weighty matters: public health aspects of the obesity epidemic martin t donohoe

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

DefinitionsDefinitions

Waist to height ratio and waist-Waist to height ratio and waist-hip ratio other measureship ratio other measures The latter is more effective in The latter is more effective in

determining heart disease riskdetermining heart disease risk Metabolic abnormalities linked Metabolic abnormalities linked

more with visceral adipose more with visceral adipose tissue than subcutaneous tissue than subcutaneous adipose tissue adipose tissue

ObesityObesity

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

2012: 68% overweight, 34% 2012: 68% overweight, 34% obese (BMI > 30), 6% obese (BMI > 30), 6% morbidly obese (BMI > 40)morbidly obese (BMI > 40)

20-25% of American children 20-25% of American children are overweight or obeseare overweight or obese 80% of obese children become obese 80% of obese children become obese

adultsadults

Sex Differences in Overweight Sex Differences in Overweight and Obesityand Obesity

Combined overweight and Combined overweight and obese:obese:Men 72%Men 72%Women 64%Women 64%

Obese:Obese:Men 32%Men 32%Women 36%Women 36%

ObesityObesity

Worldwide 1.5 billion adults are Worldwide 1.5 billion adults are overweight or obeseoverweight or obese 2.8 million deaths/yr2.8 million deaths/yr

20% of US dogs obese (obese 20% of US dogs obese (obese masters tend to have obese pets)masters tend to have obese pets)

Causes of and Contributors Causes of and Contributors to Obesityto Obesity

Poor dietPoor diet Inadequate exercise (also linked Inadequate exercise (also linked

with poor academic performance)with poor academic performance) Inadequate/irregular sleepInadequate/irregular sleep Car culture – less Car culture – less

walking/bicyclingwalking/bicycling Excessive television watchingExcessive television watching


Genetic factors (estimates range from Genetic factors (estimates range from 1% to 75% of cases)1% to 75% of cases) E.g., FTO (fat mass and obesity associated E.g., FTO (fat mass and obesity associated

gene)gene) 32 distinct genetic variations associated 32 distinct genetic variations associated

with obesity or body-mass indexwith obesity or body-mass index Hormones and neurochemicals Hormones and neurochemicals

(including leptin, ghrelin, phthalates, (including leptin, ghrelin, phthalates, BPA)BPA)

Air pollutionAir pollution


Snacking on high glycemic foods Snacking on high glycemic foods during late pregnancyduring late pregnancy

Maternal smokingMaternal smoking Viruses and bacteria – microbiomeViruses and bacteria – microbiome Antibiotic use in early infancyAntibiotic use in early infancy 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, antidepressants, Medications: e.g., OCPs, antidepressants, antipsychotics, etc.antipsychotics, etc.

HypothyroidismHypothyroidism High birth weight (more common in mothers High birth weight (more common in mothers

who gain excessive weight during pregnancy)who gain excessive weight during pregnancy) Both large and small babies, as opposed to Both large and small babies, as opposed to

normal birthweight babies, prone to obesitynormal birthweight babies, prone to obesity 94% of mothers of overweight toddlers see 94% of mothers of overweight toddlers see

child’s size as normalchild’s size as normal


Shorter or no breastfeedingShorter or no breastfeeding Lack of mother-child bonding Lack of mother-child bonding

in infancyin infancy Childhood traumaChildhood trauma Menopause (attenuated by Menopause (attenuated by

exercise)exercise)

Causes of and Causes of and Contributors to ObesityContributors to Obesity

Childhood ability to delay gratificationChildhood ability to delay gratification Parents frequently fail to recognize Parents frequently fail to recognize

childhood overweight and obesitychildhood overweight and obesity Energy in > energy out (3500 extra Energy in > energy out (3500 extra

calories of food leads to approximately calories of food leads to approximately 1 lb wt gain)1 lb wt gain)

Perception: many overweight and Perception: many overweight and obese individuals think there is nothing obese individuals think there is nothing wrong with their weightwrong with their weight

ObesityObesity

More common among lower income More common among lower income individuals, rural Americans, individuals, rural Americans, Hispanics, and African-AmericansHispanics, and African-Americans Cultural explanations, food Cultural explanations, food

insecurity, fast food restaurants; insecurity, fast food restaurants; neighborhood safetyneighborhood safety

More prevalent in adults with sensory, More prevalent in adults with sensory, physical and mental health conditionsphysical and mental health conditions Healthy diet may help prevent Healthy diet may help prevent

depression and anxietydepression and anxiety

Obesity PreventionObesity Prevention

Ideal diet: 45-65% of calories from CHOs, Ideal diet: 45-65% of calories from CHOs, 20-35% from fat, and 10-35% from protein20-35% from fat, and 10-35% from protein Average daily consumption up 570 calories Average daily consumption up 570 calories

compared with 1970scompared with 1970s Ideal exercise = 1 hour per dayIdeal exercise = 1 hour per day

30% of Americans get regular exercise, 40% 30% of Americans get regular exercise, 40% get none; 10% of high school students get get none; 10% of high school students get recommended amountrecommended amount

