The Relationship Between Hofstede’s Cultural Dimensions,Schwartz’s Cultural Values,and Obesity

Abstract

According to the World Health Organization, obesity is a major public health issue. In 2014, there were more than 600 million obese people around the world. According to the data of the World Health Organization, obesity rates differ among countries. One possible underlying reason of the difference can be culture, more specifically shared cultural values. The strategies and policies regarding obesity were developed; however, the effect of culture is not adequately considered. The aim of the study is to investigate the relationship between obesity rates of countries, Hofstede’s cultural dimensions, Schwartz’s values, and Gross National Income per capita per country. The data consist of obesity ranking (i.e., the percentage of the population with a body mass index of 30 kg/m² or higher), Gross National Income per capita for each country, and cultural variables (i.e., Hofstede’s cultural dimensions for 54 nations and Schwartz’s cultural values for 57 nations). Hierarchical regression analysis results revealed that Gross National Income per capita was not a significantly related obesity at the aggregated level. Among Hofstede’s dimensions, individualism and uncertainty avoidance were positively associated with obesity, and long-term orientation was negatively associated with obesity. The relationship between Schwartz’s cultural values and obesity was not found to be significant. Findings suggest that Hofstede’s cultural dimensions should be considered when developing national level strategies and campaigns to decrease obesity.

Keywords

Obesity culture gross national income per capita body mass index

Introduction

Obesity

According to the World Health Organization (WHO, 2015), obesity is a major public health issue and a worldwide problem, which has doubled since 1980. In 2014, there were more than 600 million obese people around the world. Although obesity is a serious threat for both sexes, women are more likely to be obese than men. Obesity can be described as a major imbalance between calories consumed and expended, which leads to an excessive amount of fat accumulation in the body (Pooyé, 2010; WHO, 2015). Obesity is diagnosed worldwide by using Body Mass Index (BMI), which is calculated by dividing a person’s weight in kilograms by the square of his/her height in meters (kg/m²). According to the classifications, BMI greater than or equal to 25 is considered overweight, and BMI greater than or equal to 30 is considered obese (Hall & Cole, 2006). Obesity can lead to many negative health outcomes including cardiovascular diseases, diabetes, musculoskeletal disorders, certain types of cancers, as well as premature death and disability (Deveci, 2013; Hall & Cole, 2006; WHO, 2015).

Obesity can be triggered by many factors such as genetics, eating habits, sedentary lifestyle, socio-economic status, or psychological factors. Additionally, the number of meals per a day, the size of portions, fast food habits, and low physical activity are all associated with obesity (Alphan, 2008; Apovian, 2004; Deveci, 2013; Ganley, 1989; Turkish Ministry of Health, 2012). The lack of preventive or supportive governmental policies such as health, agriculture, transport, urban planning, environment, food processing, distribution, marketing, and education should also be considered when trying to understand the underlying reasons for obesity (WHO, 2015). Although there are many factors that are related to obesity as listed above, it is a preventable disease. Interventions both at the individual and societal level can help people make healthier lifestyle choices. At the individual level, people can choose healthier foods, engage in a regular physical activity, and get more help from health professionals. At the societal level, preventive and/or supportive governmental policies can be adopted. This might include increasing accessibility and affordability of healthy food and/or physical activity, developing a well-designed health-care system or improving regulation of the food industry for nutritional quality. However, these societal level interventions differ by countries. When global obesity data are investigated, it is clear that obesity rates vary by countries (WHO, 2015). Although it can be hypothesized that this variance is due to differences in nutrition and/or exercise habits among countries (Alphan, 2008; Apovian, 2004; Deveci, 2013; Ganley, 1989), it is believed that these habits are strongly linked with culture like other many health-related behaviors. Based on the strong link between culture and economy, and the knowledge that obesity rates are also associated with the Gross National Income (GNI) per capita (GNIPC) of the country (WHO, 2015), it is assumed that cultural aspects of obesity are needed to be investigated.

