DOI: 10.31038/AWHC.2018135

Abstract

Background: Not meeting physical activity guidelines is a major public health concern. Studies show that Black and Latina women have general lower levels of physical activity (PA) than White women and are therefore at higher risk for chronic diseases including cardiovascular disease, diabetes, and obesity. The purpose of this study is to analyze National Health Interview Survey (NHIS) data to determine what factors, if any may contribute to Black and Latina women between the ages of 18 and 47, adhering to the federal PA guidelines. Identifying these factors will help in the development of PA promotion programs aimed at increasing adherence to the federal PA guidelines among minority women.

Method: Secondary analysis of data from the National Health Interview Survey 2008–2014 was analyzed to determine factors which may be associated with PA adherence among Black (N = 23,162) and Latina (N = 37,103) women.

Results: Logit modeling examined mean differences between groups and related variables. Blacks are more likely to meet muscle-strength guidelines with increased education and increased income. Latinas are more likely to meet muscle-strength as education and US acculturation increases.

Conclusion: These findings highlight the importance of understanding and considering racial/ethnic differences when developing strategies for promotion of PA among minority women. Identifying strategies and factors for increasing PA is a major step toward reducing risk factors associated with inadequate PA. Practitioners should be aware of these results and trends when discussing PA recommendations with their patients.

Introduction

Not engaging in adequate physical activity is a major public health problem associated with increased morbidity and mortality, accounting for 3.2 million deaths each year [1]. The numbers of individuals not meeting recommended physical activity levels have risen significantly over the last decade, contributing to increased prevalence of heart disease, diabetes, colon cancer, and high blood pressure [2]. Engaging in regular physical activity as per physical activity guidelines has shown to be essential and beneficial in reducing risk factors for many of these diseases (cardiovascular diseases, type 2 diabetes, breast & colon cancers) thereby reducing premature all-cause mortality [3]. Minority women, such as Black and Latino, are more likely to be less physically active in comparison to White women [4].

In 2008, the federal government adopted physical activity guidelines for all Americans [5]; the second edition of these guidelines was recently released in the fall of 2018 [6]. These guidelines serves as the primary, authoritative voice of the federal government for evidence-based guidance on physical activity, fitness, and health for Americans that describe the amount, types, and intensity of physical activity needed to achieve many health benefits for Americans across the life span [6]. These guidelines are further broken down into aerobic and Muscle Strengthening (MS) activities aimed at improving one’s health. The minimal recommendations for adults living in the United States are:

1. 2 hours and 30 minutes (150 minutes) of aerobic activity of moderate intensity, such as, brisk walking every week, along with 2 or more days a week of muscle-strengthening activity that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms (p.56, 2018).

Unfortunately, the overwhelming majority of Black and Latina women in the United States are not consistently meeting these guidelines. The prevalence of meeting aerobic physical activity guidelines for Black women in the US is 35% and 41% for Latina women, in comparison to White women at 51% [4]. The lower level of physical activity noted in minority women may account for the significant health disparities noted between White women and Black. (Table 1) shows the significant differences noted between White and Black women regarding diseases and risk factors.

Table 1. Prevalence of Diseases & Risk Factors in Women by Race/Ethnicity (%)

Physical activity is defined as bodily movement that increases energy expenditure above the basal level [7]. Leisure-time physical activity is defined as physical activities performed during free time, other than work or school, such as recreation and/or exercise [8]. Healthy People 2020 have defined health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage that adversely affects specific population groups [9].” Common themes noted in the literature that may help to explain these differences are cultural attitudes (body image, hair maintenance, society norms) and family responsibilities. Therefore, the purpose of this study is to analyze National Health Interview Survey (NHIS) data to determine what factors, if any may contribute to Black and Latina women between the ages of 18 and 47 adhering to the federal physical activity guidelines. Identifying these factors will help in the development of physical activity programs aimed at promoting adherence to the federal physical activity guidelines among minority women. Improving adherence to physical activity guidelines can lead to health promotion and disease prevent of various chronic diseases (hypertension, heart disease, obesity, diabetes, and some form of cancers) among minority women.

The Literature Regarding Racial/Ethical Differences

Black Women

A person’s experiences and perceptions play a major role in determining her participation in regular physical activity. A person’s attitude is shaped by her experiences, beliefs, and cultural influences [10, 11]. Evidence suggests that racial/ethnic differences exist regarding Black women’s attitudes toward physical activity.[11, 12] These attitudes toward physical activity may help explain the significant decline noted in Black women in comparison to White women. In the Black community, women are less concerned with body size and are more accepting of fuller, curvaceous figures [12–16]. Therefore, Black women who are satisfied with their body size may perceive being physically active as a waste of time since they have no desire to lose weight. Also, Black women are more accepting of individuality and tend not to conform to society’s views of beauty. [17] Although having a positive image of one’s self is a generally a good thing, such an attitude may help contribute to some Black women being less interested in engaging in adequate physical activity.

One aim of a systematic review of qualitative studies conducted by Siddiqi, Tiro, and Shuval [18] was directed at understanding barriers to physical activity among Black adults. This review indicated that among Black women, hair maintenance, family responsibilities, and environmental condition were some of the barriers the women gave for not being physically active. Hair maintenance is a major concern among Black women due to the cost and time-consuming process involved. Hair maintenance among Black women tends to be a major deterrent for engaging in PA [19–22].

Another barrier is family responsibilities [20, 23]. In 2011, 67.8% of Black births in the United States were to single Black or African American women, which is a significant rise in the last decade [24]. Being a single mother juggling multiple responsibilities related to work and caring for children does not leave sufficient time to be physically active for many women. Research shows that women with children are more likely to have decreased physical activity [25, 26]. Such a significant rise in single Black mothers may be one explanation why physical activity levels are significant lower in Black women than in White women [19, 24].

Latina Women

Similar to Black women, Latinas regard fuller figures as more desirable [27]. Latinas and Blacks have reported more of a positive body self-image at higher BMIs than White women, suggesting that they have higher thresholds for what is considered healthy [27]. Personal hygiene issues such as desire not to sweat are also barriers to Latinas engaging in physical activity similar to the desire not to redo their hair for Black women [12, 17].

Latinas’ cultural emphasis on family and familial unity or familismo highlights their sense of family duties and responsibilities [28]. Latinas also tend to be the homemaker and caregiver, which might influence how they engage in physical activity because their energy and time is put into household duties instead of Leisure Time Physical Activity (LTPA) [29]. Marianismo and acculturation are also influencing factors on Latinas participation in PA [28]. Marianismo, or prioritization of family responsibilities over self-care, has been shown to affect physical activity among Latina women. D’Alonzo (2012) found that Latina women who immigrated to the United States were less likely to participate in LTPA due to family priorities and working outside the home. Many Latina women feel that family is a priority and taking time to go to the gym or engage in physical activity takes away time that could be spent with children, spouses, or other family members [28].

Immigration to the United States and subsequent acculturation also plays a role in leisure time physical activity among Latina women. D’Alonzo (2012) showed that decrease leisured time physical activity among Latina women who had recently immigrated to the United States due to “role overload” was associated with lifestyle changes and acculturation (p. 138). These changes include working outside the home, increased number of hours worked in a day, socioeconomic pressures, decreased social support, learning English, and transitioning from a collective culture to an individualistic one [28].

Latinas also have a higher fertility rate than White women, and which several researchers [29–31] have found the increasing number of children to be negatively associated with reported physical activity levels. Having more children would presumably increase the duties and therefore hours associated with childcare and household tasks, thus reducing the number of hours available to engage in physical activity participation for Latinas as their family commitments would be more time consuming [32].

Methods and Materials

Design

Secondary analysis of data from the National Health Interview Survey (NHIS) 2008–2014 was analyzed to explore factors which may be associated with physical activity adherence among Black and Latina women. The NHIS is an annual in-person household survey conducted by the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) and administered by the US Census Bureau [33]. The data is publicly accessible with no identifiable information of the participants. Adults aged 18 years or older are randomly selected through a complex stratified clustered process that oversamples Hispanics and non-Hispanic Blacks from the noninstitutionalized civilian population [33]. Oversampling of minorities allows for more precise estimation of health characteristics in these segments of the populations. The conditional response rate for this time frame was approximately 80% [33].

To be included in this study, NHIS responders for the years 2008–2014 had to be female, between the ages of 18 and 47, and identify race as Black or Latino. Sample size consisted of N=23,162 Blacks and N=37,103 Latinas women aged 18 to 47 years. This is 4.1% of the total population of respondents regardless of sex, age, or race.

