ORIGINAL ARTICLE

The Body Image Scale: A Simple and Valid Tool for Assessing Body
Image Dissatisfaction in Inflammatory Bowel Disease
Edel McDermott, MB,* ,† Jenny Moloney, BSc,‡ Niamh Rafter, BComm,* ,† Denise Keegan, RGN,* ,†
Kathryn Byrne, BSc,* ,† Glen A. Doherty, PhD,* ,† Garret Cullen, MD,* ,† Kevin Malone, MD,†,§
and Hugh E. Mulcahy, MD* ,†

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Background: Body image refers to a persons’ sense of their own physical appearance. This can be negatively influenced by a number of factors
including disease states and treatments. Inflammatory bowel disease (IBD) carries a distinct psychosocial and a physical burden, but body image has not
been formally assessed in patients with IBD, nor is there a validated body image questionnaire. Our aim was to assess and validate a body image
questionnaire for patients with IBD.
Methods: Three hundred thirty-eight ambulatory patients (median age, 36; 174 male) completed a questionnaire that included the Hopwood body
image scale adapted from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group. Data from another
scale, the Cash Body Image Disturbance Questionnaire, were also collected in addition to demographic and clinical data.
Results: Factor analysis resulted in a single factor solution explaining 65% of the variance. Internal consistency of the body image scale was
demonstrated with a Cronbach alpha of 0.93. Convergent validity was established with a correlation coefficient of 0.64 (P , 0.001) with the
Cash Body Image Disturbance Questionnaire. Females (P , 0.001) and those who had undergone either stoma or nonstoma forming surgery
experienced more body image dissatisfaction (P ¼ 0.002), indicating predictive validity. Reliability was confirmed with a test–retest correlation
of 0.82 (P , 0.001).
Conclusions: The modified body image scale is a valid tool for assessing body image in patients with IBD.
(Inflamm Bowel Dis 2014;20:286–290)
Key Words: inflammatory bowel disease, Crohn’s disease, ulcerative colitis, body image, questionnaire

B ody image refers to a person’s sense of their own physical

appearance and to their perception of how others see them. A
normal individual’s body image is thought to be influenced by
perceived pressure for females to be thin and for males to have
a muscular physique frequently impacts on the normal individu-
al’s emotional and interpersonal experiences and quality of life.4,5
many factors including gender, personality type, and cultural and An individual’s body image may change in response to
social norms. Body image has a major influence on social inter- aging, media and advertising exposure, previous life events, and
actions and relationships, and individuals with a negative body both positive or negative interpersonal experiences. It may also be
image may experience feelings of shame, embarrassment, and influenced by physical disease that results in changes in appear-
anxiety about their physical appearance. Body image dissatisfac- ance or physical function.6 Body image dissatisfacton has been
tion is commonly found in the general population.1 As an exam- found in patients with rheumatological, dermatological, and renal
ple, 62% of female and 38% of male European university students diseases,7–9 and in patients undergoing surgery.10 However, only
consider themselves “too fat.”2 High rates of body image dissat- a single study has assessed body image in inflammatory bowel
isfaction are also found in American university students,3 and the disease (IBD).11 This Australian postal questionnaire included
a single specific question regarding body image impairment and
provided interesting initial insights into patient concerns. Two-
Received for publication September 21, 2013; Accepted November 1, 2013. thirds of respondents reported body image impairment as a result
From the *Department of Gastroenterology, St Vincent’s University Hospital, of their disease, and the authors emphasized the importance of
Dublin, Ireland; †UCD School of Medicine and Medical Science, University College
Dublin, Dublin, Ireland; ‡Department of Gastroenterology, St Luke’s Hospital, body image in IBD and the need for further research.
Kilkenny, Ireland; and §Department of Psychiatry, Psychotherapy and Mental Health Although body image issues are clearly important to
Research, St Vincent’s University Hospital, Dublin, Ireland.
patients with IBD, study is hampered by the absence of a suitable
The authors have no conflicts of interest to disclose.
assessment tool to collect standardized data. A number of scales
Reprints: Hugh E. Mulcahy, MD, Department of Gastroenterology, St Vincent’s
University Hospital, Elm Park, Dublin 4, Ireland (e-mail: hemulc@[Link]). have been developed to assess body image dissatisfaction in
Copyright © 2013 Crohn’s & Colitis Foundation of America, Inc. physical diseases,12,13 but none has been tested or validated in an
DOI 10.1097/[Link].0000438246.68476.c4 IBD population. Our aim was to assess and validate a body image
Published online 26 December 2013. scale specifically for use with patients with IBD.

