In last week’s 2015 Lancet series on obesity, the majority of papers focus on policy interventions to address obesity. It suggests that a reframing of the obesity discussion, that avoids dichotomies (like nature vs. nurture debates) may provide a path forward – both in prevention and management.
The policy framework presented by Christina Roberto and colleagues in The Lancet, is based on the NOURISHING framework, proposed by the World Cancer Research Fund International to categorise and describe these actions.
Together, the actions in this framework address the food environment (e.g. food availability, taxation, restrictions on advertising, etc.), food systems (e.g. incentives and subsidies for production of healthier foods) and individual behaviour change (e.g through education and counselling).
This “food-centric” view of obesity is complemented by recognising that physical activity, much of which is dictated by the built environment and captivity of the population in largely sedentary jobs, also has a role to play.
On a positive note, the Christina and colleagues suggest that there may be reasons for careful optimism – apparently 89% of governments now report having units dedicated to the reduction of non-communicable diseases (including obesity), although the size and capacity of many of these units is unknown.
On the other hand, despite an increasing number of such efforts over the past decades, no country has yet reversed its epidemice (albeit there is a flattening of obesity growth rates in the lower BMI ranges in some developed countries – with continuing rise in more severe obesity).
Despite the potential role of government policies in reducing non-communicable diseases (including obesity) by “nudging” populations towards healthier diets and more physical activity, the authors also note that,
“…the reality is that many policy efforts have little support from voters and intended programme participants, and although the passage of policies is crucial, there is also a need to mobilise policy action from the bottom up.”
Indeed, there is growing list of examples, where government policies to promote healthy eating have had to be reversed due to lack of acceptance by the public or were simply circumvented by industry and consumers.
Nevertheless, there is no doubt that policies in some form or fashion may well be required to improve population health – just how intrusive, costly and effective such measures will prove to be remains to be seen.
All of this may change little for people who already have the problem. As the article explains,
“There are also important biological barriers to losing excess weight, once gained. Changes in brain chemistry, metabolism, and hunger and satiety hormones, which occur during attempts to lose weight, make it difficult to definitively lose weight. This can prompt a vicious cycle of failed dieting attempts, perpetuated by strong biological resistance to rapid weight loss, the regaining of weight, and feelings of personal failure at the inability to sustain a weight-loss goal. This sense of failure makes people more susceptible to promises of quick results and minimally regulated claims of weight loss products.”
Not discussed in the article is the emerging science that there may well be other important drivers of obesity active at a population level that go well beyond the food or activity environment – examples would include liberal use of antibiotics and disinfectants (especially in agriculture), decreased sleep (potentially addressable through later school start times and mandatory afternoon naps in childcare settings), increasing maternal age at pregnancy (addressable by better access to childcare), time pressures (e.g. policies to address time-killing commutes), etc.
Perhaps what is really needed is a reframing of obesity as a problem where healthy eating and physical activity are seen as only two of many potential areas where policies could be implemented to reduce non-communicable diseases (including obesity).
Some of these areas may well find much greater support among politicians and consumers.
Last week the McKinsey Global Institute, with much media fanfare, released a 120 page discussion paper titled, “Overcoming obesity: An initial economic analysis“, which estimates that the economic cost of the global obesity epidemic is upwards of $2 trillion, a number similar to the economic cost of tobacco consumption or armed conflicts.
The report identifies 74 interventions in 18 areas (ranging from policy and population health to health care) deemed to be cost effective, which, if implemented, could lead to annual savings of $1.2 billion in the UK National Health Services alone.
However, when it comes to the actual impact of these 74 strategies, the report is far more sobering in that it notes that many of these interventions are far from proven:
“The evidence base on the clinical and behavioral interventions to reduce obesity is far from complete, and ongoing investment in research is imperative. However, in many cases this is proving a barrier to action. It need not be so. We should experiment with solutions and try them out rather than waiting for perfect proof of what works, especially in the many areas where interventions are low risk. We have enough knowledge to be taking more action than we currently are.”
In other words, let’s not wait to find out what works – let’s just do something – anything (and keep our fingers crossed).
Thus, the report urges us to
“(1) deploy as many interventions as possible at scale and delivered effectively by the full range of sectors in society; (2) understand how to align incentives and build cooperation; and (3) do not focus unduly on prioritizing interventions because this can hamper constructive action.”
I can see why politicians would welcome these recommendations, as they are essentially a carte blanche to either doing nothing (we don’t have the evidence) or doing whatever they want (anything is better than nothing).
The fact that,
“Based on existing evidence, any single intervention is likely to have only a small overall impact on its own. A systemic, sustained portfolio of initiatives, delivered at scale, is needed to address the health burden.”
means that when any measure fails, it is not because it was the wrong measure but because there was either not enough of it or it was not complemented by additional measures.
Again, a free pass for politicians, who can pass whatever measures they want (based on their political ideologies or populistic pressure from their constituencies), without having to demonstrate that what they did, had any effect at all.
Of course, no report on obesity would be complete without also stressing the importance of “personal responsibility”, as if this was somehow more important for obesity than it is for diabetes, lung disease, heart disease, or any other disease I can think of.
