Why are we still obese?

Few people would be surprised to learn that the epidemic prevalence and serious health threats posed by obesity have earned it a description as “one of the most important medical and public health problems of our time.” What might be surprising is that this description was issued in 1979, by Professor Emeritus George Bray, one of the world’s longest-serving leading obesity researchers.

It is hard to understand why, almost 40 years later, we have seen so little progress in our attempts to tackle this issue. With the proliferation of four decades’ worth of healthy eating and exercise messages, surely we know and hear more about managing our weight than ever before. Yet despite this, the prevalence remains at its highest ever. In Australia, 11.2 million adults – 63.4% of the adult population – and 27.4% of children aged 5-17 years are classified as overweight or obese according to their body mass index (BMI). Certain groups in the population – those facing socioeconomic disadvantage, or living in regional areas, for example, are at disproportionately higher risk.

Why have we failed to address obesity?

Unfortunately, knowledge and awareness alone are insufficient for dealing with the obesity epidemic, which has been described by the United Nations as a ”wicked problem” – one that is highly resistant to resolution, due not only to the sheer numbers affected but also the widespread, changing, interconnected and competing aetiological drivers.

Responsibility for obesity is often attributed primarily to individuals themselves (or to parents, in the case of young children), which can lead to a tendency to blame individuals for their ‘failure’ to maintain a healthy weight. In fact many factors combine to increase the risk of obesity. While some of these are characteristics or behaviours of individuals – skills, values and priorities related to nutrition and physical activity, for example – other contributing factors are less amenable to individual control. Financial hardship and poverty, food insecurity, prevailing social or cultural norms, lack of social support, work and other psychosocial stressors, time poverty and competing demands, poor physical or mental health, excessive exposure to food marketing and supplies of cheap energy-dense foods, sedentary workplaces, urban sprawl and long commutes, and lack of access to health-promoting foods or physical activity options in local neighbourhoods have all been implicated in obesity risk.

Is there any hope?

The good news is that there are success stories. At Deakin University’s Institute for Physical Activity and Nutrition (IPAN), we have followed more than 4,000 women and children living in disadvantaged neighbourhoods to investigate how some manage, despite their increased risk, to stave off obesity. Key predictors of this ‘resilience’ to obesity included confidence, self-control and skills that facilitated healthy eating and physical activity, but also social and physical environments that were supportive of these behaviours.

The National Weight Control Registry in the USA is tracking more than 10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time. Just under half of the participants lost weight on their own, and the other half did so through some sort of formal program. Almost all (98%) reported that they modified their food intake in some way to lose weight, and 94% increased their physical activity, mostly by walking more. More than three-quarters of participants reported eating breakfast every day; 75% weighed themselves at least once per week; and 62% watched less than 10 hours of TV per week.

What can healthcare professionals do?

Healthcare professionals can play a key role in assisting clients to achieve and maintain a healthy weight. Lifestyle change remains the cornerstone of weight management – that is, increased physical activity, reduced energy intake, and incorporating behaviours such as eating a healthy breakfast and weekly self-weighing. Psychological and behavioural interventions including cognitive behaviour therapy, stimulus control techniques, self-monitoring, and behaviour modification techniques such as goal-setting can all be useful components of a weight loss approach. But weight management support cannot be delivered in a vacuum – it needs to be holistic, tailored to individuals’ circumstances, barriers and broader environmental risk factors. This will require assessing the contexts in which individuals are living. For example, the healthcare professional might frame a discussion around questions such as:

• How confident are clients to engage in weight-management behaviours?
• What is stopping them?
• How can they overcome these barriers?
• What are the supports available in their homes, workplaces, peer groups, local neighbourhoods?
• If needed, can the healthcare professional facilitate access to ongoing psychological support, or support for stress management, or time management, or financial assistance, or strategies to garner social support (e.g. involving families or others in treatment)?
• Can they encourage or assist the client to explore their local environment for opportunities (does the supermarket stock affordable, quality fresh produce? Are there safe walking/bicycle tracks, parks or public open spaces to exercise in? Are there other weight, food or exercise support groups?) and even to advocate for these if they are lacking?

Finally, weight management is typically a long-term undertaking, and the importance of ongoing support, review, and assistance in dealing with relapse cannot be understated.

Achieving and maintaining a healthy weight is challenging in modern societies, but it is not impossible. Healthcare professionals can play a key role in supporting clients with their weight management efforts by remaining cognisant not only of the specific behaviour changes required, but also of the broader contextual drivers of the obesity epidemic.

Alfred Deakin Professor Kylie Ball is a National Health & Medical Research Council Principal Research Fellow in the Institute for Physical Activity and Nutrition (IPAN) at Deakin University.  Her research focuses on the epidemiology and prevention of obesity, particularly amongst vulnerable groups such as those facing socioeconomic disadvantage.