American Journal of Epidemiology
Copyright © 1998 by The Johns Hopkins University School of Hygiene and Public Health
All rights reserved
Vol. 148, No. 11
Printed in U.S.A.
Relation of Self-image to Body Size and Weight Loss Attempts in
Black Women
The CARDIA Study
Nikki M. Riley,1 Diane E. Bild, 1 Lawton Cooper,1 Pamela Schreiner,2 Delia E. Smith,3 Paul Sorlie,1 and
J. Kevin Thompson 4
blacks; body constitution; body image; body mass index; self concept; weight loss; weight perception;
women
The prevalence of obesity among US black women
is almost twice that of white women (1). This presents
a major public health concern because of the associations between obesity, hypertension, diabetes mellitus,
and other health conditions (1-10). Although a fuller
figure may be considered a positive attribute within
the black community (2, 11), the health risks of excessive weight are well recognized (12, 13).
Many studies have examined behavioral factors related to obesity in black women and white women
(14-17). These studies have suggested that the higher
Received for publication February 25, 1997, and accepted for
publication April 10, 1998.
Abbreviations: AES, Appearance Evaluation Subscale; BIS, Body
Image Satisfaction; CARDIA, Coronary Artery Risk Development in
Young Adults.
1
Division of Epidemiology and Clinical Applications, National
Heart, Lung, and Blood Institute, Bethesda, MD.
2
Division of Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, MN.
3
Division of Preventive Medicine, School of Medicine, University
of Alabama at Birmingham, Birmingham, A L
4
Department of Psychology, College of Arts and Sciences, University of South Florida, Tampa, FL.
prevalence of obesity among black women may be due
to fewer educational and financial resources (15), cultural influences leading to a deemphasis of the thin
body type in the black community (12, 18, 19), low
physical activity levels (16), and ineffective dieting
behavior (12, 16, 20). These data also suggest that one
reason for the high prevalence of obesity in black
women may be that self-image in black women is not
strongly dependent on body size (12, 15, 18, 19, 21).
Although suggestive, most of these studies were not
population-based, tending to draw convenience samples from college campuses (18, 19, 22), and comparison with white women has obscured a focus on black
women.
Few studies have explored relations of self-image,
body size, and dieting behavior within black women to
identify culture-specific associations with self-image.
Therefore, psychosocial factors related to the high
prevalence of obesity in the black female population
may not have been fully addressed, and potentially
important motivating factors (or lack thereof) for dieting behavior in black women remain poorly understood.
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It has been suggested that the prevalence of obesity in black women is high partly because self-image in
black women is not strongly dependent on body size. To determine associations between self-image, body
size, and dieting behavior among black women, the authors assessed an Appearance Evaluation Subscale
(AES) score (range, 1-5), a Body Image Satisfaction (BIS) score (range, 2-11), and reported dieting behavior
in a population-based sample of 1,143 black women aged 24-42 years from the fourth follow-up examination
(1992-1993) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Lower AES and BIS
scores indicate poorer self-image and lower body size satisfaction, respectively. After adjustment for age,
education, smoking, and physical activity, women in the lowest, middle, and highest tertiles of body mass
index (weight (kg)/height (m)2) had mean AES scores of 3.7, 3.3, and 2.9, respectively (p < 0.001), and mean
BIS scores of 7.8, 6.7, and 5.9, respectively (p < 0.001). After additional control for body mass index as a
continuous variable, both AES and BIS scores were inversely related to ever dieting, current dieting, and
previous weight loss of 10 pounds (4.5 kg) or more in all tertiles of body mass index. These results suggest that
among black women, a higher body mass index is associated with poorer self-image and lower body size
satisfaction and that these perceptions may be an avenue to promoting weight control. Am J Epidemiol 1998;
148:1062-8.
Self-image and Dieting Behavior in Black Women
Body image and body weight satisfaction were
recently examined in a population-based cohort of
young adult men and women in the Coronary Artery
Risk Development in Young Adults (CARDIA) Study
(23). Notably, black women and white women demonstrated similar levels of satisfaction with their body
size, despite greater obesity in the black women. Black
women evaluated their overall appearance more positively than did white women. The current study extends the previous analysis and examines associations
between self-image, obesity, and dieting behaviors
among black women.
