Percepção da imagem corporal e indicadores antropométricos e de composição corporal associados em idosos

rbcdh Revista Brasileira de Cineantropometria & Desempenho Humano Rev. bras. cineantropom. desempenho hum 1415-8426 1980-0037 Universidade Federal de Santa Catarina Resumo O envelhecimento acarreta perdas psicológicas e alterações físicas diversas que, associadas a padrões de corpo estereotipados pela sociedade, podem causar distúrbios na percepção da imagem corporal (PIC) dos idosos. O objetivo deste estudo foi avaliar a PIC de idosos residentes no município de Campina Grande/PB e sua relação com diferentes indicadores antropométricos e de composição corporal. Este estudo é domiciliar, transversal, realizado com idosos, de ambos os sexos, cadastrados na Estratégia Saúde da Família de Campina Grande, PB. A PIC foi considerada como variável dependente e o índice de massa corporal (IMC), a circunferência da cintura (CC), a dobra cutânea tricipital (DCT) e a área de gordura do braço (AGB) como variáveis independentes. A associação entre a PIC e os indicadores antropométricos foi verificada por meio do teste qui-quadrado de Pearson (X2), regressão logística simples e múltipla, com nível de significância p<0,05. Foram entrevistados 420 idosos (68,1% de mulheres), dos quais 409 informaram sobre a percepção da imagem corporal real. Quanto à percepção da imagem corporal idealizada, 11 idosos não responderam e 230 estavam satisfeitos, visto que 179 desejavam outra silhueta. Idosos com IMC indicativo de sobrepeso/obesidade apresentaram maior chance de insatisfação com a imagem corporal em relação àqueles eutróficos. Os idosos com DCT excessiva apresentaram maior insatisfação com a imagem corporal em relação àqueles eutróficos. As mulheres apresentaram maior chance de insatisfação com a imagem corporal. Com isso, observa-se que as variáveis IMC, DCT e sexo foram, independentemente, associadas à satisfação com a imagem corporal. INTRODUCTION The aging process leads to progressive changes in functional, motor, psychological and social aspects1. The natural decline of the functions of all physiological systems, common in advanced age, may limit the coding capacity of stimuli coming from the sensory system (vision, touch, proprioception), interfering with the body’s awareness and mental structuring of the individual over his own body -called body image2. Psychological and affective losses, as well as typical aging-related physical alterations, are also negatively affected by concepts and values of society full of stereotypes associated with certain body patterns. Body image can suffer serious distortions in these individuals subject to society pressures. There is also a constant influence of the media on body perception and satisfaction3. Possible disturbances in body perception can be investigated based on the relationship of body image perception and anthropometric indicators and body composition4. Studies have shown that the real body classification is proportional to the body mass index value1,5. In view of the complexity in the detection of these disorders, some results point to the need for further studies in this area in order to better understand the aging process and body self-perception3,6. Among the anthropometric and body composition variables, body mass index (BMI) has been used to describe changes in body image construction. BMI is a variable of easy calculation; however, in the elderly, its use presents difficulties in interpretation due to aging changes such as decreased height, adipose tissue accumulation, reduced lean body mass and decrease in the amount of water in the organism3. Thus, it is important to verify the association of body image with other anthropometric indicators, for example, waist circumference, triceps skinfold and arm fat area1. Thus, the importance of knowing the relationship that older adults have with their body is highlighted, especially the view of health professionals, who can act in a positive and more efficient way in their practices -evaluations and interventions -in all aspects that involve health, either physical, psychological, emotional and mental, aiming at understanding and holistically stimulating these individuals4. This study aimed to evaluate the body image perception of elderly residents in the city of Campina Grande/PB and its association with different anthropometric and body composition indicators. METHODOLOGICAL PROCEDURES This study is part of a broader