Ethnic differences in the self-recognition of obesity and obesity-related comorbidities: a cross-sectional analysis.
ABSTRACT Obesity and its related co-morbidities place a huge burden on the health care system. Patients who know they are obese may better control their weight or seek medical attention. Self-recognition may be affected by race/ethnicity, but little is known about racial/ethnic differences in knowledge of obesity's health risks.
To examine awareness of obesity and attendant health risks among US whites, Hispanics and African-Americans.
Cross-sectional self-administered survey.
Adult patients at three general medical clinics and one cardiology clinic.
Thirty-one questions regarding demographics, height and weight, and perceptions and attitudes regarding obesity and associated health risks. Multiple logistic regression was used to quantify the association between ethnicity and obesity awareness, controlling for socio-demographic confounders.
Of 1,090 patients who were offered the survey, 1,031 completed it (response rate 95%); a final sample size of 970 was obtained after exclusion for implausible BMI, mixed or Asian ethnicity. Mean age was 47 years; 64% were female, 39% were white, 39% Hispanic and 22% African-American; 48% were obese (BMI ≥30 kg/m(2)). Among obese subjects, whites were more likely to self-report obesity than minorities (adjusted proportions: 95% of whites vs. 84% of African-American and 86% of Hispanics, P = 0.006). Ethnic differences in obesity recognition disappeared when BMI was >35 kg/m(2). African-Americans were significantly less likely than whites or Hispanics to view obesity as a health problem (77% vs. 90% vs. 88%, p < 0.001); African-Americans and Hispanics were less likely than whites to recognize the link between obesity and hypertension, diabetes and heart disease. Of self-identified obese patients, 99% wanted to lose weight, but only 60% received weight loss advice from their health care provider.
African-Americans and Hispanics are significantly less likely to self report obesity and associated health risks. Educational efforts may be necessary, especially for patients with BMIs between 30 and 35.
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ABSTRACT: Abstract Background: While knowledge of cardiovascular disease (CVD) has improved, it remains low among minority women, thereby contributing to disparities and posing health challenges. Moreover, substantial numbers of women do not recognize that excess weight imposes CVD risk and increases morbidity and decreases survival. In order to test the hypothesis that CVD knowledge is reduced among overweight and obese women, CVD knowledge and weight perception was compared among Hispanic and non-Hispanic white (NHW) women. Methods: Data from 382 Hispanic and 301 NHW women, participants in the Heart Health in Action database (n=829), were analyzed from a structured behavioral risk factor surveillance system (BRFSS) questionnaire to assess demographics, risk factors, and CVD knowledge. Multivariable logistic regression analysis was utilized to test for differences between Hispanic and NHW women regarding knowledge with covariates of age, education, and body mass index (BMI). Results: Hispanics (27%) were less likely than NHW (88%) to correctly identify the leading cause of death among women, (p<0.0001). Years living in the United States did not relate to the percentage of respondents who correctly identified the leading cause of death among women or knew the symptoms of a heart attack. Differences between Hispanic and NHW remained significant after adjustment for age, education, and BMI (p<0.0001). Hispanics (69.4%) were less likely than NHW (82.9 %) to correctly estimate weight (p<0.0001). Underestimation of weight was greater among Hispanics (24.8%) than NHW (5.0%); 48.5% of overweight Hispanic participants versus 12.7% of overweight NHW participants underestimated weight (p<0.0001) and 17.2% of obese Hispanic versus 0% of NHW obese participants (p=0.001) underestimated weight. The percentage underestimating the silhouette corresponding to their weight was related to years in the United States: 29.3% for<10 years, 38.3% with 10-19 years, and 49.3% with ≥20 years (p=0.01 for trend). Conclusions: Effective prevention strategies for at-risk populations need to target CVD knowledge and awareness among overweight and obese Hispanic women.Journal of Women s Health 11/2013; · 1.42 Impact Factor
