Undernutrition and Obesity: the View from the Public Sector

Undernutrition and Obesity: the View from the Public Sector

William H. Dietz, MD, PhDDivision of Nutrition and Physical Activity

CDC

Undernutrition and ObesityUndernutrition and Obesity

Undernutrition ObesityWomen > men Women > men

Ethnic differencesSES gradient SES gradient in white womenChildren esp vulnerable Adults > children

Large disease and financial burdenBreastfeeding protects

Food insecurity Food insecurity?

Undernutrition ObesityWomen > men Women > men

Ethnic differencesSES gradient SES gradient in white womenChildren esp vulnerable Adults > children

Large disease and financial burdenBreastfeeding protects

Food insecurity Food insecurity?

Examples of the Elimination of Micronutrient Malnutrition in the United States

Examples of the Elimination of Micronutrient Malnutrition in the United States

Iodine deficiency

Pellagra

Neural tube defects

Iodine deficiency

Pellagra

Neural tube defects

The Full Spectrum of Iodine Deficiency

Reduced intellectualperformance

Goiter

Cretinism

Iodized Salt in the United States

Morton developsIodized salt to help prevent goiters, which were common at the time. The Food and Drug Administration later requests that the product be labeled with the message, “This salt provides iodide, a necessary nutrient.”

1924

0

10

20

30

40

50

1924 1929 1951

Year

Pe

rce

nt

0

10

20

30

40

50

1924 1929 1951

Year

Pe

rce

nt

Salt Iodization in the US:Trend in Goiter Prevalence in Michigan

WHO Monograph Series No. 44

Examples of the Elimination of Micronutrient Malnutrition in the United States

Examples of the Elimination of Micronutrient Malnutrition in the United States

Iodine deficiency

Pellagra

Neural tube defects

Iodine deficiency

Pellagra

Neural tube defects

Mo

rtal

ity

and

Mo

rbid

ity

Rat

es p

er

100

,00

0 P

op

ula

tio

n

Year

Mandatory Enrichment LawBecame Effective (1945)

1000

100

10

1

0.11925 1935 1945 195519401930 1950

Morbidity and Mortality Rates of Pellagra in Mississippi

Voluntary BreadEnrichment Began (1938)

MorbidityMortality

Source: AMJ Public Health 2000; 90:727

Examples of the Elimination of Micronutrient Malnutrition in the United States

Examples of the Elimination of Micronutrient Malnutrition in the United States

Iodine deficiency

Pellagra

Neural tube defects

Iodine deficiency

Pellagra

Neural tube defects

Prevalence of spina bifida and anencephaly by year and quarter of birth for 24 surveillance programs

(1995-99)

Prevalence of spina bifida and anencephaly by year and quarter of birth for 24 surveillance programs

(1995-99)

World Bank Rankings of Cost Effective InterventionsWorld Bank Rankings of Cost Effective Interventions

Relative Cost Per DALY

$0 $5 $10 $15 $20 $25 $30 $35

Iron Fortification

Iodine Fortification

Vitamin ASupplementation

Iron Supplementation

ORT for Diarrhea

Antibiotics forInfections

Vitamin A Fortification

Relative Cost Per DALY

$0 $5 $10 $15 $20 $25 $30 $35

Iron Fortification

Iodine Fortification

Vitamin ASupplementation

Iron Supplementation

ORT for Diarrhea

Antibiotics forInfections

Vitamin A Fortification

Copenhagen Consensus“Very Good Proposals”Copenhagen Consensus“Very Good Proposals”

• Challenge Opportunity• Diseases Control of HIV/AIDS• Malnutrition Providing micronutrients • Subsidies & trade Trade liberalization• Diseases Control of malaria

• Challenge Opportunity• Diseases Control of HIV/AIDS• Malnutrition Providing micronutrients • Subsidies & trade Trade liberalization• Diseases Control of malaria

Flour Fortification InitiativeA Public-Private-Civic Investment in Each Nation

What Can Industry Do? What Can Industry Do?

• New product development• Help make the case for fortification

Recognize successDevelop and argue the ROIUse business to business networks

• Support a level playing field• Market the approach

• New product development• Help make the case for fortification

Recognize successDevelop and argue the ROIUse business to business networks

• Support a level playing field• Market the approach

Source: International Obesity Task Force

Global Prevalence of Obesity, 1988-94Global Prevalence of Obesity, 1988-94

Samoa (urban)

Kuwait

East Germany

USA

Saudi Arabia

W. Germany

Czech Republic

England

Canada

Netherlands

Australia

Brazil

Japan

China

Women Men

80 60 40 20 0 20 40 60 80

% population

Age range

25-6918+

25-6420-74

15+25-6920-6516-6418-7420-5920-6915-6425-64

20+20-45

19961991

2004

Obesity Trends* Among U.S. Adults1991, 1996, 2004

No Data <10% 10%-14% 15%-19% 20%-24% 25%

Consequences of Adult ObesityConsequences of Adult Obesity

• Psychosocial• Cardiovascular

– Hyperlipidemia– Diabetes mellitus– Hypertension– Respiratory– Cardiac

• Psychosocial• Cardiovascular

– Hyperlipidemia– Diabetes mellitus– Hypertension– Respiratory– Cardiac

• Medical– Polycystic ovary disease– Gall bladder disease– Osteoarthritis– Cancer

