Robyn Toomath on obesity in New Zealand


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Taking account of research around the relationship between genetics and our new ‘food environment’, Dr Robyn Toomath (endocrinologist and Clinical Director Wellington Hospital) argues that we are in the middle of an obesity epidemic which impacts widely on public health. She advocates for new approaches to obesity based not on blame or impossible personal goals, but on outcomes. She argues it is the responsibility of all to become informed and active (personally and politically), in working for change to present health policies and gives examples of what can be done.

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  • We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.
  • Robyn Toomath on obesity in New Zealand

    1. 1. Why Do We Need To Do Something About Obesity?
    2. 2. Overview <ul><li>Is there really an obesity epidemic? </li></ul><ul><li>Does obesity really cause ill health? </li></ul><ul><li>What is it due to? </li></ul><ul><li>Is our current approach making the problem better...or worse? </li></ul><ul><li>What else could we do? </li></ul>
    3. 3. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
    4. 4. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%
    5. 5. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%
    6. 6. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    7. 7. The NZ scenario <ul><li>In 2002, 21 percent of children aged 15-14 years were overweight and a further 10 percent were obese. </li></ul><ul><ul><li>the figures for Maori were higher being 35% for boys and 47% for girls </li></ul></ul><ul><ul><li>For Pacific Islanders 60% of boys and 64% of girls are overweight or obese </li></ul></ul><ul><li>The prevalence of obesity in adults doubled from 1997 to 1002/03, from 9 to 20 percent in males and 11 to 22 percent in females. </li></ul>
    8. 11. Prevalence of overweight and obesity in adults 1977 to 2003 Ministry of Health 2004e
    9. 12. The Effects of Obesity
    10. 15. Table 1  Health risks associated with increasing Body Mass Index (BMI) Overweight/obesity plus hypertension is associated with increased risk of ischaemic stroke Obesity is a contributing factor to cardiac failure in >10% of patients 70% of obese women with hypertension have left ventricular hypertrophy Dyslipidaemia progressively develops as BMI increases from 21 kg m −2 with rise in small particle low-density lipoprotein 3.6× risk of CAD for each unit change in BMI Coronary artery disease (CAD) and stroke 85% of hypertension is associated with a BMI >25 kg m −2 66% of hypertension is linked to excess weight 5× risk in obesity Hypertension 90% of type 2 diabetics have a body mass index (BMI) of >23 kg m −2 Type 2 diabetes 30% of middle-aged people in developed countries have features of metabolic syndrome Metabolic syndrome
    11. 16. Table 1  Health risks associated with increasing Body Mass Index (BMI) 4 Obesity Related Morbidity. Obesity Reviews   8  (s1), 13-17. 3× risk of gall bladder disease in women with a BMI of >32 kg m −2 ; 7× risk if BMI of >45 kg m −2 Overweight and obesity associated with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NASH). 40% of NASH patients are obese; 20% have dyslipidaemia Liver and gall bladder disease Frequent association in the elderly with increasing body weight – risk of disability attributable to OA equal to heart disease and greater to any other medical disorder of the elderly Osteoarthritis (OA) Impotency and infertility are frequently associated with obesity in men 6% of primary infertility in women is attributable to obesity Reproductive function 10% of all cancer deaths among non-smokers are related to obesity (30% of endometrial cancers) Cancers Neck circumference of >43 cm in men and >40.5 cm in women is associated with obstructive sleep apnoea, daytime somnolence and development of pulmonary hypertension Respiratory effects
    12. 17. Top 20 causes of death, by risk factor, NZ 1997
    13. 18. Increased Morbidity Due to Late Presentation <ul><li>A study of nearly 7000 women,14 included in the National Health Interview Survey for 1992, found that increased BMI was associated with both increased physician visits and decreased preventive health care services. Obese women were significantly more likely than non-obese women to delay breast and gynecologic exams and Pap tests, despite more frequent visits. </li></ul>
    14. 19. Obesity and DNA rates. <ul><li>One study found a significant relation between body mass index (BMI) and appointment cancellation. </li></ul><ul><li>32% of women with BMI over 27 and 55% of women with BMI over 35 delayed or cancelled visits because they knew they would be weighed. </li></ul><ul><li>The most common reason for delaying appointments was embarrassment about weight. </li></ul>
    15. 20. Who would want to be obese?
