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Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief (2019)

Chapter: Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief

Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
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Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
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Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 3
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 4
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 5
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 6
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 7
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 8
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 9
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
×
Page 10
Suggested Citation:"Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Current Status and Response to the Global Obesity Pandemic: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25349.
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Page 11

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Proceedings of a Workshop IN BRIEF January 2019 Current Status and Response to the Global Obesity Pandemic Proceedings of a Workshop—in Brief On October 9, 2018, the Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a public workshop titled Current Status and Response to the Global Obesity Pan- demic in Washington, DC. The workshop examined the status of the global obesity pandemic and explored approaches used to manage the problem in different settings around the world. Speaker presentations discussed the importance of understanding the obesity epidemic in a global context and shared perspectives on the implications of obesity as a global problem for preven- tion and treatment efforts in the United States, with an emphasis on reducing disparities. This Proceedings of a Workshop—in Brief highlights the presentations and discussions that occurred at the workshop and is not intended to provide a comprehensive summary of information shared during the workshop.1 The information summa- rized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop participants, the Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine. GLOBAL TRENDS IN OBESITY The workshop’s first session described the global state of obesity by examining its collective prevalence, trends, costs, and driv- ers around the world, and also indicated country and regional differences. Lindsay Jaacks, Assistant Professor at the Harvard T.H. Chan School of Public Health, said that according to the Noncom- municable Disease Risk Factor Collaboration (NCD-RisC), adult body mass index (BMI) has steadily increased in the United States and worldwide (see Figure 1), based on measured height and weight data from 1975 through 2016. She also referenced NCD- RisC data to point out a global trend of increasing BMI among children and adolescents (aged 5–19 years), though she noted the rise in BMI has not been as steep as it has been for adults (NCD-RisC, 2017). Based on data from 1975 through 2014 (for men and women) or 2016 (for boys and girls), she reported that global obesity prevalence has risen approximately two percentage points per decade (NCD-RisC, 2016, 2017). Jaacks displayed data illustrating the worldwide proportion of adult men and women in low (<20 kg/m2), normal (20 to <25 kg/m2), and high (≥25 kg/m2) BMI categories across several decades. For the first time in history, she said, the proportion in the high BMI categories has now surpassed the proportion in the low BMI categories, according to the most recent (2016) figures. While Jaacks said that undernutrition is still more prevalent than over-nutrition (high BMI) among children, she cited a projection that the opposite would be true by 2022 if trends of increasing BMI continue (NCD-RisC, 2017). Jaacks touched on examples of socioeconomic differences in obesity prevalence, noting that these differences may con- tribute to disparities in prevalence within a single country. Regarding geographic differences, she noted increases in prevalence of overweight and obesity in both the rural and urban areas of several major world regions. In approximately half of the coun- tries she analyzed, there were greater increases in rural than in urban areas (Jaacks et al., 2015). Mentioning substantial variation in obesity rural-urban prevalence within countries such as China, India, Nigeria, and the United States, Jaacks appealed for more local-level data. High BMI is among the top risk factors that contribute to disability-adjusted life years both globally and in high-income countries (GBD 2016 Risk Factors Collaborators, 2017), Jaacks reported. Other consequences of the global obesity epidemic 1 The workshop agenda, presentations, and other materials are available at http://nationalacademies.org/hmd/Activities/Nutrition/ObesitySolutions/ 2018-OCT-9.aspx (accessed November 20, 2018).

