Diabesity: A call to action

During my service as board director for the South Georgian Bay Community Health Centre, I was introduced, essentially as a random yet timely occurrence, to Dr. Mark Hyman’s presentation on TedMed.com about utilizing social networking to combat “diabesity.”

Tedmed.com presentation by Mark Hyman, published on Jun 19, 2012

Unhealthy lifestyles have brought on a social epidemic of "diabesity," says author Mark Hyman, and community-driven solutions may be the only way out. http://www.youtube.com/watch?v=8dYTa6xhHlM

Basic concepts

Obesity is a major health concern and is the leading cause of preventable adult onset morbidity and untimely mortality.

Degenerative arthritis of the load bearing joints,

Cardiovascular

Kidney

Some cancers

Diabetes type 2.

Diabetes 2 is a major health concern on its own, and  makes everything else worse.

70% of the prevention and management of diabetes 2 may come down to managing obesity.

Targeting the two problems together as “Diabesity” allows the same resources to be targeted at the two different yet interconnected issues - deal with one - deal with the other. Two for the price of one.

Reducing obesity reduces cardiovascular disease, stroke, kidney disease, degenerative arthritis, some cancers, emotional and social health. That's a lot of potential return for targeting one disease.

Conventional management of obesity as an individual health issue is largely ineffective. 

Approaching diabesity as a social disease may be more effective toward changing public attitudes and collective behaviours.

It is possible to affect the health of a larger number of a community by using social networking to change attitudes and behaviours.

Examples

Hyman describes his church changing from sweet snacks to veggies, prayer meetings to prayer walks…. Collectively losing weight.

Business initiatives as in walking clubs – participants encourage each other to accumulate steps such as virtually walking to Patagonia.

Seventh Day Adventists in California live 5 years longer.

There is ample evidence to support this direction.

Diabesity and Direction

Executive summary

1. Obesity is a major health concern and is the leading cause of preventable adult onset morbidity and untimely mortality.
2. Diabetes 2 is a major health concern and just makes everything else worse.
3. 70% of the prevention and management of diabetes 2 may come down to managing obesity.
4. Targeting the two problems together as “Diabesity” allows the same resources to be targeted at the two different yet interconnected issues - deal with one - deal with the other. Two for the price of one. Reducing obesity reduces cardiovascular disease, stroke, kidney disease, degenerative arthritis, some cancers, emotional and social health. That's a lot of potential return for targeting one disease.
5. Conventional management of obesity as an individual health issue is largely ineffective. 
6. Approaching diabesity as a social disease may be more effective toward changing public attitudes and collective behaviours.
7. It is possible to affect the health of a larger number of a community by using social networking to change attitudes and behaviours.
8. There is ample evidence to support this direction.

Introduction

Tax evasion can be solved through peer pressure

Using studies conducted on persuasion and peer pressure, the British tax agency, Her Majesty's Revenue and Customs (HMRC) has been testing different strategies to make people pay their taxes. Alexander Besan November 9, 2012 16:00 Revenue agencies are increasingly relying upon peer pressure to make tax cheats pay up.

Tax evasion is a rampant, yet underreported problem around the world that has extraordinarily detrimental effects on numerous economies. Just ask Greece. Solutions to tax evasion normally involve painstaking investigations by authorities and sometimes police. However, some economists think that one of the most effective ways to crack down on people who don't pay taxes is simple peer pressure.

Using studies conducted on persuasion and peer pressure, the British tax agency, Her Majesty's Revenue and Customs (HMRC) has been testing different strategies to make people pay their taxes, reported Reuters. In letters to Britons who haven't paid taxes, the agency writes: "Nine out of 10 people in the UK pay their tax on time." ”You are one of the few who have not paid us yet," it adds later, said the Consumerist, which raised the success rate of people paying by 3.8 percent. That rate jumped to over six percent when those people were told they were one of the only people in town to have unpaid taxes.

Behavioral economists say that penalties may not be as effective as more emotional targeting, such as shaming, as material self-interest is only part of the problem. Reuters said that Washington State's revenue service also changed their procedures in telling people in more straightforward language about their tax compliance issues. This raised revenue over 40 percent and earned the state an extra $321 million in revenue.

The Greek government in their desperate search for extra tax revenue might want to listen closely.

http://www.globalpost.com/dispatch/news/science/121109/tax-evasion-can-be-solved-through-peer-pressure

Negative and Positive Effects of Peer Pressure

We tend to get influenced by the lifestyle of our peers. Their thinking, their choices and their behavior influences us. We feel compelled to follow them. That's peer pressure. It is beneficial to a certain extent. But its negative effects are more apparent. Peer pressure can be of two types, negative and positive. The section of society which is most vulnerable to the effects of peer pressure is of teenagers. Let's try to understand the positive and negative effects of peer pressure on people.

Positive Effects

Adopting Good Habits: Peer pressure is not always bad. It can help you reflect on yourself. Peers may teach you good things and encourage you to follow them. You may be able to change yourself for better. Looking at what others do, can help you bring a positive change in your way of thinking. If you can pick selectively, peer pressure can push you towards something positive. For example, when a child knows that some of his friends regularly read storybooks or that they have subscribed to a library, even he feels tempted to do so. He may get into the habit of reading because of his peers. Seeing that some of your friends exercise daily, even you may take up the habit. Positive peer pressure can lead you to adopt good habits in life.

Exposure to the World: Your peers, their choices and ways of life give you a glimpse of the world outside the four walls of your house. What they think about things in life, how they perceive situations, how they react in different circumstances can actually expose you to the world around. Being part of a larger group of peers exposes you to the variety in human behavior. This makes you reflect on your behavior and know where you stand. Peer pressure can lead you to make right choices in life.

Giving Up Bad Habits: If you are fortunate enough to get a good peer group, your peers can influence the shaping of your personality in a positive way. Their perspective of life can lead you to change yours. It's not pressure every time; sometimes it's inspiration, which makes you change for good. For example, positive peer pressure can make you quit smoking or give up bad habits that you may have. Your peers can inspire you to become more optimistic or more confident. Your peers may influence you to change and make you a better human being.
 

http://www.buzzle.com/articles/negative-and-positive-effects-of-peer-pressure.html

Background

The SGBCHC has two mandates. The first is to provide comprehensive primary health care services to populations not served well by the mainstream medical programs – more so – populations at risk of marginalization.

We are making progress.

The second mandate is to promote the health of the community at large. 

Two things happened concurrently which piqued my interest.

One was our visioning process and the other was Mark Hyman’s presentation on TedMed on regarding obesity and diabetes as a collective disease, and to tackle the disease as a social problem, and leveraging social networks to do the heavy work of fighting diabesity.

Obesity

The single most common predictor of preventable adult onset disease – morbidity and mortality – is being over weight – the effects are multiplicative.

http://psychcentral.com/lib/2007/obesity-and-mental-health/all/1/

The causal relationship of most of these conditions to overweight and obesity has been demonstrated by research projects in which individuals were assisted in losing weight and the degree of the conditions was reduced or eliminated

As would be expected for a condition that increases the risk of heart disease, diabetes and other serious medical conditions, overweight and obesity increase the rate of [premature] mortality.

…resulting in economic costs of $300 billion per year in the United States and Canada. These costs result from an increased need for medical care and the loss of economic productivity resulting from excess mortality and disability.

…The evidence they provide in support of a strong statistical association and the elimination of other potential causes points to a causal relationship between obesity and certain diseases.

…Whether obesity is the primary cause of a disease or simply an aggravating factor, we believe the cost increases and economic effects estimated in this paper would not arise but for obesity in the population.

Society of Actuaries, 2010. Obesity and its Relation to Mortality and

Morbidity Costs http://www.soa.org/research/research-projects/life-insurance/research-obesity-relation-mortality.aspx

Diseases associated with obesity

Relative risk	Associated with metabolic consequences	Associated with weight
Greatly increased	Type 2 diabetes Gall bladder disease Hypertension Dyslipidaemia Insulin resistance Atherosclerosis	Sleep apnoea Breathlessness Asthma Social isolation/depression Daytime sleepiness/fatigue
Moderately increased	Coronary heart disease Stroke Gout/hyperuricaemia	Osteoarthritis Respiratory disease Hernia Psychological problems
Slightly increased	Cancer (breast, endometrial, colon) Reproductive abnormalities Impaired fertility Polycystic ovaries Skin complications Cataract	Varicose veins Musculo-skeletal problems Bad back Stress incontinence Oedema/cellulitis

http://www.health.gov.au/internet/main/publishing.nsf/ 

Content/health-pubhlthstrateg-hlthwt-obesity.htm

The World Health Organization (WHO) believes that we are in the grip of a global epidemic, and it is estimated by the year 2020 obesity will be the single biggest killer on the planet.

http://psychcentral.com/lib/2007/obesity-and-mental-health/all/1/

Both the direct and indirect medical costs of obesity will become a major burden for health care systems around the world. In the U.S., a 1998 study found that medical expenses attributed to both overweight and obesity accounted for 9.1 percent of total U.S. medical expenditure — possibly reaching $78.5 billion (the equivalent of nearly $100 billion today). Half of these costs were paid by Medicaid and Medicare.

