SERIES: Part 3 – Even more causes of rising obesity incidence in the United Kingdom

This is Part 3 of my Obesity in the UK series. If you missed Part 1, or Part 2, you can find them by following the links. 🙂 Like part two, this part addresses causal factors but with a greater emphasis on some indirect causes.

Beliefs, Perceptions and Stigmatisation

There is evidence to support that a potential driver of obesity is the failure of obese persons, or parents of obese children, to recognize themselves or their child as obese. In short, weight perceptions among obese adults in Britain do not match clinical definitions of obesity. Most obese adults do not describe themselves as obese. Another study of 2976 English children found that a third of parents underestimate their child’s BMI.

As more people in the community grow into the category of obesity, perceptions of “normal” for everyday Britons may be increasingly swayed. Even teenagers, were not immune to this warped self-perception in terms of weight: 39% of overweight teenagers described themselves as “normal”.

At first glance, these findings seem almost counterintuitive. However, in a society that stigmatizes obesity, it is no surprise that many do not wish to recognize themselves as “obese”.

Moreover, overweight and obese individuals who reported experiencing fat stigmatization gained 0.95kg over a year. In an image-obsessed world, many people are experiencing stigmatization due to their weight. Thus, paradoxically, this cruel, “skinny-culture” may be a factor driving more overweight individuals towards obesity.

 

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Socioeconomic status

At first glance, higher levels of obesity among low-income groups may too seem counter-intuitive. However, in the UK, as in many other high and middle-income countries, this is the case.

There is an existing or emerging inverse relationship between income and obesity. Attempts to explain these trends follow the assumption that in high and middle- income nations, the vast majority of the population is able to afford to be adequately fed. Thus, a very negligible proportion of the population will be underweight due to an economic inability to access food. What may be significant in understanding this is how socioeconomic factors drive the types of food that individuals and families consume on a regular basis.

Whilst the prevalence of childhood obesity and overweight in the UK has stabilized in recent years, children from the lowest socioeconomic groups have continued to exhibit increased levels of overweight and obesity in comparison to their counterparts from other socioeconomic strata. The outlook is similarly bleak for low-income adults. This points to the importance of appropriate education on diet. According to the HSE, lower income women exhibited a higher proportion of obesity: 26% – 31%, as opposed to 15% – 18% in the highest income quintiles. Men in the lowest income groups were also more likely to be obese: 29% – 30% were classified as obese, versus 23% – 24%.business-cash-coin-concept-41301

Urbanization is shown to have an effect on diet. In a study examining obesogenic environments, it was found that individuals in the most deprived areas consumed significantly fewer portions of fruit daily; as did those living in densely populated environments. According to the World Bank, in 1985, 78% of people in the UK lived in urban areas, versus 82% today, a percentage that is expected to increase.

Furthermore, energy-rich, processed foods are cheaper to produce and thus cheaper to purchase. Many are increasingly marketed towards children from a young age. These subtle lifestyle changes may be driving many Britons transition into overweight and obesity, resulting in continued increased incidence.

Slightly distinct from the factor of income is that of income inequality. Studies show that national income inequality is associated with higher BMIs within obese populations, lower life expectancy and other negative health and psychosocial outcomes. It is theorized that life near the bottom of more hierarchical societies, such as the USA, results in higher levels of psychosocial stress than in more equal nations, such as Sweden.

Compared to many other high-income countries, the United Kingdom has a very high level of income and wealth inequality. Moreover, the gap growing: between 1985 and 2010 inequality rose by almost 25%, making the UK the most unequal country in Europe.

Thus, growing inequality may be one of the primary factors driving growing waistbands.

SERIES: Part 2 – Causes of Rising Incidence of Obesity in the United Kingdom

This is Part 2 of my Obesity in the UK series. If you missed Part 1, you can find it here.

So back to Causes.

Among other factors, rising incidence of obesity in the UK can be explained by behavioral theories relating to changes in physical activity and eating behavior.

