Discussion
Our study showed that significant visual body size misperception exists in all respondent groups in estimating others weight, however, they were reasonably accurate in estimating their own body weight. Majority of respondents share similar attitudes about the causes of obesity, knows major cardiovascular diseases associated with obesity, however, the knowledge about other risks of obesity is inadequate. Age, realistic weight perception and feelings about own weight are associated with lifestyle changing behavior.
The first step in treating obesity is to diagnose it and clearly communicate diagnosis to the patient. Our study reveals that healthcare professionals and PHE have similar level of visual body size misperception as the patients. People tend to recognize visually only extreme, high-risk class III obesity and neglect early stages. One possible explanation could be that in general there is a greater acceptance of heavier body weights in the population [
12]. Beside this, people make choices for food consumption based on how individual weight compares to social norms [
13]. In the questionnaire that was used in the current study there was the question how people feel about their weight. None of the overweight nurses and only 8% doctors with overweight replied that they are “about the right weight”. In contrast, about one fifth of the overweight patients and one fourth of overweight PHE have chosen this answer. Similar results were established in the National Health and Nutrition Examination Survey (NHANES) in the United States. Twenty four percent of overweight individuals from US civilian population thought that their weight was about the right [
14].
Only 2.5% of patients with obesity in our study replied that their weight is about the right, while nobody among healthcare providers or PHE have chosen this definition for their current weight. By contrast, 3% of women and 12% of males with obesity in US population thinks that they have about the right weight [
15]. Participants with obesity in our study were less likely to be engaged in lifestyle change, if they underestimated their weight category. Underestimation of weight category maybe caused due to the lack of information about personal weight and obesity definition, or because of the belief that their weight is normal. However, the information about real weight status provided by physicians increases likelihood that the patients with overweight/obesity will attempt to lose weight [
16].
Individual’s body size perception was evaluated asking which figure represents their body shape best. More than half of the overweight individuals overestimated their body size. Such findings correlate well with the data from the other studies [
17,
18]. Overestimation of body size may have a negative influence on self-esteem and rise psychological, social and dietary issues [
19]. It must be noted that female patients perceive their body size more realistically than males. Male patients think that they are thinner than they are, and this is more evident with increasing body size or weight status [
20]. The other aspect is feelings about individual body size. Several studies have pointed on direct relation between increasing BMI and dissatisfaction with the body size [
21,
22]. Moreover, these studies also revealed that dissatisfaction with body size is an important motivator for engaging in weight loss activities. However, feelings about height or specific body areas may also be included in the concept of satisfaction with body size [
23]. In our study we narrowed the idea of body size and asked participants only how they feel about their current weight. Individuals with obesity were mostly unhappy with their weight and only 5% of patients and nurses responded that they are happy with their current weight. Results similar to those from current international study by Caterson ID et al. [
24] where only 6% of patients with obesity were happy with their weight. Respondents with obesity, but not overweight, were more likely to change their lifestyle if they were dissatisfied with their current weight.
Several theories and conceptual models are used to understand health behavioral change [
25]. In most of them motivation to change is based on attitudes, possible benefits, perceived threat or risk of a specific condition, or desire to achieve positive outcomes. Motivation alone without intentions is not enough to change lifestyle. GPs may form appropriate intentions however, it is important to consider how much intended behaviour is driven by attitudinal or normative considerations, or by feelings of perceived behavioral control [
26]. Moreover, patients are more likely to be engaged in a particular behavior, if it is presented as an action with a target, performed within a given context and at a certain point in time [
26]. If the patients already intend to act, it is unlikely that they need more information. However, if the patients are going to be engaged in the class of behaviors such as lifestyle change, they may need stronger motivation, proper context and much longer time. Awareness of the risks associated with obesity may motivate people to change lifestyle. The results of our study as well as the data from the literature reveal that individuals and health care providers recognizes heart disease, high blood pressure and T2DM as adverse health consequences of obesity [
27‐
29]. However, nearly half of the PHE and GPs failed to recognize association of obesity with some types of cancer and depression, and even more with asthma. The knowledge of the nurses about obesity as a risk factor was similar to that of the patients. French study has found that GPs who subscribed medical journals or have taken CME courses about the management of weight problems felt more effective in treating individuals with obesity [
29]. Failure to recognize diseases associated with obesity may be a barrier for weight loss counseling especially in overweight patients. Also, misperception of risks associated with obesity may prevent strong action on the society level.
