tag:theconversation.com,2011:/global/topics/obesity-epidemic-1493/articlesObesity epidemic – The Conversation2023-10-30T16:15:23Ztag:theconversation.com,2011:article/2164562023-10-30T16:15:23Z2023-10-30T16:15:23ZDiabetes is South Africa’s second biggest killer disease: hiking the sugar tax would help<p><a href="https://www.macrotrends.net/countries/ZAF/south-africa/death-rate">Death rates in South Africa</a> have declined slightly during the past few years. But the country faces a steady rise in both death and disability caused by <a href="https://www.statssa.gov.za/?p=16729#:%7E:text=In%20South%20Africa%2C%20deaths%20due,males%20and%2069%20for%20females.">increases</a> in non-communicable diseases such as diabetes and cancer.</p>
<p>According to the <a href="https://ncdalliance.org/">NCD Alliance</a>, a civil society network, non-communicable diseases <a href="https://ncdalliance.org/why-ncds/NCDs">cause 71% of deaths</a> globally. Of these deaths <a href="https://www.afro.who.int/countries/south-africa/publication/acting-against-non-communicable-diseases-south-africa-investing-healthier-future">85% occur in low and middle income countries</a>. </p>
<p>In South Africa, according to <a href="https://www.statssa.gov.za/?p=16729#:%7E:text=In%20South%20Africa%2C%20deaths%20due,males%20and%2069%20for%20females.">Statistics South Africa</a>, there was an increase of 58% in deaths from non-communicable diseases from 1997 to 2018. <a href="https://www.statssa.gov.za/?p=16729">Diabetes is the second leading cause of death</a> in South Africa after tuberculosis. </p>
<p>Diabetes affects <a href="https://www.up.ac.za/faculty-of-health-sciences/news/post_2972065-our-research-shows-gaps-in-south-africas-diabetes-management-programme#:%7E:text=In%20South%20Africa%2C%20diabetes%20affects,89%2C834%20people%20died%20of%20diabetes.">12%</a> of the adult population, wreaking massive damage to individuals’ health and livelihoods, and to the national fiscus. The direct cost of diabetes to South Africa’s health system is <a href="https://www.wits.ac.za/news/latest-news/opinion/2022/2022-09/obesity-costs-south-africa-billions-we-did-the-sums.html">R2.7 billion</a> (US$150 million) – and that is only for those patients who are diagnosed. It does not factor in the indirect costs of loss of jobs and income. </p>
<p>If all cases were diagnosed and treated, PRICELESS SA, a research unit based at the School of Public Health at the University of the Witwatersrand, estimates this would cost R21.8 billion (US$1.2 billion) a year, rising to R35 billion (US$1.9 billion) in real terms by 2030.</p>
<p>Finance minister Enoch Godongwana will table the <a href="https://www.treasury.gov.za/comm_media/press/2023/2023091101%20MEDIA%20ADVISORY-MEDIUM%20TERM%20BUDGET%20POLICY%20STATEMENT%20DATE.pdf">medium-term budget</a> policy statement this week. Based on our <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30304-1/fulltext">research</a> and the experience elsewhere in the world, we believe Godongwana has an opportunity to improve both South Africa’s fiscal health and its public health in one swift, effective action: by increasing the Health Promotion Levy, better known as the “sugar tax” on beverages.</p>
<h2>Why the urgency?</h2>
<p>Most South Africans with diabetes are either diagnosed very late, by which time they are much sicker, or are not diagnosed at all. The SA Demographic Health Survey data from 2016, the most recent study, <a href="https://pubmed.ncbi.nlm.nih.gov/35236427/">found that 67% of all men and women were “pre-diabetic”</a> and suggested that a “large portion” of South Africans remained undiagnosed, and therefore untreated.</p>
<p>Untreated or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8383848/">badly controlled diabetes</a> can result in amputations, kidney failure and blindness. Many of these same individuals also have high blood pressure and end up with stroke as a result of brain haemorrhage. </p>
<p>Obesity is known to be linked to diabetes – and rates of <a href="https://pubmed.ncbi.nlm.nih.gov/34986330/#:%7E:text=The%20accumulation%20of%20an%20excessive,prevalence%20of%20type%202%20diabetes.">obesity and overweight</a> people, too, are increasing relentlessly. Current rates of obesity in South Africa are 11% among men (with another 20.3% overweight), and 41% among women (with another 26.6% overweight). At this rate it is expected that <a href="https://s3-eu-west-1.amazonaws.com/wof-files/World_Obesity_Atlas_2022.pdf#page=25">50%</a> of South African women will be obese by 2030. </p>
<p>Both obesity and diabetes are known to be triggered by <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sugar/how-much-sugar-is-too-much#:%7E:text=Men%20should%20consume%20no%20more,32%20grams">over-consumption</a> of sugar. <a href="https://pubmed.ncbi.nlm.nih.gov/31054268/">Liquid sugar</a> is known to be particularly harmful and has no nutritional value. This is why the public health recommends at least a 20% tax on sugary beverages. </p>
<p>The Health Promotion Levy should also include 100% fruit juices in the list of products subject to the tax.</p>
<h2>Sugar tax</h2>
<p>In 2018, in an attempt to address South Africa’s obesity, diabetes and other non-communicable diseases, National Treasury imposed a tax on sugar-sweetened beverages, known as the <a href="https://www.sars.gov.za/customs-and-excise/excise/health-promotion-levy-on-sugary-beverages/">Health Promotion Levy</a>. It equates to 2.1 cents per gram of sugar above a 4 gram threshold per 100 millilitres – which amounts to a levy of approximately 11% on the price.</p>
<p>As of June 2022, the sugar tax alone had raised more than R10 billion (US$750 million) in revenues that went directly to the treasury. Only R24 million (US$1.3 million) in 2019/2020 and R14 million (US$0.7 million) in 2020/2021 was allocated to expenditure on <a href="https://knowledgehub.health.gov.za/system/files/elibdownloads/2023-04/National%252520health%252520promotion%252520policy%252520and%252520strategy%2525202015%252520-%2525202019.pdf">“health promotion”</a>. </p>
<p>But the South African sugar industry fought the sugar tax from the outset. The tax started out at a lower rate than originally planned: it was designed to be <a href="https://www.who.int/news/item/11-10-2016-who-urges-global-action-to-curtail-consumption-and-health-impacts-of-sugary-drinks">20%</a> in line with World Health Organization recommendations, but was slashed to 11% because of sugar industry <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747348/">pressure</a> during a prolonged public consultation period. The already ailing industry alleged it would cause further job losses. </p>
<p>In reality, other global sugar market realities are the cause of declines in local sugar production and jobs. For example <a href="https://www.namc.co.za/wp-content/uploads/2017/09/Document-3-Legislative-environment.pdf">distorted global prices</a> are below South Africa’s cost of production. This predated the introduction of the sugar tax. </p>
<p>The South African government has not increased the sugar levy from its initial 11% in the five years since it started. It has put previously planned increases on hold. In the <a href="https://www.gov.za/speeches/minister-enoch-godongwana-2023-budget-speech-22-feb-2023-0000">February 2023 budget speech</a> the minister again imposed a two-year moratorium on the Health Promotion Levy, not even allowing for an inflation-related increase. In real terms, the sugar tax has effectively been reduced.</p>
<p>The South African Sugarcane Growers’ Association has <a href="https://apps.fas.usda.gov/newgainapi/api/Report/DownloadReportByFileName?fileName=South%20African%20Sugar%20Industry%20Crushed%20by%20Not%20So%20Sweet%20Tax_Pretoria_South%20Africa%20-%20Republic%20of_3-5-2019">expressed concern</a> at the prospect of an increase in the levy, fearing negative impacts on the sugar industry. Yet research from PRICELESS, analysing data from the <a href="https://www.statssa.gov.za/publications/P0211/P02112ndQuarter2019.pdf">South African Quarterly Labour Force Survey</a> from January 2008 to June 2019, shows that the sugar levy has had little effect on sugar-industry employment.
Even at its current weaker-than-ideal rate, the tax has reduced consumers’ consumption of sugary beverages by about 2g per capita per day, separate <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30304-1/fulltext">research</a> led by PRICELESS SA scientists shows. </p>
<h2>Government could turn the tide</h2>
<p>To reverse South Africa’s fatal diabetes trend and pour additional, much-needed billions into public funds, the government should increase the rate of the Health Promotion Levy to the 20% endorsed by the WHO. </p>
<p>Early detection and treatment is key to reducing the disabling effects of diabetes and the cost to the state. Therefore better diagnosis in the public health system should be prioritised – and funded from Health Promotion Levy revenues. </p>
<p>The fact that the Health Promotion Levy has already yielded more than R10 billion to the treasury is testament to its revenue potential. The win-win consequences of raising the levy seem indisputable.</p><img src="https://counter.theconversation.com/content/216456/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Goldstein receives funding from the Bloomberg Foundation and UK research foundations (UKRI and NIHR) as well as the IDRC. </span></em></p><p class="fine-print"><em><span>Karen Hofman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Diabetes affects about 12% of South Africa’s adult population.Karen Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandSusan Goldstein, Associate Professor in the SAMRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2025952023-05-05T12:14:19Z2023-05-05T12:14:19ZObesity in children is rising dramatically, and it comes with major – and sometimes lifelong – health consequences<figure><img src="https://images.theconversation.com/files/524166/original/file-20230503-24-l7rhni.jpg?ixlib=rb-1.1.0&rect=22%2C33%2C7326%2C4869&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Knowing how to talk to kids about healthful eating is key.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/xtd3zYWxEs4">MI PHAM/Unsplash</a></span></figcaption></figure><p>In the past two decades, <a href="https://doi.org/10.1542/peds.2021-053708">children have become more obese</a> and have developed obesity at a younger age. A 2020 report found that <a href="https://www.cdc.gov/obesity/data/childhood.html#">14.7 million</a> children and adolescents in the U.S. live with obesity. </p>
<p>Because <a href="https://childhoodobesityfoundation.ca/what-is-childhood-obesity/complications-childhood-obesity/">obesity is a known risk factor</a> for <a href="https://www.mayoclinic.org/diseases-conditions/childhood-obesity/symptoms-causes/syc-20354827">serious health problems</a>, its <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7037a3.htm">rapid increase during the COVID-19 pandemic</a> raised alarms.</p>
<p>Without intervention, many obese <a href="https://doi.org/10.1111/obr.12334">adolescents will remain obese</a> as adults. Even before adulthood, some children will have serious health problems beginning in their preteen years.</p>
<p>To address these issues, in early 2023, the American Academy of Pediatrics released its <a href="https://www.aap.org/en/news-room/news-releases/aap/2023/american-academy-of-pediatrics-issues-its-first-comprehensive-guideline-on-evaluating-treating-children-and-adolescents-with-obesity/">first new obesity management guidelines</a> in 15 years.</p>
<p>I am a <a href="https://www.scvmc.org/find-provider-result?field_specialties_target_id=536&field_spoken_language_target_id=All&title=&field_gender_target_id=All&sort_bef_combine=field_last_name_value_ASC">pediatric gastroenterologist</a> who sees children in the largest public hospital in California, and I have witnessed a clear trend over the last two decades. Early in my practice, I only occasionally saw a child with a complication of obesity; now I see multiple referrals each month. Some of these children have severe obesity and several health complications that require multiple specialists.</p>
<p>These observations prompted my reporting for the <a href="https://centerforhealthjournalism.org/2023/03/06/pandemic-made-childhood-obesity-even-worse-how-can-we-help-children-most-risk">California Health Equity Fellowship</a> at the University of Southern California. </p>
<p>It’s important to note that not all children who carry extra weight are unhealthy. But evidence supports that obesity, especially severe obesity, requires further assessment.</p>
<h2>How obesity is measured</h2>
<p>The <a href="https://www.who.int/health-topics/obesity#tab=tab_1">World Health Organization defines obesity</a> as “abnormal or excessive fat accumulation that presents a risk to health.” </p>
<p>Measuring fat composition requires specialized equipment that is not available in a regular doctor’s office. Therefore most clinicians use body measurements to screen for obesity. </p>
<p>One method is body mass index, or BMI, a calculation based on a child’s height and weight compared to age- and sex-matched peers. BMI doesn’t measure body fat, but when <a href="https://www.cdc.gov/healthyweight/assessing/bmi/index.html">BMI is high</a>, it correlates with total body fat.</p>
<p>According to the <a href="https://doi.org/10.1542/peds.2022-060640">American Academy of Pediatrics</a>, a child qualifies as overweight at a BMI between the <a href="https://www.cdc.gov/growthcharts/clinical_charts.htm">85th and 95th percentile</a>. Obese is defined as a <a href="https://www.cdc.gov/obesity/basics/childhood-defining.html">BMI above the 95th percentile</a>. Other screens for obesity include <a href="https://www.nccor.org/nccor-tools/a-guide-to-methods-for-assessing-childhood-obesity/">waist circumference and skin-fold thickness</a>, but these methods are less common. </p>
<p>Because many children exceeded the limits of existing growth charts, in 2022 the Centers for Disease Control and Prevention introduced <a href="https://www.cdc.gov/growthcharts/extended-bmi.htm">extended growth charts</a> for severe obesity. Severe obesity occurs when a child reaches the 120th percentile or has a BMI over 35. For instance, a 6-year-old boy who is 48 inches tall and is 110 pounds would meet criteria for severe obesity because his BMI is 139th percentile.</p>
<p><a href="https://doi.org/10.1161/cir.0b013e3182a5cfb3">Severe obesity</a> carries a heightened risk of liver disease, cardiovascular disease and metabolic problems such as diabetes. As of 2016, almost <a href="https://doi.org/10.1542%2Fpeds.2017-3459">8% of children ages 2 to 19 had severe obesity</a>.</p>
<p>Other health problems associated with severe obesity include <a href="https://doi.org/10.1155%2F2012%2F134202">obstructive sleep apnea</a>, <a href="https://orthoinfo.aaos.org/en/diseases--conditions/slipped-capital-femoral-epiphysis-scfe">bone and joint problems</a> that can cause early arthritis, <a href="https://doi.org/10.5527%2Fwjn.v4.i2.223">high blood pressure</a> and <a href="https://doi.org/10.1159/000492826">kidney disease</a>. Many of these problems occur together.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ZpbZ33Dc53E?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">More and more children are developing diseases that have traditionally only been seen in adults.</span></figcaption>
</figure>
<h2>How obesity affects the liver</h2>
<p>The liver disease associated with obesity is called nonalcoholic <a href="https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash-children#">fatty liver disease</a>. To store excess dietary fat and sugar, the liver’s cells fill with fat. Excess carbohydrates in particular get processed into substances similar to the <a href="https://doi.org/10.3945%2Fan.112.002998">breakdown products of alcohols</a>. Under the microscope, a pediatric fatty liver looks similar to a liver with alcohol damage.</p>
<p>Occasionally children with fatty liver are not obese; however, the <a href="https://doi.org/10.1002/cld.1027">greatest risk factor for fatty liver</a> is obesity. At the same BMI, Hispanic and Asian children are more susceptible to fatty liver disease than Black and white children. Weight reduction or reducing the consumption of fructose, a naturally occurring sugar and common food additive – even without significant weight loss – improves fatty liver.</p>
<p>Fatty liver is the most common chronic liver disease in children and adults. In Southern California, <a href="https://doi.org/10.1542%2Fpeds.2020-0771">pediatric fatty liver doubled</a> from 2009 to 2018. The disease can progress rapidly in children, and <a href="https://doi.org/10.1136/gut.2008.171280">some will have liver scarring</a> after only a few years. </p>
<p>Although few children currently require liver transplants for fatty liver, it is the most <a href="https://doi.org/10.1097/mcg.0000000000000925">rapidly increasing reason for transplantation in young adults</a>. Fatty liver is the second-most common reason for liver transplantation in the U.S., and it will be the <a href="https://liverfoundation.org/about-your-liver/facts-about-liver-disease/fatty-liver-disease/">leading cause in the future</a>.</p>
<figure class="align-center ">
<img alt="A light micrograph image of fatty liver, with large vacuoles of triglyceride fat accumulated inside liver cells." src="https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524456/original/file-20230504-17-zbul98.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A light micrograph image of fatty liver, with large vacuoles of triglyceride fat inside liver cells.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/light-micrograph-of-a-fatty-liver-royalty-free-image/851075118?phrase=fatty+liver&adppopup=true">Dr_Microbe/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>Links between obesity and diabetes</h2>
<p><a href="https://doi.org/10.1016/S2213-8587(14)70032-4">Fatty liver is implicated</a> in <a href="https://www.nhlbi.nih.gov/health/metabolic-syndrome">metabolic syndrome</a>, a group of conditions that cluster together and increase the risk of cardiovascular disease and diabetes.</p>
<p>In a telephone interview, Dr. Barry Reiner, a pediatric endocrinologist, voiced his concerns to me about obesity and diabetes.</p>
<p>“When I started my practice, I had never heard of type 2 diabetes in children,” says Reiner. “Now, depending on which part of the U.S., between a quarter and a third of new cases of diabetes are type 2.”</p>
<p><a href="https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011">Type 1 diabetes</a> is an autoimmune disease previously called juvenile-onset diabetes. Conversely, <a href="https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193">type 2 diabetes</a> was historically considered an adult disease. </p>
<p>However, type 2 diabetes is increasing in children, and obesity is the <a href="https://www.endocrine.org/news-and-advocacy/news-room/2017/childhood-obesity-quadruples-risk-of-developing-type-2-diabetes">major risk factor</a>. While both types of diabetes have genetic and lifestyle influences, type 2 is more modifiable through diet and exercise. </p>
<p>By 2060, the number of people under 20 with type 2 diabetes will <a href="https://doi.org/10.2337/dc22-0945">increase by 700%</a>. Black, Latino, Asian, Pacific Islander and Native American/Alaska Native children will have more type 2 diabetes diagnoses than white children. </p>
<p>“The seriousness of type 2 diabetes in children is underestimated,” says Reiner. He added that many people express a misconception that type 2 diabetes is a mild, slow-moving disease.</p>
<p>Reiner pointed to an important study showing that type 2 diabetes acquired in childhood <a href="https://www.adameetingnews.org/live-updates/session-coverage/today2-study-youth-onset-type-2-diabetes-more-severe-than-adult-onset-disease">can rapidly progress</a>. As early as 10 to 12 years after their childhood diagnosis, patients developed nerve damage, kidney problems and vision damage. By 15 years after diagnosis, at an average age of 27, almost <a href="https://doi.org/10.1056/NEJMoa2100165">70% of the patients had high blood pressure</a>.</p>
<p>Most patients had more than one complication. Although rare, a few patients experienced heart attacks and strokes. When people with childhood onset diabetes became pregnant, 24% delivered premature infants, over <a href="https://www.marchofdimes.org/peristats/reports/united-states/prematurity-profile#">double the rate in the general population</a>.</p>
<h2>Heart health</h2>
<p>Cardiovascular changes associated with obesity and severe obesity can also increase a child’s lifetime chance of heart attacks and strokes. Carrying extra weight at 6 to 7 years old can result in higher blood pressure, cholesterol and artery stiffness by <a href="https://doi.org/10.1542/peds.2019-3666">11 to 12 years of age</a>. Obesity <a href="https://doi.org/10.1093/eurheartj/ehv089">changes the structure of the heart</a>, making the muscle thicken and expand. </p>
<p>Although still uncommon, more people in their 20s, 30s and 40s <a href="https://doi.org/10.1161/STROKEAHA.119.024156">are having strokes</a> and <a href="https://www.acc.org/about-acc/press-releases/2019/03/07/08/45/heart-attacks-increasingly-common-in-young-adults">heart attacks</a> than a few decades ago. Although many factors may contribute to heart attack and stroke, obesity adds to that risk.</p>
<h2>Talk about being healthy, not focusing on weight</h2>
<p>Venus Kalami, a registered dietitian, spoke with me about the environmental and societal influences on childhood obesity.</p>
<p>“Food, diet, lifestyle and weight are often a proxy for something greater going on in someone’s life,” says Kalami.</p>
<p>Factors beyond a child’s control, including <a href="https://med.stanford.edu/news/all-news/2018/04/pediatric-obesity-depression-connected-in-the-brain.html">depression</a>, <a href="https://doi.org/10.1542/peds.2021-055571">access to healthy food</a> and <a href="https://doi.org/10.1210/endrev/bnac005">walkable neighborhoods</a>, contribute to obesity.</p>
<p>Parents may wonder how to help children without introducing shame or blame. First, conversations about weight and food should be age appropriate.</p>
<p>“A 6-year-old does not need to be thinking about their weight,” says Kalami. She adds that even preteens and teenagers should not be focusing on their weight, though they likely already are. </p>
<p>Even <a href="https://doi.org/10.1542/peds.2016-1649">“good-natured” teasing</a> is harmful. Avoid diet talk, and instead discuss health. Kalami recommends that adults explain how healthy habits can improve mood, focus or kids’ performance in a favorite activity.</p>
<p>“A 12-year-old isn’t always going to know what is healthy,” Kalami said. “Help them pick what’s available and make the best choice, which may not be the perfect choice.”</p>
<p>Any weight talk, either criticism or compliments for weight loss, may backfire, she adds. Praising a child for their weight loss can reinforce a negative cycle of disordered eating. Instead, cheer the child’s better health and good choices.</p>
<p>Dr. Muneeza Mirza, a pediatrician, recommends that parents model healthful behavior.</p>
<p>“Changes should be made for the whole family,” says Mirza. “It shouldn’t be considered a punishment for that kid.”</p><img src="https://counter.theconversation.com/content/202595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Nguyen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The American Academy of Pediatrics has recently released new obesity management guidelines in order to help address the growing obesity crisis in children.Christine Nguyen, 2023 California Health Equity Fellow, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1791762022-04-20T12:17:46Z2022-04-20T12:17:46ZBeer and spirits have more detrimental effects on the waistline and on cardiovascular disease risk than red or white wine<figure><img src="https://images.theconversation.com/files/458683/original/file-20220419-15105-khdsoe.jpg?ixlib=rb-1.1.0&rect=20%2C61%2C6869%2C2623&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Researchers are working to tease apart how various alcohol types contribute to weight gain and disease risk.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/six-drinks-royalty-free-image/157333486?adppopup=true">pixhook/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>Drinking beer and spirits is linked to elevated levels of <a href="https://doi.org/10.1259/bjr/38447238">visceral fat</a> – the harmful type of fat that is associated with an increased risk of cardiovascular disease, metabolic syndrome, and other health complications – whereas drinking wine shows no such association with levels of this harmful fat and may even be protective against it, depending on the type of wine consumed. In fact, we found that drinking red wine is linked to having lower levels of visceral fat. These are some of the key takeaways of <a href="https://doi.org/10.1002/osp4.598">a new study</a> that my colleagues and I recently published in the Obesity Science & Practice journal. </p>
<p>Although white wine consumption did not influence levels of visceral fat, our study did show that drinking white wine in moderation might offer its own unique health benefit for older adults: denser bones. We found higher bone mineral density among older adults who drank white wine in moderation in our study. And we did not find this same link between beer or red wine consumption and bone mineral density.</p>
<p>Our study relied on a large-scale longitudinal database called <a href="https://www.ukbiobank.ac.uk/">the U.K. Biobank</a>. We assessed 1,869 white adults ranging in age from 40 to 79 years who reported demographic, alcohol, dietary and lifestyle factors via a touchscreen questionnaire. Next, we collected height, weight and blood samples from each participant and obtained body composition information using a direct measure of body composition called <a href="https://radiology.ucsf.edu/blog/dxadexa-beats-bmi-using-x-ray-exam-measure-body-composition-fat-loss">dual-energy X-ray absorptiometry</a>. Then, we used a statistical program to examine the relationships among the types of alcoholic beverages and body composition. </p>
<h2>Why it matters</h2>
<p>Aging is often accompanied by an increase in the problematic fat that can lead to heightened cardiovascular disease risk as well as by a <a href="https://doi.org/10.1177/1759720X11430858">reduction in bone mineral density</a>. This has important health implications given that nearly 75% of adults in the U.S. <a href="https://www.cdc.gov/nchs/data/hestat/obesity-adult-17-18/overweight-obesity-adults-H.pdf">are considered overweight or obese</a>. Having higher levels of body fat has been consistently linked to an increased risk for acquiring many different diseases, including <a href="https://doi.org/10.1161/CIR.0000000000000973">cardiovascular disease</a>, <a href="https://doi.org/10.1056/NEJMoa021423">certain types of cancer</a>, and <a href="https://doi.org/10.1056/NEJMoa0801891">a higher risk of death</a>. And it’s worth noting that national medical care costs associated with treating obesity-related diseases total more than <a href="https://doi.org/10.18553/jmcp.2021.20410">US$260.6 billion annually</a>.</p>
<p>Considering these trends, it is vital for researchers like us to examine all the potential contributors to weight gain so that we can determine how to combat the problem. Alcohol has long been considered one possible driving factor <a href="https://doi.org/10.1007/s13679-014-0129-4">for the obesity epidemic</a>. Yet the public often hears conflicting information about the potential <a href="https://doi.org/10.1111/psyp.12134">risks</a> and <a href="https://doi.org/10.1016/j.mayocp.2013.11.005">benefits</a> of alcohol. Therefore, we hoped to help untangle some of these factors through our research. </p>
<h2>What still isn’t known</h2>
<p>There are many biological and environmental factors that contribute to being overweight or obese. <a href="https://doi.org/10.1007/s13679-014-0129-4">Alcohol consumption</a> may be one factor, although there are <a href="https://doi.org/10.1111/j.1753-4887.2011.00403.x">other studies</a> that have not found clear links between weight gain and alcohol consumption. </p>
<p>One reason for the inconsistencies in the literature could stem from the fact that much of the previous research has traditionally treated alcohol as a single entity rather than separately measuring the effects of beer, cider, red wine, white wine, Champagne and spirits. Yet, even when broken down in this way, the research yields mixed messages.</p>
