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

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

‘ 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

‘ 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

‘ 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

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

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

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

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

Food

Exercise

Wellbeing

Disease consequences:

Morbidity and mortality

Use of health services

Use of medication

Lifestyle and Behaviour

Diet and nutrition

Physical activity

“ Risk Factors”

Income

Education

Occupation

Life

Stages

Childhood

Adolescence

Adulthood

Educational facilities

Health/Social services

Material infrastructure

Employment, Wealth

Conditions :

Poverty , crime

Social disorder

Chronic stress

Accessible capitals:

Social, Economic

Human, Cultural

Neuroendocrine loading

catecholamines, blood pressure

Maladaptive regulatory shifts

Insulin resistance, dyslipidemia

Oxidative stress, inflammation

Obesity

Overweight

Abdominal

adiposity

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

www.foresight.gov.uk/obesity

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?

What explains individual differences in body fatness?

What explains population differences in obesity prevalence?

What explains the recent rise in obesity globally?

Variability in population obesity rates Source: Ulijaszek SJ & H Lofink. Annual Review of Anthropology 2006, 35:337-60.

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

"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)

Kg per person per year

Kg per person per year

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

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

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

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

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)

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)

www.iotf.org/sydneyprinciples

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

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

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)

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%

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

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