research paper on body image

ORIGINAL RESEARCH article

Body dissatisfaction, importance of appearance, and body appreciation in men and women over the lifespan.

• 1 Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Osnabrück University, Osnabrück, Germany
• 2 Department of Research Methodology, Diagnostics & Evaluation, Institute of Psychology, Osnabrück University, Osnabrück, Germany
• 3 Clinical Psychology and Psychotherapy, Institute of Psychology, University of Münster, Münster, Germany

Body image disturbance is associated with several mental disorders. Previous research on body image has focused mostly on women, largely neglecting body image in men. Moreover, only a small number of studies have conducted gender comparisons of body image over the lifespan and included participants aged 50 years and older. With regard to measurement, body image has often been assessed only in terms of body dissatisfaction, disregarding further aspects such as body appreciation or the importance of appearance. The aim of this cross-sectional study was to explore different aspects of body image in the general German-speaking population and to compare men and women of various ages. Participants completed an online survey comprising questionnaires about body image. Body dissatisfaction, importance of appearance, the number of hours per day participants would invest and the number of years they would sacrifice to achieve their ideal appearance, and body appreciation were assessed and analyzed with respect to gender and age differences. We hypothesized that body dissatisfaction and importance of appearance would be higher in women than in men, that body dissatisfaction would remain stable across age in women, and that importance of appearance would be lower in older women compared to younger women. Body appreciation was predicted to be higher in men than in women. General and generalized linear models were used to examine the impact of age and gender. In line with our hypotheses, body dissatisfaction was higher in women than in men and was unaffected by age in women, and importance of appearance was higher in women than in men. However, only in men did age predict a lower level of the importance of appearance. Compared to men, women stated that they would invest more hours of their lives to achieve their ideal appearance. For both genders, age was a predictor of the number of years participants would sacrifice to achieve their ideal appearance. Contrary to our assumption, body appreciation improved and was higher in women across all ages than in men. The results seem to suggest that men’s and women’s body image are dissimilar and appear to vary across different ages.

Introduction

Many people are concerned about at least one part of their body ( 1 ). A negative cognitive evaluation of one’s body can be an expression of a negative body image ( 2 ). Body image is conceptualized as a multidimensional construct, which encompasses a behavioral component involving body-related behaviors (e.g. checking behaviors), a perceptual component involving the perception of body characteristics (e.g. estimation of one’s body size or weight), and a cognitive-affective component involving cognitions, attitudes, and feelings toward one’s body ( 3 – 6 ).

Negative thoughts and feelings about one’s body are defined as body dissatisfaction ( 7 ), which is considered to be the most important global measure of stress related to the body ( 4 ). Body dissatisfaction has been found to be a predictor for the development of an eating disorder ( 8 ) and occurs in individuals with different mental disorders, such as binge eating disorder or social anxiety disorder (e.g. 6 , 9 ), as well as in healthy persons (e.g. 10 – 12 ). It represents one of the two poles of the satisfaction-dissatisfaction continuum of body image disturbance ( 4 ), which encompasses measures of satisfaction (e.g. being satisfied with particular body areas; e.g. 13 ) and dissatisfaction (e.g. weight or muscle dissatisfaction; e.g. 14 , 15 ).

Another construct which is related to both the cognitive-affective and the behavioral component is the importance of appearance, also termed appearance orientation, which reflects the cognitive-behavioral investment in one’s appearance as an expression of the importance people place on their appearance ( 16 , 17 ). This construct was shown to be distinguishable from the construct of appearance evaluation ( 18 ), which also represents a measure of body satisfaction/dissatisfaction.

Besides negative body evaluation and the importance of appearance, a positive appraisal of one’s body also forms part of the cognitive-affective component. For instance, body appreciation is defined as accepting, respecting, and having a favorable opinion of one’s own body, as well as rejecting unrealistic body ideals portrayed by the media ( 19 ). Body appreciation was shown to predict indices of well-being beyond other measures of body image ( 19 ) and occurred simultaneously with body dissatisfaction, highlighting the independence of the two concepts ( 20 ).

In the past, studies have investigated the impact of gender and age on body features related to the cognitive-affective component. Specifically, research on body dissatisfaction has shown that girls and female adolescents (e.g. 21 – 24 ), and women of all ages (e.g. 12 , 25 , 26 ) report body dissatisfaction. While some studies revealed that the level of body dissatisfaction varied across different age groups ( 27 , 28 ), others found that body dissatisfaction remained quite stable across the adult lifespan in females ( 20 , 25 , 29 , 30 ). Studies examining other aspects of the satisfaction-dissatisfaction continuum, such as weight dissatisfaction ( 15 , 31 ) or satisfaction with particular body parts ( 13 , 32 ), also found body dissatisfaction in women. Frederick and colleagues ( 33 ) estimated that 20% to 40% of women are dissatisfied with their bodies. Nevertheless, body dissatisfaction is also reported in men, suggesting that 10% to 30% of men show body dissatisfaction ( 33 ) or 69% of male adolescents to be dissatisfied with their bodies in terms of their weight ( 34 ). Frederick and colleagues ( 14 ) even reported that 90% of male US students in their sample described themselves as being dissatisfied with respect to muscularity. In terms of body evaluation, striving for increased muscularity, referred to as drive for muscularity ( 35 ), has emerged as a central issue for boys and men (e.g. 35 – 38 ). It was shown to be distinct from body dissatisfaction ( 39 ). However, although previous studies reported that body dissatisfaction does not differ across age in women, it remains unclear whether the level of body dissatisfaction changes across age in men.

While body dissatisfaction seems to remain stable across age in women, studies suggest that the importance of appearance appears to decrease with age ( 40 ). In line with Pliner and colleagues, Tiggemann and Lynch ( 41 ) found in a group of females aged 20 to 84 years that the importance of appearance was lower in older than in younger women. For men, only one study has examined the importance of appearance, and found that it varied between age groups and reached a peak at age 75 years and older ( 42 ). To our knowledge, no other study has examined the importance of appearance in men over the lifetime. Thus, it remains relatively unclear whether the importance of appearance remains stable or changes over the lifetime in men.

With respect to body appreciation, Tiggemann and McCourt ( 20 ) demonstrated higher body appreciation in older than in younger women. Furthermore, high body appreciation was found to be protective against the negative effects of media exposure to thin models in women ( 43 ). Other studies reported that body appreciation in men and women was associated with a low level of consumption of Western and appearance-focused media ( 44 ) and correlated negatively with internalization of sociocultural ideals ( 45 ). However, studies focusing on age differences regarding body appreciation in males are lacking.

Previous studies on body image have mostly considered age-related changes in either men or women, or in particular age groups (e.g. college students, adolescents). Only a limited number of studies have compared men and women with respect to the aforementioned aspects of body image. These studies generally found greater body dissatisfaction in females than in males (e.g. 29 , 30 , 46 – 49 ). Men (vs. women) seem to place less importance on their appearance ( 42 , 50 , 51 ) and report slightly higher levels of body appreciation (e.g. 45 , 52 – 54 ). Tylka and Wood-Barcalow ( 55 ) also reported higher body appreciation in college men (vs. college women), but were unable to replicate this effect in a community sample. In contrast to this latter result, Swami and colleagues ( 53 ) reported higher body appreciation in men than in women in a sample from the general Austrian population. However, these studies comparing men and women did not analyze their data with respect to the impact of age.

Only a small number of studies have investigated the effect of age and gender on body dissatisfaction, importance of appearance and body appreciation. In a two-year longitudinal study, Mellor and colleagues ( 56 ) found that body dissatisfaction was higher in females than in males and higher in younger than in older participants. In another longitudinal study, Keel and colleagues ( 15 ) examined men and women over a period of 20 years. As men aged, the authors observed increasing weight and increasing weight dissatisfaction, while weight dissatisfaction decreased in women despite analogous increases in weight. The authors concluded that women appear to be more accepting of their weight as they age ( 15 ). Unfortunately, the mean age at the 20-year follow-up was only 40 years, meaning that conclusions could not be drawn about the whole adult lifespan. Similarly, in a large sample of men and women aged 18 to 49 years, Ålgars et al. ( 46 ) found that overall body dissatisfaction was higher in women than in men, but that only in women was age associated with decreasing body dissatisfaction, while in men, body dissatisfaction changed across the different age groups ( 46 ). However, these results have to be interpreted with caution, as the sample consisted of twins and was thus not representative of the general population.

Other studies found higher levels of body dissatisfaction ( 28 ) and lower levels of satisfaction with certain body areas ( 29 ) in women than in men. However, the latter study did not find any gender- or age-related effect on overall body dissatisfaction ( 29 ). Concerning the importance of appearance, Öberg and Tornstam ( 42 ) found that women placed more importance on their appearance than did men, and that this factor remained stable across different age groups in women but varied in men. These results are contrary to the findings of Tiggemann and Lynch ( 41 ) and Pliner et al. ( 40 ), who found that the importance of appearance decreased with age in women. However, this discrepancy may be due to the assessment method in the study by Öberg and Tornstam, as they used a single item to evaluate the importance of appearance. Hence, the development of importance of appearance in men and women across the lifespan remains unclear.

Although, as mentioned above, some studies have found that women place less importance on their appearance as they age ( 40 , 41 ), this aspect has not been examined in a large population sample comprising different age groups in relation to the impact of gender and age. Furthermore, studies comparing body appreciation between men and women across different age groups are lacking. To our knowledge, no previous study has examined body dissatisfaction, importance of appearance and body appreciation in the general population including men and women aged 16 to 50 years and older. Therefore, the present study aims to fill this research gap by analyzing these negative and positive aspects of body image in a general population sample considering gender and age.

First, based on the previous findings outlined above, we predicted that body dissatisfaction would be higher in women than in men (Hypothesis 1) and would remain stable across age in women (Hypothesis 2). As no previous study has investigated body dissatisfaction across the whole lifespan in men, we aimed to examine a potential influence of age on body dissatisfaction in men.

Second, we hypothesized that women would place more importance on their appearance than men (Hypothesis 3), but that in line with the aforementioned studies, across age, older women would report lower levels of importance than younger women (Hypothesis 4). Given the lack of corresponding studies in men, we intended to investigate the importance of appearance and its relation to age in men in an exploratory analysis. Furthermore, appearance orientation assesses the importance of appearance in terms of the extent of investment in one’s appearance (e.g. grooming behaviors) and in terms of the attention one pays to one’s appearance. However, it does not quantify how many hours or years people would be willing to invest in their appearance to look the way they want to. Therefore, as a measure of the importance of appearance, we additionally assessed the number of hours men and women would be willing to invest per day to achieve their ideal appearance, and the number of years of their life they would sacrifice to achieve their ideal appearance.

Third, we predicted that body appreciation would be higher in men than in women (Hypothesis 5). As the aforementioned studies examined gender differences without analyzing the impact of age, we aimed to investigate potential changes in body appreciation across age in an exploratory manner.

Fourth, to take into account the well-documented increase in BMI over the lifetime (e.g. 46 , 57 , 58 ) and its potential association with the outcome variables, we examined these relations as a control analysis by calculating correlations between the subjective evaluations of body image and BMI.

Materials and Methods

Participants.

Inclusion criteria were age 16 years and older, sufficient German-language skills, and internet access. Data were collected from N = 1,338 persons. From the original data set, n = 4 participants had to be excluded due to ambiguous details about their age or invalid responses to questions. Moreover, n = 7 persons were excluded as they did not fit into the binary gender categories male or female. The final study sample comprised n = 942 women and n = 385 men, aged 16 to 88 years (total sample: n = 1,327).

Demographic Data

All participants completed a questionnaire assessing demographic data such as gender, age, height and weight, educational level, relationship status, sexual orientation, and number of children. The item on sexual orientation was optional. Self-reported weight and height were used to calculate the body mass index (BMI, kg/m 2 ).

