Knowledge and perceptions of obese housewives in Sri Lanka: a qualitative study

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Nearly 39% of adults in Sri Lanka are obese and the majority represents the middle-aged women. Knowledge and perceptions about causes, comorbidities, dietary and lifestyle management of obesity is vital in developing sustainable and feasible interventions. Therefore, present study aims to assess the knowledge and perceptions of obesity among a group of housewives with obesity in Sri Lanka using qualitative research methods. Methods A descriptive qualitative study conducted using 35 individual interviews. Interviews were steered with purposely selected housewives with obesity aged 25–50 years living in Pannala area. All the interviews were conducted in participants’ native language and transcribed verbatim. Data were analyzed using NVIVO v12.0 software and themes and subthemes were derived. Results As stated, only a few of obese housewives perceived them as either overweight or obese. Unhealthy diet, physical inactivity, genetics, surgeries, contraception methods, and multiple pregnancies were the perceived causes of obesity. Majority believed that diet and physical activity has an impact on obesity. Perceived personal barriers for obesity management were lack of time, lack of motivation and less interest. Inconvenience in continuing a diet plan, impact of family members, limited time to do exercises, less interest in losing body weight and physical inconveniences following the exercises were the barriers related to dietary management and engage in physical activities. Conclusions Findings of the current study highlighted the lack of knowledge and awareness about their current obesity condition by the obese women, thus urge of initiating awareness and education programmes is emphasized. Despite the knowledge and perceiving the importance of healthy diet and physical activities for managing their obesity condition, most of them were unable to adhere to a healthy lifestyle pattern due to personal and social circumstances. Diet Housewives Knowledge Lifestyle Obesity Physical activity Perceptions Background Prevalence of obesity is increasing at alarming rate worldwide. Overweight and obesity is now recognized as public health emergency in Sri Lanka. In 2005, 25.2% of adult Sri Lankans were overweight, 9.2% were obese and 26.2 were centrally obese with one in every two urban dwelling females were affected by central obesity as per the Asian cut off values [ 1 ]. In fact, female gender, urban living, higher education, higher income and being in the middle age were revealed to be strongly associated with overweight and obesity among Sri Lankans [ 1 ]. A national survey conducted in 2012 further revealed that prevalence of overweight (BMI > 23kgm- 2 ) and obesity (BMI > 25 kgm − 2 ) were 28.7% and 15.2% among adult females [ 2 ]. Above findings were further verified by a recent study conducted in urban setting of Sri Lanka where 34.3% of adults were overweight and 32.1% were obese where adult females found be having higher rates of obesity and central obesity [ 3 ]. Further, STEPS survey conducted in 2021 showed that 39% of adults were obese (BMI > 25 kgm − 2 ) and prevalence of obesity among adult females was 48% [ 4 ]. Rapid urbanization, shift in the dietary pattern from traditional plant-based diet to the ‘Western type of diet’, sedentary lifestyle, development of infrastructure facilities might have contributed to the higher rates of overweight and obesity among adults in Sri Lanka. Awareness of obesity and central obesity and the motivation towards reducing the body weight and waist circumference is an integral part of an effective nutrition intervention. One of the previous studies has reported that over two third of overweight and one third of obese Sri Lankan adults had the misconception on their body weight as either ‘normal’ or ‘underweight’ [ 5 ]. Perceptions of obesity is a vital component of individual’s lifestyle pattern towards achieving healthy body weight and waist circumference. Knowledge and perceptions of obesity indicate the readiness of behavior change towards reducing the body weight and waist circumference through lifestyle management and maintenance of attained better health outcomes. Although the obesity is continuing to rise particularly among adult females, there are no proper public health interventions targeted on reversing the current obesity trend in Sri Lanka. Planning of compatible public health interventions requires in depth studies on understanding individual perceived causes and comorbidities of obesity, purview of obesity management strategies and potential barriers for adhering to lifestyle management strategies. Further, assessment of current level of knowledge and awareness on obesity condition would enable in developing feasible and sustainable interventions to combat the current obesity trends. Therefore, the present study aims to assess the knowledge and perceptions of obesity among middle aged obese adult females of Sri Lanka those who served as housewives. Their perception on causes, comorbidities, possible management strategies of obesity and barriers for adhering to healthy lifestyle pattern were appraised. Materials and methods Study design and participants This qualitative study was conducted with thirty-five (n=35) obese (Body Mass Index>25 kgm -2 ) volunteer housewives in the age range of 35-55 years through convenient sampling. Obese housewives were residents of sub-urban areas of Kurunegala District of Sri Lanka. They were apparently healthy without a history of any non-communicable diseases, psychological problem and eating disorders. Obese housewives with any form of diseases, mental illness, physical disabilities and pregnant and lactating mothers were excluded from the study. Screening session was conducted to verify the BMI (BMI>25kgm -2 ) and general health status of obese housewives. At the screening session, they were invited to take part in the study. Data collection Socio-demographic data Socio-demographic details of the participants were collected including age, gender, area of residence, marital status, level of education, occupation, family income prior to the interviews using a questionnaire. Anthropometric measurements Standing height and weight were measured in indoor light clothing using a stadiometer and digital weighing scale respectively. Waist circumference was measured using a non-stretchable tape at the point of umbilicus. BMI was derived by dividing the body weight (kg) by the height square (m 2 ). All the anthropometric measurements were taken after overnight fasting following the standard procedures. Obesity perceptions Individual interviews were conducted with a semi-structured questionnaire (additional file). Questionnaire had a set of open-ended questions to guide the participants and to ensure the uniformity between individual interviews. Duration of each interview was 15 minutes and each interview was tape recorded with consent of participants. All the interviews were conducted in their native language, Sinhalese. One independent observer (facilitator) at each interview were responsible for verbatim recording / transcribing and documenting the emotional responses of participants with the support of an assistant. The facilitator provided the guidance and assisted in keeping the focus of interviews while stimulating and regulating the flow of each interview. Data analysis Direct content analysis of qualitative data was conducted with the support of NVIVO v12.0 software (QSR International, UK). Themes were determined as a template prior to the data analysis. Participants’ responses were grouped under these identified themes thereafter. Themes include obesity perceptions of housewives, causes of obesity, obesity related comorbidities, management of obesity, use of lifestyle management strategies (dietary and physical activity) to manage the obesity and barriers faced in obesity management through diet and physical activities. Immediately after concluding each interview, facilitator and assistant analyzed respective interview using their notes and tape recording. It included both the verbal and non-verbal responses of each participant at individual interview. All the documented responses were collectively analyzed after completing the interviews. The data were initially transcribed in Sinhalese, the native language of study participants and later translated to English language by an independent translator. Final document with the responses of study participants was generated with the consensus of all research team members. Obesity was defined as BMI ≥25.0 kgm- 2 [6]. Abdominal obesity was defined as a waist circumference >90 cm for males and >80 cm for females [6]. Results General characteristics Thirty-five obese housewives were recruited (response rate 80%) with a mean age of 44.0 ± 5.7 years (range 35-55 years). All were Sinhalese in ethnicity. Mean BMI, waist circumference and waist to hip ratio of the participants were 30.7 ± 5.7 kgm -2 , 100.9 ± 7.6cm and 0.96 ± 0.14, respectively. Majority were educated up to the grade 6-11 in secondary school ( n =25, 71%), unemployed ( n =28, 80%) and had a mean monthly household income of LKR 30,000 (US$ <140). Knowledge and perceptions about obesity Almost all the housewives with obesity ( n -35) either thought or felt that their body weight is high. Their general believes on their body weight were as follows; “I think my weight is high.” (I 1 , 38 years) “I feel my weight is higher than normal weight.” (I 6 , 47 years) However, only a few of them (n-8) perceived themselves as either overweight or obese. Some of their perceptions of obesity were; “According to my height, this weight is too much. I think I am overweight.” (I 2 , 33 years) “I feel my body weight is high and therefore I might be