See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/11466323

Obesity prevention: The case for action

Article  in  International Journal of Obesity · April 2002

DOI: 10.1038/sj.ijo.0801938 · Source: PubMed

CITATIONS READS

443 17,500

5 authors, including:

Shiriki Kumanyika Alfredo Morabia

Drexel University City University of New York - Queens College
406 PUBLICATIONS   38,795 CITATIONS    585 PUBLICATIONS   19,288 CITATIONS   

SEE PROFILE SEE PROFILE

Cheryl Ritenbaugh
The University of Arizona
245 PUBLICATIONS   17,323 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Tobacco Cessation through Chiropractors, Acupuncturists and Massage Therapists View project

CAM and Placebo - USA View project

All content following this page was uploaded by Cheryl Ritenbaugh on 01 June 2014.

The user has requested enhancement of the downloaded file.

 International Journal of Obesity (2002) 26, 425–436
ß 2002 Nature Publishing Group All rights reserved 0307–0565/02 $25.00
www.nature.com/ijo

REPORT

Obesity prevention: the case for action

S Kumanyika, RW Jeffery, A Morabia, C Ritenbaugh and VJ Antipatis
Public Health Approaches to the Prevention of Obesity (PHAPO) Working Group of the
International Obesity Task Force (IOTF)*
Contents
1. Obesity and the global burden of disease
2. Prevalence, trends and economics
3. Targets for action
4. The action agenda
5. Potential solutions
6. Tracking outcomes
7. Glossary of terms
8. Key references and further reading
9. Case studies: Available on Nature website at www.naturesj.com=ijo=index.html
International Journal of Obesity (2002) 26, 425 – 436. DOI: 10.1038=sj=ijo=0801938

Introduction and physical activity patterns. This requires that a wide

International experts participating in the first ever World
Health Organization (WHO) Expert Consultation on
Obesity in June 1997 immediately recognized that ‘Over-
weight and obesity represent a rapidly growing threat to
the health of populations and an increasing number of
countries worldwide.’1
The diverse countries represented at the consultation
were: Australia, Bahrain, Canada, Chile, China, Cyprus, Den-
mark, Egypt, India, Ireland, Japan, Malaysia, Mauritius,
Netherlands, Nigeria, Pakistan, Polynesia, South Africa,
Sweden, Switzerland, Thailand, UK, USA.
Experts from the United Nations, Food and Agricultural
Organization, and WHO Collaborating Centers as well as
advisers from the International Obesity Task Force (IOTF)
facilitated the recognition of obesity as a global problem.
Development and implementation of effective obesity
prevention strategies was identified as an immediate action
priority.
This case statement proposes a relevant action agenda — it
highlights the need for:

Correcting the societal causes of obesity through direct
and indirect actions to change population food intake
*Correspondence: IOTF Secretariat, 231 N Gower St, London NW1 2NS, UK.
E-mail: obesity@IOTF.org
range of sectors and settings to be addressed including
transport, environment, workplaces, schools, public edu-
cation, health, food, nutrition, social welfare, and trade
and industry.

Intervention and commitment to action at all levels,
from the individual through the community to national
and international players.

Links between independent policies and processes in
different settings and sectors.

Strategies for the population as a whole as well as strate-
gies aimed at improving individual lifestyles.
1. Obesity and the global burden of disease
‘In every country in the world today, depending on its
stage of epidemiologic transition, chronic non-commu-
nicable diseases such as cardiovascular disease, cancer,
diabetes, and osteoporosis are either newly appearing,
rapidly rising, or already established at high levels.’2
Obesity is a major contributor to the global burden of
disease and disability
Overweight and obesity are important risk factors for a wide
range of medical conditions, including:
 Obesity prevention
PHAPO Working Group of the IOTF
426

Many life-threatening chronic non-communicable dis-

eases which lead to disability and death, eg heart disease,
type 2 diabetes, hypertension, stroke and certain cancers.
The risk of developing these conditions is greatest when
the majority of excess fat is located around the abdomen
(central obesity) rather than around the hips and thighs
(peripheral obesity).

A wide range of debilitating conditions which can dras-
tically reduce quality of life and are costly in terms of
absence from work and use of health resources, eg
osteoarthritis, gallbladder disease, respiratory difficulties,
Figure 1 Projected trends in death by broad cause, developing regions.
infertility and skin problems. Source: The Executive Summary of The Global Burden of Disease and

Psychosocial problems, eg clinical depression, lowered Injury Series.8
self-esteem, job discrimination and other forms of social
stigmatization. Ischaemic heart disease is predicted to become the
leading worldwide cause of disease burden in 2020
(Table 1).

Non-communicable diseases threaten to overwhelm The non-communicable disease burden outlook in

health care services worldwide
The Global Burden of Disease Study, a collaborative effort of
the WHO and The World Bank, provided the first compre-
hensive picture of the world’s present and future health
needs.
Globally, in terms of deaths:

Communicable maternal, perinatal and nutritional dis-
orders (the traditional enemies) are expected to account
for 10.3 million deaths a year in 2020 — a decline from
17.2 million deaths in 1990.