Around the world, the WHO found the economic costs of obesity to be in the range of two to seven percent of total healthcare costs, as a conservative estimate.

 http://psychcentral.com/lib/2007/obesity-and-mental-health/all/1/

With respect to children, the most important long term consequence of childhood obesity is its persistence into adulthood. Obesity is more likely to persist when its onset is in late childhood or adolescence and where children have obese parents. There is now epidemiological evidence to support the theory that the association between obesity and disease begins early in life. There are several new large well conducted studies that have shown a clear relationship between excessive body weight and increased mortality and morbidity. Mortality and morbidity are also associated with the amount of weight gained in adult life. For example, a weight gain of 10kg or more since young adulthood is associated with increased mortality, coronary heart disease, hypertension, stroke and type 2 diabetes.

http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-hlthwt-obesity.htm

Diabetes

In June 1998 the American Heart Association announced that it was upgrading obesity to a ‘major risk factor’ for CHD. Obesity also is an important causal factor in type 2 diabetes, and it complicates management of the disease, making treatment less effective.

http://psychcentral.com/lib/2007/obesity-and-mental-health/all/1/

The prevalence of diabetes in Ontario, Canada increased substantially during the past 10 years, and by 2005 already exceeded the global rate that was predicted for 2030. In view of this linear growth in prevalence, more than 10% of the adult population of Ontario will be diagnosed with diabetes before 2010. If similar trends are occurring throughout developed countries, then the size of the emerging diabetes epidemic is far greater than anticipated.

Trends in diabetes prevalence, incidence, and mortality in Ontario, Canada 1995–2005:

a population-based study http://www.iumsp.ch/Enseignement/postgradue/

medecine/doc/Lipscombe_diabetes_07.pdf

Aboriginal people and certain ethnic groups such as people of South Asian, Asian, Latin American and African decent are at higher risk for developing diabetes. Individuals living in lower-income neighbourhoods in Ontario have diabetes rates that are 50 percent higher than diabetes rates among those living in high-income neighbourhoods.

Bodkin A, Ding HK, Scale S. (2009).

Obesity: An overview of current landscape and prevention-related activities in Ontario. Prepared for the Public Health Agency of Canada. Toronto, ON: April 30th, 2009

The progression to diabetes generally takes many years and is mostly asymptomatic. This means that the number of people not knowing that they have diabetes is very high. Studies estimate that for every one or two diagnosed cases of diabetes there is one undetected case.

Diabetes is a severe disease. If it is not diagnosed and treated properly it can lead to serious and costly complications such as cardiovascular disease, diabetic neuropathy, diabetic foot syndrome with amputations, renal failure and blindness. Hyperglycaemia (even prior to diabetes) also increases cardiovascular risk and exacerbates periodontal infection (gum disease). The longer the duration of the disease, the more likely it is that there will be costly complications. In European countries, diabetes accounts for up to 18% of total healthcare spending. With an ageing population, these costs are likely to increase if the epidemic cannot be reversed. Furthermore, the costs to society through lost productivity may be as much as five times the direct healthcare costs. Additionally, diabetes has a major impact on the quality of life of the patient and his / her family.  * Multiplicative effect*

Evidence from large trials from Finland, Sweden, the USA, China, India, and Japan has proven that lifestyle interventions can halt, or at least delay, the onset of diabetes in people who are identified as having high risk. The key to prevention is lifestyle changes such as weight reduction (if participants were overweight), increased physical activity, dietary modifications to increase dietary fibre and reduce total and saturated fat intake. The more of these goals the participants achieved, the lower their risk of developing diabetes

TAKE ACTION TO PREVENT DIABETES:

A toolkit for the prevention of type 2 diabetes Europe

http://nebel.tumainiserver.de/dp/pdf/IMAGE_Final_version_of_toolkit.pdf

Another four studies found that diabetes prevention is more cost effective than treatment.

Society of Actuaries. 2010.

Obesity = Diabetes?

Type 2 diabetes, once rarely diagnosed in adolescence, is now increasingly appearing in adolescents and even in children, and can be attributed to the increasing rate of childhood obesity.

Bodkin A, Ding HK, Scale S. (2009).

Obesity: An overview of current landscape and prevention-related activities in Ontario. Prepared for the Public Health Agency of Canada. Toronto, ON: April 30th, 2009

… overweight and obesity account for about 60 percent of the cases of diabetes (pg. 23) A 5-kilogram weight loss over time could account for a 55 percent reduction in the risk of diabetes (pg. 22). (Society of Actuaries, 2010).

… the risk for type 2 diabetes was increased by 78% in the overweight group (p<0 .01="" span="">

Obesity (Silver Spring). 2007 Jul;15(7):1827-40. http://www.ncbi.nlm.nih.gov/pubmed/17636102

The fact that the level of obesity in the population may be influenced by education and public policy and that the reduction in obesity, other things being equal, would lead to a decrease in morbidity and mortality, justify the isolation of obesity as one of the causes of morbidity. …

Society of Actuaries. 2010. Obesity and its Relation to Mortality

and Morbidity Costs http://www.soa.org/research/research-projects/life-insurance/research-obesity-relation-mortality.aspx

The link between obesity is so strong that to target diabetes management and prevention one typically targets preventing obesity.

Targeting obesity, however, is unpopular.

No one likes to be told they are fat …

However, there is emerging a term that gives us the potential for HUGE leverage in managing both diabetes and obesity.

Diabesity

I was first introduced to this term by a Ted.com video presentation from Mark Hyman – which I shared with the Board.

Hyman also introduced me to the idea of treating Diabesity as a social disease and leveraging social networks to make the changes necessary in attitude and values at a societal level in order to affect individual behaviour.

http://www.youtube.com/watch?v=8dYTa6xhHlM

Diabesity –  is a very useful term.

It is jiggy. … Marketable

It allows us to focus on the issue of weight gain associated with diabetes, without specifically targeting and taking away the moral/character affects associated with obesity management.

It is empowering.

Further considerations for targeting obesity via diabetes.

Mental health

Levels of obesity are higher in those with schizophrenia and depression, as is mortality from obesity-related conditions such as coronary heart disease. Medication side effects, particularly the metabolic side effects of antipsychotic medications, contribute to the high levels of obesity in those with schizophrenia

Obesity among those with mental disorders: a National Institute of Mental Health meeting report. American Journal of Preventive Medicine [2009, 36(4):341-350]

Obesity was significantly associated with any mood disorder), major depressive disorder, any anxiety disorder (OR 1.46), and most strongly with some individual anxiety disorders such as post-traumatic stress disorder (PTSD).

Obesity and mental disorders in the adult general population.

Department of Psychological Medicine, Wellington School of Medicine

and Health Sciences, Otago University, New Zealand

http://dx.doi.org/10.1016/j.jpsychores.2007.09.006

The most rigorous clinical studies suggest that (1). children and adolescents with major depressive disorder may be at increased risk for developing overweight; (2). patients with bipolar disorder may have elevated rates of overweight, obesity, and abdominal obesity; and (3). obese persons seeking weight-loss treatment may have elevated rates of depressive and bipolar disorders.

The most rigorous community studies suggest that (1). depression with atypical symptoms in females is significantly more likely to be associated with overweight than depression with typical symptoms; (2). obesity is associated with major depressive disorder in females; and (3). abdominal obesity may be associated with depressive symptoms in females and males; but (4). most overweight and obese persons in the community do not have mood disorders. Studies of phenomenology, comorbidity, family history, biology, and pharmacologic treatment response of mood disorders and obesity show that both conditions share many similarities along all of these indices.

Although the overlap between mood disorders and obesity may be coincidental, it suggests the two conditions may be related.

Are mood disorders and obesity related? A review for the mental health professional.

The Journal of Clinical Psychiatry. 06/2004; 65(5):634-51, quiz 730.

