Biomedical Research

Abstract

Misperception of body weight has become common in the global world and may affect motivation to lose weight particularly in overweight and obese subjects, leads to psychological distress. With the growing prevalence of obesity in Saudi Arabia, there is an urgent need of exploring the determination of serious epidemic. We investigate the prevalence of weight misperception with weight loss attitudes, behaviors’ and psychological distress in Saudi medical students. A cross-sectional study was conducted in primary care clinic at King Saud University Medical City during 2015-2016. In this study, 446 subjects were enrolled with an age range of 18-60 years of both genders. Data was collected by well-designed questionnaire and with International Physical Activity Questionnaire (IPAQ) and Kessler 10 scale (K10) for psychological assessment. The prevalence of misperception was 63.9%. Weight underestimation was present mostly in the female, young aged, married, high monthly family income and obese. There was a significant correlation between misperception and BMI (p ≤ 0.001). No association was observed in psychological distress, and weight misperception (p=0.258), and the effect of chronic diseases was a significant predictor of IPAQ (p ≤ 0.001). Misperception of body weight is common among Saudis. Although most of our studied population wants to lose weight, they had sedentary life style and imbalance diet. Understanding the cultural context of obesity in Saudi community and targeting misperception may facilitate the advice of healthy lifestyle behaviors and improve the effectiveness of obesity interventions.

Keywords

Weight misperception, Psychological distress, Physical activity, Weight loss behaviors.

Introduction

Weight misperception can ensue when the person's perceived weight differ through the status of initial weight [1]. The growth of medical complication risks prone on account of Body Mass Index (BMI) and abdominal obesity. Overall, 85%, 50% Type 2 Diabetes Mellitus patients are overweight and obese. The adult prevalence of obesity was estimated to be 63.6% in Saudi Arabia; females (71%) were more prone than males in obesity (56%) [2]. Overweight and obesity prevalence was confirmed as 23% and 9% in school children [3]. Obesity is significantly associated with increase the risk of more than 20 chronic diseases such as Type 2 Diabetes Mellitus, Coronary heart disease, heart disease, blood pressure, stroke, abnormal body fats, metabolic syndrome, cancer, osteoarthritis, sleep apnea, obesity hypoventilation syndrome, gout, reproductive problems in female, gall stones, gall bladder, gestational diabetes, congenital heart and kidney diseases. T2DM prevalence was majorly prone in Saudi adult population due to obesity risk factor [4-6]. Underestimation of body weight in overweight and obese population might lead to decreased motivation to lose weight [5,6]. Individuals have confirmed more misperceive themselves due to the physical activity [7]. Misperception status for the genuine body may be an important factor to understand weight control-related behaviors [8]. Earlier studies confirm parents’ fail to identify their offspring's overweight due to their weight, child's gender, younger age and many other factors [9]. Results of Al-Qauhiz [10] studies confirm misperception rate was found 54.2% in overweight and 17.4% of obese female students in Riyadh provenance. So, we aim to investigate the prevalence of weight misperception with weight loss attitudes, behaviors’ and psychological distress in Saudi medical students.

Methodology

Study design and setting

A quantitative observational cross-sectional study was conducted at primary care clinics in King Saud University Medical City (King Khalid university hospital) which is one of the leading teaching hospitals in Riyadh, Saudi Arabia. Data was collected in November 2015 March 2016. This study has Institutional Review Board (IRB) approval from the research ethical committee of College of Medicine, King Saud University.

Study population

The population included Saudi adult (aged 18 to 60 years) of both genders. Pregnant, lactating women, psychiatric patients and those on psychiatric medications were excluded from the study. Sampling method was consecutive non-randomize technique. Based on Duncan et al. [11] study sample size was calculated using one-way proportion equation (N=(Z2α) (P (1- P)/D2) and collected 446 samples as estimated with 95% confidence level and 5% precision.

