Proceedings of the Symposium and Workshop, forging effective strategies for the prevention and management of overweight and obesity in Asia: Research, Education and Partnerships
Overweight and obesity have started to emerge as a significant public health arisen from the changing dietary pattern towards energy-dense and high fat diets, together with a more sedentarylifestyle arising from increasing urbanization. Obesity's threat to the health and economy of the population gives urgency to meeting the problem headlong before it gets any worse. Fundamental knowledge gaps, however, constrain the institution prevent and manage this growing problem. Foremost the region, coupled with a lack of uniformity in reference standards and cut-off points. While the principles of dietary management, physical activity and behaviour modification are well known, integrating these strategies into a national policy and program in the face of competing priorities is the greatest challenge of all. This requires the collaboration of government, academia, the food industry, the private sector, NGOs and the community, with the assistance of international and bilateral aid agencies, to develop and implement such policies and programs.
The prevalence of obesity is rising in many parts of the world. In Singapore, the 1998 National Health Survey reported the crude prevalence of obesity (BMI 30 kg/m2) amongst adults as 6%. Together with the increase in obesity in certain sectors of the Singapore population (Malay community) there has been a parallel increase in the prevalence of impaired glucose tolerance. If left unchecked, this epidemic of obesity and its comorbidities will lead to reduced quality of life amongst its sufferers as well as an increase in consumption of healthcare resources. Although strategies at the community level are important to check this epidemic, when managing the individual patient with clinically significant obesity and its comorbidities, adjunctive pharmacotherapy and surgical measures are sometimes required besides lifestyle measures and behaviour therapy. Since these therapeutic measures are not without risks, a customized approach utilizing risk-benefit evaluation is appropriate. Pharmacotherapy for the management of obesity has had a chequered history Prom the early disrepute brought about by patient dependence when using amphetamine-like agents, it improved in standing when obesity became more widely accepted as a chronic disorder requiring chronic adjunctive pharmacotherapy. However, the adverse cardiovascular effects reported with the 'fen-phen' combination again reduced enthusiasm for long-term pharmacotherapy. Subsequently, the availability of intestinal lipase inhibitor, orlistat, followed by the mixed noradrenergic-serotoninergic re-uptake inhibitor, sibutramine, gave fresh impetus to this therapeutic area. Both agents were made available for clinical use only after published clinical trial experience of one to two years duration. The difficulties encountered in management of patients with marked obesity have prompted adjunctive surgical initiatives. Follow-up reports from the Swedish Obese Subjects study which began in 1987, have provided valuable data on the effect of surgery on obesity as well as its comorbidities. At the same time, technological advances in surgery have facilitated the widespread use of less invasive approaches to bariatric surgery. It is hoped that with these technological advances, this group of patients will be able to enjoy the benefits of surgery without being exposed to excessive surgical risks.