…loneliness occurs in clusters, extends up to 3 degrees of separation, is disproportionately represented at the periphery of social networks, and spreads through a contagious process. The spread of loneliness was found to be stronger than the spread of perceived social connections, stronger for friends than family members, and stronger for women than for men. The results advance understanding of the broad social forces that drive loneliness and suggest that efforts to reduce loneliness in society may benefit by aggressively targeting the people in the periphery to help repair their social networks and to create a protective barrier against loneliness that can keep the whole network from unraveling.

Alone in the crowd: The structure and spread of loneliness in a large social network.

Journal of Personality and Social Psychology, Vol 97(6), Dec 2009, 977-991.

doi: 10.1037/a0016076

Overweight adolescents were more likely to be socially isolated and to be peripheral to social networks than were normal-weight adolescents. Although overweight adolescents listed similar numbers of friends as normal-weight adolescents, overweight adolescents received significantly fewer friendship nominations from others than were received by normal-weight adolescents (mean [SE] number of friendship nominations, 3.39 [0.08] vs 4.79 [0.04]; P<.001). Overweight adolescents were also more likely to receive no friendship nominations than were normal-weight adolescents (odds ratio, 1.71; 95% confidence interval, 1.39-2.20). Decreased television viewing (P<.001), increased levels of sports participation (P<.001), and increased participation in school clubs (P<.001) were associated with significantly more friendship nominations and higher network centrality scores among both overweight and normal-weight adolescents. Conclusions  Many overweight adolescents are socially marginalized. Such isolation may aggravate the social and emotional consequences of overweight in this age group.

Social Marginalization of Overweight Children.

Arch Pediatr Adolesc Med. 2003;157(8):746-752.

doi:10.1001/archpedi.157.8.746.

Higher individual network social capital is associated with a lower likelihood of elevated WC risk and overweight and obesity. [Obesity is correlated with social isolation.]

Association of individual network social capital

with abdominal adiposity, overweight and obesity.

Oxford Journals Medicine Journal of Public Health

Volume 31, Issue 1 Pp. 175-183.

…exploratory study results suggest that greater levels of social capital are protective against obesity and diabetes. This initial finding warrants subsequent empirical investigations designed to identify strategies that can be used to foster the creation of social capital in areas of the United States with an especially high prevalence of obesity and diabetes. In addition, these investigations should operate at multiple levels, examining individual, social-network, and community-level measures of social capital.

Is Social Capital a Protective Factor Against Obesity and Diabetes? Findings From an Exploratory Study. Annals of Epidemiology Volume 16, Issue 5, May 2006, Pages 406–408 http://www.sciencedirect.com/science/article/pii/S1047279705002838

…data on 2,123 participants living in Alameda County. Taking into account factors such as social class, social support, chronic medical conditions and life events, they found that “obesity at baseline was associated with increased risk of depression five years later. The reverse was not true; depression did not increase the risk of future obesity.”

http://psychcentral.com/lib/2007/obesity-and-mental-health/all/1/

Both people with obesity and mental illness experience bias and stigmatization. 2. People with enduring mental health problems are two to three times more likely to develop obesity and related disorders like diabetes and heart disease than the general population. 3. Conversely, obesity can negatively affect mental health. 4. Shared societal, environmental and/or biological drivers are implicated in this frequent association of mental illness and obesity.

2012 Toronto Charter on Obesity and Mental Health http://www.drsharma.ca/toronto-charter-on-obesity-and-mental-health.html

Summary:

Persons with serous mental health issues are at greater risk of obesity and subsequent health impact.

Obesity can have a reciprocal impact on emotional health. This is a chicken and egg argument and the effects are highly individual, yet significant due to the prevalence of impaired emotional health issues. 

Emotional well being has multiplicative effects on other aspects of personal health as well impact upon family, social and community health.

It is probable that managing obesity by targeting its association with diabetes will have impact on disorders that in themselves have multiplicative effects on physical, emotional, and social well being.

Managing Diabesity More Effectively

We know for certain that the obesity epidemic is due to a combination of individual behaviors and environmental factors that result in low levels of physical activity and over-consumption of calories. From our experience with smoking control and the effectiveness of health promotion programs in other countries, we know this epidemic can be controlled. However, this will require the concerted efforts of all elements of our society and the commitment of real resources, not only good intentions. If we fail to act vigorously, we have every reason to believe that the epidemic will intensify and the burden of suffering and early death due to overweight and obesity will become greater.

STRATEGIC PLAN FOR THE PREVENTION AND CONTROL OF

OVERWEIGHT AND OBESITY IN NEW ENGLAND http://www.neconinfo.org/docs/Strategic%20Plan%2002-11-03.pdf

A person’s weight is affected not only by what they eat and how active they are, but by the environments in which they live, learn, work and play: a complex combination of biological, lifestyle, socio-economic, cultural and environmental factors. Rates of overweight and obesity also varies with lifestyle; developing healthy habits early in life have a positive effect on health outcomes, and are likely to be carried into adulthood (Bodkin, 2009)

Family life and culture can impact weight. Food is often used to express cultural traditions. Perceptions of obesity can also vary by ethnicity; for example, obesity may not be recognized as a health issue in cultures that value body size as a statement of wealth. Culture, particularly when combined with the length of time that new Canadians have been in the country, also impacts physical activity and sport participation. Rates of physical activity and sport participation are lower Amongst children and youth who have been in Canada less than five years, when compared with those children and youth born in Canada    (Bodkin, 2009)

“Unhealthy lifestyles have brought on a social epidemic of "diabesity,"

says author Mark Hyman, and community-driven solutions may be the only way out.”

This was the “Ah-Ha!” idea from the Hyman presentation – instead of tackling diabesity as an individual medical problem – focus rather on diabesity as a social disease – and – use social networks to do the heavy lifting of changing the people’s attitudes and thereby change the people’s attitudes.

“It takes a village to eliminate Diabesity”

Hyman gave his own real life example as how this could work where the church he was attending was growing… not in the number of people but the size of the people… they were becoming obese. And considering how almost every church function is focused on food… and sweet treats it is not surprising. The leadership made it a priority to encourage healthier choices and ultimately have been successful in encouraging weight loss through healthier eating and exercise. … by creating a culture/social network that made weight loss more rewarding than what was in place before. 

A further example of a social network that successfully encourages healthier choices is the Seventh Day Adventists.

Research funded by the U.S. National Institutes of Health has shown that the average Adventist in California lives 4 to 10 years longer than the average Californian. The research, as cited by the cover story of the November 2005 issue of National Geographic, asserts that Adventists live longer because they do not smoke or drink alcohol, have a day of rest every week, and maintain a healthy, low-fat vegetarian diet that is rich in nuts and beans.

http://en.wikipedia.org/wiki/Seventh-day_Adventist_Church

The serum cholesterol levels of 233 nonvegetarians were compared with those of 233 vegetarians who had been matched for place of residence, sex, age, marital status, height, weight, and occupation. The difference between the serum cholesterol levels of the two groups was statistically significant (P < 0.01).

A Comparison between Vegetarians and Nonvegetarians in a Seventh-day Adventist

Group Diet and Serum Cholesterol Levels. 1968 by The American Society for Clinical Nutrition, Inc

***** It is concluded that the life style of Seventh-day Adventists is conducive to lessened morbidity, delayed mortality, and decreased call on health services in comparison with the general population.

Health status of Seventh-Day Adventists.The Medical Journal of Australia

[1979, 1(10):417-420] (PMID:470666)

Distribution and correlations of obesity by state

More than 72 million American adults are obese, according to estimates from the National Center for Health Statistics. But obesity varies greatly by state. The map below, from the Centers from Disease Control (CDC), shows the obesity rate for the 50 states, measured as the share of people with a Body Mass Index (BMI) over 30 which the CDC classifies as "obese." WHY?

Smoking was significantly correlated with obesity as well as being correlated with education levels, class structure, and other factors. ..correlation does not imply causality, but simply points to associations between variables. Still, a number of interesting things stand out.

… states with higher levels of obesity have significantly higher rates of death from cancer, heart disease, and cerebrovascular diseases like hypertension. There is a significant correlation between obesity and death rates from cancer (.7), heart disease (.7), and cerebrovascular disease (.7).

It might be, however, that states with greater percentages of obesity are those where people pay less attention to their health generally or are more likely to engage in risky behavior. And that's what we find at least in the case of smoking which correlates highly with state levels of obesity (.8).

