Non-Communicable Diseases V

Overweight, Obesity and Diabetes Mellitus

Today we’ll be discussing the battle of the bulge, which is now the global public health challenge. We recognize now that overweight and obesity are becoming a major threat not only to public health, but also to global economy and to sustainable development. In  1980, about 4.8% of the men were declared to be obese. By 2008, it was 10%. And among women from 7.9% in 1980 to 14% obesity rates in 2008, again a substantial rise in a relatively short time. When we look at the world today we find that the Pacific Islands have the highest rates of obesity.

551The lowest are among the men in Congo and the women in Bangladesh. But globally it is a problem and it’s particularly visible in the United States which has the highest rates of obesity among the high income countries. In fact this is a country with the most rapid rise in the body mass index, which is the way we measure obesity, in the last 30 years. Overweight and obesity are also major health problems in a continuum. It is estimated by a metric which compares body weight with height, called the body mass index, if that index is 30 or more, then we call people obese. If it is between 25, but less than 30 we say they’re overweight. But both of these carry health risks. It has been estimated that currently we have a billion adults who are currently overweight and 475 million further are obese. It has also been estimated by the World Health Organization that in Asia we probably need lower thresholds for defining overweight and obesity for public health or clinical action. That is because at any given level of body mass index, the Asians, particularly in South Asia but elsewhere too seem to have a higher percentage of body fat and that puts them at a high risk, even at a lower level of body mass index compared to the western populations. So if you take that also into account, the number of obese adults currently is more than 600 million. And globally up to 200 million school children are either overweight or obese. This is not a problem only of high income countries. Indeed, over the years, we have seen that the number of people with overweight and obesity are rising much more sharply in the developing countries and by 2008, the numbers there have far exceeded those in the high income countries. Recently, a report by McKinsey Global Institute suggests that among the various threats to global economy in terms of economic and social burdens overweight and obesity are very high up on the list, ranking third in the list of social burdens. How did this happen? There have been several factors which have been accelerating the nutrition transition in the developing countries. Firstly there’s been a shift in the diet structure towards a high fat and refined sugar western diet. And there’s been a shift in a activity patterns with lower levels of physical activity and an increased level of sedentary habits. And all of these have contributed together to overweight and obesity. And some of this transition has been amazingly rapid. If you look at Mexico, between 1999 and 2006, the rates of overweight and obesity have markedly increased and the rate of rise of this problem has accelerated substantially, doubling in terms of its speed between 1999 and 2006. Similarly in China, over an eight year period, there was a substantial shift in the distribution of body mass index across the population to the right. That means the average body mass index was increasing and when we start applying the metrics of overweight and obesity among the Chinese adults, in the age group of 20 to 45, there was a tripling of male obesity and doubling of female obesity, all in an eight year period. And when we look at what are the factors that actually pushing this process forward we see a huge amount of marketing pressure which is pushing unhealthy foods which are obesogenic. Well nutritionists may come up with nutrition pyramids and suggest what should we eat in plenty and what in moderation and what should only be occasionally taken, but if you look at the way advertising works, most of the advertising campaign is to push the promotion of colas and other sugary drinks, chips and salted snacks, biscuits, pastries and so on and a huge variety of fast foods. The industry is very seductive in appealing to your taste and creates an addiction to unhealthy foods. High salt, high sugar and high fat foods are usually very addictive. And indeed food industry scientists say, cram as much hedonics as you can in one dish. And this condition, hyper-eating, becomes a response to the stimulus created by these foods. But the price of some of these unhealthy foods is also falling. Just as we start seeing increase in portion sizes, we also see super-sizing of foods and we see that soft drinks for example, the sugar sweetened beverages are becoming not only larger in their containers, but also falling in overall price. And soft drinks now account for 7% of all calories consumed in America. It has been estimated that if the average American drinks water instead of sugary drinks, she or he would weigh 15 pounds less. Aggressive transnational marketing of unhealthy foods also is accelerating the obesity epidemic across the world, especially in low and middle income countries. We see for example between 1989 and 2006 snack imports into the Central American countries from United States rose for a variety of snack foods, all of which were high calorie and low in nutrition. Similarly pastry, biscuit and confectionary imports as well as frozen French Fries, all of these rose markedly during this period. The way trade also acts as a major barrier for promoting health is exemplified by Samoa. Samoa started getting a large amount of turkey tail import from the United States and New Zealand after World War II. It was never a part of the Samoan diet. But now it had actually transformed the Samoan diet into an obesogenic high fat diet. And when the Samoan government decided that because of the high levels of diabetes and hypertension in Samoa as well as the huge levels of obesity with 53% of Samoans being obese, they needed to do something about the food policy. They banned the import of turkey tails in 2007. But when Samoa started entering into the WTO, the World Trade Organization said, you cannot ban turkey tails. You have to import them because that is part of the international trade rules. So this country