Nutrition Section DOI : 10.7860/JCDR/2018/37748.12332
Year : 2018 | Month : Dec | Volume : 12 | Issue : 12 Page : OC06 - OC09

Body Mass Index and Weight Loss Efforts in Middle-Aged Saudi Women: The Mediating Role of Body Appreciation

Hala Hazam Al Otaibi1

1 Associate Professor, Department of Food Sciences and Nutrition, Community Nutrition, College of Agriculture and Food Sciences, King Faisal University, Hofuf, Al-Ahsa, Saudi Arabia.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Hala Hazam Al Otaibi, PO Box 95Al-Ahsa, 31982, Hofuf, Al-Ahsa, Saudi Arabia.


Body Appreciation (BA) is the most widely used measure of positive body image and assesses an overall positive orientation to the body. Little is known about BA among Saudi middle-aged women related to weight status and weight loss efforts. Most published studies in Saudi Arabia have been conducted among college-age females.


The primary aim was to identify BA, weight status Body Mass Index (BMI), and Weight Loss (WL) efforts among middle-aged Saudi women. The divond aim was to test the mediation effect of BA on the association between BMI and WL.

Materials and Methods

A cross-divtional face-to-face interview design study included 326 middle-aged women recruited from all primary health centers in Hofuf city. Correlation analysis was used to describe univariate relationships among BMI, BA, and WL. Hayes tests for mediation were conducted, where BMI was the predictor, the WL score was the outcome, and BA was the mediator under investigation.


Mean age was 49.14±8.35 years, and mean BMI was 29.64±5.82 kg/m2. The mean BA score was 3.92±2.43. Majority of them (228; 69.9%) were unsatisfied with their body weight; and 256 (78.5%) had made an effort to lose weight. BMI and WL were significant correlates of BA. We found that BA fully mediated the relationship between BMI and WL in women.


BA mediated the relationship between BMI and WL, which can contribute to our understanding of specific factors that can influence body image among middle-aged women.

How to cite this article

Hala Hazam Al Otaibi, .BODY MASS INDEX AND WEIGHT LOSS EFFORTS IN MIDDLE-AGED SAUDI WOMEN: THE MEDIATING ROLE OF BODY APPRECIATION.Journal of Clinical and Diagnostic Research [serial online]2018 Dec[cited:2019 Sep 17] 12 OC06 - OC09
 Available from


Middle age is the period between ages 45 and 65 years; women in this stage of life have already established their family and career roles. They experience complex changes in their lives as they undergo social and biological changes [1]. Women are more likely to be overweight and obese during middle age, which may be in part due to hormonal changes that negatively impact quality of life and increase the risk of developing chronic diseases [2,3]. However, weight losing 5–10% of body weight can decrease these health problems [4]. Augustus-Horvath CL et al., found that middle-aged women had a lower level of positive body image because of the appearance of ageing and were less motivated to diet or reduce their weight [5].

BA is the most widely used measure of positive body image and assesses an overall positive orientation to the body [6]. BA is associated with age, and it usually increases with age [7,8]. On other hand, middle-aged women (ages 45–65 years) had lower levels of BA compared to other age groups [5]. A cross-sectional study, which included 405 women from two races (African-American and Caucasian), found that middle-aged women were dissatisfied with their appearance and with their weight, with no significant differences between races [9]. In an online survey that included 1,800 women and aimed to assess body satisfaction among middle-aged women (ages 50 years and older), researchers found that 71% of women were dissatisfied with their weight and would need to make a major effort to lose weight, especially among women with a higher Body Mass Index (BMI); 64% experienced thoughts about their weight on a daily basis; and 62% reported that weight/shape negatively affected their lives [10]. Additionally, previous studies found the level of BMI significantly correlate with WL efforts, and the relationship between BMI and WL was mediated through BA [7,11,12].

