Philippine Study About Body Image 102o6b

Philippine Journal of Science 138 (1): 67-74, June 2009 ISSN 0031 - 7683

Correlates of Body Image Satisfaction Among Economically Depressed Urban Filipino Women Mildred T. Aquino*, Consuelo L. Orense, Celeste C. Tanchoco, Sofia V. Amarra, Merlyn G. Tajan, and Evelyn O. Dela Cruz Food and Nutrition Research Institute Department of Science and Technology, General Santos Avenue, Bicutan, Taguig City, Philippines The study assessed body image satisfaction with diet, body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR), age, income, and education among 251 women in a depressed urban barangay. Results showed that most women were younger, had low education, and had no occupation. Using BMI, 28.7% were overweight and obese, and 11.6% were underweight. Using WHR and WC, 59% and 13.5%, respectively, were at risk. Six out of ten women were not satisfied with their body image. Nutrient intake and adequacy between women who were satisfied and those who were not satisfied with their body image were not significantly different. Adequacy of intake was below the Recommend Energy and Nutrient Intake (RENI) for most nutrients except niacin. Women satisfied with their body image had lower BMI, WC, and WHR. Body image satisfaction was associated with BMI, WC, and WHR but WHR was the only significant variable affecting image satisfaction. Android or central body adiposity affects body image satisfaction among women because of the change in body shape brought by fat deposition. Key Words: body image, body mass index, nutrient intake-adequacy, urban Filipino women, waist-hip ratio, waste circumference

INTRODUCTION Body image is defined as “how a person feels about his appearance.” Developing and nurturing a positive body image is considered part of a healthy mental attitude and is crucial to a person’s happiness and wellness. Body image is a combination of how we perceive ourselves about basic looks and how we react emotionally in certain situations (Sloan 2006). Having a negative body image may be a contributing factor to poor self-esteem, feelings of perfectionalism, and negative eating attitudes and behaviors which have been identified as predisposing factors to eating disorders (Perez et al. 2003) Women seem to be more dissatisfied or negative about their bodies at all ages. Body dissatisfaction seems to *Corresponding author: [email protected]

be remarkably stable across the entire female lifespan. Women aged 30 to 75 yrs show potential levels of body dissatisfaction just like younger women. Between 55% to 95% of women express dissatisfaction with their bodies, and chronic dieting may pose a particular health risk for women as they age (Tiggeman 1999). Being overweight and obese are sources of dissatisfaction, depression, and frustration which may lead to extreme dieting and eating disorders such as Anorexia nervosa and Bulimia. The most common assumption about the link between depression and obesity is that overweight is viewed negatively by the society resulting in discrimination even among children in schools and adults in workplaces (Margraf 2000). Females who perceived themselves to be overweight prior to puberty scored significantly higher 67

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on measures of eating disorders, body dissatisfaction, ascetism, drive for thinness, and perfectionism. It has been acknowledged from the results of a longitudinal study of the National Heart, Lung and Blood Institute that weight concerns and a drive for thinness at ages 11 to12 are important risk factors leading to daily smoking at ages 18 to19 years (NIH 2002). Studies show that cultural diversity in body image exists. Black and white women differed regarding their ethnic group’s ideal body image and their perceptions of how they compared with their ideal body image (Mciza et al. 2005; Pan 2000; Perez et al. 2003). Women who perceived themselves as bigger or smaller than the ideal body size for their ethnic group showed bulimic symptoms (Perez et al. 2003). Caucasian and Hispanic Americans were found to exhibit more weight-related body image disturbance than African-Americans and Asian-Americans. Studies are needed to determine whether the association between body dissatisfaction and disordered eating attitude holds in various socioeconomic groups in developing countries. Foreign studies have shown that poverty and food insecurity without hunger may be contributing factors to adult obesity. The study of Drewnowski and Specter (2004) stated that the highest rates of obesity occur among population groups with the highest poverty rates and least education. He mentioned that energy-dense foods are mostly composed of refined grains and added sugars, and fats which may be the least costly foods available to consumers. Moreover, these energy-dense foods which are high in sugar and fats are the most palatable and can easily satisfy hunger. Although poverty and food insecurity are often associated with lower food expenditures, quality of the diet is mostly affected, as there is lesser intake of fruits, vegetables and other protein sources. In another study done by Townsend et al. (2001), there was an association between food insecurity and being overweight and obese in women resulting in chronic diseases. However, aging is also associated with alterations in body weight and may have an important impact on health. According to the 6th National Nutrition Survey conducted by Food and Nutrition Research Institute (FNRI) in 2003 (FNRI 2006), undernutrition among Filipinos is still a problem; however, there has been an increased prevalence of overweight and obesity from 1998 to 2003. Among adults, 24% are overweight to obese. In addition, chronic diseases are becoming number one problem of the country. To date, only a handful of studies were conducted to determine if the condition of being overweight or obese affects the perception of body image of adult Filipino women.

