NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS

Journal of Advanced Nursing
Dimensional analysis of the concept of obesity
ISSN: 0309-2402
Accession: 00004471-200605030-00013
Full Text (PDF) 88 K
Author(s):

Davidson, Maryanne MSN RN CPNP; Knafl, Kathleen A. PhD FAAN
Issue:
Volume 54(3), May 2006, p 342–350
Publication Type:
[NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS]
Publisher:
Copyright © 2006 Blackwell Publishing Ltd.
Institution(s):
Doctoral Student, Yale University School of Nursing, New Haven, Connecticut, USA (Davidson)
Elisabeth N. Gray Distinguished Professor and Associate Dean for Research and Faculty Affairs, School of Nursing, Oregon Health and Sciences University, Portland, Oregon, USA (Knafl)
Correspondence: Maryanne Davidson, Doctoral Student, Yale University School of Nursing, 100 Church Street South, PO Box 9740, New Haven, CT 06536-0740, USA. E-mail: maryanne.davidson@yale.edu
Accepted for publication 13 October 2005
Keywords: concept analysis, culture, dimensional analysis, meaning, nursing, obesity, perspective
Abstract

Aim: The aim of this paper is to explore the evolution of the concept of obesity and to identify variations in its meaning and use from the perspectives of healthcare professionals and Black Americans, Caucasian Americans, and Latino Americans.

Background: Obesity constitutes an emerging global healthcare epidemic. Little convergence is found between the meaning and use of the concept of obesity by healthcare professionals and those they are trying to serve. This lack of convergence points to the need for exploration of the assumptions, use and various meanings associated with this important concept.

Method: The analysis included 20 papers from 18 research studies from the fields of nursing, psychology, epidemiology, medicine, and sociology. Caron and Bowers' dimensional analysis method guided the analysis.

Results: Eight dimensions were identified: objective measure, attractiveness, sexual desirability, health, body image, strength or goodness, self-esteem, and social acceptability. Substantial differences in assumptions, use, and meanings of this concept were found within and between the perspectives studied. However, there were insufficient data to fully assess use and meaning of the concept of obesity from the Latino American perspective.

Conclusion: This analysis contributes to the development of an understanding of the meaning and use of the concept of obesity within varied socio-cultural contexts as well as from a healthcare perspective. Culture was found to play a significant role in how obesity is understood by the individual.

Introduction

Obesity is an emerging worldwide healthcare epidemic. The World Health Organization estimates that globally there are at least 300 million obese adults and another 1 billion adults who are overweight (World Health Organization 2005). Obesity rates range from below 5% in China, Japan, and some African nations to >75% in urban Samoa (World Health Organization 2005). The International Association for the Study of Obesity (2005) estimates that the prevalence of obesity has increased from 10% to 40% in the majority of European countries. Recent data also suggest that 54% of the adult population of the United States of America (USA) is obese or overweight (Fitzgibbon et al. 2000). Across cultures, women appear to be particularly affected. Obesity rates for non-Hispanic black women are reported at 37.4%, 34.2% for Mexican American women, and 22.4% for non-Hispanic white women (Fitzgibbon et al. 2000). The amount of associated obesity-related morbidity is staggering and includes diabetes, high blood pressure, high blood cholesterol, asthma, and some cancers (Pi-Sunyer 1991, Must et al. 1999, Mokdad et al. 2003). It is imperative that researchers and healthcare providers understand the meaning and use of the concept of obesity by people in different cultures in order to allow the development of culturally appropriate prevention and intervention strategies.

Healthcare providers and researchers typically define obesity in physiological terms as the Body Mass Index. There is no reason to believe, however, that this concept is shared by the people they serve. In fact, it could be argued that obesity is as much 'in the eye of the beholder' as is beauty. This gap between scientific and lay understandings of obesity has led to growing recognition of the need to place the concept in a socio-cultural context (Balcazar & Cobas 1993, Kumanyika et al. 1993, Walcott-McQuigg et al. 1995, Miller et al. 2000). Although a frequently used term in both social and healthcare contexts, obesity appears to be an example of a concept which is presumed to be understood but has not been explicitly defined in its everyday sense. Different cultural groups also appear to have different notions of obesity. Such differences are found both in research and lay literature, yet little is known about the evolution, use, or essential elements of the concept. There are no known analyses of the concept of obesity.
Background

Cultural anthropologists report variations in amount of body fat since the beginning of time. Weight is dependent on such factors as climate, agriculture and hunting. History is replete with instances of preoccupation with weight. For example, the Spartans are reported to have ostracized a man for being fat, and Socrates is reported to have danced each morning to keep his weight within reason (Beller 1977). Excess weight was then a common concept, but where did the present concept of obesity originate?

