Presentation to the Institute of Population Health
2 June 2004
Mark S. Kaplan, DrPH
Visiting Professor and Fulbright Scholar
University of Ottawa

“Gluttony is the mother of lust, the nourishment of evil thoughts, the laziness in fasting, obstacle to asceticism, terror to moral purpose, the imagining of food, sketcher of seasonings, unrestrained colt, unbridled frenzy, receptacle of disease, envy of health, obstruction of the (bodily) passages, groaning of the bowels, the extreme of outrages, confederate of lust, pollution of the intellect, weakness of the body, difficult sleep, gloomy death.
-Fourth-century Desert Father, Evagrius of Pontus (In F. Prose, Gluttony: The Seven Deadly Sins, 2003)

“Obesity is now on everyone’s plate”
-Brian Vastag (JAMA.2004;291:1186)
“Fat is the new tobacco”
-Heart and Stroke Foundation of Canada (2004)

Obesity as a global health problem
 Epidemic of overweight and obesity affects many developed and developing countries around the world, according to the World Health Organization
 In many countries obesity has doubled or tripled over the past decades
 Over 300 million obese adults worldwide
 Over 115 million people suffer from obesity-related problems in developing countries
WHO “A global response to a global problem: the epidemic of over nutrition.”Bulletin of the World Health
Organization2002;80:952-958

Obesity as a global health problem
 In developing countries, obesity-related illness is replacing undernutrition and infection as main cause of death
 Acculturation to the Western lifestyle is associated with an increased prevalence of obesity
 Obesity harms health and costs as much as smoking
 Obesity is associated with similar comorbidity as poverty and smoking
WHO “A global response to a global problem: the epidemic of over nutrition.” Bull of the World Health
Organization2002;80:952-958

Obesity as a global health problem
International Obesity Task Force

 BMI = weight in kilograms divided by the square of height in meters
– Underweight < 20.0
– Normal weight 20.0 to 24.9
– Overweight 25.0 to 29.9
– Obese => 30.0
WHO Obesity: preventing and managing the global epidemic.” Report of a WHO consultation on obesity. Geneva: WHO,2000.
Canadian Guideline for Body Weight Classification in Adults. Health Canada, 2003. M. Hooper (personal communication)

Obesity in North America
 North American obesity rate soared in the 1990s
 1/3 of U.S. adults were obese by the end of the decade
 Between 1991 and 2000, obesity rate increased by more than 60% in the US
 In Canada, the prevalence of obesity more than doubled between 1985 and 1998
 Obesity may be responsible for more than 200,000 deaths in US and Canada per year
Ogden et al., “Epidemiologic trends in overweight and obesity.”Endocrinol Metab Clin N Am2003;32:741-760.
Katzmarzyk, “The Canadian obesity epidemic, 1985-1998.” CMAJ2002;166:1039-1040.

Obesity as a global health problem

Obesity as a global health problem

1985
Prevalence of Obesity Among U.S. Adults
1990 1994
1996 1998 2002
No Data <10% 10%–14% 15%–19% 20%–24% >=25%
CDC. “Obesity trends among U.S. adults between 1985 and 2002.”

1985
Prevalence of Obesity Among Canadian Adults
1990 1994
1996 1998
< 10%
10% - 14%
Katzmarzyk, “The Canadian obesity epidemic, 1985-1998.” CMAJ2002;166:1039-1040
15% - <20%
2000
>= 20%

Obesity in Canada
8
6
4
2
0
16
14
12
10
5.6
9.2
13.4
12.7
14.8
14.9
Health promotion survey,
1985
Health promotion survey,
1990
National
Population
Health
Survey
1994-1995
National
Population
Health
Survey
1996-1997
National
Population
Health
Survey
1998-1999
Canadian
Community
Health
Survey
2000-2001
Katzmarzyk, “The Canadian obesity epidemic, 1985-1998.” CMAJ2002;166:1039-1040.
Canadian Institute for Health Information, 2004.

Socioeconomic burden of obesity
Country
U.S.
Year BMI Study Estimated direct cost
1998 => 25 Finkelstein $92.6 billion
Total health expenditure
9.1%
Canada 1997 => 27 Birmingham $1.8 billion 2.4%
Birmingham et al., “The cost of obesity in Canada.” CMAJ1999;160:483-488.
Finkelstein et al.,”National spending attributable to overweight and obesity” Health Aff2003;W3:219-226.

