Factors and Strategies for Treating Adult Obesity in England

This dissertation discusses the factors that cause adult obesity in England and the strategies of treating the condition. It covers the impact of obesity on the economy and public health policies to prevent it. The high prevalence of obesity in England as in other parts of the world is a serious threat to public health.

The factors that cause adult obesity in England and the strategies of treating the condition
Name
University

Factors that cause obesity 2
Abstract
In recent decades obesity has assumed mammoth proportions. A high proportion of the world
population is now either obese or overweight. The problem is further exacerbated due to the
co-morbidities associated with increasing BMIs. Causes of high BMIs and high waist to hip
ratio are sedentary lifestyles coupled with an energy dense diet. Food choices that are high in
fats, sugar with bigger portion sizes has turned the blessing of food abundance into a curse
due to overindulgence. Psychological problems such as depression, stress and distress have
led to a change in our relationship with food. Whether obesity causes depression or whether
depression causes obesity is a subject often discussed. But eating disorders and binge eating
are common disorders. A better understanding of health behaviour is necessary to deal with
the problem. Seeking medical intervention is a choice that many obese people have to opt for
because of complex health problems that obesity can trigger. Pharmaceuticals and surgery are
often the last resort that people take to lose weight. But policy recommendations on changing
the food scene, with respect to smaller portion sizes, levying taxes on sweetened beverages,
use of healthier ingredients and an emphasis on home cooking and eating are important when
trying to change the obesogenic environment that we live in. Public health campaigns that
promote healthy lifestyles and are easy to dissipate through mass and social media can prove
to be effective at prevention of obesity. Treatment is often long drawn and bereft with the risk
of weight gain over time.

Factors that cause obesity 3
Introduction.......................................................................................................................................4
Chapter 1...........................................................................................................................................7
Chapter 2.........................................................................................................................................16
Chapter-3.........................................................................................................................................24
Conclusion.......................................................................................................................................33
References.......................................................................................................................................35

Factors that cause obesity 4
Introduction
Obesity is a serious public health problem. And obesity, that afflicts more than 25% of the
population in the United Kingdom is a natural outcome of our food culture, the culture of
sedentary lifestyle and the affluence that our economy bestows us with. Food rich in
carbohydrates and fats and the inability to burn fewer calories than we consume has resulted
in a malady that, like the rest of the world, is making us burst at our seams. According to the
WHO 'overweight and obesity are defines as abnormal or excessive fat accumulation that
may impair health' (WHO, n.d.). An urgent call by the World Health Organisation to halt the
rate of spread of non-communicable diseases is also a call for us to check our weight
(Jackson, et al., 2014). The body mass index is an index that relates height to the weight of a
person. Therefore a person's BMI
= Weight (in kg) / Height in meters squared
A BMI of 27.3, for women and a BMI of 27.8, for men means that a person is overweight. A
BMI of 30 or more than 30 for men and women is enough for a person to be classified as
obese (Medicinenet, n.d.).
According to the World health organisation (WHO), the worldwide statistics of obesity are
alarming. Since 1975 the number of obese in the world has tripled. 1.9 billion adults were
overweight in 2016, of these 650 million were obese. 39% of adults in the world were
overweight in 2016 of which obesity was found in 13%. In most countries overweight and
obesity is responsible for more mortality than people who are underweight (WHO, n.d.)
Among the two genders there is greater deposition of subcutaneous fat among women. If the
BMI of a man and a woman is same, the woman will carry more fat. The android deposition
of fat (adipose deposition occurs in the abdominal area) is a risk factor for cardiovascular
disease and diabetes. The gynoid pattern of fat deposition occurs to a greater degree around

Factors that cause obesity 5
the hips and is a protective factor for diabetes and cardiovascular disease (Wiklund, et al.,
2008). Waist to hip ratio is also used to account for distribution of fat and in conjunction with
BMI, it is used s a measure of obesity.
It is estimated that in England, by 2025, 47% males and 36% females will be obese and the
projections for 2050 are 60% of the male population and 50% of females could become
obese. Only 10% males will have a healthy BMI in 2050 (a drop of 30% from now) and just
15% females will have a healthy BMI ( a drop of 25%) (Butland, et al., n.d.). These are
alarming figures and public health policy will have to be designed to arrest the rate of spread
of obesity in the population through prevention rather than treatment since the latter course
impacts the economy in a negative manner.
Though the problem of the rise in obesity is a public health issue, stakeholders in the areas of
healthcare, health insurance, policy making, food and beverage industry and economists are
worried because of the associated complexities of weight gain. Obese people are at a higher
risk of hypertension, diabetes and cardiovascular disease. (Banning, 2005). The risk of
cancer among the obese is 20% higher than among the healthy weight individuals (De
Pergola & Silvestris, 2013). In case cancer occurs, outcomes for obese individuals are usually
poorer (Wolin, et al., 2010). A meta analysis and systematic review found that a 5kg/m2
increase in the BMI among men raised the risk of oesophageal adenocarcinoma, thyroid,
renal and colon cancers. In women, a similar increase in BMI could cause gallbladder,
endometrial, and renal cancers. (Renehan, et al., 2008).
Health promoting lifestyle recommendations had the most public support at 71%, while food
labelling had the support of 66% respondents. At 32% there was minimum public support for
increased taxes on unhealthy foods. Greater effort at increasing awareness about the causes of
obesity could lead to higher support for public health policy (Beeken & Wardle, 2013).

Factors that cause obesity 6
In England, the 1996 figures for overweight men and women were 56% and 46% respectively
(Banning, 2005). Obesity poses different risks based on the location fat deposition for
different people. Fat distributed around the abdomen is termed central adiposity and makes
individuals more prone to hypertension and heart disease as compared to peripheral adiposity.
According to McKeigue et al waist circumference of ˃102cm in men and ˃88cm in women
is an indicator of obesity (McKeigue, et al., 1991).
Impact of obesity
Obesity and overweight related expenditure on treatment by NHS in 2014-2015 was £6.1
billion. (Gov.uk, n.d.). Every year Britain spends more on obesity and diabetes treatment
than the expenditure on services such as, police, fire services and the judicial system taken
together. Economic development is severely impacted by the expenses on obesity treatment
and related costs. The costs actually add up to a whopping £27 billion. And since the problem
of obesity is expected to grow the cost to NHS is projected to increase to £9.7 billion and
overall cost to £49.9 billion annually by the year 2050 (Gov.uk, n.d.). Impact of obesity on
the economy is enormous (Tremmel, et al., 2017).
This dissertation discusses the factors that cause adult obesity in England and the strategies of
treating the condition. The high prevalence of obesity in England as in other parts of the
world is a serious threat to public health. This thesis attempts to discuss the psychological
effects of obesity in adults and the interventions that can help to solve the problem of obesity.

