European Journal of Clinical Nutrition (2002) 56, 866–872
ß 2002 Nature Publishing Group All rights reserved 0954–3007/02 $25.00
www.nature.com/ejcn
ORIGINAL COMMUNCIATION
Self-perception of being overweight in Spanish adults
JL Gutiérrez-Fisac1*, E López Garcı́a1,2, F Rodriguez-Artalejo1, JR Banegas Banegas1 and P GuallarCastillón1,2
1
Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain; and 2Centro
Universitario de Salud Pública, Consejerı́a de Sanidad de la Comunidad de Madrid, Universidad Autónoma de Madrid, Madrid,
Spain
Objective: To describe the frequency, distribution and trend in misperceived overweight and obesity.
Design: Three independent cross-sectional studies carried out in 1987, 1995 and 1997 over representative samples of Spanish
adult population.
Setting: Spanish adult population aged 20 y and over.
Subjects and interventions: A total of 11 496 men and women aged 20 y and over with a body mass index (BMI) 25 kg=m2.
Main outcome measures: Prevalence and time trend of misperceived overweight and obesity based on self-perceived weight
and height.
Results: Some 28.4% of the population did not perceive themselves to be overweight or obese in 1987 (26.9% in 1995=97).
Overweight was more frequently misperceived among men, persons over 64 y of age, those residing in rural areas and those
with an elementary educational level. The largest percentages of misperceived overweight were in the more moderate levels of
BMI: 50% of men and 30% of women with a BMI of 25 – 26.9 kg=m2 in 1995=1997 did not perceive themselves to be
overweight.
Conclusions: Misperceived overweight and obesity is frequent in the adult population in Spain. Some social and cultural factors
may explain its higher frequency in men, older individuals and those with elementary level of education. The fact that most of
those who do not perceive themselves to be overweight are in the moderate levels of overweight should be taken into account
when designing strategies for the prevention and control of overweight and obesity in the general population.
European Journal of Clinical Nutrition (2002) 56, 866 – 872. doi:10.1038=sj.ejcn.1601404
Keywords: overweight; obesity; self-perception; epidemiology
Introduction
Obesity is perhaps one of the most important emerging
health problems in our time. Its frequency has continued
to rise over the past several decades.The proportion of obese
persons is of considerable magnitude: between 15 and 20%
of the adult population in most European countries. If overweight is also taken into account these percentages go up
sharply, reaching more than 50% (Seidell, 1995; Flegal et al,
1998). This fact, together with its association with the leading causes of illness and death, has made obesity a high-
*Correspondence: JL Gutiérrez-Fisac, Departamento de Medicine
Preventiva y Salud Pública, Facultad de Medicina, Universidad Autónoma
de Madrid, Avda. Arzobispo Morcillo s=n, 28029 Madrid, Spain.
Guarantor: JL Gutiérrez-Fisac.
Contributors: JLG-F, ELG, FRA, JRBB and PG-C were involved with the
conception of the study, data analysis and writing the manuscript.
Received 9 July 2001; revised 7 December 2001;
accepted 10 December 2001
priority problem on many governments’ agendas (Department of Health, 1995; US Department of Health and Human
Services, 2000).
Strategies to prevent obesity are based, on the one hand,
on improving conditions related to diet and physical activity
in the general population and, on the other, on detecting
and treating high-risk individuals. Despite some improvements in these areas, however, obesity continues to increase.
The importance of individual motivation in the prevention and treatment of obesity is well known (National
Institutes of Health, 1998). A pre-condition of individual
motivation to lose weight is the perception or consciousness
that one’s weight is higher than normal for good health.
Most research on perceived weight has focused on qualitative aspects related with personal satisfaction with body
weight (Pingitore et al, 1997; McElhone et al, 1999) or
social acceptability (Rand & Resnick, 1997, 2000; Craigh &
Caterson, 1990), whereas few studies have investigated to
what extent people recognize the presence of overweight
Self-perception of overweight
JL Gutiérrez-Fisac et al
and obesity (Gorynski & Krzyzanowski, 1989; Blokstra et al,
1999).