Obesity is negatively associated with state happiness (with a correlation of -.6). Since these correlations only reflect associations between variables and not causality, it's hard to say whether this reflects the fact that happier people eat less, are healthier, or are less prone to obesity, or if unhappier people eat more, are unhealthier, or are somehow more prone to obesity, or if both obesity and happiness levels reflect something else.

Common sense would suggest that more affluent people would have lower levels of obesity and poorer ones higher, and we find such an association. Obesity is correlated with income levels (-.6) and more moderately so with economic output, measured as gross state product per capita (-.4).

One would think that states with greater concentrations of more highly educated people have lower levels of obesity, and that is what we find. States with higher levels of human capital, measured as the percentage of adults with a college degree, have lower levels of obesity (the correlation being -.8).

To what extent does obesity reflect the kind of work people do? We examine the relationships between obesity and three classes of jobs - creative/professional/knowledge jobs, blue-collar working class jobs, and standardized service class jobs like those in food processing and home health care. Obesity is strongly associated with the share of working class jobs (with a correlation of .7). Obesity is negatively correlated with the share of creative class jobs (-.6). Obesity is also negatively correlated with the share of service class jobs (-.4), though more moderately so.

Obesity is lower in states with higher concentrations of artists, musicians, and entertainers (with a correlation of-.6), those with larger concentrations of gays and lesbians (-.5), and immigrants (-.5). This likely reflects broader structural characteristics of those states, as more highly educated states also tend to be more tolerant and open to diversity.

Richard Florida, Nov.  2009.,The Geography of Obesity, The Atlantic

http://www.theatlantic.com/national/archive/2009/11/the-geography-of-obesity/30347/

Why is there less obesity in BC than in most of the rest of Canada? Is there some social force at play that encourages a leaner lifestyle? What can we learn from this?

Family and peers also influence the way people eat. Parents are role models in helping children to develop a taste for healthy food. Taking the time to savour food and enjoy meals together helps to make eating pleasurable and helps children develop a healthy attitude toward food. As children grow, their peers become more of an influence.

In addition, increase of marketing of high fat, high calorie food is associated with rising overweight and obesity rates. Poor eating habits formed in childhood,such as by result of lack of access to healthy foods, lack of food skills preparation and poor health choices are likely to be carried into adulthood.

In Ontario, there is a recent shift in focus from the promotion of healthy eating and active living to the prevention of obesity. Recent obesity prevention-related initiatives, which target specific population within a specific setting, are limited by their cost to implement on a large scale or relevance of their application across the province. In order to effectively address obesity and its prevention, a comprehensive systems approach is required to support a healthy environment, to improve health and to address the increasing burden of chronic disease in Ontario.

 Bodkin A, Ding HK, Scale S. (2009). Obesity:

An overview of current landscape and prevention-related activities in Ontario.

Prepared for the Public Health Agency of Canada.

Toronto, ON: April 30th, 2009

Minority groups are often more vulnerable to health inequalities and poor Healthcare:

• Reaching minority groups for lifestyle education and education is often more difficult than standard local populations, given barriers in language, culture, and neighbourhoods.

• The effectiveness and generalizeability of traditional diabetes prevention programs is uncertain in minorities and immigrants.

• Finally, given social cohesiveness of minority populations, optimizing interventions for minority social networks could possible be important to managing diabetes in minorities.

http://ec.europa.eu/research/health/pdf/event12/eric-ding-workshop-2_en.pdf

Evidence for the success of commercial self-help groups such as the Weight Watchers is also predominantly anecdotal. One of the few studies showed no effect on weight loss. The proliferation of self-help groups, however, indicates the public's belief in their effectiveness

(European Journal of Clinical Nutrition, 2005)

Despite soaring obesity rates, few effective obesity management systems are in place around the world. Experts believe the most effective approach for weight loss in obese people is a diet aimed at reducing total energy intake; however, all but five percent of people who lose weight on a diet regain it all. Nevertheless the diet industry is worth $40 billion a year in the U.S. alone.

http://psychcentral.com/lib/2007/obesity-and-mental-health/all/1/

The WHO began sounding the alarm in the 1990s, and stated that obesity is predominantly a “social and environmental disease.” They recommend a range of long-term strategies for groups at risk of obesity — an integrated, population-based approach, with support for healthy diets and regular exercise.

(psychcentral.com, 2007)

Type 2 diabetes is largely preventable by taking several simple steps: keeping weight under control, exercising more, eating a healthy diet, and not smoking. Yet it is clear that the burden of behavior change cannot fall entirely on individuals. Families, schools, worksites, healthcare providers, communities, media, the food industry, and government must work together to make healthy choices easy choices. Focus on food and physical activity related policy changes that can promote healthy environments, encourage healthy behaviors, and ultimately, help turn around the diabetes epidemic.

The Nutrition Source Diabetes Prevention Toolkit

http://www.hsph.harvard.edu/nutritionsource/diabetes-

prevention/diabetes-prevention-toolkit/

Another four studies found that diabetes prevention is more cost effective than treatment.

Society of Actuaries. 2010. Obesity and its Relation to Mortality

and Morbidity Costs http://www.soa.org/research/research-

projects/life-insurance/research-obesity-relation-mortality.aspx

It has been suggested that social support from health professionals may have a limited effect in comparison to support from patients' natural support networks. This is largely due to the nonreciprocal relationship between patients and health professionals. A similar nonreciprocal situation is present when trained peers receive financial rewards or when worksite based programs involve supervisors or managers for support, however, anecdotal evidence from various worksites that worksite weight management programs supported by employers can be very successful.

European Journal of Clinical Nutrition (2005)

Peer pressure [double edged sword]

Social psychological theories suggest that a person's friends are likely to share similar lifestyle behaviors, such as diet and levels of physical activity, and thus be at similar risk for overweight.

Prev Chronic Dis. 2009 Adolescent Obesity and Social Networks

July; 6(3): A99. PMCID: PMC2722403

… besides being positively correlated with health, social support can also counteract health behaviour changes. Peer smoking, for example, may negatively affect the success rate of patients' quitting attempts or people may (unknowingly) give false or incomplete informational support (European Journal of Clinical Nutrition, 2005)

… social networks seem to have a significant influence on risk factors such as smoking and obesity. On the basis of the Framingham Study data, an individual was more likely to become obese if his or her spouse was obese; if a friend was obese as well, the chance of obesity was exponentially greater. In the case of tobacco, the same social network associations applied. However, those smokers who quit, usually quit in groups. The bottom line? Social networks are a powerful tool for influencing individual behaviors both good and bad.

Center for Disease Control’s LEAN Works! - A Workplace Obesity Prevention Program http://www.cdc.gov/leanworks/

Discernible clusters of obese persons were present in the network at all time points, and the clusters extended to three degrees of separation. These clusters did not appear to be solely attributable to the selective formation of social ties among obese persons. A person's chances of becoming obese increased by 57% (95% confidence interval [CI], 6 to 123) if he or she had a friend who became obese in a given interval. Among pairs of adult siblings, if one sibling became obese, the chance that the other would become obese increased by 40% (95% CI, 21 to 60). If one spouse became obese, the likelihood that the other spouse would become obese increased by 37% (95% CI, 7 to 73). These effects were not seen among neighbors in the immediate geographic location. Persons of the same sex had relatively greater influence on each other than those of the opposite sex. The spread of smoking cessation did not account for the spread of obesity in the network. Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions. N Engl J Med. 2007

The spread of obesity in a large social network over 32 years.

Jul 26;357(4):370-9. 2007 Jul. http://www.ncbi.nlm.nih.gov/pubmed/17652652

Social network approaches can contribute to research on the role of social environments in overweight and obesity and strengthen interventions to prevent disease and promote health. By capitalizing on the structure of the network system, a targeted intervention that uses social relationships in families, schools, neighborhoods, and communities may be successful in encouraging healthful behaviors among children and their families.

… the health of adult family members depends somewhat on their social ties.  Social ties and the structure of these ties can affect behavior and health through social influence, social support, access to resources, and access to information.

Prev Chronic Dis. 2009 Adolescent Obesity and Social Networks

July; 6(3): A99. PMCID: PMC2722403

EMPOWERMENT: We have opportunity and must be watchful to promote an emotionally positive experience  - edification. Opportunity to promote emotional health.

Slogans that stigmatize obesity don't get their message across and may do more harm than good.

What they found is basically what was expected: the public craves positive reinforcement and rejects stigmatizing or otherwise negative messages. A simple message from First Lady Michelle Obama's "Let's Move" campaign -- "Move Everyday" -- was the public's favorite.

