obesity and public health

Weighty Matters:Public Health Aspects of

the Obesity Epidemic

Martin T Donohoe

Average height and weight of Average height and weight of AmericansAmericans

Men: 5’9”, 191 lbsMen: 5’9”, 191 lbs

Women: 5’4”, 164 lbsWomen: 5’4”, 164 lbs

DefinitionsDefinitions

BMI (Body Mass Index) =BMI (Body Mass Index) =

weight (kg)/height squared weight (kg)/height squared (meters squared)(meters squared)

Overweight: BMI Overweight: BMI ≥ 25≥ 25

Obese: BMI Obese: BMI ≥ 30≥ 30

ObesityObesity

1950: ¼ of Americans 1950: ¼ of Americans overweight (BMI overweight (BMI > 25)> 25)

2005: 60% overweight, 2005: 60% overweight, 24% obese (BMI > 30)24% obese (BMI > 30)

20-25% of American 20-25% of American children are overweight or children are overweight or obeseobese

Causes of and Contributors Causes of and Contributors to Obesityto Obesity

Poor dietPoor diet Inadequate exerciseInadequate exercise Inadequate sleepInadequate sleep Car culture – less Car culture – less

walking/bicyclingwalking/bicycling Excessive television watchingExcessive television watching


Genetic factors (may be Genetic factors (may be associated with up to 75% of associated with up to 75% of cases)cases)

Hormones and neurochemicalsHormones and neurochemicals Viruses and bacteriaViruses and bacteria Sugar substitutes:Sugar substitutes:

May increase appetite for sweet May increase appetite for sweet foods and promote overeatingfoods and promote overeating


Medications: e.g., OCPs, Medications: e.g., OCPs, antidepressants, antidepressants, antipsychotics, etc.antipsychotics, etc.

Shorter or no breastfeedingShorter or no breastfeeding Energy in > energy outEnergy in > energy out

ObesityObesity

More common among lower More common among lower income individuals, rural income individuals, rural Americans, African-AmericansAmericans, African-Americans Cultural explanations, food Cultural explanations, food

insecurity, fast food insecurity, fast food restaurantsrestaurants

More prevalent in adults with More prevalent in adults with sensory, physical and mental sensory, physical and mental health conditionshealth conditions

Obesity PreventionObesity Prevention

Ideal diet: 45-65% of calories from Ideal diet: 45-65% of calories from CHOs, 20-35% from fat, and 10-35% CHOs, 20-35% from fat, and 10-35% from proteinfrom protein

Ideal exercise = 1 hour per dayIdeal exercise = 1 hour per day 30% of Americans get regular exercise, 30% of Americans get regular exercise,

40% get none40% get none Exercise associated with education, Exercise associated with education,

income, being married (single status income, being married (single status associated with strengthening exercises, associated with strengthening exercises, primarily in men), West Coast, suburbsprimarily in men), West Coast, suburbs

ObesityObesity

Responsible for 300,000 US Responsible for 300,000 US deaths/yeardeaths/yearvs. 450,000/year from smoking vs. 450,000/year from smoking (400,000 direct, 50,000 (400,000 direct, 50,000 environmental tobacco smoke)environmental tobacco smoke)

Decreases in life expectancy and Decreases in life expectancy and increase in early mortality increase in early mortality similar to that seen with similar to that seen with smokingsmoking

Sequelae of ObesitySequelae of Obesity

Heart diseaseHeart disease Certain cancers (e.g., breast, Certain cancers (e.g., breast,

uterine, cervical, colon, esophageal)uterine, cervical, colon, esophageal) 14% of all deaths from cancer in men, 14% of all deaths from cancer in men,

20% in women20% in women Type II Diabetes: 1998 – 4.9%; 2000 Type II Diabetes: 1998 – 4.9%; 2000

– 6.5%– 6.5% Epidemic of type II diabetes in childrenEpidemic of type II diabetes in children

GallstonesGallstones


Sleep apneaSleep apnea Pseudotumor cerebriPseudotumor cerebri GERDGERD Worsening of asthmaWorsening of asthma


Weaker bonesWeaker bones Depression and suicideDepression and suicide Decreased fertilityDecreased fertility Increased risk of diabetes, Increased risk of diabetes,

obesity, and multiple birth obesity, and multiple birth defects among offspringdefects among offspring


Decreases in social and Decreases in social and physical functioningphysical functioning

Decrease in some health-Decrease in some health-related quality of life (QOL) related quality of life (QOL) measuresmeasuresSeverely obese children and Severely obese children and adolescents have QOL adolescents have QOL similar to those with cancersimilar to those with cancer


Barrier to preventive careBarrier to preventive caree.g., mammograms and Pap e.g., mammograms and Pap smears, despite higher smears, despite higher rates of breast and cervical rates of breast and cervical cancer)cancer)

20% more likely to have 20% more likely to have false-positive mammogramsfalse-positive mammograms


Marginalization and discriminationMarginalization and discrimination

Lower life expectancyLower life expectancy

More strongly associated with More strongly associated with chronic medical conditions and chronic medical conditions and reduced health-related quality of reduced health-related quality of life than smoking, heavy drinking or life than smoking, heavy drinking or povertypoverty