either overweight or obese.” (I 3 , 40 years) About 35% of them (n-12) knew about BMI and the only a few of them (n=5) were aware about the proper interpretation of individual BMI value as stated below; “As I think, BMI shows whether we have the proper weight for height. I think my BMI is higher than what I should have.” (I 4 , 43 years) “I think I am obese according to my BMI.” (I 7 , 48 years) Majority ( n =25) of housewives with obesity perceived the central obesity as the protrusion of belly; “I think protrusion of belly is the central obesity.” (I 5 , 50 years) About 17 % ( n =6) knew that the obesity is the excess deposition of fat and weight gain is indicated as overweight and obesity. “I think obesity develops due to the deposition of fat inside the body. Excess fat deposition is the reason for weight gain. So excess fat deposition causes the obesity.” (I 4 , 43 years) Nearly 11% ( n =4) knew that obesity causes diseases like diabetes, hypertension and other cardiovascular diseases as stated; “I think obesity is a reason for diseases like diabetes and high blood pressure.” (I 1 ,38 years) Perceived causes for obesity Majority of housewives with obesity (n-29) believed that lifestyle has an impact on their current obesity status. Some of the participants stated that; “ Less physical activities and eating without control are the causes of obesity.” (I 2 , 33 years) “Overnutrition causes the obesity.” (I 7 , 48 years) Almost all of them (n-29) recognized the unhealthy diet as one of the causes of obesity. Some of their perceptions on relationship between the unhealthy diet and obesity were; “I think I am overeating. I used to take four meals per day. I’m having similar quantities of food per each meal. I think it is a major reason for obesity.” (I 7 , 48 years) “Most of the times I eat yams, flour confectioneries, so I think, it affects to gain my body weight.” (I 2 , 33years) Some of them (n-13) perceived physical inactivity as an important cause of their obesity as denoted by; “Usually, I do not do exercise because I work in a café and I sleep just after eat and I think my sedentary lifestyle also reason for obesity.” (I 2 , 33years) “I think sleeping too much of time is also a reason for my obesity. Because I usually sleep after having my lunch.” (I 18 , 50years) However, some (n-5) believed that there is no impact of their current lifestyle pattern on obesity as mentioned by; “I think my day-to-day lifestyle doesn’t impact of my obesity.” (I2,33 years) According to their purview, genetics (n-6), surgeries (n-3), birth control methods (n-3) and multiple pregnancies (n-3) were the other causes of obesity. Some of their responses were; “I think I’m obese because of my genetics. Even as a child, I was obese. My all-family members are obese.” (I 6 , 47 years) “Two years ago, I faced a surgery, thereafter I became obese. Because I can eat more than past after that surgery.” (I 3 , 40 years) “I was slim before having babies. I became obese after having babies.” (I 1 , 38 years) Unhealthy eating Majority (n-29,83%) of the housewives with obesity knew that their poor dietary habits have contributed to the current obesity condition. Most of them perceived overeating (n-21), higher meal frequency (n-5), excessive consumption of sweets and flour confectioneries (n -14) and oily foods (n-24) as unhealthy eating practices that have led them to become obese. Some of their responses were; “I think, overeating is the reason for obesity.” (I4, 43 years) “I think over eating and eating oily food (fried food) also can cause the obesity.” (I5,50 years) “I think, eating oily food and flour confectioneries reason for gaining excessive body weight.” (I8, 50years) “Overeating of sweets, flour confectionaries and other food cause for the obesity.” (I3, 40years) A few of housewives with obesity (n-3) believed that excessive consumption of meat and fish also has contributed to their obese condition as denoted by; “I think, overeating of fish and meat can increase the body weight.” (I14 30years) In addition, some recognized overeating at night (n-5), eating similar quantities of food in every meal (n-3), sleeping after the meals (n-4) and in proper timing of meals (n-5) have contributed to their current obesity condition. Some of their views are shown below; “I think, over eating and over eating at dinner are reasons for the obesity.” (I8, 50 years) “I am overeating (4 meals per day). I’m having similar quantities of food per each meal. I think it is a major reason for obesity.” (I2, 33 years) “Normally I do not get my meals on time. So, I think it causes the obesity.” (I6, 47years) “I think sleeping too much of time is also a reason for my obesity. Because I usually sleep after having my lunch.” (I18, 50 years) However, some participants (n-5) stated that contribution of their dietary habit to become obese is less significant as denoted by; “Normally I am having a balanced diet. So, I don’t think my food habits affect my body weight.” (I24, 48 years) Physical inactivity Out of the 35 housewives with obesity, twenty-nine (n-29, 83%) were aware that physical inactivity has contributed for their current obesity. Majority believed that lack of time in their tiring lifestyle for physical activities and the use of automated equipment are the main reasons for their sedentary behavior. Some of their perceptions on contribution of physical inactivity towards obesity were; “I think sedentary lifestyle and low exercises causes obesity.” (I15, 25years) “ I’m not doing any exercise though I do daily household work. So, I’m getting fat.” (I11,48 years) “Every day, I’m doing my day-to-day household work, but I’m a less active person. Also, I sleep too much which can be affected to obesity.” (I9, 47 years) However, some of them (n-4) perceived engaging in household chores is enough them as mentioned by; “I am engaged in household work every day. So, I think it is enough for me.” (I20, 47 years) A few obese housewives believed that there is no any effect of physical activities on weight gain as denoted by; “I think my day today activities do not have any impact on my weight gain.” (I6,47yeras) Perceived comorbidities of obesity Majority (n-26,74%) of the obese housewives reported that they are affected with muscular skeletal problems such as difficulties in sitting, walking, knee pain and back pain due to their current condition. They believed that the obesity condition has disturbed their routine and some of their views are as follows; “Actually, after becoming obese, I faced lot of problems such as leg and hand pain and extra tiredness when walking.” (I5,50 years) “I’m getting fatigue quickly when I’m doing household work. I have a back pain” (I15, 25 years) “I feel uncomfortable when walking. I can’t walk well as the past because of knee pain and edema in ankles. I can’t do my day-to-day work actively.” (I13,50 years) Some of the housewives (n-5) believed that obesity has complicated their other health and disease conditions as shown by; “I have difficulties in breathing and knee pain due to protrusion of belly and feel uncomfortable.” (I12,40 years) In addition, most of them reported the issues pertaining to their appearance and body size particularly in selecting the cloths as denoted by; “There are no suitable clothes to buy me when I’m doing shopping as the sizes are not matching with my body size.” (I3,40 years) “I feel stressed when I can’t wear my old clothes.” (I6,47 years) Management of obesity Majority of obese housewives perceived that their current lifestyle pattern has contributed to their condition. They believed that dietary modification (n-18) and engaging in the physical activities (n-14) will allow them to lose weight as shown by; “Body weight can be reduced by dieting.” (I8,50 years) “I think if I do exercises, I can lose the weight.” (I20, 47 years) Most of them (n-12) believed that combination of dietary modification and exercises would assist them in losing the body weight. Some of their responses were; “I think I can lose my body weight by dieting and exercising.” (I7, 48 years) Some of the obese housewives perceived to follow dietary modifications. One stated; “I’m on a special diet. I’m taking a small quantity of food at dinner. So, I think it will help me to lose weight.” (I10, 50 years) Barriers for weight management Although the majority of obese housewives knew importance of managing the body weight and perceived the role of diet and physical activities in attaining proper body weight, they were lagging behind several barriers. Major barriers for weight management through lifestyle modification were the less motivation (n-10) and less interest (n-9) as per the views of the housewives with obesity. Some of their responses were; “I don’t need to lose the body weight. I’m not interest about it.” (I3, 40 years) “I have never tried to lose my weight because I don’t care much.” (I21, 48 years) “I have tried to lose body weight. But I didn’t continue it because I’m lazy.” (I19, 44 years) Further they stated that lack of dedicated personal time for engaging in physical activities or exercises (n-9) and social and familial issues (n-3) restricting them to modify their current lifestyle pattern as mentioned by; “I have no time to do exercises and to manage my diet due to my busy lifestyle.” (I14, 30 years) “Actually, we should do exercises but practically unable to find time to do this with day to day house hold work.” (I2, 33 years) “I have to prepare food according to the demand of my family members, so I cannot prepare the food that I really want to eat.” (I1, 38 years) “I have tried to control my body weight by dieting but it was unsuccessful. Because my family members dislike to eat the food that I prepared aiming the weight control.” (I32,33 years) According to some of the housewives with obesity, hunger feeling after eating less quantity of food and