F E AT U R E S
The Perception of Obese Persons Cross Cultural Considerations ■
¨ uzo˘ ¨ glu, PhD ■ Sevcan Topc¸u, MScN Esra Oksel, PhD ■ Nazmiye C¸ıray Gund The aim of this study was to evaluate the perception of obesity in adults. The study sample included 586 participants (body mass index ≥30 kg/m2 and age ≥18 years). A questionnaire consisting of 22 questions was developed by the researchers in accordance with the literature. A statistically significant difference was found between the description and perception of weight as a threat to health (χ 2 = 57.65; P = .001). The perception of a threat to health was significantly higher in the group that described itself as overweight than other groups, and the group that described itself as having a normal weight had a significantly lower perception of a threat to health than other groups. The most important result of this investigation was that obesity was described by people but there was no awareness of the disease. It is suggested that future studies would increase people’s awareness of obesity management. KEY WORDS: obesity, self-perception, Turkey Holist Nurs Pract 2015;29(4):225–231
The World Health Organization (WHO) defines obesity as “abnormal or excessive fat accumulation in fat tissues in a degree to cause a health problem.” To determine obesity, the WHO’s definition is used, and, generally, the body mass index (BMI) is used as the unit. According to the frequently used WHO classification, a person with a BMI of 30 kg/m2 or more is generally considered obese. A person with a BMI of 40 kg/m2 or more is considered morbidly obese.1 Diseases that are caused by modifiable causes, which are related to lifestyles that include inappropriate nutrition, physical inactivity, and smoking, are very serious health problems. According to the WHO’s predictions, 60% of the causes of death in developed countries are diseases that are caused by lifestyle.2 As one of these diseases, obesity has gradually become prominent as a social problem within postmodern societies and has drawn attention due to its prevalence and incidence. According to the Author Affiliations: Departments of Medical Science Nursing (Drs Oksel and G¨und¨uzo˘glu) and Public Health Nursing (Ms Topc¸u), Ege University Faculty of Nursing, Bornova, Izmir, Turkey. Presented as a poster in 7th Metabolic Syndrome Symposium, April 29-May 2, 2010, Belek-Antalya, Turkey. The authors declare no conflict of interest. Correspondence: Esra Oksel, PhD, Department of Medical Science Nursing, Ege University Faculty of Nursing, 35100 Bornova, Izmir, Turkey ([email protected]). DOI: 10.1097/HNP.0000000000000094
WHO data, there are more than 400 million obese and approximately 1.6 billion slightly overweight people in the world.1 This rate is expected to grow to 700 million and 2.3 billion by the year 2015, respectively. The data obtained from the studies “Heart Disease Risk Factors of Adults in Turkey”’ (TEKHARF) and “Diabetes, Obesity and Hypertension Epidemiology in Turkey’ (TURDEP) showed that in the past 25 years in Turkey, the prevalence of obesity has increased in parallel with the growth observed in the world. TURDEP II was completed in 540 centers from 15 cities in the year 2010. The study found that the obesity frequency was 32% in Turkey.3 The gradual increase of obesity is called the “obesity epidemic.” The WHO sees this situation as a “global obesity epidemic.” With increasing frequency in the entire world, obesity is a chronic disease contributing to the risk of developing diabetes mellitus, metabolic syndrome, stroke, hypertension, ischemic heart disease, gallbladder disease, and certain carcinoma types.4 Body perception is how a person perceives his or her body when he or she envisions it in his or her head. Body perception, which is the whole mental notion of the body’s organs, creates the idea of “ego.” An individual’s perception of his or her own body is more subjective than objective. One person’s perception may not be in agreement with, and often is more negative than, others’ judgments. Body perception is important to consider as part of the general treatment of obese people.5 Most obese people do not like their 225
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appearance, and this is generally the main reason why they want to lose weight. They believe that weight loss will increase their attractiveness and, consequently, they will feel better about themselves.6 Ideal standards of body size are culture-specific. Cultural values play an important role in understanding individual self-perception and comprehending the way in which an individual is perceived in the community. Culture and community play important roles in the configuration and development of body image. Body image created from a cultural point of view begins to form on the basis of the individual internalization of physical standards and messages from the community.7,8 From the community point of view, opinions related to body image in our country change daily. The general bias in our community is that slimness is perceived as illness, whereas obesity is associated with power, prosperity, and health.9 An old Turkish proverb states, “A piece of kilo covers a thousand defects.”10 The traditional understanding promotes a heavy weight as an ideal situation. Today, this traditional opinion is starting to change because of alterations in sociocultural views, largely with the support of mass communication tools; accordingly, the ideal of a slim body figure has started to appear for women and the ideal of a muscular body figure has begun to appear for men.7,11 In examining obesity and body perceptions, people’s dislike of themselves stands out. However, it is important for obese persons to demand appropriate treatment to evaluate their body perception properly and to find a resolution through the process. Accordingly, individual perception and awareness in obesity management are important elements that must be defined as effective factors. Therefore, the aim of this study was to determine the factors affecting obesity and the participants’ self-perception of obesity.
