1 Public Health Aspects of the Obesity EpidemicWeighty Matters: Public Health Aspects of the Obesity Epidemic Martin T Donohoe

2 Average height and weight of AmericansMen: 5’9”, 191 lbs Women: 5’4”, 164 lbs

3 Definitions BMI (Body Mass Index) =weight (kg)/height squared (meters squared) Overweight: BMI ≥ 25 Obese: BMI ≥ 30

4 Definitions Waist to height ratio and waist-hip ratio other measuresThe latter is more effective in determining heart disease risk Metabolic abnormalities linked more with visceral adipose tissue than subcutaneous adipose tissue Fat/bone ratio also promising

5 Obesity 1950: ¼ of Americans overweight or obese (BMI > 25)2016: 33% overweight, 36% obese (BMI > 30), 6% morbidly obese (BMI > 40)

6 Obesity 20% of American children are overweight or obese9% of preschool children / 17% of grade schoolers / 17% of teens are obese 80% of obese children become obese adults

7 Sex Differences in Overweight and ObesityCombined overweight and obese: Men 72% Women 64% Obese: Men 35% Women 40%

8 Obesity More common among lower income individuals, rural Americans, Hispanics, and African-Americans; less common among Asian-Americans Cultural explanations, food insecurity, fast food restaurants, neighborhood safety

9 Obesity and Pregnancy Proper weight gain during pregnancy depends on BMI 1/3 of women gain too much weight during pregnancy 1/3 proper amount, 1/3 too little Excessive weight gain most common in women who were already overweight before pregnancy

10 Obesity Worldwide 1.5 billion adults are overweight or obese (11% of men/ 14% of women obese; 9% of men/10% of women underweight) Overweight/obesity → 2.8 million deaths/yr U.S. has highest rates in world (36% vs. 32% Mexico, 25% Canada, 4% Switzerland, 2% India) 20% of US dogs obese (obese masters tend to have obese pets)

11 Causes of and Contributors to ObesityEnergy in > energy out (3500 extra calories of food leads to approximately 1 lb wt gain) Poor diet Poor hydration Inadequate exercise (also linked with poor academic performance)

12 Causes of and Contributors to ObesityInadequate/irregular sleep Car culture – less walking/bicycling Excessive television watching

13 Causes of and Contributors to ObesityGenetic factors (estimates range from 1% to 75% of cases, best estimate is that genes account for as much as 21% of BMI variation) 97 distinct genetic variations associated with obesity or body-mass index FTO (fat mass and obesity) gene began to influence BMI in 1940s (technological advances/less activity and increased availability of high calorie processed foods)

14 Causes of and Contributors to ObesityHormones, neurochemicals, and environmental obesogens (including leptin, ghrelin, phthalates, BPA, PCBs, PBDEs, PFOA) Phthalates common in fast foods Air pollution Noise pollution

15 Causes of and Contributors to ObesitySnacking on high glycemic foods during late pregnancy Maternal smoking Viruses and bacteria – microbiome Infections in infancy Antibiotic use in pregnancy, +/- early infancy (in absence of infection), and childhood (alter microbiome)

16 Causes of and Contributors to ObesityHuman microbiome being altered by diet, mass extinction of healthy bacteria underway (including those involved in digestion and mucosal protection against microbes and endotoxin) Calls for microbiome repopulation of Western guts, even development of storage repository of healthy bacteria Microbiome might control up to 10% of body weight

17 Causes of and Contributors to ObesitySugar substitutes: May increase appetite for sweet foods and promote overeating Medications: e.g., OCPs, antidepressants, antipsychotics, etc. Hypothyroidism

18 Causes of and Contributors to ObesityC-section High birth weight (more common in mothers who gain excessive weight during pregnancy) Both large and small babies, as opposed to normal birthweight babies, prone to obesity 94% of mothers of overweight toddlers see child’s size as normal

19 Causes of and Contributors to ObesityShorter or no breastfeeding Lack of mother-child bonding in infancy Childhood trauma Menopause (attenuated by exercise)

20 Causes of and Contributors to ObesityChildhood ability to delay gratification Parents frequently fail to recognize childhood overweight and obesity Approximately ¾ describe their children as “about the right weight) Perception: many overweight and obese individuals think there is nothing wrong with their weight

21 Obesity More prevalent in adults with sensory, physical and mental health conditions Healthy diet may help prevent depression and anxiety More common in bisexual and lesbian women, less common in homosexual males

22 Obesity Prevention Ideal diet: 45-65% of calories from CHOs, 20-35% from fat, and 10-35% from protein Average daily consumption up 570 calories compared with 1970s Ideal exercise = 1 hour per day 30% of Americans get regular exercise, 40% get none; 10% of high school students get recommended amount Exercise associated with education, income, being married (single status associated with strengthening exercises, primarily in men), West Coast, suburbs

23 Obesity Responsible for 300,000 US deaths/year (nearly 1/5)vs. 480,000/year from smoking (438,000 direct, 42,000 environmental tobacco smoke) Decreases in life expectancy and increase in early mortality similar to that seen with smoking

24 Obesity vs. Smoking Smoking causes greater health burden from premature deaths than from disability and activity limitations Obesity causes greater burden from disability and activity limitations than from premature deaths

25 Sequelae of Obesity Heart diseaseArrhythmia (50% higher risk of atrial fibrillation Hyperlipidemia Type II Diabetes: 1998 – 4.9%; 2000 – 6.5%; 2010 – 8% Epidemic of type II diabetes in children