Multidimensional Body-Self Relations Questionnaire–Appearance Scales

The Multidimensional Body-Self Relations Questionnaire–Appearance Scales [MBSRQ-AS; ( 16 ); German-language version: ( 17 )] is a self-report questionnaire consisting of 34 items and five subscales to assess different appearance-related aspects of body image. The MBSRQ-AS has been validated for participants aged 15 years and older and for both men and women ( 16 ). For the purpose of this study, the Appearance Evaluation Scale (seven items) and Body Areas Satisfaction Scale (nine items) were used to assess body dissatisfaction, and the Appearance Orientation Scale (12 items) was applied to examine the importance people place on their appearance. According to Cash ( 16 ), the Appearance Evaluation Scale measures overall satisfaction/dissatisfaction with one’s appearance and physical attractiveness, with high scores indicating body satisfaction and low scores indicating body dissatisfaction. Furthermore, the Body Areas Satisfaction Scale (nine items) assesses satisfaction/dissatisfaction with particular body areas; high and low scores are analogous to the Appearance Evaluation Scale. The Appearance Orientation Scale (12 items) evaluates the investment in one’s appearance, with low scores indicating that people do not place importance on or invest much effort into being “good-looking”. All items are rated on a 5-point Likert scale with different response labeling ( Appearance Evaluation Scale and Appearance Orientation Scale : 1 = definitely disagree to 5 = definitely agree; Body Areas Satisfaction Scale : 1 = very dissatisfied to 5 = very satisfied). While the English-language version has been validated in both men and women ( 16 ), the German-language version has only been validated for females ( 17 ). In the German validation, all subscales showed good internal consistency (α = .78–.90; 17 ). In the current sample, high internal consistencies were found ( Appearance Evaluation Scale : α = .88; Appearance Orientation Scale : α = .85; Body Areas Satisfaction Scale : α = .81), both for men ( Appearance Evaluation Scale : α = .87; Appearance Orientation Scale : α = .85; Body Areas Satisfaction Scale : α = .80) and women ( Appearance Evaluation Scale : α = .89; Appearance Orientation Scale : α = .86; Body Areas Satisfaction Scale : α = .81).

Body Appreciation Scale-2

The Body Appreciation Scale-2 (BAS-2; 55 ; German-language version: Steinfeld, unpublished manuscript) assesses body appreciation in a gender-neutral manner using 10 items rated on a 5-point Likert scale (1 = never to 5 = always). High internal consistency (α = .96) was found for the BAS-2 in an English-speaking sample of men and women ( 55 ). In our sample, internal consistency was high (α = .94), both in males (α = .92) and females (α = .94).

Investment in One’s Appearance

To investigate the amount of time which men and women would be willing to invest in and sacrifice for their own appearance, participants were asked the following two questions: “How many years of your life would you be willing to sacrifice if you could look the way you want?”, “How many hours a day would you invest in your appearance if you could look the way you want?”

Single-Item Self-Esteem Scale

The Single-Item Self-Esteem Scale (SISE; 59 ) measures self-esteem using the item “I have high self-esteem,” which is rated on a 5-point Likert scale (1 = not very true of me to 5 = very true of me). It has shown high correlations with the Rosenberg Self-Esteem Scale and a high test-retest reliability after four years ( r tt = .75) ( 59 ).

Depression Anxiety Stress Scales–Depression Subscale

The Depression Anxiety Stress Scales–Depression Subscale (DASS-D) ( 60 ; German-language version: 61 ) consists of seven items assessing depressive mood over the past week on a 4-point Likert scale (0 = never to 3 = always). For the German version of the DASS-D, high internal consistency has been found (α = .88) ( 61 ). In the present study, internal consistency ranged from α = .89 for men to α = .91 for women (total sample: α = .90).

Study Procedure

Participants were recruited via social media, mailing lists, press releases, advertisements, and flyers and were asked to take part in a short online survey comprising different questionnaires about body image. To access the study website, they could either scan a barcode or use a web link. The online survey was set up using the software Unipark (Version EFS Winter 2018; 62 ). Participants were informed about the purpose of the study and were asked to provide their informed consent by clicking a button next to a declaration asserting that they agree to the processing of their personal data according to the given information. The survey began once participants had provided consent and took approximately 10 min to complete. Participants were offered no financial compensation for study participation. The research project was conducted in accordance with the Declaration of Helsinki and was approved by the ethics committee of Osnabrück University.

Data Analysis

Data analysis was performed using the software SPSS Statistics (version 25; IBM 63 ) for descriptive statistics, correlation analysis, and general linear models and the software R (version 3.5.3; R 64 ) with the DHARMa package (version 0.2.4; 65 ), the glmmTMB package (version 0.2.3; 66 ), and the MASS package (version 7.3–51.3; 67 ) for generalized linear models. As we intended to explore homogenous hypotheses in terms of body dissatisfaction, the power was set at a significance level of p = .10 for the variable age.

For group comparisons on demographic and descriptive variables ( Table 1 ), we calculated Mann-Whitney U Tests, as our data were not normally distributed (except BMI). Since inferential statistics for simple comparisons are massively overpowered in such large samples, we additionally report effect sizes. For better interpretability, U -values were converted into correlation coefficients r ( 68 , 69 ). For correlations between BMI and the body image variables ( Table 3 ), Spearman’s rank correlations were calculated due to non-normally distributed data.

Table 1 Descriptive statistics and group comparisons regarding age, height, weight, BMI, depression, and self-esteem.

For linear and generalized linear models, gender was dummy-coded, with men as the reference category. Age was centered to simplify the interpretation of the model coefficients. Due to missing data on single items within the questionnaires, the sample sizes for the initial model estimations varied, since participants were only included in the respective data analysis if they answered all items of a scale. To examine the individual impact of gender and age for each dependent variable, we started with the general linear model and inspected the residual distributions, tested statistically and by visual inspection for normality, and tested for homogeneity of variance as well as for skewness, kurtosis, and outliers (Mahalanobis and Cook’s distance, Leverage). While Cook’s distance should be smaller than 1 ( 70 ) and Leverage for large samples <3 k / N ( 71 ), a value was identified as an outlier if the Mahalanobis distances were above the critical χ 2 value exceeding the probability of 0.01 ( 72 ) and if studentized deleted residuals were larger than 3 standard deviations. The highest number of outliers was detected for the Body Areas Satisfaction Scale, with 3.36%. Comparisons of the models with and without outliers revealed no substantial differences; hence, we report the models without potential outliers, as power issues were not expected for such a large sample size and precision of estimates was prioritized. Final sample sizes are reported for each model ( Tables 4 and 5 ).

For the Body Areas Satisfaction Scale, the assumption of homogeneity was violated. Therefore, a general linear model was calculated, using the HC3 method for robust estimation of the standard errors. Furthermore, due to skewness and non-normal distribution of the data, responses to the Body Appreciation Scale-2 were inverted and a generalized linear model with a gamma distribution and identity link function was used. The analyses of hours people would invest in their appearance and years people would sacrifice from their lives indicated severe violations of the assumptions of the general linear model, since their distributions were similar to zero-bounded count data. Therefore, the numbers of hours and years were rounded to integer values to enable us to calculate several Poisson and negative binomial regression models, which are suitable for count data. The fit of each model was assessed by tests for overdispersion and zero inflation, as well as by tests of residual fit using the DHARMa package. As a final model for the analyses of the years people would sacrifice from their lives, we used a negative binomial regression with a log-link and linearly increasing variance ( 73 ) and adjustment for zero inflation for the intercept using the glmmTMB package. For the analyses of the hours people would spend on their appearance, we used a negative binomial regression with the log-link function using the MASS package.

Sample Characteristics

Descriptive statistics and group differences are shown in Table 1 . Men and women differed significantly in terms of age, height, weight, BMI, and self-esteem. Compared to women, men were slightly older, taller, and heavier and had a higher BMI. This is in line with data from the German Federal Statistical Office ( 57 ), which reported a mean weight of 68.7 kg, a mean height of 166 cm and a mean BMI of 25.1 in German women, and a mean weight of 85.0 kg, a mean height of 179 cm and a mean BMI of 26.1 in German men. As indicators of psychopathology, men and women did not differ regarding depressive mood over the past week ( p = .152), whereas self-esteem was higher in men than in women.

Information about educational level, relationship status, number of children, and sexual orientation is reported in Table 2 . Of the total sample, n = 29 participants (of whom n = 23 were female) refused to answer the question regarding sexual orientation, and n = 3 participants (of whom n = 1 was female) did not state whether they had children. A recent study on the proportion of Lesbian, Gay, Bisexual, and Transgender (LGBT) persons in Europe reported that 7.40% of the German population identify themselves as LGBT ( 74 ). In our sample, 10.17% reported a sexual orientation other than heterosexuality, which is slightly higher than the reported value for the German population, but can be still considered as representative.

Table 2 Numbers and percentages regarding educational level, relationship status, and sexual orientation for total sample, women, and men.

The Spearman’s rank correlations of BMI with body dissatisfaction, importance of appearance, the number of hours per day participants would invest and years they would sacrifice to achieve their ideal appearance, and body appreciation are displayed in Table 3 .

Table 3 Spearman’s correlations between BMI and the scores on the scales Appearance Evaluation, Body Areas Satisfaction, Appearance Orientation, the number of hours per day participants would invest to achieve their ideal appearance, and the number of years participants would sacrifice to achieve their ideal appearance and Body Appreciation for total sample, women, and men.

General and Generalized Linear Models

Table 4 presents the descriptive statistics for appearance evaluation, body areas satisfaction, appearance orientation, hours of investment, and years of sacrifice, as well as body appreciation, separated for total sample, men, and women. The results of the general and the generalized linear models are displayed in Table 5 . Regarding body dissatisfaction, gender emerged as the only significant predictor of appearance evaluation ( t = −2.012, p = .044) and body areas satisfaction ( t = 4.282, p < .001), indicating lower appearance evaluation and lower body areas satisfaction in women than in men. Age (appearance evaluation: t = −1.489, p = .137; body areas satisfaction: t = −1.605, p = .109) and the interaction of age × gender (appearance evaluation: t = 1.630, p = .103; body areas satisfaction: t = 1.257, p = .209) did not reach statistical significance. In terms of the importance of appearance, gender ( t = 6.597, p < .001), age ( t = −3.636, p < .001), and the interaction of gender × age ( t = 3.194, p < .001) significantly predicted appearance orientation, revealing that women placed more importance on their appearance than did men, whereas age only influenced the importance of appearance in men. The number of hours which participants would spend on their appearance if they could achieve their ideal appearance was predicted by gender ( z = 2.037, p = .042) and age ( z = −4.654, p < .001), indicating that women would invest more hours than men, but that with higher age, both genders would invest fewer hours in their appearance. The interaction of gender × age ( z = 0.428, p = .67) was not significant. Age was the only predictor of the number of years participants would be willing to sacrifice to achieve their ideal appearance ( z = −5.828, p < .001), revealing that with higher age, men and women would sacrifice fewer years for their ideal appearance. Neither gender ( z = −0.526, p = .60) nor the interaction of gender × age ( z = 1.015, p = .310) had a significant impact on the number of years. Furthermore, gender ( t = 2.828, p = . 005) and the interaction of gender × age ( t = −2.186, p = . 029) were significant predictors of body appreciation, insofar as with higher age, women reported higher body appreciation than men, while body appreciation in men remained stable with higher age. Age ( t = 0.127, p = . 899) did not reach statistical significance.

Table 4 Descriptive statistics regarding the scores on the scales Appearance Evaluation, Body Areas Satisfaction, Appearance Orientation, hours of investment, and years of sacrifice, as well as Body Appreciation for total sample, women and men used in the final models.

Table 5 General linear models for the prediction of Appearance Evaluation, Body Areas Satisfaction and Appearance Orientation as well as generalized linear models for the prediction of Body Appreciation, the number of hours per day participants would invest to achieve their ideal appearance, and the number of years participants would sacrifice to achieve their ideal appearance, with gender and age as predictors.

The aim of the present study was to investigate potential gender differences and the impact of age on body dissatisfaction, importance of appearance, the number of hours per day participants would invest and the number of years they would sacrifice to achieve their ideal appearance, and body appreciation in the general population.

As predicted in our first hypothesis, we found an effect of gender on the Appearance Evaluation Scale and the Body Areas Satisfaction Scale, suggesting that women were significantly more dissatisfied with their bodies than men. This is in accordance with the results of several studies (e.g. 28 , 30 , 46 , 56 ), which likewise reported higher levels of body dissatisfaction in women than in men. In line with our results, Fallon and colleagues ( 29 ) found that women (vs. men) reported higher levels of body dissatisfaction on the Body Areas Satisfaction Scale, but contrary to our study, the authors did not find an effect of gender on the Appearance Evaluation Scale. Keel et al. ( 15 ) even found higher weight dissatisfaction in men than in women, which is also in contrast to previous findings. Therefore, it might be possible that women may be more satisfied with their weight while still reporting more body dissatisfaction.

