Obesity - a major public health
challenge
W Philip T James MD,DSc, FRCP
London School of Hygiene and Tropical Medicine
President, International Association for the Study of Obesity
Central2h
obesity
and insulin
insulin (mU/l)
resistance: South Asian
susceptibility: probably
50
applies
to Middle East &
Mexico
Diabetes
prevalence
%
Diabetes prevalence
(%)
30
30
South Asian
40
20
20
30
20
opean
10
10
10
European
6
7
0
0.8
0.9
1
1991,
337:
382
ose McKeigue et al. Lancet,
Waist
/ hip
ratio
000.8
0.8
From Mckeigue et al. Lancet, 1991, 337: 382
0.9
0.9
11
Waist // hip
hip ratio
Waist
ratio
The top risk factors underlying the disease burden
of high income countries (all preventable)
Smoking
High blood pressure
Overweight & obesity
High cholesterol
Alcohol use
Physical inactivity
Low fruit & veg. intake
Illicit drug use
Unsafe sex
Iron deficiency anemia
-2
0
2
4
6
8
Attributable disease burden
(% regional DALYs; total 149 million)
WHO / World Bank. Global Burden of Disease. Lopez et al., 2006.
10
The current obesity dilemma
UK Government report Oct. 2007
Provided on a non - political basis by the Chief Scientist
Obesity is a normal "passive" biological
response to our changed physical and
food environment
Some children/adults are more
susceptible for genetic, social and
economic reasons
Overwhelming environmental
impact reflects outcome of normal
industrial development
Obesity reflects failure of the
free market
Predicted diabetes health care costs in
England with different prevention strategies
Annual costs £ Millions
1453
No Action
Childhood
prevention
6-10 yrs
1049
654
BMI All ages Cap at 30;
50% effective
240
38
-164
20+yrs: BMI -4 units
-366
2004
2014
2024
2034
2044
Foresight Report on Obesity.2007. http://www.foresight.gov.uk/Obesity/14.pdf
The costs of different degrees of excess
weight in the USA
Per capita costs $
18
5000
16
4500
4000
14
3500
12
3000
10
2500
8
2000
6
1500
4
Per capita costs $
Total Excess Expenditure $ billion
Total Excess Expenditure $ billion
1000
2
500
0
0
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
>40
BMI
Arterburn D et al. Impact of morbid obesity on medical expenditure in
adults. IJO, 2005; 29: 334-339.
Why the obesity pandemic?
An OECD 2010 perspective
• “ The mass production of food over time has changed
•
•
•
•
both the quality and availability of food
Falling relative food prices contributed up to 40% of the
increase in BMI in the US 1976-1994….
Convenience also played a major role, in combination
with falling prices, with the spread and concentration of
fast food restaurants…..
The use of increasingly sophisticated marketing
techniques is naturally associated with an increase in the
supply of food….
These effects are consistent with the patterns observed
in the distribution of obesity among population groups,
with more vulnerable individuals and families and those
whose time available for meal preparation and cooking
has become more limited being more exposed to the
influence of supply-side changes.”
Economic development and falling food needs
US
Intakes
Kcals
3000
UK
Intakes
2000
Increasing
obesity
Energy needs
Car Use
Mechanical aids
1000
TV
Computers
Economic development and ageing
The keys to success in the food business
and in obesity and chronic disease (NCDs)
prevention
• Marketing
• Price
• Availability
The natural history of childhood overweight/obesity using IOTF cut-offs
in Australia over the last century and regional global increases
Global total now: obese 74 mil. +overwt. 287 mil.
50
% overweight + obese
40
Australia
e.g. US
45
40
Raw data
30
All data
35
e.g. S.Arabia
e.g. UK
30
% 25
20
20
15
10
10
e.g. Japan
e.g. India
South East Asia (1997-2002)
West Pacific (1993-2000)
5
0
1900
1920
1940
1960
Year
1980
2000
Norton K et al, Int J Ped Ob 2006
Americas (1988-2002)
Eastern Med (1992-2001)
Europe (1992-2003)
0
Recent surveys
Projected 2006
Projected 2010
Wang and Lobstein, IOTF, Int J Ped Ob 2006.
