By Susan Blumenthal, M.D. and Samara Levin
Obesity is a global epidemic. The global population is expanding in numbers, but also in weight. Rates of obesity worldwide have more than doubled since 1980. In 2014, 1.9 billion adults were overweight and 600 million were obese. Every country included in the World Health Organization's data repository experienced an increase in adult obesity rates from 2010 to 2014. None of these nation's obesity rates stayed the same or declined during this time period. For example, over 42 percent of Qatar's adult population is obese, nearly 40 percent of adults in Kuwait are obese, 28 percent of adults in England and Northern Ireland are obese, almost 24 percent of France's adult population are obese and 38 percent of the U.S. population is obese. And the obesity epidemic is not just an adult problem; 42 million children under the age of 5 worldwide were overweight or obese in 2013. And surprisingly, industrialized countries are no longer at the forefront of the global obesity epidemic. Developing countries have more than a 30 percent higher rise in the rate of childhood obesity than high-income countries. In fact, in Africa, the number of overweight and obese children under five has almost doubled from 5.4 million in 1990 to 10.3 million in 2014. These countries are now battling the public health problems of underweight and overweight children simultaneously -- with hunger and obesity co-existing, often in the same population groups. According to the World Health Organization (WHO), if current obesity trends are not reversed, over 70 million infants and young children will be overweight or obese by 2025.
In developing countries, societal norms regarding food and activity are changing. Instead of eating fresh foods from farms and fish from rivers and oceans, people in developing countries are eating more processed foods imported from Western nations that are full of sugar and saturated fats. As these nations become wealthier, people are using more technology to travel such as cars, buses, and trains which result in less physical activity. Lack of education also plays a major role in rising obesity rates in both developing and industrialized nations. Many people do not know the health damaging consequences of obesity; instead, in some countries obesity is viewed as a sign of being able to provide food for your family. In some Sub-Saharan nations, for example, people may associate thinness with having AIDS, while obesity is associated with being healthy. In other developing nations such as Nigeria and Gambia, some women may associate obesity with wealth and beauty.
Additionally, the rising obesity rates worldwide are leading to a chronic disease tsunami with increasing rates of cardiovascular disease, Type 2 diabetes, stroke, and some types of cancer. Obesity causes fat to build up in the arteries, narrow vessels, and leads to reduced blood flow to the heart, linked to heart attacks. In 2000, there were 6 million deaths worldwide from ischemic heart disease and by 2012 there were 7.4 million deaths -- over a 20 percent increase. The rate of Type 2 diabetes is also significantly increasing and not just in adults, but in children as well. The mortality rate from diabetes worldwide has increased significantly from 1 million deaths in 2000 to 1.5 million deaths in 2012.
Experts believe that diabetes may be the biggest health threat to urban populations -- from Houston to Copenhagen to Mexico City to Shanghai and Tianjin. Findings from the world's largest ever study of urban diabetes -- in five cities which together are home to 60 million people -- suggest cities must reconsider public health and city planning strategies to address the rise of the condition. Over 400 million people worldwide have diabetes, more than two thirds of whom live in cities. The study revealed that a number of social and cultural factors are putting people at increased diabetes risk as well as affecting the diagnosis and treatment of the disease. These factors include financial, geographical, resource and time constraints while cultural determinants included the perception of body size and health and deep-seated traditions. For example, in Houston, the study revealed that many people link diabetes with lower socioeconomic status when in reality, people of all economic classes are vulnerable to the disease. In Mexico City, gender roles may play a role with women neglecting their own health and thus diabetes may go undiagnosed and untreated in this population group. Although Copenhagen is regarded as one of the healthiest cities in the world, according to the study, the public does not prioritize concerns about the disease, placing greater importance on issues including unemployment, finances, and loneliness. Diabetic patients in Shanghai do not reach out to friends, family or physicians for help because having a disease like this one can be viewed as a personal weakness. In Tianjin, high diabetes rates are linked to poor eating habits, working too much and mental health problems. The wide range of social and cultural factors affecting diabetes rates globally underscores how much work remains to be done to effectively address this major public health problem worldwide.
Obesity in America
Globally, America has one of the highest rates of obesity. The average American is more than 24 pounds heavier today than in 1960. A recent report from the Centers for Disease Control and Prevention (CDC) found that obesity rates in American adults had increased from 35 percent in 2011-2012 to 38 percent in 2013-2014. This upward trend is going in the wrong direction.
What is contributing to increasing obesity rates in the United States? While more than 50 genes have been identified that are linked to obesity, our genes have not changed over the past five decades. What has changed dramatically is the American lifestyle. The equation is straightforward: energy in must equal energy out; however, in the United States, the majority of Americans are eating more and exercising less. Food portions served in U.S. restaurants have doubled and some even have tripled over the past 20 years. Unhealthy foods are also less expensive than healthy foods. According to the Harvard School of Public Health, a healthy diet costs about $1.50 more a day than an unhealthy diet. For a family of four this can amount to more than $2,000 a year. Furthermore, unhealthy foods are much more readily available. There are as many as 50,000 fast food restaurants in America and children, ages 6 -14 in the United States consume fast food 157,000,000 times each month.
Obesity rates have also dramatically risen for children. Schools play a major role as children consume 50 percent of their daily calories there and unfortunately, unhealthy foods are served in cafeterias and other venues on these campuses. Additionally, in America, children view on average 8,000 television food and beverage commercials annually. Only 165 of them are for healthy foods.