Measures

Co-habitation status (partner present vs. no partner), education [less than high school (LHS); High School/General Education Diploma (HS/GED); some college, Associates Degree (AD), Bachelor’s, greater than Bachelor’s)] and family income which was categorized as multiples of the federal poverty level (FPL) [not poverty, below poverty limit, 150% above FPL, 200% above FPL, 250% above FPL, 300% above FPL, 400% FPL and above] were the primary variables that were explored to identify association to physical activity adherence related to the federal physical activity guidelines. Also, an acculturation measure was created, combining language spoken most often (Spanish or English) and place of birth (US born or foreign born). These categories are (a) English/US born, (b) English/ foreign born, (c) English and Spanish/ US born, (d) English and Spanish/ foreign born, (e) Spanish/ US born, and (f) Spanish/foreign born. Based on the federal physical activity guidelines recommendations and the available data, 2008–2014 IHIS participants were grouped as follows: one variable capturing adherence to only moderate aerobic activity recommendations was dichotomized into “meets recommendations” or “does not meet recommendations;” a second variable capturing adherence to only vigorous aerobic activity recommendations was dichotomized into “meets recommendations” or “does not meet recommendations;” and a third variable capturing adherence to muscle-strengthening activities was dichotomized into “meets recommendations” or “does not meet recommendations.”

Data Analysis

The analysis was conducted with the Statistical Package for the Social Sciences (SPSS) [34]. The primary outcome for this analysis was identification of factors associated with adherence to meeting the federal physical activity guidelines among Black and Latina women.

Bivariate analysis of the independent variables partner presence, educational level and income were performed to determine impact on meeting moderate aerobic, vigorous aerobic, and muscle-strengthening activities as outlined above. Logistic regression models were used to identify a relationship with the variables associated with higher odds of engaging in moderate or vigorous aerobic activity and adherence to muscle-strengthening recommendations. Results are reported using odds ratios adjusted for all listed associated variables, significant effects (SEs), and p values.

Results

Due to the difference between Black and Latina women, the results will be reported based on race. Results are reported using adjusted odds ratios for all listed variables, significant effects (SEs), and p values. For Black women, none of the associated variables were significant for meeting moderate or vigorous aerobic activity guidelines. However, bivariate analysis revealed partner presence, educational level and income significantly impacted adherence to muscle-strengthening (MS) guidelines (p<0.05) and engaging in MS are a significant part of the federal physical activity guidelines. Multivariable logistic regression was then performed to ascertain the effects the independent variables of partner presence, educational level and income had on the likelihood that Black women age 18 to 47 met the recommended muscle-strengthening guidelines. These independent variables were chosen based on their p value (p < 0.05) from the bivariate analysis. For Black females, the logistic regression model including combined effects of partner status (cohabitating or non-cohabitating), education and income level was statistically significant, χ²(30) = 77.70, p < .05. Results are reported using adjusted odds ratios for all listed variables, significant effects (SEs), and p values.

The multivariable logistic regression showed income and education to significantly impact the likelihood of meeting recommended muscle-strengthening guidelines for cohabitating Black women aged 18 to 47. Results were not significant for women who were non-cohabitating. Income significantly impacted those with a high school diploma or General Education Degree (GED), while education significantly impacted women who identified as having an income below the federal poverty level (FPL). The comparison group was Black women age 18 to 47 with less than a high school diploma, no partner present, and identified as “not poverty”.

(Table 2) shows Black women age 18 to 47 with a high school diploma or GED are significantly less likely to meet muscle-strengthening guidelines as income increases from Federal Poverty Level (FPL) to above FPL. Specifically, women with a family income identified as below the Federal Poverty Level (FPL) were 0.51 times less likely to meet muscle-strengthening act (p<0.01), while those with an income of 150% above the FPL were 0.67 times less likely to meet muscle-strengthening guidelines (p<0.01). However, there was an increase in likelihood of meeting muscle-strengthening guidelines as income rose from 150% above FPL. While still less likely to meet muscle-strengthening guidelines than women with an income below the FPL, those who made 200% and 300% above FPL were only 0.55 (p<0.05) and 0.59 (p<0.05) times less likely to meet muscle-strengthening guidelines.

Table 2. Effects of Income in Cohabitating Black Women Age 18–47 with a High School Diploma or General Education Degree on Meeting Muscle Strengthening Guidelines.

Among cohabitating Black women age 18 to 47 who identified a family income of below FPL, education appears to increase the likelihood of meeting muscle-strengthening guidelines (see Table 3). Women with a high school diploma or GED were 0.51 times less likely to meet muscle-strengthening guidelines (p<0.01), while those with some college were only 0.48 times less likely (p<0.05). However, women who had a partner present, identified family income of FPL, and had an associate degree were 0.74 times less likely to meet muscle-strengthening guidelines (p<0.05).

Table 3. Effects of Education in Cohabitating Black Women Age 18–47 with a Family Income of Below Federal Poverty Level on Meeting Muscle Strengthening.

For Latina women, none of the associated variables were significant for Latinas in meeting moderate aerobic activity guidelines. However, trends in the data showed that Latinas were more likely to meet moderate aerobic activity guidelines as education and acculturation increased. They were less likely to meet moderate aerobic activity guidelines with increasing income. These trends are displayed in (Table 4) None of the associated variables were significant for vigorous aerobic activity for Latinas, nor were any trends present in the data.

Table 4. Latina Women Age 18–47 Moderate Aerobic Activity Guidelines.

However, just like with Black women, many of the associated variables for meeting muscle-strengthening guidelines were significant (p <.05) for Latinas as evidenced in (Table 5) As education increased, odds of meeting muscle-strengthening guidelines also increased in Latinas who had a bachelor’s degree; they were 87.9% [OR=1.88, CI=1.18–2.99, p=.008] more likely to meet muscle-strengthening guidelines than were Latinas with no high school degree. Data also showed that as income increased, Latinas were more likely to meet muscle-strengthening guidelines. Latinas who earn 400% or more above FPL were 215% [OR=2.15, CI=1.26–3.65, p=.005] more likely to meet muscle-strengthening guidelines that Latinas who earned income equivalent to the FPL. Latinas were 89.3% [OR=.11, CI=0.03–0.44, p=.002] less likely to meet muscle-strengthening guidelines if they were currently pregnant. Also, data showed that the odds of meeting muscle-strengthening guidelines increased as acculturation increased. Latinas born outside of the U.S. who predominantly spoke English were 22.5% more likely to meet muscle-strengthening guidelines than those who predominantly spoke Spanish [Eng/FB (OR=.68, CI=.50-.93, p=.014); Sp/FB (OR=.46, CI=.3-.70, p=.000)]. Trends in the data also showed that as BMI increased, the likelihood of a Latina meeting muscle-strengthening guidelines decreased. Latinas in the Obese III category were 68.6% [OR=.31, CI=.17-.58, p=.000] less likely to meet muscle-strengthening guidelines than a Latina of normal BMI.

Table 5. Latina Women Age 18–47 Muscle-Strengthening Guidelines.

Limitations

The data utilized in this study was obtained from secondary analysis of NHIS data, which should be considered a limitation due to the inability to consider other variables that may be associated with physical activity. NHIS represents a cross-sectional research design that obtained household interviews of a sample clusters of addresses from each state. Therefore, because participants were not randomized the sample may not be representative of the population, contributing to selection bias. In addition, cause and effect cannot be determined with a cross-sectional design and the data may only capture what is occurring at that particular time and moment, which may not be transferable to other times or situations. NHIS relies on self-reported data, therefore, recall bias is a major issue and can potentially increases the risk of participants’ bias. Participants may also over or under report certain information to look good or to please the interviewer (socially acceptable bias). These findings may not be generalizable to other populations that are not women of Black or Latina descent.

Discussion

The findings and trends presented here are significant to understanding and developing effective strategies that could improve physical activity among Black and Latina women. Strategies to address physical activity participation in minority women must occur at multiple levels that consider cultural differences.

Although, no variables were found to be significant for meeting moderate or vigorous aerobic activity guidelines in either Black or Latina women. Adherences to muscle-strengthening activities were found to be associated with a few variables in both groups. Although, muscle-strengthening activities are only a partial requirement of the federal physical activity guidelines, it still represents some level of activity in these women. And current studies support that some activities are better than none [6].

For Black women, partner presence was associated with Black women maintaining muscle-strengthening activities, which stands to reason that Black women with a partner present, that is supportive may show higher levels of commitment due to encouragement and interest in them being active. A qualitative study by Mama et al. (2015) revealed that Black women did view support of a spouse or friend as important factor in engaging in regular physical activity [35]. The support can be in the form of working-out together, prompting, to offering to pay for a gym membership.

Higher educational attainment was associated with muscle-strengthening activities in both groups, which is consistent with other studies indicating that higher educational attainment is associated with being more physically active [36]. A study by Ainsworth et al. (2003) that looked at African-American women in South Carolina showed that educational attainment had a strong relationship for Black women to be physically active, with college educated women revealing a two-times higher likelihood of being physically active over high school educated Black women [37].

Also, income was associated with muscle-strengthening activities; these findings of income are consistent with other studies that have shown that women from lower socioeconomic status tend to be less physically active. [38, 39] In the Black community there is a higher prevalence of single family homes, headed by women, where they are the sole source of income for their families [24]. Therefore, being the head-of-the household may place financial burdens on single Black mothers that prevent them from being physically active (i.e., no money for gym fees, or a babysitter that would allow her to go out to a gym). Black women from a lower socioeconomic background may also have greater difficulty being physically active compared to their higher income counterparts due to environmental barriers as well (no local gym or nearby park, unsafe neighborhood and heavy traffic patterns) [40]. More research is needed that considers the economic context of physical activity among low-income Black women. A study by Harley et al. (2013) emphasizes the need for better understanding of how significant, if any, income is regarding being physically active. A recent study by Sun and colleagues (2016) revealed that higher socioeconomic status was positively associated with young Black women being physically active [36].