Exercise associated with education, income, Exercise associated with education, income, being married (single status associated with being married (single status associated with strengthening exercises, primarily in men), strengthening exercises, primarily in men), West Coast, suburbsWest 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

Obesity vs. SmokingObesity vs. Smoking

Smoking causes greater health Smoking causes greater health burden from premature deaths than burden from premature deaths than from disability and activity from disability and activity limitationslimitations

Obesity causes greater burden from Obesity causes greater burden from disability and activity limitations disability and activity limitations than from premature deathsthan from premature deaths

Sequelae of ObesitySequelae of Obesity

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

cervical, colon, esophageal, renal, cervical, colon, esophageal, renal, liver thyroid)liver thyroid) 24% of all cancers (higher 24% of all cancers (higher

percentages in women than in men) percentages in women than in men) due to diet, physical activity, and due to diet, physical activity, and body fatbody fat

100,000 cancers/yr attributable to 100,000 cancers/yr attributable to obesityobesity


Type II Diabetes: 1998 – 4.9%; Type II Diabetes: 1998 – 4.9%; 2000 – 6.5%; 2010 – 8%2000 – 6.5%; 2010 – 8% Epidemic of type II diabetes in Epidemic of type II diabetes in

childrenchildren HyperlipidemiaHyperlipidemia GallstonesGallstones Sleep apneaSleep apnea Pseudotumor cerebriPseudotumor cerebri


Venous thromboembolismVenous thromboembolism GERDGERD Worsening of asthmaWorsening of asthma Urinary incontinenceUrinary incontinence


Increased predisposition to food Increased predisposition to food allergies, higher IgE levelsallergies, higher IgE levels

Weakened immune systems; Weakened immune systems; lower CD4 response to HAART lower CD4 response to HAART in HIV+ patientsin HIV+ patients

Higher rates of infection/sepsis Higher rates of infection/sepsis after traumaafter trauma


Poor wound healingPoor wound healing Increased risk of skin infectionsIncreased risk of skin infections UTIsUTIs Possible increased risk of Possible increased risk of

melanoma and inflammatory melanoma and inflammatory dermatoses (e.g., psoriasis)dermatoses (e.g., psoriasis)

Psoriatic arthritisPsoriatic arthritis


Weaker bonesWeaker bones Lower levels of vitamin DLower levels of vitamin D OsteoarthritisOsteoarthritis GoutGout Loss of brain tissue, dementiaLoss of brain tissue, dementia Multiple sclerosisMultiple sclerosis Depression and suicideDepression and suicide


Erectile and ejaculatory dysfunction in Erectile and ejaculatory dysfunction in menmen But not sexual dysfunction in womenBut not sexual dysfunction in women

Decreased fertility, lower sperm quantity Decreased fertility, lower sperm quantity and qualityand quality

EndometriosisEndometriosis Increased risk of diabetes, obesity, and Increased risk of diabetes, obesity, and

multiple birth defects (including multiple birth defects (including congenital heart disease) among offspringcongenital heart disease) among offspring


Earlier menarche (4 months)Earlier menarche (4 months) Associated with increased risk of Associated with increased risk of

breast cancerbreast cancer Associated with high risk sexual Associated with high risk sexual

behavior in adolescent girls (as is behavior in adolescent girls (as is underweight)underweight)

Less use of contraceptionLess use of contraception Oral contraceptives less effective (IUD Oral contraceptives less effective (IUD

more effective)more effective)


Less likely to breast feedLess likely to breast feed Higher rates of unintended Higher rates of unintended

pregnancy and abortionpregnancy and abortion Associated with fetal/infant death, Associated with fetal/infant death,

autism/developmental disordersautism/developmental disorders Childhood exposure to intimate Childhood exposure to intimate

partner violence against mother partner violence against mother associated with adult obesityassociated with adult obesity

Sequelae of ObesitySequelae of Obesity Decreases in social and physical Decreases in social and physical

functioningfunctioning Increases in chronic painIncreases in chronic pain Decrease in some health-related Decrease in some health-related

quality of life (QOL) measuresquality of life (QOL) measures Obesity in adolescents confers same Obesity in adolescents confers same

risk for premature death in risk for premature death in adulthood as smoking adulthood as smoking > ½ ppd> ½ ppd

Severely obese children and Severely obese children and adolescents have QOL similar to adolescents have QOL similar to those with cancerthose with cancer


Barrier to preventive care? Barrier to preventive care? e.g., probably mammograms and e.g., probably mammograms and

Pap smears (despite higher rates of Pap smears (despite higher rates of breast and cervical cancer)breast and cervical cancer)

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

Reluctance to being weighed a Reluctance to being weighed a common barriercommon barrier


Marginalization, discrimination, Marginalization, discrimination, bullyingbullying

Lower life expectancyLower life expectancy Worse school performanceWorse school performance 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 life than smoking, heavy drinking or povertyor poverty