26 Sequelae of Obesity Certain cancers (e.g., breast, uterine, ovary, cervical, colon, esophageal, renal, liver, thyroid, gall bladder) 25% of cancers attributable to obesity (33% when add poor nutrtition and inactivity, higher percentage in women) 30% due to smoking

27 Sequelae of Obesity Fatty liver (NASH)Higher risk than heavy alcohol consumption Gallstones Sleep apnea

28 Sequelae of Obesity Pseudotumor cerebri Venous thromboembolism GERDWorsening of asthma Urinary incontinence

29 Sequelae of Obesity Increased predisposition to food allergies, higher IgE levels Childhood asthma and eczema linked to fast food Weakened immune systems; lower CD4 response to HAART in HIV+ patients Higher rates of infection/sepsis after trauma

30 Sequelae of Obesity Poor wound healingIncreased risk of skin infections UTIs Possible increased risk of melanoma and inflammatory dermatoses (e.g., psoriasis) Psoriatic arthritis

31 Sequelae of Obesity Weaker bones Lower levels of vitamin DOsteoarthritis Gout Loss of brain tissue, dementia Multiple sclerosis Depression, anxiety, and suicide

32 Sequelae of Obesity Erectile and ejaculatory dysfunction in menBut not sexual dysfunction in women Decreased fertility, lower sperm quantity and quality Endometriosis

33 Sequelae of Obesity Earlier menarche (4 months)Associated with increased risk of breast cancer Associated with high risk sexual behavior in adolescent girls (as is underweight) Less use of contraception Oral contraceptives less effective (IUD more effective)

34 Sequelae of Obesity Less likely to breast feedHigher rates of unintended pregnancy and abortion Increased risk of C-section Associated with fetal/infant death, autism/developmental disorders

35 Sequelae of Obesity Increased risk of diabetes, obesity, heart attack, stroke, multiple birth defects (including congenital heart disease), and psychosis among offspring Childhood exposure to intimate partner violence against mother associated with adult obesity

36 Sequelae of Obesity Decreases in social and physical functioningIncreases in chronic pain Decrease in some health-related quality of life (QOL) measures Obesity in adolescents confers same risk for premature death in adulthood as smoking > ½ ppd Severely obese children and adolescents have QOL similar to those with cancer

37 Sequelae of Obesity Barrier to preventive care?e.g., probably mammograms and Pap smears (despite higher rates of breast and cervical cancer) 20% more likely to have false-positive mammograms Reluctance to being weighed a common barrier

38 Sequelae of Obesity Marginalization, discrimination, bullyingHigher risk of dying in motor vehicle accident Lower life expectancy Worse school performance Less likely to wear seatbelts; more likely to die in auto accidents More strongly associated with chronic medical conditions and reduced health-related quality of life than smoking, heavy drinking or poverty

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

40 Excess U.S. Medical Costs35% 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

41 Economic Consequences of ObesityHalf of costs covered by Medicare, which now classifies obesity as a disease Increased costs of care due to: Prescription drugs More complications from surgery Increased lengths of stay Increased use of health care services during pregnancy

42 Economic Consequences of ObesityCosts to business: Lost productivity Absences Underperformance Higher insurance premiums Obesity contributes to increasing carbon emissions and global warming, decreased water availability

43 Military Consequences of Obesity1/20 U.S. would-be military enlistees rejected because of a criminal record 1/3 rejected because of physical unfitness

44 Nutritional Changes and ObesityAgriculture 10,000 years ago Benefits: community, local food production Adverse consequences: class-based, hierarchical societies; large-scale warfare; sedentary lifestyles; dramatically decreased crop and game diversity; corporate control of agriculture and poverty

45 Nutritional Changes and ObesityIncreases in portion size Spread of fast food franchises since the mid-20th Century Use of artificial sweeteners and trans fatty acids in processed foods High levels of consumption of sugar- and caffeine-containing sodas In part a consequence of increased salt intake Soft drink consumption linked to violent behavior in children

46 Fast Foods and SupersizingPortion sizes and restaurant dinner plates have increased over last half century Americans spend about one-half of their food budgets and consume about one-third of their calories outside the home Fast food spending increased 18-fold since 1970 $200 billion/yr industry over $100 billion per year in U.S.

47 Fast Foods and SupersizingU.S. food industry produces 3800 cal/person/day Average caloric need only 2500 calories/person/day Americans average 11% of total daily calories from fast food On any given day, 8% of Americans eat at McDonalds 14,000 stores in U.S. alone

48 Fast Foods and SupersizingFast food industry CEOs averaged $24 million compensation in 2013 > 4-fold increase since 2000 > 1,200X average fast food workers (whose salaries have increased 0.3% since 2000) Predatory wage policies subsidized by U.S. taxpayers Almost 950,000 fast food workers receive federal and state aid worth $7 billion Support raising minimum wage and single payer health care

49 Fast Foods and SupersizingTypical American eats 30 pounds of French fries per year McDonalds’ fries in 1955: 2.4 oz. / 210 calories Today 7 oz. / 610 calories 1916: typical bottle of Coca Cola = 6.5 oz. / 79 calories Today 16 oz. / 194 calories

50 Las Vegas’ Heart Attack GrillDiners (patients) wear hospital gowns over their clothes and have their pulses checked by waitresses (nurses) Home of the Quadruple Bypass Burger Anyone over 350 lbs eats for free 2012: Pitchman dies at age 51 of heart attack