had no option but to again, lift the ban on turkey tails, subjecting their population again, to an avalanche of unhealthy imports. Therefore we recognize that overweight and obesity are not simple problems operating at a physiological level in the individual, quite often doctors and scientists will tell you it is an imbalance between energy intake and energy expenditure. Eat less, or exercise more. But there are so many factors that are operating at the societal level. For example, what is the work environment like, the school environment like, and home environment like? Are they promoting leisure time activity or home activity or work activity? Or are they making you chair bound or addicted to the television? Those are factors that come in. There are also factors which operate at the community and locality. Is there a safe environment for pleasurable physical activity? What are the media influences like? What is the transport situation like? Is walking on the streets a health hazard because of accidents? All these factors play a role. Similarly there are national and regional factors. We just spoke of imports, but there are a number of other factors like how the health system is, how the media is responding, what is the education system talking about healthy nutrition, what are the cultural factors? All of these factors play a role and of course transport But also transnational and global factors like for example import policies as well as transnational media influences which encourage some type of new unhealthy eating patterns, greater consumption of soft drinks and so on. All of these factors need to be contended with if we have to stem this epidemic of overweight and obesity. So the causal web is fairly large, but we have to act at each step. We therefore must recognize that among the various interventions that are available, there are interventions which are directed at the individual, asking for behavior change and of course information and education, motivating change in health beliefs and behaviors are very important. But there are also interventions that operate at the nonpersonal level, at the population level, through policy nudges, by creating environmental prompts and stimuli and by providing supportive environments for behavior change. The McKinsey Institute again put together a long list of interventions and said, a majority of them are cost effective. But particularly cost effective are those which act at the subconscious level, at the population level through policy interventions, through environmental interventions, which actually nudge the individual to adopt healthy practices rather than just preaching to him or her as to how to change personal behavior. So it is this combination of interventions, particularly those which use policy and environmental reengineering by creating supportive environments which are going to be very critical as we move along the path to sustainable development. In terms of interventions, a single intervention is seldom effective. We need a composite combination of interventions. It is this multi-component intervention that is usually successful whether in tobacco or in the case of obesity and that is what we really ought to be looking at. In terms of national interventions, there have been certain steps that have been recently taken. Recognizing that sugar sweetened beverages are particularly dangerous from point of view of diabetes and obesity, Mexico, which as we said, has experienced one of the largest increases in obesity rates in the last two decades has decided to impose a 10% tax on sugar sweetened beverages in 2013. India too imposed a 5% tax on aerated sugary drinks in July 2014. Mexico also went ahead and imposed a…an 8% tax on junk foods, which again, extends the whole area beyond just cola drinks, but also into the whole area of junk foods which are also dangerous from the point of view of the epidemic. We have been so far talking about born small in size also results in certain types of obesity which are also very dangerous. A child that is born small can during the period of nutritional supplementation between 2 to 12 years can gain a lot of fat instead of muscle. It’s called rebound adiposity. Much of this fat gets deposited in the abdomen, around the liver and inside the abdominal cavity. And this can be particularly dangerous when we start looking at the effects of it, because the visceral adiposity or abdominal adiposity as it is called has great correlation with diabetes as well as certain abnormal blood fat patterns like decreased amounts of protective cholesterol, or the good cholesterol, also called HDL cholesterol, high triglycerides, more likely to have high blood pressure, more likely to get heart attacks early. So this whole problem of diabetes is definitely linked overweight and obesity, but also seems rather surprisingly, linked to low birth weight with rebound adiposity. So don’t be surprised if in some of the developing countries like India you find thin individuals with overweight and with diabetes, because most of the fat is in the abdomen and even if it’s not visible elsewhere and that can also make them prone to diabetes. Indeed, if when you look at what’s happening in India, an example is of two diabetologists, one Indian and one British, who are sitting side by side in this picture and they have an identical body mass index of 22.3, which is very good by all international standards. But the Indian diabetologist has almost twice the level of percentage of body fat compared to his British counterpart at the same level of body mass index. That means he has much greater amount of body fat which predisposes him to health problems associated with visceral adiposity. So overweight and obesity are not very simple ballooning of the body. It also means what kind of fat is deposited and where it is deposited. Now in terms of diabetes, we are seeing a huge explosion of diabetes all over the world. And particularly this is happening in the developing countries, adding to the overall global burden of diabetes. And if we have to reduce the incidence of diabetes and also reduce the complications of diabetes, we have to adopt strategies which protect people from developing diabetes in the first place, but also early detection of diabetes and effective treatment so that we avoid complications like heart attacks, strokes, kidney failure, or amputated limbs due to foot ulcers and so