Arya M. Sharma, MD

Conventional wisdom of public health ‘gurus’ dictates that the solution to the obesity epidemic is to start early - particularly to target ‘prevention’ measures at kids - the younger the better.

A thoughtful and provocative commentary by Robert C. Whitaker, from the Departments of Public Health and Pediatrics, Temple University, Philadelphia, published in the latest issue of Archives of Pediatric and Adolescent Medicine, suggests that it may be time to focus on societal norms and the values underlying those norms rather than focusing on the ’symptom’ (childhood obesity).

Thus, Whitaker reminds us that:

“The childhood obesity epidemic is just one symptom of our way of living. Reversing the epidemic may require that we apply a new approach to improving child health in the 21st century. One approach is to make societal changes to enhance human well-being rather than to prevent a particular symptom, such as childhood obesity. In the process, we may address obesity and other socially determined health conditions while preventing new ones from emerging.”

The discussion about ‘diet and exercise’ recommendations or targeting advertising to children is ‘misguided’ because it distracts from the broader societal discussion of how much value we place on creating a healthy and nurturing environment for our children.

As I have pointed out before - the questions (and answers) should focus on the ‘whys’ and not the ‘whats’ that determine our childrens’ health and well-being - in fact, obesity is only one of many problems attributable to the same ‘whys’.

Or, in Whitaker’s words:

“Many of the other “new morbidities,” such as depression, substance use, attention-deficit disorder, and bullying, are likely to share causes rooted in our way of living. To address those root causes, we must ask not only how our way of living has changed but why.”

Ignoring the ‘why’, Whitaker warns, may actually make things worse - not better:

“It is plausible that we could reverse the obesity epidemic by changing children’s environments in ways that make children less well than they are now, especially if we do not recognize that obesity may reflect how children are coping with multiple stresses induced by our current way of living.

For example, protecting children from food marketing or removing televisions from their bedrooms may leave children lean, but not well, if we fail to address the questions of whether we should market anything to young children or have more than 1 working television in a household.”

It is these decisions (that adults have made) that shape the environment for our kids.

“The decisions that led to changes in our way of living reflected the values of adults—what was important to us. Although these changes may have been disproportionately influenced by the values of those with the most political and economic power, the changes also reflected the values that parents brought to parenting, consumers brought to the marketplace, and voters brought to the polls.”

In fact, Whitacker suggests, the underlying ‘root causes’ of both the adult and childhood obesity (and other) epidemics likely share the same shift in values (consumerism, time pressure, etc.). Recognising these common roots should shift societal norms and values to benefit all - young and old, and not just their body weights.

“For example, addressing the problems of food insecurity and neighborhood safety can improve the well-being of both adults and children, involves questions of societal values, and can affect problems beyond the symptom of obesity. The need for a shared framework is also suggested by the fact that reversing the childhood obesity epidemic requires reversing the adult obesity epidemic, which should not necessarily require different approaches.”

Thus, both children and adults

“… need to find purpose and meaning in life, which requires lifelong growth and development… autonomy, competence, mastery, self-acceptance, positive relations with others, and transcending self through commitment or connection to something or someone else.”

“An emphasis on relationships might also clarify the tradeoffs in connecting to others through face-to-face vs electronic communication. The importance of helping children identify their natural gifts and find meaning and purpose in their lives might highlight the trade-offs in education between children’s cognitive development and their social, emotional, and spiritual development. Such trade-offs, while not about obesity per se, could also affect energy balance.”

I, for one, certainly concur with Whitaker that it will take a major and open public dialogue about the norms and values that underlie the way we run our societies to address these health issues of our times.

As I have said before, blaming, shaming and punishing will not solve the problem - this is simply shooting the messenger.

Nor will calls for laws and bans or other measures that target the symptoms (e.g. fast food) without addressing the real problem (e.g. lack of time) really solve the obesity issue (should we perhaps be learning something from the hopelessly lost ‘war on drugs’ here?)

No one said this would be easy.

AMS
San Francisco, CA

p.s. Hat Tip to Geoff Ball for alerting me to this article

Whitaker RC (2011). The childhood obesity epidemic: lessons for preventing socially determined health conditions. Archives of pediatrics & adolescent medicine, 165 (11), 973-5 PMID: 22065178

Who, in the light of the obesity epidemic and its myriad consequences, could possibly object to public health messages and other measures that would target obesity?

Aren’t messages to increase physical activity and eat healthier, even if provided with a ‘nudge’ (fat tax, BMI report cards, etc.), a reasonable and necessary step in the interest of promoting public health and tackling obesity?

It turns out that things are less clear than you may think, especially if you consider the ‘ethics’ of such measures and their implications for those, who these measures seek to educate and change for the better.