Over the same period, deaths from non-communicable
diseases are expected to rise from 28.1 million to 49.7
million a year — an increase in absolute numbers of 77%.
In terms of disease burden (measured in ‘Disability Adjusted
Life Years’, DALYs):

The contribution from communicable maternal, perina-
tal and nutritional disorders is projected to decline from
44% in 1990 to 20% in 2020.

The contribution from non-communicable diseases is
expected to rise from 41% in 1990 to 60% in 2020.
developing countries is particularly serious (see Figure 1)

The largest increases in deaths and disease burden from
non-communicable diseases will occur in the developing
regions where four-fifths of the world’s population live.

In the developing world, deaths from non-communicable
diseases are expected to rise from 47% of the burden in
1990 to almost 70% in 2020.

More people already die from non-communicable dis-
eases than from communicable causes in several major
developing regions, eg Latin America and the Caribbean
have almost twice as many deaths, and China has four
and a half times as many deaths from non-communicable
diseases.

In countries undergoing economic transition, overnutri-
tion often coexists with undernutrition. People below a
body mass index (BMI) of 18.5 kg=m2 tend to be under-
nourished. However, the distribution of BMI is shifting
upwards in many populations. This leads to an increasing

Table 1 Change in the rank order of disease burden (measured in

DALYs) for the five leading causes, world 1990 – 2020a

Rank in 1990 Rank in 2020

1. Lower respiratory infections 1. Ischaemic heart disease

2. Diarrhoeal diseases 2. Unipolar major depression
3. Perinatal conditions 3. Road traffic accidents
4. Unipolar major depression 4. Cerebrovascular disease
5. Ischaemic heart disease 5. Chronic obstructive pulmonary disease
Figure 2 Distributions of body mass index of five population groups at
a
The risk of developing conditions highlighted in bold is increased in obesity. different stages of economic transition. Body mass index (BMI) is a simple
Source: The Executive Summary of The Global Burden of Disease and Injury index of fatness calculated by dividing body weight in kilograms by
Series.8 height in meters squared (kg=m2). Source: Rose.4

International Journal of Obesity

 Obesity prevention
PHAPO Working Group of the IOTF
427
proportion of people who are obese (ie above BMI
30 kg=m2; Figure 2).

Recent studies have shown that people who were under-
nourished in early life and then become obese in adult-
hood tend to develop conditions such as hypertension,
heart disease and diabetes at an earlier age, and in a more
severe form, than people who were never undernour-
ished.

India and China, with around two billion people in total,
still have a large proportion of infants born undernour-
ished. Both are already experiencing high levels of adult
obesity and associated chronic disease in many areas.

Thus, obesity must be addressed even where undernutri-
tion persists.
Figure 3 Number of people with diabetes in the adult population
(aged  20 y) by year and country group. Source: King et al.3

Type 2 diabetes is one of the major links between obesity
and other non-communicable diseases

The World Health Organization estimated that around
143 million adults were diabetic worldwide in 1997. This
figure is expected to rise to 154 million by the year 2000
and to 300 million by 2025.

The likelihood of developing type 2 diabetes rises steeply
with increasing body fatness. Approximately 85% of
people with diabetes can be classified as type 2, and of
these 90% are obese or overweight.

People with type 2 diabetes are at high risk of a range of
disabling conditions (eg heart disease, hypertension,
amputation, stroke, renal failure and blindness) and pre-
mature death.

Duration of obesity, accumulation of abdominal body fat,
and inactivity further increase the risk of diabetes.

Diabetes is now most frequent in developing countries.
In countries such as the US, UK and Australia, ethnic
minority populations are most at risk, eg American
Indians, Micronesians, Polynesians, Asian Indians, Aus-
tralian Aborigines, Mexican Americans, African Ameri-
cans and Hispanics.

India, China and the US are the three countries with the
highest number of adults with diabetes (Table 2).

In 1995, the Established Market Economies had the
highest number of persons with diabetes. If current
trends continue, India and the Middle Eastern Crescent
will have taken over by 2025. Large increases will also be
observed in China, Latin America and the Caribbean, and
the rest of Asia (Figure 3).
2. Prevalence, trends and economics
‘The prevalence of obesity is increasing worldwide at an
alarming rate.’1
Obesity has already reached epidemic proportions in
many countries and population groups

A clear relationship exists between average BMI and the
prevalence of obesity in a population. When the average is
below 23 kg=m2, few individuals are obese. However, for
every single unit increase in average BMI above 23 kg=m2,
there is an almost 5% increase in obesity prevalence (Figure
4).
Obesity rates in adults are increasing rapidly in all parts
of the world, both in affluent Western countries and in
poorer nations (see Figure 5)

Current obesity levels range from below 5% in China,
Japan and certain African nations to over 75% in urban
Samoa (Table 3).
60
r=0.94
b=4.66% per unit BMI
50
Prevalence (%) of obesity

