Chapter Three

Chapter three will provide a comprehensive overview of literature that are relevant to the

current research topic of obesity among adults aged 18 to 75 in London. This chapter will be

divided into themes aligned to the study objectives and will have the following sections: (3.1)

Brief view on obesity; (3.2) Prevalence of obesity among adults (18-75) in London and England;

(3.2.1) Analysis of prevalence of obesity; (3.3) Risk factors associated with obesity among adults

in London; (3.3.1) Analysis of the factors of obesity among adults in London; (3.3.2)

Implications of obesity in adults in London; (3.3.3) Implications of obesity on adults in London;

(3.4) Implications of health and socio-economic status on obesity; (3.4.1) Analysis of the

implications of health and socio-economic status on obesity; (3.5) Governmental and non-

governmental interventions; (3.5.1) Analysis of governmental and non-governmental

interventions. The chapter will be concluded with a summary of the key issues discussed in the

review.

3.1 Brief view on obesity

Obesity has been defined as the Body Mass Index (BMI) of 30 or more in an individual.

According to CDC (2020), the obesity condition is a critical health issue among adults and is

associated with significant risks of chronic diseases such as cancer, cardiovascular diseases and

type 2 diabetes. CDC (2020) also noted that obesity provides a disproportionate expanse of

body-fat mass on the human body, standard for global epidemic partaking adverse health

implications with reduced life expectant and augmented morbidity risk. Risk factors associated

with adult lifestyle and inappropriate governmental and non-governmental interferences may put

adults aged 18-75 at a greater risk of obesity and its associated co-morbidities (CDC, 2020). 
3.2 Prevalence of obesity among adults (18-75) in London and England

Previous research shows that the population of adults living with obesity in England

varies, with some areas having more significant increases than others (Hancock, 2021). For

instance, an analysis of 2019 data from the Health Survey for England (HSE) shows that obesity

had the highest prevalence in the North East and West Midlands among adults (34%) and was

lowest in South East (24%) and London (23%) (Hancock, 2021). Nonetheless, Hancock

(2021) noted an increase in obesity prevalence across all areas in England over the last twenty-

seven years. An analysis of data from HSE by NHS (2010) shows that about a quarter of the

adult population in England was obese, with women (25%) being more obese than men (24). The

report by NHS (2010) is in line with the findings by Hancock (2021) on the increase of the rates

of obesity in England, with 1 in 4 adults being identified as obese. However, the analysis by

NHS (2010) is a bit deeper as it delved into the anthropometric measures of obesity, particularly

BMI and waist circumference. Based on the analysis, while the BMI in men and women in 2008

were almost similar (27.2kg/m2 and 26.9kg/m2, respectively), the prevalence of obesity was

higher in older age groups (NHS, 2010). Unlike NHS (2010), the House of Commons Library

(2021) relied on more recent data as it analysed the 2019 HSE findings on the adult obese

population in England. Based on the report, approximately 28% of adults in England were obese

in 2019, with men being identified as more obese than women (68.2% of men and 60.4% of

women) (House of Commons Library, 2021). This is as illustrated in figure 1 below. 

 Figure 1: Obesity Prevalence in England between 1993 and 2019 (Source: House of

Commons Library, 2021)

While the House of Commons Library (2021) agree with Hancock (2021) and NHS

(2010) that the rates of obesity among adults increase with age, they provide more precise data

showing that adults aged between 45 and 74 are more likely to be obese than younger adults. The

presented data also indicates that the prevalence of obesity is 9% higher in more deprived areas

in England than in other areas (House of Commons Library, 2021). A summary of the prevalence

of obesity, as presented by the House of Commons Library (2021), is shown in figure 2. 
 Figure 2: Obesity Levels by Age Group in England (Source: House of Commons Library,

2021).

In agreement with the reports reviewed in this section, National Clinical Guideline Centre (2014)

also identified a significant increase in the obese population in England as the rates nearly

doubled from 1993 to 2011. The obese population rose from 16% of women and 13% of men in

1993 to 26% of women and 24% of men in 2011 (National Clinical Guideline Centre, 2014).

