The disproportionately elevated and steadily increasing rates of overweight and obesity among racial/ethnic minority communities [1
] constitutes a major public health crisis. The major determinants of the obesity epidemic in all populations – dietary and physical activity practices – may be heavily patterned by sociocultural influences, such as the tendency to misperceive one's weight status. In the present study, we found that overweight and obese Blacks, compared to their White counterparts, were disproportionately more likely to categorize themselves as being "about the right" weight.
Overweight Black men and women each had more than a two-fold increased likelihood of perceiving their weight status. Relative to Whites, obese Black adults were even more likely to exhibit weight status misperceptions. These results were independent of sociodemographic characteristics, traditional individual-level measures of socioeconomic position, and self-reported receipt of physician diagnosis of overweight. Our findings highlight the importance of more frequently incorporating sociocultural factors, particularly perceived weight status, into both clinical and public health obesity reduction approaches for Blacks.
Racial/ethnic differences in perceived weight among women have been previously shown; however, most studies have been conducted among relatively small, select samples, including high proportions of college students. Among the few previous studies conducted using nationally-representative data, Paeratakul et al (in the 1994–1996 Continuing Survey of Food Intakes by Individuals and the Diet and Health Knowledge Survey) showed that Whites were 2.3 times more likely than non-Whites to perceive themselves to be overweight. However, the authors failed to disaggregate the non-White category to examine whether Blacks and/or Hispanics had higher odds of inaccurate perceptions. In the NHANES III cohort, Kuchler and Variyam [9
]reported that the prevalence of perceived overweight was lower among both overweight and obese Blacks, compared to Whites. Trends for Hispanic respondents in the study were similar to those of Blacks; however the prevalence of misperception among obese Hispanics did not significantly differ from Whites. Kuchler and Variyam's analysis was limited to the presentation of prevalence data; however, this allows us to compare the prevalence of misperception in the NHANES III cohort (1988–1994) to our data in the NHANES 1999–2002 samples. Over a period of time characterized by secular trends for weight gain in the general population, misperception rates among Black in particular, continued to increase among both men and women. Among overweight men, the prevalence of misperception increased in all racial/ethnic groups (White: 8%, Black: 14%, Hispanic: 22%); however, for obese men, misperception rates decreased for both Whites and Hispanics by about 13.5%, while over the same period they increased by over 49% for Blacks. Among women, sizeable increases were seen in the prevalence of perceived normal weight among both White and Black overweight (44% and 52% respectively) and obese (16% and 21% respectively) women. However, among Hispanic women, a 5% decrease in misperceptions was seen for both overweight and obese women.
What might explain the greater potential for overweight Blacks to misperceive their weight status? As has been previously mentioned, considerable research evidence has identified myriad sociocultural influences (e.g. heavier body image ideals, fewer social pressures to lose weight) that might be implicated [2
]. An unanswered question concerns whether Blacks' tendency to misperceive their weight status is a function of weight satisfaction, or a lack of awareness about the extent of their overweight. Given previous evidence of Blacks' high levels of weight satisfaction, it is possible that responses to the studied perceived weight question may have been biased among those who were more weight satisfied. Alternatively, our findings may highlight a lack of awareness about the clinical thresholds for overweight and obesity; this limited awareness may be influenced by the high prevalence of the conditions among Blacks. We have previously speculated that, rather than considering their membership in BMI-defined categories, some Blacks might rely on social comparison to make judgments about their respective weight status. Given that overweight and obesity among Blacks (particularly among women) has reached nearly normative levels, such social comparison among the overweight might negatively bias individuals' judgments about their respective weight status. Whether this potential mechanism extends to Black men (given their lower absolute levels of overweight and obesity compared to women) is unclear. The mechanisms responsible for Blacks' weight status perceptions may be particularly important to discern, given our finding that misperceptions persisted after adjustment for self-reported physician diagnosis of overweight.
We were surprised to find that racial/ethnic differences going perceived weight remained after adjusting for adjustment for receipt of physician diagnosis of overweight. Physician diagnosis and counseling for weight reduction among the overweight has increasingly been recommended, [12
] though its frequency remains low . Given that Blacks remained more likely to misperceive their weight after adjustment for the diagnosis variable, we hypothesize that some Black patients might be resistant to physician diagnoses of overweight. Generic messages of a patient's overweight (i.e. those that do not discuss the clinical thresholds of overweight in some detail, provide a description of the health risks associated with overweight and obesity), or non-comprehensive counseling may have little effect, particularly given that many Blacks do not recognize the health consequences of overweight and obesity [11
] and may not be readily motivated by weight-related aesthetic concerns. However, as weight status misperception may also protect against eating and body image disorders (which are less common among Blacks), misperception correction strategies should be carefully considered.
Our study has several strengths and extends prior findings in a number of important ways. First, rather than presenting only prevalence data, our focus was to systematically examine sources of racial/ethnic variation in perceived weight status, adjusted for relevant confounders. Our data were collected during the period of time when public awareness of obesity and its associated health consequences increased dramatically. One might have expected the greater public attention to obesity occurring during this period to have enhanced individual's ability to more accurately perceive their weight status. Of course, a number of considerations may limit interpretations drawn from our findings. BMI as a measure of body weight does not incorporate body fat distribution, which may be differentially associated with obesity-related health conditions by race/ethnicity. Furthermore, the variable reflecting physician diagnosis of overweight was not time-delimited (e.g., prior 12 months), thus providing some possibility of temporal differences in the time since receipt of diagnosis. However, responses to this variable are unlikely to vary systematically by race/ethnicity. Small cell sizes in some categories may have impacted our estimates. Finally, Mexican-Americans are overrepresented in the NHANES category; thus, there should be cautioned own revelations made to other Hispanic sub-groups.
Correcting misperceptions of weight status may be necessary to actively and successfully engage individuals in overweight and obesity control efforts. As increasing attention is directed towards the treatment and prevention of obesity among racial/ethnic minorities, identifying similar disproportionately prevalent sociocultural influences should be a high priority.