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besity Research & Clinical Practice (2008) 2, 125—131

ur perception of weight: Socioeconomic andociocultural explanations

atasha J. Howarda,∗, Graeme J. Hugob,nne W. Taylorc, David H. Wilsond

Nutrition Obesity Lifestyle and Environment (NOBLE) Project, Discipline of Geographical andnvironmental Studies, The University of Adelaide, Adelaide, SA, AustraliaDiscipline of Geographical and Environmental Studies, The University of Adelaide,delaide, SA, AustraliaPopulation Research and Outcome Studies Unit, SA Department of Health,.O. Box 287, Rundle Mall, Adelaide, SA, AustraliaDiscipline of Medicine, The University of Adelaide, Adelaide, SA, Australia

eceived 18 December 2007; received in revised form 12 March 2008; accepted 12 March 2008

KEYWORDSPerceptions;Obesity;Weight status;Social disadvantage;Sociocultural

SummaryObjective: To compare self-reported perception of weight with biomedically mea-sured body mass index in different socioeconomic and cultural groups.Method: Of the original North West Adelaide Health (Cohort) Study (n = 4060) 68.5%(n = 2780) underwent a computer assisted telephone interview (CATI) answering addi-tional questions related to their social and health status. The participants wereasked ‘‘In terms of your weight, do you consider yourself to be. . . too thin, a littlethin, normal weight, a little overweight or very overweight’’. The self-perceptionof weight was compared to biomedically measured BMI (body mass index). Binarylogistic regression was used to compare those participants who were obese (BMI ≥ 30)with the self-perceived weight status of ‘a little overweight’. The outcome mea-sures included the Socioeconomic Indexes for Areas Index of Relative Socioeconomic

Disadvantage (SEIFA IRSD), country of birth and household income.Results: Of those that were underestimating their obese weight status, 41.5%were male and 32.2% female. The highest misclassification was for those whoconsidered their weight to be ‘a little overweight’, with 59.6% biomedicallymeasured with a BMI of over 30. The odds of being biomedically mea-sured obese (BMI ≥ 30) were compared to those who considered themselvesto be ‘a little overweight’. Those that misreported their weight status and

Abbreviations: CATI, computer assisted telephone interview; BMI, body mass index; NWAHS, North West Adelaide HealthCohort) Study; SEIFA IRSD, Socioeconomic Indexes for Areas Index of Relative Socioeconomic Disadvantage; WHO,World Health Organisation.∗ Corresponding author. Tel.: +61 8 8303 4815; fax: +61 8 8303 3498.

E-mail address: natasha.howard@adelaide.edu.au (N.J. Howard).

871-403X/$ — see front matter. Crown Copyright © 2008 Published by Elsevier Ltd on behalf of Asian Oceanian Association for the Study of Obesity. All rights reserved.

oi:10.1016/j.orcp.2008.03.003

126 N.J. Howard et al.

were biomedically obese, were more likely to be living in the lowest quintile of dis-advantage, have a household income of less then $20,000 or be born in Eastern orWestern Europe.Conclusion: There are psychosocial, sociocultural and social environmental influencesrelated to the perception of weight status. Future research will need to understandthe processes whereby people are not aware they have a weight problem.

Published by Elsevier Ltd on behalf of Asian Oceanian Asso-Obesity. All rights reserved.

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Introduction

The prevalence of obesity has steadily increasedover time within both the developed and develop-ing world [1], with obesity being described as mostprevalent among those who are socioeconomicallyand locationally disadvantaged [2]. The causes,prevention and outcomes associated with obesityare complex and incompletely understood, andthere is recognition from leading obesity expertsof the need for more interdisciplinary researchinto the condition [3,4]. One such area needingfurther investigation is that of the psychosocialinfluences on, and self-perceptions of, body weightand health.

