Obesity in the UK
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Obesity in the UK – individual problem or national plague?
Introduction: Levels of obesity are on the rise in the UK and following calls from doctors and other health professionals, the government has pledged to fight obesity with promises to help British society to fight the problem on a number of levels. Predictions are that in 2010 almost one third of adults will be obese (Lean et al., 2006), and the obesity epidemic, which is running out of control could bankrupt the health service (Haslam et al., 2006) adding to the calls for something to be done about the problem. Tony Blair has offered to provide money for prevention and fighting the existing symptoms of obesity. Obesity is arguably the greatest challenge to public health in Britain today and there is a need for effective action. One of the major warning signs is the rising levels of obesity among children and there is a growing recognition that if the problem is not tackled with some degree of urgency in this group the long term health of the nation will suffer. While there are now a number of well established potential treatments for obesity in the UK, it has been suggested that measures for enhancing self esteem would be particularly important in those groups identified as being at risk from later eating disorders and obesity (Button et al., 1997, p.46). The issue of health in general concerns the nation, with the government, consumers and businesses sharing the burden of addressing health related issues. The National Audit Office has estimated that obesity accounts for eighteen million days of sickness absence and 30 000 premature deaths each year (Bourn, 2001). Obesity has physical and psychological causes and symptoms but the nature of the psychological mechanisms involved in adjusting to obesity are unclear (Ryden et al., 2001). There are a number of health problems associated with obesity, with mortality rising exponentially with increasing body weight (Wilding, 1997).Despite the growing level of the problem, questions have been asked in respect of whether Britons really need this help at a national level and if they realise that obesity is a problem for individuals and the nation as a whole. The purpose of this study is to assess the views of Britons on the obesity issue. Levels of psychological well being, the locus of control and self esteem will be measured in relation to being overweight. Differences between men and women will be considered. In addition two different age groups will be investigated – under thirties will be compared with over thirties to ascertain similarities and differences. There is also an investigation into the effects, if any, of ethnicity on obesity. The main focus of interest will be to determine if there is a difference in self perception between those who consider themselves to be overweight and those who do not. In order to investigate the issue the body mass index will be calculated for all participants and compared with the perceptions they have of themselves in terms of being overweight. It is hypothesised that men will have higher levels of self esteem and will score more highly on measures of psychological well being than women. Previous studies have suggested that there are no significant differences between men and women in terms of locus of control in respect of weight (Furnham and Greaves, 1994). In order to investigate if this finding is still valid, the study will test the above variables taking into consideration differences in age and weight.
Methodology: The sample will consist of a selection of individuals attending Weight Watchers meetings and sessions at the local gym. There will be sixty participants consisting of men and women aged over eighteen.
Materials: A questionnaire will be designed to examine the variables discussed above and any relationship between them. The questionnaire will be divided into four parts: ? Part One – will ask questions about gender, age group (under thirties and over thirties), weight, height and will ask participants to declare whether o nt they believe themselves to be overweight; ? Part Two – will ask questions in respect of self esteem; ? Part Three – will ask questions in respect of locus of control; ? Part Four – will ask questions about psychological well being. In order to measure the effects of the various variables the following instruments will be used: Rotter's Internal-External Locos of Control Scale (Rotter, 1996), Radloff's CES-D Depression Scale (Radloff, 1977) and Rosenberg's Self-Esteem Scale (SES) (Rosenberg, 1965).
Procedure: Half of the questionnaires will be given to those attending Weight Watchers sessions and the other half will be administered to those attending the local gym. Participants will be informed of the nature and purpose of the study and will be given assurances tat all information given will be treated in the strictest confidence and will not be used for any other purpose. It will be stressed that participation in the study is voluntary and participants are free to withdraw at any time. Participants will also be free to omit any questions which they do not want to answer. Written consent will be obtained before participants take part in the study. Contact details will be given to the researcher in case of follow up queries.
Analysis of Data: Data collected will be analysed using quantitative statistical analysis in the form of TTests.