Economic Consequences of Economic Consequences of ObesityObesity

Obesity-attributable national Obesity-attributable national medical expenditures $75 medical expenditures $75 billion (2003)billion (2003)Ranged from $87 million in Ranged from $87 million in Wyoming to 7.7 billion in Wyoming to 7.7 billion in CaliforniaCalifornia

Costs will rise as population Costs will rise as population agesages


Half of costs covered by Medicare, Half of costs covered by Medicare, which now classifies obesity as a which now classifies obesity as a diseasedisease

Increased costs of care due to:Increased costs of care due to: Prescription drugsPrescription drugs More complications from surgeryMore complications from surgery Increased lengths of stayIncreased lengths of stay Increased use of health care Increased use of health care

services during pregnancyservices during pregnancy


Costs to business:Costs to business:Lost productivityLost productivityAbsencesAbsencesUnderperformanceUnderperformanceHigher insurance premiumsHigher insurance premiums

Nutritional Changes and Nutritional Changes and ObesityObesity

AgricultureAgriculture 10,000 years ago10,000 years ago Benefits: community, local food Benefits: community, local food

productionproduction Adverse consequences: class-based, Adverse consequences: class-based,

hierarchical societies; large-scale hierarchical societies; large-scale warfare; sedentary lifestyles; warfare; sedentary lifestyles; dramatically decreased crop and game dramatically decreased crop and game diversity; corporate control of diversity; corporate control of agriculture and povertyagriculture and poverty

Nutritional Changes and Nutritional Changes and ObesityObesity

Increases in portion sizeIncreases in portion size Spread of fast food franchises since Spread of fast food franchises since

the mid-20the mid-20thth Century Century Use of artificial sweeteners and Use of artificial sweeteners and

trans fatty acids in processed foodstrans fatty acids in processed foods High levels of consumption of sugar- High levels of consumption of sugar-

and caffeine-containing sodas and caffeine-containing sodas

Fast Foods and Fast Foods and SupersizingSupersizing

Portion sizes and restaurant dinner Portion sizes and restaurant dinner plates have increased over last half plates have increased over last half centurycentury

Americans spend about one-half of Americans spend about one-half of their food budgets and consume their food budgets and consume about one-third of their calories about one-third of their calories outside the homeoutside the home

Fast food spending increased 18-fold Fast food spending increased 18-fold since 1970since 1970


U.S. food industry produces 3800 U.S. food industry produces 3800 cal/person/daycal/person/day Average caloric need only 2500 Average caloric need only 2500

calories/person/daycalories/person/day Fast foods 10% of total caloric Fast foods 10% of total caloric

intakeintake On any given day, 8% of On any given day, 8% of

Americans eat at McDonaldsAmericans eat at McDonalds


Typical American eats 30 pounds of Typical American eats 30 pounds of French fries per yearFrench fries per year

McDonalds’ fries in 1955: 2.4 oz. / 210 McDonalds’ fries in 1955: 2.4 oz. / 210 caloriescalories Today 7 oz. / 610 caloriesToday 7 oz. / 610 calories

1916: typical bottle of Coca Cola = 6.5 oz. 1916: typical bottle of Coca Cola = 6.5 oz. / 79 calories/ 79 calories Today 16 oz. / 194 caloriesToday 16 oz. / 194 calories

Some mega-sized fast food burgers on the Some mega-sized fast food burgers on the market today contain > 1000 caloriesmarket today contain > 1000 calories

Fast Foods and the Inner Fast Foods and the Inner Cities / Poor CommunitiesCities / Poor Communities

Fast food outlets target poor Fast food outlets target poor inner city communitiesinner city communities

Meals inexpensive and Meals inexpensive and convenientconvenient Helps consumers working two Helps consumers working two

jobs, raising children solo or jobs, raising children solo or lacking inadequate kitchen lacking inadequate kitchen facilitiesfacilities

Fast Foods and ChildrenFast Foods and Children

Fast food industry directly targets Fast food industry directly targets childrenchildren Produces 20% of Saturday morning Produces 20% of Saturday morning

televisiontelevision Offers prizes and inducements based on Offers prizes and inducements based on

characters which appeal to youngsters, characters which appeal to youngsters, often in collusion with motion picture often in collusion with motion picture industryindustry

Fast food restaurants clustered around Fast food restaurants clustered around schoolsschools

Fast Foods and HospitalsFast Foods and Hospitals

Some US hospitals have regional Some US hospitals have regional and national fast food franchises and national fast food franchises located on the grounds of their located on the grounds of their main medical centersmain medical centersSends the wrong message to Sends the wrong message to

patients and their families patients and their families about optimal nutritionabout optimal nutrition

