A STUDY OF THE IDEAL BODY IMAGE FOR GHANAIAN WOMEN


1
A STUDY OF THE IDEAL BODY IMAGE FOR GHANAIAN
WOMEN

• Rosemary B. Duda M.D. M.P.H.
• Associate Professor of Surgery HMS

2

• Grant Title
• Reducing Obesity in a Culture that Values
  Traditionally Built Women A Pilot Study
  Assessing Feasibility for a Weight Reduction
  Clinical Trial
• PI Rosemary B. Duda M.D. M.P.H.
• Co-I Allan G. Hill Ph.D.
• Naana Afua Jumah D. Phil.
• Joseph Seffah M.D.
• Richard Biritwum M.D.

3
Theory

• Cultural factors influence the ideal body image
  for Ghanaian women.

4
Hypothesis

• The current body image can be modified by
  associating a normal body weight with a healthier
  life.

5
Specific Aims

• Develop a culturally adapted prototype Figural
  Stimuli (FS)
• Establish normative data
• Assess Current Body Image and Ideal Body Image

6
Specific Aims

• Dissatisfaction score
• Determine specific factors would influence a
  change in CBI

7
Specific Aims

• Determine level of interest in a weight control
  clinical study in order to maintain or improve
  overall health

8
Background

• WHO reports on world wide obesity
• Ghanaian Women Delegation to Harvard Law School
• Womens Health Study of Accra

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Womens Health Study of Accra

• Measure prevalence of communicable and
  non-communicable disease
• Adult Ghanaian women
• Reside in urban Accra
• Measure risk factors for chronic diseases

10
Womens Health Study of Accra

• 3200 women participated
• 3187 - Household Survey
• 1328 - Comprehensive Clinical and
  Laboratory Examination
• Participation rate
• 98.4 HHS
• 99.0 CMLE

11
WHSA Pertinent Results

• Body Mass Index
• Underweight 7.9
• Normal Weight 29.8
• Overweight 27.6
• Obese 34.7
• 62.3 of women were either overweight or obese

12
WHSA Obesity and Co-morbid Illnesses

• Hypertension
• OR 2.97 CI 2.17-4.05 p
• Diabetes
• OR 1.94 CI 1.04 3.62 p0.037
• Chest pain on exertion
• OR 2.17 1.43-3.32 p0.001
• Shortness of breath on exertion
• OR 2.19 1.56-3.08 p

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WHSA Obesity and other ailments

• Difficulty walking (p
• Palpitations (p
• Hypercholesterolemia (p
• Elevated total cholesterol
• Low HDL
• Hypertriglyceridemia (p0.049)

14
WHSA Obesity Risk Factors

• Significantly associated with
• Increasing Age to 60
• Number of pregnancies 5
• Mean age last delivery 34 years
• Television
• Telephone
• Refrigerator
• p

15
WHSA Obesity Not Associated with

• Education
• Income
• Area of residence
• Diet
• Work activity
• Leisure time activity

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Ideal Body Image

• Why are so many Ghanaian women in Accra
  overweight or obese
• Diet
• Amount
• Type
• Activity
• Genetic
• Cultural
• Combination of factors
• It is unhealthy.

17
IBI MethodsFigural Stimuli

• Developed culturally specific Figural Stimuli
  using computerized body morph assessment tools
• Scale is robust
• Correlated with measured BMI
• Adjunct to measured or self-reported height and
  weight for large population-based studies

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IBI MethodsStudy Population

• Adult women 18 and older
• All body types
• Not pregnant or nursing
• Able to step on a scale
• Able to understand some English
• Verbal consent
• Approved by four (4) IRB Committees

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IBI MethodsDesign

• Women interviewed at Korle Bu Teaching Hospital
  University of Ghana
• Anthropometric measurements
• BMI calculated
• Survey administered verbally
• Women provided with BMI and educational materials

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IBI MethodsSurvey

• Demographic information
• Self-report of overall health (SF-36)
• Figural Stimuli to determine CBI and IBI
• Decision analysis
• Assessing level of interest in participating in a
  weight reduction clinical trial

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IBI ResultsFigural Stimuli
22
IBI - Results

• Conducted in July - August 2005
• 305 women surveyed
• Mean age 35.9 (range 19-74 years)
• Marital Status
• Never Married 22.0
• Currently Married 71.1
• Widowed 4.3
• Divorced 1.6
• Separated 1.0

