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© 2007 The American Society for Nutrition J. Nutr. 137:488-492, February 2007

Symposium: Evidence-Based Public Nutrition: An Evolving Concept

Public Health Response to the Obesity Epidemic: Too Soon or Too Late?1

Tim Byers* and Rebecca L. Sedjo

University of Colorado Health Sciences Center, Aurora, CO 80045

* To whom correspondence should be addressed. E-mail: tim.byers{at}uchsc.edu.


   ABSTRACT
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 LITERATURE CITED
 
Public health actions in response to new threats are often taken despite uncertainty about the efficacy of the action. The challenge, then, is to make ongoing judgments about whether actions are taken too soon, before a sufficient understanding of the efficacy of interventions is known, or too late, after much of the prevention potential is lost. The ongoing obesity epidemic presents exactly this type of challenge. General lessons learned from the AIDS and tobacco epidemics as well as others can be useful now as we contemplate options for reversing the ongoing epidemic of obesity in the United States. In this article we briefly review current evidence regarding the efficacy of obesity interventions in both clinical and community settings. We conclude that although little direct evidence is available on the efficacy of interventions for the obesity epidemic, there are some reasonable options derived from experience with other public health epidemics that can contribute to the solution of the obesity problem.


   Introduction
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 LITERATURE CITED
 
The obesity epidemic in the United States over the past 20 y has been a remarkable event. In the past decade, the prevalence of obesity has more than doubled among both adults and children. The causes of this epidemic are complex, embedded in the many social, cultural, and economic factors that determine the amount and quality of food intake balanced against the amount and quality of energy expenditure. In short, because we are eating more and moving less, we are getting fatter. This epidemic is actually a pandemic, as obesity is on the increase in most countries where nutritional status is being monitored across the world. Populations particularly at risk are those that only a generation ago experienced food shortages. Most developing counties are now facing the coexistence of overweight and underweight in both urban and rural areas with higher prevalence of overweight than underweight being reported (1). Thus, developing and implementing interventions to reverse the epidemic of obesity are global public health needs. This article briefly reviews the current literature regarding the current evidence basis for efficacy of various interventions to reduce the obesity epidemic.


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We searched the literature using Medline and the Cochrane databases for systematic literature reviews and meta-analyses pertaining to interventions targeting obesity. We did not include studies of dietary supplements or complementary and alternative medicines. We limited our search to the published English literature since 2000 with keywords of overweight or obesity or weight-loss. In this summary, we selected the largest and/or the most recent of these reviews on each of several topic areas. Furthermore, Medline and web-based searches were performed on obesity prevention guidelines using keywords of obesity, prevention, guidelines, and recommendations. Selected guidelines since 2000 are presented.


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Table 1 summarizes selected systematic reviews and meta-analyses (2–25). These reports cover nutritional topics from breast-feeding to clinical interventions to health promotion in schools, worksites, and selected communities. In general, these reviews conclude that breast-feeding produces very modest reductions in childhood obesity, but the effectiveness of other interventions in children is less certain. Clinical interventions in adults using pharmaceuticals or behavioral methods produce modest effects, but bariatric surgery produces substantial effects. Table 2 describes selected action plans and expert panel reports on overweight and obesity published since 2000 (26–48). In general, these action plans call for education approaches to increase awareness about personal choices in food and physical activity habits as well as a broad set of policy interventions tied to food availability, physical activity promotion, and community design.


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  		TABLE 1 Selected systematic reviews and meta-analyses of interventions to reduce obesity published since 2000

 

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  		TABLE 2 Selected obesity prevention guidelines issued as expert panel reports since 2000

 
Public health programs should, of course, be based on sound evidence of both need and efficacy. The need to reverse the obesity epidemic is clear. However, the current evidence base is very weak, with very few interventions having been proven to be effective. Few large-scale intervention trials with sufficient statistical power have been conducted. Despite the weakness of the evidence base, a shadow epidemic has followed the obesity epidemic: the epidemic of obesity action plans. Many organizations have issued action plans of various sorts, from very general strategies to more specific tactics.

The cornerstone of these prevention plans focuses on the need to promote lifelong healthy eating patterns with regular physical activity, thus maintaining a healthy weight throughout life. The U.S. Health and Human Services 2005 Dietary Guidelines that emphasize a diet rich in nutrient-dense foods such as fruits, vegetables, and whole grains combined with regular physical activity (42) are very similar to recommendations that have been proposed by other organizations including the American Cancer Society (29), American Heart Association (28), American Diabetes Association (38), American Dietetic Association (39), American Association of Pediatrics (33), the Institute of Medicine (IOM)2 (36), and the World Health Organization (WHO) (37). The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity provides specific measures to promote healthy food choices with reasonable portion sizes in the home, schools, worksites, and communities as well as to promote building physical activity in normal routines through quality physical education in the schools, physical activity in worksites, establishing community facilities, and reducing sedentary activity (27). The Task Force on Community Preventive Services has found sufficient scientific evidence to support workplace diet and physical activity programs (45). To encourage beneficial food choices for children, one of the recommendations of the IOM report Preventing Childhood Obesity is to limit advertisement and marketing of unhealthy foods to children (36). Evidence of the role of food advertisements targeted at children and their choices and purchases has been presented in the IOM report Food Marketing to Children and Youth: Threat or Opportunity? (46). WHO has recommended fiscal policies to encourage favorable health choices similar to the tax on tobacco products (37). Several organizations have recommended education for prevention and treatment of individuals, healthcare providers, and society, including WHO (37), the Surgeon General (27), the Food and Drug Administration (35), and the IOM (36). The U.S. Preventive Task Force has found fair evidence to support screening of adults for obesity, a recommendation echoed in several action plans (32). To complement the community programs as well as treatment options, an investment in research has been proposed by the Surgeon General and by WHO, with specific agendas highlighted by the National Institutes of Health (27,37,41).


