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4 Swinburn - Obesity
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  • 1. The global nature of obesity, its causes and what needs to be done Boyd Swinburn Director, WHO Collaborating Centre for Obesity Prevention Deakin University Melbourne Holding Corporations to Account
  • 2. Outline
    • ‘ Causes’ of obesity
    • What is the right question?
    • Opportunities for corporate leadership and action
    • Obesity as a commercial success but economic failure
    • Example: marketing to children
      • IOTF Sydney Principles
    • Conclusions
  • 3. ‘ Causes’ of obesity
    • ‘ Eating too much and not exercising enough’
    • Determinants is a better term
      • Layered
      • Not linear
      • Not inevitable
    • Knowing the determinants may or may not help with the solutions
      • Occupational physical inactivity
      • Commercial drivers
  • 4. O I T Y P R E V A L E INDIVIDUAL Energy Expenditure POPULATION % OBESE OR UNDERWT Food intake : Nutrient density Source: see Kumanyika Ann Rev Pub Health 2001; 22:293-308 “ Causal Web” FACTORS INTERNATIONAL Development Globalization of markets School Food & Activity WORK/ SCHOOL/ HOME Infections Labour Worksite Food & Activity Leisure Activity/ Facilities Agriculture/ Gardens/ Local markets COMMUNITY LOCALITY Health Care System Public Safety Public Transport Manufactured/ Imported Food Sanitation NATIONAL/ REGIONAL Food & Nutrition Urbanization Education Health Social Security Transport Family & Home National perspective Media & Culture Media programs & advertising Biology
  • 5. An Ecological Model of Diet, Physical Activity, and Obesity Health Outcomes Behaviors Influences Gordon-Larsen. NHLBI Workshop: Predictors of Obesity, Weight Gain, Diet, and Physical Activity; August 2004, Bethesda MD Energy Balance Eating Dietary patterns, nutrient intake Sedentary Behaviors TV, computer use, driving Physical Activity Recreation, transportation, occupation, domestic Body Weight, Fat, & Distribution Risk Factors, CVD, Diabetes, Cancers, Costs Biological & Demographic Age, sex , race/ethnicity, SES, genes Psychological Beliefs, preferences, emotions, self-efficacy, intentions, pros, cons, behavior change skills, body image, motivation, knowledge Social/Cultural Social support, modeling, family factors, social norms, cultural beliefs, acculturation Physical Environment Access to & quality of foods, recreational facilities, cars, sedentary entertainment; urban design, transportation infrastructure, information environment Policies/Incentives Cost of foods, physical activities, & sedentary behaviors; incentives for behaviors; regulation of environments Organizational Practices, programs, norms, & policies in schools, worksite, Health care settings, businesses, community orgs
  • 6. A Graphical Model of Childhood Obesity x 1 x 2 x 5 x 10 x 12 x 8 x 15 x 17 x 14 x 3 x 4 x 9 x 16 Economic Educational Environmental Parents’ nutritional knowledge Parents’ values Diet Physical activity Physical fitness Triceps skinfold thickness x 18 x 11 Waist circumference x 13 Body mass index Time x 6 Child’s values x 7 Child’s nutritional knowledge y 1 Cost of Diet Non-alcoholic fatty liver disease Sleep apnoea Hypertension Type II diabetes QA Life expectancy Chalabi and Dowie 2004 Social factors Behavioural factors Intermediate outcome measures Health outcome Health response Cognitive states
  • 7. A conceptual framework for biosocial pathways
    • Food
    • Exercise
    • Wellbeing
    Local attributes of place: social/physical environs Spatialising Processes Time: Ongoing evolution of person-place interaction Time: Cumulative exposures, variable induction periods, lagged outcomes
    • Disease consequences:
    • Morbidity and mortality
    • Use of health services
    • Use of medication
    Cardiovascular disease, diabetes
    • Lifestyle and Behaviour
    • Diet and nutrition
    • Physical activity
    • “ Risk Factors”
    Indirect-Cognitive Path “ Risk Modifiers/Mediators” Direct-Contextual Path “ Risk Markers” Conscious Perception of Environment Mastery and Control, Affect Mental Health Psychosocial Factors
    • Income
    • Education
    • Occupation
    Non-Conscious Perceptions Individual SES and resources
    • Life
    • Stages
    • Childhood
      • Adolescence
        • Adulthood
    Opportunities : Environmental “ Risk Conditions” Structural Factors Asymmetry in distribution of, access to, resources:
    • Educational facilities
    • Health/Social services
    • Material infrastructure
    • Employment, Wealth
    • Conditions :
    • Poverty , crime
    • Social disorder
    • Chronic stress
    Contextual Factors Cardiometabolic Disease
    • Accessible capitals:
    • Social, Economic
    • Human, Cultural
    Environmental Characteristics Individual Attributes Biological Mediators and Moderators Outcomes and Consequences Daniel M et al. (2007). Framing the biosocial pathways underlying associations between place and cardiometabolic disease. Health & Place, doi:10.1016/j.healthplace.2007.05.003 Allostatic Load Autonomic nervous system, and hypothalamic-pituitary-adreno-cortical dysregulation
    • Neuroendocrine loading
    • catecholamines, blood pressure
    • Maladaptive regulatory shifts
    • Insulin resistance, dyslipidemia
    • Oxidative stress, inflammation
    • Obesity
    • Overweight
    • Abdominal
    • adiposity
  • 8. R Uauy, 2007 Nutrition Related Susceptibility (life-course exposure) Energy Balance Energy dense diets (fat &sugar) Physical Activity Appetite & food intake Control Pre & postnatal growth Macronutrient quality Micronutrient balance Hormonal response to diet Underlying Factors Access to safe and healthy foods (quantity and quality) Balancing Energy Intake and expenditure Factors affecting food and PA supply chain Policies affecting marketing, advertisement, subsidies Urban space and facilities for active lives (household school & workplace) Psycho-social determinants of food intake and PA Basic Causes Community empowerment demand for: safe & healthy foods, active lives Public and private sector response to people’s health demands Government response in protection of public interest International and National framework policies: health, education, agriculture, economic, urbanization, recreation, transport, trade Legislative framework and norms: to promote, support and protect right to safe and nutritious foods. present efforts potential for future effectiveness Adipocyte Cell Growth Hormones Receptors OBESITY Genetic Monogenic Polygenic Epigenetic genes
  • 9.  