Additionally, we found that body dissatisfaction on the Appearance Evaluation Scale and on the Body Areas Satisfaction Scale was not influenced by age or by the interaction of gender and age, indicating that body dissatisfaction remains stable across all ages for both genders. For women, this finding confirms our second hypothesis, which assumed that body dissatisfaction would not be influenced by age, and also supports previous findings (e.g. 20 , 25 , 29 , 30 ). One study by Öberg and Tornstam ( 42 ) found that body satisfaction was higher in older than in younger women, which is also in contrast to our findings, as we found no influence of age on body dissatisfaction. For men, our results indicate that body dissatisfaction remains stable across different ages. This is in contrast to Ålgars and colleagues ( 46 ), who found that body dissatisfaction varied across different age groups in men. However, the latter finding might be attributable to artificial grouping strategies, as the authors investigated the impact of the continuous variable age as a categorical variable through the use of age groups. Moreover, Ålgars and colleagues ( 46 ) only assessed participants between the age of 18 and 49 years. The present study included men and women aged from 16 to 88 years, thus covering a broader proportion of the lifespan in Germany; according to the German Federal Statistical Office ( 75 ), the average life expectancy lies at 78.4 years for men and 83.2 years for women. To sum up, body dissatisfaction seems to remain relatively stable across different ages, both for men and for women.

In line with our third hypothesis that women would place more importance on their appearance than men, we found a significant effect of gender on the Appearance Orientation Scale, indicating that women indeed place more importance on their appearance compared to men. This finding corroborates previous studies ( 42 , 50 , 51 ). Moreover, age was a significant predictor of appearance orientation, as was the interaction of gender and age. Although age and the interaction of gender and age reached statistical significance, only in men did higher age bring about a lower importance of appearance. For women, the regression weights of age and the interaction of gender and age cancelled each other out. Therefore, gender was the only factor to impact appearance orientation in women, and the importance of appearance was not affected by age in women. This is in contrast to our fourth hypothesis that older women would report lower levels of importance of appearance than younger women. It also conflicts with previous findings ( 40 , 41 ), as we found that appearance orientation remained stable across all ages in women. In line with our finding, Öberg and Tornstam ( 42 ) also reported that the importance of appearance remained stable in women of different ages. They further found a small variation of the importance of appearance across different age groups in men, with the level of importance being more pronounced from the age of 45 years and older ( 42 ). However, we observed that older men seem to place less importance on their appearance than do younger men.

As the construct of importance of appearance does not reflect the extent to which people are willing to invest time in order to reach their ideal appearance, we additionally assessed the amount of hours per day participants would invest, and the number of years of their lives they would sacrifice, in order to achieve their ideal appearance. We found an effect of gender and age on the number of hours spent on appearance, but only an effect of age on the number of years which participants would sacrifice for their appearance. Women were more likely to spend more hours per day on their ideal appearance than men. However, older men and women would invest fewer hours than their younger counterparts. Concerning the number of years people would be willing to sacrifice to achieve their ideal appearance, we found no effect of gender, but found age to be a significant predictor, meaning that older men and women would sacrifice fewer years from their lives for the sake of their ideal appearance. This indicates that in terms of their behavioral investment regarding the importance of appearance, men and women may be more similar than hitherto assumed. Apparently, women might find it easier to relinquish a small number of hours per day to be invested in their appearance compared to men, but regarding lifetime investment, both genders might be unwilling to sacrifice years of their lives for the sake of their appearance.

Furthermore, we examined the impact of gender and age on body appreciation, and found gender and the interaction of gender and age to be significant predictors. The significant effect of gender suggested that women showed less body appreciation than did men. This is in line with our fifth hypothesis that women would show lower levels of body appreciation than men, and is also in accordance with other studies ( 45 , 53 , 76 ). However, the significant interaction of gender and age indicates that with higher age, women report higher levels of body appreciation compared to men. This is in contrast to the aforementioned studies (e.g. 45 , 53 , 76 ), but may provide an explanation for the lack of a gender effect in an English-speaking community sample in the study by Tylka and Wood-Barcalow ( 55 ). Interestingly, compared to our study, Tylka and Wood-Barcalow ( 55 ) reported slightly higher values (from 3.22 to 3.97) for their samples for both genders. Furthermore, the significant interaction in our study suggested that body appreciation also improves in women across age, and older (vs. younger) women report higher levels of body appreciation. This is in line with Tiggemann and McCourt ( 20 ), who found greater body appreciation in older than in younger women. Regarding men, as pointed out above, no previous study has investigated the impact of age on body appreciation. In our study, the level of body appreciation remained quite stable across different ages in men, and was lower compared to that of women. An explanation might be that men are possibly more affected by restrictions of their body’s functionality due to aging processes ( 27 ), whereas women may cherish their body and the remaining functionality.

With respect to the associations between BMI and the aspects of body image, we found significant negative correlations between BMI and the Appearance Evaluation Scale and Body Areas Satisfaction Scale for men and women, insofar as with increasing BMI, values on both scales decreased (= higher body dissatisfaction). This is in line with previous research, which found that BMI was positively associated with body dissatisfaction in both genders (e.g. 77 – 81 ). Body appreciation was found to be negatively correlated with BMI for both genders, which is partially in line with previous research: One study found this association for women but not for men ( 53 ), while other studies yielded mixed findings, reporting either a negative association between BMI and body appreciation (e.g. 82 , 83 ) or no significant results (e.g. 44 ). Concerning the importance of appearance, we found no significant association with BMI for either gender. In line with our results, some previous studies found no association between the importance of appearance and BMI in both men and women ( 13 , 84 ), while others reported a positive correlation for women but no significant association for men ( 85 ). The latter may be explained by the differentiation between the importance of appearance and the investment of time in appearance, as we found that BMI was positively associated with the number of invested hours for both genders, but was only associated with the number of years participants would sacrifice to achieve their ideal appearance in women. These findings emphasize the distinction between the evaluative perspective of the importance of appearance (How essential are my looks to me)? and the behavioral perspective of the extent of investment in appearance (How many hours/years am I willing to invest in my appearance)?. For instance, a person may place importance on his or her appearance, but as appearance is less important than years of his or her life, he or she is unwilling to invest much effort in appearance. As shown in our study, women reported quite stable, higher levels of importance across age than did men. Consequently, it might be assumed that they have to invest more time in order to achieve their ideal appearance. Nevertheless, as older men and women would invest fewer hours and sacrifice fewer years, the extent of investment or sacrifice is evidently not expressed by the importance of appearance. These results underline the need to differentiate between the importance of appearance and the investment of time in one’s appearance.

Although in the present study, women reported a higher degree of body dissatisfaction than did men, men’s and women’s responses on average lay slightly above the value of 3 on the 5-point Likert scale ( Table 4 ). This indicates, on average, neither agreement nor disagreement on the two scales (3 = I neither agree nor disagree) and possibly reveals a more neutral to slightly positive evaluation of one’s body. These results are in line with those of Cash ( 16 ) and Fallon et al. ( 29 ), who reported similar values on both scales for men and women. Therefore, on average, men and women may be neither particularly dissatisfied nor particularly satisfied with their bodies.

In consideration of all of the aforementioned research, one has to raise the more general question of whether the absence of body dissatisfaction is synonymous with the presence of body satisfaction in terms of a continuum model as proposed by Thompson et al. ( 4 ). Another possibility lies in an alternative model, in which body satisfaction and body dissatisfaction coexist alongside one another. For instance, it may be possible for a person to report high levels of overall body dissatisfaction, while simultaneously reporting high levels of body satisfaction with certain areas (e.g. “In general, I am dissatisfied with my body, but I like my legs, my cheeks and my hair.”). This could result in neither agreement nor disagreement on a continuum scale. Further research is needed to investigate a possible coexistence of both concepts.

Some limitations have to be mentioned when interpreting the results of the present study. Although several coefficients turned out to be significant, they contribute only a minimum of change to the dependent variables. In addition, according to the conventions of Cohen ( 86 ), we found very small values for the R 2 s, as the R 2 s in the present study explained only 0.5% (appearance evaluation) up to 5.2% (appearance orientation) of the total variance. Due to our total sample size of N = 1,327, the significance of the coefficients therefore might be attributed to the study’s power. Moreover, as was the case for most of the previous studies (except for 15 and 56 ), we did not investigate age effects in a longitudinal design. Therefore, it is not possible to disentangle the effects of age and birth cohorts. The effects found in this study may be related to different birth cohorts, the way in which people were brought up and socialized, or different ideals of beauty and fashion. Longitudinal studies including different age cohorts of men and women are therefore required.

Another limitation may lie in the assessment method. As younger people use the internet more frequently than older people ( 87 ), it cannot be excluded that this could have led to a stronger selection bias in older participants. Further, the online assessment may not be representative for the general population ( 88 ). Thus, there was no control regarding the implementation conditions of participation (e.g. whether there were distractions while participating) or regarding who was participating ( 88 ). False answers on variables such as weight, height, and age seem to be easier to notice in the laboratory. However, false statements concerning the variables of body image may be just as difficult to detect in the laboratory or in paper-and-pencil examinations as in online assessments. Our calculation of correlations between BMI and the outcome variables may be seen as a control analysis, as the participants’ answers on BMI were associated with our dependent variables, in line with aforementioned research.

Furthermore, our sample included more women than men. This may reflect the fact that women are more likely to participate in studies than men (e.g. 89 , 90 ). Although general and generalized linear models are able to control for different sample sizes, men and women differed significantly regarding age, height, weight, and self-esteem. While the differences in weight and height could be explained by natural gender differences, men were slightly older than women. As a further limitation, the assessment was restricted to certain body-related aspects and omitted other concepts such as the drive for muscularity ( 35 ) or drive for thinness ( 91 ). We only included appearance-related aspects of body image and body appreciation in order to shorten the length of our study and to decrease the burden of our survey on respondents. Therefore, we concentrated on more general aspects related to the cognitive-affective component of body image. Future studies need to investigate the impact of gender and age on other components of body image, such as perceptual estimation of body size (e.g. 92 ) or checking behaviors (e.g. 93 ). Although some studies have already investigated body image regarding genders other than the distinct categories of male and female (e.g. 94 , 95 ), we did not analyze these persons in the present study due to the insufficient sample size ( N = 7). Moreover, we did not investigate the relation between sexual orientation and body image, although previous studies have found indications of an influence of sexual orientation on body image ( 96 – 99 ). Therefore, future research should investigate the impact of age on body image for different sexual orientations.

In conclusion, the present study is one of the first to examine body dissatisfaction, importance of appearance, the number of hours participants would be willing to invest per day to achieve their ideal appearance and the number of years they would sacrifice to achieve their ideal appearance, and body appreciation in relation to gender and age. Body appreciation was higher in older than in younger women and women reported higher levels of body appreciation compared to men. While the importance of appearance was lower in older than in younger men and remained stable in women, neither gender was willing to relinquish a large amount of time for the sake of their appearance. Although we found higher body dissatisfaction for women than for men, both genders seem to be neither satisfied nor dissatisfied with their bodies on average. Eating disorder prevention programs, or therapeutic approaches for several mental disorders, could benefit from a more functional perspective on the absence of body satisfaction, as this does not necessarily equate with the presence of body dissatisfaction.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethics committee of Osnabrück University. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.

Author Contributions

HQ, SV, AH, and UB planned and conducted the study. RD and HQ analyzed the data. HQ wrote the first draft of the manuscript. All authors contributed to the compilation of the manuscript and read and approved the submitted version.

We acknowledge support by Deutsche Forschungsgemeinschaft (DFG) and the Open Access Publishing Fund of Osnabrück University for the publication of the article.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: body image, body dissatisfaction, body appreciation, importance of appearance, gender comparison, age, lifespan

Citation: Quittkat HL, Hartmann AS, Düsing R, Buhlmann U and Vocks S (2019) Body Dissatisfaction, Importance of Appearance, and Body Appreciation in Men and Women Over the Lifespan. Front. Psychiatry 10:864. doi: 10.3389/fpsyt.2019.00864

Received: 14 July 2019; Accepted: 04 November 2019; Published: 17 December 2019.

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Copyright © 2019 Quittkat, Hartmann, Düsing, Buhlmann and Vocks. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Hannah L. Quittkat, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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• Published: 14 January 2020

Body image perception and body composition: assessment of perception inconsistency by a new index

• Luciana Zaccagni 1 , 2 ,
• Natascia Rinaldo   ORCID: orcid.org/0000-0002-6972-3085 1 ,
• Barbara Bramanti 1 , 3 ,
• Jessica Mongillo 1 &
• Emanuela Gualdi-Russo 1 , 2  

Journal of Translational Medicine volume  18 , Article number:  20 ( 2020 ) Cite this article

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A correct perception of the body image, as defined by comparison with actual anthropometric analyses, is crucial to ensure the best possible nutritional status of each individual. Bioimpedance analysis (BIA) represents a leading technique to assess body composition parameters and, in particular, the fat mass. This study examined the self-perception of body image at various levels of adiposity proposing a new index.