The origin of the concept of obesity in the United States of America (USA) appears to rest in the hands of the insurance industry. It was in studies published in 1912 that tables of height and weight were first introduced which defined 'average' and acceptable standards of weight for US adults. In 1959, the Build and Blood Pressure Study was the basis for revised insurance company tables. These new tables replaced those of 1912, and replaced 'average' weight standards with 'ideal' weights. Obesity was thus defined by weight in excess of 20% above ideal body weight. By this time, medicine had begun to document the strong association between weight, morbidity, and mortality; individuals were placed at increased risk of disease if they fell outside the ideal weight range, the high end of the range being classified as 'obesity'. Using these tables in 1959, 40% of the adult female population was deemed seriously overweight (Hutchinson 1959).

The earliest reference to obesity in the field of nursing was found in 1966 in the Nursing Mirror and Midwives Journal, and nine papers were found in nursing journals between 1966 and 1971. Most were written by physicians and covered topics related to aetiology and weight loss. Only one paper from a Registered Nurse (RN) addressed the role of nurses in promoting weight control. The paper by Dowling (1967), 'Your obese patient may not be able to reduce', was published in 1967.

Nursing-directed research on the topic of obesity was not found in the literature until Laffery published a study in 1986, but nursing is now making significant contributions to the study of obesity. Much of the current nursing research assumes the biomedical definition of obesity introduced by the insurance industry in 1959, but it is not limited to this definition. Nursing also is expanding the focus beyond aetiology and treatment to family, cultural, and community factors influencing health behaviours in the obese population.
The study
Aim

The aim of this concept analysis was to explore the evolution of the concept of obesity and to describe variations in the meaning and use of the concept from the perspectives of Black Americans, Caucasian Americans, Latino Americans, and healthcare providers.
Method

A dimensional analysis (Rodgers & Knafl 2000) was the preferred approach. This is a method of concept analysis that emphasizes generation of knowledge of how concepts are socially constructed and how they vary across perspectives and contexts. Through the identification of variations in use of the concept, meanings in these culturally situated contexts can be understood. This method also provides a structure to explore further the relationship between conceptual context and meaning (Rodgers & Knafl 2000).

Dimensional analysis examines both explicit definitions/descriptions of the concept, as well as how the concept is used. The method requires exploration of all the ways the concept is used and the consequences of its use. Context and perspective are used to explain how the concept is constructed and under what conditions it varies in meaning.

Caron and Bowers (2000) provided the structure for this analysis. They suggest that dimensional analysis is to be used when the goal is to 'understand the conceptual nature and evolution of concepts, and the fluidity of concepts across perspectives and contexts' (2000, p. 291). This method also allows for 'insight into the relationships among the concept (as object or social definition) and the social, historical, cultural influences resulting in predictable and patterned variations' (2000, p. 292).

The perspectives of Black Americans, Caucasian Americans, Latino Americans and health professionals were analysed. The use of the concept of obesity by healthcare professionals was limited to the authors of the studies used in this analysis. The context for all of the studies included in the analysis was socio-cultural.
Sample

A series of searches of the CINAHL, PsychINFO, and Medline databases were conducted for the years 1990–2001. All studies were retained that met the following criteria: participants were 18 years of age or older, ethnicity or race was defined as Black American, Caucasian American or Latino American, the study was conducted in the USA, was published in English, and the study results included descriptions of the concept of obesity from the perspective of the participants and researcher or the participants only. These criteria were selected to give the best possible picture of the use of the concept of obesity in adults across the chosen ethnic groups. After review of abstracts and elimination of references not meeting the criteria, 20 papers from 18 studies were retained. Five of the studies were qualitative, 14 were quantitative, and one used mixed methods.
Data analysis

