Study of self-image in a group of obese and overweight adults

The self-image in the obese has been insufficiently studied and the studies that have been carried out present us with unfinished methodologies, starting from the conscious perception of the subject and the rational elaborations of the possible distortions of this reflection. Several authors coincide in stating the need to carry out systematic studies with the Human Figure Drawing that support the psychometric quality of the technique and its evaluation parameters. Studies of specific groups of subjects (such as the obese) so far do not provide a comprehensive answer to this question. These antecedents led us to the assumption that self-image was inadequate, both consciously and unconsciously, in obese subjects. To verify this assumption, we developed a methodology that combined structured and unstructured or projective techniques, with a view to covering all factors associated with self-image.

Index

1. Summary
2. Introduction
3. What is the self-image of the overweight or obese subject like and what is the relationship with weight?
4. Why do we work with obese people?
5. Why do we work with self-image?
6. Why is it important for the obese to transform their self-image, even when it is adequate?
7. Methodology - Dimensions and indicators of self-image
8. Methodology - Universe
9. Methodology - Ethical aspects
10. Methodology - Criteria for inclusion of the sample
11. Results
12. Discussion
13. Conclusions

• Objective: In this way, we carry out the characterization of self-image in obese or overweight subjects. Methods: We select a group of overweight or obese adults who receive care in the Endocrinology Service of the Hospital Surgical Clinical Teacher "October 10" and in a Primary Health Care area of ​​the same municipality, in Havana, Cuba. We classify the self-image for its study into conscious and unconscious. The techniques used to identify conscious self-image were the in-depth interview and the Rodríguez Rebustillo self-perception test. contrasting the results with the Rockport Test and physical efficiency tests, and for the unconscious self-image we used the Human Figure Drawing Test by K. Machover, collated with a semi-structured interview and the production of a story about the drawn figure.
• Results: the results reveal the contradiction between conscious and unconscious self-image in these subjects. Consciously, most of the subjects studied have an adequate self-image, they are motivated by losing weight, they show dissatisfaction with their body weight and adequately reflect their capabilities physical. However, unconsciously, most of them resist self-image, feel satisfied with their weight and body, and even feel attractive.
• Conclusions: We conclude that this contradiction between the conscious and unconscious self-image may influence the ineffectiveness of the treatments regarding the loss of body weight and its maintenance in these subjects, which corresponded to the degree of obesity; the greater the obesity, the greater the satisfaction with the unconscious body self-image.
• Keywords: body self-image, obese and overweight adults, methodology to characterize self-image

Our first studies on self-image were carried out in teenagers and young people (1). In this study, we presented a theoretical-methodological proposal to address the different personality functions in these age groups. Although we tried to make a general characterization of the adolescent's personality, we emphasize this important psychic function, since the bodily changes that occur in this stage, Together with the change in cognitive function in terms of the predominance of thought and its capacity for abstraction, they caused a modification in the reflection of its own image and in the assessment of is. The presence of cognitive errors that were revealed in the form of perceive their own image by adolescents, establishing significant differences between both sexes.

In Cuba there are some references on the self-esteem of the obese and body figure. According to Fuillerat, obese subjects often feel incapable of exercising the necessary control over their behavior and the environment to be able to start and maintain an adequate diet, due to low levels of self-esteem, self-deception and rejection of their body shape (2).

According to the approach carried out on this subject in other countries, the deterioration of the self-image of the obese is related to the large number of failed attempts at weight loss, which creates stress and frustration (3-7).

In these studies, techniques and instruments are proposed aimed at studying self-image, consciously perceived by the subject. Such is the case of the Pan-European Survey, corresponding to the 1997 Body Weight and Physical Activity project (8) or Slade's Model of determining factors of Body Image, (9). In these instruments, the items aim to explore various areas related to the self-image regarding weight: thoughts about the self-image associated with weight, attitudes about that self-image and behaviors related to weight and its social reinforcement.

Other researchers have used the Machover human figure drawing (10) and some variants such as Zukerfeld's (11), where the slogan refers to the drawing of “how I look” and “how I would like to see myself”. In our opinion, this variant loses all its projective value, with a view to exploring the unconscious self-image.