The problem does not end here. People are also expending less energy because of lack of physical activity. Only 1 out 5 American adults gets the recommended amount of physical activity by the Federal government. In the U.S. people work an average of 47 hours each week at sedentary jobs totaling over 350 extra hours sitting at a desk each year as compared to what was a 40-hour workweek in the past. Even if people have time to workout, many communities lack safe areas to participate in physical activity and many schools do not offer exercise programs as well.
But, the problem of obesity is not unique to America -- in fact, the United States is no longer the most overweight of industrialized nations. A recent report from WHO reveals that obesity rates are rising in almost every nation worldwide and will likely continue to increase unless effective programs are implemented to tip the scales towards health. Lifestyles are rapidly changing around the world as unhealthy food options become more accessible with more than 500,000 fast food establishments globally and as use of technology such as cars and computers results in a more sedentary way of life.
Tipping the Scales: A Roadmap to Reverse Global Obesity
Clearly, obesity is a major public health threat in countries around the world but with the right policies and strategies in place, the alarming statistics about the growing epidemic can change. For these reasons, the United Nations convened its first global summit on non-communicable diseases in 2011. Recommendations from this meeting included a list of "best buys," which are cost-effective and feasible interventions that can be implemented to prevent non-communicable diseases (NCDs) in countries around the world. To address unhealthy diets and physical inactivity linked to NCDs, the WHO recommended that countries implement policies to reduce salt intake, replace trans fats with polyunsaturated fats, and promote public awareness about healthy diets and the importance of physical activity.
Many nations have taken steps to reverse obesity within a generation. President Obama established a White House Childhood Obesity Prevention Task Force in 2010 that produced an action plan to reverse this public health problem. As part of this plan, the President signed into law the Healthy, Hunger-Free Kids Act that included healthier standards for school meals. First Lady Michelle Obama established the Let's Move Campaign to promote healthy diets and physical activity for kids. Mexico's Congress passed a tax on soft drinks and high-caloric foods and the Health Ministry in Ecuador established regulations for labeling processed foods. Most countries have developed and implemented national plans to combat obesity as follow-up to the WHO's recommendations to involve all sectors of society in the response. Several countries, such as Hungary, Finland, Norway, and France, to name a few, have implemented policies to prevent obesity rather than just treat it by taxing sugary foods and drinks. Interestingly, these countries have lower obesity rates than other nations with rates ranging from 20 percent to 24 percent.
The UN Summit on NCD's represented a turning point in addressing the obesity epidemic worldwide. It highlighted the health and economic impact of the four most prevalent and preventable non-communicable diseases: diabetes, cardiovascular disease, stroke, and chronic lung disease. Prior to the Summit, non-communicable diseases had been omitted from the Millennium Development Goals (MDGs) despite representing 68 percent of deaths worldwide and 80 percent of all chronic disease deaths occur in low and middle income countries. This public health oversight was addressed in the UN's Sustainable Development Goals released in 2015 with objectives aimed at "reduc[ing] by one-third premature mortality from non-communicable diseases through prevention and treatment and promot[ing] mental health and well-being."
The Way Forward
Despite the significant actions that many nations have taken so far, much more needs to be done. For the obesity epidemic to be reversed within a generation, all sectors of society must be mobilized in a "health in all policies" approach with government, schools, media, businesses, health care providers, families and individuals involved. Governments must establish policies to promote physical activity and healthy eating that establish built environments safe for physical activity, lower the price of healthy foods, eliminate food deserts, and prevent rather than just treat obesity. Schools must provide rigorous physical activity programs at all grade-levels and healthy food options in cafeterias and vending machines. Health education programs should be included in the curriculum for students at every level to learn about healthy lifestyles. The media must help too, using their marketing skills to promote healthy lifestyles in television, on line, and in print venues. Individuals also have an important role to play by eating healthy and engaging in physical activity.
Some cities have already adopted a "health in all policies" approach. Seinäjoki, a community in Finland, has seen positive results using this strategy. Six years ago, nearly 1 in 5 five-year-olds were overweight or obese in this city. As a result of implementing their obesity prevention plan, this number has been reduced by 50 percent with all sectors of their society working together to make the school environment healthier, require physical and nutrition education including cooking classes, and provide yearly health exams for all students. This Finnish success story underscores there is hope to halt the obesity epidemic across communities and countries worldwide.
With the global obesity epidemic growing, "the health in all policies" approach is a cornerstone to eradicating this preventable condition. Governments, schools, media, businesses, health care providers, families, and individuals all play important roles in promoting healthy lifestyles and creating a climate for sustained change where hopefully globesity someday will be found only in the history books.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of The Huffington Post. She is a Senior Fellow in Health Policy at New America and a Clinical Professor at Tufts and Georgetown University Schools of Medicine. She is also the Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the federal government in the Administrations of four U.S. presidents including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, and as Senior Global Health Advisor in the U.S. Department of Health and Human Services. She also served as a White House advisor on health. She provided pioneering leadership in applying information technology to health, establishing one of the first health websites in the government (womenshealth.gov) and the "Missiles to Mammogram" Initiative that transferred CIA, DOD and NASA imaging technology to improve the early detection of breast and other cancers. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch, Head of the Suicide Research Unit, and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health. She has chaired many national and global commissions and conferences and is the author of many scientific publications. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal was named the Health Leader of the Year by the Commissioned Officers Association and as a Rock Star of Science by the Geoffrey Beene Foundation. She is the recipient of the Dr. Rosalind Franklin Centennial Life in Discovery Award.
Samara Levin is a senior at The George Washington University with a major in Economics and a minor in Health and Wellness. She will be a medical student at The George Washington School of Medicine next fall. Samara is a Health Policy Intern at New America.