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Saturday, 1 October 2011

Obesity - a big problem with bigger political implications

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It’s a growing problem, the battle of the bulge. And it is not a pretty sight. 
Taken as any other public health problem, it has some interesting contexts.   We all need to eat, and obesity is the result of having eaten too much.   Such a high proportion of the population do not have a healthy weight, only 45% of women and 31% of men.   Taking public health issues back to the basics, the first step is to describe the problem. Obesity in Canada Obesity in Canada  is a publication released in June with so much fanfare that I only just discovered the link while surfing the PHAC website and I can find no record of any media release of its announcement.    Perhaps the communications department is a bit too thin. 
While Canada is substantively smaller than our cousins to the south, obesity rates of 25% and continuing to grow are unacceptable. 
There is lots of great information in the publication.   Epidemiologists doing what they do best, describing the problem in minute detail.  It is reference material that many will find useful in helping tackle the problem.  That is where the challenge begins.  Despite the largeness of the dilemmia, effective interventions are hard to grasp onto. 
There are several thrusts that are required, and need to be kept distinct.
1.      Preventing the expansion of the problem
2.      Managing those with increased weight problems
This is not an all or nothing issue like tobacco, or even as graduated a challenge as controlling alcohol.  We all consume calories during the day, and usually through multiple meals.  Cutting back is just not that simple – no doubt most of us have tried with varying success and more often not. 
The simpler issue may be to prevent the problem.  Of course, lets torture our children into behaviours that we ourselves struggle to adopt.   Eliminate the sugary drinks, increase the physical exercise, support them in adopting healthy habits while we sit back and chug another cola.   While we know we need to do something, and I fully support the need to do something, we really don’t know what will be effective in the long term.
Worse still is that our ability to intervene to support persons who are over their ideal weights is even less clear.   Physical activity, while an important supplement to weight reduction, has not yet been shown to be sustainable in supporting healthy weight loss.   Dietary manipulation seems the logical solution, yet debates rage about low fat versus high fat versus healthy fat.  Low carbohydrates versus low sugars with complex carbohydrates.  High protein, low protein. Its no wonder that the diet industry is estimated to be worth nearly $600 Billion dollars globally annually (okay, for those who would like to see their purses and wallets fattened, here is ‘healthy’ growth).  The Canadian market likely comes in at about $4-5 Billion annually.
Almost perversely, the best evidence for successful weight loss and maintenance is in bariatric (weight reduction) surgery.  Given many surgical procedures lack good evidence of their effectiveness, it is the irony that here is one which has been reasonably well documented for those with extreme weights.
Of course, in the face of evidence to change public policy like limiting certain foods, reducing portion sizes, engineering foods with less calories, increasing prices of poor quality high calorie foods etc.  all of which will more than likely be vehemently opposed by the food industry (they have effectively shut down efforts to reduce salt content of processed foods).  “Big Sugar” is the growing term similar to “Big tobacco” and “Big Pharma” to represent these vested interests. 
The absence of clearly effective approaches in the face of industry opposition must cause political reluctance.   Obesity reduction strategies have been in the works in some provinces.  They are usually couched in either a diabetes prevention strategy, or a childhood obesity strategy but full strategies do not seem to see the light of day because of the implications on the food industry.  
Perhaps we need to exercise a bit and find out why comprehensive obesity strategies have not been released, and the PHAC report just “showed up” with no fanfare.   It’s a heavy subject and public health has rarely shied away from difficult problems.  Time to step to the plate. 

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