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= Prevalence and Perceptions of Obesity: The Epidemic Affecting the World =

More than one billion adults across the globe are overweight, and at least 300 million are clinically obese (Wilborn, 2005). As the rate of obesity continues to rise, stronger perceptions of obesity are established within countries plagued by the disease. Perceptions are largely influenced by cultural determinants as well as the rate of obesity within subpopulations. The top three immigrant populations within the United States are India, China, and Mexico. It is important to understand the prevalence and perception of obesity within the U.S. and use the United States as a baseline in order to analyze how obesity is viewed within those countries of high immigrant populations to the United States. Also, given that the Latino population is the highest immigrant population in the U.S., it is vital to look at them as a subset within the United States as well.

Introduction
Obesity in America has reached epidemic proportion. It adversely affects the rates of chronic disease, quality of life and health economics in this country. Data from the 2015-2016 National Health and Nutrition Examination Survey, show that the prevalence of obesity was 39.8% among adults ages 20 and older and 18.5% among children in the United States (Centers for Disease Control and Prevention, 2017). In the U.S., rates of obesity continue to rise in many populations, with few signs of substantial slowing. If America's obesity trend continues at its current pace, all 50 states could have obesity rates above 44 percent by 2030 (Trust for America's Health, 2012). As the rates of obesity increase, the perception of obesity is changing in response. More people are becoming aware of the co-morbidities associated with the disease and there is an increase in body weight stigmatization.

History
Before the second half twentieth century, obesity was highly desirable and was considered a symbol of health, wealth, prosperity, and strength in America. This perception dates back centuries, when there was never a long period of uninterrupted food abundance and famines were frequent. As a result, fat accumulation, when food was available, meant survival in times of shortages. Natural selection rewarded the “thrifty” genotypes of those who could store the greatest amount of fat from the least amount of available foods and release it as frugally as possible over the long run. Thus, being obese was highly desirable and often linked to extreme wealth, as these individuals had access to resources to survive famine. Even in the 18th century when industrialization hit America and brought changes in farming and more bountiful harvests, perceptions of obesity did not change. It was not until the second half of 20th century that perceptions started to change and obesity formerly seen as desirable, started to be seen as undesirable. This shift in attitudes towards obesity in the U.S. was largely due to the discovery that obesity was linked to a myriad of health problems. The 20th century was the time when the study of fat became an acceptable scientific pursuit, and numerous researchers began to unlock obesity’s secrets. At the same time, the rates of obesity in this country continued to rise as a result of the “obesogenic environment.” As researchers continued to discover the harmful effects of obesity and the tremendous toll it had to the health of its victims, there was a simultaneous increase in the negative view of being obese (Eknoyan, 2006). Currently, weight bias in the U.S. is at an all time high. In fact, a national survey conducted in 2018, found that 34 percent of Americans say they or someone they know is dealing with the issue of “fat shaming,” a term that describes the act of humiliating someone based on their weight by making mocking or critical comments about their body size (Ethicon, 2018). Another study finds that the prevalence of weight discrimination has increased by 66% over the past decade in America (Fruh et al., 2016). Thus, the perceptions of obesity has changed drastically over time, from being desirable to now being loathsome.

Childhood Obesity
Childhood obesity rates have tripled in the last 30 years and have reached an all-time high. The CDC reported that in 2015-2016, the prevalence of childhood obesity in America was 18.5% and that this rate is rapidly growing each year (Centers for Disease Control and Prevention, 2017). Americans are concerned about the epidemic of obesity in children and there is strong public support for interventions aimed at reducing overweight and obesity among children and adolescents. However, some parents have a hard time identifying their child as being obese. In a recent systematic review, it was found that parental misperception is common, with as much as 62.4% of overweight/obese children being incorrectly perceived by their parents as having normal weights (Rietmeijer-Mentink et al., 2012). Parents, especially those from low-income families, described their overweight children as “solid” or thick”. This misclassification of children’s weight could be a result of the fact that weight norms for children have risen so dramatically over the past three decades. It can also be attributed to fear of their children being stigmatized, a harsh reality for the obese population in America. This could be problematic however, as parents who do not identify their children as overweight or obese, would be less motivated to help their children improve their diet to promote a healthy body weight (Jain et al., 2001).

