obesity dissertation uk

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• v.11(6); 2021

Original research

Changing the narrative around obesity in the uk: a survey of people with obesity and healthcare professionals from the action-io study, carly a hughes.

1 Fakenham Weight Management Service, Fakenham Medical Practice, Fakenham, UK

2 Norwich Medical School, University of East Anglia, Norwich, UK

Amy L Ahern

3 MRC Epidemiology Unit, University of Cambridge, Cambridge, UK

Harsha Kasetty

4 Novo Nordisk Ltd, Gatwick, UK

Barbara M McGowan

5 Institute of Diabetes, Endocrinology and Obesity, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Helen M Parretti

Ann vincent.

6 Department of Medicine, University College London, London, UK

Jason C G Halford

7 School of Psychology, University of Leeds, Leeds, UK

Associated Data

Data are available upon reasonable request. De-identified participant data will be made available for this article on a specialised SAS data platform. Datasets from Novo Nordisk will be available permanently after completion of data analysis. Access to data can be made through a request proposal form and the access criteria can be found online (novonordisk-trials.com). Data will be shared with bona fide researchers submitting a research proposal requesting access to data. Data use is subject to approval by the independent review board.

To investigate the perceptions, attitudes, behaviours and potential barriers to effective obesity care in the UK using data collected from people with obesity (PwO) and healthcare professionals (HCPs) in the Awareness, Care, and Treatment In Obesity maNagement–International Observation (ACTION-IO) study.

UK’s PwO (body mass index of ≥30 kg/m 2 based on self-reported height and weight) and HCPs who manage patients with obesity completed an online survey.

In the UK, 1500 PwO and 306 HCPs completed the survey. Among the 47% of PwO who discussed weight with an HCP in the past 5 years, it took a mean of 9 years from the start of their struggles with weight until a discussion occurred. HCPs reported that PwO initiated 35% of weight-related discussions; PwO reported that they initiated 47% of discussions. Most PwO (85%) assumed full responsibility for their own weight loss. The presence of obesity-related comorbidities was cited by 76% of HCPs as a top criterion for initiating weight management conversations. The perception of lack of interest (72%) and motivation (61%) in losing weight was reported as top reasons by HCPs for not discussing weight with a patient. Sixty-five per cent of PwO liked their HCP bringing up weight during appointments. PwO reported complex and varied emotions following a weight loss conversation with an HCP, including supported (36%), hopeful (31%), motivated (23%) and embarrassed (17%). Follow-up appointments were scheduled for 19% of PwO after a weight discussion despite 62% wanting follow-up.

Conclusions

The current narrative around obesity requires a paradigm shift in the UK to address the delay between PwO struggling with their weight and discussing weight with their HCP. Perceptions of lack of patient interest and motivation in weight management must be challenged along with the blame culture of individual responsibility that is prevalent throughout society. While PwO may welcome weight-related conversations with an HCP, they evoke complex feelings, demonstrating the need for sensitivity and respect in these conversations.

Trial registration number

{"type":"clinical-trial","attrs":{"text":"NCT03584191","term_id":"NCT03584191"}} NCT03584191 .

Strengths and limitations of this study

• Strengths include the scientific rigour in the study design and implementation.
• The large number of UK respondents and the ability to directly compare the UK data to the equivalent global dataset is an additional strength.
• Limitations of this study include possible response bias from the population sampled and recall bias.

The causes of obesity are complex and multifaceted, encompassing biological, genetic, environmental, economic, social and psychological factors. 1–3 The chronic and relapsing nature of obesity is associated with many serious physical and psychological comorbidities, reduced quality of life and increased healthcare costs. 2 4–8 The WHO has recognised obesity as a disease, and the National Institute for Health and Care Excellence provides guidance on its assessment and treatment. 9 More recently, it has been recognised as a risk factor for severity of COVID-19 infection. 5 6 The prevalence of overweight and obesity among adults in the UK has been increasing and was 63% in 2018. 7 This increase is thought to be primarily caused by people’s latent biological susceptibility interacting with a changing environment that includes more sedentary lifestyles and increased dietary abundance. 1 The prevalence of adiposity in the UK population is approaching similar levels to those reported in the US (71%), Chile (74%) and Mexico (75%), which are among the highest recorded adult overweight and obesity levels in the world. 8 The number of people with obesity (PwO) in the UK continues to rise, and severe and complex obesity (body mass index (BMI) ≥40 kg/m 2 ) increased from less than 1% of the total population in 1993 to nearly 4% in 2017. 10 The UK-wide National Health Service (NHS) costs attributable to overweight and obesity are projected to reach £9.7 billion by 2050, with wider societal costs estimated to reach £49.9 billion per year. 11 The significant increase in the prevalence of obesity has not been matched by a proportionate expansion of continuing education on the biological basis and clinical management of obesity and training provision for healthcare professionals (HCPs), irrespective of their discipline. 12 Moreover, little effort has been made to address weight stigma and societal effects of weight bias, which continue to be experienced in a consistently negative way by those who have excess weight or obesity. Current evidence demonstrates that weight stigma is widespread in the UK, 13 that weight stigma is experienced in many settings 14 15 and that experience of stigma is associated with negative psychosocial outcomes, increased eating, reduced engagement with physical activity and weight gain. 16

The variability of causal pathways of weight gain is inherently unsuited to a ‘one size fits all’ treatment approach. 1 There is a range of existing guidance to support practice and care throughout the obesity care pathway in the UK. 9 17 However, the extent and range of the provision of weight management services is inconsistent and geographically dependent. 18 The obesity care pathway has an important role within the whole systems approach to tackling obesity, as outlined in the Foresight’s report, 1 and endorsed in the Department of Health and Social Care’s (DHSC) Call to Action 19 and the Public Health England’s paper on a whole systems approach to obesity. 20 The DHSC clinical policy outlines a tiered system of obesity care with a focus on public health and community advice in tier 1; primary care, community interventions and pharmacotherapy in tier 2; multi-disciplinary weight management service in tier 3 and secondary care and bariatric surgery in tier 4. 21

Despite its wide global prevalence, obesity remains poorly understood by the general public and HCPs, and this contributes to the high levels of stigma associated with obesity. 22 Society is continually informed through intense media coverage that obesity is simple and easily manipulated. 23 This attitude contributes to greater perceptions of individual responsibility, contrary to evidence that suggests that many factors outside a person’s control influence obesity. 22 23 To improve the quality and accessibility of obesity care, a better understanding of the disease and the gaps between current and optimal obesity management strategies is required. The Awareness, Care, and Treatment In Obesity maNagement–International Observation (ACTION-IO) study assessed the perceptions, attitudes and behaviours of PwO and HCPs. 24 The global dataset 24 revealed a need to increase understanding of obesity and improve education concerning its aetiology. The aim of this subanalysis was to identify the perceptions, attitudes, behaviours and potential barriers to effective obesity care in the UK.

Study design and participants

The ACTION-IO study was a cross-sectional, non-interventional study that collected data via an online survey in Australia, Chile, Israel, Italy, Japan, Mexico, Saudi Arabia, South Korea, Spain, the UK and the United Arab Emirates. The full methods for the ACTION-IO study have been reported previously. 24 Eligible PwO in the UK were 18 years or older, with a current BMI of at least 30 kg/m 2 based on self-reported height and weight. The PwO sample was targeted for demographic representativeness based on gender, age, income, race/ethnicity and region. Therefore, PwO were excluded if they declined to provide any of these variables. Respondents were also excluded for non-obesity reasons, for high BMI or for dramatic weight loss, that is, if they were pregnant, participated in intense fitness or body building programmes, or had significant, unintentional weight loss in the past 6 months. Eligible UK’s HCPs were in practice for 2 years or more, with at least 70% of their time spent in direct patient care, and who had seen 100 or more patients in the past month, at least 10 of whom had a BMI of at least 30 kg/m 2 . HCPs specialising in general, plastic or bariatric surgery were excluded. Respondents were recruited via online panel companies (via email) to whom they had given permission to be contacted for research purposes, and completed the survey in English. All respondents provided electronic informed consent prior to initiation of the screening questions and survey. Preceding participation, PwO were only informed of the purpose of the study, and were blinded to the specific study goals.

Survey development and procedures

The study was designed by an international steering committee of obesity experts (representing primary care, endocrinology and psychology, and including three medical doctors employed by Novo Nordisk), with support from KJT Group (Honeoye Falls, New York, USA), and based on the ACTION US and Canada questionnaires. 25 26 KJT Group managed the acquisition and analysis of data; UK responses were collected between September 2018 and October 2018. Questionnaire items were carefully phrased and presented in identical order for each respondent. Items in a list were displayed in alphabetical, categorical, chronological or random order as relevant for each response. Respondents accessed the survey using a unique web link, details regarding the digital fingerprinting system used to assess unique site visitors has been previously described. 24 To prevent duplicate survey entries, unique site visitors were recorded via a user ID that was passed along the unique web link that respondents used to access the site. The system checked every respondent entering the survey against previous user IDs logged in its database. Respondents who began the survey and suspended were able to re-enter the survey while it was still open and finish the survey where they left off. Respondents who had already received a terminal status (complete, over-quota or terminate) were blocked from re-entering the survey. Following closure of the survey, no users were able to gain access. The user ID and data of suspended respondents were stored until the survey was closed and were then eliminated from the data analysis. The study was conducted in accordance with the Guidelines for Good Pharmacoepidemiology Practices. 27

To ensure representativeness to the general population, the final PwO sample was weighted to demographic targets within each country for age, gender, income, race/ethnicity and region. The HCP data were not weighted. Only data from those who completed the survey were included in the analyses.

Patient and public involvement

No patients or members of the public were involved in the design or conduct of the study. A patient representative was involved in the analysis and interpretation of the UK data and is an author on this article. She will also be involved in disseminating these findings to a wider audience.

Demographics

A total of 69 676 PwO and 2508 HCPs, in the UK, were invited. The response rate to the survey was 14% (9786/69 676) for PwO and 35% (886/2508) for HCPs, as expected for this type of study and in line with the target sample size. 24 Of those who completed the screening questions, the eligibility rate was 22% (2146/9779) for PwO and 53% (387/737) for HCPs. The final UK sample for the ACTION-IO survey was 1500 PwO and 306 HCPs, of whom 156 were primary care professionals (PCPs) and 150 were secondary care professionals (SCPs) ( table 1 ). Some differences were observed in the survey outcomes between PCPs and SCPs, which will be reported in full at a later date.

Sample demographics and characteristics

All ‘n’ sizes for PwO are from unweighted data. Demographic percentages (age and gender) are also from unweighted data. All non-demographic percentage results are for PwO weighted data. HCP data were not weighted; therefore, n sizes and percentages are all unweighted data.