The baseline CARDIA examination (1985-1986)
assessed 5,115 women and men from four US population centers (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California), including 1,480 black women. Participants aged
18-30 years were randomly sampled from the total community or from selected census tracts, except in Oakland,
where a health plan membership was used. Study
design details have been published previously (24).
Participants
Participants in the CARDIA Study have been followed with serial examinations. The data used in the
current analysis were obtained from the fourth examination (1992-1993) and included 1,143 black women
aged 24-42 years, which represents 77 percent of the
black women who originally enrolled in the study. At
baseline, participants who attended the fourth examination were older (24.6 vs. 23.9 years, p - 0.005) and
better educated (13.2 vs. 12.8 years, p < 0.0001) than
those who did not attend. Participants who attended
the fourth examination were as likely to be current
dieters at baseline as nonattenders (9.2 percent vs. 8.7
percent, p = 0.82) but were somewhat more likely to
report having ever been on a weight-reducing diet (40
percent vs. 34 percent, p — 0.08). However, there were
no differences between attenders and nonattenders in
body mass index (26.0 vs. 25.6, p = 0.37).
Measures
Weight (to the nearest 0.2 kg) and height (to the
nearest 0.5 cm) were measured using a calibrated
balance-beam scale and a vertical ruler while the participant stood in light clothing without shoes. Body
mass index was calculated as weight in kilograms
divided by the square of height in meters. Sociodemographic data (age, education, marital status, employAm J Epidemiol
Vol. 148, No. 11, 1998
ment status, and income) and information on dieting
behavior and self-image were obtained from selfadministered questionnaires.
The Appearance Evaluation Subscale (AES), a measure of conceptual self-image, was derived from the
Multidimensional Body-Self Relations Questionnaire
(25). Participants responded on a Likert scale (18)
(scored 1-5) to seven statements about satisfaction
with overall appearance. AES scores for the total sample ranged from 1.0 to 5.0, with tests of normality
indicating only a slight deviation from normality. The
AES scale has demonstrated excellent psychometric
qualities, with an internal consistency of Cronbach's
alpha = 0.88 among adult women (26, 27). A lower
AES score is associated with a poorer self-image.
The Body Image Satisfaction (BIS) score was derived from the Figure Rating Scale (27, 28), which
presents images of nine figures ranging from very thin
to very heavy. The discrepancy between the figure
selected as ideal and the current body size was utilized
as the BIS score. The BIS scores were linearly transformed, so that the direction of the BIS scores corresponded with that of the AES scores, by subtracting
the BIS score from the constant 8 (the difference
between the numbers of the highest and lowest figures). The 2-week test-retest reliability for the ideal
rating is 0.71 (29), indicating a strong internal consistency of the BIS score. The BIS scores for the total
sample ranged from 2 to 11, with normality tests
indicating only a slight deviation from normality. BIS
scores ranging from 2 to 7 indicate a desire to be
thinner, while BIS scores ranging from 9 to 11 indicate
a desire to be heavier; a BIS score of 8 indicates a
woman who is satisfied with her body size.
A physical activity score was calculated for the past
year from a questionnaire which yielded participation
rates for 13 activity categories, as well as an estimate
of energy expenditure for each activity. The scale has
demonstrated reliability and validity for the population
studied (30). Scores ranged from 0 to 1,385, and the
distribution was markedly right-skewed. Therefore,
scores for physical activity were based on natural
logarithm-transformed values and are presented as
geometric means. Smoking was defined as current,
former, or never smoking on the basis of self-report.
Dieting behaviors were measured by affirmative
responses to the questions "Have you ever been on a
weight-reducing diet?" and "Are you on such a diet
now?". Each participant was also asked the number of
times she had previously lost 10 or more pounds (4.5
kg). Responses were categorized as having lost 10 or
more pounds on one or more occasions or not having
done so.
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MATERIALS AND METHODS
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Riley et al.
Statistical analyses
RESULTS
Spearman correlations demonstrated that AES and
BIS scores were positively correlated (r = 0.52, p <
0.0001).
Univariate analyses
Age was significantly associated with body mass
index, with older women having higher body mass
indices (table 1). Educational level did not vary statistically by body mass index. Women with higher
Multivariate analyses
After adjustment for education, age, log physical
activity, and smoking, both AES and BIS scores decreased significantly with increasing body mass index
(table 2). Thus, significant differences in self-image
evaluation were evident among the body mass index
groups.
