Archives of Gerontology and Geriatrics 55 (2012) 505–521

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Archives of Gerontology and Geriatrics

journal homepage: www.elsevier.com/locate/archger

Review

The body image construct among Western seniors: A systematic review

of the literature
Mathieu Roy a,*, Hélène Payette a,b
a
Research Center on Aging, Health & Social Services Center-University Institute of Geriatrics of Sherbrooke, Quebec, Canada
b
Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada

A R T I C L E I N F O A B S T R A C T

Article history: Despite numerous body image researches focusing on children, adolescents, young and middle-aged
Received 3 February 2012 adults, there is a dearth regarding the body image of Western seniors. In this paper, we reviewed this
Received in revised form 16 April 2012 literature using a systematic three-step extraction procedure plus a quality evaluation assessment for
Accepted 17 April 2012
each retained article. The results showed that, while body dissatisfaction (BD) and body image distortion
Available online 10 May 2012
(BID) exist at older ages, the importance given to body image as it relates to physical appearance is lower
in comparison with younger samples. Associations between body image and physical/mental health
Keywords:
were also shown. Various tensions regarding the aging body (appearance vs. health, inside vs. outside,
Body image
Perception
natural vs. unnatural) as well as a double standard of aging were also reported among older women. We
Health conclude that the body image experience of Western seniors has both specificities and similarities with
Elderly the one of younger populations. We also conclude that some methodological aspects of the literature on
Aged body image among older adults need to be addressed in order to move forward with this field of research.
ß 2012 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
2.1. Identification of keywords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
2.2. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
2.3. Study extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
2.4. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
3.1. Study extraction results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
3.2. Quality assessment results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
3.3. Results of the systematic literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
3.3.1. Quantitative studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
3.3.2. Qualitative studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
3.3.3. Reviews or comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
4.1. Summary of findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
4.1.1. About the four main body image dimensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
4.1.2. About the other aspects of body image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
4.1.3. About the methodological aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
4.1.4. Strengths and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519

* Corresponding author at: Research Center on Aging, CSSS-IUGS, 1036 Belvédère Street South, Sherbrooke, Quebec, Canada J1H 4C4. Tel.: +1 819 780 2220x45417;
fax: +1 819 821 7141.
E-mail address: mathieu.roy7@usherbrooke.ca (M. Roy).

