J Cross Cult Gerontol (2008) 23:255–264 DOI 10.1007/s10823-008-9061-y ORIGINAL ARTICLE
Body-Shape Perceptions and Body Mass Index of Older African American and European American Women Petra B. Schuler & Debra Vinci & Robert M. Isosaari & Steven F. Philipp & John Todorovich & Jane L.P. Roy & Retta R. Evans
Published online: 1 April 2008 # Springer Science + Business Media, LLC 2008
Abstract The prevalence of obesity is higher in African American compared to European American women. Ethnic differences in body-shape perceptions such as greater acceptance of overweight figures, higher levels of body shape satisfaction, or an underestimation of one's body-shape have been suggested as possible contributors. The purpose of this investigation was to compare body-shape perceptions and body mass index of older African American and European American women. Eighty-nine European American and 115 African American women (mean age, 72 years) completed a questionnaire, composed of three parts: general demographic and anthropometric information, and questions regarding body-shape perceptions. The results suggested an underestimation of body-shape in African American women as a possible contributor to obesity. The findings of the present study suggested that in order to enhance the effectiveness of dietary interventions in older African American women, measures to assess the accuracy of self-perceived body-shape should be included. Keywords Age . Body shape . Obesity . Race . BMI
Introduction Obesity is a significant health problem linked to a variety of chronic diseases including diabetes, cardiovascular disease, hypertension, and hyperlipidemia (Lee et al. 1993). Although the health risks of obesity are well-known, the prevalence of obesity continues to rise, particularly among minority groups and women of lower socioeconomic status. It is P. B. Schuler (*) : D. Vinci : R. M. Isosaari : S. F. Philipp : J. Todorovich Department of Health Leisure and Exercise Science, University of West Florida, 11,000 University Parkway, Pensacola, FL 32514, USA e-mail:
[email protected] J. L. Roy : R. R. Evans Department of Human Studies, The University of Alabama at Birmingham, 1530 Third Avenue South, Birmingham, AL 35294, USA
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estimated that as many as 48.6% of African-American women compared to 32.9% of European-American women are overweight or obese and that African-American women suffer more from obesity related conditions when compared to European-American women (Kuczmarski et al. 1994; Kumanyika 1994). Researchers propose various theories to explain these ethnic differences, including genetic differences (Bouchard and Perusse 1988), behavioral differences in diet and exercise habits, differences in socioeconomic status that result in a lack of access or time for leisure activities (Sobal and Stunkard 1989), or the effects of in-utero-stress that infants experience as a result of, among other things, maternal stress of living in low-status, low socioeconomic environment (Magness and Poston 2005). Of particular interest to the current study was a theory suggesting that ethnic differences in obesity may be related to differences in body-shape perceptions (Rucker and Cash 1992). According to this theory, differences between African-American and European-American women in how they see their body (perceptual body image) and how they feel about their body (attitudinal body image) may influence their responses to changes in body weight and weight control. Chandler et al. (1994) hypothesized that a greater acceptance of overweight figures and higher levels of body shape satisfaction at heavier weights in African-American women, contributed to higher obesity rates. Patt et al. (2002) observed an underestimation of obesity in African-American women: the largest women [based on measured body mass index (BMI)] often did not select the largest images to represent themselves, suggesting that many obese women did not realistically identify themselves as obese. Similarly, Schieman et al. (2007) in a recent study, found that, overall, black older adults were generally more likely than White older adults to underestimate their current body weight (i.e. describe themselves as appropriate weight when in fact they were categorized as overweight or obese based on their BMI). While these findings collectively reveal that ethnic differences do exist between European- and African-American women in their body shape perceptions, the cause of these differences remain to be determined. A historical rationalization of this ethnic difference in body shape perception is provided by Johnson and Broadnax (2003). The authors suggest that perceived control of body size and proportion may be rooted in early America when female slaves perceived a larger physique as being less attractive to abusive men such as slave owners who used their “attractive” female slaves as concubines or for sexual gratification. Johnson and Broadnax go on to suggest that in a modern adjustment to this belief, modern African-American women may perceive their dietary intake and food choices as one source of “control” in a world where there exists little perceived or real control for many African-American women living in a low-status and/or low socioeconomic status culture. While the present study does not purport to directly determine the underlying psychosocial factors that drive these differences, the context determining African-American women’s body shape perceptions becomes important as a lens to analyze these findings. In order for interventions aimed at obesity prevention and treatment to be successful, it is important that individuals have accurate perceptions of their body-shapes and weights (Paeratakul et al. 2002). Overweight individuals who perceive themselves as having normal-weight may lack the motivation to engage in behaviors to control their weight; hence, the risk of developing obesity increases. Certainly, at a minimum, determination of ethnic differences among perceived body shapes, supports continued research efforts to investigate the factors that influence these changes and development of interventions to address them. A close examination of the literature reveals that the majority of studies examining ethnic differences in body-shape perceptions were conducted in young (adolescent and
