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BODY IMAGE PERCEPTION AMONGST WOMEN AGED 25-35 YEARS IN A RURAL AREA OF TAMIL NADU, ITS

ASSOCIATION WITH THE CURRENT NUTRITIONAL STATUS, BODY IMAGE PERCEPTION DISCREPANCIES,

WEIGHT REDUCING BEHAVIOURS AND EATING DISORDERS

A dissertation submitted in partial fulfilment of the

requirement of the Tamil Nadu Dr M.G.R Medical University,

Chennai, for the degree of MD Branch-XV

(Community Medicine) examination to be held in May 2018

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PLAGIARISM ANALYSIS REPORT URKUND

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ACKNOWLEGEMENTS

I would like to thank

The almighty God for providing all grace to complete my thesis

Dr Shantidani Minz, my guide for all the guidance, help and effort taken to bring my thesis into its final form

Dr Anu Oommen for helping and guiding me through each and every step of the study. I would never have been able to complete this thesis without her help and encouragement. There are no words to thank her enough

Dr Jasmin Helan Prasad for facilitating the whole process of doing the thesis.

Dr Kuryan George and Dr Venkata Raghava for their valuable suggestions and encouragement

Dr Bhavya and Dr Sam Marconi for all the personal and professional support Dr Ann, Dr Tobey and Dr Asha for all the moral support

Dr Jenit, Dr Bennet, Dr Arun, Mr Vivian, and Mrs Gifta for helping with the translation of questionnaire

Dr Dheeraj Kattula for his help and guidance

Mrs Sumi, Mrs Mary and Mr Williams for helping me with the formatting and printing of thesis

All the nursing staff, especially Mrs Mary, Mrs Sumathi, Mrs Geetha, Mrs Deva, Mrs Jeevitha, Mrs Malathi for lifting my spirits whenever I was feeling low and honestly wishing good for me.

All the health aides for their help and willingness to work irrespective of the day and time. Without their help, I would never have been able to do my study Mr Suresh for his promptness and help at all time

Shalini, my best friend who stood like a rock behind me whenever I needed, irrespective of her inconveniences and worries. Without her support and help, I would never have been able to surpass the most stressful times in the past three years

Swathi, my soul sister for being with me throughout the Post-Graduation period

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vii Madhu for supporting and consoling me and making me a part of his and Shalini’s home

Sandeep, Ananthram, Deepak, Ranjith, and Anjali for being there whenever I needed

My parents who have been there throughout my life, helping me tide through each and every step of the life and for all their prayers and hard work in raising me My sister, brother in law and in laws for their support

My husband Shobith for just stepping in and helping me in all the ways possible and for standing next to me through all tough times

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ABBREVIATIONS

NCD - Non Communicable Disease

BMI - Body Mass Index

WC- Waist Circumference

SD - Standard Deviation

OR - Odds Ratio

AOR- Adjusted Odds Ratio

CI - Confidence interval

P value – Probability value

WHO - World Health Organization

CHAD – Community Health And Development

EAT – Eating Attitudes Test

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TABLE OF CONTENTS

1 INTRODUCTION AND JUSTIFICATION ... 1

2 OBJECTIVES ... 6

3 REVIEW OF LITERATURE ... 7

3.1 Obesity ... 7

3.1.1 Definition of obesity: ... 7

3.1.2 Change in lifestyle leading to obesity ... 7

3.1.3 Obesity: a global threat ... 8

3.1.4 Burden of obesity ... 9

3.1.5 Health expenditure due to obesity ... 12

3.2 Assessment of body size ... 12

3.2.1 Subjective Assessment– Body image perception ... 13

3.2.2 Changing perception of body image across the world in time ... 14

3.2.3 Objective assessment of body image perception ... 15

3.2.4 Objective measurement ... 21

3.3 Factors influencing body image perception ... 25

3.3.1 Non modifiable factors ... 25

3.3.2 Modifiable factors... 27

3.4 Influence of Societal opinions ... 28

3.5 Influence of media ... 29

3.6 Influence of diagnosis for overweight and health education ... 30

3.7 Effects of body image perception ... 31

3.7.1 Body image perception and weight losing activities ... 33

3.7.2 Abnormal and unhealthy body image perceptions and the effects on individuals . ………34

3.8 Body image perception and eating disorders ... 36

3.8.1 Screening for eating disorders ... 38

3.8.2 Eating Attitudes Test (EAT) 26 questionnaire ... 38

3.9 Recommendation on lifestyle modification for weight management ... 39

3.9.1 Exercise ... 39

3.9.2 Diet modification ... 39

3.10 Relevance of correct body image perception ... 40

3.11 Kappa statistic ... 41

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4 Methodology ... 43

4.1 Study design: Population based cross sectional study ... 43

4.2 Study setting: ... 43

4.3 Study population: Women aged 25 to 35 years residing in Kaniyambadi block ... 43

4.4 Period of study: December 2015 to September 2017 ... 43

4.5 Sampling method: Two stage cluster sampling ... 43

4.6 Inclusion and Exclusion criteria: ... 44

4.7 Sample size calculation: ... 45

4.8 Variables: ... 45

4.9 Tools for data collection: ... 46

4.9.1 Stunkard body image silhouette figure rating scale... 47

4.9.2 Eating Attitude Test (EAT) 26 questionnaire ... 47

4.10 Method of data collection ... 48

4.11 Data entry and analysis: ... 49

4.12 Expression of data: ... 50

5 RESULTS ... 52

5.1 Socio-demographic characteristic ... 52

5.2 Education and occupation of the head of the family ... 54

5.3 Morbidity profile ... 55

5.4 Use of family planning methods ... 56

5.5 Use of media ... 56

5.6 Results of assessment of perceptions regarding body size ... 57

5.7 Nutritional status according to Body Mass Index (BMI) and waist circumference . 58 5.8 Waist circumference ... 59

5.9 Agreement between BMI and self-perception ... 61

5.10 Factors influencing body image perception... 63

5.10.1 Classification of body weight by health professionals and life style advices ... 63

5.10.2 Societal opinion and emotional response to the opinions by BMI ... 64

5.11 Factors affecting incorrect perceptions ... 66

5.12 Factors affecting life style modification... 68

5.13 Screening of eating disorders ... 73

5.14 Multivariate logistic regression ... 77

6 DISCUSSION ... 79

7 CONCLUSION ... 88

8 LIMITATION ... 90

9 RECOMMENDATIONS ... 91

10 BIBLIOGRAPHY ... 93

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11 ANNEXURES ... 100

11.1 Annexure I ... 101

11.2 Annexure II ... 103

11.3 Annexure III ... 105

11.4 Annexure IV ... 107

11.5 Annexure V ... 109

11.6 Annexure VI ... 120

11.7 Annexure VII... 122

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INDEX OF TABLES

Table 3-1 WHO international classification for BMI ... 23

Table 3-2 Asia Pacific classification for BMI ... 24

Table 3-3 WHO cut off points and risk of metabolic complications ... 24

Table 3-4 WHO- Co-morbidities risk associated with waist circumference in Asian adults 25 Table 3-5 International Diabetes Federation Cut offs for waist circumference for different ethnic groups ... 25 ethnic groups 25 Table 4-1 Scoring of the questions in EAT questionnaire... 50

