Vet, Fit en Gezond? Over lichamelijke activiteit, eigen verantwoordelijkheid en the Nanny State

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1 Vet, Fit en Gezond? Over lichamelijke activiteit, eigen verantwoordelijkheid en the Nanny State Willem van Mechelen VU University Medical Centre Amsterdam Department of Public and Occupational Health, EMGO Institute

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3 INHOUD Wat is het probleem? Wat is de oorzaak? Vet, fit en gezond? Eigen verantwoordelijkheid en zelf-regulatie of Nanny knows best?

4 A need for a common language

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6 BMI Weight/Height 2 overweight > 25 Obesity > kg by 1,86 m

7 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI? 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% Source: Behavioral Risk Factor Surveillance System, CDC.

8 video

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10 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI? 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% Source: Behavioral Risk Factor Surveillance System, CDC.

11 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI? 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% Source: Behavioral Risk Factor Surveillance System, CDC.

12 Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI? 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% Source: Behavioral Risk Factor Surveillance System, CDC.

13 Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI? 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% >?20% Source: Behavioral Risk Factor Surveillance System, CDC.

14 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI? 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% >?30% Source: Behavioral Risk Factor Surveillance System, CDC.

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20 Obesity prevalence across Europe, % Obesity < 5 % Males % % % % 25% International Obesity TaskForce 2005

21 Obesity prevalence across Europe, % Obesity < 5 % Males % % % % 25% Self Reported data International Obesity TaskForce 2005

22 Mixed-longitudinal development of overweight in the Netherlands, men a) men 28 Mean BMI (kg/m 2 ) with 95% CL Age of cohort at baseline y y y y Average age of cohort during measurement (y)

23 Mixed-longitudinal development of overweight in b) women 28 the Netherlands, women Mean BMI (kg/m 2 ) with 95% CL Age of cohort at baseline y y y y Average age of cohort during measurement (y)

24 NL O&O trends ,6 million 36% & 12% = 48% 8,0 million 41% & 18% = 59% 8,7 million 35% & 30% = 65%

25 Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis

26 However: people with an unhealthy lifestyle also WORK!

27 2.5 Relative risk Work disability in Finns women men < >32.5 body m ass index (kg/m 2 ) (Rissanen et al. BMJ 1990)

28 mean sick leave by frequency of vigorous PA 3 mean sick leave (in days) 2,5 2 1,5 1 0,5 OBiN POLS frequency (in x per week)

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30 The Netherlands: direct cost: indirect cost: Euro 0,5 billion per year Euro 2,0 billion per year RVZ, 2002

31 CBS cijfers maandag 17 november 2008: Lager opgeleiden 6-7 jaar eerder dood. Mensen in lagere sociaal-economische groepen hebben gemiddeld een slechtere gezondheid

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35 What causes the problem?

36 Energy balance intake expenditure

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38 Energy intake of 140 kcal/week Glass of beer Some peanuts Croissant Chocolate cookie Dia geleend van Seidell

39 Energy expenditure = 21 min = 14 min = 19 min = 35 min Dia geleend van Seidell

40 Voeding of bewegen? moeten wel op het juiste doel afgaan!

41 Trends in Energy-intake (Kilojoules) in the Netherlands Dutch Health Council, Trends in Nutrition, report 2002/12

42 conditions have changed.

43 society has changed also Chips

44 Er is één en ander veranderd. Stone-age (Palaeolithic) genen in space-age ( de-vitalised ) omstandigheden

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47 Physical inactivity Abnormal reaction to a normal environment? Normal reaction to an abnormal environment?

48 Determinants of behaviour gender age SES etc. attitude social influence self-efficacy barriers behaviour De Vries OU 1993

49 The environment individual behaviour

50 .various kinds of influences individual behaviour physical environment economic environment socio-cultural environment Macro environment Micro environment BMJ, Egger& Swinburn, 1997

51 Deteminants of health behaviour (Aarts et al., 1997) External factors awareness cognition (A/S/E) behaviour Behavioural intention habits barriers Social & physical environment

52 Vet, fit en gezond?

53 lichamelijke activiteit lichamelijke fitheid gezondheidstoestand: welzijn * ziekte * sterfte Beïnvloedende factoren: * erfelijkheid * leefstijl * fysieke en sociale omgeving * overige HVZ DM-II hypertensie osteoporose colon ca. functionaliteit milde depressie angst Bouchard, 1994

