Obesity Epidemic – Timeline, scenarios, Projections and Ethical Implications.

Global Timeline of Obesity

Overweight and Obesity levels have risen dramatically across the globe over the last 50 years. This rise has led to Obesity being classified as an epidemic. In 2008 1.4 billion adults aged 20 or over were overweight with 500 million of these classed as Obese (WHO, 2008). The World Health Organisation (WHO), classify Overweight and Obesity as a person having a Body Mass Index (BMI) 25-29.9kg/m2 for overweight and BMI ≥30kg/m2 for Obese.

A person with a BMI within a range of 18-24.9 kg/m2 is classified as falling within a normal range. Elrick, Samaras, and Demas (2002) found that America has seen a massive 30% increase over the past fifty years in overweight and obesity, where 70.8% of the population is now overweight or obese. In Ireland the rates for such a small country are alarmingly high with 61.9% of the population overweight with 26.2% of males obese and 24.2% of females falling into the obese category (WHO, 2008).

As recording health related issues became more frequent especially from 1960 onwards, the escalation in incidence of obesity has been well documented. Various studies and surveys have highlighted not only the fact that incidence of Obesity is increasing, but its dramatic rise is at epidemic proportions compared to other diseases. Surveys such as NHES (National Health Examination Survey) later to become NHANS (National Health and Nutrition Examination Survey), which are a cross sectional, nationally representative series carried out across the United States of America from 1960 to 2008 by the National Centre for Health Statistics of the U.S. Centres for Disease Control and prevention. All the surveys included a standardised physical examination carried out in a mobile examination centre, where weight and height, were measured using a standard protocol. The results of the various surveys have shown that Obesity levels from 1960 until 1980 were relatively stable, but more than doubled 15% in 1980 to 34% in 2006. What is interesting about the data from these surveys is that the increase in Obesity is substantial as it rises from 14.5% (NHANES 1, 1971-1974) to 34.3% (NHANES 2007-2008).

Probably the most conclusive studies carried out on chronic diseases are two that have been conducted by the WHO. They are the Multinational Monitoring Trends and Determinants in Cardiovascular Diseases (MONICA) and Countrywide Integrated Noncommunicable Diseases Intervention (CINDI). While the Monica report was primarily about cardiovascular disease on a worldwide scale, CINDI was a report on chronic disease in Europe. The Monica report highlighted that hypertension, obesity, diabetes, high blood lipid levels, were the sole contributing factors to cardiovascular disease and were the root cause of the cardiovascular epidemic. What we can take from Monica is that Obesity is not only on the rise, but contributes to other diseases also. Cindi was designed to promote the overall goal of having a strategy to prevent and reduce chronic diseases through an integrated public health at local, government and regional levels. The report highlighted that chronic diseases could be reduced by implementing plans at a national level and even following some simple guidelines such as twelve steps to healthy eating and recommendations on physical activity. These studies highlight the prevalence and the distribution of chronic diseases such as Obesity throughout Europe and the World.

A study by Berghofer et al (2008) reviewed 49 separate studies, which were mainly cross sectional surveys that estimated the prevalence of Obesity within the European area. The studies used by the authors spanned a time line between the mid-1980s to 2003. The authors found that prevalence of Obesity in Men ranged from 4% (France) to 28% (Spain) and women 6% (Lithuania) to 36% (Poland). The highest rates of Obesity were found in the Mediterranean countries and Eastern Europe. This is an increase from the mid 1980s when 15% of males and 17% of females were classified as obese. The authors noted that obesity has risen approximately 30% over the last 10 to 15 years before their study was published. From the studies we can see that there is an east/west, north/south division for obesity, however, the overall rise in obesity levels across Europe is alarming.