Table 5-1 Socio-demographic characteristics of participants... 52

Table 5-2 Education and occupation of the head of the family ... 54

Table 5-3 Presence of Non Communicable disease (NCD) among participants and ... family/household members... 55

Table 5-4 Perception of the ideal body shape using Stunkard body image silhouette ... 57

Table 5-5 Perceptions of one’s own body shape using Stunkard body image silhouette ... 57

Table 5-6 Self-categorization of body size ... 58

Table 5-7 Distribution of BMI among the participants ... 59

Table 5-8 Waist circumference with Stunkard current body perception ... 60

Table 5-9 Waist circumference with self-categorization of body size ... 60

Table 5-10 Agreement between actual BMI category and the Stunkard current body image .... perception ... 61

Table 5-11 Agreement between actual BMI category and self-categorization of body size ... 61

Table 5-12 Agreement between current body size perception using Stunkard image and ... self-categorization of body size ... 62

Table 5-13 Lifestyle modification advice for those diagnosed overweight by a health care ... professional ... 63

Table 5-14 Lifestyle modification advice for various categories of BMI ... 64

Table 5-15 Family opinion about body size for various categories of body weight ... 64

Table 5-16 Societal Opinions and emotional response to societal opinions in each weight ... category ... 65

Table 5-17 Agreement between self-categorization of body size and family opinion ... 65

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xiii Table 5-18 Incorrect body shape perception by self-categorization and Stunkard scale with BMI ... 66 Table 5-19 Factors associated with incorrect body size perception by self-categorization .. 67 Table 5-20 Association between self-categorization of body size and life style ...

modification ... 69 Table 5-21 Association between BMI category and lifestyle modification ... 70 Table 5-22 Socio-demographic and Individual factors influencing lifestyle modification .... 71 Table 5-23 Characteristics of women with screened positive for eating disorder... 74 Table 5-24 Association between self- categorization of body size and screened positive for eating disorder ... 75 Table 5-25 Association between actual BMI and screened positive for eating disorder ...

eating disorders ... 75 Table 5-26 Association between opinion of self and screened positive for eating disorders 76 Table 5-27 Factors associated with incorrect perception ... 77 Table 5-28 Factors associated with life style modification ... 78

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INDEX OF FIGURES

Figure 3-1 Age-standardized prevalence of overweight and obesity (By IOTF cutoffs),

ages 2−19 years, by sex, 1980−2013 ... 10

Figure 3-2 Trends of diabetes, hypertension and overweight among adults aged 30–60 ... years in Vellore ... 11

Figure 3-3 Stunkard figure rating scale ... 18

Figure 4-1 Stunkard body image silhouette figure rating scale ... 47

Figure 4-2 Flow chart of methodology ... 48

Figure 5-1 Use of media ... 56

Figure 5-2 Waist circumference among the women ... 59

Figure 5-3 Proportion of women who followed any life style modification activity ... 68

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1 INTRODUCTION AND JUSTIFICATION

Obesity has become a global threat today.(1) When lifestyle changed from hunter-gatherer to farmer to a sedentary life, changes in food habits were inevitable. Globalization and urbanization have resulted in people even in developing countries opting for more junk foods that are less in fiber and high in calories. This has resulted in the surge of obesity and other lifestyle-related illnesses. Obesity is no longer a disease of the affluent. It is affecting developing countries as well and the prevalence is increasing even in the rural areas.(2,3) As a result of this change, India has become the diabetic capital of the world.(4) There is also rise in the other non-communicable diseases like hypertension, dyslipidemia, cerebrovascular accidents, ischemic heart disease, diabetic nephropathy, etc. leading to increased morbidity and mortality.

Overweight and obesity contributed to four million deaths in 2015. It contributed to loss of 120 million Disability Adjusted Life Years (DALYs) globally.(5) There is an urgent need to take action to address the problem of obesity and other illnesses related to it.

One of the difficulties in reducing the burden of obesity is that the individuals may not realize that they are obese and hence, they may not feel the need to take active steps to manage their weight. The realization of one’s body size is necessary to follow any lifestyle modification.(6) Those who perceive

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2 themselves as fat tend to follow diet modification and increase physical activity. Those who perceive themselves as thin would eat more.(6)

Body image perceptions have always been a major concern in the western world. But with modernization and influence of media, even people in the developing countries have started becoming interested in maintaining a certain body image.

Body image perception is the way a person sees himself /herself. It is a mental picture of one’s own body.(7) It is a major factor contributing to the self- esteem of an individual. There are multiple factors which affect the body image perception like race, gender etc.(8),(9)Women are more affected than men by body image issues. Those individuals with distorted image perception tend to have eating disorders and unhealthy practices like trying to lose weight with laxatives, induced vomiting, starvation, exhaustive exercises etc.(10),(11).

Correct perception of body image is necessary for managing a healthy body and keeping the weight within normal limits.(6) The positive perceptions will help individuals follow a healthy lifestyle, while the negative perception will lead to unhealthy weight losing or gaining practices. Negative body image perceptions may also lead to poor self-esteem and mental health issues.(12) Body image perception cannot replace assessment of nutritional status by objective measurements. However, in countries like India perception can play an important role since a culture of weight management based on body weight or BMI does not exist. Since perceptions are subjective and depend on complex socio-culture beliefs, use of objective tools to estimate perceptions becomes

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3 important. The Stunkard Figure Rating Scale is one of the tools used to assess body image perception. It is a validated tool,(13) but is more accurate in picking up the overweight and the obese individuals.

Eating disorders are associated with distorted body image perceptions. With the rise in obesity and the change in the trend to “thin is ideal”, we expect eating disorders also to rise. Eating disorders like anorexia nervosa and bulimia can result in serious health issues. Eating Attitude Testing (EAT)(14) is a widely used tool for screening of eating disorders.

