BMC Public Health 2009, 9:1 http://www.biomedcentral.com/1471-2458/9/1 60,0 50,0 40,0 %30,0 20,0 10,0 0,0 underestimated 3 underestimated 2 underestimated 1 clacsosirfriecacttion overestimated 1 overestimated 2 overestimated 3 Figure 2 Body image disturbance in participants of the SUN study according to sex. Underestimated 3 = the person who underestimated 3 silhouettes below his/her body mass index; Underestimated 2 = the person who underestimated 2 silhouettes below his/her body mass index; Underestimated 1 = the person who underestimated 1 silhouettes below his/her body mass index; Correct classification = the person who assess correctly his/her body image; Overestimated 1 = the person who overestimated 1 silhouettes above his/her body mass index; Overestimated 2 = the person who overestimated 2 silhouettes above his/ her body mass index; Overestimated 3 = the person who overestimated 3 silhouettes above his/her body mass index. explained because we considered the difference between BMI and the silhouettes proposed by Stunkard et al. (1983) [32] as a proxy of body image disturbance, which does not accurately evaluate this outcome. Other studies applied questionnaires to measure the degree of con- tentment with physical appearance, such as the Body Satisfaction Scale [33], the Body Image Avoidance Questionnaire [34], the Selves Questionnaire [35] and the Multidimensional Body Self-Questionnaire [36]. Nevertheless, a major concern in the assessment of body image has been the apparent failure to recognize the complexity of the body image construct. There have been important advancements in the development of standardized body image measurement tools in recent years. However, it would be premature to assume that any of these methods assesses body image in its entirety [37]. It has been proposed that the body image disturbance is not due to any perceptual deficit, but is based on cognitive-evaluative dissatisfaction [38]. Furthermore, some authors have used body image disturbance and body image dissatisfaction as synonyms and these terms do not have the same meaning [29]. Other limitations of this study were: (1) Depression was defined using the question, "Have you ever been diagnosed with depression by a health professional?" However, this question has been validated with this cohort by our group in previous research. In that study a self-reported physician-made diagnosis of depression was validated in our cohort using the Structured Clinical Interview for DSM-IV (SCID-I) applied by blinded experienced psychiatrists as the Gold Standard (sub- mitted article). Other studies applied questionnaires for diagnosing depressive symptoms, particularly the Beck Depression Inventory [39]; (2) Unfortunately, we did not asses variables such as family history of depression or adverse life events which might impact on the incidence of depression [40-42]; (3) The differences between the participants and non-participants of this study could also influence our results. Despite not being the initial objective of our study, it is important to highlight some secondary results that we observed. Men who underestimated their body size were those with higher rates of overweight and obesity. Among women, those who overestimated their body size had higher rates of underweight. These findings are consistent with the theory already presented in the introduction of this article which asserts that the aesthetic standards typical of Western cultures can influence body image disturbance [8, 9]. Women want to lose weight, despite leanness, a fact which may contribute to the occurrence of anorexia and bulimia [43, 44]. Men wish to gain muscle mass, despite having anthropometric standards within the normal range, which is contributing to the occurrence of muscle dysmorphia [45]. Conclusion We conclude that no association was found between body image disturbance and the incidence of depression in participants of the SUN study. Other longitudinal studies among adults should be conducted to confirm our results. Competing interests The authors declare that they have no competing interests. Authors' contributions AMP carried out the statistical analysis, drafted the manuscript and gave final approval of the version to be published. ASV was involved in drafting the manuscript, revised it critically for important intellectual content and gave final approval of the version to be published. Page 7 of 9 (page number not for citation purposes)