*Participation rate (those who completed the screener) was 99.9% for PwO and 84.7% for HCPs; completion rate was 100% for PwO and 85.8% for HCPs.

†Disclosure of height and weight was optional for HCPs. The percentages for the BMI categories were calculated using the number of respondents to this question as the denominator.

‡A physician who meets at least one of the following criteria: at least 50% of their patients are seen for obesity/weight management; or has advanced/formal training in treatment of obesity/weight management beyond medical school; or considers themselves to be an expert in obesity/weight loss management or works in an obesity service clinic. 24

BMI, body mass index; HCP, healthcare professional; PCP, primary care professional; PwO, people with obesity; SCP, secondary care professional.

Pre-consultation and initiation of weight management discussion

People with obesity.

Only about half (47%) of all PwO had discussed excess weight or losing weight with an HCP in the past 5 years. It took a median of 6 years and mean of 9 years (range: 0.0–56.0 years; IQR: 13 years) between the time when PwO said that they first started struggling with excess weight or obesity and when they first had a weight management conversation with an HCP ( figure 1A ). In comparison, globally it took a median of 3 years and a mean of 6 years (range: 0.0–68.0 years; IQR: 8 years ( figure 1A )). 24 Forty-seven per cent of PwO who discussed weight with an HCP reported that they initiated the conversation themselves. When PwO were asked to name the top five reasons why they may not discuss weight management with their HCP, the most common reason was the belief that it was their own responsibility to manage their weight (51% of PwO) ( figure 1B ). Indeed, when asked whether they agreed with the statement ‘my weight loss is completely my responsibility’, 85% of PwO agreed with the statement. Thirty-four per cent of PwO said that they were motivated to lose weight, and 36% provided a neutral response (neither agreed nor disagreed that they were motivated). Only 4% of PwO reported an indifference to losing weight as a reason for not discussing managing their weight with an HCP. Sixty-five per cent of PwO who previously had a weight conversation with their HCP liked that their HCP discussed their weight with them, and 58% who not previously had a conversation would have liked their HCP to bring up weight during their appointments. Most PwO (81%) believed that obesity has a large impact on overall health, similar to other chronic diseases such as diabetes (82%), stroke (88%), cancer (82%) or chronic obstructive pulmonary disease (COPD; 84%). The internet was cited as a source of information used by 31% of PwO for managing weight ( figure 2A ). Other sources of information were reported as family and friends (27%), weight loss programmes (26%), information from an HCP (23%) and media (books/magazines: 21%, television programmes: 20%) ( figure 2A ).

Number of years between when struggle with weight began and first discussed with an HCP and PwO/HCP reasons for not discussing weight management. (A) Approximate number of years reported by the UK and global PwO (ACTION-IO study steering committee, personal communication) between the beginning of their struggle with weight and first discussion with an HCP. Calculated at respondent level from questions, ‘Approximately how old were you when you first remember struggling with excess weight or obesity?’ and ‘Approximately how old were you when a healthcare provider first discussed your excess weight or recommended that you lose weight?’. (B) Reasons reported by the UK’s PwO for not discussing managing their weight with an HCP. (C) Reasons reported by the UK’s HCPs for not discussing weight management with their patients. ACTION-IO, Awareness, Care, and Treatment In Obesity maNagement–International Observation; HCP, healthcare professional; PwO, people with obesity.

Sources of information and feelings after a weight discussion. (A) Sources of information most frequently used by the UK’s PwO for managing weight (reported by PwO). (B) Feelings reported by the UK’s PwO after their most recent weight or weight loss discussion with an HCP in the past 5 years. HCP, healthcare professional; PwO, people with obesity.

Healthcare professionals

Those HCPs who discussed weight with their patients reported that 35% of the time the patient initiated the conversation. Compared with PwO (85%), a smaller proportion of HCPs (33%) placed the responsibility for weight loss on PwO. Only 13% of HCPs thought that their patients were motivated to lose weight, and 42% provided a neutral response (neither agreed nor disagreed that their patients were motivated). The most commonly selected reason for not discussing weight management with a patient (selected by 72% of HCPs) was the perception that the patient was not interested in losing weight, and 61% of HCPs selected lack of patient motivation ( figure 1C ). Other reasons provided for not discussing obesity with a patient were that the appointments were not long enough and that they felt rushed (selected by 68% of HCPs), and that more important health issues/concerns were an impediment to discussing obesity with a patient (selected by 58% of HCPs). In addition, almost one-third of HCPs (31%) reported that the good health of a patient and the absence of weight-related comorbidities would be a reason for not discussing weight management. The most important criterion for initiating weight management conversations with a patient was the presence of obesity-related comorbidities, cited by 76% of HCPs. Only 68% of the UK’s HCPs (vs 76% of global HCPs 24 ) recognised the impact of obesity on health, and it was rated as less serious than diabetes, cancer, stroke or COPD by 40%, 65%, 62% and 43% of the UK’s HCPs, respectively.

Consultation

Eighty-one per cent of the PwO who had discussed weight with an HCP had had a discussion with a PCP, 42% with a nurse, 18% with a dietitian/nutritionist and 17% with a diabetes educator. PwO reported a complex mixture of feelings following a weight loss conversation with an HCP ( figure 2B ). PwO cited a combination of feelings such as supported 36%, hopeful 31%, motivated 23%, embarrassed 17%, indifferent 16%, discouraged 11%, relieved 10%, blamed 10%, rushed 10%, offended 4% and confused 4% ( figure 2B ).

Fifty-nine per cent of HCPs reported that they were extremely or very comfortable discussing weight, 30% were neither comfortable nor uncomfortable and 11% were a little or not at all comfortable discussing weight. On average, HCPs reported that they spent 10 min interacting with their patients when discussing weight (range: 1–20 min).

Consultation outcomes and follow-up

Among the 47% of PwO who had discussed their weight with an HCP in the past 5 years, 49% reported that they had been diagnosed with obesity in the past by an HCP (24% of all PwO, figure 3 ). Only 19% of PwO who had discussed their weight with an HCP had a follow-up appointment scheduled (9% of all PwO) ( figure 3 ). However, 62% of PwO would have liked a follow-up appointment and 96% reported attending or planning to attend a follow-up appointment if scheduled. The most frequent methods for managing weight tried by PwO were general improvements in eating habits/reducing calories (reported by 61% of PwO) and general increases in physical activity (55%), which were reported at a greater frequency than by global PwO (51% and 39% for general eating habits and physical activity, respectively; ACTION-IO study steering committee, personal communication). Bariatric surgery and behavioural therapy referral rates were reported in small numbers by the UK’s PwO (1% and 2%, respectively). Visits to a nutritionist/dietician and obesity specialist were reported less frequently by the UK’s PwO than global PwO (nutritionist/dietician: 11% UK, 24% global; obesity specialist: 2% UK, 9% global; ACTION-IO study steering committee, personal communication).

Obesity diagnoses and follow-up appointments with an HCP. Proportion of the UK’s PwO who discussed weight or weight loss with an HCP in the past 5 years and the frequency of obesity diagnoses and follow-up appointments. HCP, healthcare professional; PwO, people with obesity.

On average, HCPs scheduled follow-up appointments with 33% of their patients for obesity and 46% of HCPs said that patients kept these follow-up appointments always or most of the time. HCPs most frequently recommended general improvements in eating habits/reducing calories (reported by 61% of HCPs) and general increases in physical activity (65%). Referrals to obesity specialists were recommended less frequently by UK HCPs (12%) compared with the global dataset (23%). 24

PwO are faced with biological predispositions, and societal and environmental conditions that contribute to obesity, weight stigma and discrimination. Obesity prevention and management are key health priorities and require a whole systems approach. However, the national response for obesity focuses on individual responsibility regarding nutrition and lack of physical activity. In this study, multiple barriers to effective weight management were identified, which are summarised in figure 4 and discussed below.

A conceptual model of the obesity treatment pathway and barriers to obesity care in the UK. BMI, body mass index; HCP, healthcare professional; PwO, people with obesity.

Initiation of weight management discussion with HCPs

Fewer than half of PwO in the UK (47%) had a discussion with an HCP about their weight in the past 5 years, despite HCPs being the gateway to weight management care in the NHS. Moreover, for the PwO who did have a weight discussion, it took a mean of 9 years after they first started struggling with their weight before having the discussion (compared with 6 years globally). 24 This delay is particularly important as it may create an opportunity for significant obesity-related complications to develop. This long delay may also reflect a higher degree of obesity stigma in the UK 28 and a culture of individual responsibility for obesity. 29 30 Indeed, a focus on individual responsibility is reflected in UK government policy on obesity. 31 Reducing the time gap by initiating earlier weight management discussions may be an effective strategy for improving obesity treatment and preventing the development of comorbidities.

From the PwO perspective, a delay in seeking help could be linked to the high percentage (85%) of PwO who perceived their weight loss as completely their responsibility. From the HCP perspective, a delay in discussing obesity with a patient could be linked to reported perceptions that the patient was not interested or motivated in losing weight, consistent with previous research. 32 33 Other impediments to the discussion were HCPs’ views that there were more important health issues to discuss and that a weight management discussion is only required when weight-related comorbidities are present, as supported by other studies. 33 34 Moreover, HCPs in the UK underestimated the effect of obesity on health to a greater extent than the UK’s PwO and global HCPs. 24 For PwO, this will likely require a change in the narrative around obesity to lessen focus on individual responsibility, and for HCPs a need to increase the understanding of the health consequences of obesity and the desire of PwO for help and support. The internet, media, and family and friends formed a substantial source of information for PwO for managing weight. We need to change this from personal responsibility to recognising the aetiology of obesity and its implications for PwO.

Primary care is the gateway to obesity treatment, and most weight management discussions were held with a primary care physician or nurse. While many PwO welcomed weight discussions with HCPs, they also reported experiencing complex and varied emotions after these discussions. It is important to acknowledge the complexity of the experience for PwO. Studies have previously reported patients feeling that their obesity had been ignored, dismissed, distorted or attributed as the explanation of all their health problems by HCPs. 35–37 Negative experiences can contribute to depression, anxiety, low self-esteem and body dissatisfaction. 38 39 Dissatisfactory conversations with an HCP may discourage PwO from seeking further weight management help in the future and reinforce feelings of personal responsibility for weight management. The attitudes of health professionals towards obesity and its management have been generally reported to be negative, and knowledge and skills in managing obesity have been noted to be inconsistent. 40–45 Even well-intended acts can cause offence and humiliation, 46 and PwO often experience their weight in profoundly negative ways as a result of the pervasive stigmatisation of obesity. Patient experiences are valid indications of the strengths and shortcomings of the services they receive. 47 It is important to ensure that the narrative around obesity resonates with the lived experiences of those affected by it and encourages patients to engage with an HCP. 47 HCPs in turn should aim to provide compassionate care that is free of bias and use supportive communication and language to facilitate successful and meaningful conversations. 47

HCPs often have limited time and resources, and lack of time has previously been reported as a barrier to discussing obesity. 48 49 More HCPs in the UK (68%) than globally (54%) indicated that the limited appointment time would be a factor in not having a weight loss conversation. 24 This may be a reflection of the average primary care consultation time in the UK, which is 10 min and considerably shorter than in many other countries. 50 51 Other potential barriers described in the literature have included uncertainty about appropriate language, 48 concerns about compromising rapport 9 and concerns discussing a potentially upsetting and stigmatising topic. 22 50 52 However, in this study, relatively few HCPs reported discomfort with weight discussions.