Sodas and Artificial Sodas and Artificial SweetenersSweeteners

High fructose corn syrup - artificial High fructose corn syrup - artificial sweetener added to many products, sweetener added to many products, including sodas and fruit drinksincluding sodas and fruit drinks 1,000+% increase in consumption over 1,000+% increase in consumption over

last few decadeslast few decades Consumption of fast and junk foods Consumption of fast and junk foods

begins early in lifebegins early in life 3-10% of US infants and toddlers eat 3-10% of US infants and toddlers eat

candy dailycandy daily 4-23 consume sweetened soda beverages4-23 consume sweetened soda beverages

SodasSodas

Soft drinks account for 20-24% of Soft drinks account for 20-24% of calories for 2- to 19-year-oldscalories for 2- to 19-year-olds associated with tooth decay and associated with tooth decay and

decreased consumption of fruits and decreased consumption of fruits and vegetablesvegetables

Majority of adults drink soda dailyMajority of adults drink soda daily Per capita soda consumption has more Per capita soda consumption has more

than doubled since 1970, from 24 gallons than doubled since 1970, from 24 gallons per year to 53 gallons per yearper year to 53 gallons per year

““Big Gulp” and “Super Big Gulp”Big Gulp” and “Super Big Gulp”

Sodas and CaffeineSodas and Caffeine

70% of soft drinks consumed in US 70% of soft drinks consumed in US contain caffeinecontain caffeine

Evidence suggests that the mood-Evidence suggests that the mood-altering and physical dependence-altering and physical dependence-producing effects of caffeine (a producing effects of caffeine (a central nervous system stimulant) central nervous system stimulant) have contributed to high rates of have contributed to high rates of consumption of caffeinated soft consumption of caffeinated soft drinksdrinks

Sodas and CaffeineSodas and Caffeine

Soda’s addictive properties Soda’s addictive properties put imbibers at risk of put imbibers at risk of caffeine-withdrawal caffeine-withdrawal symptoms such as headachesymptoms such as headache

Other caffeinated beverages: Other caffeinated beverages: e.g., Red Bulle.g., Red Bull

The National School Lunch The National School Lunch ProgramProgram

NSLP gives schools more than NSLP gives schools more than $6 billion/yr to offer low-cost $6 billion/yr to offer low-cost meals to more than 27 million meals to more than 27 million schoolchildren at 99,000 schools schoolchildren at 99,000 schools and childcare centersand childcare centers

Began in 1946Began in 1946 Administered by USDAAdministered by USDA


Conflicting missions of providing healthy Conflicting missions of providing healthy meals to children, regardless of income, meals to children, regardless of income, subsidizing agribusiness, and shoring up subsidizing agribusiness, and shoring up demand for beef and milkdemand for beef and milk

Meals emphasize meat and dairy products Meals emphasize meat and dairy products at the expense of fruit and vegetables, at the expense of fruit and vegetables, contain high levels of fat, and fail to meet contain high levels of fat, and fail to meet government’s own, inadequate, nutritional government’s own, inadequate, nutritional standards, which are out of date with standards, which are out of date with current science and have not been updated current science and have not been updated since the 1970ssince the 1970s


81% of schools serve lunches exceeding 81% of schools serve lunches exceeding 30% fat content, less than 45% serve 30% fat content, less than 45% serve cooked vegetables other than potatoes cooked vegetables other than potatoes (usually French-fried) and less than 10% (usually French-fried) and less than 10% serve legumesserve legumes

Overemphasis on milk products may Overemphasis on milk products may increase long-term the risk for breast increase long-term the risk for breast cancer, particularly if the milk comes cancer, particularly if the milk comes from cattle treated with rBGHfrom cattle treated with rBGH

Does not help to establish good Does not help to establish good nutritional habitsnutritional habits


Dramatic changes in NSLP Dramatic changes in NSLP unlikely to occur given political unlikely to occur given political clout wielded (and campaign clout wielded (and campaign dollars donated) by beef and dairy dollars donated) by beef and dairy industriesindustries

Former lobbyists in key positions Former lobbyists in key positions in the Department of Agriculturein the Department of Agriculture

Pouring Contracts and Soda Pouring Contracts and Soda ConsumptionConsumption

““Pouring rights” contracts with Pouring rights” contracts with soda manufacturerssoda manufacturers Signed by cash-strapped school Signed by cash-strapped school

districts to gain additional income to districts to gain additional income to compensate for cuts in educational compensate for cuts in educational and athletic programsand athletic programs

2002: 240 U.S. school districts had 2002: 240 U.S. school districts had exclusive contractsexclusive contracts

Conflicts with schools’ responsibility Conflicts with schools’ responsibility to teach proper nutritionto teach proper nutrition


In return for the placement of In return for the placement of soda machines on campus and soda machines on campus and exclusive marketing rights to the exclusive marketing rights to the districts’ children, companies districts’ children, companies sponsor sports and other sponsor sports and other extracurricular activitiesextracurricular activities Rooftop adsRooftop ads T-shirt suspension and free T-shirt suspension and free

speechspeech


Some school districts have banned Some school districts have banned the sale and marketing of soda (e.g., the sale and marketing of soda (e.g., Los Angeles)Los Angeles)

Federal law now requires school Federal law now requires school districts to have nutritional wellness districts to have nutritional wellness policies in placepolicies in place These will be strengthened over These will be strengthened over

the coming few years, and should the coming few years, and should help to curb pouring contractshelp to curb pouring contracts


