Globesity

Obesity is taking over many parts of the world. EHM spoke with WHO’s Chizuru Nishida and Jonathan Siekmann about the implications of the new epidemic.

EHM. How could obesity develop into an epidemic?

JS. There are a lot of theories. But certainly it’s a combination of decreased physical activity, changing diets, and increased urbanization. People are moving away from traditional lifestyles in rural areas to cities, where they are more sedentary. There’s a greater variety of foods. People are sometimes less likely to prepare food themselves, and eat out. So it’s a combination of these factors working together. But it also depends on the country.

CN. We organized expert consultations specifically around obesity in 1997. The title was ‘Obesity: Preventing and managing the global epidemic ’. The consultation reviewed the different factors affecting this epidemic. It is a serious disease, but its development isn’t inevitable. It is largely preventable through lifestyle and societal changes.

EHM. The global strategy on diet, physical activity, and health is one WHO initiative to tackle the problem of obesity. What is this strategy all about?

CN. The WHO Global Strategy on diet, physical activity and health is actually the WHO’s global strategy for preventing chronic diseases, not obesity per se. Of course, obesity prevention is one of the main focuses of this global strategy as obesity is an important comorbidity for serious chronic diseases, such as coronary heart disease, hypertension and stroke, certain types of cancer, and type 2 diabetes. It was adapted by the World Health Assembly in 2004, and much efforts are being made by WHO together with Member States and various other stakeholders to implement the global strategy.

EHM. What else is WHO doing to help reduce obesity?

CN. On the nutrition side, we promote exclusive breastfeeding for the first six months and the introduction of appropriate complimentary feeding. Those definitely will contribute to the promotion of healthy diets and prevention of the overweight and obesity problem. Also, last year we launched the new growth standard for children under five years of age. These new standards are based on the breastfed child as the norm for growth and development. This brings coherence for the first time between the tools used to assess growth, and national and international infant feeding guidelines, which recommend breastfeeding as the optimal source of nutrition during infancy. This will now allow accurate assessment, measurement and evaluation of breastfeeding and complementary feeding. Related to that area of growth reference, we have recently developed growth reference for school-age children and adolescents, which will also provide an internationally agreed growth reference for those age groups which are lacking at the present time.

Focusing on that age group, we also have an initiative which was recommended by the expert consultation we had on childhood obesity. That is the Nutrition-Friendly Schools Initiative (NFSI), which focuses on school settings to address not only overweight and obesity, but a whole spectrum of nutrition problems. It addresses the double burden of malnutrition, which covers under nutrition all the way to overweight and obesity and other related chronic diseases at the school-based programs.

CN. Moving on from there, we also support countries in developing intersectoral, integrated food and nutrition plans and policies. In many countries, the nutrition policies do need to encompass both spectrums of nutrition problems. We are trying to cover as many countries as possible, but in a sustainable manner. In collaboration with our regional offices and partner agencies, we organize regional and subregional capacity-building training workshops, which we have held for selected countries in Africa twice. We also had one for Eastern Mediterranean countries and Southeast Asian countries respectively. In the Pacific regions, they have been organizing this capacity-building workshop on an annual basis for the last four years. Their fifth one is being planned for February 2008.

EHM. Which countries are particularly affected by obesity?

CN. Obesity is a huge problem in the Pacific countries, for example. And associated with it is diabetes in that whole subregion. We are trying to help the countries integrate their NCD and nutrition policies in order to improve their dietary practices, and also to increase the physical activity, as well as to address environmental and societal factors that are affecting their dietary and physical activity patterns. For instance, many of the countries in the Pacific depend heavily on importation of food items which are often very high-fat, energy-dense, and micronutrient poor.

JS. At WHO, we make guidelines and recommendations. We collect the evidence that allows countries to use and implement their own policies. In the case of the US, the government is shaping its health policies – the Centers for Disease Control and Prevention, primarily. There’s also the US Department of Agriculture, which is in charge of nutrition policy.

EHM. In the US, government and regulatory authorities such as the FDA are criticized for not getting more involved in the prevention of obesity by improving the diet of many Americans. Why is this still being neglected?

