Tobacco and obesity epidemics: not so different after all?
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7455.1558 (Published 24 June 2004) Cite this as: BMJ 2004;328:1558
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Smoking and obesity are two of the most important global health risk
factors (1).The increase in obesity worldwide has an important impact on
the global health. Awareness of the association of obesity with health
problems is longstanding. A classical example of the emergence of an
obesity-disease link was established in 1921 by one JAMA article which
showed that a large proportion of diabetes patients were overweight (2).
Worldwide, around 250 million people are obese, and the World Health
Organization has estimated that in 2025, 300 million people will be obese
(3).
The increase in obesity worldwide will have an important impact on
the global incidence of cardiovascular disease, type 2 diabetes mellitus,
cancer, osteoarthritis, work disability, and sleep apnea. Obesity has a
more pronounced impact on morbidity than on mortality. A 1% increase in
the prevalence of obesity in such countries as India and China leads to 20
million additional cases of obesity (4).
The state of childhood obesity in Canada and many countries worldwide
has reached epidemic proportions. The Canadian prevalence has tripled from
1981-1996.(5) A stunning 40% of obese children and 70% of obese youth
continue this trend into adulthood.(6) This has led to higher rates of
adult obesity and associated conditions such as type 2 diabetes and
cardiovascular disease.
Obesity is a public health, medical, legislative, environmental, and
societal concern. Total direct cost of obesity in Canada is estimated to
be over 1.8 billion dollars per year, representing approximately 2.4% of
total health expenditures. Canadians ingest large amounts of refined sugar
and fat-containing foods. The most popular Canadian beverage is the soft
drink with greater than 110 litres consumed per person per year. With
their busy schedules, families rely more readily on meals from fast food
restaurants where large portions of fatty foods are consumed (7, 8).
In addition, children are not engaged in sufficient amounts of
regular physical activity. At least half of Canadian children are not
physically active enough for optimal growth, and development and levels of
activity drop as they get older. Adolescents are on average 10% less
physically active than children 2-12 years of age. Girls are less active,
and do less physically intense activities than boys. The reduction in
physical activity levels begins 2 years earlier in girls (14-15 vs 16-17
years) compared with boys (7, 8). Hypoactivity is even more prevalent in
obese children and youth, which results in less energy expenditure and
more weight gain.
If we hope to stop the epidemic of obesity in Canada and world, fat
diets are undoubtedly not the answer. Instead, a focus on healthy active
living within families, schools, communities, and all levels of government
must be adopted. Healthy food choices should be promoted. These include
restricting soft drink and juice intake in childhood, increasing the
intake of carbohydrates made from whole grains, eating foods high in fiber
and limiting portion sizes (8). Family practices related to food
preparation include use of fat or oil in cooking or cream, butter,
margarine, or high-fat cheeses in recipes. Reduction of added fat during
food preparation also represents a logical approach to reducing calorie
intake.
Differences in people's dietary intake are thought to account for
more variation in cancer incidence than any other factor, including
cigarette smoking. Carefully conducted epidemiological observational
studies, both prospective and case-control, show repeatedly that dietary
factors are associated with several chronic diseases, including coronary
heart disease, some types of cancer, stroke, and non-insulin dependent
diabetes, and thereby contribute substantially to the burden of
preventable illness (9).
Consumption of fruits, vegetables, and whole grains may potentially
offset high-calorie intake. Families have to reduce their fast food
consumption and the fast food industry must be committed to providing
healthier food choices. The most substantial data identify family
interactions related to food consumption as a logical approach to the
prevention of obesity. Family practices also affect the behavior patterns
associated with physical activity (10).
Children and youth also need to increase their levels of physical
activity in all aspects of daily life by taking part in outdoor play,
active transportation, physical activities with family members, organized
sports and mandatory quality daily physical education in schools. Physical
activity is likely to be increased among children with siblings and
playmates or among children who live in neighborhoods where opportunities
exist for safe outdoor play. Daily activities that could become part of a
child's daily physical activity are walking to school or to do errands
with parents.
