Obesity and Weight Perceptions in Turkish College Students
By Zabin Salim Patel (’14) and Rida Malick (’14) | Faculty Advisor: Dr. Mercedes Carnethon | Department of Preventative Medicine, Feinberg School of Medicine | Sept. 28, 2015 | NURJ Online 2014-15
Global forces are linked to changing food patterns and the rise of global obesity (Seidell & Visscher, 2001). In Turkey, the national obesity and overweight rates are 17.2% and 34.8% among Turkish citizens over the age of 15 according to a report by the Turkish Statistics Institute (TurkStat, 2012). The adoption of Western influenced food intake in Turkey’s urban centers has resulted in changes to a diet high in saturated fat and sugar, with reduction in physical activity levels (Yumuk et al., 2005). In 2010 The Ministry of Health of Turkey launched “The Obesity Prevention and Control Program of Turkey” effective until 2014 to combat Turkey’s rising obesity rates. The purpose of this study was to investigate obesity and weight perceptions in a sample of Turkish college students. Participants (N = 276) completed a questionnaire to assess their current weight status, weight satisfaction, and ideal body type. Statistical analyses showed significant differences in body weight perceptions and body size satisfaction between young men and women. Findings may help inform behavioral health interventions targeted toward this age group.
One of the ways that people are evaluated in Western society is through physical appearance (Grogan, 1999). The image that a person has about his or her body is largely shaped by social experience, culture, and the media. Thus, body image is an elastic construct and is more complex than Schilder’s definition as “the picture of our own body which we form in our own mind” (1950, p.11, as cited in Cash & Pruzinsky, 2002). Studies about body image have often concentrated on body image disturbance (BID), which is composed of two elements: body image dissatisfaction, the discrepancy between what the person perceives their body size to be versus the body size they would like to be ideally, and body size estimation, which is how accurately an individual perceives their body. These issues can range from broader concerns about weight, size, and body build to more specific characteristics like face, hair, and eyes. BID is a continuing problem especially among college-aged individuals and is associated with eating disorders and possibly obesity (Thompson, 1996).
It is generally accepted that the spread of Western culture is associated with growing rates of body dissatisfaction and disordered eating attitudes and behaviors among non-Western cultures (Nasser, 1988). Turkey is a Eurasian country in which the prevalence of obesity in children and the adult population is 13.8% and 29.5% respectively according to WHO classification (Yumuk et al., 2005; Garipagaoglu et al., 2009). Both overweight and obesity are positively correlated risk factors for hypertension, type 2 diabetes, cardiovascular disorders, digestive disorders, and cancer (Arslan & Iseri, 2008). As such, increasing rates of overweight and obesity have become serious public health concerns especially during adolescence and young adulthood. A nationwide cross-sectional study found a higher prevalence of both obesity and overweight in male populations ages 20-24, with 9% of men obese versus 3% of women, and 67% of men overweight versus 30% of women (Arslan & Iseri, 2008). Previous research shows that the Turkish population has a higher rate of obesity relative to European countries, with trends similar to those of the United States.
The purpose of this study was to investigate the incidence of obesity and weight perceptions in a sample of Turkish university students. While a number of studies have examined these issues in the West, little work has been done on this topic in Turkish college students specifically. Studies in the United States targeting this population suggest that low levels of physical activity and high prevalence of unhealthy diets exist in college students (Huang et al., 2003). Because physical inactivity and unhealthy eating patterns are associated with increased rates of obesity and body dissatisfaction, and understanding these factors in youth may facilitate the breakdown of weight loss barriers (Desai et al., 2009).
In Turkey specifically, to combat the increasing prevalence of overweight and obesity, The Ministry of Health of Turkey has implemented an obesity prevention and control program aimed at achieving a reduction in the prevalence of obesity by 2014. The plan calls for the cooperation by public, private and academic bodies, as well as civil organizations to promote a healthy lifestyle in local communities. Study of urban Turkish college populations can provide better insight into the effectiveness of the obesity prevention action plan as well as strategies to better improve public health campaigns.
Based on previous research we hypothesized that primarily because of physical inactivity and poor nutritional choices the rates of overweight and obesity in this sample would similar to those of other Western nations. Secondly, based on Arslan & Iseri’s (2008) findings we predicted that the rates of obesity and overweight would be higher in men than women. In the United States, recent evidence suggests that 30-35% of college students are overweight or obese (Ferrara et al., 2013). In prior research, body mass has been found to be a significant predictor of body shame, body satisfaction, and shape concern. A study examining the role of media messages on body image and body dysmorphic disorder in undergraduates found that underweight and normal weight students were more satisfied than overweight, obese, and extremely obese students (Wester, 2003).
Gender and body size satisfaction
In affluent Western societies, slenderness is generally associated with happiness, success, youthfulness, and social acceptability (McKinley, 2002, as cited in Cash & Pruzinsky, 2002). In contrast, overweight is connected to laziness, lack of willpower and control. Images in print and film media have continually depicted thinner models; as a result adolescents and young adults have become increasingly dissatisfied with their physical appearance. For women in Western societies, the ideal body is slim, young and toned; for men the ideal is slenderness and moderate muscularity.
Jackson’s meta-analysis concluded that throughout the life span women from adolescence to adulthood are more body dissatisfied because they regularly view themselves as unacceptably overweight, even at average weights (1992, as cited in Cash & Deagle, 1997). As such, internalization of the cultural “thin ideal” may result in women being evaluated according to gender stereotypic standards for physical appearance. In these societies, women’s bodies are central to both increasing rates of obesity and body dissatisfaction (Thompson et al., 1999, as cited in Hausenblas & Fallon, 2006).