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college age) and middle aged (35–50 years) women. Few reports are available studying ethnic differences in the body-shape preferences of older women. Generally, with respect to young women, the majority of studies suggested that African-American women had larger body-shape ideals, reported less body-shape dissatisfaction, and often perceived themselves as thinner than they actually were (Abrahams et al. 1993; Akin and Grilo 1995; Harris 1995; Kemper et al. 1994; Perez and Joiner 2003; Rucker and Cash 1992). Concerning middle-age women, the results seem less consistent. Fitzgibbon et al. (2000) and Snooks and Hall (2002) found no significant ethnic differences in body-shape preferences, whereas Becker et al. (1999) and Wilfley et al. (1996) reported that European-American women were significantly more dissatisfied with their body image compared to African-American women. Reports about the role of ethnicity in body-shape perceptions of older women are rare. To our knowledge, only a few studies have investigated this topic, the majority of which found that, similar to other age groups, older African-American women were more satisfied with their body-shape compared to European-American women (Lieberman et al. 2003; Stevens et al. 1994). In light of the rapidly increasing number of adults age 65 and over and the increasing prevalence of obesity with age (Xiaoxing and Baker 2004), it appears that interventions aimed at obesity treatment and prevention would benefit from an increased understanding of body-shape perceptions in this segment of the population. Hence, the primary goal of this investigation was to study body-shape perceptions and body mass index of older African-American and European-American women. Based on the review of literature, it was hypothesized that: (1) older African-American women would be more satisfied with their body-shape; (2) older African-American women would choose larger current and ideal body-shapes compared to European-American women, and (3) older overweight AfricanAmerican women would underestimate their current body-shape.
Methods Participants A sample of 204 older female volunteers (89 European-American and 115 AfricanAmerican) ranging in age from 55 to 86 years (72 + 9) completed a pencil-and-paper questionnaire developed by Schuler et al. (2004). Participants were actively recruited from local community centers and independent living facilities in the southeastern USA. Once permission was obtained from supervising personnel at the sample sites, researchers visited each site and verbally recruited participants. Procedure A brief overview of the procedures and purpose of the study was provided to all respondents at the beginning of the study. Respondents were then asked to sign an informed consent and complete the study survey. At each site, the researchers were present during the completion of the survey questionnaire to ensure accuracy and completeness of survey responses. Participants were continually encouraged to ask questions when needed. The pencil and paper questionnaire took approximately 20 min to complete and was composed of two parts: general information (age, sex, height, weight, race, level of income, and education) and questions regarding body-shape perceptions. Level of income was assessed by asking individuals to indicate if their annual household income was below $20,000 (=1),
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between $20,000 and 40,000 (=2), or greater than $40,000 (=3). Level of education was determined by asking individuals to choose one of the following categories: 1=grade school or left high school before graduation, 2=high school graduate, junior college, or technical/trade school, and 3=college graduate (bachelors, masters, or doctorate). Assessment of body-shape perceptions A variety of methods have been used to assess body-shape perceptions including interviews and questionnaires, picture evaluations, or estimations of bodily sizes, using both part body and whole body estimation techniques (Grogan 1999). The current study utilized the silhouette-scale technique in which participants were presented with a nine-figure body silhouette scale designed and validated by Stunkard et al. (1983). The figures ranged ordinally from very thin to very heavy; individual figures were assigned a number ranging progressively from 1=thinnest to 9=heaviest. As there were no standards provided by Stunkard and colleagues for the images relative to weight categories, Patt et al. (2002), using a panel of nutritionists, epidemiologist, anthropologists, and behavioral scientist, classified the images as follows: images 1–3 were considered normal weight, 4–6 overweight, and images 7–9 were categorized as obese. The normal category included obviously slender images with no visible excess