Self-perceived bodyweight status among adults who are overweight or have obesity, with and without high cardiovascular risk

Background: Accurate self-perception of body weight status is important for patient engagement and effective management of overweight and obesity. We estimated the prevalence of misperceived weight status and lack of clinician counseling among US adults who meet criteria for being overweight or obese. Methods: Pooled cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) from 2013 through March 2020. Adults aged ≥20 years with measured body mass index (BMI) and self-reported weight status were included. Our primary exposure was BMI categorized as: 1) overweight (25-29.9 kg/m²), 2) class I obesity (30-34.9 kg/m²), 3) class II obesity (35-39.9 kg/m²), or 4) class III obesity (≥40 kg/m²). Sensitivity analysis redefined overweight as 27.0-29.9 kg/m² as well as restricting to those with an elevated BMI and waist circumference (102 cm for men and 88 cm for women). Our primary outcome was the proportion of respondents who did not perceive themselves to be overweight. Secondary outcomes included the proportion reporting a clinician-recommendation to lose weight. We used multivariable survey-weighted Poisson regression (adjusted prevalence ratios [aPRs]) to describe trends over time. We stratified analyses by presence of cardiovascular disease (CVD) and diabetes, separately. Results: Among 16,124 NHANES participants with BMI ≥25.0 kg/m² (representing approximately 182 million US adults), 20.5% were classified as overweight (25.0-29.9 kg/m²), 14.4% as class I obese (30.0-34.9 kg/m²), 4.8% as class II obese (35.0-39.9 kg/m²), and 3.2% as class III obese (≥40.0 kg/m²). The prevalence of adults who did not perceive themselves as overweight was highest among those classified as overweight (48.0%) and declined with increasing BMI category: 17.5% among those with class I obesity, 6.2% with class II obesity, and 3.1% with class III obesity. In contrast, clinician recommendation to lose weight increased with BMI: 17.2% of those with overweight, 42.6% with class I obesity, 57.4% with class II obesity, and 71.3% with class III obesity reported receiving such advice within the past 12 months. Conclusions: Nearly one-third of all US adults who are overweight or obese do not perceive themselves to be overweight and a significant portion have not been recommended to lose weight by a clinician. Gaps between patient perceptions about their weight and their weight status reflect a critical opportunity for intervention in preventive care.