Obesity in Indonesian and Taiwanese Adolescents Related to Self Perception, Diet, Exercise, and Body Image

Obesity prevalence in Asia was raising. Self-perception became an increasingly determinant predictor of a healthier lifestyle. The purpose of this study was to investigate the relationship between self-perception and actual BMI among Indonesian and Taiwanese teenagers. This research was cross sectional and using participatory sampling of 415 participants from 6 high schools in Indonesia


Introduction
Obesity is a nutrition-related disease with the highest prevalence globally.This condition impacts medical, psychological, social and economic problems faced by countries in the upcoming years (Cena et al., 2017;Khan et al., 2020).Obesity could began from the childhood period due to more consumption of high energy, sweet and fat contained meals compared to fiber and nutrition-rich food like fruits and vegetables (Xu & Xue, 2016).The typical problem occurs on obese teenagers were stress because of unsatisfied feeling about their body shape.This perception leads to the lost motivation thus making the weight reduction America, and East Asian ancestors (Bradfield et al., 2019).
Taiwan was close to Indonesia in terms of economy, social, and culture.There were many Indonesian lived in Taiwan, mostly as students and migrant workers.This condition created shared culture between two countries.Malnutrition was one of the shared problems in both countries.In Taiwan, the prevalence of overweight relatively stabilized, but the prevalence of morbid obesity and obesity increased sharply from 0, 4% and 11,8% in 19934% and 11,8% in -19964% and 11,8% in to 1,4% and 22% in 20134% and 11,8% in -20144% and 11,8% in (Chang et al., 2017)).The increasing prevalence mainly caused by low physical activity, decreased leisure sit time, and decreased sleep time.The problem is made worse by the low health literacy among school children and the high consumption of sugar-sweetened beverages (Lin et al., 2016).Fortunately, obese children in Taiwan are harboring some unique characteristics, they tend to have less disruptive behavior, have a lower prevalence of anxiety, and more unlikely to fall into depression (Puhl et al., 2013).The difference in self-perception of their own body were related to their respective cultures (Chiu et al., 2017;Handayani et al., 2020).
The community awareness regarding the risk of obesity was still low.People saw obesity as a negative trait, often showed by continuously shaming obese persons of their own body.Increasing stigma to the obese person causing them to avoid any conversation of fat and physical activity (Webb et al., 2016).This condition particularly occurs in high school teenagers or those who just enter the college.This problem requires specific approaches, particularly related to the perception of health promotion target thus the community can accept and implement communicated messages (Redline et al., 1999).This research provided analysis of self-perception and actual body weight among Indonesian and Taiwanese teenagers.

Method
This study focused on understanding self-perceptions and actual weight teenagers in both Indonesia and Taiwan.This research was conducted using a quantitative approach with a cross-sectional design.The study was conducted after the proposal received ethical proof of ethics commissions in each country.The respondents were from 6 high schools in Indonesia and 7 high schools in Taiwan.The sampling technique used in this research was purposive sampling at the schools which meet three criterias.These criterias were: located in urban areas, public school with excellent accreditation, and agree to participate in the research.Students sit in the 11th grade were then asked for their consent to volunteered as respondents for the research.This consideration was taken to prevent our research from obstructing teaching and learning process.The reason behind the three criterias was for having similar school quality between Indonesia and Taiwan.Totally, there were 415 participants in Indonesia and 717 participants in Taiwan completed all survey package.
We adapt the questionnaire of the Obesity Impact on the Quality of Life Perception Questionnaire (ObI-Q), and the Projective Test (Hochdorn et al., 2014;Rendón-Macías et al., 2014;Zaman, 2015).The ObI-Q and the Projective Test were adapted as it is.In both countries, researcher employ translator and enumerator to help students in understanding the questions.Data analysis used a quantitative approach using the chi-square test for bivariate analysis and the logistic regression for multivariate analysis.