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ABSTRACT: Objective To measure knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults and examine the relationship to prior weight loss. Methods Knowledge of the health consequences of obesity was assessed among 410 Black and Hispanic adults with BMI ≥ 25 kg/m2 enrolled in a behavior change weight loss study. The relationship between obesity risk knowledge and previous weight loss was also examined. Results The majority of participants were knowledgeable of the risk of hypertension (94%), diabetes (96%), high cholesterol (91%), joint pains/arthritis (89%) and sleep apnea (89%) associated with obesity. Among post-menopausal age women, 53% were aware of the increased risk of breast cancer. There was no significant relationship between obesity risk knowledge and previous weight loss of 10 pounds or more (OR = 1.075, 95% CI: [0.808, 1.430]). Conclusions We found that knowledge of the health consequences of obesity was high, except for knowledge of the risk of breast cancer. Obesity risk knowledge was not associated with past weight loss. Practice implications Further health education is needed regarding the increased risk of breast cancer associated with obesity. Our data suggest that knowledge of the health consequences of obesity is not associated with weight loss success.Patient Education and Counseling 01/2014; 94(1):123–127. · 2.37 Impact Factor
- Journal of Women s Health 12/2013; 22(12):1001-1002. · 1.42 Impact Factor
Ethnic Differences in the Self-Recognition of Obesity
and Obesity-Related Comorbidities: A Cross-Sectional Analysis
Senthil K. Sivalingam, MD1,4, Javed Ashraf1,4, Neelima Vallurupalli1,4, Jennifer Friderici3,
James Cook1,4, and Michael B. Rothberg2,4
1Division of Cardiology, Baystate Medical Center, Springfield, MA, USA;2General Medicine, Department of Medicine, Baystate Medical
Center, Springfield, MA, USA;3Department of Academic Affairs Administration, Baystate Medical Center, Springfield, MA, USA;4TuftsUniversity
School of Medicine, Boston, MA, USA.
BACKGROUND: Obesity and its related co-morbidities
place a huge burden on the health care system. Patients
who know they are obese may better control their
weight or seek medical attention. Self-recognition may
be affected by race/ethnicity, but little is known about
racial/ethnic differences in knowledge of obesity’s
OBJECTIVE: To examine awareness of obesity and
attendant health risks among US whites, Hispanics
DESIGN: Cross-sectional self-administered survey.
PARTICIPANTS: Adult patients at three general medical
clinics and one cardiology clinic.
MAIN MEASURES: Thirty-one questions regarding de-
mographics, height and weight, and perceptions and
attitudes regarding obesity and associated health risks.
Multiple logistic regression was used to quantify the
association between ethnicity and obesity awareness,
controlling for socio-demographic confounders.
KEY RESULTS: Of 1,090 patients who were offered
the survey, 1,031 completed it (response rate 95%); a
final sample size of 970 was obtained after exclusion
for implausible BMI, mixed or Asian ethnicity. Mean
age was 47 years; 64% were female, 39% were white,
39% Hispanic and 22% African-American; 48% were
obese (BMI≥30 kg/m2). Among obese subjects,
whites were more likely to self-report obesity than
minorities (adjusted proportions: 95% of whites vs.
84% of African-American and 86% of Hispanics, P=
0.006). Ethnic differences in obesity recognition
disappeared when BMI was>35 kg/m2. African-
Americans were significantly less likely than whites
or Hispanics to view obesity as a health problem
(77% vs. 90% vs. 88%, p<0.001); African-Americans
and Hispanics were less likely than whites to recog-
nize the link between obesity and hypertension,
diabetes and heart disease. Of self-identified obese
patients, 99% wanted to lose weight, but only 60%
received weight loss advice from their health care
CONCLUSIONS: African-Americans and Hispanics
are significantly less likely to self report obesity and
associated health risks. Educational efforts may be
necessary, especially for patients with BMIs between
30 and 35.
KEY WORD: obesity; ethnic difference; self recognition.
J Gen Intern Med 26(6):616–20
© Society of General Internal Medicine 2011
Obesity is epidemic in the US and other Western countries.