40

Table 2 Top five countries for estimated number of adults with 30

diabetes, 1995 and 2025
20
Rank in 1995 Rank in 2025
10
1. India (19.4 million) 1. India (57.2 million)
2. China (16.0 million) 2. China (37.6 million) 0
3. US (13.9 million) 3. US (21.9 million) 15 20 25 30 35
Mean BMI (kg/m2 )
4. Russian Federation (8.9 million) 4. Pakistan (14.5 million)
5. Japan (6.3 million) 5. Indonesia (12.4 million)
Figure 4 Relationship between average BMI and prevalence of obesity
Source: King et al.3 in a population. Source: Rose.4

International Journal of Obesity

 Obesity prevention
PHAPO Working Group of the IOTF
428
Table 3 Obesity prevalence (BMI  30 kg=m2) around the world

Prevalence of
obesity (%)

Country Year Age Men Women

Africa
Cape Peninsula (Coloured) 1990 15 – 64 8 44
Mauritius 1992 25 – 74 5 15
Rodrigues (Creoles) 1992 25 – 69 10 31
Tanzania 1986=1989 35 – 64 0.6 4

Australasia and Oceania

Australia 1995 25 – 64 18 18
New Zealand 1989 18 – 64 10 13
Papua New Guinea (U) 1991 25 – 69 37 54
Samoa (U) 1991 25 – 69 58 77

Central and South America

Brazil 1989 25 – 64 6 13
Figure 5 Trends in obesity prevalence (BMI  30 kg=m2) in a selection Curacao 1993 – 1994 18 þ 19 36
of countries. Mexico (U) 1995 Adults 11 23

Europe

Even in relatively low prevalence countries such as Czech Republic 1988 20 – 65 16 20
England 1997 16 – 64 17 20
China, levels are almost 20% in some cities. Finland 1997 25 – 64 19 19

In most populations, more women than men are obese. France 1994 25 – 79 10 11
Germany 1990=1991 25 – 69 17 19
Italya 1994 15 þ 7 6
Childhood obesity is already epidemic in some areas, and Netherlands 1995 20 – 59 8 9
Russia 1996 Adults 11 28
on the rise in others Scotland 1995 16 – 64 16 17

Approximately 22 million children under 5 y are over-
Middle East
weight across the world.
Bahrain (U) 1991=1992 20 – 65 10 30

In Thailand, the prevalence of obesity in 6 – 12-y-old Cyprus 1989=1990 35 – 64 19 24
children rose from 12.2 to 15.6% in just 2 y. Jordan (U) 1994 – 1996 25 þ 33 60

In Japan, the percentage of obese children aged 6 – 14 y Kuwait 1994 18 þ 32 44
Saudi Arabia 1990=1993 15 þ 16 24
resident in Izumiohtsu city doubled from 5 to 10%
between 1974 and 1993. North America

In the US, the percentage of obese children aged 6 – 11 y has Canada 1991 18 – 74 15 15
United States
more than doubled since the 1960s. Prevalence rose from Total 1988 – 1994 20 – 74 20 25
5% in 1963 – 1965 to 11% in 1988 – 1991 in both sexes. NHW 1988 – 1994 20 – 74 20 22
Obesity prevalence in youths aged 12 – 17 y has also NHB 1988 – 1994 20 – 74 21 37
increased dramatically — from 5 to 13% in boys, and from MA 1988 – 1994 20 – 74 23 34

5 to 9% in girls, between 1966 – 1970 and 1988 – 1991 South and East Asia
respectively. China 1992 20 – 45 1.2 1.64
India (Delhi mid-class) (U) 1997 40 – 60 3 14
Japan 1993 20 þ 2 3
Kyrgyztan 1993 18 – 59 4 11
Obesity can affect all income levels Malaysia 18 – 60 5 8
Economic growth fosters obesity, particularly in developing Singaporeb 1992 Adults 4 6
and transition countries. 5
Adapted from Antipatis and Gill.

As the socioeconomic conditions of a country improve, U, urban; NHW, non-hispanic whites; NHB, non-hispanic blacks; MA, Mexican
Americans.
the average weight of the population rises and the a
Data are self-reported.
number of people who are obese increases. b
Obesity criterion: BMI  31 kg=m2.

In the early stages of transition, undernutrition remains the
main problem in the poor whilst the more affluent tend to
among affluent women in ethnic minority populations.
show an increase in people with a high BMI. As transition
Risks for men may increase when jobs no longer require
proceeds, overweight and obesity also begin to increase
manual labour.
among the poor, especially among women (Figure 6).

In affluent societies, obesity levels tend to be highest in Obesity is an extremely costly health problem
the lower socio-economic classes — again, especially
Obesity accounts for 2 – 6% of total health care costs in
among women. However, obesity sometimes persists several developed countries (Table 4). The true costs are

International Journal of Obesity

 Obesity prevention
PHAPO Working Group of the IOTF
429
greater than those of heart disease and 2.7 times greater
than those of hypertension (Figure 7).

