Preventing obesity: challenges and pitfalls for health promotion

Individual user involvement at Healthy Life Centres: a qualitative study exploring the perspective of health professionals

The aim of this study was to explore how professionals experience user involvement at an individual level and how they describe involving users at Healthy Life Centres. Four focus group interviews were conducted with a total of 23 professionals. Data were analysed using systematic text condensation. Four themes were identified: (1) Involving users through motivational interviewing; (2) Building a good and trustful relation; (3) Assessing and adjusting to the user’s needs and life situation; and(4) Strengthening the user’s ownership and participation in the lifestyle change process. Motivational interviewing was described by the professionals as a way to induce and ensure user involvement. However, seeing motivational interviewing and user involvement as the same concept might reduce user involvement from being a goal in itself and evolve into a means of achieving lifestyle changes. The professionals might be facing opposing discourses in their practice and a dilemma of promoting autonomy and involvement and at the same time promoting change in a predefined direction. Greater emphasis should thus be put on systematic reflection among professionals about what user involvement implies in the local Healthy Life Centre context and in each user’s situation.

Abbreviations: HLC: Healthy Life Centre; MI: Motivational Interviewing; NCD: Non-communicable diseases; STC: Systematic Text Condensation. SDT: Self-determination theory

Becoming a normal guy: Men making sense of long-term bodily changes following bariatric surgery

Background

To date, research on bodily changes following bariatric surgery has focused predominantly on women, leaving the long-term experience of men relatively unexplored. In this paper, we draw on interviews with men who have undergone an irreversible gastric bypass procedure to explore their bodily changes more than 4 years post-surgery. We apply a phenomenological framework that draws on Leder's perspectives on the “disappearing” and “dys-appearing” body, combined with a gender-sensitive lens that draws on Connell's theory of hegemonic masculinity and Robertson's conceptions of embodied masculinity.

Findings

Our principal finding was that the men negotiated their bodily changes following bariatric surgery in profoundly ambivalent ways. Although they enthusiastically praised the surgery for improving their health, self-esteem, and social functioning, they also emphasized their efforts to cope with post-surgical side effects and life-threatening complications. Our analysis elaborates on their efforts to adjust to and come to terms with these changes, focusing on episodes of hypoglycemia, severe pain and internal herniation, and the significance of physical activity and exercise.

Conclusions

Our findings point to the need to acknowledge men's ways of making sense of profound and ongoing bodily changes following bariatric surgery and how these negotiations are closely intertwined with masculine ideals of embodiment and social value.

When is it ok to tell patients they are overweight? General public's views of the role of doctors in supporting patients' dieting and weight management

The objective was to explore the general public's views on the role of health professionals in the management of weight with diet and the implementation of behaviour change. Semi-structured interviews were conducted. An inductive grounded theory approach utilised a coding framework; recurring concepts/themes explored in future interviews and thematic saturation achieved. Two themes summarised views on the role of health professionals in supporting dieting and weight management: responsibility to initiate talk and what patients expect. Individuals perceive health professionals as having a role in their weight management. Individuals have disparate views about responsibility for initiation of weight management talk.

The ambivalence of losing weight after bariatric surgery

This study is grounded in a phenomenological lifeworld perspective. It aims at providing rich descriptions of lived experience of the process of losing weight after obesity surgery. Two women participated in in-depth interviews four times each during the first postoperative year. Based on the women's experiences, a meaning structure--the ambivalence of losing weight after obesity surgery--was identified across the women's processes of change. This consisted of five core themes: movement and activity--freedom but new demands and old restraints; eating habits and digestion--the complexity of change; appearance--smaller, but looser; social relations--stability and change; and being oneself--vulnerability and self-assurance. These core themes changed over time in terms of dominance. The experience of ambivalence is discussed according to a phenomenological perspective of the body as lived experience.

Ethnic differences and parental beliefs are important for overweight prevention and management in children: a cross-sectional study in the Netherlands

Background

The prevalence of obesity and overweight is highest among ethnic minority groups in Western countries. The objective of this study is to examine the contribution of ethnicity and beliefs of parents about overweight preventive behaviours to their child’s outdoor play and snack intake, and to the parents’ intention to monitor these behaviours.

