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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
In a world where obesity has now reached epidemic proportions, a thorough understanding of the underlying causes of the problem is essential if society, public health initiatives and government policies are to successfully address the issue. The obesogenic environment describes all the possible influences that our environment presents which encourage overweight and obesity in individuals and populations. Beginning with an overarching introduction to obesity and its implications for health and wellbeing, the book will move on to consider such crucial areas as eating behaviours and food environments, physical activity and the environment, the urban environment, methods, policy and future research directions. * Brings together expertise from across a range of disciplines * Written by a truly multidisciplinary team of international authors * Presents some of the most innovative thinking in the battle against obesity This groundbreaking book brings together for the first time the knowledge of experts with backgrounds in nutrition and dietetics, policy, epidemiology, environmental sciences, medical sciences, town planning and urban design, transport, geography and physical activity in order to offer a multidisciplinary approach to public health, suggesting new and exciting ways to shape our environment to better support healthful decisions.
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Seitenzahl: 512
Veröffentlichungsjahr: 2011
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Contents
Title
Copyright
Contributors
About The Editors
Dedication
Acknowledgements
1 An International Perspective on Obesity and Obesogenic Environments
1.1 Introduction: the emergence of obesity
1.2 The magnitude of the problem
1.3 The basis for the current underestimated burden of obesity
1.4 Individual susceptibility to weight gain and the persistence of obesity
1.5 The environmental basis for the obesity epidemic
References
2 Towards Transdisciplinary Approaches to Tackle Obesity
2.1 The focus on interdisciplinary research
2.2 Defining modes of interdisciplinarity
2.3 The complexity of obesity
2.4 The challenge of interdisciplinary understanding
2.5 Interdisciplinary policy and practice
2.6 Discussion
References
3 Walkability, Neighbourhood Design and Obesity
3.1 Introduction
3.2 What is walkability?
3.3 Measuring walkability
3.4 Linking neighbourhood design aspects of walkability to obesity
3.5 Breaking down walkability
3.6 Urban sprawl, geographic location and obesity
3.7 Other design features and obesity
3.8 Neighbourhood design as a moderator
3.9 Summary of findings and future directions in research on the impact of neighbourhood design and/ or walkability and obesity?
3.10 Summary
References
4 Availability and Accessibility in Physical Activity Environments
4.1 Introduction
4.2 The concept of availability and accessibility
4.3 Perceived and objective measures of the physical activity environment
4.4 Comparing perceived and objective measures
4.5 Relationships with utilisation
4.6 Equity of access and facility provision
4.7 Conclusions
References
5 Defining and Mapping Obesogenic Environments for Children
5.1 Children’s obesogenic environments
5.2 Advantages of mapping obesogenic environments in children
5.3 How to map obesogenic environments - data representation
5.4 Problems with spatial data
5.5 Spatial analysis techniques
5.6 Conclusion
5.7 Acknowledgements
References
6 Objective Measurement of Children’s Physical Activity in the Environment: UK Perspective
6.1 UK policy and research context
6.2 A brief review of current studies in the United Kingdom
6.3 Objective measurement in physical activity research
6.4 Conclusion
References
7 Physical Activity and Environments Which Promote Active Living in Youth (US)
7.1 Introduction
7.2 Case examples
7.3 School and child care
7.4 Community settings (home/neighbourhood)
7.5 Conclusions and future research
References
8 Active Travel
8.1 The potential for active travel
8.2 Trends in active travel
8.3 Barriers to active travel
8.4 Overcoming the barriers to active travel
8.5 Policies and measures to increase the volume of active travel
8.6 The effectiveness of policies and measures to increase the volume of active travel
8.7 Conclusions
References
9 Greenspace, Obesity and Health: Evidence and Issues
9.1 Introduction
9.2 Greenspace, health and obesity
9.3 Greenspace, obesity and food
9.4 Greenspace and physical activity
9.5 Greenspace and children’s health
9.6 Greenspace provision and policy
9.7 Conclusions
References
10 Eating Behaviours and the Food Environment
10.1 Introduction
10.2 Which eating behaviours influence obesity risk?
10.4 Adults
10.5 Children and adolescents
10.6 Summary of evidence
10.7 How should we interpret existing evidence?
10.8 Defining the neighbourhood environment
10.9 Conclusions and future research directions
References
11 Food Policy and Food Governance - Changing Behaviours
11.1 Introduction
12 Neighbourhood Histories and Health: Social Deprivation and Food Retailing in Christchurch, New Zealand, 1966–2005
12.1 Introduction
12.2 Results
12.3 Discussion
12.4 Conclusion
12.5 Acknowledgement
References
13 Environmental Correlates of Nutrition and Physical Activity: Moving Beyond the Promise
13.1 Introduction
13.2 Environmental correlates of physical activity and diet: underlying reasons for promising findings
13.3 Environmental correlates of physical activity
13.4 Environmental correlates of diet
13.6 Concluding remark
References
14 Obesogenic Environments: Challenges and Opportunities
14.1 Introduction
14.2 Complexities
14.3 Perceptions
14.4 Objective measures
14.5 Future directions
References
Index
This edition first published 2010
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Library of Congress Cataloging-in-Publication Data
Obesogenic environments: complexities, perceptions, and objective measures/edited by Amelia A. Lake, Tim G. Townshend, Seraphim Alvanides.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-8263-8 (pbk.: alk. paper) 1. Obesity - Epidemiology. 2. Obesity - Prevention.
I. Lake, Amelia A. II. Townshend, Tim G. III. Alvanides, Seraphim. [DNLM: 1. Obesity - epidemiology. 2. Diet. 3. Environment. 4. Feeding Behavior - psychology. 5. Health Promotion - methods. 6. Obesity - etiology. WD 210 O129 2010]
RC628.O333 2010
614.5′9398 - dc22
2010001847
Editors
Lake, Amelia A.
Senior Lecturer in Food and Nutrition, Applied Biosciences, School of Applied Sciences, Northumbria University, UK.
Dr Amelia A. Lake trained as a dietitian and worked in the NHS before taking up a research post with Newcastle University where she completed a Ph.D. and held a National Institute for Health Research Postdoctoral Fellowship on the theme of Obesogenic Environments. Amelia is currently a Senior Lecturer in Food and Nutrition at Northumbria University and her research interests include the obesogenic environment, food environments and food choice.