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One study conducted by Hawks et al. (2005) among working women in Bacolod revealed that a significant number of women were unnecessarily concerned about reducing body size, and that this attitude was associated with eating disorder attitudes and restrictive dieting behaviors. Studies of this kind may contribute to better understanding of the relationship between body image satisfaction among economically depressed women with their dietary intake, age, annual income, education and, obesity indices. Moreover, there is a need to establish if there is such an existing body image dissatisfaction among depressed urban Filipino women, in order to guide nutrition planners plan for appropriate programs and intervention to alleviate conditions associated with overweight and obesity. The study generally aimed to assess the relationship of body image satisfaction with dietary intake, obesity indices such as body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR), and socio-demographic factors (age and annual income) among economically depressed urban Filipino women. Specifically, it aimed to: (1) determine the socio-demographic characteristics of the women; (2) determine intake of nutrients among women who were satisfied and not satisfied with their body image; (3) compare body mass index (BMI), waist circumference (WC), and waist-hip ratio (WHR) of respondents by body image satisfaction; and (4) determine which of the factors (socio-demographic, obesity indices, nutrient intake) relate to body image satisfaction.

METHODS Data from this study was taken from a previous project on body image satisfaction, dietary intake, and health outcomes in urban Filipino women (Amarra et al. 2005 unpublished report). The project was conducted in Barangay Bagong Silang, Caloocan City which is located north of the City of Manila. Bagong Silang is a relocation area where most of the households are classified as social class C, D, and E based on the classification system developed by the Philippine Statistical Association (NSCB 1974). A total of 251 women participated in the study from whom data on socio-demographic, body image satisfaction, dietary intake, weight, height, waist and hip ratio were taken. Pre-tested questionnaires were used to collect sociodemographic data and body image satisfaction. Two-day 24-hour food recall, done on a week-end and another on a weekday, was used to gather data on food intake. Detecto weighing scales and microtoise were used to take weight and height, respectively, using standard methods and techniques. A fiberglass tape measure was used to

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Aquino et al.: Body Image Satisfaction of Women and Correlates

get the waist and hip circumference measures. Waist circumference was taken at the narrowest point between the lowest rib and iliac crest while hip circumference was obtained at the widest circumference around the greater trochanter.

body image satisfaction. Logistic regression was used in determining which of the factors influence body image satisfaction.

Household measures of the 24-hour food intake of two non-consecutive days were recalled from the women to estimate week-day and week-end intake, as studies have shown differences of intake between these periods (Gibson 1990). Instruments such as measuring cups, ruler, and portion size models were used as a way to prompt and accurate recall of the food quantities. Household measures of the food items from the two-day food recall were translated into edible portion (EP) weights using the standard weights and measures, Food Exchange List (FEL) and actual weights.

