Abstract

Adult obesity has become a major public health crisis in the UK. Presently, 25% of the adult population in the country is obese, with projections indicating that this proportion may double in the next three decades or so. This clearly points to the need for greater attention to the crisis. Though obesity has been linked to origins such as genetics, lack of physical activity and the consumption of unhealthy foods remain the major risk factors. This implies that regular physical activity and reduced consumption of high-calorie diets can substantially decrease the risk of obesity. Nonetheless, since these interventions are often implemented at an individual or small-group level as opposed to the population level, little effectiveness has been achieved. It is only in the recent past that nationally-focused public health campaigns relating to obesity have been initiated in the UK. The few studies that have been conducted in this relatively new area show that effectively implemented public health campaigns have considerable potential in terms of obesity prevention and management at the national level. However, reversing obesity prevalence may still be a challenge since the condition originates from not only individual and behavioural factors, but also environmental factors such as the food industry, workplaces, and the design of public spaces, which often hinder efforts to eat healthy and engage in regular physical activity. Therefore, for public health campaigns to be more successful, they must be accompanied by changes to the larger macro-environment. Since the use of nationally-focused public health campaigns in obesity prevention and management is a fairly new practice, more research is required to determine what works more effectively as well as the role of environmental changes in mediating the impact of obesity-related public health campaigns.

 

 

Table of Contents

Abstract 2

Introduction. 4

Search Strategy. 6

Obesity and Related Prevalence. 7

Mortality, Morbidity, and Economic Burden. 8

Causes and Risk Factors. 10

Prevention and Management 13

The Role of Public Health Campaigns. 17

Rationale for Obesity Public Health Campaigns. 19

Obesity Public Health Campaigns Internationally and in the UK.. 22

Effectiveness of Obesity Public Health Campaigns. 23

Conclusion. 26

Recommendations. 28

References. 30

 

 

 

 

 

Introduction

Obesity has become an issue of major public concern in the UK, with adults being the most affected. In 2014, 61.7% of adults (generally defined in the UK as individuals aged 16 and above) were overweight or obese (Public Health England [PHE], 2016a). More specifically, as reported by the National Health Service (NHS) (2015), approximately 25% of adults in the UK are obese. This makes the UK have the highest prevalence of adult obesity in Western Europe (Marie et al., 2015). Statistics further indicate that the prevalence of adult obesity in the UK has remained on an upward trend since the early 1990s (NHS, 2015; (PHE, 2016a).

These statistics are alarming by any means. The statistics actually imply that a significant proportion of adults in the country have an unhealthy body mass index (BMI), which implies greater risk for complications such as diabetes, heart disease, and cancer (NHS, 2015). This further implies greater risk for avoidable mortality, not to mention the substantial economic burden the condition imposes on individuals, families, health care providers, and the government (Wang et al., 2011; Campbell-Scherer and Sharma, 2016). It has actually been reported that approximately 30,000 deaths in the UK annually are attributed to obesity (NHS, 2015), and that the condition costs the country more than £4 billion in direct costs and £15 billion in indirect costs every year (PHE, 2016c). The implication is that adult obesity in the UK is a public health crisis requiring greater attention than ever before, without which the condition may become an even more disturbing crisis in the future (Paton, 2007; Paton, 2013; National Obesity Forum, 2013).

Literature extensively demonstrates that lifestyle factors, such as dietary habits and lack of physical exercise, are the major risk factors for obesity (Health and Social Care Information Centre [HSCIC], 2015; Dietz et al., 2015; Okop et al., 2016; Kobyliak et al., 2016). This is particularly true for the UK, where there has been a rapid increase in sedentary lifestyles and the consumption of high-calorie food (Shaw, 2012; Adams and White, 2015; NHS, 2015; Lopez and Johnson, 2016; Ulijaszek and McLennan, 2016). The implication is that changes in lifestyle present the major solution as far as the prevention and management of obesity is concerned. For this to be achieved, however, a major shift in public behaviour is vital. Public health campaigns can be useful in this regard. Studies have actually shown the potential of public health campaigns in changing public behaviour, particularly with respect to health issues resulting from lifestyle factors such as obesity (Morley et al., 2009; Walls et al., 2011; King et al., 2013; Tsai et al., 2014). Nonetheless, since obesity development is also influenced by environmental factors such as the food industry and the built environment, the impact of public health campaigns would be mediated by changes in these factors (Bombak, 2014; Reiheld, 2015)

To this end, this paper provides a review of literature relating to the role of public health campaigns in the prevention and management of obesity in adults aged 18 and above in the UK. The review was important in advancing the author’s knowledge of this area, which has turned out to be a major public health concern. First, the methodology utilised in locating the literature is described. Next, the findings of the literature located are presented. This section particularly focuses on the definition of obesity and its prevalence among adults in the UK; associated mortality, morbidity, and economic costs; causes and risk factors; as well as prevention and management strategies. The section also pays attention to the importance, rationale, and effectiveness of public health campaigns in eliminating or minimising the prevalence of the condition amongst the target population. Finally, a conclusion and recommendations for research and practice are offered.

Search Strategy

The aim of the search process was to locate literature relating to the role of public health campaigns and changes in obesity-related environmental factors in the prevention and management of adult obesity in the UK. A review of literature essentially encompasses a summary and synthesis of literature in a given subject or area (Oliver, 2012). This is often aimed at improving understanding of the given subject, identifying gaps in the prevailing literature, as well as providing evidence to support a given intervention or policy (Ridley, 2008).

The search for the literature was conducted on the internet (Google) as well as EBSCO, Proquest, CINAHL, and PubMed databases using the following search terms and phrases: adult obesity, UK, prevention, management, and public health campaigns. Boolean operators were particularly useful in locating more focused results (Oliver, 2012). For instance, searching “adult obesity in the UK”, “obesity prevention and management”, as well as “obesity and public health campaigns” returned more specific results. The initial search obviously returned hundreds of thousands of hits. Nonetheless, focus was on locating the most recent literature on the topic. The search was, therefore, narrowed to literature published in the period 2005-2016. The importance of obtaining up-to-date evidence when conducting a literature review cannot be overemphasised (Ridley, 2008).

It is also important to consider the credibility of the literature (Oliver, 2012). This was particularly true for the internet search. In this case, focus was on obtaining literature published by credible UK government agencies such as the Department of Health, Public Health England, NHS, and NICE. This implies that information provided by the media and other sources of questionable credibility was excluded from the review. C

redibility was also considered during the database search. First, only articles published in a scholarly journal were included. This implies that unpublished works, newspaper articles, conference proceedings, as well as articles published in books were not included. The credibility of articles published in scholarly journals is often informed by their peer-reviewed nature (Oliver, 2012). There was no discrimination on the type of articles published in scholarly journals – original studies (qualitative and quantitative), systematic reviews, meta-analyses, and opinion articles were all included. There was also no discrimination on the basis of country context – literature focusing on both the UK and other countries was included. This was particularly important given the scarcity of literature pertaining to obesity-related public health campaigns, especially within the context of the UK. Based on the above inclusion criteria, approximately 500 items were located

The second stage of the search process involved a more detailed scrutiny of titles, abstracts, and content. According to Bryman (2012), this helps in getting even more relevant literature. Focus at this stage was also on eliminating duplicated articles. Finally, 73 items were located, 19 from the internet search and 54 from the database search. The findings of these items are summarised in the remainder of this paper.