CN. There is an effort being made by various states in the US. We understand they are making great effort, for example, in removing trans fatty acid from the processed foods. WHO, through our regional office for America, is trying to encourage and also assist in that effort not only in the US, but for the whole region, through the establishment of The Task Force on Transfat-Free America.

Could the authorities do more? Yes, but nothing is perfect. However, some work has been done, not only by the FDA, but by the HHS. They formed a study group and scientific advisory group to develop the strategies for addressing childhood obesity, for example. They also looked at the marketing of food to children. And I understand that there are various committees being formed in order to address obesity issues in the US.

EHM. How can hospitals and physicians contribute to reducing obesity?

JS. While I was in California last year, Kaiser Permanente, which is a big healthcare provider on the West Coast, had some great advertising campaigns, for example, advertising fruit and vegetables in an innovative way. They were sponsoring farmers' markets on Wednesdays. They also have messages inside the hospitals, and the meals that they serve to patients reflect a lot of vegetables and fruits. They also have a research unit based in Oakland, California, looking at public health issues and chronic disease, diet, and nutrition.

They are setting a good example, and as far as physicians are concerned, they are becoming more aware of weight, and incorporating discussions of weight and overweight into routine visits. But it’s also difficult for physicians to talk about overweight. Sometimes the physicians themselves are overweight, and they don’t feel like they can be talking to their patients about it, if they themselves are. But it is definitely helpful if physicians incorporate talking about weight issues into the standard practice.

EHM. Where will you concentrate your efforts in the future?

JS. We provide guidelines, and taking scientific evidence and producing guidelines – at least in my opinion – is one of our primary functions. In addition to the WHO growth standards for children under five released in 2006, we have recently developed growth references for school-age children and adolescents that fit well with the under-five growth standards at five years and the recommended adult cut-offs for overweight and obesity at 19 years.

BMI is, of course, one indicator of overweight. But people also use other indicators such as waist circumference and waist-to-hip ratio. And in fact, waist circumference might be a better indicator of risk for cardiovascular disease or diabetes than BMI. Currently, WHO does not have a WHO-endorsed cut point for waist circumference or waist-to-hip ratio. So we are trying to work on that and review the evidence. There are cut points that other people use. But at present there are not internationally agreed cut-off points.

We are also trying to solidify methodologies for estimating overweight and obesity in the world. This is a very important topic. We hope to have global, regional, and, ideally, country-level estimates of overweight and obesity. And we don’t want to forget about underweight. With all the focus on overweight and obesity, we must not forget that underweight is still a problem in many countries. We’re therefore trying to strengthen the underweight data of our global BMI database as well.

CN. We have specific recommendations on how to deal with weight gain and obesity. And related to that, we are now updating the recommendations on various nutrients, like carbohydrates, for example, and their relationship with weight gain and obesity. We will be working on more of those kinds of guidelines over the next couple of years. As part of the implementation of the global strategy on diet, physical activity, and health, WHO is planning to hold a consultation and dialogue with the private sectors in early 2008..

We are also working with several of our regional offices to develop regional food-based dietary guidelines, which provide guidance on healthy diets and address the prevention of overweight and obesity and other nutritional related chronic diseases, so that each one of the countries can adopt the regional guidelines and modify them to suit each country situation. And so the strengthening of the food-based dietary guideline and implementation in several regions, including Africa, is going to be our focus for next year.

[Jonathan Siekmann]
Since November 2006, Jonathan Siekman has been managing and maintaining WHO’s global database on body mass index. Actively searching and collecting data on weights, heights and BMI, Siekmann is building a database used for estimating global and regional prevalence of overweight and obesity.

[Chizuru Nishida]
Chizuru Nishida is a scientist at WHO’s Department of Nutrition for Health and Development. She is responsible for the program areas related to obesity, as well as the program areas related to nutrition policies, food and nutrition security, and dietary guidelines.

Major Food Sources of Trans Fat for American Adults
40%: cakes, cookies, crackers, pies, bread
21%: animal products
17%: margarine
8%: fried potatoes
5%: potato chips, corn chips, popcorn
4%: household shortening
3%: salad dressing
1%: breakfast cereal
1%: candy
Data based on FDA’s “Trans Fatty Acids in Nutrition Labeling, Nutrient Content Claims, and Health Claims”

Factoid
5.8 grams or 2.6 % of calories = average daily trans fat intake