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bodyweight and the economic impact of obesity on healthcare systems, .... BMI (kg/m2). BMI ≤25. BMI >25. No BMI criteria. Profession in health care of any kind.

443604 2012

SJP0010.1177/1403494812443604C. Sikorski et al.Scandinavian Journal of Public Health

Scandinavian Journal of Public Health, 2012; 40: 271–277


Perception of overweight and obesity from different angles: A qualitative study

Claudia Sikorski1,2, Christiane Riedel1,2, Melanie Luppa2, Beate Schulze2, Perla Werner3, Hans-Helmut König4, & Steffi G Riedel-Heller2 1IFB

Adiposity Diseases, Leipzig University Medical Center, Leipzig, Germany, 2Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany,3Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel, and 4Department of Medical Sociology and Health Economics, Hamburg-Eppendorf University Medical Center, Hamburg, Germany

Abstract Aims: Up to this date, the obesity pandemic has yet to be confined, with prevalence rates still rising in most countries. Aside from numerous negative consequences such as comorbid diseases and a reduction in life expectancy due to excessive bodyweight and the economic impact of obesity on healthcare systems, negative outcomes in overweight and obese individuals are also affected by perceived stigmatisation and discrimination. Knowledge of common views and perception overweight and obesity in the general public as well as in specific populations (e.g. healthcare professionals) is crucial in order to develop stigma-reduction interventions. The specific aim of the current study was to develop an appropriate questionnaire to be used in the survey to follow and further to enhance existing instruments. Methods: This qualitative study reports results from focus groups with normal-weight and overweight individuals as well as healthcare professionals. Results: Contents of the discussion of overweight and obesity did not differ substantially between the three groups. Results show that the definition of obesity in our focus groups is a subjective construct influenced mainly by aesthetics, sympathy, and activity. Within the groups, obesity was mainly seen as a controllable condition; however, external, such as societal, factors were named as well. In line with this and as expected from theoretical background, obese individuals are ascribed mainly negative attributions. Conclusions: With these results, this study enlightens lived realities of different groups of people. The results can be applied to improve existing instruments for the measurement of attitudes towards obesity. Key Words: Focus groups, healthcare professionals, illness and disease, instrument development, obesity/overweight, public health campaigns, stigma

Introduction Obesity, defined by a body mass index (BMI) of greater than 30 kg/m2, is already highly prevalent in Western countries and is predicted to become even more prevalent, reaching a level where almost half of the population in the USA and other countries (such as South Africa, Egypt, and Argentina) will be considered obese by the year 2015 [1]. Having played only a minor role in building healthcare strategies in many countries previously, because of the excessive rise in prevalence rates and healthcare costs, obesity

awareness and prevention are now becoming part of public health initiatives [2]. At the same time, public awareness has also changed substantially. During the early 2000s, only 2−3% of the population considered obesity to be one of the most important health issues, while nowadays the majority in, for example, Germany recognises the significance of the problem [3]. However, not only economic and health considerations call for the urgent need of adequate treatment and prevention measures. Obese individuals

Correspondence: Claudia Sikorski, Institute of Social Medicine, Occupational Health and Public Health. Public Health Research Unit, University of Leipzig, Philipp-Rosenthal-Straße 55, D-04103 Leipzig, Germany. E-mail: [email protected] (Accepted 7 March 2012) © 2012 the Nordic Societies of Public Health DOI: 10.1177/1403494812443604

272    C. Sikorski et al. Table I.  Inclusion criteria and sociodemographic characteristics for each focus group.

Inclusion criteria Age (years) BMI (kg/m2)   Sociodemographic characteristics Age (years) BMI (kg/m2)



Healthcare professionals

18−70 BMI ≤25

BMI >25

  No BMI criteria Profession in health care of any kind

24.5 21.0

32.9 34.0

29.8 21.0

BMI, body mass index.

