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Being able to be stable: exploring primary weight maintenance as a public health strategy for obesity prevention
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Overweight and obesity are considerable public health issues internationally as well as in Sweden. On a global level, the obesity prevalence has nearly doubled over the last 30 years. Currently in Sweden, more than one third of all women, and slightly more than half of all men, are either overweight or obese. The long-term results of obesity treatment programs are modest as reported by other studies. The importance of extending the focus to not only obesity treatment, but also prevention of weight gain, has therefore been emphasized.

Aim The overall aim of this thesis is to explore the concept of primary weight maintenance (PWM) and to increase the knowledge of the attitudes, behaviours, strategies and surrounding circumstances that are important for PWM in a Swedish middle-aged population.

Material and methods All study participants were recruited based on their previous participation in a health survey in their home setting; The Västerbotten Intervention Programme (VIP) in Västerbotten Sweden (paperI-IV), or the Upstate Health and Wellness Study in Upstate New York (IV), USA. All subjects had participated twice, with a time period of ten years between health surveys. The prevalence of obesity between the years 1990-2004 was calculated for VIP participants (paper I). Ten-year non-gain (lost weight or maintained body weight within 3% of baseline weight) or weightgain (≥3%) was calculated for individuals aged 30, 40, or 50 years at baseline. A multivariate logistic regression model was built to predict weight non-gain. In-depth interviews were conducted with 23 maintainers and four slight gainers in Sweden and analysed using Grounded Theory (paper II). A questionnaire study was conducted including 2138 Swedish and 2134 US participants (paper III and IV). Analysis of variance (ANOVA), correlation, and linear regression were performed to identify attitudes, strategies, and behaviours that are predictive of PWM in different age, sex and BMI subgroups in Sweden (paper III). Further, the pattern of ten-year weightchange (% and kg) in 1999-2009 was calculated for Swedish and US women within different subgroups (paper IV). ANOVA, correlation and chi-squaretests were conducted to contrast eating and exercise habits between the two countries that may explain the differences in weight change.

Results The prevalence of obesity (BMI ≥30) in Västerbotten increased from 9.4% in 1990 to 17.5% in 2004 (I). Older age, being female, being overweight at baseline, later survey year, baseline diagnosis of diabetes, and lack of snuff use increased the chances of not gaining weight. Based on the in-depth interviews, describing attitudes, behaviours and strategies of importance for PWM, a model was constructed (II). Weight maintenance was characterized as “a tightrope walk” and four strategies of significance for PWM were described as “to rely on heritage”, “to find the joy”, “to find the routine” and “to be in control”. The questionnaire study aimed at identifying predictors of PWM in different age, sex and BMI groups (III). The pattern of significant predictors was widely disparate between different subgroups. Of 166 predictors tested, 152 (91.6%) were predictive of PWM in at least one subgroup. However, only 4.6% of these were significant in half of the subgroups or more. The mean percent weight changes (in all cases weightgain), between 1999-2009 for Swedish and US women, were 4.9% (SD=5.8) and 9.1% (SD=13.7) respectively (p for t-test˂0.001) (IV). For the US women, the largest weight change occurred among the 30 year olds for all three BMI strata. For the Swedish, it was seen among overweight and obese 30 year old women. The largest difference in ten-year weight change between the two countries for any two matched subgroups was seen in normal weight 30 year olds. Significantly more of the women in this Swedish subgroup stated having more of healthy behaviours. However, there was a tendency for unhealthy behaviours to be strongly associated with greater weight gain in the US, but much less so in Sweden.