FIGURE 1 Global trends in adult body mass index (BMI). SOURCES: Presented by Lindsay Jaacks, October 9, 2018. From Noncommunicable Disease Risk Factor Collaboration (NCD-RisC). 2017. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2,416 population-based measurement studies in 128.9 million children, adolescents, and adults. Lancet 390(10113):2627–2642. she described include increasing loss of disease-free years (Nyberg et al., 2018) and increasing diabetes mortality (IHME, 2018). Reiterating the burden of obesity in every region of the world, Jaacks finished by citing that 50 million girls, 74 million boys, 390 million women, and 281 million men were estimated to have obesity in 2016 (NCD-RisC, 2017). Vasanti Malik, Research Scientist at the Harvard T.H. Chan School of Public Health, discussed obesity trends in Asian populations. She opened by explaining that obesity prevalence has steadily increased in Asia from 1975 to 2014, yet prevalence there remains low compared to other global regions (Our World in Data, 2018). She cited data (Barnes et al., 2008) showing that overweight prevalence varies among Asian subgroups living in the United States; it is highest among Asian Indian and Fili- pino populations and lower in East Asian populations such as the Chinese. There is a high prevalence of diabetes and cardiovascular risk factors in parts of Asia where the average BMI is below 25 kg/m2, the typical threshold for overweight, Malik said. This is the threshold at which metabolic risk factors are observed among western populations, but not necessarily among Asian populations, she noted. Some, especially South Asians, tend to have less muscle and more abdominal fat compared to white Europeans, so the same BMI may represent a higher percentage of body fat in Asians, she explained. This highlights the limitations of BMI for assessing adiposity and cardiometabolic risk in many Asian populations, and Malik hypothesized that this may help explain why diabetes tends to occur at lower BMIs and younger ages among Asian populations. Malik shared World Health Organization (WHO) data that indicate a trend of increasing global type 2 diabetes prevalence, mirroring the trend of increasing global obesity prevalence (WHO, 2016a). She explained that the relation- ship between obesity and diabetes is not consistent across populations, pointing out a comparison of the United States and eight Asian countries among which India had the highest prevalence of type 2 diabetes but the lowest prevalence of obesity. She reported that the prevalence of type 2 diabetes among 30- to 39-year-olds in Asian countries was higher than its prevalence among the same age group in the United States (Yoon, 2006). Development of diabetes at younger ages may help explain its rapidly rising prevalence in Asian regions, Malik sug- gested. She displayed the International Diabetes Federation’s projection of increases in worldwide adult diabetes prevalence; the regions expected to experience the greatest rise between 2017 and 2045 are Southeast Asia (84 percent increase), the Middle East and North Africa (110 percent increase), and Africa (156 percent increase) (International Diabetes Federation, 2012). As diabetes may occur at lower BMIs in Asian populations, Malik reported that WHO has suggested lower BMI cut-off points for overweight and obesity for Asian populations (WHO Expert Consultation, 2004). WHO’s traditional overweight range is 25.0 to 29.9 kg/m2, whereas for Asian populations it is 23.0 to 27.4 kg/m2, she pointed out. For obesity, the traditional range is ≥30 kg/m2 and for Asian populations, it is ≥27.5 kg/m2. Ethnic-specific cut-off points have also been suggested for waist circum- ference (WHO, 2011). Malik proposed incorporating Asian BMI and waist circumference cut-off points in screening programs to help reduce the diabetes burden in Asian populations in Asia and globally. The world is experiencing rapid ethnic diversification due to an increase in international migration, said Karlijn Meeks, postdoctoral researcher in the Department of Public Health at the Academic Medical Center at the University of Amsterdam. 2

According to the United Nations (UN), there were about 173 million international migrants in 2000 and 258 million in 2017 (UN Department of Economic and Social Affairs, Population Division, 2017), Meeks said. She outlined three methods to assess migrant health. The first and most commonly used is to compare the migrant population with the host population, looking at ethnic differences or inequalities, she explained. A second method is to compare the same migrant group living in different countries, studying the role of national context, she continued. A third method is to compare a migrant group with its compatri- ots who have not migrated, studying the role of migration. Meeks presented insights from the Research on Obesity and Diabetes Among African Migrants (RODAM) study (Agyemang et al., 2016), which examined the roles of both migration and national context. Data were collected for nearly 6,400 Ghanians in five locations: rural and urban Ghana and Ghanaian migrants living in Amsterdam, Berlin, and London. For both men and women, prevalence of three outcomes: overweight and obesity (BMI ≥25 kg/m2), obesity only (BMI ≥30 kg/m2), and abdominal obesity (waist circumference >102 cm in men, >88 cm in women) was lowest in rural Ghana, followed by urban Ghana, and highest in the three European cities. Meeks stated that the role of migration was larger than the role of national context for these outcomes. While the prevalence of all three outcomes was higher among women than men in all of the five locations, she reported that the prevalence of type 2 diabetes was higher among men in every location except for rural Ghana. Among men with the same BMI, the probability for developing diabetes varied by location, she said. The same pattern was observed for waist circumference and there