ACTIVATE was initiated in 1999 by the International Food Information Council (IFIC) Foundation and the International Life Sciences Institute Center for Health Promotion. Extensive qualitative research was conducted to help understand consumer beliefs, attitudes, and perceptions about preventing overweight, specifically overweight in childhood. ACTIVATE then used the research findings to develop potential avenues for communicating obesity prevention messages. The research, conducted with children and their parents, consisted of three progressive phases of focus groups, with each building on information obtained from the previous phase. The findings suggest the need for parents and children to work together to address the obesity prevention issue, as well as the need for effective tools to facilitate this conversation. Parents need to learn how to talk about eating and exercise habits with their children in positive and encouraging ways and how to help sustain their child's involvement in eating healthily and staying physically active. Children themselves need direct messages to motivate them to change their exercise and eating habits, as well as tips on partnering with their parents to achieve fitness goals. Children and parents both stated that positive and realistic approaches to getting fit that seem achievable and accessible would be of great help in their efforts. Both groups considered ongoing encouragement and 'small victories' to sustain involvement in getting fitter to be critical factors to success. Children and parents are also looking for support and customized information to help them in their efforts. ACTIVATE responds to the critical need for comprehensive obesity prevention initiatives. It is a communications program designed to help children and their families achieve healthy lifestyles through regular physical activity and good nutrition. ACTIVATE promotes sound nutrition advice by emphasizing that healthy eating is based on the overall diet, not any one food or any one meal. The message that all foods can fit into a healthy diet when consumed in moderation is an integral piece of ACTIVATE. Being physically active is equally as important as eating well, and various ways to incorporate activity into children's lives are emphasized. Particular attention is placed on making physical activities fun, enjoyable, and sustainable. ACTIVATE is also a unique partnership. The IFIC Foundation is working closely with several organizations to develop ACTIVATE's program elements and to extend ACTIVATE's reach. These partner organizations are the American Academy of Family Physicians (AAPP); the American College of Sports Medicine (ACSM); the American Dietetic Association (ADA); the International Life Sciences Institute Center for Health Promotion (ILSI CHP); and the National Recreation and Park Association (NRPA). In addition, ACTIVATE is advised by individual experts in physical activity, nutrition, family medicine, and child psychology. Currently, the IFIC Foundation and its partners are using the research findings to develop ACTIVATE's customized program elements program elements that will deliver positive, balanced information on physical activity and nutrition to help families achieve healthy lifestyles.
Epidemiology of obesity and public health strategies for its control in Japan Nobuo Yoshiike MD, Fumi Kaneda MS and Hidemi Takimoto MD Obesity has become a public health problem in Japan. The National Nutrition survey (2000) showed prevalence of preobese (body mass index: 2529.9 kg/m2) and obesity ( 30 kg/m2) was 24.5% and 2.3%, respectively, in males, and 17.8% and 3.4%, respectively, in females aged 20 years and over. Trends in prevalence of overweight in the last 25 years differed among age-sex groups and across residential areas. The most significant increase in overweight was observed in men in small towns, whilst there was a remarkable decrease in women in metropolitan areas. In the 10 year national plan for health promotion named 'Health Japan 21', maintaining appropriate body weight (obesity control and prevention of thinness brought about by dieting in young women) is a core component of the prioritized issues. Increasing the number of people who know their healthy body weight and practice weight control is also listed as an important objective. The proportion of people engaged in regular exercise for health and following the recommended average number of steps in daily life is a major indicator for evaluation of the program. We conclude that when formulating effective public health strategies for obesity control, it is important to consider each country's own situation related to obesity issues including the proper BMI cutoff point, which might be much different from that in western societies.
In December 2001, the World Health Organization launched the Mega Country Health Promotion Network. This network includes the countries with populations of 100 million or more. The 11 countries that are part of this network account for more than 60% of the world's population. The overall goal of this network is to promote healthy lifestyles; much of the focus of activities will be on promoting a healthy diet, based on food-based dietary guidelines and increased physical activity. Data will be presented that illustrate the 'double burden' of disease in the low income populations in these 11 countries. The network is attempting to identify new paradigms for health promotion, including the innovative use of public/private partnerships. Examples of these innovations will be presented.
Undernutrition and hunger have always formed the foundation of the Food and Agriculture Organisation's (FAO) mandate. Working in collaboration with the International Dietary Energy Consultative Group (IDECG), FAO began to examine both appropriate cut-off points of the body mass index (BMI) at the lower end of the spectrum and the functional consequences of low BMI (<16.0 = Category III Chronic Energy Deficiency (CED); 16.0 16.9 = Category II CED; 17.0 18.4 = Category I CED). Over the past decade FAO has recognized the growing obesity epidemic occurring not only in the developed world but also among all income and socio-economic groups of the developing world. In response, FAO and the World Health Organization (WHO) have collaborated together in joint initiatives. Following the WHO 1998 Obesity Consultation on Preventing and Managing the Global Epidemic, a number of regions examined their individual situation regarding obesity. In looking at the BMI risk-based cut-off points, there appeared to be need for a tailoring of the cut-off points for Asia. The publication The Asia-Pacific Perspective: Redefining Obesity and its Treatment (2000) proposed area-specific cut points. While such efforts to individualize reference values to a region or situation are attractive and even commendable, there is always the danger of creating confusion particularly if later these figures are changed. It is very important that before values are promulgated, a thorough review is conducted and full confidence can be placed on them.