Obesity diagnoses, follow-up appointments and referrals to specialists were infrequently reported by PwO, which could incorrectly reinforce the feeling of individual responsibility. Indeed, methods for managing weight reported by PwO, which relied largely on general improvements in eating habits and physical activity, suggest a lack of knowledge of effective treatment methods and/or a consequence of the availability of therapeutic options (see below).

The data from HCPs on the frequency of follow-up appointments and methods for obesity management largely aligned with the data from PwO. Barriers to effective weight management cited in the literature have included lack of effective and individualised treatment and/or referral options. 40 41 50 53 Weight management services in the UK exist as part of fragmented health and social care systems, which are geographically dependent. 49 54 55 The range of services and treatments, including pharmacotherapy and bariatric surgery, is limited in the UK, which may restrict HCPs in what they can offer patients. Indeed, HCPs report insufficient management options and scepticism about their efficacy. 56 57 This is further compounded by limited consultation times for the UK’s general practitioners. 50 51 The limited availability of weight management services, effective treatments and coherent, joined-up strategies in the UK health system are significant barriers to providing effective obesity care. 55

Strengths and limitations

Strengths of this study include scientific rigour in the study design (including carefully phrased and ordered questions to prevent biased responses, blinded purpose of the survey for PwO and determination of eligibility by initial screening questions to eradicate bias during recruitment) and implementation (including stratified sampling to provide a representative cohort of the general population and rigorous data analysis). Other strengths include the large number of UK’s PwO and HCP respondents and the ability to directly compare the UK data to the equivalent global dataset. Limitations include the cross-sectional design and reliance on accurate reporting from the PwO and HCP respondents, which could be perceived as recall bias. The self-reported height and weight could underestimate the BMI of the PwO. A higher proportion of HCPs than might be expected self-identified as obesity specialists using the broad criteria specified in table 1 . The low response rates could affect sample representativeness and is a known limitation for this type of study. Response bias from the population sampled cannot be ruled out. However, the PwO sample was representative of the demographics of the general population.

This study demonstrates the need to change the narrative around obesity, with less stigmatising focus on individual responsibility, for the government, commissioners, general public, PwO and HCPs. The findings identified areas that prevent PwO from seeking help and receiving appropriate care. In addition, the attitudes of HCPs prevent them from offering the support PwO require for obesity management. The consultation about weight with an HCP is the gateway to treatment in the NHS and improving the frequency and quality of PwO–HCP conversations is essential. Sufficient time should be given to HCPs to approach the topic of overweight and obesity sensitively and effectively. The current survey did not have high numbers of people with a BMI of over 40 kg/m 2 ; further research is required to understand whether people with higher BMIs have distinct experiences in the management of their obesity.

To conclude, a whole systems approach is required to address and eliminate weight bias and stigmatisation, to change the narrative around obesity in the UK, and to improve provision of NHS services. Educating the whole population, including PwO and HCPs, about the aetiology and psychology of obesity and the interaction with the obesogenic environment should help to ensure that patients access and receive quality care and effective weight treatment and management. Changing the narrative around obesity will allow for a more effective delivery framework for health service providers and greater access to effective treatment pathways and weight management services for PwO.

Supplementary Material

Acknowledgments.

We thank the participants of the study. Medical editorial assistance was provided by Anna Bacon from Articulate Science, and was funded by Novo Nordisk.

Contributors: CAH and JCGH are members of the ACTION-IO study steering committee and contributed to the design of the study. CAH, ALA, HK, BMM, HMP, AV and JCGH participated in the interpretation of data, and drafting and revision of the manuscript. All authors reviewed and approved the final, submitted version.

Funding: This work and ACTION-IO was supported by Novo Nordisk. ALA is funded by the Medical Research Council through grant MC_UU_00006/6.

Competing interests: CAH reports financial support from Novo Nordisk to attend an obesity conference during the conduct of the study, grants from the Rona Marsden Fund at Fakenham Medical Practice and personal fees from Orexigen Therapeutics, Consilient Health, Nestlé, Ethicon and Alva outside the submitted work. ALA reports grants from UKRI Medical Research Council and National Institute for Health Research, and non-financial support from WW (formerly Weight Watchers). HK is an employee of Novo Nordisk and owns shares in Novo Nordisk. BMM reports grants paid to her institution from Novo Nordisk and personal fees (consultancy and advisory board) from Novo Nordisk, Boehringer Ingelheim and Orexigen Therapeutics; and has received speaker fees for Eli Lilly, Novo Nordisk, Boehringer Ingelheim, Janssen, MSD and Sanofi. HMP reports grants from the National Institute for Health Research and Public Health England and an honorarium from Novo Nordisk (educational grant) outside the submitted work. AV acted as a speaker for Obesity Empowerment Network and is a board member of the Clinical Advisory Committee on the All Wales Obesity Strategy. JCGH reports fees (honoraria) paid to the University of Liverpool from Novo Nordisk, Orexigen and Boehringer Ingelheim during the conduct of the study.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not required.

Ethics approval

The National Health Service Health Research Authority (Central Research Ethics Committee, London) advised that ethical approval was not needed in the UK.

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A Qualitative Study of Local Obesity Policy Processes across South Yorkshire

--> Weir, Carol J (2019) A Qualitative Study of Local Obesity Policy Processes across South Yorkshire. PhD thesis, University of Sheffield.

Introduction Obesity is a serious public health problem facing England, the UK, and other high-income countries. In South Yorkshire, childhood and adult obesity prevalence is consistently reported amongst the highest in England. Local authorities have a responsibility for population health with numerous levers available to influence obesity. Currently there is limited evidence on how local obesity policy processes operate in England. This research explores local obesity policy processes in practice, through a set of case studies in South Yorkshire. It draws on Bacchi’s (2009) WPR (what the problem represented to be) approach, in order to understand how obesity is framed as a policy issue and how this shapes local policy practices. Methods An interpretative qualitative approach was taken. Documentary analysis of local policies was completed (n=52) using a Framing Matrix (Jenkin et al. 2011). Semi structured interviews were completed with a purposive sample of local authority and Clinical Commissioning Group leaders, public health commissioners and weight management service providers (n=40), using thematic analysis. Results Despite nuances, obesity was dominantly represented across South Yorkshire as an individual health issue related to choices about diet and physical activity. This representation was operationalised in the context of: a lack of clarity on responsibilities for effectively addressing obesity; reducing resources; challenges of public health leadership in local authorities; and a lack of effective local leadership and governance for obesity. Combined, these factors influence local (in)action, prioritisation and resource allocation for approaches or interventions, and subsequent outcomes and impacts on local obesity prevalence. Conclusion Local obesity policy is developed and implemented within a complex, socio-political local public health system. The changes from the Health and Social Care Act (2012) led to local obesity policy ‘inertia’, set in the context of challenges of local views of obesity, evidence of effectiveness, financial constraints, and a lack of clarity regarding local responsibility for action. Whole systems approaches have been advocated as having potential to address these complex issues in a system, however, without any evidence of impact to date.

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• Research article
• Open access
• Published: 25 March 2011

The views of young children in the UK about obesity, body size, shape and weight: a systematic review

• Rebecca Rees 1 ,
• Kathryn Oliver 2 ,
• Jenny Woodman 3 &
• James Thomas 1  

BMC Public Health volume  11 , Article number:  188 ( 2011 ) Cite this article

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There are high levels of concern about childhood obesity, with obese children being at higher risk of poorer health both in the short and longer terms. Children's attitudes to, and beliefs about, their bodies have also raised concern. Children themselves have a stake in this debate; their perspectives on this issue can inform the ways in which interventions aim to work.

This systematic review of qualitative and quantitative research aimed to explore the views of UK children about the meanings of obesity and body size, shape or weight and their own experiences of these issues.

We conducted sensitive searches of electronic databases and specialist websites, and contacted experts. We included studies published from the start of 1997 which reported the perspectives of UK children aged 4-11 about obesity or body size, shape or weight, and which described key aspects of their methods. Included studies were coded and quality-assessed by two reviewers independently.

Findings were synthesised in two analyses: i) an interpretive synthesis of findings from open-ended questions; and ii) an aggregative synthesis of findings from closed questions. We juxtaposed the findings from the two syntheses. The effect of excluding the lowest quality studies was explored. We also consulted young people to explore the credibility of a subset of findings.

We included 28 studies. Instead of a focus on health, children emphasised the social impact of body size, describing experiences and awareness of abuse and isolation for children with a greater weight. Body size was seen as under the individual's control and children attributed negative characteristics to overweight people. Children actively assessed their own size; many wished their bodies were different and some were anxious about their shape.

Reviewers judged that children's engagement and participation in discussion had only rarely been supported in the included studies, and few study findings had depth or breadth.

Conclusions

Initiatives need to consider the social aspects of obesity, in particular unhelpful beliefs, attitudes and discriminatory behaviours around body size. Researchers and policy-makers should involve children actively and seek their views on appropriate forms of support around this issue.

Peer Review reports

There are high levels of concern about obesity in Westernised societies, and about obesity in children in particular [ 1 ]. The National Child Measurement Programme (NCMP) was implemented in the UK in order to monitor changes in average body size amongst children who are starting or about to leave primary education. In 2008/9 this classified almost one in ten (9.6%) children aged 4-5 as obese and, for 10-11 year olds, almost one in five (18.3% [ 2 ]. Children are likely to experience immediate physical and psychosocial problems as a result of being obese and are at a higher risk of obesity as they grow older [ 3 ]. Children's attitudes to and beliefs about their bodies, which can include high levels of body dissatisfaction, have also raised concern [ 4 , 5 ].

The right of children to participate in decision-making that relates to them is enshrined in the United Nations Convention on the Rights of the Child [ 6 ]. Children, like other members of society, have a stake in debates about body size, and their ideas about health and other aspects of their lives are increasingly seen as valid contributions to the development of social policy [ 7 , 8 ]. As well as leading to more effective policies and better services, research and policy-making that involves children actively in debate and decision-making can provide them with experiences of collective work and create a culture of shared responsibility and mutual trust [ 9 ]. Recent initiatives that act on this include one that has involved young people as advisers to a nationwide public health research programme [ 10 ].