Conclusion: Younger individuals, those of normal body weight, and those without health conditions (e.g. diabetes type 2) and cardiovascular riskfactors – were the least likely to maintain their weight over the 10 year period (I). Educational efforts on the prevention of overweight and obesity should therefore be broadened to include those individuals. The in-depth interview study showed great variety with regard to attitudes, strategies and behaviours important for PWM (II). The results from this study informs health personnel about the need to tailor advice related to body weight, not only to different sub-groups of individuals trying to lose weight but also to subgroups of primary weight maintainers who are trying to maintain weight. This statement was also supported by the questionnaire data, where the large disparity in the pattern of significant variables between subgroups suggests that these interventions should be tailored to the person’s demographic (age,sex and BMI) (III). Paper IV showed that even though the prevalence of obesity among Swedish women has increased substantially during these ten years, it has not kept pace with the increase in the US. One explanation for this may be that normal 30 year old Swedish women have more healthy behaviours than do US women. However, the insensitivity of the Swedish women to weight gain for healthy versus unhealthy alternatives may also be a factor. If the exact reason behind this phenomenon can be identified this may contribute to a deeper understanding of PWM both in Sweden and the US.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2013. , 105 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1584
Keyword [en]
Overweight, Obesity, Weight maintenance, Primary weight maintenance, Sweden, US, Middle-aged, Obesity prevention, Public health
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-79653ISBN: 978-91-7459-695-3 (print)OAI: oai:DiVA.org:umu-79653DiVA: diva2:643681
Public defence
2013-09-20, Aulan, Vårdvetarhuset, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2013-08-30 Created: 2013-08-28 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Who is maintaining weight in a middle-aged population in Sweden? A longitudinal analysis over 10 years.
Open this publication in new window or tab >>Who is maintaining weight in a middle-aged population in Sweden? A longitudinal analysis over 10 years.
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2007 (English)In: BMC Public Health, ISSN 1471-2458, Vol. 7, 108- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Obesity has primarily been addressed with interventions to promote weight loss and these have been largely unsuccessful. Primary prevention of obesity through support of weight maintenance may be a preferable strategy although to date this has not been the main focus of public health interventions. The aim of this study is to characterize who is not gaining weight during a 10 year period in Sweden.

METHODS: Cross-sectional and longitudinal studies were conducted in adults aged 30, 40, 50 and 60 years during the Västerbotten Intervention Programme in Sweden. Height, weight, demographics and selected cardiovascular risk factors were collected on each participant. Prevalences of obesity were calculated for the 40, 50 and 60 year olds from the cross-sectional studies between 1990 and 2004. In the longitudinal study, 10-year non-gain (lost weight or maintained body weight within 3% of baseline weight) or weight gain (> or = 3%) was calculated for individuals aged 30, 40, or 50 years at baseline. A multivariate logistic regression model was built to predict weight non-gain.

RESULTS: There were 82,927 adults included in the cross-sectional studies which had an average annual participation rate of 63%. Prevalence of obesity [body mass index (BMI) in kg/m2 > or = 30] increased from 9.4% in 1990 to 17.5% in 2004, and 60 year olds had the highest prevalence of obesity. 14,867 adults with a BMI of 18.5-29.9 at baseline participated in the longitudinal surveys which had a participation rate of 74%. 5242 adults (35.3%) were categorized as non-gainers. Older age, being female, classified as overweight by baseline BMI, later survey year, baseline diagnosis of diabetes, and lack of snuff use increased the chances of not gaining weight.

CONCLUSION: Educational efforts should be broadened to include those adults who are usually considered to be at low risk for weight gain--younger individuals, those of normal body weight, and those without health conditions (e.g. diabetes type 2) and cardiovascular risk factors--as these are the individuals who are least likely to maintain their body weight over a 10 year period. The importance of focusing obesity prevention efforts on such individuals has not been widely recognized.

Keyword
Adult, Age Distribution, Analysis of Variance, Body Composition, Body Mass Index, Body Weight, Cross-Sectional Studies, Exercise, Female, Health Education/*organization & administration, Humans, Incidence, Life Style, Logistic Models, Longitudinal Studies, Male, Middle Aged, Multivariate Analysis, Obesity/*epidemiology/*prevention & control, Patient Participation, Primary Prevention/organization & administration, Retrospective Studies, Risk Factors, Sex Distribution, Sweden/epidemiology
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-16213 (URN)10.1186/1471-2458-7-108 (DOI)17565692 (PubMedID)
Available from: 2007-08-31 Created: 2007-08-31 Last updated: 2015-04-29Bibliographically approved
2. Weight maintenance as a tight rope walk: a grounded theory study
Open this publication in new window or tab >>Weight maintenance as a tight rope walk: a grounded theory study
2010 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 10, no 51Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Overweight and obesity are considerable public health problems internationally as well as in Sweden. The long-term results of obesity treatment are modest as reported by other studies. The importance of extending the focus to not only comprise obesity treatment but also prevention of weight gain is therefore being emphasized. However, despite the suggested change in focus there is still no consensus on how to prevent obesity or maintain weight. This study reports findings from a qualitative study focusing on attitudes, behaviors and strategies important for primary weight maintenance in a middle-aged population.

METHODS: In depth interviews were conducted with 23 maintainers and four slight gainers in Sweden. The interviews were transcribed and an analysis of weight maintenance was performed using Grounded Theory.