agreed to participate, were included. No sampling method was used for this research. In this study, the WHO obesity classification was used. Five hundred eighty-six participants who were 18 years and older and with a BMI of 30 kg/m2 and above who applied to ¨ the primary health centers in Odemis ¸-Izmir were included in the study, which took place over the course of 1 year. Primary health centers were located close to individual residences. These centers were the first health institutes to apply for health services. They provided detailed and continuous primary care, diagnostics, treatment, and rehabilitation services as well as individually oriented preventive health services. The reasons for application provided by the participants were in line with the services provided by the institution. Investigators interviewed obese individuals who applied to these centers during the research period. Data were collected via face-to-face structured interviews in a suitable environment. The interviews took approximately 20 to 25 minutes. The cultural values of the participants that potentially affect body perception were similar to the general national values. The people who participated in the study were aged between 18 and 82 years, and their mean age was 48.59 ± 13.58 years. The gender distribution of the participants was 79.9% women and 20.1% men. It was determined that 55.5% of the participants were elementary school graduates, 79.5% were married, 90.8% had children, 58.2% had an income equal to their expenses, 92.5% had health insurance, and 51.7% lived with their spouse. The lifestyle characteristics of the participants indicated that 91.9% of the obese people under study did not use alcohol and 84% did not smoke, and 94.6% of the morbidly obese people did not use alcohol and 83.7% did not smoke.
Measurements
MATERIAL AND METHODS Design The study used a cross-sectional descriptive design to evaluate the obesity and health perceptions of obese and morbidly obese people and the factors that affect them.
Sample Five hundred eighty-six people who were 18 years and older with a BMI of 30 kg/m2 and above, and who
To collect data, a questionnaire with a total of 22 questions addressed the participants’ sociodemographic characteristics, wellness-disease perceptions, and perceptions of obesity. The sociodemographic questionnaire consisted of questions on sex, marital status, having a child, education, income, life conditions, and social security. The wellness-disease form consisted of questions on having chronic disease, obesity history of the family, a previous important disease, constant drug usage, alcohol, smoking, and appetite. Questions posed to the participants regarding obesity perceptions are shown in the Box.
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Obesity Perception
Ethical consideration Patients included in the study sample were informed about the objective of the study. Permission from the institutions where the research was conducted and a written permission letter were obtained for their voluntary participation, and they were assured that the data would be used without revealing their names.
Data analysis In evaluating the data, number, mean, and percentage distributions were used. To compare sociodemographic variables with obesity situations, the χ 2 test was used.
about dieting and consulting a doctor to lose weight, 53.8% of the obese participants reported that they never followed a diet and 62% of the morbidly obese participants followed diets, and 75.5% of the obese and 65.1% of the morbidly obese participants did not consult a doctor (Table 1). Analysis of wellness-disease perception revealed that 56.5% of the obese and 76.7% of the morbidly obese participants had chronic disease, although 51.4% of the morbidly obese people did not have a history of obesity in their families (62.4% of the morbidly obese people had a family history of
TABLE 1. Definitions Related to Obesity Perception
RESULTS
Morbidly Obese
Obese
In comparing the participants’ obesity with sociodemographic variables, a significant difference for sex, marital status, education, income, having social security, and living conditions (smoking, alcohol usage) could not be detected (P > .05). In evaluating people’s definition of their obesity perception, it was found that 80.1% of obese people and 76% of morbidly obese people see obesity as a disease. It was found that 60% of the obese people consider themselves obese, 24.7% as normal weight, and 15.3% as morbidly obese. When the morbidly obese people’s definitions were analyzed, it was found that 50.4% saw themselves as obese, 37.2% as morbidly obese, and 12.4% as normal weight. Of the people classified as obese, 63.9% of obese people and 60.5% of morbidly obese people were regarded as morbidly obese by their environments. When their perception of BMI as a threat was evaluated, it was found that 66.3% of obese participants and 75.2% of morbidly obese participants saw their weights as a threat. Furthermore, 59.1% of the obese participants and 75.2% of the morbidly obese participants stated that their weight affected their daily lives. When asked
Obesity Perceptions
n
%
n
%
Do you see obesity as a disease? Yes 366 80.1 98 76 No 47 10.3 16 12.4 Don’t know 44 9.6 15 11.6 How would you describe yourself? Normal 113 24.7 16 12.4 Obese 274 60.0 65 50.4 Morbidly obese 70 15.3 48 37.2 How would people around yourself describe you? Normal 93 20.4 6 4.7 Fat 292 63.9 78 60.5 Morbidly obese 72 15.8 45 34.9 Do you think your weight is a threat to your health? Yes 303 66.3 97 75.2 No 154 33.7 32 24.8 Does your weight affect your daily life? Yes 270 59.1 97 75.2 No 187 40.9 32 24.8 Have you ever followed a diet to lose weight? Yes 211 46.2 80 62 No 246 53.8 49 38 Have you ever consulted a doctor about your obesity? Yes 112 24.5 45 34.9 No 345 75.5 84 65.1
Box. Obesity Perception Questions Do you see obesity as a disease? How would you describe yourself? How would people around yourself describe you? Do you think your weight is a threat to your health? Does your weight affect your daily life? Have you ever followed a diet to lose weight? Have you ever consulted a doctor about your obesity?