Systematic reviews of intervention research indicate that there is a dearth of evidence from well-conducted studies to help us decide what can be done to prevent or deal with obesity [ 11 , 12 ]. Although children's own perspectives on obesity and body size, shape and weight can inform the ways in which interventions aim to bring about positive outcomes, there has been no previous attempt to bring studies of children's perspectives together. This systematic review aims to address this gap and to examine recent research findings where children aged from four to eleven provide views about their own body sizes or about the body sizes of others. The review sought studies conducted recently in the UK with the aim of informing policy development and the commissioning of further research in the UK. An additional review was conducted of studies of young people aged 12-18, as it was considered that perspectives might differ considerably between these two groups (at the time of writing, the report of this separate review is completed but under peer review).

This review addressed the following questions:

What are children's views about the meanings of obesity or body size, shape or weight (including their perceptions of their own body size), and what experiences do they describe relating to these issues?

What are children's views about influences on body size?

What are children's views about changes that may help them to achieve or maintain a healthy weight?

Inclusion criteria

To be included in the review, studies had to report views about obesity, body size, shape or weight, sought from children in the UK aged four to eleven. Reports needed as a minimum to have described one of two key aspects of a study's methods (either data collection or analysis). They needed to have been published in English since the start of 1997 (to cover this recent period of heightened public health, research and media interest in the topic of obesity). Studies where all children had multiple, complex health needs were excluded.

We defined views as attitudes, opinions, beliefs, feelings, understandings or experiences, and excluded studies that measured only health or weight status, behaviour or factual knowledge. Views could be reported as a point on a scale, as agreement with a statement, as an answer to a closed question or as answers to, and discussion around, open-ended questions.

The inclusion criteria were initially piloted by four reviewers and a sample of early screening decisions was double-checked by the first-named author at the start of the screening process. Screening was then done individually by the four reviewers.

Search strategy

During June and July 2009, we searched 18 electronic databases from the fields of health, public health, education, social science and social care, taking care to include sources rich in UK-based journal and report literature. To supplement this, we searched three key journals and sixteen websites by hand, scanned reference lists, looked for papers that had cited key studies, and contacted key informants for relevant research. Additional file 1 (online) details the search strategy in full. We managed review data using our specialised online review software EPPI-Reviewer [ 13 ].

Describing and appraising studies

We described the final set of included studies using a standardised classification system developed for public health and health promotion research [ 14 ], and another set of questions which built upon frameworks used in previous reviews of the views of children and young people [ 15 ].

We appraised the quality of included studies using criteria modified from a set developed for examining the findings of evaluations of intervention processes (Table 1 ) [ 16 , 17 ]. As a final step in quality assessment, the studies were each allocated a 'weight of evidence' in two dimensions. First, we assigned a weight (low, medium or high) to rate the reliability or trustworthiness of the findings (the extent to which the methods employed were rigorous and minimized bias and error). This weighting focused on the criteria numbered 1 to 4. Secondly, we assigned a weight to rate the usefulness of the findings within our review (based on the richness and complexity of the description and analysis of children's views, and whether or not the data threw light on children's own perspectives of body size). This weighting focused on the criteria numbered 5 and 6. For all of the tasks, two reviewers worked independently on each study, then compared their descriptions and judgements, and came to a consensus.

We synthesized findings in two separate analyses. One aimed to develop conceptual themes. This used the findings of studies where children had been enabled, by open-ended questioning, to describe their views in their own words. We labelled this synthesis 'interpretive' to reflect both the methods employed in the primary studies and those used to synthesise them (see below). The second synthesis used findings where children selected from responses already set by researchers. These researchers then explored variation in responses, for example in terms of differences in age, gender or Body Mass Index (BMI). We labelled this second synthesis 'aggregative', to capture the way that it, and the studies within it, primarily aimed to summarise data.

Two reviewers worked on the syntheses. In the interpretive synthesis, we used thematic synthesis to examine each line of each study's findings and create codes that described their meaning and content [ 18 ]. We then looked for similarities and differences between codes, grouped them into a hierarchical tree structure and wrote a narrative to illustrate each theme. For the aggregative synthesis, we grouped analyses into categories according to the type of view that had been analysed and then wrote a descriptive account of the reported findings [ 19 ]. We then looked at each finding from the two syntheses in turn to see if it related to a theme or question in the other synthesis. This brought together findings about perceptions and experiences of body size rooted in children's perspectives with findings about the circumstances in which children might hold these and other kinds of views about body size.

We drew up a table for each synthesis to count the number of themes to which each study contributed. This was then examined to see how much influence the lowest quality studies had on the syntheses.

User involvement

The study was designed with the assistance of an expert steering group that included a representative from the review's funder. The group provided feedback on the review protocol.

We held a consultation with young people that explored the credibility of part of the review's findings. The consultation was held in two workshops organised by PEAR, a group established by the National Children's Bureau to enable young people's views and opinions to influence public health research [ 20 ]. After a brief discussion of the review's aims, participants in each workshop discussed the themes developed in the interpretive synthesis. They were asked whether they seemed believable and whether they thought any important themes were missing [ 19 ].

This section describes the focus and quality of recent UK-based research that has asked children for their views on body size. It then presents the substantive findings, and ends with findings from the consultation and the sensitivity analysis.

The state of the literature: in what ways have children in the UK been asked for their views about body size?

A total of 11,128 citations were identified and screened for relevance and 28 studies were found that could be incorporated into the review's syntheses (Additional file 2 - online - details the process of excluding studies).

These studies varied considerably in terms of their stated aims and collection of data (see Additional file 3 - online - for a description of each study). Of the 15 studies in the interpretive synthesis, only seven focused directly on body size, shape or weight, or the act of measuring BMI [ 21 – 27 ]. Five studies explored a variety of perceptions about either physical activity [ 28 , 29 ] or children's eating [ 30 – 32 ]. Three were focused more broadly on mental health, or on health as a whole [ 33 – 35 ]. The 13 studies in the aggregative synthesis [ 36 – 48 ] were in the main focused on attitudes towards body size, and explored the relationships between children's views (for example, perceptions of their own size, body shape ideals, satisfaction and stereotyping responses) and demographic variables such as gender and age.

We found no studies that asked children directly what they thought should be done to help them to reach or maintain a healthy size. The rest of this paper reports findings about the meanings of body size for children (including their perceptions about their own body size) and their reported experiences in this area. Findings about children's views about influences on body size are reported in full elsewhere [ 19 ].

Nearly all of the children in the 28 studies were recruited through their schools and were described as having a normal range of body sizes, or were not characterized at all in these terms. Only three studies aimed to study children with very high body sizes [ 22 , 24 , 27 ]. Children's ethnicity and socio-economic status were also frequently not stated by the study authors. Only eight studies included children aged under seven [ 25 , 28 , 29 , 33 , 35 – 38 ].

In terms of quality, very few studies were judged to have highly reliable findings (Additional files 4, 5 and 6 - online). For example, many studies providing data for the interpretive synthesis reported their data analysis methods only very briefly, or not at all. Few in the aggregative synthesis reported methods for increasing sampling rigour. Furthermore, many studies were judged to have taken only minimal steps to privilege children's perspectives; steps which were necessary to provide the most useful data for this review. Only a few, for example, appeared to have used questioning techniques that encouraged children to develop their own ideas.

Four studies in the interpretive synthesis [ 25 , 27 , 28 , 34 ] and two studies in the aggregative synthesis [ 38 , 48 ] were judged to be low in terms of both reliability and usefulness for those syntheses. An analysis of the potential influence of excluding the findings of these six studies from the synthesis can be found at the end of the results section.

Substantive findings: what does body size mean to children and what are their perceptions and experiences of their own and others' body sizes?

The children's perceptions and experiences of their own and others' body sizes were grouped under four main themes: i) how body size is or is not a matter of importance in the world; ii) desirable and acceptable bodies; iii) embodied experiences (children's experiences of and feelings about their own body sizes); and iv) gender. A further 15 sub-themes arose from these findings (see Table 2 ) and the remainder of this section illustrates these in turn. The complete set of themes produced in the syntheses can be found in the review's technical report [ 19 ].

Body size matters

Body size might not always seem relevant.

The salience of body size for children varied. Some did not mention body size at all when asked about issues that were important for them, or for their health or well-being [ 22 , 34 , 35 ]. It was thought that size might be a problem later in life, rather than in the present [ 21 , 32 , 35 ]. As one child put it,

'as a teenager you get fat and have other problems and that's when you need help most.'[[ 35 ]; p35]

Body size was, however, clearly highly central to many overweight children's lives. When encouraged to talk about any aspect of their lives, several very overweight children in one study introduced body size as the very first thing they wanted to talk about [ 22 ].

Being overweight is seen as a social problem

The main aspect of body size considered important by children, regardless of their own size, appeared to be how being large can affect popularity and fitting in. Body size was seen by children to affect both the way they interact with each other and how included they feel. Children thought that overweight children might not have people to play with, or be lonely [ 34 ], might be less popular than thin children [ 21 , 34 ], might only have fat friends [ 30 ], might need to choose a boyfriend or girlfriend the same size as themselves [ 21 ], or might even need to get slim in order to make friends [231, [ 22 ]].

Body sizes are judged

Some children referred to the idea that appearance should be discounted in favour of other characteristics [ 21 , 22 , 34 ], for example,

'if you're a good person on the inside, then it doesn't really matter how you look on the outside' [[ 34 ], p14].

But this was challenged by other children's accounts [ 21 , 22 ]. As two boys put it,

'It's not a very good image if you are going round with a fat person.' (Boy cutting in:) 'nowadays it's all on your looks' [[ 21 ], p10].

Another said,

'they say that now, but in real life they'll make fun of you if you're different' [[ 21 ], p210].

Discrimination is normal

Children thought that it was usual for overweight children to be treated differently because of their body size [ 22 , 23 , 31 ]. Summing up how such children could expect to be singled out, one child said,

'They'll be miserable for the rest of their lives because they'll get picked on' [[ 21 ], p209].

In one study, boys were said to regard teasing as a legitimate response if being overweight was someone's own fault [ 23 ]. Overweight children also reported believing that teasing would cease if they lost weight [ 27 ].

Boys described feeling conflicted about taking part in size-related ridicule, with one saying,

'Your mates pick on them and you join in, but you don't want to inside' [[ 21 ], p109].

In two studies, even those boys who had been teased or bullied themselves seemed accepting of it [ 21 , 24 ]. As one clinically obese boy said,

'You hear people calling them fat but that's just normal isn't it?'[[ 24 ], p921].

Children are aware that body size is a public issue

Children were aware of public interest in body size, and about common media representations. They described fictional and reality television programmes as influencing their awareness, sometimes providing information and sometimes contradicting reality [ 21 , 31 , 34 ]. One girl said,

'They make clothes for stick-thin people and in magazines everybody's thin and you don't get fat people in them' [[ 21 ], p210].