To date, much of the research on self-perceptionof weight has focused on parents’ perceptions oftheir children’s weight. Recent findings in theUnited States report that nearly two-thirds ofmothers did not recognise that their children wereoverweight [5] and another study in Australiafound a high-proportion of parents did not expressconcern of their children’s weight [6]. Studies onweight perception or appropriateness in the UnitedStates have shown that there is a misclassificationof weight status for adults by medical standards[7]. A majority of research focuses on genderand age influences, although there have beensome studies investigating the ethnic dispari-ties associated with weight status in adults [8].Research into the awareness of risks among ruralAustralians found that there is a significant differ-ence between those that considered themselvesoverweight and the number that were classifiedoverweight according to body mass index (BMI) [9].However, limited studies have been conducted onperception of weight within a general, randomlyselected, representative population.

Behaviour change research has investigatedthe challenges faced by health practitioners and

researchers. In the transtheoretical model stageof precontemplation, there is no intention by theindividual to change behaviour in the foreseeablefuture, and individuals are unaware or underawareof their problems [10]. There is a need for the issue

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f weight gain or excess weight to be recognised ifhe individual is to be able to proceed on a pathwayf achieving healthy weight.

There has been research undertaken whichxplores the lay perspectives on health and well-eing and discusses some of the different ways inhich people perceive the health care system andealth issues [11,12]. In gaining an understandingf weight appropriateness an individual will alsoequire a perception of risk, which is the subjectiveudgement that people make about the character-stics and severity of the risk of a behaviour orctivity. The concept of risk is different for publicealth practitioners and those people that expe-ience the risk. A study of cervical cancer riskxplored the embodied risks—–risks identified asharacteristics of their body. The study found thathe embodied risk is not experienced by the individ-al until after they are actually diagnosed and thisabelling then confronts them with a range of uncer-ainties they had not previously experienced [13].he individual will often reconstruct the threat ofhe perceived risk by denying its personal rele-ance. These are all important features to considern addressing healthy weight and helping those whoisclassify their weight status to understand the

isks associated with excess weight.This paper is a preliminary exploration into the

elf-perception of weight status, a psychosocialspect of obesity that is explored through threeain themes—–individual and area level socioeco-

omic disadvantage and sociocultural influences.he aim of the paper is to firstly compareelf-perception of weight with the World Healthrganisation (WHO) definition for BMI categories.econdly, to compare and discuss socioeconomicnd sociocultural themes related to self-perceptionf weight using a population-based study.

ethods

he North West Adelaide Health Study (NWAHS) is aiomedical cohort study of a representative popula-ion sample of adults living in the north west region

Socioeconomic and sociocultural explanations for perception of weight 127

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Figure 1 Flowchart of North West Ad

f Adelaide [14]. The NWAH Study is spatially ref-renced data (at the individual point level) for 99%f the original cohort offering a unique opportu-ity to research sociodemographic and biomedicalata within the north west metropolitan area ofdelaide. Further information on the methodologynd study population of the North West Ade-aide Health Study has been previously published14].

The biomedical findings have been comparedo other metropolitan regions or country areas inouth Australia and limited biases were reported15]. The NWAHS data were weighted to theustralian Bureau of Statistics 1999 Estimated Res-

dential Population by the north west region, ageroup, sex and probability of selection in the house-old to provide estimates for the population. Ofhe total initial eligible sample (n = 4060), 90.1%n = 3566) provided information for the second stagef the study (Stage 2, 2004—2006) and 81.0%

n = 3206) attended the clinic. Fig. 1 is a flowchartf the NWAHS cohort data collection 2000—2008.he participants’ self-perceived weight status wasollected during a follow up of the NWAHS cohort

(ohb

e Health Study timeline 2000—2008.

uring August and September 2007 (n = 2382), aesponse rate of 74.3%.

The participants answered the following sur-ey question: ‘‘In terms of your weight, do youonsider yourself to be. . .too thin, a little thin,ormal weight, a little overweight or very over-eight?’’ The objective weight status was based oneasured BMI that was calculated using height in

entimetres (measured to the nearest 0.5 cm usingstadiometer) and weight in kilograms (measured

o the nearest 0.1 kg in light clothing and withouthoes using a standard digital scales).