2006: Coca-Cola, Pepsi, and other 2006: Coca-Cola, Pepsi, and other soft drink manufacturers announced soft drink manufacturers announced new voluntary policies to remove new voluntary policies to remove soda and other sugary drinks from soda and other sugary drinks from schools nationwideschools nationwide

Nevertheless, soft drink advertising Nevertheless, soft drink advertising still reaches students through still reaches students through television and magazine television and magazine advertisements and via Channel Oneadvertisements and via Channel One

ExerciseExercise

IOM recommends exercise one IOM recommends exercise one hour of exercise per day, double hour of exercise per day, double the 1996 recommendation by the 1996 recommendation by the Surgeon Generalthe Surgeon General

70% of American adults are not 70% of American adults are not active in their leisure time; 40% active in their leisure time; 40% are not active at allare not active at all

Exercise and SchoolExercise and School 1/3 of children do not participate in the 1/3 of children do not participate in the

minimum recommended level of physical minimum recommended level of physical activityactivity

Number of children taking part in Number of children taking part in physical education courses has dropped physical education courses has dropped significantly, in part due to school significantly, in part due to school funding cutsfunding cuts

Daily physical education associated with Daily physical education associated with better school attendance, more positive better school attendance, more positive attitudes about school, and better attitudes about school, and better academic performanceacademic performance

Exercise and Poor Exercise and Poor CommunitiesCommunities

Neighborhoods with high levels of Neighborhoods with high levels of minorities and individuals of low minorities and individuals of low socioeconomic status have paucity of socioeconomic status have paucity of facilities that enable and promote facilities that enable and promote physical activity, such as parks and physical activity, such as parks and gymnasiagymnasia

Perception of one’s neighborhood as Perception of one’s neighborhood as less safe is also associated with an less safe is also associated with an increased risk of overweight in childrenincreased risk of overweight in children Fear of exercising outdoorsFear of exercising outdoors

TelevisionTelevision Television, the internet, and video gamesTelevision, the internet, and video games

Average American watches over 4 Average American watches over 4 hrs/dayhrs/day

Average youth spends 67% more time Average youth spends 67% more time watching TV per year than he/she spends watching TV per year than he/she spends in the classroomin the classroom 32% of children aged 2-7 have TVs in 32% of children aged 2-7 have TVs in

their rooms (65% of children aged 8-18)their rooms (65% of children aged 8-18) Diminishes parental control over Diminishes parental control over

viewing time and contentviewing time and content

Television and Television and OvereatingOvereating

Increases in television viewing Increases in television viewing are associated with increased are associated with increased calorie intake among youthcalorie intake among youthEspecially of calorie-dense Especially of calorie-dense

low-nutrient foods of the type low-nutrient foods of the type promoted on TVpromoted on TV

MarketingMarketing

Businesses spend estimated $13 billion Businesses spend estimated $13 billion annually marketing food and drinks in annually marketing food and drinks in the USthe US Much TV advertisingMuch TV advertising

American children exposed to 40,000 American children exposed to 40,000 food ads/yrfood ads/yr 72% for candy, cereal, and fast food72% for candy, cereal, and fast food

Convenience/fast foods and sweets over Convenience/fast foods and sweets over 80% of foods advertised during children’s 80% of foods advertised during children’s programmingprogramming

MarketingMarketing

African-American-oriented television African-American-oriented television airs far more junk food ads targeted at airs far more junk food ads targeted at kids than general-oriented networkskids than general-oriented networks

Neither FTC nor FCC has authority to Neither FTC nor FCC has authority to limit advertising, despite the fact that limit advertising, despite the fact that children are vulnerable to exploitive children are vulnerable to exploitive advertising messages and unable to advertising messages and unable to discern truth from fiction in adsdiscern truth from fiction in ads

2007: Kelloggs to restrict food 2007: Kelloggs to restrict food marketing to childrenmarketing to children

TelevisionTelevision

Overweight and obese characters Overweight and obese characters represent < ½ their percentages in represent < ½ their percentages in the general populationthe general population Such characters less likely to be Such characters less likely to be

considered attractive, to interact considered attractive, to interact with romantic partners, or to with romantic partners, or to display physical affectiondisplay physical affection

Perpetuates stereotypesPerpetuates stereotypes

StigmatizationStigmatization

Reality: the overweight and obese Reality: the overweight and obese suffer from stigmatizationsuffer from stigmatization Overweight and obese women get Overweight and obese women get

fewer promotions and face more fewer promotions and face more job discriminationjob discrimination

Not true for heavyset menNot true for heavyset men

The Food Industry and The Food Industry and Medical GroupsMedical Groups

Medical groups have taken money from food Medical groups have taken money from food companies (troubling conflict of interest):companies (troubling conflict of interest): American Dietetic Association:American Dietetic Association:

Published “Straight Facts about Beverage Choices,” Published “Straight Facts about Beverage Choices,” supported by grant from National Soft Drink supported by grant from National Soft Drink AssociationAssociation