study aimed at carrying out a multidimensional assessment of the health of older adults enrolled in the Family Health Strategy (EST) of Campina Grande/PB, and is characterized as being cross-sectional homebased with collection of primary data. This study investigated individuals aged 60 years and over of both sexes. Individuals with severe clinical impairments without therapeutic possibility, and those who were absent from their Basic Family Health Unit (UBSF) for longer than field research were excluded. Data collection was carried out from August 2009 to May 2010 by three pairs of interviewers, duly trained by the research coordinating professor and collaborating professors. During anthropometric training, the reliability of values obtained in the assessment of variables, both intra-rater and inter-rater, was assured considering the values proposed by Lohman et al.7. A pilot study was conducted with 42 older adults (10% of the total number of individuals to be interviewed), for possible methodological adjustments. The sample was calculated by estimating prevalence of outcomes of at least 25%. The sample size was calculated using the following equation: {[E2 x p (1-p)] x c} / A2, where E is the confidence limit (1.96), c is the sample correlation coefficient (2.1), and A is the accepted precision for the estimated prevalence (A = 6%). The sample was proportional to each Health District, comprising 420 older adults. Body image perception was verified through the nine-silhouette scale proposed by Stunkard et al.6, which represents images from thinness (Silhouette 1) to severe obesity (Silhouette 9). Initially, individuals were instructed to observe the scale and show which silhouette best represented their current physical appearance (Perception of Real Body Image -PICR). After the answer, individuals were asked if they would like to have the silhouette pointed out or to have another one (Perception of Idealized Body Image -PICI). Individuals were categorized as satisfied or dissatisfied with their body image, according to the result of the difference between PICR and PICI, ranging from -8 to +8. For result equal to zero, individuals were classified as satisfied with their body image and, for nonzero result, individuals were classified as dissatisfied. Independent variables evaluated were: body mass index (BMI), waist circumference (WC) (cm), triceps skinfold thickness (TSF) (mm) and arm fat area (AFA) (cm2). In order to calculate BMI (weight / height2), weight and height were measured according to techniques described in Lohman et al.7. To analyze BMI, individuals were classified as follows: low weight (BMI <23 kg / m2), normal weight (23 ≥ BMI <28 kg / m2), overweight (28 ≥ BMI <30 kg / m2) and obese (≥ 30kg/m2) 8. WC and arm circumference (AC) (measured for AFA calculation) were measured using techniques described in Lohman et al.7. The following cutoff points were used for the WC classification and were considered not adequate (presence of metabolic risk): WC ≥ 102 cm for men and WC ≥ 88 cm for women9. TSF and AC values were used to calculate the arm fat area (AFA). Triceps skinfold was measured using the Lange compass, according to techniques described in Lohman et al. 7. AFA was calculated according to equation proposed by Frisancho10: A G B ( c m ) 2 = C B ( c m ) 2 4 π - C B ( c m ) - π x D C T ( c m ) 2 4 π TSF and AFA classification was performed based on values distributed in percentiles (P), according to sex, described by Menezes and Marucci 11. Thus, they were classified as follows: insufficiency (≤ P25), eutrophy (> P25 and <P75) and excess (≥ P75). Control variables were: sex and age group (60-69 years, 70-79 years, 80 years or more). Statistical procedures Pearson’s Chi-square test (X2) was used to verify the association between body image perception and sex, age group, and anthropometric and body composition indicators. Simple logistic regression models were estimated to calculate the crude odds ratio (OR). For the multiple model, variables that presented p <0.20 (Wald test) obtained in the simple analysis were considered. The stepwise forward input method was used to calculate the adjusted OR, with 95% confidence interval (95% CI). In the final model, the variables that remained in the model with p <0.05 were considered significant. The evaluation of the logistic model adjustment was performed using the Hosmer-Lemeshow test. Data were analyzed using the SPSS 22.0 statistical package (IBM