Obesity in the UK: A psychological perspective

Transcription

1 Obesity i the UK: A psychological perspective Obesity Workig Group 2011 Chair: Dr J.A. Waumsley

2 Ackowledgemets It has bee my great pleasure to Chair the BPS Workig Group o Obesity. A great deal of excellet work has bee coducted by experieced specialists across the domais of psychology ad cousellig. I would therefore like to ackowledge ad thak those who cotributed to this report for their sterlig, importat ad valued cotributios: Mr Nigel Atter Dr Susa Boyle Professor Julia Buckroyd Dr Kaire Culle Dr Jacqui Fiiga Dr Beverley Flit Mr Stuart Flit Miss Emma Kewi Dr David Marchat British Psychological Society Cosultat Cliical Psychologist, Glasgow & Clyde Weight Maagemet Service Professor Emeritus of Cousellig, Hertfordshire Uiversity Educatioal Psychologist Cousellig Psychologist Chartered Cliical Psychologist, Camde Adult Weight Maagemet Service Departmet of Sport ad Exercise Sciece, Aberystwyth Uiversity Chartered Cousellig Psychologist, Specialist Bariatric Team, North Bristol Trust Seior Lecturer i Sport ad Exercise Psychology, Edge Hill Uiversity Professor Naette Mutrie Professor of Exercise ad Sport Psychology, Uiversity of Strathclyde Dr Lisa Newso Dr Kathry Roberts Health Psychologist, NHS Kowsley Public Health Team Eatig Disorders Northampto JuLiE WAuMSLEy, CPsychol, DipCous Dr Julie Waumsley Chair of Obesity Workig Group BPS Chartered Sport & Exercise Psychologist, Director of Psychology & Cousellig, Uiversity of Northampto

3 Cotets Page 3 itroductio Julie Waumsley 5 Physical Activity ad Exercise Psychology: Our role i healthy weight maagemet for adults Julie Waumsley & Naette Mutrie 16 Exercise for Obese idividuals David Marchat 26 Applied Psychology ad Obesity Maagemet Lisa Newso & Beverley Flit 39 Weight Loss Surgery Emma Kewi & Susa Boyle 51 Pharmacological itervetios Kathry Roberts & Stuart Flit 56 Obesity i Childre Kaire Culle 66 Psychological itervetios for People with a BMi 35 Julia Buckroyd 79 Coclusio Julie Waumsley If you have problems readig this documet ad would like it i a differet format, please cotact us with your specific requiremets. Tel: ; P4P@bps.org.uk. isbn Prited ad published by the British Psychological Society. The British Psychological Society 2011 The British Psychological Society St Adrews House, 48 Pricess Road East, Leicester LE1 7DR, UK Telephoe Facsimile mail@bps.org.uk Website Icorporated by Royal Charter Registered Charity No

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5 Itroductio Julie Waumsley, Chair of Obesity Workig Group Obesity is a moder epidemic i the developed world, the prevalece of which has ever before bee experieced. I Eglad aloe, 1 i 4 adults are curretly obese, with more tha half the adult populatio overweight or obese (NICE, 2006). This tred is set to double by 2050 (Departmet of Health, 2009). Obesity levels i Wales are predicted as higher tha those i Eglad, ad Scotlad has oe of the highest levels of obesity i coutries of the OECD (Orgaisatio for Ecoomic Co-operatio ad Developmet), with over a millio adults ad over 150,000 childre obese. This is predicted to worse with adult obesity levels reachig over 40 per cet by 2030 (Scottish Govermet, 2010). I Norther Irelad 60 per cet of adults have a weight problem ad as may as 1 i 5 are obese. Figures from 2006/07 show that approximately 22 per cet of Norther Irelad s primary schoolchildre are classed as overweight or obese (Norther Irelad Executive, 2008). It is also estimated that oe third of childre ad youg people i the Wester world are overweight or obese ad this is set to rise by two thirds by 2050 (Reilly, 2009). Obesity is ot just a cosmetic problem for may but a serious risk to health. The strai to the NHS ad the cost to the wider ecoomy are eormous give the associated health risks, such as heart disease, stroke, diabetes, some types of cacer, gout ad gall bladder disease. Beig overweight ca also cause problems such as sleep apoea (iterrupted breathig durig sleep) ad osteoarthritis. Obesity has received much media attetio of late ad geeral awareess amogst govermet ad UK society is ackowledged. As such, there is a great deal beig doe at local govermet ad withi the Natioal Health Service to try to stem the rise of obesity. The govermet s healthy livig messages permeate commuities ad the Natioal Istitute for Health ad Cliical Excellece (NICE) have recetly set up a cosultatio group to address a whole-systems approach to obesity. O-goig utritioal ad sociological issues such as diet, trasport, exercise friedly tows ad available educatioal programmes for childre ad adults iform o ways to redress the growth of obesity. It is geerally accepted that obesity is a multifaceted issue that requires a biopsychosocial respose. However, whilst Cogitive Behavioural Therapy is briefly metioed i the NICE (2006) obesity guidelies as the recommeded way to address behavioural chage through psychological issues associated with obesity, psychological issues are geerally ot receivig as much attetio as sociological ad diet issues as ways of tacklig this growig epidemic. This report, commissioed by the British Psychological Society, attempts to redress this with a cohesive approach betwee academic ad applied work by producig a report o psychological approaches to obesity. The first two papers examie physical activity ad exercise behaviour for the obese, ad lack thereof, from a psychological perspective. The first paper defies obesity ad offers examples ad recommedatios of ways i which physical activity behaviour chage may occur. This is followed, i the secod paper, by a overview of research which highlights Obesity i the UK: A Psychological Perspective 3

