overweight, obesity and body image perception among ... · l 52.8% of undergraduates with normal...

Overweight, Obesity and Body Image Perception among Medical Students

in Sarawak, Malaysia

PX Kuan1, WK Chan2, PF Chua3, JJP Yeo4, ES Fatin1, B Mohamad Adam1, S Asri4,51 Clinical Research Centre, Sarawak General Hospital, Sarawak, Malaysia2 Anaesthesiology and Intensive Care, Sarawak General Hospital, Sarawak, Malaysia3 Department of Paraclinical Science, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak, Malaysia4 Department of Cardiology, Sarawak Heart Centre, Sarawak, Malaysia5 Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak, Malaysia

Outline of Presentation

l Introductionl Objectivesl Methodsl Resultsl Discussion

l Conclusionl Limitationsl Acknowledgmentl Fundingl Gallery

Introduction

Prevalence of Overweight & Obesity

l The prevalence of overweight and obesity in young adults is increasing substantially worldwide

l It is a contributing factor to non-communicable diseases (NCDs)

l Many Malaysians were overweight or obese, possibly one of the highest rate in Asia [1]

1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2014; 384 (9945): 766-781

Figure 1: Percentage of Overweight and Obesity among Different Genders (Based on Age Groups) in Malaysia

8.8

22.5

43.8

11.4

19.1

7.2

48.6

16.7



l Children and Adolescents Group [1]

Ø Developed Countries: Boys (23.8%) > Girls (22.6%) Ø Developing Countries: Girls (13.4%) > Boys (12.9%)

l 52.8% of undergraduates with normal BMI (Male = Female)l 28.0% with overweight BMI (Male > Female) [2]


2. Kuan PX, Ho HL, Shuhaili MS, Siti AA, Gudum HR. Gender differences in body mass index, body weight perception and weight loss strategies among undergraduates in Universiti Malaysia Sarawak. Mal J Nutr. 2011; 17(1): 67-75.

Global status report on NCDs (2014) [3]

• Overweight and obesity in adults are increasing

• OverweightØ39% of adults ≥ 18 years old ØFemale (40%) > Male (38%)ØRegions of America (61%) > South-east Asia Region (22%)

• ObeseØ> 0.5 billion adults worldwide (amount had nearly doubled

compared to 1980)ØFemale (15%) > Male (11%)ØRegions of America (27%) > South-east Asia Region (5%)

3. World Health Organization. Global Status Report on Noncommunicable Diseases. 2014; 1-280.


l Overweight and obesity were estimated to cause the followings in the year 2010 [1]:Ø 3.4 million mortality rateØ 3.9% of years of life lostØ 3.8% of disability-adjusted life years (DALYs)

l Obesity was a significant predictor and independent risk factor for cardiovascular disease (CVD) [4]

l CVD accounts for 30% out of an estimated 58 million of reported deaths globally in 2005 [5]

1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2014; 384 (9945): 766-781.

4. Hubert HB, Feinleib M, Mc Namara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. 1983; 67(5): 968-977.

5. World Health Organisation. Prevention of cardiovascular disease In: Guidelines for assessment and management of cardiovascular risk. 2007; 1-92.

Disease Burden

• Awareness of the deviation of own body perception from an ideal body image is an indirect indicator of one’s insight

• A high percentage of students had wrong perception about their body weight status [2]

ØMale: • Perceived themselves as overweight compared to underweight • Same goes to their ideal body weight

ØFemale: • Perceived themselves as underweight • Preferred underweight as their ideal figures and showed more concerns

about their body weight, shape and eating behaviours leading to practicing of unhealthy strategies for weight-loss


Body Image Perception

Hatami et al. (2015) reported: [6]

• Body Image Dissatisfaction (BID) Score is measured by current body size score minus desired body size score (perceptions)

• Perceived body image size among 1109 adolescents was positively associated with weight status (p < 0.001)

• Body dissatisfaction showed association with weight status • The higher BMI groups (overweight and obese) were more likely

to select thinner ideal body size than the normal BMI group• Half of the adolescents had thinner body weight perception in

comparison to their real BMI

6. Hatami M, Taib MNM, Djazayery A, Mojani SM, Mejlej HF. Relationship beween body image, body dissastifaction and weight status in Iranian adolescents. Archives of Obesity 2015; 1(1): 1-7.

