Explanations for why people get fat:

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UNIT FOR BIOCULTURAL VARIATION AND OBESITY
Seminar series - Michaelmas Term 2007

• Explanations for why people get fat
• an integral approach

Mike Rayner British Heart Foundation Health
Promotion Research Group Department of Public
Health University of Oxford
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Aims of talk

• Causal webs
• Critique of systems theory
• Integral theory
• Causal webs

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The relationship between environment and health
can be conceptualised as a 'causal web'
Distal socio-economic Proximal causes
Physiological and Outcomes causes

pathophysiological

causes
Personal
Smoking
Blood cholesterol
CVD
Environ-mental
Diet
Blood pressure
Cancer
Overweight and obsity
Physical activity
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The relationship between environment and health
can be conceptualised as a 'causal web'
Distal socio-economic Proximal causes
Physiological and
Outcomes causes

pathophysiological

causes
CVD CHD Stroke
Diet Foods Nutrients
Personal Income Occupation Education
Overweight and obesity BMI Waist hip ratio
Environmental Physical Cultural
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Distal socio-economic Proximal causes
Physiological and
Outcomes causes

pathophysiological

causes












Soft drinks


NSP

Price


Raied blood
CVD

Free sugar

Fast food

cholesterol

Carbohydrate

Promotion

Cancer

Raised blood
pressure

Energy

Availablity
Milk and dairy
products

Fat

Butter

Overweight and
Saturated fat

obesity

Vegetable oils

Type II diabetes

Poly
-
unsaturated
fat

Fish

Mono
-
unsaturated fat

Income

Dental disease

Dental erosion

Plant sterols

Fruit and
Education

vegetables

Whole grain
Sodium

cereals

Detiorating bone
Osteoporosis

Calcium

tissue

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The width of the lines between boxes can indicate

• The strength of the evidence for causality
• The strength of the causal relationship
• The extent to which the causal relationship is
  modifiable

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The relationship between diet and health can be
conceptualised as a 'causal web'
Distal socio-economic Proximal causes
Physiological and Outcomes causes

pathophysiological

causes
Personal
Fruit and veg
Blood cholesterol
CVD
3.9
7.6
Environ-mental
Saturated fat
Blood pressure
Cancer
10.9
BMI
Salt
7.4
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Aristotles four causes

• The material cause that out of which, e.g.,
  the bronze of a statue.
• The formal cause the form, the account of
  what-it-is-to-be, e.g., the shape of a statue.
• The efficient cause the primary source of the
  change or rest, e.g., the artisan, the person
  who commissioned the statue, the art of
  bronze-casting
• The final cause the end, that for the sake of
  which a thing is done, e.g. to commemorate a
  famous person

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Aristotles four causes

• The material cause the accumulation of fat in
  adipocytes
• The formal cause an imbalance between energy
  intake and energy expenditure.
• The efficient cause individual choice, societal
  breakdown
• The final cause because human beings are by
  nature greedy because human beings are adapted
  to situations of feast and famine

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Missing boxes and lines
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Missing boxes and lines

• Education
• Social marketing
• Legislation
• School environment
• School meals
• Vending

• Media availability
• Media consumption
• Demand for health
• Self esteem
• Food literacy
• Socio-cultural valuation of activity
• Female employment
• Self esteem
• Social rejection of smoking

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The meaning of lines
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The width of the lines between boxes can indicate

• The strength of the evidence for causality
• The strength of the causal relationship
• The extent to which the causal relationship is
  modifiable

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Meaning of lines
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The relationship between boxes
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Clusters are

• Disciplines
• But missing sociology, anthropology,
• But over-emphasised psychology, physiology
• More diet than physical activity?
• Types of determinant
• But food production? Retailing, catering,
  marketing? Why not food environment?

