Obesity: Tackling the Global Epidemic

Philip James

Leading DALYs in 2000: developed countries 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Tobacco Blood pressure Alcohol Cholesterol Overweight Low fruit & vegetable intake Physical inactivity Illicit drugs Unsafe sex Iron deficiency 12.2% 10.9% 9.2% 7.6% 7.4% 3.9% 3.3% 1.8% 0.8% 0.7%

WHO World Health Report 2002

The cover of "The Economist", Dec. 13-19, 2003.

BMI distribution curves from the Intersalt Study populationsProbability density? ASIAN NORMAL O/WT OBESE

0.10

0.05

0.00 14

16

18

20

22

24

26

28

30

32

34

36

38

40

42

44

Body Mass Index (kg/m2)Adapted from: Rose, G. (1991) .

Prevalence (%) of overweight among children in Europe

13 21 18 22 18

1418 15 18 16 30 36ECOG - IOTF 2002 36

19 16 18

2716 20

Societal policies and processes influencing the population prevalence of obesityINTERNATIONAL FACTORS NATIONAL/ REGIONAL COMMUNITY LOCALITY WORK/SCHOOL/ INDIVIDUAL HOMELeisure Activity/ Facilities

POPULATION

Transport

Public Transport

Globalization of markets

Urbanization

Public Safety

Labour

Energy Expenditure

Health Development Social security Media & Culture

Health Care

Infections

%OBESE AND Food intake : Nutrient density OVER-WEIGHT

Sanitation

Worksite Food & Activity

Media programs & advertising

Manufactured/ Imported Food

Family & Home

Education School Food & Activity

Food & Nutrition

Agriculture/ Gardens/ Local markets

National perspectiveModified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipathies V. IOTF website 1999: http://www.iotf.org

Levels of prevention measures

Targeted prevention (directed at those with existing weight problems)

Obesity Report, WHO 2000.

Long-term management of childhood obesityChange in % overweight

10 5 0 -5 -10

Non-specific Average age on follow-up 20 years: one parent obese with a variety of management techniques based on general advice (non-specific targeting, child targeting only or detailed involvement of both parent and child.)

Child only

95%confidence interval

Child + parent

-15-20 0 5 Years after treatment 10

Epstein et al. (1994) Health Psychology, 13: 373

Formulating a nutrition policy for the prevention of NCDs. Emerging concepts from WHO 2002 Consultation

WHONational InformationHealth statistics Dietary & risk fact.surveys Nutritional surveillance Food production Agricultural Food production statistics Market structure Import/export policies Food security measures Public perception Economic evaluation of policy proposalsMINISTRY of HEALTH (HEALTH POLICY GROUP)

FAO, UNICEF, UNESCO, WTO, World Bank etc.

Ministry of health actions1. Professional training 2. Health promotion national networks (NGO, voluntary Orgs.) national campaign 3. Regional and district food policy 4. Catering establishments 5. Priorities, research and surveillanceMinistry of Education Ministry of Information

INDEPENDENT NATIONAL INSTITUTION

school & postgraduate education school meals

Actions

coordinating educational materials

Ministry of re-evaluation of current Agriculture/Environment policies Nongovernmental organizations and consumer representatives Ministry of Trade Ministry of Finance Ministry of Foreign Affairs

Private sector

controls on food industry licensing, cooperative trade arrangements tax, subsidy adjustments policy on import / export trade coordinating regional actions

Weighing up potential gains and risks: a portfolio planning approachIncreasing returns/health gains Very high gain- low uncertainty Not found Moderate gains - low uncertainty Not found

High gain- moderate High gain - high uncertainty uncertainty 1. Very promising 3. Promising Moderate gain -moderate uncertainty 2. Promising moderate gains high uncertainty 4. some promise

Low gain - low Low gain - moderate Low gain - high uncertainty uncertainty uncertainty Treatment options inappropriate Inappropriate