Based on the prediction by the National Clinical Guideline Centre (2014) following the

systematic review of relevant literature on obesity, an additional 11 million adults may become

obese in the UK by 2030.

3.2.1. Analysis of Prevalence of obesity in London and England

The evidence presented in the previous section and chapter one of this study shows an

increase in the rates of obesity in England since 1993. The data shows that the obese population

in England rose from 15% in 1993 to 28 in 2019, indicating a 50% incline in the obesity rates
within twenty-six years (Agha and Agha, 2017; House of Commons Library, 2021; Figure 1).

However, recent literature shows that the statistics between 2015 and 2021 were higher than the

figures reported in previous years. For instance, the data presented by Baker (2021) showed that

the population of obese men rose from 0.3% between 1993 and 2010 to 2.2% between 2017 and

2019. A similar trend was observed in the population of obese women as the rates increased from

1.5% between 1993 and 2010 to 4.5% between 2017 and 2019 (Baker, 2019). Based on the

analyses by Baker (2021), NHS (2020; chart 1), Physical Inactivity Report (2017), NHS (2010),

House of Commons Library (2021) and National Clinical Guideline Centre (2014), while the

rates of obesity have been identified as more prevalent among older adults, women have been

found to be more obese than men over the years. The significant differences between the

population of obese men and obese women were attributed to the rates of physical activity as it

was noted that women have lower rates of meeting the recommended daily activities compared

to men (Public Health England, 2014). 

Risk factors associated with obesity among adults in London and England

Previous research shows physical inactivity, unhealthy diets coupled with weight-related

lifestyle have affected obese individuals during the COVID-19 pandemic (Robinson et al., 2021).

According to Robinson et al., (2021) although 56% of the study participants observed they have

been snacking frequently and faced challenges managing their weight, these trends were mostly

observed among individuals with high body mass index and low physical activity levels. Based

on the research findings, participants with high BMI reported to have difficulties accessing

health foods, lacked control and motivation to healthy easting as well as lacked social support

(Robinson et al., (2021). In agreement with the study by Robinson et al., (2021), analysis of data

from the NHS (2017) shows 26% of adults were categorized as inactive engaging in less than 30
minutes of physical activity weekly while 61% of the adults were considered as active, engaging

in more than 150 minutes of physical activity every week. The report shows the physical activity

decrease with increase with age, showing that those aged between 18 to 26 years rarely were

inactive at 15% compared to 54% inactivity levels in those above 65 years of age. This is

illustrated by figure 3 below:

Figure 3: Physical activity of adults (18-75) (Source:

Further analysis of the report shows the physical activity decrease with increase with age,

showing that those aged between 16 to 24 years rarely were inactive at 15% compared to 54%

inactivity levels in those above 65 years of age as shown in figure 4 below:

Figure 4: Physical activity by age group.

Biological factors

The accumulation of excess body fat results to obesity and is associated with adverse

health effects such as cancer, type 2 diabetes, and cardiovascular diseases. Despite obesity

development being highly influenced by environmental factors, studies have estimated 40% to

70% genetic predisposition component is needed (Herrera and Lindgren, 2010). According to the

study conducted by Albuquerque et al., (2017), the effects of the interactions between

environmental factors and genes account for the missing heritability of obesity in individuals

with the predisposing obesity gene intermingling with lifestyle leading to a modification of the

risk of obesity. Analysis of the effects brought by the interaction of physical activity and obesity

related activities by Albuquerque et al., (2017) suggests that adults taking part in high intense

activities may weaken the adverse effects obesity has on the body. While Albuquerque et al.,

(2017) agrees with Herrera and Lindgren, (2010), they provide more precise data showing that

there exists specific sex genes that contribute to the traits related to obesity vary and points out

fat distribution is accounted more by genes in women compared to men with estimated
heritability of 40% to 70% in men and 30% to 60% in women. Albuquerque et al., (2017) notes

that age and sex are linked with the differences in body composition and obesity. Women store

more fat subcutaneously compared to the visceral adipose tissue meaning that women have more

body fat compared to men at the same BMI (Albuquerque et al., 2017).