Each reference was initially assigned to a specific category based on the discipline of the first author: nursing (n = 5), psychology (n = 9), epidemiology (n = 3), medicine (n = 2), and sociology (n = 1), and was given a number. Each paper was read in its entirety before summarizing the dimensions of the concept, the perspective reflected in the text, contextual elements contributing to the definition and use of the concept, assumptions integrated into the text, and the implications of how the concept was constructed and used (Caron & Bowers 2000). Papers were summarized by the first author and then reviewed by the second author. A table was constructed for each paper identifying the important elements of the analysis as well as implications and author notes. These tables also included phrases and quotes from the papers supporting each dimension identified. Once the initial analysis was complete, the tables were used as a basis for comparison across all papers. A final table was produced to summarize the data across perspectives and dimensions.
Findings

Eight dimensions of the concept of obesity were identified as a result of the analysis. These dimensions were: objective measure, attractiveness, sexual desirability, health, body image, strength or goodness, self-esteem, and social acceptability. Although men were included in some study samples, the following results focus primarily on perceptions of obesity in women, whether by women or men.
Objective measure

Healthcare professionals and researchers defined obesity in terms of objective measures, regardless of cultural context, and were the only group to define obesity in this manner. The authors of 14 of the 20 papers defined obesity objectively, using in all cases the scientific equation for Body Mass Index (BMI). BMI is calculated by dividing the body weight in kilograms by the square of height in metres (Walcott-McQuigg et al. 1995). Despite this objective measure, obesity was not consistently quantified at the same level of BMI, and the terms used to categorize obesity also differed. For example, Laffrey (1986) defined obesity as a weight to height ratio of >10% of the norm using the 1980 standards from the Michigan Department of Public Health. Allan et al. (1993) defined normal weight as BMI >18.8 to <24,>24 to <28,>28 to 45. Allan (1998) later revised these categories as follows: normal weight (BMI 18.8–24.9), mild overweight (BMI 25–27.9), moderate overweight (BMI 28–31.9) and severe overweight (BMI > 32). In 1995, Walcott-McQuigg et al. (1995) used the following criteria: mildly obese (BMI 27–32) and morbidly obese (BMI 33–46). As these examples illustrate, health professionals have a varied perspective on what constitutes obesity, but all based obesity solely on the objective measure of BMI. The discrepancies in use of BMI to define obesity contribute to difficulties in interpretation of results and in comparing research results across studies.
Attractiveness

Attractiveness was a dimension of obesity found in three of the four perspectives studied. Health professionals did not define obesity on this dimension. Twelve of the 15 studies that described obesity from the Black American perspective included the notion of attractiveness (Allan et al. 1993, Kumanyika et al. 1993, Stevens et al. 1994, Powell & Kahn 1995, Walcott-McQuigg et al. 1995, Wilfley et al. 1996, Caldwell et al. 1997, Allan 1998, Smith et al. 1999, Baturka et al. 2000, Fitzgibbon et al. 2000, Miller et al. 2000). A majority of these studies (11/12) found obesity and attractiveness to be positively related (Allan et al. 1993, Kumanyika et al. 1993, Stevens et al. 1994, Powell & Kahn 1995, Walcott-McQuigg et al. 1995, Wilfley et al. 1996, Allan 1998, Smith et al. 1999, Baturka et al. 2000, Fitzgibbon et al. 2000, Miller et al. 2000). One study reported positive and negative aspects of attractiveness (Walcott-McQuigg et al. 1995) and one study found a negative relationship (Caldwell et al. 1997): that is, for the majority of Black American participants studied, obesity was conceived as being physically attractive. (Allan et al. 1993, p. 330) reported the representative response of one Black American woman regarding her feelings about body size and attractiveness: 'I want to look like a female, like a grown-up woman, not a little kid. I want a waist and some curves and some meat, not straight up and down like those thin white girls. My husband wants something to hug'. Another Black American woman in the same study was quoted as saying: 'In this society, women are supposed to always be slender, never look like they had children. There is an image of what is beautiful, and it's typically blonde, blue-eyed, and thin. I think it's only recently that black women have not agreed with that image' (Allan et al. 1993, p. 328).

