"Obesity" and "Clinical Obesity" Men's understandings of obesity and its relation to the risk of diabetes: A qualitative study

Background The 2007 Wanless report highlights the ever increasing problem of obesity and the consequent health problems. Obesity is a significant cause of diabetes. An increasing evidence base suggests that in terms of reducing diabetes and CVD risk, it is better to be "fit and fat" than unfit and of normal weight. There has been very little previous research into the understandings that men in the general population hold about the issues of weight, exercise and health; we therefore undertook this study in order to inform the process of health promotion and diabetes prevention in this group. Methods A qualitative study in North East England General Practice using a purposive sample of men aged 25 and 45 years (selection process designed to include 'normal', 'overweight' and 'obese' men). One to one audio-recorded semi structured interviews focused on: overweight and obesity, diet, physical activity and diabetes. Transcripts were initially analysed using framework analysis. Emerging themes interlinked. Results The men in this study (n = 17) understand the word obesity differently from the clinical definition; "obesity" was used as a description of those with fat in a central distribution, and understandings of the term commonly take into account fitness as well as weight. Men in their late 30s and early 40s described becoming more aware of health issues. Knowledge of what constitutes a 'healthy lifestyle' was generally good, but men described difficulty acting upon this knowledge for various reasons e.g. increasing responsibilities at home and at work. Knowledge of diabetes and the link between obesity and diabetes was poor. Conclusion Men in this study had a complex understanding of the interlinked importance of weight and fitness in relation to health. Obesity is understood as a description of people with centrally distributed fat, in association with low fitness levels. There is a need to increase understanding of the causes and consequences of diabetes. Discussion of increased health awareness by men round the age of 40 may indicate a window of opportunity to intervene at this time.


Background
The 2007 Wanless report [1] highlights the ever increasing problem of obesity and the consequent health problems. Despite many attempts to develop interventions to prevent obesity, little success has been reported. Levels of obesity in the UK are predicted to rise to 33% of men, 28% of women and over 20% of all children by 2010. The health consequences are well documented; for example obesity is estimated to account for a 54% increase in the incidence of type 2 diabetes between 1998 and 2003 [2]. Even though in 'westernised' countries there is a strong association between self perceived weight status and weight control behaviour [3], men are much less likely to perceive themselves as over weight than women across all weight categories [4,5]. Men of lower socioeconomic status are known to have higher levels of abdominal obesity, be at greater risk of cardiovascular disease (CVD) and diabetes and be particularly hard to reach with health promoting interventions. Too little is known about middleaged men's attitudes to and understanding of obesity, diabetes and CVD.
An increasing evidence base suggests that in terms of reducing diabetes and CVD risk it is better to be "fit and fat" than unfit and of normal weight [6]. There is evidence to suggest that much of the morbidity and mortality associated with overweight and obesity is due to being physically inactive. It is suggested that messages which focus on weight loss alone are unsuccessful and that a more successful prevention strategy may result from finding ways of increasing physical activity. In this qualitative study we examine the views of men on the subjects of weight, diet and exercise.

Methods
This was a qualitative study in which a purposive sample of men (stratified for age, BMI, and post code) aged between 25 and 45 years was recruited from the patient register of one general practice list in Newcastle upon Tyne UK. Men who responded to a letter of invitation took part in a one to one audio-recorded semi structured interview with LH at a location of their choice. No incentives were offered to participants to take part. An interview schedule developed by the joint research team (based on a previous study [7]), used questions to stimulate discussion around topics of interest (i.e. overweight and obesity; diet; physical activity; diabetes), rather than to elicit specific answers (Table 1). BMI was recorded for each participant. Recruitment ceased when saturation of themes was achieved, that is, when no new themes emerged. Interviews were transcribed for analysis, and coded for anonymity. Initial thematic analysis of data was carried out separately by both NW and LH using framework analysis [8]. All text was systematically coded for subject matter. Emerging themes were examined by the project team. Further detailed analysis was conducted by NW and MM.

Conclusion
Are there things that we have not discussed but which you would have wanted us to discuss?
Analysis was an iterative process in which the process of writing itself informed understanding [9]. Emerging themes were interlinked, and we found striking similarities in the views and perceptions of the men in the studypresented below.

Ethical and research governance
Approval for the study was given by Northumberland Local Research Ethics Committee and Newcastle PCT.