Conceptual framework: Ecological systems theory

Obesity is a global problem. In the literature, there are studies that focus on the underlying reasons of obesity. These studies can be categorized under different levels based on the Ecological Framework developed by Bronfenbrenner (1979). Ecological framework suggests that behavior is affected by multiple contexts: individual level, microsystem, exosystem, and macrosystem. Individual level includes variables like personality traits, attitudes, and beliefs. Microsystem is about the social environment where an individual lives. Microsystem also includes peers and families of a person. The exosystem is about the social context including neighborhood, institutions, systems, and political system. The macrosystem, which is the most general level is about the shared societal and cultural norms, values, and ideologies.

When the Ecological Framework is used to examine the obesity literature, it can be argued that the studies are mainly focused on the individual level and exosystem. For example, several studies investigated the relationship between obesity and the number of meals per a day, the size of portions, fast food habits, low physical activity (Alphan, 2008; Apovian, 2004; Deveci, 2013; Ganley, 1989; Turkish Ministry of Health, 2012); these can be considered as studies that addressed the individual level. The studies about preventive or supportive governmental policies (e.g., health, agriculture, transport, urban planning, environment, food processing, distribution, marketing, and education) (WHO, 2015) can be considered those that address the exosystem. In the literature, there are studies, which investigated other public health issues (e.g., road traffic safety) (Özkan & Lajunen, 2015) at the macro level; however, there are no studies that investigated obesity at macro level including Hofstede’s cultural dimensions and Schwartz’s value dimensions, which have a global perspective. Hence, the current study will make a contribution to the existing literature by focusing on the macro level, including economy, Hofstede’s cultural dimensions, Schwartz’s cultural values, and obesity rates among countries.

Economy

Generally, GNIPC has important relationships with the majority of health-related issues (Klish, 1995; Swinburn & Egger, 2004). GNI is described as “gross domestic product, plus net receipts from abroad of wages and salaries and of property income, plus net taxes and subsidies receivable from abroad” (Organisation for Economic Co-operation and Development, 2018). WHO (2015) states that obesity rates are also affected by the GNIPC of the country. Based on the findings presented by WHO (2014a), the prevalence of obesity increased in Europe and also it showed a dramatic increase in groups with low socioeconomic status. It is also argued that the relationship between obesity and low socioeconomic status, especially for women is strong. Related literature shows contradictory findings of the effect of income on obesity at both the individual and societal levels (Deveci, 2013; WHO, 2015). In general, obesity rates in high-income countries are over four times higher than the rates of low-income countries. High GNIPC causes not only an ease of access to food but also an overconsumption of fast food or foods containing high levels of sugar (Deveci, 2013; WHO, 2015). On the other hand, low- and middle-income countries are struggling with both underweight and obesity problems. Both can be the direct result of low GNIPC, while low income may lead to under-weight problems as variety and quality of the food may be limited, it may also lead to greater exposure to high fat, high sugar, high-sodium foods, which are cheaper but have poor nutritional value (WHO, 2014a, 2015). Accordingly, obesity rates are on the rise in developing countries, this is exacerbated by the lack of supportive and preventive governmental policies related to health (Klish, 1995; Swinburn & Egger, 2004; WHO, 2015). Similarly, new technologies to process and deliver food are also related to obesity. Obesity rates in countries which support traditional agriculture and delivery systems are dramatically lower than others (Cutler, Gleaser, & Shapiro, 2003).

The economy has effects on the quality and quantity of the nutrition which is consumed, or how much preventive and supportive governmental policies related to health are developed (Mackenbach, 2014; Mackenbach et al., 2008; Miller & Pumariega, 2001). The economy has effects on both obesity and culture in a various way. However, since the focus of the study is the relationship between culture and obesity, the economy is included as a control variable.

The interwoven relationship between economy and culture is associated to obesity through different mechanisms. Cutler et al. (2003) state that, education, age, race, marital status, employment, and the occupation can be considered as contributors to obesity. However, the authors found that demographic variables do not provide sufficient explanation, they can only explain up to 10% of the rise in obesity rates. Other mechanisms such as perceived attractiveness in society, the role of media, fast living and presence of tools, which make life both easier and lazier by minimizing physical activity are direct consequences of economy-culture link and predictors of obesity (Pooyé, 2010). Still, our knowledge regarding obesity and its relationship with culture is very limited.