<p>For example, <a href="https://doi.org/10.1093/oxfordjournals.aje.a117556">one study has suggested</a> that drinking more beer contributes to a higher waist-to-hip ratio, while <a href="https://pubmed.ncbi.nlm.nih.gov/17416040/">another study</a> concluded that, after one month of drinking moderate levels of beer, healthy adults did not experience any significant weight gain.</p>
<p>As a result, we’ve aimed to further tease out the unique risks and benefits that are associated with each alcohol type. Our next steps will be to examine how diet – including alcohol consumption – could influence diseases of the brain and cognition in older adults with <a href="https://www.nia.nih.gov/health/what-mild-cognitive-impairment">mild cognitive impairment</a>. </p>
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<p class="fine-print"><em><span>Brittany Larsen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research has been inconclusive on the degree to which drinking alcohol leads to the growth of harmful fat. But a new study suggests that beer and spirits are far bigger culprits than wine.Brittany Larsen, Ph.D. Candidate in Neuroscience & Graduate Assistant, Iowa State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1313412020-02-19T15:43:48Z2020-02-19T15:43:48ZObesity is more common than you think – here’s why<figure><img src="https://images.theconversation.com/files/316177/original/file-20200219-11044-1n4wp7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-happy-cute-boy-eating-donut-632097332">Shutterstock</a></span></figcaption></figure><p>The World Health Organization has <a href="https://www.who.int/nutrition/topics/obesity/en/">described</a> obesity as a global epidemic and one of today’s “most blatantly visible yet neglected public health problems”. In the last few years <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1614362">reports</a> on the rise of this life-threatening condition among children and adults across the globe have been <a href="https://www.ncbi.nlm.nih.gov/pubmed/29029897">alarming</a>. </p>
<p>A total of 107.7 million children and 603.7 million adults were considered to be obese in 2015. But now our <a href="https://www.who.int/bulletin/volumes/96/11/17-205948/en/">research</a> shows that obesity is even more common than these reports suggest, and that in many countries most people are now living with obesity. </p>
<p>Obesity is a disease in which the amount of body fat is too high – high enough to harm health. It can increase the risk of diabetes, high blood pressure, heart problems, stroke and some cancers. But measuring body fatness accurately is difficult – and so most scientific studies and national surveys do not measure it, but use instead the weight-to-height <a href="https://www.nhs.uk/common-health-questions/lifestyle/what-is-the-body-mass-index-bmi/">body mass index</a> (BMI) as a simple proxy for body fatness.</p>
<p>But the issue here is that the BMI can be a misleading proxy for high body fatness in both children and adults – and even more so in particular ethnic groups. This means that many people with apparently healthy BMI will actually be living with high body fatness without being aware of it, and so be at risk of the serious health consequences without realising it. Our research aimed to assess how problematic BMI is when used as a proxy for high body fatness in African children.</p>
<h2>The problem with body-mass index</h2>
<p>A high BMI or BMI-for-age – in children and adolescents BMI has to be adjusted for age because it increases with growth and maturation – is usually taken to represent high body fatness. The problem is that while almost all <a href="https://www.ncbi.nlm.nih.gov/pubmed/20125098">adults</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24961794">children</a> who have a high BMI will have a high level of body fat, many people with an apparently healthy BMI will also have a high level of body fat.</p>
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<p>It is well known that BMI misclassifies the body fatness of athletes, bodybuilders and sportsmen and women, because a high muscle mass produces a high BMI. Only a small proportion of the population are athletic though, and the far more common problem with BMI is that it misclassifies body fatness of this much larger, non-athletic portion of the population – but in the opposite direction, meaning it downplays its extent.</p>
<p>The extent of the misclassifying of body fatness by BMI matters. Most studies which have measured both body fatness and BMI have taken place in Europe and North America – and in these studies the prevalence of high body fatness has been as much as two to three times greater than the prevalence of high BMI. In <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033308">one example</a>
26% of US adults were obese according to their BMI, while 64% of the same adults were obese according to a more accurate measure which images the amount of fat in the body directly using X-rays. </p>
<h2>Obesity and ethnicity</h2>
<p>The problem of underestimating obesity is even worse in some population groups. The extent to which the BMI misclassifies the body fatness of people <a href="https://www.ncbi.nlm.nih.gov/pubmed/27383689">depends on their ethnicity</a>. It is well established, but not well known, that BMI misclassifies children and adults in south and east Asia even more than Europeans.</p>
<p>There is emerging evidence that this problem extends to using BMI in other population groups too. In our <a href="https://www.who.int/bulletin/volumes/96/11/17-205948/en/">recent study</a> of children living in eight cities across Africa from Windhoek in the south to Tunis in the north, we found that 9% were obese according to their BMI-for-age, but 29% had high body fat according to a <a href="https://humanhealth.iaea.org/HHW/Nutrition/BodyComposition/RefsBodyComp/TBW_2015.pdf">stable isotope technique</a> designed for measuring body fatness.</p>
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<img alt="" src="https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=378&fit=crop&dpr=1 600w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=378&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=378&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=475&fit=crop&dpr=1 754w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=475&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=475&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People in south Asia are more likely to misclassified according to the BMI measure of fatness than Europeans.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/obese-brother-sister-eating-box-lunch-697576930">Shutterstock</a></span>
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<p>By underestimating the prevalence of obesity because of reliance on BMI in clinics, research studies and national health surveys, we also underestimate the need for action to prevent and treat obesity. To use our African study as an example, the case for action at a 29% prevalence of obesity is much stronger than at a prevalence of 9%. Obesity is far more common than it seems, and it requires much greater effort and more urgent attention than it is currently receiving. </p>
<p>As we enter a new decade it is time for national resolutions that are more ambitious. The main drivers of the global obesity epidemic are well known: excessive fat and sugar intake, lack of sleep, too much screen time, insufficient physical activity. We need global measures across all age groups to address these elements and we need them now.</p><img src="https://counter.theconversation.com/content/131341/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John J Reilly receives funding from the Scottish Funding Council, Scottish Government Chief Scientist Office, Hannah Research Foundation, Cunningham Trust, World Health Organisation.. </span></em></p>The problematical body-mass index method of measuring fatness means the number of people who are obese has been seriously underestimated.John J Reilly, Professor of Physical Activity and Public Health Science, University of Strathclyde Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1016292018-09-05T07:52:10Z2018-09-05T07:52:10ZIt’s eating fat that makes you fat, new mouse study suggests<figure><img src="https://images.theconversation.com/files/234811/original/file-20180904-45166-fuwx1x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Worldwide obesity has <a href="http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight">tripled since 1975</a>, with 1.9 billion adults considered overweight. The condition now kills more people across the globe than underweight and malnutrition.</p>
<p>One of the NHS’s <a href="https://www.independent.co.uk/news/health/nhs-obesity-diabetes-prevention-smoking-cost-health-service-weight-loss-sugar-tax-eat-healthy-a8254426.html">biggest cost burdens</a>, a staggering <a href="https://www.nuffieldtrust.org.uk/news-item/can-the-nhs-help-tackle-the-uk-s-obesity-epidemic">70% of UK adults</a> are expected to have overweight or obesity by 2034. Obesity is a problem of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302369/">energy balance</a>. If a person has more calories coming in than are going out, then the difference is generally stored as body fat. But what needs to be identified are the factors causing the imbalance of intake and spending in the first place. Why don’t humans have a control system that allows them to eat exactly what they need and no more? Understanding the answer to this question may help tackle the obesity epidemic.</p>
<p>There have been several explanations of why people sometimes overconsume calories. These generally revolve around the <a href="https://www.huffingtonpost.co.uk/entry/what-are-macronutrients-and-why-do-you-need-them_uk_5a155ed1e4b009b331ad7600">macronutrient</a> composition of our diets. Macronutrients consist of fats, protein and carbohydrates. One explanation for over-consumption of calories is called the <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/obr.12131">protein leverage hypothesis</a>. The idea is that we primarily eat food for its protein content. If the amount of protein falls in relation to the amount of fat and carbohydrate, then to meet our protein needs we overconsume calories.</p>
<p>An alternative is the <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2686146">carbohydrate-insulin model</a>. This maintains that it is carbohydrates that make us fat, because when we eat them they stimulate the production of <a href="https://www.endocrineweb.com/conditions/type-1-diabetes/what-insulin">insulin</a>, which promotes storage of the carbohydrates as fat and stimulates hunger to procure additional intake. This idea has become very popular in the wake of <a href="https://www.amazon.co.uk/Low-Carb-Diet-Books/b?ie=UTF8&node=5687274031">several books</a> that have spawned the whole “high fat-low carb” (HFLC) diet movement.</p>
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<img alt="" src="https://images.theconversation.com/files/234814/original/file-20180904-45172-1pqiij1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/234814/original/file-20180904-45172-1pqiij1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/234814/original/file-20180904-45172-1pqiij1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/234814/original/file-20180904-45172-1pqiij1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/234814/original/file-20180904-45172-1pqiij1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/234814/original/file-20180904-45172-1pqiij1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/234814/original/file-20180904-45172-1pqiij1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Over a quarter of adults in England and almost a third of adults in Scotland have obesity.</span>
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<p>The classic idea, however, is that what makes us fat is eating fat, because fat stimulates reward centres in our brains that encourage us to overeat. This has been called the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3254791/pdf/nihms330047.pdf">hedonic over-ride hypothesis</a>.</p>
<h2>Of mice and men</h2>
<p>You might think that testing between these ideas would be rather straightforward – simply expose people to the different diets and see who gets fat. But a randomised controlled trial in humans would never get permission because ethically it would not be acceptable to expose anyone to a trial where the expected outcome is gross obesity and a threat to their health.</p>
<p>So the best we can do is trial the diets in animals such as mice and see what happens to give us some clues as to what may happen in humans. We have recently completed such a <a href="https://www.sciencedirect.com/science/article/pii/S1550413118303929?via%3Dihub">study</a> using a total of 1,000 mice exposed to 30 different diets for three months (equivalent to nine years’ exposure in a human). </p>
<p>The study included 12 diets where the protein content varied between 5% and 30% and 12 diets varying the fat content from 8.3% to 80%. The fat composition was designed to mimic the composition of the average American diet. In all these diets the sugar content was held constant at 5%.</p>
<p>Finally, in the last six diets we held the fat and protein constant and let the sugar vary from 5% to 30%. The balance in all cases was made up of highly processed carbohydrates such as <a href="https://www.thespruceeats.com/what-is-corn-starch-1328466">corn starch</a>. We repeated the study on five different strains of mice including ones considered to be prone or resistant to obesity. Food intake and body weights were measured every day, and each week we used a small mouse MRI machine to quantify how fat they were.</p>
<p>The results of this massive experiment were very clear. First, changing protein levels had minimal impact on total calorie intake and body fatness. So the protein leverage idea was not supported. Second, when we fixed the protein and fat levels, varying sugar also had no significant impact on body fatness, possibly because the other carbohydrates in the diet were already highly refined. Nevertheless, higher levels of these carbohydrates were on average protective against weight gain, which does not support the carbohydrate-insulin model.</p>
<p>In fact, the only thing that made the mice fat was eating more fat in their diets. But the relationship was not linear. With up to around 50%-60% fat in the diet, the mice ate more food and put on more weight. However, at higher levels of fat they gained less weight. A mouse eating 80% fat in its diet increased in weight by about the same amount as one eating 30% fat. We don’t know exactly why, only that on these super high-fat diets the mice consumed fewer calories and didn’t gain as much weight.</p>
<h2>Looking at the results</h2>
<p>There are several limitations to this work. Crucially, these experiments were done on mice. While convenient and we know lots about their genetics and physiology, it is possible that mice might respond differently to humans.
However, a definitive experiment in humans cannot take place because of ethical concerns, so the hope is that mice can help us understand what is going on. There are a number of other limitations that are worth highlighting. Cost restrictions meant we were only able to study one sex of mice at a single age. So it’s possible these results would not replicate at older ages and in the opposite sex.</p>
<p>We also only gave the mice sugar as part of their diet, but <a href="https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/longterm-sucrosedrinking-causes-increased-body-weight-and-glucose-intolerance-in-normal-male-rats/7041112FF75AE2D7D1A63F67014B0F03">some studies</a> suggest that delivering it in drinking water has a bigger effect on fatness in rodents. Higher sugar levels than 30% by calories may also be an issue but we didn’t study them in this instance.</p>
<p>Overall our data suggests that if the responses of mice data do translate to humans, then if you are lean and want to avoid becoming fat, then the best strategy is to limit fat in your diet to less than 20% of overall calories. Sugar up to 30% of total calories in food may not be a major problem, but in liquid form it may be more of an issue. Protein levels appeared to make little difference.</p>
<p>But this advice applies only to people who are already lean and hoping to avoid putting on weight. Whether this is also the best strategy for someone who is already obese is not informed by our study. Fortunately, that is something that can be studied in human clinical trials.</p><img src="https://counter.theconversation.com/content/101629/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Speakman receives funding from the Chinese Academy of Sciences who funded the work described in this article.</span></em></p>If you want to remain lean, this study of mouse diets suggests your fat intake should make up just a fifth of your overall calorie intake.John Speakman, Chair in Zoology, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/980612018-06-15T03:08:09Z2018-06-15T03:08:09ZDoctors are drowning in a tsunami of liver disease and cancer<figure><img src="https://images.theconversation.com/files/223082/original/file-20180613-32342-ty2dm8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis B, hepatitis C and obesity all play a part in the rising incidence of liver cancer -- in Canada and globally.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Deaths from liver cancer in Canada have doubled over the past 25 years. And to make matters worse, there’s an epidemic of liver cancer on the horizon if action isn’t taken soon.</p>
<p>While less people are dying from most major cancers — such as breast cancer and lung cancer — liver cancer (hepatocellular carcinoma or HCC) is bucking the trend and heading in the wrong direction. </p>
<p>In 1993, <a href="http://www.cancer.ca/en/cancer-information/cancer-type/liver/statistics/?region=on">liver cancer rates in Canadian men</a> were five cases per 100,000 population. By 2017 this had risen to 9.9 cases. </p>
<p>For women, rates are much lower, but the trend is the same. In 1993, 1.6 Canadian women per 100,000 were diagnosed with liver cancer; by 2017 this had almost doubled. In hard numbers this means that last year 1,900 men in Canada were diagnosed with liver cancer and 580 women. A total of 950 men died from liver cancer and 270 women.</p>
<p>This is not unique to Canada; a <a href="http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx">similar pattern is seen in the United States, the United Kingdom, Australia and most other developed countries</a>.</p>
<p>At this week’s <a href="http://www.globalhepatitissummit2018.com/">Global Hepatitis Summit</a> in Toronto (June 14-17), I will be among a group of liver cancer experts exploring these trends. </p>
<h2>The role of hepatitis and obesity</h2>
<p>What are the reasons for this increase, and why are they being discussed at the Global Hepatitis Summit? It is because both <a href="https://www.liver.ca/patients-caregivers/liver-diseases/hepatitis-b/">hepatitis B</a> and <a href="https://www.liver.ca/patients-caregivers/liver-diseases/hepatitis-c/">hepatitis C</a> are serious liver infections that cause inflammation. </p>
<p>When left untreated, both infections can progress to liver scarring, cirrhosis, liver cancer and, ultimately, an early death.</p>
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<img alt="" src="https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">3D image of cirrhosis of the liver.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Today, there are an estimated 230,000 Canadians with hepatitis B and 250,000 with hepatitis C. Almost half of each group do not know they are infected, which hugely increases their risk of progression to serious liver disease and cancer. </p>
<p>An enormous effort will be needed from provincial and territorial governments —with federal government support — to find, diagnose and treat these missing patients and to link them to care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-all-canadian-infants-need-a-hepatitis-b-vaccination-98060">Why all Canadian infants need a hepatitis B vaccination</a>
</strong>
</em>
</p>
<hr>
<p>Also contributing to Canada’s liver cancer problem is the <a href="https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009620">obesity epidemic</a>: about two thirds of Canadian men and half of women are thought to be overweight or obese. </p>
<p>Some one in five Canadians have some degree of <a href="https://www.liver.ca/patients-caregivers/liver-diseases/fatty-liver-disease/">non-alcoholic fatty liver disease</a> (NAFLD), which causes inflammation and can progress to cirrhosis and liver cancer.</p>
<h2>A lack of liver cancer specialists</h2>
<p>Canada’s limited number of liver specialists (less than 100 nationwide) and a few oncologists dealt with around 5,000 cases of liver cancer during 2017. </p>
<p>However, the hepatitis B and C epidemics, combined with Canada’s continuously increasing obesity problem, threaten to drown liver cancer specialists with new cases in the coming decades — with numbers reaching tens of thousands annually over the next 20 years.</p>
<p>We are completely unprepared to deal with such an epidemic of liver cancer. Not only would we be submerged in the sheer number of cases, the financial considerations for provinces and territories and the federal government would be phenomenal. </p>
<p>And many of these liver cancers strike people in their 50s, when they are still of working age. So families are not only in danger of losing a loved one, but possibly the main breadwinner in their family unit.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">As obesity in Canada shows no signs of retreating, new treatments for fatty liver disease could play a part in helping to reduce future incidences of liver cancer.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Not only is Canada’s system of liver specialists being gradually overwhelmed, but there is also a shortage of new liver specialists interested in HCC being trained.</p>
<p>Graduating liver specialists (hepatologists) tend not to specialise in liver cancer. Nor is it a popular speciality in oncology. However, this area is a growing field and there are plenty of opportunities for young physicians to do both practice and research. </p>
<p>Provinces and territories must also take a fresh look at remuneration for liver specialists, who are generally not as well paid as those in other specialities such as gastroenterology.</p>
<p>It may be necessary to develop some special programs to address this issue and boost recruitment in order to deal with the tsunami of liver disease and cancer that Canada is facing.</p>
<h2>How to reverse the trend</h2>
<p>However, the news is not all bad. Even though Canada’s incidence and mortality rates for liver cancer have doubled over the last 25 years, the actual numbers are much better for Canada than other developed nations. With six new cases per 100,000 population per year, Canada’s liver cancer incidence is lower than <a href="https://www.aihw.gov.au/reports/cancer/acim-books/contents/acim-books">Australia</a> (7.4) the <a href="https://seer.cancer.gov/csr/1975_2015/results_merged/sect_14_liver_bile.pdf">U.S.</a> (9.2) and the <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/liver-cancer">U.K.</a> (9.6).</p>
<p>A similar pattern is seen with mortality: Canada’s death rate for liver cancer (three per 100,000 population) is less than half that of the U.S. and Australia (both 6.6) and the U.K. (8.7). </p>
<p>I believe this is due to our excellent record in finding cases of liver cancer very early, when they can still be successfully operated and treated. The U.S. obviously lacks universal health coverage and the U.K. has a high level of alcoholic liver disease contributing to the epidemic there.</p>
<p>To reverse the increasing trend in liver cancer in Canada and elsewhere, a combination of things will need to occur. First, more patients with hepatitis B and hepatitis C must be diagnosed and treated or cured. Second, new therapies within the next decade should also greatly improve care and prognosis for hepatitis B. </p>
<p>Finally, because obesity in Canada shows no signs of retreating, we will be dependent on new treatments in the pipeline for fatty liver disease. It is unclear at this point how many cases of cirrhosis and liver cancer this will prevent.</p><img src="https://counter.theconversation.com/content/98061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Morris Sherman sits on safety committees for Merck, Celsion, Sirtex and Adaptimmune, all of which have products currently under test for the treatment of hepatocellular carcinoma</span></em></p>To prevent the epidemic of liver cancer that looms on the horizon, we need to tackle hepatitis B, hepatitis C and obesity.Morris Sherman, Affiliate Scientist, Toronto General Hospital Research Institute (TGHRI) and Emeritus Professor, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/922512018-03-02T11:45:09Z2018-03-02T11:45:09ZWill holding the cheese and chocolate milk on Happy Meals make a difference?<figure><img src="https://images.theconversation.com/files/208136/original/file-20180227-36677-198i8iu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Happy Meal with chocolate milk and cheeseburger at a Brandon, Miss., McDonald's.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-McDonalds-Happy-Meal-Changes/25f6c7f7a8b2461287862d53008044b5/1/0">AP Photo/Rogello V. Solis</a></span></figcaption></figure><p>McDonald’s recently <a href="https://www.healthiergeneration.org/_asset/h4xjlv/McDonaldCommittment.pdf">announced a major commitment</a> to improve the nutrition quality of its kids’ meals. Globally, at least 50 percent of Happy Meal bundles, which include a main dish, side and drink, will meet nutrition limits on calories, saturated fat, added sugar and sodium set by McDonald’s. In the U.S., the restaurant will use strategies such as not listing cheeseburgers or chocolate milk on Happy Meal menus – but providing the items if customers ask – to meet this goal. </p>
<p>This commitment is a positive step, but reducing children’s consumption of nutritionally poor fast food will require much more.</p>
<p>I have spent 10 years studying fast-food kids’ meals marketing and nutrition. My research and that of others demonstrate an enormous challenge for parents to select healthy options when the environment inside fast-food restaurants makes the unhealthy options so much more appealing. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/2Ng_X4D4SSA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
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<h2>Fast food: Children are lovin’ it</h2>
<p>Improving the nutrition of fast-food kids’ meals is important to public health. Childhood obesity rates have skyrocketed over the past four decades, <a href="http://pediatrics.aappublications.org/content/early/2018/02/22/peds.2017-3459">with no improvement</a> in recent years. In the U.S., 58 percent of children ages 6 to 8 and 41 percent of preschoolers are overweight or obese. </p>
<p>Sugary drinks are a big problem, but so is fast food. Despite recent introductions of healthier items, <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_Summary.pdf">nearly all fast-food items,</a> including on kids’ meal menus, exceed recommendations for maximum calories, sugar, saturated fat and/or sodium in a meal for children. <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_Summary.pdf">Fewer than 3 percent of kids’ meal bundles</a> offered by top fast-food restaurants, including McDonald’s, meet the industry’s own standards – set by the National Restaurant Association – for healthy meals for kids. </p>
<p>Furthermore, on any day, <a href="http://www.bridgingthegapresearch.org/research/powell2012_ajpm/">one-third of children</a> consume fast food. And on days they eat fast food, <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/1389390">children consume 126 additional calories</a>, and more sugar, saturated fat and sodium. </p>
<p>Support for mandating healthier kids’ meals is growing, as local communities enact laws setting nutrition standards for kids’ meals. The <a href="http://baltimore.cbslocal.com/2018/02/26/baltimore-kids-drinks-bill/">Baltimore City Council</a> just approved legislation requiring healthy drinks as the default in kids’ meals, <a href="http://www.foodmarketing.org/wp-content/uploads/2017/04/NationalMovement.pdf">following the lead of other cities</a>, including Davis, California, and Lafayette, Colorado. </p>
