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A Population Health Based Approach to the Obesity Epidemic

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Title: A Population Health Based Approach to the Obesity Epidemic


1
A Population Health Based Approach to the Obesity
Epidemic
  • Presentation to the Institute of Population
    Health
  • 2 June 2004
  • Mark S. Kaplan, DrPH
  • Visiting Professor and Fulbright Scholar
  • University of Ottawa

2



3
Gluttony is the mother of lust, the nourishment
of evil thoughts, the laziness in fasting,
obstacle to asceticism, terror to moral purpose,
the imagining of food, sketcher of seasonings,
unrestrained colt, unbridled frenzy, receptacle
of disease, envy of health, obstruction of the
(bodily) passages, groaning of the bowels, the
extreme of outrages, confederate of lust,
pollution of the intellect, weakness of the body,
difficult sleep, gloomy death. -Fourth-century
Desert Father, Evagrius of Pontus (In F. Prose,
Gluttony The Seven Deadly Sins, 2003)
4
Obesity is now on everyones plate -Brian
Vastag (JAMA.20042911186) Fat is the new
tobacco -Heart and Stroke Foundation of Canada
(2004)
5
Obesity as a global health problem
  • Epidemic of overweight and obesity affects many
    developed and developing countries around the
    world, according to the World Health Organization
  • In many countries obesity has doubled or tripled
    over the past decades
  • Over 300 million obese adults worldwide
  • Over 115 million people suffer from
    obesity-related problems in developing countries

WHO A global response to a global problem the
epidemic of over nutrition.Bulletin of the World
Health Organization200280952-958
6
Obesity as a global health problem
  • In developing countries, obesity-related illness
    is replacing undernutrition and infection as main
    cause of death
  • Acculturation to the Western lifestyle is
    associated with an increased prevalence of
    obesity
  • Obesity harms health and costs as much as smoking
  • Obesity is associated with similar comorbidity as
    poverty and smoking

WHO A global response to a global problem the
epidemic of over nutrition. Bull of the World
Health Organization200280952-958
7
Obesity as a global health problem
International Obesity Task Force
8
Body Mass Index
  • BMI weight in kilograms divided by the square
    of height in meters
  • Underweight lt 20.0
  • Normal weight 20.0 to 24.9
  • Overweight 25.0 to 29.9
  • Obese gt 30.0

WHO Obesity preventing and managing the global
epidemic. Report of a WHO consultation on
obesity. Geneva WHO,2000. Canadian Guideline
for Body Weight Classification in Adults. Health
Canada, 2003. M. Hooper (personal communication)



9
Obesity in North America
  • North American obesity rate soared in the 1990s
  • 1/3 of U.S. adults were obese by the end of the
    decade
  • Between 1991 and 2000, obesity rate increased by
    more than 60 in the US
  • In Canada, the prevalence of obesity more than
    doubled between 1985 and 1998
  • Obesity may be responsible for more than 200,000
    deaths in US and Canada per year

Ogden et al., Epidemiologic trends in overweight
and obesity.Endocrinol Metab Clin N
Am200332741-760. Katzmarzyk, The
Canadian obesity epidemic, 1985-1998.
CMAJ20021661039-1040.
10
Obesity as a global health problem
11
Obesity as a global health problem
12
Prevalence of Obesity Among U.S. Adults
1985
1990
1994
1996
1998
2002
CDC. Obesity trends among U.S. adults between
1985 and 2002.
13
Prevalence of Obesity Among Canadian Adults
1985
1990
1994
2000
1998
1996
10 - 14
lt 10
15 - lt20
gt 20
Katzmarzyk, The Canadian obesity epidemic,
1985-1998. CMAJ20021661039-1040
14
Obesity in Canada
Katzmarzyk, The Canadian obesity epidemic,
1985-1998. CMAJ20021661039-1040. Canadian
Institute for Health Information, 2004.
15
Socioeconomic burden of obesity
Birmingham et al., The cost of obesity in
Canada. CMAJ1999160483-488.