RESULTS AND DISCUSSION

The diet was evaluated for the nutritional content in of energy, protein, fat, carbohydrates, dietary fiber, calcium, iron, vitamin A, thiamin, riboflavin, niacin, and ascorbic acid using the Philippine Food Composition Tables (FCT) (FNRI 1997) . A data base program was used to compute the nutrient content of the diet on a daily basis. Nutritional adequacy of the diet per respondent per day was assessed using the 2002 Recommended Energy and Nutrient Intakes (FNRI 2002). BMI was calculated from the weight in kilograms divided by the square of the height in meters. From the calculated BMI, the women were categorized into four classes based on the World Health Classification (WHO) classification: underweight for BMI <18.5; normal, for BMI 18.5 - 24.9, overweight for BMI 25.0 – 29.9, and obese for BMI ≥ 30.0. Waist-Hip Ratio (WHR) was obtained from the measurement of the waist over the circumference of the hips. WHR of less than 1.0 for men and less than 0.85 for women, and WC of less than 102 cm in men and 88 cm in women were considered to be of low risk in metabolic and cardiovascular diseases, while levels above these cut off points considered the person at risk (WHO 1998). Data Analysis Means and standard deviations for absolute variables such as age, income and nutrient intake were generated, while frequencies and percentages were computed for categorical variables such as level of schooling, category of obesity indices, and body image satisfaction. Data were also tested for normality using Kolmogorov-Smirnov test. Comparison of means between women who were satisfied and not satisfied with their body image was done using t-test for normal data and Mann-Whitney test for non-normal data. Chi square test (χ2) test was used to determine the association between obesity indices and

Respondents’ Profile Table 1 shows the distribution of the participants in of age, education, and obesity classification. The findings reveal that majority of the respondents’ age were below 40 years, with the age group of 30-39 years having the most number of participants. About two-thirds of the women were non-working; one-tenth Table 1. Profile of women respondents Variables (N-251)

No

%

20-29

70

28

30-39

80

32

40-49

51

20

50-59

45

18

60 & over

5

2

Elementary

37

15

High School

56

22

HighSchool graduate

83

33

College

47

19

College graduate

10

4

Vocational

18

7

Age (yrs)

Education

Occupation None

159

63

Employee

5

2

Sales/Service

23

9

Sari-sari store owner

20

8

Vendor

28

11

Others

16

6

Underweight (<18.5)

29

12

Normal (18.5-24.9)

150

60

Overweight(25.0–29.9)

57

23

Obese (≥30.0)

15

6

No Risk (<88 cm)

217

87

At Risk (≥88 cm)

34

14

No Risk (<0.85)

103

41

At Risk (≥0.85)

148

59

BMI

Waist Circumference

Waist Hip Ratio (WHR)

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were engaged in selling either as sari-sari store owner, vendor, or buy and sell businesswoman; the rest were engaged in service activities such as manicure or laundry, and very few (2%) were employed. Their mean income was Php 97,800.13 (SD ± 79,654.57) per annum (not shown in table). The classification by BMI was normal in almost half of respondents, while almost one third were either overweight or obese and the rest (11.6%) were underweight. The proportion of overweight and obese in this sample is similar to the national prevalence for Filipinos (27.3%), while for underweight, the proportion of underweight is smaller (FNRI 2006). Almost 90% of the respondents had a WC of less than 88 cm, and, thus, were classified as having no risk. Considering WHR, there were more (59.0%) at risk among women (≥ 0.85) but four out of ten respondents (41%) were classified as having no risk. The proportion of at risk using WC (13.5%)

in this sample was lower than the national prevalence (17%) while for WHR, the proportion of at risk (59%) is slightly higher (54.8%) by about 4 percentage points (FNRI 2006). Mean nutrient intake by body image satisfaction Table 2a shows the mean intake of macro and micronutrients by body image satisfaction category. The means showed no significant differences between women in the satisfied and not satisfied groups using the Mann-Whitney test. Similarly, the means of percent nutrient adequacy (Table 2b) were not significantly different between the two groups of respondents. Among the nutrients, only niacin reached a mean adequacy higher than the RENI. The mean adequacy in most nutrients was less than 50% except for protein and niacin. Nutrient intake is not directly related to body image satisfaction, but it affects body weight,

Table 2a. Mean energy and nutrient intake by category of body image satisfaction Nutrient