0167-4943/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.archger.2012.04.007
506 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521
1. Introduction
The Austrian psychiatrist Paul Schilder (1886–1940) was the
first to define the body image construct in his 1935 seminal work
entitled ‘‘The image and appearance of the human body’’ as ‘‘the
picture of our own body which we form in our mind, that is to say, the
way in which the body appears to ourselves’’ (Schilder, 1935). From
this very first description of body image not solely defined as a
physiological entity, but also as a psychosocial construct, emerged
a much more comprehensive definition of this concept. The body
image concept is now defined as the systematic, cognitive,
affective, conscious, and unconscious representation that people
have concerning their bodies during their biological development
and throughout their social relationships (Ledoux, Mongeau, &
Rivard, 2002). This contemporary definition of the body image
construct is the result of numerous researches focusing on
children, adolescents, young adults, and even middle-aged adults
body image over the last decades.
The body image concept is multidimensional (Banfield &
McCabe, 2002; Cash, 2005; Cash & Pruzinsky, 1990; Cuzzolaro,
Vetrone, Marano, & Garfinkel, 2006; Grogan, 2008). It fluctuates
across the lifespan as a result of biological, physiological,
psychological, and social circumstances (Cash & Pruzinsky,
1990; Grogan, 2008). This multidimensional concept is mainly
captured along four dimensions: (1) an attitudinal, (2) a
perceptual, (3) a behavioral, and (4) a cognitive (Roy, 2010). The
attitudinal dimension of body image refers to individual feelings
expressing that someone likes or dislikes his body, his shape, or
other aspects of his appearance (Roy & Forest, 2007). This first
dimension of body image is operationalized with body (dis)satis-
faction (Gardner & Boice, 2004; Slade, 1988) and pertains to the
discrepancy between the perceived and the ideal body (Fallon &
Rozin, 1988; Higgins, 1987). The perceptual dimension of body
image corresponds to the accuracy of judgment regarding self or
other current body size (Roy & Meilleur, 2010). This discrepancy
between current and perceived body size is assessed with BID (Roy
& Forest, 2007; Roy & Meilleur, 2010). The behavioral dimension of
body image taps into behaviors adopted as a consequence of our
own body image representation as well as a result of the attitudes
of others regarding our body (Brown, Cash, & Mikulka, 1990; Cash,
1994; Cash & Henry, 1995; Grogan, 2008). Questionnaires and/or
interviews are usually used to assess this third body image
dimension. Finally, the cognitive dimension of body image refers to
the process by which individuals become aware of the surrounding
reality from their own body image representation (Ricciardelli &
McCabe, 2002). To measure this fourth body image dimension, two
Australian researchers (Ricciardelli & McCabe, 2002) have devel-
oped a questionnaire to quantify the importance attributed to body
image in individuals’ daily life.
A negative body image (whatever the investigated dimension)
has been linked with an array of unhealthy physical and mental
health outcomes among children, adolescents, and also young and
middle-aged adults. Two recent studies reported that body image
dissatisfaction is a stronger determinant of health than current
body size among adolescents (Jansen, van de Looij-Jansen, de
Wilde, & Brug, 2008) and adults (Muennig, Jia, Lee, & Lubetkin,
2008). Only during the last decade, negative body images were
associated with an increased likelihood of affective, emotive,
anxious, and depressive disorders as well as psychological distress
among children, adolescents, young and middle-aged adults
(Faulkner et al., 2001; Schwartz & Brownell, 2004; Stice, 2002;
Wichstrom, 1999; Woodside & Staab, 2006). Negative body images
have also been associated with increasing risk of eating and
weight-related disorders such as anorexia and bulimia nervosa,
binge-eating disorder, excess weight or obesity as well as with
unhealthy weight management strategies, inappropriate weight
goals in regard to current body size, and unhealthy and disordered
health-related behaviors (Neumark-Sztainer, Paxton, Hannan,
Haines, & Story, 2006; Neumark-Sztainer, Story, Faulkner, Beuhr-
ing, & Resnick, 1999; Ricciardelli, McCabe, Holt, & Finemore, 2003;
Ricciardelli, McCabe, Lillis, & Thomas, 2006; Roy & Gauvin, 2009).
Despite this wealth of research pertaining to children, adoles-
cents, and young and middle-aged adults’ body image, there is a
dearth of knowledge regarding body image among seniors (Allaz,
Bernstein, Van Nes, Rouget, & Morabia, 1999; Baker & Gringart,
2009; Krauss Whitbourne & Skultely, 2002; Tunaley, Walsh, &
Nicolson, 1999). An overview of this literature highlights the
absence of body image construct from the public health content
directed toward elders as well as the paucity of studies on this
specific health-related topic (Ferraro et al., 2008). We think that
these two limitations are of concern because the proportion of
seniors is increasing faster than any other age category among
western societies (Ferraro et al., 2008; Lewis & Cachelin, 2001). As a
result, seniors represent a potential major burden in terms of health
care costs and utilization (Statistics Canada, 2006) and this is of
concern in front of physical and mental health outcomes usually
associated with negative body images. Finally, when body image is
examined among seniors, the hypotheses and research designs are
often systematically reproduced from children, adolescent, and
young adult literature (Deeny & Kirk-Smith, 2000). The body image
experience of seniors, however, has been found to differ from that of
younger populations (Hurd Clarke, 2002a; Lamb, Jackson, Cassiday,
& Priest, 1993; Paulson & Willig, 2008; Tunaley et al., 1999). We then
think that present knowledge about seniors’ body image has to be
synthesized in order to document, and possibly clarify, a theoretical
framework specific to the experience of older adults.
The main objective of this paper was to review the existing
literature about Western seniors’ body image. More specifically,
we want to address four specific areas of body image, that are: (1)
the body image dimensions, (2) the measures used to assess these
dimensions, (3) the individual body image experience, and (4) the
associations between this body image experience and physical and
mental health. In order to tackle our main objective as well as our
four body image specific research areas, a systematic three-step
extraction procedure was undertaken to identify papers investi-
gating the body image construct among Western seniors. A quality
evaluation assessment was furthermore carried out with each
retained article. Our hypotheses were that: (1) western older
adults body image dimensions are the same as those observed
among western younger age groups, (2) measures used to assess
western older adults body image dimensions are the same as those
used among western younger age groups, (3) body image
experience among Western seniors is different from the one of
their younger fellow citizens, and finally (4) associations between
body image experience, and physical and mental health in Western
seniors are different than those observed in younger age groups.
2. Materials and methods
2.1. Identification of keywords
We a priori defined two lists of keywords to locate literature on
older adults’ body image (Table 1). The first list of keywords (11
terms) was used to identify senior literature whereas the second
list (15 terms) served to locate body image studies.
2.2. Selection of studies
A computer-based search was conducted during October 2010
in MedLine (1950–2010), Embase (1980–2010), Cochrane database
of systematic reviews (2005–2010), PsycINFO (1967–2010), and
AgeLine.
 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521
Table 1
Two lists of keywords produced to locate relevant literature on Western seniors’
body image.a
(1) List of senior keywords (2) List of body image keywords
(1.1) Elder (2.1) Body image
(1.2) Elderly (2.2) Body awareness
(1.3) Eldest (2.3) Body shape
(1.4) Older (2.4) BD
(1.5) Old age (2.5) Body distortion
(1.6) Senior (2.6) Body perception
(1.7) Aging (2.7) Body importance
(1.8) Advanced age (2.8) Body discrepancy
(1.9) Great age (2.9) Body anxiety
(1.10) Golden age (2.10) Body checking
(1.11) Bloom (2.11) Body surveillance
(2.12) Body shame
(2.13) Body concern
(2.14) Body consciousness
(2.15) Body image disturbance
a
Each possible combination of keywords (n = 165) was entered in each database
queried.
2.3. Study extraction
The study extraction used a systematic three-step procedure.
First, all combinations of keywords (n = 165; Table 1) were crossed
in each database. The title and abstract of each resulting hit were
examined. Articles with a title or an abstract containing a reference
to adult body image or body image without mention of the
investigated sample were retained for the second step of
extraction. In this second step, the remaining articles were read
in-depth and retained based on six inclusion criteria: (1) a sample
or subsample of adults aged 65 years or over, (2) seniors living in
Western society, (3) French or English language peer-reviewed
article, (4) body image measure as an outcome or exposure
variable in quantitative studies, (5) body-related theme for
qualitative studies, and (6) review or comment on body image.
Finally, as the third and final step of the procedure, references for
each retained article were examined to include articles not listed
by our systematic procedure.
2.4. Quality assessment
As proposed by the 2009 Cochrane collaboration updated
method guidelines for systematic reviews, all articles retained for
this review underwent a quality assessment procedure as regards
their methodological strength and were graded according to the
quality of their evidences (Furlan, Pennick, Bombardier, & van
Tulder, 2009). This process of quality evaluation assessment for
each study included in a systematic review allows comparison of
studies and helps authors to put more emphasis on articles with
better quality score (Stroup et al., 2000).
Because this systematic review contains different approaches
(quantitative and qualitative) and different categories of publica-
tion (original research, reviews, and comments), three different
checklists were used to assess the quality of the retained studies,
namely quantitative studies, qualitative studies, and reviews. No
quality assessment procedure was carried out for comments.
The checklist used to evaluate quality of quantitative studies
was the one of Timmer, Sutherland, and Hilsden (2003). This
checklist contains 19 observable items plus one extra source of
points. From this checklist, we used 16 items out of 19 because
three items were specific to interventions studies (all the
quantitative studies included in this review were observational).
As suggested, two points were allocated if the item was fully met,
one if partially met, and none if it was not met. Five extra points
were awarded based on study design and on whether there is
randomization or not. The maximum score was 37. All items were
507
not applicable to all studies. For each item not applicable to the
assessed study, two points were subtracted from 37. This resulted
in a new maximum score. A ratio was then computed by dividing
the score by the maximum score for this article. Possible score of
quality were between 0 and 1 with articles closer to 1 better than
articles closer to 0. Timmer et al. (2003) checklist has been found to
have good construct validity for the assessment of quantitative
studies and has been used in recently published medical review of
the literature (Acosta & Cash, 2009; Buzas & Jozan, 2007; Young,
Gentry, Acosta, Greenwald, & Riddle, 2010).
The checklist used to assess the quality of qualitative studies
was the one used by the National Institute for Health and Clinical
Excellence (www.nice.org.uk) for the elaboration of their clinical
guidelines (National Institute for Health and Clinical Excellence,
2007). This checklist contains 13 items appraising six different
qualitative studies components: (1) aims, (2) design, (3) recruit-
ment and data collection, (4) analysis, (5) findings/interpretation,
and (6) research implications. Each item was dichotomous (e.g.
appropriate/not appropriate, rigorous/not rigorous, clear/unclear,
adequate/inadequate). Based on each item appraisal, an overall
quality assessment was made. The article was scored ++ if all or
most of the items have been fulfilled, + if some of the items have
been fulfilled or if few or no items have been fulfilled. To remove
subjectivity, we scored ++ the articles addressing at least 11 out of
13 items, + the articles addressing 7–10 out of 13 items, and the
articles addressing less than 7 items out of 13.
The checklist used to evaluate the quality of reviews was the
MOOSE checklist (Meta-analysis of Observational Studies in
Epidemiology; Stroup et al., 2000). This checklist made from 35
dichotomous items and divided into six sections (1 – background, 2
– research strategy, 3 – methods, 4 – results, 5 – discussion, and 6 –
conclusion) was created to check if all components of a perfect
gold-standard meta-analysis or systematic review were present in
a review under assessment. Even though all reviews included in
this paper were narrative, this checklist is useful as it indicates the
quality of the review. The presence (vs. the absence) of an item
gave one point and higher the total score is, more complete is the
assessed review. This widely known and cited tool has been used
repeatedly in health-related literature (e.g. Bellamy, Casa, Hingor-
ani, & Williams, 2009; Li, Shin, Ding, & van Dam, 2009; Stothard,
Tennant, Bell, & Rankin, 2009).
3. Results
3.1. Study extraction results
Fig. 1 shows the flow chart of this review. Keyword combina-
tions yielded 7504 hits. The analysis of titles and abstracts yielded
82 articles with a title or an abstract containing a reference to adult
body image or body image without the mention of examined
sample. Of these 82 articles, 25 were further excluded (Table 2)
because they did not meet selection criteria. After this second step
of exclusion, references of remaining article (n = 57) were
thoroughly examined to include relevant articles not identified
by our systematic procedure. This identified 26 new articles,
bringing the final number of articles in this review to 83.
3.2. Quality assessment results
Among retained quantitative studies (n = 61), 20 had a quality
score ranging from 0.80 to 0.89, 14 had a quality score ranging from
0.70 to 0.79, 15 had a quality score ranging from 0.60 to 0.69, while
the remaining 12 quantitative papers had a quality score under
0.60. Regarding the quality assessment of qualitative papers
(n = 14), nine had a quality score of ++ (11 out of 13 items fulfilled)
whereas the five others had a quality score of + (between 7 and 10
508 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521

# of hits resulting from keyword combination (n = 7504)

-Medline + Embase + Cochrane (n = 1092)
-AgeLine (n = 214)
-PsycINFO (n = 6198)

1st step of exclusion (n = 7422)

Relevant title and/or abstract kept for in-depth reading

(n = 82)

2nd step of exclusion (n = 25; see Table 2)

Relevant article according the inclusion criteria

(n = 57)

# of articles in this review

(n = 83)
Examination of each reference of all relevant articles
(n = 26)

Fig. 1. Flow chart of the systematic review.