Data collection

Well-design questionnaire was prepared by the research team using International scales to measure psychological distress and physical activity. Outcome variables are weight misperception, behaviors, attitudes for losing weight, psychological distress, dietary inquiry and physical activity. Age, gender, marital status, the level of education and monthly family income are documented as demographic variable data and order to avoid duplication of collected data; we set the participant medical file number as a unique identifier. The unpublished pilot study had conducted to know the estimation time to fill questionnaire and average estimated time for completion of the questionnaire was 10-15 minutes.

Anthropometric measurements

Qualified nurses have measured anthropometric measurements through height in centimeters and weight in kilograms. Height and weight were measured without shoes and with light clothes through stadiometer and electronic scales [12,13]. Body Mass Index (BMI) was calculated using weight in kilograms divided by squared height in meters. Body status classified according to BMI into 4 categories: underweight (BMI ≤ 18.5 kg/m²), normal (BMI between 18.5–24.9 kg/m²), overweight (BMI 25– 29.9 kg/m²), obesity (BMI ≥ 30 kg/m²) [14].

Measurement of weight

The status of weight perception and misperception was calculated with figure risk scale [15]. This scale consists of seven body sizes accounted for gender's (males and females) physical appearance graded from 1-9. Picture of bodies’ interpretation was: 1, 2 categorized as underweight; 3-5 denoted normal weight; 6, 7 represents as overweight and 8, 9 were confirmed as obese. The participants were asked to choose the body that looks close to them. Misperception was considered when there is disagreement between the calculated BMI and the selected body that looks like them.

The participants have answered several quires regarding weight loss attitudes and behaviors such as laxative, herbs and fasting for a long time which was unhealthy weight loss behaviors [16,17].

Measurement of psychological distress

Kessler et al. [18] 10 Scale (K10) was used to evaluate psychological distress in the selected participants. Validated Arabic version was used due to its simplicity in measuring general distress, designed for quality frequency and severity of anxiety related symptoms experienced in the four weeks before screening. The similar scale has been reported earlier in Saudi studies [19,20], consists of ten different questions, and each of them was scored on Likert scale ranging from 1-5 (none of the time all of the time). The lowest possible score was 10, and the highest possible score was 50. Lower K10 scores indicate a lower level of psychological distress while higher scores indicate a greater level of psychological distress.

Diet and physical activities

Participants questionnaire consists of variable questions for spotting their eating and drinking habits, an Arabic form “International Physical Activity Questionnaire” (IPAQ) was used [21] to measures the intensity and frequency of physical activity during last seven days in adult population ranging from 15-69 years. The important factor of this questionnaire was to obtain data used for comparing internationally on healthrelated physical activity. Another phase in the questionnaire consists of knowledge regarding BMI which links up with diet and physical activity.

Statistical analysis

Statistical Package for Social Sciences (SPSS) version 21 was used for data entry and analysis. We assessed the prevalence (data frequency and percentage) of misperception, BMI groups, Wight loss behaviors and attitudes, dietary intake and physical activity among our studied sample. No missing values or duplicated cases are recorded. Descriptive analyses (Chi- Square test) were used to examine associations between Misperception and (actual BMI, psychological distress, weight loss behaviors and attitudes). P<0.05 is considered as statistical significance level. We tested for interactions between groups of misperception with all the socio-demographic variables (age, sex, marital status, education level and monthly family income) and chronic diseases.

Results

Characteristics of study population

A total of 446 Saudi adults were enrolled in this study. The mean age was about 37 years. Socio-demographic characteristics were shown in (Table 1). Prevalence of misperception was 63.9%. Men and women who misperceive themselves were (51.8% and 74%) respectively with (p<0.001). Weight misperception was associated with sociodemographic factors as sex, age, marital status, occupation, educational level and monthly family income. The 40-49 years of age groups have more misperception than the other age group (p ≤ 0.001). As per educational levels, university graduates have additional realistic perceptions (p ≤ 0.001) compared to others. Participants with monthly income more than 10,000 SR were more likely to have misperception (p<0.05). There was no significant relationship between misperception and chronic diseases (p>0.05).

Table 1. Association between self-perception and socio-demographic characteristics of studied sample Saudi Adult, Riyadh (2016) (n=446).

