric surgery.
The main nding was that a higher dissatisfaction with the perception of one's own body image was strongly associated with higher psychological symptoms and a lower psychological health. This nding is consistent with the result of a descriptive study that has investigated this kind of positive and direct relationship between the body image and the psychological well-being [26]. A higher satisfaction of one's own body image corresponds to a greater and better psychological health. This result could be explained by the fact that, due to the multidimensional and complexity of body image, there may be several factors that in uence the development of a negative body image, mainly in people suffering from obesity [27]. These ndings seem to support that the perception of one's own body image is not only dependent on a possible mismatch between perceived and desired body shapes, but also on the presence of mental images, emotions and thoughts that lead to associate body appearance with personal value in the social context [14]. Indeed, these people are often made fun of for their weight and appearance, the social stigma and discrimination can worse low self-esteem and depression [28].
Another nding of the present study was that the BMI did not show any signi cant association with the psychopathological outcome and with quality of life. This result suggests that the effective real physical weight did not represent a risk factor per se. In fact, despite previous studies on obese patients showed strong association between the BMI and the psychopathological state [29][30][31], the present study showed only a few correlations between BMI and some psychological variables. Moreover, in the regression models the BMI, inserted as predictor with the two body image measures, did not show any signi cant effect on the psychological outcome. These ndings suggest a greater relevance of the body image on the psychological state compared to the BMI. A possible explanation of this result seems to be that the experience of one's own weight is majorly related to the expectations that the individual and the others have about body image more than to the objective weight with important clinical implications. This perspective motivates the consideration of body image as a crucial variable in the outcome of interventions focused for the treatment of obesity.
In the present study, only the dissatisfaction for body image was associated with psychological outcomes (BUT-A), while the hate for a speci c part of one's own body (BUT-B) showed lower grades of correlation with the psychological outcomes and when inserted in the regression models, it did not show any signi cant effects. This result suggests that the preoccupation for speci c parts of one's own body seems to have less relevant role compared to the global dissatisfaction for body image in the relationship with the psychological outcomes.
In contrast with previous studies [10,11], the present study did not show high presence of hopelessness in the obese sample. This result could be explained by the fact that the participants were waiting for a bariatric surgery to solve their obesity. This expectation could in uence their feelings of hopelessness. It seems relevant to investigate the evolution of hopelessness after the bariatric surgery to identify risk factors in its increase.
Finally, the participants in our study, obese patients undergoing bariatric surgery, showed well-de ned psychological aspects in the pre-operative phase. They reported moderate and severe levels of psychological distress, especially in the somatic, obsessive-compulsive, interpersonal hypersensitivity, and depressive aspects. Furthermore, regarding the perception of their own body image, the participants showed a high level of discomfort, particularly on aspects related to weight phobia and preoccupation with their body image. Finally, they reported low levels of both physical and mental well-being and a mild presence of hopelessness feelings. This is the rst study that investigated the relative role of body image compared to body mass index in the association with psychological outcome in obese patients.
This study had some limitations. The rst was that self-report measures were used. The second limitation was found to be the lack of gender balance in the participant group. Finally, the sample was recruited from a single health-care centre.
What is already known on this subject?
The body image dissatisfaction is more common in people with severe obesity, particularly those who choose bariatric surgery to cure their obesity.
What does this study add?
The present study suggests a more relevant role of body image compared to the BMI in the association with psychological outcomes.