Discussion: The obesity epidemic in the UK continues to run out of control, with none of the measures that have been taken showing any sighs of halting the problem much less reversing the trend (Haslam, 2006, p.640). A number of areas have been identified which need to be addressed. There is the recognition that mental health problems in the context of low self esteem are associated with eating disorders. Mental well being is affected in the context of the workplace, with obese people often facing some degree of discrimination in their professional and social lives. There is also a growing body of evidence to suggest that the problem is more widespread in some ethnic groups than in others. Many of the medical problems and complications associated with obesity are found in adults, but the increasing prevalence of obesity or the tendency to become obese in children, is also a worrying trend, further strengthening suggestions that prevention rather than cure is the key to tackling the problem in the long term. While prevention in terms of maintaining weight loss and preventing people from putting on weight in the first place is the ideal, maintaining weight loss has been a major limitation of many of the approaches so far adopted (Wliding, 1997,p.998).
Self Esteem: Although there is a general consensus that there are a number of factors at work in the context of eating disorders, self image has frequently been thought of as having a high profile role in the nature of these disorders (Button et al., 1997, p.39). Research in this area has been to a large degree unclear as those who have typically participated in the research have been those who have been in the process of seeking help and may therefore not be representative of the obese population in general (Ryden et al., 2001, p.186). It has often been suggested that a low self image is present and can be a contributory factor in causing individuals to develop eating disorders. Dyken and Gerrard gathered considerable empirical evidence to suggest that patients with eating disorders had slower levels of self esteem than their counterparts who are of normal weight (Dyken and Gerrard, 1986). A great deal of the research has been speculative in nature with very little evidence to suggest a causal link between low self esteem and the onset of eating disorders. As discussed above, it has been documented that obese individuals face discrimination on a number of levels. This can lead to their accepting these negative perceptions which can reduce self esteem even further and can lead to mental health problems (Ryden et al., 2001). Studies carried out in Sweden have supported this idea, with individuals who were obese experiencing significantly psychological distress than not only their healthy counterparts, but than those who had been involved in various forms of accidents or who were chronically ill (Sullivan et al., 1993). Studies carried out by Button found that girls aged 11-12 who had low levels of self esteem were, indeed more likely to have developed an eating disorder than their counterparts when they took part in a follow up study some years later when they were aged 15-16. These girls also displayed a range of other psychological problems (Button, 1990 cited in Button et al., 1997). Dieting usually results in weight loss and the lower the calorie intake, the more weight will be lost. Weight is usually regained and there is evidence that cognitive behaviour therapy may be a more successful approach, particularly if it is coupled with physical exercise. This may have more long term success, making it an effective approach with children and adolescents as good behaviour patterns in terms of adopting a healthy lifestyle can be developed and maintained (Wilding, 1997). In order to investigate the area of self esteem further Button and colleagues investigated rates of self esteem in a much larger sample of girls aged 15-16. Those who were identified as having eating disorders did display lower levels of self esteem than their counterparts, and the area in which they had the lowest levels of self esteem was in respect of their external appearance, cited as an area of low self esteem by 75% of the respondents who were problematic eaters (Button et al., 1997).
Gender Differences: Eating disorders have been viewed as largely affecting women, with relatively few studies having been carried out in respect of men who have problems with weight and weight control. Since the 1990s there have been increasing numbers of males being identified as having eating disorders (Fernandez-Aranda et al., 2004, p.368). Research has begun to focus on whether there are gender differences associated with eating disorders. It has been suggested that men who develop eating disorders have higher levels of the personality traits associated with these disorders as overall rates are less for men than they are for women. Research has shown that men had less of a preoccupation with ideal body size and the drive for thinness than females (Fernandez-Aranda et al., 2004).
Mental Health: Eating disorders in general, and obesity in particular have been attributed to underlying psychological problems such as depression or an inability to cope with certain aspects of life (Leon and Roth, 1977). This has led to the increasing adoption of cognitive therapy methods, providing training in better ways to deal with the difficulties in one's life which can lead to obsessive eating behaviour. Ryden and colleagues have proposed that the coping mechanisms which individual shave at their disposal can have an enormous impact on whether or not they will become obese (Ryden et al., 2001).
The Extent of the Problem: The body mass index has been increasing in a number of countries and in the UK the National Audit Office have found that in the period from 1984 to 1993 rates of obesity doubled for both men and women (National Audit Office, 1994) and have been on the rise ever since. Not only are the rates of obesity continuing to rise, with 17% of men and 21% of women currently obese in the UK, but they are rising at a faster rate than in the past, with people being fatter than they were in the past (Clark, 2006, 123). Obesity levels are rising faster in the UK than elsewhere (While, 2002, p.438). There are also some quite startling differences, with women in the UK who are the heaviest weighing up to twice as much as their counterparts of the same height who are not overweight. Despite an increasing awareness about obesity and the benefits of healthy eating and exercise, the obesity problem continues to rise, being attributed to a complex interplay between a number of environmental factors. In their work in respect of eating disorders and self esteem Button and colleagues found that the rates of partial eating disorders were quite high at about 8% (Button et al.,1997). Obesity is starting to overtake smoking in the UK as the greatest preventable cause of illness and premature death (Haslam, 2006, p.641). Obesity has been strongly linked with poverty and with a lack of available public information, with many individuals realising that high fat products were unhealthy but they were unable to judge which products were high in fat and by how much (Vlad, 2003p. 1308).