() Yes () Normal () Normal () Yes () Yes () Yes () Yes
() No () Obese () Obese () No () No () No () No
() Don’t know () Morbidly obese () Morbidly obese
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obesity). There was consistent drug use among 53% of the obese and 72.1% of the morbidly obese people. It was determined that 91.9% of the obese participants did not use alcohol and 84.5% of them did not smoke, and 94.6% of the morbidly obese persons did not use alcohol and 83.7% did not smoke. The results showed that 44.9% of the obese people under study described their appetite as large and 55.8% of the morbidly obese people described their appetite as large. According to the participants’ self-descriptions, a significant difference was found between the groups in their perception of weight as a threat. This perception was significantly higher in the group that defined itself as obese than that in the other groups, and the perception of those who perceive themselves as normal was significantly lower than that of the other groups (χ 2 = 57.65; P = .01). According to the participants’ self-definitions, a significant difference was found between the groups in their perception of weight affecting their lives (χ 2 = 43.48; P = .01). A significant difference was also found for following a diet to lose weight among groups. After further analysis, it was determined that this difference was caused by the obese group (χ 2 = 23.33; P = .01). No correlation was found between the groups about consulting a doctor for obesity management (Table 2). A significant difference was found between participants’ BMI and individual obesity perception (χ 2 = 32.47; P = .01). A significant correlation was not found between BMI and the perception of weight as a threat to health. Furthermore, 59.1% of the obese and 75.2% of the morbidly obese participants expressed that their weight affected their daily lives.
A statistically significant difference was found between people’s weights affecting their daily lives depending on their BMIs (χ 2 = 11.15; P = .01). A significant difference was also found between following a diet to lose weight and their BMI. After further analysis, it was determined that this difference was caused by the obese group (χ 2 = 10.10; P = .01). No significant difference was found between obesity management and consulting a doctor depending on the persons’ BMI (Table 3).
DISCUSSION Correct body weight is defined as the harmony between perceived and measured body weight and potentially reveals the level of awareness regarding weight status and related health risks. The limited existing data show that incorrect body perception between overweight and obese individuals is related to key components that prevent weight control and weight loss, including weight-related attitudes (interest in eating and weight) and behaviors (fewer weight loss attempts, unhealthy food consumption, lower physical activity level).12 Body weight perception is related to certain elements, including sex, race, actual body weight, and socioeconomic status. In addition, sociocultural pressure perceived by the individual is very important for body perception. McCabe and Ricciardelli13 stated that sociocultural variables affect body image and body change strategies more than biological effects, age, and BMI. In this study, it was determined that obese individuals
TABLE 2. Comparison of Obesity Perceptions and Self-determination Self-determination Normal Obesity Perceptions
n
%
Do you think your weight is a threat to your health? Yes 60 46.5 No 69 53.3 Does your weight affect your daily life? Yes 57 44.2 No 72 55.8 Have you ever followed a diet to lose weight? Yes 51 39.5 No 78 60.5 Have you ever consulted a doctor about your obesity? Yes 35 27.1 No 94 72.9
Obese
Morbidly Obese
n
%
n
%
χ2
P
232 107
68.4 31.6
108 10
91.5 8.5
57.65
.00
210 129
61.9 38.1
100 18
84.7 15.3
43.48
.00
159 180
46.5 53.1
81 37
68.6 31.4
23.33
.00
87 252
25.7 74.3
35 83
29.7 70.3
0.72
.69
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229
TABLE 3. Comparison of Obesity Perceptions and BMI BMI Obese Obesity Perception
n
Morbidly Obese %
How would you describe yourself? Normal 113 27.4 Obese 274 60.0 Morbidly obese 70 15.3 Do you think your weight is a threat to your health? Yes 303 66.3 No 154 33.7 Does your weight affect your daily life? Yes 270 59.1 No 187 40.9 Have you ever followed a diet to lose weight? Yes 211 46.2 No 246 53.8 Have you ever consulted a doctor about your obesity? Yes 112 24.5 No 345 75.5
n
%
χ2
P
16 65 48
12.4 50.4 37.2
32.47
.00
97 32
75.2 24.8
3.67
.06
97 32
75.2 24.8
11.15
.00
80 49
62.0 38.0
10.10
.00
45 84
34.9 65.1
5.22
.14
Abbreviation: BMI, body mass index.