Basic weight gain is most commonly caused by excess energy consumption for expenditure. Rising incidence of overweight and obesity on a population level, however, is more complex. Whilst there are individual physiological and genetic factors resulting in obesity, one may infer that obesity trends are a result of multiple direct and indirect factors including social, political and economic factors affecting our behaviour. Some of them are introduced here.

Environmental Obesogenicity

Environmental factors of societal and market forces driving eating behavior within the population are an area of increasing interest. An obesogenic environment is one where the food and activity environment may drive individuals towards obesity progression. Plenty can be said about obseogenic environments and I will write about this particular aspect more pointedly in future.

Physical Activity and Inactivity

Similarly, It is well understood that appropriate physical activity is a means of effective weight management. It has been argued that the cause of weight gain pertaining to physical exercise is not only low levels of physical activity, but also by high levels of physical inactivity. Sedentary behaviour in itself is linked to co-morbidities.

One theory for increased incidence of obesity considers decreased levels of energy expenditure. An example of this is a change in shopping behavior. Greater accessibility and affordability of services such as online grocery shopping and delivery positively impact the lives of many people, e.g. disabled and elderly, but many modern conveniences have come at a social cost to health.

A greater proportion of the working population in the UK is employed in occupations conducive to levels of relative inactivity. Improved transport services, urbanization, affordability of vehicles and even mobile internet access have made life more convenient, de-necessitating much of our passive physical activity. As early as 1984, a US telephone company estimated that an additional phone extension in the household saves approximately 1.6km of walking annually.

It has been found that children were more likely to be obese for each additional hour of sedentary time. Low levels of activity have been shown to be the most prominent risk factor for weight gain. This trend of increased sedentary behavior may form part of the forces driving obesity incidence in the UK.

Eating Behaviour

Genetics & Physiology

A number of studies have explored the genetic bases of obesity. In particular, twin studies and Genome-wide association studies (GWAS). Results of the Twins Early Development Study (TEDS) show a strong heritability of adiposity and waist circumference as do GWAS. However, these explain less than 3% of BMI variation in children and adults.

Furthermore, it is unlikely that genetic factors are central to rising obesity incidence, as these have not changed substantially, relative to the short time frame of rising prevalence discussed earlier.

 

 

There is no doubt that the causes of rising obesity are complex, multiple and multifactorial. Thus, this article has a Part 2: More Causes of Rising Incidence of Obesity in the United Kingdom

SERIES: Rising incidence of obesity in the United Kingdom – Introduction

In the past three decades obesity in the United Kingdom has increased three-fold, emerging as one of the UK’s most prominent public health challenges. Obesity is largely a lifestyle and behavior associated condition, although there are also some genetic factors.

Obesity is measured by a standard anthropometric measurement of known as Body Mass Index (BMI). The terms overweight and obese are usually classified as increased weight-for-height. The figure below classifies the BMI ranges used to define BMI status. (Do you know your BMI?) BMI is calculated by dividing the weight in kilograms by the square of the height in meters. (Or googled)

BMI INDEX FOR GLOBAL HEALTH BLOG

An individual whose weight is two or more times the ideal weight is classified as morbidly obese.

Recent studies show steady increases in obesity incidence both nationally and internationally. Indeed, today we live in a world where more people are clinically obese than those suffering morbidity or mortality due to starvation.

Globally, the percentage of people classified as overweight or obese increased in both men and women from 28.8% and 29.8% in 1980 to 36.9% and 38.0% respectively. Child overweight and obesity also increased. In 2013, World Health Organization adopted a target of halting the rise in child obesity by 2025.

The primary reason obesity is a public health concern is because it is a risk factor for other non-communicable diseases (NCDs) such as Type II Diabetes Mellitus (T2DM), hypertension and coronary heart disease (CHD). Morbid obesity, considered the most serious stage of obesity, can leave patients at the highest risk of mortality related to their obese status.

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Throughout this series I will outline the causes and consequences of rising obesity incidence as identified in empirical studies and literature. All sources are available upon request.