Ten studies reported the notion of attractiveness from the perspective of people in the Caucasian American culture (Allan et al. 1993, Stevens et al. 1994, Powell & Kahn 1995, Wilfley et al. 1996, Caldwell et al. 1997, Allan 1998, Smith et al. 1999, Fitzgibbon et al. 2000, Rand & Wright 2000, Arriaza & Mann 2001). In all 10 studies, Caucasian American participants equated obesity with unattractiveness. Allan et al. (1993) studied the meaning of body size in a group of Caucasian and Black American women. One Caucasian, an obese, middle-aged school teacher, described her notion of obesity and attractiveness in this way: 'I know that I'm never going to catch up with the 'in image'. I remember studying art and looking at Ruben's women and thinking: I'm just in the wrong century. It's my fate that now it's the opposite shape that's 'in'Allan et al. 1993, p. 328).

Only three studies were found that discussed obesity and attractiveness from the perspective of Latino Americans (Allan 1998, Fitzgibbon et al. 2000, Arriaza & Mann 2001). Two studies supported the relationship between obesity and attractiveness and one refuted this finding. In Allan's (1998) study, a Latino American woman who did not associate weight with unattractiveness was quoted as saying:

Why worry about weight loss or body image? What is important is having a family, a good job, being happy. There are those rich Mexican snobs who want to be perfect. They gain a pound and think they gained 10! That is silly. It is what is inside that is important (Allan 1998, p. 58).

Another study by Fitzgibbon et al. (2000) provided further support for differences in associations between weight and body dissatisfaction in a cohort of 84 Latino Americans compared with 60 Caucasian and 204 Black Americans. The Latino American participants reported a neutral body dissatisfaction rating at 28.57, 3.94 above that of Caucasian American participants [t (340) = 3.06, P < 0.05], a BMI above the overweight criteria of 25. Arriaza and Mann (2001) studied ethnic differences in eating disorder symptoms and the role of BMI in 232 Caucasian American women and 52 Latino American women who were enrolled in college. These authors found that weight had the greatest impact on concerns about body weight and shape. Ethnic differences disappeared after controlling for weight, a finding suggesting that weight was the factor behind ethnic differences in the sample studied. This study employed a small, homogeneous population of Latino American women, responses were limited to one standardized instrument, and BMI was calculated from self-reported height and weight, all factors contributing to the questionable validity of the findings.
Sexual desirability

There were important differences found across groups on the dimension of sexual desirability. Seven studies addressed this dimension from the Black American perspective (Allan et al. 1993, Powell & Kahn 1995, Walcott-McQuigg et al. 1995, Wilfley et al. 1996, Gore 1999, Baturka et al. 2000, Miller et al. 2000). In all of these studies, Black American men and women expressed the view that obesity is a sexually desirable trait. In the study by Walcott-McQuigg et al. (1995), a woman spoke about her experiences of how Black American men perceive weight:

When I give a weight reduction class one of the things I might emphasize is how black men feel about how black women should look. When I talk to women about their weight they say, well, my husband doesn't think I should lose any more weight. Now by my measurements and the Metropolitan height and weight tables that person would definitely be considered well overweight. But by the eye standard of what her husband thinks, she might be too small or just right (Walcott-McQuigg et al. 1995, p. 514).

Twenty-five per cent of the women in this study suggested that Black American men like women with a rounded, more shapely figure, women with 'more meat on their bones' (Walcott-McQuigg et al. 1995, p. 514). In contrast, two studies of Caucasian American women (Wilfley et al. 1996, Miller et al. 2000) and one study including Caucasian American men (Powell & Kahn 1995) placed sexual desirability with obesity in a negative context. Miller and colleagues studied three groups of Black Americans, Caucasian Americans, and Latino Americans who were enrolled in two universities. Each group comprised 20 men and 20 women. Participants were administered several tools measuring perceptions of body image and attractiveness. People were not classified according to weight categories. Black Americans scored statistically significantly higher (P < 0.001) on measures of appearance and body area satisfaction with Black American women rating themselves higher than Caucasian American women on sexual attractiveness. Caucasian American women scored lowest in perceptions of their sexual attractiveness with Latino American women in the middle (Miller et al. 2000). This was the only study that looked at this dimension from the Latino American perspective. Allan et al. (1993) had similar findings in a study involving 36 Caucasian American and 31 Black American women. During interviews Caucasian American women described thinness as the ideal for themselves as well as for the men in their lives. One Caucasian woman poignantly stated:

We live in a society where people are first attracted to each other by mere physical appearance and this means thinness. If you don't have that, your choices and options are limited when it comes to men. You innately know, as a woman, as your mother always told you, the best way to get a man and keep him is to be thin (Allan et al. 1993, p. 330).

