Validation of the Norwegian short version of the Body Shape Questionnaire (BSQ-14) HILDE KAPSTAD, MEGAN NELSON, MARIA ØVERÅS, ØYVIND RØ
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Kapstad H, Nelson M, Øverås M, Rø Ø. Validation of the Norwegian short version of the Body Shape Questionnaire (BSQ-14). Nord J Psychiatry 2015;Early Online:1–6. Background: The Body Shape Questionnaire (BSQ) is a widely used self-report measure of body shape dissatisfaction. Aims: We aimed to establish psychometric properties and report normative data for the Norwegian 14-item BSQ in a clinical and non-clinical sample. Methods: A total of 423 female students, 267 male students and 49 female inpatients [anorexia nervosa (AN) and subthreshold AN] were administered the BSQ, the Body Checking Questionnaire (BCQ), and the Eating Disorder Examination Questionnaire (EDE-Q). Results: On average, the male and female controls were aged (mean⫾ standard deviation) 20.98 ⫾ 5.68 years and 24.35 ⫾ 9.89 years with mean body mass indexes (BMIs) of 23.34 ⫾ 3.13 and 22.30 ⫾ 3.62 kg/m2, respectively. Patients were 19.04 ⫾ 3.06 years with a mean BMI of 16.48 ⫾ 1.81. Divergent validity was indicated by significantly (P ⬍ 0.001) different means between the patient group versus female controls, 56.80 ⫾ 18.89 and 35.89 ⫾ 15.19, respectively. Cronbach’s alpha was satisfactory for all three groups (0.91–0.96), indicating excellent internal consistency. The BSQ correlated significantly (P ⬍ 0.001) with the BCQ and EDE-Q, indicating concurrent validity. BMI and BSQ scores did not correlate significantly within the population as a whole. However, when subdividing the sample, higher BMI was associated with higher BSQ scores among females and males within the non-clinical sample. Conclusions: Our study provides psychometric support for the Norwegian version of the BSQ-14 among a clinical and non-clinical sample of both young men and women. • Body Shape Questionnaire, Norms, Psychometric properties, Validation. Øyvind Rø, Oslo University Hospital, Ullevål, PO Box 4956, Nydalen, N-0424 Oslo, Norway, E-mail: [email protected]; Accepted 15 January 2015.
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ody shape concern and dissatisfaction have been found among females of all ages in western cultures, in both the general population and eating disorders groups (1, 2). Body dissatisfaction and body size estimation problems are conceptualized as a part of body image disturbances (BID). The magnitude of BID has been found to predict the development and severity of disordered eating (3–6). Although BID has been defined as a key criterion for the diagnosis of anorexia nervosa (AN) and bulimia nervosa, BID has also been suggested as a significant predictor of the development of eating disorders in general (ED) (7, 8). For instance, several studies have found that a distorted body image precedes and predicts the development of eating disorders (9) and has been associated with treatment attrition, as well as higher rates of relapse following ED treatment (4, 10, 11). There appears to be a consensus in the literature that body image in adolescents and adults is a multidimensional construct that includes perceptual, evaluative, affective, cognitive and behavioral components (12).
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At present, there are several assessment instruments and methods designed to measure body image. However, most self-report measures do not assess the body image construct according to the conceptualization of body image as a multidimensional construct. As a response to this, the Body Shape Questionnaire (BSQ) was developed in 1987 (13). The BSQ has been found useful in eating disordered groups, as well as detecting at-risk groups (13, 14). The original form of the BSQ consists of 34 questions. However, the measure has been shortened into briefer versions (BSQ-16A, BSQ-16B, BSQ-14, BSQ-8A, BSQ-8B, BSQ-8C and BSQ-8D) (15–17). The psychometric properties, specifically validity and reliability of the BSQ, in its long and short forms, have been reported and found to be satisfactory in several studies among both non-clinical and clinical populations (18–20). The 14-item version has been shown to have reasonable psychometric properties (21). The one-factor structure of this measure has been confirmed (17). Both the original and short versions of the BSQ have been translated into DOI: 10.3109/08039488.2015.1009486
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several languages (18, 21–24), and recently, the BSQ-14 has been translated into Norwegian. Studies have found significant gender differences in body image. One study (25) found that gender differences in body dissatisfaction begin between the ages of 13–14, and this divergence continues to increase as boys and girls grow older, with a peak around 16–17 years of age. Females score significantly higher on the BSQ than males (26). In addition to gender, age and body mass index (BMI) are also related to body dissatisfaction (27), as well as shape and weight concerns (28).
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Aims The aims of the present study were to validate and report norms among young Norwegian females and males compared with patients suffering from AN using the Norwegian translation of the 14-item BSQ. The present study also investigated associations between the BSQ-14, age and BMI in clinical and non-clinical samples.
Methods Participants A total of 739 men and women (49 patients, 690 controls) participated in the study. The patients (n ⫽ 47) that comprised the clinical sample were recruited from five different specialist eating disorder centers across Norway. The patients filled out the questionnaires at different timepoints during the course of their treatment. The diagnostic items from the Eating Disorder Examination (29) were used in the diagnostic evaluation of the patients. Patients were female with a mean age (⫾ standard deviation) of 19.04 ⫾ 3.06 years (range 14–26 years) and mean BMI of 16.48 ⫾ 1.81 kg/m2 (range 12.34–20.19 kg/m2). For the non-clinical sample, a total of 690 students (267 men, 423 women) were recruited from high schools, colleges and one university. The non-clinical sample ranged in age from 14 to 60 years (mean ⫽ 23.05 ⫾ 8.67 years). Mean age for the male controls was 20.98 ⫾ 5.68 years (range 15–56 years) and mean BMI was 23.34 ⫾ 3.13 kg/m2 (range 16.79–42.90 kg/m2). Mean age for the female controls was 24.35 ⫾ 9.90 years (range 14–60 years) and mean BMI was 22.30 ⫾ 3.62 kg/m2 (range 14.04–39.01 kg/m2). Three participants had missing recordings of gender and were excluded from the study, and 32 participants did not report their weight and were not included in analyses about weight.