51 Fast Foods and SupersizingSome mega-sized fast food burgers on the market today contain > 1000 calories Even Joy of Cooking recipes have shown increases of 33% in caloric density and portion size since 1940s Fast food companies “leanwashing” themselves

52 Fast Foods and the Inner Cities / Poor CommunitiesFast food outlets target poor inner city communities Meals inexpensive and convenient Helps consumers working two jobs, raising children solo or lacking inadequate kitchen facilities

53 Fast Foods and ChildrenFast food industry directly targets children Produces 20% of Saturday morning television Offers prizes and inducements based on characters which appeal to youngsters, often in collusion with motion picture industry McDonalds holds McTeachers Nights, where teachers work behind the counter and serve their students in exchange for a small donation to their schools

54 Fast Foods and ChildrenFast food restaurants clustered around schools Students in proximate schools eat fewer servings of fruits and vegetables, consume more soda, and are more likely to be overweight Fast food diet linked to worse academic performance and Alzheimer’s Disease

55 Fast Foods and HospitalsSome US hospitals have regional and national fast food franchises located on the grounds of their main medical centers 42% of 234 academic-affiliated hospitals surveyed in 2006 Sends the wrong message to patients and their families about optimal nutrition Health Care Without Harm – Healthy Hospitals Initiative

56 Sodas and Artificial SweetenersHigh fructose corn syrup (55% fructose, 45% glucose) - artificial sweetener added to many products, including sodas and fruit drinks 1,000+% increase in consumption over last few decades (more soda sold in U.S. than in any other country) Fructose twice as sweet as glucose, metabolized primarily by liver (glucose by all cells) – association of obesity with fatty liver (25% of US adults, over 70% of type 2 diabetics, 75-92% of morbidly obese)

57 Sodas and Artificial SweetenersConsumption of fast and junk foods begins early in life 3-10% of US infants and toddlers eat candy daily Soda consumption linked to inattention aggression in children 4-23% consume sweetened soda beverages

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60 Sodas Soft drinks account for 20-24% of calories for 2- to 19-year-olds Associated with tooth decay and decreased consumption of fruits and vegetables Associated with gout Increases risk of obesity, DM II, CV disease

61 Sodas 200,000 deaths worldwide/yr attributed to sugary drinksGlobal soft drink market worth nearly $870 billion in annual sales (2015)

62 Sodas Majority of adults drink soda dailyPer capita soda consumption more than doubled between 1970 and 1998, from 24 gallons per year to 53 gallons per year (recent dramatic decrease to 40 gals/yr) “Big Gulp” and “Super Big Gulp” Products heavily marketed, celebrity endorsers E.g., Michael Jackson and Beyonce for Pepsi, Lebron James - Coke Overweight Americans who drink diet sodas eat more food – ?feel “permission” to eat more food

63 Sodas and Caffeine 70% of soft drinks consumed in US contain caffeineEvidence suggests that the mood-altering and physical dependence-producing effects of caffeine (a central nervous system stimulant) have contributed to high rates of consumption of caffeinated soft drinks High fructose corn syrup-containing products also frequently contaminated with mercury

64 Sodas and Caffeine Soda’s addictive properties put imbibers at risk of caffeine-withdrawal symptoms such as headache Other caffeinated beverages: e.g., Red Bull Diet soda drinkers have increased risk of obesity, DM II, and CAD, and CHF

65 The National School Lunch ProgramNSLP gives schools more than $6 billion/yr to offer low-cost meals to 31 million schoolchildren at over 100,000 schools and childcare centers Kids eat free if their parents earn less than 130% of the poverty line; small charge if parents earn up to 180% of the poverty line

66 The National School Lunch ProgramBegan in 1946 Reimburses schools $2.28/meal Cost = almost $10 billion per year Administered by USDA

67 The National School Lunch ProgramConflicting missions of providing healthy meals to children, regardless of income, subsidizing agribusiness, and shoring up demand for beef and milk Meals emphasize meat and dairy products at the expense of fruit and vegetables, contain high levels of fat, and fail to meet government’s own, inadequate, nutritional standards, which are out of date with current science and have not been updated since the 1970s

68 The National School Lunch Program81% of schools serve lunches exceeding 30% fat content, less than 45% serve cooked vegetables other than potatoes (usually French-fried), 42% don’t serve daily fruits and vegetables, and less than 10% serve legumes Overemphasis on milk products may increase long-term the risk for breast cancer, particularly if the milk comes from cattle treated with rBGH Does not help to establish good nutritional habits

69 The National School Lunch ProgramHelpful changes to program made in early 2012 More fresh fruits and vegetables available, more kids choosing healthy options Rules cover fat, meat, and vegetables, but no limits on sugar Exception: Smart Snacks in Schools guidelines prohibit vending machines with snack bars/treats exceeding 200 cals or containing trans fats

70 The National School Lunch ProgramDramatic changes in NSLP unlikely to occur given political clout wielded (and campaign dollars donated) by beef and dairy industries Former lobbyists in key positions in the Department of Agriculture

71 Pouring Contracts and Soda Consumption“Pouring rights” contracts with soda manufacturers Signed by cash-strapped school districts to gain additional income to compensate for cuts in educational and athletic programs 2012: 10 of the largest 25 school districts have or are considering agreements Yet ads generate < 0.05% of school revenues Conflicts with schools’ responsibility to teach proper nutrition

72 Pouring Contracts and Soda ConsumptionIn return for the placement of soda machines on campus and exclusive marketing rights to the districts’ children, companies sponsor sports and other extracurricular activities Rooftop ads T-shirt suspension and free speech