We investigated 487 young Italian adults (mean age of males: 21.9 ± 2.4 years; mean age of females: 21.0 ± 2.2 years). Each subject could choose, on the Contour Drawing Rating Scale, the silhouette that he/she considered most resembling his/her perceived body image as well as his/her ideal body image. On each subject, we performed anthropometric measurements and determined the values of Fat mass and  %Fat with BIA. A new index, FAI FAT (Feel fat status minus Actual fat status Inconsistency), was developed to evaluate possible fat status perception inconsistencies by BIA.

Based on ideal and feel body image comparison, women showed higher dissatisfaction than men and preferred slimmer silhouettes. FAI FAT values indicated that the fat status perception was correct in the majority of the examined individuals and only three subjects showed a serious misperception.

Conclusions

Our findings suggest that FAI FAT is an appropriate index for assessing the perceived fat status from the body image when compared with data obtained by BIA. In a population, the use of this index will allow the correct identification of groups at risk for eating disorders.

An adequate nutritional status is essential to maintain healthy conditions in singular individuals and populations. Malnutrition impacts the risk of disease, the course of the disease, and enhances the risk of mortality [ 1 , 2 , 3 ]. The risk of morbidity and mortality increases particularly with increasing abdominal fat [ 4 ], while the body mass index (BMI) alone does not represent an adequate predictive indicator of the individual health status [ 5 , 6 , 7 ].

Obesity is increasing worldwide and, particularly, in industrialized countries [ 8 ]. In the same countries, there is an increase in negative perception of the body image and, consequently, an increase in eating disorders [ 9 , 10 , 11 , 12 , 13 ] and unhealthy behaviors. Recent studies have demonstrated an association between high BMI with body image dissatisfaction and self-reported overvaluation of the body size. This may lead to dietary concerns, depression and fear of weight gain [ 14 , 15 ]. Other studies show that a poor body image perception leads to poor self-esteem with an increased risk of anxiety and depression [ 16 , 17 ]. On the other hand, a self-image misperception, as well as a depressive status, boosts the risk of eating disorders [ 18 , 19 ] and can lead to an unhealthy lifestyle, increasing sedentary and poor nutritional habits [ 20 , 21 ]. All these factors can result in malnutrition with an increasing risk of disease and mortality [ 22 ]. In fact, strong discrepancies between the perceived and the ideal figure (dissatisfaction), as well as an incorrect self-image of the body size (inconsistency), can result in inappropriate behaviors, with serious and long-lasting implications on the health of the individuals [ 23 ]. Conversely, a positive body perception is commonly associated with self-esteem, optimism and a healthier nutritional behavior [ 24 , 25 ].

Thus, to evaluate the nutritional status of an individual, we consider fundamental to explore his/her correct perception of the body image based on the body size evaluated through anthropometric methods. An objective evaluation of the actual body size, and in particular of the parameters of body composition, allows the individuals to undertake appropriate corrective actions in terms of diet and exercise, where necessary.

Body composition analysis can be carried out in adults with clinically available methods, such as dual-energy X-ray absorptiometry, Computed Tomography and Magnetic Resonance Imaging [ 26 , 27 , 28 , 29 ], yet anthropometric techniques are those most widely used for their reliability and simplicity of use.

Despite its utility in assessing conditions of malnutrition, which are of growing importance in modern societies, body image self-perception in relation to body size is still a poorly explored field. In 2014, Zaccagni et al. [ 30 ] developed a new tool (the FAI index) that assesses the perceived weight status, analyzing the figure chosen as their actual and BMI in a sample of undergraduate students. More recently, Cohen et al. [ 31 ] proposed an index (body weight self-satisfaction index) similar to the previous one on the basis of another Figure Rating Scale. For the present study, we decided to evaluate in a large sample of young adults the consistency of the body figure perceived as actual with the fat status objectively assessed by bioimpedance analysis (BIA). Although also this technique shows some few limits [ 32 ], BIA represents a leading method for body composition assessment and allows with confidence the estimation of fat percentage (%F) in obese individuals [ 29 ]. In addition, BIA is a more reliable anthropometric method for adiposity status assessment in comparison to BMI [ 33 , 34 ].

Aim of this study was to propose a new index (FAI FAT ), which relates the body image chosen as actual to body composition parameters (Fat) obtained with BIA. We took into consideration also possible differences of FAI FAT between sexes. The FAI FAT index gives a simple score to discriminate a subject according to own fat-status in underestimated, consistent or overestimated, allowing to promptly identify who needs corrective measures to solve any wrong nutritional behaviors.

We carried out a cross-sectional study on a sample of 487 Italian students in the Faculty of Medicine, Pharmacy and Prevention at the University of Ferrara (North-Italy) by convenience sampling selection. The students were 303 males (aged 21.9 ± 2.4) and 184 females (aged 21.0 ± 2.2).

The criteria for inclusion among the participants were: (1) being Italian; (2) being aged 18 years or older. Those with diagnosed health problems which may interfere with anthropometric measurements or body image perception were excluded.

The study protocol was approved by the Ethics Committee for Biomedical Research of the Ferrara University. After receiving explanations about the objectives of the study, the subjects of this survey provided written informed consent.

Stature and weight were measured according to standardized procedures [ 35 ] by trained operators with a mechanical scale (precision 0.1 kg, Seca) and a wall-mounted stadiometer (precision 0.1 cm; Magnimeter, Raven Equipment Limited, UK), respectively. BMI (weight/stature 2 , kg/m 2 ) was calculated to define the weight status of the subjects. According to the WHO classification, BMI can be stratified into ‘underweight’, ‘normal weight’, ‘overweight’ or ‘obese’, encoded respectively as 1, 2, 3 and 4.

Body resistance (ohm) and reactance (ohm) values were taken for each subject by means of an Akern 101 Sport Edition analyzer (Akern, Florence, Italy), with a right-sided tetrapolar electrode-placement in standard conditions. Bioelectrical values were used to assess body composition parameters, i.e. fat free mass (FFM, kg), fat mass (FM, kg), and fat percentage (%F). FFM was calculated with the regression equation proposed by Kyle et al. [ 36 ]. FM was calculated as weight—FFM and %F as (FM/weight) * 100.

On the basis of %F and cut offs by sex and age proposed by Gallagher et al. [ 37 ], the subjects were classified into ‘underfat’, ‘normal fat’, ‘overfat’ and ‘very overfat’ categories, respectively encoded as 1, 2, 3 and 4.

Body image perception was assessed by means of the Contour Drawing Rating Scale [ 38 ]. For each sex, nine silhouettes were proposed, numbered and sorted in ascending order, from emaciated (silhouette 1) to obese (silhouette 9). Each subject had the possibility to choose the silhouettes closest to his/her own perception (Feel figure) and to his/her own ideal (Ideal figure) body shape. Dissatisfaction in body image perception was calculated as feel–ideal difference (FID) [ 39 , 40 ].

The inconsistency between the body image perception (Feel figure) and the actual weight status assessed by means of BMI was calculated as FAI (feel weight status minus actual weight status inconsistency) [ 30 ].

To assess the inconsistency on the basis of body fat assessment by BIA and the feel figure, we devised the index FAI FAT (Feel fat status minus actual fat status Inconsistency by BIA). FAI FAT uses the silhouette matching technique as a proxy to verify whether there is a realistic fat status perception in the subject. The FAI FAT was computed by subtracting the conventional code assigned to the actual fat status of the subject (code: 1 for underfat, 2 for normal fat, 3 for overfat and 4 for very overfat, as assessed by BIA) from the one corresponding to her/his feel figure according to the following correspondence: silhouettes 1 and 2 match fat status 1 (underfat); silhouettes 3, 4 and 5 match fat status 2 (normal fat); silhouettes 6 and 7 match fat status 3 (overfat); silhouettes 8 and 9 match fat status 4 (very overfat).

The FAI FAT scores range from − 3 to + 3: negative FAI FAT values point to an underestimated fat status, whereas positive FAI FAT values to an overestimated fat status. A FAI FAT score of 0 means a consistent perception of the own fat status.

Statistical analyses

Distribution normality was assessed by sex (Kolmogorov–Smirnov test). Comparisons between sexes were performed using the t-test (for traits normally distributed) or U Mann–Whitney test. Comparisons between fat status categories was performed using Kruskal–Wallis non parametric test (for traits not normally distributed) and a Tukey’s post hoc test was used for comparisons among groups. Comparisons between dependent samples were carried out with Wilcoxon test. Categorical data were analyzed by means of Pearson’s Chi square test. Comparisons among fat status categories were performed by means of Kruskal–Wallis test. Spearman’s rank correlation was used to evaluate associations between %F and the new index FAI FAT . Next, linear regression analysis was performed and visually inspected in order to identify risk values of body misperception.

Values of p < 0.05 were considered statistically significant. All statistical analyses were performed using the Statistica software, version 11.0 (StatSoft srl, Tulsa, OK).

In Table  1 , we summarized the mean anthropometric values and the mean body image indicators derived from the sample separately by sex. Regarding anthropometric and body composition parameters, females were significantly shorter and lighter than males, with significantly lower mean values of BMI and FFM, and significantly higher mean values of adiposity parameters (FM and %F). The silhouettes chosen by males were, on average, significantly bigger than those chosen by females both in term of Feel and Ideal figures. Females reported a significantly higher FID value than males, which demonstrated in young women a higher dissatisfaction due to their wish to be slimmer than they actually were. In any case, both sexes preferred an Ideal figure which was significantly thinner than their own ( p  = 0.0401 in males; p  < 0.0001 in females). Nevertheless, both sexes demonstrated a good perception of their body, as revealed by the values close to 0 of the FAI and FAI FAT indices, although females showed a slight tendency to see themselves as fatter (positive FAI FAT values) and males as thinner (negative FAI FAT values) than they actually were (Table  1 ). When we made a comparison between the mean FAI and FAI FAT values within the two groups, the differences resulted significant (FAI vs FAI FAT : p  < 0.0001 in males; p  = 0.0147 in females).

In Table  1 , we also reported the absolute and relative frequencies of weight- and fat-status found in our sample, divided by sex. The differences between sexes were significant in both weight- and fat-status percentages. All post hoc group-wise comparisons, apart from obese, in weight status were significant (p < 0.01). Among the males, we observed a higher percentage of overweight, overfat and very overfat subjects, while among females a higher number of under- and normal weight, underfat and normal fat.

Table  2 shows the mean results of the body image perception scores divided by sex and by fat status categories. In both sexes, the mean Feel figures significantly differ between the different categories, increasing in value as the %F increases. In contrast, the mean Ideal figure chosen is similar for all categories in males, while its score significantly increases in value within the fat categories in females. Mean FID values increase with increasing body fat, both in males and females. However, females reported lower dissatisfaction than males in the under-fat groups, but higher in the other fat categories and all of them wished to be thinner, while under fat and normal fat males preferred a higher number in the body image rating scale. The mean FAI values, that indicate the consistent perception of themselves on the basis of BMI, are significantly different within the fat categories only in males. However, in both sexes and in all categories with the exception of very overfat females, the mean FAI values are positive (indicating an overestimation of their own weight-status), or close to 0 (indicating a general consistent perception of themselves). Moreover, the difference in FAI values is significant only between normal fat and overfat males (p = 0.0106). In fact, while overfat males had higher FAI values, the other fat categories had values of FAI very close to each other, indicating a similar perception of their fat.

When considering the FAI FAT , the mean values are significantly different between the fat categories with the highest values (both positive and negative) in the outermost groups (positive in underfat and negative in very overfat), indicating a higher inconsistency between actual body fat and the Feel figure. Compared with FAI, the FAI FAT values resulted significantly different (Wilcoxon test; p < 0.05) in all the fat groups and in both sexes, except in underfat males and in very overfat females (Table  2 ).

The majority of the male students chose the silhouettes 5 and 6 (Table  3 ) to define their perceived body image (feel figure), whereas their mean BMI and F% fall within the range of normal weight and normal fat. In fact, as demonstrated by the mean FAI and FAI FAT values, they generally overestimated their body size and underestimated their body fat. The female students chose prevalently silhouette number 4 and 5 (Table  3 ) as their perceived body image (Feel figure), which is in accordance with their mean weight- and fat-status. In general, females tended to fat overestimation (FAI FAT values > 0), whereas males to fat underestimation (FAI FAT values < 0).

This aspect has been analysed more in detail in Table  4 , which shows the frequencies of the subjects, divided per fat-status and sex, that underestimated (FAI FAT  < 0), overestimated (FAI FAT  > 0) or had the right perception (FAI FAT  = 0) of their own body fat. Most males demonstrated a right perception of their body, especially those with normal fat and overfat status. The three subjects in the category “underfat” overestimated their body fat, while the majority of the very overfat subjects underestimated it. Also, the majority of females had a good perception of their body, even if 24% of them tended to overestimate it and just 10% to underestimate it. In particular, the majority of normal fat females had a right perception of their body, meanwhile underfat females saw themselves fatter and very overfat females saw themselves thinner than they were.