Measures The short version of BSQ (16) was translated into Norwegian by Ph.D.-level researchers at the Regional Eating Disorders Service at Oslo University Hospital. The translation process adhered to existing international guidelines adapted from the World Health Organization (30).
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The short version of the BSQ consists of 14 items measuring cognitive, affective and behavioral antecedents, and consequences of body size and shape concerns during the last 2 weeks. Responses are measured on a 6-point Likert scale ranging from 1 (never) to 6 (always). A total score is obtained by adding the item scores, resulting in a total score range from 14 to 84. Higher scores indicate greater body image concerns. The Body Checking Questionnaire (BCQ) is a 23-item self-report questionnaire designed to measure the frequency and nature of body checking behaviors (31). Each item is scored on a 5-point Likert scale from 1 (never) to 5 (always), resulting in a score range from 23 to 115. Higher scores indicate higher frequency of checking behaviors. The Norwegian version of BCQ has demonstrated good psychometric properties (32). The BCQ was included as a measure of convergent validity in the present study. The Eating Disorder Examination Questionnaire (EDE-Q) is a 28-item self-report questionnaire adapted from the Eating Disorders Examination (29), which assesses eating disordered related behaviors, thoughts and feelings during the last 4 weeks across a global score and four subscales: Restraint, Shape Concern, Weight Concern and Eating Concern. Responses are rated on a scale from 0 to 6, with higher scores indicating higher levels of eating disorder pathology. The Norwegian translation of the EDE-Q has shown satisfactory psychometric properties (33, 34). The EDE-Q was included as a measure of convergent validity. DEMOGRAPHIC QUESTIONNAIRE Participants were asked demographic information, including age, current height and weight. BMI (kg/m2) was computed via self-reported weight and height. In the patient group, weight and height was obtained from their therapists.
Procedure The patients (n ⫽ 47) completed the questionnaires as a part of larger research project. All participants in the clinical sample provided written informed consent, which was approved by the Norwegian Ethical Committee for Medical Research Ethics. The control participants were recruited via advertisements at school and they received a negligible form of compensation for their participation. Participation was anonymous and written consent was obtained. A fraction of the participants were asked to fill in the BSQ-14 1 week later and post it anonymously in a self-addressed, stamped envelope. The two copies of the BSQ short form were linked by anonymous codes.
Statistics Internal consistency was tested by Cronbach’s alpha. Correlation analyses and 1-week test–retest reliability NORD J PSYCHIATRY·EARLY ONLINE·2015
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were assessed by calculating Pearson’s correlation coefficients. Student t-tests were used to investigate differences between male and female controls, female controls and female patients, as well as BSQ scores at T1 and T2. Analysis of covariance (ANCOVA) was also used to investigate differences in BSQ between female controls and female patients when adjusting for age and BMI. Significance levels were set at P ⬍ 0.05 and all analyses were performed using the Statistical Package for Social Sciences (SPSS) version 20.0.
When split between the patient samples, female controls and male controls, the BSQ-14 total score correlated significantly with the BCQ (r ⫽ 0.79, P ⬍ 0.001; r ⫽ 0.76, P ⬍ 0.001; r ⫽ 0.49, P ⬍ 0.001, respectively) and the EDE-Q total score (r ⫽ 0.84, P ⬍ 0.001; r ⫽ 0.90 P ⬍ 0.001; r ⫽ 0.68, P ⬍ 0.001, respectively). There were also significant correlations between the BSQ-14 and the four EDE-Q subscales for the patients, female controls and male controls with scores ranging from r ⫽ 0.69 to r ⫽ 0.89, r ⫽ 0.71 to r ⫽ 0.91 and r ⫽ 0.36 to r ⫽ 0.77 respectively.
Discriminant validity
Results Descriptives/norms Nord J Psychiatry Downloaded from informahealthcare.com by Kainan University on 04/15/15 For personal use only.
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As shown in Table 1, there were significant differences in age between the control group and the patients (P ⬍ 0.001), the female control group and the male control group (P ⬍ 0.001), as well as the female control group and the patients (P ⬍ 0.001). There were also significant differences in BMI between the control group and the patient group (P ⬍ 0.001), the female control group and the patients (P ⬍ 0.001), as well as between the female control group and the male control group (P ⬍ 0.001). Patients diagnosed with AN and subthreshold AN (eating disorder not otherwise specified, EDNOS) had a mean BSQ-14 score of 56.80 ⫾ 18.89. The control group had a mean BSQ-14 score of 30.88 ⫾ 14.44. We compared male and female controls to investigate gender differences on BSQ mean scores. The female control group had a mean score of 35.89 ⫾ 15.19 and the male group had a mean score of 22.94 ⫾ 8.39.
Concurrent validity To establish concurrent validity, the BSQ-14 was correlated with the BCQ and EDE-Q. Within the whole sample, including males and females, the BSQ-14 total score correlated significantly with the BCQ (r ⫽ 0.80, P ⬍ 0.001) and the EDE-Q total score (r ⫽ 0.90, P ⬍ 0.001). There were also significant correlations between the BSQ-14 and EDE-Q subscales, with scores ranging from r ⫽ 0.74 to r ⫽ 0.92, with the highest correlation between the BSQ-14 and the Shape Concern subscale.
As expected, there was a significant difference on total BSQ score between the female controls and female patients (P ⬍ 0.001), even after adjusting for age and BMI, as well as on all the 14 separate items (P ⬍ 0.05 to ⬍ 0.001).
Internal consistency Internal consistency as measured by a Cronbach’s alpha coefficient was 0.97 for the BSQ-14, indicating excellent internal consistency for the whole sample. Internal consistency was satisfactory for patients, female controls and male controls (Cronbach’s alpha ⫽ 0.94, 0.96 and 0.91, respectively).
