Guilty conscience: obesity as a 21st century disease

WELLNESS AND EDUCATION
CHAPTER XI
University of Szczecin,
Faculty of Physical Education and Health Promotion,
Department of Health Promotion
Uniwersytet Szczeciński,
Wydział Kultury Fizycznej i Promocji Zdrowia,
Zakład Promocji Zdrowia
KATARZYNA SYGIT
Guilty conscience: obesity as a 21st century disease
Rachunek za grzech – otyłość chorobą XXI wieku
Keywords: overweight, obesity, disease of civilization
Słowa kluczowe: nadwaga, otyłość, choroby cywilizacyjne
INTRODUCTION
Overweight and obesity have always accompanied the humankind [1, 12, 15,
17], but the development of science has allowed us to define them as an imbalance
between consumption and spending of energy (energetic homeosthasis of the body),
which results in an increase in fatty tissue. With time, the process intensifies and
results in various pathologies and dysfunctions of all systems and organs [28].
In the Middle Ages, obesity was perceived as a symbol of wealth, beauty and
abundance [22]. Today, obesity and overweight are considered to be epidemic, causing many diseases, including fatal ones [2, 3, 14, 29, 34].
Civilization progress has become a direct cause of the increased obesity incidence [3, 9, 20], as it results in changing lifestyle of society [23, 28]. Work in the developed countries has become almost completely automated, e.g. the computer became
a playground for children, a meeting place for adolescents, and for adults a way to
pay the bills and do the shipping without leaving the house. This reduces our physical activity to bare minimum [22, 27, 28].
To maintain the correct body weight, there must be a balance between energy
consumption and energy spending, therefore balanced meals and physical activities
are extremely important. Despite an increasingly easier access to health care, many
people are unable to make healthy choices. Among the reasons for this inability is
e.g. lack of education on nutrition [13, 19, 25, 26, 29, 30, 35, 36].
To a large extent, overweight and obesity depend on sex, education, origin etc.
[30].
WELLNESS AND EDUCATION
EPIDEMIOLOGY OF OBESITY
In the recent years, WHO put forward a definition of obesity, which qualifies
body weight as ‘obese’ based on the BMI (Tab. I) [4,7,8,25,31,32].
Tab. I BMI categories (WHO 1997) [31]
Category
Underweight
Norm
Overweight (pre-obesity)
Class I obesity
Class II obesity
Class III obesity
BMI [kg/m2]
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
≥40
BMI over 30 kg/m2 is a borderline, above which obesity starts.
According to the WHO and the National Institute of Heath, obesity is classified
as epidemic disease, as it is a world-wide problem which concerns all age and socioeconomic groups.
There are 10-25% of obese men and 10-30% of obese women in Europe. In the
last decade, incidence of obesity increased in most European countries by 10-40%;
over 50% of people are overweight/obese (Fig.1) [33].
30%
25%
20%
2000 years
15%
2010 years
10%
5%
Ro
m
an
ia
Ita
Bu ly
lg
ar
A u ia
st
Fr i a
a
Sw nce
ed
De en
nm
G ark
er
m
Po any
rtu
g
Fi a l
nl
an
d
Sp
ai
Es n
to
ni
Sl
a
ov
a k La
Cz R tvi
ec ep a
u
h
Re blic
pu
bl
ic
M
a
Un
lt a
ite Ire
d
l
Ki an d
ng
d
Hu om
Sw ng
itz ar y
er
la
nd
0%
Fig. 1. Increasing obesity rates among adults in European countries,
2000 and 2010 [21]
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Guilty conscience: obesity as a 21st century disease
In the EU member states, covered by Eurostat, proportion of obese/overweight
women was between 36.9% and 56.7% in 2008 (Fig.2) [18].
