Francesca Colombo, Head, Health Division, OECD Directorate for Employment, Labour and Social Affairs
In 2010, the OECD’s influential report, Fit not Fat:Obesity and the Economics of Prevention, warned about the rapidly rising challenge of obesity and its consequences for our health.
Nearly a decade later, the situation has unfortunately not improved enough. Our new data released today (http://www.oecd.org/health/obesity-update.htm) show that the obesity epidemic has spread further, even though this has happened at a slower pace than before. Today, over half of all adults and nearly one in six children are overweight or obese in the OECD area. In the United States and Mexico, one every three adults is obese (see our chart). Social disparities persist and have increased in some countries. Less-educated women are two to three times more likely to be overweight than those with a higher level of education.
Obesity rates have grown rapidly in England, Mexico and the United States since the 1990s. The outlook for the future is worrying, as new projections show a continuing increase of obesity, if no significant change occurs. Obesity rates are projected to increase at a faster pace in Korea and Switzerland where rates have been historically low.
There are many reasons why we must tackle obesity. Obesity is a key risk factor for numerous chronic disease, such as diabetes and cardiovascular disease. The failure of health systems to tackle obesity leads to millions of deaths and disability. This also damages our economies. Obese people are less likely to be employed than normal-weight people. They are less productive at work due to more sick days and fewer worked hours, and they earn about 10% less than non-obese people (OECD/EU (2016), Health at a Glance: Europe 2016 – State of Health in the EU Cycle, OECD Publishing, Paris. http://dx.doi.org/10.1787/9789264265592-en.)
The good news is that much of this is preventable, as OECD work shows. Comprehensive policy packages, including school-based and worksite interventions, interventions in primary care settings, and broader regulatory and fiscal policies can address obesity effectively. A number of countries have recently implemented policies, ranging from tax measures (e.g. Belgium, Chile, Finland, France, Hungary, and Mexico) and subsidies to encourage active commuting instead of cars (e.g., Canada and France both at subnational level), to prescription of physical activity (e.g., France, Sweden), reformulation of food products (e.g., Canada, Chile, Korea, UK, Industry on its own) and change in portion sizes (e.g., France, Sweden, Turkey, UK, New York City ).
In the past few years, new policies to fight obesity have emerged, including communication. Improving nutrient information displayed on food labels through easy-to-understand symbol that is placed in front of pre-packaged food products can help consumers make healthier food choices. These symbols exist in Australia, Chile, Denmark, England, France, Iceland, Korea, Lithuania, New Zealand, Norway, and Sweden. Health promotion campaigns have also been spread through social media. Examples of health-promotion-dedicated website, mobile apps and online tools to help people change their behaviours can be seen in Chile, Estonia, England and the Netherlands. Some countries have reinforced the regulation of marketing of potentially unhealthy foods and sweetened beverages directed at children and young adults. Chile, Iceland, Ireland, and Mexico, for example, ban advertising of foods and beverages on television and radio during peak children audience hours. Other bans apply in schools (e.g., Chile, Spain, Turkey and Poland), in public transport (e.g., Australia) and in theatres (e.g. Norway). While the impact of these polices has not been fully evaluated yet, early evidence shows they empower people to make healthier choices, and can also affect food manufacturers’ behaviours.
These are just some examples. Most OECD countries are now using simultaneously complementary policy tools and creating synergies to promote healthier lifestyles. But there is no room for complacency. OECD countries on average still allocate only around 3% of their health budgets to public health and prevention. Addressing obesity requires investment, and comprehensive policies that target broad social and environmental determinants. Crucially, it requires strong leadership and political will.
Sassi, Franco (2010) “Fighting down obesity” OECD Observer No 281, October http://oecdobserver.org/news/fullstory.php/aid/3339/Fighting_down_obesity_.html
Summer is just around the corner, and the newsstands are suddenly covered with magazine covers promising to get you trim and toned for the beach. But, this year, squeezing into the swimsuit will be harder than ever. Why? We’re getting fatter.