Townshend, Tim G.
Director of Planning and Urban Design and Senior Lecturer in Urban Design, School of Architecture, Planning and Landscape, Newcastle University, UK. Tim Townshend is a Senior Lecturer, Director of Planning and Urban Design and a member of the Global Urban Research Unit (GURU) at the School of Architecture, Planning and Landscape, Newcastle University. He was recruited to academia from practice in 1993 and since then he has developed a national and international profile in a wide range of areas in urban design research, most recently exploring the links between urban form and obesity.
Alvanides, Seraphim
Social Geographer, School of Geography, Politics & Sociology, Newcastle University, UK.
Dr Seraphim Alvanides is an academic geographer with postgraduate studies in computational geography and consultancy experience in geographical project management. His current research is concerned with the evaluation of obesogenic environments and environmental supportiveness for physical activity within an environmental justice framework.
Contributing authors
Ball, Kylie
Associate Professor, Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia.
Brown, Caroline
Research Associate, School of the Built Environment, Heriot-Watt University, Edinburgh, UK.
Brug, Johnannes
Director of the EMGO Institute for Health and Care Research, Chair of Division VI and the Department of Epidemiology & Biostatistics, and Professor of Epidemiology at the VU University Medical Center, Amsterdam, the Netherlands.
Cooper, Ashley
Reader in Exercise and Health Science, Department of Exercise, Nutrition and Health Science, Bristol University, UK.
Crawford, David
Alfred Deakin Professor and Director of the Centre for Physical Activity and Nutrition Research, Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia.
Day, Peter
Researcher and GIS Analyst, GeoHealth Laboratory, Department of Geography, University of Canterbury, New Zealand.
Edwards, Kimberley L.
Lecturer in Epidemiology, Division of Epidemiology, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, UK.
Ells, Louisa
Obesity and Physical Activity Lead, North East Public Health Observatory, Wolfson Research Institute, University of Durham, Queen’s Campus University Boulevard, Stockton on Tees, UK.
Giles-Corti, Billie
Winthrop Professor and Director, Centre for the Built Environment and Health, School of Population Health, The University of Western Australia, Crawley, Western Australia.
Grow, H. Mollie Greves
Assistant Professor of Paediatrics, Seattle Children’s Hospital Research Institute and the University of Washington, USA.
Jackson-Leach, Rachel
Senior Policy Officer, International Association for the Study of Obesity, London, UK.
James, W. Phillip T.
President of the International Association for the Study of Obesity, Hon Prof. London School of Hygiene and Tropical Medicine, London, UK.
Jones, Andy
Reader, Centre for Diet and Activity Research (CEDAR), School of Environmental Sciences, University of East Anglia, Norwich, UK.
Mackett, Roger L.
Professor of Transport Studies, Centre for Transport Studies, University College London, UK.
Midgley, Jane L.
Lecturer in Planning, School of Architecture, Planning and Landscape, Newcastle University, UK.
Page, Angie
Senior Lecturer, Department of Exercise, Nutrition and Health Science, Bristol University, UK.
Panter, Jenna
Research Associate, Centre for Diet and Activity Research (CEDAR), School of Environmental Sciences, University of East Anglia, Norwich, UK.
Pearce, Jamie
Reader in Human Geography, Institute of Geography, School of GeoSciences, University of Edinburgh, Edinburgh, UK.
Rigby, Neville
Former Director of Policy and Public Affairs International Obesity TaskForce, London, UK.
Robertson-Wilson, Jennifer
Assistant Professor, Department of Kinesiology and Physical Education, Wilfrid Laurier University, Ontario, Canada.
Saelens, Brian E.
Associate Professor of Pediatrics and Psychiatry & Behavioral Sciences, Seattle Children’s Hospital Research Institute and the University of Washington, USA.
Salmon, Jo
Associate Professor, Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia.
Timperio, Anna
Senior Lecturer, Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia.
Van Lenthe, Frank J.
Assistant Professor, Social Epidemiology, Department of Public Health, Erasmus Medical Centre Rotterdam, the Netherlands.
About the Editors
Dr Amelia A. Lake is a dietitian and public health nutritionist and works as a Senior Lecturer in Food and Nutrition at Northumbria University. Amelia’s current work is to explore the obesogenic environment. She has particular interest in the food environment, the environments of young people and the workplace environment. Her research involves transdisciplinary collaborations to examine how the environment interacts with individual’s behaviours. Amelia received her first degree from Glasgow Caledonian University and worked in the Health Service before taking up a research post with Newcastle University, where she completed a Ph.D. Amelia is a committee member of the Association for the Study of Obesity, a council member for the Nutrition Society and also member of the British Dietetic Association. Along with Tim Townshend, Amelia is a co-founder of the North East Obesogenic Environment Network (NEOeN; www.neoen.org.uk). Amelia is currently a Beacon for Public Engagement Fellow (www.ncl.ac.uk/beacon) apart-from being a regular contributor to her profession’s publications. Amelia has extensive experience of working with non-specialist audiences as well as academics and has produced various training programmes and related material.
Tim G. Townshend is Senior Lecturer in urban design and a member of the Global Urban Research Unit (GURU) at Newcastle University; he has been Director of Planning and Urban Design since August 2008. Tim was recruited to academia from practice in 1993; since then he has developed a national/international profile in urban design research. He has published on a range of topics addressing the impact of the design of the built environment in relation to contemporary social concerns - in particular, fear of crime, sustainable neighbourhoods and, most recently, obesity. Tim is further interested in issues of transdiciplinarity and the role of transdisciplinary working in tackling complex issues. He has exemplary links into practice. His work attempts to maximise its impact and as such is always policy relevant. He has been a consultee on a series of planning policy documents and sits on a number of external committees and panels. Along with Amelia Lake, Tim is a co-founding member of the North East Obesogenic Environment Network (NEOeN) www.neoen.org.uk.
