In our study of South Asian Americans, the prevalence of overweight and obesity were high, and underestimation of weight status and the consequences of being overweight were common. Misperceptions about weight status and weight-related health consequences were particularly common among participants who had a BMI between 23 and 27.5; these people are considered overweight or moderate risk according to Asian-specific categories, but about half are considered normal weight according to general population categories. To our knowledge, ours is the first research study describing perceptions of weight and the health effects of weight in South Asian Americans, a population at high risk for diabetes and cardiovascular disease (15
Our finding that South Asian Americans underestimate their weight status and weight-related health consequences is not surprising. These underestimations are common and increasingly prevalent among the general population of the United States (9
). Among white populations, approximately one-third of overweight and 5% of obese people perceive their weight to be normal (10
). Among Hispanic and African American populations, the magnitude of underestimation is even higher (10
). Studies in the United Kingdom indicate that overweight South Asian women are more likely than white women to underestimate their weight status (20
) and to equate a larger body size with health (22
). Although our study did not compare South Asians with other racial/ethnic groups, the degree of underestimation of weight status may be greater among South Asians than among other groups.
Although study participants frequently cited physical weight-related problems, few associated their weight with the risk for developing chronic diseases. Many participants were aware in general that excess weight can contribute to chronic diseases, but most did not personalize this risk. The gap between general risk perception and personal risk perception has been documented in other medical conditions, including HIV (23
). Lack of a perceived connection between one’s weight and chronic disease risk has been reported among other populations (24
), but it may be a particular problem for South Asian Americans, who develop insulin resistance (and thus diabetes and cardiovascular disease) at a lower BMI than do other racial/ethnic groups.
Our study suggests a possible association between increasing age and greater underestimation of weight status, which deserves further exploration in future studies. Increasing age has been positively correlated with misperception of weight status in other studies and populations, including adults in Pakistan (26
). These misperceptions may relate to acceptance of weight gain with age, greater prevalence of overweight among older people, and the tendency for people to assess their weight status in comparison with their peers. Studies among white populations have suggested that overweight women are more likely than men to agree that they are overweight (27
), but our study did not identify any differences by sex.
Our study has several strengths. First, the qualitative research design allowed for a richness of data not found in secondary data analyses. Second, half the participants were men, for whom data are lacking in research on weight. Third, this research addresses weight perceptions among a low-income and underinsured South Asian population that prefers to communicate in a non-English language — a population that may be harder to reach and at even higher risk for diabetes and cardiovascular disease than the general South Asian population (28
). Fourth, BMI was calculated from measured heights and weights, not self-reported data. Finally, we used rigorous qualitative methods; 20% of the surveys were coded by 2 investigators.
Our study has several limitations. We used a convenience sample from a federally qualified health center and a community center in a single metropolitan area; the sample size was not sufficient to evaluate differences between Indian and Pakistani Americans. Although our participants were similar demographically to the South Asian population of the neighborhood from which the sample was drawn, our results may not be generalizable to all South Asians in the United States (12
). Second, open-ended responses related to perceived weight status were not corroborated with close-ended categorical classification. Third, because participants were not probed about the many ways in which their weight could affect their health, their responses reflect a prioritized, rather than comprehensive, view. Fourth, because our study was not powered to evaluate differences by sociodemographic characteristic, our analyses should be considered exploratory. Fifth, our data were collected several years ago, but they are still relevant because societal attitudes toward weight have not changed much since then. Despite aggressive public health campaigns to increase awareness and understanding of the concept of healthy weight, the general population continues to under-recognize overweight and obesity (30
Our study suggests that interventions to promote weight loss among South Asian Americans should focus on reforming perceptions of normal weight, establishing the connection between overweight and the development of chronic diseases, and strengthening the perceptions of personal risk. These measures will be difficult to achieve unless the US health care system formally adopts lower BMI cut-offs for overweight and obesity for South Asian Americans.