Economic Consequences of Economic Consequences of ObesityObesity

Obesity-attributable national Obesity-attributable national expenditures $127 billion/yr expenditures $127 billion/yr (health care) + $49 billion (health care) + $49 billion (lost productivity due to (lost productivity due to excess mortality) + $43 billion excess mortality) + $43 billion (lost productivity caused by (lost productivity caused by disability) = $319 billion (U.S. disability) = $319 billion (U.S. and Canada, 2009)and Canada, 2009)

Excess U.S. Medical CostsExcess U.S. Medical Costs

35% of total healthcare expenditures (higher than smoking)

Obese men/women account for an additional $1,152/$3,613 per year in health care expenditures (2012)

Costs will rise as population ages Limits transplant donor pool


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 productivity AbsencesAbsences UnderperformanceUnderperformance Higher insurance premiumsHigher insurance premiums

Obesity contributes to increasing Obesity contributes to increasing carbon emissions and global carbon emissions and global warmingwarming

Military Consequences of Military Consequences of ObesityObesity

1/20 U.S. would-be military 1/20 U.S. would-be military enlistees rejected because of a enlistees rejected because of a criminal recordcriminal record

1/3 rejected because of physical 1/3 rejected because of physical unfitnessunfitness

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 the Spread of fast food franchises since the

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

fatty acids in processed foodsfatty acids in processed foods High levels of consumption of sugar- and High levels of consumption of sugar- and

caffeine-containing sodascaffeine-containing sodas In part a consequence of increased salt intakeIn part a consequence of increased salt intake Soft drink consumption linked to violent Soft drink consumption linked to violent

behavior in childrenbehavior in children

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

Fast food spending increased 18-fold Fast food spending increased 18-fold since 1970since 1970 $184 billion industry$184 billion industry over $100 billion per year in U.S.over $100 billion per year in U.S.


U.S. food industry produces U.S. food industry produces 3800 cal/person/day3800 cal/person/dayAverage caloric need only Average caloric need only

2500 calories/person/day2500 calories/person/day 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. / McDonalds’ fries in 1955: 2.4 oz. / 210 calories210 calories Today 7 oz. / 610 caloriesToday 7 oz. / 610 calories

1916: typical bottle of Coca Cola = 1916: typical bottle of Coca Cola = 6.5 oz. / 79 calories6.5 oz. / 79 calories Today 16 oz. / 194 caloriesToday 16 oz. / 194 calories


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

Even Even Joy of CookingJoy of Cooking recipes have recipes have shown increases of 33% in caloric shown increases of 33% in caloric density and portion size since 1940sdensity and portion size since 1940s

Fast food companies “leanwashing” Fast food companies “leanwashing” themselvesthemselves

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 Produces 20% of Saturday

morning televisionmorning television Offers prizes and inducements Offers prizes and inducements

based on characters which appeal based on characters which appeal to youngsters, often in collusion to youngsters, often in collusion with motion picture industrywith motion picture industry

Fast Foods and ChildrenFast Foods and Children

Fast food restaurants clustered Fast food restaurants clustered around schoolsaround schools Students in proximate schools eat Students in proximate schools eat

fewer servings of fruits and fewer servings of fruits and vegetables, consume more soda, vegetables, consume more soda, and are more likely to be and are more likely to be overweightoverweight

Fast food diet linked to Alzheimer’s Fast food diet linked to Alzheimer’s DiseaseDisease

Fast Foods and HospitalsFast Foods and Hospitals

Some US hospitals have regional and Some US hospitals have regional and national fast food franchises located on national fast food franchises located on the grounds of their main medical centersthe grounds of their main medical centers 42% of 234 academic-affiliated 42% of 234 academic-affiliated

hospitals surveyed in 2006hospitals surveyed in 2006 Sends the wrong message to patients Sends the wrong message to patients

and their families about optimal and their families about optimal nutritionnutrition

Health Care Without Harm – Healthy Health Care Without Harm – Healthy Hospitals InitiativeHospitals Initiative

Sodas and Artificial Sodas and Artificial SweetenersSweeteners

High fructose corn syrup (55% High fructose corn syrup (55% fructose, 45% glucose) - artificial fructose, 45% glucose) - 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 Fructose twice as sweet as glucose, Fructose twice as sweet as glucose,

metabolized primarily by liver (glucose by metabolized primarily by liver (glucose by all cells) – association of obesity with fatty all cells) – association of obesity with fatty liver (25% of US adults, over 70% of type liver (25% of US adults, over 70% of type 2 diabetics, 75-92% of morbidly obese)2 diabetics, 75-92% of morbidly obese)

Sodas and Artificial Sodas and Artificial SweetenersSweeteners

Consumption of fast and junk Consumption of fast and junk foods begins early in lifefoods begins early in life3-10% of US infants and 3-10% of US infants and

toddlers eat candy dailytoddlers eat candy dailyChildhood candy consumption Childhood candy consumption

linked to violence in adulthoodlinked to violence in adulthood4-23% consume sweetened 4-23% consume sweetened

soda beveragessoda beverages

SodasSodas

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

consumption of fruits and vegetablesconsumption of fruits and vegetables associated with goutassociated with gout