35%
30%
25%
20%
Obese
Overweight
15%
10%
5%
0%
Belgium
Czech Estonia
Republic
Spain
Italy
Latvia
Malta
Poland Slovenia
United
Kingdom
Fig. 2. Proportion of overweight and obese women [18]
As for obese and overweight men, they constituted 51.0%-69.3% of population
(Fig.3) [18]
50%
45%
40%
35%
30%
Obese
25%
Overweight
20%
15%
10%
5%
Be
lg
iu
m
Cz
B
ec ulg
h
a
Re r ia
pu
G blic
er
m
a
Es ny
to
n
G ia
re
ec
e
Sp
ai
Fr n
an
ce
Ita
Cy ly
pr
us
La
t
v
Hu ia
ng
ar
y
M
al
ta
Au
st
ri
Po a
la
Ro nd
m
a
Sl nia
ov
e
Un
S nia
ite lov
a
d
Ki kia
ng
do
m
0%
Fig. 3. Proportion of overweight and obese men [18]
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WELLNESS AND EDUCATION
The lowest proportion of obese men and women aged 18+ was noted in Romania, Italy, Bulgaria and France.
80%
70%
60%
50%
Y18-24
40%
Y25-44
Y45-64
30%
20%
10%
Be
lgi
u
Cz
Bu m
ec
lga
h
Re r ia
pu
Ge blic
rm
an
Es y
to
n
Gr ia
ee
ce
Sp
ai
Fr n
an
ce
Ita
l
Cy y
pr
us
La
t
Hu via
ng
ar
y
M
alt
Au a
str
i
Po a
lan
Ro
d
ma
nia
Sl
ov
e
Un
Sl nia
ov
ite
a
d
Ki kia
ng
do
m
0%
Fig. 4. Overweight and obesity in women according to age [18]
90%
80%
70%
60%
Y18-24
50%
Y25-44
40%
Y45-64
30%
20%
10%
Be
lgi
u
Cz
Bu m
ec
lga
h
Re r ia
pu
Ge blic
rm
an
Es y
to
n
Gr ia
ee
ce
Sp
ai
Fr n
an
ce
Ita
l
Cy y
pr
us
La
t
Hu via
ng
ar
y
M
alt
Au a
str
i
Po a
lan
Ro
d
ma
nia
Sl
ov
e
Un
Sl nia
ov
ite
a
d
Ki kia
ng
do
m
0%
Fig. 5. Overweight and obesity in men according to age [18]
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Guilty conscience: obesity as a 21st century disease
The highest proportion of corpulent women was noted in the UK, Malta, Latvia
and Estonia (Fig. 4); as for men, the highest proportion was noted in Malta, Hungary, the UK and Czech Republic (Fig 5).
WHO research conducted in Europe indicated that 22% of women and 15% of
men were obese, and the number of obese Europeans has tripled in the last 20 years
[5].
80%
70%
60%
50%
Males
40%
Females
30%
20%
10%
Un
i
ted
Ki
M
alt
a
ng
do
m
Sl
ov
en
Gr ia
ee
ce
Sp
ain
Po
lan
Cz
Cy d
ec
p
r
h
Re ys
pu
Ge blic
rm
a
Hu ny
ng
ar
y
Sl
ov
ak
ia
Ro
ma
nia
La
tvi
Au a
str
ia
Ita
Be ly
lgi
u
Sw m
ed
en
Fr
an
ce
0%
Fig. 6. Proportion of persons aged 15+ with obesity or overweight
in the EU countries according to the latest Publisher data [33]
Since 1970s, the number of overweight/obese schoolchildren tripled in the USA,
Canada, Brazil, Germany and Greece (Fig.6) [15].
In North America and Europe, as well as in the western part of the Pacific region, there is the highest incidence of overweight and obesity in the world, approx.
20%-30%.
A significant increase in the number of overweight/obese children has been also
noted in developing countries, where recent years saw economic changes (Brazil,
Mexico, Egypt) [2].
Europe faces an increased head count of overweight children and adolescents by
400,000 and obese children and adolescents by 85,000 each year. Such considerable
number of overweight/obese children in these countries may be explained by ‘Americanization’ of lifestyle: insufficient physical activity and abandoning the Mediterranean diet [26,36].
Compared to other European countries, incidence of overweight and obesity in
Poland is at a medium level. 8.7% of children and adolescents aged 7-17 suffer from
excess weight, while 3.4% face obesity. These proportions increase with age
(Tab.II) [22,28].
