Addressing overweight,

Obesity and NCDs

Corazon VC Barba, PhD
Professor Emeritus
Institute of Human Nutrition and Food
University of the Philippines Los Banos
Overweight
a state in which the weight exceeds the standard based on
height

Obesity
a condition of excessive fatness, either generalized
or localized; body fat or adiposity can be assessed
using BMI, waist circumference, and waist-hip ratio

Both carry many medical co-morbidities, including diabetes mellitus, several cardiac
risk factors, increased risk of malignancy, etc.
 BMI or wt
Quetelet’s index = (ht)2

Cut-off points used in classifying NS of

children, based on BMI for age, WHO-CGS

Severe wasting/thinness <-3SD

Wasting/thinness <-2SD to -3SD
Normal -2SD to +2SD
Overweight >+2SD to +3SD
Obesity >+3SD
Classification BMI (kg/m2) Risk of co-morbidities

Underweight < 18.5 Low

(but risk of other
clinical problems
increased)

Normal range 18.5 - 24.9 Average

Overweight  25 Increased
Pre-obese 25 - 29.9 Moderate
Obese class I 30.0 - 34.9 Severe
Obese class II 35.0 - 39.9 Very Severe
Obese class III  40.0
 the BMI spectrum in adults
BMI score
<16 16-<17 17-<18.5 18.5-<25 25-<30 30-<40 40

Severely Moderately Mildly Healthy Mildly Moderately Severely

underweight underweight underweight range over obese obese

Physical symptoms Physical Physical symptoms

become more symptoms that increase in
pronounced as BMI of healthy BMI frequency as BMI
declines levels increases

 Thin for their height  Normal,  Sedentary lifestyle

 Inadequate energy for active life  Cardiovascular diseases
normal activity  Less risk  Diabetes
 Listless, lethargic of illness  Risk of certain cancers
 Susceptible to disease  No nutrition-  Health problems caused
 Poor maternal and infant related by macro-and
health health micronutrient imbalances
 Health problems caused problems,
by macro- and given a well-
micronutrient deficiencies balanced diet FAO 2000
 Males Females
Caucasians Asians Caucasians Asians
mean sd mean sd mean sd mean sd
BMI 25.1 3.0 23.4 3.0 23.9 3.4 22.5 3.3

BF% 19.3 6.4 21.4 6.3 30.1 8.7 31.6 6.5

Source: Wang et al, 1994

<18.5 Underweight
18.5 to <23.0 Low to moderate risk
23.0 to <27.5 Moderate to high risk
=>27.5 High to very high risk

Source: Lancet 363:2004

2002
2010
2005
2010
2005
2002
 OVERWEIGHT AND OBESITY PREVALENCE
RATES IN ADULTS IN SELECTED COUNTRIES

Country % Overweight % Obesity

(BMI>25) (BMI>30)
Male Female Both Male Female Both
Lao PDR 6.8 11.4 9.3 0.7 1.4 1.1
Malaysia 24.1 29.0 26.5 4.0 7.6 5.8
Philippines 20.1 24.4 22.3 4.5 7.6 6.1
Singapore 33.9 27.0 30.4 5.3 6.7 6.0
Thailand 13.2 25.0 - - - -
Japan 26.8 20.7 23.4 2.9 3.3 3.1
Netherlands 43.5 36.5 - 6.5 9.1 -
Netherlands 65.57 59.49 - 25.81 31.78 -
SOURCE: Nishida, C., Mucavele, P., SCN Nine # 29, 2004-2005.
Influences on Energy Balance and Weight Gain
(Energy Regulation)

Individual/
biological
susceptibility Dietary
and physical
activity patterns
Energy regulation
Intake Expenditure

Fat Stable weight Lo Activity

Ga i n ss
CHO TEF

Protein BMR

Source: WHO, 2000 BODY FAT STORES

 CRITICAL DRIVING
FORCES
Accelerating globalization and trade liberalization
Rapid urbanization
Health and nutrition crises
Degradation of natural resources and increasing water
scarcity
The changing face of agriculture
Sweeping technological liberalization
Climate change
Changing roles and responsibilities of key factors

SOURCE: IFPRI, 2002

 ACCELERATING GLOBALIZATION
AND TRADE LIBERALIZATION

Changes in the food system

Competition for market share of food purchases
- multinational fast foods vs. street food
- supermarket chain vs. wet markets

Shift in food culture, reality of food availability

 RAPID URBANIZATION

More women in the workforce

Rural to urban migration

Sedentary lifestyles

Convenience foods, diets with more

fats, sugar and/or salt
 Changing food & nutrition trends
 In the last 4 decades the relative availability of staple foods
(cereals, pulses, & starchy roots) decreased almost
everywhere

 Staple foods were replaced:

 by vegetable oils and sugar in low and lower-middle

income countries
 by vegetable oils, sugar and meat in upper-middle income

countries
 by vegetable oils and meat in higher income countries

 Availability of F&V was only slightly increased in most

countries, but it is still well below the recommendations in
both developed & developing countries
 Impact of changing trends in food availability on
nutritional parameters of human diet