Gradual disappearance of safe sidewalks as well as cycling trails
seem likes significant effects not only on obesity but as well on overall
public health. Road and related infrastructure and its unreasonable
acquirement from cyclists and walkers to entire use for motor vehicle
transportation is one of the chief barriers to active living that effect
the health of our communities in powerful ways. In recent decades, changes
in patterns of transportation and personal behavior have effectively
engineered physical activity out of our lives.
Communities are designed to promote increased and faster vehicle
flow, with little attention to safe pedestrian and bike routs. Evidence
shows that physical activity brings substantial health benefits to young
and people of all ages. However, much more needs to be done to create
opportunities and enhance existing road environment and related structures
to support safe physical activities like walking and cycling.
Prevention of obesity in children and adolescents is vital and focus
must be placed primarily on factors within family, school, and community
environments that affect food intake and physical activity. There should
be consistent use of social marketing for physical activity with high
population recall and systematic development of target-group plans to
support program delivery. In addition governmental and non-governmental
organizations as well as fast food industry need to join forces to ensure
a safe and healthy environment for the global population. A concerted
effort on the part of all parties involved is needed if we are to succeed
in our battle against obesity. Environmental and policy approaches (e.g.,
by-laws, subsidies) may help to address inequities in opportunities and
support activity where people work, live and play (11).
References:
1. Chopra, M., Darnton-Hill, I., Tobacco and obesity epidemics: not
so different after all? BMJ 2004; 328: 1558-1560
2. Joslin EP. The prevention of diabetes mellitus. JAMA 1921; 76:79-84
3. WHO. 1998. Life in the 21st Century A Vision for All. The World Health
Rep. Geneva, Switzerland: World Health Org.
4. Tommy L.S., Visscher, S., Jacob, S., The public health impact of
obesity. Annual review of Public Health 2001 ;( 22) 355-375
5. Mossberg HO. 40-year follow-up of overweight children, Lancet 1989; ii:
491-93.
6. Tremblay MS, Willms JD. Secular trends in the body mass index of
Canadian children. CMAJ 2000;163:1429-33
7. laird Birmingham C, Muller JL, Palpcpu A, Spinelli JJ, Anis AA. The
cost of obesity in Canada. CMAJ 1999; 23:483-88.
8. LeBlanc CMA. The growing epidemic of child and youth obesity - Another
twist? Can J Public Health 2003; 94(5):329-30
9. Howe GR, Hirohata T, Hislop TG, Iscovich JM, Yuan JM, et al. Dietary
factors and risk of breast cancer: combined analysis of 12 case-control
studies. J. Natl. Cancer Inst. 1990; 82:561-9
10. Johnson SL, Birch LL. Parents' and children's adiposity and eating
style. Pediatrics 1994; 94:653-61
11. McKinaly J, Marceau L. US public health and the 21st century: Diabetes
mellitus. Lancet 2002; 356:757-6
Competing interests:
None declared
Competing interests: No competing interests
I found this recent press release interesting (1), though I do wonder
whether the friend that forwarded it to me was trying drop a subtle hint
that what I affectionately call my small but comfortable "ballast" may
require more than self-limitation of choccie consumption to remove on a
more permanent basis.
(1)In The Obese, Metabolic Adaptations After Weight Loss Lead To The
Regaining Of The Shed Pounds:
http://www.the-aps.org/press/journal/04/14.htm
Competing interests:
None declared
Competing interests: No competing interests
Don't get me wrong. I am not for coke nor do I subscribe to the
strange notion that milk is only for babies.
However,even New Zealand milk is, I am sure, pasteurised and
homogenised;procedures which turn a good product into a substandard one.
And, of course there is UHT milk or similarly denatured products, all of
these are best not consumed with the thought that one is getting adequate
nutrition.