In general, the higher percentage of students who underestimated their body fat is among overfat subjects of both sexes (males: 45.6%; females: 70.6%) and very overfat male subjects (50.9%). Notably, among those who overestimated their body fat, there were 75.0% of underfat males and 70.7% of normal fat females (Table  4 ).

Given the highly significant negative correlations between FAI FAT and %F in both sexes of the examined sample (males: r = − 0.5013; females: r = − 0.3564; p  < 0.0001), we performed a regression analysis identifying body misperception for subjects with FAI FAT ≥ 2 or ≤ − 2 (Figs.  1 and 2 ) in accordance with previous studies [ 41 , 42 ] on the interpretation of perceived figure (Feel figure) and actual anthropometric values. In particular, only one subject from the female subsample (Fig.  1 ) had FAI FAT  = 2: this normal fat young woman misperceived her body as very overfat (FAI FAT  = Feel fat status 4—actual fat status 2 = 2). In the male subsample (Fig.  2 ), there were two overfat subjects with FAI FAT  = − 2, misperceiving their body as normal fat (FAI FAT  = Feel fat status 2—actual fat status 4 = − 2).

Scatterplot representing the relationship between %F and FAI FAT in females. Highlighted in grey the two risk zones

Scatterplot representing the relationship between %F and FAI FAT in males. Highlighted in grey the two risk zones

In this study, we examined the body composition and the body image perception of a sample of Italian University students and we proposed a new index, FAI FAT , in order to evaluate the inconsistency between the perceived body image and the measured fat status.

Our findings on this sample, in which both sexes are well represented, suggest that the body image perception, used as a proxy and measured by the fat status in relation to the estimated body image, was adequate in most subjects. With the exception of three individuals over the entire sample (0.6%), all the considered subjects had a consistent perception of their body with a general tendency to fat overestimation in females and to fat underestimation in males. In particular, according to the new proposed index, under-fat students of both sexes overestimated their body fat and over-fat students underestimated their body fat, suggesting that individuals from extreme groups poorly assess their body fat.

More in general and in accordance with literature in the field [ 11 , 12 , 43 ], the analysis of body image perception shows that females were higher dissatisfied than males and preferred slimmer silhouettes than males did. Almost 23% of males chose silhouette 6 (representing overweight/overfat) as their ideal. The reason might be that they misunderstood this silhouette interpreting it as a more muscular body image, as reported also by other studies [ 44 ].

This new index (FAI FAT ) and the other one previously proposed (FAI) [ 30 ] assess the inconsistency between the body image perception and the actual size of an individual. Nevertheless, the first (FAI FAT ) evaluates the inconsistency on the basis of fat status (%F), while the latter on the basis of weight status (BMI). In the present study, the %F was derived from the analysis of bioelectric impedance (BIA). While BMI tends to overestimate subjects with a high level of fat-free mass [ 45 ], the fat status does not seem to be affected by the same limitations and can be applied even on athletes. A further development of this study will consider applying FAI FAT to body composition parameters obtained using different methodologies (e.g., plicometry). The bias between FAI and FAI FAT is confirmed by our results with FAI showing almost all positive values, and FAI FAT positive values (indicating overestimation) prevalent in lower fat categories and negative values (indicating underestimation) in the overfat and obese categories.

Our new proposed index contributes to the literature a proxy measure of general appropriateness of body image perception according to fat status. Since this index is based on the fat component of the body, its analysis implies that interventions on eating disorders could be more effective by simultaneously monitoring the evolution of body composition and body perception of the patients. This approach might achieve greater success in combating eating disorders.

In conclusion, we deem that further research into health risk is necessary and urgent, especially with regard to non-communicable diseases [ 46 , 47 ]. At a population level, the assessment of body perception and composition by FAI FAT ensures an easy identification of sub-groups in risk zones with the view to monitor and correct their health situation. This control strategy is particularly important to avoid health risk behaviors in case of under fat and over fat people misperceiving their fat status.

Availability of data and materials

The data of this study are not publicly available, but they are available from the corresponding authors upon reasonable request.

Abbreviations

bio-impedance analysis

body mass index

feel weight status minus actual weight status inconsistency

feel fat status minus actual fat status inconsistency assessed by BIA

fat free mass

feel ideal difference

fat percentage

standard deviation

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Acknowledgements

The authors would like to thank all participants for their contribution to this study.

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Luciana Zaccagni, Natascia Rinaldo, Barbara Bramanti, Jessica Mongillo & Emanuela Gualdi-Russo

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Luciana Zaccagni & Emanuela Gualdi-Russo

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EGR, LZ, NR, BB conceived and designed the study. BB, NR, JM collected anthropometric and body image perception data. LZ, NR, JM conducted data analyses. EGR, LZ, NR drafted the manuscript. All authors read, and approved the final manuscript.

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Correspondence to Natascia Rinaldo or Barbara Bramanti .

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Zaccagni, L., Rinaldo, N., Bramanti, B. et al. Body image perception and body composition: assessment of perception inconsistency by a new index. J Transl Med 18 , 20 (2020). https://doi.org/10.1186/s12967-019-02201-1

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DOI : https://doi.org/10.1186/s12967-019-02201-1

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Cultural differences in body image: a systematic review.

1. Introduction

2. materials and methods, 2.1. study protocol, 2.2. eligibility criteria and study selection.

• Inclusion criteria
• Original peer-reviewed research articles published in English;
• Including human subjects of any gender and ethnicity;
• Participants with age more than 4 years old;
• Empirical research articles, including cross-sectional, longitudinal, and experimental designs;
• Published between 1990 and 2023;
• Focus on body image, body dissatisfaction, or related constructs with a cultural or cross-cultural component.
• Exclusion criteria
• Conference papers, review papers, book chapters, etc.;
• Participants less than the age of 4 years old;
• Non-English research articles;
• Articles not focusing on body image or related constructs;
• Studies without a cultural or cross-cultural component.

2.3. Assessment of Quality

3.1. sample characteristics, 3.2. body image and culture, 3.3. vulnerable groups, 3.4. mental health, 4. discussion, 5. limitations and future directions, 6. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Abdoli, M.; Scotto Rosato, M.; Desousa, A.; Cotrufo, P. Cultural Differences in Body Image: A Systematic Review. Soc. Sci. 2024 , 13 , 305. https://doi.org/10.3390/socsci13060305

Abdoli M, Scotto Rosato M, Desousa A, Cotrufo P. Cultural Differences in Body Image: A Systematic Review. Social Sciences . 2024; 13(6):305. https://doi.org/10.3390/socsci13060305

Abdoli, Marzieh, Marco Scotto Rosato, Avinash Desousa, and Paolo Cotrufo. 2024. "Cultural Differences in Body Image: A Systematic Review" Social Sciences 13, no. 6: 305. https://doi.org/10.3390/socsci13060305

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Social media and body image: Recent trends and future directions

Affiliations.

• 1 School for Mass Communication Research, KU Leuven, Parkstraat 45, 3000, Leuven, Belgium. Electronic address: [email protected].
• 2 School of Psychology, UNSW Sydney, New South Wales, 2052, Australia. Electronic address: [email protected].
• 3 College of Education, Psychology and Social Work, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia. Electronic address: [email protected].
• PMID: 35030460
• DOI: 10.1016/j.copsyc.2021.12.002

This review presents recent trends in social media and body image research, with a particular focus on different social media platforms, features unique to social media, and potentially positive content for body image. First, it was found that visual platforms (e.g. Instagram) were more dysfunctional for body image than more textual platforms (e.g. Facebook). Second, taking and editing (but not posting) selfies resulted in negative effects on body image. Positive comments intensified the effects of exposure to idealized content. Third, of the forms of potentially positive content examined in recent research (i.e. fitspiration, disclaimer labels, and body positivity), only body positivity content had a positive effect on body image. Recommendations for future research are offered.

Keywords: Body image; Body positivity; Objectification; Social comparison; Social media.

Copyright © 2021 Elsevier Ltd. All rights reserved.

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Conflict of interest statement

Conflict of interest statement Nothing declared

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Body Image Distress and Its Associations From an International Sample of Men and Women Across the Adult Life Span: Web-Based Survey Study

Alyssa milton.

1 Brain and Mind Centre, The University of Sydney, Sydney, Australia

2 Sydney School of Medicine, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia

Ashlea Hambleton

3 Project Synergy, InnoWell Pty Ltd, Sydney, Australia

4 Inside Out Institute for Eating Disorders, Charles Perkins Centre, University of Sydney, Sydney, Australia

Anna Roberts

Tracey davenport.

5 The Movember Foundation, Australia, East Melbourne, Australia

Associated Data

Frequency statistics, chi-square, and analysis of variance comparing body image items by age and sex.

Linear regression of body image distress by age group.

Pearson correlations of body image items with health and well-being measures for each age group.

Previous research on body image distress mainly relied on samples that were small, generally homogeneous in age or sex, often limited to one geographical region, and were characterized by a lack of comprehensive analysis of multiple psychosocial domains. The research presented in this paper extends the international literature using the results of the web-based Global Health and Wellbeing Survey 2015. The survey included a large sample of both men and women aged ≥16 years from Australia, Canada, New Zealand, the United Kingdom, or the United States.

The main objectives of this study are to examine body image distress across the adult life span (≥16 years) and sex and assess the association between body image distress and various psychosocial risk and protective factors.

Data were extracted from the Global Health and Wellbeing Survey 2015, a web-based international self-report survey with 10,765 respondents, and compared with previous web-based surveys conducted in 2009 and 2012.

The body image distress of young Australians (aged 16-25 years) significantly rose by 33% from 2009 to 2015. In 2015, 75.19% (961/1278) of 16- to 25-year-old adults reported body image distress worldwide, and a decline in body image distress was noted with increasing age. More women reported higher levels of body image distress than men (1953/3338, 58.51% vs 853/2175, 39.22%). Sex, age, current dieting status, perception of weight, psychological distress, alcohol and other substance misuse, and well-being significantly explained 24% of the variance in body image distress in a linear regression ( F 15,4966 =105.8; P <.001).

Conclusions

This study demonstrates the significant interplay between body image distress and psychosocial factors across age and sex.

Introduction

There is a clear need to understand and address body image distress, particularly when considering the increasing prevalence rates of body image distress worldwide [ 1 - 3 ] and the noted relationship between body image distress and mental ill-health [ 4 ]. Furthermore, there is scant large-scale international research examining body image across the adult life span [ 4 ] and from the perspectives of both men and women [ 5 ].

Body image is a multifaceted construct encompassing one’s body-related self-perceptions and self-attitudes, including thoughts, feelings, behaviors, and beliefs toward the body [ 6 ]. Research suggests that body image dissatisfaction occurs when there is a discrepancy between how an individual views their body ( actual body image ) and how they want it to be ( ideal body image ) [ 7 , 8 ]. Dissatisfaction, overevaluation, and preoccupation are considered as contributing factors to body image distress [ 9 ]. Current body ideals predominantly promote thinness for women and muscularity for men [ 10 , 11 ]. Given the difference between current body ideals and the actual body shape and size of most of the population, it is not surprising that many people view their bodies negatively and experience distress because of this negative self-perception [ 12 ].

Body Image Distress Over Time

Body image is ranked as a top concern for young people [ 13 ]. Research suggests that the proportion of the population experiencing increased body image distress is increasing. It has been well documented that viewing appearance-focused media contributes to the development of body image concerns [ 14 , 15 ]. In the past 10 years, there has been a stark rise in multimedia platforms, such as Instagram, Snapchat, and TikTok. The imagery on social media is often filtered and edited in a way that promotes an unrealistic appearance ideal. Research has shown that social media use is associated with increased body image dissatisfaction [ 14 ] because it facilitates comparison, and appearance-related comments and praise are reinforced with likes, follows, and comments.

Body Image, Age, and Sex

The association between weight status (as measured by BMI) and body image dissatisfaction has been previously explored [ 16 ]. Research has demonstrated that increased BMI is associated with greater body image dissatisfaction in college students [ 17 ], help-seeking adults [ 18 ], adolescent men [ 19 ], and nonclinical samples of adult women [ 20 ]. Risk of body dissatisfaction is not restricted to individuals with higher BMI; adolescent women with either a healthy or an overweight BMI experience higher levels of body dissatisfaction, whereas underweight women have the highest levels of body satisfaction [ 19 ]. Similarly, in a sample of middle-aged women, 70% of participants reported a desire to be thinner, despite most being considered normal weight [ 21 ]. Overall, these findings fit the current cultural narrative that a thin body is both desirable and idealized in Western societies [ 22 ].