Desirable and acceptable bodies

Desirable bodies are not overweight.

Being overweight was almost always described as undesirable. A few positive comments were made by boys who noted that fat might help keep you warm [ 21 , 22 ] and that it was preferable to [ 21 ], or could help prevent [ 22 ] starvation.

Overall, children talked mainly in negative terms when they evaluated different sizes. Girls talked solely in favourable terms about having a 'slim' body [ 26 , 34 ] or 'a good figure' [ 31 ], but did not discuss this in any depth. Only one study encouraged boys to describe their aspirations for their bodies. In contrast to girls' emphasis on body fat, these boys expressed their ideal body as one that 'looked fit' [[ 23 ], p224].

Views about being underweight were more mixed. Children in several studies described how girls of their age might want to be 'thin' or 'skinny'[ 21 , 22 , 30 ]. Both boys and girls, however, also linked being 'too thin' unfavourably with anorexia [[ 31 ], p548] and girls linked it with being 'quite ill' [[ 21 ], p210] and 'obsessed'[[ 30 ], p21]. In one study, children aspired to the 'lovely wee skinny little bodies' of models and some media celebrities, while also judging some to be 'too thin' [[ 31 ], p549].

Several studies explored variations in children's preferred and aspired-to shapes. Differences between boys and girls are discussed in 'Gender', below. In one study, children's preferences had been contrasted with the measured averages for children's BMI [ 39 ]. Many of these children aspired to thin or very thin bodies, and over three-quarters wanted bodies the same or smaller than the 25% of children at the 'leanest' end of the scale. The boys' and girls' preferences in this study were similar.

A large body size means you are...

Children provided consistently negative evaluations of overweight people [ 26 , 36 , 38 , 40 , 41 ]. This was seen in children across a range of ages, and in some as young as five [ 36 , 38 ]. They attributed a wide variety of negative behavioural, personal and social characteristics to generalised representations of overweight children and adults, including: eating food and drinks with a high fat and/or sugar content [ 26 , 30 , 33 ]; not eating healthy food [ 33 ]; eating inedible or unrealistic food items [ 26 ]; laziness and watching too much television [ 30 , 33 ]; poor table manners [ 26 ]; not washing, not exercising [ 33 ]; 'trouble-making'[ 30 ]; and having no hobbies [ 30 ].

While children did provide researchers with generalisations about overweight people, only one study reported children's reflections on these ideas. In the following excerpt, two children, supported by a researcher, discussed an imaginary 'unhealthy child'. When encouraged to express themselves more fully, they indicated their understanding of the difficulties that overweight children might experience,

'She's fat, and ... really smelly' 'and she has bad breath' 'and she's always stroppy and stressed' 'so she doesn't have many friends' ... 'Well it's quite likely that a person who's fat would be selfish. I think. Do you think?'

(Adult directs back to other child - 'what do you think?')

'I think maybe [they would feel] stressed. So it would be hard to think about other kids.' 'Yeah it would be hard to run.' 'It would be hard to do anything.' 'You wouldn't feel good' [[ 33 ], p11].

Children apportion blame and responsibility for fat

Children talked judgementally about overweight children and adults. In one study, boys linked becoming overweight with a weakness of will and saw it as something that people had control over [ 23 ]. In another, children implied that being overweight could be a just punishment for this lack of control. One said, for example,

'[They] deserve to be fat if they eat sweets all the time' [[ 21 ], p209].

Children were viewed as more accountable if they had become overweight through self-indulgence or by eating the wrong food. They were less accountable if their size was linked with genetics, or was in some way 'natural'. For example, one child said,

'If it's weight they've put on, they should do something; if they're genetically like that, then they shouldn't' [[ 21 ], p209].

Embodied experiences

Children actively assess their own size.

Children described how they compared their bodies over time and with other children's bodies. Some studies explored the extent to which children were able to estimate their own body size, using pictorial scales that showed actual body sizes [ 26 , 39 , 41 – 43 ]. These found that children of all sizes generally produced relatively accurate estimations of their own body shapes.

Girls in one study commented that boys, when they appraise the degree to which someone is 'fat', sometimes start with a person's overall size and confuse muscularity and body fat [ 21 ]. They also said that if a boy was fat, they would describe themselves as 'muscly'. To illustrate, one boy is reported as saying,

'You could be fat and healthy like rugby players who have a lot of exercise' [[ 21 ], p211].

In two studies, very overweight children commented critically on others' assessment of their size [ 22 , 24 ]. In both cases, the children were disagreeing with their parents' evaluations of their bodies. One child, for example, said,

'My mum tells me that I'm not overweight, but I know I am' [[ 22 ], p235].

Discomfort and feelings of pressure accompany a focus on body size

Children described negative emotions around body size, including a generalized anxiety and pressure, regardless of their weight. In two studies, both boys and girls who probably had a healthy weight, expressed anxiety when asked about being measured [ 25 , 53 ]. The anxiety seemed to be about being labelled as an unacceptable size and disclosure of this information to peers. As one boy put it,

'I'd get scared and worried if the rest of the class were there in case you are fatter than you think you are' [[ 25 ], p5].

Children described their perceptions of pressures on girls in particular [ 21 , 30 , 31 , 34 ], saying, for example,

'When you think of boys you think of sweets, you think of chocolate ...Yeah, they think they are already strong so they don't have to go on any diets'[[ 30 ], p25].

Girls themselves sometimes expressed anxiety about their own bodies. They talked about feeling self-conscious on occasions when they had to expose more of their bodies - particularly when swimming, or feeling uncomfortable when swimming with a friend who was more developed physically [ 34 ]

Children may also experience a more diffuse sense of unease about body size. In two studies, researchers noted that children reacted unexpectedly to the topic of obesity [ 33 , 34 ]. In one, researchers found girls reluctant to talk about body size and appearance at all [ 34 ].

Children express dissatisfaction with their bodies

In many studies, children across a range of body sizes reported low levels of satisfaction with their bodies. The satisfaction of girls whose actual BMI classified them as overweight was consistently lower than that of other girls [ 22 , 26 , 43 , 44 ]. In contrast, two studies found that boys' satisfaction with their body shape sometimes increased when their actual body size rose above levels recognised to be healthy [ 22 , 26 ]. This difference is described further below (see 'Gender').

Only one study asked children what they did like about the shape and size of their bodies [ 26 ]. Just over half of these children, who were mainly neither overweight nor underweight, answered 'nothing'. In this study, 'tummies' were the body part liked the most. In contrast, the stomach was viewed by children who were overweight, in a separate study, as the only part of the body that was a problem [ 22 ].

Children's explanations for their dissatisfaction were not recorded, apart from in the case of one very overweight boy. Again, this child emphasised a desire to fit in, saying,

'I don't look very nice. When I'm dressed up I look all right ... slimmer ... I feel different from the others'[[ 22 ], p225].

However, body size could not always predict whether children would express dissatisfaction or satisfaction with their bodies. One girl, described as only moderately overweight, was moved to tears when she discussed how much she wanted to become thinner and so be accepted by a friendship group that she wished to join. But being very overweight did not mean that weight was necessarily described in negative terms. One very overweight girl, when asked if she would like to change anything about herself, said she was 'not really bothered'. This was corroborated by a friend, who said '[she] likes the way she is ... She don't mind' [[ 22 ], p232].

The consequences of body size are experienced as social in nature

Very overweight children had felt the negative social consequences of overweight described by their healthy weight peers. In one study, a third of overweight children described feeling less socially accepted than their peers. Fewer than one in ten children with a more optimal weight reported feeling this way [ 22 ]. One very overweight girl described how weight 'gets in the way' of her making friends [[ 22 ], p228] and one very overweight boy reported feeling disliked because of his weight. Others reported being abandoned by friends. Nearly three-quarters of obese children in another study felt that they would have more friends if they lost weight [ 27 ].

Overweight children reported that size-related abuse had led to negative changes in their behaviour. Some boys described how bullying led to retaliation and other uncharacteristic behaviours, which in turn led to punishment by exclusion from school activities [ 22 , 24 ]. One reported doing a friend's homework in return for protection against bullying that he believed was to do with his size [ 27 ].

Very overweight children are made to feel 'different and terrible'

One clinically obese child who had experienced size-related taunting described feeling, 'fat, you're slow, you're ignorant, you're useless'[[ 24 ], p921]. Other responses from overweight children to size-related abuse again emphasised the importance of fitting in socially. One boy said he wore 'baggy T-shirts. I try to hide it' [[ 22 ], p233]. Another described how the likelihood of name-calling had made him feel 'different and terrible, like I'm not like everyone else' [[ 24 ], p921].

Very overweight children also described difficult experiences with clothes and body-size, including difficulties finding clothes that fit [ 21 ], feeling exposed when shopping [ 24 ] and having clothes that were the wrong size [ 22 ]. They also experienced their bodies as getting in the way of physical activity, either due to physical inability [ 25 , 28 ], name calling when exercising [ 22 ], or embarrassment when changing clothes in public [ 22 , 24 ].

Satisfaction with body size differs between the sexes

Nine studies explored whether girls were more or less satisfied with their body shape than boys [ 22 , 26 , 39 – 42 , 45 – 47 ]. These found that higher proportions of girls wanted a different body shape from the one they perceived they had, or that more girls than boys described their bodies as 'too heavy' or 'too big'. The girls in these studies consistently wanted their bodies to be 'leaner'. When boys were dissatisfied with their body shape, it was often because they wanted to be 'bulkier'[ 26 , 41 , 42 ], although the most recent study [ 39 ] found 'dissatisfied' boys more often wanted to be thinner, rather than larger.

Body size stereotypes vary with gender

As described above, children were critical of generalized representations of overweight people. While two studies found boys to be more negative than girls in all or some of their appraisals of the same figure (e.g., of athletic ability, fitness and eating habits)[ 36 , 40 ], three found no evidence of a difference [ 26 , 38 , 41 ]. However, responses did differ according to the gender of the body being considered. One study found that bulkier female figures received more negative assessments than leaner ones [ 38 ]. In another, children attributed fewer feminine characteristics to overweight female figures [ 37 ]. In both studies, the size of male figures made no difference to children's assessments.

Checking the robustness of the review: the sensitivity analysis and credibility check with young people

Examination of the contribution of the six lowest quality studies to the two syntheses found that the themes that they contributed to were all supported by a number of other, higher quality studies (for detail see Additional file 7 - online). Therefore, the removal of the lowest quality studies from the synthesis, while it might have changed some of the fine detail, would not have modified the findings to any great extent. Because of the focus of these lower quality studies, the strength of findings relating specifically to girls, very overweight and very young children would be reduced.