73 Pouring Contracts and Soda ConsumptionSome school districts have banned the sale and marketing of soda (e.g., Los Angeles) 63% of US schools limited carbonated soft drinks in 2008, compared to 38% in 2006 May not decrease overall soda consumption Vending machines substituting juice made with HFCS, bottled water

74 Pouring Contracts and Soda ConsumptionFederal law now requires school districts to have nutritional wellness policies in place These will be strengthened over the coming few years, and should help to curb pouring contracts

75 Pouring Contracts and Soda Consumption2006: Coca-Cola, Pepsi, and other soft drink manufacturers announced new voluntary policies to remove soda and other sugary drinks from schools nationwide Led to decreases in numbers of drinks bought ?effect on calories Nevertheless, soft drink advertising still reaches students through television and magazine advertisements and via Channel One

76 Supplemental Nutrition Assistance Program (SNAP)Formerly known as food stamps Serves 47 million people each month Avg. benefit = $1.50/meal 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

77 Exercise IOM recommends exercise one hour of exercise per day, double the 1996 recommendation by the Surgeon General 70% of American adults are not active in their leisure time; 40% are not active at all

78 Exercise and School 1/3 of children do not participate in the minimum recommended level of physical activity Number of children taking part in physical education courses has dropped significantly, in part due to school funding cuts Daily physical education associated with better school attendance, more positive attitudes about school, and better academic performance

79 Exercise and Poor CommunitiesNeighborhoods with high levels of minorities and individuals of low socioeconomic status have paucity of facilities that enable and promote physical activity, such as parks and gymnasia

80 Exercise and Poor CommunitiesHealthy weight status associated with amount of local park space Perception of one’s neighborhood as less safe is also associated with an increased risk of overweight in children Fear of exercising outdoors

81 Worrisome Trends TelevisionAverage American watches over 4 hours of TV daily Average American child aged 8-18 spends 8 hrs/day using an electronic device or watching TV TV sets now outnumber homes in America Average US teen sends/receives 88 text messages per day

82 Television and the InternetAverage youth spends 67% more time watching TV per year than he/she spends in the classroom 32% of children aged 2-7 have TVs in their rooms (65% of children aged 8-18) Diminishes parental control over viewing time and content

83 Television and OvereatingIncreases in television viewing are associated with increased calorie intake among youth Especially of calorie-dense low-nutrient foods of the type promoted on TV

84 Marketing Businesses spend estimated $13 billion annually marketing food and drinks in the US ($2 billion marketing to kids) Much TV advertising American children exposed to 40,000 food ads/yr 72% for candy, cereal, and fast food Numbers increasing

85 Marketing Convenience/fast foods and sweets over 80% of foods advertised during children’s programming African-American-oriented television airs far more junk food ads targeted at kids than general-oriented networks “Mommy bloggers” paid by industry to promote certain foods

86 Marketing WHO recommends food marketing curbsNeither FTC nor FCC has authority to limit advertising, despite the fact that children are vulnerable to exploitive advertising messages and unable to discern truth from fiction in ads

87 Marketing 2007: Kelloggs restricts food marketing to children2011: Jack-in-the-Box stops including toys in kids’ meals 2015: Disney to ban junk food ads on children’s TV and radio programs 2016: UK bans ads for unhealthy food targeted at children from TV, radio, cinema, newspapers, magazines, and online and social media Coca-Cola funds Global Energy Balance Network (emphasizes exercise, de-emphasizes diet) [and scientists who do the same]

88 Television Overweight and obese characters under-representedMen 25%; Women 10% Obese and overweight characters less likely to be considered attractive, to interact with romantic partners, or to display physical affection Perpetuates stereotypes Weight loss shows: e.g., Biggest Loser - ?Helpful?

89 Stigmatization Reality: the overweight and obese suffer from stigmatization Overweight and obese women are less likely to be offered college admission, get fewer promotions and face more job discrimination Not true for heavyset men 6 cities ban discrimination against the overweight in hiring ADA protects obese (disability) EU’s top court ruled obesity a disability Weight discrimination potential contributor to obesity

90 The Food Industry and Medical GroupsMedical groups have taken money from food companies (troubling conflict of interest): American Dietetic Association: Published “Straight Facts about Beverage Choices,” supported by grant from National Soft Drink Association Has accepted money from Coca Cola, Mars, Hersheys, other corporations AAFP’s magazine, “Family Doctor: Your Essential Guide to Health and Well Being,” marinated in ads from junk food companies, including McDonalds, Kraft (maker of Oreo cookies), and Dr. Pepper

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

92 Donations from Coca-Cola to Major Professional Organizations (2009-2015)American Academy of Pediatrics - ($3 million) Largest sponsor of its HealthyChildren.org website; ended relationship in 2015 American College of Cardiology - $3.1 million American Cancer Society - $2 million Academy of Nutrition and Dietetics (largest U.S. organization of dieticians) - $1.7 million (ended relationship in 2015)

93 The Food Industry and Medical GroupsAAFP partnership with Coca-Cola to support its family doctor website - $3.5 million (AAFP ends relationship in 2015) American Academy of Pediatric Dentistry Accepted $1 million donation from Coca Cola (2003) Claimed that “the scientific evidence is certainly not clear on the exact role that soft drinks play in terms of children’s oral disease” (2011) Contradicted earlier statement on dental caries