3. Targets for action

‘The rising epidemic reflects the profound changes in

society and in behavioural patterns of communities.’1

Environmental factors predominate

Development of effective preventive solutions requires a
sound understanding of the key forces that are driving the
Figure 6 Obesity prevalence (BMI  30 kg=m2) in low, middle and high obesity epidemic.
income groups in Curaçao. Source: Grol et al.6
Genes are important in determining a person’s suscept-
ibility to weight gain, but societal changes are driving the
epidemic; the rapid rises in obesity rates around the
world have occurred in too short a time for there to
Table 4 Conservative estimates of the direct healthcare costs of obesity
have been any evolutionary genetic changes within
National healthcare populations.
Country Year Estimated direct costs costs (%)
Economic growth, modernization, urbanization and glo-
balization of food markets are just some of the societal
Australia 1989=1990 AUD $464 million > 2%
Canada 1997 Can $1.8 billion 2.4% and environmental forces thought to underlie the epi-
France 1992 FF 12 billion 2% demic. All are important features of societal develop-
Netherlands 1981=1989 Guilders 1 billion 4% ment, but they have also led to widespread increases in
NZ 1990=1991 NZ $135 million 2.5%
consumption of high-fat high-energy diets and=or
US 1995 US $52 billion 5.7%
decreases in physical
Source: IOTF, Economic Costs of Obesity, unpublished. activity.

The human body is designed to store fat for times of
shortage, an adaptation which has become a liability in
modern times. This is true for all populations, albeit to
varying degrees, suggesting that obesity rates will con-
tinue to increase in the next millennium if current diet
and physical activity patterns do not improve.

Populations worldwide are consuming diets high in fat

Figure 7 Direct costs of obesity and several related diseases in the US
(1995 dollars). Data source: Wolf and Colditz.7
undoubtedly much greater as not all obesity-related con-
ditions are included in the calculations.

New methods for measuring the economic costs of obe-
sity are currently being developed. These will include
indirect and personal costs to give a more complete
picture of the total economic burden that obesity can
impose on a country.

In the US in 1995, the direct healthcare costs of obesity
were similar to those for type 2 diabetes, 1.25 times
and energy

As incomes rise and populations become more urban,
diets high in complex carbohydrate and fibre generally
give way to more varied diets with a higher proportion of
fats, saturated fats and sugars. The greater availability of
cheap vegetable oils and fats in the global economy is
now resulting in higher fat consumption even among
low-income nations.

Some developed countries have shown a small decrease
in both overall energy intake and the proportion of fat in
the diet in recent years. However, many experts believe
that this is a distortion caused by dietary under-reporting
among other things. Indeed, dietary intakes in most
developed countries are still characterized by a high
level of fat that is well above the World Health Organiza-
tion recommended limit of 30% energy.
Lifestyles are becoming more and more sedentary

Large shifts towards less physically demanding work have
been observed on a worldwide basis, both in terms of the
proportion of people working in agriculture, industry and

International Journal of Obesity

 Obesity prevention
PHAPO Working Group of the IOTF
430
Figure 8 Obesity and inactivity in the UK. Source: Prentice and Jebb.9
services, and in the type of work within most occupa-
tions.

Shifts towards less physical activity are also found in the
increased use of automated transport, technology in the
home, and passive leisure. Proxy indicators of physical
inactivity such as television viewing and car ownership
parallel changes in obesity rates over recent years (Figure
8).

Few people engage in enough exercise during leisure time
to compensate for the decreases in daily energy expendi-
Figure 9 Societal policies and processes with direct and indirect influences on the prevalence of obesity and under-nutrition. Vertical and horizontal links
will vary between different societies and populations.
International Journal of Obesity
ture associated with sedentary activity in other aspects of
their daily routine.
Societal solutions are critical, especially for the long term
Societal-level interventions are the key to tackling the obe-
sity problem in a population. Although they may take a
long-time to put into place, and even longer to yield results,
they can begin to counteract the powerful forces that lead to
steady population weight gain.

The vast array of factors impinging upon food intake and
energy expenditure in Figure 9, and the numerous inter-
actions between them, challenge the notion of individual
‘free will’ regarding food choice and energy expenditure.
Indeed, many things that individuals do are influenced
by factors ‘upstream.’

Societal policies and processes operating within and
across a range of different settings and sectors influence
individual diet and activity patterns, and hence popula-
tion weight status.

Interventions aimed at improving individual lifestyles,
when conducted in isolation of societal intervention,
tend to have limited success. They are most effective in
motivating the socially advantaged who already have
sufficient lifestyle options open to them. Over time,
this may actually aggravate disparities between the
more and less advantaged.


No single aspect of the web of policies and processes can
be addressed without a potential impact on other areas —
many of which have competing commercial interests.
Key issues for societal level solutions

Food and nutrition policy initiatives must be central to
societal solutions for obesity prevention, but will not
suffice on their own.