For prevention of obesity in the Chinese population, it is necessary to define the optimal range of healthy weight and the appropriate cut-off points of body mass index (BMI) and waist circumference for Chinese adults. The Working Group on Obesity in China under the support of the International Life Sciences Institute Focal Point in China organized a meta-analysis on the relationship between BMI, waist circumference and risk factors of related chronic diseases (e.g., high diabetes, diabetes mellitus, and lipoprotein disorders). Thirteen population studies in all met the criteria for enrolment, with data of 239 972 adults (2070 years of age) surveyed in the 1990s. Data on waist circumference was available for 111 411 persons, and data on serum lipids and glucose were available for more than 80 000. The study populations were located in 21 provinces, municipalities and autonomous regions in mainland China as well as in Taiwan. Each enrolled study provided data according to a common protocol and uniform format. The Center for Data Management in the Department of Epidemiology, Fu Wai Hospital, was responsible for the statistical analysis. The prevalence of hypertension, diabetes, dyslipidemia and clustering of risk factors all increased with increasing levels of BMI or waist circumference. A BMI of 24 with best sensitivity and specificity for identification of the risk factors was recommended as the cut-off point for overweight; a BMI of 28, which may identify the risk factors with specificity around 90%, was recommended as the cut-off point for obesity. A waist circumference over 85 cm for men and over 80 cm for women were recommended as the cut-off points for central obesity. Analysis of a population-attributable risk percentage illustrated that reducing the BMI to the normal range (<24) could prevent 4550% of the clustering of risk factors. Treatment of obese persons (BMI = 28) with drugs could prevent 1517% of clustering of risk factors. When waist circumference is controlled at under 85 cm for men and under 80 cm for women, it could prevent 47 58% of clustering of risk factors. Based on these guidelines, a classification of overweight and obesity for Chinese adults is recommended. For prevention of obesity in the Chinese population, it is necessary to define the optimal range of healthy weight and the appropriate cut-off points of body mass index (BMI) and waist circumference for Chinese adults. The Working Group on Obesity in China under the support of the International Life Sciences Institute Focal Point in China organized a meta-analysis on the relationship between BMI, waist circumference and risk factors of related chronic diseases (e.g., high diabetes, diabetes mellitus, and lipoprotein disorders). Thirteen population studies in all met the criteria for enrolment, with data of 239 972 adults (2070 years of age) surveyed in the 1990s. Data on waist circumference was available for 111 411 persons, and data on serum lipids and glucose were available for more than 80 000. The study populations were located in 21 provinces, municipalities and autonomous regions in mainland China as well as in Taiwan. Each enrolled study provided data according to a common protocol and uniform format. The Center for Data Management in the Department of Epidemiology, Fu Wai Hospital, was responsible for the statistical analysis. The prevalence of hypertension, diabetes, dyslipidemia and clustering of risk factors all increased with increasing levels of BMI or waist circumference. A BMI of 24 with best sensitivity and specificity for identification of the risk factors was recommended as the cut-off point for
overweight; a BMI of 28, which may identify the risk factors with specificity around 90%, was recommended as the cut-off point for obesity. A waist circumference over 85 cm for men and over 80 cm for women were recommended as the cut-off points for central obesity. Analysis of a population-attributable risk percentage illustrated that reducing the BMI to the normal range (<24) could prevent 4550% of the clustering of risk factors. Treatment of obese persons (BMI = 28) with drugs could prevent 1517% of clustering of risk factors. When waist circumference is controlled at under 85 cm for men and under 80 cm for women, it could prevent 47 58% of clustering of risk factors. Based on these guidelines, a classification of overweight and obesity for Chinese adults is recommended.