accompanied difficulties in sleeping due to low satiety were some of the perceived barriers for food portion control. One stated; “I can’t sleep after eating less amount of food. I have tried to diet, but I feel hungry after I had a low quantity of food.” (I34, 34 years) Further, some of them believed that reduced food intake might lead to gastritis condition as mentioned by; “If I want to lose the body weight, then I have to diet. There can be some problems by reducing the food consumption such as gastritis.” (I24, 48 years) A few of them were reluctant to engage in any form of physical activities as they experienced physical inconveniences following physical activities as denoted by; “I have a pain in my knees when I’m jogging, it prevents me getting some exercises.” (I2, 33 years) Discussion According to our knowledge this is the first qualitative study conducted to evaluate the knowledge and perceptions of obese housewives about their condition. Obesity is more prevalent among women in Sri Lanka thus significant proportion of women with obesity is comprised of housewives. Therefore, assessing their knowledge and perceptions on causes, comorbidities, possible management strategies and potential barriers of obesity management is of great importance in developing appropriate lifestyle interventions. Although the almost all obese housewives thought or felt about their excess body weight, only a few perceived them as either overweight or obese. A few of them knew that the excess fat accumulation and weight gain are indicated in obesity and central obesity and obesity leads to other non-communicable diseases such as type 2 diabetes mellitus, hypertension and other cardiovascular diseases. As the appearance of non-communicable diseases taken place at the middle age and particularly the obese women are more prone to the NCDs [ 5 ], this study highlights the importance of educating middle aged women on relationship between obesity and NCDs through the currently operating “Well Women Clinics” at the primary healthcare setting. About one third of them were knew about the BMI. A few of them were aware about proper interpretation of their individual BMI value. It indicates the poor knowledge and understanding about BMI and its interpretation among studied population and consistent with the previous findings on body weight and BMI perceptions [ 7 , 8 ]. Although the BMI is widely used indicator of obesity, findings of the current study highlighted the necessity of more targeted education and awareness on use of BMI for self-identification of the weight status of adults. Inability of study participants to recognize their weight status can keep them away from healthy behaviors thus leading to increased risk of obesity related comorbidities. Majority of them recognized the central obesity as the protrusion of belly and had sufficient knowledge on use of waist circumference as an indicator of central obesity. It may be due to the self-consciousness of body shape by the women and frequent use of waist circumference in clothing. As most of them were concerned in selecting suitable clothing due to altered body shape and size of their current obesity, positive rewarding appeal can be used in behavior change communication to reach the previous body shape and size of obese women. Majority of obese housewives perceived their lifestyle has an impact on their current obesity status. Unhealthy diet and physical inactivity were the major perceived causes of obesity similar to the previous findings [ 9 – 16 ]. Conversely some of our study participants only recognized the contribution of physical inactivity for their obesity status. According to the STEPS survey 2021, Sril Lankan women were found to be more physically inactive than males [ 5 ]. Few of study participants perceived genetics as cause of obesity. In addition, obese housewives of this study emphasized surgeries, contraceptive methods and multiple pregnancies as other causes of obesity. There is a common cultural belief that the pregnant and lactating women should eat more. Particularly during the pregnancy period, common cultural belief is to ‘consume food for two’. In fact, that increased food consumption is believed to be associated with proper foetal growth and wellbeing. Additionally, increased food intake during the lactation period is believed to increase the milk production and well-being of both mother and new born. Therefore, it necessitates providing proper education for women of reproductive age about obesity risk and its connection to the NCDs through health promotion campaigns. Further it is important to create awareness on underlying factors of socio-cultural and medical origins to address the obesity related social stigma. Most of the housewives with obesity knew that their poor dietary habits have contributed to the current obesity. They perceived overeating, higher meal frequency, excess consumption of sweets and flour confectionaries and oily food as dietary contributors of their current obesity status. In most of houses, housewives are the last family members to consume the food, particularly in the night time. Therefore, there is a great possibility of consuming remaining excess food by the housewives leading to weight gain. Food environment plays a vital role in purchasing and preparing food [ 14 ]. Our study participants reported that they consume fried foods and flour confectionaries due to their availability in the surrounding environment and frequent purchasing of those for their children. As this kind of unhealthy behavior exert risk for younger family members for developing obesity and other NCDs in later life, improving their food environment should accompany the community education programs. Most of them were aware that the physical inactivity has contributed to their obesity status. However, the recognition of physical inactivity as a major contributor was low due to limited awareness of potential benefits. Some knowledge gap was apparent as few of them believed engaging in household work is enough for weight management and expressing their reluctance in allocating a dedicated time for physical activities similar to the previous findings among obese adults [ 9 – 11 ]. In the present study, majority of housewives with obesity were aware of importance of diet and physical activities in managing the obesity. However, adhering to the planned diet and following regular physical activities is restricted by difficulties faced by them. Less motivation and interest in adhering to a healthy lifestyle in achieving a proper body weight and limited awareness of adverse outcomes of obesity were identified in this study. It urges the need of taking immediate steps towards creating awareness and lifestyle focused education for obese housewives. Further, some of the barriers faced by the obese housewives need to be addressed through behavior change communication. Hence, use of motivation through individual or small group communication programmes aimed at behavior change would help them to overcome ‘less interest’ and ‘less motivation and ensure the self-commitment. Family support is essential in adopting a healthy lifestyle. Conforming family practices with lifestyle would have restricted food choices of housewives and allocating time for physical activities. Therefore, it is important to take the possible social issues into account when behavior change programmes are planned with modified diet and physical activity as suggested by previous authors [ 17 , 18 ]. Findings of the current study emphasizes the urge of initiating education and awareness programs among general public targeting the housewives on obesity and lifestyle management of obesity through adhering to a healthy dietary pattern and physical activity. Further, it highlights the need of individual or group counseling to motivate people with obesity to modify their behavior. Hence these urges allocating resources, developing facilities and training healthcare professionals to perform nutrition counseling at the in the primary healthcare settings. This is the first qualitative study conducted in Sri Lanka to identify the knowledge and perceptions of obesity among obese housewives in suburban community. Open ended questions used in the interviews allowed to comprehensive understanding of the perspectives of participants in terms of causes, comorbidities, methods of assessing the obesity, obesity management and barriers for obesity management through lifestyle approaches. Nevertheless, this study was limited to a suburban area, where perceptions of the urban and rural obese women may not be represented. All study participants were Sinhalese in ethnicity. Hence the representation of perceptions of other ethnicities lacks in the study. Despite of the given limitations, current study provides valuable insights on perceptions of obese housewives. Further studies are suggested to assess the impact of perceptions on obesity management behaviors. Conclusions Misperception of obesity was common among the obese housewives. Unhealthy diet, physical inactivity, genetics, surgeries, contraception methods, and multiple pregnancies were the perceived causes of obesity. Majority believed that diet and physical activity has an impact on obesity. However, majority of obese housewives were unable to implement healthy lifestyle behaviors due to personal and social barriers. Perceived personal barriers for obesity management were lack of committed time, lack of motivation and less interest. Inconvenience in continuing a diet plan, impact of family members, limited time to do exercises, less interest in losing body weight and physical inconveniences following the exercises were the barriers related to dietary management and engage in physical activities. Findings of the current study urges initiating health promotion programs for general public targeting the