Elsevier

The Lancet

Volume 376, Issue 9754, 20–26 November 2010, Pages 1775-1784
The Lancet

Series
Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness

https://doi.org/10.1016/S0140-6736(10)61514-0Get rights and content

Summary

The obesity epidemic is spreading to low-income and middle-income countries as a result of new dietary habits and sedentary ways of life, fuelling chronic diseases and premature mortality. In this report we present an assessment of public health strategies designed to tackle behavioural risk factors for chronic diseases that are closely linked with obesity, including aspects of diet and physical inactivity, in Brazil, China, India, Mexico, Russia, and South Africa. England was included for comparative purposes. Several population-based prevention policies can be expected to generate substantial health gains while entirely or largely paying for themselves through future reductions of health-care expenditures. These strategies include health information and communication strategies that improve population awareness about the benefits of healthy eating and physical activity; fiscal measures that increase the price of unhealthy food content or reduce the cost of healthy foods rich in fibre; and regulatory measures that improve nutritional information or restrict the marketing of unhealthy foods to children. A package of measures for the prevention of chronic diseases would deliver substantial health gains, with a very favourable cost-effectiveness profile.

Introduction

The action plan devised by WHO as part of the global strategy for the prevention and control of non-communicable diseases1 focuses on four chronic diseases that account for 60% of deaths worldwide: cardiovascular disease, cancer, diabetes, and respiratory disorders. Prominent yet largely preventable behavioural risk factors associated with these diseases—either directly or indirectly via risk factors such as increased blood pressure or cholesterol concentrations—include tobacco, harmful alcohol use, unhealthy diets, physical inactivity, and obesity.

Underpinned by the forces of globalisation—including increased amounts of international trade, travel, and shared communication—the obesity epidemic is rapidly becoming a worldwide problem.2 Before 1980, obesity rates were generally much lower than 10%. Since then, rates have doubled or tripled in many countries, and in more than half of countries of the Organisation for Economic Co-operation and Development (OECD), 50% or more of the population is overweight. Mexico's population is one of the most affected. Between 2000 and 2006, the prevalence of overweight (body-mass index [BMI] ≥25 kg/m2) increased from 62·1% to 69·9%, and the prevalence of obesity from 23·7% to 30·4%.3 In China, where rapid changes in dietary habits are exacting a large toll,4 overweight rates doubled from 13·5% to 26·7% between 1991 and 2006, and the number of people who are obese tripled from 1·1% to 3·2%.5 The prevalence of diabetes in China is estimated to be as high as that in the USA, with more than 92 million cases.6 In Brazil, obesity rates tripled in men and almost doubled in women between 1975 and 2003.7 Smaller increases in overweight were recorded in India (rates for women rose from 10·6% to 12·6% between 1998–99 and 2005–06), but increases were steepest in urban areas in the west of the continent, where rates approached 40% in the early 2000s, almost doubling in less than 10 years.8 Overweight and obesity are now the prominent features of malnutrition in South Africa,9 where a third of women and a tenth of men are obese,10 with highest rates in black women and white men. After the political and economic transition, rates of obesity rose also in Russia, where one in four women and one in ten men are now obese, and rates are projected to grow fast in the coming years.10

Key messages

  • Cost-effective interventions aimed at tackling obesity by improving diets and increasing physical activity could usefully be added to a package of measures designed to deal with chronic diseases in low-income and middle-income countries.

  • Price interventions and regulation can produce the largest health gains in the shortest timeframe. Interventions in primary care can be very effective in countries with less capacity constraints.

  • A strategy of several interventions would generate substantially larger health gains than would individual interventions, often with a favourable cost-effectiveness profile.

  • Health gains from interventions targeting children occur in the long term. Regulation of food advertising to children can be more effective and efficient than can school-based health promotion.

  • Private-sector initiatives might contribute to tackling some risk factors while alleviating the burden on public-sector budgets, but more evidence of their effectiveness is needed.

The gap between available and required resources to tackle the global burden of obesity and chronic diseases is already very large and, on present trends, is set to grow further. In addition to making new resources available to address chronic diseases on a large scale—eg, via tobacco or alcohol tax levies—there is a consequent need to improve the use of existing resources to ensure adequate returns in terms of health, longevity, and economic progress. Cost-effectiveness information, together with strong financial and budgetary analysis, has a key part to play in identification of core packages of chronic disease interventions that can be realistically scaled up in countries at different levels of income, thus contributing to the business case for large-scale investment and action. Much of the latest available economic evidence in support of interventions that tackle effectively key risk factors for non-communicable diseases was reviewed in a preceding Series on chronic disease in The Lancet.11, 12, 13 In this third report in the Series about chronic diseases, we present new findings relating to the efficiency of interventions aimed at tackling the rapidly escalating obesity epidemic (via healthier dietary habits and increased amounts of physical activity), and set these findings in the context of latest available economic evidence for other risk-factor prevention strategies for non-communicable diseases.

Section snippets

Model of the health effects of diet, physical activity, and obesity

The OECD and WHO jointly developed a microsimulation model (chronic disease prevention [CDP] model) that implements a so-called causal web of lifestyle risk factors for selected chronic diseases. This model was initially applied to the European A WHO region, under the scrutiny of an expert group convened by the OECD.14 A microsimulation approach is best suited to addressing questions that would be difficult or impossible to answer through empirical investigation. In the assessment of the

Effect of diet and physical activity interventions on health outcomes and expenditures

Interventions to tackle obesity by improving diets and increasing physical activity have the potential to reduce the incidence of ischaemic heart disease and stroke and, to a lesser extent, the incidence of at least three types of cancer. The effect of interventions on morbidity, in terms of numbers of years lived without chronic diseases, is generally larger than their effect on mortality. Interventions tend to delay the onset of chronic diseases, rather than prevent them altogether, which

Strengths and limitations of the model

The CDP model developed for this study has provided new insights into the complex reality that exists with respect to the effect of interventions on a range of inter-related risk factors and disease outcomes. Nevertheless, the model can only ever be a simplified representation, and is heavily constrained by the availability of national (or subnational) data for the many required input parameters. The model, for example, does not take into account the potential confounding effect of risk factors

Chronic disease prevention: from evidence to practice

Calls for renewed global action on chronic diseases need to be supported by further evidence of the effectiveness and cost-effectiveness of different policy measures that are capable of reducing a rising burden of disease. The analysis presented in this report is intended to address a notable gap in the international economic evidence base for chronic disease prevention—namely, the identification of public health strategies that are most cost effective to tackle unhealthy diets, physical

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