Obesity and Related Prevalence

Obesity basically denotes a condition characterised by excess fat in the body (Lawlor and Chaturvedi, 2006). Though there are various techniques for measuring the condition, the commonest is the BMI, which entails calculating the weight of the body in relation to height (HSCIC, 2015). It is, however, important to note that BMI does not represent an express measure of the body’s fat mass or its distribution, and that BMI measures may at times be inaccurate due to high muscle mass (PHE, 2016e). A person is termed as obese if their BMI is 30 and above (PHE, 2016a).

In the UK, one in every four adults is obese (Marie et al., 2015; HSCIC, 2015). This prevalence is over three times higher compared to the 1980s, when it was 6-8% (NHS, 2015). This implies that the prevalence of obesity among adults in the UK has more than tripled in the last three decades. More unfortunately, projections indicate that the prevalence of adult obesity in the UK may double by 2050 (PHE, 2016a). This projection arises from the fact that no one country in the world, with the exception of Cuba, has managed to reduce obesity prevalence in the last three decades (NHS, 2015). The reduction of obesity prevalence in Cuba was, however, an unintended outcome of an economic recession in the early 1990s, which resulted in the loss of 5.5 kilograms on average per citizen owing to a serious food and fuel scarcity (NHS, 2015). The difficulty of reversing obesity trends is a clear indication that the condition needs different thinking.

Mortality, Morbidity, and Economic Burden

Although obesity can be effectively addressed through lifestyle and dietary changes, it can have severe consequences for those already affected, particularly in relation to morbidity and quality of life (University of Birmingham, 2016). According to NHS (2015), being obese raises the risk for other avoidable morbidities such as heart disease, cancer, type 2 diabetes, high blood pressure, and stroke. For instance, compared to a man with a healthy weight, a man with obesity is five times more likely to be a victim of type 2 diabetes, three times more likely to develop colon cancer, and over two times more likely to develop high blood pressure (NHS, 2015). Additionally, compared to a woman with a healthy weight, a woman with obesity is approximately 13 times more likely to be a victim of type 2 diabetes and over three times more likely to develop high blood pressure and a heart attack (NHS, 2015).

Other morbidities that may arise from obesity include liver disease, gall bladder disease, angima, osteoarthritis, ovarian cancer, musculoskeletal disorders, obstructive sleep apnoea, asthma, and infertility (Erickson et al., 2015; HSCIC, 2015; Okop et al., 2016; PHE, 2016f). This clearly demonstrates the significant morbidity burden associated with obesity. In addition to disease, obesity can result in reduced self-esteem, poor mental health, low quality of life, and inability to find work (NHS, 2015; Dreber et al., 2015).

The huge morbidity burden associated with obesity translates to a substantial economic burden (Campbell-Scherer and Sharma, 2016). Statistics indicate that direct costs relating to the treatment of obesity and related morbidities in the UK have grown from approximately £480 million in 1998 to £4.2 billon in 2007, while indirect costs such as lost productivity grew from £ 2.6 billion to £15.8 billion over the same period (PHE, 2016c). Whereas these figures point to a tremendous increase in treatments costs relating to obesity, it is important to note that there is no universally accepted definition of costs. This makes it quite difficult to interpret trends. Even so, the direct and indirect costs associated with obesity remain substantial. Projections have even indicated that the costs will increase significantly in the next two decades or so given that the prevalence of obesity is expected to be much greater (Wang et al., 2011).

Obesity is associated with not only a huge morbidity and economic burden, but also a significant mortality burden. According to NHS (2015), approximately 30,000 deaths (or 6% of all deaths) in the UK every year are attributable to obesity, with 30% of these occurring prior to retirement age. This shows that obesity can not only cause death, but also reduce life expectancy. In fact, obesity can reduce life expectancy by up to 10 years (University of Birmingham, 2016). A major limitation with these estimates, however, is that they are based on a report released by the National Audit Office (NAO) in 2001 (PHE, 2016b). It is highly likely that the figures may have changed given that the prevalence of adult obesity has increased significantly since then.

Additionally, while evidence extensively demonstrates that obesity is a significant predictor of mortality, measuring the number of deaths attributable to obesity remains a complex undertaking. For instance, summing up the number of times obesity is documented as a cause of death may underestimate the percentage of deaths associated with the condition. In a recent study, for example, it was established that obesity was identified as a cause of death in only 0.23% of the total deaths recorded in England in 2006 (cited in PHE, 2016b). This is certainly a significant deviation from the figure of 6%. Furthermore, the relationship between obesity and mortality may be mediated by factors such as sex and smoking (PHE, 2016b). All the same, the relationship between obesity and the risk of death remains positive.

Causes and Risk Factors

Obesity occurs when the intake of energy through foods and drinks exceeds the consumption of energy through physical activity and the body’s metabolism over a long-lasting period of time, thereby causing a build-up of excess fat in the body (PHE, 2016d). This is often caused by a combination of several individual, behavioural, biological, and environmental factors (Yumuk et al., 2015; Ulijaszek and McLennan, 2016). Individual factors are particularly important causative agents of obesity. It is widely acknowledged that reduced physical activity coupled with the consumption of foods and drinks with high levels of calories, sugar, and saturated fats increases the risk of obesity (Batch and Baur, 2005; Lawlor and Chaturvedi, 2006; Fitch et al., 2013; Yao, 2013; HSCIC, 2015; Dietz et al., 2015; Kobyliak et al., 2016; University of Birmingham, 2016). Physical activity in this regard denotes all types of activity including everyday walking, cycling, active recreation, active play, work-related activity, swimming, gardening, playing games, as well as competitive and non-competitive sports (PHE, 2016g). Since physical activity significantly influences energy consumption in the body, lack of it often results in an imbalance between energy input and expenditure. The imbalance is further compounded by the excessive intake of unhealthy foods and drinks (NICE, 2015).

In the UK, a significant proportion of adults do not adhere to the recommended guidelines for physical inactivity and diet. It is recommended that adults aged 18 above should spend at least 150 minutes in moderate activity such as walking, gardening, and cycling every week; or at least 75 minutes in intense activity such as running, swimming, and football (HSCIC, 2015). Statistics based on self-reported physical activity show that in 2012 33% of men and 45% of women did not meet these recommendations, with non-compliance being more pronounced amongst older adults (HSCIC, 2015). Statistics further indicate that there was a clear relationship between meeting recommendations for physical activity and BMI: 75% and 64% of men and women who were not overweight or obese, respectively, complied with the guidelines (HSCIC, 2015). Though self-report data often involves less time and cost in terms of collection, validity problems are usually common as participants may exaggerate their responses (Crosby, DiClemente and Salazar, 2006). This appears to have been the case as objective measures of physical activity amongst adults in the UK during the same period show that only 6% and 4% of men and women, respectively, achieved the recommended guidelines for physical activity (HSCIC, 2015).

The UK government also provides guidelines for diet and nutrition. The HSCIC (2015) report reveals startling statistics as far as adult compliance with the guidelines is concerned. For instance, the report shows that: overall fruit and vegetable purchases declined between 2010 and 2013; the consumption of fruits and vegetables fell below the recommended level of at least five portions per day; the average consumption of oily fish was below the recommended level of 140g per week; the average consumption of saturated fat surpassed the recommended level of at most 11% food energy; and the consumption of non-milk extrinsic sugars surpassed the recommended level of at most 11% food energy. This clearly shows that a significant proportion of adults in the UK give little attention to the healthiness of the foods they consume; a trend which may perhaps be attributed to lack of knowledge of healthy diets and/or the health risks posed by unhealthy diets as well as wrong perceptions about obesity.

