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Obesity Prevalence and Its Influence on Weight Related Behaviors Through Mediation by Weight Perception

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Obesity Prevalence and Its Influence on Weight Related Behaviors Through Mediation by Weight Perception OBESITY PREVALENCE AND ITS INFLUENCE ON WEIGHT RELATED BEHAVIORS THROUGH MEDIATION BY WEIGHT PERCEPTION By Johnathan N. Au A Thesis Presented to the Department of Public Health and Preventive Medicine and the Oregon Health and Science University School of Medicine in partial fulfillment of the requirements for the degree of Master of Public Health September 2013 TABLE OF CONTENTS List of Tables ..................................................................................................................... iii List of Figures .................................................................................................................... iv Acknowledgments............................................................................................................... v Abstract ............................................................................................................................. vii Chapter 1 – Introduction ..................................................................................................... 1 Obesity – Public Health Implications ............................................................................. 1 Weight Perception ........................................................................................................... 2 Environmental Exposure of Obesity Prevalence ............................................................ 4 Mediation of Weight Related Behaviors by Weight Perception ..................................... 6 Study Objectives ............................................................................................................. 7 Chapter 2 – Methods ......................................................................................................... 10 Study Population ........................................................................................................... 10 Obesity Prevalence (Primary Explanatory Variable) .................................................... 13 Perceived Weight Status (Mediating Variable) ............................................................ 14 Weight Related Behaviors (Primary Outcome Variables) ............................................ 15 Covariates ..................................................................................................................... 16 Statistical Analyses ....................................................................................................... 17 Univariate Preliminary Data Analysis ...................................................................... 17 Bivariate Preliminary Data Analysis ........................................................................ 17 i Multivariate Analysis ................................................................................................ 18 Chapter 3 – Results ........................................................................................................... 22 Population Characteristics ............................................................................................ 22 Crude Associations Among Study Variables ................................................................ 24 Perceived Overweight ............................................................................................... 24 Meeting Physical Activity Recommendations .......................................................... 24 Extreme Dieting ........................................................................................................ 25 Logistic Regression Analysis ........................................................................................ 28 Estimated effect of obesity prevalence on perceived overweight ............................. 28 Estimated effect of perceived overweight on weight related behaviors ................... 29 Estimated effect of obesity prevalence on weight related behaviors ........................ 31 Obesity prevalence mediation on weight related behaviors by weight perception ... 34 Chapter 4 – Discussion ..................................................................................................... 35 Estimated effects of obesity prevalence on perceived overweight ............................... 35 Estimated effects of overweight perception on weight-related behaviors .................... 36 Estimated effects of obesity prevalence on weight-related behaviors .......................... 38 Public Health Implications ............................................................................................ 39 Limitations and Strengths ............................................................................................. 41 Future Studies ............................................................................................................... 43 Study Conclusions ........................................................................................................ 43 References ......................................................................................................................... 45 Appendix ........................................................................................................................... 49 ii List of Tables Table 1 - Estimated means for obesity prevalence by tertile stratified by sex ..................14 Table 2 - Study population characteristics, stratified by sex .............................................23 Table 3 - Crude associations among obesity prevalence (primary exposure) and confounders with weight perception (potential mediator) and weight related behaviors (primary outcome) ..............................................................................26 Table 4 - Estimated Effect of Obesity Prevalence on Perceived Overweight stratified by Sex and tested for BMI interaction .....................................................................29 Table 5 - Estimated Effect of Perceived Weight Status on Weight related Behaviors stratified by Sex and tested for BMI interaction .................................................31 Table 6 - Estimated Effect of Obesity Prevalence on Weight related Behaviors stratified by Sex and tested for BMI interaction ................................................................33 Table 7 - Diagnostic procedures, goodness-of-fit and Receiver Operating Characteristic (ROC) curves, for study models .........................................................................50 iii List of Figures Figure 1 - Diagram illustrating potential influential factors for weight-related behaviors ..7 Figure 2 - Histograms for obesity prevalence stratified by sex .........................................14 Figure 3 - Mediation by perceived weight status for the relationship between obesity prevalence and weight related behavior ............................................................34 Figure 4 - Study subject flow diagram ...............................................................................49 iv Acknowledgments The completion of this thesis would not have been possible without the dedication and guidance from several individuals. Foremost, I would like to begin by expressing my sincerest gratitude to Dr. Janne Boone- Heinonen. Without her insatiable patience and moral support, completion of this thesis would not have been possible. Her ability to always constructively challenge my thinking provided a fruitful and engaging learning experience. Her guidance extended to all aspects of public health research, from developing the appropriate and novel research question, to correctly applying epidemiologic concepts, and writing in a clear and logical manner in the hope of bringing positive change. Dr. Boone-Heinonen has been a wonderful teacher, and I could not have imagined having a better mentor for my thesis experience. Additionally, I would also like to extend my appreciation to my committee members, Dr. Thuan Nguyen, Dr. Jackilen Shannon, and Dr. Elizabeth Daniels, for their support and guidance throughout this process. Dr. Nguyen always graciously provided in depth explanations, ensuring understanding and appropriately used statistical analysis. Dr. Shannon presented creative and intriguing questions, pushing my thinking to consider other aspects of public health related to my thesis. Lastly, Dr. Daniels provided great advice and expertise on psychological considerations, which has intrigued my interest regarding the interface of psychology and epidemiology. v I would also like to convey my appreciation to the Public Health and Preventive Medicine Department at Oregon Health & Science University for an amazing educational experience and myriad of academic resources. Finally, I would also like to thank family and friends: my parents for their continued support and encouragement; Priya Srikanth for providing insightful explanations on data management and model diagnostics; Ralpha Newton for her efforts in reviewing my project on multiple occasions; and Raina Tamakawa for her moral support and her time in performing copious reviews of my written work. vi Abstract Background. Obesity is a top public health priority in the 21st century. The prevalence of obesity has grown considerably over the past quarter century. Exposure to communities of higher obesity prevalence may be shifting the public’s perception of ideal weight to heavier weights. The divide between weight perception and objective weight measures may ultimately change weight related behaviors. Purpose. Our study investigates the relationship between obesity prevalence and weight related behaviors,
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