This morning, I am presenting a plenary talk in Berlin to about 200 colleagues involved in childhood obesity prevention.
The 1-day symposium is hosted by Plattform Ernährung und Bewegung e.V. (Platform for Nutrition and Physical Activity), a German consortium of health professionals as well as public and private stakeholders in public health.
Although, as readers are well aware, I am by no means an expert on childhood obesity, I do believe that what we have learnt about the complex socio-psycho-biology of adult obesity in many ways has important relevance for the prevention and management of childhood obesity.
Not only do important biological factors (e.g. genetics and epigenetics) act on the infant, but, infants and young children are exposed to the very same societal, emotional, and biological factors that promote and sustain adult obesity.
Thus, children do not grow up in isolation from their parents (or the adult environment), nor do other biological rules apply to their physiology.
It should thus be obvious, that any approach focussing on children without impacting or changing the adult environment will have little impact on over all obesity.
This has now been well appreciated in the management of childhood obesity, where most programs now take a “whole-family” approach to addressing the determinants of excess weight gain. In fact, some programs go as far as to focus exclusively on helping parents manage their own weights in the expectation (and there is some data to support this) that this will be the most effective way to prevent obesity in their offspring.
As important as the focus on childhood obesity may be, I would be amiss in not reminding the audience that the overwhelming proportion of adults living with obesity, were normal weight (even skinny!) kids and did not begin gaining excess weight till much later in life. Thus, even if we were somehow (magically?) to completely prevent and abolish childhood obesity, it is not at all clear that this would have a significant impact on reducing the number of adults living with obesity, at least not in the foreseeable future.
Let us also remember that treating childhood obesity is by no means any easier than managing obesity in adults – indeed, one may argue that effectively treating obesity in kids may be even more difficult, given the the most effective tools to managing this chronic disease (e.g. medications, surgery) are not available to those of us involved in pediatric obesity management.
Thus, I certainly do not envy my pediatric colleagues in their struggles to provide meaningful obesity management to their young clients.
I am not sure how my somewhat sobering talk will be received by this public health audience, but then again, I don’t think I was expected to fully toe the line when it comes to exclusively focussing on nutrition and activity (as important as these factors may be) as an effective way to prevent or even manage childhood obesity.
Over the past weeks, I have presented a miniseries on the pros and cons of calling obesity a chronic disease.
Clearly, I am convinced that the arguments in favour, carry far greater chances of effectively preventing and controlling obesity (defined as abnormal or excess body fat that impairs health) than continuing to describe obesity merely as a matter of ‘lifestyle’ or simply a ‘risk factor’ for other diseases.
That said, I would like to acknowledge that the term ‘disease’ is a societal construct (there is, to my knowledge no binding legal or widely accepted scientific definition of what exactly warrants the term ‘disease’).
As all societal constructs are subject to change, our definitions of disease are subject to change. Conditions that may once have been deemed a ‘normal’ feature of aging (e.g. type 2 diabetes or dementia) have long risen to the status of ‘diseases’. This recognition has had profound impact on everything from human rights legislations to health insurance to the emphasis given to these conditions in medical education and practice.
People living with obesity deserve no less.
Thus, I come down heavily on the ‘utilitarian’ principle of calling obesity a disease.
When, calling obesity a ‘disease’ best serves the interests of those affected by the condition, then, by all means, call obesity a ‘disease’ – it is as simple as that.
We can only hope for the same impact of the Canadian Medical Association declaring obesity a disease – the sooner, the better for all Canadians living with obesity.
Continuing in my miniseries on arguments in favour of calling obesity (defined as excess or abnormal fat tissue that impairs health) a disease, I turn to the perhaps most important reason of all – access to care.
Currently, few health care systems feel obliged to provide individuals presenting with obesity treatment for their condition (beyond a few words of caution and simplistic advise to simply eat less and move more).
Most health plans do not cover treatments for obesity, arguing that this is simply a lifestyle issue.
In some countries (e.g. Germany), health insurance and health benefit plans are expressly forbidden by law to cover medical treatments for obesity.
Although long established as the only evidence-based effective long-term treatment for severe obesity, many jurisdictions continue to woefully underprovide access to bariatric surgery, with currently less than 4 out of 1,000 eligible patients receiving surgery per year in Canada.
Pretty much all of this can be blamed on one issue alone – the notion that obesity is simply a matter or personal choice and can be remediated by simple lifestyle change.