While dietary habits and sedentary lifestyles present the biggest risk factors for obesity, it is important to note that the condition does not simply result from these factors. According to NHS (2015), environmental factors significantly influence the decisions individuals make in relation to their lifestyle. In essence, people increasingly live in environments that encourage inactivity and unhealthy dietary habits, thereby increasing proneness to obesity. These environments have been termed as obesogenic environments (PHE, 2016g). For instance, owing to factors such as technological advancements, urbanisation, as well as increased economic activity, modern life is ever more characterised by greater dependence on cars, computers, desk-based jobs, longer working hours, and fast foods (NHS, 2015). This has in turn implied reduced physical activity and increased consumption of high-calorie foods.

It has actually been reported that the average distance an individual walks for purposes of transport has decreased from 255 miles annually in 1976 to 192 miles in 2003; and that the use of cars has grown by over 10% (NHS, 2015). In other words, though people today travel overwhelmingly greater distances compared to four decades or so ago, much of the travel is made by car. Other environmental factors that have shaped lifestyle decisions include safety concerns, reduced access to green spaces, as well as diminished availability of safe and convenient cycling lanes and healthy foods (NHS, 2015; PHE, 2016a).

Other risk factors for obesity include genetics, ethnicity and racial background, socioeconomic status, some prescription drugs, as well as underlying medical conditions (Batch and Baur, 2005; Shaw, 2012). For instance, individuals whose family have a history of obesity are often at a greater risk of becoming obese during childhood and even adulthood compared to those from a family without a history of obesity (NHS, 2015).  Additionally, compared to the general population, Asians tend to have a greater risk for obesity (University of Birmingham, 2016). More research is, however, needed to validate the link between these factors and obesity.

Prevention and Management

            Since diet and physical activity present the biggest risk factors for obesity, the significance of change in dietary and activity behaviour cannot be overemphasised as far as the prevention and management of the condition is concerned (Fitch et al., 2013; Yao, 2013; Foo et al., 2013; Brauer et al., 2015; Yumuk et al., 2015). The National Institute for Health and Care Excellence (NICE) actually provides important recommendations for diet and physical activity (NICE, 2015). NICE particularly advocates for: adherence to the recommended guidelines for diet and physical activity; identification of habits, perceptions, or circumstances that may hamper efforts to maintain a healthy BMI; keen checking of food and drink labels before purchase; limitation of alcohol consumption; self-monitoring of weight and related behaviours; and communication to the public of the benefits of maintaining a healthy weight.

Studies conducted in various parts of the world have extensively demonstrated the usefulness of physical activity and healthy diet in the prevention and management of obesity, especially in the short-term (Greaves et al., 2011; Hutfless et al., 2013; Vinkers et al., 2014; Lombard et al., 2014; Ross et al., 2015; Rice et al., 2016; Al-Shehri et al., 2016; Lombard et al., 2016). This clearly shows the wide evidence base for the effectiveness of healthy eating and physical activity in addressing adult obesity. Technological advancements have even made the delivery of the interventions easier as the internet, email, text messages, mobile applications, podcasts, monitoring devices, and other technological tools can now be used to relay diet and physical activity guidelines (Hutchesson et al., 2015).

Studies conducted in the UK have also reported similar findings. In their study, for instance, which included 1.3 million adults with obesity attending a large-scale commercial weight management programme ran in various parts of the country as well as Ireland, Stubbs et al. (2015) found that the programme resulted in an average weight loss of 3.9 kg during the first three months of attendance. Whereas these findings add weight to the effectiveness of physical activity and healthy eating in addressing adult obesity, it is not clear whether they are also representative of free or non-commercial weight management programmes. Nonetheless, as shown in Flint’s and Cummins’s (2016) cross-sectional study of 72,999 men and 83,667 women drawn from 22 assessment centres across the UK, active walking and cycling significantly reduced BMI and body fat. A major strength of Flint’s and Cummins’s (2016) study is that it compared car-only commuters and active commuters (walking and cycling). Nevertheless, the study focused on a single-component intervention as opposed to a multiple-component intervention. Studies have demonstrated that interventions combining multiple strategies such as physical activity and diet tend to be more effective in obesity prevention and management compared to those with a single strategy (Ryan et al., 2015; Lombard et al., 2014; Lombard et al., 2016).

While literature extensively documents the effectiveness of dietary and physical activity interventions in dealing with adult obesity, there are a number of shortcomings with the literature. First and foremost, much of the literature does not clearly indicate the types of exercise and diet that most effectively reduce the risk. More research is, therefore, required in this area. In addition, it still remains quite unclear whether the interventions are effective in the long term since most trials have not involved significantly prolonged follow-up. Another shortcoming is that attention is mainly paid to weight-loss assessment – there is often little focus on obesity-related cardiovascular risk factors such as heart disease and hypertension.          More importantly, even if a great deal of studies has shown the effectiveness of behavioural change in addressing obesity, most of the studies focus on individuals or small groups. This makes it quite difficult to establish whether the interventions are effective for the general population given that dietary and activity behaviours are largely influenced by the food industry, the built environment, transport policy, and other micro- and macro-environmental factors (Batch and Baur, 2005; Lawlor and Chaturvedi, 2006; Cummins and Macintyre, 2006; Musingarimi, 2008; Ulijaszek and McLennan, 2016). All the same, there is considerable evidence that well-targeted behaviour and lifestyle change programmes can be effective in preventing and managing obesity.

Other interventions for obesity prevention and management include over-the-counter dietary supplements, pharmacological treatments, and surgery (Batch and Baur, 2005; Lawlor and Chaturvedi, 2006). These interventions may be particularly helpful in instances of severe obesity or where dietary and physical activity interventions have failed or achieved little effectiveness (Lawlor and Chaturvedi, 2006). Even so, the interventions may not be effective in the long term if there is no change in dietary and physical activity behaviour.

In spite of these interventions, reversing the prevalence of adult obesity remains a difficult objective to achieve, with the prevalence of the condition in most countries generally rising year after year (Ross et al., 2015). In fact, as aforementioned, no country in the world has managed to achieve the objective in the last three decades. Nonetheless, with different thinking the objective could perhaps be achieved. According to NHS (2015), addressing the obesity crisis requires the involvement of not only individuals, but also the government, businesses, and the society as a whole. In other words, whereas individuals and families should eat healthier and engage in more physical activity, the government, businesses, and the society as a whole have an important role to play in building an environment that fosters physical activity and healthy eating.

For instance, the government has a crucial role to play with respect to advising citizens on healthier foods and physical activity, recognising obesity as a priority for action, providing the necessary resources, mandating businesses to enhance the labelling of foods and drinks, as well as enacting supportive legislation (NHS, 2015; NICE, 2015; Huang et al., 2015). In the UK, the government has demonstrated commitment to addressing the obesity crisis by introducing initiatives such as the Change4Life programme and enacting supportive legislation (NHS, 2015; Department of Health, 2015; Capehorn, Haslam and Welbourn, 2016). Businesses’ role on the other hand relates to reducing the proportion of fat and sugar in food products, disclosing calorie information on food labels, providing opportunities for employees to engage in physical activity and eat healthy, and encouraging customers to eat healthy (NHS, 2015; NICE, 2015).

