Chapter IIV
V
OBESITY: THEORETICAL BACKGROUND
4.1 Theory of Planned Behaviour
4.2 Behavioural Susceptibility Theory of Obesity
Contents
4.3 Schachter’s Externality Theory of Obesity
4.4
Fat Cell Theory
4.5 Set Point Theory
4.6 Theory of Thermogenesis
4.7 External Cue Theory
4.8 Ecological Theory of Obesity
4.9 Conclusion
Obesity is the most nutritional disorder in which there is excessive
storage of energy in the form of fat as per height, weight, race and gender
(WHO, 2005). An analysis of characteristics of different human
populations may provide insight into the causes of obesity. There are
various theories explaining causes of obesity. It is broadly classified under
the following heads.
Theory of Planned Behaviour
Behavioural Susceptibility Theory of Obesity
Schachter’s Externality Theory of Obesity
Fat Cell Theory
Set Point Theory
Theory of Thermogenesis
External Cue Theory
Ecological Theory of Obesity
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4.1 Theory of Planned Behaviour
In Psychology, the theory of Planned Behaviour (TPB) is a theory
about the link between beliefs and behaviour. The concept was proposed by
Icek Ajzen (Professor of psychology, University of Massachusetts) to
improve on the predictive power of the theory of reasoned action by
including perceived behavioural control. The theory states that attitude
toward behaviour, subjective norms, and perceived behavioural control
together shape an individual’s behavioural intentions and behaviour. It is
one of the most predictive persuasion theories. It has applied to studies of
the relations among beliefs, attitudes, behavioural intentions and
behaviours in various fields such as advertising, public relations and health
care (www.wikipedia.org/wiki/theory_of_planned_behavior).
4.1.1 Theory of Planned Behaviour and Obesity
A study by Kassem et al, (2003) identified factors that influence
regular soda consumption among 707 female students aged 13-18 years,
attending North Los Angeles Country Public Schools. Participants
completed a group-administered Theory of Planned Behaviour- based
questionnaire. Attitude, subjective norms and perceived behavioural control
had statistically significant positive association with intention and were
each significant predictors of intention to drink regular soda and together
explained 64 per cent of its variance. The strongest predictor was attitude,
followed by perceived behavioural control and subjective norm. The results
suggest that efforts to reduce soda consumption should include parents and
friends. It is also important that soda should not be excessively available at
home or widely accessible to teenagers at schools. Healthy eating messages
for adolescents need to be developed and incorporated into existing and
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future campaigns to reinforce the perception that there are other healthier
drinks that quench thirst and taste good as well.
Perceived behavioural control and attitudes predicted children’s
intention to participate physical activity. The findings of the study suggests
that gender differences related to intent to participate in vigorous activity,
perceived behavioural control and sense of competency are evident in
eighth grade and may begin in fifth grade. These gender differences in
perception therefore precede the gender difference in participation in
vigorous activity demonstrated among ninth graders in the 1990 Youth
Risk Survey. Promotion of activities children enjoy, and in which they feel
a sense of competency, is likely to sustain participation in vigorous activity
throughout adolescence and possibly reduce the prevalence of obesity
(Craig et al., 1996).
Schifter et al., (1985) conducted a study to know the success of
weight reduction among college women on the basis of a Theory of
Planned Behaviour. 83 women expressed their attitudes, subjective norms,
perceived control and intentions with respect to losing weight. In addition,
the extent to which they had made weight reduction plans was assessed as
were a number of general attitudes and personality factors. 76 women were
reassessed six weeks later. In support of the theory, intentions to lose
weight were accurately predicted on the basis of attitudes, subjective norms
and perceived control. Perceived control and intentions were together
moderately successful in predicting the amount of weight women actually
lost over 6 weeks period. Actual weight loss was also found to increase
with ego strength, factors that were assumed to increase control over goal
attainment.
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The aim of a study made Godin et al., (1993) was to verify the basic
assumption underlying the theory of planned behaviour for the prediction
of exercising, intentions and behaviour among adults of the general
population (study 1) and a group of pregnant women (study 2). In both
studies baseline data were collected at home with trained interviewers. The
self report on behaviour was obtained six months (study 1) and between
eight and nine months (study 2) after baseline data collection. In study 1,
perceived behavioural control influenced behaviour only through intention.
In study 2, none of the Aizen model variables was associated to exercising
behaviour. Nonetheless, intention was influenced by attitude, habit and
perceived behavioural control.