54 Cooper Institute for Aerobics Research Study mannen vrouwen aantal leeftijd jaar jaar follow-up duur 8,4 jaar 7,5 jaar sterfte 601 (226) 89 (21) Blair et al., JAMA, 1996

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56 Cooper Institute for Aerobics Research Study - tredmolentest en medisch onderzoek groepsindeling op basis van tredmolenresultaten: 20% minst fitte, versus 40% gemiddeld fit en 40% zeer fit fitheid sterfte HVZ/iedere oorzaak (onder correctie voor overige risicofactoren) Blair et al., JAMA, 1996

57 Fitness and Mortality UNFIT FIT Relative Risk of Death Fitness Group Men Women Blair et al. JAMA 1989;262:

58 man Blair et al., JAMA, 1996

59 man Blair et al., JAMA, 1996

60 man Blair et al., JAMA, 1996

61 man Blair et al., JAMA, 1996

62 Vet, fit en gezond?

63 Adjusted RR for All-Cause Mortality by Fitness and % Body Fat Fit Unfit Adj RR* *adj for age, exam year, smoking, alcohol, & fam history Lean Normal Obese <16% 16-<25% 25% Body Fat Lee CD et al. Am J Clin Nutr 1999.

64 Aerobics Center Longitudinal Study 25,714 Men, , followed until Fit Unfit Risk of CVD Death Normal Weight Overweight Obese Wei et al. JAMA 1999;282:

65 Lipid Research Clinics Study ( ), 24 year follow-up: Women 2.5 Fit Unfit Risk of CVD Death Low BMI High BMI Stevens et al., Am J Epidemiol 2002; 156:

66 Harvard Alumni Study ( ), 15 year follow-up: Men Active Inactive Risk of Death Not Overweight Overweight Lee and Paffenbarger, Am J Epidemiol 2000; 151:

67 Metabolic Syndrome, Fitness, and Mortality CVD Mortality Among 19,223 Men from the Aerobics Center Longitudinal Study: 10 Years of Follow-up CVD death rate per man-y Healthy Unfit Fit Metabolic Syndrome Katzmarzyk et al. Arch Intern Med 2004;164:

68 Wat kunnen we er aan doen?

69 Prevention Strategies High Risk vs. Population Truncate high risk end of exposure distribution Secondary & tertiary prevention. Reduce risk a little risk in most people Primary & promiordial prevention

70 Energy balance intake expenditure

71 Physical inactivity Abnormal reaction to a normal environment? Normal reaction to an abnormal environment?

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73 Social Ecological Model of Physical Activity Organizational PA policies ENVIRONMENTAL/ POLICY Area-level SES Active transport policies Aesthetics of environment Seasonality Topography Urban planning policies Ethnicity Social norms Cultural norms Social capital Access to recreational facilities Physician influence Social support friends Access to parks/ playgrounds Education level Gender DIETARY HABITS Enjoyment Peer & sibling interactions SOCIOCULTURAL INDIVIDUAL PHYSICAL ACTIVITY Barriers Walking/cycling tracks Self-efficacy Children same age live nearby Age Social support family SES SEDENTARY BEHAVIOR Beliefs Social isolation Time spent outdoors Sibling PA Family rules PA Someone to be active with Parental PA Connectivity of streets Perceptions of safety Living in cul-de-sac Crime rates & neighborhood safety Traffic (volume/speed) Stranger danger (Adapted from Davison & Birch 2001)

74 Food for thought

75 Eigen verantwoordelijkheid en zelfregulatie, of Nanny knows best?

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83 More Food for thought

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86 30 kg approx. 90 minutes swimming to get rid of 100 grams of Dutch cake Three cakes: 3,1 * 3 * 1,5 (uur) = 14 hours of swimming

87 Do interventions aiming at voluntary behavioral change make Public Health sense?? Yes they do, but perhaps more Draconic action is needed!!

88 Sanitation: pragmatism works Johan P Mackenbach, BMJ 2006

89 Consumption of tobacco products in Finland First tobacco law Statistics Finland 1998 Cigarettes/grams per adult Tobacco and Health Reports New tobacco law The European Conference on Health Enhancing Physical Activity and Active Living, Belfast - Tapani Piha 23 Oct 2000

90 video

91 However, the future looks bright!

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