6 issues to do with physical activity ad the obese idividual. Next, the report offers isight from a health psychologist s perspective, examiig ways of workig with obese idividuals withi the Natioal Health Service. The report goes o to examie weight loss surgery ad the psychological issues therei, followed by a examiatio of pharmaceutical itervetios. Up to this poit the report focuses, i the mai, o adult obesity. The fifth paper provides a overview of childhood obesity, offerig a psychological slat. What the esues is a paper addressig psychological issues with specific regard to emotioal eatig. The report is the cocluded. Each sectio of the report is writte by specialists i their field ad offers recommedatios for follow up work ad/or applied examples of ways i which to work with obese idividuals from a psychological perspective. The authors are aware that obesity affects people from may differet backgrouds ad i differig situatios. It is, though, beyod the scope of this report to address specific issues of socioecoomic status, the stigma attached to beig obese ad special populatios, icludig idividuals from differig ethic backgrouds. The aim of this report is to offer a cross-disciplied psychological perspective o ways i which to help idividuals who may be strugglig with weight problems ad i so doig, plug the gap which the authors feel has ot yet bee fully addressed by curret obesity itervetios. Empirical evidece ad applied practice itertwie to offer the reader a report that reflects the psychological perspectives from exercise ad physical activity psychology, cliical psychology, health psychology, educatioal psychology, cousellig psychology ad therapeutic itervetios. Refereces Departmet of Health (2009). Cost of obesity to NHS i Eglad. Retrieved 7 August 2009 via NICE (2006). Obesity: Guidace o prevetio, idetificatio, assessmet ad maagemet of overweight ad obesity i adults ad childre. Nice Cliical Guidelie No 43. Lodo: Natioal Istitute for Health ad Cliical Excellece. Norther Irelad Executive (2008). Obesity time bomb is tickig louder tha ever orth ad south. Retrieved 12 April 2010 from Reilly, J.J. (2009). Obesity i childre ad youg people. Highlight No 250. Lodo: Natioal Childre s Bureau. Scottish Govermet (2010). Prevetig overweight ad obesity i Scotlad: A route map towards healthy weight. Retrieved via 4 Professioal Practice Board

7 Physical Activity ad Exercise Psychology: Our Role i Healthy Weight Maagemet for Adults Julie Waumsley & Naette Mutrie Defiig obesity Obesity may be defied as a disorder i which excess body fat has accumulated to a extet that health may be adversely affected (Royal College of Physicias, 1998). The most commoly used measure of body fatess is Body Mass Idex (BMI), which is calculated as weight i kilograms divided by the square of height i metres. Icreased body fat cotet is associated with icreasig mortality with a BMI of betwee 25 ad 30kg/m², with further progressive icreases above a BMI of 30 (Calle et al., 1999). There are differeces for childre ad differet ethic groups. However, whilst BMI remais the stadard measure of fatess i social sciece research, the medical literature regards BMI as a iferior measure of fatess because it records the mass of the body ad does ot distiguish betwee the lea ad fat mass. Thus, two idividuals may be of same weight ad BMI yet oe may have 15 per cet body fat ad the other, 35 per cet. The latter may be sigificatly more at risk of poor health tha the former, but both would be reported as a obese statistic. Clearly, BMI measuremets may result i substatial misclassificatio of idividuals ito weight classificatios, which may result i a overestimatio of the prevalece of obesity (Burkhauser & Cawley, 2008). Whilst it is ot yet kow which measure of fatess is best, cadidates iclude: total body fat; percet body fat (which is total body fat divided by total mass); waist circumferece; ad waist-to-hip ratio (Burkhauser & Cawley, 2008). Use of air displacemet techological equipmet will more accurately assess levels of lea muscle tissue ad subcutaeous bodyfat but is more expesive ad cumbersome tha BMI or waist measuremets. A waist circumferece greater tha 80cm (32i) for wome ad 94cm (37i) for me icreases the risk of cardiovascular diseases. The greatest risk is for wome with a waist measuremet of more tha 88cm (35i) ad me with a waist measuremet of more tha 102cm (40i). Waist circumferece (or other more accurate measures) may be a more useful measure of obesity for muscular athletes sice BMI ofte misclassifies them as overweight (Burkhauser & Cawley, 2008; Jolliffe, 2004; McKay, 2002). Cotributig factors of obesity People geerally become obese whe, over a period of time, their eergy itake exceeds their eergy expediture. There is a complex iteractio of cotributory mechaisms ifluecig this, icludig biopsychosocial ad evirometal factors. Part of this complex iteractio is iactivity, which is cotributig to the obesity epidemic i the Uited Kigdom. Almost 1 i 4 adults i Eglad are curretly obese with more tha half the adult populatio, overweight or obese (NICE, 2006). If this tred cotiues, 9 i 10 adults will be overweight or obese by The cost of overweight ad obese idividuals to the NHS i 2007 was estimated to be 4.2 billio, estimated to rise to 6.3 billio i 2015 ad Obesity i the UK: A Psychological Perspective 5