Body Image Perception

Objectives

OBJECTIVES

Prevalence of Overweight &

Obesity

BMI & BID

Score

Current vs. Ideal Body Image Perceptions

Methods

Methods• Study Design: Cross-sectional study• Study Duration: September to October 2016 • Study Population: Medical students from Universiti

Malaysia Sarawak (UNIMAS), Malaysia• Sample size:

Ø Calculated with 95% confidence level and expected prevalence of obesity of 30.0% and total of 604 students [7]

Ø The minimum recruitment was 301 medical students’volunteers (with anticipated about 30% of incomplete or missing data)

Ø Total recruitment: 319 medical students7. Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Archives of Orofacial Sciences. 2006; 1: 9-14.

l The Original Figure Rating Scale (FRS) inventory [8]

Ø Consists of 9 scales ranging from 1 to 9 (from thinnest to fattest)

Ø Subjects were required to rate of their own perceived and ideal body images based on the figures shown

8. Stunkard AJ, Sorensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis 1983; 60:115–120.

Figure 2: The Original Figure Rating Scale 8. Stunkard AJ, Sorensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis 1983; 60:115–120.

Ø We further classified the figures based on the BMI categories for analysis subsequently:

8. Stunkard AJ, Sorensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis 1983; 60:115–1209. BMI Classification 2015. http://apps.who.int/bmi/index.jsp? Intro Page=intro_3.html. Accessed May 21, 2015

Table 1: Figure Rating Scale Classification

a) Body Mass Index (BMI)• Height (in metre) and weight (in kilogram) were

measured using standardized Secca Digital Medical Scale

• Body mass index (BMI) was calculated and then categorized according to World Health Organization (WHO) classification [9]

9. BMI Classification 2015. http://apps.who.int/bmi/index.jsp? Intro Page=intro_3.html. Accessed May 21, 2015

Anthropometric Measurements

Classification BMI (kg/m2)

Underweight <18.5

Normal 18.5-24.9

Overweight ≥25.0

Obese ≥30.0

Table 2: BMI Classification

b) Waist Circumference • Measured by using standard 1.50 metre measuring tape at

midway between hip bone and bottom of the ribs• Classification based on health risk for CVD and stroke • High waist circumference indicates excess internal body fat

especially around vital organs [10]

10.Waist Measurement by Heart Foundation. https://heartfoundation.org.au/your-heart/know-your-risks/healthy-weight/waist-measurement. Accessed March 20, 2017.

Gender Increased health risk of heart disease and stroke based on waist circumference

Male >94cm

Female >80cm

Table 3: Health Risk Based on Waist Circumference

Data Analysis• By using the Statistical Package for Social Sciences (SPSS)

version 16.0• Multiple regression models were used to examine the

predictors for perceived current and ideal body image and association of BMI with BID scores

• Kappa analysis was used to study the agreement between actual BMI and perceived body image among the different genders

• Statistical significance was set at p< 0.05

Results

Table 4: Demographic ProfileVariables Category Mean (SD) n (%)

Age 21.00 (1.58)

Gender Male 81 (25.40)

Female 238 (74.60)

Marital Status Single 316 (99.10)

Married 3 (0.90)

Others

Medical Illness Cardiac risk 0

Non -Cardiac risk 11 (3.40)

No Illness 308 (96.60)

Body Weight 57.46 (12.17)

Height 1.60 (0.08)

BMI 22.37 (3.96)

Underweight 48 (15.00)

Normal 199 (62.40)

Overweight 57 (17.90)

Obese 15 (4.70)

Waist Circumference 74.14 (9.81)

Male Health risk if >94cm 8 (9.90)

No health risk if ?94 73 (90.10)

Female Health risk if >80cm 45 (18.90)

No health risk if ?80cm 193 (81.10)

Table 4: Demographic ProfileVariables Category Mean (SD) n (%)

Age 21.00 (1.58)


Female 238 (74.60)


Married 3 (0.90)

Others


Non -Cardiac risk 11 (3.40)



Height 1.60 (0.08)

BMI 22.37 (3.96)


Normal 199 (62.40)


Obese 15 (4.70)



No health risk if ?94 73 (90.10)


No health risk if ?80cm 193 (81.10)

Variables Category Mean (SD) n (%)

Age 21.00 (1.58)


Female 238 (74.60)


Married 3 (0.90)

Others


Non-Cardiac risk 11 (3.40)



Age 21.00 (1.58)


Female 238 (74.60)


Married 3 (0.90)

Others




Body Weight 57.46 (12.17) Height 1.60 (0.08) BMI 22.37 (3.96)


Normal 199 (62.40)


Obese 15 (4.70)



No health risk if ≤94 73 (90.10)


No health risk if ≤80cm 193 (81.10)

Table 4: Demographic Profile



Height 1.60 (0.08)

BMI 22.37 (3.96)


Normal 199 (62.40)


Obese 15 (4.70)

Figure 3: BMI Distribution


Age 21.00 (1.58)


Female 238 (74.60)


Married 3 (0.90)

