CHANGES IN THINKING ABOUT OBESITY AND OVERFATNESS
While fatness has never been highly regarded in modern societies, and while there has been a weight control industry around for some time to cater for people with cosmetic concerns, the real interest in fatness—as a health issue—is relatively new. It began in the 1950s with the discovery that a high body weight and abdominal fat were related to a number of diseases. Our understanding of these factors has increased in recent years with a growing awareness of the extent of the problem. Table 1.5 shows some of the changes in thinking that have occurred in that time.
The most significant changes have occurred in our understanding of measures of body fatness, what causes fatness and appropriate treatment and prevention strategies.
Ideas about measuring fat have shifted with changes in technology, and we have a better understanding of the types and distribution of fat related to disease. In general there has been a shift away from a single fat measure towards a combination, including body mass index, sagittal diameter and waist circumference, that can be used in a practical situation.
The main changes in thinking about the causes of overfatness centre around the type, rather than quantity of food eaten (e.g. the influence of energy from fat on total energy), and the impact of individual factors (particularly genetics) in influencing body fatness. There are, for example, big genetic differences in fat gain and in the extent of fat loss in response to a particular exercise or diet stimulus, and these have not been sufficiently recognised in the past. The interaction of biology with the environment and behaviour also needs to be considered. Understanding the causes of fatness is, of course, vital to the development of correct techniques of coping with it. The implications of all these changes for those interested in fat loss or maintenance of body fat are quite new.
Other changes in orientation have included a re-analysis of the role of fatness in ill-health. Epidemiological studies carried out in the 1960s and 1970s found little correlation between weight and major diseases like heart disease, because the measure of fatness used was generally a measure of body mass (i.e. weight or body mass index (BMI)), which ciiscriminates against healthy, lean, muscular individuals. Epidemiological studies also looked for independent effects of obesity, whereas its effects are largely mediated via other risk factors such as high blood pressure. A re-analysis of these data has now shown that fat distribution is a key factor in ill-health and this explains much of the earlier epidemiological evidence. It’s not only someone is fat that is important in health terms, but also where they are fat.
There has also been an increasing emphasis on gender, race and age and other individual factors on fat gain and loss, to the extent that it’s becoming apparent that any program must be individualised, as stressed throughout this book. However, recognition of the importance of the environment also makes a public health approach imperative.
There has also been a change away from the concentration on ‘diet’ as a form of treatment towards a change in lifestyle which, unlike short term diets, can be maintained over a lifetime. This includes a move away from exercise designed for cardiovascular fitness, towards an increase in the level of total activity—both planned and ‘incidental’—that is carried out within our changing, modem technological lifestyles. To this extent, professionals who deal only in prescribing diets or exercise are unlikely to maintain a primary role in fat loss through lifestyle management in the future.
Finally, a major shift in direction, begun in the 1990s, has been a change in thinking about the psychological aspects of obesity and body fat maintenance. In the 1970s, the use of behaviour modification techniques in weight control began and this has now become standard in most modem programs. More recently it’s been recognised that much more complex, emotional and cognitive (thinking) functions are involved in obesity. This is particularly so in the case of many women, who have suffered much more social and psychological pressure than men to attain an unrealistic body shape, and as a result have often developed counter-productive cognitive cycles of guilt, depression and anger associated with food and food restriction. Modem approaches need to pay more attention to dealing with these issues. Counselling also needs to become more reflective and less directive to empower people to resolve these issues themselves rather than simply replace one dependency (food) with another (a counsellor).
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