Expert opinion regarding the prevalence, health risks, obesogenic environment determinants and public health strategies on obesity. What are we still doing wrong?

ONISEI Tatiana2, POP Anca Lucia1*, IONITA Ana Corina1 MOROSAN Elena1, UDEANU Denisa1, MITITELU Magdalena1, VARLAS Valentin1, NASUI Bogdana Adriana3, ZETU Cornelia4, LUPULIASA Dumitru1, DRAGANESCU Doina1

1 University of Medicine and Pharmacy”Carol Davila” Bucharest (ROMANIA)

2 National Institute R&D for Food Bioresources, National Service for Medicinal, Aromatic Plants and Bee Products, 6 Dinu Vintila Street, 2nd District, Bucharest, Romania, Tel/Fax: +40212109128; +40212113639

3 University of Medicine and Pharmacy, Cluj-Napoca, Department of Community Health 

4 National Institute of Diabetes, Nutrition and Metabolic Diseases “Prof. Dr. N. Paulescu” Romania

Corresponding author: ancapop@hotmail.com

Abstract 

The overweight and obesity, as well as their related noncommunicable diseases (NCD’s) are preventable through lifestyle changes targeted in public health actions – but unfortunately with little or no succes untill now. In the present work we analysed the most important actual studies in the field – in order to provide and reccomend updated strategies to target efficiently the public health objectives. We identified four main topics of high importance in the current approach towards obesity: (1) the increasing prevalence and multiple health consequences (2) current public health (PH) strategies for risk factor reduction and obesity prevention (3) the influence of the obesogenic environment on individual behaviour (4) recent data on weight loss and weight loss maintenance programs (5) existance of a new obesity entity – normal weight obesity to be targeted as a pre-morbid state for noncommunicable diseases (NCDs).  A new approach is needed towards the (1) causative factors; (2) public health measures adressed precise to the remarkable regional differences in obesity prevalence and trends drived from the ethio-patogenic factors and PH reccomandations – most of them related to nutrition patterns and food quality – all together with lifestyle and environment measures. 

Keywords: obesity, overweight, public health strategies, NCD, noncommunicable diseases, WHO

Introduction

NCDs threaten is enlisted on WHO 2030 Agenda for Sustainable Development that includes a target of reducing premature deaths from NCDs by one-third by 2030. Metabolic risk factors contribute to four key metabolic changes that increase the risk of NCDs: (1) raised blood pressure (2) overweight/obesity (3) hyperglycemia and (4) hyperlipidemia. Detecting, screening and treating these diseases is critical to accomplish the WHO objectives by a integrate approach: including health, education, agriculture, finance – targeted to the modifiable factors that are on the core of the NCD’s: tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol [1, 2].

Defined as abnormal or excessive body fat accumulation that may impair health, the overweight and obesity has risen dramatically, among children and adolescents aged 5-19 from just 4% in 1975 to over 18% in 2016. Actually, in 2016, 18% of girls and 19% of boys were overweight, while 6% of girls and 8% of boys were obese (WHO, 2020). Available data show that the most dramatic increases in obesity are in developing countries. [3]. In Europe the overweight rate was 63% (men) and 54.3% (women) in 2016, while the obesity rate was 21.9% (men) and 24.5% (women). In Romania 46,4% of the adult population is overweight, while the  rate of obese people is 19,4%. The overweight and obesity, and the related noncommunicable diseases are largely preventable but unfortunately with no succes, despite the public health measures and enormous actual level of knowledge. So, the continuous screening of the databases is of key importance in order to identify, correlate and apply integrated approach by the healthcare specialists. A new tactic is needed targeted to the (1) causative factors; (2) public health measures drived from them and reccomandations – most of them related to nutrition patterns and food quality – all together with lifestyle and environment measures. The objective of this work is to analyse the most important and recent studies in the field in order to provide and reccomend updated strategies to target efficiently the public health objectives. 

Materials and methods

In the present study we scanned the recent literature and reviewed our experience regarding the prevalence of obesity and health outcomes due to this morbidity in the context of multiple public health measures to limit the continuous increase of the obesity worldwide, we analysed the role pro-overfeeding actions in the envirnment acting in opposition with the public health measures and reviewed the recent data on weight loss and weight loss maintenance programs. Data selection: we screened and synthesysed the literature on the obesity topic and current barriers in reducing the prevalence, morbidity and mortality due to obesity during the last five years but also notable refferences prom previous years. Data sources: Electronic databases (PubMed, Data Citation Index, Current Contents Connect, Cross Ref, Scopus, Web of Science, Google Scholar and Medline) were systematically searched for studies using the terms and categories: “obesity”, “obesity epidemic” “overweigh”& comorbidities” “childhood obesity”, “obesity and nutritional intervention”, “obesity and public health actions” „child obesity”, „obesity prevention programs”, “normal weight obesity”. The search withdrawed over 600.000 results on Google Scholar, over 125,483 results on Web of Science, 124.199  on Medline®,  with a media of over 30.000 articles during the last five years, 6 575 on Data Citation Index, Current Contents Connect – 87,129 articles and reviews 

 

A.