For Latina women, factors associated with lower levels of engagement in sufficient physical activity levels include lower income, lower education levels, and greater number of children [29–31]. This study found that Latinas were less likely to meet moderate aerobic activity guidelines with increasing income. The difference could be explained by different definition of physical activity or the use of leisure time physical activity versus total physical activity.

With the increase of reported education beyond high school and income, the odds of Latinas meeting muscle-strengthening guidelines increased. This study’s findings were consistent with the literature regarding the negative association of pregnancy and likelihood of meeting muscle-strengthening guidelines with Latinas who reported being currently pregnant were less likely to meet muscle-strengthening guidelines [41]. Similarly, as acculturation to the US increases, odds of meeting muscle-strengthening guidelines increased for Latinas. This is consistent with literature reporting on total leisure time physical activity associated with meeting physical activity guidelines [41]. Our data demonstrated similar trends regarding the association with increasing BMI and decreasing likelihood of meeting muscle-strengthening guidelines [41]. This study found racial/ethnic differences among Black and Latina women as pertains to their level of physical activity; these differences must be taken into consideration if we hope to reduce the growing trend of insufficient physical activity among minority women. Working together, providers, patients, and policy makers can reduce health care disparities associated with diseases related to engaging in insufficient physical activity.

Acknowledgment: Brian Rathmell for his review and assistance with the statistical analysis.

Funding: This work was supported by the Dean’s Summer Research Fund, School of Nursing, Camden, New Jersey, USA.

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DOI: 10.31038/AWHC.2018134

A technique for revealing surface morphology of human cervical cancer cells has been developed to facilitate early diagnostics of a pre-cancer and cancer cells under reflected light microscopy. The offered method was borrowed from optical microscopy of a solid state surface where the Metallographic Inverted Microscopy (MIM) are usually used. Unlike common accepted transmitted light microscopy for biological applications MIM technique allows to reveal a morphology and topology of a biological cells surface without any treatment by chemicals (fixing, staining, drying, freezing et al). The MIM method was demonstrated by analyzing fresh native smears from epithelium of uterine neck. MIM micrographs of 167 patients with diagnosis cervical cancer allow visualizing on the cancer cells surface numerous of the Light Reflective Formations (LRF). It is supposed that LRF are connected with exocytosis on the cell membrane. For smears of cervix epithelium throughout the field of view of a microscope numerous ballooning-outs , which have a mean size from 0.1-0.5 to 1.2 -1.3 mkm, are seen located on the cell surface. It is accepted that in result of a cancer cell metabolism a granules or vesicles originate inside of cell and move towards cell surface to release its contents. Visualization of such morphological formations has however been limited, partly due to the difficulties with imaging native living or structurally intact cells because convenient transmitted light microscopy technique do not reveal surface cell features which are usually removed after fixing, drying and other treatments of smears. We suppose that offered method to visualize cell topography in air without fixation and dehydration may be alternative and complementary to Pap-test.

Keywords

Cervical Cancer, Reflected Light Microscopy, Cell Membrane, Smears.

Introduction

Cervical cancer is the second most common cancer in women worldwide. More than 80% of cervical cancers occur in the developing world where the least resources exist for management. Most cases of cervical cancer can be prevented by screening measures which detects precancerous lesions and subsequent treatment. Indeed in many countries where screening programs have been established, the morbidity and mortality of cervical cancer have been sharply reduced. Unfortunately many developing countries have not necessary resources and infrastructure for screening program so the annual cases of cervical cancer accounts 493 000 and deaths about 273,500 [1].

Currently, optical microscopy techniques are the primary method for cell visualization, with microscopic characteristics of cells traditionally used for diagnosis and classification of cancers [1]. However, because the differences in characteristics can be subtle, accurate detection can be challenging and ambiguous [2,3]. Particularly at present time the key accepted technique in the world to detect cervical cancer cells is Papanicolau (Pap) test [1]. To realize Pap-test need to visualize pathological peculiarities of nuclear, cytoplasm and cell shape. For this purpose need to fix smears, and next many step treatments by chemicals (staining by dyes, washing, dehydration etc). This procedures lead to destruction of alive cells, removing very important diagnostic signs and artifacts emergence. Besides there is another problem with analyzing Pap smears, connected with drying changes in cells due to delays in applying the fixing procedure. It is very difficult to evaluate smears that have dried in air and still distinguish abnormal cells. Sample handling and its evaluation of Pap-test is a time consuming procedure and demands a sophisticated testing infrastructure and highly trained professionals to evaluate the cytological test as a result, the vast majority of women in the developing world do not have access to life-saving screening programs [4]. To reach the main goal of cervical cancer screening we need to find an accessible, simple, low cost, highly sensitive and fast complementary or substitutive method to detect cervical cancer cells instead of the Pap-test.

One of lacks of modern clinical cytology is use basically transmitted light optical microscopes. But clinical cytology almost does not pay attention to such important element of a cellular structure as features of membrane topography. The last can be result of infringement of a metabolism of all whole cell or only components of the membrane [4]. Structural changes of an external membrane can arise due to external physical and chemical factors, or thank to internal response to immune stresses. Meanwhile in the standard clinical microscopy techniques the surface of cells in smears is not investigated. According to the accepted rules smears of a patient undergo many step chemical processing. In so way rather valuable probably diagnostic signs of pathological cells will removed. Quite probably that as a result of processing occurrence in structure of objects of the various artifacts distorting the analysis [5].

For partial elimination of above mentioned shortcomings it is offered to use the optical microscopes working in reflected light. Besides it is possible to notice that received pictures of a cellular structure in an offered method of the analysis sometimes with such features which can be received only using a raster electronic microscope. At slanting illumination of a surface of analyzed cells, fine pattern of their structure get volume perception that facilitates decoding of results of the analysis.

Another high resolution tools such as the atomic force (AFM) or scanning electron microscopes (SEM) let us to see cell membrane and organelle more in detail but they operate in environments too harsh for living cells that leads to its damage. Typically, cells have to be treated with chemicals for fixation, dehydration and drying, and in the case of the SEM, coated with metal. Recently proposed Bioimprint method [6] is a soft lithography replication technique used to create a time-shot replica of biological cells in a polymer during curing. Cells at near-native states can be imprinted into a photo-curable polymer, and the imprint analyzed without imaging directly impacting on cell viability. A technique for permanently capturing a replica impression of biological cells has been developed to facilitate analysis using nanometer resolution imaging tools, namely AFM. The transfer of nanometer scale biological information is presented as an alternative imaging technique at a resolution beyond that of optical microscopy.

James K. Gimzewski, Jianyu Rao (Nat. Nanotechnol. DOI: 10.1038/nnano.2007.388) find that AFM can be used to distinguish metastatic cancer cells from normal cells on the basis of stiffness rather than shape. The cancer cells are significantly squishier than the normal cells, and the method promises to improve cancer diagnostics. The researchers find that metastatic cancer cells are nearly four times softer than normal cells.

This paper presents an alternative method for studying biological cells using a optical metallographic inverted microscope (MIM) technique, to enable imaging of the surface topography of human cervical cancer cells. Here we present a new optical-probe technique based on light-scattering microscopy that is able to detect precancerous and early cancerous changes in cell-rich epithelia.

Methods

Smears from uterine neck were collected for patients with diagnosis cervical cancer. Smears were collected by Ayre’s spatula after exposing the cervix by a Cusco’s speculum. Samples collected were transferred to glass slides. Glass slides were preliminarily cleaned thoroughly in a 2 vol.% detergent followed by repeated washing in pure deionized water. Two set of slides were prepared for each patient and fixed by 95% ethanol. Relevant information was obtained from the patient and recorded on a specially designed proforma. The first sets of marked slides were then sent to cytology laboratory to view at high magnification with MIM without fixing and any treatment by dyes. This native smears has been observed under optical reflected microscope “Neophot-2”. For each smear under investigation from 4 to 10-13 field of view was captured. In this case we watched a morphology and topology of cell membrane and captured these images on digital photocamera. This measurement has been performed in Institute of Electronics Uzbek Academy of Science. Both practitioner and patient can then see smears image in color. The results are then used as a basis for prescribing supplements.

The second set of smears was prepared on glass and fixed by 95% ethanol and stained with Papanicolaou dyes and were then sent to Pathology Institute and each slide was then carefully examined by a cytopathologist to distinguish normal cells from leased one. Relevant information was recorded on a specially designed proforma on PC and was marked on the slides. It was clearly specified whether smear was satisfactory or not. Slides showing some abnormal changes in the cellular pattern were further scrutinized by a cytopathologist. Images has been observed on optical microscope “JENAMED-2” and captured by digital high Resolution Microscopy Camera AxioCam MRc Rev. 3 FireWire.

