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ANTC68: Deconstructing Epidemics Lecture 11: Deconstructing Obesity The Age of Obesity and Inactivity (Gaziano 2010)  1960-1962 National Health Examination Survey, an estimated 31.6% of men and women met the definition for “preobesity” or overweight (BMI = 25.0 - 29.9), and 13.4% were obese  Latest data from the National Health and Nutrition Examination Survey (NHANES) (see Flegal et al. 2010): in 2007-2008, 68% of US adults were overweight, of whom 33.8% were obese  More men (72.3% of above figures) than women (64.1% of above figures) were overweight or obese  Threatens progress made in reducing morbidity and mortality in adulthood (increasing longevity), i.e., due to public health efforts to reduce smoking, alcohol consumption, hypertension (salt intake) and cholesterol intake  “First generation to die at a younger age than their parents”... Obesity is Pandemic (Jeffery and Sherwood 2008)  Extensive data indicates a growing prevalence of obesity (BMI >30), and the causal role of obesity in adverse health a major global problem  WHO’s Global Database on Body Mass Index includes comprehensive data on obesity trends; absolute prevalence of obesity varies among countries from 0.7% - 78.5%  Rates of obesity in adults have: o Roughly tripled in Japan (from 0.84% in 1980 to 2.86% in 2001) o Brazil (from 2.4% in 1974-5 to 8.9% in 2002-3) o England (from 6.2% in 1982 to 22.6% in 1999) o the United States (from 11.5% in 1990 to 34. 10%in 2004), o Seychelles (from 4.2% in 1989 to 15% in 2004) Obesity Findings (US)  1960-1980: obesity prevalence was relatively stable  1980-1990s: significant increases  1999-2008: reduced prevalence increases among women  Recent US data (Flegal et al. 2010; Ogden et al. 2010) suggest that decades-long steady upward trend in overweight / obesity may have slowed or stabilized  Though data still indicate that approximately 68% of US adults are overweight or obese (1/3 obese), and almost 32% of school-aged US children are at or above the 85th percentile of BMI for age (overweight/obese)(see Ogden et al. 2012)  Assuming current trends, researchers predict that by 2020: almost half of US adults will meet WHO criteria for obesity (BMI > 30) (Stewart et al. 2009) Childhood / Adolescent Obesity  Prevalence of overweight/obesity in children and adolescents has paralleled adult increases, in western nations as well as the developing world (see Jeffery & Sherwood 2008)  U.S. NHANES data: obesity in 1976-80: 6.5% among 6-11 yr olds; 5% among 12-17 yr olds  2003-4: 19% among 6-11 yr olds; 17% among 12-17 yr olds  2007-2008: almost 17% of school-aged children and adolescents are “obese”, defined as BMI for age at or above the previously established 95th percentile, and almost 32% categorized as at or above the 85th percentile of BMI for age, the lowest CDC cutoff for overweight (Ogden et al. 2012)  Prevalence of overweight school-age kids as high as 35% in parts of Europe (see Jeffery and Sherwood 2008) Explaining Obesity  Besides excessive food intake, explanations have included:  Reduced physical activity, i.e., due to urban sprawl, changes in employment with industrialization, crime, etc.  Viruses(“infectobesity”; strain of adenovirus...common cold) (Dhurandhar 2001; Whigham et al. 2006)  High-fructose corn syrup  Obesogens: drugs or chemical pollutants that disrupt lipid metabolism and hormone regulation  Medications  Genetic predisposition  Endocrine disorders  Psychiatric illness Structural Factors: SES and (Urban) Poverty Obesity's Consequences  Risk factor for many chronic conditions: o Diabetes o Hypertension o High cholesterol o Stroke o Heart disease o Some cancers o Arthritis and joint conditions o Sleep apnea o Asthma  Widely considered a risk for excess mortality, primarily from cardiovascular disease, diabetes, and certain cancers (esophagus, breast, endometrium, colon, rectum, kidney, pancreas, thyroid, gallbladder) Obesity and Diabetes  Data from the Behavioral Risk Factor Surveillance System and the National Ambulatory Medical Care Survey (1995-2004) indicate that during a period in which the prevalence of overweight and obesity increased by nearly 24%, the prevalence of diabetes increased by ~ 76% and the number of diabetes-related visits to primary care doctors more than doubled (Pearson 2007) Economic Consequences  According to the CDC: spending for obesity-related conditions accounted for an estimated 10% of the total annual US medical expenses in 2008, or $147 billion  In Canada: 2005 – obesity-related (not “overweight”) chronic conditions accounted for $4.3 billion in direct ($1.8 billion) and indirect ($2.5 billion) costs – considered by Gov of Can as an underestimation of the total costs of excess weight in cost of illness in Canada in 2005 = approx. $202 billion (2.12% of total annual costs) Biosocial Consequences of Obesity  Serious psychosocial and biological consequences o Social alienation / isolation o Disordered eating o Negative body–self relationships o Depression o Anxiety o Risk for suicide  Stigmatization and size discrimination  Blaming the individual “Obesity is Exaggerated” (Basham and Luik 2008)  Current data are highly ambiguous for claims of an epidemic  Average population weight gain in the US in the past 42 years is 10.9 kg or 0.26 kg a year (Ogden et al. 2005)...  “Determination of the categories of normal, overweight, and obese is entirely arbitrary and at odds with the underlying evidence about the association between body mass index and mortality (no clear association between BMI and mortality), a fact that destroys the index's scientific pretensions and diagnostic value”  Trends in obesity-related health outcomes do not always parallel trends in the prevalence of obesity: despite increases in obesity, incidence of cardiovascular disease (and related mortality) has declined steeply (CVD deaths declined 18% over past decade), as has heart disease mortality; due to improvements in diet or better medical treatments/interventions (Flegal et al. 2010) “Obesity is Exaggerated”: Some Findings  Flegal et al. 2005: excess body weight is responsible for only 26,000 deaths/year in US, a number lower than that which results from “weighing too little”  Flegal et al. 2005: weight group with the lowest death rate was the overweight group  Gronniger 2005: found negligible differences in risk of death among people with BMI values from 20-25.7  Gregg et al. 2005: obese Americans have better cardiovascular disease risk profiles than did their leaner counterparts 20–30 yrs ago  Even significant associations suggest risks so low “as to be highly suspect”: death risks for overweight and obese people are in many instances closer to 0.5-1.75 times risk for people with normal weight (Lee et al. 1993) (while lung cancer risks for smokers are typically 10-15 times higher than for non-smokers) “Obesity is Exaggerated”  Size and “overweight” does not necessarily = poor health  Weight is not the same as fat (or obesity), thus overweight should not be used as a proxy for obesity  Losing weight for some considered “overweight” or “obese” does not necessarily result in improved health  Clear association of overweight and obesity with higher risks of chronic disease is difficult to assess, partly because of the multifactorial character of these diseases (Basham & Luik 2008)  Despite the “abnormal” levels of overweight and obesity around the world (especially in Western nations), life expectancy continues to increase globally Deconstructing Obesity: The Politics of Pathology (Oliver 2006)  Media has consistently remarked about an “obesity epidemic” since 1999, yet:  1.Disease characterization has less to do with the health consequences of excess weight and more with the various financial and political incentives of the weight loss industry, medical profession, and public health bureaucracy  2.The “epidemic” aspect of obesity is the result of specific acts of culturally this case, changes in weight indices that were communicated via a specific mode of information transmission: powerpoint maps Obesity as “Disease”?  Obesity as disease is a flawed construct (Oliver 2006)  According to Stedman’s Medical Dictionary (2000), a disease is “an interruption, cessation, or disorder of body function, system, or organ.”  According to Oliver (2006: 612): o “By this definition, if obesity is a disease, then we must assume that, at some level, body fat is pathological. However, there is no clear evidence about what level or even how, exactly, adipose tissue is harmful to our health. For some extremely heavy people, their body fat may disrupt their ability to function, particularly their ability to exercise, or may create joint problems like osteoarthritis, but for the vast majority of technically obese people (those with a BMI between 30 and 35), there is no clear evidence that their fatness is a disorder.” Obesity as Disease  Emphasized as a “disease” since the early 1980s by a relatively small group of doctors and public health officials, with substantial assistance from the weight-loss industry (see Oliver 2006)  Worked to change public perceptions of obesity as something beyond most people’s control (thus: a medical disease), rather than a consequence of individual choice (Oliver 2006)  Industry-sponsored groups such as the American Obesity Association have worked to expand the government’s role in funding obesity research, to increase coverage for weight-loss treatments, and to put diet drugs and weight-loss surgery on the same level as any other necessary medical procedure Cultural Construction of Disease  Post 1998  Factors in the emergence of obesity as a disease: 1. William Dietz, 1997, new director of the Division for Nutrition and Physical Activity at the Centers for Disease Control and Prevention, believed that obesity was a problem that needed to be addressed on a national scale (“the person who infected lots of people with the idea that obesity was an epidemic disease”, Oliver 2006: 613); obesity as something that happened to people, rather than just the result of personal choices 2. Mode of information transmission: effective powerpoint of changing obesity levels in US over geographic space and time: Dietz and Mokdad, CDC, 1998) Misleading CDC Maps (Oliver 2006: 616-617)  The maps only show the percent of people in each state with a BMI of 30+; they do not show the spread of a disease  By using state boundaries, the maps also exaggerate the extent of obesity, because the geographic size of a state doesn’t relate to the size of its population: North Dakota is pictured as the functional equivalent of Pennsylvania, even though it has a fraction of its population  The colors on the maps are also overly evocative, going from cool blues to hot reds as the obesity rates increase, thus giving the impression of increasing danger from an epidemic “hot zone”....that is spreading geographically like infection Misleading CDC Maps (Oliver 2006: 616-617)  In reality, obesity disproportionately affects some groups more than others, esp. the poor and minorities  The first “outbreaks” were in Mississippi, Alabama, and West Virginia not because they were near some viral source, but because these states are largely rural and poor  These maps still widely accepted and used  “Nothing,” Dietz believes, “has been more effective at increasing the visibility of the obesity epidemic than the CDC slides” (Dietz, personal communication, Dec. 23, 2004)...  CDC maps have been very successful at depicting obesity as a rampant epidemic, spiraling out of control Critiquing BMI  Focuses only on weight, rather than measuring fat  Concept that weight associated with optimum health and longev
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