IS OBESITY PREVENTABLE?

The pandemic of overweight and obesity is now so advanced and so widespread that few regions of the world (with the possible exception of parts of sub Saharan Africa) appear to have escaped the effects of this major public health problem. Previous chapters have highlighted the strong biological influences that contribute to the creation and maintenance of a positive energy balance in humans; current attempts to abate the rapid increase in body weight at both an individual and a community level have been less than inspiring. This has led some people to question whether it is possible to prevent continued increases in population body weight.
Despite these concerns about the effectiveness of current obesity prevention approaches, there is indirect evidence from a range of sources that supports the view that prevention is not only feasible, but offers the only solution to controlling the worldwide epidemic of obesity. Bouchard (4) indicates that the heritability of obesity and body fat stores is only moderate and that recent increases in obesity rates have occurred at a rate too fast to be explained by changes in the frequency of obesity genes or susceptibility alleles. He concludes that the increase in obesity prevalence can only be due to the fact that a greater number of children and adults are in positive energy balance and that it should be possible to attend to this through influencing diet and physical activity patterns. This view is supported by studies of monozygotic (MZ) twins discordant for body mass index (BMI) which have shown that mean body weight can vary between the overweight and lean sibling by up to 16 kg in men and 19 kg in women, even though they have exactly the same genotype.
While the obesity epidemic appears to be affecting all regions of the world, there are some countries that appear to less affected than others. In the Netherlands, the rates of obesity for both men and women are only half of that experienced in the United Kingdom or neighboring Germany and are increasing at a much slower rate. In Brazil the prevalence of obesity within
upper-income, urban women has actually decreased in recent times, although men continue to put on weight at a rapid rate . In addition, while rates of obesity continue to climb in Finland, men from higher education grades have shown only a marginal increase.
Attempts to reduce the rising rates of obesity and poor physical fitness in Singapore appear to have been successful, at least in the short term. Intensive programs of physical training and influence over dietary intake resulted in a significant reduction in the number of schoolchildren being classified as overweight between 1992 and 1995 . Studies of young men inducted into the Singapore army also showed improvements in mean BMI during their periods of service, which unfortunately are reversed when they are released from the military.

Cultural Differences as Influences on Approaches to Obesity Treatment

Culture influences all human behavior and dialectically shapes social institutions and social interactions among populations groups and individuals. Culture has many definitions, but all embody the underlying concept of implicit and explicit guidelines that are inherited and shared by members of a particular society or societal subgroup . These guidelines define ‘‘how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods, and to the natural environment’’ .
These cultural perspectives are identifiable and transmitted from one generation to the next through distinctive symbols, language, and rituals. Of particular relevance to cross-cultural treatment issues, cultural influences on behavior tend to be relatively invisible. Certain types of behavior seem universal, natural, and nonnegotiable to those influenced by a given culture .
In fact, the influence of culture often becomes evident only when cultural differences are encountered, e.g., in interactions between individuals or groups that have contrasting beliefs, expectations, or values related to a particular issue; that is, one might not perceive that one
is operating within a culture until one has to operate outside of it.
To be theoretically sound, cultural adaptation strategies should link culturally influenced variables to specific aspects of treatment process and outcomes. Examples of such possible links from the client and provider perspective . For example, body image and other attitudes may have an influence primarily through effects on the motivation to seek treatment initially or to continue with treatment. Outreach to increase enrollment in a program might then employ persuasive strategies to increase awareness of the possible health or functional status benefits of modest weight loss (e.g., on blood pressure, breathing difficulties, or knee problems) as separate from potentially less salient social or physical attractiveness issues. Cultural sensitivity in the way treatment is delivered would be helpful in ensuring that participants fully engage in the process (quality of participation). The distinction between factors affecting initial adoption versus long-term behavior changes is informed by Rothman’s proposition that different theoretical models are needed to explain initial adoption and maintenance. For example, whereas initial adoption is related primarily to a desire to achieve a favorable outcome and expectations that these outcomes will be achieved, once adopted, behaviors may be maintained by satisfaction with the outcomes that result.
Thus, offering behavior change content in ways that are relevant to the patient’s lifestyle issues and accessible from the perspective of language and learning style would be expected to facilitate short-term behavior changes. Contextual factors such as the world view, the general salience of health considerations in making lifestyle choices, and the structural constraints would be most relevant at the level of maintaining long-term change. Ultimately then, the rewards of having lost weight must be sufficiently reinforcing (positively) within the applicable context to motivate continued practice of the altered eating and activity patterns or, rather, according to Bouton, to drown out the inherently strong reinforcement for the prior, original, and culturally embedded behavior pattern. Clinical programs may be able to maintain changes by providing continued reinforcement through continued treatment.
On the other hand, given the nature of obesity and its determinants, a better alternative might be to reframe obesity treatment within health promotion paradigms. Health promotion paradigms are broader than clinical paradigms, are more inclusive of contextual issues, and are ahead of clinical paradigms in articulating specific frameworks for addressing cultural variables.

