Obesity
Preventing obesity: Challenges and pitfalls for health promotion

https://doi.org/10.1016/j.pec.2008.12.012Get rights and content

Abstract

Objective

To explore challenges to health promotion strategies against obesity, with special attention to the Scandinavian context.

Methods

Analytic induction, a procedure for verifying theories and propositions, based on purposefully selected literature references, with subsequent critical reflection.

Results

Health promotion efforts against obesity face challenges related to the unequal distribution of vulnerability to weight gain within the population, and to the complex neuroregulatory determinants that explain why obesity is not just a simple matter of lifestyle. Cultural understandings of identity and morality may create victim blaming and disempowerment, thus obstructing clinical health promotion strategies for weight control. Finally, the conceptual validity of obesity measurements and their predictive power deserves attention.

Conclusion

Preventing obesity is difficult. Awareness of individual vulnerability and neurobiological mechanisms that lead to weight gain must be taken into account when strategies for health promotion are developed. These strategies must transcend a simplistic energy balance view.

Practice implications

Clinical health promotion needs to be highly individualized and tailored. Preventing weight gain requires attention to the person's sociodemographic, cultural and genetic characteristics. Cultural trends such as sedentary lifestyles and the nutrition transition should be counteracted without turning body weight control into a question of morality and inferior identity.

Introduction

Population body weights are increasing worldwide, with the US in a leading position [1]. Around 396 million people, or 9.8% of the global population, are obese, when measured as body mass index (BMI)  30 kg/m2 [2]. This escalating prevalence is not only observed in industrialized Western countries, but also in developing ones [3]. WHO calls obesity a global epidemic [4], due to the parallel rise of related morbidity and risk factors (type 2 diabetes, cardiovascular disease, cancer, musculoskeletal problems, sleep apnoea, and gall bladder disorders) [5], [6], [7], [8]. Recently, a systematic review delineated the extent of this epidemic in Europe and found higher prevalence rates in the Central, Eastern and Southern than in the Western or Northern regions [9].

The Scandinavian countries rank low on the European obesity list [10]. Nevertheless, Norwegian population-based studies demonstrate that the obesity epidemic has reached Scandinavia—one out of five Norwegians across age groups was obese in 2000–2003 [11], [12], [13]. Authorities in several countries have called for public and clinical health promotion strategies to counteract this development and its consequences [14], [15].

Once an individual has become obese, the long term success of treatment outside of bariatric surgery to promote weight loss is limited [16], [17]. Clinicians and patients may hold opposing attitudes to causality and solutions. General practitioners may believe in behavioural, structural, social and psychological causes whereas the lay population endorses a more biological approach [18]. Preventing obesity in the population, as well as prevention of further weight gain for those who are already obese are therefore important challenges for public health and clinical health promotion [19], [20]. However, the structural and individual targets might call for different preventive approaches [20], and very few strategies have actually been shown to be successful. According to Candib, behavioural lifestyle interventions are inadequate to counter the force and interactions of genetic, physiological, psychological, familial, social, economic, and political determinants of increased body fat stores [21], [22]. Moreover, as stated by Gard and Wright, the human body is not an autonomous machine, but located within social and cultural contexts that shape people's behaviours and access to physical activity and healthy foods [23].

In this article, we aim to identify some specific challenges related to health promotion strategies aimed at the obesity problem from a Scandinavian perspective. We place the epidemiological observations in a sociocultural context, while keeping contemporary biophysiological evidence in mind. We do not intend to provide answers or offer remedies, but aim to highlight questions, challenges, and paradoxes deserving further attention.

Section snippets

Analytic induction

Our approach was different from, and more restricted and focused than that of a systematic review, where the aim would be to identify and synthesize the results from all available studies on health promotion and obesity. We followed a procedure which can be compared with a qualitative case study based on analytic induction. Patton describes this as a systematic procedure for exploring deduced propositions by means of cases [24]. We started by developing logic arguments to articulate the

Which groups are most vulnerable to weight gain?

A recent review serves as a point of departure to notable subgroup variations in obesity prevalence in Norway [13]. Age, gender, geography, social gradients, and ethnicity impact the distribution and trends of the population body mass [27], [28], [29]. The prevalence of obesity is increasing in all age groups below 70, especially in the youngest [30].

Among the youngest age groups, gender does not appear to influence the distribution of body weight substantially, however, obesity is more

Limitations and strengths of the presented approach

Health promotion involves strategic and pragmatic application of available evidence according to normative and cultural values of how health is defined and enacted. The real-life complexity of such a context is very different from the standard evidence-based situation in medicine, such as a new medication being implemented from the foundation of corresponding findings from several randomized controls. This is why we in this article chose to pursue our objective along a different path than the

Competing interest

We are aware of no competing interest. Serena Tonstad has received honorariums for consulting or lectures or both from the manufacturers of antiobesity drugs (Roche, Abbott and sanofi-aventis).

Acknowledgements

Thanks to Anita A. Aadland, Sverre Maehlum, and Mette Svendsen for important contributions and discussion.

Authors’ contributions: KM conceived the idea of the article and drafted the first version of the manuscript, while ST joined the process by contributing to editing, writing, and focusing the discussion of the article, and by strengthening the evidence base. Both authors read and approved the final manuscript.

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    This project has been financed with the aid of EXTRA funds from the Norwegian Foundation for Health and Rehabilitation.

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