Research Article
Body Mass Index and Weight Loss in Overweight and Obese Korean
Women: The Mediating Role of Body Weight Perception
Sunjoo Boo, RN, PhD *
College of Nursing, Gachon University, Yeonsu-gu, Incheon, South Korea
a r t i c l e i n f o
s u m m a r y
Article history:
Received 24 February 2013
Received in revised form
22 July 2013
Accepted 2 September 2013
Purpose: This study were to assess the relationships among BMI, body weight perception, and efforts to
lose weight in a public sample of Korean women who are overweight and obese and to examine the
mediating role of body weight perception on the relationship between BMI and weight loss efforts.
Methods: This cross-sectional study used data from the 2008 Korea National Health and Nutrition
Examination Survey. The sample was 1,739 Korean women 20 years old or older with body mass index
(BMI) 23 kg/m2. Bivariate relationships among variables of interests were assessed. Three separate
regressions were used to test the mediating role of body weight perception on the relationship between
BMI and weight loss efforts.
Results: BMI and body weight perception were signicant correlates of weight loss efforts. BMI was
signicantly associated with weight perception, but a large proportion of women underestimated their
weight. Weight perception partially mediated the relationship between BMI and weight loss efforts in
Korean women.
Conclusion: In light of the high prevalence of overweight or obesity and the many health consequences
associated with obesity, Korean women should be aware of a healthy body weight and try to achieve that
weight. Nursing interventions should consider body weight perception to effectively motivate overweight and obese Korean women to lose weight, as necessary.
Copyright 2013, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Keywords:
Korean
obesity
weight loss
weight perception
women
Introduction
Over the past several decades, Korea has experienced rapid
economic growth, resulting in unhealthy changes in lifestyle and
diet that have led to signicant increases in obesity (Yoon et al.,
2006). A recently published study using nationally representative
data showed that one in two Korean women aged 20 or older is
overweight or obese, while more than 60% of women aged 50 or
older are considered overweight or obese (Boo & Froelicher, 2012a).
Excess weight is a risk factor for numerous chronic conditions,
including diabetes mellitus and cardiovascular disease (Must et al.,
1999). Weight loss can favorably reduce the risk for such diseases
(Hamman et al., 2006; Pi-Sunyer et al., 2007). Therefore, overweight or obese individuals need to be counseled and encouraged
to embark on efforts to lose weight.
Research has shown that trying to lose weight is related to the
level of overweight (Andreyeva, Long, Henderson, & Grode, 2010;
* Correspondence to: Sunjoo Boo, RN, PhD, College of Nursing, Gachon University,
191 Hambakmoero, Yeonsu-gu, Incheon, 406-799, South Korea.
E-mail address: sjboo@gachon.ac.kr
Bersamin, Hanni, & Winkleby, 2010; Bish et al., 2005; Koo & Park,
2011), but not everyone who is overweight or obese tries to lose
weight (Andreyeva et al.; Bersamin et al.; Bish et al.; Koo & Park). A
study by Koo and Park showed that only 23.5% of overweight and
17.2% of obese middle-aged Korean women are trying to control
weight. This may be an indicator of a low level of readiness for
weight loss in overweight or obese individuals. Thus, an important
opportunity exists for the success of weight loss interventions.
Sociodemographic factors such as age, race, education level, income, and smoking status are also related to trying to lose weight
(Anderson, Eyler, Galuska, Brown, & Brownson, 2002; Bersamin
et al.; Bish et al.; Lee et al., 2005). Although these factors are useful
in deciding where to direct weight loss interventions, they may not
be helpful in designing more effective or appropriate weight loss
interventions. A better understanding about what motivates overweight or obese individuals to try to lose weight might help in
designing more effective weight loss interventions.
Motivation for weight loss in women can include body weight
perception, which is the subjective evaluation of ones body weight
and is related to weight loss concerns or health behaviors (Clarke,
2002; Putterman & Linden, 2004). Studies from the United States
have demonstrated that dissatisfaction with weight is a strong
1976-1317/$ e see front matter Copyright 2013, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
http://dx.doi.org/10.1016/j.anr.2013.09.003
192
Methods
Study design
This is a cross-sectional secondary data analysis. Data from the
2008 Korea National Health and Nutrition Examination Survey IV
(KNHANES IV) by the Korea Centers for Disease Control and Prevention (KCDC) were used. KNHANES IV used a stratied, multistage probability sampling design. Details of the sampling design
and survey procedures of the original study are provided elsewhere
(Boo & Froelicher, 2012a, 2012b).