Culture

Hofstede (2001) defines culture as “the collective programming of the mind that distinguishes the members of one group or category of people from another” (p. 9) and investigates culture under five dimensions: power distance, uncertainty avoidance, individualism versus collectivism, masculinity versus femininity, and long-term versus short-term orientation. Specifically, power distance represents how a society generates solutions to resolve inequality among their members. Uncertainty avoidance represents the cultural tendency toward being uncomfortable when encountering an unknown future. Individualism versus collectivism reflects the societal position on the value of loose ties among members or the integration of members with their own groups. Masculinity versus femininity reflects the cultural tendency for differentiating gender roles. Long-term orientation represents the cultural preference of puting the individuals’ efforts in the present or the future focus (Hofstede, 2001).

Later, Schwartz (2006) developed his theory of culture based on individual differences in value priorities and their effects on belief and behavior systems. Schwartz’s theory claim that there are three cultural value dimensions that all societies must face embeddedness versus autonomy, hierarchy versus egalitarianism, and mastery versus harmony. These three value dimensions are formed by seven cultural value orientations including embeddedness, intellectual autonomy, affective autonomy, egalitarianism, hierarchy, harmony, and mastery. Embeddedness versus autonomy describes the extent to which people are autonomous or embedded in their groups. To solve this problem, two types of autonomy were described: Intellectual autonomy refers to intellectual encouragement such as creativity, and affective autonomy refers to affective encouragement towards positive experiences, such as pleasure. On the other hand, embeddedness represents an encouragement towards collectivity, social relationships such as tradition. The second value dimension is hierarchy versus egalitarianism which represents a societal problem of whether people behave in a way that preserves the social structure. To solve this problem, egalitarianism is defined as perceiving others as moral equals. Egalitarianism encourages values such as equality or social justice. Another solution is a hierarchy which is an unequal distribution of power in society which encourages values such as authority. Harmony versus mastery, the last cultural value dimension, represents a conflict between the natural and social world. Harmony refers to fitting oneself into the world and appreciating differences, whereas mastery concerns working towards mastering or changing the environment. Harmony encourages values such as peace and protecting the environment, and mastery encourages values such as ambition or success (Schwartz, 2006).

Although both Hofstede and Schwartz investigate cultural values using similar concepts, there are some differences between the theories regarding theoretical reasoning, methods, respondents and time-period, etc. (Schwartz, 1994). Schwartz (1992) defines values based on needs, which consist of “individuals’ requirements as biological organisms, society’s requirement for coordinated social interaction and groups’ requirement for survival and support.” On the other hand, Hofstede’s value framework is related to macroeconomic variables and it was shaped on the basis of norms (Hofstede, 2001). The relationship between GNIPC and culture, especially in individualism-collectivism dimension, is stronger in the Hofstede model (Gouveia & Ros, 2000).

Considering the aforementioned role of culture on behavior, the present study aims to investigate the relationships between both Hofstede’s (2001) cultural dimensions and Schwartz’s values and obesity with aggregated level variables. Culture determines attitudes, beliefs, norms, and values towards almost everything that surrounds us (Lim Gonzalez, Wang-Letzkus, & Ashing-Giwa, 2009; Mackenbach, 2014). Since food is not just for nutrition but also have a social role to unite people, it is also open to effects of cultures (Rozin, 1996). In other words, culture determines what we eat, how we eat, and how much we eat or exercise. From large-portion sizes of fast food in the United States to traditions related with nutrition in Japan, the culture of food consumption has direct effects on health (Pooyé, 2010). Previous findings lead us to expect that cultural variable (i.e., power distance, uncertainty avoidance, individualism versus collectivism, masculinity versus femininity, and long-term versus short-term orientation) and values (i.e., embeddedness, intellectual autonomy, affective autonomy, egalitarianism, hierarchy, harmony, and mastery) will be related to obesity rankings. Health behaviors are open to effects of cultural norms, values, beliefs, or traditions just like other behaviors. Although obesity can simply be described as an overconsumption of food and reduce in physical activities, aforementioned systems shape attitudes towards nutrition (Airhihenbuwa, 2010).