Factors that cause obesity 7
Chapter 1
Factors of adult obesity in Britain
The aim of this chapter is to investigate through a literature search, the factors that are
responsible for obesity in England. Several factors appear to have increased the incidence of
obesity among adults in Britain. Lifestyle and sedentary behaviours account for most of the
cases. Energy dense food availability has increased. People prefer to eat outside rather than
cooking healthy homemade meals. Food rich in fats and sugar has become part of the food
landscape and this has caused waistlines to grow. Weight perception differs on the basis of
race and ethnicity. Some cultures may believe that being overweight or obese is a sign of
good health. There are ethnicities that do not perceive being overweight with the need to
make efforts to lose weight. Several cases of obesity can be explained on the basis of genes.
Many genes predispose people to obesity and cause hyperphagia or overeating leading to
obesity and diabetes. Individual behaviour that leads to faulty diet, sedentary lifestyle and
compromised sleep duration adds to the problem of obesity. Even though knowledge about
healthy diet, need to exercise and proper sleep is not scarce, people find it difficult to change
behaviours. An obesogenic environment where there are fewer green spaces, cycling is
difficult and energy dense food is easier to find the obese have a difficult time changing
lifestyles.
1.1 Food culture
The main factors like elsewhere in the world exist in England in a similar manner and include
behaviour, environment, genetics and culture. The food culture of most places including
England is such that if one chooses to eat outside the home it is difficult to find food that is
healthy. More and more people seek convenience and pleasure and seek to eat outside while
home cooked food has fewer takers. Most food available at take-aways, bakeries, sandwich
outlets, corner shops and fast food restaurants is laden with sugar, carbohydrates and fats.

Factors that cause obesity 8
Eating outside the home from once to several times a week has increasingly become a part of
food culture of Britain. 18% of the total meals were consumed outside the home in 2015 as
compared to 5% in 2014 (Gov.uk, n.d.). Every meal that is consumed away from home at a
restaurant is more likely to be richer in terms of calories and such consumption adds to the
cases of obesity.
Readily available and cheap meals outside the home have also increased their popularity and
such foods are also convenience foods and so a choice for people from all age-groups. The
number of take-away outlets, fast food outlets and fish and chips restaurants in England in
2014 was 50,000. The food served at all such outlets is rich in sugar, fats, saturated fats, salts
and low in micronutrients. 27% of the adult population eats at one such outlet at least once a
week (Gov.uk, n.d.).
Another factor that has caused the numbers of obese to grow is that people in Britain are not
burning the calories that are consumed. The impact of technology on homes and work places
is such that people are able to remain sedentary. Physical activity has fallen by 20% and is
expected to fall by 30% by the year 2030. Making the choice to include 150 minutes of
activity per week is now a necessary part of lifestyles.
The problem of availability of unhealthy food in outlets is prevalent to a greater extent in low
income areas. Reasons that affect the profitability of small food businesses include limited
variety in their menus so that healthy food is not available. Space and equipment resources
are lacking for cooking of healthier food. Fresh fruit and vegetables have a shorter shelf life,
so it is not seen as an economical option. Meals with lower salt may not go down well with
customers. Whereas, in reality, using less oil, serving smaller portions and using healthy
products might be more profitable for small food businesses.

Factors that cause obesity 9
2.2 Ethnicity and perception of overweight
Women are more likely to perceive themselves as overweight as compared to men. Women
of the white race are more sensitive to overweight perception as compared to their black and
Hispanic counterparts, though their perception may be correct or incorrect. The perception of
overweight and obesity among white men is more than what is seen among black men.
Higher socioeconomic status, higher levels of education, a higher BMI and being a white
woman increased the perception of being overweight. This increases the risk of obesity
among men because they consider themselves to be within normal range of weight whereas
they may be actually obese or overweight (Paeratakul, et al., 2002). Yet another study
compared weight perception in Italian women living in Britain, with the women in general
population and South Asians born in Britain or recent migrants. The connection of weight
perception with economic stability has been emphasized and since South Asian migrants
come from a society with low economic levels they tend to associate body sizes with larger
BMIs with health and reproduction. Their own dissatisfaction with weight does not translate
into efforts to lose the weight. Since the age group of study participants was between 20 and
42 years of age their ideas were expected to converge regarding thinness because it could led
to success at job and likely matrimony. South Asians born in Britain had negative attitudes
towards large body sizes like their counterparts from the general population. British born
Italian women had the most negative perception of large body sizes. The study fails to
pinpoint the cause of change in perception between the migrant and Britain born South Asian
women. Economic insecurity cannot be the only reason for the change in thinking (Bush, et
al., 2001).
Trends in obesity change according to ethnicity and race. Obesity among Pakistani men and
women in Britain and black African women are similar to that of the white population. While
obesity among Indians is expected to rise only slightly. In certain cultures obesity and

Factors that cause obesity 10
overweight is considered as being healthy Skinny but fit individuals are considered weak.
Proper education is important to help ethnic groups to differentiate between the medically fit
and the obese. Also, eating well is associated with overeating in some cultures. Consumption
of sweetened food and drink is also integral to some cultures, so it is important that
understand the link of such food with obesity.
In study on the dietary habits and eating behaviour on overweight or obese South Asian men
living in the UK, the participants were assessed on the basis of their dietary intake and the
factors that influence their eating behaviours. Their perception on type 2 diabetes were also
studied because the people from South Asia are more likely to suffer from diabetes. The age-
group of participants varied from 18 years to 65 years, they did not have diabetes and their
BMI were more than 23kg/m2. They were also asked to complete the UK diet and diabetes
questionnaire. From the UKDDQ scores the study inferred that 54% of the men consumed a
healthy diet but 69.8% of them had unhealthy levels of sugar in their diet in the form of
sweetened beverages. They experienced barriers to changing their diets due to frequent
attendance at family and religious get-togethers. They also lacked time and motivation.
Culturally, their diet tends to include more rice, ghee and Indian sweets that are high in
calories. In a high risk population for T2DM, the dietary behaviour adds to the problem
(Emadian, et al., 2017).
2.3 Genetics
So far, more than 60 genetic markers have been found to be the cause of obesity. Obesity
could be either monogenic obesity which a severe form of obesity that is characterised by
developmental delays in an individual or it could be syndrome obesity which could be
associated with some form of mental retardation that lead to dysmorphic features or
developmental delays; Prader-Willi syndrome is an example. A third form, the common
obesity affects people from the general population. About 20 types of single gene disruptions