are subject to a high level of stigmatisation resulting in discrimination [4]. A recent review by Puhl and Heuer [5] finds disadvantages for obese people in numerous areas, including employment and healthcare settings as well as in interpersonal relationship aspects. Stigmatisation can be seen as a process, linking deviant, undesirable labels to an individual because of a “mark” within the individual [6]. Until now, research on weight stigma has mainly been based on samples in selected settings. While having the advantage of established psychometric properties, existing questionnaires were usually derived by experts, drawing on the previous scientific literature. Through this procedure, the very quality standards for measurement tools may run the risk that the concepts measured are uninformed by the lived realities of the people studied. In quality of life research, for example, people with schizophrenia were found to give predominantly positive quality of life ratings, even in the face of poor health and economic adversity. Biographical interviews revealed that they adapt their expectations to the current living situation, thus modifying the criteria against which they judge what is considered “good quality of life” [7]. Similarly, stigma research has long been based almost exclusively on studies investigating the attitudes of the general public [8]. Only when the views of those exposed to stigma were explored in qualitative research, stigma was redefined as a multidimensional concept, including structural discrimination and the direct impact of public images of mental illness in addition to the hitherto dominant conceptualisation which had confined stigma to the realm of interpersonal interaction [9−11]. Relying entirely on established measurement tools may thus leave us with an incomplete, if not inaccurate, picture. In preparation of a representative survey of the German population, the study team conducted focus groups to understand the everyday conceptions of weight bias and stereotypes in three different population groups: normal-weight participants, overweight participants as well as participants working in healthcare professions. The specific aim of the current study was to develop an appropriate questionnaire to

be used in the survey to follow, enhancing existing instruments by taking aspects of respondents’ weight and profession into account as potential moderating factors to cover a wide range of beliefs and opinion toward obesity in the general public. Results are reported contrasting the three groups. Methods Focus groups served as a qualitative approach to inform the development of an interview schedule for the project “The stigma of overweight and obesity in the general population and among healthcare professionals”, a project conducted at the IFB Adiposity Diseases, Leipzig University Medical Center. Focus groups are qualitative group interviews led by a facilitator to structure discussion between participants. They are characterised by flexibility, allowing participants to cover issues not yet thought of by the research team [12]. Additional benefits for exploring participants’ subjective perspectives can be gained as the group dynamics stimulate thinking, exchange, and creativity, facilitating what Morgan calls close resemblance to “naturally occurring interaction” [13]. Recruitment and participants We recruited three groups of participants mainly through a Leipzig regional electronic bulletin board. The advertisement included listing of the inclusion criteria and study details. Additional recruitment strategies included contacting a self-help group for adiposity in Leipzig and posters in large grocery stores. Table I shows inclusion criteria for each participant group. All participants were rewarded by a small monetary incentive (€20). Although homogeneity of the focus group is a principle proposed by Morgan [14], it can be assumed that the ensured weight homogeneity is sufficient to allow the participating individuals to engage in the discussion fully. Study participants were selected on the basis of theoretical sampling [15]. This approach aims at including the most important differences along relevant criteria (age, gender, professional

Perception of overweight and obesity   273 Table II.  Questions used in the focus groups. 1. When is a person considered overweight? 2. What is the prevalence of overweight and obesity in Germany? 3. What do you consider causes of overweight and obesity? 4. Additional to those causes you mentioned, research suggests these − please discuss the five most important causes. 5. How are overweight and obese individuals seen in the public eye? What attributes are they ascribed? 6. Additional to those attributes you mentioned, research suggests these − please discuss the 10 most relevant attributes. 7. Have you experienced problems with overweight and obese individuals in your work life?a 8. What kind of preventive measures to avoid overweight and obesity do you know? 9. Additional to those measures you mentioned, research suggests these − please discuss the 10 most relevant measures. 10. Could you imagine having the public finance these preventive measures? aOnly

healthcare professionals.

background, and experience with obesity) in the study population. Aiming attempt to capture a wide range of opinions, we followed the principle of “inclusion on the basis of maximum variation” [15]. As a first step, we identified three stakeholder groups whose attitudes are crucial in improving the prevention and treatment of obesity: people with obesity, health professionals, and members of the general public with normal bodyweight. Secondly, age and gender within each group were kept as heterogeneous as possible. This was taken into account when accepting potential participants. For the focus group of healthcare professionals, we further ensured equal representation regarding participants’ professional background.