had a more accurate body weight perception than morbidly obese individuals. In the Coulson et al14 study, it was determined that 43% of the obese participants considered themselves as having a normal weight and 56% as being morbidly obese. Some researchers say that overweight and obese people may be incorrectly perceiving their weight as normal.14,15 According to Cachelin et al,16 a greater Anglo orientation was associated with a greater preference for thinner figures. Conversely, a greater Mexican orientation was associated with more tolerance for being overweight. The result of this research shows that people view obesity as a disease, but the lower average of people who consulted a dietician or a doctor for obesity management shows that there is not adequate awareness about this subject. Cultural structure can affect a person’s point of view and awareness toward obesity. In studies conducted in our country, increased dissatisfaction with one’s body has been observed among overweight individuals.7,11,12,17 The most important conclusion of this study was that most of the participants perceived obesity as an illness and considered it to be a threat to their health. The literature shows that obese people may be unaware of the increased risk for illnesses due to their weight.14,15 This finding highlights the success of informative studies related to obesity in our country. Although a slim body image is currently en vogue, the traditional inclination was that a lean figure indicates
sickness in some regions of our society and that obesity is a sign of power, prosperity, and health.9,12 This traditional understanding may affect the ability of individuals struggling with obesity to take action. Besides the cultural considerations, lifestyle changes are key for obesity management, and this process of change requires an individual to develop control over his or her health.18 In evaluating these data, it should not be forgotten that the difficulty of this process will affect obesity management at all stages. The results of this and similar studies will focus attention on the struggles related to obesity and chronic disease in our country at the national level, and detailed programs are being formed to increase awareness and provide actionable processes.19
CONCLUSION Although body perception and its relationship with obesity is an interesting field of study, the research in our country has mostly focused on the physiological aspects of obesity and the psychological and sociological effects of obesity have been neglected. Nursing is a profession that handles the individual as a whole with regard to physiological, psychological, and sociological aspects. Therefore, it is important for nurses to be aware of perceptions and problems related to physiological diseases or disorders, such as
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obesity; understanding these perceptions and issues is very important for the prevention of obesity and for ensuring its diagnosis and treatment in a holistic manner.8,20 The results of this study revealed that participants described obesity as a disease, in contrast to the traditional tendency. This result might mean that the national studies aimed at obesity have been effective in encouraging acceptance of obesity as a disease over the last few years. However, a lower percentage of people consulting health care professionals indicate that people’s awareness has not developed sufficiently, and it shows there are still obstacles in fighting obesity. Regarding the results of our study, we suggest that future studies should increase not only the knowledge but also the awareness of obesity.
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Limitations and suggestions There are some limitations to our research. Our sample cohort was sufficient in size, but the following limitations require discussion: r The participants’ chronic diseases were only evaluated on the basis of their existence or nonexistence; the details were not known. Similarly, continuous medication usage was only evaluated by answering questions with “yes” or “no.” It is difficult to ascertain which comes first, chronic illness or obesity, or whether both arise simultaneously. In studies on body perception in obese individuals, the collection of detailed data related to this subject would be useful. r Self-respect is an important indicator of perceived body image dissatisfaction. In our study, the effects of self-respect on body image were not evaluated, and more research on this subject is warranted in future studies. r In this study, data were required to define sociocultural attitudes that may affect body perception. More detailed studies should be performed to characterize sociocultural attitudes related to body perception. These studies are necessary to help determine the course and substance of preventive measures for the management of obesity.
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REFERENCES 1. World Health Organization. Obesity and Overweight. Obesity and Overweight Fact Sheet No: 311. Geneva, Switzerland: World Health Or-
18.
ganization. http://who.int/mediacentre/factsheets/fs311/en/print.html. Accessed May 17, 2014. Chan WB. Management of obesity—from life style modification to weight reduction. Hong Kong Med Diary Med Bull. 2010;15(2):5-7. Satman I; TURDEP II C ¸ alıs¸ma Grubu (TURDEP II Working Group). T¨urkiye Endokrinolojik Hastalıklar Prevelans C ¸ alıs¸ması [Turkey Endocrinologic Diseases Prevalence Study]. http://istanbultip.istanbul.edu .tr/wp-content/uploads/attachments/021_turdep.2.sonuclarinin .aciklamasi.pdf. Published 2010. Accessed May 17, 2013. ¨ Ozarma˘ gan S, Bozbora A. Obezitenin tanımı ve temel bilgiler [Definition of obesity and basic information]. In: Orhan Y, Bozbora A, eds. Obezite Medikal ve Cerrahi Tedavi [Medical and Surgical Treatment of Obesity]. Istanbul, Turkey: ˙Istanbul Medikal Yayıncılık Ltd; 2008: 289-301. Cooper Z, Fairburn C, Hawker DM, eds. Cognitive Behavioral Treatment of Obesity: A Clinicians Guide. New York, NY: Guilford Press; 2003. Obezitenin Bilis¸sel Davranıs¸c¸ı Tedavisi. C¸etin M, Sabancıo˘glu F, trans-eds. Istanbul, Turkey: Yıltem Matbaası; 2007. Rosen JC. Obesity and body image. In: Fairburn CG, Brownell KD, eds. Eating