Van der Kolck also uses this test in order to assess body image, selecting items that, according to the literature consulted, have a meaning directly associated with body image, related to the size and proportion of the figure, the quality of the strokes, the location on the page, etc. (12, 13). The interpretation is given directly by the evaluation of possible psychological factors associated with self-image, such as impulsivity, the tendency to immaturity, passivity, dependence, insecurity, the search for the satisfaction of her needs in the plane of fantasies, low self-esteem and inhibition. These are characteristics that have usually been attributed to the obese by the psychological literature and that confirm the results obtained by other direct techniques, such as questionnaires.

Self-image is the reflection (conscious and unconscious) that the subject has of his own body scheme and of her physical capacity. Self-image is conscious when the subject talks about how he perceives himself or how he thinks he is and is unconscious when, in a projective way, it refers to the body scheme or physical capacity of other imaginary subjects or real.

From our point of view, the proposed methodologies for the study of self-image make no distinction between conscious and unconscious self-image of the subject, but rather, they aim to explore the conscious perception that this envelope may have his body image and the rational elaborations he makes of the possible distortions of this reflection.

According to data from the Institute of Nutrition and Food Hygiene and the National Institute of Hygiene and Epidemiology in the 2010, 30 percent of the male population and more than 31 percent of the female population in Cuba present overweight.

The studies that preceded this study led us to the assumption that self-perception in obese subjects was inadequate, both consciously and unconsciously. However, to verify this assumption, we developed a methodology that combined structured and unstructured or projective techniques, with a view to covering all the factors associated with self-image in these subjects.

Our specific objectives were to develop a methodology for the characterization of self-image in adults and, on the other hand, to identify the factors involved in shaping the self-image in overweight or obese adults.

The statistical values ​​of recent years clearly indicate that the management of body overweight and obesity in the Cuban population requires particular attention in public health actions, oriented towards compliance with the strategies of the Pan American Health Organization on nutrition and health, and for the prevention and control of chronic diseases with the inclusion of a diet and physical activity (14). Despite the efforts made from different health and social media, overweight and obesity increase at a worrying speed and become a problem pointed out by world public health specialists (15). Which indicates that the treatment of obesity is a problem not yet resolved.

Working with self-image allows any person, especially in adulthood, an important support for self-awareness in general and a necessary feedback on their physical and psychological qualities.

We could think that in the case of the obese, accepting a self-image is the most appropriate to avoid suffering and maladjustment. Any self-help manual recommends being satisfied, accepting ourselves as we are, prioritizing moral or psychological qualities to the detriment of physical ones. The phrase is a very common slogan: "what is important is what is inside and not physical beauty." From our point of view, one thing is not more important than the other, psychological qualities are as important as physical ones. The image we provide of ourselves allows us find psychological balance necessary and develop adequate self-esteem and prevent physical illness. There is no reason to give up a pleasant physique, because when this is not the case, certain compensatory mechanisms are established at the unconscious level. or resistances that, far from helping, constitute disturbances that generate false security, making us more rigid and less adaptable.

At the beginning of our study, we thought that it was enough to determine the degree of adequacy of self-image in adults obese with a view to proposing a psychological treatment that would contribute to therapy based on diet and exercise physical. However, after the end of the study, we found that the treatment based mainly on the cognitive behavioral therapy may not be enough to achieve behavioral changes in these patients. Appealing to the so-called "willpower" in the obese patient does not solve the problem, since it is not a question of the subject becoming whether or not he proposes to lose weight because consciously he does not like the extra pounds he has, but, unconsciously, he has arrived to develop certain defense mechanisms or resistance that prevent them from losing weight or maintaining weight once they have managed to get off.

It is very common to observe the so-called "Yoyo effect" in these patients. That is, they lose weight as a result of the therapy and after a few months they gain weight again. Even when they begin to lose weight, in many cases, they stop attending the consultation.

The problem is not whether the self-image of the obese person is adequate or inadequate, but rather how is the position of the subject with respect to his self-image: if you are satisfied or dissatisfied, according to the desired body image. The question is not in accepting yourself as you are, which implies a passive attitude, but in the search for balance. Above all, an obese figure does not present a good “gestalt” (configuration), it is unbalanced or badly configured from the perceptual point of view.