As these focus groups served as a qualitative hypotheses generating approach in questionnaire development, we derived all questions from previous research (e.g. [16]), trying to enlighten under-represented topics using open-ended questions and validate previously used questionnaires. Based on that approach, all open questions were followed by presenting previously used scales and measures. We asked participants to rank group-generated and research-based items according to significance for the topic. This article focuses on issues of perception and causes of overweight and obesity as well as attitudes toward overweight and obese individuals. All groups lasted approximately 90 minutes.


Data analysis

We conducted three focus groups in August 2010. They took place in the afternoon and were held in Leipzig. Two researchers were present during each focus group; a facilitator leading the group and an assistant facilitator ensuring equal discussion, participation, and organisation of the group. At the beginning of each focus group, the study team described the study and participants were asked to sign a consent form and provide basic sociodemographic information. To avoid bias prior to the discussion, the wording stigma and stereotype were avoided in study explanation; the study topic was referred to as investigating opinions and perceptions of overweight in Germany. The focus groups were conducted using standard methods as proposed by Morgan [14]. In line with our study aims to understand subjective perspectives of obesity to improve existing attitude questionnaires, open-ended exploration was combined with feedback on specific questionnaire items. Consequently, focus groups followed a semi-structured format based on seven main questions (questions 4, 6, and 9 being supplementary) that were complemented with follow-up questions as needed. Table II provides an overview of the question guide.

All focus group sessions were audio-taped and then transcribed verbatim by an experienced assistant. One research assistant, who did not participate in the focus groups, as well as the two facilitators of the groups read through the transcripts and designated sets of topic areas inductively [17]. The three evaluators met to discuss the identified topics of each focus group and across groups. We discussed each theme until agreement was reached. We analysed questions 4, 6, and 9 (see Table II) deductively because given categories were discussed by the participants. Results Demographics Table I shows sociodemographic information of the three groups. BMI was assessed via self-report. The normal-weight and healthcare professionals focus groups presented a slight majority of female participants. The focus group of overweight and obese participants showed a totally homogeneous distributed set of participants. Considering all focus groups, the participants’ age ranged from 19 up to 47. Within the normal-weight

274    C. Sikorski et al. focus group, the majority of participants had at least a high school diploma, so there was little variation of education in this group. The two other focus groups were heterogeneous as to educational background. Focus group results For all themes, a summary and supporting quotes can be found in Table III. Theme 1: Definition of overweight. The definition of overweight and obesity is subjective, although the BMI was mentioned as an appropriate measure by all focus groups. All participants in the groups focused on aesthetics of proportion and overall appearance as their primary definition of overweight; however, sympathy, activity, and clothing style were seen as influencing factors. The BMI as an objective measure of overweight was critically discussed by participants in the group of healthcare professionals. Only this group acknowledged deficits in generalisability to athletes which display elevated bodyweight because of excessive muscle proportion. The overweight and obese participants went as far as to propose a new definition of overweight and obesity BMI-wise because the majority of people are at least slightly overweight. Normalweight participants mentioned the BMI criteria, but went to focussing on overall appearance and proportions of the figure. Legs, belly, and buttocks were named to define unfavourable proportions. Theme 2: Controllability.  Shared causes of overweight and obesity were seen in genetic influences, quality of food, lack of physical activity, and psychological issues. While normal-weight individuals presented a rather differentiated view on causes of obesity by naming external (e.g. societal influences, food environment) and internal (e.g. lack of physical activity, bad choices of food) causes to the same extent, overweight and obese individuals presented a much higher tendency to attribute overweight and obesity to internal factors. When confronted with a set of additional causes of obesity, predominately internal factors were considered to be of importance. Theme 3: Emotional response.  Mainly negative attributes were ascribed to obese and overweight individuals. They are seen as lazy, slothful, and weak-willed. Despite potential influences of social desirability, even harsher adjectives were named, such as smelly and dumb. Positive attributes were confined to common widespread views regarding the overweight and obese as funny and sociable.