Dr Seraphim Alvanides is a social geographer with the Research Cluster Society, Space and Practice in Geography at Newcastle University. Seraphim has extensive experience of geographical information technologies from his engagement with practice and academic research. His current research interests involve the measurement and evaluation of obesogenic environments, focusing on physical activity within an environmental justice framework. Following his undergraduate studies, Seraphim was employed as a geographical project manager and consultant in the private sector. Subsequently, he returned to academia to complete an MA (with distinction) in Geographical Information Systems and a Ph.D. in Human Geography (University of Leeds, UK). He has since published on methodological aspects of geographical information science and its application in understanding the obesogenic environment. Seraphim is a Fellow of the Royal Geographical Society (with IBG) and a committee member of Geography of Health Research Group. He is committed to public engagement and outreach through consultancy projects with local authorities and voluntary organisations, as well as delivery of training programmes and events.
This book is dedicated to transdisciplinary working and international co-operation.
Acknowledgements
The editors would like to acknowledge the contribution of the chapter authors in developing this transdisciplinary volume. The international experts who have contributed to this volume are representative of a broad range of disciplines and illustrate the range of disciplines required to tackle the global issue of overweight and obesity.
In addition, the editors would like to acknowledge Carolyn Fahey who designed the front cover, the UK Government’s Foresight Programme (Foresight Government Office for Science, Department of Innovation Universities and Skills, Crown Copyright URN 07/1179) for permission to use the Foresight Obesity Systems Map in Chapter 2 of this book and the World Health Organisation for permission to use Table 7 from p. 63 of the WHO 916 Report in Chapter 1 of this book. Every attempt has been made to contact copyright holders of materials used in this book.
1
An International Perspective on Obesity and Obesogenic Environments
W. Philip T. James, Rachel Jackson-Leach and Neville Rigby
1.1 Introduction: the emergence of obesity
The obesity epidemic started becoming a serious public health issue in most western societies only in the early 1980s.1 The problem emerged later in lower income countries as they went through the extraordinary economic and societal changes accompanying what is known as the ‘nutritional transition’. Nevertheless, in countries emerging from extreme circumstances, for example, in post-war Germany or in the richer classes of poor countries, for example, Brazil, women characteristically put on weight first; then the business man’s ‘paunch’ became an index of success. The same persists in African countries where prevailing malnutrition is accentuated by the new fear of ‘slim disease’ - a consequence of HIV infection. Recent studies2,3 show that in affluent societies obesity emerged in children in the early 1980s and since then has become an intense societal concern because no longer could one ignore the fact that environmental pressures must be a major factor in determining this extraordinary development.
Obesity was first highlighted as a major global concern by World Health Organisation (WHO) in 1997, preliminary work having been undertaken by the newly formed International Obesity Task Force (IOTF). In its report the full range of complications from excess weight gain were set out.4 The WHO acceptance of ‘normal’ weights for a population was based on the body mass index (BMI) method for relating weight to height, that is, weight (kg)/[height (m)]2. So people of normal shape and composition but of varying heights had the same BMI, with ‘healthy’ values being taken as between 18.5 and 25, for both men and women of all ages. These values were based on early US insurance figures.1 However, the ready acceptance of the importance of obesity came with the WHO millennium analyses of the major risk factors underlying the burden of premature death and disability from all the major diseases throughout the world.5 The IOTF’s contribution6 showed that the optimum average BMI for a population was only about 21 because the risk of diabetes, high blood pressure and coronary heart disease increased throughout the so called ‘normal’ range. Thus, the risk of diabetes was 5–6 times greater at a BMI of just under 25 than at BMIs of 21. Obese people - that is, with BMIs ≥30 - had more extreme risks.
1.2 The magnitude of the problem
The risks of weight gain include the development of diabetes, heart disease, strokes, high blood pressure, cancers of the breast (post-menopause), colon and rectum, kidney and gallbladder, together with physical handicaps, for example, arthritis. These effects made excess weight, that is, BMIs ≥ 21, rank as the sixth greatest global risk factor for all illnesses accounting for sickness and early death throughout the world! Since then, further analyses in 2006 by WHO, the World Bank and the Centers for Disease Control and Prevention in the United States showed that excess weight is now the third highest risk factor in the affluent world and is within the top 10 risk factors in the regions of the world with the poorest people.7
New IOTF analyses in 2008 showed that there were over 525 million obese adults, with over 1 billion already being overweight (BMIs 25–29.9). This problem is affecting ever younger adults; now in every region of the world, women aged 45-60 years have the maximum rates of overweight and obesity. In the Middle East over 80% of women are affected (of whom >40% are obese), these values exceeding the North American, Latin American, European and Oceania prevalences of >25-35% obesity, with a total prevalence for overweight and obesity of 50-70%. Only Africa and Asia have lower prevalences and even here the middle-aged have obesity rates of 8-15% with totals of 30-40% for BMIs ≥ 25. Men in general have lower values, with North American men showing the greatest prevalence of obesity. In most countries, 50-70% of middle-aged men have BMIs ≥ 25, with obesity rates of >30% in North America, and 15-20% in Latin America, Europe, Middle East and Oceania. Only Asia and Africa have significantly lower rates.
Within more affluent societies there is a strong relationship between the socioeconomic circumstances of a group of children and adults and their susceptibility to gain weight. This also relates to their educational status, with the more affluent and educated groups having much lower obesity rates and a longer life expectancy.
1.3 The basis for the current underestimated burden of obesity
Childhood obesity rates now seem to be accelerating. Four years ago IOTF estimated that 10% of children in the world were overweight or obese8 when the internationally accepted IOTF criteria of overweight were used.9 Yet Figure 1.1 reveals that on average over 15% of the world’s children are now affected; over one-third of North American (including Cuban) children are overweight or obese. Only Africa has an overall prevalence of <10%. The rates are going up remarkably rapidly and now there is clear evidence in affluent societies that even modestly overweight children have a greater lifelong risk of early death and cardiovascular disease, i.e. with high blood pressure, heart disease and strokes.10 Thus, the current burden of ill-health from excess weight gain is an underestimate because the earlier an adult becomes overweight, the greater their future handicap. Current estimates of the burden of overweight and obesity have not included the future impact of such high proportions of overweight children now entering adult life.
Figure 1.1 Overweight and obesity in children around the globe (based on IOTF cut off points).