Corp., Armonk, United States). Ethical Considerations The major study, of which this is part, was submitted and approved by the Ethics Research Committee (CEP) of the State University of Paraíba (UEPB) (0228.0.133.000-08). Participants received explanations about the study and, when they agreed to participate, they signed the Informed Consent Form. RESULTS Overall, 420 individuals were interviewed (68.1% of women), with mean age of 71.6 years (SD = 9.19). Of the 420 elderly survey respondents, 409 reported on the PICR. Regarding PICI, 11 participants did not respond and 230 were satisfied, since 179 desired another silhouette. Table 1 presents the bivariate analysis between body image perception and associated factors. In this table, it is possible to observe that the highest proportion of older adults dissatisfied with their body image were overweight / obese (63.9%), inadequate WC (61.0%), excess TSF (60.0%) and excess AFA (59.7%). There was a statistically significant association between body image perception and BMI (p <0.0001), and WC (p <0.0001), and TSF (p <0.0001) and AFA (p <0.0001). Table 1 Distribution of participants according to the association between body image perception and anthropometric and body composition indicators. Campina Grande / PB, Brazil. Body Image Perception Satisfied (%) Dissatisfied (%) p Variables BMI <0.0001 Normal weight 68.9 31.1 Low weight 70.5 29.5 Overweight / Obesity 36.1 63.9 WC <0.0001 Adequate 67.6 32.4 Inadequate 39.0 61.0 TSF <0.0001 Normal weight 60.6 39.4 Insufficiency 69.6 30.4 Excess 40.0 60.0 AFA <0.0001 Normal weight 62.0 38.0 Insufficiency 68.0 32.0 Excess 40.3 59.7 Note. BMI: body mass index; WC: waist circumference; TSF: triceps skinfold; AFA: Arm fat area. Table 2 presents the multiple logistic regression results, showing the variables that remained in the final model and that are significantly associated to body image perception, regardless of other variables analyzed. Table 2 Logistic regression for BMI, TSF and sex in relation to body image dissatisfaction. Campina Grande / PB, Brazil. Variables Crude OR Adjusted OR** 95% CI p BMI Normal weight Low weight 0.93 1.08 0.55 - 2.15 0.817 Overweight / Obesity 3.92 2.71 1.44 - 5.10 0.002* TSF Normal weight Insufficiency 0.67 0.89 0.44 - 1.81 0.754 Excess 2.30 2.24 1.29 - 3.90 0.004* Sex Male Female 2.02 2.07 1.19 - 3.58 0.010* Note. BMI: body mass index; TSF: triceps skinfold; OR = odds ratio. * Statistically significant association. ** Obtained from model that includes WC and age group and the significant variable in the univariate analysis. BMI, TSF and sex were independently associated with body image dissatisfaction, adjusted by WC and age group. Overweight / obese individuals (OR = 2.71, 95% CI: 1.44 -5.10) were more likely of being dissatisfied with their body image in relation to those with normal weight. Individuals with excessive TSF (OR = 2.24, 95% CI: 1.29 -3.90) were more likely of being dissatisfied with their body image in relation to those with normal weight. Women were more likely of being dissatisfied with their body image (OR = 2.07, 95% CI: 1.19 -3.58). DISCUSSION Body image perception, an important component of personal identity, is a multidimensional construction that represents how the person perceives his own body5. In this study, it was observed that BMI, TSF and sex were variables independently associated with body image dissatisfaction. Recent national studies have shown that more than half of the adult population is overweight12, and that there is greater occurrence of body weight dissatisfaction among women than among men13. Regarding anthropometric variables, it was observed that overweight / obese individuals in this study were more likely of being dissatisfied with their body image compared to those with normal weight. This result is similar to that of other studies with older adults who found greater body image dissatisfaction among obese participants2,14,19. A study with 179 women with mean age of 45 years and BMI > 30 kg/m2 found that women with BMI > 40 kg/m2 expressed greater body image dissatisfaction and low self-esteem15. Although studies show association between body image satisfaction / dissatisfaction and nutritional status, a consensus on this association cannot yet be established due to personal factors that interfere in their selfassessment, from physiological and socioeconomic changes to changes in family structures and distribution of resources in society14. The