The analyses covered three focus areas, individ-al socioeconomic status (household income), areaevel disadvantage index (SEIFA IRSD), and socio-ultural influences (country of birth). Area levelocioeconomic status was measured using the Indexf Relative Social Disadvantage a component ofhe Socioeconomic Indexes for Areas, (SEIFA IRSD)s compiled by the Australian Bureau of Statistics

ABS) at the Collector District Level (around 200r 300 households) [16]. Questions on the house-old income were asked in a self-reported paperased questionnaire sent out to the participants

128 N.J. Howard et al.

Tabl

e1

Com

pari

son

ofse

lf-p

erce

ptio

nof

body

wei

ght

and

biom

edic

ally

mea

sure

dW

HO

BMIc

lass

ifica

tion

s

WH

OBM

Icla

ssifi

cati

ons

Self

-per

cept

ion

ofw

eigh

t

Too

thin

/alit

tle

thin

(%)

Nor

mal

wei

ght

(%)

Alit

tle

over

wei

ght

(%)

Very

over

wei

ght

(%)

Tota

l(%)

Und

erw

eigh

t(B

MI<

18.5

0)70

.3(n

=26

)29

.7(n

=11

)0.

00.

010

0.0

(n=

37)

Nor

mal

(BM

I18.

50—

24.9

9)14

.9(n

=11

2)66

.3(n

=44

9)18

.3(n

=13

8)0.

5(n

=4)

100.

0(n

=75

3)O

verw

eigh

t(B

MI2

5.00

—29

.99)

1.3

(n=

12)

33.4

(n=

302)

62.1

(n=

561)

3.2

(n=

29)

100.

0(n

=90

4)O

bese

(BM

I≥30

)0.

3(n

=2)

5.8

(n=

40)

59.6

(n=

410)

34.3

(n=

236)

100.

0(n

=68

8)

WH

OBM

I(W

orld

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x).

before each clinic appointment. Each participantwas asked about their country of birth during theoriginal recruitment for the study at Time 1.

The null hypothesis to be tested is that there isno relationship between three measures of socioe-conomic status and self-perceived weight status.Self-perceived weight status was compared withthe biomedically measured WHO BMI classifica-tions by crosstabulation and Chi-square testing.The overestimation, agreement and underestima-tion of self-perceived weight status was analysedby gender. Binary logistic regression was used tocompare those participants with a BMI ≥ 30 withthe self-perceived weight status of ‘a little over-weight’ (n = 1109). The outcome measures includedthe SEIFA IRSD, country of birth and householdincome.

Results

The prevalence of measured obesity within theNorth West Adelaide Health Study at Time 1(2000—2003) was 27.0%. Table 1 is a comparisonof self-perception of body weight and biomedicallymeasured WHO BMI classifications. Of those thatwere biomedically measured as obese (BMI ≥ 30),59.6% (n = 410) perceived their weight to be ‘a littleoverweight’ and 5.8% (n = 40) perceived they wereof ‘normal’ weight. Of those people that were over-weight, 33.4% (n = 302) actually thought that theywere of ‘normal’ weight status. In addition, 29.7%(n = 37) of people who were underweight thoughtthey were of ‘normal’ weight, and of those thatwere biomedically measured with a BMI between18.00 and 24.99 (or normal), 18.3% thought thatthey were ‘a little overweight’ and 0.5% thoughtthat they were ‘very overweight’.

Table 2 Underestimation, agreement and overesti-mation of self-perceived weight status by gender

Self-perception of weight statusagreement status with BMI

n %

MalesUnderestimated 493 41.5Agreement 637 53.6Overestimated 58 4.9

FemalesUnderestimated 384 32.2Agreement 684 57.3Overestimated 125 10.5

Socioeconomic and sociocultural explanations for perce

Table 3 Association with self-perceived ‘a littleoverweight’ and obesity (BMI ≥ 30)

‘A littleoverweight’

Obesity (BMI ≥ 30)