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Table II. Obesity and overweight among schoolchildren
in various age groups 11-12, 13-14, 15-16-year-olds in 2006 and 2010 [10]
Age (years)
11-12
13-14
15-16
Weight
Obese
Overweight
Obese
Overweight
Obese
Overweight
2006
3.3
14.3
2.3
13.3
1.9
11.3
Boys
2010
4.7
20.7
4.0
17.9
3.6
13.9
2006
1.6
9.5
1.0
7.6
0.3
5.7
Girls
2010
2.1
15.8
2.8
11.9
1.8
9.3
ETIOLOGY OF OBESITY
Epidemic of obesity is an unintended consequence of economic, social and technological advances in recent decades [23,27].
The mechanism of obesity development is complex and conditioned by many
factors:
 Environmental – in the last decades, the lifestyle has significantly changed, incl. nutrition patterns, quality of food, as well as reduced physical
activity.
 Genetic – obesity often concerns whole families, which triggered the search for genetic predispositions. It has not been, however, confirmed by a
simple inheritance model. There may be many genes and interactions between them that cause the development of obesity. Research on genetics
of obesity has revealed the existence of so-called obesity gene FTO (FAT
mass and obesity associated). People with that gene are more likely to accumulate fatty tissue. So far, there has been no indication of the main gene or mutation responsible for the development of obesity.
 Metabolic – sensation of hunger is controlled by the nervous system, stimulated by neurotransmitters. i.e. serotonin, dopamine and noradrenalin.
 Psychological – among psychological conditions that favor obesity one
can identify: personality traits, difficulties with coping with stress and
emotions. Often in stressful situations eating become a way to silence
problems. Excessive eating may be a way to draw other people’s attention. It expresses a need for care and rewarding oneself.
Additional factors include:
 Sex – overweight and obesity is more common in women than in men,
which points to a probable biological predisposition of women towards
obesity. Unlike women, men are more able to generate lean muscle mass
during body mass increase. Hormones also play a role, especially a decrease in female hormones in the post-menopause period.
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Guilty conscience: obesity as a 21st century disease
 Age – at which excess body weight accumulates. Obese children face a
higher risk of becoming obese adults.
 Type of diet – diets may slow down basic metabolism [6,16,24,36].
HEALTH CONSEQUENCES OF OBESITY
The issue of overweight and obesity is accompanied by a range of health, psycho-social and economic consequences. Obesity increases the risk of incidence of
many diseases with high mortality rate (Tab. III) [28].
Table III. Health consequences of obesity
Diabetes, metabolic syndrome, postinflammatory effect
Hypertension, coronary artery disease, cerebral stroke, heart attack,
Cardiovascular diseases
peripheral artery disease, chronic
heart failure, cardiac arrhythmia
Respiratory system diseases
Asthma, asphyxia, sleep apnea
Esophageal, small bowel, pancreatic,
Cancer
kidney
Osteoarticular changes
Osteoarticular pain, joint overload
Polycystic Ovary Syndrome, birth
Fertility disorders
complications, infertility
Proteinuria, skin infections, dental
Other
and periodontal disorders
Fear, depression, low self-esteem,
Psychological and social
stigmatization, discrimination on the
consequences
labor market
Metabolic disorders
Source: own work
In 2010 a prospective research results were published, which encompassed 1.46
million subjects. The research was aimed at investigating correlation between death
rate and BMI [4,31]. The lowest mortality rate was noted for BMI range of 20.024.9 kg/m2. BMI over 30 kg/m2 resulted in a death rate which increased proportionally to relative body weight [25].
It must be noted that obesity is a risk factor of diabetes, dyslipidaemia, ischaemic heart disease, hypertension, circulatory insufficiency, cerebral stroke, some
malignant cancers, osteoarticular diseases and other. Given the common incidence
of these diseases in developed countries, they constitute a great social and economic
problem, as they considerably increase healthcare costs, as well as financial losses
related to absenteeism. Thus, increased worldwide incidence of obesity is an alarming phenomenon, although the rate of the increase depends on the level of development of particular countries. Finucane et al. conducted a research which included
9.1 million people from 199 countries; they proved an increase of BMI in years
1980-2008 by an average 0.4 kg/m2 (men) and 0.5 kg/m2 (women) [7].
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COMPONENTS OF TREATMENT
1. Diet is a key element of prevention and treatment of overweight and obesity.
One needs to closely follow dietician’s recommendations. The most common recommendations are: reducing the energy density of consumed food and drinks,
reducing portion sizes, avoiding snacking between meals, not skipping breakfast,
avoiding eating at night, reducing episodes of lack of control and gluttony [19,
32].
