The aim of the present study was to investigate the role of appearance-related sociocultural attitudes conveyed by the media in relation to the development of two common comorbid psychological features of obesity, namely, body dissatisfaction and depression, among participants of a hospital weight loss program in Hungary.
Scores above 15 points on the CES-D Depression Scale indicate significant degree of depression. In the present study the mean of CES-D was 18 points (SD = 9.63), suggesting that the participants are characterised by increased level of depression. According to our results the depression level is higher among women, and individuals with lower education. Such relationship between depression and demographic variables are well-known from the national representative Hungarostudy research (35).
The bi-directional relationship between obesity and depression (5, 9) can be mediated by a number of factors, such as behavioral, cognitive, physiological, and social mechanisms (10). One of the cognitive factors mediating the relationship between obesity and depression is body image dissatisfaction (10, 17, 18). Results of previous studies show that exposure to unrealistic media images and messages has been identified as a risk factor for body dissatisfaction, and mental health concerns (12).
Our results showed that the importance given to appearance-related messages from the media and the perceived pressure from the media to achieve thinness did not directly contribute to the level of depressive symptoms, but led to increased body image dissatisfaction through thin ideal internalization, which in turn was strongly associated with depression. All of these support the need for psychologists and counselors to assess media consumption, body image, any ongoing depressive symptoms or potential for symptoms to develop. Providers should also emphasize how media images are often unrealistic (12).
In contrast to the correlations obtained in previous studies (12, 28), we could not detect a significant linear relationship between BMI and perceived pressures to attain the cultural ideals of physical appearance portrayed by the media. This may be due to the fact that in these studies the young age group (high school students, college students) was examined, while in the present research most of participants are middle-aged, and patients undergo a weight-loss treatment. Although body dissatisfaction was remarkably stable across the adult life span for women, at least until they are quite elderly, the importance of body shape, weight and appearance decreased as women aged (36). Therefore, middle-aged and older women are less likely to compare their shapes with images from the media, and presumably due to this, the perceived pressure did not show a significant relationship with the increase in excess weight.
Nevertheless, our results suggest that body image dissatisfaction is predicted by the subjective importance of information from the media, namely through perceived pressure and through the internalization of the body ideal, and pressure is directly related to body image dissatisfaction in addition to the indirect path through thin ideal internalization. Body image dissatisfaction, in turn, partially mediates the relationship between gender and depressive symptoms, as well as the degree of obesity and depressive symptoms.
It should be also emphasized that in the case of the reciprocal relationship between obesity and depression (5, 9) a circular causal relationship can be assumed, including through health behaviors. For example, in a population-based Finnish study it was found that emotional eating and exercise-related self-efficacy play a partial mediating role between depression and obesity (37). In terms of eating behavior, it can also be said that depression affects unhealthy food choices in two ways. This is because higher levels of depression are associated not only with higher consumption of sweets, but also with lower consumption of vegetables and fruit (38).
In the present research, we did not find a meaningful association between appearance-related sociocultural attitudes and depression. Based on our results, it appears that depressive symptoms may be exacerbated in patients with overweight participating in multicomponent hospital weight loss therapy in association with other factors not examined by us. However, sociocultural attitudes related to appearance also play a significant role in the development of body dissatisfaction in the present study, which in turn is a correlate of depression. All this suggests that it is worth considering this topic for those taking weight loss treatments, as depression can be associated with behaviors that may contribute to the maintenance or exacerbation of overweight. Therefore, efforts should be made to eliminate or at least mitigate the triggers for depression.
All of this can be accomplished in everyday medical practice as follows. Assessing body dissatisfaction can be accomplished with a number of easy, quick-to-fill questionnaires, or even by visual analog scales. If body dissatisfaction is present to a significant extent, its causes should be mapped out, and if media messages about appearance and sociocultural pressure for weight loss play a significant role, education can be given. It may be proposed in this context to increase awareness and to explore of media influences regarding cultural attitudes related to “ideal” body. Cognitive ways to reduce body dissatisfaction are presented in several therapeutic manuals (e.g., (19, 39)). The first step is to educate patients about the essential differences between body image and appearance, the consequences of a negative body image during everyday life and the pursuit of weight control, and finally that of successful long-term weight management. The improvement of the body image is facilitated by the reduction of social pressure, the increase of the personal significance of other areas of self-esteem and the reduction of the behavioral expression of the negative body image. An example of the latter is the examination of the body in a mirror, or the cognitive restructuring of negative automatic thoughts about the body (19). Since depressive symptoms go hand in hand with body dissatisfaction, increasing body satisfaction can help alleviate those symptoms. However, in the case of low and moderate or even severe depression, the use of low-intensity psychological interventions could be useful as part of a stepped care model (40).
Several limitations of the present study should be mentioned. We do not have any data about those people who refused participation in the study, thus we are not aware of the nature of the potential selection bias. Generalizability of our results is limited to a non-invasive, professional inpatient weight loss treatment program for people with excess weight. Future studies should include a wider variety of groups and wider segments of the population. There was no objective measure of anthropometric data, therefore, the BMI scores should be interpreted carefully. The cross-sectional study design does not permit causal conclusions; in addition, alternative models are conceivable. The SATAQ-3 measure does not include more current forms of media, such as the Internet (e.g., YouTube, online magazines, fashion blogs), and future studies should examine media consumption and perceived pressures related to body image as it pertains to Internet media.
Strengths of this study include the use of structural equation modeling to test the hypothesized model when the potential background variables (gender, age, education) were controlled. The data collection was carried out in a well-defined large sample derived from a clinical population. To our knowledge, this is also the first study that has examined the sociocultural determinants of depressive symptoms among participants of a hospital weight loss program.