94 The Food Industry and Medical GroupsCoke spent $120 million for research and academic sponsorships between 2010 and 2015 Yale School of Medicine fellowship in obesity studies sponsored by PepsiCo American Heart Association has accepted money from similar companies, and allows its label on certified “heart-healthy” products CDC has accepted money from Coca Cola and PepsiCo

95 The Food Industry and Research/PublicationsSugar industry paid for and helped develop an influential literature review published in NEJM in 1967, which had a major influence on dietary sugar recommendations over subsequent decades Promoted low fat/high carbohydrate diets, leading to unknown number of new cases of obesity and diabetes Funding/participation not disclosed 2 Harvard researchers (Drs Mark Hegsted and Robert McGandy) paid total $48,900

96 The Food Industry and Research/Publications2016 analysis of 60 trials, systematic reviews,s and meta-analyses All 26 articles showing no link between sugar-sweetened beverages and the risk of obesity or diabetes were industry-funded Only 1/34 studies showing a positive association was industry-funded

97 From Soda to Bottled WaterCoca-Cola and PepsiCo both produce bottled water Coke: Dasani (tap water), others PepsiCo: Aquafina (tap water) Produces massive waste, expensive, highly profitable (on track to overtake soda sales by 2017)

98 Bottled Water Bottled water a $400 billion/yr profit-driven industry11.7 billion gallons/yr in U.S.; over 50% of population drinks Lacks essential minerals, fluoride

99 Bottled Water Costs 1,400 to 3,000 times more than tap waterUses up to 2,000 times more energy to produce than tap water 45% is tap water

100 Bottled Water Ratio of amount of water needed to produce 1 plastic bottle to amount of water in the bottle = 2:1 Weaker standards, dangers of plastics, energy costs/global warming, reduction of local water tables, recycling rate of plastic bottles only 23%

101 Bottled Water “Water is an efficient product. It is a product which normally would be free, and it is our job to sell it.” Suez CEO Gerard Mestrallet

102 Coca-Cola’s Human Rights and Environmental AbusesGuatemala bottling plants excoriated by human rights groups for labor rights violations, including rape, murder, and attempted murder Bottled water operations in India are depleting local water tables (soda contaminated with pesticides and heavy metals)

103 Food Producers and ObesitySugar producers, the packaged food industry, and producers of high fructose corn syrup sweetener: Contribute generously to politicians Top executives among President George W Bush’s biggest fundraisers Have exercised political influence to weaken food standards and labeling laws in the US and to pressure the WHO to weaken its anti-obesity guidelines

104 US Agricultural SubsidiesSince the 1960s, US agricultural subsidies have caused real (inflation-adjusted) price of Fats and oils to decrease by 10% Sugars and sweets to decrease by 15% Carbonated drinks to decrease by 34% Fresh fruits and vegetables to increase by 50%

105 Fruits and Vegetables About1/10 of Americans meet guidelines for fruit and vegetable intake Over 127,000 deaths/yr from cardiovascular disease could be prevented and $17 billion health care costs saved if Americans simply ate the recommended daily amount of fruits and vegetables

106 Consolidation and Industrialization of US Agriculture6.8 million farms in 1935 (vs. < 2 million today) The average farmer now feeds 129 Americans (vs. 19 in 1940) Americans spend less than 10% of their incomes on food, down from 18% in 1966 Subsidies mean one dollar can buy 1,200 calories of potato chips or 875 calories of soda or 250 calories of vegetables or 170 calories of fresh fruit

107 The Obesity Economy Plus-size apparel market worth $17 billion20% of women’s clothing sales (up from 11% in 2001) Half of all U.S. women wear size 14 or larger 1985: average size was 8.70

108 The Obesity Economy XXXL sized clothes; oversized autos, furniture, and coffins, and specialized medical equipment such as lifts, special chairs and toilets SWA requires obese to buy extra seat Other airlines considering

109 Obesity Worldwide America’s weight problem is occurring in the midst of a global epidemic of overweight and obesity Obese = 1.1 billion = Underfed Migration from countries with lower rates of cancer and more healthy diets (e.g., many SE Asian nations) adopt American diet within a generation Become more overweight/obese and suffer higher rates of cancer and obesity-related illnesses Cultural export of fast food outlets / supersizing

110 Underweight and Pathological Eating BehaviorsAbnormal self-image Prevalence of eating disorders has risen in US and developing countries Consequence (in part) of media’s depiction of “ideal” (excessively thin) woman 66% of women and 52% of men report feelings of dissatisfaction or inadequacy regarding their body weight

111 Underweight and Pathological Eating Behaviors60% of girls in grade 9-12 trying to lose weight 24% of boys #1 wish of girls aged 11 to 17 is to lose weight Women more likely to judge themselves overweight when they are not Men the opposite

112 Underweight and Pathological Eating BehaviorsWomen who desire to lose weight more likely to do so in the hopes of improving their appearance Men more likely to be concerned about future health and fitness Body image distress classified as a psychological disorder (body dysmorphic disorder)

113 Underweight and Pathological Eating Behaviors5-10 percent of females / 1-2% of males have some form of eating disorder Adolescent girls: anorexia nervosa (0.5%) bulimia (1-2%) DSM-V recognizes “Binge Eating Disorder” Seen in 10-20% of obese, also in normal weight individuals

114 Underweight and Pathological Eating Behaviors20% of female athletes have an eating disorder Male and female high school athletes at high risk for risky weight-control behaviors E.g., restricting food intake, vomiting, over-exercising, using diet pills, inappropriately taking prescribed stimulants or insulin, and using nicotine Some adolescents dehydrate by restricting fluid intake, spitting, wearing rubber suits, taking daily steam baths and/or saunas, and using diuretics or laxatives