Health

Of the 15 studies exploring obesity from the Black American perspective, seven studies addressed the notion of obesity and health (Allan et al. 1993, Kumanyika et al. 1993, Walcott-McQuigg et al. 1995, Wilfley et al. 1996, Allan 1998, Gore 1999, Baturka et al. 2000). Five studies reported findings that supported the notion that obesity is not considered a health risk from this cultural perspective (Allan et al. 1993, Walcott-McQuigg et al. 1995, Wilfley et al. 1996, Allan 1998, Baturka et al. 2000). Allan et al. (1993) reported conflicting findings in their mixed method study of 36 Caucasian American women and 36 Black American women. Both groups of women rated ideal, healthy and attractive body size below medical standards. No statistically significant differences were found between groups on ratings of what were healthy or attractive (Allan et al. 1993). However, during interviews, Black American women presented beliefs about weight that did not conform to standardized cut-offs for obesity. One Black American woman was quoted as saying:

I think normal for me is 190. That's the weight I was when I graduated from high school and it feels good to me [is currently 5' 9'' and 260 pounds]. According to the doctor, that's too much for me but if I weighed 150 like he says, I'd be skin and bones and sick. I'm large boned like all the women in my family and I need the weight to look good (Allan et al. 1993, p. 329).

A study by Gore (1999) found a different view of health and obesity among a group of 55 Black American women. It was found that some of these women defined obesity by how it affected their health. Two women from this study stated: 'When it affects your health, you know you're overweight and you need to do something', and 'When your legs and back hurts. You can feel it' (Gore 1999, p. 76). These studies also raise the question of the definition of health from the Black American perspective.

A study by Allan et al. (1993) found the Caucasian American perspective of obesity and health to be substantially different from the Black American perspective. They found that Caucasian American women talked more frequently about health problems related to overweight. One other study from this perspective supported these findings (Wilfley et al. 1996). Two studies, however, identified obese Caucasian American women who did not associate obesity with health consequences (Laffrey 1986, Allan 1998). Allan (1998) studied 40 Caucasian American women who reported believing that the consequences of overweight were personal rather then medical (Allan 1998). Laffrey (1986) studied 33 normal weight and 26 overweight Caucasian American women. In the overweight group, participants accurately reported themselves as overweight, but perceived themselves to be just as healthy as participants in the normal weight group (Laffrey 1986).

The Latino American perspective of obesity and health were found in two studies. One study population reported a strong relationship between obesity and health risk and the other study population reported a lack of association. A 34-year-old obese Latino American woman in Allan's study illustrated how individuals may fail to link health and obesity: 'Diabetes runs like an arrow straight through my family. Although my weight is more than ideal, I'm healthy. I exercise and do anything I want. I think thin people are more at risk for diseases. This is me. I feel OK about my weight' (Allan 1998, p. 57).
Body image

Nine studies explored the relationship between obesity and body image from the Black American perspective (Harris 1994, Stevens et al. 1994, Walcott-McQuigg et al. 1995, Riley et al. 1998, Gore 1999, Smith et al1999, Baturka et al. 2000, Fitzgibbon et al. 2000, Miller et al. 2000). Of the nine studies, only one study supported the perspective of a negative association between obesity and body image (Riley et al. 1998). Several studies had similar results to those of Stevens et al. (1994). These authors studied 278 Caucasian American women and 126 Black American women. For the overweight women in this study, Black American women were found to be 2.5 times as likely as Caucasian American women to be satisfied with their weight and 2.7 times more likely to consider themselves attractive.