were similar patterns among women, Meeks added, which she said illustrates the influence of national context beyond only BMI. Meeks briefly discussed three underlying components of overweight and obesity to consider in the RODAM study pop- ulation: environmental, genetic, and epigenetic. Different environmental factors such as food environment and diet, physical activity, and stress can increase the risk of overweight and obesity in migrants compared to non-migrants, she said. Regarding genetics, more than 80 loci have been associated with polygenic obesity but these loci explain only a small fraction of heritabil- ity, Meeks remarked. She also noted that data from genetic studies on African populations are very limited. Finally, she described how lifestyle can alter epigenetics—the cellular mechanisms that regulate gene expression—and lead to changes in health risks. The RODAM study described epigenetics associated with obesity (Meeks et al., 2017), she said, but more work could identify whether certain environmental factors drive these epigenetic changes to increase the risk of overweight and obesity, or if over- weight and obesity induce the epigenetic changes and thereby increase the risk for other diseases. It is important to include the double burden of malnutrition in the conversation about global obesity, said Rachel Nugent, Vice President for Global Noncommunicable Diseases at RTI International. This refers to the simultaneous presence of undernutrition (one or more of stunting, wasting, or micronutrient deficiencies) and overweight/obesity, which can be mea- sured at the individual, household, regional, and national levels, she explained. In 2014 the Second International Congress on Nutrition framed the issue as malnutrition in all its forms, Nugent said, a terminology that she noted is becoming more accepted though many of the relationships between undernutrition and overweight and obesity are not fully understood. Nugent explained that the occurrence of the double burden of malnutrition varies depending on the cut-offs used for undernutrition and prevalence of overweight and obesity. At the national level, only a few countries experience a high preva- lence of overweight and obesity alongside high levels of undernutrition, she said. But the two conditions co-exist in more coun- tries when the definition is based on a lower prevalence of overweight and obesity and a broader measure of undernutrition, Nugent explained. She added that if subnational level data were being considered, the double burden of malnutrition would appear in even more places. Drivers of the double burden include scientific and technological change, economic change, urban- ization, and globalization, Nugent explained. Only two studies have examined the economic costs of both undernutrition and overweight and obesity, Nugent re- ported (Popkin et al., 2001; UN, 2016). She emphasized that common measures do not exist because different metrics are used to estimate the economic impacts of the two malnutrition conditions. Both studies measured losses in gross domestic prod- uct (GDP) ranging up to approximately 4 percent in some countries, Nugent said. Despite the lack of modeling capacity and empirical data, “we can feel pretty certain that there is a significant economic impact from both of these conditions,” Nugent observed. She listed a number of “double-duty” interventions and policies that can address all forms of malnutrition, adding the caveat that while there is evidence for their impact on one or another form of malnutrition, there is a gap in evidence that dem- onstrates their impact on the double burden. She highlighted three interventions that have produced strong impact data (i.e., data for which there was confidence in the effect sizes, though effects were not necessarily large) on both undernutrition and overweight/obesity: breastfeeding promotion, school nutrition programs, and food advertising. To close, Nugent reiterated some of the challenges associated with the double burden of malnutrition and obesity: a complex set of drivers and conditions, uneven and non-comparable data sources on the various forms of malnutrition, inter- generational factors that are both epigenetic and environmental, different outcome measures that reflect the various impacts of malnutrition across the lifecycle, and the lack of evidence from double-duty interventions and programs. 3

GLOBAL OBESITY PREVENTION AND TREATMENT EFFORTS The second session highlighted global efforts to identify, promote, and monitor policy and systems initiatives related to obesity prevention and control. Olivia Barata Cavalcanti, Director of Health Systems and Professional Education at the World Obesity Federation, dis- cussed its Management Advocacy for Providers, Patients, and Systems (MAPPS) program. Its main goal, she shared, was to learn how in-country health care systems and practices function regarding obesity policy, prevention, and treatment. The data will be used to create a Health Systems for Obesity Index, she said. Cavalcanti shared a brief description of the MAPPS methodology, which included forming a working group of expert ad- visors; conducting an online literature review, stakeholder mapping, and key informant interviews; analyzing data; and drafting country report cards. She shared preliminary results, beginning with countries’ progress toward defining obesity as a disease. Every country is at a different place in this journey, but there is consistency in that it is more common for health care providers, compared to government officials, to rate their country as being farther along in the process, she observed. Interviewees also described their country’s five biggest barriers to obesity treatment, Cavalcanti continued. Lack of specialized obesity treatment training for health care providers was the most common barrier, named by 50 percent of respondents, followed by a lack of access to treatment