The objective of this study is to describe the frequency
and distribution of the perception of overweight and obesity
in the adult population in Spain and trends in these figures
between 1987 and 1997.
Materials and methods
The data were taken from the national health surveys carried
out by the Ministry of Health in the adult population in
1987, 1995 and 1997. In these surveys, interviews were held
with a household sample of persons representative of the
non-institutionalized Spanish population aged 16 y and
above (Ministerio de Sanidad y Consumo, 1989, 1996,
1999). The number of persons interviewed in each survey
was 29 647, 6395 and 6396, respectively. The 1987 sample
was made up of 50 provincial subsamples, each of which was
selected using a multistage procedure and stratified by size of
locality. Because the sampling fraction was not the same in
each province, each individual in the sample was assigned a
weighting coefficient as a function of the province of origin.
In contrast, in 1995 and 1997 the samples were selfweighted, since in both of those years a single sample was
selected at the national level, also using a multistage procedure and stratified by size of locality. In order to compensate
for the difference in sample size, the 1995 and 1997 surveys
were combined, so that the estimates in the first period were
obtained with the data from the 1987 survey, while the
estimates for the second period are based on the data taken
from combining the 1995 and 1997 surveys.
The body mass index (BMI) or Quetelet index (weight in
kg divided by height in m2) was calculated based on the
information on self-reported weight and height obtained by
asking the following two questions: ‘can you tell me about
how much you weigh without your shoes or clothes on?’ (in
kg); and ‘can you tell me about how tall you are without your
shoes on?’ (in cm). The present study was limited to the
population aged 20 y and older who had a BMI 25 kg=m2.
The response rate for weight and height in 1987 and
1995=1997 was 81.7 and 89.4%, respectively. After eliminating persons with missing information for some of the variables considered, the sample size was 6957 in 1987 and 4539
in 1995=1997, which represents 35.7 and 48.6% of the whole
population aged 20 y and over for the two periods, respectively. Table 1 shows the number of persons and the percent
distribution by the variables studied.
Misperceived overweight or obesity was defined in accordance with the response to the following question on the
survey questionnaire — ‘And in relation to your height,
would you say that your weight is: (1) a lot higher than
normal; (2) somewhat higher than normal; (3) normal; (4)
less than normal’. Persons were considered to have misperceived overweight when the answer to the question was (3)
normal or (4) less than normal.
Table 1
Number of persons with BMI 25 kg=m2 and percent
distribution by age, educational level, size of place of residence and
leisure-time physical activity. Persons aged 20 y and over, in 1987 and
1995=1997
1987
n
Total
Age (y)
20 – 34
35 – 49
50 – 64
65 and over
Educational level (maximum level reached)
Elementary
Secondary or higher
Size of place of residence (population)
< 10 000
10 001 – 100 000
100 001 – 400 000
400 001 – 1 000 000
Over 1 000 000
Leisure-time physical activity
Vigorous or moderate
Light
Sedentary
6957
867
1995=1997
%
100
n
4539
%
100
1390
2220
2247
1100
19.9
31.9
32.3
15.8
1037
1311
1356
835
22.8
28.9
29.9
18.4
5678
1279
81.6
18.4
3149
1390
69.4
30.6
670
1228
1611
393
3055
9.6
17.7
23.2
5.6
43.9
348
870
1073
398
1850
7.7
19.2
23.6
8.8
40.8
392
1845
4720
5.6
26.5
67.8
466
1874
2199
10.3
41.3
48.4
The results are presented separately for men and women
for each of the periods studied. The prevalence of misperceived overweight is broken down by age, educational level,
size of place of residence and level of leisure-time physical
activity. Leisure-time physical activity was obtained via the
question: ‘What type of physical exercise do you do in your
leisure time? Tell us which of the following possibilities best
describes the major part of your leisure time activity: (a) I do
no exercise at all. I spend most of my leisure time in a
sedentary fashion (reading, watching television, going to
the cinema, etc.); (b) I do some occasional physical or
sports activity (walking or riding a bicycle, gardening, easy
gymnastics, etc.); (c) I do regular physical activity several
times a month (tennis, gymnastics, running, swimming,
etc.); (d) I do physical training several times a week.