"The most positively rated were campaigns that focused on encouraging specific health behaviors or actions, like eating fruits and vegetables every day or engaging in physical activity" said lead author Rebecca Puhl, "And the most motivating were the ones that made no mention of obesity or weight at all."

The findings call attention to our feelings about personal responsibility -- respondents generally didn't seem to mind having the onus put on them to lose weight ("Eat Well. Move More. Live Longer" scored well), but they were against being told that their or their child's obesity was their fault ("The more you gain, the more you have to lose," didn't do well, and "Childhood obesity is child abuse" fared worst).

Obese respondents, in particular, were significantly more offended by messages like "Skip seconds... lose your gut" and "Fat kids become fat adults." They also responded more negatively to slogans that, at first glance, don't seem to be particularly stigmatizing, like "You have the strength to take control of your health," and "It's not a diet, it's a lifestyle." Based on what did do well, the problem may have stemmed from being told that they should be doing something different without being given clear advice on how that might be accomplished.

The word "obesity" itself can carry pejorative connotations, as Puhl's team has studied elsewhere. "Certainly what we find is when more neutral words are used, like 'unhealthy weight' or 'high BMI' those are preferred and viewed to be more motivating," Puhl told me.

What's really needed, of course, is a behavior-based study that attempts to measure people's actual compliance with the messages of PSAs. It seems obvious that people would say they're more likely to comply with instructions that teach them specifically how to live more healthfully,

But Puhl points out that despite the large amounts of money that go into these campaigns, little research has been done by the organizations behind them on their practical effectiveness. She urges the people spreading these messages to pay more attention to the effects they may be having -- especially when they're in danger of causing harm. As the authors wrote, "Considerable evidence demonstrates that individuals who feel stigmatized or shamed about their excess weight engage in higher calorie intake, unhealthy eating behaviors, binge-eating patterns, as well as avoidance of exercise." And previous studies done by these researchers revealed that exposing people to stigmatizing images worsens their attitudes toward obese people.

The trick is figuring out how to be anti-obesity without being anti-obese people -- and boiling these issues down to a slogan makes this difficult to do.

Lindsay Abrams (Sep. 2012)., Obesity Campaigns:

The Fine Line Between Educating and Shaming.

The Atlantic/ http://www.theatlantic.com/health/archive/

2012/09/obesity-campaigns-the-fine-line-between-educating-and-shaming/262401/

Focus on empowering the individual. Behaviour change is not a passive process and only the individual concerned can make the necessary changes. Give encouragement and help develop the client’s confidence that he / she will be able to do this (TAKE ACTION). Reward the affirmative, rather than punish the negative.

The theoretical rationale for social support in lifestyle interventions is strong. While the rationale for incorporating support in Stages of Change-based interventions is just as strong, there is hardly any evidence from intervention trials. The results of social support in nonstaged interventions are sometimes conflicting, but suggest beneficial effects of the inclusion of social support in interventions aimed at long-term health behaviour change. Adding social support to lifestyle interventions programs has the potential to reduce workload for health professionals, and is appreciated by at least part of the patient population. … studies have related social support to health, and social support has also been shown to be important in achieving and maintaining health behaviour change social support may counter the state of denial patients had been in to protect themselves from psychosocial effects of their illness  (European Journal of Clinical Nutrition, 2005)

Family members, friends, colleagues, and (church) communities are part of patients' natural support network and can play a role in the provision of social support. Involving natural support resources in intervention programs is valued by patients and increases program effectiveness, but negative consequences are also reported. Bringing new sources of support such as peers into action may be helpful when social support from patients' natural networks is insufficient. This may not only lead to improved health of the patient but also of the support giver, for example, because providing support makes them feel good about themselves. This is referred to as the helper-therapy.

Role of social support in lifestyle-focused weight management interventions.

European Journal of Clinical Nutrition (2005) 59,

Suppl 1, S179–S186. doi:10.1038/sj.ejcn.1602194

Despite significant efforts, obesity continues to be a major public health problem, and there are surprisingly few effective strategies for its prevention and treatment. We now realize that healthy diet and activity patterns are difficult to maintain in the current physical environment.

Recently, it was suggested that the social environment also contributes to obesity. For a wide variety of conditions and networks, we show that individuals with similar BMIs will cluster together into groups, and if left unchecked, current social forces will drive these groups toward increasing obesity. Our simulations show that many traditional weight management interventions fail because they target overweight and obese individuals without consideration of their surrounding cluster and wider social network.

The popular strategy for dieting with friends is shown to be an ineffective long-term weight loss strategy, whereas dieting with friends of friends can be somewhat more effective by forcing a shift in cluster boundaries.

Fortunately, our simulations also show that interventions targeting well -connected and/or normal weight individuals at the edges of a cluster may quickly halt the spread of obesity. Furthermore, by changing social forces and altering the behavior of a small but random assortment of both obese and normal weight individuals, highly effective network-driven strategies can reverse current trends and return large segments of the population to a healthier weight.

Exploiting Social Networks to Mitigate the Obesity Epidemic

6 SEP 2012. DOI: 10.1038/oby.2008.615

Together, as we begin to think about the idea that people are connected in vast social networks, we realized the social influence does not end with the people we know. If we affect out friends, and they affect their friends, then our actions can potentially affect people we have never met. We began by studying various health effects. We discovered that if your friend’s friend’s friend gained weight, you gained weight. We discovered if your … stopped smoking, you stopped smoking. And we discovered that if …. Became unhappy, you became unhappy.

As we studied social networks more deeply, we began to think of them as a kind of human superorganism. The grow and evolve, All sorts of things flow and move within them. This superorganism has its own structure and a function ….

Neighbours or even stangers can influence behavours …

… people can transcend themselves and their own limitations.

Nicholas A. Christakis, James H. Fowler.  Connected:

The Surprising Power of Our Social Networks and How They Shape ...

http://books.google.ca/books?hl=en&lr=&id=LXHi4wgIkzEC&oi=fnd&pg=PT4&dq=social+network+obesity+prevention+strategy+ontario&ots=3pzAleQ-9_&sig=xW_QDvIcyeWHAa3fqmqrSI00Gyk#v=onepage&q&f=false

Lean Works - CDC

Workplace obesity prevention programs can be an effective way for employers to reduce obesity and lower their health care costs, lower absenteeism and increase employee productivity.  “We believe that Wellness is a business strategy and core to our culture and should be included in our belief statements.” – Corporate and community/council initiatives.

… positive health practices need to be connected with the abilities and possibilities of today, not with the nebulous threat of infirmity at some time later.

Soft communications are low-tech approaches to messaging that are delivered at the work site. …. When branded, promoted, and distributed properly, soft communications applications are a point-of-service strategy that can be very effective at engaging the target population and reinforcing a culture of health.

Hard communications are high tech communications tools that deliver content, resources, and social support—virtually. With the evolution of the Internet and delivery devices such as smart phones and electronic tablets, people have 24/7 access to tailored health content, coaching platforms and tutorials, and peer-support groups. In addition, with the explosion of social media such as Facebook, Twitter, and Second Life, the creation of health-related affinity groups or communities provide an information and support network that connects employees virtually.

A major advantage of virtual communications is the scalability of health content and support (e.g., coaching, disease management) in connecting geographically dispersed populations.

… Encourage the development of affinity groups or clubs. Many organizations support the development of social groups or clubs that share common recreational pursuits (e.g., groups for running, cycling, skiing, triathlons), hobbies, and health and life concerns (e.g., weight management, single parents, retiree, AA, specific disease states). Depending on the organization, affinity groups can meet regularly and connect through electronic bulletin boards and other social media platforms.

… Other soft approaches to creating social networks can include the development of team challenges, buddy-up promotions, and mentoring programs.

Center for Disease Control’s LEAN Works! - A Workplace Obesity Prevention Program http://www.cdc.gov/leanworks/

Partnerships

A comprehensive approach to diabetes prevention should combine population based primary prevention with programs targeted at those who are at high risk. This approach should take account of the local circumstances and diversity within modern society (e.g. social inequalities). The challenge goes beyond the healthcare system. We need to encourage collaboration across many different sectors: education providers, non-governmental organizations, the food industry, the media, urban planners and politicians all have a very important role to play.