Table 2
Excluded articles (n = 25) in the 2nd step of the study extraction procedure.
Excluded article
1. Albani, Gunzelmann, and
Brahler (2009)
2. Gunzelmann, Brahler,
Hessel, and Brahler (1999)
3. Kipp (2001)
4. Von Gruchalla, Hahlweg-
Widmoser, Gugger,
Teschner, and Debus (2003)
5. de Moraes and de
Azevedo e Souza (2005)
6. Pereira, Teixeira, Borgatto,
and Daronco (2009)
7. Jiang, Li, and He (2007)
8. Musaiger and D’Souza (2009)
9. Liang et al. (2009)
10. McCabe and Ricciardelli (2004)
11. Sharma et al. (2007)
12. Fleming (1999)
13. Oberg and Tornstam (2003)
14. Niaura et al. (2003)
15. Gyllensten, Hui-Chan,
and Tsang (2010)
16. Hurd Clarke and Bundon (2009)
17. Mayo Clinic (2009)
18. Tatarelli and Girardi (1991)
19. Besancon (1991)
20. Richard (1983)
21. Voorrips, Meijers, Sol, Seidell,
and Van Staveren (1992)
22. Teising (2007)
23. Donkin et al. (1998)
24. Wadsworth and Johnson (2008)
25. Oderda, Monino, Zitella, Tizzani,
and Gontero (2008)
out of 13 items fulfilled). No qualitative paper had a quality score of
(less than 7 out of 13 items fulfilled). Finally, the following
Rationale quality scores were obtained for the 6 reviews included in this
Written in German paper: 5, 6, 11, 12, 12, and 14 (on a maximum score of 35).
3.3. Results of the systematic literature review
3.3.1. Quantitative studies
The study extraction procedure identified 61 quantitative
studies (73.5% of all papers; Table 3).
Written in Portuguese
3.3.1.1. Attitudinal dimension of body image. There was a consensus
within extracted studies that seniors are still dissatisfied with their
Written in Chinese bodies (Bedford & Johnson, 2006; Cash & Henry, 1995; Lewis &
Seniors from non-Western Cachelin, 2001). Proportions of BD across quantitative studies
countries (Kuwait and ranged from 31.1% to 70.8%, with lower BD proportions among
China, respectively) studies using questionnaires (such as multidimensional body-self
relations questionnaire (MBSRQ), McKinley and Hyde’s objectified
Articles without senior subjects body consciousness scale (MHBCS), and diagnostic survey for
eating disorders (DSED); see Table 3) and higher BD proportions
Articles on the aging process among studies using silhouette based measures (Allaz, Bernstein,
rather than body aging or Rouget, Archinard, & Morabia, 1998; Anderson, Eyler, Galuska,
body image Brown, & Brownson, 2002; Grippo & Hill, 2008; Mangweth-Matzek
et al., 2006; Schieman, Pudrovska, & Eccles, 2007). As a
Articles with misuse of body image consequence, BD was not age dependent (Cash & Henry, 1995;
Davies, Whelan, & King, 2000; Grippo & Hill, 2008; Schuler et al.,
2004; Tiggemann & Lynch, 2001). Two studies, however, disagreed.
Articles with no or incidental The first, which consisted of a random digit-dial telephone survey
mention of body image
(quality score = 0.66), reported decreasing BD with increasing age
among older Canadian women (Boisvert & Harell, 2009). The
second, using a BD index (actual ideal body mass index (BMI)/
actual BMI) among a representative population-based sample of
Swiss women first (quality score = 0.83), indicated that, after
controlling for BMI, younger women evidenced greater BD than
older women (Allaz et al., 1998).
A second consensus across quantitative studies suggests that
older women are more dissatisfied with their bodies than older men
(Boisvert & Harell, 2009; Ferraro et al., 2008; Franzoi & Koehler,
 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521 509

Table 3
Quantitative studies extracted by the systematic procedure.

Authors Setting Sample DS Body image Summary of findings Quality

measurement score

Abadie et al. (1996) USA 110 men CS SS AA elders practicing PA experienced 0.43
more BD than AA elders who did not
practice PA or than white elders
practicing PA.

Allaz et al. (1998) Geneva 242 senior women CS BD index 62% of women wanted to lose weight 0.83
(Switzerland) even though 65% of them were normal
weight.
After controlling for BMI, younger
women had more BD than older
women.
Body weight preoccupation was the
2nd most important concern.

Anderson et al. (2002)
USA 608 adults CS How do you feel about BD among adults aged 60–69 was 40.7% 0.89
your body size right and 31.1% for those over 70.
now? BD was the strongest correlate of
weight loss attempts.
AA older women were more BS than
older white women.

Armstrong et al. (1999) Texas (USA) 51 seniors CS 36 items questionnaire Face characteristics were important for 0.37
the body image of older women.

Baker and Gringart Perth (Australia) 148 seniors CS 9 subscales of the Body image had self-esteem 0.63
(2009) MBSRQ consequences.
BD among women remained until the
age of 79.
Men used fewer behaviors than women
in response to their body image
representation.
Body image was no longer defined as
physical appearance but also as body
competence.

Bedford and Johnson Nova-Scotia 51 senior women CS SS There was BD among seniors. 0.69
(2006) (Canada) Diet and exercise were the most
frequently used behaviors in response
to body image.

Bennett and Stevens Nottingham (UK) 97 women CS EDI The proportion of women with weight 0.49
(1996) anxiety was similar to younger women.

Boisvert and Harell Alberta (Canada) 69 senior women CS 5 items: 3 from EDI Body shame was linked to BD. 0.66
(2009) and 2 from MHBCS Even if seniors had BD, they
experienced more BS than other age
categories.

Carver et al. (1998)
Miami (USA) 66 women LG 8 items assessing Women who are invested in their 0.81
concern about appearance before surgery reported
appearance and body more distress during the subsequent
integrity year, but less disruption of their sense
of femininity and sexual desirability.
Women who are invested in their sense
of body integrity before surgery
reported more disruption in social
activities and a stronger sense of ‘‘not
being themselves anymore’’.

Cash and Henry (1995) USA 159 women CS 3 subscales of the BD was a normative discontent. 0.80
MBSRQ
Cornwell and Schmidt New York State 77 adults CS BCSC Seniors with SLE had poorer body 0.80
(1990) (USA) image (vs. healthy seniors and those
with RA).
Davies et al. (2000) UK 99 seniors CS 1 subscale of the EDI No BD differences between congestive 0.60
heart failure patients and healthy
seniors.

DeFrank et al. (2007)
Iowa and New 399 adults CS 1 subscale of the Prostate cancer survivors had better 0.80
Jersey (USA) MBSRQ body image outcomes than other
cancer survivors.
A composite variable (cancer
recurrence, multiple cancers, and/or
metastatic cancer) was a strong
predictor of BD for female cancer
survivors.
BD was a common side effect of cancer
and its treatment.
510 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521

Table 3 (Continued )

Authors Setting Sample DS Body image Summary of findings Quality

measurement score

Donaghue and Australia 120 adults CS PPRS People made self-deprecating 0.66
Smith (2008) judgments about their body sizes and
self-enhancing judgments about their
attractiveness and sexiness.
People rated themselves as being more
overweight than others consider them
to be.

Ferraro et al. (2008) North Dakota (USA) 55 adults CS 1 subscale of the EDI, Women were more likely to choose 0.54
BSQ, and figure line underweight silhouettes as pretty and
drawing acceptable.
There was BD among seniors.

Figueiredo et al. (2004) 4 USA states and 563 senior women LG 4 items from CRES-SF BD was more prevalent among women 0.81
New York City who had mastectomy (vs. other
surgery).

Franzoi and Milwaukee (USA) 142 seniors CS BES Women have more BD than men. 0.71
Koehler (1998) Seniors are less satisfied with items
related to physiological functioning (vs.
young adults).
Older women are more satisfied with
items related to weight (vs. younger
women).

Grippo and Hill (2008) New York City 138 women CS 2 subscales of the BD is not age-dependent. 0.71
(USA) MBSRQ and 1 subscale BD is around 40%.
of the MHBCS

Gupta and Schork (1993)
Windsor (Canada) 178 adults CS 2 EDI subscales and 6 There is a correlation between aging- 0.57
aging-related items related concerns and drive for thinness
among adults.
Women score at aging-related items
was higher.
Aging-related concerns among adults
were associated with a desire to lose
weight.

Hallinan and Schuler (1993) USA 78 women CS SS BD is associated with the practice or not 0.57
of PA.
BD decreases after 80 years of age.

Hansell, Sherman, and New Jersey (USA) 592 seniors LG 4 items assessing body Body awareness is associated with 0.73
Mechanic (1991) awareness healthcare utilization among seniors.
Harrington et al. (2009) Phoenix (USA) 132 men CS BIS Prostate cancer has body image 0.77
consequences on sexuality and on
masculinity.

Heinberg, Haythornthwaite, Maryland (USA) 68 adults LG SS and MBSRQ Higher BD at 15 months follow-up 0.81
Rosofsky, McCarron, and means less weight loss.
Clarke (2000) BD plays a beneficial role in weight loss.

Hetherington (1994)
Scotland (UK) 1st study: 50 CS EAT, TFQ, BSQ, DEBQ, BD was not age dependent. 0.49
women and desired weight Over half women were former dieters.
2nd study: 20 change Despite normal weight status, women
women want to lose weight.
Dietary restraint was not age-
dependent.
When diet status is plotted across the
ages, the extreme are less likely to diet.

Hetherington and Scotland (UK) 50 women CS EAT, BSQ, and desired The majority of older women is (or has 0.77
Burnett (1994) weight change been) on a diet.
The social norm is BD.

Homan and Boyatzis Pennsylvania (USA) 127 adults CS 1 MBSRQ subscale and Men experienced more BS than women. 0.77
(2009) another from AAS There is a correlation between
religiosity and BS among seniors.

