Agreement of adolescents’ self-perception of their body image with the analysis on the three-dimensional body image

Susana Cararo Confortin Camila Meireles Souza Bianca Rodrigues de Oliveira Karla Daniele Silva Marques Lívia Carolina Sobrinho Rudakoff Elma Izze da Silva Magalhães Antônio Augusto Moura da Silva About the authors

Abstract

Objectives:

to verify the agreement among adolescents’ perception of their own body image and the health professionals’ analysis based on three-dimensional body image and the inter-rater agreement.

Methods:

a cross-sectional study was carried out with 1,662 adolescents, aged 18 to 19 years old, from the 1997/98 birth cohort in São Luís, Maranhão. Self-perception of body image was assessed using the Stunkard’s body image scale. Three nutritionists evaluated the three-dimensional body image obtained by the Photonic Scanner (3D Body Scanner) and classified according to the Stunkard’s scale. The agreement between raters was verified by using weighted Kappa.

Results:

the analysis of agreement between raters in the general group and when stratified by sexwas considered moderate to good by Kappa. Regarding the intraclass correlation (ICC), good and excellent correlation values were observed both in the general group, males and females. There was a greater perception of overweight by all raters, when compared with the adolescents’ self-assessments. When stratified by sex, examiner 1 had the same perception as male self-assessments, as for females the perception of overweight was more frequent, as well as raters 2 and 3, for both sexes.

Conclusion:

agreement between raters and self-assessments was considered weak/moderate in Kappa and good/excellent in ICC.

Key words
Adolescent; Body image; Body dissatisfaction

Resumo

Objetivos:

verificar a concordância da autopercepção da imagem corporal de adolescentes com a análise de profissionais da saúde a partir de imagem corporal tridimensional e a concordância inter-avaliadores.

Métodos:

estudo transversal, com 1662 adolescentes, de 18-19 anos, da coorte de nascimento de 1997/98 de São Luís, Maranhão. A autopercepção da imagem corporal foi avaliada pela escala de imagem corporal de Stunkard. Três nutricionistas avaliaram a imagem corporal tridimensional e classificaram conforme Stunkard. A concordância foi verificada utilizando Kappa ponderado.

Resultados:

a análise de concordância entre os avaliadores no grupo geral e quando estratificada por sexo foi considerada moderada a boa pelo Kappa. Em relação a correlação intraclasse (ICC), observou-se valores de correlação bons e excelentes tanto no grupo geral, quanto no sexo masculino e no feminino. Notou-se maior percepção de excesso de peso por todos os avaliadores, quando comparado às autoavaliações dos adolescentes. Quando estratificado por sexo, o avaliador 1 teve a mesma percepção que as autoavaliações do sexo masculino, enquanto para o sexo feminino a percepção de excesso de peso foi mais frequente, assim como os avaliadores 2 e 3, para ambos os sexos.

Conclusão:

a concordância entre avaliadores e as autoavaliações foram consideradas fracas/moderadas no Kappa e bons/excelente pela ICC.

Palavras-chave
Adolescência; Imagem corporal; Insatisfação corporal

Introduction

Body image is the mental image that an individual has of the size, shape and parts of their own body, perceptions, feelings, attitudes and experiences associated with that image.11 Côrtes MG, Meireles AL, Friche AAL, Caiaffa WT, Xavier CC. O uso de escalas de silhuetas na avaliação da satisfação corporal de adolescentes: revisão sistemática da literatura. Cad Saúde Pública. 2013 Mar; 29 (3): 427-44.,22 Hartman-Munick SM, Gordon AR, Guss C. Adolescent body image: influencing factors and the clinician’s role. Curr Opin Pediatr. 2020 Aug; 32 (4): 455-60. It is built since childhood based on a dynamic process33 Miranda VPN, Morais NS, Faria ER, Amorim PRS, Marins JCB, Franceschini SCC, et al. Body dissatisfaction, physical activity, and sedentary behavior in female adolescents. Rev Paul Pediatr. 2018 Oct/Dec; 36(4): 482-90.,44 Neves CM, Cipriani FM, Meireles JFF, Morgado FFR, Ferreira MEC. Body image in childhood: an integrative literature review. Rev Paul Pediatr. 2017 Jul/Sep; 35 (3): 33-9. which becomes even more complex in adolescence due to the biopsychosocial changes inherent to this phase and the greater vulnerability to influences from society, family, friends and media regarding the ideal body.55 Carvalho GX, Nunes APN, Moraes CL, Veiga GV. Body image dissatisfaction and associated factors in adolescents. Ciênc Saúde Coletiva. 2020 Jul; 25 (7): 2769-82.