2. Modification of behavior (CBT, cognitive behavioral therapy), which is a technique used to help patients modify their self-esteem and understand their
thoughts and convictions about body weight regulation, obesity and its consequences; it strengthens desired behaviors to succeed in reduction and maintaining
correct body weight.
Modification of behavior includes a number of elements, such as: selfobservation (e.g. consumption journal), control techniques for the consumption
process, controlling and reinforcing stimuli, awareness and relaxation techniques. Modification of behavior may be an element of slimming down treatment or
an addition to a program, a base for a specialist intervention [16].
3. Physical activity
Apart from high er energy expenditure and loss of fatty tissue, physical activity has rother beneficial effects: reduction of abdominal fat, increase of lean
muscle mass (muscles and bones), prevention of basal energy expenditure reduction related to slimming down, lowering blond pressure, improved glucose tolerance, insulin sensitivity and lipid profile, improved physical fitness, improved
adaptation to diet and keeping the correct body weight for a long time, improved
mood and self-esteem, reduction of fear and depression.
Actions typical of sedentarny life style (watching TV, using computer) need
to be reduced, while everyday activities, such as walks, bicykle rides instead of
driving a car, using stairs instead of elevators, need to be introduced. Physical
exercise needs to be adjusted to the level of fitness and health of an individual
and gradualny intensified. Nowodays, individuals of all ages are encouraged to
30-60-minute, medium-intensity physical activity (such as fast walks) every day
of the week, if possibile [6, 12, 15, 22, 27].
Most published studies evaluating the efficacy of exercise for the treatment
of obesity refers to a short observation period, usually no longer than several
weeks. Unfortunately, very little work concerns the long-term observation period
and the possibility of evaluating the effectiveness of various programs of physical exercise in the prevention and treatment of overweight and obesity. Few studies corresponds to the rigors posed a contemporary randomized clinical trials.
Most of the work indicate that regular endurance exercise within 30-60 minutes used by most days of the week that lead to reduced body fat, and frequently
also to reduce weight. Extending the duration and / or increase in exercise intensity increases weight loss. In overweight women participating in the exercise
(over 200 minutes / week) had a greater weight loss (-13.6% from baseline)
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Guilty conscience: obesity as a 21st century disease
compared with those training did not exceed 150 minutes of a week (-4.7% of
output). There is no doubt that the combination of a suitable in terms of dose (ie.
The duration, frequency, energy expenditure) training with proper diet brings
better results than the exclusive use of the diet. Meta-analyzes of the best in
terms of our study suggest that losing weight immediately after a few weeks intervention program (exercise combined with dieting) reaches 13.0 kg, and one year
after the end of the intervention of the difference is still more than 6.0 kg [11].
4. Psychological support
Sometimes psychological factors (e.g. depression) make effective treatment
of depression more difficult. Psychological support and/or treatment may then
become an integral part of the obesity treatment; in some cases (fear, depression
stress), a consultation with a specialist may be advised. Support group may also
prove helpful in such situations [24].
5. Pharmacological treatment
Pharmacotherapy may help a patient adjust to recommendation, reduce health
risk related to obesity and improve life quality. It may also help prevent the
development of diseases that accompany obesity (e.g. type 2 diabetes). Nowadays, prescribed medicine in advised to patients with BMI ≥ 30 kg/m2 or BMI
≥ 27, if there are diseases typical of obesity (e.g. hypertension, type 2 diabetes).
Drugs need to be taken according to recommendation, with consideration given
to counter indications, only when prescribed and always under doctor’s supervision [3].
6. Surgery
Surgery is an effective method of treating class 3 obesity. It may be recommended to patients aged 18–60 with BMI ≥ 40 or BMI 35–39.9 kg/m2 (if they
suffer from accompanying diseases) when surgical treatment and mass reduction
is believed to improve these diseases (such as type 2 diabetes and other metabolic disorders, cardiovascular diseases, respiratory diseases, osteoarticular diseases and severe psychological problems related to obesity). Bariatric treatment
requires support from inter-disciplinary team of specialists. The treatment needs
to be carried out in centers which can provide adequate pre-surgical assessment
of patient’s health, thorough and comprehensive diagnostics, proper treatment
and long-term care after the surgery [10].