Janelli (1986a) New York State 25 senior women CS BCSC and DAP Older women felt that the total picture 0.66
(USA) of the body was more important than
any body part.
Janelli (1988) New York State 150 women CS BCSC and DAP There was a correlation between BS and 0.54
(USA) the absence of health problems.
Janelli (1992) New York State 39 men CS BCSC and DAP Seniors experienced more BS than other 0.66
(USA) category of age.
Janelli (1993) New York State 89 adults CS BCSC and DAP Body image representation among 0.57
(USA) older women was worse than among
older men
 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521 511

Table 3 (Continued )

Authors Setting Sample DS Body image Summary of findings Quality

measurement score

Kaminski and Hayslip Midwest (USA) 95 adults CS BES An age by gender interaction indicated 0.74
(2006) that men were more disparaging of
body function and appearance in their
last decades of life.

Knight et al. (2009) Melbourne 76 seniors CS PPRS BID was 39.5%. 0.83
(Australia) The ideal body for seniors was 4 points
of BMI under the actual body.

Kozar and Damhorst Iowa, Kansas and 161 women CS BIIQ and 1 MBRSQ With the aging process, there was less 0.74
(2008) Mississippi (USA) subscale social comparison.
Weight remains the most central
physical appearance determinant
among seniors.

Lewis and Cachelin USA 125 senior women CS SS There was BD among older women. 0.80
(2001) There were no age differences in BD.

Lieberman et al. (2003) Florida (USA) 11 women CS Photo rating Underweight silhouette was perceived 0.43
as sick and undesirable.
Excess weight silhouette was linked
with sickness, diabetes, and
hypertension.

Loomis and Thomas Windsor (Canada) 53 senior women CS BES Females in nursing home expressed less 0.86
(1991) BS than other women.
Being a female in nursing home was
associated with decreased satisfaction
in body function.

Mangweth-Matzek Innsbruck (Austria) 475 women CS 6 items: (1) How fat do A majority of women had BD. 0.84
et al. (2006) you feel, (2) I really like 45.2% of women reported that self-
my body, and 4 items esteem was weight and shape
from the DSED dependent.
63.8% of women reported that physical
appearance really mattered.

Miller et al. (1991) Los Angeles (USA) 183 senior men CS EAT There was an association between 0.83
psychological distress and BD.
58% of underweight seniors reported
that other people did not find
themselves underweight.

Mock (1993) USA 257 women CS BIS and the body image Body image outcomes were better in 0.74
visual analog scale conservative surgeries (vs.
mastectomy).
Body image outcomes among women
with cancer were worse (vs. healthy
women).

Montepare (1996) Massachusetts 265 women CS BES Women of all ages held unfavorable 0.71
(USA) attitudes toward their weight.
Subjective age rather than
chronological was a strong predictor of
BD.

Oberg and Tornstam Sweden 2002 adults CS 4 items: (1) My looks
(1999) are important to me,
(2) I worry about how
my looks will change
as I grow older, (3) I am
satisfied with my body
and (4) I feel that my
body reflects who I
really am
Physical appearance was more 0.66
important for women than for men.
Young and old women were more
worried about their bodies (vs. middle-
aged).
Older men were the most worried
about their bodies.
Men experienced BS whatever the age.
Women experienced more BS with
increasing age.

Oh and Damhorst (2009) Florida (USA) 94 married couples CS 4 items: (1) How Senior assessment of physical 0.71
physically attractive appearance was positively correlated
do you see yourself as, with the physical appearance
(2) How pleased are assessment of his/her spouse.
you with your physical
appearance, (3) How
physically attractive
you saw your spouse,
and (4) How pleased
are you with your
spouse’s physical
appearance
512 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521

Table 3 (Continued )

Authors Setting Sample DS Body image Summary of findings Quality

measurement score

Paxton and Phythian Melbourne 119 adults CS 7 MBSRQ subscales Self-esteem was linked with physical 0.74
(1999) (Australia) and 3 BAQ subscales appearance, fitness assessment and
orientation, and salience of weight and
shape.
Petronis et al. (2003) Miami (USA) 237 women LG Body apperception Concern about body integrity was 0.84
questionnaire related to psychological distress and to
social and psychosexual disruption.

Pliner et al. (1990) Toronto (Canada) 639 adults CS 45 items assessing
weight importance/
appearance, EAT, FSIS
Females were more concerned about 0.66
eating, weight, and physical
appearance (vs. males).
Females had lower appearance self-
esteem (vs. males).

Plutchik et al. (1973a) New York City 94 seniors CS Items assessing how The most valued body parts were eyes, 0.51
(USA) much money someone arms, and legs.
would like to receive The least valued body parts were
as compensation for fingers and toes.
body parts lost Males placed a greater dollar values on
their body parts.

Plutchik, Conte, and New York City 94 seniors CS BFQ Seniors described their head as good, 0.54
Weiner (1973b) (USA) happy, pleasurable, and active (vs.
psychiatric seniors).
Psychological well-being was more
important than age in body image
representation.

Plutchik, Conte, Weiner, New York City 81 seniors CS DAP and Koppitz Seniors had greater body image 0.69
and Teresi (1978) (USA) emotional indicators disturbances than other adults.

Plutchik, Weiner, New York City 94 seniors CS Body worries form Head, eyes, stomach, and back were 0.66
and Conte (1971) (USA) areas of discomfort.
Seniors tended to be worried by the
possibility of stomach upsets and
constipation.
Males were worried about heart pain
and breathing problem while females
were worried about headaches.

Reboussin et al. (2000) Stanford, Dallas, 854 adults CS 9 ACTQ items Body function was more important 0.84
Memphis (USA) than body appearance among seniors.
Perceived well-being was more related
to body competence (vs. body
appearance).
Older men expressed more BS than
women.

Ross et al. (1989) Saint Louis (USA) 30 seniors CS BCQ Body competence was age-dependent. 0.63
Seniors’ assessment of body
competence was better than evaluation
of body appearance

Schieman et al. (2007) District of 1164 seniors CS How would you BD: white women (63.8%), black 0.83
Columbia, describe your weight? women (70.8%), white men (62.7%),
Maryland (USA) black men (56.5%).
Black seniors were more likely to
underestimate their weight.
White women were more likely to
overestimate their weight.

Schuler et al. (2004) Florida (USA) 175 adults CS SS There was BD among seniors. 0.71
BD was not age dependent.
BS among men shifted from wanting
either to gain or lose weight toward
losing weight.

Schuler et al. (2008) USA 204 women CS SS Overweight AA women were more 0.80
likely to underestimate their weight
(vs. white women).
No ethnic differences in the ideal body
size.

Sharpe et al. (2001) South Carolina 101 women CS SS, and 1 item: (1) Do There was BID. 0.63
(USA) you think as yourself 89% of AA women that perceived
being overweight? themselves as overweight were trying
to lose weight.

Sidney and Shephard Toronto (Canada) 42 seniors LG Items assessing BID Seniors underestimated excess weight. 0.73
(1976) and BD Women had more BD than men.
 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521 513

Table 3 (Continued )

Authors Setting Sample DS Body image Summary of findings Quality

measurement score

Stevens et al. (1994) South Carolina 404 senior women CS SS Obese women had more BD. 0.80
(USA) Obese AA women experienced more BS
(vs. obese white women), were less
likely to diet or feel body shame, and
were more likely to report being
attractive.
White non-overweight women were
more likely to perceive themselves as
overweight.

Stokes and Daytona Beach 38 women CS BES and EAT Women’s happiness was related to 0.86
Frederick-Recascino (USA) sexual attractiveness.
(2003)

Tiggemann and Lynch Victoria (Australia) 73 women CS SS, BES, AAS, SOQ, and Body shame and BD remained stable 0.83
(2001) 1 MHBCS subscale with increasing age.
BD measures decreasing with age: self-
objectification, body monitoring,
appearance anxiety, dietary restraint,
and disordered eating.

Van Deusen, Harlowe, USA 39 adults CS Semantic scales Young women were more likely to be 0.63
and Baker (1989) satisfied with their hands.
Wilcox (1997) St. Louis (USA) 47 adults CS MBSRQ Among women exercisers, increasing 0.69
age is link with BS (vs. BD among non-
exercisers).
Note: AA = Afro-Americans; AAS = Anxiety about aging scale; ACTQ = Activity counselling trial questionnaire; BAQ = Body attitudes questionnaire; BCQ = Body consciousness
questionnaire; BCSC = Body-Cathexis Self-Cathexis questionnaire; BD = Body dissatisfaction; BES = Body esteem scale; BID = Body image distortion; BFQ = Body feeling
questionnaire; BIIQ = Body image ideals questionnaire; BIS = Body image scale; BMI = Body mass index; BS = Body satisfaction; BSQ = Body shape questionnaire; CRES-
SF = Cancer Rehabilitation Evaluation System-Short Form; CS = Cross-sectional; DAP = Draw-a-person technique; DEBQ = Dutch eating behavior questionnaire; DS = Design;
DSED = Diagnostic survey for eating disorders; EAT = Eating attitudes test; EDI = Eating disorder inventory; FSIS = Feelings of social inadequacy scale; LG = Longitudinal;
MBSRQ = Multidimensional body-self relations questionnaire; MHBCS = McKinley and Hyde’s objectified body consciousness scale; PA = Physical activity; PPRS = Personal
photo-rating scale; RA = rheumatoid arthritis; SLE = systemic lupus erythematosus; SOQ = Self-objectification questionnaire; SS = Stunkard silhouettes; TFQ = Three-factor
eating questionnaire; UK = United Kingdom; USA = United States of America.