Self-assessment of body image can be influenced by factors such as sex, age, media, and how the body is seen in different beliefs, values and attitudes inserted in a culture. An inaccurate perception of a body image can lead to inappropriate behaviors, causing nutritional changes.66 Moraes C, Anjos LA, Marinho SMSA. Construção, adaptação e validação de escalas de silhuetas para autoavaliação do estado nutricional: uma revisão sistemática da literatura. Cad Saúde Pública. 2012 Jan; 28 (1): 7-20. Individuals dissatisfied with their body image may present depressive symptoms,77 Solomon-Krakus S, Sabiston CM, Brunet J, Castonguay AL, Maximova K, Henderson M. Body image self-discrepancy and depressive symptoms among early adolescents. J Adolesc Health. 2017 Jan; 60 (1): 38-43. eating disorders,88 Amaral ACS, Ferreira MEC. Body dissatisfaction and associated factors among Brazilian adolescents: a longitudinal study. Body Image. 2017 Sep; 22: 32-8. suicidal behavior,99 Brausch AM, Muehlenkamp JJ. Body image and suicidal ideation in adolescents. Body Image. 2007 Jun; 4 (2): 207-12. in addition to problems with social acceptance, job opportunities, self-esteem, well-being and socioeconomic status.1010 Mintem GC, Gigante DP, Horta BL. Change in body weight and body image in young adults: a longitudinal study Health behavior, health promotion and society. BMC Public Health. 2015; 15 (1): 1-7.

High prevalence of distortion and dissatisfaction with body image have been observed, especially in female33 Miranda VPN, Morais NS, Faria ER, Amorim PRS, Marins JCB, Franceschini SCC, et al. Body dissatisfaction, physical activity, and sedentary behavior in female adolescents. Rev Paul Pediatr. 2018 Oct/Dec; 36(4): 482-90.,88 Amaral ACS, Ferreira MEC. Body dissatisfaction and associated factors among Brazilian adolescents: a longitudinal study. Body Image. 2017 Sep; 22: 32-8. overweight adolescents.22 Hartman-Munick SM, Gordon AR, Guss C. Adolescent body image: influencing factors and the clinician’s role. Curr Opin Pediatr. 2020 Aug; 32 (4): 455-60.,1111 Ribeiro-Silva RC, Fiaccone RL, Conceição-Machado MEP, Ruiz AS, Barreto ML, Santana MLP. Body image dissatisfaction and dietary patterns according to nutritional status in adolescents. J Pediatr (Rio J). 2018 Mar/Apr; 94 (2): 155-61. Usually, girls want to be thin, and boys want a muscular/athletic body.1212 Moehlecke M, Blume CA, Cureau FV, Kieling C, Schaan BD. Self-perceived body image, dissatisfaction with body weight and nutritional status of Brazilian adolescents: a nationwide study. J Pediatr (Rio J). 2020 Jan/Feb; 96 (1): 76-83.

Body image is measured by using questionnaires, interviews, drawings and image distortion techniques. Epidemiological studies both in Brazil and in other countries generally use silhouette scales.55 Carvalho GX, Nunes APN, Moraes CL, Veiga GV. Body image dissatisfaction and associated factors in adolescents. Ciênc Saúde Coletiva. 2020 Jul; 25 (7): 2769-82.,66 Moraes C, Anjos LA, Marinho SMSA. Construção, adaptação e validação de escalas de silhuetas para autoavaliação do estado nutricional: uma revisão sistemática da literatura. Cad Saúde Pública. 2012 Jan; 28 (1): 7-20.,88 Amaral ACS, Ferreira MEC. Body dissatisfaction and associated factors among Brazilian adolescents: a longitudinal study. Body Image. 2017 Sep; 22: 32-8.,1010 Mintem GC, Gigante DP, Horta BL. Change in body weight and body image in young adults: a longitudinal study Health behavior, health promotion and society. BMC Public Health. 2015; 15 (1): 1-7. These scales use images that vary from a very thin to an obese subject1313 Gardner RM, Friedman BN, Jackson NA. Methodological concerns when using silhouettes to measure body image. Percept Mot Skills. 1998 Apr; 86 (2): 387-95. where the individual must choose the figure that represents his or her current, ideal or desired body. The Silhouettes scale of Stunkard et al.,1414 Stunkard AJ, Sørensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis. 1983; 60: 115-20. validated for the Brazilian population presents nine silhouettes for men and women, separately.1515 Scagliusi FB, Alvarenga M, Polacow VO, Cordás TA, Queiroz GKO, Coelho D, et al. Concurrent and discriminant validity of the Stunkard’s figure rating scale adapted into Portuguese. Appetite. 2006 Jul; 47 (1): 77-82.