The PEAR group of young people who were consulted about the findings of the interpretive synthesis felt that the themes were likely to have covered the most important issues for children. Areas that they felt might be missing were the influence of the media, diversity amongst children and the effectiveness of strategies for achieving and maintaining a healthy size.

Following the consultation, these areas were searched for in the study data, to see if they had been overlooked or had not been given sufficient emphasis. However, children in the studies had not talked about the effectiveness of action aimed at facilitating healthy body sizes, or about diversity amongst children. They had referred in several studies to the size of celebrities and in one study to body sizes in magazines, but these were presented by study authors as though they were only one of many points of discussion. Authors had not described or quoted children as talking specifically about feeling influenced by the media. The data had influenced the development of themes about appropriate and ideal bodies and body comparisons. It did not seem appropriate to turn the idea of media influence into a theme or modify the synthesis structure further.

The UK children whose views were included in this review varied in the extent to which body size was directly relevant to their lives. Children with healthy body sizes did not appear to have this issue high on their everyday agendas. When they were asked directly about body size, being overweight was seen as a problem because of the impact it could have on their lives as social beings, from reduced popularity through to discrimination. The health consequences of obesity appeared to be largely irrelevant. These findings resonate with several recent large-scale consultations that show that children often do not bring up health issues when given a blank sheet on which to identify the priorities for action in their lives [ 49 ]. Similarly, it has previously been found that the physical health outcomes of health behaviours are not salient for children, compared with other aspects of their lives, such as friendships and enjoyment [ 50 , 51 ].

Whatever their size, however, these children seemed extremely aware of our society's heightened interest in body size. When asked, many wished their bodies were leaner, sometimes to the extent of aspiring to body weights that would be unattainable for most, as well as unhealthily thin. This dissatisfaction and aspiration for thinness were both seen in other research conducted with children in the UK and elsewhere in the mid-1990s [ 52 , 53 ]. This review's findings suggest that young children, despite often having healthy body sizes, continue to dislike their own bodies.

Negative stereotyping of overweight people has been reported in numerous studies of adults and children in the US, and in UK studies of children aged 11 which were conducted earlier than this review's chronological scope [ 54 ]. In several studies in this review, children blamed overweight people for their size and size was represented as something that could be controlled. This emphasis on personal culpability contrasts starkly with widespread understanding in public health of the overriding importance of social and environmental factors largely outside individual control, such as work patterns, transport options and the production and sale of food [ 1 , 55 ]. A reminder that children might have even less control over the factors that affect their body size is provided by a recent review of studies, from the UK and elsewhere, of parents' perceptions about preventing childhood obesity. Amongst the barriers to preventing obesity amongst children identified by parents were, family behaviours, parental attitudes and beliefs, and environmental factors, such as children's schooling and day care arrangements, and parents' access to exercise programmes and other resources [ 56 ].

The very overweight children in this review described being teased and bullied on account of their larger size. They reported how this impacted seriously on their well-being and behaviour. A large-scale longitudinal study in the UK found that obese eight-year-old children were one-and-a-half times more likely to have been bullied than average-weight children [ 57 ]. Weight-based teasing and bullying has been implicated in weight gain in young people in the US because of its role in increased unhealthy eating and reduced physical activity [ 58 ]. It is notable that the children in this review commented on the negative impact of size-related abuse in relation to getting changed for, or taking part in physical activity. It is likely that very overweight children in the UK who attempt to exercise as a way of reducing their body size will experience a major barrier in the shape of humiliation and size-related teasing from some of their peers.

The aspirations of girls and boys in this review for their bodies differed, and girls were consistently more dissatisfied with their size. The interest in a 'lean' body shape seen among girls in this review resonates with findings from earlier research in the UK and elsewhere [ 53 ], and is in line with 'feminine' ideals presented in the media [ 59 , 60 ]. Boys' interest in fitness and muscles and the aspiration of some for bulkier body shapes suggests the influence of ideals around male muscularity [ 61 ]. While girls' aspirations are still more likely to raise concern, a large proportion of boys also aspired to very thin body shapes in the most recent study found during this review. This might be an indicator that unhealthily thin body size ideals should no longer be seen as limited to girls and young women.

Strengths and limitations of this review

This is the first review of which we are aware that seeks out, appraises and synthesizes in a systematic way the findings from studies of children's views about body size. As with all reviews, it is possible that this one has missed some relevant literature, and it is impossible to gauge the impact that this might have had on its findings. However, to reduce the likelihood that we have missed studies, very sensitive searches of bibliographic databases were supplemented by other methods to seek out literature that can be hard to find, such as theses and unpublished reports. Since sources often cover literature from the US better than they do other countries, specific searches of UK-rich data sources were also conducted so as to increase our yield of UK literature.

The review is, however, limited by the methodological quality of existing research. Findings about children's views about body size were relatively scarce and were not presented in much depth or with much contextual detail. Few of the studies described taking many steps to ensure rigour and increase confidence in the quality of their findings. Adding some face validity to our findings is the fact that our consultation did not identify any themes that appeared unexpected to a group that, relatively recently, would have been the same age as children studied in the review (the PEAR group). The findings of the aggregative synthesis also add confidence about the generalizability of some of the findings in the interpretive review, in particular the disparity between boys' and girls' satisfaction with their body sizes. However, many of the studies in this synthesis were small and limited in their reporting of how their samples were constructed. While it is clear that a range of children had been involved in many of the studies, some appear to be underrepresented, in particular young children and those who were socio-economically disadvantaged or not at school.

Furthermore, very few studies in this review reported using approaches that privilege children's own framing of issues in their lives or started from the position that children themselves may usefully contribute ideas and analyses to help develop theories about their own lives and the questions asked of them. The studies often aimed primarily to explore or test existing theories. Frameworks used to analyse children's responses also often appeared to have been developed without any consultation or collaboration with children themselves.

As a result, many of the views expressed and reported in the studies in this review may be constrained by adult preconceptions as to what might be important to children. It is unclear what kinds of insights or emphases the children in these studies might have offered if they had been fully enabled to present or consider their own perspectives. It is also possible that the children in some of the studies may have been saying what they thought adult researchers or other children present with them in focus groups wanted to hear. Some children made it clear that they were aware of contradictions between the seemingly benign and neutral statements that children and others make about large body size, and the less-than-neutral actions that are then taken; for example, people saying that size does not matter, but then discriminating on this basis. The highly social nature of body size, coupled with evidence of discomfort and anxiety amongst some children around this topic, point to the need to take extreme care when constructing research environments for children to discuss this issue.

The facilitated exchange of ideas between two children in the Cole and colleagues' study (described above under 'A large body size means you are...') illustrates how children's views can be nuanced [ 33 ]. This study's data collection methods built upon existing relationships between the children themselves, and between the children and the research team. The methods included observational, drawing and play techniques and provide an example of one way in which researchers might help children describe and analyse their own lives. Such studies are likely to be small-scale, because of the need for careful attention to the relationships central to data collection [ 9 ]. There is an urgent need to conduct qualitative research that combines the use of these kinds of child-friendly, or co-constructive, data collection methods, with rigorous data analysis and thorough reporting of all methods, in order to strengthen the evidence-base.

This systematic review has identified a disparate set of qualitative and quantitative studies containing data from UK children about their views and experiences of body size, shape and weight. It has synthesized this into a coherent whole that explores children's views in the areas of: how body size matters; desirable and acceptable bodies; embodied experiences of body size; and gender. However, in only a few of the studies had attempts been made to encourage children's own analyses, or sufficient efforts been taken to encourage children's full engagement and participation in research on this topic. The studies did not fully represent children's diversity, and so seriously restrict any analysis of variations in perspective between children. A strong evidence-base for policy on children and body size would include findings from good quality research about children's views, since children have direct experience and a considerable stake in the matter. This review indicates however, that research with children on their views on this topic needs to be far more rigorous and equitable than is currently the case.

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Acknowledgements

The study was funded by the Department of Health (England). The views expressed are those of the authors and not necessarily those of the Department of Health.

We acknowledge the work of the authors of studies included in this review and the children who participated in them. Thanks go to Theo Lorenc and Claire Stansfield, for work searching and screening for the review; to members of our Steering Group; to Louca-Mai Brady, Deepa Pagarani and the participants in the NCB PEAR Group for their work reflecting on the review's findings; and to others at the EPPI-Centre for suggestions and support.

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The review protocol was developed by RR, JT and JW. RR and JW conducted searches and screened studies. RR, JW and KO developed the data extraction tool. Data extraction, quality appraisal and synthesis were conducted by RR and KO. KO conducted the consultation with the NCB PEAR group. All authors contributed to the writing of this paper.

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Rees, R., Oliver, K., Woodman, J. et al. The views of young children in the UK about obesity, body size, shape and weight: a systematic review. BMC Public Health 11 , 188 (2011). https://doi.org/10.1186/1471-2458-11-188

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Effectiveness of weight management interventions for adults delivered in primary care: systematic review and meta-analysis of randomised controlled trials

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• Peer review
• Claire D Madigan , senior research associate 1 ,
• Henrietta E Graham , doctoral candidate 1 ,
• Elizabeth Sturgiss , NHMRC investigator 2 ,
• Victoria E Kettle , research associate 1 ,
• Kajal Gokal , senior research associate 1 ,
• Greg Biddle , research associate 1 ,
• Gemma M J Taylor , reader 3 ,
• Amanda J Daley , professor of behavioural medicine 1
• 1 Centre for Lifestyle Medicine and Behaviour (CLiMB), The School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
• 2 School of Primary and Allied Health Care, Monash University, Melbourne, Australia
• 3 Department of Psychology, Addiction and Mental Health Group, University of Bath, Bath, UK
• Correspondence to: C D Madigan c.madigan{at}lboro.ac.uk (or @claire_wm and @lboroclimb on Twitter)
• Accepted 26 April 2022

Objective To examine the effectiveness of behavioural weight management interventions for adults with obesity delivered in primary care.

Design Systematic review and meta-analysis of randomised controlled trials.

Eligibility criteria for selection of studies Randomised controlled trials of behavioural weight management interventions for adults with a body mass index ≥25 delivered in primary care compared with no treatment, attention control, or minimal intervention and weight change at ≥12 months follow-up.

Data sources Trials from a previous systematic review were extracted and the search completed using the Cochrane Central Register of Controlled Trials, Medline, PubMed, and PsychINFO from 1 January 2018 to 19 August 2021.

Data extraction and synthesis Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Meta-analyses were conducted with random effects models, and a pooled mean difference for both weight (kg) and waist circumference (cm) were calculated.

Main outcome measures Primary outcome was weight change from baseline to 12 months. Secondary outcome was weight change from baseline to ≥24 months. Change in waist circumference was assessed at 12 months.