Gender
Obesity rates in America differ by sex with with females have slightly higher rates of obesity at 41.2 % versus 38.1% for males (Centers for Disease Control and Prevention, 2017). Not surprisingly, the perception of obesity also varies by sex. A recent study using the NHANES data showed that in general, obese women are more aware of their current weight status than men. Furthermore, the study found that women are more likely to overestimate their weight than men are. The study also highlighted that men are more likely to underestimate their weight (Infoplease, n.d.). In fact, obese men are less likely to identify themselves as obese when compared to obese women (Oldham & Robinson, 2017). It only takes a small weight gain for women to experience weight discrimination but men can gain significant amounts of weight before experiencing similar bias. Women are twice as likely to report weight discrimination and weight-related workplace bias and interpersonal mistreatment due to obesity. Taken together, these findings underscore the notion that society has thinner standards and is less tolerant of weight gain in women as compared to men. Current societal norms in the U.S. as represented and propagated in the media continue to portray the ideal women as thin. This is not the case for men. As a result, obese women in the U.S. experience a higher rate of stigmatization in comparison to men and obesity is a greater social burden for women (Puhl, Andreyeva, & Brownell, 2008).

Acculturation of Latino American Immigrants & Perceptions of Obesity
Immigrant populations living in the United States are confronted with new, oftentimes more stringent cultural norms related to body weight. Many Latino Americans for example, who were considered to be normal weight in their home country feel overweight and self-conscious in the United States where thinness is considered beautiful and weight is more heavily stigmatized despite the rising prevalence of obesity in America. Immigrant populations that want to assimilate feel an added pressure to fit the mold of a certain body shape and size that society deems to be socially acceptable. And despite added pressure to maintain a healthy weight, immigrants must adjust to a new built environment that is oftentimes more obesogenic than the place from which they emigrated, which makes it extremely difficult for them to achieve these weight standards. Consequently, the prevalence of obesity among Latino American immigrants is higher (38.7%) compared to 32.8% for non-Latino whites and Latina women are even more disproportionately affected by obesity with a prevalence of 45.1% compared to 35.5% for all women (Agne, Daubert, Munoz, Scarinci, & Cherrington, 2012).

Many Latina women experience a shift in cultural norms from body acceptance in their home country to body dissatisfaction and a desire to lose weight in America. Agne, Daubert, Munoz, Scarinci, & Cherrington (2012) conducted focus groups of twenty-five Latina immigrants who were recruited from a community hospital in Jefferson County, Alabama in 2009. They measured constructs of the Health Belief Model to explore their perceptions of obesity as a function of length of time in the United States and level of acculturation based on language preference in childhood, day-to-day living, media, and social relationships (Agne, Daubert, Munoz, Scarinci, & Cherrington, 2012).

Many participants perceived themselves to be more susceptible to obesity since moving to the United States due to changes in diet and physical activity, stress, social isolation, and depression. In terms of severity, participants associated overweight and obesity with physical discomfort such as breathlessness, fatigue, and low energy and reduced mobility. Looking good and acting as a good role model for their children were identified as the benefits of maintaining a healthy body weight, but there was no mention of reduced risk for obesity-related illnesses, which could indicate a dearth of health awareness/knowledge about the long-term health consequences of obesity. Lack of sidewalks, availability of public transportation, and America’s ‘culture of driving’ were identified as barriers to physical activity. Barriers to healthy eating include availability of processed foods that are quick and convenient, the high cost of alternative fresh foods, children’s preference for unhealthy American snack foods, and loss of structured mealtime due to changing work and school schedules. Finally, participants cite a general lack of social support to exercise and eat healthy in the Latino community as well as spousal tolerance for a higher weight. One participant explains, ‘‘It seems like well that’s the way my husband loves me and I feel fine and we keep eating” (Agne, Daubert, Munoz, Scarinci, & Cherrington, 2012, pg. 1066).