Psychological Well Being: Eating disorders in general have been linked to overall psychological well being. This means that in addition to the nation's physical health, obesity must be addressed in the context of the effect it is having on the nation's psychological well being. Button et al. found that those who had been identified as having eating disorders scored low on the self esteem scale but also had higher scores on the anxiety scale than their counterparts. The authors pointed out that their work which involved school students, was carried out close to examinations which may account for increases in levels of anxiety, and they could therefore not suggest a causal link without further follow up work (Button et al., 1997). Button and colleagues used a questionnaire in order to elicit further information in respect of self esteem in their subjects. When girls expressed general dissatisfaction with themselves, this was most often referred to in the context of physical appearance, with those identified as having eating disorders being more likely to make globally negative comments about themselves (Button et al., 1997, p.45). The same research found that family was an important factor in negative perceptions and low self esteem with a significant number of those identified as having eating disorders reporting that their family lives were characterised by arguments and an inability to communicate. The growing recognition that obesity has a psychological component, with low self esteem being recognised as an important factor, has led to suggestions that support needs to be given to people who are obese rather than ridiculing them (Mayor, 2004).
Causes of Obesity: If obesity is to be successfully tackled in the UK and elsewhere, a sound understanding of the root causes must be established. The spiralling levels of obesity in the UK and elsewhere over the past thirty years have prompted suggestions that it is the environment which is playing the largest part in the problem as genes could not have changed to such a degree in such a short space of time (Clark, 2006, p.124), although there is recognition that there is a genetic component (Barth, 2002, p.119), with research from twin studies suggesting that the tendency to become obese is inherited. Not only are people eating more than they did a generation ago, but there have been a number of changes to the types of activities in which people are engaged. There has been a steady decline in the need for active working at home or in the workplace and an associated increase in sedentary jobs and occupations. In real terms physical activity has been seen as having shifted from something which people were paid to do, to something which people must now pay for in the form of joining a gym or similar pastimes. Considerable criticism has been levelled at the food production industry which produces high calories foods which are being eaten as snacks, taking daily calorie allowances above the recommended allowances. There has been an attempt to address this problem in the form of a number of initiatives such as those to increase physical activity to two hours per week in schools and the promotion of fruit and vegetables in schools, but there is little evidence of widespread success. Research carried out by Skidmore and Yarnell has suggested that the majority of obese adults were not overweight as children. This is suggestive of the fact that obesity comes about as the result of excess calorie intake over a period of many years. Education for healthy eating and living is therefore seen as vital in preventing future obesity and the associated health risks (Skidmore and Yarnell, 2004).
Environmental factors: Despite the identification of a genetic component, it has been argued that obesity can be largely prevented, with lack of physical activity and chronic consumption of excess calories, being the main preventable causes of obesity (Skidmore and Yarnell, 2004, p. 819). It has been suggested that the environment provides a number of opportunities for the over consumption which leads to excessive weight gain. This has led to the conclusion that the obesity epidemic can only be effectively targeted if there are major changes in the environment and the ways in which people interact with it in respect of food and eating (Clark, 2006).
Effects of Obesity: Obesity affects people of all ages including children and has damaging effects on all organs in the body. Long term consequences include diabetes and hypertension which can ultimately lead to strokes and coronary heart disease (Barth, 2002, p.119). The effects of obesity in relation to mortality can be marked. Research carried out has found that the risk of diabetes in men who were very overweight increased to a risk of being forty two times more likely than those who were not overweight and women and children have been identified by research as the groups most affected by obesity (Bhate, 2007, p.173). The governments proposed intervention has come about due to the realisation that many individuals are not able to make enough proactive changes to prevent excess weight gain and are simply reacting to their environment, one in which people eat larger portions, are more prone to snacking and are taking less exercise than their counterparts from a generation ago. Food is seen to be attached to a range of emotions, with eating being associated with celebration as well as a comfort when one is depressed. Because of the huge impact which the environment appears to be having on obesity, it has been argued that education alone will be insufficient in dealing with the problem, and environmental changes are urgently needed (Lean et al., 2006). Attempts to tackle the obesity problem have themselves brought difficult issues in terms of adverse outcomes such as the rise in eating disorders as more and more people battle with their weight. It has been suggested that long term monitoring of approaches to treating obesity is required in order to deal with these associated problems (Skidmore and Yarnell, 2004).
