ACHSE Symposium on Obesity, August 2007, Melbourne Obesity: Understanding the “Millennium Disease”: ACHSE Symposium on Obesity, August 2007, Melbourne Obesity: Understanding the “Millennium Disease” Louise A Baur
Discipline of Paediatrics & Child Health, University of Sydney
NSW Centre for Overweight & Obesity
The Children’s Hospital at Westmead
Email: louiseb3@chw.edu.au
Obesity: One of today’s most blatantly visible – yet most neglected – public health problems
The public health equivalent of climate change
The Millennium Disease Obesity WHO; www.who.int/nut/obs.htm; Laing & Rayner, Obesity Reviews 2007; www.iotf.org
How big is the problem for Australian adults?: How big is the problem for Australian adults?
Australian adults 1999-2000: 2 out of 3 men and 1 in 2 women overweight or obese … and 1 in 5 obese: Australian adults 1999-2000: 2 out of 3 men and 1 in 2 women overweight or obese … and 1 in 5 obese Overw’t & obesity Obesity
(BMI >25 kg/m2) (BMI >30 kg/m2)
Adult males 67.5% 19.3%
Adult females 52.2% 22.2%
AusDiab Study: Cameron et al, MJA 2003
Measured heights & weights; adults >25 y
Risks of obesity in Caucasians: Risks of obesity in Caucasians Relative risk
Greatly increased
(RR >>3)
Moderately increased
(RR 2–3)
Slightly increased
(RR 1-2) Disease
Type 2 diabetes Dyslipidaemia
Insulin resistance Sleep apnoea
Gall bladder disease
Heart disease Hypertension
Cancer Osteoarthritis
Gout
Infertility Anaesthetic risk
Polycystic ovary syndrome
Obesity is associated with high costs: Obesity is associated with high costs The economic costs of obesity. Access Economics, 2006. Financial cost of obesity $ 3.8 billion
Net cost of lost well-being $17.2 billion
Total cost of obesity $21.0 billion
What about children and adolescents?: What about children and adolescents?
Slide8: Trends in combined overweight & obesity
in school-aged children since 1970 0 5 10 15 20 25 30 35 1970 1980 1990 2000 Prevalence % Lobstein et al. Obesity Reviews 2004
Slide9: Trends in combined overweight & obesity
in school-aged children since 1970 0 5 10 15 20 25 30 35 1970 1980 1990 2000 Prevalence % Lobstein et al. Obesity Reviews 2004 NZ - 2002 NSW - 2004 Lobstein et al. Obesity Reviews 2004; NZ Children’s Nutrition Survey 2002; NSW Schools Physical Activity & Nutrition Survey, Booth et al, 2006
Slide10: Trends in combined overweight & obesity
in school-aged children since 1970 0 5 10 15 20 25 30 35 1970 1980 1990 2000 Prevalence % Lobstein et al. Obesity Reviews 2004 NZ - 2002 NSW - 2004 Lobstein et al. Obesity Reviews 2004; NZ Children’s Nutrition Survey 2002; NSW Schools Physical Activity & Nutrition Survey, Booth et al, 2006 1 in 4 Australia children
& adolescents are
overweight or obese
Prevalence rates are increasing
Slide11: Complications of obesity in children and adolescents Source: Ebbeling et al, Lancet 2002
Slide12: Complications of obesity in children and adolescents Source: Ebbeling et al, Lancet 2002 What are the health & economic
consequences of increased numbers
of adolescents entering adulthood
with:
Established obesity
Established type 2 diabetes
Risk factors for heart disease & diabetes
Other co-morbidities?
What causes obesity?: What causes obesity?
Slide14: Genetic predisposition Chronic energy
imbalance
What are the factors in our environment promoting the development of obesity?: What are the factors in our environment promoting the development of obesity?
Summary of trends in obesity-related behaviours - 1: Summary of trends in obesity-related behaviours - 1
ADULTS CHILDREN & ADOLESCENTS Weight-related behaviour Current situation Recent trends Current situation Recent trends High Increased slightly (3-4%) High Increased substantially (11-15%) Total sugar intake High Increased (6-12%) High Increased substantially (19-25%) Sweetened drink intake High Increased (9-15%) High Increased substantially (29-48%) NSW Centre for Public Health Nutrition 2003
Australian data for longitudinal trends
Summary of trends in obesity-related behaviours - 2:
ADULTS CHILDREN & ADOLESCENTS Weight-related behaviour Current situation Recent trends Current situation Recent trends Fast food intake High Increased High Increased Confectionery Moderate Increased (28%) High Substantial increase (40-56%) Level of physical activity Low Decreased (9%) Moderate Probably stable Passive leisure TV, computer games .. High Probably stable High Increased Active travel to work/school Low Decreased Low Decreased NSW Centre for Public Health Nutrition 2003
Australian data for longitudinal trends Summary of trends in obesity-related behaviours - 2
What factors are influencing food and physical activity behaviours?: What factors are influencing food and physical activity behaviours?