Factors that cause obesity 11
have been identified that cause obesity due to autosomal genes (O'Rahilly, 2009). The
individual differences in obesity are due to the 32 common genetic variants for obesity. A
difference of 7 kg can be attributed to two people a high or low genetic risk of obesity. The
first to be associated with obesity was found in 2007, the FTO, fat mass and obesity
associated gene. It appears to have a role in energy balance and feeding behaviour. Many of
the genes or loci that are now known to be associated with obesity are expressed in the
central nervous system, the hypothalamus in particular and most have a role to play in
behaviour, appetite, satiety and energy expenditure. 6% of severe cases of obesity among
adults occur due to the MC4R (melanocortin 4 receptor) gene (O'Rahilly & Farooqi, 2008). It
is known to cause hyperphagia, hyperglycemia and hyperinsulinemia. BDNF (brain derived
neurotrophic factor)and neurexin 3, NRXN3 are genes responsible for substance use and
reward behaviour. Several genes and their possible roles in development of obesity in some
but not others have now been identified.
Other factors that show the impact of genetics on development of obesity are parental diet,
overall lifestyle, exposure to famine, obesity among parents, chemicals that cause hormone
disruption, smoking, weight gain during gestation and maternal gestational diabetes.
Epigenetic mechanisms during life stages from fetal stage impact the chances of developing
obesity. The effect of socioeconomic status and availability of food decide the course of a
person's life trajectory (Herrera & Lindgren, 2010).
2.4 Individual behaviours
Behaviour of an individual with regard to diet, physical exercise, sedentary behaviour and the
duration of sleep are additional factors that cause obesity.
2.4.1 Diet
Just as restriction of calories is a common and first ways to lose excessive weight, an
imbalance between intake and expenditure causes obesity. Mitigation efforts for obese people

Factors that cause obesity 12
therefore begin with reducing intake of food calories. Clinical management of weight
involves huge cut down on the number of calories consumed and helps in shedding weight.
The combination of macronutrients that make up the diet is a big factor in managing the
intake of reduced calories and producing desirable outcomes for the obese patients. By
remaining consistent with a diet and adhering to the prescribed diet for a prolonged period of
time substantial weight loss can be achieved by obese individuals (Hruby & Hu, 2015). Food
choices such as, potatoes, potato chips, sweetened beverages and intake of red meat cause
weight gain. While weight loss is associated with food choices such as, fruits, vegetables,
whole grains, seeds, nuts and probiotic foods like yoghurt (Mozaffarian, et al., 2011).
Behaviours of food consumption can be changed by changes in policy, additional tax on
sweetened beverages, limited advertisement of beverages and selling beverages in smaller
sized packages.
2.4.2 Physical activity, tendency of sedentary behaviour
The long duration of time spent watching television has increased sedentary behaviour. And
this has been identified as a cause for weight gain. Any deviation below the 150-250 minutes
of physical activity per week can cause increase in body weight. Leisure activities should be
chosen such that these do not increase the sedentary time, otherwise weight loss or weight
maintenance are difficult to achieve (Herrera & Lindgren, 2010). Active lifestyles and at
workplace and at home are important to control obesity (Shrestha, et al., 2016). More people
like to watch sports and sporting events, live or televised, than participating in an active sport.
Watching sports increases the sedentary behaviour and compromises on the active leisure
time.
2.4.3 Sleep
It has been reported that modern lifestyles are increasingly associated with sleep deprivation.
In a culture with long work schedules and leisure time stretching into the night time, the

Factors that cause obesity 13
hours of sleep have been severely curtailed. Sleep is required to maintain normal
neuroendocrine function and fewer hours of sleep affect the body in many ways. Glucose
metabolism, decreased glucose tolerance, decreased insulin sensitivity, increased
concentrations of cortisol in the evenings, higher levels of ghrelin, lower levels of leptin and
more hunger and higher appetite than normal are the outcomes of sleep deprivation (Beccuti
& Pannain, 2011) (Chamorro, et al., 2011). Together all these changes due to a disturbed
circadian rhythm can cause obesity. Sleep deprivation causes increase in hunger and an
increase in food intake that causes fatigue. Fatigue leads to a decrease in energy expenditure
and can cause weight gain (Zimberg, et al., 2012). Insufficient sleep hinders the recovery of
hormonal profile and causes obesity. Sleep is the only sedentary activity that is essential for
weight loss (Chaput, et al., 2010). The use of multimedia devices that include television,
internet and computer takes up the time denoted for sleep and less sleep leads to higher
BMIs. More sedentary time, higher intake of calories and long hours of commute add to the
problem obesity (Bayon, et al., 2014). Ina study in the UK, the maintenance of a sleep diary
revealed that those with a sleep debt were more likely to be obese than those with adequate
sleep patterns. 30 minutes of sleep deficit the risk for obesity increased by 18% (Arora, et al.,
2016). Education about sleep hygiene needs to be a mandatory part of counselling the obese.
2.5 Environment
Environmental factors shape the way energy intake and expenditure occurs. An obesogenic
environment is defined as the 'sum of the influences that the surroundings, opportunities or
conditions of life have on promoting obesity in individuals and populations' (Swinburn &
Egger, 2002). The social, cultural and infrastructural environment that affects and impacts a
person's choices of adopting a healthy lifestyle are described by the term 'obesogenic
environment'. The risk of obesity has increased among adults due to an environment that
promotes spending leisure time in inactive pursuits. Outdoor or active leisure is often not the

Factors that cause obesity 14
preferred choice for many. The current environment supports non-manual work, use of
several appliances t home, online shopping and thus the more technologically advanced we
are, the less is the need to stay active.
Even when outdoors, walking by a person for transport has decreased in England from 255
miles in 1975 to just 193 miles in the year 2003 annually. Cycled distances have dwindled
from 51miles per person to 34 miles between 195 and 2003. Car use in the same period has
grown by 10%. Even though people commute longer distances than before, under one mile
distances are being increasingly covered by car. People are largely employed in occupations
where physical or manual work is not required. The need for physical activity has increased
due to abundance of food that is cheap. Consumption of more calories has not been matched
with the level of physical exercise or movement to burn the calories consumed. Even
organisations shape beliefs and habits by giving incentives for commuting by car and by not
providing incentive for using bicycles. The food provision at office vending machines or food
outlets are also choices made by the organisation rather than an individual. The availability of
green spaces in the residential areas is an important factor in ensuring compliance with daily
exercise (Jones, et al., 2009). Just has technology has affected the way we travel, the
availability of gadgets and appliances has ensured that we move less and adopt a more
sedentary lifestyle.
The ease of availability of palatable food more frequently and encountering sight, smell and
availability of food can increase appetite and 'hedonic hunger' is felt, this disrupts the control
mechanisms that a person had in place.
2.6 Biology
Biology is a large factor that influences a person's health. Individual differences in
physiology decide whether a person is more likely to be obese or not. Some people have a
lean constitution and have a balance between food intake and calorie burn, Problem occurs