United States and Japan can be used to illustrate the role cultural variables play in obesity since the two countries are at the opposing end of the individualism versus collectivism spectrum. In collectivistic cultures, such as Japan, which has a higher level of power distance, sharing resources is an important part of the social context, and it is a way to establish relationships. Thus, people use food sharing as a social tool (Hofstede, 2001; Rozin, 1996; Triandis, 1989). Since conformity to social norms is what it is expected in collectivistic cultures, emotional, or environmental triggers towards food are less powerful than in individualistic cultures (Pooyé, 2010). On the other hand, in individualistic cultures, such as the United States, food is perceived as an indicator of power (Pooyé, 2010). The need for being autonomous and independent lead them to eat faster without the presence of the other people and become more vulnerable to emotional or environmental triggers (Rozin, 1996). As such, individuals living in individualistic cultures can be expected to be more vulnerable to obesity than individuals living in collectivistic cultures. According to data obtained from WHO (2015), Japan has an obesity rate of 3.3%, whereas this rate is 33.70% for the United States; and these rates support the link between individualism and obesity. Similarly, Bergiel, Bergiel, and Upson (2012) state that the reason why the United States has higher and Japan has lower levels of obesity rates can be explained by the level of uncertainty avoidance since the United States has lower levels of uncertainty avoidance than Japan. Hence, it is expected that obesity will be negatively related to uncertainty avoidance and positively related with individualism.

Regarding the relationship between long-term versus short-term orientation and obesity, intervention programs which focus on weight reduction can be used as an example. These programs require systematic actions over a long time period; however, long-term goals can be the reason for the failure of these programs in countries that are short-term oriented. In long-term oriented societies, people believe that the most important events of their lives have not been lived yet and they will happen in the future. Accordingly, perseverance, long-term outcomes, and long-term planning are perceived as important goals (Hofstede, 1991). Long-term and short-term orientations might be related to weight reduction since individual motivations to lose weight can be directly influenced by them. Since long-term oriented societies give importance to the future, individuals might seek for healthier lifestyles. Hence, a negative relationship between long-term oriented societies and obesity is expected. Lastly, the relationship between masculinity and obesity is ambiguous. Since masculinity/femininity is related to accomplishment and quality of life (Hofstede, 2001), it can be hypothesized that it is negatively related to obesity. However, there is no empirical evidence for this hypothesis.

Aim of the study

In this present study, it is believed that BMI differences between countries can be a result of differences in culture. Thus, it is aimed to investigate cultural variables which can be triggers of obesity in macro level. The aim of current study is to investigate the relationships between global obesity rates, Hofstede’s cultural dimensions, Schwartz’s cultural values, and GNIPC.

Among Hofstede’s cultural dimensions, it is expected that uncertainty avoidance and individualism are positively related to and long-term orientation is negatively related to obesity. Among Schwartz’s values, it is expected that embeddedness, hierarchy are negatively associated to and harmony is positively associated to obesity. Hypothesized relationships based on literature are presented in Table 1.

Table 1.

The hypothesized relationships among study variables.

	Expected
Hofstede’s cultural dimensions
1. Power distance	0
2. Uncertainty avoidance	+
3. Individualism	+
4. Masculinity	0
5. Long-term orientation	−
Schwartz’s values
1. Harmony	+
2. Embeddedness	−
3. Hierarchy	−
4. Mastery	0
5. Affective autonomy	0
6. Intellectual autonomy	0
7. Egalitarianism	0

Note: + represents positive relationship; − represents negative relationship; 0 represents no relationship.