Physical activity policy initiatives are also essential and
may be motivated by fields other than health, eg sustain-
able transport, family recreation.

Links are needed between policies and processes in dif-
ferent sectors and social structural levels.

The types of initiatives needed to shift policies and
process towards the promotion of healthy population
diets, activity levels and weight status will differ cultu-
rally and between and within countries.
Societal approaches must also emphasize increasing
options and removing barriers to healthy living among
those who are the least advantaged.
Short-term action aimed at improving individual lifestyles
should be taken in parallel with efforts to establish long-term
remedies from broader public health and policy perspectives.
4. The action agenda
‘The aim of obesity prevention is ‘to stabilize the level
of obesity in the population, to reduce the incidence of
new cases and, eventually, to reduce the prevalence of
obesity.’1
The action agenda for obesity prevention consists of key
Recommendations, Principles and Target Outcomes.
Action recommendations
From the previous section, it is clear that a comprehensive
approach to obesity prevention should:

address both dietary habits and physical activity patterns
of the population;

address both societal and individual level factors;

address both immediate and distant causes;

have multiple focal points and levels of intervention (ie
at national, regional, community and individual levels);

include both policies and programmes;

build links between sectors that may be otherwise viewed
as independent.
Action principles
Ground breaking work in the field of obesity prevention has
only just begun. The 10 action principles listed in the next
column therefore draw on evidence and recommendations
from alternative sources including:
Obesity prevention
PHAPO Working Group of the IOTF
431

community prevention trials conducted for risk reduc-
tion of other non-communicable diseases, eg cardiovas-
cular disease, cancer, diabetes; many of these have
included interventions to promote healthy eating and
physical activity;

the principles of health promotion as outlined by the
‘Ottawa Charter for Health Promotion’ and subsequent
declarations related to the World Health Organization
global strategy ‘Health for All.’
Here are the 10 principles upon which efforts to prevent
obesity at the population level should be based:
1. Education alone is not sufficient to change weight-related
behaviours. Environmental and societal intervention is
also required to promote and support behaviour change.
2. Action must be taken to integrate physical activity into
daily life, not just to increase leisure time exercise.
3. Sustainability of programmes is crucial to enable positive
change in diet, activity and obesity levels over time.
4. Political support, intersectoral collaboration and commu-
nity participation are essential for success.
5. Acting locally, even in national initiatives, allows pro-
grammes to be tailored to meet real needs, expectations
and opportunities.
6. All parts of the community must be reached — not just
the motivated healthy.
7. Programmes must be adequately resourced.
8. Where appropriate, programmes should be integrated
into existing initiatives (Box 1).
9. Programmes should build on existing theory and evi-
dence.
10. Programmes should be properly monitored, evaluated
and documented. This is important for dissemination
and transfer of experiences.
Box 1 Integrating obesity prevention into existing
initiatives
In certain situations, an integrated approach to obesity
prevention is recommended whereby activities concern-
ing related conditions are simultaneously co-ordinated.
This approach is preferable to an obesity-specific
approach because:

overweight and obesity are key modifiable risk factors
for a range of chronic non-communicable diseases;

the key targets for obesity prevention — population
food intakes and physical activity levels — are also
central to economic=social processes and to the pre-
vention and management of certain other chronic
diseases;

an integrated approach avoids competition for scarce
public health resources as well as the attention of mass
media and other channels of public health education.
International Journal of Obesity
 Obesity prevention
PHAPO Working Group of the IOTF
432
Targeted outcomes for obesity prevention
Well-designed obesity prevention programmes have two
types of targeted outcome — impact outcomes and process
outcomes. It is important to understand that these outcomes
cannot be achieved overnight — most will take years to
achieve.
Impact outcomes. These are the ultimate targets of obesity
prevention programmes. They should relate to the level of
obesity in a population, for example:

to prevent increases in average population BMI;

to reduce the incidence of new cases of obesity;

to move toward an optimum average population BMI of
21 – 23 kg=m2;

to reduce the prevalence of obesity;

to reduce the disproportionately high prevalence of
obesity among population subgroups;

to reduce the prevalence of obesity in children;