The other underestimate of the impact of obesity relates to the fact that Asian communities are far more prone to developing type 2 diabetes and cardiovascular disease than Caucasian adults in western environments.11 This is ascribed to genetic differences, but this is probably incorrect because the body’s susceptibility to adult disease is often programmed by the health and nutritional status of the mother during pregnancy and the child’s growth and well-being in the first 2 years of postnatal life. Thus, European and North American children who are born small and/or grow slowly in the first 2 years of life are much more susceptible to developing selective abdominal obesity with its higher risks of diabetes, cardiovascular disease and some cancers, particularly if they put on excess weight after 2 years of age. This is also evident in India, China and several other developing countries. In India it is being linked to vitamin B12 deficiency and abnormalities of the body’s handling of folic acid metabolism probably exacerbated by low intakes of animal foods.12 Asian adults, at any BMI above 23 (now considered the upper ‘acceptable’ BMI limit for Asians), have a 2–5 fold increased risk of diabetes and high blood pressure. Mexicans are also more susceptible to diabetes and hypertension than US non-Hispanic Whites and acquire the problems rapidly as they gain weight in early adult life.13 So throughout the world the previously termed ‘maturity-onset’ diabetes is now being seen in early adult life and even in children, particularly in the poorer countries.
These data suggest that the majority of the world’s populations may well be more prone to the consequences of excess weight gain than we originally thought. Therefore, given the prevalences of childhood overweight and obesity in the poorer parts of the world (Figure 1.1) we are now confronting a huge global medical problem. Medical costs are rising rapidly; financial analysts show that the medical costs of treatment have increased by 2% per annum above the economic growth of both affluent and poor countries for many decades and about 50% of the increasing medical costs in the United States relate to increasing rates of overweight and obesity. Many lower income countries, previously geared to coping with childhood malnutrition, are already overwhelmed with the problems of the adult chronic diseases. Already over 4 times as many adults die from cardiovascular disease in lower income countries as in Europe, North America, Australasia and Japan. World Bank also shows the irretrievable debts incurred by 40% of Indians’ attempt to cover their medical care costs, and in China the latest parliamentary session recognised the medical plight of the hundreds of millions of poor Chinese rural dwellers as critical. Thus, whether we are dealing with rich or poor countries, the future medical costs are unsustainable. So the challenge is how to convert the political processes which focus on single, short-term solutions to recognise and respond to the need to prevent these problems.
1.4 Individual susceptibility to weight gain and the persistence of obesity
An individual’s susceptibility to put on excess weight is very dependent on his or her genetic make-up. The effect is powerful and explains 50-75% of the difference in the range of weights within any one group living in a particular environment. Thus, in any socio-economic class or educational level those who develop obesity first are the genetically prone to weight gain. Their environmental circumstances or resulting behavioural patterns are still important but it is unwise to blame individuals within a society for their poor health. They can improve their prospects by changing their diet and physical activity patterns, but this is much more difficult for people who are susceptible to weight gain. Also, once adults have gained weight, it is now clear that the brain adapts - perhaps physically in terms of neural pathways - to resist subsequent slimming. This seems to be a strong contributor to the persistence of the epidemic despite the public pressure to lose weight and the billions of dollars spent on weight loss remedies. It is also true that the prevailing environmental pressures are intense; so to overcome these pressures, a family must create its own ‘microenvironment’ to cope. This is a task few can accomplish and there is much inappropriate prejudice relating to both obese children and adults’ excess weight when the most appropriate response is to consider their environmental circumstances and their particular need for help.
1.5 The environmental basis for the obesity epidemic
The fundamental environmental basis for the obesity epidemic was recently highlighted by the UK government analysis known as the Foresight report.14 Some implications of this report are summarised in Box 1.1. The emphasis on the normal biological response in terms of weight gain is important because it emphasises the environmental basis for the current epidemic. Therefore, one has to consider both the changes in the energy demand for physical work etc. as well as factors affecting food intake. The latest WHO summary of the factors affecting weight gain is given in Table 1.1. The fall in the demand for physical exertion seems to have come several decades ago in affluent countries with the progressive mechanisation of society, which has reduced the need for physical work. Globally, one of the important factors has been urbanisation with the consequent reduction in the need for the strenuous physical work normally required of peasant farmers. Thus, we calculated that Chinese men and women, formerly living a hard farming life, on transfer to an urban setting but still involved in long hours of building activity or other forms of manual labour, reduced their energy needs by 300–400 kcal/day. This automatically means that this is the reduction in food intake needed by the brain’s automatic regulatory system to prevent weight gain.15 The differences between cycling to work, taking public transport or becoming sufficiently affluent to have one’s own car are also important. Transferring from bicycles - the normal mode of Chinese transport 10 years ago - to public transport saves a further 150 kcal/day or so; having a car reduces the energy demand by about another 100 kcal/day. Thus, the total impact of increasing mechanisation, the constraints of city living and the pressure to sit watching television means that food intakes may need to fall by 400–800 kcal/day for a Chinese adult to compensate for the changes in their working and living conditions: it is a world away from the physical demands of their traditional agricultural subsistence way of life. Indeed, they readily opt for these changes perhaps because the evolutionary demand for intense and/or prolonged physical activity meant that the human race evolved to recognise the value of minimising the demands for physical work.
Box 1.1 Understanding the obesity epidemic and the need for prevention now
1 Obesity is a normal ‘passive’ biological response to our changed physical and food environment.
2 Some children or adults are more susceptible for genetic, social and economic reasons.
3 Overwhelming environmental impact reflects outcome of normal industrial development.
4 Obesity reflects failure of the free market.
5 Obesity is similar to climate change:
Table 1.1 The contributors to the development of obesity as set out by WHO and categorised by the level of evidence for each contributor.
Source: Table taken from Diet, Nutrition and the Prevention of Chronic Diseases, WHO 2003, TRS 916. Geneva
aAssociated evidence and expert opinion.
