Effect of Intermittent Fasting on Body Image Satisfaction and Appreciation Among Saudi Adults

Background: Obesity remains a public health concern, and intermittent fasting (IF) is a popular strategy for weight loss that has gained considerable scientific and popular attention. However, weight control can affect body image. Poor body image and its impact on psychological well-being are linked to obesity in many individuals. Body appreciation is a crucial characteristic of positive body image. However, there is a lack of studies assessing these relationships in Saudi adults. Aim: To evaluate the associations between IF diet, body image satisfaction, and body appreciation in Saudi adults. Method: A web-based cross-sectional study was done with healthy Saudi adults aged 18 to 50 years old who followed the IF diet. The questionnaire had five sections: a brief study introduction, sociodemographic variables, adherence to the diet, modified body image scale, and body appreciation scale. Ethical approval was obtained. Results: A total of 190 participants were included in this study, including 59 (31.1%) males and 131 (68.9%) females. Comparing before and after IF, the body mass index (BMI) significantly decreased after IF (p < 0.001). After IF, a significant decrease in the body image dissatisfaction score was observed (p < 0.001). A significant increase was noted in the body appreciation score (p < 0.001). Conclusion: IF is significantly associated with better body image satisfaction and body appreciation. These results may help weight loss studies and may have public health implications.


Introduction
Obesity is a disease in which the body has excessive fat, resulting in impairment of physical and psychological health and well-being. It remains a significant public health concern and issue. It is mostly induced by the interaction of multiple factors, including environmental, genetic, nutritional, physical, and behavioral factors. It has been noted that obese people have a high risk for developing chronic diseases, type 2 diabetes, cardiovascular disease, and some cancers [1,2]. Therefore, studying factors associated with weight loss is highly needed.
Overweight and obesity prevalence are rapidly increasing worldwide. In 2016, more than 1.9 billion adults were overweight, including 650 million who were suffering from obesity, and approximately 2.8 million adults die each year due to the condition [3]. If the prevalence of obesity continues rising, by 2030, an estimated 38% of the globe's adult population will be overweight, and another 20% will be obese [2]. In the Kingdom of Saudi Arabia, large nationwide population-based surveys predicted a remarkable increase in obesity prevalence by 2022 [4]. Moreover, Saudi Arabia is now among the nations with the highest prevalence rates of obesity and overweight due to a number of contributing factors, including a sedentary lifestyle and a high-calorie diet [1].
Intermittent fasting (IF) is a popular strategy for weight loss, which may present independent health benefits. It has gained considerable scientific and popular attention and has been introduced as a feeding method under certain conditions in clinical practice [5]. It has many forms, but the basic premise involves taking periodic breaks from eating [6]. One common form of IF is fasting for up to 24 h once or twice a week with ad libitum food intake for the remaining days, which is known as periodic prolonged fasting or intermittent calorie restriction. Other forms are time-restricted feeding, such as eating for only eight hrs and then fasting for the other 16 hrs of the day, and alternate-day fasting (ADF). Most ADF programs involve alternating feast (ad libitum intake) and fast days (≤25% of energy needs), with some protocols allowing no caloric intake on fast days [7,8].
A huge body of evidence shows that body-weight control can affect body image. Body image is a subjective and multidimensional construct. It is composed of the perceptions (i.e., perceptual component) and the emotions, cognitions, and attitudes (i.e., evaluative component) that we have toward our body, which are translated into bodyweight and appearance-management efforts (i.e., behavioral component) [9]. However, weight misperception may limit the effectiveness of obesity prevention and management efforts [10]. Personal perceptions about the body refer to how a person considers their own body weight, size, shape, and composition to be. Poor body image and its impact on psychological well-being are inextricably linked to obesity in many individuals. Therefore, determining whether weight loss interventions affect body image in obese individuals is a worthwhile endeavor [11].
Body appreciation has been defined as accepting, holding favorable opinions toward, and respecting the body, while also rejecting media-promoted appearance ideals as the only form of human beauty. Studies have identified body appreciation as a key characteristic of positive body image, which is more narrowly described in these investigations as gratitude toward the body. Other positive body image characteristics detected in previous studies include body acceptance and love, inner positivity influencing outer demeanor, and a broad conceptualization of beauty. These appear to fit within the scope of the definition of body appreciation which is operationalized and measured via the 13-item body appreciation scale [12]. To our knowledge, this is the first study that evaluates the association between IF and body image satisfaction and appreciation. We hypothesize that people who fast for up to 16 hours per day develop a sense of accomplishment, which boosts self-esteem and thus body appreciation. To approach this hypothesis, we aimed to investigate the association between IF, body image satisfaction, and body appreciation among Saudi adults. The specific objectives are to compare body mass index (BMI), body image satisfaction, and appreciation before and after following the IF diet and to identify factors associated with body image satisfaction and body appreciation after following the IF diet.