<p><a href="https://www.healthiergeneration.org/mcdonalds_report/">Over the past five years,</a> McDonald’s has done more than most fast-food restaurants to voluntarily improve the nutritional quality of its kids’ meals. In 2013, it reduced the size of french fries in Happy Meals and added a healthier side, such as apple slices or yogurt. In 2014, the restaurant initiated a policy to remove sugary sodas from kids’ meal menus and only list healthier drinks, including milk, chocolate milk and 100 percent juice as options. </p>
<p>McDonald’s also has more at stake. The <a href="http://www.uconnruddcenter.org/files/Pdfs/FACTS-2017_Final.pdf">company spent US$33 million advertising</a> Happy Meals in 2016. Children aged 2 to 5 viewed, on average, 2.7 TV ads for Happy Meals each week, while 6- to 11-year-olds saw three ads. Notably, children saw more ads for McDonald’s Happy Meals than for any other food brand in 2016, and the company placed more than 10 times as many ads on children’s TV networks (e.g., Nickelodeon or Cartoon Network) than any other fast-food restaurant. </p>
<p>This marketing works. <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_2010.pdf">In a survey of parents,</a> 41 percent said their child asked to go to McDonald’s at least once a week, while 15 percent of parents of preschoolers reported that their child asked to go every day.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A 3-year-old girl appears to enjoy her Happy Meal. Kids like her often ask their parents to take them to McDonald’s.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/auckland-nov-12-2017little-girl-naomi-753590665?src=dZRCOTFWbf3FdAjONumXiQ-1-5">ChameleonsEye/Shutterstock.com</a></span>
</figcaption>
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<p>Persuading parents to say “yes” to their children’s requests is also part of McDonald’s marketing strategy. <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_2010.pdf">When advertising to parents,</a> trips to McDonald’s and Happy Meals become a way to make children and parents happy. Public relations campaigns announcing nutritious options in Happy Meals also support this strategy. In a recent survey that has not yet been published, my research group found that 80 percent of parents said they had purchased lunch or dinner for their children under age 12 from McDonald’s in the past week. And two-thirds said they would take their child to McDonald’s more often because of the restaurant’s healthier kids’ meal policies.</p>
<p>Yet despite positive attitudes about healthier Happy Meals, unhealthy sides and drinks with Happy Meals persist. In our 2016 survey, we asked parents who reported purchasing a Happy Meal for their child what drink they received; 42 percent answered that they received a soda. This proportion has not changed since 2010. In addition, 64 percent reported that they received french fries, while 31 percent did not receive a healthy side. (Happy Meals come with two sides.) Furthermore, 18 percent of parents purchased an item, such as dessert, plus the Happy Meal for their child, and 25 percent did not purchase a kids’ meal at all. Notably, parents were more likely to purchase Happy Meals and healthier drinks for preschoolers than for older children.</p>
<p><iframe id="j65zu" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/j65zu/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>The tantalizing smell of fries</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Nothing smells quite like french fries cooking in hot oil, and the aroma can be a powerful trigger.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/delicious-french-fries-taken-out-hot-320193203?src=B0SkemvOAeGjGUpPhuX9wg-1-30">Whiteaster/Shutterstock.com</a></span>
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<p>Parents decide whether their child gets apple slices and milk or french fries and soda with Happy Meals. But research on consumer choices shows that making the healthy choice in this situation is difficult, even for adults. Consider the environment inside a fast-food restaurant: the smell of french fries, the prominent soda fountain with soda brand logos, the images of ice cream and large burgers on posters and menu boards. These cues all trigger desire for these unhealthy but highly appetizing choices. </p>
<p>Studies by <a href="https://www.journals.uchicago.edu/doi/full/10.1086/684364">behavioral economists</a> also show that simply offering healthy options alongside unhealthy options is not enough to increase consumers’ selection of healthy option.</p>
<p>However, offering healthier drinks and sides by default – and only providing unhealthy options upon consumer request – significantly increases the likelihood that consumers will accept the healthy items. Disney theme parks use this approach with their kids’ meals. <a href="https://www.journals.uchicago.edu/doi/full/10.1086/684364">An evaluation of their policy</a> demonstrated high acceptance of healthier options. </p>
<p>Publicizing healthier Happy Meal options while also offering unhealthy options raises concerns about potential “health halo” effects. Research has shown that depicting <a href="https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/exposure-to-healthy-fast-food-meal-bundles-in-television-advertisements-promotes-liking-for-fast-food-but-not-healthier-choices-in-children/FB446383F6AD78401F8DAEE3ABBF499C">more nutritious kids’ meal items</a> in fast-food commercials does not increase children’s selection of healthier items, but it does increase their reported liking of fast food generally. Advertising for unhealthy food, such as cookies and fruit drinks, using nutrition messages increases <a href="http://onlinelibrary.wiley.com/doi/10.1111/ijpo.12257/full">children’s beliefs that these products are healthy</a>. <a href="https://foodpsychology.cornell.edu/sites/default/files/unmanaged_files/health_halos-JCR_2007.pdf">Studies with adults </a> have also shown increased calorie consumption and purchases of unhealthy fast-food sides resulting from health halo marketing messages. </p>
<p>Finally, <a href="http://www.uconnruddcenter.org/healthierkidsmeals">a recent evaluation</a> of McDonald’s healthier kids’ meal side and drink policies revealed inconsistent implementation at individual restaurants. In some cases, menu boards still showed french fries and sugary drinks as kids’ meal options, and counter personnel continued to suggest these items with kids’ meal orders. </p>
<p>McDonald’s new commitment to set nutrition standards for Happy Meal bundles is a positive first step. However, I believe the restaurant must do more to prove its commitment to children’s health and supporting parents. Healthy Happy Meals should be the most appealing choice for children, the most convenient choice for parents, and the only Happy Meal options available at their restaurants. McDonald’s could also, in my view, stop advertising directly to children as young as 2 years old so that parents can make the decision about if and when to introduce their children to McDonald’s.</p><img src="https://counter.theconversation.com/content/92251/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Harris has received grant funding from the Robert Wood Johnson Foundation and Healthy Eating Research to examine fast food marketing and nutrition of kids' meals. </span></em></p>McDonald’s recently announced it will make its Happy Meal, which accounts of about 15 percent of all sales, healthier. Will it make kids healthier? That’s unclear, but it could lower parents’ guilt.Jennifer Harris, Professor of Allied Health Sciences, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/904362018-02-12T04:30:34Z2018-02-12T04:30:34ZI’m not overweight, so why do I need to eat healthy foods?<figure><img src="https://images.theconversation.com/files/203927/original/file-20180130-170413-1xjdut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No, being thin doesn't mean you can live off junk food. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>We all have that one friend whose eating habits and body shape simply don’t add up. While enjoying the unhealthiest of meals and a sedentary lifestyle, somehow they effortlessly retain a slender figure.</p>
<p>At first glance we may assume these slim people are healthy, but it’s not always the case. So if you don’t have weight to worry about, what’s the impetus for avoiding sweet or salty temptations and eating good, nutritious foods instead?</p>
<h2>Healthy weight ≠ good health</h2>
<p><a href="https://www.heartfoundation.org.au/your-heart/know-your-risks/healthy-weight/bmi-calculator">Body mass index or BMI</a>, the tool most often used to determine “healthy weight ranges”, was designed primarily to track the weight of populations.</p>
<p>While it’s a simple and useful screening tool when looking at groups of people, it’s not a good marker of individual health. This is because BMI is a measure of our height and our weight, and the ratios of their combination. But weight alone doesn’t discriminate between a kilogram of fat versus a kilogram of muscle, nor does it account for body shape and fat distribution differences relating to, say, ethnicity or gender.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/viewpoints-can-you-be-healthy-at-any-weight-18539">Viewpoints: can you be healthy at any weight?</a>
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<p>Just as <a href="https://academic.oup.com/eurheartj/article/34/5/389/481217">not all obese individuals</a> have heart disease risk factors or unhealthy metabolisms (the conversion of food into energy), nor do <a href="https://academic.oup.com/jcem/article/89/6/2569/2870288">all lean people have healthy ones</a>. </p>
<p>There’s a well-documented subset of people known as <a href="http://diabetes.diabetesjournals.org/content/47/5/699">metabolically obese, normal weight individuals</a>. These people are not obese as determined by their height and weight, but may face metabolic dysfunction such as insulin resistance (which leads to a build-up of sugar in the blood) and, like their physically obese counterparts, are predisposed to type 2 diabetes, high levels of fats in the blood, heart disease and even some cancers. </p>
<h2>Food is health</h2>
<p>The most compelling reason to eat healthy foods is the correlation between good nutrition and well-being. Coupled with regular exercise, eating a diet rich in whole foods and grains, healthy oils and low in sugar and salt has been shown to convey a number of benefits. These include a <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0081877">longer life with less pain and suffering</a>, less risk of back pain or muscular problems, and even an increased libido.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-all-have-to-die-of-something-so-why-bother-being-healthy-83508">We all have to die of something, so why bother being healthy?</a>
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<p>Studies from around the world also show people with healthy diets are <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-10-149">less likely to experience depression</a>, while unhealthy diets may put individuals at an <a href="http://bjp.rcpsych.org/content/195/5/408?sid=17f751de-5dba-4526-9dc6-9d3fc057c7cc">increased risk of depression</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203928/original/file-20180130-170439-rft1jb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">People with nutritious diets are less likely to be depressed.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<p>Food has been identified as an important risk factor for <a href="https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-14-132">cognitive decline and dementia in older age</a>. </p>
<p>A healthy diet combined with physical activity can <a href="https://www.ncbi.nlm.nih.gov/pubmed/25963237">strengthen bones</a> and reduce body aches and pains. And these benefits are conferred irrespective of your baseline weight or age.</p>
<h2>Health risks aren’t always visible</h2>
<p>While it might be easy to take solace in a thinner weight, many of the serious health risks associated with poorer diet are often hidden from plain sight.</p>
<p>Excessive salt consumption can cause the kidneys to hold on to more water, resulting in an increase in blood pressure. High blood pressure strains the arteries that supply blood to our vital organs, including our heart and brain, and <a href="http://www.bloodpressureuk.org/microsites/salt/Home/Whysaltisbad/Saltseffects#TklJ">increases our risk</a> of stroke, dementia, heart attack and kidney disease.</p>
<p>Consumption of high amounts of sugar, especially from sugar-sweetened beverages, is associated with an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405421/">increased risk in fatty liver disease</a>, among many other health problems. This in turn significantly increases our risks of liver scarring, heart disease and stroke.</p>
<p>Recent research has also reconfirmed a <a href="http://www.wcrf.org/int/research-we-fund/continuous-update-project-findings-reports/colorectal-bowel-cancer">link between bowel cancer and red meat consumption</a>. Processed meats such as ham, bacon and salami appear to be especially problematic. </p>
<p>Not only can all of these occur without any visual cues, but they can also develop irrespective of our weight.</p>
<h2>Our kids’ health</h2>
<p>The importance of a good diet is not just limited to our own health. Children of parents with poor diets are significantly more likely to <a href="https://www.ncbi.nlm.nih.gov/pubmed/22089441">inherit similarly unhealthy eating habits</a>. </p>
<p>And it doesn’t stop there. Through a mechanism called <a href="https://theconversation.com/how-epigenetics-may-help-us-slow-down-the-ageing-clock-76878">epigenetics</a>, our health and our diet can result in alterations to the expression of our genes.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203931/original/file-20180130-170422-1oudmy5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">We pass our habits on to our kids. Make them good ones.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<p>Animal studies have shown <a href="https://theconversation.com/how-your-grandparents-life-could-have-changed-your-genes-19136">epigenetic changes resulting from poor diet</a> (and other stressors) can influence the healthiness of future generations. Many scientists now believe the same will prove true for humans too. </p>
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<p>
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Read more:
<a href="https://theconversation.com/childhood-obesity-are-parents-really-to-blame-8325">Childhood obesity: are parents really to blame? </a>
</strong>
</em>
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<h2>Saving lives and money</h2>
<p>Contrary to what many of us think, the latest evidence suggests <a href="https://theconversation.com/a-healthy-diet-is-cheaper-than-junk-food-but-a-good-diet-is-still-too-expensive-for-some-57873">eating a healthy diet is actually cheaper</a> than consuming the unhealthy foods that now dominate many Australian households. </p>
<p><a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-2996-y">Analysis</a> of both wealthier and poorer suburbs in Brisbane, for example, showed the average family of four spends 18% more on current diets than would be required if they could more closely adhere to healthy dietary recommendations.</p>
<p>This is not to say eating healthily is easy, accessible or even possible for everyone, but it might be <em>more</em> possible than we first think.</p>
<p>Not only would adopting a healthy diet be a beneficial investment for individuals and families, it might also go a long way to curbing the <a href="https://www.pwc.com.au/pdf/weighing-the-cost-of-obesity-final.pdf">major societal costs</a> of growing weight gain. The annual costs from obesity already add up to A$830 million in Australia alone.</p>
<p>The consequences of poor diet increasingly burden Australians and our healthcare system. While it’s easy to measure our health based on a reading of the bathroom scales, eating a diverse and nutritious diet will bring overwhelming benefits to everyone – regardless of our current weight.</p>
<hr>
<p><em>Thomas Goodwin contributed to the research and writing of this article.</em></p><img src="https://counter.theconversation.com/content/90436/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alessandro R Demaio is a full-time staff member of the World Health Organization in Geneva. This article represents the views of the authors alone and not those of any third party or organisation. </span></em></p>Most people assume the only reason to eat healthy foods is to stay slim. But being slim doesn’t mean you’re healthy, and doesn’t mean it’s OK to eat junk.Sandro Demaio, Australian Medical Doctor; Fellow in Global Health & NCDs, University of CopenhagenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/866012017-12-26T14:36:54Z2017-12-26T14:36:54ZOur fight with fat: Why is obesity getting worse?<figure><img src="https://images.theconversation.com/files/199353/original/file-20171215-25993-51v4qo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman exercising. Thousands of people will be doing the same this week in an effort to lose weight, a perennial resolution.</span> <span class="attribution"><a class="source" href="http://www.uconnruddcenter.org/resources/upload/images/press/ImageGallery/JPEG/122.jpg">UConn Rudd Center for Food Policy and Obesity</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Gyms across the country will be packed in the new year with people sticking, however briefly, to their New Year’s resolution to lose weight. Most of them do not know that the cards are stacked against them and that weight loss is much more complicated than working out and not eating dessert.</p>
<p>Years into the obesity epidemic, millions of Americans have tried to lose weight, and millions of them have failed to do so long term. </p>
<p>It’s so serious now that <a href="https://www.cdc.gov/nchs/fastats/body-measurements.htm">close to 40 percent of Americans are obese</a>. The average woman in the <a href="https://www.washingtonpost.com/news/wonk/wp/2015/06/12/look-at-how-much-weight-weve-gained-since-the-1960s/?utm_term=.e9755d26095c">United States today weighs about 168 pounds</a>, or roughly the same as an average man in 1960.</p>
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<img alt="" src="https://images.theconversation.com/files/199279/original/file-20171214-27558-89ohe0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/199279/original/file-20171214-27558-89ohe0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199279/original/file-20171214-27558-89ohe0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199279/original/file-20171214-27558-89ohe0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199279/original/file-20171214-27558-89ohe0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199279/original/file-20171214-27558-89ohe0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199279/original/file-20171214-27558-89ohe0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">President John F Kennedy and First Lady Jacqueline Kennedy Arrive at Inaugural Ball on Jan. 20, 1961.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:President_John_F._Kennedy_and_First_Lady_Jacqueline_Kennedy_Arrive_at_Inaugural_Ball.jpg">Abbie Rowe/White House Photographs John F. Kennedy Library</a></span>
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<p>Not that guys’ waists haven’t ballooned, too. Men have gained on <a href="https://www.cdc.gov/nchs/fastats/body-measurements.htm">average nearly 30 pounds</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/15544194">since John F. Kennedy’s inauguration</a> in 1961.</p>
<p>From 1976 to 1980, <a href="https://www.cdc.gov/nchs/data/hus/hus02cht.pdf">just under 1 in 7 American adults, or 15.1 percent, were obese</a>. </p>
<p>Now, despite people’s concerted efforts, obesity is at its highest level ever, with about <a href="https://www.cdc.gov/nchs/products/databriefs/db288.htm">40 percent of U.S. adults and 18.5 percent of children</a>, considered obese. This is itself an increase of about 30 percent, just since 2000 when roughly <a href="https://www.cdc.gov/nchs/data/databriefs/db219.pdf">30 percent of American adults were obese</a>. </p>
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<p>The U.S., and increasingly the world, is in the grip of a real epidemic – the seriousness of which is lost in our obsession with diets. One study estimated an additional <a href="https://www.ncbi.nlm.nih.gov/pubmed/21872750">65 million obese Americans</a> by 2030, and increased medical costs between US$48 billion to $66 billion a year.</p>
<p>As an endocrinologist, I study obesity and treat people with obesity every day. Here are some things I see, and some things I see that could begin to address the problem.</p>
<h2>Costs across the board</h2>
<p>Obesity, defined as a body mass index of at least 30, is about far more than vanity. It impairs quality of life and exacerbates health risks involving many medical conditions in children and adults. Obese people incur <a href="http://journals.sagepub.com/doi/pdf/10.4278/ajhp.120905-QUAN-428">more medical costs, live shorter lives and miss more work </a>than their thinner counterparts. </p>
<p>The health risks include gallbladder disease, osteoarthritis, gout, sleep apnea, polycystic ovarian syndrome, cardiovascular disease and a broad spectrum of cancers, such as pancreatic, liver, breast and kidney cancers.</p>
<p>Obesity also leads to metabolic conditions such as hypertension, Type 2 diabetes and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387293/">nonalcoholic fatty liver disease</a>, which has long been overlooked as a life-threatening consequence of poor eating habits. This disease was rare until 1980.</p>
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<p>The medical costs associated with obesity are enormous – and growing. One study estimated the annual medical care costs of obesity in the United States in 2008 dollars at <a href="https://www.ncbi.nlm.nih.gov/pubmed/22094013">$209.7 billion</a>. To put that in perspective, consider that that’s almost half the amount of the estimated <a href="https://www.thebalance.com/current-u-s-federal-budget-deficit-3305783">federal deficit</a> for fiscal year 2018. About 1 in 5 health care dollars are spent to treat obesity-related illness.</p>
<p>The costs are also high to individuals. Compared with normal-weight individuals, <a href="https://www.ncbi.nlm.nih.gov/pubmed/19635784">obese patients spend 46 percent more on inpatient costs</a>, 27 percent more on outpatient care and 80 percent more on prescription drugs. </p>
<h2>A sickness of American society?</h2>
<p>Obesity’s roots are in American culture, from the stress of the workplace to the onslaught of food advertising, to our tradition of holiday overindulgence. The taste buds of our youth are raised on junk food and sugary treats, habits that follow children into adulthood.</p>
<p>American society is structured around productivity and long work hours. This leads to unbalanced lives, unhealthy lifestyles and unhappy people. Stress and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542973/">lack of sleep can contribute to obesity</a>.</p>
<p>For many families struggling between paychecks, the foods that make the most financial sense are the processed, packaged, fatty choices serving up the most calories.</p>
<p>Meal portions at restaurants have sharply increased in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447051/">recent decades</a> as well. The percentage of our food budget spent on out-of-home dining climbed to <a href="https://www.ncbi.nlm.nih.gov/pubmed/18309297">46 percent in 2006, up 20 percent since 1970</a>. The temptation of unhealthy food greets us on every street corner, in our breakrooms and at our favorite supermarkets. We Americans are eating too much yet we can’t seem to reverse it. Why? </p>
<p>Some blame the epidemic on the advent of the microwave and the growth of fast food options since the 1970s. Also, our <a href="https://www.ncbi.nlm.nih.gov/pubmed/21525258">food choices</a> have changed, with food industries mass market fattening foods to children. </p>
<p>Americans are more sedentary <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4524881/">than we were decades ago</a>. Our lives are tied to computer screens, big and small, in both our jobs and our homes. Our children are now raised on hand-held devices that serve as surrogate playmates in a world where “playing ball” is more likely to be done via internet connection than the actual playing field.</p>
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<h2>Blaming the victim?</h2>
<p>Many of us invoke “willpower” in our fight against fat, blaming and shaming ourselves and others for not losing weight. While many people have lost weight in the short term, they struggle to break the cycle of food addiction and unhealthy food choices. Yet scientists have learned that this is not about a shortage of willpower but about an abundance of physiological factors that make the body hold onto fat.</p>
<p>Patients standing alone with just their willpower and the latest diet to guide them invariably face great difficulty against a complex disease like obesity. <a href="https://www.nature.com/articles/ijo2017287.pdf?origin=ppub">Going it alone may be a barrier</a> to appropriate treatment options, such as behavioral modification counseling, anti-obesity drugs and <a href="https://asmbs.org/patients/bariatric-surgery-procedures">bariatric surgery</a>.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/21247515">Weight regain</a> is common, as structured diets are hard to follow over the long haul. The body resists long-term calorie restriction by sending signals to our brains that trigger a craving for food, making diets prone to failure.</p>
<p>Because of the frustration of failure, many people are simply giving up on slimming down, making obesity an accepted social norm. One study has shown a declining percentage of <a href="https://www.ncbi.nlm.nih.gov/pubmed/28267846">men and women trying to lose weight since 1988</a>, perhaps due to a lack of motivation after failed efforts.</p>
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<h2>Fixes</h2>
<p>Even so, we’re making some progress battling this epidemic. Studies show obesity appears to be plateauing in Caucasians, <a href="https://www.cdc.gov/nchs/products/databriefs/db288.htm">though not in ethnic minorities</a>. But the numbers are already so high, “plateauing” seems more euphemistic than hopeful.</p>
<p>Scientific research has shown that the fixes are not about dieting, however. The solutions are complex and will take time and resources. Patients need more support than they are receiving.</p>
<p>Clearly, our country needs a greater systematic effort in the realms of public health, the government and industry. For starters, our political leaders should make combating obesity a top priority. Our nation faces many challenges, and the obesity epidemic has fallen to the bottom of a long list of health care problems. </p>
<p>Schools could play a role. Students should receive additional education in schools on good eating habits and how to control stress. </p>
<p>As someone who sees this devastating illness every day, I believe that health care insurers need to be more willing to pay upfront to manage obesity before it becomes a much more expensive disease to treat. Given the structure of health insurance now, physicians simply cannot spend the time needed with patients to properly communicate and educate.</p>
<p>Studies have shown that <a href="https://www.ncbi.nlm.nih.gov/pubmed/28063213">many insurers exclude treatments</a> for obesity.</p>
<p>Each of us needs to become an advocate for a healthier way of life. Adults can start by teaching our youngsters about good dietary habits, by insisting on a better balance in the workplace, and by demanding more accountability from the food and health industries, and our government. Doing that will help ensure a brighter and healthier future for our children.</p><img src="https://counter.theconversation.com/content/86601/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth Cusi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite the efforts of millions of Americans, obesity rates continue to climb. Why is it so hard to lose weight and to keep it off? It’s a lot more complicated than just pushing back the plate.Kenneth Cusi, Professor of Endocrinology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/747262017-03-27T13:03:48Z2017-03-27T13:03:48ZSubsidies for healthy foods are a price worth paying to tackle obesity<p>The heavy costs of an increasingly obese population are well known. Physical problems associated with a <a href="http://www.who.int/topics/obesity/en/">Body Mass Index over 30</a> include type 2 diabetes, strokes, and certain types of cancer. Psychological issues include depression and low self esteem. But there is also a significant financial price to pay.</p>