Accepted money from Mars and Coca Cola for annual Accepted money from Mars and Coca Cola for annual meetingmeeting

AAFP’s magazine, “Family Doctor: Your AAFP’s magazine, “Family Doctor: Your Essential Guide to Health and Well Being,” Essential Guide to Health and Well Being,” marinated in ads from junk food companies, marinated in ads from junk food companies, including McDonalds, Kraft (maker of Oreo including McDonalds, Kraft (maker of Oreo cookies), and Dr. Peppercookies), and Dr. Pepper

The Food Industry and The Food Industry and Medical GroupsMedical Groups

Cadbury Schweppes (makers of Dr. Cadbury Schweppes (makers of Dr. Pepper and chocolate candies) donated Pepper and chocolate candies) donated a few million dollars to the American a few million dollars to the American Diabetes Association (ADA) in exchange Diabetes Association (ADA) in exchange for getting to use ADA label on its diet for getting to use ADA label on its diet drinksdrinks

AHA has accepted money from similar AHA has accepted money from similar companies, and allows its label on companies, and allows its label on certified “heart-healthy” productscertified “heart-healthy” products

Food Producers and Food Producers and ObesityObesity

Sugar producers, the packaged food Sugar producers, the packaged food industry, and producers of high industry, and producers of high fructose corn syrup sweetener:fructose corn syrup sweetener: Contribute generously to politiciansContribute generously to politicians Top executives among President George Top executives among President George

W Bush’s biggest fundraisersW Bush’s biggest fundraisers Have exercised political influence to Have exercised political influence to

weaken food standards and labeling laws weaken food standards and labeling laws in the US and to pressure the WHO to in the US and to pressure the WHO to weaken its anti-obesity guidelinesweaken its anti-obesity guidelines

The Obesity EconomyThe Obesity Economy

Plus-size apparel market worth Plus-size apparel market worth $17 billion$17 billion20% of women’s clothing sales 20% of women’s clothing sales

(up from 11% in 2001)(up from 11% in 2001) Half of all U.S. women wear size Half of all U.S. women wear size

14 or larger14 or larger1985: average size was 8.701985: average size was 8.70

The Obesity EconomyThe Obesity Economy

XXXL sized clothes; oversized XXXL sized clothes; oversized autos, furniture, and coffins, and autos, furniture, and coffins, and specialized medical equipment specialized medical equipment such as lifts, special chairs and such as lifts, special chairs and toiletstoilets

SWA requires obese to buy extra SWA requires obese to buy extra seatseat Other airlines consideringOther airlines considering

Obesity WorldwideObesity Worldwide

America’s weight problem is occurring in the America’s weight problem is occurring in the midst of a global epidemic of overweight and midst of a global epidemic of overweight and obesityobesity Obese = 1.1 billion = UnderfedObese = 1.1 billion = Underfed

Migration from countries with lower rates of Migration from countries with lower rates of cancer and more healthy diets (e.g., many SE cancer and more healthy diets (e.g., many SE Asian nations) adopt American diet within a Asian nations) adopt American diet within a generationgeneration Become more overweight/obese and suffer higher Become more overweight/obese and suffer higher

rates of cancer and obesity-related illnessesrates of cancer and obesity-related illnesses Cultural export of fast food outlets / supersizingCultural export of fast food outlets / supersizing

Underweight and Underweight and Pathological Eating Pathological Eating

BehaviorsBehaviors Abnormal self-imageAbnormal self-image Prevalence of eating disorders has Prevalence of eating disorders has

risen in US and developing countriesrisen in US and developing countries Consequence (in part) of media’s depiction Consequence (in part) of media’s depiction

of “ideal” (excessively thin) womanof “ideal” (excessively thin) woman 66% of women and 52% of men report 66% of women and 52% of men report

feelings of dissatisfaction or feelings of dissatisfaction or inadequacy regarding their body inadequacy regarding their body weightweight


BehaviorsBehaviors 60% of girls in grade 9-12 trying to 60% of girls in grade 9-12 trying to

lose weightlose weight 24% of boys24% of boys

#1 wish of girls aged 11 to 17 is to #1 wish of girls aged 11 to 17 is to lose weightlose weight

Women more likely to judge Women more likely to judge themselves overweight when they are themselves overweight when they are notnot Men the oppositeMen the opposite


BehaviorsBehaviors Women who desire to lose weight more Women who desire to lose weight more

likely to do so in the hopes of improving likely to do so in the hopes of improving their appearancetheir appearance Men more likely to be concerned about Men more likely to be concerned about

future health and fitnessfuture health and fitness Body image distress classified as a Body image distress classified as a

psychological disorderpsychological disorder Five to 10 percent of females have eating Five to 10 percent of females have eating

disorderdisorder Anorexia nervosa or bulimiaAnorexia nervosa or bulimia


BehaviorsBehaviors Male and female high school athletes at Male and female high school athletes at

high risk for risky weight-control behaviorshigh risk for risky weight-control behaviors E.g., restricting food intake, vomiting, over-E.g., restricting food intake, vomiting, over-

exercising, using diet pills, inappropriately exercising, using diet pills, inappropriately taking prescribed stimulants or insulin, and taking prescribed stimulants or insulin, and using nicotineusing nicotine