tissue, while the overweight category showed increasing thickness in the waist, hips, and buttocks. A similar classification was used by Becker et al (1999) who considered figures of <5 on the rating scale to be “normal” without any visible fat. Participants were asked to determine their perceived current body-shape (“Which body shape looks most like your own?”) and their ideal body-shape (“Which body shape do you want to look like?”). A body-shape dissatisfaction score was calculated using the discrepancy between the participant’s choice for ideal and current body-shape. This technique is one of the most widely used quantitative measures of degree of direction of body-shape dissatisfaction (Grogan 1999). Although data were collected on the divergence between perceived and actual body shape, it should be noted that these participants may not actually feel a great degree of dissatisfaction and may have resigned themselves to their current body shape; however, in the present study this divergence between ideal and perceived body weight is operationally defined as “body shape dissatisfaction” in congruence with previous research (e.g., Grogan 1999). Statistical analysis A one-way analysis of variance (ANOVA) was used to test for ethnic differences in anthropometric and demographic variables with ethnicity as the independent variable and age, height, weight, body mass index (BMI=kg/m2), and level of education and income as dependent variables. Obesity was defined as a BMI>30; frequencies were calculated to determine the percentage of obese women in each ethnic group. Ethnic differences in body-shape perceptions were studied using a multiple analysis of variance (MANOVA) with ethnicity and as the independent variable and perceived current and ideal body-shape as dependent variables, while controlling for level of education and income. A paired sample t-test was utilized to compare ideal and current body-shapes for the entire group. In order to compare the accuracy of self-perception of body-shapes between older AfricanAmerican and European-American women, a multiple linear regression was calculated to predict BMI based on current body image and ethnicity. Significance was set at p<0.05 for all tests.
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Results Participants’ age, anthropometric, and demographic variables are summarized in Table 1. Forty-eight percent of African-American women were obese compared to 13% of European-American women. The one-way ANOVA revealed significant ethnic differences in the level of education and income, body weight, and body mass index (BMI). AfricanAmerican women were significantly heavier [F (1, 203)=27.72, p<0.01], had significantly higher BMI’s [F (1, 203)=23.15, p<0.01), and had significantly lower levels of education [F (1, 203)=17.72, p<0.01] and income [F (1, 203)=14.97, p<0.01]. The mean level of education reported for European-American women was 2.2 (high school graduate/junior college; SD=0.54), whereas the mean for the African-American women was 1.84 (grade school/left high school before graduation; SD=0.64). The mean annual income reported for European-American women was 2.0 ($20,000–40,000; SD=0.48) and for AfricanAmerican women it was 1.60 (<$20,000; SD=0.49). Body-shape perceptions and ethnicity Due to missing cells (a few of the participants did not answer all body-shape questions) only 179 individuals were included in the MANOVA. Although African-American women’s mean current body shape (M=5.00; SD=1.62) was slightly higher than European-American women (M=4.58; SD=1.56) as shown in Table 2, statistical analysis revealed no ethnically based statistical differences. However, paired sample t-tests did reveal a significant difference between current and ideal body shape (t=14.33, p<.01) for the entire group; all women selected a significantly larger current body-shape compared to ideal their body-shape, regardless of ethnicity. A significant regression equation was found [F(2,150)=61.031, p<0.001] with an R2 of 0.449. Subjects predicted BMI was equal to 13.421 2.038 (Current) 2.954 (Ethnicity) when ethnicity was coded as 1=European-American and 2=African-American, and current bodyshape was measured on the nine-figure body silhouette scale (Stunkard et al. 1983). The participants BMI increased by 2.038 with each consecutive current body-shape and the African-American women’s BMI was 2.954 higher for each consecutive current body-shape compared to European-American women (see Fig. 1). These results suggest that AfricanTable 1 Age, Anthropometric, and Demographic Measures for African American (AA) and European American (EA) Women EA Women (n=89) M Age (years) Weight (kg) Height (m) BMI (kg/m2) Level of incomea Level of Educationb a
73.11 67.90 1.62 25.61 2.00 2.20
(AA) Women (n=115) SD 7.94 14.99 0.06 5.46 0.80 0.54
M
SD 71.41 80.29 1.64 29.77 1.60 1.84
7.29 14.58* 0.08 5.27* 0.64* 0.64*
Level of income was ranked as follows: 1=< $20,000, 2=$20,000–40,000, and 3=> $40,000
b
Level of education, 1=grade school or left high school before graduation, 2=high school graduate, junior college, or technical/trade school, and 3=college graduate *p<0.01
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Table 2 Body-shape Perceptions of Older African American (AA) and European American (EA) Women EA Women (n=82)
Current body-shape Ideal body-shape a
AA Women (n=97)
M
SD
M
SD
4.58a 3.34a
1.56 0.85
5.00a 3.57a
1.62 0.96
Corrected model evaluated in the model at: level of income=1.8249, level of education=2.0508
American women are more likely to underestimate their body shape than EuropeanAmerican women.