and medications and a lack of knowledge and awareness about obesity’s causes and impact. She also shared data on the availability of specialized obesity training, observing that the diversity of responses indicates a lack of a consistent plan of action in how different health systems tackle obesity. “That is one of the biggest problems that we have at the moment,” she maintained. In addition, lower availability of qualified obesity treatment professionals was reported in rural compared to urban areas, she said. Results of the data analyses are shared with country governments in the form of report cards, Cavalcanti said. Traffic light colors indicate areas where a country is doing well and where it can improve, she explained. Fiona Bull, Programme Manager in the Department of Prevention of Noncommunicable Diseases (NCDs) at WHO, described the role of physical activity in obesity solutions and reviewed the WHO global action plan to increase physical activity (WHO, 2018). Physical activity gained a “good foothold” with the 2013 release of the WHO Global Action Plan for the Prevention and Control of NCDs, Bull said. That document made suggestions for policy actions to promote physical activity and presented “best buys” and “good buys,” which she described as cost-effective interventions that are relevant for all countries. Most re- cently and after much consultation, she said, WHO produced a global action plan on physical activity for 2018–2030 to acceler- ate implementation of the suggested policy actions. Bull paused to share the latest physical activity data, underscoring that 28 percent of adults globally do not achieve the levels of physical activity recommended for optimal health (Guthold et al., 2018). This figure has been relatively unchanged since 2001 and the trend has also remained flat for men and women individually, she said, with approximately 25 percent and 31 per- cent, respectively, not meeting recommended levels. She discussed regional differences in the current prevalence of inactivity, and also pointed out that prevalence is lowest among low-income countries (per the World Bank’s income classification), higher among middle-income countries, and highest in high-income countries. Turning back to the global action plan on physical activity, Bull underscored its message that there are many ways to be active. She said that talking about some of those specific ways, such as play, dance, cycling, or walking, resonates with non- health sectors that may be less accustomed to the term “physical activity.” The plan maintains the 2013 plan’s global target for a 10 percent relative reduction in the prevalence of insufficient physical activity by 2025, and also targets a 15 percent reduction by 2030. These targets will be pursued through the plan’s mission to provide safe and enabling environments as well as more opportunities for physical activity in daily life, Bull explained, maintaining that “one without the other will not be effective.” She outlined the plan’s four strategic objectives, each supported by policy recommendations: (1) create active societies by changing social norms and attitudes around physical activity; (2) create equitable access to safe spaces and places for physi- cal activity; (3) create active people by reaching them with programs and opportunities across multiple settings; and (4) create active systems through governance and policy enablers such as surveillance, advocacy, and evaluation. The plan and its call for multisector commitment and action are being disseminated actively, Bull said. To make progress in implementation, Bull suggested tailored, region-specific tools to help guide countries to develop or update their National Action Plans for Physical Activity; capacity building for multisector collaboration; and a global monitoring framework to monitor and evaluate to hold countries accountable for their progress. Fabio da Silva Gomes, Ministry of Health Senior Officer at the Pan American Health Organization/WHO, shared food and nutrition actions that Latin America and the Caribbean have implemented to support obesity solutions. An observation from the region’s experience is that it is common to jump from problems to solutions, he began, “without digging into the causes … where we can find most of the solutions,” he asserted. Da Silva Gomes invited participants to consider the causes and devise solutions via an unconditional approach: by 4

identifying strategies to worsen diets and increase obesity. Eating ultra-processed foods2 is associated with poorer dietary qual- ity and higher obesity prevalence, he said, because these foods have characteristics that encourage faster consumption, slower and weaker satiety, and less compensation from other energy sources (Fardet, 2016; Fardet et al., 2017, 2018; Gombi-Vaca et al., 2016). On the other hand, “real food” (i.e., unprocessed or minimally processed food) is not a good choice to promote obesity, he said, because people would need to eat a greater volume, it would take more time to prepare and eat, and it would require sitting down to eat rather than doing so while multi-tasking. Could we solely promote real food to solve obesity? Could we sim- ply reduce the calories in ultra-processed foods? No, said da Silva Gomes, arguing that, in addition, marketing and advertising practices of ultra-processed foods can be regulated, pointing to the regulation of specific price and promotion techniques like the use of licensed characters on food packaging and to prevent misleading information on food labels. He encouraged clear, straightforward, front-of-package labeling, citing data demonstrating that consumers try to minimize cognitive effort in repeat in-store purchase decisions (Hoyer, 1984). He referenced Chile’s front-of-package warning labels, noting that products that carry the labels are also prohibited from using licensed characters and restricted in how they are allowed to advertise. Da