  • 10. www.foresight.gov.uk/obesity
  • 11.  
  • 12. The determinant questions
    • What explains individual differences in body fatness?
    • What explains population differences in obesity prevalence?
    • What explains the recent rise in obesity globally?
  • 13.  
  • 14. Variability in population obesity rates Source: Ulijaszek SJ & H Lofink. Annual Review of Anthropology 2006, 35:337-60.
  • 15. What is driving the obesity trends?
    • "You hear plenty of explanations for humanity's expanding waist-line, all of them plausible. Changes in lifestyle …. Affluence … Poverty … Technology …. Clever marketing … All these explanations are true, as far as they go. But it pays to go a little further, to search for the cause behind the causes. Which, very simply, is this: When food is abundant and cheap, people will eat more of it and get fat ." (p 102)
    Source: Pollan M. The Omnivore's Dilemma: A Natural History of Four Meals , Penguin Books, 2006. Change from 1970-2000 in total calories of food produced per capita in 6 countries
  • 16. Kg per person per year
  • 17. Kg per person per year
  • 18. Commercial success, economic failure
    • Commercial success
      • Achieved overconsumption and GDP growth
    • Economic failure (market failure)
      • Choices for short-term desires (driven by marketing) which produce long-term detriments are too easy
    • ‘ Market failure’ is a justification for government policy intervention
    Moodie et al Int J Ped Obesity 2006
  • 19. Influencing food choices Food corporations High profits (= high consumption) Taste (HFSS) Portion size Low price High value Convenient Accessible Target groups Selective disclosure Claims Taxes Subsidies Schools Children Labelling Food claim regs Guidelines Standards Governments Social, economic, political outcomes Products Price Placement Promotion Food choices
  • 20. Influencing food choices Taste (HFSS) Portion size Low price High value Convenient Accessible Target groups Selective disclosure Claims 1 4 3 2 5 6 8 7 Food corporations High profits (= high consumption) Taxes Subsidies Schools Children Labelling Food claim regs Guidelines Standards Governments Social, economic, political outcomes Products Price Placement Promotion Food choices
  • 21. Corporate action for consumer health
    • Support (not undermine) government policy actions for improved public health
    • No marketing to children
    • Reduce fat, sugar, salt content where possible (multiple small, undiscernible steps), develop and promote healthier choices
    • Full disclosure of nutrient information to consumers (support for government-based nutrient profile system)
    • Support school policies to reduce junk food & soft drinks
    • Use appropriate portion sizes
    • Support tight regulations on food claims
    • Reduce super-sizing options (lower relative cost for high volumes)
  • 22. www.iotf.org/sydneyprinciples
  • 23. IOTF ‘Sydney Principles’ to reduce marketing to children
    • Support the rights of children
    • Afford substantial protection for children
    • Be statutory in nature
    • Take a wide definition of commercial promotions
    • Guarantee commercial-free childhood settings
    • Include cross-border media
    • Be evaluated, monitored and enforced
    www.iotf.org/sydneyprinciples
  • 24. Sydney Principles: Global consultation
    • Launched at Int Congress on Obesity (Sydney, 2006)
    • Feedback from ICO delegates and global e-consultation
      • Including major food industry organisations
    • Full support (except industry disagreed with the need for regulations, #3)
    • Age – 70% said 16 years or higher
    • Products
      • All products – 31%
      • All foods and beverages – 24%
      • HFSS foods and beverages – 45%
    Swinburn et al (under review)
  • 25. Conclusions
    • Move from causes to solutions
      • ‘ Is there any evidence to prove that banning TV ads reduces childhood obesity?’
      • ‘ Is a ban on the marketing of obesogenic foods to children a promising , cost-effective measure as part of a comprehensive approach to reducing childhood obesity?’
    • Industry can do a lot (much of which runs counter to their short term commercial drivers)
    • International Code on Marketing to Children is a priority