    16. 21. What Causes Obesity?
    17. 22. The body-mass index of twins who have been reared apart AJ Stunkard, JR Harris, NL Pedersen, and GE McClearn                                                                                 Next       Pr evious Number 21      May 24, 1990      Volume 322:1483-1487
    18. 23. Study of 247 identical and 426 non-identical twin pairs reared together and apart... <ul><li>The intra-pair correlation coefficients of identical twins reared apart were 0.70 for men and 0.66 for women...only very slightly different to those for identical twins reared together. </li></ul><ul><li>Authors Conclusion: genetic influences on body-mass index are substantial, whereas childhood environment has little or no influence. </li></ul>
    19. 24. Identifying the responsible genes... <ul><li>Monogenic Causes of Obesity </li></ul><ul><ul><li>Studies of families in which children have developed marked obesity in infancy </li></ul></ul><ul><li>Polygenic Causes </li></ul><ul><ul><li>Candidate gene approach </li></ul></ul><ul><ul><li>Genome wide scanning </li></ul></ul>
    20. 25. Examples of Monogenic Causes of Obesity….. <ul><li>Leptin deficiency in the ob/ob mouse </li></ul><ul><ul><li>Very rare cases of human equivalent. Affected individuals have hypogonadism, obesity and hyperphagia. </li></ul></ul><ul><li>Melanocortin 4 receptor deficiencies </li></ul><ul><ul><li>May be as common as 1% of the population </li></ul></ul><ul><li>Pro-opoid melanocortin abnormalities </li></ul>
    21. 26. Genome Wide Scanning... <ul><li>A study of 2,000 people with diabetes led to the discovery of the FTO gene a variant of which confers susceptibility to diabetes and even more strongly, predisposition to obesity </li></ul><ul><ul><li>16% of Europeans are homozygous for the variant and on average they are 3kg heavier than those with no copies of the gene variant </li></ul></ul><ul><ul><li>Heterozygotes are 1.2 kg heavier on average </li></ul></ul><ul><ul><li>Science Published Online April 12, 2007. DOI:10.1126/science.1141634. </li></ul></ul>
    22. 27. How Does the Genotype Link to Phenotype?
    23. 28. Jane Wardell, University College, London <ul><li>Mathematical modeling of 2,500 UK twin pairs shows that </li></ul><ul><ul><li>Weight at the age of 4 years is 60% genetically determined and at the age of 11 it is 77% genetically determined. </li></ul></ul><ul><ul><li>Having two overweight parents increased the risk of you being overweight ten times – independent of any environmental effect </li></ul></ul>
    24. 29. Food and activity preferences in children of lean and obese parents. J Wardle1, C Guthrie1, S Sanderson1, L Birch2 and R Plomin3 <ul><li>METHODS : A total of 428 children aged 4-5 y, whose parents were either obese/overweight or normal-weight/lean were selected from a population sample of families with twin births. Food and activity preferences were assessed with a combination of food intake and taste tasks, and questionnaires completed by the mother during a home visit. </li></ul><ul><li>FINDINGS : Children from the obese/overweight families had a higher preference for fatty foods in a taste test, a lower liking for vegetables, and a more 'overeating-type' eating style. </li></ul><ul><li>International Journal of Obesity (2001) 25, 971-977 </li></ul>
    25. 30. Aspects of appetite... <ul><li>Responsiveness to food cues </li></ul><ul><ul><li>Fatter children work harder for food rewards than for other types of reward </li></ul></ul><ul><ul><li>When presented with ice cream of varying palatability, fatter children eat proportionately more of the nicer ice cream </li></ul></ul><ul><ul><li>Fatter children don’t decelerate their rate of eating as they approach satiety </li></ul></ul>
    26. 32. 1998 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007 (*BMI  30, or about 30 lbs. overweight for 5’4” person) 2007 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    27. 33. Our Diet... <ul><li>Food balance sheet data from 1961 to 2003 shows.. </li></ul><ul><ul><li>The supply of energy increased by 9 percent from 12,300 to 13,400 kcal/day </li></ul></ul><ul><ul><li>Takeaway food outlet sales revenue increased by 67 percent </li></ul></ul><ul><ul><li>In 2003/04 average weekly household food expenditure on confectionery ($6.50) was greater than expenditure on fresh fruit ($5.90) </li></ul></ul><ul><ul><li>MOH, Food and Nutrition monitoring report 2006 </li></ul></ul>
    28. 35. Factors influencing dietary intake <ul><li>In 2005, advertising on chocolate, sweets and soft-drinks was $57,289,000. Nine times the amount spent advertising fruit and vegetables </li></ul><ul><li>The total advertising expenditure on fast food outlets and cafes was $67,352,000 with McDonalds accounting for a third of this </li></ul>
    29. 36. “ Genetic epidemiological studies and multiple genome-wide linkage analyses have established that the causes of common obesity are complex involving a Westernized lifestyle in the presence of genetic predisposition” Dahlman I and Arner P. Review. Int J Obes (2007) 31, 1629-1641.
