06 October, 2014:
With aging, women's bodies undergo changes that can affect body image perception, yet little is known about body image in midlife. In a subset of the SWAN cohort from Chicago, the associations between body image and depressive symptoms were investigated . Body image was measured using the Stunkard Adult Female Figure Rating Scale, and a clinically significant level of depressive symptoms was defined as a Center for Epidemiologic Studies Depression Scale (CES-D) score of ≥ 16 (total n = 405; depression n = 63 (15.6%)). Differences between perceived actual, perceived ideal and actual body size and responses to questions concerning weight satisfaction and attractiveness were examined using logistic regression for associations with a CES-D score of ≥ 16. Women with body image dissatisfaction (odds ratio, OR = 1.91; p = 0.04) or who perceived themselves as 'unattractive' (OR 7.74; p < 0.01) had higher odds of CES-D of ≥ 16. There was no significant difference by race, and results were not confounded by body mass index. To conclude, midlife women with poor body image may be more likely to have clinically significant levels of depressive symptoms.
Body image was defined by Slade as 'the picture we have in our minds of the size, shape and form of our bodies; and to our feelings concerning these characteristics and our constituent body parts' . The scope of body image may also include one's perception of one's visual appearance, esthetics and sexual attractiveness. Body image is distorted in anorexia nervosa, but this is part of the psychiatric features of the disease. Disturbances in self-body image may accompany disease situations such as cancer or disfiguration, but my commentary will not discuss this type of issue. Many studies have looked into the potential emotional consequences of dissatisfaction with one's physical appearance in the healthy population, a situation which is more common in women and in aging persons. For example, dissatisfaction with body appearance or image may lead to depression. Overweight and obesity may be the trigger for potential problematic body image and ensuing depression , although this may not be the rule, as many fat persons are happy with what they see in their mirror. In fact, the study by Jackson and colleagues  actually showed that body mass index was not a confounder for depression related to body image.
As mentioned before, studies on body image and related depression in menopausal women are very scarce. A PubMed search using the key words 'depression, menopause and body image' yielded publications that mainly focus on breast or genital aspects rather than on the holistic perception of body size and shape. The association of body size from childhood to age 40 with depression in postmenopausal women was recorded in the French E3N study . Participants reported birth characteristics and silhouettes matching theirs at age 8, at puberty, at 20–25, and 35–40 years (n = 41,144). Depression was assessed by CES-D and split into new-onset and recurrent depression according to women's history of psychological disorder. Low or high birth weights were associated with risk of depression. A large body size at age 8 and a large body size over the life course were both associated with the risk of new-onset depression specifically, while women with a large increase in body size at puberty were at risk of recurrent depression. Largest body sizes at 20–25 or 35–40 years were associated with both the risk of new-onset and recurrent depression, especially in normal weight women. However, a lean silhouette at 35–40 years was associated with the risk of recurrent depression only. Women with a large body size from childhood to adulthood might be at higher risk of new-onset postmenopausal depression, while leanness in adulthood could be associated with a higher risk of recurrent depression.
A study from Korea, of which the abstract was the only section written in English, used the five-item General Health Short Form (SF-36) Health Survey Questionnaire to measure health perception . Body image was measured by the Semantic Differential scale, and CES-D indicated the level of depression. Participants included 182 perimenopausal and postmenopausal women who had not received hormonal replacement therapy. In a stepwise regression analysis, 21.7% of variance in depression was attributed to perceived health and body image in the postmenopausal women. However, in perimenopausal women, perceived health and sexual function explained 34.5% of variance in depression. In another study from Austria (51 patients, aged 43–63), about half of women were not satisfied with their physical appearance . They filled a symptom questionnaire (0–3 scale) which included the items 'depression' and 'feeling misery', and a self-esteem score was recorded as well. A significant connection was found between high self-esteem and high satisfaction with one's own body. Women who were satisfied with their physical appearance experienced fewer troublesome menopausal symptoms. Specifically, significant differences between women with high and low self-esteem could be ascertained in regard to self-reported 'depression'.
Body image is a combination of what we see, what we feel and what we expect, with some additional impact from the signals we receive from surrounding people. Any dissatisfaction may lead to, or contribute to, depression. Ironically, treatment of depression with SSRIs and SNRIs may be associated with weight gain and may jeopardize body image.
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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