Currently nearly one-third of Americans are obese.1Data from
the National Health and Nutrition Examination Survey
(NHANES) show that the prevalence of obesity in US adults
has increased dramatically since 1960, and now approaches
34%.1,2Annual mortality attributable to obesity in US adults
has been estimated at between 280,000 and 325,000.3
Although the disparity in obesity by socioeconomic status
(SES) has decreased over the past 3 decades, ethnic and
racial disparity persists.1,4Obesity is more prevalent in non-
Hispanic black adults (44%) than in Mexican-American
(39%) or non-Hispanic white adults (32%).2The higher
prevalence of obesity-related co-morbidities such as hyper-
tension, diabetes mellitus and coronary heart disease
among minority groups1,5challenges health care providers
to improve education and care provided to these groups.
Racial/ethnic differences in weight misperception have also
been reported; weight underestimation was more common in
blacks and Mexican-Americans than in whites, and more
common in men than women.6–8However, previous studies
have not evaluated recognition of obesity (as opposed to
overweight), have not included non-Mexican Hispanics, and
have not assessed ethnic differences in awareness of
obesity-related comorbidities such as diabetes, cardiovascu-
lar disease and early mortality.
According to the Health-Belief model, perceived personal
susceptibility increases prevention and treatment seeking
behaviors.9,10Thus, recognition of one’s own obesity and its
health risks is a prerequisite to seeking treatment. To
Electronic supplementary material The online version of this article
(doi:10.1007/s11606-010-1623-3) contains supplementary material,
which is available to authorized users.
Received July 29, 2010
Revised December 3, 2010
Accepted December 9, 2010
Published online January 11, 2011
examine self-recognition of obesity and awareness of associ-
ated health problems in a sample of US adult patients, we
administered a survey to adult patients in four ambulatory
clinics. Based on previous studies, we hypothesized African-
American and Hispanic patients would be less likely than
white patients to recognize themselves as obese, viewing their
weight as normal. We further hypothesized that this lack of
recognition would lead African-American and Hispanic
patients to underestimate the health risks of obesity.
We conducted a cross-sectional survey of adult patients
visiting three general medicine clinics and one cardiology clinic
associated with Baystate Health (BH) during March and April
2008. The sites were chosen because they serve a mixture of
white, African-American and Hispanic patients, and are
teaching sites affiliated with Baystate Health. Medical assis-
tants distributed the survey to consecutive adult patients
(aged≥18 years) at check-in, during which the patient was
weighed. Participants needed to be literate in either English or
Spanish. Patients were informed that the survey was anony-
mous and voluntary, and completion implied consent. No
incentive or assistance was provided, and no attempt was
made to characterize patients who refused the survey or did
not return it. Patients completed the questionnaires in the
waiting area and returned them to the medical assistants. The
study protocol was approved by Baystate Medical Center’s
Institutional Review Board.
The survey (see online appendix) was created primarily by the
investigators with input from clinical staff and physician from
the sites. An initial pilot study to assess the logistics of
administering and collecting the survey forms was performed;
no questions were modified as a result of the pilot study. The
questionnaire consisted of 31 questions: 7 demographic ques-
tions, 1 direct question about racial/ethnic identity and 7
questions regarding beliefs about obesity. Demographic ques-
tions included age (in years); gender; primary language
(English, Spanish and other); education level (categorized in
four levels: high school, college, graduate school or other);
current employment status (yes or no); income (<$10,000,
$10,000–50,000, $50,000–100,000 and >$100,000) and mar-
tial status (single, married, divorced, partnered). For race/
ethnicity, respondents were asked which best described their
cultural background: African-American, Hispanic, white or
Asian. Patients reported their current weight and height as
measured on the day of clinic visit. Body mass index (BMI) was
calculated in kg/m2; we used a standard definition of BMI to
classify individuals as normal (BMI≤25), overweight (BMI 25.1
to 29.9) or obese (BMI≥30). BMI is a widely used index for
weight adjusted for height and has accurate correlation with
adverse health effects, including mortality.11,12
The two primary correlates of the study, self-perception of
obesity and awareness of obesity’s link to health problems,
were assessed by the questions: "Do you think that you are
obese?” and “Do you consider obesity to be a health problem?”
Knowledge of obesity’s association with specific health outcomes
(e.g., early mortality) was assessed using true/false questions
(questions 14–18). All participants completed the demographic
and knowledge components of the survey (questions 1–21).