<p><a href="https://www.noo.org.uk/NOO_about_obesity/adult_obesity/UK_prevalence_and_trends">Data from 2015</a> shows that 57% of the population in the UK is overweight. Even more worrisome than this number is the trend behind it. The percentage of overweight people has more than doubled since 1980 and is <a href="https://www.theguardian.com/society/2015/may/05/obesity-crisis-projections-uk-2030-men-women">expected</a> to hit 69% by 2030 according to the WHO.</p>
<p>It is <a href="http://opus.bath.ac.uk/49768/">estimated</a> that every overweight patient costs the NHS about £1,800 more over their lifetime compared to a non-overweight person. The portion of the NHS budget spent on caring for overweight and obese people has been <a href="https://www.ncbi.nlm.nih.gov/pubmed/21562029">calculated</a> to be about 16% a year - around £6 billion.</p>
<p>So what do we do about it? Governments across the world are trying to tackle this epidemic in a variety of ways. Some of these are financially driven, with taxes on unhealthy products such as the “<a href="https://www.gov.uk/government/news/soft-drinks-industry-levy-12-things-you-should-know">sugar tax</a>” on soft drinks, and subsidies given to <a href="https://www.gov.uk/apply-free-school-meals">healthier meals</a>.</p>
<p>There are also <a href="https://www.nice.org.uk/Media/Default/Get-involved/Citizens-Council/Reports/CCReport14Incentives.pdf">discussions</a> about an alternative type of policy: cash incentives. This means paying people to lose weight. In such a scheme, overweight participants would be assessed and given a weight-loss target timeline matched with a financial incentive if the timed target is met. </p>
<p>If this works the aim is that they would have also developed a habit of healthy eating that will continue once the payments and regular check-ups ended.</p>
<p>In <a href="http://opus.bath.ac.uk/49768/">our research</a> we developed a mathematical model that accurately mimics observed how people behave with respect to food consumption, both healthy and unhealthy. It also predicts how people respond to changes in their circumstances and the environment. </p>
<p>We used it to predict the reaction of individuals to three different events: a tax on unhealthy food, a subsidy for healthy foods, and cash incentives in return for eating healthy.</p>
<p>The mathematical model allowed us to predict whether or not, and to what degree, each of these three policies would affect individual behaviour. We wanted to find out whether each of these polices would actually reduce the number of overweight people and, if so, by how much. Importantly, we also wanted to know how much each of these policies would cost.</p>
<p>Mathematical models can be superior to other information gathering methods such as surveys, because they use data from observed behaviour, rather than relying on self-reported – and often wrong – answers. </p>
<p>In <a href="http://opus.bath.ac.uk/49768/">our results</a> we found that subsidies (a 10% discount) on healthy foods (fresh fruit and vegetables, fish and lean meats) was the most effective policy, reducing the percentage of overweight people from 57% to about 13%. But at a cost of about £991m. However, when accounting for the saving to the NHS of not having to treat as many overweight related conditions, the net benefit of the policy equated to £6 billion in the long run.</p>
<h2>Taxing the rich (foods)</h2>
<p>Cash incentives were the second most useful policy, reducing the percentage of overweight people to about 21%. However, this scheme had by far the highest running costs. We estimated that the amount of cash that needed to be given was about £10 per person per day. The net effect of the policy when counting the savings to the NHS was actually negative – it would cost taxpayers about £138m.</p>
<p>Taxes (a 10% tax on all unhealthy food) were the least effective way of reducing the percentage of overweight people – to about 34% of the population. But even though this was the least effective policy, it was the only one which would generate any revenue. The British government could expect to make around £86m from this idea.</p>
<p>So subsidies outperformed the other two policies in both effectiveness at reducing the number of overweight people, and generating a benefit to the government. </p>
<p>Subsidies are also relatively straightforward to implement. But they suffer one major modern setback – delayed gratification. Society would pay an expensive price up front, and only benefit later on, when the number of overweight people has been reduced. But any forward looking government should take a serious look at subsidising healthy foods as a worthwhile investment. It could be the best way of securing a healthier future.</p><img src="https://counter.theconversation.com/content/74726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Javier Rivas does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Weighing up the cost of improving people’s diets.Javier Rivas, Senior Lecturer in Economics, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/631082016-09-21T20:27:20Z2016-09-21T20:27:20ZExplainer: what is fat studies?<figure><img src="https://images.theconversation.com/files/133721/original/image-20160811-9203-yx81uk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fat studies is challenging the way that fat human bodies are portrayed and treated.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Fat studies is an academic area of research and scholarship. It’s not about fat as a dietary substance, but rather about <a href="https://www.amazon.com/Fat-Shortcuts-Deborah-Lupton/dp/041552444X">fat human bodies</a>. Fat studies is <a href="http://www.tandfonline.com/toc/ufts20/current">an interdisciplinary field</a>, combining perspectives and research methods from the humanities and social sciences. It builds on the tradition of gender studies and queer studies, focusing attention on the social, cultural, historical and political aspects of the ways in which fatness as a phenomenon and fat people are portrayed and treated. </p>
<p>In the late 20th century, concern began to be expressed in medical and public health circles about an apparent “obesity epidemic” in western countries, including Australia. The media reported warnings from doctors and health promoters that an increasing proportion of people in these countries could be categorised as “overweight” or “obese” using the body mass index (BMI) measurement. This was viewed as a public health crisis, as it was calculated that people in these categories would suffer from higher rates of illness and disease, and die prematurely. </p>
<p><a href="https://www.amazon.com/Bodies-Health-Media-Jayne-Raisborough/dp/1137288868">News reports</a> referred to the “ticking time bomb” of obesity, and the subsequent need to wage “a war on fat”. These reports and other media portrayals of fat people, like <a href="http://www.imdb.com/title/tt0818297/">The Biggest Loser</a> reality TV series, frequently portrayed them as not only unhealthy, but also ignorant, lazy, gluttonous, ugly and a drain on health budgets. </p>
<p>The “<a href="http://charlottecooper.net/publishing/digital/headless-fatties-01-07/">headless fatty</a>” image was commonly used in news coverage, showing the body of a fat person with the head cropped off. While news producers may argue that the person’s head was removed to preserve their anonymity, activists have argued that this convention works to further dehumanise fat people. </p>
<h2>Fat acceptance</h2>
<p>Public health campaigns used by governments to encourage people to lose weight have frequently employed messages and images that portray body fat, and fat people themselves, as <a href="https://theconversation.com/what-does-the-yuck-factor-achieve-in-anti-obesity-campaigns-8451">disgusting</a> and <a href="http://www.huffingtonpost.com/leah-berkenwald/shame-and-blame-facing-th_1_b_1223659.html">shameful</a>. It has often seemed that rather than “waging a war on fat”, such campaigns are directly attacking fat people.</p>
<p>In response to these portrayals and the increasing stigmatisation of, <a href="https://theconversation.com/what-does-fat-discrimination-look-like-10247">and discrimination against</a>, people who were deemed to be too large, activists have called for <a href="http://www.sbs.com.au/news/thefeed/story/fat-pride-growing-movement-people-looking-fat-acceptance">fat acceptance</a> and <a href="https://en.wikipedia.org/wiki/Body_Positive_Movement">body positive</a> initiatives.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133725/original/image-20160811-18014-4p7ynq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Some fat studies academics combine activism with their research to empower those who do not fit the thin mould.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>These challenge simplistic assumptions that thin people are healthy, virtuous and responsible citizens, whereas fat people are diseased, morally culpable and unable to control their appetites. Activists have taken up the term “fat”, instead of medicalised terms like “overweight” and “obese”, because of their connotations of unhealthiness and disease. </p>
<p>The use of the term “fat studies” to describe an academic field is a reflection of this preference. There are strong intersections between fat activism as a political movement, and the academic field of fat studies. Some university researchers contributing to fat studies scholarship combine activism with their research. </p>
<p>Another term that is sometimes used by university researchers is “<a href="http://link.springer.com/chapter/10.1057%2F9780230304239_9">critical weight studies</a>”. This incorporates critical research into all sizes of human bodies, including the extreme thinness of those people living with restricted eating disorders such as anorexia, or the highly muscular bodies of athletes.</p>
<h2>Contradictions in the ‘war on fat’</h2>
<p>Fat studies scholars are interested in a number of key questions. How is fatness defined and portrayed, and how has that changed over time? How does it differ between geographical locations, between social groups and cultures?</p>
<p>What is it like to be a fat person in a fat-shaming world? What kinds of social and economic discrimination do fat people experience, and how can it be alleviated? What are the political and ideological underpinnings of the “obesity crisis” and the “war on fat”? </p>
<p>Some researchers have engaged in detailed analysis of the medical and epidemiological literature on obesity, drawing attention to discrepancies and contradictions in definitions of obesity, and calculations about its health effects. </p>
<p>For example, in his book <a href="https://www.goodreads.com/book/show/10569953-the-end-of-the-obesity-epidemic">The End of the Obesity Epidemic</a> (2010), University of Queensland researcher Michael Gard argues that the “crisis” has not happened according to dire predictions, and that life expectancies are increasing in the Western world. Others have called attention to the “<a href="https://www.goodreads.com/book/show/18114259-the-obesity-paradox">obesity paradox</a>”: fat people with certain chronic diseases are sometimes healthier than thin people with the same conditions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133740/original/image-20160811-28149-ex6r8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The media’s stigmatisation of fatness has lead to negative eating habits in young people.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<h2>The future of fat studies</h2>
<p>The fervid news coverage of the “obesity epidemic” has died down somewhat over the past few years. <a href="http://www.tandfonline.com/doi/abs/10.1080/02640414.2015.1093650">Experts in medicine and public health</a> are recognising the complexity of body weight and its association with illness and premature mortality. </p>
<p>However, discrimination against fat people continues. Fat children and young people <a href="http://edition.cnn.com/2010/HEALTH/05/03/obesity.bullying/">are particular targets</a>, facing bullying, shaming and social exclusion. Young people who are not medically identified as fat are also beginning to hold <a href="http://www.tandfonline.com/doi/abs/10.1080/01596306.2012.696500">disturbingly negative views of their bodies</a>. The incidence of eating disorders, disordered eating and body image problems <a href="http://www.nedc.com.au/eating-disorders-in-australia">has significantly risen in Australia</a> over the past three decades. </p>
<p>Future research in fat studies is needed to identify, critique and challenge the ways in which fat people are portrayed and treated, highlighting the unintended consequences of anti-obesity, school-based education and public health campaigns.</p><img src="https://counter.theconversation.com/content/63108/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Lupton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>What is it like to be a fat person in a fat-shaming world? What are the political and ideological underpinnings of the ‘obesity crisis’? Fat studies is an emerging academic field that asks such questions.Deborah Lupton, Centenary Research Professor, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/621222016-07-07T18:05:40Z2016-07-07T18:05:40ZNew study may help explain how type 2 diabetes and obesity are inherited<figure><img src="https://images.theconversation.com/files/129584/original/image-20160706-12736-1k0sal.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=6eUwKu6tlBhJ5n58ij3Asg&searchterm=DNA&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=328604552">Sergey Nivens/Shutterstock.com</a></span></figcaption></figure><p>The most exciting recent development in human genetics research has been the ability to perform large-scale systematic studies of genetic variation in thousands of people. These genome-wide association studies (GWASs) have revolutionised our understanding of many different complex diseases. </p>
<p>But despite these advances, we are still only able to explain a small fraction of the heritability of many health conditions. In a study that my lab has <a href="http://science.sciencemag.org/content/early/2016/07/06/science.aaf7040">just published in Science</a>, we show that a person’s attributes could be strongly influenced by genetic variation in an unexpected part of the genome that has been overlooked in previous studies.</p>
<p>The environmental factors that play a role alongside genetics in determining a person’s attributes are also present in the womb. When offspring are in the womb, what their mothers experience environmentally (including diet, stress, smoking) has the potential to influence an offspring’s attributes when they become adults. This “developmental programming” is understood to be a large contributor to the obesity epidemic seen today.</p>
<p>A key player in this process is epigenetics. Epigenetics are modifications that sit outside the genome and determine which bits of DNA to make more active or inactive. One such modification involves tagging DNA with compounds called methyl groups. Methyl groups determine whether genes are expressed (switched on) or not. Liver cells and kidney cells are genetically identical apart from their epigenetic marks. It has been proposed that in response to a poor environment in the womb, an offspring’s epigenetic profile will change.</p>
<p>In our study, we compared the offspring of pregnant mice when given a low-protein diet (8% protein) and a normal diet (20% protein). After they were weaned, all offspring were given a normal diet. We then looked at the difference in the offspring’s DNA methylation, comparing those mice whose mothers had a low-protein diet to those whose mothers had a normal diet.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/129582/original/image-20160706-12736-yhc5nj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/129582/original/image-20160706-12736-yhc5nj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/129582/original/image-20160706-12736-yhc5nj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/129582/original/image-20160706-12736-yhc5nj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/129582/original/image-20160706-12736-yhc5nj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/129582/original/image-20160706-12736-yhc5nj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/129582/original/image-20160706-12736-yhc5nj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some of the pregnant mice were fed a low-protein diet.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=gzEnLoge2vho_LZjCCTozg&searchterm=mouse%20model&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=177481676">Marques/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Looking in the wrong place</h2>
<p>Initially, we found nothing, so that was a big surprise, but then we looked at the ribosomal DNA (rDNA) data and found huge epigenetic differences. Ribosomal DNA is the genetic material that forms ribosomes – the protein-building machines within the cell.</p>
<p>When cells are stressed – for example when nutrient levels are low – they alter protein production as a survival strategy. In the mice whose mothers were fed a low-protein diet, we found that they had methylated rDNA. This slowed the expression of their rDNA and resulted in smaller offspring – as much as 25% lighter.</p>
<p>These epigenetic effects occur in a critical developmental window while the offspring is in the womb but is a permanent effect that remains into adulthood. So a mother’s low-protein diet while pregnant is likely to have more severe consequence on the offspring’s epigenetic state and weight than an offspring’s own diet after it has been weaned.</p>
<p>Looking beyond the epigenetic markers, when we looked at the basic genetic sequence of the rDNA, we found an even bigger surprise. Even though all the mice in the study were bred to be genetically identical, we found that the rDNA between the individual mice was not genetically identical – and that, even within an individual mouse, different copies of rDNA were genetically distinct. So there is huge variation in rDNA which is also playing a big role in determining the attributes of offspring.</p>
<p>In any given genome, there are many copies of rDNA, and we found that not all copies of the rDNA were responding the same way epigenetically. Only one type of rDNA – the “A-variant” – appeared to undergo methylation and affect weight. This means that the epigenetic response of a given mouse is determined by the genetic variation of their rDNA – those who have more A-variant rDNA end up being smaller. </p>
<p>Heritability (how much the risk of a disease is explained by genetic factors) of type 2 diabetes has been estimated to be between 25% and 80% in different studies. However, only about 20% of the heritability of type 2 diabetes has been explained by genome studies of people with the disease. </p>
<p>The fact that genetic variation of ribosomal DNA seems to have such a strong influence suggests that GWASs in humans could be missing a key part of the puzzle, as so far they have only looked at the single copy part of people’s genomes. Genetic and epigenetic analysis of rDNA in humans could yield very important insights into a variety of human diseases.</p><img src="https://counter.theconversation.com/content/62122/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span><a href="mailto:v.rakyan@qmul.ac.uk">v.rakyan@qmul.ac.uk</a> receives funding from BBSRC.</span></em></p>Scientists find the missing link in epigenetics that could explain the mystery of inherited disease.Vardhman Rakyan, Professor of Epigenetics, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/601302016-06-10T10:10:28Z2016-06-10T10:10:28ZIn obesity fight, UK’s heavy-handed soda tax beats US’ watered-down warning<p>Soda drinks are under attack in the US and the UK, but the weapons employed on the two fronts are different. </p>
<p>In the US, San Francisco <a href="http://time.com/3915485/san-francisco-soda-warning-label/">enacted a law</a> last year that requires advertisements for soda and sweetened drinks to alert consumers: “WARNING: drinking beverages with added sugar(s) contributes to obesity, diabetes and tooth decay.” The law <a href="http://www.usatoday.com/story/money/2016/05/18/soda-makers-must-issue-ad-warning-san-francisco/84532214/">was set to take effect</a> in July but was <a href="http://www.wsj.com/articles/san-franciscos-sugary-drinks-warnings-delayed-pending-appeal-1465404121">just put on hold</a> by a federal judge, pending appeal. </p>
<p>On the other side of the Atlantic, UK Prime Minister David Cameron announced the introduction of a “<a href="http://www.theguardian.com/politics/2016/mar/19/sugar-tax-all-fizz-or-weighty-blow-obesity">soda tax</a>.” Starting in April 2018, a tax of 24 pence (36 cents) and 18 pence will be levied on each liter of high-sugar or low-sugar fizzy drinks, respectively. The tax is not only intended to cut soda consumption, but is projected to raise <a href="http://www.theguardian.com/news/datablog/2016/mar/16/will-a-sugar-tax-actually-work-budget">£520m</a> (US$757m) in revenue in the first year alone. </p>
<p>Which of these approaches is more likely to accomplish its intended goal, a reduction in obesity? </p>
<p>Evidence from behavioral, economic and health research suggests that the heavy-handed approach is not only more likely to succeed, but in fact does not go far enough. </p>
<h2>Two approaches to policy</h2>
<p>The difference between the above US and UK approaches to the obesity epidemic raging in both countries reflects more general differences in policy: the UK tends to have a heavy hand, while the US adopts a lighter touch.</p>
<p>For example, governments in both countries have grown alarmed with low savings for retirement – resulting in large part from the transition from plans with defined benefits to plans with defined contributions (a euphemism for “save for your own retirement”). As a result, both countries have enacted legislation aimed at getting more employees to save by automatically enrolling them in a retirement savings plan.</p>
<p>The <a href="https://www.gov.uk/workplace-pensions-employers">UK approach</a>, however, is much more aggressive, mandating – rather than encouraging, as in the U.S. – automatic enrolment. Employers must pay a contribution alongside their employees. Right now, the minimum contribution is 2% of salary with both paying half, but from 2019 that will climb to 8%, with 3% paid by the employer. The government pitches in with tax relief on contributions. Early withdrawals are prohibited, and there is already <a href="http://citywire.co.uk/new-model-adviser/news/webb-new-govt-must-prioritise-pension-auto-escalation/a797743">increasing pressure</a> to ramp up contribution levels still further. </p>
<p>Differences between the UK and US approaches to health care are even more striking, but too <a href="http://www.health.org.uk/sites/default/files/HowDoesTheNHSCompareWithHealthSystemsInOtherCountries.pdf">well-known</a> to warrant describing.</p>
<p>On the other hand, Philadelphia may soon be following the UK’s more heavy-handed approach. The <a href="http://www.nytimes.com/2016/06/09/upshot/novel-strategy-puts-big-soda-tax-within-philadelphias-reach.html?_r=0">city council plans to hold a final vote</a> on June 16 on whether to pass a 1.5 cent per ounce tax on sweetened drinks, which would be the first soda tax in the US.</p>
<h2>Lessons from the war on tobacco</h2>
<p>The war on tobacco has taught us some <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)66521-X/fulltext">valuable lessons</a> about which approaches have been most successful at <a href="http://www.who.int/gho/tobacco/policies/en/">curtailing smoking</a>, from warnings and taxes to outright bans. </p>
<p>For example, there is <a href="http://www.who.int/tobacco/global_report/2015/en/">mixed evidence</a> that <a href="http://www.cochrane.org/CD011244/TOBACCO_tobacco-packaging-design-reducing-tobacco-use">warning labels alone</a> reduce cigarette consumption. </p>
<p>On the other hand, there is much <a href="http://www.bmj.com/content/321/7257/358.short">stronger evidence</a> that the <a href="http://tobaccocontrol.bmj.com/content/8/2/196.full">combination</a> of warnings, <a href="http://tobaccocontrol.bmj.com/content/21/2/172.full">higher taxes</a> and <a href="http://www.cochrane.org/CD005992/TOBACCO_does-legislation-ban-smoking-reduce-exposure-secondhand-smoke-and-smoking-behaviour">bans</a> on smoking in <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60521-9/fulltext?rss%3Dyes">public environments</a> together have had a substantial impact.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=774&fit=crop&dpr=1 600w, https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=774&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=774&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=973&fit=crop&dpr=1 754w, https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=973&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/125981/original/image-20160609-7096-l6csbr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=973&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A company put up posters like these in its cafeterias to steer employees away from sugary sodas and toward zero-calorie beverages. It didn’t work.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Labels alone don’t work</h2>
<p>So is there any scientific support for San Francisco’s soda warning? In general, there is very little evidence that <a href="http://content.healthaffairs.org/content/28/6/w1110.full">calorie labels</a> or warnings about added sugars will have much of an effect. </p>
<p>Most studies have shown that simply informing people about the caloric content of food and drink <a href="http://www.cmu.edu/dietrich/sds/docs/loewenstein/EatingByTheNumbers.pdf">has little impact</a> on how much they consume. Nor have more creative approaches, such as telling consumers how many minutes they would have to run on a <a href="http://www.cmu.edu/dietrich/sds/docs/loewenstein/ImpactPriceDiscounts.pdf">treadmill</a> to burn off the calories from a can of soda. </p>
<p>The best prospect for labeling to have an effect is through a kind of <a href="http://www.annualreviews.org/eprint/5tASysE9n8dAIecvtVkK/full/10.1146/annurev-economics-080213-041341">“Tell-tale Heart” effect</a>, whereby food retailers and producers change their offerings or improve the nutritional content of existing selections in response to feared consumer reactions, even if such fears are only imaginary, like in the eponymous Edgar Allan Poe story. </p>
<h2>How about a soda tax?</h2>
<p>Realistically, there isn’t a lot of evidence that a soda tax will have much of an impact either, certainly on obesity but even on <a href="http://www.ifs.org.uk/uploads/budgets/budget2016/budget2016_ks.pdf">soda consumption</a> itself. </p>
<p>More worryingly, a soda tax is <a href="http://www.ifs.org.uk/bns/bn49.pdf">regressive</a> because low-income families tend to consume more soda than more affluent families. The new policy adds yet one more tax on activities, such as smoking, drinking and playing the lottery, that lower-income individuals are more likely to engage in. </p>
<p>If the tax had a disproportionately greater impact on how much soda and calories lower-income people consume, then the overall effect would be less regressive. But existing research provides little grounds for hope that a soda <a href="http://www.ifs.org.uk/publications/8203">tax</a>, by itself, will do so.</p>
<h2>Tip of iceberg</h2>
<p>Furthermore, why target soda for a tax when low pop prices are just the tip of the iceberg of the mispricing of unhealthy foods? In our view, the main problem with the soda tax is that it doesn’t go far enough. </p>
<p>All forms of “<a href="https://global.oup.com/academic/product/fat-economics-9780199213863?cc=gb&lang=en&">junk food</a>,” not just soda, have become progressively cheaper than healthy alternatives in recent decades. According to <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev.publhealth.26.021304.144628">economists</a>, this is largely responsible for the <a href="http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/obesity-and-the-economics-of-prevention_9789264084865-en#page1">obesity epidemic</a>. </p>
<p>Moreover, the attraction of nutritionally poor food arises not only from its low, and dropping, monetary cost, but also by time costs. Personal time constraints further enhance the appeal of prepared and takeaway foods. </p>
