‘Ask Me Why I'm Fat!’ The Need to Engage with Potential Recipients of Health Promotion Policy to...

The Australian Economic Review, vol. 41, no. 1, pp. 72–7

Policy Forum: A Multidisciplinary View of Obesity

‘Ask Me Why I’m Fat!’ The Need to Engage with Potential

Recipients of Health Promotion Policy to Prevent Obesity

Flora Douglas, Joe Greener and Edwin van Teijlingen∗Department of Public Health, University of Aberdeen

1. Introduction

This paper highlights the value of engaging di-rectly with potential recipients of health poli-cies and programs aimed at reducing and pre-venting obesity. The benefits are in understand-ing their likely impact and their acceptance bythe target population. Policymakers and healthprofessionals worldwide have become increas-ingly concerned about population trends in obe-sity. Paradoxically, over the last two decades,health service and commercial weight loss pro-grams and initiatives have proliferated. Whilethere is some evidence that such interventionscan help people to reduce their weight in theshort term, sustained weight loss is less likely.

If we are to gain more success in tacklingthis public health issue, it is vital to engage withand understand lay perspectives about the ori-gins of specific health problems, and the associ-ated beliefs about socially and culturally sensi-tive and acceptable health interventions (Tonesand Tilford 2001; Green and Kreuter 1999). In-deed, a substantial body of research has exam-ined individual patients’ compliance with drugand other therapeutic treatment regimes (Alder1999, pp. 133–8) to understand their views and

∗ This paper is based on a wider research project calledPROGRESS (PRevent Obesity GRowing Economic Syn-thesis Study). The project is funded by the National Preven-tative Research Initiative (NPRI), a consortium of Publicand Charitable funders within the United Kingdom, coor-dinated by the MRC, with cofunding from the Universityof Aberdeen, Scotland and the University of Melbourne,Australia. The research team consists of the following re-searchers: Luke Vale, Kostas Mavromaras, Alison Avenell,Alison Goode, Flora Douglas, Anne Ludbrook, Lorna Au-cott, Mandy Ryan, Tony Scott, Mat Sutton, Deokhee Yi,Murray Smith, Joe Greener and Edwin van Teijlingen.

beliefs about their disease or illness, and alsotheir perceptions of acceptability and the social,cultural and economic barriers to following pre-scribed treatments. Similarly, it is importantto understand how overweight or obese peo-ple view the causes of obesity and to be awareof the factors that enable or prevent them com-plying with lifestyle advice (or interventions)in future plans to develop strategies aimed atarresting population obesity trends. Therefore,this paper presents the perceptions of obese andoverweight people about the causes of obesityand the factors they believe enabled or hinderedweight reduction.

2. Our Approach and Methods

The rather naive assumptions of Homo eco-nomicus have tended to dominate many pasthealth education initiatives. The underlying as-sumption of Homo economicus is the idea thatan individual who knows what is best for theirlong-term physical and mental health (or whoshould know when they have been imbuedwith the appropriate information) can be re-lied upon to make the right (rational) decisionfor themself. However, it is also widely recog-nised that people do not always act rationally,or apparently in their own best interest (Tonesand Green 2004; Naidoo and Wills 2000). Thelimitations of having to rely on the concept ofHomo economicus when planning health pro-motion interventions can be (partly) negated,or improved through the use of qualitative re-search. Qualitative research methods are usefulin addressing the ‘why’ and ‘why not’; theycan add significant value to the ‘how much’and ‘how many’ questions.

C©2008 The University of Melbourne, Melbourne Institute of Applied Economic and Social Research

Published by Blackwell Publishing Asia Pty Ltd

Douglas, Greener and van Teijlingen: ‘Ask Me Why I’m Fat!’ 73

Qualitative research is widely used to un-derstand the range of different perspectivesheld by policymakers, service providers and(intended) users of health care. The lat-ter can ‘sensitise’ health professionals topatients’ views (Nunkoosing 2005; Green andThorogood 2004). It generates rich accountsof complex social phenomena and qualitativeresearch is particularly well suited to investi-gating questions of behaviour or experiences,opinion or beliefs, feelings and knowledge(Britten 2000). It also explores people’s subjec-tive understandings of their everyday lives (vanTeijlingen and Forrest 2004) and, based as it iswithin an interpretive framework, supports theinvestigation of meanings and understandingsthat emerge from place to place and from per-son to person (Rubin and Rubin 1995). Semi-structured interviews offer a framework thatenables comparisons between interviews, aswell as exploration of additional ideas in moredepth (Silverman 2001; Britten 2000; Gomm,Needham and Bullman 2000, pp. 199–209).