Option (a) was considered as sedentary, option (b) as light
and options (c) and (d) as vigorous or moderate. The percentage of persons with misperceived overweight and obesity is
also shown by BMI.
Data processing and analysis were performed using the
SAS statistical package (SAS, 1996).
Results
Figure 1 shows the prevalence of misperceived overweight
and obesity in the whole population aged 20 y and over:
28.4% in 1987 and 26.9% in 1995=1997. This figure also
shows the percentage of individuals with a BMI 25 kg=m2
in the whole population aged 20 y or more, which increased
from 35.7% in 1987 to 48.6% in 1995=1997.
European Journal of Clinical Nutrition
Self-perception of overweight
JL Gutiérrez-Fisac et al
868
was considerable, from 18.7% in 1987 to 8.7% in 1995=1997,
and statistically significant (Table 3).
By educational level, the prevalence of misperceived overweight was higher in persons with elementary level education. With regard to trend, of note is the increase in the
prevalence of misperceived overweight observed among
women with elementary educational level, which rose from
16.4% in 1987 to 19.1% in 1995=1997.
In general, the prevalence of misperceived overweight was
higher in men and women residing in areas with small
populations; the proportion decreased with increasing population of the place of residence. With regard to physical
activity, a greater prevalence of misperceived overweight
was observed in sedentary persons except for men in
1995=1997.
Finally, Figure 2 shows the percentage of men and women
with misperceived overweight by BMI. The largest percentage of individuals with misperceived overweight was seen
among those with a BMI of 25 – 26.9, among whom 50% of
men and 30% of women did not perceive themselves to be
overweight in 1995=1997. As can be seen, this proportion
decreases with increasing BMI. For the same period, 31% of
men and 18% of women with a BMI between 27 and 28.9 did
not perceive themselves to be overweight. Misperceived
overweight was more frequent in men in all categories of
BMI.
Figure 1 Prevalence of overweight and obesity (BMI 25 kg=m2) and
prevalence of misperceived overweight and obesity in the Spanish
population aged 20 y and over in 1987 and 1995=97.
Tables 2 and 3 show the percentage of men and women
with a BMI 25 kg=m2 who did not perceive themselves to be
overweight in the two periods studied. Misperceived overweight was greater in men than in women in both 1987 (36.6
and 16.5%, respectively) and 1995=1997 (33.2 and 17.7%).
Statistically significant differences were seen by age in both
sexes, with the highest prevalences in persons aged 65 and
over. With regard to the trend by age between the two
periods, a notable decrease in misperceived overweight was
seen in all age groups in men, whereas in women a decrease
was seen only in those aged 20 – 34, though the reduction
Discussion
The results obtained reveal several important facts. Together
with the high prevalence of overweight and obesity in the
Spanish adult population aged 20 and over, which reached
Table 2 Percentage of men with BMI 25 kg=m2 who did not perceive their overweight, by age, educational level,
size of place of residence and leisure-time physical activity in 1987 and 1995=1997
1987
Total
Age (y)
20 – 34
35 – 49
50 – 64
65 and over
Educational level (maximum level reached)
Elementary
Secondary or higher
Size of place of residence (population)
< 10 000
10 001 – 100 000
100 001 – 400 000
400 001 – 1 000 000
Over 1 000 000
Leisure-time physical activity
Vigorous or moderate
Light
Sedentary
a
95% CI, 95% confidence interval.