Disorders and Obesity: A Comprehensive Handbook. New York, NY: Guilford Press; 2002:399-402. Arma˘gan A. Obez kadınlarda benlik saygısının beden imgesi u¨ zerindeki etkisinde bic¸imleyici de˘gis¸kenlerin incelenmesi [Examining of Forming Variables the Influence of Self-esteem on Body Image in Obese Women] [master’s thesis]. Istanbul, Turkey: Psychology Department, Okan University; 2013:16-19. Aslan D. Beden algısı ile ilgili sorunların yaratabilece˘gi beslenme sorunları [Nutritional problems caused by body perception]. STED J Contin Med Educ. 2004;13(9):326-329. T¨urkiye Cumhuriyeti Sa˘glık Bakanlı˘gı Temel Sa˘glık Hizmetleri M¨ud¨url¨ug˘ u¨ (Republic of Turkey Ministry of Health). Sa˘glıklı Beslenelim, Kalbimizi Koruyalım Projesi Aras¸tırma Raporu. [Project research. Report: let’s eat healthy to protect cardiac health]. http:// www.beslenme.gov.tr/content/files/yayinlar/kitaplar/diger_kitaplar/ kalbimizi_koruyalim.pdf. Published 2004. Accessed June 5, 2013. T¨urk Dil Kurumu (Turkish Language Institute). Atas¨ozleri ve Deyimler S¨ozl¨ug˘ u¨ [Dictionary of Proverbs and Idioms]. http://tdk. gov.tr/index.php?option=com_atasozleri&arama=kelime&guid=TDK. GTS.54ca0919bc1de0.41437517. Accessed January 27, 2015. Ata A, Vural A, Keskin F. Beden algısı ve obezite [Body perception and obesity]. Ankara Med J. 2014;14(3):74-84. T¨urkiye Cumhuriyeti Sa˘glık Bakanlı˘gı Sa˘glı˘gın Gelis¸tirilmesi Genel M¨ud¨url¨ug˘ u¨ (Republic of Turkey Ministry of Health). T¨urkiye beden a˘gırlı˘gı algısı aras¸tırması [Body weight perception survey in Turkey]. http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/bedenagir tr.pdf. Published 2012. Accessed January 26, 2015. McCabe M, Ricciardelli L. Parent, peer and media influences on body image and strategies to both increase and decrease body size among adolescent boys and girls. Adolescence. 2001;36(142): 225-240. Coulson FR, Ypinazar VA, Margolis SA. Awareness of risks of overweight among rural Australians. Rural Remote Health. 2006;6: 514-527. Miller EC, Schulz MR, Bibeau DL, Galka AM, Spann LI, Martin LB. Factors associated with misperception of weight in the stroke belt. J Gen Intern Med. 2007;23:323-328. Cachelin FM, Monreal TK, Juarez LC. Body imageand size perceptions of Mexican American women. Body Image. 2006;3(1): 67-75. Batı U. Reklamcılıkta Retorik Bir Unsur Olarak Kadın Bedeni Temsilleri [Feminine body portrayal preferences in advertising as a component of rhetoric]. K¨ult¨ur ve I˙letis¸im (Cult Commun). 2010;13(1): 103-133. Bahar Z, Bes¸er A, G¨ordes N, Ersin F, Kıssal A. Sa˘glıklı yasam bic¸imi davranıs¸ları o¨ lc¸e˘gi II’nin gec¸erlilik g¨uvenilirlik c¸alıs¸ması [Healthy Life
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Obesity Perception Style Behavior Scale II: a reliability and validity study]. CU¨ Hems¸irelik Y¨uksekokulu Dergisi (Cumhuriyet Univ J Nurs). 2008;12(1):1-13. 19. T¨urkiye Cumhuriyeti Sa˘glık Bakanlı˘gı, Halk Sa˘glı˘gı Kurumu (Republic of Turkey Ministry of Health, Public Health Institution). T¨urkiye obezite ile m¨ucadele ve kontrol programı (2010-2014) [Struggle with obesity and control program in Turkey]. http://ailehekimligi
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The Perception of Obese Persons Cross Cultural Considerations ■
¨ uzo˘ ¨ glu, PhD ■ Sevcan Topc¸u, MScN Esra Oksel, PhD ■ Nazmiye C¸ıray Gund The aim of this study was to evaluate the perception of obesity in adults. The study sample included 586 participants (body mass index ≥30 kg/m2 and age ≥18 years). A questionnaire consisting of 22 questions was developed by the researchers in accordance with the literature. A statistically significant difference was found between the description and perception of weight as a threat to health (χ 2 = 57.65; P = .001). The perception of a threat to health was significantly higher in the group that described itself as overweight than other groups, and the group that described itself as having a normal weight had a significantly lower perception of a threat to health than other groups. The most important result of this investigation was that obesity was described by people but there was no awareness of the disease. It is suggested that future studies would increase people’s awareness of obesity management. KEY WORDS: obesity, self-perception, Turkey Holist Nurs Pract 2015;29(4):225–231
The World Health Organization (WHO) defines obesity as “abnormal or excessive fat accumulation in fat tissues in a degree to cause a health problem.” To determine obesity, the WHO’s definition is used, and, generally, the body mass index (BMI) is used as the unit. According to the frequently used WHO classification, a person with a BMI of 30 kg/m2 or more is generally considered obese. A person with a BMI of 40 kg/m2 or more is considered morbidly obese.1 Diseases that are caused by modifiable causes, which are related to lifestyles that include inappropriate nutrition, physical inactivity, and smoking, are very serious health problems. According to the WHO’s predictions, 60% of the causes of death in developed countries are diseases that are caused by lifestyle.2 As one of these diseases, obesity has gradually become prominent as a social problem within postmodern societies and has drawn attention due to its prevalence and incidence. According to the Author Affiliations: Departments of Medical Science Nursing (Drs Oksel and G¨und¨uzo˘glu) and Public Health Nursing (Ms Topc¸u), Ege University Faculty of Nursing, Bornova, Izmir, Turkey. Presented as a poster in 7th Metabolic Syndrome Symposium, April 29-May 2, 2010, Belek-Antalya, Turkey. The authors declare no conflict of interest. Correspondence: Esra Oksel, PhD, Department of Medical Science Nursing, Ege University Faculty of Nursing, 35100 Bornova, Izmir, Turkey ([email protected]). DOI: 10.1097/HNP.0000000000000094