Obesity and the Primary Care Physician

A significant portion of the time spent in the evaluation and treatment of the obese patient can be expedited by use of protocols and procedures. A self-administered medical history questionnaire can be either mailed to the patient prior to the initial visit or completed in the waiting room. In addition to standard questions, sections of the form should inquire about past obesity treatment programs, a body weight history, current diet and physical activity levels, social support, and goals
and expectations. The review-of-systems section can include medical prompts that are more commonly seen among the obese, such as snoring, morning headaches and daytime sleepiness (for obstructive sleep apnea), urinary incontinence, intertrigo, and sexual dysfunction, among others.
Identifying the body mass index (BMI) as a fifth vital sign may also increase physician wareness and prompt counseling. This method was successfully used in a recent study where a smoking status stamp was placed on the patient chart, alongside blood pressure, pulse, temperature, and respiratory rate . Use of prompts, alerts, or other reminders has been shown to significantly increase physician performance of other health maintenance activities as well. Once the patient is identified as overweight or obese, printed food and activity diaries and patient information sheets on a variety of topics such as the food guide pyramid, deciphering food labels, healthy snacking, dietary fiber, aerobic exercise and resistance training, and dealing with stress can be used to support behavior change and facilitate patient education. Ready-to-copy materials can be obtained from a variety of sources free of charge such as those found in the Practical Guide, or for a minimal fee from other public sites and commercial companies.
Based on the health promotion literature, use of written materials and counseling protocols should lead to more effective and efficient obesity care. In a study of community-based family medicine physicians, Kreuter et al. showed that patients were more likely to reduce smoking, increase physical activity, and limit dairy fat consumption when physician advice is supported by health education materials. In another randomized intervention study by Swinburn et al. a written goal-oriented exercise prescription, in addition to verbal advice, was more effective than verbal advice alone in increasing the physical activity level of sedentary individuals over a 6-week period. Several exercise assessment and counseling protocols have been developed that can be easily incorporated into obesity care.
These include Project PACE (Provider-based Assessment and Counseling for Exercise) , ACT (the Activity Counseling Trial), and STEP (the Step Test Exercise Prescription). Finally, protocols and procedures for various treatment pathways can be established for obtaining periodic laboratory monitoring and referral to allied health professionals, such as registered dietitians, exercise specialists, and clinical psychologists.

IN WHICH REGIONS OF THE WORLD IS HEALTH MOST AFFECTED BY ENVIRONMENTAL FACTORS, AND HOW?

Developing regions carry a disproportionately heavy burden for communicable diseases and injuries.
The largest overall difference between WHO regions was in infectious diseases. The total number of healthy life years lost per capita as a result of environmental burden per capita was 15-times higher in developing countries than in developed countries. The environmental burden per capita of diarrhoeal diseases and lower respiratory infections was 120- to 150-times greater in certain WHO developing country subregions as compared to developed country subregions. These differences arise from variations in exposure to environmental risks and in access to health care.
No overall difference between developed and developing countries in the fraction of noncommunicable disease attributable to the environment was observed.
… However, in developed countries, the per capita impact of cardiovascular diseases and cancers is higher.
The number of healthy life years lost from cardiovascular disease, as a result of environmental factors, was 7-times higher, per capita, in certain developed regions than in developing regions, and cancer rates were 4-times higher. Physical inactivity is a risk factor for various noncommunicable diseases including ischaemic heart disease, cancers of the breast, colon and rectum, and diabetes mellitus. It has been estimated that in certain developed regions such as North America, physical inactivity levels could be reduced by 31% through environmental interventions, including pedestrian- and bicycle-friendly urban land use and transport, and leisure and workplace facilities and policies that support more active lifestyles.