Discussion The current study explored the perceptions of overweight and obesity among different groups: those unaffected, those affected by overweight, and healthcare professionals. Results of this study provide a unique insight and elaboration into the topics (problem definition, causes of obesity and attitudes toward obese individuals) covered within the focus group discussions. Contrary to quantitative analyses of questionnaires, no relevant information is lost because of necessary abstraction and summarisation in means and can therefore be considered to enhance quantitative research on stigma of obesity. Definition of overweight It becomes clear that for all participants the definition of overweight and obesity is a rather subjective interpretation that is mainly based on appearance and aesthetics. All groups mentioned the BMI as an objective measure but questioned its relevance for their own perception of obesity. This view is expressed by the lay public as well, putting the finger on relevant criticism of the BMI. Obviously, the BMI cannot differentiate between weight because of excessive muscle percentage and proportions of body fat. According to the World Health Organization (WHO), additional anthropometric measures ought to be applied to determine bodyweight status of individuals: waist circumference and waist-to-hip-ratio have been suggested to be used additionally [18]. Another downfall (expressed by the suggestion of a participant to raise the optimal BMI because the average population is slightly overweight) is the lack of agespecific BMI guidelines. As Janssen and Mark [19] summarise, morbidity risk of increased BMI have primarily been examined in middle-aged populations, while recent studies show no elevated risk of mortality in adults aged 65 and older. Rather than adhering to set benchmarks (e.g. BMI >25 = overweight), it seems more relevant to take epidemiological results into account when setting these cut off points for intervention. As Pischon et al. [20] show, mortality risk was lowest among women with a BMI of 24 kg/m2 and men with a BMI of 25 kg/m2 − both bordering the WHO definition of overweight. Another interesting point raised in the focus groups is the reliance on sympathy and acquaintance when judging someone’s weight. According to our focus group participants, a closer relationship leads to a milder perception of potential overweight. This goes in line with recent findings by Taylor, Funk and Craighill [21], who report an interesting observation concerning the American civil population. Their

Perception of overweight and obesity   275 Table III. Themes and supporting quotes. Theme 1: Definition of overweight The definition of overweight and obesity is subjective; although the BMI is mentioned as an appropriate measure by all focus groups. All groups focus on aesthetics of proportion and overall appearance as their primary definition of overweight; however, sympathy, activity, and clothing style are seen as influencing factors. “I think it’s a visual thing. Someone who’s tall and is overweight according to BMI might not be seen as overweight.” (HCP) “I go by looks as well. A male that goes to the gym every day has a BMI of over 25 but is anything but overweight!” (HCP) “It is about sympathy − if I am friends with an overweight person, I tend not to notice the overweight.” (HCP) “A BMI over 25 is considered overweight. But I, for my part, decide to ignore that fact − overweight starts at a BMI of over 30.” (OW) “The average person is somewhat overweight; the average BMI ought to be raised as well.” (OW) “When you meet someone on the street, you don’t have that formula in mind. It’s rather: ‘Oh, he has a huge belly, she has a fat behind.’” (OW) Theme 2: Controllability Shared causes of overweight and obesity are seen in genetic influences, quality of food, lack of physical activity, and psychological issues. While normal-weight individuals present a rather differentiated view on causes of obesity by naming external (e.g. societal influences, food environment) and internal (e.g. lack of physical activity, bad choices of food) causes to the same extent, overweight and obese individuals present a much higher tendency to attribute overweight and obesity to internal factors. When confronted with a set of additional causes on obesity, predominately internal factors are considered to be of importance. “Cultural influences. There are cultures where overweight is seen as something desirable.” (NW) “It is not only knowing what to eat, it is also the quality of food. (. . .) You think you are eating something good for your body but the industry has put so many extras in food that it is not that easy to tell.” (NW) “I think that with knowledge and a high activity level, one can compensate for genetic factors very well.” (HCP) “(. . .) But if one does not think about anything and eats, eats, eats and thinks: ‘Why am I so fat?’ and then continues eating the next day, then it is a vicious circle.” (HCP) “It is the incentives of buying unhealthy food. Media connects a positive association with unhealthy foods, like ‘Nutella’ being associated with soccer players from the national team. Especially for children, advertisement is modelled that way: you’ll be happy, you’ll have friends.” (HCP) “Daily rhythm. It is proven that working night shifts promotes overweight. Sleep deprivation is also a factor.” (HCP) “I think it is more an issue of willpower. I claim that every person that’s overweight has the initial will to lose weight but hates him/herself for not being persistent in the long run.” (OW) “I go to the gym, I do everything to lose weight, but unhealthy eating makes all effort useless. A pizza is done in 5 to 10 minutes. Cooking myself, well . . ., no.” (OW) “I feel helpless in the whole situation. I cannot determine what is really the cause of my overweight − do I exercise too little, do I eat wrong, is it my social environment, do I have a metabolism disorder? To challenge these is nearly impossible.” (OW) Top five causes (ranked): Normal-weight