Results and Discussion

Cervical normal and cancer cells was evaluated both traditional Pap-test and new MIM technique. On the figure 1 we can see image of normal cell (control smears) surface captured by MIM technique. with pronounced nuclear. Three kinds of multilayer epithelial cells were observed in control smears (Figure 1 b). Epithelial cells of upper layer had polygonal shape with smoothed cell surface and size about 30-60 mkm with small (about 6 mkm ) nuclear. Cells of more deep layers had smaller size. Parabasal cells of cervix epithelial layer had round shape with size 12-17 mkm and coarse nuclear enclosed by cytoplasm. Minor auto flora around cells was observed. Fine granularity was observed in cell cytoplasm of upper and deeper epithelial layers.

Figure 1. Control cervical smears with normal epithelial cells. a-separate cells, b-parabasal cells of many layer pavement cervix epithelium.

In the case of traditional Pap-test cervical smears was fixed and stained by dyes (Figure 2). Here we can basically see content of cells (nuclear, nucleolus, cytoplasm, vacuole etc) and their shape. Hyperchromic pronounced enlarged nuclear rounded shape, anomalous ratio between nuclear and cytoplasm usually is main diagnostic peculiarity of Pap-test to distinguish cancer and normal cells. But Pap-test do not permit to see cancer cell membrane destruction due to removing any diagnostic signs on cell membrane. Offered here MIM technique deals with native smears and let us to see just membrane morphology in reflected light. Indeed for cervical cancer cells we observed ballooning–out of cell membrane with specific distribution around nuclear (Figure 2). This ballooning-out formations have high light reflectivity due to its content and smooth shape and named by us Light Reflecting Formations (LRF) (Figure 2.). They have rather small diameter (0.3-0.5 microns) and consequently were accurately observed only at big optical magnifications (800-1000×).

Figure 2. Typical view of cervical cells after staining by dyes (Pap-smears).

For cervical epithelial cells two rinds of LRF arrangement on cell membrane are possible. The first variant is connected with presence of LRF only on polygonal cells from the top layer of multicellular epithelium (Figure 1). Thus LRF can settle down on a surface of cell membranes as by the piece (them it is possible even to count (Figure 3 a,b), and in the form of high density LRF associations (Figure 4а, b).

Figure 3. Cervical cells of upper epidermal layer of patients with diagnosis Cr. coli uteri

Figure 4. Assosiations of  LRF on  cervical cells of upper epidermal layer of patients  with diagnosis  а-Cr. coli uteri  and   b-Cr. corporis  uteri T₁N₀M₀

The second really observable variant of LRF in cervical smears is connected with cells of intermediate and parabasal layers (Figure 5а). In intermediate roundish cells besides LRF it is sometimes shown clumpy granularity of cytoplasm and excentricly located nuclear (Figure 5а). In parabasal cells of the bottom epidermal layers from cervix LRF in size 12-15 microns basically settle down separately (Figure 5b). Thus, experimental data indicate that for cervical cancer cells LRF are observed on polygonal top layer epidermal cells or only on bottom layer cells. In the first case for some patients the surface of epithelial cells contained isolated LRF which was possible even to count them by the piece (Figure 3). But for other women similar cells have been entirely was choked up LRF (Figure 5а). It is not clear yet what is reason so difference in LRF arrangement on a cervical cancer cell surface, and density its distribution along membrane. The nature of LRF occurrence and a its chemical compound is not clear yet too The analysis of the literature let us to assume that observed structural phenomenon in cervical smears may be connected with strengthened vacuolisation of cytoplasms and intensive aerobic glycolysis (fermentation) in cancer cells [7].

Figure 5. Neoplastic  intermediate (а) and parabasal (b) cells of many layer epithelium  of cervix.

Figure 6. Ballooning–out of cervical cancer cells membrane.

Really, in the course of experiment we accurately observed intensive process of a cell membrane reorganization of cervical cancer cells. The location of the LRF on the cell membrane is shown in Fig. 4 too for patients with late stage of disease, where they are seen predominantly concentrated at areas around the nucleus. The diameter of non-dysplastic cell nuclei is typically 5 mkm, whereas dysplastic nuclei can be as large as 10 mkm and more.

The nature and mechanism formation these features of cancer cells are not understood up to now but they are potentially associated with exocytosis. It is accepted that in result of a cancer cell metabolism a granules or vesicles originate inside of cell and move towards cell surface to release its contents. Visualization of such morphological formations has however been limited, partly due to the difficulties with imaging native living or structurally intact cells because convenient transmitted light microscopy techniques do not reveal surface cell features which are usually removed after fixing, drying and other treatments of smears.

Much is yet to be known about the nature of cervical cancer cells and until now there has not been a reliable, simple method for cervical cell testing. We suppose that offered MIM method to visualize cell topography in air without fixation and dehydration may be alternative and complementary to Pap-test. Being able to directly view membrane structures regulated by exocytosis will enable researchers to analyze the secretory nature and response of cells, yielding insights into drug responses and effects [6]. Considerable variability in the sizes of LRF, as well as dynamic formation and grouping of these structures around the nucleus, illustrates that cells have diverse morphologies.

Conclusion

A technique for revealing surface morphology of human cervical cancer cells has been developed to facilitate early diagnostics of a pre-cancer and cancer cells under reflected light microscopy. The offered method was borrowed from optical microscopy of a solid state surface where the Metallographic Inverted Microscopy (MIM) is usually used. Unlike common accepted transmitted light microscopy for biological applications MIM technique allows to reveal a morphology and topology of a biological cells surface without any treatment by chemicals (fixing, staining, drying, freezing et al). The MIM method was demonstrated by analyzing fresh native smears from epithelium of uterine neck. MIM micrographs of 167 patients with diagnosis cervical cancer allow visualizing on the cancer cells surface numerous of the Light Reflective Formations (LRF). It is supposed that LRF are connected with exocytosis on the cell membrane. For smears of cervix epithelium throughout the field of view of a microscope numerous ballooning-outs, which have a mean size from 0.1-0.5 to 1.2 -1.3 mkm, are seen located on the cell surface. It is accepted that in result of a cancer cell metabolism a granules or vesicles originate inside of cell and move towards cell surface to release its contents. Visualization of such morphological formations has however been limited, partly due to the difficulties with imaging native living or structurally intact cells because convenient transmitted light microscopy techniques do not reveal surface cell features which are usually removed after fixing, drying and other treatments of smears. We suppose that offered method to visualize cell topography in air without fixation and dehydration may be alternative and complementary to Pap-test.

Acknowledgement

This work has been supported by Grant № X11-001 of Coordination Center for Science and Technology Republic of Uzbekistan.

References

1. Koss LG (1989) The Papanicolaou test for cervical cancer detection. A triumph and a tragedy. JAMA 261: 737–743. [crossref]
2. Hamby L (2002) Gene expression patterns and breast cancer. Cancer Genetics News, Spring 4: 1
3. Palaoro LA, Blanco AM, Gamboni M, Rocher AE, Rotenberg RG (2007) Usefulness of ploidy, AgNOR and immunocytochemistry for differentiating benign and malignant cells in serous effusions. Cytopathology 18: 33–39.
4. Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, Gordillo-Tobar A, Levin C, et al. (2005) Cost-effectiveness of cervical-cancer screening in five developing countries. N Engl J Med 353: 2158-2168. [crossref]
5. DaCosta RS, Wilson BC, Marcon NE (2007) Fluorescence and spectral imaging. ScientificWorldJournal 7: 2046–2071. [crossref]
6. Muys JJ, Alkaisi MM, Melville DOS, Nagase J, Sykes P, et al. (2006) Cellular transfer and AFM imaging of cancer cells using Bioimprint. Journal of Nanobiotechnology 4: 1–10.
7. Mirabal YN, Chang SK, Atkinson EN, Malpica A, Follen M, et al. (2002) Reflectance spectroscopy for in vivo detection of cervical precancer. J Biomed Opt 7: 587–594. [crossref]

DOI: 10.31038/AWHC.2018133

Abstract

Background: Traditional Ghanaian culture has held that the ideal body image for women favors a larger size as symbolic of wealth and status.

Objectives: This investigation evaluated the complex relationship between social and cultural variables and the body image perspectives of women and men residents of Cape Coast, Ghana in an attempt to provide a framework for assessing the diverse factors that influence body image.

Methods: An oral survey was administered by the investigators to 400 outpatients at the Regional Central Hospital. The survey included questions on body image; weight changes; media exposure; social and cultural influences on ideal image; food security; and select SF-36 questions.

Results: Both women and men selected an Ideal Body Image (IBI) figural silhouette that represented a size greater than a normal body mass index. Television was the most frequently identified source of media exposure and had the greatest influence on IBI. Some 21.1% of participants reported that their IBI was highly influenced by television, without a statistically significant difference between men and women. Women were significantly more likely to report being highly influenced by newspapers and magazines than men (18.3% versus 10.7%, p = 0.046). Women and men who were highly or moderately influenced by family opinions were significantly more likely to be dissatisfied with current body image than those not influenced by family (80.5% versus 64.8%, p = 0.017), (75.4% versus 48.0%, p = 0.001), respectively.

Conclusion: Social media exposure is common for the inhabitants of Cape Coast. Television was the most influential form of media on the body image. Social relationships were also an important determinant of body image dissatisfaction.