8 is forecasted to more tha double by The cost to the wider ecoomy is 16 billio, ad this is predicted to rise to 50 billio per year by 2050 if left uchecked (Departmet of Health, 2009). There is evidece to suggest that the Govermet s healthy livig messages are failig to get through, as figures show obesity levels have almost doubled i 14 years (24 per cet of me ad wome were obese i 2007 compared with 16 per cet of wome ad 13 per cet of me i 1993; HSE, 2007). Childhood obesity is also icreasig with the associated health problems, icludig a rise i Type 2 diabetes (NICE, 2006). The govermet Foresight report o obesity recogises the complexity of the causes of obesity ad i so doig clearly locates iactivity as a major problem (Govermet Office for Sciece, 2005). Recommedatios for physical activity The potetial beefits of physical activity to health are huge. If a medicatio existed which had similar effect, it would be regarded as a woder drug or a miracle cure CMO 2009). The terms exercise ad physical activity are ofte used iterchageably, but their differeces have importat implicatios for uderstadig exercise psychology. To clarify their differetiatio: Physical activity is ay bodily movemet produced by skeletal muscles that results i eergy expediture ad is usually measured i kilocalories per uit of time (Casperse et al., 1985). Physical activity might iclude walkig, stair climbig, bicyclig ad swimmig. Exercise is a sub-set of physical activity ad is plaed, structured, repetitive bodily movemets that someoe egages i for the purpose of improvig or maitaiig physical fitess or health ad may iclude activities such as aerobic dace, cyclig, ruig or joggig, brisk walkig, swimmig laps or weightliftig. I terms of itesity, moderate to vigorous levels are recommeded for health. Moderate itesity is a level that people ca egage i ad at the same time cotiue a coversatio with someoe, while vigorous itesity (such as ruig or playig a fast sport such as squash) is a level that makes coversatio difficult because of the icreased demad o breathig required. Physical activity/exercise psychology suggests that a graduated approach to icreasig activity is appropriate ad will help avoid ijury. The active livig approach, i which idividuals are ecouraged to make active choices i everyday life such as choosig to walk rather tha drive, choosig the stairs rather tha the escalator or choosig to walk the dog more, is recommeded as a route to achievig regular activity without cost or the eed to atted a particular facility. Physical activity combied with the restrictio of eergy itake leads to greater fat loss tha either treatmet o its ow (Crest, 2005) ad the health beefits of a physically active lifestyle are well documeted. However, idividuals are ofte cofused about how much physical activity or exercise to take ad what type of exercise to take. The recommedatio for Eglad, Norther Irelad, Scotlad ad Wales is for adults to do at least 30 miutes of moderate-itesity physical activity o five or more days a week, with this activity comprisig oe sessio of 30 miutes or several lastig 10 miutes or more (CMO, 2009; NICE, 2006; Scottish Executive, 2003). To prevet obesity, people may eed to do miutes of moderate-itesity activity a day, particularly if they do ot reduce their eergy itake. Those who have bee obese ad have lost weight may eed to do miutes of activity a day to avoid regaiig weight (NICE, 2006). Recet guidace from the Scottish 6 Professioal Practice Board

9 Itercolleagiate Guidelies Network (SIGN, 2010) suggests that overweight ad obese idividuals should do miutes per week of moderate itesity physical activity, which may be achieved through five sessios of miutes per week, or lesser amouts of vigorous physical activity ca be accumulated over the course of the day i multiple small sessios of at least te miutes duratio each. The guidace o the recommeded duratio ad itesity of physical activity required for health is curretly beig updated i the UK with all four home coutries ivolved i the process. Psychology of physical activity, exercise ad sport There is ofte some cofusio i termiology whe examiig the psychology of sport, exercise ad physical activity. The psychology of sport ad exercise both ivolve examiig the relatioships betwee physical movemet ad beliefs ad emotios. However, a primary purpose of sport psychology is to examie the effects of such variables so as to ehace performace, ofte i competitive sport. A primary purpose of exercise psychology is to ehace the adoptio ad maiteace of regular exercise ad its effects o psychological well-beig. The psychological ad biological cosequeces of physical activity are studied to determie its effects o metal health (Buckworth & Dishma, 2002). Prevalece of physical iactivity The examiatio of physical activity behaviour ad isight ito the ways i which idividuals adopt ad maitai regular physical activity have bee grouded i psychological theories of behaviour chage. The potetial impact of exercise ad physical activity itervetios o public health is great cosiderig the low level of activity i most segmets of the populatio ad the established liks betwee physical activity ad health. Iactivity affects more people i Eglad tha the combied total of those who smoke (20 per cet), misuse alcohol (6 9 per cet) or are obese (24 per cet). O average iactivity costs each local area care team 5 millio per year due to health cosequeces (CMO, 2009). Fidigs from the Health Survey for Eglad (2007) suggest people believe they are more active tha they actually are. The physical activity of 1,998 me ad 2,509 wome aged 16 ad over was assessed usig accelerometry, a tool used for measurig physical activity more accurately ad precisely tha self report measures. Oly 6 per cet of me ad 4 per cet of wome met the govermet s curret recommedatios for physical activity by achievig at least 30 miutes of moderate or vigorous activity o at least five days i the week of accelerometer wear, accumulated i bouts of at least 10 miutes. Self report measures suggest 46 per cet of me ad 36 per cet of wome who were either overweight or obese met the recommedatios, followed by 41 per cet of me ad 31 per cet of wome who were overweight ad 32 per cet of me ad 19 per cet of wome who were obese (HSE, 2007). I Norther Irelad, 25 per cet of adults are chroically sedetary, takig less tha 20 miutes of physical activity per week (Crest, 2005). The most recet data from Scotlad suggests that aroud 60 per cet of the populatio do ot achieve the recommeded levels of activity for heath gai (a miimum of 30 miutes of moderate itesity activity most days of the week) (Bromley et al., 2009). Obesity i the UK: A Psychological Perspective 7