Figures released by the OECD earlier this week show that most adults in the developed world are now overweight. More worrying, almost one in five are not just overweight but obese. In the United States, Mexico and New Zealand, that proportion rises to one in three. (If you’re wondering about your own body, you can estimate your Body Mass Index, or BMI, here. Among adults, a BMI of 25 or over means you’re overweight; 30 or over means you’re obese; and 40 or over means you’re severely obese.)
The problem is not just confined to rich countries. Worldwide, not a single developed or developing country has managed to turn the tide on obesity over the past three decades, according to findings from the Global Burden of Disease Study reported this week. Over that period, the proportion of overweight or obese adults worldwide rose about 8 percentage points to just under 37% for men and to 38% for women, and there were also big rises among children and adolescents.
So, the obesity epidemic shows no signs of going away, although there are signs that it’s levelling off in some rich countries. According to the OECD data, obesity rates are stabilising, or growing only very slowly, in around six OECD countries and regions, including the U.S., Spain and Canada. But in others, such as Mexico and Australia, they’re still galloping along.
They also look to be rising among people on the bottom end of the economic ladder, who tend to suffer higher rates of obesity in any case. The Great Recession didn’t help: In a number of countries, there are signs that families cut their spending on food, typically by replacing fresh produce with highly calorific but less nutritious processed foods – goodbye salad, hello cheeseburger.
For a number of reasons, the global rise in obesity is increasingly seen as a serious issue for public health policy. For one thing, obesity – just like cigarettes and alcohol – is a killer. People who are severely obese cut eight to ten years off their lives, while every extra 15 kilograms of weight increases the risk of early death by about 30%.
Another reason is that it’s clear that people don’t have the information they need to make good decisions about food. That’s not too surprising. We live, after all, in a world filled with food designed, quite literally, to make us go on eating – try eating just one Pringles chip, for instance. We are also bombarded by endless, and often contradictory, advice on what and what not to eat. Right now, it seems, sugar is replacing butter as Public Enemy No. 1. Neither, of course, is a “super-food” – a list of comestibles that promises to make us slim, sexy and smart and that now includes everything from blueberries and pomegranates to vinegar, cauliflower and even dandelions.
It’s no wonder people are confused.
Recent years have seen a swathe of policy initiatives to try to tackle the obesity epidemic, and a range of approaches is being taken. One of the most popular – and controversial – involves introducing higher taxes on fatty or sugary foods. Designing these taxes is not easy, however. Denmark, for example, introduced a “fat tax” on foods containing more than 2.3% saturated fat, but rescinded it after not much more than a year amid pressure from retailers, producers and politicians.
Other initiatives include better food labelling. The UK, for example, has introduced a voluntary “traffic-light” system to inform consumers about the levels of salt, sugar and fat in their food. Food advertising is also being targeted in some OECD countries: As part of its ambitious National Strategy on obesity, Mexico has banned TV advertising of potentially harmful foods during hours of the day when children are likely to be watching. Financial and other incentives are also being tried out in some OECD countries to encourage people to lose weight.
Many of these initiatives are fairly recent, so it will take time before their impact becomes clear. No doubt, some will work better than others – indeed, some may not work at all. However, there is good evidence to show that public policy really can have an impact on major health issues. Take smoking – down almost a third in just two decades in rich countries and, with luck, likely to fall still further.
OECD work on the economics of prevention
Last year, the world spent the equivalent of $2000 on arms for every one of the planet’s 870 million malnourished people. Other than giving the gun money (or guns) to the hungry, how else could we fight malnutrition? On its annual World Food Day, the FAO argues that agricultural cooperatives are the “key to feeding the world”. Co-ops are far more important than most of us realise. According to the FAO, around 1 billion people worldwide are members, and cooperatives provide over 100 million jobs across all sectors, 20% more than multinationals. In 2008, the top 300 cooperatives were responsible for an aggregate turnover of $1.1 trillion, roughly the size of the world’s tenth largest economy, Canada.