Obesity as a Disorder: There is a growing recognition that obesity comes about as a result of an addiction to food, and, as with all addictions those who suffer require help and advice. It would appear that many of those who are obese eat not when they are hungry but in the context of a wider social agenda, fuelled by the constant availability of food. Once the cycle of weight gain begins it becomes cyclical in its nature and is compounded by lack of exercise, which leads to greater levels of weight gain. Many commentators have suggested that the failure of traditional approaches to tackling obesity point to the fact that a more successful approach may be to take the view of obesity being a disability which is characterised by a range of adverse consequences. Like other addictions, obesity requires treatment and support. The benefits of effective treatment cannot be overstated as even a small weight loss can reduce health risk for obese individuals (Goldstein, 1992).
Addressing the Obesity Issue: The problem of obesity is placing a strain on public resources in the National Health Service as well as endangering the nation's health. Action is therefore required at the national level as it has been argued that many of the factors operating at the environmental level such as the availability if fast food and the lack of exercise cannot be dealt with at the level of the individual and must therefore be addressed through a number of public health initiatives. Guidelines for prevention and treatment have been introduced in the United States and the United Kingdom, but it has been suggested that their implementation may take a number of years due to their complex nature and the number of organisations involved in the process (Skidmore and Yarnell, 2004). It has been suggested that the issue can only really be addressed through changes in the environment which will enable individuals to make more healthy lifestyle choices. Suggestions include making public transport more appealing and parks more inviting in order that individuals will want to take some moderate exercise and will not have to make considerable effort and choice in order to achieve this end. Eating healthy food should become the norm as these foods should be more prominently displayed in shops and other food outlets. While it is recognised that prevention would be the best ideal outcome in respect of obesity, until there is some success with preventative measures, the goal should be to help patients to deal with some of the physical and psychological costs of the problem and to ensure that any treatment given does not compound the problems that obese individuals already have.
Prevention: Prevention is more important and easier to achieve than weight loss, with research showing that one third of obese patients will not lose weight by any medical means. It is therefore necessary to focus on preventing obesity in the first place, and enabling individuals to maintain their current weight. The principles of losing weight and maintaining weight loss are well known, but an effective evidence base of effective measures for preventing obesity does not currently exist (Haslam, 2006, p.641). The promotion of healthy eating and regular physical exercise is essential for both the prevention of future obesity and for treating individuals who are already overweight or obese. It has been suggested that obesity management should be included as an important part of health service planning with increasing numbers of staff trained in dealing with the problem. Research has shown that not only is considerable weight loss achievable through a programme of diet and exercise, but that this can also prevent the onset of type 2 diabetes, which is becoming more common due to the increasing obesity problem (Skidmore and Yarnell, 2004, p.821).
Goals of Obesity Management: With the recognition that obesity is having a major effect on the health of the nation comes the realisation that something must be done to tackle the problem. The basic goal of obesity management is for individuals to reduce their weight in a way which is safe and not overly restrictive in terms of diet, which can lead to harmful adverse effects. Current recommendations from the World Health Organisation are that individuals should attempt to lose around 10% of their body weight (World Health Organisation, 1997), but for many individuals, particularly those who are unhealthy or physically inactive, this may not be realistic and it may be more reasonable to suggest not gaining any further weight as a realistic goal.