• Pregnancy and the postpartum• Mortality• Erectile dysfunction

• Medical– Polycystic ovary disease– Gall bladder disease– Osteoarthritis– Cancer

• Pregnancy and the postpartum• Mortality• Erectile dysfunction

Diabetes* Trends Among U.S. Adults,BRFSS 1990, 1996, and 2004

* Includes Gestational Diabetes

1990 1996

2004

No Data <4% 4%–6% 6%–8% 8%–10% >10%

Duration of Diabetes and Nephropathy (Pima Indians)Duration of Diabetes and Nephropathy (Pima Indians)

• The duration of diabetes, rather than the age at diagnosis, is predictive of nephropathy (Krakoff. Diabetes Care 2003;26:76)

• The duration of diabetes, rather than the age at diagnosis, is predictive of nephropathy (Krakoff. Diabetes Care 2003;26:76)

0

5

10

15

20

25

0 4 8 12 16

0

5

10

15

20

25

0 4 8 12 16

Cumulative IncidenceCumulative Incidence

Nephropathy (%)Nephropathy (%)

15 - 24 Y15 - 24 Y

35 - 44 Y35 - 44 Y

25 - 34 Y25 - 34 Y

Duration (years)Duration (years)

Costs of ObesityCosts of Obesity

Costs of illness

Costs of absence from work

Costs of reduced productivity

Costs of injuries

Costs of disability

Costs of illness

Costs of absence from work

Costs of reduced productivity

Costs of injuries

Costs of disability

Annual Direct and Indirect Costs Attributable to

Obesity in the United States (Billions of 1995 Dollars)

Annual Direct and Indirect Costs Attributable to

Obesity in the United States (Billions of 1995 Dollars)

Type 2 DMCHDHypertensionGallbladderBreast CaEndometrial CaColon CaOsteoarthritisTotal

Type 2 DMCHDHypertensionGallbladderBreast CaEndometrial CaColon CaOsteoarthritisTotal

DiseaseDisease Direct CostsDirect Costs Indirect CostsIndirect Costs$32.4$ 7.0$ 3.2$ 2.6$ 0.8$ 0.3$ 1.0$ 4.3$51.6

$32.4$ 7.0$ 3.2$ 2.6$ 0.8$ 0.3$ 1.0$ 4.3$51.6

$30.7$ NA$ NA$ 0.1$ 1.5$ 0.5$ 1.8$ 12.9$47.5

$30.7$ NA$ NA$ 0.1$ 1.5$ 0.5$ 1.8$ 12.9$47.5

Wolf and Colditz, Ob Res 1998;6:97Wolf and Colditz, Ob Res 1998;6:97

% Total Change in Spending by Top 10 Conditions

1987-2000 % Total Change in Spending by Top 10 Conditions

1987-2000

Heart diseasePulmonary conditionsMental disordersCancerHypertensionTraumaCerebrovascular diseaseArthritisDiabetesBack problems

Heart diseasePulmonary conditionsMental disordersCancerHypertensionTraumaCerebrovascular diseaseArthritisDiabetesBack problems

30%

16%

Thorpe et al. Health Affairs 2004; W4-437

Costs of ObesityCosts of Obesity

Costs of illness

Costs of absence from work

Costs of reduced productivity

Costs of injuries

Costs of disability

Costs of illness

Costs of absence from work

Costs of reduced productivity

Costs of injuries

Costs of disability

Effects of Obesity on Health and Disability among 50-69 yo Women with BMI > 35

Effects of Obesity on Health and Disability among 50-69 yo Women with BMI > 35

Report poor health 40.5%# Chronic conditions 2.31Any ADL limitation 21.4%Report health limits work 45.7%

Sturm et al. Health Affairs 2004;23:199

Report poor health 40.5%# Chronic conditions 2.31Any ADL limitation 21.4%Report health limits work 45.7%

Sturm et al. Health Affairs 2004;23:199

Partners in the Prevention and Treatment of Obesity

Partners in the Prevention and Treatment of Obesity

• Medical Settings• School• Work Site• Community• Industry

• Medical Settings• School• Work Site• Community• Industry

Relationship Between Energy Requirements, Physical Activity, and Weight

Ene

rgy

Req

uire

men

ts

Level of Physical Activity

Ene

rgy

Req

uire

men

ts

Weight

What Can Industry Do? What Can Industry Do?

• Recognize the threat• Use business to business contacts• Become model worksites – healthful choices, medical benefit

packages• New product development

Create and meet consumer demand• Use creative packaging• Share non-proprietary market research

• Recognize the threat• Use business to business contacts• Become model worksites – healthful choices, medical benefit

packages• New product development

Create and meet consumer demand• Use creative packaging• Share non-proprietary market research

Division of Nutrition and Physical Activity, Adolescent and School

Health, and VERB Websites

Division of Nutrition and Physical Activity, Adolescent and School

Health, and VERB Websites

• cdc.gov/nccdphp/dnpa

• cdc.gov/nccdphp/dash

• cdc.gov/youthcampaign

• VERBnow.com

• VERBparents.com

• healthierus.gov/steps

• cdc.gov/nccdphp/dnpa

• cdc.gov/nccdphp/dash

• cdc.gov/youthcampaign

• VERBnow.com

• VERBparents.com

• healthierus.gov/steps