Silva Gomes continued by suggesting the relative affordability of ultra-processed foods contributes to their displacing real foods. He advo- cated for correcting the distortion of prices so that real foods are more affordable, and ultra-processed foods are less affordable. Da Silva Gomes described how solutions are undermined in this region by the opposition’s efforts to weaken, delay, or impede them. “Part of the solution is exposing and studying these tactics that corporations are using to push back the solutions,” he suggested. He provided examples that he said show how these entities use legal action to hinder legislation and attempt to frame the debate and shape the evidence base on diet and public health–related issues. In closing, he reiterated that it is impor- tant not only to expose the causes associated with the obesity problem in Latin America and the Caribbean, but also to show that it is possible to do things differently. CHALLENGES AND CROSS-CULTURAL INSIGHTS INTO MANAGING THE GLOBAL EPIDEMIC The workshop’s third session featured three speakers who went into greater depth about navigating the obesity epidemic and cross-cultural insights about obesity research, policy, and practice related to high risk populations. Simón Barquera, Nutrition and Health Research Center Director at the Mexican National Institute of Public Health, said that close to three-quarters of the country’s population has obesity or overweight and its mortality attributable to diabetes (9.34 percent) is among the highest in the world. Barquera highlighted what he said were successful initiatives in diverse countries in Latin America. Related to Mexico’s soda tax, he said that evaluation data show a sustained reduction in sugar-sweetened beverage purchases 2 years after the tax was implemented in Mexico in 2014 (Colchero et al., 2017). The 7.6 percent average reduction in consumption represents about 67,000 tons of sugar that were not consumed in these 2 years, he reported. He also highlighted contrasts in the packag- ing of the same cereal product in Mexico and in Chile, noting stricter front-of-package regulation in Chile. Barquera listed several challenges to obesity prevention efforts in Latin America: presence of the double burden of malnutrition; inequalities in prevalence that are concentrated around socioeconomic status; scarce resources to invest in obesity prevention and in evaluating interventions; and primary health care systems that were created when infectious diseases were the main concern and thus lack training and resources to handle chronic diseases. Another challenge is that Mexico experiences interference from industry, Barquera observed, such as aggressive mar- keting in poor communities. For example, healthy foods such as fruits and vegetables are inexpensive in Mexico, so Barquera explained, companies are more aggressive there than in developed nations to sell junk foods and soft drinks. He also main- tained that obesity prevention policies face a coordinated response of opposition from food industry groups. Recounting an experience with front-of-package nutrition labeling systems to promote healthier choices, he described an industry-developed labeling system as complex and difficult to understand, compared to a warning label system developed by academics in Chile that he said is easily interpreted even by children. On the positive side, the problem of obesity has high political visibility, Barquera said, and the Latin American region’s linkages mean that some of the policies have domino effects as countries advise and consult with each other. Many cost- effective interventions to prevent obesity do not include expensive technology, he continued, so these solutions can be repli- cated in low- and middle-income countries worldwide. Barquera ended with suggestions to promote double-duty policies that can affect both undernutrition and obesity, with a focus on low-socioeconomic status groups: refine tax policies and other regulations to improve obesogenic environ- ments; and address industry involvement, particularly from multinational companies, in the decision-making parts of the system. 2 “Ultra-processed foods” are defined by the Pan American Health Organization as industrial formulations manufactured from substances derived from foods or synthesized from other organic sources. See http://iris.paho.org/xmlui/bitstream/handle/123456789/7699/9789275118641_eng.pdf (accessed December 27, 2018). 5

Shiriki Kumanyika, Research Professor in the Department of Community Health and Prevention at the Dornsife School of Public Health at Drexel University and Professor Emerita of Epidemiology at the University of Pennsylvania Perelman School of Medicine, and Harriet Kuhnlein, Emerita Professor at McGill University, shared cross-cultural insights about obesity research, policy, and practice related to high-risk populations. In her presentation exploring common threads in obesity risk among racial/ethnic and migrant minority populations, Kumanyika took a health inequities perspective. Given that racial/ethnic minority status is associated with above-average obesity risk compared to white majority populations, she said, examining patterns of obesity risk in populations of color in different country contexts can lead to new insights and potentially, solutions (Kumanyika, 2012). For context, she noted that population-wide increases in obesity are driven by societal forces—and the policies gov- erning them—that directly or indirectly relate to food systems or physical activity and converge to make it hard for people to maintain their weight. Apparently, she went on, within high-income countries, these forces operate differentially for minority populations. The question is why. Moving on to review adult obesity prevalence in several countries, stratified by race/ethnic group, she pointed out a tendency of higher prevalence in minority populations of color relative to