Participants who identified themselves as obese were also
instructed to complete the second half of the questionnaire
(questions 22–31). This consisted of questions regarding the
loss and preferred weight loss treatments.
Statistical analyses were performed using STATA version 10.1
(© 2009, StataCorp LP, College Station, TX). Data were
analyzed with mean ± SD or proportions where appropriate.
Differences in perception of obesity, awareness of related
cardiovascular risks, effects of obesity on health and any
discussion of the obesity issue with their physicians among
three racial/ethnic groups were analyzed using χ2 or Fisher’s
exact tests. Multivariate logistic regression was used to derive
odds ratios and adjusted proportions (fitted values) to quantify
ethnic differences in obesity perception, controlling for demo-
graphic and socioeconomic confounders. A two-sided alpha of
0.05 was specified for all tests of significance.
Of 1,090 patients approached, 33 patients refused to partici-
pate and 26 forms were returned without being completed,
leaving a total 1,031 completed questionnaires (response rate
95%). Additional respondents were excluded for missing (n=
31) or implausible (n=4) BMIs, or self-reported ethnicity that
was either missing (n=10), Asian (n=9) or mixed (n=7), leaving
a final sample size of 970.
Characteristics of the sample are summarized in Table 1.
The mean age was 47.4 (SD 15.4) years, and 64% were female.
The mean BMI was 30.7 (SD 7.2) kg/m2, with nearly half (49%,
95% CI 45% to 52%) of the sample meeting criteria for obesity.
White subjects were older, had higher incomes and were less
likely to be obese than non-white subjects. Twenty-two percent
of the remaining subjects were missing at least one variable
necessary for multivariate analysis (e.g., income, education,
age, sex). Subjects with missing data were significantly older
(7.43 years, 95% CI 5.20, 9.67), more likely to be non-white
(OR 2.82, 95% CI 1.93, 4.12) and less likely to believe they
were obese (OR 0.63, 95% CI 0.45, 0.87).
Overall, most respondents believed that obesity is a health
problem, that it is treatable, and that it is associated with
heart disease, high blood pressure diabetes and early death
(Table 2). Significant differences in recognition existed along
racial/ethnic lines even after adjustment for confounders:
awareness for most associations was highest in white respon-
dents, intermediate in Hispanic respondents and lowest in
30 kg/m2, most (74%, 95% CI 70% to 78%) were aware of their
own obesity. African-American and Hispanic patients were
significantly less likely than white patients to recognize their
Among subjects with BMI ≥
Sivalingam et al.: Self-Recognition of Obesity
own obesity (Table 3). After multivariate adjustment, women
and patients with higher incomes were more likely than others
to report themselves as obese. Self-recognition of obesity was
not associated with education level, age or employment status
(Table 3). Even though 22% of patients were excluded from
multivariate models for missing demographics, we found
similar differences by race upon re-analysis in the full data
set. Ethnically based discrepancies in obesity recognition were
most pronounced in obese patients whose BMIs were border-
line (i.e., ≤35 kg/m2), where 75% of white patients, but only
58% of Hispanic and 44% of African-American patients,
reported themselves to be obese (Fig. 1). However, recognition
levels were similar in those with BMI ≥35 kg/m2[98% of white
patients versus 93% of Hispanic (P=0.21) and 99% of African-
American patients (P=0.70)].
Attitudes towards obesity and its treatment are summarized
in Table 4. Most (80%, 95% CI 79% to 82%) self-identified
obese respondents said that their weight had affected their
health and lives, with Hispanics being the most likely and
African-Americans being the least likely to report this. Only
about half of respondents (59%, 95% CI 57% to 61%) reported
that health care providers had discussed obesity and weight
management with them. Provider discussion did not vary
significantly according to race/ethnicity. Almost all (93%,
95% CI 93% to 94.0%) respondents said they had tried to lose
weight, regardless of race/ethnicity, and of those who have
tried, 55% (95% CI 53% to 58%) reported success. However,
success was not associated with race/ethnicity, knowledge of
obesity as a health problem, ever being told not to lose weight
or discussions with a health care provider.
self-identified obese subjects (87%, 95% CI 86% to 89%)
expressed interest in treatment for their obesity. Hispanics
were more likely than whites or African-Americans (P=0.02 for
both comparisons) to state they were interested in treatment.