The rise in home TV, video, DVD, Playstation and IT use by children and adults : The rise in home TV, video, DVD, Playstation and IT use by children and adults
Slide20: The changing
food environment
Slide21: http://hp2010.nhlbihin.net/portion/index.htm 20 y ago Now Portion sizes have increased
Per capita consumption of milk and soft drink - Australia: Per capita consumption of milk and soft drink - Australia 0 20 40 60 80 100 120 140 160 Per capita consumption (L) Milk Soft drink 1939 1949 1959 1969 1979 1989 1999 Apparent Consumption of Foodstuffs. ABS 4306.0 ?
What role marketing?: What role marketing? TV and radio (ads, program sponsorship, product placement)
Cinema (ads, product placement)
Websites
Phone promotions
Text messaging
Direct marketing
Sponsorship of events, teams, clubs
Branded toys & computer games
In store (shelf, special offers, displays)
On, or in, the product (product formulation, portions, gifts & vouchers)
Schools (sponsorship, vending machines, participation in promotion schemes)
Blogs
Interactive digital billboards
The wide range of types of marketing of foods & beverages
Slide24: What about advergaming?
On-line games involving consumer products
Changing urban landscape – the car rules: Changing urban landscape – the car rules
Urban planning that promotes car use rather than “walkability” and active transport: Urban planning that promotes car use rather than “walkability” and active transport
Where is the play space?: Where is the play space?
In the early 21st century the unhealthy choices (around food and physical activity) are the easy choices: In the early 21st century the unhealthy choices (around food and physical activity) are the easy choices
We live in the most obesity-conducive environment known in the history of humankind
So, how do we tackle this epidemic?: So, how do we tackle this epidemic?
Slide30: Individual
behaviour change Adapted from Puska P, 2004 Healthy eating
Healthy activity
Healthy weight Complementary approaches to prevention The environmental
gradient is steep Environmental
change
Slide31: Individual
behaviour change Adapted from Puska P, 2004 Healthy eating
Healthy activity
Healthy weight Complementary approaches to prevention So, changing
the gradient … Environmental
change
Slide32: Individual
behaviour change Adapted from Puska P, 2004 Healthy eating
Healthy activity
Healthy weight Complementary approaches to prevention … will make it easier
to change behaviour Environmental
change
Slide33: So, what approaches can:
Make the gradient less steep?
and/or
Support individuals and families
to change behaviour?
Some of the Australian obesity policies and guidelines to date: Some of the Australian obesity policies and guidelines to date
Slide35: !
The reports have lots of great ideas
The challenge has been
getting them into funded policy
Many types & levels of intervention are needed: Many types & levels of intervention are needed SUPPORTING FAMILIES
- parenting support
healthy food & activity environments in child care SCHOOLS/ CHILD CARE
healthy school canteens
support & fund PE & sports
vending machines
school sponsorships URBAN DESIGN
protect open spaces
pedestrian precincts, bike paths
links with public transport HEALTH CARE
health professional training
coordinated health service delivery
funding for services MARKETING & MEDIA
regulation of food marketing to children
promotion of fruit & veg
public health campaigns underpinning other strategies FOOD INDUSTRY
healthy food choices
portion sizes
food labelling TRANSPORT
- expand & support public transport & active transport WORK SITES
healthy food choices
physical activity opportunities
Many types & levels of intervention are needed: Many types & levels of intervention are needed SUPPORTING FAMILIES
- parenting support
healthy food & activity environments in child care SCHOOLS/ CHILD CARE
healthy school canteens
support & fund PE & sports
vending machines
school sponsorships URBAN DESIGN
protect open spaces
pedestrian precincts, bike paths
links with public transport HEALTH CARE
health professional training
coordinated health service delivery
funding for services MARKETING & MEDIA
regulation of food marketing to children
promotion of fruit & veg
public health campaigns underpinning other strategies FOOD INDUSTRY
healthy food choices
portion sizes
food labelling TRANSPORT
- expand & support public transport & active transport WORK SITES
healthy food choices
physical activity opportunities
Most of these settings for
intervention are beyond the
scope of the Health Sector!
