Too young to die

The unprecedented growth in the prevalence of childhood obesity is set to place a heavy burden on the health budgets of many countries and send countless children to the grave before their parents if urgent action by governments and the private sector is not taken. Callan Emery reports.

Obesity has reached pandemic proportions around the world and is now the greatest single contributor to chronic disease and the single biggest preventable cause of death. The Middle East is not exempt from this crisis. To the contrary, prevalence rates are so high in the region that it sits behind only the United States in the world obesity stakes.

There are now more overweight people in the world – one billion – than undernourished – 800 million – and the scourge is no longer confined to the developed world. Obesity has engulfed the developing world as well, as it adopts the physical and dietary habits of the affluent western nations.

And with childhood obesity forecast to increase dramatically in most parts of the world, there is, for the first time in human history, the possibility of millions of parents outliving their children. It is anticipated that many children will die at an early age from obesity-related illnesses such as diabetes and cardiovascular disease.

These critical issues were highlighted at the 10th International Congress on Obesity (ICO2006) in Sydney, Australia, in September and are at the core of the drive to reverse this trend by anti-obesity campaigners.

At this all-important congress, held every four years, speakers urged governments around the world and international captains of industry to take action in the battle against obesity or face dire consequences in a few years’ time.

They warned that the dramatic rise in the prevalence of obesity in the past ten years, and which is forecast to double in many countries in the next five to ten years, will place an extremely heavy burden on government health budgets.

For example, in 2001 in the United States the total direct and indirect cost attributable to obesity was $123 billion, according to research (Wolf AM, Manson JE, Colditz GA. The Economic Impact of Overweight, Obesity and Weight Loss. Ed Eckel R in Obesity. Lippincott, Williams and Wilkins, 2002).

The researchers looked at the economic costs attributable to obesity for type-2 diabetes, coronary heart disease, hypertension, gallbladder disease, breast, endometrial and colon cancer, and osteoarthritis.

They also included factors such as excess physician visits, work-lost days, restricted activity, and beddays attributable to obesity. Although this study is slightly dated and USspecific it gives a good indication of the massive financial burden countries around the world can expect if this frightening trend in obesity is not reversed.

Speakers at ICO2006 said obesity should be considered the keystone of all health priorities and warned governments they would have to rethink many national policies if they wanted to avoid the massive financial burden that obesity poses.

They also emphasised that the private sector had an important role to play in reducing the burden of obesity by promoting healthy lifestyles and healthy diet, through responsible marketing and improving the price structure of healthy food.

Overweight and obesity defined

Overweight and obesity is assessed by using body mass index (BMI), defined as the weight in kilogrammes divided by the square of the individual’s height in metres (kg/m2 ). A BMI over 25 kg/m2 is defined as overweight, and a BMI of over 30 kg/m2 as obese. These markers provide common benchmarks for assessment.

Childhood obesity

Childhood obesity is already epidemic in some areas of the world and is rising fast in others. ICO2006 highlighted this critical issue by making childhood obesity the central theme of the congress.

The latest estimates by the International Obesity Taskforce (IOTF - www.iotf.org) put the prevalence of overweight and obesity in children aged 5-17 at around 10%, or 155 million, worldwide. Around 30-45 million within that figure are classified as obese – accounting for 2-3% of the world’s children of school-going age.

According to earlier IOTF data a further 22 million children younger than five are also estimated to be overweight. In the World Health Organisation (WHO)- defined Eastern Mediterranean region, which includes the Levant and all countries on the Arabian Peninsula, the prevalence of overweight and obesity in school-age children, according to a 1992-2001 survey, is estimated to be 23.5%, of which 5.9% are obese.

IOTF projections estimate these figures to be 35.3% and 9.4% respectively for 2006, which will increase to a phenomenal 41.7% and 11.5% respectively in 2010. In other words, in the 10 years from 2000 obesity in school-age children will double in the region.

These worrying figures place this region just slightly behind the Americas which leads the world in the obesity stakes. Professor Philip James, chairman of the IOTF, referring to the latest research, said the new studies provided “illuminating evidence that the rapidly worsening problem of childhood obesity is not confined to Europe or indeed the Western world but to many major economically developing countries”.

Dr Tim Lobstein, co-ordinator of the IOTF’s childhood and adolescent obesity research programme, said the analysis of worldwide trends he had undertaken with Dr Youfa Wang from the Department of International Health at Johns Hopkins University in the USA, showed how widespread the problem was becoming.

“The obesity estimates are very cautious, but extremely worrying. When we looked at the overweight it was astonishing to see that nearly half of children in both North and South America could be overweight in just four years time.

In Europe we are seeing substantial increases with overweight at 38% – up 60% on the level we saw throughout the late 1990s. Experts at the congress warned that this is a problem that will manifest itself with massive chronic health consequences when these overweight and obese children get older.

Many obese children carry the antecedents of several diseases that are responsible for early mortality in adults. Of particular concern in this regard is the growing prevalence of type-2 (or adultonset) diabetes in children.

Children with type-2 diabetes can expect to have a substantially shortened life span. Professor Kate Steinbeck of Sydney Royal Prince Alfred Hospital, reiterated this point when she told delegates at the ICO2006 that it is likely many children will die before their parents as a consequence of being overweight or obese.

Health impact

So, what are the main impacts on health of overweight? The effects of overweight and obesity on health are now fairly well established.

According to numerous studies, overweight and obesity can lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance, or what is now commonly referred to as Metabolic Syndrome.

