Introduction
Body image is a relatively neglected topic in patients with health problems, despite the fact that most health problems have the potential to change a person’s body, whether as a direct result of the illness or its treatment. Where body image has been studied in health contexts, typically investigators have: (a) compared individuals with an illness to a healthy control group and found that body image is compromised across a range of medical conditions (e.g., Cornwell and Schmitt, 1990; Schiavi et al., 1995; Sarwer et al., 1999; Yuen and Hanson, 2002; Lazaridou-Terzoudi et al., 2003; Weinstein et al., 2003; Huang et al., 2006; Noyan et al., 2006; Abbott et al., 2007; Kaymak et al., 2007; Moin et al., 2009; Guenther et al., 2010; Versnel et al., 2010; Blashill and Wal, 2011; Steinmann et al., 2011; Versnel et al., 2011) and/or (b) found a relationship between body image disturbance and psychosocial outcomes (e.g., Rybarczyk et al., 1995; Breakey, 1997; Carver et al., 1998; Eiser et al., 2001; Marcusson et al., 2002; Perez et al., 2002; Taleporos and McCabe, 2002; Benrud-Larson et al., 2003; Petronis et al., 2003; Limb, 2004; Tebble et al., 2004; Coffey et al., 2009; Fingeret et al., 2011; Sharpe et al., 2011; Bullen et al., 2012; Teo et al., 2018; Fang et al., 2019; Pieta et al., 2020). However, very little of this research has been driven by theoretical models that have asked questions about the nature of body image disturbance and the way in which body image factors likely contribute to poorer psychosocial outcomes (Feragen and Stock, 2018).
Although there are many models of body image for the general population, White’s (2000) Heuristic Cognitive Behavioral Model of body image for oncology patients remains the only theoretical model of body image developed specifically for patients with a chronic illness (Pruzinsky, 2004). White suggests that any bodily change will be processed in the context of an individual’s pervasive beliefs about themselves (i.e., self-schema) that are triggered by a real or perceived change in their appearance. According to White’s model, these schemas will determine the degree of importance individuals place on their appearance. People who have negative self-schema and are invested in their bodily appearance become invested in the changed body part, which contributes to the development of the self-ideal discrepancy. White (2000) proposes that negative body image schemas, investment in appearance and a self-ideal discrepancy lead to the activation of negative appearance-related assumptions, negative automatic thoughts and/or images, maladaptive behaviors, and ultimately emotional distress. Both emotional distress and unhelpful behaviors (such as avoidance) in turn maintain the negative schemas and investment in body ideals.
White’s (2000) model built upon the connections described by cognitive behavioral accounts of body image (Cash and Szymanski, 1995; Cash, 2002, 2011), with specific attention to the impact of cancer. In doing so, White’s (2000) model was the first to provide a hypothesis-generating conceptual framework for understanding the possible etiology of body image disturbance in oncology. Numerous studies in oncology provide support for one or more of the central tenets of White’s model in a range of cancers, including breast cancer (Petronis et al., 2003; Figueiredo et al., 2004; Metcalfe et al., 2005; Browall et al., 2008; Dahl et al., 2010; Moreira and Canavarro, 2010; Collins et al., 2011), colorectal cancer (Cotrim and Pereira, 2008; da Silva et al., 2008; Sharpe et al., 2011), prostate cancer (Perez et al., 2002), head/neck cancer (Fingeret et al., 2011), oral cavity cancer (Fingeret et al., 2010), osteo- or ewings-sarcoma (Eiser et al., 2001), gynecological cancer (Teo et al., 2018), and melanoma (Lichtenthal et al., 2005). All of these studies provide support for the strong association between body image disturbance and poor psychosocial outcomes in cancer. Moreover a number of these studies employed prospective designs and found that body image was a significant predictor of future psychosocial outcome (Shimozuma et al., 1999; Browall et al., 2008; Moreira and Canavarro, 2010; Sharpe et al., 2011; Bullen et al., 2012; Taylor-Ford et al., 2012). However, most of the literature, to date, has tested only some of the simple relationships between variables described in White’s model and only in oncology groups. The full model has not been examined using path analysis or structural equation modeling, nor has the model been tested extensively outside of the cancer literature, despite suggestions that it could be equally relevant to other illnesses (Pruzinsky, 2004). Therefore, the above mentioned are the overarching aims of the current study.