115 Consequences of Abnormal Weight Loss BehaviorsDelayed maturation Impaired growth Menstrual irregularities / amenorrhea Infections Dental problems / tooth decay Eating disorders Depression Alternatively, such behaviors can be a sign of depression or verbal, physical, or sexual abuse

116 The Role of the Media Media images contribute to misguided perception of the “ideal” body Models today weigh 23% less than average women; 1986: 8% Dimensions of the average fashion model: 5’9”, 110lbs Dimensions of average American woman: 5’4”, 164 lbs

117 The Role of the Media Waist-to-height ratio: Barbie Doll 25%Lifesize Barbie would have a 17” waist Ken Doll 36% Female college swimmers 42% Male college swimmers 43% General healthy cutoff 50%

118 Modeling Schools for TeensCreate unrealistic expectations Only a very “select” few models achieve financial success Of these, beginners earn $1500 per day, those in the top tier $25,000 per day, and supermodels $100,000 or even more per day)

119 Modeling Almost ½ of 500 models studied were malnourished by WHO standards Some major fashion locales (e.g., Paris, Milan, Madrid, Israel) now require minimum BMI of 18 (not NYC) 2016: London banned “unrealistic body images” from public transportation system

120 Food Insecurity and HungerWorldwide, hunger-related causes kill as many people in 2 days as died in the atomic bombing of Hiroshima US faces increasing mal-distribution of wealth and significant levels of poverty and hunger Twenty-five percent of children live in poverty, and 4 million go hungry each day

121 Food Insecurity and HungerUSDA: 12% of US households suffer from food insecurity (limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable food in socially acceptable ways) Another 4% face outright hunger (the uneasy or painful sensation caused by the recurrent lack of access to food)

122 Waste Meanwhile, American households waste over $43 billion worth of food per year 1,400 calories per day (40% of food supply) wasted 3 times as much as in 1985

123 Gluttony and Eating ContestsInternational Federation of Competitive Eating sponsors more than 150 annual gorgefests Chicken wings, oysters, jalapenos, etc. Official newsletter: “The Gurgitator” Nathan’s Annual Fourth of July Hot Dog Eating Contest The World Cup of food bolting Past winners have consumed over 60 wieners and buns in just ten minutes

124 Treatments for ObesityDecrease caloric intake (especially simple carbohydrates and trans-fatty acids) Eat slowly Drink two glasses of water before eating Exercise more Get adequate sleep Behavioral modification

125 Treatments for ObesityEnlist familial and social support network Economic incentives (?sustainability) Rule out contributing factors (e.g., hypothyroidism) Treat associated conditions / sequelae

126 Treatments for ObesityAdults should receive 45% to 65% of calories from carbohydrates, 20%-35% from fat, and 10%-35% from protein 2/3 of women and 1/3 of men with BMI > 27 have attempted weight loss Most who initially succeed regain lost weight within 5 yrs

127 Treatments for ObesityCommercial weight-loss programs Jenny Craig and Weight Watchers most successful (4.9% and 2.6% greater weight loss at 12 mos c/w counseling and education alone) Nutrisystem shows potential (3.8%, but less well-studied)

128 Treatments for ObesityIn some countries, insurance companies cover obesity treatment Most in the U.S. do not, although they do cover myriad expensive health consequences of obesity Americans spend an estimated $30 billion each year on diet pills, diet foods, exercise videos, health club dues, and other weight loss tools Weight loss product scams are the most common type of product-related fraud (FTC)

129 Treatments for ObesityWeight loss drugs are a billion dollar per year business in the US Nearly 5 million US adults used prescription weight loss pills between 1996 and 1998 However, ¼ of users were not overweight Use especially common among women [Slentrol – 1st FDA-approved weight loss drug for dogs]

130 Treatments for ObesityDrug therapy may be appropriate for patients with a BMI > 30 or a BMI > 27 with additional risk factors Sibutramine and orlistat reduce weight 10% when combined with diet and exercise

131 Weight Loss Medications (2016 systematic review, meta-analysis)Over 1 yr, 23% % of patients taking placebo lost at least 5% of body weight Amount of weight loss over placebo at 1 yr Orlistat (Xenical) kg Liraglutide – 5.3 kg Naltrexone SR/Bupropion SR (Contrave) – 5.0 kg Lorcaserin (Belvique) – 3.2 kg Phenteramine + Topirimate ER (Qsymia) – 8.8 kg

132 Treatments for ObesityFenfluramine and dexfenfluramine taken off market in 1997 Numerous reports of cardiac valvulopathy Orlistat (Xenical) = inhibits intestinal lipases Side effects include GI discomfort, fecal urgency, liver failure, oxalate-induced kidney injury, and pancreatitis

133 Treatments for ObesityNaltrexone SR/Bupropion SR (Contrave) Side effects: N, HA, elevated BP and HR Black box warning re suicidality and neuropsychiatric events

134 Treatments for ObesityLorcaserin (Belvique) - serotonin agonist: Appetite suppressant Improves glycemic control, hypertension, lipids Side effects: URIs, HA, N; may increase risk for tumors, depression, and valvulopathies

135 Treatments for ObesityPhenteramine + Topirimate ER (Qsymia) – sympathomimetic anorectic + antiepiliptic drug Favorable effects on HbA1c, HTN, HDL Unlikely to cause valvulopathy Topirimate teratogenic (orofacial clefts)