The dramatic changes in the lifestyle of many Asian communities, and the resultant changes in the food and nutrition issues facing the communities in the region have been documented by various investigators. Health authorities and researchers have given greater attention to the problem of overweight and obesity. Available data are lacking, but various estimates have indicated that the emerging problem of overweight amongst children cannot be ignored. Estimates of overweight by the World Health Organization (WHO) amongst preschool children in Asia in 1995 was around 2.9%. Data extracted from selected studies in individual Asian countries show much higher prevalences, ranging from 5% to 9% amongst several urban cities in Asia. In several other developing countries in the region, the prevalence is probably very low, with prevalences of less than 1%. There is thus considerable variation in this prevalence amongst the various countries. The problem of increasing overweight and obesity amongst adults in Asia has been highlighted for more than a decade. The database on the extent of the problem is far from being comprehensive, but various studies have pointed out the severity of the problem. Various reports in the 1990s have pointed out prevalences of overweight of over 20% and obesity of over 5% amongst urban population groups of the more developed countries in the region. It is also to be noted that there are also reports indicating that the most affluent societies in the region, such as Seoul and Tokyo, did not have the highest prevalence of overweight. There are also data on increasing prevalence of overweight among rural areas in the last 10 years. The situation for children is similar: there is considerable variation in the severity of the problem. In the Philippines National Surveys, for example, slightly lower prevalences have been reported. Countries in the region will continue to progress, accompanied by continued changes in lifestyle of communities. It is therefore of utmost importance to continue to monitor the nutritional status of communities. The lack of nationally representative data which is regularly updated is a major concern. The lack of data for certain age groups such as the adolescents and the elderly need to be addressed. One of the main obstacles in the formulation and effective implementation of intervention programs in developing countries is the lack of comprehensive data on the extent of the problems in many cases and the causes of such problems specific to the communities concerned. In addition to the lack of good data, other concerns too need to be addressed. These include methodological issues such as the need for harmonization of methods in assessment of nutritional status for the various groups, the appropriateness of criteria for cut-offs, growth reference to be used, and association of overweight and obesity with comorbidities.
Obesity, increasingly recognized as a chronic disease, is associated with physical, psychosocial and economic consequences to society. With the burgeoning global epidemic, health care workers must rally together to understand, treat and prevent obesity and its complications.
Obesity has been identified as an epidemic in the United States for more than two decades and yet the numbers of overweight and obese adults and children continue to grow. Currently, the rates of both overweight and obesity in the US are 61% and 14% in adults and children, respectively. Among US adults aged 2074 years, the prevalence of overweight (defined as BMI 25.029.9) has increased from 33% in 1980 to 35% of the population in 1999. In the same population, obesity (defined as BMI 30) has nearly doubled from approximately 15% in 1980 to an estimated 27% in 1999. The percentage of children and adolescents who are defined as overweight has more than doubled since the early 1970s. About 14% of children and adolescents are now seriously overweight. Obesity burdens the health care system, strains economic resources, and has far reaching social consequences. The disease is associated with several serious health conditions including: type 2 diabetes mellitus, heart disease, high blood pressure and stroke. It is also linked to higher rates of certain types of cancer. Obesity is an independent risk factor for heart disease, hypoxia, sleep apnea, hernia, and arthritis. Obesity is the seventh leading cause of death in the US. The total cost of overweight and obesity by some estimates is $100 billion annually. Others put the cost of health care for obesity alone at $70 billion. Other annual costs associated with obesity are 40 million workdays of productivity lost, 63 million doctors' office visits made, and 239 million restricted activity days and 90 million bed-bound days. Emotional suffering may be among the most painful aspects of obesity. American society emphasizes physical appearance and often equates attractiveness with slimness, especially for women. Such messages may be devastating to overweight people. Many think that obese individuals are gluttonous, lazy, or both, even though this is not true. As a result, obese people often face prejudice or discrimination in the job market, at school, and in social situations. Feelings of rejection, shame, or depression are common. Since the 1950s, national dietary recommendations have come to acknowledge obesity as a significant societal trend. The Surgeon General's 2001 Call To Action, Healthy People 2010, and the Dietary Guidelines for Americans 2000 all emphasize the importance of healthy weight. There are some new tools available to help in the fight against overweight and obesity: Weight Control Information Network, The Third National Cholesterol Education Program's Adult Treatment Panel, and The Practical Guide: Identification, Evaluation, & Treatment of Overweight & Obesity in Adults from the National Institutes of Health and National Heart Lung and Blood Institute.