It is not only Europe and the developed world that obesity effects, but is now affecting the developing industrial countries where there is now available data (B.Caballero, 2007). Factors influencing the increase of Obesity in developing countries have been rapid urbanisation, subsidised agriculture, the provision of cheap refined oils, fats and carbohydrates, more affordable forms of motor transport, a huge increase in sedentary pastimes such as watching television (A.M. Prentice, 2005). Studies from most regions across the globe have highlighted the increased obesity levels, however, there is little data from developing countries except for Brazil, China and India and Mexico to support this claim. Studies have until recently suggested that Obesity was more of a problem found amongst the poor and in rural areas, with the reverse in lower income countries (.J. Jones-Smith, L.P. Gordon, A. Siddigi, B.M. Popkin. 2011)

Within developed and developing countries we can see the impact of obesity, as it is now a major concern amongst the child populations across the across the world. Research carried out by Wang and Lobstein (2006) on childhood obesity prevalence, studied papers and surveys conducted in 60 countries (from the 191 countries represented at the WHO) within different regions around the world. The authors used papers published after 1980 and used subjects up to the age of 18 years. These papers used weight for height or BMI to report the prevalence of Obesity in children. The authors reported a growing trend in childhood obesity across all regions of the world especially industrialised countries, where the increase has been very dramatic and spread very quickly. America, Canada, Brazil, Chile, Japan, Australia, Greece, Spain and the United Kingdom show that childhood obesity levels are rising across all corners of the world. Alarmingly, the authors summarised that if secular trends continue on a linear basis then 46% of school going children will be overweight in the Americas, 41% in Eastern Mediterranean, 38% in the European Region, 27% in the Western Pacific, and 22% in South East Asia by 2010. The NHANES surveys show how childhood obesity is affecting North America. In 1980 the prevalence of overweight and Obesity was for children between 2 and 19 years of age was 5.5%. In 2003-2006 show that 31% of children aged between 2-19 years of age had a BMI at or above 85th percentile of the 2000 CDC BMI-for-age growth charts, and 16.3% were above or at the 95th percentile BMI for the age. Children are a population where we can implement policies and reduce their risk of developing an early onset of obesity.

While diet and calorie intake are probably the most important components of obesity and overweight, another factor is also important. The amount of physical activity a person gets is also an important factor in obesity epidemic. We have seen that there has been an increase in calorie consumption over the past fifty years and a reduction in physical activity.  By including a weekly exercise routine that only requires an expenditure of 1400 calories after metabolic rate adjustment, can minimise mortality (Elrick et al, 2002). By increasing energy expenditure and by lowering energy intake will result in weight reduction over time. However, rather than increasing physical activity to match this energy intake, we have actually reduced the amount of physical activity we do on a daily basis. We do not participate in as much recreational sport as we used to, and due to time constraints, increased sedentary lifestyles such as watching television or playing computer games, we have seen a diminishing number of participants taking part in recreational team sports (Jacoby, 2004). In Canada, the self reporting, Canadian Community Health Survey (CCHS) reported in 2009 that 51% of women and 44% of men were inactive, with 59% of men and 44% women had increased health risks from their inactivity. In Ireland the report of the National Task force on Obesity reported in 2005 that 51% of the Irish population engaged in some form of physical activity with only 22% performing mild exercise four or more times per week. The report also highlighted that there was now a growing trend in inactivity particularly amongst girls over the age of fifteen. With the rise in obesity and the reduction in physical activity, it would not be hard to reverse the trend. Swindburn, Sacks and Ravussin (2009) reported that a reversal of 500kcals for adults and 350kcals for children daily would be needed for a return to the mean body weight for the population of the US of the 1970’s. If we increased our activity levels we could help lower the risk of Obesity in the population. As we can see from the data we appear to be eating more and exercising less, and as a result we will continue to see an increase in obesity unless we implement policies and procedures that will reverse this upward trend

Certain scenarios for future based on the projections in the literature.

There are many studies on the predictions of what the future holds for populations as overweight and Obesity rise. Many researchers have calculated that what the effect on behaviour, policies, interventions will have from the individual to the population. They are forecasting a future of high rates of Obesity, which will impact societies policies and views on health, economics and finance (Gortmaker et al, 2011). It is estimated that by 2030 if current trends continue, that there will be 65 million more obese adults in the USA, and 11 million more obese adults in the UK (C. Wang, 2011).