Factors that cause obesity 15
when individuals with a higher intake of food are unable to consume calories through
sufficient physical activity to match and they put on weight and become obese. Predisposition
to obesity was not very clear in the days of food scarcity. But in developed countries such as,
Britain, the atmosphere of food abundance requires a conscious effort to balance calories
consumed versus calories burned. The opportunity for physical activity during a long day of
work is very less. So it is recognised that most of the physical activity should be done while
performing daily chores (Butland, et al., n.d.).
It is therefore, not just individual choices but the environment also makes it difficult to
change lifestyles. With so many people putting on weight and finding it difficult to change
behaviours, this is the flip side of food abundance.

Factors that cause obesity 16
Chapter 2
Psychological effects of obesity
The aim of this chapter is to find the relation between obesity and its psychological effects
through a literature search. The impact of psychology on the relationship that the obese have
with food has been well researched. Obesity in the public arena has come to be associated
with laziness and the problems that the obese confront are poorly understood. The possibility
that obesity could be due to medical reasons is not understood by many and leads to ridicule
and discrimination against the obese. Behaviour change among the obese needs the
understanding of the discrimination and prejudice that confronts the obese. Psychological
counselling can help them cope with the negative attitudes against the obese and treat their
eating disorders, such as, emotional eating in stressful conditions. Cognitive behavioural
therapy has been used with some success when treating the obese. It changes the relationship
of a person with food. When migrant adopt a new country, they are torn between their own
culture and the culture of the new country. In their effort to cope with stressors of adjusting to
a culture, they may often make wrong food choices that can affect their health negatively.
Mood disorders among the obese can be treated with exercise. Better mood can facilitate
healthier lifestyle choices. Habits drive people to make certain choices when eating.
Counselling can help people break old ways of consuming food and develop the habit of
working out. Socioeconomic factors also affect the psychology related to food consumption.
While people from lower socioeconomic backgrounds tend to choose cheap food irrespective
of whether it is healthy or energy dense. An interesting experiment on behaviour change has
tied more physical activity with financial reward and the authors have reported interesting
findings. The likely financial benefit is not something that can cause the behaviour change
permanently but the participants can appreciate the improvement in their health parameters as
they move to lower BMIs.

Factors that cause obesity 17
Psychological well being of people with obesity is adversely affected and leads to a poorer
quality of life (Jackson, et al., 2015). Although one-fourth of the adult population in Britain is
overweight or obese, attitudes towards them is often prejudiced. The obese are more likely to
be stereotyped as sloppy, lazy and lax with regard to compliance and self-discipline and less
competent. They may receive unequal treatment and may be treated unjustly and suffer from
inequities in healthcare settings, employment opportunities and even when in educational
institutions, such as, schools and universities (Jackson, et al., 2015). An all pervasive bias
against the obese and the stigma against the obese makes them vulnerable to unjust attitudes
and a higher possibility of being treated in an unjust manner. Such conditions lower their
quality of life and lead to fewer opportunities due to the stigma attached with being obese
(Puhl & Heuer, 2009). The problem of discrimination and prejudice against the obese is often
compared to racism. Though there are studies that were unable to prove a link between
obesity and poor psychological well being on surveying women (Hill & Williams, 1998). The
main reason for obesity is the faulty intake of more calories than a person can burn. The
intake of three filling meals every single day could cause overeating which is believed to be
due to psychogenic factors, such as, stress, mental trauma or illness of a severe nature
(Banning, 2005). It is indeed a two-way problem where stress leads to overeating, nutritional
excess and obesity and the impact of obesity on health, social problems and issues related to
fewer opportunities at workplace or school/university causes stress and a lack of sense of
wellbeing.
2.1 Depression and obesity
Whether obese individuals also suffer from depression is a question that has not yielded
definite answers. According to some studies, obesity and depression appear to occur together.
There are cases where obese women score better than the non-obese on the indices of mental
health (Jorm, et al., 2003). But whether depression causes obesity or obesity causes an onset

Factors that cause obesity 18
of depression is not clear. There are sub-groups within the obese population that exhibit a
negative association with depression. Studies have also found that gender influences whether
an obese person will be depressed or not. There have even been findings that point towards a
negative association between the two conditions. It has been found in one study that
depression may cause ill health but the incidence of poor physical health is more likely to
cause obesity. The order in which poor physical health, depression and obesity occur is
difficult to decipher but there is little doubt about the fact that the three conditions are indeed
correlated (Keddie, 2011). There have been studies that have tried to find a correlation
between the severity of obesity and depression. It has been found that the more the severity of
obesity, higher is the likelihood of depression. Women are more likely to suffer from
depression due to severe obesity than men (Onyike, et al., 2003). Depression among the
severely obese has been attributed to higher BMI and several co-morbidities a person suffers
from (Dong, et al., 2004). Psychological distress has been found to be an outcome of
overweight perception among men and women rather than weight perception (Atlantis &
Ball, 2008). Different reason have been found to cause depression among the obese but it is
evident that even if all obese people are not depressed, there may be an association between
their physical condition and mental health. It has been speculated that stigmatization due to
obesity could spur a person to follow healthy behaviour and follow a diet and exercise
regimen leading to weight loss but Nolan and Eshleman have found that the distress caused
by stigma could actually promote overeating and that a person may become prone to binge
eating and develop disinterest in physical exercise (Nolan & Eshleman, 2016). And sadly for
the obese struggling to lose weight, it is not even politically incorrect to be discriminated
against.
A study has analysed the impact of psychological parameters of stress induced depression
and distress on dietary behaviour among adults with a BMI of 25 or more. 91 participants