Study design and participants
This study was a web-based cross-sectional survey. The questionnaire was distributed from January 2022 to February 2022. The sample for this study included participants aged 18 years and older who followed the IF diet with healthy medical records in Saudi Arabia. Participants received an online questionnaire through WhatsApp™, Twitter™, email, and other social media platforms.

Exclusion criteria
Participants were excluded from this study if they did not follow the IF diet, had a chronic health problem, were following a therapeutic diet, had severe psychological disorders, were pregnant, or were younger than 18 years old.

Main outcome measures
The questionnaire was obtained from previous studies [12,13]. Google Forms was used to easily distribute it via social media platforms. The first section included a brief introduction of the study, the purpose of conducting the study, the time expected to complete the questionnaire, the researcher's e-mail address in case of any concerns or questions, and clarification indicating that the participant's information is confidential and that participation is anonymous. Before proceeding with the questionnaire, participants consented to the following statement: "I express my agreement to participate in this study by completing the questionnaire. Before finishing the questionnaire, I can freely and without consequences terminate my participation." The second section of the questionnaire collected sociodemographic variables including gender, age, nationality, social status, place of residence, educational level, career, and health status. The third section contained self-reported anthropometric measurements and the duration of following the IF diet. The fourth and fifth sections included a body image scale that measures body image satisfaction [13] and the Body Appreciation Scale 2 (BAS-2) [12].
On the body image satisfaction scale, participants scored each question from 0 ("Not at all") to 3 ("Very much"), and the possible score range was 0 to 27, with higher scores indicating higher body image dissatisfaction [13]. On the Body Appreciation Scale, participants scored each question from 1 ("never") to 5 ("Always"). The possible score range was 1 to 50, with a higher score reflecting more body appreciation [12]. If the score is less than 50%, it was considered a low body image dissatisfaction level. If the score was 50-75%, it was indicated as a moderate body image dissatisfaction level, and higher than 75% showed a high body image dissatisfaction level.

Variables
BMI was calculated using the participants' self-reported weights and heights in the questionnaire. Participants' weights in kilograms were divided by their heights in meters squared (BMI = weight in kg/height 2 {in m 2 }). We categorized the BMIs according to the guidelines of the World Health Organization (WHO): underweight -BMI below 18.5 kg/m 2 , normal weight -BMI greater than or equal to 18.5 to 24.9 kg/m 2 , pre-obesity -BMI greater than or equal to 25 to 29.9 kg/m 2 , obesity class I -BMI greater than or equal to 30 to 34.9 kg/m 2 , obesity class II -BMI greater than or equal to 35 to 39.9 kg/m 2 , obesity class III -BMI greater than 40 kg/m 2 [3,14].

Survey translation
In order to translate the survey tool into Arabic, a forward-backward translation method was used. It was translated from English to Arabic by two researchers, revised by two different researchers, and approved by the Biomedical research ethics committee. To maintain the accuracy of the translated statements, we put more emphasis on conceptional translation than word-by-word translation.

Piloting study
The questionnaire tool was evaluated and validated by clinical nutritionists from Umm Al-Qura University. They were questioned regarding the questions' simplicity and understandability, as well as their validity on their face and whether any of them were challenging to comprehend. They were also questioned about whether any of the inquiries offended or upset them. They claimed the questionnaire was easy to comprehend and complete. Before the questionnaire was used on a broader scale, pilot research with a small group of participants was carried out to gauge comprehension, and they confirmed that it is simple and clear.

Statistical analysis
Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 23 (IBM Corp., Armonk, NY). The frequency and percentages were used to display categorical variables. The mean and standard deviation were used to display continuous variables. Paired t-tests were used to determine if there was a significant change in the BMI, body appreciation score, and body image dissatisfaction after following an IF diet compared to before following the diet. An independent t-test and ANOVA test were also used to determine factors associated with the body image dissatisfaction score and body appreciation score. An ANOVA test followed by Tukey's post-hoc test was used to determine differences between groups. Pearson's correlation coefficient was used to determine the correlation between the two variables. A coefficient < 1 means that there is a strong negative correlation, while a coefficient > 1 means that there is a strong positive correlation. The level of significance was set at 0.05.

