Self-perceptions of body size in women at an inner-city family-planning clinic

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

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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.

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%)

BMI, body mass index. Percentages of underweight, normal weight, overweight, and obese women by race. Potti. Self-perceptions of body size. Am J Obstet Gynecol 2009.

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

Number of participants choosing each silhouette (corresponding body mass index [BMI]). Potti. Self-perceptions of body size. Am J Obstet Gynecol 2009.

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

Number of participants choosing each silhouette (corresponding body mass index [BMI]). Potti. Self-perceptions of body size. Am J Obstet Gynecol 2009.

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

Comparing body mass index (BMI) based on silhouette selection of current body size and comparing with measured BMI. SD, standard deviation. Potti. Self-perceptions of body size. Am J Obstet Gynecol 2009.

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

Comparing body mass index (BMI) based on silhouette selection of current body size and comparing with measured BMI. SD, standard deviation. Potti. Self-perceptions of body size. Am J Obstet Gynecol 2009.

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

Percentages of unemployed, low annual income, and educational and marital status by measured body mass index (BMI). Potti. Self-perceptions of body size. Am J Obstet Gynecol 2009.

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.