Thus, a comprehensive analysis of the surprisingly problematic ethics of some of the public health approaches to obesity prevention, by the medical ethicist Inez de Beaufort and colleagues, from the University of Rotterdam, published in the latest issue of OBESITY REVIEWS, makes a most enlightening and thought-provoking read.

In their paper, the researchers look at 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluate their ethically relevant aspects.

As the authors point out, while efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, may appear ‘ethical’ as they are aimed at improving individual and public health, enabling informed choice and diminishing societal costs, they also raise potential ethical objections against such efforts.

The long list of potentially ethically problematic aspects identified include:

• Effects on physical health (of proposed interventions) are uncertain or unfavourable;
• There are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination;
• Inequalities are aggravated;
• Inadequate information is distributed;
• The social and cultural value of eating is disregarded;
• People’s privacy is disrespected;
• The complexity of responsibilities regarding overweight is disregarded;
• Interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding Freedom of private enterprise or regarding policy choices by schools and other organizations.

Whether or not the ‘ethical’ incentives to combat the obesity epidemic should ‘automatically’ override the potential ethical constraints, is less than clear.

The complexity of some of these ‘well meant’ initiatives can have unintended ethically problematic consequences: e.g. ‘demonizing’ candy, fast food, or chocolate milk can ostracize the child, who consumes these foods because of socioeconomic or other constraints. Oversimplistic and unrealistic messages about the benefits of diet and exercise can not only reenforce obesity bias and stigma but also lead to disengagement by the very individuals, for whom these messages are intended.

Blame, shame, and punish (tax) approaches to combatting obesity (implicit in many public health interventions) are ethically problematic not only because of lack of evidence of their effectiveness but also because such measures are unlikely to lead to positive and constructive solutions for the targeted individuals.

Thus, the authors recognise an urgent need to develop an ethical framework to support decision makers in balancing potential ethical problems against the need to do something.

Clearly, the need to kicking tires around the ethics of programmes to target obesity, is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a program may hamper its effectiveness.

As I have noted before, the principle of First Do No Harm, should apply as much to public health interventions as to individual care.

AMS
Edmonton, Alberta

ten Have M, de Beaufort ID, Teixeira PJ, Mackenbach JP, & van der Heide A (2011). Ethics and prevention of overweight and obesity: an inventory. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (9), 669-79 PMID: 21545391

Yesterday, I blogged about the rather weak relationship between BMI and health risks in the Manitoba Centre for Health Policy (MCHP) Report on Adult Obesity, and suggested that the results may have looked very different had the same data been analysed using the Edmonton Obesity Staging System.

Today, I want to address another interesting finding of this report, namely, the researcher’s attempts to identify the ’causes’ of obesity in Manitoba.

Variables examined included age, sex, marital status, education, employment, household income, activity restrictions, occupational physical activity, self-perceived life stress, satisfaction with life, self-rated mental health, sense of community, eating fruits and vegetables, physical activity leisure and travel, sedentary activities, current smoking, binge drinking, recent changes to improve health, food insecurity, and regular doctor.

Among these, location of residence, age, sex, education, employment, and marital status were particularly strong predictors of excess weight.

Interestingly, the psychological variables had little additional ‘effect’.

leisure– and travel–time activity level was the most strongly associated variable and showed a dose–response relationship—higher levels of activity were associated with lower likelihood of obesity. Other important variables were smoking (which was associated with a lower likelihood of obesity) and time spent in sedentary activities (more than 30 hours per week was associated with a higher likelihood of obesity).

Notably, only age and geography were significantly related to BMI values in youth.

Apart from the fact that such analyses cannot actually prove ‘causality’ as they are merely associated and therefore assumptions about modifying any of the modifiable variable will in fact reduce BMI, the researcher also made another notable observation:

“It is important to note that despite including many variables, this study was only able to explain a small amount of why people are obese. This means there are other reasons for the recent rises in weight, perhaps changes in our diets or our physical and social environment.”

Indeed, I would easily have predicted that factors not considered in this analysis, including parental BMI, birth weight, maternal weight at inception and birth of the participant, duration of sleep, etc. may well have accounted for some of the increase in obesity.

This should not detract from the importance of factors like sedentariness, stress, food insecurity and other variables that had some influence on obesity rates in this study.

It should, however, make us cautious in accepting the commonly held notion that the ‘root cause’ of obesity is simply increased sedentariness and eating too much.

Clearly, this is not the whole (and perhaps not even the biggest part) of this ’story’.

AMS
Edmonton, Alberta

Today, as I attend the 47th European Association for the Study of Diabetes (EASD) Annual Meeting here in Lisbon, I cannot help but discuss an article by Kenneth E. Thorpe and Zhou Yang, Emory University, Atlanta, Georgia, published in the latest issue of Health Affairs.