Although the research has mainly focused on young women, some studies indicate that body image concerns are pervasive across the adult life span [ 12 ] for both sexes [ 5 ]. The picture appears to be more complex for men [ 23 ]. For example, adolescent men tend to be equally divided between wanting to lose weight (predominantly high body fat) and gain weight (muscle mass) [ 5 , 24 ]. As men move into adulthood, there is an increase in the desire to lose weight [ 5 ]. Within cohorts of middle-aged women, only 11% of participants endorsed being satisfied with their bodies [ 25 ]. Women’s dissatisfaction with their bodies appears relatively stable across the adult life span [ 8 , 12 ]. However, some research suggests that the impact of body image on an individual’s self-esteem and self-concept may diminish over time [ 26 ]. Furthermore, there is more tolerance in what body sizes are considered acceptable with increasing age [ 4 , 27 ]. However, overall, body image research looking at age, sex, and weight is fragmented, and a comprehensive picture is lacking.

Body Image Distress and Psychopathology

Body image dissatisfaction in childhood and early adolescence can predict adverse health outcomes in later life, including engaging in dangerous weight control behaviors and general psychological distress [ 28 ]. As highlighted above, research with adolescents is much more extensive than with their adult counterparts, with several studies demonstrating an association between body dissatisfaction and anxiety [ 29 - 33 ], depression [ 29 , 30 , 34 - 37 ], self-harm [ 38 - 42 ], and low self-esteem [ 28 , 36 , 37 ].

Research has reported that body image dissatisfaction is associated with higher levels of depression, anxiety, disordered eating [ 43 - 45 ], and distress [ 46 ]. Furthermore, research has identified associations between body image with other aspects of health, such as tobacco smoking [ 47 ], alcohol misuse [ 48 ], poor self-esteem [ 18 , 49 , 50 ], and poor mental and physical health–related quality of life [ 46 ].

Conversely, optimism, positive affect, self-compassion, life satisfaction, and subjective happiness [ 51 - 61 ] are associated with positive body image. Social well-being has also been reported to play a part in both positive and negative body image, particularly in adolescents [ 59 , 62 - 64 ]. For example, Bearman et al [ 63 ] observed higher levels of body dissatisfaction in girls and boys who had deficits in their social support from parents and peers. Meanwhile, individuals with more supportive parental relationships have reported higher body image satisfaction [ 62 ].

Current Research

Previous research exploring body image distress mainly relied on small samples that were generally homogeneous in age or sex, lacked a comprehensive analysis of multiple psychosocial domains, and were limited to one geographical region. This study extends the international literature using the results of the Global Health and Wellbeing Survey 2015, a large web-based sample of both men and women (aged ≥16 years) from Australia, Canada, New Zealand, the United Kingdom, or the United States. Additional data sources included the headspace web-based Community Youth Survey (2009) and the Young and Well First National Survey on the web (2012).

This study has 3 main aims, including the assessment of (1) the changes in body image distress over time (between 2009 and 2015) for young people aged 16 to 25 years; (2) the associations between weight range (BMI), dieting status, and perceived body image distress by sex and age group; and (3) the association of various demographic, health, and well-being factors with body image distress or preoccupation.

Participants

Participants were a voluntary community sample of men and women (aged ≥16 years) who reported that they had lived in 1 of the 5 target countries (Australia, Canada, New Zealand, the United Kingdom, or the United States) for the best part of the past 12 months. A total of 16,510 people reviewed the consent and eligibility screen. Of the 16,510 people, the total eligible sample was 10,765 (65.2%) respondents. Of those excluded, 26.2% (4326/16,510) did not consent to participate, and 4.3% (710/16,510) were younger than 16 years.

Procedures and Recruitment

The primary study received institutional ethics approval from The University of Sydney Human Research Ethics Committee (protocol 2015/412). All procedures complied with the ethical standards of the relevant national and institutional committees on human ethics and the Helsinki Declaration of 1975, as revised in 2008.

The survey was hosted on the internet from July 1, 2015, to December 11, 2015. For optimizing recruitment in the 5 target countries, the following strategies were used: both paid and free advertising across multiple social media channels such as Facebook, Twitter, and YouTube for survey dissemination [ 65 ]; layering of recruitment messages [ 66 ]; passive web-based snowballing via social media to spread study information through sharing, liking, and tweeting [ 65 , 67 ]; and traditional snowballing [ 68 ]. Targeted recruitment based on age, sex, and region was carried out through paid advertising channels to maximize responses from groups hard to reach. Respondents consented on the website and were informed that their responses were confidential, nonidentifiable, and that they could cease participation at any time. Participants were informed that the survey would take between 20 and 45 minutes to complete depending on participant answers and the survey skip pattern. Any respondents indicating psychological distress or problematic alcohol or substance use in their responses were provided with the contact details of local support lines.

Items in this substudy were extracted from the Global Health and Wellbeing Survey 2015 [ 69 ], and where items could be compared, from the headspace web-based Community Youth Survey (2009) and the Young and Well First National Survey on the web (2012) . Areas of interest specific to this substudy are described in the following sections.

Demographics

The respondents first provided their sex (men and women) and age (16-25 years, 26-49 years, or ≥50 years).

Weight, Body Image, and Eating Behaviors

BMI was determined by asking respondents their weight (kg or lb) and height (meters or feet and inches). Respondents with a BMI less than 18.5 were classified as underweight , a BMI between 18.5 and 24.9 as healthy weight , a BMI between 25.0 and 29.9 as overweight , and a BMI higher than 30.0 as obese .

Current dieting status was determined by the question “Are you currently dieting?” adapted from Blashill and Wilhelm [ 70 ]; this item provided 3 response options (“yes, to lose weight”; “yes, to gain weight”; and “no”).

For assessing body image attitudes, respondents were asked to self-evaluate the importance of weight and shape for them over the past 3 months: “How much has your shape influenced how you feel as a person?” This question was answered on a 6-point Likert scale ranging from not at all to a great deal .

For assessing body image distress or preoccupation, respondents were asked, “Do you get very distressed or preoccupied by any specific aspect of your physical appearance?” using a dichotomous yes or no response option. If respondents indicated distress or preoccupation, a follow-up question asked which areas of their body they were concerned about, such as facial features , arms or legs , and weight [ 71 ]. This body image distress item was also asked in the web-based headspace Community Youth Survey in 2009 and the Young and Well National Survey on the web in 2012 with 16- to 25-year-old adults [ 71 ]. These data were used in this research for longitudinal cohort comparisons.

Mental Health and Well-being

Physical activity was measured by the International Physical Activity Questionnaire short form, which classifies individuals into 1 of 3 levels of physical activity ( inactive vs minimally active vs health-enhancing physical activity ) [ 72 ].

Current psychological distress was measured using the 10-item Kessler Psychological Distress Scale (K10) [ 73 ]. Total scores were grouped into 4 levels of psychological distress (10-15=low, 16-21=moderate, 22-29=high, and 30-50=very high) [ 74 ].

Respondents’ levels of suicidal thoughts and behaviors in the past 12 months were measured using the 5-item suicidal thoughts and acts subscale from the Psychiatric Symptom Frequency Scale [ 75 ].

The likelihood of alcohol or other substance misuse was calculated using 2 items. If respondents positively endorsed one of either item, “...recently thought that you should cut down...” or “...another person suggested you should cut down...,” they were categorized as having a possible alcohol or other substance misuse. Endorsement of both items resulted in probable alcohol or other substance misuse. Endorsement of neither item resulted in being placed in the not likely category.

Days out of role was extracted from the Brief Disability Questionnaire [ 76 ] to investigate functioning. The 7-item Personal Well-being Index [ 77 ] was used to assess subjective well-being.

Happiness was measured by the 4-item Oxford Happiness Questionnaire [ 78 ], and resilience was measured by the 4-item Brief Resilience Coping Scale [ 79 ].

Perceived social support and conflict in close relationships were measured by the 5-item Schuster Social Support and Conflict Scale [ 80 ].

Survey data were prepared and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp, 2013). For addressing aim 1, body image distress data in 2009 and 2012 were compared with 2015 data using a one-sample two-tailed t test. To address aim 2, descriptive and frequency statistics were used to describe all weight, dieting, and body image items by basic demographics (sex and age). Chi-square and analysis of variance tests were completed to compare items by sex and age. For addressing aim 3, an initial scoping analysis using Pearson product-moment r correlations [ 81 ] was conducted to independently assess the strength of the relationship between body image distress and these health and well-being items (healthy weight; no vs yes based on BMI data), current dieting status ( no vs yes ), perception of weight ( about the right weight vs all others ), physical activity (International Physical Activity Questionnaire short form), psychological distress (K10), suicidal ideation (Psychiatric Symptom Frequency Scale), alcohol and/or other substance misuse, days out of role, well-being (Personal Well-being Index), happiness (Oxford Happiness Questionnaire), resilience (Brief Resilience Coping Scale), intimate bonds (Intimate Bond Measure), and social support (Social Support and Conflict Scale). A subsequent linear regression analysis was conducted to determine which of the health and well-being items significantly explained variance in body image distress when considered together while controlling for sex and age.

Respondent Participation Rates and Characteristics

Most of the eligible respondents were women (6464/10,765, 60.05%). Of the 10,753 respondents, 2874 (26.73%) were aged between 16 and 25 years, 2879 (26.77%) were aged between 26 and 49 years, and 5000 (46.49%) were aged ≥50 years. A breakdown of demographics by country, age, and sex is presented in Table 1 . Further demographic details can be found in related publications [ 82 , 83 ].

Participant demographics by country, age, and sex (N=10,765).

Main Findings

Aim 1: changes in body image distress over time across the life span.

Of those young Australians (aged 16-25 years) who completed the 2009 ( headspace web-based Community Youth Survey), 2012 (Young and Well First National Survey on the web), or 2015 (Global Health and Wellbeing Survey) surveys, self-reported body image distress rose by 33% from 2009 to 2015 (419/949, 44.2% reported distress in 2009; 1158/1731, 66.89% in 2012; and 300/388, 77.32% in 2015). The mean difference was significant across both the 2009 and 2012 time points (2009 vs 2015: t 387 =15.56, P <.001; 2012 vs 2015: t 387 =4.90, P <.001).

Aim 2: Body Image, BMI, and Dieting by Age and Sex

Table 2 displays frequency statistics for measures of body image items, BMI, and current dieting status by age band and sex from the Global Health and Wellbeing Survey 2015. Significance tests comparing items across sex and age are presented in Multimedia Appendix 1 . Approximately half of all respondents (2806/5513, 50.89%) reported feeling very distressed or preoccupied with their body image. Women reported higher levels of distress related to body image than men (1953/3338, 58.51% vs 853/2175, 39.22%). Respondents aged 16-25 years showed higher levels of body image distress than all other age groups, at 75.19% (961/1278), with distress decreasing as age increased.

Frequency statistics for measures of body image item by age and sex (maximum N=5517).

Only 17.01% (935/5496) of respondents in the full sample indicated that their weight and shape did not influence how they thought of themselves as a person. Women (425/3327, 12.77%) and the younger age bands (16-25 years: 130/1275, 10.19%; 25-44 years: 181/1497, 12.09%) were significantly less likely to endorse that their weight or shape did not influence their self-perception ( P <.001).

Although 57.77% (721/1248) of young people (16-25 years) were in the healthy BMI range, fewer (574/1279, 44.88%) considered themselves about the right weight. This pattern was repeated in women, of whom 41.19% (1344/3264) were in the healthy BMI range, but fewer (1057/3339, 31.66%) endorsed that they were about the right weight. The percentage of men who were in a healthy BMI range was 31.73% (671/2115), which reflected the rates of men who felt they were about the right weight (646/2176, 29.69%). In the older age brackets, more participants were in the obese BMI category (26-49 years: 406/1464, 27.75%; ≥50 years: 961/2667, 36.03%) than those who felt that they were very overweight (26-49 years: 274/1503, 18.23%; ≥50 years: 718/2733, 26.27%). Across the full sample, 23.47% (1295/5517) of all participants were currently dieting to lose weight, and 1.38% (76/5517) were currently dieting to gain weight. Across ages, not engaging in any dieting was relatively consistent (between 1112/1503, 73.99% and 972/1278, 76.06%). Women reported they were dieting to lose weight significantly more frequently (868/3339, 25.99%) than men (427/2178, 19.61%; P <.001).