Saudi Arabia has one of the highest prevalence rates of obesity/overweight worldwide, in that seven out of 10 people are overweight or obese; especially among women. List of factors could be attributed to obesity/overweight as age, marriage, low education, and being diagnosed with chronic diseases, consumption energy-dense foods, snacking and sedentary lifestyles [13]. Little is known about BA among Saudi middle-aged women related to weight status and weight loss efforts. However, most published studies in Saudi Arabia have been conducted among college-age females (ages 18–25 years) [14,15]. To our knowledge, there are no studies conducted among middle-aged or older women. The current study aims to identify BA, weight status, and weight loss efforts among middle-aged Saudi women. The second aim was to test the mediation effect of BA on the association between weight status (based on BMI) and WL efforts.

Materials and Methods

This was a cross-sectional face-to-face interview design study, with the convenience sampling technique adopted to collect the samples, which included those who were consented to participate in the study. All the primary health centeres (nine) in Hofuf city, Saudi Arabia, were included in the study. Data were collected over a three-month period (October to December 2017). Sample size based on Wang [16] sample size formula (n=z2pq/d2), the required sample for this study was 207 women, where n is the minimum sample size, z= standard deviation score =1.96, p= prevalence of obesity 84% among Saudi middle-aged women [17], q=1-p, d= 0.05 at the 95% confidence interval. n= (1.96)2x (0.84) x (1 - 0.84)/ (0.05)2 =207 women.

Four female student nutritionists attended a cooperative training course and they were trained to assist in the data collection with the researchers (training included interview technique and anthropometric measurements); each woman participating in the study was interviewed individually by one of the nutritionists (took about 10–15 minutes to complete). The inclusion criteria were women living in Hofuf city visiting a health centere for personal checkups, accompanying a family member, or attending their children’s checkups; 45–65-year-old; not pregnant or breastfeeding; and not having any chronic illness or taking any medication. Women meeting the criteria were invited to participate and asked to provide informed consent. Women who did not complete the interview for any reason were excluded to avoid the missing data. Subjects were approached in the waiting rooms of the health centeres. The ethical approval was obtained from the College of Agriculture and Food Science at King Faisal University (#19161) .


Background Information: This included age, marital status, level of education, work status, household income, and having children.

BA: This was measured by the Body Appreciation Scale (BAS), developed by Avalos L et al., [6]. BAS is a 13-item scale which addresses appreciation, respect, attention given to one’s body, and acceptance. The13-item scale was translated from English to Arabic and pretested for clarity of meaning then translated back to ensure validity. Some example items include-I feel good about my body, I respect my body, I feel that my body has at least some good qualities. Responses are on a 5-point Likert scale (1=never, 2=seldom, 3=sometimes, 4=often, and 5=always). The mean score is calculated for all items, the maximum mean score is five and the minimum mean score is one. The total score range from 13 to 65, with higher scores representing more BA or a positive body image. The internal consistency (reliability) of the items was α=0.81, which was deemed acceptable.

BMI: Weight (taken on digital scales) and height (taken on stadiometers) were measured by the trained nutritionists using standardised protocols. BMI was categorised to normal weight (BMI between 18.5 and 24.9), overweight (BMI between 25.0 and 29.9), and obese (BMI 30.0 and more) [18].

Body Weight Satisfaction: Women were asked to respond to the question “How do you feel about your body weight?” with two response options, satisfied and dissatisfied. The question has been previously shown to be an indicator of body weight satisfaction and has been validated in previous study [19].

Weight Loss Efforts (WL): We used the three items of readiness to change and well-being questionnaire for weight control [20]. Items included importance (Rate the importance of reaching and sustaining a healthy weight) and confidence (My confidence level in my ability to reach and sustain a healthy weight); change or improve efforts to reach a healthy weight, women were asked (Are you trying to change or have improvements in your weight during the past 12 months?) responses are on a 10-point Likert scale, with 1 as the lowest and 10 as the highest level, with higher scores representing greater WL efforts. We classified women’s responses into two answers according to WL efforts for the last question: from zero to five=not tried to lose weight, and from six to ten =yes tried to lose weight. The mean score was calculated for all items to describe the WL efforts; scores ranged between one to three, with higher scores representing more attention to losing weight. The internal consistency (reliability) of the items was α=0.76, which was deemed acceptable.