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Source Wilber K, A Theory of Everything, 2000
Individual Objective
Individual Subjective
Group Subjective
Group Objective
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Individual Objective
Individual Subjective
Theological
Physiological Psychological
Economic
Organisational Sociological
Historical Cultural
Group Subjective
Group Objective
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Individual Objective
Individual Subjective
Trans-personal
Physiological Psychological
Economic
Organisational Sociological
Historical Cultural
Group Subjective
Group Objective
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Theories to explain health related behaviour
.people get fat
Individual/Objective
Individual/Subjective
If energy intake exceeds energy expenditure If
people increase their consumption of energy dense
foods If people are confronted by a range of
different foods they eat more foods and
People are by nature self-interested so
There is an increased availability of different
energy dense foods so Increasing economic wealth
leads to an increasing availability of different
energy dense foods so
In post modernity people are defined by what they
consume so.
Group/Subjective
Group/Objective
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Theories to explain health related behaviour
Individual Objective
Individual Subjective
Trans-personal
Physiological Psychological
Organisational Sociological
Historical Cultural
Group Subjective
Group Objective
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Theories to explain health related behaviour
Individual Objective
Individual Subjective
Trans-personal
Physiological Psychological
Organisational Sociological
Historical Cultural
Group Subjective
Group Objective
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Theories to explain health related behaviour
Individual Objective
Individual Subjective
Trans-personal
Physiological Health belief model Theory of
reasoned action Social cognitive theory
Organisational Sociological
Historical Cultural
Group Subjective
Group Objective
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Theories to explain health related behaviour
Individual Objective
Individual Subjective
Trans-personal
Health belief model Theory of reasoned
action Social cognitive theory
Organisational Sociological
Historical Cultural
Group Subjective
Group Objective
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Theories to explain health related behaviour
Individual Objective
Individual Subjective
Trans-personal
Health belief model Theory of reasoned
action Social cognitive theory
Systems theory Diffusion of innovation
theory Sociological
Historical Cultural
Group Subjective
Group Objective
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Theories to explain health related behaviour
Individual Objective
Individual Subjective
Trans-personal
Health belief model Theory of reasoned
action Social cognitive theory
Systems theory Diffusion of innovation
theory Community organisation theory
Historical Cultural
Group Subjective
Group Objective
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• Greed is the seed of apocalypse
• Source The Tao Te Ching, Lao Tzu

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A psychological model (Health belief model)
Perceived susceptibility to problem
Perceived threat
Perceived seriousness of problem
Self-efficacy
Energy intake
Perceived benefits of specified action
Outcome expectations
Perceived costs of specified action
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An economic model
Cost of ingredients
Taxes
Subsidies
Price of unhealthy foods
Price of healthy foods
Income
Energy intake
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Cost of ingredients
Taxes
Subsidies
Price of
unhealthy'
Price of

healthy

foods
foods
Income
Perceived susceptibility
to problem
Perceived
threat
Perceived seriousness
of problem
Energy intake
Self
-
efficacy
Perceived benefits
of specified action
Outcome
expectations
Perceived costs
of specified action
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Cost of ingredients
Taxes
Subsidies
Price of
unhealthy'
Price of

healthy

foods
foods
Income
Perceived susceptibility
to problem
Perceived
threat
Perceived seriousness
of problem
Energy intake
Self
-
efficacy
Perceived benefits
of specified action
Outcome
expectations
Perceived costs
of specified action
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Cost of ingredients
Taxes
Subsidies
Price of

unhealthy'
Price of

healthy

foods
foods
Income
Perceived susceptibility
to problem
Perceived
threat
Perceived seriousness
of problem
Energy intake
Self
-
efficacy
Perceived benefits
of specified action
Outcome
expectations
Perceived costs
of specified action
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Agricultural subsidies
Education children
Cost of ingredients
Taxes
Subsidies
Compositional standards foods
Price of

unhealthy'
Price of

healthy

foods
foods
Income
Perceived susceptibility
to problem
Perceived
Compositional standards meals
threat
Perceived seriousness
of problem
Energy intake
Self
-
efficacy
Perceived benefits
of specified action
Outcome
expectations
Social advertising adults
Perceived costs
of specified action
Food availability
Vending standards
Commercial advertising
Food Labelling
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Integrated approaches to obesity Stanley
Ulijaszek Institute of Social and Cultural
Anthropology University of Oxford
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Integrated approaches to obesity