Obesity in Children: One of the major areas of concern in respect of the obesity debate is the increasing prevalence of obesity in children. The government has set targets for the reduction of obesity in this age group but it has been suggested that the targets for reduction of the problem by 2010 are unlikely to be met because of confusion which exist among professional in respect of how to effectively tackle the problem. Even if preventative measures in respect of obesity were immediately successful, there would still be an epidemic of diabetes and related complications in the next two decades, because so many young people are already in the clinically “latent” phase of the disease, before clinical complications present (Haslam, 2006, p.641). As noted above one of the main problem areas is the issue of obesity in children, and many food preference choices are made in childhood, largely as a result of parental influence (Skidmore and Yarnell, 2004, p.821). In March 2005, the Health secretary John Reid, when announcing the government's three year strategy in respect of obesity, said that improving children's eating habits is central to making Britain a healthier nation. The issue of childhood obesity is of concern due to the short term and long term effects. Most of the recommendations in this strategy concerned ways of tackling the problem of obesity in children. The Audit Commission has pointed out that little progress has been made in the area o childhood obesity and if present trends continue, the next generation will have a shorter life expectancy than their parents (The Audit Commission, 2003, cited in Cole, 2006). The British Medical Association has recommended a series of preventative measures for schools, including provision of healthy food in schools and the development of a curriculum pertaining to healthy eating. Advertising of unhealthy foodstuffs particularly aimed at children has largely been banned, and there have been calls for the Food Standards Agency to develop new standards in nutritional content, food labelling and marketing. It has been shown that there is a correlation between socioeconomic status and poor diet, so it has been suggested that efforts should be particularly concentrated on less well off parents to enable them to make better choices for their children (Skidmore and Yarnell, 2004, p.821). Reilly and colleagues have investigated a number of risk factors for obesity in children. A number of factors have been identified but the causal links are largely unclear. One of the factors identified is the level of parental obesity, but it is unclear whether this is the result of a genetic component or the shared environment of the parents and their children (Reilly et al., 2005). Their study provides evidence for the early intervention in childhood obesity. Traditional methods have tended to focus on preventative measures in childhood and adolescence, an approach which Reilly has suggested is not beginning early enough and would go some way to explaining why these interventions have been largely unsuccessful. These authors have suggested that future preventative strategies should focus on short periods in early infancy, early childhood or even in utero.
Self Perception: The effects on physical health of being obese are well documented, but recent years have seen an increasing focus on the psychological effects. Attention has increasingly focused on how having a body weight that deviates from that regarded as normal, may affect the way in which people evaluate themselves. There is some support in the literature that satisfaction of physiological, love and belonging, and self esteem needs are related to eating behaviour or weight management (Timmerman and Acton, 2001). A variety of theoretical perspectives suggest that overweight people should have lower levels of self esteem than their peers, but data in this respect have been inconsistent with reviewers unable to agree on a consensus of opinion (Pokrajac- Bulian, 2005). Obese individuals do tend to suffer from low levels of self esteem, and the lives of children can be made exceedingly difficult as they suffer considerable rebuke from their peers (While, 2002). The relationship between self esteem and health behaviours has had mixed results, suggesting that there may be additional factors to be taken into consideration, suggesting the need for further research in this area. Evidence indicates that in addition to low self esteem, those who are overweight suffer feelings of stigmatisation, indulge in binge eating and have a lower quality of life than their peers who do not have weight problems (Clark, 2006, p.123). It is more likely that those who have weight problems will experience depression and associated illnesses with one fifth of obese patents reporting having at least one period of clinical depression which required treatment. Obesity is associated with a number of problems in respect of self perception. It has been shown that diets which improve weight loss are often ineffective in the long term with individuals regaining the weight. This has been shown to led to binge eating (Polivy and Herman, 1995), which can further damage self confidence and self esteem. This can lead to further eating disorders with research showing that females who had dieted were eight times more likely to develop eating disorders than their counterparts who had not dieted (Patton et al., 1990, cited in British Dietetic Association, 1997, p.95). Research has also shown that there is a positive correlation between high levels of self esteem in women and prolonged weight loss and maintenance. This has important implications in the context of developing self esteem as it is women who are most at risk from the effects of obesity.
Emotional Eating: Eating in response to emotions has been identified as a possible cause of the consumption of excess calories (Timmerman and Acton, 2001, p.691). These negative emotions can occur when basic needs as defined by Maslow's hierarchy of needs are not satisfied and can cause stress to an individual. An individual's ability to care for himself or herself is based on the availability of a number of resources internal and external to the individual. Self esteem has been identified as part of a person's internal resource base, and if the basic needs of love and so on are met continually over time, this will be well developed and built upon. This means that in times of stress an individual can call on this bank of resources to deal with stress in a way which is not detrimental to overall well being. If needs are consistently not met the individual is unable to build up a bank of resources and may experience a decreased ability to deal with stressful situations which can in turn lead to emotional eating and the risk of obesity and associated health problems associated with this.