10 Self-report measures (Health Survey for Eglad, 2007) show that people overestimate the amout of exercise they are doig ad these figures are much greater tha actual measured reports of physical activity. I short, despite well-kow beefits, oly a miority of people i idustrialised coutries are sufficietly physically active to have a beeficial effect o their health. Physical activity behaviour chage The fact that the majority of wester populatios do ot meet curret miimum recommedatios for the amout of physical activity eeded for health ecessitates a greater uderstadig of the determiats of ivolvemet i exercise ad physical activity, icludig motivatio (Biddle & Mutrie, 2008). Traslatig itetios ito behaviour remais a key challege. Implemetatio itetios are self-regulatory strategies that ivolve the formatio of specific plas that specify whe, how ad where performace of behaviour will take place ad are likely to be effective i promotig physical activity behaviour (Biddle & Mutrie, 2008). Whilst it is beyod the scope of this paper to offer a i-depth discussio of all the various psychological theories of behavioural chage, it is perhaps of beefit to detail theories ad models of use i physical activity research ad metio those that have offered a uderpiig for effective behaviour chage with physical activity. Very broadly, psychological behavioural chage theories fall ito three categories: Attitudial approaches, Motivatioal approaches ad Stage-based approaches. Withi the former, the Theory of Plaed Behaviour (Ajze, 1985; 1988; 1991) has the most supportig research, with The Health Actio Process Approach (Schwarzer, 1992; 2001) ad Protectio Motivatio Theory (Rogers, 1983) also showig promisig results. Amogst the may motivatioal theories, Self Determiatio Theory (Deci & Rya, 1985; 1991) (motivatio likig to competece ad cofidece); Goal Perspectives Theory (Maehr & Nicholls, 1980) ad Self-efficacy Theory (Badura, 1986; 1997) have support from the literature. Perhaps the best kow Stage-based Theory is The Trastheoretical Model (Prochaska et al., 1992) ad this model has support i the physical activity literature. Attitudes, particularly perceptios of cotrol ad itetio, are cetral to the psychology of physical activity determiats, as is motivatio, but o oe costruct ca explai all that we do. Notwithstadig this, despite the static ad ui-dimetioal approach of the Theory of Plaed Behaviour (Ajze, 1985; 1988; 1991) it has bee the most successful approach i physical activity psychology, showig attitude to accout for about per cet of the variace i itetios ad itetios to share about 30 per cet of the variace i physical activity assessmet (see Biddle & Mutrie, 2008 for a overview). Cogitive Evaluatio Theory (Deci, 1975; Deci & Rya, 1985) ivolves the processig of iformatio cocerig reward structures ad teases apart itrisic ad extrisic motivatio to physical activity. Thus, it remais a viable theory for the study of motivatioal process i physical activity behaviour. Extedig this perspective, ad icludig the psychological eeds of competece, autoomy ad relatedess, Deci ad Rya (1985; 1991) propose Self-determiatio Theory, which is a importat perspective for the study of motivatio i physical activity. Theoretical approaches that have focused o the self-perceptios of efficacy ad competece show that participatio i physical activity is associated with perceptios of 8 Professioal Practice Board

11 competece but more specific perceptios of competece/efficacy are likely to be better predictors of specific behaviours tha more geeralised beliefs i competece (see Biddle & Mutrie, 2008 for a overview). The Trastheoretical Model (Prochaska et al., 1992) offers a dyamic advace o the static models metioed ad a appropriate ad ituitively plausible framework to uderstad behaviour ad behaviour chage. This model has bee successfully used i other health settigs, which leds cofidece to its applicatio to physical activity. Ideed, may itervetios have used TTM as their theoretical framework (e.g. Cox, et al., 2003; Du, et al., 1999). BOX 1: A case study of a physical activity itervetio based o the trastheoretical model of behaviour chage It is recommeded that physical activity behaviour chage itervetios are guided by relevat theory. The trastheoretical model was used to iform the desig of a trial to determie if people could be ecouraged to walk or cycle (actively commute) to work istead of usig their cars (Mutrie et al., 2002). Such a chage i behaviour has become of iterest ot oly for physical activity promotio but as a elemet i campaigs to limit car use ad cogestio ad potetially improve the eviromet. The first way that the theory was applied i this study cocered targetig people who were thikig about active commutig (cotemplators) or preparig to actively commute (doig some irregular active commutig). A stages of chage questio was used as a screeig tool for iterested participats ad oly cotemplators ad preparers were the ivited ito the trial. The materials for the itervetio group were delivered as a self-help istructioal booklet amed Walk I to Work Out Pack, desiged for the cotemplatio ad preparatio stages. The pack cotaied writte iteractive materials that guided participats through elemets of the trastheoretical model of behaviour chage, such as cosiderig a decisioal balace sheet (pros ad cos) for icreasig active commutig behaviour, cosiderig how to ehace self-efficacy for active commutig ad settig goals for icreasig walkig or cyclig to ad from work. The pack also cotaied local iformatio about distaces ad routes, ad safety iformatio. The cotrol group received the pack six moths later. The results showed that the itervetio group was almost twice as likely to icrease walkig to work as the cotrol group at six moths (odds ratio of 1.93, 95 per cet cofidece itervals 1.06 to 3.52). The cotemplators, that is those who had bee cosiderig active commutig at the begiig of the trial, added more miutes per week to their walkig tha the preparers although the preparers also achieved a icrease. The itervetio was ot successful at icreasig cyclig with very few participats optig for this method of actively travellig. Twety five per cet (95 per cet cofidece itervals 17 per cet to 32 per cet) of the itervetio group, who received the pack at baselie, were regularly actively commutig at the 12-moth follow-up. The materials were updated ad reproduced both i Scotlad ad Eglad ad are available to employers who wish to promote active commutig to their workforces. Mutrie, N., Carey, C., Blamey, A., Crawford, F., Aitchiso, T. & Whitelaw, A. (2002). Walk i to work out: A radomised cotrolled trial of a self help itervetio to promote active commutig. Joural of Epidemiology ad Commuity Health, 56(6), Obesity i the UK: A Psychological Perspective 9