Synopsis
Obesity has been classified as one of the ‘diseases of affluence’ and poses a
significant threat to health of the humankind. Results of epidemiologic research
are very alarming: in the last decade, a proportion of men and women in Europe
who suffer from overweight and obesity, has significantly increased. Weight
problem is especially acute amongst children and adolescents in both urban and
rural settings. Obesity and overweight lead to grave health consequences. They
result in diseases of circulatory system, respiratory system, some types of cancer
and osteoarticular disorders. The main factor causing obesity is an unhealthy life
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style, with a special emphasis on unhealthy nutrition and insufficient physical activity.
This paper presents the epidemic of obesity, with special consideration given
to the BMI (Body Mass Index), the status of the epidemic in Europe, etiology of
obesity with emphasis on the lifestyle, which is one of key factors contributing to
health and wellbeing, the impact of obesity on health, and specific components
of obesity treatment. The paper highlights the need to implement prevention programs and early treatment of overweight/obesity amongst children and adolescents due to spreading epidemic of these diseases.
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ABSTRACT
Epidemiological data suggest that obesity has become an increasingly common
problem in many countries, Poland included. Obesity may have grave health consequences, as it increases the risk of cardiovascular diseases, e.g. atherosclerosis,
type 2 diabetes, some malignant cancers and other disorders. Current tendencies
may result in shortened average life expectancy in the next decades. Treating obesity
and its complications consumes a lion’s share of healthcare expenditure. Strain is
put on national budgets also by spending related to disabilities and premature mortality. It is believed that general practitioners play a key role in prevention and treatment of obesity, but the role of each specialist responsible for patients’ nutrition
habits is also significant. If the fight with obesity is to be effective, doctors need to
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Guilty conscience: obesity as a 21st century disease
treat BMI and waist size and a basic examination components. Doctors should also
advise on healthy nutrition and lifestyle. According to the ‘European Charter on
Counteracting Obesity’, prevention of obesity amongst schoolchildren and adolescents is extremely vital. It is advised to promote desired, healthy behaviors by educating them about healthy lifestyle, highlighting the role of healthy nutrition, sensible choice of food products and drinks available at schools, and increasing their
physical activity. These actions will create a chance to prevent obesity epidemic and
its consequences in the future generation of adults. If families, schools and doctors
will not actively engage in the fight with obesity epidemic, its incidence and proportion is bound to increase. This, in turn, will contribute to a dramatic health situation,
which will result in shortened average life expectancy, increased incidence of cardiovascular diseases, type 2 diabetes and cancer.
STRESZCZENIE
Otyłość uznana jest za jedną z chorób cywilizacyjnych i stanowi ogromne zagrożenia dla zdrowia ludzkości. Wyniki badań epidemiologicznych są bardzo niepokojące. W ciągu ostatniej dekady znacznie wzrósł w Europie odsetek kobiet i mężczyzn z nadwaga i otyłością. Szczególnie duży problem jest obecnie zauważalny
wśród dzieci i młodzieży wieku szkolnym zarówno w środowisku miejskim jak i
wiejskim. Otyłości jak i nadwaga pociągają za sobą olbrzymie konsekwencje zdrowotne. Prowadzą do rozwoju chorób układu krążenia, układu oddechowego, niektórych chorób nowotworowych czy zaburzeń kostno-stawowych. Za przyczynami
otyłości kryje się przede wszystkim antyzdrowotny styl życia. Uwagę należałoby
zwrócić na nieprzestrzeganie zasad zdrowego odżywiania oraz niską aktywność
fizyczną. W pracy przedstawiono epidemiologie otyłości ze szczególnym uwzględnieniem wskaźnika do oceny masy ciała BMI (body mass index), sytuacje epidemiologiczną w Europie, etiologie otyłości z wyszczególnieniem stylu życia uznawanego
za jeden z podstawowych czynników warunkujących zdrowie człowieka, konsekwencje zdrowotne otyłości oraz specyficzne składowe leczenia otyłości. Wskazano
na potrzebę wdrażania programów profilaktycznych i wczesnego leczenia nadwagi i
otyłości w populacji dzieci i młodzieży ze względu na narastającą epidemię tych
schorzeń.
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