Martinez, Powell, Agne, Scarinci & Cherrington (2012) conducted focus groups of 16 Latino immigrant men to explore their perspectives on weight, diet, physical activity, perceived susceptibility to obesity and obesity-related illness, and perceived barriers and facilitators to healthy living. Men defined obesity in terms of the physical burden of carrying too much weight and associated it with feelings of lower self-esteem and social rejection. Improved mobility and decreased morbidities were identified as benefits to maintaining a healthy weight. Harassment by law enforcement while walking and the heavy reliance on cars as the primary mode of transportation were seen as factors inhibiting healthy weight management. As one study participant put it: “We don't walk here. You don't get out of (the car) for anything, not even for food! You go through a drive‐thru…same for the pharmacy or the bank” (Martinez, Powell, Agne, Scarinci & Cherrington, 2012, pg. 496). Other perceived barriers to a healthy weight included demanding work schedules, fear of losing employment, and fatigue from physical labor, which precluded additional forms of physical activity after work hours. Men referred to women as the nutritional gatekeeper of the home with the power to determine what and how much is prepared and expressed an obligation to overeat as a sign of appreciation and respect. As one participant puts it, “The mother has the absolute power in the kitchen” (Martinez, Powell, Agne, Scarinci & Cherrington, 2012, pg. 495). Another mentioned that when women begin working outside of the home, they are not able to cook as many homemade meals prompting families to choose fast food or other unhealthy, yet convenient meal options to feed the household.

Cultural perceptions of obesity among immigrant populations living in America are important to consider in order to design effective obesity prevention and control strategies for this vulnerable population that is disproportionately affected by the obesity epidemic in the U.S. For example, the qualitative interviews revealed that a family-based approach is preferred by Latino Americans so future public health initiatives should seek to involve adults, kids, and their broader social networks. It seems there is a lack of education about obesity-related illnesses among the Latino immigrant community so it would be wise to include an educational component as well. Finally, women expressed their family’s preference for traditional foods so any meal plans created or dietary advice given should try to incorporate these foods.

American immigrants are forced to reconcile their desire to fully immerse themselves in American culture by adopting the norms, values, and customs (many of which are actually obesity-promoting) and their desire to meet societal expectations of body shape and weight. It is a conundrum that all Americans face, but is particularly burdensome for immigrant populations who are trying to navigate this already difficult transition and who so desperately want to feel accepted by American society.

Introduction
A country traditionally known for malnutrition, is now facing increasing rates of people who are overweight or who have obesity. With this shift, the country has also developed new public health consequences, including a rise in metabolic syndrome and type-2 diabetes. Other concerns include the direct link between obesity and high blood pressure, cardiovascular disease and osteoporosis. Although obesity is a global epidemic, India is in the unique, and somewhat alarming state, of having to deal with overnutrition at the same time as they are grappling with continued issues of malnutrition (Kalra & Unnikrishnan, 2012).

History
Diet and the malnutrition epidemic in India can be traced back to British colonial rule. The people of India relied heavily on their crops as sources food, creating great hardship in times of poor weather. The Great Famine of 1876-1878, which is also often called the Madras Famine of 1877, occurred due to an intense drought that resulted in crop failure across much of south and southwestern India. The famine spread up to the north in its second year resulting in a death toll that was estimated to be in the range of 5.5 million residents (BBC News, 2016). Finding crops that could withstand the harsh weather of various parts of the country was becoming harder and harder. Diseases, like scurvy and rickets, related to poor nutrition and health began to run rampant across the country (Arnold, 1994). The entrenched history of famine and poverty in the country persisted and continues to be the image of the country. However, more recently there has been an increase in obesity to alarming extents.

Industrialization has had a large impact on the ways in which the population’s diet and priorities have changed. Despite its reputation for being unfavorable to foreign businesses, India has increasingly added American fast-food chains to its cities. The younger population in the country is welcoming the new trend with open arms, allowing for greater expansion. McDonald’s, for example, is adding a coffeehouse-style chain, which is called McCafe (Bagri, 2014). The country has seen a shift the popularity of fast-food in India today.

Childhood Obesity
According to an article written in The Times of India,“Between 1990 and 2014, the number of overweight children in low and middle in income countries has more than doubled from 7.5 million to 15.5 million”, and “almost half (48%) of all overweight and obese children under 5 years of age lived in Asia” (TNN, 2016). A study conducted in 2004, used the WHO standards to classify overweight and obese categories in order to better understand the prevalence of the two in India, specifically. The results found that the prevalence of obese children is 11.1% and 14.2% for overweight children between the ages of 9 and 15. The research also found a greater prevalence is higher in boys than girls, with about a 3% difference (Chhatwal et al., 2004). In addition to the differences among gender, it became apparent through the research that more children of higher socio-economic status suffered greater prevalence of overweight and obese. The researchers stated that “Pediatric obesity is an emerging problem in developing countries, especially among higher socio-economic status groups. Significant gender disparity is seen, with boys of affluent background having a higher prevalence” (Chhatwal et al., 2004).