These dramatic changes with urbanisation and technological developments involve both irreversible processes and some options, for example, in the design of the urban physical and social environment. These options can either limit or promote routine and spontaneous physical activity and are primarily determined by central and local governments. These decision makers are, however, influenced by massive industrial pressures attempting to persuade us to use personal motorised transport, personal entertainment and gadgets which minimise the need for any physical activity in the home, in transport or at work. Table 1.2 summarises some of the optional changes in the physical environment which condition everyday physical activity. These changes are heavily influenced by industrial interests and have been very poorly analysed compared with those environmental factors affecting food intake.16
Food intakes should have fallen substantially throughout the world on the basis of the decades’ long progressive fall in the demand for physical work, but for centuries societies everywhere have been concerned with food deprivation. Thus, in several countries intakes have risen and in others they have not fallen enough to match reducing energy needs. The cultural emphasis on food governs adults’ responses to its value and their own perceived need for food as well as their approach to feeding their children. Furthermore, we have evolutionary mechanisms with specific taste buds linked to brain pleasure centres which respond positively to salt, meat, sweetness and fats in the form of essential fatty acids. Now these food components are abundantly available in the industrialised food chain which now forms the most powerful marketing consortium in the world. The global food chain is, therefore, completely inappropriate for a world which is now predominantly sedentary. In a free-market-based world the agricultural, food and marketing sectors continue to maximise their profits, with food outlets and supermarkets filling their shelves with items selected by taste panels. The vast arrays of products are also marketed intensively on the basis of price and they are made available everywhere. ‘Branding’ is also promoted with all the subtlety that psychologists and others can devise. These developments have led to an overwhelming ‘obesogenic’ environment which particularly affects the more vulnerable sectors of society and is transforming the food systems of lower income countries. These pressures operate throughout society with additional lobbying of prime ministers and ministers to ensure that no coherent response is prepared which could threaten the booming food chain profits. These forces are more difficult to combat than the pressures of the tobacco industry.
Table 1.2 Inevitable and optional changes in physical activity.
Inevitable • Rural to urban transition from agricultural work reducing demand for work • Labour changes from manual to service occupations limiting activity • Mechanisation/computerisation of standard work; also home duties, for example, cooking, washing, cleaning minimising physical exertion Optional • Urban building policies: high intensity or US style sprawl has huge impact on dominance of cars and pedestrian activity • Road and community design affect safe and ready access for play/walking • Office and supermarket location policies determine transport needs • Car/traffic policies based on preference for cyclists/pedestrians? • Policies on free spaces for children’s play; lighting for safety, e.g. for older people • Park/leisure/sports facilities/school physical activity lessons • Reducing the retail food environment index, i.e. the density of fast food outlets in urban environments • Ease of transport of perishable foods into towns/citiesThe British government’s Foresight report set out the immense challenges which require immediate action but far more political resolve is needed than is currently evident. One ray of hope, however, relates to urban planning and the promotion of physical activity as set out in this book. Urban design not only relates to factors influencing physical activity but also to those affecting food intake. Thus, the retail food environmental index relates to the density of fast food restaurants and convenience stores. This density has been found to relate to the prevalence of obesity and diabetes,17 and new plans in China are to have a MacDonald’s restaurant in every new petrol station built!
The current emphasis on climate change provides a synergy with the need to transform our physical environment so that we promote spontaneous rather than sports-related or deliberate physical activity. The challenge then is for urban designers to include the health benefits of more physical activity in their assessments of competing schemes and to present them as a bonus accruing from the many strategies being developed to tackle climate change. Both changes in food intake and physical activity are needed, but if we could, by changes in urban design, induce an increase in spontaneous activity of 200 kcal/day (equivalent to an extra hour on one’s feet moving/walking/day) and if this affected the whole of society these measures would make the required additional fall of perhaps 300 kcal/day in total food intake by limiting fat/sugar energy rich snacks and reducing the energy density of normal foods to achieve energy balance at lower body weights much more readily achievable.15
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4. World Health Organization. (2000) Obesity: Preventing and Managing the Global Epidemic. World Health Organisation Technical Report Series No. 894. WHO, Geneva.
5. Ezzati, M., Lopez, A.D., Rodgers, A., Vander Hoorn, S., Murray, C.J. Comparative Risk Assessment Collaborating Group. (2002) Selected major risk factors and global and regional burden of disease. Lancet. 360(9343):1347–1360.
6. James, W.P.T., Jackson-Leach, R., Ni Mhurchu, C., Kalmara, E., Shayeghi, M., Rigby, N.J., Nishida, C., Rodgers, A. Overweight and obesity (high body mass index). In: ComparativeQuantification of Health Risks. Global and Regional Burden of Disease Attributable toSelected Major Risk Factors. (Eds. Ezzati, M., Lopez, A.D., Rodgers, A., Murray, C.J.L.) Chapter 8, Volume 1. World Health Organization, Geneva, 2004 pp. 497–596.
7. Lopez, A.D., Mathers, C.D., Ezzati, M., Jamison, D.T., Murray, C.J.L., eds. Global Burdenof Disease and Risk Factors. New York, NY, Oxford University Press, 2006. 8. Lobstein, T., Baur, L., Uauy, R. (2004) Obesity in children and young people: a crisis in public health. Obesity Reviews. 5(s1):4–85.
9. Cole, T.J., Bellizzi, M.C., Flegal, K.M., Dietz, W.H. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. British Medical Journal. 320:1240–1243.
10. Baker, J.L., Olsen, L.W., Sørensen, T.I. (2007) Childhood body-mass index and the risk of coronary heart disease in adulthood. New England Journal of Medicine. 357(23):2329–2337.
11. Huxley, R.T., James, W.P.T., Barzi, F., Patel, J.V., Lear, S.A., Suriyawongpaisal, P., Janus, E., Caterson, I., Zimmet, P., Prabhakaran, D., Reddy, S., Woodward, M. on behalf of the Obesity in Asia Collaboration. (2008) Ethnic comparisons of the cross-sectional relationships between measures of body size with diabetes and hypertension. Obesity Reviews. 9(Suppl. 1):53–61.
12. James, W.P.T. (2008) The epidemiology of obesity: the size of the problem. Journal of Internal Medicine. 263(4):336–352.