high body image dissatisfaction that affects overweight/obese older adults may be due to the non acceptance of body changes, characteristics of the aging process, considering that with the aging process, BMI tends to increase16. This body image dissatisfaction due to obesity can induce these individuals to adopt harmful strategies in order to achieve the desired weight, such as inappropriate use of medications and the adoption of radical diets, surgical and aesthetic procedures and physical activity beyond their capacity3. Thus, individuals compromise their quality of life and favor the adoption of self-depreciative measures with respect to their body, impairing their self-esteem, being a cause of suffering, depression and social isolation. Another anthropometric variable that presented association with body image perception in this study was TSF, considering that individuals with excessive TSF were more likely of being dissatisfied with their body image in relation to those with normal weight. Studies that evaluated TSF as a risk factor for body image dissatisfaction were not found in literature. However, this information is relevant, given that excess body fat can lead to various diseases, among them the high disability and mortality rates due to chronic noncommunicable diseases, such as cardiovascular diseases17. Therefore, it is necessary to carry out studies that provide specific information about this association. The high prevalence of excessive TSF in the elderly evidenced in this study differs from results obtained in other studies that verified high prevalence of insufficient TSF in the elderly5,18. This divergence evidences the specificity of certain physical characteristics, whether by regional or local issues; thus requiring individualized attention that aims to monitor the nutritional status of older adults enrolled in the Family Health Strategy of the city of Campina Grande/PB, since TSF is an evaluation variable that, when in excess, is a risk factor for cardiovascular and metabolic diseases. Changes in body fat distribution and other age-related body changes are common: appearance of wrinkles and senile signs, as well as decreased physical fitness, with loss of muscle mass. These changes directly affect body satisfaction, especially among women19. Two studies conducted in Brazil, one conducted in Florianópolis/SC and the other in Pelotas/RS, found that sex is directly related to body image dissatisfaction. These studies showed that women presented 50% greater risk of being dissatisfied with body image, when compared to men16,20, which corroborates result found in the present research. International studies have found association between BMI and sex; however, they have shown higher prevalence of overweight/obesity in men, when compared to women14,21. Data from the National Survey on Surveillance of Risk Factors and Protection for Chronic Diseases by Telephone Inquiry (VIGITEL) of 2014 indicated a similar result in Brazil, with greater prevalence of overweight among men12. In addition to the presence of overweight / obesity, the influence of media and cultural aspects on today’s society is considered as one of the possible reasons for greater probability that overweight women to be more dissatisfied with their body image than men22. There is a media appeal that the individual should be young, show no signs of aging and have perfect body measurements to fit society based on beauty and consumption industry14. The presence of unwanted aesthetic elements, as well as body limitations that make it difficult to perform several activities, are contributing factors for body image dissatisfaction23. These aspects are worrisome, since studies have reported that women with inadequate nutritional status and dissatisfied with their own body are at greater risk for psychological diseases such as depression24,25. Thus, older women construct their self-image based on a relationship between body, nutrition, health and happiness3. As previously observed, variables related to excess body fat and weight reflected in body image dissatisfaction among participants in this study, suggesting that body image dissatisfaction may reflect knowledge about the inadequacy of their nutritional status. This is a relevant aspect, considering that this self-knowledge can have repercussions on changes in unsatisfactory living habits aiming at reversing this condition3. However, it should be considered that the feeling