Sunday, 16 November 2008
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"Obesity" and "Clinical Obesity" Men's understandings of obesity and its relation to the risk of dia
Institute of Health and Society, University of Newcastle upon Tyne, Newcastle upon Tyne, UK. nicolaweaver@blueyonder.co.uk
BACKGROUND: The 2007 Wanless report highlights the ever increasing problem of obesity and the consequent health problems. Obesity is a significant cause of diabetes. An increasing evidence base suggests that in terms of reducing diabetes and CVD risk, it is better to be "fit and fat" than unfit and of normal weight. There has been very little previous research into the understandings that men in the general population hold about the issues of weight, exercise and health; we therefore undertook this study in order to inform the process of health promotion and diabetes prevention in this group.
METHODS: A qualitative study in North East England General Practice using a purposive sample of men aged 25 and 45 years (selection process designed to include 'normal', 'overweight' and 'obese' men). One to one audio-recorded semi structured interviews focused on: overweight and obesity, diet, physical activity and diabetes. Transcripts were initially analysed using framework analysis. Emerging themes interlinked.
RESULTS: The men in this study (n = 17) understand the word obesity differently from the clinical definition; "obesity" was used as a description of those with fat in a central distribution, and understandings of the term commonly take into account fitness as well as weight. Men in their late 30s and early 40s described becoming more aware of health issues. Knowledge of what constitutes a 'healthy lifestyle' was generally good, but men described difficulty acting upon this knowledge for various reasons e.g. increasing responsibilities at home and at work. Knowledge of diabetes and the link between obesity and diabetes was poor.
CONCLUSION: Men in this study had a complex understanding of the interlinked importance of weight and fitness in relation to health. Obesity is understood as a description of people with centrally distributed fat, in association with low fitness levels. There is a need to increase understanding of the causes and consequences of diabetes. Discussion of increased health awareness by men round the age of 40 may indicate a window of opportunity to intervene at this time.
The main findings of this study are as follows:
• The men in this study understood the word obesity differently from the clinical definition; the term "obesity" was used mainly as a description of those with centrally distributed fat, and understandings of the term commonly took into account fitness as well as weight.
• Men described becoming more aware of health issues in theirlate 30s and early 40s, suggesting there may be a window of opportunity to intervene at this time.
• Knowledge of healthy lifestyles was generally good, but men described difficulty acting upon this knowledge as they approach middle-age and have increasing responsibilities at home and at work.
• Knowledge of diabetes and the link between obesity and diabetes was poor.
This study set out to understand important health issues from the individual perspectives of men in the general population. As a qualitative study this research sets out to understand the range of views held by men but does not make claims about the distribution of those views, and is therefore not generalisable in the quantitative sense. We can however generalise theoretically in the sense that the understandings gained here enable us to better judge the issues of importance to men in this age and socio economic group and provide the parameters for quantitative studies of the distribution of these understandings. Validity in qualitative research is established through standard mechanisms to assess the plausibility and credibility of the claims made. Here this was achieved through saturation of themes, exposition of methods, attention to negative cases and reflexivity. While we interviewed men in the age group 25 to 45 years and achieved a good mix of weight and occupation, the group had higher levels of educational attainment than would be expected in the general population and this is a potential source of bias. Our conclusion that men in their late 30s and early 40s are open to change could result from having particularly attracted a group of participants who feel this way. Conversely however, the lack of understanding of diabetes in this relatively well educated group suggests that the problem may be much worse in a different sample which better represents the average educational achievement in the population at large.
For men in this study the word obesity implies elements relating to the central distribution of body fat, and to levels of physical fitness. The focus on 'round' body shape interestingly fits with scientific research which suggests that waist circumference is a better measure of cardiovascular risk that BMI. Many men actually prefer the way they look when their BMI is > 25 and do not see this higher level of weight as a problem in the context of a healthy lifestyle. These men aspire to be physically fit, and public health messages about healthy eating seem to have made an impact. They discuss the factors which limit opportunities for exercise and healthy diet. Patterns of employment are seen as very significant, as well as the related economic factors e.g. sedentary occupations, such as taxi driving, and easy access to cheap fast food. They notice an age related increase in their awareness of health issues.
The ideas we demonstrate about the scepticism held in relation to a target BMI of < 25 have been seen elsewhere. Monaghan interviewed 37 men, (mean age 43), exploring the way men felt about conforming to a 'healthy' BMI, and found "talk about the compatibility of heaviness, healthiness and physical fitness; looking and feeling ill at a putatively 'healthy' BMI; and the irrationality of standardisation".
Research showing that the association between overweight or obesity and mortality is markedly attenuated and in some instances eliminated when objectively measured cardio respiratory fitness is included in the statistical models fits with the perception of the men in this study, that any level of weight cannot be viewed in isolation from levels of physical fitness.
For the men in this study the word diabetes conjures up a number ofconcepts which link to it, but are not easy to understand as a whole. Facts relating to 'type one' and 'type two' diabetes are mixed together, and the side effects of insulin are mixed up with the signs and symptoms of diabetes. Diabetes is understood as an illness, rather than a risk factor, but people are confused about the lack of tangible symptoms relating to the 'illness' of diabetes itself. The understanding of diabetes is like self assembly furniture without the instructions-there are lots of pieces which clearly go together but it is not clear how.
There is little published research into the general population's understanding of diabetes with which to compare these findings. Diabetes UK commissioned a MORI conducted survey of 2,135 adults in the UK in 2000 which found that public understanding of diabetes and its impact is poor. Four out of five people believed that some people get a milder form of diabetes than others; three quarters (76 per cent) of those in high risk groups were unaware of their risk of developing the condition; less than half (46 per cent) of the public know that death can result from diabetes; only one quarter of the population know that diabetes can lead to heart disease despite the fact that it significantly increases the risk. Our findings mirror these results.
A number of men described knee pain as having significantly interrupted their exercise regime. The perception seems to be that exercise is responsible for the problem, and that weight gain is a consequence. Some evidence suggests that participation in exercise does not cause knee osteoarthritis , but other more specific follow up studies of professional footballers do indicate long term problems, including osteoarthritis of the knee . Obesity however is clearly associated with knee pain and osteoarthritis in the knee . In obesity and diabetes prevention in men, education about good knee care, and the impact of weight on knee problems may be an important factor.
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