1998; Homan & Boyatzis, 2009; Janelli, 1993; Oberg & Tornstam,
1999). Body weight was even found to be the second most important
concern among older women (after memory loss) according to a
representative population-based sample study with a quality score
of 0.83 (Allaz et al., 1998). This finding was used to explain why BD
was reported in normal weight older women (Allaz et al., 1998;
Hetherington & Burnett, 1994). Two studies proposed a cut-off age at
which BD began to decrease: Baker and Gringart (2009) with the
MBSRQ indicated age 79 years, whereas Hallinan and Schuler (1993),
using Stunkard silhouettes (SS), gave an age of 80 years. A third study
with an acceptable quality score of 0.71 and using 29 items from the
original 35-item Body Esteem Scale (BES) (Montepare, 1996) added
that subjective age (rather than chronological age) was the strongest
predictor of BD among seniors.
There are also some consistent findings about senior BD across
ethnicities. It was shown with an item derived from the U.S.
Women’s Determinants Study (Anderson et al., 2002; see Table 3)
and with SS (Schuler et al., 2004; Stevens, Kumanyika, & Keil, 1994)
that African-Americans seniors were more satisfied with their
bodies than white seniors. Only one study with a poor quality score
(0.43) reported the opposite (Abadie et al., 1996). This study, which
also used SS, examined the effect of age, physical activity (PA), and
ethnic identity on representation of body shape among 110 men
between the ages of 55 and 90. Two other studies were specifically
about senior body satisfaction (BS) (instead of dissatisfaction). One
using MBSRQ and anxiety about aging scale (AAS) questionnaires
(see Table 3), reported a positive correlation between religiousness
and BS among 127 Americans over age 61 (Homan & Boyatzis, 2009).
In contrast, the other, using the BSCS questionnaire (see Table 3),
associated BS with the absence of health problems among 150
American women between the ages of 60 and 98 (Janelli, 1988).
3.3.1.2. Perceptual dimension of body image. BID exists among
Western seniors (Knight, Illingworth, & Ricciardelli, 2009; Schie-
man et al., 2007; Sharpe et al., 2001; Sidney & Shephard, 1976).
Knight et al. (2009; quality score of 0.83) quantified the proportion
of BID within their convenience sample of 73 Australian seniors
age 65–97 at 39.5% using a personal photo rating scale (PPRS)
procedure. Another study with the same quality score (0.83) and
using data derived from face-to-face interviews with 1164 seniors,
reported that black seniors tended to underestimate their body
weight, whereas white elders were more prone to overestimate it
(Schieman et al., 2007). This result was supported by studies
showing that older overweight African-American women under-
estimated their weight compared to white women with the same
characteristics (Schuler et al., 2008). Finally, Donaghue and Smith
(2008) revealed that Western adults were more likely to rate
themselves as overweight than other adults would assess them,
based on their convenience sample of 120 Australians between
ages 18 and 88 using a PPRS procedure.
3.3.1.3. Cognitive dimension of body image. Findings about body
image importance are conflicting but also complementary. On the
one hand, some evidence suggests that body image importance
remains a concern at older ages. One study with a quality score
over 0.80 states that physical appearance mattered for 63.8% of the
470 women aged 60–70 years comprising their study group
(Mangweth-Matzek et al., 2006). Earlier studies in Sweden and
Canada also confirmed this preoccupation with body appearance
among adults aged between 20 and 85 (Oberg & Tornstam, 1999;
Pliner, Chaiken, & Flett, 1990). Others indicated which body parts
or aspects were of particular concern in terms of assessing
appearance: face (Armstrong, Saunders, & Roberts, 1999); eyes,
arms, and legs (Plutchik, Conte, & Weiner, 1973a); and weight
(Allaz et al., 1998; Kozar & Damhorst, 2008). On the other hand,
some studies also suggested that, even though body image in
relation to physical appearance remains important with age, this
aspect of body image decreased proportionally because body
competence, an area of body image specifically important to
seniors, significantly increased with age (Baker & Gringart, 2009;
514 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521
Reboussin et al., 2000). So, while seniors are aware of their physical
appearance, they are more sensitive to issues related to body
competence (Janelli, 1986a; Ross et al., 1989; Tiggemann & Lynch,
2001). Finally, a study of 95 Americans aged 60–91 reported an age
by gender interaction revealing that the male subjects were more
critical of both body image appearance and competence during
their last decades of life, while the women were not (Kaminski &
Hayslip, 2006). All extracted studies (with two exceptions)
focusing on this body image dimension consistently used
standardized and validated questionnaires. The exceptions (Oberg
& Tornstam, 1999; Plutchik et al., 1973a) used non-validated
questionnaires and had quality scores under 0.70.
3.3.1.4. Behavioral dimension of body image. Studies reported
adoption of behaviors in response to body image. Dieting and
exercising were the most frequently reported behaviors to reach
weight goals among 51 Canadian seniors aged 65–74 (Bedford &
Johnson, 2006; quality score = 0.69) and among 50 Scottish adults
between the ages of 60 and 78 (Hetherington & Burnett, 1994;
quality score = 0.77). One study using various validated ques-
tionnaires (body shape questionnaire (BSQ), Dutch eating behavior
questionnaire (DEBQ), eating attitudes test (EAT), three-factor
eating questionnaire (TFQ); see Table 3) however specified that
dietary restrictions and dieting behaviors were age-specific, with
younger (15–19 years) and older (65–85 years) women less likely
to report these behaviors than middle-aged women (Hetherington,
1994). This study has however a poor score of quality (0.49). Baker
and Gringart (2009) finally noted, with MBRSQ (see Table 3), that
older men were less likely than older women to adopt behaviors as
a response to body image representation within their sample of
148 Australian seniors aged 65–85 (quality score = 0.69).
Studies also report cross-cultural differences. Afro-American
(AA) elders who practiced PAs were more dissatisfied with their
bodies than their counterparts who did not engage in PAs or than
white elders who did (Abadie et al., 1996). These findings are
congruent with a study reporting that BD among 78 American
women aged 60–88 was more closely related to practicing PAs than
age (Hallinan & Schuler, 1993). These results were however from
studies with a quality score under 0.60. A final study with a quality
score of 0.69 however suggested an age by exercise interaction
among 47 American women aged 60–80 (Wilcox, 1997). This study
determined that increasing age among women exercisers was linked
with BS, whereas it was related to BD among non-exercisers. All
these results were obtained with both standardized and validated
questionnaires and with SS based measures.
3.3.1.5. Other body image aspects. Other findings were also
reported across extracted studies.
3.3.1.5.1. Body image and mental health. Associations were found
between seniors’ body image and mental health. Self-esteem was
indeed linked with body image preoccupation among 148
Australian seniors (Baker & Gringart, 2009; quality score = 0.63)
as well as with physical appearance, fitness evaluation and
orientation, and salience of weight and shape among 119 same
country adults aged 60–79 (Paxton and Phythian, 1999; quality
score = 0.74; assessed with body attitudes questionnaire (BAQ)
and MBRSQ; see Table 3). BD among seniors (assessed with EAT,
see Table 3) was found to be related to psychological distress and
depression among 183 American seniors aged 70 or over (Miller,
Morley, Rubenstein, & Pietruszka, 1991), whereas concern about
body integrity was related to psychological distress and with social
and psychosexual disruption among 237 American women
between the ages of 27 and 87 (Petronis, Carver, Antoni, & Weiss,
2003). Quality of both preceding studies was over 0.80. Lastly, a
study indicated that associations between body image and mental
health were less pronounced among males than females (Pliner
et al., 1990). This study has however a quality score under 0.70.
3.3.1.5.2. Body image and physical health. BD was reported as a side
effect of cancer and its treatment (DeFrank, Mehta, Stein, & Baker,
2007; quality score = 0.80). A study (with MBRSQ; see Table 3) of
237 US women between 29 and 79 years with breast cancer
revealed that conservative surgery resulted in more positive body
image outcomes compared to other types of surgery (i.e.
mastectomy with delayed reconstruction or mastectomy with
immediate reconstruction; Mock, 1993). These findings were
supported by two studies (quality score over 0.80) made in six
different American states reporting that BD (assessed with Cancer
Rehabilitation Evaluation System-Short Form (CRES-SF) and eight
items assessing concern about body appearance and integrity; see
Table 3) was more prevalent among women with history of
mastectomy (Carver et al., 1998; Figueiredo, Cullen, Hwang,
Rowland, & Mandelblatt, 2004). A composite measure including
history of cancer recurrence, multiple cancers, and/or metastatic
cancer was also found to be a strong predictor of BD among 234
female cancer survivors with a mean age of 59.8 (DeFrank et al.,
2007). Among men, prostate cancer was found to have body image
consequences on sexuality and masculinity (assessed with body
image scale (BIS); see Table 3) among 132 American aged between
60 and 91 (Harrington, Jones, & Badger, 2009). Prostate cancer
survivors, however, were more likely to express positive body
image than men surviving other cancers within a sample of 165
other American men with a mean age of 64.7 (DeFrank et al., 2007).
Body image was also found to be related to other aspects of
physical health. One study made with 77 American between the
ages of 24 and 79 (mean age of 50.5; Body-Cathexis Self-Cathexis
questionnaire (BCSC) questionnaire; see Table 3) showed that
negative body images were associated with chronic conditions
such as arthritis (Cornwell & Schmidt, 1990; quality score = 0.80).
3.3.1.5.3. The ideal body. The ideal body weight among seniors
(men and women) is about four BMI points less than their current
body size (Knight et al., 2009; quality score = 0.83). This is similar
to the ideal body weight of younger women (Hetherington, 1994;
Hetherington & Burnett, 1994). Consequently, older women still
want to lose weight (Allaz et al., 1998; Anderson et al., 2002; both
quality scores over 0.80) even though their weight falls within the
‘‘healthy’’ range category (Allaz et al., 1998; Hetherington, 1994;
Hetherington & Burnett, 1994). Using eating disorder inventory
(EDI), BSQ, figure line drawing, and individual pictures (see Table
3), it was found that older women were more likely to qualify
underweight silhouettes as pretty and acceptable (vs. males who
defined them unhealthy, sick, and undesirable; Ferraro et al., 2008;
Lieberman, Probart, & Schoenberg, 2003; respective quality scores
of 0.54 and 0.43). No ethnic differences in ideal body weight
(assessed with SS) were found between 115 AAs and 89 Caucasians
living in the US (Schuler et al., 2008).
3.3.2. Qualitative studies
The study extraction procedure identified 14 qualitative studies
(16.9% of all papers; Table 4).
3.3.2.1. Attitudinal dimension of body image. Qualitative studies
also discussed seniors’ BD (Hurd Clarke, 2002a, 2002b; Hurd Clarke
& Griffin, 2008b). BD was perceived as normal in Western older
women (Hurd Clarke, 2002b; Tunaley et al., 1999). One study
(quality score ++) reported that 17 out of 22 senior women were
body dissatisfied (Hurd Clarke, 2002a) and another with the same
quality score indicated that older women’s definitions of their
bodies was mainly negative (Hurd Clarke, 2002b). The impact of
mothers’ attitudes on BD development among their children was
 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521 515