There is consensus among recent studies that adolescents’ diets are
nutritionally far from ideal. In an effort to increase understanding of the
factors affecting food choice decisions in this age group, Ajzen’s theory of
planned behaviour was employed by Dennison (1995). 675 adolescents
comprising both males and females from two age groups and two types of
schools completed a questionnaire which focused on intentions to eat three
common foods at lunch time. Attitudes and perceptions of control were the
components of the model found to account for the most variance in
intentions. The addition of a novel measure of friend’s behaviour increased
the model’s explanatory power further. Significant gender and age
differences in attitudes, beliefs, levels of dietary restraint and perceived
social pressure were present. The effects of social background and types of
school upon these variables were minimal.
Stefamine and Smith (2006) investigated the efficacy of the Theory
of Planned Behaviour to predict healthy eating behaviour in a group of
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urban Native American youth. Native American boys and girls (n=139)
ages 9-18 years old were given self-administered survey to assess eating
behaviour using TPB constructs (intention, attitude, subjective norms,
barriers, self-sufficiency and perceived behavioural control). Youth were
also measured for height and weight and BMI was calculated. Bivariate
correlations and stepwise regression analysis of TPB model were
performed with SPSS software. No association was found between
intention and healthy eating behaviour. However, independently healthy
eating behaviour was correlated with barriers, attitude, perceived
behavioural control and subjective norm. The most predictive barriers to
eating healthy included the availability and taste of foods.
Childhood obesity is a significant problem in the United States. A
number of communication campaigns and intervention have been
conducted to combat the problem, with parents being recognized as an
important target audience. A critical aspect of involving parents in such
campaigns is formative research on parents’ perceptions of their role in
preventing childhood obesity. To facilitate this process, a study was
conducted in which parents (n=201) responded to theory of planned
behaviour survey items as they relate to providing healthy foods and
limiting unhealthy foods for their children. Results indicated support for
TPB predictions. Additionally, the degree to which parents viewed
providing healthy food and limiting unhealthy foods as effective in
preventing obesity was predictive of parent tracking of children’s unhealthy
eating behaviour. Finally, parents’ TV viewing behaviour was related to
perceive response efficacy of limiting children’s TV viewing hours
(Andrews, 2010).
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4.2 Behavioural Susceptibility Theory of Obesity
One factor contributing to weight variation could be genetically
determined differences in appetite that modulates susceptibility to the
environment. Some individuals are more susceptible than others to both
negative and positive environmental conditions. This theory proposes that
individual differences in appetite are heritable behavioural characteristics
which in concert with, environmental exposures determine weight gain.
4.2.1 Behavioural Susceptibility Theory and Obesity
Recent behavioural and psychometric studies demonstrate that
appetitive characteristics such as responsiveness to internal satiety signals
and external food cues not only differentiate obese and normal weight
groups, but are quantitatively associated with weight. The results indicate
that sensitivity to internal and external appetitive signals are heritable
phenotypes that increase the risk of overeating in obesogenic environment.
A behavioural susceptibility model helps to explain how weight is both
highly heritable and highly responsive to environmental characteristics
(Carnell and Wardle, 2009).
Carnell and Wardle examined associations between adiposity and
two appetitive traits: satiety responsiveness and food cue responsiveness in
children. Parents of two groups of children, 8-11 years old and 3-5 years
old completed the child eating behaviour questionnaire. Association
between appetite and adiposity are consistent with a behavioural
susceptibility model of obesity. Assessing appetite in childhood could help
to identify higher risk children while they are still at a healthy weight,
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enabling targeted interventions to prevent obesity (Carnell and Wardle,
2008).
Webber et al, (2009) collected data from 406 families to test the
hypothesis that quantitative variation in eating behaviour traits shows a
graded association with weight in children. Satiety responsiveness in eating
and food fussiness showed a graded negative association with weight,
whereas food responsiveness, enjoyment of food, emotional overeating and
desire to drink were positively associated. There was no systematic
association with weight for emotional under-eating. The results support the
idea that approach-related and avoidance-related appetitive traits are
systematically related to adiposity and not exclusively associated with
obesity. Early assessment of traits could be used as indicators of
susceptibility to weight gain.
The modern environment is ubiquitously ‘obesogenic’, yet people
vary enormously in weight. One factor contributing to weight variation
could be genetically determined differences in appetite that modulate
susceptibility to the environment. They assessed the relative contribution to
genes and environment for two aspects of appetite that have been
implicated in obesity. The high heritability of appetite traits that are known
to be related to weight suggests that genetic vulnerability to weight gain
could operate through behavioural as well as metabolic pathways.
