Obesity - a major public health challenge

1. 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

2. Diabetes prevalence % 30 South Asian 20 10 European 0 0.8 0.9 1 Waist / hip ratio Central obesity and insulin resistance: South Asian susceptibility: probably applies to Middle East & Mexico McKeigue et al. Lancet, 1991, 337: 382

3. Smoking High blood pressure Overweight & obesity High cholesterol Alcohol use Physical inactivity Low fruit & veg. intake Illicit drug use Unsafe sex Iron deficiency anemia The top risk factors underlying the disease burdenof high income countries (all preventable) -2 0 2 4 6 8 10 Attributable disease burden (% regional DALYs; total 149 million) WHO / World Bank. Global Burden of Disease. Lopez et al., 2006.

4. 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

5. 1453 1049 654 240 38 -164 -366 2004 2014 2024 2034 2044 Predicted diabetes health care costs in England with different prevention strategies Annual costs £ Millions NoAction Childhood prevention6-10 yrs BMI All ages Cap at 30;50% effective 20+yrs: BMI -4 units Foresight Report on Obesity.2007. http://www.foresight.gov.uk/Obesity/14.pdf

6. The costs of different degrees of excess weight in the USA Arterburn D et al. Impact of morbid obesity on medical expenditure in adults. IJO, 2005; 29: 334-339.

7. 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.”

8. 3000 2000 1000 Economic development and falling food needs US Intakes Kcals Increasing obesity UK Intakes Energy needs Car Use Mechanical aids TV Computers Economic development and ageing

9. The keys to success in the food business and in obesity and chronic disease (NCDs) prevention • Marketing • Price • Availability

10. 40 Raw data 30 All data % % overweight + obese 20 e.g. Japan 10 e.g. India 0 1900 1900 1920 1940 1960 1980 2000 Year 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. Australia e.g. US e.g. UK e.g. S.Arabia Norton K et al, Int J Ped Ob 2006 Wang and Lobstein, IOTF, Int J Ped Ob 2006.

12. 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

13. 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

14. End of aisle display increases sales 2-5 fold

15. 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 • Humans: reduced dopamine receptor availability/striatal dysfuntion associated with obesity and weight gain: craving, persistent eating despite consequences and uncontrolled consumption seen in both. • Genetic and environmnetal factors well accepted in addiction; also in obesity • Blaming the individual first was immediate reaction to addiction as in obesity; individual treatment limits blame + both cost-effective. • Policy initatives crucial to reducting burden of both addiction and obesity Addiction.2011; 106: 1208-1212

16. 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: • Taxation b) limiting access c) banning marketingResults: dramatic improvement to personalefforts when add policies - but only if properly implemented Adapted from Gearhardt et al Addiction 2011;106 1208-1212

17. 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

18. 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?

19. 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?

20. 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 counter-marketing 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

21. 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