RESULTS: Based on the informants' stories, describing attitudes, behaviors and strategies of importance for primary weight maintenance, a model illustrating the main findings, was constructed. Weight maintenance was seen as "a tightrope walk" and four strategies of significance for this "tightrope walk" were described as "to rely on heritage", "to find the joy", "to find the routine" and "to be in control". Eleven "ideal types" were included in the model to illustrate different ways of relating to the main strategies. These "ideal types" described more specific attitudes and behaviors such as; eating food that is both tasteful and nutritious, and choosing exercise that provides joy. However, other somewhat contradictory behaviors were also found such as; only eating nutritious food regardless of taste, and being physically active to control stress and emotions.

CONCLUSION: This study show great variety with regards to attitudes, strategies and behaviors important for weight maintenance, and considerations need to be taken before putting the model into practice. However, the results from this study can be used within primary health care by enhancing the understanding of how people differ in their relation to food and physical activity. It informs health personnel about the need to differentiate advices related to body weight, not only to different sub-groups of individuals aiming at losing weight but also to sub-groups of primary weight maintainers aiming at maintaining weight.

National Category
Nutrition and Dietetics
Research subject
Food and Nutrition
Identifiers
urn:nbn:se:umu:diva-32651 (URN)10.1186/1471-2458-10-51 (DOI)000275406500001 ()20122140 (PubMedID)
Available from: 2010-03-19 Created: 2010-03-19 Last updated: 2017-12-12Bibliographically approved
3. Primary weight maintenance: an observational study exploring candidate variables for intervention
Open this publication in new window or tab >>Primary weight maintenance: an observational study exploring candidate variables for intervention
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2013 (English)In: Nutrition Journal, ISSN 1475-2891, E-ISSN 1475-2891, Vol. 12, 97- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Previous studies have focused on weight maintenance following weight loss, i.e. secondary weight maintenance (SWM). The long-term results of SWM have been rather modest and it has been suggested that preventing initial weight gain, i.e. primary weight maintenance (PWM), may be more successful. Therefore, developing a prevention strategy focused on PWM, enabling normal weight or overweight individuals to maintain their weight, would be of great interest. The aim of this study was to identify attitudes, strategies, and behaviors that are predictive of PWM in different age, sex and BMI groups in Northern Sweden. METHODS: A questionnaire was mailed to 3497 individuals in a Swedish population that had two measured weights taken ten years apart, as participants in the Västerbotten Intervention Programme. Subjects were between 41-63 years of age at the time of the survey, had a baseline BMI of 20-30, and a ten year percent change in BMI greater than -3%. The respondents were divided into twelve subgroups based on baseline age (30, 40 and 50), sex and BMI (normal weight and overweight). Analysis of variance (ANOVA), correlation, and linear regression were performed to identify independent predictors of PWM. RESULTS: Of the 166 predictors tested, 152 (91.6%) were predictive of PWM in at least one subgroup. However, only 7 of these 152 variables (4.6%) were significant in 6 subgroups or more. The number of significant predictors of PWM was higher for male (35.8) than female (27.5) subgroups (p=0.044). There was a tendency (non significant) for normal weight subgroups to have a higher number of predictors (35.3) than overweight subgroups (28.0). Adjusted R-squared values ranged from 0.1 to 0.420. CONCLUSIONS: The large number of PWM predictors identified, and accompanying high R-squared values, provide a promising first step towards the development of PWM interventions. The large disparity in the pattern of significant variables between subgroups suggests that these interventions should be tailored to the person's demographic (age, sex and BMI). The next steps should be directed towards evaluation of these predictors for causal potential.

National Category
Public Health, Global Health, Social Medicine and Epidemiology Nutrition and Dietetics
Identifiers
urn:nbn:se:umu:diva-79136 (URN)10.1186/1475-2891-12-97 (DOI)000322032600001 ()23855935 (PubMedID)
Available from: 2013-08-09 Created: 2013-08-09 Last updated: 2017-12-06Bibliographically approved
4. Comparisons of weight change, eating habits and physical activity between women in Northern Sweden and Rural New York State-results from a longitudinal study
Open this publication in new window or tab >>Comparisons of weight change, eating habits and physical activity between women in Northern Sweden and Rural New York State-results from a longitudinal study
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2015 (English)In: Nutrition Journal, ISSN 1475-2891, E-ISSN 1475-2891, Vol. 14, 88Article in journal (Refereed) Published
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-79582 (URN)10.1186/s12937-015-0078-0 (DOI)000360332300001 ()26319494 (PubMedID)
Note

Originally included in thesis in submitted form, with the title "Comparisons of weight change, eating habits and physical activity between Swedish and US women : implications for the obesity epidemic".

Available from: 2013-08-26 Created: 2013-08-26 Last updated: 2017-12-06Bibliographically approved

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