Diabetes and heart disease are prevalent chronic diseases in the United States. Diabetes affects 8.3% of US adults (1), heart disease, 6.5% (2). Approximately half of those diagnosed with diabetes are women (1), and more women than men die from heart disease (3).

Obesity is a contributing risk factor for both diabetes and heart disease (4). However, many US adults are not aware of this association (5) and do not consider obesity to be a serious health concern (6). Accurate weight perception is a key tool in identifying risk for obesity-related chronic disease and may encourage people to lose weight (4). Despite efforts and encouragement by physicians and other health professionals, a strong societal focus on weight loss and management, and marketing efforts to accurately assess weight and encourage weight loss, more than 75% of overweight Americans fail to accurately identify themselves as overweight or obese (7).

As with weight perceptions, many Americans tend to underestimate their risk for obesity-related chronic diseases, including diabetes and heart disease (8). Women, particularly black and Hispanic women, frequently underestimate their health risks associated with obesity (9). Higher health literacy is associated with more knowledge of chronic disease (10) and may play a role in perceived risk for chronic diseases such as diabetes and heart disease. Limited health literacy is associated with low medication adherence for chronic disease (11), heart disease deaths (12), poor glycemic control, and more diabetes-related complications (13).

Our objective was to examine predictors of perceived risk for diabetes and heart disease among overweight and obese women, specifically, perceptions about being overweight. Given the high rates of obesity among black and Hispanic women (14), study findings can contribute to targeted disease risk interventions for high-risk populations. We excluded men from our study because of sex differences in overweight and obesity; being overweight is associated with better psychosocial functioning in men but not women (15). Because people with poor health literacy might not be aware of the link between being overweight and chronic disease, we stratified analyses by health literacy. We hypothesized that perceiving oneself as overweight and believing that being overweight is a personal health problem would be associated with perceived risk for disease in women with higher but not lower health literacy.

Forty-three percent of our sample was non-Hispanic black, 30% was Hispanic, and 27% was non-Hispanic white (Table 1). Thirty-nine percent had higher health literacy. Black (χ² = 4.2, P = .04) and Hispanic (χ² = 21.6, P < .001) participants were more likely to have lower health literacy than were white participants.

Overall, beliefs about one's weight were associated with greater perceived risk for diabetes and heart disease among overweight and obese women. Although some studies have examined awareness of the link between obesity and chronic illness (5,21), to our knowledge, no other studies have examined personal weight perceptions and the association with perceived risk for diabetes and heart disease.

On the basis of previous research on health literacy, we reasoned that health literacy would be associated with greater perceived risk for diabetes and heart disease among women who are overweight or obese, which would indicate that these women accurately identify themselves as overweight and are aware that being overweight increases their risk for diabetes and heart disease. When we stratified the analyses by level of health literacy, weight perceptions were associated with perceived risk for diabetes but not heart disease among women with higher health literacy. However, participants with lower health literacy accurately identified themselves as at greater risk for heart disease based on their weight and family history. These results may indicate that people perceive diabetes and heart disease differently. The risk factors for heart disease may be better known than for diabetes because heart disease is the leading cause of death among women. Therefore, perhaps less attention is paid to diabetes, and the risk factors for this disease are less well known, which has been shown in research on perceived risk for diabetes (22,23).

It is unclear why weight perceptions were associated with perceived risk for diabetes but not heart disease among participants with higher health literacy. Given the prevalence of heart disease, perhaps people with higher health literacy educate themselves more on other risk factors for heart disease, such as high triglyceride levels and smoking (24,25). If so, people with higher health literacy may view these risk factors as having a greater effect than being overweight. People with higher health literacy also may be engaging in weight-loss behaviors to a greater extent than those with lower health literacy. A study of older adults did not find an association between health literacy and unhealthy behaviors (26), but future research should examine this possible association in a more generalizable sample. People engaging in healthy behaviors may perceive their risk for chronic disease as reduced, but additional research with a larger sample is needed.

We did not find, as another study did, that black and Hispanic women have poorer perceived risk for chronic disease than do white women (21), perhaps be because our sample came from a socioeconomically homogenous group of county health center patients. Socioeconomic status may be a greater predictor of perceived risk for chronic disease than race/ethnicity. Sociocultural differences associated with race/ethnicity should also be factored into risk and weight perceptions.

This study had several limitations. Questionnaire responses were collected from a convenience sample of low-income women from Long Island, New York. Our findings may not generalize to women from other parts of the country. We did not assess Participants' reasons for visiting the health centers, and data are based on self-reports. We attempted to address the latter issue by conducting an anonymous survey. Although people sometimes underestimate their weight, their estimates are generally accurate (27,28); however, the lack of an objective measure of BMI is a major study limitation. BMI does not assess adiposity, and being overweight but not obese, based on BMI standards, does not always result in adverse health consequences (29,30). The results from the analyses stratified by health literacy should be interpreted cautiously, given the small cell sizes. Nevertheless, stratifying the analyses by level of health literacy was preferable to treating health literacy as a covariate, given our interest in examining health literacy as a moderator.

A study strength is that we used a comprehensive definition of weight perception by including both an item about perceived weight status and an item about perception of one's weight status being a health problem. Future research should continue to examine accuracy of perceived weight status and associations with perceived risk for other conditions associated with obesity, such as hypertension and some types of cancer. Future studies should also use larger, representative samples because it is possible that some effects were undetected, given our small cell sizes. Appropriately identifying pathways that are associated with disease risk perceptions may lead to a greater understanding of other obesity-related risk factors. Health professionals should try to ensure that patients who are overweight are aware of their own weight status and of the associated health risks. Health professionals should also be aware of the role of health literacy when offering health recommendations to patients.