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Epidemiology of Obesity. A Global Pandemic. Joan Temmerman, MD. Stages of Epidemiologic Transitions. Gaziano, JAMA 2010;303(3). 1 st (most of human history): pestilence & famine Infectious disease & malnutrition  average life expectancy 30 yrs

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epidemiology of obesity

Epidemiology of Obesity

A Global Pandemic

Joan Temmerman, MD

stages of epidemiologic transitions
Stages of Epidemiologic Transitions

Gaziano, JAMA 2010;303(3)

1st (most of human history): pestilence & famine

  • Infectious disease & malnutrition average life expectancy 30 yrs

2nd (late 19th & early 20th century): receding pandemics: industrialization & urbanization

  • increasing wealth, food availability, better nutrition, water & sewer systems decreased mortality, increased life expectancy
stages of epidemiologic transitions1
Stages of Epidemiologic Transitions

3rd (mid 20th century): degenerative & human-made diseases

  • increasing disease fromCVD (cardiovascular disease) & cancer; smoking, decreased activity, increased fats and animal products

4th (mid 1960’s): delayed degenerative diseases

- - decreased CVD mortality, better prevention and technology

5 th stage the age of obesity inactivity
5th stage: The age of obesity & inactivity
  • Threatens steady gains in longevity & QOL
the age of obesity inactivity
The age of obesity & inactivity
  • If trends continue, almost half of US adults will be obese by 2020
  • Significant progress in decreasing chronic disease rates during last 40 years will be overturned
  • Possibly decreased life expectancy

Gaziano, JAMA 2010;303(3)


Obesity Trends* Among U.S. AdultsBRFSS,1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC

obesity is a pandemic

Obesity is a pandemic!

Obesity affects all ages and socioeconomic groups

Threatens to overwhelm both developed and developing countries (WHO)

Pandemic refers to a worldwide epidemic. Although typically used in context of infectious diseases, it can describe chronic diseases as well.

obesity pandemic
Obesity pandemic
  • Global: affecting almost all countries with enabling economic conditions
  • Rapidly transmissible (near simultaneous upswing of the epidemic across countries over the past 40 years

Swinburn BA et al; Lancet. 2011 Aug. 27;378(9793):803-14

global prevalence adults
Global prevalence-adults
  • In 2005 WHO estimated1.6 billion adults worldwide overweight; >400 million obese
  • By 2015 2.3 billion overweight; >700 million obese projected

Nguyen & El-Serag, Gastroenterol Clin North Am. 2010

global prevalence children
Global prevalence-children
  • Estimated 170 million children (<18) globally overweight or obese in 2008
  • This is >25% of children in some countries!

Swinburn BA et al; Lancet. 2011 Aug. 27;378(9793):803-14


Estimates of percentage of childhood population overweight and obese

in a selection of countries

Swinburn BA et al; Lancet. 2011 Aug. 27;378(9793):803-14

global prevalence
Global prevalence
  • Poor increasingly burdened
  • Paradoxically coexists with undernutrition (WHO)
  • Many countries in transition faced with doubleburden of undernutrition as well as overnutrition, obesity, & related diseases
  • The higher the level of income inequality, the higher the prevalence of obesity independent of the overall wealth of a country

Swinburn BA et al; Lancet. 2011 Aug. 27;378(9793):803-14

• Obesity associated with

increased mortality

• 2-3-fold increased risk of death

Serious health effects: obesity major risk for DM, CVD, HTN, stroke, and some cancers

James WPT, J Intern Med 2008:336-352

Nguyen & El-Serag, Gastroenterol Clin North Am. 2010

Obesity strongly related to the

epidemic of type 2 diabetes.

strong link between obesity and t2dm
Strong link between obesity and T2DM


increased risk


increased risk

Marrero DG. J Diabetes Sci Technol 2009;3(4):757-760.

financial burden
Financial burden
  • Total annual economic cost of overweight & obesity in US and Canada caused by medical costs, excess mortality and disability was approximately $300 billion in 2009

Obesity and its Relation to Mortality and Morbidity Costs.” December 2010

what is driving this
What is driving this?

What is driving this?

dietary changes since 1970 s us
Dietary changes since 1970’s: US
  • Types of sugar: fructose
  • Sweetened beverages
  • Salty snacks, pizza, pasta, cakes, bread, cereals
  • Energy from snacks 50%
  • Food away-from-home

40% eaten outside home

Gibson & Shepherd, Aliment Pharmacol Ther 2005;21

shift in dietary patterns
Shift in dietary patterns
  • More women working; single households
  • Decreased cooking skills taught in schools
  • Consuming prepared meals rather than cooking
  • Dependency on manufactured, processed foods
  • Tremendous shift to eating outside the home

James WPT, J Intern Med. 2008;263:336-352

american trends
American trends
  • 50% of US food expenditure is now spent on food outside the home
  • Eating out is associated with obesity

Clauson & Leibtag, USDA 2011


Trends in restaurant expenditures and obesity in the United States, 1940–2004.