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

doubled since 1970, from 24 gallons per year doubled since 1970, from 24 gallons per year to 53 gallons per yearto 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 contain 70% of soft drinks consumed in US contain caffeinecaffeine

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

High fructose corn syrup-containing High fructose corn syrup-containing products also frequently contaminated products also frequently contaminated with mercurywith mercury

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 $6 NSLP gives schools more than $6 billion/yr to offer low-cost meals to billion/yr to offer low-cost meals to 31 million schoolchildren at over 31 million schoolchildren at over 100,000 schools and childcare 100,000 schools and childcare centerscenters

Kids eat free if their parents earn Kids eat free if their parents earn less than 130% of the poverty line; less than 130% of the poverty line; small charge if parents earn up to small charge if parents earn up to 180% of the poverty line180% of the poverty line


Began in 1946Began in 1946

Reimburses schools $2.28/mealReimburses schools $2.28/meal Cost = almost $10 billion per yearCost = almost $10 billion per year

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), 42% don’t serve (usually French-fried), 42% don’t serve daily fruits and vegetables, and less than daily fruits and vegetables, and less than 10% serve legumes10% serve 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 from cancer, particularly if the milk comes from cattle treated with rBGHcattle treated with rBGH

Does not help to establish good nutritional Does not help to establish good nutritional habitshabits


Helpful changes to program made in early Helpful changes to program made in early 20122012

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

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

Pouring Contracts and Soda Pouring Contracts and Soda ConsumptionConsumption

““Pouring rights” contracts with soda Pouring rights” contracts with soda manufacturersmanufacturers Signed by cash-strapped school districts to Signed by cash-strapped school districts to

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

2012: 10 of the largest 25 school districts 2012: 10 of the largest 25 school districts have or are considering agreementshave or are considering agreements

Yet ads generate < 0.05% of school Yet ads generate < 0.05% of school revenuesrevenues

Conflicts with schools’ responsibility to Conflicts with schools’ responsibility to teach proper nutritionteach 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) 63% of US schools limited carbonated 63% of US schools limited carbonated

soft drinks in 2008, compared to 38% in soft drinks in 2008, compared to 38% in 20062006

May not decrease overall soda May not decrease overall soda consumptionconsumption

Vending machines substituting juice Vending machines substituting juice made with HFCS, bottled watermade with HFCS, bottled water


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 soft drink 2006: Coca-Cola, Pepsi, and other soft drink manufacturers announced new voluntary manufacturers announced new voluntary policies to remove soda and other sugary policies to remove soda and other sugary drinks from schools nationwidedrinks from schools nationwide Led to decreases in numbers of drinks boughtLed to decreases in numbers of drinks bought ?effect on calories?effect on calories

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

Supplemental Nutrition Assistance Program (SNAP) Formerly known as food stamps Serves 47 million people each month Use of benefits for non-essential items (e.g.,

hot food and food for on-premises consumption) and products with adverse health effects (e.g., tobacco and alcohol) prohibited

USDA recently refused states requests to eliminate SNAP benefits for sugar-sweetened beverages Possibly secondary to industry pressure

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

Exercise and Poor Exercise and Poor CommunitiesCommunities

Healthy weight status associated Healthy weight status associated with amount of local park spacewith amount of local park space

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

Television and the Television and the InternetInternet

Television, the internet, and Television, the internet, and video gamesvideo gamesAverage American watches Average American watches

over 4 hrs/dayover 4 hrs/dayAverage child spends 8-10 Average child spends 8-10

hrs/day engaged with hrs/day engaged with commercial mediacommercial media

Television and the Television and the InternetInternet

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

in their rooms (65% of children in their rooms (65% of children aged 8-18)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 Businesses spend estimated $13 billion annually marketing food and billion annually marketing food and drinks in the US ($1.6 billion drinks in the US ($1.6 billion marketing to kids)marketing to kids) Much TV advertisingMuch TV advertising

American children exposed to American children exposed to 40,000 food ads/yr40,000 food ads/yr 72% for candy, cereal, and fast food72% for candy, cereal, and fast food Numbers increasingNumbers increasing

MarketingMarketing

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

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

MarketingMarketing

WHO recommends food marketing WHO recommends food marketing curbscurbs

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

MarketingMarketing

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

2011: Jack-in-the-Box stops including 2011: Jack-in-the-Box stops including toys in kids’ mealstoys in kids’ meals

2015: Disney to ban junk food ads on 2015: Disney to ban junk food ads on children’s TV and radio programschildren’s TV and radio programs

TelevisionTelevision

Overweight and obese characters under-Overweight and obese characters under-representedrepresented Men 25%; Women 10%Men 25%; Women 10% Obese and overweight characters less Obese and overweight characters less

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

Perpetuates stereotypesPerpetuates stereotypes Weight loss shows: e.g., Biggest Loser Weight loss shows: e.g., Biggest Loser

- ?Helpful?- ?Helpful?