<p>What is more, “supersizing” practices, such as pricing large and high-calorie meals in ways that make them seem like deals, are common in the food and retail industries, and likely to be especially attractive to families who are financially strapped. The <a href="http://www.voxeu.org/article/changing-economic-factors-and-rise-obesity">ubiquitous availability</a> of junk food creates a constant temptation for consumers, particularly for those from <a href="http://www.voxeu.org/article/obesity-s-rise-let-s-have-courage-tax-junk-food">low-income families</a>, who often reside in neighborhoods with little access to good-quality or fresh food. </p>
<h2>A comprehensive approach</h2>
<p>One possible rationale for a soda tax is that the government should start by attacking the most egregious problems, and sweetened drinks are an especially attractive bull’s-eye for policymakers given their lack of almost any nutritional component. They’re also the single <a href="https://www.hsph.harvard.edu/nutritionsource/sugary-drinks-fact-sheet/">largest source</a> of sugars for children aged 11 to 18. </p>
<p>But to have any prospect of significantly improving diet, a more comprehensive “junk food tax” would have to be levied on a much <a href="http://www.theguardian.com/commentisfree/2016/mar/20/sugar-tax-good-idea-go-after-processed-foods-next">broader range</a> of <a href="http://www.ifs.org.uk/uploads/publications/bns/BN180.pdf">sugary</a>, fatty and <a href="http://www.nhs.uk/Livewell/Goodfood/Pages/the-eatwell-guide.aspx">nutritionally poor foods and drinks</a>. </p>
<p>If only soda is taxed, moreover, there is the risk of unintended <a href="http://www.sciencedirect.com/science/article/pii/S0167487014001068">compensatory effects</a> in which consumers end up indulging more in other unhealthy, and tax-exempt, foods or drinks. </p>
<p>To be really effective, such a tax on junk food should be combined with a comprehensive assault on the problem – similar to the fight against tobacco. This should include subsidizing health foods, like fruits and vegetables, as well as regulating ads. </p>
<p>Warning labels can be a part of this, but governments hoping to turn the tide on the obesity epidemic should also regulate unhealthy default options on menus, and supersizing practices – such as former New York City Mayor Michael Bloomberg’s <a href="http://www.bloomberg.com/news/articles/2014-06-26/new-york-big-soda-ban-rejected-by-n-y-top-court-as-overreach">failed effort</a> to ban oversized sodas.</p>
<p>At the same time, revenue from any taxes levied should go toward helping low-income families: for example, by subsidizing healthy foods, since low-income families will be most hurt by the tax. </p>
<p>Posting calories and warning consumers is fine as far as it goes, as is a soda tax, but in our view these policies don’t go nearly far enough.</p><img src="https://counter.theconversation.com/content/60130/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Behavioral research shows why a heavy-handed approach like the UK’s soda tax works better than the mere warning that San Francisco wants to put in advertisements.Matteo M. Galizzi, Assistant Professor of Behavioural Science, London School of Economics and Political ScienceGeorge Loewenstein, Professor of Economics and Psychology, Carnegie Mellon UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/565152016-05-23T19:31:47Z2016-05-23T19:31:47ZLimited food options take their toll on the health of South Africa’s rural poor<figure><img src="https://images.theconversation.com/files/123549/original/image-20160523-11010-8biejl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Siphiwe Sibeko/Reuters</span></span></figcaption></figure><p>In the past 20 years, researchers have linked the increase of obesity and chronic diseases like diabetes and hypertension in low- and middle-income countries to urbanisation, changing diets and less active lives. </p>
<p>The spread of big retail food chains and fast food has also had an impact – increasing the availability of processed, high-energy, nutrient-poor foods and making them more affordable than fresh, healthy food. </p>
<p>Though this is <a href="http://www.cpc.unc.edu/projects/nutrans/whatis">accurate</a>, it does not entirely capture the realities of the rural, agrarian poor people and the nutrition challenges they face. </p>
<p>Most South Africans’ food energy needs are adequately met and extreme hunger is a thing of the past. This is thanks, in part, to one of the largest cash-based <a href="http://www.hsrc.ac.za/en/review/hsrc-review-november-2013/social-grants-fiscas">social welfare programmes</a> on the continent. </p>
<p>But the reality is that rural poor people are among the most disempowered among <a href="http://link.springer.com/article/10.1007%2Fs10460-005-6042-4#/page-1">food citizens</a>. Most poor rural South Africans <a href="http://www.up.ac.za/en/coe-fs/news/post_2147313-healthy-diet-remains-unaffordable-for-most-south-africans">cannot afford</a> a healthy, balanced diet with adequate fruits, vegetables and legumes. Where these are not locally produced, supermarkets supply them with hefty price tags that are often higher than city prices. As a result, poor people living in rural areas may suffer from malnutrition.</p>
<p>For children, malnutrition comes as chronic under-nutrition. It translates into <a href="http://data.unicef.org/nutrition/malnutrition.html">stunting</a> or growth faltering. This often occurs simultaneously with obesity. For adults, it means a higher risk of <a href="http://www.hst.org.za/news/more-south-african-adults-now-die-obesity-poverty">obesity</a>.</p>
<p>If the current trajectory continues, the costs of treating obesity-related chronic diseases could be staggering, let alone for a health system that already heaves under the burden of HIV. </p>
<p>And the social and economic <a href="http://thousanddays.org/tdays-content/uploads/Stunting-Costing-and-Financing-Overview-Brief.pdf">costs</a> of childhood stunting due to nutritional deficiencies are even higher, robbing children of quality of life and nations of potential.</p>
<h2>Why rural poor face particular problems</h2>
<p>Industrialised and highly urbanised developed countries have been leading the charge in the <a href="http://www.who.int/nutrition/topics/obesity/en/">global obesity epidemic</a>, but the world’s poorest countries are rapidly catching up.</p>
<p>Researchers refer to this as <a href="http://www.cpc.unc.edu/projects/nutrans/whatis">nutrition transition</a>. This is explained as shifts in food consumption, physical activity levels and increasing urbanisation. </p>
<p>But this does not explain why obesity is also on the rise among rural people. It challenges a common argument around obesity: it is caused by unhealthy lifestyle choices, including inactivity and eating junk food. </p>
<p>Clearly the phenomenon of obesity in poor rural communities has little to do with an addiction to drive-through burgers. But it is no less related to food environments. </p>
<p>Food environments are the ways in which food is produced, distributed and consumed. These are determined largely by <a href="http://www.srfood.org/en/trade-sp-1847639719">global trade</a> policies, national food production and distribution patterns, agriculture and nutrition policies and, increasingly, the unfolding crisis of <a href="http://www.unscn.org/files/Statements/SCN_statement_climate_change_final.pdf">climate change</a>. </p>
<p>And although nutrition transition is linked to changing food preferences, it is also linked to changing rural livelihoods, land and water entitlements, <a href="ftp://ftp.fao.org/docrep/fao/010/i0112e/i0112e00.pdf">agricultural diversity</a> and urbanisation. The dynamics of these push and pull factors are complex.</p>
<h2>The South African case</h2>
<p>Livelihoods and food environments – rather than personal choices – often determine the consumption of healthy or unhealthy food. In South Africa, for example, the particular challenge is that most rural people buy, rather than produce, their own food. This is because the country has an <a href="http://www.plaas.org.za/plaas-publication/agrarian-transformation-smallholder-agriculture-south-africa-diagnosis-bottlenecks">underdeveloped</a> smallholder and subsistence-farmer sector and a weak culture of home food production. As a result their choices are severely limited by income, the retail environment and their capacity to produce their own food. </p>
<p>Producing their own food, in turn, is constrained by the high costs of inputs, land and water shortages, and the lack of support for subsistence and small food producers and marketers.</p>
<p>So instead of vibrant local production and markets, rural people rely mainly on processed foods – refined carbohydrates like maize meal, white sugar, mass-produced vegetable oils and, occasionally, <a href="http://www.who.int/mediacentre/news/statements/2015/processed-meat-cancer/en/">processed animal products</a> – bought largely from big retail chains, because these are the cheapest and most prolific.</p>
<p>Food security in rural South Africa is heavily reliant on cash incomes, which, in turn, are boosted considerably by social grants. But, unlike food prices, these do not increase in response to frequent price hikes. </p>
<p>Rural people are often trapped in cycles of chronic food insecurity. Although they get enough calories, they suffer from hidden hunger. This results in micronutrient deficiencies and obesity due to poor food quality, perpetual anxiety about future food supplies and unstable livelihoods. </p>
<h2>There are answers</h2>
<p>Malnutrition in rural communities cannot be addressed through manufacturing more food and trucking it to rural areas or sending more food charity. What is needed is a systemic approach that considers the underlying causes of hunger and malnutrition and the the whole food system. </p>
<p>Researchers, civil society groups and activists are increasingly highlighting the fact that food systems that primarily generate profits not only fail to deliver adequate nutritious food, but also <a href="http://rajpatel.org/2009/10/27/stuffed-and-starved/">contribute to</a> environmental damage, biodiversity loss and climate change – and a global obesity epidemic.</p>
<p>South Africa produces enough food for local consumption. It also has the natural resources and technology to do this in more sustainable, nutritious and culturally appropriate ways. The key to this is diversification.</p>
<p>The retail sector is critical when most people rely on food purchased with cash. But like ecosystems, when food systems rely too heavily on one component, it makes for weakness and vulnerability. Relying heavily on purchased food from too few sources is making rural people <a href="http://www.economist.com/news/finance-and-economics/21672342-fuel-price-shocks-have-big-influence-price-food-oily-food">vulnerable</a>. </p>
<p>One solution may be to improve small-scale farming and household production. With the right support, <a href="https://www.grain.org/article/entries/4929-hungry-for-land-small-farmers-feed-the-world-with-less-than-a%20quarter-of-all-farmland">small-scale</a>, diverse and ecologically sustainable farming need not be a struggle for survival. </p>
<p>But small producers need access to land, water and inputs, vibrant local markets and protection against <a href="https://www.academia.edu/20879940/Between_Markets_and_Masses_Food_assistance_and_food_banks_in_South_Africa">corporate and charitable dumping</a>. This is but one suggestion. There is much wider scope for innovation in food and agricultural policies.</p>
<p>Addressing current nutrition and health challenges will require improved access to good quality, diverse diets – ending malnutrition is no longer about delivering enough calories to prevent starvation.</p><img src="https://counter.theconversation.com/content/56515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angela McIntyre is a PhD candidate at the University of Pretoria Faculty of Natural and Agricultural Sciences and affiliated with the Institute for Food Nutrition and Wellbeing.</span></em></p>In many rural areas, poor people are suffering from malnutrition, which takes the form of stunting and obesity. To change this, their food environments must change.Angela McIntyre, Doctoral student affiliated with the UP Institute for Food, Nutrition and Wellbeing (IFNuW) and the Centre for the Study of Governance Innovation, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/555792016-03-03T04:18:30Z2016-03-03T04:18:30ZWhat’s driving sub-Saharan Africa’s malnutrition problem?<figure><img src="https://images.theconversation.com/files/113546/original/image-20160302-25912-1nts5bn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A staple daily diet for millions of South Africans is this traditional porridge, known as "pap", made from mielie-meal (ground maize).</span> <span class="attribution"><span class="source">Reuters/Siphiwe Sibeko </span></span></figcaption></figure><p>Sub-Saharan Africa has the highest level of food insecurity in the world. An estimated <a href="http://www.fao.org/3/a-i4635e.pdf">220 million people</a> lack adequate nutrition. The nature of the problem is shifting rapidly, with overweight status and obesity emerging as new forms of food insecurity while malnutrition persists. But continental policy responses do not address this changing reality. </p>
<p>Food insecurity is the outcome of being too poor to grow or buy food. But it’s not just any food. According to the United Nations’ Food and Agriculture Organisation’s <a href="http://www.who.int/trade/glossary/story028/en/">definition</a>, people need:</p>
<blockquote>
<p>… sufficient, safe, nutritious food to maintain a healthy and active life.</p>
</blockquote>
<p>Current policy focuses on alleviating undernutrition through increased production and access to food. It does not focus on the systemic issues that inform the food choices people make. This may result in worsening food insecurity in the region.</p>
<p>The thinking around food security in Africa is stuck, even though there are calls for a more nuanced understanding of the problem. The common thought is that the food insecure are poor, hungry people who don’t have the means to grow or buy enough food.</p>
<p>The other misconception is that obese people are overweight or unhealthy because of what they eat; that they are at fault for making bad choices. This leads us to believe that people need nutrition education to help them make better choices, and that they deserve a healthy portion of blame if they make poor ones.</p>
<p>Both understandings are wrong. Food insecurity is driven by the economics and the geographies of the food system.</p>
<h2>A poverty related obesity epidemic</h2>
<p><a href="http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130126/filename/130337.pdf">In the region</a>, 33% of adults are overweight and a further 11% are obese. The levels of diet-related non-communicable <a href="http://www.sciencedirect.com/science/article/pii/S0140673614604608">diseases</a> are rising as a result of rapid urbanisation, the urbanisation of poverty and rapidly changing <a href="http://www.foresightfordevelopment.org/featured/food-insecurity">food systems</a>.</p>
<p>Obesity affects both rich and poor people. In the developed world <a href="http://www.sciencedirect.com/science/article/pii/S0140673614604608">obesity rates</a> are levelling off. But they continue to climb in the developing world. This has significant developmental outcomes. In 2010 overweight status and obesity <a href="http://www.sciencedirect.com/science/article/pii/S0140673614604608">caused</a> about 3.4 million deaths, 3.9% of years of life lost and 3.8% of <a href="http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/">disability-adjusted life-years</a> – a calculation of the number of years of life lost to ill health, disability or early death.</p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0140673610615140">Obesity rates</a> have not doubled and tripled in recent decades because people have spontaneously and collectively started to make bad food choices. </p>
<p>The poor eat badly because it makes economic sense for them to do so. South Africa’s food system, for example, is one in which <a href="http://www.plaas.org.za/plaas-publication/rr-42">corporate power</a> is concentrated. The system is dominated by <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001253">“Big Food”</a> – large commercial entities that control the food market. The South African experience mirrors global trends in which food markets have been deregulated and liberalised.</p>
<p>For example, the <a href="http://www.tandfonline.com/doi/abs/10.1080/19452829.2014.896323">liberalisation of trade</a> has opened up imports of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513184/">highly processed</a>, cheap food, and large private companies that sell highly processed foods are able to <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62089-3/abstract">exert pressure</a> on national governments. This has handed power over nutrition to food processors and retailers. </p>
<p>Healthier alternatives like low-fat foods are <a href="https://theconversation.com/why-bad-food-is-good-for-business-23438">generally more expensive</a> than less healthy <a href="http://www.ncbi.nlm.nih.gov/pubmed/21074973">options</a> because they are “value padded” with sugars and refined carbohydrates. At the same time, the <a href="http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/9580.pdf">price of fresh produce</a> has increased at a faster rate than that of processed foods.</p>
<p>This economic logic is reinforced by marketing and advertising that sends conflicting health messages. For example, soft drink companies or fast-food chains associate themselves with sports events and healthy lifestyles; and schools advocate healthy eating but also have on-site tuckshops that sell junk food. </p>
<p>Poor people also have limited access to storage and <a href="http://www.foresightfordevelopment.org/featured/food-insecurity">refrigeration</a>, which affects their options.</p>
<h2>What the response should be</h2>
<p>Blaming the poor for a logical response to a systemic problem is not helping the situation, and nutrition education alone will not change what people eat.</p>
<p>Governments must shift their attention from the individual to the system when considering why people eat what they eat. Governments must also consider the effects when good food policy is overridden by economic growth imperatives that support a food system dominated by highly processed foods.</p>
<p>South African Finance Minister Pravin Gordhan recently announced that the country will implement a tax on sugar-sweetened beverages <a href="http://www.treasury.gov.za/documents/national%20budget/2016/speech/speech.pdf">from 2017</a>. The sugar industry argues that this will harm businesses and negatively affect the <a href="http://ewn.co.za/2016/02/26/Beverage-Association-disappointed-by-proposed-Sugar-Tax">poor</a>. It is, in part, correct. </p>
<p>Regulation of unhealthy foods without corresponding incentivisation of healthier foods is regressive. Likewise, if issues like access, storage, refrigeration and transport are not addressed, efforts to moderate food choice through pricing will only be an additional tax on the poor. It will not remedy food insecurity of either kind.</p>
<p>Food insecurity in Africa needs to be understood in the context of the wider food system, as well as in the way that food connects to economic and other practices. There needs to be a radical reconfiguration of food security policy that moves away from focusing on production and household poverty alleviation to consider the nature and dynamics of the food system. </p>
<p>Failure to do so will simply accelerate the transition from one form of food insecurity to another.</p><img src="https://counter.theconversation.com/content/55579/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Battersby receives funding from the ESRC and DFID as part of the Joint Fund for Poverty Alleviation Research project, Consuming Urban Poverty. </span></em></p>Food insecurity is not only a cause of bad food choices, it is a result of the economics and geographies of the food system.Jane Battersby, Researcher in Urban Food Security, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/482832015-11-09T11:05:38Z2015-11-09T11:05:38ZFitness versus fatness: which matters more?<p>There is a longstanding <a href="http://www.nytimes.com/2015/06/16/upshot/to-lose-weight-eating-less-is-far-more-important-than-exercising-more.html?_r=0">debate</a> in the research community about the importance of <a href="http://atvb.ahajournals.org/content/25/3/e20.full">fitness</a> <a href="http://jama.jamanetwork.com/article.aspx?articleid=199376&resultClick=3">versus </a><a href="http://www.health.harvard.edu/staying-healthy/is-it-okay-to-be-fat-if-youre-fit">fatness</a> in <a href="http://well.blogs.nytimes.com/2015/08/09/coca-cola-funds-scientists-who-shift-blame-for-obesity-away-from-bad-diets/">health</a>. Are exercise and improving fitness more important than eating well and maintaining a healthy weight? </p>
<p>Some researchers <a href="http://bjsm.bmj.com/content/43/1/1.full.pdf+html">argue</a> <a href="http://well.blogs.nytimes.com/2012/03/07/getting-fat-but-staying-fit/?_r=0">fatness</a> does not affect health as long as you are <a href="http://www.sciencedirect.com/science/article/pii/S0033062013001552">fit</a>, which means your heart and lungs are strong. And national campaigns like <a href="http://www.letsmove.gov/">Let’s Move</a> are focused on exercise for health without a specific focus on weight loss. </p>
<p>But for people who are obese, losing weight might be more important to their overall health than focusing on fitness. In fact, <a href="http://bjsm.bmj.com/content/early/2015/05/07/bjsports-2015-094911.full">evidence</a> shows that exercise alone is not an effective way to lose weight. Rather, effective weight loss is mostly about what you eat, though it should also include exercise.</p>
<p>As family physicians, we see obese patients who have heard the message to “just be fit” and have added 10-15 minutes of walking to their daily routine or have bought a Fitbit to track their physical activity. We applaud these efforts. </p>
<p>But for many obese people, the message that physical activity is more important than managing weight is not only unhelpful but also not true. When it comes to health and wellness, fatness can matter more than fitness. And of course, for most people, fatness is related to fitness, because excess weight can make exercise much harder.</p>
<h2>How are fitness and fatness are linked?</h2>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0033062013001552">Multiple studies</a> have looked at fitness and obesity as two separate entities because they are seemingly separate concepts: one measures how well your heart and lungs work to supply oxygen to your muscles while the other is a measure of your body height and weight. </p>
<p>However, the measures of fitness and fatness are both influenced by how much you weigh. Because of the way fitness is calculated, for two people with the same oxygen-transferring power, weighing more typically means lower fitness.</p>
<p>Likewise, what researchers mean by fatness is really body mass index (<a href="http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm">BMI</a>), a measure of body fat based on height and weight. People are often surprised at what is considered normal weight. To be in the normal weight range, a person who is 5'7" needs to weigh less than 160 pounds. If this same person weighs over 190 pounds, he or she would be considered obese.</p>
<p>Strictly speaking, obesity does not mean you are automatically unfit. There are obese people who run every day, and then there are thin people who couldn’t run a mile for their life. A muscular individual can also be considered obese, because muscle weighs more than fat, and be very fit. </p>
<p>But these are exceptions, not the rule. Studies <a href="http://dx.doi.org/10.1016/j.amepre.2010.12.016">show</a> that when someone is categorized as obese, the likelihood of them being fit is very low. So in our society, being obese still generally means lower fitness.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/100986/original/image-20151105-16277-t3bdsf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/100986/original/image-20151105-16277-t3bdsf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/100986/original/image-20151105-16277-t3bdsf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/100986/original/image-20151105-16277-t3bdsf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/100986/original/image-20151105-16277-t3bdsf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/100986/original/image-20151105-16277-t3bdsf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/100986/original/image-20151105-16277-t3bdsf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Extra weight can make it harder to move.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-301492823/stock-photo-weight-scale-scale-gauge.html?src=lIYZitt9-ATgh5MyVNb5yw-1-35">Scale via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Fatness makes it harder to improve fitness</h2>
<p>For people who are obese, focusing on losing weight is a better place to start than just focusing on fitness. That’s because extra weight can make it harder to move, and thus harder to exercise. Obese individuals often have a difficult time doing physical activity due to body size, limited mobility and joint pain.</p>
<p>Physiologically, it is <a href="http://www.ncbi.nlm.nih.gov/pubmed/10918530">more difficult</a> for an obese individual to do the same amount of exercise as a healthy-weight person because of the extra weight they carry. Heavier people need more oxygen to do the same exercise as a healthy-weight person. Some obese people report that even walking can seem tough. Fitness is just harder to achieve if you can’t move easily.</p>
<h2>Fatness decreases your quality of life</h2>
<p>The debate around fitness and fatness centers on <a href="http://dx.doi.org/10.1016/j.pcad.2013.09.002">studies</a> that show that compared to normal weight-fit individuals, unfit individuals had twice the risk of mortality regardless of BMI. But as these studies show, a relatively small proportion of people are fit <em>and</em> obese.</p>
<p>But mortality is not the only issue. Obesity has been shown to predict diabetes, heart disease, liver disease and <a href="http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks">a whole host of health problems</a> that may require taking daily pills or having daily injections, or lead to invasive procedures. Even if a higher BMI does not predict earlier death, this does not mean that it “doesn’t matter” to your health. </p>
<p>While exercise can and does improve health, for people who have health conditions like diabetes or fatty liver disease, exercise alone won’t make a huge difference in reversing these conditions. However, these conditions can be improved or even resolved with weight loss (decreasing body fat). </p>
<p>Fatness also has a lot of other implications outside of strictly health effects. For family physicians like us that care for obese patients, the most heartbreaking stories are from obese patients who can’t go on roller coasters with their children or can’t keep themselves clean due to their size. </p>
<p>Increasing physical activity without losing weight will not likely improve these patients’ lives. To improve their health and quality of life, it is important to exercise every day, eat healthy food and, most importantly, lose some weight.</p><img src="https://counter.theconversation.com/content/48283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline R Richardson receives funding from NIH, VA,BCBSF, RWJF, AJPM, NEJM. She has recently been or is currently affiliated with the University of Michigan and the Ann Arbor VA. </span></em></p><p class="fine-print"><em><span>Tammy Chang does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For many obese people, the message that physical activity is more important than managing weight is not only unhelpful but also not true.Tammy Chang, Assistant Professor, Family Medicine, University of MichiganCaroline R Richardson, Associate Professor of Family Medicine , University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/380822015-04-24T09:45:38Z2015-04-24T09:45:38ZDiscount food and restaurants stand out as major factors in the obesity epidemic<figure><img src="https://images.theconversation.com/files/78827/original/image-20150421-9008-ou4jzs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Do warehouse stories contribute to the obesity epidemic?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/hawaii/14683760680">Ryan Ozawa/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>Obesity has reached epidemic proportions in the United States. The proportion of US adults who are obese – defined as a body mass index (BMI), a measure of body fat based on height and weight – of at least 30, has risen from <a href="http://europepmc.org/abstract/med/9481598">13% in 1960</a> to <a href="http://jama.jamanetwork.com/article.aspx?articleID=1832542">35% in 2011-2012</a>. Estimates of the annual costs of obesity include <a href="http://jama.jamanetwork.com/article.aspx?articleid=200731">112,000 lives lost</a> and <a href="http://www.sciencedirect.com/science/article/pii/S0167629611001366">US$190 billion</a> in medical expenses. </p>