Factors that cause obesity 19
were part of the study, but under-reporting of dietary intake was the major problem
confronted by the researchers. But their findings show that depression is indeed associated
with increased consumption of food and beverages than those without depression. Depression
can be attributed to higher consumption of energy dense food and beverages and higher
consumption of calories by overweight working professionals than those without any
depressive symptoms. The study was plagued by under-reporting of food intake and
inclusion of educated working professionals and hence should be repeated. The study
remained inconclusive on whether reduction in depressive symptoms reduces the intake of
high density food and thereby reduces a risk of cardiovascular disease (Grossniklaus, et al.,
2010).
2.2 Psychology of migrants
Among migrant adult populations in the United Kingdom, the prevalence of obesity occurs
due to change in diet as they cope with the stress of moving to a new country. In a study on
postpartum mothers, it was found that the lack of food security led to an intake of lower
quality of diet. While their consumption of vegetables was low, their tendency to consume
sugar sweetened beverages increased and this caused an increase in their BMI (Yang, et al.,
2018).
2.3 Eating disorders
Eating disorders such as bulimia nervosa and binge eating disorder can cause obesity. Low
self esteem among the obese leads to anxiety and depression. Their need to cut down on
calorie intake causes emotional disturbances. Weight gain may be an outcome of major
depressive disorder. The medicines that are used to treat symptoms of depression may also
cause increase in weight. Binge eating is an eating disorder which is the cause for obesity and
the underlying causes are emotional disturbances. Anorexia nervosa is usually seen in young
women and those conscious of body image. It is often more difficult to treat than bulimia

Factors that cause obesity 20
nervosa and the binge eating disorder (Williamson, et al., 2004). Binge eating is often a
precursor to weight gain that causes overweight and obesity. Dieting, dissatisfaction with
body, talking about weight and teasing about weight are social behaviours that need to be
addressed when treating eating disorders (Neumark-Sztainer, 2012). Unhealthy and
ineffective weight control behaviours practised in the youth can often be due to irregular
family meal time and difficulty in creating a positive atmosphere at family meal times
(Neumark-Sztainer, et al., 2004).
2.4 Discrimination
Discrimination of people based on overweight and obesity causes people to overeat. Often
overeating is known to be the coping mechanism when people are discriminated against on
the basis of sex, race or age and even physical disability. Stigma of being obese is also known
to cause increase in binge eating episodes and further deteriorate a person's condition. It is
becoming clear now that the stigma attached to being obese worsens health outcomes and
leads to behaviours that exacerbate the problem of weight gain rather than solving it. The
psychological stress response that the stigma triggers warrants the need to understand the
patient's standpoint and address treatment that factors in the patient's mental health (Puhl &
Suh, 2015). Psychologically maladjusted patients of obesity with known eating pathology
undergo physiological stress. Society rejects individuals with eating problems and there are
negative stereotyping leads to giving personal blame that increases the degree of weight
stigma that patients face (Puhl & Suh, 2015).These factors need to be addressed at the time of
treatment and behaviour change counselling of obese patients.
It has been part of public belief that teasing due to obesity or people joking about overweight
could trigger a need to lose weight among the obese, but the contrary is often true. The
stigma of being overweight causes them to get stressed and more mood related overeating
prevents the obese from losing weight.

Factors that cause obesity 21
2.5 Cognitive behavioral therapy
Cognitive behavioural therapy for treating obese patients who need a long time for recovery
and to avoid the pitfalls of weight regain, has proven to be a useful line of treatment.
Modification of behaviour that leads to a balanced food intake and maintaining the prescribed
physical activity as these are the key variables and modifiable changes that form the first line
of treatment (Castelnuovo, 2017) (Davin & Taylor, 2009). It is possible to help patients to
lose weight with cognitive behavioural therapy so that the patient is able to replace
dysfunctional behaviour with cognitive processes. The patient can then self monitor the food
intake, stick to prescribed portion sizes of food through better self control, adopt strategies
like thorough chewing of food, eating with mindfulness that helps with better sensory
satisfaction and makes the process of eating more pleasurable. Another aspect of treatment
involves prevention of a relapse and improving coping skills of patients when faced with
depression inducing circumstances (Castelnuovo, 2017) (Villa, et al., 2009).
2.6 Mood disorders
Mood disorders are commonly observed in obese individuals. It is difficult for them to
incorporate enough exercise in their schedules to bring about weight loss. But moderate
exercise is able to improve mood and this improvement in psychological factors may help in
controlling intake and led to weight loss. The mood enhancement may be particularly useful
in cases where emotional eating has caused weight gain. Development of self regulation due
to mood enhancement through exercise may help in developing generalised self efficacy for
weight management (Annesi, 2011).
2.7 Habits
Self-monitoring and positive self-talk can help in the mechanism required for behaviour
change. Setting goals for oneself has been found to increase physical activity (Saelens, et al.,
2000). Food behaviour is affected by psychological factors. Habits are repetitive behaviours,
so much so that they are almost done automatically. Habits are difficult to break and

Factors that cause obesity 22
changing habits is difficult due to the absence of motivation to do so. Beliefs are based on
social norms and may be associated with positive or negative association. Consumption of
fats may be a belief associated with ill health, but chocolate cake is associated with a positive
outcome.
An interesting aspect of behaviour related to food choices is that although people know the
healthy food choices they need to make, they continue to consume and enjoy unhealthy food.
For people to be able to value healthy food they need to exercise self-control when making
food choices (Petit, et al., 2016). Block et al have made an interesting statement about food
choices, ''No one sits down to eat a plate of nutrients. Rather, when we sit down for a meal,
we are seeking physical as well as emotional and psychological nourishment.'' (Block, et al.,
2011). But controlling weight is possible only when tremendous self-control is exercised. It is
important to find pleasure and taste in healthy food. Often, people with high BMI believe that
if a food is healthy it is unlikely that it will taste good. Such negative perceptions have to be
changed to be able to lose weight (Petit, et al., 2016). Many people trying to diet are drawn to
unhealthy food. This happens because the brain is able to process tastier food options before
the healthy options (Sullivan, et al., 2015).
Another study that is directed at changing habits related to physical exercise studied the effect
of providing opportunities to exercise at the work place. Growing obesity also leads to higher
absenteeism and decrease in productivity. If the intervention of physical exercise could be
offered at the workplace, it could provide a direct economic benefit to the employers and
physical and mental health benefits to the employees. 776 employees were recruited for this
randomised control trial and were either allocated to the intervention group or the control
group. Rewards, such as, retail vouchers were given to the participants of the intervention
group. Steps per day were recorded using a pedometer for a week. Movement was recorded
by employing sensors in the vicinity of the workplaces of the participants. Secondary