Some criticisms have been made regarding the use of silhouette scales, such as the low reliability of the human body, the use of few figures and the biotypes used, which can lead to discrepancies between the real perceived or idealized image.11 Côrtes MG, Meireles AL, Friche AAL, Caiaffa WT, Xavier CC. O uso de escalas de silhuetas na avaliação da satisfação corporal de adolescentes: revisão sistemática da literatura. Cad Saúde Pública. 2013 Mar; 29 (3): 427-44.,1313 Gardner RM, Friedman BN, Jackson NA. Methodological concerns when using silhouettes to measure body image. Percept Mot Skills. 1998 Apr; 86 (2): 387-95.

Three-dimensional scanners are a validated method for use in children and adolescents that provide automated, quick and easy evaluations of bodies measurements, providing reproducible, reliable and accurate data.1616 Rumbo-Rodríguez L, Sánchez-Sansegundo M, Ferrer-Cascales R, García-D’Urso N, Hurtado-Sánchez JA, Zaragoza-Martí A. Comparison of body scanner and manual anthropometric measurements of body shape: a systematic review. Int J Environ Res Public Health. 2021 Jun; 18 (12): 6213.

Studies show that parents of children and adolescents have the perception of their children’s body image that corresponds to the classification of the nutritional status of these children/adolescents.1717 Battisti M, Bergjohann P, Adami FS, Fassina P. Percepção da imagem corporal associada ao estado nutricional de crianças e adolescentes. Rev Bras Prom Saúde. 2017; 30 (1): 86-92.,1818 Vieira RS, Dal Bosco SM, Grave MTQ, Adami FS. Percepción de imagen corporal de los adolescentes y sus padres en relación a niveles de presión arterial y el estado nutricional. Nutr Hosp. 2015 Apr; 31 (4): 1839-44. In this sense, other individuals can perceive the actual nutritional status and even identify possible dissatisfactions and distortions in the adolescents’ body image. Considering that body image distortion can lead to physical and mental health problems in adolescents, the comparison between the body image that individuals in this age group have of themselves and the perceived image of this self-assessment by health professionals can provide information about the real level of this dissatisfaction and distortion.

We did not find studies comparing the self-perception of body image in adolescents and the image obtained by three-dimensional scanners, nor studies that used a silhouette scale to analyze the agreement between self-perceived body image in adolescents and the assessment carried out by health professionals through three-dimensional body image. Thus, in this study, we sought to verify the agreement of self-perception of body image in adolescents with the analysis of health professionals based on a three-dimensional body image and to analyze possible inter-rater agreement.

Methods

A cross-sectional study, conducted with individuals aged 18 to 19, participants of the third phase of the 1997/1998 São Luís Birth Cohort. In the first phase of the study, a systematic sample of 1/7 of births residing in São Luís in 10 maternity hospitals in the city was selected. The sample was stratified by the maternity hospitals, with shared proportional to the number of births in each unit, in 1997, totaling 2,493 live births. The first follow-up was carried out in 2005/2006, with 673 children aged 7 to 9 years old, and the second follow-up was carried out in 2016, with adolescents aged 18 to 19 years old (n=654). Due to the small number of individuals who agreed to participate in the study in the previous phases, we decided to increase the sample size, including other individuals born in São Luís in 1997, who were not initially drawn to be part of the birth cohort. Thus, 1,861 individuals identified through school or university registration and military enlistment were included in the second segment of the cohort, totaling 2,515 individuals participating in this phase.1919 Simões VMF, Batista RFL, Alves MTSSB, Ribeiro CCC, Thomaz EBF, Carvalho CA, et al. Saúde dos adolescentes da coorte de nascimentos de são luís, maranhão, de 1997/98. Cad Saúde Pública. 2020; 36 (7): e00164519.

Data were collected between January and November, 2016. Individual interviews were carried out to collect demographic, socioeconomic and behavioral information, obtaining a three-dimensional body image and assess of self-perception of the body image. The analytical sample of this study was 1,662 individuals. These individuals were the ones who performed the assessment of the three-dimensional body image and had valid images for analysis.

Self-perception of the body image was assessed through the individual’s perception of their body image among the nine silhouettes proposed by Stunkard et al.1414 Stunkard AJ, Sørensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis. 1983; 60: 115-20. (Figure 1a). The individual was asked to choose a silhouette that would consider their current appearance or image that identified themselves (Percepção da Imagem Corporal Real - PICR) (Perception of Real Body Image).

Figure 1
Set of silhouettes and models for assessing body image.