Based on their analysis of the significant impact of even modest sustained weight reduction on the incidence of type 2 diabetes, these authors suggest that enrolling overweight and obese pre-diabetic US adults aged 60–64 into a proven, community-based weight loss program nationwide could save Medicare $1.8–$2.3 billion over the following ten years.

Estimated savings would be even higher ($3.0–$3.7 billion) if equally overweight people at risk for cardiovascular disease were also enrolled.

Thus, lifetime Medicare savings could range from approximately $7 billion to $15 billion, depending on how broadly program eligibility was defined and actual levels of program participation, for a single “wave” of eligible people.

A key assumption in their proposal, is that a fully funded sixteen-twenty week community program (perhaps delivered by the YMCA), would deliver about 4% weight loss and replicate the almost 50-70% reduction in progression to diabetes seen in some diabetes prevention studies.

Using our Edmonton Obesity Staging System definitions - this program would target Stage 1 patients (pre-diabetes) or Stage 2 patients (with hypertension or dyslipidemia).

There is no doubt that community based ‘lifestyle’ interventions are the only plausible way in which any program can be delivered to millions of eligible individuals. There is also little doubt that in randomised controlled trials, considerable benefits have been demonstrated.

The question remains, however, whether enough eligible participants will in fact participate and persist with these ‘lifestyle’ changes without continuing and ongoing support (which is generally what the clinical trials have delivered). The notion that an intervention of limited duration (even twenty weeks) will lead to sustainable effects, may be a bit over optimistic, even if 10 year follow-up data from some diabetes preventions studies suggest long-term benefits even after the end of the trials.

It is also worth discussing whether or not success is actually dependent on losing weight (not a behaviour) rather than simply increasing physical activity and eating better (which are behaviours).

Whether or not there is indeed a realistic chance that millions of people can be enrolled in community based interventions programs will remain to be seen, but it is certain that, if feasible, savings would indeed be substantial.

This is why, in the recently announced Alberta Health Services Obesity Initiative, there is a significant emphasis on the importance of community based programs (such as Thr!ve on Wellness, a joint initiative from Alberta Health Services and the Alberta Cancer Foundation, which will soon be expanded to over 100 Alberta communities).

If successfully adopted, these programs should have benefits far beyond diabetes prevention and reduce rates of heart disease, cancers, musculoskeletal problems and hopefully also improve mental health and well being.

Perhaps this is when we can truly claim to be moving towards a ‘health care’ rather than a ’sickness care’ system.

AMS
Lisbon, Portugal

Thorpe KE, & Yang Z (2011). Enrolling people with prediabetes ages 60-64 in a proven weight loss program could save medicare $7 billion or more. Health affairs (Project Hope), 30 (9), 1673-9 PMID: 21900657

While the growing concern about childhood overweight and obesity has spawned a wide-ranging discussion on the causes and approaches to best tackle this epidemic, evidence to support actions that will demonstrably reduce childhood obesity remain hotly debated.

In the light of this discussion, it is not only important to better understand the determinants of childhood obesity but also to examine proposed intervention strategies both in terms of feasibility and efficacy.

This exercise was undertaken by Kuhle and colleagues from the University of Alberta in a paper just published in the Canadian Journal of Public Health that examines the prevention potential of risk factors for childhood overweight.

In order to estimate the population-attributable risk for childhood overweight risk factors, the researchers examined data from a population-based survey of Grade 5 students who participated in the 2003 Children’s Lifestyle and School Performance Study in Nova Scotia, Canada. Data from this survey was linked to a provincial perinatal registry to also determine the role of maternal factors in the risk for excess weight in childhood.

Of the various “preventable” factors that were considered, including physical activity, sedentary activity, maternal smoking during pregnancy, and maternal pre-pregnancy weight, both sedentary activity (as estimated from time spent viewing TV, computers and video games or “screen time”) and maternal pre-pregnancy weight appear to offer the greatest potential for prevention.

Based on their analyses, the researchers concluded that addressing these two issues could potentially prevent approximately 40% of overweight in childhood.

Obviously, this calculation assumes that there are effective ways of actually reducing pre-pregnancy weights and the time kids spend on sedentary activities. Regular readers of these pages probably appreciate that this may not be quite as straightforward as it sounds.

On the other hand, recognizing where intervention strategies can perhaps provide the “biggest bang for the buck” is certainly a step in the right direction.

AMS
Edmonton, Alberta

Kuhle S, Allen AC, & Veugelers PJ (2010). Prevention potential of risk factors for childhood overweight. Canadian journal of public health. Revue canadienne de sante publique, 101 (5), 365-8 PMID: 21214049