So, what can the Health Sector do to tackle obesity - 1?: So, what can the Health Sector do to tackle obesity - 1? Opportunities for Primary Prevention:
Leadership in advocating for health promotion & obesity prevention
Interventions with other sectors (transport, agriculture, education, local government, urban planning …)
Health services and hospitals:
Healthy food policies (Sydney-West Area-Health Service is finalising policies for contracts with food vendors)
Planning to promote physical activity (eg public transport, walkability, sign-posted stairwells, staff pedometers & gyms)
Sponsorship & marketing policies
etc…..
So, what can the Health Sector do to tackle obesity - 2?: So, what can the Health Sector do to tackle obesity - 2? Effective management of obesity & co-morbidities
Models of care required for obesity, not just its co-morbidities
Consider adapting the Chronic Disease Care pyramid
Slide40: Level 1
70-80% of o’wt/obese patients
Self-care & community based care Level 2
High risk patients
Multidisciplinary care Level 3 Obesity and the chronic disease care pyramid Complex patients
Specialist care GPs, other 1o care
Group programs Acute care facilities
Specialist allied health
Group programs Acute care facilities & special
obesity clinics
Specialist teams Health promotion
Slide41: Level 1
70-80% of o’wt/obese patients
Self-care & community based care Level 2
High risk patients
Multidisciplinary care Level 3 Obesity and the chronic disease care pyramid Complex patients
Specialist care GPs, other 1o care
Group programs Acute care facilities
Specialist allied health
Group programs Acute care facilities & special
obesity clinics
Specialist teams Health promotion
So, what can the Health Sector do to tackle obesity - 2?: So, what can the Health Sector do to tackle obesity - 2? Effective management of obesity & co-morbidities
Models of care required for obesity, not just its co-morbidities
Consider adapting the Chronic Disease Care pyramid
How do primary care, the community health sector & secondary & tertiary care services link up around obesity?
So, what can the Health Sector do to tackle obesity - 2?: So, what can the Health Sector do to tackle obesity - 2? Effective management of obesity & co-morbidities
Models of care required for obesity, not just its co-morbidities
Consider adapting the Chronic Disease Care pyramid
How do primary care, the community health sector & secondary & tertiary care services link up around obesity?
Equipment and protocols for sensitively managing larger patients
Bariatric surgery implications
Management of patients who have obesity complicating the disease which is their primary reason for contacting the health system
Obesity - summary: Obesity - summary The Millennium Disease – a major public health problem
Healthy lifestyle choices for individuals and families are difficult in 21st century Australia
Obesity – the questions to consider:: Obesity – the questions to consider: How do we make the environmental gradient less steep?
How do we support individuals and families so they can make healthy lifestyle choices?
What models of care are needed to treat the large numbers of affected people?
Extra slides: Extra slides
Slide48: http://www.iuns.org/features/obesity/tabfig.htm#Figure%201: Adult obesity – prevalence in different countries
Health consequences of adult obesity: Health consequences of adult obesity Being obese at age 40 y takes 7 y off your life
Being overweight at age 40 y takes 1 y off your life
Obesity leads to a more than 3-fold risk of:
type 2 diabetes, high blood pressure, sleep apnoea, insulin resistance, breathlessness
… and increases the risk of many other diseases
Peeters et al Ann Intern Med 2003
WHO, 2002
Slide50: Economic costs of obesity. Access Economics 2006. Web-site: http://www.accesseconomics.com.au/publicationsreports/showreport.php?id=102
Net financial cost of obesity: $3.767 billion
Net cost of lost well-being (dollar value of burden of disease): An additional $17.2 billion
How would you respond to a disease with the following characteristics? Take 1: How would you respond to a disease with the following characteristics? Take 1 Affecting increasing numbers of the population – mainly adults, but increasingly seen even in children
Associated with decreased quality of life, increased disability and shortened life expectancy
Strong genetic predisposition
Globally prevalent
High economic burden
A significant contributor to death from other major diseases
Most health professionals are untrained in its management
!!!!!!!!!!: !!!!!!!!!! Action stations!
How would you respond to a disease with the following characteristics? Take 2: How would you respond to a disease with the following characteristics? Take 2 Strong genetic predisposition, but this is only manifest in a given environment
Highly stigmatised
Not perceived as a disease by much of the community and the medical profession
The subject of media voyeurism and victim-blaming
Affected individuals are seen as:
Less attractive
Weak-willed, morally vulnerable, lacking will-power and strength
Bringing the disease on themselves
Probably of lower value than those who are unaffected
Welcome to the issue of obesity!: Welcome to the issue of obesity!
Slide55: Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999: http://www.iotf.org Societal policies and processes influencing the population prevalence of obesity
Slide56: http://hp2010.nhlbihin.net/portion/index.htm 20 y ago Now Portion sizes have increased
Who owns the streets? The private car? Pedestrians? Cyclists?: Who owns the streets? The private car? Pedestrians? Cyclists?