The three-dimensional body image of the human body (Figure 1b) was obtained using a Photonic Scanner (3D Body Scanner). This equipment extracts several anthropometric measurements in a short time, without using radiation or causing any discomfort to the individual, as well as complementing body composition measurements. For such purpose, the individual remains in a darkroom receiving light beams, which generate the three-dimensional body image on the computer.

Three nutritionists were asked to assess the adolescents’ three-dimensional images. Nutritionists who belonged to the research team of the study, with experience in research in the field of nutritional assessment, were selected. The raters were instructed to classify each three-dimensional body image according to one of the nine silhouettes established by Stunkard et al.1414 Stunkard AJ, Sørensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis. 1983; 60: 115-20. The classification was listed in a Microsoft Excel® software spreadsheet with the identification code of each participant referring to the evaluated image. The procedure was performed by the observers with the same images, independently, in order to verify inter-examiner variability. After performing the evaluation and classification of the images, the raters discussed and scored the main obstacles and difficulties observed during this phase of the study.

Agreement analyses and comparison of the ratings of the raters among themselves and between the adolescents and the raters were carried out to assess the perception of overweight or thinness. The comparison was performed by subtracting the number referring to the silhouette indicated by the raters by the number equivalent to the silhouette with which the adolescents classified themselves. The difference ranges from-8 to +8 and was considered the same perception when the variation was equal to zero, thinness perception when the difference was negative and overweight perception when the difference was positive.

The variables used to describe the study sample were: age (18 to 19 years old), sex (male, female), schooling (illiterate to 11 years, 12 years or more), self-reported skin color (white, black, mixed race) - according to the options provided by the Instituto Brasileiro de Geografia e Estatística (IBGE),2020 IBGE (Instituto Brasileiro de Geografia e Estatística). Características étnico-raciais da população: um estudo das categorias de classificação de cor ou raça. Rio de Janeiro: IBGE; 2011. (Brazilian Institute of Geography and Statistics) marital status (no partner, consensual union), total physical activity (insufficiently active, physically active),2121 Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003 Aug; 35 (8): 1381-95. alcohol consumption (yes, no), smoking (yes, no) and socioeconomic classification according to the Critério de Classificação Econômica do Brasil 20162222 ABEP (Associação Brasileira de Empresas de Pesquisa). Critério Brasil e alterações na aplicação do Critério Brasil, válidas a partir de 16/04/2018. São Paulo: ABEP; 2018. (Brazilian Economic Classification Criteria) grouped in A-B, C and D-E.

Statistical analyses were performed using Stata software version 14. Descriptive analysis was applied to characterize the sample. The analysis of the distribution of the participants between the groups that carried out the assessment of the three-dimensional body image and the ones that did not was carried out to verify sample similarity. Agreement analysis was carried out regarding the ability to measure identical results, applied to the same subject/phenomenon, by different raters, and between raters and adolescents using weighted Kappa,2323 Miot HA. Análise de concordância em estudos clínicos e experimentais. J Vasc Bras. 2016 Apr/Jun; 15 (2): 89-92. in the general sample and by sex. Stratification by sex was performed considering that previous studies have shown differences in questions related to body image between male and female adolescents.55 Carvalho GX, Nunes APN, Moraes CL, Veiga GV. Body image dissatisfaction and associated factors in adolescents. Ciênc Saúde Coletiva. 2020 Jul; 25 (7): 2769-82.,2424 Soares Filho LC, Batista RFL, Cardoso VC, Simões VMF, Santos AM, Coelho SJDDAC, et al. Body image dissatisfaction and symptoms of depression disorder in adolescents. Braz J Med Biol Res. 2020; 54 (1): 1-7. Kappa agreement was classified as poor (<0.20), weak (0.21 to 0.40), moderate (0.41 to 0.60), good (0.61 to 0.80) and excellent (0.81 to 1.00).2525 Sim J, Wright CC. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther. 2005 Mar; 85 (3): 257-68. An intraclass correlation coefficient (ICC) analysis was performed, classified as poor (<0.40), fair (0.4 to <0.6), good (0.6 to <0.75) and excellent (0.75 to 1.00).2626 Cicchetti DV. Interreliability standards in psychological evaluations. Psychol Assess. 1994; 6 (4): 284-90. The research was approved by the Research Ethics Committee - Zip Code - HUUFMA (CAAE No 49096315.2.0000.5086) in all of its stages. The participants signed an informed consent form.

Results

In total, 4,333 three-dimensional images were obtained from the image bank extracted from Photonic. Repeated images whose quality did not allow for body analysis were excluded, resulting in 1,662 individuals with valid images.