Test–retest A total of 182 participants (124 female and 58 male controls) completed the BSQ-14 1 week later (7.2 days). The participants’ responses to the BSQ-14 on both occasions showed a high correlation (r ⫽ 0.94, P ⬍ 0.001), but a significant difference (P ⬍ 0.001) from 32.55 ⫾ 16.10 to 28.54 ⫾ 14.32. When subdividing the control sample according to gender, there was a high correlation coefficient of r ⫽ 0.94 (P ⬍ 0.001) and r ⫽ 0.86 (P ⬍ 0.001) between T1 and T2 for female and male controls, respectively. There were significantly (P ⬍ 0.001) lower scores for female (from 34.88 ⫾ 13.93 to 32.60 ⫾ 14.87) and male (from 22.34 ⫾ 6.73 to 19.79 ⫾ 7.70) controls at T2.
Impact of BMI and age There was no significant relationship between BSQ scores and BMI (r ⫽ 0.03, P ⫽ 0.510) for the total
Table 1. Mean score (standard deviation) for female controls, male controls and patients.
Age, years BMI (kg/m2) BSQ-14 total
M:F comparison (only control data)
AN patients vs. female controls
Female controls n ⫽ 423
Male controls n ⫽ 267
Female AN patients n ⫽ 49
t-value
P-value
t-value
P-value
24.35 (9.89) 22.30 (3.62) 35.89 (15.19)
20.98 (5.68) 23.34 (3.13) 22.94 (8.38)
19.04 (3.06) 16.80 (1.95) 56.80 (18.89)
5.67 3.91 14.40
P ⬍ 0.001 P ⬍ 0.001 P ⬍ 0.001
8.15 18.28 55.711
P ⬍ 0.001 P ⬍ 0.001 P ⬍ 0.001
BSQ-14, Body Shape Questionnaire—14 item short version; BMI, body mass index. 1F-value analysis of covariance adjusting for age and BMI. NORD J PSYCHIATRY·EARLY ONLINE·2015
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sample. However, when subdividing it, the BSQ scores and BMI produced a moderate positive relationship within the female control group (r ⫽ 0.36, P ⬍ 0.001) and for male controls (r ⫽ 0.34, P ⬍ 0.001), but not for the patient sample (r ⫽ 0.03, P ⫽ 0.834). Within the total sample, there was no significant relationship between BSQ scores and age (r ⫽ ⫺ 0.04, P ⫽ 0.289). When subdividing the sample, there was a negligible negative significant relationship between BSQ scores and age within the female control group (r ⫽ ⫺ 0.10, P ⬍ 0.05), and no significant relationship for patients (r ⫽ ⫺ 0.18, P ⫽ 0.227) or male controls (r ⫽ 0.06, P ⫽ 0.343).
Discussion The aims of this study were to report normative data and to establish psychometric properties for the Norwegian version of the 14-item BSQ in clinical and non-clinical samples, which included men. The results indicate that the Norwegian version of the BSQ-14 has good discriminant validity, excellent internal consistency, high test–retest reliability, and demonstrates high concurrent validity with already established and previously validated disordered eating-relevant measures.
Validity The patients diagnosed with AN and subthreshold AN had significantly higher mean scores on the BSQ-14 compared with the female controls after controlling for age and BMI, reflecting the measurement’s strong discriminant validity. The mean BSQ-14 total score for our clinical sample was 57.17 ⫾ 18.84, which is quite similar to the findings of Dowson & Henderson (16) within a clinical sample of AN binge–purge subtype (59.6 ⫾ 14.4), but higher than the clinical sample of AN-restricting subtype (44.1 ⫾ 17.8). Other clinical samples have also shown similar mean scores. For instance, one study (35) reported a mean of 56.40 ⫾ 16.18 within a sample of female obese patients without binge eating disorder (BED). However, the authors reported significantly higher BSQ scores in female obese patients with BED (65.66 ⫾ 10.95). As expected, we found that females scored significantly higher than males on the BSQ and this is in line with a previous study (36). Through the development and validation of the original BSQ, Cooper et al. (13) established concurrent validity based on significant correlations between the BSQ and Eating Attitudes Test and the Body Dissatisfaction subscale of the Eating Disorder Inventory. Findings have suggested that shortened versions have shown acceptable convergent and divergent validity in non-clinical and clinical samples (15, 37). The Norwegian version of the BSQ-14 correlated significantly with previously validated
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disordered eating-relevant measures, including the BCQ (r ⫽ 0.80) and the EDE-Q (r ⫽ 0.90), particularly the EDE-Q subscale Shape Concern (r ⫽ 0.92). This corresponds with the findings from a Swedish study (20) who found the BSQ-8C correlated significantly with the Shape Concern subscale of the EDE-Q, and at a similar level (r ⫽ 0.90, P ⬍ 0.001), while investigating the psychometric properties of the BSQ-8C and norms within a general female and male Swedish population.
Reliability Pook and colleagues (17) investigated the reliability of the full-length 34-item of the BSQ and the seven derivative short-forms, including the BSQ-14. All versions were found to have high internal consistency. In line with Pook and colleagues’ finding, we found satisfactory internal consistency for all clinical and control (M:F) groups. Dowson & Henderson (16) found similar findings with the BSQ-14 in 75 patients with low weight and a history of full or partial AN. Our findings showed that the Norwegian version of the BSQ-14 also exhibited excellent test–retest reliability. The participants’ responses to the BSQ-14 scales on both occasions (approximately 1 week apart) showed a high correlation coefficient (r ⫽ 0.94, P ⬍ 0.001). Our findings was similar to those of Lentillon-Kaestner and colleagues (35) (r ⫽ 0.97, P ⬍ 0.001), which were derived from retest data from eight different versions of the BSQ (including the BSQ-14), administered to both non-clinical and clinical samples (obese patients with and without BED) with a 3-week interval.