Body image dissatisfaction score before and after following the IF diet
Participants' body image dissatisfaction decreased after the IF diet compared to before the diet. As illustrated in Table 3, the mean body image dissatisfaction score before the diet was 15.25 + 7.07, while after following the diet, it decreased to 8.17 + 6.9 ( Table 4). Around 26.3% of the participants had a moderate body image dissatisfaction level before the diet, while 10% had a moderate body image dissatisfaction level after following the diet. 29.5% had a high body image dissatisfaction level before following the diet compared to 5.8% after following the diet.   Body appreciation assessment before and after following the IF diet Table 5 displays the participants' body appreciation before and after the IF diet. The mean body appreciation score before the IF diet was 31.59 + 11.34, while after following the diet, it increased to 39.68 + 10.36 ( Table  6). Scores less than 50% were considered low body appreciation levels, 50-75% were considered a moderate body appreciation level, and higher than 75% was considered a high body appreciation level. Out of the total, 36.8% of the participants had a moderate body appreciation level before the diet, while 20.5% had a moderate body appreciation level after following the diet, 35.8% of the participants had a high body appreciation level before following the diet compared to 67.9% after following the diet.   Weight and BMI significantly decreased after the diet Table 7 shows that weight and BMI significantly decreased after the IF diet compared to before. The mean BMI for participants before the IF diet was 31.23 ± 5.88 compared to 26.75 + 4.77 after the diet (p < 0.001). A significant decrease in the body image dissatisfaction score was observed (p < 0.001) when comparing the before-diet score and the after-diet score (15.25 + 7.07 before the diet vs. 8.17 + 6.9 after the diet). A significant increase was also noted in the body appreciation score (p < 0.001) when comparing the beforediet score and after-diet score ( Table 8 shows the factors associated with the body image dissatisfaction score measured after the IF diet. A significant difference was observed in the body image dissatisfaction score measured after the IF diet between males and females (p = 0.049): males had a significantly higher body image dissatisfaction score than females (8.54 + 7.58 vs. 6.41 + 6.49). The use of medication/supplements was also significantly associated with the body image dissatisfaction score measured after the IF diet (p = 0.032). The Tukey posthoc test revealed that those taking a supplement had a significantly higher dissatisfaction score than those who did not use medication or supplements (p < 0.05). The number of fasting hours showed a significant, weak, positive correlation with the body image dissatisfaction score measured after the IF diet (p = 0.003, correlation coefficient = 0.216) ( Table 9). Marital status, place of residence, education, employment, duration of following the IF diet, and age were all not significantly associated with the body image dissatisfaction score measured after the IF diet.

Factors associated with body appreciation score
Tukey post-hoc test revealed that those taking supplements had a significantly lower appreciation score when compared to those who did not use medication or supplements (p < 0.05). Gender, marital status, place of residency, education, employment, duration of following the IF diet, age, and number of fasting hours were all not significantly associated with the body appreciation score measured after the IF diet ( Table  10). Table 11 shows the factors correlated with the body appreciation score measured after the IF diet. The use of medication/supplements was significantly associated with the body appreciation score measured after the IF diet (p = 0.029).