12 Reviews of successful itervetios coclude that a key elemet i physical activity behaviour chage is to have a theoretically drive itervetio. What is less clear is which of several competig theories is best (Hillsdo et al., 2007; Kah et al., 2002). I Box 1 we have added a case study that shows the use of a theoretically drive itervetio aimed at icreasig active commutig i a work place settig. Maitaiig physical activity behaviour chage Sustaiig chages i physical activity levels remais a challege to exercise sciece. Leisure cetres ofte offer fitess assessmets to ecourage members to atted although there is little to evidece sustaied behavioural chage i this approach. Health professioals might better assist through approaches such as Motivatioal Iterviewig, a cliet-cetred cousellig style for elicitig behaviour chage by helpig cliets to explore ad resolve ambivalece (Rollick & Miller, 1995, p.326). However, ecouragig chage through motivatio is a complex task. Thus, this itervetio should be delivered by those traied i psychological approaches ad who exhibit a ability to attue ad empathise with those seekig help ad who also display excellet commuicatio ad reflective listeig skills. Practitioers will also have good kowledge about physical activity for geeral ad cliical populatios, icludig the curret activity recommedatios, ad BOX 2: Steps i a typical physical activity cousellig sessio (See Biddle & Mutrie, 2008 for more details) Step 1: Determie Physical Activity History Discuss the reasos that the perso has for watig to icrease activity. Take ote of whe the perso was last active, the kids of activities they might like ow ad a measure of recet physical activity, e.g. Seve-day recall. Step 2: Discuss Decisio Balace Ask the perso to cosider what the pros ad cos of icreasig activity are for them. If there are more cos tha pros ask them to cosider how to miimise some of the cos. Step 3: Esure Social Support Determie with the perso what kid of support they might eed ad who ca provide it. Step 4: Negotiate Goals Help the perso set realistic ad time phased goals for gradually icreasig activity up to a level they have determied, e.g. i four weeks time I would like to be walkig for 30 miutes more o at least three days of the week. Write these goals dow. Step 5: Discuss Relapse Prevetio If there is time or if the cousellig sessio is with someoe who is already doig activity the discussio o how to prevet relapse from regular activity should take place. Step 6: Provide iformatio o local opportuities All iformatio o relevat local activities, such as walkig paths, swimmig pools ad classes should be o had to supplemet discussio as required. 10 Professioal Practice Board

13 exhibit a uderstadig of the various theories of behaviour chage ad factors that will ifluece whether or ot a perso will succeed i becomig more active. For a obese populatio, these qualificatios ad attributes are of exceptioal importace give the sesitive ature of physical activity i the lives of those who fid activity difficult for a variety of physical, evirometal, social ad psychological reasos, ad i view of the cosequeces of ot icorporatig physical activity ito otherwise ofte sedetary lives. Guidelies for coductig physical activity cosultatios are available (see Kirk et al., 2007). A outlie of the recommeded steps to take i coductig a physical activity cosultatio is provided i Box 2 below. These steps are evideced based ad show the use of may cogitive ad behavioural techiques used i other areas of behaviour chage. Commuity approaches The NICE (2006) guidelies suggest a multidimesioal approach to tacklig obesity withi local healthcare teams ad commuities that address the issues of lifestyle, diet, physical activity, workig with adults ad childre, motivatio ad behaviour chage. However, aecdotal evidece from a cross sectio of healthcare teams i Eglad ad Wales (27 out of 57 cotacted) suggests that although there are obesity cliics workig specifically withi local healthcare teams, some cliicias are ot cofidet i kowig how to implemet behaviour chage ad motivatio strategies. Nor are some practitioers cofidet i prescribig exercise ad physical activity programmes ad may ot be aware of how activity is to be recommeded because of wide ragig health beefits eve if weight loss is ot rapid. Evidece produced from quota samplig also suggests that exercise specialists are rarely part of the obesity teams withi the healthcare teams. The commo model appears to be healthcare teams referrig obese idividuals to obesity services ru as commuity-based programmes, such as healthy eatig, commercial weight maagemet programmes or exercise related programmes operatig from local leisure cetres. Some ivolved i such programmes do have some basic cogitive behavioural therapy ad motivatioal iterviewig traiig. Noetheless, there are several presetig cocers from the model described. First, commuity-based itervetio programmes ofte have a short duratio (for example a 12-week course). Research suggests that ay behavioural chage activity is required for a duratio of six moths or loger to prevet relapse (Biddle & Mutrie, 2008). Secod, the programmes beig utilised by healthcare teams appear ot to promote itrisic motivatio, which may affect adherece issues. Uless the psychological eeds of autoomy, competece ad relatedess are satisfied i ay behavioural chage programme, a idividual is likely to revert to old behavioural habits (Deci & Rya, 1985). Fially, weight related criticism has a egative effect o physical activity participatio (Faith et al., 2002) as do self-presetatio cocers (Biddle & Mutrie, 2008). Although exercise specialists ca advise o exercise ad physical activity programmes, it appears that psychological issues associated with physical activity behaviour chage are ot beig addressed to offer support ad uderstadig towards exercise motivatio ad behavioural chage to obese idividuals. Itervetios to chage physical activity are still i their ifacy (Biddle & Mutrie, 2008) ad there are social, physical ad political eviromets that ofte reiforce ad ecourage sedetary livig ad foster obesogeic eviromets (Govermet Office for Sciece, 2005; Swibur & Egger, 2004). There is little uderstadig of appropriate modes of activity for those who are Obesity i the UK: A Psychological Perspective 11

14 overweight ad obese; it might be advatageous to begi exercise ad physical activity programmes with o-weight bearig activity such as swimmig or statioary cyclig because they put less strai o joits but these activities preset challeges of accessig public chagig facilities or fitess gyms. The challege of access may be psychological (ot feelig sporty or embarrassmet) but the challege may be mobility especially for the super obese i gettig out of the house ad to a facility. Thus home-based programmes that are supported properly may be eeded. Uderstadig persoal ad evirometal factors that are associated with sedetary lifestyles ad low rates of adoptio ad adherece to physical activity, ad support i chagig these sedetary behaviours, requires attetio from psychologists. More work is required i care settigs to establish how the care team ca ifluece physical activity levels ad exercise ad physical activity psychologists would add much value to a cliical team workig with obese idividuals across the Uited Kigdom. Other behavioural challeges I additio to the behavioural challeges aroud icreasig activity to a level that will achieve health gai ad cotribute to weight loss, there are two other behavioural challeges that face psychologists attemptig to help those who are obese gai cotrol over their weight. These issues are sedetary behaviour per se ad the cocept of behavioural compesatio for icreased activity. There is growig evidece that there are health implicatios of sedetary time, idepedet of physical activity levels (Healy et al., 2008). A dose respose associatio has bee established betwee sittig times ad mortality from all causes ad CVD, idepedet of leisure time physical activity (Katzmarzyk et al., 2009). Thus a ew behavioural challege is to ecourage people ot to sit dow for exteded periods of time although the criterio level (e.g. ot more that two hours) has ot bee established. Physiologists have bee aware for a log time that people who udertake traiig begi to compesate for this additioal eergy expediture by either icreasig the amout they eat or by decreasig the amout of icidetal or everyday activity they udertake. A further behavioural challege for psychologists is to brig compesatory behaviour to a coscious level ad help people fid ways of overcomig compesatio. To date, there is o psychological evidece examiig this issue. Coclusio Psychologists are able to help uderstad motivatios ad barriers to icreasig activity, decreasig sedetary time ad usig compesatory behaviours. I additio we ca develop ad test itervetios ad work as part of multi-discipliary teams egaged i helpig those who are obese gai cotrol over their weight. 12 Professioal Practice Board

