Experts still searching for solutions to obesity crisis

Featured article in the Fall 2015 Issue of Nutrition Close-Up; written by David Madsen

Overweight and obesity (OW/OB) now present a major global health problem and challenge–a “pandemic.”^1-4  The CDC estimates that 35% of adults in the U.S. are OW or OB,⁵ while 17% of children are affected.⁶ The global picture is similar: 37% for adults (mean, both genders); for children and 13% and 23% in developing and developed countries, respectively.²

The problem, of course, has multiple causes and multiple consequences, all of them negative. The health burdens are alarming: in 2010 OW/OB was estimated to have caused 3.4 million deaths globally, 3.9% years of life lost, and 3.8% of Disability-Adjusted-Life-Years (DALY – a measure of quality of life).²  The financial costs are staggering;  the estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars.⁵

The causes of OW/OB continue to be heatedly debated at all levels and in many ways. Some of the more prominent proposed and purported causes include: sugared foods and beverages, processed foods, sedentary lifestyles, altered intestinal flora, environmental toxins, genes, caloric imbalance, and declining rates of breastfeeding (“breastfeeding protects against obesity,” some say). The sum total of these may be referred to as our “obesogenic environment.”⁷

• Those in the field have called for urgent action and leadership, expressing such notable concerns as: “There are no exemplary populations in which the obesity epidemic has been reversed by public health measures.”³

• “Little progress has been made beyond acknowledging that there is a worldwide problem with far-reaching consequences for health and wellbeing.”⁸

This all sounds dire. What is being done in response, and to what extent?  International organizations have issued recommendations for policies to turn things around.

• The World Health Organization has published a Global Action Plan.⁴
• Lobstein et al.⁹ recommend policies to promote healthy growth and household nutrition security, more physical activity, consumption of nutrient-dense foods, and to restrict marketing to children.

 

 

• Swinburn et al.¹⁰ proposed that an improved food environment requires strengthened “accountability systems.” The authors go on further to suggest, “several non-regulatory mechanisms (e.g., quasiregulatory, political, market-based, and public and private communications) are underutilized; these mechanisms will help strength the difficult step of holding private sector to account for performance.
• Gortmaker et al.¹ assess that “the empirical evidence base for effective interventions is limited but growing.” The authors call for involvement of all sectors: government, international organizations, private sector, and civil society. Their  proposed policies include improving the food environment and the built environment, securing more funds for prevention and monitoring, and embedding actions into both health and non-health sectors.

In order to implement policies, what specific programs should be implemented at the local and national levels?  Mayne et al.¹¹ reviewed  more than 1,000 abstracts and 115 papers, arriving at 37 papers as part of their systematic review of studies of the impact of policy and built environment changes on obesity-related outcomes in what they termed “natural experiments.”  Measures included nutrition and diet (intake), physical activity, and effects on BMI or weight.

Results were instructive. For nutrition-related outcomes, improvements in the food environment were positive (bans/restrictions on certain foods; altering purchase/payment rules for food stamps). On the other hand, menu labeling with health information, or new supermarkets, were ineffective.  Regarding physical activity, positive impacts were seen with improvements in transportation infrastructure (promotion of cycling, walking). Only one of three studies that directly measured impact on BMI or weight produced a positive effect.

Mayne et al.¹¹ devoted ample discussion to evaluate the quality of reviewed research and how it might be improved. The study designs varied greatly in strength and quality. One serious limitation of most of the studies is that they measured process outcomes, but did not assess ultimate effects on obesity or BMI.

The above deal with higher-level policies.  There are numerous proposals for preventing or treating OW/OB: -“wonder” products, elaborate diet plans, physical activity promotions, and environmental modifications among them. Some are undoubtedly ineffective, while others may be worthwhile, if we’re willing to make the effort.  Roberto et al.¹² note that while personal responsibility is basic and critical in the current setting, it is difficult and wearying to fight an unhelpful (obesogenic) environment.

I am heartened by many examples of local and community efforts to address OW/OB. Of great interest is a recent report¹³ on an elementary school district in California that has shown a 5% decrease in overweight children since 2010. A collaboration of policy makers, parents and educators devised a comprehensive health and wellness program to increase physical activity (throughout the school day) and add more fruits and vegetables to lunch menus, leading to tangible results that went well beyond school hours.

A final thought is that in addition to assuming more personal responsibility for our health, and participating in well-coordinated community efforts such as they did in California, we should also become involved in broader policy efforts at the local, state and national levels by communicating and counseling elected policy makers.

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 David Madsen, PhD, has worked in the nutrition, food and pharmaceutical industries for more than three decades, and occasionally writes on topics of interest in those areas.

 

References

1. Gortmaker SL, Swinburn BA, Levy D, Carter R, Mabry PL, Finegood DT, Huang T, Marsh T, Moodie ML.  Changing the future of obesity: science, policy, and action.  Lancet. 2011;378:838-47.

2. Ng M, Fleming T, Robinson M et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766-81.
3. Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011; 378: 804–14.
4. WHO. Global Action Plan for the Prevention and Control of Noncommunicable diseases 2013–2020. Geneva: World Health Organization, 2013.
5. CDCa. http://www.cdc.gov/obesity/data/adult.html
6. CDCb. http://www.cdc.gov/obesity/data/childhood.html
7. Lake A, Townshend T.  Obesogenic environments: exploring the built and food environments.  J R Soc Promot Health. 2006;126:262-7.
8. Kleinert S, Horton R. Rethinking and reframing obesity. Lancet. 2015;385:2326-8.
9. Lobstein T, Jackson-Leach R, Moodie ML, Hall KD, Gortmaker SL, Swinburn BA, James WP, Wang Y, McPherson K. Child and adolescent obesity: part of a bigger picture. Lancet. 2015;385:2510-20.
10. Swinburn, B. Kraak V, Rutter H, et al.  Strengthening of accountability systems to create healthy food environments and reduce global obesity.  Lancet. 2015;385:2534-45.
11. Mayne SL, Auchincloss AH, Michael YL. Impact of policy and built environment changes on obesity-related outcomes: a systematic review of naturally occurring experiments. Obes Rev. 2015;16:362-75.
12. Roberto CA, Swinburn B, Hawkes C et al. Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking.  Lancet. 2015; 385:2400-9.
13. http://www.utsandiego.com/news/2015/may/06/childhood-obesity-rates-down-in-chula-vista/

 

Key Messages

• An estimated 35% of adults and 17% of children in the U.S. are overweight or obese, which accounted for obesity-related medical costs of approximately $147 billion in just one year.
• A thorough review of recently enacted programs designed to reverse obesity trends showed that restricting or banning certain foods can be effective; while adding health information to menus, or opening a new supermarket in the community, proved ineffective.
• Assuming personal responsibility for weight management is basic and critical, but difficult and challenging in America where high-calorie foods are widely available and heavily marketed.