Results 34 trials were included: 14 were additional, from a previous review. 27 trials (n=8000) were included in the primary outcome of weight change at 12 month follow-up. The mean difference between the intervention and comparator groups at 12 months was −2.3 kg (95% confidence interval −3.0 to −1.6 kg, I 2 =88%, P<0.001), favouring the intervention group. At ≥24 months (13 trials, n=5011) the mean difference in weight change was −1.8 kg (−2.8 to −0.8 kg, I 2 =88%, P<0.001) favouring the intervention. The mean difference in waist circumference (18 trials, n=5288) was −2.5 cm (−3.2 to −1.8 cm, I 2 =69%, P<0.001) in favour of the intervention at 12 months.

Conclusions Behavioural weight management interventions for adults with obesity delivered in primary care are effective for weight loss and could be offered to members of the public.

Systematic review registration PROSPERO CRD42021275529.

Introduction

Obesity is associated with an increased risk of diseases such as cancer, type 2 diabetes, and heart disease, leading to early mortality. 1 2 3 More recently, obesity is a risk factor for worse outcomes with covid-19. 4 5 Because of this increased risk, health agencies and governments worldwide are focused on finding effective ways to help people lose weight. 6

Primary care is an ideal setting for delivering weight management services, and international guidelines recommend that doctors should opportunistically screen and encourage patients to lose weight. 7 8 On average, most people consult a primary care doctor four times yearly, providing opportunities for weight management interventions. 9 10 A systematic review of randomised controlled trials by LeBlanc et al identified behavioural interventions that could potentially be delivered in primary care, or involved referral of patients by primary care professionals, were effective for weight loss at 12-18 months follow-up (−2.4 kg, 95% confidence interval −2.9 to−1.9 kg). 11 However, this review included trials with interventions that the review authors considered directly transferrable to primary care, but not all interventions involved primary care practitioners. The review included interventions that were entirely delivered by university research employees, meaning implementation of these interventions might differ if offered in primary care, as has been the case in other implementation research of weight management interventions, where effects were smaller. 12 As many similar trials have been published after this review, an updated review would be useful to guide health policy.

We examined the effectiveness of weight loss interventions delivered in primary care on measures of body composition (weight and waist circumference). We also identified characteristics of effective weight management programmes for policy makers to consider.

This systematic review was registered on PROSPERO and is reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. 13 14

Eligibility criteria

We considered studies to be eligible for inclusion if they were randomised controlled trials, comprised adult participants (≥18 years), and evaluated behavioural weight management interventions delivered in primary care that focused on weight loss. A primary care setting was broadly defined as the first point of contact with the healthcare system, providing accessible, continued, comprehensive, and coordinated care, focused on long term health. 15 Delivery in primary care was defined as the majority of the intervention being delivered by medical and non-medical clinicians within the primary care setting. Table 1 lists the inclusion and exclusion criteria.

Study inclusion and exclusion criteria

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We extracted studies from the systematic review by LeBlanc et al that met our inclusion criteria. 11 We also searched the exclusions in this review because the researchers excluded interventions specifically for diabetes management, low quality trials, and only included studies from an Organisation for Economic Co-operation and Development country, limiting the scope of the findings.

We searched for studies in the Cochrane Central Register of Controlled Trials, Medline, PubMed, and PsychINFO from 1 January 2018 to 19 August 2021 (see supplementary file 1). Reference lists of previous reviews 16 17 18 19 20 21 and included trials were hand searched.

Data extraction

Results were uploaded to Covidence, 22 a software platform used for screening, and duplicates removed. Two independent reviewers screened study titles, abstracts, and full texts. Disagreements were discussed and resolved by a third reviewer. All decisions were recorded in Covidence, and reviewers were blinded to each other’s decisions. Covidence calculates proportionate agreement as a measure of inter-rater reliability, and data are reported separately by title or abstract screening and full text screening. One reviewer extracted data on study characteristics (see supplementary table 1) and two authors independently extracted data on weight outcomes. We contacted the authors of four included trials (from the updated search) for further information. 23 24 25 26

Outcomes, summary measures, and synthesis of results

The primary outcome was weight change from baseline to 12 months. Secondary outcomes were weight change from baseline to ≥24 months and from baseline to last follow-up (to include as many trials as possible), and waist circumference from baseline to 12 months. Supplementary file 2 details the prespecified subgroup analysis that we were unable to complete. The prespecified subgroup analyses that could be completed were type of healthcare professional who delivered the intervention, country, intensity of the intervention, and risk of bias rating.

Healthcare professional delivering intervention —From the data we were able to compare subgroups by type of healthcare professional: nurses, 24 26 27 28 general practitioners, 23 29 30 31 and non-medical practitioners (eg, health coaches). 32 33 34 35 36 37 38 39 Some of the interventions delivered by non-medical practitioners were supported, but not predominantly delivered, by GPs. Other interventions were delivered by a combination of several different practitioners—for example, it was not possible to determine whether a nurse or dietitian delivered the intervention. In the subgroup analysis of practitioner delivery, we refer to this group as “other.”

Country —We explored the effectiveness of interventions by country. Only countries with three or more trials were included in subgroup analyses (United Kingdom, United States, and Spain).

Intensity of interventions —As the median number of contacts was 12, we categorised intervention groups according to whether ≤11 or ≥12 contacts were required.

Risk of bias rating —Studies were classified as being at low, unclear, and high risk of bias. Risk of bias was explored as a potential influence on the results.

Meta-analyses

Meta-analyses were conducted using Review Manager 5.4. 40 As we expected the treatment effects to differ because of the diversity of intervention components and comparator conditions, we used random effects models. A pooled mean difference was calculated for each analysis, and variance in heterogeneity between studies was compared using the I 2 and τ 2 statistics. We generated funnel plots to evaluate small study effects. If more than two intervention groups existed, we divided the number of participants in the comparator group by the number of intervention groups and analysed each individually. Nine trials were cluster randomised controlled trials. The trials had adjusted their results for clustering, or adjustment had been made in the previous systematic review by LeBlanc et al. 11 One trial did not report change in weight by group. 26 We calculated the mean weight change and standard deviation using a standard formula, which imputes a correlation for the baseline and follow-up weights. 41 42 In a non-prespecified analysis, we conducted univariate and multivariable metaregression (in Stata) using a random effects model to examine the association between number of sessions and type of interventionalist on study effect estimates.

Risk of bias

Two authors independently assessed the risk of bias using the Cochrane risk of bias tool v2. 43 For incomplete outcome data we defined a high risk of bias as ≥20% attrition. Disagreements were resolved by discussion or consultation with a third author.

Patient and public involvement

The study idea was discussed with patients and members of the public. They were not, however, included in discussions about the design or conduct of the study.

The search identified 11 609 unique study titles or abstracts after duplicates were removed ( fig 1 ). After screening, 97 full text articles were assessed for eligibility. The proportionate agreement ranged from 0.94 to 1.0 for screening of titles or abstracts and was 0.84 for full text screening. Fourteen new trials met the inclusion criteria. Twenty one studies from the review by LeBlanc et al met our eligibility criteria and one study from another systematic review was considered eligible and included. 44 Some studies had follow-up studies (ie, two publications) that were found in both the second and the first search; hence the total number of trials was 34 and not 36. Of the 34 trials, 27 (n=8000 participants) were included in the primary outcome meta-analysis of weight change from baseline to 12 months, 13 (n=5011) in the secondary outcome from baseline to ≥24 months, and 30 (n=8938) in the secondary outcome for weight change from baseline to last follow-up. Baseline weight was accounted for in 18 of these trials, but in 14 24 26 29 30 31 32 44 45 46 47 48 49 50 51 it was unclear or the trials did not consider baseline weight. Eighteen trials (n=5288) were included in the analysis of change in waist circumference at 12 months.

Studies included in systematic review of effectiveness of behavioural weight management interventions in primary care. *Studies were merged in Covidence if they were from same trial

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Study characteristics

Included trials (see supplementary table 1) were individual randomised controlled trials (n=25) 24 25 26 27 28 29 32 33 34 35 38 39 41 44 45 46 47 50 51 52 53 54 55 56 59 or cluster randomised controlled trials (n=9). 23 30 31 36 37 48 49 57 58 Most were conducted in the US (n=14), 29 30 31 32 33 34 35 36 37 45 48 51 54 55 UK (n=7), 27 28 38 41 47 57 58 and Spain (n=4). 25 44 46 49 The median number of participants was 276 (range 50-864).

Four trials included only women (average 65.9% of women). 31 48 51 59 The mean BMI at baseline was 35.2 (SD 4.2) and mean age was 48 (SD 9.7) years. The interventions lasted between one session (with participants subsequently following the programme unassisted for three months) and several sessions over three years (median 12 months). The follow-up period ranged from 12 months to three years (median 12 months). Most trials excluded participants who had lost weight in the past six months and were taking drugs that affected weight.

Meta-analysis

Overall, 27 trials were included in the primary meta-analysis of weight change from baseline to 12 months. Three trials could not be included in the primary analysis as data on weight were only available at two and three years and not 12 months follow-up, but we included these trials in the secondary analyses of last follow-up and ≥24 months follow-up. 26 44 50 Four trials could not be included in the meta-analysis as they did not present data in a way that could be synthesised (ie, measures of dispersion). 25 52 53 58 The mean difference was −2.3 kg (95% confidence interval −3.0 to −1.6 kg, I 2 =88%, τ 2 =3.38; P<0.001) in favour of the intervention group ( fig 2 ). We found no evidence of publication bias (see supplementary fig 1). Absolute weight change was −3.7 (SD 6.1) kg in the intervention group and −1.4 (SD 5.5) kg in the comparator group.

Mean difference in weight at 12 months by weight management programme in primary care (intervention) or no treatment, different content, or minimal intervention (control). SD=standard deviation

Supplementary file 2 provides a summary of the main subgroup analyses.

Weight change

The mean difference in weight change at the last follow-up was −1.9 kg (95% confidence interval −2.5 to −1.3 kg, I 2 =81%, τ 2 =2.15; P<0.001). Absolute weight change was −3.2 (SD 6.4) kg in the intervention group and −1.2 (SD 6.0) kg in the comparator group (see supplementary figs 2 and 3).

At the 24 month follow-up the mean difference in weight change was −1.8 kg (−2.8 to −0.8 kg, I 2 =88%, τ 2 =3.13; P<0.001) (see supplementary fig 4). As the weight change data did not differ between the last follow-up and ≥24 months, we used the weight data from the last follow-up in subgroup analyses.

In subgroup analyses of type of interventionalist, differences were significant (P=0.005) between non-medical practitioners, GPs, nurses, and other people who delivered interventions (see supplementary fig 2).

Participants who had ≥12 contacts during interventions lost significantly more weight than those with fewer contacts (see supplementary fig 6). The association remained after adjustment for type of interventionalist.