European Journal of Clinical Nutrition
1995=1997
n
%
95% CIa
n
%
95% CIa
1515
36.6
35.2 – 38.1
899
33.2
31.4 – 35.0
350
475
442
248
35.8
35.0
36.4
42.2
32.8 – 38.9
32.5 – 37.6
33.7 – 39.2
38.2 – 46.4
252
231
237
179
34.6
28.7
31.8
41.8
31.2 – 38.2
25.6 – 32.0
28.5 – 35.1
37.1 – 46.7
1165
350
37.6
33.8
35.8 – 39.3
31.0 – 36.8
584
315
34.8
30.6
32.4 – 37.2
27.8 – 33.5
171
310
363
83
588
41.6
39.1
36.9
35.5
34.2
36.9 – 46.7
35.7 – 42.6
33.9 – 40.0
29.3 – 41.8
32.0 – 36.6
82
177
225
83
332
38.1
33.9
34.7
33.7
30.9
31.7 – 42.0
29.9 – 38.2
31.1 – 38.5
27.9 – 40.1
28.1 – 33.8
110
467
938
31.6
36.8
37.2
26.7 – 36.7
34.2 – 39.6
35.3 – 39.1
122
408
369
34.7
35.2
30.9
27.7 – 39.9
32.5 – 38.0
28.3 – 33.6
Self-perception of overweight
JL Gutiérrez-Fisac et al
Table 3 Percentage of women with BMI 25 kg=m2 who did not perceive their overweight, by age, educational
level, size of place of residence and leisure-time physical activity in 1987 and 1995=1997
1987
Total
Age (y)
20 – 34
35 – 49
50 – 64
65 and over
Educational level (maximum level reached)
Elementary
Secondary or higher
Size of place of residence (population)
< 10 000
10 001 – 100 000
100 001 – 400 000
400 001 – 1 000 000
Over 1 000 000
Leisure-time physical activity
Vigorous or moderate
Light
Sedentary
a
869
1995=1997
a
a
n
%
95% CI
n
%
95% CI
464
16.5
15.1 – 17.9
324
17.7
16.0 – 19.5
77
115
153
119
18.7
13.3
14.8
23.3
15.1 – 22.9
11.2 – 15.8
12.7 – 17.1
19.7 – 27.1
27
70
98
129
8.7
13.8
16.0
31.7
5.9 – 12.6
11.0 – 17.2
13.3 – 19.2
27.3 – 36.5
422
42
16.4
17.2
15.0 – 17.9
12.8 – 22.7
282
42
19.1
11.7
17.2 – 21.3
8.6 – 15.5
49
78
110
29
198
19.1
17.8
17.5
18.0
14.8
14.7 – 24.7
14.3 – 21.6
14.6 – 20.7
12.3 – 24.8
13.0 – 16.9
37
63
80
20
124
27.8
18.1
18.8
13.2
16.0
20.6 – 36.4
14.3 – 22.6
15.3 – 22.9
8.4 – 19.8
13.5 – 18.8
6
91
367
14.3
15.7
16.7
5.4 – 26.9
12.8 – 18.9
15.2 – 18.3
11
121
192
9.6
16.9
19.1
5.1 – 17.0
14.3 – 19.9
16.7 – 21.7
95% CI: 95% confidence interval.
49% in 1997, we observe a high percentage of persons who
did not perceive themselves to be overweight or obese. In
1995=1997, around 27% of adults with BMI 25 kg=m2 did
not perceive their weight to be abnormally high.
A phenomenon of possible importance from the perspective of health is the prevalence of misperceived overweight
by BMI. As shown in our results, the prevalence of misperceived overweight decreases with increasing BMI, so that the
highest percentages occur among individuals with more
moderate levels of overweight. Thus, in 1995=1997, around
50% of men and 30% of women with a BMI between 25 and
26.9 did not perceive their weight as abnormally high. If the
next category of BMI is added to this, 42% of men and 25%
of women with a BMI between 25 and 28.9 did not perceive
themselves to be overweight. This high prevalence is extremely important given that the largest percentage of the
population is concentrated in the more moderate categories
of overweight. Although a BMI between 25 and 26.9 has only
a small risk of health-related problems, with a slightly higher
risk for a BMI between 27 and 29.9 (Calle et al, 1999), it is
also the fact that moderate overweight is understood to be
one of the main risk factors for obesity. In addition, it is
relatively easier to lose weight at these moderate levels than
at higher levels of overweight. Thus, persons with a BMI
between 25 and 29 kg=m2 who do not perceive themselves to
be overweight may be a target group for programmes and
strategies aimed at reducing obesity in the population. Such
programmes should consider the importance of the individual being able to detect these moderate levels of overweight, knowing the associated risks and being able to
implement a series of measures to reduce body weight.