reference or host populations in these countries, especially for women. In addition, she said, longitudinal studies in migrants indicate that initially lower weights yield to excess weight gain over time. Cross-national studies within groups point to the effects of western environments compared to home countries, she added. “[These data have] been critical to refute the idea of default genetic explanations,” Kumanyika explained, because the observation that people with the same general genetic background have more weight when they are in a different circumstance suggests that there are other factors at work. One big question, she said, is what is different about minority populations of color compared to host or reference populations? A second, she continued, is what is similar in different societies as it relates to minority populations of color? She noted that these minority population issues are also important to explore but are much more complex. She discussed potential influences on obesity in minority populations of color, describing variables such as race/ethnic category, socioeconomic status, migration stress, language and literacy, cultural assets, and resilience, and their associated contextual factors that might influ- ence weight. Kumanyika described that there are population subgroups, such as migrant and indigenous children, at higher obesity risk due to rapid acculturation and poor access to public health information (WHO, 2016b). Finally, Kumanyika described a diagram depicting pathways that produce racial/ethnic and migrant inequities in obe- sity, along with potential intervention points. She proposed that an intersection exists between race and ethnicity and migrant status and any other stratification variables that apply in a country to determine health inequities, and then those inequities condition the social determinants of health (such as neighborhood of residence and access to health care). She ended by under- scoring that if the pathways arise solely or in part from social stratification, “then the ultimate solutions to these excess risks in populations of color requires a major disruption in the “isms” [e.g., racism] that get us where we are today.” Kuhnlein explored how traditional cultures can contribute to resolving the obesity pandemic, with a particular focus on Indigenous Peoples. The United Nations has on record 370 million indigenous and tribal people in more than 90 countries, she began. These people face intractable poverty, racism, and discrimination, and the United Nations has recognized that their marginalization is due to the violation of their right to traditional lands and territories, she added (UN, 2018). Indigenous Peoples’ food systems knowledge is derived from their collective experience in managing 22 percent of the world’s ecosystems and land mass, as well as preserving its biodiversity, Kuhnlein explained. That knowledge may offer insights in terms of promoting energy balance, because based on the limited information available, “we recognize that most of these people [did not have obesity],” she said. Citing U.S. Centers for Disease Control and Prevention (CDC) data, Kuhnlein stated that now nearly 75 percent of U.S. Indigenous adults have overweight or obesity, compared to about 61 percent of non-Hispanic white adults (CDC, 2017). But their prevalence of diabetes is more than double, she pointed out. Turning to international data, she said that the prevalence of stunting in Indigenous children <5 years of age in four countries is much greater among indigenous children in contrast to the benchmark populations in each country (Anderson et al., 2016). Kuhnlein described an effort to understand the local food resources in a cultural context conducted in 12 community groups of Indigenous Peoples located throughout the world. The lessons from this work, she said, can help others improve nutrition and health (Kuhnlein et al., 2009, 2013). The research team discovered “unique and delicious foods with surprising nutrient values,” she said, and “learned how those foods are being lost to large, global agricultural and food marketing practic- es that are penetrating these communities,” she continued. There are many risks for loss of indigenous food system knowledge, she said, including habitat destruction; displacement from indigenous territory; loss of language and culture; urbanization and migration of knowledge-holders and youth; acceptability of more commercial foods; and loss of seeds and wildlife (CDC, 2017; GBD, 2015; UN, 2018). A systems approach is key to preventing obesity for indigenous people, Kuhnlein advised, describing that self- determination can lead to food security and well-being. To build capacity for self-determination, she called for using 6

community-specific information as a platform for health promotion activities, respecting indigenous ways of knowing and be- ing, and recognizing the “global megaforces” that undermine indigenous cultures, as well as historical trauma that cultures have experienced. Kuhnlein shared Delormier and colleagues’ (2017) viewpoints on facing the challenges, which emphasize cultural sensi- tivity and tailoring efforts to local values, conditions, and context. It is important to understand Indigenous Peoples’ connection to nature, she stressed, and to help communities understand their foods, dietary intakes, and the impact of commercial foods. According to Kuhnlein, Indigenous Peoples’ experience can inform us to the extent that we document and learn from their health strategies and the diversity of their food systems. She proposed building an international platform for this knowl- edge and urged intercultural education for the resolution of the obesity pandemic affecting all populations. REFLECTIONS ON THE GLOBAL APPROACH AND LESSONS FOR NEXT STEPS Speakers in the workshop’s final session reflected on what has been done to date and discussed the lessons for prevention and