India is a country with alarming rise in obesity and other chronic diseases. A study with repeated cross-sectional surveys done by Oommen et al among adults aged 30-60 years in Vellore, Tamil Nadu showed that diabetes and obesity have increased three times between 1994 and 2012, and hypertension has doubled in the rural areas.(3) This is an alarming change requiring serious effort towards control and reduction in risk factors. It is necessary to assess whether the people are perceiving their appropriate body size and acting on it.

In India, where malnutrition was a norm in the past, a heavier body size is likely be considered good or normal.(15),(16) Studies show that body image of another person affects one’s own perception.(17) So, in a world, where overweight and obesity is increasing, overweight may be accepted and mistakenly thought as healthy. Those who perceive overweight body sizes as normal and acceptable are less likely to restrict their food intake resulting in overweight and obesity.(18)

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4 Even though many studies are available from other countries, studies on factors affecting body image perception and their effect on lifestyle and diet are few in India. Most of the studies assess the body image satisfaction and dissatisfaction with the perception of one’s own body size. There is a dearth of studies that try to objectively categorize the perceptions, correlate it with BMI, and study its effects on diet and physical activity. The knowledge about body image perceptions would be helpful in planning weight control programs, education about ideal nutritional status and methods that can be followed to achieve healthy weight and shape.

Currently, women are more affected with overweight and obesity than men are.(19). For women, the age between 25- 35 years is crucial. This age is a time of transition in their lives from youth to womanhood where they go through stages of marriage and childbearing. This is a time when they seem to lose control over their physique; gaining a lot of weight during pregnancy and postpartum period and not being able to reduce later in life. Resulting obesity or overweight increases their risk of non-communicable diseases, as they grow older. Therefore, identifying obesity in women at younger ages, screening and educating them regarding ideal body weight and healthy lifestyle is essential.

Though body image issues have been widely studied among women in the western countries, it has been overlooked in the developing and underdeveloped countries. Studies regarding body image perception in India have been mostly among adolescent girls and scarce among rural Indian women. Since culture and attitudes vary with country and ethnicity, finding

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5 from the studies conducted outside India may not be generalizable to our populations. Without focusing on changing people’s understanding of a healthy body size, interventions for reducing obesity may not be successful. Hence, it is important to carry out a study to assess the perceptions, its accuracy, the factors affecting perception and its effects on lifestyle choices.

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2 OBJECTIVES

Primary objective:

To assess body image perceptions amongst women aged 25- 35 years residing in Kaniyambadi block

Secondary objectives:

i. To measure the agreement between the perception of one’s own weight and the actual BMI (Body Mass Index) category

ii. To study the factors associated with incorrect body image perception iii. To study the association between following healthy life style and

other factors like perceptions of body size, actual BMI and socio- demographic factors

iv. To assess the proportion of women aged 25- 35 years with symptoms of eating disorder and its relationship with body image perception

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3 REVIEW OF LITERATURE

3.1 Obesity

Obesity is the global epidemic of the 21st century.(1) Earlier, it was a problem affecting mainly the affluent upper class living in urban areas and developed countries, while malnutrition was the problem of the poor. However, it has now become a major health hazard affecting the rich as well as the poor, children as well as adults, people in developed countries as well as developing countries.

3.1.1 Definition of obesity:

Obesity is a condition in which the fat is accumulated abnormally or excessively in the body parts to an extent where health gets impaired.(20) According to the World Health Organization’s (WHO) international classification, overweight is when the body mass index (BMI) of an individual is more than or equal to 25 kg/m2 and obesity is when the BMI is more than or equal to 30 kg/m2.(3) There is also a separate classification for Asians where the BMI cut off for overweight lower at 23 kg/m2.(21)

3.1.2 Change in lifestyle leading to obesity(22–24)

Obesity is a major global health issue. Earlier men and women mainly relied on agriculture for their livelihood. Later on, due to modernization, people started moving from agriculture and adopted more of sedentary work. With the invention of modern machines, there was a shift from manual work to mechanized processes. With the technology boom, lifestyle changes started

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8 affecting all ages. The surge of electronic media such as a computer, internet, video games, computer games etc. resulted in children and adults involving in less physical activity. The adults who used to work outside the house started spending more time at home. There was a change in the job pattern from manual work to more of white-collar jobs that required spending many hours sitting and restricted the physical activity. The advertisements have played an important role in inducing the need for junk foods and other unhealthy food items. People started eating more of processed food, which is tastier but has more carbohydrates and sugar. These factors lead to the overall decrease in the physical activity and increase in the consumption of unhealthy food. In addition, after World War II, the results of research in the field of medicine led to better cure of diseases and a longer lifespan. Thus, as change in food habits and sedentary lifestyle resulted in the rise of obesity, a longer lifespan led to many diseases related to it.

3.1.3 Obesity: a global threat

Obesity has become a global threat. It is considered a global pandemic because of the rising trend of overweight and obesity.(25) It is affecting people of all ages and socioeconomic status in developed as well as in developing countries.(26) This leads to increased morbidity and mortality. Overweight and obesity are risk factors for diseases like hypertension, diabetes mellitus, hyperlipidemia, ischemic heart disease, stroke, backache, arthritis etc.(27) Lifestyle, obesity and the non-communicable disease are related. The burden of diabetes, hypertension and ischemic cardiovascular diseases can be reduced if

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9 obesity is curbed. These diseases can cause chronic morbidity and result in severe complications.(20)Some types of cancers are related to obesity.(28) There are large cohort and observational studies showing an association of obesity to different cancers. Some of these are, cancers of the endometrium, breast, gastric cardia, gall bladder, renal cell, meningioma, multiple myeloma, pancreas and colorectal cancer.(12) This imposes a significant burden on the individual as well as the health system in terms of morbidity, premature death and cost of care.

3.1.4 Burden of obesity

3.1.4.1 Global burden of obesity

Obesity is affecting the developed as well as the developing countries and has tripled since 1975.(29) According to WHO Global Health Observatory Data 2014, 39% of women and 38% of men were overweight and 15% of women and 11% of men were obese. The mean BMI has risen from 1975 through 2014 in both men and women.(30) In 2015, overweight and obesity accounted for a total of four million deaths and were associated with 7.1% of death from all causes. Around 120 million Disability Adjusted Life Years (DALYs) were lost due to overweight and obesity which amounts to 4.9% of DALYs lost due to any cause globally.(5) Almost 1.9 million adults were overweight and 650 million were obese in 2016.(29) Among the under-five children 41 million and among adolescents, 340 million were overweight or obese in the same year.

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10 A study done by Marie Ng et al in Australia showed that the proportion of overweight adults (Body Mass Index (BMI) > 25 kg/m2) increased between 1980 and 2013 from 28·8% to 36·9% in men, and from 29·8% to 38·0% in women (figure 3.1)(16).