WHO data, there are more than 400 million obese and approximately 1.6 billion slightly overweight people in the world.1 This rate is expected to grow to 700 million and 2.3 billion by the year 2015, respectively. The data obtained from the studies “Heart Disease Risk Factors of Adults in Turkey”’ (TEKHARF) and “Diabetes, Obesity and Hypertension Epidemiology in Turkey’ (TURDEP) showed that in the past 25 years in Turkey, the prevalence of obesity has increased in parallel with the growth observed in the world. TURDEP II was completed in 540 centers from 15 cities in the year 2010. The study found that the obesity frequency was 32% in Turkey.3 The gradual increase of obesity is called the “obesity epidemic.” The WHO sees this situation as a “global obesity epidemic.” With increasing frequency in the entire world, obesity is a chronic disease contributing to the risk of developing diabetes mellitus, metabolic syndrome, stroke, hypertension, ischemic heart disease, gallbladder disease, and certain carcinoma types.4 Body perception is how a person perceives his or her body when he or she envisions it in his or her head. Body perception, which is the whole mental notion of the body’s organs, creates the idea of “ego.” An individual’s perception of his or her own body is more subjective than objective. One person’s perception may not be in agreement with, and often is more negative than, others’ judgments. Body perception is important to consider as part of the general treatment of obese people.5 Most obese people do not like their 225
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
HOLISTIC NURSING PRACTICE • JULY/AUGUST 2015
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appearance, and this is generally the main reason why they want to lose weight. They believe that weight loss will increase their attractiveness and, consequently, they will feel better about themselves.6 Ideal standards of body size are culture-specific. Cultural values play an important role in understanding individual self-perception and comprehending the way in which an individual is perceived in the community. Culture and community play important roles in the configuration and development of body image. Body image created from a cultural point of view begins to form on the basis of the individual internalization of physical standards and messages from the community.7,8 From the community point of view, opinions related to body image in our country change daily. The general bias in our community is that slimness is perceived as illness, whereas obesity is associated with power, prosperity, and health.9 An old Turkish proverb states, “A piece of kilo covers a thousand defects.”10 The traditional understanding promotes a heavy weight as an ideal situation. Today, this traditional opinion is starting to change because of alterations in sociocultural views, largely with the support of mass communication tools; accordingly, the ideal of a slim body figure has started to appear for women and the ideal of a muscular body figure has begun to appear for men.7,11 In examining obesity and body perceptions, people’s dislike of themselves stands out. However, it is important for obese persons to demand appropriate treatment to evaluate their body perception properly and to find a resolution through the process. Accordingly, individual perception and awareness in obesity management are important elements that must be defined as effective factors. Therefore, the aim of this study was to determine the factors affecting obesity and the participants’ self-perception of obesity.
agreed to participate, were included. No sampling method was used for this research. In this study, the WHO obesity classification was used. Five hundred eighty-six participants who were 18 years and older and with a BMI of 30 kg/m2 and above who applied to ¨ the primary health centers in Odemis ¸-Izmir were included in the study, which took place over the course of 1 year. Primary health centers were located close to individual residences. These centers were the first health institutes to apply for health services. They provided detailed and continuous primary care, diagnostics, treatment, and rehabilitation services as well as individually oriented preventive health services. The reasons for application provided by the participants were in line with the services provided by the institution. Investigators interviewed obese individuals who applied to these centers during the research period. Data were collected via face-to-face structured interviews in a suitable environment. The interviews took approximately 20 to 25 minutes. The cultural values of the participants that potentially affect body perception were similar to the general national values. The people who participated in the study were aged between 18 and 82 years, and their mean age was 48.59 ± 13.58 years. The gender distribution of the participants was 79.9% women and 20.1% men. It was determined that 55.5% of the participants were elementary school graduates, 79.5% were married, 90.8% had children, 58.2% had an income equal to their expenses, 92.5% had health insurance, and 51.7% lived with their spouse. The lifestyle characteristics of the participants indicated that 91.9% of the obese people under study did not use alcohol and 84% did not smoke, and 94.6% of the morbidly obese people did not use alcohol and 83.7% did not smoke.
Measurements
MATERIAL AND METHODS Design The study used a cross-sectional descriptive design to evaluate the obesity and health perceptions of obese and morbidly obese people and the factors that affect them.
Sample Five hundred eighty-six people who were 18 years and older with a BMI of 30 kg/m2 and above, and who
To collect data, a questionnaire with a total of 22 questions addressed the participants’ sociodemographic characteristics, wellness-disease perceptions, and perceptions of obesity. The sociodemographic questionnaire consisted of questions on sex, marital status, having a child, education, income, life conditions, and social security. The wellness-disease form consisted of questions on having chronic disease, obesity history of the family, a previous important disease, constant drug usage, alcohol, smoking, and appetite. Questions posed to the participants regarding obesity perceptions are shown in the Box.
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Ethical consideration Patients included in the study sample were informed about the objective of the study. Permission from the institutions where the research was conducted and a written permission letter were obtained for their voluntary participation, and they were assured that the data would be used without revealing their names.