treatment efforts in the United States. Following the speakers, workshop participants raised topics including the viability of fiscal initiatives and the importance of evaluation. James Sallis, Professor Emeritus of Family Medicine and Public Health at the University of California, San Diego, de- scribed the global lessons for physical activity promotion. After a brief overview of disparities in the prevalence, environments, and policies for physical activity in the United States, he focused on international examples of physical activity initiatives that he said could “inspire and instruct us.” He provided examples for each of the four strategic objectives in the WHO Global Action Plan on Physical Activity. To highlight the first objective, to create active societies, Sallis described Ciclovias, which are “open street” practices that close down miles of streets to cars and “let people take over the streets.” Ciclovias have become integrated into the culture in parts of Latin America, but are more limited in scope and frequency in the United States, he observed. In Brazil, he mentioned “Academias de Saude” or “health academies,” which facilitate and encourage physical activity in public spaces. Focusing on the second objective, to create active environments, Sallis explained how some localities in Spain ban cars from the center of the city. He encouraged making cities more bikeable, noting that half of all trips in the United States are a bikeable distance (5 miles or less) but the actual share of bike trips in cities is only 1 percent. Regarding the third objective, to create active people, Sallis highlighted an enduring Canadian physical activity pro- motion initiative called ParticipACTION. It aims to change social norms about physical activity through a media campaign and partnerships to promote messages, and has coincided with Canada being one of the few countries with a trend of increasing physical activity, Sallis said. He also mentioned Agita Mundo, a Latin American initiative to “massively mobilize” lots of people to get active, as well as Finland’s requirement for 2 hours per day of physical activity in schools. For the fourth objective, to create active systems, Sallis pointed to ThaiHealth as an example, explaining its policy of col- lecting taxes on alcohol and tobacco to fund initiatives to promote healthy behaviors. A second example is South Africa’s Bicycle Empowerment Network, he continued, which promotes bicycle use for commuting to jobs to alleviate poverty and provide low- cost transportation. Lower-income households can save a considerable proportion of disposable income if they do not own cars, according to data that Sallis shared from a recent study (Rachele et al., 2018). There are many great strategies for promoting physical activity around the world, Sallis observed. He insisted that many of these could be adapted, implemented, and evaluated in the United States if there were funding, policy support, and political will for policy change. Bloomberg Philanthropies partners with top advocacy and research organizations to raise awareness of obesity and to identify, implement, and evaluate effective obesity prevention policies in six low- and middle-income countries, said Neena Prasad, Director of Global Obesity Prevention and Maternal & Reproductive Health Programs. Bloomberg Philanthropies is also supporting the evaluation of policies implemented in Chile and in some U.S. cities through an evaluation fund, she added. To improve food environments so that healthier options are the default, Prasad said that the organization pursues na- tional policy change in four priority areas: fiscal measures, marketing restrictions, front-of-package warning labels, and healthier schools. It supports policy change by funding advocacy, mass media, and research activities, and then it evaluates policy implementation. To explain why Bloomberg Philanthropies takes a regulatory approach, Prasad contrasted the different rates of progress for a voluntary versus regulatory initiatives aimed to reduce sugar-sweetened beverage consumption, noting that they are not perfect comparisons. She emphasized the organization’s commitment to evidence-based policy advocacy and shared examples of research that supports policy initiatives. A large proportion of the organization’s resources goes toward public awareness campaigns, Prasad continued, which are usually coupled with a policy campaign. She shared an awareness-raising video that aired alongside a sugar-sweetened beverage tax campaign, reporting that testing before and after the video indicated an impact on viewers’ understanding of the causes and consequences of consuming sugar-sweetened beverages, as well as their expectations of what their governments 7

could be doing to protect them. Prasad said public buy-in is important because “often when policy makers know the public is on [their] side, they are more willing to take those risks.” In addition, keeping an issue in the news and maintaining its sense of urgency creates or softens the ground for policy action, she said. Prasad moved on to discuss coalition-building activities, highlighting coalitions in South Africa, Brazil, and Mexico that she said have engaged numerous diverse, credible organizations around common ground. If a policy passes, Bloomberg Philan- thropies supports post-implementation evaluation to assess impact, she added. Finally, Prasad underscored that Bloomberg Philanthropies wants to accelerate the generation of the evidence base for “what works” in obesity prevention. It wants to see the implementation of diverse policies in its six focus countries; evaluation of the early impact of these policies in both the focus and non-focus countries; and the beginnings of a policy package that any country can begin to adopt, she observed. The World Bank focuses on obesity as an economic issue, said Meera Shekar, Global Lead for Nutrition. It is only a mat- ter