Impact of age and BMI As age and BMI have shown to be correlated with the shape and weight concern subscales of the EDE-Q (28), and the BSQ has been highly correlated with the EDE-Q, it was hypothesized that a similar pattern regarding BMI and age would emerge with the BSQ-14. In accordance with previous findings (15, 20), BSQ-14 scores in this study showed a moderate positive relationship with BMI of about r ⫽ 0.30–0.40 for both genders, but not in the clinical sample. Similarly, in a study of female university graduates and staff, Rosen and colleagues (38) found significant associations between BMI and total score on the 34-item BSQ (r ⫽ 0.30 and r ⫽ 0.39, respectively), but no significant correlations were found for obese dieters (age ⫽ 26–68 years). Another study (36) also reported significant correlation between the BSQ-34 and BMI (r ⫽ 0.22–0.45) among a non-clinical sample that included both Brazilian boys and girls (n ⫽ 1494; age ⫽ 11–17 years). Contrary to findings from our clinical sample, however, Dowson & Henderson (16) found BMI to positively correlate with BSQ scores (r ⫽ 0.29) in 75 patients with low weight and a history of full or partial AN (mean age ⫽ 24.0 ⫾ 6.7 years). NORD J PSYCHIATRY·EARLY ONLINE·2015
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Regarding age, we found no significant relationship between BSQ-14 scores and age (r ⫽ ⫺ 0.04, P ⫽ 0.289) within the total sample. However, there was a negligible relationship between BSQ-14 scores and age within the female control group (r ⫽ ⫺ 0.10, P ⬍ 0.05). This is similar to the findings of Evans and Dolan (15), who reported a comparable low and negative correlation (r ⫽ ⫺ 0.11 to ⫺ 0.17) between age and the BSQ-34, as well as several shortened forms of BSQ, when using a sample of 342 adult women with a comparable mean age of 27.1 ⫾ 8.5). These findings are contrary to the findings from an Indian study (39), who reported no significant correlation between age and the BSQ-34 (r ⫽ ⫺ 0.01) when investigating body shape and eating attitudes among female nursing students in India. This difference may be due to sample characteristics, such as lower average age of the female nursing students, or potentially cultural differences.
Gender The current study is the first to introduce gender-specific normative data for the Norwegian translation of the BSQ-14, as well as presenting psychometric data. Given the measure’s low number of items and good psychometric properties, the BSQ-14 is a valuable instrument for measuring body shape dissatisfaction. Another potential advantage of the BSQ-14 is its gender non-specificity. The wording of some of the items in the original version of the BSQ makes it less appropriate for use with males, whereas the BSQ-14 does not contain any items that might be exclusively relevant for females. Thus future studies might be able to further investigate the level of body shape dissatisfaction in male populations using the BSQ-14.
Study limitations There are some limitations that should be considered. The clinical sample size was quite small and included only patients with AN or subthreshold AN. Thus, results may not be generalizable to other types of eating disorders. This study relied upon self-reported weight and height for the control participants, which may have affected the validity of the calculated BMI values. In most BSQ versions, body dissatisfaction over the past 4 weeks is evaluated, but in this study the timeframe was 2 weeks. As the BSQ has good test–retest stability, this might not influence the results of this study in a considerable way. Furthermore, to date, multiple abbreviated versions of the BSQ exist, which may potentially complicate efforts to compare across studies. All of the BSQ short forms have received varying, yet mostly positive, degrees of psychometric support, which likely reflects the unidimensionality and reliability of the original 34 items. Regarding this specific short version, the BSQ-14 has
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one distinct disadvantage, which should be noted. The method used to select the 14 items has not been clearly described. Two of the 14 items measure shape preoccupation using nearly identical wording (items 1 and 8). Nevertheless, a subsequent factor analytic study supported the unidimensionality of these 14 items (19). When Pook et al. (17) investigated the psychometric properties of eight different versions of the BSQ using confirmatory factor analyses, they found three (BSQ-14, BSQ-8B and BSQ-8C) to be favorable in terms of sensitivity to change. However, in that study, only sensitivity to change in a patient sample of bulimic patients was tested, which may be different in other diagnostic groups.
Conclusions Our study adds support to a growing body of literature of studies worldwide demonstrating the satisfactory psychometric properties of the BSQ-14, in both clinical and non-clinical samples. Future research is necessary to replicate and extend these findings across diverse clinical samples. Acknowledgements—This study was supported by the Regional Department for Eating Disorder at Oslo University Hospital, Norway. We thank Deborah L. Reas, Ph.D., for her valuable comments on the manuscript.
Disclosure of interest: All other authors declare that they have no conflicts of interest.