Figure 3-1 Age-standardized prevalence of overweight and obesity (By IOTF cutoffs), ages 2−19 years, by sex, 1980−2013

Source: Marie Ng, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a

systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2014 Aug 30; 384 (9945):766–81

Prevalence of overweight has substantially increased in children and adolescents also. In 2013, 23·8% of boys and 22·6% of girls were overweight or obese in developed countries. The prevalence of overweight and obesity has also increased in children and adolescents in developing countries, from 8·1%

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11 to 12·9% in 2013 for boys and from 8·4% to 13·4% in girls.(2) Till date, no country has been able to make a success story in controlling obesity.

3.1.4.2 India

Obesity is showing a rising trend in India. The prevalence of obese individuals was 2.2% in 1989 which increased to 19.5% in 2006.(31) Obesity is more among women (7.8%) as compared to men(6.2%).(32) Previously, obesity was the problem of the rich people and was more common in the urban population.

Nevertheless, due to the change in work pattern, migration and eating habits, rural population is also affected by obesity and overweight.

3.1.4.3 Tamil Nadu

Figure 3-2 Trends of diabetes, hypertension and overweight among adults aged 30–60 years in Vellore

Source: Oommen AM, Abraham VJ, George K, Jose VJ. Rising trend of cardiovascular risk factors between 1991–1994 and 2010–2012: A repeat cross sectional survey in urban and rural Vellore. Indian Heart Journal. 2016; 68(3):263-269. doi:10.1016/j.ihj.2015.09.014

The prevalence of overweight among men in Tamil Nadu increased from 14.5% in 2005 to 28.2% in 2015. Similarly, the overweight among women

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12 showed an increasing trend from 20.9% in 2005 to 30.9% in 2015.(33) A study with repeat cross-sectional surveys conducted by Oommen et al in urban and rural Vellore between 1991-94 and 2011-12 showed three times rise in people with obesity and overweight.(3)

3.1.5 Health expenditure due to obesity

Increased obesity results in increased hospitalization and increased financial burden. Direct medical costs related to obesity amounts to about 5-10% of total health budget in USA. (21) In a study by Agarwal et al in Delhi to compare the health expenditure among the obese and overweight women with the normal weight women, it was found that the health expenditure is much more among the overweight and obese women as compared to the normal women. Around 15% of the overweight, 16% of the obese and 21% of the morbidly obese women had health expenditure accounting for more than 5% of their total household expenditure, while only 10% of normal weight women spent similar amount of money. These women were also likely to spend two times higher amount on their health (OR 2.29 95% CI 1.07-4.90) as compared to the normal weight women.(34)

3.2 Assessment of body size

The reason for rising obesity is that the individuals do not consider their weight as abnormal or obese and hence, do not feel the need to take any active steps to manage their weight. A study done by Agrawal et al in Delhi reports that appropriate knowledge of one’s own body size improves the adoption of

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13 weight management techniques.(6,35) Studies have shown that individuals, especially women with normal body weight have difficulty in assessing their accurate body size.(36) It is very important to identify the accurate body size for achieving the ideal body weight and maintaining it.

There are two ways of assessing the body size – subjective and objective assessment.

3.2.1 Subjective Assessment– Body image perception

Here the person is asked for perception of their own body image. Multiple studies have been done globally to assess the body image perceptions, the factors influencing it and the effects of those perceptions on the individual.

3.2.1.1 What is body image perception

It is the mental picture of one’s own body. It is a product of perceptions, thoughts, feelings and attitudes towards one’s own body. (7) It is the internalized representation of the external appearance.

The different aspects of body image perception are(10)

Perceptual: The way you see your body

Affective: How you feel about the way you perceive your body image; leading to body image satisfaction or dissatisfaction

Cognitive: How you think about it, leading to preoccupation related to body size and shape

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Behavioral: Leads to following various techniques to reach the ideal desired body image.

3.2.2 Changing perception of body image across the world in time

Body image perception is not static.(37) It varies across time and culture. It is influenced by multiple factors. Initially it was a problem affecting only the women in the west. Now, it has started becoming a problem among individuals in all parts of the world.

The ideas about the ideal body image has changed over time.(38) It has evolved from a plump rounder, heavier image to a fragile, slender image. Historically, the painters portrayed voluptuous women as a sign of beauty and health.

Between 17th to early 20th century, a well-rounded and full figure was considered ideal. It was a symbol of prosperity, attractiveness and fertility.

However, in the late 1930s, the ideal image shifted to a shapelier and curvaceous figure. By 1960s, the slimmer image became the ideal image. From 1980s, the ideal image became thinner and thinner. The role of media in shaping the ideal image as slender in people’s mind was great. In today’s world, being thin is associated with youthfulness, success, happiness and social acceptability. Slenderness represents beauty, personal accomplishment and character. Beauty pageants have played a major role in propagating zero figure as ideal among women. The media, advertising companies, diet management industry have all contributed to this wrong notion. An overweight person

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15 today, is associated with lack of willpower, lack of self-control and laziness.(39)

3.2.3 Objective assessment of body image perception

Body image perception is an internal reflection of the externally visible body. It varies from time to time, person to person and region to region. It is never constant. It is influenced by multiple factors. Therefore, it is necessary to find a way in which the body image can be measured more objectively.

As appropriate perception can bring about healthy life style activities, recognition of one’s current body size is necessary.

The two ways in which the perceptions can be measured are by

Verbal assessment of perception

Visual assessment of perception

Verbal assessment of perception

In this method, the participant is asked a question about what they think their current body size is and what the ideal body size should be. This can be asked using a scale like the Likert scale with responses of too thin, thin, normal, fat and too fat. It can be compared with the body mass index and the level of accuracy in perception can be measured. People are also asked to grade their satisfaction about their body image and the dissatisfaction is correlated with their perception. It is also used for assessing body image satisfaction. It is a quick way of assessment.

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16 In a study done by Goswami et al among female college students, using Likert scale for body image perception and satisfaction, a discrepancy between self- reported perception and their actual BMI was reported. Among the students, 15.62% perceived themselves to be overweight/obese when actually only 11.54% of them had BMI greater than 23. In the same way, only 8.33%

perceived themselves to be underweight/thin when in fact 29.16% had BMI less than 18.5. There was overestimation of overweight and underestimation of underweight. Students who were underweight had significantly higher (85.71%) body image satisfaction as compared to the overweight students (P<0.001). Body image satisfaction had significant relationship with BMI.(40) Sinhababu did a study in West Bengal which showed that the faulty weight perception was 38.6% and was found to be higher among those who perceived themselves overweight.(41) In a cross sectional study done in Tehran for assessment of perceptions by verbal rating, the agreement between the self- reported BMI and body image perception was found to be 38 percentage in women and 23 percentage in men.(42) Verbal assessment studies in general show poor agreement with actual weight/BMI.