Intake by Body Image Satisfaction Not Satisfied (n=176)

Satisfied (n=75)

Total (N=251)

P-Value*

Energy (kcal)

1326 ± 512.32

1420 ± 563.51

1354 ± 28.78

0

Protein (g)

35.90 ± 15.10

38.71 ± 16.51

36.72 ± 5.55

0

Fat (g)

25.10 ± 15.67

28.61 ± 15.45

26.76 ± 5.62

0

Carbohydrates(g)

237.0 ± 94.35

252.2 ± 106.08

241.5 ± 8.04

0

Dietary Fiber (g)

8.4 ± 4.60

9.3 ± 5.06

8.6 ± 4.75

0

Iron (mg)

9.3 ± 4.79

9.8 ± 4.74

9.4 ± 4.77

0

Calcium (mg)

323 ± 229.51

349 ± 266.96

331 ± 41.07

0

Thiamin (mg)

.57 ±.33

.62 ±.40

.58 ±.35

0

Riboflavin (mg)

.50 ±.24

.53 ±.26

.50 ±.24

0

15.4 ± 6.28

16.7 ± 7.30

15.7 ± 6.62

0

Vitamin A (RE)

200 ± 204.07

217 ± 211.83

206 ±206.13

0

Ascorbic (mg)

22 ± 21.66

23 ± 21.93

22 ± 21.71

0

Niacin (mg)

*p-value of >0.05 indicates no significant difference in mean intake of nutrients between women in the satisfied and not satisfied group

Table 2b. Mean energy and nutrient adequacy by category of body image satisfaction Intake Adequacy by Body Image Satisfaction Nutrient

Not Satisfied (n=176)

Satisfied (n=75)

Total (N=251)

P-Value*

Energy (kcal)

74.0 ±27.75

79.6 ± 31.89

75.7 ±29.10

0

Protein (g)

61.3 ± 26.23

66.7 ±28.46

62.9 ±26.97

0

Iron (mg)

34.5 ± 17.74

36.0 ± 17.55

35.0 ± 17.66

0

Calcium (mg)

42.6 ± 30.51

45.9 ± 34.91

43.6 ± 31.86

0

Thiamin (mg)

51.4 ±30.26

56.9 ±36.37

53.1 ±32.23

0

Riboflavin (mg)

45.0 ±21.68

47.7 ±23.56

45.8 ±22.25

0

Niacin (mg)

109.1 ±44.83

119.1 ±52.14

112.1 ±47.25

0

Vitamin A (RE)

40.3 ±40.85

43.4 ±42.36

41.2 ±41.25

0

Ascorbic (mg)

30.7± 30.95

32.9 ±31.32

31.3 ±31.01

0

*p-value of >0.05 indicates no significant difference in mean intake of nutrients between women in the satisfied and not satisfied group

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which has been linked to body image in some studies (Song et al. 1999; Monteath and McCabe 1997; Office for Women 2003). Increase in BMI results from sustained overconsumption of food, especially food rich in calories. Underweight can result if a person consumes less calories than what is needed for energy. Besides food intake, other factors such as sedentary lifestyle increase weight and, subsequently, BMI. The non-significant differences noted between women who were satisfied and not satisfied with their bodies suggest that other factors may have affected the person’s BMI, but these were not covered in this paper. Moreover, the possibility of capturing the usual intake may be missed with the use of recall methods such as the two-day 24-hour food recall. Related limitations inherent with this tool is the ability of the individual to accurately describe the dimensions of the food, deliberate refusal to report intake, or memory lapse due to age or low education (Gibson 1990). Obesity indices, age and income of participants by body image satisfaction Table 3 presents the means of BMI, WC, WHR, age and income of participants classified by body image satisfaction. Age and annual income of women in the two groups did not differ significantly; but, the means of BMI, WC and WHR were significantly lower among women who were satisfied with their body image. The relationship between age and body image has been mentioned by Katzmarzyk and Davis (2001) from the data of the National Heart, Lung, and Blood Institute of Growth and Health Study which said that even girls nine to ten years were trying to lose weight. Zerbe and Domnitei (2004) also reported that older women tend to become more negative about their body image due to weight gain associated with aging. The present data does not agree with previous studies, but a similar result has been noted in the report of Haartl et al.(2003) that revealed no association of age and body image satisfaction. The