To carry out the analysis of the distribution of the participants, they were divided into two groups: those who carried out the three-dimensional body image assessment and those who did not. Significant differences were observed regarding age (p < 0.001), sex (p = 0.046), schooling (p < 0.001), skin color (p = 0.007) and economic class (p < 0.001) (Table 1).

Table 1
Percentage distribution of adolescents who participated and did not participate in the study, according to sociodemographic, socioeconomic and behavioral characteristics. São Luís, Maranhão, Brazil, 2016/2017.

Most participants were female (51.0% versus 49.0%), aged 18 years old (87.4% versus 12.6%), mixed race (65.2% versus 18.1% white, and 16.7% black), with 0 to 11 years of schooling (53.1% versus 46.9%), economic class C (50.3% versus 27.2% Class A/B and 22.5% Class D/E), without a partner (96.6% versus 3.4%), did not smoke (96.8% versus 3.2%), consumed alcoholic beverages (53.3% versus 46.7%) and was physically active (58.7% versus 41.3%) (data not shown in Table).

The analysis of agreement between raters in the general group and when stratified by sex was considered moderate to good. The agreement between the raters and the adolescents’ self-assessments in the general group and stratified by sex was considered weak for raters 1 and 3 and moderate for rater 2. We observed a greater perception of overweight by all raters when compared with the adolescents’ self-assessments. When stratified by sex, rater 1 had the same perception as the males’ self-assessments, while for females the perception of overweight was more frequent, as well as the raters 2 and 3, for both sexes.

In the general group, it was observed that the agreement was moderate between raters 1 and 2, with the percentage of agreement between the measures beyond what was expected by chance and the weighted k=Kappa of 58.80% (p < 0.001). Between raters1 and 3, the percentage of agreement between measurements beyond what was expected by chance and the weighted Kappa was 69.43% (p < 0.001), which was considered good agreement. The percentage of agreement between the measures beyond what was expected by chance and the weighted Kappa was moderate, being 55.36% between raters 2 and 3 (Table 2).

Table 2
Weighted Kappa values and intraclass correlation coefficient for the sample in general and stratified by sex. São Luís, Maranhão, Brazil, 2016/2017.

When analyzing the agreement between raters 1 and 2 by sex, we observed that the percentage was 47.27% for males (p < 0.001), considered moderate. For females, the percentage was 68.54% (p < 0.001), being classified as good. Between raters 1 and 3, the percentage of agreement was 68.00% (p < 0.001) for males and 69.79% (p < 0.001) for females, which was considered good. Between raters 2 and 3, agreement was moderate, being 48.88% (p < 0.001) for males and 58.44% (p < 0.001) for females (Table 2).

The agreement between rater 1 and the self-assessments carried out by the adolescents was considered weak, with the percentage of agreement between the measures beyond what was expected by chance and the weighted Kappa of 32.91% (p < 0.001). When stratified by sex, agreement was weak for both sexes, a percentage of 33.81% (p < 0.001) and 32.27% (p < 0.001), for females and males, respectively (Table 2).

The agreement between rater 2 and the adolescents’ self-assessments was considered moderate and the percentage of agreement between the measures was higher than that expected by chance and the weighted Kappa was 43.07% (p < 0.001). When stratified by sex, the agreement of rater 2 with the self-assessments of males remained moderate, a percentage of 47.44% (p < 0.001), but was weak in females, 39.78% (p < 0.001) (Table 2).

The agreement between rater 3 and the self-assessments carried out by the adolescents was considered weak, and the percentage of agreement between the measures was higher than that expected by chance and the weighted Kappa of 29.29% (p < 0.001). When stratified by sex, the rater 3 agreement with male self-assessments remained weak, a percentage of 37.22% (p < 0.001); however, it was weak for females, 23.29% (p < 0.001) (Table 2).

Regarding intraclass correlation (ICC), good values were observed for the correlation between rater 1 and self-assessments, and rater 3 and self-assessments both in the general group, in males and females. The other correlations were considered excellent.

When analyzing the frequency of the raters’ perception of thinness or overweight compared to the adolescents’ self-assessments, a greater perception of overweight was observed by all the raters. However, raters 2 and 3 noticed more overweight individuals (69.27% and 71.02%, respectively) when compared with rater 1 (48.58%) (Figure 2). When considering sex, rater 1 had the same perception as male self-assessments in 40.30% of cases, whereas the perception of overweight was more frequent (65.88%) for females. For raters 2 and 3, the perception of overweight was more frequent for both males (61.31% and 57.60%, respectively) and females (76.90% and 83.89%, respectively) (Figure 3).

Figure 2
Distribution of perception of the same weight, thinness or overweight by raters 1, 2 and 3 in relation to the adolescents’ self-assessments. São Luís, Maranhão, Brazil, 2016/2017.