Data analysis In evaluating the data, number, mean, and percentage distributions were used. To compare sociodemographic variables with obesity situations, the χ 2 test was used.
about dieting and consulting a doctor to lose weight, 53.8% of the obese participants reported that they never followed a diet and 62% of the morbidly obese participants followed diets, and 75.5% of the obese and 65.1% of the morbidly obese participants did not consult a doctor (Table 1). Analysis of wellness-disease perception revealed that 56.5% of the obese and 76.7% of the morbidly obese participants had chronic disease, although 51.4% of the morbidly obese people did not have a history of obesity in their families (62.4% of the morbidly obese people had a family history of
TABLE 1. Definitions Related to Obesity Perception
RESULTS
Morbidly Obese
Obese
In comparing the participants’ obesity with sociodemographic variables, a significant difference for sex, marital status, education, income, having social security, and living conditions (smoking, alcohol usage) could not be detected (P > .05). In evaluating people’s definition of their obesity perception, it was found that 80.1% of obese people and 76% of morbidly obese people see obesity as a disease. It was found that 60% of the obese people consider themselves obese, 24.7% as normal weight, and 15.3% as morbidly obese. When the morbidly obese people’s definitions were analyzed, it was found that 50.4% saw themselves as obese, 37.2% as morbidly obese, and 12.4% as normal weight. Of the people classified as obese, 63.9% of obese people and 60.5% of morbidly obese people were regarded as morbidly obese by their environments. When their perception of BMI as a threat was evaluated, it was found that 66.3% of obese participants and 75.2% of morbidly obese participants saw their weights as a threat. Furthermore, 59.1% of the obese participants and 75.2% of the morbidly obese participants stated that their weight affected their daily lives. When asked
Obesity Perceptions
n
%
n
%
Do you see obesity as a disease? Yes 366 80.1 98 76 No 47 10.3 16 12.4 Don’t know 44 9.6 15 11.6 How would you describe yourself? Normal 113 24.7 16 12.4 Obese 274 60.0 65 50.4 Morbidly obese 70 15.3 48 37.2 How would people around yourself describe you? Normal 93 20.4 6 4.7 Fat 292 63.9 78 60.5 Morbidly obese 72 15.8 45 34.9 Do you think your weight is a threat to your health? Yes 303 66.3 97 75.2 No 154 33.7 32 24.8 Does your weight affect your daily life? Yes 270 59.1 97 75.2 No 187 40.9 32 24.8 Have you ever followed a diet to lose weight? Yes 211 46.2 80 62 No 246 53.8 49 38 Have you ever consulted a doctor about your obesity? Yes 112 24.5 45 34.9 No 345 75.5 84 65.1
Box. Obesity Perception Questions Do you see obesity as a disease? How would you describe yourself? How would people around yourself describe you? Do you think your weight is a threat to your health? Does your weight affect your daily life? Have you ever followed a diet to lose weight? Have you ever consulted a doctor about your obesity?
() Yes () Normal () Normal () Yes () Yes () Yes () Yes
() No () Obese () Obese () No () No () No () No
() Don’t know () Morbidly obese () Morbidly obese
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obesity). There was consistent drug use among 53% of the obese and 72.1% of the morbidly obese people. It was determined that 91.9% of the obese participants did not use alcohol and 84.5% of them did not smoke, and 94.6% of the morbidly obese persons did not use alcohol and 83.7% did not smoke. The results showed that 44.9% of the obese people under study described their appetite as large and 55.8% of the morbidly obese people described their appetite as large. According to the participants’ self-descriptions, a significant difference was found between the groups in their perception of weight as a threat. This perception was significantly higher in the group that defined itself as obese than that in the other groups, and the perception of those who perceive themselves as normal was significantly lower than that of the other groups (χ 2 = 57.65; P = .01). According to the participants’ self-definitions, a significant difference was found between the groups in their perception of weight affecting their lives (χ 2 = 43.48; P = .01). A significant difference was also found for following a diet to lose weight among groups. After further analysis, it was determined that this difference was caused by the obese group (χ 2 = 23.33; P = .01). No correlation was found between the groups about consulting a doctor for obesity management (Table 2). A significant difference was found between participants’ BMI and individual obesity perception (χ 2 = 32.47; P = .01). A significant correlation was not found between BMI and the perception of weight as a threat to health. Furthermore, 59.1% of the obese and 75.2% of the morbidly obese participants expressed that their weight affected their daily lives.
A statistically significant difference was found between people’s weights affecting their daily lives depending on their BMIs (χ 2 = 11.15; P = .01). A significant difference was also found between following a diet to lose weight and their BMI. After further analysis, it was determined that this difference was caused by the obese group (χ 2 = 10.10; P = .01). No significant difference was found between obesity management and consulting a doctor depending on the persons’ BMI (Table 3).