13. Sanchez-Castillo, C.P., Velasquez-Monroy, O., Lara-Esqueda, A., Berber, A., Sepulveda, J., Tapia-Conyer, R., James, W.P.T. (2005) Diabetes and hypertension increases in a society with abdominal obesity: results of the Mexican National Health Survey 2000. Public Health Nutrition. 8(1):53–60.
14. Foresight (2007). Tackling Obesities: Future Choices - Project Report. 2nd Edition, London, Government Office for Science. http://www.foresight.gov.uk.
15. James, W.P.T. (2008) The fundamental drivers of the obesity epidemic. Obesity Reviews. 9(Suppl. 1):6–13.
16. James, W.P.T., Rigby, N. The challenge of the chronic diseases epidemic for science and society. In: Essentials in Human Nutrition. (Eds. Mann, J.I., Truswell, A.S.) 3rd Edition. Oxford, Oxford University Press, 2007 pp. 249–259.
17. California Center for Public Health Advocacy. (2008) Designed for Disease: The Linkbetween Local Food Environments and Obesity and Diabetes. California Center for Public Health Advocacy, Policy Link, and the UCLA Center for Health Policy Research. http://www.publichealthadvocacy.org/designedfordisease.html.
2
Towards Transdisciplinary Approaches to Tackle Obesity
Tim G. Townshend, Louisa Ells, Seraphim Alvanides and Amelia A. Lake
2.1 The focus on interdisciplinary research
It has been argued that the traditional academic disciplines set around specific knowledge areas - the sciences, arts and humanities - have thrived on specialisation and differentiation, each establishing isolated academic cultures with their own language1,2 and ethos,3,4 regardless of whether this reflected the real world.5 In the more recent past, however, there has been increased emphasis on academic research that addresses real-life issues6-8 and research that is carried out in the context of application.9,10 A key dynamic is that ‘real life’ issues often do not fit neatly into disciplinary boundaries. Further, as observed by Khan and Prager,11 the idea of the solitary academic toiling away in search of solutions to problems was a myth which served as a barrier to preventing a collective response from academia to the problems of mankind. Increasingly, academic foundations and policymakers have accepted the need for interdisciplinary working, reflecting a reality that over the next decades many of the major challenges in research will cross over the boundaries of disciplines that have their roots in previous centuries.12,13
The challenge of obesity is a clear case in point, for until recently, it was framed as a medical problem and understandably so, since obesity is linked to so many medical conditions. More recently, however, there is growing recognition that the medical profession alone are unable to successfully arrest the rise in obesity rates and that a more holistic approach is required. This is not to suggest, however, that taking an interdisciplinary approach to health problems is new. A vote in 2007 in the British Medical Journal on the most important medical advance since the journal was published in 1840 was awarded to the ‘sanitary revolution’,14 recognising that, in the 19th century, epidemics of contagious diseases, such as cholera and typhus, were treated with a combination of newly emerging medical knowledge and treatments, engineering improvements to water supply and sanitation and urban planning regulations. This approach was typified by the comprehensive health acts and bills passed on either side of the Atlantic in the second half of that century.
In the 20th century, as highlighted by Ceccarelli, there have been a number of key texts that were of ‘broad interdisciplinary persuasion’ (p. 2)15 and she argues that these are, in fact, part of a long tradition of texts, some of which have been accepted and others, which have caused huge controversy. Yet, today there seem to be more inhibitors to interdisciplinary working that must be addressed than have traditionally been the case. The general organisation of Universities into discipline-specific departments and research institutes is demonstrative proof of the longevity of academic adherence to disciplinary boundaries and certainties. Universities themselves often specialise in particular disciplines and sub-disciplines; funding bodies like narrowly focused research proposals and specialisation wins academic advancement and accolades. Such issues as outlined below may provide major hurdles to interdisciplinary advancement.
2.2 Defining modes of interdisciplinarity
What exactly is meant by interdisciplinary research? There are a number of terms, interdisciplinary, multidisciplinary, pluri-disciplinary, cross-disciplinary and transdisciplinary,16 which, erroneously, are often used interchangeably. Analyses of interdisciplinarity, for example, suggest three levels or stages of working.17,18 Firstly, multidisciplinary research suggests that researchers work on a common problem, but in discrete environs, the results of their work are brought together, but with little actual engagement between the various individuals concerned. Interdisciplinary working, on the other hand, suggests common epistemological approaches linking different discipline areas employed by a team of experts, as Pellar puts it ‘in an organized program to attack a challenging problem’ (p. 502)19; this mode of working does not, however, involve the re-evaluation of research practice within the individual disciplines, or the adoption of methods and techniques from one discipline to another.
Beyond these modes, ‘radical interdisciplinarity’17 or transdisciplinary16,18 working involves the sustained interrogation of the different research approaches from the disciplines involved, to question the assumptions and cultures of the various disciplines and to generate new collective ways of working. It, therefore, develops a common conceptual framework that bridges the relevant disciplines and serves as a basis for generating new research approaches defined directly by the research questions in hand. An aspect of transdisciplinarity, therefore, is that the focus of academic endeavour is outside traditional disciplinary boundaries. In effect, there is something of a continuum with multidisciplinary working at one end and fully integrated transdisciplinary research at the other.
The key advantage of transdisciplinary working is that by bringing different disciplines together it has the potential for fostering innovation, to create novel interventions, policies and practice; this is highly pertinent in the fight against obesity where traditional approaches have largely failed. An advantage of bringing the social sciences into the traditional medical arena should be that the social scientist is able to stand as a proxy for society and as such help the medical sciences become as responsive to societal needs as possible. Though one must be wary of this argument, since it might be claimed it positions the social sciences in overly idealistic light. In the recent past, geographers, for example, have been criticised for being uncritical of the corporatisation of their discipline.20 Interdisciplinary working highlights such issues and therefore is challenging to those involved.
