In the largest self-reported survey study of its kind, the SHIELD data revealed that compared with men without diabetes mellitus, men with T2DM generally did not significantly differ in their selection of a body image on the FRS, based upon similar mean BMI, except at the extremes in body image. In contrast, women with T2DM generally had a higher BMI for each body figure that they felt best reflected their appearance compared with women without diabetes mellitus.
Limitations of this study include potential selection bias since the SHIELD survey was a mailed survey but the response rate was very high for a mailed survey (75%). Also, household panel surveys, like SHIELD, tend to under-represent the very wealthy and very poor segments of the population and do not include military or institutionalized individuals [21, 22]. Another concern is that patients may not accurately self-report measurements such as height and weight. However, other studies have indicated that such self-reported measurements are accurate [23, 24]. Also, the high correlation between BMI and body image might not mean that the respondents' perception is close to their actual BMI. Respondents could consistently underestimate or overestimate BMI and still have a high correlation with body image. Regarding the self-reporting of metabolic disease, prior analyses have demonstrated generally good correlation between the prevalence of T2DM as assessed by SHIELD when compared with the prevalence of T2DM determined by objectively measured surveys such as US NHANES [4, 25]. This is likely, in large part, because the diagnosis of diabetes mellitus is dependent upon a single parameter (glucose) that is generally known and frequently measured.
Also, the FRS may have limitations due to scale coarseness and constant height across the different figures . However, this scale is one of the most widely used assessment tools in body image and psychometric research [5–7, 9, 10] and reported to be valid and reliable . Approximately, 20% of SHIELD respondents did not answer the body image question; however, the respondents with missing data were not significantly different from those who did respond. Finally, while perceived body images may vary among those of differing ages, racial and ethnic groups, countries, and psychological profiles, no adjustments were made for these parameters in this analysis since the study population was largely Caucasian, all respondents were from the U.S., and of similar age range.
Self-reported survey data have advantages in specific circumstances. A main component of this analysis included the FRS. As opposed to the generally objective BMI, the FRS is entirely subjective. As such, ascribing BMI to individual figures in the FRS cannot be done solely by objective analysis. Rather, the only manner to derive subjective data is to ask individuals to provide their perceptions. A self-reported survey completed within a home environment may be a more "objective" way to determine subjective data, in that it is possible that individuals may be more comfortable, and thus more honest, in selecting body images than might occur in a clinical setting.
The importance of the findings of this study is at least 2-fold. Firstly, given the large number of respondents, this may represent the best available data in assigning BMI to individual FRS figures for T2DM. A review of the literature reveals limited information as to what BMI correlates to individual FRS figures in men and women, with no prior similar analysis of this size having been published for T2DM. One prior study attempted to establish BMI norms for the FRS  and included twins and their family members, mostly from Virginia, USA. The present study found higher BMI levels for each body figure for men and women without diabetes mellitus than observed in the Bulik twin study . This difference may be partially because the present study respondents included non-twin individuals from across the US. The findings of this current analysis were, however, similar to other studies that have examined self-perception of body weight. For example, a study of patients receiving care from general practitioners in Australia  found that a large proportion of overweight and obese patients did not perceive themselves as being overweight based on self-reported weight.
Secondly, this is the first study to suggest that there are discrepancies in body image among individuals with T2DM, at least in women. The reasons for these discrepancies are unclear. Even though this study found a strong correlation between BMI and body image perception, misperception of one's own weight-related appearance is common . Previous studies suggest that body image may be a risk factor for obesity [14, 28]. One could speculate that it is a discrepancy of body image perception that might contribute to excessive body weight, and thus an increased risk for T2DM. Another possibility is that it is not a discrepancy of perceived body image that precedes the diagnosis of T2DM. Instead, it may be that after diagnosis of T2DM, patients may then develop an altered perception of body image. Once an individual is diagnosed with T2DM, little doubt exists that the patient's life changes in the form of altered insurance rate status, interaction with family and friends, increased doctor visits (including routine eye examinations, foot examinations, etc), more frequent laboratory testing, and greater evaluation and management of multiple risk factors, especially regarding nutrition, physical exercise, lifestyle, blood pressure, and lipids. It could be that these daunting life changes upon being diagnosed with T2DM might result in alterations in multiple health-related perceptions, including perceptions of body image compared with those without diabetes mellitus. It is possible that once diagnosed with T2DM and confronted with its associated health and cost burdens, patients may then place less emphasis on body image.