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Abstract

• Increasing proportions of Australians are overweight or obese, a problem shared by all developed and, increasingly, developing nations. Now as many people in the world are overweight as underweight.
  
• Increasing obesity is a serious public health as well as economic problem. Its associated greater risks of high blood pressure, heart disease, osteoarthritis, type 2 diabetes, some cancers and other health problems consume considerable proportions of healthcare budgets.
  
• Health inequalities often reflect social inequalities, but with overweight there is also a male-female difference in the relationship between overweight and socioeconomic status. Health promotion campaigns are underestimating the social determinants of health, and "risk fatigue" is affecting attitudes to complying with healthy lifestyle standards.
  
• Proposals to reverse the obesity trend, such as taxing or restricting the advertising of unhealthy foods, raise contentious issues of choice and regulation.

The problem

We share these trends with many other developed and, increasingly, with developing nations. In January 2001, the US Surgeon General announced a national action plan to be developed over this year to reduce the prevalence of overweight and obesity.³ Of particular concern is the near-doubling of overweight and obesity among children and adolescents since 1980. According to William Dietz, Director of Nutrition at the Centers for Disease Control and Prevention, childhood obesity in the United States is an epidemic "the likes of which we have not had before in chronic disease".⁴ The Worldwatch Institute recently reported that, for the first time in human history, the number of overweight people in the world rivalled the number of underweight people — there are an estimated 1.1 billion of each.⁵

Health consequences

The increased prevalence of obesity is a serious public health issue because obesity is associated with greater risks of high blood pressure, heart disease, osteoarthritis, type 2 diabetes, some cancers and other health problems.^2,3 Recent research suggests health risks increase with weight increases, even within "healthy" weight ranges.⁶ Type 2 diabetes is a risk factor for cardiovascular and renal disease, peripheral neuropathy, loss of vision and pregnancy complications. The number of Australians with type 2 diabetes has more than trebled from 285 000 to 940 000 in the past 20 years, and one in four adult Australians now have diabetes or are at risk of developing it in the next 5-10 years.¹ In the United States, the incidence of type 2 diabetes, previously considered a disease of adults, especially in those over 40, has increased 10-fold over the past decade among children and adolescents.⁷

Economic consequences

At each stage of this process, the consumer may well be making a rational choice to maximise his or her utility or satisfaction (as economists are wont to argue), and the market and government responding to consumer demand. Taken together, however, this sequence of events represents diminished quality of life, a clear case where "more" does not mean "better".

Social causes

There is, however, more to social influences on health than inequality. In Australia, a socioeconomic dimension to weight exists, but is not clear-cut. It also depends on the sex of the person. For women, there is a social gradient, with the proportion who are overweight or obese declining with increasing socioeconomic status (Dr Tim Armstrong, Senior Project Manager, Cardiovascular Disease and Risk Factor Monitoring Unit, Australian Institute of Health and Welfare, Canberra, personal communication). But, among men, there is no clear gradient; in fact, the most overweight group is the second highest of five social categories (Box 3).

One reason for this male-female difference may be that men are less likely than women to regard themselves as overweight, despite more of them being so. In a recent Australian study, half the men who were overweight or obese, but only a quarter of the overweight or obese women, considered their weight to be acceptable.¹¹ In another survey, over two-thirds of Australian men defined overweight at a level higher than the current standard used by health authorities, compared with only a quarter of women.¹² A 1999 Gallup Poll in the United States also found that more women than men characterised themselves as overweight, felt they needed to lose weight, worried about their weight and were taking serious steps to lose weight.¹³

In other words, there appears to be a cultural dimension to these sex differences — different relative importance is attached to body image and to being slim. This difference may disappear at the top of the social scale, where overweight and obesity also decline among men. As average girth grows, it seems the elite are increasingly using slimness to distinguish themselves from the rest. This inverse association between social status and body size is reflected — and taken to the extreme — in the emaciated looks of growing numbers of today's leading female models, movie stars and TV celebrities. Idealising thinness and seeking meaning and control over one's body and life through fasting are implicated in eating disorders such as anorexia nervosa. Such are the cultural tensions and contradictions that confront us.

Risk fatigue?

This is hardly surprising. "Healthy lifestyle" standards are becoming harder to meet as "unhealthy lifestyle" temptations get stronger. For example, the "7-a-day" program, launched in 1999 by the federal Minister for Health, is intended to persuade Australians to eat seven serves of fruit and vegetables a day.¹⁴ Few of us come near this target. And, despite being urged to be more active, only 55% of adult Australians participated in any sport or physical activity (undertaken for its own sake) in 1999-2000 — down from 59% in 1998-1999.¹⁵

When it comes to reducing risk behaviours and promoting healthier lifestyles, there is a real danger of causing "risk fatigue" by asking too much of people too often. The problem with health promotion campaigns aimed at individuals is that they underestimate the social determinants of health. They also overlook the extent to which some social trends run counter to health messages, making compliance so much harder.