Methods

A cross-sectional survey was conducted among parents of native Dutch children and children from a large minority population (Turks) at primary schools, sampled from Youth Health Care registers.

Results

Native Dutch parents observed more outdoor play and lower snack intake in their child and had stronger intentions to monitor these behaviours than parents of Turkish descent. In the multivariate analyses, the parents’ attitude and social norm were the main contributing factors to the parental intention to monitor the child’s outdoor play and snack intake. Parental perceived behavioural control contributed to the child’s outdoor play and, in parents who perceived their child to be overweight, to snacking behaviour. The associations between parents’ behavioural cognitions and overweight related preventive behaviours were not modified by ethnicity, except for perceived social norm. The relationship between social norm and intention to monitor outdoor play was stronger in Dutch parents than in Turkish parents.

Conclusions

As the overweight related preventive behaviours of both children and parents did differ between the native and ethnic minority populations of this study, it is advised that interventions pay attention to cultural aspects of the targeted population. Further research is recommended into parental behavioural cognitions regarding overweight prevention and management for different ethnicities.

Anti-obesity effect of resveratrol-amplified grape skin extracts on 3T3-L1 adipocytes differentiation

Resveratrol (3,4,5-trihydroxy-trans-stilbene), a phytoalexin found in grape skin, grape products, and peanuts as well as red wine, has been reported to have various biological and pharmacological properties. The purpose of this study was to investigate the anti-obesity effect of resveratrol-amplified grape skin extracts on adipocytes. The anti-obesity effects of grape skin extracts were investigated by measuring proliferation and differentiation in 3T3-L1 cells. The effect of grape skin ethanol extracts on cell proliferation was detected by the MTS assay. The morphological changes and degree of adipogenesis of preadipocyte 3T3-L1 cells were measured by Oil Red-O staining assay. Treatment with extracts of resveratrol-amplified grape skin decreased lipid accumulation and glycerol-3-phosphate dehydrogenase activity without affecting 3T3-L1 cell viability. Grape skin extract treatment resulted in significantly attenuated expression of key adipogenic transcription factors, including peroxisome proliferator-activated receptor, CCAAT/enhancer-binding proteins, and their target genes (FAS, aP2, SCD-1, and LPL). These results indicate that resveratrol-amplified grape skin extracts may be useful for preventing obesity by regulating lipid metabolism.

Power and powerlessness: GPs' narratives about lifestyle counselling

BACKGROUND

Power in doctor-patient relationships is asymmetrically distributed. The doctor holds resources the patient needs and has a mandate to promote healthy living. Power may benefit or harm the patients' health, and the doctor-patient relationship.

AIM

To identify aspects of power and powerlessness in GPs' narratives about lifestyle counselling.

DESIGN AND SETTING

A qualitative study using focus groups from peer-group meetings of Norwegian GPs attending continuing medical education.

METHOD

GPs discussed case stories about lifestyle counselling in focus groups. The discussions were transcribed and the text analysed using systematic text condensation.

RESULTS

Aspects of power concerning the framework of the consultation and the GPs' professional role were found. Also identified were: power expressed by opportunistic approaches to change patients' lifestyle; rhetoric communication; paternalism; and disclosure. GPs reported powerlessness in complex communication, when there were difficulties reaching goals, and when patients resisted or ignored their proposals.

CONCLUSION

Case-study discussions in peer groups disclose several aspects of power and powerlessness that occur in consultations. Consciousness about aspects of power may facilitate counselling that benefits the patient and the doctor-patient relationship.

Associations between obesity (BMI and waist circumference) and socio-demographic factors, physical activity, dietary habits, life events, resilience, mood, perceived stress and hopelessness in healthy older Europeans

BACKGROUND

It is important to understand the psycho-social context of obesity to inform prevention and treatment of obesity at both the individual and public health level.

