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Worldwide Trends in Obesity

The Worldwide Obesity Epidemic: Trends and Potential Solutions Joel Gittelsohn, PhD October 3, 2019. Worldwide Trends in Obesity. Lancet. 2017 Dec 16;390(10113):2627-2642. doi : 10.1016/S0140-6736(17)32129-3. Epub 2017 Oct 10.

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Worldwide Trends in Obesity

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  1. The Worldwide Obesity Epidemic:Trends and Potential SolutionsJoel Gittelsohn, PhDOctober 3, 2019

  2. Worldwide Trends in Obesity

  3. Lancet. 2017 Dec 16;390(10113):2627-2642. doi: 10.1016/S0140-6736(17)32129-3. Epub 2017 Oct 10. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. NCD Risk Factor Collaboration (NCD-RisC).

  4. Methods • Pooled 2416 population-based studies with measurements of height and weight on 128·9 million participants aged 5 years and older, including 31·5 million aged 5–19 years • Used model to estimate trends from 1975 to 2016 in 200 countries for mean BMI and for prevalence of obesity

  5. Age-standardized mean BMI by sex and country in 2016 in children and adolescents. Children and adolescents were aged 5–19 years. BMI=body-mass index.

  6. Age-standardized prevalence of obesity by sex and country in 2016 in children and adolescents.Children and adolescents were aged 5–19 years. Obesity was defined as more than 2 SD above the median of the WHO growth reference.

  7. Key Findings • Regional change in age-standardized mean BMI in girls from 1975 to 2016 ranged from virtually no change in eastern Europe to an increase of 1·00 kg/m² per decade in central Latin America and an increase of 0·95 kg/m² per decade in Polynesia and Micronesia. • Global age-standardized prevalence of obesity increased from 0·7% in 1975 to 5·6% in 2016 in girls, and from 0·9% in 1975 to 7·8% in 2016 in boys. • Trends in mean BMI have recently flattened: • Northwestern Europe and the high-income English-speaking and Asia-Pacific regions for both sexes • Southwestern Europe for boys • Central and Andean Latin America for girls • The rise in BMI has accelerated: • East and south Asia for both sexes • Southeast Asia for boys

  8. Trends in the number of children and adolescents with obesity by region. Children and adolescents were aged 5–19 years. BMI=body-mass index.

  9. Trend in prevalence of obesity in the U.S. Hales et al., 2017

  10. What’s going on?

  11. Change in dietary habits and weight in US women (NHS) + 0.9 lbs + 3.3 lbs + 1.0 lbs + 1.7 lbs - 0.4 lbs - 0.2 lbs - 0.5 lbs Weight change in 20 years follow-up (1986-2006). Adjusted for: age, baseline BMI, sleep, PA, TV, smoking, alcohol, and all the other dietary factors. Mozaffarian et al., 2011

  12. Shifts in the food and beverage supply • Increased : • availability • variety • portion size • processed and packaged foods • marketing • costs of many healthy foods

  13. Food environment and obesity Accessibility Higher availability of grocery stores (counts) positively associated with healthier diet Bivoltsis et al., 2018 Availability Proximity to fast foods positively associated with higher BMI and fast-food intake Black et al., 2014

  14. Lancet. 2019 Feb 23;393(10173):791-846. doi: 10.1016/S0140-6736(18)32822-8. Epub 2019 Jan 27. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, De Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH.

  15. The Global Syndemic • Three pandemics— obesity, undernutrition, and climate change—represent The Global Syndemic that affects most people in every country and region worldwide • They constitute a syndemic, or synergy of epidemics, because they co-occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers • Will require systems approaches to understand

  16. Methods • Systems perspective to understand and address the underlying drivers of The Global Syndemic • The major systems driving The Global Syndemic are food and agriculture, transportation, urban design, and land use

  17. Strategies to Address the Obesity Epidemic

  18. Strategies at Multiple Levels • International/global? • Federal • City/Local • Institutional • Household • Individual

  19. Obesity Prevention Policies • Federal • Improving food assistance programs (e.g., SNAP, WIC in the US) • Healthier school meal standards (Healthy, Hunger-Free Kids Act of 2010) • Advertising restrictions • Restricting price promotions on unhealthy foods and beverages • Nutritional Ranking Systems • SSB/Junk Food Taxes (Mexico) • State • Food sales in government buildings • City/local/tribal • Staple food ordinances • SSB Taxes • Financial Incentives to Purchase Healthy Foods (e.g., Double Up Food Bucks) • Menu Labeling Requirements (Calorie information) • Rezoning

  20. SSB Taxes, systematic review (Teng et al 2019) • Inclusion criteria: Comparison between pre-post tax (n = 11) or taxed and untaxed jurisdiction(s) (n = 6) • Consumption outcome: sales, purchasing, and intake (reported by volume, energy, or frequency) • Taxed and untaxed beverage consumption outcomes examined separately by meta-analysis with adjustment for the size of each tax • 10% SSB tax was associated with an average decline in beverage purchases and dietary intake of 10.0% (95% CI: -5.0% to -14.7%, n = 17 studies, 6 jurisdictions) • 10% SSB tax was also associated with a nonsignificant 1.9% increase in total untaxed beverage consumption (eg, water) (95% CI: -2.1% to 6.1%, n = 6 studies, 4 jurisdictions)