Essentially, initiatives aimed at preventing and managing obesity must be conducted at micro and macro levels as opposed to individual or small-group levels. Lawlor and Chaturvedi (2006) actually state obesity prevention and management initiatives are more likely to be effective if they are targeted towards an entire population as opposed to a small group or an individual. The need for a more holistic approach to the prevention and management of obesity stems from the obesogenicity of modern environments, which play an instrumental role in accelerating obesity (Batch and Baur, 2005; Foo et al., 2013; Yumuk et al., 2015; Ulijaszek and McLennan, 2016). The implication is that obesity prevention and management efforts may not be effective if the environments where people live, eat, work, study, play, and socialise are not changed to encourage the eating of healthy diets and involvement in physical activity. In other words, changes must be made to home environments, neighbourhoods, recreational and community facilities, transport and health systems, as well as food production, retailing, and advertising.

The Role of Public Health Campaigns

            Public health campaigns can be useful in facilitating behaviour change at a macro level. Though there is no broadly accepted definition, a public health campaign basically denotes a health promotion initiative that utilises mass media tools to cause behaviour change in a large population (Department of Health, 2009). The campaign seeks to educate a population and raise awareness about a certain issue, change attitudes towards the issue, and change public behaviour in relation to the issue (Musingarimi, 2008).

Public health campaigns borrow significantly from social marketing and behaviour-change theory. Social marketing essentially denotes the organised application of marketing principles and concepts to accomplish defined behavioural objectives for a social good (Department of Health, 2009). It also refers to the deployment of commercial marketing ideas to provoke change of behaviour in a certain community or population (Walls et al., 2011). The marketing component of a public health campaign implies that aspects such as segmentation, consumer behaviour, and communication are crucial. For instance, segmenting a population facilitates the identification of at-risk populations, proper understanding of their attitudes and behaviours and the origin of the attitudes and behaviours, effective choice of communication techniques, as well as efficient resource allocation (Department of Health, 2009). In this case, for instance, adults in the UK are at a great risk of obesity due to unhealthy diets and lack of physical activity. As such, effectively communicated messages can be useful in helping individuals shift to healthy diets and regular physical activity.

Communication is a particularly important component of a public health campaign. First and foremost, consideration should be made to message comprehensibility, memorability, clarity, conciseness, style, and content if the intended outcomes are to be achieved (Dixon et al., 2015; Royne and Levy, 2015). For instance, using complex terminologies may limit comprehensibility. Equally, poor choice of style and content may elicit negative emotions, thereby hindering the effectiveness of the message. In this case, for example, messages depicting obesity or overweight in a negative manner may unintentionally result in greater stigmatisation of individuals with obesity as well as increased dissatisfaction with one’s body amongst populations at risk (Puhl and Heuer, 2010; Puhl, Luedicke and Lee, 2013; Puhl, Peterson and Luedicke, 2013; Dixon et al., 2015).

Additionally, messages must be packaged and delivered in a manner that resonates with the target population (Department of Health, 2009; Hatfield et al., 2015). For instance, a given method of communication may work for children but not necessarily for adults. Equally, a given method may work for a certain segment of the adult population but may be ineffective for another. This implies that attention must be paid to understanding the preferences of the target population as far as communication is concerned.

With the advancement of technology, designers of public health campaigns now have a wider variety of communication techniques to choose from – television, radio, the print media, the internet, social media, as well as mobile applications (Hutchesson et al., 2015). Since a population may often comprise different segments, it is usually prudent to rely on multiple methods of communication (Department of Health, 2009). In this case, for instance, the current adult population comprises veterans, baby boomers, generation X, and the millenials. Each of these groups embodies unique characteristics. For instance, since they have been brought up in an era of rapid technological advancement, the millenials tend to be more technologically-savvy compared to the other age-groups. Therefore, while modern communication methods such as social media may be relevant for them, they may not be necessarily relevant for veterans and baby boomers. Essentially, a public health campaign targeting a population with diverse sub-populations is likely to be more successful if the communication of the intended messages is done with consideration of the distinctive characteristics of each sub-population.

Social marketing pays attention mainly to prevention as opposed to management (Department of Health, 2009). This arises from the old adage that “prevention is better than cure.” Essentially, instead of focusing on weight-loss programmes for already obese people, public health campaigns focus on changing at a population level the behaviours and circumstances that cause weight gain. The rationale for this is that weight gain occurs across the spectrum of body weight, not merely in obese or overweight people (Walls et al., 2011). In fact, public health campaigns that have explicitly focused on weight loss have generally achieved poor outcomes (Lang and Rayner, 2007; Veerman et al., 2007). For behaviour change to occur, however, the right preconditions must be created, the targeted populations must be supported across the entire behaviour change trajectory, and individuals must understand what they should do to change as well as the consequences of failure to change behaviour (Department of Health, 2009). In this case, for instance, individuals must understand the consequences of unhealthy eating and physical inactivity and they must be supported in shifting to healthy diets and frequent physical activity by being provided with the necessary information and making changes to the environment in which they live, work, play, and learn.

Rationale for Obesity Public Health Campaigns

            Statistics clearly indicate that adult obesity has turned out to be a public health crisis in the UK (National Obesity Forum, 2013; NHS, 2015; PHE, 2016a). This is particularly because of its significantly growing prevalence and the increasingly huge morbidity, mortality, and economic burden it has imposed on individuals, families, communities, health care organisations, the government, and the UK society as a whole. It is, therefore, an issue that requires greater attention than ever before and, more importantly, different thinking. Over the years, interventions aimed at addressing adult obesity in the UK have mainly been targeted at individuals or small groups; which to some extent explains why little success has been achieved. In fact, adult obesity in the UK has more than tripled in the last three decades despite these interventions (NHS, 2015). For obesity prevention and management initiatives to be more effective, they need to be targeted at the population as a whole. In this regard, public health campaigns can be a useful tool, though evidence in this area remains scarce (Walls et al., 2011).

Moreover, unlike other health promotion categories such as smoking and drugs, in which individuals generally have a choice to engage in risky behaviours, obesity-related risky behaviours are exhibited by virtually everyone (Department of Health, 2009). This is particularly because of the obesogenic nature of the modern environment, which exposes everyone to situations that may result in weight gain. For instance, it may be quite difficult for people to adhere to the recommended dietary and physical activity guidelines in an environment flooded with high-fat and high-calorie foods, or with little or no room for physical activity. This further justifies the significance of obesity-related public health campaigns.

The justification for obesity public health campaigns further stems from the need to improve the knowledge of obesity and its risk factors as well as change incorrect perceptions of body size, overweight, and obesity on the part of the public. Inadequate knowledge of and wrong perceptions about obesity remain a major problem, which partly explains why obesity prevention and management efforts often do not achieve the intended outcomes (Department of Health, 2009). A qualitative study carried out in a low-income urban community in South Africa found that though participants generally understood the association between obesity and cardiovascular conditions such as heart disease and hypertension, obese participants with chronic disease conditions depicted stronger perceptions of obesity and cardiovascular risk compared to those without chronic disease conditions (Okop et al., 2016). The study, which included men and women aged 35-70 years obtained through purposive sampling, also found that overweight participants, especially women, viewed overweight as normal as opposed to a disease.