METHODS

Representative samples of middle-aged adults aged ≥43 years were recruited in Great Britain (GB) (n = 1182) and Portugal (n = 540) and interviewed to explore associations between body mass index (BMI), waist circumference (WC), demographic factors, physical activity, dietary habits (FFQ), life events (LES), Resilience (RS11), Mood (MS), Hopelessness (BDI) and Perceived Stress (PSS4). BMI (kg/m2) and WC (cm) were dependent variables in separate multiple linear regression models for which predictors were entered in 4 blocks: 1. demographic factors; 2. stressful life events; 3. diet/activity; and, 4. psychological measures.

RESULTS

In the GB sample, BMI (kg/m2) was predicted by less education, illness in a close friend or relative, frequent alcohol consumption and sedentary behaviour. Among the Portuguese, higher BMI (kg/m2) was predicted by lower resilience. Being male and less education were independent predictors of having a larger WC (cm) in both countries. Within GB, not working, illness in a close friend or relative, sedentary lifestyle and lower resilience were also independent predictors of a larger WC (cm).

CONCLUSIONS

These data suggest that intervention to treat and/or prevent obesity should target males, particularly those who have left education early and seek to promote resilience. In GB, targeting those with high alcohol consumption and encouraging physical activity, particularly among those who have experienced illness in a close friend or relative may also be effective in reducing obesity.

Obesity, stigma, and responsibility in health care: A synthesis of qualitative studies

Objective

To synthesize research findings on experiences and attitudes about obesity and stigma in health care.

Methods

We compiled qualitative studies and applied Noblitt & Hare's meta ethnography to identify, translate, and summarize across studies. Thirteen qualitative studies on experiences and attitudes about obesity and stigma in health care settings were identified and included.

Results

The study reveals how stigmatizing attitudes are enacted by health care providers and perceived by patients with obesity. Second-order analysis demonstrated that apparently appropriate advice can be perceived as patronizing by patients with obesity. Furthermore, health care providers indicate that abnormal bodies cannot be incorporated in the medical systems—exclusion of patients with obesity consequently happens. Finally, customary standards for interpersonal respect are legitimately surpassed, and patients with obesity experience contempt as if deserved. Third-order analysis revealed conflicting views between providers and patients with obesity on responsibility, whereas internalized stigma made patients vulnerable for accepting a negative attribution. A theoretical elaboration relates the issues of stigma with those of responsibility.

Conclusion

Contradictory views on patients’ responsibility, efforts, knowledge, and motivation merge to internalization of stigma, thereby obstructing healthy coping and collaboration and creating negative contexts for empowerment, self-efficacy, and weight management. Professionals need to develop their awareness for potentially stigmatizing attitudes towards vulnerable patient populations.

Patients' experiences with lifestyle counselling in general practice: a qualitative study

OBJECTIVE. (1) To elucidate the relevance of Habermas's theory as a practical deliberation procedure in lifestyle counselling in general practice, using a patient perspective. (2) To search for topics which patients consider of significance in such consultations. DESIGN. Qualitative observation and interview study. SETTING. General practice. Subjects. A total of 12 patients were interviewed after lifestyle consultations with their GPs. MAIN OUTCOME MEASURES. How the patients perceived the counselling, how it affected them, and what they wanted from their GP in follow-up consultations. RESULTS. The GP should be a source of medical knowledge and a caretaker, but also actively discuss contextual reasons for lifestyle choices, and be a reflective partner exploring values and norms. The patients wanted their GP to acknowledge emotions and to direct the dialogue towards common ground where advice was adjusted to the concrete life situation. A good, personal doctor-patient relationship created motivation and obligation to change, and allowed counselling to be interpreted as care. CONCLUSION. The findings underscore the necessity of a patient-centred approach in lifestyle counselling and support the relevance of Habermas's theory as practical guidance for deliberation. IMPLICATIONS. The findings suggest that GPs should trust the long-term effects of investing in a good relationship and personalized care in lifestyle consultations. The study should incite the GP to act as an encouraging informer, an explorer of everyday life and reasons for behaviour, a reflective partner, and a caretaker, adjusting medical advice to patients' identity, context, and values.