to reduce the prevalence of obesity-related health
problems.
Process outcomes related to food intake and physical activity.
Process outcomes related to food intake and physical activity
patterns are critical for ensuring that efforts to prevent obesity
are on course. These guide short-term progress towards
achievement of the long-term impact targets.
In setting process outcomes, it is recommended that each
country consider the following population-based guidelines.
These are common to national nutrition and health policies
in a range of countries where chronic disease risk reduction
is a priority. They should also promote energy balance
whereby energy intake from food and drink is balanced
with energy output through physical activity.
Food intake.
1. Food-based dietary guidelines: eat lots of fruit, vegetables,
fish and starchy carbohydrate foods. Limit fatty, sugary
and salty foods.
2. Nutrient-based dietary guidelines: aim for about 10%
energy from protein, 15 – 30% energy from fat, more
than 50% energy from complex carbohydrates. Limit
salt and alcohol intakes.
Physical activity.
1. Active living: for adults who are currently inactive or not
regularly active, aim to accumulate 30 min or more of
moderate intensity physical activity on most days of the
week.
2. Regular exercise: for adults who are already doing regular
moderate activities, aim to include three bouts per week
of vigorous intensity activity which lasts for at least
20 min.
For countries where obesity levels and chronic disease are
not yet high, it may be more appropriate to focus on
International Journal of Obesity
preservation of healthy traditional food and activity practices
when setting target process outcomes.
5. Potential solutions
‘Epidemic projections for the next decade are so serious
that public health action is urgently required.’1
Potential societal-level solutions
Settings and sectors offer practical opportunities for the
implementation of comprehensive societal level strategies
(Table 5).
Case studies, often implemented for reasons other than
obesity prevention, give some idea about how these work in
different countries and populations around the world. See
Appendix 1 (available in on-line version) for example case
studies related to different settings and sectors.
6. Tracking outcomes
‘Systematic assessment and evaluation should be a rou-
tine part of all interventions aimed at preventing and
managing obesity.’1
The need for monitoring and evaluation
Evaluation is an essential tool for providing information
about, and strengthening, obesity prevention programs. It
helps to:

identify sub-groups of the population with particularly
high or rising obesity prevalence;

provide information about the implementation and
effect of the programme;

track progress in accomplishing goals and objectives;

provide feedback to those involved in project planning to
determine which parts of the programme are working
well and which are not;

make improvements or adjustments in the process of
implementation;

value the efforts of those involved;

document experience gained from the project so it can be
shared with others.
Evaluation and monitoring principles

Evaluation should be considered from the outset and
remain ongoing. It can be conducted on an intermediate-
term as well as a long-term basis.

For many countries with limited resources, intermediate-
term process evaluation may be more feasible than
long-term outcome evaluation, which can be costly and
complex.
 Obesity prevention
PHAPO Working Group of the IOTF
433
Table 5 Potential societal level solutions for obesity prevention

Setting or sector Potential societal intervention

1. National government
eg food and nutrition, transport, education, health, welfare

Integrate nutrition, physical activity and obesity prevention objectives into
relevant policies and programmes, eg, conduct obesity impact assessments
for all new and existing policies

Increase ability of low income populations to buy foods that are rich in
micronutrients but low in fat and sugar, eg, provide price support for
healthy food

Reduce dependence on sugary soft drinks, eg, provide a safe, palatable
and affordable water supply for all

Improve general food supply, eg, provide economic incentives for supply
of ‘healthy’ foods and disincentives for supply of ‘unhealthy’ foods

Increase cycling and walking for short journeys and leisure, especially in
urban areas, eg, develop and implement sustainable transport policies

2. Food supply
eg manufacture, marketing, distribution, retail, catering

Improve nutrition quality of food served in catering outlets, eg, introduce
award or accreditation schemes for preparation, provision and promotion
of healthy food options in catering outlets

Improve nutrition quality of general food supply, eg, develop, produce,
distribute and promote food products that are low in dietary fat and energy

Help consumers to make informed food purchase choices, eg, introduce new
and improved food labeling schemes (covering fat, energy and salt) which
do not mislead the consumer

3. Media
Reduce advertising and marketing practices that promote over-consumption

of food and drink, eg, regulate television food advertising aimed at children

Promote a healthy lifestyle culture, eg, incorporate positive behaviour change
messages into television programmes and popular magazines

4. Non-governmental=international organizations
Support action on diet, physical activity and obesity, eg, develop and implement
healthy eating, physical activity and obesity prevention programmes; advocate
action on diet, physical activity and obesity

5. Healthcare services
Promote healthcare intervention before obesity develops, eg, provide training
in obesity prevention and management for doctors and other healthcare workers

Promote adoption of healthy activity and dietary habits by patients, eg, Provide
physical activity and=or nutrition and cooking skills programmes for patients

6. Education sites
Improve nutrition quality of foods available, eg, introduce nutrition standards
eg pre-school, school, further education for school meals

Encourage choice of healthy foods, eg, introduce reward schemes for choice
of healthy foods

Empower students to prepare healthy meals, eg, provide classes in practical
food preparation and cooking

Encourage uptake of physical activities, eg, increase range of enjoyable, non-
competitive physical activities on offer at school

Encourage integration of walking or cycling into daily routine, eg, develop and
implement ‘safe-routes-to-school’ programmes

7. Worksites
Improve nutrition quality of foods available, eg, provide appetizing healthy food
and drink options in staff restaurants

Encourage choice of healthy foods, eg, subsidize healthy options in staff restaurants

Empower employees to integrate physical activity into work day, eg, provide
exercise and change facilities

Encourage integration of walking or cycling into daily routine, eg, provide
incentive schemes for walking and cycling to work

Empower employees to integrate physical activity into work day and reduce
reliance on convenience pre-processed food, eg, implement flexible work hours

8. Neighbourhoods, homes and families

Increase access of low income groups to healthy food, eg, set up community
garden programmes and food co-operatives

Increase access to safe exercise and recreation facilities, eg, set up walking
programmes in shopping malls, parks etc

Promote walking (and cycling), eg, pedestrianize city centres

Increase access to, and consumption of, fruit and vegetables (and encourage
physical activity), eg, home gardening projects

International Journal of Obesity

 Obesity prevention
PHAPO Working Group of the IOTF
434
Long-term outcome evaluation
Outcome evaluation is needed to measure whether, and to
what extent, the goals of the intervention have been
achieved.