Sources: Flegal et al.& Ogden et al; USDA Food Expenditure Tables.

Neil et al, Am J Prev Med. 2008 February ; 34(2): 127–133

eating out increases calorie intake worsens dietary quality
Eating out increases calorie intake, worsens dietary quality
  • Poorer diet quality (more calories, fats and carbohydrates) & larger portion sizes compared to foods at home
  • People select more indulgent food when they eat out: more calories, fat, and saturated fat than at-home meals and snacks

Todd & Mancino, 2010; Neil et al; 2008

Glanz et al, 2007; Mancino et al, 2009

the american lifestyle
The American Lifestyle
  • 50% of US food budget is spent eating outside the homeClauson & Leibtag,USDA 2011
  • Only 9% keep track of caloriesand can accurately estimate how many calories they should eat
  • Physical activity has disappeared

IFIC Foundation Releases 2011 Food & Health Survey

  • 40% of adults get no activity at all!
what is the global driver
What is the global driver?
  • What is the environmental factor that has changed substantially over the past 40 years (coinciding with the upswing of the epidemic)?

Swinburn BA et al; Lancet. 2011 Aug. 27;378(9793):803-14

  • Energy imbalance: dietary changes and decreased physical activity (PA)
  • Reduced heavy work; increased motorized transport, cheaper cars, technological aids to remove physical demands at home & work
  • Increased computer and TV time

Possible to earn good wages & have enjoyable leisure with virtually no PA!

James WPT; J Intern Med. 2008;263:336-352

  • Penetration of Western-style media and fast-food outlets into developing world
  • US not only has highest obesity rates, but has led transformation of society to toxic “obesogenic” environment
  • Globalization of Western food systems and consumer culture has infiltrated all world societies

James WPT, Int J Obesity 2008;32:S120-126

Sobal J, Int J Epidemiol. 2001;30(5):1136-1137.

what is globalization
What is Globalization?
  • Increased mobility of goods, services, labor, technology and capital throughout the world
  • Process of worldwide integration & unification
  • World considered a global unit

Huneault et al, Obes Rev. 2011;12(5): e64-72

Sobal J. Int J Epidemiol. 2001;30(5):1136-1137.

  • Globally decreased activity: universal & inexpensive transportation, cars, TV, energy-saving components of built environment
  • Global food systems & global vehicles, appliances and mass media are underlying causes of increases in global obesity

Sobal J, Int J Epidemiol. 2001;30(5):1136-1137.

  • Industrialization and computerization almost totally replacing physical work
  • Small gas-powered systems for ploughing and other activities
  • Reduced cost of producing & distributing food

Huneault et al, Obes Rev. 2011;12(5): e64-72

Popkin BM, Nutr Rev. 2009;S79-82

global nutrition transition
Global nutrition transition
  • Shift from traditional plant-based foods to more energy-dense diet
  • High in animal fat, sugar, processed, less fiber

Kimokoti & Millen, J Am Diet Assoc. 2011;11(8):1137-40

global transitions
Global transitions
  • Reductions in time-cost of food is major driver of global obesity epidemic
  • Rural urban
  • Infectious diseases non-communicable
  • Technological: low high mechanization and motorization
  • Traditional foods more processed, energy-dense

Swinburn BA et al, Lancet. 2011 Aug. 27;378(9793):803-14.

dietary changes
Dietary changes
  • Energy-dense, cheap, tasty,

highly accessible food

  • Highly effective marketing to buy immediately available food for instant gratification
  • Massive agricultural subsidies (fruit and vegetables least)
  • Cheaper meat, butter, oils, fats, sugars

James WPT, J Intern Med. 2008;263:336-352

global corporations
Global corporations
  • Establishing industrialized food systems providing 24-7 consumer access to unlimited volumes of cheap, calorie-dense foods
  • All people, all places, all times via supermarkets, vending, drive-throughs, catering, home-delivered, fast/snack foods

Sobal J, Int J Epidemiol. 2001;30(5):1136-1137.

Technological changes creating cheaper, more available food


Strong economic forces driving consumption

Overconsumption & obesity


Swinburn BA et al; Lancet. 2011 Aug. 27;378:803-14

global solutions
Global solutions
  • Obesity represents a worldwide epidemic, therefore is a global pandemic
  • Not a set of independent occurrences in various nations
  • Global conditions have underlying global causes
  • Require global interventions

Sobal J, Int J Epidemiol. 2001;30(5):1136-1137.

areas for future public health efforts
Areas for future public health efforts
  • Obesity must be recognized as major public health issue across the world
  • Recognition of obesogenic environment as main driver
  • Government leadership, regulation, investment to tackle toxic environment
  • Global priority for population-based policies promoting optimal nutrition
  • Consumer education, individual behavior
policy changes a sustained worldwide effort
Policy changes: a sustained worldwide effort
  • Interventions to reverse obesogenic drivers must be predominantly policy-led: mainly government policy (shifting agricultural policies to incorporate health outcomes, banning unhealthy food marketing to children, healthy food sector service policies)
  • Also address built environment, transport systems, active recreation opportunities, food culture.

