Undernutrition and Obesity: the View from the Public Sector
William H. Dietz, MD, PhD Division of Nutrition and Physical Activity CDC
Undernutrition and Obesity
Undernutrition Obesity
Women > men Women > men Ethnic differences SES gradient SES gradient in white women Children esp vulnerable Adults > children Large disease and financial burden Breastfeeding protects Food insecurity Food insecurity?
Examples of the Elimination of Micronutrient Malnutrition in the United States Iodine deficiency Pellagra Neural tube defects
The Full Spectrum of Iodine Deficiency
Cretinism
Goiter Reduced intellectual performance
Iodized Salt in the United States
Morton develops Iodized salt to help prevent goiters, which were common at the time. The Food and Drug Administration later requests that the product be labeled with the message, “This salt provides iodide, a necessary nutrient.”
1924
Salt Iodization in the US: Trend in Goiter Prevalence in Michigan
50 40
Percent
30 20 10 0
1924 1929 Year 1951
WHO Monograph Series No. 44
Examples of the Elimination of Micronutrient Malnutrition in the United States Iodine deficiency Pellagra Neural tube defects
Morbidity and Mortality Rates of Pellagra in Mississippi
Mortality and Morbidity Rates per 100,000 Population
1000 Mandatory Enrichment Law Became Effective (1945)
Morbidity Mortality
100
10
1
Voluntary Bread Enrichment Began (1938)
0.1 1925 1930 1935 1940 1945 1950 1955
Year
Source: AMJ Public Health 2000; 90:727
Examples of the Elimination of Micronutrient Malnutrition in the United States Iodine deficiency Pellagra Neural tube defects
Prevalence of spina bifida and anencephaly by year and quarter of birth for 24 surveillance programs (1995-99)
World Bank Rankings of Cost Effective Interventions
Relative Cost Per DALY
Vitamin A Fortification Antibiotics for Infections ORT for Diarrhea Iron Supplementation Vitamin A Supplementation Iodine Fortification Iron Fortification
$0 $5 $10 $15 $20 $25 $30 $35
Copenhagen Consensus “Very Good Proposals”
• • • • • Challenge Diseases Malnutrition Subsidies & trade Diseases Opportunity Control of HIV/AIDS Providing micronutrients Trade liberalization Control of malaria
Flour Fortification Initiative
A Public-Private-Civic Investment in Each Nation
What Can Industry Do?
• New product development • Help make the case for fortification Recognize success Develop and argue the ROI Use business to business networks • Support a level playing field • Market the approach
Global Prevalence of Obesity, 1988-94
Women
Samoa (urban) Kuwait
Men
Age range
25-69 18+ 25-64 20-74 15+ 25-69 20-65 16-64 18-74 20-59 20-69 15-64 25-64 20+ 20-45
East Germany
USA Saudi Arabia W. Germany Czech Republic England Canada Netherlands Australia Brazil Japan China
80 60 40 20 0 20 40
60
80
% population
Source: International Obesity Task Force
Obesity Trends* Among U.S. Adults 1991, 1996, 2004
1991 1996
2004
No Data
<10%
10%-14%
15%-19%
20%-24%
25%
Consequences of Adult Obesity
• Psychosocial • Cardiovascular – Hyperlipidemia – Diabetes mellitus – Hypertension – Respiratory – Cardiac • Medical – Polycystic ovary disease – Gall bladder disease – Osteoarthritis – Cancer • Pregnancy and the postpartum • Mortality • Erectile dysfunction
Diabetes* Trends Among U.S. Adults, BRFSS 1990, 1996, and 2004
1990 1996
2004
No Data
<4%
4%–6%
6%–8%
8%–10%
>10%
* Includes Gestational Diabetes
Duration of Diabetes and Nephropathy (Pima Indians)
Cumulative Incidence Nephropathy (%)
25 20 15 10 5 0
35 - 44 Y
15 - 24 Y
25 - 34 Y
• The duration of diabetes, rather than the age at diagnosis, is predictive of nephropathy (Krakoff. Diabetes Care 2003;26:76)
0
4
8
12
16
Duration (years)
Costs of Obesity
Costs of illness Costs of absence from work Costs of reduced productivity Costs of injuries Costs of disability
Annual Direct and Indirect Costs Attributable to Obesity in the United States
(Billions of 1995 Dollars)
Disease
Type 2 DM CHD Hypertension Gallbladder Breast Ca Endometrial Ca Colon Ca Osteoarthritis Total
Wolf and Colditz, Ob Res 1998;6:97
Direct Costs
$32.4 $ 7.0 $ 3.2 $ 2.6 $ 0.8 $ 0.3 $ 1.0 $ 4.3 $51.6
Indirect Costs
$30.7 $ NA $ NA $ 0.1 $ 1.5 $ 0.5 $ 1.8 $ 12.9 $47.5
% Total Change in Spending by Top 10 Conditions 1987-2000
Heart disease Pulmonary conditions Mental disorders Cancer Hypertension Trauma Cerebrovascular disease Arthritis Diabetes Back problems
Thorpe et al. Health Affairs 2004; W4-437
30%
16%
Costs of Obesity
Costs of illness Costs of absence from work Costs of reduced productivity Costs of injuries Costs of disability
Effects of Obesity on Health and Disability among 50-69 yo Women with BMI > 35
Report poor health # Chronic conditions Any ADL limitation Report health limits work 40.5% 2.31 21.4% 45.7%
Sturm et al. Health Affairs 2004;23:199
Partners in the Prevention and Treatment of Obesity
• • • • • Medical Settings School Work Site Community Industry
Relationship Between Energy Requirements, Physical Activity, and Weight
Energy Requirements Energy Requirements
Level of Physical Activity
Weight
What Can Industry Do?
• Recognize the threat • Use business to business contacts • Become model worksites – healthful choices, medical benefit packages • New product development Create and meet consumer demand • Use creative packaging • Share non-proprietary market research
Division of Nutrition and Physical Activity, Adolescent and School Health, and VERB Websites
• • • • • • cdc.gov/nccdphp/dnpa cdc.gov/nccdphp/dash cdc.gov/youthcampaign VERBnow.com VERBparents.com healthierus.gov/steps