Healthcare professional

Lack of physical activity Eating habits/awareness Cultural influences Psychological issues Quantity of food

Quantity of food Quality of food Lack of physical activity Metabolism Psychological issues

Lack of physical activity Psychological issues Issues of upbringing Social environment Cultural influences

Theme 3: Emotional response Mainly negative attributes are ascribed to obese and overweight individuals. They are seen as lazy, slothful, and weak-willed. Despite potential influences of social desirability, even harsher adjectives were named, such as smelly and dumb. Positives attributes are confined to common stereotypical views regarding the overweight and obese as funny and sociable. Attributes named in free association (in order of appearance): Normal-weight


Healthcare professional

Lazy Phlegmatic Depressed Dissatisfied Weak-willed Confident Extraverted Vulnerable          

Taking things easy Lazy Inconsequent Weak-willed Dull Unmotivated Smelly Unathletic Slothful Unconfident Funny Sociable Affectionate

Hoggish Lazy Unfriendly Dull Slothful Inappropriate Dumb Round Happy Funny Cuddly    

“I would add ‘dishonest’ to the extent that they keep claiming to feel comfortable about themselves.” (HCP) “Overweight patients smell.” (HCP) “They keep lying to themselves and making up excuses which are the biggest problems in counselling.” (HCP) “Untidy − in a way that one generalises the lazy aspect because they aren’t being active and then they cannot keep their apartment neat.” (NW) HCP, healthcare professional; NW, normal-weight participant; OW, overweight participant.

276    C. Sikorski et al. findings show that people seem to be much more likely to consider individuals of a more distanced level of familiarity overweight or obese rather than they would people they know or themselves − just as if they used different scales for different people. As for the questionnaire to be developed, several conclusions were drawn from these findings. Aside from BMI calculation via self-reported height and weight, participants will be asked to rate their subjective view of their own weight into categories (under-/ normal-/slightly over-/overweight). Also questions concerning obesity and overweight in one’s social network will be included to compare subjective, networkrelevant prevalence rates to general prevalence rates of overweight. Another interesting aspect will be the analysis of participants’ children’s weight, also including a question on subjective rating of that weight. Controllability and emotional response Contrary to previous research on the lay public’s view on causes of obesity, linking excess weight mainly to the individual’s failure to eat less and exercise more (summarised in [22]), participants in our study displayed a rather differentiated view on causes, naming both internal and external factors. Media influence was named as one specific aspect as it has been considered in other studies as well [23]. However, when asked to rank the most important causes, it is again internal, controllable factors that are emphasised, even by healthcare professionals. This attribution of obesity to internal control of the individual may be the basis of weight stigma. Crandall and Moriarty [24] show that the more a disease is perceived as under volitional control, the more it is stigmatising − substance abuse, for example, being highly stigmatising − with obesity generally being perceived as highly under control [25]. Phelan et al. [26] state that when behaviour is perceived to be voluntary (e.g. under self-control), stigma plays a normative role, serving to enforce compliance with existing social norms to push individuals to adjust their behaviour to those standards. Interestingly, this line of thought is quite different from evidence of the stigma of mental illness, e.g. schizophrenia. Research has shown that the stigma of schizophrenia is mainly driven by notions of dangerousness [24] and seems to fit into another category of stigma development. Phelan et al. [26] propose that “keeping people away” serves as the primary motivation in schizophrenia stigma. Stigma and negative attributes associated with obesity include labelling obese individuals as lazy, unintelligent, and unmotivated [5]. Findings from our focus groups revealed the expected association