Socioeconomic burden of obesity
 The soaring problem of obesity has implications for North American health care systems.
 US annual medical costs of obese individuals is
37% higher than normal-weight people.
 US Medicare and Medicaid cover half of the obesity-related health care costs
 Obesity-related conditions threaten the long-term financial sustainability of national health care systems

Relative risk of health problems associated with obesity
Greatly increased
(Relative risk>3)
 Diabetes
 Gall bladder disease
 Hypertension
 Dyslipidaemia
 Insulin resistance
 Breathlessness
 Sleep apnoea
Moderately increased
(Relative risk 2-3)
 Coronary heart disease
 Osteoarthritis
(knees)
 Hyperuricaemia and gout
Slightly increased
(Relative risk 1-2)
 Cancer
 Reproductive hormone abnormalities
 Polycystic ovary syndrome
 Impaired fertility
 Lowback pain
 Increase anaesthetic risk
 Foetal defects
International Obesity Task Force

Chronic conditions across BMI groups
Age-adjusted prevalence (%) of chronic diseases for older (65+) women and men by BMI categories, 1996
BMI
Women
<18.5
18.5 to <25 25 to <30 >= 30 <18.5
Men
18.5 to <25 25 to <30 >= 30
CVD
Diabetes
Hypertension
Arthritis
24.9
3.3
32.2*
21.1
4.5
41.9
23.8
11.1***
51.2***
47.1
48.4
58.3***
Any disease 86.6
85.8
92.3***
Mean number of diseases 2.9
2.7
2.9*
* P<0.05, **P<0.01, *** P<0.001 for differences with the normal-weight group
28.7***
17.4***
64.7***
70.1***
94.8***
3.5***
38.2
15.0
36.3
22.3
84.3
3.0
30.6
8.6
37.7
32.8
85.7
2.8
31.4
12.3**
32.0
21.2***
47.6*** 57.1***
40.3*** 49.1***
86.8
2.9
93.3***
3.1***
Yan et al., “BMI and health related quality of life in adults 65 years and older.” Obes Res2004;12:69-76

Obesity among older adults
 Prevalence of obesity among elderly persons in industrialized countries ranges from 15% - 20%
 In the US, obesity rates were 14.9% in 1996 and
18.2% in 2000 (BRFSS)
 In Canada, rates were 12.8% in 1996/97 and
17.7% in 1998/99 (NPHS)
Yan et al., “BMI and health related quality of life in adults 65 years and older.” Obes Res2004;12:69-76
Flegal et al., “prevalence and trends in obesity among US adults, 1999-2000.” JAMA2002;288:1723-1727
Macdonald et al.,”Obesity in Canada: e descriptive analysis.” CMAJ1997;157:S3-S9.

Prevalence (%) of Obesity Among Older Adults by Provinces C A N A D A
BC
9.9
BC
9.9
AB AB
Prevalence (%) of Obesity Among Older Adults by Provinces
NPHS 1996
NB
12.4
PEI
8.7
PEI
26.1

Prevalence of underweight, normal weight, overweight and obesity
38.2%
Men
41.4%
44.6%
Wom en
34.1%
11.3%
12.4%
13.2%
4.8%
Underweight Normal weight Overweight Obes e
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-1030.

6.9%
Prevalence of underweight, normal weight, overweight and obesity
Underweight Normal weight Overweight
50.5%
Obese
34.6%
41.8%
39.8%
41.7%
39.4%
40.3%
26.8%
17.4%
16.6%
13.7%
12.3%
7.9%
5.3% 4.8%
65-69 70-74 75-79 80+
Age
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-1030.

Prevalence of underweight, normal weight, overweight and obesity
Normal Weight Overweight Obese Underweight
40.0%
42.9%
37.1%
39.7%
46.4%
34.3%
34.0% 42.3%
16.6%
6.7%
10.4%
10.9%
3.5%
12.0%
6.2%
Active Inactive Active Inactive
Men Women
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-30.
16.9%

Demographic risk factors for men
Overweight Obese
 Young old (65-69)
(OR=4.12, p<.001)
 Married
(OR=1.28,p<.001)
 Eur/US/Aust born
(OR=1.20,p<.01)
 Residing in Atlantic
Provinces
(OR=1.86,p<.001)
 Young old (65-69)
(OR=19.35, p<.001)
 Less educated
(OR=2.17, p<.001)
 Residing in Atlantic provinces
(OR=2.57, p<.001)
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-1030.

Demographic risk factors for women
Overweight Obese
 Young old (65-69) (OR=2.13, p<.001)
 Young old (65-69) p<.001)
(OR=7.96,
 Less educated
(OR=1.29, p<.001)
 Less educated
(OR=1.48, p<.001)
 Married
(OR=1.23, p<.001)
 Unmarried
(OR=1.31, p<.001)
 Canadian born
(OR=2.80, p<.001)
 Eur/US/Aust born
(OR=1.51, p<.001)
 Residing in Que, Prairie, BC
(ORs=1.30, 1.16, 1.09, p<.001)
 Residing in Atlantic provinces
(OR=1.57, p<.001)
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-1030.

Health risk factors for men
Overweight
 Non or former smoker
(OR=1.60, p<.001)
 Physical inactivity
(OR=1.43, p<.001)
 Functional limitations
(OR=1.22, p<.01)
Obese
 Abstainer
(OR=2.04, p<.001)
 Chronic condition
(OR=1.60, p<.01)
 Physical inactivity
(OR=2.49, p<.001)
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-1030.