Method

Sample

In the present study, Hofstede’s cultural dimensions (i.e., power distance, uncertainty avoidance, individualism, masculinity, and long-term orientation), Schwartz’s cultural values (i.e., harmony, embeddedness, hierarchy, mastery, affective autonomy, intellectual autonomy, and egalitarianism), the percentage of the population with a BMI of 30 kg/m² or higher, and GNIPC for each country were used at national level. Data concerning Hofstede’s cultural dimensions were taken from Hofstede’s book (Hofstede, Hofstede, & Minkov, 2010), GNIPC rankings (calculated by ATLAS method) were taken from the World Data Bank (2014), and obesity data were obtained from WHO (2014b). The data set including countries’ mean scores for cultural values was taken from Schwartz (S. Schwartz, personal communication, May 2014). All data sets were retrieved from open source databases.

Data collection

Economy

National accounts and balance of payment data came from two sources: (i) current reports gathered by the Bank's country management units and (ii) data obtained from official sources (World Data Bank, 2018). To calculate GNI, The World Bank uses Atlas conversion method for avoiding exchange rate fluctuations between countries (for details see World Data Bank, 2018).

Hofstede’s cultural dimensions

Hofstede collected data from IBM between the years of 1967 and 1973. Then, in 2010, (Hofstede et al., 2010) he presented the cultural dimensions scores for 76 countries, which are results of replications and extensions of the IBM study. The data were collected from international populations and different scholars.

Schwartz’s cultural values

Schwartz (2008) developed a survey based on literature and prepared a list of single values. Then he formulated the seven cultural value orientations. He collected data between the years of 1988 and 2000 from elementary school teachers and college students. Scores of Schwartz’s cultural value orientations for 80 national groups were generated.

Body mass index

Estimated rates for BMI are based on aggregated data that are provided to WHO and the Noncommunicable Disease Risk Factor Collaboration, and review of published and unpublished literature. The inclusion criteria for estimation analysis were as follows: (i) a random sample of the general population and (ii) clearly indicated survey methods. The adjustments were conducted based on the following factors in order to standardize the data: (i) standard risk factor definition, (ii) standard set of age groups for reporting, (iii) standard reporting year, and (iv) representativeness of population (for more details see WHO, 2018).

Procedure

To combine the three data sets (i.e., economy, Hofstede’s cultural dimensions, Schwartz’s values, and obesity), first, the countries that have data for Hofstede’s cultural dimensions and Schwartz’s cultural values were listed. Then countries that have data for obesity and economy were added to the data set, respectively. Data that were collected for different sub-groups for one country were excluded from the list (e.g., Switzerland-French speakers and Switzerland-German speakers). It is because we are not sure where other data are collected from. For instance, the data for obesity might be collected from only from German speakers or vice versa. Hence data cannot be combined. After merging the data, the analysis was conducted for 54 countries which had data for Hofstede’s cultural dimensions, obesity, and GNIPC and with 57 countries which had data for Schwartz’s values, obesity, and GNIPC. The details about the number of countries and the name of the countries for each study variable are shown in Table 2.

Table 2.

Name of countries that have data for the study variables.

Country	OBE	GNI	PD	Idv	Mas	UA	LTO	Har	Emb	Hie	Mast	AA	IA	Ega
Argentin	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Australi	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Austria	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Banglade	+	+	+	+	+	+	+
Bosnia	+	+						+	+	+	+	+	+	+
Brazil	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Bulgaria	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Chile	+	+	+	+	+	+	+	+	+	+	+	+	+	+
China	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Colombia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Costa Ri	+	+						+	+	+	+	+	+	+
Croatia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Czech Re	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Denmark	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Egypt	+	+						+	+	+	+	+	+	+
El Salva	+	+	+	+	+	+	+
Estonia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Ethiopia	+	+						+	+	+	+	+	+	+
Finland	+	+	+	+	+	+	+	+	+	+	+	+	+	+
France	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Georgia	+	+						+	+	+	+	+	+	+
Ghana	+	+						+	+	+	+	+	+	+
Greece	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Hungary	+	+	+	+	+	+	+	+	+	+	+	+	+	+
India	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Indonesia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Iran	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Ireland	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Israel	+	+	+	+	+	+	+
Italy	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Japan	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Jordan	+	+						+	+	+	+	+	+	+
Korea So	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Latvia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Lithuani	+	+	+	+	+	+	+
Luxembou	+	+	+	+	+	+	+
Macedoni	+	+						+	+	+	+	+	+	+
Malaysia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Mexico	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Morocco	+	+	+	+	+	+	+
Netherla	+	+	+	+	+	+	+	+	+	+	+	+	+	+
New Zeal	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Nigeria	+	+					+	+	+	+	+	+	+	+
Norway	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Pakistan	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Peru	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Philippi	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Poland	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Portugal	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Romania	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Russia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Serbia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Singapore	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Slovak R	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Slovenia	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Spain	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Sweden	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Thailand	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Trinidad	+	+	+	+	+	+	+
Turkey	+	+	+	+	+	+	+	+	+	+	+	+	+	+
U.S.A.	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Uganda	+	+					+	+	+	+	+	+	+	+
Ukraine	+	+					+	+	+	+	+	+	+	+
Uruguay	+	+	+	+	+	+	+
Vietnam	+	+	+	+	+	+	+
Zimbabwe	+	+					+	+	+	+	+	+	+	+