Women were also asked on separate question about their reason for weight loss with six options (to look better, for easier movement, to be healthier, to be able to wear a wider range of clothes, because of family or friends’ comments, and to be sexier) to know more about the main reason that can influence women to lose weight.

Media Use: Women were asked to respond to the question “Do you browse the internet and social network sites (e.g., Twitter, Facebook, Instagram) or use apps?” with two response options were scored as one for Yes and zero for No.

Statistical Analysis

We used SPSS Statistics (version 23) for data analysis. All study variables were screened for suspected errors, and missing or outliers data. Mean, SD, frequency and percentages were calculated. Correlation analysis was used to describe univariate relationships among BMI, BA, and WL. To test the mediating role of BA, the PROCESS analysis was used by applying Model 4 with 1000 bias-corrected bootstrap samples [21], with BMI as the independent variable (X), BA as the Mediating variable (M), and WL as the dependent variable (Y). A p-value was considered statistically significant at less than 0.05. All the participants in the study included in the analysis.


A total of 326 middle-aged Saudi women were enrolled in this study. All women were married and had children; the mean age was 49.14 years, with 26.14 mean years of marriage. The majority (228; 69.9%) of them were unemployed, 109 (33.4%) had an education level of secondary school or less, and 198 (60.7%) had a monthly household income of 5,000 or more [Table/Fig-1].

Socio-demographic characteristics of middle aged Saudi women (N=326).

VariablesNumber %
Age (mean±SD) years.49.14±8.35
Years of married (mean±SD)26.14±5.82
Secondary or less217(66.6%)
College or higher109(33.4%)
Work status
Household income (monthly in Saudi Riyals)

Approximately, 46% (149) of the women were overweight, and almost 55% (177) classified as obese, with a high mean BMI of 29.64 kg/m2 and a low mean BA of 3.92; 228 (69.9%) of the women were unsatisfied with their body weight, and 256 (80%) of the them had made an effort to lose weight. The main reason for weight loss was health (111; 34%), then to look better (67; 20%), and to be sexier (56; 17.2%); the lowest percentage was in response to family or friends’ comments (17; 5.2%). A total of 283 (87%) of women browsing the internet and social network sites [Table/Fig-2].

Mean, SD, frequency and percentages of study variables.

VariablesNumber %
Body appreciation score (mean±SD)3.92±2.43
Body mass index (kg/m2) (mean±SD)29.64±5.82
Body weight satisfaction
Weight loss efforts score (mean±SD)1.61±0. 21
Reason for weight loss
To look better67(20%)
For easier movement31(9.5%)
To be healthier111(34%)
Wider range of cloths44(13.5%)
Family or friends comments17(5.2%)
To be more sexy56(17.2%)
Media use

The women’s BA was significantly negatively correlated with BMI (r=-0.237, p< 0.01), and BA was positively correlated with WL (r=0.508, p<0.01). In the mediation model, the total effect showed BMI was a significant predictor of WL, controlling for the mediating factor (BA), β=-8.32, t(-8.35), df 324 p≤.00001 (path c). BMI was a significant predictor of the mediator BA; β=-1.25, t(-4.39), df 324, p≤.00001 (path a). Process analysis showed that the mediation (BA), controlling for BMI, was a significant predictor of WL, β=1.61, t(9.38), df 323, p≤.00001 (path b). The analyses revealed that, controlling for the mediation (BA), the direct effect of BMI was a significant predictor of WL, β=-6.29, t(-6.92), df 232, p≤.0001 (path c’). The satisfaction of these conditions indicates that there is an indirect (mediating) effect (path ab) of BMI on WL through BA, β=-2.02 p≤.0001. A Sobel test was conducted and found full mediation in the model (Z=-3.96, p≤.0001). It was found that BA fully mediated the relationship between BMI and WL [Table/Fig-3].

