BOOKS & ELECTRONIC MEDIA

Obesity prevention and public health

Robert Beaglehole

Chronic Diseases and Health Promotion, World Health Organization, 1211 Geneva 27, Switzerland (email: beagleholer@who.int)

Editors: David Crawford & Robert W Jeffery
Publisher: Oxford University Press, Oxford, 2005
ISBN: 978-0-19-856600-7; hardcover, 352 pages; price £49.50

This book is both depressing and exciting. Depressing because it lays bare the inability of public health practitioners to respond adequately to the obesity pandemic. We have been content to observe its emergence and entrenchment in wealthy countries over the last three decades and more recently in low- and middle-income countries. Only in the last 5 years has the public health community become seriously engaged with the problems presented by obesity to the health of populations, and especially poor populations. The excitement comes when the contributing authors become less academic and begin to consider the opportunities for addressing the environmental causes of the obesity pandemic — regrettably this only comes towards the end of the book where the last three (out of fourteen) chapters begin to get serious about the public health options with a real chance of success.

I read the book in a variety of obesegenic environments: an Indian Ocean atoll, a Beijing hotel, and a long-haul air flight. In each of these locations excessive amounts of food (mostly buffets) were readily available (and with no price disincentive since it was included in the "room rate") and the natural environments were not conducive to serious physical activity — the temperature on the atoll and the pollution and traffic in Beijing. At least my physical activity options were not immediately harmful to my health. During my Beijing visit, 20 middle-school children and their teacher were killed by a truck while out jogging in the early morning. Even if physical activity is only a partial answer to obesity, it must be safe.

The focus of the book — said by one of the contributors to be the first of its kind — is inevitably on the USA, both because this is where the obesity epidemic has achieved the greatest levels and received the most media attention and also where the surveillance data are the most complete. However, even for the USA the available data are grossly insufficient to identify the relative contributions of trends in food intake and physical activity pattern to the obesity epidemic. It is clear, however, that the most important contribution of obesity to the global burden of ill-health will occur in low- and middle-income countries. In almost all these countries the epidemic is rapidly taking hold driven by the nutrition transition and even more rapid changes in urban design, especially work and transportation patterns. In some parts of Africa and Asia the situation is complicated by the coexistence of obesity and underweight, sometimes in the same family.

Despite the academic nature of many of the chapters (the book has a total of 1200 references) it is clear that increases in energy intake are the major factor responsible for the rise of obesity. Furthermore, this increase is driven by environmental forces, not the free choices of individuals, especially in childhood. Thus, major changes will be required from the food industries to ensure the global availability of products with a marked reduction in levels of fats, sugar and salt. WHO is in dialogue with the food and non-alcoholic beverages industries, and similar discussions have been held, not only in wealthy countries, but also recently in India and China. The positive statements made by multinational and national companies in this respect will need to be taken up by small-scale companies and systems set in place to monitor the promises of the industry. Major contributions will also be required from other sectors, notably marketing and advertising, education, trade, transport and urban design.

A key issue to be resolved in all countries is the balance of responsibility between individuals and the environments for creating the obesity epidemics. In most of the book a "balanced" approach is predominant. Only in the last three chapters, and appropriately in my view, is the overwhelming role of the environment stressed. It was these chapters that captured my enthusiasm and gave me hope for the future. They deal with the power of litigation to set the terms of engagement; a case study on efforts in Tonga to reduce the importation of fatty foods; and, especially, the agenda for action, despite incomplete evidence for effectiveness, laid out in the final chapter.

So far no country has achieved any notable success in the fight against obesity. Small-scale successes have been achieved in some settings, notably schools and workplaces. But the rise of obesity has yet to show any signs of slowing. Perhaps it will be China that will lead the way — the traditional diet is still entrenched for the majority of the population, "super sizing" has not yet swept the country, and once the authorities get to grips with the problem, positive changes may be possible in a short time.