136 Treatments for ObesitySibutramine (Meridia) = SSRI/NARI Average weight loss 4.2 kg over one year Can increase heart rate and blood pressure 2010: Withdrawn from market due to increased risk of stroke and MI Liraglutide (glucagon-like peptide) Mildly effective, risks include pancreatitis and possibly increased incidence of thyroid and breast cancers, very expensive

137 Treatments for ObesityNon-prescription supplements can be dangerous Unregulated with respect to purity, composition, and effectiveness Multiple contaminants Especially avoid compounds containing ephedra Banned by FDA, but still found in a number of preparations sold in the US and purchased abroad

138 Treatments for ObesityFuture pharmaceutical treatments will likely be directed against hormones involved in the regulation of satiety, such as leptin and ghrelin, and may include vaccines

139 Treatments for ObesityOther agents may act on adiponectin or irisin (the latter affects brown/white fat ratio) White fat stores calories, brown fat burns calories / generates heat Transcranial stimulation to quell cravings

140 Surgical Treatments for ObesityBMI > 40 (or BMI > 35 with DM2 or OSA) may be eligible for bariatric surgery Procedures include vagal nerve blockade (minimal weight loss, potential adverse consequences), Roux-en-Y gastric bypass (best outcomes), vertical sleeve gastrectomy, stapled gastroplasty, duodenal swithch, adjustable gastric banding, gastric balloon, and duodenal-jejunal bypass liner Designed to reduce stomach size and control caloric intake

141 Surgical Treatments for Obesity220,000 procedures performed annually Only 0.6% of eligible adults underwent a procedure; some teens now getting Less common among African-Americans

142 Surgical Treatments for ObesitySubstantial health benefits common Average weight loss after one year/three years: 62%/71% with Roux-en-Y gastric bypass (but only 21% more than controls at 10 yrs), 43%/55% with gastric banding Excess weight loss of up to 70%

143 Surgical Treatments for ObesitySubstantial health benefits common Resolution of HTN in 68% Resolution of dyslipidemia in 71% Resolution of diabetes in 1/3 to ¾ of patients Up to 65% lower risk of death; reduced risk of MI, CVA Improvements in memory function Increased chance of pregnancy Decreased urinary incontinence

144 Surgical Treatments for ObesityPerioperative mortality 0.4% Reoperation rate = 7% Complication rates almost 20-30% over a 180-day period Liposuction

145 Surgical Treatments for ObesitySide effects include dehydration, nausea/vomiting, reflux, GI symptoms, nutritional and electrolyte abnormalities Increased risk of alcohol abuse, depression, suicide, and hip/femur/pelvic fractures post-gastric bypass surgery

146 Other Invasive Treatments for ObesityVBLOC Vagal Blocking therapy Implanted neuroregulator; 8.5% wt loss over 12 months; reversible Reverse feeding tube (AspireAssist, developed by Segway inventor Dean Kamen) Removes 30% of consumed calories; weight loss at 1 yr 12% vs 4% controls Gastric balloon pills (swallowed, removed vie endoscopy after 6 months)

147 Public Health Measures to Reduce ObesityDHHS’s Healthy People 2010 objective: reduce prevalence of obesity to 15% <1/2 of obese US adults visiting a primary care physician counseled about weight loss Those counseled twice as likely to attempt weight loss 44% of US physicians overweight or obese – less likely to counsel

148 Public Health Measures to Reduce ObesityNeed for improved health care provider education in nutrition and increased use of nutritionists in primary care settings Would likely be cost-saving School- and community-based health education campaigns tailored to cultural background, gender, and age group

149 Public Health Measures to Reduce ObesityMedia health messages to correct misperceptions regarding weight and promote healthy behaviors Enhanced, science-based public school health curricula Not corporate-sponsored (e.g., “Count Your Chips” computational skills curriculum, sponsored by National Potato Board, others)

150 Public Health Measures to Reduce ObesityObesity report cards 20 states 23% of US elementary schools Lincoln University in PA requires students with BMI > 30 to pass a physical fitness test to graduate

151 Public Health Measures to Reduce ObesityMore healthful school and hospital cafeteria meal choices No fast foods, soda pop machines, or exclusivity contracts in schools (consider elimination of HFCS-laden juices and bottled water sales also) Enhanced state funding for public education Provision of healthier menu options in federally-sponsored school lunches increases student participation in NSLP

152 Public Health Measures to Reduce ObesityUse of local produce from community-supported agriculture, especially organics, would decrease adverse consequences of pesticides on the environment and amount of harmful greenhouse gasses produced in transportation of food over long distances

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

154 Public Health Measures to Reduce ObesityPedestrian malls Recreational centers, parks, and workplace gyms Requiring physical education at school Providing insurance coverage for membership in athletic clubs and insurance discounts for participation in exercise programs

155 Public Health Measures to Reduce ObesityAlabama: $25/month health insurance surcharge on state workers whose BMI exceeds 35 and who fail to enroll in a free wellness program and “show progress” State workers, however, pay lower rates for lower BP, FBS, cholesterol, and weight, or if they see a doctor to address health problems or participate in an exercise class

156 Public Health Measures to Reduce ObesityPPACA (ObamaCare) allows employers to charge obese workers 30%-50% more for health insurance if they decline to participate in a qualified employee wellness program