Visual assessment of perception

Visual perception is a more objective method of assessment of body image. It is a figure rating scale with nine silhouettes. The figures depict the body size in increasing order, the first image being the thinnest and the last image being the most obese.(43) The individual is asked to point out the figure corresponding to their perceived body size and also to point out the figure which they think is

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17 ideal. The difference between the perceived body size and the actual body weight status gives the degree of inconsistency in the self-perception.

A study done by Sanchez-Villegas et al among a representative sample in European Union showed more accurate perception among underweight men and women. Overall, women were better than men (correction proportions 57.6% vs. 32.7%). Perception of body image as a method of assessment for body size has different validity depending on the regional, socio -demographic and attitudinal categories.(44)

Even though multiple figure rating scales are used for body image perception, the most commonly used tool is the Stunkard body silhouette figure rating scale.

3.2.3.1 Stunkard figure rating scale(45)

Stunkard figure rating scale was developed in 1983 as a tool to measure the body image dissatisfaction among men and women. It is an easy to administer, self-reported measure of body image. It presents nine images each of men and women separately, the silhouette sizes representing the thinnest to the most obese. The individuals are asked to identify their ideal body image and current body. The discrepancy is a measure of dissatisfaction. It can be an adjunct to self- reported height and weight. It is widely used in epidemiological studies. It is also used to estimate the body size of an individual who is deceased.

Though initially it was developed to measure the body image dissatisfaction, researchers started using it to find various associations with body image

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18 perceptions and its effect on the individuals. Multiple studies have been done to show the association of body image dissatisfaction with eating disorder and unhealthy weight reducing techniques.

Certain studies have tried to correlate the images with BMI to understand the discrepancies in perceptions. Some studies have looked at how the perceptions of overweight help individual to identify that they are under risk and to adopt healthy weight reduction techniques and maintenance.(46) It has undergone minor modifications for use in different countries.

Figure 3-3 Stunkard figure rating scale

Source: Stunkard AJ, Sorensen T, Schulsinger F, Use of the Danish Adoption Register for the study of obesity and thinness. ResPubl Assoc Res Nerv Ment Dis 1983;60:115–20

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19 3.2.3.2 Validation of Stunkard Scale

This is a validated tool for assessing the body image perceptions. The reliability and validity has been tested in many studies.(47) Thompson and Altabe did a study amongst 91 male and 146 female undergraduates. The findings showed a good test–retest reliability. It also showed moderate correlations with the effects such as body image dissatisfaction, overall self- esteem and eating disturbances. The main questions which were asked were - to choose their ideal figure, the figure that reflects how they think they look, the figure that reflects how they feel most of the time, the figure that they think is most preferred by men, the figure that they think is most preferred by women and the opposite sex figure that they find most attractive. For checking validity, the figure ratings were transformed into the three discrepancy measures - feel minus ideal, think minus ideal and feel minus think.(47)

A study was done by Conti et al among Brazilian men consisting of a trial group with eating disorders and a control group. It showed good correlation of figure rating scale with anthropometric measurements.(48) The discriminant validity was achieved by measuring the association between the groups studied and the scales of current body image perception score, ideal body image perception score and body dissatisfaction. Reliability was assessed by comparison of the score averages and by intra class coefficient correlation.

Another study was conducted by Tiffani et al to correlate the figure rating with the actual BMI (49)In this study, each woman was assigned a figure rating by a

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20 research assistant (figure rating scale out of 17 points) and also by another research assistant who watched the women only on the video tape independently using the 17 point and nine point figure rating scale. Pearson’s correlation coefficients were calculated the in person rating, videotape figure rating and the BMI. It showed that the BMI and in person ratings showed high correlation (r = 0.91). There was also good correlation between BMI and video - taped nine point figure rating (r = 0.87) and 17 point figure rating (r = 0.89).

The inter rater agreement was also more than 80% for each of the ratings with the BMI. The scale has a significant correlation with measured percentage of overweight (r = 0.79) and it is a reliable predictor of obesity.(45)

Various studies have tried to establish BMI value to figural stimuli. Bulik et al conducted a study among a large cohort of Caucasian twins to ascertain BMI values to each figural stimuli in the Stunkard scale. They drew Receiver Operating Curves (ROC) which indicated that the figural stimuli was effective in classifying individuals as thin or obese. The image which was selected by all age cohorts silhouette no.4 which corresponded to a BMI of 23.1 + 2.2.(40) Bhuiyan et al did a study among the black and white population in Bogalusa, Louisiana. The numbers on the scale were categorized into five groups - figure no.1 and no.2 as underweight, figure no.3 and no.4 as correct weight, figure no.5 as slightly overweight, figure no.6 and no.7 as moderately overweight and figure no.8 and no.9 as very overweight. Body image discrepancy score was calculated from the difference between z-standardized values of body image perception and body mass index.(50) Lynch et al did a study among black and

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21 white adults using the same classification : figure no1 and no.2 - underweight, figure no.3 and no.4 – normal, figure no.5 to no.7 – overweight, and no.8 and no.9 – obese.(13)

The Stunkard scale helps us to assess the body image perception. Better perception can lead to adoption of healthy life style. This is an easy tool to administer and it agrees fairly with the body size. Hence this can be administered for health education.

3.2.4 Objective measurement

The various objective methods of assessing the nutritional status of the body are(51,52)

Clinical examination

The individual can be clinically examined for anemia, hypo-proteinaemia, bitot’s spots for vitamin A deficiency, enlarged thyroid gland and other signs of nutritional deficiency.

Nutritional Assessment

The nutritional intake can be assessed by dietary recall methods such 24 hour dietary recall, food frequency questionnaire etc.

Body composition analysis

This is done by various methods such as dual-energy X-ray absorptiometry (DEXA), underwater (hydrostatic) weighing, bioelectrical impedance analysis (BIA) and air displacement plethysmography (ADP).

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22

Chemical assessments

This type of assessment is done by measuring serum levels of proteins and essential nutrients Eg: Serum levels of total protein, albumin, iron, ferritin, vitamin B12, zinc, calcium etc.

Biomarkers to assess the level of nutrients

It is useful to test the adequacy of essential nutrients using biomarkers. It is an indicator of intake and or status of a nutrient. E.g. A higher Homocysteine level indicates lower plasma concentrations of folic acid.