absence of a significant association between age and body image satisfaction could mean that women in the study might have a more tolerant attitude towards aging which leads to better acceptance of their current body shape. In the majority of the Filipino communities, people usually accept the fact that women get bigger as they become older. This acceptance in the immediate environment of the woman makes her feel comfortable of whatever body shape she has. In contrast to other societies, people can become dissatisfied with their body shape as a result of other factors such as ridicule or teasing by others, especially among young people (Levine et al. 1994). The average income which was not different between the two groups indicate that body image satisfaction does not discriminate between income levels, be it high or low income bracket. Dissatisfaction with body image can also occur even in women who belong to depressed communities as noted from other studies (Drewnowski and Specter 2004; Office for Women 2003). The higher means of BMI, WC, and WHR from the dissatisfied group of women was an indication that higher body weights may be a factor for the women’s dissatisfaction with their bodies. Obesity could affect the shape of one’s body. With an increase in body fat, weight also increases. When more fat is deposited in the body, the distortion of the body shape becomes more evident, leading to one’s dissatisfaction with his/her body image. Dissatisfaction with one’s body image can also happen when a person is too thin or underweight. Studies that relate body image satisfaction and BMI have already been reported by Song et al. (1999); and Monteath and McCabe (1997); and in other publications ( Office for Women 2003). Table 4 shows that the levels of BMI, WC, and WHR by body image satisfaction are significantly associated. With BMI as indicator, higher proportion of women dissatisfied with their body image were either overweight

Table 3. Mean Age, Income, Body Mass Index (BMI), Waist Circumference (WC ), Waist-Hip Ratio (WHR) by body image satisfaction Age (yrs)

Annual Income (PhP)

BMI (kg/m2)

Waist Circumference (cm)

Waist-Hip Ratio

Not Satisfied

37.66 ± 1.149

101,491.00 ± 86,043.16

23.58 ± 4.18

78.21 ± 10.10

.87 ± .06

Satisfied

38.33 ± 11.30

89,138.67 ± 61,796.20

22.18 ± 3.06

74.9 ± 7.56

.85 ± .04

Total (N=251)

37.86 ± 11.18

97,800.13 ± 79,654.57

23.16 ± 3.93

77.22 ± 9.52

.86 ± .05

Mean Difference

-0

12,352

1

3

0

P-value

0

0

.016*

.019*

.005*

Body Image Satisfaction

* significant difference at α = 0.05

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Table 4. Distribution of Women by Obesity Indices and Body Image Satisfaction Body Image satisfaction Obesity Indices

Not Satisfied No

%

Total

Satisfied No

X2

p-value

11

.003*

4

.038*

4

.043*

%

BMI Underweight (< 18.5 kg)

21

72

8

28

29

Normal (18.5 – 24.5 kg)

94

63

56

37

150

61

85

11

15

72

176

70

75

30

251

Overwt & Obese (≥25 kg) Total Waist Circumference No Risk (< 88 cm)

147

68

70

32

217

At Risk ( ≥ 88 cm)

29

85

5

15

34

176

70

75

30

251

65

63

38

37

103

Total Waist-Hip Ratio No Risk (< 0.85) At Risk (≥ 0.85) Total

111

75

37

25

148

176

70

75

30

251

* Significant association at α =0.05

(84.7%) or underweight (72.4%). This means that body dissatisfaction does not only arise from excess weight but also from inadequate body weight. BMI is highly correlated with fat; thus, distortion of body shape due to excess or lack of fat is evident in people with extremely high or low body weight (Song et al. 1999; Monteath and McCabe 1997). Similarly, using WC and WHR, a greater proportion (85.3% and 75.1%, respectively) of those considered at risk were not satisfied with their body image. These indices considered as measures of central body obesity are known risk factors to metabolic syndrome and related diseases such as diabetes mellitus, cardiovascular disease, and lipid disorders, among others (Alberti & Zimmet 1998; Dobbelsteyn et al. 2001; Woo et al. 2002). The variables BMI, WC, and WHR which were found to be associated with body image in the previous Chi square test were entered in the logistic regression as shown in Table 5. Out of these variables, only WHR emerged as the significant factor that contribute to the variation in Table 5. Factors Related to Body Image Satisfaction in the Logistic Regression WHRab a

a b

B

S.E.

