Prof. W. Philip T. James International Obesity TaskForce Delivering successful strategies for changing diet & physical activity
Current IOTF initiatives and supported global developments 2000. • Chinese Action Group established April 26: obesity burden analyses & preventive options - Beijing, Dec. 11-13. • EU Diet & Health: policy needs proposed - Crete, May 18-20 • FLASO Initiative: Ata do Rio de Janeiro - June 30-July 2. • WHO Europe - Health Ministers' Regional Committee, Sept. 15-16. Obesity now a priority. • Commonwealth Health Ministers. IOTF/WHO Workshops • Pacific Islands: 17 countries, Sept. 26-29. • Caribbean: over 15 countries, November 20-22. • WHO Global Burden of Disease: Dec. 5-7 - Auckland, NZ. • French Presidential Initiative Council of Health Ministers; Paris launch on Dec. 15. Obesity to be highlighted.
The strength of evidence on diet and disease 1. Ecological studies of associations 2. Clinical observations 3. Case / control studies 4. Cohort studies + indices of individuality 5. Clinical therapy - analyses of different treatments 6. Population comparisons, e.g. of cities / state responses 7. Randomised controlled trials (+ double-blind placebo)
Public Health Strategies to implement FBDG and enhance lifestyles • MYTHS: • Primary prevention strategies are not effective • They take too long to have an effect • People do not like to be told what to do • the food industry will suffer • Nutritionists do not agree Need resources for public health strategies on diet and physical activity.
Rose's population approach Required reduction in mean to halve prevalence of high risk groups Variable (definition of high) Systolic B.P. (>140 mmHg) 8 mmHg 4 mmHg Diastolic B.P. (>90 mmHg) Obesity (BMI >30) 2.6 (kg/m2) 39 mmol/d Sodium intake (>250 mmol/d) Rose, G. in CHD Epidemiology. Ed. Marmot & Elliott, Oxford Med. Pub. 1992.
BMI distribution curves from the Intersalt Study populations Probability density Body Mass Index (kg/m2) Source: Rose, G. (1991) .
Optimum nutrient intakes derived from international (especially European) reports
Optimum nutrient or dietary intakes derived from international (especially European) reports
The traditional Mediterranean diet * Chemical Analyses in the 7-Country Study with Crete 36%, Corfu 27%. Recent re-evaluation of some original diet records suggest 42% for Crete(Kafatos et al. 2000). Some fatty acid values estimated by difference.
Prevention of diabetes in glucose intolerant adults. Cumulative incidence diabetes % Control * +0.3 -1.8 25.8 + 3.8 45 -0.8 -3.5 31 55 1.7% -3.7% 26.6 + 3.1 48 Weight loss kg (%): Baseline BMI + SD Age (yrs): * Dietary change in all three studies involved detailed recurrent dietetic advice. Physical training in sports centre or on own for >12 months with 6 year follow-up and recurrent monitoring and help.
Legislation Health education Community development Fiscal change Organisational change Re-orientation of services PUBLIC HEALTH NUTRITION STRATEGIES
A step-by-step approach to FBDG • IDENTIFY: • Major food sources of nutrient of interest • Foods providing substantial part of population intake • Foods explaining variations in intakes Then formulate FBDG
Total lipids % E in food supply for the Caribbean - 1990 Calculated by Ferro-Luzzi from FAO Food Balance Sheets
Saturated Fatty Acids % Energy in food supply for the Caribbean - 1990 Calculated by Ferro-Luzzi from FAO Food Balance Sheets
Fruit and Vegetable intake - 1990. Calculated by Ferro-Luzzi from FAO Food Balance Sheets
The % contribution to total fat intake (% energy from fat) in Irish Adults (18 years+) Food Group Contribution Fresh meat 18 Spreadable fats 17 Milk 16 Biscuits/cakes/pastries/ desserts 11 Meat products 7 Potatoes 6 Eggs 5 Bread 5 Other dairy products 4 Chocolate confectionery 2 Savoury snacks 1 92% of total Institute of European Food Studies (IEFS) Ireland, 2000
Sources of non-milk extrinsic sugars (NMES) in pre-school children
Odds ratios and 95% confidence intervals of being overweight / obese (BMI >25) if sedentary. Progressively higher physical activity level (PAL) values have been used to discriminate sedentary from active lifestyles. Ferro-Luzzi & Martino. 1996 Obesity and Physical Activity - Ciba Foundation Symposium 20, publs. John Wiley & Sons, pp. 207-221
Options for increasing physical activity to desirable 1.7 PAL ALTERNATIVE STRATEGIES A normal sedentary day Daily Once weekly Walk 60' BMRx4.0 Jog 20' BMRx11.0 Jog 140' BMRx11.0 Walk 420' BMRx4.0 Travel (BMR x 2.56) Domestic activity (BMR x 2.82) Work (BMR x 1.60) Time allocation mins/day Active leisure Passive leisure Sleeping, washing etc. (BMR x 1.06) The day's PAL From Ferro-Luzzi and Martino (1996). Modelling was performed for an average 70 kg male to determine the nature, duration and timing of active leisure required to achieve an overall mean physical activity level of around 1.70. Columns 2 and 3 indicate how this can be achieved by exercising on a daily basis, whilst columns 4 and 5 show what is required if exercise is concentrated into one day per week.
Extracurricular sports in children aged 7-11 years at primary school and their enjoyment of these activities during lessons
The percentage of English secondary schoolchildren aged 12-13 years who engaged in each sport more than 10 times per year These levels of physical activity are much lower than in many other countries. Taken from Mason, 1995. Young people and Sport in England, 1994. A National Survey.
Television watching and weight gain in children 18 lessons 30-50 mins. Over 2-3 months to to 92 children aged 9 yrs. in intervention and 100 in control school. Random assignment of school: T.V. stopped for 10 days (67%) then 7 hr/week budget and "intelligent viewing". No link to obesity. Robinson, T.N., 1999. JAMA;282:1561
The ANGELO Strategy Socio- cultural Constraints Physical Economics Political Environmental Micro Macro Egger, G. and Swinburn B. An ecological approach to the obesity pandemic. BMJ, 1997; 315: 477-480.
Options for change: food • 1. Target nutrients / foods • Total fat • Saturated fats • Free sugars • Salt • Vegetables • Fruits
Physical Micro-settings: • Neighbourhood: Shop availability Safe walking / cycle paths recreation & sports facilities. • School: Canteens serving food Tuck shops Play grounds • Home: Gardens • Market: Local food availability (fruit & vegetables • Work: Food arrangements Cycle sheds Changing facilities
Options for change: food • 2. Target places to eat:- • Hotels • Restaurants • Schools • Workplace: public and private • Street stalls • Home
Options for change: food purchasers • Incremental but progressive changes targeting:- • Importers • Hotels • Supermarkets
Options for change: physical activity (1) • Standing • Walking • Cycling • Elevators / stairs • Leisure activities: target women particularly • Dancing • Swimming • Other single / dual activities ?
Options for change: physical activity (2) • Healthy active schools: Education Dept. • Walkway/pedestrian areas : Planning Dept. • Cycle paths: need coherent transport policy - treasury ? • Swimming lessons: Education Dept. • Work facilities: Employment/Commerce Depts.
Options for change: socio-cultural targets • Vegetables types • Sugary drinks • Use of salt • Foods in pregnancy • Fats / Fries • Overweight women • Waistline • Exercising women