Gender
Unlike the gender differences found among pre-adolescent and adolescent populations, where boys are more likely than girls to be obese, studies have shown that opposing trends later in life. For example, a study conducted by researchers Sanjay Kalra and AG Unnikrishnan, used a cross-sectional study to find the prevalence of obesity in India. Obesity was found to have a higher prevalence in females over males (Kalra & Unnikrishnan, 2004). Additionally, “the percentage of women who are overweight or obese is highest in Punjab (30%), followed by Kerala (28%) and Delhi (26%), all of which are relatively richer states” (Kalra & Unnikrishnan, 2004).

Introduction
As this obesity epidemic becomes more and more of a developing world problem, China and its own problem follows this trend as there are large increases in the amount of obese citizens. As of 2006, about one fifth of the one billion overweight or obese people in the world were Chinese (Wu, 2006). Compared to other countries, especially the United States, China had a relatively low percentage of obesity years ago, but the very alarming news is how rapidly this country is rising in ranks now. Since 2017, China has the world’s biggest population of obese children and is second only to the United States in the number of obese adults (Pinghui). This trend will continue to increase due to how vast the country is in size and in the number of people living there. More importantly, the cities have a greater percentage since there much more populated compared to the rural parts and the abundance of fast food restaurants.

With the large increase in weight, there follows a large increase in cardiovascular diseases, obesity-related cancers, type 2 diabetes, high blood pressure and more with the Chinese people. The problem is that the population does not have enough awareness and lacks knowledge of nutrition and what constitutes a reasonable diet. The government is attempting to reduce the problem with building more playgrounds, passing a law which requires students to exercise or play sports for an hour a day at school and restricting the amount of fast food outlets. For the country, there are so many actions that are needed to be taken to improve the lives of the Chinese and slow down and stop this obesity epidemic.

History
In the past, China was once considered to have one of the leanest populations. These attitudes and beliefs largely stem from the historical context of famine and poverty in China, where being slim represented poverty and poor health. Malnutrition, previously a persistent problem under the leadership of Mao Zedong, has declined from 30% of the population in 1980 to less than 12% in 2014. The rapid improvements in living standards, such as availability and accessibility, have come with rising rates of obesity that threaten to reverse some of the gains in overall health.

Many Chinese people have always looked and will always look to the way they advance in life is getting a better education, so they can get a better job. Having a better job usually correlates with a greater salary, which falls into the following cycle of people eating more unhealthy foods as described in the next paragraph. The heavy emphasis on schoolwork and the pressure to do so much into that direction keeps children away from play and from physical activity.

Chinese modernization over the past 20 years has changed the economic landscape dramatically, with major increases in economic development and wealth. As has been seen in low- and middle-income countries around the globe, economic development is soon followed by obesity (Gordon-Larsen, 2014). In the last decade, changes in diet and activity in China have occurred more rapidly than previously recorded for any country and have included increased intake of edible oils, fried foods, animal-source foods, and snacking as well as declining occupational, domestic, and travel activity and increasing TV time (Gordon-Larsen, 2014).

Childhood Obesity
At present, obesity has become a global public health concern that has jeopardized the health of children, more specifically, in China. The Physical Fitness and Health Survey of Chinese Students in 2000 showed that 10.7% and 5.0% of urban boys and 6.3% and 2.8% of urban girls were detected with overweight and obesity (Guansheng). In comparison, 4.2% and 1.7% rural boys and 3.5% and 1.1% rural girls were found to be overweight and obese (Guansheng). The same survey in 2014 found that the overweight and obesity detection rate for urban boys and girls from 7 to 18 stood at 17.1% and 11.1%, and 10.6% and 5.8%; while, 12.6% and 7.7% of the rural boys and 8.3% and 4.5% of the rural girls were detected with overweight and obesity (Guansheng). If this problem persists with no treatment or policies, the detected obesity rate among children from 0 to 7 will hit 6.0% and the number of obese children will grow to 6.7 million (Guansheng).