Whose responsibility? While it is now recognised that obesity is a problem for the country as a whole, questions have been asked about who should take responsibility. The increased levels of obesity have raised questions in respect of who should take responsibility for the nation's health. This has caused ideas about corporate social responsibility to impact on the debate at a number of levels including the economy, the food industry and public perception of the food industry (Bhate, 2007). Research carried out by Bhate sought to investigate who was perceived by the public as having responsibility for the problem of obesity. There was a clear finding that consumers thought that the public should take responsibility for growing levels of obesity. Individuals were aware when they were eating unhealthy foods that there were certain health risks associated with these and may feel personally responsible for their actions (Bhate, 2007, p.174). Individuals did feel that there was not enough information given in respect of some foods and that this was the responsibility of manufacturers who should be put under pressure for adequate labelling by the government.
Education and Training: As mentioned above, one of the danger areas in respect of obesity, is the fact that the problem is so widespread in children. Education is vital, not only in addressing and preventing the obesity, but in tackling the prejudice that is associated with obesity. Education in school should include healthy eating advice as well as the introduction of fun sporting activities. Despite a number of initiatives in this area, results from school base programmes have been disappointing. It has been suggested that possible reason for this are the levels of advertising carried out by the food industry, an area in which governments have been reluctant to intervene because of the power which many of these companies have. In the United States the food industry have joined with other agencies an attempt to address the problem, a strategy which could be used to good effect in the UK. Education must also take place in the adult sphere including with health care workers so that obesity can be optimally treated. Nutrition has traditionally been given a low profile in the curriculum for training for professionals, with many health professional expressing disappointment in their efforts to treat obese patients (Hunter, 1997). A strong case now exists for making obesity a core part of the medical curriculum for all health care professionals (Lean et al., 2006), to facilitate successful interventions. There has been a seismic shift in thinking about obesity among health professionals. While it was previously thought that the most effective way to manage obesity was to restrict the calorie intake of individuals, this has been shown to be largely ineffective in the long term with individuals showing a propensity to regain weight which has been lost. This has caused the ethics of these approaches to be called into question and has caused a revision of thinking to facilitate greater levels of prevention.
Managing Obesity: The benefits of managing obesity are numerous, with primary prevention being desirable not least because it would significantly reduce the incidence of secondary associated diseases (Haslam, 2006, p. 642). Obesity is unique among the chronic disease in that it does not require a scientific breakthrough to be treated successfully, with sufficient evidence being available about the causes and possible cures for this to be unnecessary. Management must be undertaken at the level of individual patients as well as society as a whole. The management programme chosen in the context of an individual programme will depend on the degree to which an individual is overweight and must include priority treatment of risk factors for cardiovascular disease and associated diseases. For individuals who are mildly or moderately overweight, psychologically based interventions are the preferred treatment method. These can usually focus on behaviour therapy methods and programmes aimed at prevention. There are to goals associated with treatments of this type: ? To change individual lifestyle choices and treatments to lead people to adopt more healthy lifestyles and experience improvements in psychological and general well being. In order to achieve this individuals are taught a range of self help strategies including keeping food diaries, stress management and reducing barriers to change; ? For individuals who are morbidly obese, these interventions are largely ineffective and surgery or drug treatments are the preferred courses of action. In drug intervention programmes, patients are typically given anti obesity drugs in conjunction with dietary advice and physical activity programmes. A number of initiatives have been introduced in workplaces and other organisations but the research suggests that these are thinly spread and as such are unlikely to impact on significant numbers of the population (Barth, 2002, p.119). Concerns have been expressed because at the strategy level, resources will have to be allocated for obesity management and issues such as the shortage of dieticians need to be addressed (Barth, 2002, p.121), which calls for considerable government expenditure.
Effective Assessment: In order to treat obesity effectively, a thorough assessment of individuals is required. The main aims of assessment in addition to effective treatment are to establish a trusting relationship between individuals and health care professional as there are a number of negative perceptions associated with obesity. In order to assess appropriately, time must be allocated in order to gather the following information: ? Height and weight to assess the body mass index which can then be used to assess the severity of the obesity; ? Medical assessment to assess the risks associated with the obesity; ? Family weight history to identify possible genetic factors; ? Life long weight history to identify any cyclical patterns in weight loss and gain; ? Life long dieting history to explore the experience of dieting and any effects that this has on attitudes to obesity treatment; ? Eating behaviour history to identify any disordered eating; ? Current eating patterns to identify areas for change; ? Current levels of physical activity to identify changes which need to be made; ? Personal effectiveness to assess motivation and ability to make the necessary lifestyle changes, to identify personal concerns and potential barriers to change; ? Socio economic and cultural factors which may influence personal eating and exercise habits; ? Social situation to identify possible sources of support or inhibition of lifestyle changes.(British Dietetic Association, 1997).