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27. Penelo E, Espionoza P, Portell M, Raich RM. Assessment of body image: Psychometric properties of the Body Image Questionnaire. J Health Psych 2011;17:556–66. 28. Rø Ø, Reas DL, Rosenvinge J. The impact of age and BMI on Eating Disorder Examination Questionnaire (EDE-Q) scores in a community sample. Eat Behav, 2012;13:158–61. 29. Fairburn CG, Beglin SJ. Eating Disorder Examination Questionnaire (EDE-Q 6.0). In Fairburn CG, editor. Cognitive behaviour therapy and eating disorders. New York: Guilford Press; 2008. p. 309–13. 30. Reas DL, Bang L, ØveråsM, Lask B, Rø Ø. Oversettelse og kulturell tilpasning av psykometriske instrumenter: Erfaringer fra tester som benyttes ved spiseforstyrrelser. Tidsskr Norsk Psykolog 2012;49:260–4. 31. Reas DL, Whisenhunt BL, Netemeyer R, Williamson DA. Development of the body checking questionnaire: A self-report measure of body checking behaviors. Int J Eat Disord 2002;31: 324–33. 32. Reas DL, Von Soest T, Lask B. Reliability and validity of the Norwegian version of the Body Checking Questionnaire. Tidsskr Norsk Psykolog 2009;46:260–2. 33. Rø Ø, Reas DL, Lask B. Norms for the Eating Disorder Examination Questionnaire among female university students in Norway. Nord J Psychiatry 2010;64:428–32. 34. Reas DL, Øverås M, Rø Ø. Norms for the eating disorder examination questionnaire (EDE-Q) among high school and university men. Eat Disord 2012;20:437–43. 35. Lentillon-Kaestner V, Berchtold A, Rousseau A, Ferrand C. Validity and Reliability of the French Versions of the Body Shape Questionnaire. J Pers Assess 2014;96:471–7. 36. Santana ML, Silva RC, Assis AM, Raich RM, Machado ME, de J Pinto E, de Moraes LT, Ribeiro Junior Hda C. Factors associated with body image dissatisfaction among adolescents in public schools students in Salvador, Brazil. Nutr Hosp 2013;28:747–55. 37. Mazzeo SE. Modification of an existing measure of body image preoccupation and its relationship to disordered eating in female college students. J Couns Psychol 1999;46:42–50. 38. Rosen JC, Jones A, Ramirez E, Waxman S. Body Shape Questionnaire: Studies of validity and reliability. Int J Eat Disord 1996;20:315–19. 39. Balhara YPS, Mathur S, Kataria DK. Body shape and eating attitudes among female nursing students in India. East Asian Arch Psychiatry 2012;22:70–4. Hilde Kapstad, Regional Eating Disorders Service, Division of Mental Health and Addiction, Oslo University Hospital, Norway. Megan Nelson, Regional Eating Disorders Service, Division of Mental Health and Addiction, Oslo University Hospital, Norway. Maria Øverås, Regional Eating Disorders Service, Division of Mental Health and Addiction, Oslo University Hospital, Norway. Øyvind Rø, M.D., Ph.D., Regional Eating Disorders Service, Division of Mental Health and Addiction, Oslo University Hospital, and Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Norway.
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Kapstad H, Nelson M, Øverås M, Rø Ø. Validation of the Norwegian short version of the Body Shape Questionnaire (BSQ-14). Nord J Psychiatry 2015;Early Online:1–6. Background: The Body Shape Questionnaire (BSQ) is a widely used self-report measure of body shape dissatisfaction. Aims: We aimed to establish psychometric properties and report normative data for the Norwegian 14-item BSQ in a clinical and non-clinical sample. Methods: A total of 423 female students, 267 male students and 49 female inpatients [anorexia nervosa (AN) and subthreshold AN] were administered the BSQ, the Body Checking Questionnaire (BCQ), and the Eating Disorder Examination Questionnaire (EDE-Q). Results: On average, the male and female controls were aged (mean⫾ standard deviation) 20.98 ⫾ 5.68 years and 24.35 ⫾ 9.89 years with mean body mass indexes (BMIs) of 23.34 ⫾ 3.13 and 22.30 ⫾ 3.62 kg/m2, respectively. Patients were 19.04 ⫾ 3.06 years with a mean BMI of 16.48 ⫾ 1.81. Divergent validity was indicated by significantly (P ⬍ 0.001) different means between the patient group versus female controls, 56.80 ⫾ 18.89 and 35.89 ⫾ 15.19, respectively. Cronbach’s alpha was satisfactory for all three groups (0.91–0.96), indicating excellent internal consistency. The BSQ correlated significantly (P ⬍ 0.001) with the BCQ and EDE-Q, indicating concurrent validity. BMI and BSQ scores did not correlate significantly within the population as a whole. However, when subdividing the sample, higher BMI was associated with higher BSQ scores among females and males within the non-clinical sample. Conclusions: Our study provides psychometric support for the Norwegian version of the BSQ-14 among a clinical and non-clinical sample of both young men and women. • Body Shape Questionnaire, Norms, Psychometric properties, Validation. Øyvind Rø, Oslo University Hospital, Ullevål, PO Box 4956, Nydalen, N-0424 Oslo, Norway, E-mail: [email protected]; Accepted 15 January 2015.
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ody shape concern and dissatisfaction have been found among females of all ages in western cultures, in both the general population and eating disorders groups (1, 2). Body dissatisfaction and body size estimation problems are conceptualized as a part of body image disturbances (BID). The magnitude of BID has been found to predict the development and severity of disordered eating (3–6). Although BID has been defined as a key criterion for the diagnosis of anorexia nervosa (AN) and bulimia nervosa, BID has also been suggested as a significant predictor of the development of eating disorders in general (ED) (7, 8). For instance, several studies have found that a distorted body image precedes and predicts the development of eating disorders (9) and has been associated with treatment attrition, as well as higher rates of relapse following ED treatment (4, 10, 11). There appears to be a consensus in the literature that body image in adolescents and adults is a multidimensional construct that includes perceptual, evaluative, affective, cognitive and behavioral components (12).
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At present, there are several assessment instruments and methods designed to measure body image. However, most self-report measures do not assess the body image construct according to the conceptualization of body image as a multidimensional construct. As a response to this, the Body Shape Questionnaire (BSQ) was developed in 1987 (13). The BSQ has been found useful in eating disordered groups, as well as detecting at-risk groups (13, 14). The original form of the BSQ consists of 34 questions. However, the measure has been shortened into briefer versions (BSQ-16A, BSQ-16B, BSQ-14, BSQ-8A, BSQ-8B, BSQ-8C and BSQ-8D) (15–17). The psychometric properties, specifically validity and reliability of the BSQ, in its long and short forms, have been reported and found to be satisfactory in several studies among both non-clinical and clinical populations (18–20). The 14-item version has been shown to have reasonable psychometric properties (21). The one-factor structure of this measure has been confirmed (17). Both the original and short versions of the BSQ have been translated into DOI: 10.3109/08039488.2015.1009486
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several languages (18, 21–24), and recently, the BSQ-14 has been translated into Norwegian. Studies have found significant gender differences in body image. One study (25) found that gender differences in body dissatisfaction begin between the ages of 13–14, and this divergence continues to increase as boys and girls grow older, with a peak around 16–17 years of age. Females score significantly higher on the BSQ than males (26). In addition to gender, age and body mass index (BMI) are also related to body dissatisfaction (27), as well as shape and weight concerns (28).