Likely due to methodological challenges, much of the available data on obesity in the UK and elsewhere discuss prevalence and not necessarily incidence. However, understanding disease prevalence and its nuances is useful in interpreting both causal and consequential factors of incidence.

 According to Health Survey for England (HSE), in 2013, 26% of men and 24% of women were classified as obese; 41% of men and 33% of women were classified as overweight. Scotland and Wales had similar findings.

The UK has seen increases in obesity in children for several years. In 1995, 11% of boys and 12% of girls were classified as obese. By 2005, these numbers were 18% and 19% respectively. These increases have since leveled off: to 16% of boys and 15% of girls in 2013.

The prevalence of obesity is significantly higher in some groups. Children were more likely to be obese if they lived in an urban area. Whilst 22% of boys and 21% of girls from the lowest-income families were already obese.

Rising incidence of obesity is a problem

The major problem presented is the co-morbidities with which obesity is associated. Obesity is a major risk factor for many NCDs, thus causing and contributing to a high proportion of morbidity and mortality.

Type 2 Diabetes Mellitus (T2DM) is strongly correlated with obesity. The detrimental effects on an individual living with obesity and T2DM are multiple-fold. Rising incidence of obesity in children is well correlated with incidence of childhood T2DM. Expectedly, in terms of reducing the risk of cardiovascular diseases, particularly coronary heart disease, greater reduction in adiposity results in greater risk reduction. With the exception of LDL cholesterol, fat loss in obese patients improves blood pressure, glycemic control and lipids.

T2DM is simply hyperglycemia resulting primarily from a resistance to insulin but also from impaired insulin secretion. Clinical studies have shown the metabolic effects of high sugar, particularly fructose. These sugars mediate fatty liver and insulin resistance in humans. In a typical Western diet, the majority of fructose comes from sugary, soft and fruit drinks, often resulting in significantly elevated levels of fasting glucose and thus, high levels of insulin, leading to resistance.

Obesity also has a role in worsening nocturnal hypoxia in obstructive sleep apnea syndrome (OSAS). It has been theorized that oxidative stress and inflammation caused by OSAS is a major factor causing cardiovascular morbidity and mortality in obese patients.

This series will explore the causes, consequences and some potential solutions to rising obesity incidence in the UK. The significant contribution of behavioural factors to the rising prevalence and incidence of obesity suggests an important role for well-defined interventions to manage and reduce obesity levels. It is clear, however, that the burden and cost of the consequences of obesity justify the need for the United Kingdom to aspire to meet its own targets and those set by the World Health Assembly.

Cheers,

Christiana

On Booze, Babies and Birth defects:

A brief commentary on Foetal Alcohol Spectrum Disorders

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Foetal Alcohol Spectrum Disorders (FASDs) are a group of disorders of global concern. Entirely attributed to prenatal alcohol exposure, affected individuals suffer a lifetime of physical, psychological and social consequences. Foetal Alcohol Syndrome (FAS), has a global prevalence of 2.89 per 1000 live births, with some regions as high as 55.42 per 1000 live births. FASDs are preventable but there seem to be significant gaps in knowledge and practice.

In its 2014 Global status report on Alcohol and Health, the WHO emphasized the importance of strengthening capacity for prevention of FAS and the spectrum of associated disorders. As with many diseases of global concern, a variety of cultural, population and behavioral factors result in certain regions being more profoundly affected than others. FASDs are no exception. Some of the highest prevalence of the disorders globally is seen in South Africa, Canada and Croatia.

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The discussion on FASDs is part of a broader discourse. For the most part, the consequences of the harmful use of alcohol are well understood and documented. Most recent data from a systematic literature review estimates the global prevalence of FAS at 2.89 per 1000 live births. The prevalence of FASDs, however, including other disorders within the spectrum is estimated to be far higher.

The World Health Organization (WHO) estimates that 3.3 million annual deaths occur as a result of the harmful use of alcohol, accounting for 5.9% of preventable deaths worldwide.