of time before obesity overwhelms the health sector and the economy, she maintained, pointing out that the problem af- fects low-, middle-, and high-income countries. She also explained that as per capita income increases in countries, the burden of overweight and obesity shifts to the poor. The World Bank has begun to review potential policies and strategies to address overweight and obesity, said Shekar. Through a review of policies implemented in nine countries, the World Bank has begun to identify which policies work, in what context, and how those policies are scalable within different conditions. Shekar shifted to highlight key milestones in global action on obesity and previewed a number of forthcoming reports. However, she noted, many reports on NCDs do not focus on overweight and obesity, and “that’s something I think we really do need to try and fix.” The World Bank has invested much of its funding on undernutrition, but Shekar said that while awareness of obesity is increasing, concrete action at scale is elusive. She suggested that though the World Bank contributes money, what is more useful is its contribution of convening power and ability to reach high-level national leaders and decision makers, as well as Ministries of Finance, with messages and evidence. Mobilizing domestic resources is critical to change the financing landscape for any of these issues, she maintained. Shekar described the World Bank’s new Human Capital Project that aims to accelerate “more and better investments” in people globally, focusing on health and education. It will include a Human Capital Index to make the case for investment in the human capital of the next generation; improve measurement and provide analysis to support investments in human capital formation; and support early adopters, and ultimately all countries, to prepare national strategies that accelerate progress on human capital, she said. In closing, Shekar shared three strategies for how the World Bank can do more in the obesity arena: (1) maximize the potential of its multisectoral engagement (with health, agriculture, and transport sectors, for example); (2) scale up promising policies and interventions; and (3) leverage the range of World Bank instruments at all levels, including its ability to convene/ advocate at the global and through development policy and lending at the country level. Reflecting on the day’s presentations, William (Bill) Dietz, Director of the Sumner M. Redstone Global Center for Pre- vention and Wellness at the Milken Institute School of Public Health at The George Washington University, applauded what he called a rich series of talks that covered many topics and themes. He made a number of observations, remarking on common trends in obesity prevalence worldwide; the health systems that will be challenged by obesity and an ensuing wave of diabetes; changing community infrastructure to promote physical activity in rapidly urbanizing low-income countries; globalization of the food supply as a contributor to the epidemic and the imperative to establish trust with the food industry; and confront- ing the inequities that drive disparities in obesity prevalence. He also described social norms that lead to obesity being valued or at least “not considered a negative.” He challenged participants to consider sustainability in light of the interrelationships of undernutrition, obesity, and climate change. 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DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Emily A. Callahan as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Acad- emies of Sciences, Engineering, and Medicine. REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop— in Brief was reviewed by Ihouma Eneli, American Academy of Pediatrics, and Robert Post, Chobani, LLC. Lauren Shern, National Academies of Sciences, Engineering, and Medicine served as the review coordinator. SPONSORS: This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American College of Sports Medicine; American Council on Exercise; American Heart Association; American Society for Nutrition; Bipartisan Policy Center; Blue Cross Blue Shield of North Carolina Foundation; The California Endowment; ChildObesity180/Tufts University; Edelman; General Mills Foundation; Greater Rochester Health Foundation; Health Partners, Inc.; Healthy Weight Commitment Foundation; The JPB Foundation; Kaiser Permanente; The Kresge Foundation; Mars, Inc.; National Recreation and Park Association; Nemours Foundation; Nestlé Nutrition; Nestlé USA; Novo Nordisk; Obesity Action Coalition; The Obesity Society; Partnership for a Healthier America; Reebok, International; Reinvestment Fund; Robert Wood Johnson Foundation; Salud America!; Weight Watchers International, Inc.; and YMCA of the USA. For additional information regarding the meeting, visit nationalacademies.org/obesitysolutions. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Current status and response to the global obesity pandemic: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25349. Health and Medicine Division Copyright 2019 by the National Academy of Sciences. All rights reserved. 11

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On October 9, 2018 the National Academies of Sciences, Engineering, and Medicine held a public workshop titled “Current Status and Response to the Global Obesity Pandemic” in Washington, DC. The workshop examined the status of the global obesity pandemic and explored approaches used to manage the problem in different settings around the world. This Proceedings of a Workshop–in Brief highlights presentations which discussed the importance of understanding the obesity epidemic in global context and shared perspectives on the implications of obesity as a global problem for prevention and treatment efforts in the United States, with an emphasis on reducing disparities.

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