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Aims The aims of the present study were to validate and report norms among young Norwegian females and males compared with patients suffering from AN using the Norwegian translation of the 14-item BSQ. The present study also investigated associations between the BSQ-14, age and BMI in clinical and non-clinical samples.
Methods Participants A total of 739 men and women (49 patients, 690 controls) participated in the study. The patients (n ⫽ 47) that comprised the clinical sample were recruited from five different specialist eating disorder centers across Norway. The patients filled out the questionnaires at different timepoints during the course of their treatment. The diagnostic items from the Eating Disorder Examination (29) were used in the diagnostic evaluation of the patients. Patients were female with a mean age (⫾ standard deviation) of 19.04 ⫾ 3.06 years (range 14–26 years) and mean BMI of 16.48 ⫾ 1.81 kg/m2 (range 12.34–20.19 kg/m2). For the non-clinical sample, a total of 690 students (267 men, 423 women) were recruited from high schools, colleges and one university. The non-clinical sample ranged in age from 14 to 60 years (mean ⫽ 23.05 ⫾ 8.67 years). Mean age for the male controls was 20.98 ⫾ 5.68 years (range 15–56 years) and mean BMI was 23.34 ⫾ 3.13 kg/m2 (range 16.79–42.90 kg/m2). Mean age for the female controls was 24.35 ⫾ 9.90 years (range 14–60 years) and mean BMI was 22.30 ⫾ 3.62 kg/m2 (range 14.04–39.01 kg/m2). Three participants had missing recordings of gender and were excluded from the study, and 32 participants did not report their weight and were not included in analyses about weight.
Measures The short version of BSQ (16) was translated into Norwegian by Ph.D.-level researchers at the Regional Eating Disorders Service at Oslo University Hospital. The translation process adhered to existing international guidelines adapted from the World Health Organization (30).
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The short version of the BSQ consists of 14 items measuring cognitive, affective and behavioral antecedents, and consequences of body size and shape concerns during the last 2 weeks. Responses are measured on a 6-point Likert scale ranging from 1 (never) to 6 (always). A total score is obtained by adding the item scores, resulting in a total score range from 14 to 84. Higher scores indicate greater body image concerns. The Body Checking Questionnaire (BCQ) is a 23-item self-report questionnaire designed to measure the frequency and nature of body checking behaviors (31). Each item is scored on a 5-point Likert scale from 1 (never) to 5 (always), resulting in a score range from 23 to 115. Higher scores indicate higher frequency of checking behaviors. The Norwegian version of BCQ has demonstrated good psychometric properties (32). The BCQ was included as a measure of convergent validity in the present study. The Eating Disorder Examination Questionnaire (EDE-Q) is a 28-item self-report questionnaire adapted from the Eating Disorders Examination (29), which assesses eating disordered related behaviors, thoughts and feelings during the last 4 weeks across a global score and four subscales: Restraint, Shape Concern, Weight Concern and Eating Concern. Responses are rated on a scale from 0 to 6, with higher scores indicating higher levels of eating disorder pathology. The Norwegian translation of the EDE-Q has shown satisfactory psychometric properties (33, 34). The EDE-Q was included as a measure of convergent validity. DEMOGRAPHIC QUESTIONNAIRE Participants were asked demographic information, including age, current height and weight. BMI (kg/m2) was computed via self-reported weight and height. In the patient group, weight and height was obtained from their therapists.
Procedure The patients (n ⫽ 47) completed the questionnaires as a part of larger research project. All participants in the clinical sample provided written informed consent, which was approved by the Norwegian Ethical Committee for Medical Research Ethics. The control participants were recruited via advertisements at school and they received a negligible form of compensation for their participation. Participation was anonymous and written consent was obtained. A fraction of the participants were asked to fill in the BSQ-14 1 week later and post it anonymously in a self-addressed, stamped envelope. The two copies of the BSQ short form were linked by anonymous codes.
Statistics Internal consistency was tested by Cronbach’s alpha. Correlation analyses and 1-week test–retest reliability NORD J PSYCHIATRY·EARLY ONLINE·2015
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were assessed by calculating Pearson’s correlation coefficients. Student t-tests were used to investigate differences between male and female controls, female controls and female patients, as well as BSQ scores at T1 and T2. Analysis of covariance (ANCOVA) was also used to investigate differences in BSQ between female controls and female patients when adjusting for age and BMI. Significance levels were set at P ⬍ 0.05 and all analyses were performed using the Statistical Package for Social Sciences (SPSS) version 20.0.
When split between the patient samples, female controls and male controls, the BSQ-14 total score correlated significantly with the BCQ (r ⫽ 0.79, P ⬍ 0.001; r ⫽ 0.76, P ⬍ 0.001; r ⫽ 0.49, P ⬍ 0.001, respectively) and the EDE-Q total score (r ⫽ 0.84, P ⬍ 0.001; r ⫽ 0.90 P ⬍ 0.001; r ⫽ 0.68, P ⬍ 0.001, respectively). There were also significant correlations between the BSQ-14 and the four EDE-Q subscales for the patients, female controls and male controls with scores ranging from r ⫽ 0.69 to r ⫽ 0.89, r ⫽ 0.71 to r ⫽ 0.91 and r ⫽ 0.36 to r ⫽ 0.77 respectively.
Discriminant validity
Results Descriptives/norms Nord J Psychiatry Downloaded from informahealthcare.com by Kainan University on 04/15/15 For personal use only.
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As shown in Table 1, there were significant differences in age between the control group and the patients (P ⬍ 0.001), the female control group and the male control group (P ⬍ 0.001), as well as the female control group and the patients (P ⬍ 0.001). There were also significant differences in BMI between the control group and the patient group (P ⬍ 0.001), the female control group and the patients (P ⬍ 0.001), as well as between the female control group and the male control group (P ⬍ 0.001). Patients diagnosed with AN and subthreshold AN (eating disorder not otherwise specified, EDNOS) had a mean BSQ-14 score of 56.80 ⫾ 18.89. The control group had a mean BSQ-14 score of 30.88 ⫾ 14.44. We compared male and female controls to investigate gender differences on BSQ mean scores. The female control group had a mean score of 35.89 ⫾ 15.19 and the male group had a mean score of 22.94 ⫾ 8.39.
