Obesity is serious because it is associated with poorer mental health outcomes and lower quality of life.
Obesity
is also associated with leading causes of death in the United States and around the world, including diabetes, heart disease, stroke and some cancers. Overweight and obesity are linked to more deaths worldwide than underweight. Globally, more people are obese than underweight, and this is true in all regions except parts of sub-Saharan Africa and Asia.Overweight and obesity are the fifth leading risk of death in the world. At least 2.8 million adults die each year as a result of being overweight or obese. In addition, 44% of the burden of diabetes, 23% of the burden of ischaemic heart disease and between 7% and 41% of the burden of certain cancers are attributable to overweight and obesity. However, these serious public health threats mask the ever-present and growing scourge of obesity in the United States.
Nearly one in five deaths among African Americans and Caucasians aged 40-85 is attributed to obesity, a rate that is increasing across all generations. It is clear that society needs better strategies to address this public health emergency. As a health economist who has spent decades studying ways to prevent disease, I believe there are some policy options that could help. Many factors contribute to obesity, including genetics, diet, physical inactivity, medications, lack of education and food marketing.
From a public investment point of view, the potential return on investment is even greater for obesity than for tobacco. In my view, a successful campaign against obesity must encourage people to be less sedentary; invest in new medical treatments and nutritional science; and create regulatory and health insurance policies that reward behavioural change. It also means wider access to effective therapies. Our current emphasis on behavioural interventions has been disappointing.
Society needs to find a way to talk about obesity and find ways of dealing with it that do not involve body shaming. Losing weight means either eating less or exercising more, or both, but there are no guarantees with either approach. Getting people to exercise is difficult. Nearly 80 per cent of adults do not meet key guidelines for aerobic and muscle-strengthening activity.
Getting people to change their diet is equally ineffective. According to one study, half of dieters had gained 5 kilos five years after starting their diet - some progress, but hardly enough. Similarly, nutrition labels have had little effect on consumers' food intake and body mass index. So what should policy makers do? I believe the time has come for several new approaches.
The intellectual property rights of companies that develop novel approaches to weight loss, such as mimicking the effects of exercise, should be protected and rewarded through patent law and other mechanisms. Currently, if a company discovers a way to get people walking with a new app or programme, IP protection and reimbursement are uncertain. The government should offer greater rewards for behavioural interventions that can demonstrate long-term gains under the same rigorous regulatory standards similar to those required for new drugs. Companies invest billions of dollars to develop pharmaceuticals.
In contrast, there is less social investment in other prevention activities. Although not a solution for everyone, gastric bypass and adjustable gastric banding, among other procedures, have proven effective. New incentives could expand access to these surgeries by lowering the BMI threshold for eligibility. Some insurers have put up barriers to this treatment because obesity is neither immediately life-threatening nor related to our traditional notion of disease.
We need to find better ways to negate the cost of surgery and increase access by linking reimbursement to outcomes. Other insurers with an interest in long-term outcomes, such as the life insurance industry, can play an important role. They have a financial interest in preventing mortality and disability, but have traditionally stood on the sidelines while Americans get fatter. Another approach is to consider new drugs and use the successful approach that has been used to combat hypertension.
Some 50 years ago, hypertension was considered untreatable. Diet and exercise were the predominant means of control. The discovery of multiple agents to combat hypertension, starting with diuretics and beta-blockers, was transformative. A similar story occurred with high cholesterol.
About half of the decline in coronary heart disease deaths in the United States can be attributed to medical therapies such as these. Several clinically proven anti-obesity drugs already exist for people who do not respond to lifestyle modification. In addition, there is a robust clinical pipeline, with some 250 compounds in development, including dozens of new compounds. Medicines such as these can help change the trajectory of the obesity epidemic, if they are made widely available and challenges in the current health insurance system are reimbursed.
Finally, the food and restaurant industry deserves some of the blame. Restricting access - as the US tried with its ban on alcohol consumption and sales - will not work. But responsible measures to regulate portions might. Smart and bold strategies have helped us address public health crises in the past, such as smoking and hypertension.
We need to be just as aggressive on obesity if we are to prevent hundreds of thousands of needless deaths. Just as we did with smoking, it is time to make obesity the top public health priority. The root cause of obesity and overweight is an energy imbalance between calories consumed and calories expended. Illustration of how disability and mobility functioning and health-related quality of life are seen as a result of interactions between obesity, body functions and structures, environmental factors and personal factors.
Supportive environments and communities are central to shaping people's choices, making healthier food choices and regular physical activity the easiest option (accessible, available and affordable) and thus preventing obesity. Obesity and its impact is a major source of morbidity and deterioration in quality of life, and its complications can have a major influence on life expectancy. These dietary patterns, together with lower levels of physical activity, lead to a sharp increase in childhood obesity, while malnutrition problems remain unresolved. Obesity increases the incidence of cancer (7) in part through the conversion of fatty acids supplied by the high-fat diet or de novo synthesised fatty acids into pro-tumourigenic signalling lipids.
Governments, international partners, civil society, non-governmental organisations and the private sector have a key role to play in contributing to obesity prevention. Obesity has marked effects on the secretion and metabolism of sex hormones, modifying the bioavailability of oestrogens and androgens. For example, 65% of the world's population lives in countries where overweight and obesity kill more people than underweight (this includes all high-income and most middle-income countries). Pulmonary function tests (PFTs) of obese patients often show impaired expiratory reserve volume (ERV), functional residual capacity (FRC) and total lung capacity (TLC), secondary to increased abdominal burden and altered chest wall mechanics (45,4).
Obese people face an increased risk of diabetes, heart disease, stroke, high blood pressure and certain cancers, among other conditions. In the UK, the healthcare costs associated with obesity account for 2.3-2.6 of all public health spending (10 , Studies on the economic impact of obesity sometimes examine direct costs, while others focus on indirect costs or both. Physiological changes, such as increased muscle mass, connective tissue and total body water in obese patients, alter the pharmacokinetics and pharmacodynamics of drugs (90). Obesity, once associated with high-income countries, is now also prevalent in low- and middle-income countries.