Sig.

Exp.(B)/(95 % C.I. for Exp B)

-10

4

0

.000

( 0.000 - 0.196)

WAIST

0

0

0

1.056

( 0.965 – 1.55)

BMIa

-0

0

0

.845

(0.698 – 1.023)

Constant

8

3

0

2181

Variable(s) entered :BMI, WAIST, WHR Significant factor affecting body image satisfaction

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body image satisfaction (p-value = 0.35; 95% C.I. : 0.000 to 0.196). The negative value of WHR indicates that an increase in WHR would correspond to decrease the degree of satisfaction with body image of the women. Between the obesity indices, WHR would give a more obvious picture of the woman’s image based on the silhouette given, from very thin, to ideal body shape and to the extremely large physical shape. Thus, it is not surprising that WHR appeared as the significant predictor of the outcome variable in this group of women.

CONCLUSIONS AND RECOMMENDATIONS The study assessed body image satisfaction among urban women and examined the factors that influence satisfaction, such as socio-demographic characteristics, dietary intake, and obesity indices. In general, the findings reveal that body image dissatisfaction exists in seven out of ten women in this depressed urban community. The conclusions specific to the objectives of the study are the following: • Majority of the sampled women are less than 40 years of age, have High School level of education, and no occupation. By nutritional status using BMI, 28.7% are overweight and obese and 11.6% are underweight while the rest are normal. Android obesity based on WHR is noted in 59% of the women while based on WC, 13.5% are considered at risk.

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• Mean nutrient intake and adequacy of intake among women not satisfied are not significantly different from those who are satisfied with their body image. Adequacy of nutrient intake is below the RENI for most nutrients except niacin. Mean intake adequacy of most nutrients except protein and niacin are less than 50% adequate. • Mean BMI, WC and WHR were significantly lower among women categorized as satisfied with their body image. Age and income are not different between the two groups of women. The association between body image satisfaction and the obesity indices : BMI, WC, and WHR are significant. • Among the study variables, WHR emerged as the only significant factor that influenced body image satisfaction. Thus, having high WHR, an indicator of central body or android obesity, affects satisfaction of the women with their body image. Based on the results of this study, it is recommended that : • Programs on weight reduction to bring WHR measures to normal could improve the body image of the women and help reduce the possible negative effect of body image dissatisfaction. • Further studies be done on the causes of body image dissatisfaction to identify other factors not included in this study and consider these in planning health programs. For example, if having an apple shaped body deters one from ing exercise programs, include workshops or seminars to boost self-esteem. • The effect of body image dissatisfaction on various psychological, biological and other conditions can be studied in our local situation. • Use other complementary methods of determining food intake of individuals in addition to classic methods to check on the validity of reported intake by the participants, such as food record or observation methods.

ACKNOWLEDGMENTS The authors wish to thank the respondents from Barangay Bagong Silang, Caloocan City and the barangay health officers. Acknowledgments are also given to the following researchers: Michael Angelo G. Lijauco, Ermelita N. Bautista, Mildegarde C. Capitrano, Maureen C. Ugat, and Ferdinand A. Bagunu. The authors would like to give special thanks to Ma. Sofia V. Amarra, Ph.D., former section head of LNS-NSTD, Ms. Elenita V. Castillo for guiding us with the statistical analysis, and Maria Zorayda A. Torres, Ph.D. for editing the article.

Aquino et al.: Body Image Satisfaction of Women and Correlates

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