TAKE ACTION TO PREVENT DIABETES:

A toolkit for the prevention of type 2 diabetes Europe

http://nebel.tumainiserver.de/dp/pdf/IMAGE_Final_version_of_toolkit.pdf

The International Diabetes Federation is engaged in action to tackle diabetes from the local to the global level - from programs at community level to worldwide awareness and advocacy initiatives.

World Diabetes Day  http://www.idf.org/worlddiabetesday/the-campaign/unite-for-diabetes

The activities of IDF aim to influence policy, increase public awareness and encourage health improvement, promote the exchange of high-quality information about diabetes, and provide education for people with diabetes and their healthcare providers. IDF's awareness and advocacy initiatives are grounded in the experiences of our global network of national diabetes associations. http://www.idf.org/whatwedo

The mission of the International Diabetes Federation is to promote diabetes care, prevention and a cure worldwide. Our strategic goals are to: Drive change at all levels, from local to global, to prevent diabetes and increase access to essential medicines. Develop and encourage best practice in diabetes policy, management and education. Advance diabetes treatment, prevention and cure through scientific research. Advance and protect the rights of people with diabetes, and combat discrimination. http://www.idf.org/mission

About the Ontario Diabetes Strategy: As part of the ongoing effort to improve the health and health care of Ontarians, the Ontario Diabetes Strategy (ODS) will help people with diabetes and those who are at high risk of developing it.

The Ontario Diabetes Strategy (ODS) will do this by: educating the public, especially those at high risk, about diabetes and ways to prevent it supporting patients managing their disease increasing the adoption of approved practice guidelines and proven care and treatment continually improving local health coordination identifying gaps in health care and addressing them; setting targets for clinical performance; enhancing accountability and monitoring performance.

http://www.mhp.gov.on.ca/en/prevention/diabetes.asp

The literature regarding the prevention of diabetes provides few standards for community-based initiatives. The present article offers four principles for engaging communities in comprehensive community approaches to diabetes prevention including (1) facilitating meaningful and central roles for communities, (2) giving primary attention to participatory processes rather than to best practices, (3) emphasizing cultural relevance in designing interventions particularly in racial and ethnic communities, and (4) incorporating social ecology approaches that are holistic and that address larger environmental influences rather than individual behavioral change alone. In order that community public health practitioners may operationalize the principles, models are provided for each.

Applying Comprehensive Community-based Approaches in Diabetes Prevention:

 Rationale, Principles, and Models. Jr  Journal of Public Health Management & Practice:

November/December 2006 - Volume 12 - Issue 6 - p 545-555. http://journals.lww.com/jphmp/Abstract/2006/11000/Applying_Comprehensive_Community_based_Approaches.8.aspx

Potential Funding Sources for Obesity Prevention-Related Activities

The following section provides an overview of the current scope of existing

Ontario-based initiatives that may provide funding for obesity prevention-related

activities.

• Canadian Institute for Health Research Various. Primary fit with Institute of Nutrition,
• Metabolism and Diabetes - Institute of Population and Public Health
• Ministry of Health Promotion Communities in Action Fund
• Ontario Stroke Strategy
• Ontario Ministry of Agriculture, Food and Rural Affairs
• Ontario Market Investment Fund
• Ontario Trillium Foundation Streams - Healthier / More Active Ontarians -Enhanced Success for Students and Learners
• Laidlaw Foundation Youth Organizing Grants – Catalyst - Project
• Heart and Stroke Foundation of Ontario Community Advocacy Fund
• Wellesley Institute Enabling Grants
• Various Streams, change by year

Other Potentials

Partnerships with academic institutions

Partnerships with Health Institutions

Partnerships with Government.

Research

Research – Does it fit within our mandate – vision – mission?

Will the politicians be pleased we are spending their.. I mean the tax payers … money wisely and with good expectation of return on the investment? Not an entirely facetious statement – as it makes the SGBCHC a more valuable asset and … we could justify asking for more funding.

Research – validation – What research/experience supports that diabesity is a significant health issue. That would be easier to do.

Research – validation –  is this a feasible project? What precedents are there?

Research – Expected outcomes

Research – partnerships – Governments / academic / research / community partners.

Research – Funding sources.

Research – Program development.

Implementation

Monitoring / measurement. 

Publishing results.

Expansion of the project.

Can the same model of development then be applied to another community health issue?

A lot of return for the investment.

Branding –

Think Blue – Wear Blue campaigns.  To tie into international campaigns.

Award – South Georgian Bay Community Health Alliance* recognizes ______________ in their effort to promote a healthier community.

*partnerships.

Seal of approval for menu items.

Award of merit to schools, teachers, students who participate and show leadership.

Initial campaign…

Permeate the community with the message….

THE FIRST STEP TO LOSING WEIGHT IS TO STOP GAINING WEIGHT!

Pound the message into the subconscious mind of the community.

Aggressively recognize and promote health conscious initiatives and partnerships.

Incentives to groups that prove success by documenting increased activity levels and/or decreases weight.

Eg:

-          Reward for a group to collectively walk to Patagonia.

-          Exploit the rivalry that Wasaga Beach has for Collingwood by a substantial reward for the first community to collectively walk to the moon.

New Guidelines Urge Docs to Focus on Obesity

Published: Nov 15, 2013 | Updated: Nov 15, 2013

Download Complimentary Source PDF 

By Kristina Fiore, Staff Writer, MedPage Today

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

• A guideline for the management of overweight and obesity in adults by the AHA, ACC, and the Obesity Society has been developed aimed at primary care physicians.
• An algorithm is provided that focuses on the identification of patients with excess body weight and those at risk for obesity-related health problems. Its purpose is to guide weight management decision making.

ATLANTA -- Doctors should diagnose and treat obesity at every clinic visit, the way they would any other chronic disease, according to new national guidelines. But some experts disagree.
"It's an enormous shift," Donna Ryan, MD, co-chair of the guideline committee, told MedPage Today during an interview at Obesity Week here. "The current way [primary care clinicians] engage obese patients, if at all, is to tell them to lose weight. They recommend weight loss, but they don't own weight management."

"They don't really engage in helping patients achieve weight loss, either through referral or providing counseling or prescribing," said Ryan, a professor emeritus at Pennington Biomedical Research Center in Louisiana. "They have been reluctant to do that. But that is changing."

The obesity guidance is one of four updated guidelines on cardiovascular prevention commissioned by the National Heart, Lung, and Blood Institute and developed by the American Heart Association and the American College of Cardiology. The Obesity Society partnered with those two institutions to develop the obesity-specific guidelines -- which hadn't been updated since 1998.

Ryan said the guidelines are geared toward primary care clinicians and offer an algorithm for managing obesity. They focus on identifying at-risk patients and prescribing appropriate interventions.
The first step, she said, is assessing who needs to lose weight, and current body mass index (BMI) cutpoints are a good place to start.

Those who have a BMI of 30 and up need treatment, no questions asked. Those who fall into the overweight category -- a BMI of 25 to 30 -- should be treated if they have other risk factors, including an elevated waist circumference of 35 inches and up for women or 40 inches and up for men.

Although there's been some debate about the utility of BMI as a screening tool, Ryan said the research shows "very clearly that as BMI increases, the risk for cardiovascular disease, diabetes, and cancer all go up."

As far as how much weight patients need to lose, the guidelines urge that even a minimal amount brings health benefits.

"Weight loss as little as 3% to 5% can produce health benefits, but what we're really aiming for is 5% to 10% weight loss," Ryan said. "That's where we can get a lot of health benefits."

"The message is not 3%, 5% or 10%," Ryan added. "The message is that you don't have to go down to a normal weight. You don't have to hit a BMI of 25 to achieve a lot of health benefits."

Which diet should doctors prescribe? That depends on the patient, the guidelines say.

Ryan said the group reviewed 17 diets, and not surprisingly, found that "there is no magic diet."

Instead, clinicians should prescribe a diet based on patients' other risk factors. Someone with hypertension, for instance, may benefit from the DASH diet, while those with other cardiovascular risks might try a Mediterranean diet.

"As long as you're creating a negative energy balance, usually 500 to 1,000 calories per day, you're going to get weight loss, regardless of the diet," Ryan said.

And that diet should be part of a comprehensive lifestyle intervention that includes physical activity and behavioral changes -- which should be delivered by a trained interventionist. The guidelines recommend that patients meet with this counsellor 14 times in the first 6 months, and follow up for at least a year.

Even though that may not be widely covered by all insurances, Ryan urged that "we have the evidence to support its efficacy and we're very much hoping that it will be covered."