Keywords

Body Mass Index, Cultural Determinants, Current Body Image, Ghana, Ideal Body Image, Social Media

Financial Support: Scholars in Medicine Program, Harvard Medical School

Introduction

The influences on body image can be multifaceted and include social, cultural, media and relationship determinants. An understanding of such influences on women’s and men’s body image can assist health care providers to address the risks for noncommunicable illnesses such as hypertension and diabetes that are linked to an increased body mass index (BMI) as well as to introduce preventive measures or medical treatments 1,2].

One of the most broadly accepted theories of the determinants that influence body image is the sociocultural model, which suggests that standards of attractiveness set by Western society are unattainable for the vast majority of individuals, leading to a disparity between ideal and reality 3–8]. In a previous study assessing the ideal body image of women residing in Accra, Ghana and testing the hypothesis that the ‘traditional build’ is the ideal, the investigators instead found that the majority of women selected the IBI as one that represented a normal body mass index, and the least healthy image was that figure that represented morbidly obesity 2]. A direct relationship exists between media exposure and thin body size for women and body image dissatisfaction, with most finding a small-to-medium effect from media 9–12]. Studies focused exclusively on men have demonstrated a relationship between body image dissatisfaction and exposure to images of idealized bodies, many with a particular focus on the idea that exposure to images of enhanced male muscularity can modify male ideal body image [13–16]. Because body image and dissatisfaction appear to be highly specific to the cultural context in which they are developed, conclusions drawn in Westernized countries should not be applied directly to other countries or even across ethnic and racial lines [17, 18]. Studies in both developing and developed countries have documented body image dissatisfaction in various degrees across cultures and have confirmed the association of exposure to media images of so-called western ideals of attractiveness with such dissatisfaction [19]. This investigation evaluated the complex relationship between social and cultural variables and the body image perspectives of residents of Cape Coast, Ghana, a medium sized regional capital city [20].

Material and Methods

Study setting and population

The study was conducted at the Central Regional Hospital (now Cape Coast Teaching Hospital) in Cape Coast, Ghana, the capital of the Central Region of Ghana. The metropolis covers an area of about 122 square kilometers with a population of approximately 170.000. The Central Regional Hospital in Cape Coast serves as the main referral center for both primary and secondary healthcare facilities within the Central Region. The 400-bed hospital serves the residents within the Cape Coast municipality [21]. The study population included participants attending the Out-Patient Department (OPD) between June and July 2012. English-speaking Ghanaian men and women 18 years or older were approached as they entered the waiting area of the OPD. English is the official language of Ghana, and many regional languages exist in spoken form. Exclusion criteria included age less than 18 years, pregnancy or lactation status, residence outside the metropolis and inability to communicate sufficiently in English to complete the survey. Few patients approached ( < 5%) declined the survey or were consider ineligible because of language restrictions.

Survey

Participants were asked to complete survey administered by the investigators comprised of the following components: demographic information; exposure and impact of media and cultural influences including television, radio, print materials, billboards, Internet cell phones, family, spouse, friends and religion; food access and select questions from the Medical Outcome Short Study Form-36 [22–25]. Each participant was provided with a card indicating their personal measurements, their BMI and waist/hip ratio, and an explanation of each measurement (underweight, normal, overweight, obese) as a token of appreciation of their participation.

Figural Stimuli

Culturally appropriate figural stimuli for men and women were created based upon the mean height and weights obtained from the Women’s Health Study of Accra from 2003 [1]. Twenty-five individual silhouettes were created ranging from a representation of underweight figures to morbidly obese figures, uniformly changing in size by 10% increments (Figure 1, 2). Silhouette 8 represents the middle of the normal body mass index range. Participants were presented with two printed posters depicting images of men and women and asked to identify, by number, the figure that most closely matched their current body image (CBI), that of their spouse/partner, as well as an ideal body image (IBI) for self, spouse/partner, and Ghanaian men and women in general.

Figure 1. Figural stimuli silhouettes – Women (Figure 8 represents the mid-range of a normal body mass index).

Figure 2. Figural stimuli silhouettes – Men (Figure 8 represents the mid-range of a normal body mass index).

Anthropomorphic Measures

Anthropometric measurements were taken with participants wearing light street clothes without shoes [2]. Height and weight were obtained and recorded to the nearest 0.1 centimeters and 0.1 kilograms, respectively, with a standing measuring stick and a calibrated, portable scale. Waist and hip measurements were collected to the nearest 0.5 centimeters with a flexible tape measure designed for body measurements. WHO STEPS protocols were followed, with the tape measure fitted snuggly, and with waist defined as the midpoint between the lower margin of the last palpable rib and the top of the iliac crest and hip defined as the widest portion of the buttocks [26].

Statistical Analysis

BMI was calculated for each participant and categorized according to WHO standards, with underweight ≤ 18.5, normal weight 18.6–24.9, overweight ≥ 25.0 and obese ≥ 30.0. A body image dissatisfaction score (DS) was calculated by subtracting the figure selected as the IBI for self from that selected as the CBI (DS = CBI – IBIself). Statistical analysis was performed using SPSS version 16.0 for Windows and included descriptive statistics for frequency and mean values Fisher’s Exact Test (FET) 1-sided, student T-test, chi-square test, Pearson correlation, binary logistic regression analysis and multinomial regression analysis.

Institutional Review Board Approval

The investigation was approved by the Institutional Review Boards at Harvard Medical School, Boston, MA, USA and the University of Cape Coast School of Medical Sciences, Cape Coast, Ghana. Verbal consent was considered sufficient for participation in the survey and an informed consent signature waiver obtained.

Results

Participant characteristics

A total of 400 patients agreed to participate in this study. There was an equivalent number of male and female participants (49% versus 51%) and no statistically significant difference between gender and mean age, highest level of education attained, marital status, religion, and environment of birth and current residence
(Table 1). Women, however, were two times more likely to be unemployed compared with men (14.2% versus 7.7%, p = 0.026 FET), univariate analysis Odds Ratio (OR) = 2.0, 95 CI % (1.03–3.90), p = 0.039. Responses to the Medical Outcome Short Study Form-36 revealed that most of the participants (81.7%) reported they were in good to excellent health, were in much or somewhat better health compared to last year (53.0%) and were somewhat to very happy at the time of survey (85.1%).

Table 1. Participant Characteristics.

Body Mass Index

Height and weight measurements were available for all 400 participants. The distribution of BMI and gender are shown (Table 2). Obesity was identified significantly more often in women compared with men (20.1% versus 6.1%, p < 0.001), OR 1.6, 95% CI (1.25–1.96), p < 0.001.

Table 2. Body Mass Index by Gender.

Current Body Image

The most frequently selected CBI for women were figures 11, 13, and 14 (9.3% each), larger than the silhouette representing the middle range of a normal BMI. The mean ± standard deviation current body image (CBI) silhouette selected by women was figure 14.5 ± 4.5 (range 1 to 25). Only 8 women (3.9%) selected figure 8 (mid-range of normal BMI) as their CBI. There was a significant correlation (r = 0.727, p < 0.001) between BMI and CBI silhouette for women.

The most frequently selected CBI for men were figures 10, 12, 13, and 14 (9.2, 12.8, 14.8 and 11.2%, respectively), as found with the women, larger than the silhouette representing the middle range of BMI. Only 5 men (2.6%) selected figure 8 (mid-range of normal BMI) as their CBI. The mean ± standard deviation current body image (CBI) silhouette selected by men was figure 13 ± 3.7 (range 2 to 24). There was also a significant correlation between increasing CBI silhouette selected and increasing BMI for men (r = 0.603, p < 0.001).

Ideal Body Image for Women and Men

Both women and men selected a figure that represented a size larger than Silhouette 8, the middle of the normal body mass index range. The most frequently selected silhouette for women to represent their ideal body image (IBI) for themselves was figure number 14 (mean figure 13.6 + 3.6, range 1 – 25). The most frequently selected silhouette for IBI by men for themselves was figure number 13 (mean figure 13.8 + 3.6, range 2 – 25). There was also a significant correlation between BMI and IBI for both women and men. The Pearson correlation between BMI and IBI for women was (r = 0.260, p < 0.001) and between CBI and IBI for women was (r = 0.551, p < 0.001). The Pearson correlation between BMI and IBI was (r = 0.141, p = 0.049) and between CBI and IBI for men was (r = 0.596, p < 0.001).

Women and men most frequently selected figure 13 as the IBI for a spouse/significant (15.6% and 17.1%, respectively). The most frequently selected IBI for a Ghanaian woman in general by women was figure 14 (15.5%, range 7–25, r = 0.480, p < 0.001). Figure 15 (13.5%, range 2–23) was most commonly selected by men as the IBI for a Ghanaian woman. In comparison, women and men both selected figure 15 as the IBI for men (range 7 – 25 and 4 to 25, respectively). There was a significant correlation between a man’s IBI for himself and for a man in general (r = 0.553, p < 0.001).