This in turn can lead to cardiovascular disease, stroke, type-2 diabetes, certain types of cancers, especially the hormonally related and large-bowel cancers; and gallbladder disease. Other non-fatal but debilitating health problems associated with obesity include respiratory difficulties, such as sleep apnoea; chronic musculoskeletal problems; skin problems; infertility; early puberty in young girls; and often overlooked psychosocial problems.

Obese kids, obese adults

In recent research which emphasises the importance of combating obesity in childhood, it is shown that obese children are much more likely to become obese adults compared to children who are not overweight.

The study published in the September issue of Paediatrics shows that children who are overweight as toddlers or preschoolers are more likely to be overweight or obese in early adolescence and that obese adolescents are likely to become overweight adults.

The research examined more than 1,000 children from 10 US locations in the United States by a team led by Philip R Nader, MD, Professor Emeritus of Pediatrics at the University of California, San Diego, School of Medicine.

Dr Lobstein said that the results if such research “reinforces the need for immediate and urgent action to protect our children and stop this runaway trend.

We can only do this if we seriously address the need to cut down the consumption of extra empty calories in high fat and high sugar food products, and do much more to improve children’s opportunities to be active.”

Reversing the trend

So what can and should be done to reign in this approaching obesity pandemic in children? First, we have to know why this is happening.

According to the WHO, the rising epidemic reflects the profound changes in society and in behavioral patterns of communities over recent decades.

The health organisation points out that while genes are important in determining a person’s susceptibility to weight gain, so is energy balance, which is determined by the equilibrium between calorie intake and physical activity.

Societal changes, such as increasingly sedentary lifestyles, and worldwide nutrition transition, such as increasing consumption of high-fat fast food, are driving the obesity epidemic.

Economic growth, modernisation, urbanisation and globalisation of food markets are just some of the forces underlying the epidemic. As incomes rise and populations become more urban, diets high in complex carbohydrates give way to more varied diets with a higher proportion of fats, saturated fats and sugars.

At the same time, large shifts towards less physically demanding work have been observed worldwide. Moves towards less physical activity are also found in the increasing use of automated transport, technology in the home, and more passive leisure pursuits. Pointing out just how insidious the problem can be, Dr Marie-Laur Frelut, speaking at the World Congress of Cardiology in Barcelona, Spain, in September, referred to the effect on childhood obesity of junk food TV advertising targeted at children.

“In Europe if you plot the prevalence of overweight children in countries with commercial TV advertising for children for junk food, there is a direct correlation between rate of prevalence and rate of advertising.” In other words, more junk food advertising results in more overweight children.

Dr Frelut said an inverse weaker correlation is found for advertising for healthy foods. She said there were many factors affecting what she termed “the pressure to eat”, among them the easy availability of junk food, the pricing structure – junk food costs less than healthy alternatives – and supersizing which promoted over consumption. The problem is a complex one and needs to be tackled on many fronts – in the home, at local government level, at national government level and internationally in the private sector.

A recent report commissioned by the US Institute of Medicine provides a number of recommendations for the US Government, which are applicable to governments in the Middle East and around world. The report also provides recommendations for private sector industry.

Recommendations for government

The recommendations are drawn from the report, Progress in Preventing Childhood Obesity: How Do We Measure Up? (2007) and call on governments to:

- demonstrate leadership by establishing the childhood obesity epidemic as an urgent public health priority

- prioritise funding

- co-ordinate the public and private-sector response

- establish a robust information- gathering system to monitor progress and guide the development of programmes and policies Other elements of the proposed government response to the obesity epidemic include a strong governmental workforce and an enhanced organisational capacity.

Governments have influence in many spheres. They can legislate against junk food advertising for children, for example. They can effect change to ensure that healthy food replaces junk food in school tuck shops.

To combat increasing sedentary lifestyles they can make extramural sporting activity compulsory in schools. This sorely lacking in the region. In the hot summer months there are many indoor sports that can be played and the in the winter months outdoor sports.

Recommendations for industry

The report says market forces may be very influential in changing both consumer and industry behaviours.

All relevant industry stakeholders – including food and beverage companies, quick serve and full serve restaurants, food retailers, recreation and leisure companies, entertainment companies, and the media should share responsibility for supporting childhood obesity prevention goals.

Industry can be instrumental in changing social norms so that reducing childhood obesity prevalence will be acknowledged as an important and preventable health outcome and healthy eating and regular physical activity will be the accepted and encouraged standard. The report recommends:

- Increasing the proportion of a company’s product portfolio and marketing resources devoted to developing, packaging, and promoting products that contribute to healthy lifestyles;

- Reducing the portion sizes of food and beverage products and restaurant meals;

- Disseminating information that promotes healthy diets and regular physical activity; -

- Engaging in publicprivate partnerships to promote healthy eating and active lifestyles to children and their families.

Other recommendations

Dr Frelut offered a few of recommendations during her talk at the World Congress of Cardiology. She noted that children are vulnerable – they cannot criticise advertising”. She suggested changes that could be made at the local level:

- No TV adverts for kids under 12

- Protection at school – no ads, no vending machines, healthy catering

- Increased physical activity – in school, leisure and lifestyle At the global level she called for:

- A coherent global food policy

- Healthy foods at better prices

- Education with food labelling that is easy to understand for the consumer

- Marketing on quality of food, not only on size of portions

However, the success of such recommendations depends on the will and commitment of government, industry and relevant stakeholders.

As Dr Frelut points out: “We will succeed only if international medical federations collaborate and if their collaborations are strong enough to trigger concern on a political level among those who have the power to change the environment.”

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