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 job fewer promotions and face more job discriminationdiscrimination

Not true for heavyset menNot true for heavyset men 6 cities ban discrimination against 6 cities ban discrimination against

the overweight in hiringthe overweight in hiring ADA protects obese (disability)ADA protects obese (disability)

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


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


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

American Academy of Pediatric DentistryAmerican Academy of Pediatric Dentistry Accepted $1 million donation from Coca Cola Accepted $1 million donation from Coca Cola

(2003)(2003) Claimed that “the scientific evidence is Claimed that “the scientific evidence is

certainly not clear on the exact role that soft certainly not clear on the exact role that soft drinks play in terms of children’s oral disease” drinks play in terms of children’s oral disease” (2011)(2011)

Contradicted earlier statement on dental cariesContradicted earlier statement on dental caries


AAFP partnership with Coca-Cola to AAFP partnership with Coca-Cola to support its family doctor websitesupport its family doctor website Company’s Guatemala bottling plants Company’s Guatemala bottling plants

excoriated by human rights groups excoriated by human rights groups for labor rights violations, including for labor rights violations, including rape, murder, and attempted murderrape, murder, and attempted murder

Its bottled water operations in India Its bottled water operations in India are depleting local water tables (soda are depleting local water tables (soda contaminated with pesticides and contaminated with pesticides and heavy metals)heavy metals)


Yale School of Medicine Yale School of Medicine fellowship in obesity studies fellowship in obesity studies sponsored by PepsiCosponsored by PepsiCo

Coca-Cola and PepsiCo both Coca-Cola and PepsiCo both produce bottled waterproduce bottled water

Coke: Dasani (tap water), othersCoke: Dasani (tap water), othersPepsiCo: Aquafina (tap water)PepsiCo: Aquafina (tap water)

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

US Agricultural US Agricultural SubsidiesSubsidies

US agricultural subsidies have caused US agricultural subsidies have caused real (inflation-adjusted) price of fats and real (inflation-adjusted) price of fats and oils to decrease by 10%, of sugars and oils to decrease by 10%, of sugars and sweets to decrease by 15%, of sweets to decrease by 15%, of carbonated drinks to decrease by 34%, carbonated drinks to decrease by 34%, and of fresh fruits and vegetables to and of fresh fruits and vegetables to increase by 50% since the 1960sincrease by 50% since the 1960s Less than 1/10 of Americans meet Less than 1/10 of Americans meet

guidelines for fruit and vegetable guidelines for fruit and vegetable intakeintake

Consolidation and Consolidation and Industrialization of US Industrialization of US

AgricultureAgriculture 6.8 million farms in 1935 (vs. < 2 million 6.8 million farms in 1935 (vs. < 2 million

today)today) The average farmer now feeds 129 The average farmer now feeds 129

Americans (vs. 19 in 1940)Americans (vs. 19 in 1940) Americans spend less than 10% of their Americans spend less than 10% of their

incomes on food, down from 18% in 1966incomes on food, down from 18% in 1966 Subsidies mean one dollar can buy 1,200 Subsidies mean one dollar can buy 1,200

calories of potato chips or 875 calories of calories of potato chips or 875 calories of soda or 250 calories of vegetables or 170 soda or 250 calories of vegetables or 170 calories of fresh fruitcalories of fresh fruit

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 Women who desire to lose weight

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

about future health and fitnessabout future health and fitness Body image distress classified as a Body image distress classified as a

psychological disorder (body psychological disorder (body dysmorphic disorder)dysmorphic disorder)


BehaviorsBehaviors Five to 10 percent of females Five to 10 percent of females

(and 1-2% of males) have some (and 1-2% of males) have some form of eating disorderform of eating disorderAdolescent girls:Adolescent girls:

anorexia nervosa (0.5%)anorexia nervosa (0.5%)bulimia (1-2%)bulimia (1-2%)


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 Dental problems / tooth decayDental problems / tooth decay Eating disordersEating disorders DepressionDepression

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

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: 5’9”, 110lbsmodel: 5’9”, 110lbs Dimensions of average American Dimensions of average American

woman: 5’4”, 164 lbswoman: 5’4”, 164 lbs

The Role of the MediaThe Role of the Media

Waist-to-height ratio:Waist-to-height ratio: Barbie Doll 25%Barbie Doll 25%

Lifesize Barbie would have a 17” Lifesize Barbie would have a 17” waistwaist

Ken Doll 36%Ken Doll 36% Female college swimmers 42%Female college swimmers 42% Male college swimmers 43%Male college swimmers 43% General healthy cutoff 50%General healthy cutoff 50%

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)

ModelingModeling

Almost ½ of 500 models studied Almost ½ of 500 models studied were malnourished by WHO were malnourished by WHO standardsstandards

Some major fashion cities (e.g., Some major fashion cities (e.g., Milan) now require minimum BMI of Milan) now require minimum BMI of 18 (not NYC)18 (not NYC)

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 year1,400 calories per day (40% 1,400 calories per day (40% of food supply) wastedof food supply) wasted