<p>Economists have been trying to pinpoint some of the economic factors that could have contributed to this rise in adult obesity for years. </p>
<p>Some have examined the role of cheaper and more readily available food, as measured by <a href="http://onlinelibrary.wiley.com/doi/10.1111/ecoj.12124/full">grocery food prices</a>, <a href="http://www.sciencedirect.com/science/article/pii/S0167629604000207">restaurant prices</a>, <a href="http://ajae.oxfordjournals.org/content/early/2010/05/27/ajae.aaq041.short">access to restaurants</a>, <a href="http://www.sciencedirect.com/science/article/pii/S0094119010000690">access to supercenters</a>, or <a href="http://ajae.oxfordjournals.org/content/90/2/287.short">receipt of food stamps</a>. Others have focused on incentives related to physical activity. For instance, <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1465-7295.2009.00266.x/abstract?systemMessage=Wiley+Online+Library+will+be+disrupted+on+21st+March+from+10%253A30+GMT+%252806%253A30+EDT%2529+for+up+to+six+hours+for+essential+maintenance.++Apologies+for+the+inconvenience.&userIsAuthenticated=false&deniedAccessCustomisedMessage=">cheaper gasoline</a> may lead to more driving and less walking, while <a href="http://www.sciencedirect.com/science/article/pii/S0167629610000974">urban sprawl</a> reduces community walkability. </p>
<p>Still other studies ask whether tobacco control measures such as <a href="http://www.sciencedirect.com/science/article/pii/S0167629604000207">cigarette taxes and smoking bans</a> may have had the unintended consequence of contributing to the rise in obesity, since nicotine can be a metabolic stimulant and appetite suppressant. Finally, another category of studies estimates the role of changing characteristics of the labor force, such as the <a href="http://www.degruyter.com/dg/viewarticle/j$002ffhep.2009.12.2$002ffhep.2009.12.2.1123$002ffhep.2009.12.2.1123.xml">rise in female labor participation</a> (which might lead to an increased reliance on convenience food) and the <a href="http://www.jstor.org/discover/10.2307/4132827?sid=21106184562173&uid=2&uid=4">increasingly sedentary nature of jobs</a>.</p>
<p>These are some of the numerous different factors that could have played a role in the skyrocketing obesity rate. But which ones have the greatest influence? To figure that out my colleagues and I compared 24 factors attributed to the rise in adult obesity to understand which ones had the biggest effect. </p>
<h2>So what factors have the most influence on obesity?</h2>
<p>In a <a href="http://www.nber.org/papers/w20892">working paper</a> recently released by the National Bureau of Economic Research, Joshua Pinkston, Christopher Ruhm, George Wehby and I combine these factors and others into a single model to figure out which ones have contributed to obesity the most.</p>
<p>To do this we matched state-level data on 24 different economic factors to data on 2.9 million people from the CDC’s <a href="http://www.cdc.gov/brfss/">Behavioral Risk Factor Surveillance System</a> from 1990 through 2010. After controlling for demographics, state and year, we were able estimate the effects of these economic factors on weight outcomes. </p>
<p>The analysis is essentially a “statistical horse race” to see which, if any, of the these factors that are alleged to have contributed to the obesity epidemic stand out once all the possible contributors are mixed together and analyzed statistically.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79183/original/image-20150423-25558-3uvb5e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">All of these factors contribute to obesity epidemic, but some have more of an effect than others.</span>
<span class="attribution"><a class="source" href="http://www.nber.org/papers/w20892.pdf">Charles Courtemanche/NBER</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>All factors play a role in obesity</h2>
<p>Taken together, we estimate that these 24 economic variables together explain 37% of the rise in BMI across the country, 43% of the rise in obesity, and 59% of the rise of what is called moderate and severe obesity, defined as a BMI of 35 of higher (called <a href="http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000348.htm">class II/III obesity</a>). </p>
<p>We calculated these percentages by estimating the effects of the economic factors on each weight outcome (eg BMI), and then we multiplied these effects by the observed changes in the economic variables during the sample period. Then we divided the result by the overall change in the weight outcome during the sample period. </p>
<p>This means that how people respond to changing economic incentives appears to explain a lot of the upward trend in weight. And this especially large influence on the rise in severe obesity is particularly important, as the severe obesity threshold is where the <a href="http://jama.jamanetwork.com/article.aspx?articleID=1555137&">increased mortality risk from obesity</a> begins to appear. In other words, economic incentives do not affect BMI uniformly throughout the population. The impact is concentrated among those who already obese. </p>
<h2>More restaurants and gigantic grocery stores</h2>
<p>When we look at these factors on their own, two stand out as the “winners” of the horse race. </p>
<p>First is the increase in restaurants per capita, which by itself explains 12% in BMI, 14% of the rise in moderate obesity, and 23% of the increases severe obesity. Greater availability of restaurant food likely increases obesity because more people are substituting relatively unhealthy restaurant meals for home-cooked meals. And fast food is not the lone culprit. If we split the restaurant variable into fast-food and full-service restaurants, their estimated effects are similar.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/78825/original/image-20150421-9043-x6m3lx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/78825/original/image-20150421-9043-x6m3lx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=824&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78825/original/image-20150421-9043-x6m3lx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=824&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78825/original/image-20150421-9043-x6m3lx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=824&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78825/original/image-20150421-9043-x6m3lx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1036&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78825/original/image-20150421-9043-x6m3lx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1036&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78825/original/image-20150421-9043-x6m3lx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1036&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More restaurants in a neighborhood correlate with higher obesity rates.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/dickuhne/425934404/in/photolist-DD2sC-2gfuho-fu13tf-ftKJ4z-9qVaq9-cBS2GQ-5HW5zK-ohBKf7-2gfaDE-2gfrrb-2gfgeo--5ScXEA-7Hs6p9-rFgdsh-kJrTjU-ME2Ye-6apnto-478tUn-2gb42H-2gfa8u-2gaJgc-2gfmUL-2gaTHi-2gfnMo-2gaSSx-2gb4Dp-2gb2d4-2gfc9w-2gaMUX-2gaKLT-2gfsFm-2gb6kB-2gffkJ-2gfmfU-2gb5ez-2gb5PP-2gfh1o-2gf8tS-2gb85F-2gaScP-2gfdj9-2gfcTL-2gb2J4-2gaJL4-2gaGhP-2gaM4D-2gfyhm-2gfgz5-nrpjQ">dickuhne/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The second major contributor is the increase in superstores, like Walmart SuperCenters and warehouse club chains like Costco, Sam’s Club and BJ’s Wholesale Club, per capita. This factor accounts for 17% of the rise in BMI, 16% of the rise in moderate obesity, and 24% of the growth in severe obesity. </p>
<p>Perhaps the most likely explanation for the impact of these stores on obesity is that they sell food at a <a href="http://onlinelibrary.wiley.com/doi/10.1002/jae.994/abstract;jsessionid=37767591A6821CDAED20745DA63978B0.f02t03?systemMessage=Wiley+Online+Library+will+be+disrupted+on+21st+March+from+10%253A30+GMT+%252806%253A30+EDT%2529+for+up+to+six+hours+for+essential+maintenance.++Apologies+for+the+inconvenience.&userIsAuthenticated=false&deniedAccessCustomisedMessage=">discount of around 20%</a> relative to a traditional grocery store. It’s also possible that buying food in bulk contributes to overeating.</p>
<p>But if we split the superstore variable and look at certain stores on their own, we find that Walmart Supercenters have roughly the same effect as warehouse clubs, which often sell food in bulk. And since Walmart Supercenters sell food in traditional package sizes, this seems to rule out bulk-buying as being the leading explanation. </p>
<h2>Cheap food isn’t a bad thing</h2>
<p>While restaurants, supercenters and warehouse clubs appear to have contributed substantially to the rise in obesity, this doesn’t necessarily mean that they are bad for society. The availability and affordability of food brought about by these businesses are undoubtedly of substantial benefit to consumers. Our results simply suggest that progress comes at a cost. Future research should investigate the reasons why restaurants and superstores contribute to obesity with the aim of helping policymakers develop targeted solutions.</p><img src="https://counter.theconversation.com/content/38082/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Courtemanche does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How people respond to changing economic incentives appears to explain a lot of the upward trend in weight.Charles Courtemanche, Department of Economics, Usery Workplace Research Group, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/374712015-03-05T03:43:19Z2015-03-05T03:43:19ZEven if obesity were a disease, exercise may be too bitter a pill<figure><img src="https://images.theconversation.com/files/72602/original/image-20150220-29182-1doplgj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors recommend drugs and surgery for most diseases but exercise may actually be a better answer for obesity.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/bensphotots/12530377135/in/photolist-k6gsz6-e6xXdb-8qJF3W-5worNL-5nhbik-drTmrb-yDAyQ-8LLHUE-tGbGe-64fGf6-h2staS-mRtpi-g76XVA-aEkXF8-8sKnzw-5UEYNb-eixuns-71v32W-q2MnoN-925p9e-9WSJee-bAp7Pw-8maDLx-5p4Mqo-7ouG1p-2Q7AnH-aoxcNU-6MynS-AHYsv-8YyfoT-pwywzn-bZNzNQ-Ck6ae-2GTjpR-qGn1ev-64ebVo-8PhXah-dZKXE-orRUyM-x6iiC-7R1LzQ-88u7xS-8PeVZa-gWVkpg-8MkMmW-88qSqt-7AKGup-qYGWWN-8Zvxwy-7XBRr3">Ben Bradshaw/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Imagine you’re obese. Would you describe yourself as “diseased”? The American Medical Association would. In 2013, <a href="http://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html?_r=0">it decided obesity was a disease</a>. This was mainly, it must be said, for pragmatic reasons, to “help change the way the medical community tackles this complex issue”. </p>
<p>Or, as somebody far more cynical than I might say, in order to give doctors something else they could bill health insurers for.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/11673757">Not everyone was convinced</a>. Obesity, critics argued, lacks a tightly defined set of symptoms (you don’t get a fever or break out in spots) and specific functional impairments. Obesity may be one of the causes of diseases such as diabetes, but surely calling it a disease in itself was drawing a long bow, they claimed.</p>
<p>This is more than a semantic debate; it involves stigma, blame, drugs and lots and lots of money.</p>
<h2>The disease solar system</h2>
<p>I find it helpful to think of diseases as being organised as a kind of solar system, in a series of concentric circles. At the very heart of the disease solar system are “paradigm diseases”, such as Ebola and measles. They have physical effects caused by a single vector (an agent that carries and transmits the disease), they’re communicable and have a well-defined set of signs and symptoms. </p>
<p>A little further out from the centre, we might find depression, which has specific diagnostic criteria, appears to be treatable by common drugs such as <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1916904">anti-inflammatories</a>, but is not really communicable. </p>
<p>Far from the centre, we might see, say, cerebral palsy. Is it a disease at all, or a condition? And then there are “diseases” such as irritable bowel syndrome and repetitive strain injury, which whizz in and out of our disease solar system like haywire comets.</p>
<p>Diseases share a number of characteristics, but not all diseases have all those characteristics. They follow a pattern that the philosopher <a href="http://en.wikipedia.org/wiki/Philosophical_Investigations#Family_resemblances">Wittgenstein called “family resemblances”</a>. </p>
<p>Obesity certainly has some disease characteristics. It has a clear diagnostic criterion – a BMI of 30 or more. It has a known set of common symptoms (high blood fats, for instance, and poor blood sugar regulation).</p>
<p>Obesity may even be <a href="http://dash.harvard.edu/bitstream/handle/1/3710802/Christakis_SpreadofObesity.pdf?sequence=2">communicable through social networks</a>. <a href="http://dash.harvard.edu/bitstream/handle/1/3710802/Christakis_SpreadofObesity.pdf?sequence=2">One study found</a> that a person’s chances of becoming obese increased by 57% if they had a friend who became obese.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/72596/original/image-20150220-29186-ypzwc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/72596/original/image-20150220-29186-ypzwc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72596/original/image-20150220-29186-ypzwc6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72596/original/image-20150220-29186-ypzwc6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72596/original/image-20150220-29186-ypzwc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=536&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72596/original/image-20150220-29186-ypzwc6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=536&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72596/original/image-20150220-29186-ypzwc6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=536&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Like debates about whether Pluto is a planet, the status of obesity as a disease is not the most important point.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/ericvanderpool/5903891117/in/photolist-686wuV-9ZGZ9a-8KWK7B-4sjws9-eYgav-4nPf7p-CdnDq-cfeBrb-dnWvXd-bn5LWb-fnop7-8skees-cCVJjL-6Uo3qX-rSHv7-2HQZUM-4EN7sn-i9SQUn-9x2Cmr-49S7GF-5nJqBn-vVh2Y-2CFwTq-rc8Rie-7z6cQt-9Uhj1D-7zxnKi-9cmUzN-mdN4EV-qz86wL-mFHwdV-c1Upy3-9cscF1-no2hhX-9cmUzA-d5681d-d567Qw-d567VU-FzTdq-8VsNyy-aT1Fpa-aT1EWx-aT1FaP-aT1EuM-aT1E8r-aT1EJx-aT1Ejg-Hj594-4EJ89m-9a8qVp">Eric Vanderpool/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>And obesity has a recommended treatment: diet and exercise — but we’ll come to that in a minute.</p>
<h2>Obesity as disease</h2>
<p>Most people agree that if obesity is a disease, it’s out there on the fringes of the solar system. While declaring a condition to be a disease is rather like deciding whether Pluto is a planet (call it what you like, it’s still out there), it has <a href="https://theconversation.com/columns/jane-ogden-96406?page=3">very important practical implications</a>. </p>
<p>If I’m obese and obesity is a disease, I can reasonably expect the government and health funds to cough up money for my treatment, researchers to be funded to explore causes and cures, and pharmaceutical companies to be reimbursed for developing their magic pills. </p>
<p>I could sue those responsible for giving me the disease or for failing to take reasonable steps to prevent it (just who did put the Coke machine at the base of the lift?). </p>
<p>A lot of people — doctors, lawyers, researchers, pharma — have a lot of skin in the game and their common interests in <a href="http://news.bbc.co.uk/2/hi/health/4898488.stm">manufacturing illness</a> may be just a little too closely aligned. And if I’m obese, I have skin in the game, too. Now that I’m a person with a disease, I feel the burden of blame and uncertainty lift from my shoulders. </p>
<p>Diseases just happen to people. Nobody blames a person for having Ebola. It takes the pressure off me to treat myself; I become a medical problem. I feel the reassuring passivity of the patient in the hands of doctors and nurses – my treatment has been socialised. </p>
<p>I am no longer solely responsible for sticking to monastic diets, or the endless hours of preening and pec-flexing at the gym.</p>
<h2>Bitter pill</h2>
<p>But will it do me any good? Six years ago, the American College of Sports Medicine launched its “Exercise is Medicine” campaign with the words: </p>
<blockquote>
<p>According to a recently released study, it’s estimated that half of all adults in the US will be obese by the year 2030. </p>
</blockquote>
<p>But <a href="http://www.thelancet.com/journals/landia/article/PIIS2213-8587(15)00009-1/abstract">a new opinion piece in The Lancet</a> has suggested that diet and exercise are about as useful as an ashtray on a motorbike. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/72599/original/image-20150220-29157-1s3w12z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/72599/original/image-20150220-29157-1s3w12z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=588&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72599/original/image-20150220-29157-1s3w12z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=588&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72599/original/image-20150220-29157-1s3w12z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=588&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72599/original/image-20150220-29157-1s3w12z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=739&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72599/original/image-20150220-29157-1s3w12z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=739&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72599/original/image-20150220-29157-1s3w12z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=739&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The main problem with the scalpel-and-drugs approach is that exercise and diet have benefits regardless of weight loss.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/veo/2358714636/in/photolist-4Ar2FJ-9hR3h5-7k2eiP-8kvpxn-7k2efR-8kyAAj-kd3h6e-8jYvHF-8kyAt9-8kvuo2-6av1cG-fXiMMw-6XYRzp-jJ4MRc-8dRm3K-tXWox-7k68fQ-ecLHjT-8kvuq8-8kvpBR-8kyANb-8kyFCw-8kvuwz-8kyFGA-8kyFDQ-8kyAEf-8kyFyo-8kvpvD-8kyFBq-8kvuvZ-8jYvMV-8jYvKn-8kyAvd-3UKgno-5Ev36i-4xPSDw-6Ggf76-5jLUQU-7RQR6d-4cVogW">Rob/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>Indeed, diet and exercise interventions have a very poor record of long-term success. <a href="http://ajcn.nutrition.org/content/74/5/579.long">One review</a> found that, after five years, the average weight loss from diet or exercise interventions – or a combination of both – was just three kilograms. One reason for this is that obese adults have more fat cells, and therefore greater fat storage capacity. </p>
<p>Long-term obesity also leads to an enhanced neurochemical response to food rewards (you know, that thrilling surge of dopamine when the Ferrero-Rochers go from the plate to the palate). What’s more, when you’ve been obese for a long time, your body resets its idea of what weight you should be — the body weight setpoint — and it becomes very hard to shift.</p>
<p>In fact, obese people are swimming against a much stronger biological tide than the lean and are being swept out by the rip, drowning not waving. The <a href="http://www.thelancet.com/journals/landia/article/PIIS2213-8587(15)00009-1/abstract">authors of The Lancet article</a> recommend we turn to drugs and bariatric surgery (stomach-stapling) as they are “the only available treatment to show long-term effectiveness”. </p>
<p>Essentially, as far as treating obesity is concerned, diet and exercise are like medicines that we know will work, but which taste so bad that nobody will take them.</p>
<p>But the main problem with the scalpel-and-drugs approach is that exercise and diet have benefits regardless of weight loss. A number of studies show it’s <a href="http://www.health.harvard.edu/blog/dont-gauge-exercise-benefits-on-weight-loss-alone-201207135025">better to be fit and fat</a> than unfit and lean. And exercise is as effective as drugs in treating a range of other conditions, such as <a href="http://cebp.nl/media/m1121.pdf">depression</a>. </p>
<p>What’s more, even a modest weight loss of five kilograms can have very significant effects on obesity-related risk factors.</p>
<p>Perhaps you do think obesity is a disease and exercise is not the right medicine. If you do, be sure to send your obese friends a “get well soon” card. They may soon be your ex-friends.</p><img src="https://counter.theconversation.com/content/37471/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tim Olds receives funding from the NHMRC and ARC.</span></em></p>Most of us know that obesity is a growing problem across the globe but would you call it a disease? While it may seem like a semantic debate, it is actually a serious issue with major implications.Tim Olds, Professor of Health Sciences, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/374832015-02-18T13:49:57Z2015-02-18T13:49:57ZKiller couches are the key to tackling fat and fitness<figure><img src="https://images.theconversation.com/files/72292/original/image-20150217-19472-fn60os.jpg?ixlib=rb-1.1.0&rect=18%2C3%2C962%2C702&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Overbalanced. Is it possible to be fit and fat?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/dwaas76/2919473388/in/photolist-5rZ4J5-69RY57-8uCTwX-86q9DD-5QiXoa-o7JhN-bUbJQ-2W7SbB-NuL1B-NuivA-5rUHqx-NujGA-NuM56-NukRo-39LETo-5rUGng-4oVrxh-5rZ4eA-5rZ4jj-9g6gtg-6yEpRW-86tji9-86tj9u-8n4iyw-o7DRQ-oscSvM-6yAhuv-5EDzuD-o7GRN-8srq5H-22oTKR-6yAe7M-86tjJh-8suoJs-8susRu-o7GRe-86tjSw-8srmEV-8srpFV-6yBomK-74ysPT-6yAgpc-6yEmeY-6yEpfu-5pti3v-6yAhmv-6yAeJK-6yEpnJ-6yEmDd-6yAeSp">sophietica</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The link between exercise, diet and ill health has been recognised for a considerable length of time. The ancient Greek physician, Hippocrates (460-370BC), wrote:</p>
<blockquote>
<p>Eating alone will not keep a man well; he must also take exercise. For food and exercise … work together to produce health. </p>
</blockquote>
<p>Hardly a day goes by without some headline concerning <a href="http://www.theguardian.com/society/2015/feb/16/punishment-not-way-tackle-obesity-benefits">an obesity epidemic</a> and the threats to health. The debate is often couched as a simple choice between fat and thin; high BMI reading or low. But it is an approach which risks missing the real point – that getting people to lose weight is a more complex affair and long-term project rather than an answer found in a short equation or crash diet. </p>
<p>Obesity is very often defined <a href="http://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx">using BMI</a>, or the Body Mass Index, which is calculated from the ratio of body weight to height squared. In adults, where growth in height has stopped, any weight gain, usually body fat, will increase BMI. The fear about the health risks linked to this come because the classification of BMI categories was mapped against increased risks of preventable, non-communicable diseases. Higher BMI values were seen to <a href="http://www.cancer.gov/cancertopics/factsheet/Risk/obesity">increase risks of certain cancers</a>, heart disease and diabetes. </p>
<p>And so we look for ways to reduce our body fat, and cut the risks. The cause for increased BMI may be simplified as an imbalance between the energy we take in (food) and that which is expended for living and undertaking work, activities, exercise or sport. When we eat more energy than we use, the excess is stored and raises body weight, and the most efficient way the body has found to store this excess energy is as fat tissue.</p>
<h2>Living hand-to-mouth</h2>
<p>So an apparently simple relationship where weight gain is the result of more food eaten than energy expended should be simple to solve. However, despite all the solutions and advice offered in the large <a href="http://www.webmd.com/diet/why-do-we-keep-falling-for-fad-diets">number of dietary books and articles</a>, the rise of obesity continues apace. So how is it that we still struggle to apply science to correct the energy imbalance and reverse its effects on health? Surely the best and only advice would be to eat less and exercise more?</p>
<p>Closer inspection of the “simple” equation describing weight management (body weight equals food in, minus energy used), reveals that the control of food intake and energy expenditure are complex themselves and involve many factors.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72293/original/image-20150217-19493-1kvc02c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">What goes in, must come off.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/garydenness/6452794149/in/photolist-4cmG8r-7DrkY4-2roo2V-4es3Uq-7EoXZW-91j4ZD-aDrGU-32D1o8-fmKjvN-nx5iG8-97g4Vf-7V5CRN-7xGX9Z-4dvK1B-aQdfTx-eRDDAM-5AMtD3-6TyXdh-bFLyYk-dmtGEq-qt9bZL-7KyiTV-7NbGgm-4ak3m3-dY36Nx-dyRaWM-8gpQ1B-8gdkwL-brD12H-95US99-o1Ym3n-8TJ5QR-97g61Q-4aY3uq-875MD9-97qak9-aH9m6F-6SmC88-872AHn-875wBu-872Ahe-cJYnow-8rK66y-wS3LR-4XSNDm-4NBxYm-8WKx7U-6jGBMB-4rqbpa-7Ek7mF">Gary Denness</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>To alter the amount consumed seems to be the target for most interventions and simplest part of the energy balance relationship to deal with and there are many available diets available to choose from. Many of them can have a short term impact on body weight but none have a lasting effect.</p>
<h2>Body shock</h2>
<p>One reason that diets seem to be unsustainable as a method for prolonged weight management is that the body is able to sense and respond to reduced food intake, leading to increased appetite, lower energy used and altered behaviour. Often the result is a weight reduction followed by a return to pre-diet weight, leading to the so-called <a href="http://www.nhs.uk/news/2012/08august/Pages/Yo-Yo-diets-not-a-No-No.aspx">“yo-yoing” of body weight</a>.</p>
<p>Simply telling people that they need to reduce how many calories they eat and to exercise more has not worked. Some of this may be due to a belief that diet is the major problem and that weight loss by eating less is the way to solve the problem. Some reporting of the issue indicates that <a href="http://www.huffingtonpost.ca/yummy-mummy-club/how-to-eat-healthy_b_2116885.html">gluttony of individuals is the issue</a> – that people eat the wrong foods and too much of them. The large number of available diets offering advice often contain conflicting advice on foodstuffs and promise more weight loss and benefits than any have ever delivered. When the effects of diets have been measured they do lead to weight loss for most people, but never for everyone and rarely for anyone for a prolonged period (beyond 18 months).</p>
<p>It is clear from many studies that not everyone in a treatment or research group responds in an identical manner. In dietary studies there are always those who respond well to the attention and dietary changes and others who do not and may even increase in weight. Yet interpretation of the data is often extrapolated to everyone with the same “condition” and an assumption is made that the whole population will benefit from the same intervention. </p>
<h2>Breaking it down</h2>
<p>A recent <a href="http://www.phc.ox.ac.uk/news/what2019s-the-right-diet-for-you-a-bbc-horizon-experiment">series of Horizon programmes</a> tried to provide some insight into how to approach the problem a little differently, by placing overweight and obese volunteers into categories dependent on their answers to questions concerning eating habits, some genes identified with risk of being overweight and measures of certain hormones in their blood. </p>