Dissatisfaction Score

The dissatisfaction score (DS) was calculated by subtracting the IBI from the CBI for women and men. Less than one-third (32.6%) of participants had a DS = 0, indicating the CBI = IBI. There was no significant difference between women and men with a DS = 0 (29.4% versus 35.9%, OR 1.34, 95% CI (0.88, 2.0), p = 0.168) (Table 3). However, women were significantly more likely to select an IBI smaller than the CBI compared with men (42.2% versus 28.4%, OR 1.51, 95% CI 1.18–1.94, p = 0.001). On a multivariate analysis, the variables significantly associated with a DS = 0 included: children (any versus none), stable weight for the past year, anticipating a stable weight in the next year, being less likely to have been told as an adult to gain or lose weight, and being less likely to be influenced by spouse/partner (Table 4). In addition, 64.6% of participants with a DS = 0 had a normal BMI; however, for each BMI category, most participants were dissatisfied with CBI (p < 0.001) (Table 5).

Table 3. Dissatisfaction score = Current Body Image – Ideal Body Image by Gender.

Table 4. Variables significantly associated with Dissatisfaction Score (DS) = 0 on multivariate analysis.

Table 5. Body Mass Index and Dissatisfaction Score.

On multivariate analysis, a smaller IBI (DS = CBI > IBI) versus a larger IBI (DS = CBI < IBI) was statistically associated with: attempt to lose weight by caloric restriction, attempt to lose weight by exercise, told as an adult to lose weight, expect weight to decrease over the next year, and agree that weight has a very large effect on health, report no television viewing. Variables associated with a larger versus a smaller IBI included: unmarried status, attempt to increase weight with food (51.1% versus 18.6%), and told as an adult to gain weight (Table 6). Pertinent variables not associated with DS include environment of birth, environment of current residence, and media (television, radio, billboards, and internet usage), family, friends, religion, and food security.

Table 6. Multivariate analysis for variables that influence a positive or negative Dissociation Score.

Media Influence and Ideal Body Image

A majority of participants reported exposure or access to each form of media assessed (Table 7). There was a significant difference in exposure to radio and newspaper/print between women and men. Men were significantly more likely to listen to the radio (OR = 2.51, 95% CI 1.13, 5.59) and read the newspaper (OR = 1.10, 95% CI 1.02, 1.16, p = 0.004) compared with women. A radio and television was present in 92.3% and 92.5% of all households, respectively. In addition, 97% of all participants had access to a cell phone and 60.2 percent had access to the Internet, with no statistical significant difference between women and men (97.1% versus 96.9%, p = 0.587 and 58.3% versus 62.2%, p = 0.243, respectively).

Table 7. Media Exposure and Influence on Ideal Body Image for Self by Gender.

Television was the most frequently identified source of media exposure and had the largest influence on IBI. Television was viewed daily by 75.2% of participants and 21.1% of participants reported that their IBI was highly influenced by television, without a statistically significant difference between men and women. Television was significantly associated with dissatisfaction, with those watching television seven days a week having significantly higher dissatisfaction score compared with those not watching television (–0.70 v. 0.48, p < 0.001). Although they read less print media overall, women were significantly more likely to report being highly influenced by newspapers and magazines than men (18.3% versus 10.7%, p = 0.046). Women who were highly or moderately influenced by friend or family opinions were significantly more likely to be dissatisfied (any versus none) with CBI compared with women not influenced at all (77.8% versus 60.0%, p = 0.011, and 80.5% versus 64.8%, p = 0.017, respectively, FET 2 sided). Women’s dissatisfaction score was not significantly associated with influence of television, radio, print media, billboards, spouse, or religion. However, men who were highly or moderately influenced by spouse or friend opinions were significantly more likely to be dissatisfied with CBI compared with men not influenced at all (63.3% versus 44.4%, p = 0.049, FET, 1-sided, and 75.4% versus 48.0%, p = 0.001, FET 2 sided, respectively). Men’s dissatisfaction score was not significantly associated with influence of television, radio, print media, billboards, family, or religion.

Social Influences and Ideal Body Image

Cultural, social and family determinants also had modest influence on IBI for self (Table 8). A spouse/partner had the overall influence on IBI (29.2%), although there was no statistical difference based upon participant gender. Women were significantly more likely to be influenced by friends compared with men (OR = 1.07, 95% CI 1.02, 1.14, p = 0.013).

Table 8. Cultural, Social and Family Influences on Ideal Body Image for Self by Sex.

Social and family influences on gaining/losing weight were assessed for childhood and adulthood. During childhood, most participants were not encouraged to lose weight (91.7%), but almost one-third were told to gain weight (34.5%). Women were significantly more likely to have been told to gain weight as a child compared with men (OR = 1.68, 95% CI 1.10, 2.55, p = 0.015). In contrast, adult women were more likely to be told to lose weight compared with adult men (OR = 2.52, 95% CI 1.64, 3.88). Women were much more likely to have attempted weight loss compared with men. Women were significantly more likely to attempt to lose weight by dieting, (47.1% versus 18.4%, OR = 3.9, p < 0.001, CI = 2.0–7.9), exercising (48.5% versus 31.1%, OR 2.1, p = 0.001, CI = 1.4–3.1) and diet pills (10.8% versus 5.6%, p = 0.045, FET 1-sided).

Additional Health Related Determinants Influence on IBI

An open-ended question inquired about other possible factors that may influence IBI. Most respondents provided no additional types of influence (72%). However, of the 113 (64 men and 71 women) who did provide an open ended response, 53.1% of men and 33.8% of women stated improved health-related reasons as an important influence on their body image, while 23.9% of men and 17.0% of women mentioned a desire to appear more attractive. Only 3.1% of men and 5.6% of women noted social pressures as an external influence on IBI.

Discussion

Ghana provides a particularly unique environment to study body image. First, traditional Ghanaian culture has favored a larger image as ideal that for women, symbolic of wealth and higher status [27–30]. Second, there exists interplay between traditional and modern cultures resulting from rapid economic development, urbanization, modernization and social changes such as shifts in gender roles and exposure to western cultural practices and norms [20]. Further, rural-urban migration continues to occur at a rapid pace, with the rural proportion of Ghana’s total population dropping each year since 1960 and recently dropping below 50% [31]. The implication is that more and more traditional Ghanaian values are being brought along with such migrants to the city, even as recent migrants are exposed to new cultural values in the urban environment. Finally, the growing prevalence of overweight and obesity coupled with increasing longevity mean a rapidly increasing burden of chronic disease for Ghana, a problem that is pervasive in much of the developing world [32, 33]. Because of its position as a key parameter in understanding overweight and obesity and in shaping emotional health, body image is an important public health concern [34, 35].

The choice of 25 figures with standard variation ordered by increasing size was based on the example of the BIAS-BD figural drawing scale, the original version of which depicted 17 human figures [36]. Subsequent research on effective use of figural stimuli has shown that figural stimuli products using a discrete number of images (rather than a size range) and with images arranged in ascending/descending size order [as opposed to random) are the most accurate and effective as research tools [37]. While static figures obviously limit the creativity with which participants can express their ideal body image perspectives, we did test for and confirm that they were accurate in representing a participant’s current body image in regards to BMI, and we limited our investigation of body image to size rather than including other considerations such as shape or build.

We investigated determinants in combination with body image perspectives to better understand the factors that shape Ghanaians’ weight and their ideas about weight. Our study found a notable disparity between men and women in terms of proportion overweight and obesity, with 50.0% of women categorized as overweight or obese compared with 27.5% of men. These numbers are consistent with previous findings in Cape Coast [38]. We found only a few correlates for overweight or obesity, none of which provided a satisfying explanation for this gender disparity. As expected, age correlated with weight for both genders, as did number of children. Men were significantly more likely than women to be employed, and work of all types has been found to contribute to a less sedentary lifestyle [39] and lower rates of overweight/obesity; however, employment status was not correlated with BMI for men or women in our study. Further study might delve deeper into the relationship between employment type and body weight. We also found no relationship between education level and BMI, although such a relationship has been found in previous research in the region [28, 40].

We found no correlation between location of residence and BMI, although this has also been shown to be an important correlate of BMI [41]. This may be accounted for by the fact that participants are relatively mobile as – approximately 28.5% had lived in at least four places in their lives—and that a large number (37.5%) had lived in one or both of the two largest cities in Ghana (Accra or Kumasi) at some point, suggesting that even semi-urban and rural residents may have significant exposure to urban environments. Studies on body image have shown that both men and women are influenced by the figures they see in the media and in particular television, and that media exposure often creates unrealistic expectations for body image, leading to increased body dissatisfaction [4,13, 42]. One of the most notable findings in our research was the high level of media exposure reported by participants. These high levels of media exposure suggest that Ghanaians are susceptible to media influences that may influence their body image perceptions. One limitation to this assumption is that we did not examine amounts of daily media exposure, nor did we attempt to document the type of content participants were exposed to, both of which might have helped us better understand our participants and the influences on them.

We observed a significant relationship between high levels of television viewership and body image dissatisfaction within our sample population, suggesting the plausible presence of media content that may influence people’s body image ideals. Interestingly, unmarried men who watched television were significantly more likely to choose an IBI larger than their CBI, indicating a desire to be larger than their current size. Other studies have reported similar findings, and have suggested that men may be under increasing pressure to develop greater degrees of muscularity [4]. Indeed, formal and informal comments from men during the course of the survey confirmed that many were interested in being larger and more muscular.