3 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 60 wieners Past winners have consumed over 60 wieners

and buns in just ten minutesand buns in just ten minutes

Treatments for ObesityTreatments for Obesity

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

Eat slowlyEat slowly Drink two glasses of water before Drink two glasses of water before

eatingeating Exercise moreExercise more Get adequate sleepGet adequate sleep Behavioral modificationBehavioral modification


Enlist familial and social support Enlist familial and social support networknetwork

Economic incentives (?Economic incentives (?sustainability)sustainability)

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

Nearly 5 million US adults used Nearly 5 million US adults used prescription weight loss pills between prescription weight loss pills between 1996 and 19981996 and 1998 However, ¼ of users were not overweightHowever, ¼ of users were not overweight Use especially common among womenUse especially common among women [Slentrol – 1[Slentrol – 1stst FDA-approved weight loss FDA-approved weight loss

drug for dogs]drug for dogs]


Drug therapy may be appropriate Drug therapy may be appropriate for patients with a BMI > 30 or a for patients with a BMI > 30 or a BMI > 27 with additional risk BMI > 27 with additional risk factorsfactors

Sibutramine and orlistat reduce Sibutramine and orlistat reduce weight 10% when combined with weight 10% when combined with diet and exercisediet and exercise

Treatments for ObesityTreatments for Obesity Fenfluramine and dexfenfluramine taken off Fenfluramine and dexfenfluramine taken off

market in 1997market in 1997 Numerous reports of cardiac valvulopathyNumerous reports of cardiac valvulopathy

Orlistat (Xenical) = inhibits intestinal lipasesOrlistat (Xenical) = inhibits intestinal lipases Average weight loss 2.89 kg over one yearAverage weight loss 2.89 kg over one year Side effects include GI discomfort, fecal Side effects include GI discomfort, fecal

urgency, liver failure, oxalate-induced urgency, liver failure, oxalate-induced kidney injury, and pancreatitiskidney injury, and pancreatitis


Sibutramine (Meridia) = SSRI/NARISibutramine (Meridia) = SSRI/NARI Average weight loss 4.2 kg over Average weight loss 4.2 kg over

one yearone year Can increase heart rate and blood Can increase heart rate and blood

pressurepressure 2010: Withdrawn from market due 2010: Withdrawn from market due

to increased risk of stroke and MIto increased risk of stroke and MI


Naltrexone SR/Bupropion SR Naltrexone SR/Bupropion SR (Contrave)(Contrave) Weight loss of 5-10% (vs. 1-6% placebo)Weight loss of 5-10% (vs. 1-6% placebo) Side effects: N, HA, elevated BP and HRSide effects: N, HA, elevated BP and HR FDA requiring more phase 3 trialsFDA requiring more phase 3 trials Orexigen shelves plans to seek FDA Orexigen shelves plans to seek FDA

approval (2011)approval (2011)


Lorcaserin (Belvique) - serotonin Lorcaserin (Belvique) - serotonin agonist:agonist: Appetite suppressantAppetite suppressant 4kg weight loss more than placebo over 4kg weight loss more than placebo over

1 year1 year Improves glycemic control, Improves glycemic control,

hypertension, lipidshypertension, lipids Side effects: URIs, HA NSide effects: URIs, HA N


Phenteramine + Topirimate ER Phenteramine + Topirimate ER (Qsymia) – sympathomimetic (Qsymia) – sympathomimetic anorectic + antiepiliptic druganorectic + antiepiliptic drug Loss of 8% body weight over one year Loss of 8% body weight over one year

(vs. 3% placebo)(vs. 3% placebo) Favorable effects on HbA1c, HTN, HDLFavorable effects on HbA1c, HTN, HDL Unlikely to cause valvulopathyUnlikely to cause valvulopathy Topirimate teratogenic (orofacial clefts)Topirimate teratogenic (orofacial clefts)


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 Multiple contaminantsMultiple contaminants Especially avoid compounds containing Especially avoid compounds containing

ephedraephedra Banned 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 against hormones involved in the regulation of satiety, such as the regulation of satiety, such as leptin and ghrelin, and may leptin and ghrelin, and may include vaccinesinclude vaccines


Other agents may act on Other agents may act on adiponectin or irisin (the latter adiponectin or irisin (the latter affects brown/white fat ratio)affects brown/white fat ratio) White fat stores calories, brown fat White fat stores calories, brown fat

burns calories / generates heatburns calories / generates heat


BMI > 40 (or BMI > 35 with DM2 or BMI > 40 (or BMI > 35 with DM2 or OSA) may be eligible for bariatric OSA) may be eligible for bariatric surgerysurgery

Procedures include Roux-en-Y gastric Procedures include Roux-en-Y gastric bypass (best outcomes), stapled bypass (best outcomes), stapled gastroplasty, duodenal swithch, gastroplasty, duodenal swithch, adjustable gastric banding, and adjustable gastric banding, and duodenal-jejunal bypass liner)duodenal-jejunal bypass liner) Designed to reduce stomach size and Designed to reduce stomach size and

control caloric intakecontrol caloric intake


220,000 procedures performed annually220,000 procedures performed annually Only 0.6% of eligible adults underwent Only 0.6% of eligible adults underwent

a procedure; some teens now gettinga procedure; some teens now getting Substantial health benefits commonSubstantial health benefits common