Anthropometry

In this method parameters such as height, weight, waist circumference, waist to hip ratio, mid upper arm circumference and skin fold thickness can be measured. Height and weight are used to calculate the body mass index, skin fold thickness is used to calculate body density and mid upper arm circumference to provide an estimate of the lean body mass. The most commonly used measurement of nutritional status in adults is Body Mass Index (BMI).

3.2.4.1 Body Mass Index (BMI)

Body mass index is the most widely used method of assessing nutritional status in adults. It is given by the formula

BMI = Weight in kilograms / (Height in meter)2

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23 The WHO international classification for BMI is given in table no.3-1(53) Table 3-1 WHO international classification for BMI

Classification BMI (kg/m2) Risk of co morbidities

Underweight < 18.5 Low

Normal range 18.5 – 24.9 Average

Overweight > 25

Pre obese 25 – 29.9 Increased

Obese I 30 – 34.9 Moderate

Obese II 35 -39.9 Severe

Obese III > 40 Very severe

Source: Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies, The Lancet • Vol 363 • January 10, 2004 • www.thelancet.com,available at http://www.who.int/nutrition/publications/bmi_asia_strategies.pdf

Asians have a higher percentage of body fat at a lower BMI. Hence, they are prone to cardiovascular and cerebrovascular risk factors at a lower BMI. Due to this, the cut off given for overweight and obese according to the WHO guidelines for the Asia Pacific region for intervention are lower than international cut-off (Table 3-2) (21)

WHO recommends cut off points of BMI at 23, 27.5, 32·5, and 37·5 kg/m2as points of public health action. BMI above 23 kg/m2 represents increased risk and BMI above 27.5 kg/m2 represents higher high risk. It also recommends that among populations predisposed to central obesity and increased risk of metabolic syndrome, waist circumference also should be used to redefine action levels along with BMI. (53)

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24 Table 3-2 Asia Pacific classification for BMI

Classification BMI (kg/m2) Risk of co morbidities

Underweight <18.5 Low

Normal range 18.5 – 22.9 Average

Overweight > 23

At risk 23 -24.9 Increased

Obese I 25 – 29.9 Moderate

Obese II > 30 Severe

Source: The Asia Pacific Perspective: Redefining obesity and its treatment, World Health Organization, Western Pacific Region, February 2000, available at

http://www.wpro.who.int/nutrition/documents/docs/Redefiningobesity.pdf

3.2.4.2 Waist circumference and waist to hip ratio

Waist circumference is a good measure of total body fat. Waist to hip ratio is used to assess the total body fat distribution. These are good predictors of cardiovascular and

Cerebrovascular disease risk. The cut off points and the risk of metabolic complications are as follows (54)

Table 3-3 WHO cut off points and risk of metabolic complications

Indicator Cut off points Risk of metabolic

complications

Men Women

Waist

circumference

>94 cm >80 cm Increased

Waist

circumference

>102 cm >88 cm Substantially increased Waist to hip ratio > 0.90 > 0.85 Substantially increased

Source: Waist Circumference and Waist-Hip Ratio Report of a WHO Expert Consultation Geneva, 8–11 dec 2008, available at http://apps.who.int/iris/bitstream/10665/44583/1/9789241501491_eng.pdf

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25 Table 3-4 WHO- Co-morbidities risk associated with waist circumference in Asian adults(21)

Waist circumference Co-morbidities risk

Men Women

Waist circumference > 90 cm > 80 cm Increased

Source: Waist Circumference and Waist-Hip Ratio Report of a WHO Expert Consultation Geneva, 8–11 dec 2008, available at http://apps.who.int/iris/bitstream/10665/44583/1/9789241501491_eng.pdf

Table 3-5 International Diabetes Federation Cut offs for waist circumference for different ethnic groups

Ethnicity Waist circumference

Men Women

European 94 cm 80cm

South Asian, Chinese 90 cm 80 cm

Source: Alberti KGMM, Zimmet P, Shaw J. Metabolic syndrome—a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med. 2006 May 1;23(5):469–

80

3.3 Factors influencing body image perception

There are multiple factors influencing perception of body image. (31).

3.3.1 Non modifiable factors

Race/ethnicity

Ethnicity plays a major role in body image perceptions. The western women are known to have more body image issues. Eating disorders were first identified in the west. In contrast, the women of African descent tend to be happy with the broader body shape. Genetically they are taller and broader than the other group of people, considering it sign of health. Hence, the body image issues are not very common among them.(55)

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26 A community based study by Bhuiyan et al among the blacks and whites showed that the blacks prefer a heavier body image.(50) Mean BMI was found to be higher among the black women (27.1kg/m2) than the white women (24.2kg/m2). Since the black women preferred a heavier body image, a higher proportion of overweight black women (6.8%) considered themselves normal as compared to 4.9% of overweight white females.

A study conducted by Kronfield et al to find the ethnic differences in body image perception showed that the white women preferred leaner body images than the Afro – American women.(9)Another study conducted by Mikolajczyk among US students reported higher body image satisfaction among Afro American students.(56)

Gender

Gender plays a major role in the body image perceptions. In the Western society, attractiveness is linked to different factors for men and women.(8) Thinner women are considered attractive, whereas men with muscular body are considered attractive. With the obesity on the rise, the gap between the ideal thin image and the actual body image widens. This results in the unattainability of the ideal shape. This leads to psychological issues among women. In order to achieve the "ideal", women often resort to unhealthy eating practices and exercises that can harm the body.(57) Eating disorders are more common among the women, especially the college going girls.

In a study done by Zaccagni et al among Italian university students, men tend to underestimate their body size and women tend to overestimate their body

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27 size. Men mostly chose larger body size as desirable while the women mostly chose the leaner image as ideal.(7,58) As a result of this, women were reported to have more dissatisfaction related to their body image as compared to men.(58, 59)Various studies done all over the world show that the women are more affected by body image perceptions. Women's body image perceptions was more distorted, they had more body image dissatisfaction, more consequent low self-esteem and depression, and more eating disorders.(60, 61) 3.3.2 Modifiable factors

The factors like education, type of schooling, socioeconomic status, presence of chronic diseases also play a role in the body image perception.(62) Many studies have been done to assess the influence of education and socio economic status. Most studies show that the people from poorer socio economic status and lower education have more incorrect perceptions.(11) The results are not very conclusive and they change according to region and the groups of people studied.(57,63)

Studies have also shown that the presence of a life style related disease like diabetes mellitus or cardiovascular disease can affect the perception of body image(64) Presence of a life style disease in the individual or a family member is expected to increase their knowledge about ideal body size and the methods to attain or modify it. In a country like India where individuals are not weighed on a routine basis, perception is likely to improve with presence of a disease in self or another known person.