Raw cow's milk used to be available from the farm in many areas of the
world and it is a food that has sustained generations of people. Today,
most family farms have disappeared and our public servants have buckled
under the threats and promises of Big Industry to eliminate access to
these healthy products.And let us not forget that the fairy tale of A-2
milk , a totally laughable, junk science figment of the fertile and greedy
imagination of a NZ entrepreneurial learned man.You will find raw milk in
California supermarkets and you will also find more beautiful smiles in
that state.The Swiss guards to the Vatican hail from an area of
Switzerland where physical perfection is the norm.Raw dairy products are
the order of the day there. For plenty of information on the subject I
recommend the book by dentist Dr.Weston A.Price "Nutrition and Physical
Degeneration". Don't take my word for it.
Experts will point to the increased lifespan of today as compared to 100
years ago. Well, the people who represent this increase were raised on raw
milk and thrived without the 'benefits' of pateurisation and
homogenisation.
One cannot raise a calf on modern store milk,although I haven't tried
coke. But there is always the potential for a brief period of bovine
happiness with old Mr. Pemberton's drink.
Competing interests:
None declared
Competing interests: No competing interests
Coke rots teeth.
Milk doesn't.
Milk contains calcium and contributes to bone strength in children. Coke
contributes nothing but sugar and caffeine.
Ian is welcome to come and sit with me in the South Auckland
clinics where I work and witness for themselves how extraordinarily
destructive fruit juice and soft drinks are.
They should be heavily taxed and milk should be subsidised.
Yours sincerely
Andrew Montgomery MBChB BSc
Competing interests:
None declared
Competing interests: No competing interests
PLEASE do not compare smoking and obesity. That someone is overweight
does not expose others to many carcinogens and poisons, as does tobacco
smoke!
Obesity has been overstated by the tobacco people, who want to divert
attention from the murder and genocide caused by their drug-pushing.
Competing interests:
None declared
Competing interests: No competing interests
There is a very great difference between the tobacco and obesity
epidemics. While I agree with a lot of Chopra and Darnton-Hill's argument
for the causes of obesity, they have left out the most important cause of
obesity: Government dietary advice.
That advice is simple: cut down on fats, base meals on starchy foods
and take more exercise.
Blaming the food companies is to pass the buck to here it isn't
deserved. The food companies will only produce food that people will buy.
And people have been taught to want low-fat, carbohydrate-rich foods. It
must be the most successful advertising campaign of all time -- and the
most disastrous.
The simple truth is that the Prudent Diet, or 'healthy eating', call
it what you will, is fattening. Carbohydrate-rich foods are fattening.
Dietary fats, on the other hand have a slimming action.
Since William Banting wrote his 'Letter on Corpulence' in 1863,
epidemiological studies and clinical trials have consistently demonstrated
that the easiest, safest and healthiest way to lose weight and maintain a
healthy, normal weight is with a low-carbohydrate, high-protein/fat diet -
- precisely the opposite of current advice.
And, while exercise may have other benefits, no trial to my knowledge
has ever demonstrated any long-term benefit in obesity.
So before talking about taking legal action against the food
companies for the massive increase in obesity, we would be better advised
to look to current official advice, or any such legal action might
backfire.
HL Mencken wrote: "For every problem there is a solution -- neat,
plausible and wrong!" Chopra and Darnton-Hill's paper is a good example of
this.
Competing interests:
None declared
Competing interests: No competing interests
Almost to a man, the world's top nutrition and obesity authorities
believe that weight control necessitates a balance between caloric intake
and energy expenditure. We're told that because fat contains more than
twice as many calories per gram as protein or carbohydrate, eating too
much fat is a major factor in the obesity epidemic. Another half truth.