Clearly, Okop et al.’s (2016) study demonstrates that individuals may often not perceive obesity as a threat to their health until they develop severe symptoms. Even so, the qualitative nature of the study is a major limitation, particularly due to the sampling method used, which may have involved some bias (Guest and Namey, 2014). The generalisability of the study to other populations is further hindered by the fact that it was carried out in South Africa, which is a developing country. Individuals in developed countries may depict stronger perceptions of obesity risk given the relatively higher levels of education and knowledge in those countries. All the same, the possibility of low perception of obesity in developed countries cannot be ignored. In the UK, for instance, a considerable proportion of adults do not follow the recommended guidelines for diet and physical activity (HSCIC, 2015). Moreover, misinformed or wrong perceptions of what qualifies as healthy and excess body weight are common in the UK (Musingarimi, 2008). This somewhat suggests that many adults in the UK have little or no understanding of obesity and its risk factors. Public health campaigns can be instrumental in enhancing public understanding of obesity and related risk factors, demystifying distorted perceptions, and contributing to behaviour change.

The rationale for public health campaigns is also informed by their broad acceptability by the public compared to other interventions. In their study, which aimed to compare the public acceptability of five interventions for reducing the consumption of sugar-sweetened beverages in the US and UK, Petrescu et al. (2016) found that education was the most acceptable compared to taxation, reducing portion size, changing the shape of drink packaging, and changing the location of the drinks on the shelf. The study included 1,093 and 1,082 adults from the UK and US, respectively. The fairly large sample used is one of the major strengths of the study (Jacobsen, 2016). Most importantly, the study provides evidence that public health campaigns are an acceptable mechanism for educating the public about obesity risk factors and prevention strategies. Without public acceptability, a public health campaign may not be as effective as expected. Even so, more research is required in this area as few studies have been conducted to examine the public acceptability of public health campaigns, especially within the context of population-focused obesity prevention.

Obesity Public Health Campaigns Internationally and in the UK

While public health campaigns in other categories such as tobacco consumption, drugs, and sexually transmitted diseases (STDs) have been in existence for decades in several countries across the world, including the UK, public health campaigns aimed at obesity prevention and management are fairly new in most countries, with most of them emerging in the last 10 years or so (Dixon et al., 2015). However, this does not necessarily imply that there have historically been no obesity prevention and management initiatives. The initiatives have been there, though most of them have not been nationally-focussed. Essentially, holistic, nationally-focused obesity public health campaigns have gained popularity in the 21^st century, especially towards the end of the first decade and the beginning of the second decade. In Australia, for instance, the first national obesity campaign was initiated in 2008, while similar campaigns were initiated in the US in the early 2010s (Dixon et al., 2015). Singapore has also recently launched public health campaigns aimed at addressing adult obesity, with the focus of the campaigns being to create a ground-up social movement that enables and empowers everyone to live a healthy lifestyle (Foo et al., 2013).

In the UK, obesity prevention and management has been a policy issue since the late 1980s and early 1990s, with policy papers such as the 1992 Health of the Nation white paper aiming to reduce the prevalence of the condition to 6% and 8% for men and women, respectively, by 2005 from 7% and 12% in 1986-1987 (Musingarimi, 2008). Nonetheless, these initiatives were not targeted at the national level, and hence did little or nothing to change the situation. Commendable progress has, however, been made since 2008. Two programmes that have particularly been implemented since then include the Change4Life Programme (implemented in 2009) as well as the Healthy Weight, Healthy Lives Programme (implemented in 2008) (Department of Health and Department of Health and Department for Children, Schools and Families, 2008; NHS, 2015). The two programmes, which represent UK’s first ever comprehensive national campaigns aimed at reducing the prevalence of obesity, recognise the role of the government in providing clear and comprehensible information to people about food and physical activity. The programmes also clearly identify marketing as an important tool for facilitating change in dietary and physical activity behaviour (Department of Health, 2009).

While these programmes mark a step in the right direction, a major limitation is that they are primarily targeted at children as opposed to adults. This somewhat suggests that the issue of adult obesity in the UK is yet to get the attention it serves. Nonetheless, some progress has been made in terms of targeting adults. For instance, a Change4Life programme for adults was introduced in 2009, with a focus on changing dietary and physical activity habits (Cross-Government Obesity Unit, 2010).

Effectiveness of Obesity Public Health Campaigns

            As mentioned earlier, public health campaigns aimed at preventing and managing obesity at a population or national level are relatively new. This implies that research in this area is largely at a developing stage. Even so, evidence from other public health categories such as smoking demonstrates that campaigns premised on social marketing principles can successfully improve knowledge, change attitudes, and facilitate behaviour change (Grier and Byrant, 2005; Musingarimi, 2008; Wakefield, Loken and Hornik, 2010; Durkin, Brennan and Wakefield, 2012; Bandera, 2016; Wilensky, 2016). It is not quite clear whether the same approach may be effective for population-focused obesity control given that obesity differs from other health promotion categories in terms of its origin and vulnerability.

However, the few studies conducted specifically within the context of obesity prevention show that social marketing campaigns have the potential to increase public knowledge of obesity and risk factors and cause the necessary behaviour change. In their cross-sectional study, for instance, which involved 1,107 participants, Tsai et al. (2014) found that the implementation of a state-wide public education campaign in Colorado, USA, was effective in enhancing obesity awareness, identification, as well as health self-assessment. The study, which measured outcomes before and after the campaign, particularly found that after 22 weeks of intensive television advertising entrenched in a multimedia campaign, most participants were less cheerful about their weight and health behaviours, and could more accurately distinguish between normal weight, overweight, and obesity. Though it may be difficult to tell whether the outcomes were sustainable in the long term, the study shows the potential of public health campaigns in promoting healthy behaviours, especially in terms of diet and physical activity.

Another cross-sectional study conducted in New South Wales, Australia, and which involved 1,006 adults, found that an obesity public health campaign dubbed Measure-Up significantly increased the knowledge of the association between obesity and chronic disease and weight monitoring behaviour, even though there were insignificant changes in physical activity participation as well as fruit and vegetable consumption (King et al., 2013). The campaign utilised multiple channels of communication, including television, radio, press, outdoor advertising, as well as local community activities. Though the study relied on self-reported data, it further demonstrates the potential of public health campaigns with regard to obesity prevention and management. An earlier study conducted in Victoria, Australia, to examine the impact of mass media campaign on raising awareness about the association between obesity and cancer also reported somewhat similar outcomes, though the study found that the campaign had no impact on weight-loss behaviour as well as self-knowledge of weight status (Morley et al., 2009).

At the time of writing this review, it was difficult to locate a study conducted specifically within the UK context. Nevertheless, these studies (Morley et al., 2009; King et al., 2013; Tsai et al., 2014) provide valuable lessons for the UK given the close cultural resemblance between the UK, US, and Australia. Nonetheless, this does not necessarily imply that the findings can readily be generalised to the UK. More importantly, despite the availability of some evidence showing the potential of public health campaigns in obesity prevention and management, what works effectively remains less clear since no country has been able to reverse the increasing prevalence of obesity.