The increase in Obesity will lead to extra pressure on local health services and health care as the incidence of diseases linked to obesity increase. Such diseases as diabetes, cardiovascular diseases and many forms of cancer will all see increases. The increases in these diseases will see an increase in mortality rates linked to obesity, where the life expectancy will be lowered from poor health. Wang (2011) reports that for every BMI increase of 5kg/m2 there is an increased chance of oesophageal cancer by 52 % and colon cancer by 24% in men. Women have a much higher risk of contracting endometrial cancer and gall bladder cancer both by 59%. These are the more serious conditions that are linked to obesity. However, we shall also see a steep increase in other disorders that are linked to excessive bodyweight such as sleep apnoea, prostate hypertrophy, infertility and asthma. As Obesity becomes more prevalent in younger persons, we can see populations of people living vast majorities of their life in chronic pain and disability. Finkelstein, Fiebelkorn and Wang (2003) argue that Obese patients incur more than 46% of inpatient care, 27% of physician visits and outpatient costs, and 80% increased spending on prescription drugs. This will have a huge effect on the spending of governments. In 2003 it was reported that medical costs in excess of $75 billion were attributed to Obesity in USA (Wang et al, 2011). Obese patients tend between 14% and 25% more doctors visits than normal weight patients (M. Effrat and R. Effrat, 2012). Obese patients cost the US Healthcare system $147 billion in 2008. This burden was a huge 10% of the overall budget for the healthcare system.

This burden on the healthcare system will mean that governments need to implement effective interventions. Physical activity and weight loss are important factors in reducing any future burden on healthcare. Modest weight reduction in the region of anywhere between 5 and 10% will show significant decrease in developing type 2 diabetes. With the life expectancy of a 30 year old man with a BMI≥35 will have a lower life expectancy of 5 years (J. Manson, J Skerrett, P. Greenland, T. Vanltallie, 2004). It becomes more evident that for longevity of life the overweight and obese need to implement a more physical active lifestyle in order to prolong their lives (Mansion et al, 2004)

The Obesity epidemic will have severe problem on the health service. We have seen worldwide that healthcare services are already stretched to capacity. With the many diseases and illnesses associated with obesity these services are going to be stretched even further. The medical cost of Obesity will have to be borne by the health service. As obesity continues to rise, there will no doubt have to be an increase in departments devoted to Obesity and Obesity related diseases. This places, an added burden on the finances of health departments of governments, as they will incur added costs for drugs, treatments, and hospital care. It is estimated that the direct cost of Obesity to healthcare in the U.S. was in the region $24 billion in 1995 or 9.4% of the total healthcare budget (Manson et al, (2004). In Canada the total cost was $3.9 billion or 4.9% of the healthcare budget. Obesity accounts from anywhere between 2% and 4% of the healthcare budgets of Australia, France and the Netherlands (Mansion et al, 2004). As we can see as Obesity increases across the world, the cost to the healthcare system rises. At some stage Obesity will account for 100% the healthcare budget if trends keep increasing. Jacoby (2004) argues that if we can treat the illnesses associated with obesity such as hypertension, diabetes and serum cholesterol at an early stage then there can be a positive health outcome, which will reduce the cost on the health service.

All the latest surveys and statistics point to a growth in obesity that is now a global epidemic. Many nations that are carrying out and recording the results of these surveys are recording the increase in BMI and show obesity to be rising at an alarming rate. Diet is one reason for the increase in Obesity. We have seen a huge global increase in the consumption of food where the daily calorie intake in Industrialised countries has increased from just over 2947kcals per day to an estimated 3440kcals per day by 2015(L. Rattan, 2005). This increase is mirrored across less developed countries such as Near East and North African countries which show an increase in daily calorie consumption from 2290kcal in the 1960’s to an estimated 3090kcal per day by 2015 (L. Rattan, 2005). This increase in energy consumption can be tied into changing attitudes to energy dense processed meals and fast foods. We have seen a shift away from traditional meal type diets towards energy dense processed food. It is now more affordable to base our dietary habits on more refined grains, added sugars and added fats, compared to basing our diets on lean meats, fish, fresh vegetables and fruit (Drewnowski,2004).