OR (95% CI) P

SEIFA (IRSD)Highestquintile

1.00

High quintile 0.89 (0.46—1.73) 0.739Middle quintile 0.77 (0.51—1.16) 0.205Low quintile 1.11 (0.76—1.61) 0.583Lowest quintile 1.67 (1.14—2.46) 0.008

Country of birthAustralia 1.00UK/Ireland 1.17 (0.83—1.64) 0.369Eastern orWesternEurope

1.72 (1.07—2.75) 0.024

Asia and other 0.68 (0.27—1.75) 0.428

Household incomeGreater then$60,000

1.00

$40.001 to$60,000

1.32 (0.95—1.85) 0.099

$20,001 to$40,000

1.35 (0.96—1.89) 0.085

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their obesity status the distribution was variedalong the BMI continuum, with 14.3% (n = 40) of

Up to $20,000 1.82 (1.27—2.61) 0.001

SEIFA IRSD (Socioeconomic Indexes for Areas Index of RelativeSocioeconomic Disadvantage).

Table 2 explores by gender those people thatnderestimated, overestimated or had agreementith their self-perceived weight status and bodyass index classification. Underestimation of self-erceived weight status was found to be higheror males (41.5%) compared to females (32.2%).here were also found to be 10.5% of females over-stimating their weight status, that is having theelf-perception of their weight status being heavierhen compared with their biomedical classifica-

ions of BMI.Table 3 describes obesity by those factors asso-

iated with self-perceived weight status ‘a littleverweight’. Those who were biomedically obeseut self-perceived themselves ‘a little overweight’ere more likely to be from the lowest quintile ofEIFA (OR 1.67), born in Eastern or Western EuropeOR = 1.72) and have an annual household incomef less than $20,000 (OR = 1.82).

iscussion

revious research in South Australia has shownncreasing rates of overweight and obesity in

tw

ption of weight 129

dults and children [17—19]. In this particularopulation there was a high percentage of peoplen this study who were misclassifying their weighttatus. Around two-thirds (65.7%) of those thatere biomedically obese were misclassifying theireight status by not reporting their current weight

o be ‘very overweight’.The obesity epidemic confronts us with emerging

ssues across the social gradient. The relationshipf obesity with socioeconomic status is complexith both those that are highly educated and of aigher income experiencing increasing prevalences well as a lower prevalence of the condition20]. Those within the lowest quintile of disad-antage and low household income levels wereound to be more likely to interpret their weighttatus as ‘a little overweight’ when they reallyere biomedically obese. The social and physicalnvironmental influences and their relationshipith an individual’s health status is yet to be fullyetermined, although research has suggested thatndividuals living in disadvantaged areas are atreater risk of obesity regardless of their individualevel of disadvantage [21,22]. This research hashown that it is those that are locationally andocioeconomically disadvantaged who are moreikely to underreport their weight. This may meann individual’s temporal awareness of the ‘risk’ ofhronic disease further into their future, and thessociation with social environments in which thesendividuals exist, is yet to be fully determined [23].

People born in Eastern or Western Europe wereore likely to misinterpret their weight status toe a ‘little overweight’ when they were actuallyiomedically obese when compared to those thatere Australian born. Within this population thereave been limited studies exploring the perceptionf weight amongst different cultural groups. In thenited States there have been a number of studiesxploring the racial discrepancies between black,ispanic and white populations [24,25]. There areociocultural factors that drive the standards ofesirable body weight within cultures, which in turnrive the lifestyles that people lead. As the popu-ation mean of body mass index shifts further alongn obesity continuum there is a need to determinehether these social and cultural norms and theerceptions of body image or weight are changingimultaneously.

Of those people that were found to misreport

hose participants having a BMI > 35 or classifiedith severe obesity (BMI ≥ 35).1 Those that are mis-

1 Howard, NJ. Further analyses of data, 2007.

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130

classifying their weight status are actually biomedi-cally measured as being at high risk of a chronic con-dition and are therefore not just slightly misclassi-fying [26]. In addition, there were a high percent-age of people that were misreporting their weightin the other direction, that is over reporting theirweight status. These findings draw attention toissues such as body image, self-esteem and increas-ing eating disorders among our population concur-rently with the rising obesity prevalence [27].