The effects of consuming eggs for lunch on satiety and subsequent food intake

The aim of the present work was to investigate the effects of eggs consumed for lunch on satiety, satiation and subsequent energy intake at the next meal. Thirty-one healthy male and female subjects participated in a randomized, three-way, crossover study. Following consumption of a standard breakfast, participants were asked to consume three isocaloric test lunches: omelette, jacket potato and chicken sandwich. Subjective measures of satiety were recorded using visual analog scales at regular intervals throughout the day. Energy intake at the next meal was assessed 4 h after lunch with an ad libitum meal. The egg lunch showed a significantly stronger satiating effect compared with the jacket potato meal. No effect on energy intake was seen. These data indicate that consumption of an omelette meal consumed at lunch could increase satiety to a greater extent than a carbohydrate meal and may facilitate reduction of energy consumption between meals.

Public health campaigns and obesity - a critique

BACKGROUND

Controlling obesity has become one of the highest priorities for public health practitioners in developed countries. In the absence of safe, effective and widely accessible high-risk approaches (e.g. drugs and surgery) attention has focussed on community-based approaches and social marketing campaigns as the most appropriate form of intervention. However there is limited evidence in support of substantial effectiveness of such interventions.

DISCUSSION

To date there is little evidence that community-based interventions and social marketing campaigns specifically targeting obesity provide substantial or lasting benefit. Concerns have been raised about potential negative effects created by a focus of these interventions on body shape and size, and of the associated media targeting of obesity.

SUMMARY

A more appropriate strategy would be to enact high-level policy and legislative changes to alter the obesogenic environments in which we live by providing incentives for healthy eating and increased levels of physical activity. Research is also needed to improve treatments available for individuals already obese.

Understanding change in medical practice: the role of shared meaning in preventive treatment

Health care organizations are experiencing a rising demand for change in the organization of preventive health services. Many initiatives designed to cater for change fail to achieve their aim. To understand how organizational dynamics in health care organizations influence the adoption of new initiatives, I explored the implementation of motivational interviewing, a health behavior concept that was introduced into ten general practice clinics in Denmark. Within an institutional framework I explored how modern ideas of prevention related to this concept were translated into medical practices. Using a qualitative multiple-case study design, I examined the institutionalization process in different clinical settings. I found that clinics constructed various types of preventive routines and thereby imposed new meaning on the health behavior concept. In adopting the concept, clinics developed a new routine against the background of existing practice, (re)producing an alternative, self-contained routine that diverged from their usual medical practice.

An activity-based intervention for obese and physically inactive children organized in primary care: feasibility and impact on fitness and BMI A one-year follow-up study

OBJECTIVE

To investigate the feasibility and impact on BMI and physical fitness of an intervention for obese and inactive children, based on physical activity and carried out in primary health care.

DESIGN

A prospective, longitudinal one-year follow-up study.

SETTING

The community of Kristiansand, Norway (80 000 inhabitants).

INTERVENTION

A 40-week structured intervention based on physical training with some lifestyle advice for the obese child and one parent. Subjects. A total of 62 physically inactive children aged 6-14 years with iso-BMI ≥ 30 kg/m².

MAIN OUTCOME MEASURES

Body mass index (BMI), maximum oxygen uptake, and physical fitness in tests of running, jumping, throwing, and climbing assessed at baseline and after six and 12 months as well as number of dropouts and predicting factors.

RESULTS

A total of 49 out of 62 children completed the first six months and 37 children completed 12 months. Dropout rate was higher when parents reported being physically inactive at baseline or avoided physical participation in the intervention. The children's maximum oxygen uptake increased significantly after 12 months from 27.0 to 32.0 ml/kg/min (means), as did physical fitness (endurance, speed, agility, coordination, balance, strength) and BMI was significantly reduced.

CONCLUSION/IMPLICATIONS

This one-year activity-based intervention for obese and inactive children performed in primary health care succeeded by increasing cardiovascular capacity and physical fitness combined with reduced BMI in those who completed. Dropout was substantial and depended on the attendance and compliance with physical activity by the parents.

Obesity in general practice: a focus group study on patient experiences

OBJECTIVE

To explore obese patients' experiences with GPs' management of their weight problems.