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28

3.4 Influence of Societal opinions

Humans are social beings and in all societies, they are influenced by opinion of others. As the outward appearance is an important factor governing socialization, an individual can be greatly influenced by other’s perception about the body size. The major social factors are described below.

Family and peers

Study done in Australia by Mc Cabe et al showed that parental pressure plays an important role in transmitting the socio cultural norms to their children which leads to formation of thin image for women as ideal.(61) It also showed that parents provide more feedback to daughters regarding the body image, as compared to sons. Fathers had more influence on the daughter’s attitude while mothers had more effect on the son’s attitude. Mothers had stronger influence on body image perception and fathers had a stronger influence on exercise and dieting. Mother’s influence was mostly positive comments, but father’s influence was mainly criticism.(65)

Another study by Rodgers and Chabrol showed that parental encouragement helped children in dealing with the pressures regarding body image perception and eating disorders.(66) Male peers encouraged to gain weight while female peers encouraged to lose weight irrespective of the BMI.(61) These studies are not from India and there is a possibility of the influences being different on Indian women.

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29 Criticism

Criticism is an important factor affecting the body image perception. Most people whether they are thin or fat, fall prey to weight teasing. This can cause detrimental effects in the individual. Sometimes even a normal weight individual is called fat. The increasing effect of the “size zero” trend can cause even the normal individuals to think that they are fat. This leads to inappropriate and distorted body image perception and poor self-esteem, depression and eating disorders. Multiple studies have documented the effect of negative body image on self-esteem.(62) In general women are affected more by weight teasing than men. Younger women have more desire to be thinner and experience more societal influence on their body image.(67) Studies have shown that overweight individuals have higher degree of body dissatisfaction.(34)

3.5 Influence of media

With the advent of internet age, media is playing a major role in shaping the idea of the ideal body size. The influence of media has resulted in thinner being thought as the ideal. It is currently one of the most influential factors especially among the young people. The change from a widely accepted plump, rounded figure as the ideal body image to the thin one was mainly due to the influence of media, notably the films and advertisements.

A meta-analysis done by Shelly et al linked media exposure to women’s internalization of thinner body image, body image dissatisfaction and eating

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30 disorders.(58) Another study done by Mc Cabe et al, showed that media plays a prominent role in shaping the thinner body image as ideal.(61) This leads to a distorted body image of themselves for women. The new generation female models shown on television and on the cover page of fashion magazines are extremely thin. The girls and women internalize this image. Media does not give a clear definition of ideal body image for men. Hence they are less likely to be affected by body image issues.(60, 61)

3.6 Influence of diagnosis for overweight and health education

The perception of overweight or underweight markedly improves when the weight is checked. In India, people are not keen on checking and knowing their body weight. They usually go by self-perception and social opinion. These opinions may be right or wrong. But objectively measuring the weight, informing the individuals about the weight status and the measures to be taken for a healthy life style helps in correctly understanding the current status and taking required steps.

A study done by Yaemsiri et al showed that the perception and weight reduction activities are better in the people who were diagnosed to be overweight by a health care professional as compared to the undiagnosed.

Among overweight/obese individuals, those who were diagnosed with overweight/obesity were more likely to follow weight reducing diet (74 versus 52%), exercise (44 versus 34%), or pursue both (41 versus 30%, all P<0.01) as compared to those who remained undiagnosed.(46)

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31

3.7 Effects of body image perception

There are many studies done in the past which show that self-realization of body size is essential for weight management. Those who perceive themselves as fat tend to follow diet modification and increase physical activity, while those who perceive themselves as thin would eat more. Those individuals with distorted image perception tend to have eating disorders and unhealthy practices to lose weight such as use of laxatives, induced vomiting, starvation, exhaustive exercises etc.(68) Appropriate perception of body image is necessary for managing a healthy body and keeping the weight within normal limits.

A study done by Chandler et al among European Americans and African Americans showed that even the perception of other’s weight is very important in managing one’s own weight.(18) If the peers are of overweight size, the individuals tend to think that overweight is ideal. Hence, there is less tendency to lose weight. Among European American women, the perception of others’

body size was inversely associated with rate of weight loss and positively associated with body fat gain following a weight loss intervention. The women who perceived others as large had greater percent body fat one year after weight loss as compared to those who perceived others as thin.(18)

Positive and negative effects

A person can be positively or negatively affected by the body image perception. Positive body image is necessary to accept, respect and appreciate

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32 one’s own body. This will build up their self-esteem and confidence. Negative body image leads to dissatisfaction, poor self-esteem, and social withdrawal.

This might put them into very serious emotional conflicts, eating disorders and other unhealthy weight losing or gaining techniques.(10) A person can perceive the body image in three ways namely, overestimation, correct estimation and under estimation. Overestimation is when underweight individuals consider themselves as normal or overweight and when the normal weight category considers themselves as overweight or obese. Under estimation is when overweight/ obese category individuals consider themselves normal or underweight and normal category individuals consider themselves underweight. Inappropriate body image perceptions lead to irrational weight losing and weight gaining behaviors.(11)

Priya et al did a study among female medical students in Mangalore. The study looked at the body image perceptions and the weight reducing attempts.(69) The students were administered a questionnaire with Stunkard scale and was asked about their body image perceptions. Height and weight were checked and BMI was calculated. 90.9% of the overweight students perceived themselves as overweight. Most of them perceived their images correctly. All the overweight and obese individuals were dissatisfied about their body image and tried to lose weight. Of the 28.6% who skipped meals to reduce weight, obese formed the majority. Other Indian studies on the body image perception, actual weight status and body image dissatisfaction are done by Sinhababu et al (41) and Goswami et al(40)

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33 Incorrect body image perception is a matter of major concern. In majority of the studies done, women show high body image dissatisfaction. Even underweight individuals perceive themselves as overweight and resort to unhealthy practices.

3.7.1 Body image perception and weight losing activities

A longitudinal study was done by Lynch et al, to assess the relationship between body size perception and change in the body mass index over 13 years.(13) The perception was assessed by Stunkard figure rating scale. The figure in the scale were classified as underweight (figure no.1, 2), normal weight (figure no. 3, 4), overweight (figure no.5, 6, 7) and obese (figure no. 8, 9). The study showed that obese women who perceived themselves obese showed a loss of 0.09 BMI units annually, where as those who perceived themselves as normal weight gained 0.31 units annually (P 0.0005). Obese women who perceived their body size much too large had less weight gain annually than those who perceived their body size just a bit too large (0.21 vs.

0.38 BMI units; P 0.009). The obese women who perceived their image as too large gained less weight than the obese women who were satisfied with their body image.