Sifting through weight control literature, one encounters occasional
evidence that the body does not absorb every calorie that finds its way
into the stomach. The digestive system is basically a chambered tube with
an entrance and an exit. Just as a wood stove does not transfer all energy
released through combustion to the environment being heated, the transfer
of digested energy molecules is considerably less than 100 percent
efficient. Researchers report overall calorie excretion rates ranging from
20 to 60 percent and fat excretion rates ranging from 2 to 42 percent. The
soluble fiber fraction in the food is largely responsible for the
percentage of calories that exit with the fecal material.
Another important consideration is the fact that, physiologically,
the body constantly remodels itself internally to accomodate the quality,
quanity, and timing of food intake. For example, the size of the stomach
and the surface area of the small intestine tend to increase with food
restriction and decrease with increased fat consumption, thus changing the
absorption efficiency of the digestive system.
Clearly, there is much to be learned about how the digestive system
responds to different mixes of fiber, macronutrients, and micronutrients.
Calorie excretion deserves some attention.
References:
A. Antonis et. al., "The Influence of Diet on Fecal Lipids in South
African White and Bantu Prisoners," American Journal of Clinical
Nutrition, Vol. 11, August 1962, pp 142-155.
J.O.Hill,H. Douglas, and J.C.Peters, "Obesity Treatment:Can Diet
Composition Play a Role?" Annuls of Internal Medicine 119(2):7 (1993):694
-697.
Competing interests:
None declared
Competing interests: No competing interests
You say "Mexicans now drink more Coca Cola than milk" and
"...the rise in obesity in the United States during 1980-94 could be
explained by an average daily
increase in consumption of only 3.7 kcal..." as if one was an inevitible
consequence of the other.
I don't think that Coke is a good thing, but it isn't a particularly high calorie
drink (see table). If its consumption is replacing water consumption, that
would be
bad.
| Drink | kCal/100g |
|---|---|
| milk | 64 |
| semi-skimmed | 50 |
| orange juice | 45 |
| Coke | 42 |
| skimmed milk | 35 |
| diet coke | 4 |
Calorie values are taken from the USDA nutrition database.
Competing interests:
None declared
Competing interests: No competing interests
It’s the economy, stupid
We agree with Chopra and Darnton-Hill that the ubiquity of processed,
energy-dense foods is a crucial component of the obesogenic environment,
and we would support many of their proposed measures to reduce the market
influence of unhealthy food products. [1] However, their analysis can give
the impression that the food industry is an exogenous hazard against which
we need to defend ourselves — a pathogen employing dissembling tactics
against our societal energy balance in the way that a virus finds ways to
circumvent our immune defences. At an individual level, it is virtually
impossible to challenge the dominance of Big Food, especially in the most
disadvantaged communities. But at a population level, our contemporary
food distribution system (like other elements of the obesogenic
environment) has not really been imposed on us: it reflects the values we
have chosen as a society, [2] whether explicitly or by inadvertent
collusion.
Our consumerist economy is built on the premise that personal and
collective economic growth is the most important priority of society. Many
of us who are able choose to devote more effort to acquiring possessions
and pursuing career goals, leisure and personal development, and less
effort to growing, shopping for, preparing, sharing and enjoying food
(among other things). Surely, then, we should not be surprised that an
industry has developed whose primary aim is not to provide an optimal
nutritional supply to the population, but to maximise profits by selling
us food whose convenience in terms of shelf-life and preparation comes at
the expense of nutritional quality. Statutory control measures may help in
the short term, and we are certainly not arguing against them, but perhaps
we also need to look beyond modifying the obesogenic environment to
redefining the obesogenic society we have become. Our collective
priorities are not immutable.
[1] Chopra M, Darnton-Hill I. Tobacco and obesity epidemics: not so
different after all? BMJ 2004; 328: 1558-60.
[2] Budewig K, Crawford F, Hamlet N, Hanlon P, Muirie J, Ogilvie D.
Obesity in Scotland: why diets, doctors and denial won't work.
www.obesescotland.org.uk, 2004.
Competing interests:
None declared
Competing interests: No competing interests