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Perspectives in Health Magazine |
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This issue of Perspectives in Health is the last of the Pan American Health Organization’s centennial year, and it is perhaps appropriate that we close 2002 with a bang rather than a whimper. Toward that end, we have chosen one of the humorously provocative works of Colombian artist Fernando Botero to grace the magazine’s cover. It does not imply that obesity, the subject of our cover story, is a laughing matter. It does suggest that it is fast on its way to becoming—as Botero seems to see it—an integral part of the human condition. Obesity has reached global epidemic proportions. What was once the problem of rich countries now afflicts developing countries as well. Experts point out that in poorer countries, obesity often coexists with malnutrition, and like malnutrition, it should be seen as a nutritional illness—certainly not simply as too much of a good thing. While obesity has been a public health concern in the richer countries for several decades, the messages that have been sent to counter it have generally put the onus on the individual. Now advocates for control of the epidemic are telling us—quite convincingly—that much of the problem is due to our changing culture and environment. With globalization and urbanization have come vast food surpluses, mass-marketing of energy-dense foods, increasingly sedentary work and ubiquitous labor-saving devices. Under these conditions, it may be easier to become obese than not. Medical research has devoted considerable attention to obesity, yet the underlying biological mechanisms are still not fully understood. Best estimates of its heritability range from 15 percent to 33 percent. Recent advances in genetic research include the identification of the protein leptin, which helps regulate appetite and metabolism, and in October of this year, the discovery of “HOB1,” a gene said by its discoverers to be one of perhaps “10 to 12 genes that will prove to be important in obesity and metabolism.” These developments raise hope for new gene-based drug treatments of the disease. But genetics does not go far in explaining the rapid emergence of obesity as a worldwide phenomenon. Genes do not change over a decade, but over thousands or millions of years. So what is the role of public health? There is no single answer. Prevention programs, particularly those targeting children and schools, are important in developed and developing countries, since childhood obesity is on the rise in both. Walmir Coutinho, head of the Latin American Consensus on Obesity, notes that research shows that “in transitional societies, income tends to be a risk factor for obesity, but education tends to be protective.” He argues that in developing countries, education is the key to controlling the epidemic. Others say new dietary recommendations are badly needed to take account of recent findings in nutrition and obesity research. We now know, for example, that not all carbohydrates are equal; complex carbohydrates, like those in whole grains, are harder for the body to turn into fat than the simple carbohydrates found in refined foods. Nor are all fats the same: Saturated fats and transfatty acids contribute to heart disease, while oils from fish, nuts, and other plant products protect the heart. How fat consumption per se affects appetite and metabolism is a matter of considerable debate. Another intriguing issue of particular interest to the Americas was raised recently by an international expert group convened by the Food and Agriculture Organization (FAO) and the World Health Organization (WHO). It pointed out that using standard weight-for-age indicators can lead to “gross underestimation” of obesity in populations with high rates of growth stunting. In Latin America, some 90 million people are beneficiaries of food programs, but by more appropriate measures, only 10 million of these may be truly underweight. The observation adds further complexity to an already complicated problem. The importance of tackling the global obesity epidemic was duly noted at this year’s World Health Assembly in Geneva, where WHO’s member countries called on the director-general to develop a global strategy on diet, physical activity and health. This is a daunting challenge as posed by the international obesity experts. Countering the larger forces at work—“obesogenic environments” and “nutrition transitions”—is a huge task that may require, as our cover story suggests, a rethinking of what constitutes a better standard of living. Millions of the world’s people need to learn that some of the things they take for granted or even strive for in modern life are not at all good for their health.Donna Eberwine |
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