As we move more and more towards the burger counter in the local fast food establishment, and away from our kitchens, we can see the influence fast food has had on obesity levels since 1980. It is around this time that high fructose corn syrup (HFCS) began to replace sugar as a low priced substitute. HFCS is made up of roughly 55% fructose and 45% glucose. Carmen (1982) highlighted the advantages to business and food producers to substituting sugar with HFCS with a reduction in production costs that could be passed onto consumers with a lower priced product. Carmen stressed that consumer savings per capita would be small. However, given the link between HFCS and Obesity, Carmen could not have estimated the cost not only to government health care but also society in general. Vos et al (2008) highlighted that in 1978 the daily intake of fructose was 37g (8% of total intake)., and it increased by an estimated to 54.7 g/day which is almost a 50% increase from data collected between 1988 and 1994. The authors argued that measuring this increase has implications for health Improvements and advances in the technology of food production, processing and marketing has driven down the cost of producing processed foods. This has meant that by 1996 over 40% of the average US dollar was spent on food consumed away from the home compared to 25% in 1970 9Jacoby, 2004). Major commodities such as chocolate (10.1%), pet food (23.3%) and pastry (10.6%) have all enjoyed huge increases in growth between 1980 and 1998. However Wheat  (.2%), Corn (.5%) and cocoa beans (.1%) have not enjoyed such health growth since 1980 (FAOSTAT). The growth in energy dense commodities, tie in with a technological drive for improvements in food production, processing, and marketing (Jacoby, 2004). As we become less physically active and spend more time in front of tv sets, we become more influenced by marketing and advertisement campaigns for fast food companies and a variety of sugary drinks and chocolate bars. These products do not tell us the down side of consuming them, but how happy they will make us feel after eating them. It is important that we implement the correct warnings to lessen the influence these advertising campaigns can have on our decision to make good food choices.

There have been many theories put forward for the increase in Obesity over the past 50 years, however a common trend appears in much of the data and analysis for some common factors that have led to these increases. One factor for the increase in Obesity is linked to our changing dietary habits. It is now more affordable to base our dietary habits on more refined grains, added sugars and added fats, compared to basing our diets on lean meats, fish, fresh vegetables and fruit (Drewnowski,2004). This has led to an increase in daily energy intake and a sharp increase in the consumption of energy dense meals. Drewsnowski (2004) argues that taste and convenience has led us to adding extra sugar and fat to our meals and can influence our food choice in the direction of prepared and pre-packaged foods. One factor for this increased fast food choice is our income. Jacoby (2004) states that in 1970 only 25% the average US dollar was spent on food consumed away from home. This figure has increased to 35% in 1985 and was up to 40% by 1996.  .

Recommendations to tackle the issues.

The following recommendations are designed to create awareness and influence people’s lifestyles in order to reduce the obesity epidemic:

Firstly, we need to change our attitude and approach towards obesity. We can target the roots of obesity before it creates overweight adults by emphasising good nutrition in preschool and primary schools. Nutritional education needs to start with the young, and so more resources and time needs to be given to this education before children early adulthood. This would give future generations the tools to make healthy choices with regards their diet and physical wellbeing. By educating children to make these choices we reduce to risk of early onset of many diseases that are associated with being overweight and obese. It will be important to particularly target children from disadvantaged areas, as this socio economic group appears to have the most exposure to fast food and poor nutritional options.

Second. There should be a campaign within schools and by local governments to target the education of parents with regard healthy eating. This will enable the children to receive the best support possible for improved nutrition. It should also act as trigger for parents who have poor nutritional habits to begin to improve their diets. It may help with encouraging parents to be more physically active and encourage their children to also be more active, so that they operate on the same level as teachers educating children in schools.

Third. We need to look at the way the food industry makes its profits. We understand that companies need to make a profit to be viable. However, if we can encourage companies to increase profits by producing healthier products, the industry may become more proactive in promoting healthier products with lower energy density. There are many ways of encouraging companies to promote healthier foods that they offer. This is where governments can play a significant role. One idea would be to increase taxes on unhealthy energy dense processed food, and also fast food. In return, it would be only fair to reduce taxes on healthy foods, to ensure that consumers moved towards the cheaper healthier option.

