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 populations

Probability 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

14
18 15 18 16 30 36
ECOG - IOTF 2002 36

19 16 18

27
16 20

Societal policies and processes influencing the population prevalence of obesity

INTERNATIONAL FACTORS NATIONAL/ REGIONAL COMMUNITY LOCALITY WORK/SCHOOL/ INDIVIDUAL HOME
Leisure 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 perspective
Modified 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 obesity

Change 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

WHO
National Information
Health 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 proposals
MINISTRY of HEALTH (HEALTH POLICY GROUP)

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

Ministry of health actions

1. 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 surveillance
Ministry 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 approach

Increasing 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 risk

Adapted 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 change
Energy density: fat & refined CHOs
BULK, e.g. vegetables, tubers, cereals

Physical inactivity
+ +
Sex hormone changes

+ +

+ +

OBESITY DIABETES CHD

+

Phytoestrogens bioactivate molecules

Folate, B6

HYPERTENSION CANCERS: breast, endometrium

Homocysteinaemia Thrombosis

+ Trans fatty acids + n-3 fatty acids Total Fat

Saturated fats

Atherosclerosis
+

Antioxidants

24 hour energy expenditure is reduced by weight loss

kcal/day
3000 2500 Reduced need

Cost of movement returns to normal

Thermogenesis reduced
Reduced by 200 or 300 kcal/d

2000
1500

1000
500 0

BMR and lean body mass fall

Activity Thermogenesis Basal Metabolic Rate

83 kg

73 kg

Preventing type 2 diabetes in glucose intolerant adults.

60
Control

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

40 30 20 10 0
Sweden 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 obesity
Evidence Convincing Probable Decreases risk
Regular physical activity. High dietary NSP (fibre) intake Home & school environments that support healthy food choices for children **. Promoting linear growth Breastfeeding

No relationship

Increases risk
High 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 evidence
and 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 foods

Burgers S'market pies, pasties
Fat 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 options

Prentice 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<0.01

Marketing to Children

Manipulating children's behaviour

Food promotion
Can confuse nutritional knowledge, e.g. whether fruit is in product. Changes food preferences Changes purchasing behaviour

Influences choice and consumption by Brand

Alters balance of categories of food eaten.
UK Food Standards Agency, 25th September, 2003.

Recommendations on childhood overweight & obesity in Europe Recognise: as an escalating major public health problem strong genetic factors affecting individuals and their management but epidemic is environmental - restricted activity & major dietary change

Recommend: Facilitate physical activity a) rapidly in schools b) by long-term correction of traffic policies and urban design e.g. Netherlands Focus on food and drink to reduce total fat,sat. fatty acids, sugars & salt - increase fibre, fruit & vegetable intakes Protect children from marketing of foods & drinks e.g.TV. & schools e.g. Sweden Specific controls on school foods and training e.g. Finland Transform food labelling everywhere; now incomprehensible Tax corrections for CAP cheapening of fats &sugars Need action from new European Food Authority and a new CDC for public health

Components of an integrated comprehensive model for school-based obesity prevention.

Family and community linkages

Nutrition environment of the school

School
food services School health services

Goal: enhancing healthy eating practices and physical activity patterns and achieving healthy weights in children and adolescents
Health instruction (curriculum)

School-site health promotion for faculty and staff Physical education classes

School counselling and psychology programs

Fruit Sales as a Function of Price

100

Mean weekly fruit sales

80 60 40 20 0
Average School 1 urban

Baseline 1 Low price Baseline 2

School 2 Suburban

Average vs each school Average vs each school

French et al, 1997 French et al, 1997

Current misleading food labelling (2)

Specifying average nutrient goal for consumer use condemns at least 50% of population to high intakes:

Men aged 25 need if: moderately active normal high BMR weight 80 kg Women aged 60 need if: inactive normal low BMR weight 45 kg

13.5 MJ

7.0 MJ

Specifying total intake neglects range in needs by age, sex and size.

Governmental responsibilities for food 1. 2. 3. 4. 5. Advertising Food labelling Fiscal policies Research policies Food standards for pre-school nurseries/schools Public sector catering Health policy development New role for Public Health Sector Health education

6. 7. 8. 9.

Obesity: Time for Action A joint statement from a CPG/IOTF meeting of 25 NGOs. Recommend that the Government:

Appoint a cabinet minister for comprehensive cross-departmental action

Establish an independent government agency responsible to Parliament for monitoring action & progress, proposing new measures and ensuring compliance ban the marketing of high fat/sugar/salt products e.g. on TV Simple labelling on all foods and outlets of high/medium/low fat/sugar/salt content

use public procurement and fiscal measures to counteract current subsidies

require all urban planning, transport etc to ensure safe activity as part of normal living

increase obesity directed resources in NFS management for PCTs and guidelines for monitoring children and progress in management and prevention

Obesity: Time for Action

A joint statement from a CPG/IOTF meeting of 25 NGOs.

The Food Industry and Retail Sector should:

Develop a range of reformulated staple foods with a benefit to health Support rules to prohibit promotion of high fat/sugar/salt foods Develop healthier snacks ,confectionery and soft drinks

Initiate and support a long-term marketing campaign to promote fruit and vegetables to children

Waiting for a green light for health? Europe at the crossroads for diet and disease

IOTF Position Paper - September 2003