The guidelines do not make specific references to obesity medications because there was only one available -- orlistat (Alli, Xenical) -- when the committee was reviewing the evidence. Since then, two new diet drugs have been approved by the FDA: lorcaserin (Belviq) and phentermine/topiramate (Qsymia).
The drugs could fit into an overall lifestyle intervention plan, but aren't likely to help all on their own, Ryan said when pressed about whether an increased focus on treating obesity could lead to more liberal writing of scripts for obesity drugs.

"These medications work by reducing hunger and increasing satiety, and you're only going to get that if you're trying to diet," Ryan said. "You'll get minimal weight loss if you just write the prescription. But if you combine it with a diet and lifestyle intervention, you will achieve and sustain much better weight loss. It's a much better business model than just writing prescriptions."

She said the drugs are "used as an intensification approach. When patients can't do it on their own, they may need biological reinforcers to achieve behavioral change."

The fifth and final recommendation in the obesity guidance focuses on bariatric surgery for weight loss. It maintains recommendations to refer patients with a BMI of 40 and up, or 35 plus at least one obesity-related comorbidity, to bariatric surgery when other interventions fail.

"It's not a change in recommendation, but it's a much stronger endorsement of surgery," Ryan said. "Doctors should actively consider surgery and refer patients who might benefit from it, because the efficacy and safety evidence is strong."

Not all groups, however, agree with the guidance. Jeffrey Mechanick, MD, of Mount Sinai Icahn School of Medicine in New York, and president of the American Association of Clinical Endocrinologists, said his organization reviewed the guidelines and did not endorse them.

Alan Garber, MD, of Baylor College of Medicine, and a former past-president of AACE, said the guidelines don't accurately reflect the literature.

"It's a very narrow slice of a highly pre-specified kind of evidence base, which doesn't necessarily extrapolate to the whole of the at-risk population and therefore leaves many patients untreated or at residual risk," Garber said. "To be blunt, it's inadequate."

Ryan reported relationships with Alere Wellbegin, Amylin, Arena Pharmaceuticals, Eisai, Novo Nordisk, Nutrisystem, Orexigen, Takeda, Vivus, and Scientific Intake. The other members of the writing groups reported numerous relationships with industry.

---

Primary source: Obesity
Source reference: Jensen MD, et al "2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults" Obesity 2013; DOI: 10.1002/oby.20660.

Childhood Obesity Reversed

Discover Magazine: FROM THE JANUARY/FEBRUARY 2014 ISSUE  

By Jeff Wheelwright|Tuesday, December 03, 2013 RELATED TAGS: OBESITY, FAMILY HEALTH

For years, health professionals have been urging better nutrition and more exercise for children. Are we finally listening?

5

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Public health officials call it an epidemic. The American Medical Association calls it a disease. During the past 30 years, obesity rates in the U.S. have more than doubled among adults (to 35 percent) and tripled among children and adolescents (to 17 percent). The problem seemed unstoppable — until this year. 

For the first time in decades, reported the Centers for Disease Control and Prevention (CDC), obesity rates declined among low-income preschool children, a particularly vulnerable demographic group. No magic diet was involved: This public health success seems to be the result of promoting healthier foods and physical activity. 

Between 2008 and 2011, the CDC measured the weights and heights of about 12 million children between the ages of 2 and 4 in 40 states, two territories and the District of Columbia. The preschoolers were on the rolls of federal nutrition programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides dietary counseling and food vouchers to low-income mothers. 

In 18 states, obesity rates declined slightly. Three states showed increases; the remaining 19 had no change from the prior survey. 

This small change could have big benefits down the road. Young children’s weight predicts their future health, says epidemiologist Ashleigh May, the lead author of the CDC report: “If they’re obese at this age, they’re five times as likely to become obese as adults.” Overweight children can develop high blood pressure and high blood sugar, which raises their risk of cardiovascular disease and diabetes when they grow up.

Four years ago, WIC revised its list of approved groceries to emphasize fruits and vegetables — one possible cause for the turnaround. More women are now breast-feeding, and breast-fed babies are more likely to be at a healthy weight. 

The CDC also credits public awareness programs like “Let’s Move,” championed by first lady Michelle Obama, that promote healthy eating and exercise in day care centers and among child care providers. “We were expecting spotty progress, but this [decline] was widespread,” Let’s Move Executive Director Sam Kass says.

A White House task force calls for childhood obesity rates to fall to 5 percent by 2030. Is it a reasonable goal? 

“All the public health campaigns in this country required concerted efforts over many years,” says pediatrician David Ludwig, director of the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital. He cites drives to reduce traffic fatalities and curb tobacco use. “We have every reason to hope for an eventual
victory.”

Jan 2014

1.

Here is development of a peer support healthy eating and lifestyle plan - social networking and support is an integral factor.
http://www.danielplan.com/

"One of the reasons The Daniel Plan has already helped thousands of people succeed in creating a healthier lifestyle is the fact that it is designed to be done in community. The fact is God created us to thrive in relationship, and together we are crucial to each other’s healing and success.

Watch and listen to what people have discovered while living The Daniel Plan lifestyle.

We encourage you to invite a few friends and start a Daniel Plan Small Group.  Check out our 6-Week Small Group Study to learn more."

While this plan/method is targeted to a faith based community, the essentials can easily be translated to a secular community.

2.


Sandra argues that healthy habits are cumulatively more effective in promoting healthy outcomes than focusing on weight alone.

http://www.ted.com/talks/sandra_aamodt_why_dieting_doesn_t_usually_work.html?utm_source=newsletter_weekly_2014-01-11&utm_campaign=newsletter_weekly&utm_medium=email&utm_content=talk_of_the_week_button
Ergo.. instead of focusing on obesity, promote healthy habits and the obesity will manage itself. 
Regardless... the social networking theory would still apply.


Jan 16/14

 However, major changes have occurred in population lifestyles. These include the decreasing prevalence of smoking¹⁸ and a remarkable increase in obesity since the 1990s.¹⁹ Given that changes in health behaviors may be socially patterned,^20,21 previous studies with a single assessment of behaviors may have provided an inaccurate estimation of their contribution to the association between socioeconomic factors and mortality. In this study, health behaviors over a 24-year period were used to assess their role when only baseline measures were used compared with when measures were repeated over the follow-up period. We further examined whether this difference is similar for the 4 health behaviors of smoking, alcohol consumption, diet, and physical activity.

 The higher prevalence of unhealthy behaviors in lower socioeconomic positions^7- 9 is seen to be one of the mechanisms linking lower socioeconomic position to worse health.^10,11 Combinations of potentially modifiable behavioral factors such as smoking, alcohol consumption, dietary patterns, physical activity, and body mass index have been shown to explain 12% to 54% of the socioeconomic differences in mortality.

Association of Socioeconomic Position With Health Behaviors and Mortality

Silvia Stringhini, MSc; Séverine Sabia, PhD; Martin Shipley, MSc; Eric Brunner, PhD; Hermann Nabi, PhD; Mika Kivimaki, PhD; Archana Singh-Manoux, PhD

JAMA. 2010;303(12):1159-1166. doi:10.1001/jama.2010.297

http://jama.jamanetwork.com/article.aspx?articleid=185584

March 16, 2014

Brazil takes an unambiguous new approach to fighting fat

By ADRIANA BARTON, Accessed via: http://www.theglobeandmail.com/life/health-and-fitness/health/brazil-takes-an-unambiguous-new-approach-to-fighting-fat/article17496796/

Scroll to the end of the article for common sense approaches to managing overeating. 

Experts praise country's approach, which encourages citizens to be critical of food industry and advertising

Brazil, like Canada, is getting fatter by the year.

Obesity has reached such epic proportions that Brazil's new soccer stadiums include more than double the number of extra-wide seats required by World Cup authorities to accommodate both people with disabilities and heavyweight fans. On Brazil's famous beaches, adipose folds have multiplied as fast as the pizza joints and Burger Kings that were virtually non-existent two decades ago.

Nevertheless, Brazil has a plan to reverse obesity – and it's winning raves from North America's toughest nutrition critics, including author Michael Pollan, food-industry watchdog Marion Nestle and Canadian bariatric expert Yoni Freedhoff.

Unlike food guides in Canada and the United States, it does not include arranging food groups in pie or pyramid shapes, adding up recommended servings listed in grams, or colour-coding nutrient groups that correspond to sectors of the agricultural industry – dairy, meat and grain. Nor does it require people to measure servings of pasta by the half-cup, or carve up steak into helpings the size of a deck of cards.