Fourth. A more straightforward public policy is needed to ensure that the most efficient nutritional advice is being provided from all professions from the medical profession both private and public on education society on the negative aspects for health and everyday living from poor nutrition. General Practitioners need to be better educated to advise their patients on good nutritional habits and healthy lifestyles, as it is very important that we have proper knowledge in the healthcare system so that they can educate people on the importance diet with regards good health. It should also be public policy to ensure that the health risks from obesity are more widely known. Campaigns that highlight the consequences for health from Obesity should also be undertaken much in the same way as anti smoking advertising has been undertaken by governments worldwide.

Fifth, marketing energy dense fast food to children, need to be monitored, curtailed, even banned during children’s television programmes. This is the one time that advertisers can be sure that vast amounts children will be watching. This is generally, before meal times when they can promote their clown eating a happy meal or show a cartoon monkey or tiger enjoying a bowel of cereal. Children are the most impressionable section of society and there must be a responsibility on the fast food industry to help in promoting healthier eating habits, and if they promote burgers, they must also promote salads as equally as appetising as the burgers to the captive audience.

Sixth, a nationwide program needs to roles out to promote physical exercise. Government funded support groups that could initiate walking groups, even jogging in local parks could be set up to encourage more people to become physically active. These could be done by local parks who could organise fun run/walk races once a week during summer months and one a fortnight during winter months. This could motivate people to take up more physically demanding exercise during the week to increase their fitness levels for their local Saturday race.

Seventh. The government should insist that all fast food outlets provide clear nutritional information and composition on all packaging and menus. There should be additional leaflets in fast food restaurants detailing all nutritional values of each meal and each combination meal sold in that fast food outlet.

Eight. Fast food restaurants and global food companies that produce energy dense, unhealthy food, should have to contribute 30% of their advertising budget to advertising their healthy products. This would ensure that the healthier section of the fast food industry was least promoted enough that consumers may take a chance and try it.

Make a brief statement on the ethical and financial implications of your recommendations.

With all recommendations that require careful planning, administration and implementation, there will be a cost involved. However, what cost can be put on ones health. Governments need to undertake nationwide awareness campaigns to highlight the link between Overweight, Obesity and the negative implications on health by an unhealthy diet and sedentary lifestyle. As more diseases are linked to overweight and obesity, we will see an increase in the amount of money needed to fund health services. The knock on effect of this will be increased taxes and levies to fund the extra burden on the health services worldwide. Also, with the increase in obesity we will continue to see a rise in energy dense processed food, and as a result we will find less healthy options available at cheaper prices.

When intervening in a persons’ wellbeing are we intentionally or unintentionally imposing the views of a large section of society on a smaller section of society. Should we leave the final decision on whether a person lives a healthy lifestyle with a good nutritious diet and plenty of physical activity or should we insist that everybody tries to live a healthy lifestyle with plenty of exercise and healthy food. Holm (2011) argues that we need to look at when is it appropriate and justified to intervene in a persons own health and wellbeing if they do not wish to have an intervention. Socially, the author also states that there is a certain amount of stigmatization and a change in self-perception in identifying and targeting high risk groups such as Obesity. However, Efrat (2012) argues that it is fine for an individual to engage in a sedentary lifestyle and poor diet, if the person realises the cost that their lifestyle has on society, and bears that cost themselves. Basically the author argues that government intervention is only necessary if the person cannot bear the full financial cost of their lifestyle. When these costs shift to the state, the state must then implement policies to reduce the cost on the public healthcare system. The private healthcare system already shows what happens when normal weight individuals bear the cost of health insurance by about $1,900 over their lifetime in the pooling of healthcare costs according to Keeler et al. We do need to be careful not to stigmatise overweight and Obese subjects where a prejudice against their size becomes one for public ridicule and resentment, especially in times of recession when extra income for necessary services like healthcare become more scarce. Private healthcare has been shown to be one of the first items people cut back on when income is reduced. If we can reduce the cost of private healthcare it should be possible for most people to afford even the most basic package on offer.

One of the main implications will be the need of the general population to change its eating habits and perception on diet. We will be forced to do this in order to reduce the ratio of obese to normal sized persons. The negative effect is that sections of society must change their habits to suit another section of society. Holm (2011) argues that people that are overweight or perceive themselves to be will have to change their lifestyles in order to reduce obesity. Many of these according to the author may never suffer from obesity or have any related problems that one gets with obesity.


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