BACKGROUND: Body image concerns are important as they negatively affect health and nutrition status. With rising obesity rates among Black South African women, understanding obesity from a socio‑behavioural perspective is imperative. Despite extensive work on obesity determinants, little is known about the causal pathways underlying body image dissatisfaction (BID) and body size distortion (BSD) in this population. This study provides the first causal‑pathway analysis of BID and BSD among Black South African women using nationally representative survey data. METHODS: We analysed nationally representative data from SANHANES‑1 (2012) for Black South African women aged ≥ 18 years. A complete case analysis approach was used (n = 1,514). BID and BSD were categorised (none/low/moderate/high). Determinants were examined using multinomial logistic regression (unadjusted, age‑adjusted, fully adjusted). Multiple mediation tested whether body mass index (BMI) and education mediated socio‑demographic factors (age, marital status, income, geographic location) on BID and BSD. Moderation tested interactions among socio‑demographics. RESULTS: Obesity, low education (Grades 1-5), being married or divorced/widowed and urban informal residence were strong predictors of high BID. BSD was primarily driven by BMI, with both obesity and underweight status showing the highest distortion. Income and marital status partially predicted BSD. BMI emerged as a consistent mediator linking age, marital status, and income to both BID and BSD. Education did not mediate any of these relationships. A significant location × income interaction indicated that BSD increased at higher income levels depending on geographic location. CONCLUSIONS: Findings distinguish BID (socio‑culturally patterned) from BSD (predominantly BMI‑anchored). They identify BMI as the central mediator linking socio‑demographic factors to body image outcomes and highlight contextual amplification of BSD among higher‑income women by location. These causal pathways provide important insights for targeted and culturally relevant interventions aimed at addressing body image concerns and informing obesity‑prevention strategies among South African women.
Chiromba et al. (Wed,) studied this question.