Self-perceptions of body size in women at an inner-city family-planning clinic
Article Outline
Objective
The objective of the study was to determine the relationship between body mass index (BMI) and body size perception among female patients in an inner-city family-planning clinic.
Study Design
All participants (n = 81) were measured for height and weight and completed an anonymous survey. Self-perceived, current, and ideal body sizes were determined by using a standardized scale. Body image discrepancy was calculated by the difference between body image perception and measured BMI.
Results
Approximately two-thirds of the participants were obese or overweight. As measured BMI increased, the body image discrepancy increased, with significant differences in body perception in both obese (P < .001) and overweight (P < .001) women. Ideal body size increased with measured BMI.
Conclusion
Overweight and obese women in an inner-city clinic are likely to underestimate their body size. Our data support the need for culturally sensitive education for this population, because many do not view themselves at risk for complications related to excessive weight.
Key words: body mass index, body size, obesity, self-perceptions
Obesity is now recognized as one of the most pressing public health issues. More than half of the US population is overweight, defined as a body mass index (BMI) of 25 kg/m2 or greater, or obese, defined as a BMI of 30 kg/m2 or greater.1
Obesity is considered a risk factor for the development of multiple chronic and life-threatening diseases.2 The number of overweight and obese individuals in the United States has increased substantially over the past decade, with the highest prevalence observed in Mexican American and African American women.3
Cultural and socioeconomic factors may play a role in women's self-perception of bodyweight and hinder their concern for obesity-related complications. Mexican American and black women have the highest prevalence of obesity when compared with other women.3 More than one-third of non-Hispanic black women and Mexican American women are obese, in contrast to one-fifth of non-Hispanic white women.4
Erroneous perception of body size may have important health and behavioral implications. Overweight women may be at risk of obesity and related complications if they continue to perceive themselves as having normal weight.
The Temple University Hospital gynecology clinic serves a diverse population of women, many of whom meet the criteria of being overweight or obese by BMI. The questionnaire assessed whether these women recognized themselves as overweight or obese.
Materials and Methods
After receiving institutional review board approval, an English or Spanish questionnaire was distributed to all patients scheduled to see physicians at the Temple University Hospital's Family Planning Clinic. All participants were women, and no exclusion criteria were applied. After agreeing to complete the anonymous survey, the patient's height and weight were recorded on the survey by trained medical assistants. Weight was recorded using a stadiometer and height was measured using a standard height bar. BMI was computed (weight/height2, kilograms per square meter). Participant perception of current and ideal body size was determined by using the Stunkard Figure Rating Scale and the established conversion to BMI (Figure).5, 6
FIGURE.
Stunkard Figure Rating Scale and established conversion to BMI
Figure 1 18.3 kg/m2 Underweight Figure 2 19.3 kg/m2 Normal Figure 3 20.9 kg/m2 Normal Figure 4 23.1 kg/m2 Normal Figure 5 26.2 kg/m2 Overweight Figure 6 29.9 kg/m2 Overweight Figure 7 34.3 kg/m2 Obese Figure 8 38.6 kg/m2 Obese Figure 9 45.4 kg/m2 Obese Each of these figures corresponds to a previously established body mass index (BMI).
Derived from Kety et al.5
Reproduced, with permission, from Bulik et al.6
Potti. Self-perceptions of body size. Am J Obstet Gynecol 2009.
To determine the body image discrepancy (discrepancy between body image perception and actual BMI), we first converted each silhouette to the BMI standardized by the population-based norms linking BMI to the 9 silhouettes, as previously described by Bulik et al.6 A body image discrepancy score was then calculated for each subject by subtracting the subject's perceived silhouette-linked BMI value from the measured BMI. Demographic data were obtained, including age, race, employment status, income, education, and marital status.
Statistical methods
Group data are presented as means with standard deviations (SDs). Categorical variables are presented as frequencies with percentages. Patient characteristics and demographics were cross-tabulated using PROC FREQ software (version 9.1; SAS Institute, Cary, NC). Within-subject comparisons (ie, body image discrepancies) were carried out using 2-tailed paired Student t tests (PROC TTEST). P ≤ .05 was considered statistically significant.
Results
A total of 81 women answered the questionnaire. Table 1 presents the percentages of obese, overweight, underweight, and normal weight women categorized by race.
TABLE 1. Race by measured BMI
| Race (n) | BMI, n (%) | |||
|---|---|---|---|---|
| < 18.5 kg/m2 | 18.5-24.9 kg/m2 | 25-29.9 kg/m2 | ≥ 30 kg/m2 | |
| African American (52) | 2 (4%) | 15(29%) | 12(23%) | 23(44%) |
| Hispanic (26) | 1(4%) | 8(31%) | 10(38%) | 7(27%) |
| White (2) | 1(50%) | 1(50%) | 0(0%) | 0(0%) |
| Total (80) | 4(5%) | 24(30%) | 22(27%) | 30(38%) |
Table 2 compares ideal figures to the recorded BMI. All of the participants chose an ideal body silhouette in the range of Figures 2-7 (normal-obese). Approximately 20% of the obese women selected overweight or obese silhouettes as their ideal body shape.