Instead, Brazil's proposed guide (in public consultation until May) emphasizes meals, not nutrients. It urges people to be critical of food-industry advertising, and introduces healthy eating as a lifestyle choice that involves learning how to cook from scratch and taking the time to sit down and eat with others.

The concept is so simple, experts say, that it just might work.
Pollan (known for the phrases, "Eat food. Not too much. Mostly plants.") called the new dietary guidelines "radical" in a recent tweet. The highly influential Nestle, who blogs at FoodPolitics.com, praised Brazil for its "sensible, unambiguous" approach.

And Freedhoff, Canada's own healthy-eating guru, described Brazil's food guide, released in February, as "refreshingly free of industry bias" and "exactly what we need to be doing as a society."

How people eat is as important as what they eat, said Jean-Claude Moubarac, a Montreal-based postdoctoral scholar of public health and nutrition who spent two years as a member of the University of Sao Paulo team responsible to the Brazilian ministry of health for developing the new guidelines.

Research has shown that when people sit down at mealtimes with friends and family, "they tend to eat less" than when they're eating alone or on the run, Moubarac explained.

Brazil's new food guide contains no information on calories or how to limit serving sizes to reduce body mass index. Instead, it tells Brazilians what to leave off the dinner plate. The guide recommends that people limit or avoid ready-to-eat products such as snack foods, candy, sweetened beverages, instant soups and microwaveable meals.

The warning to be wary of food-industry advertising is a world's first for government-issued dietary guidelines, Moubarac said. Compared with U.S. and Canadian guidelines, which don't address the impact of the food industry on dietary habits, "It's a huge thing that a ministry of health is saying, 'be critical of commercial advertising,'" he said.

Canada's Food Guide has not succeeded in shrinking waistlines in this country, where 18 per cent are now obese – a rate that has tripled since 1985.
Canada's guidelines are based on recommended daily intake of specific nutrients derived from food groups. But the guidelines are not as evidence-based as they seem, according to Freedhoff, director of the Bariatric Medical Institute in Ottawa. For the most part, "RDIs are theoretical," he said.

The nutrient-based approach has enabled the food industry to market products such as sugary cereals and over-salted soups as part of a healthy diet, based on added minerals or protein advertised on the box, Freedhoff explained. "This focus on nutrients has steered people towards nonsensical patterns," he said.

Added vitamins or not, heavily processed foods are loaded with excess sugar, fat and salt, which work against the biological mechanisms that let us know when we've eaten enough, studies have shown. Meals made from scratch are more likely to trigger feelings of satiety, Freedhoff said. "It is very challenging to consume very large quantities from fresh foods – you're full."

Cooking a healthy meal can be as simple as frying an egg, tossing a salad or making a sandwich, he added.

The trouble is that a growing number of people – Canadians and Brazilians – have either gotten out of the habit of making their own food, or never learned in the first place.

In Brazil, many grow up with a team of maids or grandmas who spend hours in the kitchen peeling and chopping meat and vegetables for almoco, the midday meal. A typical almoco consists of a dozen plates of food laid out on the table for the family to enjoy on a two-hour break from work or school.

But Brazil's booming economy has resulted in longer working hours – which cut into almoco time – as well as job opportunities that lure workers far from home.

Young Brazilians who didn't learn to cook from their parents are easily seduced by the convenience of fast food, Moubarac said. Focus groups conducted by the researchers who created Brazil's new guidelines identified university students as the group most likely to say they did not like, or know how, to cook.

And now, many in Brazil have disposable income for the first time, thanks to economic and social reforms that pulled 20 million Brazilians out of poverty between 2003 and 2009. This means new freezers and microwaves to store and reheat food, and money for fast food.

Transnational food companies have seized the market opportunity, including McDonald's (which has nearly 700 restaurants in Brazil), KFC and Burger King, which was acquired in 2010 by a Brazilian-owned global investment firm.
For lower-income Brazilians, eating a Big Mac holds far more social cachet than cooking rice and beans from the corner market. "It's a way to climb the social hierarchy," Moubarac said.

Escalating obesity has been the result. Nearly half of Brazilians are overweight – a proportion that has more than doubled since 1990. More than 15 per cent are obese, and in a decade or so, Brazil is predicted to reach the current U.S. obesity level of 35 per cent.

Moubarac acknowledged that dietary guidelines alone can't counteract international market forces and major socioeconomic shifts that have added to Brazil's girth. The new food guide is the first step in a larger plan that will include community-based programs designed to help lower-income families learn about healthy portion sizes and how to cook homemade meals with moderate amounts of sugar, fat and salt, he said.

He added that Brazilians who lack the time or inclination to cook can still make healthy choices by frequenting Brazil's ubiquitous "por quilo" (by the kilogram) buffet-style restaurants, which offer a wide variety of freshly prepared meat and vegetarian dishes sold by weight.

Canada should borrow pages from Brazil's new book, Freedhoff said.
Instead of focusing on abstract nutrition concepts, health authorities should support and encourage Canadians to cook simple, healthy, everyday meals.
Initiatives could include reintroducing home-economics classes for boys and girls in primary school and offering after-school programs that help parents learn how to cook, Freedhoff said.

In the meantime, he said, Brazil is a trailblazer: "These are guidelines that countries around the world should encourage their citizens to adopt."

10 key points in Brazil's proposed guidelines

The authors of Brazil's proposed dietary guidelines boiled down the 87-page document into 10 basic steps:

1. Prepare meals using fresh and staple foods.

2. Use oils, fats, sugar and salt in moderation.

3. Limit consumption of ready-to-eat food and drink products.

4. Eat at regular mealtimes and pay attention to your food instead of multitasking. Find a comfortable place to eat. Avoid all-you-can-eat buffets and noisy, stressful environments.

5. Eat with others whenever possible. Refer to the French Paradox http://drwaynecoghlan.blogspot.ca/2008/10/losing-weight.html

6. Buy food in shops and markets that offer a variety of fresh foods. Avoid those that sell mainly ready-to-eat products.

7. Develop, practise, share and enjoy your skills in food preparation and cooking.

8. Decide as a family to share cooking responsibilities and dedicate enough time for healthy meals.

9. When you eat out, choose restaurants that serve freshly made dishes. Avoid fast-food chains.

10. Be critical of food-industry advertising.


Source: Guia Alimentar Para a Populacao Brasileira (2014).   

Fat to Blame for Half a Million Cancers a Year

http://www.scientificamerican.com/article/fat-to-blame-for-half-a-million-cancers-a-year/?WT.mc_id=SA_SP_20141201

 

The problem is particularly acute in North America, the World Health Organization's cancer research agency said 

 

 

November 25, 2014

By Kate Kelland

LONDON (Reuters) - Some half a million cases of cancer a year are due to people being overweight or obese, and the problem is particularly acute in North America, the World Health Organization's cancer research agency said on Wednesday.

In a study published in the journal The Lancet Oncology, the WHO's International Agency for Research on Cancer (IARC) said high body mass index (BMI) has now become a major cancer risk factor, responsible for some 3.6 percent, or 481,000, of new cancer cases in 2012.

"The number of cancers linked to obesity and overweight is expected to rise globally along with economic development," said Christopher Wild, IARC's director.

He said the findings underlined the importance of helping people maintain a healthy weight to reduce their risk of developing a wide range of cancers, and of helping developing countries avoid the problems currently faced by wealthier ones.

The IARC study found that, for now, North America has by far the worst cancer problem linked to weight, with some 111,000 obesity-related cancers diagnosed in 2012, accounting for 23 percent of global cancer cases linked to high BMI.

In Europe, obesity is to blame for around 6.5 percent of all new cancers a year, or around 65,000 cases.
While in most Asian countries the proportion of fat-related cancers is smaller, it still translates into tens of thousands of cases because populations are so large, IARC said.
In China, for example, about 50,000 cancer cases are associated with being too fat, accounting for 1.6 percent of new cancer cases.
In Africa, on the other hand, obesity is to blame for only 1.5 percent of cancers.
Having a high BMI -- a person's weight in kilograms divided by the square of their height in meters -- increases the risk of developing cancers of the oesophagus, colon, rectum, kidney, pancreas, gallbladder, postmenopausal breast, ovary and endometrium. A BMI score of 25 or more is classed as overweight, while 30 or more is obese.
Melina Arnold, who co-led the IARC study, noted that women are disproportionately affected by obesity-related cancers.
For postmenopausal breast cancer, for example - the most common women's cancer worldwide - the findings suggest that 10 percent of cases could be prevented by not being overweight.