Gender
As previously shown through the numbers, boys had higher odds of being overweight and obese compared to girls within both urban and rural areas. The majority of the obese children of different sex at younger age are first mildly obese. However, the proportion with moderate and severe obesity rising with the older age groups. Severe obesity is mainly found with the children after three years old and more in boys than girls. Adolescent boys more likely had energy intake exceeding recommendations, self-perceived underweight, underestimated their body weight, and were satisfied with their physical activity level than adolescent girls (Wang, 2018). These adolescent girls practiced weight loss management more through diet and self-perceived overweight than the boys (Wang, 2018). Mothers more likely identified their daughters’ weights accurately but underestimated their sons’ weights (Wang, 2018).

Introduction
According to the Food and Agriculture Organization of the United Nations, the obesity rate in Mexico has surpassed that of the United States. In 2017, an estimated 32.8%, or one third, of the population in Mexico was obese, with 70% of the population considered either obese or overweight (Easton, Stephen, & Sicilia, 2017). And the country has also experienced an increase in obesity-related illnesses such as cardiovascular diseases, type 2 diabetes mellitus, osteoarthritis, and certain cancers (DiBonaventura, Meincke, Lay, & Fournier,  2017). The increase in rates of obesity is largely due to high importation of unhealthy foods, increased consumption of calorie dense foods, and sedentary lifestyles.

There are programs and treatment options available in Mexico to help in reducing the incidence and prevalence of obesity in the country. But these programs and services are underutilized due to lack of self-awareness about obesity, which is caused by self-perception of body weight. And self-perception of body weight in Mexico is largely influenced by cultural beliefs, values, and norms.

History
For centuries, being overweight was viewed as a sign of health and wealth in Mexico, while being normal and underweight was viewed as being poor and malnourished. Mexico’s perception of weight and body image was largely due to high rates of poverty and distribution issues. But the perception of overweight is slowly changing in Mexico with the increase in obesity rates in the country. Interventional efforts and an increase in awareness about the health implications of obesity has influenced people’s perception of weight. Though many Mexicans, especially the older generation, still view being obese and overweight as more ideal compared to being normal and underweight and equate having an overweight child to being a good parent (National Institute of Health, 2012). Because of these beliefs, mothers are under increased pressure to overfeed and keep their children overweight despite knowing the health implications. Weight perception is slowly changing, especially among people for higher socioeconomic status. Change in weight perception is mainly due to higher educational attainment and increased access to healthier foods.

Childhood Obesity
The prevalence rate of childhood obesity is rapidly increasing in Mexico. Today, approximately 13% of Mexican children are obese, and over 35% are considered overweight (BBC, 2018). Several intervention efforts have been carried out in Mexico to prevent and reduce childhood obesity. However, existing interventional efforts are limited by individual motivation to change, which is influenced by self-awareness, self-perception, and cultural and familial attitude towards obesity.

For years, there was a huge underestimation of children’s weight status in Mexico due to cultural beliefs. Weight status underestimation is still common in many places in Mexico, especially in populations with high prevalence of obesity (Rendon-Macias, Rosas-Vargas, & Villasis-Keever, 2014). Medium and low-income families in Mexico still equate chubbiness in children to health and good living. Parents from these socio-economic classes view overfeeding children as an act of love and care and encourage children to eat more than the daily recommended amount and look heavier in order to fit into societal norms. Such beliefs and practices influence a child’s weight, obesity, and body image perception, and jeopardizes the success of any childhood obesity intervention efforts in the country. Study results from a survey conducted in an elementary school in Mexico showed that many obese children saw no difference between obese and non-obese people, and did not believe that obesity can negatively affect the quality of life in adulthood (Rendon-Macias, Rosas-Vargas, & Villasis-Keever, 2014).

Gender
Weight, obesity, and body image perception also differ by gender in Mexico. A study conducted in a rural area of Mexico showed that men are more likely than women to underestimate their weight status. Overweight and obese men perceived themselves as thinner and more normal weight, while women perceived themselves to be heavier. The difference in weight and obesity perception is due to cultural norms as well as social stigmatization. In this area of Mexico, obesity is more stigmatized in women than in men, hence the difference in weight estimation.