housewives through primary healthcare setting of Sri Lanka. Further it emphasizes to motivate housewives through behavior change communication thus allocation of resources and training healthcare professionals is recognized as a timely necessity. Abbreviations BMI Body mass index NCDs Non-communicable diseases WHR Waist to hip ratio Declarations Ethics approval and consent to participate Ethical approval was obtained from the Ethics Review Committee, Faculty of Livestock, Fisheries and Nutrition (201806HI06). Informed written consents were obtained from each study participant after a briefing session of the study and clarifying the queries raised by them before the study commenced. The current study was conducted in accordance with the principles described in the Declaration of Helsinki. Consent for publication Not applicable Availability of data and materials The data sets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial and not-for-profit sectors. Authors' contributions HPG and SR made substantial contribution to conception and study design. HPG, SR and NCJ were involved in data collection and data analysis. HPG and SR were involved in drafting the manuscript. All authors read and approved the final manuscript. Acknowledgements Authors would like to acknowledge the study subjects for their volunteer participation and research team of the Department of Nutrition and Dietetics for their assistance. Authors' information (optional) HP Gunawardena 0094 773759475, [email protected] S Rangajeewa, [email protected] NC Jayaweera, [email protected] References Katulanda P, Jayawardena MAR, Sheriff MHR, Constantine GR, Mathews DR. Prevalence of overweight and obesity in Sri Lankan adults. Obes Rev. 2010; DOI:10.1111/j.1467-789X.2010. 00746.x Jayatissa R, Hossain SMM, Gunawardena S, Ranbandara JM, Gunathilake M and De Silva PC. 2012. Prevalence and associations of overweight among adult women in Sri Lanka: a national survey. Sri Lanka Journal of Diabetes, Endocrinology and Metabolism. 2012; 2:61-68, http://dx.doi.org/10.4038/sjdem.v2i2.4774 Somasundaram N, Ranathunga I, Gunawardana K, Ahamed M, Ediriweera D, Antonypillai CN, Kalupahana N. 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Knowledge and perceptions about diet and physical activity among Sri Lankan adults with diabetes mellitus: a qualitative study. BMC Public Health. 2015; https://doi.org/10.1186/s12889-015-2518-3 Additional Declarations No competing interests reported. Supplementary Files Interviewguideforindividualinterviewsknowledgeandperceptionsofobesehousewives.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Oct, 2025 Reviews received at journal 24 Sep, 2025 Reviews received at journal 20 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers agreed at journal 12 Sep, 2025 Reviewers agreed at journal 12 Sep, 2025 Reviewers invited by journal 11 Sep, 2025 Editor assigned by journal 11 Sep, 2025 Editor invited by journal 03 Sep, 2025 Submission checks completed at journal 02 Sep, 2025 First submitted to journal 02 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Gunawardena","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBACAyBmBpH8DAxsYBE+HmK1SDZAtbARpwXEOECsFnP2s48/FxTcsdt8I8fsAUONHVDLAfxaLHvSzaRnGDxL3nYjx9yA4VgyAxtvAwGHHUhjY+YxOJxsdjvHTIKBDeg8fkJ+Of+M+TNIi/FskJZ/xGi5kcYgDdRiZyAN1MLYdoAIh914xgbU8ixB4v6zcoPEvmQegt43OJ8GdNifO/b8PYe3PfjwzU6OnyeBgMsg4EBiAwOHAQNQMaFYQWixZ2Bgf0Cs6lEwCkbBKBhhAAApGD1EchGlCQAAAABJRU5ErkJggg==","orcid":"","institution":"Wayamba University of Sri Lanka, Gonawila (NWP)","correspondingAuthor":true,"prefix":"","firstName":"Harshi","middleName":"Prasadini","lastName":"Gunawardena","suffix":""},{"id":516257328,"identity":"f5a3ba1b-9d5a-48a9-b49f-179eb7b40b4e","order_by":1,"name":"Supun Rangajeewa","email":"","orcid":"","institution":"Wayamba University of Sri Lanka, Gonawila 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study","fulltext":[{"header":"Background","content":"\u003cp\u003ePrevalence of obesity is increasing at alarming rate worldwide. Overweight and obesity is now recognized as public health emergency in Sri Lanka. In 2005, 25.2% of adult Sri Lankans were overweight, 9.2% were obese and 26.2 were centrally obese with one in every two urban dwelling females were affected by central obesity as per the Asian cut off values [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In fact, female gender, urban living, higher education, higher income and being in the middle age were revealed to be strongly associated with overweight and obesity among Sri Lankans [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A national survey conducted in 2012 further revealed that prevalence of overweight (BMI\u0026thinsp;\u0026gt;\u0026thinsp;23kgm-\u003csup\u003e2\u003c/sup\u003e) and obesity (BMI\u0026thinsp;\u0026gt;\u0026thinsp;25 kgm\u003csup\u003e\u0026minus;\u0026thinsp;2\u003c/sup\u003e) were 28.7% and 15.2% among adult females [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Above findings were further verified by a recent study conducted in urban setting of Sri Lanka where 34.3% of adults were overweight and 32.1% were obese where adult females found be having higher rates of obesity and central obesity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Further, STEPS survey conducted in 2021 showed that 39% of adults were obese (BMI\u0026thinsp;\u0026gt;\u0026thinsp;25 kgm\u003csup\u003e\u0026minus;\u0026thinsp;2\u003c/sup\u003e) and prevalence of obesity among adult females was 48% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Rapid urbanization, shift in the dietary pattern from traditional plant-based diet to the \u0026lsquo;Western type of diet\u0026rsquo;, sedentary lifestyle, development of infrastructure facilities might have contributed to the higher rates of overweight and obesity among adults in Sri Lanka.\u003c/p\u003e\u003cp\u003eAwareness of obesity and central obesity and the motivation towards reducing the body weight and waist circumference is an integral part of an effective nutrition intervention. One of the previous studies has reported that over two third of overweight and one third of obese Sri Lankan adults had the misconception on their body weight as either \u0026lsquo;normal\u0026rsquo; or \u0026lsquo;underweight\u0026rsquo; [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Perceptions of obesity is a vital component of individual\u0026rsquo;s lifestyle pattern towards achieving healthy body weight and waist circumference. Knowledge and perceptions of obesity indicate the readiness of behavior change towards reducing the body weight and waist circumference through lifestyle management and maintenance of attained better health outcomes.\u003c/p\u003e\u003cp\u003eAlthough the obesity is continuing to rise particularly among adult females, there are no proper public health interventions targeted on reversing the current obesity trend in Sri Lanka. Planning of compatible public health interventions requires in depth studies on understanding individual perceived causes and comorbidities of obesity, purview of obesity management strategies and potential barriers for adhering to lifestyle management strategies. Further, assessment of current level of knowledge and awareness on obesity condition would enable in developing feasible and sustainable interventions to combat the current obesity trends. Therefore, the present study aims to assess the knowledge and perceptions of obesity among middle aged obese adult females of Sri Lanka those who served as housewives. Their perception on causes, comorbidities, possible management strategies of obesity and barriers for adhering to healthy lifestyle pattern were appraised.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eStudy design and participants\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis qualitative study was conducted with thirty-five (n=35) obese (Body Mass Index\u0026gt;25 kgm\u003csup\u003e-2\u003c/sup\u003e) volunteer housewives in the age range of 35-55 years through convenient sampling. Obese housewives were residents of sub-urban areas of Kurunegala District of Sri Lanka. They were apparently healthy without a history of any non-communicable diseases, psychological problem and eating disorders. Obese housewives with any form of diseases, mental illness, physical disabilities and pregnant and lactating mothers were excluded from the study. Screening session was conducted to verify the BMI (BMI\u0026gt;25kgm\u003csup\u003e-2\u003c/sup\u003e) and general health status of obese housewives. At the screening session, they were invited to take part in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSocio-demographic data\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSocio-demographic details of the participants were collected including age, gender, area of residence, marital status, level of education, occupation, family income prior to the interviews using a questionnaire.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnthropometric measurements\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStanding height and weight were measured in indoor light clothing using a stadiometer and digital weighing scale respectively. Waist circumference was measured using a non-stretchable tape at the point of umbilicus. BMI was derived by dividing the body weight (kg) by the height square (m\u003csup\u003e2\u003c/sup\u003e). All the anthropometric measurements were taken after overnight fasting following the standard procedures.