286 | [Link] Inflamm Bowel Dis  Volume 20, Number 2, February 2014
Inflamm Bowel Dis  Volume 20, Number 2, February 2014 Tool for Assessing Body Image Dissatisfaction

in overall body image dissatisfaction. In the development of the

TABLE 1. Demographic and Clinical Details of 338 IBD original scale, Hopwood et al14 described the process of item
Study Patients generation and scale construction, using “the literature, discussion
Gender (male/female) (%) 174 (51)/164 (49) with health professionals, and extensive interviews with breast
Age, median (range), yr 36 (18–83) cancer patients.” We assessed content validity of the scale in
Disease type (Crohn’s 187 (55)/150 (45) our IBD population with a team of multidisciplinary health care
disease/ulcerative colitis) (%)a professionals involved in the care of patients with IBD. The orig-
Disease duration, median (range), yr 6.4 (0.1–37.3) inal scale included a question “Have you been dissatisfied with
Prior surgery (yes/no) (%) 98 (29)/240 (71) the appearance of your scar?”. This question biases dissatisfaction
Current biologic use (yes/no) (%) 97 (29)/241 (71) towards those who have undergone operation, since those not
Current immunomodulator use (yes/no) (%) 133 (39)/205 (61) having had surgery necessarily score zero. We therefore excluded

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this question. We also added a number of questions to Hopwood’s
a
Data missing for 1 patient.
original scale during the content validation phase, specifically
targeted towards patients with IBD. These assessed dissatisfaction
related to body odor and noise, both potentially pertinent to our
MATERIALS AND METHODS patient population. However, factor analysis revealed that these
Three hundred eighty-seven patients attending ambulatory additional items formed a separate factor, reduced predictive abil-
clinics in 1 of 2 medical centers, between July 2011 and ity when compared with the original scale and reduced internal
November 2012, were invited to participate in the study. Three reliability. These items were deemed to be measuring a different
patients declined, 43 did not return the questionnaire, and a further construct, and were excluded from the modified scale. Thus, the
3 had critical body image data missing. The study therefore final questionnaire included 9 items (Fig. 1). Patients scored from
included 338 patients whose demographic and clinical details are 0 (“Not at all”) to 3 (“Very much”) on each question so the lowest
shown in Table 1. possible total score was 0 and the highest 27, with higher scores
Patients completed a self-administered questionnaire that indicating increasing body image dissatisfaction. Ethical approval
included a modified body image scale by Hopwood et al.14 This was obtained from local Ethics Committees.
scale was designed as a brief self-report measure in conjunction Psychometric properties of the body image scale were
with the European Organization for Research and Treatment of assessed in a number of ways. Response prevalence, i.e., the
Cancer (EORTC) Quality of Life Study Group. It has been tested frequency with which a score of 1 or more was obtained for each
and validated on a broad range of cancer patients, and coverage question, was determined. Previous guidelines suggest an appro-
has proved acceptable to both male and female patients with priate response rate of greater than 30%.14 Principal componant
a range of body image concerns.14,15 The scale is not specific to analysis with varimax rotation was employed to assess the struc-
any 1 disease and focuses on the effects of both disease and ture and content validity of the scale (factoral validity). Internal
treatment on body image. We therefore considered it a suitable consistency of the baseline scores was determined using Cron-
candidate tool for use in patients with IBD in whom both the bach’s alpha coefficient, with levels above 0.7 reflecting high
primary disease and its treatment might be expected to play a part levels of consistency. Construct validity was tested using

FIGURE 1. Modified body image scale.

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FIGURE 2. Percentage of 338 patients with IBD answering each of 9
body image scale questions: “Not at all,” “A little,” “Quite a lot,” and
“Very much”. FIGURE 3. Frequency of body image scale scores in 338 patients with
IBD.

a combination of validation techniques. Convergent validity was

assessed by comparing the body image scale with the Cash Body variance, indicating that the 9-item scale performed well on scale
Image Disturbance Questionnaire.3 This body image tool has a dif- structure testing. Internal consistency of the questions was dem-
ferent format to the body image scale, with both quantitative and onstrated with a Cronbach’s alpha of 0.93. Figure 3 shows the
qualitative components, and has been validated in patient cohorts frequency of total body image scores. Forty-five patients had
and in healthy students.3,8 We felt this was relevant to our IBD a body image scale score of 0 and the median score was 6.
population, whose disease is frequently diagnosed in young adult-
hood. The Body Image Disturbance Questionnaire was developed Construct Validity
within a cognitive behavioral framework and focuses on the psy- Figure 4 shows the association between the modified Body
chosocial impact of body image disturbance. We performed Image Scale and the Body Image Disturbance Questionnaire.
known group comparisons (predictive validity) by comparing Convergent validity was established with a correlation coefficient
body image scores in males and females, and in patients who of 0.64. Figure 5 shows the association between body image,
had no previous surgery, nonstoma, or stoma forming surgery gender, and previous surgery. Females tended to experience more
with the expectation that both gender and surgery would influence body image dissatisfaction than males (P , 0.001), whereas
a valid body image scoring system.2,10,16 Thirty-eight patients, patients who had undergone either nonstoma or stoma forming
whose treatment remained unchanged, completed the body image surgery also tended to have higher dissatisfaction scores on the
scale, a median of 11 months (range, 2 wk–18 mo) apart to Body Image Scale (P ¼ 0.002). Linear regression analysis indi-
determine test–retest reliability. cated that body image was unrelated to disease type (P ¼ 0.77)
Continuous data are presented as medians and interquartile and confirmed that younger age, female gender, and both
ranges. Correlations were analyzed using Spearman’s rank correla-
tion coefficient (rs). Differences between groups were assessed
using the Mann–Whitney U test and Kruskal–Wallis test as appro-
priate. Test–retest reliability was measured using Spearman’s rank
correlation coefficient. Linear regression analysis was performed to
determine factors independently associated with body image dis-
satisfaction. Analyses were performed using the Statistical Package
for the Social Sciences (SPSS 18.0; SPSS, Chicago, Illinois).