Some adolescents dehydrate by restricting Some adolescents dehydrate by restricting fluid intake, spitting, wearing rubber suits, fluid intake, spitting, wearing rubber suits, taking daily steam baths and/or saunas, taking daily steam baths and/or saunas, and using diuretics or laxativesand using diuretics or laxatives

Consequences of Abnormal Consequences of Abnormal Weight Loss BehaviorsWeight Loss Behaviors

Delayed maturationDelayed maturation Impaired growthImpaired growth Menstrual irregularities / amenorrheaMenstrual irregularities / amenorrhea InfectionsInfections Eating disordersEating disorders DepressionDepression

Alternatively, such behaviors can be a Alternatively, such behaviors can be a sign of depression or verbal, physical, or sign of depression or verbal, physical, or sexual abusesexual abuse

The Role of the MediaThe Role of the Media

Media images contribute to Media images contribute to misguided perception of the “ideal” misguided perception of the “ideal” bodybody Models today weigh 23% less than Models today weigh 23% less than

average women; 1986: 8%average women; 1986: 8% Dimensions of the average fashion Dimensions of the average fashion

model: 5’11”, 117lbsmodel: 5’11”, 117lbs Dimensions of average American Dimensions of average American

woman: 5’4”, 140 lbswoman: 5’4”, 140 lbs

Modeling Schools for Modeling Schools for TeensTeens

Create unrealistic expectationsCreate unrealistic expectations Only a very “select” few models Only a very “select” few models

achieve financial successachieve financial success Of these, beginners earn $1500 Of these, beginners earn $1500

per day, those in the top tier per day, those in the top tier $25,000 per day, and supermodels $25,000 per day, and supermodels $100,000 or even more per day)$100,000 or even more per day)

Food Insecurity and Food Insecurity and HungerHunger

Worldwide, hunger-related causes Worldwide, hunger-related causes kill as many people in 2 days as died kill as many people in 2 days as died in the atomic bombing of Hiroshimain the atomic bombing of Hiroshima

US faces increasing mal-distribution US faces increasing mal-distribution of wealth and significant levels of of wealth and significant levels of poverty and hungerpoverty and hunger Twenty-five percent of children live in Twenty-five percent of children live in

poverty, and 4 million go hungry each poverty, and 4 million go hungry each dayday

Food Insecurity and Food Insecurity and HungerHunger

USDA: 12% of US households suffer USDA: 12% of US households suffer from food insecurity (limited or from food insecurity (limited or uncertain availability of nutritionally uncertain availability of nutritionally adequate and safe foods or limited or adequate and safe foods or limited or uncertain ability to acquire acceptable uncertain ability to acquire acceptable food in socially acceptable ways)food in socially acceptable ways)

Another 4% face outright hunger (the Another 4% face outright hunger (the uneasy or painful sensation caused by uneasy or painful sensation caused by the recurrent lack of access to food)the recurrent lack of access to food)

WasteWaste

Meanwhile, American Meanwhile, American households waste over $43 households waste over $43 billion worth of food per yearbillion worth of food per year3 times as much as in 19853 times as much as in 1985

Gluttony and Eating Gluttony and Eating ContestsContests

International Federation of International Federation of Competitive Eating sponsors more Competitive Eating sponsors more than 150 annual gorgefeststhan 150 annual gorgefests Chicken wings, oysters, jalapenos, etc.Chicken wings, oysters, jalapenos, etc. Official newsletter: “The Gurgitator”Official newsletter: “The Gurgitator” Nathan’s Annual Fourth of July Hot Dog Nathan’s Annual Fourth of July Hot Dog

Eating ContestEating Contest The World Cup of food boltingThe World Cup of food bolting Past winners have consumed over 50 wieners Past winners have consumed over 50 wieners

and buns in just twelve minutesand buns in just twelve minutes

Treatments for ObesityTreatments for Obesity

Decrease caloric intake Decrease caloric intake (especially simple carbohydrates (especially simple carbohydrates and trans-fatty acids)and trans-fatty acids)

Exercise moreExercise more Get adequate sleepGet adequate sleep Behavioral modificationBehavioral modification


Enlist familial and social support Enlist familial and social support networknetwork

Rule out contributing factors Rule out contributing factors (e.g., hypothyroidism)(e.g., hypothyroidism)

Treat associated conditions / Treat associated conditions / sequelaesequelae


Adults should receive 45% to 65% of calories Adults should receive 45% to 65% of calories from carbohydrates, 20%-35% from fat, and from carbohydrates, 20%-35% from fat, and 10%-35% from protein10%-35% from protein

2/3 of women and 1/3 of men with BMI > 27 2/3 of women and 1/3 of men with BMI > 27 have attempted weight losshave attempted weight loss Most who initially succeed regain lost weight Most who initially succeed regain lost weight

within 5 yrswithin 5 yrs With the exception of one trial involving With the exception of one trial involving