More recently, men have started to feel pressure to control their size and shape. However, Thompson and colleagues (1999) note that for men the emphasis appears to be on a slender and muscular physique rather than extreme thinness. Consequences of inaccurate body perceptions in men are associated with anxiety, symptoms of mood, compulsive gym activity, and an increasing prevalence of anabolic steroid abuse. Research on male attitudes towards body satisfaction is currently in its initial phase due to the fact that most studies have focused on the bodily perceptions of women. Thus, our third hypothesis was that the high prevalence of overweight and obesity would contribute to problems of BID in this population and this effect would be stronger for women than men.
A convenience sample of participants (N = 276) from five Turkish universities in Ankara (Hacettepe Universitesi), Konya (Mevlana Universitesi), Izmir (Izmir Universitesi and Izmir Katip Celebi Universitesi), and Istanbul (Istanbul Universitesi) was used. Students were randomly recruited and asked to complete an electronic or pen and paper questionnaire following informed consent. Participants were excluded if they were not between 18 to 27 years of age because the focus of the study was on young adults. Of the 276, 112 (40.6%) were male and 164 (59.4%) were female with a mean age of 20.4 years (SD = 1.29). The mean BMI (kg/m2) of male participants was 23.5 (SD = 3.77), the minimum BMI was 15.7, and maximum BMI was 43.2. The mean BMI (kg/m2) of female participants was 21.4 (SD = 3.37), the minimum BMI was 15.2, and maximum BMI was 46.1. Participants were not compensated for participation.
An electronic or pen and paper questionnaire was used for data collection (Appendix 1). In addition to demographic questions regarding age, sex, ethnicity, height, weight, and physical activity, the questionnaire consisted of items from two scales including questions regarding (1) body weight satisfaction and (2) weight perceptions. The questionnaire was developed in English and translated into Turkish.
Five items included open-ended and multiple-choice questions measuring sex, age, height, weight, and university enrollment status. Participants were asked their height and weight so that Body Mass Index (BMI) could be calculated. BMI is measured by comparing an individual’s weight with their height (National Institute of Health, [NHL], 2002) and is used for the study of obesity. BMI is then categorized into 5 categories: (1) underweight, (2) normal weight, (3) overweight, (4) obese, and (5) extremely obese, according to the NHL classifications. In this study, BMI was used to determine overweight and obesity prevalence within the sample.
Body weight satisfaction
Three items developed by the researchers were used to assess weight satisfaction. The first question asks participants to report to what degree they are happy with their current weight status (e.g., “Very happy” to “Very unhappy”), the second asks participants to estimate their current weight status (e.g., “Underweight” to “Very overweight”), and the last question asks if participants are currently trying to “gain weight”, “lose weight” or “maintain weight”.
The perceptions of self and ideal body size were measured using the Stunkard scale (1983). The Stunkard scale consists of 9 silhouette figures that increase gradually in size from very thin (a value of 1) to very obese (a value of 9). Similar to previous researchers, we classified these figures into underweight (figures 1 and 2), normal weight (figures 3 and 4), overweight (figures 5 through 7), and obese (figures 8 and 9). Self-body size perception is the number of the figure selected by participants in response to the prompt: “Which figure do you think is closest to your current body size?” Ideal body size perception is the number of the figure selected by participants in response to the prompt: “Which figure is most similar to your ideal body shape?”
The third body size perception variable used in this study, body size satisfaction, was defined as the difference between one’s perceived self body size and perceived ideal body size. A body size satisfaction variable was created for each participant by subtracting the number of the figure selected as the ideal body size from the number of the figure selected as the self body size: too small (self – ideal < 1), satisfied (self = ideal), too large (self – ideal > 1), much too large.
Data were collected from students enrolled in five universities in four of Turkey’s largest cities: Ankara, Konya, Izmir, and Konya either through an electronic questionnaire or pen and paper survey. The questionnaire was distributed to students in Turkish via university faculty or the researchers. Participants first provided consent to participate and were then instructed to answer a series of questions regarding Turkey’s rising obesity rates, weight satisfaction, and body size perceptions.
After five demographic questions, participants were presented with three items to assess weight satisfaction. The Stunkard scale with two items regarding body size perception followed.
The total time of assessment ranged from fifteen to twenty minutes and no identifying information linking answers to identity was collected. The electronic questionnaire was designed so that participants had to complete every question of the survey in order to submit the survey. If at any time a participant decided that they did not want to complete all questions or did not want to take part in the survey, they could exit out of the questionnaire and their data would not be saved or collected. Participants were asked to complete the questionnaire using mostly radio buttons for Likert-type questions and text boxes for BMI calculations.
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We would like to express our gratitude towards Northwestern University and the Office of the Provost for the support of this project through the Undergraduate Research Grant. Thank you to Peter John de Chavez for guidance in data analysis. We would also like to acknowledge the following individuals for helping us with date collection in Turkey:
Dr. Gül Baltacı, Hacettepe Üniversitesi, School of Physical Therapy and Rehabilitation, Ankara, Turkey
Dr. Indrani Kalkan, Mevlana Üniversitesi, School of Health Services, Konya, Turkey
Dr. Emine Çakırcalı, İzmir Üniversitesi, School of Health Nursing Dept., Izmir, Turkey
Dr. Leyla Baysan Arabacı, Katip Çelebi Üniversitesi, Faculty of Health Sciences, Izmir, Turkey
Dr. Tevfik Ecder, İstanbul Üniversitesi, School of Medicine, Istanbul, Turkey