TABLE 2. Ideal body size by measured BMI
| Figure (BMI) | < 18.5 kg/m2 | 18.5-24.9 kg/m2 | 25-29.9 kg/m2 | ≥ 30 kg/m2 |
|---|---|---|---|---|
| Figure 2 (19.3 kg/m2) | 0 | 2 | 0 | 1 |
| Figure 3 (20.9 kg/m2) | 1 | 8 | 10 | 5 |
| Figure 4 (23.1 kg/m2) | 3 | 9 | 11 | 19 |
| Figure 5 (26.2 kg/m2) | 0 | 5 | 1 | 5 |
| Figure 7 (34.3 kg/m2) | 0 | 0 | 0 | 1 |
| Total | 4 | 24 | 22 | 31 |
Table 3 compares self-perception of current body size to measured BMI. Seventy percent of the participants (n = 57) selected one of the Figures 3-6 (BMI, 20.9-29.9 kg/m2) as the silhouette to represent their current body size. Only 5 of the 31 obese patients selected a figure that correlated with their measured BMI.
TABLE 3. Perceived current body size by measured BMI
| Figure (measured BMI) | < 18.5 kg/m2 | 18.5-24.9 kg/m2 | 25-29.9 kg/m2 | ≥ 30 kg/m2 |
|---|---|---|---|---|
| Figure 1 (18.3 kg/m2) | 2 | 0 | 0 | 0 |
| Figure 2 (19.3 kg/m2) | 0 | 2 | 1 | 0 |
| Figure 3 (20.9 kg/m2) | 1 | 12 | 1 | 0 |
| Figure 4 (23.1 kg/m2) | 1 | 7 | 13 | 4 |
| Figure 5 (26.2 kg/m2) | 0 | 3 | 7 | 10 |
| Figure 6 (29.9 kg/m2) | 0 | 0 | 0 | 12 |
| Figure 7 (34.3 kg/m2) | 0 | 0 | 0 | 4 |
| Figure 8 (38.6 kg/m2) | 0 | 0 | 0 | 1 |
| Total | 4 | 24 | 22 | 31 |
The body image discrepancy was significant (P < .05) for the obese and overweight women. Table 4 demonstrates that the obese participants underestimated their body size by approximately 20%, and the overweight participants underestimated their body size by approximately 12%. The normal and underweight participants were not found to have a significant body image discrepancy.
TABLE 4. Body image discrepancy by measured BMI
| BMI group (n) | Body size | Mean | SD | Minimum | Maximum | T value | P value |
|---|---|---|---|---|---|---|---|
| Obese (31) | Measured | 36.5 | 5.3 | 30.3 | 49.2 | — | — |
| Perceived | 28.6 | 3.7 | 23.1 | 38.6 | — | <.0001 | |
| Discrepancy | 7.8 | 4.2 | -9.9 | 16.7 | 10.25 | ||
| Overweight (22) | Measured | 27.18 | 1.4 | 25.1 | 29.6 | — | — |
| Perceived | 23.8 | 1.8 | 19.3 | 26.2 | — | — | |
| Discrepancy | 3.36 | 2.3 | -1.0 | 7.4 | 6.69 | <.0001 | |
| Normal (24) | Measured | 22.2 | 1.7 | 19.5 | 24.8 | — | — |
| Perceived | 22.0 | 1.9 | 21.1 | 26.2 | — | — | |
| Discrepancy | 0.22 | 2.0 | -3.9 | 3.5 | 0.55 | .58 | |
| Underweight (4) | Measured | 17.6 | 0.3 | 17.2 | 18.0 | — | — |
| Perceived | 20.1 | 2.3 | 18.3 | 23.1 | — | — | |
| Discrepancy | -2.5 | 2.68 | -5.8 | -0.2 | -1.88 | .15 |
As shown in Table 5, African American and Hispanic women significantly underestimated their current body size (P < .05). In contrast, the 2 white women overestimated their body size.
TABLE 5. Body image discrepancy by race
| Race (n) | Variable | Mean | SD | Minimum | Maximum | T value | P value |
|---|---|---|---|---|---|---|---|
| African American (52) | Measured | 29.8 | 7.66 | 17.2 | 49.2 | — | — |
| Perceived | 25.2 | 3.8 | 18.3 | 34.3 | — | — | |
| Discrepancy | 4.6 | 4.9 | -5.8 | 16.7 | 6.86 | <.0001 | |
| Hispanic (26) | Measured | 27.4 | 6.4 | 18.0 | 44.0 | — | — |
| Perceived | 24.5 | 4.7 | 18.3 | 38.6 | — | — | |
| Discrepancy | 2.8 | 3.8 | -2.9 | 11.0 | 3.82 | .0008 | |
| White (2) | Measured | 18.4 | 1.6 | 17.3 | 19.6 | — | — |
| Perceived | 22.0 | 1.5 | 20.9 | 23.1 | — | — | |
| Discrepancy | -3.5 | 0.09 | -3.5 | -3.4 | -54.5 | .0117 |
Table 6 compares the demographic data by BMI. Unemployment, annual household income < $30,000, and unmarried status were more common among overweight and obese participants than underweight and normal weight participants.