2.3 The complexity of obesity
As reviewed in Chapter 1, obesity has only been recognised as a serious problem since the 1980s. In the interim period, however, it has developed into a major global pandemic, interlinked with the greatest challenge facing mankind, climate change. At one level, the issue of energy balance appears deceptively simple - to encourage people to increase their physical exercise (energy expenditure) and to modify their diet to reduce their energy intake. At the individual-level, however, the propensity of people to become overweight, or obese, varies between subsets within the overall population and, indeed, at different stages in any individual’s life cycle.21 Thus obesity is a complex interplay between individual biology, eating behaviour and physical exercise. It has been suggested that ‘human biology has become out of step with the structure of society’ (p. 791).22 The underlying biological tendency for humans to acquire and store energy, and the desensitisation of our appetite control system (at the core of the obesity systems map21) within the context of an obesogenic environment, means individuals exert less control and choice over their lifestyle patterns, which impacts on their weight.23
Moreover, as pointed out by the UK Foresight report, this is set against a ‘social, cultural and environmental landscape’ (p. 79)21 and raises complex social and economic issues, encompassing food manufacturing, production and retailing, healthcare and education, and includes the way we plan and develop our towns and cities - subjects which have been addressed throughout the chapters of this book. In addition, key influences, particularly the thrust of years of public policy and competition and market forces, have worked together since the end of World War II to encourage greater food availability and the accommodation of the private car. These two aspects, taken as norms of life in the developed world (and increasingly in the developing world), now run counter to the need to reduce food intake and encourage exercise.
In their development of a framework for interdisciplinary research on environment, design and obesity, Wells et al.23 suggested that clothing, food, technology (labour-saving devices), buildings and neighbourhood design, in addition to the natural environment, are all implicated in the obesity equation. The UK Foresight report suggests seven key subsystems that should be considered in the obesity epidemic:
Physiology - biological variables related to obesity, such as genetic predispositionIndividual physical activity - for example, the levels of activity involved in one’s employment, or home lifePhysical activity environment - opportunities for physical exercise, the nature of the living environment, and so onFood consumption - the amounts and types of food consumedFood production - drivers of the food industry, such as efficiency, growth and profitIndividual psychology - stress levels, degree of social interactionSocial psychology - influence at societal level, for example, education, mediaInterrelated issues emerge from this list of sub-themes. Firstly, it is clear that much of this is outside the traditional medical and life sciences arena, where most obesity-related research has been located. Secondly, the sheer number of traditional disciplines that are involved in studying and understanding the relationships within and between the subsystems is extremely large, and those disciplines operate at different levels and through different legal structures. Further, by looking at the interfaces between just two or perhaps three sub-theme areas might appear to break the complexity into manageable tasks. However, because the system is so highly interconnected (Figure 2.1) - 108 variables and 304 causal links involved in the ‘obesity system’ - tackling any particular interface, or causal link, carries its own risks.
This obesity systems map suggests that the consequence of intervention at any one interface may actually be discharged away from the original focus; or may even be compensated for by unintended changes elsewhere in the system. For example, a campaign to encourage children to walk to and from school may expose them to the temptation of more sweet shops and fast food outlets, potentially producing a null effect. In adolescents, the attempted suppression of risky behaviour, for example, through a media campaign aimed at highlighting obesity risk to their age group, may actually lead them to engage in other health risk behaviours (the theory of reactance) such as drug taking, smoking or eating disorders.24 This may, in part, explain why interventions to tackle obesity have thus far had limited success.
Figure 2.1 Foresight obesity systems map showing thematic clusters. With permission from the Government Office for Science, London.
2.4 The challenge of interdisciplinary understanding
The Foresight obesity systems map provides us with insight into the complexity of, and interrelationships between, various determinants of obesity. Moreover, research on obesity from the medical, life and social sciences has explained a great deal about many of these complex determinants; however, most work to date has not been ‘well integrated across the disciplines’ (p. 43).21 How best might this be achieved and what barriers to effective working might be met? Since the amount of interdisciplinary work that has been carried out in the study of obesity is limited, the following sections look more broadly at debates on interdisciplinary research, as well as the editors’ own experience in attempting to answer these key questions.
2.4.1 Lessons from the field of sustainability
The field of sustainability provides some interesting insights in relation to interdisciplinary working. Issues around sustainable urbanism were recognised as requiring input from the natural, engineering and social sciences from the 1980s onwards. A review of three research programmes funded by UK Research Councils and specifically tasked with developing new forms of interdisciplinary working, however, found significant challenges.17 Firstly, the authors suggested that in the studies they had reviewed, the social and cultural dimensions (and differences) of knowledge and its location within specific epistemic cultures had not been addressed sufficiently. In particular, they suggested that the funding bodies themselves were incapable of ‘breaking down the distinctions that gave their own identity meaning’ (p. 1025).17 This is extremely important since if interdisciplinary projects on obesity are to be appropriately funded, then funding bodies may have to radically address their research funding processes and the criteria on which they give awards (see Section 2.4.3). Moreover, since transdisciplinary projects will almost certainly need more lead-in time in order for academics from different disciplines to fully understand each other’s perspectives, they may appear relatively expensive and contain large amount of unproductive time. These, in particular, challenge normal institutional working practices where expectations of what constitutes a ‘worthwhile’ project to fund, based on value for money, precedents and track record are often deeply engrained.
The problems of disciplinary cultures and norms will also be a challenge for those working in an interdisciplinary team. Evans and Marvin suggest that being part of a particular discipline is ‘not just a matter of mastering a technical discourse, it is also a matter of being a particular kind of person’ (p. 1018)17; though, to some extent, there are, in reality, universally upheld values and beliefs within broad disciplines (such as geography) might seem open to question. Moreover, different outlooks by individual researchers may not necessarily be drawn along discipline boundaries. It may be, therefore, that difference in culture and values are highlighted by interdisciplinary working and might be used as an excuse for creating barriers to effective working.
2.4.2 Language as a barrier
On a relatively pragmatic note, the co-editors note that language may be a key barrier to effective working, particularly in the early stages of a research project when disciplinary differences are unknown and unexpected. The difficulties of language in interdisciplinary projects have also been highlighted elsewhere.1,2 However, language may prove problematic in more than one way, for example, when trying to address issues that lie outside the usual boundaries of their discipline, an academic team with the best intentions may develop their own vocabulary for phenomena that are already prescribed by specific terminology by others. In setting out to map health problems investigated for possible links with the built environment, Rao et al.25 use the term ‘appearance’; this is not, however, a term that has a particular meaning in the built environment disciplines. Examining the sense in which ‘appearance’ is being used, the term ‘quality of the public realm’ would actually be applied by those disciplines.