 Increased total fat content, in particular saturated &

trans fatty acids everywhere
 Increased energy density everywhere
 Decreased total carbohydrate content (including dietary
fibre)
 Decrease in some vitamins and minerals
 Decreased protein content in less developed countries
 Changing physical activity patterns

Population-wide declines in physical activity

► Leisure-time physical activity: slightly increasing

► Work-related activity: declining
► Transportation activity: declining
► Activity in the home: declining
► Sedentary activity: increasing

↓
Total physical activity: declining
 Changing physical activity patterns

Factors affecting physical inactivity:

► Inter-generational declines in PA: at home, school &

community
► Lack of PE in schools
► Reduced free play, walking & cycling to school
► PA ‘unfriendly’ communities
►‘Drive through’ conveniences
► Transport system dominated by cars
► Elevators & escalators (plus inaccessible stairs)
► TV, computer games, internet, remote controls
► Labour-saving devices, etc.
Parallel changes in prevalence?
HEALTH AND NUTRITION CRISES

Double burden of malnutrition

Micronutrient deficiencies

Tuberculosis

HIV/AIDS
 Double burden
Persistent undernutrition and
micronutrient deficiencies
among children and
vulnerable groups,

along with rising

overweight, obesity and
diet- and lifestyle-related
NCDs in adults.
 Fetal undernutrition

‘Brain sparing’
Hormonal
Altered blood flow
Reduced growth re-setting
Blood vessels
Disproportion Insulin
Liver
IGF-1 and GH
Kidney
Corticosteroids
Pancreas

“world of
plenty”

Adult Coronary Heart Disease and Diabetes

Source: ACC/SCN Nutrition Policy Paper No. 18, Sept. 2000 p.7
 Genome

Intra-uterine environmental triggers

Undernutrition
Glucocorticoids

Postnatal environment

Amplifiers
Minimiser
Adult disease
Source: Newnham, et al, 2002
 Short-term Long-term

Brain Cognitive and

development educational
performance
Early
nutrition Growth and Immunity
in utero & muscle mass Work capacity
childhood Body composition

Risks to:
Metabolic Diabetes
programming Obesity
of glucose, lipids, Heart disease
protein hormone/ High blood pressure
receptor/gene Cancer
Stroke
Source: FNB Supplement, 21:3, Sept. 2000 p.29 Aging
Impact of early nutrition on later health

Fetal origins of adult health & disease:

metabolic efficiencies serving well in
condition of fetal undernutrition become
maladaptive in the obesogenic environment
leading to the development of:
- abnormal lipid profiles
- altered glucose and insulin metabolism
- overweight & obesity
↓
Need for "life course approach"
 Transition from Malnutrition to Abdominal Adiposity and Diabetes
Childhood obesity and
adolescent type 2
diabetes
Higher mortality rate/
impaired mental
Poor baby development
care:
Elderly Fatter
mothers Weaning unto high fat
abdominally baby foods
working
obese, H/T Baby
diabetic TV/advertising
LBW energy dense foods
& drinks
Rapid
weight gain High fat/
sugar foods
Poor fetal & drinks
Energy dense, nutrition
low quality Child
food: poor fat &
health care stunted
Women: abdom.
7 Reduced
O/wt but anemic mental
capacity
Pregnancy: O/wt,
glucose intol.; anemia O/wt, short Energy/dense food/
adolescents drinks in school: TV
viewing; restricted
physical activity
Higher maternal
mortality; early type 2
diabetes Sedentary with burger/cola diet -
micronutrient, e.g. folate, deficient
Source: James, WPT 2002
Lifecourse approach:
the proposed causal links
Impaired mental
Higher mortality
development
rate
Untimely/inappropriat
e weaning
Societal and Fetal & Frequent
environmental Reduced infant infections
capacity for malnutrition Inadequat Inappropriate food,
factors care e health & care
Rapid catch up
Elderly Inadequate weigh growth
malnutrition fetal t gain Child
nutrition malnutrition

Abdominal Reduced
obesity, H/T, intellectual
Diabetes potential
Inappropriate food,
Inappropriate food,
health & care
health & care
Adult
malnutrition Adolescent
malnutrition
Pregnancy
Low weight Reduced
gain
Inappropriate food, intellectual
health & care potential
Higher maternal
mortality
Source: Darnton-Hill, Nishida, James. PHN, 2003, 7(1A):101-121
How can the nutrition & public health communities
─ already burdened by the challenges of poverty,
undernutrition and underdevelopment ─ deal
with seemingly contradictory goal of promoting
lesser food intake to prevent overweight, obesity
& associated nutrition-related NCDs?

↓
There is no contradiction!
It is not a question of more or less food,
but of an adequate amount of healthy diet.
Healthy diet is fundamental to:
- alleviate undernutrition & micronutrient deficiencies
- interrupt the intergenerational transmission of
poverty
- prevent nutrition-related NCDs
- promote healthy lives

A major first step is the realization that:

the policy options for the double burden of

malnutrition & nutrition-related ill-health are the
same
Some examples of common policy options

 Closely linking poverty alleviation programmes

(either food or cash distribution) with other
nutrition promotion activities

 Transport and environmental policies to

promote physical activity

 School policies that:

- improve health literacy
- promote healthy diet
- provide opportunities for physical activity
and facilities
Thank you!