DISCUSSION Correct body weight is defined as the harmony between perceived and measured body weight and potentially reveals the level of awareness regarding weight status and related health risks. The limited existing data show that incorrect body perception between overweight and obese individuals is related to key components that prevent weight control and weight loss, including weight-related attitudes (interest in eating and weight) and behaviors (fewer weight loss attempts, unhealthy food consumption, lower physical activity level).12 Body weight perception is related to certain elements, including sex, race, actual body weight, and socioeconomic status. In addition, sociocultural pressure perceived by the individual is very important for body perception. McCabe and Ricciardelli13 stated that sociocultural variables affect body image and body change strategies more than biological effects, age, and BMI. In this study, it was determined that obese individuals
TABLE 2. Comparison of Obesity Perceptions and Self-determination Self-determination Normal Obesity Perceptions
n
%
Do you think your weight is a threat to your health? Yes 60 46.5 No 69 53.3 Does your weight affect your daily life? Yes 57 44.2 No 72 55.8 Have you ever followed a diet to lose weight? Yes 51 39.5 No 78 60.5 Have you ever consulted a doctor about your obesity? Yes 35 27.1 No 94 72.9
Obese
Morbidly Obese
n
%
n
%
χ2
P
232 107
68.4 31.6
108 10
91.5 8.5
57.65
.00
210 129
61.9 38.1
100 18
84.7 15.3
43.48
.00
159 180
46.5 53.1
81 37
68.6 31.4
23.33
.00
87 252
25.7 74.3
35 83
29.7 70.3
0.72
.69
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Obesity Perception
229
TABLE 3. Comparison of Obesity Perceptions and BMI BMI Obese Obesity Perception
n
Morbidly Obese %
How would you describe yourself? Normal 113 27.4 Obese 274 60.0 Morbidly obese 70 15.3 Do you think your weight is a threat to your health? Yes 303 66.3 No 154 33.7 Does your weight affect your daily life? Yes 270 59.1 No 187 40.9 Have you ever followed a diet to lose weight? Yes 211 46.2 No 246 53.8 Have you ever consulted a doctor about your obesity? Yes 112 24.5 No 345 75.5
n
%
χ2
P
16 65 48
12.4 50.4 37.2
32.47
.00
97 32
75.2 24.8
3.67
.06
97 32
75.2 24.8
11.15
.00
80 49
62.0 38.0
10.10
.00
45 84
34.9 65.1
5.22
.14
Abbreviation: BMI, body mass index.
had a more accurate body weight perception than morbidly obese individuals. In the Coulson et al14 study, it was determined that 43% of the obese participants considered themselves as having a normal weight and 56% as being morbidly obese. Some researchers say that overweight and obese people may be incorrectly perceiving their weight as normal.14,15 According to Cachelin et al,16 a greater Anglo orientation was associated with a greater preference for thinner figures. Conversely, a greater Mexican orientation was associated with more tolerance for being overweight. The result of this research shows that people view obesity as a disease, but the lower average of people who consulted a dietician or a doctor for obesity management shows that there is not adequate awareness about this subject. Cultural structure can affect a person’s point of view and awareness toward obesity. In studies conducted in our country, increased dissatisfaction with one’s body has been observed among overweight individuals.7,11,12,17 The most important conclusion of this study was that most of the participants perceived obesity as an illness and considered it to be a threat to their health. The literature shows that obese people may be unaware of the increased risk for illnesses due to their weight.14,15 This finding highlights the success of informative studies related to obesity in our country. Although a slim body image is currently en vogue, the traditional inclination was that a lean figure indicates
sickness in some regions of our society and that obesity is a sign of power, prosperity, and health.9,12 This traditional understanding may affect the ability of individuals struggling with obesity to take action. Besides the cultural considerations, lifestyle changes are key for obesity management, and this process of change requires an individual to develop control over his or her health.18 In evaluating these data, it should not be forgotten that the difficulty of this process will affect obesity management at all stages. The results of this and similar studies will focus attention on the struggles related to obesity and chronic disease in our country at the national level, and detailed programs are being formed to increase awareness and provide actionable processes.19
CONCLUSION Although body perception and its relationship with obesity is an interesting field of study, the research in our country has mostly focused on the physiological aspects of obesity and the psychological and sociological effects of obesity have been neglected. Nursing is a profession that handles the individual as a whole with regard to physiological, psychological, and sociological aspects. Therefore, it is important for nurses to be aware of perceptions and problems related to physiological diseases or disorders, such as
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obesity; understanding these perceptions and issues is very important for the prevention of obesity and for ensuring its diagnosis and treatment in a holistic manner.8,20 The results of this study revealed that participants described obesity as a disease, in contrast to the traditional tendency. This result might mean that the national studies aimed at obesity have been effective in encouraging acceptance of obesity as a disease over the last few years. However, a lower percentage of people consulting health care professionals indicate that people’s awareness has not developed sufficiently, and it shows there are still obstacles in fighting obesity. Regarding the results of our study, we suggest that future studies should increase not only the knowledge but also the awareness of obesity.
2. 3.
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Limitations and suggestions There are some limitations to our research. Our sample cohort was sufficient in size, but the following limitations require discussion: r The participants’ chronic diseases were only evaluated on the basis of their existence or nonexistence; the details were not known. Similarly, continuous medication usage was only evaluated by answering questions with “yes” or “no.” It is difficult to ascertain which comes first, chronic illness or obesity, or whether both arise simultaneously. In studies on body perception in obese individuals, the collection of detailed data related to this subject would be useful. r Self-respect is an important indicator of perceived body image dissatisfaction. In our study, the effects of self-respect on body image were not evaluated, and more research on this subject is warranted in future studies. r In this study, data were required to define sociocultural attitudes that may affect body perception. More detailed studies should be performed to characterize sociocultural attitudes related to body perception. These studies are necessary to help determine the course and substance of preventive measures for the management of obesity.
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