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We now find ourselves in a situation with urgent need and armed with numerous recommendations but only weak evidence to guide interventions. In this setting, then, we should expect controversy for most interventions, especially for those featuring policy changes designed to alter either food intake or physical activity. Policy discussions in this type of setting can be contentious. Much of the rhetoric regarding obesity policy tends to assume that there is a discrete boundary between individual choice and public policy. The rhetoric, at its extreme, paints a picture of distinct options being personal responsibility, with obesity being a cumulative consequence of unfavorable choices in diet and physical activity, versus public policy, with obesity being a consequence of the synergistic effects of food marketing and technology that favor a sedentary lifestyle in both work and leisure settings. Many in the general public are alarmed by overzealous nutritionists who would restrict food choice (often derided as "Food Nazis"). The ongoing struggle between choice and policy that is playing out in tobacco control is also often apparent in food policy. Public health nutritionists who see the enormous successes in tobacco control through policy initiatives look to positive policy solutions involving food and physical activity, whereas many in the more skeptical public regard such policies as infringements on free choice. In fact, however, individual choice and public policy are not in conflict. Combinations of choice and policy have been synergistically effective in many different public issues in the past. Personal choice to smoke cigarettes has not been substantially threatened by policies that protect nonsmokers from the harm of second-hand smoke or that fund tobacco-control programs with cigarette excise taxes.

In the current situation, where the evidence for effectiveness of interventions to reverse the obesity epidemic is scant, what should we now do? It would be unwise to choose simply to await convincing evidence before taking action. In fact, a strategy of experimentation, evaluation, and modification could well guide a process whereby we take action as part of the very process of creation of evidence. This is precisely the general strategy we have taken to reduce the burden from other epidemics. We did not await certainty of effectiveness of community-based educational interventions for acquired immunodeficiency syndrome (AIDS) or the effectiveness of policy interventions for tobacco control before we embarked on the still-evolving public health process of implementation, evaluation, adaptation, and reimplementation. The overall effect of such public health approaches to new threats has been to reduce disease burden over time. Likewise, the obesity epidemic could benefit from reasonable interventions that are implemented, evaluated, and adapted in an ongoing process. The evidence base for effective interventions can thereby be developed as part of the process of addressing the problem rather than as a preliminary step before the process begins.

The obesity epidemic clearly has occurred subsequent to population-wide increases in caloric intake coupled with reductions in physical activity. It is certainly reasonable, therefore, to assume that caloric intake and physical activity will necessarily be the targets of any interventions to reverse this epidemic. Recommendations to reduce the obesity epidemic have included such policy options as increased education on diet and physical activity, limiting advertisements of unhealthy food to children and adolescents, limiting access to unhealthy foods in schools, levying a tax on foods of low nutritional value, and promoting physical activity in schools and worksites. These guidelines provide the most logical starting place from which to begin implementing public health interventions along with evaluation components to further guide the public health effort to reduce the obesity epidemic.

Because the obesity epidemic is on us, and as the usual process of scientific discovery is not likely to provide evidence in the near future, we think a process of experimentation, evaluation, and adaptation is the best current option for slowing and then reversing the obesity epidemic.


   FOOTNOTES
 
1 Presented as part of the symposium "Evidence-Based Public Nutrition: An Evolving Concept" given at the 2006 Experimental Biology meeting on April 4, 2006, San Francisco, CA. The symposium was sponsored by the Dannon Institute and the Connecticut EXPORT Center of Excellence for Eliminating Health Disparities among Latinos (NIH-NCHMD grant 1P20MD001765-01). This supplement is the responsibility of the guest editors to whom the Editor of The Journal of Nutrition has delegated supervision of both technical conformity to the published regulations of The Journal of Nutrition and general oversight of the scientific merit of each article. The opinions expressed in this publication are those of the authors and are not attributable to the sponsors or the publisher, editor, or editorial board of The Journal of Nutrition. Guest editors for the symposium publication are Rafael Pérez-Escamilla, University of Connecticut, Storrs, CT, and Janet King, Children's Hospital Oakland Research Institute, Oakland, CA. Back

2 Abbreviations used: AIDS, acquired immunodeficiency syndrome; BMI, body mass index; ERD, energy restrictive diets; HBD, hypoenergic balanced diets; IOM, Institute of Medicine; LFD, low-fat diet; MR, meal replacements; PA, physical activity; PMR, partial meal replacement; PSMD, protein-sparing modified diet; RCD, reduced-calorie diets; SOY, soy very low-energy diets; VLCD, very low-calorie diet; VLED, very low-energy diets; WHO, World Health Organization. Back


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