The mediation model, ****p= <.00001, ***p= <.0001


Positive body image is an important factor in weight control practices [22]. This study has assessed BA, body weight satisfaction, and weight loss efforts among 326 middle-aged Saudi women. The main findings of the study showed that women had a low BA or negative body image (3.92±2.43) which similar to 247 American women who were reported to have a very low mean (3.67) BA [23]. In addition, Tiggemann M et al., found that BA was associated with age and that older women had a higher BA and body satisfaction than young and middle-aged [7]. Older women had less socio-cultural pressures about the ideal of female beauty than young and middle-aged women.

Almost 55% of women were classified obese (29.64±5.82), usually BMI increases over the years in women by 0.25 kg/m2 after the age of 40, resulting in decrease in metabolic activity and the hormone estrogen; this consequently increases fat deposition [24]. The prevalence of overweight/obesity in the present study was more than that observed in a national study conducted by the Saudi Ministry of Health, which included 10,735 Saudis aged 15 years or older, 51.1% of them women; the reported prevalence of obesity was 33.5%. However, the risk of obesity increased among women with age (55 years or more), being married, and having less than a high school education, and we observed the same results [25]. Eighty percent of unemployed women were concerned about their appearance and weight, which was in accordance with previous work among middle-aged Spanish women, were unemployed women perceived themselves as having bad health and linked to increased health factor risks such as obesity [26].

Losing weight during the menopausal transition is an important problem facing middle-aged women, and many of them describe their weight as a major source of displeasure and a source of greater body dissatisfaction (69.9%). This is consistent with results reported in studies, where a higher BMI is associated with greater body dissatisfaction [26,27]. Almost 80% of women tried to lose weight, which is similar to a cross-sectional study conducted in the United States among 1,571women aged 50 years and more with mean BMI 28.3±6.4; had body size dissatisfaction, 78% of the women tried to lose weight [28]. These results were consistent with those of Lemon SC et al., who found that 65% of the overweight and 78% of the obese employed women who participated in a cross-sectional study reported that they were currently trying to lose weight using different methods (diet or exercise) [29].

Usually, middle and older aged women were more concerned about their health as a result of hormonal changes [30]; likewise, we found that 34% of the women had tried to lose weight to be healthier and to avoid health problems. Twenty percent wanted to look better, and 17.2% wanted to be sexier; these women were likely exposed to media and social media that reminded them how their bodies deviate from the young ideal. Further, 13.5% wanted to lose weight for access to a wide range of clothes, which was similar to another finding that was observed among Gulf Cooperation Council (GCC) women who tried to lose weight for better-fitting clothes [31].

BA was negatively correlated with BMI, similar to results observed in both western and non-western countries. For example, among American women aged between 18 and 58 years, BA was negatively correlated with BMI (r=-0.2, p≤0.05) [23]; findings were similar in 262 Indonesian women [8]. As a result, BA mediated the relationship between BMI and WL in middle-aged women. Therefore, for Saudi women, BA is a very important and modifiable factor in controlling body weight. Notably, low BA can be an incentive for overweight and obese women to lose weight; today’s socio-cultural shift to a preference for a thin body size as ideal beauty standard due to recent globalisation and the adoption of a western lifestyle in Saudi Arabia has caused conflict between cultural norms and passed along mixed messages received from global social media about body image and weight control. Additionally, it is possible that women experience heightened cultural pressure to ensure that their weight remains ‘proper’. Our findings are consistent with prior research indicating that Polish women facing change in their culture have a more negative body image and low BA, which puts them under pressure to lose weight to be thinner [32].