Figure 3
Distribution of perceptions by raters 1, 2 and 3 compared the adolescents’ self-assessments, by sex.

Discussion

To the best of our knowledge, this was the first study to use three-dimensional imaging to assess the body image of Brazilian adolescents. The main results of this study showed moderate to good agreement between raters. The analysis of agreement between raters and the adolescents’ self-assessments was considered weak to moderate, with a greater perception of overweight by all the raters, except rater 1 for males.

To date, no studies were identified that investigated the concordance of self-perceived body image in adolescents with the analysis of health professionals based on three-dimensional body image and inter-rater agreement. However, some studies have assessed the perception of parents or guardians regarding their children’s body image and the self-perception of the body image of children and adolescents regarding their nutritional status. The study by Battisti et al.,1717 Battisti M, Bergjohann P, Adami FS, Fassina P. Percepção da imagem corporal associada ao estado nutricional de crianças e adolescentes. Rev Bras Prom Saúde. 2017; 30 (1): 86-92. with 122 children and adolescents aged 6 to 19 years old and their parents from a city in the state of Rio Grande do Sul, observed that their parents’ perception of body image was significantly associated with the children’s self-perception of body image and classification of their nutritional status. Moreover, self-perception of the body image in children and adolescents was associated with their nutritional status. The study by Vieira et al.,1818 Vieira RS, Dal Bosco SM, Grave MTQ, Adami FS. Percepción de imagen corporal de los adolescentes y sus padres en relación a niveles de presión arterial y el estado nutricional. Nutr Hosp. 2015 Apr; 31 (4): 1839-44. carried out with 914 parents and adolescents aged 10 to 19 years old from two cities in Vale do Taquari, Rio Grande do Sul, observed a direct and significant correlation between the body mass index with the adolescents’ self-perception and the parents’ perception of the body image, showing that adolescents and their parents have a real perception of their body image.

The modest agreement observed between the raters may be the result of difficulties inherent to the scale used. Among the obstacles reported by the raters, the difficulty in classifying the images of some individuals stands out, since they did not fit into any of the silhouettes presented, which constitutes one of the criticisms of the instrument reported in the literature. Studies suggest that scales with a greater number of silhouettes could reduce the problem of loss of information resulting from the use of Likert- type scales to assess a continuous variable such as body size.11 Côrtes MG, Meireles AL, Friche AAL, Caiaffa WT, Xavier CC. O uso de escalas de silhuetas na avaliação da satisfação corporal de adolescentes: revisão sistemática da literatura. Cad Saúde Pública. 2013 Mar; 29 (3): 427-44.,1313 Gardner RM, Friedman BN, Jackson NA. Methodological concerns when using silhouettes to measure body image. Percept Mot Skills. 1998 Apr; 86 (2): 387-95. However, some authors report that a larger number of silhouettes would not solve this issue since, in addition to confuse the individual,11 Côrtes MG, Meireles AL, Friche AAL, Caiaffa WT, Xavier CC. O uso de escalas de silhuetas na avaliação da satisfação corporal de adolescentes: revisão sistemática da literatura. Cad Saúde Pública. 2013 Mar; 29 (3): 427-44.,2727 Ambrosi-Randić N, Pokrajac-Bulian A, Takšić V. Nine, seven, five, or three: how many figures do we need for assessing body image? Percept Mot Skills. 2005 Apr; 100 (2): 488-92. only two to three central figures tend to be chosen by the participants when using scales with many silhouettes.11 Côrtes MG, Meireles AL, Friche AAL, Caiaffa WT, Xavier CC. O uso de escalas de silhuetas na avaliação da satisfação corporal de adolescentes: revisão sistemática da literatura. Cad Saúde Pública. 2013 Mar; 29 (3): 427-44.,1313 Gardner RM, Friedman BN, Jackson NA. Methodological concerns when using silhouettes to measure body image. Percept Mot Skills. 1998 Apr; 86 (2): 387-95.

Another difficulty reported by the raters was related to the body shape, which often differs from the images presented. The same individual could fit into two silhouettes according to their body characteristics, such as adolescents who had thinner upper limbs and larger lower limbs. In this case, the upper body could be classified into one silhouette and the lower one into another. According to the literature, this can be explained by the fact that those responsible for illustrating the figures built most scales, including the one used in this study, to correspond to what they subjectively believe represent a variety of weights rather than known anthropometric body dimensions for varying weights.2828 Gardner RM, Brown DL. Body image assessment: a review of figural drawing scales. Pers Individ Dif. 2010; 48 (2): 107-11.