<p>The volunteers were then placed into one of three groups defined by the scientists leading the study: constant cravers, feasters and emotional eaters, and given a different diet to follow. Their weight was measured over 12 weeks. The suggestion, from the scientists’ interpretation of the data, was that each group required a different approach to dealing with their energy balance problem. There may well be different combinations of factors leading to different categories of individuals yet to be identified. </p>
<h2>Fat and fit</h2>
<p>Exercise is another intervention used to help with the energy used side of the equation. However, this too is ineffective in weight reduction, many studies have shown only <a href="http://journals.lww.com/acsm-msse/Abstract/1999/11001/Physical_activity_in_the_treatment_of_the.10.aspx">small benefits over diet alone</a>, in terms of weight loss, despite significant increases in energy burned during the exercises. Part of this may be because exercise stimulates muscle growth and any loss of fat mass during exercise is offset by increases in muscle. </p>
<p>It is well recognised that sedentary behaviour has a major <a href="http://bjsm.bmj.com/content/48/3/169.full.pdf+html">impact on health</a> and deaths from <a href="http://apps.who.int/iris/bitstream/10665/112739/1/WHO_HIS_HSI_14.1_eng.pdf?ua=1">non-communicable diseases</a> Increases in technological aids and devices have contributed to this, as has urbanisation. We do less walking, standing and exercise than our ancestors. More time is spent sitting. Yet the benefits of only <a href="http://ajcn.nutrition.org/content/93/4/826.full.pdf+html?sid=42dd5342-3e0c-4da3-8b00-4741fa2e6543">small amounts of activity</a> are clear, and crucially, the benefits are there even for people who are overweight and obese. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=465&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=465&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=465&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=584&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=584&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72357/original/image-20150218-20784-1bimnmx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=584&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Busted. Hippocrates had some sound health advice.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/andrewbain/1523666727/in/photolist-6y5h3e-mGPbgT-bw46an-nPifpx-nVNc2Q-2t7ij-7bKjKG-7tkNwa-z2Lty-GGsB-3jDc2Z-nHS8zr-9AnUco-nHY4sC-69DUed-hKMoG-4GrLwq-a2pD8v-a2svLj-a2pAXR-7bKjKs-cv7icy-2t7jo-dtF2d2-4KJmkV-5qfdXd-5CeWEL-5UAo2-a6Ec2U-hKMoF-4jYVw-o5rsWs-7dSR6v-5zeGqb-a2rRF7-7N99ZJ-etuVx-cwh93-jyaXo4-cwfhX-8pkB93-8zusD1-psNR6e-FKMcW-cwiRB-8Ufjx7-ngPz6p-cw9P1-7GBTRV-6542YN">Taber Andrew Bain</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Hippocrates may have been the first to consider the point, but more recently, studies with data from large populations have made it clear. It is possible to improve health outcomes by sustaining physical activity and that the active overweight have better health risks than “normally” weighted individuals, with a BMI between 20 and 25, who are sedentary. The optimal BMI and high fitness level may well be the best for improving your risks for not developing chronic diseases such as diabetes, high blood pressure and certain cancers. But if you are overweight, then being active is better than being an optimal weight and sedentary. The killer can be the couch, not necessarily the spare tyre.</p><img src="https://counter.theconversation.com/content/37483/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Watt received funding from BBSRC and Diabetes UK. He is affiliated with The Physiological Society and Diabetes UK.</span></em></p>The link between exercise, diet and ill health has been recognised for a considerable length of time. The ancient Greek physician, Hippocrates (460-370BC), wrote: Eating alone will not keep a man well…Peter Watt, Reader, University of BrightonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/365762015-02-10T11:19:14Z2015-02-10T11:19:14ZCalories in, calories out – obesity and the energy imbalance gap<figure><img src="https://images.theconversation.com/files/70881/original/image-20150203-9217-ll5zfv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Balanced?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-116252986/stock-photo-close-up-on-numbers-of-a-bathroom-scale-with-green-translucent-pin-blur-effect.html?src=IRTuuG6xd483iIL9Du0ffQ-1-11&ws=0">Scale via Olivier Le Moal/Shutterstock</a></span></figcaption></figure><p>The prevailing notion about obesity is that if we just work out harder and eat a little bit better, then perhaps the obesity trend will subside in a few years. However, the key to really making a difference is food – the number of calories we eat is the most important factor in obesity. But changing the way people eat will take a very long time.</p>
<p>Things like individual routines, menus, food access and affordability, and cultural practices all influence how we live and eat. All of these things can influence the energy imbalance gap (EIG). The EIG is essentially how many calories you consume versus how many calories you burn in a day. It controls the speed of change in body mass and is at the core of understanding obesity.</p>
<p>Think of the EIG like a gas pedal in a car. If you push the pedal, the gap is positive and obesity trends speed up. If you push the brake, then the gap becomes negative and we would have fewer obese people. A zero gap is like cruise control with a steady obesity prevalence. For example, an EIG of about 10 calories a day leads to weight gain of approximately <a href="http://dx.doi.org/10.1001/jama.2009.1912">one pound per year</a>.</p>
<h2>Measuring the energy imbalance gap</h2>
<p>In a <a href="http://dx.doi.org/10.2105/AJPH.2014.301882">recent study</a>, my colleagues and I applied system dynamics, a simulation method for understanding complex socio-technical systems, to estimate EIG trends in the US. </p>
<p>Measuring EIG directly is complex – even a 1% error in measuring daily energy intake would render the EIG values unreliable. And in typical, self reported calorie intake logs, the main EIG direct measure applicable to large groups, have errors in <a href="http://ajcn.nutrition.org/content/97/6/1413.short">excess of 10%</a>. In fact few previous studies provided reliable EIG estimates for large populations. So we developed a method to reverse engineer the EIG trends based on weight data, just as you can estimate acceleration rates from data on the speed of a car at different times. This method separates the contribution of EIG to population weight profile from other factors such as differential mortality rates due to obesity.</p>
<p>Based on weight data from <a href="http://www.cdc.gov/nchs/nhanes.htm">National Health and Nutrition Examination Survey</a> (NHANES) our research looked at changes in the EIG over the past four decades in representative samples of three different population groups: Non-Hispanic Whites, African-Americans, and Mexican-Americans. We found significant differences among these three population groups as well as between genders within each group.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/70884/original/image-20150203-9217-7l3m4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/70884/original/image-20150203-9217-7l3m4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/70884/original/image-20150203-9217-7l3m4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/70884/original/image-20150203-9217-7l3m4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/70884/original/image-20150203-9217-7l3m4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/70884/original/image-20150203-9217-7l3m4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/70884/original/image-20150203-9217-7l3m4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">10 extra calories a day can lead to 1 lbs of weight gain a year.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-73034776/stock-photo-nutrition-facts-close-up.html?src=PKnFUyXa9Cs73ftTxE4bNA-3-31&ws=0">Label via Ekaterina_Minaeva/Shutterstock</a></span>
</figcaption>
</figure>
<p>For Non-Hispanic Whites, the largest group in the survey (and the largest population group in the US), we found that the average EIG has been positive over the last four decades. That means that this group has been gaining weight consistently, a trend reflected in the current obesity epidemic. But our model shows that the gap is actually shrinking. Once the gap reaches zero, the obesity rate will have stabilized (meaning it is not growing nor shrinking) – and for this population we may be already at that point. This doesn’t mean that the problem of obesity is solved for this group, but it does mean that the problem is no longer getting worse.</p>
<p>We see a different story for African-Americans and Mexican-Americans. For African-Americans, the rate of obesity is growing and the EIG is still not close to zero. The average gap is positive, around 15 extra calories per day, which is a powerful engine behind continued obesity trends. The good news for African-Americans is that the energy gap has started to shrink. Based on current trends we may expect the gap to stay positive for at least another decade before it begins to close. This means that in the future we’ll see more challenges with obesity in the African-American community, which may peak in a decade or so.</p>
<p>The situation for Mexican-Americans is more critical. Not only is the gap positive, at approximately 20 calories a day, it is above the estimates for any other population group. And the EIG is growing at an alarming rate. Not only this group faces a obesity epidemic today, but also the situation is getting worse at an accelerating rate. This population group needs much more attention to turn the tide of the obesity epidemic.</p>
<p>As for gender, our most notable finding pertains to African-American females, who generally have had higher EIGs than African-American males. This means that obesity has been getting worse for females faster than for males. More recently Mexican-Americans show a similar gender gap, with higher EIG for females in the last few years. For Non-Hispanic Whites, the energy gaps are bigger for males than females, thus obesity trends are growing faster for men than women. From food and activity environment to social norms, various factors may explain these differences across population groups, and more research is needed to pin down the exact contribution of each factor.</p>
<h2>Where do we go from here?</h2>
<p>We know obesity is an epidemic so these findings aren’t that surprising. However what is remarkable is the differences among ethnicities. There are numerous programs and policies that target obesity with varying success. Focusing on the ones that research finds <a href="http://dx.doi.org/10.1186/1471-2458-9-419">cost-effective</a> and targeting population groups most at risk would best leverage the limited available resources in controlling future obesity trend and its costs.</p><img src="https://counter.theconversation.com/content/36576/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazhir Rahmandad receives funding from National Institutes of Health.</span></em></p>The energy imbalance gap is how many calories you consume versus how many you burn. Understanding how it differs among different populations could lead to better policies to target obesity.Hazhir Rahmandad, Visiting associate professor , Massachusetts Institute of Technology (MIT)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/239282014-11-18T03:32:41Z2014-11-18T03:32:41ZResettled refugees adopt Australia’s bad food habits<figure><img src="https://images.theconversation.com/files/64217/original/jwcn6hfm-1415684490.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Newly arrived refugees face many obstacles to making healthy food choices.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/annegirl/3217174302">Lucian/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Refugees settling in Australia constantly face new challenges. They have to re-adjust to new income levels, cultural practices and language. They also face a new food environment, where many traditional foods aren’t available and Western foods and preparation styles seem strange or unfamiliar. </p>
<p>In Australia, refugees are often resettled in areas with many unhealthy foods outlets and poor access to fresh fruit and vegetables. Newly arrived refugees have little money to spend on food. They also often don’t have access to a car or nearby public transport, diminishing their ability to make healthy food choices.</p>
<p>This situation is leading to an unhealthy assimilation. By adopting unhealthy diets, refugees are <a href="http://www.health.vic.gov.au/diversity/refugee">at risk</a> of excess weight gain. In turn, that can lead to chronic illnesses such as type 2 diabetes, cardiovascular disease, arthritis and osteoporosis. </p>
<h2>Existing disadvantage</h2>
<p>For refugees, many factors impact on food preferences. These include housing insecurity, employment, financial hardship, changed social status and adapting to a new culture and environment. Parents may prioritise other settlement needs, such as settling children into school and earning an income, ahead of their own health. </p>
<p>Added to these burdens, many newly arrived refugees are contending with significant mental health issues. A <a href="http://www.ncbi.nlm.nih.gov/pubmed/15823380">large British review</a> that tracked 7,000 refugees in resettlement found 9% of adults and 11% of children had post-traumatic stress disorder (PTSD) and 5% of adults suffered major depression. </p>
<p>Pre-arrival factors that <a href="http://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.148.11.1548">may continue</a> to influence diet and nutrition during settlement include prolonged deprivation, <a href="http://www.sciencedirect.com/science/article/pii/014067369291143V">malnutrition</a>, contaminated water, untreated or undiagnosed illnesses such as parasitic infections and chronic diarrhoea, and dental problems that may cause difficulties eating. </p>
<p>Refugees are then faced with unfamiliar Western foods, different food preparation styles, changes to lifestyle and exercise, lack of nutritional education and reduced local access to affordable food. They may not be able to access the traditional foods they’re used to and prefer. </p>
<p>The poor financial situation refugees find themselves in, coupled with a lack of family support and multiple psychosocial stressors, greatly diminishes their ability to make healthy food choices.</p>
<h2>Case study: Woodridge</h2>
<p>We mapped the availability of food outlets and vegetable consumption among a group of resettled African refugees in Woodridge, in Queensland’s Logan Central area. </p>
<p>Woodridge has a total population of 20,650. There are 0.9 fast food outlets per 1,000 people and only 0.1 healthy food outlets per 1,000 people. </p>
<p>We asked 28 participants to complete a questionnaire on household vegetable availability and consumption. The participants ranged in age from 19 to 52 and had lived in Australia for an average of 4.5 years. </p>
<p>We then mapped the routes (using the streets network analysis) from each of the 28 participants’ households to their nearest food outlet. </p>
<p>Within a radius of two kilometres from their home, the participants had access to three healthy food outlets, with a median distance of 841 metres and walking time of 10.5 minutes. They had access to 19 fast food outlets, with a median distance of 641 metres and walking time of eight minutes. </p>
<p>We found participants who lived near a healthy food outlet such as a supermarket or farmers’ market had a higher intake of vegetables than those who lived further away. The critical threshold was around 400 metres.</p>
<p>Those who had significantly better access to takeaways and convenience food shops favoured unhealthy food. </p>
<h2>Adapting to the new food environment</h2>
<p>This complex problem requires a strategic multilevel response. Public health policymakers need to work with refugee communities to develop and implement health promotion strategies to improve diet and nutrition early in the settlement process. </p>
<p>First, initial health assessments must identify nutritional deficiencies and take into consideration the impacts of malnutrition. </p>
<p>Second, newly arrived communities need more information and education about the nutritional value of Western foods, how to assess their healthiness and how to substitute unhealthy foods with more nutritious options. Dietitians and social workers also need to be trained to address cultural differences and traditional preferences.</p>
<p>A culturally sensitive model to “train the trainers” could help newly arrived refugees adapt to their new food environment. This is when one individual from the community is trained, then teaches the skills to others and so on. The training could increase awareness of available healthy Western food, improve cooking skills and educate community members about the impact of unhealthy diets on health.</p>
<p>Finally, and most importantly, governments need to act on the heavy distribution of unhealthy food outlets and lack of access to healthy foods, particularly in refugee settlement areas. </p>
<p><em>This article was co-authored by former Griffith University PhD student Catherine Gichunge.</em></p><img src="https://counter.theconversation.com/content/23928/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Refugees settling in Australia constantly face new challenges. They have to re-adjust to new income levels, cultural practices and language. They also face a new food environment, where many traditional…Ori Gudes, Research fellow, Curtin UniversitySanjoti Parekh, Research fellow, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/322292014-10-09T16:25:58Z2014-10-09T16:25:58ZWhy losing weight is hard – but not impossible<figure><img src="https://images.theconversation.com/files/61279/original/g26twyzk-1412860374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Takes time and effort.</span> <span class="attribution"><span class="source">maradonna 8888</span></span></figcaption></figure><p>Seeing pictures of preened celebrities, or even slimmer friends, makes many wish that their arms were that little bit thinner or abs more tightly toned. Most of us have an existing desire to be a normal healthy weight, but not everyone seems able to achieve this goal. </p>
<p>A government report on obesity, recently <a href="https://www.gov.uk/government/policies/reducing-obesity-and-improving-diet">published by the Department of Health</a>, states that in England most people can be classified as being overweight or obese – 61.9% of adults and 28% of children currently have an unhealthy body mass index (BMI). The government is calling these increasing national obesity levels an “epidemic”, issuing policy changes at an individual, group and societal level. But just how is it that the nation is getting so much rounder?</p>
<h2>Addicted to calories</h2>
<p>Take a trip to your local supermarket and you will instantly be overwhelmed with the abundance of highly-processed junk food which lines the shelves. This widespread availability of unhealthy treats means there is a constant temptation to overindulge. </p>
<p>This contemporary taste for junk food is not exactly a modern phenomenon, and can be traced back two million years. Our ancestors, the first in the <em>Homo</em> genus, developed a taste for high-calorie foods in order to satisfy the energy demands of their burgeoning brains. The 21st-century person has retained these fatty-food cravings, as well as the highly developed large brain. While resisting these high-calorie temptations may fall to the individual, some people may show more addictive behaviours than others.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/61280/original/59kz999h-1412860608.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/61280/original/59kz999h-1412860608.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/61280/original/59kz999h-1412860608.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/61280/original/59kz999h-1412860608.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/61280/original/59kz999h-1412860608.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/61280/original/59kz999h-1412860608.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/61280/original/59kz999h-1412860608.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Too tempting to not have it all.</span>
<span class="attribution"><span class="source">ChameleonsEye</span></span>
</figcaption>
</figure>
<p>The brain’s limbic system is responsible for falling to these temptations. The limbic system is made up of a collection of brain structures, including the <a href="http://thebrain.mcgill.ca/flash/i/i_04/i_04_cr/i_04_cr_peu/i_04_cr_peu.html">amygdala</a>, <a href="https://theconversation.com/explainer-what-happens-in-the-hippocampus-32589">hippocampus</a> and <a href="http://thebrain.mcgill.ca/flash/i/i_03/i_03_cr/i_03_cr_par/i_03_cr_par.html">nucleus accumbens</a>. It rewards us for performing behaviours which aid our survival, like eating or exercising, through the release of the chemical dopamine. </p>
<p>Dopamine makes you feel happy and positive, meaning we are much more likely to repeat the behaviour which led to its release. Engaging with recreational drugs can initially cause the brain to release much higher levels of dopamine than normal. In those with a well-developed substance-dependency, the brain lowers the levels of naturally produced dopamine in an attempt to regain some chemical balance. This leads to a vicious cycle of addiction in which the addict needs more of the substance just to achieve normal levels of dopamine.</p>
<p>Scientists have begun to apply what they know about the brain and addiction to study the relationship between overweight individuals and overeating. <a href="http://www.ncbi.nlm.nih.gov/pubmed/23803881">Research</a> done by the Harvard Medical School found that processed food with a high glycemic index led to increased activations in the nucleus accumbens of overweight participants. </p>
<p>As part of the limbic reward system, the nucleus accumbens has been linked with chronic drug use and addiction. These findings provide some support for the possibility of real physical addiction to food and overeating. Eating sugary, fatty foods which you enjoy may lead to the release of dopamine in the nucleus accumbens, motivating you to repeat these particular eating patterns.</p>
<h2>Negative attitudes to weight gain</h2>
<p>It is the hope that such research may aid the government and the individual in their mission to tackle that pesky inflated BMI. Perhaps if we understand more about influencing factors on chronic overeating, we can better target effective treatment avenues. </p>
<p>That, though, hasn’t stopped people with negative attitudes. Recently, a former Apprentice contestant Katie Hopkins <a href="http://www.theguardian.com/commentisfree/2014/aug/25/katie-hopkins-apprentice-fat-shaming">came under fire</a> for “fat-shaming”. She is working on a documentary for American TV in which, having gained about 25kg earlier this year, she is hoping to show how easy it is to lose weight. </p>
<p>Hopkins and many others place the blame of obesity on idleness, a negative attitude which can be damaging and counterproductive. Shaming people is never a useful way to bring about change. In fact, these sorts of attitudes can <a href="http://hsb.sagepub.com/content/46/3/244.short">prove more detrimental</a> in the quest for weight loss.</p>
<h2>It’s not just about fat</h2>
<p>In some cases these negative beliefs about oneself can lead to a lowered self-esteem, a lack of confidence and even depressive episodes. As with most addictions, depression and depressive thoughts are much more common among the overweight population. The label of “depression” however can attract more unwanted stigma and criticism, despite the fact that <a href="http://www.mentalhealth.org.uk/publications/fundamental-facts/">one in four people</a> a year will experience some kind of mental health problem.</p>
<p>Mental health issues are physical problems which a person cannot just ignore or snap out of. Mental illness <a href="http://www.nimh.nih.gov/health/topics/depression/index.shtml">cause</a> physiological changes to the brain. The “feel-good” chemical serotonin is diminished in the depressed brain, leading to intense sadness and a low mood. </p>
<p>Drug treatments for depression aim to increase the levels of serotonin in the brain. However, it is a more complex picture than a simple chemical imbalance. If we look at the brain of a depressed person, there are certain structures which are smaller than average and have fewer neural connections. The hippocampus in particular is affected, the area associated with controlling memory. There is also increased activity in certain regions of the brain, for instance the amygdala, which has been linked with the experience of emotions.</p>
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<img alt="" src="https://images.theconversation.com/files/61281/original/vhc3sp5m-1412860747.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/61281/original/vhc3sp5m-1412860747.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/61281/original/vhc3sp5m-1412860747.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/61281/original/vhc3sp5m-1412860747.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/61281/original/vhc3sp5m-1412860747.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/61281/original/vhc3sp5m-1412860747.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/61281/original/vhc3sp5m-1412860747.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File:Blausen_0614_LimbicSystem.png">BruceBlaus</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>The hippocampus has a critical role in the processing of long-term memory and memory recollection. Increased exposure to the stress hormone cortisol during episodes of depression can <a href="http://paincenter.wustl.edu/c/BasicResearch/documents/Shelinebiopsy2000.pdf">impair</a> the growth of nerve cells in this region of the brain, leading to a significantly smaller hippocampus. </p>
<p>The amygdala is another part of the limbic system, and is comprised of a group of structures in the brain which are associated with emotions such as anger, pleasure and fear. Activity in the amygdala is higher when a person is sad or clinically depressed. This increased activity means that a depressed person may feel the emotion of sadness more strongly and consistently. </p>
<h2>Tailoring treatments</h2>
<p>In light of the physiological changes which can occur in the brain of the overweight individual, it seems some acknowledgement is in order. Losing weight is not easy. It isn’t as simple as “eat less” or “stop being lazy”. What is required is some sensitivity, some patience and better treatment options. Most people know from experience that eating less or more healthily is hard. If you decided to lose weight, you must first motivate yourself to overcome negative mood or lowered self-esteem, and then overcome the addiction to the food.</p>
<p>It is not all doom and gloom. While losing weight is difficult, it isn’t impossible. It may be possible to train your brain to prefer healthier food. In a recent <a href="http://www.nature.com/nutd/journal/v4/n9/full/nutd201426a.html">study</a>, a group of overweight individuals were enrolled on a weight-loss programme designed by researchers, in which they were given portion-controlled menus and recipe plans. Brain scans were taken of the individuals enrolled in the programme and compared to overweight people in a group that didn’t participate in the programme. </p>
<p>When presented with images of low-calorie food, those in the weight-loss condition showed significantly more activity in the reward centres of the brain. The programme was successfully able to reverse the addictive power of unhealthy foods.</p>
<p>Addiction can also be targeted through behavioural treatments. In more difficult cases cognitive-behavioural therapy (CBT) may be useful to help patients recognise, avoid and cope with situations in which they are most likely to over-indulge. However, an excellent, fun and successful alternative to CBT could be to join a local weight loss group. Weight loss groups provide social support, proven to be an <a href="http://www.apa.org/monitor/jan04/teaming.aspx">effective and economical tool</a> in tackling obesity. Group support and discussion provides the opportunity to share diet and exercise tips, receive encouragement and set realistic weight-loss goals.</p>