Discussion The primary goal of this investigation was to evaluate whether ethnic differences in overweight and obesity were related to differences in body-shape perceptions in a sample of older African-American and European-American women. Specifically, the study sought to determine whether a greater acceptance of overweight figures, higher levels of body shape satisfaction, or an underestimation of one’s body-shape, were possible contributors to the greater prevalence of overweight and obesity in the present sample of older AfricanAmerican women. Generally, the results of the present study showed that significant differences in body-shape perceptions existed between the older African-American and European-American women. Most importantly, the findings suggested that overweight African-American women underestimated their current body-shape. The average BMI associated with each of the nine figures identified by the women as their current body-shape was consistently higher in African-American compared to European-American women. The
40.00 Mean BMI For Each Current Body Shape
Fig. 1 Mean BMI and current body-shapes for AfricanAmerican (n=97) and EuropeanAmerican Women (n=82); the plot was generated from a univariate ANOVA with BMI as the dependent variable and race and current body image as fixed factors
African-American 35.00
30.00
EuropeanAmerican
25.00
20.00 2.00
3.00
4.00
5.00
6.00
7.00
8.00
Which Body Shape Looks Most Like Your Own? (Current)
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present study did not find ethnic differences in desired body-shapes. All women, regardless of ethnicity selected an ideal body-shape (3.34 and 3.57) that was within a range considered “normal” (without visible fat; <5; Becker et al. 1999) on the nine figure rating scale. The apparent underestimation of one’s body-shape in the older overweight AfricanAmerican women seems of particular importance with respect to weight control and obesity prevention. If women categorized as overweight based on their BMI (>25 kg/m2, <30 kg/m2) do not perceive themselves as such, they most likely lack the motivation to engage in behaviors to control their weight, rendering interventions aimed at obesity prevention potentially ineffective. In the present study, this was especially apparent for current body shapes within the normal range (<5 on the figure scale). The corresponding mean BMI’s for current figures 2, 3, and 4, for European-American women, were 20.6, 23.0, and 24.8, respectively, all of which are in the normal range (<25 kg/m2). In contrast, the corresponding mean BMI’s for the African-American women were 26.1, 26.5, and 28.2, all of which fall into the overweight category. Similar findings were reported by Patt et al. (2002) who showed that African-American women classified as overweight based on BMI, did not perceive themselves as overweight. Overall the findings of the present investigation suggest that overweight African-American women, regardless of age, might be more likely to underestimate their body-shape compared to European-American women; hence, obesity treatment programs should include measures of body-shape perceptions when designing effective weight loss and weight maintenance interventions. There are numerous explanations for why inaccurate self-perceptions of body-shapes might have been more prevalent in African-American compared to European-American women. For example, it has been suggested that African-American women are more conflicted about their body-images than European-American women (Stevens et al. 1994) because on one hand their communities value larger sizes and on the other hand US society generally values slimness (Liburd et al. 1999). In addition, it has been hypothesized that asking women to adopt a “special diet” might challenge their role as “gatekeepers” for food in the family, further contributing to the conflict (Lieberman et al. 2003). A believe supported by historical epidemiologists, that wasting and low body weight are signs of illness, and a larger body is important in reducing morbidity and mortality (Brown and Konner 1987), might be of particular relevance to older African-American women. AfricanAmericans still have limited access to health care and health insurance, hence, the fear of prolonged bouts of illness leading to significant weight loss and wasting, might be more pronounced in older African-American women compared to European-American women. On the other hand, the many older adults are aware, through community health education and promotions efforts, that the combined effects of aging and overweight and obesity, significantly increase the risk for chronic diseases (Clarke 2002). It is tempting to speculate that the erroneous self-perceptions observed in the present sample of older AfricanAmerican women may have been the result of conflicting messages created by their historical perspectives and experiences, cultural pressures, the media, and medical messages promoting slenderness and health. This notion is supported somewhat by the literature and observation of the racialization of weight (e.g., Johnson and Broadnax 2003). For example European-American women appear to have much thinner role models than AfricanAmerican women which might contribute to pursuit of a much smaller body size even if they are not overweight. Clearly, cultural and racial heritage influence these perceptions, and certainly suggests that researchers should continue this line of research. Considering the numerous ethnic, cultural, and societal explanations which can be offered for the present study, the present findings should be interpreted with caution. When asked to report current and ideal body shapes, all women, regardless of ethnicity, selected