Swinburn BA et al; Lancet. 2011 Aug. 27;378(9793):803-14)

Hill JO et al, Obes Rev. 2008;9(S1):41-47


A framework to categorize obesity determinants and solutions

Layers of determinants






Swinburn BA et al; Lancet. 2011 Aug. 27;378(9793):803-14

sustained worldwide effort
Sustained worldwide effort
  • Many parties (governments, international organizations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach.
  • Prioritize policies to improve food and built environments, cross-cutting actions (leadership, healthy public policies, and monitoring), and much greater funding for prevention programs.
  • Increased obesity monitoring in populations
  • Integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) to augment the influence and sustainability of policies.

Gortmaker SL et al, Lancet. Aug. 27;378: 838–847

  • Gaziano JM. Fifth phase of the epidemiologic transition: the age of obesity and inactivity. JAMA. 2010;303(3):275-276
  • Obesity trends among US adults; Behavioral Risk Factor Surveillance System, CDC. Accessed 12/2/11 at http://www.cdc.gov/obesity/data/trends.html
  • Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, Gortmaker SL. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011 Aug. 27;378(9793):804-14.
  • Nguyen DM, El-Serag HB. The epidemiology of obesity. Gastroenterol Clin North Am. 2010 Mar;39(1):1-7.
  • James WPT. The epidemiology of obesity: the size of the problem. J Intern Med. 2008;263:336-352
  • Marrero DG. The prevention of type 2 diabetes: an overview. J Diabetes Sci Technol 2009;3(4):756-760.
  • Obesity and its Relation to Mortality and Morbidity Costs.” December 2010. Accessed 12/2/11 at: http://www.soa.org/files/pdf/research-2011-obesity-relation-mortality.pdf
  • Gibson PR, Shepherd SJ. Personal view: food for thought-western lifestyle and susceptibility to Crohn’s disease. The FODMAP hypothesis. Aliment Pharmacol Ther 2005;21:1399-1409
  • Clauson A, Leibtag E. Food CPI and Expenditures Briefing Room. Table 12. US Department of Agriculture. www.ers.usda.gov/Briefing/CPIFoodAndExpenditures/Data/Expenditures_tables/table12.htm. Accessed May 10, 2011
  • Neil K. Mehta NK, Chang VW. Weight Status and Restaurant Availability: A Multilevel Analysis. Am J Prev Med. 2008 February ; 34(2): 127–133
  • Todd JE, Mancino L. Eating Out Increases Daily Calorie Intake Amber Waves June 2010. USDA ERS. http://www.ers.usda.gov/AmberWaves/June10/Findings/EatingOut.htm
  • Glanz K, Resnicow K, Seymour J, Hoy K, Stewart H, Lyons M, Goldberg J. How major restaurant chains plan their menus: The role of profit, demand, and health. Am J Prev Med. 2007 May;32(5):383-8.
  • Mancino L, Todd J, Lin BH. Separating what we eat from where: Measuring the effect of food away from home on diet quality. Food Policy 2009;34(6):557-562.
  • International Food Information Council (IFIC) Foundation. http://www.foodinsight.org/Press-Release/Detail.aspx?topic=Price_Approaches_Taste_as_Top_Influencer_for_Americans_When_Purchasing_Foods_Beverages Accessed May 26, 2011
  • James WPT. WHO recognition of the global obesity epidemic. Int J Obesity 2008;32:S120-S126.
  • Sobal J. Commentary: Globalization and the epidemiology of obesity. Int J Epidemiol. 2001;30(5):1136-1137.
  • Huneault L, Mathieu ME, Tremblay A. Globalization and modernization: an obesogenic combination. Obes Rev. 2011 May;12(5):e64-e72.
  • Popkin BM. What can public health nutritionists do to curb the epidemic of nutrition-related noncommunicably disease? Nutr Rev. 2009;27(S1):S79-82.
  • Kimokoti RW, Millen BE. Diet, the global obesity epidemic, and prevention. J Am Diet Assoc. 2011 Aug;111(8):1137-40.
  • Hill JO, Peters JC, Catenacci VA, Wyatt HR. International strategies to address obesity. Obes Rev. 2008;9(S1):41-47.
  • Gortmaker SL, Swinburn BA, Levy D, Mabry PL, Finegood DT, Huang T, Marsh T, Moodie ML. Changing the future of obesity: science, policy, and action. Lancet. Aug. 27;378: 838–847.