of not having a sufficiently beautiful body, within socially constructed standards -that is, thin, slender, shaped, young and muscular -can be a serious failure, leading to loss of self-esteem, insecurity and diseases26. Thus, undesirable aesthetics and the difficulty in performing several activities brought about by the aging process negatively impact the individual’s self-image, especially of women, and increase the possibility of psychological and social suffering linked to complications in the wellbeing and self-esteem of these individuals3. Thus, in addition to the risk of developing obesity-related diseases, older adults may experience negative feelings of sadness, anger and depreciation with their bodies through body image dissatisfaction, which is accompanied by a relationship of not accepting the process of functional decline and the impossibility of reversing the aging process, as well as the social requirement by an established ideal physical shape27. Thus, the high proportion of body image dissatisfaction in the elderly population is justified. These factors must be worked by family and health professionals, and can determine positive changes in the health status of this population. The present study presents limitations typical of cross-sectional studies, because although associations between body image perception and BMI, TSF and sex have been observed, it is not possible to establish a causal relationship. Another aspect relates to silhouettes used to verify body image perception, since they are two-dimensional and may make it difficult for older adults to understand. It is suggested the creation of a mechanism that uses three-dimensional images facilitating the body perception and, consequently, increasing the reliability of the information collected. One difficulty experienced during the conduction of this study was the lack of research that evaluated the association between body image and anthropometric and nutritional variables in the elderly. Thus, only few studies that could be compared with this study were found. Further studies aimed at analyzing body image dissatisfaction in the elderly and the factors that predispose to the risk of body image dissatisfaction are suggested. In addition, studies that assess psychological, social and cultural aspects and contribute to reduce body image dissatisfaction in the elderly are of extreme importance in the scientific field. CONCLUSION Therefore, it is necessary to recognize the importance of body image perception and its relationship with anthropometric and body composition indicators during the implementation of strategies to promote health among older adults, considering the need of weight control, mainly for those who exhibit distorted body image perception. Thus, it is necessary to motivate eutrophic and unsatisfied individuals to maintain their weight and satisfy themselves with their body image. As for overweight/obese or underweight individuals who are satisfied with their body image, it is important that they have the knowledge about their nutritional status so that they can seek the right weight. In this way, the chances that risk factors related to inadequate nutritional status affect the health of older adults are reduced. Funding This research received funding from National Council for Scientific andTechnological Development (CNPq) – Universal Notice - 15/2007. Ethical approval Ethical approval was obtained from the local Human Research Ethics Committee – Paraiba State University, and the protocol was written in accordance with the standards set by the Declaration of Helsinki. REFERENCES 1 1 Póvoa TIR, Sanche JF, França LN, Lima SS, Silva TCD. Imagem corporal e estado nutricional de idosas praticantes de exercícios físicos. Rev Movimenta 2012;5(4):282 –92. Póvoa TIR Sanche JF França LN Lima SS Silva TCD Imagem corporal e estado nutricional de idosas praticantes de exercícios físicos Rev Movimenta 2012 5 4 282 292 2 2 Lopes KMDC, Oliveira RJ, Lima RM, Godoy JRP, Silva VZM, Silva ML. Associação entre imagem corporal e variáveis da aptidão física relacionada à saúde em mulheres idosas. Rev Geriatr Gerontol Aging 2012;6(2):167-76. Lopes KMDC Oliveira RJ Lima RM Godoy JRP Silva VZM Silva ML Associação entre imagem corporal e variáveis da aptidão física relacionada à saúde em mulheres idosas Rev Geriatr Gerontol Aging 2012 6 2 167 176 3 3 Ferreira AA, Menezes MFG, Tavares EL, Nunes NC, Souza FP, Albuquerque NAF, et al. Estado nutricional