• No single discipline has the answers
• Foresight (UK government) has a systems map,
  launched October 17th, 2007
• Work with the logic of the systems map to
  identify possible lines of multidisciplinary
  research in obesity with best pay-off
• Doesnt exclude other lines of multidisciplinary
  research

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Domains and factors in the Foresight obesity
systems map

• Domain Factors
• Media Media consumption TV watching media
  availability availability of passive
  entertainment options exposure to food
  advertising
• Social Social acceptability of fatness
  importance of ideal body image
  conceptualization of obesity as a disease
  socio-cultural valuation of food peer
  pressure acculturation societal pressure to
  consume perceived lack of time parental
  control childrens control of diet social
  rejection of smoking smoking cessation
  socio-cultural valuation of activity social
  depreciation of labour
• Psychological Stress self esteem demand for
  indulgence / compensation desire to resolve
  tension psychological ambivalence conscious
  control of accumulation perceived danger in
  the environment perceived inconsistency of
  science-based messages
• Economic Purchasing power market price of food
  offerings cost of ingredients
  standardisation of food offerings desire to
  minimise cost desire to maximise volume level
  of employment effort to increase efficiency of
  production pressure on job performance effort
  to increase efficiency of consumption pressure
  for growth and profitability female
  employment dominance of sedentary employment
  cost of physical exercise reliance on
  labour-saving devices
• Food Food exposure food abundance tendency to
  graze deskilling abundance of food offerings
  food variety alcohol consumption palatability
  of food offerings energy density of food
  offerings portion size food literacy demand
  for convenience fibre content of food and
  drink nutritional quality of food and drink
  force of dietary habits rate of eating
  strength of lock-in to accumulate energy

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Domains and factors in the Foresight obesity
systems map

• Domain Factors
• Physical activity Functional fitness level of
  domestic activity level of recreational
  activity non-volitional activity level of
  transport activity level of occupational
  activity access to opportunities for physical
  activity safety of unmotorised transport
  opportunity for unmotorised transport
  dominance of motorised transport walkability of
  living environment degree of innate activity
  in childhood parental modelling of activity
  learned activity patterns in early childhood
  opportunity for team-based activity
• Infrastructure Education face to face
  interaction individualism degree of
  physical education
• Developmental Appropriateness of maternal body
  composition appropriateness of embryonic and
  fetal growth appropriateness of child growth
  quality and quantity of breastfeeding (and
  weaning)
• Biological Importance of physical need effort
  to acquire energy level of available energy
  tendency to preserve energy degree of primary
  appetite control genetic and / or epigenetic
  predisposition to obesity level of
  thermogenesis resting metabolic rate level of
  adipocyte metabolism level of fat free mass
  appropriateness of nutrient partitioning
  level of satiety degree of optimal GI
  signalling extent of digestion and
  absorption side effects of drug use
  predisposition to activity
• Medical Reliance on pharma remedies reliance on
  surgical interventions use of medicines
  level of infections

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Impacts of high or very high strength on the key
determinants

• Primary appetite control none
• Level of physical activity none
• Psychological ambivalence none
• Force of dietary habits convenience

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Work on postulated linkages with the key
determinants, but where knowledge is lacking

• Primary appetite control no direct postulated
  linkages
• Level of physical activity no direct postulated
  linkages
• Psychological ambivalence should be influenced
  by
• Food literacy
• Force of dietary habits should be influenced by
• Demand for indulgence/compensation
• Alcohol consumption
• Purchasing power