Health risk factors for women


Overweight
Non or former smoker
(OR=1.65, p<.001)
Abstainer, infrequent
(OR=1.29 & 1.26, p<.001)


Obese
Non or former smoker
(OR=12.77, p<.001)
Abstainer, infrequent
(ORs=2.06 & 2.59, p<.001)
 Functional limitations
(OR=1.29, p<.001)
 Functional limitations
(OR=1.28, p<.01)
 Chronic condition
(OR=1.75, p<.001)
 Chronic condition
(OR=1.93, p<.001)
 Physical inactivity
(OR=1.27, p<.001)
 Physical inactivity
(OR=1.85, p<.001)
 Poor self-rated health
(OR=1.02, p<.001)
 Poor self-rated health
(OR=1.29, p<.01)
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-1030.

Psychosocial risk factors
Obese Men
 High social support
(OR=1.49, p<.001)
Overweight and Obese women
 Lower social support
(OR=1.21, p<.001 & OR=1.50, p<.001)
 Psychological distress
(OR=1.22, p<.001 & OR=1.28, p<.001)
Kaplan et al., “Prevalence and correlates of overweight and obesity among older adults.” JGeronMedSci2003;58A:1018-1030.

Limitations in studying late life obesity
 Validity of self-reported h/w - Older adults tend to overestimate their height and underestimate their weight
 BMI may underestimate body fat in persons who have lost muscle mass
 Selective survival - Obesity declined with age from
16.6% to 5.3% across the 25-year age range.
Kuczmarski et al., “Effects of age on validity of self-reported height, weight, and body mass index.” JAmDietAssoc2001;101:28-34
Visscher et al., “The public health impact of obesity.” AnnRevPublHealth2001;22:355-375.

Prevalence of physical inactivity among older adults
Infrequent Frequent
57.6%
50.4%
49.6%
42.4%
Men Women
Gender
Kaplan et al., “Demographic & Psychosocial Correlates of Physical Activity in Late Life.” AJPM2001;21:306-12.

Prevalence of physical inactivity among older adults
52.9%
47.1%
Infrequent
57%
43%
Frequent
60.9%
40.7%
59.3%
39.1%
< secondary Secondary Some postsecondary postsecondary
Kaplan et al., “Demographic & Psychosocial Correlates of Physical Activity in Late Life.” AJPM2001;21:306-12.

Prevalence of physical inactivity among older adults
50.4%
Infrequent
49.6%
Frequent
55.4%
44.6%
Not married Married
Kaplan et al., “Demographic & Psychosocial Correlates of Physical Activity in Late Life.” AJPM2001;21:306-12.

Other factors associated with physical inactivity
 One or more chronic conditions
 Lower levels of social support
 Higher levels of psychological distress
 Higher BMIs
Kaplan et al., “Demographic & Psychosocial Correlates of Physical Activity in Late Life.” AJPM2001;21:306-12.

Weight loss and physical activity
 Reduced need for medications for obesity-related conditions
 Small weight loss can improve functional health and quality of life
 Physical activity decrease mortality risk among obese older adults
 Exercise help in maintaining weight loss
Rossner, “Obesity in the elderly – a future matter of concern?” ObesityRev2001;2:183-188.
Jensen et al., “Obesity in older persons.” JAmDietAssoc1998;98:1308-1311.

Strategies to prevent obesity
National Government
 Setting of national priorities
 Tax on foods with low nutritional value
 Subsidies for healthy foods
 Funding of research to prevent or treat obesity
Hitchcok et al., “Management of overweight and obese adults.” BMJ2002;325:757-729
Canadian Institute for Health Information 2004

Strategies to prevent obesity
Food industry
 Labels identifying ingredients and nutrient content
 Inclusion of healthy food choices on restaurant menus
 Restrictions on advertisements for low nutritional values foods
Hitchcok et al., “Management of overweight and obese adults.” BMJ2002;325:757-729
Canadian Institute for Health Information 2004

Strategies to prevent obesity
Healthcare participation
 Reimbursement for intervention for health promotion and lifestyle change
 Training and guideline for health professionals
 Identification of high risk groups and individuals such as low income
Hitchcok et al., “Management of overweight and obese adults.” BMJ2002;325:757-729
Canadian Institute for Health Information 2004

Strategies to prevent obesity
Community effort
 Safer venues for physical activity such as walking
 Local education campaigns and events promoting physical activity
 Bring multiple institutions, systems and organizations together toward decreasing obesity
Hitchcok et al., “Management of overweight and obese adults.” BMJ2002;325:757-729
Canadian Institute for Health Information 2004

International Obesity Task Force
International Obesity Task Force Causal Web

Further research
 Need for additional comprehensive surveillance data on the dietary habits of Canadians across the lifespan (lifecourse perspective)
 More research targeting baby boomers
 Strengthening body weight, physical activity and diet measurement
 Longitudinal (vs cross-sectional) analysis