Intervention strategies aimed at improving satiety responsiveness reducing
food cue responsiveness in high risk individuals could help in preventing
the development of obesity (Carnell, 2008).
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4.3 Schachter’s Externality Theory of Obesity
In the late 1960s the social psychologist Stanely Schachter proposed
that obese people eat not because of hunger, stress or boredom but in
response to external food cues which drive eating in the obese until those
cues are removed or consumed (Grossberg and Grant, 1976).
When
external cues are absent, these obese are not motivated to eat, even if they
are substantially food-deprived. This theory achieved widespread attention
because it challenged long standing ideas about the causes of obesity by
means of several innovative and dramatic experiments. Schachter’s
research was correlational, showing that obesity is associated with
externality. He assumed that externality causes obesity. According to this
theory, the eating behaviour of normal weight individuals is primarily
controlled by internal hunger cues, while that of the obese is more
influenced by external stimuli such as the sight, smell and taste of food,
talk about food, etc. The obese should be less reactive than normal at low
levels of stimulation and more reactive at high levels.
4.4 Fat Cell Theory
Fat Cell Theory has been popular in medical fields for more than 30
years. The idea behind the theory is that each body is programmed to have
a basic set number of cells. Fat cell theory shows that during growth, fat
cells increase in number. When energy intake exceeds expenditure, fat cells
increase in size. When fat cells have reached their maximum size and
energy intake continues to exceed energy expenditure, fat cells increase in
number again. When fat loss, the size of the fat cells shrinks, but not the
number. The theory states that the creation of new fat cells is far easier than
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losing old ones, a fact that plays an important role in adult weight loss
(www.livestrong.com/article/4208-need-fat-cell-theory/).
Fat accretion in the body as it relates to obesity occurs in fat cells
known as ‘adipocytes’. These cells originate either directly or indirectly
from the embryonic mesenchyme tissue, but can’t be identified as
adipocytes until they begin to accumulate lipid. As an individual grows and
develops, the size of the adipose tissue will be affected by factors that
modify cell division and the enlargement of the cells.
Adults whether normal or obese, have a fixed number of adipocytes
in the body. Obesity developing in adult life is associated only with the
enlargement of fat cells (hypertrophic obesity). Obesity developing in
infancy or childhood is associated with an increase in cell number
(hyperplastic obesity). Current infant feeding practices, particularly those
which involve high energy intakes, stimulate fat cell hyperplasia.
Hyperplastic obesity is more resistant to weight reduction therapy than
hypertrophic obesity, and the two types may have a different morbidity and
mortality.
The possible etiologies of obesity are numerous. The primary cause
may be in adipose tissue or in other tissues that influence energy
expenditure. While number and size of fat cells influence the quantity of
adipose tissue, new information indicates that changes during maturity in
these cellular parameters are also important to the success of weight
reduction program (Bulter and Allen, 1979).
The contribution of cell number and size to the growth of the fat
deposit in non obese children varies with age (Knittle et al., 1979).
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Deviations from this normal development were observed in obese children
shortly after one year of age. By eleven years of age obese children
exceeded the mean cell number found in non-obese adults. Indeed, obese
subjects displayed more rapid and earlier elevations in both cell number
and size. Thus obese children display both quantitative and qualitative
differences in fat tissue development when compared to non-obese
children. The data indicate that the rate and type of adipose tissue cellular
development one encounters in children may play a role in the development
of the enlarged fat deposits found in obese subjects.
4.5 Set Point Theory
Obesity is a consequence of the complex interplay between genetics
and environment. Set point theory states that body weight is maintained at a
stable range known as the ‘set point’, despite the variability in energy
intake or energy expenditure. The body tends to maintain a certain weight
by adjusting hunger, appetite and food energy intake compared to
metabolism so that a person’s effort to alter weight may be unsuccessful.
The theory states that body maintains its normal weight and body
fat level with internal regulatory controls that dictate how much fat one has.
According to set point theory, some individuals have a high set point and
others have a low set point. This theory suggests that despite dieting efforts,
the body tends to return to its set point weight. However, regular, consistent
exercise may help to adjust the natural set point.
(www.weightloss.about.com/od/glossary/g/setpoint/html).
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4.6
Theory of Thermogenesis
This theory states that our bodies produce heat by a process called
thermogenesis. This production requires energy which utilizes our
metabolism and burns calories. The theory revolves around ramping up this
heat production function with the idea that if we are able to increase our
thermogenetic capacity, our bodies will metabolize excess calories or body
fat as heat rather than tucking them into storage (www.ehow.com/about5543982-thermogenic-theory.html).