Table 4
Qualitative studies extracted by the systematic procedure.

Authors Setting Sample Method Summary of findings Quality

score

Deeny and Kirk-Smith (2000) Northern Ireland 9 seniors II and TI Two dimensions concerning aging body: (1) +
physical appearance and (2) body
competence.

Dumas et al. (2005) Montréal (Canada) 51 senior women II Three differences between SC: (1) money for +
the body, (2) body preservation concern, and
(3) the body as social distinction.
Two similarities between SC: (1) a
reassessment of social norms and (2) the
adherence to new social norms.

Fooken (1994) Germany 60 women II BS was linked with good perception of his +
sexuality and with psychological well-being.
Hurd Clarke (2001) Canada 22 women II A tension between inside self and outside self. ++

Hurd Clarke (2002a) Canada 22 women II BD (n = 17/22). ++

A tension between health and appearance.

Hurd Clarke (2002b) Canada 22 women II The social norm was BD. ++
Social comparison among older women was
made with women of their age and beauty
standards were from their youth.
Older women said that beauty was a life
achievement and the theme of inner beauty
emerged (vs. physical appearance).

Hurd Clarke and Griffin (2007a) Canada 44 women II A tension between natural and unnatural ++
body.
Women who rejected cosmetic procedures
saw natural aging positively. Others
considered it risky, unattractive, and
undesirable.

Hurd Clarke and Griffin (2007b)
Canada 14 women II Negative body image comments made by ++
mothers toward their children encouraged the
body as an object development.
Body image = the product of the negotiation
with significant others met during life.

Hurd Clarke et al. (2007)
Canada 44 women II The use of cosmetic procedures to increase ++
physical attractiveness and self-esteem.
Treatments that involved skin alteration are
viewed less risky than the injection of foreign
substances into the body.

Hurd Clarke and Griffin (2008a) Canada 31 women II Trauma had body image consequences: (1) ++
body image disparagement, (2) reluctance to
appear attractive, and (3) body hiding.

Hurd Clarke and Griffin (2008b) Canada 20 senior women II There was BD among seniors. ++
Chronic conditions had body image
consequences for seniors.

Paulson and Willig (2008)
UK 10 women II 4 discourses about the aging body: (1) +
biological discourse, (2) social discourse, (3)
beauty discourse, and (4) feminist discourse.
Behaviors used in response to aging: make-up,
hair, and clothing.
A tension between body and mind.

Tunaley et al. (1999) UK 12 women II Seniors had BD and weight-loss +

preoccupations.
Being thin meant being pretty and being able
to wear the clothes they wanted.
There was a paradoxical discourse regarding
the aging body.

Whitehead and Lavelle (2009) UK 29 women II Body image was linked with PA among older ++
women with a history of breast cancer.
Note: BD = Body dissatisfaction; BS = Body satisfaction; II = Individual interview; PA = Physical activity; SC = Social classes; TI = Telephone interview; UK = United Kingdom;
USA = United States of America.