Social interactions and body dissatisfaction relationships with friends and family were shown to be influential determinants in the establishment of body image, and in determining how an individual is affected by their body image [43]. Research in the United States has shown the influence of social relationships and support organizations on body image can be incredibly powerful in both positive and negative ways [44, 45]. We found that both spouse/partner and friends had a negative rather than positive influence on female body image, with women who identified strong influences from these determinants having greater body image dissatisfaction scores. However, family influence was not correlated with dissatisfaction, which may suggest either that adults are less influenced by the opinions of their families, or that family members are more likely to be supportive, making them less apparent as a source of influence.

Although our question about self-reported influence did not reveal as strong a relationship between social forces and dissatisfaction as we found for television, our secondary social influences questions, which assessed whether participants had ever been told to change their weight, were incredibly telling. Among a wide variety of factors, being told to change weight as an adult was the most strongly associated with body image dissatisfaction, and what participants had been told was tied to the type of dissatisfaction they experienced, with those who had been told to gain weight favoring a smaller ideal, and those who had been told to lose weight favoring a smaller one. This supports the idea that negative messages about weight from social networks are very powerful.

The concept of influence from media and relationships seemed to be an idea that some participants were familiar, while others appeared to have a much more difficult time contextualizing the way in which images, ideas or other people could affect their personal body image concept. This may have led to some participants providing arbitrary or inaccurate answers to our influences questions. Further study into body image in this context is warranted. In particular, drawing out more detailed information about the types of influences present in Ghanaian media, adding qualitative inquiry methods to our work and perhaps determining novel ways to inquire about the concept of influence would all be helpful in revealing more about body image attitudes in Ghana.

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DOI: 10.31038/AWHC.2018132

Abstract

Hormonal imprinting is a physiological process, when hormone receptors and the target hormone meet in the first occasion, perinatally. This process is needed for the normal function of the receptor-hormone complex and valid for life. However, hormone-like molecules also can bind to the developing receptor causing faulty imprinting and its consequences: altered binding of hormones, inclination to diseases, manifestation of diseases, disturbing the physiological hormonal regulation. The faulty imprinting also has a lifelong effect. Industrial, communal, nutritional and medical endocrine disruptors are faulty imprinters and their variables as well, as amounts are enormously growing in the human environment. The faulty imprinting influences also the microsomal enzyme system. Numerous diseases, manifested at adult age can be deduced to perinatal faulty hormonal imprinting and the higher sensitivity of women to drugs (more adverse reactions) could be explained by perinatal events. The extremely growing variants and amount of endocrine disruptors could rearrange the whole endocrine system, which could be disastrous or useful alike in the future.

Keywords

Bisphenol A, DOHaD, Endocrine Regulation, Steroid Hormones, Perinatal Period, Functional Teratogens

Introduction

During fertilization the genom of the women’s egg contain the maternal informations and the paternal informations are brought by the sperm. After the fusion of two germ cells the zygote is existing, which is able to develop further to the complete organism (individuum), controlled by the fused genome (ontogeny). The zygote is totipotent which means that it is able for developing to any organs (cells) of the organism however, during the ontogenetic development there is a continuous loss of potencies, to pluripotent (multipotent) and at last to unipotent cells, which are able to produce cells (by cell division) similar to the mother-cell, or are unable to divide (e.g. nerve cells) at all. This means that during the ontogenetic development a continuous narrowing of potencies happens which is resulted in diffent types of cells, with different structure and function. Therefore, in different cell types of the organism different genes are manifested (are working, giving information for function), while others are closed by methylation of the cytosin nucleotids of DNA. The organization of these different units is the duty of the neuroendocríne system in which the direct transmitter humoral components are the hormones. However, the neuroendocrine system can regulate only such functions, which are permitted by the genes, which are open for giving information to the given functions.

The Physiological and Faulty Hormonal Imprinting

The hormones are present in the blood circulation, where any cells of the organism can meet them. However, only such cells can decipher the message contained by the hormone, which have cell membrane or nuclear receptors for the given hormone, which can bind the hormone and after that can transmit the coded information into the cytoplasm or into the nucleus. These receptors are specific for a given hormone, nevertheless this specificity also develops gradually during the ontogenetic development. During the embryonal and early fetal period of human life maternal hormones (passed across the placenta) are dominating however, at the end of the fetal and during the perinatal period (prenatally, at birth and early postnatally) the „homegrown” hormones appear and hormonal imprinting is taking place, conforming the receptors for themselves. This imprinting is necessary, without it the fitting of receptor-hormone system is not working well [1]. The setting is valid for life and inherits to cell to cell inside the cell line as well as to the progenies of the individuum, as it is an epigenetic process, which alters the methylation pattern of a given gene (the expression of the gene), without disturbing the nucleotid sequences [2]. However in this critical perinatal period the receptors’ specificity is weak, what means that other members of a hormone family or synthetic hormones, hormone-like molecules also can be bound by them and the amount of imprinter is also very important. In this case a faulty hormonal imprinting can develop, which is also have a lifelong validity and causes disturbed functions, with abnormal binding of hormones in adult age [3]. Consequently, disturbed functions appear in behavior [4–6], sexuality [6–8], body composition [9], in bone development [10]; the neurotransmitter production of brain is also altered and immune functions are changed (e.g. autoimmunity develops). One single encounter with very low doses of hormone-like molecules in the critical perinatal period is enough for the provocation of faulty imprinting and for the manifestation of their consequences in adult age. The hormonal imprinting which was observed, described and experimentally justified by us (at first in 1980) [11] was the first in the series of new theories which lead to metabolic imprinting [12], immunological imprinting [13] and to the developmental origin of health and disease (DOHaD) [14]. As hormonal imprinting is an epigenetic process, the alterations happened in the perinatal period can be manifested at any time of life and also can be manifested in the progenies and by this, epigenetic alterations of the future generations are settled on the already changed genetic arrangements. This is important as the response of a faulty imprinted cell or organism would be different from which is observed in the present time.

The Endocrine Disruptors

Endocrine disruptors are molecules similar to (first of all, steroid) hormones, which are present in our environment and can enter into our organism by air, water, food, drug consumption and can be bound by hormone receptors influencing cell functions, stimulating or hindering them. Endocrine disruptors has been always present during the evolution of men in our environment as e.g. aromatic hydrocarbons produced by volcanic eruptions, food components (phytoestrogens, present in soy and other vegetables), smoke etc. However, they were not named to „endocrine disruptors” as their such effects were not known and their amount was insignificant. At present, in our modern (industrial) age their variety is high, their amount is large and both are enormously growing. They causes a crisis in the endocrine system as well in the systems, which are seriously influenced by the distorted endocrine system.

Endocrine disruptor exposures are believed harmful in adult age and this is demonstrated by many research data and statistics. However, they are more harmful in the critical periods of development, mainly in the time of hormonal imprinting. In this case they are causing faulty hormonal imprinting with lifelong consequences. In animal experiments single treatment with aromatic hydrocarbons (benzpyrene or dioxin) are decreasing the binding capacity of glucocorticoid receptor as well as estrogen receptor. Vitamin D3 (which is not a vitamin in reality, but a steroid-like hormone having receptors in the cytoplasmic-nuclear steroid receptor family [15], lifelong decreases the sexual activity (libido) of female and male rats, similar to industrial or communal endocrine disruptors [16].

Faulty Hormonal Imprinting and Functional Teratogenicity of Endocrine Disruptors

Teratogen materials, which evoke morphological alterations which are visible at birth are known from immemorial time and these are most effective during the embryonal period and their effects gradually decreases whith the time passed and vanishes after birth. Faulty hormonal imprinting does not provoke morphologically observable important alterations, but changes in functions of cells organs or systems which are manifested in diseases. They are not diagnosed at birth however, manifested later, mostly in adults. This is a functional teratogenity, without organic changes. An other difference to the morphological (real) teratogens that the possibility for exposure is longer: the perinatal period is the late phase of intrauterine development for morphological teratogens however, faulty imprinting can be provoked at any time e.g. also postnatally, few days or weeks after birth and other critical periods of life. The absolute need for taking place is the multiplication and differentiation of the touched cells.

Faulty hormonal imprinting inclines to diseases, alters behaviors, influences cell-responses to attacks, etc. In the scientific literature there are extreme amount of experimental data and also human observations can be found however, in the frame of a short review paper only a selection of them can be shown. Nevertheless they are represantatively demonstrate the importance and amount of the problems caused by it in the present modern age.