One thing that emerges from Morley et al.’s (2009) and King et al.’s (2013) studies is that obesity-related public health campaigns may not be effective in promoting weight loss behaviour even though they may significantly increase the awareness of obesity and its risk factors. To enhance their effectiveness, obesity-related public health campaigns must be accompanied by the creation and maintenance of an environment that encourages healthy eating and physical activity (Department of Health, 2008; Cross-Government Obesity Unit, 2010; Department of Health, 2011; Bombak, 2014; Reiheld, 2015). This is particularly because obesity originates from not only individual and behavioural factors, but also structural and environmental factors. Creating an environment that encourages healthy eating and physical activity entails enacting supportive legislation and policies, reformulating food products, making healthy foods accessible to everyone, creating workplaces that encourage healthy eating and physical activity, redesigning public space to create more room for walking and cycling, and so forth. The implication is that obesity prevention and management is a responsibility of not only individuals, but also business organisations, local governments, and the society as a whole.

In the UK, tremendous progress has been made in terms of cultivating an environment that encourages healthy eating and physical activity. For instance, more than 1,000 playgrounds across England have been upgraded since 2009; nine healthy towns were launched in 2009; new guidelines for food production, labelling, marketing, and retailing have been introduced; and partnerships between the concerned government agencies and employers have been initiated to foster healthy eating and physical activity at workplaces (Musingarimi, 2008; Cross-Government Obesity Unit, 2010). By changing the larger macro environment, individuals are presented with more opportunities for eating healthy and engaging in physical activity, which may mediate the impact of public health campaigns. Nonetheless, it should be noted that there is little evidence to demonstrate the direct impact of macro-environmental adjustments on obesity prevention and management. This scarcity of literature is, however, understandable given that nationally-focused obesity control is fairly a new phenomenon.           

Conclusion

This paper sought to provide a review of literature relating to the role of public health campaigns and environmental changes in preventing and managing obesity amongst adults aged 18 and above in the UK. Statistics clearly indicate that adult obesity is a major public health crisis in the country. It has particularly been reported that the prevalence of adult obesity in the UK has more than tripled in the last three decades. Presently, a quarter of adults in the country are obese, with projections indicating that this proportion may double in the next three decades or so. This clearly indicates that the crisis requires greater attention than ever before if the increasingly huge morbidity, mortality, and economic burden it has imposed on the UK society is to be reduced.

Though obesity has been linked to origins such as genetics and ethnic background, lack of physical activity and the consumption of unhealthy foods remain the major risk factors for the condition. Research has even extensively demonstrated that regular physical activity and reduced consumption of high-calorie foods and drinks can substantially decrease weight gain and hence the risk of obesity. Nonetheless, one wonders why the prevalence of obesity has remained on an upward trend despite the remarkable evidence of effectiveness of these interventions. First and foremost, most weight management interventions tend to be short-term in nature in the sense that there is often no long-term follow-up. In addition, most obesity prevention and management initiatives are implemented at an individual or small-group level as opposed to the population level. Actually, it is only in the recent past that nationally-focused public health campaigns relating to obesity have been initiated in the UK. This to a significant extent explains why obesity prevention and management efforts have achieved little or no effectiveness.

Public health campaigns have particularly been useful in causing behaviour change at a population level in other public health categories such as smoking and drugs. This suggests that the same approach may as well be effective for obesity, even though the category differs from most other health promotion categories in terms of origin and vulnerability. The few studies that have been conducted in this relatively new area show that effectively implemented public health campaigns have considerable potential in terms of increasing public knowledge of obesity and related risk factors, changing wrong perceptions about the condition, as well as facilitating behaviour change with respect to weight monitoring, nutrition, and physical activity.

It is, however, important to note that reversing the prevalence of obesity may still be a challenge even with effectively implemented public health campaigns. As demonstrated by literature, it is quite difficult for public health campaigns to generate the desired outcomes, especially in terms of shifting to healthy diets and regular physical activity, if the environment in which people live, work, learn, socialise, and play does not encourage healthy eating and physical activity. Environmental factors are particularly important influences as far as the risk of obesity is concerned. Therefore, for public health campaigns to achieve the intended outcomes, they must be accompanied by changes to the larger macro-environment, especially with respect to the food industry, public spaces, and workplaces.

Recommendations

This literature review raises important implications for both practice and research. Like most other countries, the UK has recently appreciated the role of public health campaigns in addressing obesity. Nonetheless, much focus has been on child obesity, with little attention to adult obesity. With the rapidly growing prevalence of adult obesity, it is imperative for campaigns specifically targeted at adults to be given greater attention. Additionally, while obesity prevention is primarily an individual responsibility, it is important to acknowledge that greater effectiveness is achieved when the burden of responsibility is shifted from the individual to the society as a whole. In other words, workplaces, communities, local governments, as well as the national government have a crucial role to play in terms of creating an environment that empowers and encourages individuals to eat healthy and participate in regular physical activity. This role relates to enacting the necessary policies and legislation, reformulating food products, changing food advertising and retailing, creating more room for physical activity in public spaces, and encouraging customers and employees to eat healthy and engage in frequent physical activity.

As for research, it is important for more scholarly attention to be directed to this area. Since the use of nationally- or population-focused public health campaigns in obesity prevention and management is a fairly new practice, less is known about what works effectively. More research would be important in providing this knowledge. Additionally, there is little evidence to demonstrate the effectiveness of changes in obesity-related environmental factors in mediating the impact of obesity-related public health campaigns. With more research, this obscurity can be overcome.

 

 

References

Adams, J. and White, M. (2015) Characterisation of UK diets according to degree of food           processing and associations with socio-demographics and obesity: cross-sectional   analysis of UK National Diet and Nutrition Survey (2008-12). The International   Journal of Behavioural Nutrition and Physical Activity, 12(161).

Al-Shehri, F., Moqbel, M., Al-Khaidi, Y., Almoreished, T. et al. (2016) Prevention and     management of obesity: Saudi guideline update. Saudi Journal of Obesity, 4(1), 25.

Bandera, C. (2016) Design and management of public health outreach using interoperable             mobile multimedia: an analysis of a national winter weather preparedness campaign.      BMC Public Health 16, 436.

Batch, J. and Baur, L. (2005) Management and prevention of obesity and its complications in       children and adolescents. The Medical Journal of Australia, 182(3), 130-135.

Bombak, M. (2014) Obesity, health at every size, and public health policy. American Journal        of Public Health, 104(2), e60-e67.

Brauer, P., Gorber, S., Shane, A., Jaramillo, A., Shaw, E., Singh, H., Bell, N. and Tonelli, M.        (2015) Recommendations for prevention of weight gain and use of behavioural and          pharmacologic interventions to manage overweight and obesity in adults in primary             care. Canadian Medical Association Journal, 187(3), 184-195.

Bryman, A. (2012) Social research methods (4^th edition). Oxford: Oxford University Press.

Campbell-Scherer, D. and Sharma, A. (2016) Improving obesity prevention and management        in primary care in Canada. Current Obesity Reports.

Capehorn, M., Haslam, D. and Welbourn, R. (2016) Obesity treatment in the UK health    system. Current Obesity Reports.

Crosby, R., DiClemente, R. and Salazar, L. (2006) Research methods in health education.             Hoboken: Wiley.