Concurrent validity To establish concurrent validity, the BSQ-14 was correlated with the BCQ and EDE-Q. Within the whole sample, including males and females, the BSQ-14 total score correlated significantly with the BCQ (r ⫽ 0.80, P ⬍ 0.001) and the EDE-Q total score (r ⫽ 0.90, P ⬍ 0.001). There were also significant correlations between the BSQ-14 and EDE-Q subscales, with scores ranging from r ⫽ 0.74 to r ⫽ 0.92, with the highest correlation between the BSQ-14 and the Shape Concern subscale.
As expected, there was a significant difference on total BSQ score between the female controls and female patients (P ⬍ 0.001), even after adjusting for age and BMI, as well as on all the 14 separate items (P ⬍ 0.05 to ⬍ 0.001).
Internal consistency Internal consistency as measured by a Cronbach’s alpha coefficient was 0.97 for the BSQ-14, indicating excellent internal consistency for the whole sample. Internal consistency was satisfactory for patients, female controls and male controls (Cronbach’s alpha ⫽ 0.94, 0.96 and 0.91, respectively).
Test–retest A total of 182 participants (124 female and 58 male controls) completed the BSQ-14 1 week later (7.2 days). The participants’ responses to the BSQ-14 on both occasions showed a high correlation (r ⫽ 0.94, P ⬍ 0.001), but a significant difference (P ⬍ 0.001) from 32.55 ⫾ 16.10 to 28.54 ⫾ 14.32. When subdividing the control sample according to gender, there was a high correlation coefficient of r ⫽ 0.94 (P ⬍ 0.001) and r ⫽ 0.86 (P ⬍ 0.001) between T1 and T2 for female and male controls, respectively. There were significantly (P ⬍ 0.001) lower scores for female (from 34.88 ⫾ 13.93 to 32.60 ⫾ 14.87) and male (from 22.34 ⫾ 6.73 to 19.79 ⫾ 7.70) controls at T2.
Impact of BMI and age There was no significant relationship between BSQ scores and BMI (r ⫽ 0.03, P ⫽ 0.510) for the total
Table 1. Mean score (standard deviation) for female controls, male controls and patients.
Age, years BMI (kg/m2) BSQ-14 total
M:F comparison (only control data)
AN patients vs. female controls
Female controls n ⫽ 423
Male controls n ⫽ 267
Female AN patients n ⫽ 49
t-value
P-value
t-value
P-value
24.35 (9.89) 22.30 (3.62) 35.89 (15.19)
20.98 (5.68) 23.34 (3.13) 22.94 (8.38)
19.04 (3.06) 16.80 (1.95) 56.80 (18.89)
5.67 3.91 14.40
P ⬍ 0.001 P ⬍ 0.001 P ⬍ 0.001
8.15 18.28 55.711
P ⬍ 0.001 P ⬍ 0.001 P ⬍ 0.001
BSQ-14, Body Shape Questionnaire—14 item short version; BMI, body mass index. 1F-value analysis of covariance adjusting for age and BMI. NORD J PSYCHIATRY·EARLY ONLINE·2015
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sample. However, when subdividing it, the BSQ scores and BMI produced a moderate positive relationship within the female control group (r ⫽ 0.36, P ⬍ 0.001) and for male controls (r ⫽ 0.34, P ⬍ 0.001), but not for the patient sample (r ⫽ 0.03, P ⫽ 0.834). Within the total sample, there was no significant relationship between BSQ scores and age (r ⫽ ⫺ 0.04, P ⫽ 0.289). When subdividing the sample, there was a negligible negative significant relationship between BSQ scores and age within the female control group (r ⫽ ⫺ 0.10, P ⬍ 0.05), and no significant relationship for patients (r ⫽ ⫺ 0.18, P ⫽ 0.227) or male controls (r ⫽ 0.06, P ⫽ 0.343).
Discussion The aims of this study were to report normative data and to establish psychometric properties for the Norwegian version of the 14-item BSQ in clinical and non-clinical samples, which included men. The results indicate that the Norwegian version of the BSQ-14 has good discriminant validity, excellent internal consistency, high test–retest reliability, and demonstrates high concurrent validity with already established and previously validated disordered eating-relevant measures.
Validity The patients diagnosed with AN and subthreshold AN had significantly higher mean scores on the BSQ-14 compared with the female controls after controlling for age and BMI, reflecting the measurement’s strong discriminant validity. The mean BSQ-14 total score for our clinical sample was 57.17 ⫾ 18.84, which is quite similar to the findings of Dowson & Henderson (16) within a clinical sample of AN binge–purge subtype (59.6 ⫾ 14.4), but higher than the clinical sample of AN-restricting subtype (44.1 ⫾ 17.8). Other clinical samples have also shown similar mean scores. For instance, one study (35) reported a mean of 56.40 ⫾ 16.18 within a sample of female obese patients without binge eating disorder (BED). However, the authors reported significantly higher BSQ scores in female obese patients with BED (65.66 ⫾ 10.95). As expected, we found that females scored significantly higher than males on the BSQ and this is in line with a previous study (36). Through the development and validation of the original BSQ, Cooper et al. (13) established concurrent validity based on significant correlations between the BSQ and Eating Attitudes Test and the Body Dissatisfaction subscale of the Eating Disorder Inventory. Findings have suggested that shortened versions have shown acceptable convergent and divergent validity in non-clinical and clinical samples (15, 37). The Norwegian version of the BSQ-14 correlated significantly with previously validated
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disordered eating-relevant measures, including the BCQ (r ⫽ 0.80) and the EDE-Q (r ⫽ 0.90), particularly the EDE-Q subscale Shape Concern (r ⫽ 0.92). This corresponds with the findings from a Swedish study (20) who found the BSQ-8C correlated significantly with the Shape Concern subscale of the EDE-Q, and at a similar level (r ⫽ 0.90, P ⬍ 0.001), while investigating the psychometric properties of the BSQ-8C and norms within a general female and male Swedish population.