between internal controllability and negative attitudes. Research has shown, when the stigmatised person is held responsible for his/her condition, the emotional response to beliefs of controllability is expected to be negative [27]. The few positive adjectives named in this study were confined to stereotypical associations such as happy and funny. Most strikingly, even participants in the overweight group applied negative stereotypes to themselves. This could be an indicative for existing self-stigma. Self-stigmatisation links the internalisation of negative attributes by stigmatised individuals, regarding them as fitting [28]. For the questionnaire development results meant including a wide range of both internal and external causes of overweight and obesity and, because of time-limitations, relying on those causes primarily named in the focus groups. Also, because age- and gender-specific differentiation was addressed in the focus groups (as to causes of obesity among children compared to middle-aged and aged adults), vignettes will be introduced, varying in age and gender. As for stigmatising attitudes, it was decided to include the Fat Phobia Scale, a semantic differential scale [29]; however, we chose to cover positive attitudes as well by adding those named within the focus groups. Implications for stigma reduction in public health The dominance of initially named internal factors by overweight and obese participants brings up the issue of internalised stigma. Being faced with public stigmatisation, stigmatised individuals may apply undesirable characteristics linked with their group to themselves because of shared common values and beliefs prior to being stigmatised (e.g. shared beliefs about obese individuals are carried over when becoming obese themselves), obviously even adopting the view of complete own responsibility [28]. Considering the negative impact of weight stigma on affected individuals (for an overview, see [25]), it is necessary to spread the word about the numerous causes of obesity in an attempt to reduce internal attributions that are simplified and contradict the known interaction of genetic, social, and individual factors. Sharma and Padwal [30] present an aetiological framework that encompasses the multifactorial nature of causes of obesity by seeing a chronic energy excess whose causes have to be assessed, making obesity a sign and over-eating a symptom. The authors provide an exhaustive model to assess individual causes of the chronic energy excess leading to obesity, making increased energy intake and reduced activity variables that yet are to be explained by additional causes such as sociocultural factors, medications, and so on. As

Perception of overweight and obesity   277 linking obesity and overweight to an individual’s failure of a healthy lifestyle is associated with the attribution of stereotypes and weight stigma, public campaigning with elaborated models as the one by Sharma and Padwal may help reduce weight stigma in general. Limitations There are several limitations to the current study. First, our sample size per group was small, only including one focus group per category (normalweight/overweight/healthcare professional). Secondly, instead of sampling homogenous groups, we decided for age and gender heterogeneity to cover a broad range of opinions. Although qualitative research methods have some limitations concerning generalisability, focus groups were well suited to examine the objectives of the current study: to learn about opinions and views toward obesity within different groups of the general public to develop appropriate instruments. Future research may pursue two avenues. On the one hand, our results can be applied to improve existing instruments for the measurement of attitudes toward obesity, and to study their patterns and prevalence in representative population samples. In addition, the specific attitude dimensions identified could be explored in more depth in further qualitative work. Conflict of interest The authors declare that there is no conflict of interest. Funding This work was supported by the Federal Ministry of Education and Research (BMBF), Germany grant number (FKZ): 01EO1001. References   [1] World Health Organization. WHO global infobase: data for saving lives. Available at: https://apps.who.int/infobase/Index.aspx (2010, consulted June 2010).  [2] Fussenegger D, Pietrobelli A, Widhalm K. Childhood obesity: political developments in Europe and related perspectives for future action on prevention. Obes Rev 2008;9:76−82.   [3] Hilbert A, Rief W, Braehler E. What determines public support of obesity prevention? J Epidemiol Community Health 2007;61:585−90.   [4] Puhl RM, Brownell KD. Bias, discrimination, and obesity. Obes Res 2001;9:788−805.   [5] Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring) 2009;17:941−64.  [6] Jones E, Farina A, Hastorf A, Markus H, Miller D, Scott R. Social stigma: the psychology of marked relationships. New York: Freeman, 1984.   [7] Kilian R. [Can quality of life be measured? Problems of quantitative and possibilities for qualitative assessment of quality of life in psychiatry]. Psychiatr Prax 1995;22:97−101.

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