Public perception of overweight

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a347 (Published 10 July 2008) Cite this as: BMJ 2008;337:a347
  1. Sara N Bleich, assistant professor of health policy and management
  1. 1Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
  1. sbleich{at}jhsph.edu

    Underestimation of weight status hasimportant implications for public health programmes

    The mismatch between self perceived and self reported weight has been documented for decades; women typically view themselves as heavier than they really are, whereas men often underestimate their weight.1 We do not know whether people’s perception of their weight has changed with the rapidly growing obesity epidemic, in which more than 300 million adults worldwide are overweight.2

    In the linked study, Johnson and colleagues look at adults’ changing perceptions of weight in the United Kingdom over eight years and find that heavier people were less likely to think that they were overweight in 2007 than in 1999.3 The authors attribute the declining concordance between self reported and self perceived weight to the greater stigma of being overweight, which may discourage people from identifying themselves as overweight or obese, and to changing societal norms, which may have increased the threshold at which people think of themselves as overweight. This shift is reinforced by media presentations of people who are morbidly obese, who are not representative of the overweight population. Johnson and colleagues also found that concordance between self reported and self perceived weight among normal and underweight individuals had improved—a trend most notable among women. This finding suggests that fewer people of healthy weight now have negative body images.

    Data on temporal trends in public perception of weight are important, given the positive association between self perceived weight status and behaviours to control weight. Because individuals who view themselves as overweight or obese are, for example, more likely to engage in dieting,4 this implies that a better understanding of changing perceptions of weight and its determinants is key, particularly in those subpopulations where the prevalence of obesity is highest.

    Since behaviour change is largely motivated by perceived risk,5 the public’s failure to accurately assess their weight status in accordance with clinically accepted categories has important implications for public health programmes targeting overweight people. If a considerable proportion of overweight people misclassify their weight, they may ignore important messages about modifying their lifestyles.

    Healthcare professionals have a role in correcting misconceptions about weight. Doctors, who underdiagnose and undermanage obesity,6 should be better trained and given incentives to manage overweight patients, who are more likely to try to lose weight when advised to do so.7 Tackling weight related discrimination among health professionals is also important.8 The evidence indicates, however, that although solutions at an individual level are important, they have mostly been unsuccessful at reducing the prevalence of obesity because they ignore the nested relationship between the individual, the family, and the broader environment. People’s decisions, actions, and health outcomes depend not only on their characteristics but also on the social forces that shape the way they live.9

    Highlighting the importance of treating obesity as a multilevel problem, Friel and colleagues wrote, “Missing in most obesity prevention strategies is the recognition that obesity—and its unequal distribution—is the consequence of a complex system that is shaped by how society organises its affairs.”10 This belief that interventions to prevent obesity would be more effective if they included a combined focus on the individual and broader society is widely held by experts. Yet, efforts in this direction are moving slowly because of the challenges of obtaining funding and the complexity of conducting multilevel research on a problem for which the debate about the exact set of proximal and distal causes continues.

    How, then, can we better align perceptions of weight with reality at the population level? As a first step, we should recognise that the complexity of self perceived weight does not lend itself to a magic bullet solution. Rather, correcting a person’s misconceptions about their weight takes time and requires a comprehensive approach. In the interim, public health programmes might consider some concrete strategies. One important theme is education. Efforts should be made to sensitise the entire population to the importance of healthy lifestyle modifications—a goal that could be achieved through media messages that target many aspects of the environment (such as, home, workplace, and community).

    Most people believe that obesity is related more to personal behaviour than to the broader society,11 so educating the public about the obesogenic (weight promoting) environment is also critical. Another important theme is increasing people’s awareness of healthy lifestyle in a manner that considers weight related stigma. Creating public health campaigns focused on the entire population rather than only on overweight or obese individuals is one possibility. Working with the popular press and television industry to diminish negative stereotyping of obese people is another.12 Partnerships with the food, beverage, or television industries—promoting healthy lifestyles or positive body images—may help facilitate these activities.

    Correcting misconceptions about weight is not simple, and represents one piece of the complicated puzzle that is the obesity epidemic—a problem that requires concerted efforts at the local, national, and global levels, which needs to capitalise on evidence to shape public health policy.


    Cite this as: BMJ 2008;337:a347