(B)
Weight-loss efforts
(A)
M or % (SE)
Age (yr), M
40
41e65
66
Marital status (married & living together), %
Education (high school or less), %
Below poverty levela, %
Work status (yes)
Current smoker, %
BMI (kg/m2), M
23 BMI < 25, %
BMI 25, %
Body weight perception
Underweight
About right
Overweight
Obese
Weight loss efforts (yes)
49.79
28.3
54.1
17.7
71.1
82.3
25.4
45.8
6.6
25.88
44.5
55.5
(0.55)
(1.56)
(1.52)
(1.19)
(1.30)
(1.31)
(1.46)
(1.44)
(0.86)
(0.08)
(1.47)
(1.47)
3.7
21.5
56.3
18.6
59.5
(0.49)
(1.12)
(1.23)
(1.12)
(1.48)
Range
20.00 e 93.00
e
e
e
23.00 e 40.54
Note. BMI body mass index; KNHANES Korea National Health and Nutrition
Examination Survey IV; SE standard error.
a
Below poverty level a poverty-income ratio of less than 1.
Covariates
Covariates of interest were age, marital status, education level,
poverty level, work status, and smoking status. In particular, no
ofcial poverty line has been dened in Korea, so the concept of
poverty income ratios (PIR) was used to dene poverty level for this
study. The PIR represents the ratio of family income adjusted by
family size to the poverty threshold, which is based on the minimum cost of living as established by the Ministry of Health and
Welfare (KRW 1,400,000 per month for a household of four people,
i.e., approximately US$ 1,230 per month). Ratios below 1 indicate
that the income for the respective family is below the poverty
threshold and were dened as being below the government
poverty level in this study. A ratio of 1 or greater is above the
poverty level. Women were considered current smokers if they
reported that they were currently smoking.
Data analysis
Statistical analyses were performed using SPSS Complex Samples 19.0 (SPSS Inc., Chicago, IL, USA). All study variables were
screened for missing data, outliners, and suspected errors. The
KNHANES IV used a stratied, multistage probability sampling
design. Thus, data were weighted to generate appropriate population estimates. Weighted means or percentages were presented to
describe participant characteristics. Chi-square tests were used to
assess the associations among objective weight status based on
BMI, self-perceived weight status, and weight loss efforts.
193
Spearmans r correlations were used to describe univariate relationships among BMI, body weight perception, weight loss efforts, and covariates.
To test the mediating role of body weight perception, a series of
three regression analyses specied by Baron and Kenny (1986)
were performed. The rst model regressed weight perception
(the mediator) on BMI (the independent variable). The second
equation regressed weight loss efforts (the dependent variable) on
BMI. The third equation regressed weight loss efforts on both BMI
and weight perception. To establish mediation, the following conditions should be met: The independent variable (BMI) is a significant predictor of the mediator (body weight perception) in the rst
equation. The independent variable (BMI) is a signicant predictor
of the dependent variable (weight loss efforts) in the second
equation. The mediator (body weight perception) is a signicant
predictor of the dependent variable (weight loss efforts), and the
strength of the relationship between the dependent variable
(weight loss efforts) and the independent variable (BMI) is significantly reduced with the addition of the mediator variable in the
third equation (Baron & Kenny). For the rst equation, an ordered
logistic regression model was used to assess the predictive effects
of BMI on weight perception as an ordered, four-category response
variable (underweight, about right, overweight, & obese). The
second and third equations were examined with logistic regressions, as weight loss efforts were a dichotomous variable. Signicant covariates with the dependent variable (p > .05) from the
Spearmans r correlations were simultaneously entered into all
regression models to control for their effects.
Results
Table 1 shows the characteristics of participants of Korean
women with BMI 23 kg/m2. The mean age was 49.79 years. More
than half (54.1%) were between 41 and 65 years old. About 70% of
the women were married and living with their spouses. The majority (82.3%) of them had an education level of high school or less.
Less than half (45.8%) were employed, and 25.4% of the women
would be considered as having low incomes below the poverty
level as dened by PIR. The rate of current smokers was 6.6%.
Approximately 45% were classied as overweight and 55% as obese,
although signicantly less (18.6%) perceived themselves as obese,
and 56.3% perceived themselves as overweight and 25.2% as underweight or about right. Overall, two out of every ve women
reported that they were trying to lose weight.