The perspective of body image in Caucasian American women was found to be dramatically different from that of Black American women. Of the seven studies found exploring this dimension, all reported findings that support the Caucasian American cultural view of obesity and negative body image (Laffrey 1986, Harris 1994, Stevens et al. 1994, Allan 1998, Smith et al. 1999, Fitzgibbon et al. 2000, Miller et al. 2000). This association was supported through the work of Stevens et al. (1994) who found that in their population of 278 Caucasian American women, 46% of the women who were not overweight reported they were overweight. Likewise, Fitzgibbon et al. (2000) found in their study of 63 Caucasian American women, 231 Black American Women and 95 Latino American women that Caucasian American women became dissatisfied with their bodies at a weight that was still defined as a normal weight range. This study found that Latino American women did not exhibit body dissatisfaction until they were in the overweight range, a similar finding in the Black American women studied. One other study by Miller et al. (2000) explored body image in a group of 40 Latino American men and women compared with 40 Caucasian American men and women and 40 Black American men and women. Miller and colleagues found the Latino American group scored in the middle on measures of appearance and body satisfaction with Black Americans scoring higher and Caucasian Americans scoring the lowest.
Strength or goodness

The dimension of strength and/or goodness was also found in the literature exploring the Black American perspective. This dimension was not found in the literature describing Caucasian American or Latino American perspectives. Two studies out of the total of 15 discussed this dimension of obesity. Allan et al. (1993) identified the following adjectives used by Black American women when asked to discuss the meaning of a 'healthy body size' (considered by conventional standards as overweight): shapeliness, strength, stamina and presence. Thirty-six Black American women were part of a qualitative study by Walcott-McQuigg et al. (1995). In this study, women were interviewed regarding numerous dimensions of weight. Several of these women spoke from a historical perspective about Black American obesity. One of the dimensions discussed was the perception of weight as a sign of strength and wealth. As one woman reported: 'We are still part African, no matter how long we have been here. Fat was looked at as a sign of wealth. You know, if you were fat in Africa you were just good. You had a lot of wealth and it was OK to be fat' (Walcott-McQuigg et al. 1995, p. 514).
Self-esteem

Self-esteem is a dimension of obesity that varied across perspectives. Overall, findings supported the view that Black Americans do not associate obesity with lower self-esteem, Caucasian Americans do associate obesity with lower self-esteem, and Latino Americans report conflicting beliefs (Allan et al. 1993, Wilfley et al. 1996, Caldwell et al. 1997, Allan 1998, Riley et al. 1998, Gore 1999, Smith et al. 1999, Baturka et al. 2000, Miller et al. 2000, Arriaza & Mann 2001). Miller et al. (2000) studied three groups of 20 men and 20 women from each ethnic perspective described above. These authors measured both body image and self-esteem. Black Americans were found to have scored the highest in body satisfaction and self-esteem with Caucasian Americans scoring the lowest and Latino Americans scoring the same or greater than Caucasian Americans (Miller et al. 2000). These authors did not further specify the ethnicity of their Latino American population. Allan interviewed 40 Latino American women and found that in general, these women placed less importance on body size than Caucasian American women (Allan 1998).
Social acceptability

Of the 15 studies addressing obesity from the Black American perspective, six studies supported the Black American view that obesity is a socially acceptable phenomenon in their culture (Allan et al. 1993, Kumanyika et al. 1993, Powell & Kahn 1995, Allan 1998, Gore 1999, Baturka et al. 2000). Only one study did not support this view (Wilfley et al. 1996). Baturka et al. (2000) found in their qualitative study of 24 Black American women (50% of the sample were obese) that the majority spoke about perceived social pressure not to lose weight. Many women spoke of the acceptance and desire by significant men in their lives to maintain their weight (Baturka et al. 2000). As the authors reported: 'The pervasive attitude of others in these women's lives was acceptance' (Baturka et al. 2000, p. 238).

In contrast, all of the studies that addressed the dimension of social acceptability from the Caucasian American perspective reported that participants perceived obesity to be socially unacceptable (Powell & Kahn 1995, Wilfley et al. 1996, Rand & Resnick 2000, Rand &Wright 2000). There were no studies to challenge this view. Powell and Kahn (1995) surveyed a cohort of 38 Black American women, 33 Black American men, 59 Caucasian American women and 60 Caucasian American men who were enrolled at a university. They asked participants about ideal body size, attractiveness, and social pressure to be thin. Caucasian American women chose a statistically significantly thinner ideal body size (mean = 3.56, SD = 1.24) than did black women (mean =4.71, 1.54, t(93) = -4.01, P < 0.0005). Caucasian women also felt statistically significantly greater pressure to be thin (mean = 18.03, SD = 5.23) compared with black women (mean = 14.38, SD = 5.14, t(93) = 3.23, P < 0.005). Black American men reported more willingness to date women with larger body sizes and said they would be less ridiculed than white men if they did date such a woman (Powell & Kahn 1995).