More investigations are needed to look at thecomplexities in the distribution of weight, forexample waist to hip ratio, and other definitionsrelated to the perception of weight status. It wasthe aim of this research to use a commonly definedmeasurement for obesity, the BMI. The analysis isundertaken with caution as BMI is an arbitrary mea-sure for defining obesity in our population and anindividual may not necessarily report incorrectlyif other measurements of body fat distributionare taken into account. Numerous studies havereported that BMI is not the most appropriate mea-sure in determining risk of chronic disease, ratherother body fat and distribution measures providemore reliable estimates [28,29]. These discrep-ancies are apparent in this research with 0.3%self-reporting their obesity status as ‘too thin ora little thin’ when actually they have a BMI greaterthen 30. Further investigations highlighted thatthose misreporting in this case were males with anormal waist to hip ratio.2

This research draws upon Giddens’ StructurationTheory which places an individual within a broadercontext and accounts for the multilevel natureof simultaneous individual and group level inter-action [30]. There is a two way process betweenindividuals and the social environments in whichthey live, work and play. Giddens writes that ‘‘Itis important to grasp how history is made throughthe active involvements and struggles of humanbeings, and yet at the same time both forms thosehuman beings and produces outcomes which theyneither intend nor forsee [31].’’ More research isneeded to explore these processes of the individualand social environmental interaction in relation tohealthy weight.

There are a broad range of other socioculturaland psychosocial factors that could be explored inrelation to the self-perception of weight status.These include the influence of other sociocul-

tural themes such as lifecourse indicators such asmother’s and father’s country of birth, and influ-ence of an individual’s life trajectory and social

2 Howard, NJ. Further analyses of data, 2007.

TtUpt

N.J. Howard et al.

ontext which shape the contemporary social envi-onment, both of which contribute to the culturalandscapes of consumption and behaviour.

The research presented in this paper presentshallenges for policy and intervention. The trans-osing of this research into healthy weightessages at the population level appears to be aifficult task if people do not perceive their weighto be a problem. An intervention is not likely to beffective if it is based on the assumption that peo-le recognize their weight to be a problem when inctual fact they do not consider this to be the case.ore recognition of the perception of risk and layerspectives of obesity are needed to understandhe complexity of obesity within our population.

The strength in the NWAHS lies in the repre-entative nature, the large random sample, andhe relatively high response rate. In addition, theWAHS has strength in the standardised clinical pro-edures with stringent measurement standards andegular calibration of scales and height measureso provide reliable BMI data. Self-reported heightnd weight has commonly been used to determineMI at a population level. There are recognisedroblems associated with self-reported height andeight, in that height is generally over-reportednd weight under-reported [32]. The self-reportata have previously been shown to underestimatehe extent of obesity within this population [33].uture research would need to consider the differ-nt measures of obesity and cut off points to lookt biomedically assessed weight and perceived bodymage. As well as investigating how to target inter-entions towards healthy weight when people areot aware they have a problem.

The present paper has been able to make onlyome preliminary observations on one main themerea of the socio-spatial context, that is the per-eptions of weight status. There is a need to gainn understanding of the processes whereby peo-le are not aware that they have a problem whent comes to their weight. Future research of theohort will explore the multilevel nature of theseelationships and how the spatial landscape has thebility to influence individual level outcomes suchs social reproduction of lifestyles, behaviour andocial disadvantage.

cknowledgements

he authors would like to express their appreciationo the Population Research and Outcome Studiesnit, South Australian Department of Health forroviding access to data. We would especially likeo acknowledge the work of the North West Ade-

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ocioeconomic and sociocultural explanations for p

aide Health Study Team and the participants thatave given up their valuable time.

Natasha Howard is funded under a scholar-hip with the Nutrition Obesity Lifestyle andnvironment (NOBLE) project which is an Aus-ralian Research Council (ARC) Linkage ProjectLP0455737) ‘‘Obesity, Health, Social Disadvantagend Environment’’.

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