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As shown above, after Alcohol use disorders, Foetal Alcohol Syndrome is the most significant cause of death or Disability, measured in Disability Adjusted Life Years (DALYS), attributed to harmful alcohol use. Unlike most health effects and consequences resulting from alcohol consumption, such as Alcohol-use Disorders and liver cirrhosis, FAS does not directly affect the individual. Instead it affects the foetus. Furthermore, unlike almost all other alcohol-attributable diseases, FAS is entirely attributed to alcohol exposure. This relationship between the alcohol consumption of the mother and the adverse, irreversible effects on the infant raises a number of ethical issues in preventing, measuring, interpreting and regulating the factors related to the condition.

DALYs are years of healthy life lost to disease due to disability. One DALY equates to one year of healthy life lost.

Whilst not always considered the most useful measure of morbidity in terms of disability, in conjunction with other indicators, it is generally accepted as a useful metric for understanding health status change and, from a broader perspective, the effectiveness of policy and intervention. In this regard, FASDs are unique. They are not acquired at some point in life as is the case with pancreatitis or accident related injury. In essence, every year of the affected individual’s life is a DALY.

Quality Adjusted Life Years (QALYs), as a metric, are also not immune to criticism. QALYs measure the quality of life provided by healthcare interventions. To its credit, this measure combines both qualitative and quantitative measures of patient’s life quality. In terms of FASDs, however, QALYs are a poor measure. FASD patients require lifelong medical and social intervention to thrive – this is a high level of resource allocation for a condition that can only be monitored, perhaps ameliorated, but never treated.

FASDs are important because they present an important social as well as public health problem in many communities. A major challenge lies in identifying appropriate intervention programs aimed at reducing alcohol intake by pregnant women who are at greatest risk of giving birth to infants with FASD.

In South Africa, the Western and Northern Cape regions have the world’s highest recorded rates of FASDs. Heavy alcoholism within certain groups remains very much commonplace, particularly in the nation’s rural areas. High levels of alcoholism and binge drinking behavior have their centuries old heritage in the dop system, directly translated to mean “tot” or “shot”, whereby Dutch colonists paid farm workers on vineyards entirely or partially in cheap alcohol.

Furthermore, it is reported that on many farms in the Cape provinces of South Africa the use of alcohol as a form of partial remuneration still exists covertly. Current legislation in South Africa prohibits dop, but the legacy of a culture of heavy alcoholism lives on: today some of my beloved country’s rural areas prevalence of FAS is as high as 10.2%.

Foetal Alcohol Syndrome is diagnosed using criteria of facial abnormalities, including smooth philtrum, reduced palpebral fissures and even cleft lip and/or palate. Often infants suffer impaired cognitive development. Those affected by FAS often experience brain dysfunction, mental impairment, psychological disorders and learning disabilities. Furthermore, it often goes undiagnosed for several years. There is no cure for FAS.

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Foetal Alcohol Spectrum Disorders in particular, distinct from the syndrome, tend to be poorly diagnosed. Particularly where health workers are not very familiar with the condition. Nonetheless, the long-term consequences of FASDs, including pFAS, ARBD and ARND, have a profound impact on the intellectual and social development of the individual.

Although no formal international guidelines on primary, secondary and tertiary prevention of Foetal Alcohol Spectrum Disorders exist, a handful of regional and national studies have investigated prevention methods used in certain areas with an aim to better understand the effectiveness of these varied approaches and how they may be implemented at a larger scale. Indeed, one study showed that merely gaining access to prenatal care resulted in a significant decrease in alcohol use during pregnancy, a luxury to which many women globally, particularly from lower socioeconomic backgrounds, have little or no access

Nonetheless, I would argue that it is the culture of frequent and/or binge drinking that perpetuates prenatal alcohol exposure; perhaps even to a larger degree than ignorance, misinformation or apathy.

Images: whattoexpect; WHO; FASlink;