on. Unfortunately the developing countries are bearing the brunt of this. If you look at the top ten countries with diabetes, in 2011, seven of the top ten countries are low and middle income countries. By 2030, you will have eight of the low and middle income countries in the top ten league. China and India will continue to lead with huge numbers in both 2011 already happening and 2030 in the future. But if we want to prevent diabetes, we recognize again, healthy diet and physical activity are very effective interventions. In the United States the diabetes prevention program trial compared no action at all versus giving a medicine called Metformin, which is an anti-diabetic drug, versus a lifestyle intervention with regulated physical activity pattern plus a healthy diet and they tried it out in people who are likely to develop diabetes or at high risk of developing diabetes. Not yet developed diabetes, but because of family history, because of overweight and obesity or borderline blood sugars, who are deemed to be at a high risk of developing future diabetes. And when they tried all these three interventions, low and behold, lifestyle triumphed much more than medicines. Compared to the no intervention group or the placebo group, 58% decrease in the incidence of diabetes in the lifestyle group, 35% in the Metformin group. Was it an isolated result? No, it got very well confirmed with 58% reduction also in Finland and similar levels of reduction in China, also replicated in India. So we have seen across the world diet and physical activity coming up trumps in terms of effectively reducing the incidence of diabetes if properly followed. And indeed, this can also be supported by some individual interventions for reinforcement of health messages. A trial in India showed that messaging on mobile telephony, on healthy diets and physical activity in a randomized, controlled trial, it was seen that people who received the messages and followed them had substantially lower incidence of diabetes and the amount of dietary energy or calories they consumed was also lower. However, once you develop diabetes and manifest it, there is also the danger of complications if you do not control it well. Tragically, despite all the knowledge that is available about diabetes and how to treat it and what happens if you don’t treat it, there are very few persons with diabetes who are adequately controlled. And that is a problem of the health system. So how do we actually insure that diabetes is controlled? And along with that, the other risk factors like high blood pressure, abnormal blood lipids, all of these are controlled because all of these cumulatively can cause a lot of damage to the blood vessels and cause heart attacks, stroke and kidney failure. It has been shown that we don’t have to always depend only on doctors to do this. For example, in Kwa-Zulu-Natal in South Africa, nurses were able to control 68% of the patients with diabetes, 82% of the patients with hypertension, 84% of the patients with asthma, and treatment adherence also substantially increased. In Iran, similar results were found with trained rural primary healthcare, community healthcare workers where the management of blood pressure as well as diabetes was substantially better once these people were trained and intervened in the community. Similar packages were also tried out through community health worker training in India and Pakistan. So one of the advances in primary healthcare is to use technology enabled primary healthcare providers for earlier detection and better management of diabetes and associated risk factors which is eminently possible, even for the under-resourced health systems of low and middle income countries. So if we really want to tackle these problems of overweight, obesity and diabetes we need dietary changes from high glycemic foods which generate high blood sugar levels in a fast time to a high fiber diet which reduces the sugar peaks and slows down the sugar release over a longer period. We need to move from unhealthy fats to healthy fats. We need to moderate our salt intake because high salt intake also can cause high blood pressure, accentuate the problems of diabetes and, and also of overweight and obesity. But now we recognize that even too low salt a diet may be sometimes problematic, so moderate salt diet should be attempted. And in most countries, already the salt intake is very high, so a reduction is perfectly in order. But at the same time we need more intake of fruit and vegetables because they contain more fiber, they contain more protective phytonutrients, but they also contain potassium which reduces the effect of dietary salt or sodium. So if we take this kind of diet and also have regular sustained physical activity, not only at leisure time, but also at work, at home, during transport, then we are much more likely to be protecting ourselves from diabetes and overweight and obesity. But this requires solutions both at the level of personal behavior and at the level of the societal environment which is supportive for healthy living choices. And that is where we ought to link that with creation of a sustainable development framework where all of these choices are available to people and we protect ourselves as well as the planet while doing so.

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Pedro Pereira Leite

Researcher and professor. He had his PhD. on museology in 2011, with the title “Muss-amb-ike Homeland: The commitment on musicological process”, that was published in 2011. In 2012 he finishes a Post-PhD Research on "Biographical Glances: The intersubjectivity poetry on museology, at Lusófona University (Lisbon). Presently he is working in his Post PhD. Research about: “Global Heritages" with the aims to build a network on local cognizance and memory manager has a tool to build the will of action in 3 different communities, linked by past communed heritages.” He works at CES. He participates on different Research network, presented papers in national and international conferences, and had published books on research subjects.

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OpenEdition sugere que esta publicação seja citada da seguinte forma:
Pedro Pereira Leite (18 de Maio de 2015). Non-Communicable Diseases V. Global Heritages. Recuperado em 28 de Abril de 2025 de https://doi.org/10.58079/p2oy


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