Finkelstein et
al.,National spending attributable to overweight
and obesity Health Aff2003W3219-226.
16
Socioeconomic burden of obesity
  • The soaring problem of obesity has implications
    for North American health care systems.
  • US annual medical costs of obese individuals is
    37 higher than normal-weight people.
  • US Medicare and Medicaid cover half of the
    obesity-related health care costs
  • Obesity-related conditions threaten the long-term
    financial sustainability of national health care
    systems

17
Relative risk of health problems associated with
obesity
  • Slightly increased (Relative risk 1-2)
  • Cancer
  • Reproductive hormone
  • abnormalities
  • Polycystic ovary
  • syndrome
  • Impaired fertility
  • Lowback pain
  • Increase anaesthetic
  • risk
  • Foetal defects
  • Moderately increased (Relative risk 2-3)
  • Coronary heart disease
  • Osteoarthritis (knees)
  • Hyperuricaemia and gout
  • Greatly increased (Relative riskgt3)
  • Diabetes
  • Gall bladder
  • disease
  • Hypertension
  • Dyslipidaemia
  • Insulin resistance
  • Breathlessness
  • Sleep apnoea

International Obesity Task Force
18
Chronic conditions across BMI groups
Yan et al., BMI and health related quality of
life in adults 65 years and older. Obes
Res20041269-76
19
Obesity among older adults
  • Prevalence of obesity among elderly persons in
    industrialized countries ranges from 15 - 20
  • In the US, obesity rates were 14.9 in 1996 and
    18.2 in 2000 (BRFSS)
  • In Canada, rates were 12.8 in 1996/97 and 17.7
    in 1998/99 (NPHS)

Yan et al., BMI and health related quality of
life in adults 65 years and older. Obes
Res20041269-76
Flegal et al.,
prevalence and trends in obesity among US
adults, 1999-2000. JAMA20022881723-1727

Macdonald et al.,Obesity in Canada e
descriptive analysis. CMAJ1997157S3-S9.

20
C A N A D A
Prevalence () of Obesity Among Older Adults by
Provinces
NFLD 17.3
NFLD 17.3
PEI 8.7
Quebec 11.8
Quebec 11.8
PEI 8.7
BC 9.9
BC 9.9
MB 14.9
MB 14.9
NS 26.1
AB 11.4
SACK 18.9
AB 11.4
Ontario12.6
Ontario12.6
SASK 18.9
NB 12.4
NS 26.1
NB 12.4
Prevalence () of Obesity Among Older Adults by
Provinces
NPHS 1996
21
Prevalence of underweight, normal weight,
overweight and obesity
Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-1030.
22
Prevalence of underweight, normal weight,
overweight and obesity
Age
Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-1030.
23
Prevalence of underweight, normal weight,
overweight and obesity
Men Women
Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-30.
24
Demographic risk factors for men
  • Overweight
  • Young old (65-69) (OR4.12, plt.001)
  • Married (OR1.28,plt.001)
  • Eur/US/Aust born (OR1.20,plt.01)
  • Residing in Atlantic Provinces
    (OR1.86,plt.001)
  • Obese
  • Young old (65-69) (OR19.35, plt.001)
  • Less educated (OR2.17, plt.001)
  • Residing in Atlantic provinces (OR2.57,
    plt.001)

Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-1030.
25
Demographic risk factors for women
  • Obese
  • Young old (65-69) (OR7.96, plt.001)
  • Less educated (OR1.48, plt.001)
  • Unmarried (OR1.31, plt.001)
  • Eur/US/Aust born (OR1.51, plt.001)
  • Residing in Atlantic provinces (OR1.57,
    plt.001)
  • Overweight
  • Young old (65-69) (OR2.13, plt.001)
  • Less educated (OR1.29, plt.001)
  • Married (OR1.23, plt.001)
  • Canadian born (OR2.80, plt.001)
  • Residing in Que, Prairie, BC (ORs1.30, 1.16,
    1.09, plt.001)

Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-1030.
26
Health risk factors for men
  • Overweight
  • Non or former smoker (OR1.60, plt.001)
  • Physical inactivity (OR1.43, plt.001)
  • Functional limitations (OR1.22, plt.01)
  • Obese
  • Abstainer (OR2.04, plt.001)
  • Chronic condition (OR1.60, plt.01)
  • Physical inactivity (OR2.49, plt.001)

Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-1030.
27
Health risk factors for women
  • Obese
  • Non or former smoker (OR12.77, plt.001)
  • Abstainer, infrequent (ORs2.06 2.59,
    plt.001)
  • Functional limitations (OR1.28, plt.01)
  • Chronic condition (OR1.93, plt.001)
  • Physical inactivity (OR1.85, plt.001)
  • Poor self-rated health (OR1.29, plt.01)
  • Overweight
  • Non or former smoker (OR1.65, plt.001)
  • Abstainer, infrequent (OR1.29 1.26, plt.001)
  • Functional limitations (OR1.29, plt.001)
  • Chronic condition (OR1.75, plt.001)
  • Physical inactivity (OR1.27, plt.001)
  • Poor self-rated health (OR1.02, plt.001)

Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-1030.
28
Psychosocial risk factors
  • Obese Men
  • High social support (OR1.49, plt.001)
  • Overweight and Obese women
  • Lower social support (OR1.21, plt.001
    OR1.50, plt.001)
  • Psychological distress (OR1.22, plt.001
    OR1.28, plt.001)

Kaplan et al., Prevalence and correlates of
overweight and obesity among older adults.
JGeronMedSci200358A1018-1030.
29
Limitations in studying late life obesity
  • Validity of self-reported h/w - Older adults tend
    to overestimate their height and underestimate
    their weight
  • BMI may underestimate body fat in persons who
    have lost muscle mass
  • Selective survival - Obesity declined with age
    from 16.6 to 5.3 across the 25-year age range.

Kuczmarski et al., Effects of age on validity of
self-reported height, weight, and body mass
index. JAmDietAssoc200110128-34
Visscher et al., The public health
impact of obesity. AnnRevPublHealth200122355-37
5.
30
Prevalence of physical inactivity among older
adults
Gender
Kaplan et al., Demographic Psychosocial
Correlates of Physical Activity in Late Life.
AJPM200121306-12.
31
Prevalence of physical inactivity among older
adults
Kaplan et al., Demographic Psychosocial
Correlates of Physical Activity in Late Life.
AJPM200121306-12.
32
Prevalence of physical inactivity among older
adults
Kaplan et al., Demographic Psychosocial
Correlates of Physical Activity in Late Life.
AJPM200121306-12.
33
Other factors associated with physical inactivity
  • One or more chronic conditions
  • Lower levels of social support
  • Higher levels of psychological distress
  • Higher BMIs

Kaplan et al., Demographic Psychosocial
Correlates of Physical Activity in Late Life.
AJPM200121306-12.
34
Weight loss and physical activity
  • Reduced need for medications for obesity-related
    conditions
  • Small weight loss can improve functional health
    and quality of life
  • Physical activity decrease mortality risk among
    obese older adults
  • Exercise help in maintaining weight loss

Rossner, Obesity in the elderly a future
matter of concern? ObesityRev20012183-188.

Jensen et al.,
Obesity in older persons. JAmDietAssoc19989813
08-1311.
35
Strategies to prevent obesity
  • National Government
  • Setting of national priorities
  • Tax on foods with low nutritional value
  • Subsidies for healthy foods
  • Funding of research to prevent or treat obesity

Hitchcok et al., Management of overweight and
obese adults. BMJ2002325757-729

Canadian Institute
for Health Information 2004
36
Strategies to prevent obesity
  • Food industry
  • Labels identifying ingredients and nutrient
    content
  • Inclusion of healthy food choices on restaurant
    menus
  • Restrictions on advertisements for low
    nutritional values foods

Hitchcok et al., Management of overweight and
obese adults. BMJ2002325757-729

Canadian Institute
for Health Information 2004
37
Strategies to prevent obesity
  • Healthcare participation
  • Reimbursement for intervention for health
    promotion and lifestyle change
  • Training and guideline for health professionals
  • Identification of high risk groups and
    individuals such as low income

Hitchcok et al., Management of overweight and
obese adults. BMJ2002325757-729

Canadian Institute
for Health Information 2004
38
Strategies to prevent obesity
  • Community effort
  • Safer venues for physical activity such as
    walking
  • Local education campaigns and events promoting
    physical activity
  • Bring multiple institutions, systems and
    organizations together toward decreasing obesity

Hitchcok et al., Management of overweight and
obese adults. BMJ2002325757-729

Canadian Institute
for Health Information 2004
39
International Obesity Task Force Causal Web
International Obesity Task Force
40
Further research
  • Need for additional comprehensive surveillance
    data on the dietary habits of Canadians across
    the lifespan (lifecourse perspective)
  • More research targeting baby boomers
  • Strengthening body weight, physical activity and
    diet measurement
  • Longitudinal (vs cross-sectional) analysis

41
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