Obesity Has Legs

The July issue of the German Journal of Sports Medicine is dedicated to the topic Adiposity. Since the 1980s, there has been an obvious increase in overweight and adiposity, which has reached the status of a global epidemic. Now 2.1 billion people are overweight; there are more overweight and adipose than people with malnutrition on the planet – this could be viewed as a success of modern agriculture. Apparently, the food supply is sufficient for so many people, and even further increase in the world population (presently by 156 people per minute) can be dealt with, if the foods were better distributed. The increased prevalence of overweight and adiposity, however, also mean a change in morbidity and mortality. Since the 1980s, childhood adiposity in particular has increased dramatically. This increases the risk of subsequent Type 2 Diabetes, stroke and coronary heart disease and cancer, as well as early retirement or premature death (44, 46). This development is considered one of the greatest challenges for the next 30 years (17). This trend affects all parts of the world and, in accordance with the “America first” doctrine, is led by the USA (see figure 1) (35) The development in Germany is only a few years behind the USA  (ca. 25% of adults are adipose (30)), and if we are not successful in bringing about the necessary changes in time, we will not avoid catching up. But we know the risk constellation of the metabolic syndrome, the importance of diet (29) and of physical activity (22) and thus have possibilities to ward off the threatening menace by lifestyle interventions before the debilitating consequential damage occurs (8, 20).

In the same period, we have also achieved a marked increase of knowledge in this area. We now know that adipocytes are not purely fat stores, but have decisive influence on the metabolism - the article by Krüger describes the sequalae of a “sterile inflammation” with all their consequences (21). We have come to better understand the regulation of appetite, and there have been successful trials to influence this by means of drugs – unfortunately no preparations low in side effects or risks have been developed. Likewise, we have recognized that the composition of a diet has relatively little influence on the weight loss accomplished; the essential decisive parameter is compliance with dietary modification (6, 11, 45). This simplifies the matter enormously: instead of making the adipose individual swear to maintain one of the innumerable praised dietary regimens, the best diet is that which one can maintain over the long term. In order to achieve weight loss, either the caloric intake must be limited, or the caloric consumption cranked up – ideally both. Unfortunately, nearly all programs fail in the majority of patients with respect to effective, long-lasting weight reduction. And this despite the fact that the importance of calory reduction is apparently known among the population. More than half the US population say at any time that they are dieting, but apparently this is unsuccessful for nearly all of them over the long term (19). Only bariatric surgery can present with results of significant weight reduction in a majority of the patients, whereby we have to wait for evaluation of the long-term results.

Why do our efforts fail like this? The prevalence of overweight and adiposity has not decreased in any country over the past 30 years (18, 38). And what new impulses could bring improvement here? Since this is a worldwide problem, we can observe which measures have been successfully performed in other countries around the globe.

State measures could have a targeted influence on the dietary of the population (1, 10, 25, 36, 43). In Denmark, taxation resulted in a decrease in the consumption of saturated fatty acids by 10-15% (14). In Hungary, targeted taxation achieved a reduction in the consumption of “unhealthy products” by 25-35% (28). Mexico taxed sweetened drinks, which account for ca. 15% of the caloric intake (2), and also had a positive influence on the consumption (5). Such changes in sales figures can put pressure on the food producing companies. Thus, some manufacturers in Hungary altered the ingredients in food products in order to avoid the taxation. Likewise, the obligation of declaring the trans-fatty acid contents in products led in the USA, Canada and South Korea to a reformulation of the food product (23, 33, 47). A profit-oriented food industry has the goal of increasing sales with products in cost-optimized products. For this reason, ingredients like sugar, fats and salt, along with taste enhancers, additives and caffein, or their combination are changed to optimize sales and market value (12). Many of the ultraprocessed foods contain only little roughage or protein, although it is known that these ingredients increase saturation and may delay the resorption of other ingredients, such as sugar. Modern foods, by contrast, have often been altered so that it is difficult for the human organism to control appetite and thus weight. Animal experiments show that ultraprocessed foods, which contain a lot of sugar, fat and salt, lead to changes in behavior and in neurobiochemical reactions, similar to addictive behavior (15). This reminds one strongly of the cigarette industry, which continued to increase addiction to cigarettes by additives, despite knowing the injurious effects of smoking. This biological sensitivity to ultraprocessed foods is especially dangerous for children, since they react more than adults to sweet foods (7, 40).

It is enormously important to set the proper course for the youngest so they won’t become tomorrow’s patients. Even during pregnancy, the fetal phenotype is influenced by maternal diet. Postpartum, nursing is considered the optimum form of feeding and should provide infant food wherever possible. Additionally, we have to make efforts to create an environment in which healthy behavior patterns can be learned. The first 2 years are already formative (13). Especially parents and caregivers must be supported in learning the corresponding competencies to create optimized conditions (41). Disruptive factors, like advertising for unhealthy foods, should be minimized in addition (26). Only measures which are in tune with one another will lead to the desired success (24, 48). Likewise with respect to school meals, standards could achieve improved nutrition, as has been successful in Great Britain (42)). It is decisive that all levels of society are reached, since there is a relationship between prevalence and the socioeconomic status. And especially cheap foods or prepared meals often don’t meet the demands of a health-promoting diet. An appropriate diet often costs more and these higher costs must be recognized as meaningful (37). The knowledge, understanding and evaluation possibilities for foods and for a healthy lifestyle must also be improved at all levels. Most consumers are not able to interpret the simple listing of macronutrients and the proportion of saturated fatty acids on our food packaging anyway.

As described, behavioral prevention can be achieved only with inadequate success. Consequently, scientific societies (German Diabetes Society (DDG), German Society of Cardiology (DGK), German Alliance of  Non-communicable Diseases (DANK) and DiabetesDE) demand as a means of behavioral prevention among other things, daily at least 1 hour of exercise or sports in schools and kindergartens, taxation of adipogenic foods and reduced taxation of healthy foods, binding quality standards for lunches in kindergartens and schools, as well as a ban on food advertising directed to children and adolescents (9).

Along with the reduction of caloric intake, the caloric expenditure must also be increased for effective combatting and prevention of adiposity. Only a small proportion of German adults achieve the targets recommended by the WHO for energy expenditure. But we know that even a much lower amount of exercise than that demanded by the WHO Guidelines produces a marked benefit compared to complete inactivity (49). Even without attendant weight loss, physical activity can relieve some of the metabolic dysbalances (39). Physical fitness is the decisive mortality parameter and modulates the influence of adiposity (34). In countries with low and middle income, physical activity is usually performed at work, in the household or in transport, while in rich countries it plays a role predominantly in leisure time (27). In the latter, the proportion of sitting jobs at the workplace has increased and thus contributed to a reduced caloric expenditure by ca. 100cal/d (4). In this respect it would be a logical solution to increase the caloric expenditure at work again. Employer-organized programs (such as “active breaks. sponsored memberships in fitness studios with regional providers near the workplace or national), running groups, or introductory courses at company health days could be offered. Likewise, activity programs during working hours have been evaluated positively (3, 16, 31, 32). The setting at the workplace makes it possible to reach possibly stimulate people with these measures who would never have participated in activity programs on their own. The Prevention Law of 2015 supports these measures, the number of programs and certified providers is growing. Professional cooperation among sports physicians, sports scientists and industrial physicians is needed to develop and implement good projects. If the parents or one parent is physically active, there is hope in rich countries for a positive influence on the next generation. And the children of today are the adults of tomorrow.