Changing perceptions of weight in Great Britain: comparison of two population surveys
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a494 (Published 10 July 2008) Cite this as: BMJ 2008;337:a494
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Dear Editor,
Our recent research echoes concerns raised by F Johnson et al (1) for
public health campaigns aimed at reducing obesity, if overweight
individuals do not perceive themselves to be overweight and therefore fail
to “identify themselves as targets”. We systematically reviewed the
parental perception of overweight status in overweight children (2). We
identified the proportion of parents able to recognize overweight status
in their children, who were recorded as being overweight by
internationally recognized standards. In twenty-three studies,
representing 3864 overweight children from 7 countries, we found that more
than half of parents were unable to recognize when their child was
overweight. 17/ 23 studies defined overweight status in children using
body mass index (BMI) > 95th centile or the International Obesity Task
Force criteria (3), but in total 5 distinct standard definitions of
overweight status were reported. Parental recognition of their child's
overweight status ranged from 6.2% to 73%, but in 19 of 23 studies, it was
less than 50%.
This low rate of recognition is even more alarming than findings from
Johnson et al’s adult survey (1) but both research pieces highlight that
in this increasingly overweight nation, despite increasing media coverage,
we cannot rely on individuals to refer themselves or their children for
weight-reduction interventions. This also presents difficulties for health
professionals who opportunistically raise the issue of health risk from
being overweight, particularly in children where definitions for
overweight status are inconsistently applied. We predict as populations
get fatter that perceptions will adjust to accept overweight morphology as
the norm and therefore reliance on individuals to seek weight-reduction
interventions is likely to be increasingly ineffective.
A more systematic approach to identify overweight children through
population, primary care or school based screening would avoid reliance on
parents to come forward. Currently the paucity of successful weight
reduction interventions in children who are already overweight and at risk
of obesity means that such screening does not meet WHO criteria. Further
research into interventions that tackle overweight and prevent obesity
must be a research priority.
References:
1.Johnson F, Cooke L, Croker H, Wardle Jane. Changing perceptions of
weight in Great Britain: comparison of two population surveys. BMJ
2008;337:a494
2.Parry L, Netuveli G, Parry J, Saxena S. A Systematic Review of
Parental Perception of Overweight Status in Children. J Ambul Care Manage
2008 Jul-Sep;31(3):253-68)
3.Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard
definition for child overweight and obesity worldwide: international
survey. BMJ 2000;320:1240-1243
Competing interests:
None declared
Competing interests: No competing interests
Johnson et al have interpreted reduced self-reporting by over-weight
or obese individuals as 'a marked decline in sensitivity with respect
to individuals' detection of their own weight'. I would like to
propose an alternative hypothesis for interpreting these results.
The results do show people who are 'not' over weight or obese were
actually more aware of their 'achievement', hence the results show
increased specificity.
In recent years, we have seen an increase in social pressure to be
thin with the rise of the size zero culture. This can potentially have
stigmatizing effect on those who do not possess the perfect body. This
might have added to the burden of shame on these individuals and could
have further marginalized them from disclosing their honest
perceptions. The lack of sensitivity found in this study might have
been a reflection of their psychological defense where they have used
minimization strategies to avoid blame from society for their weight.
Moreover, during this time the World Health Organization lowered the
cut-off for the 'normal' BMI from 20 to 18.5. This attempt at coming
up with a 'one-size-fit' for the whole world have also added to
increased pressures to be thin.
While obesity has increased shockingly, incidences for conditions such
as bulimia nervosa are also increasing. There is little to tell us
about the prevalence of conditions such as binge eating disorder in
the general population or in obese or over-weight people.
If public health campaigns come across as harsh and critical they risk
further pushing away these already estranged and vulnerable people,
and would fail to offer true help. Campaigns should be motivational
and sensitive to have a wide appeal and to avoid breaking the first
rule of medicine in avoiding doing harm to people. On this matter, I
was appalled at the lack of sensitivity of BMJ cover for the issue.
Competing interests:
None declared
Competing interests: No competing interests
The article by F Johnson et al, “Changing perceptions of weight in
Great Britain: comparison of two population surveys” (1) has in an
interesting way elucidated the perception change undergone by two
populations over a period of time.
The questions that we would like to raise are,
1) What are the different racial populations studied and their
numbers within the entire number of people surveyed? As Britain has
different ethnic groups, especially a large South- East Asian population,
weight perceptions in these different populations tend to differ and hence
further demographic composition should have been taken into consideration
and stated in the study by the authors.
2) The second point that we would like to raise is the WHO
recommended cut-off for normal BMI which is 18.5-24.9 (2). Recent studies
have shown that Asian populations need to have a lower cut-off in their
BMI to define being overweight and obesity as metabolic syndrome and the
risk for diseases like diabetes and coronary heart disease are higher in
these populations(3,4). If the study population has included multi-ethinic
people of Caucasian, Asian and African origin, then the revised criteria
should have been applied to these specific populations in the study for
obesity cut-off values.
3) What is the socio-economic stratification of the people surveyed?
This has not been done and could have added additional dimensions to the
perception change that has occurred over the years.
The perception of being overweight has an aura of unhealthiness
around it. We would like to emphasize that BMI happens to be a simplistic
way of assessing this parameter and is only a reflectance of body weight
and not of adiposity (5).