When comparing the raters’ perception to self-assessments, it is clear that the three assessed adolescents had more perception of overweight than the adolescents themselves. The way individuals see themselves continually changes over time and with the culture in which they are inserted,2929 Gleeson K, Frith H. (De)constructing body image. J Health Psychol. 2006 Feb; 11 (1): 79-90. which may have made the raters’ perceptions of the body different from those of the adolescents.

This study has some limitations. The use of scales that are two-dimensional figures, which do not represent the human body accurately. Another limitation refers to the losses related to the participants who performed the three-dimensional body image, which can lead to selection bias, since the adolescents with better health were more likely to be those that attended the test or these had their own characteristics that interfered with their self-perception of body image, for example. Furthermore, the subjectivity of the raters and adolescents can interfere with the classification of individuals on the scale, which may contribute to the disagreements observed. The fact that instruments are highly subject to individual subjectivity made it impossible to obtain a standardization for the study raters, which could reduce the differences in classifications. Furthermore, the differences were important to respond to one of the objectives of the study, which was to assess the inter-rater agreement of the three-dimensional images compared to the Stunkard’s scale.

The findings in this study show that the agreement between the raters was acceptable, being considered weak or moderate in Kappa and good and excellent in ICC. However, when compared with the adolescents’ self-assessment, a greater perception of overweight by the raters were found. These results may be related to both the subjectivity of the individuals and the inherent limitations of the scale used.

The greater perception of overweight by the raters may reflect the training of the nutritionist when dealing with nutritional assessments, since this professional is qualified to detect health situations that require nutritional interventions. In this sense, the greater detection of overweight individuals may reflect the concern of this professional the damage that overweight can bring to health. Furthermore, although silhouette scales are widely used in epidemiological studies, the need to develop and validate a scale with figures that are more realistic to the characteristics of Brazilian adolescents is highlighted, using, for example, technological tools such as three-dimensional images.

We conclude that, although subjectivity is a fundamental factor when considering agreement in the perception of others and self-perception of the body image, health professionals, especially nutritionists, tend to have a sensitive eye for detecting overweight situations, even when this is not self-perceived by adolescents, directing and guiding these individuals at nutritional risk for health promotion actions.