Others




Body Weight 57.46 (12.17) Height 1.60 (0.08) BMI 22.37 (3.96)


Normal 199 (62.40)


Obese 15 (4.70)






Table 4: Demographic Profile


Waist

Circumference 74.14 (9.81)





Table 5: Distribution of Perceived Current and Ideal Body Images by Gender

Figure Rating

Scale

Number (%) Choosing Score

for "Current Body Image"


for "Ideal Body Image"Male

n (%)

Female

n (%)

Male

n (%)

Female

n (%)1 (Thinnest) 2 (2.50) 4 (1.70) 0 (0) 0 (0)2 13 (16.00) 26 (11.00) 0 (0) 20 (8.40)3 7 (8.60) 34 (14.30) 12 (14.80) 88 (37.10)4 25 (30.90) 88 (37.10) 38 (46.90) 115 (48.50)5 15 (18.50) 51 (21.50) 31 (38.30) 13 (5.50)6 14 (17.30) 20 (8.40) 0 (0) 0 (0)7 5 (6.20) 11 (4.60) 0 (0) 1 (0.40)8 0 (0) 1 (0.40) 0 (0) 0 (0)9 (Fattest) 0 (0) 2 (0.80) 0 (0) 0 (0)

Table 5: Distribution of Perceived Current and Ideal Body Images by Gender

Figure Rating

Scale


for "Current Body Image"


for "Ideal Body Image"Male

n (%)

Female

n (%)

Male

n (%)

Female

n (%)1 (Thinnest) 2 (2.50) 4 (1.70) 0 (0) 0 (0)2 13 (16.00) 26 (11.00) 0 (0) 20 (8.40)3 7 (8.60) 34 (14.30) 12 (14.80) 88 (37.10)4 25 (30.90) 88 (37.10) 38 (46.90) 115 (48.50)5 15 (18.50) 51 (21.50) 31 (38.30) 13 (5.50)6 14 (17.30) 20 (8.40) 0 (0) 0 (0)7 5 (6.20) 11 (4.60) 0 (0) 1 (0.40)8 0 (0) 1 (0.40) 0 (0) 0 (0)9 (Fattest) 0 (0) 2 (0.80) 0 (0) 0 (0)

• Current Body Image: The perceptions for both genders were almost similar (majority perceived themselves as normal BMI)

• Ideal Body Image: Female students preferred thinner figures when compared to male students

Underweight

Obese

Normal weight

Overweight

Figure 4: Current and Ideal Perceived Body Images among Different Genders

Table 6: Actual BMI and Current Body Image Perception

• More than half of the overweight students (56.1%) perceived themselves as normal weight

• Only 73.3% of the obese students correctly perceived their body image

Current Body Image Perception

Underweightn (%)

Normaln (%)

Overweightn (%)

Obesen (%)

Actual BMI Categories

Underweight 40 (83.3) 7 (14.6) 0 1 (2.1)

Normal 46 (23.2) 138 (69.7) 14 (7.1) 0

Overweight 0 32 (56.1) 18 (31.6) 7 (12.3)

Obese 0 2 (13.3) 2 (13.3) 11 (73.3)Note: The association was statistically significant with p <0.001

Variable

Perceived Current Body Image

(Adjusted R2=0.35)

Perceived Ideal Body Image

(Adjusted R2=0.18)

Body Image Dissatisfaction Score (Adjusted R2=0.31)

β (95% CI) p-value β (95% CI) p-value β (95% CI) p-valueOverweight/obese 2.034 (1.726, 2.342) <0.001 0.372 (0.179, 0.566) <0.001 1.662 (1.366, 1.957) <0.001

Age 0.006 (-0.075, 0.088) 0.880 -0.043 (-0.094, 0.008) 0.101 0.490 (-0.029, 0.127) 0.217

Female 0.127 (-0.170, 0.423) 0.400 -0.686 (-0.872, -0.500) <0.001 0.813 (0.529, 1.097) <0.001

Table 7: Linear Regression Models to Examine Predictors for Perceived Current and Ideal Body Image and Body Image

Dissatisfaction Score

• Perceived Current Body ImageØ Significant associations with weight status onlyØ Higher BMI (Overweight/ Obese) rate fatter self-image for their perceived current body image

• Perceived Ideal Body ImageØ Significant associations with weight status and female studentsØ Overweight/ obese students rate higher scale (normal BMI) compared to non-overweight/ non-obeseØ Female students rate thinner self-image compared to male students

• BID ScoresØ Significant associations with weight status and female studentsØ Overweight/ obese and female students have higher BIDs

Perceived Current BodyImage as Too

Thin(BID<0)

n (%)

Satisfied with Perceived Current

Body Image(BID=0)

n (%)