Waist circumference

The mean difference in waist circumference was −2.5 cm (95% confidence interval −3.2 to −1.8 cm, I 2 =69%, τ 2 =1.73; P<0.001) in favour of the intervention at 12 months ( fig 3 ). Absolute changes were −3.7 cm (SD 7.8 cm) in the intervention group and −1.3 cm (SD 7.3) in the comparator group.

Mean difference in waist circumference at 12 months. SD=standard deviation

Risk of bias was considered to be low in nine trials, 24 33 34 35 39 41 47 55 56 unclear in 12 trials, 25 27 28 29 32 45 46 50 51 52 54 59 and high in 13 trials 23 26 30 31 36 37 38 44 48 49 53 57 58 ( fig 4 ). No significant (P=0.65) differences were found in subgroup analyses according to level of risk of bias from baseline to 12 months (see supplementary fig 7).

Risk of bias in included studies

Worldwide, governments are trying to find the most effective services to help people lose weight to improve the health of populations. We found weight management interventions delivered by primary care practitioners result in effective weight loss and reduction in waist circumference and these interventions should be considered part of the services offered to help people manage their weight. A greater number of contacts between patients and healthcare professionals led to more weight loss, and interventions should be designed to include at least 12 contacts (face-to-face or by telephone, or both). Evidence suggests that interventions delivered by non-medical practitioners were as effective as those delivered by GPs (both showed statistically significant weight loss). It is also possible that more contacts were made with non-medical interventionalists, which might partially explain this result, although the metaregression analysis suggested the effect remained after adjustment for type of interventionalist. Because most comparator groups had fewer contacts than intervention groups, it is not known whether the effects of the interventions are related to contact with interventionalists or to the content of the intervention itself.

Although we did not determine the costs of the programme, it is likely that interventions delivered by non-medical practitioners would be cheaper than GP and nurse led programmes. 41 Most of the interventions delivered by non-medical practitioners involved endorsement and supervision from GPs (ie, a recommendation or checking in to see how patients were progressing), and these should be considered when implementing these types of weight management interventions in primary care settings. Our findings suggest that a combination of practitioners would be most effective because GPs might not have the time for 12 consultations to support weight management.

Although the 2.3 kg greater weight loss in the intervention group may seem modest, just 2-5% in weight loss is associated with improvements in systolic blood pressure and glucose and triglyceride levels. 60 The confidence intervals suggest a potential range of weight loss and that these interventions might not provide as much benefit to those with a higher BMI. Patients might not find an average weight loss of 3.7 kg attractive, as many would prefer to lose more weight; explaining to patients the benefits of small weight losses to health would be important.

Strengths and limitations of this review

Our conclusions are based on a large sample of about 8000 participants, and 12 of these trials were published since 2018. It was occasionally difficult to distinguish who delivered the interventions and how they were implemented. We therefore made some assumptions at the screening stage about whether the interventionalists were primary care practitioners or if most of the interventions were delivered in primary care. These discussions were resolved by consensus. All included trials measured weight, and we excluded those that used self-reported data. Dropout rates are important in weight management interventions as those who do less well are less likely to be followed-up. We found that participants in trials with an attrition rate of 20% or more lost less weight and we are confident that those with high attrition rates have not inflated the results. Trials were mainly conducted in socially economic developed countries, so our findings might not be applicable to all countries. The meta-analyses showed statistically significant heterogeneity, and our prespecified subgroups analysis explained some, but not all, of the variance.

Comparison with other studies

The mean difference of −2.3 kg in favour of the intervention group at 12 months is similar to the findings in the review by LeBlanc et al, who reported a reduction of −2.4 kg in participants who received a weight management intervention in a range of settings, including primary care, universities, and the community. 11 61 This is important because the review by LeBlanc et al included interventions that were not exclusively conducted in primary care or by primary care practitioners. Trials conducted in university or hospital settings are not typically representative of primary care populations and are often more intensive than trials conducted in primary care as a result of less constraints on time. Thus, our review provides encouraging findings for the implementation of weight management interventions delivered in primary care. The findings are of a similar magnitude to those found in a trial by Ahern et al that tested primary care referral to a commercial programme, with a difference of −2.7 kg (95% confidence interval −3.9 to −1.5 kg) reported at 12 month follow-up. 62 The trial by Ahern et al also found a difference in waist circumference of −4.1 cm (95% confidence interval −5.5 to −2.3 cm) in favour of the intervention group at 12 months. Our finding was smaller at −2.5 cm (95% confidence interval −3.2 to −1.8 cm). Some evidence suggests clinical benefits from a reduction of 3 cm in waist circumference, particularly in decreased glucose levels, and the intervention groups showed a 3.7 cm absolute change in waist circumference. 63

Policy implications and conclusions

Weight management interventions delivered in primary care are effective and should be part of services offered to members of the public to help them manage weight. As about 39% of the world’s population is living with obesity, helping people to manage their weight is an enormous task. 64 Primary care offers good reach into the community as the first point of contact in the healthcare system and the remit to provide whole person care across the life course. 65 When developing weight management interventions, it is important to reflect on resource availability within primary care settings to ensure patients’ needs can be met within existing healthcare systems. 66

We did not examine the equity of interventions, but primary care interventions may offer an additional service and potentially help those who would not attend a programme delivered outside of primary care. Interventions should consist of 12 or more contacts, and these findings are based on a mixture of telephone and face-to-face sessions. Previous evidence suggests that GPs find it difficult to raise the issue of weight with patients and are pessimistic about the success of weight loss interventions. 67 Therefore, interventions should be implemented with appropriate training for primary care practitioners so that they feel confident about helping patients to manage their weight. 68

Unanswered questions and future research

A range of effective interventions are available in primary care settings to help people manage their weight, but we found substantial heterogeneity. It was beyond the scope of this systematic review to examine the specific components of the interventions that may be associated with greater weight loss, but this could be investigated by future research. We do not know whether these interventions are universally suitable and will decrease or increase health inequalities. As the data are most likely collected in trials, an individual patient meta-analysis is now needed to explore characteristics or factors that might explain the variance. Most of the interventions excluded people prescribed drugs that affect weight gain, such as antipsychotics, glucocorticoids, and some antidepressants. This population might benefit from help with managing their weight owing to the side effects of these drug classes on weight gain, although we do not know whether the weight management interventions we investigated would be effective in this population. 69

What is already known on this topic

Referral by primary care to behavioural weight management programmes is effective, but the effectiveness of weight management interventions delivered by primary care is not known

Systematic reviews have provided evidence for weight management interventions, but the latest review of primary care delivered interventions was published in 2014

Factors such as intensity and delivery mechanisms have not been investigated and could influence the effectiveness of weight management interventions delivered by primary care

What this study adds

Weight management interventions delivered by primary care are effective and can help patients to better manage their weight

At least 12 contacts (telephone or face to face) are needed to deliver weight management programmes in primary care

Some evidence suggests that weight loss after weight management interventions delivered by non-medical practitioners in primary care (often endorsed and supervised by doctors) is similar to that delivered by clinician led programmes

Ethics statements

Ethical approval.

Not required.

Data availability statement

Additional data are available in the supplementary files.

Contributors: CDM and AJD conceived the study, with support from ES. CDM conducted the search with support from HEG. CDM, AJD, ES, HEG, KG, GB, and VEK completed the screening and full text identification. CDM and VEK completed the risk of bias assessment. CDM extracted data for the primary outcome and study characteristics. HEJ, GB, and KG extracted primary outcome data. CDM completed the analysis in RevMan, and GMJT completed the metaregression analysis in Stata. CDM drafted the paper with AJD. All authors provided comments on the paper. CDM acts as guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: AJD is supported by a National Institute for Health and Care Research (NIHR) research professorship award. This research was supported by the NIHR Leicester Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. ES’s salary is supported by an investigator grant (National Health and Medical Research Council, Australia). GT is supported by a Cancer Research UK fellowship. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: This research was supported by the National Institute for Health and Care Research Leicester Biomedical Research Centre; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

The lead author (CDM) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported, and that no important aspects of the study have been omitted.

Dissemination to participants and related patient and public communities: We plan to disseminate these research findings to a wider community through press releases, featuring on the Centre for Lifestyle Medicine and Behaviour website ( www.lboro.ac.uk/research/climb/ ) via our policy networks, through social media platforms, and presentation at conferences.

Provenance and peer review: Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/ .

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Publication, Part of Health Survey for England

Health Survey for England, 2021 part 1

Official statistics, National statistics, Survey

Previous Chapter

• Part 3: Drinking alcohol

Current Chapter

• Overweight and obesity in adults

Next Chapter

• Part 1: Methods and definitions

This report examines the prevalence of overweight and obesity among adults in 2021. The estimates were produced using prediction equations that adjusted self-reported values of height and weight in order to predict measured values of height and weight. 

Detailed tables accompanying this report can be accessed here .  

Key findings for 2021

• In 2021, 26% of adults in England were obese. 
• A higher proportion of men than women were either overweight or obese (69% compared with 59%). 
• Obesity prevalence was lowest among adults living in the least deprived areas (20%) and highest in the most deprived areas (34%).
• 11% of obese adults reported that they had had a diagnosis of diabetes from a doctor, compared with 5% of overweight adults and 3% of those who were neither overweight nor obese.  
• Introduction

Obesity is a major public health problem in England and globally (Source: World Health Organization ). In adults, overweight and obesity are associated with life-limiting conditions, such as Type 2 diabetes, cardiovascular disease, and some cancers. 

The burden on the National Health Service (NHS) due to obesity and related illnesses is well recognised. The monetary cost each year, uplifted for inflation, was estimated at £6.1 billion in 2019 (Source: Department of Health and Social Care ). 

The COVID-19 pandemic has had a disproportionate effect on people with obesity, who are at increased risk of being hospitalised, admitted to intensive care, and of dying from COVID-19 (Public Health England, 2020; Saul, Gursul and Piernas, 2022). 

The Health Survey for England (HSE) is the main data source for monitoring overweight and obesity in the general population in England. Between 1993 and 2019, height and weight were directly measured during the interviewer visit in each year of the HSE series, and these values were used to calculate body mass index (BMI). 

For most of 2021 it was not possible to directly measure participants’ height and weight because of COVID-19 pandemic precautions. Instead, participants were asked about their height and weight during the telephone interview. This report presents findings on the prevalence of overweight (including obesity) and obesity for adults after applying adjustments to these self-reported heights and weights. 

Last edited: 15 December 2022 5:13 pm

Pages in this publication

• Adults' health-related behaviours
• Part 1: Smoking
• Part 2: E-cigarette use
• Part 2: Overweight and obesity
• Part 3: Overweight, obesity and health
• Part 4: Trends
• Part 5: References
• Part 6: Technical appendix
• Data Quality Statement