Misperception of weight status was highly prevalent in our study population. We observed that a substantial proportion of individuals in the overweight and obese categories inaccurately classified their weight status; almost half of the overweight and most of the obese participants misperceived their weight status. Appropriate perception of weight is strongly associated with weight loss efforts across genders and BMI categories . Underestimation of weight status contributes to denial or minimization of current weight being a health risk and thus contributes to increase in health problems associated with obesity due to a failure to respond to health professional's advice [14–16].
Higher proportions of misperception have been reported previously. A study from an urban family medicine centre in United States reported similar proportion of misperception of obesity (BMI > 30) in participants coming for screening health checkups . A nationally representative sample from Australia reported half of men and one quarter of women do not consider themselves to be overweight/obese . A community sample from Australia also reported 66% of obese (BMI > 30) and 34% of overweight (BMI > 25) participants failing to recognize their correct weight status .
An important finding of our study is that a large number of overweight participants did not categorize themselves as overweight. Similar findings have been reported from a nationally representative sample of Spanish adults  and a community sample in Australia . Being overweight (BMI = 23-24.9) is also risk factor for health related problems. This is also true in South Asian cultures, putting them at risk of excessive weight gain and associated health risks . Being overweight is a precursor to obesity and it is relatively easier to lose weight at these moderate levels than at higher levels of weight gain. Thus overweight people should be educated about the associated health risks of being overweight and advised about appropriate weight loss strategies.
We found that being happy or not thinking about their weight was most strongly associated with weight misperception. A large proportion of overweight/obese participants in our study were either content or not concerned about their weight. Anderson et.al. found half of the overweight and obese women in their study to be satisfied with their body size in a national survey of overweight and obese women in United States  and Green et. al. observed a large proportion of overweight/obese men to be content with their weight in a nationally representative sample of Canadian adults . This can be explained by social and cultural factors which influence the standards accepted for weight . Traditionally body weight has been regarded as a symbol of health, prosperity and wealth in various populations . This is also true in South Asian culture where people still consider weight to be associated with good health and wealth. They would therefore tend to accept overweight/obesity as a norm and are thus at higher risk of not perceiving it to be of any concern
Comparison between genders showed that a large proportion of men did not consider themselves to be overweight/obese compared with women. Similar trends have been observed in earlier population based studies [8, 24]. This difference in perception again could be the result of social or cultural factors. Social and family pressures to maintain an acceptable body image affect women more than it affects men; consequently women are more sensitive of their weight status and they perceive their weight more accurately than men do. There is epidemiological evidence from Western countries that show an increasing trend of obesity in men , and the same trend may now be emerging in developing countries as well.
In our study, men and women aged 40 years and over were more likely to misperceive their weight status, which is in concordance with other studies [26, 27]. Possible reasons may be that in Pakistan, older people are less concerned about their body image than younger people, which may alter their perception of weight. It may also be related to the increased prevalence of overweight and obesity in older age groups, which is usually accepted as an age related phenomenon . This is a cause of concern because accumulation of risk factors with advancing age can increase the likelihood of chronic diseases.
Another important finding of our study associated with misperception is inadequate knowledge of ideal body weight which may lead the obese/overweight people to consider themselves of ideal weight. A study by Kuk et al observed higher ideal weight to be associated with greater body satisfaction and lower intention to participate in weight loss activities .
Presence of comorbid conditions lead to increased susceptibility and thus increased awareness of being overweight and obese, but an opposite phenomenon has been observed in our study. This may be because people having hypertension/dyslipidemia/diabetes mellitus may focus more on their primary illness and overlook their weight status. Also they may not consider obesity as a risk factor for chronic disease. Similar findings of poor perception of weight in people with diabetes and coronary heart disease have been observed in a community sample in Cracow, Poland . Powell et al have reported about the weight misperception in people with comorbid conditions in a multi-ethnic urban cohort in Dallas, United states . This weight misperception along with unhealthy life styles contributes to development and progression of chronic disease. This makes it imperative that the high risk groups correctly perceive their weight as knowledge of health risk associated with obesity alone may not prompt attempts to lose weight. Kruger et al., observed in a study of US adults that despite the knowledge of benefits associated with weight loss only half of the obese participants attempted to lose weight . Awareness of one's weight did not improve weight perception among the participants in our study. Possible explanation may be the social or cultural factors that tolerate a higher body weight and inadequate knowledge of ideal body weight.
A large proportion of overweight/obese participants (64%, n = 202) in our study reported not being advised about their weight; only one third (n = 113) of them reported getting weight related advice. This is a global problem. A trend analysis of behavioral risk factors in the United States and a recent study on overweight and obese elderly in Unites States have shown identical proportions of individuals not being advised about weight by health professionals [32, 33]. Moreover, majority of overweight/obese participants with comorbid conditions were not given weight advice by health professionals (n = 56, 78%) and most of the participants who were not advised misperceived their weight (n = 45, 80%). Physician's advice is a strong motivator to weight loss attempts as shown in multiple previous studies [32, 34], therefore it is assumed that it would lead to improved perception of weight. However, it did not improve perception in our study. Probable reasons may be the powerful role of social demographic and personal factors like body size satisfaction in weight perception.
Low socioeconomic status is associated with weight misperception in many populations [8, 11]. In our study, education was taken as proxy marker for socioeconomic status and we did not find any association between weight misperception and level of education.
Body size dissatisfaction is another important determinant of disordered weight control practices besides misperception of weight. Anderson et al., observed that women who were not satisfied with their body size were approximately nine times and women who were satisfied with their body size were three times more likely to try to lose weight as compared with women who were very satisfied with their body size . It has been observed that greater body size satisfaction is associated with healthy lifestyle behavior and less weight gain in later years in children and adolescents . Besides distorted perception, body dissatisfaction is strongly associated with increasing BMI and can lead to inappropriate weight control practices like binge eating and anorexia .
As the epidemic of obesity becomes global, it is imperative that steps are taken to control it. Obesity management now covers a wide range of long term strategies ranging from prevention, through weight maintenance and management of obesity comorbids to weight loss . Therefore it is important for health professionals to identify overweight/obese people, educate them about the health risks of obesity and advise them about appropriate strategies for weight loss. More importantly concerted efforts need to be undertaken to prevent weight gain by emphasizing healthy eating habits and adequate exercise in children , adolescents and adults .
Our study has limitations. The study took place in an urban setting and hence these results cannot be generalized to the entire Pakistani population. But it can be assumed that the misperception rates may be higher than the rates observed in our study. There were more male participants than females probably because we included patients as well as attendants and female patients are usually accompanied by male attendants in our setting. We did not study body size dissatisfaction, which is another important determinant of weight loss. Instead, we enquired about their feelings regarding weight which we used as an indirect measure of body size dissatisfaction.