For addressing aim 3, a series of linear regressions were conducted to examine the relationship between body image distress or preoccupation and health and well-being items. Table 3 presents the full sample results ( Multimedia Appendix 2 for each age group). Individual Pearson product-moment r correlations for each health and well-being item by body image distress are presented in Multimedia Appendix 3 . The regression model using the full sample significantly accounted for 24% of the variance in body image distress or preoccupation ( F 15,4966 =105.8; P <.001; R 2 adj =0.24). After controlling for sex (β=.12; P <.001) and age (β=−0.24; P <.001), 5 variables significantly explained model variance. This included current dieting status (β=.13; P <.001), perception of weight (β=.09; P <.001), psychological distress (β=.21; P <.001), alcohol and/or other substance misuse (β=.04; P <.001), and well-being (β=−0.07; P <.001). Specifically, respondents who were currently dieting reported body image distress or preoccupation more frequently. Those who did not report that they were about the right weight reported higher psychological distress and had a higher likelihood of problematic alcohol or other substance use and higher body image distress or preoccupation. Participants with higher personal well-being scores reported lower levels of body image distress or preoccupation.

Linear regression of body image distress ( F 15,4966 =105.8; P <.001; R 2 adj =0.24).

a df =15,4966

b IPAQ: International Physical Activity Questionnaire short form.

c K10: 10-item Kessler Psychological Distress Scale.

d PSFS: Psychiatric Symptom Frequency Scale.

e PWI: Personal Well-being Index.

f OHQ: Oxford Happiness Questionnaire.

g BRCS: Brief Resilience Coping Scale.

h SSCS: Schuster Social Support and Conflict Scale.

i IBM: Intimate Bond Measure.

When analyzed separately by age group ( Multimedia Appendix 2 ), sex, current dieting status, perception of weight, and psychological distress consistently explained model variance across all age groups. Variation was found for happiness, alcohol or other substance misuse, and well-being items. Specifically, lower happiness also explained body image distress (β=−0.16; P =.003) in young people (aged 16-25 years). For those aged 26 to 49 years, alcohol and/or other substance misuse remained an item that explained body image distress (β=.07; P =.008). Conversely, for the ≥50 years age group, lower well-being continued to explain body image distress (β=−0.10; P =.001) variance.

Principal Findings

To our knowledge, this is the largest international study to examine body image distress—and other related factors, including self-reported and perceived weight range and dieting status—across time, age, and sex. Our findings show that body image distress has become a highly prevalent issue by 2015. Of concern, considerable levels of body image distress were present in women and young people, and multiple psychosocial risk factors were associated with this distress.

One of our key findings comes from the cross-sectional longitudinal Australian data. Self-reported body image distress in young people aged 16 to 25 years increased from 44.2% (414/949) of those surveyed in 2009 to three-quarters (961/1278, 75.19%) in 2015. This finding is consistent with the increasing prevalence rates of body image distress in countries such as the United States [ 1 ]. Furthermore, although there are some suggestions in the literature that concern regarding body image has increased in Australia [ 84 - 86 ], this is the first known study to report changes across these 3 time points using web-based samples. Our data indicate that the issue is much more prevalent. This increasing prevalence of body image distress corresponds with the rise of social media. During the time frame of the survey, Instagram was launched in 2010, Snapchat was released in 2011, and TikTok was released in 2016. As photographs and videos are central to the use of these platforms, and previous research has shown an association between body image distress and social media use, perhaps this increased level of distress has occurred in parallel with the rise of social media [ 14 , 15 ].

This rise in prevalence is particularly concerning, given our findings that body image distress was associated with increased levels of current dieting, poorer self-perception of weight , higher psychological distress, increased alcohol or other substance misuse, and poorer personal well-being. This is consistent with previous research where higher body image dissatisfaction directly correlated with poor mental health–related quality of life and psychosocial functioning [ 17 ]. Furthermore, literature examining body appreciation has reported associations with greater subjective happiness [ 56 ] and fewer days of feeling mentally or physically unhealthy [ 87 ]. It is unclear whether these factors are precipitating factors or consequences of body image distress. As 24% of the variability in body image distress was accounted for by these factors, future research could endeavor to explore what other factors are potentially missing from this model that also contribute to distress, such as social media use or history of disordered eating. Overall, when considering the rise of body image distress and its link to poorer psychosocial outcomes, a sharper focus on this area is needed.

Another important finding was that in our 2015 international sample, more than half of the participants’ BMI in the overweight or obese range (59.34%), with men reporting higher levels of obesity than women. This in itself is concerning, as obesity is considered one of the greatest health epidemics worldwide [ 88 - 91 ]. Furthermore, our findings demonstrated a notable sex difference concerning how men and women perceive their weight compared with their self-reported weight as measured by BMI. Specifically, despite a higher percentage of men having an overweight or obese BMI, more women (772/3339, 23.12%) considered themselves to be very overweight than men (351/2176, 16.13%). Although more women in this sample were in a healthy weight range (women: 1344/3264, 41.19%; men: 671/2115, 31.73%), only one-third of women believed they were about the right weight . This is consistent with data from previous studies demonstrating that women are more likely to perceive themselves as overweight compared with men [ 35 , 92 - 95 ]. In the literature, possible factors that may contribute to this discrepancy include self-esteem [ 96 ], sociocultural influences, and expectations [ 97 - 99 ].

Interventions in this area are relatively unexplored, particularly those targeting both men and women. Evidence-based interventions include self-monitoring, cognitive restructuring, exposure exercises, fitness training, mirror work [ 100 ], media literacy, self-esteem enhancement, and psychoeducation. However, these interventions only achieve minor improvements in body image [ 101 , 102 ]. Interventions with a greater focus on stress management training, cognitions, and negative body image causes appear to be more effective [ 101 ]. There is some evidence that self-compassion training can be beneficial for weight loss, nutrition behaviors, eating behaviors, and body image [ 103 ]. This training focuses on promoting self-worth, creating a more positive body image, and decreasing body dissatisfaction, and may be the way forward to improve health outcomes in distressed individuals.

These discrepancies between actual and perceived weight were not only a function of sex but also of age. Our 2015 survey results indicated that 57.77% of young people were in the healthy BMI weight range—the highest endorsement across all age groups. Despite this, three-quarters of young people reported body image distress. Again, this was the highest endorsement across all age groups. As participants aged, their BMI increased—with far more in the overweight and obese categories. However, the rate of body image distress declined as participants aged, as did the influence of weight or shape on how they viewed themselves as a person. Previous literature supports this phenomenon [ 104 - 107 ]. This change could be attributed to a shift in body comparisons with age-appropriate peers [ 8 ], less cultural fat phobia [ 105 - 107 ], or a focus on body function rather than body appearance [ 108 ].

Furthermore, research has theorized that people’s preoccupation and desire to change their body weight via dieting behavior becomes less salient with age [ 26 ]. Interestingly, our survey results demonstrated that approximately three-quarters of people reported they were not dieting, and this proportion remained relatively stable across each age group. Thus, although body image distress decreases with age, in line with the Webster and Tiggemann study [ 26 ], our contradictory finding is that dieting behaviors remain relatively consistent. Further research is needed to examine whether this is explained by the changes in people’s reasons for dieting as they age. For example, older people might be dieting for health or medical reasons rather than because of their body image concerns.

Implications for Policy and Practice

This study supports the clear link between body image distress and poorer health and well-being [ 28 ]. Prevalence rates of body image dissatisfaction have increased worldwide in the past 30 years [ 109 ]. Our research shows that this prevalence is 3 in 4 young people when using a web-based survey methodology. These are compelling statistics. In 2019, the Australian government invested US $146 million into the prevention, detection, assessment, and treatment of eating disorders [ 110 ]. Although this is timely, our findings on the inverse relationship between individual distress and psychosocial outcomes make a strong case for the need for prevention and early intervention before eating disorders emerge. This may include more comprehensive assessment when accessing health services and the use of health information technologies to improve support services [ 111 ]. Given our findings, such interventions may benefit from targeting across sex and age.

Previously, body image distress was thought to result from the discrepancy between actual and perceived body image. However, our results suggest that the rates of body image distress within some age groups far exceed the proportion of the population who experience a discrepancy, indicative of other factors contributing to distress. For example, research is needed to determine whether these results are related to the considerable increases in the use and availability of social media in the past decade [ 14 ]. Exposure to social media, particularly in an individual’s formative years, could have a considerable impact on a young person’s sense of self, quality of life, and body image than is currently known. Some studies have demonstrated that the use of highly visual social media such as Instagram or Snapchat is linked to upward social comparison and internalization of symptoms of body dysmorphia, resulting in increased body image distress [ 112 - 115 ]. The more time spent on social media, the more significant the body image concerns [ 116 - 118 ]. Photograph-based activity (eg, posting photographs and viewing or making comments on others’ photographs) is particularly salient in contributing to body dissatisfaction and disordered eating [ 14 ]. As the data in this study were from a web-based sample recruited using social media channels, the results may reflect the experience of body image distress of a web-based population, who may be more likely to be using other platforms such as Instagram.

Body image distress and dieting behaviors are well understood to be risk factors for disordered eating and the development of an eating disorder. Our results indicate a relationship between dieting behavior, psychological distress, and the self-perception of weight, in addition to alcohol and/or other substance use and well-being impact on body image distress. The triangulation of items such as those used in this survey (BMI vs distress vs dieting status, or BMI vs distress vs perceptions of weight) may be beneficial as a brief screening tool. Given the burden of completing lengthy psychometrics, how these brief screeners compare with lengthier eating disorder questionnaires should be explored.

Strengths and Limitations

A key strength of this study is that it is one of the largest samples to date, providing data on weight, perceptions of weight, dieting status, body image distress, and health and well-being. As outlined in the main report’s executive summary [ 69 ], a key limitation of the research is the nonepidemiological nature of the web-based research; targeting efforts were made for age, sex, and by country to address this. Although most individuals in the participating countries have widespread internet access [ 119 ], this study will also yield some level of internet bias, in that those who do not frequently access the internet or social media recruitment websites may not have participated. However, a major advantage to using a web-based surveying methodology is that previous research has found that it is associated with increased disclosure of sensitive information [ 120 ], such as the items asked in this survey. There is also the possibility of avidity bias occurring, as those with a greater interest in the subject may be more likely to participate [ 121 ]. However, overall, this research remains highly relevant, as it is the interactions between variables, not merely the statistical frequencies, that generate meaningful information. Furthermore, as we move further into the 21st century, web-based questionnaires may become more the norm than the exception.

Where possible, measures that have been tested for reliability and validity across general populations worldwide were used. For example, the K10 is the standard tool used to measure distress in Australia’s National Survey of Mental Health and Wellbeing (Burgess et al [ 122 ]) and is used widely in international studies. The BMI [ 121 ] is the most recommended and widely used tool for classifying weight range in adults [ 123 ]. However, the use of BMI is limited and has several deficiencies as a measure of obesity [ 124 ]. BMI is not a reliable reflection of health status, does not accurately reflect changes that occur with age, cannot account for muscle mass, and is a poor indicator of body fat percentage [ 123 ].

Furthermore, the participants were asked to self-report their height and weight. Responses may have been subject to bias as BMI is often calculated with overestimated height and underestimated weight data [ 125 ]. Furthermore, owing to the breadth and sheer size of the Global Health and Wellbeing Survey 2015, validated measures for eating disorders such as Eating Disorder Inventory, third edition [ 126 ] and the Eating Attitudes Test [ 127 ] were not viable to use. Instead, we asked brief questions (all adapted from established literature) on areas such as dieting status, perceptions of weight, and body image distress. Overall, the results are still meaningful. Although they may not be fully representative of the populations with eating disorders, they demonstrate a clear link between body image distress and health and well-being concerns.

This research demonstrates the significant interplay between body image distress and psychosocial risk factors, including currently dieting, worse perceptions of weight, elevated psychological distress, increased alcohol or other substance misuse, and poorer personal well-being. Considering that an increasing number of young people are experiencing body image distress, body image should be closely monitored, given its association with poorer health outcomes. Further research into tailored intervention and prevention strategies for those experiencing any level of body image distress, obesity, eating disorders, and other health-related concerns is needed.

Acknowledgments

The Global Health and Wellbeing 2015 Survey was commissioned by the Movember Foundation and conducted by the University of Sydney’s Brain and Mind Centre and the Young and Well Cooperative Research Center (Young and Well Cooperative Research Centre: 2011-2016). The authors would like to acknowledge the respondents who consented to participate on the web in the Global Health and Wellbeing 2015 Survey; the international consortia for the Global Health and Wellbeing 2015 Survey, including Professor Sagar Parikh, Professor Richard Porter, Professor Jan Scott, and Dr Michael Rovito; the Movember Foundation (Australia) lead on the project Therese Fitzpatrick; and the Brain and Mind Centre team: Victoria Baldwin, Lisa Whittle, Django White, Laura Ospina Pinillos, Sarah Piper, Hannah Yee, and Frank Iorfino. The authors would also like to acknowledge the Young and Well CRC and headspace for the 2012 and 2009 data sets. The Movember Foundation commissioned this research. This project is also supported by philanthropic funding, for which donors are families affected by mental illness who wish to remain anonymous. This study was also funded by a National Health and Medical Research Council Australia Fellowship (No. 511921, awarded to IH).