Results
One hundred and forty invitation letters generated 17 positive responses. The 17 men interviewed (table 2) were aged between 28 and 44, with more participants towards the older end of the invited group (one aged < 30 yrs; four aged 30-34 yrs; six aged 35-39 yrs; six aged 40-45). Participants had a broad spread of BMI values (BMI 25 or less = 4; BMI 26-29 = 6; BMI 30-35 = 6; BMI of 36 = 1). The men in the study had a variety of educational background and occupation. None were unemployed. 9/17 participants had 'A' levels or degree, and a further 3/17 had undertaken some form of further education. Below we present the views and perspectives which emerged from the thematic analysis of the data.

Obesity
It was clearly stated that when the word obesity is used in everyday language it does not have the same meaning as when it is used in a clinical setting: "...there is a difference between the common opinion of what obesity is, and what clinical obesity is..." (Jim, line [15][16]. Obese people were described by participants as being fat with an obvious central distribution of the excess weight. Words such as "round" (Mark 1.1) and "balloon" are used (Jim 1.1). Having a lack of obvious muscle is seen as part of the definition of obesity by some (Jack 1.2), and again when Dave (line 64) describes his appearance he points out that he has "muscly arms and legs" giving the impression that this somehow counterbalances his excess weight. Ideas about obesity incorporated an element of difficulty in taking exercise in the definition, so for Richard (line 37-38) obesity is "Somebody being overweight, and not necessarily unfit, but struggle with their breathing and things like that, and struggle to move around" Here obesity is described in the sense of bodily experience and of leading to health problems rather than as being a health problem per se.
Many (but not all) men who had a BMI greater than 25 described feeling comfortable with how they look, and felt that the extra weight was not bad for them if they led an otherwise healthy lifestyle e.g. Chris (1.4) BMI 27. Peter (1.5) with a BMI of 36 thinks it is not normal to be too thin and talked about the harm caused, particularly to women, by striving to be "two sizes smaller than what they actually should be". For Peter to be too thin is seen as harmful whereas to be overweight is not described as such. Men demonstrated clear recognition that health problems can result from being very heavy but they also described people with a high BMI who are active strong people who appear healthy and fit, rather than the round shape that is recognised as obese. There was evident understanding that people can have a high BMI as a result of muscle mass, as well as because of excess fat. In addition there was understanding of the complexity of issues relating to weight and fitness. It was recognised that people of the same weight, normal or otherwise, can have very different fitness levels and are therefore very different in terms of health. Men placed a high value on physical fitness and interlinked the issue of weight with this, placing less importance on any fixed idea of a correct weight.

Being fit and eating a healthy diet
Many of the men described having taken part in regular sporting activity at some point. Men valued exercise in a variety of ways. Some like the way it makes them look; Obesity and excess weight 1.1 "I have always had this sort of stigma, obese people being sort of round shapes with legs" (Mark, line 35-36); and, "Very large waist, you know, very, very big arms at the top, not so wide at the bottom, just looks oversized or inflated, somebody whose general appearance looked like an inflated balloon". (Jim, line 39-41).
1.2 "to me obese is, is not what I am [BMI 32], its basically these people who are a lot larger and basically, fat, I mean where you can actually see physically not a lot of muscle, so stocky and things like that, so to me obesity is that." (Jack, line 18-21) 1.3 "but I think it is somebody who maybe is too overweight to do any sort of normal physical exercise and by that would mean, if you are too overweight that you can't run or jog" (George, line 31-33) 1.4 "I mean, I am overweight, but I wouldn't say I was overweight you know, ...(Chris, line 39) I probably look better than I did a few years ago when I was less weighty you know, because I have filled out etc you know, because I mean for years I was always 11 1/2 stone, until maybe about 5 year ago and then I just you know, the thirties start and I just went "poof", so either like you know I see myself much nicer ..." (Chris, line 53-57) 1.5 "...I suppose maybe it's not directly answering the question. What I don't think is a normal look, is when people strive to be stick thin and, well it's slightly different for men, but for women, strive to be a size, sort of two sizes smaller than what they actually should be... " (Peter, line 39-42) 2.10 "I seen it as an opportunity to get myself fitter, and then when I did get put on the production line" (Richard line 74-5).
others value the weight control aspect. Others simply value it for its effects on well being (John 2.1), or as a sociable activity. Mike (2.2) believes that there is a balance to be struck whereby exercise can counteract some of the ill effects of an unhealthy diet.
There was good knowledge of what constitutes a healthy diet, and many men would prefer to eat this way at least part of the time. There was awareness of Government intervention in promoting public health messages around diet, and of the influence of the media. Most men could give a brief description of a sensible approach to healthy eating, mentioning five pieces of fruit and vegetables a day, (Rob 2.3 and George 2.4), and including references to brown bread, brown rice, avoiding fats and high salt, avoiding fried and processed foods (Jack 2.5). Others describe their approach to buying and cooking food in a health conscious way.
Employment was seen as a key factor in the perceived restrictions on both eating a healthy diet and opportunities to exercise. Access to food was discussed in a number of ways.