Weight Watchers, evidence to support major Weight Watchers, evidence to support major commercial and self-help weight loss commercial and self-help weight loss programs is sub-optimalprograms is sub-optimal


In some countries, insurance In some countries, insurance companies cover obesity treatmentcompanies cover obesity treatment Most in the U.S. do not, although they Most in the U.S. do not, although they

do cover myriad expensive health do cover myriad expensive health consequences of obesityconsequences of obesity

Americans spend an estimated $30 Americans spend an estimated $30 billion each year on diet pills, diet billion each year on diet pills, diet foods, exercise videos, health club foods, exercise videos, health club dues, and other weight loss toolsdues, and other weight loss tools


Weight loss drugs are a billion Weight loss drugs are a billion dollar per year business in the dollar per year business in the USUS

Nearly 5 million US adults used Nearly 5 million US adults used prescription weight loss pills prescription weight loss pills between 1996 and 1998between 1996 and 1998 However, ¼ of users were not However, ¼ of users were not

overweightoverweight Use especially common among womenUse especially common among women


Drug therapy may be appropriate for Drug therapy may be appropriate for patients with a BMI > 30 or a BMI > 27 patients with a BMI > 30 or a BMI > 27 with additional risk factorswith additional risk factors Sibutramine and orlistat reduce weight 10% Sibutramine and orlistat reduce weight 10%

when combined with diet and exercisewhen combined with diet and exercise Sibutramine can increase blood pressureSibutramine can increase blood pressure

Fenfluramine and dexfenfluramine Fenfluramine and dexfenfluramine taken off market in 1997taken off market in 1997 Numerous reports of cardiac valvulopathyNumerous reports of cardiac valvulopathy


Non-prescription supplements can be Non-prescription supplements can be dangerousdangerous Unregulated with respect to purity, Unregulated with respect to purity,

composition, and effectivenesscomposition, and effectiveness Especially avoid compounds Especially avoid compounds

containing ephedracontaining ephedraBanned by FDA, but still found in a Banned by FDA, but still found in a number of preparations sold in the number of preparations sold in the US and purchased abroadUS and purchased abroad


Future pharmaceutical Future pharmaceutical treatments will likely be directed treatments will likely be directed against hormones involved in the against hormones involved in the regulation of satiety, such as regulation of satiety, such as leptin and ghrelin, and may leptin and ghrelin, and may include vaccinesinclude vaccines


BMI > 40 may be eligible for bariatric BMI > 40 may be eligible for bariatric surgerysurgery

Procedures include Roux-en-Y gastric Procedures include Roux-en-Y gastric bypass, stapled gastroplasty, and bypass, stapled gastroplasty, and adjustable gastric bandingadjustable gastric banding

>200,000 procedures performed >200,000 procedures performed annuallyannually 2002: Almost $1 billion2002: Almost $1 billion Only 0.6% of eligible adults underwent a Only 0.6% of eligible adults underwent a

procedureprocedure


Procedures designed to reduce Procedures designed to reduce stomach size and control caloric stomach size and control caloric intakeintake

Substantial health benefits commonSubstantial health benefits common Excess weight loss of up to 70% and Excess weight loss of up to 70% and

resolution of diabetes in 77% of patientsresolution of diabetes in 77% of patients Complication rates almost 40% over a Complication rates almost 40% over a

180-day period180-day period LiposuctionLiposuction

Public Health Measures to Public Health Measures to Reduce ObesityReduce Obesity

DHHS’s Healthy People 2010 DHHS’s Healthy People 2010 objective: reduce prevalence of objective: reduce prevalence of obesity to 15%obesity to 15%

<1/2 of obese US adults visiting a <1/2 of obese US adults visiting a primary care physician counseled primary care physician counseled about weight lossabout weight loss Those counseled more likely to Those counseled more likely to

attempt weight lossattempt weight loss


Need for improved health care Need for improved health care provider education in nutrition and provider education in nutrition and increased use of nutritionists in increased use of nutritionists in primary care settingsprimary care settings Would likely be cost-savingWould likely be cost-saving

School- and community-based health School- and community-based health education campaigns tailored to education campaigns tailored to cultural background, gender, and cultural background, gender, and age groupage group


Media health messages to Media health messages to correct misperceptions correct misperceptions regarding weight and promote regarding weight and promote healthy behaviorshealthy behaviors

Enhanced public school health Enhanced public school health curriculacurricula


More healthful school and hospital More healthful school and hospital cafeteria meal choicescafeteria meal choices

No fast foods, soda pop machines, or No fast foods, soda pop machines, or exclusivity contracts in schoolsexclusivity contracts in schools Enhanced state funding for public Enhanced state funding for public

educationeducation Provision of healthier menu options in Provision of healthier menu options in

federally-sponsored school lunches federally-sponsored school lunches increases student participation in NSLPincreases student participation in NSLP


Use of local produce from Use of local produce from community-supported agriculture, community-supported agriculture, especially organics, would especially organics, would decrease adverse consequences of decrease adverse consequences of pesticides on the environment and pesticides on the environment and amount of harmful greenhouse amount of harmful greenhouse gasses produced in transportation gasses produced in transportation of food over long distancesof food over long distances