Agrawal et al did a population based follow up survey among Indian women, who were selected from the second round of National Family Health Survey (NFHS-2) conducted in 1998-1999. The women were re-interviewed in 2003.(6) This study looked at the self-perception of body weight and its

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34 association with future weight-management intentions and the actual weight management behavior in normal weight, underweight and overweight Indian women. The study showed discrepancies between the perceived body weight and the actual bodyweight. Almost one fourth of the overweight women and one tenth of the obese women perceived themselves as normal weight. 25% of the overweight and 4% of the obese women were satisfied with their body image and did not want to reduce it. Only 33.3% overweight and 25% of the obese women were actually doing exercise for weight reduction. The overweight (AOR 6·07, 95% CI 2·21- 16·59, P value 0·080) and obese (AOR 3·17, 95% CI 1·06-9·78, P value 0·082) women were more likely to do physical activity as compared to normal-weight women.

In a study conducted by Yaemsiri, overweight perception was positively associated with adoption of weight control methods (for women- OR 3.74, 95% CI 2.96 - 4.73, for men - OR 2.82, 95% CI 2.11 - 3.76.(46) It was better when overweight and obesity was diagnosed by a health care professional (OR for women 2.22, 95% CI 1.69- 2.91, OR for men 2.14, 95% CI 1.58 - 2.91)(46)

3.7.2 Abnormal and unhealthy body image perceptions and the effects on individuals

A study conducted by Hong EK et al in Korea among adolescent girls showed that 66.3% of the underweight and 98% of the normal weight girls perceived themselves as too fat. 42.4 % of them tried to lose weight by exercise, fasting, mono-diet, laxatives, very low calorie diet etc.(70) The eating disorders like

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35 anorexia nervosa and bulimia nervosa are dangerous issues and can even be fatal. The distorted image perception leads to poor self -esteem, absence of self-confidence and depression.

Lee et al did a study among high school students which showed both overestimation of body image are associated with unhealthy eating behaviours (AOR 1.54, 95 % CI 1.37–1.72), sadness (AOR 1.25, 95 % CI 1.16–1.35) and suicidal ideation (AOR 1.20, 95 % CI 1.08–1.33). Cheung et al did a study in Hong Kong amongst students, which showed that 30.9% of the underweight women and 75.5% of the normal weight women desired a slimmer body shape.(11) The underweight women had more chances of having eating disorder and other adverse outcomes.

There are several studies suggesting the correlation between body image dissatisfaction and self-esteem. The association of self-esteem with body image dissatisfaction varies according to age, gender and ethnicity. Study done by Furnham et al showed that the esteem was more affected for women as compared to men.(71) Beth et al reported better self-esteem and positive body image among Afro American women as compared to the Caucasian women.(72)

Another study done by Christina et al showed that 79% of the girls interviewed were dissatisfied by their physical appearance. There was a significant negative correlation between body image dissatisfaction and self-esteem (r = - 0.36, p < 0.0005)(73)

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36

3.8 Body image perception and eating disorders

Distorted body image perception is known to cause eating disorders. There are two types of eating disorders – Anorexia nervosa and Bulimia Nervosa.

In anorexia nervosa, the individual restricts the food intake to very unhealthy levels that results in caloric deprivation. By contrast, bulimia nervosa involves binge episodes of overeating followed by unhealthy weight reduction techniques like self-induced vomiting, laxatives use, diuretics, or obligatory exercise to counteract excessive caloric intake.(74) This leads to severe calorie dearth which will in turn result in malnutrition and various macro and micro nutrient deficiency disorders. In addition, prolonged starvation and laxatives cause metabolic acidosis and induced vomiting causes hypokalemia and metabolic alkalosis.(75) In the effort to lose weight the individuals become severely underweight and become susceptible to diseases like Acid Peptic disease, anemia etc.

According to the study done by Gloria et al among mixed origin college women, those who were teased more seemed to develop more eating disorders and they had more body dissatisfaction.(76) They reported that the Caucasians and the African Americans were more likely to be affected by body image dissatisfaction and eating disorders as compared to Asian Americans. Cheung et al did a study amongst the adolescents which showed that the ones who perceived them as overweight did severe diet restriction(11)

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37 Story et al did a study among students in Minnesota to find the relationship of ethnicity and socioeconomic differences with body image perceptions and eating disorders.(77) It showed that the Asian females had more binge eating, Hispanic females had greater use of diuretics and blacks had higher rates of vomiting as compared to the white women. A study done by Nicoli et al showed that people with higher self-image inadequacy have more binge eating disorders.(78)

Studies regarding eating disorders are lacking in India. In a study done by Srinivasan et al, the prevalence of eating disorders was found to be 14.7%.(16) A study was done by Lal et al to compare the eating disorders among Indians and Australians. The study reported that Indians had more of binge eating and over eating as compared to the Australians. Indians were not aware of the symptoms of eating disorders such as losing control over food, preoccupation with food etc. Indians did not think that eating and exercise had any effect on their social life and relationship, but they linked it more to medical issues.(79) A hospital based study conducted by Mammen et al in Tamil Nadu among children and adolescents in a tertiary care setting showed that the prevalence of eating disorders were 1.25% in the study population.(80) Eating disorder identified was predominantly psychogenic vomiting followed by anorexia.

They reported that the eating disorders were associated with another co morbidity in 43.9% of the patients. However, the study did not look into the relationship between the eating disorder and the body image perceptions.

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38 3.8.1 Screening for eating disorders

There are multiple tools to screen for eating disorder like EAT 26 questionnaire, SCOFF questionnaire(81), EDEQ questionnaire(82) etc. The most commonly used questionnaire for screening of eating disorder is Eat Attitudes Test 26 (EAT 26) questionnaire. It is extremely effective in screening for anorexia nervosa.

3.8.2 Eating Attitudes Test (EAT) 26 questionnaire

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This test was developed by Garner and Garfinkel as an easy tool to screen eating disorders. This 26-item questionnaire measures the symptoms and concerns which are characteristic of eating disorder. It was designed as a self- administered too but can be administered to a group of people in schools, colleges etc. It is not a diagnostic test, but a screening tool for eating disorder risk.

The responses are rated on a six point scale – always, usually, often, sometimes, rarely, never. It has three subscales – dieting, bulimia and food preoccupation and oral control. The total score is calculated by adding scores of all three subscales (Refer methodology section – tools). The score of 20 and above indicates that there is high level of concern about problematic eating behavior and dieting. Such individuals need evaluation from a trained mental health professional.

This is a standardized tool. The validity has been tested in a Mexican study done by Rayon et al. which showed an adequate level of internal consistency

References

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