B.

Figure 1 Treemap of data results on the search term „obesity” (A) and „child obesity” (B) performed on web of Sciene Databases on a period of five years

From the screened data we selected twelve main topics linked with obesity regarding the obesity prevalence and health consequences, the socio-economic status and obesity, level of education, race and ethnicity, current public health strategies for risk factor reduction and obesity prevention, multifactorial determination of individual behaviour in the obesogenic environment, addictive diets and palatability, neuro-endocrine behavioural factors, normal weight obesity, point-of-choice nutrition information, per capita Kcal/day provision in different communities, weight loss nutrition programs.

Results 

The obesity prevalence and health consequences. According to WHO, overweight and obesity are defined as abnormal or excessive body fat accumulation that may impair health (WHO, 2020). BMI is a simple index of weight-for-height commonly used to classify overweight (BMI >= 25) and obesity in adults (BMI >= 30) [4]. 

However, the use of BMI does not distinguish between weight associated with muscle and weight associated with fat, the measure of intra-abdominal or central fat accumulation to reflect changes in risk factors for cardiovascular diseases and other forms of chronic diseases is better than BMI [5]. Numerous studies have compared the appropriateness of various anthropometric indices for assessing obesity and predicting obesity-related health risks, including BMI (James, 2005) [6], waist-to-hip ratio (WHR), waist circumference (WC), and waist-to-height ratio (WHtR) [7]. WHR was shown to be a good predictor of health risk, and a high WHR (>1.0 in men and >0.85 in women) indicates abdominal fat accumulation [8]. A health risk classification based on WC is suggested to be more useful for health assessment than either BMI or WHR, alone or in [9]. 

In the United States, a higher rate of obese was registered among adults aged 40–59 as compared to adults aged 20–39, both in men and women [9]. Overall, about one in 3 American adults is obese, followed by Mexicans (30% rate of obesity in the adult population), New Zealanders (26.5%), Australians (24.6%), and Canadians (24.2 percent), where 1 in 4 adult people is obese [1]. In European countries the rate for overweight was in 2016 about 63% among men and 54.3% among women, respectively, while obesity rate was 21.9% among men and 24.5% among women. Overall, national-level data for 2016 showed that, in most countries in the European Region, overweight was more prevalent among men, while obesity was more prevalent among women (WHO, 2018). In Romania a survey conducted by the National Institute of Statistics, in 2014, showed 46,4% of the adult population was overweight, while the  rate of obese people was 19,4%. A higher percentage of obese women was registered, which could be explained by their sedenary activities as compared with men, which are predominantly overweight. Interstingly, in Romania obesity has been more common in less educated women, while in men, obesity was observed in those with a high education level.

The socio-economic status and obesity. Once considered a high-income country problem, the overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings, due to the nutrition transition and a potential decrease in physical activity. Another factor which has been less discussed in previous studies is a lack of self-esteem among low SES people who adopt less positive attitudes towards physical activity [10].

The level of education. Ziraba (2009) showed that in Africa, with increasing urbanization, the poverty and social exclusion are likely to increase the risks of developing a chronic disease. The prevalence of overweight and obesity went up nearly 46% among non-educated women, while among educated women at the level of secondary school or higher dropped by about 10% [11]. Similar results have been reported for 2016-2018 in USA where the adults without a high school degree or equivalent had the highest self-reported obesity (35.0%), followed by high school graduates (33.1%), adults with some college (33.0%) and college graduates (24.7%) [12]

Race and ethnicity. There are also a notable differences by race and ethnicity. A meta-analysis among different ethnic groups showed that body fat percentage was 3−5% higher in Asian populations compared to Caucasian populations for the same BMI [13]. Combining USA data from 2016 through 2018 highlighted non-Hispanic blacks had the highest prevalence of self-reported obesity (39.1%), followed by Hispanics (33.3%) and non-Hispanic whites (29.3%). 

Normal weight obesity. A new guy in town. An individual with a normal body mass index but high percentage of body fat is a normal weight obese (NWO) measured with dual-energy X-ray absorptiometry (DXA) but also ultrasound A techniques [14] with a cutoff point for diagnosis 30% body fat in europeans  and in recent large scale studies 23.1 % for men and 33.3 % for women [15]; ≥23.5% in men; ≥29.2% in women in Koreans [16, 17]. The situation is gaining attention since due to connection with pro-oxidative effects and systemic low-grade chronic subclinical (general and vascular) inflammation, metabolic dysregulation [18, 19, 20] dyslipidemia, insulin resistance [21], changes in blood pressure. An increase in body fat percentage is linked to sedentary behavior and poor eating habits, the affected individuals are seldom identified through routine healthcare needing more than BMI status making mandatory the body composition screening in normal BMI subjects in order to identify people at a high risk of cardiometabolic abnormalities [22].