The net impact of obesity prevention interventions can
be assessed by shifts of the average population BMI,
obesity prevalence and=or another indicator of obesity
towards lower values (Box 2).
Box 2 Outcome evaluation: example obesity-related
indicators

Obesity prevalence

Average population BMI

Prevalence of obesity-related non-communicable dis-
eases and health problems
NB. More than one indicator may be used for evaluation.

The time required to achieve an improvement in obesity
levels is likely to be slow.
Intermediate-term process evaluation
Process evaluation is needed to track the progress that is
being made towards achieving the overall goals. It can be
split into three main areas.
Impact on food and activity patterns. Given the time
expected to see an effect on obesity levels, it is important
Box 3 Process evaluation: example indicators for assess-
ment of impact on food and activity patterns
Food intake

Average fat intake (g=day)

Average consumption of fruit and vegetables (g=day)
Physical activity

Proportion of the population who are moderately
active for at least 30 min on most days of the week

Average time spent being moderately active (min=
week)

Average distance walked or cycled per week

Proportion of the population who walk or cycle to
work
NB. These indicators can apply both to the general popu-
lation and to specific sub-groups within that population.
International Journal of Obesity
to assess the impact of the intervention on food intake and
physical activity patterns. See Box 3 for example indicators.
Impact on societal factors. The impact of preventive
action on societal contributors to obesity can be assessed at
many different levels, from the international level through
to the work=school=home level in Figure 8 (Box 4).
Box 4 Process evaluation: example indicators for assess-
ment of impact on societal factors
International

Budget spent by international corporations on pro-
moting and marketing healthy foods

Provision of funding by international agencies for
obesity prevention initiatives
National=state

Integration of obesity prevention into health and
environmental impact assessments

Implementation of an integrated nutrition policy

Implementation of an integrated transport policy to
promote sustainable forms of transport and reduce
dependence on motorised transport

Percentage investment in public transport vs private
car ownership

Regulation of food advertising to children
Communities

Availability of community food initiatives for low
income groups

Availability of community exercise and recreation
facilities

Availability and uptake of training and education for
health professionals in obesity prevention and man-
agement
Work=school=home

Number of schools with a comprehensive nutrition
policy

Average time allocated to physical education classes in
local schools

Number of worksites with cafeteria programmes to
promote healthy food choices
Indicators related to diet and physical activity should
provide the focus for evaluation. Many of the variables on
the left hand side of Figure 8, such as schooling, transporta-
tion and urbanization, are of socio-economic nature and are
routinely collected in countries.