Perceived Current Body

Image as Too Fat(BID>0)

n (%) p-value

Total 73 (23.0) 85 (26.7) 160 (50.3)

Gender

Male 32 (43.8) 17 (20.0) 32 (20.0)<0.001

Female 41 (56.2) 68 (80.0) 128 (80.0)

Body Weight StatusNon-overweight/ Non-obese

73 (100.0) 78 (91.8) 95 (59.4)

<0.001Overweight/ Obese 0 (0) 7 (8.2) 65 (40.6)

Table 8: Body Dissatisfaction by Gender, Age and Weight Status

Perceived Current BodyImage as Too

Thin(BID<0)

n (%)

Satisfied with Perceived Current

Body Image(BID=0)

n (%)

Perceived Current Body

Image as Too Fat(BID>0)

n (%) p-value

Total 73 (23.0) 85 (26.7) 160 (50.3)

Gender

Male 32 (43.8) 17 (20.0) 32 (20.0)<0.001

Female 41 (56.2) 68 (80.0) 128 (80.0)

Body Weight StatusNon-overweight/ Non-obese

73 (100.0) 78 (91.8) 95 (59.4)

<0.001Overweight/ Obese 0 (0) 7 (8.2) 65 (40.6)

Table 8: Body Dissatisfaction by Gender, Age and Weight Status

• Only 26.7% were satisfied with their body image (BID=0), 23.0% perceived themselves as too thin (BID<0) and 50.3% as fatter than ideal body image (BID>0)

• Female students has higher BIDs compared to male students

• 8.2% of overweight/ obese groups were satisfied with their perceived current body image (BID=0)

Gender Kappa % of agreement p-value

Male 0.25 53.1 <0.001

Female 0.46 69.2 <0.001

Table 9: Inter-rater Reliability Analysis Between Actual BMI and Perceived Current Body Image Based on Gender

• The Kappa analysis showed more consistent responses in terms of actual BMI and perceived current body image among female students when compared to male students

Discussion

Discussionl Prevalence of Overweight and Obesity

Ø One quarter of the medical students were overweight and obese [2]

l Perceived Current Body ImageØ Our review showed similar positive association with body weight

status [6] where higher BMI groups rate fatter self-imageØ However, only 73.3% of the obese students correctly perceived

their body image, with the remaining underestimated their body image

Ø 56.1% of the overweight students perceived themselves as normal weight



• Perceived Ideal Body ImageØ Overweight/ obese students rate higher scale (normal BMI)

compared to non-overweight/ non-obeseØ Female students rate thinner self-image [2]

l BID ScoresØ There were significant associations with weight status and female

studentsØ Female students have higher BIDs compared to male students [6]

Ø Only 26.7% were satisfied with their body image (BID=0), 23.0% perceived themselves as too thin (BID<0) and 50.3% as fatter than ideal body image (BID>0); different from the previous study [6]

2 . Kuan PX, Ho HL, Shuhaili MS, Siti AA, Gudum HR. Gender differences in body mass index, body weight perception and weight loss strategies among undergraduates in Universiti Malaysia Sarawak. Mal J Nutr. 2011; 17(1): 67-75.


l BID Scores (Continued)Ø 8.2% of overweight/ obese groups were satisfied with their

perceived current body image (BID=0)

l Female students had more consistent responses in terms of actual BMI and perceived current body image when compared to male students

Conclusion

Conclusion

Higher BMI status Gender Discrepancy Health promotion & education

Limitations

Limitationsl Due to constraint in sample recruitment, non-probability

sampling was appliedl Although the sample might not cover all medical students

in Malaysia, this result could be generalized to all medical students particularly in Malaysia due to its large sample size

l When the sample size reached at least 300, the statistics analyzed from the sample are likely the same with the parameters in that particular population[11]

11. Bujang MA, Sa’at N, Joys AR, Mohamad Ali M. An audit of the statistics and the comparison with the parameter in the population. AIP Conference Proceedings. 2015; 1682:050019.

Acknowledgment

AcknowledgmentWe would like to take this opportunity to thank:

1. Director General of Health Malaysia for his permission to present this paper

2. Medical Research and Ethics Committee (MREC), UNIMAS Ethical Board and the dean of the medical faculty for the permissions to conduct research in the university

3. Our research nurses Marwan Bin Mahlil, Esther Anak Jaming, Fiona Lyn Anak Joseph Tau, Natasya Marliana Bt Abdul Malik and Imelda Jana for their effort in helping data collection

Funding

Funding

The study was funded by a research grant from Ministry of Health (National Institute of Health Research Grant) for research materials (KKM.400-5/2/14(50))

Gallery

Team Members

Gallery

Thank you

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