The results of logistic regression analyses represent
the odds of each dieting behavior's being associated
with a 1-unit increase in self-image as measured by
AES or BIS within each tertile of body mass index,
after adjustment for age, education, smoking, physical
activity, and body mass index as a continuous variable.
The overall adjusted odds ratios for AES were 0.61,
0.75, and 0.67 for having ever been on a weightreducing diet, current dieting, and weight loss of 10
pounds or more, respectively. The overall adjusted
odds ratios for BIS were 0.65, 0.74, and 0.77 for
having ever been on a weight-reducing diet, current
dieting, and weight loss of 10 pounds or more, respectively. This suggests that the prevalence of each dieting behavior decreases with increasingly positive evaluations of self-image.
Within each tertile of body mass index, both AES
and BIS were inversely associated with having ever
been on a weight-reducing diet (figure 1). The odds
ratios for current dieting in relation to AES and BIS
were similar to those for having ever been on a weightreducing diet. For BIS, the inverse association with
having ever been on a weight-reducing diet and current dieting weakened with increasing tertile of body
mass index. Previous weight loss of 10 pounds or
more was inversely associated with AES and BIS in all
tertiles of body mass index, and, as with the other two
previous dieting variables, the relation between weight
loss of 10 pounds or more and BIS tended to weaken
with increasing tertile of body mass index. Further
adjustment for marital status, parity, employment status, and income level did not significantly change the
odds ratios for each dieting behavior model. When
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Vol. 148, No. 11, 1998
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Analyses included participants with body mass index data and either an AES score (n = 1,078) or a BIS
score (n = 1,087). To determine whether self-image,
dieting behavior, and other characteristics differed by
body mass index, means and proportions for each
variable were calculated by tertile of body mass index.
Differences across body mass index tertiles for categorical data were tested by Cochran-Mantel-Haenszel
analysis, and differences in continuous variables were
determined by analysis of variance. Relations between
self-image measures and body mass index, with body
mass index as an independent variable, were additionally analyzed after adjustment for age, log physical
activity, education, and smoking, with analysis of covariance.
Multiple logistic regression models were constructed to determine whether self-image predicted
dieting behavior within each tertile of body mass index. Because of the broad range of body mass indices
within each tertile, body mass index was also included
as a continuous variable in models predicting dieting
behavior within each body mass index tertile, to control for residual confounding. Tests for interactions
between body mass index tertile and self-image in the
predictions of dieting behavior were conducted. In all
of these models, adjustments for smoking, age, physical activity levels, and education were made because
of their potential relations to body mass index (4, 14,
31) and their possible role as confounders. Additional
adjustments for marital status (married, widowed, divorced, separated, and never married), parity, full-time
employment (no or yes), and annual income (eight
categories) were included in other analyses.
Only 11 percent of the women expressed a desire to
be heavier, based on their BIS scores. Thus, a separate
logistic regression analysis excluding women who had
BIS scores greater than 8 (indicating a desire to be
heavier (n = 124)) was conducted to determine
whether the results would be affected. The Statistical
Analysis System (version 6.10) was used for the analyses
(SAS Institute, Inc., Cary, North Carolina).
body mass indices reported lower levels of physical
activity and were less likely than women with lower
body mass indices to be current smokers, but these
relations did not reach statistical significance.
A higher proportion of women in the lowest body
mass index category had no children. Income levels
less than $12,000, current marital status, and full-time
employment did not vary significantly by body mass
index. Women with higher body mass indices were much
more likely to report currently being on a weight-reducing diet, having ever been on a weight-reducing diet, and
previously losing 10 or more pounds on one or more
occasions (p < 0.001 for each factor).
Self-image and Dieting Behavior in Black Women
1065
TABLE 1. Demographic data and prevalence of dieting behavior and weight loss attempts in black
women, by tertile of body mass index, CARDIA* Study, 1992-1993
Tertile of body mass index!