Sexual and Behavioral Problems Caused by Faulty Hormonal Imprinting

Perinnatal exposure to TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin) an environmental contaminant (originated from volcanic eruptions as well as from exhaust gas of cars) and industrial or agricultural imprinters (bisphenol A, vinclozolin) pushes the boy-adventageous sex-ratio (more boys are delivered than girls) for the adventage of girls after paternal exposure (in human [16] and also to maternal exposure [17]) (in rats and mice). Bisphenol A (the well known plasticizer and representative of endogen disruptors) by prenatal and lactational exposure, changes the behavior of adults. Prenatal bisphenol A exposure provokes externalizing behavior in 2 years old children, especially in females [18] and abolishes the differences between male and female sexual behavior [19] and also modifies sexual behavior in female mice. It also alters sex difference in affective disorders. There is such opinion which calls attention to the future problems with school age. Some experiments and observations point to the possible association between early bisphenol A exposures (perinatal imprinting) and autism spectrum disorders)[19,20]. Pubertal bisphenol A exposures caused long term alterations in microglia of the prefrontal cortex when this was lower in males and higher in females [21]. There were also alterations in body weight and composition. Perinatal treatment and adolescent reexposure exacerbated adverse effects in females and reduce differences in males. Symptoms of sex dependent anxíety/depression appeared in 7–9 years girls without expression in boys after gestational bisphenol A exposures [22]. Altered sociosexual and mood disorders were observed in animal models and children after developmental exposure by bisphenol A [23].

Other Problems Caused by Faulty Hormonal Imprinting

Reproductive organs and puberty

First in the US and later in Europe an alteration in the timing of puberty (decline) was observed and also the growing number of obesity for which environmental factors, mainly endocrine disruptors was believed as responsible, by influencing genetic factors [24] These problems were observed after imprinting with polychlorinated biphenyls, polibrominated biphenyls, DDT and phtalate esters [25]. Both puberty age and menarche age were influenced [26, 27]. The perinatal endocrine exposures can provoke central precocious puberty or isolated breast development in 2 months to 4 year old girls [28].

Growing number of human (male and femele) infertility and decreased fertility were observed [29]. In the case of perinatal exposure by bisphenol A decreased methylation of DNA and increased histone H3 acetylation were observed in the cerebral cortex and hippocampus, affecting the liver, gut, adipose tissue endocrine pancreas, mammary gland and reproductive tract functions [30]. Maternal programming was also altered [31]. Neonatal exposure to diethylstilbestrol (DES) caused early or delayed puberty, depending on the dose [32] by affecting hypothalamus and hippocampus. This is supported by rodent and human data [33]. Exposure in people is a result of contamination of foods or inhalation (e.g.house or occupational dust). Endocrine disruptors (bisphenol A and phtalates) negatively influence the function of the immune system, altering T cell subsets, B cell functions, dendritic cell and macrophage biology, and provoking autoimmune diseases [34,35]. They have a controversial role in influencing longevity [36]. The developing immune system, the cells of which have steroid (estrogen) hormone receptors is very sensitive to the presence of endocrine disruptors [35]. Faulty imprinting by endocrine disruptors could be responsible for pathological development of bones as well, as for changes in bone mineralization and osteoporotic fractures or other bone problems [37–41].

Gender differences in adverse drug reactions between men and women

It is very difficult to compare data of gender differences in the past-time adverse reaction to drugs, with relatively fresh (which were won in the time of endocrine disruptors) data as earlier always mens’data were studied and dosages of drugs were also prescribed exclusively for men [42–44]. However, new data show that women have 1.5 to 1.7-fold greater risk for adverse drug reactions than men [43]. For example, anti-bacterial and anti-inflammatory drugs cause more adverse reactions in females, as compared to males [42]. Cardiovascular diseases are the first case in mortality and disability of women [44]. There is a similar situation in case of addictions: considering alcohol intoxication compared to men, women metabolize alcohol less than men, it become intoxicated drinking half as much, develop cirrhosis more rapidly and have a greater risk of dying from alcohol-related accidents [45]. Drug abuse and dependence are not identical in males and females and females are less successful in quitting of alcoholism and nicotinism.

Conclusion

As most of the known endocrine disruptors are steroid hormone-like molecules, the functions [46], which are regulated by physiological steroid hormones are disturbed by them. The palette of these functions is broad, from sexuality to immunity and the period in which their effects are manifested is also very broad. They already disturb the sexual (male-female) ratio at birth, pushing it to the adventage of females, cause malformations of sexual organs (micropenis, cryptorchidism and hypospadias), provoke, as functional teratogens, faulty hormonal imprinting. However there are other critical periods of life (development) at weaning, during adolescence and for continuously dividing cells, during the whole life. In these cases endocrine disruptors are also able to provoke hormonal imprinting, which can modify the perinatal setting however, the effect of them less serious, than the perinatal one.

The difference between males and females in adverse drug reactions can be explained by sex differences in pharmacokinetics and pharmacodynamics, in which the liver microsomal enzyme system has an important role. The hormonal imprinting touches not only the hormonal system but also the (microsomal) enzyme system [47,48] and this interferes into the different adverse drug reactions by males and females. There is a gender-dependent metabolism which is influenced by microsomal enzymes which are different in the two sexes [49]. This influences pharmacokinetics and consequently toxicity. As was mentioned, this factor can give some explanation to the differences in adverse reactions by males and females, and faulty hormonal imprinting can disturb this process. This means that in contrast to the real (morphological ) teratogens faulty hormonal imprinting does not causes morphological alterations, which are visible to the naked eye, however alterations in the hormonal or receptorial system as well, as in the enzyme system, durably changing the function of the cells, which are regulated by hormones. This renders likely (though the animal and human data are modest) that women (females) are more sensitive to faulty imprinters and some of their adverse reactions (and the overweight of women in adverse reactions) can be wrote to the expense of faulty perinatal hormonal imprinting.

It was mentioned that a single low dose of an endocrine disruptor seems to be enough for the provocation of faulty hormonal imprinting if it arrives in the optimal time for doing it (e.g.perinatal critical period). It is not surprizing if somebody consider that during the differentiation of the brain, when the direction of sexual development is determined, a part per billion of testosterone and about twenty parts per trillion of estradiol (endogeneous estrogen) actually predict entirely different brain structures, behavioral traits, enzyme levels and receptor levels in tissues [50]. It must be consider that the brain is basically female and it must be exposed to testosterone and related hormones for transforming to male . This means, that the receptorial system is ready to accept the imprinters, the developmental window is open for setting by single minimal doses of hormone-like materials (endocrine disruptors) and this is „exploited” by them (faulty imprinters). The gender differences in sensitivity and its epidemiological importance should be considered.

The late manifestation of alterations after the faulty hormonal imprinting makes more difficult to recognize the participation of faulty imprinting in the manifestation of a disease, or in the changes of behavior. It is supposed, that prenatal exposure to bisphenol A may be related to increased behavioral problems in school age boys, but not girls. However, although serious problems are expectable very difficult to forecast their quality and quantity. At any rate, thorough observations would be needed, for avoiding the problems. However, it seems to be difficult really to avoid, as the variants and amount of different endocrine disruptors are enormously growing because of the claims of the industry, which wants to earn a lot of money, and the people, who want to live more comfortable. In additon, when a new molecule justifies its usefulness in the industry or as a medicament, it is not known (however sometimes could be guessed, but the expected pleasant effects suppresses anxiety), that it will be an endocrine disruptor. Fortunately, it is known that during pregnancy new exogeneous molecules must be avoided however, it is not known by lay medical practitioners and laywomen, that this regulation -in the light of faulty imprinting- must be extended to the whole period of pregnancy and also postnatally.

The task of medicine is to help people in the avoidance of illnesses or to heal ill people. This is done by giving advices or after diagnosing a disease, giving therapy for healing, which is mostly done by prescribing drugs. However, some drugs are endocrine disruptors themselves, for example anticoncipients and some vitamins. Anticoncipients are used for avoiding pregnacy, consequently they do not cause faulty imprinting in the person (women), who intakes it. However, the wast products of metabolized anticoncipients are present in the urine and contaminates drinking water, which is drinked by other, (pregnant) women. If we know, that minute amounts of an endocrine disruptor is able to provoke faulty imprinting, this could be done by the communal water. This is obvious, however can not be declared without exact measurements. Other medicaments are not tested for imprintership before running to circulation and can also contaminate the waters, or influence the endocrine system of developing fetus, directly. Drugs entering into breastmilk also can be faulty imprinters [51] and it is also known that most of baby foods are soy-based, consequently contain phytoestrogens (coumestrol, genistein and daidzein), which are known faulty imprinters [52–54]. Lipid soluble vitamins are prescribed by doctors and can be bought in pharmacies however, also can be purchased without prescription in self-service shops [55]. This shows that mankind is not prepared for the invasion and effects of faulty imprinters.

Afterwords

Pessimistically grasping, the growing of disruptor-inventar and the amount of disruptors, the future of mankind seems to be dangerous and threatening, as -endocrine disruptors -by faulty hormonal imprinting- can attack the whole endocrine system and the desorganization of the gene-level determined well- functioning system could cause hitherto unknown diseases or proliferation of known malignancies. In addition, the alterations are inherited to the progenies, epigenetically. However, there is -optimistically- an other version [55]: some of the endocrine disruptors internalized into the present endocrine system and new (better) functions will be manifested, which will be better suited to the continuously transformed world. Some examples had been observed to such transformation in the past, e.g. the infiltration of lipid soluble vitamins (e.g.vitamin A and D -hormones) and their prominent function in animal (human) life [56] . As can not be known what scenario will be the winner, the protection of women (as mothers) from endocrine disruptor effects is a very important mission of the present day mankind.

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