15 Refereces Ajze, I. (1985). From itetios to actios: A theory of plaed behaviour. I J. Kuhl & J. Beckma (Eds.), Actio cotrol: From cogitio to behaviour (pp New York: Spriger-Verlag. Ajze I. (1988). Attitudes, persoality ad behaviour. Milto Keyes: Ope Uiversity Press. Ajze, I. (1991). The theory of plaed behaviour. Orgaizatioal Behavior ad Huma Decisio Processes, 50, Badura, A. (1986). Social foudatios of thought ad actio: A social cogitive theory. Eglewood Cliffs, NJ: Pretice-Hall. Badura, A. (1997). Self-efficacy: The exercise of cotrol. New York: W.H. Freema. Biddle, S.J.H. & Mutrie, N. (2008). Psychology of physical activity: Determiats, well-beig ad itervetios. Lodo: Routledge Bromley, C., Bradshaw, P. & Give, L. (2009). The Scottish Health Survey Available from Buckworth, J. & Dishma, R.K. (2002). Exercise psychology. Leeds: Huma Kietics. Burkhauser, R.V. & Cawley, J. (2008). Beyod BMI: The value of more accurate measures of fatess ad obesity i social sciece research. Joural of Health Ecoomics, 27, Calle, E.E., Thu, M.J., Petrelli, J.M., Rodriguez, C. & Heath, C.W (1999). Body-mass idex ad mortality i a prospective cohort of US adults. New Eglad Joural of Medicie, 34(15), Casperse, C.J., Powell, K.E. & Christeso, G.M. (1985). Physical activity, exercise ad physical fitess: Defiitios ad distictios for health-related research. Public Health Reports, 100, Chief Medical Officer (2009). Aual report of the Chief Medical Officer. Lodo: Departmet of Health. Crest (2005). Guidelies for the maagemet of obesity i secodary care. Belfast: Cliical Support Efficiecy Support Team. Cox, K.L., Gorely, T.J., Puddey, I.B., Burke, V. & Beili, L.J. (2003). Exercise behaviour chage i year-old wome: The SWEAT study (Sedetary Wome Exercise Adherece Trial). British Joural of health Psychology, 8, Deci, E.L. (1975). Itrisic motivatio. New York: Pleum. Deci, E.L. & Rya, R.M. (1985). Itrisic motivatio ad self-determiatio i huma behavior. Pleum Press: New York. Deci, E.L. & Rya, R.M. (1991). A motivatioal approach to self: Itegratio i persoality. I R.A. Diestbier (Ed.), Nebraska symposium o motivatio: Perspectives o motivatio (Vol. 38, pp ). Licol, NE: Uiversity of Nebraska Press. Departmet of Health (2009). Cost of obesity to NHS i Eglad. Accessed 7 August 2009 from Obesity i the UK: A Psychological Perspective 13

16 Dishma, R.K. & Du, A.L. (1988). Exercise adherece i childre ad youth: Implicatios for adulthood. I R.K. Dishma (Ed.), Exercise adherece: Its impact o public health (pp ), Champaig, IL: Huma Kietics. Du, A.L, Marcus, B.H., Kampert, J.B., Garcia, M.E., Kohl, H.W. & Blair, S.N. (1999). Compariso of lifestyle ad structured itervetios to icrease physical activity ad cardiorespiratory fitess: A radomised trial. Joural of the America Medical Associatio, 281, Faith, M.S., Leoe, M.A., Ayers, T.S., Heo, M. & Pietrobelli, A. (2002). Weight criticism durig physical activity, copig skills, ad reported physical activity i childre. Pediatrics, 110, Govermet Office for Sciece (2005). Foresight: Tacklig obesities: Future choices - project report. Health Survey for Eglad (HSE) (2007). The NHS Iformatio Cetre, Accessed 7 August 2009 via Healy, G.N., Dusta, D.W., Salmo, J., Shaw, J.E., Zimmet, P.Z. & Owe, N. (2008). Televisio time ad cotiuous metabolic risk i physically active adults. Medicie & Sciece i Sports & Exercise, 40(4), Hillsdo, M., Foster, C. & Thorogood, M. (2007). Itervetios for promotig physical activity. Cochrae Database of Systematic Reviews, 1. CD Jolliffe, D. (2004). Cotiuous ad robust measures of the overweight epidemic: Demography, 41(2), Kah, E.B., Ramsey, L.T., Browso, R.C., Heath, G.W., Howze, E.H., Powell, K.E., Stoe, E.J., Rajab, M.W. & Corso, P. (2002). The effectiveess of itervetios to icrease physical activity A systematic review. America Joural of Prevetive Medicie, 22(4), Katzmarzyk, P.T., Church, T.S., Craig, C.I. & Bouchard, C. (2009). Sittig time ad mortality from all causes, cardiovascular disease, ad cacer. Medicie & Sciece i Sports & Exercise, 41(5), Kirk, A., Barett, J. & Mutrie, N. (2007). Physical activity cosultatio for people with Type 2 diabetes. Evidece ad guidelies. Diabetic Medicie, 24, Maehr, M.L. & Nicholls, J.G. (1980). Culture ad achievemet motivatio: A secod look. I N. Warre (Ed.), Studies i cross-cultural psychology (Vol 2, pp ). New York: Academic Press. McKay, B. (2002). Govermet s stadard lumps huks athletes with truly obese. Wall Street Joural, July 23. Mutrie, N., Carey, C., Blamey, A., Crawford, F., Aitchiso, T. & Whitelaw, A. (2002). Walk i to work out : A radomised cotrolled trial of a self help itervetio to promote active commutig. Joural of Epidemiology ad Commuity Health, 56(6), Natioal Istitute for Health ad Cliical Excellece (2006). Obesity: guidace o prevetio, idetificatio, assessmet ad maagemet of overweight ad obesity i adults ad childre. Cliical Guidelie 43. Lodo: NICE. 14 Professioal Practice Board