Average weight loss after one Average weight loss after one year/three years: 62%/71% with Roux-year/three years: 62%/71% with Roux-en-Y gastric bypass, 43%/55% with en-Y gastric bypass, 43%/55% with gastric bandinggastric banding

Excess weight loss of up to 70%Excess weight loss of up to 70%


Substantial health benefits commonSubstantial health benefits common Resolution of HTN in 68%Resolution of HTN in 68% Resolution of dyslipidemia in 71%Resolution of dyslipidemia in 71% Resolution of diabetes in 77% of Resolution of diabetes in 77% of

patientspatients Up to 45% lower risk of death; reduced Up to 45% lower risk of death; reduced

risk of MI, CVArisk of MI, CVA Improvements in memory functionImprovements in memory function


Perioperative mortality 0.6% - 2%Perioperative mortality 0.6% - 2% Complication rates almost 20-30% Complication rates almost 20-30%

over a 180-day periodover a 180-day period Increased risk of alcohol abuse Increased risk of alcohol abuse

post-gastric bypass surgerypost-gastric bypass surgery

LiposuctionLiposuction

Public Health Measures to Public Health Measures to Reduce ObesityReduce Obesity

DHHS’s Healthy People 2010 objective: DHHS’s Healthy People 2010 objective: reduce prevalence of obesity to 15%reduce prevalence of 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 twice as likely to Those counseled twice as likely to

attempt weight lossattempt weight loss 44% of US physicians overweight or 44% of US physicians overweight or

obese – less likely to counselobese – less likely to counsel


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

Public Health Measures Public Health Measures to Reduce Obesityto Reduce Obesity

Obesity report cardsObesity report cards 20 states20 states 23% of US elementary schools23% of US elementary schools

Lincoln University in PA requires Lincoln University in PA requires students with BMI students with BMI > 30 to pass a physical > 30 to pass a physical fitness test to graduatefitness test to graduate


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 schools (consider exclusivity contracts in schools (consider elimination of HFCS-laden juices and elimination of HFCS-laden juices and bottled water sales also)bottled water sales also) Enhanced state funding for public educationEnhanced state funding for public education

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


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


Alabama: $25/month health Alabama: $25/month health insurance surcharge on state workers insurance surcharge on state workers whose BMI exceeds 35 and who fail whose BMI exceeds 35 and who fail to enroll in a free wellness program to enroll in a free wellness program and “show progress”and “show progress”

State workers, however, pay lower State workers, however, pay lower rates for lower BP, FBS, cholesterol, rates for lower BP, FBS, cholesterol, and weight, or if they see a doctor to and weight, or if they see a doctor to address health problems or address health problems or participate in an exercise classparticipate in an exercise class


PPACA (ObamaCare) allows PPACA (ObamaCare) allows emploers to charge obese emploers to charge obese workers 30%-50% more for workers 30%-50% more for health insurance if they decline health insurance if they decline to participate in a qualified to participate in a qualified employee wellness programemployee wellness program


Comprehensive employee Comprehensive employee wellness programs yield average wellness programs yield average reduction in healthcare reduction in healthcare expenditures of 26%expenditures of 26%

Several state insurance plans impose a Several state insurance plans impose a $25/month surcharge on smokers$25/month surcharge on smokers

Others give up to 20% premium Others give up to 20% premium reductions to those who meet certain reductions to those who meet certain health guidelineshealth guidelines


Enhanced health insurance Enhanced health insurance coverage for obesity prevention and coverage for obesity prevention and treatmenttreatment Adjusted premiums based on Adjusted premiums based on

weight in several statesweight in several states

Health and life insurance companies Health and life insurance companies own 1.9 billion of stock in the 5 own 1.9 billion of stock in the 5 leading fast food companies (2010)leading fast food companies (2010)


Airline’s requiring obese passengers Airline’s requiring obese passengers on full flights to rebook or purchase on full flights to rebook or purchase two seatstwo seats

Child abuse/child custody statutesChild abuse/child custody statutes

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


Laws to prohibit weight discrimination Laws to prohibit weight discrimination (MI only state, others considering)(MI only state, others considering) Have broad popular supportHave broad popular support Some doctors refuse to treat obese patients Some doctors refuse to treat obese patients

(higher risk of surgical complications, etc.)(higher risk of surgical complications, etc.) Fat Acceptance/CelebrationFat Acceptance/Celebration

Fat StudiesFat Studies National Association to Advance Fat National Association to Advance Fat