Self-image refers to self-knowledge and, therefore, is a very important function of the psyche, not only human, but also animal. This function is relatively late, since it is only possible to manifest after the function arises cognitive, and will have an immediate or mediate character depending on the cognitive possibilities of the subject.

We agree with L. TO. Venguer when he states that the child: "... only begins to recognize himself in the middle of the third year of life." (16).

This awareness as a stage of the emergence of the self allows the person to description of some qualities that characterize it. When speaking of qualities, we are referring to the representations that are configured on the physical properties of directly observable objects. The child may recognize that he is thin or short. Later, the adolescent, with the growing possibilities offered by the development of abstract thinking, will be able to include parameters in his self-knowledge. values, such as, he will be able to assess whether he is honest or responsible, since these are qualities that require a greater degree of abstraction to be able to represent them.

To the extent that the adult becomes more rational, that is, he relies more on thought to reflect reality and moves further away from the direct perception of objects, the Perceptual self-image will become increasingly inaccurate. If to this we add that many adults go to the mirror in one or two moments of the day, for a few seconds and this is also small size which does not allow it to reflect the body in its entirety, then the image you have of yourself may not be the most adequate. In other cases, there are adults who do not think it necessary to look in the mirror. It exists in the popular imagination that he who looks a lot in the mirror is vain, narcissistic, and that as As the years go by, it is preferable not to look in the mirror because it will give us an image that we do not like much. Many times people are surprised when they see themselves in a photograph or video, by how fat or old they look.

The prominent psychotherapist E. Gendlin states that in the patient: "only his body knows how his problems make him feel and the only one who knows where they are is his body." (17, 18)

The human body is a representation, a narrative of oneself and of others and others. A symbolic expression of who we are or pretend to be. (19)

Results of previous research (Bjorntorp, 1991), consider that various psychological and psychosocial factors can influence the human waist circumference. Under stress conditions, neuroendocrine and endocrine responses lead to increased visceral fat (20). Increased waist thickness was found in several people with high levels of depression and anxiety (Wing et al., 1991; Lloyd, Wing & Orchard, 1996). In some ways, waist circumference is an important factor for body self-concept (Sorensen et al., 1997). According to these authors, the roundness of the waist can be an important motivation for changing eating behavior and participating in a physical exercise program (5, 6, 7).

Adequacy of self-image

• The self-image will be adequate: When the reflection of your body scheme (measurements and shape) and your physical capacity (duration and intensity of physical activity that can perform the subject based on the values ​​of oxygen consumption and heart rate) correspond to the Body Mass Index (BMI) BMI = mass (kg) / (height (m)) ², results of physical efficiency tests (Rockpot Test and the Six Minute Test walking).
• The self-image will be inappropriate: When there is no correspondence between the reflection of his body scheme, his physical capacity, the (BMI) and the results of the physical efficiency tests.

Satisfaction with self-image

• The subject will be satisfied with your self-image: When he consciously refers and / or unconsciously projects his conformity with weight and body image.
• The subject will be dissatisfied with your self-image: When the subject consciously refers and / or unconsciously projects his dissatisfaction with weight and body image.

Self-image preservation

• The self-image will be very deteriorated: When the subject resists performing the Human Figure Drawing (HFD) test by K. Machover and in the drawing of the figure perform the head after the body, draw the head with unusual shapes, draw only the head and omit the body, draw "stick" or "wire" men, "snow" men, drawings of monsters or grotesque figures, drawings of clowns, robots or any other figure not human.
• The self-image will be somewhat impaired: When the subject makes an unfavorable or negative comment regarding the quality of the drawing or its possibilities of drawing the human figure, make strokes loose, insistence on retouching any slip, shading of the body and extremities, stains or smudges, cross-out, transparencies after drawing the figure dressed. Small head in relation to the body and little detailed facial features. Narrow or weak trunk in relation to the rest of the body. Refill the middle part of the figure with details or adornments. Omissions of parts of the body.
• The self-image will be preserved: When the subject has a good disposition before the test and his drawing of the human figure does not present any of the aforementioned characteristics.