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObesity perceptions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIndividual interviews were conducted with a semi-structured questionnaire (additional file). \u0026nbsp;Questionnaire had a set of open-ended questions to guide the participants and to ensure the uniformity between individual interviews. Duration of each interview was 15 minutes and each interview was tape recorded with consent of participants. All the interviews were conducted in their native language, Sinhalese. One independent observer (facilitator) at each interview were responsible for verbatim recording / transcribing and documenting the emotional responses of participants with the support of an assistant. The facilitator provided the guidance and assisted in keeping the focus of interviews while stimulating and regulating the flow of each interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDirect content analysis of qualitative data was conducted with the support of NVIVO v12.0 software (QSR International, UK). Themes were determined as a template prior to the data analysis. Participants\u0026rsquo; responses were grouped under these identified themes thereafter. Themes include obesity perceptions of housewives, causes of obesity, obesity related comorbidities, management of obesity, use of lifestyle management strategies (dietary and physical activity) to manage the obesity and barriers faced in obesity management through diet and physical activities. Immediately after concluding each interview, facilitator and assistant analyzed respective interview using their notes and tape recording. It included both the verbal and non-verbal responses of each participant at individual interview. All the documented responses were collectively analyzed after completing the interviews. The data were initially transcribed in Sinhalese, the native language of study participants and later translated to English language by an independent translator. Final document with the responses of study participants was generated with the consensus of all research team members. Obesity was defined as BMI \u0026ge;25.0 kgm-\u003csup\u003e2\u003c/sup\u003e[6]. Abdominal obesity was defined as a waist circumference \u0026gt;90 cm for males and \u0026gt;80 cm for females [6].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eGeneral characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty-five obese housewives were recruited (response rate 80%) with a mean age of 44.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 years (range 35-55 years). All were Sinhalese in ethnicity. Mean BMI, waist circumference and waist to hip ratio of the participants were 30.7 \u0026plusmn; 5.7 kgm\u003csup\u003e-2\u003c/sup\u003e, 100.9 \u0026plusmn; 7.6cm and 0.96 \u0026plusmn; 0.14, respectively. Majority were educated up to the grade 6-11 in secondary school (\u003cem\u003en\u003c/em\u003e=25, 71%), unemployed (\u003cem\u003en\u003c/em\u003e=28, 80%) and had a mean monthly household income of LKR 30,000 (US$ \u0026lt;140).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eKnowledge and perceptions about obesity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlmost all the housewives with obesity (\u003cem\u003en\u003c/em\u003e-35) either thought or felt that their body weight is high. Their general believes on their body weight were as follows;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think my weight is high.\u0026rdquo; (I\u003csub\u003e1\u003c/sub\u003e, 38 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel my weight is higher than normal weight.\u0026rdquo; (I\u003csub\u003e6\u003c/sub\u003e, 47 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, only a few of them (n-8) perceived themselves as either overweight or obese. Some of their perceptions of obesity were;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;According to my height, this weight is too much. I think I am overweight.\u0026rdquo; (I\u003csub\u003e2\u003c/sub\u003e, 33 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel my body weight is high and therefore I might be either overweight or obese.\u0026rdquo; (I\u003csub\u003e3\u003c/sub\u003e, 40 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAbout 35% of them (n-12) knew about BMI and the only a few of them (n=5) were aware about the proper interpretation of individual BMI value as stated below;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;As I think, BMI shows whether we have the proper weight for height. I think my BMI is higher than what I should have.\u0026rdquo; (I\u003csub\u003e4\u003c/sub\u003e, 43 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I am obese according to my BMI.\u0026rdquo; (I\u003csub\u003e7\u003c/sub\u003e, 48 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMajority (\u003cem\u003en\u003c/em\u003e=25) of housewives with obesity perceived the central obesity as the protrusion of belly;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think protrusion of belly is the central obesity.\u0026rdquo; (I\u003csub\u003e5\u003c/sub\u003e, 50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAbout 17 % (\u003cem\u003en\u003c/em\u003e=6) knew that the obesity is the excess deposition of fat and weight gain is indicated as overweight and obesity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think obesity develops due to the deposition of fat inside the body. Excess fat deposition is the reason for weight gain. So excess fat deposition causes the obesity.\u0026rdquo; (I\u003csub\u003e4\u003c/sub\u003e, 43 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNearly 11% (\u003cem\u003en\u003c/em\u003e=4) knew that obesity causes diseases like diabetes, hypertension and other cardiovascular diseases as stated;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think obesity is a reason for diseases like diabetes and high blood pressure.\u0026rdquo; (I\u003csub\u003e1\u003c/sub\u003e,38 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived causes for obesity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority of housewives with obesity (n-29) believed that lifestyle has an impact on their current obesity status. Some of the participants stated that;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eLess physical activities and eating without control are the causes of obesity.\u0026rdquo; (I\u003csub\u003e2\u003c/sub\u003e, 33 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Overnutrition causes the obesity.\u0026rdquo; (I\u003csub\u003e7\u003c/sub\u003e, 48 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlmost all of them (n-29) recognized the unhealthy diet as one of the causes of obesity. Some of their perceptions on relationship between the unhealthy diet and obesity were;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I am overeating. I used to take four meals per day. I\u0026rsquo;m having similar quantities of food per each meal. I think it is a major reason for obesity.\u0026rdquo; (I\u003csub\u003e7\u003c/sub\u003e, 48 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Most of the times I eat yams, flour confectioneries, so I think, it affects to gain my body weight.\u0026rdquo; (I\u003csub\u003e2\u003c/sub\u003e, 33years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome of them (n-13) perceived physical inactivity as an important cause of their obesity as denoted by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Usually, I do not do exercise because I work in a caf\u0026eacute; and I sleep just after eat and I think my sedentary lifestyle also reason for obesity.\u0026rdquo; (I\u003csub\u003e2\u003c/sub\u003e, 33years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think sleeping too much of time is also a reason for my obesity. Because I usually sleep after having my lunch.\u0026rdquo; (I\u003csub\u003e18\u003c/sub\u003e, 50years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, some (n-5) believed that there is no impact of their current lifestyle pattern on obesity as mentioned by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think my day-to-day lifestyle doesn\u0026rsquo;t impact of my obesity.\u0026rdquo; (I2,33 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to their purview, genetics (n-6), surgeries (n-3), birth control methods (n-3) and multiple pregnancies (n-3) were the other causes of obesity. Some of their responses were;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I\u0026rsquo;m obese because of my genetics. Even as a child, I was obese. My all-family members are obese.\u0026rdquo; (I\u003csub\u003e6\u003c/sub\u003e, 47 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Two years ago, I faced a surgery, thereafter I became obese. Because I can eat more than past after that surgery.\u0026rdquo; (I\u003csub\u003e3\u003c/sub\u003e, 40 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was slim before having babies. I became obese after having babies.\u0026rdquo; (I\u003csub\u003e1\u003c/sub\u003e, 38 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnhealthy eating\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority (n-29,83%) of the housewives with obesity knew that their poor dietary habits have contributed to the current obesity condition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost of them perceived overeating (n-21), higher meal frequency (n-5), excessive consumption of sweets and flour confectioneries (n -14) and oily foods (n-24) as unhealthy eating practices that have led them to become obese. Some of their responses were;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think, overeating is the reason for obesity.\u0026rdquo; (I4, 43 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think over eating and eating oily food (fried food) also can cause the obesity.\u0026rdquo; (I5,50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think, eating oily food and flour confectioneries reason for gaining excessive body weight.\u0026rdquo; (I8, 50years)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Overeating of sweets, flour confectionaries and other food cause for the obesity.