Association between misperception and BMI

The prevalence of underweight, normal, overweight and obese were (3.8 %, 24.9%, 27.4%, 43.9%) respectively. There was a significant association between misperception and BMI (p ≤ 0.001).

The BMI of obese people who underestimate themselves was statistically significant (81.1%; p ≤ 0.001) (Table 2). The participants with high BMI had the complex misperception (p ≤ 0.001).

Table 2. Association between misperception and BMI in Saudi Adult, Riyadh (2016) (n=446).

Association between weight misperception, weight loss attitudes and behaviors

Approximately, 70% of our subjects were keen to lose weight. Results of weight misperception were highly motivated for weight loss (p ≤ 0.001) and data were tabulated in Table 3. However, misperception was not significantly associated in people to requisite surgery for losing weight (p=0.602). Only (11%) of studied population assumes the surgery required for weight loss. The statistical association appeared between misperception and weight loss behaviors (p ≤ 0.001). Maximum subjects underestimated themselves when opted exercise to lose weight (70%; p ≤ 0.001). Other behaviors were not significantly associated excluding usage of herbs for losing weight (75.7%; p=0.049). Lowest percentage existed who induces vomiting after eating (1.6%; p=0.427) (Table 4).

Table 3. Association between misperception and Weight lose behaviors and attitudes among Saudi adults, Riyadh (2016) (n=446).

Association between weight misperception and psychological distress

Table 4. Association between Misperception and unhealthy Weight lose behaviors of Saudi Adult, Riyadh (2016) (n=446).

Association between weight misperception and psychological distress

Although higher levels of psychological distress have an inverse relationship with misperception (56.5%), There was no significant association was found between Misperception and K10 scale as shown in Table 5 (p=0.258).

Table 5. Association between misperception and K10 score in Saudi Adult, Riyadh (2016) (n=446).

Dietary intake and physical activity inquiry

In our study, 67.3% of participants consume a cup of coffee, and 7.7% consume junk food on a daily basis (Table 6). Frequently, 27% of them drink a water of 6 cups/day. The percentage of IPAQ scale was; low active (61.7%), moderately active (29.1%) and highly active (9.2%). IPAQ score varies significantly with age and gender (p=0.004) (Table 7).

Table 6. Diet inquiry in Saudi Adult, Riyadh (2016) (n=446).

Table 7. Association between IPAQ and sex and age groups of Saudi Adults, Riyadh (2016) (n=446).

Association between misperception and BMI knowledge

As shown in Figure 1, BMI knowledge was not a significant predictor on Weight misperception. The participants who perceived about BMI were (37.9%; p=0.225) and who alleged about the known of BMI scores were (16.1%; p=0.217).However, 4.0% of participants were able to accurately perceive their weight.

Figure 1: Misperception of Body Weight and BMI Knowledge among Saudi Adults, Riyadh (2016). Percentages within the rows (BMI knowledge). Statistically significant (p<0.05).

The effect of chronic diseases on misperception, K10 and IPAQ scores

The relationship between weight misperception with or without chronic diseases was not statistically significant (p=0.068). Also, the number of chronic diseases with K10 was not statistically significant (p=0.503). The effect of morbid diseases was a significant predictor of IPAQ scores (p ≤ 0.001).