Note: OBE: obesity; GNI: gross national income; PD: power distance; Idv: individualism; Mas: masculinity; UA: uncertainty avoidance; LTO: long-term orientation; Har: harmony; Emb: embeddedness; Hie: hierarchy; Mast: mastery; AA: affective autonomy; IA: intellectual autonomy; Ega: egalitarianism.

Bold tags represent countries that have data for obesity, GNI, and Hofstede’s cultural dimensions. Italic tags represent countries that have data for obesity, GNI, and Schwartz’s values. Bold and italic tags represent countries that have data for all study variables.

Results

Correlations between obesity percentages, Hofstede cultural dimensions, Schwartz values, and GNIPC

In Table 3, the correlations among study variables (i.e., GNIPC, Hofstede’s cultural dimensions, Schwartz’s values, and obesity percentages) and their means and standard deviations are presented. GNIPC had significant negative correlations with power distance, uncertainty avoidance, embeddedness, and hierarchy and positive correlation with individualism, harmony, affective autonomy, intellectual autonomy, egalitarianism, and obesity. Obesity had significant negative correlations with power distance, long-term orientation, embeddedness, and hierarchy, whereas it had significant positive correlations with individualism, uncertainty avoidance, harmony, affective autonomy, intellectual autonomy, and egalitarianism.

Table 3.

Means, standard deviations, and correlations among study variables.

	N	M	1	2	3	4	5	6	7	8	9	10	11	12	13
1. GNI	66	20702.73	1
2. PD	54	58.8	−.64**	1
3. Idv	54	44.43	.63**	−.62**	1
4. Mas	54	47.44	−.18	.22	−.01	1
5. UA	54	67.81	−.30*	.14	−.21	.06	1
6. LTO	54	47.78	.05	.12	.05	.01	−.05	1
7. Har	57	4.05	.28*	−.20	.30*	−.09	.25	.15	1
8. Emb	57	3.78	−.68**	.65**	−.60**	.12	−.08	−.04	−.48**	1
9. Hie	57	2.34	−.46**	.37*	−.47**	.20	−.14	−.06	−.64**	.52**	1
10. Mast	57	3.94	−.14	.11	−.28	.19	.03	−.08	−.49**	.01	.45**	1
11. AA	57	3.47	.62**	−.65**	.55**	−.22	−.07	.02	.22	−.82**	−.38**	.06	1
12. IA	57	4.34	.60**	−.43**	.50**	−.16	.21	.08	.60**	−.87**	−.63**	−.22	.71**	1
13. Ega	57	4.66	.54**	−.49**	.39**	−.18	.05	−.41*	.39**	−.61**	−.52**	−.19	.35**	.54**	1
14. Obesity	66	19.52	.25*	−.32*	.46**	−.07	.32*	−.36**	.27*	−.37**	−.42**	−.22	.27*	.40**	.35**

Note: GNI: gross national income; PD: power distance; Idv: individualism; Mas: masculinity; UA: uncertainty avoidance; LTO: long-term orientation; Har: harmony; Emb: embeddedness; Hie: hierarchy; Mast: mastery; AA: affective autonomy; IA: intellectual autonomy; Ega: egalitarianism.