The results obtained also show some interesting sociodemographic variations. With regard to sex, while 33% of men did
not perceive themselves to be overweight (1997), the percentage was 18% in women. This difference (also observed in
the 1987 data) is similar to that obtained in a Polish population, in which 24% of men and 14% of women who were
overweight perceived their weight as normal (Gorynsky &
Krzyzanowski, 1989). Other studies also show that women
are less likely to misperceive their overweight than men
(McElhone et al, 1999; Blokstra et al, 1999; Steward &
Brook, 1983; Wright & Whitehead, 1987). This different
perception between the two sexes could be related to certain
social and cultural factors. It is well known that social and
family pressures to maintain a body image in accordance
with reigning values, which equate beauty with a slender
figure, affect women more strongly than men (Craigh &
Caterson, 1990; Bowen et al, 1991). This fact may lead
them to have a more accurate perception of their overweight
than men.
The differences in perceived overweight between the sexes
could also be related to an important epidemiological phenomenon. In general, obesity is more frequent among
women. In recent years, however, an increasing trend is
beginning to be seen in several developed countries, in
which the prevalence of obesity is higher in men than in
women (Flegal et al, 1998; Gutiérrez-Fisac et al, 2000; Galuska
et al, 1996; Jeffery et al, 1991). In this regard, women’s
stronger perception of their overweight may lead them to
maintain greater weight control. This shows the importance
of considering the male adult population as a high risk group
for developing obesity associated with misperceived overweight.
European Journal of Clinical Nutrition
Self-perception of overweight
JL Gutiérrez-Fisac et al
870
Figure 2 Misperceived overweight and obesity (in %) by BMI, for men
and women aged 20 y and over in 1987 and 1995=97.
With regard to age, the greatest frequency of misperceived
overweight is observed in adults aged 65 and over, which is
similar to the results of other studies (Gorynsky & Krzyzanowski, 1989; Blokstra et al, 1999). The explanation for this
may be that older persons are less concerned about body
image than those who are younger, which would undoubtedly reduce their perception of overweight. The greater
misperception of a certain degree of overweight in the
older population may also be related to the increased prevalence of overweight and obesity that occurs with age. This
increase is falsely understood to be inevitable or natural
(Grundy, 1998), which may reduce the perception of overweight in adults over a certain age. Measures to increase
consciousness of the fact that the weight gain with age is, in
European Journal of Clinical Nutrition
part, avoidable could increase the perception of overweight
in older persons and thus reduce the prevalence of overweight and obesity in these population groups.
Another result that should be highlighted is the enormous
difference in the prevalence of misperceived overweight
between young men and women. In 1997, 35% of men
aged 20 – 34 y did not perceive themselves to be overweight,
whereas in women the percentage was 9%. This difference
could be due not only to women’s greater concern with body
image, as previously discussed, which would be more important at young ages, but also to methodological questions. It
is well known that BMI cannot distinguish between overweight due to fat and that due, for example, to highly
developed muscle mass (Roche & Chumela, 1992). Since
developing muscle mass is more important for men than
for women, especially among young people, part of the
difference observed in the non-perception of overweight
could be due to the fact that a smaller percentage of the
younger men were truly overweight, thus fewer of them
would recognize it. This same argument may explain why
the age trend in the prevalence of misperceived overweight is
not maintained and why, in women (only in 1987), but
especially in men (particularly in 1995=1997), the prevalence
in persons 20 – 34 y is greater than in older age groups.
Another sociodemographic variation seen is the higher
prevalence of misperceived overweight in rural than in
urban areas. Although the results of obesity prevalence
studies are inconclusive regarding variations by population
size (which seem to change according to a country’s level of
development), urbanization is generally found to be a risk
factor for overweight and obesity (Grundy, 1998). The higher
prevalence of misperceived overweight in rural areas may be
related to the fact that in these areas obesity as a health
problem is still poorly understood.