Treating Obesity: A number of drug and radical surgical treatments have been made available for the treatment of obesity, but the problem is now so wide spread that these are unlikely to be feasible in the context of the general population. The problem in respect of treatment is often compounded as relapse from initially successful weight loss is common place (Timmerman and Acton, 2001). It has therefore been suggested that what is needed is along term approach, part of which considers the correlation between self esteem and emotional eating, which considers the long term changes that are necessary in order to tackle the problem. This requires a multi disciplinary approach with a number of health professional working together to develop strategies for its implementation.
Weight Management Programmes: Due to the severity of the problem of obesity, and the health risks associated with it, a number of possible solutions have been put forward to address the issue. Evidence is accumulating to suggest that obesity considerably heightens the risk of cardiovascular disease leading to death (Clark, 2006, p.123). When individuals have gone through programmes in which they have lost weight, maintaining the weight loss remains problematic (Clark, 2006, p.124). Problems have occurred with many of these strategies as they have been piecemeal in nature, and these must be linked together in an imaginative way in order to tackle the problem by appealing to the overweight population and those who are likely to become overweight (Barth, 2002, p.121). Research conducted in the form of clinical trials has shown that individuals are generally unable to continue losing weight for a period of more than about 12-16 weeks, and individuals who have failed to lose weight or have had repeated attempts and failed are unlikely to achieve success in the future. This has led to suggestions that a period of weight loss should be followed by a periods of weight maintenance (Hunter, 1997, p.37). The maintenance of a stable weight in individuals who are obese should be seen as a legitimate treatment option (Clark, 2006).
Slimming on Referral: This is an approach which has been used with some success and has come about through a collaboration between GPs and a commercial slimming organisation. Those who were involved in the programme were entitled to a reduced fee for the slimming club. Patients were given a free membership for twelve weeks and in the majority of the sample the weight loss was impressive. After the free time was completed however, the majority of people in the sample stopped going to the slimming club and opted out once they had to take responsibility for the payment of their own fees. This suggests that people can often be successful in terms of weight loss when they are given support but that once this has been withdrawn, it tends to become less easy. The individuals involved in this particular study lived in socially deprived areas and it may be the case that money was a consideration, suggesting that these results may not be applicable to the general public (Clark, 2006, p.125). If further research were to support the findings from this research it would have important implications for the government's strategy in respect of obesity, with individuals clearly requiring support throughout the process. This has implications in respect of funding and training professionals to give adequate support.
Developing New Treatments: Given the failure of traditional approaches to tackling obesity, new treatments must be developed. It is important to understand the nature of the regulation of energy and expenditure and to identify the factors that cause obesity. In the past few years a greater understanding of the mechanisms involved in people becoming obese has been developed through studies on humans and animals. These studies have seen a combination of genetic and physiological studies (Wilding, 1997, p.998).
Establishing an Obesity Strategy: Research has indicated that repeated unsuccessful attempts at weight loss can have a more detrimental effect on health than remaining obese, with substantial research pointing to the difficulty of sustaining weight loss in the long term (Clark, 2006, p.125). Proposals have been put forward for strategies to tackle obesity in the long term, which have become more compelling than ever due to the increasing levels of obesity. Among proposals in respect of obesity management it has been suggested that each community should have an obesity strategy, multi pronged to include public authorities, schools and so on, which will be determined by geographical factor (Barth, 2002, p.120). This is necessary so that the issue can be addressed at the community level as the idea of treating individuals would be too much of a drain on resources. There also needs to be a medical model with a health care team on hand to give advice about nutrition and lifestyle. Research has identified a clear framework for lifestyle changes that favour enhanced weight control, including reductions in the energy levels of the diet and increases in physical activity (Gill, 1997). While these have been shown to be highly effective in controlled experimental settings, they have had little effect in the public health context where the environmental factors seem to outweigh everything else. This adds weight to calls for the development of strategies to tackle the problem, particularly in light of increasing research that suggests that increasing or promoting dietary restraint can result in an increased preoccupation with food, which can lead to more of a preoccupation with food, greater levels of depression and increased eating behaviour. Considerable research has shown that individuals who are obese pose considerable challenges in respect of treatment. Approaches that have traditionally been used including behavioural treatments, drug based ones and diet based approaches have been shown to be largely unsuccessful in maintaining long term weight loss, suggesting the development of alternative approaches is a matter of urgency.