e autopercepção da imagem corporal de idosas de uma Universidade Aberta da Terceira Idade. Rev Bras Geriatr Gerontol 2014;17(2):289-301. Ferreira AA Menezes MFG Tavares EL Nunes NC Souza FP Albuquerque NAF Estado nutricional e autopercepção da imagem corporal de idosas de uma Universidade Aberta da Terceira Idade Rev Bras Geriatr Gerontol 2014 17 2 289 301 4 4 Caluête MEE, Nóbrega AJS, Gouveia RA, Galvão FRO, Vaz LMM. Influência do estado nutricional na percepção da imagem corporal e autoestima de idosas. Rev Bras Geriatr Gerontol 2015;18(2):319-26. Caluête MEE Nóbrega AJS Gouveia RA Galvão FRO Vaz LMM Influência do estado nutricional na percepção da imagem corporal e autoestima de idosas Rev Bras Geriatr Gerontol 2015 18 2 319 326 5 5 Alencar MSS, Melo MTSM, Sousa RC, Campos CMF, Meneses AV, Sepúlveda LS, et al. Perdas de massa muscular e adiposa após institucionalização: atenção aos mais idosos. Rev Geriatr Gerontol Aging 2015;9(4):150-55. Alencar MSS Melo MTSM Sousa RC Campos CMF Meneses AV Sepúlveda LS Perdas de massa muscular e adiposa após institucionalização: atenção aos mais idosos Rev Geriatr Gerontol Aging 2015 9 4 150 155 6 6 Stunkard AJ, Sorenson T, Schlusinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis 1983;60(1):115-20. Stunkard AJ Sorenson T Schlusinger F. Use of the Danish Adoption Register for the study of obesity and thinness Res Publ Assoc Res Nerv Ment Dis 1983 60 1 115 120 7 7 Lohman TG, Roche AF, Martorell R. Anthropometric standardization reference manual. Champaign, Illinois: Human Kinetics Books; 1988. Lohman TG Roche AF Martorell R Anthropometric standardization reference manual Champaign, Illinois Human Kinetics Books 1988 8 8 Lebrão ML, Duarte YAO. O Projeto SABE no Município de São Paulo: uma abordagem inicial. Brasília: OPAS/MS; 2003. Lebrão ML Duarte YAO. O Projeto SABE no Município de São Paulo: uma abordagem inicial Brasília OPAS/MS 2003 9 9 World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva: World Health Organization; 2000. p. 253. WHO Technical Report Series, 894. World Health Organization Obesity: preventing and managing the global epidemic. Report of a WHO Consultation Geneva World Health Organization 2000 253 253 WHO Technical Report Series 894 10 10 Frisancho AR. Anthropometric standards for the assessment of growth and nutritional status. Ann Arbor: University of Michigan Press; 1990. Frisancho AR Anthropometric standards for the assessment of growth and nutritional status Ann Arbor University of Michigan Press 1990 11 11 Menezes TN, Marucci MFN. Perfil dos indicadores de gordura e massa muscular corporal dos idosos de Fortaleza, Ceará, Brasil. Cad Saúde Pública 2007;23(12):2887-95. Menezes TN Marucci MFN Perfil dos indicadores de gordura e massa muscular corporal dos idosos de Fortaleza, Ceará, Brasil Cad Saúde Pública 2007 23 12 2887 2895 12 12 Brasil. Ministério da Saúde. Agência Nacional de Saúde Suplementar. VIGITEL Brasil 2015: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde. 2017. Disponível em: http://www.ans.gov.br/images/stories/Materiais_para_pesquisa/Materiais_por_a ssunto/2015_vigitel.pdf [2017 abr 21]. Brasil Ministério da Saúde Agência Nacional de Saúde Suplementar. VIGITEL Brasil 2015: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico Brasília Ministério da Saúde 2017 Disponível em: http://www.ans.gov.br/images/stories/Materiais_para_pesquisa/Materiais_por_a ssunto/2015_vigitel.pdf 2017 abr 21 13 13 Martins CR, Gordia AP, Silva DAS, Quadros TMB, Ferrari EP, Teixeira DM, et al. Insatisfação com a imagem corporal e fatores associados em universitários. Estud Psicol (Natal) 2012;17(3):241-46. Martins CR Gordia AP Silva DAS Quadros TMB Ferrari EP Teixeira DM Insatisfação com a imagem corporal e fatores associados em universitários Estud Psicol (Natal) 2012 17 3 241 246 14 14 Alencar MSS, Melo MTSM, Sousa RC, Campos CMF, Meneses AV, Sepúlveda LS, et al. Perdas de massa muscular e adiposa após institucionalização: atenção aos mais idosos. Rev Geriatr Gerontol Aging 2015;9(4):150-55. Alencar MSS Melo MTSM Sousa RC Campos CMF Meneses AV Sepúlveda LS Perdas de massa muscular e adiposa após institucionalização: atenção aos mais idosos Rev Geriatr Gerontol Aging 2015 9 4 150 155 15 15 Hill AJ, Williams J. Psychological health in a non-clinical sample of obese women. Int J Obesand Relat Metab Disord 1988;22(6):578-83. Hill AJ Williams J Psychological health in a non-clinical sample of obese women Int J Obesand Relat Metab