AcceptanceAcceptance


Provision of nutrition information on Provision of nutrition information on restaurant menusrestaurant menus Consumers strongly supportConsumers strongly support Required in NYC (upheld by federal Required in NYC (upheld by federal

appeals court in 2009)appeals court in 2009) Consumers underestimate calorie Consumers underestimate calorie

content of restaurant food by 28-48%content of restaurant food by 28-48% Effective in decreasing calorie Effective in decreasing calorie

consumptionconsumption Required by Obama Health PlanRequired by Obama Health Plan


As of January 1, 2006, all conventional As of January 1, 2006, all conventional food items must include information food items must include information re the amount of trans fatty acids they re the amount of trans fatty acids they containcontain FDA: will prevent from 600 to 1200 FDA: will prevent from 600 to 1200

cases of coronary heart disease and cases of coronary heart disease and 250 to 500 deaths each year250 to 500 deaths each year

IOM supports front-of-package IOM supports front-of-package labeling for calories, sugar, fat, and labeling for calories, sugar, fat, and sodium using simplified systemsodium using simplified system


CA, NYC, Philadelphia, Cleveland CA, NYC, Philadelphia, Cleveland have banned use of artificial trans-have banned use of artificial trans-fatty acids in restaurantsfatty acids in restaurants 2008: McDonalds eliminating 2008: McDonalds eliminating

trans fatty acid cooking oilstrans fatty acid cooking oils Less than 2% of NYC restaurants Less than 2% of NYC restaurants

using trans fats (2009)using trans fats (2009)


Denmark, Sweden, Iceland, Denmark, Sweden, Iceland, Switzerland have banned trans-Switzerland have banned trans-fats (other countries considering)fats (other countries considering)

Some claim that these Some claim that these compounds add flavor and compounds add flavor and texture to fried foods, but texture to fried foods, but suitable, less dangerous cooking 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 content impact of poor nutritional content

Prohibit drive-through serviceProhibit drive-through service Supersize soda bans (NYC)Supersize soda bans (NYC)


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” regulating marketing of “junk foods” to kidsto kids

40 states tax non-nutritious foods 40 states tax non-nutritious foods (e.g., soft drinks and candy)(e.g., soft drinks and candy) 11cent/oz tax could reduce consumption of sugared cent/oz tax could reduce consumption of sugared

beverages by up to 15%beverages by up to 15%


Taxes on sugar-sweetened beverages Taxes on sugar-sweetened beverages recommended by IOM, which could (over 10 recommended by IOM, which could (over 10 years)years) Reduce soda consumption by 15%Reduce soda consumption by 15% Prevent 26,000 premature deathsPrevent 26,000 premature deaths Save over $17 billion in medical costsSave over $17 billion in medical costs


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

Some states considering class Some states considering class action suitsaction suits

Food and beverage industry fighting Food and beverage industry fighting back against government-mandated back against government-mandated efforts (expensive, intense lobbying)efforts (expensive, intense lobbying)

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

ReferencesReferences Donohoe MT. Weighty matters: public health aspects of the obesity Donohoe MT. Weighty matters: public health aspects of the obesity

epidemic. Part I – Causes and health and economic consequences of epidemic. Part I – Causes and health and economic consequences of obesity. Medscape Ob/Gyn and Women’s Health 2007 (posted 12/12/07). obesity. Medscape Ob/Gyn and Women’s Health 2007 (posted 12/12/07). Available at Available at http://www.medscape.com/viewarticle/566056

Donohoe MT. Weighty matters: public health aspects of the obesity Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part II – Economic Consequences of Obesity, the “Obesity epidemic. Part II – Economic Consequences of Obesity, the “Obesity Economy,” and the Role of Nutrition, Exercise, and Television. Medscape Economy,” and the Role of Nutrition, Exercise, and Television. Medscape Ob/Gyn and Women’s Health 2008 (posted 1/04/08). Available at Ob/Gyn and Women’s Health 2008 (posted 1/04/08). Available at http://www.medscape.com/viewarticle/566349?src=mp

Donohoe MT. Weighty matters: public health aspects of the obesity Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part III – A look at food and beverage industries. Medscape epidemic. Part III – A look at food and beverage industries. Medscape Ob/Gyn and Women’s Health 2008 (posted 3/25/08). Available at Ob/Gyn and Women’s Health 2008 (posted 3/25/08). Available at http://www.medscape.com/viewarticle/568110_print

Donohoe MT. Weighty matters: public health aspects of the obesity Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part IV – Obesity worldwide, pathological underweight, and epidemic. Part IV – Obesity worldwide, pathological underweight, and gluttony. Medscape Ob/Gyn and Women’s Health 2008 (Posted 3/19/08). gluttony. Medscape Ob/Gyn and Women’s Health 2008 (Posted 3/19/08). Available at Available at http://www.medscape.com/viewarticle/571497_print

Donohoe MT. Weighty matters: public health aspects of the obesity Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part V – Treatments and public health approaches to combating epidemic. Part V – Treatments and public health approaches to combating the problem. Medscape Ob/Gyn and Women’s Health 2008 (posted the problem. Medscape Ob/Gyn and Women’s Health 2008 (posted 4/10/08). Available at 4/10/08). Available at http://www.medscape.com/viewarticle/571139_print..

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