Cross-Government Obesity Unit (2010) Healthy Weight, Healthy Lives: two years on.        Cross-Government Obesity Unit. Available at: https://www.more-          life.co.uk/userfiles/dh_113495.pdf [accessed 27 July 2016]

Cummins, S. and Macintyre, S. (2006) Food environments and obesity – neighbourhood or           nation? International Journal of Epidemiology, 35, 100-104.

Department of Health (2009) Change4Life marketing strategy. Department of Health.       Available at: http://www.nhs.uk/change4life/supporter-     resources/downloads/change4life_marketing%20strategy_april09.pdf [accessed 27    July 2016]

Department of Health (2011) Healthy Lives, Healthy People. Department of Health.          Available at:             https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213720      /dh_130487.pdf [accessed 27 July 2016]

Department of Health (2015) 2010 to 2015 government policy: obesity and healthy eating.             Available at: https://www.gov.uk/government/publications/2010-to-2015-            government-policy-obesity-and-healthy-eating/2010-to-2015-government-policy-       obesity-and-healthy-eating [accessed 25 July 2016]

Department of Health and Department for Children, Schools and Families (2008) Healthy            Weight, Healthy Lives: A Cross-Government Strategy for England. Department of    Health and Department for Children, Schools and Families. Available at:      http://webarchive.nationalarchives.gov.uk/20100407220245/http://www.dh.gov.uk/pr            od_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_084024.pdf     [accessed 27 July 2016]

Dietz, W., Baur, L., Hall, K., Puhl, R., Taveras, E., Uauy, R. and Kopelman, P. (2015)      Management of obesity: improvement of health-care training and systems for             prevention and care. Lancet, 385(9986), 2521-2533.

Dixon, H., Scully, M., Durkin, S., Brennan, E. et al. (2015) Finding the keys to successful             adult-targeted advertisements on obesity prevention: an experimental audience testing      study. BMC Public Health 15: 804.

Dreber, H., Reynisdottir, S., Angelin, B. and Hemmingsson, E. (2015) Who is the treatment-        seeking young adult with severe obesity: a comprehensive characterisation with     emphasis on mental health. PLoS ONE, 10(12): e0145273.

Durkin, S., Brennan, E. and Wakefield, M. (2012) Mass media campaigns to promote        smoking cessation among adults: an integrative review. Tobacco Control, 21, 127-       138.

Erickson, K., Monsen, K., Attleson, I., Radosevich, D., Oftedahl, G., Neely, C. and Thorson,       D. (2015) Translation of obesity practice guidelines: measurement and evaluation.      Public Health Nursing, 32(3), 222-231.

Fitch, A., Everling, L., Fox, C., Webb, B. et al. (2013) Prevention and management of       obesity for adults. Institute for Clinical Systems Improvement. Available at:             https://www.healthpartners.com/ucm/groups/public/@hp/@public/documents/docume            nts/cntrb_037112.pdf [accessed 26 July 2016]

Flint, E. and Cummins, S. (2016) Active commuting and obesity in mid-life: cross-sectional,         observational evidence from UK biobank. The Lancet, 4(5), 420-435.

Foo, L., Vijaya, K., Sloan, A. and Ling, A. (2013) Obesity prevention and management:   Singapore’s experience. Obesity Reviews, 14(2), 106-113.

Greaves, C., Sheppard, K., Abraham, C., Hardeman, W., Roden, M., Evans, P. et al. (2011)          Systematic review of reviews of intervention components associated with increased     effectiveness in dietary and physical activity interventions. BMC Public Health, 11:           119.

Grier, S. and Byrant, C. (2005) Social marketing in public health. Annual Review of Public            Health 26, pp. 319-339.

Guest, G. and Namey, E. (2014) Public health research methods. London: SAGE.

Hatfield, D., Sliwa, S., Folta, S., Economos, C. and Goldberg, J. (2015) The critical role of           communications in a multilevel obesity-prevention intervention: lessons learned for       alcohol educators. Patient Education and Counselling. doi: 10.1016/j.pec.2016.01.005

Health and Social Care Information Centre (HSCIC) (2015) Statistics on obesity, physical             activity and diet. Health and Social Care Information Centre. Available at:     http://www.hscic.gov.uk/catalogue/PUB16988/obes-phys-acti-diet- eng-2015.pdf [accessed 26 July 2016]

Huang, T. Cawley, J., Ashe, M., Costa, S. et al. (2015) Mobilisation of public support for policy actions to prevent obesity. The Lancet, 385(9985), 2422-2431.

Hutchesson, M., Rollo, M., Krukowski, R., Ells, L., Harvey, J., Morgan, P., Callister, R.,   Plotnikoff, R. and Collins, C. (2015) eHealth interventions for the prevention and         treatment of overweight and obesity in adults: a systematic review with meta-analysis.            Obesity Reviews, 16, 376-392.

Hutfless, S., Gudzune, K., Maruthur, N., Wilson, R., Bleich, S. et al. (2013) Strategies to prevent weight gain in adults: a systematic review. American Journal of Preventive             Medicine, 45(6), 41-51.

Jacobsen, K. (2016) Introduction to health research methods (2^nd edition). Burlington: Jones          & Bartlett Learning.

King, E., Grunseit, A., O’Hara, B. and Bauman, A. (2013) Evaluating the effectiveness of an       Australian obesity mass-media campaign: how did the measure-up campaign measure in New South Wales? Health Education Research, 28(6), 1029-1039.

Kobyliak, N., Conte, C., Cammarota, C., Haley, A.,  Kruzliak, P. et al. (2016) Probiotics in           prevention and management and treatment of obesity: a critical review. Nutrition &            Metabolism, 13, 1-13.

Lang, T. and Rayner, G. (2007) Overcoming policy cacophony on obesity: an ecological    public health framework for policymakers. Obesity Reviews. 8, 165-181.

Lawlor, D. and Chaturvedi, N. (2006) Treatment and prevention of obesity – are there critical      periods of intervention? International Journal of Epidemiology, 35(1), 3-9.

Lombard, C., Harrison, C., Kozica, S., Zoungas, S., Keating, C. and Teed, H. (2014)         Effectiveness and implementation of an obesity prevention programme: the HeLP-her             cluster randomised controlled trial. BMC Public Health, 14: 608.

Lombard, C., Harrison, C., Kozica, S., Zoungas, S., Ranasinha, S. and Teede, H. (2016)    Preventing weight gain in women in rural communities: a cluster randomised    controlled trial. PLoS Medicine, 13(1), e1001941.

Lopez, A. and Johnson, L. (2016) Associations between restrained eating and the size and            frequency of overall intake, meal, snack and drink occasions in the UK Adult      National Diet and Nutrition Survey. PLoS ONE, 11(5): e0156320.

Marie, N., Fleming, T., Robinson, M., Gakidou, E. et al. (2015) Global regional and           national prevalence of overweight and obesity in children and adults during 1980- 2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet,       384(9945), 766-781.

Morley, B., Wakefield, M., Dunlop, S. and Hill, D. (2009) Impact of a mass media campaign        linking abdominal obesity and cancer: a natural exposure evaluation. Health     Education Research, 24(6), 1069-1079.