Research across a range of illnesses has supported the contention that health related changes in appearance have a negative impact on body image; including pectus excavatum (Steinmann et al., 2011), HIV (Huang et al., 2006; Blashill and Wal, 2011), facial cleft (Marcusson et al., 2002; Versnel et al., 2010, 2011), craniofacial abnormality (Sarwer et al., 1999), ankylosing spondylitis (Guenther et al., 2010), arthritis (Pieta et al., 2020), physical disability (Moin et al., 2009), dermatological conditions (Kaymak et al., 2007), breast cancer (Noyan et al., 2006), cystic fibrosis (Abbott et al., 2007), burns (Thombs et al., 2008), and scoliosis (Weinstein et al., 2003). Perhaps unsurprisingly, illnesses that result in a highly visible bodily changes to the chest and face appear to have a greater negative impact on body image (Marcusson et al., 2002; Versnel et al., 2010; Steinmann et al., 2011). Therefore, although the perception of one’s body and any resulting change is no doubt important, it may also be important to highlight the importance of actual bodily change on body image experience. Interestingly, White’s model indicates that personal investment is a direct predictor of psychosocial outcome. While relationships between personal investment and psychosocial outcomes have been found in studies that have assessed these constructs, the relationship appears to be an indirect one (Lawrence et al., 2004, 2006; Thombs et al., 2008; Moreira and Canavarro, 2010; Partridge and Robertson, 2011). That is, personal investment appears to predict subjective body image disturbance, which in turn predicts psychosocial outcomes. Hence, this suggests that it would be appropriate to include an assessment of subjective body image to better understand these relationships.
On the basis of available research, we aim to examine White’s model of body image disturbance with two distinct but related health groups. We planned to examine two distinct pathways in which objective bodily changes (due to illness, disability, and/or associated treatment) influence subjective body image experience. That is, objective changes can directly influence body image, however, they can also indirectly influence body image experience through increasing personal investment and self-ideal discrepancy. Secondly, based on the broader health literature, we also planned to examine the role of subjective body image experiences. Specifically, how subjective body image is directly influenced by the bodily changes, and how it is also indirectly influenced by the level of investment and self-ideal discrepancy. We hypothesized that subjective body image will be directly associated with psychosocial outcomes and will mediate the relationship between personal investment and self-ideal discrepancy and psychosocial outcomes.
The aim of the present study was therefore to test the validity of White’s (2000) model in two related health groups with rising prevalence rates. To test this model, we selected two health groups, which differ with respect to the degree of visible objective bodily changes. These groups were individuals with diabetes and individuals with an amputation.
Diabetes Mellitus (DM) is a common metabolic disorder with not only increasing prevalence rates observed over the past decade, but according to the World Health Organization the estimated global prevalence rate of diabetes will be 4.4% by the year 2030. In 2017, there were 5 million deaths due to diabetes and the cost of diabetes that year was in excess of $US50 million (Cho et al., 2018). Empirical research demonstrates that body image is strongly associated with depression (Carroll et al., 1999; Ali et al., 2006), poorer treatment adherence (Carroll et al., 1999; Ritholz et al., 2010; Chao et al., 2012), and DM-related complications (Shaban, 2010; Williams et al., 2011, 2013; McDonald et al., 2014). While the presence of complications can cause clear objective and visible bodily changes, such as amputation, many people with diabetes do not have observable change in appearance as a result of their illness. Nevertheless, these results indicate that body image in diabetes has a major impact not only on psychological factors, but also on illness variables. Given that body image may have a role in the illness trajectory for individuals with diabetes, a clear theoretical framework from which to develop interventions to support those individuals where body image is compromised is important.