In our study, semi-structured interviews wereheld with 18 to 50 year old volunteers whowere overweight, lived in different parts of theUnited Kingdom and came from diverse eth-nic and socioeconomic backgrounds. Purposivesampling was used to recruit a broadly repre-sentative group (Mason 2002). Interviews wereaudio recorded and fully transcribed.

The computer program NVivo was used tomanage and code data and the Framework ap-proach was used for analysis and synthesis ofthe coded data. The latter allows the coded datato be displayed in a thematically headed grid,which was useful for our non-qualitative col-laborators.

3. Findings

Thirty-four people were interviewed by the sec-ond author as we explored a number of issues.Table 1 lists all key themes emerging from ouranalysis. Due to the word constraints for thisarticle we have focused on a small number ofthemes below. This paper concentrates on thefactors that participants believed had: (i) causedtheir weight problems; (ii) enabled them to loseor maintain weight in the past; and (iii) had

Table 1 Themes Identified among People

Who Are Overweight or Obese

Causes of weight problems• Laziness and gluttony• Inherited—genetics, family upbringing

or social environment• Response to life events or illness

Barriers to weight loss• Psychological• Social• Environmental (economic and physical)• Medical or biological

Enabling factors• Psychological or motivational• Social support and work• Environmental

prevented them from doing so. The quotes pre-sented below are illustrative examples of thethemes identified during this study. Quotes arenumbered to maintain anonymity.

3.1 Causes of Obesity

Accounts of the causes of obesity were domi-nated by beliefs of individual causation: peopleregarded it as a problem that they had created,or were individually responsible for, either di-rectly or indirectly. Participants described theirweight problems as due to: (i) being lazy andgluttonous; (ii) inherited, that is either geneti-cally, through their upbringing, or through theirsocial environment; and (iii) their response tolife events or illness. Most pointed to combi-nations of these factors as being more or lesssignificant at different times in their lives.

Gluttony and Laziness

Many talked of experiencing an energy imbal-ance which was blamed on their individual glut-tony, personal failure to resist bad foods andtheir lack of physical activity. Many viewedlifestyle choices as something that they hadcontrol over and that if they changed these, theywould achieve permanent weight loss. This isillustrated by the following quote.

Obviously, my problem was I was always eatingtoo much and therefore I wasn’t using enoughof the calories, but I can’t say the trigger was


74 The Australian Economic Review March 2008

emotional or anything it was just adrift. . . Youlike to eat the same as everyone else. I don’t blameanyone else, it’s my hand that’s putting the foodin my mouth (R02).

Interestingly, no one thought their over-weight status was due to hunger.

Inherited Biology, Family and SocialInfluences

While most blamed themselves for their weightproblems, many pointed simultaneously to‘hereditary’ elements. Participants would of-ten reveal late in the interviews the genetic orbiological reasons behind their struggles withweight issues. In the same vein, many believedthat they had learned ‘bad’ habits over thecourse of their life, mentioning early family ex-periences of meals and eating. The followingexcerpt is typical of ‘blaming’ genetics.

Yeah, because what everybody say is it the boneof me, the fact it’s not moving, I am eating less,because I coming to the dietician . . . I am goingto the gym and it still not moving (R14).

Other biological reasons included childbirth,with some women believing they had put onweight during pregnancy and were unable tolose it post partum. Age was also seen as anexplanatory factor. For example, it was usuallythought that getting to a certain age meant itwas harder to maintain a lower weight.

Life Events or Illness

Life events and changes in circumstances wereoften blamed for weight gain (and its loss). Forexample, marriage and employment status werelinked with weight changes, often because ofemotional changes experienced at these times.Some talked about periods of stress causingweight gain, while some others related stressto a loss of appetite. A common theme was abelief that food was a comfort (specifically intimes of stress).

We had, within a short period of time, we hada lot of deaths within the family, the only way

I can describe it is if you go to a zoo and yousee an animal in a cage, and it’s pacing back andforth you know, and, or they maybe would beeating but it was like frenzied eating, where a lotof normal people would go off their food if theywere worried about anything, I need to eat (R01).

Illness and injury also featured in these nar-ratives.