References

  • 1
    Côrtes MG, Meireles AL, Friche AAL, Caiaffa WT, Xavier CC. O uso de escalas de silhuetas na avaliação da satisfação corporal de adolescentes: revisão sistemática da literatura. Cad Saúde Pública. 2013 Mar; 29 (3): 427-44.
  • 2
    Hartman-Munick SM, Gordon AR, Guss C. Adolescent body image: influencing factors and the clinician’s role. Curr Opin Pediatr. 2020 Aug; 32 (4): 455-60.
  • 3
    Miranda VPN, Morais NS, Faria ER, Amorim PRS, Marins JCB, Franceschini SCC, et al. Body dissatisfaction, physical activity, and sedentary behavior in female adolescents. Rev Paul Pediatr. 2018 Oct/Dec; 36(4): 482-90.
  • 4
    Neves CM, Cipriani FM, Meireles JFF, Morgado FFR, Ferreira MEC. Body image in childhood: an integrative literature review. Rev Paul Pediatr. 2017 Jul/Sep; 35 (3): 33-9.
  • 5
    Carvalho GX, Nunes APN, Moraes CL, Veiga GV. Body image dissatisfaction and associated factors in adolescents. Ciênc Saúde Coletiva. 2020 Jul; 25 (7): 2769-82.
  • 6
    Moraes C, Anjos LA, Marinho SMSA. Construção, adaptação e validação de escalas de silhuetas para autoavaliação do estado nutricional: uma revisão sistemática da literatura. Cad Saúde Pública. 2012 Jan; 28 (1): 7-20.
  • 7
    Solomon-Krakus S, Sabiston CM, Brunet J, Castonguay AL, Maximova K, Henderson M. Body image self-discrepancy and depressive symptoms among early adolescents. J Adolesc Health. 2017 Jan; 60 (1): 38-43.
  • 8
    Amaral ACS, Ferreira MEC. Body dissatisfaction and associated factors among Brazilian adolescents: a longitudinal study. Body Image. 2017 Sep; 22: 32-8.
  • 9
    Brausch AM, Muehlenkamp JJ. Body image and suicidal ideation in adolescents. Body Image. 2007 Jun; 4 (2): 207-12.
  • 10
    Mintem GC, Gigante DP, Horta BL. Change in body weight and body image in young adults: a longitudinal study Health behavior, health promotion and society. BMC Public Health. 2015; 15 (1): 1-7.
  • 11
    Ribeiro-Silva RC, Fiaccone RL, Conceição-Machado MEP, Ruiz AS, Barreto ML, Santana MLP. Body image dissatisfaction and dietary patterns according to nutritional status in adolescents. J Pediatr (Rio J). 2018 Mar/Apr; 94 (2): 155-61.
  • 12
    Moehlecke M, Blume CA, Cureau FV, Kieling C, Schaan BD. Self-perceived body image, dissatisfaction with body weight and nutritional status of Brazilian adolescents: a nationwide study. J Pediatr (Rio J). 2020 Jan/Feb; 96 (1): 76-83.
  • 13
    Gardner RM, Friedman BN, Jackson NA. Methodological concerns when using silhouettes to measure body image. Percept Mot Skills. 1998 Apr; 86 (2): 387-95.
  • 14
    Stunkard AJ, Sørensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis. 1983; 60: 115-20.
  • 15
    Scagliusi FB, Alvarenga M, Polacow VO, Cordás TA, Queiroz GKO, Coelho D, et al. Concurrent and discriminant validity of the Stunkard’s figure rating scale adapted into Portuguese. Appetite. 2006 Jul; 47 (1): 77-82.
  • 16
    Rumbo-Rodríguez L, Sánchez-Sansegundo M, Ferrer-Cascales R, García-D’Urso N, Hurtado-Sánchez JA, Zaragoza-Martí A. Comparison of body scanner and manual anthropometric measurements of body shape: a systematic review. Int J Environ Res Public Health. 2021 Jun; 18 (12): 6213.
  • 17
    Battisti M, Bergjohann P, Adami FS, Fassina P. Percepção da imagem corporal associada ao estado nutricional de crianças e adolescentes. Rev Bras Prom Saúde. 2017; 30 (1): 86-92.
  • 18
    Vieira RS, Dal Bosco SM, Grave MTQ, Adami FS. Percepción de imagen corporal de los adolescentes y sus padres en relación a niveles de presión arterial y el estado nutricional. Nutr Hosp. 2015 Apr; 31 (4): 1839-44.
  • 19
    Simões VMF, Batista RFL, Alves MTSSB, Ribeiro CCC, Thomaz EBF, Carvalho CA, et al. Saúde dos adolescentes da coorte de nascimentos de são luís, maranhão, de 1997/98. Cad Saúde Pública. 2020; 36 (7): e00164519.
  • 20
    IBGE (Instituto Brasileiro de Geografia e Estatística). Características étnico-raciais da população: um estudo das categorias de classificação de cor ou raça. Rio de Janeiro: IBGE; 2011.
  • 21
    Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003 Aug; 35 (8): 1381-95.
  • 22
    ABEP (Associação Brasileira de Empresas de Pesquisa). Critério Brasil e alterações na aplicação do Critério Brasil, válidas a partir de 16/04/2018. São Paulo: ABEP; 2018.
  • 23
    Miot HA. Análise de concordância em estudos clínicos e experimentais. J Vasc Bras. 2016 Apr/Jun; 15 (2): 89-92.
  • 24
    Soares Filho LC, Batista RFL, Cardoso VC, Simões VMF, Santos AM, Coelho SJDDAC, et al. Body image dissatisfaction and symptoms of depression disorder in adolescents. Braz J Med Biol Res. 2020; 54 (1): 1-7.
  • 25
    Sim J, Wright CC. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther. 2005 Mar; 85 (3): 257-68.
  • 26
    Cicchetti DV. Interreliability standards in psychological evaluations. Psychol Assess. 1994; 6 (4): 284-90.
  • 27
    Ambrosi-Randić N, Pokrajac-Bulian A, Takšić V. Nine, seven, five, or three: how many figures do we need for assessing body image? Percept Mot Skills. 2005 Apr; 100 (2): 488-92.
  • 28
    Gardner RM, Brown DL. Body image assessment: a review of figural drawing scales. Pers Individ Dif. 2010; 48 (2): 107-11.
  • 29
    Gleeson K, Frith H. (De)constructing body image. J Health Psychol. 2006 Feb; 11 (1): 79-90.
  • 30
    Fonseca AS, Lemos VHB, Silva AA, Braz Júnior G, Paiva AC, Silva AAM. BodyRating: uma proposta para anotação de silhueta corporal para avaliação de autopercepção. In: Anais do 17º Workshop de Informática Médica (WIM), Congresso da Sociedade Brasileira de Computação (CSBC), 02-06 jul 2017. São Paulo (SP): CSBC; 2017. p. 1983-6.

Publication Dates

  • Publication in this collection
    09 May 2022
  • Date of issue
    Jan-Mar 2022

History

  • Received
    28 Jan 2021
  • Reviewed
    25 Nov 2021
  • Accepted
    14 Dec 2021
Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br