Impact on individual factors. The impact of preventive
action on individual factors can be assessed by shifts in
knowledge, attitudes and beliefs related to physical activity,
food intake, body size, body image and voluntary weight
control.
7. Glossary of terms
Active living. Any moderate-intensity physical activity taken
incidentally while performing other functions. Examples
include walking to school and climbing the stairs.
Body mass index (BMI). A simple index of body fatness
calculated by dividing body weight in kilograms by height
in metres squared (kg=m2).
Disability adjusted life years (DALY). A comprehensive assess-
ment of health status based on both disability and premature
death data. One DALY is one lost year of healthy life.
Disease burden. See Disability Adjusted Life Years.
Economic costs of obesity. These can be broadly divided into
direct and indirect costs. Direct costs relate to the medical
costs of obesity within the health care system. They are
usually calculated as the sum of the proportion of medical
costs of co-morbidities that are attributable to obesity. Indir-
ect costs are the value of lost output because of cessation or
reduction of productivity caused by morbidity and mortality.
Indicator. A characteristic of an individual, population, or
environment which is subject to measurement (directly or
indirectly) and can be used to describe one or more aspects of
the health of an individual or population.
Intersectoral collaboration. A recognized relationship between
part or parts of different sectors of society which has been
formed to take action to prevent obesity in a way that is
more effective, efficient or sustainable than might be
achieved by any one sector acting alone.
Moderate-intensity physical activity. Activity which increases a
person’s heart rate slightly and makes them feel warm, but
does not make them get out of breath. Examples include
brisk walking, cycling, dancing, swimming, washing the car,
heavy housework and gardening.
Obesity prevalence. The proportion of a population that is
obese, ie with a BMI > 30 kg=m2.
Obesity. BMI greater than or equal to 30 kg=m2.
Overweight. BMI greater than or equal to 25 kg=m2.
Obesity prevention
PHAPO Working Group of the IOTF
435
Physical activity. Any bodily movement produced by skeletal
muscles that results in energy expenditure. For the purpose
of this report, it is an umbrella term that includes exercise,
incidental activity, active living and sport.
Setting. The place or social context in which people engage in
daily activities where environmental, organizational and
personal factors interact to affect health and wellbeing.
Examples include neighbourhoods, worksites, schools and
homes.
Sustainable development. Development that meets the needs
of the present without compromising the ability of future
generations to meet their own needs. It incorporates many
elements, and all sectors, including the health sector, which
must contribute to achieve it.
Target outcome. The intended change in a characteristic of an
individual, group or population which is attributable to a
planned intervention or series of interventions. Impact out-
comes relate to changes in obesity levels. Process outcomes
relate to changes in the determinants of obesity levels, ie
food intake and physical activity patterns.
Transitional country. A previously low-income country which
is now undergoing rapid economic, nutritional and epide-
miological transition. Examples include China, Brazil, Chile,
Korea, Taiwan, Malaysia.
Undernutrition. BMI less than or equal to 18.5 kg=m2.
Vigorous-intensity physical activity. Activity which increases a
person’s heart rate substantially (around 70 – 80% of max-
imum heart rate) and makes them breath heavily. Examples
include brisk hillwalking, running, cross-country skiing,
football (soccer), and fast cycling.
8. Key References and further reading
References
1 World Health Organization. Obesity: preventing and managing the
global epidemic. Report of a WHO Consultation. WHO Technical
Report Series 894: Geneva; 2000.
2 Posner BM, Quatromoni PA, Franz M. Nutrition policies and
interventions for chronic disease risk reduction in international
settings: the INTERHEALTH nutrition initiative. Nutr Rev 1994; 52:
179 – 187.
3 King H, Aubert RE, Herman WH. Global burden of diabetes, 1995 –
2025: prevalence, numerical estimates, and projections. Diabetes
Care 1998; 21: 1414 – 1431.
4 Rose G. Population distributions of risk and disease. Nutr Metab
Cardiovasc Dis 1991; 1: 37 – 40.
5 Antipatis VJ, Gill TP. Obesity as a global problem. In: Bjorntorp P
(ed). International textbook of obesity. Wiley: Chichester; 2001. pp
3 – 22.
6 Grol ME, Eimers JM, Alberts JF, Bouter LM, Gerstenbluth I, Halabi
Y, van Sonderen E, van den Heuvel WJ. Alarmingly high preva-
lence of obesity in Curacao: data from an interview survey strati-
fied for socioeconomic status. Int J Obes Relat Metab Disord 1997;
21: 1002 – 1009.
International Journal of Obesity
 Obesity prevention
PHAPO Working Group of the IOTF
436
7 Wolf AM, Colditz GA. Current estimates of the economic cost of
obesity in the United States. Obes Res 1998; 6: 97 – 106.
8 Murray CJL, Lopez AD (eds). The executive summary of the global
burden of disease and injury series. Harvard University Press: Cam-
bridge; 1996. http://www.hsph.harvard.edu/organizations/bdu/
summary.html
9 Prentice AM & Jebb SA. Obesity in Britain: gluttony or sloth?
Br Med J 1995; 311: 437 – 439.
Further reading
1 Allander E, Lindaho BIB. Why is prevention so difficult and slow?
Scand J Soc Med 1997; 25: 145 – 148.
2 Antipatis VJ, Kumanyika SK, Jeffery RW, Morabia A, Ritenbaugh C.
Confidence of health professionals in public health approaches to
obesity prevention. Int J Obes Relat Metab Disord 1999; 23: 1004 –
1006.
International Journal of Obesity
View publication stats
3 Glenny AM, O’Meara S et al. The treatment and prevention of
obesity: a systematic review of the literature. Int J Obes Relat Metab
Disord 1997; 21: 715 – 737.
4 James WPT. A public health approach to the problem of obesity. Int
J Obes Relat Metab Disord 1995; 19(Suppl 3): S37 – S45.
5 Popkin BM. The obesity epidemic is a world-wide phenomenon.
Nutr Rev 1998; 56: 106 – 114.
6 Schooler C, Farquhar JW, Fortmann SP, Flora JA. Synthesis of
findings and issues from community prevention trials. Ann Epide-
miol 1997; 7(Suppl 7): S54 – S68.
7 Tansey G, Worsley A. The food system. A guide. Earthscan, 1996.
8 Kumanyika S, Antipatis V, Jeffery R, Morabia A, Ritenbaugh C,
James WPT. The International Obesity Task Force: its role in public
health prevention. Appetite 1998; 31: 426 – 428.
9 PHAPO working group. Caught in the causal web — a new per-
spective on social factors affecting obesity. Obesity, IASO=IOTF
newsletter, Spring 1999; 10 – 11.