Agricultural cooperatives (the main type in many countries) can offer their members a range of services, including credit, training, marketing and access to information, as well as improving their bargaining power when buying inputs or in policy making. That can help them take advantage of opportunities like the surges in food prices seen in 2007-2008, that in fact left many poor farmers worse off because they couldn’t increase their own production but still had to pay higher prices for things they didn’t produce themselves.
People in this situation can become trapped in a vicious circle, where food insecurity is not just an immediate tragedy, but a threat to longer-term wellbeing. As Joe Dewbre explains in the OECD Observer, faced with hunger, families first tend to reduce consumption of higher quality foods, such as meat or vegetables. But if the crisis continues, they may have to sell the means by which they normally earn a living – their animals or tools for instance – or take out loans that will leave them impoverished and indebted for years to come. Or even worse. Earlier this year, the Indian media reported on a wave of suicides among farmers in Bengal unable to repay loans.
Dewbre argues that historical evidence – and common sense – suggest that as a society becomes richer, food security becomes less of a problem. An OECD working paper shows that developing countries with very different levels of economic development, population size and geographical location have succeeded in reducing poverty and improving nutrition. Despite the significant differences among them, they share some characteristics. During the period when they had the greatest success in reducing poverty, the macroeconomic context became progressively more favourable. Their own governments were lowering export taxes, reducing overvalued exchange rates and dismantling inefficient state interventions in agricultural markets. Meanwhile, the governments of rich country trading partners were reducing the kinds of support to their farmers that distorted production and trade the most.
As we discussed in this article, hunger exists in rich countries too, but the main food-related problem here is obesity. According to the OECD Obesity Update 2012, obesity rates in OECD countries have doubled or tripled from 1980, when fewer than one person in ten was obese. Now, the majority of the population is overweight or obese in 19 of the 34 OECD countries, and OECD projections suggest that more than two out of three people will be overweight or obese in some OECD countries by 2020. The good news is that the progression of the epidemic has effectively come to a halt for the past ten years in some countries, including Korea (where obesity rates have stabilised at 3% to 4% of the population), Switzerland (7% to 8%), Italy (8% to 9%), Hungary (17% to 18%) and England (22% to 23%).
However, the epidemic isn’t regressing anywhere, and it’s also becoming a problem in developing countries. Data from the WHO show that overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings. Close to 35 million overweight children are living in developing countries, compared to 8 million in developed countries. The WHO ranks overweight and obesity as the fifth leading risk for global deaths. At least 2.8 million adults die each year as a result of being overweight or obese. In addition, 44% of the diabetes burden, 23% of the ischaemic heart disease burden and between 7% and 41% of certain cancer burdens are attributable to overweight and obesity.
That said, hunger and malnutrition are still the number one risk to the health worldwide — greater than AIDS, malaria and tuberculosis combined. That $1.738 trillion used to buy arms last year could have been better spent.
Kieron Smith, Boy by James Kellman describes life in Glasgow in the 1960s as seen by a child from ages four to almost thirteen. Nothing is presented other than Kieron’s thoughts, so what we are told directly is what he finds interesting and what he thinks about it. Indirectly, the novel describes a number of social and other situations that were starting to change, including this: “There was a fat boy in our street. People called him fatso.” At the time, obesity was unusual enough to draw attention. Yet now more than a third of Scottish 12-year-olds are considered to be overweight, a fifth to be obese and over one in ten severely obese. The statistics for adults are even worse, with almost two-thirds of men and more than half of women.
The situation is better in the other OECD countries, apart from the United States, but overweight is a concern almost everywhere. Obesity is one of the few cases where the popular perception that things were better in the old days is supported by a range of objective evidence. The facts also suggest that people are right in blaming the problem on changes in lifestyle and diet. Kellman’s hero is outside as much as possible, and is usually involved in highly physical pastimes like football, climbing or running. He hardly ever has any pocket money and can rarely afford to buy snacks or a soda. Indeed, another boy is remarkable because he can buy chips once a week on the way home from a youth group.
That doesn’t mean his diet was particularly healthy, but hours of physical activity and no income to buy junk food compensated for all the carbohydrates. Diets for lower socio-economic groups have remained just as poor, or have got worse in some respects, at the same time the amount of exercise has declined.