Discussion
The prevalence of obesity is rising worldwide along with the subsequent health-related issues that it causes in both physical aspects (e.g., diabetes mellitus type II and hypertension) and psychosocial aspects (e.g., body image dissatisfaction and poor body appreciation). Thus, losing and maintaining a healthy weight has been a major concern for people in all age groups [3,12,15]. Fasting has recently been a trending method for safe weight loss [16][17][18]. The aim of this study was to evaluate the effect of IF on body image dissatisfaction and appreciation among Saudi adults.
We found that following the IF diet for less than one month to more than four months resulted in a significant drop in weight (from a mean of 83.2 kg to 71.2 kg) and BMI (from a mean of 31.2 to 26.75). These results are consistent with the study by Welton et al., who systematically reviewed 27 trials of IF and found that there was a loss of weight occurred among those who fasted in an intermittent manner, which ranged from 0.8% to 13% of baseline, as well as an average decline in BMI by 4.3% [19]. Collectively, these findings indicate that abstinence from food for a set period of time in a daily manner is an effective strategy for weight loss in the short term. These results paved the way for assessing whether weight loss through IF in particular has a positive impact on body image satisfaction and body appreciation.
In our study, the mean score of body image dissatisfaction was found to be 15.25 before following the IF diet and then decreased to 8.17 after following the IF diet. This reduction showed a significant positive correlation between IF and body image dissatisfaction (p < 0.001). This association might be related to the fact that the thinner someone is, the more his or her facial features become evident and detailed, thus increasing the attractiveness perceived by oneself and others. This can be reflected in the form of selfconfidence, social praise, compliments, and encouragement, eventually increasing one's sense of satisfaction with one's body image.
An additional factor that should be taken into consideration is the psychosexual nature of men and women, who respectively tend to favor leanness and muscularity [20]. Both of these characteristics might be obscured to some degree by excessive fat but are regained with IF when weight is lost. Finally, nowadays, people are engaged in different social media platforms, where they may find themselves either consciously or unconsciously driven to compare their appearances with those of their peers, leading to body image dissatisfaction [21]. They subsequently try to look as similar as possible to their idealized figure, such as by losing weight by fasting intermittently, which ultimately leads to better body image satisfaction.
We found that the participants scored an average of 31.95 on BAS-2 before going through the IF diet, but it increased to 39.68 after following the IF diet, which may have been due to the participants' weight loss. This increase showed a significant positive correlation between IF and body appreciation (p < 0.001). This association may be related to the consequences that being overweight or obese may impose on the body, which may improve with IF, leading to a better quality of life and body appreciation. Self-esteem and subjective perception of health have been identified as psychological factors affecting body appreciation [22][23][24][25][26].
Male gender has been found to significantly increase the score of dissatisfaction with body image in this study. These findings oppose the results of a study that found body image dissatisfaction to be significantly associated with the female gender [13,26,[28][29][30]. In a previous study, males being more satisfied with their body image was explained by their tendency to pair the perfection of the body with functionality rather than appearance [31]. Furthermore, we assume that when males are overweight or obese, their fat is accumulated in the abdomen, giving them the appearance of an apple. This shape is cosmetically less appealing than the pear-shaped obesity of their female peers, making them more dissatisfied with their body image.
Participants taking supplements were observed to have a significantly higher score of body image dissatisfaction and a lower score of body appreciation compared to those who did not take supplements or medications. Likely, this is because people who are dissatisfied with their body image and do not appreciate it tend to take supplements such as multivitamins or minerals, believing that they could somehow have a positive effect on their body either functionally or cosmetically. Our result is consistent with several studies that found people taking dietary supplements tend to follow many healthy habits such as healthier nutritional practices and exercising regularly in order to maintain a healthy weight [16]. Moreover, many studies have found that people take supplements because they want to maintain their overall health, fulfill their nutritional needs, improve their physical appearance, and boost weight loss [16].
Marital status, place of residence, education, employment, and age were not found to have a significant association with body image dissatisfaction and body appreciation in our study. However, previous studies found that body image dissatisfaction does not change with age in women, and it is still unclear whether the level of body image dissatisfaction changes with age in men. Although body image dissatisfaction remains the same with age among women, appearance value tends to decline with age [32].
To our knowledge, this is the first study that assessed the relationship between IF, body image satisfaction, and body appreciation in a sample Saudi population. Furthermore, both genders were included in the study with ages ranging between 18 and 71 years. On the other hand, our study has some limitations. First, the survey was self-administered. This might have affected the accuracy of the results. Secondly, most of our participants were female (68.9%), so the results could be biased. One of the main limitations of an online survey is that some of the intended groups may have been missed, which may have affected how generalizable our results were. Finally, our sample size was too small to generalize our results to the Saudi population.
We recommend studying the effect of IF on body image satisfaction and body appreciation with data collected from males and females equally in a larger sample size so that less biased results can be obtained. We also recommend that future researchers examine the effects of IF on body image satisfaction and body appreciation in a group of people who are similar in age, education level, employment, and circumstances so that more accurate results can be obtained. Our findings could give insight to public health providers, especially clinical dietitians in Saudi Arabia. The results could help them to focus extensively on integrating IF practice regardless of the number of fasting hours. According to our preliminary results, this integration may improve body appreciation and lower dissatisfaction, which eventually might have an impact on not only the physical appearance of obese people but also their mental and emotional health. This study may be useful in raising the Saudi public's health satisfaction and encouraging weight loss.

Conclusions
In conclusion, IF was significantly associated with better body image satisfaction and body appreciation. Males had a significantly higher body image dissatisfaction compared to females, and the use of medication/supplements was an important factor correlated with body image dissatisfaction. These results may have significant implications for future studies using IF as a weight loss method. Further cohort studies are warranted to identify other variables influencing body image satisfaction and body appreciation. This will help in designing interventions that enhance patients' satisfaction.