Dietary guidelines and exhortations to be physically active run up against increasing affluence, increasing advertising, increasing availability of "junk" food and drink, more labour-saving devices, more sedentary lifestyles and leisure activities (eg, television, computer games and the Internet), and greater concerns about the safety of children playing on the streets and in other public spaces — a complex amalgam of social, economic and cultural factors. Is it any wonder more people are giving up or failing? The food industry has not been slow to capitalise on the capitulation: in the United States a new range of treats that boast a high fat content is being labelled "food porn".¹⁶

What can be done?

The Worldwatch Institute goes further, arguing that stopping the "obesity epidemic" will require redesigning communities to restore exercise to our daily routines — for example, making public transport the focus of urban transport systems, and building more trails and paths to encourage walking, jogging and cycling.¹⁷ Going still further, we could restrict private car access to central business districts and major venues like schools (some of these measures would also have other health and environmental benefits).

As these examples indicate, at the heart of the obesity problem, as with other public health problems, are the contentious issues of choice and regulation. Should the food industry be required to take more responsibility for the personal and social costs of unhealthy products? Should consumer choice be constrained for people's own good, and the wider social interest? The crux of the issue is how far we intervene to decrease the choice people have in managing their own health-risk factors (Dr Michael Booth, Coordinator, NSW Centre for the Advancement of Adolescent Health, The Children's Hospital at Westmead, personal communication). We already do this with tobacco, alcohol, road safety and vaccination; is it time overweight/obesity was added to the list?

Looking beyond specific countermeasures, we also need to educate the public about the quite fundamental ways in which modern society and its economy and culture can threaten our health and well-being. The story of growing obesity in Australia and many other nations reveals the complex interplay between social, economic and cultural factors which health authorities and policymakers must better acknowledge. It is a parable of the excesses that characterise our times and our way of life.

Acknowledgements

References

1. Dunstan D, Zimmet P, Welborn T, et al, on behalf of the AusDiab Steering Committee. Diabesity and associated disorders in Australia — 2000. Melbourne: International Diabetes Institute, 2001.
2. Australian Institute of Health and Welfare. Australia's health 2000. Canberra: Australian Institute of Health and Welfare, 2000. (AIHW Catalogue No. 19.)
3. Satcher D. Surgeon General launches effort to develop action plan to combat overweight, obesity. Office of the Surgeon General, US Department of Health and Human Services, 8 January 2001. <www.surgeongeneral.gov/todo/press releases/obesitypressrelease.htm> (accessed March 2001).
4. Critser G. Let them eat fat. The Australian Financial Review 2000; 24 March: 1,2,6,7 (reprinted from Harper's Magazine).
5. Gardner G, Halweil B. Underfed and overfed: the global epidemic of malnutrition. Worldwatch paper 150. Washington DC: Worldwatch Institute, 2000. <www.worldwatch.org/pubs/paper/150.html>; Chronic hunger and obesity epidemic eroding global progress. Worldwatch news release, 4 March 2000. <www.worldwatch.org/alerts/000304.html> (accessed August 2000).
6. Liu S, Manson JE. What is the optimal weight for cardiovascular health? BMJ 2001; 322: 631-632.
7. Goran MI, Sun M. Total energy expenditure and physical activity in prepubertal children: recent advances based on the application of the doubly labeled water method. Am J Clin Nutr 1998; 68: 944S-949S.
8. National Health and Medical Research Council. Acting on Australia's weight: a strategic plan for the prevention of overweight and obesity — summary report. Canberra: NHMRC, 1997: 69.
9. Marmot M. Social determinants of health: from observation to policy. Med J Aust 2000; 172: 379-382.
10. Turrell G, Mathers CD. Socioeconomic status and health in Australia. Med J Aust 2000; 172: 434-438.
11. Donath S. Who's overweight? Comparison of the medical definition and community views. Med J Aust 2000; 172: 375-377.
12. Crawford D, Campbell K. Lay definitions of ideal weight and overweight. Int J Obesity 1999; 23: 738-745.
13. Gallup Poll. When it comes to weight, Americans are loosening their belts. Princeton: The Gallup Organisation, 15 August, 1999. <www.gallup.com/poll/ index.asp> (accessed August 1999).
14. Wooldridge M. The push is on for a healthier Australia, media release, 16 June 1999. Canberra: Commonwealth Department of Health and Aged Care. <www.health.gov.au/mediarel/yr1999/mw/mw99061.htm> (accessed June 1999).
15. Australian Bureau of Statistics. Participation in sport and physical activities, Australia. Canberra: ABS, 2000. (Catalogue No. 4177.0); Australians less active — ABS, media release, 24 October 2000, no. 146/000. <www.abs.gov.au> (accessed October 2000).
16. Fat in a pack comes back. The Sydney Morning Herald 2000; 13 May: 30 (reprinted from The Telegraph, London).
17. Brown LR. Obesity epidemic threatens health in exercise-deprived societies. Worldwatch issue alert 2000-11, 19 December 2000. <www.worldwatch.org/alerts/indexia.html> (accessed May 2001).

Authors' details

Reprints will not be available from the author.
Correspondence: Mr R M Eckersley, National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT 0200.
richard.eckersleyATanu.edu.au

©MJA 2001
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