Statement of competing interests: None
References
1) F Johnson, L Cooke, H Croker, Jane Wardle. Changing perceptions of
weight in Great Britain: comparison of two population surveys. BMJ. 2008
July 10;337:a494
2) World Health Organization. Report of a WHO Consultation on
Obesity. Obesity: preventing and managing the global epidemic. Geneva:
World Health Organization, 1998.
3) WHO Expert Consultation. Appropriate body-mass index for Asian
populations and its implications for policy and intervention strategies.
Lancet. 2004 Jan 10;363(9403):157-63.
4) Wen CP, David Cheng TY, Tsai SP, Chan HT, Hsu HL, Hsu CC, Eriksen
MP. Are Asians at greater mortality risks for being overweight than
Caucasians? Redefining obesity for Asians. Public Health Nutr. 2008 Jun
12:1-10. [Epub ahead of print]
5) Van S Hubbard. Defining overweight and obesity: what are the
issues? American Journal of Clinical Nutrition. 2000 Nov; 72(5):1067-1068
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Johnson et al suggest several explanations for the increasing
inability of overweight individuals to recognise themselves as such.
An additional factor encouraging such misperception might be clothing
size. UK ladies clothing sizes have the arbitrary classification of
10,12,14 etc. This system gives purchasers no accurate feedback about
their actual size and allows scope for self-deception!
For example, in my wardrobe hang a pair of size 14 trousers purchased
from a leading high street merchandiser in approximately 1995. Although
these trousers remain a good fit (neither too large nor too small) I now
require a size 10 trouser from the same retailer.
So should I believe that I am two sizes smaller than when an SHO!
The fashion industry might influence in this area of public health.
Realistic and consistent sizing rather than the current ever-expanding and
increasingly generous system might help people both to recognise their
size and take appropriate action. Without the intervention of a physician
most ladies would surely pale to realise they are not the perfect 10 they
have been encouraged to imagine!
Yours sincerely,
Sara Smith
Competing interests:
None declared
Competing interests: No competing interests
Professor Wardle (BMJ 2008;337:a494) observes that in part the public
fails to recognise overweight people because "Photographic illustrations
often depict severely obese people, untypical of the overweight
population."
On the cover of today's BMJ there are two women sunbathing, one is of
normal build (I guess around BMI=23) and the other is not (I guess
BMI>40). I looked for information about the actual BMI of these two,
but failed to find it.
Did you intend this cover picture to test, or to educate your
readers? It did neither, but comitted the error about which Prof Wardle
was complaining. What a pity that you did not show a model of BMI=31 and
ask your readers is she was obese. (The correct answer is "YES").
Competing interests:
None declared
Competing interests: No competing interests
A time to move on to a new categorization for weight issues.
There is perhaps a need to have a re-look at the classification of
weight. At times it may be the constitution/ build of an individual which
might be the reason for the overweight or underweight. There could be
individuals who might be underweight or overweight and might be having
underlying or related issues or perhaps some complications. Recently,
Roger Collier and Dutton et al have raised a very pertinent issue about
the stigma being associated with the term obesity [1,2]. We also feel
that the classification of weight by categorizing them underweight, normal
weight, overweight, and obesity is outdated and needs a change as well.
The classification, we feel, should be meaningful, not embarrassing any
individual, and should be able to grade the problem appropriately.
For this, we propose a classification which could be more meaningful,
acceptable, and would also be taking away the stigma [3].
(a) Weight "N" (healthy weight, BMI 18.5-24.9)
(b) Weight "UNC" (underweight constitutional/ heredity)
(c) Weight "UN" (underweight)
(d) Weight "CUN" (underweight with complications)
(e) Weight "A" (overweight)
(f) Weight "AC" (overweight constitutional/ heavy built)
(g) Weight "B" (simple obesity)
(h) Weight "C" (obesity with complications)
(i) Weight "D" (BMI 50 or above, for mammoth, monstrous and
grotesque)
(j) Weight "E" (obesity relapse after bariatric surgery)
Perhaps a still better classification can be worked out by the
experts. This is just an example of how can weight be classified, making
it clinically more relevant, and may be helpful in formulating strategies
for identifying and management, while taking away the stigma of being
labeled as obese or underweight. Such a classification can perhaps
provide a standardized framework making it possible to describe the extent
and impact of disease in a way that all clinicians, researchers and health
insurance companies/ payers might comprehend easily.
Best regards.
Dr. Rajesh Chauhan
Dr. Shruti Chauhan
Dr. Akhilesh Kumar Singh
Dr. Parul Chauhan
References:
1. Roger Collier. Who you calling obese, Doc? CMAJ 2010; 182: 1161-
1162
2. Dutton GR., Tan F, Perri MG, Stine CS, Dancer-Brown M, Goble M,
Vessem NV. What Words Should We Use When Discussing Excess Weight? J Am
Board Fam Med 2010 23: 606-613.
3. Rajesh Chauhan. A new categorization for weight issues. CMAJ 16
August 2010. http://www.cmaj.ca/cgi/eletters/182/11/1161#595599 (Accessed
15 Dec 2010)
Competing interests: No competing interests