An amputation is marked by a clear visible and objective change to the body, which can be caused by a disease process (i.e., complication associated with diabetes), but also by trauma. Individuals with an amputation commonly experience symptoms of depression and anxiety within the first 2 years following amputation, however, when this persists it has been associated with poorer physical rehabilitation (Horgan and MacLachlan, 2004). Notably, research indicates that presence of negative body image is significantly associated with prolonged experiences of depression, anxiety, lower QOL, and activity restriction (Breakey, 1997; Coffey et al., 2009; Zidarov et al., 2009).
The use of two different illness groups with differing levels of objective change in bodily appearance allows us to investigate the relevance of body image disturbance in different presentations. Furthermore, it is unknown whether the White’s heuristic model applies solely to populations with observable physical changes to their body as a result of illness (e.g., women with breast cancer following surgery) or whether it also applies in illnesses where there is no identifiable change in appearance due to the illness.
The objective of the present study was to examine the validity of White’s model for individuals with diabetes and individuals with an amputation. It was predicted that structural pathways proposed in White’s model would provide a good fit to the data for both groups. Specifically, it is proposed that body image disturbance, personal investment, and self-ideal discrepancy will all directly predict psychosocial outcome. It was further hypothesized that the total variance accounted for will be greater in the amputation group than the diabetes group given the objective visible bodily changes experienced by this group. It was also predicted that body image disturbance in both groups will mediate the relationships between (a) personal investment and psychosocial outcome, and (b) self-ideal discrepancy and psychosocial outcome. Finally, it is predicted that the structural pathways under examination will be invariant across groups.
Discussion
Overall, the aim of the study was to test a well-known theoretical model of body image disturbance in health, in two distinct samples. To this end, we chose individuals with diabetes and individuals with an amputation, who differ importantly on the degree of objective and visible bodily change. Results from both groups indicate support for White’s (2000) model for use outside of oncology. Specifically, as predicted, body image disturbance, personal investment, and self-ideal discrepancy all independently and directly predicted psychosocial outcome, over and above demographic and medical factors. Consistent with our hypotheses the structural model explained greater variance in psychosocial outcome for individuals with amputation than for individuals with diabetes. These findings are consistent with the findings of previous research. Notably, it appears that the visible difference associated with a condition (in this case amputation) influences the degree of body image disturbance experienced. There was evidence to support the hypothesis that the relationship between personal investment and psychosocial outcomes was mediated by body image experience for both groups, and there was also evidence that body image experience partially mediated the relationship between importance weighted self-ideal discrepancy and psychosocial outcome in both groups.
Finally, the study also examined the hypothesis that the model would be equivalent across the two groups. It was found that despite the distinct difference between the two groups, there was structural invariance across the two groups. That is, the theoretical model of direct and indirect relationships among variables was the same. Only the structural residuals varied across the two groups, meaning that the explanatory power of the model in predicting body image disturbance and psychosocial outcome differed between groups, as predicted. Importantly, these results were also found when the analyses were run with purely independent models (i.e., anyone with an amputation removed from the diabetes group and anyone with diabetes removed from the amputation group). The structural invariance highlights that the pattern of the core relationships between subjective body image disturbance, personal investment, self-ideal discrepancy, and psychosocial outcome are the same among groups of individuals with a chronic illness (diabetes) and individuals with a disability (amputation).