23
IBI - Education

• Highest level of education attained
• None 5.6
• Primary 7.5
• Middle/JSS 25.2
• Secondary/SSS 25.9
• Higher 35.7

24
IBI - Ethnicity

• Ethnicity
• Ga 15.9
• Asante 11.8
• Fante 12.3
• Ewe 22.3
• Other 37.3
• Dont Know 0.5

25
IBI Children

• Number of Children
• None 48.2
• One 15.7
• Two 11.5
• Three 10.8
• Four 6.2
• Five 3.6
• Greater than 5 5.0

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IBI - Income

• Monthly Income (USD1 8500 cedis)
• None 15.2
• 35-59 16.5
• 60-118 20.5
• 118 26.3
• Dont know/Refused 13.1

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IBI Food Security

• Less than 1 of the women stated that they often
  did not have enough food to eat
• 58.7 had enough to eat and enough of the types
  of food they wanted to eat
• 27.5 had enough to eat but not always the types
  of food they desired

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IBI Food Preparation

• 78.1 of the women interviewed personally shopped
  for the food
• 9.4 stated an elder female relative shopped for
  food
• 92.3 stated that they prepared the meals at home

29
IBI BMI

• Body Mass Index
• n
• Underweight 4 1.3
• Normal 101 33.1
• Overweight 94 30.8
• Obese 106 34.8
• WHO Criteria

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IBI Past Medical History

• Hypertension 18.6
• Diabetes 2.3
• Myocardial infarction 1.3
• Cerebral vascular accident 1.0
• Obesity 14.0
• Malaria 79.5

31
IBI Weight Awareness

• Weight change over the last year
• 34.8 same
• 36.5 increased
• 29.1 decreased
• Intentional weight loss
• 53.2 attempted
• 51.2 by exercising
• 100 by eating less
• 12.5 by medications/supplements/aides

32
IBI Weight Awareness

• Childhood weight
• 28.5 encouraged to gain weight
• 14.9 encouraged to lose weight
• Adult weight
• 50.2 encouraged to lose weight
• 34.0 encouraged to gain weight

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IBI Obesity Awareness

• 94.6 reported that they were aware that there
  were health risks with obesity
• Most common sources
• Radio 17.5
• Television 16.8
• Newspaper 10.6
• Doctor 10.3

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IBI Self Health Assessment SF-36

• Response
• Question Excellent Good Fair Poor
• Overall health 15.8
  25.2 46.6 12.4
• Compared to last year 22.5
  22.5 35.6 13.8
• Improve Same Worsen
• Compared to next year 84.9 14.8 0.3
• Better Same Worse
• Compared to friends 51.6 28.3 10.1
• I expect my health to worsen over the next year
  
• True Neither True/False False
• 1.7 0.7 97.7

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IBI Body Image Selection

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IBI Frequency Current Body Image

• Figure selected
• Underweight 14.8
• Normal 38.4
• Overweight 39.2
• Obese 7.5

37
IBI Comparison of BMI and CBI

• Figure selected BMI
• Underweight 14.8 1.3
• Normal 38.4 33.1
• Overweight 39.2 30.8
• Obese 7.5 34.8

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IBI Selection of Normal Weight Figures

• Nulliparous
• (OR 1.25 1.1-1.4 p
• Highest education levels
• (OR 1.30 1.1-1.5 p0.001)
• Highest income levels
• (OR 1.40 1.1-1.6 p

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IBI Frequency Ideal Body Image

• Figure selected
• Underweight 14.0
• Normal 60.2
• Overweight 24.1
• Obese 1.7

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IBI FrequencyHealthiest Body Image

• Figure selected
• Underweight 17.5
• Normal 65.3
• Overweight 15.2
• Obese 2.0

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IBI FrequencyLeast Healthy Body Image

• Figure selected
• Underweight 24.5
• Normal 1.0
• Overweight 1.0
• Obese 73.5

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IBI Dissatisfaction Score

• Difference between the CBI and the IBI
• (DS CBI IBI)
• DS n range
• 0 71 23.6
• 144 47.8 1 - 8
• - 86 28.5 1 -10
• 67.4 selected a change 1 to 2 sizes different
  than her CBI