Factors that cause obesity 23
outcomes were also measured by studying the mental wellbeing, health parameters,
absenteeism and quality of life that changed as a result of the physical activity at the work
place. Cost-benefit to the employer was assessed. Retailers were roped in to analyse their
views on the sustainability of a loyalty card which would remain connected to public health
goals in return for the increased footfalls that they could expect as an offshoot of the
discounts offered on the cards. Although financial reward is not expected to motivate exercise
for long, it helps during the evaluation of the intervention. Goals of physical activity re also
more likely to be met in a formal setting than when a person is free to choose the location of
exercise. Change in health behaviour was connected in this case to business who sponsored
the participant benefit reward points (Hunter, et al., 2016). This RCT was well designed and
factored in business sponsored research. The outcome was measurable and therefore health
behaviour change could be quantified.
2.8 Socioeconomic status
Behaviour while purchasing food is affected by socioeconomic status. Shoppers with low
education are less likely to choose food that is expensive but rich in fibre, low in salt, sugar
and fat. The main deciding factor for choice of food purchases is determined by the cost. Low
income households are less likely to spend on certain food just because it is good for health
and meets the dietary recommendations (Turrell & Kavanagh, 2006). Inequalities in nutrition
knowledge affect the way people from low or high socioeconomic backgrounds make food
choices when purchasing food. The socio economically deprived are more likely to choose
cheap but high density calorie containing food and are less likely to engage in physical
activity in their leisure time as compared to the economically advantaged sections of the
society. This happens because it healthy food is expensive and unhealthy but energy dense
food is not only cheap but it is also easily available (Zhu, et al., 2015). The underlying stress
associated with poverty reduces the motivation to adopt a healthy lifestyle. Most studies on

Factors that cause obesity 24
the link between socioeconomic level and obesity choose to use only one marker to determine
socioeconomic level but Zhu et al have used three criteria to determine the socioeconomic
level - the education level, household income and occupational social class. Education reveals
the most consistent determinant for making healthier lifestyle choices. The messages in the
public space are understood better and people are more likely to adhere to advice about
nutrition and exercise. The availability of greater resources among the wealthy ensure that
they choose healthier food and have better access to physical fitness related activity. More
work in the area of correlation between diet and disease and public knowledge is required so
that people with lower household incomes can make healthier food choices (McKinnon, et
al., 2014).

Factors that cause obesity 25
Chapter-3
Interventions
The aim of this chapter is to carry out a literature search on the interventions that can be made
to treat obesity. Once the problems associated with obesity are understood, the need for
urgency in action in the public health sector, healthcare sector and policy making becomes
clear, it becomes easier to throw light on the possible interventions that can either prevent
obesity or help treat the malady. The psychology associated with development of obesity and
the psychology of obese people who are being treated or seeking treatment are important
aspects of the problem. Due to the risk of co-morbidities associated with obesity, weight loss
treatment of the obese is priority. Lifestyle modifications that involve diet and exercise are
effective in losing weight, maintenance of weight loss and even prevention of obesity.
Psychotherapy has to be given to the obese patients because often eating disorders and
bulimia nervous are associated with being obese. Depression leads to eating and the obese
suffer from distress, at times due to co-morbidities. Screening of overweight patients helps to
determine the actual number of obese people. The cause of obesity can then be diagnosed and
appropriate treatment can be given to the patient. eHealth or surveillance or intervention
through the use of smart phone, internet or wearable devices can help in giving reminders to
patients about diet, exercise, medication and other information. It is a good means of keeping
in touch with the patient, since treatment may continue for months. Pharmacotherapy is often
chosen for treatment of obesity when the patient has BMI more than 30 or 35 kg/m2.
Sibutramine and Orlistat are two examples of the many drugs that have been used to treat

Factors that cause obesity 26
obesity. The side effects associated with drugs that cause weight loss often call for long
clinical trials that may result in withdrawal of the drug. Bariatric surgeries of various types
are available. Depending on the patient's requirement, a surgery may help to treat an obese
person.
With a quarter of the population in the UK being obese, it is now the second largest health
issue to be tackled by public health professionals, next only to smoking. Medical intervention
for treating obesity is the way forward with many co-morbidities that afflict obese patients.
Targeting weight loss alone is not the solution but a comprehensive management of
hypertension, reduces glucose tolerance and overall physical fitness and mental well being
are important. Primary care along with specialist care including surgery may be required with
a change in the obesogenic environments where patients live. Availability of gyms, parks,
access to weight loss groups and cooking classes are part of the larger plan required for
sustained weight loss. Most of the obese lead sedentary lives and a radical change in
behaviour may require counselling and psychotherapy. Treatment plan needs to target the
possibility of weight gain soon after weight is lost. A coherent national policy is required to
treat the menace of growing waist lines. Restoration of a healthy BMI is not the goal but
adoption of a healthy lifestyle needs to be stressed (Barth & O'Kane, 2016). The healthcare
staff at NHS is under mounting work pressure and it would be a good option to train nurses
and motivate them to advise patients of obesity to adopt lifestyle changes so that they can
lose weight and improve health parameters (Drummond, 2002).
3.1 Lifestyle modifications
Left untreated, obesity can cause a host of morbidities, such as, cardiovascular disease,
diabetes, hypertension, arthritis and others. Losing weight is obviously the best way to
prevent conditions that have obesity as the root cause. Lifestyle changes through a modified
diet and physical activity are the best option for those wanting to fight the bulge. Not only do

Factors that cause obesity 27
patients lose weight, they can also reduce the risk of developing co-morbidities, such as,
diabetes. In a study participants were placed in three groups and given a placebo, metformin
and counselling sessions for change in lifestyle, the group that made lifestyle changes by
taking a reduced calorie but conventional diet and 150 minutes of physical activity per week.
The group that modified lifestyle, lost the maximum weight at an average of 5.6Kg as
opposed to a loss of 0.1Kg by the metformin group and 2.1 Kg by the placebo group after 2.8
years (Wadden, et al., 2012). The benefit remains even if weight is regained once the
behaviour therapy is discontinued. So, benefits of losing weight through lifestyle
modifications have a lasting impact on the health of the obese.
Another study studied the effect of weight reduction interventions through diet and exercise
programs among diabetes patients. The group with interventions received individual
counselling for reducing calorie intake and physical exercise and was compared with patients
who followed a diabetes education program. More than 5000 participants in the age group of
45-74, who were diabetics and had a BMI of 27 or more were included in the study. Not only
did people in the interventional group lose more weight, they had to take lesser medicines for
diabetes, hypertension and dyslipidemia (Group, 2007). Lifestyle interventions and changes
are usually the first choice for weight loss and treatment of obesity.
3.1.1 Social media and mass media campaigns for public awareness
Media campaigns have focussed on reduction of fat intake and increasing exercise.
Newspaper articles largely report on obesity among children, men and then women, in that
order (Hill & Williams, 1998). There is an increase in media content on the importance of
increasing the consumption of fruits and vegetables and low fat milk. The changes in
government policy on changing food labels to include more information about nutritional
components on packaged food have occurred due to such campaigns. Slowly but steadily the
health behaviour of people is undergoing a change and nutrition labels are being read in