    30. 37. Genes and the Environment BMI 1977 2006 * * * Genetically thin Genetically fat
    31. 38. How should we tackle the problem? Personal endeavour or environmental engineering?
    32. 39. Inquiry into Obesity and Type 2 Diabetes in New Zealand FOE has released a report which analyses all the submissions to the Inquiry. Read the report (PDF) The Health Select Committee is expected to release its own report by mid 2007. Find out more about the Inquiry... <ul><li>Our petition to Parliament closed on 1 May 2006 with over 4000 signatures. </li></ul><ul><li>The petition asks Parliament to take actions to combat obesity in children, including: </li></ul><ul><li>Preventing the sale of junk food and drink in schools; </li></ul><ul><li>Banning advertisements of junk food and drink during children's TV programmes. </li></ul><ul><li>We presented it to Parliament in June. </li></ul><ul><li>Sign up on this website for updates about the petition, the Inquiry and other FOE news. </li></ul><ul><li>FOE 2005 Poll </li></ul>
    33. 40. FOE Goals (2001) <ul><li>Increase awareness of the risks of obesity and the magnitude of the problem </li></ul><ul><li>To reduce obesity rates in children through public health measures </li></ul><ul><li>To emphasise a regulatory or legislative approach as the most likely successful means for bringing about change (as per tobacco ) </li></ul>
    34. 41. Legislation….. <ul><li>Revision of the Public Health Act </li></ul><ul><li>Private Members Bill </li></ul><ul><ul><li>To prohibit advertising directed to children under the age of 12 (for all products) </li></ul></ul><ul><ul><li>To prohibit advertisements of food and drink within 5 mins either side of children’s TV programmes </li></ul></ul><ul><ul><li>To prevent the sale of inappropriate, calorie dense food and drink in pre-schools & schools </li></ul></ul>
    35. 42. Progress in 2007 <ul><li>Revision of the Public Health Acts </li></ul><ul><li>HEHA initiatives </li></ul><ul><li>Health Select Committee Inquiry </li></ul>
    36. 43. Mission On <ul><li>Extensive Programme for schools and pre-schools with curriculum material, cafeteria recipes and other resources </li></ul><ul><li>Traffic-light type grading of cafeteria foods– </li></ul>
    37. 44. Food and Beverage Guidelines <ul><li>Everyday foods: appropriate for everyday consumption. Encourage and promote these foods and drinks in your school. </li></ul><ul><li>Sometimes foods: for restricted provision. Do not let these foods and drinks dominate the choices available, and provide in appropriate serving sizes </li></ul><ul><li>Occasional foods: not for provision. Limit provision of these foods or drinks to about ONE occasion per term. </li></ul>
    38. 46. Where to from here? <ul><li>Lessons from tobacco </li></ul><ul><li>United Health Sector Response </li></ul><ul><li>Support from the Economic Sector </li></ul>