In this study respondent beliefs about biological and lifestyle factors as a cause of obesity was investigated. All respondent groups agreed that exercising too little and eating too much causes obesity. Moreover, all groups disagreed that inheritance is a cause of obesity. Similar results were found in Caterson ID et al. study [
24] where patients and healthcare providers emphasized life-style related factors, but not a genetic predisposition as a barrier to weight loss. By contrast, it is now widely recognized that obesity has a genetic predisposition and obesogenic environment increases genetic risk for obesity [
30]. In general, influence of genes has to be discussed with the patient as this may diminish self-blame and the patients have to be informed that genetic risk for obesity maybe reduced by increasing physical activity and avoiding some specific dietary components [
24,
30].
One third of individuals with overweight and half of those with obesity have changed their lifestyle during last 12 month in our study population and there was no difference between patients, healthcare providers and PHE. In comparison, 61% of US adults with obesity over the last 12 months tried to lose weight [
31]. Among overweight individuals those who were younger than 45 years were more likely to change their lifestyle. Individuals with obesity were more prone to adopt healthier lifestyle if they had higher education, were females and were unhappy with their weight. Beside higher education and female gender, increasing BMI, insurance coverage, comorbidities such as diabetes or arthritis and Hispanic race were associated with more weight loss activities among US adults with obesity [
31]. Overestimation of weight among individuals with overweight and underestimation among those with obesity precluded lifestyle changes in our study population. These data are similar to Duncan DT et al. [
32] findings that weight misperception was a strong predictor of weight loss activities for both genders and all racial/ethnic groups among US adults with overweight and obesity.
This study explored attitudes about obesity in different social groups. Healthcare providers as well as PHE in general have similar attitudes to those of general population. It seems that attitudes and beliefs rooted in society is hard to change even with specialized education. More focused teaching should be aimed at paradigm shift. The people fail to recognize obesity in the others in an early stage, when weight control can be more efficient. People themselves tend to be realistic about their weight. The data from this study and the literature show, that individuals with overweight and obesity are more motivated to lose weight, if they have realistic perception of their weight. But they need support. Recent international multicenter study found that it took a median of 3 years and a mean of 6 years between the time when individuals started struggling with excess weight or obesity and when they had a first weight management conversation with a healthcare provider. Moreover, 46% of individuals have initiated discussion themselves [
24]. BMI estimation and assessment of individuals’ health profile maybe an effective way to start such conversations [
33]. Timely interventions may prevent potential complications of obesity. Furthermore, education may help for individuals to understand less apparent relationship between obesity and health. The lack of information is likely to compromise patients’ abilities to make informed choices about their health. Swift JA et al. [
34] observed that intended weight loss was positively associated with health beliefs. However, in our study knowledge about obesity as a risk factor for cardiovascular and non-cardiovascular diseases had no impact on healthier behavior.
Our study has some limitations. First, the majority of the patient respondents questioned were women. This could be due to the fact that in overall, percentage of women in the population is higher (especially in age over 60), also women are covered by larger number of prevention programs and attend GPs office more frequently. In addition, they do accept invitation to participate in the survey more positively in comparison with men. Second, the primary care centers that participated in our survey are teaching centers and are affiliated with Lithuanian University of Health Sciences. In all centers family medicine residents have their practice. Thus, GPs and nurses who participate in the teaching activities may have more knowledge than healthcare providers from other primary care offices. Third, we used self-reported weight and height to estimate BMI of the patients, and this approach is subject to the bias [
35]. However, the percentage of individuals with overweight and obesity among the respondents was similar to the data from population studies performed in Lithuania [
36]. Fourth, we did not ask participants, if adoption of healthier lifestyle was motivated by necessity to lose weight. By presenting a broader question we intended to cover also individuals whose primary goal was to increase physical activity and/or adopt healthier diet not only for weight loss purposes. Finally, from cross-sectional survey data we were unable to establish causal association between body weight satisfaction and healthier lifestyle. It is unclear whether dissatisfaction with weight motivates to change lifestyle or change in lifestyle alters perception of weight and results in the feelings of dissatisfaction.