Factors that cause obesity 28
restaurants, food packages and even vending machines. Physical activity behaviours have
also undergone a big change. People prefer using staircases, there are walking campaigns that
urge people to walk. The main competition that such campaigns receive comes from
marketing and advertisement of energy dense food and packaged food. Once the campaign
ends the messages do not sustain the test of time. recommendations of healthy food and
appropriate exercise also change over time when new findings are made (Wakefield, et al.,
2010). The reach of mass media is large and the ability to repeat the message several times at
low cost makes it a good choice (Hilton, et al., 2012). But on the flip side the impact may not
occur consistently and may fall short of expectations (Wakefield, et al., 2010).
3.2 Psychotherapy
When obesity is an outcome of eating disorders, treatment often includes a behavioural
therapy to effect a change in the eating behaviour. Binge eating, bulimia nervosa and
anorexia nervosa can be treated using cognitive behaviour therapy. Binge eating disorders
include uncontrolled eating, emotional eating and loss-of-control eating and commonly occur
as a consequence of weight stigma internalization and severe psychological distress. Such
patients are counselled to promote psychological acceptance of their condition and to practice
mindfulness when eating (O'Brien, et al., 2016). A combination of pharmacotherapy and
psychotherapy has been found to be effective in the treatment of obesity when the underlying
cause is an eating disorder (Williamson, et al., 2004). Antidepressant medication has been
used with success in treating binge eating followed by purging. Selective serotonin uptake
inhibitors that include fluoxetine hydrochloride are known to reduce the frequency of obesity
causing eating behaviour (Mitchell, et al., 2003). The drugs have been found to be specially
effective in controlling a relapse in patients who have lost weight, because regaining of
weight by patients of obesity is also a serious problem. There is however evidence that
pharmacotherapy in conjunction with psychotherapy is more likely to produce lasting effect

Factors that cause obesity 29
in obese patients who suffer from depression (Mitchell, et al., 2003). Other drugs that have
been used to treat obesity are diethylpropion, Qsymia, phendimetrazine, topiramate, Qnexa,
Iorcaserin, and Belviq (Yanovski & Yanovski, 2014).
The restructuring of the NHS in 2012 was accompanied by new policy guidelines for the
treatment of obesity that includes weight management at the community level and bariatric
surgery for the obese with complex health problems (Capehorn, et al., 2016).
3.3 Screening
Management of obesity according to Kushner and Ryan requires that all adults be screened
for overweight and obesity. A systematic approach should include a medical history that has
detailed information about the determinants that include diet and physical activity,
psychosocial background, and family traits regarding obesity. A 5-10% weight loss should be
set s the goal for the patient if the patient's BMI exceeds 30 (Kushner & Ryan, 2014). A
health benefit can be achieved by such weight loss even if the BMI of the patient is higher
than 25.
3.4 Monitoring through health tech
Advances in the area of health technology have meant that monitoring of lifestyle is now
possible through the use of smart phones. Interventions can be sent to patients through
videos, text messages and 24x7 monitoring of physical activity is possible. Smart phones
have been used in studies where pedometers and text messages have been used to remind
patients about nutritional guidelines and to monitor changes in behaviour related to physical
activity. A study found that the use of smartphone communication actually helped people to
lose weight (Woo, et al., 2013). It will be interesting to see the impact on the treatment of
obesity as newer apps are developed and health professionals are able to track whether
patients are following the diet and exercise guidelines through health technology. It is now
becoming clear that a multidisciplinary approach to weight loss that involves treatment

Factors that cause obesity 30
through nutrition, physiotherapy, psychiatric treatment, psychology and endocrinological
parameters of the patients. Treatment is usually long drawn and may be improved through the
mHealth approach. Communication with the patient through mobile devices for delivery of
some health services could bring positive outcomes for the patient (Castelnuovo, et al., 2014).
3.5 Pharmacotherapy
When lifestyle modification is not effective for sufficient weight loss drug therapy for
treatment of obesity may be given to the patient. But patients receiving drug therapy for
weight loss must have a BMI of more than 30. The therapy includes a prescribed diet,
physical exercise and behaviour modification. Sibutramine and orlistat are the drugs that are
used for therapy in obese patients. Sibutramine reduces gastrointestinal motility and improves
satiety, which helps in reducing fat, lowering of the BMI and about 5-10% of weight. Orlistat
prevents the absorption of fat in the small intestines and 30% of the fat that could have been
absorbed is excreted. Characteristic 'fatty stools', higher frequency of elimination and urgency
with oil spotting re often experienced by patients being treated with Orlistat (Garrow, 1998).
The side effects discourage the patient from consumption of fat. But Orlistat is of little
relevance to patients whose fat consumption is already low (Bray & Greenway, 2007). But
the drug can be prescribed to the obese with a BMI of more than 30 or those with a lower
BMI of 28 but suffering from co-morbidities of obesity. In a study that compared the effects
of the two drugs on a small sample of patients, both drugs were found to cause weight loss
but Orlistat improved the lipid profile of the participants of the study (Anagnostis, et al.,
2012). There is a possibility of increase in hypertension upon administration of Sibutramine
which has led to its withdrawal from the market (Tziomalos, et al., 2009). The problem with
drugs being currently used as monotherapy for weight loss is that the degree of reduction in
weight achieved after prolonged intake of medication is less than the 12% loss required for
patients to be protected from the onset of diabetes. Because losing weight is not the only goal