The dimension of social acceptability was not directly measured in any of the five studies that looked at obesity from the perspective of Latino Americans. A paper by Allan (1998) quoted a Latino American participant as relating cultural strength and love with food, but not necessarily with obesity (Allan 1998). This appears to be an area not yet well studied in this group.
Discussion

The results of this analysis reflect a wide level of diversity in how the concept of obesity is perceived and used within certain cultural groups of the American population. A limitation of this study is the paucity of findings related to the concept of obesity from the Latino American perspective. The results presented must be interpreted with caution due to the small number of studies found describing obesity from this perspective. The population of Latino American participants is very heterogeneous and further research is needed with various Latino American subgroups to further explore their perspectives on obesity.

The use of standardized categories of BMI as an objective measure was found to vary and this is consistent with previous findings in the literature. Presently, the USA is moving towards standardized measurements of obesity and overweight using BMI through guidelines set forth by the 2000 Dietary Guidelines for Americans (US Department of Agriculture and US Department of Health and Human Services 2000). The International Obesity Task Force has set adult cut-off points using BMI to help address the need for a global objective measure (2005). The use of standardized measures will no doubt aid in improving both accurate assessment of global trends in weight as well as accurate interpretation of global research findings. Despite the development of a global consensus on the objective measure of obesity, this analysis points to the equally important need to assess how individuals from all cultural backgrounds perceive the concept of obesity.

According to Caron and Bowers: 'The outcome of dimensional analysis is intended to provide a better understanding of systematically generated differences in meanings and use of the concept' (2000, p. 297). This analysis contributes to the development of an understanding of the meaning and use of the concept of obesity within varied socio-cultural contexts as well as from a healthcare perspective. The findings of this analysis reveal substantial differences in assumptions, uses, and meanings of this concept. The first assumption to be challenged by this analysis is that obesity can be universally measured and understood by use of quantitative measures alone.

Black American participants were found to define obesity in positive terms related to attractiveness, sexual desirability, body image, strength or goodness, self-esteem and social acceptability. This same group of participants did not view obesity as a cause for concern about health. In almost a diametrically opposing way, Caucasian American participants defined obesity in negative terms, describing it as unattractive, not sexually desirable, associated with negative body image, decreased self-esteem, and socially unacceptable. The data exploring the dimension of health from this cultural perspective both supported and refuted belief in obesity as a cause for medical concern. These differences could pose substantial threats to communication and understanding between healthcare providers and their patients. For interventions to be acceptable and useful for patients they must be responsive to the beliefs and desires of the patient.

This analysis provides a preliminary understanding of the concept of obesity for a small subset of the American population. As the obesity epidemic has reached global proportions, future research is needed to explore the use and meaning of obesity in cultures worldwide. In the absence of such knowledge and understanding, interventions, though well meaning, may be misdirected.
Conclusion

This analysis revealed a lack of association between health and weight for many of the participants studied. It is imperative that culturally sensitive education be developed that promotes the prevention of obesity and delineates the mortalities and morbidities associated with living with this condition. Nurses can play a key role in the development of culturally sensitive interventions that will meet the needs of the diverse population of overweight people and in the development of interventions that help to close the gap in understanding of the major health risks related to obesity. Further research is needed to explore the use and meaning of obesity in diverse populations.
Author contributions

This study was designed in collaboration with both authors. Data were analysed by MD and confirmed by KAK. The manuscript was written by MD and KAK.
What is already known about this topic
* Obesity is an emerging healthcare epidemic.
* Typically defined in physiological terms relating to Body Mass Index, there is a lack of convergence between the definition and use of the concept of obesity by scientists and healthcare providers and those whom they are trying to serve.
What this paper adds
* There are substantial differences in assumptions, use and meanings of the concept of obesity across the Black American, Caucasian American and Latino American cultures.
* Culture plays an important role in how obesity is defined by an individual and, therefore, the concept of obesity needs to be placed in a socio-cultural context.
* A challenge is offered to the assumption that obesity can be universally measured and understood using quantitative measures alone.
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Keywords: concept analysis; culture; dimensional analysis; meaning; nursing; obesity; perspective
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