Abbreviations

Multimedia Appendix 1

Multimedia appendix 2, multimedia appendix 3.

Conflicts of Interest: IH was an inaugural Commissioner on Australia’s National Mental Health Commission (2012-18). He is the codirector of Health and Policy at the Brain and Mind Centre (University of Sydney, Australia). The Brain and Mind Centre operates early-intervention youth services at Camperdown under contract to headspace. IH has previously led community-based and pharmaceutical industry–supported (Wyeth, Eli Lilly, Servier, Pfizer, and AstraZeneca) projects focused on the identification and better management of anxiety and depression. He was a member of the Medical Advisory Panel for Medibank Private until October 2017, a board member of Psychosis Australia Trust, and a member of the Veterans Mental Health Clinical Reference group. He is the chief scientific advisor to and a 5% equity shareholder in InnoWell Pty Ltd. InnoWell was formed by the University of Sydney (45% equity) and PwC (Australia; 45% equity) to deliver the Aus $30 (US $22.2) million Australian government–funded Project Synergy (2017-20; a 3-year program for the transformation of mental health services) and lead transformation of mental health services internationally through the use of innovative technologies. JB is chair of the National Advisory Council for Open Arms, Veterans, and Families Counseling Service. She is a well-being and digital health consultant to Bupa, a member of the Veterans Mental Health Clinical Reference group, and a chief investigator and author of the Defense and Veterans Transition and Well-being Study. She is the founder of and an equity shareholder in InnoWell. She is a professor of Social Innovation and Chair of the Center for Mental Health at Swinburne University and an adjunct professor of Social Impact and Entrepreneurship at Royal Melbourne Institute of Technology. TD is now the director of Research & Insights at the Australian Digital Health Agency. The other authors have no conflicts of interest to disclose.

Nursing aide turned sniper: Thomas Crooks' mysterious plot to kill Trump

BUTLER, Pa. – Donald Trump and would-be assassin Thomas Crooks started on their violent collision course long before the former president's political rally ended in gunshots and death.

Crooks, 20, was a one-time registered Republican, a nursing home worker with no criminal record, shy in school, and living in a decent middle-class neighborhood in suburban Pennsylvania with his parents. Trump, 78, was eyeing Crooks' state as a key battleground – but not in the way that anyone envisioned on Saturday.

Riding high on polls showing that he's got a strong chance of toppling President Joe Biden, the former president had been campaigning for reelection in swing states, and Pennsylvania is a key prize. Trump won the state in 2016 but lost it four years later.

And on July 3, Trump's campaign announced he would hold a rally at the Butler Farm Show grounds, about 30 miles north of Pittsburgh.

"Pennsylvania has been ravaged by monumental surges in violent crime as a direct result of Biden’s and Democrats’ pro-criminal policies," Trump's campaign said in announcing the event, noting that when he's elected, he'll "re-establish law and order in Pennsylvania!"

The Saturday attack on Trump turned the heated rhetoric of the 2024 presidential campaign freshly violent. Authorities said bullets fired from Crooks' AR-15 style rifle about 150 yards away grazed Trump's ear, killed a rally attendee as he dove to protect his family, and critically wounded two others. Secret Service agents killed Crooks moments later.

Attack planned well in advance

Investigators are still seeking Crooks' motive – despite his Republican leanings, he had donated recently to a progressive voter-turnout campaign in 2021 – but indicated he'd planned the attack well in advance.

The shooting marks the first assassination attempt against a former or current U.S. president since President Ronald Reagan was injured in a March 1981 shooting at a Washington, D.C., hotel. 

There are many questions about why Crooks turned into a would-be presidential assassin, firing indiscriminately into hordes of political supporters.

FBI special agent Kevin Rojek said on a call with media that law enforcement located "a suspicious device" when they searched Crooks' vehicle and that it's being analyzed at the FBI crime lab.

"As far as the actions of the shooter immediately prior to the event and any interaction that he may have had with law enforcement, we're still trying to flesh out those details now," Rojek said.

None of Crooks' shocked neighbors or high school classmates described him as violent or that he in any way signaled he was intent on harming Trump. Sunday morning, reporters and curious locals swarmed the leafy streets of the home where Crooks lived with his parents in Bethel Park, about 50 miles from the shooting scene.

Those who knew him described a quiet young man who often walked to work at a nearby nursing home. One classmate said he was bullied and often ate alone in high school.

Sunday morning, neighbor Cathy Caplan, 45, extended her morning walk about a quarter mile to glimpse what was happening outside Crooks’ home.“It came on the morning news and I was like ‘I know that street,’” said Caplan, who works for the local school district. "It feels like something out of a movie.”

Dietary aide turned deadly killer

Authorities say they are examining Crooks' phone, social media and online activity for motivation. They said he carried no identification and his body had to be identified via DNA and biometric confirmation.

Although no possible motive has yet been released, Crooks nevertheless embodies the achingly familiar profile of an American mass shooter: a young white man, isolated from peers and armed with a high-powered rifle. His attack was one of at least 59 shootings in the United States on Saturday, according to the Gun Violence Archive.

According to records and online posts of the ceremony, Crooks graduated from Bethel Park High School, about 42 miles from Butler County, on June 3, 2022. That same day, Trump met briefly with investigators at his Mar-a-Lago club in Florida as they examined whether he improperly took classified documents with him when he left the White House.

A classmate remembered Crooks as a frequent target of bullies. Kids picked on him for wearing camouflage to class and his quiet demeanor, Jason Kohler, 21, said. Crooks usually ate lunch alone, Kohler said.

Crooks worked as a dietary aide at the Bethel Park Skilled Nursing and Rehabilitation, less than a mile from his home. In a statement provided to USA TODAY on Sunday, Marcie Grimm, the facility's administrator, said she was "shocked and saddened to learn of his involvement."

Neighbor Dean Sierka, 52, has known Crooks and his parents for years. The families live a few doors apart on a winding suburban street, and Sierka’s daughter, who attended elementary, middle and high school with Crooks, remembers him as quiet and shy. Sierka said they saw Crooks at least once a week, often when he was walking to the nursing home from his parents' three-bedroom brick house.

"You wouldn’t have expected this," Sierka said. "The parents and the family are all really nice people."

"It's crazy," he added.

Secret Service role: Did they do enough?

Founded in 1865, the Secret Service is supposed to stop this kind of attack, and dozens of agents were present Saturday. As the former president and presumptive Republican presidential nominee, Trump's public appearances are managed by the Secret Service, which works with local law enforcement to develop security plans and crowd-management protocols.

In the days before the event, the agency's experts would have scouted the location, identified security vulnerabilities, and designed a perimeter to keep Trump and rally attendees safe. Congress and the Secret Service are now investigating how Crooks was able to get so close to the former president, and several witnesses reported seeing him in the area with the gun before Trump took the stage.

As the event doors opened at 1 p.m., the temperature was already pushing close to 90, and ticketed attendees oozed through metal detectors run by members of the Secret Service's uniformed division. Similar to airport security screenings, rallygoers emptied their pockets to prove they weren't carrying guns or other weapons.

Media reports indicate the Secret Service had in place, as usual, a counter-sniper team scanning the surrounding area for threats.

In an exclusive interview, former Secret Service Director Julia Pierson told USA TODAY that maintaining such a sniper security perimeter is part of the agency's responsibility for safeguarding protectees like Trump from harm. She said agents typically consider 1,000 yards to be the minimum safe distance for sniper attacks.

The Secret Service has confirmed that it is investigating how Crooks got so close to Trump, who took the stage shortly after 6 p.m. Officials say Crooks' rifle was legally obtained but have not yet released specifics.

Outside the venue at that time, Greg Smith says he tried desperately to get the attention of police. He told the BBC that he and his friends saw a man crawling along a roof overlooking the rally. Other witnesses said they also saw a man atop the American Glass Research building outside the official event security perimeter, well within the range of a 5.56 rifle bullet.

"We noticed the guy bear-crawling up the roof of the building beside us, 50 feet away from us," Smith told the BBC. "He had a rifle, we could clearly see him with a rifle."

Smith told the BBC that the Secret Service eventually saw him and his friends pointing at the man on the roof.

"I'm thinking to myself, why is Trump still speaking, why have they not pulled him off the stage?" Smith said. "Next thing you know, five shots rang out."

From his nearby deck, Trump supporter Pat English watched as the former president took the stage to Lee Greenwood's "God Bless the U.S.A.," and attendees raised their cell phones to record.

English had taken his grandson to see the rally earlier but left when it got too hot. From his deck, they listened as Trump began speaking at 6:05 p.m., backed by a crown of red-hatted MAGA supporters waving "fire Joe Biden" signs.

And then gunfire began.

Boom, boom, boom

"I heard a 'boom, boom, boom' and then screams,” English said Sunday. "I could see people running and the police run in."

Trump was saying the word "happened" as the first pop rang out. He reached up to grab his ear as two more shots echoed, and the crowd behind him – and Trump himself – ducked. Plainclothes Secret Service agents piled atop the president as a fusillade of shots rang out, apparently the Secret Service killing Crooks.

The crowd screamed, and the venue's sound system picked up the agents atop Trump planning to move the former president to safety. One yelled, "shooter's down. Let's move, let's move."

The agents then helped Trump back to his feet as they shielded him on all sides.

The sound system then picked up Trump's voice: "Wait, wait," he said, before turning to the audience and triumphantly raising his fist to yell "fight, fight" as the crowd cheered, blood streaming down his face.

By 6:14 p.m. Trump's motorcade was racing from the scene, and in a later statement, Trump's campaign said he was checked out at a local medical facility.

"I was shot with a bullet that pierced the upper part of my right ear," Trump said in a statement. "I knew immediately that something was wrong in that I heard a whizzing sound, shots, and immediately felt the bullet ripping through the skin. Much bleeding took place, so I realized then what was happening."

Firefighter 'hero' gunned down

Outside of the Butler Township Administration Office Sunday afternoon, Pennsylvania Gov. Josh Shapiro identified the rally attendee killed by Crooks as Corey Comperatore, a firefighter, father of two and longtime Trump supporter.

“Corey died a hero,” Shapiro said. “Corey dove on his family to protect them last night at this rally. Corey was the very best of us. May his memory be a blessing.”

Two other Pennsylvanians are still undergoing treatment for their injuries, Shapiro said.

Pennsylvania State Police identified two wounded attendees David Dutch, 57, of New Kensington, and James Copenhaver, 74, of Moon Township. Both are hospitalized and listed in stable condition. Shapiro said he spoke with the family of one victim and received a message from the other.

Biden spoke briefly with Trump on Saturday night, and the president condemned the assassination attempt as “sick.” He said there’s no place for political violence in the U.S. and called on Americans to unite together to condemn it.

But earlier in the week, Biden told campaign donors in a private phone call it was time to stop talking about his own disastrous presidential debate performance and start targeting Trump instead.

"I have one job and that's to beat Donald Trump," Biden said. "We're done talking about the (June 27) debate. It's time to put Trump in the bullseye."

Republicans across the country have used similar language to attack their opponents over the years, and political scientists say violent rhetoric used worldwide almost invariably leads to physical violence.

On Sunday, someone parked a truck-mounted electronic billboard at the gates to the Butler Farm Show grounds reading "Democrats attempted assassination," along with a picture of Trump clutching an American flag, his face overlaid with a bullseye crosshairs.

Authorities say they have not yet determined a motive for Crooks' attack. But in a statement, Trump declared the shooting an act of evil and thanked God for preventing the unthinkable.

"We will fear not, but instead remain resilient in our faith and defiant in the face of wickedness," Trump said.

And he said he'd be back on the campaign trail for the Republican National Convention in Milwaukee, which starts Monday.

"Based on yesterday’s terrible events, I was going to delay my trip to Wisconsin, and the Republican National Convention, by two days," Trump said on his Truth Social account Sunday, "but have just decided that I cannot allow a 'shooter,' or potential assassin, to force change to scheduling, or anything else."

Contributing: David Jackson, Aysha Bagchi, Christopher Cann, Bryce Buyakie, Emily Le Coz, Josh Meyer, USA TODAY Network

How the assassination attempt unfolded : Graphics, maps, audio analysis show what happened

The Effects of Social Media on Body Image Constructs Among Active Women

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