Functional Brain Maturation Curve implying that
protecting adolescents from marketing is a critical
issue: marketing bans should apply up to 18 yrs of age
"Blood oxygen level–
dependent time
courses were generated
for 160 regions of
interest derived from a
series of meta-analyses
of task-related fMRI
studies that cover
much of the brain"
Dosenbach et al . Prediction of individual brain maturity using
fMRI. Science 2010;329: 1358-1361
Snack Foods are everywhere








Car washes
Book stores
Hardware stores (Home Depot)
Gas stations
Office buildings (vending machines)
Health clubs/gyms
Video stores
Car repair shops
End of
aisle
display
increases
sales 2-5
fold
1. Major parallels between addiction characteristics and conditioned
desire for hyperpalatable foods: food cues and consumption can
activate neurocircuitary (meso-cortical- limbic pathways) implicated
with addiction
2. Humans: reduced dopamine receptor availability/striatal dysfuntion
associated with obesity and weight gain: craving, persistent eating
despite consequences and uncontrolled consumption seen in both.
3. Genetic and environmnetal factors well accepted in addiction; also
in obesity
4. Blaming the individual first was immediate reaction to addiction as
in obesity; individual treatment limits blame + both cost-effective.
5. Policy initatives crucial to reducting burden of both addiction and
obesity
Addiction.2011; 106: 1208-1212
Obesity: parallels with addiction
• Personal responsibility always applied by public,
politicians and the relevant industries to:
a) Tobacco b) Alcohol c) Obesity
• Policy developments delayed by emphasis on
individual strategies for treatment + prevention
• Refocus on addictive properties leads to bold
public health measures:
a) Taxation b) limiting access c) banning marketing
Results: dramatic improvement to personal
efforts when add policies
- but only if properly implemented
Adapted from Gearhardt et al Addiction 2011;106 1208-1212
Diabetes prevention on a
national scale in Finland
 Incidence of DM
Normal GT:
2.0 % men, 1.2% women
Impaired FG: 13.5% men, 7.4% women
Impaired GT: 16.1% men, 11.3% women
 Incidence DM in obese without diabetes:
2.5-4.9 %
weight loss: 28% less diabetes
>5%
weight loss: 69% less diabetes
But
>2.5%
weight gain: 10% more diabetes
Saaristo et al . One year follow–up of the Finnish National Diabetes
Prevention Program (FIN-D2D). Diabetes Care 2010;33: 2146-2151
Local opportunities: obvious immediate needs
• Baby friendly hospitals?
• Breast feeding duration? Facilities?
• Nursery school policies for food and physical
activity?
• Food control in all schools? School
water/banned soft drinks?
• Measurement of children in school - policies?
Parental notification? Advice
• School policies on education: Academies?
Importance of parental pressure groups
• Focus on young girls and pre-pregnancy
weight?
Local opportunities: immediate needs
• Food in all local government funded
facilities exclusively high nutritional
standards? Offices, police, colleges?
• State of obesity of publicly funded
workers? Work- site initiatives.
• Diabetes prevention policies? Evidence
of benefit overwhelming
• GP groups - who specialises in obesity?
Clear evidence of benefit. Links to
weight control groups?
• Retirees: activity and dietary policies?
Organisational strategy
• Public health leaders : bring in to the centre of
strategy on Council business as in pre-1984.
• Think radically but move progressively.
• Watch conflicts of interest: brilliant countermarketing and policy manipulation by industrial
interests
• Use public meetings and local media to change
cultural attitudes - see smoking, seat belt, school
food policies.
• Industry brainwashing : Remember parents and
young people already persuaded to focus on
"choice" and 24hr availability of food, drinks and
entertainment
Local opportunities: progressive strategies:
make Cornwall the county of new initiatives
• Physical activity: progressive policies on restricted car use
with pedestrian and cycle promotion.
• Council devised progressive reduction in salt, sugar and fat in
standard recipes of canteens, restaurants
• Take Bloomberg New York approach to food for the public Calorie labelling of menus; make a feature of Cornish quality
products only if nutritionally comply
• Move towards Finnish approach to vegetables in cost of main
meals and salad bar "free"
• Local bakers - salt reduction
• Restricting vending machines, fast food outlet density
• Council devised and organised walking groups for huge health
burden of middle aged and elderly patients identified by GPs