4.7
External Cue Theory
This theory states that people overeat as a response to stimuli in
their surroundings – foremost among them, the availability of a multitude
of delectable foods (www.asianbariatrics.rxpinoy.com/new-1-index.html).
A study by Currie et al, (2010) supports the external cue theory.
How changes in the supply of fast food restaurants affect weight outcomes
of 3 million children and 3 million pregnant women are investigated by the
researchers. Among the ninth graders, a fast food restaurants within 0.1
miles of a school results in 5.2 percent increase in obesity rates. Among
pregnant women a fast food restaurant within 0.5 miles of residence results
in a 1.6 per cent increase in the probability of gaining over 20 kilos. The
implied efforts on caloric intake are one order of magnitude larger for
children than for mothers, consistent with smaller travel cost for adults.
Calorie underestimation is often alleged to contribute to
obesity. By developing a psychophysical model of meal size estimation the
authors show that the association between body mass and calories
underestimation found in health science research is a spurious consequence
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of the tendency of high body mass people to choose and thus estimate
larger meals. They also find that using a piecemeal decomposition
improves calories estimation and leads people to choose smaller but equally
satisfying fast food meals. The finding is that biases in calorie estimation
are caused by meal size and not body size has important implications for
allegations against the food industry and for the clinical treatment of
obesity (Chandon and Wansink, 2007).
The two most viable pathways according to Gable and Lutz (2000)
to prevent and reduce childhood obesity seem to be through parent’s
education and television-reduction programs for children. All parents need
to understand the important role they play in socialising children’s healthy
eating habits and how to best enact that role through food selection and
mealtime expectations. Guaranteeing that all adults who are involved with a
child’s life are operating from the same base of information about general
child nutrition and about specific child likes and dislikes is crucial for
children’s healthy development.
4.8 Ecological Theory of Obesity
The ecological theory states that driving force for the increasing
prevalence of obesity in populations is the increasingly obesogenic
environment rather than any pathology in metabolic defects or genetic
problems within individuals. Current strategies are not containing the
obesity pandemic. A shift is needed away from the traditional view of
obesity as a personal disorder that requires treatment. An ecological
approach regards obesity as a normal response to an abnormal environment
rather than vice versa. Understanding, measuring and altering the
obesogenic environment is important to reduce obesity. A paradigm shift to
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understanding obesity as “normal physiology within a pathological
environment” signposts the directions for a wider public health approach to
the obesity pandemic (Egger and Swinburn, 1997).
Environmental policy and social changes are important contributors
to the rapid rise in obesity over the past few decades and there has been
substantial progress toward identifying environmental and policy factors
related to eating and physical activity that can point toward solutions (Sallis
and Glanz, 2009).
There is relationship between childhood obesity and many
obesogenic environment variables such as deprivation, urbanisation, access
to local amenities as well as dietary and physical activity behaviour
(Procter et al, 2008).
The aim of the study was to determine whether socio-economic
status is associated with overweight and obesity in prepuberal children. The
cultural resources of the mother and the economical resources of the family
seem to influence the prevalence of weight gain in prepuberal children.
This should be taken into account when planning programmes for the
prevention or reduction obesity in children (Gnavi, 2000).
Research indicates that parents’ food selections are related to
demographic characteristics of the family. Single parent households and
households in which both parents work full time have a tendency to favour
the consumption of prepared food items, which tend to be high in fat and
sodium (Crockett and Sims, 1995).
Television is a complex phenomenon and contributes to obesity
through multiple mechanisms: children are physically idle, cognitively
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under the influence of television advertisement, and have less opportunity
to engage in extracurricular activities (Robinson, 1999).
The data also support the claim that children will eat high sugar,
high fat and junk foods if they are available in home. Nutritionists believe
that socializing healthy child eating habits requires parents to provide a
wide variety of nutritious foods and to allow children to choose what, and
how much, to eat. Children are innately equipped to monitor their own food
intake and to determine when they are satiated (Birch and Fisher, 1995).
4.9 Conclusion
All these theories explain the influence of socio-economic
background, dietary habits and sedentary lifestyle of modern people.
However, External Cue Theory and Ecological Theory, Behavioural
Susceptibility Theory, Theory of Planned Behaviour and Schachter’s
Externality Theory of obesity are prominent and more acceptable in the
changing socio-economic background, dietary habits and sedentary lifestyle
of people in modern world. The analyses of the present study also support
these theories.
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