Analysis of risk factors associated with obesity among adults (18-75) in London and

England (NOT FINISHED)

Implication of health and socio-economic status on obesity among adults (18-75) in London

and England

Research by Booth, Charlton, and Gulliford (2016) evaluated the socio-economic

inequality among individuals with BMI less than 40 by analyzing Health Survey for England

from 2011 to 2014. According to Booth, Charlton, and Gulliford (2016), women, 3.7% are more

affected by obesity compared to 1.7% men. The high prevalence of obesity is associated with

greater income inequality, with London experiencing both high obesity rates and high income

inequalities (Devaux and Sassi, (2013); Booth, Charlton, and Gulliford (2016). The study

provides evidence of a consistency between low morbid obesity with high education levels and

high household incomes (Booth, Charlton, and Gulliford 2016). However, Booth, Charlton, and

Gulliford (2016) cites that education and income inequalities affect health through multiple

streams, but not limited to physical activity, diet quality and lifestyle choices. Nonetheless, the

study provides a convincing argument to show by occupying higher socioeconomic positions

protected individuals from developing obesity in England.

 Pechey and Monsivais (2016) conducted a qualitative study from the Kantar WorldPanel

UK household survey to investigate the extent of food expenditure and socioeconomic

inequalities in household health. Based on their findings, Pechey and Monsivais (2016) found

that individuals occupying high social class occupations were linked with high expenditure on

food, which translated to healthier purchasing. 63% of socioeconomic difference associated with

unhealthy foods was mediated by 36% of expenditure on fruits and vegetables (Pechey and

Monsivais, 2016). It was noted that supermarket choice by individuals is determined by factors

associated to expenditure and their motivations such as quality perceptions, convenience, or

preferences, thus supermarket influence on the choice represent various other motivators that

have an influence on healthiness of food and vary by socioeconomic status. Pechey and

Monsivais, (2016) conclude that while cost contributes significantly to healthy choice of food,

large proportions of socioeconomic inequalities is mediated by individual expenditure.

In agreement with the studies reviewed in this section, Adams (2020) notes that obesity

and overweight are more prevalent in higher affluent socioeconomic groups in low-income

countries and the reverse is observed in high-income countries. In England, individuals in less

affluent neighborhoods are more exposed to obesity (36%) compared to those living in more

affluent neighborhoods with a 20% obesity prevalence (Adams, 2020). Similarly, the study by

Kim and von dem Knesebeck, (2018) revealed that both social causation and reverse causality

explain the association between income and obesity. Those with lower incomes are more likely

to develop obesity. Because of the risk of developing obesity disappearing and becoming

inconclusive after the examination of the hypothesis of social causation, the sensitivity analyses

revealed that women are more likely to experience reverse causality than men are and it is cause

by the perceived disadvantages of being overweight (Kim and von dem Knesebeck, 2018). The
cultivation theory of social sciences states that women have a stronger idealization of thinness

and this could explain why women are more likely to be punished for being thin than men.

However, Kim and von dem Knesebeck, (2018) conclude that while the same social desirability

bias can be observed in weight and height reports, they can also be assumed that the effects of

income on obesity are underestimated when self-reports are used.

Analysis of Implication of health and socio-economic status on obesity among adults (18-

75) in London and England (NOT FINISHED)

Impact of government strategies in addressing obesity among adults (18-75) in London and

England

Research by Rauber et al., (2020) examines the relationship between consumption of high

processed foods with excess adiposity in the body. According to the study by Rauber et al.,

(2020), high processed food consumption is associated with a higher adiposity in the adult

population in United Kingdom.. The findings by Rauber et al., (2020) are based on the analysis

of primary data relating to the research. Based on research findings, the consumption of high

processed foods appears to promote overconsumption. Other characteristics that are associated

with the composition of food and industrial processes, such as fat removal and the alteration of

microbial composition, have been linked to the development of metabolic diseases (Rauber et al.,

2020). Rauber et al., (2020) conclude that high processed food consumption is associated with

the increased prevalence of obesity in both women and men and the consumption of these high

processed food groups should be reduced in order to prevent the development of type 2 diabetes

and other health complications.