Current public health strategies for risk factor reduction and obesity prevention. A proposed framework by Sacks (2009) suggests that policy actions to the development and implementation of effective public health strategies to obesity prevention should (1) target the food environments, the physical activity environments and the broader socioeconomic environments; (2) directly influence behavior, aiming at improving eating and physical activity behaviors; and (3) support health services and clinical interventions. These areas include fiscal food policies, mandatory nutrition panels on the formulation and reformulation of manufactured foods, implementation of food and nutrition labeling, and restricting marketing and advertising bans of unhealthy foods [23]. The primary aim of the EU (European Union) strategy is to fight against the obesogenic environment (i.e. an environment that promotes weight gain) and help citizens reduce high-risk behaviours, such as poor nutrition and lack of exercise, that lead to overweight and obesity. White paper (2007) sets out to achieve this by focusing on actions (information campaigns) that enable consumers to make informed choices to ensure that healthy options are available (e.g. in supermarkets and canteens); encourage the food industry (including retailers) to reformulate its product recipes (in particular by reducing levels of salt, sugar and fats) and target responsible marketing to promote healthier options (affordable and available for all population groups, especially children); employers could encourage healthy lifestyles (e.g. “active transport and commuting”, walking, cycling or using public transport); motivate people to undertake regular physical activity (making it more accesible) by stressing the health benefits. 

Addictive diets and palatability. Aiming to understand how the pleasure of food affects our brain and behavior, Lee and Dixon have examined the neurobiological and phenotypic similarities and differences between hedonic pathway striggered by food compared with other addictive substances [24]. The biochemical properties within certain common foods have the potential to cause an addictive process, leading to a typical range of addiction-related problematic behaviours that in some individuals are sufficient to cause clinically significant impairment or distress [25]. The “non-homeostatic” or “hedonic” eating refers to food intake that is not regulated by metabolic feedback and is related to cognitive, reward, and emotional factors [26]. 

Neuro-endocrine behavioural factors. Individuals vary in their responses to the same stimuli, environmental cues, or signals of hunger and satiety. Once food is consumed, the motivation to eat is inhibited by the processes of satiation and satiety, which involve episodic feedback from hormonal signals in the gastrointestinal tract and tonic feedback from leptin and insulin, secreted in proportion to fat mass. Thus, it is proposed that the net effect of these stimulatory and inhibitory signals has a determining influence on eating behaviours like meal size and meal frequency [27]. The development of common overeating behavior is rooted in the family environment and being internalized, stress related alleviation-reward systems – are resistant to different nutritional and medical therapies [28] impposing the need for change in the parental attitudes and feeding environment of their child – generating eventually engagement in overeating in response to stress. The nutritional assistance/parenting programs of the families has to be strongly connected with the mandatory pshychological assistance [29].

Weight loss and weight loss maintenance programs. Obesity prevention and treatment frequently fail in the long term (for example, behavioural interventions aiming at reducing energy intake and increasing energy expenditure) or are not available or suitable (bariatric surgery) for the majority of people affected [30]. Supportive environments and communities are fundamental in shaping people’s choices, by making the choice of healthier foods and regular physical activity the easiest choice. The constructs of interest include the availability and price of healthy food choices, quality of food, portion sizes, within-outlet promotions, and point-of-choice nutrition information [31]. 

Point-of-choice nutrition information. Per capita Kcal/day provision. The food industry tends to act opportunistically in the interests of maximizing profit, and this aim does not necessarily coincide with public health efforts for obesity control. Food market in the United States, for example, provides about 3900 kcal per capita each day, roughly twice the population’s energy needs [32]. To expand profits in this environment, food companies’ strategies include promoting larger portions, frequent snacking and the normalization of sweets, soft drinks, snacks and fast food as daily fare. Although the majority agreed that some types of foods are addictive, there was very little support for increasing taxes on these obesogenic foods [33]. 

Interventions in worksites and through clinical and public health programs. Stress reduction may also be an important component of weight-loss interventions in worksites and in clinical and public health programs. A mindfulness-based intervention may be effective in reducing stress and improving stress-related over eating. Mindfulness training would enhance awareness of and responsiveness to bodily sensations and reduce psychological distress, emotional eating, and cortisol secretion; may support weight maintenance efforts, and actual weight loss might occur for those participants who eat a high proportion of meals mindfully.

Conclusions

The first-line treatment of obesity is dietary management combined with behavior modification; secondarily, increased physical activity – safe, efficacious, healthy and nutritionally adequate, culturally acceptable and economically affordable diet, without severe restrictions or nutritional exaggerations and should ensure long-term compliance and maintenance of weight loss.  Effective public health strategies to obesity prevention should (1) target the food environments, the physical activity environments, the broader socio-economic environments with intervention at the obesogenic marketing attitudes level; (2) directly influence individual behavior, aiming at improving eating and physical activity behaviours, supporting the sports environments at all age levels, good psychological training and support – and (3) support health services and clinical/nutritional interventions in worksites, through clinical and public health programs, founded on early nutritional education in school curiccula and in parents groups. Parenting programs in order to change the parental attitudes and feeding environment of their child, the future adult would be  The screening of the new type of normal body weight obesity (NWO) is mandatory for children and adults in order to timely foresee and act to prevent BMI obesity and NCD’s. 

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