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similar shapes which suggested a similar degree of dissatisfaction for both ethnic groups. If one assumes however, that the “Actual” current body-shape of the African-American women was greater than the one selected, then the “actual” degree of dissatisfaction was also greater in the African-American women compared to the European-American women. From an intervention perspective, however, it should be noted that while older women regardless of ethnicity desire to be a different body type, the degree of dissatisfaction may vary based on how resigned one is to accept their weight or perceive it to be a real health or social threat. While the present study does identify differences between ethnic groups, researchers should continue to look for deeper psychosocial perspectives regarding these differences. The importance of accurately identifying current and ideal body-shapes in weight control interventions is further supported by Anderson et al. (2002), who identified the degree of discrepancy between current and ideal body-shapes as the strongest predictor of trying to lose weight in a large sample of overweight and obese middle-aged and older women. Women who were not satisfied were nine times more likely to report trying to lose weight compared to those who were very satisfied. Finally, the results of the present study did not support the hypothesis that there was a greater acceptance of overweight figures in African-American women since the ideal figures selected by both ethnic groups were in the “normal range” (<5; without visible fat). Again, one could argue that the erroneous perceptions of current body-shapes also question the validity of ideal body-shape perceptions. Unfortunately, based on the self-reported nature of the present study this remains speculative. Some limitations have to be considered when interpreting the results of the present study. First, self-reported weight and height were used. Hence, an under-or over-estimation of current body weight can not be excluded. Xiaoxing and Baker (2004) suggested that, in general, participants tend to underestimate their true weight. They further speculated that the validity of self-reporting may vary by ethnicity. However, no data currently exists to support this suggestion. In general though, studies indicate that self-reported and measured weight are highly correlated and estimate the degree of underestimation to between 1 and 2 kg (Villaneuva 2001; Lawlor et al. 2002). Second, the question exists to whether the current BMI obesity classification is appropriate for older African-American and EuropeanAmerican women. Evan et al. (2005) suggested that for the same BMI, older AfricanAmerican women had 1% lower body fatness than European-American women, and that BMI values of 28.4 kg/m2 for African-American women and 26.9 kg/m2 for Caucasian women maximized obesity classification accuracy. Similarly, Rush et al. (2007) showed that the relationship between percent body fat and BMI varies with ethnicity which may be due, in part, to differences in central fatness and muscularity. For example, a regression equation developed by the authors to predict percent body fat from BMI revealed that at a BMI of 30 kg/m2 for South African Europeans, the predicted percent body fat of 39% equates to a BMI of 29 kg/m2 for South African Black women. However, based on the magnitude of the differences reported by Rush et al. (2007), the authors of the present study feel confident that, using different classification criteria would not have changed the findings of the present study. Third, the study sample was drawn from community centers and independent living facilities from the southeastern part of the United States; it is not suggested that the present data necessarily represent the general population of older African-American and European-American women. The women in the present study lived independently, were relatively healthy, and socially engaged. Last, the Stunkard et al. (1983) figure rating scale, though used by the majority of studies reviewed, is not ethnic specific. It has been suggested that studies employing this scale should shade the uncovered skin portions of the scale to improve ethnic relevance (Becker et al. 1999).
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In conclusion, keeping the limitations in mind, the findings of this study suggest that in the present sample of older women, ethnic differences in body-shape perceptions were present and that interventions aimed at weight reduction and maintenance need to include measures of body-shape perceptions to enhance their effectiveness. In particular, it appears important to assess the accuracy of self-perceived body-shape when working with older overweight African-American women. Future studies should include objective measures of body weight and shape in addition to self-reports, measures of energy consumption and expenditure, and estimates of perceptual as well as attitudinal body-shape components, to enhance our understanding of the factors contributing to the ethnic disparities in obesity rates in women.
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