Reliability Pook and colleagues (17) investigated the reliability of the full-length 34-item of the BSQ and the seven derivative short-forms, including the BSQ-14. All versions were found to have high internal consistency. In line with Pook and colleagues’ finding, we found satisfactory internal consistency for all clinical and control (M:F) groups. Dowson & Henderson (16) found similar findings with the BSQ-14 in 75 patients with low weight and a history of full or partial AN. Our findings showed that the Norwegian version of the BSQ-14 also exhibited excellent test–retest reliability. The participants’ responses to the BSQ-14 scales on both occasions (approximately 1 week apart) showed a high correlation coefficient (r ⫽ 0.94, P ⬍ 0.001). Our findings was similar to those of Lentillon-Kaestner and colleagues (35) (r ⫽ 0.97, P ⬍ 0.001), which were derived from retest data from eight different versions of the BSQ (including the BSQ-14), administered to both non-clinical and clinical samples (obese patients with and without BED) with a 3-week interval.
Impact of age and BMI As age and BMI have shown to be correlated with the shape and weight concern subscales of the EDE-Q (28), and the BSQ has been highly correlated with the EDE-Q, it was hypothesized that a similar pattern regarding BMI and age would emerge with the BSQ-14. In accordance with previous findings (15, 20), BSQ-14 scores in this study showed a moderate positive relationship with BMI of about r ⫽ 0.30–0.40 for both genders, but not in the clinical sample. Similarly, in a study of female university graduates and staff, Rosen and colleagues (38) found significant associations between BMI and total score on the 34-item BSQ (r ⫽ 0.30 and r ⫽ 0.39, respectively), but no significant correlations were found for obese dieters (age ⫽ 26–68 years). Another study (36) also reported significant correlation between the BSQ-34 and BMI (r ⫽ 0.22–0.45) among a non-clinical sample that included both Brazilian boys and girls (n ⫽ 1494; age ⫽ 11–17 years). Contrary to findings from our clinical sample, however, Dowson & Henderson (16) found BMI to positively correlate with BSQ scores (r ⫽ 0.29) in 75 patients with low weight and a history of full or partial AN (mean age ⫽ 24.0 ⫾ 6.7 years). NORD J PSYCHIATRY·EARLY ONLINE·2015
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Regarding age, we found no significant relationship between BSQ-14 scores and age (r ⫽ ⫺ 0.04, P ⫽ 0.289) within the total sample. However, there was a negligible relationship between BSQ-14 scores and age within the female control group (r ⫽ ⫺ 0.10, P ⬍ 0.05). This is similar to the findings of Evans and Dolan (15), who reported a comparable low and negative correlation (r ⫽ ⫺ 0.11 to ⫺ 0.17) between age and the BSQ-34, as well as several shortened forms of BSQ, when using a sample of 342 adult women with a comparable mean age of 27.1 ⫾ 8.5). These findings are contrary to the findings from an Indian study (39), who reported no significant correlation between age and the BSQ-34 (r ⫽ ⫺ 0.01) when investigating body shape and eating attitudes among female nursing students in India. This difference may be due to sample characteristics, such as lower average age of the female nursing students, or potentially cultural differences.
Gender The current study is the first to introduce gender-specific normative data for the Norwegian translation of the BSQ-14, as well as presenting psychometric data. Given the measure’s low number of items and good psychometric properties, the BSQ-14 is a valuable instrument for measuring body shape dissatisfaction. Another potential advantage of the BSQ-14 is its gender non-specificity. The wording of some of the items in the original version of the BSQ makes it less appropriate for use with males, whereas the BSQ-14 does not contain any items that might be exclusively relevant for females. Thus future studies might be able to further investigate the level of body shape dissatisfaction in male populations using the BSQ-14.
Study limitations There are some limitations that should be considered. The clinical sample size was quite small and included only patients with AN or subthreshold AN. Thus, results may not be generalizable to other types of eating disorders. This study relied upon self-reported weight and height for the control participants, which may have affected the validity of the calculated BMI values. In most BSQ versions, body dissatisfaction over the past 4 weeks is evaluated, but in this study the timeframe was 2 weeks. As the BSQ has good test–retest stability, this might not influence the results of this study in a considerable way. Furthermore, to date, multiple abbreviated versions of the BSQ exist, which may potentially complicate efforts to compare across studies. All of the BSQ short forms have received varying, yet mostly positive, degrees of psychometric support, which likely reflects the unidimensionality and reliability of the original 34 items. Regarding this specific short version, the BSQ-14 has
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one distinct disadvantage, which should be noted. The method used to select the 14 items has not been clearly described. Two of the 14 items measure shape preoccupation using nearly identical wording (items 1 and 8). Nevertheless, a subsequent factor analytic study supported the unidimensionality of these 14 items (19). When Pook et al. (17) investigated the psychometric properties of eight different versions of the BSQ using confirmatory factor analyses, they found three (BSQ-14, BSQ-8B and BSQ-8C) to be favorable in terms of sensitivity to change. However, in that study, only sensitivity to change in a patient sample of bulimic patients was tested, which may be different in other diagnostic groups.
Conclusions Our study adds support to a growing body of literature of studies worldwide demonstrating the satisfactory psychometric properties of the BSQ-14, in both clinical and non-clinical samples. Future research is necessary to replicate and extend these findings across diverse clinical samples. Acknowledgements—This study was supported by the Regional Department for Eating Disorder at Oslo University Hospital, Norway. We thank Deborah L. Reas, Ph.D., for her valuable comments on the manuscript.
Disclosure of interest: All other authors declare that they have no conflicts of interest.
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