The result is that overweight and obesity rates have been increasing relentlessly worldwide, Obesity-related problems, such as diabetes, now account for 2% to 6% of health care costs in most countries. Even lower-income countries are affected, with some of them actually having problems of obesity and under nutrition simultaneously.
The causes and consequences of obesity and how to tackle it are analysed in Fit not Fat: Obesity and the Economics of Prevention. The book asks how to trigger meaningful changes in obesity trends. The short answer is by wide-ranging prevention strategies addressing multiple determinants of health. The reality is that every step of the process is conditioned not just by public health concerns, but by history, culture, the economic situation, political factors, social inertia and enthusiasm, and the particularities of the groups targeted.
Authors Franco Sassi and Michele Cecchini of the OECD’s Health Division also contributed to a series of articles on obesity in The Lancet, the latest of which are published today. The Lancet’s conclusions are similar to the OECD’s: the changes needed are likely to require many sustained interventions at several levels, and national governments should take the lead.
That includes tougher action – including taxing junk food – but the food industry will resist such changes. Speaking to the BBC about the reports, Terry Jones, of the UK Food and Drink Federation, said “The Lancet fails to recognise the lengths to which the UK food and drink industry has gone to help improve the health of the nation, particularly in relation to rising obesity levels.”
Professor Boyd Swinburn (author of a paper on what’s driving the obesity epidemic), doesn’t agree. In fact he compares the tactics of the food industry – in terms of getting people addicted to their products and in blocking attempts to discourage consumption – to those of tobacco firms in previous decades.
Health is one of the topics included in the OECD Better Life Index. The Index allows you to put different weights on each of the topics, and therefore to decide for yourself what contributes most to well-being.
You can create your own index on the BLI site and share it on social media and other platforms.
This post is contributed by Harvey Rubin, a member of the steering group of the OECD Future Global Shocks project and Director of the Univerity of Pennsylvania Institute for Strategic Threat Analysis and Response, and Nicholas Saidel, a Research Specialist at ISTAR.
Thinking about certain aspects of public health and infectious diseases as “existential threats” to human security arguably began as early as December 10, 1948, when the General Assembly of the United Nations adopted and proclaimed the Universal Declaration of Human Rights, in which Article 3 states: “Everyone has the right to life, liberty and security of person.” This was reaffirmed in the United Nations Development Programme (UNDP) of 1994 and again in the 2003 UN Commission on Human Security. These efforts conceptualize security as human-centric rather than the traditional state-centric and include protection from the shocks that affect human safety and welfare – such as disease, hunger, unemployment, crime, social conflict, political repression and environmental hazards. In this formulation, the nature of an existential threat depends in part on the particular threatened sector.
The traditional national security threat is understood to be the threat to the survival of the sovereignty, territory and physical condition of the nation. To the medical community in general, and especially to the public health and infectious diseases sectors, survival clearly refers to taking every action to minimize morbidity and mortality as well as to minimize the effect of disease on the economic, social and political stability of communities, nations and transnational organizations. HIV/AIDS is frequently discussed in the context of securitizing public health issues. This discussion originated with the UN Security Council Resolution 1308 (2000), which placed HIV/AIDS squarely in the cross-hairs of the security debate by stating: “Stressing that the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and security.” More recently, obesity has been identified as a national security issue by retired generals and admirals in the report Too Fat to Fight, concluding: “If we don’t take steps now to build a strong, healthy foundation for our young people, then it won’t just be our military that pays the price – our nation as a whole will suffer also.” Even Michelle Obama identified obesity as a national security issue in the announcement of her ‘Let’s Move’ campaign.