Subjects diagnosed asobese or overweight (according to BMI) who receive care in the Endocrinology consultation of the HDCQ “10 de Octubre” and in two Family Physician offices belonging to the Polyclinic primary care area Luyanó.

The HDCQ "10 de Octubre" is located in the municipality of the same name, which is the one with the largest population in Havana City, with an incidence of obesity of more than 50%, in addition be the one with the highest incidence of type II diabetes mellitus in the Ciudad Habana province, whose main risk factor is obesity (Department of Statistics of the Province of Health).

In the Endocrinology service of the HDCQ “10 de Octubre” between 40 and 50 patients are seen monthly, most of them referred from other health services, such as Rheumatology, Surgical Services and Medicine consultations, according to the records hospitable. Patients also attend outpatient care from Havana City, mainly from the 10 de Octubre municipality itself. The main reason for consultation is weight loss to improve the patient's quality of life and eradicate a major risk factor for cardiovascular disease.

The consent informed of each of the participants in a document designed for this purpose, in which they were informed that their willingness to participate voluntarily in the sessions and meetings planned, as well as in the application of research instruments, that they could know the results that this study would obtain, that they would be confidential and that they could abandon the study if they did. they wanted it. These ethical aspects were reviewed and approved by the Ethics Committee of the Faculty of Medical Sciences "Calixto García".

• Belong to the selected Health Area in the Municipality of October 10 or receive care in the Endocrinology consultation of the HDCQ "October 10".
• Being diagnosed as obese or overweight.
• Be consciously motivated by the loss of body weight (according to initial individual interview).
• Be willing to participate in the study (according to informed consent).

Sample

60 subjects (36 women and 24 men). Intent: all subjects consulted in the first quarter of 2008.

• Age: Between 30 to 68 years old (Average age 45 years, according to median)
• Scholarship: Medium to University level.
• Degrees of obesity: According to BMI (Overweight: 15 Grade I: 14 Grade II: 14 Grade III: 17 Grade IV: 0)

The techniques used for the identification of the self-image in the conscious plane were: the interview in depth and the self-perception questionnaire of Rodríguez Rebustillo contrasting the results with the Test of Rockport. Other names: Mile test. Objective: To determine the maximum VO2 in subjects of low physical condition. It consists of walking according to the personal rhythm of the performer, the distance of one mile ( 1609.3 meters), monitoring the heart rate at the end of the tour, as well as the time employee. The determination of the maximum VO2 is made from the following equation:

VO2 max = 132.6 - (0.17 x CP) - (0.39 x Age) + (6.31 x S) - (3.27 x T) - (0.156 x HR)

Where PC: Body weight; S: Sex (0: women, 1: men); T: Time in minutes; HR: Heart rate.

Material and facilities: Chronometer. Athletics track or flat terrain without many curves perfectly defined.

For the unconscious self-image, the Human Figure Drawing Test (HFD) by K. Machover and the production of a story about the drawn figure.

Regarding the HFD test, the representation of two complete human figures was requested. After the realization of the first figure, it was requested to represent a human figure of another sex different from the first figure represented. Subsequently, they were asked to tell a story for each figure drawn, trying to mention their age, their sex, to what do you do, how do you feel, what are her needs and if "he" or "she" is satisfied with your figure or image bodily.

The data referring to the individual interview were used as a source to complement the information. Regarding the HFD, the data related to the two figures represented were individually collated.

Most of the subjects studied (86.6%) have a proper self-image of your body and their physical abilities. They make a calculation in ± 5 pounds of their body weight, their height is quite exact, as well as the measurements of their waist and hips, although 2 subjects did not answer this question because they declared they did not know. The shape of her body and face is correct, predominantly descriptions of the body in the shape of an "H" and the round face.

A poor command of the units of measurement is expressed, in m and cm, in some subjects.

The calculation by the subjects of the number of sit-ups, planks, distance traveled and time corresponds to the results obtained in the physical efficiency tests. applied (6-minute walking test and Rockport test: do a distance of 1500 m at the speed and time you can, measuring oxygen consumption and frequency cardiac).

