Obese and unaware: can you be too comfortable with your body size?

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© Najlah Feanny/Corbis

Feeling confident and secure about your body is important, and a critical part of having high self-esteem, and as the health care debate continues, advocates for “fat acceptance” are struggling to have their voices heard by lawmakers. Yet, while it is clearly true that weight isn’t the solitary indicator of health, a problem arises when obese patients are unaware of how their weight can negatively impact their health. For clinically obese patients who perceive their body size as healthy, or even believe they could afford to gain more weight to reach an ideal body size, researchers from the University of Texas say there may be such a thing as feeling too comfortable in your own skin. In a study of 2,056 obese patients—defined as having a body mass index of 30 or higher—8% believed that they were at a healthy weight, or could even afford to gain weight, despite having markedly high incidences of and increased risks for conditions such as diabetes, heart disease and high cholesterol.

Dr. Tiffany Powell, a cardiology fellow at the University of Texas Southwestern and lead author of the current research, which was presented this week at a meeting of the American Heart Association, says her interest in preventing heart disease prompted her to expand on body image research that, until now has primarily appeared in psychiatric and psychological literature. The finding that 8% of patients included in the study, or nearly 1 in 10 obese people, had misconceptions about their body weight was a cause for alarm, Powell says, but she found it more concerning that most of those patients said they had never been advised by their doctors to make lifestyle changes. “It’s startling that, even though they’re an obese population, they’re not getting the information they need from physicians,” Powell says. Some of that lack of information may be attributable to doctors’ discomfort addressing obesity. Though education campaigns and the broader fight against obesity in recent years has prompted many doctors to include lifestyle discussion as part of consultations, addressing patients’ weight remains a challenge for many physicians. (A 2008 Mayo Clinic study of 2,500 obese patients found that medical records for 4 out of 5 did not classify them as obese.)

Though the merits of using BMI to assess healthy body weight and classify obesity are still being debated, it remains the leading measure used by medical professionals. This current research, which used 2000 data from the Dallas Heart Study, not only measured BMI, but also compared blood analysis and other physical exam data with patients’ assessments of their own body size. Using what is known as the Stunkard scale, or series of images of progressively heavier body types labeled 1 through 9, with 9 being the heaviest, patients’ were instructed to pick out what figure best represented their current body size. Obese patients with accurate self perception were most likely to pick out the correct body size, as confirmed by researchers, and to indicate that a smaller body size would be more healthy. Yet, obese patients with skewed perceptions of their own bodies were more likely to pick out slimmer figures, and to say that an ideal body shape would actually require them to maintain their current size or even put on more weight. What’s more, while obese patients who believed they were overweight tended to exercise regularly, those who felt they were at a healthy weight, or underweight, seldom exercised and were also less likely to visit a doctor—nearly half of this group hadn’t seen a doctor in the preceding year, compared with a quarter of the group with more accurate body perception.

While a relatively small slice of the obese population had misconceptions about their body size, when the data was analyzed by age and race, clear trends emerged. To begin with, patients with inaccurate body size perceptions tended to be younger—the average age was 39.5, compared with 42 in the group with more accurate perceptions. And, in this obese population, blacks and Hispanics were more likely than whites to believe their body size was healthy: 14% of African Americans and 11% of Hispanics compared to just 2% of whites believed their body weight was healthy and they did not need to lose weight.

For Powell, those trends suggest a shift in attitudes about obesity. “I think part of it is that what’s considered normal is probably being reset by what people see around them as obesity increases and becomes more prevalent,” she says. (According to the Department of Health and Human Services, 4 out of 5 African American women are obese, and African Americans have the highest levels of overweight and obesity compared with other ethnic groups in the U.S., a trend that has been growing in recent years.) “If the majority of people around you are obese, you’re going to become more accepting of that. It becomes the norm,” Powell says. And it is precisely that issue that underscores the need for moving beyond the doctor’s office into more community-based obesity education programs, she adds. “People with body size misperception really aren’t accessing the health care system,” she says. “We as physicians need to work, not only in our clinics to target people, but I think this also calls attention to the need to work in communities.”

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