Disord 1988 22 6 578 583 16 16 Silva VSD, Souza I, Silva DAS, Fonseca MDJMD. Prevalence and factors associated with overweight in adults -Brazil, 2008-2009. Rev Bras Cineantropom Desempenho Hum 2014;16(2):161-70. Silva VSD Souza I Silva DAS Fonseca MDJMD Prevalence and factors associated with overweight in adults -Brazil, 2008-2009 Rev Bras Cineantropom Desempenho Hum 2014 16 2 161 170 17 17 Organização Pan-Americana da Saúde. Doenças crônico-degenerativas e obesidade: estratégia mundial sobre alimentação saudável, atividade física e saúde. Brasília: OPAS; 2003. Organização Pan-Americana da Saúde Doenças crônico-degenerativas e obesidade: estratégia mundial sobre alimentação saudável, atividade física e saúde Brasília OPAS 2003 18 18 Menezes TN, Marucci MFN. Avaliação antropométrica de idosos residentes em Instituições de Longa Permanência de Fortaleza-CE. Rev Bras Geriatr Gerontol 2010;13(2):235-43 Menezes TN Marucci MFN Avaliação antropométrica de idosos residentes em Instituições de Longa Permanência de Fortaleza-CE Rev Bras Geriatr Gerontol 2010 13 2 235 243 19 19 Pruis TA, Janowsky JS. Assessment of Body Image in Younger and Older Women. J General Psychol 2010;137(3):225-38. Pruis TA Janowsky JS. Assessment of Body Image in Younger and Older Women J General Psychol 2010 137 3 225 238 20 20 Simão CB, Nahas MV, Oliveira ESA. Atividade Física Habitual, Hábitos Alimentares e Prevalência de Sobrepeso e Obesidade em Universitários da Universidade do Planalto Catarinense. Rev Bras Ativ Fís Saúde 2006;11(1):3-12. Simão CB Nahas MV Oliveira ESA Atividade Física Habitual, Hábitos Alimentares e Prevalência de Sobrepeso e Obesidade em Universitários da Universidade do Planalto Catarinense Rev Bras Ativ Fís Saúde 2006 11 1 3 12 21 21 Pasco JA, Holloway KL, Dobbins AG, Kotowicz MA, Williams LJ, Brennan SL. Body mass index and measures of body fat for defining obesity and underweight: a cross-sectional, population-based study. BMC Obesity 2014;1(9):1-7. Pasco JA Holloway KL Dobbins AG Kotowicz MA Williams LJ Brennan SL. Body mass index and measures of body fat for defining obesity and underweight: a cross-sectional, population-based study BMC Obesity 2014 1 9 1 7 22 22 Guðnadóttir U, Garðarsdóttir RB. The influence of materialism and ideal body internalization on body -dissatisfaction and body-shaping behaviors of young men and women: support for the Consumer Culture Impact Model. Scand J Psychol 2014;55(2):151-59. Guðnadóttir U Garðarsdóttir RB. The influence of materialism and ideal body internalization on body -dissatisfaction and body-shaping behaviors of young men and women: support for the Consumer Culture Impact Model Scand J Psychol 2014 55 2 151 159 23 23 Vera-Villarroel P, Piqueras JA, Kuhne V, Cuijpers P, Straten AV. Differences between men and women in self-reported body mass index and its relation to drug use. Subst Abuse Treat Prev Policy 2014;9(1):1-11. Vera-Villarroel P Piqueras JA Kuhne V Cuijpers P Straten AV Differences between men and women in self-reported body mass index and its relation to drug use Subst Abuse Treat Prev Policy 2014 9 1 1 11 24 24 Simon GE, Ludman EJ, Linde JA, Operskalski BH, Ichikawa L, Rohde P, et al. Association between obesity and depression in middle-aged women. Gen Hosp Psychiatry 2008;30(1):32-9. Simon GE Ludman EJ Linde JA Operskalski BH Ichikawa L Rohde P Association between obesity and depression in middle-aged women Gen Hosp Psychiatry 2008 30 1 32 39 25 25 Gavin AR, Simon GE, Ludman EJ. The association between obesity, depression, and educational attainment in women: the mediating role of body image dissatisfaction. J Psychosom Res 2010;69(6):573-81. Gavin AR Simon GE Ludman EJ The association between obesity, depression, and educational attainment in women: the mediating role of body image dissatisfaction J Psychosom Res 2010 69 6 573 581 26 26 Sudo N, Luz M. O gordo em pauta: representações do ser gordo em revistas semanais. Ciênc Saúde Coletiva 2007;12(4):1033-40. Sudo N Luz M. O gordo em pauta: representações do ser gordo em revistas semanais Ciênc Saúde Coletiva 2007 12 4 1033 1040 27 27 Fonseca CC, Gama EF, Thurm BE, Pereira ES, Limongelli AMA, Miranda MLJ. Benefícios da estimulação perceptual corporal no esquema corporal de idosos. Rev Bras Geriatr Gerontol 2012;15(2):353-64. Fonseca CC Gama EF Thurm BE Pereira ES Limongelli AMA Miranda MLJ Benefícios da estimulação perceptual corporal no esquema corporal de idosos Rev Bras Geriatr Gerontol 2012 15 2 353 364