17 Prochaska, J.O., DiClemete, C.C. & Norcross, J.C. (1992). I search of how people chage: Applicatios to addictive behaviours. America Psychologist, 47, Rogers, R.W. (1983). Cogitive ad physiological processes i fear appeals ad attitude chage: A revised theory of protectio motivatio. I J.R. Cacioppo & R.E. Petty (Eds.), Social psychology: A sourcebook (pp ). New York: Guilford Press. Rollick, S. & Miller, W.R. (1995). What is motivatioal iterviewig? Behavioural ad Cogitive Psychotherapy, 23, Royal College of Physicias (1998). Cliical maagemet of overweight ad obese patiets with particular referece to the use of drugs, pp Lodo: author. Schwarzer, R. (1992). Self-efficacy i the adoptio ad maiteace of health behaviours: Theoretical approaches ad a ew model. I R. Schwarzer (Ed.), Self-efficacy: Thought cotrol of actio (pp ), Bristol, PA: Taylor & Fracis. Schwarzer, R. (2001). Social-cogitive factors i chagig health behaviors. Curret Directios i Psychological Sciece, 10(2), Scottish Executive (2003). Let s make Scotlad more active. Ediburgh: Crow Copyright. Scottish Executive (2005). The Scottish Health Survey Ediburgh: Crow Copyright. SIGN (2010). Maagemet of Obesity: A Natioal Cliical Guidelie. Ediburgh: Scottish Itercollegiate Guidelies Network. Sport Eglad (2006). The active people survey. Lodo: Sport Eglad Commuicatios. Swibur, B.A. & Egger, G. (2004). The ruaway weight gai trai: Too may accelerators, ot eough brakes. British Medical Joural, 329(7468), Obesity i the UK: A Psychological Perspective 15

18 Obese Idividuals ad Exercise Participatio David Marchat Give that a perso with a BMI greater tha 30 kg/m2 is classified as obese, exercise poses a sigificat physical ad psychological challege for the idividual. Furthermore, give that such idividuals require two to three times the recommeded ormal activity levels for health (e.g., see Saris et al., 2003), ad that such icreased activity levels pose sigificat stress to joits, the challege for exercise schemes ad professioals is also cosiderable. As highlighted i the previous sectio, those activities that may be the most physically appropriate such as swimmig, may oly exacerbate ay embarrassmet obese idividuals may experiece whilst exercisig (Biddle & Mutrie, 2008) due to egative self-evaluatios ad beliefs about their fitess ad co-ordiatio (e.g. Browell, 1998; Focht & Hauseblas, 2004). Ideed the sigificace of such obesity-related barriers is highlighted by Peterse et al. (2004) i their study suggestig that the relatioship leadig from obesity to iactivity is stroger tha that from iactivity to obesity, potetially cotrary to commo coceptios. What is preseted here to supplemet the previous sectio is a review of relevat research coverig psychological aspects of exercise participatio for obese idividuals. I particular, attetio is give to: exercise referrals ad itervetios; exercise professioals; ad modes, duratios ad itesities of exercise. Such factors are see as critical variables for fully uderstadig the issues associated with icreasig exercise participatio i obese idividuals. Exercise referral ad itervetio Exercise Referral schemes have become icreasigly popular withi Primary Health Care settigs, ad offer oe such structured settig through which obese idividuals ca lear about, ad safely participate, i structured ad supervised exercise. Edmuds et al. (2007) used Self-Determiatio Theory (SDT) as a model to asses those motivatioal processes related to exercise participatio, cogitios, ad well-beig amog obese idividuals participatig i a 12-week Exercise o Prescriptio (EoP) scheme for weight loss. Autoomy, competece ad relatedess satisfactio (social egagemet) all iflueced either motivatioal regulatio or exercise behaviours. Importatly, those cliets who exhibited greater adherece to the scheme preseted greater barrier efficacy tha those who adhered less. That is, these idividuals preseted with greater cofidece i overcomig those barriers idetified as obstructig their exercise participatio. Furthermore, Edmuds et al. (2007) idicate that for these overweight/obese idividuals, feeligs of choice regardig the type of exercise participated i, as well as their perceptios of competece i udertakig those exercises, assist i the developmet of self-determied motivatio. As such, they recommed that exercise referral schemes should be grouded i the developmet of self-determied motivatioal regulatio (where behaviours are performed out of choice ad through iterest i the activity itself rather tha related outcomes). This view was recetly echoed by Silva et al. (2010) whose cotiuig 16 Professioal Practice Board