We already know that body image is a serious issue among young women in Saudi Arabia [14,15], and we found similar results among middle-aged women. There is limited research concerning body image among this age group in Saudi Arabia. This paper identified these gaps and suggests more studies in this age group. Health educators such as dieticians must be aware about BA, body dissatisfaction, weight control, and dieting among middle-aged and older women. More middle-aged women today choose to engage in a variety of weight control methods, some of which can influence their physical health, self-esteem, and overall well-being. Dieticians should develop new strategies, including education and counselling about positive body image, healthy weight loss, and the benefits of physical activity and a balanced diet.


This study had several limitations. First, this is a cross-sectional study; causality is not implied. Second, the study employed a convenience sample of women in good health with moderate to higher socio-economic status, which limits the generalisability of the results to other groups. Last, we investigated BA, WL, and body dissatisfaction; there are other potential variables not examined, such as social media affect, self-compassion, body weight perception, weight control behaviors, and body acceptance by others, such as husband, friends and family. These can affect body image.


BA mediated the relationship between BMI and WL, that can contribute to our understanding of specific factors that can influence body image among middle-aged women. Future research should consider BA when studying the impact of overweight and obesity on Saudi middle-aged women.


[1]Nicolaisen M, Thorsen K, Loneliness among men and women – a five-year follow- up study Aging & Mental Health 2014 18(2):194-206.  [Google Scholar]

[2]Abdulnour J, Doucet E, Brochu M, Lavoie JM, Strychar I, Rabasa-Lhoret R, The effect of the menopausal transition on body composition and cardiometabolic risk factors: a Montreal-Ottawa New Emerging Team group study Menopause. The Journal of the North American Menopause Society 2012 19(7):760-67.  [Google Scholar]

[3]Dennis KE, Postmenopausal women and the health consequences of obesity J Obstet Gynecol Neonatal Nurs 2007 36(5):511-17.  [Google Scholar]

[4]Dengo AL, Dennis EA, Orr JS, Marinik EL, Ehrlich E, Davy BM, Arterial destiffening with weight loss in overweight and obese middle-aged and older adults Hypertension 2010 (55):855-61.  [Google Scholar]

[5]Augustus-Horvath CL, Tylka TL, The acceptance model of intuitive eating: A comparison of women in emerging adulthood, early adulthood, and middle adulthood Journal of Counseling Psychology 2011 58(1):110-25.  [Google Scholar]

[6]Avalos L, Tylka TL, Wood-Barcalow N, The body appreciation scale: Development and psychometric evaluation Body Image 2005 2(3):285-97.  [Google Scholar]

[7]Tiggemann, M, McCourt A, Body appreciation in adult women: Relationships with age and body satisfaction Body Image 2013 10(4):624-27.  [Google Scholar]

[8]Swami V, Jaafar JL, Factor structure of the body appreciation scale among Indonesian women and men: Further evidence of a two-factor solution in anon-Western population Body Image 2012 9(4):539-42.  [Google Scholar]

[9]Jackson KL, Janssen I, Appelhans BM, Kazlauskaite R, Karavolos K, Dugan SA, Body image satisfaction and depression in midlife women: the Study of Women’s Health Across the Nation (SWAN) Archives of Women’s Mental Health 2014 17(3):177-87.  [Google Scholar]

[10]Gagne DA, Von Holle A, Brownley KA, Runfola CD, Hofmeier S, Branch KE, Eating disorder symptoms and weight and shape concerns in a large web-based convenience sample of women ages 50 and above: results of the gender and body image (GABI) study International Journal of Eating Disorders 2012 45(7):832-44.  [Google Scholar]

[11]Lee RE, Harris KJ, Catley D, Shostrom V, Choi S, Mayo MS, Factors associated with BMI, weight perceptions and trying to lose weight in African-American smokers Journal of the National Medical Association 2005 97(1):53-61.  [Google Scholar]

[12]Boo S, Body mass index and weight loss in overweight and obese Korean women: the mediating role of body weight perception Asian Nurs Res 2013 7(4):191-97.  [Google Scholar]

[13]Alqarni SS, A review of prevalence of obesity in Saudi Arabia Journal of Obesity and Eating Disorders 2016 2(2):1-6.  [Google Scholar]