<p>Education about the plight of weight loss is essential. Words of judgement may be better replaced with words of encouragement. There are obstacles which stand in the way of weight loss, but by learning about these obstacles we are better equipped to tackle them.</p><img src="https://counter.theconversation.com/content/32229/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kira Shaw is affiliated with @Shef_NeuroGirls </span></em></p>Seeing pictures of preened celebrities, or even slimmer friends, makes many wish that their arms were that little bit thinner or abs more tightly toned. Most of us have an existing desire to be a normal…Kira Shaw, PhD Researcher in Neuroscience, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/273962014-09-21T20:42:42Z2014-09-21T20:42:42ZAustralia vying to be world champion of inactivity<figure><img src="https://images.theconversation.com/files/58966/original/7sg37c9v-1410742547.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Australia tops the world for physical activity-friendly built environments but ranks second last for levels of children's activity.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/niceimages/8184353426/in/photolist-662EaZ-5nLcu2-8szkFd-dtdKWD-bi1ZN4-dtdX8Q-8b2wXM-TjdN-6S3X1n-9bPojU-eUiLC-823xRB-9d9xNF-6oiytY-Hy52e-nnJjq-4pjmQD-5nsXZ5-ioNXmr-ofUZgM">drpavlof/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>If we could go back 100 years in a time machine, what would kids be like? They’d be shorter, leaner, probably dirtier and less well-fed — but would they be fitter? </p>
<p>It turns out we actually have a beautiful window on the past. In 1919, a young woman named E.M. Bedale started postgraduate research at University College London, an uncommon undertaking for a woman at that time. Her studies focused on energy balance in children, which led her to spend several years at a serendipitously eponymous school called Bedales in rural Hampshire. </p>
<p>During her two years at Bedales, Miss Bedale measured the <a href="http://rspb.royalsocietypublishing.org/content/94/662/368.full.pdf+html">energy expenditure and intake</a> of the school’s students, using methods that are still considered to be gold standards today.</p>
<p>Her data provide a startling contrast to our time. Children from almost 100 years ago were 50% more active than kids today. They accumulated over four hours more of physical activity and sat for three hours less than today’s kids - every day.</p>
<p>Clearly, we’re now in the grip of an inactivity epidemic.</p>
<h2>A shrinking world</h2>
<p>Consider, the global <a href="http://www.activehealthykidsaustralia.com.au/wp-content/uploads/2014/05/ahka_reportcard_longform_web.pdf">decline in kids walking or cycling</a> to school. In 1970, almost 70% of Australian kids walked or cycled to school. Today, this proportion is barely 25%. The trend is similar in the United Kingdom, Brazil, Switzerland, the United States and Canada.</p>
<p>In some ways, sports participation is going the same way. While overall yearly participation in sport is increasing, kids are playing fewer different kinds of sports. In 1985, 40% of Australian children played three or more sports every year. By 2000, only 11% of children reported playing this number of sports within the same period.</p>
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<img alt="" src="https://images.theconversation.com/files/59076/original/dcyn8jsv-1410833722.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/59076/original/dcyn8jsv-1410833722.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=535&fit=crop&dpr=1 600w, https://images.theconversation.com/files/59076/original/dcyn8jsv-1410833722.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=535&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/59076/original/dcyn8jsv-1410833722.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=535&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/59076/original/dcyn8jsv-1410833722.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=673&fit=crop&dpr=1 754w, https://images.theconversation.com/files/59076/original/dcyn8jsv-1410833722.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=673&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/59076/original/dcyn8jsv-1410833722.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=673&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>Free play — climbing trees in the backyard, mucking around in parks or bushland, informal ball games — is also declining. </p>
<p>In 1957, 12 to 14-year-old kids were asked to nominate their favourite play spaces. Four out of five boys and three out of five girls nominated outdoor spaces (parks, backyards, the local creek). When the survey was repeated in 2000, only 35% listed outdoor spaces. </p>
<p>In the 1960s, 83% of kids were allowed to play unsupervised in the neighbourhood. When those kids from the 1960s grew up and became parents, <a href="http://www.activehealthykidsaustralia.com.au/wp-content/uploads/2014/05/ahka_reportcard_longform_web.pdf">only 25% allowed</a> their own children to play unsupervised in the neighbourhood. </p>
<h2>Not just kids</h2>
<p>Australia is not alone. There are other signs of a global collapse in physical activity too. Worldwide, children’s fitness has been <a href="http://link.springer.com/article/10.2165/00007256-200333040-00003">declining at the rate of 3% to 5%</a> per decade since 1970. And Australian kids are now in the bottom third of the world in fitness. </p>
<p>Australia finished second last in the <a href="http://www.activehealthykidsaustralia.com.au">Global Report Card on Kids’ Physical Activity</a> released earlier this year, which showed data from 15 countries. (Thank goodness for the Scots, who finished last.) </p>
<p>We’re third worst in terms of screen time – television, computers and videogames. And it’s not just kids. </p>
<p>In the 1960s, half the jobs in private industry in the United States required at least moderate-intensity physical activity, compared to less than 20% today. </p>
<p>Work in factories and farms has <a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0019657">given way to office work</a>, and that has amounted to over 400 kilojoules less each day that adults expend at work. This difference alone results in a weight increase of about 13 kilograms over 50 years, which pretty closely matches actual changes in weight. The situation is similar here.</p>
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<img alt="" src="https://images.theconversation.com/files/59077/original/w2w49983-1410833806.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/59077/original/w2w49983-1410833806.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=713&fit=crop&dpr=1 600w, https://images.theconversation.com/files/59077/original/w2w49983-1410833806.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=713&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/59077/original/w2w49983-1410833806.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=713&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/59077/original/w2w49983-1410833806.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=896&fit=crop&dpr=1 754w, https://images.theconversation.com/files/59077/original/w2w49983-1410833806.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=896&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/59077/original/w2w49983-1410833806.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=896&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>It’s not that we don’t have the opportunity or the facilities or the climate for physical activity. Global Report Card data show Australia tops the world for physical activity-friendly built environments, and is third on school facilities. It seems that we built it but they didn’t come. </p>
<h2>Post-industrial malaise</h2>
<p>The roots of inactivity go deep into the cultural and socioeconomic logic of post-industrial societies. In many ways, the whole ethos of ease now saturates our society, and efficiency is the hallmark of modernity. </p>
<p>Think about it this way - nobody is in the market for a labour-creating device. Sit-on mowers, leaf blowers, self-opening doors and automatic car windows, robot vacuum cleaners, sensor lighting, dishwashers and microwaves all yield daily microsavings in energy expenditure that add up to hundreds of kilojoules. </p>
<p>In 1900, the average American housewife spent an estimated 40 hours every week in food preparation. Today, that time is <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639863/">barely four hours</a> — and it appears to have reached an absolute minimum.</p>
<p>What can be done about it? We’re not going to wind back time to the days of kids playing cricket in the street, families driving the Vauxhall Viva with wind-down windows, dads pushing hand mowers and mums using wringers. </p>
<p>The challenge is to fashion spaces where alternative forms of active leisure can be pursued. And we’ve already started: the gymnasium is such a space, internalising the lost world of manual labour. Exergaming (think Wii), which transposes outdoor play spaces into virtual worlds, is similar. </p>
<p>We all need to re-imagine physical activity if we’re to overcome this malaise of post-industrial society.</p><img src="https://counter.theconversation.com/content/27396/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tim Olds receives funding from the National Health and Medical Research Council, the Australian Research Council, SA Health, Beyond Blue, the National Stroke Fundation, and the Channel 7 Children's Research Foundation.</span></em></p>If we could go back 100 years in a time machine, what would kids be like? They’d be shorter, leaner, probably dirtier and less well-fed — but would they be fitter? It turns out we actually have a beautiful…Tim Olds, Professor of Health Sciences, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/282132014-09-10T20:26:45Z2014-09-10T20:26:45ZBig Food with a regional flavour: how Australia’s food lobby works<figure><img src="https://images.theconversation.com/files/53164/original/m7ks4kf7-1404717425.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Big Food in Australia is not the same as the industry in the United States, where much of the popular media has come from. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/stevecaddy/2224874595">Steven Caddy/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Criticism of the food industry has itself become a niche industry. But the tendency to embrace a US-centric conception of how the industry works risks masking local variants and inhibiting a targeted response in other countries.</p>
<p>Since the 2001 book <a href="http://en.wikipedia.org/wiki/Fast_Food_Nation">Fast Food Nation</a>, a spate of books, films and documentaries on the American food industry have helped to shape the popular idea of “<a href="http://www.ploscollections.org/bigfood">Big Food</a>”. </p>
<p>The food industry is depicted as a highly organised set of multinational food and beverage lobbyists peddling the global diet of sugary drinks and highly processed, energy-dense salty foods – akin to tobacco industry lobbyist Nick Naylor in the 2005 film <a href="https://www.youtube.com/watch?v=iBELC_vxqhI">Thank You For Smoking</a>.</p>
<p>But although it is highly globalised, the food industry is far from homogeneous. Big Food in Australia is not the same as the industry in the United States, where much of the popular media has come from. </p>
<p>Still, that doesn’t mean Australian food and beverage lobbying is benign.</p>
<h2>A public health problem</h2>
<p>Responding to the threat posed by the food industry to public health locally requires a clear understanding of food industry tactics in the context of Australia’s political and lobbying culture. </p>
<p>The food manufacturing industry is Australia’s largest manufacturing sector, accounting for $111 billion and almost one in six jobs. Its peak body, the <a href="http://www.afgc.org.au/whoweare.html">Australian Food and Grocery Council</a> (AFGC), wields enormous power. </p>
<p>The AFGC aims to shape a <a href="http://www.afgc.org.au/whatwedo.html">regulatory environment</a> that increases the profitability of the food and beverage sector. Its approach generally involves securing a seat at the policy table and arguing food industry <a href="http://www.publish.csiro.au/?paper=HE10229">regulation is unnecessary</a> or flawed. </p>
<p>It uses three main tactics to do this.</p>
<p>First, it pre-empts government regulation by introducing its own voluntary schemes. </p>
<p>Consider the long-running dispute around the food industry’s <a href="https://theconversation.com/industry-winning-the-fight-against-better-food-labelling-22472">daily intake guide</a> nutrition labelling system. <a href="http://www.biomedcentral.com/1471-2458/10/662">Much criticised</a> by public health experts, it has now been included alongside the <a href="https://theconversation.com/after-three-year-saga-health-star-rating-labels-finally-ready-to-go-25794">health star rating system</a> favoured by health and consumer groups. </p>
<p>The <a href="http://www.afgc.org.au/media-releases/1306-industry-surpassing-advertising-to-children-self-regulatory-initiatives.html">Responsible Children’s Marketing Initiative</a> is another attempt at <a href="https://theconversation.com/side-stepping-the-censors-the-failure-of-self-regulation-for-junk-food-advertising-2006">voluntary self-regulation</a>. The food industry introduced it in 2008, just as the federal government was considering tighter restrictions on food advertising to children. </p>
<p>While appearing to tick a regulatory box, public health researchers argue the initiative’s <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12134/abstract">many loopholes</a> prevent it from achieving its aims. Companies are able to choose their own nutrition criteria to identify “healthy choice” products, for instance, and the initiative doesn’t cover widely-used marketing techniques, such as product packaging and point-of-sale advertising.</p>
<p><a href="http://link.springer.com/article/10.1007/s11673-013-9441-z">Like many self-regulatory schemes</a>, it has no formal sanctions for non-compliance, and relies instead on peer pressure and companies’ fear of damage to their reputations.</p>
<p>Voluntary schemes such as this function both as a delaying tactic and a distraction: the rear-guard actions of companies that recognise the changing tone of public opinion and know government regulation can’t be far away.</p>
<p>Then, there are corporate social responsibility initiatives focusing on the exercise side of the energy imbalance equation that is leading to population-wide weight gain.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/53166/original/cj2k7tyk-1404717838.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/53166/original/cj2k7tyk-1404717838.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/53166/original/cj2k7tyk-1404717838.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/53166/original/cj2k7tyk-1404717838.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/53166/original/cj2k7tyk-1404717838.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/53166/original/cj2k7tyk-1404717838.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/53166/original/cj2k7tyk-1404717838.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Although it is highly globalised, the food industry is far from homogeneous.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/rhk313/2242916963">Rami/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>Given a choice, the food industry would prefer us to move more, rather than consume less. Sponsoring <a href="http://www.jsams.org/article/S1440-2440%2813%2900151-5/fulltext">children’s sporting events</a> and facilities has been one highly visible way of encouraging this. </p>
<p>Public health physician and researcher, Nathan Grills <a href="http://www.intechopen.com/books/public-health-methodology-environmental-and-systems-issues/new-challenges-in-public-health-practice-the-ethics-of-industry-alliance-with-health-promoting-c">argues that McDonald’s</a> has “inserted itself into the health DNA of our schools and youth clubs” in a manner that blurs the lines between altruism and exploitative marketing.</p>
<p>Less overt strategies include campaigns that recruit celebrities to encourage people to make better choices while ignoring the fact that our food environment does the opposite. One good example of this tactic is the <a href="http://www.togethercounts.com.au/">Together Counts</a> campaign, which features swimmer Susie O’Neill encouraging families to take a pledge to “making changes towards a healthier lifestyle”. </p>
<p>By focusing on exercise and consumer choice, the <a href="http://www.vicpcp.org.au/sites/default/files/18.%20From%20Norm%20to%20Eric_Baum_2011_editorial%20ANZJPH_2.pdf">food industry reinforces</a> ideas that health is a matter for personal responsibility and self-regulation - not <a href="https://theconversation.com/no-place-for-industry-in-the-fight-against-lifestyle-diseases-12150">government regulation</a>. </p>
<p>The AFGC’s third tactic is to influence policy, from both inside and outside the tent.</p>
<p>As encapsulated by <a href="http://www.deloitteaccesseconomics.com.au/uploads/File/DAE-AFGC%20reform%20FINAL%20281013.pdf">this report</a> on “Reforming regulation of the Australian food and grocery sector” from October 2013, the AFGC’s vision of regulation is in direct conflict with that of public health advocates – especially when it comes to preventive health. </p>
<p>It seeks to realise its vision of lighter regulation through <a href="http://www.afgc.org.au/tools-guides-.html">submissions to government enquiries</a>, representation on government committees and working groups, and new industry-centric regulatory initiatives such as the <a href="http://www.foodhealthdialogue.gov.au/internet/foodandhealth/publishing.nsf/Content/about-us">Food and Health Dialogue</a>. </p>
<p>And it seems the efforts are paying off. Parts of its wishlist came closer to being granted in the recent federal budget. This included cutting funds to the National Preventive Health Agency and National Partnership Agreement on Preventive Health. The AFGC believed these bodies <a href="http://www.afgc.org.au/media-releases/1938-budget-drives-practical-health-reforms.html">increased regulatory complexity and prescriptive policy interventions</a>. </p>
<h2>Deregulation is the new regulation</h2>
<p>These tactics don’t have quite the Big Food drama of lacing your hamburger with high-fructose corn syrup, covertly funding NGOs to act as <a href="http://www.nytimes.com/2014/02/12/business/rival-industries-sweet-talk-the-public.html?_r=1">front-groups</a> for the <a href="http://www.washingtonpost.com/politics/soft-lobbying-war-between-sugar-corn-syrup-shows-new-tactics-in-washington-influence/2014/02/12/8123da00-90dd-11e3-b46a-5a3d0d2130da_story.html">sugar lobby</a> or working with the agriculture department to invent <a href="http://www.nytimes.com/2010/11/07/us/07fat.html?pagewanted=all">stuffed-crust pizzas</a> as happens in the United States. </p>
<p>But it would be a mistake to confuse this lack of pyrotechnics with a lack of power. The AFGC’s tactics may seem vanilla, but they have a profound influence on the Australian food system and the way it’s regulated. </p>
<p>And don’t succumb to the temptation of reading corporate influence along party lines. Australian governments since the 1980s have been bipartisan in their faith that a thriving market economy can address most social ills. </p>
<p>The food industry’s preferences are in keeping with the broader trend for governments from both sides of politics to favour deregulation of business as a default. AFGC arguments about “easing the burden of regulation” fall on fertile ground, while calls to regulate industry influence or protect public health struggle to get a hearing. </p>
<p>These shifts are not only a problem for public health, but also for our political health.</p>
<p>Popular US representations of Big Food have been helpful in raising awareness of the influence of the food industry on diet, public health, and government action. </p>
<p>“Big Food” in Australia may not have the shock appeal of a <a href="https://www.youtube.com/watch?v=5eKYyD14d_0">Food Inc</a> or an <a href="http://en.wikipedia.org/wiki/The_Omnivore%27s_Dilemma">Omnivore’s Dilemma</a>. But taking the time to understand Australian regulatory and policy trends, and the impact of local food industry lobbying on them, will ultimately have more relevance and critical purchase.</p><img src="https://counter.theconversation.com/content/28213/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jenny Kaldor receives funding from the Australian Government under an Australian Postgraduate Award, as well as from Sydney Law School and the Charles Perkins Centre.</span></em></p><p class="fine-print"><em><span>Christopher Mayes does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Criticism of the food industry has itself become a niche industry. But the tendency to embrace a US-centric conception of how the industry works risks masking local variants and inhibiting a targeted response…Christopher Mayes, Post-Doctoral Fellow in Bioethics, University of SydneyJenny Kaldor, Doctoral researcher in public health law, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/271202014-05-26T20:08:03Z2014-05-26T20:08:03ZAdding GST to fresh food is a recipe for poor health<figure><img src="https://images.theconversation.com/files/49426/original/gs2z8yyg-1401077231.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most Australians already fail to meet the recommended daily intake of fruit and vegetables.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/norwayneedles/3747187586">Strikkelise/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>Recent calls by Australian <a href="http://www.smh.com.au/federal-politics/political-news/slap-gst-on-fresh-food-says-senior-coalition-mp-20140519-38k88.html">government ministers</a> and <a href="http://www.abc.net.au/radionational/programs/rnfirstbite/potential-health-impacts-3a-gst-on-fresh-food/5467836">senior officials</a> to broaden the goods and services tax (GST) base to include fresh fruit and vegetables would make the population’s diet go from bad to worse.</p>
<p>The latest <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.007">Australian Health Survey</a> results show less than 7% of the Australian population meet the recommended intake of vegetables (five serves per day for adults), and just over half (54%) meet the recommended serves of fruit (two serves per day for adults). </p>
<p>In contrast, a staggering 35% of the nation’s total energy consumed is from “discretionary foods” – foods considered to be of little nutritional value that tend to be high in saturated fat, sugar and salt, or alcohol. </p>
<p>Indeed, the poor diet of the population is now the <a href="http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_australia.pdf">biggest contributor</a> to disease and illness in Australia - even more than smoking. And the <a href="http://www.thelancet.com/series/obesity">main driver</a> of the problem is the ever-increasing supply of cheap, tasty, high-calorie foods that are heavily marketed and widely available. </p>
<p>As other countries consider ways to combat the problem, the Australian government seems to be discussing options that will make it worse.</p>
<h2>Effects of adding GST to fresh food</h2>
<p>Price is one of the <a href="http://www.ncbi.nlm.nih.gov/pubmed/9787717">most important factors</a> that consumers take into account when deciding what to buy. Taste is the other main consideration. </p>
<p>Fresh fruit and vegetables are currently exempt from GST, which means there’s an incentive to buy them rather than <a href="http://onlinelibrary.wiley.com/doi/10.1111/obr.12107/abstract">less healthy</a> processed food.</p>
<p>Recent <a href="https://www.mja.com.au/journal/2013/199/8/removing-gst-exemption-fresh-fruits-and-vegetables-could-cost-lives">estimates</a> show that if the 10% GST were applied to fresh fruit and vegetables, their overall consumption would decrease by about 5%. </p>
<p>When the long-term effects of this change <a href="https://theconversation.com/taxing-fresh-foods-could-have-a-big-bad-health-impact-19146">are modelled</a>, this would result in an additional 90,000 cases of heart disease, stroke and cancer each year, increasing health-care costs by around $1 billion.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/49432/original/9vth847w-1401079806.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/49432/original/9vth847w-1401079806.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/49432/original/9vth847w-1401079806.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/49432/original/9vth847w-1401079806.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/49432/original/9vth847w-1401079806.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/49432/original/9vth847w-1401079806.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/49432/original/9vth847w-1401079806.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Consumption of ‘discretionary foods’ may increase with the removal of the GST exemption on fruits and vegetables.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/muyyum/6950135761/sizes/l">Flickr: Muy Yum</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The effects are <a href="http://secure.secondbite.org/sites/default/files/A_review_of_the_literature_describing_the_link_between_poverty_food_insecurity_and_obesity_w.pdf">likely</a> to be felt strongest by people with low incomes. This group tends to spend a large proportion of its income on food and already has poorer health outcomes.</p>
<h2>Global actions in this area</h2>
<p>A move to increase taxes on fresh fruit and vegetables would fly in the face of global recommendations to improve poor health. The <a href="http://www.who.int/nmh/events/2013/revised_draft_ncd_action_plan.pdf">World Health Organisation (WHO) recommends</a> governments consider different economic tools (such as taxes and subsidies) to improve the affordability of healthier foods and discourage the consumption of less healthy options.</p>
<p>Several countries have recently adopted new taxes on unhealthy foods in line with these recommendations. From this year, <a href="http://www.theguardian.com/world/2014/jan/16/mexico-soda-tax-sugar-obesity-health">Mexico has introduced</a> a 10% tax on sugary drinks and a 5% tax on unhealthy snack foods. And <a href="http://www.spiegel.de/international/europe/battling-the-couch-potatoes-hungary-introduces-fat-tax-a-783862.html">Hungary has introduced</a> a tax on unhealthy foods.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/21079620">Estimates show</a> that if Australia were to increase taxes on unhealthy food by 10%, this would greatly benefit health and result in substantial cost savings to the government. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/19483200">Evidence indicates</a> the revenue generated from a tax on unhealthy foods should be used to subsidise fruit and vegetables in order to get even better health outcomes. </p>
<h2>Public health set to decline</h2>
<p>Australia has <a href="https://theconversation.com/who-reveals-how-tobacco-control-measures-are-improving-health-worldwide-15995">long been recognised</a> as a public health leader for its preventive health actions and, in particular, its efforts to reduce tobacco use. </p>
<p>But this reputation is set to decline with the massive cuts to <a href="http://www.budget.gov.au/2014-15/content/bp2/html/bp2_expense-14.htm">preventive health</a> in the latest budget.</p>
<p>If the country were to increase taxes on fruit and vegetables, it would undermine the reductions in chronic disease that have resulted from national success in tackling smoking. </p>
<p>It would also place the country at the bottom end of the list of countries taking globally recommended actions to improve population nutrition.</p>
<p>The question of how best to approach Australia’s rising health care, education and social welfare costs is clearly an important one. But we need to consider the ramifications of potential solutions on short- and long-term economic, social, environmental and health outcomes.</p><img src="https://counter.theconversation.com/content/27120/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gary Sacks receives funding from the Australian National Health and Medical Research Council (NHMRC)</span></em></p>Recent calls by Australian government ministers and senior officials to broaden the goods and services tax (GST) base to include fresh fruit and vegetables would make the population’s diet go from bad…Gary Sacks, Senior Research Fellow, WHO Collaborating Centre for Obesity Prevention, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.