With respect to educational level, the prevalence of misperceived overweight is generally higher in persons with
elementary education than in those with a higher educational level, a result which agrees with the results of other
studies (Gorynsky & Krzyzanowski, 1989; Blokstra et al,
1999). These differences are more notable in women,
among whom an upward trend is observed: whereas in
1987 there were no differences between the two groups, in
1997 19% of the women with elementary education did not
perceive themselves to be overweight, while this percentage
was 12% in those with higher level education. The higher
prevalence of misperceived overweight and obesity in persons with a lower educational level is consistent with the
data on the prevalence of obesity, which is also more frequent in this group. Furthermore, the greater differences
among women remind us again of the possible importance
of social and cultural factors. Social pressures to maintain a
body image in accordance with accepted social values would
have a stronger effect among women in the higher socioeconomic levels, which would lead them to be more aware of
excess weight (Bowen et al, 1991). The increase between the
two periods studied of the prevalence of misperceived over-
Self-perception of overweight
JL Gutiérrez-Fisac et al
871
weight and obesity in women with low educational level
(and the decline in those with higher educational level) may
also help to explain why the prevalence of obesity is increasing among women with low educational level (GutiérrezFisac et al, 2000). The lack of concern or consciousness about
excess weight (sometimes just beginning to appear) could
lead to an increase in the prevalence of overweight and
obesity in the short and medium term.
One of the main reasons suggested to explain the differences in obesity by socio-economic level is dietary restriction, defined as the conscious control of eating behaviour
(Sobal & Stunkard, 1989). Persons of a higher socio-economic level more frequently diet to lose weight, and this
phenomenon is especially important in women. Women of
high socio-economic levels make greater use of weight loss
measures, and this may be related to their greater perception
of overweight. This more acute perception of overweight,
together with the fact that they are better able to pay the
costs that weight control measures usually involve, could
explain why women of a high socio-economic level are able
to control their weight better and thus have a lower prevalence of overweight and obesity.
This study has some methodological limitations. BMI,
which was the model used to test the correct perception of
overweight and obesity, is based on self-reported weight and
height, and therefore, several sources of bias could have been
present: first, overestimation of height; and second, an
underestimation of weight (Roberts, 1995). Both may have
resulted in an underestimate of BMI, which is known to be
more pronounced in women and in persons of a low educational level (Nieto-Garcı́a et al, 1990). Underestimation of
overweight would have led to some overweight persons not
being included in the study sample (BMI 25 kg=m2).
Because it could be expected that most such persons do
not recognize their overweight (since they would have moderate levels of overweight), the prevalence of misperceived
overweight and obesity in the present study is likely to be an
underestimate. On the other hand, it is quite remarkable
that, even when BMI is self-reported, there is such a large
percentage of persons who do not recognize their overweight.
There is the possibility for certain degree of bias in the
response to the question about weight being ‘normal’. This
information, however, is subjective and aimed to determine,
precisely, the subject’s perception of their weight. Thus, the
bias that could have occurred, if any, is unknown. Finally,
changes in the validity of self-reported weight and height,
and in the perception of ‘normal’ weight, over the study
period, should also be considered. We have assumed, because
we are not aware of any evidence against, that the validity of
self-reported weight and height remained constant from
1987 to 1997. As regard perception of ‘normal’ weight, any
change over the study period should allow more people to
recognize their overweight in 1995=1997 than in 1987, due
to an increased interest in body image in accordance with
dominant social values (Croft et al, 1992). Hence, it could
lead to a decrease in the percentage of people who do not
perceive themselves as overweight, making our estimations
conservative.
Two important conclusions can be derived from the present study. First, a considerable proportion of persons do not
recognize a certain level of overweight, a necessary condition
to becoming conscious of the need for healthy weight loss. It
is in these more moderate levels of overweight that a treatment based on moderate dietary restriction and increased
physical activity can more effectively reduce the prevalence
of overweight, which is, in the final analysis, the main
predisposing factor for overt obesity, a condition much
more difficult to control. Second, the population groups
with the greatest misperception of their overweight are
men, older persons, those who live in rural areas, and
women with elementary education; these are the groups
among whom educational programmes could be most effective. Such programmes should focus on improving consciousness of the risks associated with moderate overweight
(the risk of various health problems and especially the risk of
overt obesity in the long run), as well as on the importance
of recognizing overweight, even when it is moderate.
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