Results and Discussion
Data regarding self-perception and BMI were available from 1,138 teenagers.Among them, a total of 415 teenagers were from Indonesia, whereas 723 teenagers were from Taiwan.Descriptive characteristics of the teenagers are reported in Table 1.The mean age was 15.79 (±1.48) years old, and there was a significant difference in means between Indonesian and Taiwanese teenagers (p<0.001).Fifty four percent of the teenagers were males, and 149 of them were from Indonesia (24.39%).When compared to male teenagers between 2 countries, there was a statistical difference between groups (p<0.001).
BMI was analyzed as a numeric variable from body weight (kg) and height (m).The mean of BMI was 21.07 (+ 4.11) kg/m2 and there was no significant difference of BMI between Indonesian and Taiwanese teenagers (p=0.77).If categorized, underweight teenagers were found in 17% participants.Among them, 57,2% of them were from Indonesia and 42,7% were from Taiwan.Normal BMI were found in 59.1% teenagers.Among them, 35.6% of them were from Indonesia and 64.4% were from Taiwan.However, there were more overweight teenagers from Taiwan (86.4%) than from Indonesia (13.6%).Likewise, in obese teenagers, there were more obese teenagers from Taiwan (61.2%) than from Indonesia (38.2%).When compared to 4 categories of BMI between 2 countries, there was a statistical difference between groups (p<0.001).The association between self-perception and BMI among 2 countries was reported in Table 2. Out of 21 self-perception variables assessed, the bivariate analysis found 10 selfperceptions associated with BMI (p<0.05):self-perception of desire to lose weight, reason to lose weight for appearance, reason to lose weight for better health, reason to lose weight for better well-being, reason to lose weight to fit the clothes, obesity might be treated by hospital, clinics, and specialist, obesity is related to degenerative disease, obesity affects mental condition, and ideal body image.
From 201 overweight teenagers, the proportion was more common in teenagers who had self-perception of desire to lose weight (86.7%) than those who did not have self-perception of desire to lose weight (15.5%).Current study also found that the proportion of overweight teenagers was higher among teenagers who had reason to lose weight for appearance (58.7%) and for better health (68.7%) compared to those who did not have reason for appearance (41,3%) and for better health (31,3%).However, teenagers who did not have reason to lose weight for better well-being, to get in shape, and to fit the clothes were more common in overweight teenagers.Seventy percent of overweight teenagers assumed that the role of genetics in obesity is important than other assumption, however, this difference was not statistically significant (p=0.20).
When compared with overweight teenagers, non-overweight teenagers had more self-perception that diet and exercise might induce weight loss (83.4%) than overweight teenagers (16.6%).Regarding the management of obesity, the perception that obesity might be treated was mostly owned by non-overweight teenagers than those who were overweight, treated by hospital, clinics, or specialists (87.2%), by general practitioners (84.9%), dietitians/ nutritionists (83.3%), social workers (85.7%), individual efforts (82.6%), bariatric surgery (84.6%), and prescribed drugs (86.1%).Of the 7 self-perceptions related to obesity management, the variable statistically associated was only obesity might be treated by hospital, clinics, or specialist (p<0.001).
Other perceptions also showed that nonoverweight teenagers had more self-perception that obesity is related to degenerative disease (84.3%), obesity is related to life expectancy (83%), obesity affects mental condition (85.2%), and obesity affects social life (85.4%)compared to those who were overweight.However, the variables statistically associated were selfperception of obesity is related to degenerative disease (p = 0.003) and obesity affects social life (p = 0.04).Self-perception that in sports, obese people could be as good as normal people showed there was no significant difference, both in teenagers who were overweight and not overweight (p=0.11).Most teenagers who were overweight and not overweight had the correct perception regarding ideal body image and it was statistically significant (p=0.04).The multivariable logistic analysis is shown in Table 3. From 10 self-perceptions associated with BMI in bivariate analysis, the multivariable analysis found 5 associated selfperceptions: desire to lose weight, reason to lose weight for better health, diet and exercise might induce weight lose, obesity might be treated by hospital, clinics, or specialist, and obesity is related to degenerative disease.
From this result, investigators concluded that self-perception of desire to lose weight was a variable with major contribution to actual BMI among teenagers.Teenagers who did not have self-perception of desire to lose weight were 6.37 times more likely to have overweight than teenagers who had self-perception of desire to lose weight.