METHODS

Focus-group study with a purposive sample of 13 participants (eight women and five men), aged 30-55 years, with BMI above 40, or BMI above 35 with additional weight-related problems. Two focus-group interviews were conducted, inviting the participants to speak about their health care experiences from general practice. Analysis applied Systematic Text Condensation inspired by Giorgi's approach, searching for issues describing or discussing participants' experiences of GPs' obesity management.

RESULTS

Obese patients want their GPs to put their weight problems on the agenda. When the patient appears reluctant, it may be a sign of embarrassment rather than rejection of the issue. However, restricted attention to obesity could lead to neglect of patients' problems. Participants complained that GPs often demonstrated insufficient engagement and knowledge regarding service resources for obesity treatment, leaving the responsibility for information on available referral resources to the patient. Finally, considerate attitudes in the GPs are needed for follow-up to be experienced as helpful by the patients. Vulnerable feelings of failure could be reinforced by well-intended advice. Degrading attitudes were perceived as especially subversive when they came from doctors.

CONCLUSIONS

The challenge for the GP is to increase his or her competence in individualized and evidence-based counselling, while acknowledging the efforts needed by the patient to achieve permanent change, and shifting attention from shame to coping.

"My quality of life is worse compared to my earlier life": Living with chronic problems after weight loss surgery

Weight loss surgery is commonly regarded as improving individuals' health and social life, and resulting in a happier and more active life for those defined as "morbidly obese." However, some researchers have started to doubt whether these positive outcomes apply to everyone and this article explores this doubt further. More specifically, we focus on the experiences of women whose life situation became worse after weight loss surgery. The material draws on qualitative interviews of five Norwegian women undergoing the irreversible gastric bypass procedure. Our findings illustrate that the women lived seemingly "normal" lives prior to the surgery with few signs of illness. Worries about future illness as well as social stigma because of their body shape motivated them to undergo weight loss surgery. After the surgery, however, their situation was profoundly changed and their lives were dramatically restricted. Chronic pain, loss of energy, as well as feelings of shame and failure for having these problems not only limited their social lives but it also made them less physically active. In addition, they had difficulties taking care of their children, and functioning satisfactorily at work. Accordingly, the women gradually felt more "disabled," regarding themselves as "outsiders" whose problems needed to be kept private. The results highlight some "subtle" consequences of weight loss surgery, particularly the shame and stigma experienced by those whose lives became dramatically worse. Living in a society where negative impacts of weight loss surgery are more or less neglected in research as well as in the public debate the women seemed to suffer in silence. Their problems were clearly present and felt in the body but not talked about and shared with others.

"Norwegians fear fatness more than anything else"--a qualitative study of normative newspaper messages on obesity and health

OBJECTIVE

To explore normative aspects of the Norwegian discourse on obesity.

METHODS

We conducted a qualitative study with data from five Norwegian newspapers, focusing normative entries about body weight. Discourse analysis provided a focus on the cultural attitudes when systematic text condensation was conducted. Data comprised 26 normative messages (prescriptions or comments on how obese people are or should be, messages mediating or discussing values prescribing a 'good' body).

RESULTS

Two main normative domains within the obesity discourse were identified. One group of entries warned about obesity from an aesthetic point of view, notifying the reader that beauty would suffer when weight increases, due to reduced attractiveness. These texts appealed to bodily conformity, linking leanness with attractiveness and delight, suggesting that fat people are ugly and unhappy. The other group referred to lack of control in the obese person, linking greediness to lack of responsibility and bad health. Fat people were displayed as undisciplined and greedy individuals who should be ashamed.

CONCLUSIONS

Cultural messages of blame and shame are associated with obesity, but also spreading from body weight to the very scene of life. People with obesity cannot escape this cultural context, only find a way of coping with it.

PRACTICE IMPLICATIONS

Quality care for people with obesity implies that public health and clinical medicine acknowledge the burden of cultural stigma. Developing awareness for cultural prejudices on body weight, doctors could counteract stigmatization and contribute to empowerment and health.