Diet was the most popular weight loss treatment choice for
African-American and white subjects, whereas medication was
the most popular treatment for Hispanic subjects. Hispanics
were significantly less interested in exercise than whites (40%
vs. 67%; P=0.001) or African-Americans (40% vs. 71%; P≤
The majority of
Table 1. Sample Characteristics By Race/Ethnicity
Age/SD, in years52.7/
Income ≥50K7 (4%)<0.001††
Graduate school30 (9%) 10 (5%)
History of heart
Normal (<25 kg/m2)
49 (14%) 27 (13%)0.05††
72 (19%)29 (14%)<0.001††
Overweight (25 kg/
Obese (≥30 kg/m2)
*Raw numbers may not correspond to percentages as denominators may
differ due to missing data. †P-values derived from one-way ANOVA F-test
for equality of means (continuous). P<0.05 suggests that at least one
group’s mean age differs significantly from the others. ††P-values
derived from Fisher’s exact test or Pearson’s χ2 (categorical). P<0.05
suggests that at least one group’s proportion differs significantly from the
Table 2. Knowledge of Obesity Health Risks in Overall Sample,
% Report % Report% Report
Obesity is a health
Obesity is treatable‡
Obesity is related to
9992 87 <0.001
*Adjusted for age, Ssex, income and education. †African-American
significantly lower than Hispanic and white (P≤0.001 both). Hispanic
vs. white NS (P=0.4). ‡Proportions for white subjects higher than
Hispanic or African-American respondents (P≤0.005, all comparisons).
African-American vs. Hispanic NS (P=0.7). §Additional adjustment for
Table 3. Predictors of Self-Awareness of Obesity in Respondents
with BMI≥30 kg/m2
Predictor Odds ratio Odds ratio
0.20 (0.10, 0.42)
0.21 (0.11, 0.42)
0.52 (0.32, 0.85)
1.01 (0.99, 1.03)
1.41 (1.27, 1.56)
1.93 (1.31, 2.84)
0.30 (0.13, 0.73)
0.39 (0.16, 0.94)
0.41 (0.22, 0.78)
1.01 (0.99, 1.04)
1.46 (1.30, 1.64)
1.68 (0.99, 2.83)
2.66 (1.50, 4.69)
2.25 (0.89, 5.68)
1.54 (0.75, 3.17)
1.27 (0.40, 4.04)
*Adjusted for gender, age (continuous), BMI (continuous), income (ordinal)
and education (categorical). †Represents the change in odds of recogni-
tion for every 1 unit increase of predictor. ‡Represents the change in odds
of obesity recognition for every 1-category increase of predictor
Sivalingam et al.: Self-Recognition of Obesity
0.001), and significantly more interested in medications than
whites (70% vs. 52%; P=0.03) or African-Americans (70% vs.
Results of this survey suggest that race/ethnicity affects not
only recognition of one’s own obesity, but also awareness of
obesity’s link to morbidity and mortality, and preferences for
obesity treatment. These disparities hold even after adjust-
ment for socioeconomic confounders. Previous studies have
also shown that obesity awareness is inversely related to the
prevalence of obesity in one’s own ethnic/gender group.6
When the prevalence of obesity is higher in an ethnic group,
obesity appears normal, and people may be less likely to
recognize their own obesity. The difference in self-recognition
of obesity and associated risk in different ethnic groups may
also be due to differences in socio-culture, contextual body
image, dietary habits and other factors.13,14The problem is
compounded by the fact that African-Americans have a
lower mortality rate compared to whites at the same
BMI15,16and are thus somewhat protected from the effects
Several studies, using NHANES or other national surveys,
have examined the discrepancies between self-reported
weight categories and ethnicity; in these studies, obese
African-Americans and Mexican-Americans were more likely
than obese whites to perceive their weight as normal.7,8
Although these studies did not use the word “obese,” rates
of recognition were almost identical to those that we
observed. Our study extends these findings to an additional
ethnic group, Hispanics primarily of Puerto Rican descent,
whose recognition rate was similar to that of Mexican-
Americans. In addition, we found that ethnic differences
also influence awareness of obesity’s link to diabetes,
cardiovascular disease and early mortality, which might
directly inform practice priorities in adult primary care
Nearly all the patients in our study who recognized
themselves to be obese expressed a desire to lose weight,
and most reported that their weight has adversely affected
their health and lives, but only about half of the subjects
reported receiving weight loss advice from their health care
provider. These findings suggest that opportunities exist for