A further difficulty is where terms or expressions have different meanings between disciplines. In Chapter 4 Jones and Panter review the concept of ‘accessibility’ from the perspective of the field of health service delivery planning. They note that accessibility implies that people with the same type and degree of health need to have an equal chance of receiving appropriate and equal quality treatment. In the field of urban design, however, ‘accessibility’ has a totally different connotation. Here the term is used as a tripartite notion of visual, physical and symbolic (psychological) qualities of public space,26 that is, would someone understand how to get to a public space, could they physically traverse the environment to enter it and would they feel comfortable and safe in doing so? There are, in fact, many terms like ‘access’, ‘environment’ and ‘surveillance’ which are in common everyday use in both the health and built environment professions, but which carry quite different disciplinary ‘baggage’ with them.
2.4.3 Academic positioning
A problem faced by any individual working in a team outside his or her own academic discipline, however, is that of academic positioning. Those journals, which are often most highly regarded in almost any discipline, are usually discipline specific, making it difficult to publish interdisciplinary work in them. In the social sciences, moreover, there is strong emphasis on demonstrating one’s ability to be an independent researcher with sole-authored articles in top journals being highly prized. This model is different in the field of medicine where team publications are more usual. Even so, top accolades, the Nobel Prize being the most obvious example, are about the individual rather than the team.
Academics and academic departments are increasingly judged by the quantity/quality of publications produced, for example, the UK Research Assessment Exercise (RAE) 200827 and the upcoming Research Excellence Framework (REF).28 In the United Kingdom, for example, the medical sciences use impact factor and citation metrics as part of this judgement, the social sciences have, thus far, not followed this method; though whether this will be imposed by the REF is still being debated. Where articles of multidisciplinary teams get published, this can, therefore, create problems for individual team members.
Related to this, there is the somewhat delicate issue of epistemic superiority that might traditionally have been assumed by some quantitative researchers over ‘softer’ qualitative research. Medical research has tended to base much of its findings on strictly controlled and regulated clinical trials, with bodies such as the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) having strict criteria as to what they will accept as ‘evidence’. In relation to their physical activity and environment guidance, however, NICE allowed a much wider interpretation of evidence, suggesting greater recognition in the value of a range of work. For their part, social-science researchers need to acknowledge the value in contributing to evidence-based policy, as much as to the development of academic theory.
2.4.4 Summary of barriers
These (potential) barriers, however real or imaginary, need to be addressed rather than be ignored, and several approaches might be adopted. Longer start-up phases for interdisciplinary projects (though this obviously involves cost and a basically unproductive period in the life of a research project), sensitive management of teams which respect traditional working practices while allowing them to be challenged, flexibility on the part of team members and a willingness to understand others’ perspectives are all key to overcoming this challenge. Such issues also apply to working across academic and policy/practice boundaries.
2.5 Interdisciplinary policy and practice
The Foresight report21 not only stressed the multifaceted nature of obesity but also the importance of tackling this right from the individual to the policy level. In England, the Government has pledged to tackle obesity through a cross-Government strategy: ‘Healthy Weight, Healthy Lives’,29 which supports the creation of a healthy society: from early years to school and food, sport and physical activity to planning, transport and health services. The aim of this strategy is ‘to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight’ (p. 5).29 This strategy has been further supported by Healthy Weight, Healthy Lives: One YearOn30 and the physical activity strategy: ‘Be Active, Be Healthy: a Plan for Getting the Nation Moving’.31
One of the key features of Healthy Weight, Healthy Lives: One Year On30 focuses on creating an environment that promotes healthy weight, as a result of the Foresight acknowledgement of the need to address wider social and economic issues in order to achieve this aim. This focus is divided into four key visions: (i) children, healthy growth and healthy weight, (ii) promoting healthier food choices, (iii) building physical activity into our lives and (iv) creating incentive for better health. These visions are supported by the Change4Life campaign, which is a society-wide movement that aims to prevent overweight and obesity by encouraging the population to ‘eat better and move more’.32 As part of the Change4Life movement, nine ‘Healthy Towns’ (Tewkesbury, Halifax, Thetford, Tower Hamlets, Manchester, Middlesbrough, Dudley, Sheffield and Portsmouth) have also been selected for a trial of new holistic approaches to promoting physical activity and healthy eating within their community and town infrastructures.
A key focus of the physical activity plan ‘Be Active, Be Healthy’ is creating an active environment. This centres around evidence from the NICE physical activity and environment33 guidance, to inform the creation of safe play spaces, enhancements to planning policy around open spaces, sport and recreation, alongside the Sport England Active Design report34; this is in addition to encouraging activity within the natural environment.
The initiation of policies and guidance to combat the obesogenic environment will help the fight against obesity; however, to be successful and sustainable these must be (i) initiated by interdisciplinary teams to ensure a combined approach with a consistency in messages and (ii) thoroughly evaluated to ensure policy and practice evolve in a positive feedback loop. Given the current weaknesses in the evidence base around the effective prevention of obesity, the National Obesity Observatory issued a standard evaluation framework for all weight management interventions35 to ensure a consistent standardised best practice approach to evaluation.
The challenge for policy is to find a way to address these issues from an interdisciplinary perspective, and if this is not established, then policymakers risk being bombarded with different perspectives from different academic disciplines. These perspectives will use different theories and different models and policymakers will face an impossible challenge to bring these together into a coherent policy approach.
2.6 Discussion
The complexity of obesity is overviewed in this chapter and discussed in detail in this book. The Foresight obesity systems map graphically highlights the vast array of variables and causal links that have been investigated in relation to obesity and even this may be something of a simplification. Furthermore, this systems map shows that many of these links cross over traditional disciplinary boundaries.
In this volume, we bring together writers from backgrounds in policy, nutrition and dietetics, epidemiology, environmental sciences, medical sciences, town planning/urban design, geography and physical activity. The editors have worked on a number of interdisciplinary projects and are fully convinced of the need to challenge our own established disciplinary perspectives. Furthermore, while true transdisciplinarity remains a goal rather than an achieved state of our work, we would argue that the very complexity of obesity demands that a move towards transdisciplinary research is in fact inevitable.
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