Low
(15.8-24.6)
(n = 368)
Demographic characteristic
Mean body mass index
Middle
(24.7-31.1)
(n=368)
High
(31.2-61.8)
(n - 368)
P
value}
21.7(2.0)§
27.6 (1.9)
37.7 (5.9)
<0.001
Mean age (years)
31.1 (3.8)
31.6 (3.8)
32.0 (3.8)
0.004
Mean years of education
13.9 (2.1)
13.9 (2.0)
13.7(1.9)
0.24
Smoking status (%)
Current smoker
Nonsmoker
Ex-smoker
33.4
56.5
10.1
29.4
62.1
8.5
26.7
60.0
13.4
0.09
128.0
113.0
0.50
37.7
29.9
28.5
<0.001
Annual income <$12,000 (%)
19.3
18.4
22.4
0.29
Married (%)
27.2
37.6
33.3
0.08
Employed full-time (%)
66.0
66.2
61.5
0.20
Weight loss information*
Ever having been on a weightreducing diet (%)
20.7
46.7
61.1
<0.001
Currently being on a weightreducing diet (%)
3.0
11.2
15.4
<0.001
30.2
62.6
77.5
<0.001
Physical activity scoreH
Previous weight loss of £10 pounds
(4.5 kg) at least once (%)
* CARDIA, Coronary Artery Risk Development in Young Adults,
t Weight (kg)/height (m)*.
$ Overall p value across tertiles of body mass index, by analysis of variance and chi-square contingency table
analysis (test for an association between dieting behavior, weight loss attempts, and tertile of body mass index).
§ Numbers in parentheses, standard deviation.
H Geometric mean.
# The proportions for the entire population sample for having ever been on a weight-reducing diet, current
dieting, and weight loss of 10 pounds or more were 42.9%, 9.9%, and 56.7%, respectively, for the low, middle, and
high tertiles of body mass index.
women with BIS scores greater than 8 were removed,
changes in the odds ratios for AES were trivial.
Significant interactions occurred between the low
and middle tertiles of body mass index (p = 0.004)
and AES, as well as between the high and low (p <
0.0001) and high and middle (/? = 0.005) tertiles of
body mass index and BIS, in predicting having ever
been on a weight-reducing diet (figure 1). Additionally, interactions occurred between the middle and
high tertiles of body mass index (/? = 0.028) and AES
and between the low and high tertiles of body mass
index (p = 0.040) and BIS in predicting currently
being on a weight-reducing diet. An interaction also
occurred between the low and high tertiles of body
mass index (p = 0.009) and BIS in predicting weight
loss of 10 pounds or more. These interactions suggest
that relations between self-image and dieting behaviors differed by level of body mass index.
Am J Epidemiol
Vol. 148, No. 11, 1998
DISCUSSION
This study demonstrated strong relations between
body mass index and self-image and between selfimage and weight loss attempts at each level of obesity
in a population-based sample of young adult black
women. The data from this study indicate that, within
their own subgroup, black women exhibit a wide range
of self-image. The most overweight women had the
lowest AES and BIS scores. Conversely, the leanest
women had the highest AES and BIS scores. Among
black women in these data, obesity is associated with
poorer self-image and lower body size satisfaction,
and these perceptions are related to dieting behavior.
The variations in self-image associated with obesity
among black women in this study demonstrated patterns similar to those of white women (32, 33). In the
CARDIA Study, white women had adjusted AES
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120.0
No children (%)
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Riley et al.
TABLE 2. Mean Appearance Evaluation Subscale (AES) and Body Image Satisfaction (BIS) scores in
black women, by tertile of body mass index, CARDIA* Study, 1992-1993
Tertile of body mass indext
(15.&-24.6)
(n = 368)
Middle
(24.7-31.1)
(n = 368)
High
(31.2-61.8)
(n = 368)
P
value!
AES score§
Unadjusted
Adjusted^
Interquartile range
3.7
3.7
3.29-4.14
3.3
3.3
2.86-3.86
3.0
2.9
2.57-3.43
<0.001
<0.001
0.16
0.19
BIS score
Unadjusted
Adjusted!
Interquartile range
7.9
7.8
7.0-9.0
6.7
6.7
6.0-7.0
5.9
5.9
5.0-7.0
<0.001
<0.001
0.33
0.36
Low
scores of 3.5, 2.9, and 2.5 in the low, middle, and high
body mass index groups, respectively (p < 0.0001,
R2 = 0.29), using the same body mass index cutpoints
as the tertile cutpoints used for the black women, with
adjustment for age, education, smoking, and physical
activity. The results were very similar to those seen in
these black women (table 2), although the contribution
of body mass index to the total variability in AES (R2)
was higher in the white women. Adjusted BIS scores
for the white women were 7.1, 6.3, and 5.4 for the low,
middle, and high body mass index groups, respectively
(p < 0.0001, R2 = 0.35). Again, this relation is
similar to, though somewhat weaker than, that seen
among the black women. Therefore, black women in
BMI Tertile
: i-
Low
Middle
AES
High
Low
Middle
High
0.1
BIS
1
10
Odds ratio
FIGURE 1. Adjusted odds ratio for having ever been on a weightreducing diet associated with a 1 -unit increase in Appearance Evaluation Subscale (AES) score and Body Image Satisfaction (BIS)
score in 1,143 black women, by tertile of body mass index (BMI)
(weight (kg)/height (m)2), Coronary Artery Risk Development in
Young Adults Study, 1992-1993. BMI tertiles: 15.8-24.6 (low), 24.731.1 (middle), and 31.2-61.8 (high). Odds ratios were adjusted for
age, education, BMI, smoking, and log physical activity. Bars, 95%
confidence interval.