Conscious satisfaction with self-image

All pose to be dissatisfied with their body or a part of it. 83.3% indicate the abdomen and waist the part that they dislike the most, 11.6% state that the thighs and hips and the rest point to the whole body. That is to say, most of them express dislike towards the waist circumference, coinciding with the approaches of Sorensen, in 1997, where he points out that waist circumference is an important factor for self-concept bodily.

100% of the subjects do not feel comfortable with their current weight. The amount in kg they want to lose ranges from 3 kg to 100 kg.

Regarding the parts of the body that they like the most, the majority (86.6%) state that it is the face and in isolation, some state the legs, hands, feet and hair. It is curious that some (35%) pose the hips, buttocks, breasts, thighs as the most attractive parts, places where there is more accumulation of fat. 21% (Obese grade II and III) state that no part of their body pleases them.

65% of the subjects consider themselves an attractive person. 63.3% consider themselves a strong person, while the rest consider themselves neither strong nor weak. None were found to have a weak physical constitution.

Table 3: Unconscious Satisfaction with Self-Image

When making a story about the drawn figure, 100% of the subjects who have grade II and III obesity found both characters in the test to be satisfied with their figure or image, that they develop well in life, that they are satisfied with their occupation, in accordance with the people around them, happy and in good health cheer up. Some refer to the expression: “you feel happy with your physical condition, you exercise and you maintain a balanced diet”. A 45-year-old female subject with Obesity Grade III, when drawing the second figure, states that she is satisfied and “thinks” that she is the best. A 35-year-old male subject with Obesity I degree states that his characters are stressed with work and that they take walks to relieve stress. There is an overweight 30-year-old woman who first draws a male figure satisfied with her weight, however, the female figure sees her unsatisfied because she wants to lose weight and eat a little less. We emphasize the expression “it is believed”. Another 41-year-old woman with grade I obesity refers to drawing a neighbor and a neighbor, who are both dissatisfied because they have gained "a little" in weight and are getting "a few rafts." Note the diminutives used. Only a 41-year-old subject, with grade I obesity, states that her figures are very sad because they want to lose weight and are worried because they are gaining weight.

It is necessary to emphasize that in the cases in which they indicated that they were not satisfied because the drawing had not turned out very well, we took them as an indicator of dissatisfaction with their self-image.

Table 4: Impaired unconscious self-image

No subject has a very deteriorated self-image since they did not draw "stick" or "wire" men, "snow" men, drawings of monsters or grotesque figures, clowns or ridiculous figures.

In the case of subjects with grade I obesity (93%), this is the group with the highest number of preserved self-image. They had a good disposition to carry out the test, strong lines, centered, heads proportionate to the body. Note that some of these subjects, coincidentally, are dissatisfied with their self-image at the unconscious level.

35.7% of the subjects present some deterioration of self-image. The types of self-image impairment that were expressed in the figure drawings were inferred from: some unfavorable comment or negative regarding the quality of the drawing, loose, hesitant strokes, insistence on retouching some part of the body, certain disproportion between the trunk and the extremities, spots or blots, transparencies, little detailed facial features, middle part of the ornate figure.

In summary, consciously most of the obese studied have a fairly adequate self-image, they state that want to lose weight, who are not satisfied with their body weight, quite objectively reflect their capabilities physical. The self-image is not impaired, rather preserved in the unconscious plane, that is, its reflection is quite objective. On the unconscious level, most are satisfied with their weight and body, they feel physically attractive.

What did we expect?

That obese or overweight subjects they were not satisfied with their self-image. That it was deteriorated and that it was not adequate, that is, that the conscious and unconscious reflection of its body and physical capabilities were quite misrepresented, given the tendency to self-deception described by several authors.

For example, Felker, in 1988, in a study with obese women on the perception of their own bodies, found that their bodily self-perception was very unfavorable. We can also cite the study by Mendelson and White, 1995, where it is stated that obese patients resort to self-deception or to the false perception, conscious or not, of their body (20, 21).

Other authors (Barros, C. M., Werutsky, Gutfreind, Biernat, Barros, T. M., 1991; Dalgalarrondo, 2000) have come to call this phenomenon as Body Image Disorder (ICT), and even suggest that this is a basic symptom of obesity, characterized by an inability to adequately perceive one's body size, influenced by experience with body weight (22).