Increasing uncertainty or riskAdapted from: Hawe and Sheil 1995 by Tim Gill 2004.NSW Report

The interlinking of physical inactivity and dietary effects on obesity and the progression of disease with industrialisation

Dietary changeEnergy density: fat & refined CHOsBULK, e.g. vegetables, tubers, cereals

Physical inactivity+ +Sex hormone changes

+ +

+ +

+

OBESITY DIABETES CHD+

Phytoestrogens bioactivate molecules Folate, B6

HYPERTENSION CANCERS: breast, endometriumHomocysteinaemia Thrombosis

+

+

+ Trans fatty acids + n-3 fatty acids Total FatSaturated fats

Atherosclerosis+

Antioxidants

-

24 hour energy expenditure is reduced by weight losskcal/day3000 2500 Reduced need

Cost of movement returns to normalThermogenesis reducedReduced by 200 or 300 kcal/d

20001500

1000500 0

BMR and lean body mass fall

Activity Thermogenesis Basal Metabolic Rate

83 kg

73 kg

Preventing type 2 diabetes in glucose intolerant adults.60Control

50Observed or predicted cumulative incidence diabetes over 5 yrs. (%)

40 30 20 10 0Sweden 1991

*

**China 1997

*Finland 2000 USA 2002

Weight loss kg (%): Baseline BMI + SD Age (yrs):

1.7% -3.7% 26.6 + 3.1 48

+0.3 -1.8 25.8 + 3.8 45

-0.8

-3.5

31 55

-0.1 -6.0 34.0 + 6.7 50.6

*

Dietary change in all four studies involved detailed recurrent dietetic advice to lose weight, limit fat (20-30%), sugar & increase vegetable/fruit intakes. Physical training in sports centre or on own for >12 months with 3- 6 year follow-up and recurrent monitoring and help.

Recommendations from the CDC review of interventions to increase physical activity

Informational Approaches to Increasing Physical Activity Intervention Community-wide campaigns "Point-of-decision" prompts to encourage stair use Recommendation Strongly Recommended Recommended

Classroom-based health education Insufficient Evidence* focused on information provision Mass media campaigns Insufficient Evidence*

N.B. * Insufficient does not mean ineffective.

Summary of level of evidence on factors that might promote or protect against weight gain and obesityEvidence Convincing Probable Decreases riskRegular physical activity. High dietary NSP (fibre) intake Home & school environments that support healthy food choices for children **. Promoting linear growth Breastfeeding

No relationship

Increases riskHigh intake of energy-dense nutrient-poor foods. Sedentary lifestyles Heavy marketing of energydense foods** and fast-food outlets. Adverse social and economic conditions (in developed countries, especially for women) Sugar-sweetened soft drinks and fruit juices

** Associated evidenceand expert opinion

Possible

Low glycaemic index foods

Protein content of the diet

Large portion sizes High proportion of food prepared outside the home (western countries) "Rigid restraint / periodic disinhibition" eating patterns

Insufficient

Increasing eating frequency

Alcohol

Table taken from Diet, Nutrition and the Prevention of Chronic Diseases, WHO 2003, TRS 916.

Relationship between energy density and fat %E of different foodsBurgers S'market pies, pastiesFat content (g 100 g-1)

Fried chicken

S'market ready meals (Indian)

Fries (chips) S'market pizzas

S'market ready meals (Italian)Gambian main meals

S'market healthy optionsPrentice AM & Jebb SA. Obesity Reviews, 2003, 4: 187-194

Energy density (kJ 100 g-1)

Adjustment in energy density needed to maintain constant intakes.C. Traditional Gambian foods and supermarket healthy options. B. Supermarket ready meals

A. Fast foods

Calculations based on intake of 8.5 MJ/d

Prentice AM & Jebb SA. Obesity Reviews, 2003, 4: 187-194

Children's responses to larger servings

Amount served to child Fisher JO, Rolls BJ & Birch LL, AJCN, 2003, 77: 1164-1170

Consumed. ** p