So if am depressed emm then I eat more, as I sayam just getting over a slipped disc I should begoing back to work next week and for two monthsI wasn’t able to do anything and for a month Iwasn’t even able to get dressed it is horrendousyour life goes on hold and you are in agony all thetime so what did I do I eat, because it was comfort,you know, so I do have a tendency to comfort eatso I have to know this there is other ways I noticethat I have found out that if I was sitting watchingtelly I eat I have broken that habit now (R11).

A related notion was boredom encourag-ing overeating or eating the wrong foodstuffs.Work was also linked with weight gain, as itpromoted a sedentary lifestyle or endorsed un-helpful eating habits, highlighted here.

Working on the fishing boats as well you see, youhad your three meals every day, it was fry upsmost of the time . . . you eat then you go to yourbed, when you are fishing, every meal is whenyou are finished on deck, you eat your meal thenyou go to your bed, it’s all totally different now(R05).

Another interviewee talked about the con-straints of work.

. . . it’s hard for someone like yourself in the jobyou do to kind of eat well sometimes cos it’salways like 10 minutes here, grab a pie (R30).

Smoking was also linked to weight gain bya sizeable number of respondents.

. . . when I quit smoking, I think it’s a shame be-cause I really want to quit smoking but one ofreasons that I do still smoke and I think it’s quitecommon for women is because I know I will puton weight when I quit smoking because it doeschange your metabolism (R19).



Other key life events that emerged were ceas-ing to play sport, imprisonment, social life andholidays. It is important to note that althoughmost offered opinions on this issue, a fewdid not consider themselves to have a weightproblem.

3.2 Factors that Prevented Weight Loss

Environmental: Economic and Physical

Among a range of factors (not discussed here),environmental (physical and economic) factorsfeatured heavily in the interviews. Poor localavailability of ‘good’ foods, and the subsequentcosts associated with travelling to buy it, werelinked with having a poor diet by some.

. . . other things that come into play, expense for astart, as a lot of the foods that I probably shouldeat are expensive to buy or if I wanted to, ournearest town is E. . . . which is 38 miles, still a bitof a trek. There are a lot of different factors thatcome into account, a lot of it is the irregularity ofthe hours I work and expense more than anything(R1).

The cost of healthy food compared with ‘rub-bish’ was also a barrier.

You know I think you’re programmed to go to thesupermarket to buy what’s on offer even if youever, you might never use the thing but when yousee an offer on half price . . . especially biscuitsand rubbish and that kinda thing, . . . They neverput fruit on half price or put offers on fruit as quickas biscuits or rubbishy stuff you know. . . (R27).

Geographical location and isolation alsofeatured for some as a barrier to obtainingweight management services or physical ac-tivity opportunities, because people lived toofar away or relied on others for transport.

A few mentioned concerns about their per-sonal safety preventing them going out in theevening, as highlighted by the following.

I went to Superslim . . . a community centre thing,but it closed down cus people wouldn’t come toit, everyone was frightened to come (R12).

3.3 Factors that Enabled Weight Loss

Just as weight gain was often linked with fac-tors outside of people’s control, so was weightloss. Some interviewees reported positive fac-tors arising from initial weight loss which en-couraged further weight loss and kept individ-uals motivated.

Psychological and Motivational

Concerns about ill health were less obviouscompared with being motivated to lose weightby more immediate concerns about appear-ances and feeling better about oneself. We iden-tified three key motivating issues: (i) familycelebrations; (ii) health; and (iii) work. The ef-fects experienced by those reporting success inweight loss then became their main motivationfor continuing to lose weight, or maintainingtheir lower weight. Almost all who had suc-ceeded at weight loss described comprehensivepositive feelings, usually associated with look-ing better, feeling more confident and havingmore energy. Interestingly, no one cited ‘feelingbetter’ as a reason in itself for losing weight.

. . . and now I’m not the grumpy, fat sod in thecorner anymore, I’m a lot more positive. It’s notjust the weight; it’s the attitude to things to ev-erything. The whole thing’s changed. I feel betterabout myself and it’s reflecting in the things I do,the way I carry myself, the way I speak. Eventhe family’s all cottoned on to it. Although sayingthat, I can still be a grumpy headed in the morningbut that’s par from the course but no, ‘changed somuch that amazes’. . . (R20).

Social

Support or pressure from friends and familywas often instrumental in successful weightloss. Some relied on friends or family to supportthem to attend weight management or exerciseclasses. However, sometimes respondents de-scribed pressure rather than support.

. . . eh I got letter I remember from an aunt of mine,my father’s sister saying she was on a diet andthat her husband, Uncle Ben, was being terriblysupportive . . . , so why didn’t you ever go on diet


76 The Australian Economic Review March 2008

for me, this was on my birthday so I went on dietafter that, but then I got pregnant (R02).