**p < .01; *p < .05.

Table 4.

Results of the hierarchical multiple regression analysis testing the relationship between Hofstede’s cultural dimensions and obesity.

Variables	t	p	β	F	p	Adj. R ²
Control variable				2.70	.074	.03
GNIPC	1.64	.106	.22
Hofstede’s cultural dimensions				9.10***	.000	.48
Power distance	.42	.679	.06
Individualism	4.21***	.000	.60
Masculinity	−.96	.344	−.10
Uncertainty avoidance	4.10***	.000	.43
Long-term orientation	−3.67***	.001	−.37

Note: GNIPC: gross national income per capita.

***p < .001.

Hierarchical regression analysis

Hierarchical regression analysis was conducted to investigate the relationship between cultural values and obesity. Separate hierarchical multiple regression analyses were conducted for Hofstede’s cultural dimensions and Schwartz’s cultural values. In the first analysis, since economy (i.e., GNIPC) might have an influence on the stated variables, it was entered in the first step as the control variable, and Hofstede’s cultural dimensions (i.e., power distance, individualism, masculinity, uncertainty avoidance and long-term orientation) were entered in the second step. As it is shown in Table 4, after controlling for GNIPC, obesity had significant positive relationships with individualism, and uncertainty avoidance, and negative relationship with a long-term orientation. In the second analysis, economy was entered in the first step as the control variable, and Schwartz’s cultural values (i.e., harmony, embeddedness, hierarchy, mastery, affective autonomy, intellectual autonomy, and egalitarianism) were entered in the second step; however, none of the study variables showed significant relationships with obesity. The list of hypothesized and supported relationships is presented in Table 5.

Table 5.

Relationships among study variables.

	Obesity
	Expected	Results
Hofstede’s cultural dimensions
1. Power distance	0	0
2. Uncertainty avoidance	+	+
3. Individualism	+	+
4. Masculinity	0	0
5. Long-term orientation	−	−
Schwartz’s values
1. Harmony	+	0
2. Embeddedness	−	0
3. Hierarchy	−	0
4. Mastery	0	0
5. Affective autonomy	0	0
6. Intellectual autonomy	0	0
7. Egalitarianism	0	0

Note: + represents positive relationship; − represents negative relationship; 0 represents no relationship.

Discussion

From a broader perspective, food has many functions in addition to nutrition. From the perspective of culture, food is a tool which influences social order and hierarchy and creates distances. Also, it shapes social linkages and even has moral functions; some food is forbidden by religion (i.e., pork for Muslims and Jews or beef for Hindus). There are major differences between countries in terms of their attitudes towards food and eating. For example, in the United States; people eat food to get full but in France, it also has another meaning to unite people and share time together. In other words, it is about the aim of eating, rather than about health outcomes (Rozin, 1996).

The related literature showed contradictory findings of the effects of socioeconomic status (i.e., economy) on obesity (e.g., Deveci, 2013); and based on ecological framework, these were individual level variables. It should be noted that aggregated data were used to test the hypothesis at the macro level (i.e., national level). In the present study, the correlation analyses result revealed a significant relationship between economy and obesity; however, when economy was entered as the control variable with the cultural variables, the significance of the relationship disappeared. Thus, the relationships between the cultural variables and obesity are more salient than the relationship between economy and obesity.

When the correlations between the study variables were investigated, obesity percentages were found to be positively associated with GNIPC, individualism, uncertainty avoidance, harmony, affective and intellectual autonomy, and egalitarianism; whereas embeddedness, hierarchy, and mastery were found to be negatively associated with obesity. However, some of the significant results disappeared after hierarchical regression analysis was conducted. Results revealed that individualism, uncertainty avoidance, and long-term vs. short-term orientation were the only variables that have significant relationships with obesity after controlling for the economy. Consistent with the hypothesis of the present study, individualism was positively related to obesity. This finding is consistent with the previous studies (Cutler et al., 2003; Hawks, Madanat, Merrill, Goudy, & Miyagawa, 2003; Rozin, 1996). Individualism can be described as a variable which is based on a need for being autonomous and independent. This need can lead people to eat alone, faster, and be easily triggered by emotional or environmental cues. Also, individualism is strongly related with power (Rozin, 1996). The link between power and food is quite strong; food is a vehicle of power, it creates social distances. From an anthropological perspective, food has been the primary object of reciprocity, cooperation, or even an indicator of social superiority (Counihan, 1992). Thus, the finding regarding the association between obesity and individualism supports our hypothesis.