… Developing countries, meanwhile, carry a heavier burden of disease from unintentional
injuries and road traffic injuries attributable to environmental factors.
In developing countries, the average number of healthy life years lost, per capita, as a result of injuries associated with environmental factors, was roughly double that of developed countries; the gap was even greater at the subregional level. For road traffic injuries, there was a 15-fold difference between the environmental burden of disease in the best performing and worstperforming subregions, and a 10-fold disparity for 'other' unintentional injuries.
The results suggest that an important transition in environmental risk factors will occur as countries develop. For some diseases, such as malaria, the environmental disease burden is expected to decrease with development, but the burden will increase from other noncommunicable diseases, such as chronic obstructive pulmonary disease (COPD), to levels approximate with those seen in more developed regions of the world.

WHICH POPULATIONS SUFFER THE MOST FROM ENVIRONMENTAL HAZARDS TO HEALTH?

Children suffer a disproportionate share of the environmental health burden.

Globally, the per capita number of healthy life years lost to environmental risk factors was about 5-times greater in children under five years of age than in the total population. Diarrhoea, malaria and respiratory infections all have very large fractions of disease attributable to environment, and also are among the biggest killers of children under five years old. In developing countries, the environmental fraction of these three diseases accounted for an average of 26% of all deaths in children under five years old. Perinatal conditions (e.g. prematurity and low birth weight); protein-energy malnutrition and unintentional injuries – other major childhood killers – also have a significant environmental component, particularly in developing countries.
On average, children in developing countries lose 8-times more healthy life years, per capita, than their counterparts in developed countries from environmentally-caused diseases. In certain very poor regions of the world, however, the disparity is far greater; the number of healthy life years lost as a result of childhood lower respiratory infections is 800-times greater, per capita; 25-times greater for road traffic injuries; and 140-times greater for diarrhoeal diseases. Even these statistics fail to capture the longer term effects of exposures that occur at a young age, but do not manifest themselves as disease until years later.

HOW SIGNIFICANT IS THE IMPACT OF ENVIRONMENT ON HEALTH?

An estimated 24% of the global disease burden and 23% of all deaths can be attributed to environmental factors.

Of the 102 major diseases, disease groupings and injuries covered by the World Health Report in
2004, environmental risk factors contributed to disease burden in 85 categories. The specific fraction of disease attributable to the environment varied widely across different disease conditions.
Globally, an estimated 24% of the disease burden (healthy life years lost) and an estimated 23% of all deaths (premature mortality) was attributable to environmental factors. Among children 0–14 years of age, the proportion of deaths attributed to the environment was as high as 36%. There were large regional differences in the environmental contribution to various disease conditions – due to differences in environmental exposures and access to health care across the regions. For example, although 25% of all deaths in developing regions were attributable to environmental causes, only 17% of deaths were attributed to such causes in developed regions. Although this represents a significant contribution to the overall disease burden, it is a conservative estimate because there is as yet no evidence for many diseases. Also, in many cases, the causal pathway between environmental hazard and disease outcome is complex. Where possible, attempts were made to capture such indirect health effects. For instance, malnutrition associated with waterborne diseases was quantified, as was disease burden related to aspects of physical inactivity attributable to environmental factors (e.g. urban design). But in other cases, disease burden was not quantifiable even though the health impacts are readily apparent. For instance, the disease burden associated with changed, damaged or depleted ecosystems in general was not quantified.
Diseases with the largest absolute burden attributable to modifiable environmental factors included: diarrhoea; lower respiratory infections; 'other' unintentional injuries; and malaria.