Wide world: public bodies are responding to a global obesity epidemic with campaigns such as US first lady Michelle Obama’s Lets Move, inspired by concern about her own daughters
As New York officials mark the first anniversary of an aggressive health campaign called “Don’t drink yourself fat” by stepping up their advertising, one group is not offering its congratulations: the soft drinks industry.
The posters and videos released by the city’s health department portray images of a man opening a fizzy drink and swallowing orange fatty goo. “When did Big Apple become Big Brother?” retaliates the Center for Consumer Freedom, a business-funded lobby group.
New York’s action is among the escalating initiatives being taken by public bodies in the US and around the world, driven by an increasing international recognition of the need to tackle one of the world’s most troubling ill-health trends: obesity.
The efforts raise the question of which approaches work best – and how far the food and drinks industry, long part of the problem, can become part of the solution, particularly at a time when economic slowdown is threatening government spending on such programmes.
The intensified action may yet trigger a new round of more aggressive regulatory controls affecting industry, just as employers feel the squeeze of rising healthcare costs and falling productivity linked to more obese staff.
The public policy response could also lead to a much wider use of the most drastic solution, for those willing to submit to it: surgery. In the UK – where on current trends obesity is forecast to cost the National Health Service nearly £50bn ($77bn) a year by 2050 – John Black, president of the Royal College of Surgeons, on Wednesday called for gastric bands to be fitted to many more people than the current annual 3,600. If just one in four who met the clinical criteria were to undergo the procedure, the net gain to the economy within three years would be an estimated £1.3bn.
Rising obesity has not yet slowed the advances in longevity achieved in recent decades, but treatments for complications of the overweight are incurring growing costs. Obese patients report higher rates of diabetes, heart disease and stroke, and have an increased risk of cancer, arthritis and lung disease. “The costs of medical care linked to obesity are enormous, reaching $150bn a year in the US,” says Thomas Farley, New York’s health commissioner, who has championed policies ranging from calorie counts in the city’s restaurants to architecture designed to encourage use of stairs rather than lifts in new buildings. “We are moving to a situation where diabetes is becoming a normal part of human existence.” MEDICAL PROGRESS
An industry’s search for a lucrative yet elusive weight-loss treatment
With obesity rates rising in developed and developing nations alike, accompanied by declining productivity and rising morbidity, there is an immense medical demand for safe drugs to help stem the epidemic. Yet, in spite of decades of research, the pharmaceutical industry has failed to launch a pill that removes excessive fat without unacceptable side-effects.
Several products launched with high hopes in recent years have been withdrawn after failing safety trials, or circumscribed with restrictions that discourage doctors from prescribing. But the potential market for a successful drug is so big – billions of dollars a year – that many companies persist in trying to develop them.
Three of the most watched contenders come from Californian companies: Lorcaserin from Arena; Qnexa from Vivus; and Orexigen’s Contrave. All have completed extensive clinical trials and are awaiting decisions by the US Food and Drug Administration this year. The verdicts will determine whether they receive marketing approval and, if so, under what conditions.
Obesity drugs work either on the guts, reducing food absorption; or on the brain, curbing the appetite. Xenical from Roche of Switzerland uses the first mechanism – it reduces fat intake through the digestive tract – but its gastrointestinal side-effects have restricted sales.
Most obesity drugs in development, including the Californian trio, act on the brain. This fits in with recent discoveries showing that the majority of genes influencing body weight affect mental rather than metabolic activity. “Considering how many factors are involved in obesity, it is interesting that research is increasingly pointing to the brain as being very important in its development,” says Robert Kaplan of New York’s Albert Einstein College of Medicine.
However some experts doubt the long-term value of drugs, which fail to address the psychological causes of overconsumption and lack of exercise in sedentary western and, increasingly, developing nations. They have “been focused predominantly on weight loss”, says Jason Halford of Liverpool university.
“Obesity is the result of many motivational factors that have evolved to encourage us to eat, not least our susceptibility to the attractions of food and the pleasures of eating energy-rich foods – factors which are, of course, all too effectively exploited by food manufacturers.”
His concern is shared by other public health experts, who were lent high-profile support this spring by Michelle Obama, the first lady, with her Let’s Move campaign to encourage exercise and improved nutrition. Her commitment, which she said was inspired by doctors’ concerns about her own daughters’ weight, comes as a generation of strong public health officials rise to influential positions and employers including the US military are struggling with obesity among recruits.
Over the past 30 years, obesity in the US has more than doubled, affecting well over one adult in three, and has tripled in children and adolescents to above 17 per cent. Amid the economic downturn since 2008, there is some evidence that sales of cheap but unhealthy fast food have held up better than healthier alternatives.
“This is a major public health problem and the only widespread one that is getting worse,” says Tom Frieden, Dr Farley’s predecessor as New York City’s health commissioner, who helped launch the aggressive campaign now being copied in other parts of the US. Dr Frieden has since championed a fresh emphasis on the topic as head of the national Centers for Disease Control and Prevention.
But obesity, once seen as a disease of decadence, is spreading fast in the poorer as well as the more industrialised world, sparking expressions of concern and a range of recent initiatives in China, India and the Middle East, as well as parts of Latin America – which have among the highest rates anywhere. Worldwide, an estimated 1.6bn adults are now overweight, with 400m of them classifiable as obese.