Factors that cause obesity 31
and prevention co-morbidities like diabetes and hypertension is also the goal of the
physicians treating obese or overweight patients (Bray & Greenway, 2007). But drug
mediated weight loss has more benefits than cosmetic weight loss as in case of liposuction
where the patient's health is not affected by the positive outcome.
3.6 Bariatric surgery
Bariatric surgery is often the choice of treatment when patient has a high BMI. Such obese
patients who have already tried the conventional routes for weight loss and have not
succeeded in losing sufficient weight are candidates for bariatric surgery. After having tried
to lose weight through diet, exercise, medication, if the patient still has a high BMI and
unresolved obesity-linked co-morbidities like diabetes, heart disease, sleep apnoea,
hypertension and others, then the patient qualifies for bariatric surgery. The BMI of such
patients is usually 35 kg/m2 or above (Karmali, et al., 2010).
The clinicians can usually choose between three types of bariatric surgeries for the patient.
The categoriztion based on function is restrictive, combined or malabsorptive surgery. The
laproscopic adjustable gastric banding surgery is a restrictive procedure. It involves the
insertion of a silicone gastric band in the upper region of the stomach that creates gastric
pouch of 30 mL volume. The pouch can be injected with a saline solution through a
subcutaneous port that promotes the feeling of satiety early during feeding. Moderate weight
loss can be expected from such a surgery. Vertical banded gastroplasty involves the method
of stapling the stomach from the front to back, just below the gastro-oesophageal opening and
it maintains the physiological continuity of the gut (Field, et al., 1992). The outlet stoma is
reduced with the help a polypropylene band that is 1 cm in diameter. The band reduces the
intake of food and causes early satiety. The rate of complications in this type of surgery is
quite high and is not routinely done on obese patients (Karmali, et al., 2010).

Factors that cause obesity 32
Laproscopic sleeve gastrectomy is a surgical procedure that involves the creation of a sleeve
shaped pouch that extends from the oesophagus to the duodenum and the size of the pouch
varies between 60 to 120 mL in different patients. 80% of the remnant stomach is removed.
This reduces the secretion of the hormone ghrelin that is responsible for inducing appetite.
This lessens hunger and reduction in intake occurs leading to weight loss and resolution of
co-morbidities (Lager, et al., 2017).
Combined restrictive and malabsorptive procedures include the Roux-en-Y gastric bypass
(RYGB) surgery and the Biliopancreatric diversion with or without duodenal switch. The
RYGB surgery is performed by constructing a small gastric pouch that is proximal in
position. The surgical procedure involves stapling and diving the stomach cavity. The pouch
that is created empties in a part of the jejunum that is brought up in proximity of the gastric
pouch in the form of a Roux-en-Y limb. The procedure is a restrictive type of surgery but it
causes malabsorption because the bypass involves parts of the stomach, duodenum and
jejunum (Karmali, et al., 2010). Outcomes are better than LAGB surgery (Nguyen, et al.,
2013).
The bilio-pancreatic diversion with or without a duodenal switch involves removal of a part
of the stomach and changes the path of the small intestine. The possibility of complications in
this procedure is high and could include malabsorption, vitamin and mineral deficiencies,
osteoporosis, anemia and ulceration. Risk of protein malnutrition is also rather high (Colquitt,
et al., 2005). A study reported 80% weight loss and reversal of diabetes (Hess & Hess, 1998).
The jejunoileal bypass is a mal-absorptive procedure of bariatric surgery. In mal-absorptive
procedures the absorption of nutrients is decreased by reducing the length of the ileum that
actually performs the function of nutrient absorption through the microvilli. The procedures
are highly effective in causing weight loss but the risk of complications remains high. The

Factors that cause obesity 33
jejunoileal bypass surgery involves reducing the length of the small intestine by attaching the
proximal portion with the distal portion of the intestine and retains only 0.35 meter length of
the absorptive intestine. Severe malnutrition occurs due the malabsorption of macronutrients
and micronutrients. Complications can include liver, kidney failure resulting in mortality
(Singh, 2009). Since long term outcomes are poor this surgery is usually not recommended to
obese patients (Karmali, et al., 2010).
The benefits of bariatric surgery are experienced by the moderately obese and morbidly obese
patients. Cardiovascular morbidity and mortality is substantially reduced in obese patients
who undergo gastric bypass surgeries. The laproscopically performed Roux-en-Y gastric
bypass has been seen to be more effective than the laproscopic adjustable gastric banding.
Higher weight loss and better resolution of co-morbidities is often seen in patients who
undergo RYGB surgeries. Rates of mortality due to surgery are low and there are fewer
complications due to RYGB than with LAGB (Athyros, et al., 2011). Different patients may
have different surgical requirements and the type of surgery is chosen on the basis of the
patient assessment.
There are several kinds of interventions for tackling obesity. But depending on the patient's
needs an appropriate option has to be chosen. From simple lifestyle modifications to complex
and expensive bariatric surgery, several options are available. Health professionals choose
one or more of the interventions described above to treat the patient.
Conclusion
It is evident that the scale of the problem of obesity is massive. People all over the world
including England are falling ill and mortality due to obesity is on the rise. Several causes of
obesity are understood, improper lifestyle, unhealthy behaviour, genetics, obesogenic
environment, biology, consumption of energy dense food and a sedentary lifestyle due to
advances in technology have put many at risk of obesity and associated co-morbidities

Factors that cause obesity 34
including diabetes, cardiovascular disease and arthritis threaten the well being of the obese.
Several underlying psychological reasons are believed to cause obesity. Depression among
the obese is one the major causes that prevents the obese from eating healthy and physical
exercise. Eating disorders, such as, binge eating, emotional eating, anorexia nervosa and
bulimia nervosa stem from mental health problems. Stigmatisation due to obesity and
discrimination and even social isolation are issues that exacerbate the problems of the obese.
Unable to participate in many activities, with little control over their health, they continue to
fall into the abyss of co-morbidities and become dependent for life on drugs to control their
blood sugar levels or lower their blood lipids. The inability to control diet and indulge in
physical exercise makes them the butt of jokes in their workplace, institution or among peers.
This further reduces their sense of well being. But obesity is now recognised as a medical
problem, several medical and public health interventions are being made to treat the obese
depending on their pathology. Cognitive behaviour therapy is important in treating associated
mental health problems that may have led to obesity or are an outcome of obesity. Bariatic
surgery and pharmacotherapy are expensive and have not led to much success.
The economic burden of obesity on the NHS and national economy is huge. Prevention, then,
appears to be a better choice, at least in cases where lifestyle modification can be practised to
reach the goal of healthy weight. Public campaigns that emphasize the facilitation of public
amenities for a physically active lifestyle, and a policy framework that discourages
advertisement, marketing and sale of food portioned into large sized servings is the way
forward. Constant reminders through mass and social media about adoption of a healthy and
active lifestyle are required. Gradually, it will help in changing the behaviour and relationship
with food. Emphasis on home cooked meals that make use of ingredients that are home
grown can change the food environment. The obesogenic environment that we live in must
change to an environment where we can handle abundance with a heightened sense of control

Factors that cause obesity 35
and mindful consumption of food. Obesity is not impossible to control given the right
environment and education about the conditions that lead to change. Food policy and health
policy framework needs to be in mutual agreement.

Factors that cause obesity 36
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