157 Public Health Measures to Reduce ObesityComprehensive employee wellness programs yield average reduction in healthcare expenditures of 26% Several state insurance plans impose a $25/month surcharge on smokers Others give up to 20% premium reductions to those who meet certain health guidelines

158 Public Health Measures to Reduce ObesityEnhanced health insurance coverage for obesity prevention and treatment Adjusted premiums based on weight in several states Health and life insurance companies own 1.9 billion of stock in the 5 leading fast food companies (2010)

159 Public Health Measures to Reduce ObesityAirline’s requiring obese passengers on full flights to rebook or purchase two seats Child abuse/child custody statutes Purge governmental bodies of those with industry connections

160 Public Health Measures to Reduce ObesityLaws to prohibit weight discrimination (MI only state, others considering) Have broad popular support Some doctors refuse to treat obese patients (higher risk of surgical complications, etc.) Fat Acceptance/Celebration Fat Studies National Association to Advance Fat Acceptance

161 Public Health Measures to Reduce ObesityProvision of nutrition information on restaurant menus Consumers strongly support Required in NYC (upheld by federal appeals court in 2009) Consumers underestimate calorie content of restaurant food by 28-48% Effective in some studies in decreasing calorie consumption Required by PPACA for many restaurants, other establishments starting 2017

162 Public Health Measures to Reduce ObesityAs of January 1, 2006, all conventional food items must include information re the amount of trans fatty acids they contain CA, NYC, Philadelphia, Cleveland have banned use of artificial trans-fatty acids in restaurants 2008: McDonalds eliminating trans fatty acid cooking oils Less than 2% of NYC restaurants using trans fats (2009)

163 Public Health Measures to Reduce ObesityIOM supports front-of-package labeling for calories, sugar, fat, and sodium using simplified system 2014: FDA announces overhaul of nutritional labels Greater emphasis on total calories, added sugars, and certain nutrients (potassium, vitamin d)

164 Public Health Measures to Reduce Obesity2015: FDA sets 2018 deadline to eliminate trans fats altogether Could prevent 20,000 heart attacks and 7,000 deaths from heart disease per year Cost of implementation estimated at $6 billion Health care and other cost savings: estimated $140 billion over 20 years

165 Public Health Measures to Reduce ObesityDenmark, Sweden, Iceland, Switzerland have banned trans-fats (other countries considering) Some claim that these compounds add flavor and texture to fried foods, but suitable, less dangerous cooking oil substitutes are available

166 Public Health Measures to Reduce ObesityProhibit distribution of toys and promotional games and presence of play equipment and video games at fast food outlets Require fast food restaurants to locate minimum distance from schools and playgrounds Limit per capita number of fast food outlets in a community

167 Public Health Measures to Reduce ObesityLimit proximity of fast food outlets to each other Charge fee to fast food outlets and use proceeds to mitigate the impact of poor nutritional content Prohibit drive-through service Supersize soda bans (NYC) - invalidated by federal judge

168 Public Health Measures to Reduce ObesityMajority of Americans believe the government should be involved in fighting obesity, particularly by regulating marketing of “junk foods” to kids 40 states tax non-nutritious foods (e.g., soft drinks and candy) 1cent/oz tax could reduce consumption of sugared beverages by up to 15%

169 Public Health Measures to Reduce ObesityTaxes on sugar-sweetened beverages recommended by IOM and APHA, which could (over 10 years) Reduce soda consumption by 12-21% Prevent 26,000 premature deaths Save over $17 billion in medical costs

170 Public Health Measures to Reduce ObesityFood and beverage industry fighting back against government-mandated efforts (expensive, intense lobbying) Soda companies spent over $100 million between 2009 and 2014 to defeat proposed sugar taxes (including in NY) Berkeley, Philadelphia, SFO, Oakland, Albany, Boulder have 1-2 cents/oz soda taxes Soda companies spent $38 million in 2016 to unsuccessfully fight 4 of these initiatives

171 Public Health Measures to Reduce ObesityEngland, France, and Mexico tax sugar-laden beverages Mexican tax decreased soda sales (more among lower SES households), but led to increased bottled water sales England taxes manufacturers, not consumers

172 Public Health Measures to Reduce ObesityWarning labels on sugar-sweetened beverages (bills proposed in CA, NY, and WA) Add “exercise equivalents” to food labels Lawsuits against purveyors of junk foods to reclaim health care costs Some states considering class action suits

173 Conclusions Epidemic of obesity in US and worldwideSerious health and economic consequences Multi-tiered approach necessary to combat

174 Covered in Other Slide ShowsIdeals of beauty and body modification Cosmetic surgery Female genital cutting Ethical and policy issues

175 References Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part I – Causes and health and economic consequences of obesity. Medscape Ob/Gyn and Women’s Health 2007 (posted 12/12/07). Available at Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part II – Economic Consequences of Obesity, the “Obesity Economy,” and the Role of Nutrition, Exercise, and Television. Medscape Ob/Gyn and Women’s Health 2008 (posted 1/04/08). Available at Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part III – A look at food and beverage industries. Medscape Ob/Gyn and Women’s Health 2008 (posted 3/25/08). Available at Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part IV – Obesity worldwide, pathological underweight, and gluttony. Medscape Ob/Gyn and Women’s Health 2008 (Posted 3/19/08). Available at Donohoe MT. Weighty matters: public health aspects of the obesity epidemic. Part V – Treatments and public health approaches to combating the problem. Medscape Ob/Gyn and Women’s Health 2008 (posted 4/10/08). Available at

176 Public Health and Social Justice WebsiteContact Information Public Health and Social Justice Website