Musingarimi, P. (2008) Obesity in the UK: a review and comparative analysis of policies    within the devolved regions. International Longevity Centre. Available at:          http://www.ilc-alliance.org/images/uploads/publication-pdfs/pdf_pdf_45.pdf [accessed 27 July 2016]

National Health Service (NHS) (2015) Britain: ‘the fat man of Europe’. Available at:             http://www.nhs.uk/Livewell/loseweight/Pages/statistics-and-causes-of-the-obesity-            epidemic-in-the-UK.aspx [accessed 5 July 2016]

National Institute for Health and Care Excellence (NICE) (2015) Obesity prevention.        Available at:             https://www.nice.org.uk/guidance/cg43?unlid=6622570012015122611338 [accessed         26 July 2016]

National Obesity Forum (2013) Obesity in the UK: analysis and expectations. National      Obesity Forum. Available at:        http://www.nationalobesityforum.org.uk/media/PDFs/StateOfTheNationsWaistlineOb            esityintheUKAnalysisandExpectations.pdf [accessed 27 July 2016]

Okop, K., Mukumbang, F., Mathole, T., Levitt, N. and Puoane, T. (2016) Perceptions of body      size, obesity threat and the willingness to lose weight among black South African         adults: a qualitative study. BMC Public Health, 16(366).

Oliver, P. (2012) Succeeding with your literature review: a handbook for students. UK:      McGraw-Hill Education.

Paton, N. (2007) Obesity in the UK poses real threat to NHS. Occupational Health 59(10), p.       7.

Paton, N. (2013) Government must act to prevent UK obesity. Occupational Health, 65(4), 7.

Petrescu, D., Hollands, G., Couturier, D., Ng, Y. And Marteau, T. (2016) Public acceptability      in the UK and USA of nudging to reduce obesity: the example of reducing sugar- sweetened beverages consumption. PLoS ONE, 11(6): e0155995.

Public Health England (PHE) (2016a) UK and Ireland prevalence and trends. Available at:             https://www.noo.org.uk/NOO_about_obesity/adult_obesity/UK_prevalence_and_tren      ds [accessed 5 July 2016]

Public Health England (PHE) (2016b) Obesity and mortality. Available at:             https://www.noo.org.uk/NOO_about_obesity/mortality [accessed 25 July 2016]

Public Health England (PHE) (2016c) Economics of obesity. Available at:             https://www.noo.org.uk/NOO_about_obesity/economics [accessed 25 July 2016]

Public Health England (PHE) (2016d) Causes of obesity. Available at:             https://www.noo.org.uk/NOO_about_obesity/causes [accessed 25 July 2016]

Public Health England (PHE) (2016e) Measurement of obesity. Available at:             https://www.noo.org.uk/NOO_about_obesity/measurement [accessed 25 July 2016]

Public Health England (PHE) (2016f) Health risks of adult obesity. Available at:             https://www.noo.org.uk/NOO_about_obesity/obesity_and_health/health_risk_adult          [accessed 25 July 2016]

Public Health England (PHE) (2016g) lifestyle and behaviours. Available at:             https://www.noo.org.uk/NOO_about_obesity/lifestyle [accessed 25 July 2016]

Puhl, R. and Heuer, C. (2010) Obesity stigma: important considerations for public health.             American Journal of Public Health, 100(6), 1019-1028.

Puhl, R., Luedicke, J. and Lee, J. (2013) Public reactions to obesity-related health campaigns.       A randomised controlled trial. American Journal of Preventive Medicine, 45(1), 36-           48.

Puhl, R., Peterson, J. and Luedicke, J. (2013) Fighting obesity or obese persons? Public     perceptions of obesity-related messages. International Journal of Obesity, 37, 774- 782.

Reiheld, A. (2015) With all due caution: global anti-obesity campaigns and the      individualisation of responsibility. International Journal of Feminist Approaches to        Bioethics, 8(2), 226-249.

Rice, K., Te Hiwi, B., Zwarestein, M., Lavalle, B., Barre, D. and Harris, S. (2016) Best     practices for the prevention and management of diabetes and obesity-related chronic            disease among indigenous peoples of Canada: a review. Canadian Journal of         Diabetes, 40(3), 216-225.

Ridley, D. (2008) The literature review: a step-by-step guide for students. London: SAGE.

Ross, R., Blair, S., de Lannoy, L., Despres, J. and Lavie, C. (2015) Changing the endpoints          for determining effective obesity management. 2013 Global Congress on Physical   Activity – All Hearts Need Exercise: A Global Call to Action by the AHA, 57(4), 330-           336.

Royne, M. and Levy, M. (2015) Reaching consumers through effective health messages: a            public health imperative. Journal of Advertising, 44(2), 85-87.

Ryan, M., Yi, D., Avenell, A., Douglas, F. et al. (2015) Gaining pounds by losing pounds:            preferences for lifestyle interventions to reduce obesity. Health Economics, Policy and Law, 10(2), 161-182.

Shaw, H. (2012) Food access, diet and health in the UK: an empirical study of Birmingham.         British Food Journal, 114(4), 598-616.

Stubbs, R., Morris, L., Pallister, C., Horgan, G. and Lavin, J. (2015) Weight outcomes audit         in 1.3 million adults during their first three months’ attendance in a commercial    weight management programme. BMC Public Health, 15: 882.

Tsai, A., Boyle, T., Hill, J., Lindley, C. and Weiss, K. (2014) Changes in obesity awareness,          obesity identification, and self-assessment of health: results from a statewide public           education campaign. American Journal of Health Education 45(6), pp. 342-350.

Ulijaszek, S. and McLennan, A. (2016) Framing obesity in UK policy from the Blair years,           1997-2015: the persistence of individualistic approaches despite overwhelming       evidence of societal and economic factors, and the need for collective responsibility.             Obesity Reviews, 17(5), 397-411.

University of Birmingham (2016) Obesity in the UK. Available at:             http://www.birmingham.ac.uk/research/activity/mds/centres/obesity/obesity-           uk/index.aspx [accessed 25 July 2016]

Veerman, J., Barendregt, J., van Beeck, E., Seidell, J. and Mackenbach, J. (2007) Stemming         the obesity epidemic: a tantalising prospect. Obesity, 15, 2365-2370.

Vinkers, C., Adriaanse, M., Kroese, F. and de Ridder, D. (2014) Efficacy of a self-           management intervention for weight control in overweight and obese adults: a             randomised controlled trial. Journal of Behavioural Medicine, 37(4), 781-792.

Wakefield, M., Loken, B. and Hornik, R. (2010) Use of mass media campaigns to change             health behaviour. Lancet, 376(9748), 1261-1271.

Walls, H., Peeters, A., Proietto, J. and McNeil, J. (2011) Public health campaigns and obesity       – a critique. BMC Public Health, 11: 36.

Wang, Y., McPherson, K., Marsh, T.,Gortmaker, S. and Brown, M. (2011) Health and      economic burden of the projected obesity trends in the USA and the UK. The Lancet,          378(9793), 815-825.

Wilensky, G. (2016) Celebrating national public health week. American Journal of Public             Health, 106(5), 777-779.

Yao, A. (2013) Screening for and management of obesity in adults: US preventive services           task force recommendation statement: a policy review. Annals of Medicine & Surgery, 2(1), 18-21.

Yumuk, V., Tsigos, C., Fried, M., Schindler, K., Busetto, L., Micic, D. and Toplak, H. (2015)      European guidelines for obesity management in adults. Obesity Facts: The European             Journal of Obesity, 8(6), 402-424.