19 logitudial radomised cotrol trial has show beeficial effects (weight loss ad exercise adherece) of exercise participatio support grouded i SDT over the first year of the study with overweight ad obese cliets. The itervetio desig promoted autoomous participatio through multi-level support, addressig physical activity ad utritio, idividual characteristics (e.g. uderstadig, body image, copig strategies) ad evirometal characteristics (e.g. activity choices, formal ad iformal physical activity). The importace of such autoomy supportive eviromets for log-term maiteace of behaviour chage i obese populatios is clear, ad exercise psychology has a critical role i its promotio ad provisio. Dalle, Grave ad colleagues (2011) recommed the icorporatio of cogitive procedures ad strategies ito the exercise referral process, ad a move towards multidiscipliary approaches to exercise promotio ad support for obese idividuals. Likewise, Shaw et al. (2005) coclude that exercise ad dietary itervetios aimed at weight loss for obese idividuals should be combied with cogitive behavioural strategies to maximise success (see also Aesi & Whitaker, 2010). Such cogitive behavioural approaches are ot oly importat for exercise adherece, but have also bee show to positively ifluece related variables uderpiig effective participatio such as body image, self-efficacy ad selfcocept whe compared to typical itroductory exercise cosolatio approaches (e.g. see Aesi 2010). After the referral process ad iitial time-period, research by Kig et al. (2006) idicates that obese idividuals require ogoig provisio of such supportive eviromets for behaviour chage to be maitaied. These authors suggest that such guidace, support ad feedback could well be achieved at distace through mail, , ad/or telephoe. Give the importace of psychological characteristics (e.g. self-efficacy, perceived competece, ejoymet) i promotig log-term participatio i exercise, their developmet should be see as a primary goal of obesity targeted exercise referral schemes. Exercise psychologists role i uderstadig ad developig these is grouded i a broad uderstadig of the idividual. For example, takig a cultural perspective, Aesi (2007) moitored chages i self-efficacy of obese females as they participated i a 20-week supported exercise ad utritioal scheme. Participatio i the scheme was associated with weight loss; however, the primary drivers of weight chage for white ad Africa America wome differed sigificatly. Whereas weight loss for obese white wome was predicted by chages i Body Area Satisfactio, Africa America wome s weight chage was predicted by their chages i Exercise Self-Efficacy. Such differeces idicate the differet cocers ad sources of self-efficacy that are importat to behaviour chage i this populatio. Exercise psychology s highlightig of both time-spa ad cultural iflueces o the idividual demostrates its importat role i supportig effective exercise ivolvemet for obese idividuals. Physical activity, rather tha referral for structured exercise, has bee a focus of childhood obesity itervetios. Whe promotig physical activity levels i obese childre, particular emphasis has bee placed o TV viewig. However, rather tha perceivig TV viewig as a behaviour to limit, TV viewig has bee utilised as a reward ad source of reiforcemet from a behavioural ecoomic perspective. Recetly, Goldfield et al. (2008) demostrated that whe icreased physical activity levels (measured with accelerometers) was rewarded with TV viewig time, boys (8 12 years) exhibited positive resposes, whe compared with Obesity i the UK: A Psychological Perspective 17

20 girls, thus highlightig importat geder differeces i icreasig activity levels i obese girls. Give that TV viewig may be a less rewardig stimulus for girls tha for boys, approaches to promotig physical activity to childre should take ito accout such geder differeces. Such a approach to ifluecig the health behaviour choices of obese childre is more flexible, ad potetially more effective i the log term. However, Ladhuis et al. (2008) war that efforts should be aimed at reducig TV viewig habits i childhood, give the associated health impact that persist ito adulthood. Recetly, Hederso et al. (2010) focused o the use of exercise cosultatio provided by a physicia to icrease physical activity participatio i obese adolescets. The exercise cosultatio sessio was based upo the trastheoretical model (e.g. see Marcus & Simki, 1994), ad physicias were traied oly through the review of exercise cosultatio guidelies set out by Loughla ad Mutrie (1995). This simple, cost-effective ad accessible itervetio approach resulted i icreased physical activity participatio ad decreased weight loss. Give that youth populatios are more likely to come ito cotact with medical rather tha exercise professioals, such itervetio traiig is promisig ad requires further ivestigatio. Fially, whe structured exercise participatio is ecessary for obese childre, tailorig the eviromet to support ejoymet of the activity or distractio from physiological sesatios have bee highlighted as key cosideratios. For example, De Bourdeaudhuij ad colleagues (2002) have demostrated icreased treadmill ruig times whe coupled with music beig played compared to o-music coditios for obese childre o a weight loss programme. The proposal that exercise prescriptio itervetios should be grouded i theory is ot a ew (if ot effectively practiced) proposal, as the Natioal Health Service (2001) guidelies idicate that exercise referral schemes should be based o theoretical behavioural models. To icrease the success of such schemes they should better icorporate motivatioal systems ad support based o soud theory. I particular, the role of exercise psychologists i the desig of schemes, iitial assessmets ad durig the course of participatio appears critical i light of evidece. Ideed, Gidlow et al. (2005) highlight the eed for more effective patiet profilig o exercise referral schemes i geeral. SDT is suggested as a key framework for utilisatio to foster basic psychological eed satisfactio ad self-determied motivatioal regulatio (Edmuds et al., 2007), whilst cogitive behavioural strategies should be icorporated throughout the referral process ad beyod to support the obese exerciser i log-term behaviour chage. The exercise eviromet The exercise eviromet poses may sigificat physical, psychological ad social challeges to the obese exerciser. Previous work has show that obese exercisers preset better adherece ad/or weight loss whe participatig i home-based rather tha facilitybased exercise programmes (e.g. Perri et al., 1997; Kig et al., 2006). However, this most likely reflects the curret state of exercise eviromets rather tha the specific efficacy of home-based exercise. Most otably for this report, research poits to the social iteractios with staff ad fellow exercisers as critical exercise eviromet variables which support exercise behaviour i obese populatios. For example, Edmuds et al. (2007) highlight key social iteractios throughout the referral scheme as a area of cocer. I their study, iteractios with staff were regular ad supportive early o i the scheme (e.g. a iitial 18 Professioal Practice Board