Obesity is associated with devastating health and fiscal consequences in countries where it is epidemic. It is beholden on us all to try to prevent obesity emerging in countries where its prevalence is starting to increase. There are many countries in Asia where this is so. Obesity prevention necessitates attention to both increasing physical activity and improving nutrition. In this paper we discuss a strategic approach for increasing physical activity. First, we need to better understand physical activity levels and the factors that impact it. Next, we need to design specific and targeted governmentally supported strategies to promote physical activity. Finally we need to critically and objectively evaluate these strategies and then promote those that are successful, and channel limited resources away from those that are not. These goals are achievable through collaborating and sharing technologies. We hope to prevent obesity from engulfing Asia.
Obesity prevalence has increased dramatically in parallel with rapid economic development and rising standards of living around the world. There is growing recognition that this 'epidemic' of overweight is being driven by environmental factors that affect our eating and physical activity behaviours. In effect, the environment overwhelms our biological capacity to maintain a healthy weight. There is little scientific evidence to quantify the relative contributions of various environmental factors to risk of overweight and obesity. However, it is easy to characterize the environment as one in which food is readily available, convenient, inexpensive and great tasting. Likewise, the modern environment discourages physical activity at work, at home and in the community, and attractive sedentary pursuits compete with activity for leisure time. In fact, the causes of obesity in our society are so manifold as to be inseparable from the way we live. Many of the forces that drive individuals to eat too much and move too little are coupled to a desire for self-efficacy and increased productivity. It can be argued therefore that obesity is an unintended consequence of the emphasis we collectively place on productivity and a desire to achieve 'the good life'. In this sense, obesity is not really a biological problem, but a social problem that requires a multifactorial social solution. In order to create demand for environmental change to promote healthy lifestyle behaviours, we will need to create a greater sense of crisis among average citizens. We will need to explore solutions that make economic sense for everyone. We will need to create a new social norm for healthy eating and active living. The magnitude of the challenge is daunting, but we can begin by engaging broad scale public private partnerships. After all, we are all part of the global community that is affected by this emerging crisis.
Obesity is a serious and growing public health problem affecting developed and developing countries. It is generally agreed that the causes of the current obesity epidemic are not genetic in origin, but are the result of changes in the environments in which we live. While acknowledging the importance of environmental factors, the central role of behaviour in the obesity epidemic cannot be ignored. It is our eating, physical activity and sedentary behaviours that form the interface between our biology and the environments to which we are exposed. However, a lack of understanding of the specific behaviours that are important in the aetiology of obesity poses a major constraint to preventing obesity. A better understanding of the behaviours that contribute to weight gain and obesity is critical in order to plan and implement effective obesity prevention initiatives. Theory-driven investigations of eating, physical activity and sedentary behaviours, their determinants, and their role in weight gain and obesity among different population groups are urgent research priorities. Without an understanding of the
key behaviours that contribute to weight gain, and the influences on these behaviours, it will remain difficult to identify where to intervene in the environment and be confident that action will prevent obesity.