Where will the securitizaton of medicine and the medicalization of security lead with regard to the future of public health, and conversely, with regard to the future of national security? These issues are generally addressed in the literature of the political scientists. For example, Stefan Elbe’s new book, “Security and Public Health,” analyzes the framing of health problems as security concerns and whether this framing helps or hinders controlling these problems in national and international political, social and economic venues. Elbe convincingly uses HIV/AIDS, SARS, and H5N1 influenza and bioterrorism as case studies of the effect of medicalizing security. Much like traditional security issues formulated in military language, a responsible reaction to threats is the development of countermeasures. Widening the security gambit to include an “inflated list of possible medical threats to security (Elbe)” can lead to a corresponding extension in funding for medical countermeasures – new vaccines and therapeutics. From our point of view—why is this bad?
The controversy over sovereignty rights concerning epidemiological data and, more specifically, on influenza sequence data that continues to engage the international community, is fascinating. This issue crystallizes many of the concerns of the national security community, including potentially weakening the traditional military agenda by widening the spectrum of security threats, removing the discussion of policy issues from the biomedical and public health practitioners and placing it in the hands of the diplomats, the military and possibly even the intelligence community, and focusing attention on the needs of the economically and militarily stronger countries and not on global health.
Understanding and dealing with the interdependencies of public health and national security spans widely divergent disciplines of clinical medicine, public health, basic biomedical science, economics, political science and international relations and deserves a deep and broad analysis by the interested parties. In this respect, Dr. Lincoln Chen’s comments in his address to the Helsinki Process Track on Human Security are instructive.
Given the perpetual tension between the demands of national security and the need to protect civil liberties, a balance must be struck whereby states can deal with national emergencies efficiently but without an unreasonable erosion of citizens’ privacy rights. Moreover, an international system that fosters, rather than inhibits, cooperation between states in terms of data sharing and bio-surveillance is required. For these reasons, we propose the implementation of a Global Compact for Infectious Diseases.
Artists never know what they’re depicting. Or rather, they may be depicting a lot more than they realise, and what seemed banal at the time becomes interesting later. Watch an old movie where the characters go to the cinema, and you’ll probably be struck more by the fact that half the people are smoking than by whatever action is supposed to grab your attention.
Historians try to glean hints of what everyday life was like in the past by examining incidental details in pictures and written accounts. In Vermeer’s Hat, for instance, Timothy Brook uses the objects and scenes in Dutch artwork to explore the development of international trade in the 17th century, examing where the fur for the hat came from for example.
Brian Wansink, of the Applied Economics and Management Department at Cornell, and his brother Craig, from the Religious Studies Department, Virginia Wesleyan College applied this approach to one of the most painted religious scenes in the history of art: The Last Supper, when Jesus and his followers shared a meal together for the last time (prompting French poet Paul Verlaine to remark that “You can’t judge a man by the company he keeps – Judas’s friends were very nice”).
The Wansinks wanted to see if the paintings revealed anything about how the average amount of food consumed over the ages has changed. Their results, published in the International Journal of Obesity, show that over the past thousand years, the size of the entrées in the paintings has grown by 69%, plate size has increased 66% and the size of the loaves of bread by 23%.
The study also shows how artists have unconsciously reflected increases in food production and affordability over the centuries. Another thing the paintings reflect is the fact that this change was extremely gradual until recently. According to records going back to the tenth century, it took a thousand years to increase wheat yields in England from around half a tonne a hectare to 2 tonnes. To increase from 2 tonnes to 6 tonnes took 40 years in the 20th century.
Portion sizes have also increased dramatically over the few decades. The average size of an American hamburger in the 1950s was just 1.5 ounces (42.5 g), compared with 8 ounces or more today (226 g), and when McDonald’s first opened in 1955, a serving of fries was 2.4 ounces and contained 210 calories, against today’s 7 ounces and 610 calories.
The impacts can be seen on any street, with obesity now a worry in all the developed countries and an increasing number of developing ones too, where the two extremes of malnourishment – obesity and hunger – may exist simulataneously.
Franco Sassi and colleagues from the OECD’s Health Division discuss strategies to prevent obesity in a working paper, and will be discussing the issues in depth a new book to be published later in the year.
The photo of what would happen to Michelangelo’s David if he adopted a modern diet and lifestyle is from an ad campaign for the German Olympic Sport Committee, “If you don’t move, you get fat”, by Scholz and Friends