TABLE 6. Characteristics of the study population: demographic variables by BMI
| Demographic variable/BMI | < 18.5 kg/m2 (%) | 18.5-24.9 kg/m2 (%) | 25-29.9 kg/m2 (%) | ≥ 30 kg/m2 (%) | Total (%) |
|---|---|---|---|---|---|
| Unemployed | 9.09 | 25 | 31.82 | 34.09 | 100 |
| Income < $30,000/y | 5.26 | 28.07 | 26.31 | 40.35 | 100 |
| Education < 12th grade | 7.14 | 39.28 | 28.57 | 25 | 100 |
| Unmarried | 1.44 | 31.88 | 27.53 | 39.13 | 100 |
Comment
As the prevalence of obesity rises and the public awareness of obesity as a serious health problem increases, it is important that individuals have an accurate perception of their bodyweight and an appropriate response to this perception. This is the first study to evaluate body image discrepancy specifically in the inner-city population seeking gynecologic care.
Our results confirm previous findings that minority women may perceive themselves as having normal weight when they are actually overweight.7, 8 Gillum and Sempos9 examined the validity of self-reported BMI in 8142 women and found that obesity was underestimated by self-report across all ethnicities but was most pronounced in Mexican American women. Bhuiyan et al1 evaluated body image discrepancy in 3698 young adults and reported that African Americans were 1.72 times more likely than whites to underestimate their body size. Moderately overweight African American women may not recognize the health consequences of their body sizes and are seldom told by health professionals that their weight is a cause for concern.7
In a previous inner-city study, more than half of the overweight and obese participants indicated that they would like their physicians to help them address weight loss.10 There is mounting evidence in the literature that physician counseling pertaining to obesity treatment significantly increases the likelihood of obese patients seeking and maintaining a weight management program over those who do not receive counseling from a physician.11
The figures and conversion to BMI by Bulik et al6 used in this study were standardized to white women and have not been standardized to this study population. Similar figural stimuli scales have been developed specifically for African American women but have not been standardized to a BMI.12 Half of the 4 underweight women overestimated their current body size, but all selected an ideal body size in the normal range. Further studies are needed to include a more diverse population to determine whether most underweight, overweight, and obese women seeking gynecologic care incorrectly perceive their body size or whether this is a phenomenon specific to the inner-city population.
Gynecologists often serve as the only primary care provider for women. As more women are becoming overweight and obese, there is a greater need for gynecologists to disseminate information to patients regarding the range and scope of adverse outcomes from excessive body size. Specifically tailored, culturally sensitive approaches to this problem should be developed to target at-risk minority and inner-city populations. Informed patients will be empowered to change their lifestyles to lead healthier lives.
References
- . Differences in body shape representations among young adults from biracial (black-white) semirural community. Am J Epidemiol. 2003;158:792–797
- . Obesity—a global public health problem. Acta Med Croat. 2007;61:161–164(in Croatian)
- . Ethnic differences in correlates of obesity between Latin-American and black women. Obes Res. 2004;12:652–660
- . The relationship between body image discrepancy and body mass index across ethnic groups. Obes Res. 2000;8:558–589
- . The genetics of neurological and psychiatric disorders. In: New York: Raven Press; 1983;p. 115–120
- . Relating body mass index to figural stimuli: population-based normative data for Caucasians. Int J Obes Relat Metab Disord. 2001;25:1517–1524
- . Body images and obesity risk among black females: a review of literature. Ann Behave Med. 1998;20:13–24
- . Weight-related attitudes and behaviors of black women. J Ann Diet Assoc. 1993;43:416–422
- . Ethnic variation in validity of classification of overweight and obesity using self-reported weight and height in American women and men: the Third National Health and Nutrition Examination Survey. Nutr J. 2005;4:27
- . Mobile health unit for minority obesity education: local residents' attitudes and perception. J Natl Med Assoc. 2006;98:1483–1488
- . Physician involvement in the management of obesity as a primary medical condition. Obes Res. 2001;9(Suppl 4):302S–311S
- . Body image assessment: comparison of figure rating scales among urban black women. Ethn Dis. 2002;12:54–62
PII: S0002-9378(08)02247-3
doi:10.1016/j.ajog.2008.11.027
© 2009 Mosby, Inc. All rights reserved.
