Undernutrition and Obesity: the View from
the Public Sector
William H. Dietz, MD, PhD
Division of Nutrition and Physical Activity
CDC
Undernutrition and Obesity
Undernutrition
Obesity
Women > men
Women > men
Ethnic differences
SES gradient
SES gradient in white women
Children esp vulnerable
Adults > children
Large disease and financial burden
Breastfeeding protects
Food insecurity
Food insecurity?
Examples of the Elimination of Micronutrient
Malnutrition in the United States
Iodine deficiency
Pellagra
Neural tube defects
The Full Spectrum of
Iodine Deficiency
Cretinism
Goiter
Reduced intellectual
performance
Iodized Salt in the
United States
Morton develops
Iodized salt to help prevent
goiters, which were
common at the time. The
Food and Drug
Administration later
requests that the product be
labeled with the message,
“This salt provides iodide,
a necessary nutrient.”
1924
Salt Iodization in the US:
Trend in Goiter Prevalence in Michigan
50
Percent
40
30
20
10
0
1924
1929
Year
WHO Monograph Series No. 44
1951
Examples of the Elimination of Micronutrient
Malnutrition in the United States
Iodine deficiency
Pellagra
Neural tube defects
Morbidity
Mortality
Mortality and Morbidity Rates per 100,000 Population
Morbidity and Mortality Rates of Pellagra in Mississippi
1000
Mandatory Enrichment Law
Became Effective (1945)
100
10
Voluntary Bread
Enrichment Began (1938)
1
0.1
1925
1930
1935
1940
1945
Year
Source: AMJ Public Health 2000; 90:727
1950
1955
Examples of the Elimination of Micronutrient
Malnutrition in the United States
Iodine deficiency
Pellagra
Neural tube defects
Prevalence of spina bifida and anencephaly by year
and quarter of birth for 24 surveillance programs
(1995-99)
World Bank Rankings of Cost Effective Interventions
Relative Cost Per DALY
Vitamin A Fortification
Antibiotics for
Infections
ORT for Diarrhea
Iron Supplementation
Vitamin A
Supplementation
Iodine Fortification
Iron Fortification
$0
$5
$10
$15
$20
$25
$30
$35
Copenhagen Consensus
“Very Good Proposals”
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Challenge
Diseases
Malnutrition
Subsidies & trade
Diseases
Opportunity
Control of HIV/AIDS
Providing micronutrients
Trade liberalization
Control of malaria
Flour Fortification Initiative
A Public-Private-Civic Investment in Each Nation
What Can Industry Do?
• New product development
• Help make the case for fortification
Recognize success
Develop and argue the ROI
Use business to business networks
• Support a level playing field
• Market the approach
Global Prevalence of Obesity, 1988-94
Women
Men
Age range
25-69
18+
25-64
20-74
15+
25-69
20-65
16-64
18-74
20-59
20-69
15-64
25-64
20+
20-45
Samoa (urban)
Kuwait
East Germany
USA
Saudi Arabia
W. Germany
Czech Republic
England
Canada
Netherlands
Australia
Brazil
Japan
China
80
60
40
20
0
% population
Source: International Obesity Task Force
20
40
60
80
Obesity Trends* Among U.S. Adults
1991, 1996, 2004
1991
1996
2004
No Data
<10%
10%-14%
15%-19%
20%-24%
 25%
Consequences of Adult Obesity
• Psychosocial
• Cardiovascular
– Hyperlipidemia
– Diabetes mellitus
– Hypertension
– Respiratory
– Cardiac
• Medical
– Polycystic ovary disease
– Gall bladder disease
– Osteoarthritis
– Cancer
• Pregnancy and the postpartum
• Mortality
• Erectile dysfunction
Diabetes* Trends Among U.S. Adults,
BRFSS 1990, 1996, and 2004
1990
1996
2004
No Data
<4%
* Includes Gestational Diabetes
4%–6%
6%–8%
8%–10%
>10%
Duration of Diabetes and Nephropathy (Pima Indians)
Cumulative Incidence
Nephropathy (%)
35 - 44 Y
25
20
15 - 24 Y
15
10
25 - 34 Y
5
0
0
4
8
12
16
Duration (years)
• The duration of diabetes,
rather than the age at
diagnosis, is predictive of
nephropathy (Krakoff.
Diabetes Care 2003;26:76)
Costs of Obesity
Costs of illness
Costs of absence from work
Costs of reduced productivity
Costs of injuries
Costs of disability
Annual Direct and Indirect Costs Attributable to
Obesity in the United States
(Billions of 1995 Dollars)
Disease
Type 2 DM
CHD
Hypertension
Gallbladder
Breast Ca
Endometrial Ca
Colon Ca
Osteoarthritis
Total
Wolf and Colditz, Ob Res 1998;6:97
Direct Costs
$32.4
$ 7.0
$ 3.2
$ 2.6
$ 0.8
$ 0.3
$ 1.0
$ 4.3
$51.6
Indirect Costs
$30.7
$ NA
$ NA
$ 0.1
$ 1.5
$ 0.5
$ 1.8
$ 12.9
$47.5
% Total Change in Spending by Top 10 Conditions
1987-2000
Heart disease
Pulmonary conditions
Mental disorders
Cancer
Hypertension
Trauma
Cerebrovascular disease
Arthritis
Diabetes
Back problems
Thorpe et al. Health Affairs 2004; W4-437
30%
16%
Costs of Obesity
Costs of illness
Costs of absence from work
Costs of reduced productivity
Costs of injuries
Costs of disability
Effects of Obesity on Health and Disability
among 50-69 yo Women with BMI > 35
Report poor health
# Chronic conditions
Any ADL limitation
Report health limits work
Sturm et al. Health Affairs 2004;23:199
40.5%
2.31
21.4%
45.7%
Partners in the Prevention and Treatment of
Obesity
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Medical Settings
School
Work Site
Community
Industry
Energy Requirements
Energy Requirements
Relationship Between Energy Requirements,
Physical Activity, and Weight
Level of Physical Activity
Weight
What Can Industry Do?
• Recognize the threat
• Use business to business contacts
• Become model worksites – healthful choices, medical benefit
packages
• New product development
Create and meet consumer demand
• Use creative packaging
• Share non-proprietary market research
Division of Nutrition and Physical
Activity, Adolescent and School
Health, and VERB Websites
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cdc.gov/nccdphp/dnpa
cdc.gov/nccdphp/dash
cdc.gov/youthcampaign
VERBnow.com
VERBparents.com
healthierus.gov/steps