Ethnicity: Concern has been expressed about the fact that some ethnic groups appear to be more sensitive than others to the metabolic effects of obesity. High levels of type two diabetes and related diseases have been found in South Asian and Arab populations (Haslam, 2006, p.640). Not everyone who is exposed to the environmental factors that contribute to obesity succumb to the disease. This has led to suggestions that lessons can be learned from other countries. Rates of obesity re considerably lower in Japan and France that they are in the UK and the United States, despite a lack of evidence that they re less sedentary than their counterparts in these countries. Their food cultures are, however, very different, with a lot less fast food being consumed and eating still being mainly a family occasion with everyone meeting for dinner, rather than the snacking and fast food culture to which we in the UK have become prone.
Future Directions: Future research is required in order to establish more cost effective ways of dealing with the obesity problem. The fact that weight loss is more difficult to achieve and maintain in adulthood further highlights the importance of tackling the problem in children. Treatment plans have traditionally been aimed at families and schools but may be unsuccessful due to the fact that the environment does not change substantially, with parents being unable for the large part to change their eating habits and other aspects of behaviour such as lack of exercise and dependency on alcohol which can lead to obesity. While the research has suggested that physical activity can be an important aspect of the maintenance of a healthy weight, it is unclear how much exercise is needed and evidence is required from further longitudinal studies (Skidmore and Yarnell, 2004). Another area which has been identified as requiring further research is the role of genetics in obesity. It has been recognised for some time that genetics may play a part, but the nature and extent of this remains unclear. Of particular research interest may be the interplay between genes and the environment. Family based interventions have met with some success, with children having lost weight as a result of intervention. Children involved in the intervention programme were able to maintain their weight loss as evidenced in follow up studies. It was also shown that children's self esteem and overall psychological well being improved, suggesting that this approach may be of value and has no adverse psychological consequences (Wardle, 2006).
Conclusions: Evidence is accumulating that increasing levels of obesity are leading to higher levels of coronary heart disease and a number of other illnesses, with an increasing number of adults falling outside the range of normal body mass index (Clark, 2005). While research has shown that the public do hold themselves responsible for the obesity crisis, in respect of the consumption of fast foods and confectionary products, there is a feeling that the government and manufacturers should do more to inform the public about the dangers (Bhate, 2007). Despite this the problem continues to rise unabated, signalling long term problems for the nation's health. It has been suggested that a shared responsibility should be taken for the nation's health and that alternatives should be made available to ensure that obesity and other illnesses related to the consumption of fatty foods are effectively managed (Bhate, 2007). Commercial weight loss programmes have been shown to have higher degrees of success than primary care treatments which have been shown to be largely ineffective even with the most highly motivated individuals (Clark, 2006, p.124). Treatments for obesity can only be effective when they enable individuals to take responsibility for making the necessary changes in their lives. In order for this to be effectively achieved health care professional must have the skills and confidence to help people through the change process and reduce the chances of relapse. It is essential to recognise that the process of tackling obesity is a long term one and must involve a number of life style changes on the parts of individuals and the nation in general. Jebb and colleagues have pointed out that, while research into obesity and its cause is essential in order to develop public health strategies, this will be insufficient on its own to address the problem. Instead what is needed is for a range of stakeholders to accept their responsibilities in addressing the issues. Effective communication between all these stakeholders including government, schools, health professionals and parents, is essential in order to facilitate the necessary changes in lifestyle (Jebb et al., 2003, p.577). There is a growing body of evidence to suggest that the problem needs to be addressed on a number of levels including an investigation of the psychological aspects, with evidence that individuals who have high levels of self esteem and who are generally happy with their lives are less likely to engage in the eating behaviours that can lead to obesity (Timmerman and Acton, 2001, p.699). All the available evidence is suggestive of the fact that obesity is a problem which is running out of control and attempts at intervention have been largely unsuccessful. While individuals do need to take responsibility for the choices they make in terms of lifestyle, government assistance is required as well as further research into dealing with the problem if the national plague is to be effectively dealt with. Not only is obesity greatly damaging the health of the nation but the cost to the NHS and industry in terms of ill health means that valuable resources are being diverted into a disease which is largely preventable.
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