providers to discuss the presence, sequelae and treatments of
obesity with affected patients, and that the need for discus-
sion is particularly high for African-American and Hispanic
patients, especially those with a BMI between 30 and 35. We
also found that preferences for type of treatment varied by
ethnicity, with whites and African-Americans preferring
exercise, while Hispanic patients preferred medications. The
reason for this preference is not known; future studies might
explore beliefs and experiences related to both medication
Our study had a number of strengths. First, we included a
large ethnically and socio-economically diverse sample, in-
cluding the predominant racial/ethnic groups of the eastern
US. Second, the study design resulted in a very high response
rate, so response bias is unlikely. Finally, all patients had
Figure 1. Discrepancies between obesity and self-report, by race/
ethnicity. *AA vs. white, P=0.046. †Hispanic vs. white, P=0.001.
Table 4. Knowledge and Attitudes in Obese Subjects Who Self-
Report Obesity Adjusted Proportions*
White Hispanic African-
n=150 n=197 n=120
Obesity is a public
Obesity has affected
Obesity has limited
I have asked my
My doctor has talked
to me about obesity
I have been told not to
I have attempted to
I succeeded in
I would like to
I would be interested
in any treatment
96 95 96 0.98
6351 53 0.49
83 67 760.07
52 7048 0.02
*Adjusted for age, sex, income, education and degree of obesity (BMI)
Sivalingam et al.: Self-Recognition of Obesity
their weight checked in the clinic on arrival, increasing the
accuracy of reported weights.
Our study also had several limitations. First, we employed
a convenience sample from three general medicine clinics and
one cardiology clinic; cardiology patients might have a better
understanding of cardiovascular risks associated with obesi-
ty. We did not identify which surveys came from the cardiol-
ogy clinic. Patients with heart disease were more likely than
those without heart disease to know they were obese, but this
finding did not reach statistical significance, and it did not
alter the association between race and obesity awareness.
Second, not all patients may share the same understanding
of the word “obese,” and it might not be their preferred
term.17Differences in recognizing obesity may therefore have
had to do with interpretation rather than self-recognition.
However, our results were almost identical to those of previous
studies that used the term overweight, and the ethnic
differences in self recognition disappeared above BMI of 35,
implying that the difference had to do with threshold rather
than understanding. Third, the anonymous nature of the
study did not allow us to confirm reported weights. Patients
reported weights after they were weighed at check-in. Even so,
some may have underestimated their weight, in which case the
problem of under-recognition is even worse than we report.
Finally, our Hispanic population is comprised almost exclu-
sively of patients of Puerto Rican heritage. Findings from this
population may not be applicable to patients from other
Hispanic cultures such as Mexican or Central American.
Treating obesity and its sequelae remains a challenge for
primary care physicians. Our study offers some important
lessons for those who treat obesity in minority populations.
Because most people who recognized their own obesity had
tried to lose weight regardless of ethnicity, physicians should
strive to improve awareness of ideal body weight and the
dangers of obesity, especially among ethnic minorities. In
particular, providers should be aware that African-Americans
and Hispanics with BMI between 30 and 35 often do not realize
that they are obese. Once aware of their obesity and its health
consequences, such patients would likely be interested in
counseling about treatment options. The providers should
then be cognizant that treatment preferences also vary with
ethnicity. Tailoring treatments according to patient preference
might lead to higher success rates in the treatment of obesity.
Acknowledgement: Prior presentations: Poster presentation at The
Obesity Society's 2009 Annual Scientific Meeting, Washington D.C.
Conflict of Interest: None disclosed.
Corresponding Author: Senthil K. Sivalingam, MD; Baystate
Medical Center, Springfield, MA, USA (e-mail: senthilkumar_mmc@
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