 Rincon-Gallardo et al., (2020) agrees with Rauber et al., (2020) that at point of purchase,

food labelling can inform consumers about the nutritional content of the food items they are

buying. However, it is not yet clear if this policy will have the desired effect. Rincon-Gallardo et

al., (2020) based their study on a two-step scoping review to examine the impact of menu

labelling policies on the reformulation and reduction of serving sizes of restaurant menu items

globally. The participants’ responses revealed that the effects of menu changes on the nutritional

quality of the food served in restaurants were not affected by the changes in the items

themselves. The study by Rincon-Gallardo et al., (2020) provides strong evidence related to the

present study to show the goal of menu labelling policies is to improve the nutritional quality and

reduce the energy consumption of consumers by encouraging restaurants and food retailers to

reformulate their menu items to meet the required nutrients target.

Sacks et al., 2011 agrees with the studies conducted by Rauber et al., (2020) and Rincon-

Gallardo., (2020) that cost effective analyses can be used in the evaluation of various

interventions in the prevention of obesity. The study by Sacks et al., (2011) shows that both

front-of-pack Traffic Light Nutrition Labelling (TLL), and a tax on unhealthy food could be

cost-effective and provides more value for money as prevention measures of obesity. To alleviate

these issues, the TLL and the food tax interventions are likely to be the most cost effective and

effective ways in preventing obesity in Australia (Sacks et al., 2011). The study also established

that policies that target whole populations are more cost effective and have higher success rates

than those that aim to motivate individuals to change their behavior. However, although Sacks et

al., (2011) provide strong evidence to support their findings, the study makes more emphasis on

the use of uncertainty analysis and conservative assumptions to evaluate the impact of public

health intervention programs.

3.5. Significant Issues Arising From the Study

The increasing level of obesity has a significant impact on the patients’ physical, mental,

and socio-economic health. It has been estimated that the impact of being obese has a greater

negative impact on the quality of life than that of aging. There is an abundance of studies on

obesity and overweight done. This has been made possible by the fact that obesity is an epidemic

affecting every country globally, from first world countries, to developing countries, to third

world counties. Studies by Jura and Kazak, (2016) presented the Third Age Theory, noting that

recent improvements in health care have extended life expectancy and the proportion of people

older than 65 years has increased. The Third Age Theory states that the decrease in hormones

during ageing has been associated with various features of the process. It has been hypothesized

that these decreases could be triggered by the antagonistic pleiotropy theories of ageing (Jura and

Kazak, 2016).

3.6. Summary

The literature reviewed revealed that being overweight or obese is a major public health

issue in the UK. It is linked to an increased risk of various chronic diseases and premature

deaths. For people with a BMI over 30, the risk of poor health increases dramatically. There are a

number of policies and initiatives put in place to address the issue of obesity. These include the

establishment of policies and initiatives aimed at tackling the problem. Although decreasing the

prevalence of obesity is important, it is also important to consider the effects of increasing

absolute inequalities. This suggests that effective policies and interventions should have equal

efforts on different groups. Although the review identified important gradients in childhood BMI

risk by measures of socio-economic inequalities (SEP), it did not provide enough evidence to

support our understanding of these gradients. Few studies simultaneously studied both area and
household level determinants of obesity. There is also limited availability of studies that have

assessed the relationship between childhood obesity and the socio-economic status (SEP)

gradient. These studies have not assessed the relative importance of the various SEP metrics in

the analysis of obesity. This study explores the role government strategies in shaping the

physical environment to mitigate obesity prevalence in the population. It also shows that these

characteristics are associated with positive behavioral change in the population. The discussion

of the findings are as discussed in the subsequent chapter.