also discussed among 14 Canadian women aged between 60 and
70 (Hurd Clarke & Griffin, 2007b). These women reported that
negative body image comments from their mothers when they
were young encouraged them to define their bodies as an object.
They consequently defined their body images as the product of the
interaction between them and significant persons encountered
during their lives (Hurd Clarke & Griffin, 2007b). Finally, BS was
found to be associated with a positive perception of body sexuality
and with psychological well-being among 60 German adults
between the ages of 58 and 85 (Fooken, 1994; quality score +). In all
of the above studies, individual interviews (IIs) were carried out
from a convenience sample (see Table 4). No examination of the
516 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521
effect of increasing age on senior BD was found among the
extracted studies.
3.3.2.2. Perceptual dimension of body image. No information was
found concerning this body image dimension among the extracted
qualitative studies.
3.3.2.3. Cognitive dimension of body image. Results of two qualita-
tive studies described the cognitive dimension of body image as a
tension between health and appearance (Deeny & Kirk-Smith,
2000; Hurd Clarke, 2002a). Both studies carried out IIs from a
convenience sample, but Deeny and Kirk-Smith (2000) also made
telephone interviews (TIs). These studies revealed that the
importance attributed to health by Western seniors was
legitimate, but the importance attributed to physical appearance
was considered vain. Along with this tension, 22 Canadian
women between the ages of 61 and 92 were more likely to report
the health benefits of weight loss, even though their true
motivator for dieting was perceived appearance dividends (Hurd
Clarke, 2002a; quality score ++). The other qualitative study
(conducted in Ireland; quality score +) raised the same polarity
and shed light on two different areas of seniors’ body image
importance: body appearance and competence (Deeny & Kirk-
Smith, 2000).
3.3.2.4. Behavioral dimension of body image. Three qualitative
studies with a quality score ++ described another tension. This
tension, discussed as the natural body vs. the unnatural body,
refers to the behavioral dimension of body image. Natural body
was defined by older women as a body unaltered by the culture
(i.e. a body unmodified by technological interventions such as
anti-wrinkle creams, hair dyes, make-up, and cosmetic surgery),
whereas the unnatural body was rather described as using these
behaviors to produce a young and natural look (Hurd Clarke &
Griffin, 2007a). Within a convenience sample of 44 Canadian
women aged 50–70 years old, it was found that 21 of them had
already used non-surgical cosmetic procedures (e.g. anti-
wrinkle creams, hair dyes, make-up, cosmetics) in response to
their body image (Hurd Clarke, Repta, & Griffin, 2007). For
women who were fans of cosmetics, natural aging was
considered risky, unattractive, and undesirable, whereas it
was positively viewed by women who rejected the use of
cosmetics (Hurd Clarke & Griffin, 2007a). A last study highlights
the use of dieting behaviors in response to BD among Canadian
older women (Hurd Clarke, 2002b). Again, the effect of increased
age on senior weight-related behaviors was not examined and
all studies carried out IIs.
3.3.2.5. Other body image aspects. Other qualitative findings
deserve mention.
3.3.2.5.1. Older women’s aging body. Four discourses about
women’s aging body arose from IIs carried out with 10 English
women aged 58–83: (1) a biological discourse emphasizing body
vulnerability, (2) a social discourse demonstrating how specific
contexts determine different ways of talking about the body, (3) a
discourse on beauty recognizing older women’s loss of control over
their appearance, and (4) a feminist discourse that views women’s
bodies as vulnerable in a patriarchal society (Paulson & Willig,
2008; quality score +). Another study, which carried out semi-
structured interviews with a convenience sample, shed light on
social class differences regarding the aging body (Dumas, Laberge,
& Straka, 2005; quality score +). In this study of 51 French-speaking
women aged 65–75, three differences (money to put invest in the
body, worry over preserving the body, and the body as a social
distinction) and two similarities (reevaluation of social norms and
adherence to new social norms) were found relating to aging
across social classes (SC).
3.3.2.5.2. The inside vs. the outside. Qualitative studies emphasized
another tension regarding women’s aging bodies: the inside self vs.
the outside self. The inside self was described as an invariant that
rarely changes, whereas the outside self was considered age-
dependent (Hurd Clarke, 2001; quality score ++). In this interview
study of 22 Canadian women between the ages of 61 and 92 using a
convenience sample, women described their bodies as a jail
holding their true identities prisoner. This tension between the
inside and the outside of the body was also raised by Paulson and
Willig (2008; quality score +) as the body vs. the mind. Again, only
IIs were carried out.
3.3.2.5.3. The ideal body. There is a paradoxical discourse concerning
the ideal body among older women. On the one hand, it was reported
that they rejected the social pressures concerning the ideal body
(Tunaley et al., 1999; quality score +). It was also found that older
women based their judgments about their bodies through
comparison with the bodies of women of their own age (Hurd
Clarke, 2002b; quality score ++). This study further revealed that the
beauty standards for older women were actresses and singers from
their youth, not women famous today (Hurd Clarke, 2002b). On the
other hand, the majority of older women perceived young bodies as
beautiful (Hurd Clarke, 2002b). Another study emphasized this
finding and reported that, for older women, being thin meant being
pretty and being able to wear clothes they wanted (Tunaley et al.,
1999). Along with these results, the theme of inner beauty emerged
as more important than physical appearance, and senior women
described beauty as a life achievement outcome rather than a cross-
sectional (CS) picture (Hurd Clarke, 2002b).
3.3.2.5.4. The impact of trauma. Two qualitative studies with a
quality score ++, which carried out IIs, indicated that past
traumatic experiences (e.g. sexual, physical, emotional abuse,
difficult childhood, poverty, loss of a loved one, illness, and divorce)
impacted on women’s body images. The first reported body image
disparagement, reluctance to appear attractive, and hiding the
body as a result of trauma experienced by 20 Canadian women
between age 68 and 88 (Hurd Clarke & Griffin, 2008a), whereas the
other developed the positive impact on body image from engaging
in PAs among breast cancer survivors (Whitehead & Lavelle, 2009).
3.3.3. Reviews or comments
Lastly, the study extraction procedure identified six reviews
and two comments on seniors’ body image (9.6% of extracted
articles; Table 5).
3.3.3.1. About body image. The reviews support that BD and BID
still exist at older ages whereas elders’ body image importance
related to physical appearance is lower as compared to younger
populations (Allaz et al., 1999; Peat, Peyerl, & Muehlenkamp, 2008;
Price, 2010; Tiggemann, 2004). Four reviews and one comment
also stated that BD was more prevalent among older women (vs.
older men; Allaz et al., 1999; Chrisler & Ghiz, 1993; Fey-Yensan,
McCormick, & English, 2002; Janelli, 1986b; Peat et al., 2008).
Furthermore, although senior women challenged the ideal of
thinness, they remained dissatisfied with their bodies and a
majority of them were striving to lose weight despite the harmful
consequences of dieting among seniors (Fey-Yensan et al., 2002).
Another review highlighted findings about the behavioral dimen-
sion of body image. It showed that seniors adopted behaviors in
response to their body image (e.g. dieting, make-up, hair grooming,
and clothing; Tiggemann, 2004). The confirmation that older
women judged their bodies in comparison with the bodies of
 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521 517

Table 5
Review or comment extracted by the systematic procedure.

Authors Type of paper Summary of findings Quality score

Allaz et al. (1999) Review BID was not age dependent. 12

There was BD.
A majority of normal weight older women experienced BD.

Chrisler and Ghiz (1993) Comment There were 3 body image triggers: (1) puberty, (2) pregnancy, and (3) N/A
menopause.
Older women were more body image sensitive than older men.
PA increased self-esteem and body image representation among older women.

Fey-Yensan et al. (2002)
Review Older men experienced more BS than older women. 6
While older women rejected thinness ideal and beauty, they were still
experiencing BD and a majority was trying to lose weight.
The consequences of dieting were more important for older women (vs.
younger ones).

Janelli (1986b) Review Older women were more concerned by body image than older men. 11

Peat et al. (2008) Review The majority of studies were solely on BD. 14
There was a lack of information about older men’s body images.
There were almost exclusively CS studies.
BD among women was stable across lifespan, while body image importance
decreased.
BD was much greater in women than men.

Price (2010) Review There was BD. 5

Older women compared their bodies to women their age.

Sontag (1972) Comment There was a double standard of aging among older women. N/A
Modern societies allow two standards of male beauty (the boy and the man) but
only one for females (the girl).
The double standard of aging means that women have to cope with the stigma
of unattractiveness simply through growing older.

Tiggemann (2004) Review BD remained stable across lifespan, but body image importance decreased. 12
Behaviors used in response to BD: make-up, hair grooming, and clothing.
Note: BD = Body dissatisfaction; BID = Body image distortion; BS = Body satisfaction; PA = Physical activity.