  21. Institutional interventions • Mainly schools (for children) • But also in hospitals, worksites (for adults)

  22. Summary of 15 review articles of school-based obesity prevention (Gittelsohn and Kumar 2007) - 1 • Successful in improving psychosocial factors (e.g., knowledge, self-efficacy, intentions) • Associated with small improvements in diet and PA (of questionable PH significance) • Impact on obesity found from 20-75% of studies (depending on review criteria), effect is modest • Modest amount of parental involvement • Little or no effort to change the food environment outside of schools

  23. Literature review on “school-community” intervention trials (Gittelsohn & Park, 2010) • Period: 1990-2009 • Inclusion criteria: • Should have both school- and community-based components • Evaluation outcomes must include obesity, PA, and/or energy intake • 10 studies (22 articles) reviewed • School-based intervention trials with extensive engagement of the broader community show positive impacts on child BMI • Programs have had limited success in actually changing food and physical activity environments. Changes made at the community and environmental levels not well documented

  24. Institutional interventions • Mainly schools (for children) • But also in hospitals, worksites (for adults) • Food retail • Prepared food sources

  25. Obesity Solutions in the Urban Food Environment

  26. Change access to foods within retail food stores and prepared food sources • Decreasing availability of less healthy foods • Increasing availability of healthy foods in small food stores • Changing the physical location of foods (e.g. store layout) and other forms of “nudging” • Store renovations (e.g., adding FV coolers) • Manipulating price (usually temporary price reductions)

  27. Change access to foods within neighborhoods and communities • Building new supermarkets • Developing farmer’s markets • Improving transportation • Introducing urban farms

  28. Other approaches • Improving food networks (distributors, producers, retailers) • Improving local production (e.g. urban agriculture) • Improving nutrient quality of foods (manufacturers) • Changing packaging of foods (manufacturers)

  29. Case Example: The Baltimore City Food System

  30. Obesity in Baltimore City Adults, 2014

  31. Baltimore’s Food System 22 wholesalers Baltimore 191 Public Schools 633 small groceries and corner stores Producers/ Manufacturers 41 Recreation Centers 80 chain convenience stores Wholesalers/ Distributors 47 supermarkets Food Sources 6 public markets Individual Households 24 urban farms 225 food pantries Individuals ~55 dollar stores Food assistance ~50 pharmacies Marketing

  32. Our food systems work in Baltimore City

  33. Approach 1: Changing the Retail Food Environment (Corner Stores) • Improve supply • Wholesaler gift cards • Nutrition training in language of store owner(s) • Promotional materials targeting store owners • Improve demand • Shelf labels, posters • Interactive sessions, taste tests • Promotional giveaways

  34. Approach 1: Results • Customer Impact: • Significant impact on food preparation methods and frequency of purchase of promoted foods • Positive trend for healthy food intentions • Store Impact: Gittelsohn et al, Health Education and Behavior, 2009 Song et al, Public Health Nutrition, 2009

  35. Approach 2: Changing the Prepared Food Environment • Phase 1: Modified menu boards and menu labeling • Healthy options highlighted with a leaf logo and promoted with photos • Phase 2: Healthy sides and beverages • Promoted currently available healthy sides and beverages • Introduced new healthy sides and provided initial stock of the healthy sides • Phase 3: Affordable Healthy combo meals • Improving food preparations methods (e.g. provide a grill) • Healthy combo mela promotion with price reduction

  36. Approach 2: Results Change in the ratio of healthy to less-healthy items sales from baseline, intervention phase Ratio of Gross Revenue at Each Phase Relative to Baseline Change in % healthy food sales from baseline, by intervention phase

  37. Approach 3: Multilevel Multicomponent Interventions • Operate at multiple levels of the Baltimore City food system • Increase affordability, availability, purchase, and consumption of healthy foods in 14 low-income minority neighborhoods • Evaluate impact on multiple levels: healthy food pricing and availability; adult food purchasing, preparation, and obesity; and child obesity, diet, and psychosocial factors

  38. Summary of BHCK Findings • Wholesalers: trend for increased sales of promoted foods and beverages • Corner stores: increased stocking of promoted foods and beverages, no impact on sales detected • Carryouts: trend for increased stocking of promoted foods and beverages

  39. Summary of BHCK Findings • Adult caregivers: greater increase in intake of fruits over time among those with higher exposure level • Children: Increased frequency of healthy food and beverage purchasing, by treatment group • Children: Reduced % of kcals from sweet snacks and desserts, by treatment group

  40. Lessons Learned • We can get small stores and carryouts to increase stocking of healthier foods, and show impact on consumer food choices, food sales, and total revenue • Sustainability of small store interventions is possible in Baltimore • Small food source interventions can improve stocking of healthier foods and consumer diet • Consider food source interventions in combination with other components of the food system to impact health outcomes

  41. Thank you! Find Us Online! E-mail: jgittel1@jhu.edu Website: healthyfoodsystems.net /bmorehealthyfs @bmorehealthyfs @ globalfoodman @bmorehealthyfs @ globalfoodman

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