Unfortunately, the report also includes rather nonsensical statements like,
“44 interventions bring 20% of overweight/obese Britons back to normal weight”
a sentence that defies the very chronic nature of obesity, where once established excess weight is vigorously “defended” by complex neuroendocrine responses that will counteract any change in energy balance to sustain excess body weight.
Thus, unfortunately, the authors fall into the common misconception about obesity simply being a matter of calories in and calories out, a balance that can be volitionally adjusted to achieve whatever body weight you wish to have.
Indeed, there is very little discussion in this “discussion paper” of the underlying biology of obesity, although it is acknowledged in passing:
“Even though there are important outstanding questions about diet composition, gut microbiome, and epigenetics, we are not walking blind with no sense of what to address. However, interventions to increase physical activity, reduce energy consumption, and address diet composition cannot just seek to reverse the historical trends that have left the population where it is today. For example, we cannot, nor would we wish to, reverse the invention of the Internet or the industrialization of agriculture. We need to assess what interventions make sense and are feasible in 2014.”
Will this report move governments to action? Or, even more importantly, will this report bring us any closer to reversing the epidemic or providing better treatments to people who already have obesity?
Readers may appreciate that I am not holding my breath quite yet.
The camp is open to a select group of graduate and post-graduate trainees from a wide range of disciplines with an interest in obesity research. Over nine days, the trainees are mentored and have a chance to learn about obesity research in areas ranging from basic science to epidemiology and childhood obesity to health policy.
Now, a formal network analysis of bootcamp attendees, published by Jenny Godley and colleagues in the Journal of Interdisciplinary Healthcare, documents the substantial impact that this camp has on the careers of the trainees.
As the analysis of trainees who attended this camp over its first 5 years of operation (2006-2010) shows, camp attendance had a profound positive impact on their career development, particularly in terms of establishing contacts and professional relationships.
Thus, both the quantitative and the qualitative results demonstrate the importance of interdisciplinary training and relationships for career development in obesity researcher (and possibly beyond).
Personally, participation at this camp has been one of the most rewarding experiences of my career and I look forward to continuing this annual exercise for years to come.
To apply for the 2015 Bootcamp, which is also open to international trainees – click here.
Godley J, Glenn NM, Sharma AM, & Spence JC (2014). Networks of trainees: examining the effects of attending an interdisciplinary research training camp on the careers of new obesity scholars. Journal of multidisciplinary healthcare, 7, 459-70 PMID: 25336965
If you have a professional interest in obesity, it’s your #1 destination for learning, sharing and networking with experts from across Canada around the world.
In 2015, the Canadian Obesity Network (CON-RCO) and the Canadian Association of Bariatric Physicians and Surgeons (CABPS) are combining resources to hold their scientific meetings under one roof.
The 4th Canadian Obesity Summit (#COS2015) will provide the latest information on obesity research, prevention and management to scientists, health care practitioners, policy makers, partner organizations and industry stakeholders working to reduce the social, mental and physical burden of obesity on Canadians.
The COS 2015 program will include plenary presentations, original scientific oral and poster presentations, interactive workshops and a large exhibit hall. Most importantly, COS 2015 will provide ample opportunity for networking and knowledge exchange for anyone with a professional interest in this field.
Abstract submission is now open – click here
- Notification of abstract review: January 8, 2015
- Call for late breaking abstracts open: Jan 12-30, 2015
- Notification of late breaking abstracts and handouts and slides due : Feb 27, 2015
- Early registration deadline: March 3, 2015
For exhibitor and sponsorship information – click here
To join the Canadian Obesity Network – click here
I look forward to seeing you in Toronto next year!
Over the next three days, I will be in Waterloo, Ontario, attending the 4th biennial Canadian Obesity Student Meeting (COSM 2014), a rather unique capacity building event organised by the Canadian Obesity Network’s Students and New Professionals (CON-SNP).
CON-SNP consist of an extensive network within CON, comprising of over 1000 trainees organised in about 30 chapters at universities and colleges across Canada.
Students and trainees in this network come from a wide range of backgrounds and span faculties and research interests as diverse as molecular genetics and public health, kinesiology and bariatric surgery, education and marketing, or energy metabolism and ingestive behaviour.
Over the past eight years, since the 1st COSM was hosted by laval university in Quebec, these meetings have been attended by over 600 students, most presenting their original research work, often for the first time to an audience of peers.
Indeed, it is the peer-led nature of this meeting that makes it so unique. COSM is entirely organised by CON-SNP – the students select the site, book the venues, review the abstracts, design the program, chair the sessions, and lead the discussions.
Although a few senior faculty are invited, they are largely observers, at best participating in discussions and giving the odd plenary lecture. But 85% of the program is delivered by the trainees themselves.
Apart from the sheer pleasure of sharing in the excitement of the participants, it has been particularly rewarding to follow the careers of many of the trainees who attended the first COSMs – many now themselves hold faculty positions and have trainees of their own.
As my readers are well aware, I regularly attend professional meetings around the world – none match the excitement and intensity of COSM.
I look forward to another succesful meeting as we continue to build the next generation of Canadian obesity researchers, health professionals and policy makers.
You can follow live tweets from this meeting at #COSM2014