Brazil, long a champion of public health, is debating warnings on some foods akin to those on tobacco packets. The UN has resolved to hold a first-ever summit on non-communicable diseases in September next year, including discussion around obesity. Ala Alwan, assistant director of the World Health Organisation, says that while infections such as HIV long captured policymakers’ attention, other diseases were until recently neglected, with none identified in the UN’s Millennium Development Goals. He adds: “We are moving towards a much more forceful era to strengthen the control and prevention of non-communicable disease.”
Most scientists agree on the causes of obesity. While human beings’ physical activity has declined significantly since their hunter-gatherer ancestors, their consumption of energy-dense food has remained stable or increased. And while it is easy to put on weight, it is much more difficult to lose it afterwards. “Once you get locked into a state of obesity, for a very substantial proportion of people it is phenomenally difficult to go back to their original weight,” says Philip James, head of the International Obesity Taskforce, a think-tank. “The evidence of a ratchet effect is pretty overwhelming: the brain chemically adapts.”
Some recent studies also suggest obesity may be higher in children born to overweight or smoking mothers; and a poor diet in young children may have a long-term impact on the formation of bacteria in their guts, increasing their long-term vulnerability to diseases including allergies.
Social changes including urbanisation and industrialisation, with a shift towards more sedentary lifestyles, have played a role. Yet while these trends have been taking place over many generations, the explosion in obesity has taken place in the past 30 years, pointing to the primary role of changing food intake.
David Kessler, a former head of the US Food & Drug Administration, argues in his recent book The End of Overeating that social trends have led to the breakdown of well-prepared, regular and healthy family meals. In their place is industry-backed “hyper-eating” throughout the day, with a combination of aggressive marketing, widespread availability and low-cost, supersized portions of “ultra-processed foods” containing ever more tempting but unhealthy combinations of fat and sugar.
Many of the same trends apply in developing countries. Stephan Rossner of the Karolinksa Institute in Stockholm says: “There is evidence that Asians are more vulnerable than Caucasians. And in China, with the one-child family, parents reward their kid for studying passively by giving them food and [electronic] games. Things are going the wrong way.”
There, as elsewhere, the result is rising medical bills as well as workplace absenteeism. Employers are starting to respond with staff wellness programmes. A smaller number take a harsher approach: Alabama and North Carolina government employees refusing to participate in health checks are from this year being charged a “fat tax” in the form of higher health insurance premiums.
Yet progress in tackling obesity has been extremely limited. While weight loss has become a huge industry, there is little evidence that most diets and supplements work in the long-term. Prescription medicines have so far also proved only modestly effective, with unpleasant and potentially severe side effects. Prof Rossner says: “It’s depressing to me as a scientist but the results of anti-obesity drugs are not very impressive and we have little to offer patients.”
Not all is gloomy. At the International Congress on Obesity held in Sweden in July, some reports suggested that for the first time the rate of growth of obesity in children in some countries including France, the UK and Sweden was beginning to slow. Tim Lobstein from the International Association for the Study of Obesity, a group of specialists, says: “We may be seeing a plateau.”
But he cautions that in spite of such signs, the trend remains upwards, particularly among the poor. Furthermore, dips in the past have been followed by fresh surges in obesity, and there are suggestions that slowing growth may be exaggerated because some obese children or their parents are no longer co-operating with studies and being weighed as in the past.
France’s Epode programme has generated international interest, with its apparent success linked to strong political leadership overseeing a range of initiatives from improved school nutrition to town planning designed to encourage exercise.
Yet neither Epode nor the UK’s more recent Change4Life programme has so far produced much systematic, peer-reviewed data. That makes it difficult to assess the impact of initiatives and to focus on those with the greatest chance of succeeding, especially as governments struggling with austerity measures are tempted to pare back on prevention programmes that will show little immediate return.
Of additional concern is the impact of the food and drink industry itself in fighting obesity. Epode’s sponsors include Orangina Schweppes, the drinks producer owned by Suntory of Japan; Kellogg, the US cereal manufacturer; and Italy’s Ferrero chocolate maker. Change4Life’s partners include Mars, the confectioner, and McCain, the frozen chips company, both of the US, and Britvic, the UK soft drinks group.
Derek Yach, in charge of global health policy at PepsiCo of the US, another Change4Life partner, which has pledged significant reductions in sugar, salt and fat in its products and to eliminate sales of sugary drinks in schools, says: “There are a lot of industry efforts, but many governments are not thinking about getting behind them.”
Others are more sceptical of industry’s involvement, suggesting its participation helps burnish its image while compromising the ability of governments to take a tougher line on issues such as restrictions on food advertising and labelling, taxes on salt and sugar content, and reduced subsidies that differentially favour less healthy ingredients such as palm oil. Tam Fry, a director of the National Obesity Forum, a UK-based group, says: “The time has come for governments to take a firm hand. They are there to govern, not to kowtow to vested interests.”
Certainly, corporate health promotion initiatives may seem modest in comparison to countervailing trends, such as a recent estimate from the Federal Trade Commission that in the US alone, companies spend $1.6bn a year just on food advertising directed at children and adolescents.
Equally, labelling remains contentious, with industry successfully lobbying this year to prevent the European parliament approving a “traffic light” system, as advocated by the UK’s Food Standards Agency, to warn consumers of less healthy food ingredients. In its place come vaguer guideline daily allowances.
Finding the right partnership with the food and drink industry will prove one of the most testing issues in the coming years in any efforts to reverse the current trends in obesity. Dr Kessler, a long-standing advocate of tough action against tobacco companies to improve public health, argues: “This will prove much tougher. We all have to eat.” Christopher Caldwell: Why fat is not a First Lady’s issue