women of the same age was provided by Price (2010). Lastly, one
review indicated that the literature about seniors’ body image was
mainly CS and almost exclusively based on BD among women (Peat
et al., 2008). All these reviews had poor quality score with the
higher score of 14 out of 35.
3.3.3.2. Some clues about the evolution of body image across the
lifespan. Two comments reported information about the evolution
of women’s body image across the lifespan. The first discussed
three main triggers of negative body image in women: puberty,
pregnancy, and menopause (Chrisler & Ghiz, 1993). This comment
also highlights the importance of practicing PAs to be able to cope
with these phases. Another seminal comment set up what it called
the double standard of aging among women. This widely known
and cited comment suggests that modern urbanized societies
allow two standards of male beauty (the boy and the man), but
only one for females (the girl; Sontag, 1972). Consequently, the
aging process in Western society means that eventually all women
will have to cope with the stigma of unattractiveness simply by
growing older (Sontag, 1972). No quality assessment was made for
comments.
4. Discussion
4.1. Summary of findings
The results of this systematic review of the literature indicate
that the body image experience among Western seniors has both
specificities as well as similarities with the body image
experience of younger populations. These results also highlight
the need to address some methodological aspects of older adults’
body image literature in order to move forward with this field of
research.
4.1.1. About the four main body image dimensions
A specificity of Western seniors’ body image experience was
highlighted in both quantitative and qualitative literature. It was
observed that, compared to younger samples, Western seniors
place less importance on the physical aspects of body image and
more on body competence (Baker & Gringart, 2009; Deeny & Kirk-
Smith, 2000; Reboussin et al., 2000; Ross et al., 1989; Tiggemann,
2004; Tiggemann & Lynch, 2001). It would be interesting to look if
this specificity is good or bad news, because it could represent both
a decrease in the negative consequences associated with a negative
assessment of one’s own physical appearance and the addition of
an extra source of dissatisfaction to already body unease. This
specificity can also be cohort specific. We will have to reproduce
this finding with the next generation of seniors, whose peer models
will include people such as Cher and Madonna, and other
individuals for whom physical appearance is very important in
their work.
It was also raised across extracted studies that Western seniors
were dissatisfied with their bodies and misperceived their current
body sizes (Allaz et al., 1998; Anderson et al., 2002; Bedford &
Johnson, 2006; Cash & Henry, 1995; Ferraro et al., 2008; Franzoi &
Koehler, 1998; Grippo & Hill, 2008; Hurd Clarke, 2002a, 2002b;
Hurd Clarke & Griffin, 2008b; Knight et al., 2009; Lewis & Cachelin,
2001; Schuler et al., 2004; Sharpe et al., 2001; Sidney & Shephard,
1976; Tunaley et al., 1999). This consensus about senior body
image experience is similar to body image experience of younger
populations. BD and BID indeed characterized the majority of
Western children, adolescents, and young and middle-aged adults
as well (Cash & Henry, 1995; Furnham & Calman, 1998; Grogan,
2008; Hildebrandt, Langenbucher, & Schlundt, 2004; Kostanski &
Gullone, 1999; Kronenfeld, Reba-Harrelson, Von Holle, Reyes, &
Bulik, 2010; McCabe & Ricciardelli, 2005; Neumark-Sztainer et al.,
2006; O’Dea & Abraham, 2000; Paquette & Raines, 2004;
518 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521
Ricciardelli & McCabe, 2001; Ricciardelli et al., 2003; Tiggemann,
2005). Another similarity between the body image experiences of
Western seniors and non-seniors raised in this review was the use
of weight-related behaviors in response to body image represen-
tation (Baker & Gringart, 2009; Bedford & Johnson, 2006;
Hetherington, 1994; Hetherington & Burnett, 1994; Hurd Clarke,
2002b).
4.1.2. About the other aspects of body image
There are other similarities between the body image experi-
ences of seniors and non-seniors. As it is the case among younger
individuals (Jansen et al., 2008; Muennig et al., 2008), body image
among seniors was found to have physical and mental health
consequences (Baker & Gringart, 2009; Carver et al., 1998; Miller
et al., 1991; Paxton and Phythian, 1999; Pliner et al., 1990). In
contrast, however, the specific health-related problems associat-
ed with negative body image among seniors were chronic
conditions such as arthritis and cancer. Even though associations
had already been observed between teenager BD and chronic
conditions (Neumark-Sztainer, Story, Resnick, Garwick, & Blum,
1995; Steel, Young, Lloyd, & Macintyre, 1989; Striegel-Moore,
Nicholson, & Tamborlane, 1992), the senior-related literature was
more developed as a result of higher prevalence of such
conditions. Quantitative studies highlighted another similarity
between the body image of seniors and non-seniors. The ideal
body weight among Western seniors was found to be very similar
to that of other Western age categories (Hetherington, 1994;
Hetherington & Burnett, 1994). This could explain why a majority
of older women, even normal weight older women, still want to
lose weight (Allaz et al., 1998; Anderson et al., 2002; Bedford &
Johnson, 2006; Hetherington, 1994; Hetherington & Burnett,
1994).
Finally, various tensions regarding the aging body described in
qualitative studies were specific to the concept of body image held
by Western senior women. These tensions oppose inside self vs.
outside self (Hurd Clarke, 2001; Paulson & Willig, 2008), health vs.
appearance (Hurd Clarke, 2002a), and natural vs. unnatural body
(Hurd Clarke & Griffin, 2007a; Hurd Clarke et al., 2007). These
tensions reported by older Western women may contribute to
what is called the double standard of aging among them in
comparison to males (Sontag, 1972).
4.1.3. About the methodological aspects
This systematic review of the literature finally highlights the
need to address some methodological aspects of research
examining body image among Western seniors. First, there are
different conceptualizations (and assessments) of the body image
construct and its dimensions in on older adults literature. As an
example, BD was sometimes correctly defined as the discrepancy
between perceived and ideal body, but it was also sometimes
wrongly assessed as the distance between current and ideal body,
even though current body size is not necessarily the same as
perceived body size. Another example is the frequent use of the
expression body image perception to designate both BD and body
image representation, while these are not related to the perceptual
component of body image. Along with this erroneous conceptuali-
zation of body image and its dimensions, there is no consensus on
which measures should be used to investigate specific dimensions
of the body image construct. This lack of consensus also expresses
itself through the large number of different measures used to
assess a single dimension of body image (e.g. questionnaires and
silhouettes to assess BD).
Another methodological concern that we want to highlight is
the generalized use of body image measurements validated on
children, adolescents, and young adults to assess body image
among seniors. Because the body image experience among seniors
has both similarities and specificities with the experience of body
image among younger populations, we think that existing
measurements of body image have to be validated on senior
samples. Furthermore, new body image measures specific to
seniors should be developed to better capture body image
specificities in this population.
Third, we want to bring out, as Peat et al. (2008) have already
done, that senior body image literature is almost completely CS.
Indeed, CS studies represent 55 out of the 61 quantitative studies
extracted for this review. We think that longitudinal (LG) studies
are needed to follow the evolution of body image across the
lifespan as well as to test cohort-specific hypotheses.
Finally, we also want to point out that all 14 extracted
qualitative studies carried out IIs within a convenience sample.
Along with this aspect of the field, we encourage the use of focus
group procedure in other qualitative studies to better understand
how negative body images get ‘‘under the skin’’ to produce
unhealthy outcomes.
4.1.4. Strengths and limitations
This literature review has major strengths. To our knowledge,
this is the first review on older adults’ body image that used a
systematic study extraction procedure. This review also took into
consideration some limits raised by Peat et al. (2008) review. We
indeed intentionally organized this review to bring out the most
evidence on all body image dimensions among both sexes (not
only the attitudinal dimension of women’s body image). Finally,
this review synthesized, and assessed the quality of, different
research approaches (quantitative and qualitative) and categories
of publication (original research and reviews).
This review has, nevertheless, some limitations. First, only
English and French peer-reviewed articles were included. Other
valuable papers are likely to have been published in other
languages or in other types of journals. Second, because individual
body image is strongly influenced by social values (Roy, Lévy, &
Alvarez, 2010), we have decided to solely include Western seniors
in this review. Inclusion of seniors from other societies should be
the subject of other reviews and or publication. Third, comments
were not submitted to any quality assessment. We are indeed not
aware of any checklist to assess the quality of a comment. Fourth,
double-checking of the study extraction procedure was not
carried out. Finally, and because one specific author produce
57.1% (8 out of 14 articles) of the qualitative field of research about
Western seniors’ body image, caution should be used with respect
to interpretation of qualitative findings. It could indeed be
possible that this prominent presence of one author leads to
limitation as regards generalizability of our results. This is
particularly true regarding the specific contributions of that
author within this field of research. There is indeed a possible
‘‘Laura Hurd Clarke effect’’ within the qualitative literature about
Western seniors’ body image. Laura Hurd Clarke additions to the
literature were identification of a tension between natural and
unnatural bodies (Hurd Clarke & Griffin, 2007a), influence of
mothers on body image development (Hurd Clarke & Griffin,
2007b) as well as impact of traumas and chronic conditions on
body image outcomes (Hurd Clarke & Griffin, 2008a, 2008b).
However, this possible bias is likely to be low in front of results
from quantitative studies in the field of children and adolescent
literature showing the impact of mothers’ BD on BD of their
children (Lowes & Tiggemann, 2003; van den Berg, Keery,
Eisenberg, & Neumark-Sztainer, 2010) as well as existing links
between chronic conditions and negative body image outcomes
(Cornwell & Schmidt, 1990; Neumark-Sztainer et al., 1995; Steel
et al., 1989; Striegel-Moore et al., 1992). The specific tension
which opposes natural and unnatural bodies was however to our
knowledge not replicated by any studies.
 M. Roy, H. Payette / Archives of Gerontology and Geriatrics 55 (2012) 505–521
5. Conclusions
We conclude that the body image experience of Western
seniors has both specificities and similarities with the body image
experience of younger populations. With respect to specificities,
seniors’ body image importance related to physical appearance
decreases whereas the one attributed to body competence
increases. Western older women body image was also defined
by various tensions. These tensions were between health and
appearance, inside self and outside self, and natural and unnatural
bodies. Older women were then more likely to report a double
standard of aging compared to men. Similarities were also
observed between the body image experience of seniors and
non-seniors. Western seniors were still dissatisfied with their
bodies and still misperceived their current body sizes. Like their
younger fellow citizens, they reported using behaviors in response
to their body image as well as associations between this
representation and physical and mental health. Furthermore,
Western seniors shared a similar body ideal with western younger
age categories.
We also conclude that there are methodological aspects of older
adults’ body image literature that need to be address to move
forward with this field of research. These aspects are related to (1)
the standardization of body image conceptualization and assess-
ment, (2) the development and validation of body image
measurements for seniors, (3) the development of older adults’
cohort examining the body image construct, and (4) the use of
focus group procedures to better understand seniors’ body image
experience. We think that research into these methodological
aspects will yield valuable knowledge that can be translated into
public health interventions aimed to promote positive body image
and positive aging.
Conflict of interest statement
Both authors have no conflict of interest to declare.
Acknowledgments
This review was funded by the first author (MR) Fonds de la
recherche en santé du Québec Postdoctoral Fellowship under the
supervision of the second author (LP) who holds a Merck Frosst
Chair on Pharmacogeriatrics. These sponsors had neither involve-
ment in any phase of the study nor in the decision to submit this
paper for publication.
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