Declaring obesity a disease can potentially change all of this.
As a disease in its own right, health care systems can no longer refuse to provide treatments for this condition.
In the same manner that no health system or insurance plan can refuse to cover treatments for diabetes or hypertension, no health system or insurance plan should be able to deny coverage for treatments for obesity.
As a chronic disease, obesity care must now be firmly integrated into chronic disease management programs, in the same manner that these programs provide services to patients with other chronic diseases.
How long will it take before this becomes accepted practice and funding for obesity treatments rises to the level of funding currently available for treating other chronic diseases?
That, is anyone’s guess, but no doubt, declaring obesity a disease finally puts patients living with this condition on an equal footing with patients living with any other chronic disease.
Please support European Obesity Day
European Obesity Day (EOD) takes place this coming Saturday, 21 May, and is aimed at raising awareness and increasing knowledge about obesity and the many other diseases on which it impacts.
EOD is a major annual initiative for the European Association for the Study of Obesity (EASO) and so would like to ask you to support the activities by joining in the conversation on social media. It will help us to reach more of the policymakers, politicians, healthcare professionals, patients and the media who we are targeting with important messages about the need to take obesity more seriously.
There are several ways you can show your support:
Like the European Obesity Facebook Page
Follow EOD on Twitter @EOD2016
Join the conversations on twitter using the hashtag #EOD2016
Pledge your support on the European Obesity Day website
Visit the EOD website to see what we have been doing
Encourage your friends and colleagues to support us too
In line with the Action for a Healthier Future theme for EOD 2016, we hope we can count on your support.
Nevertheless, epidemiologists (and folks in health promotion) appear to like the notion that there is such a weight (at least at the population level), and often define it as the weight (or rather BMI level) where people have the longest life-expectancy.
Readers of this literature may have noticed that the BMI level associated with the lowest mortality has been creeping up.
Case in point, a new study by Shoaib Afzal and colleagues from Denmark, published in JAMA, that looks at the relationship between BMI and mortality in three distinct populations based cohorts.
The cohorts are from the same general population enrolled at different times: the Copenhagen City Heart Study in 1976-1978 (n = 13 704) and 1991-1994 (n = 9482) and the Copenhagen General Population Study in 2003-2013 (n = 97 362). All participants were followed up to November 2014, emigration, or death, whichever came first.
The key finding of this study is that over the various studies, there was a 3.3 unit increase in BMI associated with the lowest mortality when comparing the 1976-1978 cohort with that recruited in 2003-2013.
Thus, The BMI value that was associated with the lowest all-cause mortality was 23.7 in the 1976-1978 cohort, 24.6 in the 1991-1994 cohort, and 27.0 in the 2003-2013 cohort.
Similarly, the corresponding BMI estimates for cardiovascular mortality were 23.2, 24.0, and 26.4, respectively, and for other mortality, 24.1, 26.8, and 27.8, respectively.
At a population level, these shifts are anything but spectacular!
After all, a 3.3 unit increase in BMI for someone who is 5’7″ (1.7 m) is just over 20 lbs (~10 Kg).
In plain language, this means that to have the same life expectancy today, of someone back in the late 70s, you’d actually have to be about 20 lbs heavier.
While I am sure that these data will be welcomed by those who would argue that the whole obesity epidemic thing is overrated, I think that the data are indeed interesting for another reason.
Namely, they should prompt speculation about why heavier people are living longer today than before.
There are two general possible explanations for this:
For one these changes may be the result of a general improvement in health status of Danes related to decreased smoking, increased physical activity or changes in social determinants of health (e.g. work hours).
On the other hand, as the authors argue, this secular trend may be that improved treatment for cardiovascular risk factors or complicating diseases, which has indeed reduced mortality in all weight classes, may have had even greater beneficial effects in people with a higher BMI. Thus, obese individuals may have had a higher selective decrease in mortality.
There is in fact no doubt that medical management of problems directly linked to obesity including diabetes, hypertension and dyslipidemia have dramatically improved over the past decades.
Thus, it appears that the notion of “healthy” weight is a shifting target and that changes in lifestyle and medical management may have more than compensated for an almost 20 lb weight increase in the population.
This is all the more reason that the current BMI cutoffs and weight-centric management of obesity both at a population and individual level may need to be revisited or at least tempered with measures of health that go beyond just numbers on the scale.