[14]Khalaf A, Westergren A, Berggren V, Ekblom Ö, Al-Hazzaa HM, Perceived and ideal body image in young women in south western Saudi Arabia Journal of Obesity 2015 2015:697163  [Google Scholar]

[15]ALAhmari T, Alomar AZ, ALBeeybe J, Nawal Asiri N, ALAjaji R, ALMasoud R, Associations of self-esteem with body mass index and body image among Saudi college-age females Eat Weight Disord 2017 22(1):1-9.  [Google Scholar]

[16]Wang WEI, Clinical Epidemiology-basic principles and practical applications 2012 BeijingHigher Education Press Publication:101  [Google Scholar]

[17]Al-Quwaidhi AJ, Pearce MS, Critchley JA, Sobngwi E, O’Flaherty M, Trends and future projections of the prevalence of adult obesity in Saudi Arabia, 1992-2022 East Mediterr Health J 2014 20(10):589-95.  [Google Scholar]

[18]World Health Organization, “Obesity: Preventing and Ma- naging the Global Epidemic. Report of a World Health Organization Consultation on Obesity,” WHO, Geneva, 1998  [Google Scholar]

[19]Kuk JL, Ardern CL, Church TS, Hebert JR, Sui X, Blair SN, Ideal weight and weight satisfaction: Association with health practices American Journal of Epidemiology 2009 170(4):456-63.  [Google Scholar]

[20]Readiness to Change and Well-Being Questionnaire. Available from:  [Google Scholar]

[21]Hayes AF, Introduction to mediation, moderation, and conditional process analysis: A regression-based approach 2013 New YorkThe Guilford PressAvailable from:  [Google Scholar]

[22]Forrester-Knauss C, Zemp-Stutz E, Gender differences in disordered eating and weight dissatisfaction in Swiss adults: which factors matter? BMC Pub Health 2012 20(12):809  [Google Scholar]

[23]Satinsky S, Reece M, Dennis B, Sanders S, Bardzell S, An assessment of body appreciation and its relationship to sexual function in women Body Image 2012 9(1):137-44.  [Google Scholar]

[24]Dubnov-Raz G, Pines A, Berry EM, Diet and lifestyle in managing postmenopausal obesity Climacteric 2007 10(2):38-41.  [Google Scholar]

[25]Memish ZA, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Obesity and associated factors-Kingdom of Saudi Arabia, 2013 Preventing Chronic Disease 2014 9(11):E174  [Google Scholar]

[26]Bibiloni M, Coll J, Pich J, Pons A, Tur J, Body image satisfaction and weight concerns among a Mediterranean adult population BMC Public Health 2017 17(39):1-11.  [Google Scholar]

[27]Reel JJ, SooHoo S, Summerhays JF, Gill DL, Age before beauty: an exploration of body image in African-American and Caucasian adult women J Gender Stud 2008 17(4):321-30.  [Google Scholar]

[28]Runfola CD, Von Holle A, Peat CM, Gagne DA, Brownley KA, Hofmeier SM, Characteristics of women with body size satisfaction at midlife: results of the Gender and Body Image (GABI) Study Journal of Women & Aging 2013 25(4):287-304.  [Google Scholar]

[29]Lemon SC, Rosal MC, Zapka J, Borg A, Andersen V, Contributions of weight perceptions to weight loss attempts: differences by body mass index and gender Body Image 2009 6(2):90-96.  [Google Scholar]

[30]Slevin KF, If I had lots of money y I’d have a body makeover’: managing the aging body Social Forces 2010 88(3):1003-20.  [Google Scholar]

[31]Al-Zadjali M, Keller C, Larkey L, Evansgcc B, Women: causes and processes of midlife weight gain Health Care for Women International 2014 35(11):1267-86.  [Google Scholar]

[32]Taylor D, Szpakowska I, Swami V, Weight discrepancy and body appreciation among women in Poland and Britain Body Image 2013 10(4):628-31.  [Google Scholar]