the CARDIA Study expressed discontent with their
body size in a manner similar to that of CARDIA
white women. These findings argue against a lack of
relation between serf-image and body size in black
women and provide only limited support for the contention that a more positive physical self-image in black
women explains their higher prevalence of obesity.
The AES score measures a multidimensional affective evaluation of physical appearance, whereas the
BIS score is a unidimensional measure of physical
self-image which compares perceived body size with
desired body size. The observed weakening of the
relations between BIS scores with increasing obesity,
but not between AES and dieting across increasing
levels of obesity, implies that AES and BIS are measuring different psychological constructs. The BISobesity-dieting relation suggests that there may be a
body size threshold above which concern about body
size diminishes, as does motivation to lose weight.
Methodological limitations of the current study include the lack of reliability and validity of the BIS
measure in black women. However, excellent internal
consistency of the AES measure for CARDIA black
women was demonstrated by a Cronbach's alpha value
of 0.82 (23). Body image satisfaction is a single-item
measure; therefore, internal consistency could not be
determined. Thus, the simplicity and content of both
measures suggest high content validity in this sample.
The limited number of geographic sites included in
this study may limit the generalizability of our findings. CARDIA participants reside in urban areas primarily and may not reflect the attitudes and behaviors
of persons living in other regions. Inclusion of a variable for study center in the analyses did not change the
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Vol. 148, No. 11, 1998
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* CARDIA, Coronary Artery Risk Development in Young Adults.
t Weight (kg)/height (m)*.
$ p < 0.001 for tertiles of body mass index by analysis of variance and covanance.
§ AES score was based on the following statements: 1. My body is sexually appealing. 2. Most people would
consider me good-looking. 3. I like my looks just the way they are. 4. I like the way I look without my clothes.
5.1 like the way my clothes fit me. 6.1 dislike my physique. 7.1 am physically unattractive.
H Adjusted for age, education, smoking, and log physical activity.
Self-image and Dieting Behavior in Black Women
Am J Epidemiol
Vol. 148, No. 11, 1998
or sexually abusive relationships (38). Clearly, these
hypotheses warrant further research.
There are very few obesity prevention and treatment
programs designed specifically for black women (39,
40). Reasons for this may include the lower socioeconomic status of black women, the inaccessibility of
health care and education for black women, and an
inability to implement and adhere to exercise programs because of inadequate resources and unsafe
environments. Persons designing obesity prevention
and weight loss programs targeting black women need
to recognize the complex issues regarding acculturation of black women, not only in the majority society
but within the black subculture as well. Prevention and
treatment programs would benefit from an understanding of the strong sense of community and family
within black culture and should implement strategies
at the individual, family, and community levels (21).
Further studies and proposed intervention programs
for obese black women must address not only genetic,
physiologic, and socioeconomic factors but also the
influence of self-image and body image on the prevalence, prevention, and treatment of obesity in black
women. The current study suggests that improved
self-image may be an avenue to promoting weight
control in black women.
ACKNOWLEDGMENTS
This research was supported by the National Heart, Lung,
and Blood Institute under a pre-IRTA [Intramural Research
Training Award] Fellowship (no. TP-HL-1000). The
CARDIA Study is carried out as a collaborative study
supported by contracts NO1-HC-48047, NO1-HC-48048,
NO1-HC-48049, NO1-HC-48050, and NO1-HC-95095
from the National Heart, Lung, and Blood Institute.
The authors thank Jane Chen, Jeanette Duggan, Joan
Pinsky, Dr. Teri Manolio, Linda Sellers, Phyliss Sholinsky,
and Michael Wolz for their assistance with this project.
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