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(I3, 40years)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA few of housewives with obesity (n-3) believed that excessive consumption of meat and fish also has contributed to their obese condition as denoted by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think, overeating of fish and meat can increase the body weight.\u0026rdquo; (I14 30years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition, some recognized overeating at night (n-5), eating similar quantities of food in every meal (n-3), sleeping after the meals (n-4) and in proper timing of meals (n-5) have contributed to their current obesity condition. Some of their views are shown below;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think, over eating and over eating at dinner are reasons for the obesity.\u0026rdquo; (I8, 50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I am overeating (4 meals per day). I\u0026rsquo;m having similar quantities of food per each meal. I think it is a major reason for obesity.\u0026rdquo; (I2, 33 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Normally I do not get my meals on time. So, I think it causes the obesity.\u0026rdquo; (I6, 47years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think sleeping too much of time is also a reason for my obesity. Because I usually sleep after having my lunch.\u0026rdquo; (I18, 50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, some participants (n-5) stated that contribution of their dietary habit to become obese is less significant as denoted by;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Normally I am having a balanced diet. So, I don\u0026rsquo;t think my food habits affect my body weight.\u0026rdquo; \u003cem\u003e(I24, 48 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical inactivity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of the 35 housewives with obesity, twenty-nine (n-29, 83%) were aware that physical inactivity has contributed for their current obesity. \u0026nbsp;Majority believed that lack of time in their tiring lifestyle for physical activities and the use of automated equipment are the main reasons for their sedentary behavior. Some of their perceptions on contribution of physical inactivity towards obesity were;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think sedentary lifestyle and low exercises causes obesity.\u0026rdquo; (I15, 25years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eI\u0026rsquo;m not doing any exercise though I do daily household work. So, I\u0026rsquo;m getting fat.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp;(I11,48 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Every day, I\u0026rsquo;m doing my day-to-day household work, but I\u0026rsquo;m a less active person. Also, I sleep too much which can be affected to obesity.\u0026rdquo; (I9, 47 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, some of them (n-4) perceived engaging in household chores is enough them as mentioned by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I am engaged in household work every day. So, I think it is enough for me.\u0026rdquo; (I20, 47 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA few obese housewives believed that there is no any effect of physical activities on weight gain\u003cem\u003e\u0026nbsp;\u003c/em\u003eas denoted by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think my day today activities do not have any impact on my weight gain.\u0026rdquo; (I6,47yeras)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived comorbidities of obesity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority (n-26,74%) of the obese housewives reported that they are affected with muscular skeletal problems such as difficulties in sitting, walking, knee pain and back pain due to their current condition. They believed that the obesity condition has disturbed their routine and some of their views are as follows;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Actually, after becoming obese, I faced lot of problems such as leg and hand pain and extra tiredness when walking.\u0026rdquo; (I5,50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m getting fatigue quickly when I\u0026rsquo;m doing household work. I have a back pain\u0026rdquo; (I15, 25 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel uncomfortable when walking. I can\u0026rsquo;t walk well as the past because of knee pain and edema in ankles. \u0026nbsp;I can\u0026rsquo;t do my day-to-day work actively.\u0026rdquo; (I13,50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome of the housewives (n-5) believed that obesity has complicated their other health and disease conditions as shown by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;I have difficulties in breathing and knee pain due to protrusion of belly and feel uncomfortable.\u0026rdquo; (I12,40 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition, most of them reported the issues pertaining to their appearance and body size particularly in selecting the cloths as denoted by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There are no suitable clothes to buy me when I\u0026rsquo;m doing shopping as the sizes are not matching with my body size.\u0026rdquo; (I3,40 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;I feel stressed when I can\u0026rsquo;t wear my old clothes.\u0026rdquo; (I6,47 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManagement of obesity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority of obese housewives perceived that their current lifestyle pattern has contributed to their condition. \u0026nbsp;They believed that dietary modification (n-18) and engaging in the physical activities (n-14) will allow them to lose weight as shown by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Body weight can be reduced by dieting.\u0026rdquo; (I8,50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think if I do exercises, I can lose the weight.\u0026rdquo; (I20, 47 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost of them (n-12) believed that combination of dietary modification and exercises would assist them in losing the body weight. Some of their responses were;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I can lose my body weight by dieting and exercising.\u0026rdquo; (I7, 48 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome of the obese housewives perceived to follow dietary modifications. One stated;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m on a special diet. I\u0026rsquo;m taking a small quantity of food at dinner. So, I think it will help me to lose weight.\u0026rdquo; (I10, 50 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers for weight management \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough the majority of obese housewives knew importance of managing the body weight and perceived the role of diet and physical activities in attaining proper body weight, they were lagging behind several barriers. Major barriers for weight management through lifestyle modification were the less motivation (n-10) and less interest (n-9) as per the views of the housewives with obesity. Some of their responses were;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t need to lose the body weight. I\u0026rsquo;m not interest about it.\u0026rdquo; (I3, 40 years)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have never tried to lose my weight because I don\u0026rsquo;t care much.\u0026rdquo; (I21, 48 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have tried to lose body weight. But I didn\u0026rsquo;t continue it because I\u0026rsquo;m lazy.\u0026rdquo; (I19, 44 years)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurther they stated that lack of dedicated personal time for engaging in physical activities or exercises (n-9) and social and familial issues (n-3) restricting them to modify their current lifestyle pattern as mentioned by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have no time to do exercises and to manage my diet due to my busy lifestyle.\u0026rdquo; (I14, 30 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Actually, we should do exercises but practically unable to find time to do this with day to day house hold work.\u0026rdquo; (I2, 33 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have to prepare food according to the demand of my family members, so I cannot prepare the food that I really want to eat.\u0026rdquo; (I1, 38 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have tried to control my body weight by dieting but it was unsuccessful. Because my family members dislike to eat the food that I prepared aiming the weight control.\u0026rdquo; (I32,33 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to some of the housewives with obesity, hunger feeling after eating less quantity of food and accompanied difficulties in sleeping due to low satiety were some of the perceived barriers for food portion control. One stated;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I can\u0026rsquo;t sleep after eating less amount of food. I have tried to diet, but I feel hungry after I had a low quantity of food.\u0026rdquo; (I34, 34 years)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurther, some of them believed that reduced food intake might lead to gastritis condition as mentioned by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If I want to lose the body weight, then I have to diet. There can be some problems by reducing the food consumption such as gastritis.\u0026rdquo; (I24, 48 years)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA few of them were reluctant to engage in any form of physical activities as they experienced physical inconveniences following physical activities as denoted by;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have a pain in my knees when I\u0026rsquo;m jogging, it prevents me getting some exercises.