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IBI Dissatisfaction Score

• Parous women
• (OR 1.20 1.1-1.3 p0.004)
• Overweight women
• (OR 1.54 1.3-1.9 p
• Obese women
• (OR 4.14 2.7-6.2 p
• 88.2 of obese women selected a smaller IBI
  compared to 15.9 of normal weight women
  (p

44
IBI Dissatisfaction Score

• The dissatisfaction score was not significantly
  associated with
• highest income level
• education level

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IBI Prediction of mens choicesof womens IBI

• Figure
• Underweight 21.6
• Normal 51.0
• Overweight 23.4
• Obese 4.0

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IBI Compare Womens and Predicted Mens
selection of womens IBI

• Figure Women Spouse/SO
• Underweight 14.0 21.6
• Normal 60.2 51.0
• Overweight 24.1 23.4
• Obese 1.7 4.0

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IBI Normative Evaluation

• Figure mean sd BMI
• Underweight 21.6 0.6
• Normal 23.8 3.1
• Overweight 29.6 4.4
• Obese 37.4 4.4
• Pearsons 0.699 p

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IBI Factors Affecting Change in CBI

• Question 1
• If you were told that your current figure (CBI)
  was associated with an increased chance of
  developing hypertension stroke heart attack
  diabetes poor vision malaria would you change
  it

49
IBI Factors Affecting Change in CBI

• Question 2
• Would you change your figure if your husband or
  significant other asked you to do so

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IBI Factors Affecting Change in CBI

• Determinant
• Hypertension 74.9
• Stroke 75.9
• Diabetes 72.9
• Heart Attack 73.9
• Poor Vision 56.5
• Malaria 61.5
• Spouse/SO 73.4
• Improve overall health 75.6

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IBI Degree of Change in CBI

• Hypertension Stroke
• -3 1.3 0.7
• -2 2.3 1.7
• -1 3.0 3.0
• 0 26.1 25.1
• 1 26.1 19.7
• 2 15.1 19.1
• 3 26.0 30.9
• A negative value reflects the selection of a new
  body image that is larger than the current body
  image.

52
IBI Degree of Change in CBI

• Diabetes MI
• -3 1.3 1.7
• -2 1.3 1.3
• -1 3.3 3.0
• 0 27.1 26.1
• 1 18.7 24.1
• 2 19.4 17.4
• 3 28.8 26.3

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IBI Degree of Change in CBI

• Spouse/SO Improve Health
• -3 3.0 2.7
• -2 1.5 2.3
• -1 2.9 4.0
• 0 34.9 24.4
• 1 18.9 23.4
• 2 13.8 16.1
• 3 25.1 27.1

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IBI Selection of New Body Image to Reduce Risk

• Significantly associated with
• Obesity (p
• Age 19 50 years
• Hypertension (85.3 vs. 14.7 p0.017)
• Stroke (85.1 vs. 14.9 p0.01)
• Diabetes (85.1 vs. 14.9 p0.012)
• MI (85.3 vs. 14.7 p0.017)
• Poor vision (83.9 vs. 16.1 p0.012)

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IBI Selection of New Body Image to Reduce Risk

• Not significantly associated with
• Education
• Income
• Marital status
• Parity

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IBI ComparisonObese to Non-Obese

• Determinant OR 95.0 C.I.
• Hypertension 2.03 1.64 - 2.51
• Stroke 1.96 1.61 - 2.38
• Diabetes 2.00 1.63 - 2.44
• MI 2.27 1.80 - 2.86
• Poor Vision 1.87 1.51 - 2.30
• Malaria 1.96 1.59 - 2.43
• Spouse/SO 2.64 1.98 - 3.52
• Overall Health 1.95 1.60 - 2.37
• p

57
IBI Comparisonof Obese to Non-Obese Degree of
Change

• Hypertension Stroke
• Other Obese Other Obese
• -3 2.9 0.5 1.9 0.0
• -2 4.9 1.0 3.9 0.5
• -1 7.8 0.5 7.8 0.5
• 0 42.7 17.4 35.9 19.0
• 1 30.1 23.6 29.1 14.9
• 2 6.8 19.5 14.6 21.5
• 3 4.8 38.4 6.8 43.2

58
IBI Comparisonof Obese to Non-Obese Degree of
Change

• Diabetes MI
• Other Obese Other Obese
• -3 3.9 0.0 3.9 0.5
• -2 2.9 0.5 3.9 0.0
• -1 6.8 1.5 7.8 0.5
• 0 42.7 18.5 40.8 18.5
• 1 25.2 15.4 28.2 21.5
• 2 11.7 23.6 11.7 20.5
• 3 6.8 33.9 3.9 38.4