The changes that come with age
Men in this study talked in many ways about the changes occurring in their lives and how these affect them. They have noticed changes in their own levels of awareness of health and illness, usually because of personal contact with colleagues, friends or family experiencing ill health.
Change often results in increasing complexity and competing demands on time. Children have a major impactseen by some as an obstacle to a healthy lifestyle (Mark 3.1), and by some as the opposite Dave (3.2), (Ben 3.3).
New health issues, particularly the onset of knee problems were described as preventing a number of men from taking part in sports which they previously enjoyed. "I played football until my knees went" (Rob 3.4) There was much discussion about the negative impact knee injuries have had on fitness opportunities, but only one man mentioned the impact that excess body weight has on causing and aggravating knee problems.
For some men all of this has resulted in loss of routine (Chris 3.5) and decreased physical activity. For others, particularly those in their late 30s and early 40s, there seems to be an increased awareness of health as a vulnerable condition, and of the importance of a healthy lifestyle. Ben (3.6), 44 yrs old, described being more conscious of health related issues than when he was younger, now noticing when people around him develop health problems. John (3.7) has noticed that he comes across people with diabetes more often. He relates this, and the fact that he is paying more attention to diet and exercise, to his age.

Diabetes
Many of the men interviewed were aware of diabetes because someone they know has the condition. Most men do not think that they understand much about diabetesthey know that there is more than one type of diabetes but they don't understand how the different types fit together. Nigel (4.1) stated that he doesn't understand diabetes but has observed that in some situations diabetics need to eat sugar to relieve symptoms. His father is diabetic but apparently doesn't need to take treatment and is well and active. He finds this confusing. Similarly Mark (line 248-9) was aware of a degree of confusion on the subject-he understands that there are two types of diabetes, which he describes as very different "both the opposite case".
The profile of the condition was seen as less prominent than some other health problems. Chris (4.2) is aware that he is picking up information about other health conditions from the media but has noticed less information about diabetes. Some are aware of the link between diabetes and excess weight e.g. Mark (4.3), who was recently shocked to be classed as obese by his doctor. Many were not clear about the significance of excess weight however. Ben (4.4) wonders if weight is just a marker for an unhealthy lifestyle. George (4.5) describes the association of weight and diabetes but wonders if diabetes results from the unhealthy lifestyle underlying the weight problem.
Some men were aware that eyesight can be damaged by diabetes; cataracts glaucoma and bleeding were mentioned. There was limited awareness of what other problems result from diabetes. Peter (4.6) understood that Diabetes 4.1 "I know very little about diabetes I mean you know, I've heard...well I've known people in the past that had diabetes who were insulin dependent they had to obviously take medication to control that, and you know, I've worked with those people and they were able to ...signs and symptoms and know when they were needed to either take sugar or whatever, diabetes that great, and obviously when my father has it he doesn't...he takes medication to control his, but quite active and quite healthy still, it's under his control," (Nigel line 307-14) 4.2 "It was the diabetes part as well (6 line 5)...in as much as it's not pushed in your face. You know obesity is touted every day on the 'tele' and on the internet, there is always some health study showing this, that and the other you know, and they always tend to, I would say concentrate a lot on high blood pressure and so forth, in fat people, obese people or who are overweight you know, and so when I was reading it out to my other half, I said to her, I don't really know much about the health implications or anything about obesity apart from the usual, you know, the blood pressure factor." (Chris line 11-18)) 4.3 "I have got a friend, a friend and neighbour who suffers from diabetes and he is the same as myself, overweight in some respects so I thought, well.. diabetes is a significant condition but did not have a clear idea about what that implies in terms of illness. George (4.7) had heard that heart problems can result. Steve (4.8) describes the problem of obesity as causing "too much fat in the blood stream" but an equivalent understanding of the effects of too much sugar in the blood stream was not as evident. Craig (4.9) made the link between excess weight and heart problems, but without knowing that diabetes is an added risk factor.