Changing jobs or finding employment wasdescribed as resulting in weight loss amongmany. This is either because some jobs allowfor healthier eating patterns or they involve in-creased activity levels.

. . . then eventually managed to get down to 12, Imanaged to stay at that weight for about a year, butI struggled, it really was a struggle and gradually. . . I managed to stay at that weight because mywork at that time meant I could have my breakfastat 8, my lunch at half past twelve, my tea later, Ihad a structured time (R01).

Environmental

Other factors that supported increased physicalactivity were dog ownership and feeling thatthere were accessible places to take physicalactivity.

I think the gym here is really good. It’s so cheapand it’s a really good facility here. . . . but gen-erally gyms can be quite expensive. I know fromhome, from when I was in college at home it wasquite expensive there but here is really good (R29).

4. Conclusion

As with any method, qualitative interviewshave inherent limitations but, as van Teijlingenand Forrest (2004) contend, they are the priceone pays for gaining more in-depth accounts ofthe phenomena under investigation. The resultsof qualitative studies often, but not always, havelimited possibilities for generalisation to otherpopulations, groups or settings. On a practicallevel, qualitative methods are generally time-consuming, with long, resource-intensive datacollection and analysis processes.

There are also a number of limitations whichbedevil both qualitative and quantitative re-search. For example, interviews are subject torecall bias (Grbich 1999, pp. 84–120); and itis impossible for interviewers to be completelyneutral (Rubin and Rubin 1995). However, it isa fallacy to suggest that any research can takeplace in a vacuum.

The qualitative themes provide us with in-sight into overweight people’s understandingand perceptions of their weight. The first keymessage is to realise that not everyone whois overweight perceives this as a problem. Sec-ond, many people have experience of some suc-cess, that is some weight loss, and failure, orregaining the weight after some time. Third, itis evident from our studies’ findings that widerdeterminants of individual behaviour, livingconditions and social circumstances need to betaken into account in the design of interven-tions and policies to reduce obesity levels insociety.

Several recent reports have highlighted theimportance of looking beyond ‘simplistic’individual behavioural change interventions(Government Office for Science 2007). Social,cultural and economic factors in people’s livescan seriously limit the individual choices opento them.

December 2007

References

Alder, B. 1999, Psychology of Health: Applica-tions of Psychology for Health Professionals,Harwood Academic Publishers, Amsterdam.

Britten, N. 2000, ‘Qualitative interviews inhealth care research’, in Qualitative Re-search in Health Care, eds C. Pope and N.Mays, BMJ Books, London.

Gomm, R., Needham, G. and Bullman, A.2000, ‘Loosely structured interviews: Thestories behind the statistics’, in EvaluatingResearch in Health and Social Care, SageOpen University, London.

Government Office for Science 2007, TacklingObesities: Future Choices—Project Report,Foresight Programme, Government Officefor Science, London.

Grbich, C. 1999, Qualitative Research inHealth: An Introduction, Sage, London.

Green, J. and Thorogood, N. 2004, QualitativeMethods in Health Research, Sage, London.

Green, L. W. and Kreuter, M. W. 1999, HealthPromotion Planning: An Educational andEcological Approach, 3rd edn, Mayfield,Boston.



Mason, J. 2002, Qualitative Researching, 2ndedn, Sage, London.

Naidoo, J. and Wills, J. 2000, Health Promo-tion: Foundations for Practice, Balliere Tin-dall, London.

Nunkoosing, K. 2005, ‘The problem with in-terviews’, Qualitative Health Research, vol.15, pp. 698–706.

Rubin, H. J. and Rubin, I. S. 1995, QualitativeInterviewing: The Art of Hearing Data, 1stedn, Sage, Thousand Oaks.

Silverman, D. 2001, Interpreting Qualita-tive Data: Methods of Analysing Talk,

Text and Interaction, 2nd edn, Sage,London.

Tones, K. and Green, J. 2004, Health Promo-tion: Planning and Strategies, Sage, London.

Tones, K. and Tilford, S. 2001, HealthPromotion: Effectiveness, Efficiencyand Equity, 3rd edn, Nelson Thornes,Cheltenham.

van Teijlingen, E. and Forrest, K. 2004, ‘Therange of qualitative research methods in fam-ily planning and reproductive health care’,Journal of Family Planning and Reproduc-tive Health Care, vol. 30, pp. 171–3.


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