\u0026rdquo; (I2, 33 years)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccording to our knowledge this is the first qualitative study conducted to evaluate the knowledge and perceptions of obese housewives about their condition. Obesity is more prevalent among women in Sri Lanka thus significant proportion of women with obesity is comprised of housewives. Therefore, assessing their knowledge and perceptions on causes, comorbidities, possible management strategies and potential barriers of obesity management is of great importance in developing appropriate lifestyle interventions.\u003c/p\u003e\u003cp\u003eAlthough the almost all obese housewives thought or felt about their excess body weight, only a few perceived them as either overweight or obese. A few of them knew that the excess fat accumulation and weight gain are indicated in obesity and central obesity and obesity leads to other non-communicable diseases such as type 2 diabetes mellitus, hypertension and other cardiovascular diseases. As the appearance of non-communicable diseases taken place at the middle age and particularly the obese women are more prone to the NCDs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], this study highlights the importance of educating middle aged women on relationship between obesity and NCDs through the currently operating \u0026ldquo;Well Women Clinics\u0026rdquo; at the primary healthcare setting. About one third of them were knew about the BMI. A few of them were aware about proper interpretation of their individual BMI value. It indicates the poor knowledge and understanding about BMI and its interpretation among studied population and consistent with the previous findings on body weight and BMI perceptions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although the BMI is widely used indicator of obesity, findings of the current study highlighted the necessity of more targeted education and awareness on use of BMI for self-identification of the weight status of adults. Inability of study participants to recognize their weight status can keep them away from healthy behaviors thus leading to increased risk of obesity related comorbidities. Majority of them recognized the central obesity as the protrusion of belly and had sufficient knowledge on use of waist circumference as an indicator of central obesity. It may be due to the self-consciousness of body shape by the women and frequent use of waist circumference in clothing. As most of them were concerned in selecting suitable clothing due to altered body shape and size of their current obesity, positive rewarding appeal can be used in behavior change communication to reach the previous body shape and size of obese women.\u003c/p\u003e\u003cp\u003eMajority of obese housewives perceived their lifestyle has an impact on their current obesity status. Unhealthy diet and physical inactivity were the major perceived causes of obesity similar to the previous findings [\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Conversely some of our study participants only recognized the contribution of physical inactivity for their obesity status. According to the STEPS survey 2021, Sril Lankan women were found to be more physically inactive than males [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Few of study participants perceived genetics as cause of obesity. In addition, obese housewives of this study emphasized surgeries, contraceptive methods and multiple pregnancies as other causes of obesity. There is a common cultural belief that the pregnant and lactating women should eat more. Particularly during the pregnancy period, common cultural belief is to \u0026lsquo;consume food for two\u0026rsquo;. In fact, that increased food consumption is believed to be associated with proper foetal growth and wellbeing. Additionally, increased food intake during the lactation period is believed to increase the milk production and well-being of both mother and new born. Therefore, it necessitates providing proper education for women of reproductive age about obesity risk and its connection to the NCDs through health promotion campaigns. Further it is important to create awareness on underlying factors of socio-cultural and medical origins to address the obesity related social stigma.\u003c/p\u003e\u003cp\u003eMost of the housewives with obesity knew that their poor dietary habits have contributed to the current obesity. They perceived overeating, higher meal frequency, excess consumption of sweets and flour confectionaries and oily food as dietary contributors of their current obesity status. In most of houses, housewives are the last family members to consume the food, particularly in the night time. Therefore, there is a great possibility of consuming remaining excess food by the housewives leading to weight gain. Food environment plays a vital role in purchasing and preparing food [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our study participants reported that they consume fried foods and flour confectionaries due to their availability in the surrounding environment and frequent purchasing of those for their children. As this kind of unhealthy behavior exert risk for younger family members for developing obesity and other NCDs in later life, improving their food environment should accompany the community education programs. Most of them were aware that the physical inactivity has contributed to their obesity status. However, the recognition of physical inactivity as a major contributor was low due to limited awareness of potential benefits. Some knowledge gap was apparent as few of them believed engaging in household work is enough for weight management and expressing their reluctance in allocating a dedicated time for physical activities similar to the previous findings among obese adults [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present study, majority of housewives with obesity were aware of importance of diet and physical activities in managing the obesity. However, adhering to the planned diet and following regular physical activities is restricted by difficulties faced by them. Less motivation and interest in adhering to a healthy lifestyle in achieving a proper body weight and limited awareness of adverse outcomes of obesity were identified in this study. It urges the need of taking immediate steps towards creating awareness and lifestyle focused education for obese housewives. Further, some of the barriers faced by the obese housewives need to be addressed through behavior change communication. Hence, use of motivation through individual or small group communication programmes aimed at behavior change would help them to overcome \u0026lsquo;less interest\u0026rsquo; and \u0026lsquo;less motivation and ensure the self-commitment. Family support is essential in adopting a healthy lifestyle. Conforming family practices with lifestyle would have restricted food choices of housewives and allocating time for physical activities. Therefore, it is important to take the possible social issues into account when behavior change programmes are planned with modified diet and physical activity as suggested by previous authors [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFindings of the current study emphasizes the urge of initiating education and awareness programs among general public targeting the housewives on obesity and lifestyle management of obesity through adhering to a healthy dietary pattern and physical activity. Further, it highlights the need of individual or group counseling to motivate people with obesity to modify their behavior. Hence these urges allocating resources, developing facilities and training healthcare professionals to perform nutrition counseling at the in the primary healthcare settings.\u003c/p\u003e\u003cp\u003eThis is the first qualitative study conducted in Sri Lanka to identify the knowledge and perceptions of obesity among obese housewives in suburban community. Open ended questions used in the interviews allowed to comprehensive understanding of the perspectives of participants in terms of causes, comorbidities, methods of assessing the obesity, obesity management and barriers for obesity management through lifestyle approaches. Nevertheless, this study was limited to a suburban area, where perceptions of the urban and rural obese women may not be represented. All study participants were Sinhalese in ethnicity. Hence the representation of perceptions of other ethnicities lacks in the study. Despite of the given limitations, current study provides valuable insights on perceptions of obese housewives. Further studies are suggested to assess the impact of perceptions on obesity management behaviors.