School wellness policy provision School wellness policy provision included in the Child Nutrition and included in the Child Nutrition and Women, Infants and Children Women, Infants and Children Reauthorization Act of 2004 mandates Reauthorization Act of 2004 mandates that schools participating in federal that schools participating in federal nutrition programs create wellness nutrition programs create wellness policies on how to improve students’ policies on how to improve students’ nutrition and health as well as set nutrition and health as well as set guidelines for all foods sold in schools guidelines for all foods sold in schools by 2006by 2006


Child Health Nutrition Promotion and Child Health Nutrition Promotion and School Lunch Protection Act, introduced School Lunch Protection Act, introduced in both the US Senate and House of in both the US Senate and House of Representatives, calls for updating Representatives, calls for updating decades-old federal nutrition standards decades-old federal nutrition standards for snack foods sold in cafeterias, stores, for snack foods sold in cafeterias, stores, and vending machines on school and vending machines on school groundsgrounds

In 2005, 40 states introduced about 200 In 2005, 40 states introduced about 200 bills addressing nutrition in schoolsbills addressing nutrition in schools


Pedestrian mallsPedestrian malls Recreational centers, parks, and Recreational centers, parks, and

workplace gymsworkplace gyms Requiring physical education at Requiring physical education at

schoolschool Providing insurance coverage for Providing insurance coverage for

membership in athletic clubs and membership in athletic clubs and insurance discounts for participation insurance discounts for participation in exercise programsin exercise programs


Enhanced health insurance coverage Enhanced health insurance coverage for obesity prevention and treatmentfor obesity prevention and treatment

Purge governmental bodies of those Purge governmental bodies of those with industry connectionswith industry connections

Provision of nutrition information on Provision of nutrition information on restaurant menusrestaurant menus


As of January 1, 2006, all As of January 1, 2006, all conventional food items must conventional food items must include information re the amount of include information re the amount of trans fatty acids they containtrans fatty acids they contain FDA: will prevent from 600 to FDA: will prevent from 600 to

1200 cases of coronary heart 1200 cases of coronary heart disease and 250 to 500 deaths disease and 250 to 500 deaths each yeareach year


NY recently banned use of artificial NY recently banned use of artificial trans-fatty acids in restaurants; trans-fatty acids in restaurants; Chicago and LA have proposed bansChicago and LA have proposed bans 2008: McDonalds eliminating trans 2008: McDonalds eliminating trans

fatty acid cooking oilsfatty acid cooking oils Some claim that these compounds Some claim that these compounds

add flavor and texture to fried foods, add flavor and texture to fried foods, but suitable, less dangerous cooking but suitable, less dangerous cooking oil substitutes are availableoil substitutes are available


Prohibit distribution of toys and Prohibit distribution of toys and promotional games and presence of promotional games and presence of play equipment and video games at play equipment and video games at fast food outletsfast food outlets

Require fast food restaurants to Require fast food restaurants to locate minimum distance from locate minimum distance from schools and playgroundsschools and playgrounds

Limit per capita number of fast food Limit per capita number of fast food outlets in a communityoutlets in a community


Limit proximity of fast food Limit proximity of fast food outlets to each otheroutlets to each other

Charge fee to fast food outlets Charge fee to fast food outlets and use proceeds to mitigate the and use proceeds to mitigate the impact of poor nutritional impact of poor nutritional content content

Prohibit drive-through serviceProhibit drive-through service


Majority of Americans believe the Majority of Americans believe the government should be involved in government should be involved in fighting obesity, particularly by fighting obesity, particularly by regulating marketing of “junk foods” to regulating marketing of “junk foods” to kidskids

2000: 19 states taxed non-nutritious 2000: 19 states taxed non-nutritious foods (e.g., soft drinks and candy)foods (e.g., soft drinks and candy)

Lawsuits against purveyors of junk foods Lawsuits against purveyors of junk foods to reclaim health care coststo reclaim health care costs

Some states considering class action Some states considering class action suitssuits

ConclusionsConclusions

Epidemic of obesity in US Epidemic of obesity in US and worldwideand worldwide

Serious health and economic Serious health and economic consequencesconsequences

Multi-tiered approach Multi-tiered approach necessary to combatnecessary to combat

Covered in Other Slide Covered in Other Slide ShowsShows

Ideals of beauty and body Ideals of beauty and body modificationmodification

Cosmetic surgeryCosmetic surgery Female genital cuttingFemale genital cutting Ethical and policy issuesEthical and policy issues

ReferenceReference

Donohoe MT. Weighty matters: Donohoe MT. Weighty matters: public health aspects of the obesity public health aspects of the obesity epidemic. Parts I-V. Medscape epidemic. Parts I-V. Medscape Ob/Gyn and Women’s Health 2007 Ob/Gyn and Women’s Health 2007 (in press)(in press)

Contact InformationContact Information

Public Health and Social Public Health and Social Justice WebsiteJustice Website

http://www.phsj.orghttp://www.phsj.org

[email protected]@phsj.org

obesity and public health

Health & Medicine