RESULTS
Figure 2 shows the response prevalence to individual ques-
tions. Between 30% and 72% of patients answered “Not at all” to
each of the 9 questions. As an example, 30% of patients answered
“Not at all” to question 1, whereas 43%, 17%, and 10% answered
“A little,” “Quite a lot,” and “Very much,” respectively. Overall, 8
of the 9 questions achieved the recommended 30% response rate FIGURE 4. Correlation between the modified body image scale
with question 7 achieving a 28% positive response rate. Factor and the body image disturbance questionnaire (BIDQ) in 338 patients
analysis resulted in a single factor solution explaining 65% of the with IBD.

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design experts,18,19 it is needed to be simple and quick to complete

and have a standardized format with unambiguous questions
throughout, so that it could be self-administered by patients with
a range of educational abilities. Finally, validity needed to be con-
firmed in a large group of patients with IBD.
The Body Image Scale largely fulfills the above criteria. It
was developed primarily for use in research trials, and has
previously been found to be a valid and succinct measure of
the impact of both disease and treatment on body image.14,15 We
found it easy to administer, and patients seemed to find it simple
and quick to use with only 3 of 341 patients who returned the

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FIGURE 5. Relationship between body image, gender, and previous questionnaire failing to complete the body image tool adequately.
surgery in 338 patients with IBD. We modified Hopwood’s original 10-item questionnaire by
excluding the question “Have you been dissatisfied with the
nonstoma and stoma forming surgery were independently associ- appearance of your scar?” as described in the methods section
ated with body image dissatisfaction (Table 2). Test–retest reli- above. Nevertheless, factor analysis confirmed that the scale is
ability was demonstrated between body image scores performed a unitary measure of body image disturbance and the question-
a median of 11 months apart (range, 2 wk–18 mo) (rs, 0.82; P , naire’s internal consistency was excellent. We found a close cor-
0.001 Spearman’s rank correlation coefficient). relation between our modified 9-item scale and the Cash Body
Image Disturbance Questionnaire, thus establishing convergent
validity.
DISCUSSION Overall, there was a wide range of scores in our patient
Body image dissatisfaction is experienced by many individ- population. Dissatisfaction was greater in females and those who
uals in the normal population, and is increased by the physical and had undergone either stoma or nonstoma forming surgery, as
functional changes of chronic disease states.17 IBD frequently de- previously found by Muller et al11 and others,10,16 establishing
velops in young adults and seems to be associated with body image predictive validity. Regression analysis indicated that body image
impairment in many patients. We sought to identify a body image was not associated with disease type and the scale is applicable to
tool that met specific requirements. First, the questions needed to patients with both Crohn’s disease and ulcerative colitis. Indeed,
focus on body image satisfaction, rather than psychological or the nonspecific nature of the questions may also allow body image
cognitive behavior, to facilitate its use by gastroenterologists and comparisons in patients with other diverse medical conditions.
provide a clear message for clinicians to understand and interpret. However, it should be noted that the questionnaire is not valid
Second, the questionnaire needed to be appropriate for both patients in normal individuals because 4 of the 9 questions relate specif-
with Crohn’s disease and ulcerative colitis, and to consider the ically to disease and treatment. Between 28% and 70% of patients
effects of treatment and disease. Third, as advocated by survey indicated some level of body image dissatisfaction to each

TABLE 2. Linear Regression Analysis Assessing Clinical Factors Associated with Body Image Dissatisfaction in 338
Patients with IBD
95% Confidence Interval for B
Variable B Beta t Value Lower Upper P

Age at study 20.09 20.19 23.68 20.14 20.04 ,0.001

Gender
Male — — — — — —
Female 2.59 0.19 3.73 1.23 3.96 ,0.001
Surgery
None — — — — — —
Nonstoma surgery 2.44 0.15 2.74 0.69 4.20 0.007
Stoma surgery 3.76 0.15 2.71 1.03 6.49 0.007
Disease
Ulcerative colitis — — — — — —
Crohn’s disease 0.22 0.16 0.29 21.27 1.70 0.77
Constant 8.93 — 7.35 6.54 11.31 ,0.001

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McDermott et al Inflamm Bowel Dis  Volume 20, Number 2, February 2014

question. Question 7, “Do you avoid people because of the way Newman Research Fellow for this study. The authors also thank
you feel about your appearance?” received the lowest positive Dr. Penelope Hopwood for permission to use the body image
response rate at 28%. It is interesting that this is the only question scale and Ms. Margaret McDermott for her helpful comments
that relates to patients’ interactions with others rather than per- during manuscript preparation.
sonal perceptions about body image, and the low positive
response rate may relate to the lack of readily noticeable signs
of disease or functional changes in most patients. Finally, it
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