Discussion

The current study was aimed to investigate the prevalence of weight misperception with weight loss attitudes, behaviors' and psychological distress in Saudi medical students. As per the records, there are no studies documented in Saudi population, and this could be the initial study carried with medical students in the Saudi population. The results of our current study confirm significant association within misperception and BMI (p<0.0001) and no association with psychological stress (p=0.25). Many studies have been implemented relation between BMI cum depression and finds both positive and negative modes. However, still, connection founds to be unclear [1,22-29]. Limited knowledge has been documented regarding BMI (37.9%), and 16% has no information about BMI. A British study has concluded obese individuals have adequate knowledge about BMI and they could recognize the difference between normal, overweight and obesity [10,30]. Misperception on human body’s weight is a known existence and various results documented from global populations [11,30-32] and our study was by the prior studies. Weight perception could be more influential in regulating weight control behaviour and in our study women were more accurate towards weight perception than men and our results were supported by Gibbs et al. [33] study [5,31-33], but Byeon [23] studies conclude underestimated male and overestimated female students were at greater risk of developing depression in Korean middle school children’s. Al-Quwaidhi et al. [34] study warn the prevalence of obesity in Saudi Arabia will be prone from 12%-41% and confirms women will have high prevalence rate than men to increase the weight. Age is an additional determination for weight misperception, and earlier reports confirm perception of overweight status is more prevalent among people with low socioeconomic status, and women [5,29,35-37]. Our results showed that women are more likely to misperceive their body weight, i.e., 74%. Lee et al. [8] studies confirm randomly half of the Korean adolescents have misperception towards their weight. Additionally, we documented people with higher monthly income are more likely to have a misperception, supported by the earlier study [24] and could be attributed mainly to dietary habits and sedentary lifestyle. Misperception on human body weight is known the existence and various results documented from global studies [11,30-32] and our study was by the prior studies. We assume sociocultural influences such as social weight comparisons play a major role in prevalent disagreement between self-assessments and actual weight in Saudi Arabia where some people still consider overweight is attractive and is a beauty mark for ladies and have their norms, so in our population comparing themselves to this norm. This is consistent with the social comparison hypothesis proposed as an explanation for this attitude by Johnson et al. [38].

Earlier and current reports showed the positive evidence in cross-sectional data [31,38,39]. Despite all efforts and attempts made to raise awareness of healthy weight by overweight people, still fail to realize that their weight could be major concern trying to understand the cultural context of this issue and figure it out in Saudi community will make it more likely to the population to interact with the calls for weight control and feel it a personally relevant. Targeting misperception may facilitate the advice of healthy lifestyle behaviors and improve the effectiveness of obesity interventions. Major participants interested for losing weight training through diet or physical exercise to lose weight. However, the majority of the sample had low physical activity scores those with chronic diseases [40]. The earlier study demonstrates subjects with no chronic illnesses have higher scores of physical activities. In fact, individuals between with and without performance with physical activity were misperceived their weight limitedly [7]. This should have considered when developing health promotion programs. Weight loss behaviors and attitudes found strongly related to misperception [29,41]. Overall, people who underestimated to lose their body weight instantly assume surgery for weight loss. Among them, quick method to lose the weight was fasting for 24 h which was consistent with other studies [41], but inconsistent studies report smoking as the most frequent method to lose weight [16].

The strength of our study was carried with a valid psychometric scale to screen for psychological distress [42] and physical activity scale [29] which was used to measure the person physical activity for adult and BMI was computed by male and female nurses to each participant through college file number. The current study limitations were (i) no connection between variables may be opting the cross-sectional study, (ii) sample collection was carried out at primary care clinics which are a single center single city (iii) recruited low sample numbers. Our study concludes weight misperception was found in obese subjects in the Saudi population. However, we could not find a relation between physiological stress and misperception. Lower physical activity was observed in chronic diseases, and our study recommends implementing training sessions for realizing weight gain, interprets to discontinue the obese.

Acknowledgement

Special thanks to our data collectors: Adulaziz Omar Jalal, Amal Saad Aseeri, Turky Abdullah Bn Duraihem, Faris Jamal Al-Mutairi, Lulua abdullah aldaej, Futoon talal alnemari, Najla Musaed Alsaikhan, Rakan Khalid Alsalem, Abdullah suliman alkhamshi, Nasser Saleh Alkhraiji, Samar AlOtaibi, Ghaida Abdullah Aljamili, Yasmen Riyadh AlFarsi, Azzam Faisal Bamugaddam, Moaath Abdullah Alasheikh, Mishari Fahad Salem Alsalem, Nasser Talal Mohammed, Waad Bader Almanie.

Competing Interests

The authors declare that they have no competing interests.

Funding

The authors declare that they have no source of fund for this study.

Authors’ Contributions

Alyousefi N, Alqarni F, Alqarni B, Almazroa S, Almutairi M and Alshehri Y participated in the design of the study, literature review, data collection, performing the statistical analysis and writing the manuscript. Alrowais N participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.

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