Before the implications of these findings can be considered it is important to bear in mind the limitations of the present study. First, as the design was cross-sectional, causal inferences cannot be made from these results. To test the causal inferences, prospective designs are needed. Secondly, the two samples are samples of convenience. It is likely that they differ in important ways from the population of people who have an amputation. For example, the rate of people in the amputation group, whose amputation was due to diabetes is lower than would be expected. On the one hand, this will limit the generalizability of the samples. However, on the other hand, there is no reason to think that the pattern of relationships between variables would be affected and these relationships were the primary interest in the present study. Furthermore, had a very high proportion of the amputation sample had diabetes, then these samples would not have had sufficient independence to answer the research questions. Third, self-reported BMI in the diabetes sample was used; therefore it is possible that this is not entirely accurate. Importantly, self-reported BMI is highly correlated with actual weight (Stunkard and Albaum, 1981). Further, it was not possible to control for BMI in the amputee group because its validity and meaning would vary depending on the nature and site of amputation. Finally, because we examined two different samples and investigated invariance of the models, we were unable to include illness-specific constructs, such as diabetes-related distress or fear of hypoglycemia. Therefore, we cannot comment on the role of body image in these important constructs.
These limitations notwithstanding, there are a number of important strengths of the present study. The present study was constructed to examine the validity of White’s (2000) model for other medical groups. Two large samples were recruited, which enabled both the inclusion of covariates and the use of structural equation modeling to examine the model in a systematic manner. In contrast to much of the previous research, the present study also utilized well-validated measures of both body image variables and psychosocial outcome. The use of large cohorts, sophisticated analyses, and controlling for covariates enable us to be confident about the findings of this study.
The present study provides preliminary empirical support that White’s (2000) cancer-specific model of body image applies to other medical groups. White’s model has been influential in the study of body image in people living beyond cancer and has been applied in a few other illnesses (e.g., multiple sclerosis; Wilski et al., 2016) but has not been applied to those following amputation or people with diabetes. It was found that body image experience, self-ideal discrepancy and personal investment all predict psychosocial outcome, though the amount of variance accounted for by the model is larger in the group with an amputation when compared to the diabetes group. This provides further evidence to support the contention that there is a direct relationship between objective change in appearance and body image disturbance, such that body image variables are more strongly associated with psychosocial outcome in groups where objective changes are caused by the illness or its treatment. However, the hypothesized relationships were nonetheless consistent across the two samples. That is, body image experience significantly mediated the relationship between personal investment and psychosocial outcome and partially mediated the relationship between self-ideal discrepancy and psychosocial outcome. The consistency of these relationships was also confirmed through our tests of invariance. These results underscore the importance of the body image experience of an individual irrespective of the degree of objective physical changes associated with their illness, disability, change in appearance or related treatment.
These results have important clinical implications. The strong relationship between body image and psychosocial outcomes suggests that body image could be an important target for intervention for individuals with diabetes and individuals with an amputation. Body image accounted for large proportions of the variance in the latent variable of psychosocial outcome, which consisted of depression, anxiety, physical, and psychological quality of life. Clearly, future research needs to test this model in other health groups to determine the generalizability of the model across illnesses. In addition, future research should utilize prospective designs to determine whether body image holds a causal relationship with psychosocial outcome for health groups. Available research, however, confirms that body image does predict future depression (Moreira and Canavarro, 2010; Bullen et al., 2012), anxiety (Sharpe et al., 2011; Bullen et al., 2012), psychological distress (Carver et al., 1998; Sharpe et al., 2011), and poorer quality of life (Shimozuma et al., 1999; Fauerbach et al., 2000; Browall et al., 2008; Taylor-Ford et al., 2012) in patients with physical health conditions. However, if confirmed, these results suggest that interventions that target body image may be of particular relevance not only for people following amputation, but also for people with diabetes. Cognitive behavioral interventions for body image disturbance have shown promise (Cash, 2002) and thus a clinical direction for future research would be to examine the efficacy of such therapeutic approaches for body image in health groups. Notwithstanding the need for future research, it is clear from the findings of the present study that body image is an important factor for individuals with diabetes and individuals with an amputation and thus it is important that body image becomes a focus of future health research and clinical interventions, rather than being a relatively neglected topic.