A negative relationship was expected between uncertainty avoidance and obesity based on the literature findings; however, in the literature, the relationship was not tested empirically at the macro level (i.e., national level). Hence, the hypothesis was based on interpretations made from related variables (e.g., Bergiel et al., 2012). In the current study, the relationship between uncertainty avoidance and obesity was tested empirically at the macro level (i.e., national level) for the first time in the literature. The results yielded contradictory findings with the hypothesis, suggesting a positive relationship. One possible explanation for the positive relationship between uncertainty avoidance and obesity might be about anxiety. Uncertainty avoidance is related to intolerable anxiety and issues related to stress management (Furnham, Ota, Tatsuro, & Koyasu, 2000). Related literature suggested that anxiety is strongly related to obesity. As a psychological problem, emotional eating is triggered by anxiety and is frequently visible among obese patients (Canetti, Bachar, & Berry, 2002).

Lastly, consistent with our hypothesis, long-term orientation was found to be negatively associated with obesity rates. In countries which are long-term oriented, people are prone to believe that long-term outcomes and long-term planning are important goals in their lives (Hofstede, 1991). Since long-term orientation focuses more on the future, people who are more long-term oriented are more likely to value a healthier lifestyle as compared to people who are more short-term oriented.

Additionally, in these countries, policies and strategies to tackle obesity are developed to encourage their members. When the relationship between individual level variables (e.g., gender, education level, and socio-economic level) and obesity are investigated, the results revealed similar results. To illustrate stated relationship can also be explained by individual’s time perspective. According to the study of Guthrie, Butler, Lessl, Ochi, and Ward (2014), obesity was found to be related to lower future time perspective and higher present-hedonistic time perspective, which indicates a tendency towards pleasure seeking. Similar with long-term versus short-term orientation, this finding supports the fact that cultures which have higher levels of obesity tend to be more focused on the now and on short-term goals.

The present study is conducted with aggregated level data, which might result in ecological fallacy. Ecological fallacy is making macro level conclusions by collecting data from individuals (Pettigrew, 2006). The data collected by Hofstede and Schwartz give general information about different cultural groups. It should be noted that, in addition to differences between cultures, there might also be differences within cultures. Hence, the representativeness of samples from different countries should be taken into account to interpret the results of the current study. In the current study, regression analyses were conducted, which do not allow to make interpretations about any cause-effect relationships. While interpreting the results, it should be considered that the results reflect a strong link between cultural variables and obesity; however, it does not suggest any causality.

Although ecological fallacy is a limitation, the present has some fruitful results. Al-Bannay, Jarus, Jongbloed, Yazigi, and Dean (2013) suggested that in health promotion studies, controlling for cultural variations have not been adequately well established. Hence, this inadequacy in the health-related literature might cause incomplete research questions, incomplete data gathering, and limited generalizability of the findings of the studies. The findings related to culture and cultural variables should be taken into account to increase the reliability, validity, and generalizability of findings in the literature (Al-Banay et al., 2013). The current study might be helpful to interpret the results of differences in obesity research and also might be helpful for governments and health-related organizations to develop new strategies and policies that are more suitable for their cultures.

The study showed that obesity, which is a worldwide problem, has strong relationships with mainly Hofstede’s cultural dimensions. These relationships might be useful in developing new interventions. For instance, societies which are high in individualism orientations and uncertainty avoidance might develop structured programs which aim to encourage people to join activities that are about healthier lifestyles both by campaigns and providing social supports. To the authors’ knowledge, this is the first study in the literature that investigates the association between culture and obesity in a macro level (i.e., national level).

Footnotes

Article Notes

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