All of this led us to expect body image disorders in the obese subjects studied.

What did we get?

There was a contradiction between the level of satisfaction with the self-image and its degree of adequacy, on the conscious and unconscious levels. Consciously, most of the obese studied have a fairly adequate self-image, they state that want to lose weight, who are not satisfied with their body weight, objectively reflect their capabilities physical. In the unconscious plane, the self-image is not deteriorated, rather it is preserved.

When we speak of preserved self-image we are referring to the fact that there are no feelings of incompleteness, of handicap organic, imperfect, there are no defects or traumatic physical complexes, they do not feel ridiculous, or discontent with themselves themselves. On the contrary, unconsciously, most are satisfied with their weight and body, they even feel attractive.

These subjects are aware that they are obese, they perceive themselves adequately, they are dissatisfied with their self-image in the plane consciously, but, contradictorily, they are satisfied unconsciously, they feel attractive and happy with their bodies.

Until now, self-image studies have placed more emphasis on the distortion of the body reflex than on the degree of satisfaction with self-image. This entails a cover-up of the problem. Settling for explanations such as that obese people have low self-esteem, excess stress, depression and frustration, makes us ignore the defense mechanisms or psychological resistance that occur in the unconscious plane with respect to the maintenance of body weight. Even several of the authors acknowledge that the factors described by them have not yet been sufficiently demonstrated (23, 24, 25, 26, 27, 28).

This led us to doubt the interpretation of the results in the studies that preceded us or of the lack of internal consistency of the techniques used (if they measured what they really intended to size).

The importance of this finding is related to the search for a therapy that works with these defense mechanisms or resistances unconscious and not with those therapies that rely on rationalization or cognitive-behavioral therapies, based on explanations nutritional and physical exercise programs, in intervention programs that point to the need to make conscious the modification of the style of life of the obese subject.

In short, the Proposed methodology by us for the characterization of the self-image of the obese adult provides the following elements:

1. The integral characterization of the self-image of the obese subject is achieved, from the differentiation of this in the conscious and unconscious planes, which allows to explain the resistance to the loss of body weight and its maintenance, despite being subjected to therapy based on diets and exercises physical.
2. The study of the degree of unconscious satisfaction with self-image is prioritized, that is, the most important thing is not to distinguish how adequate the perception of your image is body by the obese subject, as highlighted by the previously proposed methodologies, but how attractive and satisfied he feels with his self-image at the unconscious.
3. Greater precision of the indicators that measure body self-image in the Human Figure Drawing Test, based only on global analysis of the figure and the balance between the different parts of the body, without insisting on all the details that are not directly related to the self-image. The use of this test in obese groups so far is done according to the original proposal of K. Machover, taking into account all the details of the figure. Other variants of the test (1979, 1984) include other aspects not related to self-image or distort the projective character of the test in their proposals.
4. In the slogan for the production of a story about the drawn figure, we include the demand about the degree of satisfaction with the image that the character has. This makes it possible to identify the projection that the subject has in terms of satisfaction with the self-image in the unconscious plane.

The making of a Self-perception questionnaire to determine the adequacy of self-image at a conscious level, which not only includes the body figure but also the physical capacity, for which the answers are compared with the results of the physical efficiency tests.

• When characterizing the self-image of the overweight or obese subjects studied, a contradiction between conscious self-image and unconscious self-image. Consciously, most have an adequate self-image, are motivated to lose weight and show dissatisfaction with their body weight, as well as reflect adequately their characteristics and physical capacities, however, unconsciously, they feel satisfied with their weight and figure, and even feel attractive.
• The fact that obese subjects are satisfied with their body image in the unconscious plane leads us to think about the presence of various psychological resistance that prevent them from losing weight or maintaining it once lost, which probably makes conventional therapies based on diet and physical exercise ineffective.
• From our point of view, existing methodologies so far they have been insufficient for the study of self-perception in the obese, for not fully responding to all dimensions of self-image, in the conscious and unconscious planes, and by overvaluing the inadequacy of the self-image over his satisfaction with it.

This article is merely informative, in Psychology-Online we do not have the power to make a diagnosis or recommend a treatment. We invite you to go to a psychologist to treat your particular case.

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