Bivariate relationships among BMI, weight perception, and
weight loss efforts are presented in Table 2. Three variables were
signicantly associated with each other. Obese women are more
likely to report that they were trying to lose weight (62.7%)
compared to overweight women (55.4%, p .004). Among overweight women, 36.5% reported themselves as underweight or
about right, 58.3% as overweight, and 5.3% as obese. Among obese
Table 2 Bivariate Relationships among BMI, Body Weight Perception, and Weight Loss Efforts (N 1,739)
Variables
BMI, % (SE)
Overweight
p
Obesity
55.4 (2.06)
62.7 (1.83)
5.3
31.2
58.3
5.3
2.4
13.7
54.7
29.2
(0.84)
(1.97)
(2.14)
(1.04)
(0.51)
(1.15)
(1.49)
(1.66)
.004
<.001
Overweight
About right
Underweight
Obese
29.8 (1.19)
40.8 (3.19)
65.6 (1.85)
68.3 (3.13)
<.001
194
Table 4 Ordered Logistic Regression Analysis That Predicts Body Weight Perception in
Korean Women with BMI 23 kg/m2 in 2008 KNHANES IV (N 1,739)
Variables
OR
BMIa
Overweight
Obesity
Age
Married & living together
High school or less
Below poverty level
95% CI
1.00
(4.46,
(0.92,
(0.94,
(0.72,
(0.74,
5.47
0.93
1.02
0.97
0.92
6.69)
0.94)
1.11)
1.02)
1.13)
<.001
<.001
.907
.860
.517
Note. BMI body mass index; KNHANES Korea National Health and Nutrition
Examination Survey; OR odds ratio; CI condence interval.
a
Overweight 23 kg/m2 BMI < 25 kg/m2; obesity BMI 25 kg/m2.
Weight loss
efforts
BMI
Body weight
perception
Age
Marital
status
Education
Below
poverty
Work
status
Current
smoker
1.000
0.118**
1.000
.288**
.439**
1.000
.289**
.378**
.072*
1.000
.090**
.086**
.040
.285**
1.000
.142**
.158**
.078*
.425**
.076*
1.000
.161**
.109**
.099**
.310**
.157**
.201**
1.000
.039
.020
.013
.162**
.110**
.030
.029
1.000
.032
.040
.001
.087**
.067*
.015
.014
.028
1.000
Model 1
OR
BMIa
Overweight
Obesity
Body weight perception
Underweight
About right
Overweight
Obese
Age
Married & living together
High school or less
Below poverty level
95% CI
Model 2
p
OR
95% CI
1.00
1.00
1.82 (1.48, 2.24) <.001 1.31 (1.11, 1.71) <.022
0.92
1.00
0.85
0.66
(0.90,
(0.91,
(0.61,
(0.52,
0.97) <.001
1.09)
.726
1.18)
.325
0.83) <.001
1.24
2.83
3.39
0.94
1.00
0.88
0.67
1.00
(0.71,
(1.65,
(1.87,
(0.91,
(0.90,
(0.63,
(0.53,
2.14)
.406
4.84) <.001
6.17) <.001
0.98) <.001
1.08)
.669
1.23)
.461
0.85)
.001
Note. BMI body mass index; KNHANES Korea National Health and Nutrition
Examination Survey; OR odds ratio; CI condence interval.
a
Overweight 23 kg/m2 BMI < 25 kg/m2; obesity BMI 25 kg/m2.
associated disease is high even though they may look thinner than
Caucasians. If there is a discrepancy between the actual level of
obesity and perceived body weight, the gap should be closed in
order to optimize health.
In this study, the relationship between BMI and body weight
perception was assessed. Previously, few investigations have
examined this relationship in adult Korean women. Although BMI
was signicantly associated with weight perception before and
after controlling for covariates in this study sample, a large proportion of overweight or obese women perceived themselves
inaccurately. The majority of women thought they weighed less
than they really did. The heavier they were, the more likely they
were to underestimate their weight (Table 2). Overall 58.3% of
overweight and 29.2% of obese women correctly classied their
weight, while 36.5% of overweight and 70.8% of obese women
underestimated their weight. These ndings are consistent with a
study by Lemon et al. (2009), who reported that overweight or
obese women in the United States underestimate their weight
whereas women with normal weight tend to overestimate it
(Lemon et al.). Overweight or obese women who underestimate
their weight might be the group that in particular needs nursing
interventions that target the accuracy of body weight perception
and obesity-associated health risks as the underestimation of
weight in overweight women is signicantly related to a lower
likelihood of weight-control behaviors (Kim et al., 2008; Wang
et al., 2009).
The underestimation of body weight in women can also be a
critical problem because their misperception may not be limited to
how they view themselves. A recent meta-analysis showed that
overweight or obese mothers were more likely to have overweight
or obese children. More importantly, they were more likely to underestimate their childs excess weight compared to mothers with a
healthy weight (Doolen, Alpert, & Miller, 2009). If mothers underestimate their childs weight, they are unlikely to advise their child
to lose weight. This would likely contribute to the current epidemic
of obesity in Korea could continue.
The underestimation of weight in women was related with
advancing age, lower income levels, and lower level of education
(Chang & Christakis, 2003). Although this study did not aim to
assess the effect of covariates on the dependent variables, only age
was found to be statistically signicant and independently associated with body weight perception in Korean women: Education
and poverty level were not signicantly related to body weight
perception (Table 4). Older women are more likely to rate themselves at a lower weight-perception category compared to younger
195
196
Acknowledgment
This work was supported by the Gachon University Research
Fund of 2013 (GCU-2013-M021).
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