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMisperception of obesity was common among the obese housewives. Unhealthy diet, physical inactivity, genetics, surgeries, contraception methods, and multiple pregnancies were the perceived causes of obesity. Majority believed that diet and physical activity has an impact on obesity. However, majority of obese housewives were unable to implement healthy lifestyle behaviors due to personal and social barriers. Perceived personal barriers for obesity management were lack of committed time, lack of motivation and less interest. Inconvenience in continuing a diet plan, impact of family members, limited time to do exercises, less interest in losing body weight and physical inconveniences following the exercises were the barriers related to dietary management and engage in physical activities. Findings of the current study urges initiating health promotion programs for general public targeting the housewives through primary healthcare setting of Sri Lanka. Further it emphasizes to motivate housewives through behavior change communication thus allocation of resources and training healthcare professionals is recognized as a timely necessity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 517px;\"\u003e\n \u003cp\u003eBody mass index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eNCDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 517px;\"\u003e\n \u003cp\u003eNon-communicable diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eWHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 517px;\"\u003e\n \u003cp\u003eWaist to hip ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Review Committee, Faculty of Livestock, Fisheries and Nutrition (201806HI06). Informed written consents were obtained from each study participant after a briefing session of the study and clarifying the queries raised by them before the study commenced. The current study was conducted in accordance with the principles described in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data sets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial and not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eHPG and SR made substantial contribution to conception and study design. HPG, SR and NCJ were involved in data collection and data analysis. HPG and SR were involved in drafting the manuscript. All authors read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eAuthors would like to acknowledge the study subjects for their volunteer participation and research team of the Department of Nutrition and Dietetics for their assistance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information (optional)\u003c/p\u003e\n\u003cp\u003eHP Gunawardena 0094 773759475, [email protected]\u003c/p\u003e\n\u003cp\u003eS Rangajeewa, [email protected]\u003c/p\u003e\n\u003cp\u003eNC Jayaweera, [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKatulanda P, Jayawardena MAR, Sheriff MHR, Constantine GR, Mathews DR. Prevalence of overweight and obesity in Sri Lankan adults. Obes Rev. 2010; DOI:10.1111/j.1467-789X.2010. 00746.x\u003c/li\u003e\n \u003cli\u003eJayatissa R, Hossain SMM, Gunawardena S, Ranbandara JM, Gunathilake M and De Silva PC. 2012. Prevalence and associations of overweight among adult women in Sri Lanka: a national survey. Sri Lanka Journal of Diabetes, Endocrinology and Metabolism. 2012; 2:61-68, http://dx.doi.org/10.4038/sjdem.v2i2.4774\u003c/li\u003e\n \u003cli\u003eSomasundaram N, Ranathunga I, Gunawardana K, Ahamed M, Ediriweera D, Antonypillai CN, Kalupahana N. High Prevalence of Overweight/Obesity in Urban Sri Lanka: Findings from the Colombo Urban Study. J Diabetes Res. 2019:2046428. doi: 10.1155/2019/2046428\u003c/li\u003e\n \u003cli\u003eMinistry of Health and Department of Census and Statistics (2021) Non-Communicable Diseases Risk Factor Survey (STEPS survey) Sri Lanka. Available from https://ncd.health.gov.lk/images/pdf/20230817_STEPS_Survey_new_1_compressed.pdf ISBN 978-624-5719-78-5.\u003c/li\u003e\n \u003cli\u003eRannan-Eliya RP, Wijemunige N, Perera P, et al. Prevalence of diabetes and pre-diabetes in Sri Lanka: a new global hotspot\u0026ndash; estimates from the Sri Lanka Health and Ageing Survey 2018/2019. BMJ Open Diab Res Care 2023;11: e003160.doi:10.1136/bmjdrc-2022-003160\u003c/li\u003e\n \u003cli\u003eWHO [a]. The Asia-Pacific Perspectives: Redefining Obesity and Its Treatment; 2000.\u003c/li\u003e\n \u003cli\u003eJayawardena R, Byrne NM, Soares MJ, Katulanda P, Hills AP. Body weight perception and weight loss practices among Sri Lankan adults. Obes Res Clin Pract. 2014 ;8(2):e192-200. doi: 10.1016/j.orcp.2013.05.003. PMID: 24743016.\u003c/li\u003e\n \u003cli\u003ede Lanerolle-Dias M, Lanerolle dSA, Atukorala PS. BMI \u0026amp;body weight perception: the need to create awareness. AnnNutr Metab 2009;55:220.\u003c/li\u003e\n \u003cli\u003eOkop KJ, Mukumbang FC, Mathole T, et al. Perceptions of body size, obesity threat and the willingness to lose weight among black South African adults: a qualitative study. BMC Public Health 2016; https://doi.org/10.1186/s12889-016-3028-7\u003c/li\u003e\n \u003cli\u003eAgrawal P, Gupta K, Mishra V, et al. A study on body-weight perception, future intention and weight-management behaviour among normal-weight, overweight and obese women in India. Public Health Nutr 2014;17:884\u0026ndash;95.\u003c/li\u003e\n \u003cli\u003eSimkhada P, Poobalan A, Simkhada PP, et al. Knowledge, attitude, and prevalence of overweight and obesity among civil servants in Nepal. Asia Pac J Public Health 2011; 23:507\u0026ndash;17.\u003c/li\u003e\n \u003cli\u003eBlixen CE, Singh A, Thacker H. Values and beliefs about obesity and weight reduction among African American and Caucasian women. J Transcult Nurs 2006; 17:290\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eChang CT, Chang KH, Cheah WL. Adults\u0026apos; perceptions of being overweight or obese: a focus group study. Asia Pac J Clin Nutr 2009;18:257\u0026ndash;64.\u003c/li\u003e\n \u003cli\u003ePowell TM, et al. Body size misperception: a novel determinant in the obesity epidemic. Arch Intern Med2010;170(18):1695\u0026mdash;7.\u003c/li\u003e\n \u003cli\u003eRahman M, Berenson AB. Self-perception of weight and its association with weight-related behaviors in young, reproductive-aged women. Obstet Gynecol 2010;116(6):1274-80, http://dx.doi.org/10.1097/AOG.0b013e3181fdfc47.\u003c/li\u003e\n \u003cli\u003eFaber M, Kruger HS. Dietary intake, perceptions regarding body weight, and attitudes toward weight control of normal weight, overweight, and obese Black females in a rural village in South Africa. Ethn Dis 2005;15(2):238\u0026mdash;45.\u003c/li\u003e\n \u003cli\u003eShrestha S, Asthanee S, Karmacharya BM. Perceptions of obesity and overweight among adults living in suburban Nepal: a qualitative study. BMJ Open 2021; doi:10.1136/bmjopen-2020-043719\u003c/li\u003e\n \u003cli\u003eRanasinghe, P., Pigera, A.S.A.D., Ishara, M.H. et al. Knowledge and perceptions about diet and physical activity among Sri Lankan adults with diabetes mellitus: a qualitative study. BMC Public Health. 2015; https://doi.org/10.1186/s12889-015-2518-3\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diet, Housewives, Knowledge, Lifestyle, Obesity, Physical activity, Perceptions","lastPublishedDoi":"10.21203/rs.3.rs-7460183/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7460183/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eObesity is one of the major public health concerns in Sri Lanka. Nearly 39% of adults in Sri Lanka are obese and the majority represents the middle-aged women. Knowledge and perceptions about causes, comorbidities, dietary and lifestyle management of obesity is vital in developing sustainable and feasible interventions. Therefore, present study aims to assess the knowledge and perceptions of obesity among a group of housewives with obesity in Sri Lanka using qualitative research methods.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA descriptive qualitative study conducted using 35 individual interviews. Interviews were steered with purposely selected housewives with obesity aged 25\u0026ndash;50 years living in Pannala area. All the interviews were conducted in participants\u0026rsquo; native language and transcribed verbatim. Data were analyzed using NVIVO v12.0 software and themes and subthemes were derived.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAs stated, only a few of obese housewives perceived them as either overweight or obese. Unhealthy diet, physical inactivity, genetics, surgeries, contraception methods, and multiple pregnancies were the perceived causes of obesity. Majority believed that diet and physical activity has an impact on obesity. Perceived personal barriers for obesity management were lack of time, lack of motivation and less interest. Inconvenience in continuing a diet plan, impact of family members, limited time to do exercises, less interest in losing body weight and physical inconveniences following the exercises were the barriers related to dietary management and engage in physical activities.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFindings of the current study highlighted the lack of knowledge and awareness about their current obesity condition by the obese women, thus urge of initiating awareness and education programmes is emphasized. Despite the knowledge and perceiving the importance of healthy diet and physical activities for managing their obesity condition, most of them were unable to adhere to a healthy lifestyle pattern due to personal and social circumstances.\u003c/p\u003e","manuscriptTitle":"Knowledge and perceptions of obese housewives in Sri Lanka: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-19 13:38:15","doi":"10.21203/rs.3.rs-7460183/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-09T16:07:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T19:31:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-20T09:30:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191302273978004778235785342121429307099","date":"2025-09-14T13:51:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279486419170287163321316108273991824388","date":"2025-09-12T11:28:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47302255929962878102052732451389178817","date":"2025-09-12T07:24:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-12T03:09:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-12T03:06:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-03T08:17:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-02T16:47:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-09-02T16:44:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95b23046-6d89-4595-a972-d31cd57b8782","owner":[],"postedDate":"September 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T10:08:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-19 13:38:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7460183","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7460183","identity":"rs-7460183","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}