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IBI Comparisonof Obese to Non-Obese Degree of
Change

• Spouse/SO Improve Overall Health
• Other Obese Other
  Obese
• -3 8.9 0.0 4.8 1.5
• -2 3.3 0.5 5.8 0.5
• -1 7.8 0.5 8.7 1.5
• 0 52.2 26.1 37.9 16.9
• 1 22.2 17.4 28.2 21.0
• 2 3.3 19.0 11.7 18.5
• 3 2.2 36.4 2.9 40.0

60
IBI Freedom to change CBI

• Question 3
• Would be allowed (by your spouse significant
  other or parent) to change your weight if you
  wanted
• Yes 85.8

61
IBI Interest in Changing CBI

• Question 4
• Would you be willing to be a part of a research
  study at some future time to DECREASE your weight
  if it meant that you would live a healthier
  life
• Yes 87.4

62
IBI Interest in Changing CBI

• Would you be willing to increase your activity
  by exercising regularly - at least three times a
  week - to DECREASE your weight if it meant that
  you would live a healthier life
• Yes 88

63
IBI Interest in Changing CBI

• Would you be willing to follow a special diet to
  DECREASE your weight if it meant that you would
  be able to live a healthier life
• Yes 87.5

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Ideal Body Image for a Ghanaian women

• So what do the men think

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IBI Ghanaian Mens Study

• Men age 18 years and older
• Randomly selected at public places
• Weighed and height measured
• Verbal consent
• Verbal survey administration
• Figural stimuli of men
• Figural stimuli of women
• Controls were women similarly selected

66
IBI Mens Study Results

• No difference between the men and women
• Mean age
• Men 33.6 12.3 (n123)
• Women 31.8 9.9 (n62)
• Children
• Education level
• Marital status
• Body mass index

67
IBI Mens Study

• CBI BMI(mean)
• Underweight 17.9 22.1
• Normal 74.0 25.1
• Overweight 7.2 25.8
• Obese 3.2 40.4

68
IBI Mens Study Dissatisfaction Score

• Difference between the CBI and the IBI
• (DS CBI IBI)
• DS range
• 0 43.9
• 19.3 1 - 6
• - 36.7 1 - 7
• Difference in DS between men and women was
  significant
• 43.9 vs. 22.6 respectively OR 1.12
  1.03-1.20 p0.003 were satisfied with their
  CBI

69
IBI Mens Study Perception of Womans IBI

• IBI Figure Selected by
• Men Women Mens perceptions
• Underweight 13.8 14.5 13.8
• Normal 79.9 56.5 44.7
• Overweight 15.4 27.4 30.9
• Obese 0.8 1.6 10.6

70
IBI Mens Study Perception of Mans IBI

• IBI Figure Selected by
• Men Women Womens perceptions
• Underweight 10.6 11.3 4.8
• Normal 79.7 83.9 77.5
• Overweight 7.3 3.2 17.9
• Obese 2.4 1.6 4.8

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IBI Mens Study

• Significant difference between mens perception
  and womens choice of IBI p0.05
• There was no significant statistical difference
  between men and women
• healthiest and least healthy
• womens perception of mens choice of mens IBI

72
IBI Summary

• We have shown in this population of women
• A high prevalence of obesity
• A high level of body image dissatisfaction
• A high level of willingness to alter CBI to
  improve health
• Few apparent spousal obstacles
• Perception by both men and women that the IBI for
  a Ghanaian is in the normal BMI range.

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IBI Conclusion

• Cultural ideals of body image are not the basis
  for the high prevalence of obesity in urban
  Ghanaian women.

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IBI Conclusion

• There is a statistically significant disconnect
  between the genders for perceived IBI of Ghanaian
  women.

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IBI Next Steps

• NIH R21 submitted
• Clinical trial to reduce obesity
• Obese women are primary subjects
• Family health assessed and monitored
• Interventions
• Diet
• Activity
• Behavioral modifications

76
IBI Interesting Observations

• Survey took from 10 minutes to one hour to
  administer
• Some women stated that they had never been asked
  their opinion of anything in the past
• Hence these women were very thoughtful before
  giving their response

77
Thank You
Insert picture of Naana performing an interview