Discussion
The main findings of this study are as follows: • The men in this study understood the word obesity differently from the clinical definition; the term "obesity" was used mainly as a description of those with centrally distributed fat, and understandings of the term commonly took into account fitness as well as weight.
• Men described becoming more aware of health issues in theirlate 30s and early 40s, suggesting there may be a window of opportunity to intervene at this time.
• Knowledge of healthy lifestyles was generally good, but men described difficulty acting upon this knowledge as they approach middle-age and have increasing responsibilities at home and at work.
• Knowledge of diabetes and the link between obesity and diabetes was poor.
This study set out to understand important health issues from the individual perspectives of men in the general population. As a qualitative study this research sets out to understand the range of views held by men but does not make claims about the distribution of those views, and is therefore not generalisable in the quantitative sense. We can however generalise theoretically in the sense that the understandings gained here enable us to better judge the issues of importance to men in this age and socio economic group and provide the parameters for quantitative studies of the distribution of these understandings. Validity in qualitative research is established through standard mechanisms to assess the plausibility and credibility of the claims made [10,11]. Here this was achieved through saturation of themes, exposition of methods, attention to negative cases and reflexivity. While we interviewed men in the age group 25 to 45 years and achieved a good mix of weight and occupation, the group had higher levels of educational attainment than would be expected in the general population and this is a potential source of bias. Our conclusion that men in their late 30s and early 40s are open to change could result from having particularly attracted a group of participants who feel this way. Conversely however, the lack of understanding of diabetes in this relatively well educated group suggests that the problem may be much worse in a different sample which better represents the average educational achievement in the population at large.
For men in this study the word obesity implies elements relating to the central distribution of body fat, and to levels of physical fitness. The focus on 'round' body shape interestingly fits with scientific research which suggests that waist circumference is a better measure of cardiovascular risk that BMI [12]. Many men actually prefer the way they look when their BMI is > 25 and do not see this higher level of weight as a problem in the context of a healthy lifestyle. These men aspire to be physically fit, and public health messages about healthy eating seem to have made an impact. They discuss the factors which limit opportunities for exercise and healthy diet. Patterns of employment are seen as very significant, as well as the related economic factors e.g. sedentary occupations, such as taxi driving, and easy access to cheap fast food. They notice an age related increase in their awareness of health issues.
The ideas we demonstrate about the scepticism held in relation to a target BMI of < 25 have been seen elsewhere. Monaghan interviewed 37 men, (mean age 43), exploring the way men felt about conforming to a 'healthy' BMI, and found "talk about the compatibility of heaviness, healthiness and physical fitness; looking and feeling ill at a putatively 'healthy' BMI; and the irrationality of standardisation" [13].
Research showing that the association between overweight or obesity and mortality is markedly attenuated and in some instances eliminated when objectively measured cardio respiratory fitness is included in the statistical models [14] fits with the perception of the men in this study, that any level of weight cannot be viewed in isolation from levels of physical fitness.
For the men in this study the word diabetes conjures up a number ofconcepts which link to it, but are not easy to understand as a whole. Facts relating to 'type one' and 'type two' diabetes are mixed together, and the side effects of insulin are mixed up with the signs and symptoms of diabetes. Diabetes is understood as an illness, rather than a risk factor, but people are confused about the lack of tangible symptoms relating to the 'illness' of diabetes itself. The understanding of diabetes is like self assembly furniture without the instructions-there are lots of pieces which clearly go together but it is not clear how.
There is little published research into the general population's understanding of diabetes with which to compare these findings. Diabetes UK commissioned a MORI con-ducted survey of 2,135 adults in the UK [15] in 2000 which found that public understanding of diabetes and its impact is poor. Four out of five people believed that some people get a milder form of diabetes than others; three quarters (76 per cent) of those in high risk groups were unaware of their risk of developing the condition; less than half (46 per cent) of the public know that death can result from diabetes; only one quarter of the population know that diabetes can lead to heart disease despite the fact that it significantly increases the risk. Our findings mirror these results.
A number of men described knee pain as having significantly interrupted their exercise regime. The perception seems to be that exercise is responsible for the problem, and that weight gain is a consequence. Some evidence suggests that participation in exercise does not cause knee osteoarthritis [16], but other more specific follow up studies of professional footballers do indicate long term problems, including osteoarthritis of the knee [17]. Obesity however is clearly associated with knee pain and osteoarthritis in the knee [18]. In obesity and diabetes prevention in men, education about good knee care, and the impact of weight on knee problems may be an important factor.

Conclusion
We illustrate that middle aged men have a complex understanding of what it is to lead a healthy lifestyle, which includes the interlinked nature of weight and fitness. Obesity is understood as a description of people with centrally distributed fat, in association with low fitness levels, rather than simply a function of raised BMI. In general, it seems that limitations on ability to adhere to a healthy lifestyle relate less to lack of understanding of the issues than to limiting economic, social and physical factors. Raised levels of awareness may mean that there is an opportunity for intervention with men around the age of 40 to address factors affecting weight maintenance and participation in exercise. Understanding of the condition of diabetes stands out as being confused and there is a need to improve the general understanding of this condition.