This research was trying to explore the relationship between self-perception and actual BMI of teenagers in Indonesia and Taiwan.The data was collected from 1,138 11th graders spreading across 13 different schools in Indonesia and Taiwan.The average respondents age was 15.79 (±1.48) years old.There were 53.7% male teenagers and 527 female teenagers with average BMI of 21.07.
Bivariate analysis showed that there was significant difference between categories of BMI in Indonesia and Taiwan (p<0.001), but no different in numeric BMI.In Indonesia, most of teenagers were underweight and normal.On the other hand, most teenagers in Taiwan were normal and overweight.The questionnaires containing 21 self-perception variables, in which 10 self-perceptions associated with BMI (p<0.05):self-perception of desire to lose weight, reason to lose weight for appearance, reason to lose weight for better health, reason to lose weight for better well-being, reason to lose weight to fit the clothes, obesity might be treated by hospital, clinics, and specialist, obesity is related to degenerative disease, obesity affects mental condition, and ideal body image.The 10 self-perceptions then analyzed by using logistic regression.It has 5 associated self-perceptions: desire to lose weight, reason to lose weight for better health, diet and exercise might induce weight lose, obesity might be treated by hospital, clinics, or specialist, and obesity is related to degenerative disease.The desire to lose weight was a variable with major contribution to actual BMI among teenagers, if teenagers did not have self-perception of desire to lose weight, they will be 6.37 times more likely to be overweight.
Result of this research is consistent with the results of another study proving that eating behavior and physical activity are thought to be the main triggers of the high prevalence of teenagers obese teenagers (Mahdiah et al., 2004).Another study showed that obesity and stress could trigger hypertension (Korneliani & Meida, 2012).The results of data analysis showed that there was a relationship between central obesity with total blood cholesterol levels (Listiyana et al., 2013).In addition, environment factors such negative social support and stigma received resulted in psychological impact and less interactions (Muharry & Kumalasari, 2018).The study of the Gene-Environment Interaction (GEI) has shown that heritability had an impact on both monogenic and polygenic obesity.It provided convergent evidence wherein obesitypredisposition genes interact with various environments, lifestyle and exposure treatment (Reddon et al., 2016).Interventions with lifestyle approaches consisted of the promotion of healthy lifestyles, nutritional counseling, physical training, and behavioral change improved weight loss and reduced risk factors for cardiovascular disease (Galani & Schneider, 2007;Kurnia et al., 2018).
This research had different approach in understanding the nature of body weight and BMI.This uniqueness made it possible to conclude that self-perception played an important role in the actual BMI.Those with good self-perception of their own weight will be less likely to be overweight or obese.Differences in race, ethnicity, and tradition will result in differences in health treatment and health care which will shape different perception (Horowitz et al., 2000).This study combined data of Taiwanese and Indonesian teenagers, which showed that the shared culture shaped nearly similar self-perception Correct perception of obesity will help teenagers to lose their weight (Yang et al., 2014).
Obese people tend to watch more television and rarely have a physical activity or in other words have a sedentary lifestyle (Cameron et al., 2003).The habits of Indonesian teenagers who watch shows on TV during their free time and idolize popular artists who influence perceptions related to obesity and activity.In line with the results of research which states that various online media such as advertisements and public figures provide the dogma that the ideal body is slim and thin so that it can influence people's perceptions about obesity (Faccio, 2013).Good community perceptions about ideal body shape will motivate teenagers to reach a better body goal (Hesketh et al., 2005).The limitation of this research was there were no observations done in rural environments.This made the result of this research limited only to urban teenagers.

Conclusion
There were no significant differences in BMI between Indonesian and Taiwanese teenagers, but there was a significant difference in BMI categories.Most Indonesian teenagers were categorized as underweight and normal, where as Taiwanese teenagers categorized as overweight and normal.The desire to lose weight, reason to lose weight for better health, diet and exercise might induce weight lose, obesity might be treated by hospital, clinics, or specialist, and obesity is related to degenerative disease were significant perceptions affecting the actual BMI.Teenagers with no selfperception to lose weight will be more likely to developed overweight than their counterparts.It is important to include the rural areas for the future research.

Table 1 .
Description statistics of participants

Table 2 .
Self-Perception and Actual Weight (BMI Category) in Indonesian dan Taiwanese Teenagers

Table 3 .
Multivariable Logistic Analysis of Actual BMI based on Self-Perception